Can We Rely on Prophylactic Two-Level Vertebral Cement Augmentation in Long-Segment Adult Spinal Deformity Surgery to Reduce the Incidence of Proximal Junctional Complications?

Background and Objectives: Proximal junctional kyphosis (PJK) and failure (PJF), the most prevalent complications following long-segment thoracolumbar fusions for adult spinal deformity (ASD), remain lacking in defined preventive measures. We studied whether one of the previously reported strategies with successful results-a prophylactic augmentation of the uppermost instrumented vertebra (UIV) and supra-adjacent vertebra to the UIV (UIV + 1) with polymethylmethacrylate (PMMA)-could also serve as a preventive measure of PJK/PJF in minimally invasive surgery (MIS). Materials and Methods: The study included 29 ASD patients who underwent a combination of minimally invasive lateral lumbar interbody fusion (MIS-LLIF) at L1-2 through L4-5, all-pedicle-screw instrumentation from the lower thoracic spine to the sacrum, S2-alar-iliac fixation, and two-level balloon-assisted PMMA vertebroplasty at the UIV and UIV + 1. Results: With a minimum 3-year follow-up, non-PJK/PJF group accounted for fifteen patients (52%), PJK for eight patients (28%), and PJF requiring surgical revision for six patients (21%). We had a total of seven patients with proximal junctional fracture, even though no patients showed implant/bone interface failure with screw pullout, probably through the effect of PMMA. In contrast to the PJK cohort, six PJF patients all had varying degrees of neurologic deficits from modified Frankel grade C to D3, which recovered to grades D3 and to grade D2 in three patients each, after a revision operation of proximal extension of instrumented fusion with or without neural decompression. None of the possible demographic and radiologic risk factors showed statistical differences between the non-PJK/PJF, PJK, and PJF groups. Conclusions: Compared with the traditional open surgical approach used in the previous studies with a positive result for the prophylactic two-level cement augmentation, the MIS procedures with substantial benefits to patients in terms of less access-related morbidity and less blood loss also provide a greater segmental stability, which, however, may have a negative effect on the development of PJK/PJF.

A triple minimally invasive surgery combination for subacute osteoporotic lower lumbar vertebral collapse with neurological compromise: a potential alternative to the vertebral corpectomy/expandable cage strategy.

OBJECTIVE: Acute/subacute osteoporotic vertebral collapses (OVCs) in the lower lumbar spine with neurological compromise, although far less well documented than those in the thoracolumbar junction, may often pose greater treatment challenges. The authors clarified the utility of 3 familiar combined techniques of minimally invasive surgery for this condition as an alternative to the corpectomy/expandable cage strategy. METHODS: This report included the authors' first 5 patients with more than 2 years (range 27-48 months) of follow-up. The patients were between 68 and 91 years of age, and had subacute painful L4 OVC with neurological compromise and preexisting lumbar spinal stenosis. The authors' single-stage minimally invasive surgery combination consisted of the following: step 1, balloon kyphoplasty for the L4 OVC to restore its strength, followed by L4-percutaneous pedicle screw (PPS) placement with patients in the prone position; step 2, tubular lateral lumbar interbody fusion (LLIF) at the adjacent disc space involved with endplate injury, with patients in the lateral position; and step 3, supplemental PPS-rod fixation with patients in the prone position. RESULTS: Estimated blood loss ranged from 20 to 72 mL. Neither balloon kyphoplasty-related nor LLIF-related potentially serious complications occurred. With CT measurements at the 9 LLIF levels, the postoperative increases averaged 3.5 mm in disc height and 3.7 mm in bilateral foraminal heights, which decreased by only 0.2 mm and 0 mm at the latest evaluation despite their low bone mineral densities, with a T-score of -3.8 to -2.6 SD. Canal compromise by fracture retropulsion decreased from 33% to 23% on average. As indicated by MRI measurements, the dural sac progressively enlarged and the ligamentum flavum increasingly shrank over time postoperatively, consistent with functional improvements assessed by the physician-based, patient-centered measures. CONCLUSIONS: The advantages of this method over the corpectomy/expandable cage strategy include the following: 1) better anterior column stability with a segmentally placed cage, which reduces stress concentration at the cage footplate-endplate interface as an important benefit for patients with low bone mineral density; 2) indirect decompression through ligamentotaxis caused by whole-segment spine lengthening with LLIF, pushing back both the retropulsed fragments and the disc bulge anteriorly and unbuckling the ligamentum flavum to diminish its volume posteriorly; and 3) eliminating the need for segmental vessel management and easily bleeding direct decompressions. The authors' recent procedural modification eliminated step 3 by performing loose PPS-rod connections in step 1 and their tight locking after LLIF in step 2, reducing to only once the number of times the patient was repositioned.

A new technique useful for lumbosacral percutaneous pedicle screw placement without fluoroscopy or computer-aided navigation systems.

BACKGROUND: Percutaneous pedicle screw (PPS) placements in the lumbosacral spine generally rely on fluoroscopy at the expense of radiation exposure. Our accumulated experience in open PS placements without fluoroscopic guidance realized a consistent shift toward PPS insertion with newly developed devices, which require neither fluoroscopy nor navigation. We wish to report our new technique and evaluations of its accuracy. METHODS: Our equipment consisted of a pedicle targeting tool to identify and escort the cannulated awl to the correct starting point for cortical bone perforation and a cannulated awl-probe system with a guidewire to maintain the optimal position throughout the subsequent surgical steps. The surgeon could advance the blunt-tipped probe searching for the cancellous bone track using tactile feedback as experienced in open techniques. A 2-year period of transition from a free-hand (1169 screws in 286 patients) to the new PPS technique (1933 screws in 413 patients) allowed accuracy comparison between the two procedures using postoperative CT scans. RESULTS: Compared with the open-group, the PPS-group showed a lower rate of fully contained intrapedicular PS placements at L1 through S1, as a whole (90.7% vs 85.4%), but not at L4 through S1 (89.9% vs 90.2%). Less-accurate PPS placements at upper than lower lumbar spines in part reflect intended pedicle perforations laterally as a trade-off for avoiding facet violation immediately above the most cephalad screw. The PPS-group also had a higher incidence of PS-related transient nerve root complications (0% vs 1.7%). These values for the PPS-group, however, fell within those previously reported for free-hand or fluoroscopy techniques. CONCLUSIONS: Our new PPS technique, although useful for eliminating the potential risk of repeated radiation exposure, fell short of reaching the accuracy of the free-hand technique. Nerve integrity monitoring with PS stimulation, which we currently use, will help further improve the technical precision. STUDY DESIGN: Original Article. The study was approved by our institutional review boad (2,019,231).

The muscle evoked potential after epidural electrical stimulation of the spinal cord as a monitor for the corticospinal tract: studies by collision technique and double train stimulation.

To study if spinal motor evoked potentials (SpMEPs), muscle responses after electrical stimulation of the spinal cord, can monitor the corticospinal tract. Study 1 comprised 10 consecutive cervical or thoracic myelopathic patients. We recorded three types of muscle responses intraoperatively: (1) transcranial motor evoked potentials (TcMEPs), (2) SpMEPs and (3) SpMEPs + TcMEPs from the abductor hallucis (AH) using train stimulation. Study 2 dealt with 5 patients, who underwent paired train stimulation to the spinal cord with intertrain interval of 50-60 ms for recording AH SpMEPs. We will also describe two illustrative cases to demonstrate the clinical value of AH SpMEPs for monitoring the motor pathway. In Study 1, SpMEPs and SpMEPs + TcMEPs recorded from AH measured nearly the same, suggesting the collision of the cranially evoked volleys with the antidromic signals induced by spinal cord stimulation via the corticospinal tracts. In Study 2, the first and second train stimuli elicited almost identical SpMEPs, indicating a quick return of transmission after 50-60 ms considered characteristic of the corticospinal tract rather than the dorsal column, which would have recovered much more slowly. Of the two patients presented, one had no post-operative neurological deteriorations as anticipated by stable SpMEPs, despite otherwise insufficient IONM, and the other developed post-operative motor deficits as predicted by simultaneous reduction of TcMEPs and SpMEPs in the face of normal SEPs. Electrical stimulation of the spinal cord primarily activates the corticospinal tract to mediate SpMEPs.

A New Treatment Algorithm That Incorporates Minimally Invasive Surgery for Pyogenic Spondylodiscitis in the Thoracic and Lumbar Spines: The Results of Its Clinical Application to a Series of 34 Patients.

Background and Objectives: Spinal minimally invasive surgery (MIS) experts at the university hospital worked as a team to develop a new treatment algorithm for pyogenic spondylodiscitis in lumbar and thoracic spines. They modified a flow chart introduced for this condition in a pre-MIS era to incorporate MIS techniques based on their extensive experiences accumulated over the years, both in MIS for degenerative lumbar diseases and in the treatment of spine infections. The MIS procedures incorporated in this algorithm consisted of percutaneous pedicle screw (PPS)-rod fixation and transpsoas lateral lumbar interbody fusion (LLIF). The current study analyzed a series of 34 patients treated with prospective selection of the methods according to this new algorithm. Materials and Methods: The algorithm first divided the patients into those who had escaped complicated disease conditions, such as neurologic impairment, extensive bone destruction, and the need to be mobilized without delay (Group 1) (19), and those with complicated pyogenic spondylodiscitis (Group 2) (15). Group 1 had image-guided needle biopsy followed by conservative treatment alone with antibiotics and a spinal brace (12) (Group 1-A) or a subsequent addition of non-fused PPS-rod fixation (7) (Group 1-B). Group 2 underwent an immediate single-stage MIS with non-fused PPS-rod fixation followed by posterior exposure for decompression and debridement through a small midline incision (12) (Group 2-A) or an additional LLIF procedure after an interval of 3 weeks (3) (Group 2-B). Results: All patients, except four, who either died from causes unrelated to the spondylodiscitis (2) or became lost to follow up (2), were cured of infection with normalized CRP at an average follow up of 606 days (105-1522 days). A solid interbody fusion occurred at the affected vertebrae in 15 patients (50%). Of the patients in Group 2, all but two regained a nearly normal function. Despite concerns about non-fused PPS-rod instrumentation, only seven patients (21%) required implant removal or replacement. Conclusions: Non-fused PPS-rod placements into infection-free vertebrae alone or in combination with posterior debridement through a small incision worked effectively in providing local stabilization without contamination of the metal implant from the infected tissue. MIS LLIF allowed for direct access to the infected focus for bone grafting in cases of extensive vertebral body destruction.

Bone Fusion Morphology after Circumferential Minimally Invasive Spine Surgery Using Lateral Lumbar Interbody Fusion and Percutaneous Pedicle Screws without Bone Grafting in the Thoracic Spine: A Retrospective Study.

Background and Objectives: This study aimed to investigate the process and morphology of thoracic and lumbosacral bone fusion in patients with adult spinal deformity (ASD) who underwent circumferential minimally invasive spine surgery (CMIS) by lateral lumbar interbody fusion (LLIF) and percutaneous pedicle screws (PPSs) without bone grafting in the thoracic spine and who have risk factors for bone fusion failure in the thoracic spine. Materials and Methods: This retrospective study included 61 patients with spinal deformities (46 women and 15 men) who underwent CMIS with LLIF and PPSs at our hospital after 2016 and completed a 3-year postoperative follow-up. The rate and morphology of bone fusion and rod fracture rate in the thoracic and lumbosacral vertebrae were evaluated. Patients were divided into the thoracic spine spontaneous bone fusion group and the bone fusion failure group. The data of various spinopelvic parameters and the incidence of complications were compared. The vertebral body conditions in the thoracic spine were classified as less degenerative (type N), osteophyte (type O), and diffuse idiopathic skeletal hyperostosis (DISH) (type D). Results: After three postoperative years, the bone fusion rates were 54%, 95%, and 89% for the thoracic, lumbar, and lumbosacral spine, respectively. Screw loosening in the thoracic vertebrae was significantly higher in the bone fusion failure group, while no significant differences were observed in the spinopelvic parameters, Oswestry Disability Index (ODI), and rate of proximal junctional kyphosis and rod fractures. Type N vertebral body condition and screw loosening were identified as risk factors for spontaneous bone fusion failure in the thoracic spine. Conclusion: This study indicated that spontaneous bone fusion is likely to be obtained without screw loosening, and even if bone fusion is not obtained, there is no effect on clinical results with the mid-term (3-year) results of CMIS without bone grafting in the thoracic spine.

Rod contour and overcorrection are risk factors of proximal junctional kyphosis after adult spinal deformity correction surgery.

PURPOSE: To examine the risk factors of proximal junctional kyphosis (PJK) after surgery for adult spinal deformity (ASD) focusing on rod contour. METHODS: Sixty-three patients with ASD who underwent surgery using lateral lumbar interbody fusion and percutaneous pedicle screws were analyzed. Fixation range was from the lower thoracic spine to the pelvis in all cases. Patients were divided into two groups. The PJK group consisted of 16 patients with PJK. The non-PJK group had 47 patients without PJK. We examined various spinopelvic parameters and parameters related to rod contour. RESULTS: Among the various spinal and pelvic parameters, those in the PJK group were significantly larger in terms of preoperative SVA and were significantly smaller in terms of postoperative "PI-LL." For parameters related to rod contour, the rod kyphotic curve at the thoracic spine in the PJK group was significantly less than that in the non-PJK group. The inclination of the pedicle screw at the upper instrumented vertebra (UIV) was significantly more cranial in the PJK group than in the non-PJK group. The kyphotic curve of the rod at the UIV was more parallel in the PJK group than in the non-PJK group. On logistic regression analysis, insufficient kyphotic curve at the thoracic spine along with UIV and overcorrection of the lumbar spine were identified as significant risk factors. CONCLUSIONS: Insufficient kyphotic curve of the rod in the thoracic spine along with UIV and overcorrection of the lumbar spine were noted as significant risk factors of PJK.

Understanding the effect of non-surgical factors in a transcranial motor-evoked potential alert: A retrospective cohort study.

BACKGROUND: Intraoperative neuromonitoring (IONM) is important for detecting neurological dysfunction, allowing for intervention and reversal of neurological deficits before they become permanent. Of the several IONM modalities, transcranial electrical stimulation of motor-evoked potential (TES-MEP) can help monitor the activity in the pyramidal tract. Surgery- and non-surgery-related factors could result in a TES-MEP alert during surgery. Once the alert occurs, the surgeon should immediately intervene to prevent a neurological complication. However, TES-MEP monitoring does not provide sufficient data to identify the non-surgery-related factors. Therefore, this study aimed to identify and describe these factors among TES-MEP alert cases. METHODS: In this multicenter study, data from 1934 patients who underwent various spinal surgeries for spinal deformities, spinal cord tumors, and ossification of the posterior longitudinal ligament of the spine from 2017 to 2019 were collected. A 70% amplitude reduction was set as the TES-MEP alarm threshold. All surgeries with alerts were categorized into true-positive (TP) and false-positive (FP) cases according to the assessment of immediate postoperative neurological deficits. RESULTS: In total, TES-MEP alerts were observed in 251 cases during surgery: 62 TP and 189 FP IONM cases. Overall, 158 cases were related to non-surgery-related factors. We observed 22 (35.5%) TP cases and 136 (72%) FP cases, which indicated cases associated with non-surgery-related factors. A significant difference was observed between the two groups regarding factors associated with TES-MEP alerts (p < 0.01). The ratio of TP and FP cases (related to non-surgery-related factors) associated with TES-MEP alerts was 13.9% (22/158 cases) and 86.1% (136/158 cases), respectively. CONCLUSIONS: Non-surgery-related factors are proportionally higher in FP than in TP cases. Although the surgeon should examine surgical procedures immediately after a TES-MEP alert, surgical intervention may not always be the best approach according to the results of this study.

Funicular pain: a case report of intermittent claudication induced by cervical cord compression.

BACKGROUND: Neurogenic origin intermittent claudication is typically caused by lumbar spinal canal stenosis. However, there are few reports of intermittent claudication caused by cervical spinal cord compression. CASE PRESENTATION: We present the case of a 75-year-old woman who presented with intermittent claudication. She had a history of lumbar spinal fusion surgery, but there was no sign of lumbar spinal stenosis. She also reported bilateral thigh pain on cervical extension. Electromyogram (EMG), posture-induced test, myelogram, and post-myelogram dynamic computed tomography (CT) were performed. Myelography and post-myelogram dynamic CT in the cervical extension position showed narrowing of the subarachnoid space; the patient reported pain in the front of the both thigh during the procedure. We performed an electromyogram (EMG), which implied neurogenic changes below the C5 level. Based on these results, we diagnosed cervical spinal cord compression and underwent laminoplasty at C4-6 including dome-like laminectomy, which significantly relieved the thigh pain and enabled her to walk for 40 minutes. CONCLUSIONS: In this case, funicular pain presented as leg pain, but was resolved by the decompression of the cervical spinal cord. Funicular pain has various characteristics without any upper extreme symptom. This often leads to errors in diagnosis and treatment. We avoid the misdiagnosis by evaluating post-myelogram dynamic CT compared between flexion and extension. In cases of intermittent claudication, clinicians should keep in mind that cervical cord compression could be a potential cause.

Can postoperative deltoid weakness after cervical laminoplasty be prevented by using intraoperative neurophysiological monitoring?

Laminoplasty, frequently performed in patients with cervical myelopathy, is safe and provides relatively good results. However, motor palsy of the upper extremities, which occurs after decompression surgery for cervical myelopathy, often reduces muscle strength of the deltoid muscle, mainly in the C5 myotome. The aim of this study was to investigate prospectively whether postoperative deltoid weakness (DW) can be predicted by performing intraoperative neurophysiological monitoring (IONM) during cervical laminoplasty and to clarify whether it is possible to prevent palsy using IONM. We evaluated the 278 consecutive patients (175 males and 103 females) who underwent French-door cervical laminoplasty for cervical myelopathy under IONM between November 2008 and December 2016 at our hospital. IONM was performed using muscle evoked potential after electrical stimulation to the brain [Br(E)-MsEP] from the deltoid muscle. Seven patients (2.5%) developed DW after surgery (2 with acute and 5 with delayed onset). In all patients, deltoid muscle strength recovered to ≥ 4 on manual muscle testing 3-6 months after surgery. Persistent IONM alerts occurred in 2 patients with acute-onset DW. To predict the acute onset of DW, Br(E)-MsEP alerts in the deltoid muscle had both a sensitivity and specificity of 100%. The PPV of persistent Br(E)-MsEP alerts had both a sensitivity and specificity of 100% for acute-onset DW. There was no change in Br(E)-MsEP in patients with delayed-onset palsy. The incidence of deltoid palsy was relatively low. Persistent Br(E)-MsEP alerts of the deltoid muscle had a 100% sensitivity and specificity for predicting a postoperative acute deficit. IONM was unable to predict delayed-onset DW. In only 1 patient were we able to prevent postoperative DW by performing a foraminotomy.

Effective treatment of delayed union of a lumbar vertebral fracture with daily administration of teriparatide in a patient with diffuse idiopathic skeletal hyperostosis.

INTRODUCTION: We herein describe a case of delayed union of a lumbar spine fracture in a 70-year-old patient with diffuse idiopathic skeletal hyperostosis (DISH). CLINICAL COURSE AND RESULT: Because he decided not to undergo surgical treatment, we provided conservative treatment with teriparatide (TPTD). Union was obtained in 2 months, and no adverse events were observed during treatment. Six months after starting the TPTD, further bone formation was observed and the lumbar instability had resolved. CONCLUSION: This is the first report of successful use of TPTD to treat delayed union of a spine fracture in a patient with DISH without surgical intervention.

Surgical site infection in spinal surgery: a comparative study between 2-octyl-cyanoacrylate and staples for wound closure.

BACKGROUND: Surgical site infection (SSI) after spinal surgery is a devastating complication. Various methods of skin closure are used in spinal surgery, but the optimal skin-closure method remains unclear. A recent report recommended against the use of metal staples for skin closure in orthopedic surgery. 2-Octyl-cyanoacrylate (Dermabond; Ethicon, NJ, USA) has been widely applied for wound closure in various surgeries. In this cohort study, we assessed the rate of SSI in spinal surgery using metal staples and 2-octyl-cyanoacrylate for wound closure. METHODS: This study enrolled 609 consecutive patients undergoing spinal surgery in our hospital. From April 2007 to March 2010 surgical wounds were closed with metal staples (group 1, n = 294). From April 2010 to February 2012 skin closure was performed using 2-octyl-cyanoacrylate (group 2, n = 315). We assessed the rate of SSI using these two different methods of wound closure. Prospective study of the time and cost evaluation of wound closure was performed between two groups. RESULTS: Patients in the 2-octyl-cyanoacrylate group had more risk factors for SSI than those in the metal-staple group. Nonetheless, eight patients in the metal-staple group compared with none in the 2-octyl-cyanoacrylate group acquired SSIs (p < 0.01). The closure of the wound in length of 10 cm with 2-octyl-cyanoacrylate could save 28 s and $13.5. CONCLUSIONS: This study reveals that in spinal surgery, wound closure using 2-octyl-cyanoacrylate was associated with a lower rate of SSI than wound closure with staples. Moreover, the use of 2-octyl-cyanoacrylate has a more time saving effect and cost-effectiveness than the use of staples in wound closure of 10 cm in length.

Rare case of survival after traumatic disruption of the cervical spine with combined complete spinal cord injury and bilateral vertebral arterial breakdown in an 18-month-old patient.

Complete cervical disruption is a rare and lethal injury secondary to high-energy trauma. Bilateral vertebral arterial breakdown is also a rare and lethal injury. This is the first reported clinical case of an 18-month-old girl who survived after combined cervical spinal cord disruption and bilateral vertebral arterial breakdown. Although she developed cardiopulmonary arrest at the accident site, resuscitation by a bystander, early fluid resuscitation, appropriate respiratory management, and subsequent surgical stabilization resulted in survival and preservation of higher cortical functions. She underwent surgery 1 week after hospitalization; her cervical spine was stabilized by posterior fixation using pedicle screws and transarticular screws. After the operation, the burst vertebra was gradually remodeled. Approximately 4 months later, she was transferred to a rehabilitation facility. Ten years later, she is attending to an elementary school, and she is able to speak and operate a wheelchair using a portable respiratory organ. We herein report an exceedingly rare case of cervical cord injury involving a combination of disruption of the cervical spine and bilateral vertebral arterial breakdown in a young child.

Lumbar lordosis restoration by minimally invasive short-segment fusion with anterior column realignment for adult spinal deformity: minimum 2-year follow-up.

OBJECTIVE: The efficacy of anterior column realignment (ACR) remains relatively unclear, possibly because some safety concerns have limited its adoption and extensive evaluation. The authors aimed to study whether a minimally invasive surgery (MIS) triad consisting of ACR, lateral lumbar interbody fusion, and percutaneous pedicle screw fixation in a select group of adult spinal deformity (ASD) patients helps shorten fusion length without compromising clinical and radiographic outcomes over a minimum 2-year follow-up period. METHODS: A series of 61 ASD patients (mean age 72.8 years) with pelvic incidence (PI) - lumbar lordosis (LL) (PI-LL) mismatch > 10° underwent the short-segment MIS triad (mean fusion length 3.0 levels) as a single-stage operation with a mean operative time and estimated blood loss of 157 minutes and 127 mL, respectively. Exclusion criteria were 1) thoracic scoliosis as the main deformity, 2) thoracolumbar junction kyphosis > 25°, 3) ankylosed facet joints, and 4) previous spinal fusion surgery. Seven patients, who needed fusion to be extended to S1, underwent mini-open transforaminal lumbar interbody fusion at L5-S1. RESULTS: The segmental disc angle at the ACR level more than quintupled, averaging from 2.9° preoperatively to 18.9° at the latest follow-up (p < 0.0001). LL, in turn, nearly doubled from 17.0° to 32.8° (p < 0.0001) and PI-LL decreased by nearly half from 28.8° to 13.2° (p < 0.0001). At the same time, other spinopelvic deformity parameters as well as Oswestry Disability Index (ODI) scores significantly improved. Patients were divided into two groups at the latest postoperative evaluation: 36 patients whose PI-LL improved to < 10° and 25 patients who maintained a PI-LL mismatch > 10°. Binary logistic regression revealed preoperative PI-LL mismatch as the only factor that significantly influenced this dichotomous separation postoperatively. Receiver operating characteristic curve analysis identified the critical preoperative mismatch of 26.4° with 68% sensitivity and 84% specificity. Despite this different radiographic consequence, the two groups had an equally successful clinical outcome with no significant difference in ODI scores. CONCLUSIONS: As long as the ASD characteristics are consistent with the authors' exclusion criteria, the short-segment MIS triad served as an excellent surgical option in the patients with preoperative PI-LL mismatch < 26.4°, but the technique also worked well even in those with a mismatch > 26.4°, although ideal spinopelvic alignment targets were not necessarily achieved in these patients.

Electrophysiological diagnosis using sensory nerve action potential for the intraforaminal and extraforaminal L5 nerve root entrapment.

BACKGROUND: The diagnosis of lumbar intraforaminal and extraforaminal stenosis (lumbar foraminal stenosis) is sometimes difficult. However, sensory nerve action potential (SNAP) decreases in amplitude when the lesion is at or distal to the dorsal root ganglion. Therefore, the amplitude of SNAP with lumbar foraminal stenosis should be decreased. In this cohort study, the usefulness of SNAP for the preoperative diagnosis of L5/S foraminal stenosis was assessed. METHODS: In 63 patients undergoing unilateral L5 radiculopathy, bilateral SNAPs were recorded for the superficial peroneal nerve (L5 origin). The patients were divided into two groups according to the results of imaging examinations. Group A (37 patients) included patients whose lesion was located only at the intraspinal canal. In group B (26 patients), the lesion was located only at the intra- or extraforaminal area. All patients received surgery and the symptoms were diminished. The ratios of the amplitudes of SNAPs on the affected side to that on the unaffected side were compared between groups A and B. RESULTS: SNAPs could not be elicited bilaterally in four patients. The amplitude ratio for group B (median 0.42, max 1.17, min 0) was significantly lower than that in group A (median 0.85, max 1.43, min 0) (p < 0.001 by Mann-Whitney U test). Using a cut-off value of 0.5 for the amplitude ratio, the sensitivity for the diagnosis of lumbar foraminal stenosis was 91.3 % with a specificity of 85.7 %. CONCLUSIONS: Measurement of SNAP could be useful to diagnose a unilateral L5/S foraminal stenosis.

Usefulness of multi-channels in intraoperative spinal cord monitoring: multi-center study by the Monitoring Committee of the Japanese Society for Spine Surgery and Related Research.

OBJECT: The purpose of this study is to analyze the data in terms of the number of channels employed to examine the usefulness of multi-channels in intraoperative spinal cord monitoring. METHODS: The prerequisites for inclusion in the baseline data were as follows: (1) cases in which only CMAP monitoring was conducted; (2) cases in which monitoring was conducted under the same stimulation condition and the recording condition. Cases where inhalation anesthesia was used or muscle relaxants were used as maintenance anesthesia was excluded from the baseline data. Of the 6,887 cases, 884 cases met the criteria. The items examined for each of the different numbers of channels were the sensitivity and specificity, the false positive rate, the false negative rate, and the coverage rate of postoperative motor deficit muscles. RESULT: To examine these two items in terms of the number of channels, the 4-channel group had lower sensitivity and specificity scores compared with the 8- and 16-channel groups (4 channels 73/93 %, 8 channels 100/97 %, 16 channels 100/95 %). Only four channels were derived for these cases and the coverage of postoperative motor deficit muscles was 38 % with only 30 out of the 80 postoperative motor deficit muscles in total being monitored. In the 8-channel group, it was 60 % with 12 of the 20 postoperative motor deficit muscles being monitored. The 16-channel group had 100 % coverage rate of postoperative motor deficit muscles. CONCLUSION: We suggest that multi-channel monitoring of at least eight channels is desirable for intraoperative spinal cord monitoring.

Surgical Approaches and Short-Term Results of Circumferential Minimally Invasive Correction Surgery for Adult Idiopathic Scoliosis.

OBJECTIVE: We present the surgical approaches and short-term (2 years postoperative) results pertaining to circumferential minimally invasive spine surgery (CMIS) with lateral lumbar interbody fusion (LLIF) and percutaneous pedicle screw application for adult idiopathic scoliosis (AS). METHODS: We enrolled eight patients with AS who underwent CMIS (2018-2020) and examined the number of fused levels, upper instrumented vertebra, lower instrumented vertebra, number of LLIF-treated segments, number of preoperative intervertebral fusions, intraoperative blood loss, operative time, various spinopelvic parameters, Oswestry Disability Index, low back pain, visual analog scale (VAS), leg VAS, bone fusion rate, and perioperative complications. RESULTS: The upper instrumented vertebra was T4, T7, T8, and T9 in two cases, whereas lower instrumented vertebra was the pelvis in all the cases. The average numbers of fixed vertebrae and segments that underwent LLIF were 13.3 ± 2.0 and 4.6 ± 0.7, respectively. All spinopelvic parameters improved significantly after surgery (thoracic kyphosis: P < 0.05, lumbar lordosis, cobb angle, pelvic tilt, pelvic incidence-lumbar lordosis, sagittal vertical axis: P < 0.001), and good alignment was achieved. The Oswestry Disability Index and VAS scores improved significantly (P < 0.001). The bone fusion rates achieved in the lumbosacral and thoracic spine were 100% and 88%, respectively. Only 1 patient showed postoperative coronal imbalance. CONCLUSIONS: The 2-year postoperative results of CMIS for AS were good, and spontaneous bone fusion was confirmed in the thoracic spine without bone grafting. In this procedure, sufficient intervertebral release with LLIF and a percutaneous pedicle screw device translation technique enabled adequate global alignment correction. Therefore, correcting the global imbalance of the coronal and sagittal planes is more crucial than correcting scoliosis.

New Effective Intraoperative Techniques for the Prevention of Coronal Imbalance after Circumferential Minimally Invasive Correction Surgery for Adult Spinal Deformity.

This study aimed to devise measures and investigate their effect on coronal imbalance (CI) after circumferential minimally invasive correction surgery (CMIS) with lateral lumbar interbody fusion and percutaneous pedicle screw for adult spinal deformity (ASD). A total of 115 patients with ASD who underwent CMIS from the lower thoracic spine to the ilium were included. Patients were stratified based on the distance between the spinous process of the upper instrumented vertebra and central sacrum vertical line (UIV-CSVL) after the first intraoperative rod application into groups P (UIV-CSVL > 10 mm, n = 50) and G (UIV-CSVL < 10 mm, n = 65). Measures to correct postoperative CI introduced during surgery, preoperative and postoperative UIV-CSVL, and changes in UIV-CSVL after various measures (ΔUIV-CSVL) were investigated in group P. Rod rotation (RR), S2 alar-iliac screw distraction (SD), and kickstand-rod (KR) technique were performed in group P. Group P was further divided into group RR (n = 38), group SD (RR and SD) (n = 7), and group KR (RR and KR) (n = 5); the ΔUIV-CSVLs were 13.9 mm, 20.1 mm, and 24.4 mm in these three groups, respectively. Postoperative C7-CSVL < 10 mm was achieved in all three correction groups. In conclusion, our measures enabled sufficient correction of the UIV-CSVL and are useful for preventing CI after CMIS for ASD.

Visualization of axonal and volume currents in median nerve compound action potential using magnetoneurography.

OBJECTIVE: Reconstruct compound median nerve action currents using magnetoneurography to clarify the physiological characteristics of axonal and volume currents and their relationship to potentials. METHODS: The median nerves of both upper arms of five healthy individuals were investigated. The propagating magnetic field of the action potential was recorded using magnetoneurography, reconstructed into a current, and analyzed. The currents were compared with the potentials recorded from multipolar surface electrodes. RESULTS: Reconstructed currents could be clearly visualized. Axonal currents flowed forward or backward in the axon, arcing away from the depolarization zone, turning about the subcutaneous volume conductor, and returning to the depolarization zone. The zero-crossing latency of the axonal current was approximately the same as the peak of its volume current and the negative peak of the surface electrode potential. Volume current waveforms were proportional to the derivative of axonal ones. CONCLUSIONS: Magnetoneurography allows the visualization and quantitative evaluation of action currents. The currents in axons and in volume conductors could be clearly discriminated with good quality. Their properties were consistent with previous neurophysiological findings. SIGNIFICANCE: Magnetoneurography could be a novel tool for elucidating nerve physiology and pathophysiology.

Magnetoneurography to investigate the mechanisms underlying the P9 far-field potential.

OBJECTIVE: The mechanism underlying the generation of P9 far-field somatosensory evoked potentials (SEPs) is unresolved. Accordingly, we used magnetoneurography to visualize the current distribution in the body at the P9 peak latency and elucidate the origin of P9 generation. METHODS: We studied five healthy male volunteers without neurological abnormalities. We recorded far-field SEPs after median nerve stimulation at the wrist to identify the P9 peak latency. Using magnetoneurography, we recorded the evoked magnetic fields in the whole body under the same stimulus conditions as the SEP recording. We analyzed the reconstructed current distribution at the P9 peak latency. RESULTS: At the P9 peak latency, we observed the reconstructed current distribution dividing the thorax into two parts, upper and lower. Anatomically, the depolarization site at the P9 peak latency was distal to the interclavicular space and at the level of the second intercostal space. CONCLUSIONS: By visualizing the current distribution, we proved that P9 peak latency originates in the change in volume conductor size between the upper and lower thorax. SIGNIFICANCE: We clarified that magnetoneurography analysis is affected by the current distribution due to the junction potential.