Clinical differences in preoperative symptoms and surgical outcomes between early and late-teen patients with Lenke type 5C adolescent idiopathic scoliosis.

PURPOSE: This study aimed to compare the clinical features and postoperative outcomes in patients with Lenke type 5C AIS in the early and late teens. METHODS: The study included eligible patients with AIS aged < 20 years with Lenke type 5C curves who underwent selective thoracolumbar/lumbar (TL/L) fusion. The patients were divided into two groups according to the age: younger (11-15 years) and older (16-19 years). Demographic data, radiographic parameters, and 22-item scoliosis research society questionnaire (revised) (SRS-22r) scores were compared. RESULTS: Seventy-three (female: 69, male: 4, mean age: 15.1 years) patients were included. There were 45 and 28 patients in the younger and older groups, respectively. The older group exhibited a significantly smaller TL/L curve than the younger group, whereas no between-group differences were identified regarding curve flexibility and fusion length. The change in coronal balance and subjacent disc angle from preoperative to 2 years after surgery was significantly greater in the younger group, although each curve was equally corrected. Preoperative SRS-22r scores in the older group were significantly worse; however, they improved to the level of the younger group at 2 years after surgery. Postoperative coronal malalignment was observed in six patients (21.4%) in the older group, whereas no cases in the younger group (p < 0.05). CONCLUSION: In patients with Lenke type 5C AIS, we showed that late teens had significantly worse SRS-22r scores than did early teens. Postoperative coronal malalignment was frequently observed in the late teens due to the reduced ability of compensation by subjacent disc wedging.

Deep learning-based prediction model for postoperative complications of cervical posterior longitudinal ligament ossification.

PURPOSE: Postoperative complication prediction helps surgeons to inform and manage patient expectations. Deep learning, a model that finds patterns in large samples of data, outperform traditional statistical methods in making predictions. This study aimed to create a deep learning-based model (DLM) to predict postoperative complications in patients with cervical ossification of the posterior longitudinal ligament (OPLL). METHODS: This prospective multicenter study was conducted by the 28 institutions, and 478 patients were included in the analysis. Deep learning was used to create two predictive models of the overall postoperative complications and neurological complications, one of the major complications. These models were constructed by learning the patient's preoperative background, clinical symptoms, surgical procedures, and imaging findings. These logistic regression models were also created, and these accuracies were compared with those of the DLM. RESULTS: Overall complications were observed in 127 cases (26.6%). The accuracy of the DLM was 74.6 ± 3.7% for predicting the overall occurrence of complications, which was comparable to that of the logistic regression (74.1%). Neurological complications were observed in 48 cases (10.0%), and the accuracy of the DLM was 91.7 ± 3.5%, which was higher than that of the logistic regression (90.1%). CONCLUSION: A new algorithm using deep learning was able to predict complications after cervical OPLL surgery. This model was well calibrated, with prediction accuracy comparable to that of regression models. The accuracy remained high even for predicting only neurological complications, for which the case number is limited compared to conventional statistical methods.

Is histopathological synovitis score a predictor of postoperative requirement for additional or alternative drug treatment in the patients with rheumatoid arthritis?

OBJECTIVES: Histopathological synovitis scoring is useful for assessing activity in patients with rheumatoid arthritis (RA) at sampling, but it is unclear whether it can be a predictor of future drug treatment. The purpose of this study was to examine whether histopathological synovitis score is a predictor of postoperative requirement for additional or alternative drug treatment after total knee arthroplasty (TKA). METHODS: Thirty patients with RA in whom synovial samples were obtained during TKA were included. Patients were divided into the drug treatment enhanced group (EG), which included patients who needed additional or alternative drug treatment within 1 year after TKA, and the drug treatment maintenance group (MG). The Rooney synovitis score (RSS) was compared between groups. Logistic regression analysis was performed to clarify prognostic factors for postoperative drug treatment change. RESULTS: The total RSS was significantly higher in the EG than in the MG (29.3 vs 15.1; P < .001). Multivariate analysis showed that total RSS and swollen joint counts were independent variable associated with postoperative requirement for additional or alternative drug treatment (P < .05). CONCLUSIONS: Histopathological synovitis scoring may predict requirement for additional or alternative drug treatment in patients with RA after TKA.

The impact of diabetes mellitus on spinal fracture with diffuse idiopathic skeletal hyperostosis: A multicenter retrospective study.

BACKGROUND: Patients with diffuse idiopathic skeletal hyperostosis (DISH) are susceptible to spinal column injuries with neurological deterioration. Previous studies indicated that the prevalence of diabetes mellitus (DM) in patients with DISH was higher than that in patients without DISH. This study investigates the impact of DM on surgical outcomes for spinal fractures in patients with DISH. METHODS: We retrospectively evaluated 177 spinal fractures in patients with DISH (132 men and 45 women; mean age, 75 ± 10 years) who underwent surgery from a multicenter database. The subjects were classified into two groups according to the presence of DM. Perioperative complications, neurological status by Frankel grade, mortality rate, and status of surgical site infection (SSI) were compared between the two groups. RESULTS: DM was present in 28.2% (50/177) of the patients. The proportion of men was significantly higher in the DM group (DM group: 86.0% vs. non-DM group: 70.1%) (p = 0.03). The overall complication rate was 22.0% in the DM group and 19.7% in the non-DM group (p = 0.60). Poisson regression model revealed that SSI was significantly associated with DM (DM group: 10.0% vs. non-DM group: 2.4%, Relative risk: 4.5) (p = 0.048). Change in neurological status, mortality rate, instrumentation failure, and nonunion were similar between both groups. HbA1c and fasting blood glucose level (SSI group: 7.2% ± 1.2%, 201 ± 67 mg/dL vs. non-SSI group: 6.6% ± 1.1%, 167 ± 47 mg/dL) tended to be higher in patients with SSI; however, there was no significant difference. CONCLUSIONS: In spinal fracture in patients with DISH, although DM was an associated factor for SSI with a relative risk of 4.5, DM did not negatively impact neurological recovery. Perioperative glycemic control may be useful for preventing SSI because fasting blood glucose level was high in patients with SSI.

The characteristics of the young patients with cervical ossification of the posterior longitudinal ligament of the spine: A multicenter cross-sectional study.

BACKGROUND: Ossification of the posterior longitudinal ligament of the spine (OPLL) is characterized by heterotopic bone formation in the posterior longitudinal ligament of the spine. Although the patients with OPLL are more common in the 60s and 70s, we know that there are markedly young patients (e.g., early 40s). However, to the best of our knowledge, there is few reports characterize young patients with cervical OPLL in terms of the imaging features, subjective symptoms, and ADL problems. METHODS: This is the multicenter cross-sectional study. Two hundred and thirty-seven Japanese symptomatic patients with cervical OPLL confirmed by standard X-rays collected from 16 institutions belonging to the Japanese Multicenter Research Organization for Ossification of the Spinal Ligament formed by the Japanese Ministry of Health, Labor and Welfare were recruited. Whole spine CT data as well as demographic data such as age, gender, patients-based evaluations, and the 36-item Short Form Health Survey (SF-36) were evaluated. RESULTS: Young group (≦ 45 years old) consisted of 23 patients (8 females and 15 males), accounting for 9.7% of the total. Their characteristics were high body mass index (BMI), significant involvement of trauma in the onset and deterioration of symptoms, and the predominance of thoracic OPLL. The patient-based evaluations did not show a significant difference between the young and non-young groups, or between the genders in the young group except for bodily pain (BP) of SF-36. Female patients in young group had significantly lower BP score of SF-36 than that of male in young group. CONCLUSIONS: Characteristics of young patients with cervical OPLL were high BMI, significant involvement of trauma in the onset and deterioration of symptoms, lower BP score of SF-36 in female, and the predominance of thoracic OPLL.

Differences of 2-year longitudinal changes of locomotive syndrome among patients treated with thoracolumbar interbody fusion, total hip arthroplasty, and total knee arthroplasty for degenerative diseases.

OBJECTIVES: To clarify the longitudinal changes in patients with preoperative Stage-3 locomotive syndrome (LS) according to different types of surgeries, we investigated the changes in the LS stage in patients who underwent surgery for degenerative musculoskeletal diseases. METHODS: A prospective cohort study was conducted on 168 patients with degenerative diseases [46 spinal deformities treated with thoracolumbar interbody fusion (T/LIF), 86 hips with osteoarthritis treated with total hip arthroplasty (THA), and 36 knees with osteoarthritis treated with total knee arthroplasty (TKA)]. The results for the LS stage, stand-up test, two-step test, and 25-question Geriatric Locomotive Function Scale (GLFS-25) were evaluated preoperatively and at 6 months, 1 year, and 2 years postoperatively. RESULTS: Preoperatively, most patients had Stage-3 LS (89.1, 90.8, and 80.6% in the T/LIF, THA, and TKA groups, respectively). At 2 years postoperatively, the Stage-3 LS improved in 41.5, 75.6, and 55.2% of patients in the T/LIF, THA, and TKA groups, respectively. All groups showed similar improvements in the two-step test. The THA group showed the best result in the GLFS-25. CONCLUSIONS: LS stage improved in different patterns over 2 years postoperatively and the LS risk test revealed differences in postoperative movement ability according to the type of surgery.

Predictors for quality of life improvement after acute osteoporotic vertebral fracture: results of post hoc analysis of a prospective randomized study.

PURPOSE: No study has investigated the clinical and radiographic risk factors for the deterioration of quality of life (QOL) beyond 6 months after osteoporotic vertebral fractures (OVF). The purpose of this study was to identify the predictors associated with poor QOL improvement after OVF. METHODS: This post hoc analysis included 166 women aged 65-85 years with acute 1-level OVFs. For the patient-reported outcome measures, scores on the European Quality of Life-5 Dimensions (EQ-5D) scale, and visual analogue scale (VAS) for low back pain were used. Lateral radiography at 0, 12, and 48 weeks and magnetic resonance imaging (MRI) at enrollment and at 48 weeks were performed. The associations between baseline variables with change scores for EQ-5D were investigated using a multiple linear regression model. RESULTS: Univariate analysis showed that time since fracture, EQ-5D score, and VAS for low back pain at 0 week showed significant association with increased EQ-5D score from 0 to 48 weeks. According to the multiple regression analysis, the following equation was obtained: increased EQ-5D score from 0 to 48 weeks = 1.305 - 0.978 × EQ-5D at 0 week - 0.021 × VAS for low back pain at 0 week - 0.006 × age + (fluid-intensity T2-weighted MR image patterns: - 0.037, except for fluid-intensity T2-weighted MR image patterns: + 0.037). CONCLUSION: In conclusion, older patients with severe low back pain and fluid-intensity T2-weighted MR image patterns were more likely to have lower QOL improvements after OVFs and may therefore need extra support to improve QOL.

Risk factors for subsequent vertebral fracture after acute osteoporotic vertebral fractures.

PURPOSE: To investigate the incidence and characteristics of subsequent vertebral fracture after osteoporotic vertebral fractures (OVFs) and identify risk factors for subsequent vertebral fractures. METHODS: This post-hoc analysis from a prospective randomized multicenter trial included 225 patients with a 48-week follow-up period. Differences between the subsequent and non-subsequent fracture groups were analyzed. RESULTS: Of the 225 patients, 15 (6.7%) had a subsequent fracture during the 48-week follow-up. The annual incidence of subsequent vertebral fracture after fresh OVFs in women aged 65-85 years was 68.8 per 1000 person-years. Most patients (73.3%) experienced subsequent vertebral fractures within 6 months. At 48 weeks, European Quality of Life-5 Dimensions, the Japanese Orthopedic Association Back Pain Evaluation Questionnaire pain-related disorder, walking ability, social life function, and lumbar function scores were significantly lower, while the visual analog scale (VAS) for low back pain was higher in patients with subsequent fracture. Cox proportional hazards analysis showed that a VAS score ≥ 70 at 0 weeks was an independent predictor of subsequent vertebral fracture. After adjustment for history of previous fracture, there was a ~ 67% reduction in the risk of subsequent vertebral fracture at the rigid-brace treatment. CONCLUSION: Women with a fresh OVF were at higher risk for subsequent vertebral fracture within the next year. Severe low back pain and use of soft braces were associated with higher risk of subsequent vertebral fractures. Therefore, when treating patients after OVFs with these risk factors, more attention may be needed for the occurrence of subsequent vertebral fractures. LEVEL OF EVIDENCE: III.

Locomotive syndrome: Prevalence, surgical outcomes, and physical performance of patients treated to correct adult spinal deformity.

BACKGROUND: Locomotive syndrome (LS) was proposed by the Japanese Orthopedic Association and refers to a scenario in which imminent future nursing care services will be required by elderly adults to manage the functional deterioration of their locomotive organs. It is a social imperative to clarify the risk factors and treatment strategy for LS. However, the relationship between LS and adult spinal deformity (ASD) in those who are treated with spinal corrective surgery remains largely unknown. METHODS: Forty consecutive patients who had ASD and underwent spinal surgery for their disorder were included in this study. Locomotive dysfunction was evaluated using the 25-item Geriatric Locomotive Function Scale-25 (GLFS-25) questionnaire and physical performance tests including the one-legged standing test, the two-step test, the stand-up test, the handgrip strength, and gait speed test which were measured preoperatively, 6 months after surgery, and 1 year after surgery. RESULTS: Of the patients with ASD treated surgically, 95% of them had LS preoperatively and LS prevalence decreased significantly 1 year after surgery by 67.5% compared with the preoperative rate. Among physical performance tests, the walking stride and one-legged standing test improved significantly after spinal corrective surgery. The GLFS-25 items for the domains of pain, mobility, and domestic life improved overall postoperatively, whereas items in the self-care domain did not and the item for difficulty in putting on and taking off trousers and pants worsened. CONCLUSIONS: Spinal corrective surgery significantly improved physical performance tests as well as the frequency and severity of LS in patients with ASD. However, some GLFS-25 items can worsen after surgery and require attention.

Expert consensus on surgical treatment for adolescent idiopathic scoliosis in Japan.

BACKGROUND: Surgical treatment for adolescent idiopathic scoliosis (AIS) has changed significantly with the advent of new medical devices and surgical procedures. Today, pre- and postoperative management differs widely between institutions. The purpose of this study is to establish consensus regarding the surgical management of AIS in Japan through the use of a questionnaire survey of experienced spine deformity surgeons. METHODS: From February to March 2020, experienced spine deformity surgeons who perform more than 25 cases of AIS surgery annually were asked to respond to a questionnaire request regarding AIS surgical management formulated by the International Affairs Committee of the Japanese Scoliosis Society. For each of the questions, consensus was achieved upon a 70% agreement among respondents. RESULTS: Responses were received from 25 of the 32 (78%) experienced spine deformity surgeons. The average age of the responding surgeons was 52 years with an average practice experience of 28 year. Consensus was achieved on 74 (76%) of the 97 aspects of care presented in the questionnaire and is broken down as follows: 12 of 17 items for preoperative management, all 5 items for perioperative management, 11 of 14 items for surgical technique, 9 of 15 items for implant selection, 6 of 8 items for bone grafting, 7 of 10 items for blood conservation, 5 of 7 items for postoperative management, all 17 items for postoperative evaluation, and 2 of 4 items for aftercare. CONCLUSIONS: Expert consensus was achieved on 74 aspects of the surgical management of AIS in Japan. In implant selection and aftercare, consensus was obtained in less than 70% of the aspects, revealing differences in AIS management between institutions. These findings on AIS surgery in Japan, informed by expert opinion, will conceivably help spine deformity surgeons determine appropriate surgical management of AIS.

Predictors of residual low back pain after acute osteoporotic compression fracture.

BACKGROUND: Studies on the clinical and radiographic risk factors for the residual low back pain beyond 6 months after osteoporotic vertebral fractures (OVFs) are lacking. Hence, this study aimed to characterize a patient population with residual low back pain 48 weeks after acute OVFs and to identify the risk factors associated with residual low back pain. METHODS: This prospective multicenter study included 166 female patients aged 65-85 years with acute one-level OVFs. We defined the residual low back pain as visual analog scale (VAS) for low back pain ≥3.5 at 48 weeks in this study, as VAS score ≥3.5 is used to describe moderate or severe pain. Thus, outcome and risk factor analyses were performed by comparing patients with VAS scores <3.5 and ≥ 3.5. In the radiographic analysis, the anterior vertebral body compression percentage was measured at 0, 12, and 48 weeks. Magnetic resonance imaging (MRI) was performed at enrollment and 48 weeks. RESULTS: Of the 166 patients analyzed, 58 complained of residual low back pain at 48 weeks after OVFs. At 0 weeks, the VAS score was significantly higher, and the JOABPEQ mental health score and anterior vertebral body compression percentage were significantly lower in patients with persistent pain 48 weeks after OVFs. The independent risk factors in the acute phase for persistent pain 48 weeks after OVFs were a high VAS score, MRI T2 fluid-intensity image pattern, and a lower anterior vertebral body compression percentage. CONCLUSIONS: Severe low back pain, MRI T2 fluid-intensity image pattern, and severe vertebral body collapse in the acute phase were significant risk factors for residual low back pain 48 weeks after OVFs. Patients with acute OVFs who have these risk factors should be carefully monitored for the possible development of residual chronic low back pain.

Risk factors for delayed diagnosis of spinal fracture associated with diffuse idiopathic skeletal hyperostosis: A nationwide multiinstitution survey.

BACKGROUND: Patients with DISH are susceptible to spinal fractures and subsequent neurological impairment, including after minor trauma. However, DISH is often asymptomatic and fractures may have minimal symptoms, which may lead to delayed diagnosis. The purpose of this study was to identify risk factors for delayed diagnosis of spinal fractures in patients with diffuse idiopathic skeletal hyperostosis (DISH). METHODS: The subjects were 285 patients with DISH surgically treated at 18 medical centers from 2005 to 2015. Cause of injury, imaging findings, neurological status at the times of injury and first hospital examination, and the time from injury to diagnosis were recorded. A delayed diagnosis was defined as that made >24 h after injury. RESULTS: Main causes of injury were minor trauma due to a fall from a standing or sitting position (51%) and high-energy trauma due to a fall from a high place (29%) or a traffic accident (12%). Delayed diagnosis occurred in 115 patients (40%; 35 females, 80 males; mean age 76.0 ± 10.4 years), while 170 (60%; 29 females, 141 males; mean age 74.6 ± 12.8 years) had early diagnosis. Delayed group had a significantly higher rate of minor trauma (n = 73, 63% vs. n = 73, 43%), significantly more Frankel grade E (intact neurological status) cases at the time of injury (n = 79, 69% vs. n = 73, 43%), and greater deterioration of Frankel grade from injury to diagnosis (34% vs. 8%, p < 0.01). In multivariate analysis, a minor trauma fall (OR 2.08; P < 0.05) and Frankel grade E at the time of injury (OR 2.29; P < 0.01) were significantly associated with delayed diagnosis. CONCLUSION: In patients with DISH, it is important to keep in mind the possibility of spinal fracture, even in a situation in which patient sustained only minor trauma and shows no neurological deficit. This is because delayed diagnosis of spinal fracture can cause subsequent neurological deterioration.

Indications and limitations of minimally invasive lateral lumbar interbody fusion without osteotomy for adult spinal deformity.

PURPOSE: The global alignment and proportion (GAP) score was recently developed to consider proportional analysis of spinopelvic alignment and has been indicated for setting surgical goals to decrease the prevalence of mechanical complications. The goal of this study was to clarify the limitations and problems with spinal corrective surgery with minimally invasive lateral lumbar interbody fusion (LLIF) without osteotomy using GAP score, and to establish a preoperative radiographical evaluation to understand the necessity for three-column osteotomy. METHODS: We included data from 57 consecutive patients treated with spinal corrective surgery with LLIF and without Schwab grade 3-6 osteotomy for ASD. To evaluate flexibility of the pelvis and lumbar spine, we examined full-length lateral radiographs with patients standing and prone. Correlations between pre- and postoperative radiographic parameters and GAP score were determined. RESULTS: Most patients achieved a sufficiently ideal lumbar lordosis (87.7%), but ideal sacral slope (SS) was achieved in only 50.8% of patients. Preoperative prone SS showed a significant positive correlation with postoperative SS and a significant negative correlation with GAP score. Patients whose preoperative prone SS was larger than pelvic incidence × 0.59-7.5 tended to achieve proportioned spinopelvic alignment by using LLIF. CONCLUSIONS: The cause of poor outcome of GAP score for ASD corrective surgery with LLIF without osteotomy is a postoperative small SS. Preoperative prone SS is useful for predicting postoperative SS. When preoperative SS in prone patients is relatively small to ideal as calculated using PI, osteotomy or other correctors should be considered to achieve satisfactory spinopelvic parameters. LEVEL OF EVIDENCE: III. These slides can be retrieved under Electronic Supplementary Material.

Factors affecting postoperative mortality of patients with insufficient union following osteoporotic vertebral fractures and impact of preoperative serum albumin on mortality.

ABTSRACT: BACKGROUND: Numerous comparative studies of surgical procedures have focused on clinical and radiographical outcomes, as well as the effect of bone fragility on the outcome of spinal surgery; however, insights concerning a risk of mortality or morbidity have been limited. Additionally, the effect of surgical therapy on survival after vertebral compression fractures remains controversial. Our aim was to evaluate the preoperative factors that affected the long-term survival of patients who underwent spinal surgery for an insufficient union following osteoporotic vertebral fractures (OVF) and to determine postoperative mortality. METHODS: We retrospectively reviewed the cases of 105 consecutive patients who underwent spinal surgery for OVF. Mortality was estimated using the Kaplan-Meier method and a log-rank test. The preoperative backgrounds of patients were analyzed to determine which risk factors led to death among the OVF cases. Kaplan-Meier curves were used to estimate survival based on preoperative albumin levels of ≤3.5 g/dL (hypoalbuminemia) versus > 3.5 mg/dL. RESULTS: The mean follow-up time was 4.1 ± 0.8 years. Two years after surgery, percentage of patients who had died was 15%. The VAS scores and modified Frankel classification were significantly improved one year after surgery. The ratio of male-to-female was significantly higher for patients with OVF who died than for those who were still alive. No significant difference in mortality was observed among surgical procedures for OVF. The univariate analysis showed that male gender, serum albumin < 3.5 g/dl, creatinine clearance< 60 mg/dl, and the American Society of Anesthesiologists classificat0ion ≥3 were significant risk factors for postoperative mortality. Multivariate analysis revealed that only serum albumin ≤3.5 g/dL was a significant risk factor for long-term postoperative mortality of patients with OVF. CONCLUSIONS: Preoperative hypoalbuminemia was associated with postoperative mortality following surgery for OVF. LEVEL OF EVIDENCE: Level 3.

The characteristics of the patients with radiologically severe cervical ossification of the posterior longitudinal ligament of the spine: A CT-based multicenter cross-sectional study.

BACKGROUND: Ossification of the posterior longitudinal ligament of the spine (OPLL) is characterized by heterotopic bone formation in the posterior longitudinal ligament of the spine. We know that the size and distribution of the ossified lesions in patients with OPLL are different in each case. However, the characteristics of the patients with radiologically severe cervical OPLL remain unknown. METHODS: The participants of our study were symptomatic patients with cervical OPLL who were diagnosed by standard radiographs of the cervical spine. Whole-spine CT data and demographic data such as age and sex were obtained from 20 institutions belonging to the Japanese Multicenter Research Organization for Ossification of the Spinal Ligament. According to the number of the levels involved by OPLL, we stratified the patients into two subgroups: severe group (S-group) and non-severe group (NS-group) to delineate the characteristics of radiologically severe patients with cervical OPLL. We also evaluated the most compressed level and the degree of occupying ratio of cervical spinal canal by OPLL at the most compressed level. RESULTS: A total of 234 patients with a mean age of 65 years were recruited. The S-group consisted of 48 patients (21%, 12 females and 36 males) and the NS-group consisted of 92 patients (79%, 22 females and 70 males). The mean age of males in the S-group (68 years old) was significantly higher than that of males in the NS-group (64 years old); however there was no significant difference in the mean age in females between the S-group (69 years old) and the NS-group (66 years old). No significant difference of body mass index, ossification of the nuchal ligament-positivity and presence of diabetes mellitus were found between the S- and the NS-group. CONCLUSIONS: It is likely that the manner of extension of cervical OPLL is different between male and female patients.

Changes in pelvic anatomy after long corrective fusion using iliac screws for adult spinal deformity.

PURPOSE: Long fusion to the sacrum with iliac screws can decrease pelvic incidence (PI). Considering the physiological range of movement of the sacroiliac joint, this decrease may be relatively extreme. The purpose of the study was to determine changes in pelvic morphology after orthopedic surgery using long fusion with iliac screws, and examine the relationship between changes in PI and morphology. METHODS: We included data from 80 consecutive patients who underwent corrective surgery for adult spine deformity (72 female and 8 male; mean age: 71.1 years). We examined preoperative and early postoperative full-standing X-ray images and pelvic computed tomography of the patients and compared the following: (1) pre- and postoperative pelvic measurements including PI, (2) correlations between change of PI, iliac angle, and distance between posterior superior iliac spines (DPSIS). RESULTS: After surgery, PI decreased significantly (- 3.3°, 95% confidence interval [95%CI] - 4.3° to - 2.3°, P < 0.01) and DPSIS increased significantly (+ 2.7 mm, 95%CI 1.7 to 3.8 mm, P < 0.01). By contrast, iliac angle decreased significantly (- 1.4°, 95%CI - 2.1° to - 0.7°, P < 0.01). There were significant correlations between changes of PI and iliac angle (r = 0.34, P < 0.01) and between changes of DPSIS and iliac angle (r = - 0.44, P < 0.01). CONCLUSIONS: We observed changes in pelvic morphology associated with spinal pelvic correction surgery using iliac screws and changes in pelvic incidence related to these changes in pelvic morphology. We recommend selecting pelvic anchors and surgical procedures considering potential movement of the sacroiliac joint. These slides can be retrieved under Electronic Supplementary Material.

Spinal fractures in patients with Diffuse idiopathic skeletal hyperostosis:A nationwide multi-institution survey.

BACKGROUND: Diffuse idiopathic skeletal hyperostosis (DISH) increases the spine's susceptibility to unstable fractures that can cause neurological deterioration. However, the detail of injury is still unclear. A nationwide multicenter retrospective study was conducted to assess the clinical characteristics and radiographic features of spinal fractures in patients with DISH. METHODS: Patients were eligible for this study if they 1) had DISH, defined as flowing ossification along the anterolateral aspect of at least four contiguous vertebral bodies, and 2) had an injury in the ankylosing spine. This study included 285 patients with DISH (221 males, 64 females; mean age 75.2 ± 9.5 years). RESULTS: The major cause of injury was falling from a standing or sitting position; this affected 146 patients (51.2%). Diagnosis of the fracture was delayed in 115 patients (40.4%). Later neurological deterioration by one or more Frankel grade was seen in 87 patients (30.5%). The following factors were significantly associated with neurological deficits: delayed diagnosis (p = 0.033), injury of the posterior column (p = 0.021), and the presence of ossification of the posterior longitudinal ligament (OPLL) (p < 0.001). The majority of patients (n = 241, 84.6%) were treated surgically, most commonly by conventional open posterior fixation (n = 199, 69.8%). Neurological improvement was seen in 20.0% of the conservatively treated patients, and in 47.0% of the patients treated surgically. CONCLUSIONS: Minor trauma could cause spinal fractures in DISH patients. Delayed diagnosis, injury of the posterior column, and the presence of OPLL were significantly associated with neurological deterioration. Patients with neurological deficits or unstable fractures should be treated by fixation surgery.

Co-existence of ossification of the nuchal ligament is associated with severity of ossification in the whole spine in patients with cervical ossification of the posterior longitudinal ligament -A multi-center CT study.

BACKGROUND: Previous studies have shown that patients with cervical ossification of the posterior longitudinal ligament (OPLL) often have co-existing ossification of the nuchal ligament (ONL). However, no studies have focused on ONL and its relevance to the severity of OPLL or ossification of other spinal ligaments, such as anterior longitudinal ligament (OALL), ligamentum flavum (OLF), and supraspinous/interspinous ligament (OSIL). METHODS: In this multicenter study, we investigated ossification of the spinal ligaments in the whole spine computed tomography (CT) images of 233 cervical OPLL patients. The severity of ossification was evaluated using ossification index for each spinal ligament, calculated as the sum of the level of ossification. We compared the severity of ossification in each spinal ligament between patients with ONL and those without ONL. Furthermore, we investigated how the number of segments, where ONL exists, affects the severity of ossification in each spinal ligament. RESULTS: One hundred thirty patients (55.8%) had co-existing ONL in the cervical OPLL patients included in this study. The ONL (+) group included more male and aged patients. The cervical ossification indexes of OPLL and OALL were higher in ONL (+) patients than in ONL (-) patients. The thoracolumbar ossification indexes of OALL and OSIL were also higher in ONL (+) patients. Logistic regression analysis revealed that age, gender and cervical OA-index were independent factors correlating to the existence of ONL. In the cervical spine, both the ossification indexes of OALL and OPLL increased as the levels of ONL increased. Similarly, in the thoracolumbar spine, both the ossification indexes of OALL and OSIL were increased as the levels of cervical ONL increased. In the multiple regression analysis, cervical OA-index and thoracolumbar OSI-index showed significant correlation with the number of ONL levels. CONCLUSIONS: Co-existence of ONL in cervical OPLL patients was associated with the severity of spinal hyperostosis especially in cervical OPLL, OALL, thoracolumbar OALL and OSIL.

Prevalence and key radiographic spinal malalignment parameters that influence the risk for gastroesophageal reflux disease in patients treated surgically for adult spinal deformity.

BACKGROUND: Gastroesophageal reflux disease (GERD) is a factor that has a significant negative impact on the quality of life (QoL). Vertebral fractures and/or spinal malalignment may influence the frequency of GERD. However, the epidemiology and pathology of GERD in patients with adult spinal deformity (ASD) are still largely unknown. To establish the optimal surgical strategy for GERD in patients treated surgically for ASD, we sought to clarify the GERD prevalence, determine radiographically which spinal malalignment parameters influence GERD risk, and evaluate GERD improvement postoperatively. METHODS: Seventy-one consecutive patients with ASD who were treated with thoracolumbar corrective surgery and followed up for at least 1 year were enrolled. GERD was diagnosed by a gastroenterologist based on proton pump inhibitor medication response and/or an FSSG score > 8 points. Full-length lateral radiographs in a standing posture and in a supine, fulcrum backward-bending (FBB) position were taken preoperatively and 1 year postoperatively, and radiographic parameters were obtained. Correlations between radiographic parameters and FSSG scores were determined by Pearson's correlation coefficient. Multivariate logistic regression analyses were performed to evaluate the odds ratio (OR) with a 95% confidence interval (95% CI) for potential risk factors for GERD. RESULTS: Patients were classified into two groups based on GERD symptoms, with 37 (52%) in the GERD+ group. Thoracolumbar kyphosis (TLK) in the FBB position was significantly more common in the GERD+ versus the GERD- group. Multivariate logistic regression analysis showed that lumbar lordosis (LL) and TLK curve in the FBB position significantly influenced the presence of GERD. Other factors showed no association with GERD. Significant improvements in FSSG scores were noted 1 year postoperatively. However, 20 (28.2%) patients still had GERD symptoms. The postoperative TLK curve was highly significantly correlated with FSSG scores 1 year postsurgery. CONCLUSIONS: Of the 71 patients treated surgically for ASD, 37 (52%) had a high frequency of GERD symptoms. An inflexible thoracolumbar curve with increased TLK in the FBB position was significantly associated with GERD symptoms. Despite significant improvements in FSSG scores postoperatively, insufficient correction of TLK might be a risk factor for persistent GERD symptoms.

Simultaneous detection of eight species of tree nut in foods using two tetraplex polymerase chain reaction assays.

Tree nuts comprise a category of food allergens that must be included in the food labels in several countries. We developed a polymerase chain reaction (PCR) method using eight specific primer pairs to detect eight representative tree nuts (almond, Brazil nut, cashew, hazelnut, macadamia nut, pecan, pistachio, and walnut) under the same experimental conditions. The specificity of the eight primer pairs was confirmed by PCR testing against a variety of plant and animal samples. The detection limit of the method ranged from 1 fg to 1 pg DNA of individual tree nuts. The method detected tree nut DNA in processed and unprocessed food. In addition, the primer pairs could be combined into two sets of tetraplex PCR system. The developed method is specific, sensitive, and efficient, making it useful for detecting trace amounts of eight species of tree nut in foods.