Effect of saline irrigation temperature difference on postoperative acute pain and hypothermia during biportal endoscopic spine surgery.

BACKGROUND: Recently, enhanced recovery after surgery (ERAS) protocols have attracted attention; they emphasize on avoiding intraoperative hypothermia while performing lumbar fusion surgery. However, none of the studies have reported the protocol for determining the temperature of saline irrigation during biportal endoscopic spine surgery (BESS) procedure. This study evaluated the effectiveness of warm saline irrigation during BESS in acute postoperative pain and inflammatory reactions. MATERIALS AND METHODS: Fifty-five patients who underwent BESS procedure were retrospectively analyzed for the incidence of perioperative hypothermia (< 36oC), postoperative inflammatory factors (white blood cells (WBC), erythrocyte sedimentation rate (ESR), C-reactive protein (CRP), interleukin-6 (IL-6), serum amyloid A (SAA)), and clinical outcomes (back visual analog scale (VAS) score, postoperative shivering). The patients were divided into the warm and cold saline irrigation groups. RESULTS: Hemoglobin, WBC, ESR, creatine kinase, and creatine kinase-muscle brain levels did not significantly differ between the warm and cold saline groups. The mean CRP, IL-6, and SAA levels were significantly higher in the cold saline group than in the warm saline group (p = 0.0058, 0.0028, and 0.0246, respectively); back VAS scores were also higher with a statistically significant difference until two days postoperatively (p < 0.001). During the entire procedure, the body temperature was significantly lower in the cold saline irrigation group, but the hypothermia incidence rate significantly differed 30 min after the operation was started. CONCLUSIONS: Using warm saline irrigation during BESS is beneficial for early recovery after surgery, as it is associated with reduced postoperative pain and complication rates.

The progression of the vertebral body bruise associated with a spinal fracture.

BACKGROUND: Advances in magnetic resonance imaging (MRI) have made it possible to find the vertebral body bruise (VBB), which was not found in computed tomography (CT) after trauma. There has been only one study with adult patients about whether traumatic VBB will cause a collapse of the vertebral body or not. The purpose is to elucidate the progression of VBB in non-osteoporotic adult patients and to identify the possible factors influencing the progression. METHOD: The VBB was defined on MRI as band-like or diffuse zones of high signal intensity on T2-weighted sequences without fracture of the cortex based on CT. The study population with traumatic VBB associated with non-osteoporotic spinal fracture was composed of 15 females and 21 males. The minimal follow-up period was 6 months. The ratio of anterior to posterior heights of the VBB, the ratio of anterior heights of the VBB to the average of those of cranial and caudal adjacent vertebral bodies, the anterior wedge angle of the VBB, and the focal angle around the VBB were compared between the initial and final visits. We evaluated the age of the patients, the C2 plumb line distance, the regional location of VBB, the etiology of VBB, and the treatment methods of the fractures as possible risk factors influencing the progression. RESULTS: There was no difference in the ratios and angles between the initial and final visits. The differences in the ratios and angles between the initial and final visits were not dependent on the possible risk factors. The anterior superior area is the most common in the distribution of VBB. CONCLUSIONS: Unlike compression fractures, the vertebral body with traumatic VBB found in adult patients with non-osteoporotic spinal fractures of AO classification A or B types did not develop collapse. In clinical practice, it is reasonable to diagnose it as a spinal fracture rather than a VBB if the collapse of a possible VBB occurs.

Invasive dental procedures as risk factors for postoperative spinal infection and the effect of antibiotic prophylaxis.

AIM: To identify invasive dental procedures as a risk factor for postoperative spinal infection (PSI) and evaluate the effectiveness of antibiotic prophylaxis. MATERIALS AND METHODS: We analysed 229,335 patients who underwent spinal surgery with instrumentation from 2010 to 2017, using the nationwide database. The incidence of spinal infection 2 years after surgery was determined. Invasive dental procedures as a risk factor for PSI and the effects of antibiotic prophylaxis during this period were also analysed. RESULTS: A total of 15,346 patients (6.69%) were diagnosed with PSI. It was found that advanced age, male sex, and a high Charlson Comorbidity Index were risk factors for PSI. The risk of PSI did not increase following dental procedures (adjusted hazard ratio [HR] 0.850; 95% confidence interval [CI], 0.793-0.912) and was not affected by antibiotics (adjusted HR 1.097; 95% CI, 0.987-1.218). Patients who received dental treatment as early as 3 months after spinal surgery had the lowest risk of postoperative infection (adjusted HR 0.869; 95% CI, 0.795-0.950). CONCLUSIONS: Invasive dental procedure does not increase the risk of PSI, and antibiotic prophylaxis before dental procedure was not effective in preventing spinal infection.

Is There an Association Between Psychiatric Disorders and Adolescent Idiopathic Scoliosis? A Large-database Study.

BACKGROUND: Children with adolescent idiopathic scoliosis (AIS) have reduced quality of life related to poor self-image, perhaps because of cosmetic concerns. However, there has not been a large-database epidemiologic study on the association between psychiatric disorders and scoliosis. QUESTIONS/PURPOSES: Using the Korean National Health Insurance database, we asked: (1) How common are psychiatric disorders among children with AIS? (2) After controlling for gender, age, insurance type, and residential district, are psychiatric disorders more common among children with AIS than among age-matched controls? METHODS: A retrospective analysis was conducted using sample datasets from the Health Insurance Review and Assessment Service from 2012 to 2016, which is a 10% randomly extracted sample of total inpatients and outpatients each year. The mean number of total patients in each dataset was 1,047,603 ± 34,534. The mean number of children with AIS was 7409 ± 158 for each year. The age criteria was 10 to 19 years for the matching. Mood disorders, anxiety disorders, and behavioral disorders were selected as disorders possibly associated with AIS. We identified children with AIS who had any of the disorders above, and we obtained the prevalence of these disorders based on diagnostic codes. As an exploratory analysis, clinically meaningful variables were selected among the available codes in the dataset, and a univariable logistic regression test was performed for each variable. A multivariable logistic regression test with advanced variables was performed to identify the adjusted odds ratios of psychiatric disorders in children with AIS. RESULTS: The median (range) prevalence of psychiatric disorders in children with AIS from 2012 to 2016 was 7% (6% to 7%). Compared with children who did not have AIS, and after controlling for gender, age, insurance type, and residential district, children with AIS were more likely to have psychiatric disorders in all 5 years. The adjusted ORs of psychiatric disorders in children with AIS compared with children who did not have AIS ranged from 1.47 to 1.74 (2012: OR 1.60 [95% CI 1.46 to 1.75]; p < 0.001; 2013: OR 1.73 [95% CI 1.58 to 1.89]; p < 0.001; 2014: OR 1.74 [95% CI 1.59 to 1.91]; p < 0.001; 2015: OR 1.71 [95% CI 1.56 to 1.88]; p < 0.001; 2016: OR 1.47 [95% CI 1.33 to 1.62]; p < 0.001). CONCLUSION: Considering the higher prevalence of psychiatric disorders in children with AIS compared with children who did not have AIS, children with AIS and their parents should be counseled about the increased risk of deteriorating mental health of the patients, and surgeons should provide early referral to pediatric psychiatrists. Further studies should investigate the effect of the factors related to AIS, such as curve type, Cobb angle, and treatment modality. LEVEL OF EVIDENCE: Level III, prognostic study.

Reoperations after fusion surgeries for degenerative spinal diseases depending on cervical and lumbar regions: a national database study.

BACKGROUND: Reoperation is one of the key factors affecting postoperative clinical outcomes. The reoperation rates of cervical surgeries might be different from those of lumbar surgeries due to the anatomical and biomechanical differences. However, there has been no study to compare the reoperation rate between them. The purpose is to compare reoperation rates after fusion surgeries for degenerative spinal diseases depending on the anatomic region of cervical and lumbar spines. METHOD: We used the Korean Health Insurance Review & Assessment Service national database. Subjects were included if they had any of the primary procedures of fusion combined with the procedure of decompression procedures under the diagnosis of degenerative diseases (n = 42,060). We assigned the patients into two groups based on anatomical regions: cervical and lumbar fusion group (n = 11,784 vs 30,276). The primary endpoint of reoperation was the repeat of any aforementioned fusion procedures. Age, gender, presence of diabetes, associated comorbidities, and hospital types were considered potential confounding factors. RESULTS: The reoperation rate was higher in the patients who underwent lumbar fusion surgery than in the patients who underwent cervical fusion surgery during the entire follow up period (p = 0.0275). A similar pattern was found during the late period (p = 0.0468). However, in the early period, there was no difference in reoperation rates between the two groups. Associated comorbidities and hospital type were noted to be risk factors for reoperation. CONCLUSIONS: The incidence of reoperation was higher in the patients who underwent lumbar fusion surgery than those who underwent cervical fusion surgery for degenerative spinal diseases.

Which Factors Affect the Stress of Intraoperative Orthopedic Surgeons by Using Electroencephalography Signals and Heart Rate Variability?

Can we recognize intraoperative real-time stress of orthopedic surgeons and which factors affect the stress of intraoperative orthopedic surgeons with EEG and HRV? From June 2018 to November 2018, 265 consecutive records of intraoperative stress measures for orthopedic surgeons were compared. Intraoperative EEG waves and HRV, comprising beats per minute (BPM) and low frequency (LF)/high frequency (HF) ratio were gathered for stress-associated parameters. Differences in stress parameters according to the experience of surgeons, intraoperative blood loss, and operation time depending on whether or not a tourniquet were investigated. Stress-associated EEG signals including beta 3 waves were significantly higher compared to EEG at rest for novice surgeons as the procedure progressed. Among senior surgeons, the LF/HF ratio reflecting the physical demands of stress was higher than that of novice surgeons at all stages. In surgeries including tourniquets, operation time was positively correlated with stress parameters including beta 1, beta 2, beta 3 waves and BPM. In non-tourniquet orthopedic surgeries, intraoperative blood loss was positively correlated with beta 1, beta 2, and beta 3 waves. Among orthopedic surgeons, those with less experience demonstrated relatively higher levels of stress during surgery. Prolonged operation time or excessive intraoperative blood loss appear to be contributing factors that increase stress.

Mycobacterial periprosthetic joint infection after primary total knee arthroplasty.

PURPOSE: Mycobacterial periprosthetic joint infection (PJI) is very rare and is generally associated with an immunosuppressive environment. Few large-scale studies of this unusual PJI have been conducted. The current study was performed to assess the clinical features and outcomes following two-stage re-implantation for mycobacterial PJI after primary total knee arthroplasty (TKA). METHODS: We conducted a retrospective review of data collected from our database involving ten cases of two-stage re-implantation manifesting mycobacterial PJI. Patients were followed for at least five years or until recurrent infection. The mean follow-up duration in patients who remained free of infection was 7.5 years (range 5-9.5 years). RESULTS: Seven patients (70%) belonged to the American Society of Anesthesiologists' grade 3 or 4. The surgical protocol entailed resection arthroplasty and cement spacer insertion with vigorous debridement, followed by at least six weeks of systemic antimicrobial therapy and delayed re-implantation in all patients. The median duration from resection arthroplasty to re-implantation was 5.3 months (range 2-10.5 months). Following re-implantation, five patients with Mycobacterium fortuitum were treated with amikacin for six weeks and oral clarithromycin for three months. Five patients infected with M. tuberculosis received anti-tuberculosis medications immediately after pathogen isolation, for a period of 12 months. CONCLUSION: Mycobacterial PJI can be treated successfully via resection arthroplasty and delayed re-implantation combined with proper antimicrobial agents. Suspicious infection or loosening after primary TKA, particularly in an immunosuppressive environment, warrants the attention of an orthopedic surgeon to consider the possibility of unusual PJI.

Assessment of patient-reported outcomes (PROs): treatment satisfaction, medication adherence, and quality of life (QoL) and the associated factors in postmenopausal osteoporosis (PMO) patients in Korea.

Patient-reported outcomes (PROs) provide practical guides for treatment; however, studies that have evaluated PROs of women in Korea with postmenopausal osteoporosis (PMO) are lacking. This cross-sectional, multi-center (29 nationwide hospitals) study, performed from March 2013 to July 2014, aimed to assess PROs related to treatment satisfaction, medication adherence, and quality of life (QoL) in Korean PMO women using osteoporosis medication for prevention/treatment. Patient demographics, clinical characteristics, treatment patterns, PROs, and experience using medication were collected. The 14-item Treatment Satisfaction Questionnaire for Medication (TSQM) (score-range, 0-100; domains: effectiveness, side effects, convenience, global satisfaction), Osteoporosis-Specific Morisky Medication Adherence Scale (OS-MMAS) (score-range, 0-8), and EuroQol-5 dimensions questionnaire (index score range, - 0.22 to 1.0; EuroQol visual analog scale score range, 0-100) were used. To investigate factors associated with PROs, linear (treatment satisfaction/QoL) or logistic (medication adherence) regression analyses were conducted. A total of 1804 patients (age, 62 years) were investigated; 60.1% used bisphosphonate, with the majority (67.2%) using weekly medication, 27.8% used daily hormone replacement therapy, and 12.1% used daily selective estrogen receptor modulator. Several patients reported gastrointestinal (GI) events (31.6%) and dental visits due to problems (24.1%) while using medication. Factors associated with the highest OS-MMAS domain scores were convenience and global satisfaction. GI events were associated with non-adherence. TSQM scores for effectiveness, side effects, and GI risk factors were significantly associated with QoL. Our study elaborately assessed the factors associated with PROs of Korean PMO women. Based on our findings, appropriate treatment-related adjustments such as frequency/choice of medications and GI risk management may improve PROs.

Location of residual viable tumor cells after neoadjuvant chemotherapy: A new concept with high prognostic performance in osteosarcoma.

BACKGROUND AND OBJECTIVES: The purpose of this study was to establish a new concept for evaluating responses to neoadjuvant chemotherapy in osteosarcoma. METHODS: A total of 56 high-grade extremity osteosarcoma patients were retrospectively reviewed. A new conceptual method was derived from locations of residual viable tumor cells (LRVTC) after chemotherapy, whether extracompartmental or intracompartmental, rather than quantitative measurements of necrosis rates of tumor cells. RESULTS: LRVTC after chemotherapy was independently associated with overall survival ([OS]hazard ratio [HR] = 6.502, P = 0.008) after adjustment for Huvos grade (HR = 3.694, P = 0.045), alkaline phosphatase ([ALP] HR = 2.140, P = 0.226), size (HR = 0.318, P = 0.133), joint extension (HR = 2.309, P = 0.162), and metastasis at diagnosis (HR = 8.228, P = 0.009). LRVTC was also independently associated with metastasis (HR = 5.096, P = 0.002) after adjustment for Huvos grade (HR = 2.261, P = 0.101), ALP (HR = 2.558, P = 0.053), size (HR = 1.280, P = 0.641), and joint extension (HR = 1.800, P = 0.254). AUC values of LRVTC for OS and metastasis were superior to those of Huvos grade: AUCs for OS (LRVTC: 0.757, Confidence Interval [CI] = 0.618 to 0.865 vs Huvos grade: 0.590, [CI] = 0.445 to 0.725; AUC = 0.167, P = 0.086) and metastasis (LRVTC: 0.769, CI = 0.631 to 0.874 vs Huvos grade: 0.606, [CI] = 0.461 to 0.739; AUC = 0.163, P = 0.046). CONCLUSIONS: LRVTC after chemotherapy may be useful as a new method with high performance for evaluating chemo-responses in osteosarcoma.

Vitamin D deficiency adversely affects early post-operative functional outcomes after total knee arthroplasty.

PURPOSE: Vitamin D has received considerable attention in recent years owing to the increasing evidence of its importance in muscle function and physical performance. The present study attempted to determine whether patients with low serum vitamin D levels had impairment in early functional outcomes following total knee arthroplasty (TKA). METHODS: This was a prospective cohort study that included 92 patients. Patients were divided into two groups according to their vitamin D levels as assessed at the preoperative visit: (1) vitamin D-deficient group, serum 25-hydroxyvitamin D3 (25(OH)D) levels <12 ng/mL; (2) vitamin D non-deficient group, serum 25(OH)D levels ≥12 ng/mL. American Knee Society Score (KSS) and four other performance tests including the alternative step test (AST), six-metre walk test (SMT), sit-to-stand test (STS), and timed up and go test (TUGT) were used for assessment of post-operative function. All assessments were performed one day before and three months after TKA. RESULTS: Of the 92 patients included in the study, 87 patients performed all required assessments. The mean post-operative functional KSS was significantly lesser in the vitamin D-deficient group than in the vitamin D non-deficient group (67.2 vs. 73.4, p = 0.031). The mean values of time taken for post-operative AST (16.6 vs. 14.6 s, p = 0.033) and SMT (8.8 vs. 7.7 s, p = 0.012) were significantly longer in the vitamin D-deficient group than in the vitamin D non-deficient group. Post-operative STS and TUGT demonstrated higher values for mean time taken in the vitamin D-deficient group than in the vitamin D non-deficient group, but these were not statistically significant (13.6 vs. 12.4 s, not significant (n.s.); 12.7 vs. 11.7 s, n.s., respectively). CONCLUSION: Early post-operative functional outcomes following TKA appear to be adversely affected by vitamin D deficiency. LEVEL OF EVIDENCE: Prospective cohort study, Level II.

Which one is a valuable surrogate for predicting survival between Tomita and Tokuhashi scores in patients with spinal metastases? A meta-analysis for diagnostic test accuracy and individual participant data analysis.

This study is to estimate the diagnostic accuracy of Tokuhashi and Tomita scores that assures 6-month predicting survival regarded as a standard of surgical treatment. We searched PubMed, EMBASE, European PubMed central, and the Cochrane library for papers about the sensitivities and specificities of the Tokuhashi and/or Tomita scores to estimate predicting survival. Studies with cut-off values of ≥9 for Tokuhashi and ≤7 for Tomita scores based on prior studies were enrolled. Sensitivity, specificity, diagnostic odds ratio (DOR), area under the curve (AUC), and the best cut-off value were calculated via meta-analysis and individual participant data analysis. Finally, 22 studies were enrolled in the meta-analysis, and 1095 patients from 8 studies were included in the individual data analysis. In the meta-analysis, the pooled sensitivity/specificity/DOR for 6-month survival were 57.7 %/76.6 %/4.70 for the Tokuhashi score and 81.8 %/47.8 %/4.93 for Tomita score. The AUC of summary receiver operating characteristic plots was 0.748 for the Tokuhashi score and 0.714 for the Tomita score. Although Tokuhashi score was more accurate than Tomita score slightly, both showed low accuracy to predict 6 months residual survival. Moreover, the best cut-off values of Tokuhashi and Tomita scores were 8 and 6, not 9 and 7, for predicting 6-month survival, respectively. Estimation of 6-month predicting survival to decide surgery in patients with spinal metastasis is quite limited by using Tokuhashi and Tomita scores alone. Tokuhashi and Tomita scores could be incorporated as part of a multidisciplinary approach or perhaps interpreted in the context of a multidisciplinary approach.

Relationship between modic changes and facet joint degeneration in the cervical spine.

PURPOSE: Given that the disc moves simultaneously with facet joints, there would be a relationship between Modic changes and facet joint degeneration in the cervical spine. However, there is no literature investigating the relationship. The purpose is to evaluate the relationship between Modic changes and facet joint degeneration in the cervical spine. METHODS: Ninety-eight patients underwent both computed tomography (CT) and magnetic resonance images (MRI) of the cervical spine. They consisted of fifty-one males and forty-eight females and their mean age was 60.1 years (ranged from 40 years to 81 years). We compared the degree of facet joint degeneration based on CTs with Modic changes based on MRIs from C2-C3 to C6-C7. The degree of facet joint degeneration was classified into four categories and Modic changes were classified into four types. Disc degeneration was determined with Miyazaki's grading system. RESULTS: Facet joint degeneration was most common at C2-C3 and C4-C5 and rarest at C6-C7. Modic changes were most common at C2-C3 and rarest at C6-C7. However, there was no relationship between facet joint degeneration and any Modic changes at the same level. However, the presence of facet joint degeneration and the presence of Modic change are common in high grades of disc degeneration at the same level of the cervical spine. CONCLUSION: Modic changes and facet joint degeneration are most common at C2-C3 in the cervical spine. However, there were no relationships between the presence of Modic changes and facet joint degeneration at the same level of the cervical spine.

Clinical Outcome and Changes of Foraminal Dimension in Patients With Foraminal Stenosis After ACDF.

STUDY DESIGN: Prospective study. OBJECTIVE: To determine the clinical outcome and change in foraminal dimension after anterior cervical discectomy and fusion (ACDF) and to investigate the correlation between clinical outcome and foraminal dimension. SUMMARY OF BACKGROUND DATA: No previous studies have evaluated the correlation between clinical outcome and foraminal dimension after ACDF in foraminal stenosis. METHODS: A consecutive series of 44 patients (114 foramina) undergoing planned ACDF due to foraminal stenosis were studied. Clinical outcomes included the neck pain visual analogue scale (VAS), arm pain VAS, neck disability index (NDI), subjective improvement rate, dysphasia, and donor site pain. Radiologic outcomes included anterior and posterior disk height, height of foramen and anterior-posterior diameter of the foramen, and the Cobb angle of the fusion segment. Foraminal dimension was calculated. RESULTS: The neck pain VAS decreased from 3.7 preoperatively to 2.3 postoperatively. Likewise, arm pain VAS decreased from 7.2 to 2.2, and NDI decreased from 31.0% to 17.2%. Mild dysphasia occurred in 3 patients. There was no donor site pain. Subjective improvement rate was 79.3%. The anterior disk height increased from 4.75 mm preoperatively to 7.01 mm postoperatively. Likewise, posterior disk height increased from 4.11 to 5.74 mm, height of foramen increased from 7.30 to 9.25 mm, anterior-posterior diameter of foramen increased from 3.56 to 4.92 mm, dimension of foramen increased from 20.50 to 35.58 mm, and segmental angle of fusion segment increased from 2.87 to 4.95 degrees. Posterior disk height was positively correlated with foraminal dimension. An increased segmental angle was negatively correlated with foraminal dimension. The foraminal dimension was negatively correlated with the arm pain VAS. CONCLUSIONS: ACDF in cervical foraminal stenosis was a useful surgical option to improve clinical outcomes and widen the foraminal dimension. The foraminal dimension was negatively correlated with the arm pain. Restoration of posterior disk height was necessary to widen the foraminal dimension, whereas increased lordosis of the fusion segment did not help to widen the foraminal dimension.

Prognostic factors for surgical outcomes including preoperative total knee replacement and knee osteoarthritis status in female patients with lumbar spinal stenosis.

STUDY DESIGN: A retrospective clinical case series. OBJECTIVE: To investigate knee osteoarthritis (KOA) and total knee replacement (TKR) status as prognostic factors for surgical outcomes in female patients with lumbar spinal stenosis (LSS). SUMMARY OF BACKGROUND DATA: There have been many reports on numerous prognostic factors for surgical outcomes in patients with degenerative lumbar conditions; however, there has been no report on the surgical outcome in patients who underwent spinal surgery with coexisting KOA and TKR. METHODS: This study included 141 female patients (mean age, 67.6 y) who underwent spinal surgery for LSS between January 2006 and December 2010. At 1 year postoperatively, surgical outcomes were measured using the Oswestry disability index (ODI). Various clinical factors including KOA and TKR were analyzed as prognostic factors for surgical outcomes. RESULTS: Mean average scores at preoperative evaluation were 26.1±6.6 in the no KOA group, 23.6±7.9 in the KOA group, and 30.4±6.7 in the TKR group (P<0.05). Mean average scores at postoperative 1 year were 13.8±8.5 in the no KOA group, 16.8±9.5 in the KOA group, and 21.4±5.7 in the TKR group (P<0.05, Mann-Whitney U test). Preoperative ODI scores were shown to be significantly affected by the TKR status only (P<0.05), and were significantly higher in the TKR patient group. ODI scores at postoperative 3 months were significantly correlated with the preoperative ODI and the operational level (P<0.05). At postoperative 1 year, ODI scores were shown to be affected by the operational level, the preoperative ODI, and the presence of advanced radiographic KOA (Kellgren/Lawrence grades III and IV) (P<0.05). CONCLUSIONS: A poor preoperative functional score, the presence of preoperative KOA, and longer operational levels were shown to be poor prognostic factors for the 1-year surgical outcome of LSS. Also, patients in the TKR group showed the worst ODI scores at preoperative and postoperative 1-year evaluations. Consideration of these factors when planning for spine surgery could be helpful in predicting the surgical outcomes of lumbar spinal surgery.

Association between bone mineral density and clinical consequences: cross-sectional study of Korean postmenopausal women in an orthopaedic outpatient clinic.

This study is to identify the characteristics of BMD and the related clinical consequences through a nationwide, consecutive, cross-sectional study. A total of 1,281 postmenopausal women was enrolled nationwide and underwent measurement for BMD using dual energy x-ray absorptiometry. Following the T-spine and L-spine plane radiography, they were evaluated for vertebral fracture by a semi-quantitative method using the Genant's method. Relationship between BMD and osteoporotic fracture and a degree of deformity in vertebral fracture, treatment history in osteoporosis and the EQ-5D was analyzed. The distribution of the normal, osteopenia and osteoporosis group was 25.9%, 37.0%, and 37.2% in lumbar spine, and 31.4%, 45.3%, and 23.3% in femur neck, respectively. BMD in subjects with symptomatic or asymptomatic vertebral fracture was significantly lower than those without fracture. The femur neck and total hip BMDs were significantly lower in hip fracture group (0.646 g/cm(2) and 0.643 g/cm(2), respectively) and wrist fracture group (0.661 g/cm(2) and 0.712 g/cm(2), respectively) than in subjects without fracture (0.721 g/cm(2) and 0.712 g/cm(2), respectively). The BMD was significantly lower with more severe degree of deformity in vertebral fracture and lower scores in mobility, usual activities and pain/discomfort of the EQ-5D. In Korean postmenopausal women, the prevalence of osteoporosis and vertebral, hip and wrist fracture increase and quality of life decreases with lower BMD.

Herniated intervertebral disk induces hypertrophy and ossification of ligamentum flavum.

STUDY DESIGN: In vitro experiment using degenerated human ligamentum flavum (LF) and herniated intervertebral disk (IVD). OBJECTIVES: To investigate the role and effect of degenerated and herniated IVDs on LF hypertrophy and ossification. SUMMARY OF BACKGROUND DATA: Spinal stenosis is caused, in part, by hypertrophy and ossification of the LF, which are induced by aging and degenerative process. It is well known that degenerated IVDs spontaneously produce inflammatory cytokines. Therefore, we hypothesized that degenerated IVD may affect adjacent LF through secreted inflammatory cytokines. METHODS: LF and herniated lumbar IVD tissues were obtained during surgical spinal procedures. LF fibroblasts were isolated by enzymatic digestion of LF tissue. LF cell cultures were treated with disk supernatant from herniated IVDs. Secreted cytokines from IVD tissue culture were detected by enzyme-linked immunosorbent assay. After analysis of cytotoxicity, DNA synthesis was measured. Reverse transcription-polymerase chain reaction for mRNA expressions of types I, II, III, V, and XI collagen and osteocalcin, and histochemical stains were performed. RESULTS: Supernatant from tissue culture of herniated IVD showed increased production of interleukin-1α, interleukin-6, tumor necrosis factor-α, prostaglandin E2, and nitric oxide compared with disk tissue culture from traumatic condition. There was no cytotoxicity in LF cells treated with disk supernatant from herniated IVDs. There was significant increase in DNA synthesis, upregulation in mRNA expression of types III, XI collagen and osteocalcin, whereas variable expression pattern of type I and V, and strong positive stains for Von Kossa and alkaline phosphatase in LF cultures with disk supernatant. CONCLUSIONS: Degenerated and herniated IVDs provide an important pathomechanism in hypertrophy and ossification of the LF through inflammatory cytokines.

Anatomical considerations for nerve transfer in axillary nerve injury.

This study investigated the anatomical details of the axillary and radial nerves in 50 upper limbs from 29 adult formalin-embalmed cadavers, and ten fresh upper limbs. The focus was on understanding the course, division, and ramifications of these nerves to improve treatment of shoulder dysfunction caused by axillary nerve damage. The axillary nerve divided anteriorly and posteriorly before passing the quadrangular space in all specimens, with specific distances to the first ramifications. It was found that the deltoid muscle's clavicular and acromial parts were always innervated by the anterior division of the axillary nerve, whereas the spinous part was variably innervated. The longest and thickest branches of the radial nerve to the triceps muscles were identified, with no statistically significant differences in fiber numbers among triceps branches. The study concludes that nerve transfer to the anterior division of the axillary nerve can restore the deltoid muscle in about 86% of shoulders, and the teres minor muscle can be restored by nerve transfer to the posterior division. The medial head branch and long head branch of radial nerve were identified as the best donor options.

Risk Factors and Characteristics of In-Hospital Falls After Spine Surgery: A Retrospective, Single-Center Cohort Study in the Republic of Korea.

Background: Falls after orthopaedic surgery can cause serious injuries, which lengthen hospital stays and increase medical expenses. This has prompted hospitals to implement various fall-prevention protocols. The aims of this study were to determine the incidence of in-hospital falls after spine surgery, to analyze the overall risk factors, to discern factors that have a major influence on falls, and to evaluate the effectiveness of the fall-prevention protocol that we implemented. Methods: This was a retrospective, single-center study including patients who underwent spine surgery from January 2011 to November 2021 at the National Health Insurance Service Ilsan Hospital (NHISIH) in Goyang, Republic of Korea. Reported falls among these patients were examined. Patient demographics; surgery type, date, and diagnosis; and fall date and time were evaluated. Results: Overall, 5,317 spine surgeries were performed, and 128 in-hospital falls were reported (overall incidence: 2.31%). From the multivariable analyses, older age and American Society of Anesthesiologists (ASA) score were identified as independent risk factors for in-hospital patient falls (multivariable adjusted hazard ratio [aHR] for age 70 to 79 years, 1.021 [95% confidence interval (CI), 1.01 to 1.031]; for age ≥80 years, 1.035 [1.01 to 1.06]; and for ASA score of 3, 1.02 [1.01 to 1.031]). Similar results were seen in the subgroup who underwent primary surgery. Within 2 weeks following surgery, the highest frequency of falls occurred at 3 to 7 days postoperatively. The lowest fall rate was observed in the evening (6 to 10 p.m.). Morbidities, including rib, spine, and extremity fractures, were recorded for 14 patients, but none of these patients underwent operative treatment related to the fall. The NHISIH implemented a comprehensive nursing care service in May 2015 and a fall protocol in May 2017, but the annual incidence rate did not improve. The fall rate was higher after thoracolumbar surgeries (2.47%) than after cervical surgeries (1.20%). Moreover, a higher fall rate was observed in thoracolumbar cases with a greater number of fusion levels and revision spine surgeries. Conclusions: Patients with advanced age, more comorbidities, a greater number of fusion levels, and revision surgeries and who are female are more vulnerable to in-hospital falls after spine surgery. Novel strategies that target these risk factors are warranted. Level of Evidence: Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Proximity Between Screw and Endplate of Upper Instrumented Vertebra Using a Cortical Bone Trajectory Screw can Increase Radiographic Adjacent Segment Degeneration Risks in Patients With Lumbar Spinal Stenosis.

STUDY DESIGN: Retrospective observational study. OBJECTIVE: To determine the proximity between screw and endplate of the upper instrumented vertebra (UIV) using a cortical bone trajectory (CBT) screw as a predictive factor for radiographic adjacent segment degeneration (ASD) in patients surgically treated with transforaminal lumbar interbody fusion (TLIF) with CBT screws (CBT-TLIF) with lumbar spinal stenosis. SUMMARY OF BACKGROUND DATA: The risk factors for radiographic ASD after CBT-TLIF remain unknown. METHODS: Among patients surgically treated with CBT-TLIF at a single institute, 239 consecutive patients (80 males and 159 females) were enrolled. ASD was defined by the presence of one or more of the following three radiologic criteria on the adjacent segment: >3 mm anteroposterior translation, >10° segmental kyphosis, or >50% loss of disc height comparing immediate postoperative and 1-year follow-up radiographs. Clinical and radiological features associated with the development of ASD were retrospectively measured. Univariate and multivariate analyses were performed to identify risk factors associated with radiographic ASD. RESULTS: Radiographic ASD was observed in 71 (29.7%) cases at 1-year postoperative follow-up. The preoperative Pfirrmann grade of the adjacent segment (>grade 2), multi-level fusion (>2 levels), and proximity between the tip of CBT screws and endplate on the UIV were significantly associated with radiographic ASD (OR = 3.98, 95% CI [1.06-15.05], P=0.042 versus OR = 3.03, 95% CI [1.00-9.14], P=0.049 versus OR = 0.53, 95% CI [0.40-0.72], P<0.001). The cut-off value of the distance between the tip of the screw and endplate on UIV for radiographic ASD was approximately 2.5 mm (right-sided CBT screw; cut-off value 2.48 mm/ left-sided CBT screw; cut-off value 2.465 mm). CONCLUSION: Radiographic adjacent segment degeneration progression can occur when the cortical trajectory bone screw is close to the endplate of the upper instrumented vertebrae in patients with lumbar spinal stenosis undergoing fusion surgery.

Accelerated Fusion Dynamics by Recombinant Human Bone Morphogenetic Protein-2 Following Transforaminal Lumbar Interbody Fusion, Particularly in Osteoporotic Conditions.

BACKGROUND CONTEXT: Early fusion is crucial in interbody procedures to minimize mechanical complications resulting from delayed union, especially for patients with osteoporosis. Bone morphogenetic proteins (BMPs) are used in spinal fusion procedures; however, limited evaluation exists regarding time-to-fusion for BMP use, particularly in patients with osteoporosis. PURPOSE: To evaluate the difference in time-to-fusion after single-level transforaminal lumbar interbody fusion (TLIF) surgery between recombinant human bone morphogenetic protein-2 (rhBMP-2) usage and non-usage groups according to bone density. STUDY DESIGN: Retrospective single-center cohort study PATIENT SAMPLE: This study enrolled 132 patients (mean age, 65.25±8.66; male patients, 40.9%) who underwent single-level TLIF for degenerative disorders between February 2012 and December 2021, with pre- and postoperative computed tomography (CT). OUTCOME MEASURE: The interbody fusion mass and bone graft status on postoperative CT scans was obtained annually, and time-to-fusion was recorded for each patient. METHODS: The patients were divided into two groups based on rhBMP-2 use during the interbody fusion procedure. Patients were further divided into osteoporosis, osteopenia, and normal groups based on preoperative L1 vertebral body attenuation values, using cutoffs of 90 and 120 Hounsfield units. It was strictly defined that fusion is considered complete when a trabecular bone bridge was formed, and therefore, the time-to-fusion was measured in years. Time-to-fusion was statistically compared between BMP group and non-BMP groups, followed by further comparison according to bone density. RESULTS: The time-to-fusion differed significantly between BMP and non-BMP groups, with half of the patients achieving fusion within 2.5 years in the BMP group compared with 4 years in the non-BMP group (p < 0.001). The fusion rate varied based on bone density, with the maximum difference observed in the osteoporosis group, when half of the patients achieved fusion within 3 years in the BMP group compared to 5 years in the non-BMP group (p < 0.001). Subgroup analysis was conducted, revealing no significant associations between time-to-fusion and factors known to influence the fusion process, including age, gender, medical history, smoking and alcohol use, and medication history, except for rh-BMP2 use and bone density. CONCLUSIONS: RhBMP-2 usage significantly reduced time-to-fusion in single-level TLIF, especially in patients with osteoporosis. LEVEL OF EVIDENCE: Level III.