Segmental Arteries and Veins at Higher Lumbar Levels Can Intersect the Adjacent Caudal Intervertebral Disc in the Anterior Part of the Spinal Column: A Cadaveric Analysis.

STUDY DESIGN: A cadaveric study. PURPOSE: To investigate the anatomical features of segmental arteries and veins in the anterior part of the spinal column to prevent segmental vessel injury. OVERVIEW OF LITERATURE: The lateral transpsoas approach to the lumbar intervertebral discs (IVD) is associated with the risk of segmental vessel injury. Previous studies have described the vascular anatomy on the lateral part of the vertebral body. However, there are no studies that describe the segmental vessels on its anterior aspect. Here, we report the important anatomical features of the segmental arteries and veins that can intersect the anterior part of the IVD. These vessels are considered at risk of vascular injury when placing the anterior retractors during lateral lumbar interbody fusion or cutting the anterior longitudinal ligament during anterior column realignment. METHODS: Five formalin-embalmed human cadavers were used. We assessed the proportion of segmental arteries and veins that intersected the IVD in the L2-L5 range and their course on the anterior part of the spinal column. RESULTS: The segmental arteries and veins commonly intersect the anterior part of the IVD (artery, 28.1%; vein, 42.1%). Seven of 10 (70%) segmental arteries at L2 intersected the IVD, but only one artery intersected the IVD at L3 and L4. The proportions of segmental veins that intersected the IVD were 60%, 50%, and 16.7% at L2, L3, and L4, respectively. CONCLUSIONS: The segmental arteries and veins frequently intersect the IVD in the anterior part of the spinal column. Therefore, it is necessary to consider these individual anatomical features to prevent vascular damage during lateral lumbar interbody fusion surgery.

p38 Mitogen-Activated Protein Kinase Is Involved in Interleukin-6 Secretion from Human Ligamentum Flavum-Derived Cells Stimulated by Tumor Necrosis Factor-α.

STUDY DESIGN: Human ligamentum flavum-derived cells (HFCs) were obtained from surgical samples for a basic experimental study. PURPOSE: We sought to evaluate the inflammatory response of human ligamentum flavum cells to investigate hypertrophic changes occurring in the ligamentum flavum. OVERVIEW OF LITERATURE: Lumbar spinal stenosis (LSS) is a disease commonly observed in the elderly. The number of patients with LSS has increased over time, yet the pathomechanisms of LSS still have not been fully elucidated. One of the clinical features of LSS is hypertrophy of the ligamentum flavum, which results in narrowing of the lumbar spinal canal. Some reports have suggested that ligamentum flavum hypertrophy is associated with inflammation and fibrosis; meanwhile, the p38 mitogen-activated protein (MAP) kinase is involved in the hypertrophy of human ligamentum flavum cells. METHODS: HFCs were obtained from patients with LSS who underwent surgery. HFCs were stimulated by tumor necrosis factor-α (TNF-α) and a p38 MAP kinase inhibitor, SB203580. Phosphorylation of the p38 MAP kinase was analyzed by western blotting. The concentration of interleukin-6 (IL-6) in the conditioned medium was measured by enzyme-linked immunoassay and IL-6 messenger RNA expression levels were determined by real-time polymerase chain reaction. RESULTS: TNF-α induced the phosphorylation of p38 MAP kinase in a time-dependent manner, which was suppressed by the p38 MAP kinase inhibitor, SB203580. TNF-α also stimulated IL-6 release in both a time- and dose-dependent manner. On its own, SB203580 did not stimulate IL-6 secretion from HFCs; however, it dramatically suppressed the degree of IL-6 release stimulated by TNF-α from HFCs. CONCLUSIONS: This is the first report suggesting that TNF-α stimulates the gene expression and protein secretion of IL-6 via p38 MAP kinase in HFCs. A noted association between tissue hypertrophy and inflammation suggests that the p38 MAP kinase inflammatory pathway may be a therapeutic molecular target for LSS.

Differences in postural stability and dynamic visual acuity among healthy young adults in relation to sports activity: a cross sectional study.

[Purpose] Sports activity has been shown to improve postural stability and vestibular function in healthy older adults. The hypothesis was that healthy young adults undertaking sports activity will also have better postural stability and vestibular function compared with healthy young adults who do not undertake sports activity. The purpose of this study was to investigate the differences in postural stability and vestibular function between healthy young adults who undertake sports activity and those who do not undertake such activity. [Participants and Methods] Thirty-nine healthy young adults were recruited and divided into sports and non-sports groups on the basis of their response to a questionnaire concerning regular participation in sports activities over the past 12 months. In both groups, postural stability was measured during quiet standing and standing during head rotation, and dynamic visual acuity was assessed during head rotation. [Results] The results showed significant differences in postural stability during head rotation and dynamic visual acuity between the two groups, whereas no significant differences were found in postural stability during quiet standing. [Conclusion] The results suggest that healthy young adults who undertake sports activity have better postural stability during head rotation and better dynamic visual acuity. The causal effect of these differences is not clear and further investigation is warranted.

Outcomes of Fusions From the Cervical Spine to the Pelvis.

STUDY DESIGN: Retrospective cohort study. OBJECTIVE: Determine the indications, complications, and clinical outcomes in patients requiring fusions from the cervical spine to the pelvis. Several investigators have examined fusions from the thoracic spine to the sacrum, but no similar study has been performed for cervical-to-pelvis fusions. METHODS: Patients from 2003 to 2014 with an upper instrumented vertebrae (UIV) in the cervical spine (any level) and a lower instrumented vertebrae (LIV) in the sacrum or pelvis were included in the study. Those with infectious or acute trauma-related deformities were excluded. Patient demographics, medical history, diagnosis, operative procedure, and health-related quality of life measures were analyzed. Student's t test, Kruskal-Wallis test, and χ2 test were used as appropriate; significance was set at P < .05 for all tests. RESULTS: Fifty-five patients met inclusion criteria for the study. Average follow-up was 2.8 years. Proximal junctional kyphosis was the most common indication for cervical-to-pelvis fusions (36%). The most common UIV was C2 (29%) followed by C7 (24%). There was an average 31° correction in maximum kyphosis and a 3.3 cm improvement in sagittal vertical axis. In adults, the rate of complication was 71.4%, with a major complication rate of 39.3% and reoperation rate of 53.6%. There was significant improvement in the Scoliosis Research Society (SRS-22r) score (3.0 to 3.5; P < .01). CONCLUSION: Proximal junctional kyphosis is the most common indication for patients requiring fusion to the cervical spine. Adult patients incur a significant risk of major complications and reoperations. However, significant improvement in SRS-22r outcomes are noted in these patients.

Objective measures of physical activity in patients with chronic unilateral vestibular hypofunction, and its relationship to handicap, anxiety and postural stability.

OBJECTIVE: Dizziness is one of the most common symptoms in the general population. Patients with dizziness experience balance problems and anxiety, which can lead to decreased physical activity levels and participation in their daily activities. Moreover, recovery of vestibular function from vestibular injury requires physical activity. Although there are reports that decreased physical activity is associated with handicap, anxiety, postural instability and reduced recovery of vestibular function in patients with chronic dizziness, these data were collected by self-report questionnaires. Therefore, the objective data of physical activity and the relationships between physical activity, handicap, anxiety and postural stability in patients with chronic dizziness are not clear. The purpose of this research was to objectively measure the physical activity of patients with chronic dizziness in daily living as well as handicap, anxiety and postural stability compared to healthy adults. Additionally, we aimed to investigate the relationships between physical activity, handicap, anxiety and postural stability in patients with chronic dizziness. METHODS: Twenty-eight patients with chronic dizziness of more than 3 months caused by unilateral vestibular hypofunction (patient group) and twenty-eight age-matched community dwelling healthy adults (healthy group) participated in this study. The amount of physical activity including time of sedentary behavior, light physical activity, moderate to vigorous physical activity and total physical activity using tri-axial accelerometer, self-perceived handicap and anxiety using questionnaires, and postural stability were measured using computerized dynamic posturography. RESULTS: The results showed worse handicap, anxiety and postural stability in the patient group compared to the healthy group. Objective measures of physical activity revealed that the patient group had significantly longer time of sedentary behavior, shorter time of light physical activity, and shorter time of total physical activity compared to the healthy group; however, time of moderate to vigorous physical activity was not significantly different between groups. Moreover, there were correlations between physical activity and postural stability in the patient group, while there were no correlations between physical activity, handicap or anxiety in the patient group. CONCLUSION: These results suggest that objectively measured physical activity of the patients with chronic unilateral vestibular hypofunction is lower compared to the healthy adults, and less active patients showed decreased postural stability. However, the details of physical activity and causal effect between physical activity and postural stability were not clear and further investigation is needed.

Biomechanical and Anatomical Validity of the Short Posterior Arch Screw.

OBJECTIVE: This study was conducted to clarify the validity of the short posterior arch screw (S-PAS). The S-PAS is inserted only in the pedicle-analogue portion of the posterior arch. The S-PAS screw length is almost half that conventional C1 lateral mass screws inserted via the posterior arch (via-PAS). S-PAS reduces the risk of vertebral artery injury (VAI) because it never reaches the transverse foramen. Although the biomechanical validity of various C1 lateral mass screws (C1LMS) analyzed in young specimens have been published, that of unicortically inserted C1LMS such as the unicortical Harms screw, S-PAS, and via-PAS for elderly patients is concerning because of the high prevalence of osteoporosis in the elderly. METHODS: Nine fresh frozen cadavers (average age at death, 72.1 years) were used for pullout testing. The bone mineral density of each specimen was evaluated using quantitative computed tomography. RESULTS: The pullout strength of via-PAS (1,048.5 N) was significantly greater than that of the unicortical Harms screw (257.9 N) (p<0.05). The pullout strength of S-PAS was 720.3 N, which was also significantly greater than that of the unicortical Harms screw (p<0.05). CONCLUSION: The via-PAS and S-PAS are valid surgical options, even in elderly patients. Along with sufficient biomechanical strength, the S-PAS screw prevents VAI.

How Cervical Reconstruction Surgery Affects Global Spinal Alignment.

BACKGROUND: There have been no reports describing how cervical reconstruction surgery affects global spinal alignment (GSA). OBJECTIVE: To elucidate the effects of cervical reconstruction for GSA through a retrospective multicenter study. METHODS: Seventy-eight patients who underwent cervical reconstruction surgery for cervical kyphosis were divided into a Head-balanced group (n = 42) and a Trunk-balanced group (n = 36) according to the values of the C7 plumb line (PL). We also divided the patients into a cervical sagittal balanced group (CSB group, n = 18) and a cervical sagittal imbalanced group (CSI group, n = 60) based on the C2 PL-C7 PL distance. Various sagittal Cobb angles and the sagittal vertical axes were measured before and after surgery. RESULTS: Cervical alignment was improved to achieve occiput-trunk concordance (the distance between the center of gravity [COG] PL, which is considered the virtual gravity line of the entire body, and C7 PL < 30 mm) despite the location of COG PL and C7PL. A subsequent significant change in thoracolumbar alignment was observed in Head-balanced and CSI groups. However, no such significant change was observed in Trunk-balanced and CSB groups. We observed 1 case of transient and 1 case of residual neurological worsening. CONCLUSION: The primary goal of cervical reconstruction surgery is to achieve occiput-trunk concordance. Once it is achieved, subsequent thoracolumbar alignment changes occur as needed to harmonize GSA. Cervical reconstruction can restore both cervical deformity and GSA. However, surgeons must consider the risks and benefits in such challenging cases.

Efficacy of radio-hyperthermo-chemotherapy as salvage therapy for recurrent or residual malignant soft tissue tumors.

BACKGROUND: Recurrence after wide excision or residual tumor after an unplanned excision of a malignant soft tissue sarcoma (STS) is a complex problem, due to a higher recurrence rate and poorer survival rate compared with primary resection. Regional hyperthermia was used, with the expectation that it will enhance the anti-tumor effects of chemotherapy and radiotherapy. This study aimed to assess the efficacy of neoadjuvant concomitant radiotherapy, hyperthermia, and chemotherapy (RHC) for salvage of recurrent or residual malignant STS. METHODS: We identified 64 patients with recurrent or residual STS treated between 1994 and 2013. After excluding those with low-grade malignancy, with recurrent bone tumor in the soft tissues, with truncal STS, and who declined to participate, 23 patients (7 with recurrence and 16 with residual tumor) underwent RHC. The histologic diagnoses were undifferentiated pleomorphic sarcoma (n = 11), synovial sarcoma (n = 3), leiomyosarcoma and myxoid liposarcoma (n = 2 each), and other histologic types. As primary outcomes, the 5-year overall survival (OS), distant metastasis-free survival (D-MFS), and local control (LC) rates were evaluated by Kaplan-Meier analysis. RESULTS: The median follow-up period was 112.3 months. The 5-year OS, D-MFS, and LC were 86.4%, 77.4%, and 86.7%, respectively. In the univariate analysis, tumor depth was considered as a negative prognostic factor for OS and D-MFS, and a positive margin was also a negative prognostic factor for OS, D-MFS LC with retained on Cox proportional hazards model in OS, and D-MFS. CONCLUSION: RHC is an effective option for salvage treatment of recurrent and residual STS.

Continuous Peripheral Nerve Blocks for Early Active Mobilization after Hand Surgery: Four Case Reports.

Early active mobilization after hand surgery is extremely important for preventing scar tissue and adhesion. We examined four patients for whom continuous peripheral nerve blocks (CPNB) were used during and after hand surgery. This method was used for three median nerves and one ulnar nerve. A 2-cm incision was made at distal one-third of the forearm with local analgesia. The catheter tip was placed in the distal one-fourth of the forearm, and the hand surgery was begun. Early active mobilization and the self-rehabilitation exercise started immediately after the operation. The VAS scores during exercise were 0-2 (mean: 1.3); pain was controlled sufficiently. Regarding ROM, excellent results were obtained for tenolysis, with good results for arthrolysis. No infection or postoperative nerve compression was found. This method, using CPNB with a portable infusion pump, is effective and safe for use at home for postoperative pain control.

Anatomical Basis for Arthroscopy of the Proximal Interphalangeal Joints.

BACKGROUND: Arthroscopy is a widely used minimally invasive technique. Nevertheless, no report describes the arthroscopic anatomy of the proximal interphalangeal (PIP) joint for portal creation. To facilitate arthroscopy, this study elucidated the anatomy of the lateral bands of the extensor mechanism and collateral ligaments of PIP joints. METHODS: A total of 39 fingers from the right hands of 10 cadavers (4 males, 6 females) were evaluated in this study. We defined the extension line from the proximal interphalangeal volar crease as the C-line. We also defined an imaginary line along the distal edge of the proximal phalanx, which is parallel to the C-line, as the J-line. The distance between J-line and C-line was measured. On the C-line and J-line, we measured the following: from the dorsal skin to the lateral edge of the lateral band (LB), the dorsal edge of the collateral ligament (CL) and from the lateral band and the collateral ligament (D), the width of the finger (W). The finger half-width (M) was measured on the J-line. Comparison between the digits and comparison between radial and ulnar distance were measured and statistical analysis was performed. RESULTS: All PIP joint spaces were distal from the C-line, except for one ring finger. The average distances between the J-line and C-line were 1.8-3.2 mm. On the C-line, only 11 cases (14.1%) showed an interval between the lateral bands and the collateral ligaments, but, on the J-line 72, cases (92.3%) had such an interval. The interval was located 1.6-2.9 mm in a dorsal direction from the midlateral on the J-line. CONCLUSIONS: Portal creation at the J-line is safer than at the C-line. This study revealed that safe portals for arthroscopy of the PIP joint are 2 mm dorsal to the midlateral line of the finger on the J-line.

Comparison of Stand-Alone, Transpsoas Lateral Interbody Fusion at L3-4 and Cranial vs Transforaminal Interbody Fusion at L3-4 and L4-5 for the Treatment of Lumbar Adjacent Segment Disease.

STUDY DESIGN: Retrospective cohort study. OBJECTIVE: To compare outcomes and complications of stand-alone minimally invasive lateral interbody fusion (LIF) vs revision posterior surgery for the treatment of lumbar adjacent segment disease. METHODS: Adults who underwent LIF or transforaminal lumbar interbody fusion (TLIF) for adjacent segment disease were compared. Exclusion criteria: >grade 1 spondylolisthesis, posterior approach after LIF, and L5/S1 surgery. Patient demographics, estimated blood loss, hospital length of stay, complications, reoperations, health-related quality of life measures, and radiographs were examined. Data were analyzed with the χ2, Wilcoxon signed rank, and Mann-Whitney U tests. RESULTS: A total of 17 LIF and 16 TLIF patients were included. Demographics were similar. Follow up was similar (LIF: 22.9 ± 11.8 months vs TLIF: 22.0 ± 4.6 months; P = .86). The LIF patients had significantly less blood loss (LIF: 36 ± 16 mL vs TLIF: 700 ± 767 mL; P < .001) and shorter length of stay (LIF: 2.6 ± 2.9 days vs TLIF: 3.3 ± 0.9 days; P = .001). There were no intraoperative complications. Revision rate was 4 of 17 in LIF and 3 of 16 in TLIF (P = .73). Baseline health-related quality of life and radiographic measurements were similar. In both groups, back and leg pain scores significantly improved, and in LIF, the Owestry Disability Index, and EuroQol-5D significantly improved. The LIF had a significant increase in intervertebral height (LIF: 4.8 ± 2.9 mm, P < .001, TLIF: 1.3 ± 3.4 mm, P = .37), which was significantly greater for LIF than TLIF (P = .002). Similarly, LIF had a significant increase in segmental lordosis (LIF: 5.6° ± 4.9°, P < .001, TLIF: 3.6° ± 8.6°, P = .16), which was not significantly different between groups. CONCLUSIONS: Patients with adjacent segment disease may receive significant benefit from stand-alone LIF or TLIF. The LIF offers advantages of less blood loss and a shorter hospital stay. LEVEL OF EVIDENCE: 3.

Treatment of aneurysmal bone cysts using endoscopic curettage.

BACKGROUND: Although aneurysmal bone cysts (ABCs) are benign tumours, they have the potential to be locally aggressive. Various treatment approaches, such as en bloc resection, open curettage, radiotherapy, sclerotherapy, and embolization have been proposed, but the most appropriate treatment should be selected after considering the risk of tumour recurrence and treatment complications. Endoscopic curettage (ESC) may be a less invasive alternative to open curettage for ABC treatment. We aimed to describe the use of ESC for the treatment of ABCs and to report our clinical outcomes, including the incidence rate of recurrence, radiological appearance at final follow-up, time to solid union, complications, and postoperative function. METHODS: Between 1998 and 2015, 30 patients (18 men and 12 women; mean age, 17.4 years) underwent ESC for the treatment of primary ABCs at our hospital (mean postoperative follow-up, 55 months). ESC was performed under arthroscopic guidance for direct visualization, and curettage extended until normal bone was observed in the medullary cavity. To investigate bone healing after ESC, we evaluated the consolidation of cysts at the final evaluation (based on the modified Neer classification) and time to solid union after surgery, which was defined as sufficient cortical bone thickness to prevent fracture and allow physical activities. RESULTS: Recurrence was identified in 3 cases (10%). Curative outcomes were obtained after repeated ESC or open curettage. A log-rank analysis indicated that age < 10 years (p = 0.004) and contact of the tumour with the physis (p = 0.01) increased the risk of tumour recurrence. Residual tumours were identified in 9 cases (30%); these lesions remained inactive over the extended follow-up period. The average time to solid union after endoscopic curettage was 3.2 months. Transient radial nerve palsy was identified in 1 case. Good postoperative functional recovery occurred in all cases. CONCLUSIONS: ESC is a minimally invasive technique for the treatment of ABCs, and the tumour recurrence rate is comparable to that of other standard procedures. However, the application of this method should be carefully considered, especially for patients < 10 years and when the tumour comes in contact with the physis.

Treatment of simple bone cysts using endoscopic curettage: a case series analysis.

BACKGROUND: Endoscopic curettage is considered applicable for the treatment of simple bone cysts with the expectation that it might be less invasive than open curettage. In this study, we investigated the efficacy of endoscopic curettage for the treatment of simple bone cysts. The goal was to investigate the incidence of cyst recurrence and bone healing after endoscopic curettage. Moreover, complications and functionality at the final follow-up were evaluated. METHODS: From 2003 to 2014, 37 patients with simple bone cysts underwent endoscopic curettage. Twenty-four were male and 13 were female, with a mean age of 14.7 years. Endoscopic curettage was performed with the support of an arthroscope via 7-8 mm holes penetrated by cannulated drills with a small incision. The cysts underwent curettage using angled curettes, rongeurs, and an electrical shaver until the normal bone was observed in the medullary cavity. To investigate the bone healing after endoscopic curettage, we evaluated the consolidation of the cyst at the final evaluation (Modified Neer Classification) and the time to solid union after operation, which was defined as the sufficient thickness of the cortical bone to prevent fracture and allow physical activities. RESULTS: Recurrence occurred in seven patients (18.9%). A log-rank analysis revealed that contact with the physis was associated with recurrence (p = 0.006). Among 31 patients (83.7%), the consolidation of cyst was considered healed at the final X-ray follow-up period, and in these patients, the mean time taken for solid union of cortical bone thinning was 4.0 months (standard deviation, 2.4). With regard to major complications of endoscopic curettage, a transient radial nerve palsy and two postoperative fractures occurred. The former problem was managed conservatively and the latter problems by transient internal fixation; these problems were managed without any further complications. All patients had a good postoperative function. CONCLUSIONS: Endoscopic curettage might be a useful alternative as it is a minimally invasive procedure for the treatment of simple bone cysts. Considering the relatively smaller size of this study, further investigation should be necessary for deducing the reliable conclusion.

Preoperative evaluation of the efficacy of radio-hyperthermo-chemotherapy for soft tissue sarcoma in a case series.

PURPOSE: Radio-hyperthermo-chemo (RHC) therapy, which combines radiotherapy, hyperthermia, and chemotherapy, for malignant soft tissue tumors has been introduced with the aim of decreasing the possibility of local recurrence after surgery. To avoid unnecessary neoadjuvant therapy and to plan the appropriate surgical treatment, surveillance of RHC therapeutic efficacy during treatment is necessary. In this study, we determined the optimal response criteria to evaluate the efficacy of RHC by comparing preoperative images before and after RHC with pathological evaluation of necrosis in the resected tumor. PATIENTS AND METHODS: From 2004 to 2014, 20 patients were enrolled into this study. Needle biopsy revealed 6 cases of myxoid liposarcoma, 6 cases of undifferentiated pleomorphic sarcoma, 4 cases of myxofibrosarcoma, and 4 cases of synovial sarcoma. Based on the Response Evaluation Criteria in Solid Tumors (RECIST) 1.1 or modified RECIST, we calculated the responses to RHC therapy by comparing pre- and post-RHC therapy images. In addition, resected specimens underwent pathological analysis to evaluate response based on tumor necrosis. The correlation between assessment based on preoperative images and resected tumors were evaluated by the Spearman's rank-order correlation coefficient. RESULT: From the surgical specimens, pathological assessment of necrosis in resected tumor were assessed as less than 50% (2 cases), 50-90% (9 cases), 90-99% (6 cases), and total necrosis (3 cases). Use of the RECIST 1.1 underestimated good responders as stable disease (SD) or progressive disease (PD) in 5 out of 15 cases; on the other hand, use of the modified RECIST did not underestimate the pathological assessment of necrosis. The correlations between responses based on preoperative images and those based on histological assessments were 0.23 (RECIST 1.1) and 0.76 (modified RECIST). CONCLUSION: Because pathological responses can be underestimated using the RECIST 1.1, the modified RECIST, which take into consideration tumor viability, as assessed by contrast MRI, should also be considered when evaluating the efficacy of RHC.

Advantages of an on-the-screwhead crosslink connector for atlantoaxial fixation using the Goel/Harms technique.

The goal of fixation surgery for atlantoaxial instability is to achieve solid bony fusion. Achieving bony fusion as early as possible is beneficial for patients. Although placement of a transverse cross-link connector (XL) provides greater biomechanical strength, XLs have not been able to be placed when performing the Goel/Harms procedure. Recently, placing a XL on the screw head (on-the-head XL [OH-XL]) has become a viable option during the Goel/Harms procedure. However, there is little evidence demonstrating whether applying an OH-XL achieves early solid bony union. A matched-control study was conducted to investigate whether placing an OH-XLs in C1/2 fixation surgery provides earlier bone union or not. Eighteen patients who underwent atlantoaxial fusion with OH-XLs (X-group), and 17 age and sex-matched patients without OH-XLs (NX-group) were compared. Bony union was assessed using reconstructed sagittal and coronal computed tomography images. Six months after surgery, six patients in the X-group and one patient in the NX-group achieved bony union (p = .0338). One year after surgery, 14 patients in the X-group and 4 patients in the NX-group achieved bone union (p = .0010). Two years after surgery, 17 patients in the X-group and 9 patients in the NX-group achieved bony union (p = .0011). This is the first report of the clinical application of OH-XLs for the Goel/Harms procedure. OH-XLs yield earlier bony fusion; thus, placing OH-XLs is beneficial for atlantoaxial fixation surgery using lateral mass screws of the atlas.

Clinical outcomes of radio-hyperthermo-chemotherapy for soft tissue sarcoma compared to a soft tissue sarcoma registry in Japan: a retrospective matched-pair cohort study.

Regional hyperthermia is considered to enhance the antitumor effects of chemotherapy and radiotherapy. In this study, we confirmed the efficacy of concomitant radiotherapy, hyperthermia, and chemotherapy (RHC) for neoadjuvant treatment of malignant soft tissue sarcoma (STS). From 1994 to 2013, we performed RHC in 150 patients. This study was limited to 60 patients using the following exclusion criteria: salvage for recurrence or unplanned excision, trunk location, metastasis at initiation, non-STS, and no definitive surgery. As a control group, we collected data from 11,031 patients in the Bone and Soft Tissue Tumor Registry in Japan (BSTT). We performed multivariate logistic regression analysis, and propensity scores were created for comparisons between groups. The primary outcome of this study was to compare oncologic outcomes (5-year local control rate [LC] and overall survival rate [OS]). In the RHC group, two local recurrences (3.3%) occurred, and no patients underwent amputation. Margins of definitive surgery were not identical between groups [wide margins (60.0% vs. 85.3%), marginal margins (28.3% vs. 10.5%), and intralesional margins (7.4% vs. 4.2%), RHC and BSTT groups, respectively, P < 0.001]. After adjustment, the difference in OS was not significant between groups (HR = 1.26, P = 0.532); however, a statistically significant difference in LC was observed (HR = 4.82, P = 0.037). RHC resulted in a high LC at 5 years compared to the BSTT group, and amputation was averted in the RHC group, despite the wider margins in the BSTT group. This indicates that less invasive surgery might be achieved with effective neoadjuvant therapy.

Global Spinal Alignment in Cervical Kyphotic Deformity: The Importance of Head Position and Thoracolumbar Alignment in the Compensatory Mechanism.

BACKGROUND: Previous studies have evaluated cervical kyphosis (C-kypho) using cervical curvature or chin-brow vertical angle, but the relationship between C-kypho and global spinal alignment is currently unknown. OBJECTIVE: To elucidate global spinal alignment and compensatory mechanisms in primary symptomatic C-kypho using full-spine radiography. METHODS: In this retrospective multicenter study, symptomatic primary C-kypho patients (Cerv group; n = 103) and adult thoracolumbar deformity patients (TL group; n = 119) were compared. We subanalyzed Cerv subgroups according to sagittal vertical axis (SVA) values of C7 (SVAC7 positive or negative [C7P or C7N]). Various Cobb angles (°) and SVAs (mm) were evaluated. RESULTS: SVAC7 values were -20.2 and 63.6 mm in the Cerv group and TL group, respectively (P < .0001). Various statistically significant compensatory curvatures were observed in the Cerv group, namely larger lumbar lordosis (LL) and thoracic kyphosis. The C7N group had significantly lower SVACOG (center of gravity of the head) and SVAC7 (32.9 and -49.5 mm) values than the C7P group (115.9 and 45.1 mm). Sagittal curvatures were also different in T4-12, T10-L2, LL4-S, and LL. The value of pelvic incidence (PI)-LL was different (C7N vs C7P; -2.2° vs 9.9°; P < .0003). Compensatory sagittal curvatures were associated with potential for shifting of SVAC7 posteriorly to adjust head position. PI-LL affected these compensatory mechanisms. CONCLUSION: Compensation in symptomatic primary C-kypho was via posterior shifting of SVAC7, small T1 slope, and large LL. However, even in C-kypho patients, lumbar degeneration might affect global spinal alignment. Thus, global spinal alignment with cervical kyphosis is characterized as head balanced or trunk balanced.

Comparison of quantitative evaluation between cutaneous and transosseous inertial sensors in anterior cruciate ligament deficient knee: A cadaveric study.

BACKGROUND: Recently several authors have reported on the quantitative evaluation of the pivot-shift test using cutaneous fixation of inertial sensors. Before utilizing this sensor for clinical studies, it is necessary to evaluate the accuracy of cutaneous sensor in assessing rotational knee instability. To evaluate the accuracy of inertial sensors, we compared cutaneous and transosseous sensors in the quantitative assessment of rotational knee instability in a cadaveric setting, in order to demonstrate their clinical applicability. METHODS: Eight freshly frozen human cadaveric knees were used in this study. Inertial sensors were fixed on the tibial tuberosity and directly fixed to the distal tibia bone. A single examiner performed the pivot shift test from flexion to extension on the intact knees and ACL deficient knees. The peak overall magnitude of acceleration and the maximum rotational angular velocity in the tibial superoinferior axis was repeatedly measured with the inertial sensor during the pivot shift test. Correlations between cutaneous and transosseous inertial sensors were evaluated, as well as statistical analysis for differences between ACL intact and ACL deficient knees. RESULTS: Acceleration and angular velocity measured with the cutaneous sensor demonstrated a strong positive correlation with the transosseous sensor (r = 0.86 and r = 0.83). Comparison between cutaneous and transosseous sensor indicated significant difference for the peak overall magnitude of acceleration (cutaneous: 10.3 ± 5.2 m/s2, transosseous: 14.3 ± 7.6 m/s2, P < 0.01) and for the maximum internal rotation angular velocity (cutaneous: 189.5 ± 99.6 deg/s, transosseous: 225.1 ± 103.3 deg/s, P < 0.05), but no significant difference for the maximum external rotation angular velocity (cutaneous: 176.1 ± 87.3 deg/s, transosseous: 195.9 ± 106.2 deg/s, N.S). CONCLUSIONS: There is a positive correlation between cutaneous and transosseous inertial sensors. Therefore, this study indicated that the cutaneous inertial sensors could be used clinically for quantifying rotational knee instability, irrespective of the location of utilization.

Temporary Internal Fixation Using C1 Lateral Mass Screw and C2 Pedicle Screw (Goel-Harms Technique) without Bone Grafting for Chronic Atlantoaxial Rotatory Fixation.

BACKGROUND: The primary treatment strategy for chronic atlantoaxial rotatory fixation (chro-AARF) is traction followed by bracing or application of a halo device. However, to complete these conservative therapies, patient cooperation is mandatory. If conservative therapy fails, surgery is required for reduction and prevention of recurrence. It has been considered that surgery for atlantoaxial rotatory fixation necessitates solid bony fusion. However, once bony fusion is achieved, loss of range of motion is problematic. Here, we report a patient with chro-AARF who was successfully treated with temporary internal fixation using a C1 lateral mass screw and C2 pedicle screw (Goel-Harms technique) without any grafting of bone or use of bone substitute materials. CASE DESCRIPTION: A 9-year-old boy with chro-AARF was referred to our institution. He had a history of pervasive developmental disorders. He did not cooperate for the completion of conservative therapy and could not tolerate this therapy. Therefore, the orthopedic staff and his parents considered surgery. Under general anesthesia, reduction was easily performed. The Goel-Harms screw-rod construct was completed as a temporary internal fixator without any grafting of bone or use of bone substitute materials. After 6 months, the screw-rod construct was removed. Removal of the screw-rod construct was performed easily without complication. There was no ankylosis of the C1-2 joint, and cervical range of motion was maintained 2.8 years after removal of the construct. CONCLUSIONS: When conservative therapy cannot be continued, Goel-Harms surgery as a temporary internal fixator without bone grafting might be a suitable alternative for selected patients with chro-AARF.

Complications Associated With Lateral Interbody Fusion: Nationwide Survey of 2998 Cases During the First 2 Years of Its Use in Japan.

STUDY DESIGN: Retrospective nationwide questionnaire-based survey of complications. OBJECTIVE: To elucidate the incidence of complications and risk factors associated with lateral interbody fusion (LIF). SUMMARY OF BACKGROUND DATA: After its introduction to Japan in February 2013, the numbers of LIF cases have increased substantially because of the advantages of this minimally invasive procedure. However, LIF has the potential risk of several complications unique to the procedure. Although there are many reports of complications, no nationwide survey has been conducted. METHODS: Questionnaires were sent to all Japanese Society for Spine Surgery and Related Research (JSSR) members. Questionnaires requested information about surgical procedures (XLIF or OLIF), patient characteristics, preoperative diagnosis, complications, salvage procedures, final outcomes, and the surgeon's experience of LIF. The data from replies received between March 2013 and April 2015 were recorded on a web site and the details of complications were analyzed by a JSSR research team. RESULTS: Seventy-one institutions (12.3%) answered "yes" to LIF experience and 2998 cases (1995 XLIF and 1003 OLIF) were enrolled in this study. The response rate was 86.1%. A total of 540 complications were reported, of which 474 (84.8%) could be further analyzed. The overall complication rate was 18.0%. The most frequent complications were sensory nerve injury (5.1%) and psoas weakness (4.3%) and the majority resolved spontaneously. The rates of major vascular injury, bowel injury, and surgical site infection were 0.03%, 0.03%, and 0.7%, respectively. The overall reoperation rate was 2.2%. Higher rates of sensory nerve injury and psoas weakness were reported for XLIF and higher rates of peritoneal laceration and ureteral injury were reported for OLIF. CONCLUSION: A nationwide survey of complications associated with LIF was conducted. Although the majority of complications were minor, a relatively high rate of complications was reported. Approach-related specific features of the two procedures were identified. LEVEL OF EVIDENCE: 4.