Impact of osteosclerosis on cervical pedicle screw insertion using preoperative CT-based navigation.

PURPOSE: Preoperative computed tomography (CT)-based navigation is used for cervical pedicle screw (CPS) insertion to mitigate the risk of spinal cord and vertebral artery injury. In vertebrae with osteosclerosis due to degeneration or other factors, however, probing may not proceed easily, with difficulty creating the CPS insertion hole. This study investigated the impact of osteosclerosis on the accuracy of CPS insertion. METHODS: A total of 138 patients with CPS inserted at the C3-C7 level using preoperative CT navigation were retrospectively analyzed. Pre- and postoperative CT was employed to investigate screw position and Hounsfield unit (HU) values at the lateral mass to evaluate the degree of osteosclerosis in the CPS insertion pathway. RESULTS: Among 561 CPS insertions, the Grade 3 perforation rate was 1.8%, and the Grade 2 or higher perforation rate was 8.0%. When comparing insertions with and without CPS perforation, HU values were significantly higher in the perforation group (578 ± 191 vs. 318 ± 191, p < 0.01). The frequency of CPS insertion into the mid-cervical spine was also significantly greater in the perforation group (68.9% vs. 62.5%, p < 0.01). Logistic regression analysis revealed that a high HU value at the lateral mass (odds ratio 1.09, 95% confidence interval: 1.07-1.11, p < 0.01) was a significant independent factor associated with CPS deviation. CONCLUSIONS: The screw perforation rate of Grade 2 or higher in CPS insertion using preoperative CT-based navigation was 8.0%. Since osteosclerosis was an independent factor related to CPS deviation, additional care may be required during insertion into affected vertebrae.

Neurological recovery rate and predictive factors of incomplete AIS grade C spinal cord injury in the older aged population.

STUDY DESIGN: Retrospective cohort study. OBJECTIVES: To define the prognosis and predictive factors for neurological improvement in older patients with incomplete spinal cord injury (SCI) of American Spinal Injury Association Impairment Scale grade C (AIS-C). SETTINGS: Multi-institutions in Japan. METHODS: We included patients aged ≥65 years with traumatic SCI of AIS-C who were treated conservatively or surgically with >3 follow-up months. To identify factors related to neurological improvement, patients were divided into three groups according to their neurological status at the final follow-up, with univariate among-group comparisons of demographics, radiographic, and therapeutic factors. Significant variables were included in the multivariate logistic regression analysis. RESULTS: Overall, 296 older patients with SCI of AIS-C on admission were identified (average age: 75.2 years, average follow-up: 18.7 months). Among them, 190 (64.2%) patients improved to AIS-D and 21 (7.1%) patients improved to AIS-E at final follow-up. There were significant among-group differences in age (p = 0.026), body mass index (p = 0.007), status of pre-traumatic activities of daily living (ADL) (p = 0.037), and serum albumin concentrations (p = 0.011). Logistic regression analysis showed no significant differences in variables in the stratified group of patients who improved to AIS-D. Meanwhile, serum albumin was a significant variable in patients who improved to AIS-E (p = 0.026; OR: 6.20, pre-traumatic ADL was omitted due to data skewness). CONCLUSIONS: Most older patients with incomplete AIS-C SCI demonstrated at least 1 grade of neurological improvement. However, <10% of patients achieved complete recovery. Key predictors of complete recovery were high serum albumin levels on admission and independent pre-traumatic ADL. SPONSORSHIP: No funding was received for this study.

Association between restricted outings and geriatric locomotive function scale score in the general elderly population during the COVID-19 pandemic.

BACKGROUND: Restrictions in daily activities due to coronavirus infection countermeasures reduced opportunities for physical activity and social participation in people of all ages. This study investigated the associations of restricted outings on locomotive function during the COVID-19 pandemic using a cohort of middle-aged and elderly community-dwelling residents. METHODS: Registered citizens of 50-89 years old were targeted for this investigation. We established 8 groups based on age (50's, 60's, 70's, and 80's) and gender (male and female) after random sampling from the basic resident registry of Obuse town in 2014. All participants were surveyed by a 25-question geriatric locomotive function scale (GLFS-25) at the time of checkup before the COVID-19 pandemic. Then, in 2021 and 2022 after government restrictions on outings were lifted for COVID-19 pandemic, all participants were mailed questionnaires including the GLFS-25. A total of 296 (143 male and 153 female) participants who responded at least once were included. We evaluated the changes in opportunities to go out between pre- and post-pandemic time points and the impact on GLFS-25 scores. RESULTS: In total, 128 (43.2%) respondents had fewer opportunities to go out than the previous year. Pre- and post-pandemic GLFS-25 scores in the decreased outing (+) group were significantly worse than in the decreased outing (-) group (both p < 0.01). The final multivariate model revealed GLFS-25 score worsening beta coefficient of 0.27 for age (+10 years), 3.97 for male, 4.54 for decreased outings, and 4.46 for spinal canal stenosis. CONCLUSIONS: In this randomly sampled Japanese cohort based on a resident registry, restricted outings during the COVID-19 pandemic was a significant independent factor associated with lower locomotive function.

Influence of the timing of surgery for cervical spinal cord injury without bone injury in the elderly: A retrospective multicenter study.

BACKGROUND: Although previous studies have demonstrated the advantages of early surgery for traumatic spinal cord injury (SCI), the appropriate surgical timing for cervical SCIs (CSCIs) without bone injury remains controversial. Here, we investigated the influence of relatively early surgery within 48 h of injury on the neurological recovery of elderly patients with CSCI and no bone injury. METHODS: In this retrospective multicenter study, we reviewed data from 159 consecutive patients aged ≥65 years with CSCI without bone injury who underwent surgery in participating centers between 2010 and 2020. Patients were followed up for at least 6 months following CSCI. We divided patients into relatively early (≤48 h after CSCI, n = 24) and late surgery (>48 h after CSCI, n = 135) groups, and baseline characteristics and neurological outcomes were compared between them. Multivariate analysis was performed to identify factors associated with neurological recovery. RESULTS: The relatively early surgery group demonstrated a lower prevalence of cardiac disease, poorer baseline American Spinal Injury Association (ASIA) impairment scale grade, and lower baseline ASIA motor score (AMS) than those of the late surgery group (P < 0.030, P < 0.001, and P < 0.001, respectively). Although the AMS was lower in the relatively early surgery group at 6 months following injury (P = 0.001), greater improvement in this score from baseline to 6-months post injury was observed (P = 0.010). Multiple linear regression analysis revealed that relatively early surgery did not affect postoperative improvement in AMS, rather, lower baseline AMS was associated with better AMS improvement (P < 0.001). Delirium (P = 0.006), pneumonia (P = 0.030), and diabetes mellitus (P = 0.039) negatively influenced postoperative improvement. CONCLUSIONS: Although further validation by future studies is required, relatively early surgery did not show a positive influence on neurological recovery after CSCI without bone injury in the elderly.

Reduction in CT scan number with the reference frame middle attachment method in intraoperative CT navigation for adolescent idiopathic scoliosis.

PURPOSE: Elucidate whether it is preferable to use the reference frame (RF) middle attachment (RFMA) method over the edge of the planned pedicle screw (PS) insertion area for RF placement in the surgery for adolescent idiopathic scoliosis (AIS) with intraoperative computed tomography (CT) navigation. METHODS: Eighty-six consecutive patients (76 female and 10 male; mean age: 15.9 years) with AIS who underwent posterior spinal fusion using intraoperative CT navigation were enrolled. The group with the RF placed at the most distal part of the CT scan range was defined as the distal group (Group D), with other placements classified into the middle group (Group M). PS perforation rate and surgical outcome were compared between the groups. RESULTS: There was no significant difference in perforation rate between Group M and Group D (3.4% vs. 3.0%, P = 0.754). The mean ± standard deviation number of instrumented vertebrae at the first CT scan was significantly higher in Group M (8.2 ± 1.2 vs. 6.3 ± 1.2, P < 0.001), while mean blood loss was significantly lower (266 ± 185 mL vs. 416 ± 348 mL, P = 0.011). The frequency of needing a second CT scan for PS insertion was significantly lower in Group M (38% vs. 69%, P = 0.04). CONCLUSION: The RFMA method in thoracic scoliosis surgery for AIS with intraoperative CT navigation could significantly decrease the number of CT scans and blood loss while maintaining a comparable PS perforation rate to RF placement at the distal end of the planned PS insertion range.

Comparison of spinous process-splitting laminectomy versus posterolateral fusion for lumbar degenerative spondylolisthesis.

BACKGROUND: Although several studies have recently shown that spinous process-splitting laminectomy (SPSL) maintains lumbar spinal stability by preserving posterior ligament components and paraspinal muscles as compared with conventional laminectomy, evidence is scarce on the treatment outcomes of SPSL limited to lumbar degenerative spondylolisthesis. We herein compare the surgical results and global alignment changes for SPSL versus posterolateral lumbar fusion (PLF) without instrumentation for lumbar degenerative spondylolisthesis. METHODS: A total of 110 patients with Grade 1 lumbar degenerative spondylolisthesis who had undergone SPSL (47 patients) or PLF (63 patients) with minimum 1-year follow-up were retrospectively enrolled from a single institutional database. RESULTS: Mean operating time per intervertebral level and intraoperative blood loss per intervertebral level were comparable between the SPSL group and PLF group. Japanese Orthopaedic Association scores, Oswestry disability index, and visual analog scale scores were significantly and comparably improved at 1 year postoperatively in both groups as compared with preoperative levels. The numbers of vertebrae with slip progression to Grade 2 and slip progression of 5% or more at 1 year postoperatively were similar between the groups. In the SPSL group, mean pelvic tilt (PT) was significantly decreased at 1 year postoperatively. In the PLF group, mean lumbar lordosis (LL) was significantly increased, while mean sagittal vertical axis, PT, and pelvic incidence-LL were significantly decreased at 1 year after surgery. CONCLUSIONS: Compared with PLF without instrumentation, SPSL for Grade 1 lumbar degenerative spondylolisthesis displayed comparable results for slip progression and clinical outcomes at 1 year postoperatively.

Prognostic impact of respiratory dysfunction in elderly patients with cervical spinal cord injury and/or fractures: a multicenter survey.

PURPOSE: To investigate the impact of early post-injury respiratory dysfunction for neurological and ambulatory ability recovery in patients with cervical spinal cord injury (SCI) and/or fractures. METHODS: We included 1,353 elderly patients with SCI and/or fractures from 78 institutions in Japan. Patients who required early tracheostomy and ventilator management and those who developed respiratory complications were included in the respiratory dysfunction group, which was further classified into mild and severe respiratory groups based on respiratory weaning management. Patient characteristics, laboratory data, neurological impairment scale scores, complications at injury, and surgical treatment were evaluated. We performed a propensity score-matched analysis to compare neurological outcomes and mobility between groups. RESULTS: Overall, 104 patients (7.8%) had impaired respiratory function. In propensity score-matched analysis, the respiratory dysfunction group had a lower home discharge and ambulation rates (p = 0.018, p = 0.001, respectively), and higher rate of severe paralysis (p < 0.001) at discharge. At the final follow-up, the respiratory dysfunction group had a lower ambulation rate (p = 0.004) and higher rate of severe paralysis (p < 0.001). Twenty-six patients with severe disability required respiratory management for up to 6 months post-injury and died of respiratory complications. The mild and severe respiratory dysfunction groups had a high percentage of severe paraplegic cases with low ambulatory ability; there was no significant difference between them. The severe respiratory dysfunction group tended to have a poorer prognosis. CONCLUSION: Respiratory dysfunction in elderly patients with SCI and/or cervical fracture in the early post-injury period reflects the severity of the condition and may be a useful prognostic predictor.

Anatomical implications of the subvastus approach on major vascular injury during a distal femoral osteotomy: a computed tomographic venography study.

PURPOSE: This study evaluated major vascular injury risk in distal femoral osteotomy (DFO) via the subvastus approach and examined the relationship between the posterior border of the vastus medialis (VM) and the superficial femoral artery (SFA) and vein (SFV). METHODS: Eighty limbs from 80 patients were evaluated using lower extremity computed tomographic venography. The positional relationship between the VM, SFA, and SFV was evaluated by measuring the angle between each structure and the horizontal reference point (VMA: VM angle, FAA (femoral arterial angle), FVA (femoral venous angle) and the distance between VM and the SFA and SFV (VMAD: VM-arterial distance, VMVD: VM-venous distance) in each axial slice (0/10/20/30/40 mm) proximal to the level of the superior patellar margin. The proximity of the posterior border of the VM and the SFA/SFV as a vertical distance, measured between the slice of the superior border of the patella and the slice where the posterior border of the VM contacted the SFA was evaluated. Single and multiple regression analyses were performed using the vertical distance as the objective variable. RESULTS: As the slice shifted proximally, the VMA significantly increased (24.9 ± 8.5, 36.3 ± 8.8, 47.4 ± 11.8, 59.9 ± 14, 70.3 ± 13.7 degrees, respectively, p < 0.001 between all slices) and moved posteromedially from a medial direction. FAA (94.2 ± 7, 86.9 ± 9.2, 78.4 ± 9.7, 71.4 ± 9.8, 66.6 ± 10.5 degree, respectively, p < 0.001 between all slices) and FVA (100.6 ± 4.9, 98.3 ± 5.9, 93.7 ± 7.5, 88 ± 9.2, 81.1 ± 10.5 degrees, respectively, p < 0.001 between all slices) decreased and moved from a posterolateral to a posteromedial direction, while VMAD (35.4 ± 7.8, 24.1 ± 7.3, 14.3 ± 6, 8.4 ± 7, 6.2 ± 6.3 mm, respectively, p < 0.001 between all slices) and VMVD significantly decreased (42.7 ± 7.3, 32 ± 7.4, 22.4 ± 6.8, 14.5 ± 10.6, 8.7 ± 7.1 mm, respectively, p < 0.001 between all slices). The average vertical distance was 36 ± 9.3 mm (range 18.6-61.5 mm). The body height and the patellar length significantly affected the vertical distance. CONCLUSION: The posterior border of the VM shifted posteromedially from distal to proximal and contacted the SFA at an average of 36 mm from the suprapatellar border. Surgeons should be aware of the risk of major vascular injury during exposure and osteotomy. LEVEL OF EVIDENCE: Case series, Level IV.

Prevalence and Associated Factors for Primary Osteoarthritis of the Scaphotrapeziotrapezoid, Radiocarpal, and Distal Radioulnar Joints in the Japanese General Elderly Population.

PURPOSE: The incidence and etiology of primary osteoarthritis (OA) of the scaphotrapeziotrapezoid joint (STTJ), radiocarpal joint (RCJ), and distal radioulnar joint (DRUJ) remains unknown. The purpose of this study was to evaluate the prevalence and factors associated with primary wrist OA in a cross-sectional study of a basic resident registry. METHODS: A total of 1,297 residents between the ages of 50 and 89 years were randomly sampled from the registry of a Japanese town. A questionnaire was administered to all subjects, and each of them underwent radiographs of the bilateral hands, wrists, and elbows. STTJ, RCJ, and DRUJ radiographic osteoarthritis (ROA) were evaluated according to a previously described method. Associated factors for STTJ and DRUJ ROA were recorded. Associations between the incidence of ROA of the DRUJ, ulnar variance, and severity of elbow ROA were investigated. RESULTS: A total of 676 wrists (162 men and 176 women; mean age of 69.0 years) were investigated. The prevalence of STTJ, RCJ, and DRUJ ROA was 5.3%, 1.5%, and 21.2%, respectively. Factors associated with STTJ ROA were thumb carpometacarpal joint ROA, female sex, and increasing age. Factors associated with DRUJ ROA were elbow ROA, use of vibrating tools, increasing age, and positive ulnar variance. Prevalence of DRUJ ROA was 54.4% in wrists with severe-grade elbow ROA. Ulnar variance of the wrist in severe-grade elbow ROA was significantly larger than that in mild-grade or nonelbow ROA. CONCLUSIONS: The prevalence of ROA was highest in the DRUJ, followed by the STTJ, and lowest in the RCJ. The occurrence of ROA of the STTJ and DRUJ was affected by the presence of ROA of the adjacent joint. CLINICAL RELEVANCE: Primary DRUJ ROA occurs at a moderate frequency, similar to primary ROA of other extremity joints; however, primary STTJ and RCJ ROA is rare.

Worsening ambulation in elderly patients with cervical odontoid fractures: A nationwide multicenter study in Japan.

BACKGROUND: Despite the increasing prevalence of cervical odontoid fractures in older adults, the treatment strategy is controversial. The objectives of the current study are to investigate the prognosis and complications of cervical odontoid fractures in elderly patients and to identify factors associated with worsening of ambulation after 6 months. METHODS: This multicenter, retrospective study included 167 patients aged 65 years or older with odontoid fractures. Patient demographic and treatment data were investigated and compared according to the treatment strategy. To determine associations with worsening ambulation after 6 months, we focused on the treatment strategies (nonsurgical treatment [collar immobilization or halo vest], conversion to surgery, or initial surgery) and patients' background. RESULTS: Patients who received nonsurgical treatment were significantly older, and patients who underwent surgery had more Anderson-D'Alonzo type 2 fractures. Of the patients initially treated nonsurgically, 26% later underwent surgery. Numbers of complications, including death, and degrees of ambulation after 6 months did not differ significantly among treatment strategies. Patients who had worsened ambulation after 6 months were significantly more likely to be older than 80 years, to have needed assistance with walking before injury, and to have cerebrovascular disease. Multivariable analysis showed that a score of ≥2 on the 5-item modified frailty index (mFI-5) was significantly associated with worsening ambulation. CONCLUSIONS: Preinjury mFI-5 scores of ≥2 were significantly associated with worsening ambulation 6 months after treatment of cervical odontoid fractures in older adults.

Does surgery improve neurological outcomes in older individuals with cervical spinal cord injury without bone injury? A multicenter study.

STUDY DESIGN: Retrospective multicenter study. OBJECTIVES: To investigate the neurological outcomes of older individuals treated with surgery versus conservative treatment for cervical spinal cord injury (CSCI) without bone injury. SETTING: Thirty-three medical institutions in Japan. METHODS: This study included 317 consecutive persons aged ≥65 years with CSCI without bone injury in participating institutes between 2010 and 2020. The participants were followed up for at least 6 months after the injury. Individuals were divided into surgery (n = 114) and conservative treatment (n = 203) groups. To compare neurological outcomes and complications between the groups, propensity score matching of the baseline factors (characteristics, comorbidities, and neurological function) was performed. RESULTS: After propensity score matching, the surgery and conservative treatment groups comprised 89 individuals each. Surgery was performed at a median of 9.0 (3-17) days after CSCI. Baseline factors were comparable between groups, and the standardized difference in the covariates in the matched cohort was <10%. The American Spinal Injury Association (ASIA) impairment scale grade and ASIA motor score (AMS) 6 months after injury and changes in the AMS from baseline to 6 months after injury were not significantly different between groups (P = 0.63, P = 0.24, and P = 0.75, respectively). Few participants who underwent surgery demonstrated perioperative complications such as dural tear (1.1%), surgical site infection (2.2%), and C5 palsy (5.6%). CONCLUSION: Conservative treatment is suggested to be a more favorable option for older individuals with CSCI without bone injuries, but this finding requires further validation.

Hemoptysis due to progressive scoliosis associated with congenital heart disease: a case report.

BACKGROUND: Patients with congenital heart disease (CHD) are associated with an increased incidence of scoliosis, often with severe progression. We report a case of hemoptysis caused by rapid scoliosis progression subsequent to surgery for CHD that was successfully managed by surgical curve correction following coil embolization. CASE PRESENTATION: A 14-year-old girl with scoliosis had undergone open heart surgery for CHD at the age of 1 year. She was first noted to have scoliosis at 12 years of age, which began to progress rapidly. At age 13, her main thoracic curve Cobb angle was 46°, and hemoptysis with high pulmonary vein pressure due to vertebral rotation was detected. Nine months after coil embolization, she received posterior spinal fusion from T5 to L2 for scoliosis correction. Postoperatively, her pulmonary vein diameter was enlarged, with no detectable signs of hemoptysis. CONCLUSIONS: We encountered a case of hemoptysis caused by advanced scoliosis after cardiac surgery that was successfully treated by correction of the scoliotic curve following coil embolization. Patients with secondary scoliosis after surgery for CHD should be carefully monitored for the possibility of cardiovascular system deterioration.

A multicenter study of 1-year mortality and walking capacity after spinal fusion surgery for cervical fracture in elderly patients.

BACKGROUND: The 1-year mortality and functional prognoses of patients who received surgery for cervical trauma in the elderly remains unclear. The aim of this study is to investigate the rates of, and factors associated with mortality and the deterioration in walking capacity occurring 1 year after spinal fusion surgery for cervical fractures in patients 65 years of age or older. METHODS: Three hundred thirteen patients aged 65 years or more with a traumatic cervical fracture who received spinal fusion surgery were enrolled. The patients were divided into a survival group and a mortality group, or a maintained walking capacity group and a deteriorated walking capacity group. We compared patients' backgrounds, trauma, and surgical parameters between the two groups. To identify factors associated with mortality or a deteriorated walking capacity 1 year postoperatively, a multivariate logistic regression analysis was conducted. RESULTS: One year postoperatively, the rate of mortality was 8%. A higher Charlson comorbidity index (CCI) score, a more severe the American Spinal Cord Injury Association impairment scale (AIS), and longer surgical time were identified as independent factors associated with an increase in 1-year mortality. The rate of deterioration in walking capacity between pre-trauma and 1 year postoperatively was 33%. A more severe AIS, lower albumin (Alb) and hemoglobin (Hb) values, and a larger number of fused segments were identified as independent factors associated with the increased risk of deteriorated walking capacity 1 year postoperatively. CONCLUSIONS: The 1-year rate of mortality after spinal fusion surgery for cervical fracture in patients 65 years of age or older was 8%, and its associated factors were a higher CCI score, a more severe AIS, and a longer surgical time. The rate of deterioration in walking capacity was 33%, and its associated factors were a more severe AIS, lower Alb, lower Hb values, and a larger number of fused segments.

Prevalence and associated factors of primary elbow osteoarthritis in the Japanese general elderly population: a Japanese cohort survey randomly sampled from a basic resident registry.

BACKGROUND: The epidemiology of primary elbow osteoarthritis (PEOA) remains unknown. We aimed to evaluate the prevalence and associated factors of PEOA in a cross-sectional resident cohort from a municipal registry of a Japanese town. METHODS: A total of 415 residents over 50 years of age were randomly sampled from a Japanese town and were adjusted for age and gender. Those with diseases that could potentially cause a secondary osteoarthritis of the elbow were excluded. The remaining 318 subjects (150 men and 168 women) underwent bidirectional radiography of the elbow. Subjects were diagnosed with PEOA if one of their elbows was Kellgren-Lawrence (KL) grade 2 or greater. In addition, motion pain and tenderness at the elbow were examined by orthopedic surgeons. Associated factors for the PEOA were statistically analyzed. RESULTS: The prevalence of PEOA was 25.2% (male, 27.3%; female, 23.2%), and the prevalence of symptomatic PEOA was 0.9%. The age-stratified prevalence of PEOA was as follows: 50-59, 6.2% (male, 5.0%; female, 7.3%); 60-69, 15.4% (male, 17.5%; female, 13.7%); 70-79, 29.5% (male, 35.3%; female, 25.0%); and 80-89, 55.9% (male, 55.6%; female, 56.3%). Age and body mass index were revealed as associated factors that increased the prevalence of PEOA with KL grade 2 or greater. The use of vibrating tools was demonstrated as an independent associated factor that increased the prevalence of PEOA with KL grade 4 in addition to the 2 aforementioned factors. CONCLUSIONS: The prevalence of PEOA in Japanese subjects was 25.2% for those aged 50-89 years with a mean age of 69.2 years, most of which was asymptomatic OA without motion pain or tenderness at the elbow. Age and body mass index increased the prevalence of PEOA with KL grade 2 or greater. The prevalence of PEOA increased with age, but the disease was self-accommodated by most people.

A case of adult-onset Grisel's syndrome.

Aim: Grisel's syndrome is a non-traumatic subluxation of the atlanto-axial joint that occurs after infection or inflammation in the otolaryngological area, primarily in children.Method: This report describes the clinical characteristics of an extremely rare case of adult-onset Grisel's syndrome.Result: A 77-year-old woman presented with neck and bilateral shoulder pain and stiffness. Her temperature was 37.6 °C. Blood testing revealed a mildly elevated inflammatory response, although blood cultures were negative. Computed tomography (CT) showed atlanto-axial subluxation and joint destruction. T2-weighted magnetic resonance imaging (MRI) displayed high signals in the soft tissues in the anterior space of the atlas and axis, posterior wall of the pharynx, and interspinous ligament, indicating spinal cord compression at the C1 level. Differential diagnoses of inflammation and diseases causing atlanto-axial subluxation included rheumatoid arthritis, amyloidosis, pyogenic spondylitis due to posterior pharyngeal abscess, and crowned dens syndrome. After the systematic elimination of each condition, we considered Grisel's syndrome and began non-surgical treatment with intravenous antibiotics and a Philadelphia neck collar. Her inflammatory response and neck pain gradually decreased. Six months later, there was no progression of instability. She was able to walk unaided and live normally with the use of a neck collar as needed.Conclusion: Grisel's syndrome occurs predominantly in children, but can also afflict adults. Since early diagnosis and treatment can improve symptoms in some cases and prevent progressive atlanto-axial instability, prompt evaluation of the atlanto-axial joint using CT or MRI is advised in patients with neck pain and limited range of motion.

Pseudohypoxic brain swelling and secondary hydrocephalus with pseudomeningocele after lumbar surgery: a case report.

BACKGROUND: Postoperative intracranial complications are rare in spine surgery not including cranial procedures. We describe an uncommon case of pseudohypoxic brain swelling (PHBS) and secondary hydrocephalus after transforaminal lumbar interbody fusion (TLIF) presenting as impaired consciousness and repeated seizures. CASE PRESENTATION: A 65-year-old man underwent L4-5 TLIF for lumbar spondylolisthesis and began experiencing generalized seizures immediately postoperatively. Computed tomography (CT) revealed diffuse cerebral edema-like hypoxic ischemic encephalopathy. He was transported to our hospital, at which time epidural drainage was halted and anti-edema therapy was commenced. His impaired consciousness improved. However, he suffered secondary hydrocephalus due to continuous bleeding from a dural defect and spinal epidural fluid collection 3 months later. Following the completion of dural repair and insertion of a ventriculoperitoneal shunt, his neurologic symptoms and neuroimaging findings improved significantly. CONCLUSIONS: PHBS can be considered in patients with unexpected neurological deterioration following lumbar spine surgery even with the absence of documented durotomy. This might be due to postoperative intracranial hypotension-associated venous congestion, and to be distinguished from the more common postoperative cerebral ischemic events-caused by arterial or venous occlusions-or anesthetics complications.

Values for the Japanese Orthopaedic Association Back Pain Evaluation Questionnaire in the general elderly population: A Japanese cohort survey randomly sampled from a basic resident registry.

BACKGROUND: Japanese Orthopaedic Association Back Pain Evaluation Questionnaire (JOABPEQ) is widely used as a patient-based evaluation tool for lumbar spine disease in Japan. However, there are currently few established JOABPEQ reference values for the general population. This study proposes population-based reference values for JOABPEQ using a randomly sampled Japanese cohort. METHODS: Registered citizens of 50-89 years old were targeted for this survey. We established 8 groups based on age (50's, 60's, 70's, and 80's) and gender (male and female) after random sampling from the basic resident registry of Obuse town in 2014. A total of 414 participants (202 males and 212 females) were enrolled for calculations of average JOABPEQ scores for each age and gender group. We also evaluated for correlations between JOABPEQ domain scores and visual analogue scale (VAS) scores for low back pain. RESULTS: Median reference JOABPEQ scores stratified by age and gender were determined in this study. Lumbar function, walking ability, and social life function deteriorated significantly with age in both genders, with remarkable declines for the social life function domain. VAS scores for low back pain were not significantly correlated with JOABPEQ item scores. CONCLUSIONS: This first resident cohort of Japanese individuals determined median JOABPEQ scores by age and gender, which might serve as reference values for future studies.

Fragility fractures and delayed wound healing after tooth extraction in Japanese older adults.

INTRODUCTION: Fragility fractures can cause delayed wound healing after tooth extraction, which contributes to an increased risk of osteomyelitis of the jaw. We evaluated whether a history of fragility fracture was associated with increased risk of delayed wound healing after tooth extraction in older adults in Japan. MATERIALS AND METHODS: Of 5352 people aged 50-89 years in the 2014 basic resident registry of the town of Obuse, the present study included 376 subjects (190 men and 186 women) who completed a structured questionnaire and measurement of the bone mineral densities (BMDs) of the bilateral femoral neck. Delayed wound healing after tooth extraction was self-reported. Fragility fractures were confirmed via examination of hospital medical records. Logistic regression analyses adjusted for age and gender were used to evaluate association of clinical variables with delayed would healing after tooth extractions. Odds ratios (ORs) and the 95% confidence intervals (CIs) of all possible associated variables for the presence of delayed wound healing were calculated. RESULTS: Subjects with a history of fragility fractures had a significantly higher risk of delayed wound healing compared with those without previous fragility fractures (OR 2.68; 95% CI 1.11-6.46, p = 0.028). This association still remained after adjusted for all other variables (OR 2.70; 95% CI 1.10-6.60, p = 0.030). Delayed wound healing was not significantly associated with the BMD of the femoral neck. CONCLUSIONS: History of fragility fracture may be associated with increased risk of delayed wound healing after tooth extraction in Japanese men and women aged 50-89 years.

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.

The factors related to the poor ADL in the patients with osteoporotic vertebral fracture after instrumentation surgery.

PURPOSE: Osteoporotic vertebral fracture (OVF) with nonunion or neurological deficit may be a candidate for surgical treatment. However, some patients do not show improvement as expected. Therefore, we conducted a nationwide multicenter study to determine the predictors for postoperative poor activity of daily living (ADL) in patients with OVF. METHODS: We retrospectively reviewed the case histories of 309 patients with OVF who underwent surgery. To determine the factors predicting postoperative poor ADL, uni- and multivariate statistical analyses were performed. RESULTS: The frequency of poor ADL at final follow-up period was 9.1%. In univariate analysis, preoperative neurological deficit (OR, 4.1; 95% CI, 1.8-10.3; P < 0.001), perioperative complication (OR, 3.4; P = 0.006), absence of preoperative bone-modifying agent (BMA) administration (OR, 2.7; P = 0.03), and absence of postoperative recombinant human parathyroid hormone (rPTH) administration (OR, 3.9; P = 0.006) were significantly associated. In multivariate analysis, preoperative neurological deficit (OR, 4.6; P < 0.001), perioperative complication (OR, 3.4; P = 0.01), and absence of postoperative rPTH administration (OR, 3.9; P = 0.02) showed statistical significance. CONCLUSIONS: Preoperative neurological deficit, perioperative complication, and absence of postoperative rPTH administration were considered as predictors for postoperative poor ADL in patients with OVF. Neurological deficits and complications are often inevitable factors; therefore, rPTH is an important option for postoperative treatment for OVF. These slides can be retrieved under Electronic Supplementary Material.