Serum periostin levels correlate with severity of intervertebral disc degeneration.

PURPOSE: Periostin, an extracellular matrix protein closely related to mechanical stress, inflammation, and ageing, has been implicated in intervertebral disc degeneration (IVDD) in basic research. However, it has not been examined in clinical cases. This study aimed to evaluate the association between IVDD severity and serum periostin concentration as well as to analyse potential associations between IVDD and clinical and demographic factors. METHODS: This retrospective cohort study included 198 patients who underwent lumbar disc herniation and lumbar canal stenosis between January 2020 and December 2022. The severity of IVDD was evaluated using the Pfirrmann grading, whereas serum periostin levels were measured using ELISA kits. Clinical demographics, including age, sex, body mass index, comorbidities, psoas muscle index, and spinal disease, were also recorded. RESULTS: This study demonstrated a significant correlation between high serum periostin levels and IVDD severity, as indicated by a high cumulative Pfirrmann score. Serum periostin levels were identified as an independent risk factor for IVDD in a multivariate regression model. Correlation analysis showed a correlation between periostin levels and Pfirrmann grade at each lumbar level (ρ = 0.458-0.550, p < 0.001) and a strong correlation with cumulative Pfirrmann score (ρ = 0.690, p < 0.001). CONCLUSION: The higher the serum periostin level, the higher the cumulative Pfirrmann score. Multivariate analysis showed that serum periostin was an independent risk factor for IVDD. Periostin levels may be a clinically suitable and useful biomarker for diagnosing IVDD, estimating disease progression and activity, providing prognostic information, and evaluating treatment options.

How long will it take to reach the gender diversity goal for orthopaedics in Japan?

BACKGROUND: In Japan, orthopaedics is one of the medical fields with the lowest proportion of women. This study analyses the change in gender diversity over the past decade and estimates the time required to achieve the 30% gender diversity goal, according to the critical mass in Japan in 2020. METHODS: We investigated the demographic composition of orthopaedic surgeons in 2020 by age group, the gender ratio of the main clinical fields from 2010 to 2020, and estimated the time required for the bottom 10 (i.e., least diverse) medical departments in Japan to reach the proportion of 30% women. We used simple linear regression analyses to clarify the number of years. RESULTS: In 2020, the population pyramid of orthopaedic surgeons showed that those in their 50s were the largest component with 24.1%, followed by those in their 40s and 30s with 22.3% and 19.4%, respectively. The percentage of women orthopaedic surgeons increased slightly from 4.1% in 2010 to 5.7% in 2020. This means that to achieve the proportion of 30% women at the current annual increase rate, orthopaedics would require up to 160 years, cardiovascular 149 years, and neurosurgery 135 years. CONCLUSION: Contrary to the recent increase in the number of women physicians, there has been only a slight increase in the number of women orthopaedic surgeons over the past decade. Moreover, the number of young male orthopaedic surgeons has decreased. As current orthopaedic surgeons age and retire, Japan will soon face an overall shortage of orthopaedic surgeons. Issues that must still be addressed in Japanese orthopaedics include educating men and women about gender diversity and bias, changing stereotypes about surgical lifestyles, improving work-life balance, and diligent and collaborative efforts at both the individual and community levels.

Cardiopulmonary Cement Embolism Following Cement-Augmented Pedicle Screw Fixation: A Narrative Review.

Fixation using cement-augmented pedicle screws (CAPS) is being increasingly performed. However, CAPS-associated cement leakage is a critical problem that can lead to cardiopulmonary cement embolism (CPCE). This narrative review aimed to explore the incidence of and risk factors and treatment strategies for CPCE and cement leakage-related complications after CAPS fixation. Data were extracted from each article, including characteristics of CPCE after CAPS fixation (incidence, location, diagnostic method and criteria, treatment, and outcome and prognosis). Overall, 28 case series and 14 case reports that met the inclusion criteria were included. Of the 1974 cases included in the review, CPCE was noted in 123, symptomatic CPCE in 35, and death in six, respectively. The frequencies of PCE and symptomatic PCE after CAPS fixation were 6% (range: 0-28.6%) and 1.3% (range: 0-26%), respectively. The range of frequencies of PCE and symptomatic PCE after CAPS fixation may have been wide because the definition of CPCE and data collection methods differed among the reports analyzed. Since PCE due to large cement emboli may be primarily related to the surgical technique, improved technique, such as minimizing the number of CAPSs by injecting low-volume high-viscosity cement at low velocity and pressure, and careful observation of cement leakage during CAPS insertion may reduce PCE associated with cement leakage. Spinal surgeons should pay more attention to the occurrence of CPCE during and after CAPS insertion, which can cause serious complications in some patients.

Development of Silver-Containing Hydroxyapatite-Coated Antimicrobial Implants for Orthopaedic and Spinal Surgery.

The prevention of surgical site infections is directly related to the minimization of surgical invasiveness, and is in line with the concept of minimally invasive spine therapy (MIST). In recent years, the incidence of postoperative infections has been increasing due to the increased use of spinal implant surgery in patients at high risk of infection, including the elderly and easily infected hosts, the limitations of poor bone marrow transfer of antibiotics, and the potential for contamination of surgical gloves and instruments. Thus, the development of antimicrobial implants in orthopedic and spinal surgery is becoming more and more popular, and implants with proven antimicrobial, safety, and osteoconductive properties (i.e., silver, iodine, antibiotics) in vitro, in vivo, and in clinical trials have become available for clinical use. We have developed silver-containing hydroxyapatite (Ag-HA)-coated implants to prevent post-operative infection, and increase bone fusion capacity, and have successfully commercialized antibacterial implants for hip prostheses and spinal interbody cages. This narrative review overviews the present status of available surface coating technologies and materials; describes how the antimicrobial, safety, and biocompatibility (osteoconductivity) of Ag-HA-coated implants have been demonstrated for commercialization; and reviews the clinical use of antimicrobial implants in orthopedic and spinal surgery, including Ag-HA-coated implants that we have developed.

Digital Transformation Will Change Medical Education and Rehabilitation in Spine Surgery.

The concept of minimally invasive spine therapy (MIST) has been proposed as a treatment strategy to reduce the need for overall patient care, including not only minimally invasive spine surgery (MISS) but also conservative treatment and rehabilitation. To maximize the effectiveness of patient care in spine surgery, the educational needs of medical students, residents, and patient rehabilitation can be enhanced by digital transformation (DX), including virtual reality (VR), augmented reality (AR), mixed reality (MR), and extended reality (XR), three-dimensional (3D) medical images and holograms; wearable sensors, high-performance video cameras, fifth-generation wireless system (5G) and wireless fidelity (Wi-Fi), artificial intelligence, and head-mounted displays (HMDs). Furthermore, to comply with the guidelines for social distancing due to the unexpected COVID-19 pandemic, the use of DX to maintain healthcare and education is becoming more innovative than ever before. In medical education, with the evolution of science and technology, it has become mandatory to provide a highly interactive educational environment and experience using DX technology for residents and medical students, known as digital natives. This study describes an approach to pre- and intraoperative medical education and postoperative rehabilitation using DX in the field of spine surgery that was implemented during the COVID-19 pandemic and will be utilized thereafter.

Sagittal spino-pelvic alignment in rapidly destructive coxarthrosis.

PURPOSE: To investigate the sagittal spino-pelvic alignment (SSPA) in patients with rapidly destructive coxarthrosis (RDC). METHODS: SSPA was investigated in 44 patients with RDC and 70 patients with hip osteoarthritis (HOA). The study included only female patients over the age of 70 years because epidemiological reports indicate that RDC most commonly occurs in this group of patients. The SSPA parameters that were analyzed included lumbar lordosis (LL), lumbar range of motion (ΔLL), sacral slope (SS), pelvic incidence (PI), and pelvic tilt (PT). The pelvic inclination angle (PIA) in the supine position and the change in the PIA from the supine to the standing position (ΔPIA) were measured using anteroposterior pelvic radiographs. The values of these parameters were compared between the two groups. The levels of the SRS-Schwab classification modifiers were used to investigate the degree of sagittal malalignment. RESULTS: The RDC group showed significant lower LL, ΔLL and SS values, and significantly higher PT and ΔPIA values than the HOA group (P < 0.01). With regard to the sagittal modifiers in the SRS-Schwab classifications of the patients, the PI-LL and PT levels of the RDC group were significantly worse than those in the HOA group (P < 0.01). CONCLUSIONS: The present study suggests that the static factors of a reduction in the lumbar lordotic angle and greater posterior pelvic tilt, the dynamic factors of small ΔLL values and large ΔPIA values and the complex interaction of these two types of factors, may play important roles in the development of RDC.

Traumatic atlanto-occipital dislocation with successfully bystander resuscitation after cardiopulmonary arrest: A case report.

This case report describes successful bystander cardiopulmonary resuscitation after a cardiopulmonary arrest due to a traffic accident, followed by early diagnosis and treatment of a traumatic atlanto-occipital dislocation, resulting in successful community reintegration.

Thoracic spinal epidural hematoma misdiagnosed as conversion paralysis: A case report.

A woman with a history of psychiatric hospitalization was misdiagnosed with conversion paralysis despite lower extremity paralysis due to a thoracic epidural hematoma, leaving her with severe neurological deficits. Conversion paralysis is a diagnosis of exclusion and should never be made unless all possible organic causes have been ruled out.

Spinal subdural hematoma with sudden onset of paraplegia in a patient on oral anticoagulant therapy.

Spinal subdural hematoma is uncommon but may become more prevalent with increasing anticoagulant use. Early diagnosis from symptoms like lower back pain and leg paralysis is crucial for timely intervention.

Sagittal-spinopelvic alignment improves in patients with bilateral highly dislocated hip (Crowe type IV) after subtrochanteric shortening total hip arthroplasty: A retrospective radiographic study.

In patients with bilateral highly dislocated hips (HDHs), total hip arthroplasty with subtrochanteric shortening osteotomy (S-THA) is a viable option for achieving adequate reconstruction with restoration of the anatomical hip center. This procedure has the potential to improve sagittal spinopelvic alignment (SSPA). However, reports are scarce owing to the rarity of this disease. The objective of this study is to investigate pre- and post-operative SSPA in patients with HDHs who had undergone S-THA. This retrospective radiographic study included 55 patients (54 females and 1 male; average age, 63.1 ±â€…6.9 years) who underwent S-THA. Lateral spine radiographs in the standing position were obtained pre- and post-operatively. The SSPA included lumbar lordosis (LL), sacral slope (SS), pelvic incidence (PI), and intervertebral disc (ID) angle of L1/2-L5/S. The SSPA pre- and post-S-THA was compared using a paired t test. Pearson correlation coefficient was used to assess the relationships between parameters. The mean pre- and post-operative LL and SS values were 62° and 49° (LL) and 50° and 39° (SS), respectively (P < .001). The ID angle was significantly reduced post-operatively at all levels (P < .001). The correlation coefficients between preoperative LL and SS and postoperative LL and PI were 0.81 and 0.38, respectively (P < .01). The preoperative SSPA of Crowe type IV HDHs revealed excessive pelvic anteversion and lumbar hyperlordosis, with a high correlation between LL and SS, suggesting that these alterations were compensatory changes to maintain body balance. Furthermore, in patients with HDHs and residual spinal flexibility, restoring the original pelvic morphology with S-THA may contribute to improved SSPA.

Analyzing lumbar vertebral shape and alignment in female patients with degenerative spondylolisthesis: Comparisons with spinal stenosis and risk factor exploration.

PURPOSE: This study aimed to examine the vertebral body shape characteristics and spondylopelvic alignment in L4 degenerative spondylolisthesis (DS) as well as the risk factors for the development of DS. METHODS: This cross-sectional study compared vertebral morphology and sagittal spinopelvic alignment in female patients with lumbar DS and lumbar spinal stenosis (LSS). The degree of lumbar lordosis (LL), pelvic incidence (PI), cross-sectional area (CSA), and vertebral body height ratio (ha/hp) of the lumbar spine were compared using full-length spine radiographs and computed tomography in 60 females with DS and in 60 women with LSS. RESULTS: No significant differences in age or body mass index were observed between the two groups; however, the DS and LSS groups significantly differed in PI (mean, 58.9±10.8 vs. 47.2±11.6, P < 0.001), L4 CSA (mean, 1,166.2 m2 vs. 1,242.0 m2, P = 0.002) and ha/hp (mean, 1.134 vs. 1.007, P < 0.001). The L4 ha/hp was significantly higher in the DS group than in the LSS group. Additionally, LL values were negatively correlated with vertebral L5 CSA in the DS group (r = -0.28, P < 0.05). The LSS and DS groups demonstrated positive correlations between LL and L2, L3, and L4 ha/hp (r = 0.331, 0.267, and 0.317; P < 0.01, < 0.05, and < 0.05, respectively) and between LL and L4 and L5 ha/hp (r = 0.333, 0.331; P < 0.01, respectively). Multivariate regression analyses revealed that PI and ha/hp ratio may be independent predictors of DS development. CONCLUSION: The DS group had significantly larger LL, PI, and L4 ha/hp and smaller L4 CSA than the LSS group. The lumbar vertebral body shape and sagittal spinopelvic alignment in females might be independent predictors of DS development.

The first case of methotrexate-associated lymphoproliferative disorder in the sacrum: a case report.

Methotrexate (MTX) is a drug used for treating rheumatoid arthritis. Recently, the reported incidence of methotrexate-associated lymphoproliferative disease (MTX-LPD) has increased, especially in Japan. Extranodal involvement is observed in half of MTX-LPD cases. However, only a few spinal lesions have been reported, with none in the sacrum. Additionally, Epstein-Barr virus (EBV) infection has also been implicated in the pathogenesis of MTX-LPD. Herein, we describe the case of a 74-year-old woman with MTX-LPD in the sacral spine who complained of severe back pain and nocturnal pain. Radiographs revealed a tumour on the right wing of the sacrum and a positive EBV immunoglobulin G antibody titre. MTX-LPD was suspected based on imaging findings and a history of MTX administration. A pathological examination was performed on the CT-guided biopsy specimen. The histopathological diagnosis was MTX-LPD, and MTX was discontinued. Three months after MTX administration ended, the tumour tended to shrink, and 1 year later, significant tumour shrinkage was observed. This experience suggests that MTX-LPD can be treated by discontinuing MTX administration. Therefore, early and accurate diagnosis is required, as is avoiding unnecessary treatment such as surgery. MTX-LPD should be considered, especially in spinal origin tumours in EBV-infected patients on MTX.

Insights and preventive approaches of rod erosion in the occipital bone after complex posterior cervical spine surgery for destructive spondyloarthropathy: A case report.

RATIONALE: Complications of rod migration into the occipital bone after upper cervical fusion are very rare. No other cases have been reported, especially when associated with destructive spondyloarthropathy (DSA). The purpose of this case report is to remind clinicians of the risk of rod migration in cervical spine surgery in patients with DSA and to provide information on its causes, countermeasures, and treatment. PATIENT CONCERN: This case report presents the clinical course of a 61-year-old female patient with chronic kidney disease that required hemodialysis. DIAGNOSIS, INTERVENTION, OUTCOMES: The patient was diagnosed DSA involving the cervical spine. Initial treatment involved a halo vest, followed by anterior cervical corpectomy and fusion spanning from C5 to Th1. However, subsequent complications, including C5 fractures, kyphotic cervical alignment, and rod migration into the occipital bone, lead to multistage surgical interventions. This case highlights the challenges in managing DSA, the significance of optimal fixation strategies, and the importance of accounting for potential alignment changes. CONCLUSION: The effective management of occipital bone erosion after posterior cervical spine surgery for destructive spondyloarthropathy necessitates meticulous fixation planning, proactive rod length adjustment, preoperative assessment of the occipital position, and consideration of the compensatory upper cervical range of motion to prevent migration-related issues.

Conservative management of spontaneous spinal epidural hematoma: A case report with favorable prognosis.

Sudden spinal epidural hematoma (SSEH) is relatively rare. Sudden pain from the neck to the back and subsequent extremity paralysis necessitate immediate head and cervical magnetic resonance imaging or computed tomography, keeping SSEH in mind. Although surgery is recommended for progressive paralysis, conservative treatment is indicated for mildly symptomatic cases.

Traction Spurs in the Lumbar Spine: A Historical Overview and Future Perspectives.

Numerous studies have explored the connection between lumbar osteophytes, their pathophysiology, and instability since Macnab's 1971 report on traction spurs as an indicator of lumbar instability. This study provides a narrative historical overview of traction spurs, a classic finding that suggests lumbar instability. It summarizes the causes of anterior lumbar vertebral osteophytes, the relationship between traction spurs and lumbar spinal instability, and the clinical significance of traction spurs. Vertebral osteophytes are grouped into two categories, namely, traction spurs or claw spurs, which represent different stages of the same pathological process. Traction spurs are indicative of instability and occur in the early stage of disc degeneration, characterized by temporary dysfunction or instability. Traction spur formation following fusion surgery can predict union or nonunion, and it serves as an indicator of preoperative and postoperative segmental instability. The relationship between traction spurs and radiographic instability, as well as their association with imaging findings such as CT and MRI, has been clarified. Additionally, finite element analysis and mechanical testing have been used to investigate the significance of traction spurs. However, further research is needed to verify that traction spurs are an accurate indicator of pre- and postoperative lumbar instability.

Perioperative Cerebrovascular Accidents in Spine Surgery: A Retrospective Descriptive Study and A Systematic Review with Meta-Analysis.

Introduction: Perioperative cerebrovascular accidents (CVAs) related to spine surgery, although rare, can lead to significant disabilities. More studies on spine surgeries are required to identify those at risk of perioperative CVAs. The characteristics and outcomes of patients that experienced CVAs during spine surgery were assessed through a retrospective descriptive study and meta-analysis. Methods: Patients aged ≥18 years who underwent spine surgery under general anesthesia at a hospital between April 2011 and March 2023 were examined. Of the 2,391 initially identified patients, 2,346 were included after excluding 45 who underwent debridement for surgical site infections. Subsequently, a meta-analysis including the present retrospective descriptive study was conducted. Databases such as PubMed and Google Scholar were searched for original peer-reviewed articles written in English. Results: Of the 2,346 patients, 4 (0.17%) (three men, one woman) exhibited perioperative CVAs associated with spine surgery. The CVAs were diverse in nature: one case of cerebral hemorrhage resulting from dural injury during posterior occipitocervical fusion, two cases of cerebral infarctions after lumbar laminectomy and anterior thoracic fusion due to anticoagulant discontinuation, and one case of posterior reversible encephalopathy syndrome following microscopic lumbar discectomy due to gestational hypertension. The subsequent meta-analysis included three studies (n=186,860). It showed several risk factors for perioperative CVAs, including cervical level (pooled odds ratio [OR]=1.33), hypertension (pooled OR=2.27), atrial fibrillation (pooled OR=8.78), history of heart disease (pooled OR=2.47), and diabetes (pooled OR=2.13). Conclusions: It was speculated that the potential risk factors for the four perioperative CVA cases of spine surgery in this retrospective descriptive study were intraoperative dural injury, preoperative anticoagulant discontinuation, and gestational hypertension history. The meta-analysis revealed that cervical spine surgery, hypertension, atrial fibrillation, heart disease, and diabetes increased the CVA risk. This highlights the need for risk assessment, preoperative optimization, and postoperative care to reduce spine surgery-associated perioperative CVAs.

Comparison of Gender Diversity Among Spine Surgeons in the Japanese Society for Spine Surgery and Related Research and the Neurospinal Society of Japan: A Descriptive Study Through Secondary Analysis of Aggregated Data.

STUDY DESIGN: This was a descriptive study through secondary analysis of aggregated data. PURPOSE: This study aimed to describe changes in women's membership in the Japanese Society for Spine Surgery and Related Research (JSSR) for orthopedic surgery and the Neurospinal Society of Japan (NSJ) for neurosurgery over the past decade and make predictions for the future. OVERVIEW OF LITERATURE: Although the ratio of women physicians in the field of spine surgery is known to be low worldwide, there is a lack of detailed surveys in Japan. METHODS: We sent emails to the JSSR and NSJ secretariats to verify membership information (gender and age) from 2013 to 2022. Using ordinary least squares, we projected the years it would take for the JSSR and NSJ to achieve a gender diversity ratio of 30%. RESULTS: In 2013, the percentage of women in JSSR and NSJ was 2.3% and 2.7%, respectively. However, after 2018, the percentage of women in NSJ will be higher than in JSSR, rising to 2.7% in JSSR and 4.7% in NSJ by 2022. It would require 101 years for the NSJ and more than 1,000 years for the JSSR to realize 30% gender diversity. CONCLUSIONS: JSSR and NSJ have low percentages of women. Improving gender diversity is an important issue for both societies, and they may collaborate on finding a good solution. Both the JSSR and NSJ societies need to actively address gender diversity and become more attractively represented in society for the next generation of spine surgeons.

Thick Skin on the Dorsal Spine in Osteoproliferative Disease: Ossification of the Posterior Longitudinal Ligament and Diffuse Idiopathic Skeletal Hyperostosis.

Background Although the correlation between reduced skin thickness and reduced bone density has been investigated, no study has evaluated skin thickness and osteoproliferative diseases, including ossification of the posterior longitudinal ligament (OPLL) and diffuse idiopathic skeletal hyperostosis (DISH). Methodology This retrospective cohort study consisted of 99 consecutive patients aged ≥60 years treated for spinal surgery at our hospital between January 2022 and March 2023. Skin thickness was measured at the dorsal side of the cervical, thoracic, and lumbar vertebrae on the sagittal cross-section image of whole-spine CT. Based on the median value, skin thickness was categorized into two groups based on a median thickness of 4 mm. Bone mineral density (BMD) was assessed. The sum of the vertebral body and intervertebral bridging osteophytes of the anterior longitudinal and posterior longitudinal ligament were defined as the OALL index and OPLL index. Serum levels of bone metabolism-related markers, such as tartrate-resistant acid phosphatase type 5b, procollagen I N-propeptide, 25-hydroxyvitamin D, and periostin, were measured. To assess the association between skin thickness and imaging findings, we calculated the adjusted odds ratios, adjusting for age, sex, and body mass index (BMI) and using univariate and multivariate logistic regression analyses. Results No significant differences were found in skin thickness in the three dorsal regions of the cervical, thoracic, and lumbar spine (median = 3.3 mm versus 3.5 mm versus 3.4 mm, p = 0.357) and bone metabolism-related markers. Adjusting for age, sex, and BMI, cervical, thoracic, and lumbar skin thicknesses were related to DISH, the OPLL index, and the OPLL and OPLL index, respectively. Conclusions Skin thickness did not correlate with BMD but with the amount of spinal ossification. A correlation was found between skin thickness and vertebral and intervertebral ossification; vertebral osteophytes, OPLL, and DISH may be more common in thicker skin.