Comparison of Clinical Outcomes and Complications of Primary and Revision Surgery Using a Combined Anterior and Posterior Approach in Patients with Adult Spinal Deformity and Sagittal Imbalance.

BACKGROUD: The purpose of this study was to compare clinical outcomes and complications of primary and revision surgery in patients with adult spinal deformity (ASD) accompanied by sagittal imbalance. Revision surgery has been associated with poor clinical outcomes and increased risk of complications. Previous studies comparing primary versus revision surgery included data for a wide variety of diseases and ages, but few investigated patients with ASD with sagittal imbalance undergoing anterior and posterior combined surgery. METHODS: Retrospective cohort analysis of prospectively collected data. We identified 60 consecutive patients with ASD combined with sagittal imbalance who underwent primary or revision surgery; of these, 6 patients were excluded for lack of a minimal 2-year follow-up. Patients' surgical and radiological data, clinical outcomes, and complications were reviewed. RESULTS: There were 30 patients in the primary group and 24 patients in the revision group. Patient characteristics, including the prevalence of sarcopenia, were similar between the two groups. Pedicle subtraction osteotomy was performed more frequently in the revision group although there was no statistically significant difference between groups. The primary group had more proximal junctional problems, whereas the revision group had more rod breakage (p < 0.05). There were significant improvements in clinical outcomes in both groups when the preoperative and 2-year postoperative values were compared. The Oswestry disability index and visual analog scale score were similar in both groups 2 years postoperatively. CONCLUSIONS: Considering the greater pain and disability at the time of the revision procedure, revision patients benefited more from surgery at the 2-year follow-up than the primary surgery patients. Complication rates were similar between the groups except for proximal junctional problems and rod breakage. Therefore, revision surgery should not be avoided in the treatment of ASD patients with sagittal imbalance.

Sarcopenia and Back Muscle Degeneration as Risk Factors for Degenerative Adult Spinal Deformity with Sagittal Imbalance and Degenerative Spinal Disease: A Comparative Study.

BACKGROUND: Many factors affect spinal alignment in adult spinal deformity with sagittal imbalance. However, although the importance of the paravertebral muscle and ligamentum complex in proper spinal alignment is well recognized, little information is available regarding the role of the paravertebral muscles in maintaining sagittal spinal alignment. METHODS: A total of 108 patients who had visited our institution from January 2016 to June 2018 were included in the present study. The patients were categorized as follows: degenerative adult spinal deformity with sagittal imbalance group and degenerative spinal disease group. The appendicular skeletal muscle mass index and handgrip strength of each patient were measured to evaluate for sarcopenia. Computed tomography was used to measure the cross-sectional area (CSA) and fat infiltration rate to evaluate paravertebral muscle morphology. The paravertebral muscle function was assessed by measuring the lumbar flexor strength and lumbar extensor strength using a lumbar isokinetic dynamometer. RESULTS: The degenerative adult spinal deformity with sagittal imbalance group had a lower CSA index and lumbar extensor strength index and higher fat infiltration rate than the degenerative spinal disease group. No statistically significant differences in the appendicular skeletal muscle mass index and handgrip strength were found between the 2 groups. Only the CSA showed a correlation with the radiological parameters, such as pelvic tilt and lumbar lordosis. CONCLUSIONS: Degeneration of the paravertebral muscle is a risk factor for degenerative adult spinal deformity with sagittal imbalance but not for sarcopenia. Thus, spinal sagittal imbalance is affected by isolated paravertebral muscle degeneration rather than by systemic muscle degeneration.

Sarcopenia and Back Muscle Degeneration as Risk Factors for Back Pain: A Comparative Study.

STUDY DESIGN: Case-control study. PURPOSE: To investigate the independent associations of back pain with sarcopenia and with back muscle degeneration, and to introduce a new risk index for back muscle degeneration. OVERVIEW OF LITERATURE: The Asian Working Group for Sarcopenia recommends diagnosis using handgrip strength, gait speed, and skeletal muscle mass. However, these criteria do not strongly reflect back muscle degeneration. METHODS: Patients who completed a questionnaire on back-pain between October 2016 and October 2017 were enrolled in this study. Appendicular skeletal muscle index (ASMI), cross-sectional area (CSA) index, fatty infiltration (FI) rate of the paraspinal muscles, and lumbar extensor strength index (LESI) were measured and compared between no back-pain and back-pain group. Correlations between LESI and ASMI, CSA index, and FI rate were analyzed. The back-pain group was further divided according to ASMI into sarcopenia and non-sarcopenia subgroups and by our newly developed back muscle degeneration risk index based on correlation coefficients between LESI and CSA index, FI rate. Differences in ASMI, CSA index, FI rate, LESI, and Visual Analog Scale (VAS) score between subgroups were analyzed. RESULTS: The ASMI, CSA index, FI rate, and LESI differed significantly between back-pain and pain-free groups. The LESI demonstrated the strongest correlation with FI rate. There were no significant differences in VAS score and back muscle degeneration index in the back-pain group when divided according to the presence of sarcopenia. However, there was a significant difference in VAS score between back-pain patients when classified according to high and low back muscle degeneration risk index. CONCLUSIONS: We suggest that the degree of back pain is more strongly associated with back muscle degeneration than with sarcopenia. This back muscle degeneration risk index, reflecting both back muscle morphology and function, could be a useful parameter for evaluation of back pain and muscle degeneration.

Treatment of Adult Spinal Deformity with Sagittal Imbalance Using Oblique Lumbar Interbody Fusion: Can We Predict How Much Lordosis Correction Is Possible?

STUDY DESIGN: Prospective, single-center study. PURPOSE: The current trend of operative treatment for adult spinal deformity (ASD) is combined anterior-posterior staged surgery. When anterior surgery was first performed, oblique lumbar interbody fusion (OLIF) was employed; this method became increasing popular. This study aimed to determine the lordosis correction that can be achieved using OLIF and assess whether we can preoperatively predict the lordosis correction angle achieved using OLIF. OVERVIEW OF LITERATURE: Many previous studies on OLIF have shown improved clinical and radiologic outcomes. With the increase in the popularity of OLIF, several surgeons have started using larger cages to attain greater lordosis correction. Moreover, some studies have reported complications of OLIF because of immoderate cage insertion. To our knowledge, this is the first prospective study that attempted to determine whether it is possible to predict the lordosis correction angle achieved with OLIF preoperatively, using fullextension lateral view (FELV). METHODS: Forty-six patients with ASD were enrolled. All the operations were performed by a single surgeon in two stages (first, anterior and second, posterior) with a 1-week interval. Radiological evaluation was performed by comparing the Cobb's angle of the segmental and regional lordosis obtained using preoperative and postoperative simple radiography (including the FELV) and magnetic resonance imaging (MRI). RESULTS: Regional lordosis (L1-S1) in the whole-spine standing lateral radiograph was -3.03°; however, in the supine lateral MRI, it was 20.92°. The regional lordosis of whole-spine standing lateral and supine lateral (MRI) was significantly different. In the FELV, regional lordosis was 25.72° and that in the postoperative supine lateral (MRI) was 25.02°; these values were not significantly different. CONCLUSIONS: Although OLIF offers many advantages, it alone plays a limited role in ASD treatment. Lordosis correction using OLIF as well as lordosis determined in the FELV was possible. Hence, our results suggest that FELV can help predict the lordosis correction angle preoperatively and thus aid the selection of the appropriate technique in the second staged operation.

Precautions for Combined Anterior and Posterior Long-Level Fusion for Adult Spinal Deformity: Perioperative Surgical Complications Related to the Anterior Procedure (Oblique Lumbar Interbody Fusion).

Study Design: Retrospective, single-center study. Purpose: We aimed to determine the perioperative complications of oblique lumbar interbody fusion (OLIF) as a first-stage procedure in combined anterior and posterior operation for adult spinal deformity (ASD) along with sagittal imbalance. Specifically, we aimed to identify the radiological and clinical types of perioperative surgical complications and the factors affecting these complications. Overview of Literature: OLIF has recently gained popularity, and there are several reports of good outcomes and only a few of complications with OLIF; however, a few studies have focused on the perioperative surgical complications of ASD along with sagittal imbalance. Methods: The perioperative period was a 1-week interval between the anterior and posterior procedures. All patients underwent simple radiography and magnetic resonance imaging preoperatively and postoperatively. Cage placement was evaluated for displacement (i.e., subsidence and migration) and vertebral body fracture. Clinical patient complaints were evaluated perioperatively. Student t-test was used for data analysis. Results: A total of 46 patients were included, totaling 138 fusion segments. A week after OLIF, 14 patients/33 segments (30.4%/23.9%) demonstrated endplate injury-associated cage placement change. Subsidence was the most common cage placement-related complication. As compared with patients without endplate injury, those with endplate injuries showed significantly larger correction angles and a higher proportion of them had larger height cages than the disk height in the full-extension lateral view. Although 32.6% of the patients experienced perioperative clinical complications, they were relatively minor and transient. The most common complication was severe postoperative pain (Visual Analog Scale score of >7), and hip flexor weakness spontaneously resolved within 1 week. Conclusions: OLIF yielded more than expected endplate injuries from treatment modalities for ASD along with sagittal imbalance. Therefore, surgeons should be cautious about endplate injury during OLIF procedures. It is difficult to accomplish lordosis correction via OLIF alone; therefore, surgeons should not attempt this impractical correction goal and insert an immoderate cage.

Prevention of Adjacent Segmental Disease after Fusion in Degenerative Spinal Disorder: Correlation between Segmental Lumbar Lordosis Ratio and Pelvic Incidence-Lumbar Lordosis Mismatch for a Minimum 5-Year Follow-up.

Study Design: Retrospective study. Purpose: Associations among risk factors related to adjacent segmental disease (ASD) remain unclear. We evaluated the risk factors and segmental lordosis ratio to prevent ASD developing after lumbar spinal fusion. Overview of Literature: Risk factors related to ASD development are age, sex, obesity, pre-existing degeneration, number of fusion segments, and decreased postoperative lumbar lordosis (LL). However, the associations among these factors are still unclear and should be clearly identified. Methods: We retrospectively reviewed data on 274 patients who underwent lumbar spinal fusion of three segments or below for lumbar degenerative disease from January 2010 to December 2012, with over 5 years of follow-up. Patients with preoperative sagittal vertical axis (SVA) >5 cm were excluded due to sagittal imbalance. A total of 37 patients with ASD and 40 control patients (CTRL) were randomly selected in a similar distribution of matching variables: age, sex, and preoperative degenerative changes. Sex, age, number of fusion segments, radiologic measurements, L4-5-S1/L1-S1 LL ratio, and spinopelvic parameters (pelvic incidence [PI], pelvic tilt [PT], sacral slope [SS], and SVA) were analyzed. Logistic regression was used to analyze the correlation between PI-LL mismatch and L4-5-S1 segmental lordosis rate. Results: No significant difference was found between ASDs and CTRL groups regarding age, sex, number of fusion segments, fusion method, and preoperative and postoperative spinopelvic parameters (PI, SS, PT, and LL). However, regarding the L4-5-S1/L1-S1 lordosis ratio, 50% (p=0.045), 60% (p=0.031), 70% (p=0.042), 80% (p=0.023), and 90% (p=0.023) were statistically significant; <20% (p=0.478), 30% (p=0.223), and 40% (p=0.089) were not statistically significant. In the postoperative PI-LL <10 group, ASD occurred less frequently than in the PI-LL >10 group, and the difference was statistically significant (p=0.048). Conclusions: Patients with a postoperative L4-5-S1/L1-S1 lordosis ratio >50% had less occurrence of ASD. Correcting LL according to PI and physiologic segmental lordosis ratio is important in preventing ASD.

Activity of Daily Living After Long Level Fusion in Adult Spinal Deformity: Compared With Over 60-Year-Old Degenerative Spine Patients Without Adult Spinal Deformity.

STUDY DESIGN: Prospective single center study. OBJECTIVE: The aim of this study was to evaluate 1) the activity of daily living (ADL) of three categorized patients group; over 60-year-old degenerative spine patients without adult spinal deformity (ASD), nonoperative ASD patients, and operative ASD patients, 2) what kinds of activities would be impaired, and 3) how the ADL changes over time after long level fusion. SUMMARY OF BACKGROUND DATA: There is still debate how surgeons could decide treatment methods for old-aged adult spinal deformity, operatively or not. There was lack of information how long level fusion impacts daily activities, especially sedentary Asian lifestyle. In Asia, impaired ADL is much more important issue because of different lifestyle. METHODS: Patients were categorized into three groups; Group 1 was over 60-year old aged degenerative spine disease without deformity, Group 2 was ASD patients who did not have surgery, and Group 3 was ASD patients who had surgery for deformity correction. Patients were evaluated using answer Oswestry Low Back Pain Disability Questionnaire, and Assessment activities of daily living for sedentary Asian culture (ADL-SA) questionnaire. RESULTS: Group 1 showed nearly full functions in every activity (ADL-SA: 41.4). ADL-SA scores of Group 2 were similar to Group 1 (P = 0.452). However, get up from bottom (P < 0.001), and pick up object (P < 0.001) were impaired. After long level fusion, ADL was impaired but gradually improved by time. From postoperative 1 year, total ADL score recovered to acceptable range. However, among ADL, activities associated sedentary lifestyle (get up from bottom, wipe floor, pick up object, and sit cross-legged) were still impaired after 2 years postoperatively. CONCLUSION: ADL was impaired after long level fusion; however it would improve as time goes by. However, among ADL, activities associated sedentary lifestyle was still impaired. Hence give enough information to patients about limited activities before deciding operation. LEVEL OF EVIDENCE: 3.

LCP metaphyseal plate fixation for fractures of the distal third humeral shaft using brachialis splitting approach.

The authors retrospectively studied the clinical and radiographic outcomes of locking compressive plate (LCP) metaphyseal plate fixation through the anterolateral approach in patients treated surgically for unstable distal third humeral shaft fractures. Twenty seven patients were treated surgically with LCP metaphyseal plate using brachialis splitting methods through the anterolateral approach. The mean arc of elbow motion was 132.4° with a mean flexion of 133.5° and mean flexion contracture of 1.1°. Three patients had a slight elbow flexion contracture with loss of 5° (n=1), 10° (n=1), and 15° (n=1) of extension. The mean American Shoulder and Elbow Surgeons score was 92.6 points, which corresponded to excellent results in 26 shoulders and a good result in one. The mean Mayo Elbow Performance Score was 90.7 points, which corresponded to excellent results in 24 elbows, a good result in 2, and a fair result in 1. Treatment of distal third humeral shaft fracture using LCP metaphyseal plate through the anterolateral approach is an acceptable and alternative method that can provide good results.

Cemented versus cementless fixation of a tibial component in LCS mobile-bearing total knee arthroplasty performed by a single surgeon.

Although cemented tibial fixation of total knee arthroplasty accepted as the gold standard, cementless fixation as a means to supplement disadvantages of cemented fixation continues to be of interest to clinicians. One hundred sixty-eight consecutive knees undergoing primary knee arthroplasty for osteoarthritis were randomly assigned to receive either a cemented (86 knees) or cementless (82 knees) fixation of tibial component. We report the outcomes at 8 to 11years (mean, 9.5). The mean KSS, the HSS score, the mean WOMAC, the mean ranges of knee movement and radiological results were similar in both groups. No osteolysis was identified in either group. The rate of survival of the femoral and tibial components was 100% in both groups at final follow-up.