Anterior fusion surgery with overcorrection in the treatment of adolescent idiopathic scoliosis with Lenke 1 AR curve type: how to achieve overcorrection and its effect on postoperative spinal alignment.

BACKGROUND: The efficacy of anterior fusion with overcorrection in the instrumented vertebra for Lenke 1 AR type curves has been reported, but how to achieve overcorrection and how overcorrection affects spinal alignment are unclear. The purpose of this study was to identify the factors that cause overcorrection, and to investigate how overcorrection affects postoperative spinal alignment in the surgical treatment of Lenke 1 AR type curves. METHODS: Patients who had anterior surgery for a Lenke type 1 or 2 and lumbar modifier AR (L4 vertebral tilt to the right) type scoliosis and minimum 2-year follow-up were included. The radiographic data were measured at preoperative, postoperative 1 month, and final follow-up. The UIV-LIV Cobb angle was determined as the Cobb angle between the upper instrumented vertebra (UIV) and the lower instrumented vertebra (LIV), and a negative number for this angle was considered overcorrection. The screw angle was determined to be the sum of the angle formed by the screw axis and the lower and upper endplates in the LIV and UIV, respectively. The change (Δ) in the parameters from postoperative to final follow-up was calculated. The relationships between the UIV-LIV Cobb angle and other radiographic parameters were evaluated by linear regression analyses. RESULTS: Fourteen patients met the inclusion criteria. Their median age was 15.5 years, and the median follow-up period was 53.6 months. The median UIV-LIV Cobb angle was -1.4° at postoperative 1 month. The median screw angle was 4.7°, and overcorrection was achieved in 11 (79%) cases at postoperative 1 month. The screw angle (r2 = 0.42, p = 0.012) and Δ FDUV-CSVL (the deviation of the first distal uninstrumented vertebra from the central sacral vertical line, r2 = 0.53, p = 0.003) were significantly correlated with the UIV-LIV Cobb angle. CONCLUSIONS: Screw placement in the UIV and LIV not parallel to the endplate, but angled, was an effective method to facilitate overcorrection in the instrumented vertebrae. The results of the present study suggest that overcorrection could bring spontaneous improvement of coronal balance below the instrumented segment during the postoperative period.

Thoracic kyphosis in light of lumbosacral alignment in thoracic adolescent idiopathic scoliosis: recognition of thoracic hypokyphosis and therapeutic implications.

BACKGROUND: The uniqueness of spinal sagittal alignment in thoracic adolescent idiopathic scoliosis (AIS), for example, the drastically smaller thoracic kyphosis seen in some patients, has been recognized but not yet fully understood. The purpose of this study was to clarify the characteristics of sagittal alignment of thoracic AIS and to determine the contributing factors. METHODS: Whole spine radiographs of 83 thoracic AIS patients (73 females) were analyzed. The measured radiographic parameters were the Cobb angle of thoracic scoliosis, thoracic kyphosis (TK), lumbar lordosis (LL), C7 sagittal vertical axis (C7 SVA), pelvic incidence (PI), pelvic tilt (PT), and sacral slope (SS). Additionally, max-LL, which was defined as the maximum lordosis angle from the S1 endplate, the inflection point between thoracic kyphosis and lumbar lordosis, and the SVA of the inflection point (IP SVA) were measured. The factors significantly related to a decrease in TK were assessed by stepwise logistic regression analysis. In addition, cluster analysis was performed to classify the global sagittal alignment. RESULTS: The significant factors for a decrease in TK were an increase in SS (p = 0.0003, [OR]: 1.16) and a decrease in max-LL (p = 0.0005, [OR]: 0.89). According to the cluster analysis, the global sagittal alignment was categorized into the following three types: Type 1 (low SS, low max-LL, n = 28); Type 2 (high SS, low max-LL, n = 22); and Type 3 (high SS, high max-LL, n = 33). CONCLUSIONS: In thoracic AIS, a decreased TK corresponded to an increased SS or a decreased max-LL. The sagittal alignment of thoracic AIS patients could be classified into three types based on SS and max-LL. One of these three types includes the unique sagittal profile of very small TK.

Anterior instrumentation surgery for the treatment of Lenke type 1AR curve patterns.

OBJECTIVE: Previous studies have demonstrated that Lenke lumbar modifier A contains 2 distinct types (AR and AL), and the AR curve pattern is likely to develop adding-on (i.e., a progressive increase in the number of vertebrae included within the primary curve distally after posterior surgery). However, the results of anterior surgery are unknown. The purpose of this study was to present the surgical results in a cohort of patients undergoing scoliosis treatment for type 1AR curves and to compare anterior and posterior surgeries to consider the ideal indications and advantages of anterior surgery for type 1AR curves. METHODS: Patients with a Lenke type 1 or 2 and lumbar modifier AR (L4 vertebral tilt to the right) and a minimum 2-year postoperative follow-up were included. The incidence of adding-on and radiographic data were compared between the anterior and posterior surgery groups. The numbers of levels between the end, stable, neutral, and last touching vertebra to the lower instrumented vertebra (LIV) were also evaluated. RESULTS: Forty-four patients with a mean follow-up of 57 months were included. There were 14 patients in the anterior group and 30 patients in the posterior group. The main thoracic Cobb angle was not significantly different between the groups preoperatively and at final follow-up. At final follow-up, the anterior group had significantly less tilting of the LIV than the posterior group (-0.8° ± 4.5° vs 3° ± 4°). Distal adding-on was observed in no patient in the anterior group and in 6 patients in the posterior group at final follow-up (p = 0.025). In the anterior group, no LIV was set below the end vertebra, and all LIVs were set above last touching vertebra. The LIV was significantly more proximal in the anterior group than in the posterior surgery patients without adding-on for all reference vertebrae (p < 0.001). CONCLUSIONS: This is the first study to investigate the surgical results of anterior surgery for Lenke type 1AR curve patterns, and it showed that anterior surgery for the curves could minimize the distal extent of the instrumented fusion without adding-on. This would leave more mobile disc space below the fusion.

Is resuscitative endovascular balloon occlusion of the aorta for computed tomography diagnosis feasible or not? A Japanese single-center, retrospective, observational study.

BACKGROUND: Advances in medical equipment have resulted in changes in the management of severe trauma. The role of resuscitative endovascular balloon occlusion of the aorta (REBOA) in this scenario is still unclear. This study aimed to evaluate the usage of REBOA and utility of computed tomography (CT) in the setting of aortic occlusion in our current trauma management. METHODS: This Japanese single-tertiary center, retrospective, and observational study analyzed 77 patients who experienced severe trauma and persistent hypotension between October 2014 and March 2020. RESULTS: All patients required urgent hemostasis. Twenty patients underwent REBOA, 11 underwent open aortic cross-clamping, and 46 did not undergo aortic occlusion. Among patients who underwent aortic occlusion, 19 patients underwent prehemostasis CT, and 7 patients underwent operative exploration without prehemostasis CT for identifying active bleeding sites. The 24-hour and 28-day survival rates in patients who underwent CT were not inferior to those in patients who did not undergo CT (24-hour survival rate, 84.2% vs. 57.1%; 28-day survival rate, 47.4% vs. 28.6%). Moreover, the patients who underwent CT had less discordance between primary hemostasis site and main bleeding site compared with patients who did not undergo CT (5% vs. 71.4%, p = 0.001). In the patients who underwent prehemostasis CT, REBOA was the most common approach of aortic occlusion. Most of the bleeding control sites were located in the retroperitoneal space. There were many patients who underwent interventional radiology for hemostasis. CONCLUSION: In a limited number of patients whose cardiac arrests were imminent and in whom no active bleeding sites could be clearly identified without CT findings, REBOA for CT diagnosis may be effective; however, further investigations are needed. LEVEL OF EVIDENCE: Therapeutic/care management study, level V.

Can we use shorter constructs while maintaining satisfactory sagittal plane alignment for adult spinal deformity?

OBJECTIVE: Issues with spinopelvic fixation for adult spinal deformity (ASD) include loss of the physiological mobility of the entire lumbar spine, perioperative complications, and medical costs. Little is known about the factors associated with successful short fusion for ASD. The authors evaluated radiographic and clinical outcomes after shorter fusion for different subtypes of ASD at 2 years postoperatively and examined factors associated with successful short fusion. METHODS: This was a single-center study of 37 patients who underwent short fusion and a minimum 2 years of follow-up for ASD in which lumbar kyphosis was the main deformity. The exclusion criteria were 1) age < 40 years, 2) previous lumbar vertebral fracture, 3) severe osteoporosis, 4) T10-L2 kyphosis > 20°, 5) scoliotic deformity with an upper end vertebra (UEV) above T12, and 6) concomitant Parkinson's disease or neurological disease. The surgical procedures, radiographic course, and Oswestry Disability Index (ODI) were assessed, and correlations between radiographic parameters and postoperative ODI at 2 years were analyzed. RESULTS: A mean of 3.5 levels were fused. The mean radiographic parameters preoperatively, at 2 weeks, and at 2 years, respectively, were as follows: coronal Cobb angle: 22.9°, 11.5°, and 12.6°; lumbar lordosis (LL): 12.9°, 35.8°, and 32.2°; pelvic incidence (PI) minus LL: 35.5°, 14.7°, and 19.2°; pelvic tilt: 29.4°, 23.1°, and 25.0°; and sagittal vertical axis 85.3, 36.7, and 59.2 mm. Abnormal proximal junctional kyphosis occurred in 8 cases. Revision surgery was performed to extend the length of fusion from a lower thoracic vertebra to the pelvis in 2 cases. The mean ODI scores preoperatively and at 2 years were 50.7% and 24.1%, respectively. Patient age, number of fused intervertebral segments, and radiographic parameters were analyzed by the stepwise method to identify factors contributing to the ODI score at 2 years, preoperative PI, and sagittal vertical axis at 2 years. On receiver operating characteristic curve analysis of the minimal clinically important difference of ODI (15%) and preoperative PI, the cutoff value of the preoperative PI was 47° (area under the curve 0.75). CONCLUSIONS: In terms of subtypes of ASD in which lumbar kyphosis is the main deformity, if the PI is < 47°, then the use of short fusion preserving mobile intervertebral segments can produce adequate LL for the PI, improving both postoperative global spinal alignment and quality of life.

Indications for early plasma transfusion and its optimal use following trauma.

AIM: This study aimed to evaluate the effect of plasma transfusion before urgent hemostasis initiation on in-hospital mortality in hemodynamically unstable patients with severe trauma. METHODS: This retrospective observational study of patients admitted to hospital between January 2011 and January 2019 grouped patients according to whether plasma transfusion was initiated before (Before group) or after (After group) hemostasis initiation. Patients with severe trauma who were unable to wait for plasma transfusion and had started hemostasis before the plasma infusion were excluded. We used multivariable logistic regression analysis to determine the effect of plasma transfusion before the initiation of urgent hemostasis on in-hospital mortality. RESULTS: We included 47 and 73 patients in the Before and After groups, respectively. Blunt trauma was more common, and the D-dimer levels and Injury Severity Score were significantly higher in the Before group than in the After group (median D-dimer, 57.5 versus 38.1 µg/mL; P = 0.040; median Injury Severity Score, 50 versus 34; P < 0.001). Plasma given before hemostasis initiation was associated with significantly lower in-hospital mortality (adjusted odds ratio, 0.27; 95% confidence interval, 0.078-0.900; P = 0.033) in contrast with the total plasma volume given in the first 6 or 24 h. CONCLUSION: Plasma transfusion before hemostasis initiation could be an important factor for improving outcomes in hemodynamically unstable patients with blunt trauma, high D-dimer levels, or a high Injury Severity Score.

Impact of a streamlined trauma management approach and determinants of mortality among hemodynamically unstable patients with severe multiple injuries: a before-and-after retrospective cohort study.

BACKGROUND: Trauma management requires a multidisciplinary approach, but coordination of staff and procedures is challenging in patients with severe trauma. In October 2014, we implemented a streamlined trauma management system involving emergency physicians trained in severe trauma management, surgical techniques, and interventional radiology. We evaluated the impact of streamlined trauma management on patient management and outcomes (study 1) and evaluated determinants of mortality in patients with severe trauma (study 2). METHODS: We conducted a retrospective cohort study of 125 patients admitted between January 2011 and 2019 with severe trauma (Injury Severity Score ≥16) and persistent hypotension (≥2 systolic blood pressure measurements <90 mm Hg). Patients were divided into a Before cohort (January 2011 to September 2014) and an After cohort (October 2014 to January 2019) according to whether they were admitted before or after the new approach was implemented. The primary outcome was in-hospital mortality. RESULTS: Compared with the Before cohort (n=59), the After cohort (n=66) had a significantly lower in-hospital mortality (36.4% vs. 64.4%); required less time from hospital arrival to initiation of surgery/interventional radiology (median, 41.0 vs. 71.5 minutes); and was more likely to undergo resuscitative endovascular balloon occlusion of the aorta (24.2% vs. 6.8%). Plasma administration before initiating hemostasis (adjusted OR 1.49 (95% CI 1.04 to 2.14)), resuscitative endovascular balloon occlusion of the aorta (9.48 (95% CI 1.25 to 71.96)), and shorter time to initiation of surgery/interventional radiology (0.97 (95% CI 0.96 to 0.99)) were associated with significantly lower mortality. DISCUSSION: Implementing a streamlined trauma management protocol improved outcomes among hemodynamically unstable patients with severe multiple trauma. LEVEL OF EVIDENCE: Level III.

Growing rod technique with prior foundation surgery and sublaminar taping for early-onset scoliosis.

OBJECTIVE: The aim of this study was to show the surgical results of growing rod (GR) surgery with prior foundation surgery (PFS) and sublaminar taping at an apex vertebra. METHODS: Twenty-two early-onset scoliosis (EOS) patients underwent dual GR surgery with PFS and sublaminar taping. PFS was performed prior to rod placement, including exposure of distal and proximal anchor areas and anchor instrumentation filled with a local bone graft. After a period of 3-5 months for the anchors to become solid, dual rods were placed for distraction. The apex vertebra was exposed and fastened to the concave side of the rods using sublaminar tape. Preoperative, post-GR placement, and final follow-up radiographic parameters were measured. Complications during the treatment period were evaluated using the patients' clinical records. RESULTS: The median age at the initial surgery was 55.5 months (range 28-99 months), and the median follow-up duration was 69.5 months (range 25-98 months). The median scoliotic curves were 81.5° (range 39°-126°) preoperatively, 30.5° (range 11°-71°) after GR placement, and 33.5° (range 12°-87°) at the final follow-up. The median thoracic kyphotic curves were 45.5° (range 7°-136°) preoperatively, 32.5° (range 15°-99°) after GR placement, and 42° (range 11°-93°) at the final follow-up. The median T1-S1 lengths were 240.5 mm (range 188-305 mm) preoperatively, 286.5 mm (range 232-340 mm) after GR placement, and 337.5 mm (range 206-423 mm) at the final follow-up. Complications occurred in 6 patients (27%). Three patients had implant-related complications, 2 patients had alignment-related complications, and 1 patient had a wound-related complication. CONCLUSIONS: A dual GR technique with PFS and sublaminar taping showed effective correction of scoliotic curves and a lower complication rate than previous reports when a conventional dual GR technique was used.

Can we stop the long fusion at L5 for selected adult spinal deformity patients with less severe disability and less complex deformity?

OBJECTIVES: It is controversial whether to stop the fusion at L5 or S1 in adult spinal deformity (ASD) surgery. Our hypothesis is that we can stop long fusion at L5 for selected patients with less severe disability and less complex deformity. Aim was to compare minimum 5-year outcomes between ASD patients with fusion to L5 versus S1. PATIENTS AND METHODS: Consecutive 40 patients (≥50 years of age) with ASD underwent spinal fusion from lower thoracic spine to L5 or S1 between 2008 and 2011. 33 patients (82.5 %) had a minimum 5-year follow-up. Lower instrumented vertebra (LIV) was L5 in 12 patients (L5 group) and S1 in 21 (S1 group). Clinical and radiographical parameters were compared between L5 and S1 group. RESULTS: There were statistically significant differences between two groups (L5 vs S1) in %male (50 % vs 14 %), %type-N of SRS-Schwab classification (83 % vs 38 %), preop ODI (40.5 vs 56), correction loss of LL (11˚ vs 3˚), final TK (32˚ vs 50˚), correction loss of TK (-1˚ vs 17˚), final improvement of PT (3˚ vs 10˚), final improvement of PI-LL (26˚ vs 39˚), PJK (8% vs 48 %), and revision surgery rate (50 % vs 14 %). Causes of revision surgery in L5 group were distal junctional failure in 5 patients and foraminal stenosis at L5-S1 in 1. All of them underwent additional spinal fusion to the sacrum. Whereas, causes of revision surgery in S1 group were rod fracture in 2 patients and proximal junctional failure in 1. CONCLUSION: Although fusion to L5 was conducted for selected ASD patients with less severe disability (better ODI) and less complex deformity (type N), 50 % of the patients required additional fusion to the pelvis. Decision making to stop the long fusion at L5 for ASD patients ≥50 years of age should be made with careful considerations.

Usefulness of next-generation DNA sequencing for the diagnosis of urinary tract infection.

Acute urinary tract infection (UTI) is a highly common clinical condition. Although bacterial culture is the gold standard diagnostic test, false negative results may be possible, leading to the pathogen being unidentified. In recent years, bacterial DNA sequencing analysis has garnered much attention, but clinical studies are rare in Japan. In this study, we assessed the usefulness of next-generation DNA sequencing (NGS) analysis for acute UTI patients. We thus performed an observational, retrospective case series study. Urine and blood samples were collected from ten acute UTI patients, of whom four had also been diagnosed with urosepsis. Seven variable regions of bacterial 16S rRNA genes were amplified by PCR and then sequenced by IonPGM. The identified bacterial species were compared with those identified using the culture tests and the clinical parameters were analyzed. As a result, the NGS method effectively identified predominant culture-positive bacteria in urine samples. The urine NGS also detected several culture-negative species, which have been reported to be potentially pathogenic. Out of four urosepsis cases, three were pathogen-positive in blood NGS results, while two were pathogen-negative in blood culture. In one sepsis case, although blood culture was negative for Escherichia coli, this species was detected by blood NGS. For non-sepsis cases, however, blood NGS, as well as blood culture, was less effective in detecting bacterial signals. In conclusion, NGS is potentially useful for identifying pathogenic bacteria in urine from acute UTI patients but is less applicable in patients who do not meet clinical criteria for sepsis.

Effect of resuscitative endovascular balloon occlusion of the aorta in hemodynamically unstable patients with multiple severe torso trauma: a retrospective study.

Background: Although resuscitative endovascular balloon occlusion of the aorta (REBOA) may be effective in trauma management, its effect in patients with severe multiple torso trauma remains unclear. Methods: We performed a retrospective study to evaluate trauma management with REBOA in hemodynamically unstable patients with severe multiple trauma. Of 5899 severe trauma patients admitted to our hospital between January 2011 and January 2018, we selected 107 patients with severe torso trauma (Injury Severity Score > 16) who displayed persistent hypotension [≥ 2 systolic blood pressure (SBP) values ≤ 90 mmHg] regardless of primary resuscitation. Patients were divided into two groups: trauma management with REBOA (n = 15) and without REBOA (n = 92). The primary endpoint was the effectiveness of trauma management with REBOA with respect to in-hospital mortality. Secondary endpoints included time from arrival to the start of hemostasis. Multivariable logistic regression analysis, adjusted for clinically important variables, was performed to evaluate clinical outcomes. Results: Trauma management with REBOA was significantly associated with decreased mortality (adjusted odds ratio of survival, 7.430; 95% confidence interval, 1.081-51.062; p = 0.041). The median time (interquartile range) from admission to initiation of hemostasis was not significantly different between the two groups [with REBOA 53.0 (40.0-80.3) min vs. without REBOA 57.0 (35.0-100.0) min ]. The time from arrival to the start of balloon occlusion was 55.7 ± 34.2 min. SBP before insertion of REBOA was 48.2 ± 10.5 mmHg. Total balloon occlusion time was 32.5 ± 18.2 min. Conclusions: The use of REBOA without a delay in initiating resuscitative hemostasis may improve the outcomes in patients with multiple severe torso trauma. However, optimal use may be essential for success.

Impact of emergency physicians competent in severe trauma management, surgical techniques, and interventional radiology on trauma management.

AIM: Despite recent advancements in trauma management following introduction of interventional radiology (IVR) and damage-control strategies, challenges remain regarding optimal use of resources for severe trauma. METHODS: In October 2014, we implemented a trauma management system comprising emergency physicians competent in severe trauma management, surgical techniques, and IVR. To evaluate this system, of 5,899 trauma patients admitted to our hospital from January 2011 to January 2018, we selected 107 patients with severe trauma (injury severity score ≥ 16) who presented with persistent hypotension (two or more systolic blood pressure measurements <90 mmHg), regardless of primary resuscitation. Patients were divided according to the date of admission: Conventional (January 2011-September 2014) or Current (October 2014-January 2018). The primary end-point was in-hospital mortality. Secondary end-points included time from arrival to start of surgery/IVR. RESULTS: There were 59 patients in the Conventional group and 48 in the Current group. Although patients in the Current group were more severely ill compared with those in the Conventional group, mortality in the Current group was significantly lower (Conventional 64.4% versus Current 41.7%, P = 0.019), especially among patients whose first intervention was IVR (Conventional 75.0% versus Current 28.6%, P = 0.001). Time from arrival to initiation of surgery/IVR was shorter in the Current group (Conventional 71.5 [53.8-130.8] min versus Current 41.0 [26.0-58.5] min, P < 0.0001). CONCLUSIONS: This trauma management system based on emergency physicians competent not only in severe trauma management, but also surgical techniques and IVR, could improve outcomes in patients with severe multiple lethal trauma.

Cardiac arrest caused by diphenhydramine overdose.

CASE: A 45-year-old man presented to our emergency department with disturbance of consciousness; he had mentioned to his family earlier about a drug overdose. When first responders arrived, he suffered cardiac arrest. Cardiac arrest due to drug overdose was diagnosed.The patient was supported with venoarterial extracorporeal membrane oxygenation. Arterial blood gas showed mixed acidosis, and electrocardiogram showed junctional rhythm and complete right bundle branch block. OUTCOME: The patient's blood pressure gradually decreased, and he died on the third day of hospitalization. After death, his serum diphenhydramine concentration at the time of arrival was found to be 18.7 µg/mL. CONCLUSION: Although diphenhydramine is regarded as a safe medication, it shows dose-dependent toxicity. High intake is associated with death; therefore, caution should be exercised in cases of drug overdose. Developing a procedure for rapid measurement in the emergency department should be a priority.

Detection of pathogenic bacteria in the blood from sepsis patients using 16S rRNA gene amplicon sequencing analysis.

Prompt identification of causative pathogenic bacteria is imperative for the treatment of patients suffering from infectious diseases, including sepsis and pneumonia. However, current culture-based methodologies have several drawbacks including their limitation of use to culturable bacterial species. To circumvent these problems, we attempted to detect bacterial DNA in blood using next-generation DNA sequencing (NGS) technology. We conducted metagenomic and 16S ribosomal RNA (rRNA) gene amplicon sequencing of DNA extracted from bacteria-spiked blood using an Ion Personal Genome Machine. NGS data was analyzed using our in-house pipeline Genome Search Toolkit and database GenomeSync. The metagenomic sequencing analysis successfully detected three gram-positive and three gram-negative bacteria spiked in the blood, which was associated with a significant portion of non-bacterial reads, even though human blood cells were separated by low-speed centrifugation prior to DNA extraction. Sequencing analysis of seven variable regions of the 16S rRNA gene amplicon also successfully detected all six bacteria spiked in the blood. The methodology using 16S rRNA gene amplicon analysis was verified using DNA from the blood of six patients with sepsis and four healthy volunteers with potential pathogenic bacteria in the blood being identified at the species level. These findings suggest that our system will be a potential platform for practical diagnosis in the future.

Optimal Treatment for Ruptured Pancreaticoduodenal Artery Aneurysm Caused by Celiac Artery Obstruction Due to Celiac Artery Dissection.

A pancreaticoduodenal artery (PDA) aneurysm develops due to increased flow through the pancreaticoduodenal arcade in the setting of celiac or superior mesenteric artery occlusion. Additionally, there is no evidence on the computed tomography scan or angiography images that the dissection process extends to the PDA arcade. Moreover, the optimal treatment protocols for PDA aneurysms with celiac artery obstruction and for celiac artery dissection are controversial. We report 2 cases of ruptured PDA aneurysms caused by celiac artery obstruction due to celiac artery dissection in which the aneurysm was excluded, but celiac artery revascularization was not performed successfully. Our cases indicate that endovascular management for ruptured PDA aneurysms and conservative management for celiac artery obstruction due to celiac artery dissection are feasible as first-line treatment in such cases.

Postoperative Status of Global Sagittal Alignment With Compensation in Adult Spinal Deformity.

STUDY DESIGN: A retrospective study of consecutive patients undergoing surgery for adult spinal deformity (ASD). OBJECTIVE: The aim of this study was to classify postoperative ASD patients by sagittal compensation and characterize the features of each group. SUMMARY OF BACKGROUND DATA: Sagittal compensatory mechanisms to keep the erect position would function in not only nonoperative ASD patients but also in postoperative patients. However, details of sagittal compensatory mechanisms after surgery have been unclear, because the majority of previous studies examined the compensatory mechanisms in nonoperative patients. METHODS: A total of 73 postoperative ASD patients were recruited. Spinopelvic parameters and Oswestry Disability Index (ODI) were measured before surgery, at 1-month and 2-year follow-up. The changes in parameters (Δ) between postoperative 1-month and 2-year were also evaluated. Cluster analysis based on pelvic tilt (PT) and sagittal vertical axis (SVA) at 2-year follow-up was performed, and then the parameters were compared among clusters. RESULTS: Cluster analysis identified three clusters: the physiological group (n = 38, PT = 19.6°, SVA = 17.2 mm), the compensated group (n = 23, PT = 34.3°, SVA = 45.6 mm), and the decompensated group (n = 12, PT = 36.6°, SVA = 118.8 mm). Comparisons of the parameters among the groups showed that the physiological group had smaller pelvic incidence minus lumbar lordosis (PI-LL) and better ODI. The compensated group had significantly larger Δ thoracic kyphosis (TK), Δ proximal junctional angle (PJA), and ΔPT than the physiological group. The decompensated group had significantly higher PI and higher age. CONCLUSION: Three groups were defined in terms of postoperative compensatory mechanisms. Patients in the physiological group had little postoperative alignment change and good ODI value. The compensated group had pelvic retroversion to keep SVA in the physiological range, but the compensation in the thoracic spine was unlikely to work. High PI and advanced age were characteristics of the decompensated group. LEVEL OF EVIDENCE: 4.

Optimal management strategy for spontaneous isolated dissection of a visceral artery.

Objectives To describe our clinical experiences and recommend a management strategy for spontaneous isolated dissection of a visceral artery. Methods A retrospective study of patients from December 2005 to December 2015 was performed. Thirty-two patients had spontaneous isolated dissection of a visceral artery. Clinical features, computed tomography findings, the treatment method, and follow-up results were evaluated. Results There were 28 men and 4 women (mean age, 54 years). Dissection locations were the celiac artery in 10, superior mesenteric artery in 17, and celiac artery and superior mesenteric artery in 5 patients. Celiac artery stenosis existed with spontaneous isolated dissection of a visceral artery at a high rate. After diagnosis, the blood pressure of all patients was immediately controlled to a lower level. Three patients with arterial rupture and one patient with bowel infarction underwent operations for complications. Overall, the treatment of dissection involved drug therapy alone. The last follow-up computed tomography results of the true lumen residual ratio and the length of the dissected artery improved compared to the values on admission; the maximum diameter of the dissected artery did not enlarge. Eleven patients almost completely improved. No patients had any adverse event. Conclusions Most patients with spontaneous isolated dissection of a visceral artery can be first treated conservatively for dissection with strict blood pressure control and surveillance.

Use of interventional radiology as initial hemorrhage control to improve outcomes for potentially lethal multiple blunt injuries.

INTRODUCTION: Recently, trauma management has been markedly improved with interventional radiology (IVR) and damage-control strategies. However, the indications for its use in hemodynamically unstable patients with severe trauma remains unclear. In some cases, IVR may be more effective than surgery for damage-control hemostasis; however, performing IVR in life-threatening trauma settings is challenging. To address this, we practiced and evaluated a trauma-management system with emergency physicians who trained for both severe trauma management, and techniques of surgery and IVR. MATERIALS AND METHODS: Among the 1822 patients with severe trauma admitted between October 2014 and December 2016, 201 underwent emergency surgery or IVR. Among these, 16 patients whose systolic blood pressure was ≤90 mmHg, without improvement following primary resuscitation, and whose first intervention was IVR, were analyzed. We retrospectively evaluated the admission characteristics, IVR-related characteristics, and prognoses, and compared several parameters before and after IVR. RESULTS: This study included 10 men and 6 women (median age: 46 years). IVR was performed for 10 pelvic fractures; five liver-, one splenic-, and one renal injury; and one transection each of the external carotid-, vertebral-, axillosubclavian-, intercostal-, and lumbar arteries. The mean times from the patient arrival, and diagnosis to the start of IVR were 56.3 ±â€¯26.6 and 15.1 ±â€¯3.8 min, respectively. The mean time spent in the angiography suite was 50 min. The systolic blood pressure, pulse rate, base excess/deficit, serum-lactate levels, and D-dimer values were significantly improved after IVR. Although two patients needed additional treatment for morbidities following IVR intervention, all achieved complete recovery. The mortality rate was 25.0%, and no preventable deaths were noted. Eight patients showed unexpected survival. CONCLUSIONS: In some cases, IVR may be the best first measure for resuscitative hemostasis in potentially lethal multiple injuries, given efficient diagnoses/actions and the ability to deal with complications.