Gluteal Compartment Syndrome After Femoral Nail Extraction: A Case Report.

Gluteal compartment syndrome is a rare disorder and no definitive treatment has yet been established. Fasciotomy is often the treatment of choice for gluteal compartment syndrome, but there have been only a few cases that have improved with conservative therapy. A 26-year-old male with a body mass index of 40.5 who underwent femoral nail extraction surgery had severe pain in the right buttock and numbness in the right lower extremity. Initially, we suspected transient pain due to prolonged exposure to the same posture, but muscle weakness in the lower extremities and worsening of renal function appeared over time. Orthopedic evaluation revealed physical examination findings and MRI imaging findings consistent with gluteal compartment syndrome. Conservative treatment with temporary dialysis was chosen instead of fasciotomy because of the time required for diagnosis. Dialysis was started on postoperative day 3, renal function and muscle weakness recovered over time, and the patient was discharged home on postoperative day 37. At six months post-op, the patient was walking without pain and he had no changes in his peripheral neurologic examination compared to his preoperative baseline. Orthopedic surgeons should always be aware of the possibility of gluteal compartment syndrome when especially obese patients with prolonged operation times appeal to acute buttock pain. Diagnosis should be made as early as possible to get a good prognosis.

Bisphosphonates Prescription for Patients With Hip Fractures Based on Evaluation by a Dentist.

Background The purpose of this study is to clarify the current status of the prescription of postoperative bisphosphonates for patients with hip fractures and to explore the factors that prevent the postoperative prescription of bisphosphonates. Methods Of 180 patients with hip fractures treated surgically at our hospital between August 2019 and April 2020, 149 patients (46 men and 103 women; mean age: 83.9 ± 9.0 years), excluding 31 patients already prescribed bisphosphonates or denosumab, were included in the study. All patients were treated based on our clinical pathway, and their risk of jaw osteonecrosis was evaluated prior to the initiation of bisphosphonates by a dentist in our hospital. We collected data from the medical records on osteoporosis treatment interventions at admission and discharge, the reasons why postoperative bisphosphonates could not be prescribed at discharge, the proportion of patients who had follow-ups at our hospital, and patients' osteoporosis treatment status. Results Eighteen (12.8%) and 95 (63.8%) patients were prescribed anti-osteoporosis drugs at admission and discharge, respectively. One hundred and twenty-one patients (86.8%) could not be prescribed postoperative bisphosphonates at discharge - 71 (58.7%) because of oral hygiene problems, 34 (28.1%) because they did not have regular dental consultations, seven (5.8%) because of renal dysfunction, eight (6.6%) because of poor cognitive and swallowing function, and one (0.8%) because of medication side effects. Forty-nine patients (32.9%) went to our hospital for follow-up and 11 were introduced to bisphosphonates or denosumab at follow-up. Conclusions The number of patients with hip fractures who were prescribed postoperative bisphosphonates was low in our study. The oral hygiene problems identified by dentists accounted for responsible for the low prescription rate of postoperative bisphosphonates. Therefore, coordination with dentists may be important to increase the postoperative bisphosphonate prescription.

Co-existence of Lumbar Disc Herniation and Posterior Ring Apophyseal Fracture: It Is Not Rare and Computed Tomography Is Useful.

Introduction Posterior ring apophyseal fracture (PRAF) is characterized by the separation of bone fragments and sometimes coexists with lumbar disc herniation (LDH). However, how often these conditions coexist and the details of the clinical course remain unclear. Methods We analyzed 200 patients who underwent surgical treatment for LDH at our hospital from January 2016 to December 2020. Among these, we reviewed 21 patients who underwent microendoscopic surgery to treat PRAF. They consisted of 11 male and 10 female patients, ranging in age from 15 to 63 years. The average age was 32.8 months, and the average follow-up period was 39.8 years. We performed simple roentgenography and magnetic resonance imaging for all patients and computed tomography for about 80% of the patients. We evaluated the type of PRAF fragment (Takata classification), disease level, Japanese Orthopedic Association (JOA) score, Roland-Morris Disability Questionnaire (RDQ) score, operating time, intraoperative blood loss, and perioperative complications. Results A total of 10.5% of patients with LDH also had PRAF. The mean JOA score significantly improved from 10.6 ± 5.7 points before surgery to 21.4 ± 5.1 points at the final observation (p < 0.05). The mean RDQ score significantly improved from 17.1 ± 4.5 preoperatively to 5.5 ± 0.5 at the final observation (p < 0.05). The average operation time was 88.6 minutes. There were no complications requiring early surgery that were due to postoperative infection or epidural hematoma, but one patient required reoperation. Conclusion This study showed that PRAF coexisted with LDH in about 10% of cases, and the outcomes of surgical treatment were generally good. Computed tomography is recommended to improve the diagnostic rate and assist with surgical planning and intraoperative decision-making.

Efficacy of Corticosteroid Addition to a Periarticular Cocktail Injection to Counteract Nausea and Vomiting After Total Knee Arthroplasty.

BACKGROUND: Intraoperative periarticular injection of a "cocktail" of drugs is undertaken commonly in total knee arthroplasty (TKA). The addition of a corticosteroid to the periarticular injection is believed to offer greater pain relief because of its local anti-inflammatory effects, but the prevalence of postoperative nausea and vomiting (PONV) is not known. This retrospective observational study aimed to elucidate the relationship between corticosteroid addition to a periarticular cocktail injection (PCI) and PONV. MATERIALS AND METHODS: Fifty-nine patients who underwent unilateral TKA for primary osteoarthritis were divided into two groups: corticosteroid and non-corticosteroid. The former had triamcinolone acetonide (40 mg) added to the same PCI. The primary outcome was the prevalence of nausea and vomiting within 48 hours following TKA. RESULTS: There was no significant difference between the two groups in terms of patient demographics. The overall prevalence of PONV was 16.9%. Fewer patients in the corticosteroid group complained of PONV than in the non-corticosteroid group (6.4% vs. 58.3%; p = 0.012). CONCLUSIONS: The addition of a corticosteroid to a PCI suppressed PONV. Our results suggested that cocktail injections may have local and systemic effects.

Prophylactic Intrawound Vancomycin Powder in Minimally Invasive Spine Stabilization May Cause an Acute Inflammatory Response.

Introduction Surgical site infections (SSIs) with methicillin-resistant Staphylococcus aureus are serious complications of spinal instrumentation surgery. Many spine surgeons are concerned that using prophylactic vancomycin powder will lead to certain risks: the development of multidrug-resistant pathogens, anaphylactic reactions, and organ toxicity. Minimally invasive spine stabilization (MISt) is associated with shorter operation times and less blood loss and may therefore require the use of less vancomycin powder, which may reduce these risks. This retrospective comparative study of patients who underwent MISt at a single institution aimed to evaluate the complications (such as allergy, SSIs, and organ toxicity) and the local and serum levels associated with using prophylactic intrawound vancomycin powder compared with IV cefazolin alone. Methods Thirty-four patients received intrawound vancomycin powder (1 g) applied during wound closure in minimally invasive posterior lumbar interbody fusion (MIS-PLIF). This group was compared with 133 control patients who did not receive vancomycin. White blood cell counts and C-reactive protein (CRP) levels were measured for both groups on postoperative days (PODs) 1, 3, and 7 and were statistically analyzed. In the vancomycin group, serum vancomycin levels were measured on PODs 1, 3, 7, and 14; drain vancomycin levels and postoperative blood loss were determined on PODs 1 and 2. Results The CRP levels on PODs 1 and 3 were significantly higher in the vancomycin group than in the control group (P<0.001, P=0.024). In the vancomycin group, mean drain levels trended downward from 313 µg/mL (POD 1) to 155 µg/mL (POD 2). These levels correlated negatively with drain drainage volume on both days (POD 1: r=-0.48, P=0.015; POD 2: r=-0.47, P=0.019). Mean serum vancomycin levels also trended downward from 2.3 µg/mL (POD 1) to 1.7 µg/mL (POD 14). Conclusions Our results unexpectedly demonstrated that the local application of vancomycin powder causes an acute inflammatory response and the long-term detection of low serum vancomycin levels. Less than 1 g of intrawound vancomycin powder may be useful only at high risk of SSI.

The History and Development of the Percutaneous Pedicle Screw (PPS) System.

Minimally invasive transforaminal lumbar interbody fusion (MIS-TLIF) using the SEXTANT® system (Medtronic) featured the first generation of commercially available percutaneous pedicle screw (PPS) system in 2001. The innovative system has since become standard instrumentation used worldwide, and PPS is now used for long-segment minimally invasive surgery (MIS) spinal fixation from the thoracic spine to the pelvis for pathological conditions. PPS systems have been developed for approximately 20 years for the purpose of improving minimally invasive techniques, safety of instrumentation, and ease of use. The third-generation PPS systems established the insertion technique, and the development of the fourth-generation PPS systems have made great strides in minimizing the number of steps in the operative procedure. In the future, PPS systems are expected to continue making use of the latest technological advancements and to develop further with the aim of ensuring greater safety, reducing operator stress, and preventing complications such as insertion errors and infection. In this review article, we describe the historical evolution from the first-generation PPS system to the current PPS systems used today.

Minimally Invasive Spinal Treatment (MIST)-A New Concept in the Treatment of Spinal Diseases: A Narrative Review.

In the past two decades, minimally invasive spine surgery (MISS) techniques have been developed for spinal surgery. Historically, minimizing invasiveness in decompression surgery was initially reported as a MISS technique. In recent years, MISS techniques have also been applied for spinal stabilization techniques, which were defined as minimally invasive spine stabilization (MISt), including percutaneous pedicle screws (PPS) fixation, lateral lumbar interbody fusion, balloon kyphoplasty, percutaneous vertebroplasty, cortical bone trajectory, and cervical total disc replacement. These MISS techniques typically provide many advantages such as preservation of paraspinal musculature, less blood loss, a shorter operative time, less postoperative pain, and a lower infection rate as well as being more cost-effective compared to traditional open techniques. However, even MISS techniques are associated with several limitations including technical difficulty, training opportunities, surgical cost, equipment cost, and radiation exposure. These downsides of surgical treatments make conservative treatments more feasible option. In the future, medicine must become "minimally invasive" in the broadest sense-for all patients, conventional surgeries, medical personnel, hospital management, nursing care, and the medical economy. As a new framework for the treatment of spinal diseases, the concept of minimally invasive spinal treatment (MIST) has been proposed.

Factors Affecting Postoperative Spinal Epidural Hematoma and the Optimal Order of Vertebral Body Decompression in Multivertebral Microendoscopic Laminectomy.

Purpose Symptomatic postoperative spinal epidural hematoma (POSEH) is a complication of spine surgery that occurs infrequently but may cause ongoing serious neurological damage. Due to the narrow entry portal, the risk of hematoma is increased after microendoscopic laminectomy (MEL) compared with conventional open surgery, and the risk might be even higher for multivertebral MEL (m-MEL). The purpose of this study was to clarify the factors affecting the development of POSEH after m-MEL and identify the optimal order for the decompression of vertebral bodies. Methods A total of 313 patients who underwent m-MEL from 2016 to 2020 were retrospectively assessed. The cohort comprised 238 patients who underwent two-level MEL, 67 who underwent three-level MEL, and eight who underwent four-level MEL. Symptomatic POSEH was defined as the presence of an epidural hematoma at the surgical site on MRI with symptoms such as lower extremity pain or muscle weakness. We elucidated the incidence of POSEH at each vertebral level and investigated the relationship between POSEH and possible risk factors such as clinical and operative variables. Results There were 41 patients in the POSEH group and 272 patients in the non-POSEH group. Seven patients in the POSEH group underwent reoperation. The occurrence of POSEH was related to the number of decompressed vertebral bodies. Patients who underwent L2/3 and L3/4 decompression at the end of the procedure also showed a higher incidence of POSEH at the surgical level. Conclusion In patients undergoing m-MEL, treatment of the upper lumbar vertebrae at the end of decompression surgery might be a risk factor for symptomatic POSEH. The incidence of POSEH was particularly increased at L2/3, suggesting that L2/3 decompression should not be performed at last and that careful hemostasis should be applied.

A Case of Delayed Airway Stenosis Due to Retropharyngeal Hematoma Caused by Low Energy Trauma.

Airway narrowing due to trauma-induced retropharyngeal hematoma is rare. However, it is dangerous to overlook this lesion because it can lead to airway obstruction and even death. In this article, we report a case of a patient who developed pharyngeal pain and dysphagia two days after bruising on the forehead due to a fall and required intubation management. A 52-year-old man fell while walking and bruised his forehead two days before visiting our hospital. He had a sore throat and dysphagia two days after the injury and came to our hospital three days after the injury. The swelling was observed in the anterior neck, and stenotic sounds were heard in the upper airway. Cervical CT and MRI of the cervical spine showed extensive hyperabsorption areas in the ventral side of the cervical spine that appeared to be hematomas. No fracture of the cervical spine was observed. The patient has been placed on emergency tracheal intubation due to concerns about airway stenosis caused by the hematoma. Although pneumonia was observed during treatment, it resolved with antimicrobial therapy, and the hematoma tended to shrink, so the patient was extubated on the 15th day of admission. However, the patient was intubated again on the 17th day of hospitalization due to poor oxygenation. A tracheostomy was performed on the 26th day of hospitalization due to suspected narrowing of the upper airway caused by hematoma or sputum. On day 59 of hospitalization, the cannula was removed, and the patient was discharged home on the 68th day after hospitalization. Low-energy trauma tends to be underrecognized as producing anterior cervical hematomas that can lead to fatal airway narrowing. Care should be taken because fatal anterior cervical hematomas are not often part of the differential diagnosis due to their often delayed onset. More caution is needed if an underlying disease may cause coagulation abnormalities.

Efficacy of Nerve Root Block for the Treatment of Lumbar Spinal Canal Stenosis in Adults Older Than 80 Years of Age.

BACKGROUND: Patients with advanced lumbar spinal canal stenosis (LCS) often prefer non-operative treatment owing to decreased physiological function and comorbidities. Although the therapeutic value of selective nerve root block (SNRB) for LCS is confirmed, there are few reports of its effectiveness in the elderly. We investigated the efficacy of SNRB for LCS in patients over 80 years of age. METHODS:  The subjects were 112 patients aged over 80 years (mean age: 84 years; 45 men and 67 women ) with medication-resistant LCS without cauda equina syndrome who underwent SNRB. Cases with acute-onset lumbar disc herniation were excluded. We retrospectively investigated and compared the presence or absence of surgery, effect of SNRB, number of procedures, duration of disease, and magnetic resonance imaging findings. Patients who could avoid the surgery by SNRB were defined as the effective group. Patients whose symptoms were not relieved by SNRB and who underwent surgery and those whose symptoms were not relieved but who continued conservative treatment were defined as the ineffective group. A total of one to seven SNRBs were performed in both groups, and the same spine surgeon performed the entire procedure from SNRB to surgery. RESULTS:  There were 86 nonoperative patients (69 effective cases) and 26 operative patients; the overall rate of effectiveness was 61% (69/112 patients). The area of the spinal canal at the responsible level was 108.63 mm2 in the effective group compared with 77.06 mm2 in the ineffective group. This was significantly narrower in the ineffective group (p=0.0094). There was no significant difference in the duration of illness, number of blocks, or hernia complication rate between the groups. No patient experienced severe neuralgia that may have been caused by neuropathy during SNRB. DISCUSSION: Our outcome showed that more than 60% of older patients with LCS showed symptomatic improvement with SNRB. SNRB can be performed relatively safely in the elderly and appears to be a favorable treatment option for older patients with various risks, such as poor general condition. CONCLUSIONS: Multiple sessions of SNRB may provide older patients with symptomatic improvement and may be an option for treatment.

Comparison of Microendoscopic Laminotomy (MEL) Versus Spinous Process-Splitting Laminotomy (SPSL) for Multi Segmental Lumbar Spinal Stenosis.

Aims  This study was aimed to compare the perioperative and postoperative outcomes of patients who underwent posterior decompression for multi-segmental lumbar spinal stenosis by microendoscopic laminotomy (MEL) versus spinous process-splitting laminotomy (SPSL) retrospectively. Methods We retrospectively reviewed 73 consecutive patients who underwent two or three levels MEL (n=51) or SPSL (n=22) for lumbar spinal stenosis between 2012 and 2018. The perioperative outcomes were operative time, intraoperative blood loss, length of postoperative hospital stay, complications, and reoperation rate. The postoperative outcomes were evaluated using a visual analog scale (VAS) and the Japanese Orthopaedic Association Back Pain Evaluation Questionnaire (JOABPEQ) scores at one year postoperatively. Results The mean follow-up time was 26.6 months in MEL and 35.6 months in SPSL. The mean operative time was significantly longer in MEL than SPSL (two levels, 183.6 ± 43.2 versus 134.8 ± 26.7 min, respectively; three levels: 241.6 ± 47.8 versus 179.9 ± 28.8 min, respectively). MEL's mean postoperative hospital stay was significantly shorter than SPSL (12.3 ± 5.9 versus 15.5 ± 7.2 days, respectively). There was no significant difference in the mean intraoperative blood loss, complication rate, reoperation rate, and postoperative outcomes between the two groups. Conclusions This study suggests that both techniques are effective in treating multi-segmental lumbar spinal stenosis. There was no significant difference between the two procedures in intraoperative blood loss (IBL), complications rate, reoperation rate, or improvement in VAS and Japanese Orthopaedic Association Back Pain Evaluation Questionnaire (JOABPEQ) scores. MEL had an advantage in the postoperative hospital stay.

Risk Factors for Incidence of Postoperative Spinal Epidural Hematoma Following Multilevel Microendoscopic Laminectomy.

INTRODUCTION: Due to the narrow portal of entry, microendoscopic laminectomy (MEL) is associated with a risk of postoperative spinal epidural hematoma (POSEH). This risk might be higher when performing multiple-level (m-) MEL. The purpose of this study is to clarify the incidence rate of POSEH following single-level (s-) and m-MEL by each interlaminar level and identify the risk factors for POSEH following m-MEL. METHODS: A total of 379 patients underwent MEL of the lumbar spine (s-MEL, n=141; m-MEL, n=238). We determined the incidence of POSEH following s-MEL and m-MEL by each interlaminar level. For m-MEL, we clarified the correlation between POSEH and possible risk factors, such as operative findings, the sequence of operated interlaminar levels, and the preoperative cross-sectional dural area (CSA) on magnetic resonance imaging. RESULTS: The incidence rate at L2/3 was significantly higher than that at L3/4 and L4/5. Patients who underwent L2/3 decompression at the end of the procedure showed a higher incidence of POSEH at the L2/3 level. Preoperative spinal stenosis was associated with POSEH at the L2/3 level, and CSA of 56 mm2 was a predictive factor for POSEH. Logistic regression analysis revealed that both were significant risk factors. CONCLUSIONS: In patients undergoing m-MEL, the incidence of POSEH is highest at the L2/3 level, and treatment of the L2/3 level at the end of the procedure and the presence of spinal stenosis are risk factors for POSEH.

Massive Lumbar Disc Herniation Causing Cauda Equina Syndrome That Presents As Bladder and Bowel Dysfunction in the Absence of Lower Extremity Weakness.

The purpose of this report is to examine the features of cauda equina syndrome (CES) presenting as bladder and bowel dysfunction in the absence of lower extremity weakness. Between July 2015 and July 2016, we experienced four cases of massive LDH causing CES that presented as bladder and bowel dysfunction in the absence of lower extremity weakness. Herein, we describe the clinical features of these four patients (two males and two females) who were followed for a minimum of two years postoperatively. The mean age at the time of surgery was 46.8 years (range, 37-71 years). The disc herniation lesion was at the L4/5 level in one patient, and the L5/S1 level in three. The mean interval between the onset of CES and complete surgical decompression was 10.5 days (range, 1-18 days). Postoperative outcomes were better than poor in three of four cases, while one case had residual sphincter dysfunction. LDH causing CES is considered an indication for immediate surgical decompression; however, diagnosis of CES is likely to be delayed in atypical cases of CES that present as bladder and bowel dysfunction in the absence of lower extremity weakness. Diagnosis of CES tended to be delayed in cases without lower extremity weakness. Clinicians should recognize even sensory impairment alone of the dominant area supplied by S2-4 is an important diagnostic sign of CES in the early stage.

Association of Postoperative Neutrophil Lymphocyte Ratio (NLR) and Monocyte Lymphocyte Ratio (MLR) with the Presence of Osteoporosis in Japanese Patients after Hip Fracture Surgery: A Retrospective Cohort Study.

BACKGROUND: The diagnosis of osteoporosis is based on bone mineral density measurements expressed as a percentage of the young adult mean (YAM) in Japan. Osteoporosis is defined as YAM <70%, and intervention is recommended at this cutoff. Because osteoporosis has a strong association with systemic metabolic disorders, we postulated that patients with YAM <70% had higher inflammatory biomarker concentrations owing to the higher systemic stress compared with YAM >70%. METHOD: We retrospectively reviewed 94 patients with low-trauma hip fractures. Blood examinations were performed on postoperative day (POD) 1 and POD 7. We used neutrophil lymphocyte ratio (NLR) and monocyte lymphocyte ratio (MLR) to evaluate postoperative recovery. After dividing the 94 patients into two groups according to a YAM cutoff of 70%, we compared the differences in NLR and MLR. RESULTS: On POD 1, patients with YAM >70% had a median NLR of 5.7 and a median MLR of 0.66, which were significantly lower than for patients with YAM <70% (8.8 and 0.9, respectively). Similarly, on POD 7, patients with YAM >70% had a median NLR of 2.0 and a median MLR of 0.31, which were significantly lower than for patients with YAM <70% (3.5 and 0.43, respectively). CONCLUSION: A YAM cutoff of 70% is an appropriate intervention threshold regarding postoperative recovery after hip fracture surgery. Mini-Abstract. Patients with YAM >70% showed lower NLR and MLR on POD 1 and POD 7. A YAM cuffoff of 70% is an appropriate intervention threshold regarding postoperative recovery after hip fracture surgery.

Predictive factors of non-treatment and non-persistence to osteoporosis medication after fragility hip fractures at 3 years after discharge: a multicentre, prospective cohort study in the northern Kyushu district of Japan.

We examined osteoporosis medication use and factors affecting persistence in 497 patients with fragility hip fractures. Only 25.5% of patients received continuous medication for 3 years, and 44.1% of patients received no treatment. Low Barthel index at discharge was a risk factor for both non-treatment and non-persistence to osteoporosis medication. PURPOSE: Fragility hip fractures (FHF) caused by osteoporosis decrease the quality of life and worsen life expectancy. Use of osteoporosis medication may be an efficient method in the prevention of secondary FHF. However, previous studies have reported low rates of osteoporosis medication and persistence after FHF. This study aimed to evaluate osteoporosis medication use and factors affecting persistence in patients with FHF in the northern Kyushu area of Japan. METHODS: A total of 497 FHF patients aged ≥ 60 years with a 3-year follow-up were included. We prospectively collected data from questionnaires sent every 6 months regarding compliance with osteoporosis medication. We compared baseline characteristics among three groups: no treatment (NT), no persistence (NP), and persistence (P), and conducted multivariable regression models to determine covariates associated with non-treatment (NT vs. NP/P) and non-persistence (NP vs. P). RESULTS: There were 219 (44.1%), 151 (30.4%), and 127 (25.5%) patients in the NT, NP, and P groups, respectively. Factors associated with non-treatment were male sex, chronic kidney disease, no previous osteoporosis treatment, and low Barthel index (BI) at discharge. The only factor associated with non-persistence was a low BI at discharge. Factors associated with a low BI at discharge were male sex, older age, trochanteric fracture, and surgical delay. CONCLUSION: Low BI at discharge is a risk factor for both non-treatment and non-persistence to osteoporosis medication. Therefore, appropriate interventions to improve BI may result in persistence to osteoporosis medication.

Ascending Aortic Calcification as a Potential Predictor for Low Bone Mineral Density: A Pilot Study.

BACKGROUND: Identifying the factors related to low bone mineral density (BMD) can have significant implications for preventing hip fractures. The correlation between ascending aortic calcification and BMD has never been reported. Therefore, the purpose of the current study is to confirm the hypothesis that ascending aortic calcification can be used as a predictive factor for low BMD and to find a radiographic sign to show it. METHOD: Plain film and computed tomography (CT) images of the thorax were obtained from 91 patients with hip fractures. Using the images, the calcification line of the ascending aorta adjacent to the aortic arch was evaluated. A prominent calcification line confirmed by both plain film and CT was classified as +2. A line which was ambiguous on plain film but confirmed by CT was classified as +1. Cases with no calcification were categorized as 0 (control). We compared the classified score with the BMD and calculated the kappa coefficient to measure intraobserver reliabilities for this radiographic finding. RESULTS: Twenty-eight patients showed a +2 line, twenty-four patients showed a +1 line, and thirty-nine patients showed 0 lines. The median BMD of each group was 0.37 for the +2 line, 0.45 for the +1 line, and 0.51 for the 0 line. The BMD for the +2 group was significantly lower than the others. The kappa coefficient was approximately 0.6 (p < 0.01). CONCLUSION: The imaging finding of calcification of the ascending aorta might be considered as a potential surrogate marker of low BMD. In such subjects, BMD might be ordered for the confirmation of diagnosis of osteoporosis. Mini-Abstract. The Aortic Arch Tail Sign, a calcification line on the ascending aorta, was relevant to low BMD in the current study. BMD can be ordered for the confirmation of diagnosis of osteoporosis in a subject incidentally found to have ascending aorta calcification on X-ray or CT.

Changes in a Single Institution's Orthopedic Hospitalization Service in Japan Owing to COVID-19 in 2020.

Introduction The coronavirus disease 2019 (COVID-19) pandemic has had immense impact on people and institutions, including the number of admissions to hospitals for surgery. Our aim in this study was to determine the impact of the pandemic on surgeries in a single institution located in Fukuoka, Japan, between 2019 and 2020. Methods We quantified the numbers of surgeries in both years according to three sites of injury (indoor, outdoor, and unknown), 14 disease categories, and 9 primary diseases using patients' medical records. We also compared the hospital cost per day in each month from March to November in both 2019 and 2020 and compared the change in these costs between the two years. Results The number of admissions in 2020 was 1,187 cases vs 1,282 cases in 2019. The average patients' age was higher in 2020 vs 2019 (69.7 ± 0.5 vs 67.5 ± 0.5 years, respectively; p = 0.004), with no gender differences (2020: 705 women and 482 men; 2019: 716 women and 566 men). We found no significant differences in the number of admissions by month between 2019 and 2020. The percentages of outdoor injuries were significantly lower in 2020 vs 2019 (29.8% vs 37.9%, respectively; p = 0.004), and we found significantly different rates when comparing 2020 and 2019 for degenerative disease (42.6% vs 37.4%; p = 0.007), trauma related to falls (34.4% vs 30.2%; p = 0.02), chronic disease (1.9% vs 3.7%; p = 0.005), and sports injuries (0.8% vs 3.7%; p < 0.0001). The rate of sports-related injury was significantly lower in 2020 (1.6%) than in 2019 (7.7%) (p < 0.0001). The daily hospital charge was $10,517.09 (US dollars) in 2020 vs $11,225.32 in 2019, and the charges in the months of April and June were significantly higher in 2020 vs 2019 (p = 0.003 and p = 0.001, for April and June, respectively). Both the number and rate of upper limb fractures were higher in 2020. Conclusions The COVID-19 pandemic is affecting some hospitals' revenue. Although the charges per day were sufficient in our institution in 2020, compared with 2019, some hospital beds were unused during this phase of the pandemic. Hospitals may increase the revenue by mixing both short-term and long-term patients' hospital stays effectively.

Long-term outcomes of spinal meningioma resection with outer layer of dura preservation technique.

Spinal meningioma is a common benign intradural spinal tumor. It has been reported that the local recurrence rate after surgical resection increases with longer follow-up duration. Simpson grade 1 resection could reduce the risk of recurrence, but this procedure needs dural reconstruction, which would cause cerebrospinal fluid (CSF) leakage or iatrogenic spinal cord injury. Saito et al. reported dura preservation technique to reduce the risk of CSF leakage, in which the meningioma together with the inner layer of the dura is removed and the outer layer is preserved for simple dural closure. The long-term outcomes with this technique have never been investigated. In this study, we retrospectively analyzed the data of 38 surgically treated patients (dura preservation technique, 12 patients; Simpson grade 2 resection, 26 patients) to assess the long-term recurrence rate (mean, 121.5 months; range, 60-228 months). The local recurrence rate in the dura preservation group was 8.3% (1 of 12 cases), which was similar to that in Simpson grade 2 resection group (2 of 26 cases [7.7%]). Although this case series did not indicate the significant difference in the recurrence rates between the dura preservation group and Simpson grade 2 group, we consider that this technique still has advantages for surgically less invasiveness in terms of dural reconstruction which is necessary for Simpson grade 1 and higher possibility of complete resection of tumors compared with Simpson grade 2 resection.

Anatomical Evaluation of Lumbar Arteries for Lateral Lumbar Interbody Fusion with Magnetic Resonance Imaging.

INTRODUCTION: Lateral lumbar interbody fusion (LLIF) is becoming a more common surgical treatment option for adult degenerative lumbar conditions. LLIF is a mini-open access technique with wound retractors, and postoperative hematoma due to segmental vessels injury is reported. Thus, it is considered that there is a need to conduct detailed preoperative examinations to identify where the lumbar vessels are. As far as we know, there are only a few studies investigating the location of the lumbar arteries. This study evaluates the anatomical position of lumbar arteries using magnetic resonance imaging (MRI). METHODS: We studied 101 MRIs of patients with lumbar disease. The length from the upper and lower end plates of the vertebra to the lumbar arteries was measured. The measurement was conducted with coronal MRI images of every quarter slice of L1 to L4 vertebrae. We also investigated sagittal MRI images to determine whether the lumbar vessels are located on intervertebral disc in each level from L1/2 to L5/S1. RESULTS: The lumbar vessels are not always located at the center of the vertebrae. Some lumbar vessels are located within 8 mm from the end plates. Especially in L4, the lumbar vessels tended to go down from the anterior cranial side to the posterior caudal side (P < 0.01). 8, 24, and 54 lumbar vessels are located at the anterior quarter, the center, and the posterior quarter slice of the vertebrae, respectively, in L4. There were seven lumbar vessels in total located on the vertebral disc level. CONCLUSIONS: It is necessary to investigate where the lumbar arteries are located to prevent its injury in LLIF, because the lumbar artery is not always located at the center of a vertebra. MRIs may provide a valuable information to avoid vascular injury during LLIF.

Surgery-related predictable risk factors influencing postoperative clinical outcomes for thoracic myelopathy caused by ossification of the posterior longitudinal ligament: a multicenter retrospective study.

OBJECTIVE: Compression of the spinal cord by thoracic ossification of the posterior longitudinal ligament (T-OPLL) often causes severe thoracic myelopathy. Although surgery is the most effective treatment for T-OPLL, problems associated with surgical intervention require resolution because surgical outcomes are not always favorable, and a small number of patients experience deterioration of their neurological status after surgery. The aim of the present study was to examine the surgery-related risk factors contributing to poor clinical outcomes for myelopathy caused by T-OPLL. METHODS: Data were extracted from the records of 55 patients with thoracic myelopathy due to T-OPLL at institutions in the Fukuoka Spine Group. The mean follow-up period was 5.3 years. Surgical outcomes were assessed using the Japanese Orthopaedic Association (JOA) scale. To investigate the definitive factors associated with surgical outcomes, univariate and multivariate regression analyses were performed with several patient-related and surgery-related factors, including preoperative comorbidities, radiological findings, JOA score, surgical methods, surgical outcomes, and complications. RESULTS: Neurological status improved in 33 patients (60.0%) and deteriorated in 10 patients (18.2%) after surgery. The use of instrumentation was significantly associated with an improved outcome. In the comparison of surgical approaches, posterior decompression and fusion resulted in a significantly higher neurological recovery rate than did anterior decompression via a posterior approach and fusion or decompression alone. It was also found that postoperative neurological status was significantly poorer when there were fewer instrumented spinal levels than decompression levels. CSF leakage was a predictable risk factor for deterioration following surgery. CONCLUSIONS: It is important to identify preventable risk factors for poor surgical outcomes for T-OPLL. The findings of the present study suggest that intraoperative CSF leakage and a lower number of instrumented spinal fusion levels than decompression levels were exacerbating factors for the neurological improvement in T-OPLL surgery.