Performance evaluation of a rapid immunochromatographic test kit in detecting bovine mastitis-causing streptococci.

Mastitis causes significant economic losses to the dairy industry due to decreased milk production in infected cows. Identification of mastitis-causing pathogens, such as streptococci, is necessary for selecting an effective antibiotic for treating mastitis. Although bacterial cultivation is widely used for pathogen identification, it requires more than 24 hr to complete. Contrarily, Lateral flow assays are simple, rapid, and inexpensive testing procedures. In this study, the effectiveness of an immunochromatographic test kit for detecting streptococci in milk samples from cows with clinical mastitis was evaluated as an alternative to bacterial cultivation. The performance of the immunochromatographic test kit for detecting mastitis-causing pathogens was compared with that of bacterial cultivation and real-time quantitative polymerase chain reaction (qPCR). The sensitivity and specificity of the immunochromatographic test kit were 0.800 and 0.875, respectively, compared with bacterial cultivation. Additionally, the κ statistic values of the immunochromatographic test kit was 0.667, indicating substantial agreement with the results of bacterial cultivation. Statistically, sensitivity and specificity of the immunochromatographic kit and real-time qPCR did not differ significantly; thus, the immunochromatographic test kit detected mastitis-causing streptococci as effectively as real-time qPCR. Therefore, the immunochromatographic kit is a rapid, inexpensive, and simple method for detecting streptococci and contributes to the timely selection of appropriate antibiotics for treatment and promotes early recovery from mastitis.

Impact of Skeletal Muscle Mass on Physical Function and Locomotive Syndrome of Pre- and Postoperative Adult Spinal Deformity.

Background: The purpose of this study is to identify the relationship between locomotive syndrome (LS) status, physical performance and limb and trunk skeletal muscle mass before and after surgery in adult spinal surgery (ASD) patients. Methods: A retrospective observational investigation of 63 consecutive patients with ASD who underwent spinal surgery was conducted. The total skeletal muscle mass of the arms and legs was considered a measure of the total appendicular skeletal muscle mass measured with whole-body dual-energy X-ray absorptiometry. All data pertaining to the physical performance tests and LS were collected preoperatively with follow-up one year postoperatively. Results: Gait speed, the one-leg standing test and the stand-up test were significantly improved one year after surgery compared to preoperative measurements. The lower extremity skeletal muscle mass predominantly influences physical function improvement including gait stride, one-leg standing and the stand-up test after ASD surgery. Conclusions: This study is the first to show that assessing lower extremity muscles prior to ASD surgery is useful in predicting postoperative recovery.

The Utility and Appropriateness of Single-Position Circumferential Lumbar Interbody Fusion Using O-Arm-Based Navigation in the Novel Oblique Position.

PURPOSE: Single-position surgery with patients in a lateral position, which involves inserting percutaneous pedicular screws (PPS) and lateral interbody fusion (LIF) to avoid changing the position, has been reported. The purpose of the present study was to evaluate the utility and appropriateness of single-position LIF-PPS using O-arm-based navigation in the innovative oblique position. METHODS: This study involved a retrospective analysis of 92 consecutive patients with lumbar spondylolisthesis who underwent LIF-PPS using O-arm-based navigation. Thirty-five subjects demonstrated surgery with repositioning, as well as 24 in the lateral decubitus position, and 33 in the oblique during PPS, where the position was changed to the lateral decubitus position using bed rotation without resetting. We compared these three groups in terms of the surgery time, blood loss, and the accuracy of the screw placement. RESULTS: The operative time was significantly shorter in the single-position surgery, both in the lateral and oblique positions, compared to surgery in a dual position. The blood loss was significantly increased in the lateral position compared to the dual and oblique positions. The screw trajectory angle on the downside was significantly smaller in the lateral position, and the accuracy of the screw placement on the downside was significantly lower in the lateral position compared to the dual and oblique positions. CONCLUSION: Single-position surgery could reduce the average surgery time by about 60 min. The present study indicated the oblique position during PPS insertion might make single-position surgery more useful to improve the accuracy of PPS on the downside, with less blood loss.

Comparative Study for Characteristics of Locomotive Syndrome in Patients with Lumbar Stenosis and Adult Spinal Deformity.

INTRODUCTION: The differential diagnoses of lumbar spinal stenosis (LSS) and adult spinal deformity (ASD) have been demonstrated primarily using sagittal radiographic spinopelvic parameters. However, it is more important to know the differences in the characteristic clinical symptoms to make accurate treatment decisions. Recently, the relationship between spinal disease and Locomotive Syndrome (LS) has been reported. Additionally, the Geriatric Locomotive Function Scale-25 (GLFS-25) was reported to be a useful scale to evaluate disease severity and characteristic clinical symptoms in spinal disease. METHODS: Sixty-nine consecutive patients with ASD and 196 patients with LSS who underwent spinal surgery were included. Locomotive dysfunction was evaluated using the GLFS-25 questionnaire and physical performance tests including the two-step test and the stand-up test, measured preoperatively. The correlations between sagittal spinopelvic parameters of ASD and LS were examined. RESULTS: All subjects with lumbar degenerative disease in the present study were diagnosed with LS preoperatively. The severity of LS in patients with LSS and ASD were statistically similar. GLFS-25 scores in the mobility and community domain were similarly poor in both groups. Several scores in the domestic life and self-care domains were significantly worse in the ASD group. Question 20 of the GLFS-25, related to load-bearing tasks and housework, was significantly associated with a large pelvic incidence in ASD patients. CONCLUSIONS: Lumbar degenerative disease requiring surgery severely affects the LS of older people. ASD patients had more difficulty with load-bearing tasks and housework such as cleaning the yard, carrying heavy bedding, dressing, and bathing compared to LSS patients.

Laparoscopic-assisted treatment for diospyrobezoar-induced intestinal obstruction after distal gastrectomy and cholecystectomy.

Diospyrobezoar is a relatively uncommon cause of small bowel obstruction. Here we report successful treatment in a patient with small bowel obstruction due to diospyrobezoar by laparoscopic-assisted surgery. A 93-year-old woman who had undergone distal gastrectomy and laparoscopic cholecystectomy presented with nausea and anorexia. An intestinal obstruction and an intestinal intraluminal mass were discovered on abdominal enhanced computed tomography. Following a transnasal ileus tube placement, the patient underwent laparoscopic surgery to remove the diospyrobezoar from the small intestine. The postoperative course of the patient was uneventful. Laparoscopic-assisted surgery following the transnasal ileus tube was beneficial for the patient's small bowel obstruction caused by diospyrobezoar.

Radiological Assessment of Postoperative Paraspinal Muscle Changes After Lumbar Interbody Fusion With or Without Minimally Invasive Techniques.

STUDY DESIGN: Retrospective cohort study. BACKGROUND: Percutaneous pedicle screws (PPS) have the advantage of being able to better preserve the paraspinal muscles when compared with a traditional open approach. However, the nature of changes in postoperative paraspinal muscle after damage by lumbar fusion surgery has remained largely unknown. It is clinically important to clarify and compare changes in paraspinal muscles after the various surgeries. OBJECTIVE: (1) To determine postoperative changes of muscle density and cross-sectional area using computed tomography (CT), and (2) to compare paraspinal muscle changes after posterior lumbar interbody fusion (PLIF) with traditional open approaches and minimally invasive lateral lumbar interbody fusions (LLIF) with PPS. METHODS: We included data from 39 consecutive female patients who underwent open PLIF and 23 consecutive patients who underwent single-staged treatment with LLIF followed by posterior PPS fixation at a single level (L4-5). All patients underwent preoperative, 6 months postoperative, and 1-year postoperative CT imaging. Measurements of the cross-sectional area (CSA) and muscle densities of paraspinal muscles were obtained using regions of interest defined by manual tracing. RESULTS: We did not find any decrease of CSA in any paraspinal muscles. We did find a decrease of muscle density in the multifidus at 1 year after surgery in patients in the PILF group, but not in those in LLIF/PPS group. CONCLUSIONS: One year after surgery, a significant postoperative decrease of muscle density of the multifidi was observed only in patients who underwent open PLIF, but not in those who underwent LLIF/PPS.

Upper Extremity Skeletal Muscle Mass Asymmetry Exacerbated by Shoulder Imbalance in Lenke1A Adolescent Idiopathic Scoliosis.

Limb muscle strength asymmetry affects many physical abilities. The present study (1) quantified limb muscle asymmetry in patients with adolescent idiopathic scoliosis (AIS); (2) compared AIS patients with major thoracolumbar/lumbar (TL/L) or major thoracic (MT) curves; (3) examined correlations between limb muscle asymmetry and radiographic parameters. Patients with AIS with major TL/L curves (Lenke type 5C) and MT curves (Lenke Type 1A) who underwent posterior spinal fusion at our university hospitals were included. Patients with left hand dominance were excluded. Body composition was measured using whole-body dual-energy X-ray absorptiometry and asymmetry of left and right side skeletal muscles were evaluated. Upper extremity skeletal muscles on the dominant side were significantly larger than those on the nondominant side in both Lenke1A and 5C groups. The asymmetry of upper extremity skeletal muscles was significantly greater in the Lenke1A group than in the Lenke5C group. Additionally, the size of the asymmetry did not correlate with the magnitude of the major curve and rotational deformation but did correlate with a right shoulder imbalance in the Lenke1A group. These results suggest that in AIS with a constructive thoracic curve, right shoulder imbalance is an independent risk factor for upper extremity skeletal muscle asymmetry.

Preoperative Radiographic Evaluation of Thoracic Flexibility and Compensation for Adult Spinal Deformity Surgery. How to Select Optimal Upper Instrumented Vertebra to Prevent Proximal Junctional Kyphosis.

STUDY DESIGN: Retrospective study of a cohort of consecutive patients. OBJECTIVE: The aim of this study was to clarify the usefulness and value of the difference in thoracic kyphosis (ΔTK) angle in various positions by imaging the patient standing, prone, and supine to evaluate TK flexibility and compensation, and to establish optimal radiography to determine an appropriate thoracic level for upper instrumented vertebra (UIV) because a strategy to select an appropriate level to avoid proximal junctional kyphosis (PJK) remains elusive. SUMMARY OF BACKGROUND DATA: Postoperative reciprocal progression of TK is a significant risk factor for PJK. However, how to predict and prevent postoperative reciprocal progression of TK remains unclear. We hypothesized that preoperative evaluation of both TK flexibility and compensation is essential to predict PJK and determine the UIV level. METHODS: We included 144 consecutive patients with adult spinal deformity (ASD), ≥2 years' follow-up, and UIV Th9-11 in this retrospective cohort study. TK was measured from images with patients standing, prone, and supine. Supine ΔTK was calculated as standing TK- supine TK. Prone ΔTK was calculated as standing TK - prone TK. Receiver-operating characteristic (ROC) curves were analyzed to determine the thresholds of supine ΔTK and prone ΔTK for PJK occurrence. RESULTS: PJK was observed in 64 of 144 (44%) patients 2 years postoperatively. Prone and supine ΔTKs were significantly larger in patients with PJK. A significant positive correlation between prone ΔTK and supine ΔTK was observed. When data from patients with and without PJK were plotted separately, a significantly higher proportion of patients with PJK had large prone and supine ΔTKs. The cutoff values of prone and supine ΔTKs for PJK risk were determined using ROC curve analysis. CONCLUSION: Because of their significantly high risk for PJK, in patients with ASD and prone ΔTK >11.5° and supine ΔTK >18.5°, the upper-thoracic spine should be considered for UIV.Level of Evidence: 3.

Clinical Importance, Incidence and Risk Factors for the Development of Postoperative Ileus Following Adult Spinal Deformity Surgery.

STUDY DESIGN: Retrospective observational study of a cohort of consecutive patients. OBJECTIVES: Postoperative ileus (POI) is associated with a variety of adverse effects. Although the incidence of and risk factors for POI following spinal surgery have been reported, the frequency and pathology of POI after spinal corrective surgery for adult spinal deformity (ASD) are still largely unknown. The study objectives were to: (1) clarify the prevalence and clinical significance of POI, (2) elucidate the risk factors for POI, (3) determine radiographically which preoperative and/or postoperative spinal parameters predominantly influence the risk of POI after spinal corrective surgery for ASD. METHODS: We included data from 144 consecutive patients who underwent spinal corrective surgery. Perioperative medical complications and clinical information were extracted from patient electronic medical records. Preoperative radiographic parameters and changes in radiographic parameters after surgery were compared between patients with and without POI. Multivariate logistic regression analyses were performed to clarify potential risk factors for POI. RESULTS: POI developed in 25/144 (17.4%) patients and was the most common complication in the present study. The frequencies of smoking, gastroesophageal reflux disease, and lateral lumbar interbody fusion (LLIF), as well as the duration of surgery were significantly greater in the group with POI versus the group without POI. Among radiographic parameters, only the change in thoracolumbar kyphosis (TLK) from before to after surgery was significantly larger in the group with POI. Multivariate logistic regression analysis showed that male sex, LLIF and large changes in TLK from before to after surgery were significantly associated with the development of POI. CONCLUSIONS: These results suggested that LLIF and large corrections in TLK were independent risk factors for POI after ASD surgery. When patients with ASD have large TLK preoperatively, and it is determined that a large correction is needed, physicians must be aware of the potential for occurrence of POI.

Surgical Outcomes After Minimally Invasive Direct Lateral Corpectomy with Percutaneous Pedicle Screws for Osteoporotic Thoracolumbar Vertebral Collapse with Neurologic Deficits in the Thoracolumbar Spine Compared with Those After Posterior Spinal Fusion with Vertebroplasty.

STUDY DESIGN: Retrospective observational study of a cohort of consecutive patients. OBJECTIVE: The aim of this study was to compare surgical invasion, mechanical complications, and clinical and radiological outcomes 2 years after surgery between minimally invasive corpectomy following percutaneous pedicle screw placements (X-core/PPS) and posterior fixation with vertebroplasty (VP) for treating osteoporotic vertebral fractures (OVFs), which failed conservative treatment due to neurological deficits. SUMMARY OF BACKGROUND DATA: Numerous studies have proposed surgical procedures to treat OVFs that fail conservative treatment. However, an optimal approach remains controversial because patients often have numerous comorbid medical complications, frequent instrumentation failure, and/or adjacent vertebral fracture (AVF). Recently, a minimally invasive lateral approach has attracted attention as an alternative procedure to the thoracolumbar junction for corpectomy and expandable cage replacement (X-Core Adjustable VBR System). However, its usefulness and validity is largely unknown. METHODS: A cohort of 102 consecutive patients with OVF at T11-L1 who underwent surgery were followed up for >2 years after surgery. Ultimately 50 patients were included in the VP group and 45 in the X-core/PPS group. Surgical invasion, radiological examinations, and clinical outcomes between two procedures were compared. RESULTS: Both X-core/PPS and VP procedures were safe and acceptable for neurological improvement and surgical invasion. The correction loss of local kyphotic angle (LKA) and occurrence of AVF were significantly less in the X-core/PPS group. Oswestry Disability Index in the X-core/PPS group at 2 years after surgery showed better recovery than that in the VP group, and no revision surgery was needed in the X-core/PPS group. Postoperative correction loss of LKA increased significantly when intraoperative endplate injury developed. CONCLUSION: This next-generation minimally invasive anterior and posterior combined surgery was found to be a safe and useful procedure for OVF treatment to reduce correction loss, mechanical complication, and AVF, resulting in less postoperative low back pain.Level of Evidence: 3.

Factors Affecting Pedicle Screw Insertional Torque in Spine Deformity Surgery.

STUDY DESIGN: Retrospective observational study of consecutive patients. OBJECTIVE: We sought to: (1) clarify the key factors predominantly associated with the insertional torque of pedicle screws; (2) compare the optimal factors for pedicle screw insertion to obtain rigid screw fixation in patients with adult spinal deformity (ASD) and in those with adolescent idiopathic scoliosis (AIS); (3) determine the optimal screw/pedicle ratio (S/P) to obtain rigid pedicle screw fixation. SUMMARY OF BACKGROUND DATA: Rigid pedicle screw fixation is mandatory to perform corrections for spinal deformities properly and to allow successful fusion after surgery. The fixation depends mainly on screw position accuracy and patient bone quality. Traditionally, spinal surgeons have decided the screw size, trajectory, and tapping size based on their intuition. Insertional torque has been indicated as useful to predict screw fixation strength, and is correlated with screw pullout strength and frequency of postoperative screw loosening. METHODS: We compared insertion torque at L1-L3 levels of 324 screws in 68 patients with ASD and 58 screws in 32 patients with AIS. We assessed the association between screw/pedicle ratio and insertion torque by constructing a spline curve. RESULTS: Pedicle and screw diameter correlated positively with insertion torque in patients with either ASD or AIS. The optimal screw/pedicle ratio to obtain rigid pedicle screw fixation in patients with ASD was close to, but less than one, and, by contrast, was about 1 to 1.25 in patients with AIS. CONCLUSION: We propose the concept of an optimal S/P ratio for obtaining rigid pedicle screw fixation during spinal corrective surgery, which is different for patients with ASD and patients with AIS. The S/P ratio is useful for deciding the appropriate diameter screw for each case in preoperative planning.Level of Evidence: 4.

Erratum for Risk Factors and Assessment Using an Endoscopic Scoring System for Postoperative Respiratory Complications after Anterior Cervical Decompression and Fusion Surgery.

[This corrects the article DOI: 10.22603/ssrr.2020-0104.].

Risk Factors and Assessment Using an Endoscopic Scoring System for Postoperative Respiratory Complications after Anterior Cervical Decompression and Fusion Surgery.

INTRODUCTION: Postoperative respiratory complications (PRC) are one of the most serious complications. Potentially life-threatening accidents can occur after an anterior cervical discectomy and fusion (ADF), such as airway obstruction and aspiration pneumonia. Despite numerous studies, preoperative predictive and preventive methodology has yet to be established. As reported in our previous study, the evaluation of preoperative dysphagia using the eating assessment tool (EAT-10) and a flexible endoscopic evaluation of swallowing (FEES) is useful for predicting the incidence and risk factors of dysphagia after ADF. METHODS: This prospective study comprised 60 consecutive patients who underwent ADF. An otolaryngologist and a speech-language-hearing therapist preoperatively and 1 week postoperatively evaluated dysphagia using EAT-10 and Hyodo-Komagane (H-K) scores during FEES. Patient demographics, comorbidities, and pre- and postoperative dysphagia were compared between patients with and without PRC. RESULTS: Seven of 60 (11.6%) patients had preoperative dysphagia diagnosed using the H-K score. A significant positive correlation existed between the pre- and postoperative H-K scores. Of all 60 cases, eight (13.3%) had PRC. Among them, two required reintubation due to airway obstruction and six had aspiration pneumonia. The PRC(+) group was significantly older and more prone to diabetes and asthma. The preoperative H-K score of the PRC(+) group was significantly higher than that of the PRC(-) group. Postoperatively, but not preoperatively, EAT-10 was significantly higher in the PRC(+) group. CONCLUSIONS: Preoperative dysphagia may potentially exacerbate postoperative dysphagia after ADF. A preoperative evaluation of dysphagia using the H-K score during FEES is a useful method for predicting and reducing the risk of PRC. Level of Evidence: 3.

Posterior occipitocervical instrumented fusion for atlantoaxial instability in a 27-month-old child with Down syndrome: illustrative case.

BACKGROUND: Upper cervical spine instability is one of the most serious orthopedic problems in patients with Down syndrome. Despite the recent advancement of instrumentation techniques, occipitocervical fusion remains technically challenging in the very young pediatric population with small and fragile osseous elements. OBSERVATIONS: A 27-month-old boy with Down syndrome was urgently transported to the authors' hospital because of difficulty in standing and sitting, weakness in the upper limbs, and respiratory distress. Radiographs showed os odontoideum, irreducible atlantoaxial dislocation, and substantial spinal cord compression. Emergency posterior occipitoaxial fixation was performed using O-arm navigation. Improvement in the motor paralysis of the upper left limb was observed from the early postoperative period, but revision surgery was needed 14 days after surgery because of surgical site infection. The patient showed modest but substantial neurological improvement 1 year after the surgery. LESSONS: There are several clinical implications of the present case. It warns that Down syndrome in the very young pediatric population may lead to rapid progression of spinal cord injury and life crisis. This 27-month-old patient represents the youngest case of atlantoaxial instability in a patient with Down syndrome. O-arm navigation is useful for inserting screws into very thin pedicles.

Utility of a Computer-assisted Rod Bending System to Avoid Pull-out and Loosening of Percutaneous Pedicle Screws.

STUDY DESIGN: This was a retrospective observational study of a cohort of consecutive patients. OBJECTIVE: To compare the influence of (1) manual and (2) computer-assisted (CA) rod bending techniques on pedicle screw pull-out resulting in loosening during rod reduction and final tightening. SUMMARY OF BACKGROUND DATA: Our recent study showed screw pull-out during rod reduction might be a risk factor for loosening of percutaneous pedicle screws (PPSs) postoperatively, resulting in worse postoperative back pain. We retrospectively analyzed data from 53 consecutive patients who underwent minimally invasive lumbar or thoracic spinal stabilization using intraoperative computed tomography image (CT)-guided navigation with conventional manual rod bending or CA rod bending and were followed up for 1 year. METHOD: Screw pull-out length was measured on axial CT images obtained immediately after screw insertion and postoperatively. Loosening of screws and clinical outcome were evaluated radiographically, clinically, and by CT 1 year after surgery. The frequencies of screw pull-out and screw loosening between the 2 rod bending techniques were compared. Lumbar pain-related factors for both groups of patients were determined preoperatively and 1 year after surgery. RESULTS: Overall, 360 pedicle screws were placed in the manual group and 124 pedicle screws were placed in the CA group. There was no significant difference in the mean age, sex, bone mineral density, mean stabilized length, or smoking habits of patients between the groups. The diameters, lengths, and trajectory angle (axial and sagittal) of the screws placed were not significantly different between the groups. Screw pull-out rate/length and loosening in the CA group was significantly lower than that in the manual group. Postoperative low back pain improved significantly in the CA group compared with that in the manual group. CONCLUSION: CA bending is useful to avoid PPS pull-out during rod reduction and screw loosening postoperatively. CA bending is useful to avoid PPS pull-out during rod reduction and screw loosening postoperatively. This result might have been a factor leading to reduced postoperative back pain in the CA group, however, that future studies are need to investigate this association.

Locomotive syndrome: Prevalence, surgical outcomes, and physical performance of patients treated to correct adult spinal deformity.

BACKGROUND: Locomotive syndrome (LS) was proposed by the Japanese Orthopedic Association and refers to a scenario in which imminent future nursing care services will be required by elderly adults to manage the functional deterioration of their locomotive organs. It is a social imperative to clarify the risk factors and treatment strategy for LS. However, the relationship between LS and adult spinal deformity (ASD) in those who are treated with spinal corrective surgery remains largely unknown. METHODS: Forty consecutive patients who had ASD and underwent spinal surgery for their disorder were included in this study. Locomotive dysfunction was evaluated using the 25-item Geriatric Locomotive Function Scale-25 (GLFS-25) questionnaire and physical performance tests including the one-legged standing test, the two-step test, the stand-up test, the handgrip strength, and gait speed test which were measured preoperatively, 6 months after surgery, and 1 year after surgery. RESULTS: Of the patients with ASD treated surgically, 95% of them had LS preoperatively and LS prevalence decreased significantly 1 year after surgery by 67.5% compared with the preoperative rate. Among physical performance tests, the walking stride and one-legged standing test improved significantly after spinal corrective surgery. The GLFS-25 items for the domains of pain, mobility, and domestic life improved overall postoperatively, whereas items in the self-care domain did not and the item for difficulty in putting on and taking off trousers and pants worsened. CONCLUSIONS: Spinal corrective surgery significantly improved physical performance tests as well as the frequency and severity of LS in patients with ASD. However, some GLFS-25 items can worsen after surgery and require attention.

Prevalence and Key Radiographic Spinal Malalignment Parameters Associated with the Risk of Pulmonary Function Impairment in Patients Treated Surgically to Correct Adult Spinal Deformity.

INTRODUCTION: There is a significant relationship between pulmonary function and degree of spinal deformity, location of apical vertebrae, and coronal imbalance in patients with childhood spinal deformity. By contrast, the pathophysiology, epidemiology, and influence of deformity on respiratory dysfunction in patients with adult spinal deformity (ASD) remain largely unknown. We sought to clarify and compare the prevalence of pulmonary function impairment in patients with ASD with that in patients with lumbar spinal stenosis (LSS), to determine radiographically which spinal malalignment parameters are associated with a risk of respiratory dysfunction, and to determine the association of respiratory dysfunction with corrective surgery. METHODS: We conducted a prospective study of consecutive patients with a diagnosis of ASD or LSS who underwent spinal surgery. We included data from 122 consecutive patients with ASD and 121 consecutive patients with LSS. Parameters were obtained from full-length lateral radiographs taken with the patients standing and in supine and prone positions. We compared respiratory dysfunction between a group of patients with ASD and LSS and determined correlations between respiratory dysfunction and spinopelvic parameters. RESULTS: Preoperative % forced vital capacity (FVC) of patients with ASD was significantly lower than that of patients with LSS, and the frequency of restrictive ventilatory impairment was significantly higher in those with ASD (15.7%) than those with LSS (7.4%). Thoracolumbar kyphotic curvature (TK) while the patients were in supine position was significantly greater in the group with restrictive ventilatory impairment, and a significant negative correlation was found between %FVC and TK with the patients in supine position. We found no significant improvement of respiratory dysfunction 1 year after surgery. CONCLUSIONS: Spinal deformity is a potential risk factor for restrictive ventilatory impairment in the elderly. We propose that radiographs obtained when patients are in supine position are valuable for evaluating the flexibility of the TK. Rigid TK might be an etiology of restrictive ventilatory impairment in patients with ASD.

Factors affecting postoperative mortality of patients with insufficient union following osteoporotic vertebral fractures and impact of preoperative serum albumin on mortality.

ABTSRACT: BACKGROUND: Numerous comparative studies of surgical procedures have focused on clinical and radiographical outcomes, as well as the effect of bone fragility on the outcome of spinal surgery; however, insights concerning a risk of mortality or morbidity have been limited. Additionally, the effect of surgical therapy on survival after vertebral compression fractures remains controversial. Our aim was to evaluate the preoperative factors that affected the long-term survival of patients who underwent spinal surgery for an insufficient union following osteoporotic vertebral fractures (OVF) and to determine postoperative mortality. METHODS: We retrospectively reviewed the cases of 105 consecutive patients who underwent spinal surgery for OVF. Mortality was estimated using the Kaplan-Meier method and a log-rank test. The preoperative backgrounds of patients were analyzed to determine which risk factors led to death among the OVF cases. Kaplan-Meier curves were used to estimate survival based on preoperative albumin levels of ≤3.5 g/dL (hypoalbuminemia) versus > 3.5 mg/dL. RESULTS: The mean follow-up time was 4.1 ± 0.8 years. Two years after surgery, percentage of patients who had died was 15%. The VAS scores and modified Frankel classification were significantly improved one year after surgery. The ratio of male-to-female was significantly higher for patients with OVF who died than for those who were still alive. No significant difference in mortality was observed among surgical procedures for OVF. The univariate analysis showed that male gender, serum albumin < 3.5 g/dl, creatinine clearance< 60 mg/dl, and the American Society of Anesthesiologists classificat0ion ≥3 were significant risk factors for postoperative mortality. Multivariate analysis revealed that only serum albumin ≤3.5 g/dL was a significant risk factor for long-term postoperative mortality of patients with OVF. CONCLUSIONS: Preoperative hypoalbuminemia was associated with postoperative mortality following surgery for OVF. LEVEL OF EVIDENCE: Level 3.

Key Radiographic Parameters That Influence the Improvement of Postoperative Gastroesophageal Reflux Disease in Patients Treated Surgically for Adult Spinal Deformity With a Minimum 2-Year Follow-up.

STUDY DESIGN: Retrospective observational study. OBJECTIVE: The study objectives were to: (1) determine radiographically which spinal malalignment parameters predominantly influence the risk of gastroesophageal reflux disease (GERD); (2) evaluate the outcome of GERD 2 years after surgery for adult spinal deformity (ASD); and (3) clarify key factors that influence the improvement of postoperative GERD in ASD. SUMMARY OF BACKGROUND DATA: Spinal deformity is reported to be involved in the pathology of GERD. Our previous study found that approximately 50% of patients treated surgically for ASD had GERD symptoms. However, the postoperative progress of GERD and the key factors that influence the improvement of postoperative GERD are largely unknown. METHODS: Ninety-two patients with ASD treated with thoracolumbar corrective surgery and followed up for a minimum of 2 years were enrolled. All patients were asked to complete the Frequency Scale for Symptoms of GERD (FSSG) questionnaire preoperatively and at 1 and 2 years after surgery. GERD was diagnosed by FSSG score more than 8 points. Before, and at 1 and 2 years after surgery, full-length lateral radiographs were taken and radiographic parameters were obtained. RESULTS: Patients were classified into two groups based on GERD symptoms, with 47 (51.1%) in the GERD+ group. Among parameters assessed, only thoracolumbar kyphosis (TLK) was significantly greater in the GERD+ group than in the GERD- group. The FSSG score improved significantly 1 year after surgery, but no significant difference was found between groups at 2 years. A significant correction loss of TLK was observed 2 years after surgery. There was a significant highly positive correlation between the FSSG score and TLK at 2 years after surgery. CONCLUSION: GERD improved with correction of the spinal deformity but significant correction loss of the TLK even within the fusion presumably due to subsidence or proximal junctional kyphosis resulted in a cessation of that improvement over time. LEVEL OF EVIDENCE: 3.

Predictors and Clinical Importance of Postoperative Coronal Malalignment After Surgery to Correct Adult Spinal Deformity.

STUDY DESIGN: A retrospective observational study of a cohort of consecutive patients. OBJECTIVE: The objective of this study was to determine the correlations between clinical outcomes of spinal surgery to correct adult spinal deformity (ASD) including mechanical complications and coronal malalignment and clarify the risk factors for postoperative coronal malalignment. SUMMARY OF BACKGROUND DATA: Despite the coronal malalignment seen regularly in adult patients who have undergone spinal surgery to correct spinal deformity, the associations between coronal malalignment, and clinical outcomes including mechanical complications after the surgery have remained unclear until now. To understand the associations between coronal malalignment and outcomes of surgery to correct ASD, and risk factors for postoperative coronal malalignment has substantial clinical importance. MATERIALS AND METHODS: We included data from 121 consecutive patients who had undergone spinal surgery to correct ASD and were followed up for a minimum of 2 years. Iliac screws were used for pelvic fixation in all cases. The coronal balance was defined as the horizontal distance between the midpoint of C7 and the center of the sacrum on the coronal plane, and coronal malalignment was defined as when the absolute coronal balance was >20 mm. Preoperative radiographic parameters, surgical features, and clinical outcomes including mechanical complications were compared between groups of patients with coronal balance and those with malalignment. Univariate and multivariate regression analysis were used to clarify risk factors for postoperative coronal malalignment. RESULTS: Postoperative coronal malalignment had no significant association with the clinical outcome as evaluated by a Roland-Morris Disability Questionnaire and Oswestry Disability Index but had a significant association with the frequency of rod fracture. A large preoperative coronal imbalance (malalignment), L5 coronal tilt angle, and use of lateral lumbar interbody fusion were found as risk factors for postoperative coronal malalignment. CONCLUSION: Postoperative coronal malalignment had no significant association with the clinical outcome as evaluated by the Oswestry Disability Index and Roland-Morris Disability Questionnaire but was significantly associated with the frequency of rod fracture. LEVEL OF EVIDENCE: Level III.