Correlation of Sagittal Imbalance and Recollapse after Percutaneous Vertebroplasty for Thoracolumbar Osteoporotic Vertebral Compression Fracture: A Multivariate Study of Risk Factors.

STUDY DESIGN: A retrospective case control study. PURPOSE: This study aimed to assess the clinical significance of sagittal balance for predicting and managing the recollapse of cemented vertebra following percutaneous vertebroplasty (PVP) in patients with thoracolumbar osteoporotic vertebral fracture (OVF). OVERVIEW OF LITERATURE: Recently, the recollapse of cemented vertebra following PVP for OVF has been reported. Although the risk factors for recollapse have been determined, the association between sagittal spinopelvic parameters and sagittal imbalance with recollapse has not been established. METHODS: Ambulatory patients who underwent single-level PVP for thoracolumbar OVF with a follow-up of at least 24 months were retrospectively reviewed. The patients were divided into two groups depending on the presence of symptomatic recollapse at the cemented vertebra: (1) recollapsed (RC) group and (2) noncollapsed (NC) group. The patient characteristics and radiographic measurements associated with sagittal imbalance were analyzed at each follow-up visit. RESULTS: Overall, 134 patients (RC group, n=28; NC group, n=106) were enrolled. The mean fracture-free interval was 3.2 months (range, 1.2-25.1 months). The multivariate binary logistic regression analysis identified low bone mineral density (p =0.047), degree of dynamic mobility within the vertebra (p =0.025), and sagittal imbalance as significant risk factors for recollapse (p =0.013; odds ratio, 5.405). The progression of sagittal imbalance and thoracolumbar kyphosis (T10-L2) was more significant in the RC and sagittal imbalance groups than in the NC group (both p =0.000). CONCLUSIONS: Sagittal imbalance, lower bone mineral density, and dynamic mobility within the vertebra are associated with the recollapse of cemented vertebrae following PVP. Sagittal imbalance, rather than local kyphosis or thoracolumbar kyphosis, is particularly significant in that it results in more progressive collapse and sagittal deformity and is accompanied by substantial back pain and neurological deficits. Therefore, a stricter and more active management, including anti-osteoporosis medication, is required for the treatment of OVF with sagittal imbalance of the spine.

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

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

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

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

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

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

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

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

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

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

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

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

Anatomical Double-Bundle Coracoclavicular Reconstruction in Chronic Acromioclavicular Dislocation.

The purpose of this study was to evaluate the clinical and radiological outcomes of anatomical double-bundle coracoclavicular (CC) reconstruction using the coracoacromial (CA) ligament and the conjoined tendon for the treatment of chronic acromioclavicular (AC) joint dislocation. A retrospective evaluation was performed on 18 patients who underwent an anatomical CC reconstruction using the CA ligament and the conjoined tendon for chronic AC joint dislocation. Patients were treated surgically between April 2007 and January 2012. Mean follow-up was 35.3 months (range, 24-49 months). All patients were evaluated for functional outcomes using the modified University of California, Los Angeles (UCLA) shoulder rating scale for chronic AC injury and the Constant-Murley shoulder outcome score. Range of motion and shoulder and elbow strength were also measured. Plain radiographs were taken to evaluate reduction status and CC distance. Mean modified UCLA shoulder rating scale at final follow-up was 18.1 points (range, 13-20 points). No significant difference in mean Constant-Murley scores existed between the injured and contralateral shoulders (P=.26). At final follow-up, 15 (83.3%) patients had well-maintained reduction and 2 (11.1%) patients had a partial loss of reduction. One other patient had a complete loss of reduction due to a postoperative fall. The CC distance was not significantly different between the injured and contralateral shoulders in the immediate postoperative period (P=.46) or at final follow-up (P=.14). One superficial wound infection occurred and was treated with routine wound care. An anatomical double-bundle CC reconstruction using the CA ligament and the conjoined tendon for the treatment of chronic AC joint dislocation is a reliable surgical method with good results.

Intravascular glomus tumor of the forearm causing chronic pain and focal tenderness.

Introduction. A glomus tumor is a benign vascular tumor derived from glomus cells and occurs mainly in the subcutaneous layer of the subungual or digital pulp. Extradigital glomus tumors have been reported within the palm, wrist, forearm, foot, bone, stomach, colon, cervix, and mesentery. Glomus tumors can originate from the intraosseous, intramuscular, periosteal, intravascular, and intraneural layers. However, a glomus tumor originating from the intravascular layer of the forearm is a rare condition. Case Report. A 44-year-old woman had a 7-year history of chronic pain and focal tenderness of the forearm. No hypersensitivity or sensory alterations were observed. Contrast magnetic resonance imaging (MRI) showed a mass measuring 5 × 3 × 2 mm leading to a vein. Surgical excision was performed, and the tumor was completely resected. Finding of gross examination revealed a dark-red, well-defined soft tissue tumor, and histologic examination confirmed that the mass was a glomus tumor. The patient's symptoms were completely resolved postoperatively. Conclusion. Intravascular glomus tumors rarely occur in the forearm; therefore, a thorough physical exam, comprehensive medical history, in-depth imaging, and early surgical excision upon clinical suspicion may be helpful to prevent a delayed or incorrect diagnosis.

Precontoured locking plate fixation for displaced lateral clavicle fractures.

Displaced fractures of the lateral end of the clavicle are associated with an increased risk of nonunion with conservative treatment; therefore, operative treatment is recommended. Various operative treatments have been suggested, but no consensus exists regarding a gold standard for the surgical treatment of this type of fracture. The purpose of this study was to evaluate clinical and radiological outcomes using a precontoured locking compressive distal clavicular plate for Neer type II distal clavicle fractures. Thirty-five patients with Neer type II distal clavicle fractures underwent surgery between March 2009 and January 2012. All patients were evaluated for function using the Constant-Murley Shoulder Outcome Score and University of California, Los Angeles shoulder rating scale, active shoulder range of motion, time to bone union, and coracoclavicular distance. Mean follow-up was 24.2 months (range, 12-35 months). No significant difference existed between the injured and contralateral sides in mean Constant-Murley scores (P=.13) or mean University of California, Los Angeles shoulder rating (P=.27). All patients obtained bony union over a mean of 4.1 months (range, 3.5-6.0 months).The coracoclavicular distance was not significantly different between the injured and contralateral shoulders in the immediate postoperative period (P=.28) or at final follow-up (P=.35). One superficial wound infection occurred, but no major complications, such as nonunion, plate failure, secondary fracture, or deep infection, occurred. Precontoured locking compressive distal clavicular plate fixation for the treatment of displaced fractures of the lateral end of the clavicle is an acceptable surgical method with good results.