A new surgical method to treat intracanal lumbar disc herniation using the unilateral biportal endoscopic transforaminal approach: patient series.

BACKGROUND: Unilateral biportal endoscopic lumbar discectomy (UBELD) is a new minimally invasive spine surgery. The purpose of this study is to describe a new surgical method to treat intracanal lumbar disc herniation (LDH) using the unilateral biportal endoscopic transforaminal approach (UBE-TFA). The first 15 patients who had undergone UBELD for single-level LDH were included in this study. Operative time, intraoperative blood loss, postoperative stay, and intraoperative complications were recorded. The Oswestry Disability Index (ODI), numeric rating scale (NRS) score for leg pain, and modified MacNab criteria were assessed at 3 months postoperatively. OBSERVATIONS: The mean operative time was 52.0 ± 13.8 minutes. The mean intraoperative blood loss was 10.5 ± 10.2 mL. The mean postoperative stay was 1.1 ± 0.3 days. There were no complications. The postoperative mean ODI was significantly improved from 44.9 ± 14.4 to 7.7 ± 11.2 at the final follow-up (p < 0.001). There was a significant decrease in the postoperative mean NRS score for leg pain, from 6.1 ± 1.9 to 0.8 ± 1.3 at the final follow-up (p < 0.001). Based on the modified MacNab criteria, good to excellent results were obtained in 86.7% of the patients. LESSONS: We considered UBELD-TFA as not only one of the promising surgical methods for UBELD, but also a new surgical implementation of the TFA.

Partial Resection of Spinous Process for the Elderly Patients with Thoraco-Lumbar Kyphosis: Technical Report.

Background and objectives: Global sagittal imbalance with lumbar hypo-lordosis can cause low back pain (LBP) during standing and/or walking. This condition has recently been well-known as one of the major causes of reduced health-related quality of life (HRQOL) in elderly populations. Decrease in disc space of anterior elements and an increase in the spinous process height of posterior elements may both contribute to the decrease in lordosis of the lumbar spine. To correct the sagittal imbalance, the mainstream option is still a highly invasive surgery, such as long-segment fusion with posterior wedge osteotomy. Therefore, we developed a treatment that is partial resection of several spinous processes of thoraco-lumbar spine (PRSP) and lumbar extension exercise to improve the flexibility of the spine as postoperative rehabilitation. Materials and Methods: Consecutively, seven patients with over 60 mm of sagittal vertical axis (SVA) underwent PRSP. The operation was performed with several small midline skin incisions under general anesthesia. After splitting the supraspinous ligaments, the cranial or caudal tip of the spinous process of several thoraco-lumbar spines was removed, and postoperative rehabilitation was followed to improve extension flexibility. Results: The average follow-up period was 13.0 months. The average blood loss and operation time were 11.4 mL and 47.4 min, respectively. The mean SVA improved from 119 to 93 mm but deteriorated in one case. The mean numerical rating scale of low back pain improved from 6.6 to 3.7 without any exacerbations. The mean Oswestry Disability Index score was improved from 32.4% to 19.1% in six cases, with one worsened case. Conclusions: We performed PRSP and lumbar extension exercise for the patients with LBP due to lumbar kyphosis. This minimally invasive treatment was considered to be effective in improving the symptoms of low back pain and HRQOL, especially of elderly patients with lumbar kyphosis.

Evaluation of the Minimum Clinically Important Differences of the Zurich Claudication Questionnaire in Patients With Lumbar Spinal Stenosis.

STUDY DESIGN: A case-control study. OBJECT: This study aimed to evaluate the minimally clinically important differences (MCIDs) of the Zurich Claudication Questionnaire (ZCQ) after microendoscopic laminectomy in patients with lumbar spinal stenosis (LSS). SUMMARY OF BACKGROUND DATA: The ZCQ is a self-administered tool used to evaluate symptom severity and physical function in patients with LSS. It has been used in many studies worldwide. However, the MCIDs of the ZCQ have not yet been determined. MATERIALS AND METHODS: The study sample consisted of 514 patients who underwent microendoscopic laminectomy for LSS at our hospital between March 2012 and May 2014. The ZCQ, which includes 7 items for symptom severity (scored from 1 to 5) and 5 items for functional disability (scored from 1 to 4), was administered preoperatively and 1-year postoperatively. The MCID was calculated by 4 approaches, including average change, minimum detectable change, change difference, and receiver operating characteristic curve. The authors calculated the area under the curve (AUC) to evaluate the accuracy of the receiver operating characteristic curve. The responsiveness of each measurement was then analyzed. RESULTS: The authors were able to administer the ZCQ at 1-year postoperatively in 349 patients. The ZCQ score was statistically significantly improved 1-year postoperatively. The MCID of ZCQ for symptom severity varied from 0.75 to 0.84, whereas the MCID of the ZCQ score for functional disability varied from 0.60 to 0.76. The AUC of the ZCQ for symptom severity was 0.81 and that for functional disability was 0.80. CONCLUSIONS: This study showed that the MCID of the ZCQ for symptom severity varied from 0.75 to 0.84 and the MCID for functional disability varied from 0.60 to 0.76. In addition, each AUC was over 0.80, indicating that MCIDs of the ZCQ were found to have a high diagnostic performance.

Relationship between lumbar lordosis and the ratio of the spinous process height to the anterior spinal column height.

Purpose Global sagittal imbalance with lumbar hypo-lordosis leads to various problems in elderly populations and is often treated with long-segment fusion and osteotomy. These highly invasive procedures result in a wide range of rigid spines with a high rate of complications. Although some reports have mentioned the primary aetiology of hypo-lordosis, there is limited evidence. Thus, understanding the exact underlying mechanism is required for developing minimally invasive procedures. This study aimed to investigate the factors related to lumbar lordosis (LL) in elderly people. Methods A total of ninety consecutive patients aged ≥ sixty years at a single spine centre were included. We measured LL, the anterior spinal column height consisting of vertebral bodies and intervertebral discs from L1 to L5 (ASC-5) and the sum of the spinous process heights from L1 to L5 (SP-5) with computed tomography in a supine position. The relationship between LL and the SP-5/ASC-5 ratio, SP-5, and ASC-5 was analysed. Results The Pearson correlation coefficients between LL and the SP-5/ASC-5 ratio, SP-5, and ASC-5 were -0.80 (p < 0.001), -0.43 (p < 0.001) and 0.36 (p < 0.001), respectively. Conclusion LL was significantly related to the SP-5/ASC-5 ratio of the lumbar spine in elderly people. In addition to shortening of the ASC, elongation of the SP-5 also contributed to a loss of LL.

Clinical and radiographic analysis of unilateral versus bilateral instrumented one-level lateral lumbar interbody fusion.

Lateral lumbar interbody fusion (LLIF) is a widely applied and useful procedure for spinal surgeries. However, posterior fixation has not yet been decided. We compared the radiographic and clinical outcomes of unilateral versus bilateral instrumented one-level LLIF for degenerative lumbar disease. We conducted a prospective cohort study of 100 patients, who underwent unilateral (group U) or bilateral (group B) instrumented one-level LLIF for degenerative lumbar disease. Forty-one patients in group U were undergoing unilateral pedicle screw instrumentation, and 59 patients in group B were undergoing bilateral pedicle screw instrumentation. Clinical characteristic and demographic data before surgery were compared. The intraoperative data, including operative time with changes in positions, intraoperative blood loss, and X-ray exposure time, as well as the perioperative data, including postoperative hospital stay and clinical and radiographic data were compared. As a result, Group U required a significantly shorter operating time than group B. The subsidence grade and fusion rates exhibited no significant differences in the postoperative radiographic evaluation. Group U had better results in clinical assessments than group B. However, group U required more additional surgeries owing to complications.

Effect of physical therapy on early knee osteoarthritis with medial meniscal posterior tear assessed by MRI T2 mapping and 3D-to-2D registration technique: A prospective intervention study.

Objectives: The purpose of this study was to verify that exercise aimed at improving knee kinematics in early-stage knee osteoarthritis (OA) patients with medial meniscus posterior root tears (MMPRTs) reduces knee adduction angle during gait and prevents rapid cartilage degeneration in the medial compartment of the knee.Methods: Subjects were randomly assigned to an adapting alignment exercise (AAE) group, with the goal of improving knee kinematics, and a muscle training and exercise (MTE) group. Before the start of the six-month intervention and following its completion, we performed an analysis of knee kinematics during gait using a 3D-to-2D registration technique and identified the area of cartilage degeneration using MRI T2 mapping.Results: The amount of change between pre- and post-intervention measurements of the maximum angle of adduction was 0.48° (95% CI: -0.14, 1.09) in the MTE group and -0.40° (-0.84, 0.04) in the AAE group (p = .039). The amount of change in the area of cartilage degeneration according to MRI T2 mapping expressed as MTE/AAE group was 7.7 mm2 (-0.4, 15.8)/-2.7 mm2 (-10.8, 5.3) at the posterior knee (p = .043).Conclusion: AAE could be a potential treatment method that improves the natural course of knee OA with MMRPTs.

Factors related to subjective satisfaction following microendoscopic foraminotomy for cervical radiculopathy.

BACKGROUND: Microendoscopic foraminotomy has been reported to be effective for the treatment of cervical radiculopathy, using outcome measurement scores such as the neck disability index (NDI) and numerical rating scale (NRS). However, the scores for spine surgery do not always reflect the true subjective satisfaction of the patient. The purpose of this study was to evaluate factors related to subjective satisfaction following microendoscopic foraminotomy for cervical radiculopathy. METHODS: The subjects consisted of consecutive patients who underwent microendoscopic foraminotomy for cervical radiculopathy. Patient background information and operative data were collected. The NDI, the NRS score for the neck, upper back, and arm, and the EuroQOL-5D (EQ-5D) were assessed preoperatively and 1 year postoperatively. Postoperative subjective satisfaction was also assessed as a direct evaluation of satisfaction, and willingness to undergo the same operation if needed was assessed as an indirect evaluation. RESULTS: A total of 42 patients were included in this study. The mean age was 52.9 ± 11.8 years; 19.0% were female and 81.0% were male. The operation time for one level was 57.7 min and the estimated blood loss was minimal in most cases. All NDI, NRS, and EQ-5D scores improved significantly postoperatively. Univariate analyses revealed that the factors related to subjective satisfaction were younger age, non-smoking status, high preoperative NDI score, and low postoperative NRS score for the arm. Factors related to the willingness to undergo the same operation if needed were high preoperative NDI scores, high preoperative NRS scores for the arm, and low preoperative EQ-5D scores. CONCLUSIONS: Factors related to subjective satisfaction following microendoscopic foraminotomy include younger age, non-smoking status, high preoperative NDI score, high preoperative NRS score for the arm, low preoperative EQ-5D score, and a low postoperative NRS score for the arm.

Diagnosing Discogenic Low Back Pain Associated with Degenerative Disc Disease Using a Medical Interview.

PURPOSES: To evaluate the usefulness of our original five questions in a medical interview for diagnosing discogenic low back pain (LBP), and to establish a support tool for diagnosing discogenic LBP. MATERIALS AND METHODS: The degenerative disc disease (DDD) group (n = 42) comprised patients diagnosed with discogenic LBP associated with DDD, on the basis of magnetic resonance imaging findings and response to analgesic discography (discoblock). The control group (n = 30) comprised patients with LBP due to a reason other than DDD. We selected patients from those who had been diagnosed with lumbar spinal stenosis and had undergone decompression surgery without fusion. Of them, those whose postoperative LBP was significantly decreased were included in the control group. We asked patients in both groups whether they experienced LBP after sitting too long, while standing after sitting too long, squirming in a chair after sitting too long, while washing one's face, and in the standing position with flexion. We analyzed the usefulness of our five questions for diagnosing discogenic LBP, and performed receiver operating characteristic (ROC) curve analysis to develop a diagnostic support tool. RESULTS: There were no significant differences in baseline characteristics, except age, between the groups. There were significant differences between the groups for all five questions. In the age-adjusted analyses, the odds ratios of LBP after sitting too long, while standing after sitting too long, squirming in a chair after sitting too long, while washing one's face, and in standing position with flexion were 10.5, 8.5, 4.0, 10.8, and 11.8, respectively. The integer scores were 11, 9, 4, 11, and 12, respectively, and the sum of the points of the five scores ranged from 0 to 47. Results of the ROC analysis were as follows: cut-off value, 31 points; area under the curve, 0.92302; sensitivity, 100%; and specificity, 71.4%. CONCLUSIONS: All five questions were useful for diagnosing discogenic LBP. We established the scoring system as a support tool for diagnosing discogenic LBP.

The effect of a prostaglandin E1 derivative on the symptoms and quality of life of patients with lumbar spinal stenosis.

BACKGROUND: Quality of life (QOL) is a concern for patients with lumbar spinal stenosis (LSS). In this study, QOL was examined using the 5-item EuroQol (EQ-5D). METHODS: QOL and activities of daily living (ADL) were surveyed for 91 patients who visited 18 medical institutions in our prefecture and were diagnosed with LSS-associated intermittent claudication. A second survey was performed after ≥6 weeks for 79 of the subjects to evaluate therapy with limaprost (an oral prostaglandin E1 derivative) or etodolac (an NSAID). Symptoms, maximum walking time, QOL, ADL items, and relationships among these variables were investigated for all 91 patients. Leg pain, leg numbness, and low back pain while walking were surveyed by use of VAS scores (0-100). RESULTS: Leg pain, leg numbness, and low back pain while walking (VAS ≥25) were present in 83.5, 62.6, and 54.9 % of the patients in the first survey, and approximately half of the patients had a maximum walking time <15 min. The mean EQ-5D utility value for QOL was 0.59 ± 0.12. This value was significantly associated with maximum walking time (p = 0.030) based on classification of patients into groups with walking times <7.5, 7.5-15, 15-30, and >30 min, showing that maximum walking time affected health-related QOL. Of the 79 patients who completed the second survey, 56 had taken limaprost and 23 (control group) had received etodolac. Limaprost improved possible walking time, reduced ADL interference, and significantly increased the EQ-5D utility score, whereas no significant changes occurred in the control group. Maximum walking time was prolonged by ≥10 min and the EQ-5D utility value was improved by ≥0.1 points in significantly more patients in the limaprost group than in the control group. CONCLUSION: According to the findings of this survey, at an average of 8 weeks after administration limaprost improved symptoms, QOL, and ADL in LSS patients whereas treatment with an NSAID reduced pain but did not have any other effects.

The interspinous ligament should be removed for the decompression surgery with the case of lumbar spinal canal stenosis.

INTRODUCTION: Retrospective clinical study has done concerning the outcomes of lumbar spinal stenosis (LSS) patients treated with trans-interspinous ligament approach method. The object is to determine the efficacy of this procedure and to confirm that the interspinous ligament could be removed for the decompression surgery. METHOD: Seventy patients were treated with this method and 63 patients were followed up for more than 4 years. Operative time, blood loss, complications of surgery and further surgery were checked out. During the follow-up period, JOA score and lumbar spine X-ray were evaluated. RESULTS: The average operative time was 51 min, average operative time per one level was 32 min, and the average blood loss was 57 ml. The recovery rate was excellent in 26, good in 24, fair in 8 and poor in 5 patients. Four of 63 patients (6.3%) needed further surgery and among them only 2 cases (3.2%) needed reoperation because of the instability of the operative levels. CONCLUSION: The trans-interspinous ligament procedure is a simple decompression method completed quickly and accomplishes absolute decompression for LSS. The interspinous ligament should be removed for decompression with a case of lumbar spinal canal stenosis.

Posterior correction and fusion for severe cervical kyphosis in a patient with myotonic dystrophy: a case report.

STUDY DESIGN: A case report. OBJECTIVE: To report the first myotonic dystrophy case in which cervical kyphosis had been surgically corrected. SUMMARY OF BACKGROUND DATA: Myotonic dystrophy is an autosomal dominant disease that shows myotonia, progressive muscle atrophy, and other various symptoms. Instability of the neck is expected to cause disorders of the cervical spine; however, there are no detailed reports on deformity of cervical spine associated with this disease. METHODS: A 43-year-old man with cervical kyphosis due to myotonic dystrophy had undergone an occiput-T2 fusion with autogenous iliac bone using spinal instrumentation. RESULTS: The activity of daily life of the patient had improved markedly, and the good results continued to be preserved for 5 years. There were not any major perioperative complications. CONCLUSIONS: Surgical correction of cervical spine is not necessarily a contraindication for myotonic dystrophy.

Magnetic resonance and computed tomography-based scoring system for the differential diagnosis of vertebral fractures caused by osteoporosis and malignant tumors.

BACKGROUND: Previous reports have described magnetic resonance imaging (MRI) findings alleged to be specific for vertebral fractures caused by malignant lesions. Using such findings for differential diagnosis is often difficult, especially during the early phase of the fracture. With the relative inaccuracy of any single imaging finding, a validated scoring system based on a combination of imaging findings might lead to enhanced diagnostic accuracy. The purpose of this study was to establish a diagnostic scoring system for discriminating osteoporotic vertebral fractures from those caused by malignant tumors on the basis of MRI and computed tomography (CT) findings. METHODS: Ten MRI and CT scan findings of 57 osteoporotic vertebral fractures and 43 neoplastic fractures were retrospectively evaluated for their ability to discriminate between malignant and benign vertebral fractures. RESULTS: The following four MRI and two CT findings were selected as the basis for the scoring system: pedicle or other posterior element involvement; extension into the paravertebral region; preservation of normal bone marrow signal; a continuous black line representing the posterior vertebral body margin on T2-weighted MRI images; osteolytic destruction; and distinct fracture lines on CT. CONCLUSION: By combining the findings common to MRI and CT scans of vertebral fractures, a simple scoring system was devised. This scoring system was found to enhance the accuracy of imaging diagnosis of fractures caused by benign or malignant spinal lesions.

Neurogenic bladder in patients with cervical compressive myelopathy.

We examined the urinary disturbances in 56 consecutive patients with cervical compressive myelopathy using the latest International Continence Society classification. Of the 56 patients with cervical compressive myelopathy, 29 (52%) had some urinary subjective complaints, whereas the remaining 27 (48%) had none. Urologic examination indicated that 8 of these 29 (28%) patients with urinary complaints had urologic disorders other than neurogenic bladder. Of the remaining 21 patients, only 6 (25%) were judged to have neurogenic bladder on urodynamic study. Urodynamic study may be of limited value in diagnosing urinary disturbance in cervical myelopathy. Further, four cases (83%) showed underactive bladder activity in voiding phase, and only one case (17%) showed overactive bladder activity in filling phase. These results were contrary to those of previous studies indicating that cervical compressive myelopathy is associated with overactive bladder activity in filling phase. There were no significant differences in motor or sensory Japanese Orthopedic Association scores between the patients with and without urinary complaints. However, the patients with urinary complaints had significantly longer durations of myelopathy and delayed motor evoked potential latencies than those without urinary complaints. After surgery, 19 of the 21 (90%) patients with urinary complaints showed recovery from urinary disturbance. Operations in patients with cervical myelopathy were also effective against urinary disturbance. Urinary complaints may be an indication for surgical treatment despite the results of urodynamic study.

Surgical treatment with instrumentation for severely destructive spondyloarthropathy of cervical spine.

Nine patients with severely destructive spondyloarthropathy and marked neurologic deficits associated with dialysis-related amyloidosis underwent posterior decompression and fusion by means of instrumentation at our institute. All patients showed segmental kyphosis, six patients vertebral ankylosis, and eight patients spondylolisthesis. Spondylolisthesis at two levels was noted in three patients. Of the 11 levels of spondylolisthesis in all, 9 were proximally adjacent and 2 were distally adjacent to vertebral ankylosis. All patients underwent posterior decompression and multisegment fusion with autogenous iliac bone. From three to five spinal segments were fixed. Seven patients underwent posterior fusion by means of a pedicle or lateral mass screw between levels C3 and C7, one patient between C3 and C6, and one between C3 and T1. The clinical rate of improvement at the final follow-up was 74.3%. Though complete stability could not be achieved in three patients, the results were rated as good. No postoperative neurologic deterioration has been observed in this series, nor did any patients die immediately after surgery or during the postoperative follow-up period. As anterior long-span surgery might be too invasive for hemodialysis patients, we think that posterior decompression and fusion may well be a reasonable and effective strategy for severe hemodialysis-associated cervical spondyloarthropathy with neurologic deficits. To achieve complete stability, 360 degrees fusion with both anterior and posterior fixation with instrumentation may be required for these patients.

[Vertebroplasty].

Vertebroplasty for pseudoartrosis of vertebral fracture using PMMA (polymethylmetacrylate) or CPC (calcium phosphate cement) is a new less invasive surgical method providing sufficient pain relief and correction of kyphosis.

Multilevel subtotal corpectomy and interbody fusion using a fibular bone graft for cervical myelopathy due to ossification of the posterior longitudinal ligament.

A retrospective study of the outcomes of multilevel anterior decompression and interbody fusion for cervical myelopathy due to ossification of the posterior longitudinal ligament (OPLL) was performed to both investigate the long-term results and assess the cause of late deterioration. Twenty-seven patients (mean age, 58.1 years) underwent this procedure and were followed for at least 5 years. The severity of the clinical symptoms was described using the scoring system for cervical myelopathy proposed by the Japanese Orthopaedic Association (JOA score). The average preoperative JOA score was 7.7, and the score at final follow-up was 13.4 with a recovery rate of 62.0%. A delayed deterioration was attributed to a thoracolumbar lesion other than a compromising alteration of the cervical spine. Consequently, this method of treatment for OPLL could stop the progress of ossification and keep a physiological cervical alignment and thus provide good long-term results.

Clinical outcome and survival after palliative surgery for spinal metastases: palliative surgery in spinal metastases.

BACKGROUND: The authors sought to identify treatment-related factors that influenced survival after surgical treatment for metastatic spinal tumors and to evaluate the relationship between survival and postoperative ambulation time as a factor related to quality of life. METHODS: The medical records of 81 patients with metastatic spinal tumors who underwent palliative surgery at the study institution were assessed. Univariate analysis for factors influencing survival used the Kaplan-Meier log rank statistic and multivariate analysis used the Cox proportional hazards model. The Spearman correlation test was used to analyze the relationship between postoperative ambulation and survival time. RESULTS: The patients had a median age of 59.9 years and a median survival of 10.6 months after surgery. For patients, postoperative ambulatory median survival was 16.5 months and median ambulation time was 13.8 months. By univariate analysis, anatomic site of the primary tumor, postoperative ambulation, and combined adjuvant therapy (chemotherapy plus radiotherapy) were associated with prolonged survival (P < 0.05). Multivariate analysis identified primary site and postoperative ambulatory function as independent predictors of prolonged survival (P < 0.0001). Significant correlations were found between ambulation time and survival time of patients who were able to walk after surgery (P < 0.0001), even in patients with liver (P < 0.05) or lung carcinoma (P < 0.05). CONCLUSIONS: The anatomic site of primary carcinoma and postoperative ambulation were associated with longer survival after palliative surgery for metastatic spinal tumor. When ambulation is attained after surgery, it can be preserved until late in remaining life even when the primary tumor is unfavorable. Palliative surgery for spinal metastasis can improve the quality and quantity of life.

Preoperative CT examination for accurate and safe anterior spinal instrumentation surgery with endoscopic approach.

The purpose of this article is to introduce a new procedure for the surgical planning of thoracic anterior spinal instrumentation via endoscopy. For accurate and safe anterior screw insertion via the endoscopic approach, we devised a surgical plan based on the preoperative chest computed tomography (CT) findings obtained with radiographic markers. Using this method, we performed endoscopic thoracic spinal instrumentation surgery in 14 patients. Nine patients underwent anterior endoscopic correction and fusion of idiopathic scoliosis by Cotrel-Dubousset instrumentation, and five patients underwent anterior endoscopic spinal fixation with instrumentation. The accuracy of screw insertion was evaluated postoperatively by CT scanning. One interbody fusion cage and 53 screws were inserted in the 14 patients using endoscopy. Postoperative CT scans revealed that the screws were all accurately inserted without any neurologic complications. In conclusion, using this novel procedure for surgical planning based on CT findings obtained with radiographic markers, anterior screws can be inserted safely and accurately via an endoscopic approach.