Psychological Factors Can Affect the Clinical Outcome of Chemonucleolysis with Condoliase in Patients with Lumbar Disk Herniation.

Introduction: Condoliase-based chemonucleolysis is a minimally invasive intermediate treatment option between conservative approaches and surgical interventions for lumbar disk herniation (LDH). In this study, the effects of psychological factors on the clinical outcomes of condoliase therapy for LDH were assessed. Methods: This study involved patients with LDH who received condoliase injections over a 1-year follow-up period. Data from the visual analog scale (VAS) scores for leg and back pain, Oswestry Disability Index, and Hospital Anxiety and Depression Scale (HADS), which was utilized for the psychological assessment, were collected. Using magnetic resonance imaging, changes in disk height and degeneration were evaluated. Data were assessed at baseline and 1-month, 3-month, and 1-year follow-ups. Condoliase therapy was considered effective in patients whose VAS score for leg pain improved by ≥50% at 1 year from baseline and who did not require surgery. The patients were divided into two groups: those who reported effective treatment (Group E) and those who did not (Group I). Between these two groups, comparative analyses were carried out. Results: In this study, a total of 102 patients (70 men; mean age, 43.8±18.2 years) were included. Condoliase therapy was effective in 76 patients (74.5%). Thirty-five patients (34.3%) showed psychological factors (HADS-Anxiety [HADS-A]≥8 or HADS-Depression [HADS-D]≥8) preoperatively and had a significantly lower rate of effectiveness than did those without psychological factors. Group I demonstrated significantly higher baseline back pain VAS, HADS, and HADS-D scores when compared with Group E. Logistic regression analysis identified females and the baseline HADS-D score as independent factors that were related to the effectiveness of condoliase therapy. Conclusions: The patients with psychological factors tended to experience residual pain resulting in adverse effects on the clinical outcomes of chemonucleolysis with condoliase.

Evaluation of the changes in waistline asymmetry using digital photography in adolescents with idiopathic thoracolumbar/lumbar scoliosis after corrective surgery.

PURPOSE: Waist line asymmetry is a major cosmetic concern in patients with adolescent idiopathic scoliosis (AIS). The primary surgical goal in patients with AIS is to correct spinal deformities and prevent further progression while maintaining global alignment. Additionally, an important objective of surgical treatment is to address physical appearance by reducing asymmetry. This study aimed to evaluate changes in waistline asymmetry using digital photographs in adolescents with thoracolumbar/lumbar (TL/L) scoliosis who underwent corrective surgery. METHODS: We retrospectively analyzed the data of patients with Lenke types 5C and 6C AIS who underwent posterior fusion surgery with at least 2 years of follow-up. Waist line asymmetry was assessed using digital photography. The waist angle ratio (WAR), waist height angle (WHA), and waistline depth ratio (WLDR) were measured pre- and postoperatively. Radiographic parameters and the revised 22-item Scoliosis Research Society Questionnaire (SRS-22r) were also evaluated. RESULTS: Forty-two patients (40 females and 2 males; 34 with type 5C and 8 with type 6C) were included in the study. The WAR, WHA, and WLDR significantly improved after surgery (0.873 → 0.977, - 2.0° → 1.4°, and 0.321 → 0.899, respectively). Every waistline parameter moderately correlated with the apical vertebral translation of the TL/L curve (WAR: r = - 0.398, WHA: r = - 0.442, and WLDR: r = - 0.692), whereas no correlations were observed with the TL/L curve magnitude. No correlations were observed between the photographic parameters and SRS-22r scores. CONCLUSION: Lateral displacement of the apical vertebra on the TL/L curve correlated with waistline asymmetry. Preoperative waistline asymmetry improved with scoliosis correction. LEVEL OF EVIDENCE: Level 4.

Impact of malnutrition on mortality and neurological recovery of older patients with spinal cord injury.

This retrospective cohort study established malnutrition's impact on mortality and neurological recovery of older patients with cervical spinal cord injury (SCI). It included patients aged ≥ 65 years with traumatic cervical SCI treated conservatively or surgically. The Geriatric Nutritional Risk Index was calculated to assess nutritional-related risk. Overall, 789 patients (mean follow-up: 20.1 months) were examined and 47 had major nutritional-related risks on admission. One-year mortality rate, median survival time, neurological recovery, and activities of daily living (ADL) at 1 year post-injury were compared between patients with major nutrition-related risk and matched controls selected using 1:2 propensity score matching to adjust for age, pre-traumatic neurological impairment, and activity. In the Kaplan-Meier analysis, the median survival times were 44.9 and 76.5 months for patients with major nutrition-related risk and matched controls, respectively (p = 0.015). Matched controls had more individuals with a neurological improvement of American Spinal Injury Association Impairment Scale ≥ 1 grade (p = 0.039) and independence in ADL at 1 year post-injury than patients with major nutrition-related risk (p < 0.05). In conclusion, 6% of older patients with cervical SCI had major nutrition-related risks; they showed a significantly higher 1 year mortality rate, shorter survival time, poorer neurological improvement, and lower ADL at 1 year post-injury than matched controls.

Neurological recovery rate and predictive factors of incomplete AIS grade C spinal cord injury in the older aged population.

STUDY DESIGN: Retrospective cohort study. OBJECTIVES: To define the prognosis and predictive factors for neurological improvement in older patients with incomplete spinal cord injury (SCI) of American Spinal Injury Association Impairment Scale grade C (AIS-C). SETTINGS: Multi-institutions in Japan. METHODS: We included patients aged ≥65 years with traumatic SCI of AIS-C who were treated conservatively or surgically with >3 follow-up months. To identify factors related to neurological improvement, patients were divided into three groups according to their neurological status at the final follow-up, with univariate among-group comparisons of demographics, radiographic, and therapeutic factors. Significant variables were included in the multivariate logistic regression analysis. RESULTS: Overall, 296 older patients with SCI of AIS-C on admission were identified (average age: 75.2 years, average follow-up: 18.7 months). Among them, 190 (64.2%) patients improved to AIS-D and 21 (7.1%) patients improved to AIS-E at final follow-up. There were significant among-group differences in age (p = 0.026), body mass index (p = 0.007), status of pre-traumatic activities of daily living (ADL) (p = 0.037), and serum albumin concentrations (p = 0.011). Logistic regression analysis showed no significant differences in variables in the stratified group of patients who improved to AIS-D. Meanwhile, serum albumin was a significant variable in patients who improved to AIS-E (p = 0.026; OR: 6.20, pre-traumatic ADL was omitted due to data skewness). CONCLUSIONS: Most older patients with incomplete AIS-C SCI demonstrated at least 1 grade of neurological improvement. However, <10% of patients achieved complete recovery. Key predictors of complete recovery were high serum albumin levels on admission and independent pre-traumatic ADL. SPONSORSHIP: No funding was received for this study.

5-year outcomes of surgical intervention in patients with adult spine deformity according to preoperative 5-item modified frailty index scores.

PURPOSE: Frailty increases vulnerability to dependency and/or death, and is important in predicting the risk for adverse effects following adult spinal deformity (ASD) surgery. For easy determination of frailty, the 5-item modified frailty index (mFI-5) was established. However, there are few reports that show the relationship between frailty and mid-term operative outcomes after ASD surgery. The objective of this retrospective study is to determine the correlation of frailty using mFi-5 scores with postoperative medical complications, patient reported outcome measures (PROMs), and radiographic alignment 5 years after ASD surgery. METHODS: 208 patients were divided into robust (R), pre-frail (PF), and frail (F) groups based on mFI-5 scores. Postoperative medical complications, preoperative and 5-year follow-up PROMs and radiographic alignment were evaluated. RESULTS: The study included 91, 79, and 38 patients in group R, PF, and F, respectively. There was no significant difference in age and sex. Discharge to care facility (16 (18%):21 (27%):16 (42%), p = 0.014) and postoperative cardiac complications (2 (2%):0 (0%):3 (8%), p = 0.031) were higher in frail patients. Preoperative ODI (38.3:45.3:54.7, p < 0.001) and SRS-22 (2.7:2.5:2.3, p = 0.004), 5-year postoperative ODI (27:27.2:37.9, p = 0.015), 5-year postoperative SVA (57.8°:78.5°:86.4°, p = 0.039) and 5-year postoperative TPA (23.9°:29.4°:29.5°, p = 0.011) were significantly worse in group F compared to group R. CONCLUSION: Postoperatively, frail patients are more likely to have cardiac complications, inferior PROMs and deterioration of post-correction global spinal alignment. Preoperative assessment using mFI-5 is beneficial to individualize risks, optimize patients, and manage postoperative expectations.

Impact of multi-rod reinforcement on rod fractures in adult spinal deformity: A retrospective case series with a minimum follow up of 5 years.

BACKGROUND: This study aimed to determine the impact of the multi-rod construct on rod fractures over a minimum follow-up period of five years in comparison to that with the conventional two-rod construct using the same technique, rod composition, and rod reinforcement method. METHODS: Data were retrospectively retrieved from a prospectively collected, single-center database. Consecutive patients >50 years of age who underwent thoracopelvic corrective fusion with planned two-stage anterior-posterior surgery and were followed up for at least five years were included in this study. The incidence of rod fracture in the conventional two-rod and multi-rod groups was investigated. RESULTS: A total of 58 patients (mean age, 68.9 years) were included in this study (follow-up rate, 73.4 %). Rod fracture was identified in 25 patients (43.1 %), within an average period of 25.1 months. The incidence of rod fracture in the multi-rod group was significantly lower than that in the two-rod group. However, there was no significant difference in the time to rod fracture between the two groups. Reinforcement of the multi-rod to the distal portion of the connector of the iliac screw had the lowest fracture rate and no cases of reoperation. CONCLUSIONS: The incidence of rod fracture was significantly lower using multi-rod reinforcement, but the timing of rod fracture did not differ, compared to that with the two-rod construct using the same surgical technique and rod material. Multi-rod reinforcement covering the distal portion of the iliac screw is recommended to reduce the risk of fracture and reoperation.

Early Versus Delayed Surgery for Elderly Traumatic Cervical Spinal Injury: A Nationwide Multicenter Study in Japan.

STUDY DESIGN: Retrospective multicenter study. OBJECTIVES: The effectiveness of early surgery for cervical spinal injury (CSI) has been demonstrated. However, whether early surgery improves outcomes in the elderly remains unclear. This study investigated whether early surgery for CSI in elderly affects complication rates and neurological outcomes. METHODS: This retrospective multicenter study included 462 patients. We included patients with traumatic acute cervical spinal cord injury aged ≥65 years who were treated surgically, whereas patients with American Spinal Injury Association (ASIA) Impairment Scale E, those with unknown operative procedures, and those waiting for surgery for >1 month were excluded. The minimum follow-up period was 6 months. Sixty-five patients (early group, 14.1%) underwent surgical treatment within 24 hours, whereas the remaining 397 patients (85.9%) underwent surgery on a standby basis (delayed group). The propensity score-matched cohorts of 63 cases were compared. RESULTS: Patients in the early group were significantly younger, had significantly more subaxial dislocations (and fractures), tetraplegia, significantly lower ASIA motor scores, and ambulatory abilities 6 months after injury. However, no significant differences in the rate of complications, ambulatory abilities, or ASIA Impairment Scale scores 6 months after injury were observed between the matched cohorts. At 6 months after injury, 61% of the patients in the early group (25% unsupported and 36% supported) and 53% of the patients in the delayed group (34% unsupported and 19% supported) were ambulatory. CONCLUSIONS: Early surgery is possible for CSI in elderly patients as the matched cohort reveals no significant difference in complication rates and neurological or ambulatory recovery between the early and delayed surgery groups.

Long-term effects of diffuse idiopathic skeletal hyperostosis on physical function: A longitudinal analysis.

BACKGROUND: Cross-sectional studies on diffuse idiopathic skeletal hyperostosis have focused on its incidence and related factors. However, the long-term changes caused by the disease remain unclear. This longitudinal cohort study aimed to elucidate the progression of diffuse idiopathic skeletal hyperostosis and its effects on physical function, health-related quality of life, and spinal alignment. METHODS: We recruited 255 older adults (87 men and 168 women; average age, 71.3 years in 2014) who attended local health checkups in 2014 and 2020. Height, body weight, body mass index, blood pressure, grip strength, functional reach, and bone mineral density were measured. The prevalence, location, number of ossified contiguous vertebrae, and spinopelvic parameters were estimated using whole-spine standing radiographs. For health-related quality of life assessment, the Oswestry disability index and EuroQuol-5D were obtained. We performed a 1:1 case-control study with age and sex-matched patients with and without diffuse idiopathic skeletal hyperostosis and analyzed progression over a 6-year period. RESULTS: In 2014, 39 (15.3%) of 255 patients were diagnosed with diffuse idiopathic skeletal hyperostosis (24 males and 15 females), which occurred more frequently in the elderly and males. In 2020, 12 (4.3%) patients were newly diagnosed with diffuse idiopathic skeletal hyperostosis, and 28 (71.7%) of 39 patients diagnosed in 2014 showed varying degrees of progression. Compared with age- and sex-matched patients without diffuse idiopathic skeletal hyperostosis, patients with the condition had higher body mass index and lumbar bone mineral density, larger sagittal vertical axis, and greater T1-pelvic angle. Changes in physical function and spinal-pelvic parameters during the 6-year period did not differ between the groups. CONCLUSIONS: Over a 6-year period, the prevalence of diffuse idiopathic skeletal hyperostosis increased by 4.3%, and it progressed in 71.7% of patients. However, it had little effect on longitudinal physical function, health-related quality of life, and spinopelvic parameters in older adults.

The use of lateral lumbar interbody fusion for identifying adult patients with spinal deformities treatable by short corrective fusion in 2-stage surgery.

BACKGROUND: To investigate and compare the surgical outcomes of short and thoracopelvic corrective fusion with our two-stage technique using lateral lumbar interbody fusion (LLIF) and posterior open surgery. METHODS: Consecutive patients with adult spinal deformities who underwent a planned two-stage anterior-posterior surgery, using LLIF for the first stage and posterior open corrective fusion for the second stage, with a minimum of 2 years of follow-up were included. Patients who underwent lumbar or lumbosacral corrective fusion and thoracopelvic corrective fusion were categorized into the short group and thoracopelvic groups, respectively. We investigated the spinopelvic parameters and patient-reported outcome measurements. RESULTS: Seventy-four consecutive patients (8 men, 66 women; average age, 70.0 years) were included. Ten patients underwent short corrective fusion following significant improvements in the symptoms and radiographic parameters post-LLIF. Several preoperative spinopelvic parameters were better in the short group. Compared to the thoracopelvic group, those who underwent short fusion had a poorer alignment 2 years postoperatively but with comparable results and a significantly higher function score on the Scoliosis Research Society-22 r (SRS-22r) questionnaire. The mean Oswestry Disability Index and SRS-22r scores significantly improved during the 2-year postoperative follow-up in both the groups. CONCLUSIONS: Short corrective fusion can be considered in patients whose symptoms and radiographic parameters significantly improve following LLIF. Patients who undergo short fusion with LLIF application have poorer alignment than those who undergo thoracopelvic fusion 2 years postoperatively; however, the results are comparable, and the function score is significantly improved.

Influence of the timing of surgery for cervical spinal cord injury without bone injury in the elderly: A retrospective multicenter study.

BACKGROUND: Although previous studies have demonstrated the advantages of early surgery for traumatic spinal cord injury (SCI), the appropriate surgical timing for cervical SCIs (CSCIs) without bone injury remains controversial. Here, we investigated the influence of relatively early surgery within 48 h of injury on the neurological recovery of elderly patients with CSCI and no bone injury. METHODS: In this retrospective multicenter study, we reviewed data from 159 consecutive patients aged ≥65 years with CSCI without bone injury who underwent surgery in participating centers between 2010 and 2020. Patients were followed up for at least 6 months following CSCI. We divided patients into relatively early (≤48 h after CSCI, n = 24) and late surgery (>48 h after CSCI, n = 135) groups, and baseline characteristics and neurological outcomes were compared between them. Multivariate analysis was performed to identify factors associated with neurological recovery. RESULTS: The relatively early surgery group demonstrated a lower prevalence of cardiac disease, poorer baseline American Spinal Injury Association (ASIA) impairment scale grade, and lower baseline ASIA motor score (AMS) than those of the late surgery group (P < 0.030, P < 0.001, and P < 0.001, respectively). Although the AMS was lower in the relatively early surgery group at 6 months following injury (P = 0.001), greater improvement in this score from baseline to 6-months post injury was observed (P = 0.010). Multiple linear regression analysis revealed that relatively early surgery did not affect postoperative improvement in AMS, rather, lower baseline AMS was associated with better AMS improvement (P < 0.001). Delirium (P = 0.006), pneumonia (P = 0.030), and diabetes mellitus (P = 0.039) negatively influenced postoperative improvement. CONCLUSIONS: Although further validation by future studies is required, relatively early surgery did not show a positive influence on neurological recovery after CSCI without bone injury in the elderly.

Effect of Unintended Tissue Injury on the Development of Thigh Symptoms After Lateral Lumbar Interbody Fusion in Patients With Adult Spinal Deformity: A Retrospective Case Series.

STUDY DESIGN: A retrospective case series. OBJECTIVE: This study aimed to investigate the effects of lateral lumbar interbody fusion (LLIF)-induced unintended tissue damage, including cage subsidence, cage malposition, and hematoma in the psoas major muscle, on the development of thigh symptoms. SUMMARY OF BACKGROUND DATA: Thigh symptoms are the most frequent complications after LLIF and are assumed to be caused by lumbar plexus compression and/or direct injury to the psoas major muscle. However, the causes and risk factors of thigh symptoms are yet to be fully understood. MATERIALS AND METHODS: Adult patients with spinal deformity who underwent two-stage surgery using LLIF and a posterior open fusion for the first and second stages, respectively, were included. Computed tomography and magnetic resonance imaging were routinely performed after LLIF before posterior surgery to investigate cage subsidence, cage malposition, and hematoma in the psoas muscle. We evaluated the development of thigh symptoms after LLIF and examined the effects of tissue injury on the occurrence of thigh symptoms. The differences in demographics and surgical and tissue damage parameters were compared between the groups with and without thigh symptoms using unpaired t tests and chi-squared tests. Factors associated with the development of thigh symptoms and muscle weakness were also assessed using logistic regression analysis. RESULTS: Overall, 130 patients [17 men and 113 women; mean age, 68.7 (range, 47-84)] were included. Thigh symptoms were observed in 52 (40.0%) patients, including muscle weakness and contralateral side symptoms in 20 (15.4%) and 9 (17.3%) patients, respectively. The factors significantly associated with thigh symptoms identified after multiple logistic regression analysis included hematoma (odds ratio: 2.27, 95% CI, 1.03-5.01) and approach from the right side (odds ratio: 2.64, 95% CI, 1.21-5.75). The presence of cage malposition was the only significant factor associated with muscle weakness (odds ratio: 4.12, 95% CI, 1.37-12.4). CONCLUSIONS: We found unintended tissue injury during LLIF was associated with thigh symptoms. We found that hematoma in the psoas major muscle and cage malposition were the factors associated with thigh symptoms and muscle weakness, respectively.

Hangman's Fracture in Geriatric Population: A Nationwide Multicenter Study in Japan.

STUDY DESIGN: Retrospective multicenter study. OBJECTIVES: To investigate the treatments of the geriatric population with hangman's fractures using a multicenter database under the Japan Association of Spine Surgeons with Ambition (JASA). METHODS: The multicenter database included data from 1512 patients. We employed the Levine and Edwards classification for categorizing hangman's fractures. The study incorporated epidemiological data, including the prevalence of hangman's fractures, patient age, and follow-up duration. Bony fusion rates and length of hospitalization were recorded for Type I and Type II fractures, and the degree of neurological impairment was assessed. RESULTS: Hangman's fractures represented 62 cases, accounting for 7.4% of all cervical spine injuries. The patients had an average age of 76.6 ± 6.5 years, and the mean duration of follow-up was 21.5 ± 23.6 months. The study found that the bony fusion rate for hangman's fractures in the geriatric population was 88.9%. Surgical treatment was associated with a shorter hospitalization period for Type II fractures compared to conservative treatment. Thirteen cases of hangman's fractures in the geriatric population, accounting for 21%, were complicated by spinal cord injury. CONCLUSIONS: This is the largest study to date on hangman's fractures in geriatric population ≥65 years. Type I and Type II fractures, according to the Levine and Edwards classification, had a bony fusion rate of up to 90%. In patients with Type II fractures, surgical treatment led to a shorter initial hospital stay. Geriatric patients are at risk of spinal cord injury due to hangman's fractures.

Symptoms of sacral fractures after posterior spinal instrumented fusion: A case series.

BACKGROUND: Improvements in spinal fusion devices and techniques have enabled stronger spinal fusion, resulting in excellent clinical outcomes. Nevertheless, complications associated with implants, such as screw misalignment, screw lubrication, cage dislocation, and skin issues, might occur. This study aimed to investigate the characteristics and symptoms of sacral fractures after spinal instrumented fusion. METHODS: This case series retrospectively examined the medical records of eight patients (one man and seven women; mean age: 74 years) diagnosed with sacral fractures after undergoing posterior spinal instrumented fusion from February 2015 to March 2022. RESULTS: The average number of fusion levels in all patients was 3.5 (range, 1-10). The lowest instrumented vertebrae (LIV) ranged from L5 to the ilium. Sacral fractures were diagnosed at 18.8 (range, 0.5-84) months postoperatively. The average time from consultation to diagnosis was nine days (range, 0-25 days). Two patients had subclinical fractures, two had H-shaped fractures with the LIV at L5, and four had U-shaped fractures, including screw holes. Buttock pain and lower extremity pain, the most commonly reported symptoms, were observed in seven patients each. There were also instances of leg numbness, muscle weakness, and unilateral leg pain that may be related to L5 or S1 radiculopathy. In all patients, leg and buttock pain were worse during movement and in the sitting position, and better while resting and in the supine position. Three patients were treated conservatively, and five were treated with extended fixation to the ilium. CONCLUSIONS: Sacral fractures following posterior spinal fusion can cause radiculopathy and buttock pain. Symptoms are especially severe when instability occurs in the pelvic region, such as during movements or sitting. As atypical radiculopathy may lead to delays in diagnosis, spine surgeons should recognize the symptoms of this condition.

Postoperative neurological complications in intradural extramedullary tumors: A 10-year experience of a single center.

BACKGROUND: Intradural extramedullary spinal cord tumors (IDEMs) cause neurological symptoms due to compression of the spinal cord and caudal nerves. The purpose of this study was to investigate the incidence of postoperative neurological complications after surgical resection of IDEM and to identify factors associated with such postoperative neurological complications. METHODS: We retrospectively analyzed 85 patients who underwent tumor resection for IDEM between 2010 and 2020. We investigated the postoperative worsening of neurological disorders. The patients were divided into two groups: those with and without postoperative neurological complications. Patient demographic characteristics, tumor level, histological type, and surgery-related factors were also compared. RESULTS: The mean age at the time of surgery was 57.4 years, and histological analysis revealed 45 cases of schwannoma, 34 cases of meningioma, three cases of myxopapillary ependymoma, one case of ependymoma, one case of hemangioblastoma and one case of lipoma. There were five cases (5.8%) of postoperative neurological complications, and four patients improved within 6 months after surgery, and one patient had residual worsening. There were no statistically significant differences in age, sex, tumor location, preoperative modified McCormick Scale grade, histology, tumor occupancy, or whether fixation was performed in the presence or absence of postoperative neurological complications. All four cases of meningioma with postoperative neurological complications had preoperative neuropathy and meningiomas were located in the anterior or lateral thoracic spine. CONCLUSIONS: Neurological complications after surgical resection for IDEM occurred in 5.8% of patients. Meningiomas with postoperative neurological complications located anteriorly or laterally in the thoracic spine.

Prognosis of Cervical Diffuse Idiopathic Skeletal Hyperostosis-Related Spine Injuries in Elderly Patients: Analyses of Both Fracture and Spinal Cord Injury Without Fracture.

STUDY DESIGN: Retrospective multicenter study. OBJECTIVE: The purpose of this study was to compare the prognosis of elderly patients with injuries related to cervical diffuse idiopathic skeletal hyperostosis (cDISH) to matched control for each group, with and without fractures. METHODS: The current multicenter study was a retrospective analysis of 140 patients aged 65 years or older with cDISH-related cervical spine injuries; 106 fractures and 34 spinal cord injuries without fracture were identified. Propensity score-matched cohorts from 1363 patients without cDISH were generated and compared. Logistic regression analysis was performed to determine the risk of early mortality for patients with cDISH-related injury. RESULTS: Patients with cDISH-related injuries with fracture did not differ significantly in the incidence of each complication and ambulation or severity of paralysis compared to matched controls. In patients with cDISH-related injury without fracture, those who were nonambulatory at discharge comprised 55% vs 34% of controls, indicating significantly poorer ambulation in those with cDISH-related injuries (P = .023). There was no significant difference in the incidence of complications and ambulation or paralysis severity at 6 months as compared with controls. Fourteen patients died within 3 months. Logistic regression analysis identified complete paralysis (odds ratio [OR] 36.99) and age (OR 1.24) as significant risk factors for mortality. CONCLUSIONS: The current study showed no significant differences in the incidence of complications, ambulation outcomes between patients with cDISH-related injury with fracture and matched controls, and that the ambulation at discharge for patients with cDISH-related injury without fractures were significantly inferior to those of matched controls.

Worsening ambulation in elderly patients with cervical odontoid fractures: A nationwide multicenter study in Japan.

BACKGROUND: Despite the increasing prevalence of cervical odontoid fractures in older adults, the treatment strategy is controversial. The objectives of the current study are to investigate the prognosis and complications of cervical odontoid fractures in elderly patients and to identify factors associated with worsening of ambulation after 6 months. METHODS: This multicenter, retrospective study included 167 patients aged 65 years or older with odontoid fractures. Patient demographic and treatment data were investigated and compared according to the treatment strategy. To determine associations with worsening ambulation after 6 months, we focused on the treatment strategies (nonsurgical treatment [collar immobilization or halo vest], conversion to surgery, or initial surgery) and patients' background. RESULTS: Patients who received nonsurgical treatment were significantly older, and patients who underwent surgery had more Anderson-D'Alonzo type 2 fractures. Of the patients initially treated nonsurgically, 26% later underwent surgery. Numbers of complications, including death, and degrees of ambulation after 6 months did not differ significantly among treatment strategies. Patients who had worsened ambulation after 6 months were significantly more likely to be older than 80 years, to have needed assistance with walking before injury, and to have cerebrovascular disease. Multivariable analysis showed that a score of ≥2 on the 5-item modified frailty index (mFI-5) was significantly associated with worsening ambulation. CONCLUSIONS: Preinjury mFI-5 scores of ≥2 were significantly associated with worsening ambulation 6 months after treatment of cervical odontoid fractures in older adults.

Nationwide Survey of the Surgical Complications Associated with Lateral Lumbar Interbody Fusion in 2015-2020.

Introduction: Lateral lumbar interbody fusion (LLIF) has been introduced in Japan in 2013. Despite the effectiveness of this procedure, several considerable complications have been reported. This study reported the results of a nationwide survey performed by the Japanese Society for Spine Surgery and Related Research (JSSR) on the complications associated with LLIF performed in Japan. Methods: JSSR members conducted a web-based survey following LLIF between 2015 and 2020. Any complications meeting the following criteria were included: (1) major vessel, (2) urinary tract, (3) renal, (4) visceral organ, (5) lung, (6) vertebral, (7) nerve, and (8) anterior longitudinal ligament injury; (9) weakness of psoas; (10) motor and (11) sensory deficit; (12) surgical site infection; and (13) other complications. The complications were analyzed in all LLIF patients, and the differences in incidence and type of complications between the transpsoas (TP) and prepsoas (PP) approaches were compared. Results: Among the 13,245 LLIF patients (TP 6,198 patients [47%] and PP 7,047 patients [53%]), 389 complications occurred in 366 (2.76%) patients. The most common complication was sensory deficit (0.5%), followed by motor deficit (0.43%) and weakness of psoas muscle (0.22%). Among the patient cohort, 100 patients (0.74%) required revision surgery during the survey period. Almost half of the complications developed in patients with spinal deformity (183 patients [47.0%]). Four patients (0.03%) died from complications. Statistically more frequent complications occurred in the TP approach than in the PP approach (TP vs. PP, 220 patients [3.55%] vs. 169 patients [2.40%]; p<0.001). Conclusions: The overall complication rate was 2.76%, and 0.74% of the patients required revision surgery because of complications. Four patients died from complications. LLIF may be beneficial for degenerative lumbar conditions with acceptable complications; however, the indication for spinal deformity should be carefully determined by the experience of the surgeon and the extent of the deformity.

Prognostic impact of respiratory dysfunction in elderly patients with cervical spinal cord injury and/or fractures: a multicenter survey.

PURPOSE: To investigate the impact of early post-injury respiratory dysfunction for neurological and ambulatory ability recovery in patients with cervical spinal cord injury (SCI) and/or fractures. METHODS: We included 1,353 elderly patients with SCI and/or fractures from 78 institutions in Japan. Patients who required early tracheostomy and ventilator management and those who developed respiratory complications were included in the respiratory dysfunction group, which was further classified into mild and severe respiratory groups based on respiratory weaning management. Patient characteristics, laboratory data, neurological impairment scale scores, complications at injury, and surgical treatment were evaluated. We performed a propensity score-matched analysis to compare neurological outcomes and mobility between groups. RESULTS: Overall, 104 patients (7.8%) had impaired respiratory function. In propensity score-matched analysis, the respiratory dysfunction group had a lower home discharge and ambulation rates (p = 0.018, p = 0.001, respectively), and higher rate of severe paralysis (p < 0.001) at discharge. At the final follow-up, the respiratory dysfunction group had a lower ambulation rate (p = 0.004) and higher rate of severe paralysis (p < 0.001). Twenty-six patients with severe disability required respiratory management for up to 6 months post-injury and died of respiratory complications. The mild and severe respiratory dysfunction groups had a high percentage of severe paraplegic cases with low ambulatory ability; there was no significant difference between them. The severe respiratory dysfunction group tended to have a poorer prognosis. CONCLUSION: Respiratory dysfunction in elderly patients with SCI and/or cervical fracture in the early post-injury period reflects the severity of the condition and may be a useful prognostic predictor.

The relationship between frailty and spinal alignment in the elderly general population: a two-year longitudinal study.

PURPOSE: Frailty is caused by age-related decline in physical function, which may contribute to worsening spinal alignment. Cardiovascular Health Study (CHS)-criteria for assessing physical function seem more appropriate than frailty index which evaluate comorbiduty. However, there have been no reports investigating the relationship between frailty and spinal alignment using the CHS criteria. This study aimed to examine spinal radiographic parameters using the CHS criteria in volunteers participating in a health screening study. METHODS: The subjects were 211 volunteers (71 males and 140 females) aged 60-89 years old who participated in the TOEI study in 2018 and 2020. They were divided into three groups (R: robust, PF: pre-frailty, and F: frailty) according to the score of the Japanese version of the CHS (J-CHS) criteria in 2018. The radiographic parameters were evaluated using a whole-spine standing X-ray. RESULTS: There were 67 volunteers in group R, 124 volunteers in group PF, and 20 volunteers in group F. Of the five items in the J-CHS criteria, low activity was the most common in the PF group (64%). Low activity was also the most common in the F group (100%). Regarding spinal alignment, significant differences were found in C7SVA in 2020 (R:PF:F = 26:31:62 mm, P = 0.047), C2SVA in 2018 (20:34:63 mm, P = 0.019), and C2SVA in 2020 (37:47:78 mm, P = 0.041). CONCLUSION: Frailty was associated with a worsening in global alignment along the 2- year follow up. The frailty may begin with a decrease in activity and progression of exhaustion; preventing this progression is important through motivation to exercise. LEVEL OF EVIDENCE: II.