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.

Factors affecting the quality of life in the chronic phase of thoracolumbar osteoporotic vertebral fracture managed conservatively with a brace.

BACKGROUND CONTEXT: Although osteoporotic vertebral fractures (OVFs) are the most common type of osteoporotic fracture, few reports have closely investigated the factors contributing to the quality of life (QOL) in the chronic phase after thoracolumbar OVFs using detailed radiographic evaluation. PURPOSE: This study aimed to identify factors associated with the QOL in the chronic phase after thoracolumbar OVF. DESIGN: Post hoc analysis of a prospective randomized study. PATIENT SAMPLE: Participants included 195 patients with fresh thoracolumbar OVF managed conservatively with a brace who were available for radiographic analysis 48 weeks after injury. OUTCOME MEASURES: The degree of QOL impairment at 48 weeks after thoracolumbar OVF was assessed using the Japanese three-level version of the EuroQol five-dimensional questionnaire (EQ-5D) score. METHODS: Univariate and multivariate regression analyses were used to evaluate the relationships between the QOL and radiographic factors. RESULTS: The univariate analysis showed that age, analgesic use, T10/L5 Cobb angle on magnetic resonance imaging (MRI), subsequent vertebral fracture, and nonunion were significantly associated with the EQ-5D score at 48 weeks after thoracolumbar OVF. The multiple regression analysis showed that nonunion, analgesic use, subsequent vertebral fracture, and sacral slope on MRI were independently associated with the EQ-5D score at 48 weeks after thoracolumbar OVF. Receiver operating characteristic analysis for the deterioration of QOL showed that the cutoff value for sacral slope on MRI was 35 degrees. CONCLUSIONS: This study demonstrated that nonunion, subsequent vertebral fracture, and lower sacral slope were independently associated with poorer QOL in the chronic phase of thoracolumbar OVF managed conservatively with a brace. Therefore, improving or preventing these factors in patients with thoracolumbar OVF in the chronic phase may improve the QOL of the affected patients.

The Medial Tibial Plateau Can Be Used as a Direct Anatomical Reference for the Posterior Tibial Slope in Medial Unicompartmental Knee Arthroplasty.

There has been no consensus about how to determine the individual posterior tibial slope (PTS) intraoperatively. The purpose of this study was to investigate whether the tibial plateau could be used as a reference for reproducing individual PTS during medial unicompartmental knee arthroplasty (UKA). Preoperative computed tomography (CT) data from 48 lower limbs for medial UKA were imported into a three-dimensional planning software. Digitally reconstructed radiographs were created from the CT data as the lateral knee plain radiographs and the radiographic PTS angle was measured. Then, the PTS angles on the medial one-quarter and the center of the MTP (» and ½ MTP, respectively), and that on the medial tibial eminence (TE) were measured on the sagittal multiplanar reconstruction image. Finally, 20 lateral knee radiographs with an arthroscopic probe placed on the » and the ½ MTP were obtained intraoperatively, and the angle between the axis of the probe and the tangent line of the plateau was measured. The mean radiographic PTS angle was 7.9 ± 3.0 degrees (range: 1.7-13.6 degrees). The mean PTS angles on the » MTP, the ½ MTP, and the TE were 8.1 ± 3.0 degrees (1.2-13.4 degrees), 9.1 ± 3.0 degrees (1.4-14.7 degrees), and 9.9 ± 3.1 degrees (3.1-15.7 degrees), respectively. The PTS angles on the » MTP and the ½ MTP were strongly correlated with the radiographic PTS angle (r =0.87 and 0.80, respectively, p < 0.001). A statistically significant difference was observed between the mean angle of the radiographic PTS and the PTS on the TE (p < 0.01). The mean angle between the axis of the probe and the tangent line of the tibial plateau was -0.4 ± 0.9 degrees (-2.3-1.3 degrees) on the » MTP and -0.1 ± 0.7 degrees (-1.5-1.2 degrees) on the ½ MTP, respectively. An area from the medial one-quarter to the center of the MTP could be used as an anatomical reference for the individual PTS.

Treatment of thigh abscess caused by retroperitoneal perforation of cecal cancer: A case report.

Introduction and importance: Iliopsoas and iliacus abscesses are caused by hematogenous and lymphatic infections and the spread of inflammation in neighboring organs. A small number of cases have been reported in which inflammation spread not only within the iliopsoas muscle but also to the thigh. Here we report a case of retroperitoneal infiltration and perforation of cecal cancer that caused extensive abscess formation from the iliacus muscle to the thigh. Case presentation: An 80-year-old man who had undergone chemotherapy for cecal cancer had abdominal pain and right thigh pain without any particular attraction. CT images showed extensive abscess formation from the iliacus muscle to the subcutaneous part of the thigh due to retroperitoneal infiltration and perforation of cecal cancer. Ileocecal resection, colostomy, and retroperitoneal abscess drainage were performed for perforation of cecal cancer and pelvic abscess. Although the thigh was initially drained by a small incision, the infection did not heal. Extensive debridement and drainage were required for all of the contaminated areas, and after all the infection was completely cured. Clinical discussion: The optimal treatment for an abscess that has spread from the inguinal region to the thigh is unclear. In this case, active debridement and drainage of the infected area were effective and should have been done early. Conclusion: We believed that debridement and drainage should have been performed from the time of the first surgery not only by the small incision drainage but also for all of the contaminated areas when the infection had been widespread.

Factors Contributing to Residual Low Back Pain after Osteoporotic Vertebral Fractures.

Although osteoporotic vertebral fractures (OVFs) are the most common type of osteoporotic fracture, few reports have investigated the factors contributing to residual low back pain in the chronic phase after OVFs by using radiographic evaluation. We examined the contribution of nonunion, vertebral deformity, and thoracolumbar alignment to the severity of residual low back pain post-OVF. This post hoc analysis of a prospective randomized study included 195 patients with a 48-week follow-up period. We investigated the associations between radiographic variables with the visual analog scale (VAS) scores for low back pain at 48 weeks post-OVF using a multiple linear regression model. Univariate analysis revealed that analgesic use, the local angle on magnetic resonance imaging, anterior vertebral body compression percentage on X-ray, and nonunion showed a significant association with VAS scores for low back pain. Multiple regression analysis produced the following equation: VAS for low back pain at 48 weeks = 15.49 + 0.29 × VAS for low back pain at 0 weeks + (with analgesics: +8.84, without analgesics: -8.84) + (union: -5.72, nonunion: -5.72). Among local alignment, thoracolumbar alignment, and nonunion, nonunion independently contributed to residual low back pain at 48 weeks post-OVF. A treatment strategy that reduces the occurrence of nonunion is desirable.

Improvements in physical functionality in elderly patients with spinal deformity after corrective fusion surgery: a gait analysis.

OBJECTIVE: Extensive corrective fusion surgery was performed on elderly patients with adult spinal deformity (ASD) to improve abnormal posture. Varying improvements in postoperative walking function were expected owing to differences in muscular strength and bone quality between patients in their 40s and those over 75 years of age. The purpose of this study was to compare preoperative and postoperative gait posture and physical functionality in elderly patients with ASD who underwent extensive corrective fusion to the thoracic spine. METHODS: A prospectively maintained surgical database was reviewed for patients with ASD who underwent corrective fusion surgery (thoracic spine to pelvis) between 2011 and 2016. The cohort was divided into three age groups: nonelderly (40-64 years), young-old (65-74 years), and old-old (> 75 years). Patients underwent a 4-m walk test preoperatively and 2 years postoperatively to measure gait-trunk tilt angle and walking speed (meters per minute). RESULTS: Among 291 patients with ASD who underwent corrective fusion surgery, 56 patients (14 men and 42 women; mean age 68.8 years) were included. Mean preoperative gait-trunk tilt angle (12.9° vs 5.2°, p < 0.01) and walking speed (41.2 m/min vs 45.7 m/min, p < 0.01) significantly improved postoperatively. Intergroup analysis revealed that the mean preoperative gait-trunk tilt angles in the nonelderly (n = 13), young-old (n = 28), and old-old (n = 15) groups were 11.9°, 10.0°, and 19.3°, respectively; postoperatively, these improved to 4.5°, 4.5°, and 7.2°, respectively. Mean preoperative walking speeds of 47.9, 40.0, and 37.7 m/min improved to 52.4, 44.8, and 41.5 m/min postoperatively in the nonelderly, young-old, and old-old groups, respectively. There were no statistically significant differences in degree of improvement in gait-trunk tilt angle and walking speed among groups. CONCLUSIONS: Extensive corrective fusion surgery improved the postoperative walking posture of patients with ASD. Statistical analysis of gait measurements demonstrated intergroup equivalence, indicating comparable improvement in physical functionality in elderly and middle-aged patients after corrective fusion surgery.

Nontuberculous mycobacterial infection of the knee after arthrocentesis for idiopathic hemarthrosis: A case report.

INTRODUCTION: Nontuberculous mycobacterial (NTM) infections of the musculoskeletal system are uncommon. Such infections are typically acquired by direct inoculation after penetrating trauma, surgical procedures, or needle injections. There are no reported cases of NTM infection after arthrocentesis for idiopathic hemarthrosis of the knee. Here we report a case of NTM infection in the knee that developed after arthrocentesis for idiopathic hemarthrosis of the knee. PRESENTATION OF CASE: The patient was an 85-year-old woman who experienced swelling of the left knee. An arthrocentesis was carried out, and hemarthrosis was found. The patient was referred to our hospital for repeated recurrence of hematoma of the knee. Significant swelling was observed in the suprapatellar sac. Magnetic resonance imaging examination revealed a mass at the suprapatellar sac. Laboratory data showed elevation of inflammatory markers. Debridement was performed under arthroscopy and samples were collected for culture. Although routine microbiological cultures were negative, the patient continued to experience knee swelling and laboratory data showed high C-reactive protein levels. Therefore, open debridement was carried out. At 4 weeks after the first surgical treatment, intraoperative cultures yielded Mycobacterium intracellulare. At this point, we diagnosed septic arthritis of the knee due to NTM infection. The patient showed an excellent prognosis with three-drug medical treatment for 1 year. CONCLUSION: Clinically, diagnosis of septic arthritis due to NTM infection is not easy. Because selection of examination depends on clinical suspicion, NTM infections should be considered for patients with elevation of inflammatory markers after episodes of surgical procedures, and/or needle injections.

Relationship between locomotive syndrome, frailty and sarcopenia: Locomotive syndrome overlapped in the majority of frailty and sarcopenia patients.

AIM: The relationship between locomotive syndrome (LS), frailty and sarcopenia is unclear. This cohort study investigates the epidemiology of the three conditions and examines the relationship between them. METHODS: The participants were 337 Japanese adults aged ≥60 years who had undergone a healthcare checkup. LS, frailty and sarcopenia were assessed using the Geriatric Locomotive Function Scale, the Kihon Checklist and the Asian Working Group for Sarcopenia criteria, respectively. The epidemiological investigation and correlations of the three concepts were examined. RESULTS: In total, 212 participants (63%) were women. The participants' mean age was 76 years (range 60-94 years). The average Geriatric Locomotive Function Scale total score was 11.4 ± 11.2, and Kihon Checklist was 4.72 ± 3.97. A total of 202 (59.9%) participants met one of the criteria; 190 (56.9%) were diagnosed with LS, 77 (22.6%) with frailty and 26 (7.7%) with sarcopenia; and 70 out of 77 (90.1%) of frailty patients and 21 out of 26 (80.1%) of sarcopenia patients were included in LS. The relationship between the total score, subcategorical scores and survey items for each was investigated. Activities of daily living, physical function and mental status showed a strong correlation with all concepts. However, nutrition of frailty patients and muscle mass of sarcopenia patients did not correlate with other factors. CONCLUSIONS: LS overlapped with frailty and sarcopenia. LS criteria might be useful as the best tool to screen older persons who would be at risk for requiring care in the near future. However, nutrition status could only be assessed by frailty and muscle mass by sarcopenia. Geriatr Gerontol Int 2021; 21: 458-464.

Prospective nursing care certification using the 25-question Geriatric Locomotive Function Scale.

AIM: The 25-question Geriatric Locomotive Function Scale (hereafter, "GLFS-25") is a simple screening tool to detect elderly individuals at high risk of locomotive syndrome and promote interventions. This cohort study aimed to clarify if it can predict the need for nursing care certification in the near future. METHODS: Participants were 531 Japanese adults aged ≥65 years who had undergone a healthcare checkup in 2012 and never received nursing care certification until 2012. We collected baseline information and conducted a physical examination in 2012. We investigated the presence of nursing care certification and care need level from 2013 to 2018. Relationships of these factors with nursing care certification after 6 years were assessed. A receiver operating characteristic curve for both the GLFS-25 and physical examination were used to determine optimal threshold value. RESULTS: From 2013 to 2018, 114 volunteers (21.4%) applied for nursing care certification and 29 volunteers died. The group with nursing care certification (over support level 1) had an average age of 79.9 years and a mean score of 17.8 on the scale. Those without nursing care certification had an average age of 74.1 years and a mean score of 8.7. When the GLFS-25 score was 12.5, sensitivity was 0.658 and specificity was 0.760. The area under the curve was 0.736 (95% confidence interval 0.682-0.789). CONCLUSIONS: The GLFS-25 has enabled early detection of individuals with locomotive syndrome who are more likely to need nursing care certification in the near future. We propose using a cutoff score of 13 for the scale. Geriatr Gerontol Int 2021; 21: 492-497.

Factors Associated with Improved Quality of Life Outcomes in Patients Undergoing Surgery for Adult Spinal Deformity.

STUDY DESIGN: Retrospective longitudinal cohort study. OBJECTIVE: This study aimed to elucidate factors affecting the likelihood of achieving minimum clinically important difference (MCID) to patient-reported outcomes defined by the Scoliosis Research Society-22r (SRS-22r) among patients with adult spinal deformity (ASD) who underwent extensive corrective fusion surgery from the thoracic spine to the pelvis. SUMMARY OF BACKGROUND DATA: Achieving MCID for SRS-22r parameters was a measure of surgical efficacy. Patient characteristics and surgical and radiographic factors that affect the likelihood of achieving MCID for SRS-22r parameters are unknown. METHODS: Data from patients with ASD who underwent extensive corrective fusion surgery from the thoracic spine to the pelvis during 2010 to 2016 were retrospectively reviewed. Data from a total of 167 patients with ≥2 years of follow-up were included. Multivariate analysis was used to investigate factors associated with the likelihood of achieving MCID for each of the SRS-22r domains (Function, Pain, Subtotal) 2 years after surgery. The following MCID values were used: 0.90 for Function, 0.85 for Pain, and 1.05 for the Subtotal. RESULTS: MCID achievement rate was 36.5% for Function, 46.1% for Pain, and 44.3% for the Subtotal domain. In multivariate analysis, preoperative SRS-22r Function (odds ratio [OR] = 0.204, 95% confidence interval [CI] 0.105-0.396) increased the likelihood of achieving MCID for SRS-22r Function. Preoperative SRS-22r Subtotal (OR = 0.211, 95% CI, 0.107-0.413), preoperative pelvic tilt (OR = 1.072, 95% CI, 1.012-1.136), preoperative pelvic incidence minus lumbar lordosis (OR = 0.965, 95% CI, 0.934-0.997), and postoperative sagittal vertical axis (OR = 0.985, 95% CI, 0.974-0.995) affected the likelihood of achieving MCID for the SRS-22r Subtotal. CONCLUSION: Patients with poor preoperative health-related quality of life were more likely to achieve improvement in SRS-22r parameters after extensive corrective fusion surgery for ASD. Achieving postoperative sagittal alignment increased the likelihood of achieving MCID for the SRS-22r Subtotal domain.Level of Evidence: 3.

Risk factors for subsequent vertebral fracture after acute osteoporotic vertebral fractures.

PURPOSE: To investigate the incidence and characteristics of subsequent vertebral fracture after osteoporotic vertebral fractures (OVFs) and identify risk factors for subsequent vertebral fractures. METHODS: This post-hoc analysis from a prospective randomized multicenter trial included 225 patients with a 48-week follow-up period. Differences between the subsequent and non-subsequent fracture groups were analyzed. RESULTS: Of the 225 patients, 15 (6.7%) had a subsequent fracture during the 48-week follow-up. The annual incidence of subsequent vertebral fracture after fresh OVFs in women aged 65-85 years was 68.8 per 1000 person-years. Most patients (73.3%) experienced subsequent vertebral fractures within 6 months. At 48 weeks, European Quality of Life-5 Dimensions, the Japanese Orthopedic Association Back Pain Evaluation Questionnaire pain-related disorder, walking ability, social life function, and lumbar function scores were significantly lower, while the visual analog scale (VAS) for low back pain was higher in patients with subsequent fracture. Cox proportional hazards analysis showed that a VAS score ≥ 70 at 0 weeks was an independent predictor of subsequent vertebral fracture. After adjustment for history of previous fracture, there was a ~ 67% reduction in the risk of subsequent vertebral fracture at the rigid-brace treatment. CONCLUSION: Women with a fresh OVF were at higher risk for subsequent vertebral fracture within the next year. Severe low back pain and use of soft braces were associated with higher risk of subsequent vertebral fractures. Therefore, when treating patients after OVFs with these risk factors, more attention may be needed for the occurrence of subsequent vertebral fractures. LEVEL OF EVIDENCE: III.

Predictors of residual low back pain after acute osteoporotic compression fracture.

BACKGROUND: Studies on the clinical and radiographic risk factors for the residual low back pain beyond 6 months after osteoporotic vertebral fractures (OVFs) are lacking. Hence, this study aimed to characterize a patient population with residual low back pain 48 weeks after acute OVFs and to identify the risk factors associated with residual low back pain. METHODS: This prospective multicenter study included 166 female patients aged 65-85 years with acute one-level OVFs. We defined the residual low back pain as visual analog scale (VAS) for low back pain ≥3.5 at 48 weeks in this study, as VAS score ≥3.5 is used to describe moderate or severe pain. Thus, outcome and risk factor analyses were performed by comparing patients with VAS scores <3.5 and ≥ 3.5. In the radiographic analysis, the anterior vertebral body compression percentage was measured at 0, 12, and 48 weeks. Magnetic resonance imaging (MRI) was performed at enrollment and 48 weeks. RESULTS: Of the 166 patients analyzed, 58 complained of residual low back pain at 48 weeks after OVFs. At 0 weeks, the VAS score was significantly higher, and the JOABPEQ mental health score and anterior vertebral body compression percentage were significantly lower in patients with persistent pain 48 weeks after OVFs. The independent risk factors in the acute phase for persistent pain 48 weeks after OVFs were a high VAS score, MRI T2 fluid-intensity image pattern, and a lower anterior vertebral body compression percentage. CONCLUSIONS: Severe low back pain, MRI T2 fluid-intensity image pattern, and severe vertebral body collapse in the acute phase were significant risk factors for residual low back pain 48 weeks after OVFs. Patients with acute OVFs who have these risk factors should be carefully monitored for the possible development of residual chronic low back pain.

Predictors for quality of life improvement after acute osteoporotic vertebral fracture: results of post hoc analysis of a prospective randomized study.

PURPOSE: No study has investigated the clinical and radiographic risk factors for the deterioration of quality of life (QOL) beyond 6 months after osteoporotic vertebral fractures (OVF). The purpose of this study was to identify the predictors associated with poor QOL improvement after OVF. METHODS: This post hoc analysis included 166 women aged 65-85 years with acute 1-level OVFs. For the patient-reported outcome measures, scores on the European Quality of Life-5 Dimensions (EQ-5D) scale, and visual analogue scale (VAS) for low back pain were used. Lateral radiography at 0, 12, and 48 weeks and magnetic resonance imaging (MRI) at enrollment and at 48 weeks were performed. The associations between baseline variables with change scores for EQ-5D were investigated using a multiple linear regression model. RESULTS: Univariate analysis showed that time since fracture, EQ-5D score, and VAS for low back pain at 0 week showed significant association with increased EQ-5D score from 0 to 48 weeks. According to the multiple regression analysis, the following equation was obtained: increased EQ-5D score from 0 to 48 weeks = 1.305 - 0.978 × EQ-5D at 0 week - 0.021 × VAS for low back pain at 0 week - 0.006 × age + (fluid-intensity T2-weighted MR image patterns: - 0.037, except for fluid-intensity T2-weighted MR image patterns: + 0.037). CONCLUSION: In conclusion, older patients with severe low back pain and fluid-intensity T2-weighted MR image patterns were more likely to have lower QOL improvements after OVFs and may therefore need extra support to improve QOL.

Preoperative and Postoperative Sitting Radiographs for Adult Spinal Deformity Surgery: Upper Instrumented Vertebra Selection Using Sitting C2 Plumb Line Distance to Prevent Proximal Junctional Kyphosis.

STUDY DESIGN: Case-control study from a continuous series. OBJECTIVES: To study the impact of perioperative sitting radiographs in adult spinal deformity (ASD) patients and determine whether proximal junctional kyphosis (PJK) can be prevented using preoperative sitting radiograph. SUMMARY OF BACKGROUND DATA: Radiographic analysis of ASD comprises standing whole-spine radiography which cannot evaluate the relaxed posture without head-to-foot compensation. METHODS: Preoperative and postoperative whole-spine standing and sitting radiographs and proximal mechanical complications in surgically treated spinal disorders with a minimum of 1-year follow-up were studied. Whole-spinal alignment was defined by cervical lordosis (CL), sagittal vertical axis (SVA), T1 slope (T1S), thoracic kyphosis (TK), lumbar lordosis (LL), pelvic incidence (PI), pelvic tilt (PT), sacral slope (SS), and level of kyphotic apex (KA). Proximal mechanical complication was described as a PJK (proximal junctional angle >20°) or reoperation due to proximal junctional failure. RESULTS: Surgically treated 113 patients were prospectively investigated. Patients were divided into either the ASD (thoracic to ilium posterior corrective fusion), or non-ASD groups. In the ASD group, 10 patients had postoperative PJK, and three revision surgeries were carried out due to PJF with neurological deficit. Comparing standing with sitting positions, CL, TK, and PT became larger, SVA became frontal, LL and SS became smaller, and KA became caudal particularly in the ASD group. Logistic regression analysis demonstrated that the most influenced plumb line for PJK was the upper instrumented vertebra (UIV) to C2 plumb line distance, with a cutoff value of 115 mm for predicting PJK. CONCLUSION: Our findings highlight the usefulness of sitting spinal alignment evaluation, particularly in ASD patients, with maximum effort of thoracic spine and lower extremity compensation at standing. Mechanical complications such as PJK could be predicted using the distance from the planned UIV to the C2 plumb line in preoperative sitting radiographs. LEVEL OF EVIDENCE: 3.

Effect of sagittal shape on proximal junctional kyphosis following thoracopelvic corrective fusion for adult spinal deformity: postoperative inflection vertebra cranial to T12 is a significant risk factor.

STUDY DESIGN: This was a retrospective analysis of a prospectively collected consecutive case series of patients with adult spinal deformity (ASD). OBJECTIVE: This study aimed to investigate the impact of the geometrical sagittal shape of the corrected spine on the development of proximal junctional kyphosis (PJK). Several studies have documented risk factors for PJK in ASD surgery. Geometrical assessment is vital for evaluating sagittal spinal deformity. It is essential to assess the postoperative geometrical shape of the spine and the location of the correction in the spine to decrease postoperative junctional stress and PJK. METHODS: Consecutive patients with ASD who underwent corrective fusion with long constructs to the pelvis were included. Patients with neuromuscular disease, congenital and adolescent scoliosis, infection, and spinal tumor were excluded. We investigated the spinopelvic and geometrical parameters of the whole spine. The locations of the thoracic and lumbar apical vertebrae and the inflection vertebrae (IV), where the curvature of the associated adjacent vertebral bodies changes from kyphosis to lordosis, were investigated. The subjects were divided into PJK included patients who underwent revision surgery for junctional failure or with a change in proximal junctional angle ≥ 20°, and non-PJK groups. RESULTS: A total of 139 patients (mean age, 69.6 years; range 18-82 years) were included. There were 47 and 92 patients in the PJK and non-PJK groups, respectively. The IV were located significantly cranial and posterior, the lumbar apex were located significantly posterior in the PJK group at the immediate postoperative time points. The significant risk factors for PJK on binary logistic regression were cranial IV and posterior lumbar apical vertebrae. The incidence of PJK in patients with IV at T12 or cranial tends PJK significantly higher (69%) than at L1 or caudal (26%). CONCLUSIONS: Geometrical spinal shape should be taken into account to reduce the rate of postoperative mechanical complications. LEVEL OF EVIDENCE: Level of evidence III.

Relationship between Knee Osteoarthritis and Spinopelvic Sagittal Alignment in Volunteers over 50 Years of Age.

STUDY DESIGN: Large cohort study of volunteers. PURPOSE: The purpose of this study was to investigate the relationship between the severity of knee osteoarthritis, assessed using the Kellgren-Lawrence (KL) grading scale, and spinopelvic sagittal alignment in older adult volunteers. OVERVIEW OF LITERATURE: The relationship between spinopelvic alignment in the sagittal plane and knee osteoarthritis in the coronal plane is unclear. METHODS: Volunteers over 50 years of age underwent radiographic analysis. Radiographic parameters including pelvic tilt (PT), pelvic incidence (PI), lumbar lordosis (LL), thoracic kyphosis, and sagittal vertical axis (SVA) were measured. The the three Scoliosis Research Society-Schwab sagittal modifiers (PT, SVA, PI-LL) were categorized and the KL grade was assessed. Differences in spinopelvic parameters and Oswestry Disability Index (ODI) scores among KL grades were evaluated. RESULTS: A total of 396 volunteers (160 men, 236 women; mean age, 74.4 years) were analyzed. PI-LL and PT in KL4 were significantly higher compared to that in the other KL grades. However, there were no significant group differences in SVA. In women, but not in men, higher frequencies of the worst modifier grade (++) were observed for PI-LL and PT in the KL3 and KL4 groups compared to those for the other KL grades. In women, the ODI score in KL4 was worse compared to that in the other KL grades. CONCLUSIONS: Individuals over 50 years of age with severe knee osteoarthritis had poor lumbo-pelvic sagittal alignment. Moreover, the progression severity of knee osteoarthritis had more impact onstronger relationship with lumbo-pelvic malalignment and disability-related low back pain in women than in men.

Correction to: Deterioration of sagittal spinal alignment with age originates from the pelvis not the lumbar spine: a 4-year longitudinal cohort study.

Unfortunately, figure 3 was incorrectly published in the original publication. The complete correct figure 3 is given below.

Deterioration of sagittal spinal alignment with age originates from the pelvis not the lumbar spine: a 4-year longitudinal cohort study.

PURPOSE: There is controversy regarding age-related deterioration of spinal sagittal alignment in cross-sectional study. Although we reported that deterioration in spinal alignment originated at the cervical spine in males and the pelvis in females, others studies have indicated that the lumbar spine is initially implicated in both sexes. The purpose of this study was to clarify these differences in a longitudinal cohort study. METHODS: Our analysis was based on 237 individuals aged 60-89 years who participated in our health screening study in 2014 and 2018. They were classified into six groups by birth year and sex: 60-69 years (26 males, 49 females); 70-79 years (35 males, 88 females); and 80-89 years (19 males, 20 females). The following parameters were measured from standing radiographs: pelvic tilt (PT), sacral slope (SS), lumbar lordosis (LL), thoracic kyphosis, T1 slope, cervical lordosis, C7 sagittal vertical axis (C7 SVA), and C2-7 SVA. RESULTS: In males, the first significant change was an increase in the PT angle (19°, in 2014, to 21°, in 2018) in the 80-89 years age group (P < 0.05), with no significant deterioration in cervical parameters. In females, spinal deterioration included a change in the SS (32°-30°), PT (18°-20°), and SVA (- 8 to 6 mm) in the 60-69 years age group (P < 0.05), with no change in the LL. CONCLUSIONS: Contrary to prior studies, our longitudinal data indicated that deterioration in spinal alignment originates in the pelvis for both sex but develops earlier in females than males.

The Impact of Geometrical Spinal Shape on Fresh Vertebral Fractures in Elderly Volunteers: A Longitudinal Cohort Analysis.

STUDY DESIGN: Four-year, longitudinal cohort study. OBJECTIVE: The aim of this study was to investigate the effect of original spinal shape on incidental vertebral fractures (VFs) and to identify the influence of changes in pre- and post-fracture geometrical spinal shape. SUMMARY OF BACKGROUND DATA: Clinical evidence demonstrates that VFs cause spinal kyphosis, morbidities, and deteriorating quality of life in elderly people. However, knowledge of geometrical spinal shapes that affect incidental VFs is limited. METHODS: Three hundred seventeen volunteers underwent whole spine radiography as part of a health screening in both 2012 and 2016. We extracted volunteers with incidental VF in 2016. Sex- and age-matched volunteers without VF were enrolled as controls. Baseline demographic variables, geometrical spinal shape, and spinopelvic parameters were compared between the two groups. In volunteers with incidental VF, we investigated the association between baseline spinal shape and post-fracture shape. RESULTS: Twenty-seven volunteers (12 men; mean age 75.4 ±â€Š5.4 and 15 women; mean age 71.6 ±â€Š7.9) with VF were enrolled, and 175 volunteers (48 men, 127 women) without VF were selected as controls. In men with VF, the thoracic kyphosis apex was located significantly more posteriorly and caudally than in those without VF. In women with VF, the lordosis apex was located significantly more posteriorly and caudally than in those without VF. After fractures occurring above the inflexion vertebra, the low anterior apex spine (L5) changed its geometrical shape in that the posterior apex and the inflexion vertebra shifted significantly more posteriorly compared to the high anterior apex spine (L4/5). CONCLUSION: Original geometrical spinal shape affected the occurrence of VF, and post-fracture spinal shape depended on the positional relationship between the inflexion vertebra and fractured vertebra. Our study helps to understand the influence of geometrical spinal shape on the risks of VF. LEVEL OF EVIDENCE: 3.