Comparison of osteoanabolic agents (teriparatide and romosozumab) with bisphosphonates in prevention of subsequent vertebral fractures in patients treated for osteoporotic vertebral fracture for 12 months: An observational cohort study.

Introduction: Domino osteoporotic vertebral fracture (OVF) is as a subsequent fracture that develops within 3 months before the initial OVF heals. There is limited evidence regarding the efficacy of osteoanabolic agents on its treatment. This study evaluated the effects of bisphosphonates and anabolic agents teriparatide and romosozumab on subsequent domino OVF. Methods: This was post hoc analysis of a prospective, multicenter, observational study conducted across 8 hospitals, enrolling 144 patients with conservatively treated OVF, grouped into patients receiving bisphosphonate (BP, n = 55), teriparatide (TPTD, n = 62), and romosozumab (Romo, n = 27). The primary outcome was the incidence of subsequent OVF at 3 and 12 months, whereas the secondary outcomes included the incidence of pseudoarthrosis and progression of vertebral collapse (VC). Pseudoarthrosis was classified as stable or unstable based on vertebral instability. Results: The use of osteoanabolic agents did not reduce the incidence of subsequent OVF at 3 and 12 months. There were no significant differences in the background data or type of conservative treatment among the three groups. However, the TPTD and Romo groups had significantly lower rates of unstable pseudarthrosis (p = 0.03). Additionally, there were no significant differences in VC progression between groups, but it tended to be higher in the BP group than the TPTD and Romo group (p = 0.07). Conclusion: Osteoanabolic agents were beneficial in reducing unstable pseudoarthrosis, but were not more effective than bisphosphonates in the development of subsequent domino OVF. A more comprehensive approach to the treatment of osteoporosis is needed to prevent domino OVFs.

Minimally Invasive Thoracic-Lumbar Stabilization Surgery for Infected Charcot Spine Arthropathy (ICSA) After Spinal Cord Injury.

Charcot spinal arthropathy (CSA) is a very rare condition that causes destruction and deformity of the spine due to impaired sensation. We report a case of an infected Charcot spine arthropathy (ICSA) treatment with spinal reconstruction surgery using a minimally invasive surgery (MIS) technique. A 49-year-old man who had a spinal cord injury (SCI) at age 19 presented with a destructive lesion in the L2/3 and a fistula in his lower back. Spinal reconstruction surgery using a penetrating endplate screw, lateral lumbar interbody fusion (LLIF), and a computer-assisted rod bending system were performed. A CT scan taken six months after surgery showed bony fusion. Reconstruction of the destructive spine is necessary to control the infection and symptoms due to kyphotic deformity for ICSA. Although the treatment of ICSA generally requires a highly invasive approach, we have achieved good clinical results with minimally invasive reconstructive surgery.

The Relationship between the Hounsfield Units Value of the Upper Instrumented Vertebra and the Severity of Proximal Junctional Fracture after Adult Spinal Deformity Surgery.

Background and Objectives: In this retrospective cohort study, we investigate associations between the Hounsfield units (HU) value of upper instrumented vertebra (UIV) and proximal junctional kyphosis (PJK) after adult spinal deformity (ASD) surgery. Materials and Methods: The cohort consisted of 60 patients (mean age 71.7 years) who underwent long instrumented fusion surgery (≥6 vertebrae) for ASD with at least 1 year of follow-up. The preoperative bone mineral density (BMD) measured on DXA scans, the HU values at UIV and UIV+1, and the radiographic parameters were compared between the PJK and non-PJK groups. The severity of UIV fracture was assessed using a semiquantitative (SQ) grade. Results: PJK occurred in 43% of patients. No significant differences in patient age, sex, BMD, and preoperative radiographic parameters were observed between the PJK and non-PJK groups. The HU values of the UIV (103.4 vs. 149.0, p < 0.001) and UIV+1 (102.0 vs. 145.7, p < 0.001) were significantly lower in the PJK group. The cutoff values of HU at UIV and UIV+1 were 122.8 and 114.9, respectively. Lower HU values at UIV (Grade 1: 134.2, Grade 2: 109.6, Grade 3: 81.1, p < 0.001) and UIV+1 (Grade 1: 131.5, Grade 2: 107.1, Grade 3: 82.1, p < 0.001) were associated with severe SQ grade. Conclusions: Lower HU values at UIV and UIV+1 had a negative impact on signal incidence of PJK and were correlated with the severity of UIV fractures. Preoperative treatment of osteoporosis seems necessary for preoperative UIV HU values less than 120.

Patient-specific guide systems decrease the major perforation rate of pedicle screw placement in comparison to the freehand technique for adolescent idiopathic scoliosis.

PURPOSE: This study aimed to compare the accuracy of pedicle screw (PS) placement between a low-profile three-dimensional (3D) printed patient-specific guide system and freehand technique for adolescent idiopathic scoliosis (AIS) surgery. METHODS: Patients with AIS who underwent surgery between 2018 and 2023 at our hospital were included in the study. The 3D-printed patient-specific guide was used since 2021 (guide group). PS perforation was classified using Rao and Neo's classification (grade 0, no violation; grade 1, < 2 mm; grade 2, 2-4 mm; grade 3, > 4 mm). Major perforations were defined as grades 2 or 3. The major perforation rate of PS, operative time, estimated blood loss (EBL), and correction rate were compared between the two groups. RESULTS: A total of 576 PSs were inserted in 32 patients (20 patients in the freehand (FH) group and 12 patients in the guide group). The major perforation rate was significantly lower in the guide group than in the FH group (2.1% vs. 9.1%, p < 0.001). Significantly fewer major perforations were observed in the guide group than in the FH group in the upper thoracic (T2-4) region (3.2% vs. 20%, p < 0.001) and lower thoracic (T10-12) region (0% vs. 13.8%, p = 0.001). The operative time, EBL, and correction rate were equivalent between the two groups. CONCLUSION: The 3D-printed patient-specific guide notably reduced the major perforation rate of PS without increasing EBL and operative time. Our findings indicate that this guide system is reliable and effective for AIS surgery.

Subsequent Domino Osteoporotic Vertebral Fractures Adversely Affect Short-Term Health-Related Quality of Life: A Prospective Multicenter Study.

Background and Objectives: Conservative treatment is the gold standard for acute osteoporotic vertebral fractures (AOVFs). However, the treatment strategy for multiple AOVFs remains unknown. We conducted a prospective study using magnetic resonance imaging (MRI) to investigate how rapidly subsequent osteoporotic vertebral fractures (OVFs) occur as domino OVFs within 3 months. This study aimed to assess the incidence and impact of domino OVFs on quality of life (QOL) following conservative treatment for initial AOVFs. Materials and Methods: A prospective multicenter cohort study was conducted at eight hospitals. The included patients were those with AOVFs occurring within 3 weeks, aged >60 years, and diagnosed using MRI. All patients were treated conservatively and underwent MRI after 3 months. Subsequent domino OVFs were defined as newly occurring OVFs within 3 months. Patient characteristics, types of conservative treatment, and patient-reported outcomes, including a visual analogue scale (VAS), the Oswestry disability index (ODI), and the Japanese Orthopaedic Association back pain evaluation questionnaire (JOABPEQ), were evaluated and compared between the domino OVF and non-domino OVF groups. Results: A total of 227 patients were analyzed. The mean age was 80.1 ± 7.3 years and 78% were female. Subsequent domino OVFs were observed in 31 (13.6%) patients within 3 months. An increasing number of prevalent OVFs were significantly associated with domino OVFs (p = 0.01). No significant differences in bone mineral density, type of brace, and anti-osteoporosis medications were found between the two groups. The JOABPEQ (excluding social function), ODI, and VAS were significantly improved after 3 months. Patients with domino OVFs at 3 months had poorer JOABPEQ social life function, ODI, and VAS than those with non-domino OVFs. Conclusions: In this study, the incidence of domino OVFs was 13.6% within 3 months. Domino OVFs had a negative impact on QOL at 3 months and were associated with prevalent OVFs.

Effects of Perioperative Teriparatide Treatment on the Hounsfield Unit Values at the Upper Instrumented Vertebra in Adult Spinal Deformity Surgery.

STUDY DESIGN: Retrospective single-center study. OBJECTIVE: This study aimed to assess the effects of pre and postoperative teriparatide (TPTD) treatment on Hounsfield units (HU) after surgery for adult spinal deformity (ASD). SUMMARY OF BACKGROUND DATA: The most commonly used method for assessing bone mineral density is dual-energy x-ray absorptiometry. HU values at the upper instrumented vertebra (UIV) have been proposed as a surrogate method for assessing bone quality, particularly in patients with ASD. However, the effect of TPTD treatment on vertebral HU values remains unclear. MATERIALS AND METHODS: We identified 57 consecutive patients with ASD who underwent long-instrumented fusion surgery (>5 vertebrae) between 2014 and 2020. Patients were retrospectively divided into a non-TPTD group (n = 31) and a TPTD group (n = 26). HU measurements were obtained at a level above the UIV (UIV + 1). Changes in the HU value at 1-year postoperatively were compared between the TPTD and non-TPTD groups. The duration of preoperative TPTD was compared between the proximal junctional proximal junctional failure (PJF) and non-PJF groups. RESULTS: Preoperative HU values were significantly lower in the TPTD group than in the non-TPTD group, despite no significant difference in preoperative bone mineral density of the proximal femur between the two groups. Changes in HU values were significantly higher in the TPTD group than in the non-TPTD group (20.8 ± 15.7% vs -2 ± 10.2%, P < 0.001). In the subanalysis of the TPTD group, the duration of preoperative TPTD treatment was significantly shorter in the PJF group than in the non-PJF group (34.7 ± 16.8 days vs 86.9 ± 34.7 days, P = 0.004). CONCLUSIONS: Pre and post-operative TPTD treatment increased the average HU value at UIV + 1 by 20.8%. Therefore, more prolonged preoperative TPTD treatment improves bone quality and may help prevent osteoporosis-related complications.

Adjacent vertebral Hounsfield unit value of acute osteoporotic vertebral fracture is a risk factor for concomitant domino osteoporotic vertebral fractures.

BACKGROUND: Most patients with acute osteoporotic vertebral fracture (AOVF) are successfully treated conservatively. However, the optimal management method and prognosis for multiple AOVFs are unclear. This study aimed to investigate the prevalence of multiple AOVFs and identify the associated risk factors. METHODS: This study enrolled 134 hospitalized patients (mean age 83 ± 7.6 years, 66% women) with AOVF treated conservatively between 2017 and 2020. The fractures were diagnosed by magnetic resonance imaging (MRI). The AOVFs were divided into two groups; single osteoporotic vertebral fractures (OVF) and domino OVFs (at least two OVFs). The adjacent vertebral Hounsfield unit values (HU) of the OVF and dual x-ray absorptiometry (DXA) of the lumbar spine or hip were used to evaluate the bone mineral density (BMD). Logistic regression analysis was performed to identify the risk factors for domino OVFs. RESULTS: Domino OVFs were noted in 21 (15.7%) of 134 patients. There were 10 cases of adjacent level and 11 cases of remote level. The BMI (18.5 ± 4.2 vs. 21.2 ± 4.6, p = 0.025) and adjacent vertebral HU value of OVF (57.3 ± 17.5 vs. 76.6 ± 24.1, p = 0.008) were significantly lower in the domino OVFs group than in the single OVF group. Logistic regression analysis revealed the adjacent vertebral HU value of the OVF as an independent risk factor for domino OVFs, (odds ratios (OR) 0.96, p = 0.012). The domino OVF group had a significantly higher decline in gait ability (76% vs. 48%, p = 0.017). CONCLUSIONS: The adjacent vertebral HU value of AOVF is a useful tool for evaluating BMD for domino OVFs. The optimal treatment for osteoporosis should be considered to prevent subsequent domino OVFs.

The Impact of Controlling Nutritional Status (CONUT) score on functional prognosis in hospitalized elderly patients with acute osteoporotic vertebral fractures.

BACKGROUND: Nutritional status, which is associated with osteoporosis and muscle weakness is considered an important factor in the management of acute osteoporotic vertebral fracture (AOVF). However, few reports have investigated the nutritional status of hospitalized patients with AOVF and the impact of malnutrition on their functional prognosis. This study aimed to evaluate the nutritional status of hospitalized elderly patients with AOVF using the Controlling Nutritional Status (CONUT) score and to determine the usefulness of the CONUT score in predicting their functional prognosis. METHODS: The CONUT score on admission was retrospectively calculated for 134 hospitalized elderly patients (mean age 83 ± 7.6 years, 66% female) with AOVF who received conservative treatment between 2017 and 2020. Functional outcome was assessed by comparing ambulatory ability before the onset of AOVF and upon discharge. Patients were divided into two groups: CONUT-high ( ≥ 4) and CONUT-low ( ≤ 3), according to receiver operating characteristic (ROC) analysis to predict decline in ambulatory ability upon discharge. Logistic regression analysis was performed to obtain odds ratios (OR) and 95% confidence intervals (CI) of the relationships between the nutritional status and ambulatory ability. The discriminative power of the CONUT score was then compared with other nutritional assessment tools such as the Geriatric Nutritional Risk Index (GNRI) and prognostic nutritional index (PNI) by ROC analysis. RESULTS: 81% of hospitalized patients with an AOVF were malnourished at the time of admission. The CONUT-high group had a significantly higher rate of decline in ambulatory ability (P < 0.001) than the CONUT-low group. Logistic regression analysis revealed the CONUT score ( ≥ 4) as an independent risk factor for a decline in ambulatory ability (OR 3.44, 95% CI 1.61-7.37, P = 0.0014). ROC analysis showed that the area under the curve (AUC) for the CONUT score (AUC = 0.724) was significantly greater than that for the GNRI (AUC = 0.624, P = 0.021) and PNI (AUC = 0.636, P = 0.0008). CONCLUSIONS: This study showed that 81% of hospitalized elderly patients with AOVFs were malnourished and that the CONUT score was a useful predictive factor of functional prognosis.

Surgical Outcome and Features of C7 Spondylolisthesis with Myelopathy: A Case Series.

Introduction: Reports of myelopathy with C7 anterior spondylolisthesis are extremely rare, and the surgical outcomes, clinical features, and their effects remain unknown. We describe six patients who underwent surgery for C7 spondylolisthesis with myelopathy. Methods: Six patients who underwent operative treatment for C7 spondylolisthesis with myelopathy were retrospectively reviewed. C7 spondylolisthesis was defined as an anterior slippage of more than 2 mm on X-ray or computed tomography (CT). The images were evaluated using radiography, magnetic resonance imaging (MRI), and CT. Clinical outcomes were evaluated using the thoracic Japanese Orthopedic Association (T-JOA) score and Frankel grade. Results: Facet joint arthrosis was observed in all patients at the C7/T1 level. MRI revealed a juxta-facet cyst in the spinal segment in three cases and a high signal change in four cases. We could visualize C7 anterior slippage from the lateral radiograph in one case. The mean time from onset to diagnosis was 95 (range, 7-280) months. Posterior spinal fusion using pedicle screws and interlaminectomy was performed in five cases. Cystectomy with partial laminectomy was performed in one case with a juxta-facet cyst. The mean JOA score was 6±0.7 preoperatively and improved to 9±1.5 at the final follow-up. The Frankel grades of all patients improved by more than one grade. Conclusions: In this study, myelopathy with C7 spondylolisthesis was relatively severe, and we believe that the mechanical stress between the rigid thoracic vertebrae and the movable cervical spine may cause C7 spondylolisthesis. Posterior spinal fusion and partial laminectomy for C7 spondylolisthesis with myelopathy resulted in satisfactory outcomes.

Comparison of Clinical Outcomes After Transforaminal Interbody Fusion Using Cortical Bone Trajectory versus Percutaneous Pedicle Screw Fixation.

OBJECTIVE: The study aim was to compare clinical outcomes between patients undergoing transforaminal lumbar interbody fusion (TLIF) using percutaneous pedicle screw (PPS) and cortical bone trajectory (CBT) by a single surgeon. METHODS: This was a retrospective matched-cohort study of 77 patients (mean age, 71.7 years; 56% female) who underwent TLIF using CBT or PPS. Thirty-nine consecutive patients in the CBT group and 38 patients in the PPS group were matched for age, sex, and fused levels. All CBT screws were inserted by using a three-dimensional patient-specific guide (MySpine MC, Medacta). Perioperative outcomes of operative time, estimated blood loss, numeric rating scale scores, and serum concentration of creatine kinase were compared between the 2 groups. At 1 year postoperatively, clinical outcomes and radiographic outcomes, including cage subsidence, screw loosening, and fusion rates, were compared between the 2 groups. RESULTS: The numeric rating scale scores on postoperative days 3 and 7 and serum creatine kinase levels on postoperative days 1 and 3 were significantly lower in the CBT group than in the PPS group (all P < 0.005). There were no significant intergroup differences in operation time and estimated blood loss. At postoperative 1 year, there were no significant differences in cage subsidence, screw loosening, and fusion rates between the CBT group and PPS group. Clinical outcomes were equivalent between the 2 groups. CONCLUSIONS: The CBT technique using three-dimensional patient-specific guides resulted in lower perioperative pain and quicker recovery after surgery, which suggests that CBT is a less invasive procedure than PPS.

Iatrogenic subcutaneous emphysema and pneumomediastinum following a high-speed air drill dental treatment procedure.

Case: A patient was transported to our hospital with swelling in his right face and neck after restorative dental treatment. Subcutaneous emphysema and pneumomediastinum were discovered using computed tomography scans. Outcome: The patient had no severe symptoms. We prescribed prophylactic antibiotics and he recovered uneventfully. Conclusions: Clinicians must keep this pathology in mind because prompt diagnosis and treatment contribute to early improvement. Otherwise, patients may face life-threatening complications.

Application of carbon monoxide for treatment of acute kidney injury.

Acute kidney injury in critically ill patients is common and associated with a substantial increase in morbidity and mortality. Even with aggressive medical care and renal replacement therapy, acute kidney injury remains a significant health care concern. Recent published reports offer new strategies for the prevention and amelioration of acute kidney injury using carbon monoxide. Although considered a toxic environmental gas, carbon monoxide has recently aroused scientific and clinical interest, as its beneficial effects and mechanisms of action have been substantially defined in various in vitro and in vivo experiments. The exogenous application of carbon monoxide can confer cytoprotection by modulating intracellular signaling pathways through its anti-inflammatory, anti-apoptotic, vasodilative, antithrombotic and antiproliferative properties. Thus, evidence is accumulating to support the notion of carbon monoxide treatment for acute kidney disease. In this review, we focus on the extensively analyzed advantageous value of treatment with inhaled/soluble carbon monoxide in the context of kidney injury. Mechanisms such as signaling pathways, as well as an expanded view regarding toxicity and side-effects, are described broadly. In addition, we discuss the clinical applicability of carbon monoxide as a promising therapeutic strategy for the treatment of patients with acute kidney disease based on translating basic experimental findings into clinical application.

Successful treatment of a 14-year-old patient with intestinal malrotation with laparoscopic Ladd procedure: case report and literature review.

Midgut malrotation is an anomaly of intestinal rotation that occurs during fetal development and usually presents in the neonatal period. We present a rare case of malrotation in a 14-year-old patient who presented with cramping, generalized right abdominal pain, and vomiting for a duration of one day. A computed tomography abdominal scan and upper gastrointestinal contrast studies showed malrotation of the small bowel without volvulus. Laparoscopy revealed typical Ladd's bands and a distended flabby third and fourth duodenal portion extrinsically obstructing the misplaced duodeno-jejunal junction. The Ladd procedure, including widening of the mesenteric base and appendectomy, was performed. Symptoms completely resolved in a half-year follow up period. Patients with midgut malrotation may present with vague abdominal pain, intestinal obstruction, or intestinal ischemia. The laparoscopic Ladd procedure is feasible and safe, and it appears to be as effective as the standard open Ladd procedure in the diagnosis and treatment of teenage or adult patients with intestinal malrotation.