The Contribution of Deleterious Rare Alleles in ENPP1 and Osteomalacia Causative Genes to Atypical Femoral Fracture.

CONTEXT: Atypical femoral fractures (AFFs) are very rare atraumatic or mild trauma fractures in the subtrochanteric region or femoral shaft. Some unique genetic variants in Asian populations might confer susceptibility to AFF, since the incidence of AFFs is higher in Asian populations. OBJECTIVE: Because rare variants have been found to be causative in some diseases and the roles of osteomalacia causative genes have not been reported, we investigated rare variants in genes causing abnormal mineralization. METHODS: Exome sequencing was performed to detect variants in gene coding and boundary regions, and the frequencies of deleterious rare alleles were compared between Japanese patients with AFF (n = 42) and controls of the 4.7KJPN panel of Tohoku Medical Megabank by whole genome sequencing (n = 4773). RESULTS: The frequency of the deleterious rare allele of ENPP1 was significantly increased in AFF (P = .0012, corrected P [Pc] = .0155, OR 4.73, 95% CI 2.15-10.40). In multigene panel analysis, the frequencies of deleterious rare alleles of candidate genes were increased in AFF (P = .0025, OR 2.72, 95% CI 1.49-4.93). Principal component analysis of bone metabolism markers identified a subgroup of patients with AFF with higher frequencies of deleterious rare alleles in ENPP1 (P = 4.69 × 10-5, Pc = .0006, OR 8.47, 95% CI 3.76-19.09) and the candidate genes (P = 1.08 × 10-5, OR 5.21, 95% CI 2.76-9.86). CONCLUSION: AFF is associated with genes including ENPP1 that cause abnormal mineralization, suggesting that osteomalacia is an underlying condition predisposing to AFF and that higher incident rates of AFFs in Asian populations might be explained by the genetic risk factors including ENPP1.

Efficacy of lumbar orthoses after posterior lumbar interbody fusion-a prospective randomized study.

BACKGROUND: Lumbosacral orthoses (LSOs) are used as standard care after lumbar fusion surgery though their efficacy is unknown. The purpose of this prospective randomized controlled study was to elucidate the clinical and radiographic efficacies of LSO treatment in patients who underwent posterior lumbar interbody fusion (PLIF) of less than 3 segments. METHODS: Seventy-three patients who underwent PLIF were randomly allocated to 3 groups: 1 with custom-made LSO with metallic stays (C group); 1 with ready-made LSO without metallic stays (R group), and 1 without LSO (N group). The patients in the C and R groups were instructed to wear LSO postoperatively for 3 months. Clinical outcomes were evaluated using the Japanese Orthopaedic Association (JOA) score, JOA-back pain evaluation questionnaire (JOABPEQ), Roland-Morris Disability Questionnaire, and 100-mm visual analog scale for low back pain. Radiographic evaluation included intervertebral fusion rates and loss of correction postoperatively at 2 years. RESULTS: A significant difference in the clinical outcomes was observed only for the lumbar dysfunction domain of JOABPEQ postoperatively at 1 month (N vs C groups; 45% vs 10%, P = .03). Radiographic outcomes were not different between the groups. CONCLUSIONS: No effect of orthosis treatment for less than 3 segments in PLIF was observed on clinical and radiographic outcomes. The type of orthosis also did not influence the outcomes. These results suggest that the use of LSO for PLIF can be simplified or is omissible except in patients with severe osteoporosis.

Responsiveness of the Japanese Orthopaedic Association Back Pain Evaluation Questionnaire in lumbar surgery and its threshold for indicating clinically important differences.

BACKGROUND CONTEXT: Introduced in 2007, the Japanese Orthopaedic Association Back Pain Evaluation Questionnaire (JOABPEQ) has been widely used, but its psychometric properties have not been well studied. PURPOSE: The objective of this study was to assess the responsiveness of the JOABPEQ in lumbar surgery and its threshold for indicating clinically important differences. STUDY DESIGN: This is a prospective study. PATIENT SAMPLE: Two hundred three consecutive patients underwent lumbar surgeries between July 2013 and November 2015 in a single hospital. Of the 203 patients, 181 patients who completed 1 year of follow-up were included. OUTCOME MEASURES: Before and after surgery, the patients were asked to complete the questionnaire, including JOABPEQ, the 8-Item Short Form Health Survey (SF-8), and EuroQol-5D (EQ-5D). The participants were divided into five anchoring groups, ranging from "much better" to "much worse," according to reports from both physicians and patients. MATERIALS AND METHODS: The responsiveness of measures was compared among five domains of the JOABPEQ ("low back pain," "walking ability," "lumbar function," "social function," and "mental health"), two domains of the SF-8 (the physical component summary [PCS] and the mental component summary [MCS]), and the EQ-5D. The responsiveness was assessed by the paired t test, the effect size, and the standardized response mean. The Spearman rank correlation coefficient and the receiver operating characteristic (ROC) curve were assessed using the five anchoring groups as external criteria. The clinically important differences, based on the ROC curve, were assessed. RESULTS: Walking ability was most responsive, followed by low back pain and the PCS. The MCS was least responsive, followed by mental health and lumbar function. Social function and the EQ-5D had intermediate-level responsiveness. The substantial clinically important differences occurred at 20 points for low back pain and lumbar function, 23 points for walking ability, 14 points for social function, and 8 points for mental health. CONCLUSIONS: The JOABPEQ domains are responsive measures in patients who undergo lumbar surgery. For physical function, the threshold for substantial clinically important differences was approximately 20 points for the JOABPEQ.

Cost-effectiveness of lumbar fenestration surgery in the Japanese universal health insurance system.

BACKGROUND: Healthcare costs are a global concern, and cost-effectiveness analyses of interventions have become important. However, data regarding cost-effectiveness are limited to a few medical fields. The purpose of our study was to examine the Japanese universal health insurance system cost per quality-adjusted life year (QALY) for lumbar fenestration surgery. METHODS: Forty-eight patients who underwent fenestration for lumbar degenerative spinal canal stenosis between July 2013 and September 2015 were included. Effectiveness was evaluated by measuring the EuroQOL 5-dimension (EQ-5D), Short-Form 8 physical component summary (PCS), and visual analog scale (VAS). Cost was analyzed from the perspective of the public healthcare payer. Effectiveness and cost were measured 1 year after surgery. QALYs were calculated by multiplying the utility value (EQ-5D) and life years. Only direct costs based on actual reimbursements were included. Cost per QALY with a 5-year time horizon with a 2% discount rate was estimated. Sensitivity analysis was performed by varying the time horizon (2 years or 10 years). RESULTS: Mean total cost 1 year after fenestration surgery was 1,254,300 yen (standard deviation [SD], 430,000 yen; median, 1,172,300 yen). Operative cost was 406,800 yen (SD, 251,500 yen; median, 363,000 yen). Mean gained score was 0.21 for EQ-5D (SD, 0.18; median, 0.24), 11 for PCS (SD, 10; median, 12), and -43 for VAS (SD, 34; median, -38). Cost per QALY was 1,268,600 yen. Sensitivity analysis demonstrated that cost per QALY with a 10-year time horizon was 679,300 yen and that with a 2-year time horizon was 3,004,600 yen. CONCLUSIONS: Cost per QALY of lumbar fenestration with a 5-year time horizon was 1,268,600 yen (11,532 US dollar), which was below the widely accepted benchmark (cost per QALY <5,000,000-6,500,000 yen (50,000 US dollars)). Fenestration is a cost-effective intervention.

Impact of Cervical Sagittal Alignment on Axial Neck Pain and Health-related Quality of Life After Cervical Laminoplasty in Patients With Cervical Spondylotic Myelopathy or Ossification of the Posterior Longitudinal Ligament: A Prospective Comparative Study.

STUDY DESIGN: This is prospective observational study. OBJECTIVE: To prospectively investigate the correlation among axial neck pain; a newly developed patient-based quality of life outcome measure, the Japanese Orthopaedic Association Cervical Myelopathy Evaluation Questionnaire (JOACMEQ); and cervical sagittal alignment after open-door laminoplasty for cervical myelopathy. SUMMARY OF BACKGROUND DATA: Many studies have focused on postoperative axial neck pain after laminoplasty. However, the correlation among cervical sagittal alignment, neck pain, and JOACMEQ has not been investigated. MATERIALS AND METHODS: In total, 57 consecutive patients treated by open-door laminoplasty for cervical myelopathy were included (mean age, 63.7 y; 15 women and 42 men) and divided into 2 groups according to diagnosis [cervical spondylotic myelopathy (CSM) group: 35 patients, and ossification of the posterior longitudinal ligament (OPLL) group: 22 patients]. JOA score, a subdomain of cervical spine function (CSF) in the JOACMEQ, and the visual analog scale for axial neck pain were assessed preoperatively and 12 months postoperatively. Radiographic cervical sagittal parameters were measured by C2 sagittal vertical axis (C2 SVA), C2-C7 lordosis, C7 sagittal slope (C7 slope), and range of motion. RESULTS: C2 SVA values in both groups shifted slightly anteriorly between preoperative and 12-month postoperative measurements (CSM: +19.7±10.9 mm; OPLL: +22.1±13.4 mm vs. CSM: +23.2±16.1 mm; OPLL: +28.7±15.4 mm, respectively). Postoperative axial neck pain in the OPLL group showed strong negative correlations with C2 SVA and C7 slope. Strong negative correlations were found between axial neck pain and CSF in both the preoperative CSM and OPLL groups (CSM: r=-0.45, P=0.01; OPLL: r=-0.61, P<0.01) and between axial neck pain and CSF in the postoperative OPLL group (r=-0.51, P=0.05). CONCLUSIONS: This study demonstrated a significant negative correlation between neck pain and CSF in both the CSM and OPLL groups preoperatively and in the OPLL group postoperatively. Radiographic cervical sagittal alignment did not significantly correlate with preoperative or postoperative axial neck pain.

Cost-effectiveness of posterior lumbar interbody fusion in the Japanese universal health insurance system.

BACKGROUND: Globally, the cost-effectiveness of spinal surgery is becoming increasingly important. However, these data are limited to a few countries. The purpose of our study was to examine the cost/quality adjusted life year (cost/QALY) gained for posterior lumbar interbody fusion (PLIF) in the Japanese universal health insurance system. METHODS: Fifty five patients underwent PLIF for lumbar degenerative spinal canal stenosis between July 2013 and September 2015 was included. Effectiveness was measured using Euro QOL 5-dimension (EQ-5D), Short-Form 8 physical component summary (PCS), and visual analog scale (VAS). The cost was calculated from the perspective of the public healthcare payer. Effectiveness and cost were measured one year after surgery. QALYs were calculated by multiplying the utility value (EQ-5D) and life years. Only direct costs were included on the basis of actual reimbursements. Cost/QALY at a 5-year time horizon with a 2% discount rate was estimated. Sensitivity analysis was performed by varying the time horizon (2 years or 10 years). The exchange rate was defined as US $1 to Japanese 100 yen. RESULTS: Mean total cost one year after surgery was ï¿¥2,802,900 ($28029). Operative cost was ï¿¥1,779,700 ($17797). Mean gained score was 0.22 in EQ-5D, 10.3 in PCS, and -44 in VAS. Cost/QALY was ï¿¥2,697,500 ($26975). Sensitivity analysis demonstrated that cost/QALY at a 10-year time horizon was ï¿¥1,428,300 ($14283) and that cost/QALY at a 2-year time horizon was ï¿¥6,435,400 ($64354). CONCLUSIONS: Clinical outcomes after PLIF improved beyond minimum clinical improvement difference. Cost/QALY was below the widely-accepted benchmark (cost/QALY < $50000). PLIF could be regarded as cost-effective interventions.

Severe cervical flexion myelopathy with long tract signs: a case report and a review of literature.

INTRODUCTION: Hirayama disease, a type of cervical flexion myelopathy, is a rare neurological disease characterized by muscular atrophy of the forearms and hands. Generally, the pathology is limited to the gray matter of the anterior horns in the lower cervical spinal cord. However, in rare cases the damage can spread to the white matter and present as long tract signs. CASE PRESENTATION: We report on a 30-year-old female whose onset presented as unilateral muscle atrophy of the right hand in her teens. Despite conservative treatment using a cervical collar, she developed prolonged bilateral muscle atrophy, sensory disturbance and spastic gait, along with bladder and rectal disturbances. Her hands were frozen into a 'claw-like' gesture and her intrinsic muscles were highly atrophic. She was unable to unclench her hands. Although the space available for the spinal cord was large, the spinal cord was highly atrophic. She had local kyphosis with a large (61°) flexion range of motion. During flexion the spinal cord was stretched, resulting in contact with the posterior wall of the vertebrae. Posterior fusion surgery was performed to prevent progression of the myelopathy. After surgery, she gained mild improvement in both muscle strength and her hand's movement. However, her spastic gait and muscle atrophy remained. DISCUSSION: Most cases of cervical flexion myelopathy as represented by Hirayama disease have a self-limiting benign prognosis. However, some cases can develop advanced myelopathy with long tract signs. Long-term follow-up is recommended for these cases because they may require early surgical treatment.

The Relationship Between Cervical Degeneration and Global Spinal Alignment in Patients With Adult Spinal Deformity.

OBJECTIVES: To examine the relationship between cervical degeneration and spinal alignment by comparing patients with adult spinal deformity versus the control cohort. SUMMARY OF BACKGROUND DATA: The effect of degeneration on cervical alignment has been controversial. METHODS: Cervical and full-length spine radiographs of 57 patients with adult spinal deformity and 78 patients in the control group were reviewed. Adult spinal deformity was classified into 3 types based on the primary characteristics of the deformity: "Degenerative flatback" group, "Positive sagittal imbalance" group, and "Hyperthoracic kyphosis" group. Cervical degeneration was assessed using the cervical degeneration index scoring system. RESULTS: The "Degenerative flatback" group had significantly higher total cervical degeneration index score (25±7) than the control group (16±8), the "Positive sagittal imbalance" group (18±8), and the "Hyperthoracic kyphosis" group (12±7) (P<0.01). The "Degenerative flatback" group had significantly less cervical lordosis than the other groups. This reduced amount of cervical lordosis was thought to be induced by a compensatory decrease in thoracic kyphosis. In this group, increased cervical degeneration was significantly associated with a decrease in cervical lordosis. Significantly greater compensatory increase in cervical lordosis was noted in the "Positive sagittal imbalance" group (20±15 degrees) and the "Hyperthoracic kyphosis" group (26±9 degrees) compared with the control group (11±12 degrees) (P<0.02). CONCLUSIONS: Flat cervical spine coexisted with cervical degeneration when compensatory hypothoracic kyphosis was induced by degenerative flatback. In other situations, cervical lordosis could increase as a compensatory reaction against sagittal imbalance or hyperthoracic kyphosis.

Electrophysiological Study for Nerve Root Entrapment in Patients With Isthmic Spondylolisthesis.

STUDY DESIGN: A case series study. OBJECTIVE: To investigate the electrophysiological location of nerve root entrapment in patients with isthmic spondylolisthesis. SUMMARY OF BACKGROUND DATA: Although the lesion of the nerve root in patients with isthmic spondylolisthesis has been thought to be located at the pars interarticularis due to proliferation of fibrous cartilage, there is no electrophysiological study in relation to this accomplished fact. METHODS: We performed an electrophysiological study in 12 patients with isthmic spondylolisthesis during surgery. All patients presented with low-grade isthmic spondylolisthesis and unilateral radiculopathy, and underwent single-level posterior lumbar interbody fusion with instrumentation. After a total facetectomy, nerve root action potentials were recorded by stimulating the ipsilateral peroneal nerve at the popliteal fossa. Four needle electrodes were inserted into the affected nerve root at the intraspinal canal, pars interarticularis, disk level, and extralateral to the disk. The waveforms that showed either a positive waveform pattern or polyphasic waveform pattern were regarded as abnormal potentials. We also confirmed surgical records and preoperative images to investigate the relationship to the electrophysiological findings. RESULTS: An abnormal waveform pattern was demonstrated at the pars interarticularis in 6 patients, at the disk level in 5, and at the extralateral site in 1. On the basis of the electrophysiological findings of this study, the nerve root lesion was not always found on only the pars interarticularis in patients with isthmic spondylolisthesis. A relationship between the electrophysiological findings and surgical records or preoperative images was not found. CONCLUSIONS: The electrophysiological investigation in this study shows that the nerve root entrapment in patients with isthmic spondylolisthesis occurs not only at the pars interarticularis but also distal to the isthmus. This study suggests the possibility of insufficiency of decompression only at the pars interarticularis for patients with isthmic spondylolisthesis.

Factors associated with patient satisfaction for PLIF: Patient satisfaction analysis.

INTRODUCTION: Posterior lumbar interbody fusion (PLIF) has produced satisfactory clinical outcomes; however, all previous reports have only included evaluations by surgeon-based methods. The purpose of this study was to investigate patient-based surgical outcomes and the factors associated with patient satisfaction for PLIF. METHODS: Patients who underwent PLIF for lumbar spondylolisthesis were reviewed (n=443). The average follow-up period was 8 years. Surgical outcomes were assessed using an original questionnaire, a numerical rating scale (NRS), the 36-Item Short Form Health Survey (SF-36), the Japanese Orthopedic Association (JOA) score, and the recovery rate. The original questionnaire consisted of five categories, with patient-evaluated score out of 100 points for surgery, satisfaction, improvement, recommendation to others, and willingness to undergo repeat surgery on a 5-point scale. According to the questionnaire responses, patient-based outcomes were divided into three groups: positive, intermediate, and negative and were compared with the NRS, SF-36, and JOA scores. Furthermore, factors associated with patient satisfaction were examined. RESULTS: A total of 273 patients responded. Response rate was 62%. The average patient-evaluated score for surgery was 82 points. In terms of satisfaction section, positive, intermediate, and negative response rates were 82%, 7%, and 11%, respectively. With respect to other sections, positive, intermediate, and negative response rates were 87%, 7%, and 6% in improvement section; 66%, 23%, and 11% in recommending section; and 72%, 18%, and 10% in repeat section, respectively. The average pre- and postoperative JOA scores were 12 and 24, respectively. Significant correlations were detected between patient-based surgical outcomes and the NRS scores, physical component scores of the SF-36, and the JOA score. Postoperative permanent motor loss and multiple revision surgery were the major factors related to a negative response. CONCLUSIONS: High satisfaction rate to PLIF and significant correlation between patient- and surgeon-based surgical outcomes were detected. Postoperative permanent motor loss and multiple revision surgery were the major factors related to a negative response.

Prevalence, Concomitance, and Distribution of Ossification of the Spinal Ligaments: Results of Whole Spine CT Scans in 1500 Japanese Patients.

STUDY DESIGN: Cross-sectional study. OBJECTIVE: To investigate the prevalence, concomitance, and distribution of various types of ossification of the spinal ligaments in healthy subjects using computed tomography (CT). SUMMARY OF BACKGROUND DATA: CT has better diagnostic accuracy for ossification of the spinal ligaments compared to plain radiography. Currently there is no study that examines the prevalence of ossification of the spinal ligaments using whole spine CT scans. METHODS: One thousand five hundred Japanese patients (888 men and 612 women) who underwent positron emission tomography and CT (PETCT) in a private health check center between 2006 and 2013 were included. This PETCT was performed on self-paying participants as a preventive cancer screen. Existence of ossification of the posterior longitudinal ligament (OPLL), ligamentum flavum (OLF), anterior longitudinal ligament (OALL), diffuse idiopathic skeletal hyperostosis (DISH), and nuchal ligament (ONL) was examined. RESULTS: The prevalence of spinal ligament ossifications was found to be 6.3% in cervical OPLL (8.3% in men and 3.4% in women), 23% in ONL (33% in men and 8.8% in women), 1.6% in thoracic OPLL (1.4% in men and 2.0% in women), 12% in thoracic OLF (15% in men and 7.7% in women), 37% in thoracolumbar OALL (45% in men and 26% in women), and 12% in DISH (16% in men and 6.2% in women). Thirteen percent of patients with cervical OPLL had thoracic OPLL, 34% of cervical OPLL had thoracic OLF, 45% of cervical OPLL had ONL, and 36% of cervical OPLL had DISH. The most common level was C5 for cervical OPLL, T1/2 for thoracic OPLL, T11 for thoracic OLF, and T8/9 for OALL. CONCLUSION: Accurate prevalence of various types of ossification of the spinal ligaments evaluated by CT was revealed. High concomitance was observed in each classification of spinal ligament ossification. LEVEL OF EVIDENCE: 3.

Patient-Based Surgical Outcomes of Posterior Lumbar Interbody Fusion: Patient Satisfaction Analysis.

STUDY DESIGN: A retrospective study. OBJECTIVE: The purpose of this study was to investigate: (1) patient-based surgical outcomes of posterior lumbar interbody fusion (PLIF); (2) correlations between patient-based surgical outcomes and surgeon-based surgical outcomes; (3) factors associated with patient satisfaction. SUMMARY OF BACKGROUND DATA: There have been no reports of patient-based surgical outcomes of PLIF for lumbar spondylolisthesis. METHODS: Patients who underwent PLIF for L4 degenerative spondylolisthesis between 2006 and 2009 were reviewed (n = 121). Surgical outcomes were assessed 5 years after primary surgery using a questionnaire, a numerical rating scale (NRS) of pain, the 36-Item Short Form Health Survey (SF-36), the Japanese Orthopedic Association score (JOA score), and the recovery rate. The original questionnaire consisted of 5 categories, with scoring out of 100 points for surgery, satisfaction, improvement, recommendation to others, and willingness to undergo repeat surgery. Patient-based outcomes were divided into 3 groups according to the questionnaire responses as positive, intermediate, and negative and were compared with the JOA scores. RESULTS: A total of 103 patients responded, for a response rate of 85%. The average patient-evaluated score for surgery was 82 points. The positive response rate in each category was 78% for satisfaction, 88% for improvement, 74% for recommendation, and 71% for repeat. The average pre- and postoperative JOA scores were 11.2 and 23.2, respectively. The average recovery rate was 68.5%. There were significant correlations between patient-based surgical outcomes and the JOA score. Furthermore, there were significant correlations between patient-based surgical outcomes and the NRS and physical component scores of the SF-36. Postoperative permanent motor loss was a major factor related to a negative response. CONCLUSION: The patient-evaluated score for surgery was 82 points. More than 70% of patients gave positive responses in all sections of the questionnaire. There were significant correlations between patient-based and surgeon-based surgical outcomes. LEVEL OF EVIDENCE: 2.

Validity of the Japanese Orthopaedic Association scoring system based on patient-reported improvement after posterior lumbar interbody fusion.

BACKGROUND CONTEXT: The Japanese Orthopaedic Association (JOA) scoring system is a physician-based outcome that has been used to evaluate treatment effectiveness after lumbar surgery. However, patient-centered evaluation becomes increasingly important. There is no study that has examined the relationship between the JOA scoring system and patients' self-reported improvement. PURPOSE: The purpose of the present study was to validate the JOA scoring system for assessment of patient-reported improvement after lumbar surgery. STUDY DESIGN: This is a retrospective review of prospectively collected data. PATIENT SAMPLE: The patient sample included 273 mail-in responders of the 466 consecutive patients who underwent posterior lumbar interbody fusion for spondylolisthesis between 1996 and 2008 in a single hospital. OUTCOME MEASURES: The outcome measures were the JOA scoring system and patients' self-reported improvement. METHODS: Two hundred seventy three patients were divided into five anchoring groups based on self-reported improvement from "Much better" to "Much worse." Outcomes (ie, recovery rate, amount of change from preoperative condition, and postoperative score) based on the JOA scoring system were compared among groups. Using the patient's self-reported improvement scale as an anchor, the association among each of the outcomes was examined. The cutoff point and the area under the curve (AUC) that differentiated "Improved" from "Neither improved nor worse" was calculated using receiver operating characteristic (ROC) curve analysis. RESULTS: The recovery rate and postoperative score were significantly different in 9 of 10 pairs of anchoring groups. The amount of change was significantly different in six pairs. Spearman correlation coefficient for the 5-point scale anchors of patients' self-reported improvement was 0.20 (p=.001) for the baseline score, 0.31 (p<.001) for the amount of change, 0.55 (p<.001) for the recovery rate, and 0.56 (p<.001) for the postoperative score. According to ROC analysis, the best cutoff points and AUCs were 13 points and 0.69, respectively, for the amount of change, 67% and 0.73, respectively, for recovery rate, and 23 points and 0.72, respectively, for postoperative score. CONCLUSIONS: The JOA scoring system is a valid method for assessment of patients' self-reported improvement. Patients' self-reported improvement is more likely to be associated with the final condition, such as postoperative score or recovery rate, rather than the change from the preoperative condition.

Age-related surgical outcomes of laminoplasty for cervical spondylotic myelopathy.

Study Design Retrospective clinical study. Objective To investigate the age-related surgical outcomes of laminoplasty. Methods One hundred patients who underwent an en bloc laminoplasty for cervical spondylotic myelopathy from 2004 to 2008 and were followed for at least 1 year were included in this study. The clinical outcomes were assessed with the Japanese Orthopaedic Association (JOA) score. Acquired points (postoperative JOA score minus preoperative JOA score) were also calculated. To investigate the age-related effect for laminoplasty, two analyses were conducted: (1) the correlation between age and clinical outcome; and (2) the clinical outcomes by decade. Patients were divided into four groups according to their age at the time of operation as follows: group 50s, 50 to 59 years old; group 60s, 60 to 69 years; group 70s, 70 to 79 years; and group 80s, 80 to 89 years. The pre- and postoperative JOA scores, acquired points, preoperative comorbidities, and postoperative complications were then compared among the groups. Results Significant correlations were detected between age and JOA scores at the preoperative (p = 0.03), postoperative maximum (p < 0.0001), and final assessments (p < 0.0001). An age-related decline of JOA scores was observed over all periods. The analysis by decades showed the same results. On the other hand, the significant differences were not found for acquired points over all periods by either method. The preoperative comorbidities of hypertension and diabetes mellitus increased with age. Delirium was more common postoperatively in elderly patients. Conclusions Although an age-related decline of JOA scores was found over all periods, there were no severe sequelae and no differences in the acquired points that were age-related.

Factors affecting postoperative activities of daily living in patients with osteoporotic vertebral collapse with neurological deficits.

Surgical treatment of osteoporotic vertebral collapse (OVC) with neurological deficits presents significant clinical challenges because some patients have fragile bones and often have medical comorbidities, which affect the severity of osteoporosis. We hypothesized that clinical results of surgery in these patients depend on the extent of medical comorbidities that induce secondary osteoporosis. The aim of this study is to examine the effects of medical history and comorbidities on surgical outcomes for these patients, along with the factors that predict postoperative function in activities of daily living (ADL). We retrospectively reviewed data for 88 patients with OVC and neurological deficits who underwent surgery. We assessed clinical results regarding neurological deficits and function in ADL. The presence or absence of comorbidities responsible for secondary osteoporosis and treatments or medical events that affect bone metabolism were examined. We performed statistical analysis to examine prognostic factors for postoperative function in ADL. Of 88 patients, the distributions of comorbidities, treatment, and events in medical history were as follows: hypertension, 57 patients (64.8%); chronic kidney disease (CKD) stage 3 or 4, 32 (36.4%); diabetes mellitus, 16 (18.2%); liver dysfunction, 11 (12.5%); cardiovascular disease, 10 (11.4%); rheumatoid arthritis, 9 (10.2%); and glucocorticoid intake, 8 (9.1%). Twenty-five patients (28.4%) represented poor postoperative ADL (chair-bound or bed-bound), and 11 of 25 patients with poor postoperative ADL represented full neurological recovery. Multivariate analysis revealed decreased estimated glomerular filtration rate (odds ratio 0.96; 95% confidence interval 0.93-0.99; p = 0.005) and a high serum alkaline phosphatase (ALP) level (odds ratio 1.01; 95% CI 1.00-1.02; p = 0.01) were strong predictive factors for poor postoperative function in ADL. The majority of patients with poor postoperative function in ADL had advanced CKD with a disorder of bone metabolism as well as bone fragility.

Posterior lumbar interbody fusion with total facetectomy for low-dysplastic isthmic spondylolisthesis: effects of slip reduction on surgical outcomes: clinical article.

OBJECT: The management of isthmic spondylolisthesis remains controversial, especially with respect to reduction. There have been no reports regarding appropriate slip reduction. The purpose of this study was to investigate the following issues: (1) surgical outcomes of posterior lumbar interbody fusion (PLIF) with total facetectomy for low-dysplastic isthmic spondylolisthesis, including postoperative complications; (2) effects of slip reduction on surgical outcomes; and (3) appropriate slip reduction. METHODS: A total of 106 patients who underwent PLIF with total facetectomy for low-dysplastic isthmic spondylolisthesis and who were followed for at least 2 years were reviewed. The average follow-up period was 8 years. Surgical outcomes, including the scores assessed using the Japanese Orthopaedic Association scoring system, the recovery rate, and postoperative complications were investigated. As for radiographic evaluations, pre- and postoperative slip and disc height, instrumentation failure, and fusion status were also examined. RESULTS: The pre- and postoperative average Japanese Orthopaedic Association scores were 14 (range 3-25) and 25 (range 11-29) points, respectively. The average recovery rate was 73% (range 0%-100%). The average pre- and postoperative slip was 24% and 10%, respectively. A significant correlation between postoperative slip and clinical outcomes was found; clinical outcomes were better in proportion to slip reduction. Although no statistical difference was detected in clinical outcomes between postoperative slip of less than 10% and from 10% to 20%, patients with postoperative slip of more than 20% showed significantly worse clinical outcomes. Postoperative complications included neurological deficits in 7 patients (transient motor loss in 6 and permanent motor loss in 1), instrumentation failures in 7, adjacent-segment degeneration in 5, and nonunion in 4. Instrumentation failures occurred significantly more often in patients with more slip reduction, although slip reduction did not affect the other postoperative complications. All patients with instrumentation failure showed postoperative slip reduction within 10%. CONCLUSIONS: The use of PLIF with total facetectomy for low-dysplastic isthmic spondylolisthesis appears to produce satisfactory clinical outcomes, with an average of 73% recovery rate and few postoperative complications. Although clinical outcomes were better in proportion to slip reduction, excessive reduction caused instrumentation failure, and patients with less reduction demonstrated worse clinical outcomes. Appropriate reduction resulted in a postoperative slip ranging from 10% to 20%.

Neurological manifestations of thoracic myelopathy.

INTRODUCTION: Investigation of preoperative manifestations of thoracic myelopathy in a large population has not been reported. The aim of this study was to identify symptoms specific to anatomical pathology or compressed segments in thoracic myelopathy through investigation of preoperative manifestations. MATERIALS AND METHODS: Subjects were 205 patients [143 men, 62 women; mean age, 62.2 (range 21-87 years)] with thoracic myelopathy who underwent surgery at our affiliate institutions from 2000 to 2011. The disease distribution included ossification of the ligamentum flavum (OLF) in 106 patients, ossification of the posterior longitudinal ligament (OPLL) in 17, OLF with OPLL in 17, intervertebral disc herniation (IDH) in 23, OLF with IDH in 3, and spondylosis in 39. We assessed (1) initial and preoperative complaints, (2) neurological findings, (3) Japanese Orthopaedic Association scores (JOA, full score, 11 points), (4) the compressed segments, and (5) preoperative duration. Multivariate analyses were performed to examine potential relationships between preoperative manifestations and anatomical pathology or compressed segments. RESULTS: The multivariate analyses revealed relationships between lower limb muscle weakness and T10/11 anterior compression; lower limb pain and T11/12 anterior compression; low back pain and T11/12 compression; and hyporeflexia in the patellar tendon reflex/foot drop and T12/L1 anterior compression. CONCLUSION: This study elucidated symptoms specific to anatomical pathology or compressed segments in thoracic myelopathy. These relationships can be helpful in the initial investigation of thoracic diseases, although additional measures such as MRI or CT are necessary for definitive diagnosis.

Repeated adjacent-segment degeneration after posterior lumbar interbody fusion.

One of the most important sequelae affecting long-term results is adjacent-segment degeneration (ASD) after posterior lumbar interbody fusion (PLIF). Although several reports have described the incidence rate, there have been no reports of repeated ASD. The purpose of this report was to describe 1 case of repeated ASD after PLIF. A 62-year-old woman with L-4 degenerative spondylolisthesis underwent PLIF at L4-5. At the second operation, L3-4 PLIF was performed for L-3 degenerative spondylolisthesis 6 years after the primary operation. At the third operation, L2-3 PLIF was performed for L-2 degenerative spondylolisthesis 1.5 years after the primary operation. Vertebral collapse of L-1 was detected 1 year after the third operation, and the collapse had progressed. At the fourth operation, 3 years after the third operation, vertebral column resection of L-1 and replacement of titanium mesh cages with pedicle screw fixation between T-4 and L-5 was performed. Although the patient's symptoms resolved after each operation, the time between surgeries shortened. The sacral slope decreased gradually although each PLIF achieved local lordosis at the fused segment.

Surgical outcomes of posterior thoracic interbody fusion for thoracic disc herniations.

INTRODUCTION: Surgical strategy for thoracic disc herniation (TDH) remains controversial. We have performed posterior thoracic interbody fusion (PTIF) by bilateral total facetectomies with pedicle screw fixation. The objectives of this retrospective study are to demonstrate the surgical outcomes of PTIF for TDH. MATERIALS AND METHODS: We enrolled 11 patients who underwent PTIF for myelopathy due to TDH and were followed for at least 1 year. The mean age at surgery was 55.2 years and the average period of follow-up was 4.3 years. The levels of operation were T10-T11 in three cases, T12-L1 in three, and T2-T3, T3-T4, T9-T10, T11-T12, and T10-T12 in one case, respectively. The pre- and postoperative clinical status was evaluated according to the modified Frankel grade and the Japanese Orthopaedic Association (JOA) score modified for thoracic myelopathy. Additionally, postoperative complications were assessed. Local kyphosis at the operated segment and status of fusion were evaluated using plain radiographs and computed tomography. RESULTS: Improvement of at least one modified Frankel grade was observed in all but one patient. Average pre- and postoperative JOA scores were 4.9 and 8.8 points, respectively. The average recovery rate was 61%. Bony union was observed in ten cases. One patient's postsurgical outcome resulted in pseudoarthrosis, which required revision surgery due to kyphosis deterioration. Cerebrospinal fluid leakage was observed in one patient postoperatively with neither neurological deficit nor evidence of infection. CONCLUSION: PTIF has produced satisfactory outcomes for myelopathy due to TDH. Therefore, PTIF is one of the surgical treatments of choice for patients with TDH causing myelopathy.