Intraoperative Blood Loss at Different Surgical-Procedure Stages during Posterior Spinal Fusion for Idiopathic Scoliosis.

Background and Objectives: Several predictive factors have been reportedly associated with intraoperative total blood loss (TBL) during posterior spinal fusion (PSF) for idiopathic scoliosis (IS). To reduce TBL, preoperative factors and interoperative factors are considered important. However, there are few reports that have evaluated bleeding patterns according to surgical stages. This study aimed to elucidate bleeding patterns at different surgical stages and determine the predictive factors for TBL during PSF surgery in patients with IS. Materials and Methods: Preoperative data, radiographic parameters, and intraoperative data of patients undergoing PSF for IS were retrospectively collected. We divided the patients into six stages: stage 1, exposure; stage 2, implant placement; stage 3, release; stage 4, correction; stage 5, bone grafting; and stage 6, closure; then we reviewed the blood loss and bleeding speed. Multiple-regression analysis was performed to generate a predictive formula for blood loss using preoperative and intraoperative factors, including blood loss at stage 1, as explanatory variables. Results: Forty-five patients (mean age: 17.6 years) were included. The mean operative time and TBL were 287.9 min and 756.5 mL, respectively. Blood loss was the highest at stage 3, followed by stage 4. Bleeding speed was the highest at stage 4, followed by stage 3. Bleeding speeds at stages 3 and 4 were significantly higher than those at stages 1 and 2. Preoperative Cobb angle, activated partial thromboplastin time (aPTT), number of fused vertebrae, and blood loss at stage 1 were significant contributing factors. Conclusions: Blood loss and bleeding speed during the release and correction stages were high. Specifically, bleeding speed significantly increased during and after the release procedure. The preoperative Cobb angle, aPTT, number of fixed vertebrae, and blood-loss volume during PSF were significantly associated with TBL. Our findings would be helpful for reducing TBL in patients undergoing PSF for IS.

Decreased muscle mass and strength affected spinal sagittal malalignment.

PURPOSE: Correction surgeries for spinal malalignment showed good clinical outcomes; however, there were concerns including increased invasiveness, complications, and impact on medico-economics. Ideally, an early intervention is needed. To better understand the patho-mechanism and natural course of spinal alignment, the effect of factors such as muscle mass and strength on spinal sagittal imbalance were determined in a multicenter cross-sectional study. METHODS: After excluding metal implant recipients, 1823 of 2551 patients (mean age: 69.2 ± 13.8 years; men 768, women 1055) were enrolled. Age, sex, past medical history (Charlson comorbidity index), body mass index (BMI), grip strength (GS), and trunk muscle mass (TM) were reviewed. Spinal sagittal imbalance was determined by the SRS-Schwab classification. Multiple comparison analysis among four groups (Normal, Mild, Moderate, Severe) and multinomial logistic regression analysis were performed. RESULTS: On multiple comparison analysis, with progressing spinal malalignment, age in both sexes tended to be higher; further, TM in women and GS in both sexes tended to be low. On multinomial logistic regression analysis, age and BMI were positively associated with spinal sagittal malalignment in Mild, Moderate, and Severe groups. TM in Moderate and Severe groups and GS in the Moderate group were negatively associated with spinal sagittal malalignment. CONCLUSION: Aging, obesity, low TM, and low GS are potential risk factors for spinal sagittal malalignment. Especially, low TM and low GS are potentially associated with more progressed spinal sagittal malalignment. Thus, early intervention for muscles, such as exercise therapy, is needed, while the spinal sagittal alignment is normal or mildly affected.

A High Body Mass Index and the Vacuum Phenomenon Upregulate Pain-Related Molecules in Human Degenerated Intervertebral Discs.

Animal studies suggest that pain-related-molecule upregulation in degenerated intervertebral discs (IVDs) potentially leads to low back pain (LBP). We hypothesized that IVD mechanical stress and axial loading contribute to discogenic LBP's pathomechanism. This study aimed to elucidate the relationships among the clinical findings, radiographical findings, and pain-related-molecule expression in human degenerated IVDs. We harvested degenerated-IVD samples from 35 patients during spinal interbody fusion surgery. Pain-related molecules including tumor necrosis factor alpha (TNF-alpha), interleukin (IL)-6, calcitonin gene-related peptide (CGRP), microsomal prostaglandin E synthase-1 (mPGES1), and nerve growth factor (NGF) were determined. We also recorded preoperative clinical findings including body mass index (BMI), Oswestry Disability Index (ODI), and radiographical findings including the vacuum phenomenon (VP) and spinal instability. Furthermore, we compared pain-related-molecule expression between the VP (-) and (+) groups. BMI was significantly correlated with the ODI, CGRP, and mPGES-1 levels. In the VP (+) group, mPGES-1 levels were significantly higher than in the VP (-) group. Additionally, CGRP and mPGES-1 were significantly correlated. Axial loading and mechanical stress correlated with CGRP and mPGES-1 expression and not with inflammatory cytokine or NGF expression. Therefore, axial loading and mechanical stress upregulate CGRP and mPGES-1 in human degenerated IVDs, potentially leading to chronic discogenic LBP.

TGF-ß regulates nerve growth factor expression in a mouse intervertebral disc injury model.

BACKGROUND: Intervertebral disc (IVD) degeneration is a major cause of low back pain (LBP). Following disc injury, nerve growth factor (NGF) concentrations rise in IVDs, and anti-NGF therapy has been shown to attenuate LBP in humans. Increased levels of tumor necrosis factor-α (TNF-α) and transforming growth factor-ß (TGF-ß) in degenerative IVDs and in in vitro studies suggest that these factors promote NGF production. However, whether these factors regulate NGF in vivo remains unclear. Thus, we studied NGF regulation in a mouse model of IVD injury. METHODS: After inducing IVD injury, we examined mRNA levels of Tnfa, Tgfb, and Ngf in IVDs from control and IVD-injured mice across 7 days. To do this, we used magnetic cell separation to isolate CD11b ( +) (macrophage-rich) and CD11b (-) (IVD cell-rich) cell fractions from injured IVDs. To study the effect of TNF-α on Ngf expression, we examined Ngf expression in injured IVDs from C57BL/6 J and Tnfa-knockout (KO) mice (C57BL/6 J background). To study the effect of TGF-ß on Ngf expression, C57/BL6J mice were given an intraperitoneal injection of either the TGF-ß inhibitor SB431542 or DMSO solution (vehicle) one and two days before harvesting IVDs. RESULTS: mRNA expression of Tnfa, Tgfb, and Ngf was significantly increased in injured IVDs. Tnfa was predominantly expressed in the CD11b ( +) fraction, and Tgfb in the CD11b (-) fraction. Ngf expression was comparable between CD11b ( +) and CD11b (-) fractions, and between wild-type and Tnfa-KO mice at post-injury day (PID) 1, 3, and 7. SB431542 suppressed TGF-ß-mediated Ngf expression and NGF production in vitro. Further, administration of SB431542 significantly reduced Ngf expression in IVDs such that levels were below those observed in vehicle-treated animals at PID3 and PID7. CONCLUSION: A TGF-ß inhibitor reduced Ngf expression in a mouse model of IVD injury, suggesting that TGF-ß may regulate NGF expression in vivo.

ISSLS PRIZE IN CLINICAL SCIENCE 2019: clinical importance of trunk muscle mass for low back pain, spinal balance, and quality of life-a multicenter cross-sectional study.

STUDY DESIGN: A multicenter cross-sectional study. OBJECTIVES: To clarify the relationship of trunk muscle mass with low back pain, spinal sagittal balance, and quality of life. Few reports have investigated the relationship of trunk muscle mass with lumbar spine function and spinal balance, and the clinical significance of trunk muscle mass remains unclear. METHODS: Patients attending spinal outpatient clinics at 10 different medical institutions were enrolled in this study. Patient demographics, trunk muscle mass and appendicular skeletal muscle mass (ASM) measured by bioelectrical impedance analysis (BIA), body mass index (BMI), Charlson Comorbidity Index (CCI), the Oswestry Disability Index (ODI), visual analog scale (VAS) for low back pain, sagittal vertical axis (SVA), and EuroQol 5 Dimension (EQ5D) score were investigated. Multivariate nonlinear regression analysis was used to investigate the association of trunk muscle mass with the ODI, VAS score, SVA, and EQ5D score. RESULTS: Of 2551 eligible patients, 1738 (mean age 70.2 ± 11.0 years; 781 men and 957 women) were enrolled. Trunk muscle mass was significantly correlated with the ODI, VAS score, SVA, and EQ5D score (P < 0.001) when adjusted for age, sex, BMI, ASM, CCI, and history of lumbar surgery. Patient deterioration was associated with a decrease in trunk muscle mass, and the deterioration accelerated from approximately 23 kg. CONCLUSIONS: Trunk muscle mass was significantly associated with the ODI, VAS score, SVA, and EQ5D score. Trunk muscle mass may assume an important role to elucidate and treat lumbar spinal dysfunction and spinal imbalance. These slides can be retrieved under Electronic Supplementary Material.

Elevated leptin levels induce inflammation through IL-6 in skeletal muscle of aged female rats.

BACKGROUND: Chronic inflammation with aging contributes to sarcopenia. Previous studies have suggested that the accumulation of adipose tissue in skeletal muscle, referred to as intermuscular adipose tissue (IMAT), increases with age and is associated with inflammation. However, the mechanism governing ectopic inflammation in skeletal muscle due to aging is not fully understood. Leptin, an adipocytokine derived from adipose tissue, is an important mediator of inflammatory processes. We examined changes in leptin levels with age and whether leptin contributes to ectopic inflammation. METHODS: To evaluate ectopic inflammation in skeletal muscle, we measured alterations to the expression of inflammatory cytokine genes (Il1b, Il6, and Tnfa) and muscle break down-related gene (MuRF1 and Atrogin1) in the quadricep muscles of young (10 weeks) and aged (48 weeks) female rats using quantitative reverse-transcription polymerase chain reaction (Q-RT-PCR). Histological examination was performed to identify the extent of IMAT. Leptin mRNA and leptin protein expression were examined using Q-RT-PCR and enzyme-linked immunosorbent assay, respectively. The effect of leptin on the mRNA expression of Il1b, Il6, and Tnfa in quadricep muscle-derived cells was also examined by stimulating the cells with 0 (control), 1, or 10 µg/mL rat recombinant leptin using Q-RT-PCR. RESULTS: Aged rats had significantly higher Il6, MuRF1, and Atrogin1 but not Il1b and Tnfa, expression and greater levels of IMAT in their quadricep muscles than young rats. Aged rats also had significantly higher leptin expression and leptin protein concentration in their quadricep muscles than young rats. The addition of exogenous leptin to quadricep muscle-derived cells significantly increased the gene expression of Il1b and Il6 but not Tnfa. CONCLUSIONS: Our results suggest that elevated leptin levels due to aging cause ectopic inflammation through IL-6 in the skeletal muscle of aged rats.

Origin of M2 Mϕ and its macrophage polarization by TGF-ß in a mice intervertebral injury model.

INTRODUCTION: Studies have identified the presence of M1 and M2 macrophages (Mϕ) in injured intervertebral discs (IVDs). However, the origin and polarization-regulatory factor of M2 Mϕ are not fully understood. TGF-ß is a regulatory factor for M2 polarization in several tissues. Here, we investigated the source of M2 Mϕ and the role of TGF-ß on M2 polarization using a mice disc-puncture injury model. METHODS: To investigate the origin of M2 macrophages, 30 GFP chimeric mice were created by bone marrow transplantation. IVDs were obtained from both groups on pre-puncture (control) and post-puncture days 1, 3, 7, and 14 and CD86 (M1 marker)- and CD206 (M2 marker)-positive cells evaluated by flow cytometry (n = 5 at each time point). To investigate the role of TGF-ß on M2 polarization, TGF-ß inhibitor (SB431542) was also injected on post-puncture days (PPD) 5 and 6 and CD206 expression was evaluated on day 7 by flow cytometry (n = 5) and real time PCR (n = 10). RESULTS: The proportion of CD86+ Mϕ within the GFP+ population was significantly increased at PPD 1, 3, 7, and 14 compared to control. CD206-positive cells in GFP-populations were significantly increased on PPD 7 and 14. In addition, the percentage of CD206-positive cells was significantly higher in GFP-populations than in GFP+ populations. TGF-ß inhibitor reduced CD206-positive cells and Cd206 expression at 7 days after puncture. CONCLUSION: Our findings suggest that M2 Mϕ following IVD injury may originate from resident Mϕ. TGF-ß is a key factor for M2 polarization of macrophages following IVD injury.

Assessment of the duration and effectiveness of intra-articular lidocaine injections for groin pain in patients with labral tears involving early osteoarthritis.

INTRODUCTION: Intra-articular lidocaine injections have been used to confirm the hip pathology and may predict the efficacy of arthroscopic surgery. We have routinely performed the injections as a surgical indicator. The aim of this study was to assess the duration and effectiveness of these diagnostic intra-articular lidocaine injections on groin pain in patients with labral tears involving early osteoarthritis. METHODS: A total of 113 patients were included in this study. All patients received one injection of 10 ml of 1% lidocaine into the hip joint under fluoroscopy. The duration and effectiveness of the injection were assessed 2 weeks after the injection and at a minimum of 1 year of follow-up. The effect of the injection was graded as 0: unchanged or worse; 1: an effect only on the day of injection; 2: the effect lasted a few days; 3: the effect lasted about a week; and 4: symptom remission. In addition, we recorded whether hip arthroscopic surgery was eventually performed. RESULTS: The effect was rated as 0 in 19 patients (16.8%), as 1 in 30 patients (26.5%), as 2 in 38 patients (33.6%), as 3 in 13 patients (11.5%), and as 4 in 13 patients (11.5%). Seventy-two patients (63.7%) underwent hip arthroscopic surgery. No relationship with patients' characteristics was found. CONCLUSION: In total, 83% of patients experienced some effect of the lidocaine injection. Furthermore, 11.5% of patients experienced complete remission of their symptoms.

Relationships Between Spinal Alignment and Muscle Mass in Osteoporosis Patients Over 75 Years of Age Who Were Independent and Maintained Their Activities of Daily Living.

Introduction Elderly patients with osteoporosis often complain of back pain associated with pathological vertebral fractures caused by abnormal spinal alignment. Few reports evaluate the relationships among muscle mass, bone mineral density (BMD), sagittal spinal alignment, and low back pain. We hypothesized that decreasing muscle mass in elderly patients with osteoporosis could cause spinal alignment abnormalities. The aim of the current study were to compare the characteristics between spinal sagittal normal alignment and malalignment and to evaluate the relationships between sagittal spinal alignment and muscle mass in elderly patients with osteoporosis. Methods Fifty patients aged 75 years or more (mean age = 80.5 years) with osteoporosis were included in this study. We evaluated the sagittal vertical axis (SVA), pelvic tilt (PT), pelvic incidence minus lumbar lordosis (PI-LL), the number of vertebral fractures (N of VFs), BMD by dual-energy X-ray absorptiometry, and trunk and skeletal muscle mass using bioelectrical impedance. Low back pain was evaluated using the Oswestry Disability Index (ODI). Corrected trunk muscle mass (trunk muscle mass index, TMI) and corrected limb muscle mass (skeletal mass index, SMI) also were measured. Patients were divided into two groups for comparison: a 'normal' group and a sagittal spinal 'malalignment' group. Multiple regression analysis was carried out to evaluate the relationship between spinal sagittal parameters and muscle mass. Results Comparisons between normal and malalignment groups for SVA, N of VFs, BMI, and SMI showed significantly higher in the malalignment group versus the normal group (p < 0.05). N of VFs, BMI, and TMI, for PT, and BMI, TMI, SMI, and ODI scores for PI-LL showed significantly higher in the malalignment group versus the normal group (p < 0.05). There were significantly more vertebral fractures in the malalignment group than in the normal group (p < 0.05). However, there were no significant differences of pure muscle mass between the two groups. When adjusted by BMD and the number of vertebral fractures, SMI and TMI were positively correlated to PI-LL and SVA (p < 0.05). Conclusion Elderly patients with osteoporosis and a sagittal spinal malalignment had more vertebral fractures and a higher risk of low back pain than patients with normal spinal alignment. Patients with a sagittal spinal malalignment who were independent and maintained their activities of daily living (ADL) showed high BMI and maintained muscle mass, independent of BMD and the N of VFs, contrary to our hypothesis.

Reduced TGF-ß Expression and CD206-Positive Resident Macrophages in the Intervertebral Discs of Aged Mice.

Age is a key factor in intervertebral disc (IVD) degeneration; however, the changes that occur in IVDs with age are not fully understood. Tissue-resident macrophages are critical for tissue homeostasis and are regulated by transforming growth factor- (TGF-) ß. We examined changes in the proportion of resident macrophages in young versus aged mice and the role of TGF-ß in regulating resident macrophages in IVDs. IVDs were harvested from 4-month (young) and 18-month-old (aged) C57BL/6J mice. The proportion of macrophages in IVDs was determined using flow cytometry (n = 5 for each time point) and the expression of Cd11b, Cd206, and Tgfb genes, which encode CD11b, CD206, and TGF-ß protein, respectively, using real-time PCR. To study the role of TGF-ß in the polarization of resident macrophages, resident macrophages isolated from IVDs from young and aged mice were treated with recombinant TGF-ß with and without a TGF-ß inhibitor (SB431542). Additionally, SB431542 was intraperitoneally injected into young and aged mice, and Cd206 expression was examined using real-time PCR (n = 10 for each time point). The proportion of CD11b+ and CD11b+ CD206+ cells was significantly reduced in aged versus young mice, as was Cd11b, Cd206, and Tgfb expression. TGF-ß/IL10 stimulation significantly increased the expression of Cd206, an M2 macrophage marker, in disc macrophages from both young and aged mice. Meanwhile, administration of a TGF-ß inhibitor significantly reduced Cd206 expression compared to vehicle control in both groups. Conclusion. Resident macrophages decrease with age in IVDs, which may be associated with the concomitant decrease in TGF-ß. Our findings provide new insight into the mechanisms of age-related IVD pathology.

Limitations of posterior spinal fusion to L5 for flaccid neuromuscular scoliosis focusing on pelvic obliquity.

STUDY DESIGN: Retrospective comparison based on the degree of pelvic obliquity (PO). PURPOSE: To assess the controversial indications for and limitations of ending the instrumentation for posterior spinal fusion (PSF) at L5 in patients with flaccid neuromuscular scoliosis (fNMS). METHODS: We reviewed the cases of 45 patients with progressive spinal deformity as a result of fNMS treated by PSF to L5 and followed for an average of 4 years postoperatively with adequate clinical and radiological data. Anterior-posterior and lateral whole spine radiographs were evaluated. We divided patients into two groups based on the degree of pelvic obliquity (PO) at the final follow-up. Radiographic data from the two groups were analyzed to identify the indications and limitations of this surgical method focusing on PO. RESULTS: Preoperatively, there were significant differences between the two groups in Cobb angle, PO, thoracolumbar kyphosis, and lumbar lordosis (LL) while sitting; Cobb angle and LL while supine (Supine Cobb, and Supine LL); and major curve flexibility. Multivariate logistic regression analysis identified Supine Cobb and Supine LL as independent risk factors for residual PO at the final follow-up (Supine Cobb: odds ratio, 1.1; 95% confidence interval 1.0-1.2, Supine LL: odds ratio, 0.9; 95% confidence interval 0.8-1.0). CONCLUSION: Patients with larger preoperative Cobb angle and smaller LL while supine may not achieve adequate spine and pelvic correction and this may lead to deterioration in the PO over time, even after spinal fusion ending at L5.

Body Composition in Japanese Girls with Adolescent Idiopathic Scoliosis.

INTRODUCTION: There are few reports on body composition, particularly muscle mass, in patients with adolescent idiopathic scoliosis (AIS). The purpose of this study was to measure body composition including muscle mass and estimated bone mass of patients with AIS using bioelectrical impedance analysis (BIA) and to clarify the relationship between the degree of scoliosis and body composition. METHODS: The subjects were 210 girls (mean age 14.0 years, range 10-18 years) whose body composition was evaluated using BIA (Tanita MC-780). Body mass index (BMI), percent body fat (%BF), lean muscle mass index (LMI: muscle mass/height^2), and estimated bone mass index (eBoneMI: estimated bone mass/height^2) were determined by age and compared with those of previous reports. We divided 111 subjects whose bone maturation was complete into two groups for comparison of body composition metrics: those with Cobb angle <40° (moderate scoliosis group) and those with Cobb angle ≥40° (severe scoliosis group). The relationships between Cobb angle and each body composition parameter were evaluated. RESULTS: Age-adjusted BMI, %BF, and LMI tended to be low at all ages compared with means for the healthy Japanese population as previously reported. BMI, LMI, and eBoneMI were significantly lower in the severe scoliosis group compared with those in the moderate scoliosis group (p<0.05). In addition, all BMI, LMI, and eBoneMI were weakly correlated with Cobb angle (r= -0.20, -0.26, and -0.24). CONCLUSIONS: On the basis of the results of this study, patients with AIS are thinner, with lower BMI, %BF, and LMI compared with healthy girls of the same age. Furthermore, factors such as lower BMI, lower muscle mass, and lower estimated bone mass were correlated with progressive scoliosis.

Posterior Spinal Correction and Fusion Surgery in Patients with Spinal Muscular Atrophy-Associated Scoliosis for Whom Treatment with Nusinersen Was Planned.

INTRODUCTION: Spinal muscular atrophy (SMA) is defined as a neuromuscular disorder induced by progressive weakness of the skeletal muscle and is usually accompanied by progressive spinal deformity including scoliosis. The newly developed Nusinersen, which is the first approved drug worldwide for SMA, requires accurate intrathecal injection, which is sometimes difficult in patients with severe spinal deformity. TECHNICAL NOTE: For an accurate intrathecal approach in patients who have spinal fusion surgery to treat neuromuscular scoliosis, we have combined an L3 laminectomy with spinal correction and fusion surgery. Here, we review four cases of SMA in patients who underwent the additional L3 laminectomy during surgery to treat spinal scoliosis. A successful intrathecal approach was made using fluoroscopic guidance in all four patients, who were then administered with Nusinersen. CONCLUSIONS: Our findings show that additional lumbar laminectomy during surgery for spinal scoliosis has effectively allowed for intrathecal injection of Nusinersen.

Role of CD14-positive cells in inflammatory cytokine and pain-related molecule expression in human degenerated intervertebral discs.

Multiple human and animal studies suggest that the upregulation of inflammatory cytokines and other pain-related molecules in degenerated or injured intervertebral discs (IVDs) may cause discogenic low back pain (LBP). We previously reported that macrophages in injured IVD in mice produced inflammatory cytokines, but not other pain-related molecules. CD14 is a monocyte marker expressed mainly by macrophages. The aim of the current study was to evaluate the role of CD14-positive cells in inflammatory cytokine and pain-related molecule expression in human degenerated IVD. IVD samples were harvested from 14 patients, including 10 with lumbar spinal stenosis, four with adult spinal deformity, and one with lumbar disc herniation during spinal interbody fusion surgery. Harvested IVD-derived mononuclear cells were obtained and CD14-positive (+) and CD14-negative (-) cells were separated using CD14 antibody and streptavidin-labeled magnetic beads. Inflammatory cytokines messenger RNA (mRNA) in the CD14(+) and CD14(-) cells, including tumor necrosis factor ɑ (TNFA), in, terleukin-1ß (IL1B) and IL6, were determined using quantitative polymerase chain reaction (qPCR) and their expression levels were compared. To evaluate factors controlling the regulation of pain-related molecules mRNA expression, cultured CD14(-) and CD14(+) cells from IVDs were stimulated with recombinant human TNF-ɑ and IL-1ß and levels of pain-related molecules, including calcitonin gene-related peptide (CGRP) and nerve growth factor (NGF) were determined using qPCR. Levels of TNFA, IL1B, IL6, and NGF in CD14(+) cells were significantly increased compared with those in CD14(-) cells (TNFA, p = 0.006; IL1B, p = .017; IL6, p = .010; NGF, p = .027). Following TNFA stimulation, NGF levels were significantly increased in CD14(-) and CD14(+) cells (CD14(-), p = .003; CD14(+), p < .001) and CGRP was significantly increased in CD14(-) IVD cells (p = .040). Following IL1B stimulation, NGF levels were significantly increased in CD14(-) cells (p = .004). CD14(+) cells had higher TNFA, IL1B, IL6, and NGF expressions than CD14(-) cells in human degenerated IVDs. Additionally, TNFA stimulation promoted the upregulation of NGF and CGRP in CD14(-) cells. These findings suggested that CD14(+) cells directly and indirectly contributed to inflammatory cytokine and pain-related molecule expression in human degenerated IVD. CD14(+) cells might be important in the pathological mechanism of chronic discogenic LBP in humans.

Incidence of Unintentional Intraoperative Hypothermia in Pediatric Scoliosis Surgery and Associated Preoperative Risk Factors.

INTRODUCTION: Intraoperative hypothermia is associated with perioperative complications such as blood loss and wound infection. Thus, perioperative heat retention methods to prevent perioperative hypothermia such as providing a warmed blanket and active patients' warming are important. Although major surgery and pediatric patient age are noted as risk factors, only a few studies focus on hypothermia as an intraoperative complication in pediatric scoliosis surgery. The aim of this study is to investigate the incidence of intraoperative hypothermia in pediatric scoliosis surgery and the associated preoperative risk factors. METHODS: We retrospectively reviewed the records of pediatric patients who underwent posterior spinal fusion at a single institution between 2015 and 2019. We recorded the background data, perioperative data, lowest recorded core temperature, and perioperative complications. Patients were divided into those whose temperature decreased below 36°C (Group H) and those who maintained a temperature of 36°C or greater (Group N) during surgery. We compared the two groups and performed multivariate analysis to identify preoperative risk factors for intraoperative hypothermia. RESULTS: A total of 103 patients underwent posterior spinal fusion; 56 for adolescent idiopathic scoliosis and 47 for neuromuscular scoliosis. Hypothermia was observed in 40 patients (38.8%). Group H had more non-adolescent idiopathic scoliosis (AIS) patients, lower mean body mass index, greater mean blood loss, greater number of fused vertebrae, larger preoperative Cobb angle, and lower initial core body temperature (immediately after induction of anesthesia). On multivariate analysis, a diagnosis of neuromuscular scoliosis, a lower body mass index, and a lower initial core body temperature were identified as independent risk factors for intraoperative hypothermia. CONCLUSIONS: The incidence of hypothermia in pediatric posterior scoliosis surgery is 38.8%. Diagnosis of non-AIS, lower body mass index, and lower core body temperature at the time of anesthesia induction are preoperative risk factors for intraoperative hypothermia.

Factors associated with pain-related disorders and gait disturbance scores from the Japanese orthopedic association back pain evaluation questionnaire and Oswestry Disability Index in patients with osteoporosis.

In the current study, multivariate analyses were performed to determine factors associated with low back pain (LBP) in patients with osteoporosis. Aging, high bone turnover, obesity, low trunk muscle mass, spinal global sagittal malalignment, and a high number of previous vertebral fractures were potential independent risk factors of pain-related disorders, gait disturbance, or ADL deficit due to LBP. PURPOSE: Patients with osteoporosis often experience low back pain (LBP) even in the absence of acute fractures. This study identifies factors that may affect questionnaires about LBP. METHODS: The data of 491 patients with osteoporosis were retrospectively reviewed. Data included patient age, sex, body mass index (BMI), bone mineral density of the lumbar spine, tartrate-resistant acid phosphatase 5b level (TRACP5b), trunk muscle mass, sagittal vertical axis (SVA), previous vertebral fractures, secondary osteoporosis, controlling nutritional status score, pain-related disorders and gait disturbance scores from the Japanese Orthopedic Association Back Pain Evaluation questionnaire (JOABPEQ), and Oswestry disability index (ODI) scores for activities of daily living (ADL) deficit. Patients with scores of 100 for each subsection of the JOABPEQ, or an ODI scores < 12 were considered to not have dysfunction (dysfunction (-) group). Multivariate analyses were used to determine variables associated with dysfunction. RESULTS: Pain-related disorders score of JOABPEQ was associated with aging, high BMI, and high SVA. Aging, high TRACP5b, high BMI, low TM, high SVA, and more previous vertebral fractures were associated with gait disturbance score of JOABPEQ. ODI scores were associated with high BMI, low TM, high SVA, and more previous vertebral fractures. CONCLUSIONS: Aging, high bone turnover, obesity, a low TM, spinal global sagittal malalignment, and a high number of previous VFs were potential independent risk factors of pain-related disorders or gait disturbance according to the JOABPEQ or ODI score in patients with osteoporosis.

Chylous retroperitoneum following 720 degree anteroposterior-combined corrective surgery for adult spinal deformity with split vertebral fracture subluxation: a case report.

STUDY DESIGN: Clinical case report. PURPOSE: To report the rare case with post-operative chylous retroperitoneum after corrective surgery for adult spinal deformity. METHODS: We present a case of a 73-year-old woman with Parkinson's disease. She sustained a severe split fracture subluxation of the L3 vertebra with AO Spine Thoracolumbar classification type CN2M2, resulting in severe kyphoscoliosis in global alignment. She underwent a two-stage 720-degree anteroposterior-combined corrective surgery with anterior vertebral column resection of L3 and posterior fusion from T4 to the pelvis. On post-operative day 1, milky fluid in the drainage tube was noted, which was diagnosed as post-operative chylous retroperitoneum. RESULTS: Oral intake was discontinued immediately and peripheral parenteral nutrition was started. A low-fat, high-protein diet was started on post-operative day 4, and drainage was removed on day 6. A low-fat diet was continued until 3 months post-operatively, with dietary counselling by a nutritionist. The chylous retroperitoneum resolved without recurrence at the final follow-up evaluation at 3 years. CONCLUSION: Surgeons should recognize this rare complication, which might be induced by direct damage to the lymphatic flow during an operative maneuver anterior to the lumbar vertebral body and indirect damage due to shearing force during correction of a subluxated vertebra, especially in cases with a severe deformity.

Prevalence and Characteristics of Spinal Sagittal Malalignment in Patients with Osteoporosis.

Spinal sagittal malalignment due to vertebral fractures (VFs) induces low back pain (LBP) in patients with osteoporosis. This study aimed to elucidate spinal sagittal malalignment prevalence based on VF number and patient characteristics in individuals with osteoporosis and spinal sagittal malalignment. Spinal sagittal alignment, and VF number were measured in 259 patients with osteoporosis. Spinal sagittal malalignment was defined according to the SRS-Schwab classification of adult spinal deformity. Spinal sagittal malalignment prevalence was evaluated based on VF number. In patients without VFs, bone mineral density, bone turnover markers, LBP scores and health-related quality of life (HRQoL) scores of normal and sagittal malalignment groups were compared. In 205 of the 259 (79.2%) patients, spinal sagittal malalignment was detected. Sagittal malalignment prevalence in patients with 0, 1, or ≥2 VFs was 72.1%, 86.0%, and 86.3%, respectively. All LBP scores and some subscale of HRQoL scores in patients without VFs were significantly worse for the sagittal malalignment group than the normal alignment group (p < 0.05). The majority of patients with osteoporosis had spinal sagittal malalignment, including ≥70% of patients without VFs. Patients with spinal sagittal malalignment reported worse LBP and HRQoL. These findings suggest that spinal sagittal malalignment is a risk factor for LBP and poor HRQoL in patients with osteoporosis.

Gender-specific analysis for the association between trunk muscle mass and spinal pathologies.

We investigated the relationship between trunk muscle mass and spinal pathologies by gender. This multicenter cross-sectional study included patients aged ≥ 30 years who visited a spinal outpatient clinic. Trunk and appendicular muscle mass were measured using bioelectrical impedance analysis. The Oswestry Disability Index (ODI), visual analog scale (VAS) score for low back pain, sagittal vertical axis (SVA), and EuroQol 5 Dimension (EQ5D) score were investigated to evaluate spinal pathology. The association between trunk muscle mass and these parameters was analyzed by gender using a non-linear regression model adjusted for patients' demographics. We investigated the association between age and trunk muscle mass. We included 781 men and 957 women. Trunk muscle mass differed significantly between men and women, although it decreased with age after age 70 in both genders. Lower trunk muscle mass was significantly associated with ODI, SVA, and EQ5D score deterioration in both genders; its association with VAS was significant only in men. Most parameters deteriorated when trunk muscle mass was < 26 kg in men and < 19 kg in women. Lower trunk muscle mass was associated with lumbar disability, spinal imbalance, and poor quality of life in both genders, with significant difference in muscle mass.

Short-Term Impact of Staying Home on Bone Health in Patients With Osteoporosis During a State of Emergency Declaration Due to COVID-19 in Kanagawa, Japan.

Background On April 16, 2020, the Japanese government declared a state of emergency due to the spread of COVID-19 infection, leading prefectural governors to announce a stay-at-home order for 39 days until May 25, 2020. As physical inactivity is a risk factor for osteoporosis, we investigated the short-term impact of the stay-at-home order on bone health among patients with osteoporosis in our hospital in Kanagawa prefecture. Methods Thirty patients with osteoporosis with no delays in their regular medication who received care at our hospital's osteoporosis outpatient clinic within one month after the end of the state of emergency were included. Lumbar spine and femur proximal bone mineral density (BMD) were measured at the last follow-up date (May 25 to June 30, 2020; 0M) and six (6M) and 12 months (12M) before the last follow-up using dual-energy X-ray absorptiometry. Bone alkaline phosphatase (BAP), Tartrate-resistant Acid Phosphatase 5b (TRACP5b), calcium and phosphorus were assessed at the same time points. Results Serum BAP concentrations were significantly lower at 0M than 12M (p=0.040), but were comparable between 0M and 6M (p=0.527). Serum TRACP5b was significantly lower at 6M than 12M (p=0.009), but was similar between 0M and 6M (p=1.000). Serum calcium and phosphorus did not differ among the time points (p=0.516 and p=0.358, respectively). Similarly, lumbar spine and femoral neck BMD were comparable (p=0.679 and p=0.076, respectively). Conclusion Bone health in patients with osteoporosis was maintained during the short-term COVID-19 stay-at-home order among patients who experienced no delays in medication. However, larger and long-term studies are needed.