Impact of sagittal and coronal pelvic tilt on hip subluxation in non-ambulatory flaccid neuromuscular scoliosis patients following spinal correction.

PURPOSE: To evaluate the actual change in clinical hip pain and hip migration after operation for non-ambulatory flaccid neuromuscular (NM) scoliosis and investigate whether there is an association between hip migration and coronal/sagittal pelvic tilt (CO-PT/SA-PT). PATIENTS AND METHODS: This retrospective, single-center, observational study evaluated a total of 134 patients with non-ambulatory flaccid neuromuscular scoliosis who underwent surgery performed by a single surgeon between 2003 and 2020, with at least 2 years of follow-up period. Operation procedures were conducted in two stages, beginning with L5-S1 anterior release followed by posterior fixation. Radiologic parameters were measured at preoperative, immediate postoperative, and last follow-up periods with clinical hip pain and clinical hip dislocation events. RESULTS: The significant improvements occurred in various parameters after correction surgery for NM scoliosis, containing Cobb's angle of major curve and CO-PT. However, Reimer's hip migration percentage (RMP) was increased on both side of hip (High side, 0.23 ± 0.16 to 0.28 ± 0.21; Low side, 0.20 ± 0.14 to 0.23 ± 0.18). Hip pain and dislocation events were also increased (Visual analog scale score, 2.5 ± 2.3 to 3.6 ± 2.6, P value < 0.05; dislocation, 6-12). Logistic regression analysis of the interactions between ΔRMP(High) and the change of sagittal pelvic tilt (ΔSA-PT) after correction reveals a significant negative association. (95% CI 1.003-1.045, P value = 0.0226). CONCLUSIONS: In cases of non-ambulatory flaccid NM scoliosis, clinical hip pain, and subluxation continued to deteriorate even after correction of CO-PT. There was a relationship between the decrease in SA-PT, and an increase in hip migration percentage on high side, indicating the aggravation of hip subluxation.

Effect of saline irrigation temperature difference on postoperative acute pain and hypothermia during biportal endoscopic spine surgery.

BACKGROUND: Recently, enhanced recovery after surgery (ERAS) protocols have attracted attention; they emphasize on avoiding intraoperative hypothermia while performing lumbar fusion surgery. However, none of the studies have reported the protocol for determining the temperature of saline irrigation during biportal endoscopic spine surgery (BESS) procedure. This study evaluated the effectiveness of warm saline irrigation during BESS in acute postoperative pain and inflammatory reactions. MATERIALS AND METHODS: Fifty-five patients who underwent BESS procedure were retrospectively analyzed for the incidence of perioperative hypothermia (< 36oC), postoperative inflammatory factors (white blood cells (WBC), erythrocyte sedimentation rate (ESR), C-reactive protein (CRP), interleukin-6 (IL-6), serum amyloid A (SAA)), and clinical outcomes (back visual analog scale (VAS) score, postoperative shivering). The patients were divided into the warm and cold saline irrigation groups. RESULTS: Hemoglobin, WBC, ESR, creatine kinase, and creatine kinase-muscle brain levels did not significantly differ between the warm and cold saline groups. The mean CRP, IL-6, and SAA levels were significantly higher in the cold saline group than in the warm saline group (p = 0.0058, 0.0028, and 0.0246, respectively); back VAS scores were also higher with a statistically significant difference until two days postoperatively (p < 0.001). During the entire procedure, the body temperature was significantly lower in the cold saline irrigation group, but the hypothermia incidence rate significantly differed 30 min after the operation was started. CONCLUSIONS: Using warm saline irrigation during BESS is beneficial for early recovery after surgery, as it is associated with reduced postoperative pain and complication rates.

Shoulder Traction as a Possible Risk Factor for C5 Palsy in Anterior Cervical Surgery: A Cadaveric Study.

Background and Objectives: Many risk factors for postoperative C5 palsy (PC5P) have been reported regarding a "cord shift" after a posterior approach. However, there are few reports about shoulder traction as a possible risk factor of anterior cervical surgery. Therefore, we assessed the stretched nerve roots when shoulder traction was applied on cadavers. Materials and Methods: Eight cadavers were employed in this study, available based on age and the presence of foramen stenosis. After dissecting the sternocleidomastoid muscle of the cadaver, the shoulder joint was pulled with a force of 2, 5, 8, 10, 15, and 20 kg. Then, the stretched length of the fifth nerve root was measured in the extra-foraminal zone. In addition, the same measurement was performed after cutting the carotid artery to accurately identify the nerve root's origin. After an additional dissection was performed so that the superior trunk of the brachial plexus could be seen, the stretched length of the fifth and sixth nerve roots was measured again. Results: Throughout the entire experiment, the fifth nerve root stretched out for an average of 1.94 mm at 8 kg and an average of 5.03 mm at a maximum force of 20 kg. In three experiments, the elongated lengths of the C5 nerve root at 8 kg and 20 kg were 1.69/4.38 mm, 2.13/5.00 mm, and 0.75/5.31 mm, respectively, and in the third experiment, the elongated length of the C6 nerve root was 1.88/5.44 mm. Conclusions: Although this was a cadaveric experiment, it suggests that shoulder traction could be the risk factors for PC5P after anterior cervical surgery. In addition, for patients with foraminal stenosis and central stenosis, the risk would be higher. Therefore, the surgeon should be aware of this, and the patient would need sufficient explanation.

Comparison of the efficacy between sequential therapy with teriparatide and denosumab and denosumab monotherapy in suppressing fragility fracture risk.

In this retrospective study, the effectiveness of short-term teriparatide with denosumab in reducing fragility fracture risk was determined in comparison with denosumab monotherapy. Administration of sequential teriparatide with denosumab showed excellent outcomes in suppressing the risk for fragility fractures compared with denosumab monotherapy. INTRODUCTION: To determine the effectiveness of short-term teriparatide with denosumab in reducing the risk of fragility fractures in comparison to denosumab monotherapy. METHODS: The data of postmenopausal patients treated with denosumab for > 2 years between August 2015 and October 2020 were retrospectively analyzed. One hundred sixty four postmenopausal women of a total 615 were excluded, since they did not undergo > 2 bone mineral density (BMD) tests, were lost to follow-up, or received long-term teriparatide therapy. Total 320 patients received denosumab monotherapy and 131 patients received teriparatide for ≥ 3 months followed by denosumab. The number of osteoporotic fractures, presence of back pain before and after treatment, and annual BMD during treatment were comparatively assessed using t-test, Chi-square test, and linear mixed model analysis. RESULTS: Before treatment, the denosumab monotherapy group had fewer osteoporotic fractures (mean ± standard deviation; 0.459 ± 0.689) than the sequential therapy group had (1.037 ± 0.871; p < 0.001). After treatment, the sequential therapy group had fewer osteoporotic fractures than the denosumab monotherapy group had (0.119 ± 0.348 versus 0.144 ± 0.385; p < 0.001). At 1 and 2 years after treatment, the increase in lumbar spine BMD was greater in the sequential therapy group than in the denosumab monotherapy group (p = 0.08, group × time). The difference between post and pre-treatment back pain visual analog scale score was significantly lower in the sequential therapy group than in the monotherapy group (3.246 ± 3.426 versus 1.734 ± 3.049; p < 0.001). CONCLUSION: Short-term teriparatide use before denosumab showed excellent outcomes in suppressing the risk of fragility fractures compared with denosumab monotherapy.

Which Factors Affect the Stress of Intraoperative Orthopedic Surgeons by Using Electroencephalography Signals and Heart Rate Variability?

Can we recognize intraoperative real-time stress of orthopedic surgeons and which factors affect the stress of intraoperative orthopedic surgeons with EEG and HRV? From June 2018 to November 2018, 265 consecutive records of intraoperative stress measures for orthopedic surgeons were compared. Intraoperative EEG waves and HRV, comprising beats per minute (BPM) and low frequency (LF)/high frequency (HF) ratio were gathered for stress-associated parameters. Differences in stress parameters according to the experience of surgeons, intraoperative blood loss, and operation time depending on whether or not a tourniquet were investigated. Stress-associated EEG signals including beta 3 waves were significantly higher compared to EEG at rest for novice surgeons as the procedure progressed. Among senior surgeons, the LF/HF ratio reflecting the physical demands of stress was higher than that of novice surgeons at all stages. In surgeries including tourniquets, operation time was positively correlated with stress parameters including beta 1, beta 2, beta 3 waves and BPM. In non-tourniquet orthopedic surgeries, intraoperative blood loss was positively correlated with beta 1, beta 2, and beta 3 waves. Among orthopedic surgeons, those with less experience demonstrated relatively higher levels of stress during surgery. Prolonged operation time or excessive intraoperative blood loss appear to be contributing factors that increase stress.

Development of Poly(methyl methacrylate)-Based Copolymers with Improved Heat Resistance and Reduced Moisture Absorption.

Poly(methyl methacrylate) (PMMA) is widely used as a transparent material for optical applications, owing to its high light transmittance. However, it exhibits poor heat resistance and high moisture absorption, leading to distortion and deformation upon exposure to elevated temperatures and/or moisture. These structural changes decrease the transparency of PMMA, critically limiting its applicability. In this study, we synthesized poly(methyl methacrylate-co-styrene-co-acrylamide) (PMSAm) as a reference polymer and introduced one of four different comonomers [N-phenylmaleimide (PMI), N-cyclohexylmaleimide (CHMI), allyltrimethylsilane (ATMS), or 2,2,2-trifluoroethyl methacrylate (TF)] as a means to improve heat resistance and reduce moisture absorption. Four series of PMMA-based random copolymers (PMSAm-PMI, PMSAm-CHMI, PMSAm-ATMS, and PMSAm-TF) were synthesized by conventional thermal radical polymerization. All of the polymers synthesized exhibited improved heat resistance, with PMSAm-CHMI exhibiting the highest glass transition temperature (Tg = 122.54 °C) and 5% weight loss thermal decomposition temperature (T5d = 343.40 °C) as well as the lowest thermal expansion coefficient (90.3 µm m-1 °C-1). The highest hydrophobicity was exhibited by PMSAm-TF, with a water contact angle of 78.9°, indicating higher hydrophobicity compared to that of pure PMMA (69.4°). More importantly, high transparency (∼90%) was exhibited by all of the synthesized polymers. Thus, our copolymerization strategy successfully addresses the limitations, i.e., low heat resistance and high moisture absorption, of conventional PMMA-based materials.

Odontoid osteomyelitis with atlantoaxial subluxation in an infant.

PURPOSE: To report a rare case of odontoid osteomyelitis with atlantoaxial subluxation in a 6-month-old infant. BACKGROUND: Odontoid osteomyelitis with atlantoaxial subluxation is extremely rare in children. Although several cases have been reported, there have been no studies concerning proper surgical drainage and immobilization in this disease. METHODS: A 6-month-old infant with odontoid osteomyelitis with atlantoaxial subluxation was surgically treated. The patient underwent a 3-month intravenous and oral antibiotic course and the Minerva body jacket cast was used for 3 months. Follow-up was carried out with computed tomographic scans and a cervical spine dynamogram. RESULTS: At 18 months post-surgery, the patient had completely recovered with no cervical instability. Computed tomographic scans revealed complete fusion of odontoid synchondrosis. The infant remained asymptomatic with a full range of head movement. CONCLUSION: Surgical drainage and proper immobilization appears to be a satisfactory treatment for pyogenic osteomyelitis of odontoid synchondrosis secondary to retropharyngeal abscess and atlantoaxial subluxation. LEVEL OF EVIDENCE: N/A.

Clinical Outcome and Changes of Foraminal Dimension in Patients With Foraminal Stenosis After ACDF.

STUDY DESIGN: Prospective study. OBJECTIVE: To determine the clinical outcome and change in foraminal dimension after anterior cervical discectomy and fusion (ACDF) and to investigate the correlation between clinical outcome and foraminal dimension. SUMMARY OF BACKGROUND DATA: No previous studies have evaluated the correlation between clinical outcome and foraminal dimension after ACDF in foraminal stenosis. METHODS: A consecutive series of 44 patients (114 foramina) undergoing planned ACDF due to foraminal stenosis were studied. Clinical outcomes included the neck pain visual analogue scale (VAS), arm pain VAS, neck disability index (NDI), subjective improvement rate, dysphasia, and donor site pain. Radiologic outcomes included anterior and posterior disk height, height of foramen and anterior-posterior diameter of the foramen, and the Cobb angle of the fusion segment. Foraminal dimension was calculated. RESULTS: The neck pain VAS decreased from 3.7 preoperatively to 2.3 postoperatively. Likewise, arm pain VAS decreased from 7.2 to 2.2, and NDI decreased from 31.0% to 17.2%. Mild dysphasia occurred in 3 patients. There was no donor site pain. Subjective improvement rate was 79.3%. The anterior disk height increased from 4.75 mm preoperatively to 7.01 mm postoperatively. Likewise, posterior disk height increased from 4.11 to 5.74 mm, height of foramen increased from 7.30 to 9.25 mm, anterior-posterior diameter of foramen increased from 3.56 to 4.92 mm, dimension of foramen increased from 20.50 to 35.58 mm, and segmental angle of fusion segment increased from 2.87 to 4.95 degrees. Posterior disk height was positively correlated with foraminal dimension. An increased segmental angle was negatively correlated with foraminal dimension. The foraminal dimension was negatively correlated with the arm pain VAS. CONCLUSIONS: ACDF in cervical foraminal stenosis was a useful surgical option to improve clinical outcomes and widen the foraminal dimension. The foraminal dimension was negatively correlated with the arm pain. Restoration of posterior disk height was necessary to widen the foraminal dimension, whereas increased lordosis of the fusion segment did not help to widen the foraminal dimension.

Usefulness of Noninvasive Positive-pressure Ventilation During Surgery of Flaccid Neuromuscular Scoliosis.

STUDY DESIGN: This is a retrospective study. OBJECTIVE: To assess the effects of noninvasive positive-pressure ventilation (NIPPV) through evaluations of outcomes and incidences of postoperative pulmonary complications among patients with flaccid neuromuscular scoliosis for pulmonary support in the perioperative periods. BACKGROUND DATA: There is no report on the effects of NIPPV on neuromuscular scoliosis patient during the perioperative periods. METHODS: We retrospectively reviewed 73 patients diagnosed with neuromuscular scoliosis who underwent staged anterior and posterior spinal surgery and instrumentations for deformity correction from 2003 to 2010. A total of 73 patients were divided depending on whether they had received NIPPV treatment or not during the perioperative period. Twenty-eight patients who received NIPPV for respiratory support and 45 patients with no mechanical ventilation were compared according to age, sex, body mass index, number of fusion levels, and end-tidal pressure of CO(2) and forced vital capacity values. The incidence of pulmonary complications associated with either group (pneumonia, atelectasis, pneumothorax, prolonged ventilator support, and postoperative tracheostomy) was then evaluated. RESULTS: In between the 2 groups, the forced vital capacity (41% vs. 64%, P<0.0001) were observed to be significantly decreased with the use of NIPPV. End-tidal pressure of CO(2) was not statistically different between the 2 groups. Although statistically not significant, patients in the non-NIPPV group had a higher incidence of pulmonary complications (38% vs. 21%, P=0.1584). None of the aforementioned patients required tracheostomy. In addition, no other mortality or neurological complications were noted postoperatively. CONCLUSIONS: There is a definite advantage of using NIPPV, because the incidence of postoperative pulmonary complications and the need for tracheostomy in patients with severely decreased pulmonary function are not increased from the use of NIPPV.

Prognostic factors for surgical outcomes including preoperative total knee replacement and knee osteoarthritis status in female patients with lumbar spinal stenosis.

STUDY DESIGN: A retrospective clinical case series. OBJECTIVE: To investigate knee osteoarthritis (KOA) and total knee replacement (TKR) status as prognostic factors for surgical outcomes in female patients with lumbar spinal stenosis (LSS). SUMMARY OF BACKGROUND DATA: There have been many reports on numerous prognostic factors for surgical outcomes in patients with degenerative lumbar conditions; however, there has been no report on the surgical outcome in patients who underwent spinal surgery with coexisting KOA and TKR. METHODS: This study included 141 female patients (mean age, 67.6 y) who underwent spinal surgery for LSS between January 2006 and December 2010. At 1 year postoperatively, surgical outcomes were measured using the Oswestry disability index (ODI). Various clinical factors including KOA and TKR were analyzed as prognostic factors for surgical outcomes. RESULTS: Mean average scores at preoperative evaluation were 26.1±6.6 in the no KOA group, 23.6±7.9 in the KOA group, and 30.4±6.7 in the TKR group (P<0.05). Mean average scores at postoperative 1 year were 13.8±8.5 in the no KOA group, 16.8±9.5 in the KOA group, and 21.4±5.7 in the TKR group (P<0.05, Mann-Whitney U test). Preoperative ODI scores were shown to be significantly affected by the TKR status only (P<0.05), and were significantly higher in the TKR patient group. ODI scores at postoperative 3 months were significantly correlated with the preoperative ODI and the operational level (P<0.05). At postoperative 1 year, ODI scores were shown to be affected by the operational level, the preoperative ODI, and the presence of advanced radiographic KOA (Kellgren/Lawrence grades III and IV) (P<0.05). CONCLUSIONS: A poor preoperative functional score, the presence of preoperative KOA, and longer operational levels were shown to be poor prognostic factors for the 1-year surgical outcome of LSS. Also, patients in the TKR group showed the worst ODI scores at preoperative and postoperative 1-year evaluations. Consideration of these factors when planning for spine surgery could be helpful in predicting the surgical outcomes of lumbar spinal surgery.

Herniated intervertebral disk induces hypertrophy and ossification of ligamentum flavum.

STUDY DESIGN: In vitro experiment using degenerated human ligamentum flavum (LF) and herniated intervertebral disk (IVD). OBJECTIVES: To investigate the role and effect of degenerated and herniated IVDs on LF hypertrophy and ossification. SUMMARY OF BACKGROUND DATA: Spinal stenosis is caused, in part, by hypertrophy and ossification of the LF, which are induced by aging and degenerative process. It is well known that degenerated IVDs spontaneously produce inflammatory cytokines. Therefore, we hypothesized that degenerated IVD may affect adjacent LF through secreted inflammatory cytokines. METHODS: LF and herniated lumbar IVD tissues were obtained during surgical spinal procedures. LF fibroblasts were isolated by enzymatic digestion of LF tissue. LF cell cultures were treated with disk supernatant from herniated IVDs. Secreted cytokines from IVD tissue culture were detected by enzyme-linked immunosorbent assay. After analysis of cytotoxicity, DNA synthesis was measured. Reverse transcription-polymerase chain reaction for mRNA expressions of types I, II, III, V, and XI collagen and osteocalcin, and histochemical stains were performed. RESULTS: Supernatant from tissue culture of herniated IVD showed increased production of interleukin-1α, interleukin-6, tumor necrosis factor-α, prostaglandin E2, and nitric oxide compared with disk tissue culture from traumatic condition. There was no cytotoxicity in LF cells treated with disk supernatant from herniated IVDs. There was significant increase in DNA synthesis, upregulation in mRNA expression of types III, XI collagen and osteocalcin, whereas variable expression pattern of type I and V, and strong positive stains for Von Kossa and alkaline phosphatase in LF cultures with disk supernatant. CONCLUSIONS: Degenerated and herniated IVDs provide an important pathomechanism in hypertrophy and ossification of the LF through inflammatory cytokines.

Evaluation of masticatory muscles in temporomandibular joint disorder patients using quantitative MRI fat fraction analysis-Could it be a biomarker?

Temporomandibular joint disorders (TMDs) are closely related to the masticatory muscles, but objective and quantitative methods to evaluate muscle are lacking. IDEAL-IQ, a type of chemical shift-encoded magnetic resonance imaging (CSE-MRI), can quantify the fat fraction (FF). The purpose of this study was to develop an MR IDEAL-IQ-based method for quantitative muscle diagnosis in TMD patients. A total of 65 patients who underwent 3 T MRI scans, including CSE-MRI sequences, were retrospectively included. MRI diagnoses and clinical data were reviewed. There were 19 patients in the normal group and 46 patients in the TMD group with unilateral disc displacement. The TMD group was subdivided into those with and without clenching. The right and left FF values of the masseter, medial, and lateral pterygoid muscles were measured twice by two oral radiologists on CSE-MRI, and the average value was used. FF measurements using CSE-MRI showed excellent intra- and inter-observer agreement (ICC > 0.889 for both). There were no statistically significant differences between the right and left FF values in the masseter, medial pterygoid, and lateral pterygoid of the normal group (p > 0.05). A statistically significant difference was found in the TMD group without clenching, in which the masseter muscle had a statistically significantly lower FF value on the disc displacement side (3.94 ± 1.61) than on the normal side (4.52 ± 2.24) (p < 0.05). CSE-MRI, which can reproducibly quantify muscle FF values, is expected to be a biomarker for objective muscle evaluation in TMD patients. The masseter muscle is expected to be particularly useful compared to other masticatory muscles, but further research is needed.

Image quality-based dose optimization in pediatric cone-beam computed tomography: A pilot methodological study.

Purpose: This study aimed to propose a methodological approach for reducing the radiation dose in pediatric conebeam computed tomography (CBCT), focusing exclusively on balancing image quality with dose optimization. Materials and Methods: The dose-area product (DAP) for exposure was reduced using copper-plate attenuation of an X-ray source. The thickness of copper (Cu) was increased from 0 to 2.2 mm, and 10 different DAP levels were used. The QUART DVT_AP phantom and pediatric radiologic dentiform were scanned under the respective DAP levels. The contrast-to-noise ratio (CNR), image homogeneity, and modulation transfer function (MTF) were analyzed using the QUART DVT_AP phantom. An expert evaluation (overall image grade, appropriateness of field of view, artifacts, noise, and resolution) was conducted using pediatric dentiform images. The critical DAP level was determined based on phantom and dentiform analysis results. Results: CNR and image homogeneity decreased as the DAP was reduced; however, there was an inflection point of image homogeneity at Cu 1.6 mm (DAP=138.00 mGy·cm2), where the value started increasing. The MTF showed constant values as the DAP decreased. The expert evaluation of overall image grades showed "no diagnostic value" for dentiform images with Cu 1.9-2.2 mm (DAP=78.00-103.33 mGy·cm2). The images with Cu 0-1.6 mm (DAP=138.00-1697.67 mGy·cm2) had a "good," "moderate," or "poor but interpretable" grade. Conclusion: Reducing DAP beyond a 1.6-mm Cu thickness degraded CBCT image quality. Image homogeneity and clinical image grades indicated crucial decision points for DAP reduction in pediatric CBCT scans.

Accelerated fusion dynamics by recombinant human bone morphogenetic protein-2 following transforaminal lumbar interbody fusion, particularly in osteoporotic conditions.

BACKGROUND CONTEXT: Early fusion is crucial in interbody procedures to minimize mechanical complications resulting from delayed union, especially for patients with osteoporosis. Bone morphogenetic proteins (BMPs) are used in spinal fusion procedures; however, limited evaluation exists regarding time-to-fusion for BMP use, particularly in patients with osteoporosis. PURPOSE: To evaluate the difference in time-to-fusion after single-level transforaminal lumbar interbody fusion (TLIF) surgery between recombinant human bone morphogenetic protein-2 (rhBMP-2) usage and nonusage groups according to bone density. STUDY DESIGN: Retrospective single-center cohort study. PATIENT SAMPLE: This study enrolled 132 patients (mean age, 65.25±8.66; male patients, 40.9%) who underwent single-level TLIF for degenerative disorders between February 2012 and December 2021, with pre and postoperative computed tomography (CT). OUTCOME MEASURE: The interbody fusion mass and bone graft status on postoperative CT scans was obtained annually, and time-to-fusion was recorded for each patient. METHODS: The patients were divided into 2 groups based on rhBMP-2 use during the interbody fusion procedure. Patients were further divided into osteoporosis, osteopenia, and normal groups based on preoperative L1 vertebral body attenuation values, using cutoffs of 90 and 120 Hounsfield units. It was strictly defined that fusion is considered complete when a trabecular bone bridge was formed, and therefore, the time-to-fusion was measured in years. Time-to-fusion was statistically compared between BMP group and non-BMP groups, followed by further comparison according to bone density. RESULTS: The time-to-fusion differed significantly between BMP and non-BMP groups, with half of the patients achieving fusion within 2.5 years in the BMP group compared with 4 years in the non-BMP group (p<.001). The fusion rate varied based on bone density, with the maximum difference observed in the osteoporosis group, when half of the patients achieved fusion within 3 years in the BMP group compared to 5 years in the non-BMP group (p<.001). Subgroup analysis was conducted, revealing no significant associations between time-to-fusion and factors known to influence the fusion process, including age, gender, medical history, smoking and alcohol use, and medication history, except for rh-BMP2 use and bone density. CONCLUSIONS: RhBMP-2 usage significantly reduced time-to-fusion in single-level TLIF, especially in patients with osteoporosis. LEVEL OF EVIDENCE: Level III.

Association of Untreated Pre-surgical Depression With Pain and Outcomes After Spinal Surgery.

STUDY DESIGN: Prospective Cohort Study. OBJECTIVE: Untreated pre-surgical depression may prolong post-surgical pain and hinder recovery. However, research on the impact of untreated pre-surgical depression on post-spinal surgery pain is lacking. Therefore, this study aimed to assess pre-surgical depression in patients and analyze its relationship with post-surgical pain and overall post-surgical outcomes. METHODS: We recruited 100 patients scheduled for lumbar spine surgery due to spondylolisthesis, degenerative lumbar disc diseases, and herniated lumbar disc diseases. Psychiatrists evaluated them for the final selection. We assessed the Beck Depression Inventory (BDI), Japanese Orthopaedic Association (JOA), Oswestry Disability Index (ODI), and EuroQoL 5 Dimensions (EQ-5D) scores, numerical back and leg pain scales, and medication dosage data collected before and at 6 weeks, 3 months, and 6 months after surgery. RESULTS: Ninety-one patients were included in this study; 40 and 51 were allocated to the control and depression groups, respectively. The pre- and post-surgical leg pain, back pain, and functional scores were not different. However, the depression group showed higher ODI and EQ-5D and lower JOA scores than the control group 3 months post-surgery. Partial correlation analysis revealed an inverse correlation between the JOA and BDI scores and a positive correlation between the EQ-5D and BDI scores at 3 months postoperatively. CONCLUSION: Untreated depression can prolong postoperative pain and hinder recovery. Detecting and treating depression in patients before spine surgery may improve their overall quality of life and functional recovery.

Sacroiliac Joint Degeneration After Lumbar or Lumbosacral Fusion Surgery-A Comparative Study of the Number of Fused Segments and Sacral Fusion.

OBJECTIVE: In this study, we aimed to investigate whether multi-segment fusion or fusion-to-sacrum increases sacroiliac joint (SIJ) pathology compared with single-segment fusion or a non-fused sacrum. METHODS: This study included 116 patients who underwent lumbar or lumbosacral fusion and were followed up for 2 years. The patients were classified into single-segment fusion (n = 46) and multi-segment fusion (more than two levels, n = 70) groups and then reclassified into the non-fused sacrum (n = 68) and fusion-to-sacrum groups (n = 48). Preoperative and postoperative radiographs were used to evaluate radiographic parameters, and computed tomography (CT) was used to evaluate SIJ degeneration. Low back pain (LBP) was assessed using a visual analog scale (VAS, 0-10). Baseline and postoperative values were compared using a paired sample t-test. RESULTS: LBP VAS scores significantly differed at 6 months (single-segment fusion, 3.04±1.88; multi-segment fusion, 4.83±2.33; P < 0.001) and 2 years postoperatively (single-segment fusion, 3.3±2.2; multi-segment fusion, 4.78±2.59; P = 0.094). There was no significant difference in SIJ degeneration, as assessed by CT scan, between the 2 surgical groups: 14 (30%) and 19 (27%) patients in the single-segment and multi-segment (P = 0.701) fusion groups, respectively. The LBP VAS scale showed comparable differences at 1 (non-fused sacrum, 3±2.18; fusion-to-sacrum, 3.74±2.28; P = 0.090) and 2 years postoperatively (non-fused sacrum, 3.29±2.01; fusion-to-sacrum, 4.66±2.71; P = 0.095). CT scan revealed that 18 (26%) and 15 (31%) patients in the non-fused sacrum and fusion-to-sacrum groups, respectively, developed SIJ arthritis; however, there was no significant intergroup difference (P = 0.574). CONCLUSIONS: SIJ degeneration occurs independent of the number of fused segments or sacrum involvement.

Long-Term Incidence of Adjacent Segmental Pathology After Minimally Invasive vs. Open Transforaminal Lumbar Interbody Fusion.

STUDY DESIGN: Retrospective cohort study. OBJECTIVE: To compare the incidence of adjacent segmental pathology (ASP) following minimally invasive (MI) vs open transforaminal lumbar interbody fusion (TLIF) and to identify factors linked to ASP requiring reoperation. METHODS: This retrospective study reviewed the outcomes of patients who underwent MI-TLIF or open TLIF. Radiographic ASP (RASP) was evaluated using X-ray imaging to distinguish between degenerative changes, spondylolisthesis, and instability in the adjacent spinal segment. Clinical ASP (CASP) was assessed with the visual analog scale score for leg and back pain and the Oswestry disability index. Patient data were collected 1, 2, 5, and 10 years postoperatively. The timing and frequency of ASP reoperation were analyzed. RESULTS: Five years postoperatively, the RASP rate was 35.23% and 45.95% in the MI-TLIF and open TLIF groups. The frequency of CASP differed significantly between the MI-TLIF and open TLIF groups at 1 year postoperatively. The rates of RASP, CASP, and ASP necessitating reoperation were not significantly different 10 years postoperatively. Cranial facet violation significantly affected ASP in both groups. In the open TLIF group, preoperative adjacent segment disc degeneration significantly influenced ASP. CONCLUSION: The RASP rate at 5 years postoperatively and the CASP rate at 1 year postoperatively differed significantly between groups. There was no difference in the rate of ASP requiring reoperation. Cranial facet violation is a crucial driving factor for ASP after both surgical procedures.

Risk Factors and Characteristics of In-Hospital Falls After Spine Surgery: A Retrospective, Single-Center Cohort Study in the Republic of Korea.

Background: Falls after orthopaedic surgery can cause serious injuries, which lengthen hospital stays and increase medical expenses. This has prompted hospitals to implement various fall-prevention protocols. The aims of this study were to determine the incidence of in-hospital falls after spine surgery, to analyze the overall risk factors, to discern factors that have a major influence on falls, and to evaluate the effectiveness of the fall-prevention protocol that we implemented. Methods: This was a retrospective, single-center study including patients who underwent spine surgery from January 2011 to November 2021 at the National Health Insurance Service Ilsan Hospital (NHISIH) in Goyang, Republic of Korea. Reported falls among these patients were examined. Patient demographics; surgery type, date, and diagnosis; and fall date and time were evaluated. Results: Overall, 5,317 spine surgeries were performed, and 128 in-hospital falls were reported (overall incidence: 2.31%). From the multivariable analyses, older age and American Society of Anesthesiologists (ASA) score were identified as independent risk factors for in-hospital patient falls (multivariable adjusted hazard ratio [aHR] for age 70 to 79 years, 1.021 [95% confidence interval (CI), 1.01 to 1.031]; for age ≥80 years, 1.035 [1.01 to 1.06]; and for ASA score of 3, 1.02 [1.01 to 1.031]). Similar results were seen in the subgroup who underwent primary surgery. Within 2 weeks following surgery, the highest frequency of falls occurred at 3 to 7 days postoperatively. The lowest fall rate was observed in the evening (6 to 10 p.m.). Morbidities, including rib, spine, and extremity fractures, were recorded for 14 patients, but none of these patients underwent operative treatment related to the fall. The NHISIH implemented a comprehensive nursing care service in May 2015 and a fall protocol in May 2017, but the annual incidence rate did not improve. The fall rate was higher after thoracolumbar surgeries (2.47%) than after cervical surgeries (1.20%). Moreover, a higher fall rate was observed in thoracolumbar cases with a greater number of fusion levels and revision spine surgeries. Conclusions: Patients with advanced age, more comorbidities, a greater number of fusion levels, and revision surgeries and who are female are more vulnerable to in-hospital falls after spine surgery. Novel strategies that target these risk factors are warranted. Level of Evidence: Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Proximity Between Screw and Endplate of Upper Instrumented Vertebra Using a Cortical Bone Trajectory Screw can Increase Radiographic Adjacent Segment Degeneration Risks in Patients With Lumbar Spinal Stenosis.

STUDY DESIGN: Retrospective observational study. OBJECTIVE: To determine the proximity between screw and endplate of the upper instrumented vertebra (UIV) using a cortical bone trajectory (CBT) screw as a predictive factor for radiographic adjacent segment degeneration (ASD) in patients surgically treated with transforaminal lumbar interbody fusion (TLIF) with CBT screws (CBT-TLIF) with lumbar spinal stenosis. SUMMARY OF BACKGROUND DATA: The risk factors for radiographic ASD after CBT-TLIF remain unknown. METHODS: Among patients surgically treated with CBT-TLIF at a single institute, 239 consecutive patients (80 males and 159 females) were enrolled. ASD was defined by the presence of one or more of the following three radiologic criteria on the adjacent segment: >3 mm anteroposterior translation, >10° segmental kyphosis, or >50% loss of disc height comparing immediate postoperative and 1-year follow-up radiographs. Clinical and radiological features associated with the development of ASD were retrospectively measured. Univariate and multivariate analyses were performed to identify risk factors associated with radiographic ASD. RESULTS: Radiographic ASD was observed in 71 (29.7%) cases at 1-year postoperative follow-up. The preoperative Pfirrmann grade of the adjacent segment (>grade 2), multi-level fusion (>2 levels), and proximity between the tip of CBT screws and endplate on the UIV were significantly associated with radiographic ASD (OR = 3.98, 95% CI [1.06-15.05], P=0.042 versus OR = 3.03, 95% CI [1.00-9.14], P=0.049 versus OR = 0.53, 95% CI [0.40-0.72], P<0.001). The cut-off value of the distance between the tip of the screw and endplate on UIV for radiographic ASD was approximately 2.5 mm (right-sided CBT screw; cut-off value 2.48 mm/ left-sided CBT screw; cut-off value 2.465 mm). CONCLUSION: Radiographic adjacent segment degeneration progression can occur when the cortical trajectory bone screw is close to the endplate of the upper instrumented vertebrae in patients with lumbar spinal stenosis undergoing fusion surgery.

Association of Functional Gastrointestinal Disorders with Adolescent Idiopathic Scoliosis.

Numerous adolescents diagnosed with adolescent idiopathic scoliosis (AIS) often manifest symptoms indicative of functional gastrointestinal disorders (FGIDs). However, the precise connection between FGIDs and AIS remains unclear. The study involved adolescents drawn from sample datasets provided by the Korean Health Insurance Review and Assessment Service spanning from 2012 to 2016, with a median dataset size of 1,446,632 patients. The AIS group consisted of individuals aged 10 to 19 with diagnostic codes for AIS, while the control group consisted of those without AIS diagnostic codes. The median prevalence of FGIDs in adolescents with AIS from 2012 to 2016 was 24%. When accounting for confounding factors, the analysis revealed that adolescents with AIS were consistently more prone to experiencing FGIDs each year (2012: adjusted odds ratio (aOR), 1.21 [95% confidence interval (CI), 1.10-1.35], p < 0.001; 2013: aOR, 1.31 [95% CI, 1.18-1.46], p < 0.001; 2014: aOR, 1.24 [95% CI, 1.12-1.38], p < 0.001; 2015: aOR, 1.34 [95% CI, 1.21-1.49], p < 0.001; and 2016: aOR, 1.35 [95% CI, 1.21-1.50], p < 0.001). These findings suggest that AIS is correlated with an elevated likelihood of FGIDs, indicating that AIS may function as a potential risk factor for these gastrointestinal issues. Consequently, it is recommended to provide counseling to adolescents with AIS, alerting them to the heightened probability of experiencing chronic gastrointestinal symptoms.