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Background Massive blood loss is a major complication of posterior instrumented thoracolumbar surgery for adult spinal deformities. The use of flowable and absorbable hemostatic products, such as SURGIFLO ® Hemostatic Matrix (SURGIFLO; ETHICON, Inc., Raritan, NJ, US), has become feasible for spinal surgery. Hence, a retrospective observational study was conducted to evaluate the efficacy of SURGIFLO during posterior instrumented thoracolumbar spinal surgery for an adult spinal deformity. Methods This analysis included 36 consecutive patients who underwent posterior instrumented thoracolumbar spinal surgery for an adult spinal deformity at our hospital from 2018 to 2022. Patients were divided into two groups: 19 who received SURGIFLO after March 2020 (Group S) and 17 who did not receive SURGIFLO before March 2020 (Group C). Operation time, intraoperative blood loss, postoperative blood loss (calculated from the suction drain until the next morning), and the number of perioperative blood transfusions were investigated. Results No significant differences were found between groups in terms of the number of fusion levels, osteotomy grades, and average operative times. However, Group S showed significantly less intraoperative blood loss per intervertebral level compared with Group C (p=0.023). Although the amount of concentrated red cells used did not differ significantly between groups, Group S required significantly less perioperative fresh frozen plasma than Group C (p=0.021). Conclusion In patients with an adult spinal deformity undergoing posterior instrumented spinal surgery from the thorax to the pelvis, utilization of SURGIFLO Hemostatic Matrix reduced intraoperative blood loss and the perioperative use of fresh frozen plasma., Competing Interests: Human subjects: Consent for treatment and open access publication was obtained or waived by all participants in this study. Tsukuba Clinical Research & Development Organization issued approval R06-110. Animal subjects: All authors have confirmed that this study did not involve animal subjects or tissue. Conflicts of interest: In compliance with the ICMJE uniform disclosure form, all authors declare the following: Payment/services info: All authors have declared that no financial support was received from any organization for the submitted work. Financial relationships: All authors have declared that they have no financial relationships at present or within the previous three years with any organizations that might have an interest in the submitted work. Other relationships: All authors have declared that there are no other relationships or activities that could appear to have influenced the submitted work., (Copyright © 2025, Takahashi et al.)

Although neurovascular structures, including the superior gluteal artery, sciatic nerve, obturator nerve, internal iliac vein and artery, and lumbosacral plexus, are at risk when S2 alar-iliac (S2AI) screws are used, no cases of nerve injuries have been reported. An 84-year-old man was referred to our institute with persistent left sciatica for seven months after undergoing salvage surgery using S2AI screws for deep surgical site infection from a previous posterior interbody fusion surgery at L5-S1. Based on the radiographic and diagnostic selective nerve root block findings, a diagnosis of left L5 radiculopathy was suspected due to the left S2AI screw being caudally misplaced and severely protruding into the pelvic cavity. The patient underwent surgical replacement of the left S2AI screw. The patient was discharged eight days postoperatively, with a resolution of the left leg pain. At the three-month follow-up, no recurrent pain was reported. To the best of our knowledge, this is the first reported case of a misplaced S2AI screw causing L5 spinal nerve injury. If the screw is inserted caudally and deviates into the pelvic cavity, in front of the sacroiliac joint, the L5 nerve running in this region may be damaged., Competing Interests: Human subjects: Consent was obtained or waived by all participants in this study. Conflicts of interest: In compliance with the ICMJE uniform disclosure form, all authors declare the following: Payment/services info: All authors have declared that no financial support was received from any organization for the submitted work. Financial relationships: All authors have declared that they have no financial relationships at present or within the previous three years with any organizations that might have an interest in the submitted work. Other relationships: All authors have declared that there are no other relationships or activities that could appear to have influenced the submitted work., (Copyright © 2024, Funayama et al.)

Spondylolysis with pseudarthrosis may be treated surgically by repairing the spondylolysis using the smiley face rod (SFR) technique. The SFR technique can avoid adjacent segmental disease caused by transforaminal lumbar interbody fusion (TLIF), which is one of the main surgical techniques to treat isthmic lumbar spondylolisthesis. A 59-year-old woman had been playing softball since she was 12 years old and was a member of a prefectural representative team. She sought treatment because of numbness in her left lower limb and difficulty playing softball. Despite conservative treatment for a year, her symptoms did not improve. Physical examination revealed decreased patellar tendon reflexes and numbness and pain from the front of the thigh to the lower leg without muscle weakness. Imaging showed L4 isthmic spondylolisthesis with Meyerding classification grade 2 anterior slip and L5 spondylolysis with pseudarthrosis. We diagnosed L4 radiculopathy caused by L4/5 foraminal stenosis and L4 isthmic spondylolisthesis with L5 spondylolysis. She underwent surgery combining the TLIF of L4/5 and the SFR technique of L5 using dual-headed pedicle screws that can fix two types of rods with L5 pedicle screws. Three months after surgery, fusion between L4/5 and fusion of the L5 pars cleft were confirmed. She resumed sports, and one year postoperatively, she was able to participate in softball games. Two years postoperatively, she could bat, run, and play defense without adjacent segmental disease. Two-segment TLIF increases adjacent segmental disease more than single-segment TLIF. Because the L5 spondylolysis had not slipped, we chose the SFR technique to preserve mobility at L5/S1. The dual-headed pedicle screw fastens two-type rods at the head of the pedicle screw, making it a suitable design for this procedure., Competing Interests: The authors have declared that no competing interests exist., (Copyright © 2024, Tatsumura et al.)

Introduction This research aimed to explore the relationship between spinal characteristics and the length of the abdominal aorta in adult spinal deformity (ASD) patients who underwent corrective spinal surgery. We hypothesized that adjusting spinal alignment might affect the abdominal aorta's length. Methods This study included thirteen patients with ASD (average age: 63.0 ± 8.9 years; four males and nine females) who received spinal correction surgery. We measured both pre-operative and post-operative spinal parameters, including thoracolumbar kyphosis (TLK), and calculated their differences (Δ). The length of the aorta (AoL) was determined using an automated process that measures the central luminal line from the celiac artery's bifurcation to the inferior mesenteric artery. This measurement was made using contrast-enhanced computed tomography for three-dimensional aortic reconstruction. We compared the pre-operative and post-operative AoLs and their differences (Δ). The study examined the correlation between changes in spinal parameters and changes in AoL. Results Post-operatively, there was an increase in aortic length (ΔAoL: 4.2 ± 4.9 mm). There was a negative correlation between the change in TLK and the change in AoL (R 2 = 0.45, p = 0.012, β = -0.21). No significant correlations were found with other spinal parameters. Conclusions The abdominal aorta can elongate by 4.8% after spinal corrective surgery in patients with ASD. The degree of elongation of the abdominal aorta is associated with spinal alignment correction., Competing Interests: The authors have declared that no competing interests exist., (Copyright © 2024, Ohyama et al.)

We report a case of vertebral fracture in a patient with rod fractures after adult spinal deformity surgery, which occurred at the same level as the rod fractures, even though intervertebral bone fusion in the fusion range had been achieved. A 77-year-old female underwent corrective spinal surgery for adult spinal deformity from T12 to the pelvis but had a subsequent uppermost instrumented vertebral fracture, resulting in pseudarthrosis and severe kyphosis. The patient underwent proximal fusion extension to the T4, which improved alignment. A right-sided rod fracture at the lumbosacral junction occurred after 18 months; however, it showed no symptoms. After a month, the patient experienced severe low back pain with left leg pain and was diagnosed with bilateral rod fractures associated with L5 hyperextension vertebral fracture. The patient underwent revision surgery to repair the fractured rods with a multiple-rod construct. Rod fractures can occur even when bone fusion is achieved within the fusion range. When rod fractures are detected at the lumbosacral junction even if the interbody fusion was achieved, a hyperextension vertebral fracture may occur., Competing Interests: The authors have declared that no competing interests exist., (Copyright © 2023, Okuwaki et al.)

Rectangular endcap expandable cages are common in anterior thoracolumbar spine restoration. However, the cage is often too large to place in small, elderly women. In this study, we evaluated a method to place a round endcap expandable cage on the vertebral ring apophysis in elderly women. From April 2017 to August 2020, five women (mean age 75.8 years) underwent anterior-posterior spinal fusion with a round endcap expandable cage on the vertebral ring apophysis at the thoracolumbar junction. The local kyphotic angle, coronal Cobb angle, and intervertebral height were evaluated pre-and postoperatively. Cage subsidence and bone union were evaluated. The mean local kyphotic angle, coronal Cobb angle, and intervertebral height before surgery were 35.2°, 10.0°, and 65.3 mm, respectively. Immediately postoperatively, 1 week and 3 weeks after surgery, the kyphotic angle was 13.4°, 16.6°, and 18.5°; coronal Cobb angle was 2.8°, 2.2°, and 4.3°; and intervertebral height was 76.2 mm, 71.8 mm, and 70.6 mm. Cage subsidence was not observed and the bone union was achieved in all cases. An expandable cage with a round endcap was placed in small, elderly women by inserting the cage over the strong apophysis of the vertebral body. This technique may be useful to reduce the risk of postoperative subsidence and correction loss., Competing Interests: The authors have declared that no competing interests exist., (Copyright © 2022, Okuwaki et al.)

Objectives The objective of this study was to verify the usefulness of magnetic resonance imaging (MRI) with axial traction of the thumb for observing articular cartilage. Materials and methods Eleven healthy adult volunteers (39.7 ± 7.4 years) without thumb carpometacarpal joint arthritis or trauma were included in this study. A 3-tesla (3T) MRI (Magnetom Skyra, Siemens Healthineers AG, Munich, Germany) of the right thumb with axial traction applied by a finger trap with three traction weights (0, 2, and 5 kg) was performed. A 3D T2* multiecho data imaging combination (MEDIC) was selected to visualize the articular cartilage. After multiplanar reconstruction, sagittal and coronal images of the thumb carpometacarpal joint were used to evaluate the articular cartilage visibility and joint space widths at five locations. Articular cartilage visibility was evaluated using our original classification method that used the percentage of the cartilage detectable area. The Friedman test was used to compare the differences between each traction weight and location. Results Articular cartilage visibility significantly improved with axial traction. The average joint space widths with the 5-kg application were 1.9 ± 0.8, 3.9 ± 0.6, 2.0 ± 0.9, 3.9 ± 1.1, and 2.5 ± 1.4 mm at the center, volar edge, dorsal edge, radial edge, and ulnar edge, respectively. The joint space widths significantly increased proportionally with the traction weight at all locations. The joint space widths at the volar and radial edges were significantly greater than those at other locations. Conclusion Applying axial traction to the thumb increased the joint space widths and improved the visibility of the articular cartilage in the carpometacarpal joint on MRI., Competing Interests: The authors have declared that no competing interests exist., (Copyright © 2022, Ikumi et al.)

Lumbar spondylolysis is a fatigue fracture that occurs most frequently in middle and high school athletes. Conservative treatment is the first choice when the fracture is fresh. Surgical treatment of lumbar spondylolysis is often reported for pseudarthrosis cases, but surgery for cases of fresh fractures is rare. We report a case of a 16-year-old male, high jump athlete, with recurrent non-pseudoarthorotic lumbar spondylolysis. He presented to our hospital with a chief complaint of back pain, and was diagnosed as right L5, pre-lysis-stage lumbar spondylolysis. After 3 months of conservative treatment, bone union was achieved with no obvious worsening of the fracture. His back pain also disappeared and he was able to return to exercise. At 6 months after the first examination, the lesion recurred and he could no longer continue playing sports, so surgical treatment was indicated. Minimally invasive screw fixation was performed by combining Buck's method and the cortical bone trajectory. After the surgery, he started jogging at 5 weeks, resumed jumping practice at 7 weeks, and returned to competition at 2 months. He set a new personal best in a competition 3 months post-surgery. Bone union was achieved at 4 months. This technique is minimally invasive and does not involve debridement or bone grafting, which provides early pain relief and return to sports., Competing Interests: The authors have declared that no competing interests exist., (Copyright © 2021, Gamada et al.)