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Background: The extension of healthy life expectancy has become increasingly important because of rising health-care costs and decreases in the quality of life in the elderly population. Although reports have surfaced on an association between sagittal spinal alignment and physical performance, such studies on the healthy population are limited. This study investigated the relationship between sagittal spinal alignment and physical function in the general elderly population.Methods: Registered citizens who were 50 to 89 years of age were targeted for this survey. We established 8 groups based on age (50 to 59 years, 60 to 69 years, 70 to 79 years, and 80 to 89 years) and sex (male and female) after random sampling from the resident registry of the town of Obuse in 2014. A total of 412 people (203 male and 209 female) were enrolled for the measurement and analysis of radiographic parameters of sagittal spinal alignment and physical performance tests.Results: Physical function score values decreased with age, with moderate to strong correlations. Within age subgroups, worsened spinal alignment in standing whole-spinal radiographs indicated diminished physical performance results. The impact of the sagittal vertical axis was especially prominent; as the sagittal vertical axis was shifted forward by 1 standard deviation, 1-leg standing time became shortened by 3.8 seconds. Two-step scores were significantly associated with sagittal vertical axis, global tilt, cervical sagittal vertical axis, and pelvic tilt.Conclusions: Our investigation of sagittal spinal alignment on physical function in a Japanese elderly cohort revealed significant negative correlations between spinal alignment and physical performance after excluding the influence of age and sex. Posture change in the community-dwelling elderly population is an important sign of physical function impairment.Level Of Evidence: Prognostic Level IV. See Instructions for Authors for a complete description of levels of evidence. [ABSTRACT FROM AUTHOR]

Background: The tibial tubercle deviation associated with recurrent patellar dislocation (RPD) has not been studied sufficiently. New methods of evaluation were used to verify the extent of tubercle deviation in a group with patellar dislocation compared with that in a control group, the frequency of patients who demonstrated a cutoff value indicating that tubercle transfer was warranted on the basis of the control group distribution, and the validity of these methods of evaluation for diagnosing RPD.Methods: Sixty-six patients with a history of patellar dislocation (single in 19 [SPD group] and recurrent in 47 [RPD group]) and 66 age and sex-matched controls were analyzed with the use of computed tomography (CT). The tibial tubercle-posterior cruciate ligament (TT-PCL) distance, TT-PCL ratio, and tibial tubercle lateralization (TTL) in the SPD and RPD groups were compared with those in the control group. Cutoff values to warrant 10 mm of transfer were based on either the minimum or -2SD (2 standard deviations below the mean) value in the control group, and the prevalences of patients in the RPD group with measurements above these cutoff values were calculated. The area under the curve (AUC) in receiver operating characteristic (ROC) curve analysis was used to assess the effectiveness of the measurements as predictors of RPD.Results: The mean TT-PCL distance, TT-PCL ratio, and TTL were all significantly greater in the RPD group than in the control group. The numbers of patients in the RPD group who satisfied the cutoff criteria when they were based on the minimum TT-PCL distance, TT-PCL ratio, and TTL in the control group were 11 (23%), 7 (15%), and 6 (13%), respectively. When the cutoff values were based on the -2SD values in the control group, the numbers of patients were 8 (17%), 6 (13%), and 0, respectively. The AUC of the ROC curve for TT-PCL distance, TT-PCL ratio, and TTL was 0.66, 0.72, and 0.72, respectively.Conclusions: The extent of TTL in the RPD group was not substantial, and the percentages of patients for whom 10 mm of medial transfer was indicated were small.Level Of Evidence: Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence. [ABSTRACT FROM AUTHOR]

Study Design: Retrospective observational study OBJECTIVE.: To clarify the efficacy of recombinant human erythropoietin-beta (EPO-beta) injections during autologous blood donation (ABD) before spinal deformity surgery in children and teenagers.Summary Of Background Data: ABD is preferred for spinal deformity surgery. A few studies have assessed the usefulness of preoperative ABD with EPO-beta in anemic patients.Methods: Fifty-six spinal deformity surgery patients (41 females, 15 males; median age: 15 yrs; range, 5-19 yrs) underwent preoperative ABD. ABD was performed weekly according to the patient's body weight with a subcutaneous EPO-beta injection (24,000 U). The collected blood volumes were compared among the low hemoglobin (low-Hb) (<13 g/dL), mid-Hb (13-13.9 g/dL), and high-Hb (≥14 g/dL) groups using the Kruskal-Wallis test. The effects of EPO-beta injection on the Hb levels were estimated using a linear mixed model.Results: The patients underwent a median of four ABD collections (range, two to six). The median collected volume per ABD was 200 mL (range, 40-400 mL). The median total blood collection was 700 mL (range, 160-1,350 mL); the corresponding values were 700 mL, 700 mL, and 800 mL in the low-Hb, mid-Hb, and high-Hb groups, respectively (P = 0.964). The median blood loss was 500 mL (range, 10-2,940 mL); 53 out of 55 patients (96%) did not require unplanned allogeneic transfusion, including 11 out of 12 (92%) cases with blood loss >1,000 mL. The additional recovery of Hb levels with one EPO-beta injection was 0.29 ± 0.14 g/dL (P = 0.039) after adjusting for confounding factors.Conclusion: ABD with an EPO-beta injection is useful for avoiding allogeneic transfusion during spinal deformity surgery in children and teenagers, and patients in the low-Hb group achieved ABD volumes equivalent to those in the high-Hb group. Thus, an additional recovery of Hb levels of 0.29 g/dL per injection can be expected after 1 week.Level Of Evidence: 4. [ABSTRACT FROM AUTHOR]

STUDY DESIGN: Retrospective analysis. OBJECTIVE: To test the hypothesis that preoperative spinal cord damage affects postoperative segmental motor paralysis (SMP). SUMMARY OF BACKGROUND DATA: SMP is an enigmatic complication after cervical decompression surgery. The cause of this complication remains controversial. We particularly focused on preoperative T2-weighted high signal change (T2HSC) on magnetic resonance imaging in the spinal cord, and assessed the influence of preoperative T2HSC on SMP after cervical decompression surgery. METHODS: A retrospective review of 181 consecutive patients (130 males and 51 females) who underwent cervical decompression surgery was conducted. SMP was defined as development of postoperative motor palsy of the upper extremities by at least 1 grade in manual muscle testing without impairment of the lower extremities. The relationship between the locations of T2HSC in preoperative magnetic resonance imaging and SMP and Japanese Orthopedic Association score was investigated. RESULTS: Preoperative T2HSC was detected in 78% (142/181) of the patients. SMP occurred in 9% (17/181) of the patients. Preoperative T2HSC was not a significant risk factor for the occurrence of SMP (P = 0.682). However, T2HSC significantly influenced the severity of SMP: the number of paralyzed segments increased with an incidence rate ratio of 2.2 (P = 0.026), the manual muscle score deteriorated with an odds ratio of 8.4 (P = 0.032), and the recovery period was extended with a hazard ratio of 4.0 (P = 0.035). In patients with preoperative T2HSC, Japanese Orthopaedic Association scores remained lower than those in patients without T2HSC throughout the entire period including pre- and postoperative periods (P < 0.001). CONCLUSION: Preoperative T2HSC was associated with worse severity of SMP in patients who underwent cervical decompression surgery, suggesting that preoperative spinal cord damage is one of the pathomechanisms of SMP after cervical decompression surgery.Level of Evidence: 3. [ABSTRACT FROM AUTHOR]

Study Design: Retrospective cohort study with interrupted time series analysis., Objective: To examine the clinical effectiveness of gelatin-thrombin matrix sealant (GTMS) on blood loss reduction after adolescent idiopathic scoliosis (AIS) surgery., Summary of Background Data: The real-world effectiveness of GTMS on blood loss reduction in AIS surgery has not been determined., Patients and Methods: The medical records of patients receiving AIS surgery were retrospectively collected during a period before GTMS approval at our institution (January 22, 2010-January 21, 2015) as well as during a postintroduction period (January 22, 2015-January 22, 2020). The primary outcomes were intraoperative blood loss, drain output over 24 hours, and total blood loss (intraoperative blood loss + drain output over 24 h). Interrupted time series analysis using a segmented linear regression model was used to estimate the effect of GTMS on blood loss reduction., Results: A total of 179 AIS patients [mean age (range): 15.4 (11-30) yr; 159 females and 20 males; 63 preintroduction patients and 116 postintroduction patients] were included. After its introduction, GTMS was used in 40% of cases. Interrupted time series analysis revealed changes of -340 mL (95% CI: -649 to -31, P = 0.03) for intraoperative blood loss, -35 mL (95% CI: -124 to 55, P = 0.44) for drain output over 24 hours, and -375 mL (95% CI: -698 to -51, P = 0.02) for total blood loss., Conclusions: The availability of GTMS was significantly associated with reduced intraoperative and total blood loss in AIS surgery. GTMS use as needed is recommended to control intraoperative bleeding in the setting of AIS surgery., Level of Evidence: 3., Competing Interests: The authors report no conflicts of interest., (Copyright © 2023 Wolters Kluwer Health, Inc. All rights reserved.)

A retrospective multicenter study. Body mass index (BMI) is recognized as an important determinant of osteoporosis and spinal postoperative outcomes; however, the specific impact of BMI on surgery for osteoporotic vertebral fractures (OVFs) remains inconclusive. This retrospective multicenter study investigated the impact of BMI on clinical outcomes following fusion surgery for OVFs. 237 OVF patients (mean age, 74.3 years; 48 men and 189 women) with neurological symptoms who underwent spinal fusion were included in this study. Patients were grouped by World Health Organization BMI categories: low BMI (<18.5 kg/m2), normal BMI (≥18.5 and <25 kg/m2), and high BMI (≥25 kg/m2). Patients' backgrounds, surgical method, radiological findings, pain measurements, activities of daily living (ADL), and postoperative complications were compared after a mean follow-up period of 4 years. As results, the proportion of patients able to walk independently was significantly smaller in the low BMI group (75.0%) compared with the normal BMI group (89.9%; P = .01) and the high BMI group (94.3%; P = .04). Improvement in the visual analogue scale for leg pain was significantly less in the low BMI group than the high BMI group (26.7 vs 42.8 mm; P = .046). Radiological evaluation, the Frankel classification, and postoperative complications were not significantly different among all 3 groups. Improvement of pain intensity and ADL in the high BMI group was equivalent or non-significantly better for some outcome measures compared with the normal BMI group. Leg pain and independent walking ability after fusion surgery for patients with OVFs improved less in the low versus the high BMI group. Surgeons may want to carefully evaluate at risk low BMI patients before fusion surgery for OVF because poor clinical results may occur., Competing Interests: The authors have no funding and conflicts of interest to disclose., (Copyright © 2022 the Author(s). Published by Wolters Kluwer Health, Inc.)

Abstract: Recently, activities of daily living (ADL) were identified as a prognostic factor among elderly patients with heart disease; however, a specific association between ADL and prognosis after cardiac and aortic surgery is not well established. We aimed to clarify the impact of ADL capacity at discharge on prognosis in elderly patients after cardiac and aortic surgery.This retrospective cohort study included 171 elderly patients who underwent open operation for cardiovascular disease in a single center (median age: 74 years; men: 70%). We used the Barthel Index (BI) as an indicator for ADL. Patients were classified into 2 groups according to the BI at discharge, indicating a high (BI ≥ 85) or low (BI < 85) ADL status. All-cause mortality and unplanned readmission events were observed after discharge.Thirteen all-cause mortality and 44 all-cause unplanned readmission events occurred during the median follow-up of 365 days. Using Kaplan-Meier analysis, a low ADL status was determined to be significantly associated with all-cause mortality and unplanned readmission. In the multivariable Cox proportional hazard models, a low ADL status was an independent predictor of all-cause mortality and unplanned readmission after adjusting for age, sex, length of hospital stay, and other variables (including preoperative status, surgical parameter, and postoperative course).A low ADL status at discharge predicted all-cause mortality and unplanned readmission in elderly patients after cardiac and aortic surgery. A comprehensive approach from the time of admission to postdischarge to improve ADL capacity in elderly patients undergoing cardiac and aortic surgery may improve patient outcomes., Competing Interests: The authors have no conflicts of interest to disclose., (Copyright © 2021 the Author(s). Published by Wolters Kluwer Health, Inc.)

Abstract: No guidelines have been established for the evaluation of swallowing function following extubation. The factors of bedside swallowing evaluations (BSEs) that are associated with the development of pneumonia have not been fully elucidated. This study aimed to retrospectively investigate the most appropriate measurements of BSEs for predicting pneumonia.The study subjects were 97 adults who underwent BSEs following cardiovascular surgery. Patients were divided into the pneumonia onset group (n = 21) and the non-onset group (n = 76). Patient characteristics, intraoperative characteristics, complications, BSE results, and postoperative progress were compared between the groups. BSEs were composed of consciousness level, modified water swallowing test (MWST) score, repetitive saliva swallowing test score, speech intelligibility score, and risk of dysphagia in the cardiac surgery score. Univariate and multivariate analyses with the BSE as the independent variable and pneumonia onset as the dependent variable were also performed to identify factors that predict pneumonia. For factors that became significant in univariate analysis, the incidence of pneumonia was shown using the Kaplan-Meier curve.No significant differences were found in patient characteristics, intraoperative characteristics, and complications between the 2 groups. The postoperative progress was significantly different between the 2 groups, the pneumonia-onset group had a significantly longer time until the start of oral intake and a significantly lower median value of Food Intake Level Scale at the time of discharge. According to univariate and multivariate analyses, MWST score was a significant factor for predicting the onset of pneumonia even after adjusting for patient characteristics and surgical factors, and the incidence of pneumonia increased approximately 3 times when the MWST score was 3 points or less.The MWST score after extubation in cardiovascular surgery was the strongest predictor of postoperative pneumonia in BSEs. Furthermore, the incidence of pneumonia increased approximately 3 times when the MWST score was 3 points or less. Predicting cases with a high risk of developing pneumonia allows nurses and attending physicians to monitor the progress carefully and take aggressive preventive measures., Competing Interests: The authors have no conflicts of interest to disclose, (Copyright © 2021 the Author(s). Published by Wolters Kluwer Health, Inc.)

Study Design: Japanese resident cohort study based on a municipal registry., Objective: This study of a community-dwelling elderly Japanese population employed random sampling from the basic resident registry of a rural town for subject selection to investigate the differences in bone mineral density (BMD) and bone turnover markers between subjects with and without diffuse idiopathic skeletal hyperostosis (DISH)., Summary of Background Data: DISH is a condition characterized by the calcification and ossification of soft tissues. Although some reports have addressed BMD in DISH, the precise status of BMD and bone metabolism in individuals with DISH remains unclear., Methods: Eight groups based on age (50s, 60s, 70s, and 80s) and sex after random sampling from the resident registry of Obuse town were established. A total of 411 participants (202 males and 209 females) were enrolled for the evaluation of BMD and bone turnover markers. All subjects underwent a single whole-spine lateral radiographic examination for the existence of DISH. The BMD and bone turnover markers of subjects with and without DISH were analyzed for associations with the disorder using multivariate analysis., Results: DISH was detected in 66 (16.1%) participants in our population cohort. According to multivariate analysis, increased lumbar and hip BMD were significantly related to DISH (odds ratio: 7.47 and 22.8, respectively)., Conclusion: This study clarified the differences in BMD and bone turnover markers between subjects with and without DISH on a general population basis. Multivariate analysis revealed increased lumbar and hip BMD to be significantly associated with DISH, with no remarkable findings for bone turnover markers., Level of Evidence: 4.

Study Design: Retrospective multicenter cohort study., Objective: We evaluated a new upper instrumented vertebra (UIV) selection method that used the modified Shinshu line (MSL) to establish the selected UIV as the MSL vertebra (MSLV)., Summary of Background Data: No reports have addressed optimal UIV selection according to the lower instrumented vertebra (LIV) for good trunk balance in Lenke 1A curves., Methods: Forty-five consecutive patients (44 female, 14.4 ± 2.4 yrs) receiving posterior spinal fusion (PSF) for a Lenke 1A adolescent idiopathic scoliosis (AIS) curve were analyzed. We defined the novel MSL as the line between the center of the spinous process of C7 and that of the spinous process of the LIV. The vertebral body with which the MSL first contacted proximally was defined as the MSLV. The groups in which the UIV was at, proximal to, or distal to the MSLV were defined as the matched group (M-group; 15 cases [15 female], 14.7 ± 2.1 yrs), proximal group (P-group; 20 cases, [19 female], 15.0 ± 2.2 yrs), and distal group (D-group; 10 case [10 female], 14.8 ± 2.5 yrs), respectively. We measured Cobb angle, main thoracic (MT) curve correction rate, and C7 plumb line absolute value (C7PL) at pre- and 2 years postoperatively for comparisons using Dunnett test, with the M-group as the control., Results: In the M-group, P-group, and D-group, the Cobb angle correction rate between pre- and postoperative time points were 65.3 ± 1.3%, 62.4 ± 1.6%, and 52.8 ± 6.8%, respectively, and comparable apart from a smaller correction tendency in the D-group versus the M-group (P = 0.08). At 2 years postoperatively, C7PL was 0.5 ± 0.4, 1.0 ± 0.6, and 1.3 ± 0.9 cm, respectively, and significantly smaller for the M-group (both P < 0.05)., Conclusion: Better trunk balance were obtained without reducing correction rate by setting the novel MSLV as the UIV in PSF for Lenke type 1A curves., Level of Evidence: 3.

Study Design: Multicenter, prospective randomized study., Objective: Evaluate the impact of weekly teriparatide (WT) and bone contact (BC) status of grafted bone in patients recovering from multilevel lumbar interbody fusion (M-LIF)., Summary of Background Data: WT has been reported to significantly improve bone fusion following posterior or transforaminal interbody fusion in osteoporosis patients., Methods: Patients older than 50 years and osteoporotic were recruited. We defined the fusion of two or more consecutive intervertebral levels as M-LIF. All patients were instrumented with pedicle, iliac, or S-2 alar iliac screws after transplanting cages and autogenous bone between vertebral bodies. After surgical indication for M-LIF, the subjects were randomly allocated to receive either subcutaneous WT from 1 week to 6 months postoperatively (WT arm, N = 50) or a bisphosphonate (BP; BP arm, N = 54). Blinded radiological evaluations were performed using computed tomography (CT). Evaluation of bone fusion was performed at the intervertebral disc located at the bottom of the fixed range. The degree of bone fusion was calculated as a score from 2 to 6 points, with 2 defined as complete fusion. Bone fusion rate was also compared at 6 months postoperatively based on BC status of the grafted bone on CT immediately after surgery., Results: Mean bone fusion score at 6 months postoperatively was 3.9 points in the WT group and 4.2 points in the BP group. The bone fusion rate at 6 months postoperatively tended to be higher in the WT group (46.8% vs. 32.7% in the BP group). The 6-month postoperative fusion rate of immediately postoperative of BC+ patients was significantly higher than that of BC- patients (47.4% vs. 9.5%)., Conclusion: In M-LIF, there were no significant differences in bone fusion score between WT- and BP-treated patients. In contrast, BC status immediately postoperatively had a major impact on 6-month bone fusion., Level of Evidence: 1.

Study Design: Case report., Objective: Describe the clinical and radiological outcomes of a patient with a piezo-type mechanosensitive ion channel component 2 (PIEZO2)-deficient arthrogryposis receiving surgery for severe kyphoscoliosis., Summary of Background Data: Spinal deformity is a characteristic feature of arthrogryposis due to PIEZO2 gene deficiency, for which surgical correction is indicated when the deformity is progressive to avoid neurological deficits and respiratory impairment. However, there exist few reports on the surgical treatment of spinal deformity in PIEZO2-deficient arthrogryposis, and no therapeutic standards have been established., Methods: We retrospectively reviewed a case of proximal junctional kyphosis after posterior spinal fusion for severe kyphoscoliosis in PIEZO2-deficient arthrogryposis., Results: The patient was a 13-year-old girl with PIEZO2-deficient arthrogryposis who underwent posterior spinal fusion with an all-pedicle screw construct from T2 to L2 for a preoperative main thoracic curve Cobb angle of 78° and thoracic kyphotic angle of 83°. Postoperative Cobb angle of the main thoracic curve and thoracic kyphotic angle were improved at 11° and 34°, respectively. Although revision surgery was required for neurological deficits from proximal junctional kyphosis, she could walk with a crutch and improvements in clinical questionnaire scores were noted at 2 years and 3 months after surgery., Conclusion: Based on the present case, posterior spinal fusion represents a good treatment option for severe spinal deformity in PIEZO2-deficient arthrogryposis. Careful consideration of fusion level is needed to prevent proximal junctional kyphosis., Level of Evidence: 5.

Study Design: A retrospective chart review., Objective: The aim of this study was to investigate the incidence and characteristics of screw loosening in surgically treated adolescent idiopathic scoliosis (AIS) patients., Summary of Background Data: Pedicle screws are widely used in posterior spinal fusion for AIS, although postoperative loosening can occur. However, few reports exist on screw loosening after pedicle screw fixation in young scoliosis patients and the etiology of loosening is not well known., Methods: One hundred twenty AIS patients (9 males, 111 females; mean age: 15.0 years) who had received pedicle screw fixation were retrospectively reviewed. All patients underwent routine computed tomography (CT) reconstruction scans at 6 months postoperatively to assess screw position, bony fusion, and the presence of screw loosening. The perforation status of each pedicle screw was assigned a grade of 0 to 3 using Rao classification., Results: Forty-three of 1624 (2.6%) screws showed evidence of loosening on CT. Screw loosening rates according to vertebral insertion level were upper instrumented vertebra (UIV): 9.6%; lower instrumented vertebra (LIV): 5.4%; one vertebra below the UIV: 1.8%; one vertebra above the LIV: 0.5%; two vertebrae below the UIV: 1.2%; and three vertebrae below the UIV: 0.9%. Screw loosening rates based on screw perforation grade were Grade 0: 1.4%; Grade 1: 3.1%; Grade 2: 15.5%; and Grade 3: 15.2%. Multivariate analysis revealed a distance from the UIV or LIV of one vertebra as well as the presence of major perforation to be independent factors affecting screw loosening. The odds ratios (ORs) of UIV/LIV insertion and major perforation were 73.4 and 17.2, respectively. When major perforations occurred in the UIV or LIV, the OR for loosening approached 1262., Conclusion: Pedicle screw loosening after posterior spinal fusion in AIS patients tend to occur in the UIV or LIV. Major screw perforation is also significantly associated with screw loosening. The risk of loosening becomes compounded when major perforations are present in the UIV or LIV., Level of Evidence: 4.

Study Design: Case report., Objective: We report here on an 18-month-old boy with brachytelephalangic chondrodysplasia punctata (BCDP), whose atlantoaxial instability was successfully managed with occipitocervical instrumented fusion (OCF) using screw and rod instrumentations., Summary of Background Data: Recently, there have been a number of reports on BCDP with early onset of cervical myelopathy. Surgical OCF is a vital intervention to salvage affected individuals from the life-threatening morbidity. Despite recent advancement of instrumentation techniques, however, rigid OCF is technically demanding in very young children with small and fragile osseous elements. To our best knowledge, this is the first report on application of the instrumentation technique to a toddler patient with BCDP., Methods: A 16-month-old boy with BCDP presented with tetraplegia and swallow obstacle. Hypoplasia of the odontoid process and atlantoaxial instability were present in lateral radiographs. T2-weighted magnetic resonance (MR) images revealed a high signal region in the spinal cord at the C1-2 and C7-T1 levels. Cervical computed tomography (CT) showed that the pedicles and lateral masses in the cervical spine were small and immature, but the laminae were comparatively thick., Results: One week before surgery, the patient was fitted with a Halo-body jacket. We performed plate-rod placement with occipital cortical screws and C2/C3 interlaminar screws, and added an autogenous bone graft using the right 8 and 9 ribs. Rigid fixation of the occipito-cervical spine was completed successfully without major complications. Postoperative halo-body jacket immobilization was continued for 3 months, after which Aspen collar was fitted. CT confirmed occipitocervical bone fusion at 6 months after surgery. Mild clinical improvements in motor power of the affected muscles and swallowing were witnessed at 1 year postoperatively., Conclusion: Rigid fixation using screw, rod, and occipital plate instrumentation was successful in an 18-month-old toddler with BCDP and atlantoaxial instability. Bone fusion was achieved at postoperative 6 months., Level of Evidence: 5.