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Background: Postoperative SSI is a common and potentially serious complication in spine surgery. Seasonal variation occurs in rates of nosocomial infection, with higher rates found in the summer, during which hot, humid conditions may be optimal for proliferation of bacteria. This might also influence the rate of SSI. The purpose of the study was to examine seasonal variation in SSI after PLIF/TLIF surgery, including relationships with experience of surgeons and causal organisms., Methods: Cases with SSI after PLIF/TLIF surgery at 10 facilities between January 1, 2012, and December 31, 2014 were retrieved from a database. Infection was defined based on CDC guidelines for SSIs. Patients were followed for at least two years after surgery. Surgeries were examined in spring (April-June), summer (July-September), autumn (October-December), and winter (January-March). Seasonal variation and other factors with a potential association with SSIs were evaluated., Results: A total of 1174 patients (607 males, 567 females) who underwent PLIF/TLIF surgery were identified. The operations were PLIF (n = 667), TLIF (n = 443), MIS-PLIF (n = 27), and MIS-TLIF (n = 37). The total SSI rate for the 2-year period was 2.5% (29/1174), and the 2-year average SSI rates for surgeries in each season were spring, 2.6% (7/266); summer, 3.9% (13/335); fall, 1.3% (4/302); winter, 1.8% (5/271). The SSI rate was significantly higher in summer than non-summer (3.9% vs. 1.9%, p < 0.05). SSIs were caused by a variety of pathogens, including Gram-positive cocci, and Staphylococcus aureus was the most common pathogenic organism to cause SSI., Conclusion: Seasonality should be taken into account in strategies for SSI prevention, with particular attention on mitigation of increased temperature and humidity in the summer and on infection caused by Gram-positive cocci and S. aureus., Competing Interests: Declaration of Competing Interest None of the authors have a conflict of interest., (Copyright © 2020 The Japanese Orthopaedic Association. Published by Elsevier B.V. All rights reserved.)

Study Design: A retrospective review of prospectively collected data., Objective: The aim of this study was to compare quality of life (QOL) outcomes of posterior lumbar interbody fusion (PLIF) with lateral lumbar interbody fusion (LLIF) using reports from patients obtained at the 2-year postoperative follow-up., Summary of Background Data: Indirect decompression with LLIF is used to treat degenerative lumbar diseases that require neural decompression. However, the difference in improvement in QOL following indirect decompression compared with direct neural decompression using PLIF is unclear., Methods: We enrolled 284 consecutive patients with degenerative lumbar spondylolisthesis in the present study, 203 who underwent PLIF and 81 who underwent LLIF. All patients completed a minimum of 2 years of follow-up. We evaluated the effectiveness of surgery in each category of the Japanese Orthopaedic Association Back Pain Evaluation Questionnaire (JOABPEQ)., Results: The results of preoperative JOABPEQ and the severity of thecal sac stenosis were not significantly different between PLIF and LLIF, neither was the rate of perioperative complications (14.8% and 15.4% for the PLIF and LLIF groups, respectively; P = 0.91). The effectiveness at 2 years postoperatively was almost the same for all five domains of the JOABPEQ: 62.6% and 68.9% for pain-related disorders (P = 0.34), 38.3% and 42.7% for lumbar spine dysfunction (P = 0.51), 65.8% and 67.5% for gait disturbance (P = 0.79), 53.5% and 48.8% for social life dysfunction (P = 0.47), and 29.1% and 33.3% for psychological disorders (P = 0.48) following PLIF and LLIF, respectively. Visual analogue scale results for back and lower-limb pain and numbness of the lower limbs were almost the same for both groups. No significant differences were observed in terms of perioperative complications and radiographical outcomes., Conclusion: Indirect decompression using LLIF improves QOL and radiographical outcomes to a comparable degree as direct decompression via PLIF., Level of Evidence: 4.

Background: Locomotive syndrome (LS) affects the quality and activities of daily living. Although spinal sagittal balance influences LS, no report elucidated the relationship between LS risk and lumbopelvic discordance. This study aimed to investigate the relationship between lumbopelvic discordance and LS in a middle-aged community., Methods: The subjects (n = 135) were divided into three groups based on the LS risk stage, which was evaluated through spinopelvic sagittal alignment and lumbopelvic mismatch prevalence (Pelvic incidence-Lumbar lordosis >10°:PI-LL mismatch).Then, the subjects were divided into two groups (lumbopelvic matched and mismatched groups) and analyzed based on the demographic data, physical test, stabilometry, and body pain using the visual analog scale., Results: There were 76, 37 and 22 subjects in stages 0, 1, and 2, respectively. The pelvic incidence-lumbar lordosis (PI-LL) mismatched group had a higher prevalence in LS risk stage 2 than in LS risk stage 0. The prevalence of PI-LL mismatch was significantly different among the groups. Post hoc test revealed the differences in spinopelvic alignment among the stages. In each LS risk stage, the degree of PI-LL was significantly higher in stage 2 than that in stages 0 and 1. On comparing the PI-LL matched (n = 67) and mismatched groups (n = 68) with a stabilometer, the envelopment area tracing by the movement of the center of pressure and locus length/second was greater in the PI-LL mismatched group than that in the PI-LL matched group with/without eyes opened., Conclusions: The prevalence of LS risk stage 2 was more frequently observed in the PI-LL mismatched group. The degree of PI-LL was evaluated through the LS risk stages. Physical dysfunction in the PI-LL mismatched group was related to trunk imbalance based on stabilometry. These findings will help manage LS and PI-LL mismatched subjects., (Copyright © 2019 The Japanese Orthopaedic Association. Published by Elsevier B.V. All rights reserved.)

This study aims to establish radiographic parameters of lumbopelvic sagittal alignment, gender related differences, and age-related changes in a middle-aged community, to investigate whether age-related changes of lumbopelvic alignment reflect the risk of locomotive syndrome (LS). This study included 448 healthy Japanese volunteers who attended a basic health checkup supported by the local government. The subjects (184 males and 264 females, mean age: 62.7 years) were grouped according to their age by decade. Sagittal lumbopelvic parameters were collected by lateral spine radiographs including lumbar lordosis (L1-S1, LL), lower lumbar lordosis (L4-S1, LLL), pelvic incidence (PI), pelvic tilt (PT) and sacral slope (SS). The three tests (stand-up test, two-step test, and 25-question geriatric locomotive function scale [GLFS-25]) composing the LS risk test were performed. LL was significantly lower in males than in the females. A significant decrease of LL and LLL was observed from 60 s to 70 s in the females. PI did not markedly change with aging in either gender but was lower in males. A remarkable increase of PT was seen from 60 s to 70 s in the females. SS did not markedly change with aging and was lower in males in all decades. The prevalence of LS risk in males and females increased gradually with age and was greater in females in any decade. 70 s females with LS risk had significantly lower LL and higher PT compared to them without LS risk. Radiographic parameters of lumbopelvic sagittal alignment were established in community-dwelling middle-age and elderly individuals., Competing Interests: Declaration of Competing Interest The authors report no conflict of interest except for the national grant., (Copyright © 2020 Elsevier Ltd. All rights reserved.)

Background: Optimal treatment of lumbar spinal stenosis (LSS) with neurological deficit due to osteoporotic vertebral fractures (OVFs) has been controversial. We assessed the usefulness, safety, and efficacy of posterior lumbar interbody fusion (PLIF) for LSS with neurological deficit due to OVFs and compared this procedure to posterior/anterior combined surgery (PACS)., Methods: Of 36 consecutive patients with LSS with neurological deficit due to OVFs, 15 underwent PLIF (6 males, 9 females; mean age, 74 years), and 21 underwent PACS (4 males, 17 females; mean age, 70 years). Surgical complications, clinical outcomes (operative time, blood loss, American Spinal Injury Association Impairment Scale [AIS], activities of daily living [ADLs]), and sagittal alignment were investigated. Bony fusion was assessed using plain and functional X-rays and computed tomography scans., Results: There were no significant differences in age, sex, or disease or follow-up duration between the groups. Operative time was significantly shorter and intraoperative blood loss significantly less in the PLIF than in the PACS groups. AIS and ADL improved significantly postoperatively in both groups. No significant difference was observed in neurological improvement, correction angle, loss of correction, and surgical complications. No pseudarthrosis occurred, and no patient required additional surgery in the PLIF group., Conclusions: PLIF for LSS with neurological deficit due to OVFs achieves posterior rigid fixation with instrumentation, anterior column reconstruction by interbody fusion, and adequate decompression using a single posterior approach. This less invasive procedure is a useful reconstructive surgery option., (Copyright © 2019 The Japanese Orthopaedic Association. Published by Elsevier B.V. All rights reserved.)

Aim: Musculoskeletal degenerative disease (MSD; osteoporosis, knee arthritis and lumbar spondylosis) decreases the quality of life (QOL) of older people. The objective of the present study was to identify the factors related to the absence of MSD in multivariate logistic regression analysis., Methods: The participants were 1034 volunteers (444 men, 590 women, mean age 63.5 years) in the Yakumo study. Osteoporosis (percentage of young adult mean ≤70%), knee arthritis (Kellgren-Lawrence grade ≥2), and lumbar spondylosis (Nathan class ≥3) were prospectively examined. Participants were divided into those with and without MSD. Age, sex, body mass index, muscle strength, gait ability, pain, body balance, spinal sagittal alignment, geriatric syndrome (locomotive syndrome, frailty and sarcopenia) and QOL (Short Form Health Survey) were compared between these groups to identify the factors associated with the absence of MSD., Results: Significantly lower age, body mass index and pain; higher gait speed, grip and back muscle strength; more stable body balance; better sagittal spinal alignment; and lower rates of locomotive syndrome, frailty and sarcopenia were observed in the group without MSD (n = 445, 43%), with significantly better QOL (P < 0.0001). In multivariate logistic regression analysis adjusted for age and sex, lower body mass index (odds ratio [OR] 1.10, P < 0.001), lower spinal inclination (OR 1.08, P < 0.01), higher back muscle strength (OR 1.01, P < 0.05), no locomotive syndrome (OR 1.80, P < 0.05) and good body balance (OR: 1.12, P < 0.05) were significant factors for the absence of MSD., Conclusions: Factors related to an absence of MSD are also related to good QOL, and should be a focus of health interventions in healthy middle-aged and older people. Geriatr Gerontol Int 2019; 19: 1141-1146., (© 2019 Japan Geriatrics Society.)

We investigated 2-year outcomes of denosumab treatment for osteoporosis in patients with rheumatoid arthritis (RA) and predictors of good outcomes. Study participants were 74 females treated with denosumab for 24 months. After investigating baseline demographics and overall time course for each patient, we divided all cases into two groups according to percent change (%) in bone mineral density (BMD) of lumbar spine (LS-) and total hip (TH-) at 24 months (-24m); two thirds of the patients were allocated to the good outcome group (LS-GO and TH-GO), and the other third to the non-good outcome group (LS-NG and TH-NG). We performed multivariate analysis to confirm predictors of greater increases in LS- and TH-BMD. LS-BMD-24m and TH-BMD-24m increased significantly from baseline. We observed greater %LS-BMD-24m in LS-GO group than in LS-NG group, while %TH-BMD-24m showed no significant group-dependent difference. N-terminal propeptide of type 1 collagen (P1NP) and tartrate-resistant acid phosphatase (TRACP)-5b decreased more in LS-GO group than in LS-NG group at each time point. We observed greater %TH-BMD-24m in TH-GO group than in TH-NG group, while %LS-BMD-24m showed no significant group-dependent difference. Only P1NP-6m showed a larger decrease in TH-GO group relative to TH-NG group. Multivariate analysis confirmed that the larger decrease in P1NP-6m was associated with the greater increase in LS-BMD-24m, while the combined use of biologics was associated with the greater increase in TH-BMD-24m. In conclusions, denosumab increased BMD in RA patients with osteoporosis. The combined use of biologics and denosumab may provide useful treatment options., Competing Interests: Y. Hirano received lecture fees from AbbVie Inc., Eisai Co., Mitsubishi Tanabe Pharma Co., Pfizer Inc., Chugai Pharmaceutical Co., and Bristol-Myers Squibb Co. N. Takahashi received lecture fees from AbbVie Inc., Eisai Co., UCB Japan Co., Mitsubishi Tanabe Pharma Co., Takeda Pharmaceutical Co., Pfizer Inc., Chugai Pharmaceutical Co., Janssen Pharmaceuticals, and Bristol-Myers Squibb Co. N. Ishiguro received grants and lecture fees from Daiichi Sankyo Co., Takeda Pharmaceutical Co., Hisamitsu Pharmaceutical Co., Otsuka Pharmaceutical Co., Taisho Toyama Pharmaceutical Co., Kaken Pharmaceutical Co., Eisai Co., Janssen Pharmaceuticals, Bristol-Myers Squibb Co., AbbVie Inc., Chugai Pharmaceutical Co., Mitsubishi Tanabe Pharma Co., Astellas Pharma Inc., and Pfizer Inc. T. Kojima received lecture fees from Mitsubishi Tanabe Pharma Co., Takeda Pharmaceutical Co., Eisai Co., AbbVie Inc., Bristol-Myers Squibb Co., Pfizer Inc., Janssen Pharmaceuticals, Astellas Pharma Inc., and Chugai Pharmaceutical Co. The other authors declare no conflicts of interest.

Purpose: The objective was to identify risk factors for new development of gastroesophageal reflux disease (GERD) 5 years later in a prospective longitudinal cohort study., Methods: A total of 178 subjects (male 72, female 106, mean age 68 years) without GERD in 2013 were examined for GERD in 2018. A Frequency Scale for Symptoms of GERD score ≥ 8 was used for diagnosis of GERD. Body mass index, spinal alignment, muscle strength, physical ability, number of oral drugs per day, sarcopenia, and frailty determined in 2013 and 2018 were compared between the GERD(+) and GERD(-) groups in 2018. Aggravation of lumbar kyphosis and spinal inclination from 2013 to 2018 was defined as a change of ≥ 5° or ≥ 10°, and weakening of back muscle strength as a change of ≥ 10 kg. QOL (SF-36) was also examined., Results: Of the 178 subjects, 38 (21%) were diagnosed as GERD(+) in 2018. Sarcopenia in 2018 was significantly related to a GERD(+) status (p < 0.05). The GERD(+) group had significantly higher rates of changes of lumbar kyphosis ≥ 5° (p < 0.005) and ≥ 10° (p < 0.0001), of spinal inclination ≥ 5° (p < 0.0001), and of decreased back muscle strength ≥ 10 kg (p < 0.05). SF-36 were also significantly worse in the GERD(+) group (p < 0.05)., Conclusions: This prospective longitudinal study firstly demonstrated that lumbar kyphotic change, aggravation of spinal inclination, decreased back muscle strength, and sarcopenia are significant risk factors for new development of GERD. Management and prevention of these factors may contribute to reduction of GERD symptoms and increased QOL in middle-aged and elderly people. These slides can be retrieved under Electronic Supplementary Material.

Carbon-ion radiotherapy (CIRT) is a useful modality for treatment of primary spinal sarcoma, but osteonecrosis after CIRT may cause pseudoarthrosis that can make subsequent reconstruction surgery difficult. The patients were a 68-year-old man (case 1), a 30-year-old woman (case 2), and a 49-year-old man (case 3) with lumbar lesions. After CIRT, cases 1 and 3 were treated with instrumented spondylectomy and case 2 underwent posterior decompression and instrumentation surgery. Cases 1 and 2 required several salvage procedures because of failure of instrumentation (rod breakage) before bone union was achieved. After multiple revision surgeries, these cases did achieve bone union without tumor recurrence. In contrast, in case 3, only spondylectomy using a pedicle screw system at 20 months after CIRT was required for fusion. At follow-up 11 years postoperatively, CT showed bone union with invasion of autograft bone from the iliac crest into adjacent vertebra. Collapse or a finding of viable tumor cells after CIRT requires surgery such as spondylectomy with reconstruction. Instrumented fixation following CIRT for a lumbar primary tumor should be performed with multilevel anterior support using a sufficient amount of bone graft in posterior fusion levels., (Copyright © 2019 Elsevier Ltd. All rights reserved.)

Spinal fusion and bone defects after injuries, removal of bone tumors, and infections require repair by implantation. In this study, we show self-assembling peptide (SPG-178) hydrogel-induced bone healing in vivo. Posterolateral lumbar fusion and tibial intramedullary models of rabbits were prepared. In the tibia model, micro-CT analysis revealed a significantly higher degree of newly formed bone matrix in the SPG-178 group compared to the other groups. SEM/3D micrographs showed that the cavity filled with SPG-178 had collagen fibers attached to host bone. After 28 days, samples from the SPG-178 group showed significant repair of the defect. In the posterolateral lumbar fusion models, micro-CT showed a tendency for a higher degree of newly formed bone matrix in the SPG-178 group compared to the β-TCP and bone chips only groups. Von Kossa staining showed marked new bone formation attached to the lamina that was most prominent at the implanted SPG-178 composite margin. SPG-178 is a material that is likely to be used in clinical applications because it has several benefits. These include its favorable bone conduction properties, its ability to act as a support for various cells and growth factors, its lack of infection risk compared with materials of animal origin such as ECM, and the ease with which it can be used to fill defects with complex shapes and be combined with a wide range of other materials. © 2018 Orthopaedic Research Society. Published by Wiley Periodicals, Inc. J Orthop Res 36:3285-3293, 2018., (© 2018 Orthopaedic Research Society. Published by Wiley Periodicals, Inc.)

Purpose: Posterior lumbar interbody fusion (PLIF)/transforaminal lumbar interbody fusion (TLIF) can have complications that require reoperation. The goal of the study was to identify risk factors for reoperation within 2 years after PLIF/TLIF., Methods: A retrospective analysis of a prospective multicenter database was performed for patients who underwent PLIF/TLIF. A total of 1363 patients (689 males and 674 females) were identified, with an average age of 65.9 years old. Comorbidities, perioperative ASA grade, and operative factors were compared between patients with and without reoperation. Risk factors for reoperation were identified in multivariate logistic analysis., Results: There were 38 reoperations within 2 years after PLIF/TLIF (2.8%). The original surgical procedures were open PLIF (n = 26), open TLIF (n = 10), and minimally invasive surgery (n = 2). Reoperation was due to adjacent segment degeneration (ASD) (n = 10), surgical site infection (SSI) (n = 9), screw misplacement (n = 6), postoperative epidural hematoma (n = 6), pseudoarthrosis (n = 4), and cage protrusion (n = 3). Number of levels fused and dural tear were significantly associated with reoperation. In analysis of complications requiring reoperation, SSI was related to diabetes mellitus and dural tear, and postoperative epidural hematoma was related to fusion of two or more levels, EBL, and operation time. In multivariate logistic regression, fusion of two or more levels (HR 2.19) was significantly associated with reoperation., Conclusion: Surgical invasiveness, as reflected by number of fused levels, operation time, EBL and dural tear, was associated with reoperation. Fusion of two or more levels is a strong risk factor for reoperation within 2 years after initial PLIF/TLIF. These slides can be retrieved under Electronic Supplementary Material.

Objective: To report a series of four cases of intradural disc herniation (IDH) with a review of the literature., Summary of Background Data: IDH is a rare type of disc herniation. Preoperative diagnosis is difficult and IDH is only confirmed during surgery in most cases. Here, we describe four cases of IDH, including three with lumbar hernia and one with thoracic hernia., Methods: A retrospective chart review, surgical database query, and review of radiology reports are presented for each case, along with a literature review of IDH., Results: Two of the four patients had a history of surgery at the same spinal level. Ring enhancement in gadolinium-enhanced MRI, an air image in computed tomography, and complete block in myelography were observed in the series. Surgery was performed with a transdural approach in all patients. One patient underwent transforaminal lumbar interbody fusion after postoperative recurrence. Three patients with lumbar involvement had nerve root symptoms preoperatively, but showed symptomatic improvement in the early postoperative period. In contrast, the patient with thoracic involvement had preoperative muscle weakness due to myelopathy symptoms, and had residual symptoms after surgery., Conclusions: IDH is a rare disease and characteristic imaging findings can be useful for diagnosis. Intraoperative findings lead to a definitive diagnosis in many cases and recognition of the pathological characteristics of IDH is important., (Copyright © 2014 Elsevier B.V. All rights reserved.)

Purpose: The purpose of this study is to quantify the change in the volume of the interbody bone graft after the PLIF and monitor the change over time for subsequent analysis., Methods: The 114 cases were selected as the subjects of this study. The observation period was for 5 years following the surgery. The volume of the bone graft in the interbody space was calculated by summing up the cross-sectional area of the bone graft on each axial image multiplied by the height (2 mm) (the volume of the two cages was excluded). The volume ratio (%) = (bone graft volume)/(total volume of the interbody space - cage volume) was used for the purpose of evaluation., Results: The volumetric change of the bone graft was 51 % (3 months), 53 % (6 months), 54 % (1 year), 55 % (2 years), 59 % (3 years), 62 % (4 years), and 72 % (5 years), indicating a continued increase up to the 5-year mark. In particular, a significant increase was observed from the second year as compared with the previous years' result. Additionally, the volumetric increase from the second year to the fifth year was significantly higher than that before the second year., Conclusions: The post-PLIF volumes of interbody bone grafts exhibited increases particularly from the second to fifth years after the procedure. Even the elderly and those with poor bone qualities can expect to have volumetric increases over time. Sufficient interbody space should be secured for accommodating bone grafts by intraoperative reduction, wherever possible.

Spinal epidural hematoma (SEH) is an uncommon disorder, and chronic SEHs are rarer than acute SEHs. However, there is few reported involving the bone change of the vertebral body in chronic SEHs. We present a case report of lumbar epidural hematoma that required differentiation from extramedullary spinal tumors by a long process because the CT scan revealed scalloping of the vertebral body and review the relevant literature. A 78-year-old man had experienced a gradual onset of low back pain and excruciating pain in both legs. Lumbar MRI on T1-weighted images revealed a space-occupying lesion with a hyperintense signal relative to the spinal cord with no enhancement on gadolinium adminisration. Meanwhile, T2-weighted images revealed a heterogeneous intensity change, accompanying a central area of hyperintense signals with a hypointense peripheral border at the L4 vertebra. Moreover, the CT scan demonstrated scalloping of the posterior wall of the L4 vertebral body which is generally suspected as the CT finding of spainal tumor. During the epidural space exploration, we found a dark red-colored mass surrounded by a capsular layer, which was fibrous and adhered to the flavum and dura mater. Microscopic histological examination of the resected mass revealed a mixture of the relatively new hematoma and the hematoma that was moving into the connective tissue. Accordingly, the hematoma was diagnosed as chronic SEH. The particular MRI findings of chronic SEHs are helpful for making accurate preoperative diagnoses of this pathology.

Introduction: The Japanese Society for Spine Surgery and Related Research (JSSR) developed a diagnostic support tool (score range −2 to 16) for lumbar spinal canal stenosis (LSS). It is well known that patients with LSS have a forward-bending posture while walking. We could find only one study which examined sagittal alignment of LSS patients. The objectives of this study were to screen community-living people with LSS, and to investigate the association between LSS and spinal sagittal alignment, range of motion (ROM), and other spinal or physical factors., Materials and Methods: We enrolled 286 subjects ≥50 years old in the study. We regarded those with a JSSR diagnostic risk score ≥7 as having LSS. We measured and evaluated lateral lumbar radiographs, sagittal parameters, sagittal balance, and spinal mobility as determined with SpinalMouse®, back muscle strength (BMS), and body mass index (BMI). Spinal inclination angle (SIA) was used as an index of sagittal balance., Results: Multivariate logistic regression analysis indicated that increased BMI (OR 1.121, p < 0.05) and SIA (OR 1.144, p < 0.05) were important relevant factors for LSS. BMI had significant positive correlations with SIA (r = 0.214), and thoracic and lumbar kyphosis angles (r = 0.283, 0.131), and negative correlations with sacral slope angle (r = −0.166), and lumbar and total spinal ROMs (r = −0.270, −0.166). SIA had significant positive correlations with age (r = 0.334), BMI (r = 0.214) and lumbar kyphosis angle (r = 0.525), and negative correlations with BMS (r = −0.268), and lumbar and total spinal ROMs (r = −0.184, −0.171)., Conclusions: Increased SIA and BMI might be the most relevant risk factors for LSS.

Purpose: The purpose of this study is to compare bone union rate between autologous iliac bone and local bone graft in patients treated by posterior lumbar interbody fusion (PLIF) using carbon cage for single level interbody fusion., Methods: The subjects were 106 patients whose course could be observed for at least 2 years. The diagnosis was lumbar spinal canal stenosis in 46 patients, herniated lumbar disk in 12 patients and degenerative spondylolisthesis in 51 patients. Single interbody PLIF was done using iliac bone graft in 53 patients and local bone graft in 56 patients. Existence of pseudo-arthrosis on X-P (AP and lateral view) was investigated during the same follow up period., Results: No significant differences were found in operation time and blood loss. Significant differences were also not observed in fusion grade at any follow up period or in fusion progression between the two groups. Donor site pain continued for more than 3 months in five cases (9%). The final fusion rate was 96.3 versus 98.3%., Conclusions: Almost the same results in fusion were obtained from both the local bone group and the autologous iliac bone group. Fusion progression was almost the same. Complications at donor sites were seen in 19% of the cases. From the above results, it was concluded that local bone graft is as beneficial as autologous iliac bone graft for PLIF at a single level.

Study Design: Cross-sectional cohort study of elderly people., Objective: The relationships of osteophyte formation on plain lumbar radiographs with serum levels of antioxidants (carotenoids, vitamin A, vitamin E) and other factors were investigated to examine whether antioxidants are involved in lumbar spine degeneration., Summary of Background Data: Antioxidants have inhibitory effects on the onset of many diseases. However, the association of lumbar osteophyte formation with antioxidant levels in the general population has not been investigated., Methods: The subjects were 286 people (103 men and 183 women; mean age = 68 years) who underwent resident health screening. Osteophyte formation on lumbar lateral radiographs (Nathan classification), lumbar lordosis angles, sacral inclination angles, serum levels of antioxidants, triglyceride levels, body mass index, osteoporosis, back muscle strength, history of alcohol intake, and smoking history were studied in these subjects., Results: Lumbar osteophyte formation was detected in 48 subjects (17%). Osteophyte formation was significantly more common in elderly persons, men, and subjects with a history of alcohol intake; and had a significant correlation with sacral inclination angle. The levels of α-tocopherol, β-tocopherol, zeaxanthin/lutein, cryptoxanthin, lycopene, α-carotene, and β-carotene were significantly lower in subjects with osteophytes. Logistic regression analysis adjusted for all factors showed that a higher age (odds ratio [OR] = 1.1, 95% confidence interval [CI] = 1.02-1.16; P = 0.02) and a low β-carotene level (OR = 6.7, 95% CI = 1.39-32.6; P = 0.02) were risk factors for osteophyte formation., Conclusion: The serum levels of carotenoids and vitamin E were significantly lower in subjects with lumbar osteophyte formation, and a low β-carotene level was the strongest risk factor for lumbar osteophytes. This is the first evidence of an association between carotenoids and lumbar osteophyte formation. This finding suggests that appropriate dietary intake of antioxidants is important for inhibition of lumbar spine degeneration in a rapidly aging society.

Background: Lumbar surgery and associated complications are increasing as society is aging. However, definitions of complications after lumbar surgery have not been established and previous reports have varied in the definition of, and focus on, intraoperative or major postoperative complications. We analyzed the frequency and severity of perioperative complications and all minor adverse events in lumbar surgery at a single center., Methods: We retrospectively reviewed all lumbar surgery, including decompression surgery with or without fusion, at Meijo Hospital over a 10-year period. Perioperative complications and all surgery-related adverse events until 1 month postoperatively were reviewed for 1012 operations on 918 patients (average age 54 years old). The incidence of intraoperative complications was compared between junior (<10 years experience of spine surgery) and senior (≥10 years experience) surgeons., Results: Perioperative complications and adverse events occurred in 159 operations (15.7%) on 127 patients (13.8%). There were a variety of perioperative adverse events, including digestive problems. Of the 159 complications and events, 24 (2.4%) were intraoperative and 135 (13.3%) were postoperative. Incidence of intraoperative complications was not significantly higher for junior surgeons; however, the operations performed by senior surgeons were significantly more invasive. Complications were more frequent in elderly patients (p < 0.01) and in operations that were longer (p < 0.0001), had greater estimated blood loss (p < 0.0001), and involved use of spinal instrumentation (p < 0.0001). Psychotic symptoms occurred significantly more often in older patients (p < 0.001)., Conclusion: The absence of a relationship between the experience of the surgeon and incidence of intraoperative complications may be because of the greater effect of invasive surgery. Although age and invasiveness were associated with more perioperative adverse events, we do not conclude that major surgery should be avoided for elderly patients. In contrast, careful focus on the surgical indication and procedure is required for these patients.

Posterior lumbar interbody fusion (PLIF) is a popular procedure for treating lumbar canal stenosis with spinal instability, and several reports concerning fusion assessment methods exist. However, there are currently no definitive criteria for diagnosing a successful interbody fusion in the lumbar spine. We suggested evaluating fusion status using computed tomography (CT) in extension position to detect pseudoarthrosis more precisely. The purpose of this study was to evaluate its usefulness for determining bone union quality after PLIF. Eighty-one patients who underwent PLIF at 97 levels were retrospectively enrolled. The study population included 48 men and 33 women (mean age 58.9 years, range 21-85 years). Patients were followed up for more than 12 months after surgery. The mean follow-up period was 27.6 months (range 14-49 months). Fusion status was evaluated using three ways: flexion-extension radiographs, CT images in flexion and extension position. In the flexion-extension radiographs, mobility of more than 3°, a remaining clear zone, or an uncertain bone connection constituted an incomplete union. For CT images, a remaining clear zone, a gas pattern, or an uncertain bone connection constituted an incomplete union. Flexion-extension radiographs demonstrated a solid fusion in 90.7% of the 97 levels at 10.7 months postoperatively. When fusion was demonstrated on flexion-extension radiographs, the rate of fusion affirmed by flexion CT and extension CT was 87.6 and 69.1% of the levels assessed, respectively. The rate of pseudoarthrosis detected on extension CT images was significantly higher than that on flexion-extension radiographs (P < 0.001) and flexion CT (P < 0.01). The rate of fusion achieved on extension CT was 85.6% at 15.1 months postoperatively. Extension CT could detect pseudoarthrosis more clearly than flexion-extension radiography and flexion CT. The CT images are influenced by body position and dilating anterior disc space in extension CT contributes to detect pseudoarthrodesis. Thus, extension CT was a useful method for assessing fusion status after PLIF.

Study Design: A retrospective clinical study with a long-term follow-up in a single facility., Objective: The purpose of this study is to compare bone union rate between autologous iliac crest bone graft and local bone graft in patients treated by posterior lumbar interbody fusion (PLIF) using carbon cage for single-level interbody fusion., Summary of Background Data: Recently, a number of authors have reported on local bone grafting using bone that is obtained from laminectomy, and have indicated that the achieved fusion rate is similar to that of autologous iliac bone grafting. However, there is no report comparing the fusion rates between autologous iliac bone and local bone graft with a detailed follow-up of fusion progression., Methods: The subjects were 101 patients whose course could be observed for at least 2 years. The diagnosis was lumbar spinal canal stenosis in 14 patients, herniated lumbar disc in 19 patients, and degenerative spondylolisthesis in 68 patients. Single interbody PLIF was performed using iliac bone graft in 54 patients and local bone graft in 47 patients. Existence of pseudarthrosis on X-P (anteroposterior and lateral view) was investigated during the same follow-up period., Results: No significant differences were found in operation time and blood loss. Significant differences were also not observed in fusion grade at any follow-up period or in fusion progression between the 2 groups. Donor site pain continued for more than 3 months in 6 cases (11%). The final fusion rate was 94.5% versus 95.8%., Conclusion: Fusion results from the local bone group and the autologous iliac bone group were nearly identical. Furthermore, fusion progression was nearly identical. Complications at donor sites were seen in 17% of the cases. From the aforementioned results, it was concluded that local bone graft is as beneficial as autologous iliac bone graft for PLIF at a single level.

Two elderly patients with dural arteriovenous fistulas (AVF), the abnormal vessels of which were not presented on magnetic resonance imaging (MRI) are reported. Although spinal AVF was suspected from hyperintensity in the spinal cord, dilated vessels were not detected on MRI. Computed tomography (CT) angiography was performed with a 64-detector row multidetector row CT (MDCT) system in both cases. The draining dilated vein was observed in both cases and they were interpreted as perimedullary AVF. In case 1, axial scan and the dorsal section of the coronal view demonstrated continuity of the radiculomedullary artery and intercostal artery through the spinal branch at the left Th12 level. After intravascular embolization in case 1 and surgical treatment in case 2, neurological improvement was obtained in both cases. MRI findings suggestive of dural AVF have described that intradural perimedullary tortuous low signal intensities posterior to the spinal cord, known as flow void, on T(2)-weighted images is the most consistent. Recently, MDCT angiography confirmed the presence of a fistula previously suspected after MRI. There are no previous reports that describe cases of dural AVF diagnosed by MDCT angiography of which abnormal vessels were undetected by MRI images. MDCT can detect abnormal vessels which were not depicted on MRI. When dural AVF are suspected on MRI, MDCT angiography should be performed before selective angiography to diagnose.

The objectives of this study were to determine whether recombinant human bone morphogenetic protein-2 (rhBMP-2) can be used as the sole stimulator of osteogenesis with success equal to an autologous graft in posterolateral lumbar fusion (PLF) at the same level and to describe the progress until bone union. This study included 11 patients who underwent PLF of L4-5. On the right side, only rhBMP-2, for which polylactic/glycolic acid (PLGA) was used as a carrier, was used, whereas, on the left side, autogenous bone was used. The bone union rate was 73 and 82% at 12 and 24 months after surgery, respectively, on the right BMP side, while the rate on the autogenous bone side was 91%. There was no statistically significant difference in the bone union rate. rhBMP-2 can be used as the sole source of osteogenesis with success equivalent to an autologous graft of the PLF.

Study Design: A prospective study was conducted on the surgical procedures for lumbar disc herniation., Objective: The objective of this study is to investigate the surgical outcomes of different methods when performed by the same surgeon, using a prospective study., Background: Macro discectomy is widely known as a common surgical procedure for lumbar disc herniation, while microdiscectomy in place of Caspar technique (the Caspar method) and microendoscopic discectomy by a posterior approach are reported as less invasive surgical methods for this condition. However, there have not been a significant number of prospective studies conducted to compare different surgical procedures for lumbar disc herniation., Materials and Methods: The target of our study was a group of 62 patients (male: 43, female: 19) who underwent surgery by macro discectomy (A group) and 57 patients (male: 33, female: 24) who underwent surgery by microdiscectomy in place of Caspar technique (B group). The mean ages at surgery were 34 (14 to 62) years and 41 (18 to 65) years respectively, and the mean duration of follow-up was 2 years and 8 months (12 months to 4 years). For all patients, the surgery was performed by 1 of the authors. The items investigated were the operation time, amount of bleeding, duration of hospitalization, amount of analgesic agent used after surgery, pre- and postoperative scores based on judgment criteria for treatment of lumbar spine disorders established by the Japanese Orthopaedic Association score, visual analog scales (VAS, 0 to 10) for lumbago before surgery and at discharge, VAS for sciatica before surgery and at discharge, perioperative complications, and cases requiring further surgery., Results: There were no significant differences between the 2 surgical procedures in the frequency of use of an analgesic agent after surgery, the pre- and postoperative Japanese Orthopaedic Association scores or postoperative VAS for sciatica. Statistically significant differences were observed in the operation time, amount of bleeding, duration of hospitalization, and postoperative VAS for lumbar pain, but the differences were not large, and may not have been clinically significant., Conclusions: For herniotomy for lumbar disc herniation, both macro discectomy and microdiscectomy are appropriate, as long as surgeons have mastery of the procedures.

Computer-assisted surgery, which provides simultaneous, multiplanar images of bone structures, has become widely used. However, registration maneuvering remains time consuming. The objective of this paper is to document the usefulness of CT-fluoro matching for spinal navigation. A spinal navigation system (VECTORVISION compact; Brain LAB, Germany) and a digital imaging system (OEC9800; CATHEX, Tokyo, Japan) were used for CT-fluoro matching in cases of L4/5 and L5/S1 posterior lumbar interbody fusion. A reference array was attached to the L4 spinous process. Preoperative CT images and intraoperative fluoro-shots including L4, L5, and S1 were superimposed on the navigation monitor. Following insertion of L4 screws, a reference array remained to be attached to the L4 spinous process, after which a level definition and pre-registration of L5 and S1 vertebrae were performed and the screwing procedure of L5 and S1 was completed without additional fluro-shots. Registration of three vertebrae was completed without paired-point or surface-matching procedures. The calculation time for the registration in a single vertebra was 30 sec. All pedicle screws were seen to be successfully inserted on postoperative CT images. We performed the navigation surgery by matching the preoperative CT images to the intraoperative fluoro-shots without manual registration. This technique may prove useful in the future for anterior spinal surgery and percutaneous screwing without the need for total exposure of the bone surface.

Objective: The aim of this work was to elucidate the relation between the clinical course and morphologic changes of lumbar disc herniation on magnetic resonance imaging (MRI)., Methods: Twenty-one patients with lumbar disc herniation treated nonsurgically were followed for a minimum of 7 years and investigated with regard to their clinical outcome and the initial, 2-year, and final stage MRI findings. The space-occupying ratio of herniation to the spinal canal and the degree of disc degeneration were evaluated on serial MRI., Results: The mean space-occupying ratio of herniation showed significant reduction both on the 2-year and on the final scans. Progression of degeneration of the intervertebral disc was seen in all patients at the final investigation. Comparing patients with and without symptoms, no factors were detected on the initial and 2-year MR images capable of distinguishing patients who were and were not destined to develop lumbago and/or sciatica in the future. Morphologic changes of lumbar disc herniation continued to occur even after 2 years., Conclusions: Clinical outcome did not depend on the size of herniation or the grade of degeneration of the intervertebral disc in the minimum 7-year follow-up.

Objective: To assess the efficacy of posterior instrumentation and vertebral reconstruction with biodegradable calcium phosphate cement (CPC) in the treatment of osteoporotic vertebral compression fracture with neurologic deficit., Background: Vertebroplasty consists of the injection of polymethylmethacrylate (PMMA) cement into the vertebral body. While PMMA has high mechanical strength, it cures fast and thus allows only a short handling time. Other potential problems of using PMMA injection may include damage to surrounding tissues due to the high polymerization temperature or by the toxic unreacted monomer and the lack of long-term biocompatibility. Bone mineral cements such as calcium carbonate and CPCs have a longer working time and low thermal effect. They are also biodegradable while providing good mechanical strength. However, the viscosity of injectable mineral cements is high, and the infiltration of these cements into the vertebral body has been questioned. Recently, the infiltration properties of CPC have been significantly improved, making it more suitable for injection into the vertebral bodies for vertebral reconstruction., Methods: Five patients were included in this open prospective study. Inclusion criteria were delayed collapsed vertebral compression fractures responsible for severe pain and neurologic dysfunction necessitating posterior decompression surgery. Of five patients, two were male and three were female with an average age at surgery of 80.4 years (71-85 years) and an average duration of follow-up of 2.5 years (2-3.5 years). Evaluation of clinical data was based on x-ray, Japanese Orthopaedic Association (JOA) score for low back pain (full score is 29 points), and Visual Analog Scale (VAS)., Results: The levels of the delayed collapsed vertebrae were T10, L1, and L2 (for one patient each) and L4 (two patients). All patients were in poor condition, for example, renal failure, heart failure, and chronic hepatitis. The average operative time was 2 hours (1 hour 36 minutes to 2 hours 16 minutes), and intraoperative bleeding was 181 mL (85-236 mL). As for clinical symptoms, preoperative JOA score averaged 17.8 points and was improved to 26 points postoperatively, while the preoperative VAS score of 8.6 points improved to 2 points postoperatively. Morphologic evaluation showed preoperative vertebral compression ratio averaged 41% and improved to 74% immediately after the operation and finally settled at 68%. Just one of five cases experienced late vertebral collapse 3 months after the operation., Conclusion: Vertebral reconstruction with biodegradable CPC in the treatment of osteoporotic vertebral compression fracture using instrumentation was a safe and useful surgical treatment.

Low back pain is an enormous clinical and public health problem. When we use spinal instrumentation, measurements of spinal and leg alignment in the standing position are thought to be important. Knee joint pain has also become an enormous clinical problem in the increasing elderly population. However, the correlation between spinal alignment, particularly sacral inclination, and knee joint pain is not clear. We examined the correlation between lumbar lordosis, sacral inclination, and patellofemoral joint pain in elderly subjects. Three hundred and ninety-nine people aged 50-85 years were examined. Clinical findings and physical status were determined. Measurements and determination of total lordosis from L1 to S1 and sacral inclination were made from standing radiographs. The knee joints were evaluated by using the standing knee flexion angle, radiographs, and the patellofemoral (PF) joint grinding test. Thirty-nine percent of subjects were excluded because they had definite osteo-arthritis at the femorotibial joints. Fifty-eight percent of the subjects had felt low back pain within the previous 3 months, and 16% of the subjects complained of PF joint grinding pain. Sixteen percent of the subjects showed knee flexion when standing. There was a significant difference in sacral inclination between the groups with and without PF joint grinding pain ( P < 0.01). Sacral inclination was approximately 5 degrees less in the knee flexion group. A correlation between sacral inclination and PF joint pain is defined, and its prevalence in the elderly is reported. We speculate that this phenomenon is caused by changing of lumbar alignment. In addition, we think this is a new pathological concept that we call the knee-spine syndrome.