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To identify the incidence, associated factors, and impact of hospital-acquired Clostridium difficile infection (CDI) among patients who have undergone orthopedic surgery.We retrospectively reviewed the charts of all adults patients who underwent orthopedic surgery from January 2016 through December 2017 at a tertiary hospital.Of 7,363 patients who underwent orthopedic surgical procedures, 52 (0.7%) developed hospital-acquired CDI. The independent factors associated with CDI were age ≥65 years (adjusted odds ratio [aOR], 3.4; P.001), preoperative hospital stay ≥3 days (aOR, 3.7; P.001), operating time ≥3 hours (aOR, 2.5; P.005), and antibiotic use for infection treatment (aOR, 4.3; P.001). After adjusting for the timing of CDI using a multistate model, the mean excess LOS attributable to CDI was 2.8 days (95% confidence interval [CI], 0.4-5.3). The impact of CDI on excess LOS was more evident among patients aged ≥65 years (4.4 days; 95% CI, 1.8-7.0) and those with any comorbidity (5.6 days; 95% CI, 3.0-8.1).The overall incidence of CDI after orthopedic surgery was 0.7%. The occurrence of CDI after orthopedic surgery contributes to increased LOS. The greatest impact of CDI on LOS occurs among elderly patients and patients with comorbidities.

OBJECTIVE Restoring the proper sagittal alignment in adult spinal deformity (ASD) can improve radiological and clinical outcomes, but pseudarthrosis including rod fracture (RF) is a common problematic complication. The purpose of this study was to analyze the methods for reducing the incidence of RF in deformity correction of ASD. METHODS The authors retrospectively selected 178 consecutive patients (mean age 70.8 years) with lumbar degenerative kyphosis (LDK) who underwent deformity correction with a minimum 2-year follow-up. Patients were classified into the non-RF group (n = 131) and the RF group (n = 47). For predicting the crucial factors of RF, patient factors, radiographic parameters, and surgical factors were analyzed. RESULTS The overall incidence of RF was 26% (47/178 cases), occurring in 42% (42/100 cases) of pedicle subtraction osteotomy (PSO), 7% (5/67 cases) of lateral lumbar interbody fusion (LLIF) with posterior column osteotomy, 18% (23/129 cases) of cobalt chrome rods, 49% (24/49 cases) of titanium alloy rods, 6% (2/36 cases) placed with the accessory rod technique, and 32% (45/142 cases) placed with the 2-rod technique. There were no significant differences in the incidence of RF regarding patient factors between two groups. While both groups showed severe sagittal imbalance before operation, lumbar lordosis (LL) was more kyphotic and pelvic incidence (PI) minus LL (PI-LL) mismatch was greater in the RF group (p < 0.05). Postoperatively, while LL and PI-LL did not show significant differences between the two groups, LL and sagittal vertical axis correction were greater in the RF group (p < 0.05). Nonetheless, at the last follow-up, the two groups did not show significant differences in radiographic parameters except thoracolumbar junctional angles. As for surgical factors, use of the cobalt chrome rod and the accessory rod technique was significantly greater in the non-RF group (p < 0.05). As for the correction method, PSO was associated with more RFs than the other correction methods, including LLIF (p < 0.05). By logistic regression analysis, PSO, preoperative PI-LL mismatch, and the accessory rod technique were crucial factors for RF. CONCLUSIONS Greater preoperative sagittal spinopelvic malalignment including preoperative PI-LL mismatch was the crucial risk factor for RF in LDK patients 65 years or older. For restoring and maintaining sagittal alignment, use of the cobalt chrome rod, accessory rod technique, or LLIF was shown to be effective for reducing RF in ASD surgery.

Cervical radiculopathy is characterized by neurological dysfunction caused by compression and inflammation of the spinal nerves or nerve roots of the cervical spine. It mainly presents with neck and arm pain, sensory loss, motor dysfunction, and reflex changes according to the dermatomal distribution. The most common causes of cervical radiculopathy are cervical disc herniation and cervical spondylosis. It is important to find the exact symptomatic segment and distinguish between conditions that may mimic certain cervical radicular compression syndromes through meticulous physical examinations and precise reading of radiographs. Non-surgical treatments are recommended as an initial management. Surgery is applicable to patients with intractable or persistent pain despite sufficient conservative management or with severe or progressive neurological deficits. Cervical radiculopathy is treated surgically by anterior and/or posterior approaches. The appropriate choice of surgical treatment should be individualized, considering the patient’s main pathophysiology, specific clinical symptoms and radiographic findings thoroughly.

OBJECTIVE To analyze ideal indication for combined anterior column realignment (ACR) with short posterior spinal fusion (PSF) and posterior column osteotomy (PCO) for preventing proximal junctional kyphosis (PJK) in adult spinal deformity (ASD) patients with lower lumbar kyphosis and compensatory thoracolumbar lordosis. METHODS A retrospective study was conducted. This study included 27 ASD patients (average age of 66.6 years; one male and 26 females) with lower lumbar kyphosis and compensated thoracolumbar lordosis who underwent short PSF with PCO following ACR from 2006 to 2010. The minimum follow-up period was 5 years. The patients were divided into two groups based on the sagittal vertical axis (SVA) of the last follow-up radiographs, and a comparative analysis was performed evaluating spino-pelvic parameters and clinical outcomes including the Oswestry Disability Index (ODI), Visual Analog Scale (VAS), and complications. RESULTS The mean follow-up time of included patients was 109.7 months, and the mean number of fused segments was 3.7. The uppermost instrumented vertebra was L2 in 18 patients or L3 in nine patients, and lowermost instrumented vertebra was sacrum in all patients. The mean lumbar lordosis (LL) values in the optimal SVA and suboptimal SVA groups were 4.4° and 4.2° preoperatively (P = 0.639), -48.1° and -35° postoperatively (P = 0.007), and -45.2° and -20.7° at the last follow-up (P

Pedicle subtraction osteotomy (PSO) is highly effective as a sagittal correction approach in patients with adult spinal deformity, but relevant issues such as surgical complexity and long-term complications limit its applicability. Recently, minimally invasive techniques have been reported to be useful for surgical treatment of adult spinal deformity; however, few reports have directly compared these techniques with PSO.The purpose of this study was to evaluate the radiological and clinical efficacies of oblique lateral interbody fusion (OLIF) with posterior column osteotomy (PCO) using stiff rods (6.35-mm cobalt chrome [CoCr]).Retrospective comparative study.One-hundred six patients (average age 71.3 years) diagnosed with adult spinal deformity presenting with sagittal imbalance for whom follow-up of over 2 years after sagittal correction (between 2013 and 2017) was available.Description and analysis of X-ray, computed tomography scans, operative time, estimated blood loss, and clinical outcomes (Oswestry Disability Index [ODI] and Visual Analog Scale [VAS]).A comparative analysis was performed evaluating spinopelvic parameters and clinical outcomes including the ODI, VAS, and complications in patients who underwent PSO (PSO group; n=65) or multilevel prepsoas OLIF combined with PCO and open posterior spinal fusion using 6.35-mm CoCr rods (OLIF group; n=41). The authors have no conflicts of interest to disclose.There were no differences in preoperative spinopelvic parameters between the PSO and OLIF groups. Although no differences were observed between the two groups in terms of postoperative SVA (-12.66 mm vs. -16.44 mm), postoperative lumbar lordosis (-71.46° vs. -72.55°), lumbar lordosis correction (77.96° vs. 73.54°), or postoperative pelvic tilt (9.35° vs. 7.17°), the estimated blood loss was significantly lower in the OLIF group (2824 mL vs. 1736 mL, p.05). No differences were observed in clinical outcomes (ODI, VAS, and clinical complications), proximal junctional kyphosis, and spinopelvic parameters between the two groups 2 years after surgery. However, pseudarthrosis during the follow-up period, including rod fracture, occurred less frequently in the OLIF group compared with that in the PSO group (p.05). OLIF was performed from the T12-L1 to L5-S1 regions (124 segments), with an average of three segments per patient. The computed tomography scans immediately after surgery showed an average segmental correction of -18° and 12.9% (16 segments) of 124 segments showed a correction angle of30°.Multilevel OLIF with PCO using a stiff rod to treat severe sagittal imbalance resulted in similar levels of sagittal balance and lordosis correction as obtained by PSO. Multilevel OLIF with PCO using a stiff rod can be an effective alternative to PSO for patients with severe sagittal imbalance.

Scapular stabilization is thought to have an important role in improving pain and dysfunction around the neck and shoulders, but evidence of this is lacking. We aim to systematically review the effect of a scapular stabilization exercise (SSE) on pain and dysfunction in patients with nonspecific chronic neck pain (NP). We searched the PubMed, EMBASE, CINAHL, and Cochrane Library databases using the terms (NP [MeSH] OR NP OR cervical pain OR neck ache OR cervicalgia) AND (scapular exercise OR periscapular exercise OR SSEs). We included suitable studies that met the study’s inclusion criteria. Among the 227 studies identified by our search strategy, a total of four (three randomized controlled studies and one prospective study) met the inclusion criteria. The SSE was intense. It included three sets of 10 repetitions. In most of the studies, the exercises were conducted 3 times per week. Most studies reported that the SSE improved pain and dysfunction in patients with nonspecific chronic NP; however, the reviewed articles did not use the same variables for measurement. Additionally, the sample size was small. Although several studies show that SSE might improve NP and dysfunction, the effects of SSE on pain and dysfunction in the neck region remain unclear because the number of studies was small. Further high-quality studies are necessary to identify the detailed effects of SSE in patients with NP.

A known prevalence of concurrent cervical and lumbar spinal stenosis was shown to be 5%-25%, but there is a lack of evidence regarding direct relationships in canal dimension and canal-body ratio between cervical and lumbar spine. Total 247 patients (mean age: 61 years, male: 135) with cervical and lumbar computed tomography scans were retrospectively reviewed. Midsagittal vertebral body and canal diameters in reconstructed images were measured at all cervical and lumbar vertebrae, and canal-body ratios were calculated. The canal diameter and ratio were also compared according to the gender and age, and correlation analysis was performed for each value. There were significant correlations between cervical (C3-C7) and lumbar (L1-L5) canal dimension (p

STUDY DESIGN: Retrospective study. OBJECTIVE: To analyze proximal junctional kyphosis (PJK) occurrence and surgical outcomes according to degree of lumbar lordosis (LL) correction relative to pelvic incidence (PI). In addition, risk factors of PJK including LL and sagittal vertical axis (SVA) correction were investigated. SUMMARY OF BACKGROUND DATA: PJK is a common complication after adult spinal deformity surgery, and many factors are known to be associated with PJK. However, the effect of degree of LL correction on PJK occurrence is not fully understood. METHODS: Eighty-three degenerative sagittal imbalance patients treated with deformity correction and long instrumented fusion to the sacrum with a minimum follow-up of 2 years were studied. Patients were divided into three groups according to their postoperative LL angle relative to PI using the SRS-Schwab classification: Group A (undercorrection, PI-LL> 10°), Group B (ideal correction, -10°

Study design A cross-sectional design. Purpose To determine the characteristics of lumbar extensor muscle (LEM) size and isometric muscle strength and examine their correlations in women with lumbar degenerative diseases (LDDs). Overview of literature Many studies have evaluated the relationship between muscle size and strength, but the results have been controversial. Methods Seventy-four female patients (mean age, 66 years) who consecutively underwent posterior lumbar interbody fusion (L1-S1) were recruited. The cross-sectional area (CSA) of the back extensor muscles was measured between L1-2 to L5-S1, and the total sum of the CSAs at each disc level was calculated. Back extensor muscle strength was evaluated using a MedX lumbar extension machine. The Oswestry Disability Index (ODI, 0-100) and Visual Analog Scale (VAS, 0-10) of lower back pain were determined. Results The mean CSAs of the LEM at each level (L1/2-L5/S1) and the total sum were 34.3, 36.3, 35.1, 31.4, 21.9, and 156.2 cm2, respectively. The mean isometric strength at each angle (range, 0°-72°) was 32.5, 50.1, 72.0, 88.7, 100.7, 112.2, and 126.2 ft-lb, respectively. The mean ODI and VAS scores were 54.6 and 6.6, and the mean body weight and body mass index (BMI) were 59.9 kg and 24.9 kg/m2, respectively. The CSAs of the upper lumbar level (L1-4) and the total sum of the CSAs were associated with isometric strength, which was negatively correlated with patients' age and ODI and positively associated with body weight and BMI, mainly at higher lumbar flexion angles (48°-72°). Conclusions In women with LDD, LEM sizes of the upper lumbar levels (L1-4) were larger than those of the lower levels (L4-S1) and were positively associated with muscle strength. The upper lumbar levels in patients with LDDs appear to play a compensatory role when degenerative lesions are present in the lower lumbar levels.

Study design A retrospective study. Objective To identify preoperative risk factors causing cervical fifth nerve root palsy (C5 palsy) after laminectomy and fusion (LF). Summary of background data It is well known that postoperative C5 palsy is not rare after cervical surgery. Although there remains controversy, C5 palsy is considered to be more common in patients who had LF than in those who had laminoplasty. However, the reason for the higher incidence of C5 palsy in patients with LF has been poorly understood. Methods A total of 70 consecutive patients (mean age: 60.3 y) who had LF due to cervical myelopathy were reviewed. Patients were divided on the basis of the presence (group P) or absence (group N) of C5 palsy. Among various risk factors for C5 palsy from previous reports, 6 risk factors were selected as follows: (1) preoperative low Japanese Orthopedic Association score, (2) postoperatively increased lordosis, (3) low Pavlov ratio, (4) high signal intensity in the cord at C3-C5, (5) anterior protruding mass lesion compressing the spinal cord, and (6) presence of C4-C5 foraminal stenosis. With these factors, the 2 groups were compared by statistical analysis. Results C5 palsy occurred in 10 patients (14.3%). The mean onset time was 3.5 days (range, 1-8 d) and the mean recovery time was 3.4 months (range, 1-7 mo). There were no significant differences in the preoperative Japanese Orthopedic Association score, cervical lordosis, Pavlov ratio, high signal intensity, and anterior protruding mass between the 2 groups (P>0.05). However, C4-C5 foraminal stenosis was found in 80.0% (8/10) in group P and 21.7% (13/60) in group N. There were significant differences between the 2 groups in C4-C5 foraminal stenosis (P=0.004). Conclusions In this study, a high occurrence rate and risk factor for C5 palsy were verified after LF. Among the various factors, C4-C5 foraminal stenosis was the only risk factor for C5 palsy. Preoperative warning for C5 palsy after LF seems to be imperatively necessary, especially in patients with C4-C5 foraminal stenosis.

OBJECTIVE There is a lack of evidence of how back muscle strength changes after lumbar fusion surgery and how exercise influences these changes. The aim of this study was to evaluate changes in back muscle strength after posterior lumbar interbody fusion (PLIF) and to measure the effects of a postoperative exercise program on muscle strength and physical and mental health outcomes. METHODS This prospective study enrolled 59 women (mean age 58 years) who underwent PLIF at 1 or 2 spinal levels. To assess the effects of a supervised lumbar stabilization exercise (LSE), the authors allocated the patients to an LSE (n = 26) or a control (n = 33) group. The patients in the LSE group performed the LSEs between 3 and 6 months postoperatively. Back extensor strength, visual analog scale (VAS) scores in back pain, and physical component summary (PCS) and mental component summary (MCS) scores on the 36-Item Short Form Health Survey were determined for the both groups. RESULTS Mean strength of the back muscles tended to slightly decrease by 7.5% from preoperatively to 3 months after PLIF (p = 0.145), but it significantly increased thereafter and was sustained until the last follow-up (38.1%, p < 0.001). The mean back muscle strength was similar in the LSE and control groups preoperatively, but it increased significantly more in the LSE group (64.2%) than in the control group (21.7%) at the last follow-up 12 months after PLIF (p = 0.012). At the last follow-up, decreases in back pain VAS scores were more significant among LSE group patients, who had a pain reduction on average of 58.2%, than among control group patients (reduction of 26.1%) (p = 0.013). The patients in the LSE group also had greater improvement in both PCS (39.9% improvement) and MCS (20.7% improvement) scores than the patients in the control group (improvement of 18.0% and 1.1%, p = 0.042 and p = 0.035, respectively). CONCLUSIONS After PLIF, strength in back muscles decreased until 3 months postoperatively but significantly increased after that period. The patients who regularly underwent postoperative LSE had significantly improved back strength, less pain, and less functional disability at 12 months postoperatively.

OBJECTIVEMaintaining lumbosacral (LS) arthrodesis and global sagittal balance after long fusion to the sacrum remains an important issue in the surgical treatment for adult spinal deformity (ASD). The importance and usefulness of LS fixation have been documented, but the optimal surgical long fusion to the sacrum remains a matter for debate. Therefore, the authors performed a retrospective study to evaluate fusion on CT scans and the risk factors for LS pseudarthrosis (nonunion) after long fusion to the sacrum in ASD.METHODSThe authors performed a retrospective study of 59 patients with lumbar degenerative kyphosis (mean age 69.6 years) who underwent surgical correction, including an interbody fusion of the L5–S1, with a minimum 2-year follow-up. Achievement of LS fusion was evaluated by analyzing 3D-CT scans at 3 months, 6 months, 9 months, 1 year, and 2 years after surgery. Patients were classified into a union group (n = 36) and nonunion group (n = 23). Risk factors for nonunion were analyzed, including patient and surgical factors.RESULTSThe overall fusion rate was 61% (36/59). Regarding radiological factors, optimal sagittal balance at the final follow-up significantly differed between two groups. There were no significant differences in terms of patient factors, and no significant differences with respect to the use of pedicle subtraction osteotomy, the number of fused segments, the proportion of anterior versus posterior interbody fusion, S2 alar iliac fixation versus conventional iliac fixation, or loosening of sacral or iliac screws. However, the proportion of metal cages to polyetheretherketone cages and the proportion of sacropelvic fixation were significantly higher in the union group (p = 0.022 and p < 0.05, respectively).CONCLUSIONSLS junction fusion is crucial for global sagittal balance, and the use of iliac screws in addition to LS interbody fusion using a metal cage improves the outcomes of long fusion surgery for ASD patients.

Background Empiric antibiotic therapy for suspected hematogenous vertebral osteomyelitis (HVO) should be initiated immediately in seriously ill patients and may be required in those with negative microbiological results. The aim of this study was to inform the appropriate selection of empiric antibiotic regimens for the treatment of suspected HVO by analyzing antimicrobial susceptibility of isolated bacteria from microbiologically proven HVO. Method We conducted a retrospective chart review of adult patients with microbiologically proven HVO in five tertiary-care hospitals over a 7-year period. The appropriateness of empiric antibiotic regimens was assessed based on the antibiotic susceptibility profiles of isolated bacteria. Results In total, 358 cases of microbiologically proven HVO were identified. The main causative pathogens identified were methicillin-susceptible Staphylococcus aureus (33.5%), followed by methicillin-resistant S. aureus (MRSA) (24.9%), Enterobacteriaceae (19.3%), and Streptococcus species (11.7%). Extended spectrum β-lactamase (ESBL)-producing Enterobacteriaceae and anaerobes accounted for only 1.7% and 1.4%, respectively, of the causative pathogens. Overall, 73.5% of isolated pathogens were susceptible to levofloxacin plus rifampicin, 71.2% to levofloxacin plus clindamycin, and 64.5% to amoxicillin-clavulanate plus ciprofloxacin. The susceptibility to these oral combinations was lower in cases of healthcare-associated HVO (52.6%, 49.6%, and 37.6%, respectively) than in cases of community-acquired HVO (85.8%, 84.0%, and 80.4%, respectively). Vancomycin combined with ciprofloxacin, ceftriaxone, ceftazidime, or cefepime was similarly appropriate (susceptibility rates of 93.0%, 94.1%, 95.8%, and 95.8%, respectively). Conclusions Based on our susceptibility data, vancomycin combined with a broad-spectrum cephalosporin or fluoroquinolone may be appropriate for empiric treatment of HVO. Fluoroquinolone-based oral combinations may be not appropriate due to frequent resistance to these agents, especially in cases of healthcare-associated HVO.

OBJECTIVEThe incidence of proximal junctional kyphosis (PJK) after long-segment fixation in patients with adult spinal deformity (ASD) has been reported to range from 17% to 61.7%. Recent studies have reported using “hybrid” techniques in which semirigid fixation is introduced between the fused and flexible segments at the proximal level to allow a more gradual transition. The authors used these hybrid techniques in a clinical setting and analyzed PJK to evaluate the usefulness of the flexible rod (FR) technique.METHODSThe authors retrospectively selected 77 patients with lumbar degenerative kyphosis (LDK) who underwent sagittal correction and long-segment fixation and had follow-up for > 1 year. An FR was used in 30 of the 77 patients. PJK development and spinal sagittal changes were analyzed in the FR and non-FR groups, and the predictive factors of PJK between a PJK group and a non-PJK group were compared.RESULTSThe patient population comprised 77 patients (75 females and 2 males) with a mean (± SD) follow-up of 32.0 ± 12.7 months (36.7 ± 9.8 months in the non-FR group and 16.8 ± 4.7 months in the FR group) and mean (± SD) age of 71.7 ± 5.1 years. Sagittal balance was well maintained at final follow-up (10.5 and 1.5 mm) in the non-FR and FR groups, respectively. Thoracic kyphosis (TK) and lumbar lordosis (LL) were improved in both groups, without significant differences between the two (p > 0.05). PJK occurred in 28 cases (36.4%) in total, 3 (10%) in the FR and 25 (53.2%) in the non-FR group (p < 0.001). Postoperatively, PJK was observed at an average of 8.9 months in the non-FR group and 1 month in the FR group. No significant differences in the incidence of PJK regarding patient factors or radiological parameters were found between the PJK group and non-PJK group (p > 0.05). However, FR (vs non-FR) and interbody fusion except L5–S1 using oblique lumbar interbody fusion (vs non–oblique lumbar interbody fusion), demonstrated a significantly lower PJK prevalence (p < 0.001 and p = 0.044) among the surgical factors.CONCLUSIONSPJK was reduced after surgical treatment with the FR in the patients with LDK. Solid long-segment fixation and the use of the FR may become another surgical option for spine surgeons who plan and make decisions regarding spine reconstruction surgery for patients with ASD.

STUDY DESIGN A prospective study. OBJECTIVE The aim of this study was to provide methods for predicting ideal trajectory and position of C1 lateral mass screw (C1LMS) from plain radiographs. SUMMARY OF BACKGROUND DATA There has been no study on prediction of C1LMS position using plain radiographs. METHODS A total of 40 consecutive subjects (with 79 screws) who had undergone C1LMS placement were enrolled. To evaluate the C1LMS position, the positions of screw head and tips on anteroposterior radiographs, screw length, and height on lateral radiograph were graded as 0, I, and II, respectively. On the postoperative computed tomography images, we analyzed lateral mass (LM) perforation, screw-thread engagement percent (%), bicortical fixation, extruded screw length, and violation of adjacent joints. RESULTS Screws with tip located medial to LM (tip 0) showed LM perforation in all cases. Polyaxial head located within the LM (head 0) or crossing the lateral margin of the LM (head I) showed no LM perforation. Screw-thread engagement percent was the highest with head I-tip I (medial half of LM) position (97.6%), followed by head 0-tip I (90.5%) and head I-tip II (lateral half of LM) (86.4%). Screws longer than the posterior half of C1 anterior arch (AA) showed bicortical fixation in all cases with mean extruded screw length of 1.9 mm. Adjacent joint was not violated in 98%, with the screw height below half of C1AA. CONCLUSIONS On an anteroposterior radiograph, a C1LMS with the screw head located on the lateral margin of the LM and with the screw tip in the medial half of the LM resulted in the safest and longest trajectory. On lateral radiograph, a screw tip that is placed within the anterior-inferior quadrant of the C1AA results in safe bicortical fixation without injury to the adjacent structures. These plain radiographic findings may be helpful both postoperatively and intraoperatively for assessing the trajectory and length of the screw.

OBJECT The aim of this study was to examine the results of microbiological cultures from local bone autografts used in posterior lumbar interbody fusion (PLIF) and to identify their association with postoperative spinal infection. METHODS The authors retrospectively evaluated cases involving 328 patients who had no previous spinal surgeries and underwent PLIF for degenerative diseases with a minimum 1-year follow-up. Local bone was obtained during laminectomy, and microbiological culture was performed immediately prior to bone grafting. The associations between culture results from local bone autografts and postoperative spinal infections were evaluated. RESULTS The contamination rate of local bone was 4.3% (14 of 328 cases). Coagulase-negative Staphylococcus (29%) was the most common contaminant isolated, followed by Streptococcus species and methicillin-sensitive Staphylococcus aureus. Of 14 patients with positive culture results, 5 (35.7%) had postoperative spinal infections and were treated with intravenous antibiotics for a minimum of 4 weeks. One of these 5 patients also underwent reoperation for debridement during this 4-week period. Regardless of the microbiological culture results, the infection rate after PLIF with local bone autograft was 2.4% (8 of 328 cases), with 5 (62.5%) of 8 patients showing positive results on autograft culture. CONCLUSIONS The incidence of contamination of local bone autograft during PLIF was considerable, and positive culture results were significantly associated with postoperative spinal infection. Special attention focused on the preparation of local bone for autograft and its microbiological culture will be helpful for the control of postoperative spinal infection.

The aim of this study was to determine which antibiotic combinations are appropriate for culture-negative hematogenous vertebral osteomyelitis (HVO), based on the antibiotic-susceptibility pattern of organisms isolated from cases of culture-proven HVO. We conducted a retrospective chart review of adult patients with microbiologically proven HVO in five tertiary-care hospitals over a 7-year period. The appropriateness of empiric antibiotic regimens was assessed based on the antibiotic susceptibility profiles of isolated bacteria. In total, 358 cases of microbiologically proven HVO were identified. The main causative pathogens identified were methicillin-susceptible Staphylococcus aureus (33.5%), followed by methicillin-resistant S. aureus (MRSA) (24.9%), aerobic gram-negative bacteria (21.8%), and Streptococcus species (11.7%). Extended spectrum β-lactamase (ESBL)-producing Enterobacteriaceae and anaerobes accounted for only 1.7% and 1.4%, respectively, of the causative pathogens. Based on the susceptibility results of isolated organisms, levofloxacin plus rifampicin was appropriate in 73.5%, levofloxacin plus clindamycin in 71.2%, and amoxicillin-clavulanate plus ciprofloxacin in 64.5% of cases. These oral combinations were more appropriate for treating community-acquired HVO (85.8%, 84.0%, and 80.4%, respectively) than healthcare-associated HVO (52.6%, 49.6%, and 37.6%, respectively). Vancomycin combined with ciprofloxacin, ceftriaxone, ceftazidime, or cefepime was similarly appropriate (susceptibility rates of 93.0%, 94.1%, 95.8%, and 95.8%, respectively). In conclusion, in a setting with a high prevalence of MRSA HVO, oral antibiotic combinations may be suboptimal for treatment of culture-negative HVO and should be used only in patients with community-acquired HVO. Vancomycin combined with fluoroquinolone or a broad-spectrum cephalosporin was appropriate in most cases of HVO in this study.

There still remains controversy on the pathomechanism of atypical femoral fracture (AFF). The angle of lateral bowing and bone mineral density showed significant differences between subtrochanteric and diaphyseal atypical fracture groups. In addition to the use of bisphosphonate, mechanical factors might play important roles in the occurrence of AFFs. Although AFF could be divided into subtrochanteric and diaphyseal fracture according to the location of fractures, there is a lack of evidence regarding differences between two fractures and etiology of the occurrence. The aim of study is to determine differences between atypical subtrochanteric and diaphyseal fracture in Korean population. Between February 2010 and March 2015, 51 AFFs in 40 patients were included in this study. Their medical records were retrospectively reviewed. The AFF patients satisfied all the diagnostic criteria of the 2014 revised edition of the ASMBR. To analyze the differences according to the location of fracture, the AFFs were divided into subtrochanteric (n = 16) and diaphyseal (n = 35) fracture groups. The following factors were compared between two groups: patients’ demographics, underlying diseases, laboratory findings (serum-25(OH) VitD3, osteocalcin, c-telopeptide, ALP, Ca, and P), bone mineral density (BMD), duration of bisphosphonate (BP) usage, and lateral bowing of the femur at time of the fracture. All AFFs happened in female patients (mean age, 73.8 years) who have received bisphosphonate treatments except three patients. The mean duration of bisphosphonate usage was 95.3 months. Between the two groups, demographic data (age, height, weight, and BMI), underlying diseases, laboratory findings, hip BMD, and duration of BP treatment were comparable to each other (p > 0.05). However, the subtrochanteric fracture group showed higher FNSBA (femoral neck shaft bowing angle, p

It is known that sagittal compensating mechanisms are created for counteracting sagittal imbalance problems; however, they can sometimes be associated with incidents which affect the plan of management. The purpose of this study was to report a case of the occurrence of common iliac vessel displacement into the intervertebral disc space following one of the spinal compensatory mechanisms. The authors demonstrated this case by showing the patient history, physical examination, imaging studies, and treatment strategy as well as by reviewing some related literature. An 81-year-old woman presented with a long history of low back pain with claudication. An upright plain radiograph and flexion–extension study demonstrated a progressive local thoracolumbar kyphosis and losing of lumbar lordosis with significant widening of the intervertebral disc space of L4–L5. An MRI scan and 3D volume rendering spiral computed tomography (3D-CT) revealed an abnormal content which was depicted as common iliac vessels inside the disc space of L4–L5. Consequently, a rare case of the occurrence of common iliac vessel displacement into the intervertebral disc space following one of the spinal compensatory mechanisms was reported. The occurrence of vascular displacement into the intervertebral disc space related to lumbar hyperextension, as a compensating mechanism, is a rare incident but can occur. Consequently, when this mechanism presents with abnormal widening of the intervertebral disc space, especially at the low lumbar level, it should raise surgeon’s concern about the probability of vascular injury when performing a disc procedure. Thorough investigation with imaging studies and selecting the optimum surgical treatment are warranted.

Study design Prospective study. Objective To evaluate the safety of the lateral mass screw (LMS) fixation. Summary of background data LMS fixation has been known to have risk of injury to vertebral artery, nerve root, or facet joints. Methods A consecutive series of 178 patients undergoing planned LMS fixation were studied. Screw fixation was performed using the freehand technique. Entry point of screws was 2-mm medial from the center of the lateral mass. Planned divergent angle of the screw was 30o. Bicortical fixation was tried in all cases. After the surgery, all patients underwent 3-dimensional computed tomographic scan of the cervical spine. We checked the number of screws in each level, divergent angle of the screws, and violation of foramen transversarium (FT), intervertebral foramen, or facet joint by screws. A reliability test was performed. Results Total 1256 screws were fixed with 269 at C3, 318 at C4, 331 at C5, and 338 screws at C6. Mean divergent angle of the screws were 34.7o/33.1o at C3, 33.9 o/32.1o at C4, 34.7o/32.7o at C5, and 33.6o/30.7o at C6. Incidence of FT violation was 0.876%. FT violation was most common at C6 (6/11 violations). Mean divergent angle in cases of FT violation was 15.0o and was significantly smaller than that of safe cases. There was no injury to vertebral artery. There was no violation of intervertebral foramen. Incidence of facet violation was 1.433%. Seventeen facet violations were within fusion segment. Only 1 screw violated healthy facet. Facet violation was most common at C3 (12/18 violations). Conclusion LMS fixation is a safe stabilizing technique with very low incidence of violation of FT, intervertebral foramen, and facet. There is a possibility of FT violation if the divergent angle was small. FT violation was most common at C6. Facet violation was most common at C3.

Case: A 63-year-old woman with lumbar degenerative kyphosis who had undergone total hip arthroplasty 34 months previously presented after having multiple episodes of anterior hip dislocation; evaluation also revealed progressive osteoarthritis in the contralateral hip joint. The patient was managed with sagittal correction with pedicle subtraction osteotomy, which resulted in optimal positioning of the acetabular component and an upright posture. The patient had had no additional dislocation events in the involved hip and had reduced pain in the contralateral hip at the time of the 2-year follow-up. Conclusion: It is important to evaluate and address preexisting sagittal imbalance before performing total hip arthroplasty. However, for patients with neglected sagittal imbalance resulting in recurrent hip dislocation after total hip arthroplasty, sagittal deformity correction may be beneficial.

Functional disability may persist after completing treatment for hematogenous pyogenic vertebral osteomyelitis (HPVO). The objective of this study was to identify factors associated with residual sequelae after treatment of HPVO.We conducted a retrospective study of patients diagnosed with HPVO at 5 tertiary-care hospitals between January 2005 and December 2012. Sequelae were defined as an inability to walk without assistance, bladder/bowel incontinence, and/or unresolved pain that required analgesic therapy at 12 months after completing the HPVO treatment.Of the 279 patients with microbiologically proven HPVO, 79 (28.3%) had sequelae at 12 months posttherapy. Independent risk factors for sequelae were neurologic deficit (adjusted odds ratio [aOR], 3.38), recurrence within 12 months (aOR, 2.45), age ≥ 65 years (aOR, 2.05), C-reactive protein level ≥ 10 mg/dL (aOR, 2.01), and epidural/paravertebral abscess (aOR, 2.00). Among 58 patients with neurologic deficit, sequelae rates differed according to the surgical strategy, as follows: 28.6% (early surgery [48 h]), 55.0% (delayed surgery [≥48 h]), and 66.7% (no surgery) (P = 0.03). Among the 170 patients with abscess, early drainage (72 h) was an independent protective factor for sequelae (aOR, 0.35). The 12-month recurrence rates differed according to the total duration of antibiotic treatment, as follows: 20.5% (4-6 weeks), 18.4% (6-8 weeks), and 5.2% (≥8 weeks) (P 0.001).A substantial proportion of patients with HPVO experienced sequelae after completing treatment. Early surgery for neurologic deficit, early drainage of abscess, and antibiotic therapy of appropriate duration to reduce recurrence may prevent development of sequelae in patients with HPVO.

This study evaluated the characteristics of a newly developed 3-dimensional printed mesh structure titanium spacer and its efficacy for posterior lumbar interbody fusion. Posterior lumbar interbody fusion with this spacer was performed at 53 segments (40 patients; mean age, 64 years; range, 51–73 years). Data were collected prospectively. Radiographic characteristics were analyzed with changes in interbody height, instability of the segments, formation of bone bridges around the implants, and pseudarthrosis, as determined by dynamic radiographs and postoperative computed tomography scans. Clinical outcomes were evaluated with the visual analog scale for the low back and extremities, the Oswestry Disability Index, and the 36-Item Short Form Survey. Radiographically, preoperative anterior and posterior interbody height was significantly increased immediately postoperatively ( P P Orthopedics. 2017; 40(5):e880–e885.]

Study design A retrospective study. Objective The aim of this study was to present a novel, two-stage [posterior and anterior-posterior (P-AP) 540°] procedure for extensive cervical ossification of the longitudinal ligament (OPLL) with kyphotic deformity. Summary of background data The optimal surgical strategy for extensive cervical OPLL remains a controversial issue. Neurological injury and dural defect are complications of anterior surgery, while a posterior surgery can lead to poor clinical outcomes related to incomplete decompression. Methods We analyzed consecutive cases of patients who underwent procedure described herein, which consists of two stages: the first (P: laminectomy and facet release with segmental screw fixations without rod assembly) and the second 1 week later (AP: multilevel anterior cervical discectomy with fusions (ACDFs) at the apex of the deformity without decompression, placement of lordotic grafts, and posterior fusion). To assess the radiographic parameters, extent of OPLL, maximal canal occupying ratio (%), the distances from the maximal compression to the K-line, and C2-7 angle were analyzed. Clinically, we analyzed visual analog scale of neck and arm pain, neck disability index (NDI), Japanese Orthopedic Association (JOA) score, and complications. Results A total of 18 patients were enrolled (M:F = 15:3, mean age 64.5 yrs, mean follow-up was 30 months). The mean extent of the OPLL was 3.8 vertebral body levels. Posterior fusion was performed on a mean 4.5 segments and anterior fusion was on a mean 2.4 segments. The mean C2-7 Cobb angle was improved from 10.5° to -12.2° at follow-up. The K-line distance to the maximal compression and canal occupying ratio were improved from -3.3 mm, 73.5% to 3.8 mm, 38.4%, respectively. Preoperative NDI and JOA scores were significantly improved (18.5 to 9.4 and 8.2 to 14.8) at the last follow-up. Conclusion The 540° P-AP procedure could provide safe decompression, cervical realignment, and favorable outcomes without the disadvantages of the conventional anterior and/or posterior surgery for extensive cervical OPLL with kyphotic deformity. Level of evidence 4.

Background and Objective Although sirtuin 1 (SIRT1) over-expression and resveratrol exert anti-inflammatory and proinflammatory effects, their effects and the mechanism of action on human gingival fibroblast (HGF)-mediated inflammation are unknown. The aim of this study was to demonstrate the effects of activating SIRT1 using resveratrol and recombinant adenovirus encoding SIRT1 (Ad-SIRT1) on the expression of proinflammatory cytokines and to elucidate its mechanism of action of lipopolysaccharide (LPS) and nicotine stimulated-HGF. Material and Methods Cytotoxicity and the production of reactive oxygen species (ROS) were measured using the 3-(4,5-dimethylthiazolyl-2-yl)-2,5-diphenyltetrazolium bromide (MTT) assay and flow cytometry, respectively. The amount of prostaglandin E2 (PGE2) released into the culture medium was measured by radioimmunoassay. mRNA and protein levels were analyzed using RT-PCR and western blotting, respectively. Results Nicotine and LPS up-regulated the expression of SIRT1 mRNA and SIRT1 protein in a time- and concentration-dependent manner. Resveratrol and Ad-SIRT1 decreased LPS and nicotine-induced cytotoxicity, ROS and PGE2 production, and expression of cyclooxygenase-2 in HGFs. Resveratrol and Ad-SIRT1 inhibited nicotine and LPS-mediated protein kinase C (PKC), phosphatidylinositol 3-kinase (PI3K), p38, ERK, JNK, MAPK and nuclear factor-kappa B (NF-κB) activation. Conclusion This study is the first to show that the anti-inflammatory and cytoprotective effects of SIRT1 activation in HGFs occur through the PKC, PI3K, MAPK and NF-κB pathways.

Background and Objective: Analyzing responses of human periodontal ligament cells to mechanical stress and mechanotransduction is important for understanding periodontal tissue physiology and remodeling. It has been shown that the cellular response to mechanical stress can vary according to the type and duration of force and to extracellular attachment conditions. This study investigated the gene-expression profile of human periodontal ligament cells cultured in two-dimension (2D) and three-dimension (3D) conditions after application of compressive stress for 2 and 48 h. Material and Methods: Human primary periodontal ligament cells were obtained from premolars extracted for orthodontic purposes. Cells were cultured in a conventional 2D culture dish or in 3D collagen gel and compressive stress was applied for 2 and 48 h. Control cells were cultured under identical conditions but without the application of compressive stress. After the application of compressive stress, total RNA was extracted and a cDNA microarray was performed. Microarray data were analyzed using statistical methods, including david and gene set enrichment analysis to identify significant signaling pathways. Real-time PCR was performed for five mRNAs in order to confirm the cDNA microarray results. Results: The cDNA microarray analysis revealed that after application of compressive stress for 2 h, 191 and 553 genes showed changes in their expression levels in 2D and 3D cultured cells, respectively. After application of compressive stress for 48 h, 280 and 519 genes showed changes in their expression levels in 2D and 3D cultured cells, respectively. Euclidean clustering method was used to demonstrate the gene-expression kinetics. Conclusion: Analysis of the results showed that several signaling pathways, including the MAPK pathway and the focal adhesion kinase pathway are relevant to the compressive force-induced cellular response. 2D and 3D cultured cells showed significantly different gene-expression profiles, suggesting that cellular attachment to extracellular matrix influences cellular responses to mechanical stresses.

Kim Y-S, Shin S-I, Kang K-L, Herr Y, Bae W-J, Kim E-C. Nicotine and lipopolysaccharide stimulate the production of MMPs and prostaglandin E2 by hypoxia-inducible factor-1α up-regulation in human periodontal ligament cells. J Periodont Res 2012; 47: 719–728. © 2012 John Wiley & Sons A/S Background and Objective: Although hypoxia-inducible factor 1α (HIF-1α) is up-regulated in the periodontal pockets of periodontitis patients, the expression and precise molecular mechanisms of HIF-1α remain unknown in human periodontal ligament cells (PDLCs). The aim of this study was to explore the effects, as well as the signaling pathway, of nicotine and lipopolysaccharide (LPS) on the expression of HIF-1α and on the production of its target genes, including cyclooxygenase-2 (COX-2)-derived prostaglandin E2 (PGE2), MMP-2 and MMP-9 in PDLCs. Material and Methods: The expression of COX-2 and HIF-1α proteins was evaluated using western blotting. The production of PGE2 and MMPs was evaluated using enzyme immunoassays and zymography, respectively. Results: LPS and nicotine synergistically induced the production of PGE2, MMP-2 and MMP-9, and increased the expression of MMP-2, MMP-9, COX-2 and HIF-1α proteins. Inhibition of HIF-1α activity by chetomin or knockdown of HIF1α gene expression by small interfering RNA markedly attenuated the production of LPS- and nicotine-stimulated PGE2 and MMPs, as well as the expression of COX-2 and HIF-1α. Furthermore, pretreatment with inhibitors of COX-2, p38, extracellular signal-regulated kinase, Jun N-terminal kinase, protein kinase C, phosphatidylinositol 3-kinase and nuclear factor-kappaB decreased the expression of nicotine- and LPS-induced HIF-1α and COX-2, as well as the activity of PGE2 and MMPs. Conclusion: These data demonstrate novel mechanisms by which nicotine and LPS promote periodontal tissue destruction, and provide further evidence that HIF-1α is a potential target in periodontal disease associated with smoking and dental plaque.

Study design Radiological analysis and classification of normal patterns of sagittal alignment of the spine. Objective To classify the patterns of sagittal alignment of the spine in young asymptomatic adults and analyze the differences in the various spinal and pelvic parameters according to these patterns. Summary of background data Previous studies reported that the overall sagittal pattern and balance were more important than the normative values. There are few studies on white populations, classifying the normal patterns of sagittal curvature, and no studies on Asian populations. Methods Whole spine, standing lateral radiographs of 86 Korean volunteers were taken. The pelvic and spinal parameters (total thoracic kyphosis, horizontal thoracic level, thoracolumbar junctional angle (TLJA), total lumbar lordosis, lower lumbar lordosis, horizontal lumbar level (HLL), lumbar inclination, pelvic tilt, sacral slope (SS), pelvic incidence, spinal balance, spinopelvic balance, and sacropelvic balance) were measured and the correlations of all parameters were analyzed. The volunteers were classified in to three types according to their HLL. The data were analyzed statistically to determine the differences in the parameters and balance between the three types. Results The HLL showed a significant correlation with the lumbar inclination, junctional level, TLJA, spinal balance, spinopelvic balance, and SS on analyzing the correlation of the parameters. As HLL moved caudally, the TLJA and lumbar inclination increased, whereas the lower lumbar lordosis, pelvic incidence, and SS decreased and spinal balance became more negative. There were no significant differences in total thoracic kyphosis and sacropelvic balance between the three types. Conclusion The patterns of sagittal alignment could be classified into three types showing that the spinal balance becomes more negative, the lumbar inclination and TLJA increase, the SS and pelvic incidence decrease, and lumbar lordotic curves becomes shorter as the patterns of sagittal curvature move toward type 3. This classification in young adults should be considered individually as a reference for surgeons aiming to restore the lumbar lordosis and sagittal alignment in degenerative lumbar fusion surgery.

BACKGROUND: Correction of deformity in adult isthmic spondylolisthesis can affect the pelvic parameters and sagittal balance. OBJECTIVE: To evaluate the correlation with the amount of deformity correction and the subsequent change in pelvic parameters after surgical correction of adult isthmic spondylolisthesis and to determine which deformity parameter most affects the postoperative restoration of spinopelvic sagittal alignment. METHODS: Fifty-eight patients with 1-level isthmic spondylolisthesis were included. Their average age was 55 years (range, 24-76 years). All patients underwent operation by posterior lumbar interbody fusion and posterior instrumentation. The pre- and postoperative sacral slope, pelvic tilt, lumbar lordosis (LL), and sagittal balance were measured, and then the correlation between these parameters and deformity parameters such as slip degree, slip angle, and height of the intervertebral disc (HOD) was evaluated. RESULTS: The slip degree, slip angle, and HOD were significantly recovered after surgery. Pelvic parameters and sagittal balance changed subsequently. Sacral slope was increased by 4.4 degrees, and pelvic tilt was decreased by 4.4 degrees. LL was increased by 5.2 degrees and sagittal balance was displaced 5.6 mm posteriorly. Only the restoration of the HOD showed a significant correlation with the change in LL (r = 0.305, P = .02) and sagittal balance (r = 0.377, P = .004). CONCLUSION: Surgical correction of adult isthmic spondylolisthesis with posterior lumbar interbody fusion and posterior instrumentation resulted in improvement of sacral slope, pelvic tilt, LL, and sagittal balance. Only restoration of the HOD was significantly correlated with improvement of LL and sagittal balance. Therefore we presume it is important to restore the HOD in surgical correction of adult isthmic spondylolisthesis.

Object Thoracic ossification of the ligamentum flavum (OLF), a main cause of thoracic myelopathy, is an uncommon disease entity. It is seen mostly in East Asia, although the majority of reports have issued from Japan. In the present study, the clinical features and prognostic factors of thoracic OLF were examined in a large number of Korean patients. Methods Data from 51 consecutive patients who underwent decompressive laminectomy with or without fusion for thoracic OLF between 1998 and 2008 were retrospectively analyzed. Patients were evaluated pre- and postoperatively using the modified Japanese Orthopedic Association (JOA) scale (maximum total score of 11). Patient age, sex, preoperative symptoms, duration of initial symptoms, number of involved segments, duration of follow-up, presence of dural adhesion (dural tearing), intramedullary high signal intensity, morphological classification of OLF (axial or sagittal), coexisting disease, and fusion or no fusion were also evaluated. Surgical outcomes were assessed using JOA recovery rate/outcome scores, and patient satisfaction grades and prognostic factors were analyzed. Results There were 18 men and 33 women with a mean age of 60.9 years (range 38–80 years). A mean preoperative JOA score of 5.5 improved to a mean score of 7.4 at the last follow-up (mean 52 months after surgery). The mean duration of the initial symptoms was 34.5 months (range 0.1–240 months) prior to surgery. The most common symptoms were motor dysfunction (80%); sensory deficit (67%); and pain, numbness, and claudication (59%) in the lower extremities. Knee hyperreflexia appeared in 69% of the patients. There were a total of 130 ossified segments, and the mean number of segments per patient was 2.6. Ninety-two (71%) of 130 segments were located below T-8. Recovery outcomes were good (18 patients), fair (16 patients), unchanged (11 patients), or worse (6 patients). Thirty-one patients (61%) were satisfied with their operations. Patients with a beak type of OLF on sagittal MR images experienced a higher recovery rate and a better satisfaction grade than did those with a round OLF. The patients with higher preoperative JOA scores demonstrated significantly higher JOA scores postoperatively (p < 0.001), and the preoperative JOA score had a significant correlation with the recovery rate in patients exhibiting mainly motor dysfunction (p = 0.040, r = 0.330). Conclusions Of the thoracic OLF studies published to date, the present analysis involves the largest Korean population. The most common symptoms of thoracic OLF were motor dysfunction and sensory deficit in the lower extremities, although pain, numbness, and claudication were observed in some patients and were notably accompanied by knee hyperreflexia. At a minimum of 2 years after surgery for thoracic OLF, operative outcomes were generally good, and the prognostic factors affecting good surgical outcomes included a beak type of OLF and a preoperative JOA score > 6.

Spinal implant infection is a rare but significant complication of spinal fusion surgery, and the most common pathogen is Staphylococcus aureus. It is difficult to treat due to this pathogen's biofilm-forming ability and antibiotic resistance. We evaluated the therapeutic outcome of treatments for S aureus spinal implant infections. We retrospectively reviewed all patients with S aureus spinal implant infections at 11 tertiary-care hospitals over a 9-year period. Parameters predictive of treatment failure and recurrence were analyzed by Cox regression. Of the 102 patients with infections, 76 (75%) were caused by methicillin-resistant S aureus (MRSA) and 51 (50%) were late-onset infections. In all, 83 (81%) patients were managed by debridement, antibiotics, and implant retention (DAIR) and 19 (19%) had their implants removed. The median duration of all antibiotic therapies was 52 days. During a median follow-up period of 32 months, treatment failure occurred in 37 (36%) cases. The median time to treatment failure was 113 days, being

Background context Advantages of cervical artificial disc replacement (ADR) are to preserve segmental range of motion (ROM) and avoid adjacent segmental disease. To achieve successful outcome after cervical ADR, ROM maintenance is important, but few authors have investigated the factors that influence the postoperative segmental ROM. Purpose To evaluate the factors that influence the postoperative segmental ROM after cervical ADR. Study design/setting A retrospective clinical study. Patient sample Forty-one consecutive cervical ADR cases were analyzed. Outcome measures Disc height, segmental and overall ROM, and clinical parameters checked with Neck Disability Index (NDI) and visual analog scale (VAS) in neck and arm pain were assessed. Methods There were 21 men and 20 women with a mean age of 45 years (range, 27–61 years). All cases were followed up for more than 2 years (range, 24–54 months; average, 31 months). Angles of the inserted implant on the immediate postoperative lateral radiographs, segmental and overall ROM (full flexion angle−full extension angle), disc height increment (immediate postoperative disc height−preoperative disc height), and adjacent segment changes at cephalad and caudal disc space were measured. Correlations between the factors and segmental ROM at last follow-up were analyzed. Results Mean preoperative NDI was improved from 61.0 preoperatively to 11.5 at last follow-up, and mean VAS in the neck pain decreased from 56.8 preoperatively to 11.8 postoperatively and arm pain decreased from 68.1 to 18.0. The mean preoperative segmental ROM changed from 7.4±3.2° preoperatively to 10.4±5.9° at last follow-up, and mean preoperative disc height increased from 6.4±1.0 (4.1–8.4) mm preoperatively to 7.9±1.0 (6.3–9.9) mm postoperatively. The segmental ROM at last follow-up was not significantly correlated with preoperative segmental and overall ROM, angle of inserted implant, VAS, or age (p>.05). However, the segmental ROM at last follow-up was significantly correlated with the disc height increment (p=.046, r=0.374) and preoperative NDI (p=.026, r=0.412). The patient group with the postoperative segmental ROM greater than 10° had a significantly lower mean preoperative disc height than the group with the segmental ROM less than 10° (p=.050). Conclusions At a minimum of 2 years after cervical ADR, clinical outcomes were satisfactory in terms of function and pain scores. Within our results, the segmental ROM was not affected by preoperative ROM but postoperative disc height increment positively and preoperative disc height negatively.

STUDY DESIGN A retrospective study. OBJECTIVE The aim of this study was to analyze the clinical outcomes and related factors of C5 palsy (C5P) following posterior cervical laminectomy with fusion (LF) compared with laminoplasty (LP). SUMMARY OF BACKGROUND DATA C5P is more common after LF than after LP. There have not been any studies on C5P-LF compared with C5P-LP. METHODS We retrospectively analyzed consecutive cases that underwent cervical LF for nontraumatic cervical myelopathy or myeloradiculopathy (CMR). To analyze the related factors, C5P-LF and non-C5P-LF groups were compared. To assess the clinical parameters, preoperative diagnosis, clinical symptoms, surgical procedures, and outcome instruments were analyzed. Radiographically, we analyzed preoperative maximal spinal cord compression ratio, presence of C4-5 foraminal stenosis (FS), and correction angles on the sagittal plane. To compare with C5P-LP, we analyzed the incidence, time of onset, grade of muscle weakness, other accompanying cervical nerve root palsies, recovery time, and degree of final recovery in the C5P-LF and the C5P-LP groups of 100 consecutive LPs. RESULTS A total of 90 LF patients were enrolled (M:F = 54:36, mean age 61.1 yr, mean follow-up 35 months). C5P occurred in 26 patients (28.9%), and 14 cases (53.8%) demonstrated other cervical nerve root palsies. Clinically significant differences were observed between the C5P-LF and non-C5P-LF groups with regard to preoperative clinical diagnosis (CMR 88.5:42.2%, P

Vitamin D is considered essential for bone and muscle health, and some studies have demonstrated the positive effects of vitamin D on metabolic diseases and cancer. Nevertheless, a high prevalence of vitamin D deficiency has been reported in various populations, regardless of country or race. However, no studies regarding the prevalence of vitamin D deficiency in Korean orthopedic patients currently exist. This cross-sectional study included 272 male and 937 female patients aged 50 years and older who were consecutively admitted to the authors’ orthopedic department. Vitamin D (25-hydroxy vitamin D), bone turnover markers (osteocalcin, c-telopeptide), and bone mineral density were measured. The prevalence of vitamin D deficiency and its association with other factors were evaluated. Mean patient age was 67.2±8.9 years, and mean level of vitamin D was 16.1±9.1 ng/mL. Overall, 91.2% of patients had deficient (P Orthopedics. 2015; 38(10):e898–e903.]

Epidural venous engorgement can result from various lesions, such as arteriovenous malformation, thrombosis or occlusion of the inferior vena cava (IVC), or an abdominal masslike lesion. Most patients with these problems complain of low-back pain, radicular pain, or neurogenic claudication, which are symptoms suggestive of disc herniation or spinal stenosis. However, these patients rarely exhibit neurological deficits or cauda equina syndrome. The authors encountered a case of a 60-year-old man presenting with lower-extremity weakness and voiding difficulty for a period of 1 year. To investigate the patient’s myelopathy-mimicking symptoms, a lumbar spine MRI scan was performed. The MR images exhibited tortuous and dilated spinal vessels compressing the spinal cord and thecal sac at the T11-L3 level, which were concurrent with syringomyelia evidenced by a 22 × 2.5-mm cyst at the T11–12 level. 3D CT scanning of the whole aorta revealed total occlusion and regression of the IVC in the intrahepatic region 3 cm inferior to the right atrium and dilation of multiple collateral veins. The patient was diagnosed with chronic Budd-Chiari syndrome Type I. The authors performed venography, followed by intrahepatic IVC recanalization via stent placement under fluoroscopic and ultra sonographic guidance and without surgical exploration. After this treatment, there was a marked decrease in epidural venous engorgement and the patient’s symptoms resolved almost completely. This case indicates that epidural venous engorgement at thoracolumbar levels may cause symptoms suggestive of myelopathy and can be successfully treated by minimally invasive procedures to eliminate the underlying causes.