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Physiologically, people age at different rates, which leads to a discrepancy between physiological and chronological age. Physiological age should be a priority when considering the indications for adult spinal deformity (ASD) surgery. The primary objective of this study was to determine the characteristics of the postoperative course, surgical outcomes, and complication rates to extend the healthy life expectancy of older ASD patients (≥ 75 years). The secondary objective was to clarify the importance of physiological age in the surgical treatment of older ASD patients, considering frailty.A retrospective review of 109 consecutive patients aged ≥ 65 years with symptomatic ASD who underwent a corrective long fusion with lateral interbody fusion from the lower thoracic spine to the pelvis from 2015 to 2019 was conducted. Patients were classified into two groups according to age (group Y [65-74 years], group O [≥ 75 years]) and further divided into four groups according to the ASD-frailty index score (Y-F, Y-NF, O-F, and O-NF groups). To account for potential risk factors for perioperative course characteristics, complication rates, and surgical outcomes, patients from the database were subjected to propensity score matching based on sex, BMI, and preoperative sagittal spinal alignment (C7 sagittal vertical axis, pelvic incidence-lumbar lordosis, and pelvic tilt). Clinical outcomes were evaluated 2 years postoperatively, using three patient-reported outcome measures of health-related quality of life: the Oswestry Disability Index, Scoliosis Research Society questionnaire (SRS-22), and Short Form 36 (SF-36). Additionally, the postoperative time-to-first ambulation, as well as minor, major, and mechanical complications, were evaluated.In the comparison between Y and O groups, patients in group O were at a higher risk of minor complications (delirium and urinary tract infection). In contrast, other surgical outcomes of group O were comparable to those of group Y, except for SRS-22 (satisfaction) and time to ambulation after surgery, with better outcomes in Group O. Patients in the O-NF group had better postoperative outcomes (time to ambulation after surgery, SRS-22 (function, self-image, satisfaction), SF-36 [PCS]) than those in the Y-F group.Older age warrants monitoring of minor complications in the postoperative management of patients. However, the outcomes of ASD surgery depended more on frailty than on chronological age. Older ASD patients without frailty might tolerate corrective surgery and have satisfactory outcomes when minimally invasive techniques are used. Physiological age is more important than chronological age when determining the indications for surgery in older patients with ASD.

Kitchen elbow sign (KE-Sign) is a skin abnormality on the extensor side of the elbow and forearm that is often observed in patients with adult spinal deformity (ASD). The significance of KE-Sign in surgical cases was investigated. Overall, 114 patients with ASD treated with long spinal fusion were reviewed and divided into KE-Sign positive and negative groups. The preoperative and 1-year follow-up evaluations included radiographic parameters [C7 sagittal vertical axis (SVA), pelvic incidence (PI) and lumbar lordosis (LL)], the Oswestry Disability Index (ODI), visual analogue scales (VASs) for low back pain, leg pain, and satisfaction, and Short Form 36 questionnaire (SF-36). Multi-regression analysis was performed to identify patient satisfaction predictors and improvement in the ODI as dependent variables and preoperative background factors as independent variables. Preoperative characteristics showed no significant difference between both groups. Improvement in the ODI and VAS for satisfaction were significantly superior in the KE-Sign positive group. In multiple regression analysis, KE-Sign and preoperative ODI were significantly associated with improvement in the ODI; age, KE-Sign, preoperative low back pain VAS, and leg pain VAS were significantly associated with satisfaction. KE-Sign can be a predictor of better surgical outcomes in ASD patients.

Spinal fusion surgery is often performed with pelvic fixation to prevent distal junctional kyphosis. The inclusion of spinopelvic fixation has been reported to induce progression of hip joint arthropathy in a radiographic follow-up study. However, its biomechanical mechanism has not yet been elucidated. This study aimed to compare the changes in hip joint moment before and after spinal fusion surgery.This study was an observational study and included nine patients (eight women and one man) who were scheduled to undergo spinopelvic fusion surgery. We calculated the three-dimensional external joint moments of the hip during gait, standing, and climbing stairs before and 1 year after surgery.During gait, the maximum extension moment was 0.51 ± 0.29 and 0.63 ± 0.40 before and after spinopelvic fusion surgery (p = 0.011), and maximum abduction moment was 0.60 ± 0.33 and 0.83 ± 0.34 before and after surgery (p = 0.004), respectively. During standing, maximum extension moment was 0.76 ± 0.32 and 1.04 ± 0.21 before and after spinopelvic fusion surgery (p = 0.0026), and maximum abduction moment was 0.12 ± 0.20 and 0.36 ± 0.22 before and after surgery (p = 0.0005), respectively. During climbing stairs, maximum extension moment was - 0.31 ± 0.30 and - 0.48 ± 0.15 before and after spinopelvic fusion surgery (p = 0.040), and maximum abduction moment was 0.023 ± 0.18 and - 0.02 ± 0.13 before and after surgery (p = 0.038), respectively.This study revealed that hip joint flexion-extension and abduction-adduction moments increased after spinopelvic fixation surgery in the postures of standing, walking, and climbing stairs. The mechanism was considered to be adjacent joint disease after spinopelvic fusion surgery including sacroiliac joint fixation.

Recently, the number of adult spinal deformity surgeries including sacroiliac joint fixation (SIJF) by using an S2 alar iliac screw or iliac screw has increased to avoid the distal junctional failure. However, we occasionally experienced patients who suffered from hip pain after a long instrumented spinal fusion. We hypothesized that long spinal fusion surgery including SIJF influenced the hip joint as an adjacent joint. The aim of this paper was to evaluate the association between spinal deformity surgery including SIJF and radiographic progression of hip osteoarthritis (OA). This study was retrospective cohort study. In total, 118 patients who underwent spinal fusion surgery at single center from January 2013 to August 2018 were included. We measured joint space width (JSW) at central space of the hip joint. We defined reduction of more than 0.5 mm/year in JSW as hip OA progression. The patients were divided into two groups depending on either a progression of hip osteoarthritis (Group P), or no progression (Group N). The number of patients in Group P and Group N was 47 and 71, respectively. Factor that was statistically significant for hip OA was SIJF (p = 0.0065, odds ratio = 7.1, 95% confidence interval = 1.6–31.6). There were no other significant differences by the multiple logistic regression analysis. This study identified spinal fixation surgery that includes SIJF as a predictor for radiographic progression of hip OA over 12 months. We should pay attention to hip joint lesions after adult spinal deformity surgery, including SIJF.

OBJECTIVEFacet cysts may represent a sign of intrinsic facet disease and instability, increasing the importance of less-invasive approaches that limit tissue dissection and improve visualization. The authors developed an intraoperative cyst-dyeing technique, involving the injection of indigo carmine from the facet joint into the cyst, as an adjunct during decompression. This study aimed to evaluate the clinical outcomes and perioperative complication rates of microendoscopic spinal decompression for lumbar spinal stenosis (LSS) and lumbar foraminal stenosis (LFS), caused by facet cysts and to elucidate the efficacy of the cyst-dyeing method in microendoscopic surgery for facet cysts.METHODSForty-eight consecutive patients who underwent surgical treatment with microendoscopic decompression for symptomatic LSS or LFS caused by facet cysts from 2011 to 2018 were reviewed. These patients were divided into two groups: a group that did not receive dye (N), with the patients undergoing surgery from April 2011 to May 2015; and a group that received dye (D), with patients undergoing surgery from June 2015 to March 2018. The authors evaluated the operative time, blood loss, perioperative complications, visual analog scale scores for low-back and leg pain, and Japanese Orthopaedic Association scores. Surgical outcome was evaluated 2 years postoperatively and was compared between groups D and N.RESULTSThe clinical outcomes were generally excellent or good. Group N consisted of 36 patients and group D of 12 patients. Comparing the clinical results, it was found that the cyst-dyeing method reduced the perioperative complication rate, including reduction in dural tears to 0%, and shortened the average operative time by approximately 40 minutes.CONCLUSIONSIn this study, the authors demonstrated that the clinical outcomes of microendoscopic spinal decompression in patients with LSS or LFS caused by facet-joint cysts are generally favorable. Additionally, the adjunctive cyst-dyeing method effectively delineated the cystic and dural boundaries, facilitating safer and more effective cyst separation and neural decompression. Microendoscopic surgery combined with this novel facet cyst-dyeing method is a safe and effective minimally invasive technique for facet-joint cysts.

OBJECTIVEVarious surgical treatments have been reported for vertebral pseudarthrosis after osteoporotic vertebral fracture (OVF). However, the outcomes are not always good. The authors now have some experience with combined anterior-posterior short-segment spinal fusion (1 level above and 1 level below the fracture) using a wide-foot-plate expandable cage. Here, they report their surgical outcomes with this procedure.METHODSBetween June 2016 and August 2018, 16 consecutive patients (4 male and 12 female; mean age 75.1 years) underwent short-segment spinal fusion for vertebral pseudarthrosis or delayed collapse after OVF. The mean observation period was 20.1 months. The level of the fractured vertebra was T12 in 4 patients, L1 in 3, L2 in 4, L3 in 3, and L4 in 2. Clinical outcomes were assessed using the lumbar Japanese Orthopaedic Association (JOA) scale and 100-mm visual analog scale for low-back pain. Local kyphotic angle, intervertebral height, bone union rate, and instrumentation-related adverse events were investigated as imaging outcomes. The data were analyzed using the Wilcoxon signed-rank test.RESULTSThe mean operating time was 334.3 minutes (range 256–517 minutes), and the mean blood loss was 424.9 ml (range 30–1320 ml). The only perioperative complication was a superficial infection of the posterior wound that was cured by irrigation. The lumbar JOA score and visual analog scale value improved from 11.2 and 58.8 mm preoperatively to 20.6 and 18.6 mm postoperatively, respectively. The mean local kyphotic angle and mean intervertebral height were 22.6° and 28.0 mm, respectively, before surgery, −1.5° and 40.5 mm immediately after surgery, and 7.0° and 37.1 mm at the final observation. Significant improvement was observed in both parameters immediately after surgery and at the final observation when compared with the preoperative values. Intraoperative endplate injury occurred in 8 cases, and progression of cage subsidence of 5 mm or more was observed in 2 of these cases. Proximal junctional kyphosis was observed in 2 cases. There were no cases of screw loosening. No cases required reoperation due to instrument-related adverse events. Bone union was observed in all 14 cases that had CT evaluation.CONCLUSIONSThis short-segment fusion procedure is relatively minimally invasive, and local reconstruction and bone fusion have been achieved. This procedure is considered to be attempted for the surgical treatment of osteoporotic vertebral pseudarthrosis after OVF.

OBJECTIVEPersistent lumbar foraminal stenosis (LFS) is one of the most common reasons for poor postoperative outcomes and is a major contributor to “failed back surgery syndrome.” The authors describe a new surgical strategy for LFS based on anatomical considerations using 3D image fusion with MRI/CT analysis.METHODSA retrospective review was conducted on 78 consecutive patients surgically treated for LFS at the lumbosacral junction (2013–2017). The location and extent of stenosis, including the narrowest site and associated pathology (bone or soft tissue), were measured using 3D image fusion with MRI/CT. Stenosis was defined as medial intervertebral foraminal (MF; inner edge to pedicle center), lateral intervertebral foraminal (LF; pedicle center to outer edge), or extraforaminal (EF; outside the pedicle). Lumbar (low-back pain, leg pain) and patient satisfaction visual analog scale (VAS) scores and Japanese Orthopaedic Association (JOA) scores were evaluated. Surgical outcome was evaluated 2 years postoperatively.RESULTSMost instances of stenosis existed outside the pedicle’s center (94%), including LF (58%), EF (36%), and MF (6%). In all MF cases, stenosis resulted from soft-tissue structures. The narrowest stenosis sites were localized around the pedicle’s outer border. The areas for sufficient nerve decompression were extended in MF+LF (10%), MF+LF+EF (14%), LF+EF (39%), LF (11%), and EF (26%). No iatrogenic pars interarticularis damage occurred. The JOA score was 14.9 ± 2.6 points preoperatively and 22.4 ± 3.5 points at 2 years postoperatively. The JOA recovery rate was 56.0% ± 18.6%. The VAS score (low-back and leg pain) was significantly improved 2 years postoperatively (p < 0.01). According to patients’ self-assessment of the minimally invasive surgery, 62 (79.5%) chose “surgery met my expectations” at follow-up. Nine patients (11.5%) selected “I did not improve as much as I had hoped but I would undergo the same surgery for the same outcome.”CONCLUSIONSMost LFS existed outside the pedicle’s center and was rarely noted in the pars region. The main regions of stenosis were localized to the pedicle’s outer edge. Considering this anatomical distribution of LFS, the authors recommend that lateral fenestration should be the first priority for foraminal decompression. Other surgical options including foraminotomy, total facetectomy, and hemilaminectomy likely require more bone resections than LFS treatment. The microendoscopic surgery results were very good, indicating that this minimally invasive surgery was suitable for treating this disease.

ObjectivesThis study aimed to determine the feasibility of ultrasonography (US) in the assessment of cervical vertebral artery (VA) injury compared with computed tomography angiography (CTA) in the emergency room.MethodsA total of 50 VAs from 25 consecutive patients with cervical spine injury admitted to the emergency room in our hospital were analyzed in this study. US and CTA were performed to assess the VA in patients with cervical spine injury, and the sensitivity and specificity of US for CTA was clarified.ResultsThe agreement between US and CTA was 98% (49/50) with 0.92 Cohen's Kappa index. The sensitivity, specificity, and positive and negative predictive values of US were 100%, 97.7%, 85.7%, and 100%, respectively.ConclusionsUS had a sensitivity of 100% compared with CTA in assessment of the VA. It can be used as an initial screening test for VA injury in the emergency room.

Increased signal intensity (ISI) is usually recognized at the disc level of the responsible lesion in the patients with cervical myelopathy. However, it is occasionally seen at the vertebral body level, below the level of compression. We aimed to investigate the clinical significance and the radiographic characteristics of ISI at the vertebral body level.This retrospective study included 135 patients with cervical spondylotic myelopathy who underwent surgery and with local ISI. We measured the local and C2-7 angle at flexion, neutral, and extension. We also evaluated the local range of motion (ROM) and C2-7 ROM. The patients were classified into group D (ISI at disc level) and group B (ISI at vertebral body level).The prevalence was 80.7% (109/135) and 19.3% (26/135) for groups D and B, respectively. Local angle at flexion and neutral were more kyphotic in group B than in group D. The local ROM was larger in group B than in group D. Moreover, C2-7 angle at flexion, neutral and extension were more kyphotic in group B than in group D. Two years later, local angle at flexion, neutral, and extension were also kyphotic in group B than group D; however, local and C2-7 ROM was not significantly different between the two groups. There was no significant difference of clinical outcomes 2 years postoperatively between both groups.Group B was associated with the kyphotic alignment and local greater ROM, compared to group D. As the spinal cord is withdrawn in flexion, the ISI lesion at vertebral body might be displaced towards the disc level, which impacted by the anterior components of the vertebrae. ISI at the vertebral body level might be related to cord compression or stretching at flexion position. This should be different from the conventionally held pincer-mechanism concept.

Background and Study Aims Surgical treatment options for lumbar spinal stenosis (LSS) based on adjacent segment disease (ASD) after spinal fusion typically involve decompression, with or without fusion, of the adjacent segment. The clinical benefits of microendoscopic decompression for LSS based on ASD have not yet been fully elucidated. We aimed to investigate the clinical results of microendoscopic spinal decompression surgery for LSS based on ASD. Patients and Methods From 2011 to 2014, consecutive patients who underwent microendoscopic spinal decompression without fusion for LSS based on ASD were enrolled. Data of 32 patients (17 men and 15 women, with a mean age of 70.5 years) were reviewed. Japanese Orthopaedic Association score and low back pain/leg pain visual analog scale score were utilized to measure neurologic and axial pain outcomes, respectively. Additionally, after the surgeries, we analyzed the magnetic resonance imaging (MRI), computed tomography (CT) scans, or radiographs to identify any new instabilities of the decompressed segments or progression of ASD adjacent to the decompressed segments. Results The Japanese Orthopaedic Association recovery rate at the 5-year postoperative visit was 49.2%. The visual analog scale scores for low back pain and leg pain were significantly improved. The minimum clinically important difference for leg pain (decrease by ≥24 mm) and clinically important difference for low back pain (decrease by ≥38 mm) were achieved in 84% (27/32) and 72% (23/32) of cases, respectively. Regarding new instability after microendoscopic decompression, no cases had apparent spinal instability at the decompression segment and adjacent segment to the decompressed segment. Conclusions Microendoscopic spinal decompression is an effective treatment alternative for patients with LSS caused by ASD. The ability to perform neural decompression while maintaining key stabilizing structures minimizes subsequent clinical instability. The substantial clinical and economic benefits of this approach may make it a favorable alternative to performing concurrent fusion in many patients.

Adult spinal fusion surgery improves lumbar alignment and patient satisfaction. Adult spinal deformity surgery improves saggital balance not only lumbar lesion, but also at hip joint coverage. It was expected that hip joint coverage rate was improved and joint stress decreased. However, it was reported that adjacent joint disease at hip joint was induced by adult spinal fusion surgery including sacroiliac joint fixation on an X-ray study. The mechanism is still unclear. We aimed to investigate the association between lumbosacral fusion including sacroiliac joint fixation and contact stress of the hip joint.A 40-year-old woman with intact lumbar vertebrae underwent computed tomography. A three-dimensional nonlinear finite element model was constructed from the L4 vertebra to the femoral bone with triangular shell elements (thickness, 2 mm; size, 3 mm) for the cortical bone's outer surface and 2-mm (lumbar spine) or 3-mm (femoral bone) tetrahedral solid elements for the remaining bone. We constructed the following four models: a non-fusion model (NF), a L4-5 fusion model (L5F), a L4-S1 fusion model (S1F), and a L4-S2 alar iliac screw fixation model (S2F). A compressive load of 400 N was applied vertically to the L4 vertebra and a 10-Nm bending moment was additionally applied to the L4 vertebra to stimulate flexion, extension, left lateral bending, and axial rotation. Each model's hip joint's von Mises stress and angular motion were analyzed.The hip joint's angular motion in NF, L5F, S1F, and S2F gradually increased; the S2F model presented the greatest angular motion.The average and maximum contact stress of the hip joint was the highest in the S2F model. Thus, lumbosacral fusion surgery with sacroiliac joint fixation placed added stress on the hip joint. We propose that this was a consequence of adjacent joint spinopelvic fixation. Lumbar-to-pelvic fixation increases the angular motion and stress at the hip joint.

Long-term clinical outcomes of microendoscopic laminotomy (MEL) for patients with multilevel radiographic lumbar spinal canal stenosis (LSS) have not been widely explored. The clinical significance and natural progression of additional untreated levels (e.g., remaining radiographic (RR)-LSS not addressed by selective MEL) remain unknown. This retrospective study aimed to investigate the long-term clinical outcomes of selective MEL in LSS patients and compare outcomes between patients with and without remaining RR-LSS to determine the efficacy of this procedure.Forty-nine patients at a single center underwent posterior spinal microendoscopic decompression surgery for neurogenic claudication or radicular leg pain in moderate-to-severe spinal stenosis. The patients were categorized into the RR-LSS-positive and RR-LSS-negative cohorts based on unaddressed levels of stenosis. Pre-operative and 10-year follow-up evaluations, including the Japanese Orthopedic Association (JOA) score, visual analog scale (VAS) score for low back pain and leg pain, Oswestry Disability Index (ODI), and satisfaction, were compared between the groups. Additionally, the need for reoperation was determined.MEL significantly improved JOA scores, lumbar VAS, and ODI over the 10-year postoperative period. Pre-operative characteristics and postoperative outcomes were not significantly different between the cohorts. Overall, 18.4% (9/49) of patients required reoperation during the follow-up period. The reoperation rate in the RR-LSS-positive (13.8%; 4/29) group was similar to that in the RR-LL-negative (15.0%; 3/20) group.MEL is effective for lumbar stenosis, with improved clinical outcomes up to 10 years following surgery. Selective MEL, addressing only symptomatic levels in multilevel stenosis, with residual remaining lumbar stenosis, is similarly effective without increased reoperation rates. Surgeons may consider more limited selective decompression in patients with multilevel stenosis, avoiding the risk and invasiveness of extensive procedures.Level III.

Sacroiliac joint pain (SIJP) is one of the pathological conditions of adjacent segment disorders occurring after adult spinal deformity (ASD) surgery. This study aimed to test the hypothesis that even in ASD surgery using S2 alar-iliac (S2AI) screws, SIJP can develop much earlier than reported previously and can be rescued by ultrasound-guided sacroiliac joint block.Overall, 94 patients with ASD treated with long spinal fusion using S2AI screws were prospectively investigated for SIJP postoperatively, and the effect of ultrasound-guided sacroiliac joint block was evaluated. Additionally, the relationship between the symptomatic side of the SIJP and the surgical procedure; the preoperative and postoperative whole-spine sagittal and coronal alignment, lumbar pelvis sagittal plane alignment, and pelvic incidence-lumbar lordosis were retrospectively compared between the groups with and without SIJP.Eleven of 94 cases (11.7%) developed SIJP. The average onset was 12.0 (±6.2) days after surgery. The "one-finger test," "Gaenslen test," and "tenderness of the posterosuperior iliac spine" had high positivity rates for SIJP. Night pain occurred in 81.8% of patients and was one of the diagnostic features. There were no significant relationships between the symptomatic side of SIJP and the approach-side of lumbar interbody fusion, donor site of the iliac bone graft, or malposition of the S2AI screw. There were no significant differences in preoperative characteristics and radiological parameters between the SIJP-positive and -negative groups preoperatively, postoperatively, or in postoperative changes. Two of the 11 cases required the SIJ block four times, but all patients eventually achieved70% pain relief with no recurrence.For good pain control and physical therapy, the fact that early buttock-groin pain after spinal fusion surgery has a 12% likelihood of being due to SIJP and can be relieved with the ultrasound-guided SIJ block is clinically important for diagnosis and pain management.

STUDY DESIGN This was a retrospective cohort study. OBJECTIVE The objective of this study was to characterize the long-term clinical and radiographic results of articular segmental decompression surgery using endoscopy [cervical microendoscopic laminotomy (CMEL)] for cervical spondylotic myelopathy (CSM) and to compare outcomes to conventional expansive laminoplasty (ELAP). SUMMARY OF BACKGROUND DATA The spinal cord compression in CSM consists of a pincer mechanism due to bulging disk and a hypertrophied ligamentum flavum. The long-term clinical benefits of segmental decompression surgery, which removes the dorsal compressive elements of articular segment in CSM patients, have not yet been elucidated. MATERIALS AND METHODS Consecutive patients with CSM who required surgical treatment were enrolled. All enrolled patients (n=81) underwent CMEL or ELAP. All patients were followed postoperatively for >5 years. The preoperative and 5-year follow-up evaluation included neurological assessment [Japanese Orthopaedic Association (JOA) score], JOA recovery rates, axial neck pain (visual analog scale), and cervical sagittal alignment (C2-C7 subaxial cervical angle). RESULTS Sixty-four patients (CMEL group: 33, ELAP group: 31) were included for analysis. The preoperative JOA score was 10.1 points in the CMEL group and 11.1 points in the ELAP group (P=0.15). The JOA recovery rates were similar, 58.6% in the CMEL group and 55.2% in the ELAP group (P=0.55). The axial neck pain in the CMEL group was significantly lower than that in the ELAP group (P