Postoperative Residual Coronal Decompensation Inhibits Self-image Improvement in Adolescent Patients with Idiopathic Scoliosis

Methods@#A total of 120 patients with AIS who underwent posterior spinal fusion from August 2006 to March 2017 at our facility and were followed up for 2 years or more were included. Radiological parameters were measured on whole-spine anteroposterior and lateral radiographs. Revised SRS-22 (SRS-22r) values were also recorded. Coronal trunk imbalance was defined as a deviation of ≥2.0 cm between the C7PL and the central sacral vertical line. Patients with and without coronal trunk imbalance at 2 years after surgery were defined as D (+) (decompensation type) and D (-), respectively. Mean SRS-22r values, including function, pain, self-image, mental health, and subtotal were compared between the D (+) and D (-) groups. Logistic regression analysis was performed to detect the preoperative factors related to D (+) using predictors, including curve type, maximum Cobb angle, and coronal trunk imbalance. @*Results@#At 2 years after surgery, the D (+) group had a significantly lower self-image in the domain of SRS-22r scores compared with the D (-) group. Preoperative coronal trunk imbalance was significantly related to D (+) but not to significant changes in the postoperative SRS-22 score in any of the SRS-22 domains. @*Conclusions@#Postoperative C7PL deviation lowers the self-image in patients with AIS. Patients with preoperative coronal trunk imbalance were significantly more likely to be D (+).

Rehabilitation of a Patient with Severe COVID-19 Using Extracorporeal Membrane Oxygenation：A Case Report / The Japanese Journal of Rehabilitation Medicine

Coronavirus disease 2019 (COVID-19) has been spreading globally since 2019；however, comprehensive rehabilitation of elderly patients with COVID-19 pneumonia remains a challenge. A 76-year-old American woman with COVID-19 pneumonia was admitted to our hospital. Because her disease was complicated by acute respiratory distress syndrome (ARDS), she was treated with intensive care, including invasive ventilation and extracorporeal membrane oxygenation (ECMO). During and after intensive care, she exhibited physical symptoms such as weakness, pain, shortness of breath, and difficulty in movement and exercise. Furthermore, during approximately 3.5 months of hospitalization, she received swallowing and speech therapies along with physical therapy. These rehabilitation therapies enabled her to get home in the United States. Her rehabilitation schedule had to be carefully planned according to her symptoms and infectiousness of COVID-19. This paper highlights few important points regarding the difficulty in rehabilitation including that of physical function, mental health, and cognitive function of patients with COVID-19. Furthermore, this report provides a problem-solving approach for long-term rehabilitation in elderly patients with COVID-19 pneumonia.

Ten-Year Results of Reconstruction for Rheumatoid Cervical Spine Lesions and Occurrence Factor of Subaxial Subluxation

STUDY DESIGN: Retrospective chart review. PURPOSE: This study evaluated long-term surgical outcomes of computer-assisted reconstruction using transarticular or cervical pedicle screws for cervical spine lesions caused by advanced rheumatoid arthritis (RA). OVERVIEW OF LITERATURE: We routinely employ C1–C2 transarticular and cervical pedicle screw instrumentation to reconstruct advanced and unstable RA cervical lesions. However, few reports are available on the long-term results of surgical reconstruction for rheumatoid cervical disorders, particularly regarding cervical pedicle screw fixation. METHODS: Six subjects (all female) with RA cervical lesions who underwent atlantoaxial or occipitocervical fixation and were followed for at least 10 years were retrospectively studied. A frameless, stereotactic, optoelectronic, computed tomography-based image guidance system was used for correct screw placement. Variables including the Japanese Orthopaedic Association score, EuroQol, Ranawat value, and C2–C7 angle before and 2, 5, and 10 years after surgery were assessed along with the occurrence of subaxial subluxation (SAS). RESULTS: Mean age at initial surgery was 58.2±7 years (range, 51–68 years), and mean follow-up period was 141±11 months (range, 122–153 months). Lesions included atlantoaxial subluxation (AAS, n=2) and AAS+vertical subluxation (n=4). Mean C2–C7 lordotic angle before and 2, 5, and 10 years after surgery was 20.1°±6.1°, 21.0°±4.0°, 18.8°±4.7°, and 17.8°±5.3°, respectively. SAS did not occur in cases maintaining the C2–C7 lordotic angle. In two cases where the C2–C7 lordotic angle declined from 5 years postoperatively, SAS occurred at the C2–C3 level in one and at the C4–C5 level in the other, both of which required reoperation. CONCLUSIONS: Patients with rheumatoid cervical lesions who undergo atlantoaxial or occipitocervical fixation using C1–C2 transarticular or pedicle screws carry a risk of SAS for up to 10 years postoperatively, which may require reoperation.

Additive effects of eldecalcitol in poorly responding long-term bisphosphonate treatment for osteoporosis

OBJECTIVES: We examined whether eldecalcitol (ELD) provided additive bone mineral density (BMD) and bone turnover marker gains in patients undergoing long-term bisphosphonate (BP) usage, especially in osteoporotic individuals exhibiting a poor response to BPs. METHODS: Forty-two post-menopausal patients with primary osteoporosis and low lumbar BMD (L-BMD) and/or bilateral total hip BMD (H-BMD) values receiving long-term BP treatment were prospectively enrolled. Serum bone alkaline phosphatase (BAP) was measured as a bone formation marker and urinary N-terminal telopeptide of type I collagen (NTX) was assessed as a bone resorption marker. L-BMD, H-BMD, and femoral neck BMD (N-BMD) were recorded before, at the commencement of, and during ELD administration. RESULTS: BAP and urinary NTX were significantly decreased by BP therapy prior to ELD. ELD addition further significantly decreased the bone turnover markers (both p < 0.01). The mean L-BMD increase rate was 0.2% (p = 0.81) from 2 to 1 years before ELD administration, −0.7% (p = 0.30) during the year before ELD, and 2.9% (p < 0.01) during 1 year of ELD. Similar findings were observed for the mean increase rate of H-BMD, with values of 0.2% (p = 0.55), −0.7% (p < 0.01), and 1.2% (p < 0.01), respectively. The mean N-BMD increase rate was significantly increased after ELD administration (1.1%, p = 0.03) despite no gains by BP therapy alone. CONCLUSIONS: This study suggests that ELD addition may be useful for osteoporotic patients exhibiting a diminished long-term BP therapy response.

Compliance and discontinuation of denosumab treatment in postmenopausal Japanese women with primary osteoporosis or rheumatoid arthritis and osteoporosis

OBJECTIVES: The aim of this study was to examine the discontinuation and occurrence of fracture during denosumab treatment in Japanese women with primary osteoporosis or rheumatoid arthritis (RA) with osteoporosis. METHODS: This retrospective study included 143 patients with primary osteoporosis and 96 patients with RA and osteoporosis who were treated with denosumab. Treatment discontinuation, fracture occurrence, lumbar spine (L1–4) bone mineral density (LS-BMD), and bilateral total hip BMD (TH-BMD) were examined before and at 1 and 2 years after treatment commencement. RESULTS: In the primary osteoporosis group, 32 cases dropped out and no fractures occurred from 0 to 1 year. Eighteen cases were lost to follow-up and no fractures were noted from 1 to 2 years. In the RA with osteoporosis group, 7 cases dropped out and no fracture occurred from 0 to 1 year. Twenty-one cases were lost to follow-up and 2 nonvertebral fractures were noted from 1 to 2 years. In this group, 13 cases dropped out from 1 to 2 years and 16 cases dropped out during the 2-year study period due to economic reasons. LS-BMD and TH-BMD values increased continuously for 2 years of treatment in both primary osteoporosis and RA with osteoporosis groups. CONCLUSIONS: These results suggest that during denosumab therapy, the discontinuation rate is expected to remain low during 2 years of treatment in primary osteoporotic patients. In RA patients with osteoporosis, however, the discontinuation rate may increase due to economic reasons from 1 to 2 years of therapy.

Monthly minodronate inhibits bone resorption to a greater extent than does monthly risedronate

As a bisphosphonate, minodronate (MIN) is one of the strongest inhibitors of bone resorption. However, there have been no reports directly comparing the antiresorptive effects of monthly MIN with those of monthly risedronate (RIS). We enrolled 30 cases of osteoporosis (OP; 16 in the MIN group [mean age: 68.2 years] and 14 in the RIS group [mean age: 68.1 years]) to investigate the early effects of treatment by monthly MIN or RIS over a 4-month period using bone turnover marker values. Only female patients were enrolled to avoid gender bias. Urinary cross-linked N-telopeptide of type I collagen (NTX) before treatment and at 1, 2, and 4 months of therapy, as well as serum bone alkaline phosphatase and alkaline phosphatase before treatment and at 4 months afterwards, were evaluated. All bone turnover marker values were significantly decreased at 4 months in both groups. The changes in urinary NTX at the study end point for RIS and MIN were -30.1% and -63.1%, respectively. From 2 months of treatment, the antiresorptive effects on urinary NTX by MIN were significantly higher than those by RIS, indicating that MIN more immediately and strongly inhibited bone absorption. Thus, monthly MIN seems to suppress bone resorption faster and more strongly than RIS in OP treatment.

Comparison of Clinical and Radiological Results of Posterolateral Fusion and Posterior Lumbar Interbody Fusion in the Treatment of L4 Degenerative Lumbar Spondylolisthesis

STUDY DESIGN: Multicenter analysis of two groups of patients surgically treated for degenerative L4 unstable spondylolisthesis. PURPOSE: To compare the clinical and radiographic outcomes of posterolateral fusion (PLF) and posterior lumbar interbody fusion (PLIF) for degenerative L4 unstable spondylolisthesis. OVERVIEW OF LITERATURE: Surgery for lumbar degenerative spondylolisthesis is widely performed. However, few reports have compared the outcome of PLF to that of PLIF for degenerative L4 unstable spondylolisthesis. METHODS: Patients with L4 unstable spondylolisthesis with Meyerding grade II or more, slip of >10degrees or >4 mm upon maximum flexion and extension bending, and posterior opening of >5 degree upon flexion bending were studied. Patients were treated from January 2008 to January 2010. Patients who underwent PLF (n=12) and PLIF (n=19) were followed-up for >2 years. Radiographic findings and clinical outcomes evaluated by the Japanese Orthopaedic Association (JOA) score were compared between the two groups. Radiographic evaluation included slip angle, translation, slip angle and translation during maximum flexion and extension bending, intervertebral disc height, lumbar lordotic angle, and fusion rate. RESULTS: JOA scores of the PLF group before surgery and at final follow-up were 12.3+/-4.8 and 24.1+/-3.7, respectively; those of the PLIF group were 14.7+/-4.8 and 24.2+/-7.8, respectively, with no significant difference between the two groups. Correction of slip estimated from postoperative slip angle, translation, and maintenance of intervertebral disc height in the PLIF group was significantly (p<0.05) better than those in the PLF group. However, there was no significant difference in lumbar lordotic angle, slip angle and translation angle upon maximum flexion, or extension bending. Fusion rates of the PLIF and PLF groups had no significant difference. CONCLUSIONS: The L4-L5 level posterior instrumented fusion for unstable spondylolisthesis using both PLF and PLIF could ameliorate clinical symptoms when local stability is achieved.

Mini Open Foraminotomy for Cervical Radiculopathy: A Comparison of Large Tubular and TrimLine Retractors

STUDY DESIGN: Retrospective chart review. PURPOSE: A comparison of mini open foraminotomy (MOF) for cervical radiculopathy using either large tubular (LT) or TrimLine (TL) retractors. OVERVIEW OF LITERATURE: Posterior foraminotomy relieves compression of the cervical nerve root in radiculopathy patients. However, invasion of the paravertebral muscle may cause major problems in these patients. To address these problems, we performed MOF. METHODS: Twenty cervical radiculopathy patients (16 male and 4 female) who underwent MOF between May 2004 and August 2011 were assigned to LT and TL groups. Each group contained 10 subjects. Surgical and clinical outcomes were compared. RESULTS: The average operating time in the TL group was significantly shorter than that in the LT group. The final follow-up mean neck disability indices significantly improved compared to the preoperative values (LT group, 12.0+/-7.8 vs. 28.0+/-9.4; TL group, 6.0+/-5.9 vs. 21.9+/-10). The final follow-up neck pain visual analog scale (VAS) scores also decreased significantly from the preoperative of 8.0+/-1.5 and 2.5+/-2.5 to the final follow-up values of 2.2+/-2.2 and 1.0+/-2.5 in the LT and TL groups, respectively. The recovery rate for the neck pain VAS score was 70.0+/-31.9 in the LT group and 87.0+/-32.0 in the TL group, thus suggesting no significant difference between the two groups. CONCLUSIONS: MOF with the TL retractor is an easy and safe procedure. Furthermore, the use of the TL retractor allows for a minimally invasive and effective surgical treatment of cervical radiculopathy patients.

Mid-Term Results of Computer-Assisted Cervical Pedicle Screw Fixation

STUDY DESIGN: A retrospective study. PURPOSE: The present study aimed to evaluate mid-term results of cervical pedicle screw (CPS) fixation for cervical instability. OVERVIEW OF LITERATURE: CPS fixation has widely used in the treatment of cervical spinal instability from various causes; however, there are few reports on mid-term surgical results of CPS fixation. METHODS: Record of 19 patients who underwent cervical and/or upper thoracic (C2-T1) pedicle screw fixation for cervical instability was reviewed. The mean observation period was 90.2 months. Evaluated items included Japanese Orthopaedic Association (JOA) score and C2-7 lordotic angle before surgery and at 5 years after surgery. Postoperative computerized tomography was used to determine the accuracy of screw placement. Visual analog scale (VAS) for neck pain and radiological evidence of adjacent segment degeneration (ASD) at the 5-year follow-up were also evaluated. RESULTS: Mean JOA score was significantly improved from 9.0 points before surgery to 12.8 at 5 years after surgery (p=0.001). The C2-7 lordotic angle of the neutral position improved from 6.4degrees to 7.8degrees at 5 years after surgery, but this was not significant. The major perforation rate was 5.0%. There were no clinically significant complications such as vertebral artery injury, spinal cord injury, or nerve root injury caused by any screw perforation. Mean VAS for neck pain was 49.4 at 5 years after surgery. The rate of ASD was 21.1%. CONCLUSIONS: Our mid-term results showed that CPS fixation was useful for treating cervical instability. Severe complications were prevented with the assistance of a computed tomography-based navigation system.

Comparison of Spinous Process-Splitting Laminectomy versus Conventional Laminectomy for Lumbar Spinal Stenosis

STUDY DESIGN: Seventy-five patients who had been treated for lumbar spinal stenosis (LSS) were reviewed retrospectively. PURPOSE: Invasion into the paravertebral muscle can cause major problems after laminectomy for LSS. To address these problems, we performed spinous process-splitting laminectomy. We present a comparative study of decompression of LSS using 2 approaches. OVERVIEW OF LITERATURE: There are no other study has investigated the lumbar spinal instability after spinous process-splitting laminectomy. METHODS: This study included 75 patients who underwent laminectomy for the treatment of LSS and who were observed through follow-ups for more than 2 years. Fifty-five patients underwent spinous process-splitting laminectomy (splitting group) and 20 patients underwent conventional laminectomy (conventional group). We evaluated the clinical and radiographic results of each surgical procedure. RESULTS: Japanese Orthopaedic Association score improved significantly in both groups two years postoperatively. The following values were all significantly lower, as shown with p-values, in the splitting group compared to the conventional group: average operating time (p=0.002), postoperative C-reactive protein level (p=0.006), the mean postoperative number of days until returning to normal body temperature (p=0.047), and the mean change in angulation 2 years postoperatively (p=0.007). The adjacent segment degeneration occurred in 6 patients (10.9%) in the splitting group and 11 patients (55.0%) in the conventional group. CONCLUSIONS: In this study, the spinous process-splitting laminectomy was shown to be less invasive and more stable for patients with LSS, compared to the conventional laminectomy.

Myxopapillary Ependymoma of the Cauda Equina in a 5-Year-Old Boy

Myxopapillary ependymoma in childhood typically occurs in the central nervous system. There are few surgical cases of myxopapillary ependymoma of the cauda equina in children. We report a case of myxopapillary ependymoma of the cauda equina in a 5-year-old boy, who presented with leg pain and abnormal gait. Subtotal resection surgery was performed. Following the subtotal tumor resection, follow-up magnetic resonance imaging evaluation showed a recurrent tumor. As a result, we performed a second subtotal tumor resection and followed with postoperative radiation therapy. No further evidence of the disease has been noted elsewhere in the patient in over ten years of follow-up. Myxopapillary ependymoma of the cauda equina in a young boy was improved by subtotal tumor resection and postoperative radiation therapy.