Relationship between the perioperative prognostic nutritional index and postoperative gait function in elderly hip fractures

Objectives@#We investigated the relationship between the perioperative nutritional status and postoperative walking ability in patients with hip fractures. @*Methods@#We included 246 surgically treated elderly patients with hip fractures who were ambulatory before the injury. Patients were divided into two groups: group A, who were able to walk at discharge, and group B, who were unable to walk at discharge. We pair-matched these two groups according to age, preoperative subdivided walking ability, and fracture site to form groups A′ and B’. The prognostic nutritional index (PNI; PNI = 10 × serum albumin (g/dL) + 0.005 × blood total lymphocyte count (/mm 3 )) before surgery and 1 day, 1 week, and 2 weeks after surgery and energy intake 1 and 2 weeks after surgery were compared. @*Results@#After adjustments for age, preoperative subdivided walking ability, and fracture site, there were 51 patients in group A’ (mean age 84.6 years) and 51 patients in group B’ (mean age 84.7 years). In group A’/group B′, PNI was 43.38/42.60 (P = 0.19) before surgery, 33.87/33.31 (P = 0.44) 1 day after surgery, 34.99/32.35 (P = 0.01) 1 week after surgery, and 37.33/35.69 (P = 0.15) 2 weeks after surgery. Energy intake was 1380.8/ 1203.1 kcal (P = 0.01) 1 week after surgery and 1382.0/1335.6 kcal (P = 0.60) 2 weeks after surgery. @*Conclusions@#PNI and energy intake at 1 week postoperatively were associated with early postoperative nutrition and the recovery of walking ability.

Implications of the diagnosis of locomotive syndrome stage 3 for long-term care

Objectives@#Locomotive syndrome stage 3 (LS3), which has been established recently, may imply a greater need for care than LS stage 0 (LS0), LS stage 1 (LS1), and LS stage 2 (LS2). The relationship between LS3 and long-term care in Japan is unclear. Therefore, this study aimed to examine this relationship. @*Methods@#A total of 531 patients (314 women and 217 men; mean age, 75 years) who were not classified as requiring long-term care and underwent musculoskeletal examinations in 2012 were grouped according to their LS stage. Group L comprised patients with LS3 and Group N comprised those with LS0, LS1, and LS2. We compared these groups according to their epidemiology results and long-term care requirements from 2013 to 2018. @*Results@#Fifty-nine patients (11.1%) were diagnosed with LS3. Group L comprised more patients (50.8%) who required long-term care than Group N (17.8%) (P < 0.001). Group L also comprised more patients with vertebral fractures and knee osteoarthritis than Group N (33.9% vs 19.5% [P = 0.011] and 78% vs 56.4% [P < 0.001], respectively). A Cox proportional hazards model and Kaplan–Meier analysis revealed a significant difference in the need for nursing care between Groups L and N (log-rank test, P < 0.001; hazard ratio, 2.236; 95% confidence interval, 1.451–3.447). @*Conclusions@#Between 2012 and 2018, 50% of patients with LS3 required nursing care. Therefore, LS3 is a highrisk condition that necessitates interventions. Approaches to vertebral fractures and osteoarthritis of the knee could be key.

Change in Line of Sight after Corrective Surgery of Adult Spinal Deformity Patients: A 2-Year Follow-up

Methods@#This retrospective study includes 295 corrective surgery patients with ASD. Subjects were divided into two groups after propensity age matching analysis: cranial malalignment (McGS 13) and normal cranial alignment (−8≤ McGS ≤13). Lumbar lordosis (LL), pelvic tilt (PT), TK, cervical lordosis (CL), and sagittal vertical axis (SVA) were evaluated between the two groups. @*Results@#SVA (95–56 mm) and PT (34°–25°) decreased and LL (19°–41°) increased 2 years after surgery (p <0.05), but McGS (−1.1° to −0.5°) and CL (21°–19°) did not change. Conversely, in the group with cranial malalignment, SVA (120–64 mm), PT (35°–26°), and LL (12°–41°) showed similar results to the normal cranial parameter group 2 years after surgery, but in contrast, McGS (−13° to −2°) and CL (24°–18°) improved significantly. @*Conclusions@#Severe ASD adversely affects to maintain horizontal gaze but can be improved by spinal corrective surgery.

How Is Degenerative Lumbar Scoliosis Associated with Spinopelvic and Lower-Extremity Alignments in the Elderly

Methods@#Adult volunteers aged over 50 years were included in the study after participating in the screening program. Characteristic data and standing radiographic parameters were assessed. A propensity score model was established with adjustments for age and sex after a preliminary analysis, and cases were divided into DLS (Cobb angle >10°) and non-DLS (Cobb angle ≤10°) groups. @*Results@#There were significant differences in age, sex, C2 sagittal vertical axis (C2-SVA), C7-SVA, T1 pelvic angle (TPA), lumbar lordosis (LL), pelvic incidence (PI), pelvic tilt (PT), PI minus LL (PI–LL), knee angle, ankle angle, pelvic shift, C7-center sacral vertical line, L4 tilt, femur-tibia angle, and hip-knee-ankle angle (all p <0.05) using a preliminary analysis of 261 cases (75 DLS and 186 non-DLS). A one-to-one propensity score-matched analysis was used after 70 pairs of cases were selected. There were no significant differences in the characteristic data for lower extremity parameters. There were still significantly higher values of C2-SVA, TPA, PI, PT, and PI–LL in DLS group than in non-DLS group (all p <0.05). @*Conclusions@#This study showed an important relationship between DLS and sagittal spinal deformity. However, DLS was not associated with the sagittal and coronal lower extremity alignments.

Preoperative Less Right Shoulder Elevation Had a Higher Risk of Postoperative Shoulder Imbalance When Main Thoracic Curve Shows Higher Correction Regardless of the Upper Instrumented Vertebra Level for Patients with Adolescent Idiopathic Scoliosis Lenke Type 1

Methods@#We examined the data of AIS patients with Lenke type 1 curves who underwent posterior fusion surgery in a retrospective manner. PSI was defined as a 2-year postoperative absolute radiographic shoulder height (RSH) of ≥2 cm. Patients were divided into two groups based on the presence of PSI and the level of their upper instrumented vertebra (UIV) (UIV at T2 or T3 [U-UIV] or UIV below T3 [L-UIV]). The radiographic parameters and clinical outcomes were compared, and the cutoff values of risk factors were identified by multivariate analysis. @*Results@#Of 104 patients, 21 (20.2%) had left shoulder elevation PSI. The PSI group had a significantly greater preoperative RSH (−5.1 mm vs. −14.3 mm) and main thoracic (MT) curve correction rate (77.3% vs. 69.1%) than the non-PSI group. The PSI incidence did not differ between the U-UIV and L-UIV groups. Multivariate analysis identified preoperative RSH and the MT curve correction rate as independent risk factors for PSI. The receiver operating characteristic curve analysis identified the preoperative RSH cutoff value as −6.5 mm and MT curve correction rate cutoff value as 76.9%. @*Conclusions@#Even in AIS patients with Lenke type 1 curves, the incidence of PSI was relatively high (20.2%). Patients with preoperative lower right shoulder elevation (i.e., RSH >−6.5 mm) had a higher risk of PSI regardless of UIV level when the MT curve showed a higher correction rate (i.e., correction rate >76.9%).

Selective Angiography to Detect Anterior Spinal Artery Stenosis in Thoracic Ossification of the Posterior Longitudinal Ligament

Methods@#This study prospectively examined nine T-OPLL patients who underwent posterior thoracic decompression with kyphosis correction and instrumented fusion at Hamamatsu University School of Medicine between 2017 and 2019. All underwent preoperative selective angiography to detect and evaluate the Adamkiewicz artery and ASA. Intraoperative neuromonitoring and Doppler ultrasonography were performed to analyze neurological complications and spinal cord blood flow. @*Results@#All nine patients showed ASA stenosis in the area of T-OPLL. In all patients, the Adamkiewicz artery was located between T7 and L2 and the area of ASA stenosis corresponded to the level of T-OPLL and greatest spinal cord compression; intraoperative Doppler ultrasonography confirmed the ASA defect at the same spinal level. The number of spinal levels from the Adamkiewicz artery to the most compressive OPLL lesion was greater in the two patients who developed postoperative neurological deficit compared to those who did not (5.5 vs. 2.3, p=0.014). @*Conclusions@#This is the first study to report detection of ASA stenosis in patients with T-OPLL. Maintaining spinal cord blood flow is important in these patients to avoid neurological deterioration.

Association between Pelvic Parameters and Vaginal Delivery

Methods@#As part of a 2016 health screening, 320 female volunteers underwent whole-spine radiographs. Age-matched healthy women were grouped according to the number of vaginal deliveries (0, 1–2, or ≥3). Demographic variables and spinopelvic parameters were compared among the three groups. @*Results@#Of the 320 volunteers, 213 were enrolled (mean age, 71.1±7.2 years). The mean number of vaginal deliveries was 2.2. The average pelvic incidence (PI) was 55.6°±11.1° and was significantly higher in the 90 women with three or more vaginal deliveries than in the other two groups (p<0.001). The average sacral slope was 33.4°±11.1° and was significantly higher in the women with three or more vaginal deliveries than in the 18 who did not deliver vaginally (p<0.001). The 105 women with one or two vaginal deliveries had significantly higher PIs and sacral slopes than did those who did not deliver vaginally (p<0.001). @*Conclusions@#This is the first study documenting an association between vaginal delivery and pelvic parameters. Bony birth canal realignment during vaginal delivery can affect postnatal PI. Our study helps in understanding the PI changes over a woman’s life span.

Effect of denosumab on renal function in women with osteoporosis evaluated using cystatin C

Objectives@#To investigate renal function during denosumab therapy using the estimated glomerular filtration rate based on cystatin C (eGFRcys) which is more accurate than creatinine (eGFRcr) for renal function. @*Methods@#Bone mineral densities (BMDs) of lumbar spine and hip regions, eGFRcys, eGFRcr, creatinine clearance (Ccr), and serum total homocysteine (S-Hcy) were measured during 2-year denosumab therapy in 53 women with osteoporosis naïve to anti-osteoporosis drugs (new group) and 64 women who were switched from long-term bisphosphonate treatment to denosumab therapy (switch group). @*Results@#There were no significant differences in age, eGFRcr, Ccr, eGFRcys, and S-Hcy levels at baseline between the groups. BMDs in the lumbar spine, femoral neck, and total hip increased significantly after 2-year denosumab therapy in both groups. eGFRcr decreased in the switch group, and Ccr decreased in both groups; however, eGFRcys and S-Hcy levels did not change significantly in either group. To investigate the causal factors associated with the decrease in eGFRcr and Ccr, multiple regression analysis was performed in all patients. Denosumab initiation within 3 months after fracture and eGFRcr or Ccr at baseline were independent factors for the decrease in eGFRcr or Ccr during the 2-year denosumab therapy. Decline in creatinine-based renal function could be reflected by increased muscle mass during the ongoing recovery from fracture. @*Conclusions@#Renal function was preserved in all patients, including those in the switch group during denosumab therapy. Creatinine-based renal function should be cautiously interpreted during denosumab therapy in patients with recent fractures.

Impact of Spinal Correction Surgeries with Osteotomy and Pelvic Fixation in Patients with Kyphosis Due to Osteoporotic Vertebral Fractures

Study DesignCombination of retrospective and prospective study.PurposeWe aimed to compare the clinical outcomes between local fixation surgery and spinopelvic fixation surgery for the treatment of kyphosis secondary to osteoporotic vertebral fractures with spinopelvic malalignment.Overview of LiteratureThe clinical characteristics of patients with rigid kyphosis due to osteoporotic vertebral fracture differ from that of middle-aged patients with vertebral fractures in terms of bone fragility and presence of spinopelvic malalignment. Little is known about the surgical strategies for these deformities, most especially the extent of fusion of vertebra involved.MethodsWe analyzed 24 patients with vertebral osteotomy at the level of the fracture and spinal fixation without pelvic fixation (local group), and 22 patients with vertebral osteotomy and pelvic fixation (pelvic group). Radiographic parameters, the incidence of proximal junctional kyphosis (PJK), distal junctional kyphosis (DJK), rod fractures, and the Oswestry Disability Index (ODI) were compared between the two groups over a 2-year follow-up period.ResultsIn the pelvic group, postoperative spinopelvic parameters significantly improved, with the improvements maintained. No remarkable changes in spinopelvic parameters were seen in the local group. The mean ODI scores 2 years after surgery were 45.3 and 33.0 in the local and pelvic group, respectively (p-value p-value ConclusionsFor patients with rigid kyphosis due to osteoporotic vertebral fractures, better spinopelvic alignment and health-related quality of life can be achieved through extensive corrective surgery with pelvic fixation.

Impact of Spinal Correction Surgeries with Osteotomy and Pelvic Fixation in Patients with Kyphosis Due to Osteoporotic Vertebral Fractures

Study DesignCombination of retrospective and prospective study.PurposeWe aimed to compare the clinical outcomes between local fixation surgery and spinopelvic fixation surgery for the treatment of kyphosis secondary to osteoporotic vertebral fractures with spinopelvic malalignment.Overview of LiteratureThe clinical characteristics of patients with rigid kyphosis due to osteoporotic vertebral fracture differ from that of middle-aged patients with vertebral fractures in terms of bone fragility and presence of spinopelvic malalignment. Little is known about the surgical strategies for these deformities, most especially the extent of fusion of vertebra involved.MethodsWe analyzed 24 patients with vertebral osteotomy at the level of the fracture and spinal fixation without pelvic fixation (local group), and 22 patients with vertebral osteotomy and pelvic fixation (pelvic group). Radiographic parameters, the incidence of proximal junctional kyphosis (PJK), distal junctional kyphosis (DJK), rod fractures, and the Oswestry Disability Index (ODI) were compared between the two groups over a 2-year follow-up period.ResultsIn the pelvic group, postoperative spinopelvic parameters significantly improved, with the improvements maintained. No remarkable changes in spinopelvic parameters were seen in the local group. The mean ODI scores 2 years after surgery were 45.3 and 33.0 in the local and pelvic group, respectively (p-value p-value ConclusionsFor patients with rigid kyphosis due to osteoporotic vertebral fractures, better spinopelvic alignment and health-related quality of life can be achieved through extensive corrective surgery with pelvic fixation.

Relationship between Knee Osteoarthritis and Spinopelvic Sagittal Alignment in Volunteers over 50 Years of Age

Methods@#Volunteers over 50 years of age underwent radiographic analysis. Radiographic parameters including pelvic tilt (PT), pelvic incidence (PI), lumbar lordosis (LL), thoracic kyphosis, and sagittal vertical axis (SVA) were measured. The the three Scoliosis Research Society-Schwab sagittal modifiers (PT, SVA, PI–LL) were categorized and the KL grade was assessed. Differences in spinopelvic parameters and Oswestry Disability Index (ODI) scores among KL grades were evaluated. @*Results@#A total of 396 volunteers (160 men, 236 women; mean age, 74.4 years) were analyzed. PI–LL and PT in KL4 were significantly higher compared to that in the other KL grades. However, there were no significant group differences in SVA. In women, but not in men, higher frequencies of the worst modifier grade (++) were observed for PI–LL and PT in the KL3 and KL4 groups compared to those for the other KL grades. In women, the ODI score in KL4 was worse compared to that in the other KL grades. @*Conclusions@#Individuals over 50 years of age with severe knee osteoarthritis had poor lumbo-pelvic sagittal alignment. Moreover, the progression severity of knee osteoarthritis had more impact onstronger relationship with lumbo-pelvic malalignment and disability-related low back pain in women than in men.

Spinal Sagittal Alignment, Hospital Anxiety and Depression Scale Scores, and Patient-Reported Outcome among People with Sporting Activity

Methods@#The subjects were 473 volunteers. They were divided into two groups (activity and non-activity) according to participation or non-participation in sporting activities using a self-filled questionnaire. The evaluation items were height, weight, grip strength, bone density, Hospital Anxiety and Depression Scale (HADS) score, standing radiographic parameters, PRO (evaluated by EuroQol-5 dimension [EQ-5D], Oswestry Disability Index [ODI]), and NDI. @*Results@#There were 101 males in the non-activity group and 69 in the activity group and 178 females in the non-activity group and 125 in the activity group. For the males, the evaluation items with significant influence were cervical lordosis (non-activity group:activity group, 17°:22°) and T1 slope minus cervical lordosis (10°:6°, p <0.05). For the females, the evaluation items with significant influence were sagittal vertical axis (28:14 mm), HADS (10.4:8.4), EQ-5D (0.79:0.86), ODI (17:12), and NDI (12:9, p <0.01). HADS and PRO in the females were significantly correlated with the EQ-5D (−0.40), ODI (0.43), and NDI (0.55). @*Conclusions@#Males who participated in sporting activities had better cervical spine alignment but no effect on PRO. Females with sporting activities had better spinal global alignment and less mental stress. It is suggested that sporting activity in females might be associated with PRO because HADS highly correlates with PRO.

Hypertension Is Related to Positive Global Sagittal Alignment: A Cross-Sectional Cohort Study

STUDY DESIGN: Cross-sectional cohort study.PURPOSE: This study aimed to investigate the relationship between hypertension and spino-pelvic sagittal alignment in middle-aged and elderly individuals.OVERVIEW OF LITERATURE: Positive global sagittal alignment is associated with poor health-related quality of life. Hypertension is associated with tissue microcirculation disorders of the skeletal muscle. We hypothesized that hypertension may be involved in positive global sagittal alignment.METHODS: In this institutional review board-approved study, 655 participants (262 men and 393 women; mean age, 72.9 years; range, 50–92 years) who underwent musculoskeletal screening in Toei town, Aichi, Japan were included. Whole spine and pelvic radiographs were taken, and radiographic parameters (thoracic kyphosis, lumbar lordosis, pelvic tilt, sacral slope, pelvic incidence, and sagittal vertical axis [SVA]) were measured using an image-analysis software. Hypertension was assessed using the standard criteria. The study participants were divided into three subgroups as per age (50–64 years, 65–74 years, and ≥75 years). We examined the differences in the radiographic parameters of those with and without hypertension in each age subgroup.RESULTS: In each age subgroup, there was no significant difference in the age and sex of those with and without hypertension. SVA was significantly shifted forward in the hypertension group than in the non-hypertension group in those aged 50–64 years old (32.4 mm vs. 16.0 mm, p=0.018) and in those aged 65–74 years old (42.7 mm vs. 30.6 mm, p=0.012). There was no significant difference between the hypertension and non-hypertension groups in terms of the alignment of the lumbar and thoracic spine in all the subgroups. In multivariate analysis, hypertension was a significant independent factor of forward-shifted SVA (standardized beta 0.093, p=0.015).CONCLUSIONS: This study showed that hypertension was associated with forward-shifted global sagittal alignment.

Multi-Rod Constructs Can Increase the Incidence of Iliac Screw Loosening after Surgery for Adult Spinal Deformity

STUDY DESIGN: A retrospective study. PURPOSE: To investigate the incidence of iliac screw loosening with a two-rod vs. multi-rod construct and the effect on clinical and radiographic outcomes after surgery for adult spinal deformity (ASD). OVERVIEW OF LITERATURE: Multi-rod construct is useful for preventing rod fracture in ASD surgery. However, limited information is available regarding the incidence of iliac screw loosening after corrective fusion surgery using a multi-rod construct. METHODS: Total 106 patients with ASD (24 men and 82 women; mean age, 68 years) who underwent corrective fusion surgery using bilateral iliac screws and were followed up for at least 1 year were reviewed. The following variables were compared between patients who underwent surgery with a two-rod and multi-rod construct: age, sex, bone mineral density (BMD), fusion level, high-grade osteotomy, L5/S interbody fusion, screw loosening (upper instrumented vertebra [UIV], S1, and iliac), rod fracture, proximal junctional kyphosis, spinopelvic parameters, and Oswestry Disability Index (ODI) score. We also compared patients with and without iliac screw loosening in the multi-rod construct group. RESULTS: Of the 106 patients, 55 underwent surgery with a conventional two-rod construct and 51 with a multi-rod construct (three rods in 16, four rods in 35). Iliac and UIV screw loosening was observed in 24 patients (21%) and 35 patients (33%), respectively. The multi-rod group showed significantly higher incidence of iliac and UIV screw loosening and lower incidence of rod fracture. Patients with iliac screw loosening had a lower BMD than those without screw loosening; however, no significant differences were observed in the spinopelvic parameters or the ODI score. CONCLUSIONS: The use of multi-rod constructs led to a higher incidence of junctional screw loosening than the use of conventional two-rod constructs, especially in patients with osteoporosis. Iliac screw loosening did not affect sagittal alignment or clinical outcome in the short term.

Cortical Thickness Index of the Proximal Femur: A Radiographic Parameter for Preliminary Assessment of Bone Mineral Density and Osteoporosis Status in the Age 50 Years and Over Population

BACKGROUND: Bone mineral density (BMD) is the indicator of bone quality in at-risk individuals. Along with the fracture risk assessment tool (FRAX), a quick assessment of BMD from routine radiographs may be useful in the case of lacking X-ray absorptiometry data. This study aimed to investigate the correlation of cortical thickness index (CTI) and canal flare index (CFI) with BMD and FRAX and to evaluate their ability to predict femoral neck BMD (nBMD) and FRAX in the general elderly population. METHODS: A total of 560 volunteers (age ≥ 50 years) who underwent hip-spine X-ray, BMD scanning and FRAX calculation were retrospectively reviewed. CTI and CFI were measured on anteroposterior radiographs and analyzed for their correlation with BMD and FRAX and for their ability to predict nBMD. The ability of CTI to predict osteoporosis status (OPS) and fracture risk status (FRS) was also investigated and the threshold values were calculated. All the analyses were performed separately on male and female subjects. RESULTS: Significant differences in CTI, CFI, nBMD and FRAX between males and females were observed. CTI and CFI demonstrated significant positive correlation with nBMD and FRAX (all p < 0.001) in both males and females. CTI, height, and weight significantly predicted nBMD. CTI statistically predicted OPS and FRS, and the values of 0.56 and 0.62 were computed as CTI thresholds for males and females, respectively. CONCLUSIONS: CTI was significantly correlated with nBMD and it predicted nBMD at good prediction levels. Therefore, CTI may be used as a supportive tool in the assessment of OPS and FRS besides BMD and FRAX in clinical practice.

Difference in Spinal Sagittal Alignment and Health-Related Quality of Life between Males and Females with Cervical Deformity

STUDY DESIGN: Large cohort study. PURPOSE: To clarify spinal sagittal alignment and health-related quality of life (HRQOL) according to sex in volunteers aged >50 years with cervical deformity (CD). OVERVIEW OF LITERATURE: Adult spinal deformities, especially those associated with lumbosacral lesions, are more frequent in females; however, CD is observed to a greater extent in males. METHODS: We divided 656 volunteers (263 males, 393 females; age, 50–89 years [mean, 73 years]) as follows: males with CD (CDM; 82 patients); males without CD (NCDM, 181); females with CD (CDF, 36); and females without CD (NCDF, 357). CD was defined as C2–7 sagittal vertical axis (SVA) ≥40 mm. We measured pelvic tilt (PT), pelvic incidence minus lumbar lordosis (PI−LL), thoracic kyphosis, T1 slope, cervical lordosis, C7 SVA, and C2–7 SVA. HRQOL was evaluated using EuroQOL five dimensions questionnaire (EQ-5D). RESULTS: In CDM, NCDM, CDF, and NCDF groups, the respective parameters were as follows: PT: 15°, 14°, 26°, and 21°; PI−LL: 7°, 5°, 16°, and 10°; C2–7 SVA: 49, 24, 46, and 20 mm; C7 SVA: 61, 40, 75, and 47 mm; and EQ-5D: 0.82, 0.88, 0.78, and 0.81. PT and PI−LL were significantly greater in the CDF group than in the NCDF group (p < 0.05) but were not significantly different between CDM and NCDM groups. The CDF group already showed deterioration of spinopelvic alignment, although it was maintained in the CDM group. EQ-5D in showed significantly greater deterioration the CDM group than in the NCDM group; deterioration of lumbopelvic parameters had less influence in males (p < 0.05). CONCLUSIONS: Sagittal spinal deformity may have different mechanisms in males and females. The deterioration of spinal sagittal alignment in males may originate from the cervical spine, and CD may be associated with HRQOL.

Novel Measurement Technique for the Sagittal Vertical Axis and Its Clinical Application in Adult Spinal Deformity

STUDY DESIGN: Prospective physical measurement of the sagittal vertical axis (SVA). PURPOSE: To evaluate a simple method for measuring SVA by analyzing its relationship with radiographic measurements and clinical appearance. OVERVIEW OF LITERATURE: No studies have examined physical measurements using the cranial center of gravity (CCG) in a relaxed standing position. METHODS: The physical measurement of the horizontal distance between CCG and spina iliaca posterior superior (CCG-SIPS) was measured using a straight ruler in 252 healthy volunteers and 56 patients with adult spinal deformity. Health-related quality of life (HRQOL) was evaluated using the Oswestry disability index (ODI), and clinical symptoms were assessed according to standing status and the presence of gastroesophageal reflux disease (GERD). RESULTS: CCG-SIPS increased with age in the volunteer group and strongly correlated with radiographic SVA in the patient group (r=0.984). Differences increased between CCG-SIPS in patients in the relaxed position and radiographic SVA with an increase in sagittal malalignment (r=0.692, p120 mm) was significantly larger in the patient group than in the group with low sagittal malalignment (59.9±18.8 vs. 45.1±17.0; p=0.004); these patients (CCG-SIPS>120 mm) needed crutches or walkers for standing. The patient group with GERD had significantly larger sagittal malalignment than the group without GERD (160.3 mm vs. 81.0 mm). CONCLUSIONS: The CCG-SIPS correlated with age and strongly reflected radiographic SVA and HRQOL in the patients. Moreover, it reflects a relaxed posture without a backward shift in the radiographic position even in patients with severe sagittal malalignment. The critical limit of CCG-SIPS can be relevant to clinical appearance, including standing assistance (>120 mm) and the existence of GERD (>150 mm). Thus, it will be a useful predictor of true SVA in clinical practice before radiographic evaluation.

Relationship between Spinal Hemangioblastoma Location and Age

STUDY DESIGN: Retrospective case series. PURPOSE: To investigate the relationship between tumor location and clinical characteristics. OVERVIEW OF LITERATURE: Hemangioblastoma is a rare disease that develops in the central nervous system. Magnetic resonance imaging (MRI) is useful to evaluate hemangioblastomas. Hemangioblastoma's location is designated as intramedullary, intramedullary+extramedullary, or extramedullary by MRI. METHODS: We analyzed 11 patients who underwent surgery for spinal hemangioblastoma. Using T1 contrast axial MRI data, the cases were divided into three groups (intramedullary, intramedullary+extramedullary, and extramedullary). Patient demographics, MRI findings, and preoperative neurological status were analyzed and compared for each group. RESULTS: The average age of patients with intramedullary, intramedullary+extramedullary, and extramedullary hemangioblastoma was 34.0, 64.4, and 67.5 years, respectively. Patients in the intramedullary hemangioblastoma group were younger than the other groups. Extramedullary cases had a smaller syrinx compared to the other groups. CONCLUSIONS: Age may play an important role in the hemangioblastoma tumor location and the subsequent diagnosis by an MRI.

Accuracy of Percutaneous Lumbosacral Pedicle Screw Placement Using the Oblique Fluoroscopic View Based on Computed Tomography Evaluations

STUDY DESIGN: Retrospective. PURPOSE: This study aims to investigate the accuracy of the oblique fluoroscopic view, based on preoperative computed tomography (CT) images for accurate placement of lumbosacral percutaneous pedicle screws (PPS). OVERVIEW OF LITERATURE: Although PPS misplacement has been reported as one of the main complications in minimally invasive spine surgery, there is no comparative data on the misplacement rate among different fluoroscopic techniques, or comparing such techniques with open procedures. METHODS: We retrospectively selected 230 consecutive patients who underwent posterior spinal fusion with a pedicle screw construct for degenerative lumbar disease, and divided them into 3 groups, those who had undergone: minimally invasive percutaneous procedure using biplane (lateral and anterior-posterior views using a single C-arm) fluoroscope views (group M-1), minimally invasive percutaneous procedure using the oblique fluoroscopic view based on preoperative CT (group M-2), and conventional open procedure using a lateral fluoroscopic view (group O: controls). The relative position of the screw to the pedicle was graded for the pedicle breach as no breach, 4 mm. Inaccuracy was calculated and assessed according to the spinal level, direction and neurological deficit. Inter-group radiation exposure was estimated using fluoroscopy time. RESULTS: Inaccuracy involved an incline toward L5, causing medial or lateral perforation of pedicles in group M-1, but it was distributed relatively equally throughout multiple levels in groups M-2 and controls. The mean fluoroscopy time/case ranged from 1.6 to 3.9 minutes. CONCLUSIONS: Minimally invasive lumbosacral PPS placement using the conventional fluoroscopic technique carries an increased risk of inaccurate screw placement and resultant neurological deficits, compared with that of the open procedure. Inaccuracy tended to be distributed between medial and lateral perforations of the L5 pedicle, as a result of pedicle morphology and the PPS pathway. Oblique fluoroscopic views, based on CT measurement, may allow accurate PPS insertion with a shorter fluoroscopy time.