Adjacent Segment Degeneration after Short-Segment Lateral Lumbar Interbody Fusion (LLIF).

Purpose: To investigate the influence on the adjacent segment degeneration (ASD) of short-segment lateral lumbar interbody fusion (LLIF) at 2 years postoperatively. Methods: Ninety-seven consecutive patients who underwent one- or two-level LLIF were included from two institutions. We diagnosed radiographical adjacent segment degeneration with the appearance of adjacent spondylolisthesis (>3 mm) or deterioration of adjacent disk height (>3 mm) on plain radiographs or decrease of the intervertebral angle (>5 degrees). The differences between the two groups with and without radiographical ASD were investigated using univariate and multivariate analyses to determine the risk factors for ASD. The variables included extent of adjacent decompression, posterior fixation method (open method or percutaneous method), and facet violation on postoperative CT. Results: In total, 19 patients (19.6%) were diagnosed as radiographical ASD 2 years after surgery. Univariate analysis showed that the ASD (+) group had a high frequency of adjacent decompression (21.1 vs. 3.8%, p = 0.035) compared with the ASD (-) group. There were no differences between the two groups in posterior fusion method (percutaneous method 42.1 vs. 57.7%, p = 0.221) or facet joint violation (15.8 vs. 14.1%, p = 0.860). The multivariate analysis found adjacent intervertebral decompression to be a risk factor for ASD 2 years after surgery (odds ratio: 9.95; 95% confidence interval: 1.2-82.1). Conclusions: Adjacent intervertebral decompression was considered to be a potential risk factor for the development of ASD after spinal fusion with LLIF.

Associations Between Neck and Shoulder Pain and Neuropathic Pain in a Middle-aged Community-living Population.

STUDY DESIGN: A cross-sectional study. OBJECTIVE: The present study aimed to investigate the prevalence of NeP in subjects suffering from NSP to reveal the impact of NeP on the health-related QOL (HRQOL) in middle-aged and elderly people with NSP in a health checkup. SUMMARY OF BACKGROUND DATA: No previous studies have established the relationship between NSP and NeP as potential risk factors contributing to a decreased QOL in the general population. METHODS: The present study involved 203 participants (men: 84, women: 119; mean age: 63.3 yr). For each subject, anthro-pometric measurements, physical function examinations, and blood testing were performed. A cut-off score of >0 on the short-form spine painDETECT questionnaire defined the presence of NeP. Subsequently, the NSP (+) subjects were divided into 2 sub-groups: the NeP (+) and NeP (-) groups. For the assessment of QOL, the short form 36 health survey and the EuroQol 5 dimension 5 level version (EQ-5D-5L) tool were used. RESULTS: The study included 100 NSP (+) and 103 NSP (-) subjects. Among the NSP (+) subjects, 46 and 54 subjects were found to be NeP (+) and NeP (-), respectively. For the short form 36 health survey, the multivariate regression analysis revealed that the prevalence of NeP was associated with a lower physical QOL (OR 3.56) and lower mental QOL (OR 4.04). Similarly, the NeP prevalence was found to be the predictor for low QOL scores in EQ-5D-5L (EQ-5D-5L index value <0.875; OR 3.61). CONCLUSION: The prevalence of NeP was reported to be 46.0% in healthy middle-aged and elderly population suffering from NSP, where it was associated with poor HRQOL. Therefore, strategies aimed at alleviating NeP may contribute significantly to the improvement of QOL in middle-aged and elderly people with NSP.Level of Evidence: 2.

Impact of Neck and Shoulder Pain on Health-Related Quality of Life in a Middle-Aged Community-Living Population.

PURPOSE: Neck and shoulder pain (NSP) is very common in the general population. However, scarce information exists on the relationship between NSP and health-related quality of life (HRQOL) outcomes in this population. The present study described NSP prevalence and its impact on the HRQOL of middle-aged and older persons undergoing a routine medical checkup. METHODS: This study recruited 318 subjects (125 males and 193 females; average age, 63.4 years) in good health, collected underwent anthropometric measurements, physical function examinations, and blood testing. This study defined NSP as the presence of muscle tension, stiffness, pressure, or dull pain in areas between the neck and the arch of the scapular. Study subjects were divided into two groups (NSP (+) and NSP (-) groups). The subjects completed questions on the Medical Outcomes Study 36-item short-form health survey (SF-36) and the EuroQol 5-dimension, 5-level version (EQ-5D-5L) tool. RESULTS: Of the patients, 150 and 168 were NSP (+) and NSP (-), respectively. The NSP complaint rate was 47.2%. The NSP (+) group had younger and more female participants than the NSP (-) group. In the multivariate regression analysis, the NSP (+) group had lower physical QOL based on the SF-36 physical component summary (odds ratio (OR), 2.45) and lower mental QOL based on the SF-36 mental component summary (OR, 2.05). Overall, the NSP (+) group had a higher risk of having low QOL scores (EQ-5D-5L index; OR, 1.76). CONCLUSIONS: The NSP (+) rate in healthy middle-aged and older persons was 47.2%. Furthermore, NSP (+) status was directly related poor HRQOL. NSP is a predictor of suboptimal physical and mental QOL. Therefore, NSP prevention or intervention for NSP may improve middle-aged and older adults' QOL.

Enoxaparin promotes functional recovery after spinal cord injury by antagonizing PTPRσ.

The receptor-type protein tyrosine phosphatase sigma (PTPRσ) regulates axonal regeneration/sprouting as a molecular switch in response to glycan ligands. Cell surface heparan sulfate oligomerizes PTPRσ and inactivates its enzymatic activity, which in turn promotes axonal growth. In contrast, matrix-associated chondroitin sulfate monomerizes PTPRσ and activates it. This leads to dephosphorylation of its specific substrates, such as cortactin, resulting in a failure of axonal regeneration after injury. However, this molecular switch model has never been challenged in a clinical situation. In this study, we demonstrated that enoxaparin, a globally approved anticoagulant consisting of heparin oligosaccharides with an average molecular weight of 45 kDa, induced clustering and inactivated PTPRσ in vitro. Enoxaparin induced PTPRσ clustering, and counteracted PTPRσ-mediated dephosphorylation of cortactin, which was shown to be important for inhibition of axonal regeneration. Systemic administration of enoxaparin promoted anatomical recovery after both optic nerve and spinal cord injuries in rats at clinically tolerated doses. Moreover, enoxaparin promoted recovery of motor function without obvious hemorrhage. Collectively, our data provide a new strategy for the treatment of traumatic axonal injury.

The dual presence of frailty and locomotive syndrome is associated with a greater decrease in the EQ-5D-5L index.

Japan's aging society is facing an increase in the prevalence of frailty and locomotive syndrome (LS) among older adults. To evaluate the association of these age-related declines on health-related quality of life (QOL) in Japan, we investigated this relationship among Japanese middle-aged and older adults who underwent general checkups and examined whether LS or frailty has a stronger association with the Japanese version of EuroQol's five-level EQ-5D (EQ-5D-5L) index. Participants were 231 middle-aged and older Japanese adults receiving routine health checkups. The study utilized the 25-item Geriatric Locomotive Function Scale, the Japanese version of the Cardiovascular Health Study, and the Japanese version of the EQ-5D-5L. Univariate and multivariate analyses were performed to examine how frailty and LS are related to the EQ-5D-5L index. Patients with both frailty (p = 0.003) and LS (p < 0.001) had a significantly lower EQ-5D-5L index. After adjusting for age, gender, and body mass index, LS was significantly associated with a decrease in the EQ-5D-5L index (p < 0.001), whereas frailty had no significant association with the EQ-5D-5L index (p = 0.052). Further analysis showed no significant decrease in the EQ-5D-5L index among those with frailty but no LS, and a significant decrease among those with frailty and LS. The results suggest that frailty and LS are associated with a decrease in the EQ-5D-5L index, but LS has a more pronounced effect. In evaluating frailty's effects on health-related QOL, we determined the importance of separately assessing frailty both with and without LS, even within the same frailty group.

Postoperative Syrinx Shrinkage in Spinal Ependymoma of WHO Grade II.

STUDY DESIGN: A retrospective study of preoperative and postoperative magnetic resonance imaging (MRI) findings in spinal ependymoma. OBJECTIVE: The goal of the study was to examine MRI features, including the syrinx component volume, after surgical resection of spinal ependymoma, and to relate these features to extent of resection and improvement of postoperative neurological status. SUMMARY OF BACKGROUND DATA: Spinal ependymomas have a variety of MRI findings preoperatively, including a hemorrhage cap sign, gadolinium enhancement, and a spinal tumor cyst. However, little is known about these features on postoperative MRI after tumor resection. MATERIALS AND METHODS: The subjects were 38 patients treated for spinal cord ependymoma of World Health Organization grade II at our hospital. All had a spinal tumor cyst on preoperative MRI. All cases were followed with MRI for >1 year after surgery, including imaging at postoperative months (POM) 1 and 12. The maximum diameter of the syrinx was measured on mid-sagittal MRI. The extent of tumor resection was categorized as gross total resection (GTR) and subtotal resection (STR). RESULTS: The mean age of the 38 patients (22 male and 16 female individuals) was 50.9 years (range, 21-71 y) at the time of surgery. The mean preoperative duration from disease onset was 14.9 months (range, 2-47 mo). GTR was achieved in 28 patients (74%) and STR in 10 (26%). The mean syrinx sizes preoperatively and at POM 1 and POM 12 were 7.5±2.3, 4.1±1.9, and 2.5±1.8 mm, respectively, with significant differences among the time points (P<0.01). The syrinx size shrunk over time after GTR and STR. The shrinkage rate was significantly higher in GTR cases (P<0.05) and in cases with the improvement of McCormick grade for neurological status after both GTR and STR (P<0.05). CONCLUSIONS: These findings suggest that MRI can be used to evaluate the improvement of neurological status after surgery for spinal ependymoma.

Dynapenia and physical performance in community-dwelling elderly people in Japan.

Aging of society has increased the incidence of physical disability. The goal of this study was to examine the physical ability of elderly people classified as having sarcopenia, presarcopenia, or dynapenia (a low muscle function without low muscle mass) in a community in Japan. The subjects were volunteers aged >60 years who were participants in a health checkup in Yakumo, Hokkaido and were in good general health. Demographic data were collected and physical performance tests were performed to measure grip strength, walking speed, back muscle strength, maximum stride length, and 3-m timed-up-and-go (3m TUG) time. A measurement of skeletal muscle mass was used as a basis for calculating the appendicular skeletal muscle index (aSMI). The rates of sarcopenia, presarcopenia, and dynapenia were 10%, 22%, and 8% in males (n=101, age 69.7±5.4 years), and 19%, 23%, and 13% in females (n=112, 68.5±5.9 years). Body mass index in subjects with dynapenia was significantly higher compared to that in subjects with sarcopenia and presarcopenia (p<0.01). Back muscle strength, maximum stride length and 3m TUG were similar in dynapenia and sarcopenia, but differed significantly with those in presarcopenia in both males and females without the influence of age (p<0.05). Further studies are needed to evaluate the benefits of dynapenia intervention programs and to explore the underlying pathophysiology of dynapenia.

Trends in Medical Costs for Adolescent Idiopathic Scoliosis Surgery in Japan.

STUDY DESIGN: A retrospective review of clinical data and costs was performed for surgeries for adolescent idiopathic scoliosis (AIS) conducted from 2008 to 2017. OBJECTIVE: Cost containment and healthcare value have become focal points in Japanese health care policy. The purpose of the study was to investigate trends over time in medical costs for surgery for AIS. METHODS: A total of 83 patients underwent surgery for AIS from 2008 to 2017 at our hospital. Clinical data and length of stay were collected, and medical costs for surgery, local bone grafting, fees per day, and surgical instruments were evaluated. RESULTS: There were slight year-by-year decreases in fees per day and decreases in costs of surgical instruments. The average length of stay was 16.4 days and gradually decreased over time. In contrast, scoliosis surgery costs increased about 1.6 times in 10 years from $9515 to $15 130. CONCLUSION: The trends for decreases in fees per day and prices for surgical instruments reflect recent government medical cost control policies. The cost for scoliosis surgery is also defined by the government, and the increase over 10 years may reflect the perspective of valuing effective and advanced surgeries. This study of cost trends of operative spinal intervention provides an assessment of surgical benefit and is likely to influence health care costs.

Postoperative Kyphosis in Cervical Spondylotic Myelopathy: Cut-off Preoperative Angle for Predicting the Postlaminoplasty Kyphosis.

STUDY DESIGN: A prospective cohort study. OBJECTIVE: This study aimed to investigate the relationship between preoperative cervical sagittal alignment and postoperative kyphosis in patients with cervical spondylotic myelopathy (CSM) and to determine the cut-off angle for predicting the postlaminoplasty kyphosis. SUMMARY OF BACKGROUND DATA: There have been several reports describing a cervical kyphosis after laminoplasty. However, there has been no study on the cut-off angle for predicting the postoperative kyphosis in a large series of patients with CSM. METHODS: A total of 1025 consecutive patients with CSM (642 men and 383 women; mean age, 64.4 yr; range, 23-93 yrs) who underwent laminoplasty were included. The average follow-up period was 30.0 months. Radiography was performed before the surgery and at final follow-up. The cervical alignment with neutral view was measured by using the Cobb method. An alignment of C2-7 lordotic angle more than 0° was defined as lordosis and C2-7 lordotic angle less than 0° was defined as kyphosis. The incidence of postoperative kyphosis was evaluated on lateral radiographs. RESULTS: In all patients, the mean C2-7 alignment in the neutral position was 11.5° lordotic before surgery and 14.2° lordotic at final follow-up. In the patient without preoperative kyphotic alignment, receiver operating characteristic curve of preoperative C2-7 lordotic angle showed 7° as a predictor for the postlaminoplasty kyphosis (area under the curve  = 0.75, P < 0.0001). Among the preoperatively 720 patients with lordosis more than 7°, postoperative kyphosis was observed in 20 patients (2.8%), whereas in the preoperatively 191 patients with lordosis less than 7°, postoperative kyphosis was seen in 28 patients (14.7%). CONCLUSION: The cut-off value of preoperative C2-7 lordotic angle for predicting the postlaminoplasty kyphosis was 7° in CSM patient without preoperative kyphotic alignment. LEVEL OF EVIDENCE: 3.

Scoliosis Caused by Limb-Length Discrepancy in Children.

STUDY DESIGN: Single-center retrospective study in pediatric patients. PURPOSE: The purpose of the study was to investigate the effects of the presence and severity of leg-length discrepancy (LLD) on scoliosis in children. OVERVIEW OF LITERATURE: LLD is a common orthopedic problem that can result in standing imbalance, low back pain, and stress fractures. It may cause structural changes in the spine over time, but the exact effect of LLD on scoliosis is unknown. METHODS: The subjects were 23 children with LLD ≥20 mm (range, 27-65 mm) treated at Nagoya University Hospital between 2007 and 2017. Whole spine posteroanterior standing radiographs and whole lower limb radiographs in a supine position were recorded. Data were collected for demographics, LLD, Cobb angle, pelvic obliquity, and Nash/Moe index. Scoliosis was defined as a Cobb angle ≥10°. Leg length was measured from the top of the femoral head to the middle of the tibial plafond, and LLD was defined as the difference between the left and right leg lengths. RESULTS: The patients (nine males and 14 females) had a mean age of 14.0 years (range, 5-18 years). The average LLD was 44.3±17.2 mm, with LLDs of 20 to 39 mm, 40 to 59 mm, and ≥60 mm in 13, five, and five subjects, respectively. The average Cobb angle was 13.0°±7.0°, and 15 subjects (65%) had scoliosis. Convexity of the scoliosis was to the short leg side in all cases. The Cobb angle was significantly related to the severity of the LLD (R=0.736, p<0.01), pelvic obliquity (R=0.966, p<0.01), and Nash/Moe index (p<0.05). CONCLUSIONS: LLD is a common pediatric condition that can cause scoliosis of the spine. Severe scoliosis may develop if the LLD is ≥30 mm. Long-term studies are needed to examine the effect of LLD resolution on the elimination of scoliosis.

Association between locomotive syndrome and the Japanese version of the EQ-5D-5L in middle-aged and elderly people in Japan.

The Japanese version of the EuroQol 5 dimension, 5 level version (EQ-5D-5L) can now be used to quantitatively evaluate the health-related quality of life (QoL) in Japan. Locomotive syndrome (LS) is a concept advocated in Japan to describe a condition requiring care for musculoskeletal disorders. However, no detailed study on the relationship between this index and LS in Japanese health checkup has been reported. We aimed to evaluate the relationship between the Japanese version of the EQ-5D-5L and LS. We enrolled 477 participants who were undergoing health checkups in Japan. All participants were administered the 25-question Geriatric Locomotive Functional Scale for the diagnosis of LS and the Japanese version of the EQ-5D-5L. We performed statistical analysis to compare the non-LS and LS patients; moreover, the risk factors and cut-off values were calculated and verified. The Japanese version of the EQ-5D-5L index was significantly lower in patients with LS than in non-LS patients and was significantly related to LS in logistic regression analysis. In subgroup analysis targeting the five dimensions of the EQ-5D-5L, it was seen that mobility, pain/discomfort, and self-care were significantly involved in LS. The cut-off value of the EQ-5D-5L index for LS was 0.875. The Japanese version of the EQ-5D-5L index was significantly related to LS in Japan. This index will be a useful tool that can easily measure health-related quality of life in middle-aged and elderly Japanese people. Future studies should investigate the relationship of not only LS but also various diseases with the Japanese version of the EuroQol 5 dimension, 5 level version.

Risk Factors for Neuropathic Pain in Middle-Aged and Elderly People: A Five-Year Longitudinal Cohort in the Yakumo Study.

OBJECTIVE: To determine the risk factors for new neuropathic pain (NeP) after five years in healthy middle-aged and elderly volunteers. DESIGN: Prospective longitudinal cohort study (Yakumo study). SETTING: Clinical evaluation in a health checkup. SUBJECTS: A total of 366 people (male N = 146, female N = 220, average age = 63.5 years) who did not have NeP in 2013 were examined. METHODS: NeP was diagnosed based on a painDETECT questionnaire score ≥13. Body mass index (BMI), comorbidity, low back pain (LBP), sciatica, physical ability, grip and back muscle strength, osteoporosis, sarcopenia, frailty, spinal alignment, and quality of life (QOL) with the SF36 in 2013 were compared between NeP(+) and NeP(-) subjects in 2018 using multivariate logistic regression analysis. RESULTS: The NeP(+) rate in 2018 was 5.2%, with no significant differences in age and gender. NeP(+) subjects had significantly lower BMI, severe sciatica, poor gait ability, higher rates of osteoporosis and sarcopenia, greater lumbar kyphosis and spinal inclination, and poorer mental health in 2013. Poor gait ability (odds ratio [OR] = 8.05), low BMI (OR = 2.31), lumbar kyphosis (OR = 1.38), low percentage of the young adult mean (OR = 1.15), and low mental QOL (OR = 1.06) were identified as significant and independent risk factors for new NeP after five years. CONCLUSIONS: This longitudinal cohort study identified five independent risk factors for development of new NeP after five years, with related factors of spinal inclination, sarcopenia, and sciatica. New NeP may be prevented by intervention or treatment of these factors at an early stage in relatively healthy middle-aged and elderly people.

Impact of pelvic incidence on lumbar osteophyte formation and disc degeneration in middle-aged and elderly people in a prospective cross-sectional cohort.

PURPOSE: Pelvic incidence (PI) is unique to each individual and does not change throughout life. High PI is related to lumbar spondylolisthesis, but associations of PI with lumbar osteophyte formation and disc degeneration are unclear. The objective was to evaluate relationships of PI with lumbar osteophyte formation and disc degeneration, as well as spinal sagittal alignment and geriatric diseases, in middle-aged and elderly people. METHODS: A total of 1002 volunteers (male: 434, female: 568, average age: 63.5) were prospectively examined for lumbar osteophyte formation (Nathan class ≥ 2) and disc degeneration (disc score ≥ 3). High (PI > 51, n = 501) and low (PI ≤ 51, n = 501) PI groups were defined. Clinical factors, frailty, sarcopenia, and physical quality of life (QOL) were compared between these groups, and risk factors for lumbar osteophyte formation and disc degeneration were identified in multivariate logistic regression analysis. RESULTS: Physical QOL was poorer in people with lumbar osteophyte formation (54.8%) and disc degeneration (33.6%). Age, male gender, spinal parameters including PI, bone mineral density, back muscle strength, and gait ability differed significantly between the groups, whereas frailty and sarcopenia were not significantly different. Low PI, low lumbar lordosis, elder age, male gender, high BMI, and weak back muscle strength were significant risk factors for lumbar osteophyte formation and disc degeneration. CONCLUSIONS: Low PI was identified as a risk factor for lumbar osteophyte formation and disc degeneration, both of which reduce physical QOL in middle-aged and elderly people. These slides can be retrieved under Electronic Supplementary Material.

Higher extracellular water-to-total body water ratio more strongly reflects the locomotive syndrome risk and frailty than sarcopenia.

OBJECTIVE: Among body composition parameters measured by bioelectrical impedance analysis, the extracellular water-to-total body water (ECW/TBW) ratio is a known prognostic or related factor for various diseases. While concepts such as locomotive syndrome risk, frailty, and sarcopenia are gaining popularity in Japan, their relationship with the ECW/TBW ratio has not been examined in detail. This study aimed to investigate the relationships between them. METHODS: Of 1081 individuals who underwent health checkups, 550 were included in this study. The evaluations included a two-step test, stand-up test, and a 25-question geriatric locomotive function scale questionnaire. Frailty was diagnosed based on the Japanese version of the Cardiovascular Health Study criteria. Sarcopenia was evaluated according to the Asian Working Group for Sarcopenia criteria. The aforementioned ratio was measured using bioelectrical impedance analysis. RESULTS: The ECW/TBW ratio significantly increased with locomotive syndrome risk, frailty, and sarcopenia (p < 0.001 each). Nevertheless, no significant difference was found between robust and pre-frailty groups (p = 0.71) and normal and pre-sarcopenia groups (p = 0.93). Furthermore, after correcting for age, sex, and body mass index, multiple regression analysis revealed that locomotive syndrome risk (p < 0.001) and frailty (p = 0.001) were significantly associated with an increase in the ECW/TBW ratio, whereas sarcopenia was not (p = 0.97). CONCLUSIONS: An increase in the ECW/TBW ratio may reflect locomotive syndrome risk and frailty, but not sarcopenia. In bioelectric impedance analysis, this ratio is an important indicator; if it is high, it is necessary to consider locomotive syndrome risk and frailty.

A Study of Risk Factors for Early-Onset Adjacent Vertebral Fractures After Kyphoplasty.

STUDY DESIGN: Retrospective study. OBJECTIVES: To elucidate risk factors for early-onset (2 months after initial kyphoplasty) adjacent vertebral fracture (EO-AVF) after kyphoplasty. METHODS: A total of 108 vertebral bodies (95 patients) were included in this study. We examined patient backgrounds, the spinal level of EO-AVFs, surgery-related factors, and imaging findings. We divided the cases into 2 groups: patients with EO-AVF and patients without EO-AVF. Univariate, correlation, and multivariate analyses were conducted to reveal the risks factors for EO-AVFs for these 2 groups. RESULTS: EO-AVFs developed in 28 vertebral bodies; they did not develop in 80 vertebral bodies. The overall EO-AVF incidence rate was 26%. The spinal level was the thoracolumbar junction for 93% of patients and another level for 7%, thus demonstrating the concentration of EO-AVFs in the thoracolumbar junction. For patients without EO-AVF and those with EO-AVF, there were significant differences in age (76 and 80 years, respectively), preoperative vertebral angles (VAs) (17.8° and 23°, respectively), and corrected VAs (7.3° and 12.7°, respectively). Significant differences were not observed for other factors. Pearson's correlation coefficient was 0.661 (P < .000), thereby showing a significantly positive correlation between preoperative VAs and corrected VAs. Logistic regression analysis indicated that age (odds ratio, 1.112; 95% CI, 1.025-1.206) and preoperative VAs (odds ratio, 1.08; 95% CI, 1.026-1.135) were covariates and that the presence of an EO-AVF was a dependent variable. Therefore, both were predictable risk factors for EO-AVFs. CONCLUSION: Age, preoperative VAs, and corrected VAs are risk factors for EO-AVFs after kyphoplasty.

Persistence of Denosumab Therapy among Patients with Osteoporosis.

STUDY DESIGN: Retrospective study in a single center. PURPOSE: To examine denosumab persistence in patients of different ages with severe osteoporosis in Japan. OVERVIEW OF LITERATURE: Denosumab is an antibody drug used for the treatment of osteoporosis. It is mainly used in patients with severe osteoporosis who might have high motivation for treatment, and the need for only semi-annual subcutaneous injection might improve the continuation rate. However, no English-language articles have reported on denosumab persistence in the Japanese population, including young people, despite the importance of this issue in a super-aging society. METHODS: The subjects started treatment with subcutaneous denosumab in our department from July 2013 until December 2017. Persistence rates were calculated using Kaplan-Meier curves. Patients were defined as "persistent" or "non-persistent" according to the use of therapy after 60 months. RESULTS: The study included 101 patients (84 females) with a median follow-up period of 23.6±14.2 months. The persistence rate declined to 85.3%, 78.3%, 74.1%, 71.3%, and 69.3% at 12, 24, 36, 48, and 60 months, respectively. Age at the initiation of denosumab therapy differed significantly between non-persistent (n=31) and persistent (n=70) patients (81.3 vs. 72.8 years, p <0.01). Persistence was significantly lower in patients aged ≥80 years than in those aged <60 and 60-79 years (both p <0.01). The reasons for non-persistence of denosumab therapy were transfer to another hospital (n=13), interruption of outpatient visits (n=11), dental treatment (n=4), adverse events (n=2), and patient request (n=1). CONCLUSIONS: Persistence was significantly lower in patients aged ≥80 years than in patients of other ages, and strategies promoting persistence are needed for these elderly patients.

Differences of lumbopelvic sagittal parameters among community-dwelling middle-age and elderly individuals: Relations with locomotor physical function.

This study aims to establish radiographic parameters of lumbopelvic sagittal alignment, gender related differences, and age-related changes in a middle-aged community, to investigate whether age-related changes of lumbopelvic alignment reflect the risk of locomotive syndrome (LS). This study included 448 healthy Japanese volunteers who attended a basic health checkup supported by the local government. The subjects (184 males and 264 females, mean age: 62.7 years) were grouped according to their age by decade. Sagittal lumbopelvic parameters were collected by lateral spine radiographs including lumbar lordosis (L1-S1, LL), lower lumbar lordosis (L4-S1, LLL), pelvic incidence (PI), pelvic tilt (PT) and sacral slope (SS). The three tests (stand-up test, two-step test, and 25-question geriatric locomotive function scale [GLFS-25]) composing the LS risk test were performed. LL was significantly lower in males than in the females. A significant decrease of LL and LLL was observed from 60 s to 70 s in the females. PI did not markedly change with aging in either gender but was lower in males. A remarkable increase of PT was seen from 60 s to 70 s in the females. SS did not markedly change with aging and was lower in males in all decades. The prevalence of LS risk in males and females increased gradually with age and was greater in females in any decade. 70 s females with LS risk had significantly lower LL and higher PT compared to them without LS risk. Radiographic parameters of lumbopelvic sagittal alignment were established in community-dwelling middle-age and elderly individuals.

Differences of locomotive syndrome and frailty in community-dwelling middle-aged and elderly people: Pain, osteoarthritis, spinal alignment, body balance, and quality of life.

Purpose: To identify differences between locomotive syndrome (LS) and frailty.Methods: A total of 1016 subjects (males 427, females 589, mean age 64 years) were prospectively examined in the Yakumo study. LS was defined as ≥16 on the GLFS-25 questionnaire. Frailty was diagnosed as ≥3 of unintentional weight loss, grip strength weakness, low walking speed, exhaustion, and low physical activity.Results: LS (14.4%) and frailty (10.8%) were more significant in older, female subjects with weaker muscle strength, lower gait speed, severer pain, poorer spinal alignment, and poor quality of life (QOL). LS strongly reflected musculoskeletal and neuropathic pain, knee and lumbar degeneration with poor spinal alignment, and poorer body balance, whereas frailty reflected muscle weakness. In multivariate analysis adjusted for age and gender, the significant independent risk factors were LS (odds ratio (OR) 10.6), frailty (OR 3.6), pain (OR 1.02) for poor physical QOL, and LS (OR 4.4) and lower gait speed (OR 1.6) for poor mental QOL.Conclusion: LS is more strongly related to musculoskeletal factors and may be more important than frailty for poor physical and mental QOL. LS should be checked early especially in independent elderly people to maintain activities of daily living and QOL.

A comparative study of two reconstruction procedures for osteoporotic vertebral fracture with lumbar spinal stenosis: Posterior lumbar interbody fusion versus posterior and anterior and combined surgery.

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