Nutritional Status Is Associated With Survival Following Spinal Surgery in Patients With Metastatic Spinal Tumors.

Background Preoperative and postoperative nutritional statuses are reported to influence the outcomes and complications of multidisciplinary treatment, including patient survival. However, a causal relationship between nutritional status and survival following spinal surgery has not been demonstrated in patients with metastatic spinal tumors. The present study was, therefore, designed to evaluate the correlation between the nutritional status and survival following spinal surgery in patients with metastatic spinal tumors. Methods Nutritional status was evaluated using the Japanese version of the modified Glasgow prognostic score (JmGPS), C-reactive protein-to-albumin ratio (CAR), prognostic nutrition index (PNI), neutrophil-to-lymphocyte ratio (NLR), and platelet-to-lymphocyte ratio (PLR), which were calculated from the results of preoperative laboratory tests. The survival period was defined as the interval between the day preoperative data were obtained and the day of death. Results Data from 57 of 113 consecutive surgeries were retrieved. The CAR, JmGPS, and PNI were significantly correlated with the survival period (CAR, r = -0.576, P < 0.01; JmGPS, r = -0.537, P < 0.01; PNI, r = 0.316, P = 0.02). Furthermore, patients with 0 points on the JmGPS had significantly longer survival. Using receiver operating characteristic curves, CAR cutoffs of ≥0.880 and ≤0.220 were found to be optimal in predicting the 90- and 180-day postoperative survival, respectively. Conclusions The findings of the present study indicate that preoperative assessment of the JmGPS, CAR, and PNI has utility in estimating nutritional status and predicting survival following spinal surgery in patients with metastatic spinal tumors.

Optimization of the Revised Tokuhashi Scoring System: New Prognostic Criteria for Metastatic Spinal Tumor in Surgical Cases.

INTRODUCTION: The revised Tokuhashi scoring system has been used to predict survival in patients with metastatic spinal tumors. Because of the rapid progress of cancer therapy, the original criteria of the revised Tokuhashi scoring system became in recent years unsuitable. The study aim was to evaluate the validity of the revised Tokuhashi scoring system in patients who underwent spinal surgery and to establish new prognostic criteria. METHODS: The study enrolled 85 patients with metastatic spinal tumors who underwent spinal surgery. The patients' survival outcomes in October 2019 were as follows: 57 patients died; 10 were alive; and 18 had unknown prognoses. The study evaluated the validity of the Tokuhashi scoring system, and established and validated the new prognostic criteria. RESULTS: The accuracies of the Tokuhashi scoring system were 66.7% in the short-term group, 60% in the midterm group, and 100% in the long-term group. Among the patients who died, the survival period and total score were significantly correlated. Total score cutoff point was six points in the patients whose predicted survival was <6 months. Total score cutoff point was eight points in the patients whose predicted survival was ≥1 year. CONCLUSIONS: As the prognosis of patients has improved in recent years, the original criteria of the revised Tokuhashi scoring system have been questioned as to their suitability to current treatments. Especially, the survival period among the patients with total scores of 7 and 8 points was not accurate. According to this study, the new prognostic criteria of the revised Tokuhashi scoring system were set to 0 to 6 points for the short-term group, 7 points for the midterm group, and 8 to 15 points for the long-term group.

Pulmonary Function Improves in Patients with Adolescent Idiopathic Scoliosis who Undergo Posterior Spinal Fusion Regardless of Thoracoplasty: A Mid-Term Follow-Up.

INTRODUCTION: The purpose of the present study was to determine, in a mid-term follow-up 5 years or more after surgery, the forced vital capacity (FVC), forced expiratory volume in 1 s (FEV1), and expiratory flow in patients with adolescent idiopathic scoliosis (AIS) who underwent posterior spinal fusion (PSF) with or without thoracoplasty. METHODS: The subjects were 134 patients with AIS who underwent PSF between 2004 and 2013. Forty-five patients agreed to participate in the study. We divided the patients into two groups as follows: 24 patients who underwent PSF with thoracoplasty from 2004 to 2010 in the TP group and 21 patients who underwent PSF without thoracoplasty from 2011 to 2013 in the non-TP group. We evaluated whole spine X-ray imaging and pulmonary function tests (PFTs) in these patients. PFTs measured FVC, FEV1, peak expiratory flow (PEF), maximum expiratory flow at 50% FVC (V50), maximum expiratory flow at 25% FVC (V25), and the ratio of V50 to V25 (V50/V25). RESULTS: The main thoracic curves were 53.6 ± 10.1° before surgery, 19.8 ± 7.6° 1 week after surgery, 22.3 ± 8.3° 2 years after surgery, and 23.3 ± 7.6° at the most recent observation. Compared with preoperative values, FVC, FEV1, and % FEV1 were improved significantly at the most recent observation. No significant difference was observed between % FVC before surgery and at the most recent observation. Compared with preoperative values, PEF, V50, and V25 were improved significantly at the most recent observation. V50/V25 did not change significantly. The changes in PFT values in the TP group and the non-TP group were compared. No significant differences were observed in FVC, % FVC, FEV1, % FEV1, PEF, V50, or V25. CONCLUSIONS: Regardless of whether thoracoplasty was performed or not, FVC, FEV1, and expiratory flow were improved 5 years or later after PSF.

Anchor type at upper instrumented vertebra and postoperative shoulder imbalance in patients with Lenke type 1 adolescent idiopathic scoliosis.

PURPOSE: To clarify the impact of anchor type at upper instrumented vertebra (UIV) on postoperative shoulder imbalance in patients with Lenke type 1 adolescent idiopathic scoliosis (AIS) who underwent posterior spinal fusion. METHODS: Subjects were 81 patients with Lenke type 1 AIS who underwent posterior spinal fusion between 2004 and 2013. Twenty-five patients agreed to participate in the study. We divided the patients into two groups: Hook group (15 patients with hooks at UIV who underwent surgery between 2004 and 2011) and PS group (ten patients with pedicle screws at UIV who underwent surgery between 2012 and 2013). To evaluate shoulder balance, first thoracic vertebra tilt angle (T1 tilt), clavicle angle (CA), and radiographic shoulder height (RSH) were measured. RESULTS: There were no significant differences in preoperative T1 tilt, CA, or RSH between the both groups. The postoperative 1-week, 2-year, and most recently observed T1 tilts were significantly smaller in the Hook group than in the PS group. There were no significant differences in postoperative 1-week, 2-year, and most recently observed CAs between the two groups. Although there were no significant differences in 1-week postoperative RSH between the groups, the 2-year postoperative RSH was significantly smaller in the Hook group than in the PS group. The most recently observed RSH tended to be smaller in the Hook group than in the PS group, but the difference was not significant. CONCLUSIONS: In the PS group, poor shoulder balance remained over the long term. The hooks at UIV adjusted postoperative shoulder balance.

Increase in pancreatic enzymes following spinal alignment changes in the thoracolumbar junction: Potential for acute pancreatitis after kyphosis correction.

BACKGROUND: Despite the identification of various risk factors for pancreatitis and hyperamylasemia following spinal surgery, no report has investigated the relationship between spinal alignment changes and elevated serum amylase levels. The purpose of this study was to investigate the relationship between spinal alignment changes and hyperamylasemia after spinal fusion. METHODS: A total of 222 patients whose serum pancreatic amylase levels were measured before and after spinal surgery from December 2017 to May 2019 were included. Inclusion criteria were (1) spinal fusion including the thoracolumbar junction (T10-L2) and (2) serum pancreatic amylase measurements before, immediately after surgery (day 0), the day after surgery (day 1), and 1 week after surgery. Ultimately, 37 patients who met the criteria were analyzed. Patients with hyperamylasemia at day 0 and/or day 1 (H group) were then compared with those without hyperamylasemia (N group). RESULTS: No significant differences in age, sex, surgical procedure, number of fused segments, intraoperative blood loss, operative time or American Society of Anesthesiologists physical status classification were observed between both groups. The H group had significantly larger preoperative thoracolumbar kyphosis (TLK) (H group: 22.6°, N group: 6.4°), postoperative TLK (H group: 16.8°, N group: 7.6°), and preoperative T12-L1 kyphosis angles (H group: 16.2°, N group: 7.9°) compared with the N group. Moreover, the H group demonstrated a significant decrease in TLK after surgery (H group: -5.8°, N group: 1.6°). CONCLUSIONS: Risk factors for hyperamylasemia included a large preoperative TLK angle and a greater postoperative decrease in TLK. Thus, decreased TLK after spinal fusion surgery should prompt careful attention to abdominal symptoms and elevated pancreatic amylase levels.

Spinal Alignments of Residual Lumbar Curve Affect Disc Degeneration after Spinal Fusion in Patients with Adolescent Idiopathic Scoliosis: Follow-up after 5 or More Years.

INTRODUCTION: Despite preserving lumbar disc mobility, spinal sagittal, and/or coronal alignment might ultimately impede surgical success. The purpose of this study was to elucidate the effects of spinal alignment on lumbar disc degeneration after 5 or more years in adolescent idiopathic scoliosis (AIS) patients who underwent spinal fusion. METHODS: Subjects were 49 AIS patients who underwent posterior spinal fusion without lumbar curve fusion. The inclusion criteria were the following: 1) Lenke type 1A, 1B, 2A or 2B, 2) age 10 to 19 years at the time of operation, and 3) minimum 5-year follow-up. The exclusion criteria were the following: 1) diagnosed as other than AIS, 2) history of lumbar disc herniation and spondylolysis, 3) subsequent surgery, and 4) history of surgery before AIS surgery. Nineteen patients agreed to participate in this research. X-rays, lumbar MRI, and questionnaires were evaluated. Disc degeneration in non-fused segments was defined as Pfirrmann grade 3 or higher. Patients with disc degenerations at the final observation (DD[+] group) were compared to those without disc degenerations (DD[-] group). RESULTS: There were no significant differences in the preoperative or postoperative 1-week X-ray parameters between both groups. The lumbar curve was significantly larger in the DD[+] group compared with the DD[-] group at the final observation (DD[+]: 16.8 degrees, DD[-]: 10.4 degrees, p = 0.035). The sagittal vertical axis (SVA) was significantly larger in the DD[+] group compared with the DD[-] group at the final observation (DD[+]: -4.4 mm, DD[-]: -34.3 mm, p = 0.006). SRS-22 function, self-image, and satisfaction scores were lower in the DD [+] group compared with the DD[-] group at the final observation. CONCLUSIONS: The patients with DD had significantly larger lumbar curve and SVA with lower SRS-22 function, self-image, and satisfaction scores at the final observation. Even though the non-fused segments were preserved, spinal alignments of non-fused lumbar curve affect the DDs.

Thoracic Deformity Correction and Changes of Vital Capacity, Forced Expiratory Volume in 1 Second, and Expiratory Flow in Adolescent Idiopathic Scoliosis Five Years or More after Posterior Spinal Fusion with Thoracoplasty.

INTRODUCTION: The purpose of this study is to investigate thoracic deformity correction and pulmonary function changes in patients with adolescent idiopathic scoliosis (AIS) five years or more after undergoing posterior spinal fusion with thoracoplasty for correction of a thoracic deformity. METHODS: Subjects were 57 patients with AIS who underwent posterior spinal fusion between 2004 and 2010. 24 patients who had undergone thoracoplasty at least five years earlier agreed to participate in this research. X-rays, pulmonary function tests, and thoracic cage computed tomography (CT) were performed, and the Scoliosis Research Society Outcomes Questionnaire (SRS-22) was administered. CT axial images were used at the apex of the main thoracic (MT) curve. Apical vertebral rotation was evaluated using rotation angle to the sagittal plane (RAsag). Thoracic deformities were evaluated using the rib hump index (RHi) and the posterior hemithoracic symmetry ratio (PHSr). RESULTS: There were no significant differences between the preoperative and the final observation forced vital capacity (FVC) or the preoperative and the final observation %FVC. The forced expiratory volume in 1 s (FEV1) and %FEV1 were significantly improved at the final observation: FEV1 (preoperative: 1.88 L, final observation: 2.05 L, p = 0.045) and %FEV1 (preoperative: 57.1%, final observation: 66.2%, p = 0.001). FEV1/FVC was also significantly improved at the final observation (preoperative: 83.0%, final observation: 86.4%, p = 0.019). The peak expiratory flow (PEF) was significantly improved at the final observation (preoperative: 3.67 L/s, final observation: 4.38 L/s, p = 0.029). On the CT assessment for thoracic deformities, there were no significant changes in RAsag or RHi. PHSr was significantly increased at the final observation compared with the preoperative period. CONCLUSIONS: With posterior spinal fusion in combination with thoracoplasty for AIS, although the correction of deformities was limited, the pulmonary function testing demonstrated the preservation of vital capacity (VC) and improvements in the forced expiratory volume in 1 s and expiratory flow.

Hooks at the Upper Instrumented Vertebra Can Adjust Postoperative Shoulder Balance in Patients with Adolescent Idiopathic Scoliosis: 5 Years or More of Follow-up.

Study Design: A retrospective cohort study. Purpose: This study aims to investigate postoperative shoulder imbalance (PSI) ≥5 years postoperatively in patients who underwent posterior spinal fusion using hooks at the upper instrumented vertebra (UIV) for Lenke type 1 adolescent idiopathic scoliosis (AIS). Overview of Literature: Studies have reported PSI due to excessive correction of the main thoracic curve. Methods: We examined 56 patients with AIS who underwent a posterior spinal fusion with hooks at the UIV from 2004 to 2010. Of these, we enrolled 14 patients who underwent surgery, at least, 5 years ago. X-rays and Scoliosis Research Society-22 (SRS-22) questionnaire were administered. To evaluate the shoulder balance, T1 vertebral tilt angle (T1 tilt), clavicle angle, and radiographic shoulder height (RSH) were measured. PSI was considered as the absolute value of the postoperative RSH being ≥20 mm. Based on radiographs obtained immediately postoperatively, we divided patients into two groups as follows: the balanced group (absolute value of RSH <20 mm) and imbalanced group (absolute value of RSH ≥20 mm). Results: The frequency of PSI was 28.6% immediately postoperatively, 0% 2 years postoperatively, and 7.1% at the last follow-up. In the balanced group, PSI did not occur even at 2 years postoperatively or at the last follow-up. In the imbalanced group, PSI was improved in all patients 2 years postoperatively and all patients, except one patient, at the last follow-up. No significant differences were noted in the frequency of distal adding-on at 2 years postoperatively or the last follow-up between the balanced group and the imbalanced group. We observed moderate negative correlations between the absolute value of T1 tilt and the SRS-22 pain and satisfaction at the last follow-up. Conclusions: Hooks at the UIV could adjust the shoulder balance to avoid long-term PSI in patients with AIS.

Pulmonary function and thoracic deformities in adolescent idiopathic scoliosis 27 years or longer after spinal fusion with Harrington instrument.

BACKGROUND: The aim of this study was to conduct an investigation into spinal fusion with Harrington instrument (HI) in patients with adolescent idiopathic scoliosis (AIS) and to survey pulmonary function and thoracic deformity outcomes many years after surgery. METHODS: Subjects comprised 194 patients diagnosed with AIS and treated with spinal fusion using HI between 1968 and 1987. Patients who gave their informed consent were subjected to a complete standing spine X-ray, chest CT, and pulmonary function tests. Eighteen patients were eligible for inclusion. Mean age at the time of follow-up was 49.9 years and the mean duration of follow-up was 35.3 years. CT axial image was used at the apex of the main thoracic curve. Apical vertebral rotation was determined from RA sag measured by the method of Aaro et al. Thoracic cage deformities were measured as follows: Rib hump index (RHi) according to the method of Aaro et al. and posterior hemithoracic symmetry ratio (PHSr) according to the method of Campbell et al. RESULTS: Pulmonary function tests revealed mean forced vital capacity (FVC) of 2.28 (range: 1.00-3.04) L and mean %FVC of 83.5% (range: 35.6%-117.8%). Restrictive ventilation disorder with %FVC <80% was seen in 5 patients (27.7%). %FVC had strong negative correlations with RA sag (r = -0.798), RHi (r = -0.820, p < 0.001), PHSr (r = -0.705), and proximal thoracic curve (r = -0.721). Main thoracic curve (r = -0.674) and apical vertebral rotation of thoracic curve (r = -0.685) showed moderate negative correlations. Multiple regression analysis revealed RHi was a most significant factor on %FVC. CONCLUSIONS: In AIS patients examined 27 years or longer after surgery, restrictive ventilation defects were observed in 27.7%. Factors aggravating %FVC were large rib humps and large vertebral rotations. Three-dimensional correction of the spine and thoracic cage deformities is vital in order to avoid pulmonary function impairment many years after surgery.

Modic Changes and Disc Degeneration of Nonfused Segments 27 to 45 Years After Harrington Instrumentation for Adolescent Idiopathic Scoliosis: Comparison to Healthy Controls.

STUDY DESIGN: A case-control study. OBJECTIVE: The aim of this study was to investigate the long-term prevalence of the Modic changes and disc degeneration in the nonfused segments of the surgically treated adolescent idiopathic scoliosis (AIS) patients and compare with age- and sex-matched healthy controls. SUMMARY OF BACKGROUND DATA: No studies have looked at the association between Modic changes and low back pain in patients who underwent AIS surgery many years ago. METHODS: Study subjects consisted of 194 patients with AIS who underwent spinal fusion with Harrington instrumentation between 1968 and 1987. Twenty-six patients (AIS group) underwent lumbar magnetic resonance imaging (MRI), whole spine X-ray, and patient-reported outcomes evaluations [Scoliosis Research Society-22 Patient Questionnaire (SRS-22), Oswestry Disability Index (ODI)]. The mean duration of follow-up observation was 36.1 years. The lowest fusion vertebra was used as follows: T12: 2 patients, L1: 4, L2: 11, L3: 6, L4: 2, L5: 1. Twenty-nine healthy age- and sex-matched individuals were selected as a control (CTR) group. RESULTS: On the basis of MRI findings, a significantly higher percentage of subjects showed Modic changes in the AIS group (AIS group: 57.7%, CTR group: 13.8%). There were no significant differences in the percentage of subjects with disc degeneration rated Pfirrmann grade 4 or higher (AIS group: 61.5%, CTR group: 65.5%). SRS-22 scores for function and self-image were significantly lower in the AIS group. ODI was significantly worse in the AIS group. Modic changes in AIS group were found in the concave side of the curve in 61.9%. The magnitude of lumbar coronal curve was found to be a significant risk factor of Modic changes. CONCLUSION: Modic changes were observed in 57.7% of AIS patients 27 years or more after spinal fusion with Harrington instrumentation. The magnitude of lumbar coronal curve was found to be a significant risk factor of Modic changes. Modic change occurred at a higher frequency in AIS patients than CTR individuals, with lower function and worse ODI scores. LEVEL OF EVIDENCE: 4.