Search

Retrospective cohort study OBJECTIVE: To investigate the long-term effects of bone cement-augmented instrumentation in multilevel lumbar fusions SUMMARY OF BACKGROUND DATA: Cement-augmented screw is one of the techniques used to reduce early mechanical failure in multilevel lumbar fusion, especially in the elderly. However, there is little information regarding the long-term effects.Fifty one patients who underwent three or more levels of lumbar fusion were divided into two groups according to bone cement-augmented screw fixation involving the upper instrumented vertebra (UIV): 22 patients (cemented group, group I) and 29 patients (non-cemented group, group II). The analysis of radiographic adjacent segment degeneration (ASD) involved patients with lumbosacral fusion showing a similar degree of osteoporosis. Radiologic ASD was defined as more than two UCLA grades of progression at 2 years postoperatively. Other sagittal parameters were analyzed and preoperative MR Pfirrmann grades for adjacent level, probably related to ASD.Even when no significant differences existed in preoperative demographic and radiographic parameters between the two groups, the postoperative kyphotic changes at 3 months were higher in the non-cemented group. In terms of long-term effects, radiologic ASD (20 patients (95.2%) in group I; 15 (53.6%) in group II) was significantly higher in the cemented group. Logistic regression analysis of radiologic ASD including other clinical and radiological parameters, postoperative PI-LL mismatch (OR 5.201, 95% CI 1.123-24.090, p = 0.035) and cement augmentation (OR 20.193, 95% CI 2.195-185.729, p = 0.008) showed a significant correlation with the development of radiologic ASD at postoperative 2 years.Although bone cement-augmented screw implantation can prevent kyphotic deformation at the proximal junction of UIV in early postoperative stages of multi-level lumbar fusion, a discreet selection of patients is required due to possible accelerated degeneration of adjacent segments.

Lumbar interbody fusion (LIF) is an excellent treatment option for a number of lumbar diseases. LIF can be performed through posterior, transforaminal, anterior, and lateral or oblique approaches. Each technique has its own pearls and pitfalls. Through LIF, segmental stabilization, neural decompression, and deformity correction can be achieved. Minimally invasive surgery has recently gained popularity and each LIF procedure can be performed using minimally invasive techniques to reduce surgery-related complications and improve early postoperative recovery. Despite advances in surgical technology, surgery-related complications after LIF, such as pseudoarthrosis, have not yet been overcome. Although autogenous iliac crest bone graft is the gold standard for spinal fusion, other bone substitutes are available to enhance fusion rate and reduce complications associated with bone harvest. This article reviews the surgical procedures and characteristics of each LIF and the osteobiologics utilized in LIF based on the available evidence.

Previous studies of patient positioning during spinal surgery evaluated intraoperative or immediate postoperative outcomes after short-instrumented lumbar fusion. However, patient positioning during long-instrumented fusion for an adult spinal deformity (ASD) might be associated with differences in intraoperative parameters such as blood loss and longer-term outcomes such as spine alignment, and comparing types of surgical tables in the context of these larger procedures and evaluating longer-term outcome scores seem important.(1) Do blood loss and the number of transfusions differ between patients who underwent multi-level spinal fusion with a Wilson frame and those with a four-poster frame? (2) Does restoration of lumbar lordosis and the sagittal vertical axis differ between patients who underwent surgery with the use of one frame or the other? (3) Do clinical outcomes as determined by Numeric Rating Scale and Oswestry Disability Index scores differ between the two groups of patients? (4) Are there differences in postoperative complications between the two groups?Among 651 patients undergoing thoracolumbar instrumented fusion between 2015 and 2018, 129 patients treated with more than four levels of initial fusion for an ASD were identified. A total of 48% (62 of 129) were eligible; 44% (57 of 129) were excluded because of a history of fusion, three-column osteotomy, or surgical indications other than degenerative deformity, and another 8% (10 of 129) were lost before the minimum 2-year follow-up period. Before January 2017, one surgeon in this study used only a Wilson frame; starting in January 2017, the same surgeon consistently used a four-poster frame. Forty patients had spinal fusion using the Wilson frame; 85% (34 of 40) of these had follow-up at least 2 years postoperatively (mean 44 ± 13 months). Thirty-two patients underwent surgery using the four-poster frame; 88% (28 of 32) of these were available for follow-up at least 2 years later (mean 34 ± 6 months). The groups did not differ in terms of age, gender, BMI, type of deformity, or number of fused levels. Surgical parameters such as blood loss and the total amount of blood transfused were compared between the two groups. Estimated blood loss was measured by the amount of suction drainage and the amount of blood that soaked gauze. The decision to transfuse blood was based on intraoperative hemoglobin values, a protocol that was applied equally to both groups. Radiologic outcomes including sagittal parameters and clinical outcomes such as the Numerical Rating Scale score for back pain (range 0-10; minimal clinically important difference [MCID] 2.9) and leg pain (range 0-10; MCID 2.9) as well as the Oswestry Disability Index score (range 0-100; MCID 15.4) were also assessed through a longitudinally maintained database by two spine surgeons who participated in this study. Repeated-measures analysis of variance was used to compare selected radiologic outcomes between the two groups over time.Blood loss and the total amount of transfused blood were greater in the Wilson frame group than in the four-poster frame group (2019 ± 1213 mL versus 1171 ± 875 mL; mean difference 848 [95% CI 297 to 1399]; p = 0.003 for blood loss; 1706 ± 1003 mL versus 911 ± 651 mL; mean difference 795 [95% CI 353 to 1237]; p = 0.001 for transfusion). Lumbar lordosis and the sagittal vertical axis were less restored in the Wilson frame group than in the four-poster frame group (7° ± 10° versus 18° ± 14°; mean difference -11° [95% -17° to -5°]; p0.001 for lumbar lordosis; -22 ± 31 mm versus -43 ± 27 mm; mean difference 21 [95% CI 5 to 36]; p = 0.009 for the sagittal vertical axis). Such differences persisted at 2 years of follow-up. The proportion of patients with the desired correction was also greater in the four-poster frame group than in the Wilson frame group immediately postoperatively and at 2 years of follow-up (50% versus 21%, respectively; odds ratio 3.9 [95% CI 1.3 to 11.7]; p = 0.02; 43% versus 12%, respectively; odds ratio 5.6 [95% CI 1.6 to 20.3]; p = 0.005). We found no clinically important differences in postoperative patient-reported outcomes including Numeric Rating Scale and Oswestry Disability Index scores, and there were no differences in postoperative complications at 2 years of follow-up.The ideal patient position during surgery for an ASD should decrease intra-abdominal pressure and induce lordosis as the abdomen hangs freely and hip flexion is decreased. The four-poster frame appears advantageous for long-segment fusions for spinal deformities. Future studies are needed to extend our analyses to different types of spinal deformities and validate radiologic and clinical outcomes with follow-up for more than 2 years.III, therapeutic study.

OBJECTIVE The most catastrophic symptom of proximal junctional failure (PJF) following long instrumented fusion surgery for adult spinal deformity (ASD) is neurological deficits. Although previous reports have shown that PJF usually developed during the early postoperative period, some patients showed late neurological deficits. The aim of this study was to report the incidence, characteristics, and surgical outcomes of PJF with late neurological deficits. METHODS Patients surgically treated for ASD at a single institution were retrospectively reviewed. Among them, the patients requiring revision surgery for newly developed neurological deficits at least 6 months after the initial surgery were included. Patient demographic, radiographic, surgical, and clinical data were investigated. Neurological status was assessed using the Frankel grading system. RESULTS PJF with late neurological deficits developed in 18 of 385 patients (4.7%). The mean age at the onset of neurological deficits was 72.0 ± 6.0 years, and the median time from the initial surgery was 4.5 years. The most common pathology of PJF was adjacent disc degeneration and subsequent canal stenosis (11 patients). Five patients showed disc degeneration with aseptic bone destruction. Fractures at the upper instrumented vertebra (UIV), UIV + 1, and UIV + 2 occurred in 2, 3, and 2 patients, respectively. Ossification of the yellow ligament, which had not been found at the first surgery, was identified in 6 patients. Eight patients showed improvement of their neurological deficits and 10 patients showed no improvement by the final follow-up. Perioperative major complications occurred in 8 of 18 patients. CONCLUSIONS The incidence of PJF with late neurological deficits following ASD surgery was 4.7% in this cohort. The patients showed several morphological features. After revision surgery, perioperative complications were common and the prognosis for improved neurological status was not favorable.

Objective We investigated the characteristics and revision rate of junctional failure after surgical correction for thoracolumbar kyphosis in patients with ankylosing spondylitis. Methods A total of 230 patients had undergone surgical correction for thoracolumbar kyphosis from 2010 to 2019. The state of ankylosis between the uppermost instrumented vertebra (UIV) and UIV+1 and between the lowermost instrumented vertebra (LIV) and LIV−1 was analyzed using a modified Stoke ankylosing spondylitis spine score. Proximal junctional failure (PJF) and distal junctional failure (DJF) were defined as any type of symptomatic junctional failure. Results Of the 230 patients, 23 (10.0%) had developed junctional failure. Of these 23 patients, 16 had had partial ankylosis and 7 had had complete ankylosis. PJF had developed in 10 patients and DJF in 13. The most common type of junctional failure was a junctional fracture, which developed in 12 patients. PJF had developed by UIV fracture in 4 patients, UIV+1 fracture in 1 patient, and UIV+2 in 1 patient. DJF had developed by LIV fracture in 6 patients, metallic failure in 5, and progression of DJF in 2 patients. The average time to the development of PJF and DJF was 13 months and 12.4 months, respectively. All 10 patients with PJF and 7 of 13 patients with DJF (53.8%) had required reoperation. Of the 12 patients with junctional fracture, 11 (91.7%) had undergone reoperation. Conclusions Of the 23 patients with junctional failure, 16 had had immature ossification of the anterior longitudinal ligament. Therefore, to prevent junctional failure, the state of ankylosis seems to be important for selecting the fusion level after osteotomy. Once junctional failure has developed, however, reoperation should be considered owing to the stress concentration at the UIV or LIV.

The objective of this study was to investigate the incidence and risk factors of rod fractures (RFs) after a single-level lumbar pedicle subtraction osteotomy (PSO) using a side-tightening (ST) pedicle screw system.Fifty-seven consecutive patients who underwent a single-level lumbar PSO for the degenerative sagittal imbalance at a single institution were retrospectively reviewed. All surgeries were performed by a single surgeon using an ST pedicle screw system. Demographic, surgical, and radiographic data were analyzed to investigate the incidence and risk factors for RF.Seven (12.3%) patients showed RF after PSO. Four patients had bilateral RFs, and 3 patients had unilateral RFs. The location of the RF was at the PSO level in 6 of 7 patients. The ratio of adjacent interbody fusion was significantly different between the group with RF and the group without RF (16.7% vs. 74.0%, P = 0.004). The preoperative segmental angle at the PSO vertebra (-6.1° ± 5.5° vs. -1.7° ± 4.6°, P = 0.049) and postsurgical change in lumbar lordosis (48.4° ± 8.8° vs. 37.8° ± 11.9°, P = 0.033) were significantly different between the 2 groups. Risk factor analysis using stepwise logistic regression analysis revealed that the absence of an adjacent interbody cage (odds ratio = 0.011, 95% confidence interval = 0.000-0.390, P = 0.013) was a significant risk factor.The incidence of RF after a single-level lumbar PSO using the ST pedicle screw system was 12.3% in our cohort. The absence of an adjacent interbody cage was a significant risk factor for RF.

Background Decompressive laminectomy alone for degenerative lumbar scoliosis (DLS) is not recommended because it can lead to further instability. However, it is uncertain whether instability at the decompressed segments is directly affected by laminectomy or the natural progression of DLS. The purpose of this study was to evaluate the surgical outcome of decompressive laminectomy alone for DLS with spinal stenosis and to determine whether the procedure leads to post-laminectomy instability (PLI). Methods We retrospectively reviewed 60 patients with DLS. They were divided into 2 groups according to PLI criteria: stable group and PLI group. The PLI group was subdivided into 2 groups based on the level of PLI: the first group that showed PLI at the index laminectomy level (PLI-I) and the second group that showed PLI at another level other than the laminectomy level (PLI-NI). Radiological evaluation was performed to determine factors associated with the progression of DLS. Pain and disability outcomes were assessed. Results There were 34 patients (56.7%) in the stable group and 26 patients (43.3%) in the PLI group. Twelve patients (20.0%) underwent revision surgery. Eleven patients (18.3%) showed PLI at the index segments (PLI-I group), and 15 patients (25%) showed PLI at the adjacent or cephalad segments, not related to the laminectomy site (PLI-NI group). Four patients underwent revision surgery in the stable group and 8 in the PLI group. Survivorship analyses revealed that the predicted survivorship of DLS was 90.0% at 12 months and 86.4% at 24 months after laminectomy. Conclusions The development of PLI was not always related to laminectomy at the index level. However, PLI developed more rapidly at the index level, compared to the natural progression of the scoliotic curve at the adjacent segments.

STUDY DESIGN A retrospective study. OBJECTIVE The aim of this study was to investigate proximal junctional kyphosis (PJK) after lumbosacral long fusion according to preoperative Roussouly and lumbar degenerative kyphosis (LDK) types. SUMMARY OF BACKGROUND DATA Although previous studies have suggested some risk factors for PJK, the effects of preoperative grade of sagittal imbalance and paraspinal muscles degeneration on PJK remain unclear. METHODS Eighty-seven patients who had undergone lumbosacral fusion more than five levels with available clinical and radiological data were enrolled. The presence of PJK defined as sagittal Cobb angle ≥20° between the uppermost instrumented vertebra (UIV) and two supra-adjacent vertebrae at postoperative 2-year radiographs was recorded. Its occurrence was compared according to preoperative Roussouly and LDK types (Takemistu type) and the degree of paraspinal muscle degeneration at the upper level of UIV. Other sagittal radiographic parameters were also measured. RESULTS In this series, 28 patients (group I, 32.2%) showed radiological PJK, whereas 59 patients did not show radiological PJK (non-PJK patients, group II, 67.8%) at postoperative 2 years. PJK presented more prevalence in type III and type IV of LDK types (26/27, 96.3%). However, Roussouly types did not show any significant difference in PJK prevalence. In radiological parameters, a larger preoperative SVA (P = 0.018) and PI-LL (P = 0.015) were associated with PJK. Also, smaller quantity and lower quality of paraspinal muscles at T12-L1 level showed significant (P

OBJECTIVEThe purpose of this study was to investigate the rate of and the risk factors for surgery-related complications demonstrated on radiography after pedicle subtraction osteotomy (PSO) for thoracolumbar kyphosis in patients with ankylosing spondylitis (AS).METHODSThe authors retrospectively reviewed the medical records of 230 consecutive patients with thoracolumbar kyphosis due to AS who had undergone 1-level PSO at a single institution in the period from 2010 to 2017. The causes of surgery-related complications were divided into two types: surgical/technical failure and mechanical failure.RESULTSThe patients consisted of 20 women and 210 men, with an average age of 43.4 years. The average follow-up period was 39.0 months. The preoperative sagittal vertical axis was 18.5 ± 69.3 cm, which improved to 4.9 ± 4.6 cm after PSO. Of the 77 patients (33.5%) who experienced minor or major surgery-related complications, 56 had complications related to surgical/technical failure (overall incidence 24.3%) and 21 had complications related to mechanical failure (overall incidence 9.1%). Fourteen patients (6.1%) underwent reoperation. However, among the 77 patients with complications, the rate of revision surgery was 18.2%. The most common radiological complications were as follows: sagittal translation in 24 patients, coronal imbalance in 20, under-correction in 8, delayed union in 8, and distal junctional failure and kyphosis in 8. The most common causes of reoperation were coronal imbalance in 4 patients, symptomatic malposition of pedicle screws in 3, and distal junctional failure in 3. Delayed union was statistically correlated with posterior sagittal translation (p = 0.007).CONCLUSIONSPSO can provide acceptable radiographic outcomes for the correction of thoracolumbar kyphosis in patients with AS. However, a high incidence of surgery-related complications related to mechanical failure and surgical technique can develop. Thorough radiographic investigation before and during surgery is needed to determine whether complete ossification occurs along the anterior and posterior longitudinal ligaments of the spine.

Study design This was a retrospective comparative study. Objective The main objective of this article was to evaluate the clinical and radiologic efficacies of minimally invasive lateral lumbar interbody fusion (LLIF) for clinical adjacent segment pathology (ASP). Summary of background data Minimally invasive techniques have been increasingly applied for spinal surgery. No report has compared LLIF with conventional posterior lumbar interbody fusion for clinical ASP. Methods Forty patients undergoing LLIF with posterior fusion (hybrid surgery) were compared with 40 patients undergoing conventional posterior lumbar interbody fusion (posterior surgery). The radiologic outcomes including indirect decompression in hybrid surgery group, and clinical outcomes such as the Oswestry Disability Index (ODI) and Visual Analog Scale (VAS) were assessed. Postoperative major complications and reoperations were also compared between the 2 groups. Results Correction of coronal Cobb's angle and segmental lordosis in the hybrid surgery were significantly greater postoperatively (2.8 vs. 0.9 degrees, P=0.012; 7.4 vs. 2.5 degrees, P=0.009) and at the last follow-up (2.4 vs. 0.5 degrees, P=0.026; 4.8 vs. 0.8 degrees, P=0.016) compared with posterior surgery. As regards indirect decompression of the LLIF, significant increases in thecal sac (83.4 vs. 113.8 mm) and foraminal height (17.8 vs. 20.9 mm) were noted on postoperative magnetic resonance imaging. Although postoperative back VAS (4.1 vs. 5.6, P=0.011) and ODI (48.9% vs. 59.6%, P=0.007) were significantly better in hybrid surgery, clinical outcomes at the last follow-up were similar. Moreover, intraoperative endplate fractures developed in 17.7% and lower leg symptoms occurred in 30.0% of patients undergoing hybrid surgery. Conclusions Hybrid surgery for clinical ASP has advantages of segmental coronal and sagittal correction, and indirect decompression compared with conventional posterior surgery. However, LLIF-related complications such as endplate fracture and lower leg symptoms also developed. LLIF should be performed considering advantages and approach-related complications for the clinical ASP.

Background To date, there is a paucity of reports clarifying the change of spinopelvic parameters in patients with adult spinal deformity (ASD) who underwent long segment spinal fusion using iliac screw (IS) and S2-alar-iliac screw (S2AI) fixation. Methods A retrospective review of consecutive patients who underwent deformity correction surgery for ASD between 2013 and 2017 was performed. Patients were divided into two groups based on whether IS or S2AI fixation was performed. All radiographic parameters were measured preoperatively, immediately postoperatively, and the last follow-up. Demographics, intraoperative and clinical data were analyzed between the two groups. Additionally, the cohort was subdivided according to the postoperative change in pelvic incidence (PI): subgroup (C) was defined as change in PI ≥5° and subgroup (NC) with change Results A total of 142 patients met inclusion criteria: 111 who received IS and 31 received S2AI fixation. The IS group (65.6 ± 26°, 39.8 ± 13.8°) showed a significantly higher change in lumbar lordosis (LL) and upper lumbar lordosis (ULL) than the S2AI group (54.4 ± 17.9°, 30.3 ± 9.9°) (p p p Conclusions Compared with the S2AI technique, the IS technique usable larger cantilever force demonstrated more correction of lumbar lordosis, and possible increase in pelvic incidence. Further study is warranted to clarify the clinical impaction of these results.

Objective : Although radiotherapy (RT) is recommended for multiple myeloma (MM) involving spine, the treatment of choice between reconstructive surgery with RT and RT alone for pathologic vertebral fractures (PVFs) associated with structural instability or neurologic compromises remains controversial. The purpose of this study was to evaluate the clinical efficacies of reconstructive surgery with adjuvant RT for treatment of MM with PVFs by comparing with matched cohorts treated with RT alone.Methods : Twenty-eight patients underwent reconstructive surgery followed by RT between 2008 and 2015 in a single institution, for management of PVFs associated with structural instability of the spine and/or neurologic compromises (group I). Twentyeight patients were treated with RT alone (group II) after propensity score matching in a 1-to-1 format based on instability of the spine, as well as age and performance. Clinical outcomes including the overall survival rates, duration of independent ambulation, neurological status, and numeric rating scale (NRS) for back pain were compared.Results : Clinical and radiological features before treatment were similar in both groups. The median survival period was similar between the two groups. However, the mean duration of independent ambulation was significantly longer in group I (88.8 months; 95% confidence interval [CI], 66.0–111.5) than in group II (39.4 months; 95% CI, 25.2–53.6) (log rank test; p=0.022). Deterioration of Frankel grade (21.4% vs. 60.7%, p=0.024) and NRS for back pain (2.7±2.2 vs. 5.0±2.7, p=0.000) at the last follow-up were higher in the group II. Treatment-related complications were similar in both groups.Conclusion : In patients with unstable PVFs due to MM, reconstructive surgery may yield superior clinical outcomes compared with RT alone in maintaining independent ambulation and neurological status, as well as pain control despite similar median survival and complications.

To analyze the effects of direct vertebral rotation (DVR) on radiologic outcomes in the treatment of thoracic adolescent idiopathic scoliosis after selective thoracic fusion with pedicle screw instrumentation.Adolescent idiopathic scoliosis patients with single thoracic curves (n = 110) treated by selective thoracic fusion with a minimum of 2 years of follow-up were retrospectively analyzed. The patients were separated into 2 groups: non-DVR (n = 63) and DVR (n = 47).There was a significant difference in fused segments between the non-DVR and DVR groups (P0.001). There was also a significant difference in main thoracic curve postoperatively (P = 0.001) and at the last follow-up (P = 0.006) between the non-DVR and DVR groups. However, there was no significant difference in proximal thoracic and lumbar curves postoperatively (proximal thoracic curve: P = 0.186; lumbar curve: P = 0.155) and at the last follow-up (proximal thoracic curve: P = 0.250; lumbar curve: P = 0.060) between the 2 groups. Significant improvements in the lowest instrumented vertebra tilt and disc angle were noted but then slight deteriorations in such were observed during the follow-up period in the non-DVR group. The prevalence of unsatisfactory results was 20.6% (13 of 63) in the non-DVR group and 19.1% (9 of 47) in the DVR group, with no significant difference (P = 0.522).For correcting single thoracic adolescent idiopathic scoliosis by selective thoracic fusion with pedicle screw instrumentation, the addition of DVR to the surgical procedure showed comparable radiologic outcomes compared with non-DVR procedures.

Background As the prevalence of spinal fusion surgery has increased, reliable and safe bone graft substitutes have been developed in response. Biocompatible osteoconductive polymer (BOP) has been used as a bone graft alternative for spine surgery. We present a case of cervical myelopathy due to extrusion of BOP 23 years after surgery and discuss the pathophysiology in terms of spinal fusion. Case Description A 65-year-old man presented with a 3-month history of cervical myelopathic symptoms. Twenty-three years earlier, the patient had undergone cervical surgery for a C6–7 herniated disc with the use of BOP. Imaging studies of the cervical spine showed cord compression due to extruded BOP at C6–7. He underwent corpectomy of the C7 vertebral body and removal of the BOP for the neural decompression, combined with interbody fusion by use of an iliac bone graft and plate fixation. During the operation, crumbly fibers of the BOP were easily removed. His myelopathic symptoms improved immediately after surgery. Postoperative magnetic resonance imaging also showed successful decompression of the spinal cord. Histologically, a foreign body reaction and bony degeneration were found around the synthetic fibers of the BOP. Conclusions Spine surgeons should recognize the pathophysiology of the BOP used for spine fusion surgery. Although BOP is not currently used for spinal surgery, patients undergoing previous surgery with the BOP can present with related complications. Revision surgery is recommended to remove the unincorporated BOP and achieve solid spine fusion.

Objective The efficacy of preoperative embolization for hypervascular metastatic spine disease (MSD) such as renal cell and thyroid cancers has been reported. However, the debate on the efficacy of preoperative embolization for non-hypervascular MSD still remains unsettled. The purpose of this study is to determine whether preoperative embolization for non-hypervascular MSD decreases perioperative blood loss. Methods A total of 79 patients (36 cases of preoperative embolization and 43 cases of non-embolization) who underwent surgery for metastatic spine lesions were included. Representative hypervascular tumors such as renal cell and thyroid cancers were excluded. Intraoperative and perioperative estimated blood losses (EBL), total number of transfusion and calibrated EBL were recorded in the embolization and non-embolization groups. The differences in EBL were also compared along with the type of surgery. In addition, the incidence of Adamkiewicz artery and complications of embolization were assessed. Results The average age of 50 males and 29 females was 57.6±13.5 years. Lung (30), hepatocellular (14), gastrointestinal (nine) and others (26) were the primary cancers. The demographic data was not significantly different between the embolization and the non-embolization groups. There were no significant differences in intraoperative EBL, perioperative EBL, total transfusion and calibrated EBL between two groups. However, intraoperative EBL and total transfusion in patients with preoperative embolization were significantly lower than in non-embolization in the corpectomy group (1645.5 vs. 892.6 mL, p=0.017 for intraoperative EBL and 6.1 vs. 3.9, p=0.018 for number of transfusion). In addition, the presence of Adamkiewicz artery at the index level was noted in two patients. Disruption of this major feeder artery resulted in significant changes in intraoperative neuromonitoring. Conclusion Preoperative embolization for non-hypervascular MSD did not reduce perioperative blood loss. However, the embolization significantly reduced intraoperative bleeding and total transfusion in corpectomy group. Moreover, the procedure provided insights into the anatomy of tumor and spinal cord vasculature.

A retrospective comparative cohort study.To investigate the causes of jack-knife posture (JKP) without proximal junctional kyphosis (PJK) and to compare the causes of PJK and JKP without PJK.PJK causing stooping posture could be inevitable after long instrumented lumbar fusion for degenerative sagittal imbalance. However, few studies have addressed JKP without PJK, which is a different type of sagittal malalignment.Ninety-four adult patients who underwent long instrumented lumbar fusion for degenerative sagittal imbalance were divided into three groups depending on the presence of a postoperative sagittal deformity: JKP, PJK, or none. JKP was defined as a sagittal vertical axis of at least 8 cm anterior to the posterosuperior corner of S1 upper endplate without PJK. PJK was defined as a proximal kyphotic angle ≥10° and at least 10° greater than the preoperative measurement.Seventeen patients (18.1%) showed JKP, and 39 patients (41.5%) showed PJK. The mean age at the surgery of JKP and PJK patients was 70.0 and 65.5 years, respectively (p = .05). JKP developed more frequently if the preoperative pelvic tilt was25° or the sagittal vertical axis was8 cm (p = .048, 0.004, respectively). PJK developed more frequently if the preoperative pelvic tilt was25°, surgically corrected lumbar lordosis was30°, or the lumbar lordosis to thoracic kyphosis angle was0° (p = .002, .010, .031, respectively). JKP was more likely to develop in patients without sacropelvic fixation (p = .042), although they had a more degenerative L5-S1 segment (p = .010).Postoperative sagittal deformity can be classified into two types: JKP and PJK. JKP is caused mainly by hip and back extensor muscle weakness even though the cause of postoperative sagittal decompensation could be multifactorial. However, PJK developed mainly due to spinopelvic malalignment. Therefore, hip and back extensor weakness, which is age-dependent, may explain why older patients experienced more postoperative sagittal deformity.Level IV.

Study Design: Retrospective case-control study. Objectives: The aim of this study was to develop a simple and reliable imaging parameter to predict postoperative ambulatory status in patients with metastatic epidural spinal cord compression (MESCC). Methods: Sixty-three patients with MESCC underwent spine surgery because of neurologic deficits were included. On preoperative axial MRI, the cord compression ratio was analyzed for postoperative ambulatory status. The relationship between other imaging features, such as fracture of the affected vertebra and increased T2 signal intensity of the spinal cord at the compression level, and the postoperative ambulatory status were also analyzed. Results: Cord compression ratio and increased T2 signal change of the spinal cord were significantly different between the postoperative ambulatory group and the non-ambulatory group. Receiver operating characteristic analysis showed that the optimal cut-off value was 0.84. In the multivariate regression analysis, only a cord compression ratio of more than 0.84 was significantly associated with postoperative ambulatory status (odds ratio = 10.80; 95% confidence interval = 2.79-41.86; P = .001). Interobserver/intraobserver agreements were strong for the cord compression ratio, however those agreements were weak for increased T2 signal intensity. Conclusions: On preoperative MRI, the cord compression ratio may predict postoperative ambulatory status in patients with MESCC. The measurement of this imaging parameter was simple and reliable. This imaging predictor may be helpful for both clinicians and patients.

Study Design: This is a retrospective comparative cohort study.Purpose: To investigate the prevalence of anterior resorption of the cervical spine in ankylosing spondylitis (AS) and its relationship with sagittal alignment.Overview of Literature: This study believes that no published reports exist regarding the relationship between anterior resorption and spinopelvic alignment.Methods: This retrospective study included 238 patients with AS who underwent surgical correction for thoracolumbar kyphosis. Of these, 80 patients with complete subaxial ankylosis were selected and divided into two groups: groups 1 (consisting of 28 patients with anterior bony resorption) and 2 (consisting of 52 patients without anterior resorption). Cervical sagittal parameters were analyzed and compared between the two groups.Results: The average lateral diameter measured in patients with C5 anterior resorption was 84.2%±7.8% (62.4%–96.8%). Cervical lordosis was 8.7°±13.4° and 10.9°±11.5° in groups 1 and 2 (p=0.556), respectively. No significant differences were noted between the two groups on spinopelvic alignment in the T1 slope (52.2°±11.1° and 53.3°±9.9° in groups 1 and 2, respectively; p=0.742), C2–C7 sagittal vertical axis (SVA; 6.2±1.7 cm and 6.2±1.8 cm in groups 1 and 2, respectively; p=0.978), C7 SVA (14.3±4.9 cm and 14.6±6.2 cm in groups 1 and 2, respectively; p=0.823), or T1 pelvic angle (27.1°±8.9° and 31.6°±11.2° in groups 1 and 2, respectively; p=0.382). Correlation analyses were significant between the extent of anterior resorption and sagittal parameters, C2–C7 lordosis (R2=−0.428, p=0.021), and T1–T4 kyphosis (R2=−0.375, p=0.045).Conclusions: Anterior bony resorption could develop by stress concentration. However, the development was not related to the sagittal alignment. The particular segments involved in developing anterior resorption varied, possibly because of their dependence on the preceding pattern of ankylosis.

STUDY DESIGN Retrospective case-control study. OBJECTIVE To investigate the effects of postoperative sagittal alignment on radiographic adjacent segment degeneration (ASD) after lumbar fusion surgery. SUMMARY OF BACKGROUND DATA ASD is one of inherent problems with fusion surgery. Many confounding factors are related to the development of ASD. Recently, sagittal alignment has been emphasized for its significance on ASD. METHODS Seventy-three patients who underwent four-level lumbar fusion surgery (L2-S1) were divided into two groups according to postoperative sagittal alignment (pelvic incidence-lumbar lordosis [PI-LL] ≥ or

Lumbar interbody fusion (LIF) is an effective and popular surgical procedure for the management of various spinal pathologies, especially degenerative diseases. Currently, LIF can be performed with posterior, transforaminal, anterior, and lateral approaches by open surgery or minimally invasive surgery (MIS). Each technique has its own advantages and disadvantages. In general, posterior LIF is a well-established procedure with good fusion rates and low complication rates but is limited by the possibility of iatrogenic injury to the neural structures and paraspinal muscles. Transforaminal LIF is frequently performed using an MIS technique and has an advantage of reducing these iatrogenic injuries. Anterior LIF (ALIF) can restore the disk height and sagittal alignment but has inherent approach-related challenges such as visceral and vascular complications. Lateral LIF and oblique LIF are performed using an MIS technique and have shown postoperative outcomes similar to ALIF; however, these approaches carry a risk of injury to psoas, lumbar plexus, and vascular structures. Herein, we provide a detailed description of the surgical procedures of each LIF technique. We shall then consider the pearls and pitfalls, as well as propose surgical indications and contraindications based on the available evidence in the literatures.

Study Design: This study is a retrospective analysis of a case.Purpose: The purpose of this study is to investigate the fracture patterns and risk factors of sacral insufficiency fractures (SIFs) to improve their diagnosis in clinical practice.Overview of Literature: SIFs occur when normal stresses are applied to a bone with decreased density, most often due to osteoporosis. Individuals who receive lumbosacral fusion procedures may also suffer from increased incidents of SIFs because of decreased bone density related to aging.Methods: In total, 55 patients with SIFs were retrospectively investigated in this study. The study population was divided into lumbosacral fusion (n=20) and non-fusion (n=35) groups. Subsequently, the patients’ demographic characteristics, comorbidities, medication history, results of diagnostic imaging studies, and bone mineral density were assessed. The fracture patterns were classified either according to the five typical types (H-pattern bilateral vertical plus horizontal component, unilateral vertical only, bilateral vertical only, unilateral vertical plus horizontal component, and horizontal only fracture) or atypical types.Results: In total, 44 of 55 patients (80%) suffered from more than one senile disease and received corresponding medications that caused secondary osteoporosis. A total of 12 patients had S1 lumbosacral fixation. Moreover, three of these 12 patients who developed a SIF immediately after a lumbosacral fracture had an unstable sacral U fracture. The remaining nine patients showed fracture patterns similar to the non-fusion patients. Single-photon emission computed tomography (SPECT)/computed tomography (CT) can identify fracture recurrence in previously healed fractures. In total, 24 patients (43.6%) had fractures of the pelvis, femur, and thoracolumbar spine.Conclusions: SIF develops in elderly patients with multiple adult diseases that can induce secondary osteoporosis. Such fractures may occur in the patients with instrumented lumbosacral fusion. Importantly, some patients showed stress fractures after multilevel instrumented lumbosacral fusion, whereas others showed insufficiency fractures. The different fracture patterns correspond to different grades of SIF, and SPECT/CT can easily identify the fracture status.

Background There is a paucity of reports clarifying the implication of knee osteoarthritis (OA) on spinal sagittal alignment of patients undergone surgery for lumbar spine. This study aimed to analyze how osteoarthritic knee affects radiographic and clinical results of degenerative lumbar disease patients undergone lumbar fusion. Methods We retrospectively reviewed the medical records and radiographs of 74 consecutive degenerative lumbar disease patients who underwent posterior instrumentation and fusion surgery between May 2016 and June 2017 and were followed up for minimum 3 years postoperatively. The patients were divided into 2 groups according to the severity of knee OA by Kellgren-Lawrence grading (KLG) scale (group I, KLG 1 or 2 [n = 39]; group II, KLG 3 or 4 [n = 35]). Patient demographic data, comorbidities, spinal sagittal parameters and clinical scores were extracted and compared at preoperative, postoperative 1 month and the ultimate follow-up between the groups. In radiographic assessment, sagittal alignment parameters and sagittal balance were used. In clinical assessment, the scores of Oswestry disability index (ODI) and Scoliosis Research Society questionnaire (SRS-22) were used. For the frequency analysis of categorical variables across the groups, chi-square test was used and student t tests was used to compare the differences of continuous variables. Results In radiographic assessment, TLK (thoracolumbar kyphosis), LL (lumbar lordosis), PT (pelvic tilt), C7 SVA (sagittal vertical axis) in both groups improved significantly after surgery (p p > 0.05). There were significant differences between the groups at the ultimate follow-up in ODI (− 25.6 vs − 12.1, p p = 0.037), function subscore (1.4 vs 0.7, p = 0.016), and satisfaction subscore (1.6 vs 0.6, p Conclusion Osteoarthritic knee with KLG 3 or 4 have a negative influence on maintaining postoperative spinal sagittal alignment, balance, and the clinical outcomes achieved immediately by posterior instrumentation and fusion for lumbar degenerative disease. Trial registration This study was retrospectively registered with approval by the institutional review board (IRB) of our institution (approval number: 2018–11-007).

The purpose of this study was to report the characteristics of SIFs after ILSF and discuss its management focusing on pelvic deformation. We retrospectively reviewed all consecutive patients who underwent ILSF for degenerative disc diseases during the period between 2000 and 2017 and were diagnosed as SIF at our institute. The clinical and radiographic data were reviewed on their medical charts. Treatment outcomes for SIF were also investigated. Eight patients (all females) were included in this study. Mean age at SIF diagnosis was 72 years, and the mean follow-up period was 3.8 years (range 1–7 years). SIF developed average 7.5 years (range 1 month−17 years) after the index ILSF. Fracture patterns were unilateral vertical in four, bilateral vertical in three, and horizontal in 1 patient. Unlike patients with unilateral vertical SIF, patients with bilateral vertical or horizontal SIF showed a marked increase of pelvic incidence (PI) by mean 17.0°±5.0° and sagittal vertical axis (SVA) by mean 4.5 ± 2.2 cm, compared to the respective values before the onset of abrupt pain. All patients with unilateral vertical SIF were treated favorably by conservative management, however sacropelvic fixation was inevitable in patients with bilateral vertical or horizontal SIF. Bilateral vertical or horizontal SIF showed marked changes on sagittal radiographic parameters including PI and SVA. Although unilateral vertical SIF has benign courses that responded well to conservative management, bilateral vertical or horizontal SIF is likely to need surgical treatment. Treatment plan should be determined depending on fracture pattern and pelvic deformation.

Study design A propensity score-matched cohort study. Objective The objective of this study was to compare the radiologic and clinical outcomes of camptocormia in Parkinson disease (PD) with degenerative sagittal imbalance (DSI) patients. Summary of background data Camptocormia in PD and DSI could be characterized by a dynamic deformity. However, no study has directly evaluated the outcomes of patients with camptocormia and DSI. Methods Thirteen consecutive PD patients undergoing surgical correction for camptocormia were matched in a 1-to-2 format with 26 patients in the DSI group by propensity score-matching. Radiologic outcomes, including paravertebral muscle changes, and clinical outcomes were compared between the 2 groups. The rate of proximal junctional problems and reoperations were assessed. Results PD patients with camptocormia had significantly greater preoperative coronal and sagittal malalignments (29.9 vs. 16.9 mm, P=0.019; 142.8 vs. 64.4 mm, P=0.0001, respectively) and weakness of paravertebral muscles compared with the DSI patients. Regarding the clinical outcomes, reoperations were significantly higher in the camptocormia group, compared with the DSI group (53.8% vs. 7.7%, P=0.001). Moreover, proximal junctional failure was developed in 8 patients in the camptocormia group, while 1 patient in the DSI group (61.5% vs. 3.8%, P=0.0001). In subgroup analysis, independent risk factors for the proximal junctional failure were the total fusion levels (hazard ratio=0.26, P=0.018) and the degree of fatty changes of the paravertebral muscles (hazard ratio=1.15, P=0.048). Conclusions PD patients undergoing spinal surgery for camptocormia had global malalignment and higher rates of complications compared with DSI patients. Patients should be appropriately counseled regarding the increased risk of operative complications and closely followed for incipient failure.

Background More caudal osteotomy is believed to lead to greater sagittal correction; however, the osteotomy level and whether or not to use iliac screw fixation (ISF) are topics of on-going debate. The aim of this study was to compare clinical and radiographic outcomes after revisional lumbar pedicle subtraction osteotomy (PSO) for fixed sagittal imbalance (FSI) according to the osteotomy level and ISF. Methods All consecutive patients who underwent revisional PSO (at L3 or L4) for FSI in a single institute from July 2006 to January 2014 were investigated retrospectively. Thirty-eight patients with at least 2-year follow-up were finally included. Clinical outcomes including the visual analogue scale (VAS) and Oswestry Disability Index (ODI) were investigated. Radiographic spinopelvic parameters were analyzed according to the level of PSO, the degree of correction, and the use of ISF. Results The mean number of fused segments after PSO was 6.6 ± 1.8. Sagittal vertical axis (SVA) was restored after the surgery (12, 2.5, and 5.2 cm at preoperative, postoperative, and the last follow-up, respectively). PSO was performed at L3 in 16 patients and at L4 in 22 patients. The osteotomy level was not associated with any changes of spinopelvic parameters (pelvic tilt [PT] or lumbar lordosis) or sagittal alignment (T1-pelvic angle [TPA] or SVA). However, better TPA restoration was achieved with more osteotomy resection angle (P = 0.031). ISF group showed significant improvement in postoperative pelvic orientation (PT and ratio of PT to pelvic incidence) which was maintained until the last follow-up. Conclusions Although postoperative sagittal alignment was different in FSI patients according to the osteotomy level, pelvic orientation improved in ISF group. Also, the degree of correction showed significant associations with sagittal alignment. When performing revisional PSO for FSI, spine surgeon should carefully consider how to correct rather than where to do the osteotomy, and the role of ISF.

Objective To compare the radiologic union rates between autogenous iliac crest bone graft (ICBG) and local bone graft in 1- to 3-level lumbar fusion. Methods We reviewed 178 consecutive patients who underwent 1- to 3-level lumbar fusion surgery because of lumbar spinal stenosis. Fusion status of the anterior or posterior column was evaluated by plain radiographs obtained at 24 months postoperatively. If at least either the anterior or posterior column was fused, that segment was regarded as having achieved fusion and was termed segment union. The definition of overall union was achieving union of all segments in a single patient. Results For each ICBG group and local bone graft group, fusion rate of the anterior and posterior column, and rate of the segments and overall union at postoperative 2 years were not different between the groups, regardless of surgery level. In the overall union rate according to the fusion level, the ICBG group showed constant overall fusion rate according to the fusion level (i.e., 96.9%, 96.9%, and 93.1% for 1-, 2-, and 3-level fusion), but tended to decrease with increasing level in the local bone graft group (100%, 95.8%, and 85.7% for 1-, 2-, and 3-level fusion, respectively) without statistically significant differences. Conclusions The union rate of 3-level fusion was not inferior to those of 1- or 2-level fusion in both ICBG and local bone graft patients. Local bone graft could be regarded as an adequate option for not only 1- or 2-level lumbar fusion but also 3-level lumbar fusion surgery.

Background: For Grade I degenerative lumbar spondylolisthesis (DLS), both decompression alone and decompression with fusion are effective surgical treatments. Which of the two techniques is superior is still under debate. The purpose of this study was to compare clinical outcomes after decompression alone versus decompression with fusion for Grade I DLS. Materials and Methods: 139 patients who underwent surgery for Grade I DLS at L4-L5 were prospectively enrolled. Decompression alone was used to treat 74 patients, and decompression with fusion was used to treat 65 patients. Six patients in the first group and four patients in the second group were lost during the 2-year followup. Demographic data were recorded. Operation time, perioperative blood loss, total blood transfusion volume, and length of hospital stay were compared between the two groups. Back pain and functional outcomes were evaluated using the visual analog scale (VAS) and the Oswestry Disability Index (ODI), respectively. Results: Baseline demographic data were not different between the two groups. Operation time, blood loss, total blood transfusion volume, and length of hospital stay were all significantly greater in the fusion group than in the decompression group. This would be expected because fusion is the more invasive procedure. VAS scores were not different up until 6 months postoperatively. Twelve months after surgery, however, VAS scores were significantly lower in the fusion group. The same results were shown in terms of ODI. Although ODI decreased in both groups over time, the fusion group showed better functional outcomes than did the decompression group. Conclusions: Although both decompression alone and decompression with fusion improved functional outcomes for Grade I DLS, fusion surgery resulted in better results compared to decompression alone. Therefore, fusion should be considered as the treatment of choice for Grade I DLS.

Authors assumed that the stability of iliac screw (IS) fixation could affect the development of proximal junctional kyphosis (PJK). The purpose of this study was to analyze the relationship between IS loosening and PJK after long fusion surgery for adult spinal deformity (ASD). Sixty-eight ASD patients (6 males, 62 females; mean age, 68.1 years) who underwent long fusion surgery with IS fixation were reviewed. The incidence and risk factors of IS loosening were investigated. The relationship between IS loosening and PJK was also analyzed. IS loosening and PJK appeared in 33 and 19 patients, respectively. The median time for IS loosening and PJK to develop was 6.0 months (range 1.3–59.2) and 9.1 months (range 1.3–73.2), respectively. PJK developed in patients without IS loosening more frequently than in patients with IS loosening. PJK did not develop in 28 patients who presented with IS loosening first. IS loosening developed 5 months postoperatively in those 28 patients, whereas IS loosening was present 11 months postoperatively in 4 patients who presented with PJK first. Preoperative PT (OR = 1.091) and IS loosening (OR = 0.343) were significantly related with the development of PJK. IS loosening was significantly associated with postoperative PI-LL > 10° (OR = 0.957), postoperative SVA (OR = 1.023), and postoperative PT (OR = 1.072). Postoperative sagittal malalignment should be avoided to prevent IS loosening and PJK. IS loosening occurred earlier than PJK and seemed to affect the development of PJK. This relationship supports the hypothesis that distal stability of long constructs may increase proximal junctional stress. III. These slides can be retrieved under Electronic Supplementary Material.

A retrospective cohort study.To evaluate the clinical and radiological efficacies of supplementing minimally invasive lateral lumbar interbody fusion (LLIF) with open posterior spinal fusion (PSF) in adult spinal deformity (ASD).Minimally invasive techniques have been increasingly applied for surgery of ASD. Few reports have been published that directly compare LLIF combined with PSF to conventional PSF for ASD.To evaluate the advantages of minimally invasive LLIF for ASD, patients who underwent minimally invasive LLIF followed by open PSF (combined group) were compared with patients who only underwent PSF (only PSF group). The clinical and radiological outcomes for deformity correction and indirect decompression were assessed. The occurrence of proximal junctional kyphosis (PJK) and proximal junctional failure (PJF) were also evaluated.No significant differences were observed in the clinical outcomes of the Oswestry Disability Index (ODI), visual analog scale, and major complications including reoperations between the groups. No additional advantage was found for coronal deformity correction, but the restoration of lumbar lordosis in the combined group was significantly higher postoperatively (15.3° vs. 8.87°, P = 0.003) and last follow-up (6.69° vs. 1.02°, P = 0.029) compared to that of the only PSF group. In the subgroup analysis for indirect decompression for the combined group, a significant increase of canal area (104 vs. 122 mm) and foraminal height (16.2 vs. 18.5 mm) was noted. The occurrence of PJK or PJF was significantly higher in the combined group than in the only PSF group (P = 0.039).LLIF has advantages of indirect decompression and greater improvements of sagittal correction compared to only posterior surgery. LLIF should be conducted considering the above-mentioned benefits and complications including PJK or PJF in ASD.4.

Thoracic ossification of the ligamentum flavum (TOLF) is an uncommon pathology, but it may sometimes grow and cause serious neurologic manifestations. Little has been demonstrated yet about the epidemiology and etiology of TOLF.This study aimed to estimate the prevalence and clinical characteristics of TOLF.A cross-sectional study was carried out.All individuals who had undergone chest computed tomography (CT) for the evaluation of pulmonary disease or for medical examination for 1 year at our institute comprised the patient sample.Presence of TOLF and the association of these findings with thoracic kyphosis (TK), ossification of posterior longitudinal ligament (OPLL), space available for cord (SAC), age, gender, body mass index (BMI), and diabetes were the outcome measures.Prevalence and distribution of TOLF, TK, and concurrent OPLL were analyzed on CT scans. Through reviews of their medical records, clinical characteristics including age, gender, BMI, and diabetes were investigated. Logistic regression analysis was performed to determine the risk factors of TOLF.A total of 4,999 individuals (2,929 men and 2,070 women) were included for the analysis. Thoracic ossification of the ligamentum flavum was found in 1,090 individuals (674 men and 416 women. A single TOLF lesion was noted in 592 individuals and multiple lesions were noted in 498 individuals. The most commonly involved level was T10-T11. Distribution of TOLF showed two peaks: and the highest peak was at the lower thoracic spine (T10-12) and the second highest peak was at T3-T5. Thoracic kyphosis was 31.5°±9.5° in the TOLF group and 29.7°±8.9° in the non-TOLF group (p.001). Space available for cord/anteroposterior canal diameter ratio in TOLF level was 0.882. Logistic regression analysis showed that gender and TK were significantly associated with TOLF.Incidental TOLF was found in 21.8% of the study cohort. Gender and TK were related to TOLF.

Objective Patients with hematological malignancies frequently encounter spine-related symptoms, which are caused by disease itself or process of treatment. However, there is still lack of knowledge on their epidemiology and clinical courses. The purpose of this article is to review clinical presentations and surgical results for spinal involvement of hematologic malignancies. Methods From January 2011 to September 2014, 195 patients (98 males and 97 females) suffering from hematological malignancies combined with spinal problems were retrospectively analyzed for clinical and radiological characteristics and their clinical results. Results The most common diagnosis of hematological malignancy was multiple myeloma (96 patients, 49.7%), followed by chronic myeloid leukemia (30, 15.2%), acute myeloid leukemia (22, 11.2%), and lymphoma (15, 7.56%). The major presenting symptoms were mechanical axial pain (132, 67.7%) resulting from pathologic fractures, and followed by radiating pain (49, 25.1%). Progressive neurologic deficits were noted in 15 patients (7.7%), which revealed as cord compression by epidural mass or compressive myelopathy combined with pathologic fractures. Reconstructive surgery for neurologic compromise was done in 16 patients. Even though surgical intervention was useful for early paralysis (Frankel grade D or E), neurologic recovery was not satisfactory for the progressed paralysis (Frankel grade A or B). Conclusion Hematological malignancies may cause various spinal problems related to disease progression or consequences of treatments. Conservative and palliative treatments are mainstay for these lesions. However, timely surgical interventions should be considered for the cases of pathologic fractures with progressive neurologic compromise.

We report a pure distraction injury of the upper thoracic spine and uncontrolled hyperthermia without an infectious cause. Quad fever appears in the first several weeks to months after a cervical or upper thoracic SCI and is characterized by an extreme elevation in body core temperature beyond 40 °C without an infectious cause. Discriminating between infectious and noninfectious causes is important, and a thorough clinical assessment is required. A 52-year-old male visited the emergency room complaining of back pain with complete paralysis [American Spinal Injury Association (ASIA) A] of both lower extremities after a pedestrian-motor vehicle accident. He had trouble breathing due to a hemothorax and flail chest caused by fractures of the right second to eleventh and left fourth to seventh ribs. A computed tomography scan revealed severe distraction of the T1–2 intervertebral space. A magnetic resonance image showed signal changes in the spinal cord and a clean-cut margin between the T1–2 disc and T2 body. The neurological level of injury was C8 upon the initial neurological assessment. Emergency surgery was performed. C6–T3 posterior instrumentation and an autologous iliac bone graft were performed. After surgery, the core temperature increased gradually to above 38.0 °C on post-trauma day 4 and increased to 40.8 °C on post-trauma day 7. None of the repeated aerobic, anaerobic, or fungal cultures of the blood, tracheal aspirate, line tips, urine, or stool was positive until post-trauma day 21, when Candida tropicalis was identified in the urine culture. On post-trauma day 63, the blood pressure, pulse, and body temperature stabilized and the patient was transferred to the general ward. At post-trauma year 6, the injury state was still complete and the neurological level of injury was changed to C4. Based on the Grand Round case and relevant literature, we discuss the case of pure distraction injury of T1–2 with quad fever. Spinal surgeons should be knowledgeable regarding quad fever as well as the differential diagnoses and treatment strategies.

To the best of our knowledge, there has been no report regarding rheumatoid arthritis associated with spinal neuroarthropathy and combined double-level isthmic spondylolisthesis. Here, we report a rare case of spinal neuroarthropathy with double-level isthmic spondylolisthesis in a rheumatoid arthritis (RA) patient. A 56-year-old female patient under medical treatment for RA during the last 13 years presented aggravating radiating pain to her right lower extremity and a limping gait developed 4 months ago. The disease activity of RA had remained low for a long time. Serial radiographs during last 8-year follow-up showed progressive dislocation at L4–L5 and L5–S1 with double-level isthmic spondylolisthesis and severe destructive status at the last follow-up. The patient underwent decompression and circumferential fusion with sacropelvic fixation and acceptable reduction was obtained. A RA patient with double-level isthmic spondylolisthesis showed a progressive destructive lesion. In addition to clinical presentations, the imaging findings were very similar to ones of spinal neuroarthropathy. The authors conclude that this Grand Round case probably had SNA secondary to RA and that this, combined with two-level isthmic spondylolisthesis, resulted in her rapidly progressing destructive lumbar lesion.

Study design A case report and literature review. Objective To report a late dislocation of the vertebra caused by progressive dural ectasia combined with type-1 neurofibromatosis (NF-1) and the clinical results of pseudarthrosis repairs using autologous cultured osteoblasts. Summary of background data NF-1 is a well-known genetic disorder that is commonly characterized by spinal deformities including kyphoscoliosis. Late dislocation of the vertebra resulting from progressive dural ectasia after surgical correction of NF-1 scoliosis is a very rare occurrence, and pseudarthrosis frequently develops after surgical intervention for this complex spinal deformity. Methods A 32-year-old female patient with NF-1 scoliosis underwent surgical correction with posterior instrumented fusion. Seventeen years later, dislocation of the lumbar spine with implant failure resulting from massive progressive dural ectasia was observed. She underwent anterior interbody fusion three times and posterior instrumented fusion four times for pseudarthrosis followed by surgical deformity correction. For the last operation, autologous cultured osteoblasts were used as a therapeutic approach to repair the pseudarthrosis, and a three-dimensional printing technique was used to understand the surgical anatomy of the dislocated lumbar spine in detail. Results After the final operation, bone union was achieved and confirmed by clinical and radiological examination. Conclusion Spine surgeons should be knowledgeable about the possibility of late destabilization of the spine, due to pulsatile dural ectasia, and a high rate of pseudarthrosis in neurofibromatosis. Autologous cultured osteoblasts may prove to be a modality that can be applied pseudarthrosis repair to treat complex spinal deformity. Level of evidence 5.

Objective We sought to compare the radiologic outcomes for different distal fusion levels in a rigid curve with major thoracolumbar and lumbar (TL/L) adolescent idiopathic scoliosis (AIS) using rod derotation (RD) with direct vertebral rotation (DVR) after pedicle screw instrumentation (PSI). Methods This study finally enrolled 28 patients who were diagnosed with AIS in rigid curve with major TL/L curves, treated by PSI with RD and DVR and with a minimum 2-year follow-up. Patients were divided into 2 groups, L3 and L4, on the basis of the distal fusion level at the lowest instrumented vertebra (LIV) of L3 or L4. Results There was no significant difference in TL/L curve, thoracic (minor), and compensatory (caudal) curves between the L3 and L4 groups either postoperatively (P = 0.162, 0.426, and 0.762, respectively) or at the last follow-up (P = 0.952, 0.620, and 0.562, respectively). The overall prevalence of unsatisfactory results was 42.9% (12/28 patients). The prevalence of unsatisfactory results was 61.1% (11/18) in the L3 group and 10% (1/10) in the L4 group, which was significantly different (P Conclusions Unsatisfactory results occurred more often in the L3 group than in the L4 group, and unsatisfactory results had significant influence on progression of TL/L and distal compensatory curves. Such progression was closely correlated with deteriorating LIV disk angle in the L3 group. Therefore if the curve is rigid, LIV should be extended to L4 to avoid the adding-on phenomenon in the treatment of major TL/L AIS using RD with DVR after PSI.

This was a randomized clinical trial.To compare the efficacy and safety of nonsteroidal anti-inflammatory drug and opioid for acute pain management after lumbar decompressive surgery.Multimodal analgesia is associated with synergistic effects while reducing opioid-related adverse effects. However, there is no consensus on the ideal multimodal analgesic regimen. We assumed that each agent in various multimodal regimens under different conditions may have different effects.This prospective randomized clinical trial recruited adult patients who underwent single-level lumbar decompressive surgery. Patients were randomized to receive our postoperative analgesic regimen including either nonsteroidal anti-inflammatory drug (celecoxib) or opioid (extended-release oxycodone) from postoperative day 3 to 14. The Visual Analog Scale (VAS) and Oswestry Back Pain Disability Index (ODI) were used to evaluate effectiveness preoperatively and on postoperative days 2, 3, 7, and 14, and at 6 months. Drug-related adverse effects were also recorded.One hundred patients were enrolled and 93 patients (46 patients with celecoxib vs. 47 patients with oxycodone) were randomized. No differences were observed in patient demographics and preoperative VAS and ODI between the 2 groups. VAS and ODI were not different at all postoperative time points. However, subanalysis according to sex and age, revealed significant differences in efficacy: celecoxib was effective in female individuals and oxycodone was effective in male individuals on postoperative days 7 and 14; oxycodone was effective in patients aged above 65 years on postoperative days 7 and 14. Although nausea/vomiting and constipation were more common in the oxycodone group than in the celecoxib group, other adverse effects were not different.In patients who underwent single-level lumbar decompressive surgery, treatment with celecoxib and oxycodone for postoperative pain management showed no significant differences in efficacy. However, subanalysis showed that each drug was effective in different ages and sex groups.Level II.

Objective To identify clinical and radiographic features of subtypes of acute proximal junctional failures (PJFs) following correction surgery for degenerative sagittal imbalance. Methods The study included 157 patients with mean age 68.0 ± 6.3 years who underwent correction surgery for degenerative sagittal imbalance. Acute PJFs were categorized into 4 subtypes: fracture at uppermost instrumented vertebra (UIV), fracture at vertebra just proximal to UIV (UIV+1), fixation failure at UIV, and junctional subluxation. Demographic, clinical, and radiographic data were analyzed retrospectively. Results There were 18 patients with acute PJFs. PJF group had significantly lower T-score (−3.3 ± 1.1 vs. −1.9 ± 1.5) on bone densitometry and lower body mass index (BMI) (23.0 ± 3.9 kg/m2 vs. 25.6 ± 3.7 kg/m2) than non-PJF group. Radiographic parameters exhibited no significant differences. UIV fracture, UIV+1 fracture, UIV fixation failure, and junctional subluxation were observed in 5, 6, 4, and 3 patients. Fixation failure developed the earliest (median 1.3 months), followed by UIV fracture (1.5 months). UIV fracture occurred earlier than UIV+1 fracture (36 months). Patients with UIV or UIV+1 fracture had significantly lower T-scores than others. Although BMI and T-score were significant risk factors for all PJFs (P = 0.043 and P = 0.021, respectively), different risk factors for each subtype of PJFs were identified on separate risk factor analysis. Conclusions Patients with acute PJFs had lower T-score and BMI. Each subtype of PJFs had different clinical and radiographic features. Although BMI and T-score were associated with all PJFs, each subtype may have different risk factors. Identifying risk factors for each subtype of acute PJFs may help avoid it.

Background: Ankylosed spines with ankylosing spondylitis or diffuse idiopathic skeletal hyperostosis (DISH) are prone to fractures due to osteoporosis and fracture instability from long lever arm. In such cases, surgical management is the main treatment option. Case presentation: We report a first case of successful treatment of unstable bony Chance fracture at thoracolumbar junction in DISH patient using teriparatide and review previous literature on ankylosed spine fractures treated with teriparatide. An 82-year-old male patient presented with back pain after falling from a 3 m height 3 months ago. Imaging studies showed L1 unstable flexion-distraction injury (bony Chance fracture) and intravertebral vacuum cleft in ankylosed spine due to DISH. Conservative treatment, teriparatide and orthosis, was determined as the most appropriate approach because the patient declined surgery and presented with tolerable mechanical back pain without any neurologic deficits. Solid bony union was successfully achieved without any complications after 1-year treatment. Conclusion: Although surgical management is strongly recommended for unstable fracture in ankylosed spine, non-surgical treatment including teriparatide and orthosis might be safer and effective options in bony Chance fracture without neurologic deficits and intractable mechanical pain.

OBJECTIVE There have been no reports on the long-term radiographic outcomes of posterior vertebral column resection (PVCR) in patients with congenital scoliosis. The purpose of this study was to evaluate the surgical outcomes and complications after PVCR and its long-term effects on correcting this deformity in children with congenital scoliosis. METHODS The authors retrospectively analyzed the medical records of 45 patients with congenital scoliosis who were younger than 18 years at the time of surgery and who underwent PVCR and fusion with pedicle screw fixation (PSF). The mean age of the patients at the time of surgery was 11.3 years (range 2.4–18.0 years), and the mean length of follow-up was 12.8 years (range 10.1–18.2 years). RESULTS The mean Cobb angle of the main curve was 46.5° before PVCR, 13.7° immediately after PVCR, and 17.6° at the last follow-up. For the compensatory cranial curve, PVCR corrected the preoperative Cobb angle of 21.2° to 9.1° postoperatively and maintained it at 10.9° at the last follow-up. For the compensatory caudal curve, the preoperative Cobb angle of 23.8° improved to 7.7° postoperatively and was 9.8° at the last follow-up. The authors noted 22 complications, and the overall incidence of complications was 48.9%. CONCLUSIONS Posterior vertebral column resection is an effective procedure for managing congenital scoliosis in patients younger than 18 years. Use of PVCR and fusion with PSF for congenital scoliosis achieved rigid fixation and satisfactory deformity correction that was maintained over the long term. However, the authors note that PVCR is a technically demanding procedure and entails risks for major complications and excessive blood loss.

Objectives Osteoporotic spine fractures (OSFs) with delayed neurologic compromises (NCs) have been increasingly reported. Although several studies have addressed that the pathologic mechanism of NC involves nonunion and segmental instability, the risk factors remain unclear. Therefore, the purpose of this study was to assess the radiologic and clinical features of OSFs with delayed NC. Methods Thirty patients with delayed NC (group 1) were matched in a 1-to-1 format with 30 patients without delayed NC (group 2) by age, bone mineral density, body mass index, and medical treatment for osteoporosis. Clinical and radiologic parameters were assessed to determine the risk factors related to delayed NC. Clinical outcomes were also compared between the 2 groups. Results Neurologic compromises were presented as myelopathy in 20 patients and radiculopathy in 10 patients. Initial kyphotic angle (KA) and height loss (HL) were significantly greater in group 1 (21.6 ± 12.9 degrees vs. 10.5 ± 8.6 degrees, P = 0.0001 for KA; 55.8% ± 15.2% vs. 19.9% ± 10.9%, P = 0.0001 for HL). Fracture instability with intravertebral cleft, posterior wall involvement, midportion type of magnetic resonance classification, thoracolumbar level, and aortic calcification were significantly correlated with delayed NC. In multivariate analysis, initial HL (hazard ratio = 1.24; P = 0.012) and midportion-type fracture (hazard ratio = 14.9: P = 0.03) were the independent risk factors related to delayed NC. In addition, clinical outcomes at the last follow-up were significantly better in group 2. Conclusions Initial HL and midportion-type fracture were correlated with delayed NC following OSFs. Moreover, pre-existing stenotic lesions might be associated with delayed NC.

To compare clinical and radiographic outcomes and complications after vertebroplasty (VP) and kyphoplasty (KP) for osteoporotic vertebral fractures with severe collapse.Patients65 years old with single osteoporotic vertebral fracture (T10-L2) with severe collapse (40%) were prospectively enrolled and allocated to either KP or VP. Visual analog scale and Oswestry Disability Index were used for clinical assessment. Vertebral height loss (HL) and segmental kyphotic angle were measured radiographically at preoperative; postoperative; and 1-, 3-, 6-, and 12-month postoperative time points. Procedure-related and postoperative complications were recorded.Forty-six patients (27 with VP, 19 with KP) were enrolled. Visual analog scale and Oswestry Disability Index scores were similar at all time points in the 2 groups. Complication rates were also similar. HL and kyphotic angle were restored significantly in both groups. KP showed a better result in HL (KP group HL 20.5% ± 5.6% vs. VP group HL 29.8% ± 4.6%, P0.001). Progressive vertebral HL was observed, and patients with KP showed a greater collapse in height. At 1-year follow-up, there was no significant difference in vertebral height (KP group HL 29.8% ± 6.3% vs. VP group HL 33.0% ± 5.2%, P = 0.075).KP and VP showed similar improvements in pain and disability during treatment for osteoporotic vertebral fractures. Although vertebral height and segmental kyphotic angle were restored significantly in both groups, progressive vertebral HL was inevitable, especially after KP. This likely resulted from the difference of bone-cement interface as a consequence of balloon tamping in KP. Surgeons must consider the respective features of vertebral augmentations.

To assess the efficacy of a novel preemptive multimodal analgesic regimen for reducing postoperative pain and complications after primary lumbar fusion surgery. Preemptive multimodal analgesia is revealed to be an effective alternative to conventional morphine administration providing improved postoperative pain control with diminished side effects. However, an optimal regimen for spinal fusion surgery remains unknown. After Institutional Review Board approval, 80 patients who underwent primary lumbar 4–5 fusion surgery were randomly assigned to receive either only intravenous morphine or a preemptive multimodal (celecoxib, pregabalin, extended-release oxycodone, and acetaminophen) analgesic regimen. Postoperative pain and functional levels were measured by the visual analog scale (VAS) and Oswestry Disability Index (ODI), respectively, and intraoperative blood loss, postoperative Hemovac drain output, and nonunion rates were evaluated for complications. No differences were observed in the patient demographics, intraoperative blood loss, postoperative Hemovac drain output, or nonunion rate between two groups. The VAS and ODI were lower at all postoperative time points, except the ODI on postoperative day 1 in patients randomized to receive the preemptive multimodal analgesic regimen. No major identifiable postoperative complications were observed in either treatment group. The preemptive multimodal analgesic combination in this study appears to be safe and effective after lumbar fusion surgery.

Background context There is little information regarding the surgical outcomes with regard to the timing of surgery in children under age 10 years for congenital scoliosis with a long-term follow-up. Purpose The purpose of this study was to compare the surgical outcomes for congenital scoliosis in children 6 years or older but less than 10 years of age. Study design This is a retrospective study. Patient sample Eighteen congenital scoliosis patients under age 10 years at the time of surgery were treated by posterior hemivertebra resection and bilateral pedicle screw fixation. Outcome measures Outcome measures are radiological outcomes (plain radiographs and computed tomography) and complications. Methods Eighteen congenital scoliosis patients (n=18) under age 10 years at the time of surgery were treated by posterior hemivertebra resection and bilateral pedicle screw fixation. These cases were retrospectively studied and had a minimum of 7-year follow-up. We assigned patients into two groups: Group 1 (n=9) patients who had surgery before 6 years of age and Group 2 (n=9) those who had surgery after 6 years of age. Results The groups were not found to be statistically different in operative time, blood loss, and follow-up period. In the Group 1, the mean Cobb angle of the main curve was 32.4° before surgery, 6.4° after surgery, and 9.1° at last follow-up. In the Group 2, the mean Cobb angle of the main curve was 36.5° before surgery, 10.4° after surgery, and 14.5° at last follow-up. There was significantly better deformity correction of main curve immediate postoperatively and at last follow-up in Group 1. No significant difference was observed in growth rate of the vertebral body and spinal canal parameters comparing the two groups at the vertebra with or without screws. There was no crankshaft phenomena, no clinical or radiographic features suggestive of spinal stenosis during follow-up, and no major vascular or neurological complications related to the pedicle screws in either group. Conclusions In congenital scoliosis patients, posterior hemivertebra resection after pedicle screw fixation before the age of 6 years had significantly better deformity correction and did not cause a negative effect on the growth of vertebral body or spinal canal compared with the group treated after 6 years of age. Therefore, early surgical correction of a congenital hemivertebra in children under 6 years of age, before structural changes occur, effectively achieves a more satisfactory correction without causing iatrogenic spinal stenosis or neurologic complications compared with children older than 6 years but under 10 years of age.

Purpose To investigate the causes of late-onset, progressive neurological deficits in patients with severe angular kyphosis caused by spondylitis secondary to tuberculosis (TB spondylitis). Methods From 2000 to 2011, 36 patients with severe angular kyphosis secondary to TB spondylitis (TB kyphosis) were enrolled in the study. All patients had late-onset, progressive neurological deficits. The causes of these deficits were classified with respect to the level of the causative lesion. Group A (n = 25, 69.4%) comprised patients whose neurological deficits resulted from the kyphosis itself. Patients in group B (n = 11, 30.6%) had developed neurological symptoms related to a lesion cephalad or caudal from the kyphosis. Surgical intervention was performed in 23 patients; 13 patients were treated conservatively. Clinical outcomes were evaluated using the American Spinal Injury Association (ASIA) impairment scale. Results The late onset of neurological deficits was attributed to cord compression, pure cord distraction, stenosis, and instability above or below the level of the angular kyphosis. An improvement of the neurological symptoms at the cord level after surgical intervention, as indicated by a change from a non-ambulatory (ASIA impairment scale A/C) to an ambulatory (ASIA D/E) status, occurred in four of nine (44.4%) surgically treated patients. However, only 2 of 10 (20.0%) patients treated conservatively showed cord level improvement, as assessed using the ASIA impairment scale. Conclusions In their evaluation of paraplegic patients, spine surgeons should consider the many potential causes of late-onset neurological deficits in TB spondylitis to avoid performing unnecessary surgery. A simpler procedure may yield equivalent results.

Bone cement augmentation procedures have been getting more position as a minimally invasive surgical option for osteoporotic spinal fractures. However, complications related to these procedures have been increasingly reported. We describe a case of bone cement dislodgement following cement augmentation procedure for osteoporotic spinal fracture by reviewing the patient's medical records, imaging results and related literatures. A 73-year-old woman suffering back and buttock pain following a fall from level ground was diagnosed as an osteoporotic fracture of the 11th thoracic spine. Percutaneous kyphoplasty was performed for this lesion. Six weeks later, the patient complained of a recurrence of back and buttock pain. Radiologic images revealed superior dislodgement of bone cement through the 11th thoracic superior endplate with destruction of the lower part of the 10th thoracic spine. Staged anterior and posterior fusion was performed. Two years postoperatively, the patient carries on with her daily living without any significant disability. Delayed bone cement dislodgement can occur as one of complications following bone cement augmentation procedure for osteoporotic spinal fracture. It might be related to the presence of intravertebral cleft, lack of interdigitation of bone cement with the surrounding trabeculae, and possible damage of endplate during ballooning procedure.

OBJECT This retrospective study was designed to evaluate the clinical outcomes and radiological findings after open lumbar discectomy (OLD) in patients who were followed up for 10 years or longer. METHODS The authors classified 79 patients who had a mean age (± SD) of 53.6 ± 13.6 years (range 30–78 years) into 4 groups according to the length of their follow-up. Patients in Group 1 were followed up for 10–14 years, in Group 2 for 15–19 years, in Group 3 for 20–24 years, and in Group 4 for more than 25 years. In all of these patients, the clinical outcomes were assessed by using patients' self-reported scores on visual analog scales (VASs) measuring back and leg pain and by using scores from the Oswestry Disability Index (ODI). In addition, 10 radiological parameters suggesting degenerative changes or instability at the operated segment were recorded at various time points and used to calculate a numeric radiological finding (NRF) score by rating a presence for each finding of spinal degeneration or instability as 1. RESULTS The authors observed that OLD decreased pain and disability scores in all groups. Numeric radiological findings were highest in Group 4, and a significant correlation was detected between NRFs and VAS scores of back pain (p = 0.039). In this cohort, the reoperation rate was 13.9% during a mean follow-up period of 15.3 years. Clinical outcomes tended to be most favorable in Group 1, representing patients who had OLD most recently, and they tended to deteriorate in the other 3 groups, indicating some worsening of outcomes over time. Degeneration of the spine at the operated level measured with radiographic methods tended to increase over time, but some stabilization was observed. Although spinal degeneration was stable, clinical outcomes deteriorated over time. CONCLUSIONS This cross-sectional assessment of a retrospective cohort indicates that outcomes after OLD deteriorate over time. Increased back pain indicated a worsening of clinical outcomes, and this worsening was correlated with radiological findings of degeneration at the operated segment.

A retrospective comparative study.To compare pedicle subtraction osteotomy (PSO) and iliac fixation (ILF) without osteotomy as methods of correcting lumbar spine deformities due to degenerative sagittal imbalance (DSI) through the evaluation of the changes in spinopelvic alignment.Many papers have reported the surgical results after PSO and ILF for patients with fixed adult deformities. However, little is known about the difference between PSO and ILF corrections of spinopelvic alignment in adults with DSI.DSI patients who had undergone PSO or ILF with a minimum of 2-year follow-up (FU) were retrospectively studied in PSO (n=30) or ILF (n=25) groups. Lumbar lordosis (LL), thoracic kyphosis (TK), and sagittal vertical axis (SVA) were measured as spinal parameters and pelvic incidence (PI), sacral slope (SS), and pelvic tilt (PT) were used as measurements of pelvic parameters. Clinical outcomes were evaluated using a visual analogue scale (VAS) and Oswestry Disability Index (ODI) scores.There were no statistically significant differences between the PSO and ILF groups with regard to age and fused segments, but there were significant differences in operative time and estimated blood loss. Concerning spinal parameters, there were significant increases of LL and TK in PSO group immediate postoperatively (LL: P=0.014, TK: P=0.017) and at the 2-year FU (LL: P=0.021, TK: P=0.022), but no significant difference in SVA was evident between the 2 groups. Within the pelvic parameters, there was a significant increase of SS and decrease of PT in the ILF group immediate postoperatively (SS: P=0.013, PT: P=0.009) and at the 2-year FU (SS: P=0.024, PT: P=0.027), but the PI in both groups was not changed after surgery and there was no significant difference between 2 groups. VAS and ODI were significantly improved after surgery in both groups.The PSO group was better than the ILF group in the correction of the LL and TK, but not with regard to the pelvic parameters. The ILF group was superior in the correction of the pelvic orientation as compared with the PSO group when the PI was constant after surgery. Ultimately, ILF effectively achieves better correction of the pelvic parameters (SS and PT).

Study design Retrospective cohort study. Objective To investigate the fate of sclerosis and anterior osteophytes in the fused segments after instrumented lumbar fusion for degenerative lumbar disorders. Summary of background data Sclerosis and osteophytosis are well-known radiographical findings, but little is known of their significance with regard to spontaneous resorption after spine fusion. Methods Thirty patients (9 males, 21 females; 60 vertebra; mean age of 66.9 yr [45-86 yr]) were divided into a posterolateral fusion group (n = 14, 28 vertebrae) and a posterior lumbar interbody fusion group (n = 16, 32 vertebrae). Using serial radiographs obtained preoperatively; postoperatively at 3, 6, 12, and 24 months; and last follow-up, sclerotic areas of each involved vertebra were mapped and osteophyte lengths were measured. Results Sclerosis and osteophytes decreased with time for the instrumented fusion. The decrease in sclerotic areas and osteophytes length was observed as early as 3 months postoperatively, and the significant changes between each time point were noted in initial 3- and 6-month intervals. In terms of the type of surgery, similar changes were noted in the posterolateral fusion and posterior lumbar interbody fusion groups. Conclusion Resorption of osteophytes and sclerosis after instrumented spine fusion were observed. Significant resorption was noted at 3 and 6 months postoperatively. As well, most graft bone would be incorporated in postoperative 6 months. Resorption of osteophytes and sclerosis after instrumented spine fusion could be helpful to confirm the successful union. Level of evidence 4.