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Objective To assess several different cervical alignment parameters to determine the clinical relationship between cerebral palsy (CP) with cervical spondylotic myelopathy (CSM) and cervical deformity. Methods This study included consecutive patients (N = 31) with CP CSM who underwent cervical operation between January 2006 and January 2014 and who had cervical deformities, such as angular and translational deformities. Cervical spine alignment was assessed with the following parameters: C2-7 Cobb angle, C2-7 sagittal vertical axis (SVA), and T1 slope minus C2-7 Cobb angle. Other clinical values were the manual muscle test, spasticity, grip and pinch test, Box and Block test, and Jebsen-Taylor Hand Function Test. Outcome assessments (Oswestry Neck Disability Index [NDI] and modified Barthel Index) were obtained for all patients pre- and postoperatively. Results Mean follow-up duration was 3.5 years. There were 13 patients in the corrected group and 18 in the not corrected group. Angular and translational correction were 19.0° (C2-7 Cobb angle), 19.8° (T1 slope minus C2-7 Cobb angle), and 16 mm (C2-7 SVA). Postoperative NDI scores showed greater improvement in the corrected group than the uncorrected group ( P = 0.049). In the corrected group, grip power increased postoperatively (8.9 ± 8.9 vs 15.5 ± 8.3; P = 0.021). Conclusions Surgical treatment for patients with CP CSM deformity helped alleviate symptoms. Postoperative NDI scores and hand function improved in patients with CP CSM deformity, especially those in the corrected group. Clinicians should consider correcting the deformity in patients with CP CSM.

Study design Multicenter case-control study. Objective To characterize the pathogenesis of idiopathic spinal epidural lipomatosis (SEL). Summary of background data SEL is often associated with the history of steroid use or endocrine disorders; however, the pathogenesis of idiopathic SEL remains poorly understood. Methods Sixteen patients who underwent lumbar decompression surgery due to severe idiopathic SEL were included in the study (L group, 15 men and 1 woman; mean age, 71.5 yrs). Fifteen patients without SEL, who underwent decompression surgery for lumbar canal stenosis, were selected as controls (C group, 14 men and 1 woman; mean age, 70.3 yrs). The following parameters were analyzed in these two groups: body mass index (BMI), medical history, histology, the size of adipocytes in the epidural fat (EF) tissues, and the expression level of the transcripts for adiponectin, leptin, tumor necrosis factor-α (TNF-α), interleukin (IL)-1β, IL-6, and IL-8. Results The mean BMI of the L group was significantly higher than that of the C group (29.1 vs. 25.2 kg/m, P = 0.006), and there was a significant correlation between BMI and the width of EF in both groups. The average adipocyte size in the EF was significantly larger in the L group than in the C group (2846.8 vs. 1699.0 μm, P = 0.017). Furthermore, the expression levels of the transcripts for TNF-α and IL-1β in the L group were significantly higher than those in the C group [2.59-fold increase (P = 0.023) and 2.60-fold increase (P = 0.015), respectively]. Conclusion Our data suggest that the pathogenesis of idiopathic SEL is associated with obesity. In addition, the increased expression of two major inflammatory cytokines in the EF in the L group may indicate that SEL is causally related to chronic inflammation. Level of evidence 3.

Retrospective study evaluating cranial facet joint violation (FJV) by pedicle screws.The aim of the study was to determine the incidence and risk factors of FJV following screw placement via cortical bone trajectory (CBT).CBT is a new minimally invasive technique for lumbar pedicle screw insertion that minimizes muscle dissection. Inserting a screw from a more caudal entry point can reduce iatrogenic damage to the cranial facet joint; however, no previous reports exist describing the incidence of FJV secondary to the CBT technique.We reviewed 202 consecutive patients who underwent lumbar pedicle screw instrumentation using CBT from October 2011 to June 2015. Postoperative CT scans were obtained to determine the degree and incidence of FJV. Clinical and imaging data were analyzed to clarify the risk factors of FJV. The detailed positions of the proximal screws were also investigated and compared between the FJV and non-FJV groups.The incidence of FJV by the proximal screws was 11.8% (48/404), with no occurrence of intra-articular FJV. Multiple logistic regression analysis revealed that age70 years, vertebral slip10%, and adjacent facet joint degeneration (Pathria's grade 2 or 3) were independent factors significantly affecting FJV. There were statistically significant differences between the FJV and non-FJV groups in the facet-screw distance (3.2 ± 1.0 vs. 8.1 ± 2.3 mm, P 0.01), the cranial angle (25.8 ± 6.3° vs. 29.9 ± 7.6°, P 0.01), and the lamina-screw head distance (5.6 ± 1.6 vs. 6.4 ± 1.9 mm, P 0.01).Lumbar pedicle screw placement via CBT would reduce FJV; however, special care should be taken in patients with age70 years, vertebral slip10%, and facet degeneration.3.

Object This study was conducted to determine whether postoperative changes in the fractional anisotropy (FA) value and diffusion tensor imaging of the cervical spinal cord can predict functional outcome for patients with cervical compressive myelopathy (CCM). Methods Twenty patients with CCM were treated by laminoplasty from 2008 to 2009. Both T2-weighted MRI and diffusion tensor imaging were performed before and after surgery. The FA values were analyzed and fiber tracking was performed. The fiber tract (FT) ratio was calculated according to the following formula: (number of fibers at the compressed level)/(number of fibers at the C-2 level) × 100%. The Japanese Orthopaedic Association scoring system for cervical myelopathy was used to determine pre- and postoperative neurological status of the patients, and the Hirabayashi method was used to calculate the recovery rate. Results There was no significant difference in recovery rates between patients with and those without intramedullary high signal intensity on preoperative T2-weighted images. Substantial differences in FA value among spinal cord, bone, and CSF made it difficult to obtain a precise FA value for the compressed spinal cord. There was a significant correlation between the preoperative FT ratio and the recovery rate (p = 0.0006). A poor outcome (recovery rate < 40%) could be anticipated for CCM patients with preoperative FT ratios below 60%. Conclusions The preoperative FT ratio correlated significantly with the recovery rates in CCM patients. Preoperative diffusion tensor tractography can be a new prognostic predictor for neurological recovery in CCM patients after laminoplasty.

BACKGROUND: Because an idiopathic spinal extradural arachnoid cyst (SEAC) is rare, its optimal surgical treatment remains controversial. OBJECTIVE: To evaluate the results of surgical treatments for SEACs and to clarify features of the disease associated with poor outcomes. METHODS: Twelve patients with SEACs who underwent surgery at our hospital between 1988 and 2008 were examined retrospectively. The mean follow-up period was 4.7 years. Total resection of the cyst was performed in 7 patients and closure of the dural defect without cyst resection in 5 patients. Surgical outcomes were evaluated with regard to the duration of symptoms, the size of the cyst, and the surgical procedure used. RESULTS: Neurological recovery was observed in all patients, and there was no recurrence. Poor outcomes were observed in patients with a long duration of symptoms (>1 year, P 5 vertebrae, P < .05). The surgical procedure had no significant association with the postoperative neurological recovery. However, there was a significant difference in the degree of the mean postoperative kyphotic angle between the patients treated by total resection of the cyst (9.7 degrees) and those treated by closure of the dural defect without cyst resection through selective laminectomy (2.2 degrees) (P < .01). CONCLUSION: There was no significant difference in postoperative neurological recovery between the 2 surgical procedures. However, closure of the dural defect without cyst resection was less invasive, preventing postoperative kyphotic deformity of the thoracolumbar spine.

Study design Retrospective case series. Objective To evaluate the treatment strategies for spinal meningioma. Summary of background data Although previous studies have demonstrated favorable surgical outcomes for spinal meningioma, with a low incidence of tumor recurrence, few have examined long-term surgical outcomes. Methods The influence of patient age, surgical margin status (Simpson grade), tumor location, and histological subtype on tumor recurrence were examined retrospectively. In addition, the resected dura mater from Simpson grade I cases was examined for invasive tumor cells and compared with the presence or absence of a dural tail sign on magnetic resonance image. Results Complete resection (Simpson grades I and II) was performed in 62 patients. Among them, the tumor recurrence rate was 9.7%, all in patients who underwent grade II resection for ventral spinal lesions. The mean duration to reoperation in these patients was 12.2 ± 5.2 years. Of the 6 patients who underwent incomplete resection (Simpson grade III/IV), all required reoperation for tumor recurrence or regrowth, 5 years later on average. Patients younger than 50 years at the initial surgery had a significantly higher recurrence rate than those aged 50 years or older. Histologic examination of 43 dura mater specimens from Simpson grade I-resection patients revealed tumor cell invasion between the inner and outer layers in 15 patients. This invasion was noted in 8 (29%) of 28 patients who were negative for the dural tail sign on magnetic resonance image, and in 7 (47%) of 15 patients who showed a positive dural tail sign. The MIB-1 index reached about 10% for dumbbell-type meningiomas invading the vertebral body; these were associated with repeated recurrence and unfavorable prognosis. Conclusion Long-term follow-up after surgery for meningiomas indicated that Simpson grade I resection should be selected whenever practicable when treating younger patients or dumbbell-type meningiomas. Tumors recurred at 12 years, on average, in approximately 30% of patients who underwent grade II resection.

Purpose The objective of this study was to evaluate 2 years post-surgical loss of three-dimensional correction in adolescent idiopathic scoliosis (AIS) patients using multi-planar reconstruction computed tomography (CT).

Several biomarkers have been used to evaluate osteoarthritis of the limb joints. Here we evaluated the use of serum cartilage metabolites as biomarkers for degenerative lumbar scoliosis (DLS). Fifty-two DLS patients with Cobb angle > 10° were compared with 19 control patients. Serum levels of hyaluronic acid (HA), keratan sulfate (KS), cartilage oligomeric matrix protein (COMP), collagen type II cleavage (C2C), and procollagen type II C-propeptide (CPII) were measured. Serum levels of KS (DLS 1.20 ± 0.44 µg/ml vs. control 0.98 ± 0.33 µg/ml), CPII (DLS 1905.1 ± 948.2 ng/ml vs. control 1223.6 ± 884.4 ng/ml), and C2C (DLS 219.1 ± 59.2 ng/ml vs. control 177.7 ± 71.7 ng/ml) were significantly higher in DLS. There were no significant differences in the levels of HA or COMP. There was a significant positive correlation between the Cobb angle and CPII in DLS. This is the first study to evaluate the cartilage biomarkers in DLS. The results suggest DLS patients have higher levels of type II collagen synthesis and degradation, indicated by elevated serum CPII and C2C, respectively. As type II collagen is a major component of collagens in the nucleus pulposus and facet joint cartilages, its enhanced turnover may be related to the development and progression of DLS.

STUDY DESIGN Retrospective study. OBJECTIVE To examine the reliabilities of sagittal spino-pelvic alignment measurements using whole spine-pelvic and local pelvic radiographs and to determine whether spinal deformity affects these reliabilities. SUMMARY OF BACKGROUND DATA Sagittal spino-pelvic alignment is important in adult spinal deformity patients (ASD). Spino-pelvic parameters are closely related to health-related quality of life and indispensable for surgical planning. However, few studies have focused on the reliability of these measurements. METHODS Three spino-pelvic parameters, pelvic incidence (PI), pelvic tilt (PT), and sacral slope (SS) were measured in 2 patient groups: 33 adult scoliosis (AS) and 33 nondeformity (ND) patients, using whole spine-pelvic lateral radiographs (whole spine radiographs) and local pelvic lateral radiographs (local pelvic radiographs), by 5 experienced spine surgeons. Intra- and interobserver reliabilities for each procedure were evaluated by intraclass correlation coefficients (ICC). The interobserver reliability differences between the 2 procedures were statistically evaluated. The difference between the largest and smallest measurements among the 5 observers was also evaluated in the AS and ND groups. RESULTS Measurement of the 3 parameters using whole spine or local pelvic radiographs showed good to excellent intraobserver reliability (range of ICC: 0.820-0.935). The interobserver reliabilities of PI and PT from local pelvic radiographs were significantly higher than those from whole spine radiographs (P

Lumbar spinal canal stenosis (LSCS) is one of the most common spinal disorders in the elderly, and ligamentum flavum (LF) hypertrophy is an important cause of LSCS. Matrix metalloproteinase 13 (MMP13) can degrade fibrillar collagens and elastic microfibrils, and is involved in inflammation and fibrosis. The purpose of this study was to compare the expression of MMP13 in the LF from LSCS patients with diabetes mellitus [DM (+)] with that in the LF from patients without DM [DM (-)] and to analyze the relationship among DM, MMP13 expression, and LF hypertrophy.LFs from 11 DM (+) and 24 DM (-) LSCS patients were analyzed in this study. Histology analysis using hematoxylin and eosin and Masson's trichrome stain was performed for each LF. The expression of MMP13 was analyzed by quantitative real-time PCR. The thickness of LF was measured by CT.In the LF from DM (+) LSCS patients, the elastic fibers were more disorganized and had lower volumes than in the LF from DM (-) LSCS patients, while more fibrotic tissue was observed in the LF from DM (+) than from DM (-) LSCS patients. MMP13 expression was significantly higher in the LF from DM (+) LSCS patients (0.46 ± 0.61 vs. 0.05 ± 0.09, P = 0.002). The LF from the DM (+) LSCS patients was significantly thicker than that from the DM (-) LSCS patients (5.0 ± 0.9 vs. 3.1 ± 0.8 mm, P0.01), and the thickness was correlated with the expression of MMP13 (correlation coefficient = 0.43, P = 0.01, Pearson's correlation test).DM-related MMP13 expression can be one of the factors contributing to fibrosis and hypertrophy of the LF. Further research on the mechanism of this process may lead to new therapies for LF hypertrophy.

To evaluate the morphologic characteristics of the thoracic pedicle with regard to safe free-hand thoracic pedicle screw placement, based on multi-planar reconstruction CT images. Thirty adolescent idiopathic scoliosis (AIS) patients who had undergone posterior corrective surgery for major thoracic curve were included in this study. Reconstructed CT axial images at each thoracic vertebra were used to measure: (1) the shortest distance from an entry point to the ventral cortex of the lamina (critical distance), and (2) the distance from the entry point to the tangent of the spinal canal at the medial wall of the pedicle (safe distance). The critical length was defined as the distance between the critical distance and the safe distance. The distance from the entry point to the medial wall breach site (breach distance) was measured on post-operative CT images. The mean critical distance was 9.3 ± 1.1 mm. The critical distance of vertebrae from different levels was relatively constant, between 8.1 and 10.1 mm. The mean safe distance was 15.2 ± 1.3 mm. The safe distance of vertebrae from different levels was also relatively constant, between 14.5 and 16 mm. The mean critical length was 5.9 ± 1.0 mm. The critical length of vertebrae between T3 and T12 was relatively constant, ranging from 5 to 6.5 mm. The mean breach distance was 12.3 ± 1.3 mm and the each breach always recognized between the critical distance and the safe distance. The risk of pedicle medial wall perforation increases as the pedicle probe advances beyond the critical distance of 8–10 mm from the entry point, while it decreases entering into the safe distance at 14.5–16 mm. These parameters were relatively constant even in the most rotated vertebrae at T9 or those with the narrowest pedicle at T7 or T4.

To clarify the mechanism of osteoporosis in adolescent idiopathic scoliosis (AIS), we investigated radiological and histological changes in the cervical vertebrae of a chicken thoracic scoliosis model. Forty newly hatched broiler chicks were randomly divided into four equal groups: sham-operated chickens serving as control (CON), pinealectomized chickens (PNX), sham-operated (CON + MLT) and pinealectomized chickens (PNX + MLT) that received intraperitoneal administration of melatonin. Pinealectomy was performed at the age of 3 days, and the chickens were killed at 2 months of age. Postmortem X-rays were examined for the presence of scoliosis, and micro-computed tomography (micro-CT) images were taken to evaluate the microstructure of the cervical vertebrae. Histological specimens of the scanned cervical vertebra were prepared, and a midsagittal section was stained with hematoxylin and eosin and tartrate-resistant acid phosphatase to evaluate the numbers of osteoblasts and osteoclasts, respectively. Scoliosis developed at the thoracic spine in all chickens of the PNX and in two of the PNX + MLT group. Micro-CT data revealed that chickens in the PNX group had a greater degree of generalized osteoporosis compared with the other birds. The number of osteoblasts was significantly decreased in the PNX group, while no significant difference was observed among chickens in the numbers of osteoclasts. Our results suggest that melatonin deficiency reduces osteoblast proliferation and leads to the development of scoliosis and osteoporosis. The restoration of melatonin prevented the development of scoliosis and osteoporosis, indicating that melatonin levels may be crucial to the development of deformity and osteoporosis in AIS.

Stromal derived factor-1 (SDF-1) is a chemokine signaling molecule that binds to its transmembrane receptor CXC chemokine receptor-4 (CXCR4). While we previously detected that SDF-1 was co-required with bone morphogenetic protein 2 (BMP2) for differentiating mesenchymal C2C12 cells into osteoblastic cells, it is unknown whether SDF-1 is similarly involved in the osteogenic differentiation of mesenchymal stem cells (MSCs). Therefore, here we examined the role of SDF-1 signaling during BMP2-induced osteogenic differentiation of primary MSCs that were derived from human and mouse bone marrow. Our data showed that blocking of the SDF-1/CXCR4 signal axis or adding SDF-1 protein to MSCs significantly affected BMP2-induced alkaline phosphatase (ALP) activity and osteocalcin (OCN) synthesis, markers of preosteoblasts and mature osteoblasts, respectively. Moreover, disrupting the SDF-1 signaling impaired bone nodule mineralization during terminal differentiation of MSCs. Furthermore, we detected that blocking of the SDF-1 signaling inhibited the BMP2-induced early expression of Runt-related factor-2 (Runx2) and osterix (Osx), two “master” regulators of osteogenesis, and the SDF-1 effect was mediated via intracellular Smad and Erk activation. In conclusion, our results demonstrated a regulatory role of SDF-1 in BMP2-induced osteogenic differentiation of MSCs, as perturbing the SDF-1 signaling affected the differentiation of MSCs towards osteoblastic cells in response to BMP2 stimulation. These data provide novel insights into molecular mechanisms underlying MSC osteogenesis, and will contribute to the development of MSC therapies for enhancing bone formation and regeneration in broad orthopaedic situations.

Summary Objective The role of postmenopause on the pathogenesis of cartilage degeneration has been an open question. We assessed cartilage degeneration in estrogen receptor (ER)α null mice and examined the role of glucocorticoid receptor-interacting protein 1 (GRIP1) in the ERα-dependent transcription of a type II collagen gene ( col2a1 ) with special reference to a crosstalk with the transforming growth factor (TGF)-β signaling pathway. Methods The vertebral cartilaginous endplate from female ERα null mice was subjected to histological analyses. Col2a1 expression of primary chondrocytes (PCs) obtained from ERα null mice after 17β-estradiol (E 2 ) and TGF-β1 stimulation was examined by reverse transcription polymerase chain reaction (RT-PCR). Estrogen response element (ERE) or col2a1 promoter–enhancer luciferase reporter system was used to investigate the crosstalk among ERα, GRIP1, and MKK6. Col2a1 expression and glycosaminoglycan (GAG) content were measured in ATDC5 cells treated with GRIP1 small interfering RNA (siRNA). Results ERα deficiency clearly accelerated impairment of the vertebral cartilaginous endplate. E 2 and TGF-β1 stimulation increased col2a1 expression in PC from wild-type mice, but not that from ERα null mice. The same stimulation increased the col2a1 promoter–enhancer reporter activity, and the elevated activity was decreased by dominant-negative ERα and p38 mitogen-activated protein kinase (MAPK) inhibitor. GRIP1 increased the E 2 -dependent ERE activation in the presence of ERα and constitutive-active MKK6. GRIP1 siRNA repressed col2a1 expression and GAG production in ATDC5 cells. Conclusions Crosstalks between ERα/GRIP1 and TGF-β/MKK6/p38 MAPK pathway have protective roles on cartilage metabolism via regulating the extracellular matrices expression. The finding may lead to the development of a novel therapeutic approach for cartilage degeneration.

DC-STAMP is essential for fusion of osteoclasts and foreign body giant cells; however, it is not known whether dc-stamp expression in these two cell types is differentially regulated. Here, we show that dc-stamp expression and cell–cell fusion are regulated in a cell type–specific manner. Introduction: The transcription factors c-Fos and NFATc1 cooperate to regulate osteoclast differentiation, whereas PU.1 and NF-κB are activated in macrophages and osteoclasts or in both cell types. Thus, we asked what role c-Fos, NFATc1, PU.1, and NF-κB played in regulating dendritic cell–specific transmembrane protein (dc-stamp) expression and fusion of osteoclasts and macrophage giant cells. Materials and Methods: Transcriptional activation by c-Fos and NFATc1 was examined by dc-stamp promoter analysis. Multinuclear cell formation was analyzed in cells from c-Fos–deficient mice or in wildtype cells treated with the NFAT inhibitor FK506. The role of DC-STAMP in cell fusion was examined in vitro in a macrophage giant cell formation assay using DC-STAMP–deficient cells. Recruitment of c-Fos, NFATc1, PU.1, and NF-κB to the dc-stamp promoter in osteoclasts and macrophage giant cells was analyzed by chromatin-immunoprecipitation analysis. Results: Both activator protein-1 (AP-1) and NFAT binding sites in the dc-stamp promoter were needed for dc-stamp expression after RANKL stimulation of osteoclasts. dc-stamp expression was induced in osteoclasts and macrophage giant cells, and cells from DC-STAMP–deficient mice failed to form either multinuclear osteoclasts or macrophage giant cells. In contrast, c-Fos is indispensable for dc-stamp expression and cell–cell fusion under conditions favoring in vitro and in vivo induction of osteoclasts but not macrophage giant cells. Consistently, an NFAT inhibitor suppressed multinuclear osteoclast formation but not macrophage giant cell formation. In addition, PU.1 and NF-κB binding sites were detected in the dc-stamp promoter, and both PU.1 and NF-κB were recruited to the dc-stamp promoter after granulocyte-macrophage colony stimulating factor (GM-CSF) + interleukin (IL)-4 stimulation. Conclusions: dc-stamp expression is regulated differently in osteoclasts and macrophage giant cells. c-Fos and NFATc1, both of which are essential for osteoclast differentiation, are needed for dc-stamp expression and cell–cell fusion in osteoclasts, but both factors are dispensable for giant cell formation by macrophages. Because PU.1 and NF-κB are recruited to the dc-stamp promoter after stimulation with GM-CSF + IL-4, dc-stamp transcription is regulated in a cell type–specific manner.

STUDY DESIGN Experimental study on age-related changes in expression of tissue inhibitor of metalloproteinases-3 (TIMP-3) associated with transition from notochordal nucleus pulposus (NP) to fibrocartilaginous NP in rabbit intervertebral disc (IVD). OBJECTIVES To identify roles of notochordal NP in extracellular matrix (ECM) metabolism of IVD. SUMMARY OF BACKGROUND DATA One of most interesting properties of TIMP-3 is to inhibit aggrecanases in addition to matrix metalloproteinases. Balance of aggrecanase/TIMP-3 is critical to maintain homeostasis of ECM metabolism. METHODS Four-week-old and 160-week-old male Japanese white rabbits were used. Age-related changes in IVDs were evaluated histologically using previously established grading system. Immunohistochemistry of TIMP-3 and semiquantitative reverse transcriptase-polymerase reaction (RT-PCR) of TIMP-3, a disintegrin and metalloproteinases with thrombospondin motifs (ADAMTS) 4, 5, and transforming growth factor-beta1 (TGF-beta1), were conducted. RESULTS Semiquantitative assessment of histologic changes indicated that 4-week-old rabbit was equivalent to fetus to 2-year-old human and 160-week-old rabbit was equivalent to 11- to 30-year-old human, particularly 11- to 16-year-old, which corresponds to transition period from notochordal to fibrocartilaginous NP. Immunohistochemistry revealed that TIMP-3 was positive in 4-week-old rabbit only. Semiquantitative RT-PCR revealed that levels of expressions of TGF-beta1 and TIMP-3 mRNAs in 4-week-old were significantly higher than those in 160-week-old rabbits. There was no significant difference in expression of ADAMTS4 mRNA. ADAMTS5 mRNA was not detected or extremely low in both groups. Expression of TIMP-3 mRNA in NP was upregulated by TGF-beta1 but was not affected by IL-1beta. On the contrary, expression of ADAMTS4 mRNA was not upregulated by TGF-beta1 but was upregulated by IL-1beta. CONCLUSIONS Levels of expression of TIMP-3 in notochordal NP were significantly lower in 160-week-old rabbits than those in 4-week-old rabbits. Decrease in expression of TIMP-3, possibly mediated in part by TGF-beta1, may cause imbalance of ADAMTS4/TIMP-3 ratio at transition period from notochordal to fibrocartilaginous NP.

Study design In vivo analysis of insertional torque of pedicle screws using cortical bone trajectory (CBT) technique. Objective To investigate factors contributing to the fixation strength of CBT screws and to clarify the ideal cortical trajectory for lumbar fusion. Summary of background data CBT has developed as a new minimally invasive technique of lumbar instrumentation. Despite biomechanical studies demonstrating the superior characteristics of CBT, no study has elucidated the most suitable path for optimal fixation or compared the fixation within variations of trajectory. Methods The insertional torque of pedicle screws using CBT was measured intraoperatively in 72 consecutive patients. The detailed positions of a total of 268 screws were confirmed using postoperative reconstruction computed tomographic scans and were analyzed to identify factors contributing to the level of insertional torque. Investigated factors were as follows: (1) age, (2) bone mineral density of the femoral neck and lumbar vertebrae by dual-energy x-ray absorptiometry; (3) the pedicle width and height, (4) the length of the implant, (5) total screw length within the vertebra, (6) the screw length within the vertebral body, (7) the screw length within the lamina, (8) the cephalad and lateral angle of the trajectory, and (9) the distance from the long axis of the screw to the inferior and medial borders of the pedicle. Results Multiple regression analysis showed that bone mineral density of the femoral neck, screw length within the lamina, and cephalad angle were significant independent factors affecting torque. Conclusion The fixation of CBT screws varied depending on technical factors (cephalad angle and screw length within the lamina) as well as the individual patient factor of bone mineral density. The ideal trajectory was directed 25° to 30° cranially along the inferior border of the pedicle so as to obtain maximum contact with the lamina and sufficient length within the vertebral body. Level of evidence 2.

Background Although various risk factors have been reported for adjacent segment degeneration after lumbar fusion, the exact mechanisms and risk factors related to adjacent segment degeneration have not been clear. The present study was conducted to evaluate the risk factors for radiological adjacent segment degeneration in patients surgically treated for single-level L4 spondylolisthesis focusing on a single pathology, a specific fusion level, at a set interval. Methods We assessed preoperative and five-year postoperative radiographs for 72 patients who underwent L4-5 anterior or posterior lumbar interbody fusion for single-level L4 degenerative spondylolisthesis. Adjacent segment degeneration was defined as imaging evidence of one or more of the following conditions at L1-2, L2-3, or L3-4: 1) a loss of more than 20% of the preoperative disc height, 2) anterolisthesis or retrolisthesis greater than 3 mm, 3) or osteophyte formation greater than 3 mm. Results We found adjacent segment degeneration in 21 patients, with 31 discs affected. Multiple logistic regression analysis identified the following significant independent risk factors for adjacent segment degeneration: female gender (odds ratio 10.80; 95% confidence interval 1.20–96.89), posterior lumbar interbody fusion (odds ratio 7.70; 95% confidence interval 1.82–32.66), and pre-existing disc degeneration (odds ratio 12.29; 95% confidence interval 1.69–89.27). Conclusions Female gender, posterior lumbar interbody fusion, and pre-existing disc degeneration were significant independent risk factors for radiologically diagnosed adjacent segment degeneration in patients treated for L4 degenerative spondylolisthesis by interbody lumbar fusion.

OBJECT The object of this study was to investigate correlations between sagittal spinopelvic alignment and improvements in clinical and quality-of-life (QOL) outcomes after lumbar decompression surgery for lumbar spinal canal stenosis (LCS) without coronal imbalance. METHODS The authors retrospectively reviewed data from consecutive patients treated for LCS with decompression surgery in the period from 2009 through 2011. They examined correlations between preoperative or postoperative sagittal vertical axis (SVA) and radiological parameters, clinical outcomes, and health-related (HR)QOL scores in patients divided according to SVA. Clinical outcomes were assessed according to Japanese Orthopaedic Association (JOA) and visual analog scale (VAS) scores. Health-related QOL was evaluated using the Roland-Morris Disability Questionnaire (RMDQ) and the JOA Back Pain Evaluation Questionnaire (JOABPEQ). RESULTS One hundred nine patients were eligible for inclusion in the study. Compared to patients with normal sagittal alignment prior to surgery (Group A: SVA < 50 mm), those with preoperative sagittal imbalance (Group B: SVA ≥ 50 mm) had significantly smaller lumbar lordosis and thoracic kyphosis angles and larger pelvic tilt. In Group B, there was a significant decrease in postoperative SVA compared with the preoperative SVA (76.3 ± 29.7 mm vs 54.3 ± 39.8 mm, p = 0.004). The patients in Group B with severe preoperative sagittal imbalance (SVA > 80 mm) had residual sagittal imbalance after surgery (82.8 ± 41.6 mm). There were no significant differences in clinical and HRQOL outcomes between Groups A and B. Compared to patients with normal postoperative SVA (Group C: SVA < 50 mm), patients with a postoperative SVA ≥ 50 mm (Group D) had significantly lower JOABPEQ scores, both preoperative and postoperative, for walking ability (preop: 36.6 ± 26.3 vs 22.7 ± 26.0, p = 0.038, respectively; postop: 71.1 ± 30.4 vs 42.5 ± 29.6, p < 0.001) and social functioning (preop: 38.7 ± 18.5 vs 30.2 ± 16.7, p = 0.045; postop: 67.0 ± 25.8 vs 49.6 ± 20.0, p = 0.001), as well as significantly higher postoperative RMDQ (4.9 ± 5.2 vs 7.9 ± 5.7, p = 0.015) and VAS scores for low-back pain (2.68 ± 2.69 vs 3.94 ± 2.59, p = 0.039). CONCLUSIONS Preoperative sagittal balance was not significantly correlated with clinical or HRQOL outcomes after decompression surgery in LCS patients without coronal imbalance. Decompression surgery improved the SVA value in patients with preoperative sagittal imbalance; however, the patients with severe preoperative sagittal imbalance (SVA > 80 mm) had residual imbalance after decompression surgery. Both clinical and HRQOL outcomes were negatively affected by postoperative residual sagittal imbalance.

is Figure S2 showing treatment of MAPK inhibitors to AF cells with ROS. Real-time RT-PCR analysis of the expression of TNFα and MMP-3 in AF cells. MAPK signaling inhibitors, including p38 inhibitor (SB), JNK inhibitor (SP), and ERK inhibitor (PD), were treated to AF cells with H2O2 (upper) or BSO (lower). Data presented as mean ± SD of three independent experiments performed in triplicate (n = 3); *p

is Figure S1 showing molecular phenotype of the passaged rat AF cells. Real-time RT-PCR analysis of the mRNA expression of type I collagen, type II collagen, and aggrecan in the second (P2) and fifth (P5) passaged AF cells. Data presented as mean ± SD of three independent experiments performed in triplicate (n = 3); *p

Study Design. A retrospective case series. Objective. To assess whether a short fusion strategy is applicable when treating adolescent idiopathic scoliosis with Lenke type 5C curve by posterior correction and fusion surgery using pedicle-screw constructs. Summary of Background Data. Previous studies have discussed the selection of the lower instrumented vertebra to best preserve motion segments and obtain coronal balance. However, reports evaluating the selection of the upper instrumented vertebra when treating Lenke type 5C curves are not available. Methods. We evaluated 29 patients who were treated surgically for adolescent idiopathic scoliosis with Lenke type 5C curve (mean age, 16.8 ± 4.7 yr; range, 10–29 yr). The mean follow-up period was 28.0 ± 6.3 months (range, 24–48 mo). We compared radiographical parameters and clinical outcomes between patients with an upper instrumented vertebra at the end vertebra (EV) (n = 10) and those treated by short fusion (S group), with a upper instrumented vertebra 1-level caudal to the EV (n = 19 patients). Results. In the EV group, a preoperative mean Cobb angle of 50°± 15° was corrected to 8°± 7°, which was maintained at the final follow-up (7°± 1°). In the S group, a mean preoperative Cobb angle of 47°± 4° was corrected to 8°± 5°, but this increased significantly to 12°± 7° at final follow-up (P = 0.033). The mean correction rate at final follow-up was significantly lower in the S group (72%) than in the EV group (86%) (P = 0.027). Coronal and sagittal balance, thoracic kyphosis, lumbar lordosis, L4 tilt, and clinical outcomes evaluated by Scoliosis Research Society patient questionnaire-22 were equivalent between the 2 groups. Conclusion. Scoliosis Research Society patient questionnaire-22 scores and radiographical parameters other than the correction rate were equivalent between the 2 groups. A short fusion strategy, in which the upper instrumented vertebra is 1-level caudal to the upper EV, is applicable to posterior correction and fusion surgery with pedicle-screw constructs for Lenke type 5C curves. Conclusion. Level of Evidence: 4

Intervertebral disc (IVD) consists of a soft gelatinous material in its center, the nucleus pulposus (NP), bounded peripherally by fibrocartilage, annulus fibrosus (AF). Despite the number of patients with IVD degeneration, gene expression analysis has not been undertaken in NP and therefore little is known about the molecular markers expressed in NP. Here, we undertook a microarray screen in NP with the other nine tissues to identify the specific cell surface markers for NP. Five membrane associating molecules out of 10,490 genes were identified as highly expressing genes in NP compared with the other tissues. Among them, we identified CD24, a glycosylphosphatidylinositol (GPI) anchor protein as a cell surface marker for NP. CD24 expression was also detected in the herniated NP and chordoma, a malignant primary tumor derived from notochordal cells, while it was absent in chondrosarcoma. Therefore, CD24 is a molecular marker for NP as well as the diseases of IVD.

Osteoclasts are bone-resorbing cells that play a pivotal role in bone remodeling. Osteoclasts form large multinuclear giant cells by fusion of mononuclear osteoclasts. How cell fusion is mediated, however, is unclear. We identify the dendritic cell–specific transmembrane protein (DC-STAMP), a putative seven-transmembrane protein, by a DNA subtraction screen between multinuclear osteoclasts and mononuclear macrophages. DC-STAMP is highly expressed in osteoclasts but not in macrophages. DC-STAMP–deficient mice were generated, and osteoclast cell fusion was completely abrogated in homozygotes despite normal expression of osteoclast markers and cytoskeletal structure. As osteoclast multinucleation was restored by retroviral introduction of DC-STAMP, loss of cell fusion was directly attributable to a lack of DC-STAMP. Defects in osteoclast multinucleation reduce bone-resorbing activity, leading to osteopetrosis. Similar to osteoclasts, foreign body giant cell formation by macrophage cell fusion was also completely abrogated in DC-STAMP–deficient mice. We have thus identified an essential regulator of osteoclast and macrophage cell fusion, DC-STAMP, and an essential role of osteoclast multinucleation in bone homeostasis.

Although minimally invasive transforaminal lumbar interbody fusion (MIS-TLIF) has widely been developed in patients with lumbar diseases, surgeons risk exposure to fluoroscopic radiation. However, to date, there is no studies quantifying the effective dose during MIS-TLIF procedure, and the radiation dose distribution is still unclear. In this study, the surgeons' radiation doses at 5 places on the bodies were measured and the effective doses were assessed during 31 consecutive 1- to 3-level MIS-TLIF surgeries. The operating surgeon, assisting surgeon, and radiological technologist wore thermoluminescent dosimeter on the unshielded thyroid, chest, genitals, right middle finger, and on the chest beneath a lead apron. The doses at the lens and the effective doses were also calculated. Mean fluoroscopy times were 38.7, 53.1, and 58.5 seconds for 1, 2, or 3 fusion levels, respectively. The operating surgeon's mean exposures at the lens, thyroid, chest, genitals, finger, and the chest beneath the shield, respectively, were 0.07, 0.07, 0.09, 0.14, 0.32, and 0.05 mSv in 1-level MIS-TLIF; 0.07, 0.08, 0.09, 0.18, 0.34, and 0.05 mSv in 2-level; 0.08, 0.09, 0.14, 0.15, 0.36, and 0.06 mSv in 3-level; and 0.07, 0.08, 0.10, 0.15, 0.33, and 0.05 mSv in all cases. Mean dose at the operating surgeon's right finger was significantly higher than other measurements parts (P

STUDY DESIGN A retrospective case series of patients treated surgically for degenerative lumbar scoliosis (DLS). OBJECTIVE To determine incidence and risk factors of progressive global thoracic kyphosis (pGTK) after surgery for DLS. SUMMARY OF BACKGROUND DATA Sagittal balance affects the surgical treatment of spinal deformity in adults. Little is known about the loss of sagittal balance due to pGTK, or about the risk factors for pGTK, after surgery for DLS. METHODS We reviewed records from a multicenter database of adults with DLS, treated with posterior spinal fusion. Inclusion required an age of 50 years or more at the time of surgery, an upper instrumented vertebra at T9 and below, more than 5 fused segments, and at least 2 years of follow-up. We included 73 patients with a mean age of 68.3 years (range, 51-77 yr) and a mean follow-up period of 3.6 years (range, 2-11 yr). Independent risk factors for pGTK were identified by logistic regression analysis. RESULTS Significant pGTK, defined as an increase in thoracic kyphosis of more than 10° from before surgery to the time of final follow-up, was observed in 41% of the patients. Loss of the sagittal vertical axis was larger in patients with pGTK than without (4.7 vs. 1.5 cm; P = 0.02). Risk analysis showed larger lumbar lordosis correction in patients with pGTK. Multivariate logistic regression analysis identified an age greater than 75 (odds ratio, 5.53; P = 0.02, 95% confidence interval [1.4-22.4]) and sacropelvic fusion (odds ratio = 2.66, P = 0.02, 95% confidence interval [1.5-11.1]) as independent risk factors for pGTK. CONCLUSION The pGTK incidence after surgery for DLS was 41%. Age, sacropelvic fusion, and a larger sagittal correction were identified as pGTK risk factors. Long-term follow-up will provide more data on the clinical impact of pGTK in elderly patients. LEVEL OF EVIDENCE 3.

Diabetes mellitus (DM) is reported to be a risk factor for surgical site infection (SSI), which is a serious complication after spinal surgery. The effect of DM on SSI after instrumented spinal surgery remains to be clarified. The aim was to elucidate perioperative risk factors for infection at the surgical site after posterior thoracic and lumbar spinal arthrodesis with instrumentation in patients with DM.Consecutive patients who underwent posterior instrumented thoracic and lumbar spinal arthrodesis during the years 2005-2011, who could be followed for at least 1 year after surgery, were included. These included 36 patients with DM (19 males and 17 females; mean age 64.3 years). The patients' medical records were retrospectively reviewed to determine the SSI rate. The characteristics of the DM patients were examined in detail, including the levels of serum glucose and HbA1c, which indicate the level of diabetes control.Patients with DM had a higher rate of SSI (6 of 36 patients, 16.7 %) than patients without DM (10 of 309 patients, 3.2 %). Although the perioperative serum glucose level did not differ between DM patients that did or did not develop SSI, the preoperative HbA1c value was significantly higher in the patients who developed SSI (7.6 %) than in those who did not (6.9 %). SSI developed in 0.0 % of the patients with controlled diabetes (HbA1c7.0 %) and in 35.3 % of the patients with uncontrolled diabetes (HbA1c ≥7.0 %).DM patients whose blood glucose levels were poorly controlled before surgery were at high risk for SSI. To prevent SSI in DM patients, we recommend lowering the HbA1c to7.0 % before performing surgery.

Several disorders of the spine and spinal cord cause intramedullary lesions with high intensity on T2-weighted magnetic resonance imaging (MRI) scans, including cervical spondylotic myelopathy (CSM), cervical intramedullary tumor, spinal cord sarcoidosis, multiple sclerosis, spinal cord infarction, and others [1]. Previous reports demonstrated that atypical intramedullary T2 high-intensity lesions can mimic CSM or intramedullary tumor, sometimes confounding the diagnosis and resulting in delayed treatment [2, 3]. Recently, diffusion tensor imaging, which takes advantage of the diffusion anisotropy of water molecules, has been applied to spinal disorders; diffusion tensor tractography (DTT) can visualize the tracts of white matter in vivo [4]. Here we report a case in which an intramedullary cervical tumor exhibited a CSM-like pattern of T2-high intensity, which was diagnosed as an intramedullary tumor by DTT.

Background Although posterior correction and fusion surgery using pedicle screws carries the risk of vascular injury, a massive postoperative hemothorax in a patient with adolescent idiopathic scoliosis (AIS) is quite rare. We here report a case of a 12-year-old girl with AIS who developed a massive postoperative hemothorax. Case presentation The patient had a double thoracic curve with Cobb angles of 63° at T2-7 and 54° at T7-12. Posterior correction and fusion surgery was performed using a segmental pedicle screw construct placed between T2 and T12. Although the patient's respiration was stable during the surgery, 20 minutes after removing the trachea tube, the patient’s pulse oximetry oxygen saturation suddenly decreased to 80%. A contrast CT scan showed a massive left hemothorax, and a drainage tube was quickly inserted into the chest. The patient was re-intubated and a positive end-expiratory pressure of 5 cmH2O applied, which successfully stopped the bleeding. The patient was extubated 4 days after surgery without incident. Based on contrast CT scans, it was suspected that the hemothorax was caused by damage to the intercostal arteries or branches during pedicle probing on the concave side of the upper thoracic curve. Extensive post-surgical blood tests, echograms, and CT and MRI radiographs did not detect coagulopathy, pulmonary or vascular malformation, or any other possible causative factors. Conclusion This case underscores the potential risk of massive hemothorax related to thoracic pedicle screw placement, and illustrates that for this serious complication, respiratory management with positive airway pressure, along with a chest drainage tube, can be an effective treatment option.

Severe cervical kyphosis requiring surgical treatment is rare in patients with neurofibromatosis Type 1 (NF1). When it occurs, however, dystrophic changes in the vertebrae make surgical correction and fusion of the deformity extremely difficult. The authors report on 3 cases of severe cervical kyphosis associated with NF1 that were successfully treated with combined anterior and posterior correction and fusion. All patients underwent halo-gravity traction for approximately 1 month prior to surgery to correct the deformity gradually. Posterior correction and fusion were performed with segmental spinal instrumentation consisting of lateral mass screws, lamina screws, pedicle screws, and polyethylene tape for sublaminar wiring. Anterior spinal fusion was performed using a fibula strut to induce solid bone fusion. All patients used a halo vest for postoperative external fixation. Preoperative CT scans showed dystrophic cervical spine changes, and MR images demonstrated extensive neurofibromas outside the cervical spine in all 3 patients. The preoperative kyphotic angles were as follows: Case 1, 140°; Case 2, 81°; and Case 3, 72°; after halo-gravity traction, the kyphosis angles improved to 50°, 55°, and 51°, respectively; and after surgery, they were 50°, 15°, and 27°, respectively. Solid bone union was observed in all patients at the latest follow-up. All three patients experienced postoperative complications consisting of superficial infection, severe pneumonia, and partial dislocation of the distal fibula graft after removing the halo vest, in one patient each. Although dystrophic cervical vertebral changes in these patients with NF1 complicated the correction of severe cervical kyphosis, the use of preoperative halo-gravity traction, a combination of spinal instrumentations, an anterior strut bone graft, and postoperative halo-vest fixation made it possible to correct the kyphosis, maintain the correction, and achieve solid bone fusion.

Background Although microendoscopic discectomy (MED) is a minimally invasive surgical method for lumbar disc herniation (LDH), early postoperative recurrence may outweigh that advantage. The purpose of the present study was to retrospectively investigate the recurrence rate after MED for LDH and to determine the risk factors for recurrence in patients treated by a single surgeon. Materials and Methods The study included 344 patients who underwent MED (213 males and 131 females; mean age, 39.3 years; age range, 11–82 years; mean follow-up, 3.6 years; follow-up range, 2.0–6.5 years). The clinical outcomes were evaluated using the Japanese Orthopedic Association Score for Low Back Pain (JOA score). Recurrence factors investigated by logistic regression analysis included age; sex; level, laterality, and classified type of LDH; occupation; sports activity; and learning curve of the surgeon. Results LDH recurrence was observed in 37 patients (10.8%). It was observed at the same level in the ipsilateral side as the original LDH in 30 patients, in the contralateral side in three patients, and at a level adjacent to the original level in four patients. The mean time interval between MED and the recurrence was 16.6 months (range, 0.5–52 months). Twenty patients (54.1%) developed recurrence within 1 year after MED. Twenty-two patients (59.5%) were treated by revision surgery (MED in 20 patients and microdiscectomy in two patients), and 15 patients (40.5%) were treated conservatively. The mean JOA score of all the patients was 14.7 ± 3.5 before surgery and 26.5 ± 2.2 at the final follow-up, yielding an average recovery rate of 82.3 ± 15.7%. The recovery rate was 83.1 ± 14.8% in patients without recurrence and 75.7 ± 20.4% in patients with recurrence (p = 0.006). By logistic regression analysis, we identified migration of LDH as a significant factor related to recurrence. The patients with caudal migration of LDH had recurrence more frequently (19.0%) than those with rostral migration (12.5%) or without migration (10.2%) (p = 0.04; odds ratio, 2.0; 95% confidence interval, 1.0–3.8). Conclusion The recurrence rate and reoperation rate for LDH after MED were comparable to those of conventional discectomy. More than half of the cases of recurrence occurred at an early postoperative phase, and patients with caudally migrated LDH experienced recurrence significantly more often than those with rostrally migrated or nonmigrated LDH.

Background The purpose of this study was to test the hypothesis that direct vertebral derotation by pedicle screws (PS) causes hypokyphosis of the thoracic spine in adolescent idiopathic scoliosis (AIS) patients, using computer simulation. Methods Twenty AIS patients with Lenke type 1 or 2 who underwent posterior correction surgeries using PS were included in this study. Simulated corrections of each patient’s scoliosis, as determined by the preoperative CT scan data, were performed on segmented 3D models of the whole spine. Two types of simulated extreme correction were performed: 1) complete coronal correction only (C method) and 2) complete coronal correction with complete derotation of vertebral bodies (C + D method). The kyphosis angle (T5-T12) and vertebral rotation angle at the apex were measured before and after the simulated corrections. Results The mean kyphosis angle after the C + D method was significantly smaller than that after the C method (2.7 ± 10.0° vs. 15.0 ± 7.1°, p < 0.01). The mean preoperative apical rotation angle of 15.2 ± 5.5° was completely corrected after the C + D method (0°) and was unchanged after the C method (17.6 ± 4.2°). Conclusions In the 3D simulation study, kyphosis was reduced after complete correction of the coronal and rotational deformity, but it was maintained after the coronal-only correction. These results proved the hypothesis that the vertebral derotation obtained by PS causes hypokyphosis of the thoracic spine.

To date, few studies have focused on spinopelvic sagittal alignment as a predisposing factor for the development of degenerative spondylolisthesis (DS). The objectives of this study were to compare differences in spinopelvic sagittal alignment between patients with or without DS and to elucidate factors related to spinopelvic sagittal alignment.A total of 100 patients with or without DS who underwent surgery for lumbar spinal canal stenosis were assessed in this study. Fifty patients with DS (DS group) and 50 age- and gender-matched patients without DS (non-DS group) were enrolled. Spinopelvic parameters including pelvic incidence (PI), sacral slope (SS), pelvic tilt (PT), L4 slope, L5 slope, thoracic kyphosis (TK), lumbar lordosis (LL) and sagittal balance were compared between the two groups. In the DS group, the percentage of vertebral slip (% slip) was also measured.Several spinopelvic parameters, PI, SS, L4 slope, L5 slope, TK and LL, in the DS group were significantly greater than those in the non-DS group, and PI had positive correlation with % slip (r = 0.35, p 0.05). Degrees of correlations among spinopelvic parameters differed between the two groups. In the DS group, PI was more strongly correlated with SS (r = 0.82, p 0.001) than with PT (r = 0.41, p 0.01). In the non-DS group, PI was more strongly correlated with PT (r = 0.73, p 0.001) than with SS (r = 0.38, p 0.01).Greater PI may lead to the development and the progression of vertebral slip. Different compensatory mechanisms may contribute to the maintenance of spinopelvic sagittal alignment in DS and non-DS patients.

Study design A prospective follow-up study. Objective To elucidate the impact of lamina closure on long-term outcomes after open-door laminoplasty. Summary of background data In a previous study, we did not find significant associations between lamina closure and short-term outcomes. METHODS.: Of the original cohort of 82 patients who underwent open-door laminoplasty, 69 were included in this study (52 men, 17 women; mean age, 60.9 yr; mean follow-up, 6.2 yr; 56 with spondylosis or disc herniation, 13 with ossification of posterior longitudinal ligament). Lamina closure was previously observed in 23 of these patients (closure group) but not in 46 (nonclosure group). The Japanese Orthopaedic Association (JOA) scores and Japanese Orthopaedic Association Cervical Myelopathy Evaluation Questionnaire were recorded. Results The JOA score was 9.9 ± 3.2 in the closure group and 11.2 ± 2.3 in the nonclosure group before surgery (P = 0.1), 13.8 ± 2.3 and 13.8 ± 2.2 at 1.8 years (P = 0.99), and 13.6 ± 2.2 and 14.2 ± 2.7 at final follow-up (P = 0.29). The recovery rate of the JOA scores was 56.7 ± 30.0% and 46.7 ± 29.2% at 1.8 years (P = 0.22) and 51.0 ± 32.5 and 57.6 ± 31.1 at the final follow-up (P = 0.42). The subdomains assessed by the Japanese Orthopaedic Association Cervical Myelopathy Evaluation Questionnaire at follow-up were cervical spine function, 68.7 ± 27.5 in the closure group and 67.7 ± 30.0 in the nonclosure group (P = 0.93); upper extremity function, 78.6 ± 24.3 and 87.6 ± 15.4 (P = 0.40); lower extremity function, 69.9 ± 26.0 and 73.9 ± 22.5 (P = 0.68); bladder function, 74.6 ± 22.6 and 84.9 ± 29.2 (P = 0.18); and quality of life, 53.9 ± 25.3 and 56.2 ± 18.1 (P = 0.96). Conclusion Lamina closure did not significantly impact the long-term surgical outcomes of laminoplasty for cervical myelopathy. Although not statistically significant, the recovery rate tended to decline in the closure group compared with the nonclosure group during the long-term follow-up period, and the utilization of a laminar retention device to prevent the laminar closure should be considered.

Clear cell meningioma (CCM) is a rare variant of meningioma with a worse prognosis than other types of meningioma. The World Health Organization (WHO) classification of tumors of the central nervous system recognizes CCM as a meningioma variant, WHO grade II [1]. Histologically, CCM is composed of polygonal cells with a clear, glycogen-rich cytoplasm, vague whorl formations, and stromal deposits of collagen bundles. Since its first description by Scheithauer [2], CCM has been reported most frequently in spinal/intradural (thoracic and lumbar), cerebellopontine angle, and supratentorial locations, with the lumbar region and cerebellopontine angle being the most common [3]. Pediatric recurrence of these tumors is high; for adult cases secondary management strategies, including repeated resection with or without secondary radiation therapy, are controversial. Epstein et al. [4] advocated gross total resection of lumbar tumors as the current optimum management in adults, with radiation therapy reserved for secondary recurrences. In addition, although most meningiomas are based in the dura, on the basis of Pubmed from 1990 to 2011 years, 12 cases of nondura-based CCM of the lumbar spine and cauda equina have been reported [5–15]. Here, we report the case of a 43-year-old man with nondura-based CCM of the cauda equina without any local recurrence 7 years after resection.

A retrospective case-control studyShort fusion using pedicle screws (PSs) with an attempt to attain maximum correction of the main thoracic curve was conducted for patients with a Lenke type 1 curve, to prevent postoperative left shoulder elevation. The outcomes were compared with those of conventional surgery.Excessive correction of the main thoracic curve by PSs causes problematic left shoulder elevation even in a Lenke type 1 curve.Thirty-eight patients (3 male, 35 female, mean age 16.2 years, mean follow-up 24 mo) with Lenke type 1 curve underwent posterior corrective surgery using PSs. The upper instrumented vertebra was 1 level below the end vertebra in 14 patients (short, S group), and it was at the end vertebra in 24 patients (conventional, C group). There was no difference in the preoperative Cobb angle (51.8 vs. 58.0) or curve flexibility (49.7 vs. 46.1) between the 2 groups. Radiographic results, perioperative data, and scoliosis research society 22 scores were compared between the 2 groups.The postoperative Cobb angle of the main curve after surgery was 13.2±5.7 degrees in the S group and 10.6±7.3 degrees in the C group (not significant). The clavicle angle was -2.1±2.8 degrees versus -2.7±2.6 degrees before surgery (not significant), and 0.8±2.3 versus 3.8±2.4 after surgery (P0.05). The number of fused vertebrae, mean surgical time, and estimated blood loss were significantly lower in the S group than in the C group. The scoliosis research society 22 score at follow-up was not different between the 2 groups.The short fusion strategy for a Lenke type 1 curve can produce equivalent correction of the main curve and clinical outcomes to conventional fusion strategy with less surgical time and blood loss, while maintaining better shoulder balance.

To clarify the mechanism of osteoporosis in adolescent idiopathic scoliosis (AIS), we investigated radiological and histological changes in the cervical vertebrae of a chicken thoracic scoliosis model. Forty newly hatched broiler chicks were randomly divided into four equal groups: sham-operated chickens serving as control (CON), pinealectomized chickens (PNX), sham-operated (CON + MLT) and pinealectomized chickens (PNX + MLT) that received intraperitoneal administration of melatonin. Pinealectomy was performed at the age of 3 days, and the chickens were killed at 2 months of age. Postmortem X-rays were examined for the presence of scoliosis, and micro-computed tomography (micro-CT) images were taken to evaluate the microstructure of the cervical vertebrae. Histological specimens of the scanned cervical vertebra were prepared, and a midsagittal section was stained with hematoxylin and eosin and tartrate-resistant acid phosphatase to evaluate the numbers of osteoblasts and osteoclasts, respectively. Scoliosis developed at the thoracic spine in all chickens of the PNX and in two of the PNX + MLT group. Micro-CT data revealed that chickens in the PNX group had a greater degree of generalized osteoporosis compared with the other birds. The number of osteoblasts was significantly decreased in the PNX group, while no significant difference was observed among chickens in the numbers of osteoclasts. Our results suggest that melatonin deficiency reduces osteoblast proliferation and leads to the development of scoliosis and osteoporosis. The restoration of melatonin prevented the development of scoliosis and osteoporosis, indicating that melatonin levels may be crucial to the development of deformity and osteoporosis in AIS.

Study design Prospective clinical series. Objective To investigate the sterility of the posterior elements of the spine during posterior correction surgery. Summary of background data Bacterial growth in the operating field is considered one of the causes of surgical-site infection. Methods A total of 80 consecutive patients (mean age = 19.5 years) who underwent posterior correction surgery for spinal deformities were included in the study. During surgery, specimens for bacterial culture were obtained by swabs from (1) the skin after cleansing using povidone-iodine scrub solution but before draping, (2) laminae immediately after exposure, (3) laminae immediately after screw placement, (4) laminae immediately before wound closure, (5) a small piece of bone obtained from the spinous process immediately after exposure and placed on a sterile dish during surgery as a control, kept covered, and (6) a similar sample as (5), kept uncovered. The culture was conducted on both blood agar and Gifu anaerobic medium agar plates. Results No patient developed surgical-site infection. The culture was positive in specimen (S) 1 in 25 patients (31.3%), S2 in 20 (25%), S3 in 25 (31.3%), S4 in 26 (32.5%), S5 in 6 (7.5%), and S6 in 7 (8.8%). Bacterial species included Propionibacterium acnes in 15 specimens, Propionibacterium species in 9, and others in 10. Of the 25 patients with a positive culture in S1 and 55 patients without, 22 (88%) and 26 (47.3%), respectively, demonstrated a positive culture in specimens obtained during surgery. Conclusion The culture was more frequently positive in specimens obtained immediately before wound closure than in those harvested immediately after exposure and isolated from the surgical field. The results suggest that bacterial contamination of the operating field may originate from the skin of the patient during surgery.

Cavernous hemangioma consists mainly of congenital vascular malformations present before birth and gradually increasing in size with skeletal growth. A small number of patients with cavernous hemangioma develop scoliosis, and surgical treatment for the scoliosis in such cases has not been reported to date. Here we report a 12-year-old male patient with severe progressive scoliosis due to a huge subcutaneous cavernous hemangioma, who underwent posterior correction and fusion surgery. Upon referral to our department, radiographs revealed a scoliosis of 85° at T6-L1 and a kyphosis of 58° at T4-T10. CT and MR images revealed a huge hemangioma extending from the subcutaneous region to the paraspinal muscles and the retroperitoneal space and invading the spinal canal. Posterior correction and fusion surgery using pedicle screws between T2 and L3 were performed. Massive hemorrhage from the hemangioma occurred during the surgery, with intraoperative blood loss reaching 2800 ml. The scoliosis was corrected to 59°, and the kyphosis to 45° after surgery. Seven hours after surgery, the patient suffered from hypovolemic shock and disseminated intravascular coagulation due to postoperative hemorrhage from the hemangioma. The patient developed sensory and conduction aphasia caused by cerebral hypoxia during the shock on the day of the surgery. At present, two years after the surgery, although the patient has completely recovered from the aphasia. This case illustrates that, in correction surgery for scoliosis due to huge subcutaneous cavernous hemangioma, intraoperative and postoperative intensive care for hemodynamics should be performed, since massive hemorrhage can occur during the postoperative period as well as the intraoperative period.

Juvenile Paget's disease (JPD) is a rare autosomal-recessive hereditary disease and is typically diagnosed in infants or young children. JPD causes bone pain, bone expansion and deformity, and severity generally increases during adolescence. Recently, differentiation and maturation of osteoclasts, controlled by RANK, which is expressed in osteoclast precursors and its ligand, RANKL, which is expressed in osteoblasts or marrow stromal cells, have been clarified. Recent studies elucidated that JPD was caused by mutation of TNFRSF11B, which encodes osteoprotegerin, a soluble decoy receptor of RANKL. We summarize the outline and etiology of JPD.

Introduction Regression analysis of adult spinal deformity (ASD) databases in North America (NA) has yielded radiographic disability thresholds for sagittal vertical axis (SVA), pelvic tilt (PT), and pelvic incidence to lumbar lordosis (PI–LL), which have been used in formulating the Schwab–SRS ASD classification. These thresholds are often used as correction goals for surgery planning, but it is unclear whether these thresholds vary in other geographic regions or ethnicities. This is the first comparison of radiographic disability thresholds between NA and Asian populations of ASD. Patients and Methods Retrospective, multicenter case series of 595 operative patients with ASD with baseline radiographs and Oswestry disability index (ODI) from 11 sites across USA ( n = 402) and Japan (JPN, n = 193). Patients were compared at baseline in ODI, ODI need for improvement (ODIni, calculated from age/ethnic normative values), and radiographs. Linear regression was used to define thresholds for disability. Results Differences existed in mean age (USA 52.5 ± 22.5 years vs. JPN was 56.5 ± 15.4 years, p = 0.012) and revisions (USA 48% vs. JPN 2%, p Conclusion At baseline, patients in both cohorts had a similar sagittal deformity but different morphology. Disability thresholds for SVA appear to be maintained across ethnicities but with differences in pelvic morphology (PI–LL and PT). The JPN cohort had significantly smaller PI and multiple coronal curves compared with the USA cohort. Despite similar sagittal malalignment, the JPN cohort had a significantly lower ODI without a significant difference in ODIni.

Introduction Adult spinal deformity (ASD) research and treatment has continued to evolve and grow globally. International studies are now frequently presented at the SRS, but surgeons are unsure of the data comparisons and global relevance of conclusions across ethnicities. We compared HRQOL and radiographs between two countries (United States and Japan) to help define the effect of geographic variation. Materials and Methods Retrospective, multicenter case series of 337 operative patients with ASD with baseline radiographs and ODI from 11 sites across USA ( n = 235) and Japan (JPN, n = 102). Patients were compared preoperatively and postoperatively in ODI, ODI need for improvement (ODIni, using age/ethnic normative values), and radiographs. Regression was used to define thresholds for disability: USA ODI 41.9, JPN ODI 33.7. Results Differences in age (USA 55 years, JPN 65 years, p Conclusion Despite having a greater deformity at BL, there were no significant differences in BL ODI. Although both the groups improved in ODI and alignment, JPN cohort still had higher offset from the normative age-/ethnicity-matched values and more spino-pelvic malalignment at 2 years—for the same ODI, JPN patients may be masking a greater disability than represented by the score. When population-specific thresholds of disability were applied, JPN patients had a large percentage over the threshold, revealing that 60% were still with lower scores at 2 years. The ethnicity of a patient should be considered when interpreting ODI and comparing surgical outcomes for ASD using standard metrics.

IntroductionRegression analysis of adult spinal deformity (ASD) databases in North America (NA) has yielded radiographic disability thresholds for sagittal vertical axis (SVA), pelvic tilt (PT), an...

Health Survey Physical and Mental Component Summaries (SF-12 PCS and MCS), EuroQol-5D health survey (EQ-5D), NASS satisfaction METHODS: Analysis of 69 adult patients who underwent surgical correction of adult spinal deformity performed at a single institution. Patientreported outcomes (PROs) were assessed prospectively at baseline and 1 year postoperatively and included measures of back and leg pain on a numeric rating scale (BP-NRS and LP-NRS), Oswestry Disability Index (ODI), 12-Item Short Form Health Survey Physical and Mental Component Summaries (SF-12 PCS and MCS), and EuroQol-5D health survey (EQ-5D). Substantial clinical benefit (SCB) thresholds were determined by performing receiver operating curve (ROC) analysis using the NASS patient satisfaction score as an anchor. RESULTS: The mean age was 60 years (range 21-80). Fusion was performed over an average of 8 levels. Osteotomies performed included posterior column osteotomies in 53 patients (77%), pedicle subtraction osteotomies in 12 patients (17%), and vertebral column resection in 7 patients (10%). Significant improvements (p!0.01) were found in all PROs assessed except SF-12 MCS (mean improvement: BP-NRS [3], LP-NRS [2], ODI [14], SF-12 PCS [8], SF-12 MCS [1, p50.60] EQ-5D [0.2]. Surgery met patient expectations in 42 (61%) cases based on NASS Satisfaction Index. Substantial clinical benefit thresholds were 5.0 for BP-NRS, 2.0 for LP-NRS, 18 for ODI, 5.2 for SF-12 PCS, 3.5 for SF-12 MCS, and 0.09 for EQ-5D. There was a significant difference (p!0.01) seen in all PROs assessed for patients satisfied versus not satisfied. CONCLUSIONS: Thresholds of substantial clinical benefit following surgical procedures are important to understand, as they define the magnitude of improvement that patients recognize as significant postoperative improvement. This study provides these thresholds in adult patients undergoing scoliosis deformity surgery. FDA DEVICE/DRUG STATUS: This abstract does not discuss or include any applicable devices or drugs.