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Study Design: A retrospective observational study of a cohort of consecutive patients., Objective: The objective of this study was to determine the correlations between clinical outcomes of spinal surgery to correct adult spinal deformity (ASD) including mechanical complications and coronal malalignment and clarify the risk factors for postoperative coronal malalignment., Summary of Background Data: Despite the coronal malalignment seen regularly in adult patients who have undergone spinal surgery to correct spinal deformity, the associations between coronal malalignment, and clinical outcomes including mechanical complications after the surgery have remained unclear until now. To understand the associations between coronal malalignment and outcomes of surgery to correct ASD, and risk factors for postoperative coronal malalignment has substantial clinical importance., Materials and Methods: We included data from 121 consecutive patients who had undergone spinal surgery to correct ASD and were followed up for a minimum of 2 years. Iliac screws were used for pelvic fixation in all cases. The coronal balance was defined as the horizontal distance between the midpoint of C7 and the center of the sacrum on the coronal plane, and coronal malalignment was defined as when the absolute coronal balance was >20 mm. Preoperative radiographic parameters, surgical features, and clinical outcomes including mechanical complications were compared between groups of patients with coronal balance and those with malalignment. Univariate and multivariate regression analysis were used to clarify risk factors for postoperative coronal malalignment., Results: Postoperative coronal malalignment had no significant association with the clinical outcome as evaluated by a Roland-Morris Disability Questionnaire and Oswestry Disability Index but had a significant association with the frequency of rod fracture. A large preoperative coronal imbalance (malalignment), L5 coronal tilt angle, and use of lateral lumbar interbody fusion were found as risk factors for postoperative coronal malalignment., Conclusion: Postoperative coronal malalignment had no significant association with the clinical outcome as evaluated by the Oswestry Disability Index and Roland-Morris Disability Questionnaire but was significantly associated with the frequency of rod fracture., Level of Evidence: Level III.

Study Design: A multicenter, randomized, open-label, parallel-group trial., Objective: To investigate interbody bone fusion rates in titanium-coated polyetheretherketone (TiPEEK) and polyetheretherketone (PEEK) cages after posterior lumbar interbody fusion (PLIF) surgery., Summary of Background Data: Previous clinical studies have not revealed any significant difference in bone fusion rates between TiPEEK and PEEK cages., Methods: During one-level PLIF surgery, 149 patients (84 men, 65 women, mean age 67 yr) were randomly allocated to use either a TiPEEK cage (n = 69) or PEEK cage (n = 80). Blinded radiographic evaluations were performed using computed tomography and assessed by modified intention-to-treat analysis in 149 cases and per-protocol analysis in 143 cases who were followed for 12 months. Clinical outcomes were assessed using the Japanese Orthopaedic Association Back Pain Evaluation Questionnaire and the Oswestry Disability Index., Results: The interbody union rate at 12 months after surgery was 45% owing to a very strict definition of bone fusion. The rates of bone fusion were significantly higher at 4 and 6 months after surgery in the TiPEEK group than in the PEEK group in the unadjusted modified intention-to-treat analysis and were significantly higher at 6 months in the unadjusted per-protocol analysis. Binary logistic regression analysis adjusted for sex, age, body mass index, bone mineral density, and surgical level showed that using a TiPEEK cage (odds ratio, 2.27; 95% confidence interval: 1.09-4.74; P = 0.03) was independently associated with bone fusion at 6 months after surgery. Japanese Orthopaedic Association Back Pain Evaluation Questionnaire and Oswestry Disability Index results improved postoperatively in both groups., Conclusion: Using the TiPEEK cage for PLIF enabled the maintenance of better bone fusion to the endplate than using the PEEK cage at 6 months after the surgery. Our findings suggest the possibility of an earlier return to rigorous work or sports by the use of TiPEEK cage., Level of Evidence: 1.

Study Design: Retrospective observational study., Objective: The study objectives were to: (1) determine radiographically which spinal malalignment parameters predominantly influence the risk of gastroesophageal reflux disease (GERD); (2) evaluate the outcome of GERD 2 years after surgery for adult spinal deformity (ASD); and (3) clarify key factors that influence the improvement of postoperative GERD in ASD., Summary of Background Data: Spinal deformity is reported to be involved in the pathology of GERD. Our previous study found that approximately 50% of patients treated surgically for ASD had GERD symptoms. However, the postoperative progress of GERD and the key factors that influence the improvement of postoperative GERD are largely unknown., Methods: Ninety-two patients with ASD treated with thoracolumbar corrective surgery and followed up for a minimum of 2 years were enrolled. All patients were asked to complete the Frequency Scale for Symptoms of GERD (FSSG) questionnaire preoperatively and at 1 and 2 years after surgery. GERD was diagnosed by FSSG score more than 8 points. Before, and at 1 and 2 years after surgery, full-length lateral radiographs were taken and radiographic parameters were obtained., Results: Patients were classified into two groups based on GERD symptoms, with 47 (51.1%) in the GERD+ group. Among parameters assessed, only thoracolumbar kyphosis (TLK) was significantly greater in the GERD+ group than in the GERD- group. The FSSG score improved significantly 1 year after surgery, but no significant difference was found between groups at 2 years. A significant correction loss of TLK was observed 2 years after surgery. There was a significant highly positive correlation between the FSSG score and TLK at 2 years after surgery., Conclusion: GERD improved with correction of the spinal deformity but significant correction loss of the TLK even within the fusion presumably due to subsidence or proximal junctional kyphosis resulted in a cessation of that improvement over time., Level of Evidence: 3.

Study Design: Multicenter, prospective randomized study., Objective: Evaluate the impact of weekly teriparatide (WT) and bone contact (BC) status of grafted bone in patients recovering from multilevel lumbar interbody fusion (M-LIF)., Summary of Background Data: WT has been reported to significantly improve bone fusion following posterior or transforaminal interbody fusion in osteoporosis patients., Methods: Patients older than 50 years and osteoporotic were recruited. We defined the fusion of two or more consecutive intervertebral levels as M-LIF. All patients were instrumented with pedicle, iliac, or S-2 alar iliac screws after transplanting cages and autogenous bone between vertebral bodies. After surgical indication for M-LIF, the subjects were randomly allocated to receive either subcutaneous WT from 1 week to 6 months postoperatively (WT arm, N = 50) or a bisphosphonate (BP; BP arm, N = 54). Blinded radiological evaluations were performed using computed tomography (CT). Evaluation of bone fusion was performed at the intervertebral disc located at the bottom of the fixed range. The degree of bone fusion was calculated as a score from 2 to 6 points, with 2 defined as complete fusion. Bone fusion rate was also compared at 6 months postoperatively based on BC status of the grafted bone on CT immediately after surgery., Results: Mean bone fusion score at 6 months postoperatively was 3.9 points in the WT group and 4.2 points in the BP group. The bone fusion rate at 6 months postoperatively tended to be higher in the WT group (46.8% vs. 32.7% in the BP group). The 6-month postoperative fusion rate of immediately postoperative of BC+ patients was significantly higher than that of BC- patients (47.4% vs. 9.5%)., Conclusion: In M-LIF, there were no significant differences in bone fusion score between WT- and BP-treated patients. In contrast, BC status immediately postoperatively had a major impact on 6-month bone fusion., Level of Evidence: 1.

Purpose: The global alignment and proportion (GAP) score was recently developed to consider proportional analysis of spinopelvic alignment and has been indicated for setting surgical goals to decrease the prevalence of mechanical complications. The goal of this study was to clarify the limitations and problems with spinal corrective surgery with minimally invasive lateral lumbar interbody fusion (LLIF) without osteotomy using GAP score, and to establish a preoperative radiographical evaluation to understand the necessity for three-column osteotomy., Methods: We included data from 57 consecutive patients treated with spinal corrective surgery with LLIF and without Schwab grade 3-6 osteotomy for ASD. To evaluate flexibility of the pelvis and lumbar spine, we examined full-length lateral radiographs with patients standing and prone. Correlations between pre- and postoperative radiographic parameters and GAP score were determined., Results: Most patients achieved a sufficiently ideal lumbar lordosis (87.7%), but ideal sacral slope (SS) was achieved in only 50.8% of patients. Preoperative prone SS showed a significant positive correlation with postoperative SS and a significant negative correlation with GAP score. Patients whose preoperative prone SS was larger than pelvic incidence × 0.59-7.5 tended to achieve proportioned spinopelvic alignment by using LLIF., Conclusions: The cause of poor outcome of GAP score for ASD corrective surgery with LLIF without osteotomy is a postoperative small SS. Preoperative prone SS is useful for predicting postoperative SS. When preoperative SS in prone patients is relatively small to ideal as calculated using PI, osteotomy or other correctors should be considered to achieve satisfactory spinopelvic parameters., Level of Evidence: III. These slides can be retrieved under Electronic Supplementary Material.

Study Design: Case report., Objective: Describe the clinical and radiological outcomes of a patient with a piezo-type mechanosensitive ion channel component 2 (PIEZO2)-deficient arthrogryposis receiving surgery for severe kyphoscoliosis., Summary of Background Data: Spinal deformity is a characteristic feature of arthrogryposis due to PIEZO2 gene deficiency, for which surgical correction is indicated when the deformity is progressive to avoid neurological deficits and respiratory impairment. However, there exist few reports on the surgical treatment of spinal deformity in PIEZO2-deficient arthrogryposis, and no therapeutic standards have been established., Methods: We retrospectively reviewed a case of proximal junctional kyphosis after posterior spinal fusion for severe kyphoscoliosis in PIEZO2-deficient arthrogryposis., Results: The patient was a 13-year-old girl with PIEZO2-deficient arthrogryposis who underwent posterior spinal fusion with an all-pedicle screw construct from T2 to L2 for a preoperative main thoracic curve Cobb angle of 78° and thoracic kyphotic angle of 83°. Postoperative Cobb angle of the main thoracic curve and thoracic kyphotic angle were improved at 11° and 34°, respectively. Although revision surgery was required for neurological deficits from proximal junctional kyphosis, she could walk with a crutch and improvements in clinical questionnaire scores were noted at 2 years and 3 months after surgery., Conclusion: Based on the present case, posterior spinal fusion represents a good treatment option for severe spinal deformity in PIEZO2-deficient arthrogryposis. Careful consideration of fusion level is needed to prevent proximal junctional kyphosis., Level of Evidence: 5.

Study Design: A retrospective observational study., Objectives: To (1) compare skeletal muscle mass index (SMI) and the composition of paraspinal muscles between patients with lumbar spinal stenosis (LSS) and adult spinal deformity (ASD) who underwent spinal surgery, (2) determine whether paraspinal muscles influence low back pain in ASD, and (3) ascertain which radiographic spinal parameters of ASD are predominantly influenced by paraspinal muscles., Summary of Background Data: Relative muscle cross-sectional area (rmCSA; total CSA minus intramuscular fat CSA) determined using magnetic resonance imaging (MRI) is useful when evaluating not only muscle volume but also muscle quality. Currently, no study has examined paraspinal muscles using rmCSAs to determine which radiographic spinopelvic parameters identified in patients with severe spinal deformities make them candidates for thoracolumbar corrective surgery., Materials and Methods: Paraspinal muscle rmCSAs were calculated using preoperative T2-weighted MRIs at the L3/4 axial level. Whole-body bone mineral density and lean, soft tissue mass were measured using dual-energy x-ray absorptiometry. SMI was calculated as appendicular (upper and lower limbs) lean, soft tissue mass (kg/m). Correlations between low back pain according to the Roland-Morris Disability Questionnaire, Oswestry Disability Index, spinopelvic parameters, and rmCSA were evaluated for 110 consecutive patients with ASD and 50 consecutive patients with LSS who underwent spinal surgery., Results: There was no significant difference in the total SMI and morbidity rate of sarcopenia between patients with ASD and LSS. A significant negative correlation between Oswestry Disability Index and the rmCSA of the multifidus muscles and the rmCSA of the erector muscles were observed. There was a significant positive correlation between pelvic tilt/sacral slope and multifidus/erector muscles., Conclusions: Paraspinal muscles evaluated with MRI were more significantly associated with the pathology of ASD compared with appendicular skeletal muscle evaluations with dual-energy x-ray absorptiometry. The present study indicates that multifidus and erector muscles significantly influenced the maintenance of the pelvic alignment., Level of Evidence: Level III.

Purpose: This study examined for factors contributing to postoperative pain in adolescent idiopathic scoliosis (AIS), including those of sagittal alignment and lumbar disc degeneration., Methods: A total of 101 consecutive patients who underwent posterior spinal fusion for AIS and who were followed for a minimum of 2 years were included in this investigation. We assessed Lenke curve type, age, Risser grade, body mass index (BMI), radiographic parameters, lumbar disc degeneration, correction rate, number of fused vertebrae, lowest instrumented vertebra, preoperative SRS-22r survey mental health score, and pre- and postoperative SRS-22r survey pain scores. Univariate and multivariate general linear models were employed to identify factors associated with pain 2 years after AIS surgery., Results: In multivariate analysis, patients with a lower preoperative pain score (i.e. higher pain) (P < 0.01) or higher postoperative T5-12 kyphotic angle (P = 0.02) had a worsened pain score 2 years after surgery. There were no remarkable differences for Lenke curve type, age, BMI, coronal radiographic parameters, lumbar disc degeneration, correction rate, number of fused vertebrae, or lowest instrumented vertebra. Higher preoperative Risser grade (P = 0.01) and lower preoperative SRS-22r mental health score (P < 0.01) were significantly related to a diminished preoperative SRS-22r pain score., Conclusion: While preoperative lumbar disc degeneration was not associated with pre- or postoperative pain in AIS, higher preoperative pain and higher postoperative T5-12 kyphotic angle had significant associations with augmented postoperative pain. Higher preoperative pain was related to increased Risser grade and lower mental health score. These slides can be retrieved under Electronic Supplementary Material.

Purpose: Long fusion to the sacrum with iliac screws can decrease pelvic incidence (PI). Considering the physiological range of movement of the sacroiliac joint, this decrease may be relatively extreme. The purpose of the study was to determine changes in pelvic morphology after orthopedic surgery using long fusion with iliac screws, and examine the relationship between changes in PI and morphology., Methods: We included data from 80 consecutive patients who underwent corrective surgery for adult spine deformity (72 female and 8 male; mean age: 71.1 years). We examined preoperative and early postoperative full-standing X-ray images and pelvic computed tomography of the patients and compared the following: (1) pre- and postoperative pelvic measurements including PI, (2) correlations between change of PI, iliac angle, and distance between posterior superior iliac spines (DPSIS)., Results: After surgery, PI decreased significantly (- 3.3°, 95% confidence interval [95%CI] - 4.3° to - 2.3°, P < 0.01) and DPSIS increased significantly (+ 2.7 mm, 95%CI 1.7 to 3.8 mm, P < 0.01). By contrast, iliac angle decreased significantly (- 1.4°, 95%CI - 2.1° to - 0.7°, P < 0.01). There were significant correlations between changes of PI and iliac angle (r = 0.34, P < 0.01) and between changes of DPSIS and iliac angle (r =  - 0.44, P < 0.01)., Conclusions: We observed changes in pelvic morphology associated with spinal pelvic correction surgery using iliac screws and changes in pelvic incidence related to these changes in pelvic morphology. We recommend selecting pelvic anchors and surgical procedures considering potential movement of the sacroiliac joint. These slides can be retrieved under Electronic Supplementary Material.

Introduction: (1) To evaluate the influence of pedicle screw loosening on clinical outcomes; (2) to clarify the association between the pull-out length and screw loosening 1 year after surgery; and (3) to determine radiographically which screw parameters predominantly influence the pull-out resistance of screws., Methods: We analyzed 32 consecutive patients who underwent minimally invasive lumbar or thoracic spinal stabilization by intraoperative three-dimensional computed tomography (CT)-guided navigation without anterior reconstruction and were followed up for 1 year. The screw pull-out length was measured on axial CT images obtained both immediately after screw insertion and postoperatively. Loosening of screws and clinical outcomes were evaluated radiographically, clinically, and by CT 1 year after surgery., Results: There were no significant differences in the mean age, sex, bone mineral density, mean stabilized length, and smoking habits of patients with (+) or without (-) loosening. The Oswestry Disability Index and the lumbar visual analog scale 1 year after surgery were significantly higher in patients with loosening (+) than in those without (-). The overall pedicle screw pull-out rate was 16.2% (47/290) of screws and the overall screw loosening rate was 15.2% (44/290) of screws. Screws with loosening (+) had significantly lower (axial) trajectory angles and higher screw pull-out lengths than those without (-). Approximately 82% of loosened screws had been pulled out during rod connection., Conclusions: A lower axial trajectory and an increased screw pull-out length after rod reduction are crucial risk factors for screw loosening., Competing Interests: Conflicts of Interest: The authors declare that there are no relevant conflicts of interest.

Background Context: There is little information on the relationship between magnetic resonance imaging (MRI) T2-weighted high signal change (T2HSC) in the spinal cord and surgical outcome for cervical myelopathy. We therefore examined whether T2HSC regression at 1 year postoperatively reflected a 5-year prognosis after adjustment using propensity scores for potential confounding variables, which have been a disadvantage of earlier observational studies., Purpose: The objective of this study was to clarify the usefulness of MRI signal changes for the prediction of midterm surgical outcome in patients with cervical myelopathy., Study Design/setting: This is a retrospective cohort study., Patient Sample: We recruited 137 patients with cervical myelopathy who had undergone surgery between 2007 and 2012 at a median age of 69 years (range: 39-87 years)., Outcome Measures: The outcome measures were the recovery rates of the Japanese Orthopaedic Association (JOA) scores and the visual analog scale (VAS) scores for complaints at several body regions., Materials and Methods: The subjects were divided according to the spinal MRI results at 1 year post surgery into the MRI regression group (Reg+ group, 37 cases) with fading of T2HSC, or the non-regression group (Reg- group, 100 cases) with either no change or an enlargement of T2HSC. The recovery rates of JOA scores from 1 to 5 years postoperatively along with the 5-year postoperative VAS scores were compared between the groups using t test. Outcome scores were adjusted for age, sex, diagnosis, symptom duration, and preoperative JOA score by the inverse probability weighting method using propensity scores., Results: The mean recovery rates in the Reg- group were 35.1%, 34.6%, 27.6%, 28.0%, and 30.1% from 1 to 5 years post surgery, respectively, whereas those in the Reg+ group were 52.0%, 52.0%, 51.1%, 49.0%, and 50.1%, respectively. The recovery rates in the Reg+ group were significantly higher at all observation points. At 5 years postoperatively, the VAS score for pain or numbnessin the arms or hands of the patients in the Reg+ group (24.7 mm) was significantly milder than that of the patients in the Reg- group (42.2 mm)., Conclusions: Spinal T2HSC improvement at 1 year postoperatively may predict a favorable recovery until up to 5 years after surgery., (Copyright © 2017 Elsevier Inc. All rights reserved.)

The patient was an 81-year-old man who visited our hospital for paralysis of the lower half of the body. He was suspected as having a spinal tumor by computed tomography and magetic resonance imaging, and also as having prostate cancer based on a high prostate specific antingen level. A prostate needle biopsy, thoracic spinal fusion and posterior decompression were performed. The patient was diagnosed as having prostate cancer and primary spinal malignant lymphoma. Hormone therapy and chemotherapy were started for the prostate cancer and primary spinal malignant lymphoma, respectively. However, the patient died of a complication from chemotherapy.