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OBJECTIVE Proximal junctional kyphosis (PJK), which can worsen a patient’s quality of life, is a common complication following the surgical treatment of adult spinal deformity (ASD). Although various radiographic parameters have been proposed to predict the occurrence of PJK, the optimal method has not been established. The present study aimed to investigate the usefulness of the T1–L1 pelvic angle in the standing position (standing TLPA) for predicting the occurrence of PJK. METHODS The authors retrospectively extracted data for patients with ASD who underwent minimum 5-level fusion to the pelvis with upper instrumented vertebra between T8 and L1. In the present study, PJK was defined as ≥ 10° progression of the proximal junctional angle or reoperation due to progressive kyphosis during 1 year of follow-up. The following parameters were analyzed on whole-spine standing radiographs: the T1–pelvic angle, conventional thoracic kyphosis (TK; T4–12), whole-thoracic TK (T1–12), and the standing TLPA (defined as the angle formed by lines extending from the center of T1 and L1 to the femoral head axis). A logistic regression analysis and a receiver operating characteristic curve analysis were performed. RESULTS A total of 50 patients with ASD were enrolled (84% female; mean age 74.4 years). PJK occurred in 19 (38%) patients. Preoperatively, the PJK group showed significantly greater T1–pelvic angle (49.2° vs 34.4°), conventional TK (26.6° vs 17.6°), and standing-TLPA (30.0° vs 14.9°) values in comparison to the non-PJK group. There was no significant difference in the whole-thoracic TK between the two groups. A multivariate analysis showed that the standing TLPA and whole-thoracic TK were independent predictors of PJK. The standing TLPA had better accuracy than whole-thoracic TK (AUC 0.86 vs 0.64, p = 0.03). The optimal cutoff value of the standing TLPA was 23.0° (sensitivity 0.79, specificity 0.74). Using this cutoff value, the standing TLPA was the best predictor of PJK (OR 8.4, 95% CI 1.8–39, p = 0.007). CONCLUSIONS The preoperative standing TLPA was more closely associated with the occurrence of PJK than other radiographic parameters. These results suggest that this easily measured parameter is useful for the prediction of PJK.

Background Decline in cognitive function after night shift has been well described. However, in the field of spine surgery, the effect of surgeons’ sleeplessness on patient outcome is unclear. The purpose of this study was to investigate whether the risk of perioperative complications in elective thoracolumbar spine surgery could be higher if the surgeon had been on a night shift prior to the day of surgery. Methods We performed a retrospective review of patients who underwent elective posterior thoracolumbar spine surgery, as indicated in medical records, between March 2015 and September 2018. In total, 1189 patients were included and divided into two groups: the post-nighttime (n = 110) and control groups (n = 1079). A post-nighttime case was defined when the operating surgeon was on nighttime duty on the previous night, and other cases were defined as controls. We evaluated the incidence of perioperative complications (surgical site infection, postoperative hematoma, postoperative paralysis, nerve root injury, and dural tear) in both groups. Results Overall, we found no significant difference in the major or minor perioperative complication rates between the two groups, but according to the type of complication, the incidence rate of dural tear tended to be higher in the post-nighttime group (13.6% vs 8.2%, P = 0.074). Multivariate analysis showed that post-nighttime status was an independent risk factor of dural tear (adjusted odds ratio, 2.02; 95% confidence interval [CI], 1.10–3.70; P = 0.023). After stratification by surgical complexity, post-nighttime status was an independent risk factor of dural tear only in the surgeries of 3 levels or more (adjusted odds ratio, 2.81; 95% CI, 1.18–6.67; P = 0.019). Conclusions Post-nighttime status was generally not a risk factor of perioperative complications in elective posterior thoracolumbar spine surgeries, but was an independent risk factor of dural tear, especially in complex cases.

Hemodialysis has been reported to be associated with retro-odontoid pseudotumor (ROP), but its clinical characteristics have not been well described. The purpose of the present study was to investigate the factors associated with ROP in hemodialysis patients.A retrospective clinical study of hemodialysis patients was conducted with the evaluation of computed tomography and magnetic resonance imaging of cervical spinal lesions at a single institution from 2012 to 2020. The patients' characteristics and radiographic findings were assessed. A case-control analysis was performed between patients with ROP (ROP group) and patients without ROP (control group).We analyzed 46 patients. The mean duration of hemodialysis (± standard deviation) was 21.5 ± 11.8 years. The mean retro-odontoid soft tissue thickness was 4.3 ± 0.3 mm and was correlated with the duration of hemodialysis (r = 0.46, P0.01). Thirty patients (65.2%) were included in the ROP group. The ROP group showed a significantly longer duration of hemodialysis (24.9 ± 11.2 years vs. 15.2 ± 10.3 years, P0.01) and a higher incidence of osteolytic lesions in the atlantoaxial joint compared with the control group (60.0% vs. 18.8%, P0.01). Logistic regression analysis revealed the atlantoaxial osteolytic lesions are associated with retro-odontoid pseudotumor in hemodialysis patients (odds ratio, 5.1; 95% confidence interval, 1.1-24.2; P = 0.04).The existence of ROP in hemodialysis patients was associated with osteolytic lesions in the atlantoaxial joint. The finding of atlantoaxial erosive lesions in long-term hemodialysis patients requires spine surgeons to carefully evaluate the presence of ROP.

Retrospective observational study.This study examined associated factors for the improvement in spinal imbalance following decompression surgery without fusion.Several reports have suggested that decompression surgery without fusion may have a beneficial effect on sagittal balance in patients with lumbar spinal stenosis (LSS) through their postoperative course. However, few reports have examined the association between an improvement in sagittal imbalance and spinal sarcopenia.We retrospectively reviewed 92 patients with LSS and a preoperative sagittal vertical axis (SVA) more than or equal to 40 mm who underwent decompression surgery without fusion at a single institution between April 2017 and October 2018. Patients' background and radiograph parameters and the status of spinal sarcopenia, defined using the relative cross-sectional area (rCSA) of the paravertebral muscle (PVM) and psoas muscle at the L4 caudal endplate level, were assessed. We divided the patients into two groups: those with a postoperative SVA less than 40 mm (balanced group) and those with a postoperative SVA more than or equal to 40 mm (imbalanced group). We then compared the variables between the two groups.A total of 29 (31.5%) patients obtained an improved sagittal imbalance after decompression surgery. The rCSA-PVM in the balanced group was significantly higher than that in the imbalanced group (P = 0.042). The preoperative pelvic incidence (PI)-lumbar lordosis (LL) mismatch (P = 0.048) and the proportion with compression vertebral fracture (P = 0.028) in the balanced group were significantly lower than those in the imbalanced group. A multivariate logistic regression analysis identified PI-LL less than or equal to 10° and rCSA-PVM more than or equal to 2.5 as significant associated factor for the improvement in spinal imbalance following decompression surgery.A larger volume of paravertebral muscles and a lower PI-LL were associated with an improvement in sagittal balance in patients with LSS who underwent decompression surgery.Level of Evidence: 3.

While a change in the pelvic incidence (PI) after long spine fusion surgery has been reported, no studies have examined the change in the PI on the operating table. The present study examined the PI-change on the operating table and elucidated the patients’ background characteristics associated with this phenomenon. This study included patients who underwent lumbar posterior spine surgery and had radiographs taken in a full-standing position preoperatively and a pelvic lateral radiograph in the prone position in the operative room. The patients with PI-change on the operating table (PICOT; PICOT group) and without PICOT (control group) were compared for their background characteristics and preoperative radiographic parameters. There were 128 eligible patients (62 males, 66 females) with a mean age (± standard deviation) of 69.9 ± 11.7 (range: 25–93) years old. Sixteen patients (12.5%) showed a decrease in the PI > 10°, which indicated placement in the PICOT group. The preoperative lumbar lordosis (LL) and PI-LL in the PICOT group were significantly worse than those in the control group (LL: 20.8 ± 16.6 vs. 30.6 ± 16.2, p = 0.0251, PI-LL: 33.9 ± 19.0 vs. 17.3 ± 14.8, p

Study Design. Retrospective cohort study. Objective. To investigate the effects of dynamic stabilization with sublaminar taping (ST) on the upper segment adjacent to posterior lumbar interbody fusion (PLIF). Summary of Background Data. Hybrid procedures such as dynamic stabilization for adjacent segment in addition to spinal fusion have been developed for reduction of the mechanical stress and prevention of adjacent segment pathology (ASP). However, a few reports are available on hybrid procedures and their efficacy is still controversial. Methods. Of the 116 patients who underwent L4/5 PLIF between August 2006 and September 2012, 76 patients with minimum 2-year follow up were included in this study. Fifty three patients underwent L4/5 PLIF with hybrid procedure using ST on L3 lamina (group U), and 23 patients underwent conventional L4/5 PLIF (group C). The adjacent segment degeneration (ASDeg) was determined by measurements of radiograph, computed tomography, and magnetic resonance imaging; the adjacent segment disease (ASDis) was evaluated on medical records. Results. The incidence of ASDeg at L3/4 segment of group U (3.7%) was significantly less than that of group C (30.4%) (P = 0.003), although there were no significant differences at L2/3 (group U, 7.5%; group C, 13%) or L5/S1 segment (group U, 5.7%; group C, 8.7%). On the other hand, no significant difference was found between two groups in the incidence of ASDis in L2/3 to L5/S1 levels, and no patient underwent reoperation. Bivariable and multivariable logistic regression analyses for L3/4 segment ASDeg revealed that the difference of surgical procedure was the only significant factor. Conclusion. The current study showed that L4/5 PLIF with hybrid procedure using ST on L3 lamina significantly reduced the incidence of L3/4 ASDeg as compared with the conventional L4/5 PLIF without compromising L2/3 or L5/S1 segment. Although further studies and longer follow up are necessary, the hybrid procedure is expected to be effective for preventing ASP. Conclusion. Level of Evidence: 4

Interpretation of thoracic spine radiographs is difficult because they cannot clearly depict the vertebrae due to overlap with soft tissues. This study aimed to evaluate whether thoracic spine radiographs obtained using the energy subtraction method could improve the accuracy of a diagnosis of thoracic osteolytic lesions. The authors analyzed 300 thoracic vertebrae from 25 patients with multiple myeloma who underwent thoracic spine radiography. All patients underwent thoracic spine radiography with 2 views. Two sets of images were prepared: computed radiography images (CR images) acquired using conventional processing parameters; and processed images for specifically visualizing bone, using the energy subtraction method (ES images). The CR images (CR group) and paired CR and ES images (CR+ES group) were interpreted in parallel by 5 orthopedic surgeons. The presence of osteolytic lesions was evaluated for each of the 12 thoracic vertebrae, and the sensitivity and specificity of the method were compared with computed tomography (CT), which is considered the gold standard. Subgroup analysis was also performed based on location. Osteolytic lesions were found on CT in 28 (9.3%) vertebrae of 12 patients. The overall sensitivities and specificities of the CR and CR+ES groups were 17.2% and 54.3%, respectively, and 95.6% and 98.0%, respectively, with statistically significant differences. Subgroup analysis showed particular improvement in the sensitivity for the CR+ES group in the middle thoracic spine compared with that at other locations. Thoracic spine radiographs generated using this method may improve the accuracy of diagnosis of thoracic osteolytic lesions. [ Orthopedics . 2021;44(1):e31–e35.]

The surgical treatment of cervical kyphotic deformity remains challenging. As a surgical method that is safer and avoids major complications, the authors present a procedure of single-stage anterior and posterior fusion to correct cervical kyphosis using anterior interbody fusion cages without plating, as illustrated by three consecutive cases. Case 1 was a 78-year-old woman who presented with a dropped head caused by degeneration of her cervical spine. Case 2 was a 54-year-old woman with athetoid cerebral palsy. She presented with cervical myelopathy and cervical kyphosis. Case 3 was a 71-year-old woman with cervical kyphotic deformity following a laminectomy. All three patients underwent anterior release and interbody fusion with cages and posterior fusion with cervical lateral mass screw (LMS) fixation. Postoperative radiographs showed that correction of kyphosis was 39° in case 1, 43° in case 2, and 39° in case 3. In all three cases, improvement of symptoms was established without major perioperative complications, solid fusion was achieved, and no loss of correction was observed at a minimum follow-up of 61 months. We also report that preoperative total spine sagittal malalignment was improved after corrective surgery for cervical kyphosis and was maintained at the latest follow-up in all three cases. The combination of anterior fusion cages and LMS is considered a safe and effective procedure in cases of severe cervical kyphotic deformity. Preoperative total spine sagittal malalignment improved, accompanied by correction of cervical kyphosis, and was maintained at last follow-up in all three cases.

OBJECTIVEInterbody fusion cages are widely used to achieve initial fixation and secure spinal fusion; however, there are certain technique-related complications. Although anterior cage dislodgement can cause major vascular injury, the incidence is extremely rare. Here, the authors performed a review of anterior cage dislodgement following posterior lumbar interbody fusion (PLIF) surgery.METHODSThe authors retrospectively reviewed the cases of 4625 patients who had undergone PLIF at 6 institutions between December 2007 and March 2015. They investigated the incidence and causes of surgery-related anterior cage dislodgement, salvage mechanisms, and postoperative courses.RESULTSAnterior cage dislodgement occurred in 12 cases (0.26%), all of which were caused by technical errors. In 9 cases, excessive cage impaction resulted in dislodgement. In 2 cases, when the cage on the ipsilateral side was inserted, it interacted and pushed out the other cage on the opposite side. In 1 case, the cage was positioned in an extreme lateral and anterior part of the intervertebral disc space, and it postoperatively dislodged. In 3 cases, the cage was removed in the same operative field. In the remaining 9 cases, CT angiography was performed postoperatively to assess the relationship between the dislodged cage and large vessels. Dislodged cages were conservatively observed in 2 cases. In 7 cases, the cage was removed because it was touching or compressing large vessels, and an additional anterior approach was selected. In 2 patients, there was significant bleeding from an injured inferior vena cava. There were no further complications or sequelae associated with the dislodged cages during the follow-up period.CONCLUSIONSAlthough rare, iatrogenic anterior cage dislodgement following a PLIF can occur. The authors found that technical errors made by experienced spine surgeons were the main causes of this complication. To prevent dislodgement, the surgeon should be cautious when inserting the cage, avoiding excessive cage impaction and ensuring cage control. Once dislodgement occurs, the surgeons must immediately address this difficult complication. First, the possibility of a large vessel injury should be considered. If the patient’s vital signs are stable, the surgeon should continue with the surgery without cage removal and perform CT angiography postoperatively to assess the cage location. Blind maneuvers should be avoided when the surgical site cannot be clearly viewed. When the cage compresses or touches the aortic artery or vena cava, it is better to remove the cage to avoid late-onset injury to major vessels. When the cage does not compress or touch vessels, its removal is controversial. The risk factors associated with performing another surgery should be evaluated on a case-by-case basis.

Background: The interpretation of thoracic spine X-rays is difficult because these images cannot clearly visualize the thoracic spine because of the overlap with soft tissues, such as the heart and pulmonary blood vessels. Thus, to improve the clarity of thoracic spine radiographs using existing radiograph equipment, we have investigated a one-shot energy subtraction method to visualize thoracic spine radiographs. Our objective was to evaluate whether the thoracic spine radiographs generated using this method could visualize the spine more clearly than the corresponding original thoracic spine radiographs. Methods: This study included 29 patients who underwent thoracic spine radiographs. We used a one-shot energy subtraction method to improve the clarity of thoracic spine radiographs. Image definition was evaluated using vertebrae sampled from each region of the thoracic spine. Specifically, these were: Th1, Th5, Th9, and Th12. Image definition was assessed using a three-point grading system. The conventional and processed computed radiographs (both frontal and lateral views) of all 29 study patients were evaluated by 5 spine surgeons. Results: In all thoracic regions on both frontal and lateral views, the processed images showed statistically significantly better clarity than the corresponding conventional images, especially at all sampling sites on the frontal view and T5 and 9 on the lateral view. Conclusions: Thoracic spine radiographs generated using this method visualized the spine more clearly than the corresponding original thoracic spine radiographs. The greatest advantages of this image processing technique were its ability to clearly depict the whole thoracic spine on frontal views and the middle thoracic spine on lateral views. © 2012 The Japanese Orthopaedic Association.

Dialysis patients undergoing orthopaedic surgery are at high risk for postoperative infection. Diagnosis of postoperative infection is difficult in dialysis patients due to presentation of signs and symptoms similar to infection, such as fever and elevated inflammatory marker levels. Neutrophil CD64 expression (CD64), a marker of infection, is upregulated by microbial wall components and several cytokines (interferon-γ and tumor necrosis factor-α). The purpose of this study is to evaluate the usefulness of CD64 for diagnosing postoperative infection in dialysis patients post orthopaedic surgery.Between 2013 and 2014, we prospectively studied 36 dialysis patients (18 men, 18 women; mean age 65.9 years; 49 to 83) who underwent orthopaedic surgery. Dialysis patients were classified into three groups according to their postoperative course as follows; non-infected patients, infection suspected patients, and infected patients. Inflammatory markers such as white blood cell count (WBC), C-reactive protein (CRP) and CD64 were measured before operation and one week after surgery. Using the receiver-operating characteristic (ROC) curve and Akaike's Information Criterion (AIC), the cutoff value of CD64 and CRP was calculated leading to a determination of which inflammatory marker is best accurate for detecting postoperative infection.We found that postoperative CD64 and CRP levels presented a statistically significant difference between infected patients and non-infected patients (p 0.05). Furthermore, comparison of the ROC curve and AIC value between postoperative CD64 and CRP levels exhibited that CD64 was more accurate infectious marker than CRP.CD64 is a useful marker for detecting postoperative infection after orthopaedic surgery in dialysis patients.

Objective To assess the predictive factors for subjective improvement with nonsurgical treatment in consecutive patients with lumbar spinal stenosis (LSS). Materials and Methods Patients with LSS were enrolled from 17 medical centres in Japan. We followed up 274 patients (151 men; mean age, 71 ± 7.4 years) for 3 years. A multivariable logistic regression model was used to assess the predictive factors for subjective symptom improvement with nonsurgical treatment. Results In 30% of patients, conservative treatment led to a subjective improvement in the symptoms; in 70% of patients, the symptoms remained unchanged, worsened, or required surgical treatment. The multivariable analysis of predictive factors for subjective improvement with nonsurgical treatment showed that the absence of cauda equina symptoms (only radicular symptoms) had an odds ratio (OR) of 3.31 (95% confidence interval [CI]: 1.50–7.31); absence of degenerative spondylolisthesis/scoliosis had an OR of 2.53 (95% CI: 1.13–5.65)

STUDY DESIGN A retrospective, radiographical study. OBJECTIVE To evaluate short-term radiological changes in sagittal alignment after lumbar decompression without fusion for lumbar canal stenosis. SUMMARY OF BACKGROUND DATA Although the importance of global sagittal balance is underscored recently, little is known about the changes in sagittal alignment after lumbar canal decompression. METHODS We retrospectively reviewed 88 patients who underwent lumbar decompression without fusion at a single institution between November 2008 and May 2013, with a minimum follow-up of 5 months. Standing radiographs at the preoperative period and the final follow-up were assessed. Radiological parameters included the sagittal vertical axis (SVA), lumbar lordosis (LL), pelvic tilt, pelvic incidence (PI), occipital 7th cervical angle, and thoracic kyphosis, which were measured by 2 spine surgeons. The Zurich Claudication Questionnaire and visual analogue scale scores were obtained to assess the patient-based clinical outcomes. RESULTS Both LL and thoracic kyphosis significantly increased postoperatively, whereas SVA, PI-LL (PI minus LL), and pelvic tilt significantly decreased (P

血液透析患者の脊椎合併症に対し手術療法を施行した14例 (頸椎7例, 腰椎7例) のうち, 圧迫性脊髄症または馬尾・神経根症の原因が, 主として脊柱管内靱帯および硬膜外腔のアミロイド沈着によると診断された6例 (頸椎4例, 腰椎2例) について検討した. 年齢は51歳から68歳 (平均58.5歳) で, 透析歴は15年から20年 (平均17.4年) と長期化していた. 頸部脊髄症を呈した4例では, MRIとCTミエログラムにて, 頸椎後縦靱帯肥厚と黄色靱帯肥厚が認められた. いずれも脊柱管拡大術により, 神経症状の改善を得た. 手術所見では, 黄色靱帯肥厚と硬膜外腔のアミロイド沈着を認め, 硬膜管は黄色靱帯と癒着していた. 組織学的には黄色靱帯内にcongo red染色と抗β2-microglobulin陽性の多量のアミロイド沈着が証明された.腰部脊柱管狭窄を呈した2例でも, アミロイド沈着による黄色靱帯の著明な肥厚により硬膜管が絞扼されており, 椎弓切除と黄色靱帯の切除により軽快した.長期透析例では, アミロイド沈着による後縦靱帯・黄色靱帯肥厚が頸部脊髄症や腰部脊柱管狭窄症の原因として重要である. 本疾患では単純X線所見は通常正常であり, 破壊性脊椎関節症とは異なった疾患群として注目すべきである.

Computed radiography (CR) has many advantages compared with conventional radiographs, especially in image processing. Although CR is being used in chest radiography and mammography, it has not been applied to spine imaging. The purposes of this study were to formulate a set of new CR processing parameters and to test whether the resultant whole-spine radiographs visualized the spine more clearly than conventional images. This study included 29 patients who underwent whole-spine radiographs. We used 3 image processing methods to improve the clarity of whole-spine radiographs: gradation processing, dynamic range control processing, and multi-objective frequency processing. Radiograph definition was evaluated using vertebrae sampled from each region of the whole spine, specifically C4, C7, T8, T12, and L3; evaluation of the lateral view also included the sacral spine and femoral head. Image definition was assessed using a 3-point grading system. The conventional and processed CR images (both frontal and lateral views) were evaluated by 5 spine surgeons. In all spinal regions on both frontal and lateral views, the processed images showed statistically significantly better clarity than the corresponding conventional images, especially at T12, L3, the sacral spine, and the femoral head on the lateral view. Our set of new CR processing parameters can improve the clarity of whole-spine radiographs compared with conventional images. The greatest advantage of image processing was that it enabled clear depiction of the thoracolumbar junction, lumbar vertebrae, sacrum, and femoral head in the lateral view.

STUDY DESIGN Randomized controlled trial. OBJECTIVE To examine the effect of limaprost, an oral prostaglandin (PG) E1 derivative, on health-related quality of life (HRQOL) in patients with symptomatic lumbar spinal stenosis (LSS), compared to etodolac, a NSAID. SUMMARY OF BACKGROUND DATA Limaprost, an oral PGE1 derivative, was developed in Japan to treat numerous ischemic symptoms of thromboangiitis obliterans (TAO) and LSS. Previous studies have demonstrated the effectiveness of limaprost in the symptoms in patients with LSS. However, the evidence for effect on patient-reported outcomes, such as patient's HRQOL or satisfaction, is limited. METHODS This study was conducted at 4 study sites in Japan. Briefly, inclusion criteria were: age between 50 and 85 years; presence of both neurogenic intermittent claudication (NIC) and cauda equina symptoms (at least presence of bilateral numbness in the lower limbs); and MRI-confirmed central stenosis with acquired degenerative LSS. Limaprost (15 microg/d) or etodolac (400 mg/d) was administered for 8 weeks. The primary outcome was Short Form (SF)-36, and the secondary outcomes were the verbal rating scale of low back pain and leg numbness, walking distance, subjective improvement, and satisfaction. RESULTS A total of 79 participants were randomized (limaprost:etodolac = 39:40). Thirteen participants withdrew from the study (limaprost:etodolac = 5:8) and 66 completed the study (limaprost:etodolac = 34:32). Comparisons showed that limaprost resulted in significantly greater improvements in the SF-36 subscales of physical functioning, role physical, bodily pain, vitality, and mental health. Limaprost was also significantly better than etodolac for leg numbness, NIC distance, and subjective improvement and satisfaction. In the subgroup analysis stratified by symptom severity, limaprost seemed more effective for milder symptoms. No serious adverse effects were reported in either treatment group. CONCLUSION In this study, limaprost was found to be efficacious on most outcome measures, such as HRQOL, symptoms and subjective satisfaction, in LSS patents with cauda equina symptoms.

Objectives The Japanese Orthopaedic Association (JOA) score is widely used to assess the severity of clinical symptoms in patients with cervical compressive myelopathy, particularly in East Asian countries. In contrast, modified versions of the JOA score are currently accepted as the standard tool for assessment in Western countries. The objective of the present study is to compare these scales and clarify their differences and interchangeability and verify their validity by comparing them to other outcome measures. Materials and Methods Five institutions participated in this prospective multicenter observational study. The JOA and modified JOA (mJOA) proposed by Benzel were recorded preoperatively and at three months postoperatively in patients with cervical compressive myelopathy who underwent decompression surgery. Patient reported outcome (PRO) measures, including Japanese Orthopaedic Association Cervical Myelopathy Evaluation Questionnaire (JOACMEQ), the Short Form-12 (SF-12) and the Neck Disability Index (NDI), were also recorded. The preoperative JOA score and mJOA score were compared to each other and the PRO values. A Bland-Altman analysis was performed to investigate their limits of agreement. Results A total of ninety-two patients were included. The correlation coefficient (Spearman’s rho) between the JOA and mJOA was 0.87. In contrast, the correlations between JOA/mJOA and the other PRO values were moderate (|rho| = 0.03 – 0.51). The correlation coefficient of the recovery rate between the JOA and mJOA was 0.75. The Bland-Altman analyses showed that limits of agreement were 3.6 to -1.2 for the total score, and 55.1% to -68.8% for the recovery rates. Conclusions In the present study, the JOA score and the mJOA score showed good correlation with each other in terms of their total scores and recovery rates. Previous studies using the JOA can be interpreted based on the mJOA; however it is not ideal to use them interchangeably. The validity of both scores was demonstrated by comparing these values to the PRO values.

In degenerative lumbar spinal diseases with low back pain and leg pain, the indications for lumbar spinal fusion are not clear. It is unclear for the following reasons. The definition of instability is not clear. And it is also difficult to observe the exact source of the low back pain. In addition, there are limited numbers of randomized prospective study about the usefulness of spine fusion. Controversy still exists for when spinal instrumentation should be used. A spinal surgeon performs a posterolateral fusion or a posterior interbody fusion with or without instrumentation, mainly based on his experience and belief.

The clinical, radiologic, and operative findings, and clinical results in 26 cases of foraminal nerve root involvement, each treated by variable operative procedures for an existing pathologic condition, were studied. These 26 cases consisted of 8 intraforaminal or extraforaminal lumbar disc herniations and 18 foraminal nerve root entrapments. The cases with an extreme lateral lumbar disc herniation underwent lateral fenestration or osteoplastic hemilaminectomy without concomitant spinal fusion, and showed excellent operative results. A sufficient selective decompression was achieved with a good clinical result in the cases of lumbar spondylosis without preoperative spinal instability, by lateral fenestration or osteoplastic hemilaminectomy. This result suggests that the selective decompression procedure is recommended for cases with reliable preoperative diagnoses. When an intraspinal lesion makes it difficult to diagnose coexisting foraminal nerve root involvement, decompression of the nerve root canal, approaching from medial to lateral, is recommended. The fusion operation should be performed in cases undergoing even a unilateral total facetectomy, regardless of the patient's old age. A correct preoperative diagnosis is crucial in order to obtain satisfactory operative results.