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This article was updated on October 19, 2022, because of previous errors, which were discovered after the preliminary version of the article was posted online. On page 1787, in the legend for Figure 2, the sentence that had read "The vertebral collapse rate (in %) was defined as 1 - (A/P) × 100, and vertebral instability (in %) was defined as the difference in vertebral collapse rate between the loaded and non-loaded images." now reads "The vertebral collapse rate (in %) was defined as (1 - [A/P]) × 100, and vertebral instability (in %) was defined as the difference in vertebral collapse rate between the loaded and non-loaded images." On page 1788, in the section entitled "Data Collection," the sentence that had read "The vertebral collapse rate (in %) was defined as 1 - (anterior vertebral wall height/posterior vertebral wall height) × 100, and vertebral instability (in %) was defined as the difference in vertebral collapse rate between the loaded and non-loaded images 9 ." now reads "The vertebral collapse rate (in %) was defined as (1 - [anterior vertebral wall height/posterior vertebral wall height]) × 100, and vertebral instability (in %) was defined as the difference in vertebral collapse rate between the loaded and non-loaded images 9 ." Finally, on page 1791, in Table IV, the footnote for the "Primary outcome" row that had read "N = 113 in the rest group and 99 in the no-rest group." now reads "N = 116 in the rest group and 108 in the no-rest group."Although imaging findings that predict resistance to conservative treatment in patients with osteoporotic vertebral fracture (OVF) have recently been reported, no conservative treatment method has been standardized. In this study, the effects of initial bed rest on the outcomes of patients with OVF and in patients with and without poor prognostic findings on magnetic resonance imaging (MRI) were compared. This prospective cohort study at 2 facilities involved consecutive patients aged ≥65 years with OVF who began treatment within 2 weeks after their injury and were observed for 6 months. Patients at one hospital rested for 2 weeks (116 patients; mean age, 80.4 years), whereas those at the other hospital were not instructed to rest (108 patients; mean age, 81.5 years). Patients were further divided according to the presence or absence of poor prognostic MRI findings. The primary end point was the rate of transition to surgery; secondary end points included bone union rate, vertebral collapse progression, local kyphosis progression, and changes in activities of daily living (ADL). Forty-five patients in the rest group (including 3 who required surgery) and 37 patients in the no-rest group (including 9 who required surgery) had poor prognostic MRI findings. Although the difference in the rate of transition to surgery between the rest and no-rest groups did not reach significance among all patients (p = 0.06), the transition rate in the rest group was significantly lower (p = 0.02) in the patients with poor prognostic MRI findings. Both the bone union rate and changes in ADL were not significantly different between the rest and no-rest groups. The mean vertebral collapse progression was 6.4% in the rest group and 20.9% in the no-rest group (p0.001), and the mean local kyphosis progression was 2.4° in the rest group and 8.8° in the no-rest group (p0.001). Although bed rest is not recommended for all patients, hospitalized bed rest for 2 weeks reduced the number of patients with OVF who require surgery among patients with poor prognostic MRI findings. Bed rest also reduced progression of vertebral collapse and kyphosis, regardless of the MRI findings. Therapeutic Level II . See Instructions for Authors for a complete description of levels of evidence.

Background: Lumbar spondylolysis, a common identifiable cause of low back pain in young athletes, reportedly has a higher incidence rate in males. However, the reason for its higher incidence in males is not clear. This study aimed to investigate the epidemiological differences between the sexes in adolescent patients with lumbar spondylolysis. Methods: A retrospective study was conducted in 197 males and 64 females diagnosed with lumbar spondylolysis. These patients visited our hospital from April 2014 to March 2020 with their main complaint being low back pain, and they were followed-up until the end of their treatment. We investigated associations between lumbar spondylosis, their background factors, and characteristics of the lesions and analyzed their treatment results. Results: Males had a higher prevalence of spina bifida occulta (SBO) (p=0.0026), more lesions with bone marrow edema (p=0.0097), and more lesions in the L5 vertebrae (p=0.021) than females. The age at diagnosis, bone union rate, and treatment period were not significantly different between the sexes. Conclusion: The higher prevalence of SBO in males may explain the sex differences in the incidence of lumbar spondylolysis. The progression of lumbar spondylolysis is however, more advanced in females, thus making a proper early diagnosis, especially in females, important.

Introduction: Normal pressure hydrocephalus (NPH) has three characteristics: Gait disorder, urinary incontinence, and amnesia. We report a case of atlantoaxial subluxation-related NPH in a patient whose symptoms were dramatically improved by atlantoaxial fusion surgery. Case Report: A 67-year-old woman presented complaining of walking disturbance. 4 weeks after her first presentation and initial diagnosis of atlantoaxial subluxation associated with rheumatoid arthritis, the patient fell and fractured her right patella. After open surgery for the fracture with spinal anesthesia, she had urinary incontinence, cognitive decline, and gait disturbance, and brain computed tomography showed enlarged ventricles. Atlantoaxial fusion surgery was performed 8 weeks after the first presentation. Postsurgically, improvement of her memory and urinary function was noted and she was able to walk with the assistance of a cane and perform activities of daily living independently. Even 6 years after the surgery, the enlargement of the ventricles ameliorated, there was no abnormality in cognition, and she was able to walk alone and run a business. Conclusion: The atlas was subluxated, even when the cervical spine was in a neutral position, and the spinal cord was seriously compressed, which impeded cerebrospinal fluid flow. We speculate changes in cerebrospinal pressure due to spinal anesthesia-induced NPH-like symptoms, which were improved by indirect spinal decompression by atlantoaxial reduction with atlantoaxial fusion.

The usefulness of minimally invasive posterior fixation without debridement and autogenous bone grafting remains unknown. This multicenter case series aimed to determine the clinical outcomes and limitations of this method for thoracolumbar pyogenic spondylitis. Patients with thoracolumbar pyogenic spondylitis treated with minimally invasive posterior fixation alone were retrospectively evaluated at nine affiliated hospitals since April 2016. The study included 31 patients (23 men and 8 women; mean age, 73.3 years). The clinical course of the patients and requirement of additional anterior surgery constituted the study outcomes. The postoperative numerical rating scale score for lower back pain was significantly smaller than the preoperative score (5.8 vs. 3.6, p = 0.0055). The preoperative local kyphosis angle was 6.7°, which was corrected to 0.1° after surgery and 3.7° at the final follow-up visit. Owing to failed infection control, three patients (9.6%) required additional anterior debridement and autogenous bone grafting. Thus, in this multicenter case series, a large proportion of patients with thoracolumbar pyogenic spondylitis could be treated with minimally invasive posterior fixation alone, thereby indicating it as a treatment option for pyogenic spondylitis.

We aimed to investigate the risk factors that affect vertebral deformity 6 months after osteoporotic vertebral fractures (OVFs) at the time of injury. From May 2017 to May 2020, 70 postmenopausal women with OVFs were evaluated for age; body mass index; number of previous OVFs; total 25-hydroxy vitamin D [25(OH)D] levels; posterior wall injury on computed tomography; cross-sectional area (CSA) of the psoas major, erector spinae, and multifidus; fat infiltration; vertebral instability (VI) upon admission; collapse rate (CR); and kyphotic angle (KA) at 6 months after injury. A multiple regression analysis was conducted to identify the risk factors for the CR and KA. The CR was correlated with posterior wall injury (r = 0.295, p = 0.022), 25(OH)D levels (r = − 0.367, p = 0.002), and VI (r = 0.307, p = 0.010). In the multiple regression analysis, the 25(OH)D levels (p = 0.032) and VI (p = 0.035) were significant risk factors for the CR at the 6-month follow-up. The KA was correlated with the 25(OH)D levels (r = − 0.262, p = 0.031) and VI (r = 0.298, p = 0.012). In the multiple regression analysis, the CSA of the psoas major (p = 0.011) and VI (p

Purpose Lumbar spondylolysis in children of elementary school age has different characteristics from those of junior or senior high school patients. The purpose of the present study was to investigate the outcomes of conservative treatment for lumbar spondylolysis in patients of elementary school age. Methods We included 46 lesions in 32 consecutive patients of elementary school age with fresh cases of lumbar spondylolysis (5 girls and 27 boys; mean age, 11.3 years). We examined the relationship between bone union after conservative treatment and factors such as the CT axial staging, whether the lesion was unilateral or bilateral, whether the contralateral lesion was terminal stage, and the presence of spina bifida occulta. Results Bone union was achieved in 33 lesions (72%) in 23 patients, whereas 13 lesions (28%) in 9 patients could not obtain bone union. The proportion of unilateral lesions with bone union was 13 of 13 (100%), significantly higher than that for bilateral lesions (20/33 lesions, 61%, p = 0.009). Of the 33 bilateral lesions, bone union was attained in 20 of 28 (71%) lesions without contralateral terminal stage, whereas bone union was not attained in any of 5 (0%) lesions with contralateral terminal stage, showing a significant difference between those with or without contralateral terminal stage (p = 0.005). Conclusion Bilateral lesions and contralateral terminal stage are possible unfavorable factors to bone union in conservative treatment for patients of elementary school age with lumbar spondylolysis. Early diagnosis and treatment before the lesions become bilateral or progressive stage are important.

Background The smiley face rod method is an effective treatment for symptomatic terminal-stage spondylolysis. However, the risk factors for treatment failure are unknown. We investigated the association of pars defect type with the treatment outcomes of this method. Methods We retrospectively examined data from 34 patients (18.0 ± 6.7 years) with terminal-stage spondylolysis who underwent surgery using the smiley face rod method. The mean follow-up period was 44.9 ± 21.4 months. The patients were divided into 2 groups: pars defect without bone atrophy or sclerosis (group A; 18 patients), and with bone atrophy and sclerosis (group B; 16 patients). The visual analog scale (VAS) score for back pain, bone union rate, and time to return to preinjury level athletics were evaluated and compared between the groups. Fisher’s exact test and a paired t test were used when comparing the groups. VAS score between the groups were analyzed using a 2-factor repeated-measures analysis of variance. Results Within groups there were significant differences over time for VAS score (p p = 0.028) and 24 months after surgery (97.1% and 75.0%, p = 0.011). All patients returned to their respective sports, and no significant differences were observed with time to return to preinjury level athletics between the groups (p = 0.055). Conclusion These results suggested that the defect of pars sclerosis is associated with bone nonunion, but has little effect on postoperative symptoms.

Background: Prediction of postoperative complications and management based on that prediction are important for improving outcomes. The surgical Apgar score, a simple score for surgical outcomes, has been used to predict postoperative complications. The purpose of this study was to investigate the usefulness of the surgical Apgar score to predict major complications after thoracic spinal surgery. Methods: The subjects were 104 patients who underwent thoracic spinal surgery at a single institution from 2014 to 2018. Background patient and disease characteristics assessed included age, gender, body mass index (BMI), comorbidities (diabetes, hypertension or coronary artery disease), anticoagulant and antiplatelet medications, preoperative hemoglobin, controlling nutritional status (CONUT) score, and American Society of Anesthesiologists-Physical Status (ASA-PS) classification. Surgical factors evaluated were operative time, approach, presence of instrumentation, and multiple intervertebral surgery. The surgical Apgar score was calculated from intraoperative estimated blood loss, minimum heart rate, and minimum mean blood pressure. Major complications were defined as unexpected elongation of intubation for more than 48 hours, postoperative blood transfusion (bleeding) of more than 4U in 72 hours, coronary artery disease, renal failure, cerebrovascular disease, sepsis, pneumonia, severe delirium, deep vein thrombosis, pulmonary embolism (PE), or wound complications. Postoperative hospitalization days were also investigated. A multivariate statistical analysis was performed using stepwise logistic regression. The occurrence of complications and the duration of postoperative hospitalization were compared using a t-test. A p-value of Results: Major complications were observed in 19 (18.3%) patients; these were bleeding (8 patients), delirium and wound complications (4 patients each) PE (2 patients) and pneumonia and acute kidney injury (1 patient each). The multivariate analysis revealed that the surgical Apgar score (odds ratio=0.3) was significantly associated with major complications. Postoperative hospital stay was significantly longer in patients with complications (59 days) than in patients without complications (36 days; p=0.0015).Conclusion: The surgical Apgar score is an objective index that can be easily calculated from anesthesia records, and this study suggests that it may be useful in predicting major complications after thoracic spinal surgery.

We often encounter elementary school-aged children with fresh lumbar spondylolysis and non-union of bone. They may have factors that impede healing, and treatment outcomes need improvement. The purpose of this study was to investigate elementary school-aged patients with fresh lumbar spondylolysis and to identify characteristics that can aid in prompt diagnosis and proper therapy. We retrospectively compared the characteristics of fresh lumbar spondylolysis in elementary school-aged children with those of older patients. We included patients aged 6–18 years with lower back pain and evidence of bone marrow oedema of lumbar pedicles on magnetic resonance imaging (MRI). The elementary school-aged group (group E) included 100 patients aged 6–12 years, and the senior group (group S) included 251 patients aged 13–18 years. We recorded patient sex, duration of lower back pain, injured site (lumbar level, unilateral/bilateral), presence of contralateral pars defect with evidence of high signal change on MRI (short tau inversion recovery), presence of spina bifida occulta (SBO), and follow-up treatment interruption rate. One-third of the patients in group E were female, and there was an even smaller proportion of females in group S. L5 lumbar spondylolysis was more common in group E. The treatment interruption rate was lower in group E. L5 SBO and contralateral pars defect were more common in group E. L5 lumbar spondylolysis, L5 SBO, and contralateral pars defect were important diagnostic factors in elementary school-aged patients. Identification of these characteristics will aid in prompt diagnosis and proper therapy.

Objectives The objective of this study was to verify the usefulness of magnetic resonance imaging (MRI) with axial traction of the thumb for observing articular cartilage. Materials and methods Eleven healthy adult volunteers (39.7 ± 7.4 years) without thumb carpometacarpal joint arthritis or trauma were included in this study. A 3-tesla (3T) MRI (Magnetom Skyra, Siemens Healthineers AG, Munich, Germany) of the right thumb with axial traction applied by a finger trap with three traction weights (0, 2, and 5 kg) was performed. A 3D T2* multiecho data imaging combination (MEDIC) was selected to visualize the articular cartilage. After multiplanar reconstruction, sagittal and coronal images of the thumb carpometacarpal joint were used to evaluate the articular cartilage visibility and joint space widths at five locations. Articular cartilage visibility was evaluated using our original classification method that used the percentage of the cartilage detectable area. The Friedman test was used to compare the differences between each traction weight and location. Results Articular cartilage visibility significantly improved with axial traction. The average joint space widths with the 5-kg application were 1.9 ± 0.8, 3.9 ± 0.6, 2.0 ± 0.9, 3.9 ± 1.1, and 2.5 ± 1.4 mm at the center, volar edge, dorsal edge, radial edge, and ulnar edge, respectively. The joint space widths significantly increased proportionally with the traction weight at all locations. The joint space widths at the volar and radial edges were significantly greater than those at other locations. Conclusion Applying axial traction to the thumb increased the joint space widths and improved the visibility of the articular cartilage in the carpometacarpal joint on MRI.

Study Design: Retrospective cohort study.Purpose: To evaluate the clinical outcomes of the conservative treatment of “pre-lysis”-stage lumbar spondylolysis.Overview of Literature: With the widespread use of magnetic resonance imaging (MRI) for early diagnosis of lumbar spondylolysis, a new disease stage called pre-lysis has emerged, in which intensity change is observed only on MRI without a fracture line on computed tomography. This study aimed to evaluate the clinical outcomes and factors unfavorable to bone healing of the conservative treatment of pre-lysis-stage lumbar spondylolysis.Methods: Fifty-three patients with 57 fresh pre-lysis-stage lesions who had completed conservative treatment were included in the study (40 men, 13 women; mean age, 14.3 years). We investigated the rate of bone healing and the relationship between bone healing after conservative therapy and factors such as age, sex, vertebral level, unilateral/bilateral lesions, and presence of spina bifida occulta.Results: The overall bone healing rate was 95% (54/57 lesions). Bilateral lesions had a significantly lower bone healing rate than unilateral lesions (86% vs. 100%, p=0.046). There were no statistically significant differences based on age, sex, vertebral level, or presence of spina bifida occulta.Conclusions: The bone healing rate in unilateral lesions was 100%, which was significantly higher than that in bilateral lesions. It is important to detect and initiate treatment while the lesion is still unilateral, if possible.

We report a case of flexor pollicis longus (FPL) tendon rupture and carpal tunnel syndrome due to scaphoid nonunion advanced collapse deformity. Intraoperative findings showed disruption of the palmar joint capsule and a sharp proximal bone fragment protruding into the carpal tunnel. Removal of this proximal fragment and tendon grafting were performed. At the postoperative 2-year follow-up, the patient had no wrist pain, finger numbness, or restriction of thumb motion.Our results suggest that minimally invasive surgical procedures, such as proximal pole or osteophyte resection, might be optimal choices for early rehabilitation after tendon repair in cases of FPL tendon rupture due to asymptomatic scaphoid nonunion.

Growth plate injury of the proximal humerus is rare. We herein report a traumatic growth plate injury of the proximal humerus in an elite diving athlete. A 16-year-old female diving athlete injured her left shoulder during 7.5 m platform hands-first diving practice. At the first visit, she presented with upper left shoulder tenderness and left shoulder range-of-motion limitation. There was no fracture or dislocation on X-ray and computed tomography (CT), but magnetic resonance imaging (MRI) showed a high-intensity zone in the left lateral epiphysis of the proximal humerus. We treated her conservatively by rest with sling and rehabilitation. She partially restarted diving practice five weeks post-injury and returned to competition eight weeks post-injury. Even if there is no sign of fracture or dislocation, we should consider MRI for patients who are before the age of growth plate closure.

Background Lumbar spondylolisthesis is reported to present with a familiar pattern, with the dysplastic type of spondylolysis being minor but more hereditary than the isthmic type. Siblings presenting during adolescence with neurological symptoms owing to high-grade dysplastic-type spondylolisthesis are rare. Case presentation The older brother suffered from left leg pain and numbness and dysesthesia of the right posterior thigh and calf and could not walk without a crutch at the age of 15 years. He had canal stenosis with disc bulging and dysplastic bilateral facet joint at L5/S1. The L5 vertebral body was slipped anterior downward to S1, with a round-shaped S1 cranial endplate. We diagnosed dysplastic-type spondylolisthesis and performed posterior lumbar interbody fusion at L5/S with mild reduction and sublaminar wiring at L4/5. The younger brother had no neurological symptoms at age 14 years but suffered from bilateral lower leg numbness at age 18 years. He had canal stenosis with disc bulging at L4/5 and L5/S1 and dysplastic bilateral facet joint at L5/S1 with right pars defect. The L5 vertebral body was vertically displaced anterior to the S1 vertebral body, with an S1 round-shaped cranial endplate. We diagnosed dysplastic-type spondylolisthesis, and posterior lumbar interbody fusion at L4/5 and L5/S with reduction was performed. Their neurological symptoms of the lower legs disappeared, and interbody bone fusion was obtained. Conclusions The surgical technique for high-grade dysplastic spondylolisthesis remains controversial in terms of in situ fusion versus reduction. We recommend that surgery be performed promptly at the end of bone maturation because neurological symptoms often appear at the end of bone maturation. Because high-grade slips are rare but siblings may be present, the sibling should also be screened when dysplastic spondylolisthesis is detected.

Purpose: Occasionally lumbar spondylolysis in adolescents will recur after conservative treatment. The goal of this study was to retrospectively review the conditions in which recurrence transpired in a subset of adolescent patients diagnosed with acute lumbar spondylolysis. Subjects: A retrospective survey was conducted in 152 patients who had been treated for spondylolysis and had obtained bone union. Twenty subjects were selected who had recurrent lumbar spondylolysis after returning to sports activity following the first spondylolysis treatment. There were 18 males and two females with an average age at the time of initial consultation of 13.3 years and 14.1 years at the time of recurrence.Results: The average period of initial treatment was 101 days, and the average time to recurrence after healing was 149 days. There were three cases at L3, two cases at L4 and 15 cases at L5. At recurrence, 18 patients had unilateral involvement and two patients presented with bilateral occurrence. Four cases did not achieve bony union.Discussion: In this study, the recurrence rate was 13.2%. Eighty percent of cases had recurrence within six months after healing. After recurrence, 20% of the cases reached pseudoarthrosis. It is useful to take regular MRI images to detect recurrence within six months after returning to sports.

【Background】 Identification of pathogenic microorganisms are essential for pyogenic vertebral osteomyelitis (PVO). This study aimed to demonstrate the effectiveness of the blood culture bottle (BCB) system in identifying PVO causative organisms. 【Materials & Methods】 We analyzed retrospectively collected data from patients who underwent full-endoscopic spine surgery for PVO between January 2016 and March 2019. Irrigation water generated in the surgical field was incubated in the BCB system, and compared with blood culture before surgery and tissue culture taken by the conventional method. The microbial identification rate and the time from sample collection to microbial identification of the BCB system were compared with conventional blood culture and tissue cultures using the Wilcoxon signed-rank test. 【Results】 We included 17 patients (12 men, five women; mean age, 72.8 ± 11.9 years). Bacteria were cultured from 3 (17.6%), 13 (76.5%), and 12 (70.6%) patients by blood culture, tissue culture, and the BCB system, respectively. Tissue culture and the BCB system had significantly higher detection rates than blood culture (P = .002, P =.003), and there was no significant difference between tissue culture and BCB system (P = .655). In 15 cases (88.2%), the causative organism was identified by at least one method. In two cases, the causative organism (Escherichia coli) was only identified by the BCB system. The BCB system required amount of time for microbial identification (3.9 ± 3.0 days), compared with the time required for blood culture (5.0 ± 1.4 days, P =.180) and tissue culture (11.9 ± 15.1 days, P =.012). 【Conclusions】 Results suggest the possibility of improving the detection rate and time to detection of causative organisms by the BCB system as an adjunct to the conventional method.

Lumbar spondylolysis is a fatigue fracture that occurs most frequently in middle and high school athletes. Conservative treatment is the first choice when the fracture is fresh. Surgical treatment of lumbar spondylolysis is often reported for pseudarthrosis cases, but surgery for cases of fresh fractures is rare. We report a case of a 16-year-old male, high jump athlete, with recurrent non-pseudoarthorotic lumbar spondylolysis. He presented to our hospital with a chief complaint of back pain, and was diagnosed as right L5, pre-lysis-stage lumbar spondylolysis. After 3 months of conservative treatment, bone union was achieved with no obvious worsening of the fracture. His back pain also disappeared and he was able to return to exercise. At 6 months after the first examination, the lesion recurred and he could no longer continue playing sports, so surgical treatment was indicated. Minimally invasive screw fixation was performed by combining Buck's method and the cortical bone trajectory. After the surgery, he started jogging at 5 weeks, resumed jumping practice at 7 weeks, and returned to competition at 2 months. He set a new personal best in a competition 3 months post-surgery. Bone union was achieved at 4 months. This technique is minimally invasive and does not involve debridement or bone grafting, which provides early pain relief and return to sports.

Objective: Spontaneous spinal epidural hematoma is rare and therefore difficult to diagnose. This study evaluated the clinical features of this condition in patients admitted to our hospital. Patients and Methods: We evaluated 12 patients with spontaneous spinal epidural hematoma who were treated at our hospital. We investigated the following variables in these patients: underlying diseases, medications used, initial symptoms, spinal level affected, whether transported to the hospital by ambulance, department where first evaluated, mass lesion on computed tomography with soft tissue window settings, time interval between symptom onset and diagnosis, treatment received, and Frankel classification on arrival and when last observed. Results: Five patients reported the use of antiplatelet or anticoagulant drugs. All patients in this study reported acute onset of severe pain as the initial symptom, and 10 patients reported some degree of paralysis accompanying the pain. With respect to the morbidity level, the cervical region was the most common site of involvement (n=7). Ten patients were transported to the hospital at night via ambulance. Five patients first visited the Department of Internal Medicine. Seven patients presented with a mass lesion on computed tomography with soft tissue window settings. The time interval between symptom onset and diagnosis ranged from 2 hours to 6 days. Three and 9 patients received conservative and surgical treatments, respectively. No patient showed worsening of Frankel classification. Conclusion: Acute onset of severe pain was the most characteristic clinical symptom. Spontaneous spinal epidural hematoma should be included in the differential diagnosis. Computed tomography with soft tissue window settings may rule out cerebrovascular disease and cardiovascular disease, and specifically detect a hematoma. Subsequent magnetic resonance imaging can diagnose a spontaneous spinal epidural hematoma at an early stage.

Charcot spinal arthropathy (CSA) is a rare spinal disorder presenting neuropathic osteoarthropathy of facet joints leading to progressive destruction. After L4-5 PLIF, a 63-year-old woman with Parkinson's disease (PD) underwent L3-4 and L5-S1 PLIF for primary adjacent segment disease caused by degenerative change, which was found as facet joint osteophytes and a vacuum disc phenomenon with endplate sclerosis. However, her postural disorder from PD deteriorated, and strong opioid analgesics were administered for severe recurring low back pain. Anterior subluxation at L2-3 occurred because of destructive secondary adjacent segment disease, which was found as destruction of the endplate and the facet without degenerative change, and formation of paravertebral osteophytes and fluid collection in the intervertebral space. The appearance on imaging met that for neuroarthropathic change, which was previously reported as CSA. L2-3 PLIF following extension of posterior fusion to T10 was additionally performed, and the postoperative course was uneventful with symptomatic improvement. In this case, the important finding was in the different appearance of the disease between adjacent segments on imaging. It is possible that deterioration of PD and administration of the analgesics inhibited deep pain sensation, and concentration of mechanical stress in the proximal adjacent segment by the long lever arm because of extension of the fusion level resulted in neuroarthropathic change of the facets in the secondary adjacent segments. The pathophysiology of association of CSA and PD remains unknown. However, we recommend vigilance for destructive neuroarthropathic facet change as CSA after spinal surgery in patients with severe PD.

Candida spondylitis is a relatively rare disease. The primary risk factor is an immunocompromised status. Here, we report an immunocompetent patient who developed Candida spondylitis. The patient was a 70-year-old male. After multiple surgeries, he developed a fever and was diagnosed with chronic pyogenic spondylitis of the lumbar spine, which was treated by long-term antimicrobial therapy. However, his back pain persisted and the inflammatory response was prolonged. We performed posterior thoracolumbar pelvic fixation with a percutaneous pedicle screw system to stabilize the infected vertebral bodies and simultaneously performed a full-endoscopic intervertebral disc biopsy to identify the causative organisms. Candida parapsilosis was identified from a fungal culture of the biopsy specimen. The patient was diagnosed with Candida spondylitis and started on antifungal treatment with fluconazole. His back pain disappeared quickly after surgery, and up to the time of this writing, the patient has continued to receive fluconazole. We attributed the development of Candida spondylitis to the patient's long-term antibiotic treatment of a postoperative infection of the lumbar spine, which was associated with multiple back surgeries. Fungal spondylitis, including spondylitis caused by Candida spp., should be suspected in patients, even immunocompetent patients, with intractable postoperative spinal infections and pyogenic spondylitis due to microbial substitution. Long-term antimicrobial therapy without definitive identification of the causative organism of a postoperative infection of the lumbar spine that is associated with multiple surgeries can be a cause of Candida spondylitis. A biopsy is strongly recommended for the definitive diagnosis.

Three types of sacral alar fatigue fractures are elderly, postnatal, and sport-related. They are most prevalent in athletes during adulthood; there are few reports of sacral alar fatigue fractures in young athletes. The purpose of this study was to analyze sacral alar fatigue fractures in adolescent athletes. Of the 920 patients hospitalized with low back pain, 13 were diagnosed with sacral alar fatigue fractures with magnetic resonance imaging (MRI) abnormalities. We investigated age, sex, sports discipline, span from symptom onset to consultation, laterality, complication with spondylolysis, computed tomography (CT) findings, and treatment span. The average age was 14.5 years old (8-men and 5-women). The most frequent discipline was basketball. The span to consultation was 13.2 days. The number of right-side cases was 9. Seven cases were complicated by bilateral spondylolysis. MRI abnormalities were observed in all the cases. Only two patients showed abnormal findings on CT. Averagely 67 days after treatment, participants returned to their sports. Sacral alar fatigue fractures suggest that the span from onset to consultation is short. Fracture lines are often unclear on CT, and MRI is useful for diagnosis. More than half of the cases in this study were complicated by lumbar spondylolysis.

Objective: Lumbar spondylolysis, caused by stress fracture of the pars interarticularis may lead to a bony defect or spondylolisthesis. In adolescents, its surgical treatment employs the smiley face rod method for direct reduction of pseudoarthrotic spondylolysis and spondylolisthesis. Clinical outcomes of this treatment have been occasionally described; however, implant removal has not been discussed previously. We present a patient with lumbar spondylolysis with grade 1 slip at the 5th lumbar vertebra (L5) per the Meyerding classification. Patient: A 14-year-old boy presented with chronic severe lower back pain. Since conservative therapy did not resolve pain or enable resuming sports activities, the smiley face rod repair was performed 7 months after the initial treatment. Result: Anterior slippage of the L5 was surgically reduced. The patient wore a brace for 3 months postoperatively, and partial bone fusion was noted 6 months postoperatively. He resumed his sports activity 8 months postoperatively, and absolute bone fusion was confirmed 18 months postoperatively. Implant removal was performed 3 years postoperatively. Grade 1 slip was corrected with absolute bone fusion, and long-term follow-up revealed good results in terms of healing and rehabilitation. Conclusion: Smiley face rod method that allows for implant removal after bone fusion is suitable for adolescents.

Background This study evaluated the union rate of acute lumbar spondylolysis in patients treated conservatively, according to the protocol. Methods The subjects included high school students and younger patients who were diagnosed with lumbar spondylolysis presenting bone marrow edema. We investigated the union rate, the period until union, unilateral or bilateral, vertebral level, laterality (right or left), and pathological stage at the first visit. Some unilateral cases included bilateral spondylolysis with contralateral pseudarthrotic lesion; therefore, the union rate of the “true” unilateral case in which the contralateral side was normal was calculated. We excluded multi-level lesions. Results With conservative treatment for lumbar spondylolysis of 189 lesions in 142 cases, 144 healed and 45 were considered as nonunion. The average treatment period until union was 106 days. The union of “true” unilateral cases in which the contralateral side was normal was noted in 68/71 lesions, but that of bilateral cases was noted in 71/94 lesions. The union in L3, L4, and L5 vertebrae was noted in 15/17, 40/49, and 89/123 lesions, respectively. The union was observed in 63/87 on the right and 86/102 on the left. The union was noted in the pre-lysis, early, and progressive stages in 36/39, 81/97, and 27/53 lesions, respectively. Furthermore, the union was noted in stages 0, 1a, 1b, 1c, and 2 in 13/15, 47/52, 30/36, 34/42, and 20/44 lesions, respectively. Conclusion Accurate union evaluation using CT and MRI showed a union rate of 76% with conservative treatment for spondylolysis. The union rate of the “true” unilateral cases in which the contralateral side was normal was 96%, which was significantly higher than that of the bilateral cases. Moreover, the union rate of lesions in the axial progressive stage and sagittal stage 2 was significantly lower than that of lesions in other stages. Study design clinical retrospective study.

Purpose: This study aimed to examine the characteristics of lumbar spondylolysis with acute lumbar spondylolysis on one side and pseudoarthrotic spondylolysis on the other, relative to acute lumbar spondylolysis on one side only. Patients and Methods: Short-tau inversion recovery images obtained through magnetic resonance imaging were used to diagnose 58 patients with acute lumbar spondylolysis with bone marrow edema on one side only. A total of 20 patients who had pars defects on the contralateral side (terminal-stage pseudoarthrotic spondylolysis) were included in the contralateral pseudoarthrosis group (P group). The remaining 38 patients with normal images for the contralateral pars interarticularis were included in the unilateral lesion group, in which the contralateral side was normal (U group). We investigated the union rate, age, sex, lesion laterality, vertebral level, pathological stage, and existing spina bifida occulta in both groups. Results: The P group was characterized by a higher proportion of right-side cases, L5 lesions, more progressed pathological stage, and spina bifida occulta and a significantly lower union rate than the U group. Conclusion: The union rate in patients with lumbar spondylolysis with acute lumbar spondylolysis on one side and pseudoarthrotic spondylolysis on the opposite side was only 15%. We should inform patients with acute unilateral spondylolysis lesions and contralateral pseudoarthrosis about this poor union rate and urge them to choose their therapy accordingly.