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The management of cervical spine injuries in the elderly is often complicated by the presence of multiple medical comorbidities, and it is not uncommon for preoperative testing to reveal other conditions that require the postponement of surgery. However, the factors that affect the waiting time from injury to surgery have not been clarified. The purpose of this multicenter database study was to analyze the clinical features and identify the factors affecting the number of days waited between injury and surgery in elderly patients with a cervical spine injury.We retrospectively reviewed the case histories of 1512 Japanese patients with a cervical spinal injury, who were seen at 33 institutions. After excluding patients who were not initially receiving a surgery for cervical spinal injury, 694 patients were ultimately analyzed. Based on a multivariate mixed model, we determined the factors related to the number of days from injury to surgery.The mean time from injury to surgery was 12.3 days. Multivariate analysis revealed delays of 10.7 days for a renal disorder, 7.3 days for anticoagulant use, and 15.2 days for non-surgical thoracolumbar fracture as factors prolonging wait time. In contrast, a C3 or lower spine injury was significantly associated with a shortening of 9.5 days to surgery.This multicenter database study identified several factors influencing the time between injury and cervical spine surgery in elderly patients. While renal impairment, anticoagulant use, and non-surgical thoracolumbar fracture may increase the number of days to surgery, trauma to C3 or lower may expedite surgical treatment.

The number of elderly patients with cervical trauma is increasing. Such patients are considered to be at high risk for delirium, which is an acute neuropsychological disorder that reduces the patient’s capacity to interact with their environment due to impairments in cognition. This study aimed to establish a risk score that predicts delirium in elderly patients with cervical SCI and/or cervical fracture regardless of treatment type. This retrospective cohort study included 1512 patients aged ≥65 years with cervical SCI and/or cervical fracture. The risk factors for delirium according to treatment type (surgical or conservative) were calculated using multivariate logistic regression. A delirium risk score was established as the simple arithmetic sum of points assigned to variables that were significant in the multivariate analyses. Based on the statistical results, the delirium risk score was defined using six factors: old age (≥80 years), hypoalbuminemia, cervical fracture, major organ injury, dependence on pre-injury mobility, and comorbid diabetes. The score’s area under the curve for the prediction of delirium was 0.66 (p < 0.001). Although the current scoring system must be validated with an independent dataset, the system remains beneficial because it can be used after screening examinations upon hospitalization and before deciding the treatment strategy.

Ossification of the posterior longitudinal ligament (OPLL) can be complicated cervical spinal cord injury (CSCI) by low energy trauma, which is increasing among the elderly and potentially life-threatening. However, the etiology and neurological outcome of CSCI with OPLL in the elderly remain unknown. Therefore, we conducted this multi-center retrospective cohort study, which identified 1,512 patients aged ≥ 65 years and diagnosed with CSCI on admission from 2010 to 2020. We analyzed the etiology in patients with OPLL. Moreover, we performed propensity score-adjusted analyses to compare the neurological outcomes between patients with and without OPLL. The primary outcome comprised the American Spine Injury Association (ASIA) impairment scale (AIS) grade and ASIA motor score (AMS). In 332 patients with OPLL, the men:women ratio was approximately 4:1. Half of all patients displayed low energy trauma-induced injury, and one-third of the patients had CSCI without a bony injury. The propensity score matching created 279 pairs. There was no significant difference in the AIS grade and AMS between the patients with and without OPLL during hospitalization, 6 months, and 12 months following injury. In summary, OPLL was not associated with neurological recovery in the elderly with CSCI.

Retrospective multicenter study.To investigate the neurological outcomes of older individuals treated with surgery versus conservative treatment for cervical spinal cord injury (CSCI) without bone injury.Thirty-three medical institutions in Japan.This study included 317 consecutive persons aged ≥65 years with CSCI without bone injury in participating institutes between 2010 and 2020. The participants were followed up for at least 6 months after the injury. Individuals were divided into surgery (n = 114) and conservative treatment (n = 203) groups. To compare neurological outcomes and complications between the groups, propensity score matching of the baseline factors (characteristics, comorbidities, and neurological function) was performed.After propensity score matching, the surgery and conservative treatment groups comprised 89 individuals each. Surgery was performed at a median of 9.0 (3-17) days after CSCI. Baseline factors were comparable between groups, and the standardized difference in the covariates in the matched cohort was10%. The American Spinal Injury Association (ASIA) impairment scale grade and ASIA motor score (AMS) 6 months after injury and changes in the AMS from baseline to 6 months after injury were not significantly different between groups (P = 0.63, P = 0.24, and P = 0.75, respectively). Few participants who underwent surgery demonstrated perioperative complications such as dural tear (1.1%), surgical site infection (2.2%), and C5 palsy (5.6%).Conservative treatment is suggested to be a more favorable option for older individuals with CSCI without bone injuries, but this finding requires further validation.

In the current aging society, there has been a marked increase in the incidence of cervical spinal cord injury (CSCI) without major bone injury. This multi-center study aimed to identify predictors of neurological improvement in elderly patients with CSCI without major bone injury. The participants were 591 patients aged ≥65 years with CSCI without major bone injury and a minimum follow-up period of three months. Neurologic status was defined using the American Spinal Injury Association (ASIA) impairment scale (AIS). Univariate and multi-variate analyses were performed to identify prognostic factors for walking recovery in AIS A-C cases and full upper extremity motor recovery in AIS D cases. In AIS A-C cases, body mass index (odds ratio (OR): 1.112), magnetic resonance imaging signal change (OR: 0.240), AIS on admission (OR: 3.497), comorbidity of dementia/delirium (OR: 0.365), and post-injury pneumonia (OR: 0.194) were identified as independent prognostic factors for walking recovery. The prevalence of ossification of the posterior longitudinal ligament (OR: 0.494) was also found to be an independent prognostic factor in AIS B and C cases only. In AIS D cases, age (OR: 0.937), upper extremity ASIA motor score on admission (OR: 1.230 [per 5 scores]), and operation (OR: 0.519) were independent prognostic factors for full motor recovery. The severity of AIS at admission was the strongest predictor of functional outcomes. Promoting rehabilitation, however, through measures to reduce cognitive changes, post-injury pneumonia, and unhealthy body weight changes can contribute to greater neurological improvement in AIS A-C cases.

We aimed to retrospectively investigate the demographic characteristics and short-term outcomes of traumatic cervical spine injuries in patients with dementia. We enrolled 1512 patients aged ≥ 65 years with traumatic cervical injuries registered in a multicenter study database. Patients were divided into two groups according to the presence of dementia, and 95 patients (6.3%) had dementia. Univariate analysis revealed that the dementia group comprised patients who were older and predominantly female and had lower body mass index, higher modified 5-item frailty index (mFI-5), lower pre-injury activities of daily living (ADLs), and a larger number of comorbidities than patients without dementia. Furthermore, 61 patient pairs were selected through propensity score matching with adjustments for age, sex, pre-injury ADLs, American Spinal Injury Association Impairment Scale score at the time of injury, and the administration of surgical treatment. In the univariate analysis of the matched groups, patients with dementia had significantly lower ADLs at 6 months and a higher incidence of dysphagia up to 6 months than patients without dementia. Kaplan–Meier analysis revealed that patients with dementia had a higher mortality than those without dementia until the last follow-up. Dementia was associated with poor ADLs and higher mortality rates after traumatic cervical spine injuries in elderly patients.

For older patients with decreased reserve function, traumatic cervical spine injuries frequently lead to early mortality. However, the prognostic factors for early mortality remain unclear. This study included patients aged ≥65 years and hospitalized for treatment of traumatic cervical spine injuries in 78 hospitals between 2010 and 2020. Early mortality was defined as death within 90 days after injury. We evaluated the relationship between early mortality and the following factors: age, sex, body mass index, history of drinking and smoking, injury mechanisms, presence of a cervical spine fracture and dislocation, cervical ossification of the posterior longitudinal ligament, diffuse idiopathic skeletal hyperostosis, American Spinal Injury Association Impairment Scale, concomitant injury, pre-existing comorbidities, steroid administration, and treatment plan. Overall, 1512 patients (mean age, 75.8 ± 6.9 years) were included in the study. The early mortality rate was 4.0%. Multivariate analysis identified older age (OR = 1.1, p < 0.001), male sex (OR = 3.7, p = 0.009), cervical spine fracture (OR = 4.2, p < 0.001), complete motor paralysis (OR = 8.4, p < 0.001), and chronic kidney disease (OR = 5.3, p < 0.001) as risk factors for early mortality. Older age, male sex, cervical spine fracture, complete motor paralysis, and chronic kidney disease are prognostic factors for early mortality in older patients with traumatic cervical spine injuries.

Study Design Retrospective multicenter study Objectives To investigate changes over a 10-years period in the profile of cervical spine and spinal cord injuries among the elderly in Japan. Methods The current multicenter study was a retrospective analysis of inpatients aged ≥65 years, suffering cervical fracture (CF) and/or cervical spinal cord injury (CSCI). We analyzed 1413 patients’ epidemiology (from 2010 to 2019). Moreover, 727 patients who underwent surgical treatment were analyzed in 2 groups: the early (2010-2014) and late period (2015-2019). Results Both the number of patients and number of surgical patients showed a significant increasing trend ( P < .001), while the mean age, the distribution of injury levels and paralysis severity, and the proportion of surgical indications remained the same. The number of surgical patients doubled from 228 to 499 from the early to late periods. Posterior surgery was the most common approach (90.4%), instrumentation surgery with screws increased significantly, and the range of fusion was significantly longer in the late period (2.1 vs 2.7 levels, P = .001). Significantly worsening neurological symptoms were recorded in the late period (1.3% vs 5.8%, P = .006), with C5 palsy being the major one. Otherwise, perioperative, major, and other complications, including mortality, did not differ significantly in incidence. Conclusions Both the number of elderly CF and/or CSCI patients and number of patients undergoing surgery increased dramatically over the decade without any change in profile. Instrumentation surgeries with screws increased, without an increase in systemic complications.

Introduction:Spinal fractures related to diffuse idiopathic skeletal hyperostosis (DISH) are almost always caused by a long lever arm, so treatment of the fractures requires stabilization of long segments of the spine. Treatment of unstable sacral fractures in DISH patients with ankylosis of the sacroiliac joints requires a treatment strategy that includes a consideration of the condition of the spine. This article is the first report of an unstable sacral fracture in a patient with DISH. Case Report:A 95-year-old male fell and presented with severe low back pain. An X-ray and computed tomography showed unstable pelvic fracture (AO type C2) and ankylosis of the lumbar spine due to DISH. We performed minimally invasive spinopelvic posterior fixation and internal anterior fixation (INFIX) for stabilization of the pelvic fracture. Initially, due to the long lever arm created from the lumbar spine to the pelvis, we performed L2-iliac posterior stabilization while the patient was in a prone position. After that, we performed INFIX to stabilize the anterior pelvis while the patient was positioned supine. The postoperative clinical course of the patient was uneventful and bony fusion was achieved as seen on X-ray obtained 1 year postoperatively. Conclusion:This patient was ankylosed from spine to pelvis due to DISH and sacroiliac joint ankylosis and sustained bilateral sacral fractures which dissociated the sacrum from the rest of the pelvis. Therefore, this fracture required spinopelvic fixation from the ankylosing spine to the pelvis. Because this patient was so elderly and in poor general health, we performed minimally invasive spinopelvic posterior fixation using percutaneous pedicle screws. We considered that many screw insertions that would equivalently stabilize the spine several segments above and below the fracture would be needed to stabilize the sacral fractures in this patient with DISH. In this case, we stabilized the unstable right pelvis, in a patient with

An 87-year-old male having a history of C3–7 open-door cervical laminoplasty 20 years ago fell and sustained neck pain and paralysis with complete motor and sensory deficits below C6 (Frankel A). Computed tomography (CT) revealed ankylosis from C2 to C7 due to diffuse idiopathic skeletal hyperostosis (DISH) and a C5/6 fracture with C5 posterior displacement. We performed surgery the day after injury using a posterior approach for stabilization of the spinal column from C3 to T1. Translaminar screws (LS) were placed to the right (hinge side) of C3–7, lateral mass screws (LMS) to the left (open side) of C3–6, and pedicle screws to the left of C7 and bilaterally in T1. Bony fusion was achieved as seen on CT images 6 months after surgery. We conclude that long posterior stabilization using LMS and LS is an effective treatment for cervical fracture in patients with DISH having a history of cervical laminoplasty.

Context: There are no reports of patient satisfaction with implant removal after stabilization using percutaneous pedicle screws (PPS) for traumatic thoracolumbar fracture (TTF). Aims: The aim of this study was to investigate patient satisfaction with implant removal after stabilization using PPS for TTF. Settings and Design: A retrospective study. Subjects and Methods: The present study included data from 24 patients who underwent posterior stabilization using PPS for single-level TTF following implant removal. The degree of patient satisfaction was evaluated using a questionnaire. We investigated residuary back pain, using the numerical rating scale (NRS) and Oswestry disability index (ODI), and types of occupation. Patients were divided into groups of those with residuary back pain (Group P) and those without (Group N). We evaluated local kyphosis and disc degeneration after implant removal. We investigated whether residuary back pain or types of occupation affect patient satisfaction. Statistical Analysis Used: All statistical analyses were conducted using IBM SPSS statistics. Results: Patients were “extremely satisfied” in 13 cases (54%), “moderately satisfied” in eight cases (33%), and “neither” in three cases (13%). No patients answered “moderately dissatisfied” or “extremely dissatisfied.” The mean scores on the NRS and ODI in Group P were 1.8 ± 0.9 and 13.2 ± 9.3, respectively. Patient satisfaction, disc degeneration, and local kyphosis were not significantly different between Group P and Group N. Patient satisfaction was not significantly different between the hard and light workgroups. Conclusions: Patient satisfaction with implant removal was high regardless of whether persistent back pain existed and did not depend on the type of occupation.

Study design Retrospective Cohort Study Objective The purpose of this study was to investigate the prognosis of respiratory function in elderly patients with cervical spinal cord injury (SCI) and to identify predictive factors. Methods We included 1353 cases of elderly cervical SCI patients collected from 78 institutions in Japan. Patients who required early tracheostomy and ventilator management and those who developed respiratory complications were defined as the respiratory disability group. Patients’ background characteristics, injury mechanism, injury form, neurological disability, complications, and treatment methods were compared between the disability and non-disability groups. Multiple logistic regression analysis was used to examine the independent factors. Patients who required respiratory management for 6 months or longer after injury and those who died of respiratory complications were classified into the severe disability group and were compared with minor cases who were weaned off the respirator. Results A total of 104 patients (7.8%) had impaired respiratory function. Comparisons between the disabled and non-disabled groups and between the severe and mild injury groups yielded distinct trends. In multiple logistic regression analysis, age, blood glucose level, presence of ossification of posterior longitudinal ligament (OPLL), anterior vertebral hematoma, and critical paralysis were selected as independent risk factors. Conclusion Age, OPLL, severe paralysis, anterior vertebral hematoma, hypoalbuminemia, and blood glucose level at the time of injury were independent factors for respiratory failure. Hyperglycemia may have a negative effect on respiratory function in this condition.

Introduction Some reports revealed that hidden blood loss (HBL) during surgery for traumatic thoracolumbar fracture cannot be ignored, even when using a percutaneous approach. Using percutaneous pedicle screws (PPS) for traumatic thoracolumbar fracture, this study aimed to compare estimate blood loss (EBL), including HBL, between early and late fixation. Methods This investigation was a retrospective study. In the present study, data from 39 patients who underwent posterior spinal stabilization using PPS for single-level thoracolumbar fracture have been included. We divided the patients into an early group (group E) (n=20) in whom surgery was conducted within 3 days of fracture and a late group (group L) (n=19) in whom surgery was conducted more than 3 days after fracture. We evaluated hemoglobin (Hb) on the day of injury, and 1, 3 or 4, and 7 days after surgery, EBL, HBL, and transfusion requirement. Results Hb on day 1 (group E: 12.2±1.7 g/dL, group L: 12.3±1.6 g/dL) was significantly less than that on the injured day (group E: 14.2±1.7 g/dL, group L: 13.9±1.7 g/dL) in both groups. The values of Hb and EBL were not significantly different at any time between the two groups. HBL (group E: 487±266 mL, group L: 386±305 mL) was not significantly different between the two groups. No patients required transfusion in either group. Conclusions EBL in early fixation using PPS for traumatic thoracolumbar fracture is not significantly different compared with that in late surgery from days 1 to 7 postoperatively. Early fixation using PPS for traumatic thoracolumbar fracture does not result in negative outcomes any more than those in late surgery in terms of blood loss.

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.]

Purpose: Cup setting with only an alignment guide has been reported to be inaccurate in the lateral decubitus position in total hip arthroplasty (THA). We assessed the accuracy of cup positioning using only the alignment guide technique via a modified Watson Jones approach in the lateral decubitus position. Methods: Two hundred hips of 189 patients underwent THA from October 2014 to September 2016 via a modified Watson Jones approach. In the final sample, 181 hips of 171 patients (35 males, 136 females) were included in this investigation. The alignment of the cup was evaluated by an anteroposterior radiograph of the pelvis 1 week after surgery. Measurements were divided into safe zone determined by Callanan and Lewinnek. Results: There were 168 (92.8%) acetabular cups that were placed within the safe zone for both inclination and anteversion based on the safe zones defined by Lewinnek, and 134 (74%) acetabular cups that were placed within the safe zone defined by Callanan. Multiple logistic analysis showed that the laterality and the addition of the confirmation method were indicators for malpositioning of combined inclination and anteversion. Conclusion: Our data suggested that even if special tools were not used in the lateral decubitus position, using only the alignment guide enabled cup positioning to be achieved with 92.8% accuracy in the Lewinnek safe zone and 74% accuracy in the Callanan safe zone. Multiple logistic analysis showed that the laterality and the addition of a confirmation alignment guide influenced the accuracy of cup positioning.

Study design A prospective case series. Objective The aim of this study was to assess a new protocol for full spine X-ray using copper (Cu) filters to reduce radiation exposure in patients with adolescent idiopathic scoliosis (AIS). Summary of background data Radiation exposure is associated with an increased risk of cancer development in children. To reduce the radiation exposure without compromising the image quality using existing radiographic equipment, a new computed radiography protocol was optimized using a variety of heavy metal filters. Methods Study 1: Whole spine radiographs were obtained using a human body phantom, and radiation doses without and with 0.1, 0.2, and 0.3 mm thick Cu filters were compared. Study 2: Patients with AIS who underwent posterior fusion were radiographically evaluated at follow-ups; the X-ray protocols with or without the use of 0.2-mm Cu filters were alternated between consecutive follow-ups. The image quality was independently evaluated using six points in the anterior-posterior (AP) view and seven in the lateral [left-right (LR)] view by three spine surgeons using a three-point grading system. Results Study 1: The surface doses while obtaining nonfiltered X-rays in AP and LR views were 0.31 and 0.93 mGy, respectively, whereas those with 0.1-, 0.2-, and 0.3-mm Cu filters were 0.16 and 0.52, 0.11 and 0.36, and 0.08 and 0.27 mGy, respectively.Study 2: In patients with AIS, the percentage of grade 3 scores (both endplates were identifiable) on AP-view images was 85% with nonfiltered X-rays and 75% with the filtered X-rays. However, there were no significant differences between the two protocols. On LR images, the frequency of grade 3 scores was significantly lower at Th2 and Th12 on filtered images than on nonfiltered ones. Conclusion Whole spine radiographs using 0.2-mm Cu filters in patients with AIS could reduce radiation exposure more than 60% while preserving the image quality. Level of evidence 4.

Vertebral fractures occur with only slight trauma in patients with diffuse idiopathic skeletal hyperostosis (DISH). However, a lumbar vertebra fracture, due to an intraoperative body position has not been previously reported. An 87-year-old woman with kyphosis sustained a left trochanteric fracture of her femur. The patient was placed in a supine position during the operation. Postoperatively, the patient experienced severe right thigh pain. Magnetic resonance imaging revealed an L4 vertebral fracture. Computed tomography revealed ankylosis from the upper thoracic spine to the sacrum. While in a supine position under general anesthesia, the contact of the patient's lower back with operating table likely created a fulcrum at her lumbosacral spine acting as a long lever arm, bearing the mass of her upper body. We performed L1-S2 posterior stabilization. DISH patients with kyphosis placed in a supine position have an increased risk for lumbar vertebral fracture.

BACKGROUND To date there has been only 1 reported case of the symptom relapse of pediatric idiopathic intervertebral disk calcification (PIIDC), as described by Yoon and colleagues in 1987, who reported symptom relapse in a patient with multilevel PIIDC. Thus, symptom relapse in patients with single-level PIIDC have not been reported. METHODS We report here a case of single-level PIIDC with symptom relapse 1 year after the initial onset. RESULTS The patient was a 7-year-old girl who developed cervical pain and fever up to 38°C without an obvious cause. Computed tomography (CT) revealed calcification in the C4/5 intervertebral disk space and in the epidural space at the C3-5 vertebral levels. The patient was diagnosed with PIIDC and treatment with oral nonsteroidal anti-inflammatory drugs was begun. Both cervical pain and fever gradually improved and resolved in approximately 1 week. CT obtained 6 months after the initial onset showed calcifications localized in the posterior area of the C4/5 intervertebral disk space and reduced epidural calcifications, which had nearly resolved. One year after the initial onset, the patient developed similar symptoms. CT revealed an enlarged calcified lesion in the epidural space. Thus, the patient was diagnosed with symptom relapse of PIIDC. Although there was enlargement of calcifications in the epidural space, there were no calcifications involving the intervertebral disk at the time of relapse. The patient was treated conservatively. Follow-up CT revealed that the lesion resolved with time. CONCLUSIONS This report described a patient with single-level PIIDC and symptom relapse 1 year after the initial onset. In the case presented herein, calcifications of the intervertebral space had extruded into the epidural space, thus causing a symptom relapse. The patient was treated conservatively at the initial onset and at the time of relapse. The symptoms improved both times. Although patients with single-level PIIDC usually have an uneventful clinical course, it is necessary to be mindful of potential symptom relapse.

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.

seikei@pop01.kanazawa-u.ac.jp, Background Each vertebra can be regarded as a compartment surrounded by several anatomically characterized barriers. However, in some cases tumorsextend beyond these barriers. The route of vertical extension to the adjacent vertebrae is unclear. The extent ofvertical extension of a metastatic spinal tumor is important in making the preoperative decision regarding the cranio-caudal surgical margin. The objective of this study was toinvestigate the route of vertical extension of metastatic vertebral tumors. Methods We examined 20 en bloc resected metastatic vertebral bodies in which the tumors had extendedoutside the vertebral body. Five to eight sagittal sections including the pedicle, and the lateral and central parts of the PLL were prepared from each resected specimen. The sections were stained with hematoxylin and eosin, and elastica van Gieson. Histological examination focused on the routes of the vertical extension of the tumor at each barrier tissue and the degree of tumor extension along each route. Results Vertical extension ofthe tumor was observed at the ALL in 6 cases, at the central part of the PLL in 14 cases, at the lateral part of the PLL in 20 cases, at the cartilaginous endplate in 3 cases, and at the periosteum on the lateral side of vertebral body in 7 cases. The tumor had extended the farthest at the lateral part of the PLL in 18 cases, at the lateral side of the vertebral body in 1 case, and through the disc in 1 case. Conclusions Metastatic vertebral tumors most commonly extend vertically at the lateral part of the PLL. The lateralpart of the PLL is raised by the tumor, which extends between the PLL and the posterior aspect of the disc. © The Japanese Orthopaedic Association 2011.

We describe a pair of monozygotic twins with an attenuated form of mucopolysaccharidosis type I (MPS-I). At age 24, they both developed cervical myelopathy as a cardinal manifestation. They each also had mild valve abnormalities and both inguinal and umbilical hernia, however, other characteristic features of MPS-I were absent or very mild. Magnetic resonance imaging revealed the cervical cord compressed by pachymeningeal hypertrophy. Surgery with dural plasty and laminoplasty resulted in decompression of the cervical cord with clinical improvement, revealing marked thickening of the dura mater. Both patients showed a marked decrease of alpha-L-iduronidase (IDUA) activity with c.252insC (p.P55fsX62; known) and c.1209C>A (p.T374N; novel) mutations of the IDUA gene (IDUA). Patients with MPS-I have been reported to present with various clinical phenotypes and severities even if they have identical mutations of IDUA. The quite similar, unique phenotype in monozygotic twins suggests that not only IDUA mutation but also other genetic factors than IDUA markedly influence the clinical manifestations of MPS-I.

The rapidly aging population and improved long-term survival due to advancement of cancer treatment have expanded the role of surgical treatment in elderly patients with metastatic spinal disease. The purpose of this study was to evaluate in elderly patients the perioperative complications and prognosis for metastatic spinal disease. Thirty-two elderly patients (>70 years) who underwent surgical treatment based on Tomita's surgical strategy for spinal metastasis since 1999 were retrospectively reviewed. Mean survival time of 15 patients with 2 to 4 points in surgical strategy was 23.6 months; of 10 patients with 5 to 7 points was 15.2 months; and of 7 patients with 8 to 10 points was 5.2 months. In 5 elderly patients (15.6%), the appropriate surgical choice based on the surgical strategy was not possible due to their preoperative conditions. Perioperative complications encountered were respiratory in 6 patients (18.8%), cardiovascular in 3 (9.4%), and delirium in 4 (12.5%). In the nonelderly 161 patients, respiratory complications occurred in 4 patients (2.5%), cardiovascular in 1 (0.6%), and delirium in 2 (1.2%). Respiratory complications and delirium occurred at a significantly higher frequency in the elderly group. Even for elderly patients, the postoperative prognosis could be predicted by the surgical strategy. However, the optimal surgical procedure may deviate from that predicted by the surgical strategy due to their preoperative conditions and an increased risk for perioperative complications. Despite the increased potential for complications, more radical procedures, such as total en bloc spondylectomy, should not be avoided solely due to advanced patient age.

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.

This study established a new method of quantitive analysis on the form of abutment teeth prepared with natural teeth at Random Position (R. P.) under clinical situation.The subjects for this study which were the maxillary first premolars on the right and left side andthe cases of indication of extruction conveniently under orthodontic treatment were evaluated.The preparations were the chamfer type for full cast crowns on the right side and the full-shoulder type for full-bake type porcelain fused to metal crowns on the left side.Further, those data were compared with the average data of ten abutment teeth prepared withmelamine-resin teeth on a mannequin by the same operator at R.P. to evaluate this new method ofanalysis.Those data could be compared under the same standard and the form of abutment teeth preparedwith natural teeth were similar to that with melamine-resin teeth. On the side, some factors whichwere considered to influence the teeth preparation were apparent.As a result, this new method could be used for analysis of the form of abutment teeth preparedwith natural teeth.

Following are the results of a study made on the influence to the prepared tooth form, when the abutment tooth preparation with full cast crowns are done for the Maxillar Left Fixed Prosthodontics three-unit bridge in Random Position. The prepared teeth arethe Second Premolar and the Second Molar (The“Second Premolar”is abbreviated to “5” and the “Second Molar”is abbreviated to “7”).1. The reduced extent of occlusal surface was excessively large at 5 and 7 buccal cusps, while it was excessively small at Central grooves.2. The reduced extent of axial surface was excessively small at 5 and 7 all surfaces.3. The reduced extent of subgingiva tended to be shallower than the designated depth of 1.0mm at the all portions.4. As for the degree of axial taper, its made steeper toward the buccal and distal surface both 5 and 7.5. As for the relative degree of axial taper, it get the largest in degree on bothsides between5 medial surface and 7 distal surface.

The purpose of this study is to mesure the three dimentional distotions and displacements in the Non-precious (Ni-Cr) ceramometal fixed bridge using the pre-soldered method.Following conclusions were obtained as a results.1. During the Pre-soldering stage, the distotion of soldered bridge frame (the potion was made with one-piece cast method) are minimal.2. During the Pre-soldering stage, the curve of fixed bridge frame was slight opened on horizontal plane, but on the vertical displacement was larger than others.

1. The state of inclination and the change under various conditions of the imaginary axis of the tooth crown of upper jaw anterior teeth can be determined by the image measuring system and method of this study. 2. The measurement error of this system was not more than 0.3 degree. This value was sufficient for the purpose of this study. 3. The imaginary axis of the tooth crown of anterior teeth was determined on the study cast with 1 to 3 degrees in mesiodistal direction and 2 to 4 degrees in labiopalatal direction as standard deviation. 4. The imaginary axis of the tooth crown of anterior teeth was determined toward labial in the random position and toward patient's right and palatal in Standing Posture. 5. It was confirmed that the determination of the imaginary axis of tooth crown was effected by the position of the patient relative to the operator, limitation or direction of view, and approach direction.