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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.

OBJECTIVE The goal of this study was to clarify the clinical utility of paravertebral foramen screws (PVFSs) and to determine intraoperative indicators for appropriate screw placement during posterior cervical fusion surgery to improve its safety. METHODS The authors included data from 46 patients (29 men and 17 women, mean age 61.7 years) who underwent posterior cervical spine surgery with 94 PVFSs. Of the 94 PVFSs, 77 were used in C6, 9 in C3, 5 in C4, and 3 in C5. According to the cervical lateral radiographic view, the authors divided the 94 PVFSs into 3 groups as follows: a longer group, in which the tip of PVFS was located anteriorly from the line of the posterior wall of the vertebral body (> +0 mm); an intermediate group, in which the screw tip was located up to 2 mm posteriorly to the posterior wall of the vertebral body (–2 to 0 mm); and a shorter group, in which the screw tip was located more than 2 mm posteriorly (< –2 mm). The accuracy of screw placement was assessed using CT imaging in the axial plane, and the proportion of screws penetrating a vertebral foramen or a transverse foramen was compared between the 3 groups. Screw loosening was defined as a lucent zone around the screw evaluated on cervical radiography at 1 year after surgery. Complications related to PVFS insertion and revision surgery related to PVFS were evaluated. RESULTS The authors classified 25 PVFSs into the longer group, 43 into the intermediate group, and 26 into the shorter group. The proportion of screws penetrating a vertebral foramen was largest in the shorter group, and the proportion penetrating a transverse foramen was largest in the longer group. Screw loosening was confirmed for 3 of 94 PVFSs. One PVFS inserted in C6 unilaterally within a long construct from C2 to C7 showed loosening, but it did not cause clinical symptoms. Revision surgery was required for 2 PVFSs inserted in C3 bilaterally as the lower instrumented vertebra in occiput–cervical fusion because they pulled out. There was no neurovascular complication related to PVFS insertion. CONCLUSIONS PVFSs are useful for posterior cervical fusion surgery as alternative anchor screws, and the line of the posterior wall of the cervical body on lateral fluoroscopic images is a potential intraoperative reference to indicate an appropriate trajectory for PVFSs.

Recent studies have reported that confined high-intensity and diffuse low-intensity on sagittal T2-weighted magnetic resonance imaging (MRI) are distinctive features that are highly predictive of delayed union or nonunion on osteoporotic vertebral fracture (OVF). The objective of this study was to identify the characteristics of imaging findings predicting the risk for requiring surgical treatment in fresh OVF with poor prognostic features on MRI.We conducted a retrospective study of 74 patients (17 men and 57 women with a mean age of 81.1 years) of OVF with the poor prognostic MRI findings. We compared the imaging findings between the surgery group (16 patients) and the conservative group (58 patients): vertebral instability defined as the difference between the vertebral collapse ratio in dynamic X-rays, and the grade of posterior wall injury (Grade I, no spinal canal encroachment; Grade II,2 mm; Grade III, ≥2 mm) as well as the presence or absence of pedicle fracture (Grade I, none; Grade II, unilateral; Grade III, bilateral) on computed tomography.The mean vertebral instability was 24.0% ± 10.1% in the surgery group and 13.0% ± 7.8% in the conservative group, which was significantly different. Posterior wall injury in the surgery and conservative groups was Grade I in 0 and 29 cases, Grade II in 5 and 21 cases, and Grade III in 11 and 8 cases, respectively, constituting a significant difference. Pedicle fracture in the surgery and conservative groups was Grade I in 5 and 55 cases, Grade II in 6 and 2 cases, and Grade III in 5 and 1 case, respectively, also constituting a significant difference.The most high-risk OVF patients with poor prognostic MRI findings who required surgical treatment were those who exhibited greater vertebral instability as well as either more severe posterior wall injury or pedicle fracture.Retrospective clinical study.

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

Background The penetrating end plate screw (PES) technique improved the fixation strength of the pedicle screw by penetrating the end plate in posterior fusion. The "double" PES, which is a trajectory that penetrates both the upper end plate of the corresponding vertebra and the lower end plate of the upper adjacent vertebral body, provides a stronger tricortical fixation but requires a stricter trajectory. The purpose of this study was to measure the cephalad angles from T7-L5 that would allow a safe trajectory for “double” PES. Methods We analyzed 1078 pedicles of 539 vertebral bodies of 50 consecutive cases (27 males and 23 females, mean age, 63.3 years) who underwent computed tomography (CT) myelography for evaluation of spinal disorders. The mean cephalad angle to obtain the double PES trajectory of each vertebra was examined, except for cases in which the appropriate trajectory would perforate the pedicles. Results The cephalad angle for the appropriate trajectory of “double” PES ranged from 23.4 to 37.6 degrees in the thoracic spine and 34.8 to 40.8 degrees in the lumbar spine. The ratio of pedicle perforation was significantly higher at T7 (16%), L4 (26%), and L5 (52%). Conclusions It is important to measure the optimal cephalad angle by preoperative computed tomography imaging according to the vertebral level. In L4 and L5, “double” PES should be avoided because it is often unsafe.

Background: Severe spinal deformity is a risk factor for proximal junctional kyphosis (PJK) in surgery for adult spinal deformity (ASD). However, standing X-ray imaging in patients with dynamic spinal imbalance can underestimate the risk of PJK because of compensation mechanisms. This study aimed to investigate whether preoperative dynamic spinal alignment can be a predictive factor for PJK. Methods: We retrospectively included 27 ASD patients undergoing three-dimensional (3D) gait analysis before surgery. Dynamic spinal parameters were obtained using a Nexus motion capture system (Vicon, Oxford, UK). The patients were instructed to walk as long as possible around an oval walkway. The averaged dynamic parameters in the final lap were compared between patients with PJK (+) and with PJK (−). Results: PJK occurred in seven patients (26%). The dynamic angle between the thoracic spine and pelvis was larger in patients with PJK (+) than in those with PJK (−) (32.3 ± 8.1 vs. 18.7 ± 13.5 °, p = 0.020). Multiple logistic regression analysis identified this angle as an independent risk factor for PJK. Conclusions: Preoperative thoracic anterior inclination exacerbated by gait can be one of preoperative independent risk factors for PJK in patients undergoing corrective surgery for ASD.

We performed salvage surgery on a patient with kyphotic deformity after anterior cervical fusion with a tortuous vertebral artery (VA). A 69-year-old woman had undergone anterior cervical corpectomy and fusion 12 years ago. Her cervical alignment gradually became kyphotic because of bone graft collapse. Ten years after surgery, she experienced severe neck pain, recurrence of myelopathic symptoms and difficulty in keeping her head straight. The patient was diagnosed with rigid cervical kyphosis at C4–6 vertebral levels, with the right tortuous VA invaginating into the C4 vertebral body. We selected a three-stage, anterior–posterior–anterior approach to reduce cervical alignment. The key to a successful surgery in this case was to retract the tortuous VA within the C4 vertebral body, followed by total uncinectomy. Careful preoperative VA evaluation was a decisive factor in surgical planning.

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.

Although diffuse idiopathic skeletal hyperostosis (DISH) is generally asymptomatic, in rare cases it involves multiple segments and can present with intervertebral pseudoarthrosis which requires treatment. We report a case of a 47-year-old female patient with intervertebral pseudoarthrosis and severe dynamic instability in the L4–5 intervertebral disc due to DISH and provide a brief review of literature. The patient developed severe lower back pain and intermittent claudication due to the instability in the only mobile part between multiple fused vertebrae from C7 to L4 and fusion segment from L5 to the ilium. We performed long-range posterior spinal and two-stage 360° fusion with L4–5 lateral interbody fusion. After the surgery the pain and intermittent claudication were improved and bony fusion was successful. Reports of intervertebral pseudoarthrosis in DISH with no history of trauma are extremely rare. We have only been able to find 5 cases. Compared to the previous reports, the present case describes a youngest patient, first case of female, and had the longest fusion due to DISH. Therefore, the patient required long-range fusion from T10 to the iliac bone in order to achieve adequate stabilization. Moreover, the present case is the first example of choosing a lateral interbody fusion, which provides even more robust consolidation.

Although adjacent segmental disease after posterior thoracic fusion surgery is rare, thoracic myelopathy due to ossification of the yellow ligament in the lower thoracic spine could develop because of mechanical stress when the lower instrumented vertebra has been set to the middle thoracic spine during the initial surgery. We report an extremely rare case of distal adjacent segmental disease after posterior cervical-middle thoracic fusion surgery requiring reoperation after exhibiting thoracic myelopathy due to ossification of the yellow ligament in the lower thoracic spine. An obese 53-year-old man with diabetes had undergone C3-6 laminoplasty and C7-T8 posterior decompression plus fusion due to ossification of the posterior longitudinal ligament at C5-T5. Although the short-term clinical course after the initial surgery was good, symptoms of myelopathy reappeared because of the ossification of the yellow ligament that developed at T9-11 with local flexibility. Thus, reoperation with fusion extension surgery was needed 1 year and 6 months after the initial surgery. Altogether, we recommend careful monitoring of the postoperative clinical progression and, if necessary, reoperation at the earliest.

Study Design: Prospective experimental study in humans.Purpose: To determine whether the hybrid assistive limb (HAL) for Care Support can reduce lumbar load during a patient transfer.Overview of Literature: The prevalence of work-related low back pain (LBP) among nurses is high. In particular, transferring patients poses a high risk for LBP due to the large lumbar load. Attempts to reduce the lumbar load are crucial to avoid the risk of LBP. Therefore, we investigated the effects of the HAL for Care Support.Methods: Nineteen volunteers (16 men, three women) lifted a 60-kg doll from a seated position to a standing position. The first transfer was performed without the HAL for Care Support, and the second was performed with the HAL for Care Support assistive robot. We evaluated transfer performance, the visual analog scale (VAS) score for lumbar fatigue, and electromyogram analyses of the trunk and hip.Results: Four participants (two men, two women) succeeded with the HAL for Care Support even though they were unable to perform the task without it. The mean lumbar fatigue VAS score for all participants without the HAL for Care Support was 62 mm, while that with it was 43 mm. With lumbar assistance from the HAL for Care Support, subjective lumbar fatigue during the transfer decreased significantly. A power analysis indicated adequate statistical power to detect a difference in the VAS score for lumbar fatigue (0.99). The activity of the left gluteus maximus alone increased significantly during transfers with the HAL for Care Support. No adverse events occurred during use of the HAL for Care Support for transfers.Conclusions: The HAL for Care Support was able to reduce lumbar load in a simulated patient transfer.

IntroductionThe purpose of the present study was to elucidate a potential predictive factor for poor clinical outcomes in the conservative treatment of osteoporotic vertebral fractures.Materials and MethodsThis is a study of the vertebrae of 41 patients selected from 63 patients with recent osteoporotic fractures admitted to our hospital from April 2013 to March 2015. Patients with dementia were excluded. We analyzed visual analog scale (VAS: 0‒100 mm) scores and dynamic radiographic images over time for up to 12 weeks after admission. Our statistical analyses were designed to identify factors that were significantly associated with pain prolongation.ResultsLogistic regression analysis using a stepwise method revealed that the independent factor significantly associated with failure for 50% pain reduction at the final follow-up visit was VAS reduction rate at week 3 (OR = 9.0, 95% CI 0.5–17.6, p = 0.04).ConclusionsPatients who responded well to treatment reported a reduction in pain during the first 3 weeks of treatment versus nonresponders who did not. It may be possible to predict the prognosis of osteoporotic vertebral fractures early during the first 3 weeks after hospital admission.

BackgroundPlatelet-rich plasma has been increasingly used in spinal fusion surgery. However, the efficacy of platelet-rich plasma in lateral lumbar interbody fusion is unclear. In Japan, Affinos® (Kuraray Co., Tokyo, Japan), which is a β-tricalcium phosphate artificial bone, has been increasingly used for spinal fusion as a bone graft. The purpose of this trial is to demonstrate whether Affinos® impregnated with platelet-rich plasma can achieve a higher fusion rate, more rapid fusion, and better clinical outcomes than Affinos® alone.Methods/DesignThe current study is a prospective randomized controlled trial. The current trial will include consecutive patients scheduled for lateral lumbar interbody fusion. Since an intervertebral cage for lateral lumbar interbody fusion has two spaces for a bone graft, two bone grafts are inserted for each intervertebral level. In the current study, an artificial bone with plate-rich plasma will be inserted into one space and an artificial bone without platelet-rich plasma will be inserted into the other space. We will compare the fusion rates between the bone graft with and without platelet-rich plasma. Our primary endpoint will be the interbody fusion rate at 1 year after surgery. DiscussionThe current trial will verify the efficacy of platelet-rich plasma with Affinos® for bony fusion in lateral lumbar interbody fusion. This trial will provide substantial evidence for the effectiveness and safety of platelet-rich plasma in spinal fusion surgery.Trial registrationJapan Registry of Clinical Trials (jRCT), ID: jRCTb032200199. First registered on 13 November 2020, https://jrct.niph.go.jp/latest-detail/jRCTb032200199. jRCT is approved as a member of the Primary Registry Network of WHO ICTRP.

PurposeTo investigate whether preoperative dynamic spinal alignment that worsened during gait as detected by three-dimensional (3D) gait analysis can be a predictive factor for proximal junctional kyphosis (PJK) after corrective surgery for adult spinal deformity (ASD) with a minimum 1-year follow-up.MethodWe included 27 patients with ASD who underwent 3D gait analysis before corrective surgery and had >1-year follow-up. Dynamic spinal alignment parameters were obtained using a Nexus motion capture system (Vicon, Oxford, UK) with reflective markers. Spinal alignment was assessed in each region and pelvic alignment was assessed with surface markers. Patients were asked to walk for as long as possible around an oval walkway. We obtained the averaged dynamic parameters in the final lap and compared them between patients with PJK(+) and those with PJK(–).ResultsPJK occurred in 7 patients (26%). Preoperative angle between the thoracic spine and the pelvis was larger in patients with PJK(+) than in those with PJK(–) (32.3 ± 8.1 vs 18.7 ± 13.5, P = 0.020) with sufficient sample size. Multiple logistic regression analysis identified the angle between the thoracic spine and pelvis as an independent risk for PJK.ConclusionPreoperative thoracic kyphosis exacerbated by gait as determined in 3D gait analysis is a preoperative independent risk factor of PJK in patients undergoing ASD corrective surgery.

Nutritional screening scores, including Controlling Nutritional Status (CONUT) Score and Surgical Apgar Score (SAS), which reflect intraoperative hemodynamics, have been reported to be useful for predicting major postoperative complications in various kinds of surgery. We assessed independent risk factors for major complications after cervical spine surgery using those scoring measurements. We retrospectively reviewed medical records of patients who underwent cervical spine surgery at our institution from 2014 to 2019. Baseline clinical information, including the CONUT Score, and surgical factors, including the SAS, were assessed as risk factors for major postoperative complications. We analyzed 261 patients. Major postoperative complications occurred in 40 cases (15.3%). In the multivariate analysis, SAS (odds ratio [OR], 0.42; P P P

Background In general, the diagnosis of pedicle screw (PS) loosening is evaluated qualitatively based on the presence of a radiolucent area around the implant wider than 1 mm on plain radiographs and computed tomography (CT). Digital tomosynthesis is a novel imaging technology that can acquire reconstructed tomographic images of patients in different postures with relatively low radiation. In this study, PS loosening is evaluated quantitatively by measuring the PS displacement angle in the vertebrae using digital tomosynthesis. Methods We evaluated 41 patients who underwent posterior spinal fusion surgery using PS. The 72 pedicle screws at the cranial end of the fused segments were evaluated. The patients were divided in two groups, one with PS loosening (7 patients, 12 screws) and the other without PS loosening (34 patients, 60 screws), based on conventional CT findings. All patients underwent tomosynthesis in two different postures during a single CT session. Results The displacement angles of the PS in patients in a lying position and in a standing position were measured using selected slices of the same cross-sectional view from digital tomosynthesis. The displacement angle was significantly greater in the PS loosening group (5.7°) than in the group without PS loosening (0.6°) (p Conclusions This new method using digital tomosynthesis has the potential to aid diagnosis of PS loosening quantitatively and more accurately than conventional evaluations.

This study aimed to investigate whether fat infiltration in lumbar paravertebral muscles assessed by magnetic resonance imaging (MRI) could be related to dynamic sagittal spino-pelvic balance during gait in adult spinal deformity (ASD). This is a retrospective analysis of 28 patients with ASD. The fat infiltration rate of lumbar erector spinae muscles, multifidus muscles and psoas major muscles was measured by T2 weighted axial MRI at L1-2 and L4-5. Dynamic sagittal spinal and pelvic angles during gait were evaluated using 3D motion analysis. The correlation between fat infiltration rate of those muscles with variations in dynamic kinematic variables while walking and static radiological parameters was analyzed. Spinal kyphosis and pelvic anteversion significantly increased during gait. Fat infiltration rate of erector spinae muscles at L1-2 was positively correlated with thoracic kyphosis (r = 0.392, p = 0.039) and pelvic tilt (r = 0.415, p = 0.028). Increase of spinal kyphosis during walking was positively correlated with fat infiltration rate of erector spinae muscles both at L1-2 (r = 0.394, p = 0.038) and L4-5 (r = 0.428, p = 0.023). Qualitative evaluation of lumbar erector spinae muscles assessed by fat infiltration rate has the potential to reflect dynamic spino-pelvic balance during gait.

We report a case of cardiac arrest, which occurred during C1 laminectomy for irreducible atlantoaxial subluxation, with return of spontaneous circulation (ROSC) upon interruption of the laminectomy. A 60-year-old woman with rheumatoid arthritis presented with neck pain, bilateral finger numbness, and bladder-rectal disturbance. Simple radiograph images showed that the atlantodental interval (ADI) was enlarged to 8 mm, and magnetic resonance imaging revealed severe spinal stenosis at C1. She was diagnosed with cervical spondylotic myelopathy due to atlantoaxial subluxation. Cardiac arrest occurred twice during the C1 laminectomy and occipito-cervical fusion (Occ-C3), and ROSC occurred without any treatment. There was no postoperative worsening of neurological symptoms, and the improvement of sensory and motor palsy was favorable. The pathogenic mechanism was presumed to be trigeminocardiac reflex. Cardiac arrest during upper cervical spine surgery is an important intraoperative complication of which operators should be made aware.

Objectives To describe the novel technique of continuous local antibiotic perfusion (CLAP) for a surgical site infection (SSI) after instrumented spinal surgery. Methods CLAP was applied to 4 continuous patients at our institution who developed SSI after instrumented spinal surgery. Results All 4 patients were successfully treated and the infection was controlled. The implant was retained in all patients. The duration of CLAP ranged from 2 to 3 weeks. The blood level of the antibiotic used (gentamicin) at 1 week after the initiation of CLAP did not increase in any patient. No other adverse events occurred in any patient. Dramatic improvements in laboratory parameters, including the white blood cell (WBC) counts and C-reactive protein (CRP) levels were seen in every patient at 1 week after the initiation of CLAP. Conclusions CLAP controlled the infection without severe adverse events in all 4 patients, and the implants were retained. Despite its cost and the discomfort of patients, CLAP may become an option for the treatment of SSIs after instrumented spinal surgery. A large number of case series are needed to verify the efficacy of CLAP for patients with SSIs after instrumented spinal surgery.

Background The use of platelet-rich plasma has been increasing in spinal fusion surgery. However, the efficacy of platelet-rich plasma in lateral lumbar interbody fusion is unclear. In Japan, Affinos,® (Kuraray Co., Tokyo, Japan), a β-tricalcium phosphate artificial bone, has been increasingly used for spinal fusion. The purpose of this trial is to demonstrate whether Affinos® impregnated with platelet-rich plasma can achieve a higher fusion rate and better clinical outcomes than Affinos® alone. Methods The current study is a prospective randomized controlled trial. This trial will include consecutive patients scheduled for lateral lumbar interbody fusion. An intervertebral cage for lateral lumbar interbody fusion has two spaces for bone grafts. As a consequence, two bone grafts are inserted at each intervertebral level. In this study, an artificial bone with platelet-rich plasma will be inserted into one space, and an artificial bone without platelet-rich plasma will be inserted into the other space. We will compare the fusion rates between the bone grafts with and without platelet-rich plasma. Our primary endpoint will be the interbody fusion rate at 1 year after surgery. Discussion This trial will verify the efficacy of platelet-rich plasma with Affinos® for bony fusion in lateral lumbar interbody fusion. It will also provide substantial evidence for the effectiveness and safety of platelet-rich plasma in spinal fusion surgery. Trial registration Japan Registry of Clinical Trials (jRCT) jRCTb032200199. First registered on 13 November 2020. jRCT is approved as a member of the Primary Registry Network of WHO ICTRP.

The symptoms of lumbar foraminal stenosis are often exacerbated when the patient is upright. Lumbar pathological conditions related to clinical symptoms such as disc herniation, foraminal stenosis, and instability of the lumbar spine are often exacerbated when the patient is upright and hidden when the patient is supine. Lumbar radiculopathy is usually diagnosed by MRI. However, it is difficult to detect the compression of nerve roots while the patient is upright using conventional MRI when the patient is supine. Dynamic digital tomosynthesis radiculography (DTRG) while the patient is upright detects pathological changes of the lumbar nerve root while the patient is upright. We report cases of symptomatic lumbar foraminal stenosis which were diagnosed by using digital tomosynthesis radiculography with the patient in an upright position. Three patients with history of unilateral leg pain which was exacerbated when they were upright underwent selective nerve root block and DTRG in both prone and upright positions. All patients were relieved of the leg pain after selective nerve root block. DTRG with the patient in an upright position showed better exacerbation of nerve root compression than while the patient was prone in all cases. DTRG with the patient in prone and upright positions is useful to detect compression of nerve roots hidden while MRI is conducted with the patient supine. DTRG is helpful to diagnose lumbar foraminal stenosis which is exacerbated while the patient is upright.

Background A high-riding vertebral artery (HRVA) is an intraosseous anomaly that narrows the trajectory for C2 pedicle screws. The prevalence of a HRVA is high in patients who need surgery at the craniovertebral junction, but reports about HRVAs among subaxial cervical spine disorders are limited. We sought to determine the prevalence of HRVAs among patients with subaxial cervical spine disorders to elucidate the potential risk for VA injury in subaxial cervical spine surgery. Methods We included 215 patients, 94 were with a main lesion from C3 to C7 (subaxial group) and 121 were with a main lesion from T1 to L5 (thoracolumbar group). A HRVA was defined as a maximum C2 pedicle diameter of Results The patients of subaxial group were younger than those of the thoracolumbar group but the sex and BMI didn’t differ significantly between the 2 groups. The osteoarthritis grade of C1/2 facet joints of the subaxial group was statistically higher than the thoracolumbar group. A HRVA was found in 26 patients of 94 (27.7 %) in the subaxial group and in 19 of 121 (15.7%) in the thoracolumbar group. The prevalence of a HRVA in the subaxial group was statistically higher and logistic regression analysis indicated that osteoarthritis of C1/2 facet joints significantly correlated with HRVA. Conclusions The prevalence of a HRVA in patients with subaxial cervical spine disorders is higher than in those without cervical spine disorders, and osteoarthritis of C1/2 facet joints significantly correlated with a HRVA.

Background Several authors have reported favorable results in low back pain (LBP) for patients with lumbar disc herniation (LDH) treated with discectomy. However, detailed changes over time in the characteristics and location of LBP before and after discectomy for LDH remain unclear. To clarify these points, we conducted an observational study to determine the detailed characteristics and location of LBP before and after discectomy for LDH, using a detailed visual analog scale (VAS) bilaterally. Methods We included 65 patients with LDH treated by discectomy in this study. A detailed VAS for LBP was administered with the patient under 3 different conditions: in motion, standing, and sitting. Bilateral VAS was also administered (affected versus opposite side) for LBP, lower extremity pain (LEP), and lower extremity numbness (LEN). The Oswestry Disability Index (ODI) was used to quantify clinical status. Changes over time in these VAS and ODI were investigated. Pfirrmann grading and Modic change as seen by magnetic resonance imaging (MRI) were reviewed before and 1 year after discectomy to determine disc and endplate condition. Results Before surgery, LBP on the affected side while the patients were in motion was significantly higher than LBP while they were sitting (p = 0.025). This increased LBP on the affected side in motion was improved significantly after discectomy (p p = 0.015). At 1 year following discectomy, residual LBP while sitting was significantly greater in cases showing changes in Pfirrmann grade (p = 0.002) or Modic type (p = 0.025). Conclusions Improvement of LBP on the affected side while the patient is in motion suggests that radicular LBP is improved following discectomy by nerve root decompression. Furthermore, residual LBP may reflect increased load and pressure on the disc and endplate in the sitting position.

Objective: To report a case of anterior longitudinal ligament (ALL) injury that was not noticeable during lateral lumbar interbody fusion and was disclosed after posterior corrective fusion surgery. Case presentation: After performing lateral lumbar interbody fusion followed by posterior corrective fusion surgery, we observed an anterior longitudinal ligament rupture that required additional surgery. Postoperative pain in the left lower limb and muscle weakness due to nerve traction appeared, but this was improved by stabilization between the vertebral bodies. Conclusion: Unidentified anterior longitudinal ligament rupture can result in unexpected local lordosis during posterior surgery, possibly related to lower extremity palsy. Therefore, checking for possible rupture during and after anterior surgery is important. If the ALL damage is disclosed before posterior surgery, the proper surgical strategy for the posterior surgery must be considered.

Background: Several authors have reported favorable results in low back pain (LBP) for patients with lumbar disc herniation (LDH) treated with discectomy. However, detailed changes over time in the characteristics and location of LBP before and after discectomy for LDH remain unclear. To clarify these points, we conducted an observational study to determine the detailed characteristics and location of LBP before and after discectomy for LDH, using a detailed visual analog scale (VAS) bilaterally.Methods: We included 65 patients with LDH treated by discectomy in this study. A detailed VAS for LBP was administered with the patient under 3 different conditions: in motion, standing, and sitting. Bilateral VAS was also administered (affected versus opposite side) for LBP, lower extremity pain (LEP), and lower extremity numbness (LEN). The Oswestry Disability Index (ODI) was used to quantify clinical status. Changes over time in these VAS and ODI were investigated. Pfirrmann grading and Modic change as seen by magnetic resonance imaging (MRI) were reviewed before and 1 year after discectomy to determine disc and endplate condition.Results: Before surgery, LBP on the affected side while the patients were in motion was significantly higher than LBP while they were sitting. This increased LBP on the affected side in motion was improved significantly after discectomy. By contrast, the residual LBP while sitting at 1 year after surgery was significantly higher than the LBP while they were in motion or standing. At 1 year following discectomy, residual LBP while sitting was significantly greater in cases showing changes in Pfirrmann grade or Modic type.Conclusions: Improvement of LBP on the affected side while the patient is in motion suggests that radicular LBP is improved following discectomy by nerve root decompression. Furthermore, that residual LBP is found while the patient is sitting is reflective of the load and pressure put on the disc and endplate.

Attenuation of the secondary injury of spinal cord injury (SCI) can suppress the spread of spinal cord tissue damage, possibly resulting in spinal cord sparing that can improve functional prognoses. Granulocyte colony-stimulating factor (G-CSF) is a haematological cytokine commonly used to treat neutropenia. Previous reports have shown that G-CSF promotes functional recovery in rodent models of SCI. Based on preclinical results, we conducted early phase clinical trials, showing safety/feasibility and suggestive efficacy. These lines of evidence demonstrate that G-CSF might have therapeutic benefits for acute SCI in humans. To confirm this efficacy and to obtain strong evidence for pharmaceutical approval of G-CSF therapy for SCI, we conducted a phase 3 clinical trial designed as a prospective, randomized, double-blinded and placebo-controlled comparative trial. The current trial included cervical SCI [severity of American Spinal Injury Association (ASIA) Impairment Scale (AIS) B or C] within 48 h after injury. Patients are randomly assigned to G-CSF and placebo groups. The G-CSF group was administered 400 μg/m2/day × 5 days of G-CSF in normal saline via intravenous infusion for five consecutive days. The placebo group was similarly administered a placebo. Allocation was concealed between blinded evaluators of efficacy/safety and those for laboratory data, as G-CSF markedly increases white blood cell counts that can reveal patient treatment. Efficacy and safety were evaluated by blinded observer. Our primary end point was changes in ASIA motor scores from baseline to 3 months after drug administration. Each group includes 44 patients (88 total patients). Our protocol was approved by the Pharmaceuticals and Medical Device Agency in Japan and this trial is funded by the Center for Clinical Trials, Japan Medical Association. There was no significant difference in the primary end point between the G-CSF and the placebo control groups. In contrast, one of the secondary end points showed that the ASIA motor score 6 months (P = 0.062) and 1 year (P = 0.073) after drug administration tend to be higher in the G-CSF group compared with the placebo control group. Moreover, in patients aged over 65 years old, motor recovery 6 months after drug administration showed a strong trend towards a better recovery in the G-CSF treated group (P = 0.056) compared with the control group. The present trial failed to show a significant effect of G-CSF in primary end point although the subanalyses of the present trial suggested potential G-CSF benefits for specific population., Koda et al. present the results of a randomized phase 3 trial comparing granulocyte colony-stimulating factor versus placebo in patients with acute spinal cord injury. While the primary endpoint was not met, a sub-analysis revealed a trend towards superior efficacy of G-CSF versus placebo in an elderly population.

The symptoms of lumbar radiculopathy, in particular foraminal stenosis, often exacerbated when the patient is upright. However, it is difficult to detect the compression of nerve roots while the patient is upright using conventional MRI. In this study, we analyzed the compression of lumbar nerve roots using dynamic digital tomosynthesis radiculography (DTRG) in patients diagnosed with lumbar radiculopathy. And we determined the relationship between leg pain and nerve compression while the patients are either prone or upright. We evaluated 30 patients with unilateral leg pain diagnosed as lumbar radiculopathy by physical examination and MRI. The patients were divided in two groups, one with foraminal stenosis (17 patients) and the other with canal stenosis (13 patients), based on MRI findings. All patients underwent DTRG to determine the diameter of their nerve roots in the foramen while prone and upright. Pain while prone or upright was assessed using a 100-point visual analogue scale (VAS) questionnaire. The VAS for leg pain while upright was significantly higher in the foraminal stenosis group (58 ± 24.7) than it was in the canal stenosis group (19.6 ± 13.2; p = 0.0002)). The nerve root diameter while prone or upright was significantly smaller in the foraminal stenosis group (1.2 ± 0.2 mm) than it was in the canal stenosis group (0.2 ± 0.1 mm; p 0.0001). DTRG has the potential to visualize nerve compression while the patient is upright to reveal the relevance of foraminal stenosis to clinical findings. DTRG is useful for diagnosis of lumbar foraminal stenosis.

Surgical indication of posterior decompression and fusion (PDF) for cervical OPLL in mainly based on K-line, which is defined as that which connects the midpoints of the spinal canal at C2 and C7 in a plain lateral radiogram of the cervical spine. We defined K-line (+) as cases where the peak of ossification foci does not exceed the K-line and K-line (−) as cases where the peak of ossification foci exceeds the K-line. Previous reports revealed that laminoplasty produces a poor outcome in K-line (−) OPLL. One of the surgical options is PDF.

After spine fusion surgery, it is difficult to evaluate the spinal canal and nerve roots using magnetic resonance imaging (MRI) because of metallic implant-related artifacts. Digital tomosynthesis is a new radiographic technique that can acquire tomographic images with reduced metallic artifact effects compared with MRI. We report a case demonstrating the visualization of nerve roots nearby metallic implants using dynamic tomosynthesis-radiculography (DTRG) after spinal fusion surgery. A 77-year-old man, who 3 years earlier underwent spine fusion surgery at L3–L5, presented complaining of newly-onset low back pain and radicular symptoms in the right fifth lumbar (L5) nerve root area. His symptoms were exacerbated when he stood upright. We suspected right L5 nerve root radiculopathy, but MRI could not depict any lesion of the nerve root because of metallic implant-related artifacts. We performed DTRG at the right L5 nerve root with the patient in both prone and upright positions. The right L5 nerve root was detected clearly, and nerve root compression at the foramina when the patient was upright was exacerbated more than when the patient was in a prone position. DTRG is helpful to diagnose lumbar foraminal stenosis nearby metallic implants after spine fusion surgery.