Publications by authors named "Masayuki Ohashi"

56 Publications

Randomized trial of granulocyte colony-stimulating factor for spinal cord injury.

Brain 2021 Apr;144(3):789-799

G-SPIRIT Study Group, Chiba, Japan.

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.
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http://dx.doi.org/10.1093/brain/awaa466DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8041047PMC
April 2021

Minimally Invasive Spinal Stabilization with Denosumab before Total Spondylectomy for a Collapsing Lower Lumbar Spinal Giant Cell Tumor.

Acta Med Okayama 2021 Feb;75(1):95-101

Division of Orthopedic Surgery, Department of Regenerative and Transplant Medicine, Niigata University Graduate School of Medical and Dental Sciences.

A 21-year-old man consulted our hospital for treatment of a spinal giant cell tumor (GCT) of Enneking stage III. Lower lumbar-spine tumors and severe spinal canal stenosis are associated with high risk for surgical mor-bidity. Stability was temporarily secured with a percutaneous pedicle screw fixation in combination with deno-sumab, which shrank the tumor. Total en bloc spondylectomy was then performed 6 months after initiation of denosumab, and the patient was followed for 3 years. There was no local recurrence, and bony fusion was obtained. Minimally invasive surgery and denosumab allowed safer and easier treatment of a collapsing lower lumbar extra-compartmental GCT.
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http://dx.doi.org/10.18926/AMO/61442DOI Listing
February 2021

Indication for drainage for a hematogenous iliopsoas abscess: Analysis of patients initially treated without drainage.

J Orthop Sci 2020 Dec 12. Epub 2020 Dec 12.

Division of Orthopedic Surgery, Niigata University Graduate School of Medical and Dental Sciences, Niigata city, Japan.

Background: This study aimed to determine the indications for drainage in extended haematogenous iliopsoas abscesses (IPAs), which include both primary and vertebral osteomyelitis-related IPAs.

Methods: Sixty-three IPA patients who were initially treated with only antibiotics and no drainage were enrolled. The success (S) group included patients who were cured without drainage, while the failure (F) group included those who required open or percutaneous drainage or died.

Results: Compared with patients in the S group, patients in the F group (n = 15) had a higher incidence of end-stage renal disease on hemodialysis, compromised immunity, vertebral osteomyelitis of the cervicothoracic spine, other musculoskeletal infections, and multilocular abscesses. The IPAs in the F group had larger transverse and longitudinal diameters. In receiver operating characteristic curve analyses for the diameter of IPAs, the most valuable cut-off points predicting the F group were a longitudinal diameter of 5.0 cm (sensitivity, 1.0; specificity, 0.67) and a transverse diameter of 2.3 cm (sensitivity, 0.73; specificity, 0.73). A combination of both diameter cut-offs had high specificity (sensitivity, 0.73; specificity, 0.90).

Conclusions: Drainage should be applied in case of a larger abscess with transverse diameter ≥ 2.3 cm and longitudinal diameter ≥ 5.0 cm. Conversely, IPAs with longitudinal diameter <5 cm do not require drainage. Haemodialysis, compromised immunity, vertebral osteomyelitis of the cervicothoracic spine, and musculoskeletal infections are risk factors of conservative treatment failure.
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http://dx.doi.org/10.1016/j.jos.2020.10.023DOI Listing
December 2020

Significance of long corrective fusion to the ilium for physical function in patients with adult spinal deformity.

J Orthop Sci 2020 Nov 9. Epub 2020 Nov 9.

Niigata Spine Surgery Center, Japan.

Background: We aimed to investigate the impact of long corrective fusion to the ilium on the physical function in elderly patients with adult spinal deformity and its correlation with spinopelvic parameters and health-related quality of life outcomes.

Methods: We included 60 female patients who underwent long corrective fusion from T9 or T10 to the pelvis for adult spinal deformities (mean age of 69.8 years, range 55-78 years). The radiographic parameters, health-related quality of life outcomes using the Scoliosis Research Society Outcome Instrument-22 and physical function assessments were reviewed preoperatively and at 1-year postoperatively.

Results: All spinopelvic parameters, except for thoracolumbar kyphosis, and all domains of the Scoliosis Research Society Outcome Instrument-22 significantly improved at 1-year postoperatively (p < 0.0001). Physical function results, including those for one-leg standing time, timed up-and-go test, and 6-min walk tests, significantly improved at 1-year postoperatively (p < 0.005). Based on forward stepwise multivariate logistic regression, the predicted timed up-and-go test and 6-min walk test outcomes at 1-year postoperatively were as follows: timed up-and-go test, 7.8 + 0.47 × preoperative timed up-and-go test - 0.21 × 1-year postoperative grasping power +0.015 × 1-year postoperative C1 sagittal vertical axis (R2 = 0.6209, p < 0.0001); 6-min walk test, 309.2-9.1 × body mass index + 11.6 × 1-year postoperative grasping power + 3.3 × 1-year postoperative thoracolumbar kyphosis - 0.59 × 1-year postoperative C1 sagittal vertical axis (R2 = 0.4409, p < 0.0001).

Conclusions: Corrective long fusion surgery for adult spinal deformity in normalizing sagittal alignment improves trunk balance and gait performance. Postoperative physical function depends on the preoperative physical performance status and skeletal muscle status; thus, preoperative interventions for improved physical function are recommended.
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http://dx.doi.org/10.1016/j.jos.2020.09.016DOI Listing
November 2020

Compensation for standing posture by whole-body sagittal alignment in relation to health-related quality of life.

Bone Joint J 2020 Oct;102-B(10):1359-1367

Académie Nationale de Médecine, Paris, France.

Aims: The aim of this study is to test the hypothesis that three grades of sagittal compensation for standing posture (normal, compensated, and decompensated) correlate with health-related quality of life measurements (HRQOL).

Methods: A total of 50 healthy volunteers (normal), 100 patients with single-level lumbar degenerative spondylolisthesis (LDS), and 70 patients with adult to elderly spinal deformity (deformity) were enrolled. Following collection of demographic data and HRQOL measured by the Scoliosis Research Society-22r (SRS-22r), radiological measurement by the biplanar slot-scanning full body stereoradiography (EOS) system was performed simultaneously with force-plate measurements to obtain whole body sagittal alignment parameters. These parameters included the offset between the centre of the acoustic meatus and the gravity line (CAM-GL), saggital vertical axis (SVA), T1 pelvic angle (TPA), McGregor slope, C2-7 lordosis, thoracic kyphosis (TK), lumbar lordosis (LL), pelvic incidence (PI), PI-LL, sacral slope (SS), pelvic tilt (PT), and knee flexion. Whole spine MRI examination was also performed. Cluster analysis of the SRS-22r scores in the pooled data was performed to classify the subjects into three groups according to the HRQOL, and alignment parameters were then compared among the three cluster groups.

Results: On the basis of cluster analysis of the SRS-22r subscores, the pooled subjects were divided into three HRQOL groups as follows: almost normal (mean 4.24 (SD 0.32)), mildly disabled (mean 3.32 (SD 0.24)), and severely disabled (mean 2.31 (SD 0.35)). Except for CAM-GL, all the alignment parameters differed significantly among the cluster groups. The threshold values of key alignment parameters for severe disability were TPA > 30°, C2-7 lordosis > 13°, PI-LL > 30°, PT > 28°, and knee flexion > 8°. Lumbar spinal stenosis was found to be associated with the symptom severity.

Conclusion: This study provides evidence that the three grades of sagittal compensation in whole body alignment correlate with HRQOL scores. The compensation grades depend on the clinical diagnosis, whole body sagittal alignment, and lumbar spinal stenosis. The threshold values of key alignment parameters may be an indication for treatment. Cite this article: 2020;102-B(10):1359-1367.
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http://dx.doi.org/10.1302/0301-620X.102B10.BJJ-2019-1581.R2DOI Listing
October 2020

Short- versus long-segment posterior spinal fusion with vertebroplasty for osteoporotic vertebral collapse with neurological impairment in thoracolumbar spine: a multicenter study.

BMC Musculoskelet Disord 2020 Aug 1;21(1):513. Epub 2020 Aug 1.

Department of Orthopaedic Surgery, Keio University School of Medicine, 35 Shinanomachi, Shinjuku-ku, Tokyo, 160-8582, Japan.

Background: Vertebroplasty with posterior spinal fusion (VP + PSF) is one of the most widely accepted surgical techniques for treating osteoporotic vertebral collapse (OVC). Nevertheless, the effect of the extent of fusion on surgical outcomes remains to be established. This study aimed to evaluate the surgical outcomes of short- versus long-segment VP + PSF for OVC with neurological impairment in thoracolumbar spine.

Methods: We retrospectively collected data from 133 patients (median age, 77 years; 42 men and 91 women) from 27 university hospitals and their affiliated hospitals. We divided patients into two groups: a short-segment fusion group (S group) with 2- or 3-segment fusion (87 patients) and a long-segment fusion group (L group) with 4- through 6-segment fusion (46 patients). Surgical invasion, clinical outcomes, local kyphosis angle (LKA), and complications were evaluated.

Results: No significant differences between the two groups were observed in terms of neurological recovery, pain scale scores, and complications. Surgical time was shorter and blood loss was less in the S group, whereas LKA at the final follow-up and correction loss were superior in the L group.

Conclusion: Although less invasiveness and validity of pain and neurological relief are secured by short-segment VP + PSF, surgeons should be cautious regarding correction loss.
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http://dx.doi.org/10.1186/s12891-020-03539-0DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7395972PMC
August 2020

Effect of bisphosphonates or teriparatide on mechanical complications after posterior instrumented fusion for osteoporotic vertebral fracture: a multi-center retrospective study.

BMC Musculoskelet Disord 2020 Jul 1;21(1):420. Epub 2020 Jul 1.

Department of Orthopaedic Surgery, Keio University School of Medicine, 35 Shinanomachi, Shinjuku-ku, Tokyo, 160-8582, Japan.

Background: The optimal treatment of osteoporosis after reconstruction surgery for osteoporotic vertebral fractures (OVF) remains unclear. In this multicentre retrospective study, we investigated the effects of typically used agents for osteoporosis, namely, bisphosphonates (BP) and teriparatide (TP), on surgical results in patients with osteoporotic vertebral fractures.

Methods: Retrospectively registered data were collected from 27 universities and affiliated hospitals in Japan. We compared the effects of BP vs TP on postoperative mechanical complication rates, implant-related reoperation rates, and clinical outcomes in patients who underwent posterior instrumented fusion for OVF. Data were analysed according to whether the osteoporosis was primary or glucocorticoid-induced.

Results: A total of 159 patients who underwent posterior instrumented fusion for OVF were included. The overall mechanical complication rate was significantly lower in the TP group than in the BP group (BP vs TP: 73.1% vs 58.2%, p = 0.045). The screw backout rate was significantly lower and the rates of new vertebral fractures and pseudoarthrosis tended to be lower in the TP group than in the BP group. However, there were no significant differences in lumbar functional scores and visual analogue scale pain scores or in implant-related reoperation rates between the two groups. The incidence of pseudoarthrosis was significantly higher in patients with glucocorticoid-induced osteoporosis (GIOP) than in those with primary osteoporosis; however, the pseudoarthrosis rate was reduced by using TP. The use of TP also tended to reduce the overall mechanical complication rate in both primary osteoporosis and GIOP.

Conclusions: The overall mechanical complication rate was lower in patients who received TP than in those who received a BP postoperatively, regardless of type of osteoporosis. The incidence of pseudoarthrosis was significantly higher in patients with GIOP, but the use of TP reduced the rate of pseudoarthrosis in GIOP patients. The use of TP was effective to reduce postoperative complications for OVF patients treated with posterior fusion.
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http://dx.doi.org/10.1186/s12891-020-03452-6DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7331246PMC
July 2020

Associations between three-dimensional measurements of the spinal deformity and preoperative SRS-22 scores in patients undergoing surgery for major thoracic adolescent idiopathic scoliosis.

Spine Deform 2020 12 2;8(6):1253-1260. Epub 2020 Jun 2.

Orthopedics and Scoliosis Division, Rady Children's Hospital, 3020 Children's Way, MC 5062, San Diego, CA, 92123, USA.

Study Design: Retrospective study.

Objective: To analyze the relationships between three-dimensional (3D) measurements of spinal deformity and Scoliosis Research Society-22 (SRS-22) scores in preoperative patients with major thoracic adolescent idiopathic scoliosis (AIS). Previous studies reported 2D measurements were not or only weakly correlated with preoperative SRS-22 scores. However, 2D measures do not always accurately represent the 3D deformity.

Methods: A multicenter prospective registry of surgically treated AIS patients was reviewed for patients with right major thoracic AIS (Lenke type 1-4) who underwent biplanar radiography and completed the SRS-22 questionnaire preoperatively. For the 3D measurements, two reference frames were utilized: global (gravity/patient-based) and local (vertebra/disc-based). To obtain regional measurements, the individual segments in the appropriate reference plane were summed between the levels of interest. Patients were divided into two groups for each SRS-22 domain according to their scores: low (< 4) and high (≥ 4) score groups. Group differences and correlations with SRS-22 scores were analyzed with p < 0.01 as the threshold for significance.

Results: There were 405 eligible patients (mean age, 14.4 years). The mean 3D thoracic curve was 59° (45°-115°). The only significant group difference of 3D measurements occurred in the local lumbar lordosis (LL) with a small mean difference (- 3.4°, p = 0.008) in the mental health domain. In the correlation analyses, global and local thoracic kyphosis (TK) and TK/LL ratio demonstrated significant, but weak, correlations with function and total scores (|r|< 0.2, p < 0.01).

Conclusion: 3D measurements of scoliosis severity have only weak associations with preoperative SRS-22 scores, which might indicate a limit to the discriminative capacity of the SRS-22 within surgical range major thoracic AIS curves. Interestingly, the sagittal plane was the principle 3D plane in which significant correlations existed.

Level Of Evidence: II, prognostic.
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http://dx.doi.org/10.1007/s43390-020-00150-0DOI Listing
December 2020

Impact of L4/5 Posterior Interbody Fusion With or Without Decompression on Spinopelvic Alignment and Health-related Quality-of-Life Outcomes.

Clin Spine Surg 2020 Dec;33(10):E504-E511

Department of Regenerative and Transplant Medicine, Division of Orthopedic Surgery, Niigata University Graduate School of Medical and Dental Sciences.

Study Design: This was a retrospective case control study.

Objective: The objective was to determine the impact of single-level interbody fusion at L4/5 with or without concomitant decompression on various spinopelvic parameters and health-related quality-of-life (HRQOL) outcomes.

Summary Of Background Data: Recently, focus has swayed from a regional concern to a global sagittal alignment, more comprehensive approach in multilevel, corrective fusion for adult spinal deformity. However, only a few comprehensive studies have investigated the relationships between the various related spinopelvic parameters and HRQOL outcomes using single-level interbody fusion.

Materials And Methods: In total, 119 patients with lumbar degenerative disorders (mean age, 68 y; 38 males and 81 females) who underwent L4/5 single-level posterior interbody fusion with a minimum 2-year follow-up were included. Participants were divided into 2 groups according to preoperative sagittal modifiers of the SRS-Schwab adult spinal deformity classification. The correlation between spinopelvic parameters and HRQOL outcomes was investigated. Negative or positive values indicated lordosis. HRQOL outcomes were assessed using visual analog scale scores, Japanese Orthopedic Association Back Pain Evaluation Questionnaires (JOABPEQ), and short form-36 (SF-36).

Results: L4/5 local lordosis increased from 6.4±4.4 degrees preoperatively to 11.3±4.5 degrees at 2 years postoperatively (P<0.0001). Further analysis of the results also showed a correlation between change in L4/5 local lordosis and change in lumbar lordosis (LL) (rs=0.229, P=0.0143). The high pelvic incidence-LL (≥20 degrees, n=28) and high sagittal vertical axis groups (≥5 cm, n=29) had lower scores in walking ability, social life domains of JOABPEQ, and physical component summary scores of SF-36 preoperatively, and 2 years postoperatively. Fusion status did not affect the HRQOL outcomes, except that concomitant decompression at the adjacent disk level yielded lower SF-36 physical component summary scores 2 years postoperatively.

Conclusions: Improvement in L4/5 local lordosis possibly triggers a simultaneous sequence of change in total LL after posterior single-level fusion. HRQOL outcomes were negatively affected by both preoperative and postoperative pelvic incidence-LL mismatch and global sagittal malalignment.

Level Of Evidence: Level III.
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http://dx.doi.org/10.1097/BSD.0000000000001013DOI Listing
December 2020

Prospective 10-year follow-up assessment of spinal fusions for thoracic AIS: radiographic and clinical outcomes.

Spine Deform 2020 02 8;8(1):57-66. Epub 2020 Jan 8.

Cooper Bone & Joint Institute, Camden, NJ, USA.

Study Design: Prospective registry. The evolution of spinal instrumentation has provided better outcomes in adolescent idiopathic scoliosis (AIS); however, there is a paucity of reliable prospective information on 10-year post-operative outcomes of modern surgical techniques.

Methods: A prospective multicenter registry of patients who had surgical correction of AIS was reviewed. Patients with major thoracic scoliosis (Lenke types 1-4) operated on between 1997 and 2007, with 10-year post-operative follow-up data were included. Radiographic and clinical outcomes including Scoliosis Research Society (SRS)-22 scores and revision surgeries were evaluated.

Results: One hundred and seventy-four patients (mean 25.0 years of age at most recent evaluation) were included. Pedicle screw constructs were used in 102 patients (58%), hook or hybrid constructs in 22 (13%), and anterior screw-rod constructs in 50 (29%). The mean pre-operative thoracic Cobb angle was corrected from 53° to 18° initially. At 10-year follow-up, the mean thoracic curve was 22° (mean 57% correction), with 29 patients (16.7%) having loss of correction (LOC) ≥ 10°. There were a total of 14 revision surgeries performed in 13 patients (7.5%). SRS-22 pain (p = 0.035), self-image (p < 0.001), and total scores (p < 0.001) significantly improved at 2-year follow-up. The mean pain score at 10-year follow-up was similar to pre-operative scores and lower (more pain) than previously published mean scores of normal adults aged 20-40 years (p < 0.05).

Conclusions: Spinal fusion patients report SRS-22 quality of life 10 years after scoliosis surgery that is minimally reduced compared to healthy peers and substantially better than an un-operated cohort of comparably aged scoliosis patients. Adolescents with thoracic idiopathic scoliosis should expect little if any change in their health-related quality of life compared to before surgery, high satisfaction, and a 7.5% chance of revision surgery 10 years after their index spinal fusion.

Level Of Evidence: Therapeutic II.
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http://dx.doi.org/10.1007/s43390-019-00015-1DOI Listing
February 2020

The Benefits of Sparing Lumbar Motion Segments in Spinal Fusion for Adolescent Idiopathic Scoliosis Are Evident at 10 Years Postoperatively.

Spine (Phila Pa 1976) 2020 Jun;45(11):755-763

Division of Orthopedics and Scoliosis, Rady Children's Hospital, San Diego, CA.

Study Design: A prospective multicenter study.

Objective: To evaluate the effects of sparing lumbar motion segments on spinal mobility and Scoliosis Research Society-22 scores at 10 years after spinal fusion for major thoracic adolescent idiopathic scoliosis (AIS).

Summary Of Background Data: In surgical correction for major thoracic AIS, the long-term benefits of sparing lumbar motion segments remain unclear.

Methods: A prospective multicenter registry was reviewed and patients with major thoracic AIS (Lenke types 1-4) and availability of both preoperative and 10-year postoperative mobility data were included. Spinal fusions ending at L1 or above were defined as thoracic fusions (T), and at L2 or below as thoracic and lumber fusions (T + L). Spinal mobility was evaluated with a measuring tape. The excursions between the starting and ending positions were measured using the distance from the spinous processes of C7 to S1 for forward flexion (FF), and the distance from the tip of the middle finger to the floor for lateral flexion (LF). Substantial reduction of mobility was defined as a reduction rate (a ratio of postoperative change divided by preoperative mobility) of 40% or more. Motion data were correlated with lowest instrumented vertebra levels and group comparisons were performed.

Results: We identified 151 patients (average age, 25.1 years). The spinal mobility decreased with more distal lowest instrumented vertebrae (FF, rho = 0.208; right LF, 0.257; left LF, 0.371; P ≤ 0.01). Consequently, the incidence of substantial reduction of mobility was lower in the T group (n = 109) than in the T + L group (n = 42) (FF: 17.4% vs. 50%, LF: 14.8% vs. 51.2%; P < 0.001). Patients with substantial reduction in LF had lower Scoliosis Research Society-22 scores for pain, function, satisfaction, and total scores than those without substantial reduction at 10-year follow-up (P < 0.05).

Conclusion: The sparing of lumbar motion segments demonstrated clinically significant benefits at 10-year postoperatively.

Level Of Evidence: 2.
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http://dx.doi.org/10.1097/BRS.0000000000003373DOI Listing
June 2020

Health-Related Quality of Life in Nonoperated Patients With Adolescent Idiopathic Scoliosis in the Middle Years: A Mean 25-Year Follow-up Study.

Spine (Phila Pa 1976) 2020 Jan;45(2):E83-E89

Division of Orthopedic Surgery, Department of Regenerative and Transplant Medicine, Niigata University Graduate School of Medical and Dental Sciences, Niigata City, Japan.

Study Design: A retrospective long-term follow-up study.

Objective: To investigate the health-related quality of life (HRQOL) status in middle-aged patients with adolescent idiopathic scoliosis (AIS) treated non-surgically.

Summary Of Background Data: The HRQOL status using various established questionnaires for non-operated AIS patients has not been fully investigated in long-term follow-up surveys.

Methods: Inclusion criteria were non-surgical treatment for AIS, more than or equl to 30° major scoliosis at skeletal maturity (Risser grade ≥4), and age more than or equl to 30 years at the time of the survey. A total of 107 AIS patients were included and divided into three groups (single main thoracic [MT] curve group; n = 50, single thoracolumbar/lumbar [TL/L] curve group; n = 19, and double-major [DM] curve group; n = 38) based on curve location at skeletal maturity. Age- and sex-matched volunteers were selected as the control group.

Results: There were no significant differences in age at survey, body mass index, bone mineral density of the femoral neck, and skeletal muscle mass index among the groups. In all groups, major scoliosis progressed by approximately 0.5°/yr from the time of skeletal maturity to the survey. The thoracolumbar (TL/L) and double-major (DM) groups showed significantly worse visual analog scale scores for low back pain compared with the main thoracice (MT) group (P < 0.05). The all-scoliosis groups showed significantly worse scores for self-image domain of the Scoliosis Research Society Outcome Instrument-22 (SRS-22) than the control group (P < 0.0001). The TL/L group showed significantly worse scores for walking ability and social function domains of the Japanese Orthopaedic Association Back Pain Evaluation Questionnaire (JOABPEQ) (P < 0.05). There were no significant differences in Oswestory Disability Index and Short-Form-12 among the four groups.

Conclusion: AIS patients with single MT curve maintain equal HRQOL status compared with healthy controls. Patients with structural TL/L curves are likely to experience greater annual TL/L curve progression and have substantial low back pain or worse low back pain-specific HRQOL status during middle age.

Level Of Evidence: 4.
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http://dx.doi.org/10.1097/BRS.0000000000003216DOI Listing
January 2020

Three-dimensional morphological analysis of cervical foraminal stenosis using dynamic flexion-extension computed tomography images.

J Orthop Sci 2020 Sep 9;25(5):805-811. Epub 2019 Dec 9.

Department of Orthopedic Surgery, Niigata University, Medical and Dental General Hospital, 1-757 Asahimachidori, Chuoku, Niigata City, Niigata, 951-8510, Japan.

Background: Morphological features of foraminal stenosis in cervical spondylotic radiculopathy and the adequate extent of facet resection in posterior cervical foraminotomy remain uncertain. Herein, we evaluated quantitatively foraminal widths in cervical spondylotic radiculopathy on dynamic flexion-extension computed tomography using a novel three-dimensional analysis method and determined the extent of facet resection in posterior cervical foraminotomy.

Methods: Seventeen patients undergoing posterior cervical foraminotomy for cervical spondylotic radiculopathy were evaluated. A neuroforamen three-dimensional model was built from preoperative images of flexion-extension computed tomography myelography, and an ordinary cervical spine coordinate system and an original neuroforaminal coordinate system, were established. In the neuroforaminal coordinate system, minimum areas perpendicular to the long axis by the slices from inlet to outlet of neuroforamen and narrowest foraminal width in a slice of minimum area were measured. The location of the narrowest region from inlet of the foramen was calculated. Ratios of minimum and sufficient facet resection were obtained from the location of the narrowest region in the neuroforaminal coordinate system.

Results: The narrowest foraminal widths (flexion/extension) in the cervical spine coordinate system and the neuroforaminal coordinate system were 2.9/2.3 and 2.6/1.9 mm, respectively. The mean values of the location of the narrowest region (flexion/extension) were 0.27/0.22 and 0.50/0.45 mm, respectively, and the narrowest region in the neuroforaminal coordinate system was located on the outer side than in the cervical spine coordinate system (p < 0.001). The ratios of minimum and sufficient facet resection were 23 ± 8% and 32 ± 9%, respectively.

Conclusions: The narrowest regions both in flexion and extension are located at the middle of the foramen based on the neuroforaminal coordinate system. Ordinary evaluation of axial computed tomography images likely underestimates the extent of facet resection, whereas certain extent of facet resection does not exceed 50% in cases with single-level cervical spondylotic radiculopathy.

Study Design: A retrospective case control study.
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http://dx.doi.org/10.1016/j.jos.2019.11.002DOI Listing
September 2020

Surgical outcomes of spinal fusion for osteoporotic vertebral fracture in the thoracolumbar spine: Comprehensive evaluations of 5 typical surgical fusion techniques.

J Orthop Sci 2019 Nov 21;24(6):1020-1026. Epub 2019 Aug 21.

Department of Orthopaedic Surgery, Keio University School of Medicine, 35 Shinanomachi, Shinjuku-ku, Tokyo, 160-8582, Japan; Department of Orthopaedic Surgery, International University of Health and Welfare, Mita, Minato-ku, Tokyo, 108-8329, Japan.

Background: A consensus on the optimal surgical procedure for thoracolumbar OVF has yet to be reached due to the previous relatively small number of case series. The study was conducted to investigate surgical outcomes for osteoporotic vertebral fracture (OVF) in the thoracolumbar spine.

Methods: In total, 315 OVF patients (mean age, 74 years; 68 men and 247 women) with neurological symptoms who underwent spinal fusion with a minimum 2-year follow-up were included. The patients were divided into 5 groups by procedure: anterior spinal fusion alone (ASF group, n = 19), anterior/posterior combined fusion (APSF group, n = 27), posterior spinal fusion alone (PSF group, n = 40), PSF with 3-column osteotomy (3CO group, n = 92), and PSF with vertebroplasty (VP + PSF group, n = 137).

Results: Mean operation time was longer in the APSF group (p < 0.05), and intraoperative blood loss was lower in the VP + PSF group (p < 0.05). The amount of local kyphosis correction was greater in the APSF and 3CO groups (p < 0.05). Clinical outcomes were approximately equivalent among all groups.

Conclusion: All 5 procedures resulted in acceptable neurological outcomes and functional improvement in walking ability. Moreover, they were similar with regard to complication rates, prevalence of mechanical failure related to the instrumentation, and subsequent vertebral fracture. Individual surgical techniques can be adapted to suit patient condition or severity of OVF.
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http://dx.doi.org/10.1016/j.jos.2019.07.018DOI Listing
November 2019

Risk Factors for Proximal Junctional Fracture Following Fusion Surgery for Osteoporotic Vertebral Collapse with Delayed Neurological Deficits: A Retrospective Cohort Study of 403 Patients.

Spine Surg Relat Res 2019 Apr 19;3(2):171-177. Epub 2018 Oct 19.

Department of Orthopaedic Surgery, Keio University, Tokyo, Japan.

Introduction: Approximately 3% of osteoporotic vertebral fractures develop osteoporotic vertebral collapse (OVC) with neurological deficits, and such patients are recommended to be treated surgically. However, a proximal junctional fracture (PJFr) following surgery for OVC can be a serious concern. Therefore, the aim of this study is to identify the incidence and risk factors of PJFr following fusion surgery for OVC.

Methods: This study retrospectively analyzed registry data collected from facilities belonging to the Japan Association of Spine Surgeons with Ambition (JASA) in 2016. We retrospectively analyzed 403 patients who suffered neurological deficits due to OVC below T10 and underwent corrective surgery; only those followed up for ≥2 years were included. Potential risk factors related to the PJFr and their cut-off values were calculated using multivariate logistic regression analysis and receiver operating characteristic (ROC) analysis.

Results: Sixty-three patients (15.6%) suffered PJFr during the follow-up (mean 45.7 months). In multivariate analysis, the grade of osteoporosis (grade 2, 3: adjusted odds ratio (aOR) 2.92; p=0.001) and lower instrumented vertebra (LIV) level (sacrum: aOR 6.75; p=0.003) were independent factors. ROC analysis demonstrated that lumbar bone mineral density (BMD) was a predictive factor (area under curve: 0.72, p=0.035) with optimal cut-off value of 0.61 g/cm (sensitivity, 76.5%; specificity, 58.3%), but that of the hip was not (p=0.228).

Conclusions: PJFr was found in 16% cases within 4 years after surgery; independent risk factors were severe osteoporosis and extended fusion to the sacrum. The lumbar BMD with cut-off value 0.61 g/cm may potentially predict PJFr. Our findings can help surgeons select perioperative adjuvant therapy, as well as a surgical strategy to prevent PJFr following surgery.
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http://dx.doi.org/10.22603/ssrr.2018-0068DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6690093PMC
April 2019

A novel concept of posterior decompression and instrumented fusion with selective lordotic correction for cervical ossification of the posterior longitudinal ligament.

J Clin Neurosci 2019 Oct 20;68:312-316. Epub 2019 Jul 20.

Department of Orthopedic Surgery, Niigata University Medical and Dental General Hospital, Niigata City, Niigata, Japan.

Purpose: The recovery rate of Japanese Orthopedic Association (JOA) score with K-line (-) cervical ossification of the posterior longitudinal ligament (OPLL) for posterior decompression with in-situ fusion (PDF) tends to be lower than that of anterior decompression with fusion (ADF). However, ADF is a technically demanding operation and has ADF-specific complications. This prospective report introduced a novel concept of PDF with selective lordotic correction as well as prophylactic foraminal decompression.

Methods: Six consecutive patients (four men and two women; mean age, 61.8 years) were included. PDF was performed, attempting to create cervical lordosis to acquire a posterior shift of the spinal cord, while preventing postoperative C5 palsy by prophylactic facetectomy and selective lordotic correction.

Results: The mean recovery rate of JOA score at the final follow-up was 70.9 ± 20.3%. The mean C2-C7 angle preoperatively and at final follow-up was 5.5 ± 3.9° and 12.2 ± 4.8°, respectively. No symptomatic nerve root palsy, except one case with transient C7 root iatrogenic palsy, was found.

Conclusions: A novel concept of PDF with selective lordotic correction obtained recovery rates of JOA scores comparable to those of ADF. We believe that this method can improve PDF outcomes in patients with K-line (-) OPLL.
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http://dx.doi.org/10.1016/j.jocn.2019.07.040DOI Listing
October 2019

Flexibility of the thoracic curve and three-dimensional thoracic kyphosis can predict pulmonary function in nonoperatively treated adult patients with adolescent idiopathic scoliosis.

J Orthop Sci 2020 Jul 11;25(4):551-556. Epub 2019 Jul 11.

Department of Orthopedic Surgery, Niigata University Medical and Dental Hospital, 1-757 Asahimachi Dori, Chuo-ku, Niigata, 951-8510, Japan.

Background: Although several radiographic predictors for pulmonary function in adolescent patients have been reported, those in adult patients remain unclear. Therefore, we aimed to investigate the associations between spinal deformity and pulmonary function in nonoperatively treated adult patients with adolescent idiopathic scoliosis (AIS).

Methods: Of 319 patients treated nonoperatively for AIS, 90 (average age, 40.0 ± 6.5 years) underwent both full-length standing radiographs and pulmonary function test. Standard two-dimensional (2-D) radiographic measurements were performed. Three-dimensional thoracic kyphosis (3-D TK) was calculated from 2-D standing radiograph data using a validated formula: 3-D TK (°) = 18.1 + 0.81 × (2-D TK) + 0.54 × (Cobb angle of thoracic curve). 3-D TK was defined as the sum of segmental kyphosis between T5 and T12, which eliminates the overestimation of TK in 2-D measurements due to rotational deformity. Bivariable correlation analysis, followed by a stepwise multiple linear regression analysis, was performed.

Results: The average Cobb angle of the thoracic curve at the time of survey was 49.4° ± 14.6° with flexibility of 37.5% ± 18.2%. Thoracic curve magnitude, flexibility, apical vertebral rotation and translation, and 3-D TK were significantly correlated with percent-predicted forced vital capacity (%FVC) and expiratory volume in 1 s (%FEV1.0). Stepwise multiple regression analysis showed that curve flexibility and 3-D TK were significant, independent predictors of %FVC (R = 0.358) and %FEV1.0 (R = 0.335), curve flexibility having a greater impact (standardized coefficient > 0.45) than 3-D TK (<0.32).

Conclusions: Our results indicate that nonoperatively treated patients with AIS should be recommended to maintain flexibility of the thoracic curve to prevent future pulmonary impairment. Moreover, 3-D TK is another independent predictor of pulmonary function, which suggests that segmental sagittal alignment is a component of deformity correction to focus on.
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http://dx.doi.org/10.1016/j.jos.2019.06.015DOI Listing
July 2020

Long-term Impacts of Brace Treatment for Adolescent Idiopathic Scoliosis on Body Composition, Paraspinal Muscle Morphology, and Bone Mineral Density.

Spine (Phila Pa 1976) 2019 Sep;44(18):E1075-E1082

Department of Orthopedic Surgery, Niigata University Medical and Dental Hospital, Niigata, Japan.

Study Design: A retrospective, long-term follow-up study.

Objective: We aimed to investigate the long-term impacts of brace treatment for adolescent idiopathic scoliosis (AIS) on the musculoskeletal system.

Summary Of Background Data: Although full-time brace treatment is the mainstay of conservative treatment for AIS, the restrictive nature of brace treatment for lumbosacral motion might negatively affect the musculoskeletal system.

Methods: Of 319 patients treated nonoperatively for AIS, 80 patients completed clinical and imaging examinations. Body composition, including body fat mass, lean mass, fat percent, and muscle mass, was estimated via bioelectrical impedance analysis. Bone mineral density (BMD) was measured at the lumbar spine and left hip. In 73 patients, the measurement of cross-sectional area and fatty degeneration of paraspinal muscles at the superior endplate of L4 were performed using axial T2-weighted magnetic resonance imaging. Patients were divided into the full-time brace (FB; >13 hours per day) and nonfull-time brace (NFB; observation, part-time bracing, or drop out from FB within a year) groups.

Results: There were 44 patients in the FB group and 36 in the NFB group. Patients in the FB group were significantly younger at the initial visit (12.7 ± 1.3 years) and older at the final follow-up (41.5 ± 5.6 years) than those in the NFB group (14.2 ± 3.2 and 37.4 ± 7.1 years, respectively; P < 0.01). The rate of patients engaging in mild or moderate sports activity in adulthood tended to be higher in the FB group (47.7%) than in the NFB group (25%) (P = 0.11). However, there were no significant differences in body composition, paraspinal muscle morphology, and BMD between the two groups both before and after adjusting for age.

Conclusion: Full-time brace wearing during adolescence did not have any negative impacts on the musculoskeletal system in adulthood. This information will be helpful for improving the compliance of full-time bracing.

Level Of Evidence: 4.
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http://dx.doi.org/10.1097/BRS.0000000000003069DOI Listing
September 2019

Quantitative radiographic analysis of foraminal re-stenosis after posterior cervical foraminotomy with laminoplasty.

J Clin Neurosci 2019 Sep 18;67:99-104. Epub 2019 Jun 18.

Department of Orthopedic Surgery, Niigata University, Medical and Dental General Hospital, 1-757 Asahimachidori Chuoku, Niigata City, Niigata 951-8510, Japan.

Few studies have performed detailed radiographic evaluation of the cause of recurrent cervical radiculopathy. In this study, we aimed to perform quantitative analyses of foraminal re-stenosis after posterior cervical foraminotomy (PCF) concomitant with laminoplasty. Seventy-eight consecutive patients (50 males and 28 females, mean age of 62 years at surgery) with cervical spondylotic radiculomyelopathy who underwent PCF concomitant with open-door laminoplasty were included. A total of 133 foramina undergoing PCF were radiographically evaluated using the following parameters: disc height, focal range of motion at the corresponding disc level, foraminal diameter (FD) and facet joint width (FJW) in the axial view on computed tomography, and re-stenosis rate (RR) of foramina. RR was calculated as follows: (foraminal regrowth at 2 years after surgery)/(foraminal enlargement immediate postoperatively) × 100% (RR2y). FDs preoperatively, postoperatively, and at 2-year follow-up were 2.2, 6.6, and 4.6 mm, respectively, and FJWs were 14.5, 9.0, and 10.6 mm, respectively. Both parameters significantly increased at the 2-year follow-up (p < 0.001). The mean RR2y was 42% (range, -16 to 108%). On logistic regression analysis of risk factors for higher RR2y (>50%), only preoperative posterior disc height (PDH) (OR = 0.33; 95% CI = 0.193-0.563; p < 0.001) was identified. Receiver operating characteristic curve analysis showed that the cut-off value of RR2y 50% was 1-mm PDH (AUC 0.73, sensitivity 52%, specificity 86%, p value < 0.001). After posterior foraminotomy with laminoplasty, the enlarged foraminal space gradually decreased during the 2-year follow-up. Foraminal re-stenosis was mainly due to bone regrowth of the resected facet joint, which is caused by disc degeneration with loss of PDH.
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http://dx.doi.org/10.1016/j.jocn.2019.06.012DOI Listing
September 2019

Mechanisms of noradrenergic modulation of synaptic transmission and neuronal excitability in ventral horn neurons of the rat spinal cord.

Neuroscience 2019 06 13;408:161-176. Epub 2019 Apr 13.

Division of Anesthesiology, Niigata University Graduate School of Medical and Dental Sciences, Asahimachidori 1-757, Chuo-ku, Niigata-city, 951-8510, Japan; Department of Anesthesiology, Tohoku Medical and Pharmaceutical University, Fukumuro 1-12-1, Miyagino-ku, Sendai-city, 983-8512, Japan. Electronic address:

Noradrenaline (NA) modulates the spinal motor networks for locomotion and facilitates neuroplasticity, possibly assisting neuronal network activation and neuroplasticity in the recovery phase of spinal cord injuries. However, neither the effects nor the mechanisms of NA on synaptic transmission and neuronal excitability in spinal ventral horn (VH) neurons are well characterized, especially in rats aged 7 postnatal days or older. To gain insight into NA regulation of VH neuronal activity, we used a whole-cell patch-clamp approach in late neonatal rats (postnatal day 7-15). In voltage-clamp recordings at -70 mV, NA increased the frequency and amplitude of excitatory postsynaptic currents via the activation of somatic α- and β-adrenoceptors of presynaptic neurons. Moreover, NA induced an inward current through the activation of postsynapticα- and β-adrenoceptors. At a holding potential of 0 mV, NA also increased frequency and amplitude of both GABAergic and glycinergic inhibitory postsynaptic currents via the activation of somatic adrenoceptors in presynaptic neurons. In current-clamp recordings, NA depolarized resting membrane potentials and increased the firing frequency of action potentials in VH neurons, indicating that it enhances the excitability of these neurons. Our findings provide new insights that establish NA-based pharmacological therapy as an effective method to activate neuronal networks of the spinal VH in the recovery phase of spinal cord injuries.
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http://dx.doi.org/10.1016/j.neuroscience.2019.03.026DOI Listing
June 2019

Action of Norepinephrine on Lamina X of the Spinal Cord.

Neuroscience 2019 06 11;408:214-225. Epub 2019 Apr 11.

Division of Anesthesiology, Niigata University Graduate School of Medical and Dental Sciences, 1-757 Asahimachi Dori, Chuo-Ku, Niigata City, Niigata 951-8510, Japan.

Lamina X is localized in the spinal cord within the region surrounding the central canal and receives descending projections from the supraspinal nuclei. Norepinephrine (NE) is a neurotransmitter in descending pathways emanating from the brain stem; NE-containing fibers terminate in the spinal dorsal cord, particularly in the substantia gelatinosa (SG). NE enhances inhibitory synaptic transmission in SG neurons by activating presynaptic α1-receptors and hyperpolarizes the membranes of SG neurons by acting on α2-receptors; NE may thus act directly on SG neurons of the dorsal spinal cord and inhibit nociceptive transmission at the spinal level. NE-containing fibers also reportedly terminate in lamina X, suggesting that NE also modulates synaptic transmission in lamina X. However, the cellular mechanisms underlying such action have not been investigated. We hypothesized that NE might directly act on lamina X and enhance inhibitory synaptic transmission therein. Using rat spinal cord slices and in vitro whole-cell patch-clamps, we found that the bath-application of NE to lamina X does not affect the excitatory interneurons but enhances GABAergic and glycinergic miniature inhibitory postsynaptic currents (mIPSCs) and induces an outward current. NE-induced enhancement of mIPSCs was blocked by α1A-receptor antagonists, and NE-induced outward current was blocked by α2-receptor antagonists. NE did not affect GABA- or glycine- induced outward currents. These findings are similar to those obtained from SG neurons: NE may act at presynaptic terminals of GABAergic and glycinergic interneurons on lamina X to facilitate inhibitory-transmitter release through α1A-receptor activation and directly induce inhibitory interneuron membrane hyperpolarization through α2-receptors activation.
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http://dx.doi.org/10.1016/j.neuroscience.2019.04.004DOI Listing
June 2019

Surgical outcomes of spinal fusion for osteoporotic thoracolumbar vertebral fractures in patients with Parkinson's disease: what is the impact of Parkinson's disease on surgical outcome?

BMC Musculoskelet Disord 2019 Mar 9;20(1):103. Epub 2019 Mar 9.

Department of Orthopaedic Surgery, Keio University School of Medicine, 35 Shinanomachi, Shinjuku-ku, Tokyo, 160-8582, Japan.

Background: To date, there have been little published data on surgical outcomes for patients with PD with thoracolumbar OVF. We conducted a retrospective multicenter study of registry data to investigate the outcomes of fusion surgery for patients with Parkinson's disease (PD) with osteoporotic vertebral fracture (OVF) in the thoracolumbar junction.

Methods: Retrospectively registered data were collected from 27 universities and their affiliated hospitals in Japan. In total, 26 patients with PD (mean age, 76 years; 3 men and 23 women) with thoracolumbar OVF who underwent spinal fusion with a minimum of 2 years of follow-up were included (PD group). Surgical invasion, perioperative complications, radiographic sagittal alignment, mechanical failure (MF) related to instrumentation, and clinical outcomes were evaluated. A control group of 296 non-PD patients (non-PD group) matched for age, sex, distribution of surgical procedures, number of fused segments, and follow-up period were used for comparison.

Results: The PD group showed higher rates of perioperative complications (p < 0.01) and frequency of delirium than the non-PD group (p < 0.01). There were no significant differences in the degree of kyphosis correction, frequency of MF, visual analog scale of the symptoms, and improvement according to the Japanese Orthopaedic Association scoring system between the two groups. However, the PD group showed a higher proportion of non-ambulators and dependent ambulators with walkers at the final follow-up (p < 0.01).

Conclusions: A similar surgical strategy can be applicable to patients with PD with OVF in the thoracolumbar junction. However, physicians should pay extra attention to intensive perioperative care to prevent various adverse events and implement a rehabilitation regimen to regain walking ability.
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http://dx.doi.org/10.1186/s12891-019-2473-8DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6408814PMC
March 2019

Can posterior implant removal prevent device-related vertebral osteopenia after posterior fusion in adolescent idiopathic scoliosis? A mean 29-year follow-up study.

Eur Spine J 2019 06 19;28(6):1314-1321. Epub 2019 Feb 19.

Niigata Bone Science Institute, 761 Kizaki, Kitaku, Niigata City, 950-3304, Niigata, Japan.

Purpose: To determine whether posterior implant removal prevents stress-shielding-induced vertebral osteopenia within the posterior fusion area in surgically treated patients with adolescent idiopathic scoliosis (AIS).

Methods: Eighteen patients with major thoracic AIS (mean age, 43.3 years; range, 32-56 years; mean follow-up, 28.8 years, range, 20-39 years) who underwent posterior spinal fusion (PSF) alone between 1973 and 1994 were included. Participants were divided into implant removal (group R, n = 10, mean interval until implant removal, 50 months) and implant non-removal groups (group NR, n = 8). Bone mineral density was evaluated using the Hounsfield units (HU) of the computed tomography image of the full spine. The HU values of the UIV-1 (one level below the uppermost instrumented vertebra), apex, LIV+1 (one level above the lowermost instrumented vertebra), and LIV-1 (one level below the lowermost instrumented vertebra; as a standard value) were obtained. Stress-shielding-induced osteopenia was assessed as the UIV-1/LIV-1, apex/LIV-1, and LIV+1/LIV-1 HU ratios (× 100).

Results: Overall (median, 25th-75th percentile), the apex (144.7, 108.6-176.0) and LIV+1 (159.4, 129.7-172.3) demonstrated lower HU values than LIV-1 (180.3, 149.2-200.2) (both comparisons, p < .05). Comparison of groups R and NR showed no significant differences in the scoliosis correction rate, bone mineral density of the proximal femur, the HU absolute values of all investigated vertebrae, or in the HU ratios of the investigated vertebrae to LIV-1.

Conclusion: Instrumented PSF causes stress-shielding-induced osteopenia of the vertebral body within the fusion area in adulthood, which cannot be prevented by posterior implant removal, probably due to firm fusion mass formation. These slides can be retrieved under Electronic Supplementary Material.
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http://dx.doi.org/10.1007/s00586-019-05921-6DOI Listing
June 2019

En Bloc Spondylectomy for Spinal Metastases: Detailed Oncological Outcomes at a Minimum of 2 Years after Surgery.

Asian Spine J 2019 Apr 29;13(2):296-304. Epub 2018 Nov 29.

Department of Orthopedic Surgery, Niigata University Medical and Dental Hospital, Niigata, Japan.

Study Design: Retrospective case series.

Purpose: To investigate the oncological outcomes, including distant relapse, after en bloc spondylectomy (EBS) for spinal metastases in patients with a minimum of 2-year follow-up.

Overview Of Literature: Although EBS has been reported to be locally curative and extend survival in select patients with spinal metastases, detailed reports regarding the control of distant relapse after EBS are lacking.

Methods: We conducted a retrospective review of 18 consecutive patients (median age at EBS, 62 years; range, 40-77 years) who underwent EBS for spinal metastases between 1991 and 2015. The primary cancer sites included the kidney (n=7), thyroid (n=4), liver (n=3), and other locations (n=4). Survival rates were estimated using the Kaplan-Meier method, and groups were compared using the log-rank method.

Results: The median operative time and intraoperative blood loss were 767.5 minutes and 2,375 g, respectively. Twelve patients (66.7%) experienced perioperative complications. Five patients (27.8%) experienced local recurrence of the tumor at a median of 12.5 months after EBS, four of which had a positive resection margin status. Thirteen patients (72.2%) experienced distant relapse at a median of 21 months after EBS. The estimated median survival period after distant relapse was 20 months (95% confidence interval, 0.71-39.29 months). No association was found between resection margin status and distant relapse. Overall, the 2-year, 5-year, and 10-year survival rates after EBS were 72.2%, 48.8%, and 27.1%, respectively. Importantly, the era in which EBS was performed did not impact the oncological outcomes.

Conclusions: Our results suggest that EBS by itself, even if margin-free, cannot prevent further dissemination, which occurred in >70% of patients at a median of 21 months after EBS. These results should be considered and conveyed to patients for clinical decision-making.
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http://dx.doi.org/10.31616/asj.2018.0145DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6454284PMC
April 2019

Predicting Factors at Skeletal Maturity for Curve Progression and Low Back Pain in Adult Patients Treated Nonoperatively for Adolescent Idiopathic Scoliosis With Thoracolumbar/Lumbar Curves: A Mean 25-year Follow-up.

Spine (Phila Pa 1976) 2018 12;43(23):E1403-E1411

Division of Orthopedic Surgery, Department of Regenerative and Transplant Medicine, Niigata University Graduate School of Medical and Dental Sciences, Niigata, Japan.

Study Design: A retrospective, long-term follow-up study.

Objective: We aimed to clarify the predicting factors at skeletal maturity for future curve progression and low back pain (LBP) in adolescent idiopathic scoliosis (AIS) with thoracolumbar/lumbar (TL/L) curve.

Summary Of Background Data: TL/L curves are likely to progress after skeletal maturity and cause LBP.

Methods: Of 147 patients treated nonoperatively for AIS with TL/L curve, 56 (55 females; average age at the time of survey, 39.5 ± 7.1 years; average follow-up duration after maturity, 24.9 ± 6.9 years) completed questionnaires, including the visual analogue scale (VAS) for LBP and Oswestry disability index (ODI). Forty-nine patients underwent a radiological examination, and 48 underwent lumbar magnetic resonance imaging (MRI).

Results: The mean Cobb angle of the TL/L curve increased from 37.3° ± 7.5° to 47.8° ± 12.6° (0.41° ± 0.39° per year). The factors at skeletal maturity that were associated with the annual progression of the TL/L curve included a cranially located apical vertebra, and great apical vertebral translation and L3 tilt. In addition, the VAS for LBP was positively correlated with L4 tilt, and the ODI was positively correlated with L4 tilt and apical vertebral rotation. Multivariate analyses and receiver-operating characteristic curves demonstrated that L3 tilt at skeletal maturity independently predicted a curve progression ≥0.5° per year (odds ratio [OR], 1.17), while L4 tilt at skeletal maturity independently predicted a VAS ≥3 cm (OR, 1.20) and ODI ≥21% (OR, 1.25) in adulthood, with a cutoff value of approximately 16° for each factor. Moreover, lumbar disc degeneration on MRI was associated with L4 tilt at skeletal maturity and LBP in adulthood.

Conclusion: Great L3 and L4 tilt at skeletal maturity, especially those >16°, are predictors of future curve progression and LBP in adulthood, respectively. For adolescent patients with these risk factors, periodic follow-ups into adulthood should be considered.

Level Of Evidence: 4.
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http://dx.doi.org/10.1097/BRS.0000000000002716DOI Listing
December 2018

The Influence of Lumbar Muscle Volume on Curve Progression After Skeletal Maturity in Patients With Adolescent Idiopathic Scoliosis: A Long-Term Follow-up Study.

Spine Deform 2018 Nov - Dec;6(6):691-698.e1

Niigata Spine Surgery Center, Kameda Daiichi Hospital, Niigata City, Niigata, Japan.

Study Design: A retrospective cohort study.

Objectives: To investigate the relationship between skeletal muscle status of the trunk and the progression of adolescent idiopathic scoliosis (AIS) during adulthood.

Summary Of Background Data: To date, studies evaluating the risk factors for progression of AIS have principally focused on radiographic parameters.

Methods: Eighty-two women with AIS managed conservatively, who had a major curve ≥30° at skeletal maturity (Risser grade ≥4), were enrolled. Patients had been followed-up, on average, over 23.5 years (range, 12-37 years) after skeletal maturity, and were ≥30-years-old at the time of the survey (mean, 40.1 years). The ratio of the cross-sectional area (CSA) and signal intensity (SI) of muscles (multifidus [MF], erector spinae [ES], and psoas major [PM]) were evaluated using axial T2-weighted magnetic resonance images at the level of L4.

Results: The mean progression of the main thoracic and thoracolumbar/lumbar (TL/L) curves after skeletal maturity was 8.2° (mean annual rate of 0.4°) and 7.2° (mean annual rate of 0.3°), respectively. The mean CSA ratio was as follows: MF, 23.3%; ES, 79.6%; and PM, 40.5%. The mean SI ratio was as follows: MF, 34.9%; ES, 31.7%; and PM, 20.9%. On multivariate logistic regression, a higher SI ratio of the MF was predictive of a progression of the Cobb angle and translation of the apical vertebra, with a lower CSA ratio of the ES contributing to the progression of the Cobb angle for the TL/L curve.

Conclusions: In patients with AIS who have a major curve ≥30° at skeletal maturity, patients with greater TL/L curve progression have lower skeletal muscle volume and higher fatty degeneration of the lumbar extensor muscles in adulthood. However, further longitudinal or prospective studies are necessary to clarify the causal relationship between scoliosis progression and trunk muscular status.

Level Of Evidence: Level III, retrospective cohort study.
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http://dx.doi.org/10.1016/j.jspd.2018.04.003DOI Listing
February 2019

Perioperative factors associated with favorable outcomes of posterior decompression and instrumented fusion for cervical ossification of the posterior longitudinal ligament: A retrospective multicenter study.

J Clin Neurosci 2018 Nov 23;57:74-78. Epub 2018 Aug 23.

Department of Orthopedic Surgery, Niigata University Medical and Dental General Hospital, Niigata City, Niigata, Japan.

Purpose: Posterior decompression with instrumented fusion (PDF) is a suitable surgical treatment for K-line (-)-type cervical ossification of the posterior longitudinal ligament (OPLL). However, the adequate indications of PDF have not been clarified yet. The purpose of this study was to investigate the surgical results of PDF and perioperative factors that influence the surgical outcome, and to clarify the adequate indications of PDF.

Methods: Twenty-seven patients (21 men and 6 women, mean age: 61.4 years) who were diagnosed with a K-line (-)-type OPLL that was treated with PDF were included in this study. We evaluated these patients clinically and radiologically to investigate the outcomes of PDF and perioperative factors that influence improvements in the Japanese Orthopedic Association (JOA) score.

Results: The mean recovery rate of JOA score at the final follow-up examination was 53.3%. In the statistical analysis, the preoperative C2-C7 angle and the C2-C7 angle immediately postoperatively significantly predicted the surgical outcome. The C2-C7 angle immediately postoperatively was the only most important predictor. Using a receiver operating characteristic curve analysis, we found that the cutoff value of the C2-C7 angle immediately postoperatively for good outcomes (recovery rate of JOA score ≥50%) was -2.0°.

Conclusions: PDF for K-line (-)-type OPLL patients with preoperative lordotic alignment can be expected to have favorable outcomes, which is the adequate indication for PDF. Since the C2-C7 angle immediately postoperatively was the most important predictor, the physician should pay attention to maintain the cervical lordotic alignment to enhance the surgical outcomes in surgical planning.
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http://dx.doi.org/10.1016/j.jocn.2018.08.033DOI Listing
November 2018

The Natural Course of Compensatory Lumbar Curves in Nonoperated Patients With Thoracic Adolescent Idiopathic Scoliosis.

Spine (Phila Pa 1976) 2019 Jan;44(2):E89-E98

Division of Orthopedic Surgery, Department of Regenerative and Transplant Medicine, Niigata University Graduate School of Medical and Dental Sciences, Niigata, Japan.

Study Design: A retrospective, long-term follow-up study.

Objective: We investigated the natural course of compensatory lumbar curves in patients with primary thoracic adolescent idiopathic scoliosis (AIS).

Summary Of Background Data: The natural course of compensatory lumbar curves in primary thoracic AIS remains unknown.

Methods: Inclusion criteria were right-sided primary thoracic AIS ≥30° with a Lenke lumbar modifier of A or B at skeletal maturity and ≥30 years of age at the time of the survey. Fifty-one patients (mean age, 40.2 yr) returned for a follow-up evaluation (follow-up rate, 34.2%). Patients were classified into three groups based on the lumbar modifier (A or B) and direction of L4 tilt [right (R) or left (L)] (AR, n.11; AL, n.18; and B, n.22). At the time of the survey, 42 patients underwent radiological examinations and 37 underwent lumbar magnetic resonance imaging. Quality of life questionnaires were completed in all patients and in a 1:1 matched control group (no history of scoliosis).

Results: The thoracic curves had significantly progressed in all patient groups, while the compensatory lumbar curve progressed only in the B group. The C7 translation and L4 tilt shifted to the right in the AR and AL groups, but did not change in the B group. As a result, the L4 tilt (median, 11°) and C7 translation (18.6 mm) tended to be the greatest in the AR group. The incidences of Modic changes at L4/5 discs and ≥3 cm on the visual analogue scale for low back pain were significantly higher in the AR group (77.8% and 54.5%, respectively) compared with that in the other groups.

Conclusion: The natural course of compensatory lumbar curves is dependent on the lumbar modifier and direction of L4 tilt. Adolescent patients with right-sided primary thoracic AIS (≥30°) with L4 tilted to the right should be considered for periodic follow-ups into adulthood.

Level Of Evidence: 4.
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http://dx.doi.org/10.1097/BRS.0000000000002779DOI Listing
January 2019

Study protocol for the G-SPIRIT trial: a randomised, placebo-controlled, double-blinded phase III trial of granulocyte colony-stimulating factor-mediated neuroprotection for acute spinal cord injury.

BMJ Open 2018 05 5;8(5):e019083. Epub 2018 May 5.

G-SPIRIT Study Group, Chiba, Japan.

Introduction: Granulocyte colony-stimulating factor (G-CSF) is generally used for neutropaenia. Previous experimental studies revealed that G-CSF promoted neurological recovery after spinal cord injury (SCI). Next, we moved to early phase of clinical trials. In a phase I/IIa trial, no adverse events were observed. Next, we conducted a non-randomised, non-blinded, comparative trial, which suggested the efficacy of G-CSF for promoting neurological recovery. Based on those results, we are now performing a phase III trial.

Methods And Analysis: The objective of this study is to evaluate the efficacy of G-CSF for acute SCI. The study design is a prospective, multicentre, randomised, double-blinded, placebo-controlled comparative study. The current trial includes cervical SCI (severity of American Spinal Injury Association (ASIA) Impairment Scale B/C) within 48 hours after injury. Patients are randomly assigned to G-CSF and placebo groups. The G-CSF group is administered 400 µg/m/day×5 days of G-CSF in normal saline via intravenous infusion for 5 consecutive days. The placebo group is similarly administered a placebo. Our primary endpoint is changes in ASIA motor scores from baseline to 3 months. Each group includes 44 patients (88 total patients).

Ethics And Dissemination: The study will be conducted according to the principles of the World Medical Association Declaration of Helsinki and in accordance with the Japanese Medical Research Involving Human Subjects Act and other guidelines, regulations and Acts. Results of the clinical study will be submitted to the head of the respective clinical study site as a report after conclusion of the clinical study by the sponsor-investigator. Even if the results are not favourable despite conducting the clinical study properly, the data will be published as a paper.

Trial Registration Number: UMIN000018752.
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http://dx.doi.org/10.1136/bmjopen-2017-019083DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5942478PMC
May 2018

Risk factors for surgical site infection following spinal instrumentation surgery.

J Orthop Sci 2018 May 2;23(3):449-454. Epub 2018 Mar 2.

Division of Orthopedic Surgery, Department of Regenerative and Transplant Medicine, Niigata University Graduate School of Medical and Dental Sciences, Asahimachidori 1-757, Chuo-ku, Niigata-shi, 951-8510, Japan.

Background: In spinal instrumentation surgeries, surgical site infection (SSI) is one of the complications to be avoided. However, spinal instrumentation surgeries have a higher rate of SSI than other clean orthopedic surgeries. The purpose of this study was to investigate the risk factors for SSI following spinal instrumentation surgeries and contribute to the prevention of SSIs by identifying high-risk patients.

Methods: Records of 431 patients who underwent spinal instrumentation surgeries from 2011 to 2014 with a minimum follow-up period of 90 days were retrospectively reviewed. Associations of SSI with various preoperative, operative, and postoperative factors were statistically analyzed with univariate and stepwise multivariate logistic regression analysis.

Results: Deep or superficial SSIs were observed in 15 patients (3.5%). Univariate analysis revealed significant association of SSI with diabetes mellitus (odds ratio [OR] 4.7, 95% confidence interval [CI] 1.5-14.4; p = 0.012) and serum albumin ≤3.5 g/dl (OR 3.35, 95% CI 1.1-10.38, p = 0.012). The number of regular medications prescribed in patients with SSI (8.2 ± 5.4) was significantly more than that in patients without SSI (3.8 ± 4.4) (p = 0.001), and the cut-off value of the number of medications was 7, as derived from receiver operating characteristics analysis. Multivariate analysis revealed that the number of regular medications ≥7 was an independent risk factor significantly associated with SSIs (OR 7.3, 95% CI 2.3-24.0, p = 0.001).

Conclusions: Our study demonstrated that an important risk factor for SSI after spinal instrumentation surgery was number of regular medications ≥7. Number of regular medications is a simple and valuable risk index for SSI, which reflects the influence of medications and comorbidities.
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http://dx.doi.org/10.1016/j.jos.2018.02.008DOI Listing
May 2018