Filler Mixed Into Adhesives Does Not Necessarily Improve Their Mechanical Properties

OBJECTIVES

To investigate the influence of filler type/loading on the micro-tensile fracture strength (μTFS) of adhesive resins, as measured 'immediately' upon preparation and after 1-week water storage ('water-stored').

METHODS

The morphology and particle-size distribution of three filler particles, referred to as 'Glass-S' (Esschem Europe), 'BioUnion' (GC), and 'CPC_Mont', were correlatively characterized by SEM, TEM, and particle-size analysis. These filler particles were incorporated into an unfilled adhesive resin ('BZF-29unfilled', GC) in different concentrations to measure the 'immediate' μTFS. After 1-week water storage, the 'water-stored' μTFS of the experimental particle-filled adhesive resins with the most optimum filler loading, specific for each filler type, was measured. In addition, the immediate and water-stored μTFS of the adhesive resins of three experimental two-step universal adhesives based on the same resin matrix but varying for filler type/loading, coded as 'BZF-21' (containing silica and bioglass), 'BZF-29' (containing solely silica), and 'BZF-29_hv' (highly viscous with a higher silica loading than BZF-29), and of the adhesive resins of the gold-standard adhesives OptiBond FL ('Opti-FL', Kerr) and Clearfil SE Bond 2 ('C-SE2', Kuraray Noritake) was measured along with that of BZF-29unfilled (GC) serving as control/reference. Statistics involved one-way and two-way ANOVA followed by post-hoc multiple comparisons (α<0.05).

RESULTS

Glass-S, BioUnion, and CPC_Mont represent irregular fillers with an average particle size of 8.5-9.9 μm. Adding filler to BZF-29unfilled decreased μTFS regardless of filler type/loading. One-week water storage reduced μTFS of all adhesive resins except BZF-21, with the largest reduction in μTFS recorded for BZF-29unfilled. Among the three filler types, the μTFS of the 30 wt% Glass-S and 20 wt% BioUnion filled adhesive resin was not significantly different from the μTFS of BZF-29unfilled upon water storage.

CONCLUSIONS

Adding filler particles into adhesive resin did not enhance its micro-tensile fracture strength but appeared to render it less sensitive to water storage as compared to the unfilled adhesive resin investigated.

Neurological recovery rate and predictive factors of incomplete AIS grade C spinal cord injury in the older aged population

STUDY DESIGN

Retrospective cohort study.

OBJECTIVES

To define the prognosis and predictive factors for neurological improvement in older patients with incomplete spinal cord injury (SCI) of American Spinal Injury Association Impairment Scale grade C (AIS-C).

SETTINGS

Multi-institutions in Japan.

METHODS

We included patients aged ≥65 years with traumatic SCI of AIS-C who were treated conservatively or surgically with >3 follow-up months. To identify factors related to neurological improvement, patients were divided into three groups according to their neurological status at the final follow-up, with univariate among-group comparisons of demographics, radiographic, and therapeutic factors. Significant variables were included in the multivariate logistic regression analysis.

RESULTS

Overall, 296 older patients with SCI of AIS-C on admission were identified (average age: 75.2 years, average follow-up: 18.7 months). Among them, 190 (64.2%) patients improved to AIS-D and 21 (7.1%) patients improved to AIS-E at final follow-up. There were significant among-group differences in age (p = 0.026), body mass index (p = 0.007), status of pre-traumatic activities of daily living (ADL) (p = 0.037), and serum albumin concentrations (p = 0.011). Logistic regression analysis showed no significant differences in variables in the stratified group of patients who improved to AIS-D. Meanwhile, serum albumin was a significant variable in patients who improved to AIS-E (p = 0.026; OR: 6.20, pre-traumatic ADL was omitted due to data skewness).

CONCLUSIONS

Most older patients with incomplete AIS-C SCI demonstrated at least 1 grade of neurological improvement. However, <10% of patients achieved complete recovery. Key predictors of complete recovery were high serum albumin levels on admission and independent pre-traumatic ADL.

SPONSORSHIP

No funding was received for this study.

Investigation of long lateral mass screw insertion torque

Background

Here, we assessed a new trajectory and insertion torque for the placement of a long lateral mass screw (LLMS) that offers stronger posterior fixation versus a shorter lateral mass screw (LMS) in the posterior cervical spine. We report a short technical note of the insertion torque of LLMS.

Methods

The insertion trajectory/torque was evaluated in 30 patients (10 males and 20 females) undergoing posterior cervical LLMS fusions (2021-2023). Patients averaged 65 years of age. Pathology included eight cervical spine injuries, ten cord injuries, four dislocations/fractures, and eight other entities. Variables studied included the length of the LLMS inserted from C3-7, screw deviation rates, insertion torque, and adverse events.

Results

A total of 146 screws were inserted: 11 pedicle screws (PSs) and 135 LLMS. The average insertion torque was 105.9 cNm for PS and 64.9 cNm for LLMS. As the screw lengthened by 1 mm, the insertion torque increased by approximately 4.4 cNm.

Conclusion

Here, we documented that the insertion torque of LLMS was 66.1 cNm, greater than the 51.0 cNm for LMS, which should provide stronger posterior cervical fixation.

Predicting Skeletal-related Events Using SINS

STUDY DESIGN

Predictive study utilized retrospectively collected data.

OBJECTIVE

The primary objective was to evaluate the predictive association between the Spine Instability Neoplastic Score (SINS) and Skeletal-related events (SREs). Secondary objectives included examining characteristics of cases with SINS < 6 among those who developed SRE, and evaluating the impact of additional predictors on prediction accuracy.

SUMMARY OF BACKGROUND DATA

Advances in cancer treatment have prolonged the lives of cancer patients, emphasizing the importance of maintaining quality of life. Skeletal-related events from metastatic spinal tumors significantly impact quality of life. However, currently, there is no scientifically established method to predict the occurrence of SRE. SINS, developed by the Spine Oncology Study Group, assesses spinal instability using six categories. Therefore, the predictive performance of SINS for SRE occurrence is of considerable interest to clinicians.

METHODS

This predictive study utilized retrospectively collected data from a single-center registry comprising over 1,000 patients with metastatic spinal tumors. SINS and clinical data were collected. Logistic regression was used to create a prediction equation for SRE using SINS. Additional analyses explored factors associated with SRE in patients with SINS < 6.

RESULTS

The study included 1,041 patients with metastatic spinal tumors. SRE occurred in 121 cases (12%). The prediction model for SRE using SINS demonstrated an area under the curve (AUC) of 0.832. Characteristics associated with SRE included lower female prevalence, surgeries to primary sites, bone metastases to non-spinal sites, and metastases to other organs. A post hoc analysis incorporating additional predictors improved the AUC to 0.865.

CONCLUSION

The SINS demonstrated reasonable predictive performance for SRE within one month of the initial visit. Incorporating additional factors improved prediction accuracy. The study emphasizes the need for a comprehensive clinical prediction model for SRE in metastatic spinal tumors.

Impact of malnutrition on mortality and neurological recovery of older patients with spinal cord injury

This retrospective cohort study established malnutrition's impact on mortality and neurological recovery of older patients with cervical spinal cord injury (SCI). It included patients aged ≥ 65 years with traumatic cervical SCI treated conservatively or surgically. The Geriatric Nutritional Risk Index was calculated to assess nutritional-related risk. Overall, 789 patients (mean follow-up: 20.1 months) were examined and 47 had major nutritional-related risks on admission. One-year mortality rate, median survival time, neurological recovery, and activities of daily living (ADL) at 1 year post-injury were compared between patients with major nutrition-related risk and matched controls selected using 1:2 propensity score matching to adjust for age, pre-traumatic neurological impairment, and activity. In the Kaplan-Meier analysis, the median survival times were 44.9 and 76.5 months for patients with major nutrition-related risk and matched controls, respectively (p = 0.015). Matched controls had more individuals with a neurological improvement of American Spinal Injury Association Impairment Scale ≥ 1 grade (p = 0.039) and independence in ADL at 1 year post-injury than patients with major nutrition-related risk (p < 0.05). In conclusion, 6% of older patients with cervical SCI had major nutrition-related risks; they showed a significantly higher 1 year mortality rate, shorter survival time, poorer neurological improvement, and lower ADL at 1 year post-injury than matched controls.

Practical use of the central venous access port for contrast-enhanced CT: comparison with peripheral intravenous access regarding enhancement and safety

AIM

To evaluate the efficacy of using the central venous (CV) port compared with peripheral intravenous access for contrast-material injection for contrast enhancement during the portal venous phase.

MATERIALS AND METHODS

Patients were divided into three groups: CV delay, CV routine, and peripheral access (PA) groups. Patients in the CV delay group underwent injection in the arm-down position with an additional delay, while those in the CV routine and PA groups underwent injections with the routine injection protocol for portal venous phase imaging. Contrast enhancement was evaluated by measuring the mean radiodensity (Hounsfield units) values for the aortic arch, abdominal aorta, inferior vena cava, portal vein, and spleen. The peak injection pressure was recorded and compared among the three groups.

RESULTS

No complications related to power injection were observed during 119 contrast-material injections performed using the CV port device. The CV delay group showed significantly lower radiodensity values than the PA group (165.7 ± 20.1 versus 181 ± 19 HU [p<0.01] for the portal vein); however, no significant differences in mean radiodensity values were observed between the CV routine and PA groups (p>0.05). The median peak injection pressure was 73.5, 67, and 47 psi in the CV delay, CV routine, and PA groups, respectively (p<0.01).

CONCLUSION

The CV port can be used for safe contrast-material injection while maintaining contrast enhancement on portal venous phase comparable to that achieved with peripheral intravenous access.

Factors associated with non-completion of palliative radiotherapy for spinal metastasis in patients with terminal cancer: a retrospective study

BACKGROUND

Predictors of non-completion of radiotherapy (RT) should be identified to determine the optimal RT dose. Therefore, this study aimed to explore factors associated with non-completion of palliative RT in patients with terminal cancer.

METHODS

In this retrospective study, patients with terminal cancer who received RT (not including single-fraction RT) for relief of pain caused by spinal metastasis were categorized into complete and incomplete groups. Baseline characteristics, hematologic test data [e.g., total lymphocyte count (TLC)], performance status, palliative performance scale (PPS) score, psoas muscle index (PMI), Charlson comorbidity index, and age-adjusted Charlson comorbidity index of the patients were compared between the two groups.

RESULTS

The complete group comprised 58 patients (median age: 68 years; female/male: 17/41; number of irradiation fractions: ≥2 to <10, 20 patients; 10, 34 patients; and >10, 4 patients), and the incomplete group comprised 9 patients (median age: 68 years; female/male: 3/6; number of irradiation fractions: ≥2 to <10, 2 patients; 10, 7 patients; and >10, 0 patient). The proportion of patient death within 1 week or 1 month was higher in the incomplete group than in the complete group. Compared with that in the incomplete group, TLC measured 1 week before RT (pre-TLC) and PMI recorded before RT were significantly higher in the complete group (P=0.013 and P=0.012, respectively). In multivariable analyses, pre-TLC was significantly associated with the incomplete group (P=0.048). Compared with the complete group, the incomplete group included several patients whose PPS scores rapidly decreased.

CONCLUSIONS

Pre-TLC can predict non-completion of palliative RT in patients with terminal cancer.

Influence of the timing of surgery for cervical spinal cord injury without bone injury in the elderly: A retrospective multicenter study

BACKGROUND

Although previous studies have demonstrated the advantages of early surgery for traumatic spinal cord injury (SCI), the appropriate surgical timing for cervical SCIs (CSCIs) without bone injury remains controversial. Here, we investigated the influence of relatively early surgery within 48 h of injury on the neurological recovery of elderly patients with CSCI and no bone injury.

METHODS

In this retrospective multicenter study, we reviewed data from 159 consecutive patients aged ≥65 years with CSCI without bone injury who underwent surgery in participating centers between 2010 and 2020. Patients were followed up for at least 6 months following CSCI. We divided patients into relatively early (≤48 h after CSCI, n = 24) and late surgery (>48 h after CSCI, n = 135) groups, and baseline characteristics and neurological outcomes were compared between them. Multivariate analysis was performed to identify factors associated with neurological recovery.

RESULTS

The relatively early surgery group demonstrated a lower prevalence of cardiac disease, poorer baseline American Spinal Injury Association (ASIA) impairment scale grade, and lower baseline ASIA motor score (AMS) than those of the late surgery group (P < 0.030, P < 0.001, and P < 0.001, respectively). Although the AMS was lower in the relatively early surgery group at 6 months following injury (P = 0.001), greater improvement in this score from baseline to 6-months post injury was observed (P = 0.010). Multiple linear regression analysis revealed that relatively early surgery did not affect postoperative improvement in AMS, rather, lower baseline AMS was associated with better AMS improvement (P < 0.001). Delirium (P = 0.006), pneumonia (P = 0.030), and diabetes mellitus (P = 0.039) negatively influenced postoperative improvement.

CONCLUSIONS

Although further validation by future studies is required, relatively early surgery did not show a positive influence on neurological recovery after CSCI without bone injury in the elderly.

Early Versus Delayed Surgery for Elderly Traumatic Cervical Spinal Injury: A Nationwide Multicenter Study in Japan

STUDY DESIGN

Retrospective multicenter study.

OBJECTIVES

The effectiveness of early surgery for cervical spinal injury (CSI) has been demonstrated. However, whether early surgery improves outcomes in the elderly remains unclear. This study investigated whether early surgery for CSI in elderly affects complication rates and neurological outcomes.

METHODS

This retrospective multicenter study included 462 patients. We included patients with traumatic acute cervical spinal cord injury aged ≥65 years who were treated surgically, whereas patients with American Spinal Injury Association (ASIA) Impairment Scale E, those with unknown operative procedures, and those waiting for surgery for >1 month were excluded. The minimum follow-up period was 6 months. Sixty-five patients (early group, 14.1%) underwent surgical treatment within 24 hours, whereas the remaining 397 patients (85.9%) underwent surgery on a standby basis (delayed group). The propensity score-matched cohorts of 63 cases were compared.

RESULTS

Patients in the early group were significantly younger, had significantly more subaxial dislocations (and fractures), tetraplegia, significantly lower ASIA motor scores, and ambulatory abilities 6 months after injury. However, no significant differences in the rate of complications, ambulatory abilities, or ASIA Impairment Scale scores 6 months after injury were observed between the matched cohorts. At 6 months after injury, 61% of the patients in the early group (25% unsupported and 36% supported) and 53% of the patients in the delayed group (34% unsupported and 19% supported) were ambulatory.

CONCLUSIONS

Early surgery is possible for CSI in elderly patients as the matched cohort reveals no significant difference in complication rates and neurological or ambulatory recovery between the early and delayed surgery groups.

Prognostic Factors for Respiratory Dysfunction for Cervical Spinal Cord Injury and/or Cervical Fractures in Elderly Patients: A Multicenter Survey

STUDY DESIGN

Retrospective Cohort Study.

OBJECTIVE

The purpose of this study was to investigate the prognosis of respiratory function in elderly patients with cervical spinal cord injury (SCI) and to identify predictive factors.

METHODS

We included 1353 cases of elderly cervical SCI patients collected from 78 institutions in Japan. Patients who required early tracheostomy and ventilator management and those who developed respiratory complications were defined as the respiratory disability group. Patients' background characteristics, injury mechanism, injury form, neurological disability, complications, and treatment methods were compared between the disability and non-disability groups. Multiple logistic regression analysis was used to examine the independent factors. Patients who required respiratory management for 6 months or longer after injury and those who died of respiratory complications were classified into the severe disability group and were compared with minor cases who were weaned off the respirator.

RESULTS

A total of 104 patients (7.8%) had impaired respiratory function. Comparisons between the disabled and non-disabled groups and between the severe and mild injury groups yielded distinct trends. In multiple logistic regression analysis, age, blood glucose level, presence of ossification of posterior longitudinal ligament (OPLL), anterior vertebral hematoma, and critical paralysis were selected as independent risk factors.

CONCLUSION

Age, OPLL, severe paralysis, anterior vertebral hematoma, hypoalbuminemia, and blood glucose level at the time of injury were independent factors for respiratory failure. Hyperglycemia may have a negative effect on respiratory function in this condition.

Prognostic impact of respiratory dysfunction in elderly patients with cervical spinal cord injury and/or fractures: a multicenter survey

PURPOSE

To investigate the impact of early post-injury respiratory dysfunction for neurological and ambulatory ability recovery in patients with cervical spinal cord injury (SCI) and/or fractures.

METHODS

We included 1,353 elderly patients with SCI and/or fractures from 78 institutions in Japan. Patients who required early tracheostomy and ventilator management and those who developed respiratory complications were included in the respiratory dysfunction group, which was further classified into mild and severe respiratory groups based on respiratory weaning management. Patient characteristics, laboratory data, neurological impairment scale scores, complications at injury, and surgical treatment were evaluated. We performed a propensity score-matched analysis to compare neurological outcomes and mobility between groups.

RESULTS

Overall, 104 patients (7.8%) had impaired respiratory function. In propensity score-matched analysis, the respiratory dysfunction group had a lower home discharge and ambulation rates (p = 0.018, p = 0.001, respectively), and higher rate of severe paralysis (p < 0.001) at discharge. At the final follow-up, the respiratory dysfunction group had a lower ambulation rate (p = 0.004) and higher rate of severe paralysis (p < 0.001). Twenty-six patients with severe disability required respiratory management for up to 6 months post-injury and died of respiratory complications. The mild and severe respiratory dysfunction groups had a high percentage of severe paraplegic cases with low ambulatory ability; there was no significant difference between them. The severe respiratory dysfunction group tended to have a poorer prognosis.

CONCLUSION

Respiratory dysfunction in elderly patients with SCI and/or cervical fracture in the early post-injury period reflects the severity of the condition and may be a useful prognostic predictor.

Management of Antithrombotic Drugs before Elective Spine Surgery: A Nationwide Web-Based Questionnaire Survey in Japan

Introduction

The number of patients on antithrombotic drugs for coronary heart disease or cerebrovascular disease has been increasing with the aging of society. We occasionally need to decide whether to continue or discontinue antithrombotic drugs before spine surgery. The purpose of this study is to understand the current perioperative management of antithrombotic drugs before elective spine surgery in Japan.

Methods

In 2021, members of the Japanese Society for Spine Surgery and Related Research (JSSR) were asked to complete a web-based questionnaire survey that included items concerning the respondents' surgical experience, their policy regarding discontinuation or continuation of antithrombotic drugs, their reasons for decisions concerning the management of antithrombotic drugs, and their experience of perioperative complications related to the continuation or discontinuation of these drugs.

Results

A total of 1,181 spine surgeons returned completed questionnaires, giving a response rate of 32.0%. JSSR board-certified spine surgeons comprised 75.1% of the respondents. Depending on the management policy regarding antithrombotic drugs for each comorbidity, approximately 73% of respondents discontinued these drugs before elective spine surgery, and about 80% also discontinued anticoagulants. Only 4%-5% of respondents reported continuing antiplatelet drugs, and 2.5% reported continuing anticoagulants. Among the respondents who discontinued antiplatelet drugs, 20.4% reported having encountered cerebral infarction and 3.7% reported encountering myocardial infarction; among those who discontinued anticoagulants, 13.6% reported encountering cerebral embolism and 5.4% reported encountering pulmonary embolism. However, among the respondents who continued antiplatelet drugs and those who continued anticoagulants, 26.3% and 27.2%, respectively, encountered an unexpected increase in intraoperative bleeding, and 10.3% and 8.7%, respectively, encountered postoperative spinal epidural hematoma requiring emergency surgery.

Conclusions

Our findings indicate that, in principle, >70% of JSSR members discontinue antithrombotic drugs before elective spine surgery. However, those with a discontinuation policy have encountered thrombotic complications, while those with a continuation policy have encountered hemorrhagic complications.

Prognosis of Cervical Diffuse Idiopathic Skeletal Hyperostosis-Related Spine Injuries in Elderly Patients: Analyses of Both Fracture and Spinal Cord Injury Without Fracture

STUDY DESIGN

Retrospective multicenter study.

OBJECTIVE

The purpose of this study was to compare the prognosis of elderly patients with injuries related to cervical diffuse idiopathic skeletal hyperostosis (cDISH) to matched control for each group, with and without fractures.

METHODS

The current multicenter study was a retrospective analysis of 140 patients aged 65 years or older with cDISH-related cervical spine injuries; 106 fractures and 34 spinal cord injuries without fracture were identified. Propensity score-matched cohorts from 1363 patients without cDISH were generated and compared. Logistic regression analysis was performed to determine the risk of early mortality for patients with cDISH-related injury.

RESULTS

Patients with cDISH-related injuries with fracture did not differ significantly in the incidence of each complication and ambulation or severity of paralysis compared to matched controls. In patients with cDISH-related injury without fracture, those who were nonambulatory at discharge comprised 55% vs 34% of controls, indicating significantly poorer ambulation in those with cDISH-related injuries (P = .023). There was no significant difference in the incidence of complications and ambulation or paralysis severity at 6 months as compared with controls. Fourteen patients died within 3 months. Logistic regression analysis identified complete paralysis (odds ratio [OR] 36.99) and age (OR 1.24) as significant risk factors for mortality.

CONCLUSIONS

The current study showed no significant differences in the incidence of complications, ambulation outcomes between patients with cDISH-related injury with fracture and matched controls, and that the ambulation at discharge for patients with cDISH-related injury without fractures were significantly inferior to those of matched controls.

Spinal Instability as a Prognostic Factor in Patients With Spinal Metastasis of Castration-resistant Prostate Cancer

BACKGROUND/AIM

To evaluate the Spinal Instability Neoplastic Score (SINS) for prediction of survival in patients with spinal column metastasis of castration-resistant prostate cancer (CRPC).

PATIENTS AND METHODS

A retrospective study of spinal instability was performed in patients with CRPC using SINS. Overall survival was evaluated starting from the time of SINS evaluation. The subjects were 42 patients with CRPC among 261 cases diagnosed with metastatic spinal tumors by radiologists, among 42,152 cases that underwent a body computed tomography scan at Kawasaki Medical School Hospital within 32 months from December 2013 to July 2016.

RESULTS

The median age was 78 (range=55-91 years), the median prostate-specific antigen (PSA) level at SINS evaluation was 42.1 (0.1-3,121.6) ng/ml, and 11 patients had visceral metastasis. The median periods from diagnosis of bone metastasis and development of CRPC to SINS evaluation were 17 (0-158) and 20 (0-149) months, respectively. The spine was stable in 32 cases (group S) and potentially unstable or unstable in 10 (24%) (group U). The median observation period was 17.5 (0-83) months and 36 patients died. The median survival period after SINS evaluation was longer in group S than that in group U (20 vs. 10 months, p=0.0221). In multivariate analysis, PSA level, visceral metastasis, and spinal instability were significant prognostic factors. The hazard ratio for patients in group U was 2.60 (95%CI=1.07-5.93, p=0.0345).

CONCLUSION

Spinal stability evaluated using SINS is a new prognostic factor for survival of patients with spinal metastasis of CRPC.

Effects of Dementia on Outcomes after Cervical Spine Injuries in Elderly Patients: Evaluation of 1512 Cases in a Nationwide Multicenter Study in Japan

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

Risk Factors for Early Mortality in Older Patients with Traumatic Cervical Spine Injuries-A Multicenter Retrospective Study of 1512 Cases

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

Epidemiology of Cervical Fracture/Cervical Spinal Cord Injury and Changes in Surgical Treatment Modalities in Elderly Individuals During a 10-year Period: A Nationwide Multicenter Study in Japan

STUDY DESIGN

Retrospective multicenter study.

OBJECTIVES

To investigate changes over a 10-years period in the profile of cervical spine and spinal cord injuries among the elderly in Japan.

METHODS

The current multicenter study was a retrospective analysis of inpatients aged ≥65 years, suffering cervical fracture (CF) and/or cervical spinal cord injury (CSCI). We analyzed 1413 patients' epidemiology (from 2010 to 2019). Moreover, 727 patients who underwent surgical treatment were analyzed in 2 groups: the early (2010-2014) and late period (2015-2019).

RESULTS

Both the number of patients and number of surgical patients showed a significant increasing trend (P < .001), while the mean age, the distribution of injury levels and paralysis severity, and the proportion of surgical indications remained the same. The number of surgical patients doubled from 228 to 499 from the early to late periods. Posterior surgery was the most common approach (90.4%), instrumentation surgery with screws increased significantly, and the range of fusion was significantly longer in the late period (2.1 vs 2.7 levels, P = .001). Significantly worsening neurological symptoms were recorded in the late period (1.3% vs 5.8%, P = .006), with C5 palsy being the major one. Otherwise, perioperative, major, and other complications, including mortality, did not differ significantly in incidence.

CONCLUSIONS

Both the number of elderly CF and/or CSCI patients and number of patients undergoing surgery increased dramatically over the decade without any change in profile. Instrumentation surgeries with screws increased, without an increase in systemic complications.

Factors Affecting the Waiting Time from Injury to Surgery in Elderly Patients with a Cervical Spine Injury: A Japanese Multicenter Survey

OBJECTIVE

The management of cervical spine injuries in the elderly is often complicated by the presence of multiple medical comorbidities, and it is not uncommon for preoperative testing to reveal other conditions that require the postponement of surgery. However, the factors that affect the waiting time from injury to surgery have not been clarified. The purpose of this multicenter database study was to analyze the clinical features and identify the factors affecting the number of days waited between injury and surgery in elderly patients with a cervical spine injury.

METHODS

We retrospectively reviewed the case histories of 1512 Japanese patients with a cervical spinal injury, who were seen at 33 institutions. After excluding patients who were not initially receiving a surgery for cervical spinal injury, 694 patients were ultimately analyzed. Based on a multivariate mixed model, we determined the factors related to the number of days from injury to surgery.

RESULTS

The mean time from injury to surgery was 12.3 days. Multivariate analysis revealed delays of 10.7 days for a renal disorder, 7.3 days for anticoagulant use, and 15.2 days for non-surgical thoracolumbar fracture as factors prolonging wait time. In contrast, a C3 or lower spine injury was significantly associated with a shortening of 9.5 days to surgery.

CONCLUSIONS

This multicenter database study identified several factors influencing the time between injury and cervical spine surgery in elderly patients. While renal impairment, anticoagulant use, and non-surgical thoracolumbar fracture may increase the number of days to surgery, trauma to C3 or lower may expedite surgical treatment.

A multicenter study of 1-year mortality and walking capacity after spinal fusion surgery for cervical fracture in elderly patients

Background

The 1-year mortality and functional prognoses of patients who received surgery for cervical trauma in the elderly remains unclear. The aim of this study is to investigate the rates of, and factors associated with mortality and the deterioration in walking capacity occurring 1 year after spinal fusion surgery for cervical fractures in patients 65 years of age or older.

Methods

Three hundred thirteen patients aged 65 years or more with a traumatic cervical fracture who received spinal fusion surgery were enrolled. The patients were divided into a survival group and a mortality group, or a maintained walking capacity group and a deteriorated walking capacity group. We compared patients’ backgrounds, trauma, and surgical parameters between the two groups. To identify factors associated with mortality or a deteriorated walking capacity 1 year postoperatively, a multivariate logistic regression analysis was conducted.

Results

One year postoperatively, the rate of mortality was 8%. A higher Charlson comorbidity index (CCI) score, a more severe the American Spinal Cord Injury Association impairment scale (AIS), and longer surgical time were identified as independent factors associated with an increase in 1-year mortality. The rate of deterioration in walking capacity between pre-trauma and 1 year postoperatively was 33%. A more severe AIS, lower albumin (Alb) and hemoglobin (Hb) values, and a larger number of fused segments were identified as independent factors associated with the increased risk of deteriorated walking capacity 1 year postoperatively.

Conclusions

The 1-year rate of mortality after spinal fusion surgery for cervical fracture in patients 65 years of age or older was 8%, and its associated factors were a higher CCI score, a more severe AIS, and a longer surgical time. The rate of deterioration in walking capacity was 33%, and its associated factors were a more severe AIS, lower Alb, lower Hb values, and a larger number of fused segments.

Minimally Invasive Spinal Treatment (MIST)—A New Concept in the Treatment of Spinal Diseases: A Narrative Review

In the past two decades, minimally invasive spine surgery (MISS) techniques have been developed for spinal surgery. Historically, minimizing invasiveness in decompression surgery was initially reported as a MISS technique. In recent years, MISS techniques have also been applied for spinal stabilization techniques, which were defined as minimally invasive spine stabilization (MISt), including percutaneous pedicle screws (PPS) fixation, lateral lumbar interbody fusion, balloon kyphoplasty, percutaneous vertebroplasty, cortical bone trajectory, and cervical total disc replacement. These MISS techniques typically provide many advantages such as preservation of paraspinal musculature, less blood loss, a shorter operative time, less postoperative pain, and a lower infection rate as well as being more cost-effective compared to traditional open techniques. However, even MISS techniques are associated with several limitations including technical difficulty, training opportunities, surgical cost, equipment cost, and radiation exposure. These downsides of surgical treatments make conservative treatments more feasible option. In the future, medicine must become “minimally invasive” in the broadest sense—for all patients, conventional surgeries, medical personnel, hospital management, nursing care, and the medical economy. As a new framework for the treatment of spinal diseases, the concept of minimally invasive spinal treatment (MIST) has been proposed.

Is Blood Loss Greater in Elderly Patients under Antiplatelet or Anticoagulant Medication for Cervical Spine Injury Surgery? A Japanese Multicenter Survey

Introduction

In elderly patients with cervical spinal cord injury, comorbidities such as cardiovascular and cerebrovascular diseases are common, with frequent administration of antiplatelet/anticoagulant (APAC) drugs. Such patients may bleed easily or unexpectedly during surgery despite prior withdrawal of APAC medication. Few reports have examined the precise relationship between intraoperative blood loss and history of APAC use regarding surgery for cervical spine injury in the elderly. The present multicenter database survey aimed to answer the question of whether the use of APAC drugs affected the amount of intraoperative blood loss in elderly patients with cervical spinal cord trauma.

Methods

The case histories of 1512 patients with cervical spine injury at 33 institutes were retrospectively reviewed. After excluding cases without spinal surgery or known blood loss volume, 797 patients were enrolled. Blood volume loss was the outcome of interest. We calculated propensity scores using the inverse probability of treatment weighting (IPTW) method. As an alternative sensitivity analysis, linear mixed model analyses were conducted as well.

Results

Of the 776 patients (mean age: 75.1±6.4 years) eligible for IPTW calculation, 157 (20.2%) were taking APAC medications before the injury. After weighting, mean estimated blood loss was 204 mL for non-APAC patients and 215 mL for APAC patients. APAC use in elderly patients was not significantly associated with surgical blood loss according to the IPTW method with propensity scoring or linear mixed model analyses. Thus, it appeared possible to perform surgery expecting comparable blood loss in APAC and non-APAC cases.

Conclusions

This multicenter study revealed no significant increase in surgical blood loss in elderly patients with cervical trauma taking APAC drugs. Surgeons may be able to prioritize patient background, complications, and preexisting conditions over APAC use before injury when examining the surgical indications for cervical spine trauma in the elderly.

Does surgery improve neurological outcomes in older individuals with cervical spinal cord injury without bone injury? A multicenter study

STUDY DESIGN

Retrospective multicenter study.

OBJECTIVES

To investigate the neurological outcomes of older individuals treated with surgery versus conservative treatment for cervical spinal cord injury (CSCI) without bone injury.

SETTING

Thirty-three medical institutions in Japan.

METHODS

This study included 317 consecutive persons aged ≥65 years with CSCI without bone injury in participating institutes between 2010 and 2020. The participants were followed up for at least 6 months after the injury. Individuals were divided into surgery (n = 114) and conservative treatment (n = 203) groups. To compare neurological outcomes and complications between the groups, propensity score matching of the baseline factors (characteristics, comorbidities, and neurological function) was performed.

RESULTS

After propensity score matching, the surgery and conservative treatment groups comprised 89 individuals each. Surgery was performed at a median of 9.0 (3-17) days after CSCI. Baseline factors were comparable between groups, and the standardized difference in the covariates in the matched cohort was <10%. The American Spinal Injury Association (ASIA) impairment scale grade and ASIA motor score (AMS) 6 months after injury and changes in the AMS from baseline to 6 months after injury were not significantly different between groups (P = 0.63, P = 0.24, and P = 0.75, respectively). Few participants who underwent surgery demonstrated perioperative complications such as dural tear (1.1%), surgical site infection (2.2%), and C5 palsy (5.6%).

CONCLUSION

Conservative treatment is suggested to be a more favorable option for older individuals with CSCI without bone injuries, but this finding requires further validation.

Effect of Minimally Invasive Spine Stabilization in Metastatic Spinal Tumors

Background and Objectives: There have been numerous advances in spine surgery for metastatic spinal tumors, and minimally invasive spine stabilization (MISt) is becoming increasingly popular in Japan. MISt is a minimally invasive fixation procedure that temporarily stabilizes the spine, thereby reducing pain, preventing pathological fractures, and improving activities of daily living at an early stage. MISt may be useful given the recent shift toward outpatient cancer treatment. Materials and Methods: This study enrolled 51 patients with metastatic spinal tumors who underwent surgery using MISt between December 2013 and October 2020. The Spinal Instability Neoplastic Score, an assessment of spinal instability, was used to determine the indication for surgery, and the Epidural Spinal Cord Compression scale was used for additional decompression. Results: The patients comprised 34 men and 17 women, and the mean age at surgery was 68.9 years. The mean postoperative follow-up period was 20.8 months, and 35 of 51 patients (67%) had died by the last survey. The mean operative time was 159.8 min, mean blood loss was 115.7 mL, and mean time to ambulation was 3.2 days. No perioperative complications were observed, although two patients required refixation surgery. Preoperatively, 37 patients (72.5%) were classified as Frankel grade E. There were no cases of postoperative exacerbation, and six patients showed improvement of one or more Frankel grades after surgery. The median duration of patient survival was about 22.0 months. Patients with breast, prostate, renal, and thyroid cancers had a good prognosis, whereas those with gastrointestinal and head and neck cancers had a poor prognosis. Conclusions: MISt can benefit patients who are ineligible for conventional, highly invasive surgery and is also suitable because cancer treatment is increasingly performed on an outpatient basis. Furthermore, choosing the right surgery for the right patient at the right time can significantly affect life expectancy.

Efficacy of Minimally Invasive Trans-Sacral Canal Plasty between Patients with and without Failed Back Surgery Syndrome

Background and Objectives: Clinicians are required to manage a growing number of elderly patients with several medical comorbidities, and invasive surgical treatments are sometimes not advisable for these patients. The aim of this study was to evaluate the efficacy of minimally invasive intraspinal canal treatment, trans-sacral canal plasty (TSCP), for patients with and without failed back surgery syndrome (FBSS). Materials and Methods: A multicenter analysis was conducted. TSCP was performed in patients with chronic low back pain and leg pain due to lumbar spinal disorders. An adhesiolysis by TSCP was carried out, then a mixture of steroid and local anesthesia was injected. Visual Analog Scales (VAS) for low back pain and leg pain, and complications were evaluated. Results: A total of 271 patients with a minimum 6-month follow-up were enrolled. There were 80 patients who had a history of previous lumbar spinal surgery (F group), and 191 patients without previous lumbar spinal surgery (N group). There were no significant differences in sex and age between the two groups. VAS scores for low back pain (N group/F group) preoperatively, immediately postoperatively, and 1 month, 3 months and 6 months postoperatively, were 51/52 mm, 24/26 mm, 33/34 mm, 30/36 mm, and 30/36 mm, respectively. VAS scores for leg pain were 69/67 mm, 28/27 mm, 39/41 mm, 36/43 mm, and 32/40 mm, respectively. Both VAS scores for low back pain and leg pain were significantly decreased from baseline to final follow-up in both groups (p < 0.01). However, VAS scores for leg pain at 3 months and 6 months postoperatively were significantly higher in F group (p < 0.05). There were three catheter breakages (2/3 in F group), and one dural tear in F group. Conclusions: TSCP significantly reduced both VAS scores for low back and leg pain in patients with and without FBSS. However, co-existence of intractable epidural adhesion might be associated with less improvement in FBSS.

Prophylactic Effect of Liaison Treatment on the Occurrence of Skeletal-Related Events in Patients with Metastatic Spinal Tumours: An Exploratory Interrupted Time Series Study

Introduction

There is a growing momentum for the collaboration between multiple disciplines for the prevention and treatment of skeletal-related events (SREs) in patients with metastatic spinal tumors. However, the effectiveness of multidisciplinary approaches remains unclear. Hence, we conducted an exploratory study to examine the impact of liaison treatment for metastatic spinal tumor (LMST) on the prevention of SREs among patients with a metastatic spinal tumor.

Methods

This study was an exploratory interrupted time series conducted in a single medical center. Overall, 1,043 patients with a metastatic spinal tumor diagnosed between January 2011 and December 2020 were included. The LMST was implemented in January 2014. The LMST team consisted of the orthopedic surgery, thoracic surgery, breast and thyroid surgery, clinical oncology, urology, and radiology departments. Monthly joint conferences were held for patients with spinal instability, and the incidence of SRE was measured at 6-month intervals.

Results

Throughout the study period, we identified 66 SRE incidences. After the implementation of the LMST, a level change of −5.2% (95% confidence interval [CI]: −11.7 to 1.3, p = 0.11) was observed. Subsequently, a post-implementation trend change of −0.3% (95% CI: −2.0 to 1.5, p = 0.75) beyond the baseline was noted.

Conclusions

We suggest both immediate and gradual effects of the introduction of the LMST on deterring the development of SREs. Our results support the global trend of introducing a multidisciplinary approach for the treatment of metastatic spinal tumors.

Assessment of the Concordance Rate between Intraoperative Pathological Diagnosis and the Final Pathological Diagnosis of Spinal Cord Tumors

The intraoperative pathological diagnosis (IPD) plays an important role in determining the optimal surgical treatment for spinal cord tumors. The final pathological diagnosis (FPD) is sometimes different from the IPD. Here, we sought to identify the accuracy of the IPD of spinal cord tumors compared to the FPD. We retrospec-tively analyzed the cases of 108 patients with spinal cord tumors treated surgically in our institute; the IPD, FPD, mismatched cases, and concordance rate between the IPD and FPD were investigated. Five cases involved a mismatch between the IPD and FPD. The overall concordance rate was 95.4%, with 90.9% for extra-dural lesions, 98.5% for intradural extramedullary lesions, 84.2% for intramedullary lesions, and 100% for dumbbell-type tumors. The concordance rate of intramedullary lesions tended to be lower than that of other lesions (p = 0.096). A lower concordance rate was revealed for intramedullary lesions compared to the other lesions. Despite the IPD clearly remaining a valuable tool during operative procedures, surgeons should recog-nize the limitations of IPDs and make comprehensive decisions about surgical treatments.

Takotsubo Cardiomyopathy Induced by Very Low-Dose Epinephrine Contained in Local Anesthetics: A Case Report

BACKGROUND Takotsubo cardiomyopathy is a reversible left ventricular dysfunction triggered by emotional or physical stress. Perioperatively, takotsubo cardiomyopathy is sometimes induced by various psychological factors, such as stress from surgery, and non-psychological factors, such as epinephrine misinjection. This report describes a case of takotsubo cardiomyopathy induced by the administration of very low-dose epinephrine contained in a local anesthetic. CASE REPORT A 78-year-old woman with mycosis in the maxillary sinus was scheduled to undergo endoscopic sinus surgery. After the submucosal injection of 3 mL of local anesthetic (lidocaine, 0.5%; epinephrine, 1: 200 000) immediately before the incision, her heart rate and blood pressure reached 135 beats per min and 254/185 mmHg, respectively, inducing ventricular tachycardia. After receiving 50 mg of lidocaine, her cardiac rhythm resumed a normal sinus rhythm, without cardioversion. As her hemodynamics stabilized, the surgical procedure began as planned. Postoperative electrocardiography, echocardiography, and coronary arteriography demonstrated takotsubo cardiomyopathy. Subsequently, her cardiac movement gradually improved, and she was discharged from the hospital on postoperative day 9. CONCLUSIONS To the best of our knowledge, this is the first reported case in which a very small amount of epinephrine (0.015 mg) induced takotsubo cardiomyopathy. Therefore, epinephrine should be used cautiously, especially in the nasal mucosa, vaginal mucosa, and uterus, where blood flow is relatively high. If unexpected hemodynamic alterations and ST-segment abnormalities occur after epinephrine administration, asymptomatic takotsubo cardiomyopathy should be considered.

Minimally Invasive Thoracolumbar Corpectomy and Percutaneous Pedicle Screw Fixation with Computer-Assisted Rod-Bending System in Single Lateral Position: Technical Note

BACKGROUND

Thoracolumbar corpectomy and percutaneous pedicle screw (PPS) fixation is becoming the standard method for correcting and stabilizing malalignment of spine, as is often seen in osteoporotic vertebral fracture. Nowadays, this procedure can be performed in a single lateral position with navigation. For an osteoporotic spine, accurate rod bending is necessary to prevent screw back-out. We describe a new technique using the spinal rod-bending system in a single lateral position.

METHODS

A 71-year-old woman presented with severe back pain and impending paraplegia secondary to L1 osteoporotic vertebral fracture. We performed minimally invasive L1 corpectomy with an expandable vertebral cage and short-segment PPS with computer-assisted rod bending in a single lateral position under navigation guidance.

RESULTS

The patient was successfully treated with surgery, and her low back pain improved. Her clinical outcomes improved; the Oswestry Disability Index went from 54% to 26%, and her low back pain visual analog scale score went from 78 mm to 19 mm at the 2-year final follow-up.

CONCLUSIONS

Minimally invasive surgery thoracolumbar corpectomy using a computer-assisted spinal rod-bending system is a valuable technique to reduce screw back-out for osteoporotic vertebrae. With this new technique, the rod bending becomes easy, even for long PPS fusion with the severe osteoporotic or deformity patient in a single lateral position.

Visceral fat accumulation and left atrial phasic function in the general population

Background

Obesity carries independent risk for incident atrial fibrillation (AF), although the impact of abdominal fat distribution on LA morphological and functional remodeling is not fully elucidated. Speckle-tracking echocardiography is a novel and sensitive tool that allows quantification and detection of subtle alterations in left atrial (LA) phasic function.

Purpose

This study aimed to investigate whether increased visceral adiposity is independently associated with impaired LA phasic function in a community-based cohort.

Methods

We included 527 participants without overt cardiac disease who underwent laboratory testing, abdominal computed tomographic examination and speckle-tracking echocardiography. Abdominal adiposity was quantitatively assessed as visceral fat area (VFA) and subcutaneous fat area (SFA) at the level of the umbilicus. Speckle-tracking echocardiography was performed to assess LA phasic function including reservoir, conduit and pump strain as well as left ventricular global longitudinal strain (LVGLS).

Results

Mean age was 57±10 years and 362 of the participants (69%) were men. LA reservoir and conduit strain were decreased according to the VFA quartiles (both p&lt;0.05), whereas there was no significant difference in LA volume index and LA pump strain. When stratified by SFA, there was no significant differences in LA volume index and all LA phasic strain across the quartiles. In multivariable analysis, VFA as continuous variable was significantly associated with LA conduit strain, independent of traditional cardiovascular risk factors, pertinent laboratory parameters and LV morphology and function including LVGLS (standardized b=−0.146, p=0.011). Representative cases are shown in the Figure.

Conclusion

In a sample of the general population, VFA accumulation was independently associated with worse LA conduit strain, which may be involved in the pathophysiological mechanism of obesity-related AF.

Funding Acknowledgement

Type of funding source: Foundation. Main funding source(s): Yamauchi Susumu Scholarship for Cardiovascular Research

Carotid intima-media thickness and subclinical left heart dysfunction in the general population

Background

Although carotid intima-media thickness (IMT) is an established marker of atherosclerosis and carries independent risk for cardiovascular disease, its possible association with subclinical cardiac dysfunction has not been extensively evaluated. Left ventricular global longitudinal strain (LVGLS) and peak left atrial longitudinal systolic strain (PALS) can detect subclinical left heart dysfunction.

Purpose

This study aimed to investigate the association between carotid IMT and subclinical left heart dysfunction in a large sample of the general population without overt cardiac disease.

Methods

We examined 1,161 participants who underwent extensive cardiovascular examination. Ultrasonography of common carotid artery was performed for the measurement of maximal carotid IMT. LVGLS and PALS were assessed by 2-dimensional speckle-tracking echocardiography.

Results

Mean age was 62±12 years, and 56% were male. The prevalence of abnormal LVGLS (&gt;−18.6%) and PALS (&lt;31.4%) was greatest in the upper quartile of carotid IMT (both p&lt;0.001; Figure). In multivariable analyses, carotid IMT was associated with abnormal LVGLS (adjusted odds ratio = 1.33 per 1SD increase of IMT, p=0.003) as well as PALS (adjusted odds ratio = 1.33 per 1SD increase of IMT, p=0.005) independent of traditional cardiovascular risk factors, echocardiographic parameters including LV ejection fraction, LV mass index and diastolic dysfunction, and pertinent laboratory parameters. The independent association between carotid IMT and PALS persisted even after adjustment for LVGLS. When carotid IMT was examined as a categorical variable, the upper quartile of carotid IMT carried a significant risk of abnormal LVGLS and PALS in a fully-adjusted model including echocardiographic and laboratory parameters (adjusted odds ratio 2.27 and 3.03 vs. lower quartile, both p&lt;0.01).

Conclusion

Participants with increased IMT had significantly impaired LV and LA function in an unselected community-based cohort. This association may be involved in the higher incidence of cardiovascular disease in individuals with increased carotid IMT.

Funding Acknowledgement

Type of funding source: None

Sex-specific difference in the association between arterial stiffness and subclinical left ventricular dysfunction

Background

Increased arterial stiffness has been proposed as one of the key mechanisms of incident heart failure with preserved ejection fraction (HFpEF). However, the possible association between arterial stiffness and subclinical left ventricular (LV) dysfunction and possible sex-specific differences remain unclarified. LV strain is emerging as a highly sensitive tool to unmask early LV abnormalities.

Purpose

We investigated whether increased arterial stiffness is independently associated with subclinical LV dysfunction in a large community-based cohort without overt cardiovascular disease.

Methods

We examined 1,155 participants who underwent extensive cardiovascular examination. Speckle-tracking echocardiography was employed to assess LV global longitudinal strain (LVGLS) and circumferential strain (GCS), and arterial stiffness was assessed by cardio-ankle vascular index (CAVI).

Results

Mean age was 62±12 years, and 56% were male. CAVI as continuous variable was associated with abnormal LVGLS (&gt;−18.6%), independent of cardiovascular risk factors and pertinent laboratory and echocardiographic parameters (adjusted odds ratio [OR] 1.23, p=0.034), whereas there was no relationship with LVGCS. In sex-stratified analysis, more pronounced association between quartiles of CAVI and abnormal LVGLS was observed in women than in men (unadjusted OR = 6.43 in women and 2.46 in men for upper quartile vs. lower quartile, both p&lt;0.01; Figure). Multivariable analyses demonstrated that CAVI was significantly associated with abnormal LVGLS independent of cardiovascular risk factors in both sexes. However, after further adjustment for LV mass index and diastolic parameters, the independent association persisted in women (adjusted OR 1.49, p=0.041), but not in men (adjusted OR 1.15, p=0.209).

Conclusion

Increased arterial stiffness was independently associated with decreased LVGLS even in the absence of overt cardiovascular disease; a sex-specific pattern exists in the alteration of vascular-ventricular coupling, which might partially explain the greater susceptibility to HFpEF in women.

Funding Acknowledgement

Type of funding source: None

[The Liaison Service Models of Care for Metastatic Spinal Tumor]

Advances in cancer treatment helped in increasing the life expectancy of patients with cancer. However, a concomitant increase in the number of patients with bone metastases can be expected. A new multidisciplinary treatment strategy for patients with metastatic spinal tumors was designed, and has been practiced from 2013 in our hospital. The benefits of liaison treatment for metastatic spinal tumors is useful for early detection and early treatment before the collapse of the stabilization mechanism and the appearance of neurological symptoms, and enables team medical care by various experts. This system is a useful treatment for metastatic spinal tumors, because it enables radiotherapy and/or surgery before the onset of skeletal related events(SRE)and will also help maintain the activities of daily living(ADL)and quality of life(QOL)for patients with metastatic spinal tumors.

Video-Assisted Thoracoscopic Surgery for Re-Collapse of Vertebrae after Percutaneous Vertebral Augmentation (PVA)

INTRODUCTION

Due to the increase in osteoporosis accompanying the aging society in Japan, osteoporotic vertebral fractures (OVFs) are increasing. Percutaneous vertebral augmentation (PVA) has been widely used for OVFs because it reduces pain immediately with less invasiveness. Re-collapse of vertebral body after PVA is a rare, but important, complication. Once the re-collapse has occurred, patients should undergo an additional invasive salvage surgery.

METHODS

We treated 5 patients with re-collapse after PVA in our hospital. For re-collapse after PVA, we performed anterior column reconstruction with video-assisted thoracoscopic surgery (VATS), posterior fixation with percutaneous pedicle screws (PPSs) and minimally invasive spine stabilization (MISt).

RESULTS

The mean postoperative follow-up was at 62.8 months. At the final follow-up, the patients were free of low back pain, and bony union was achieved in all cases. The postoperative correction loss was 6 degrees. Perioperative complications included aspiration pneumonia in one patient and bone fracture of an adjacent vertebral body in two patients. There were no reoperation cases.

CONCLUSIONS

We perform minimally invasive combined anterior and posterior surgery with VATS for re-collapse after PVA. This procedure is useful in elderly patients with less reserve capacity.

Liaison Treatment for Metastatic Spinal Tumors

INTRODUCTION

The cancer board system employed at many hospitals and treatment centers involves multidisciplinary healthcare teams, including physicians, and the timing of treatment generally follows that of a consultation model. Thus, it is difficult to detect spinal metastases using the current implementation of the cancer board system, which can lead to delays in treatment. A new multidisciplinary treatment strategy for patients with metastatic spinal tumors was designed, and 745 patients were treated based on this strategy.

METHODS

In the first 5 years using the liaison treatment approach, 745 patients were diagnosed with metastatic spinal tumor. Tumors were discovered before a skeletal-related event (SRE) in 704 patients and after an SRE in 41 patients. We conducted our analysis in two patient groups: those with and without an SRE at the time of treatment initiation.

RESULTS

In most patients, the average spinal instability neoplastic score was 5.2, which indicates that we were able to detect the spinal tumor before a significant breakdown of the spinal support system. Ninety-five percent of patients were classified according to the Frankel grade classification during their initial diagnosis, and many patients initially underwent treatment before the onset of paralysis. Of patients with an SRE, 33% were Frankel grade E, indicating that approximately half were paralyzed at initial diagnosis. The median survival duration was prolonged by approximately 9 months in patients without an SRE compared with those with an SRE.

CONCLUSIONS

Orthopedic spine surgeons are responsible for maintaining activities of daily living, improving quality of life, and prolonging life expectancy in patients with metastatic spinal tumors. The results of this study revealed that the liaison treatment system for metastatic spinal tumors has made it possible to successfully prevent SREs without neurological deficits and to prolong survival.

Multidisciplinary treatment system for bone metastases for early diagnosis, treatment and prevention of malignant spinal cord compression

Malignant spinal cord compression (MSCC) is a serious complication of cancers. The present study aimed to establish a multidisciplinary treatment system for urgent magnetic resonance imaging (MRI) and referral to orthopedists in order to prevent neurological deficits caused by MSCC. In the present study, the extent to which this system achieved early diagnosis and treatment and prevented MSCC-caused neurological deficits was examined. The records from patients with neurological deficits caused by MSCC before (between April 2007 and March 2012; group A) and after (between April 2012 and March 2017; group B) the establishment of the multidisciplinary system at the Shikoku Cancer Center (Ehime, Japan) were retrospectively evaluated. The numbers of patients with neurological deficits were 38 and 7 in groups A and B, respectively. All patients received radiotherapy. The incidence of neurological deficits was 13.2 and 3.4% in groups A and B, respectively (P<0.001). The proportion of patients with improvement in the severity of neurological deficits was 5.3 and 28.6% in groups A and B, respectively (P<0.001). The interval between physicians' recognition of a neurological deficit and MRI and the start of treatment, the number of cases, and the severity of neurological deficits were evaluated in groups A and B. The median interval between recognition of a neurological deficit by physicians and MRI was 3 and 0 days in groups A and B, respectively (P<0.001). The median interval between physicians' recognition of a neurological deficit and the start of treatment was 3 and 0 days in groups A and B, respectively (P<0.001). By using a multidisciplinary treatment system, the incidence and severity of neurological deficits following treatment were significantly improved. Therefore, the multidisciplinary treatment system used in the present study may be useful for early diagnosis, treatment and prevention of MSCC in patients with bone metastases.

P1357 Left atrial function decreases with age in patients with repaired tetralogy of Fallot decrease

BACKGROUND

Left ventricular function has been shown to be an important prognostic indicator in patients with repaired tetralogy of Fallot (rTOF) and tends to decrease with age. In recent years, left atrial (LA) function was reported to be a useful prognostic indicator more than or equal to left ventricular function in acquired heart diseases. However, atrial function in rTOF has not yet been sufficiently examined.

PURPOSE

The aim of this study was to investigate the relationship between LA dysfunction and age in rTOF using strain analysis.

METHODS

In order to assess the relationship between LA function and age, we recruited 59 patients with rTOF ranging in age from 5-40 years. We stratified the patients into 3 groups (T1: 5-10 years, T2: 11-20 years, T3: 21-40 years) and divided 54 controls of similar age into 3 corresponding groups (N1, N2, and N3). Two-dimensional speckle tracking images (2D-STI) obtained from four- and two-chamber views were used to assess LA functions by measuring reservoir, conduit, and pump strain. Additionally, we measured the strain rate (SR) in the systole, early diastole, and late diastole.

RESULTS

LA reservoir strain (37.4 ± 2.2% vs. 47.9 ± 1.7%, P= 0.004), LA pump strain (8.3 ± 1.4% vs. 14.1 ± 2.7%, p &lt;.001), atrial systolic LA-SR (1.5 ± 0.4% vs. 2.4 ± 0.6%, p &lt;.001), and systolic LA-SR (1.5 ± 0.3% vs. 2.1 ± 0.4%, p = 0.003) were significantly decreased in T3 compared with N3. Although only LA conduit strain decreased with aging (r = -0.3204, p = 0011) in controls, all of the LA reservoir (r = -0.325, p = 0.020), conduit (r = -0.314, p = 0.025), and pump strain (r = -0.481, p &lt; 0.001) in rTOF decreased with aging.

Early diastole SR was significantly decreased in the T1 and T3 groups compared with the N1 and N3 groups (T1 vs N1, 3.00 ± 0.63% vs. 4.03 ± 0.0.80%, p &lt;.0.001, T3 vs N3, 2.31 ± 0.57% vs.3.31 ± 0.47%, p &lt; 0.001). Both systolic SR and late diastole SR decreased in T3 group compared with the N3 (1.54 ± 0.32% vs. 2.08 ± 0.42%, p = 0.003, 1.42 ± 0.32% vs.2.42 ± 0.61%, p &lt; 0.001), respectively. Although only early diastole SR decreased with aging (r = -0.415, p &lt; 0.001) in controls, all of the systole (r = -0.287, p = 0.041), early diastole (r = -0.337, p = 0.019), and late diastole SR (r = -0.407, p = 0.003) in rTOF decreased with aging.

CONCLUSIONS

In rTOF, most of the LA functions assessed by strain analysis decreased compared to normal controls in over 20 years old age. Furthermore, all measured functions decreased with age in rTOF while only two parameters decreased with age in normal controls. These results suggest that LA function may be an important indicator in long-term rTOF follow-up. These are new insights into LA function in patients with rTOF.

P198 Validation of the updated blood pressure classification based on the ACC/AHA guidelines in the perspective of subclinical atherosclerosis in general population

Background

American College of Cardiology (ACC) and American Heart Association (AHA) revised their guideline for hypertension in 2017, and the threshold of normal blood pressure (BP) was lowered, in the perspective of the prevention of optimal prevention of cardiovascular diseases. On the other hand European Society of Cardiology and European Society of Hypertension updated their guideline in 2018. However, the cut off value of blood pressure for hypertension was not changed (sBP ≥ 140 mmHg or dBP ≥ 90 mmHg). Therefore, the validity of the updated guideline of ACC/AHA still remains controversial, and there is so far no evidence regarding the BP category according to the ACC/AHA guidelines in general population.

Purpose

We aimed to clarify the association between the updated BP classification and carotid intima-media thickness (IMT), as a marker of subclinical atherosclerosis, in general population using a community-based cohort.

Methods

We analyzed 1,241 subjects undergoing medical check-ups at the University of Tokyo Hospital. Study subjects were categorized into 3 groups based on their BP levels: normal pressure (sBP &lt; 130 mmHg and dBP &lt; 80 mmHg); stage 1 hypertension (130 mmHg ≤ sBP &lt; 140 mmHg or 80 mmHg ≤ dBP&lt; 90 mmHg); and stage 2 hypertension (sBP ≥ 140 mmHg or dBP ≥ 90 mmHg, including subjects prescribed with antihypertensive agents). We defined carotid plaque as IMT ≥ 1.1 mm.

Results

Out of 1,241 subjects, 556 patients (44.8%) were categorized in the normal BP group, whereas 236 subjects (19.0%) and 449 subjects (36.2%) were categorized in the stage 1 and stage 2 hypertension groups, respectively. Among subjects categorized in the stage 2 hypertension group, 348 subjects (77.5%) patients were taking antihypertensive medications. Percentage of male gender, and age increased with BP category. Classical CVD risk factors such as diabetes mellitus and hypercholesterolemia were common in subjects in the hypertension groups. IMT increased as the BP category progressed from normal BP to stage 2 hypertension. The prevalence of carotid plaque also increased with an increase in BP. Univariate regression analysis showed the linear association between the BP category and prevalence of carotid plaque. Multivariable logistic regression analysis demonstrated that BP category as well as age ≥60 years, male gender, body mass index ≥25 kg/m2, and diabetes mellitus were independently associated with carotid plaque formation. BP category was associated with the prevalence of carotid plaque formation in any subgroup divided by age (&lt; 60 years old, and ≥60 years old) or gender.

Conclusions

Thickening of IMT developed in stage 1 hypertension, and further increased in stage 2 hypertension even in general population, indicating the importance of the therapeutic intervention according to the updated ACC/AHA guideline for hypertension.

Abstract P198 Figure.

Adverse events associated with continuous interscalene block administered using the catheter-over-needle method: a retrospective analysis

Background

Continuous interscalene block is widely used for pain management in shoulder surgery. However, continuous interscalene block performed using the catheter-through-needle method is reportedly associated with adverse events such as pericatheter leakage of the local anesthetic, phrenic nerve paralysis, and hoarseness. Because we expected that the catheter-over-needle method would reduce these adverse events, we examined cases in which continuous interscalene block was performed using the catheter-over-needle method to determine what adverse events occurred and when.

Methods

We retrospectively reviewed the anesthesia and medical records of adult patients who underwent catheter insertion to receive a continuous interscalene block performed using the catheter-over-needle method at our hospital from July 2015 to July 2017.

Results

During the surveillance period, 122 adult patients underwent catheter insertion to receive a continuous interscalene block administered using the catheter-over-needle method. No case of pericatheter local anesthetic leakage was observed. Adverse events, such as dyspnea, hoarseness, insufficient anesthetic effect, dizziness, cough reflex during drinking, or ptosis, were observed in 42 patients (34.4%; 95% confidence interval 26–42.7). Most of the adverse events occurred on postoperative day 2. The median time between surgery and the onset of adverse events was 28.5 h.

Conclusions

The catheter-over-needle method may prevent the pericatheter leakage of the local anesthetic. However, adverse events occurred in more than one-third of the patients. During continuous interscalene block, patients must be carefully observed for adverse events, especially on postoperative day 2.

Trial registration

This study was registered at the UMIN Clinical Trials Registry on August 13th, 2019 (UMIN000037673).

2140Association of arterial stiffness with left atrial structure and phasic function: a community-based cohort study

Background

Increased arterial stiffness is recognized as an independent risk factor for atrial fibrillation, although the pathophysiological mechanisms remain unclear. Cardio-ankle vascular index (CAVI) is emerging as an important tool to assess arterial stiffness noninvasively which is derived from the concept of stiffness β index and is less dependent on blood pressure at the time of measurement than pulse wave velocity.

Purpose

This study aimed to investigate the association of arterial stiffness with left atrial (LA) volume and phasic function in a community-based cohort.

Methods

We included 1,156 participants without overt cardiovascular disease who underwent extensive cardiovascular examination. Arterial stiffness was evaluated by CAVI. Speckle-tracking echocardiography was employed to evaluate LA phasic function including reservoir, conduit and pump strain as well as left ventricular global longitudinal strain (LVGLS).

Results

CAVI was negatively correlated with reservoir and conduit strain (r=−0.37 and −0.45, both p<0.001; Figure), whereas weakly, but positively correlated with LA volume index and pump strain (r=0.12 and 0.09, both p<0.01). In multivariable analysis, CAVI was significantly associated with reservoir and conduit strain independent of traditional cardiovascular risk factors, pertinent laboratory parameters and LV morphology and function including LVGLS (standardized β=−0.22 and −0.26, respectively, both p<0.001), whereas there was no independent association with LA volume index and pump strain. In the categorical analysis, the abnormal CAVI (≥9.0) carried the significant risk of impaired reservoir (<31.4%) and conduit (<12.4%) strain (adjusted odds ratio = 2.63 and 3.71 vs. normal CAVI, both p<0.01) in a fully-adjusted model including laboratory and echocardiographic parameters.

Figure 1

Conclusion

Arterial stiffness was independently associated with LA reservoir and conduit function, even in the absence of overt cardiovascular disease. This association may explain the higher incidence of atrial fibrillation in individuals with increased arterial stiffness.

P5293Effect of metabolically health obesity on carotid intima-media thickness in general population: a community-based cohort study

Introduction

Obesity is a common and independent risk factor for all-cause mortality. More specifically, obesity is a major component of atherosclerosis in association with metabolic disorders including metabolic syndrome (MetS), resulting in various cardiovascular diseases (CVD). Alternatively, obese subjects without MetS are prevalent, also referred to as metabolically healthy obesity (MHO). However, most preceding studies regarding MHO have been limited by small cohorts. Therefore, the effect of MHO on atherosclerosis in the general population remains unclear.

Purpose

In this study, we sought to clarify the effect of MHO on carotid intima-media thickness (IMT) as a marker of early stage atherosclerosis using a community-based cohort in general population.

Methods

We examined subjects who underwent medical check-up at our University Hospital. We defined obesity as body mass index ≥25.0 kg/m2. Abdominal obesity, defined as waist circumstance at umbilical level ≥85 cm in men and ≥90 cm in women, was obligatory for the diagnosis of MetS. In addition to abdominal obesity, any two of the following three abnormalities should be observed for the diagnosis of MetS, [1] Dyslipidemia: triglyceride ≥150 mg/dL, HDL-C <40 mg/dL, or use of lipid lowering medication, [2] Hypertension: systolic blood pressure ≥130 mmHg, diastolic blood pressure ≥85 mmHg, or use of antihypertensive medication, and [3] Hyperglycemia: fasting plasma glucose ≥110 mg/dL or use of hypoglycemic medication. MHO was defined as obese subjects without MetS, whereas we defined metabolically unhealthy obesity (MUO) as obese subjects with MetS. We defined carotid plaque as IMT ≥1.1 mm.

Results

Among 1,241 subjects, 857 subjects (69%) were categorized in the normal body weight group, whereas 275 subjects (22%) were categorized as MHO, and 109 subjects (9%) were categorized as MUO. Compared to non-obese subjects, prevalence of classical cardiovascular risk factors including hypertension, diabetes mellitus, and dyslipidemia increased in subjects with MHO, and further increased in those with MUO. IMT was higher in obese subjects compared to those without obesity. Similarly, the prevalence of carotid plaque formation was also higher in obese subjects. Multivariable logistic regression analysis demonstrated that age ≥60 years, male sex, hypertension, diabetes mellitus, MHO subjects (Odds ratio [OR]; 1.6, p=0.005), and MUO subjects (OR 1.7, p=0.04) were independently associated with carotid plaque formation. There was no statistical difference in the risk of carotid plaque formation between subjects with MHO and MUO.

IMT and Carotid Plaque

Conclusions

IMT and the prevalence of carotid plaque are higher in both subjects with MHO and MUO compared to non-obese subjects in the general population. We need to take obesity regardless of the presence of MetS into consideration as high-risk subjects for subsequent CVD.

P4389Effect of cigarette smoking on carotid artery atherosclerosis: a community-based cohort study

Background

Cigarette smoking is closely associated with the development of cardiovascular diseases (CVD), and the European Society of Cardiology/European Atherosclerosis Society (ESC/EAS) guidelines recommend smoking bans.On the other hand, the relationship between cigarette smoking and subclinical atherosclerosis has not been fully studied. Carotid intima-media thickness (cIMT) is commonly used as a subclinical atherosclerosis marker, and a carotid plaque feature is also known to be an important predictor of cardiovascular diseases.

Purpose

We sought to clarify the association between cigarette smoking and subclinical atherosclerosis by evaluating carotid plaque including cIMT and carotid plaque features in general population.

Methods and results

Among 1,209 participants with no prior coronary artery disease who received a medical check-up with cardiovascular examination at our institution, 450 participants (37.2%) were smokers (including both past and current smokers). We defined carotid plaque as cIMT ≥1.1 mm and high-risk plaque as carotid plaque with hypoechoic dominant and/or plaque ulceration. The value of cIMT and the rate of carotid plaque were not different between smokers and never smokers (Figure A & B). However, the rate of carotid high-risk plaque was significantly higher in participants with smokers than those with never smokers (29.7%, vs 23.5%, p=0.011) (Figure C). Even after adjustment with covariates including age, gender and traditional cardiovascular risk factors, cigarette smoking was independently associated with high-risk plaque formation (odds ratio 1.384, 95% CI 1.020–1.877; p=0.037). According to the subgroup analysis classified by age, cigarette smoking was associated with not only the development of high-risk plaque but also the increased value of cIMT in the subgroup over 60 years old, whereas only the rate of high-risk plaque was higher in smokers than never smokers in the subgroup under 60 years old.

Carotid plaque and smoking

Conclusion

The development of high-risk carotid artery plaque may precede thickening of cIMT in cigarette smokers, suggesting that the novel insight for the pathological mechanism underlying cardiovascular events and cigarette smoking.

Hemolytic reaction in the washed salvaged blood of a patient with paroxysmal nocturnal hemoglobinuria

Background

In patients with paroxysmal nocturnal hemoglobinuria (PNH), the membrane-attack complex (MAC) formed on red blood cells (RBCs) causes hemolysis due to the patient’s own activated complement system by an infection, inflammation, or surgical stress. The efficacy of transfusion therapy for patients with PNH has been documented, but no studies have focused on the perioperative use of salvaged autologous blood in patients with PNH.

Case presentation

A 71-year-old man underwent total hip replacement surgery. An autologous blood salvage device was put in place due to the large bleeding volume and the existence of an irregular antibody. The potassium concentration in the transfer bag of salvaged RBCs after the wash process was high at 6.2 mmol/L, although the washing generally removes > 90% of the potassium from the blood. This may have been caused by continued hemolysis even after the wash process. Once activated, the complement in patients with PNH forms the MAC on the RBCs, and the hemolytic reaction may not be stopped even with RBC washing.

Conclusions

Packed RBCs, instead of salvaged autologous RBCs, should be used for transfusions in patients with PNH. The use of salvaged autologous RBCs in patients with PNH should be limited to critical situations, such as massive bleeding. Physicians should note that the hemolytic reaction may be present inside the transfer bag even after the wash process.

Massive pulmonary embolism with cardiac arrest in pregnancy: A case report

A 39-year-old woman developed a pulmonary embolism at 28 weeks of gestation, after a 4-week period of bedrest, and required emergencycesarean section due to a decrease in fetal heart rate. Pulseless electrical activity (PEA) developed after intravenous anesthesia. The fetus was delivered 5 min after PEA onset, during cardiopulmonary resuscitation of the mother. Intravenous recombinant tissue-plasminogen activator injection, percutaneous cardiopulmonary support, and 24-h hypothermia therapy were administered to the mother, followed by inferior vena cava filter insertion, combined with catheter thrombus fragmentation and percutaneous thrombectomy. Both the patient and her baby survived. <Learning objective: Massive pulmonary embolism with pregnancy may result in death of both mother and child. In this case, after maternal cardiac arrest due to massive pulmonary embolism, the fetus was delivered by cesarean section, followed by thrombolysis treatment using recombinant tissue-plasminogen activator and percutaneous cardiac pulmonary support, pulmonary thrombectomy which was performed on day 3 was effective. Both the patient and her baby survived.>.

Radiculopathy Contralateral to the Side of Disc Herniation -Microendoscopic Observation

INTRODUCTION

There are patients with lumbar disc herniation (LDH) having contralateral sciatic symptoms although the mechanisms of this clinical feature are still not well understood. The purpose of this study was to investigate these mechanisms by microendoscopic findings.

METHODS

Patients were performed microendoscopic surgery using over-the-top approach (ME-OTT), with laminoplasty, extirpation of herniation, and observation of the contralateral nerve root. The over-the-top approach was applied through the same incision from the herniation side. Clinical results were assessed according to the clinical scoring system established by the Japanese Orthopedic Association (JOA) score.

RESULTS

This study consisted of five patients, with the average age of 55.6 years old. The mean preoperative JOA score was 13 points. Three cases were Grade II and two were Grade III degrees of disc herniation. Levels of herniation were one at L3-4 and four at L4-5. Remission of sciatic symptoms was obtained in all cases after surgery. The average and percent improvements (%IP) of JOA scores at 2 months after surgery were 27.8 points and 92%, respectively. By the approach from the herniation side using ME-OTT, image around the contralateral nerve root was obtained without radical intervention. By ME-OTT, redness of the nerve root and fibrosis around the symptomatic nerve root were identified, whereas inflammatory changes were not apparent on the ipsilateral nerve root.

CONCLUSIONS

Operative treatment of LDH with contralateral symptoms by ME-OTT was a useful procedure for decompression and observation of the affected nerve root. Asymptomatic disc herniation, "silent disc herniation," was considered at the herniation side since there were less inflammatory changes around the ipsilateral nerve root. In contrast, compression of dura toward the opposite side by disc herniation could have led to mechanical stress against the contralateral nerve root and triggered inflammation at lateral recess, resulting in radicular pain.