Effect of Intraoperative Tranexamic Acid on Perioperative Major Hemorrhage Requiring Transfusion in Patients Undergoing Elective Spine Surgery: A Propensity Score-Matched Analysis Using a National Inpatient Database

STUDY DESIGN

Retrospective cohort study.

OBJECTIVES

This study aimed to examine whether the use of intravenous TXA in elective spine surgery is associated with reduced perioperative massive hemorrhage requiring transfusion.

METHODS

We extracted all patients who underwent decompression with or without fusion surgery for the cervical, thoracic, and lumbar spine between April 2012 and March 2019. The primary outcome was the occurrence of massive hemorrhage requiring transfusion, defined as at least 560 mL of blood transfusion within 2 days of spine surgery or the requirement of additional blood transfusion from 3-7 days postoperatively. Secondary outcomes were the occurrence of thrombotic complications (pulmonary embolism, acute coronary syndrome, and stroke) and postoperative hematoma requiring additional surgery.

RESULTS

We identified 83,821 eligible patients, with 9747 (12%) patients in the TXA group. Overall, massive hemorrhage requiring transfusion occurred in 781 (.9%) patients. Propensity score matching yielded 8394 pairs. In the matched cohort, the TXA group had a lower proportion of massive hemorrhage requiring transfusion than the control group (.7% vs 1.1%; P = .002). There was no significant difference in the occurrence of thrombotic complications and postoperative hematoma requiring additional surgery between both groups. The multivariable regression analysis also showed that the use of TXA was associated with significantly lower proportions of massive hemorrhage requiring transfusion (odds ratio, .62; 95% confidence interval, .43-.90; P = .012).

CONCLUSIONS

In this analysis using real-world data, TXA use in elective spinal surgery was associated with reduced perioperative massive hemorrhage requiring transfusion without increasing thrombotic complications.

LEVEL OF EVIDENCE

Prognostic Level Ⅲ.

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.

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.

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.

A nationwide multicenter study of the cost effectiveness of five leading drugs for pharmacological management of cervicobrachial symptoms

BACKGROUND

Cervicobrachial pain frequently affects the quality of life (QOL) of the general public and has a significant economic impact on the health care systems of various countries. There are a number of treatment options for this disease, including widely-used drug therapy, but the effectiveness of each option is indeterminate, and there have been no published cost-effectiveness analysis studies so far. This prospective observational study aimed to examine the cost-effectiveness of drug treatment for cervicobrachial symptoms.

METHODS

A 6-month medication regimen for each of five frequently-prescribed drugs for cervicobrachial symptoms was administered to 322 patients at 24 centers in Japan. Outcome measures, including of the EuroQol Group 5D, Short Form-8, and Visual Analog Scale (VAS), were investigated at baseline and every month thereafter. Incremental cost-effectiveness ratios (ICERs) of the drug cost to quality-adjusted life years (QALYs) were calculated. A stratified analysis of patient characteristics was also performed to identify baseline factors potentially affecting cost-effectiveness.

RESULTS

The ICER of entire drug treatment for cervicobrachial symptoms was 7,491,640 yen. Compared with the reference willingness-to-pay, the ICER was assumed to not be cost-effective. A certain number of QALYs were gained during the first 3 months after the treatment intervention, but almost no QALYs were gained during the following 3 months. Stratified analysis showed that cost-effectiveness was extremely low for patients with high baseline VAS and high QOL.

CONCLUSIONS

The available medications for cervicobrachial symptoms did not have excellent cost-effectiveness. Although a certain number of QALYs were gained during the first 3 months after medication, no QALYs were gained in the latter half of the study period, suggesting that it is not advisable to continue the medication needlessly.

LEVEL OF EVIDENCE

II, prospective cohort study.

Radiographic Predictors of Subaxial Subluxation After Atlantoaxial Fusion

STUDY DESIGN

A retrospective study.

OBJECTIVE

The aim of this study was to clarify preoperative radiographic predictors associated with the development of subaxial subluxation (SAS) after surgery.

BACKGROUND

The incidence of atlantoaxial fusion for atlantoaxial instability has been increasing. SAS can develop after surgery despite atlantoaxial fusion with the optimal C1-C2 angle. We hypothesized that preoperative discordant angular contribution in the upper and subaxial cervical spine is associated with the occurrence of postoperative SAS.

MATERIALS AND METHODS

Patients who underwent surgery for atlantoaxial instability with a minimum 5-year follow-up and control participants were included. The O-C2 angle, C2 slope (C2S), C2-C7 cervical lordosis (CL), and T1 slope (T1S) were measured. We focused on the angular contribution ratio in the upper cervical spine to the whole CL, and the preoperative C2/T1S ratio was defined as the ratio of C2S to T1S.

RESULTS

Twenty-seven patients (SAS=11, no-SAS=16; mean age, 60.7 y old; 77.8% female; mean follow-up duration, 6.8 y) and 23 demographically matched control participants were enrolled. The SAS onset was at 4.7 postoperative years. Preoperatively, the O-C2 angle, C2-C7 CL, and T1S were comparable between the SAS, no-SAS, and control groups. The preoperative C2S and C2/T1S ratio were smaller in the SAS group than in the no-SAS or control group (C2S, 11.0 vs. 18.4 vs. 18.7 degrees; C2/T1S ratio, 0.49 vs. 0.77 vs. 0.78, P <0.05). The receiver operating characteristic curve analysis demonstrated that the C2/T1S ratio had higher specificity and similar sensitivity as a predictor of postoperative SAS than C2S (specificity: 0.90 vs. 0.87; sensitivity: 0.73 vs. 0.73). The estimated cutoff values of the C2S and C2/T1S ratio were 14 degrees and 0.58, respectively.

CONCLUSIONS

The preoperative C2/T1S ratio was closely associated with postoperative SAS. Patients with a C2/T1S ratio <0.58 were at a high risk of SAS after atlantoaxial fusion.

LEVEL OF EVIDENCE

Level 4.

Preoperative factors affecting the two-year postoperative patient-reported outcome in single-level lumbar grade I degenerative spondylolisthesis

Background

The choice of operative method for lumbar spinal stenosis with Meyerding grade I degenerative spondylolisthesis remains controversial. The purpose of this study was to identify the preoperative factors affecting the 2-year postoperative patient-reported outcome in Meyerding grade I degenerative spondylolisthesis.

Methods

Seventy-two consecutive patients who had minimally invasive decompression alone (D group; 28) or with fusion (DF group; 44) were enrolled. The parameters investigated were the Japanese Orthopaedic Association back pain evaluation questionnaire as patient-reported assessment, and L4 slippage (L4S), lumbar lordosis (LL), and lumbar axis sacral distance (LASD) as an index of sagittal alignment for radiological evaluation. Data collected prospectively at 2 years postoperatively were examined by statistical analysis.

Results

Sixty-two cases (D group; 25, DF group; 37) were finally evaluated. In multiple logistic regression analysis, preoperative L4S and LASD were extracted as significant preoperative factors affecting the 2-year postoperative outcome. Patients with preoperative L4S of 6 mm or more have a lower rate of improvement in lumbar spine dysfunction due to low back pain (risk ratio=0.188, p=.043). Patients with a preoperative LASD of 30 mm or more have a higher rate of improvement in lumbar dysfunction due to low back pain (risk ratio=11.48, p=.021). The results of multiple logistic analysis by operative method showed that there was a higher rate of improvement in lumbar spine dysfunction due to low back pain in patients with preoperative LASD of 30 mm or more in DF group (risk ratio=172.028, p=.01).

Conclusions

Preoperative L4S and LASD were extracted as significant preoperative factors affecting patient-reported outcomes at 2 years postoperatively. Multiple logistic analyses by the operative method suggested that DF may be advantageous in improving lumbar dysfunction due to low back pain in patients with preoperative LASD of 30 mm or more.

Risk factors for early mortality in elderly patients with unstable isolated C2 odontoid fracture treated with halo-vest or surgery

The aim of this study was to compare in-hospital mortality of three procedures -halo-vest immobilization, anterior spinal fixation (ASF), and posterior spinal fixation (PSF)- in the treatment of elderly patients with isolated C2 odontoid fracture. We extracted data for elderly patients who were admitted with C2 odontoid fracture and treated with at least one of the three procedures (halo-vest immobilization, ASF, or PSF) during hospitalization. We conducted a generalized propensity score-based matching weight analysis to compare in-hospital mortality among the three procedures. We further investigated independent risk factors for in-hospital death. The study involved 891 patients (halo-vest, n = 463; ASF, n = 74; and PSF, n = 354) with a mean age of 78 years. In-hospital death occurred in 45 (5.1%) patients. Treatment type was not significantly associated with in-hospital mortality. Male sex (odds ratio 2.98; 95% confidence interval 1.32-6.73; p = 0.009) and a Charlson comorbidity index of ≥ 3 (odds ratio 9.18; 95% confidence interval 3.25-25.92; p < 0.001) were independent risk factors for in-hospital mortality. In conclusion, treatment type was not significantly associated with in-hospital mortality in elderly patients with isolated C2 odontoid fracture. Halo-vest immobilization can help to avoid adverse events in patients with C2 odontoid fracture who are considered less suitable for surgical treatment.

Trends in cervical laminoplasty and 30-day postoperative complications: 10-year results from a retrospective, multi-institutional study of 1095 patients

PURPOSE

This study aimed to investigate the recent 10-year trends in cervical laminoplasty and 30-day postoperative complications.

METHODS

This retrospective multi-institutional cohort study enrolled patients who underwent laminoplasty for cervical spondylotic myelopathy (CSM) or ossification of the posterior longitudinal ligament. The primary outcome was the occurrence of all-cause 30-day complications. Trends were investigated and compared in the early (2008-2012) and late (2013-2017) periods.

RESULTS

Among 1095 patients (mean age, 66 years; 762 [70%] male), 542 and 553 patients were treated in the early and late periods, respectively. In the late period, patients were older at surgery (65 years vs. 68 years), there were more males (66% vs. 73%), and open-door laminoplasty (50% vs. 69%) was the preferred procedure, while %CSM (77% vs. 78%) and the perioperative JOA scores were similar to the early period. During the study period, the rate of preservation of the posterior muscle-ligament complex attached to the C2/C7-spinous process (C2, 89% vs. 93%; C7, 62% vs. 85%) increased and the number of laminoplasty levels (3.7 vs. 3.1) decreased. While the 30-day complication rate remained stable (3.9% vs. 3.4%), C5 palsy tended to decrease (2.4% vs. 0.9%, P = 0.059); superficial SSI increased significantly (0% vs. 1.3%, P = 0.015), while the decreased incidence of deep SSI did not reach statistical significance (0.6% vs. 0.2%).

CONCLUSIONS

From 2008 to 2017, there were trends toward increasing age at surgery and surgeons' preference for refined open-door laminoplasty. The 30-day complication rate remained stable, but the C5 palsy rate halved.

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.

Major Cardiovascular Events after Chemoradiotherapy with or without Durvalumab in Patients with Stage III Non-Small Cell Lung Cancer: Supplementary Analysis

PURPOSE/OBJECTIVE(S)

RTOG 0617 showed that cardiac events are relatively common after high-dose thoracic radiotherapy. The aim of this study was to investigate the incidence and risk of major cardiovascular events (MACE) after concurrent chemoradiotherapy (CCRT) with or without durvalumab in patients with stage III non-small cell lung cancer (NSCLC) using the data from a multi-institutional study in Japan.

MATERIALS/METHODS

Patients who received CCRT for stage III NSCLC between July 2018 and July 2019 were enrolled in a multi-institutional study in Japan. MACE was defined as follows: symptomatic pericardial effusion, acute coronary syndrome, pericarditis, significant arrhythmia, and heart failure. The cumulative incidence of MACE, accounting for death as a competing risk, was calculated. Pre-existing coronary heart disease (CHD) included coronary artery disease, congestive heart failure, peripheral vascular disease, stroke, and extensive coronary artery calcification. The association between patient/treatment-related factors and MACE was assessed by multivariate analysis.

RESULTS

Among 178 patients with a median follow-up period of 42.5 months, 13 patients developed MACEs. The 3-year cumulative incidence of MACE was 6.9% (95% confidence interval [CI], 4.0-11.9%). Univariate analysis showed that female sex and mean heart dose (MHD) were marginally associated (3-year cumulative incidence, male 5.6% vs. female 12.1%; P = 0.12; MHD ≥ 6.3 Gy 4.8% vs. < 6.3 Gy 9.1%; P = 0.13), and pre-existing CHD was significantly associated with an increased risk of MACE (no CHD 4.3% vs. CHD 16.8%; P = 0.026). Consolidation durvalumab was not associated with an increased risk of MACE (no durvalumab 5.2% vs. durvalumab 7.4%; P = 0.89). Multivariate analysis showed that pre-existing CHD was significantly associated with MACE (hazard ratio, 4.22; 95% CI, 1.30-13.7; P = 0.016).

CONCLUSION

The incidence of MACE based on the real-world data in Japan was lower than previously reported. Pre-existing CHD was associated with an increased risk of MACE after CCRT in patients with stage III NSCLC, whereas the administration of consolidation durvalumab was not associated with an increased risk of MACE.

Real-World Study of Overall Survival in Patients with Stage III Non-Small Cell Lung Cancer Treated with Chemoradiotherapy with or without Durvalumab and an Exploratory Analysis of Effective Radiation Dose to the Immune Cells

PURPOSE/OBJECTIVE(S)

To investigate the real-world data on overall survival (OS) in patients with stage III non-small cell lung cancer (NSCLC) treated with concurrent chemoradiotherapy (CCRT) with or without consolidation durvalumab, and to perform an exploratory analysis on effective radiation dose to the immune cells (EDIC).

MATERIALS/METHODS

In our multi-institutional retrospective study, patients who received CCRT between July 2018 and July 2019 for stage III NSCLC in Japan were investigated. EDIC was estimated using mean lung dose, mean heart dose, body volume, body mean dose, and body weight, as reported in the secondary analysis of RTOG 0617. The cut-off value of EDIC was calculated using the maximally selected log-rank statistics.

RESULTS

One hundred and seventy-eight patients were eligible for the analysis (136 patients, CCRT with consolidation durvalumab [CCRT+D] cohort; 42 patients, CCRT cohort). The median follow-up period was 42.5 months. Three-year OS rates were 59.8% in the overall cohort: 60.5% in the CCRT+D cohort, and 58.0% in the CCRT cohort with no significant difference (hazard ratio [HR], 0.76; 95% confidence interval [CI], 0.45-1.27; P = 0.29). Univariate analysis showed that ECOG-PS, smoking history, histology, EGFR mutational status, gross tumor volume and EDIC were significantly associated with OS. Multivariate analysis showed that ECOG-PS 2, gross tumor volume ≥ 57 cm3 and EDIC ≥ 4.4 Gy were associated with poor OS. Among 21 EGFR-mutated patients, 3 year-OS rates were 64.7% in the CCRT+D cohort and 100% in the CCRT cohort, while 3 year-OS rates were 68.8% and 58.7% among 90 EGFR wild-type patients. Three-year OS rates were 64.6% and 47.6% for EDIC < 4.4 Gy and EDIC ≥ 4.4 Gy in the overall cohort (HR, 1.82; 95% CI, 1.14-2.90; P = 0.015). In the subgroup analysis, 66.3% vs. 44.4% in the CCRT+D cohort (HR, 2.01; 95% CI, 1.17-3.47; P = 0.016), and 59.0% vs. 56.1% in the CCRT cohort (HR, 1.20; 95% CI, 0.48-3.01; P = 0.70), respectively.

CONCLUSION

Our real-world data in Japan showed that there was no significant difference in OS between the CCRT+D cohort and the CCRT cohort. High EDIC could be a risk for poor OS in patients treated with CCRT and consolidation durvalumab compared with those treated with CCRT.

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.

Late-Onset Esophageal Perforation After Salvage Anterior Cervical Spine Surgery in a Patient With Systemic Sclerosis

Systemic sclerosis (SSc) is a systemic, immune-mediated disease characterized by abnormal cutaneous and organ-based fibrosis that results in progressive organ dysfunction including the esophagus. We herein report our experience of a patient with SSc who underwent salvage anterior cervical spine surgery that led to late-onset esophageal perforation. A 57-year-old female had progressive cervical kyphosis after laminoplasty for cervical spondylotic myelopathy. We performed anterior cervical discectomy and fusion using a stand-alone cage. Despite prolonged use of a neck collar, migration of the anterior cage was noted three months after surgery. Rapid progression of kyphotic deformity prompted us to perform revision surgery of circumferential cervical correction. However, conventional posterior surgery was precluded due to the extremely poor condition of her neck, including severely sclerotic skin and atrophic muscles. To address this, she underwent a posterior fusion with the closed technique and C4-C5 corpectomy and bone grafting using a low-profile anterior plate. One year after the surgery, CT and routine upper gastrointestinal endoscopy (UGE) showed no evidence of esophagus injury. She remained asymptomatic thereafter. Over three years after her last surgery, however, follow-up CT incidentally revealed an abnormal air leak around the anterior plate. UGE demonstrated large esophagus perforation with the exposed metal plate. As she had already been on parenteral nutrition due to the disease progression of SSc, we decided not to remove the implant. Potential esophagus perforation after anterior cervical spine surgery, even years later, should be considered regardless of the patient's symptoms, such as chest pain and dysphagia. Spine surgeons need to be cognizant of the fragility of the esophagus, especially in patients with SSc. For patients with SSc, posterior reconstruction alone is recommended as a relatively safe option, even with a suboptimal skin condition.

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.

Association Between Early Surgery and Postoperative Opioid Use in Patients With Lumbar Disc Herniation: A Propensity Score-Matching Analysis Using an Administrative Claims Database in Japan

STUDY DESIGN

Retrospective cohort study.

OBJECTIVES

This study aimed to investigate whether early surgery shortens the duration of opioid use in patients who underwent surgery with lumbar disc herniation.

METHODS

We extracted patients who underwent surgery at least 2 weeks after they were diagnosed with lumbar disc herniation between April 2014 and May 2021. Opioid use after surgery was compared between patients who underwent surgery within 90 days (early surgery group) and 90 days or later (late surgery group). Propensity-score-matching analysis and multivariable Cox hazard regression analysis with a restricted cubic spline model were conducted to evaluate the association between the timing of surgery and termination of opioid use after surgery.

RESULTS

A total of 1597 eligible patients were identified, with 807 (51%) in the early surgery group. In the propensity-score-matched cohort, the early surgery group had a significantly lower proportion of opioid use than the control group (28% vs 48%, percent difference -20%, P < .001). Multivariable Cox hazard regression analysis showed that early surgery was significantly associated with the earlier termination of opioid use (HR, 3.13; 95% CI, 1.97-4.97; P < .001). Restricted cubic spline model showed a monotonically decreased hazard ratio and decreased hazard ratio of .50 in patients who underwent surgery 111 days or later after the diagnosis.

CONCLUSIONS

Early surgery, especially within 90 days, was associated with earlier opioid use termination after surgery. Regarding the duration of opioid use following surgery, surgical treatment may be preferable to perform within around 4 months after the diagnosis.

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.

The Association Between the Rotator Cuff Status and the Severity and Recovery of Weakness in the Shoulder Abductor Strength in a Case of Proximal Type Cervical Spondylotic Amyotrophy

STUDY DESIGN

Case series study.

OBJECTIVE

We aimed to clarify the prevalence of rotator cuff tear (RCT), and the association between RCT and the severity and prognosis in patients with proximal type cervical spondylotic amyotrophy (CSA).

METHODS

We retrospectively analyzed 35 proximal type CSA patients who were treated conservatively. The following data was collected: age, rotator cuff status on MRI, manual muscle test (MMT) score of shoulder abductor and biceps brachii muscles both at the first visit and final follow-up. We investigated the prevalence of RCT and the association between the rotator cuff status, and the severity and recovery of upper extremity weakness in patients with proximal type CSA.

RESULTS

Of the 35 patients, 21 had an RCT on MRI, indicating that the prevalence of RCT in patients with proximal type CSA was 60%. An age-adjusted analysis showed that the presence of RCT was significantly associated with the MMT score of the shoulder abductor muscles both at the first visit and at the final follow-up. The presence of RCT was significantly associated with the recovery of the shoulder abductor muscles. The size of the RCT was negatively correlated with the MMT score of the shoulder abductor muscles at the final follow-up. The size of the RCT was independently correlated with the change of the MMT score of the shoulder abductor muscles.

CONCLUSION

RCT was detected in >50% in patients with proximal type CSA, and the presence and severity of RCT can be used as prognostic factors for proximal type CSA patients who are treated conservatively.

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.

A simple scoring of beam walking performance after spinal cord injury in mice

Precise evaluation of motor functions using simple and reproducible tests for mouse models of spinal cord injury (SCI) are required. Overground walking of SCI mice has been tested by Basso Mouse Scale for locomotion (BMS). In contrast, only a few works quantify walking performances of SCI mice on narrow beams, a different task. Here, we established a novel scoring system using a single beam walking apparatus for SCI mice. The scoring system uses binary judgments of values such as retention, moving forward and reaching the goal on a beam for rating. In addition, high score was given to SCI mouse when the mouse efficiently used hindlimbs for locomotion on the beam. A high rate of concordance of the score derived from positions of hindlimbs between two observers was obtained. Mice displayed the lowest total score on the beam immediately after the SCI, then the score gradually increased like time course of BMS score. Furthermore, the total scores reflected gradation of severity of SCI in 2 strains of mice. The beam walking score proved to be strongly correlated with that of BMS score, indicating that performances between overground walking and beam walking are partly correlated in SCI mice. Collectively, the novel scoring system offers an opportunity to easily evaluate motor performances of mice with SCI.

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.

Cervical Kyphosis due to Neurofibromatosis Type 1 Treated by Circumferential Spinal Fusion using an Autologous Vascularized free Fibula Followed by Teriparatide Administration: A Case Report

Introduction

Cervical kyphosis is sometimes observed in neurofibromatosis Type 1 (NF-1). If NF-1-associated cervical deformity is progressive, surgical intervention is needed to prevent further deterioration of the deformity. The rate of nonunion after spinal fusion is high in NF-1, especially dystrophic NF-1.

Case Report

Cervical kyphosis is sometimes observed in neurofibromatosis Type 1 (NF-1). If NF-1-associated cervical deformity is progressive, surgical intervention is needed to prevent further deterioration of the deformity. The rate of nonunion after spinal fusion is high in NF-1, especially dystrophic NF-1.

Conclusion

We administered the teriparatide after spinal fusion surgery for NF-1-associated cervical deformity and obtained complete bony fusion. The administration of teriparatide may be useful to achieve complete bone fusion in patients with NF-1-associated cervical deformity.

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.

Risk factors for severe lower extremity ischemia following venoarterial extracorporeal membrane oxygenation: an analysis using a nationwide inpatient database

Objectives

Venoarterial extracorporeal membrane oxygenation is increasingly being used as a life-saving modality in critically ill patients. Despite its necessity, severe lower extremity ischemia associated with venoarterial extracorporeal membrane oxygenation remains a potentially devastating complication. We aimed to investigate the incidence and risk factors for severe lower extremity ischemia requiring fasciotomy or amputation following venoarterial extracorporeal membrane oxygenation.

Methods

All patients who received venoarterial extracorporeal membrane oxygenation during hospitalization were identified in a Japanese national inpatient database from July 1, 2010 to March 31, 2018. The primary outcome was occurrence of severe lower extremity ischemia that required fasciotomy or amputation. We used cause-specific proportional hazard models to examine the associations between potential risk factors and outcomes. We also performed a competing-risk analysis to estimate the cause-specific HR for severe lower extremity ischemia using a multivariable competing-risk Cox proportional hazard model with adjustment for potential risk factors.

Results

A total of 29 231 patients who underwent venoarterial extracorporeal membrane oxygenation during hospitalization were identified. Of these, 98 patients (0.3%) had lower extremity ischemia requiring fasciotomy or amputation. The young group (≤18 years) had a significantly higher proportion of severe lower extremity ischemia cases than the adult (19-59 years) and elderly (≥60 years) groups (1.4%, 0.5%, and 0.2%, respectively; p<0.001). In a multivariable competing-risk Cox proportional hazards regression model, younger age (HR 3.06; 95% CI 1.33 to 7.02; p<0.008) and consciousness disturbance on admission (HR 2.53; 95% CI 1.60 to 3.99; p<0.001) were significantly associated with higher likelihood of severe lower extremity ischemia.

Conclusion

In this study using a nationwide database, younger age and consciousness disturbance on admission were associated with higher risk of severe lower extremity ischemia following venoarterial extracorporeal membrane oxygenation.

Level of evidence

Level Ⅲ-prognostic and epidemiological.

The standing T1-L1 pelvic angle: a useful radiographic predictor of proximal junctional kyphosis in adult spinal deformity

OBJECTIVE

Proximal junctional kyphosis (PJK), which can worsen a patient's quality of life, is a common complication following the surgical treatment of adult spinal deformity (ASD). Although various radiographic parameters have been proposed to predict the occurrence of PJK, the optimal method has not been established. The present study aimed to investigate the usefulness of the T1-L1 pelvic angle in the standing position (standing TLPA) for predicting the occurrence of PJK.

METHODS

The authors retrospectively extracted data for patients with ASD who underwent minimum 5-level fusion to the pelvis with upper instrumented vertebra between T8 and L1. In the present study, PJK was defined as ≥ 10° progression of the proximal junctional angle or reoperation due to progressive kyphosis during 1 year of follow-up. The following parameters were analyzed on whole-spine standing radiographs: the T1-pelvic angle, conventional thoracic kyphosis (TK; T4-12), whole-thoracic TK (T1-12), and the standing TLPA (defined as the angle formed by lines extending from the center of T1 and L1 to the femoral head axis). A logistic regression analysis and a receiver operating characteristic curve analysis were performed.

RESULTS

A total of 50 patients with ASD were enrolled (84% female; mean age 74.4 years). PJK occurred in 19 (38%) patients. Preoperatively, the PJK group showed significantly greater T1-pelvic angle (49.2° vs 34.4°), conventional TK (26.6° vs 17.6°), and standing-TLPA (30.0° vs 14.9°) values in comparison to the non-PJK group. There was no significant difference in the whole-thoracic TK between the two groups. A multivariate analysis showed that the standing TLPA and whole-thoracic TK were independent predictors of PJK. The standing TLPA had better accuracy than whole-thoracic TK (AUC 0.86 vs 0.64, p = 0.03). The optimal cutoff value of the standing TLPA was 23.0° (sensitivity 0.79, specificity 0.74). Using this cutoff value, the standing TLPA was the best predictor of PJK (OR 8.4, 95% CI 1.8-39, p = 0.007).

CONCLUSIONS

The preoperative standing TLPA was more closely associated with the occurrence of PJK than other radiographic parameters. These results suggest that this easily measured parameter is useful for the prediction of PJK.

Effect of Early vs Delayed Surgical Treatment on Motor Recovery in Incomplete Cervical Spinal Cord Injury With Preexisting Cervical Stenosis: A Randomized Clinical Trial

IMPORTANCE

The optimal management for acute traumatic cervical spinal cord injury (SCI) is unknown.

OBJECTIVE

To determine whether early surgical decompression results in better motor recovery than delayed surgical treatment in patients with acute traumatic incomplete cervical SCI associated with preexisting canal stenosis but without bone injury.

DESIGN, SETTING, AND PARTICIPANTS

This multicenter randomized clinical trial was conducted in 43 tertiary referral centers in Japan from December 2011 through November 2019. Patients aged 20 to 79 years with motor-incomplete cervical SCI with preexisting canal stenosis (American Spinal Injury Association [ASIA] Impairment Scale C; without fracture or dislocation) were included. Data were analyzed from September to November 2020.

INTERVENTIONS

Patients were randomized to undergo surgical treatment within 24 hours after admission or delayed surgical treatment after at least 2 weeks of conservative treatment.

MAIN OUTCOMES AND MEASURES

The primary end points were improvement in the mean ASIA motor score, total score of the spinal cord independence measure, and the proportion of patients able to walk independently at 1 year after injury.

RESULTS

Among 72 randomized patients, 70 patients (mean [SD] age, 65.1 [9.4] years; age range, 41-79 years; 5 [7%] women and 65 [93%] men) were included in the full analysis population (37 patients assigned to early surgical treatment and 33 patients assigned to delayed surgical treatment). Of these, 56 patients (80%) had data available for at least 1 primary outcome at 1 year. There was no significant difference among primary end points for the early surgical treatment group compared with the delayed surgical treatment group (mean [SD] change in ASIA motor score, 53.7 [14.7] vs 48.5 [19.1]; difference, 5.2; 95% CI, -4.2 to 14.5; P = .27; mean [SD] SCIM total score, 77.9 [22.7] vs 71.3 [27.3]; P = .34; able to walk independently, 21 of 30 patients [70.0%] vs 16 of 26 patients [61.5%]; P = .51). A mixed-design analysis of variance revealed a significant difference in the mean change in ASIA motor scores between the groups (F1,49 = 4.80; P = .03). The early surgical treatment group, compared with the delayed surgical treatment group, had greater motor scores than the delayed surgical treatment group at 2 weeks (mean [SD] score, 34.2 [18.8] vs 18.9 [20.9]), 3 months (mean [SD] score, 49.1 [15.1] vs 37.2 [20.9]), and 6 months (mean [SD] score, 51.5 [13.9] vs 41.3 [23.4]) after injury. Adverse events were common in both groups (eg, worsening of paralysis, 6 patients vs 6 patients; death, 3 patients vs 3 patients).

CONCLUSIONS AND RELEVANCE

These findings suggest that among patients with cervical SCI, early surgical treatment produced similar motor regain at 1 year after injury as delayed surgical treatment but showed accelerated recovery within the first 6 months. These exploratory results suggest that early surgical treatment leads to faster neurological recovery, which requires further validation.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT01485458; umin.ac.jp/ctr Identifier: UMIN000006780.

Risk Factors for Throwing-Related Shoulder and Elbow Pain in Adolescent Baseball Players: A Prospective Study of Physical and Developmental Factors

Background:

Throwing-related shoulder and elbow pain continues to be reported among adolescent baseball players. Few prospective studies have specifically examined the association between throwing-related shoulder and elbow pain and physical and developmental changes.

Purpose:

To evaluate the changes in physical and developmental characteristics during 1 year with respect to throwing-related shoulder and elbow pain in adolescent baseball players.

Study Design:

Case-control study; Level of evidence, 3.

Methods:

This 1-year prospective follow-up study investigated 164 baseball players aged 7 to 13 years. Player data (age, height, weight, field position, and pitch count), lower extremity muscle tightness, and range of motion (ROM) of the shoulder, elbow, and hip joints were assessed during the 2016 and 2017 preseason medical examinations. After the 2016 season, the participants completed questionnaires related to throwing-related shoulder and elbow pain, defined as an inability to play for ≥1 week because of elbow or shoulder difficulties. For study participants with and without throwing-related shoulder or elbow pain during the 2016 season, we conducted univariate and multivariate logistic regression analysis to identify risk factors for throwing-related shoulder or elbow pain.

Results:

Overall, 21 players (12.8%) reported a shoulder pain episode, 56 players (34.1%) had an elbow pain episode, and 70 players (42.7%) reported having experienced shoulder and/or elbow pain during the 2016 season. In multivariate logistic regression analysis, (1) shoulder pain was associated with 2016 preseason height (odds ratio [OR], 1.06; 95% CI, 1.01-1.11; P = .01) and change in dominant-side elbow extension ROM from 2016 to 2017 (OR, 1.12; 95% CI, 1.02-1.24; P = .02); (2) elbow pain was associated with change in weight from 2016 to 2017 (OR, 1.21; 95% CI, 1.04-1.41; P = .014); and (3) throwing-related shoulder and/or elbow pain was associated with greater 2016 preseason height (OR, 1.04; 95% CI, 1.003-1.68; P = .03) and an increase in height from 2016 to 2017 (OR, 1.17; 95% CI, 1.01-1.35; P = .03).

Conclusion:

Our results indicated that adolescent baseball players who were taller in the preseason and those with an increase in height over the 1-year study period faced significant risks for developing throwing-related shoulder and/or elbow pain.

Cross-sectional Study of the Hip Joint Condition in Young Baseball Players

Objective

The hip joint is a crucial part of the kinetic chain for throwing baseball pitches. Nevertheless, few reports have described assessments of the functional development of the hip joint in young baseball players.

Methods

We examined 315 young baseball players, 7-14 years old, all of whom had completed a self-administered questionnaire including items related to the dominant side and throwing-related hip joint pain sustained during the previous year. We measured the hip ranges of motion (ROMs: external and internal rotation and flexion) and hip muscle strengths (external and internal rotation) on the dominant and non-dominant sides. The differences of hip ROMs and muscle strengths between the dominant and non-dominant sides and between age groups were investigated. Correlations were calculated between the players ages and hip ROMs and muscle strengths.

Results

No baseball player reported hip pain. The hip external rotation on the dominant side was smaller than that on the non-dominant side, whereas the hip internal rotation on the dominant side was greater than that on the non-dominant side. However, no significant difference was found between the dominant and non-dominant sides in terms of the hip muscle strength. Significant positive associations were found between the player's age and hip muscle strengths, whereas significant negative associations were found between the age and hip ROMs.

Conclusions

Our data concerning the relationship between age and hip joint development could be useful for supporting strategies for the prevention and rehabilitation of throwing injuries; however, hip injuries might be rare among young baseball players.

Hallux valgus deformity and postural sway: a cross-sectional study

Background

Hallux valgus deformity has been reported to be associated with increased postural sway. However, the direction and magnitude of postural sway associated with hallux valgus remain inconclusive. We assessed the association between hallux valgus deformity and postural sway using a force plate.

Methods

The subjects were 169 healthy volunteers, > 40 years old (63 males, 106 females, average age: 66.0 ± 12.4 years old), who took part in an annual medical examination. We investigated the photographic hallux valgus angle (°), total trajectory length of the gravity center fluctuation (mm), area of the center of pressure (mm²), mediolateral and anteroposterior postural sway (mm) in a standing position with 2-legged stance and eyes open, hallux pain (Numerical Rating Scale), trunk and lower limb muscle mass (kg). We classified the subjects into a hallux valgus group (n = 44, photographic hallux valgus angle of 1 or both feet ≥ 20°) and a no hallux valgus group (n = 125, photographic hallux valgus angle of both feet < 20°) and analyzed the relationship between hallux valgus and postural sway.

Results

The anteroposterior postural sway in the hallux valgus group (6.5 ± 2.8) was significantly greater than in the no hallux valgus group (5.4 ± 2.2, p = 0.014), and the lower limb muscle mass in the hallux valgus group (12.4 ± 2.2) was significantly smaller than in the no hallux valgus group (13.5 ± 3.2, p = 0.016). The total value of the photographic hallux valgus angle on both feet was positively correlated with the anteroposterior postural sway (p = 0.021) and negatively correlated with the lower limb muscle mass (p = 0.038). The presence of hallux valgus (p = 0.024) and photographic hallux valgus angle (p = 0.008) were independently related to the magnitude of anteroposterior postural sway.

Conclusions

Hallux valgus deformity and its severity were positively associated with the magnitude of the anteroposterior postural sway.

Trial registration

2017 − 135. Registered 22 August 2017.

Clinical features and early post-operative complications of isolated C2 odontoid fractures: a retrospective analysis using a national inpatient database in Japan

PURPOSE

To examine the clinical features and post-treatment complications in patients with isolated C2 odontoid fractures.

METHODS

We extracted data for all patients who were admitted with C2 odontoid fractures from the Japanese Diagnosis Procedure Combination database between July 2010 and March 2017. We then compared the post-treatment complications during hospitalization according to treatment types: conservative treatment (with or without use of halo-vest) and surgery (anterior or posterior spinal fixation).

RESULTS

A total of 3167 patients (1533 men, 1634 women; mean age, 70 years) with isolated C2 odontoid fractures were identified, including 1124 patients (35%) aged ≥ 80 years. Among the total patients, 2476 (78%) received conservative treatment (with halo-vest, 728; without halo-vest, 1748). The remaining 691 patients (22%) underwent surgery (anterior surgery, 129; posterior surgery, 556; combined surgery, 6). There were no differences between the conservative treatment and surgery groups in baseline characteristics and preexisting comorbid conditions except for age (71 vs. 69 years, p = 0.042). In-hospital death occurred in 136 patients (4.3%). There was no significant difference in in-hospital mortality between the two groups (overall, conservative treatment 4.6% vs. surgery 3.0%, p = 0.066; age ≥ 80 years, conservative treatment 7.2% vs. surgery 5.4%, p = 0.34). Use of halo-vest was not associated with increased mortality (with halo-vest 3.7% vs. without halo-vest 5.0%, p = 0.15).

CONCLUSION

The great majority of isolated odontoid fractures occurred in elderly patients. Conservative treatment and surgery had similarly low in-hospital mortality. Use of halo-vest was not associated with an increase in mortality.

Paraplegia due to Thoracic Mobile Schwannoma after Myelography

INTRODUCTION

Spinal mobile tumors are very rare. We herein report a case of paraplegia caused by migration and incarceration of thoracic mobile schwannoma after myelography. Case Presentation. A 25-year-old man who had weakness and numbness in both his legs also had pain radiating to the back that was induced by back flexion or extension and jumping. Magnetic resonance imaging (MRI) showed an intradural extramedullary lesion at the T10 and T11 levels. Myelography was performed but discontinued due to his back and lower limb pain. Computed tomography after myelography revealed a rostrally migrated intradural mass with a discrepancy in the exact location in comparison to the MRI findings. He underwent a second lumbar puncture and drained the cerebrospinal fluid (CSF) to aid the spinal cord, because the symptoms gradually worsened and led to paraplegia. After the drainage of the CSF, his symptoms were immediately resolved. The day after myelography, he underwent complete resection of the tumor with the diagnosis of schwannoma. One year after the surgery, he had been working despite having hyperreflexia in his lower limbs with no weakness or sensory disturbance.

CONCLUSION

Severe neurological deficits associated with spinal cord damage can occur due to migration of mobile tumors.

Recurrent lumbar-origin osteoblastoma treated with multiple surgery and carbon ion radiotherapy: a case report

BACKGROUND

Although osteoblastoma is an uncommon benign bone tumor, it sometimes behaves in a locally aggressive fashion. We herein report a case of recurrent lumbar spine osteoblastoma that was treated by repeated surgery and carbon ion radiotherapy.

CASE PRESENTATION

A 13-year-old Japanese girl presented with left side lumbar pain. Computed tomography and magnetic resonance imaging of the lumbar spine demonstrated a tumorous lesion in the left side pedicle of L4. Although gross total resection of the mass, including the nidus, was performed in the initial surgery, recurrence was observed repeatedly in the short term and the pathological diagnosis of all of the resected tumors was conventional osteoblastoma. We finally performed carbon ion radiotherapy after the patient's 3rd palliative operation, and achieved a good outcome. No further recurrence has been observed in 10 years of follow-up.

CONCLUSION

We performed carbon ion radiotherapy for a case of recurrent spinal osteoblastoma and achieved a good outcome without recurrence at 10 years after carbon ion radiotherapy treatment. To the best of our knowledge, this is the first case of osteoblastoma that was treated with carbon ion radiotherapy after multiple surgeries.

Malignant Peripheral Nerve Sheath Tumor of the Cervical Spine Treated with Surgical Resection Followed by X-ray Radiotherapy or Carbon Ion Radiotherapy: A Report of Three Cases

Introduction

Spinal malignant peripheral nerve sheath tumors (MPNSTs) are extremely rare. Because of vital surroundings, en bloc resection can be difficult in MPNSTs of the cervical spine. Herein, we report three cases of MPNST followed by radiotherapy or carbon ion radiotherapy (CIRT) after surgery.

Technical Note

In case 1, the patient underwent subtotal resection from both a posterior and anterior approach following by adjuvant X-ray radiotherapy. The patient died 13 years after surgery due to liver cancer unrelated to MPNST. In case 2, recurrence spread to the spinal canal in 10 months after primary CIRT. The patient underwent resection of the spinal canal lesion with the residual lesion treated by additional CIRT. Recurrence could be controlled for at least 1 year. In case 3, the patient underwent partial resection for the spinal canal lesion with the residual lesion treated by CIRT. Intradural and extradural recurrences from outside of the CIRT field were observed at 3 years after surgery.

Conclusions

Complete resection and adjuvant X-ray radiotherapy would be an effective treatment for MPNST of the cervical spine, even if en bloc resection with a wide margin is impossible. CIRT for the residual tumor after incomplete resection may have the potential to be an additional treatment option; however, further investigation is warranted.

Spontaneous functional full recovery from motor and sensory deficits in adult mice after mild spinal cord injury

The extent of spontaneous recovery in patients with a spinal cord injury (SCI) has not been thoroughly investigated. It is essentially not known whether SCI animals exhibit full recovery from both motor and sensory deficits as well. Here, we developed an appropriate condition to produce a mild SCI in mice. Mice given a mild contusion SCI showed transient low performances in the Basso Mouse Scale for locomotion (BMS), rotarod and beam walking tests after the SCI, which was followed by complete restoration in a short time. The SCI mice also showed functional full recovery from low sensitivity to light touch using dynamic touch test. Nevertheless, the fully-recovered SCI mice still exhibited significant loss of myelin in the spinal cord. These results suggest a high potential of adaptation of motor and sensory systems in mice and might provide insight into the prognoses of SCI patients.

Greenland records of aerosol source and atmospheric lifetime changes from the Eemian to the Holocene

The Northern Hemisphere experienced dramatic changes during the last glacial, featuring vast ice sheets and abrupt climate events, while high northern latitudes during the last interglacial (Eemian) were warmer than today. Here we use high-resolution aerosol records from the Greenland NEEM ice core to reconstruct the environmental alterations in aerosol source regions accompanying these changes. Separating source and transport effects, we find strongly reduced terrestrial biogenic emissions during glacial times reflecting net loss of vegetated area in North America. Rapid climate changes during the glacial have little effect on terrestrial biogenic aerosol emissions. A strong increase in terrestrial dust emissions during the coldest intervals indicates higher aridity and dust storm activity in East Asian deserts. Glacial sea salt aerosol emissions in the North Atlantic region increase only moderately (50%), likely due to sea ice expansion. Lower aerosol concentrations in Eemian ice compared to the Holocene are mainly due to shortened atmospheric residence time, while emissions changed little.

Past climate changes in Greenland ice were accompanied by large aerosol concentration changes. Here, the authors show that by correcting for transport effects, reliable source changes for biogenic aerosol from North America, sea salt aerosol from the North Atlantic, and dust from East Asian deserts can be derived.

The relationship between the degree of displacement of the atlas to axis and the clinical data in atlanto-axial subluxation due to rheumatoid arthritis

INTRODUCTION

The most common type of anatomical cervical spine involvement is atlanto-axial subluxation (AAS) in rheumatoid arthritis (RA). The purpose of this study was to clarify the relationship between the displacement of the atlas to axis and the clinical data obtained in patients with AAS due to RA.

METHODS

Fifty patients with AAS due to RA that were treated by surgery are herein reviewed. Based on the findings of preoperative lateral cervical radiographs in the neutral position, the patients were classified into two groups as follows: a 10 + group with an atlanto-dental interval (ADI) of ≧ 10 mm, and a 10 - group with an ADI < 10 mm.

RESULTS

Preoperative lateral cervical radiographs demonstrated 15 cases to belong to the 10 + group, while 35 cases belonged to the 10 - group. In the preoperative MR imaging, an intramedullary high signal intensity was observed in seven cases that belonged to the 10 + group and in four cases belonging to the 10 - group. Regarding the neurological severity, the 10 + group included significantly more cases showing severe neurological deficits before surgery; however, there was no significant difference between the two groups regarding the presence of severe deficits even after surgery.

CONCLUSIONS

The severe displacement group included significantly more cases showing an intramedullary high signal intensity in the preoperative MR images. Our results also suggest that a severe displacement before surgery affected the presence of neurological deficits before surgery; however, it did not affect the neurological recovery from such severe neurological deficits.