STUDY DESIGN: Prospective physical measurement of the sagittal vertical axis (SVA). PURPOSE: To evaluate a simple method for measuring SVA by analyzing its relationship with radiographic measurements and clinical appearance. OVERVIEW OF LITERATURE: No studies have examined physical measurements using the cranial center of gravity (CCG) in a relaxed standing position. METHODS: The physical measurement of the horizontal distance between CCG and spina iliaca posterior superior (CCG-SIPS) was measured using a straight ruler in 252 healthy volunteers and 56 patients with adult spinal deformity. Health-related quality of life (HRQOL) was evaluated using the Oswestry disability index (ODI), and clinical symptoms were assessed according to standing status and the presence of gastroesophageal reflux disease (GERD). RESULTS: CCG-SIPS increased with age in the volunteer group and strongly correlated with radiographic SVA in the patient group (r=0.984). Differences increased between CCG-SIPS in patients in the relaxed position and radiographic SVA with an increase in sagittal malalignment (r=0.692, p<0.001). ODI with high sagittal malalignment (CCG-SIPS>120 mm) was significantly larger in the patient group than in the group with low sagittal malalignment (59.9±18.8 vs. 45.1±17.0; p=0.004); these patients (CCG-SIPS>120 mm) needed crutches or walkers for standing. The patient group with GERD had significantly larger sagittal malalignment than the group without GERD (160.3 mm vs. 81.0 mm). CONCLUSIONS: The CCG-SIPS correlated with age and strongly reflected radiographic SVA and HRQOL in the patients. Moreover, it reflects a relaxed posture without a backward shift in the radiographic position even in patients with severe sagittal malalignment. The critical limit of CCG-SIPS can be relevant to clinical appearance, including standing assistance (>120 mm) and the existence of GERD (>150 mm). Thus, it will be a useful predictor of true SVA in clinical practice before radiographic evaluation.
Adult* ; Congenital Abnormalities* ; Crutches ; Gastroesophageal Reflux ; Gravitation ; Healthy Volunteers ; Humans ; Methods ; Posture ; Prospective Studies ; Quality of Life ; Volunteers ; Walkers

Objective: The study compared the treatment outcomes of surgery versus radiotherapy, including concurrent chemoradiotherapy, in stage Ib2–IIb cervical adenocarcinoma patients in Japan. Methods: Of 57,470 patients diagnosed with stage I–IV cervical cancer from January 2001–December 2011, 1,932 patients with stage Ib2–IIb cervical adenocarcinoma were initially treated by surgery or radiotherapy. The primary endpoint was 5-year overall survival (OS) in all and 614 propensity score-matched (PSM) patients (307 per group). We compared OS and prognosis factors based on age, primary stage, and treatment arm. Results: In Japan, >80% (n=1,573) of stage Ib2–IIb cervical adenocarcinoma patients underwent surgery. The 5-year OS of surgery vs. radiotherapy groups were 82.1% (n=704) vs. 79.7% (n=59) (hazard ratio [HR]=1.494; 95% confidence interval [CI]=0.826–2.702; p=0.181) for stage Ib2, 76.6% (n=239) vs. 66.7% (n=54) (HR=1.679; 95% CI=0.986–2.858; p=0.053) for stage IIa, and 71.1% (n=630) vs. 58.9% (n=246) (HR=1.711; 95% CI=1.341–2.184; p<0.001) for stage IIb. In 614 PSM patients balanced for age and carcinoma stage Ib2–IIb, the 5-year OS of surgery vs. radiation groups was 73.0% (n=307) vs. 65.5% (n=307) (HR=1.394; 95% CI=1.044–1.860; p=0.023). In multivariable analysis, age (HR=1.293; 95% CI=1.045–1.601; p=0.018), treatment arm, radiotherapy (HR=1.556; 95% CI=1.253–1.933; p<0.001), and stage IIb (HR=1.783; 95% CI=1.443–2.203; p=0.018) were independent prognosis factors for 5-year OS in stage Ib2–IIb adenocarcinoma patients. Conclusion Age (>65 years), treatment arm (radiotherapy), and stage IIb significantly affect OS in cervical adenocarcinoma patients. Surgery may be considered for <65-year-old patients with stage IIb adenocarcinoma.

Background/Aims: Although endoscopic transpapillary gallbladder drainage (ETGBD) has been reported as an alternative procedure for acute cholecystitis, it requires advanced endoscopic techniques. In terms of the certainty of achieving drainage, it remains a challenging procedure. The aim of the current study was to elucidate the practical efficacy of cholangioscopic assistance and to develop a new classification that could be used to evaluate the technical difficulty of ETGBD and provide a theoretical strategy to apply cholangioscopy appropriately for difficult ETGBD. Methods: A total of 101 patients undergoing ETGBD were retrospectively studied. The characteristics and technical outcomes of ETGBD with conventional ETGBD (C-ETGBD) and SpyGlass DS-assisted ETGBD (SG-ETGBD) were evaluated. The characteristics and technique-dependent factors of unsuccessful C-ETGBD/SG-ETGBD were evaluated using the classification based on the steps of the procedure. The predictive factors of successful C-ETGBD/SG-ETGBD were examined. Results: C-ETGBD was successful in 73 patients (72.3%). SG-ETGBD was successful in 11 of 13 patients (84.6%) who had C-ETGBD failure. Optional SG-ETGBD significantly increased the final success rate (94.1%) compared to C-ETGBD alone (p=0.003). ETGBD procedures could be classified into four steps. SG-assistance worked as an excellent troubleshooter in step 1 (failure to identify the cystic duct orifice) and step 2 (failure of guidewire advancement across the downturned angle of cystic duct takeoff). Magnetic resonance cholangiopancreatography could provide predictive information based on the classification. Conclusions Optional SG-ETGBD achieved a significantly higher success rate than C-ETGBD alone. Step classification is helpful for determining the technical difficulty of ETGBD and developing a theoretical strategy to apply cholangioscopy in a coordinated manner.

Background/Aims: Although endoscopic transpapillary gallbladder drainage (ETGBD) has been reported as an alternative procedure for acute cholecystitis, it requires advanced endoscopic techniques. In terms of the certainty of achieving drainage, it remains a challenging procedure. The aim of the current study was to elucidate the practical efficacy of cholangioscopic assistance and to develop a new classification that could be used to evaluate the technical difficulty of ETGBD and provide a theoretical strategy to apply cholangioscopy appropriately for difficult ETGBD. Methods: A total of 101 patients undergoing ETGBD were retrospectively studied. The characteristics and technical outcomes of ETGBD with conventional ETGBD (C-ETGBD) and SpyGlass DS-assisted ETGBD (SG-ETGBD) were evaluated. The characteristics and technique-dependent factors of unsuccessful C-ETGBD/SG-ETGBD were evaluated using the classification based on the steps of the procedure. The predictive factors of successful C-ETGBD/SG-ETGBD were examined. Results: C-ETGBD was successful in 73 patients (72.3%). SG-ETGBD was successful in 11 of 13 patients (84.6%) who had C-ETGBD failure. Optional SG-ETGBD significantly increased the final success rate (94.1%) compared to C-ETGBD alone (p=0.003). ETGBD procedures could be classified into four steps. SG-assistance worked as an excellent troubleshooter in step 1 (failure to identify the cystic duct orifice) and step 2 (failure of guidewire advancement across the downturned angle of cystic duct takeoff). Magnetic resonance cholangiopancreatography could provide predictive information based on the classification. Conclusions Optional SG-ETGBD achieved a significantly higher success rate than C-ETGBD alone. Step classification is helpful for determining the technical difficulty of ETGBD and developing a theoretical strategy to apply cholangioscopy in a coordinated manner.

Methods: We retrospectively reviewed the medical records of 404 patients who underwent corrective fusion surgery for ASD with a minimum 2-year follow-up. We studied cases of reoperation for postoperative rod fractures and investigated surgical procedure, intraoperative findings, clinical course, and rod refracture following revision surgery. Results: Rod fracture was observed in 88 patients (21.8%). Fifty-three patients (average age, 68.3 years; average blood loss, 502.2 mL [% estimated blood volume=16.4%]; and operation time, 203.3 minutes) who suffered from a rod fracture at an average of 28.3 months after the primary operation underwent reoperation. Surgical invasiveness had no significant differences in total or partial rod replacement; however, the procedures with and without an anterior bone graft significantly differed. The replaced rod refractured at an average of 35.3 months after the revision surgery of five patients. The rod also refractured at a level outside multiple rods in two patients and with traumatic episodes in three patients. Three patients had bone grafts in the anterior column. Conclusions Revision surgery involving a multirod with a posterior-only approach for a rod fracture that occurred after ASD was performed successfully. Bone grafting in the anterior column is unnecessary for patients without massive bone defects.

Methods: We examined the data of AIS patients with Lenke type 1 curves who underwent posterior fusion surgery in a retrospective manner. PSI was defined as a 2-year postoperative absolute radiographic shoulder height (RSH) of ≥2 cm. Patients were divided into two groups based on the presence of PSI and the level of their upper instrumented vertebra (UIV) (UIV at T2 or T3 [U-UIV] or UIV below T3 [L-UIV]). The radiographic parameters and clinical outcomes were compared, and the cutoff values of risk factors were identified by multivariate analysis. Results: Of 104 patients, 21 (20.2%) had left shoulder elevation PSI. The PSI group had a significantly greater preoperative RSH (−5.1 mm vs. −14.3 mm) and main thoracic (MT) curve correction rate (77.3% vs. 69.1%) than the non-PSI group. The PSI incidence did not differ between the U-UIV and L-UIV groups. Multivariate analysis identified preoperative RSH and the MT curve correction rate as independent risk factors for PSI. The receiver operating characteristic curve analysis identified the preoperative RSH cutoff value as −6.5 mm and MT curve correction rate cutoff value as 76.9%. Conclusions Even in AIS patients with Lenke type 1 curves, the incidence of PSI was relatively high (20.2%). Patients with preoperative lower right shoulder elevation (i.e., RSH >−6.5 mm) had a higher risk of PSI regardless of UIV level when the MT curve showed a higher correction rate (i.e., correction rate >76.9%).

Methods: Radiological parameters were extracted from the whole lateral radiographs. Patients were divided into two groups: the ASD group (segmental kyphosis of ≥10º, and/or a ≥50% loss of disc height, and/or ≥3 mm of anteroposterior translation) and the non-ASD group. Results: All 112 included patients underwent PLIF for lumbar degenerative diseases. The minimum follow-up period was 2 years, with an average follow-up time of 63.6 months. Fifty-two patients (46.4%) were classified into the ASD group and of these, 13 required reoperation due to failure of conservative treatment. Patients with ASD exhibited significantly more caudal and posterior inflection vertebrae (IV), while the lumbar apical vertebra was significantly more caudal immediately after surgery. The IV position was identified as a significant risk factor for ASD, and the ASD incidence was significantly higher in the group where IV ≤5 (L1 vertebral body) than in the group where IV ≥5.5 (T12–L1 disc) (69.0% vs. 38.6%). Conclusions The IV position is a significant risk factor for ASD development. Although it is difficult to control intraoperative IV levels, we note a high risk of ASD in patients with IV lower than T12–L1.

Methods: Radiological parameters were extracted from the whole lateral radiographs. Patients were divided into two groups: the ASD group (segmental kyphosis of ≥10º, and/or a ≥50% loss of disc height, and/or ≥3 mm of anteroposterior translation) and the non-ASD group. Results: All 112 included patients underwent PLIF for lumbar degenerative diseases. The minimum follow-up period was 2 years, with an average follow-up time of 63.6 months. Fifty-two patients (46.4%) were classified into the ASD group and of these, 13 required reoperation due to failure of conservative treatment. Patients with ASD exhibited significantly more caudal and posterior inflection vertebrae (IV), while the lumbar apical vertebra was significantly more caudal immediately after surgery. The IV position was identified as a significant risk factor for ASD, and the ASD incidence was significantly higher in the group where IV ≤5 (L1 vertebral body) than in the group where IV ≥5.5 (T12–L1 disc) (69.0% vs. 38.6%). Conclusions The IV position is a significant risk factor for ASD development. Although it is difficult to control intraoperative IV levels, we note a high risk of ASD in patients with IV lower than T12–L1.

Methods: Adult volunteers aged over 50 years were included in the study after participating in the screening program. Characteristic data and standing radiographic parameters were assessed. A propensity score model was established with adjustments for age and sex after a preliminary analysis, and cases were divided into DLS (Cobb angle >10°) and non-DLS (Cobb angle ≤10°) groups. Results: There were significant differences in age, sex, C2 sagittal vertical axis (C2-SVA), C7-SVA, T1 pelvic angle (TPA), lumbar lordosis (LL), pelvic incidence (PI), pelvic tilt (PT), PI minus LL (PI–LL), knee angle, ankle angle, pelvic shift, C7-center sacral vertical line, L4 tilt, femur-tibia angle, and hip-knee-ankle angle (all p <0.05) using a preliminary analysis of 261 cases (75 DLS and 186 non-DLS). A one-to-one propensity score-matched analysis was used after 70 pairs of cases were selected. There were no significant differences in the characteristic data for lower extremity parameters. There were still significantly higher values of C2-SVA, TPA, PI, PT, and PI–LL in DLS group than in non-DLS group (all p <0.05). Conclusions This study showed an important relationship between DLS and sagittal spinal deformity. However, DLS was not associated with the sagittal and coronal lower extremity alignments.

Methods: Radiological parameters were extracted from the whole lateral radiographs. Patients were divided into two groups: the ASD group (segmental kyphosis of ≥10º, and/or a ≥50% loss of disc height, and/or ≥3 mm of anteroposterior translation) and the non-ASD group. Results: All 112 included patients underwent PLIF for lumbar degenerative diseases. The minimum follow-up period was 2 years, with an average follow-up time of 63.6 months. Fifty-two patients (46.4%) were classified into the ASD group and of these, 13 required reoperation due to failure of conservative treatment. Patients with ASD exhibited significantly more caudal and posterior inflection vertebrae (IV), while the lumbar apical vertebra was significantly more caudal immediately after surgery. The IV position was identified as a significant risk factor for ASD, and the ASD incidence was significantly higher in the group where IV ≤5 (L1 vertebral body) than in the group where IV ≥5.5 (T12–L1 disc) (69.0% vs. 38.6%). Conclusions The IV position is a significant risk factor for ASD development. Although it is difficult to control intraoperative IV levels, we note a high risk of ASD in patients with IV lower than T12–L1.