Objectives: To investigate renal function during denosumab therapy using the estimated glomerular filtration rate based on cystatin C (eGFRcys) which is more accurate than creatinine (eGFRcr) for renal function. Methods: Bone mineral densities (BMDs) of lumbar spine and hip regions, eGFRcys, eGFRcr, creatinine clearance (Ccr), and serum total homocysteine (S-Hcy) were measured during 2-year denosumab therapy in 53 women with osteoporosis naïve to anti-osteoporosis drugs (new group) and 64 women who were switched from long-term bisphosphonate treatment to denosumab therapy (switch group). Results: There were no significant differences in age, eGFRcr, Ccr, eGFRcys, and S-Hcy levels at baseline between the groups. BMDs in the lumbar spine, femoral neck, and total hip increased significantly after 2-year denosumab therapy in both groups. eGFRcr decreased in the switch group, and Ccr decreased in both groups; however, eGFRcys and S-Hcy levels did not change significantly in either group. To investigate the causal factors associated with the decrease in eGFRcr and Ccr, multiple regression analysis was performed in all patients. Denosumab initiation within 3 months after fracture and eGFRcr or Ccr at baseline were independent factors for the decrease in eGFRcr or Ccr during the 2-year denosumab therapy. Decline in creatinine-based renal function could be reflected by increased muscle mass during the ongoing recovery from fracture. Conclusions Renal function was preserved in all patients, including those in the switch group during denosumab therapy. Creatinine-based renal function should be cautiously interpreted during denosumab therapy in patients with recent fractures.

STUDY DESIGN: A prospective, randomized, controlled study. PURPOSE: The objective of this study was to evaluate the effectiveness of two techniques of skin preparation with povidone-iodine. OVERVIEW OF LITERATURE: Preoperative skin preparation is important for preventing surgical site infection by reducing the bacteria in the surgical area. Povidone-iodine is a commonly used agent for preoperative skin preparation, and further decrease in surgical site infections can be expected by understanding how to apply it more effectively. METHODS: Eighty-nine spine surgery patients were randomly allocated to two groups. In group A, povidone-iodine was applied to the surgical site just before starting the operation; in group B, povidone-iodine was applied several minutes prior to starting the operation and was allowed to dry. We collected samples from the wound edge before suturing, and we compared the rates of positive culture between the two groups. RESULTS: The rate of positive culture was 30.2% (13 out of 43 patients) in group A, and 6.5% (3 out of 46 patients) in group B. This indicates that there was a significant difference in postoperative infection rates between group A and group B. CONCLUSIONS: Because bacteria on the skin appeared significantly reduced by allowing povidone-iodine to dry for several minutes prior to surgery, we recommend this approach to reduce the incidence of postoperative infections.
Bacteria ; Humans ; Incidence ; Povidone-Iodine* ; Prospective Studies* ; Skin* ; Spine* ; Wounds and Injuries

No abstract available.
Hypoglossal Nerve* ; Spine*

STUDY DESIGN: Case series. PURPOSE: The objective of this study was to investigate the change in pulmonary function in adult patients with a spinal deformity who underwent spinal corrective surgery. OVERVIEW OF LITERATURE: Degenerative lumbar and/or thoraco-lumbar deformities are is often prominent in adult spinal deformity cases, whereas a thoracic deformity involving the chest wall is inconspicuous. A lumbar spine deformity could affect the pulmonary function; however, few reports have investigated pulmonary function in adult patients with a spinal deformity. METHODS: This study included 14 adult patients with a spinal deformity who underwent posterior corrective fusion (3 males, 11 females; mean age, 67.4 years). We measured percent vital capacity (%VC) and percent forced expiratory volume in 1 second (%FEV1) before surgery and six months after surgery. We investigated the change in pulmonary function after corrective surgery and the correlation between radiographic parameters and pulmonary function. RESULTS: Mean preoperative %VC and %FEV1 values were 99.9% and 79.3%, respectively. Two cases were diagnosed with restrictive impairment, and two cases were diagnosed with obstructive impairment before surgery. %VC improved in the restrictive impairment cases six months after surgery. However, %FEV1 did not improve significantly after surgery in the obstructive impairment cases. CONCLUSIONS: Restrictive impairment was improved in adult patients with a spinal deformity by corrective spinal surgery. However, spinal surgery did not improve obstructive impairment.
Adult ; Aged* ; Congenital Abnormalities ; Female ; Forced Expiratory Volume ; Humans ; Male ; Spine ; Thoracic Wall ; Vital Capacity

STUDY DESIGN: Retrospective. PURPOSE: This study aims to investigate the accuracy of the oblique fluoroscopic view, based on preoperative computed tomography (CT) images for accurate placement of lumbosacral percutaneous pedicle screws (PPS). OVERVIEW OF LITERATURE: Although PPS misplacement has been reported as one of the main complications in minimally invasive spine surgery, there is no comparative data on the misplacement rate among different fluoroscopic techniques, or comparing such techniques with open procedures. METHODS: We retrospectively selected 230 consecutive patients who underwent posterior spinal fusion with a pedicle screw construct for degenerative lumbar disease, and divided them into 3 groups, those who had undergone: minimally invasive percutaneous procedure using biplane (lateral and anterior-posterior views using a single C-arm) fluoroscope views (group M-1), minimally invasive percutaneous procedure using the oblique fluoroscopic view based on preoperative CT (group M-2), and conventional open procedure using a lateral fluoroscopic view (group O: controls). The relative position of the screw to the pedicle was graded for the pedicle breach as no breach, <2 mm, 2–4 mm, or >4 mm. Inaccuracy was calculated and assessed according to the spinal level, direction and neurological deficit. Inter-group radiation exposure was estimated using fluoroscopy time. RESULTS: Inaccuracy involved an incline toward L5, causing medial or lateral perforation of pedicles in group M-1, but it was distributed relatively equally throughout multiple levels in groups M-2 and controls. The mean fluoroscopy time/case ranged from 1.6 to 3.9 minutes. CONCLUSIONS: Minimally invasive lumbosacral PPS placement using the conventional fluoroscopic technique carries an increased risk of inaccurate screw placement and resultant neurological deficits, compared with that of the open procedure. Inaccuracy tended to be distributed between medial and lateral perforations of the L5 pedicle, as a result of pedicle morphology and the PPS pathway. Oblique fluoroscopic views, based on CT measurement, may allow accurate PPS insertion with a shorter fluoroscopy time.
Fluoroscopy ; Humans ; Pedicle Screws* ; Radiation Exposure ; Retrospective Studies ; Spinal Fusion ; Spine

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

A recurrent laryngeal nerve injury is known as a complication referring to an anterior cervical spine surgery. However, hypoglossal nerve injury is not well known yet. Herein we report a rare case of a 39-years-old male with a hypoglossal nerve injury after C3/4 osteophyte resection with Smith-Robinson approach. In this case there appeared difficulties of articulation and tongue movement with deviation of the tongue to the left side after the surgery and we diagnosed a hypoglossal nerve injury due to retraction against the nerve during the operation. During the operative approach to the upper cervical spine we had to retract the internal carotid artery and the soft tissue to reach the vertebrae. This retract was the cause of the hypoglossal nerve injury. A gently traction and intermittent release is important to avoid a hypoglossal nerve damage.
Carotid Artery, Internal ; Cervical Vertebrae ; Female ; Humans ; Hypoglossal Nerve ; Hypoglossal Nerve Diseases* ; Hypoglossal Nerve Injuries ; Male ; Osteophyte ; Recurrent Laryngeal Nerve Injuries ; Spine* ; Tongue ; Traction

BACKGROUND: Bone mineral density (BMD) is the indicator of bone quality in at-risk individuals. Along with the fracture risk assessment tool (FRAX), a quick assessment of BMD from routine radiographs may be useful in the case of lacking X-ray absorptiometry data. This study aimed to investigate the correlation of cortical thickness index (CTI) and canal flare index (CFI) with BMD and FRAX and to evaluate their ability to predict femoral neck BMD (nBMD) and FRAX in the general elderly population. METHODS: A total of 560 volunteers (age ≥ 50 years) who underwent hip-spine X-ray, BMD scanning and FRAX calculation were retrospectively reviewed. CTI and CFI were measured on anteroposterior radiographs and analyzed for their correlation with BMD and FRAX and for their ability to predict nBMD. The ability of CTI to predict osteoporosis status (OPS) and fracture risk status (FRS) was also investigated and the threshold values were calculated. All the analyses were performed separately on male and female subjects. RESULTS: Significant differences in CTI, CFI, nBMD and FRAX between males and females were observed. CTI and CFI demonstrated significant positive correlation with nBMD and FRAX (all p < 0.001) in both males and females. CTI, height, and weight significantly predicted nBMD. CTI statistically predicted OPS and FRS, and the values of 0.56 and 0.62 were computed as CTI thresholds for males and females, respectively. CONCLUSIONS: CTI was significantly correlated with nBMD and it predicted nBMD at good prediction levels. Therefore, CTI may be used as a supportive tool in the assessment of OPS and FRS besides BMD and FRAX in clinical practice.
Absorptiometry, Photon ; Aged ; Bone Density* ; Diagnosis ; Female ; Femur Neck ; Femur* ; Hip Fractures ; Humans ; Male ; Osteoporosis* ; Retrospective Studies ; Risk Assessment ; Volunteers

STUDY DESIGN: Animal study. PURPOSE: To review the present warning point criteria of the compound muscle action potential (CMAP) and investigate new criteria for spinal surgery safety using an animal model. OVERVIEW OF LITERATURE: Little is known about correlation palesis and amplitude of spinal cord monitoring. METHODS: After laminectomy of the tenth thoracic spinal lamina, 2-140 g force was delivered to the spinal cord with a tension gage to create a bilateral contusion injury. The study morphology change of the CMAP wave and locomotor scale were evaluated for one month. RESULTS: Four different types of wave morphology changes were observed: no change, amplitude decrease only, morphology change only, and amplitude and morphology change. Amplitude and morphology changed simultaneously and significantly as the injury force increased (p<0.05) Locomotor scale in the amplitude and morphology group worsened more than the other groups. CONCLUSIONS: Amplitude and morphology change of the CMAP wave exists and could be the key of the alarm point in CMAP.
Action Potentials* ; Animals* ; Contusions ; Gravitation ; Laminectomy ; Models, Animal* ; Spinal Cord

STUDY DESIGN: Large cohort study. PURPOSE: To clarify spinal sagittal alignment and health-related quality of life (HRQOL) according to sex in volunteers aged >50 years with cervical deformity (CD). OVERVIEW OF LITERATURE: Adult spinal deformities, especially those associated with lumbosacral lesions, are more frequent in females; however, CD is observed to a greater extent in males. METHODS: We divided 656 volunteers (263 males, 393 females; age, 50–89 years [mean, 73 years]) as follows: males with CD (CDM; 82 patients); males without CD (NCDM, 181); females with CD (CDF, 36); and females without CD (NCDF, 357). CD was defined as C2–7 sagittal vertical axis (SVA) ≥40 mm. We measured pelvic tilt (PT), pelvic incidence minus lumbar lordosis (PI−LL), thoracic kyphosis, T1 slope, cervical lordosis, C7 SVA, and C2–7 SVA. HRQOL was evaluated using EuroQOL five dimensions questionnaire (EQ-5D). RESULTS: In CDM, NCDM, CDF, and NCDF groups, the respective parameters were as follows: PT: 15°, 14°, 26°, and 21°; PI−LL: 7°, 5°, 16°, and 10°; C2–7 SVA: 49, 24, 46, and 20 mm; C7 SVA: 61, 40, 75, and 47 mm; and EQ-5D: 0.82, 0.88, 0.78, and 0.81. PT and PI−LL were significantly greater in the CDF group than in the NCDF group (p < 0.05) but were not significantly different between CDM and NCDM groups. The CDF group already showed deterioration of spinopelvic alignment, although it was maintained in the CDM group. EQ-5D in showed significantly greater deterioration the CDM group than in the NCDM group; deterioration of lumbopelvic parameters had less influence in males (p < 0.05). CONCLUSIONS: Sagittal spinal deformity may have different mechanisms in males and females. The deterioration of spinal sagittal alignment in males may originate from the cervical spine, and CD may be associated with HRQOL.
Adult ; Animals ; Cohort Studies ; Congenital Abnormalities* ; Female* ; Humans ; Incidence ; Kyphosis ; Lordosis ; Male* ; Quality of Life* ; Sex Characteristics ; Spine ; Volunteers