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PurposeRecent studies have revealed the impact of spinopelvic factors on the risk of dislocation after total hip arthroplasty (THA). This study examined the risk factors of impingement that can lead to dislocation using pre- and postoperative spinopelvic radiographs.MethodsWe studied 143 consecutive patients with end-stage hip osteoarthritis who were eligible for THA at our institute. Pre-operative pelvic incidence (PI), sacral slope (SS), lumbar lordosis (LL), sagittal vertical axis (SVA) in the standing and sitting position, and centre-edge angle (CE) were measured. The post-operative SS, LL, SVA, femoral shaft angle, and radiographic alignment of the acetabular component were also measured. We performed a multiple linear regression analysis to determine the risk factors for anterior and posterior impingement using pre-operative demographic and radiographic parameters. The clearance of anterior and posterior implant impingement was used for the surrogate-dependent variable for dislocation.ResultsA total of 95 patients were included in the analysis. There were significant differences in SS, LL, and SVA between the standing and sitting positions (P < 0.001). A multiple linear regression analysis showed that the PI–LL, LL changes, and CE were associated with the posterior impingement (β = − 0.21, 0.24, and −0.27, respectively). Moreover, PI–LL was also associated with the anterior impingement in the sitting position (β = − 0.27).ConclusionOur results suggest that a flatback with a rigid spine leads to posterior impingement, and a well-balanced spine leads to anterior impingement, which can be a potential risk factor for dislocation.

Background Several authors have reported favorable results in low back pain (LBP) for patients with lumbar disc herniation (LDH) treated with discectomy. However, detailed changes over time in the characteristics and location of LBP before and after discectomy for LDH remain unclear. To clarify these points, we conducted an observational study to determine the detailed characteristics and location of LBP before and after discectomy for LDH, using a detailed visual analog scale (VAS) bilaterally. Methods We included 65 patients with LDH treated by discectomy in this study. A detailed VAS for LBP was administered with the patient under 3 different conditions: in motion, standing, and sitting. Bilateral VAS was also administered (affected versus opposite side) for LBP, lower extremity pain (LEP), and lower extremity numbness (LEN). The Oswestry Disability Index (ODI) was used to quantify clinical status. Changes over time in these VAS and ODI were investigated. Pfirrmann grading and Modic change as seen by magnetic resonance imaging (MRI) were reviewed before and 1 year after discectomy to determine disc and endplate condition. Results Before surgery, LBP on the affected side while the patients were in motion was significantly higher than LBP while they were sitting ( p  = 0.025). This increased LBP on the affected side in motion was improved significantly after discectomy ( p  < 0.001). By contrast, the residual LBP while sitting at 1 year after surgery was significantly higher than the LBP while they were in motion or standing ( p  = 0.015). At 1 year following discectomy, residual LBP while sitting was significantly greater in cases showing changes in Pfirrmann grade ( p  = 0.002) or Modic type ( p  = 0.025). Conclusions Improvement of LBP on the affected side while the patient is in motion suggests that radicular LBP is improved following discectomy by nerve root decompression. Furthermore, residual LBP may reflect increased load and pressure on the disc and endplate in the sitting position.

Study Design; A retrospective observational study was performed. Purpose: We investigated the relationships between skeletal muscle mass, bone mineral density (BMD), and trabecular bone score (TBS) in patients with osteoporotic vertebral compression fractures (VCFs). Overview of Literature: The TBS has attracted attention as a measurement of trabecular bone microarchitecture. It is derived from data obtained using dual-energy X-ray absorptiometry (DXA) and is a reported indicator of VCFs, and its addition to the Fracture Risk Assessment Tool increases the accuracy of fracture prediction. Methods: BMD, skeletal muscle mass, and TBS were measured in 142 patients who visited Shimoshizu National Hospital from April to August 2019. Patients were divided into a VCF group and a non-VCF group. Whole-body DXA scans were performed to analyze body composition, including appendicular skeletal muscle mass index (SMI; lean mass [kg]/height [m2]) and BMD. The diagnostic criteria for sarcopenia was an appendicular SMI <5.46 kg/m2. A logistic regression analysis was conducted to identify the risk factors for VCFs. Results: The significant (p<0.05) findings (VCF group vs. non-VCF group, respectively) included age (79 vs. 70 years), femoral BMD (0.50 vs. 0.58 g/cm2), TBS (1.25 vs. 1.29), and lower limb muscle mass (8.6 vs. 9.9 kg). The VCF group was significantly older and had a lower femur BMD and decreased leg muscle mass than the non-VCF group. Based on the multiple logistic regression analysis, lower femoral BMD and decreased leg muscle mass were identified as risk factors for vertebral fracture independent of age, but the TBS was not. Conclusions: Patients with VCFs had low BMD, a low TBS, and low skeletal muscle mass. Lower femoral BMD and decreased leg muscle mass were identified as risk factors for VCFs independent of age, whereas the TBS was not identified as a risk factor for VCFs.

This study examined the factors that inhibit the therapeutic effects of cognitive behavioral therapy (CBT) and clarify the adaptation judgment criteria of CBT. We included patients with chronic low back pain and allocated them to the adaptation (with visual analog scale [VAS] improvement) or non-adaptation group (without VAS improvement). The patients were analyzed using various psychological tests. CBT improved depressive symptoms and catastrophic thinking; however, they were not correlated with the VAS and did not directly affect low back pain improvement. The non-adaptation group showed an unexplainable/vague sense of anxiety; an excessive focus on searching for pain; a strong intimacy desire; a strong tendency of medical dependency; and fantasy or distortion of the actual experience, especially self-image. Moreover, the patients showed a low ability to objectively express or attribute meaning to pain due to poor language skills, attention-deficit hyperactivity disorder, and emotional value judgment. Individuals with the aforementioned characteristics of pre-CBT psychological tests should select a different treatment approach given the high poor-adaption possibility. Even patients with depressive or anxious symptoms are not necessarily adaptable for CBT. Therefore, pre-CBT tests for treatment suitability are necessary. Future studies should establish a protocol for psychotherapy suitable for the non-adaptation group.

PurposeDiffusion tensor imaging (DTI) is useful to evaluate lumbar nerves visually and quantitatively. Multi-band sensitivity encoding (MB-SENSE) is a technique to reduce the scan time. This study aimed to investigate if super-multi-gradient DTI with multi-band sensitivity encoding (MB-SENSE) is better in evaluating lumbar nerves than the conventional method.MethodsThe participants were 12 healthy volunteers (mean age 33.6 years). In all subjects, DTI was performed using echo planar imaging with different motion probing gradient (MPG) directions (15 without MB, and 15, 32, 64, and 128 with MB) and the lumbar nerve roots were visualized with tractography. In the five groups, we evaluated the resultant DTI both visually and quantitatively. For visual measures, we counted the number of fluffs and disruptions of the nerve fibers. For quantitative measures, the fractional anisotropy (FA) and standard deviation of the fractional anisotropy (FA-SD) values at two regions (proximal and distal) of the lumbar nerve roots were quantified and compared.ResultsAmong the five groups, the number of fluffs decreased as the number of MPG directions increased. However, the number of disruptions showed no significant differences. The FA-SD values decreased as the number of MPG directions increased, indicating that the signal variation was reduced with multi-gradient directional DTI.ConclusionHigh-resolution multi-directional DTI with MB-SENSE may be useful to visualize nerve entrapments and may allow for more accurate DTI parameter quantification with opportunities for clinical diagnostic applications.

The short T1 inversion recovery (STIR) sequence is advantageous for visualizing ligamentous injuries, but the STIR sequence may be missing in some cases. The purpose of this study was to generate synthetic STIR images from MRI T2-weighted images (T2WI) of patients with cervical spine trauma using a generative adversarial network (GAN).  Methods: A total of 969 pairs of T2WI and STIR images were extracted from 79 patients with cervical spine trauma. The synthetic model was trained 100 times, and the performance of the model was evaluated with five-fold cross-validation.  Results: As for quantitative validation, the structural similarity score was 0.519±0.1 and the peak signal-to-noise ratio score was 19.37±1.9 dB. As for qualitative validation, the incorporation of synthetic STIR images generated by a GAN alongside T2WI substantially enhances sensitivity in the detection of interspinous ligament injuries, outperforming assessments reliant solely on T2WI. The GAN model can generate synthetic STIRs from T2 images of cervical spine trauma using image-to-image conversion techniques. The use of a combination of synthetic STIR images generated by a GAN and T2WI improves sensitivity in detecting interspinous ligament injuries compared to assessments that use only T2WI.

Introduction Surgical site infection (SSI) is one of the most serious postoperative complications following instrumented spinal surgery. We previously reported the potential of continuous local antibiotic perfusion (CLAP) to retain implants for patients with SSI following instrumented spinal surgery. We conducted a retrospective multicenter study to elucidate the efficacy and limitations of CLAP for patients with SSI following instrumented spinal surgery. Methods A total of 40 patients treated with CLAP for SSI after instrumented spinal surgery were included in this study. The implant retention rate was calculated. We investigated the influence of age, presence of diabetes, number of fused vertebrae, causative pathogens, duration from diagnosis to CLAP initiation, white blood cell (WBC) count (× 10 3 /μL), and C-reactive protein (CRP) level on the development of SSI after CLAP. Patients were divided into two groups: a favorable outcome group ( n  = 28), in which SSI was promptly controlled after CLAP, and a poor outcome group ( n  = 12), in which additional surgery was required or fatal outcomes occurred after CLAP. The relationship between these two groups was evaluated. Results In 13 of 40 patients, implants had already been removed before CLAP initiation. Excluding these cases, control of SSI with implant retention was achieved by CLAP in 22 of 27 patients (81%). In the poor outcome group, antibiotic-resistant pathogens were detected at a higher rate than in the favorable outcome group ( p  = 0.022), and the WBC counts at 1 week after CLAP were significantly increased compared with the favorable outcome group (poor outcome group 7.7 ± 2.4, favorable outcome group 5.8 ± 1.6; p  = 0.013). Conclusions Application of CLAP enabled SSI control with a high rate of implant retention. However, detection of antibiotic-resistant pathogens and increased WBC count 1 week after initiating CLAP may predict poor control of SSI, even after CLAP.

Lumbar spondylolysis generally occurs in adolescent athletes. Bony union can be expected with conservative treatment, however, the fracture does not heal in some cases. When the fracture becomes a pseudoarthrosis, spondylolysis patients have the potential to develop isthmic spondylolisthesis. A cross-sectional study was performed to determine the incidence of spondylolysis and spondylolisthesis, and to elucidate when and how often spondylolisthesis occurs in patients with or without spondylolysis. Patients undergoing computed tomography (CT) scans of abdominal or lumbar regions for reasons other than low back pain were included (n = 580). Reconstruction CT images were obtained, and the prevalence of spondylolysis and spondylolisthesis were evaluated. Of the 580 patients, 37 patients (6.4%) had spondylolysis. Of these 37 patients, 19 patients (51.4%) showed spondylolisthesis, whereas only 7.4% of non-spondylolysis patients showed spondylolisthesis (p < 0.05). When excluding unilateral spondylolysis, 90% (18/20) of spondylolysis patients aged ≥60 years-old showed spondylolisthesis. None of the patients with isthmic spondylolisthesis had received fusion surgery, suggesting that most of these patients didn’t have a severe disability requiring surgical treatment. Our results showed that the majority of bilateral spondylolysis patients aged ≥60 years-old show spondylolisthesis, and suggest that spondylolisthesis occurs very frequently and may develop at a younger age when spondylolysis exists.

Purpose Extreme lateral interbody fusion provides minimally invasive treatment of spinal deformity, but complications including nerve and psoas muscle injury have been noted. To avoid nerve injury, mini-open anterior retroperitoneal lumbar interbody fusion methods using an approach between the aorta and psoas, such as oblique lumbar interbody fusion (OLIF) have been applied. OLIF with percutaneous pedicle screws without posterior decompression can indirectly decompress the spinal canal in lumbar degenerated spondylolisthesis. In the current study, we examined the radiographic and clinical efficacy of OLIF for lumbar degenerated spondylolisthesis. Methods We assessed 20 patients with lumbar degenerated spondylolisthesis who underwent OLIF and percutaneous pedicle screw fixation without posterior laminectomy. MR and CT images and clinical symptoms were evaluated before and 6 months after surgery. Cross sections of the spinal canal were evaluated with MRI, and disk height, cross-sectional areas of intervertebral foramina, and degree of upper vertebral slip were evaluated with CT. Clinical symptoms including low back pain, leg pain, and lower extremity numbness were evaluated using a visual analog scale and the Oswestry Disability Index before and 6 months after surgery. Results After surgery, significant increases in axial and sagittal spinal canal diameter (12 and 32 %), spinal canal area (19 %), disk height (61 %), and intervertebral foramen areas (21 % on the right side, 39 % on the left), and significant decrease of upper vertebral slip (−9 %) were found ( P  < 0.05). Low back pain, leg pain, and lower extremity numbness were significantly reduced compared with before surgery ( P  < 0.05). Conclusions Significant improvements in disk height and spinal canal area were found after surgery. Bulging of disks was reduced through correction, and stretching the yellow ligament may have decompressed the spinal canal. Lumbar anterolateral fusion without laminectomy may be useful for lumbar spondylolisthesis with back and leg symptoms.

The emergency department is an environment with a potential risk for diagnostic errors during trauma care, particularly for fractures. Convolutional neural network (CNN) deep learning methods are now widely used in medicine because they improve diagnostic accuracy, decrease misinterpretation, and improve efficiency. In this study, we investigated whether automatic localization and classification using CNN could be applied to pelvic, rib, and spine fractures. We also examined whether this fracture detection algorithm could help physicians in fracture diagnosis. A total of 7664 whole-body CT axial slices (chest, abdomen, pelvis) from 200 patients were used. Sensitivity, precision, and F1-score were calculated to evaluate the performance of the CNN model. For the grouped mean values for pelvic, spine, or rib fractures, the sensitivity was 0.786, precision was 0.648, and F1-score was 0.711. Moreover, with CNN model assistance, surgeons showed improved sensitivity for detecting fractures and the time of reading and interpreting CT scans was reduced, especially for less experienced orthopedic surgeons. Application of the CNN model may lead to reductions in missed fractures from whole-body CT images and to faster workflows and improved patient care through efficient diagnosis in polytrauma patients.