Details of a Researcher - Watanabe, Koota

Papers - Watanabe, Koota

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Can Postoperative Distal Adding-On be Predicted in Lenke Type 1B and 1C Curves with Intraoperative Radiographs?

Fujii T., Kawabata S., Suzuki S., Tsuji O., Nori S., Okada E., Nagoshi N., Yagi M., Michikawa T., Nakamura M., Matsumoto M., Watanabe K.

Spine (Spine) 47 ( 6 ) E215 - E221 2022.03

ISSN 03622436

Study Design.A retrospective study of consecutive collected data.Objective.To investigate risk factors for postoperative distal adding-on (DA) in Lenke Type 1B and 1C curves using intraoperative radiographs.Summary of Background Data.In adolescent idiopathic scoliosis (AIS), DA radiographic complication can negatively affect postoperative clinical results. However, few studies have focused on assessing risk factors for DA using intraoperative radiographs.Methods.We retrospectively evaluated 69 AIS patients with Lenke Type 1B or 1C curves who underwent posterior selective thoracic fusion. We divided patients into DA and non-DA groups based on radiograph data at 2-year follow-up using Wang et al (Spine 2011) definition of DA. We compared coronal radiographic parameters, including relative positions of end vertebra (EV), stable vertebra (SV), neutral vertebra (NV), and last touching vertebra (LTV) to lowest instrumented vertebra (LIV), and intraoperative radiographic parameters, between the two groups.Results.DA was present in 13 patients (18.8%) at 2-year follow-up. The mean LIV-EV, LIV-NV, LIV-SV, and LIV-LTV relative positions were significantly smaller in the DA group than in the non-DA group. Multivariate analysis showed that LIV-LTV was significantly associated with DA (DA: -0.2 ± 0.7, non-DA: 0.6 ± 0.7). Intraoperative radiographs showed that the mean angulation of the first disc below the LIV after final adjustment was significantly larger in the DA group (2.3° ± 1.1°) than in the non-DA group (0.9° ± 0.7°). Patients whose angulation of the first disc below the LIV was more than 3° were significantly associated with DA.Conclusion.The LIV selected at more cranial to the LTV may be a risk factor for postoperative DA in Lenke Type 1B and 1C curves. Moreover, it was suggested that LIV extension might be considered when the first disc's angulation below the LIV is >3° in intraoperative radiographs.Level of Evidence: 3.

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Influence of Intervertebral Level of Stenosis on Neurological Recovery and Reduction of Neck Pain after Posterior Decompression Surgery for Cervical Spondylotic Myelopathy: A Retrospective Multicenter Study with Propensity Scoring

Nori S., Nagoshi N., Aoyama R., Ishihara S., Fujiyoshi K., Shiono Y., Kitamura K., Ishikawa M., Suzuki S., Takahashi Y., Tsuji O., Yagi M., Nakamura M., Matsumoto M., Watanabe K., Ishii K., Yamane J.

Spine (Spine) 47 ( 6 ) 476 - 483 2022.03

ISSN 03622436

Study Design.Retrospective multicenter study.Objective.To identify the impact of the intervertebral level of stenosis on surgical outcomes of posterior decompression for cervical spondylotic myelopathy (CSM).Summary of Background Data.As the upper affected cervical levels in elderly patients result from degenerative changes in the lower cervical levels with aging, it is usually difficult to determine the influence of the upper affected cervical levels on surgical outcomes after posterior decompression for CSM in older age.Methods.This study involved 636 patients with CSM who underwent posterior decompression. According to the most stenotic intervertebral level, patients were divided into upper (n = 343, the most stenotic intervertebral level was C2/3, C3/4, or C4/5) and lower (n = 293, the most stenotic intervertebral level was C5/6, C6/7, or C7/T1) cervical stenosis groups. Propensity score matching of the baseline factors (characteristics, comorbidities, and neurological function) was performed to compare surgical outcomes, the Japanese Orthopaedic Association (JOA) scores, and visual analog scale (VAS) for neck pain between the upper (n = 135) and lower (n = 135) cervical stenosis groups.Results.Before propensity score matching, age at surgery was older and pre- and postoperative JOA scores were lower in the upper cervical stenosis group (P < 0.001, P < 0.001, and P < 0.001, respectively). Following matching, baseline factors were comparable between the groups. Postoperative JOA scores, preoperative-to-postoperative changes in the JOA scores, and the JOA score recovery rate were not significantly different between the groups (P = 0.866, P = 0.825, and P = 0.753, respectively). No differences existed in postoperative VAS for neck pain and preoperative-to-postoperative changes in VAS for neck pain between the groups (P = 0.092 and P = 0.242, respectively).Conclusion.The intervertebral level of stenosis did not affect surgical outcomes after posterior decompression for CSM.Level of Evidence: 3.

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Clinical outcomes and a therapeutic indication of intramedullary spinal cord astrocytoma

Nagoshi N., Tsuji O., Suzuki S., Nori S., Yagi M., Okada E., Okita H., Fujita N., Ishii K., Matsumoto M., Nakamura M., Watanabe K.

Spinal Cord (Spinal Cord) 60 ( 3 ) 216 - 222 2022.03

ISSN 13624393

Study design: Retrospective cohort study. Objectives: Although intramedullary astrocytoma is associated with a high mortality rate, the optimal treatment has not reached a consensus. This study aimed at evaluating neurologic function and overall survival rate (OSR) in the treatment of this tumor. Setting: The single institution in Japan. Methods: This study enrolled 67 subjects who underwent surgical treatment for intramedullary astrocytoma. Demographic, imaging, and surgical information were collected from each participant. Tumors were histologically categorized using the World Health Organization classification, and subjects were divided into low-grade (I and II; n = 40) and high-grade (III and IV; n = 27) groups. Neurologic status was evaluated using the modified McCormick scale (MMS). OSR was assessed using Kaplan–Meier methods. Results: The OSR decreased when the pathological grade increased (p < 0.01). Regarding the therapeutic efficacy for low-grade astrocytomas, subjects who underwent gross total resection (GTR) showed a higher OSR than those who did not (p = 0.02). GTR prevented worsening of MMS score, while non-GTR increased the MMS score (p < 0.01). In the high-grade group, 19 and 10 underwent radiation therapy and chemotherapy, respectively. However, both treatments did not improve OSR. Cordotomy was performed for subjects whose lesional area was at the thoracic level, but the OSR did not significantly increase. Conclusions: The most beneficial therapeutic strategy for low-grade astrocytomas was GTR, whereas that for the high-grade tumors was unclear. Further studies with a larger sample size are warranted to validate the effective treatment for malignant astrocytomas.

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Spontaneous Osseous Fusion after Remodeling Therapy for Chronic Atlantoaxial Rotatory Fixation and Recovery Mechanism of Rotatory Range of Motion of the Cervical Spine

Kitamura K., Ishii K., Nagoshi N., Chiba K., Matsumoto M., Nakamura M., Watanabe K.

Journal of Clinical Medicine (Journal of Clinical Medicine) 11 ( 6 ) 2022.03

We aimed to investigate the risk factors of spontaneous osseous fusion (SOF) of the at-lantoaxial joint after closed reduction under general anesthesia followed by halo fixation (remodeling therapy) for chronic atlantoaxial rotatory fixation, and to elucidate the recovery mechanism of the rotatory range of motion (ROM) after halo removal. Twelve patients who underwent remodeling therapy were retrospectively reviewed. Five patients with SOF were categorized as the fusion group and seven patients without SOF as the non-fusion group. Three dimensional CT was used to detect direct osseous contact (DOC) of facet joints before and during halo fixation, while dynamic CT at neutral and maximally rotated head positions was performed to measure rotatory ROM after halo removal. The duration from onset to initial visit was significantly longer (3.2 vs. 5.7 months, p = 0.04), incidence of DOC during halo fixation was higher (0/7 [0%] vs. 4/5 [80%], p = 0.004), and segmental rotatory ROM of Occiput/C1 (Oc/C1) at final follow-up was larger (9.8 vs. 20.1 degrees, p = 0.003) in the fusion group. Long duration from the onset to the initial visit might induce irreversible damage to the articular surface of the affected facet, which was confirmed as DOC during halo fixation and resulted in SOF. Long duration from the onset to the initial visit and DOC during halo fixation could be used to suggest the risk for SOF. Nonetheless, rotatory ROM of Oc/C1 increased to compensate for SOF.

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Surgical Predictors for Prevention of Postoperative Shoulder Imbalance in Lenke Type 2A Adolescent Idiopathic Scoliosis

Sato T., Yonezawa I., Matsumoto H., Otomo N., Suzuki T., Manabe N., Demura S., Watanabe K., Saito T., Nohara A., Kurakawa T., Shimizu T., Uno K., Matsumoto M., Kawakami N.

Spine (Spine) 47 ( 4 ) E132 - E141 2022.02

ISSN 03622436

Study Design. Multicenter, retrospective cohort study. Objective. The aim of this study was to investigate the occurrence and surgical predictors of postoperative shoulder imbalance (PSI) in Lenke type 2A adolescent idiopathic scoliosis (AIS). Summary of Background Data. Although several studies have investigated the factors influencing PSI in Lenke type 2 curves, no studies have analyzed PSI-related factors considering upper instrumented vertebra (UIV) and lumbar modifier type simultaneously. Methods. Patients with Lenke Type 2A AIS treated by spinal fusion were retrospectively identified and their data were extracted from six spine centers in Japan. Inclusion criteria were age between 10 and 20years at surgery, UIV=T2, major curve 408 to 908, and follow-up for 24 to 30months after surgery. We analyzed patient characteristics, surgical characteristics, and preoperative and immediate-postoperative radiographic parameters. We defined patients with lower instrumented vertebra (LIV) equal or proximal to the last touching vertebra (LTV) as selective thoracic fusion (STF-LTV) and patients with LIV distal to the LTV as non-STF-LTV. t Tests, Mann-Whitney U test, χ2 tests, Fisher exact tests, and multivariate logistic regression were used for statistical analyses. Results. Among the 99 consecutive patients with a mean follow-up of 25.6months, PSI was seen in 27 (27.3%) patients immediately after and in 17 (17.2%) patients at 24 to 30months. The univariate analysis revealed that the significant risk factors of PSI were preoperative radiographical shoulder height, non-STF-LTV, and high main thoracic curve (MTC) correction (immediate-postoperative MTC correction rate: ≥70%), with PSI incidence of 40.0%. The multivariate logistic regression analysis indicated that interaction term of non-STF-LTV and high MTC correction was an independent risk factor for PSI (non-STF-LTV and high MTC correction, odds ratio: 5.167, 95% confidence interval: 1.470-18.159, P=0.010). Conclusion. To prevent PSI in Lenke Type 2A AIS patients, surgeons should avoid the combination of non-STF-LTV and high MTC correction in those surgeries with UIV as T2.

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Hidden blood loss in extreme lateral interbody fusion for adult spinal deformity

Mima Y., Yagi M., Suzuki S., Tsuji O., Nagoshi N., Okada E., Fujita N., Nakamura M., Matsumoto M., Watanabe K.

Journal of Orthopaedic Science (Journal of Orthopaedic Science) 2022

ISSN 09492658

Background: Extreme lateral interbody fusion (XLIF) is often used with posterior spinal fixation (PSF) to treat adult spinal deformity (ASD). However, the amount of intraoperative blood loss (IBL) reported for XLIF may underestimate the total blood loss (TBL). The objective of this study was to determine the total perioperative blood loss in XLIF for ASD. Methods: We assessed 30 consecutive ASD patients with Schwab-SRS type L (mean age: 68.7 ± 8.2 years; mean follow-up 2.0 ± 1.3 years) who were treated by multilevel XLIF (mean, 2.5 ± 0.6 levels) followed by PSF after 3–5 days. We calculated the TBL after XLIF by the Gross equation, by hemoglobin (Hb) balance, and by the Orthopedic Surgery Transfusion Hemoglobin European Overview (OSTHEO) formula. We defined hidden blood loss (HBL) as the difference between the TBL and IBL. Pearson correlation, Spearman correlation, and multiple logistic regression analysis were performed to investigate the risk factors related to HBL. Results: Post-XLIF blood tests showed a significant decrease in the Hb (from 11.8 ± 1.1 mg/dl to 10.6 ± 1.1 mg/dl) and hematocrit (from 36.0 ± 3.2% to 32.5 ± 3.2%). Although the mean IBL was relatively small (33 ± 52 mL), we calculated the TBL as 291 ± 171 mL (Gross equation) and the HBL as 258 ± 168 mL by Gross equation, which was 8 times greater than the IBL on average. There was no difference in the results obtained using the three methods. Multiple logistic regression analysis indicated preoperative lumber lordosis was the risk factor of high HBL (Odds ratio = 1.085, 95%CI: 1.006–1.170, p = 0.035). Conclusions: The HBL in XLIF was 8 times greater than the IBL. During the perioperative course of correction and fusion surgery for ASD with XLIF, surgeons need to pay attention not to underestimate the TBL.

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Risk factors for early-onset radiographical adjacent segment disease in patients with spondylolytic spondylolisthesis after single-level posterior lumbar interbody fusion

Takeda K., Okada E., Shinozaki Y., Ozaki M., Kono H., Yasuda A., Suzuki S., Tsuji O., Nagoshi N., Yagi M., Fujita N., Ogawa J., Nakamura M., Matsumoto M., Watanabe K.

Spine Journal (Spine Journal) 2022

ISSN 15299430

BACKGROUND CONTEXT: The risk factors for radiographical adjacent segment disease (ASD) in patients with degenerative spondylolisthesis have been previously reported. However, there are only few reports on patients with spondylolytic spondylolisthesis who underwent single-level posterior lumbar interbody fusion (PLIF). PURPOSE: The study aimed to investigate the risk factors for radiographical ASD in patients with L5–S1 spondylolytic spondylolisthesis who underwent single-level PLIF. STUDY DESIGN/SETTING: A retrospective study PATIENT SAMPLE: This study retrospectively reviewed 135 consecutive patients (91 men and 44 women) with symptomatic L5–S1 spondylolytic spondylolisthesis who underwent single-level PLIF. OUTCOME MEASURES: The pre- and postoperative (at the final follow-up) spinopelvic parameters, % slip, sacral slope, lumbar lordosis (LL), pelvic tilt, pelvic incidence (PI), PI minus LL (PI − LL), lumbosacral angle, C7 sagittal vertical axis, and thoracic kyphosis were measured using standing radiographs. METHODS: Radiographical ASD was defined as disc height loss (>3 mm), increase of posterior angulation (>5°), or progression of spondylolisthesis (>3 mm) between the pre- and postoperative radiographs. Pfirrmann's classification was used to evaluate disc degeneration. The radiographical parameters and changes between the pre- and postoperative values were evaluated and compared for the non-ASD and ASD groups. Binary logistic regression analysis was performed to evaluate the adjusted associations between each potential explanatory variable and ASD development. RESULTS: The radiographical ASD incidence was 11%. Additionally, 60% of the patients with ASD had radiographical ASD at 1 year and all cases of radiographical ASD in this follow-up period occurred within 3 years after the initial surgery. The mean period of ASD occurrence after initial surgery was 21.7 ± 12.6 months. No patients required reoperation for radiographical ASD. Multivariate analysis revealed that a preoperative (odds ratio [OR], 5.9; 95% confidence interval [CI], 1.2–28.9; p=.03) and a postoperative (OR, 6.5; 95% CI, 1.2–34.5; p=.03) PI − LL of ≥15° were risk factors for radiographical ASD. CONCLUSIONS: Pre- and postoperative PI − LL value mismatch was identified as significant independent risk factors for radiographical ASD in patients with L5–S1 spondylolytic spondylolisthesis. Obtaining larger lordosis at L5–S1 may be the key to preventing radiographical ASD.

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Sublaminar Tethers Significantly Reduce the Risk of Proximal Junctional Failure in Surgery for Severe Adult Spinal Deformity A Propensity Score–matched Analysis

Yagi M., Suzuki S., Okada E., Nori S., Tsuji O., Nagoshi N., Nakamura M., Matsumoto M., Watanabe K.

Clinical Spine Surgery (Clinical Spine Surgery) 2022

ISSN 23800186

Study Design: This was a retrospective case series of prospectively collected data. Objective: The present study first described the effect of sublaminar tethering (SLT) on proximal junctional failure (PJF) in adult spinal deformity (ASD) surgery. Summary of Background Data: PJF is a devastating complication following ASD surgery. Teriparatide administration and spinous process tethering have been reported as alternatives for the prevention of PJF, but a clinically effective prevention strategy is still a matter of debate. Materials and Methods: We used data from an ASD database that included 381 patients with ASD (minimum 2-y follow-up). Among them, the data of patients who had a severe sagittal deformity and had surgery from the lower thoracic spine (T9–T11) to the pelvis were extracted and propensity score matched by age, sex, body mass index, bone mineral density, curve type, sagittal alignment, and fused level to clarify whether SLT prevented the development of PJF [SLT vs. control (CTR); age: 67 ± 7 vs. 66 ± 8 y, T-score: −1.4 ± 0.7 vs. −1.3 ± 0.6, body mass index: 22 ± 4 vs. 22 ± 5 kg/m2, C7 sagittal vertical axis (C7SVA): 12 ± 7 vs. 11 ± 5 cm, pelvic incidence−lumbar lordosis (PI−LL): 51 ± 22 vs. 49 ± 21 degrees, pelvic tilt (PT): 36 ± 10 vs. 34 ± 10 degrees, level fused: 11 ± 2 vs. 11 ± 2]. Sixty-four patients were matched into 32 pairs and compared in terms of the postoperative alignment and frequency of PJF. Results: Two years postoperatively, C7SVA and PT were significantly larger in the CTR group, while no significant difference in PI−LL was found (C7SVA: 3 ± 3 vs. 6 ± 4 cm, P < 0.01, PT: 16± 6 vs. 24± 9 degrees, P 0.01, PI−LL: 7± 9 vs. 11 ± 11 degrees, P=0.22). The proximal junctional angle was significantly greater in the CTR group (proximal junctional kyphosis: 8± 8 vs. 17± 13 degrees, P 0.01). The incidence of PJF was significantly lower in the SLT group (3% vs. 25%, P=0.03), with an odds ratio of 0.1 (95% confidence interval: 0.0-0.8, P=0.03). Conclusion: In the propensity score-matched cohort, the incidence of PJF was significantly lower in the SLT group. SLT is a promising procedure that may reduce the risk of PJF in severe ASD surgery.

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Comparison of Surgical Outcomes After Open- and Double-Door Laminoplasties for Patients with Cervical Ossification of the Posterior Longitudinal Ligament: A Prospective Multicenter Study

Nagoshi N., Yoshii T., Egawa S., Sakai K., Kusano K., Nakagawa Y., Hirai T., Wada K., Katsumi K., Fujii K., Kimura A., Furuya T., Kanchiku T., Nagamoto Y., Oshima Y., Nakashima H., Ando K., Takahata M., Mori K., Nakajima H., Murata K., Matsunaga S., Kaito T., Yamada K., Kobayashi S., Kato S., Ohba T., Inami S., Fujibayashi S., Katoh H., Kanno H., Watanabe K., Imagama S., Koda M., Kawaguchi Y., Takeshita K., Nakamura M., Matsumoto M., Yamazaki M., Okawa A.

Spine (Spine) 46 ( 23 ) E1238 - E1245 2021.12

STUDY DESIGN: A prospective multicenter study. OBJECTIVE: To evaluate and compare the surgical outcomes after open-door (OD) and double-door (DD) laminoplasties in subjects with cervical ossification of the posterior longitudinal ligament (OPLL). SUMMARY OF BACKGROUND DATA: Although previous studies compared clinical results after OD and DD laminoplasties, they were performed at a single institution with a relatively small sample size targeting mixed pathologies, including cervical spondylotic myelopathy. METHODS: This study was performed by the Japanese Multicenter Research Organization for Ossification of the Spinal Ligament. A total of 478 patients with myelopathy caused by cervical OPLL from 28 institutions were prospectively registered from 2014 to 2017 and followed up for 2 years. Of these, 41 and 164 patients received OD and DD laminoplasties, respectively. Demographic information, medical history, and imaging findings were collected. Clinical outcomes were assessed using the cervical Japanese Orthopaedic Association, Japanese Orthopaedic Association Cervical Myelopathy Evaluation Questionnaire, and visual analog scale scores. RESULTS: Age, sex, symptom duration, and comorbidities were not significantly different between the groups. Segmental ossification was the most frequent in both the groups. No significant differences in K-line type, canal occupying ratio, C2 to C7 angles, and range of motion were found. Both the procedures reduced the cervical range of motion postoperatively. A comparable frequency of perioperative complications was observed between the groups. The cervical Japanese Orthopaedic Association scores showed a similar improvement at 2 years postopera- tively. The reduction in visual analog scale score for neck pain was favorable in the OD group (P = 0.02), while other pain assessments did not show any significant differences between the groups. The functional outcomes assessed using the Japanese Orthopaedic Association Cervical Myelopathy Evaluation Questionnaire presented equivalent effective rates. CONCLUSION: The results demonstrated almost comparable surgical outcomes between OD and DD laminoplasties. Lamino- plasty is a valuable technique as a therapeutic option for cervical OPLL.Level of Evidence: 2.

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The impact of ossification spread on cervical spine function in patients with ossification of the posterior longitudinal ligament

Katsumi K., Hirai T., Yoshii T., Maki S., Mori K., Nagoshi N., Nishimura S., Takeuchi K., Ushio S., Furuya T., Watanabe K., Nishida N., Watanabe K., Kaito T., Kato S., Nagashima K., Koda M., Ito K., Imagama S., Matsuoka Y., Wada K., Kimura A., Ohba T., Katoh H., Matsuyama Y., Ozawa H., Haro H., Takeshita K., Watanabe M., Matsumoto M., Nakamura M., Yamazaki M., Okawa A., Kawaguchi Y.

Scientific Reports (Scientific Reports) 11 ( 1 ) 2021.12

Ossification of the posterior longitudinal ligament (OPLL) is a progressive disease. The bridging of ossified lesions to the vertebral body gradually increases, thereby decreasing the mobility of the cervical spine; thus, cervical spine function may decrease over time. However, cervical spine function in patients with cervical OPLL has not been evaluated in large prospective studies. Therefore, we conducted a prospective multicenter study to clarify whether ossification spread can influence cervical spine function and quality of life (QOL) in patients with cervical OPLL. In total, 238 patients (162 men, 76 women; mean age, 63.9 years) were enrolled from 16 institutions. Each patient underwent whole spine computed tomography and was evaluated for cervical spine function and QOL using the Japanese Orthopaedic Association Cervical Myelopathy Evaluation Questionnaire (JOACMEQ). In the multivariate regression analysis, a higher neck VAS score and a larger number of bridge formations of OPLL in the whole spine were significant predictors of adverse outcomes related to cervical spine function. This is the first prospective multicenter study to reveal the impact of ossification spread on cervical spine function. These findings are important to understand the natural course of OPLL and can serve as controls when evaluating postoperative cervical spine function.

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Laminectomy with instrumented fusion vs. laminoplasty in the surgical treatment of cervical ossification of the posterior longitudinal ligament: A multicenter retrospective study

Lee J.J., Kim H.C., Jeon H.S., An S.B., Kim T.W., Shin D.A., Yi S., Kim K.N., Yoon D.H., Shin H.C., Nagoshi N., Watanabe K., He D., Hoh D.J., Riew K.D., Shin J.J., Ha Y.

Journal of Clinical Neuroscience (Journal of Clinical Neuroscience) 94 271 - 280 2021.12

ISSN 09675868

Laminectomy with instrumented fusion (LF) has demonstrated better prevention of ossification of posterior longitudinal ligament (OPLL) growth compared to laminoplasty (LP). There remains uncertainty, however, as to which surgical approach is more beneficial with respect to clinical outcomes and complications. We retrospectively reviewed 273 cervical OPLL patients of more than 3 levels, from the two institutions’ databases, who underwent LF or LP between January 1998 and January 2016. Each 273 patient (85 with LF, 188 with LP) was assessed for postoperative neurologic and radiologic outcomes, complications and reoperations. The mean length of follow-up was 40.11 months. There were baseline differences between cohorts. Overall, postoperative JOA recovery rate at last follow up was significantly better in the LP group with similar improvement in visual analog neck score. Postoperative C2-7 Cobb angle was decreased compared to baseline for both LF and LP cohorts, but there was no significant difference between groups. Complications occurred in 19 (22.35%) LF patients, and 11 (5.85%) LP patients, with higher incidence of C5 palsy and instrumentation failure in the LF group. Four LF patients (4.71%) and five LP patients (2.66%) underwent reoperation during the follow up period.

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Grade III intradural extramedullary anaplastic ependymoma managed with near-complete resection and adjuvant radiotherapy: a case report

Ando S., Tsuji O., Nagoshi N., Nori S., Suzuki S., Okada E., Yagi M., Irie R., Watanabe K., Nakamura M., Matsumoto M.

Spinal Cord Series and Cases (Spinal Cord Series and Cases) 7 ( 1 ) 2021.12

Introduction: Of the 23 cases of spinal intradural-extramedullary ependymomas which have been reported to date, 11 were diagnosed as anaplastic. Here we present a very rare case of a thoracic intradural-extramedullary (not intramedullary) anaplastic ependymoma in an adult along with a literature review. Case presentation: A 29-year-old man presented with rapidly progressive gait disturbance, a sensory-deficit below the trunk and urination disorders that had begun a few months earlier. Magnetic resonance imaging of his thoracic spine revealed a dorsal-located intradural-extramedullary tumor at T4-5. The rapid deterioration of his symptoms within several months led him to refer to our department for surgery. Within one month the size of tumor increased to involve the T4-6 level, consequently worsening his gait disturbance. He underwent surgery and tumor mass was resected. However, there was leptomeningeal dissemination of the tumor cells on the surface of cord. A near-total resection was therefore achieved. Histopathology revealed the resected specimen had immunoreactivity for EMA/Vimentin/CD56/CD99/S-100/GFAP, with a Ki-67 index of ~35%. These factors led to the diagnosis of anaplastic ependymoma. Seven weeks postoperatively he received adjuvant radiotherapy to the whole brain and the whole spinal cord. He recovered as an independent ambulator without recurrence 1 year postoperatively. Discussion: Because of their rarity, there are no clear treatment or adjuvant therapy guidelines for spinal anaplastic ependymoma. Adjuvant radiotherapy to the whole brain and spinal cord was necessarily indicated after near-total resection. Although the patient’s condition has not recurred 1 year after surgery, careful and serial follow-up is necessary for this individual.

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Determining the validity and reliability of spinopelvic parameters through comparing standing whole spinal radiographs and upright computed tomography images

Fujita N., Yagi M., Watanabe K., Nakamura M., Matsumoto M., Yokoyama Y., Yamada M., Yamada Y., Nagura T., Jinzaki M.

BMC Musculoskeletal Disorders (BMC Musculoskeletal Disorders) 22 ( 1 ) 2021.12

Background: Standing whole spinal radiographs are used to evaluate spinal alignment in adult spinal deformity (ASD), yet some studies have reported that pelvic incidence, pelvic tilt, and thoracic kyphosis (TK) intra- and inter-observer reliability is low. This study aimed to evaluate the accuracy of spinopelvic parameters through comparing standing whole spinal radiographs and upright CT images. Methods: We enrolled 26 patients with ASD. All standing whole spinal posterior/anterior and lateral radiographs and upright whole spinal CT had been obtained in a natural standing position. Two examiners independently measured 13 radiographic parameters. Interclass correlation coefficients (ICCs) were used to analyze measurement intra- and inter-observer reliability. Paired t- and Pearson’s correlation tests were used to analyze validity of the standing whole spinal radiographs. Results: ICCs of upright CT were excellent in both intra- and inter-observer reliability. However, intra-observer ICCs for TK2–12, TK1–5, TK2–5, and TK5–12 on standing lateral radiographs were relatively low, as were inter-observer ICCs for TK2–12, TK1–5, TK2–5, and TK5–12. Concerning TK values, the difference between the radiographs and CT in TK1–12 and TK2–12 were 4.4 ± 3.1 and 6.6 ± 4.6, respectively, and TK values from T2 showed greater measurement error (p < 0.05). Conclusions: Upright CT showed excellent intra- and inter-observer reliability in the measurement of spinopelvic parameters. Measurement of TK with T2 on standing whole spinal radiographs resulted in a greater measurement error of up to 6.6°. Surgeons need to consider this when planning surgery and measuring postoperative TK changes in patients with ASD.

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Clinical application of diffusion tensor tractography to postoperative C5 palsy

Takano M., Tsuji O., Fujiyoshi K., Nagoshi N., Nori S., Suzuki S., Okada E., Yagi M., Matsumoto M., Nakamura M., Watanabe K.

Spinal Cord Series and Cases (Spinal Cord Series and Cases) 7 ( 1 ) 2021.12

Study design: Diagnostic study. Objective: Although C5 palsy is a well-known potential complication after cervical procedure, the exact pathophysiology remains uncertain. Diffusion tensor tractography (DTT) has recently been proposed as a useful tool to examine quantitatively and non-invasively the pathology of spinal cord disorders. The purpose of this study is to determine the clinical interest of DTT in patients with C5 palsy after cervical laminoplasty. Setting: Single university hospital. Methods: Five patients with C5 palsy out of 108 patients after cervical laminoplasty were subjected to DTT using a 1.5 Tesla magnetic resonance imaging in our hospital between 2010 and 2012. For the tractography, two regions of interest (ROI) were placed at the C5 segmental level and the bilateral C4/5 intervertebral foramen level. Results: The postoperative number of tract fibers at the C5 segmental spinal cord level was significantly increased compared to the preoperative number, despite the C5 palsy. Analyses of two ROIs (at the C5 segmental level and the C4/5 intervertebral foramen level) showed that the number of tract fibers at the palsy side was significantly decreased compared to the intact side. Furthermore, in the patient who spontaneously recovered from C5 palsy within postoperative 6 months, a gradual augmentation of tract fibers was identified at the palsy side. Conclusions: Our findings suggest that DTT can document C5 palsy in detail, as the anatomical region between C5 segmental level and C4/5 intervertebral foramen level was potentially damaged in patients with C5 palsy after laminoplasty.

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Cervical intramedullary recurrent Ewing sarcoma after 10-year disease-free survival in an adult: a case report and review of literature

Fukushima K., Tsuji O., Suzuki S., Nori S., Nagoshi N., Okada E., Yagi M., Emoto K., Nakayama R., Watanabe K., Nakamura M., Matsumoto M.

Spinal Cord Series and Cases (Spinal Cord Series and Cases) 7 ( 1 ) 2021.12

Introduction: Intramedullary metastasis of Ewing sarcoma is extremely rare. Here, we report an adult case of cervical intramedullary recurrent Ewing sarcoma after a 10-year disease-free survival after the initial surgery for a thoracic lesion. Case presentation: A 39-year-old man with a history of surgery and chemoradiotherapy for thoracic Ewing sarcoma ten years ago presented with neck pain and incomplete motor paralysis in the right upper extremity, which had suddenly appeared three months before. Cervical magnetic resonance imaging revealed a tear-drop-shaped intramedullary lesion at the C3 level accompanied by diffuse edematous change. Because of the rapid progression of his myelopathy, he underwent surgery for this intramedullary lesion. Intraoperatively, the tumor exhibited an orangish exophytic appearance. The unclearness of the tumor boundary compelled us to perform a partial resection. The histopathology showed the tumor comprised small round atypical cells with immunoreactivity for Nkx2.2 and CD99, diagnosing a metastatic Ewing sarcoma. Postoperatively, although his myelopathy improved transiently and adjuvant chemotherapy radiation was undergone, he died of cranial dissemination of the tumor two months and a half later. Discussion: To our knowledge, 31 cases of primary and only 4 cases of recurrent intramedullary spinal Ewing sarcoma have been reported to date; however, this is the first case of recurrent intramedullary Ewing sarcoma with a 10-year disease-free survival. Sadly, the prognosis of the current case was extremely poor. There is no clear treatment guideline for recurrent intramedullary Ewing sarcoma because of its rarity, and further collection of similar cases would be required.

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Neurological improvement is associated with neck pain attenuation after surgery for cervical ossification of the posterior longitudinal ligament

Koda M., Yoshii T., Egawa S., Sakai K., Kusano K., Nakagawa Y., Hirai T., Wada K., Katsumi K., Kimura A., Furuya T., Maki S., Nagoshi N., Watanabe K., Kanchiku T., Nagamoto Y., Oshima Y., Ando K., Nakashima H., Takahata M., Mori K., Nakajima H., Murata K., Matsunaga S., Kaito T., Yamada K., Kobayashi S., Kato S., Ohba T., Inami S., Fujibayashi S., Katoh H., Kanno H., Takahashi H., Fujii K., Miyagi M., Inoue G., Takaso M., Imagama S., Kawaguchi Y., Takeshita K., Nakamura M., Matsumoto M., Okawa A., Yamazaki M.

Scientific Reports (Scientific Reports) 11 ( 1 ) 2021.12

Although favourable surgical outcomes for myelopathy caused by cervical ossification of the posterior longitudinal ligament (OPLL) have been reported, factors significantly associated with post-operative neck pain attenuation still remain unclear. The primary aim of the present study was to determine factors significantly associated with post-operative neck pain attenuation in patients with cervical OPLL using a prospective multi-centre registry of surgically treated cervical OPLL. Significant postoperative neck pain reduction (50% reduction of neck pain) was achieved in 31.3% of patients. There was no significant difference in neck pain attenuation between surgical procedures. Statistical analyses with univariate analyses followed by stepwise logistic regression revealed neurological recovery as a factor having a significant positive association with post-operative neck pain attenuation (p = 0.04, odds ratio 5.68 (95% confidence interval: 1.27–22.2)). In conclusion, neurological recovery was an independent factor having a significant positive association with post-operative neck pain attenuation in patients with cervical myelopathy caused by OPLL who underwent cervical spine surgery.

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Surgical resection of arteriovenous fistula at the cauda equina

Shimizu T., Nagoshi N., Akiyama T., Suzuki S., Nori S., Tsuji O., Okada E., Yagi M., Watanabe K., Nakamura M., Matsumoto M.

Spinal Cord Series and Cases (Spinal Cord Series and Cases) 7 ( 1 ) 2021.12

Introduction: Although spinal arteriovenous fistula (AVF) has been reported widely, AVF at the cauda equina is quite rare. We described a case of AVF at the cauda equina that was fed by the distal radicular artery (DRA). Case presentation: A 50-year-old woman presented with sudden weakness of the lower extremities. Magnetic resonance imaging (MRI) revealed a lesion with a highly intense signal at the conus medullaris, which was surrounded by several low-intensity signals (flow voids). Digital subtraction angiography revealed AVF at the cauda equina and that it was fed by the DRA, which was directly fed by the L3 segmental artery. We performed surgical resection of the AVF while monitoring motor-evoked potentials. The patient’s postoperative course was uneventful, and her neurological symptoms gradually resolved. MRI 2 years after surgery showed the disappearance of both intramedullary edema and the flow voids. Discussion: For the AVF, located at the cauda equina and fed by the DRA in this case, surgical resection or endovascular embolization could have been selected. We performed open surgery to achieve complete obliteration of the AVF, which led to postoperative functional recovery without any adverse events. However, only a limited number of AVFs at the level of the cauda equina have been reported, and treatment standards have not been established. Further studies of AVFs at the cauda equina are necessary to clarify the epidemiological characteristics and clinical outcomes with an appropriate sample size.

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Surgical and Functional Outcomes of Expansive Open-Door Laminoplasty for Patients With Mild Kyphotic Cervical Alignment

Nagoshi N., Nori S., Tsuji O., Suzuki S., Okada E., Yagi M., Nakamura M., Matsumoto M., Watanabe K.

Neurospine (Neurospine) 18 ( 4 ) 749 - 757 2021.12

ISSN 25866583

Objective: To evaluate the cervical dynamics, neurological function, pain, and quality of life in patients with mild cervical kyphotic alignment who underwent expansive unilateral open-door laminoplasty (ELAP). Methods: In this retrospective single-center study, we reviewed the surgical outcomes of 80 patients with cervical spondylotic myelopathy who were followed for at least 2 years. The patients were categorized into the preoperative kyphotic group (C2–7 angle < 0°) and non-kyphotic group (angle ≥ 0°). We compared clinical information, radiographic parameters, Japanese Orthopaedic Association Cervical Myelopathy Evaluation Questionnaire (JOAC-MEQ) scores, and cervical Japanese Orthopaedic Association (JOA) scores between the groups. Results: The kyphotic and nonkyphotic groups comprised 17 and 63 patients, respectively. The preoperative C2–7 angles were-3.7° in the kyphotic group and 15.4° in the nonky-photic group (p < 0.01). In the kyphotic group, kyphotic alignment improved to lordosis at the final follow-up (2.6°, p = 0.01). The preoperative (16.4° vs. 24.1°, p < 0.01) and final-follow-up (17.8° vs. 24.5°, p < 0.01) C7 slopes were significantly smaller in the kyphotic group. ELAP reduced pain in the arms or hands (p = 0.02) and improved the JOA scores (p < 0.01) in the kyphotic group. Patient-reported outcomes assessed using the JOACMEQ showed comparable effective rates in both groups. Conclusion: Patients with mild cervical kyphosis showed smaller C7 slopes as a compensatory mechanism. Kyphotic angles significantly improved to lordosis after ELAP, resulting in favorable clinical outcomes. ELAP is a useful surgical option for patients even if they present mild kyphotic cervical angles.

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Recurrence of cervical intramedullary gliofibroma

Tokunaga K., Nagoshi N., Ohara K., Shibuya M., Suzuki S., Tsuji O., Okada E., Fujita N., Yagi M., Watanabe K., Nakamura M., Matsumoto M.

Spinal Cord Series and Cases (Spinal Cord Series and Cases) 7 ( 1 ) 2021.12

Introduction: Gliofibroma is a rare tumor that develops in the brain and spinal cord. Due to the rarity of its nature, its pathophysiology and appropriate treatment remain elusive. We report a case of intramedullary spinal cord gliofibroma that was surgically treated multiple times. This report is of great significance because this is the first case of recurrence of this tumor. Case presentation: A 32-year-old woman complained of gait disturbance and was referred to our institution. At the age of 13 years, she was diagnosed with intramedullary gliofibroma and underwent gross total resection (GTR) in another hospital. Based on imaging findings, tumor recurrence was suspected at the level of cervical spinal cord, and surgery was performed. However, the resection volume was limited to 50% because the boundary between the tumor and spinal cord tissue was unclear and intraoperative neuromonitoring alerted paralysis. At 1 year postoperatively, the second surgery was performed to try to resect the residual tumor, but subtotal resection was achieved at most. At 2 years after the final surgery, no tumor recurrence was observed, and neurologic function was maintained to gait with cane. Discussion: Although complete resection is desirable for this rare tumor at the initial surgery, there is a possibility to recur even after GTR with long-term follow-up. During surgical treatment for tumor recurrence, fair adhesion to the spinal cord is expected, and reoperation and/or adjuvant therapy might be considered in the future if the tumor regrows and triggers neurological deterioration.

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Factors significantly associated with postoperative neck pain deterioration after surgery for cervical ossification of the posterior longitudinal ligament: Study of a cohort using a prospective registry

Journal of Clinical Medicine (Journal of Clinical Medicine) 10 ( 21 ) 2021.11

Postoperative neck pain has been reported as an unsolved postoperative complication of surgery for cervical ossification of the posterior longitudinal ligament (OPLL). The aim of the present study was to elucidate factors having a significant association with postoperative deterioration of neck pain in cervical OPLL patients. We studied a cohort of patients in a prospective registry of 478 patients who had undergone cervical spine surgery for cervical OPLL. We excluded those without evaluation of preoperative neck pain. Therefore, 438 patients were included in the present study. Neck pain was evaluated with the visual analogue scale (VAS, 0–100 mm). Postoperative neck pain deterioration was defined as a ≥20 mm increase of VAS neck pain. Patient factors, neurological status, imaging factors and surgical factors were assessed. Univariate analyses followed by multivariate analysis using stepwise logistic regression was performed. Six months after surgery, 50 (11.6%) patients showed postoperative neck pain deterioration and 76 (17.4%) patients showed postoperative neck pain deterioration 2 years after surgery. Six months after surgery, the rate of neck pain deterioration was significantly higher in patients who had undergone posterior surgery. Two years after surgery, the number of levels fused was significantly correlated with neck pain deterioration.

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