CASE:A 78-year-old woman had gluteal pain radiating to both lateral thighs and calves and progressive neurogenic claudication. Imaging revealed osteoporotic thoracolumbar compression fractures, L4 spondylolisthesis with severe L4-5 stenosis, and sagittal kyphosis. Spinopelvic parameters were not measured, owing to extreme forward-flexed posture. Given the high risk of instrumentation failure and complications, spinal cord stimulation (SCS) was selected after initiating osteoporosis therapy. The pain improved, with pain relief and ambulatory function maintained at 18 months without surgery. CONCLUSION:SCS may be an alternative to fusion in selected osteoporotic patients with severe sagittal imbalance and lumbar radiculopathy.

CASE:An 82-year-old woman sustained an Anderson Type II odontoid fracture after a fall and underwent halo vest fixation. Eight weeks later, she developed eyelid edema and altered consciousness. Computed tomography revealed intracranial pin penetration, cerebrospinal fluid (CSF) leakage, and pneumocephalus. The halo vest was removed, and subsequent conservative treatment with bed rest and antibiotics led to full neurological recovery. CONCLUSION:This rare case of intracranial pin penetration and CSF leakage following halo vest fixation emphasizes the importance of close monitoring and early imaging in patients presenting with neurological symptoms during prolonged immobilization.

BACKGROUND:Trans-sacral canalplasty (TSCP) is a minimally invasive epidural adhesiolysis technique positioned between conventional block therapy and open surgery. However, the relationship among MRI-defined levels of stenosis, epidurographic block patterns, and clinical effectiveness remains unclear. OBJECTIVES:To investigate the clinical significance of mismatch between MRI-defined levels of stenosis and epidurographic block as well as to evaluate the short-term outcomes and feasibility of adhesiolysis in patients undergoing TSCP. STUDY DESIGN:A retrospective observational study. SETTING:A university hospital in Japan and an affiliated institution. METHODS:We reviewed all patients who underwent TSCP between October 2024 and August 2025. Baseline characteristics, diagnosis, surgical history, and minimum dural sac area at L3/4, L4/5, and L5/S (measured on MRI using ImageJ2) were assessed. Epidurography was performed to identify block levels, and cases were categorized as concordant (MRI-defined level of stenosis = block level) or discordant (mismatch). Discordant cases were subclassified into a "tail-stop" type (in which contrast stopped in a position caudal to the MRI-defined level of stenosis) and a "pass-through" type (in which these levels differed). Clinical effectiveness was defined as an improvement in low back pain or leg pain at one week after the procedure. Feasibility of adhesiolysis was also evaluated. RESULTS:Twenty-eight patients underwent TSCP during the study period. Nine (32.1%) showed concordance between MRI-defined levels of stenosis and epidurographic block sites, and 19 patients (67.9%) showed discordance (tail-stop, n = 11; pass-through, n = 8). Overall, 23 patients (82.1%) experienced clinical improvement. The effectiveness rate was 66.7% (6/9) in the concordance group and 89.5% (17/19) in the discordance group; however, the difference was not statistically significant (P = 0.290). In the discordance group, there was a significant difference in gender distribution between subgroups, with men predominating in the tail-stop subtype and women in the pass-through subtype (P = 0.024), but not in age, diagnosis, surgical history, or minimum dural sac area. Epidural dissection was successful in 21 patients (75.0%), with no significant difference between the effective and noneffective groups (73.9% vs 80.0%, P > 0.999). LIMITATIONS:A single-center retrospective design, small sample size, and short-term follow-up of only one week. CONCLUSIONS:TSCP demonstrated favorable short-term clinical effectiveness, even in cases with mismatches between MRI and epidurographic findings. The feasibility of adhesiolysis may contribute to the clinical success of TSCP. Epidurographic mismatch should not be considered a contraindication for TSCP, and our findings support its role as a minimally invasive option for patients with degenerative disorders of the lumbar spine who are unsuitable for open surgery.

This study aimed to identify whether the ratio of the vertebral Hounsfield unit to serum pentosidine (H/P ratio), which reflects bone density and quality, can predict screw loosening after spinal fusion surgery. A retrospective case-control study was conducted in 35 patients (mean age 71 ± 10.4 years, 18 men) who underwent spinal interbody fusion for lumbar spine disease between June 2020 and February 2022. Screw loosening was evaluated by computed tomography at 12 months postoperatively. Information was collected on patient background characteristics, including age, sex, body mass index, diagnosis, dialysis status, smoking history, diabetes, steroid use, and osteoporosis. Imaging parameters, the surgical method used, number of fixed intervertebral segments, intervertebral level (including L5/S1 or not), and the H/P ratio were also investigated. Risk factors associated with screw loosening and pseudarthrosis were examined in univariable and multivariable logistic regression analyses. A P-value of < 0.05 was considered statistically significant. Screw loosening occurred in 14 of 35 patients (40

A 51-year-old woman presented to our hospital with septic shock. Magnetic resonance imaging (MRI) revealed a spinal epidural abscess and a spinal subdural empyema (SSE). Surgery in the prone position was considered impossible because of the patient's recent history of cardiac surgery. Therefore, the patient was treated conservatively with antibiotics. Treatment was successful, and the patient was discharged without any neurological complications. Because of its high risk of mortality, subdural empyema is almost always treated by surgery. However, we have encountered a case in which conservative management alone was successful. Magnetic resonance images revealed two areas of dural tear. Patients with multiple tears may be candidates for conservative therapy.

The accuracy of pedicle screw insertion in pediatric scoliosis correction surgery using augmented reality technology in combination with a conventional navigation system was evaluated, and its usefulness was verified. A retrospective study of patients who underwent mixed reality technology-assisted posterior scoliosis correction and fixation was conducted. In total, 361 pedicle screws inserted with a mixed reality technology-assisted navigation system were analyzed; 25 pedicle screws (6.9%) showed Rao Classification Grade 1 deviation, whereas 0.83% showed Rao Classification Grade 2.3 deviation, which is a clinical deviation. In terms of the relationship between the rotation of the vertebral body and the deviation of the pedicle screw, the pedicle screw tended to deviate more easily when it was necessary to insert the pedicle screw in a more strongly oblique position due to the rotation of the vertebral body. The results suggest that the pedicle screw insertion accuracy with augmented reality technology may be superior to that with conventional navigation alone in scoliosis correction and fusion surgery for scoliosis in children. This system is expected to become a standard support tool for spine surgery and will contribute to improving the success rate of surgery and reducing the burden on the surgeon.

This exploratory study developed and evaluated an artificial intelligence (AI)-based algorithm for quantitative morphometry to assess vertebral body deformities indicative of fractures. To achieve this, 709 radiographs from 355 cases were utilized for algorithm development and performance evaluation. The proposed algorithm integrates a first-stage AI model to identify the positions of thoracic and lumber vertebral bodies in lateral radiographs and a second-stage AI model to annotate 6 landmarks for calculating vertebral body height ratios (C/A, C/P, and A/P). The first-stage AI model achieved a sensitivity of 97.6%, a precision of 95.1%, and an average false-positive ratio of 0.43 per image for vertebral body detection. In the second stage, the algorithm's performance was evaluated using an independent dataset of vertebrae annotated by 2 spine surgeons and 1 radiologist. The average landmark errors ranged from 2.9% to 3.3% on the X-axis and 2.9% to 4.0% on the Y-axis, with errors increasing in more severely collapsed vertebrae, particularly at central landmarks. Spearman's correlation coefficients were 0.519-0.589 for C/A, 0.558-0.647 for C/P, and 0.735-0.770 for A/P, comparable with correlations observed among human evaluators. Bland-Altman analysis revealed systematic bias in some cases, indicating that the algorithm underestimated anterior and central height collapse in deformed vertebrae. However, the mean differences and limits of agreement between the algorithm and external evaluators were similar to those among the evaluators. Additionally, the algorithm processed each image within 10 s. These findings suggest that the algorithm performs comparably with human evaluators, demonstrating sufficient accuracy for clinical use. The proposed approach has the potential to enhance patient care by being widely adopted in clinical settings.

This study aimed to evaluate the accuracy of pedicle screw placement using intraoperative computed tomography (CT)-based navigation in adolescent idiopathic scoliosis (AIS) surgery and to identify both patient- and screw-level risk factors associated with clinically significant screw deviation. A total of 1,082 pedicle screws were placed in 67 consecutive AIS patients using intraoperative CT-guided navigation. Screw placement accuracy was graded according to the Gertzbein and Robbins classification system, with Grade C or D (≥ 2-mm cortical breach) defined as clinically significant deviation. Univariate and multivariate logistic regression analyses were performed to investigate risk factors for screw deviation, including morphometric parameters and surgical variables such as the distance from the navigation reference frame (RF). The overall rate of clinically significant screw deviation was 3.0

Osteoporotic vertebral fractures (OVFs) in elderly patients pose challenges due to bone destruction and surgical risks. This case report describes a minimally invasive approach using calcium phosphate cement (CPC) vertebroplasty and short fusion with cement augmentation of pedicle screws (CAPS) in a 91-year-old woman with severe OVF. The patient underwent CPC vertebroplasty at L1 and CAPS fixation at T12-L2, followed by osteoporosis medication. She regained mobility with no complications, screw loosening, or loss of correction at a two-year follow-up. We suggest this combined CPC-CAPS technique as a viable treatment option for OVF in high-risk elderly patients, providing minimal invasiveness and favorable long-term outcomes.

OBJECTIVE:Cement-augmented pedicle screws (CAPS) are expected to have fewer complications than conventional pedicle screws (PS), including less risk of postoperative screw loosening and loss of correction. However, use of CAPS has been associated with a risk of other complications, such as cement leakage. In this study, we investigated the usefulness of CAPS for osteoporotic vertebral fractures (OVF) by comparing its surgical outcomes with those of PS. METHODS:The study included 46 patients (PS group, n=29; CAPS group, n=17) who underwent posterior fixation surgery for OVF at our hospital or an affiliated hospital between August 2019 and August 2023 and were followed up for 12 months postoperatively. We collected background information on each patient, including age, sex, body mass index, diagnosis, and whether they were receiving osteoporosis treatment. We also examined the level of the lesion, the range of fixation (1-1, 2-2, 3-3), whether posterior bone grafting was performed, whether anterior column reconstruction was performed, and the corrected angle. We compared surgery-related factors, including the rate of revision surgery within 12 months postoperatively, adjacent vertebral fracture, screw loosening, and loss of angle correction at 12 months postoperatively between the two groups. We also evaluated cement leakage in the CAPS group. Logistic and linear regression analyses were used to evaluate the factors associated with each outcome. RESULTS:The Elixhauser Comorbidity Index value was significantly higher in the PS group, (P=0.042), but there were no significant differences between the groups in other factors. Cement leakage was confirmed in seven of the 17 cases in the CAPS group, all of which were asymptomatic. There was no significant difference between the groups in the incidence of adjacent vertebral fractures, screw loosening, or loss of correction. There was also no significant difference in the incidence of early revision surgery between the PS group (7/36 cases) and the CAPS group (7/40 cases). The risk of adjacent vertebral fracture was shown to be significantly higher at the thoracic level than at the thoracolumbar level (odds ratio 34, P=0.043). The risk of thoracic vertebral fracture was significantly higher than that of thoracolumbar vertebral fracture in cases with loss of angle correction (B=1.312, P=0.029). No significant risk factors for screw loosening were identified. CONCLUSIONS:There was no significant difference in surgical outcomes between CAPS and conventional PS when used in posterior fusion surgery for thoracolumbar fractures. However, use of CAPS was associated with a risk of cement leakage. Therefore, the indications for its use should be carefully considered. Long-term, large-scale prospective studies are needed to assess the usefulness of CAPS in more detail.

Trans-sacral canal plasty (TSCP) is a minimally invasive lumbar spine surgery under local anaesthesia. TSCP is expected to be effective regardless of whether the patient has had previous surgery. However, there are cases in which open revision surgery is required after TSCP. This study aimed to identify risk factors for open revision surgery after TSCP in order to determine surgical indications and limitations. A retrospective case-control study was conducted in patients who underwent TSCP for lumbar spine disease. Data of 112 patients were analysed. During an observation period of 7–23 months, 34 patients (30.4%) required open revision surgery and 78 (69.6%) did not. The following patient background characteristics were investigated: age, sex, body mass index (BMI), diagnosis, history of spine surgery and the institution where the surgery was performed. Comorbidities were scored using the Elixhauser Comorbidity Index. Preoperative imaging parameters were investigated, including the lesion level (L4/5, L5/S1, other), presence of intervertebral instability, dural sac area, presence of bony stenosis and presence of epidural lipoma. Multivariate analysis revealed that intervertebral instability (odds ratio 2.56, confidence interval 1.00–6.51, p = 0.046) and a narrow dural sac area (odds ratio 0.98, confidence interval 0.97–0.99, p = 0.002) were significant risk factors for open revision surgery after TSCP.

CASE:A 62-year-old woman receiving romosozumab for 3 months underwent extreme lateral interbody fusion (XLIF) for lumbar degenerative spondylolisthesis. From 1 week after surgery, she experienced gradually increasing pain from the right groin to the front of the thigh. Examination revealed ossifying myositis in bilateral psoas major muscles. Etidronate treatment was initiated, improving pain after 4 days. Computed tomography showed lesion disappearance by 3 months after surgery. CONCLUSION:We report a rare case of myositis ossificans in bilateral psoas major muscles following XLIF surgery, possibly influenced by intraoperative manipulation and romosozumab treatment. Etidronate administration may be effective, as with heterotopic ossification.

Ossification of the ligamentum flavum (OLF) can lead to dural ossification, significantly increasing the risk of complications, including intraoperative nerve injury. The application of augmented reality (AR) and advanced digital technologies in spine surgery has the potential to reduce these risks. This case report highlights a perioperative nerve injury-free microsurgery using elastic image fusion technology, which integrates preoperative imaging with intraoperative computed tomography for a patient with severe stenotic OLF and dural ossification. A 68-year-old Japanese man presented with persistent right-sided back pain. Additionally, the patient reported mild gait instability and difficulty maintaining balance on uneven surfaces, which had progressively worsened over the past six months. Magnetic resonance imaging revealed severe OLF with 81% spinal canal stenosis. Given the risks of dural injury and cerebrospinal fluid leakage, a microsurgical procedure using AR was planned to ensure nerve protection. The surgery employed an image-guided navigation system with elastic image fusion to accurately align intraoperative and preoperative images. Additionally, microscopy enabled the real-time projection of preoperative images and navigation screens onto the surgical field. The procedure was successful, and the patient experienced no postoperative nerve damage. He regained walking stability and was discharged on the 28th postoperative day. At the two-year follow-up, he remained free of recurrences and neurological deficits. OLF with dural involvement poses a high risk of complications. In such complex cases, AR technology provides valuable intraoperative reference information, enhancing the safety and precision of spinal surgery.

Quantitative morphometry (QM) is crucial to accurately diagnose and perform follow-up of vertebral fractures. Although the semiquantitative technique by Genant is prevalent, its accuracy and reproducibility are low. This study combines an AI model that identifies the position of each vertebral body from thoracic and lumbar lateral X-ray images with another AI model that determines vertebral body height ratios required for QM to develop a software for automatic evaluations. The learning data set comprised 3,082 vertebrae annotated by an orthopedic specialist. Thereafter, the correlation and concordance were evaluated between the specialist in the validation set and external evaluators in the test set. The software required approximately 6 s to read one image. For the validation set, Spearman’s correlation coefficient (rs) was 0.605, 0.721, and 0.798 for C/A, C/P, and A/P, respectively. Bland–Altman analysis indicated that the percentage within the limits of agreement (LOA) was 96.8%, 95.7%, and 94.9%, respectively, which decreased as the vertebral body compression increased. For the test set, rs were between 0.519–0.589, 0.558–0.647, and 0.735–0.770, respectively, and the correlations between the external evaluators were similar. Additionally, LOAs were almost above 95%. The proposed software is expected to improve the diagnosis of vertebral fractures and osteoporosis, enabling appropriate treatment.

Background: Surgical treatment of spinal metastases has been associated with high morbidity and mortality in patients with sarcopenia based on low skeletal muscle mass. We assessed physical performance using the Eastern Cooperative Oncology Group performance status scale and the Barthel Index on the 30th day after palliative surgery for spinal metastases and investigated the effectiveness of surgery according to sarcopenia assessed by skeletal muscle mass. Methods: We retrospectively analyzed 78 consecutive patients with thoracic and lumbar spinal metastases who underwent palliative surgery. The value of the area of the psoas major muscle at the L3 level normalized by the vertebral area was divided into first, middle, and third tertiles. Clinical variables were compared by tertile. Variables affecting the 30-day good performance status were investigated with univariate and multivariate analyses. Results: The 30-day morbidity rates were 50%, 38.5%, and 15.4% by tertile. The 30-day mortality rate was 2%; all were in the first tertile. Good preoperative performance status scores were seen in 15.4% of first and 50% of third tertile patients. Postoperatively, the performance status improved in all groups, with 30.8%, 65.4%, and 92.3% by tertile. Multivariate regression analysis revealed that a good preoperative performance status (OR: 15.50, 95% CI: 1.610-149.0 0, P < 0.05) and the value of the area of the psoas major muscle at the L3 level normalized by the vertebral area not in the first tertile (OR: 0.22, 95% CI: 0.06-0.82, P < 0.05) were significant predictors of a good postoperative 30-day performance status. Conclusions: A good preoperative performance status and exclusion from the first tertile were clinical factors predicting a good postoperative 30-day performance status. In patients with large psoas muscle mass (third tertile), a good 30-day performance status can be expected after surgery, suggesting that surgery in this population should be pursued aggressively. & COPY; 2022 Published by Elsevier B.V. on behalf of The Japanese Orthopaedic Association.

Figure 1. Preoperative imaging. A) Axial computed tomography (CT) of the chest. White arrow shows a nodular shadow in the upper lobe of the left lung. B) CT of the thoracic spine. Pathological fracture is evident at T6. C) Preoperative sagittal T2-weighted magnetic resonance imaging. Epidural abscess is seen compressing the spinal cord. A B C CLINICAL CORRESPONDENCE SPINE SURGERY AND RELATED RESEARCH

Case: A 73-year-old woman, after spinal surgery, presented with symptomatic spinal subdural extra-arachnoid hygroma (SSEH) because of a fall on the third postoperative day. The hygroma was diagnosed by magnetic resonance imaging (MRI). Lumbar puncture was performed under local anesthesia, after which the leg pain disappeared immediately. MRI obtained immediately after puncture and 1 week later confirmed disappearance of the hygroma. Conclusion: Although dural transection is mentioned in most of the reports on treatment of symptomatic postoperative SSEH, we were able to treat this entity by epidural puncture. In the absence of paraplegia or cystorectal disturbance, puncture can be an effective and minimally invasive treatment option.

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CASE:A 73-year-old woman presented with degenerative kyphoscoliosis. Radiographs revealed sagittal and coronal imbalance with lumbar spinal stenosis. Extreme lateral interbody fusion (XLIF) was performed in the first stage of 2-stage surgery, and a closed-suction drainage tube was placed in the retroperitoneal cavity. Postoperatively, there was massive bleeding through the tube. Contrast-enhanced computed tomography revealed lumbar artery injury, which required emergency arterial embolization. CONCLUSION:Placing a drainage tube in the retroperitoneal cavity during XLIF surgery can help detect complications such as intestinal and ureteral injuries, the lumbar artery within the lumbar muscle can be injured during drain placement.

CASE:A 58-year-old man presented with lumbar spinal stenosis due to epidural lipomatosis. He underwent transsacral canal plasty (TSCP), in a manner similar to epidural adhesiolysis, which can be performed under local anesthesia. His leg pain improved dramatically in the year after surgery. Furthermore, magnetic resonance images during this time show neural decompression by reduction of the amount of epidural fat. CONCLUSION:TSCP was found not only to relieve pain but also to achieve neural decompression in this patient with spinal canal stenosis caused by lumbar epidural lipomatosis. This is the first report to demonstrate the usefulness of TSCP for spinal epidural lipomatosis.