Introduction: The lower lumbar foraminal stenosis is well recognized for the cause of failed back surgery and has recently received attention. However, little attention has been paid to the upper lumbar foraminal stenosis. The purpose of this report is to clarify the clinical and radiological findings of L1 radiculopathy caused by L1/2 foraminal stenosis.

Methods: Among 9,138 patients treated at the clinic for lumbar degenerative diseases, 16 patients who complained about unilateral low back pain and showed L1/2 foraminal stenosis on magnetic resonance imaging (MRI) were investigated. All of the patients showed improvement of the pain via L1 nerve root block. There were 12 males and 4 females with a mean age of 61 years (range, 39-86 years). For these patients the clinical symptoms and signs, and neurological and radiological findings were examined in detail.

Results: All patients complained of back pain in the posterior iliac crest. Ten patients (63%) complained about groin pain and six patients (38%) about pain around lateral of the greater trochanter. Three patients were examined via colonoscopy due to groin pain. No patients showed the pain of the distal thigh and the leg. Two patients complained of numbness at the inguinal area. The slight weakness of the iliopsoas muscle was recognized in one patient. No patients showed tendon reflex changes. Kemp test was positive in nine patients (56%). Plain radiographs showed degenerative scoliosis in seven patients (44%). On MRI findings, the round herniated masses were noted at the foraminal portion with coronal view. This sign revealed in six out of nine patients with L1/2 lateral disc herniation. All patients were relieved of their pain via L1 selective nerve root blocks; however, in three patients, the pain recurred immediately and the surgical procedures were required.

Conclusions: The characteristics of L1 radiculopathy due to L1/2 foraminal stenosis are unilateral low back pain in the posterior iliac crest with groin pain or greater trochanteric pain. The increasing pain by Kemp maneuver is recognized in 56% of the patients. From this study, the patients complaining of severe posterior iliac crest pain should be considered as suffering from L1/2 foraminal stenosis.

Introduction: The study aimed to assess the association of frailty with long-term results of cervical laminoplasty (LP) for the treatment of cervical spondylotic myelopathy (CSM) and ossification of posterior longitudinal ligament (OPLL).

Methods: We retrospectively reviewed 103 cases (73 men, 30 women, mean age 61.0 y.o., 78 CSMs and 25 OPLLs) who underwent cervical LP and followed-up for over 10 years (mean 12.0 y.o.). For evaluation of frailty, we used a 5-item modified frailty index (mFI-5). Clinical outcomes were assessed by Japanese Orthopaedic Association (JOA) scores and its recovery rate (RR) was evaluated at 1-year postsurgery and final follow-up (over 10 years postsurgery). These outcomes were compared among three groups: preoperative mFI-5 = 0 (40 cases) as a healthy group, =1 (34 cases) as a prefrail group, and ≥2 (29 cases) as a frail group.

Results: The JOA scores improved significantly in all groups 1-year postsurgery, whereas the scores deteriorated in the prefrail and frail group during follow-up periods. The 1-year RR showed significant differences between each group, whereas only the healthy group maintained the RR over 10 years. At final follow-up, the healthy group had significantly higher RR than the other groups, while prefrail and frail group decreased the RR from 1 year to final follow-up.

Conclusions: In healthy patients, JOA score improved early postoperatively and was maintained for long periods, whereas in the patients with any frailty, the early improved JOA score was not maintained for long. These results indicate that the patients with general frality could also have fragility in cervical nerve function and resilience. Since frailty had influences on the recovery and long-term maintenance of cervical nerve function, the mFI-5 should be a reliable predictor of surgical outcome for cervical myelopathy.

Introduction: In our institute, the first choice of treatment for pyogenic spondylodiscitis in the thoracic and lumbar spine is anterior debridement and bone grafting with posterior spinal instrumentation. The purpose of this study was to evaluate the clinical outcomes of this method.

Methods: We included 16 patients (12 men, 6 women, mean age 69 years) who were treated with this procedure in our institute between April 2015-March 2020. The average follow-up time was 35 months (12-60 months). The affected level was T5/6 to L5/S. The most common comorbidity was diabetes mellitus which were seen in 10 cases. Patients with moderate bony destruction and severe unrelenting back pain or leg pain were indicated for surgery. We performed radical debridement of the infected tissue until good bleeding was seen from the grafting bed and autologous iliac bone grafting was done. Percutaneous pedicle screw system was mainly used for posterior instrumentation. Preoperative patient background factors, such as C-reactive protein (CRP) levels and causative organisms, and surgery-related factors such as the use of affected vertebral screws and reconstructive procedures were reviewed. Also, clinical outcomes were investigated using VAS scale, the Disability Independence Criteria for the Japanese Elderly, infection healing, and bone fusion rate. Statistical analysis was performed and P < 0.05 was considered significant.

Results: Reconstructive surgery was performed on an average of 22 days after hospitalization. Preoperative CRP was 2.9 mg/dl, which was significantly lower than that on admission (P < 0.001). The causative organism was identified in 15 patients (94%). In 12 cases, anterior debridement and reconstruction was done first, which was the most frequent pattern of surgery. VAS scale and the patient's ADL improved significantly postoperation (P < 0.001), and 13 patients (81%) were ambulatory at final follow-up. Infection healed in all patients and bony fusion was achieved in 15 patients (94%). In 13 cases (81%), pedicle screws were inserted in the affected vertebra, without any problems. The number of posterior fixed levels was significantly lower in patients with the pedicle screws inserted in the affected vertebra compared to those without the screws in the affected vertebra (P < 0.001).

Conclusions: This surgical procedure can be useful in patients with pyogenic spondylodiscitis resistant to conservative treatment in the thoracic and lumbar spine.

Introduction: The purpose of this study is to verify the reliability and validity of the evaluation of lumbar lordosis using a flexible curve ruler.

Methods: The subjects were 10 healthy adults and 39 patients with lumbar disc herniation (LDH). The measurement was performed using a flexible curve ruler, after which the curve was traced on a piece of graph paper, and the lumbar lordosis angle was calculated. The lumbar lordosis angle was calculated using a standing X-ray lateral view.

Results: The intrarater reliability ICC (1.1) was 0.92 (95% CI: 0.79-0.98), and the interrater reliability ICC (2.1) was 0.66 (95% CI: 0.32-0.89). A positive correlation was observed between the measurement of patients with LDH by the flexible curve ruler and the lumbar lordosis angle on the X-ray image (r = 0.73, p < 0.05). The regression equation for the flexible curve ruler and the X-ray image was: X-ray image angle = 0.828 × flexible curve angle+16.351.

Conclusions: The sagittal alignment evaluation of the lumbar region using the flexible curve ruler showed high intraexaminer reliability and validity even in Japan. The measurement of the lumbar lordosis angle using the flexible curve ruler enables evaluation over time, and it is also possible to evaluate and examine the assumption of the X-ray image angle by using a regression equation.

Introduction: In an aging society, elderly people have many problems such as frailty syndrome, and locomotive syndrome, and it is important that their hospitalization is short-term, incisions are small, return to home early, and invasiveness is minimal. Full endoscopic laminotomy (FEL) using an 8 mm full endoscope has been performed in a tight working space of 4.1 mm. Consequently, it took a long time to perform surgery. Therefore, an endoscope with a more wide working space is required while keeping the invasion minimal and incisions small as much as possible. We have had discussions with Korean endoscopic specialists and participated in the development project of the percutaneous stenoscopic lumbar decompression (PSLD^®) system with Maxmore Co., Ltd. in Germany.

Methods: The PSLD^® endoscope using bilateral decompression through one-portal unilateral approach for lumbar canal stenosis has an outer tube of 9.5 mm and a working space of 5.5 mm, and Kerrison with a diameter of 1-5.0 mm, diamond burr of the same diameter, chisel, sharp curratage, etc., can be used. Quickly ablate the soft tissue and superficial layer of the ligamentum flavum with high frequency electrode, roughly cut the spinal laminar arch with a 4 mm burr, and then carefully drill the deep part with a 2.5-3 mm burr. The ligamentum flavum is detached and resected from the deep part of the spinal laminar enthesis with various Kerrisons, and when it floats, it is vertically torn in the center and removed as a mass.

Results: The results for 77 patients with spinal canal stenosis with one to three segments were excellent and good in 85.7% as per the Macnab's criteria. There were five cases of dural injury, all of which were repaired via the patch repair method or open suture, and there were no problems.

Conclusions: It was possible to use instruments similar to open surgery, and the drilling of spinal laminar bone, resection of ligamentum flavum, removal of intervertebral disc, etc., could be performed smoothly.

It is important that spinal surgery for the patient is minimally complicated and invasive; moreover, it is desirable to return to home early.

Introduction: With the aging of the population, the number of osteoporotic vertebral fractures (OVF) is increasing. Delayed union, non-union, and pseudoarthrosis could occur if the diagnosis of VCFs is delayed or its treatment did not work. The effects of early diagnosis of OVF and its treatment by balloon kyphoplasty (BKP) were examined.

Methods: A total of 118 patients who were diagnosed with OVF and underwent BKP were analyzed. After their OVF diagnosis was confirmed, patients were placed in a brace and hospitalized for BKP. Numerical rating scale (NRS) at 3 months post-BKP, radiological subsequent fracture (SF) at adjacent level, painful SF at adjacent level, and correction loss were used as the objective variables for Fisher's exact test. The time taken to confirm the diagnosis (within 7 days; early diagnosis group vs. after 7 days of injury; late diagnosis group) and the timing of BKP (within 28 days; early BKP group vs. after 28 days of OVF diagnosis; late BKP group) were used as explanatory variables, and a multivariate logistic regression analysis of the objective variables was performed after adjusting for sex, age, bone material density, and affected vertebrae level.

Results: The study participants comprised 26 men and 92 women with a mean age of 80.8 years. Patients who had their diagnosis of OVF confirmed in the early diagnosis group had significantly lower NRS scores at 3 months than those who had their diagnosis confirmed in late diagnosis group (0.62 vs. 1.46, p < 0.05). Likewise, radiological SF was significantly lower in those who had their diagnosis of OVF confirmed in the early diagnosis group than those who had their diagnosis confirmed in the late diagnosis group (11.8% vs. 34.0%, p < 0.005). The percentage of radiological SF at 3 months was significantly lower in the early BKP group than in the late BKP group (12.5% vs. 39.5%, p < 0.005). In multivariate analysis, radiological SF was significantly higher in those who had their OVF diagnosis confirmed in the late diagnosis group (odds ratio, 3.4; 95% CI, 1.06-10.9; p < 0.05). Furthermore, radiological SF was significantly higher in the late BKP group (odds ratio, 3.9; 95% CI, 1.2-12.8; p < 0.05).

Conclusions: Our results revealed that radiological SF significantly increased in patients who had their diagnosis of OVF confirmed after 7 days of injury and in those who underwent BKP after 28 days of OVF diagnosis.

Introduction: We investigated the correlation of daily life activities and patient characteristics with decreased health-related quality of life (HRQOL) in postpartum women with lumbar or pelvic pain.

Methods: A total of 37 postpartum women with lumbar or pelvic pain were enrolled in this study. For assessing HRQOL, the physical component summary (PCS) and mental component summary (MCS) of the SF-8 Health Survey were used. For assessing daily life activities, 9 subscales of the Oswestry Disability Index (ODI) were used.

Results: We found that 89% and 65% of the patients had PCS and MCS scores below the national standard, respectively. The scores of PCS were significantly negatively correlated with 4 subscales of the ODI, including lifting, sitting, social life, and personal care, and with older age. No significant correlations were found between the scores of MCS, subscales of the ODI, and patient characteristics.

Conclusions: The decreased PCS scores could be a result of the disturbance in usual behavior and movements after childbirth, such as flexion in older postpartum women with lumbar or pelvic pain.

Introduction: Osteoporotic vertebral fracture (OVF) is one of the most common fractures among the elderly, and its impact on the cost of care is a concern. Balloon kyphoplasty (BKP) is a widely used treatment for OVF. The purpose of this study is to estimate the cost of conservative treatment and BKP, including the cost of nursing care and the loss of productivity of caregivers, based on previous reports.

Methods: For the distribution of activities of daily living (ADLs) after OVF, we used data from our multicenter prospective study that evaluated BKP and conservative treatment for 6 months in patients aged ≥65 years within 2 months of the onset. Estimates of nursing care costs and informal care costs were estimated mainly based on data published by the Ministry of Health, Labor and Welfare.

Results: To compare nursing care costs, we summed up the distribution of ADLs, the level of nursing care required, and the level of independence in daily living at the end of 6 months of treatment. The per capita nursing care costs by level of nursing care required at the end of 6 months were 39,497 yen/month in the BKP group and 58,298 yen/month in the conservative therapy group with a difference of 18,801 yen/month. The per capita informal care costs by level of care required at the end of 6 months of treatment were 35,722 yen/month in the BKP group and 44,102 yen/month in the conservative therapy group, with a difference of 8,380 yen/month.

Conclusions: For patients with OVF, improvement of ADL via BKP may reduce the cost of care and caregiver productivity loss.