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Tomiya Matsumoto, Shinya Okuda, Takafumi Maeno, Tomoya Yamashita, Ryoji Yamasaki, Tsuyoshi Sugiura and Motoki Iwasaki

OBJECTIVE

The importance of spinopelvic balance and its implications for clinical outcomes after spinal arthrodesis has been reported in recent studies. However, little is known about the relationship between adjacent-segment disease (ASD) after lumbar arthrodesis and spinopelvic alignment. The purpose of this study was to clarify the relationship between spinopelvic radiographic parameters and symptomatic ASD after L4–5 single-level posterior lumbar interbody fusion (PLIF).

METHODS

This was a retrospective 1:5 matched case-control study. Twenty patients who had undergone revision surgery for symptomatic ASD after L4–5 PLIF and had standing radiographs of the whole spine before primary and revision surgeries were enrolled from 2005 to 2012. As a control group, 100 age-, sex-, and pathology-matched patients who had undergone L4–5 PLIF during the same period, had no signs of symptomatic ASD for more than 3 years, and had whole-spine radiographs at preoperation and last follow-up were selected. Mean age at the time of primary surgery was 68.9 years in the ASD group and 66.7 years in the control group. Several radiographic spinopelvic parameters were measured as follows: sagittal vertical axis (SVA), thoracic kyphosis (TK), sacral slope (SS), pelvic tilt (PT), pelvic incidence (PI), lumbar lordosis (LL), and segmental lordosis at L4–5 (SL) in the sagittal view, and C7–central sacral vertical line (C7-CSVL) in the coronal view. Radiological parameters were compared between the groups.

RESULTS

No significant change was found between pre- and postoperative radiographic parameters in each group. In terms of preoperative radiographic parameters, the ASD group had significantly lower LL (40.7° vs 47.2°, p < 0.01) and significantly higher PT (27° vs 22.9°, p < 0.05) than the control group. SVA ≥ 50 mm was observed in 10 of 20 patients (50%) in the ASD group and in 21 of 100 patients (21%, p < 0.01) in the control group. PI-LL ≥ 10° was noted in 15 of 20 patients (75%) in the ASD group and in 40 of 100 patients (40%, p < 0.01) in the control group on preoperative radiographs. Postoperatively, the ASD group had significantly lower TK (22.5° vs 30.9°, p < 0.01) and lower LL (39.3° vs 48.1°, p < 0.05) than the control group had. PI-LL ≥ 10° was seen in 15 of 20 patients (75%) in the ASD group and in 43 of 100 patients (43%, p < 0.01) in the control group.

CONCLUSIONS

Preoperative global sagittal imbalance (SVA > 50 mm and higher PT), pre- and postoperative lower LL, and PI-LL mismatch were significantly associated with ASD. Therefore, even with a single-level PLIF, appropriate SL and LL should be obtained at surgery to improve spinopelvic sagittal imbalance. The results also suggest that the achievement of the appropriate LL and PI-LL prevents ASD after L4–5 PLIF.

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Junichi Kushioka, Tomoya Yamashita, Shinya Okuda, Takafumi Maeno, Tomiya Matsumoto, Ryoji Yamasaki and Motoki Iwasaki

OBJECTIVE

Tranexamic acid (TXA), a synthetic antifibrinolytic drug, has been reported to reduce blood loss in orthopedic surgery, but there have been few reports of its use in spine surgery. Previous studies included limitations in terms of different TXA dose regimens, different levels and numbers of fused segments, and different surgical techniques. Therefore, the authors decided to strictly limit TXA dose regimens, surgical techniques, and fused segments in this study. There have been no reports of using TXA for prevention of intraoperative and postoperative blood loss in posterior lumbar interbody fusion (PLIF). The purpose of the study was to evaluate the efficacy of high-dose TXA in reducing blood loss and its safety during single-level PLIF.

METHODS

The study was a nonrandomized, case-controlled trial. Sixty consecutive patients underwent single-level PLIF at a single institution. The first 30 patients did not receive TXA. The next 30 patients received 2000 mg of intravenous TXA 15 minutes before the skin incision was performed and received the same dose again 16 hours after the surgery. Intra- and postoperative blood loss was compared between the groups.

RESULTS

There were no statistically significant differences in preoperative parameters of age, sex, body mass index, preoperative diagnosis, or operating time. The TXA group experienced significantly less intraoperative blood loss (mean 253 ml) compared with the control group (mean 415 ml; p < 0.01). The TXA group also had significantly less postoperative blood loss over 40 hours (mean 321 ml) compared with the control group (mean 668 ml; p < 0.01). Total blood loss in the TXA group (mean 574 ml) was significantly lower than in the control group (mean 1080 ml; p < 0.01). From 2 hours to 40 hours, postoperative blood loss in the TXA group was consistently significantly lower. There were no perioperative complications, including thromboembolic events.

CONCLUSIONS

High-dose TXA significantly reduced both intra- and postoperative blood loss without causing any complications during or after single-level PLIF.

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Sho Dohzono, Hiromitsu Toyoda, Shinji Takahashi, Tomiya Matsumoto, Akinobu Suzuki, Hidetomi Terai and Hiroaki Nakamura

OBJECTIVE

Little is known about the relationship between sagittal spinal alignment in patients with lumbar spinal canal stenosis (LSS) and objective findings such as spinopelvic parameters, lumbar back muscle degeneration, and clinical data. The purpose of this study was to identify the preoperative clinical and radiological factors that predict improvement in sagittal spinal alignment after decompressive surgery in patients with LSS.

METHODS

The records of 61 patients with LSS who underwent microendoscopic laminotomy and had pre- and postoperative clinical data collected were retrospectively reviewed. Spinopelvic parameters, including sagittal vertical axis (SVA), lumbar lordosis (LL), sacral slope, pelvic tilt, and pelvic incidence (PI), were evaluated. On T2-weighted MRI, the cross-sectional area and the percentage of fat infiltration of the paravertebral muscles (PVMs) before surgery were calculated. For patients with preoperative SVA > 40 mm (n = 30), the correlation between SVA improvement and preoperative clinical and radiographic parameters was calculated.

RESULTS

SVA improvement correlated with preoperative LL (r = −0.39) and PI –LL (r = 0.54). Multiple regression analysis showed that preoperative PI –LL (beta = 0.62; p < 0.01) and symptom duration (beta = −0.40; p < 0.05) were independently associated with SVA improvement. The percentage of fat infiltration of the PVM at L4–5 was significantly greater in patients with preoperative SVA ≥ 40 mm than in those patients with SVA < 40 mm.

CONCLUSIONS

Preoperative PI –LL and symptom duration were independently associated with SVA improvement in LSS patients with forward-bending posture. PVM degeneration at the lower lumbar level was significantly greater among patients with preoperative SVA ≥ 40 mm than in patients with SVA < 40 mm.

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Sho Dohzono, Hiromitsu Toyoda, Tomiya Matsumoto, Akinobu Suzuki, Hidetomi Terai and Hiroaki Nakamura

OBJECT

More information about the association between preoperative anterior translation of the C-7 plumb line and clinical outcomes after decompression surgery in patients with lumbar spinal canal stenosis (LSS) would help resolve problems for patients with sagittal imbalance. The authors evaluated whether preoperative sagittal alignment of the spine affects low-back pain and clinical outcomes after microendoscopic laminotomy.

METHODS

This study was a retrospective review of prospectively collected surgical data. The study comprised 88 patients with LSS (47 men and 41 women) who ranged in age from 39 to 86 years (mean age 68.7 years). All patients had undergone microendoscopic laminotomy at Osaka City University Graduate School of Medicine from May 2008 through October 2012. The minimum duration of clinical and radiological follow-up was 6 months. All patients were evaluated by Japanese Orthopaedic Association (JOA) and visual analog scale (VAS) scores for low-back pain, leg pain, and leg numbness before and after surgery. The distance between the C-7 plumb line and the posterior corner of the sacrum (sagittal vertical axis [SVA]) was measured on lateral standing radiographs of the entire spine obtained before surgery. Radiological factors and clinical outcomes were compared between patients with a preoperative SVA ≥ 50 mm (forward-bending trunk [F] group) and patients with a preoperative SVA < 50 mm (control [C] group). A total of 35 patients were allocated to the F group (19 male and 16 female) and 53 to the C group (28 male and 25 female).

RESULTS

The mean SVA was 81.0 mm for patients in the F group and 22.0 mm for those in the C group. At final follow-up evaluation, no significant differences between the groups were found for the JOA score improvement ratio (73.3% vs 77.1%) or the VAS score for leg numbness (23.6 vs 24.0 mm); the VAS score for low-back pain was significantly higher for those in the F group (21.1 mm) than for those in the C group (11.0 mm); and the VAS score for leg pain tended to be higher for those in the F group (18.9 ± 29.1 mm) than for those in the C group (9.4 ± 16.0 mm).

CONCLUSIONS

Preoperative alignment of the spine in the sagittal plane did not affect JOA scores after microendoscopic laminotomy in patients with LSS. However, low-back pain was worse for patients with preoperative anterior translation of the C-7 plumb line than for those without.

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Yoshifumi Takahashi, Shinya Okuda, Yukitaka Nagamoto, Tomiya Matsumoto, Tsuyoshi Sugiura and Motoki Iwasaki

OBJECTIVE

Although the importance of spinopelvic sagittal balance and its implications for clinical outcomes of spinal fusion surgery have been described, to the authors’ knowledge there have been no reports of the relationship between spinopelvic alignment and clinical outcomes for 2-level posterior lumbar interbody fusion (PLIF). The purpose of this study was to elucidate the relationship between clinical outcomes and spinopelvic sagittal parameters after 2-level PLIF for 2-level degenerative spondylolisthesis (DS).

METHODS

This study was limited to patients who were treated with 2-level PLIF for 2-level DS at L3–4-5. Between 2005 and 2014, 33 patients who could be followed up for at least 2 years were included in this study. The average age at the time of surgery was 72 years, and the average follow-up period was 5.6 years. Based on clinical assessments, the Japanese Orthopaedic Association (JOA) score and recovery rate were evaluated. The patients were divided into 2 groups based on the recovery rate: the good outcome group (G group; n = 19), with recovery rate ≥ 50%, and the poor outcome group (P group; n = 14) with recovery rate < 50%. Spinopelvic parameters were measured using lateral standing radiographs of the whole spine as follows: sagittal vertical axis (SVA), thoracic kyphosis (TK), sacral slope (SS), pelvic tilt (PT), pelvic incidence (PI), lumbar lordosis (LL), and segmental lordosis (SL) at L3–4-5. The clinical outcomes and radiological parameters were assessed preoperatively and at the final follow-up. Radiological parameters were compared between the 2 groups.

RESULTS

The mean JOA score improved significantly in all patients from 10.8 points before surgery to 19.6 points at the latest follow-up (mean recovery rate 47.7%). For radiological outcomes, no difference was observed from preoperative assessment to final follow-up in any of the spinopelvic parameters except SVA. Although no significant difference between the 2 groups was detected in any of the spinopelvic parameters, there were significant differences in the change in SL and LL (ΔSL 3.7° vs −2.1° and ΔLL 1.2° vs −5.6° for the G and P groups, respectively). In addition, the number of patients in the G group was significantly larger for the patients with ΔSL-plus than those with ΔSL-minus (p = 0.008).

CONCLUSIONS

The clinical outcomes of 2-level PLIF for 2-level DS limited at L3–4-5 appeared to be satisfactory. The results indicate that acquisition of increased SL in surgery might lead to better clinical outcomes.

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Yi-Syuan Li, Chun-Yu Chen, Chi-Hui Chen, Zhi-Kang Yao, Yu-Hsiang Sung, Kai-Cheng Lin, Yih-Wen Tarng, Chien-Jen Hsu and Jenn-Huei Renn