Hitoshi Tonomura's research while affiliated with Kyoto Prefectural University of Medicine and other places

Background: Preoperative estimations of blood loss are important when planning surgery for cervical spine injuries in older adults. The association between ankylosis and blood loss in perioperative management is of particular interest. This multicenter database review aimed to evaluate the impact of ankylosis on surgical blood loss volume in elderly patients with cervical spine injury. Methods: The case histories of 1512 patients with cervical spine injury at among 33 institutions were reviewed. After the exclusion of patients without surgery or whose blood loss or ankylosis status was unclear, 793 participants were available for analysis. Differences in blood loss volume were compared between the Ankylosis (+) group with ankylosis at the cervical level and the Ankylosis (−) group without by the inverse probability of treatment weighting (IPTW) method using a propensity score. Results: Of the 779 patients (mean age: 75.0 ± 6.3 years) eligible for IPTW calculation, 257 (32.4%) had ankylosis at the cervical level. The mean blood loss volume was higher in Ankylosis (+) patients than in Ankylosis (−) patients (P < 0.001). This difference did not reach statistical significance when weighted by background factors, with mean blood loss of 244 mL and 188 mL, respectively, after adjustment. Conclusions: This study revealed that ankylosis was significantly associated with increased blood loss volume when unadjusted by surgical time. Elderly patients with cervical spine injury accompanied by ankylosis appear predisposed to higher bleeding and severe hemorrhage, both as a result of the condition and their particular demographic characteristics.

Klippel–Feil syndrome (KFS) is characterized by the congenital fusion of the cervical vertebrae and is sometimes accompanied by anomalies in the craniocervical junction. In basilar invagination (BI), which is a dislocation of the dens in an upper direction, compression of the brainstem and cervical cord results in neurological defects and surgery is required. A 16-year-old boy diagnosed with KFS and severe BI presented with spastic tetraplegia, opisthotonus and dyspnea. CT scans showed basilar impression, occipitalization of C1 and fusion of C2/C3. MRI showed ventral compression of the medullocervical junction. Posterior occipitocervical reduction and fusion along with decompression were performed. Paralysis gradually improved postoperatively over 3 weeks. However, severe spasticity and opisthotonus persisted and intrathecal baclofen (ITB) therapy was initiated. Following this, opisthotonus disappeared and spasticity of the extremities improved. Rehabilitation therapy continued by controlling the dose of ITB. Five years after the surgery, self-propelled wheelchair driving was achieved and activities of daily life improved. The treatment strategy for patients with BI and congenital anomalies remains controversial. Posterior reduction and internal fixation using instrumentation were effective techniques in this case. Spasticity control achieved through a combination of surgery and ITB treatment enabled the amelioration of therapeutic efficacy of rehabilitation and the improvement of ADL.

Objectives For older adults, dysphagia is a serious problem that can occur after spinal cord injury (SCI), but its risk factors are unclear. This study aimed to identify risk factors for dysphagia in elderly patients (≥65 years) with cervical SCI. Methods This multicenter study included 707 patients with cervical SCI (mean age 75.3 years). Univariate and multivariate analyses were conducted for patient characteristics and geriatric nutritional risk index (GNRI). Results Dysphagia occurred in 69 patients (9.8%). The significant factors were as follows: male sex (odds ratio [OR] 3.43), GNRI <92 (1.83), dementia (2.94), fracture (3.40), complete paralysis (3.61), anterior surgery (3.74), and tracheostomy (17.06). Age was not identified as a risk factor. Conclusions Low GNRI before injury was one of the independent risk factors for dysphagia after geriatric cervical SCI. GNRI represents the comprehensive nutritional status of the elderly and reflects feeding function and its recovery capacity.

Objective Elderly patients have a higher frequency of upper cervical fractures caused by minor trauma; nevertheless, the clinical differences between mid- and lower-cervical (C6–C7) injuries are unclear. The aim of this study was to compare the epidemiology of lower- and mid-cervical injuries in the elderly. Methods This multicenter, retrospective study included 451 patients aged 65 years or older who had mid- or lower-cervical fractures/dislocations. Patients' demographic and treatment data were examined and compared based on mid- and lower-cervical injuries. Results There were 139 patients (31%) with lower-cervical injuries and 312 (69%) with mid-cervical injuries. High-energy trauma (60% vs. 47%, p = 0.025) and dislocation (55% vs. 45%, p = 0.054) were significantly experienced more often by elderly patients with lower-cervical injuries than by patients with mid-cervical injuries. Although the incidence of key muscle weakness at the C5 to T1 levels were all significantly lower in patients with lower-cervical injuries than those with mid-cervical injuries, impairments at C5 occurred in 49% of them, and at C6, in 65%. No significant differences were found in the rates of death, pneumonia, or tracheostomy requirements, and no significant differences existed in ambulation or ASIA impairment scale grade for patients after 6 months of treatment. Conclusions Elderly patients with lower-cervical fractures/dislocations were injured by high-energy trauma significantly more often than patients with mid-cervical injuries. Furthermore, half of the patients with lower-cervical injuries had mid-cervical level neurological deficits with a relatively high rate of respiratory complications.

This retrospective cohort study established malnutrition’s impact on mortality and neurological recovery of older patients with cervical spinal cord injury (SCI). It included patients aged ≥ 65 years with traumatic cervical SCI treated conservatively or surgically. The Geriatric Nutritional Risk Index was calculated to assess nutritional-related risk. Overall, 789 patients (mean follow-up: 20.1 months) were examined and 47 had major nutritional-related risks on admission. One-year mortality rate, median survival time, neurological recovery, and activities of daily living (ADL) at 1 year post-injury were compared between patients with major nutrition-related risk and matched controls selected using 1:2 propensity score matching to adjust for age, pre-traumatic neurological impairment, and activity. In the Kaplan–Meier analysis, the median survival times were 44.9 and 76.5 months for patients with major nutrition-related risk and matched controls, respectively (p = 0.015). Matched controls had more individuals with a neurological improvement of American Spinal Injury Association Impairment Scale ≥ 1 grade (p = 0.039) and independence in ADL at 1 year post-injury than patients with major nutrition-related risk (p < 0.05). In conclusion, 6% of older patients with cervical SCI had major nutrition-related risks; they showed a significantly higher 1 year mortality rate, shorter survival time, poorer neurological improvement, and lower ADL at 1 year post-injury than matched controls.

Background: The usefulness and problems with lateral lumbar interbody fusion (LLIF) with a percutaneous pedicle screw (PPS) for dialysis-related spondyloarthropathy are not clear. Therefore, we investigated the usefulness and problems with LLIF with PPS in dialysis-related spondyloarthropathy. Methods: In total, 77 patients who underwent LLIF with PPS were divided into two groups: the dialysis-related spondyloarthropathy group (“Group D”) consisted of 15 patients (10 males and 5 females) with a mean age of 70.4 years and a mean duration of hemodialysis of 10.8 years; and the lumbar degenerative disease group (“Group L”) included 62 patients (31 males and 31 females) with a mean age of 71.0 years. The mean follow-up period was 4 years in Group D and 3 years 9 months in Group L. We compared surgical invasiveness (operative time, blood loss), perioperative complications, clinical outcomes (Improvement ratio of the JOA score), bone fusion rate, reoperation, sagittal alignment, and coronal imbalance between the two groups. Results: There were no significant differences in operative time, blood loss, or the improvement ratio of the JOA score, but dialysis-related spondyloarthropathy was observed in one patient with superficial infection, three patients with endplate failure, and one patient with restenosis due to cage subsidence. Conclusions: We consider LLIF with PPS for dialysis-related spondyloarthropathy to be an effective treatment option because its surgical invasiveness and clinical outcomes were comparable to those for cases of lumbar degenerative disease. However, as endplate failure due to bone fragility and a reduced bone fusion rate were observed in dialysis spondylolisthesis cases, we advise a careful selection of indications for indirect decompression as well as the application of suitable pre- and postoperative adjuvant therapies.

Study design: Retrospective cohort study. Objectives: To define the prognosis and predictive factors for neurological improvement in older patients with incomplete spinal cord injury (SCI) of American Spinal Injury Association Impairment Scale grade C (AIS-C). Settings: Multi-institutions in Japan. Methods: We included patients aged ≥65 years with traumatic SCI of AIS-C who were treated conservatively or surgically with >3 follow-up months. To identify factors related to neurological improvement, patients were divided into three groups according to their neurological status at the final follow-up, with univariate among-group comparisons of demographics, radiographic, and therapeutic factors. Significant variables were included in the multivariate logistic regression analysis. Results: Overall, 296 older patients with SCI of AIS-C on admission were identified (average age: 75.2 years, average follow-up: 18.7 months). Among them, 190 (64.2%) patients improved to AIS-D and 21 (7.1%) patients improved to AIS-E at final follow-up. There were significant among-group differences in age (p = 0.026), body mass index (p = 0.007), status of pre-traumatic activities of daily living (ADL) (p = 0.037), and serum albumin concentrations (p = 0.011). Logistic regression analysis showed no significant differences in variables in the stratified group of patients who improved to AIS-D. Meanwhile, serum albumin was a significant variable in patients who improved to AIS-E (p = 0.026; OR: 6.20, pre-traumatic ADL was omitted due to data skewness). Conclusions: Most older patients with incomplete AIS-C SCI demonstrated at least 1 grade of neurological improvement. However, <10% of patients achieved complete recovery. Key predictors of complete recovery were high serum albumin levels on admission and independent pre-traumatic ADL. Sponsorship: No funding was received for this study.

Study Design Retrospective multicenter study. Objectives The effectiveness of early surgery for cervical spinal injury (CSI) has been demonstrated. However, whether early surgery improves outcomes in the elderly remains unclear. This study investigated whether early surgery for CSI in elderly affects complication rates and neurological outcomes. Methods This retrospective multicenter study included 462 patients. We included patients with traumatic acute cervical spinal cord injury aged ≥65 years who were treated surgically, whereas patients with American Spinal Injury Association (ASIA) Impairment Scale E, those with unknown operative procedures, and those waiting for surgery for >1 month were excluded. The minimum follow-up period was 6 months. Sixty-five patients (early group, 14.1%) underwent surgical treatment within 24 hours, whereas the remaining 397 patients (85.9%) underwent surgery on a standby basis (delayed group). The propensity score-matched cohorts of 63 cases were compared. Results Patients in the early group were significantly younger, had significantly more subaxial dislocations (and fractures), tetraplegia, significantly lower ASIA motor scores, and ambulatory abilities 6 months after injury. However, no significant differences in the rate of complications, ambulatory abilities, or ASIA Impairment Scale scores 6 months after injury were observed between the matched cohorts. At 6 months after injury, 61% of the patients in the early group (25% unsupported and 36% supported) and 53% of the patients in the delayed group (34% unsupported and 19% supported) were ambulatory. Conclusions Early surgery is possible for CSI in elderly patients as the matched cohort reveals no significant difference in complication rates and neurological or ambulatory recovery between the early and delayed surgery groups.

Study Design Retrospective multicenter study. Objectives To investigate the treatments of the geriatric population with hangman’s fractures using a multicenter database under the Japan Association of Spine Surgeons with Ambition (JASA). Methods The multicenter database included data from 1512 patients. We employed the Levine and Edwards classification for categorizing hangman’s fractures. The study incorporated epidemiological data, including the prevalence of hangman’s fractures, patient age, and follow-up duration. Bony fusion rates and length of hospitalization were recorded for Type I and Type II fractures, and the degree of neurological impairment was assessed. Results Hangman’s fractures represented 62 cases, accounting for 7.4% of all cervical spine injuries. The patients had an average age of 76.6 ± 6.5 years, and the mean duration of follow-up was 21.5 ± 23.6 months. The study found that the bony fusion rate for hangman’s fractures in the geriatric population was 88.9%. Surgical treatment was associated with a shorter hospitalization period for Type II fractures compared to conservative treatment. Thirteen cases of hangman’s fractures in the geriatric population, accounting for 21%, were complicated by spinal cord injury. Conclusions This is the largest study to date on hangman’s fractures in geriatric population ≥65 years. Type I and Type II fractures, according to the Levine and Edwards classification, had a bony fusion rate of up to 90%. In patients with Type II fractures, surgical treatment led to a shorter initial hospital stay. Geriatric patients are at risk of spinal cord injury due to hangman’s fractures.

Study design: Retrospective multicenter study. Objective: The purpose of this study was to compare the prognosis of elderly patients with injuries related to cervical diffuse idiopathic skeletal hyperostosis (cDISH) to matched control for each group, with and without fractures. Methods: The current multicenter study was a retrospective analysis of 140 patients aged 65 years or older with cDISH-related cervical spine injuries; 106 fractures and 34 spinal cord injuries without fracture were identified. Propensity score-matched cohorts from 1363 patients without cDISH were generated and compared. Logistic regression analysis was performed to determine the risk of early mortality for patients with cDISH-related injury. Results: Patients with cDISH-related injuries with fracture did not differ significantly in the incidence of each complication and ambulation or severity of paralysis compared to matched controls. In patients with cDISH-related injury without fracture, those who were nonambulatory at discharge comprised 55% vs 34% of controls, indicating significantly poorer ambulation in those with cDISH-related injuries (P = .023). There was no significant difference in the incidence of complications and ambulation or paralysis severity at 6 months as compared with controls. Fourteen patients died within 3 months. Logistic regression analysis identified complete paralysis (odds ratio [OR] 36.99) and age (OR 1.24) as significant risk factors for mortality. Conclusions: The current study showed no significant differences in the incidence of complications, ambulation outcomes between patients with cDISH-related injury with fracture and matched controls, and that the ambulation at discharge for patients with cDISH-related injury without fractures were significantly inferior to those of matched controls.