OBJECTIVEThis retrospective study aimed to clarify the influence of comorbid severe knee osteoarthritis (KOA) on surgical outcome in terms of sagittal spinopelvic/lower-extremity alignment in elderly patients with degenerative lumbar spondylolisthesis (DLS).METHODSIn total, 110 patients aged at least 65 years (27 men, 83 women; mean age 74.0 years) who underwent short-segment lumbar fusion were included in the present study. Using the Kellgren-Lawrence (KL) grading system, patients were categorized into those with no to mild KOA (the mild-OA group: KL grades 0–2), moderate KOA (moderate-OA group: KL grade 3), or severe KOA (severe-OA group: KL grade 4). Surgical results were assessed using the Japanese Orthopaedic Association (JOA) scoring system, and spinopelvic/lower-extremity parameters were compared among the 3 groups. Adjacent-segment disease (ASD) was assessed over a mean follow-up period of 4.7 years (range 2–8.1 years).RESULTSThe study cohort was split into the mild-OA group (42 patients), the moderate-OA group (28 patients), and the severe-OA group (40 patients). The severe-OA group contained significantly more women (p = 0.037) and patients with double-level listhesis (p = 0.012) compared with the other groups. No significant differences were found in mean postoperative JOA scores or recovery rate among the 3 groups. The mean postoperative JOA subscore for restriction of activities of daily living was only significantly lower in the severe-OA group compared with the other groups (p = 0.010). The severe-OA group exhibited significantly greater pelvic incidence, pelvic tilt, and knee flexion angle (KFA), along with a smaller degree of lumbar lordosis than the mild-OA group both pre- and postoperatively (all p < 0.05). Overall, the rate of radiographic ASD was observed to be higher in the severe-OA group than in the mild-OA group (p = 0.015). Patients with ASD in the severe-OA group exhibited significantly greater pelvic tilt, pre- and postoperatively, along with less lumbar lordosis, than the patients without ASD postoperatively (all p < 0.05).CONCLUSIONSA lack of lumbar lordosis caused by double-level listhesis and knee flexion contracture compensated for by far greater pelvic retroversion is experienced by elderly patients with DLS and severe KOA. Therefore, corrective lumbar surgery and knee arthroplasty may be considered to improve sagittal alignment, which may contribute to the prevention of ASD, resulting in favorable long-term surgical outcomes.

Intraoperative sonography during laminoplasty appears to be very useful for evaluating spinal cord decompression status. Our original classification system based on restoration patterns of the space ventral to the spinal cord is considered to be practical for predicting neurologic improvement in cervical compressive myelopathy.

The purpose of this study was to investigate the clinical and radiological features of osteoporotic burst fractures affecting levels below the second lumbar (middle-low lumbar) vertebrae, and to clarify the appropriate surgical procedure to avoid postoperative complications. Thirty-eight consecutive patients (nine male, 29 female; mean age: 74.8 years; range: 60–86 years) with burst fractures affecting the middle-low lumbar vertebrae who underwent posterior-instrumented fusion were included. Using the Magerl classification system, these fractures were classified into three types: 16 patients with superior incomplete burst fracture (superior-type), 11 patients with inferior incomplete burst fracture (inferior-type) and 11 patients with complete burst fracture (complete-type). The clinical features were investigated for each type, and postoperative complications such as postoperative vertebral collapse (PVC) and instrumentation failure were assessed after a mean follow-up period of 3.1 years (range: 1–8.1 years). All patients suffered from severe leg pain by radiculopathy, except one with superior-type fracture who exhibited cauda equina syndrome. Nineteen of 27 patients with superior- or inferior-type fracture were found to have spondylolisthesis due to segmental instability. Although postoperative neurological status improved significantly, lumbar lordosis and segmental lordosis at the fused level deteriorated from the postoperative period to the final follow-up due to postoperative complications caused mainly by PVC (29%) and instrument failure (37%). Posterior-instrumented fusion led to a good clinical outcome; however, a higher incidence of postoperative complications due to bone fragility was inevitable. Therefore, short-segment instrument and fusion with some augumentation techniqus, together with strong osteoporotic medications may be required to avoid such complications.

Gorham’s disease is a rare disorder of unknown etiology and variable clinical presentation and is characterized by the proliferation of lymphatic vessels associated with massive regional osteolysis. Although 10 cases involving the skull and cervical spine have been reported in the literature, little is available concerning the surgical treatment of either atlantoaxial dislocation or basilar impression. Most cases have experienced universally unsuccessful treatment with bone grafts, which have led to dissolution. This case report describes the clinical course, and radiotherapeutic, medical, and surgical treatment for Gorham’s disease with basilar impression and massive osteolysis of the skull and upper cervical spine. The case of a 27-year-old man with progressive massive osteolysis of the skull and cervical spine is reported. Multiple surgical treatments to decompress the spinal cord and stabilize the skull and upper cervical spine with autologous fibular grafts were performed in order to prevent the progression of atlantoaxial dislocation and basilar impression. Pathologically, radiotherapy failed to show any effect. The efficacy of antiresorptive therapy with bisphosphonates could not be confirmed either clinically or radiologically. Although solid bone fusion was not obtained, the patient has achieved a satisfactory functional outcome and remains completely active after repeated surgeries. Surgical treatment is extremely difficult in cases of Gorham’s disease involving the skull and upper cervical spine. Fibular bone grafts seem to show resistance to erosion to osteolytic tissue.

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