Preoperative Upright Research Articles

P150. Optimizing lower instrumented vertebra selection in adult idiopathic scoliosis using preoperative upright and supine last touched vertebra

P150. Optimizing lower instrumented vertebra selection in adult idiopathic scoliosis using preoperative upright and supine last touched vertebra

Total hip arthroplasty in patients with vertebral compression fracture is associated with poor clinical outcomes – retrospective analysis on 453 cases

PurposeTotal hip arthroplasty (THA) is increasingly performed in older adults, and the prevalence of vertebral compression fracture (VCF) increases with age. We aimed to investigate the clinical outcomes of THA in patients with VCF.MethodsWe reviewed the records of 453 patients who underwent THA at our institution between 2015 and 2021. We classified patients into those with and without VCF. VCF was identified using preoperative upright whole-spine radiographs. Spinal parameters, preoperative and 1-year postoperative clinical outcomes of the Harris hip score (HHS), Oxford hip score (OHS), and visual analog scale (VAS) for low back pain (LBP) were assessed. Furthermore, propensity score-matched cohorts for age, sex, body mass index, and spinal parameters were created, and the clinical outcomes were compared between the two groups.ResultsAmong the 453 patients, 51 (11.3%) with VCF and 402 without VCF were identified. Before matching, patients with VCF were older (p < 0.01), had sagittal spinal imbalance (p < 0.01), and had worse clinical outcomes pre- and postoperatively. After matching 47 patients in both groups, patients with VCF had worse HHS (p < 0.05), especially regarding support and distance walked, and worse VAS scores for LBP (p < 0.05) pre- and postoperatively. However, the improvements in scores were not significantly different between the groups.ConclusionsHHS, especially regarding support and distance walked, and VAS scores for LBP were poorer in patients with VCF preoperatively and 1-year postoperatively. Our findings suggest that hip surgeons should evaluate not only spinal alignment but also the presence of VCF before performing THA.Level of evidenceLevel III, Retrospective cohort study.

A New Preoperative Upright Design for Dermatochalasis Correction.

Conventional assessment of the height of upper eyelid skin excision in dermatochalasis correction is performed with patient's eyes closed in supine position. It is not able to consider the effects of gravity on the upper eyelid, thus may lead to asymmetric postoperative appearance. The authors herein report a novel preoperative upright design (PUD) that can accurately determine the amount of skin excision with patients' eyes open in dermatochalasis correction. Patients with dermatochalasis underwent PUD during blepharoplasty were enrolled and were followed-up for 9 to 15 months. A total of 116 patients (mean age 55.1 ± 6.1 years, range 46-78 years) successfully underwent the surgery. Using the PUD, the vertical height of skin excision was 8.2 ± 2.4 mm (6-19 mm), the preoperative margin fold distance was -0.5 ± 1.0 mm (-4 - 1 mm), which improved to 2.1 ± 0.6 mm (1-3 mm, P < 0.05) at the last follow-up visit. A total of 107 of 116 patients (92.2%) were judged as "good" (natural double eyelid folds with symmetric margin fold distance), 9 patients (7.8%) were judged as "fair" (natural double eyelid folds with the differences of margin fold distance between fellow eyelids within 2 mm), and no one was judged as "poor" (unsmooth double eyelid folds or the differences of margin fold distance between fellow eyelids is more than 2 mm). Preoperative upright design is a simple and effective method to accurately determine the amount of skin excision in blepharoplasty, and help to achieve symmetric double eyelids.

Effect of patient position on the lordosis and scoliosis of patients with degenerative lumbar scoliosis.

This study aimed to analyze the effect of patient positions on the lordosis and scoliosis of patients with degenerative lumbar scoliosis (DLS).Seventy-seven patients with DLS were retrospectively analyzed. We measured lordosis and Cobb's angle on preoperative upright x-rays and magnetic resonance imagings in supine position. The lordosis and scoliosis of surgical segments in intraoperative prone position were measured on intraoperative radiographs of 20 patients to compare with that in standing position. Paired t tests were performed to investigate the parameters of the sample.From standing to supine position the whole lordosis increased (29.2 ± 15.7 degree vs. 34.9 ± 11.2 degree), and the whole scoliosis decreased (24.3 ± 11.8 degree vs. 19.0 ± 10.5 degree); 53 of 77 (68.8%) cases had increased lordosis, and 67 of 77 (87%) cases had decreased scoliosis. The lordosis of surgical segments in standing position had no difference with that in intraoprerative prone position. But in changing from supine/standing position to intraoprerative prone position, the scoliosis of surgical segments decreased (14.7 ± 9.4 degree vs. 11.4 ± 7.0 degree; 19.0 ± 11.8 degree vs. 11.4 ± 7.0 degree, respectively), and 18 of 20 (90%) cases had decreased scoliosis in intraoperative prone position than that in standing position.Compared with standing position in DLS patients, supine position increased lordosis and reduced scoliosis, and intraoperative prone position reduced scoliosis significantly. When evaluating the severity of DLS and making preoperative surgical plans, lumbar lordosis in supine position should also be evaluated in addition to upright x-ray, and the effects of different positions should be taken into consideration to reduce deviation.

Lumbar Lordosis of Spinal Stenosis Patients during Intraoperative Prone Positioning.

BackgroundTo evaluate the effect of spondylolisthesis on lumbar lordosis on the OSI (Jackson; Orthopaedic Systems Inc.) frame. Restoration of lumbar lordosis is important for maintaining sagittal balance. Physiologic lumbar lordosis has to be gained by intraoperative prone positioning with a hip extension and posterior instrumentation technique. There are some debates about changing lumbar lordosis on the OSI frame after an intraoperative prone position. We evaluated the effect of spondylolisthesis on lumbar lordosis after an intraoperative prone position.MethodsSixty-seven patients, who underwent spinal fusion at the Department of Orthopaedic Surgery of Gwangmyeong Sungae Hospital between May 2007 and February 2012, were included in this study. The study compared lumbar lordosis on preoperative upright, intraoperative prone and postoperative upright lateral X-rays between the simple stenosis (SS) group and spondylolisthesis group. The average age of patients was 67.86 years old. The average preoperative lordosis was 43.5° (± 14.9°), average intraoperative lordosis was 48.8° (± 13.2°), average postoperative lordosis was 46.5° (± 16.1°) and the average change on the frame was 5.3° (± 10.6°).ResultsAmong all patients, 24 patients were diagnosed with simple spinal stenosis, 43 patients with spondylolisthesis (29 degenerative spondylolisthesis and 14 isthmic spondylolisthesis). Between the SS group and spondylolisthesis group, preoperative lordosis, intraoperative lordosis and postoperative lordosis were significantly larger in the spondylolisthesis group. The ratio of patients with increased lordosis on the OSI frame compared to preoperative lordosis was significantly higher in the spondylolisthesis group. The risk of increased lordosis on frame was significantly higher in the spondylolisthesis group (odds ratio, 3.325; 95% confidence interval, 1.101 to 10.039; p = 0.033).ConclusionsIntraoperative lumbar lordosis on the OSI frame with a prone position was larger in the SS patients than the spondylolisthesis patients, which also produced a larger postoperative lordosis angle after posterior spinal fusion surgery. An increase in lumbar lordosis on the OSI frame should be considered during posterior spinal fusion surgery, especially in spondylolisthesis patients.

Difference in nasolabial features between awake and asleep infants with unilateral cleft lip: Anthropometric measurements using three-dimensional stereophotogrammetry.

Cleft lip repair is performed in the supine position, tilting the head back under general anesthesia. However, postoperative results are evaluated in the upright position while patients are awake. The purpose of this study was to anthropometrically assess whether nasolabial features of infants with unilateral cleft lip are influenced by posture and anesthesia. Three-dimensional facial images in a preoperative upright position and operating supine position under general anesthesia were captured from 51 consecutive infants with unilateral cleft lip. Twenty-four indirect anthropometric measurements (11 for the nose and 13 for the lip elements) were considered on each infant. In the supine position under general anesthesia, alar surface distance was significantly shorter (p<0.001). Regarding lip measurements, medial lip height of the cleft side and philtrum height were significantly smaller (p<0.05 and p<0.05, respectively), whereas vermilion height was greater (p<0.01). In addition, the cleft width and lip width were significantly broader (p<0.001 and p<0.001, respectively) after general anesthesia. Several nasolabial alteration patterns are found after general anesthesia that are presumably attributable to cessation of nasal breathing and the action of muscle relaxation. Surgeons should take these nasolabial changes into account during preoperative planning and postoperative assessment.

Airway management of an ankylosing spondylitis patient with severe temporomandibular joint ankylosis and impossible mouth opening

Airway management of an ankylosing spondylitis patient with severe temporomandibular joint ankylosis and impossible mouth opening

Lumbar facet joint effusion in MRI: a sign of instability in degenerative spondylolisthesis?

The term "segmental instability" of the lumbar spine is not clearly defined, especially as it relates to degenerative spondylolisthesis (DS) and rotational translation (RT). We investigated whether facet joint effusion on conventional supine MRI indicated increased abnormal motion in DS and RT. 160 patients (119 female, 41 male, mean age 68.8 years, range 38.8-89.3 years) who had undergone decompression only or decompression with instrumented fusion for degenerative spondylolisthesis with different degrees of narrowing of the spinal canal were identified retrospectively from our spine surgery database. All had preoperative upright X-rays in AP and lateral views as well as supine MRI. The imaging studies were assessed for the following parameters: percent of slippage, absolute value of facet joint effusion, facet angles, degree of facet degeneration and spinal canal central narrowing, disc height, presence of facet cysts and the presence of rotational translation in the AP X-ray. 40/160 patients showed no facet joint effusion, and in these the difference in the values for the % slip on upright X-ray and % slip on supine MRI was ≤3%. A further 12 patients also showed a difference ≤3%, but had some fluid in the joints (0.44 ± 0.38 mm). In 108 patients, the difference in the % slip measured on X-ray and on MRI was >3% (mean 10.6%, range 4-29%) and was associated with a mean facet effusion size of 2.15 ± 0.85 mm. The extent of effusion correlated significantly with the relative slippage difference between standing and supine positions (r = 0.64, p < 0.001), and the extent of the left/right difference in effusion was associated with the presence of rotational translation (RT 1.31 ± 0.8 mm vs. no-RT 0.23 ± 0.17 mm, p < 0.0001). Facet joint effusion is clearly correlated with spontaneous reduction of the extent of slippage in the supine position compared to the upright position. Also, the greater the difference in right and left facet effusion, the higher the likelihood of having a RT. Future studies should assess whether analysis of facet joint effusion measured on routine MRI can help in decision-making regarding the optimal surgical treatment to be applied (decompression alone or combined with fusion).

Increasing Lumbar Lordosis of Adult Spinal Deformity Patients via Intraoperative Prone Positioning

A retrospective evaluation. To evaluate the change in lumbar lordosis in spinal deformity patients who underwent an instrumented posterior spinal fusion on the Orthopedic Systems Inc. (OSI) "Jackson" frame. Intraoperative prone positioning with hip extension may posturally increase lumbar lordosis during adult spinal deformity reconstructive surgery, as has been shown in adult lumbar degenerative surgery. Radiographs of 44 operative spinal deformity patients (43 females/1 male; mean age, 57.4 years) were analyzed. Diagnoses included idiopathic scoliosis (29), degenerative lumbar scoliosis (9), and other (6). Total lumbar lordosis (T12-S1), segmental disc angles, and C7 plumbline were measured on preoperative upright and supine, intraoperative prone, and postoperative upright lateral radiographs. All patients were positioned intraoperatively with hip extension on the OSI frame. Average preoperative upright and supine, intraoperative prone, and postoperative upright lumbar lordosis (T12-SAC) measurements were -38.1 degrees, -46.0 degrees, -46.2 degrees, and -51.8 degrees, respectively (P < 0.05 for preoperative upright to all other comparisons). Two groups were noted: those with increased lumbar lordosis (>5 degrees) during intraoperative prone positioning (n = 25, increased lordosis group) as compared to the preoperative measurement versus those with minimal to no change in lordosis (< or =5 degrees) during intraoperative prone positioning (n = 19, unchanged lordosis group). The corresponding lumbar lordosis measurements for the increased lordosis group were -25.9 degrees, -40.0 degrees, -43.1 degrees, and -48.9 degrees (P < 0.05 for preoperative upright to all other comparisons). The corresponding lumbar lordosis measurements for the unchanged lordosis group were -54.2 degrees, -53.8 degrees, -50.3 degrees, and -55.7 degrees (no significant differences). Preoperative upright lumbar lordosis in the unchanged lordosis group was substantially higher than increased lumbar lordosis group (P < 0.05). Adult spinal deformity patients with preoperative hypolordosis who were positioned prone during reconstructive surgery had an enhanced lumbar lordosis via positioning alone compared with theirpreoperative upright radiographs. Conversely, those with substantial preoperative lordosis remained unchanged with intraoperative prone positioning. This knowledge will help in the surgical planning of adult spinal deformity reconstructive surgery to optimize sagittal alignment and balance.

Preoperative gastric emptying and patterns of reflux as predictors of outcome after laparoscopic fundoplication

Some studies have suggested that patients with predominantly upright reflux have a poor outcome after laparoscopic antireflux surgery. It has been proposed that this might be related to gastric emptying. The aim of this study was to evaluate the relationship between preoperative upright reflux pattern, gastric emptying rate and outcome after laparoscopic fundoplication. Patients presenting for antireflux surgery underwent 24-h ambulatory pH testing and dual-isotope radionuclide gastric emptying studies. Reflux pattern was determined by the acid exposure in the distal oesophagus (percentage of time at pH < 4) during supine and upright posture. Outcome after fundoplication was assessed by a standardized postal questionnaire administered at 3 months, and 1, 2 and 5 years after surgery. Of 372 patients identified from a prospectively maintained database, 109 had upright reflux, 57 supine reflux and 206 bipositional reflux. Overall patient satisfaction was not influenced by reflux pattern at any time after surgery. Delayed gastric emptying was documented in 31.0 per cent of patients, but there was no relationship with reflux pattern. Patients with upright reflux did not have a less favourable outcome after fundoplication. Categorizing patients according to reflux pattern is of no value in predicting outcome or selecting patients for surgery.

Analysis of the Lowest Instrumented Vertebra Following Anterior Spinal Fusion of Thoracolumbar/Lumbar Adolescent Idiopathic Scoliosis: Can We Predict Postoperative Disc Wedging?

A retrospective radiographic study. To investigate which radiographic parameters correlate best to ultimate lowest instrumented vertebra (LIV) position and subjacent disc wedging following anterior spinal fusion (ASF) for thoracolumbar/lumbar (TL/L) adolescent idiopathic scoliosis (AIS). In an ASF of TL/L AIS, part of the operative goals are often to horizontalize and centralize the LIV, or potentially minimize subjacent disc wedging after surgery. To our knowledge, no study has investigated the specific radiographic parameters involved with obtaining these goals. Sixty-one patients with TL/L AIS were treated with an instrumented ASF with a minimum 2-year follow-up. Preoperative and postoperative radiographs were examined measuring various radiographic parameters of the curve itself along with the LIV and subjacent disc. Specific correlation of these parameters to the coronal disc angle immediately below the LIV (disc angle), LIV translation, and global coronal balance (C7-CSVL distance) at 2 years postoperative was analyzed, respectively. The preoperative disc angle was 4.49 degrees +/- 5.48 and postoperative -5.85 degrees +/- 4.37. The change of the disc angle was significantly correlated to the LIV level relative to the preoperative lower end vertebra (LEV) (P < 0.006). Regressive analysis demonstrated the correlative parameters to the postoperative disc angle to be: preoperative upright disc angle; preoperative apex-LIV distance; and preoperative T12-LIV lordosis (P < 0.0001, r2 = 0.51). The correlative parameters to postoperative LIV translation were preoperative LIV translation and preoperative LIV rotation (P = 0.002, r2 = 0.2). The correlative parameter to postoperative C7-CSVL distance was only preoperative C7-CSVL distance (P < 0.0001, r2 = 0.3). Postoperative subjacent disc wedging occurs most often when the preoperative subjacent disc is nearly parallel and when a shorter fusion excluding the LEV is performed. Preoperative LIV rotation significantly correlates to postoperative LIV translation. Surgeons should note these preoperative predictive factors to optimize radiographic results of the operative treatment of TL/L AIS.

呼吸管理を考える 肺合併症（特にＭａｓｓｉｖｅ ａｔｅｌｅｃｔａｓｉｓ）の予防ならびに治療 選択的左右別気管支内吸引について

This prospective study was designed to survey the incidence, prevention and treatment of massive atelectasis in 1222 consecutive patients following upper abdominal surgery. The massive atelectasis was assessed by radiologically.Following perioperative examinations were undertaken: 1. Pulmonary function test except emergency case. 2. Preoperative upright and supine chest x-ray. Supine chest x-ray was taken before extubation and at 24, 48, 72 and every day or every two days thereafter unless required frequently. 3. Blood gases were analysed preoperative, operative and postoperative period when indicated. 4. Frequent and close auscultation of the chest.Preventive measures were as follows: 1. Preoperative deep breathing exercise by tissue paper breathing method and coughing exercise. 2. Coughing and selective bronchial suctioning using a curved tipped catheter with a guide mark during operation and before extubation. 3. Encouraging deep breathing by tissue paper breathing method and coughing postoperatively. We did not use IPPB nor incentive spirometer. The chest x-ray was taken and blood gases were analysed when the breath sound did not improved by above mentioned measures (2 and 3) or when indicated.Following treatments were performed. 1. Vigorous tracheal compression. 2. Transtracheal injection. 3. Selective bronchial suctioning following endotracheal intubation, when the breath sound did not improved by 1 and 2 procedures or atelectasis was assessed by the chest x-ray.Results: No atelectasis was found at the end of operation. Five atelectasis occurred in 5 out of 1222 patients. Two cases of atelectasis occurred among 81 cases of emergency. One case was treated by vigorous external tracheal compression and another one case was treated by transtracheal injection. The rest of three cases was treated by selective bronchial suctioning following endotracheal intubation. We did not use bronchofiber scope in this study.We found that important preventive measures were frequent and close auscultation of the chest, coughing and selective bronchial suctioning during operation and bofore extubation. In the postoperative period, encouraging deep breathing and coughing were also important measures of prevention. The important procedures of treatment were external tracheal compression, transtracheal injection and selective bronchial suctioning following intubation. The proper techniques of selective bronchial suctioning was described.