古矢 丈雄

BACKGROUND: Ossification of the posterior longitudinal ligament of the spine (OPLL) is characterized by heterotopic bone formation in the posterior longitudinal ligament of the spine. Although the patients with OPLL are more common in the 60s and 70s, we know that there are markedly young patients (e.g., early 40s). However, to the best of our knowledge, there is few reports characterize young patients with cervical OPLL in terms of the imaging features, subjective symptoms, and ADL problems. METHODS: This is the multicenter cross-sectional study. Two hundred and thirty-seven Japanese symptomatic patients with cervical OPLL confirmed by standard X-rays collected from 16 institutions belonging to the Japanese Multicenter Research Organization for Ossification of the Spinal Ligament formed by the Japanese Ministry of Health, Labor and Welfare were recruited. Whole spine CT data as well as demographic data such as age, gender, patients-based evaluations, and the 36-item Short Form Health Survey (SF-36) were evaluated. RESULTS: Young group (≦ 45 years old) consisted of 23 patients (8 females and 15 males), accounting for 9.7% of the total. Their characteristics were high body mass index (BMI), significant involvement of trauma in the onset and deterioration of symptoms, and the predominance of thoracic OPLL. The patient-based evaluations did not show a significant difference between the young and non-young groups, or between the genders in the young group except for bodily pain (BP) of SF-36. Female patients in young group had significantly lower BP score of SF-36 than that of male in young group. CONCLUSIONS: Characteristics of young patients with cervical OPLL were high BMI, significant involvement of trauma in the onset and deterioration of symptoms, lower BP score of SF-36 in female, and the predominance of thoracic OPLL.

腰痛患者では複合的な疼痛要素が関与する可能性があり,下肢痛・臀部痛の存在が神経障害性疼痛の可能性を示唆する。2019年に発刊された腰痛診療ガイドライン改訂版では日常診療を反映した実践的ガイドラインとしての編纂がなされた。薬物治療の項では初版の急性・慢性腰痛に加えて坐骨神経痛が加味された。慢性腰痛を中心に有効性が述べられた運動療法は,近年広まりつつあるサルコペニアの概念とともに注目を浴びており,今後のさらなる研究が待たれる。(著者抄録)

Objective: In recent years, there has been an increase in research on the therapeutic effects of exergaming, but there have been few studies on these types of interventions for chronic low back pain. In this study, we hypothesized that the Nintendo Ring Fit Adventure (RFA) exergame would be effective for patients with chronic low back pain, and we conducted a randomized prospective longitudinal study.Materials and Methods: Patients with chronic low back pain were included in this study. Twenty randomly selected patients (9 males and 11 females, mean age 49.3 years) were included in the RFA group, and RFA exergaming was performed once a week for 40 minutes for 8 weeks. Twenty patients (12 males and 8 females, mean age 55.60 years) served as the control group and received oral treatment for 8 weeks. Pain and psychological scores (pain self-efficacy, pain catastrophizing, and kinesiophobia) were measured and analyzed before and after 8 weeks of treatment in both groups.Results: In the RFA group, low back pain, buttock pain, and pain self-efficacy were significantly improved after 8 weeks of RFA exergaming, but there was no significant improvement in lower limb numbness, pain catastrophizing, or kinesiophobia. In the control group, no significant improvement was observed after 8 weeks of oral treatment.Conclusion: RFA exergaming increased pain self-efficacy and reduced pain in patients with chronic low back pain. Future treatment protocols should be developed to improve pain self-efficacy.

BACKGROUND: Degenerative cervical myelopathy (DCM) can significantly impair a patient's quality of life (QOL). In this study, we aimed to identify predictors associated with QOL improvement after surgery for DCM. METHODS: This study included 148 patients who underwent surgery for DCM. The European QOL-5 Dimension (EQ-5D) score, the Japanese Orthopedic Association for the assessment of cervical myelopathy (C-JOA) score, and the Nurick grade were used as outcome measures. Radiographic examinations were performed at enrollment. The associations of baseline variables with changes in EQ-5D scores from preoperative to 1-year postoperative assessment were investigated using a multivariable linear regression model. RESULTS: The EQ-5D and C-JOA scores and the Nurick grade improved after surgery (P < 0.001, P < 0.001, and P < 0.001, respectively). Univariable analysis revealed that preoperative EQ-5D and C-JOA scores were significantly associated with increased EQ-5D scores from preoperative assessment to 1 year after surgery (P < 0.0001 and P = 0.045). Multivariable regression analysis showed that the independent preoperative predictors of change in QOL were lumbar lordosis (LL), sacral slope (SS), and T1 pelvic angle (TPA). According to the prediction model, the increased EQ-5D score from preoperatively to 1 year after surgery = 0.308 - 0.493 × EQ-5D + 0.006 × LL - 0.008 × SS + 0.004 × TPA. CONCLUSIONS: Preoperative LL, SS, and TPA significantly impacted the QOL of patients who underwent surgery for DCM. Less improvement in QOL after surgery was achieved in patients with smaller LL and TPA and larger SS values. Patients with these risk factors may therefore require additional support to experience adequate improvement in QOL.

The aim of this study was to determine whether advanced glycation end products (AGEs) revealed by skin autofluorescence (SAF), serum and urine pentosidine level, and serum homocysteine level can serve as a biomarker for sarcopenia in older women. The participants were 70 elderly women. The AGEs pentosidine, homocysteine, and SAF were measured as aging markers. This study shows that among the biomarkers for aging, serum pentosidine correlates with a loss of appendicular lean mass and can serve as a biomarker for sarcopenia. Moreover, SAF and homocysteine values exhibited a positive correlation with age and correlated with each other.Abbreviations: AGEs: advanced glycation end products; BIA: bioelectrical impedance analyzer; BMD: bone mineral density; DLS: degenerative lumbar scoliosis; DXA: dual-energy X-ray absorptiometry; ELISA: enzyme-linked immunoassay; HHcy: hyperhomocysteinemia; RIA: radioimmunoassay; SAF: skin autofluorescence; SMI: skeletal muscle mass index; T2DM: type 2 diabetes patients.

＜文献概要＞既存椎体骨折は将来の椎体骨折を4倍,またすべての骨折リスクを2倍に高めるとも報告されている。すなわち,骨粗鬆症性椎体骨折受傷直後から骨折の連鎖を止めるための薬物治療(二次骨折予防)を開始することが必須である。そこで本稿では,骨粗鬆症性椎体骨折に対する薬物療法について,(1)骨折の連鎖を止めるための薬物治療(二次骨折予防),(2)術前後の薬物治療(骨癒合促進)の2つの観点から概説する。

われわれ痛み診療に従事する医師にとって、骨粗鬆症と腰痛は非常に密接した病態であり、それらの機序を正確に理解することが診断および治療の観点から非常に重要である。骨粗鬆症患者が腰痛を訴える原因として、(1)骨折、(2)骨粗鬆化、(3)サルコペニア、(4)酸化ストレスの4つが注目されている。重要な点は、これらの原因は独立して存在するのではなく、お互いが重複して存在することが多いということである。このことを常に念頭に置き、腰痛のある骨粗鬆症患者を診察、治療していくことが重要であると考える。(著者抄録)

腰痛の予防においては、初発発生率の抑制、慢性化・悪化の防止、再発予防などが基本的な概念となる。健康的な生活を送るよう心がけることや理想体重の維持など生活習慣改善は腰痛予防に寄与し、運動療法は腰痛予防に有用である。運動療法による腰痛予防は「腰への負担をかけない姿勢や動作を取ること」や「筋力トレーニングやストレッチなどの体操を行うこと」を習慣づけ日常生活での姿勢改善と体幹筋筋力と筋持久力を回復することが重要である。また、腰痛予防や治療には日々新しいアイデアが創出され、昨今ではフィットネスゲームを腰痛改善を含む健康増進に役立てるexergamingも腰痛予防・治療の手段として報告されている。(著者抄録)

＜文献概要＞はじめに 後彎症は脊柱アライメント異常を呈する疾患であるが,加齢とともに増悪する傾向があり患者の生活の質(QOL)を著しく阻害することは周知の事実である.具体的には後彎変形による歩行能力低下に起因した日常生活動作(ADL)低下および持続的な慢性背筋疲労による難治性腰痛が臨床的な問題である.これらの症状は治療抵抗性(リハビリテーション介入や鎮痛薬を含めた薬剤介入など多くの保存的治療が無効)であることもよく知られている.一方で,近年ではこのような病態に対する手術的治療法の有効性が報告されているが,侵襲が大きすぎる点と高額の医療費がかかる点からスタンダードな治療法になるにはいたっていない.すなわち高齢社会を迎え患者数は年々増大しているが,その対策は後手に回っているといえる.そこで本稿では,高齢者後彎症の(1)病態メカニズム,(2)治療戦略に関する最新の知見について概説する.

We investigated the relationship between trunk muscle mass and spinal pathologies by gender. This multicenter cross-sectional study included patients aged ≥ 30 years who visited a spinal outpatient clinic. Trunk and appendicular muscle mass were measured using bioelectrical impedance analysis. The Oswestry Disability Index (ODI), visual analog scale (VAS) score for low back pain, sagittal vertical axis (SVA), and EuroQol 5 Dimension (EQ5D) score were investigated to evaluate spinal pathology. The association between trunk muscle mass and these parameters was analyzed by gender using a non-linear regression model adjusted for patients' demographics. We investigated the association between age and trunk muscle mass. We included 781 men and 957 women. Trunk muscle mass differed significantly between men and women, although it decreased with age after age 70 in both genders. Lower trunk muscle mass was significantly associated with ODI, SVA, and EQ5D score deterioration in both genders; its association with VAS was significant only in men. Most parameters deteriorated when trunk muscle mass was < 26 kg in men and < 19 kg in women. Lower trunk muscle mass was associated with lumbar disability, spinal imbalance, and poor quality of life in both genders, with significant difference in muscle mass.

畳み込みニューラルネットワーク(CNN)を用いてMRIによる神経鞘腫と髄膜腫の鑑別を行った。当院で腫瘍摘出術を受けた硬膜内髄外脊髄腫瘍患者(神経鞘腫50人、髄膜腫34人)を対象とした。T2強調像および造影T1強調像に基づくCNNのROC曲線のAUCはそれぞれ0.88および0.87であった。2人の放射線科医の感度はT2強調像と造影T1強調像の両方でCNNの感度よりも優れていた。特異度においては、CNNがT2強調像の2人の放射線科医よりも良好であり、造影T1強調線でも同様の傾向がみられたが有意差はなかった。CNNの正確度はT2強調像で放射線科医よりも優れている傾向にあったが、造影T1強調像では正確度は同等であった。本研究のCNNは経験豊富な放射線科医の鑑別能に匹敵する高い鑑別能で脊髄神経鞘腫と髄膜腫を識別することができた。

STUDY DESIGN: Retrospective observational study. PURPOSE: Lumbar spinal stenosis (LSS) has traditionally been evaluated morphologically, there is a paucity of literature on quantitative assessment of LSS. The purpose of this study was to investigate whether intraspinal diffusion tensor imaging (DTI) parameters such as apparent diffusion coefficient (ADC) and fractional anisotropy (FA) are useful for assessing LSS. OVERVIEW OF LITERATURE: Quantitative assessment of LSS is challenging. METHODS: Study participants comprised five healthy volunteers (mean age, 27.2 years) and 27 patients with LSS (mean age, 58.4 years) who were individually assessed using 3.0 Tesla magnetic resonance imaging. Intraspinal ADC and FA values of 10 intervertebral discs from healthy volunteers and 52 intervertebral discs from LSS patients were measured. Also, intraspinal canal area, Schizas classification (A: normal, B: mild stenosis, C: severe stenosis) and correlations with symptoms were investigated. Clinical symptoms were checked for the presence of low back pain (LBP), intermittent claudication (IMC), and bladder and bowel dysfunction (BBD). RESULTS: Compared to healthy individuals, LSS patients had significantly lower ADC (p<0.05) and significantly higher FA values (p<0.01). In Schizas classification, stenosis worsened from A to C. ADC values decreased significantly while FA values increased significantly in that order (p<0.05). A positive correlation was found between intraspinal canal area and ADC values (r=0.63, p<0.01) and a negative correlation between intraspinal canal area and FA values (p=-0.61, p<0.01). No correlations were noted between LBP and ADC or FA values. On the other hand, ADC values were significantly lower (p<0.05) and FA values were significantly higher (p<0.05) in patients with IMC or BBD. CONCLUSIONS: Intraspinal DTI parameters such as ADC and FA values were associated with the Schizas classification, intraspinal canal area, and clinical symptoms, suggesting that ADC and FA may be useful for quantitative assessment of LSS.

肺癌骨転移例で、主科(呼吸器内科または呼吸器外科)から当科に対して骨生検検体による遺伝子検索の依頼があった9例10検体の検索結果を報告した。検体採取部位の内訳は、腰椎椎弓根が4検体、腸骨3検体、胸椎椎弓根2検体、胸椎横突起1検体であった。病変の組織採取ができたのは9検体で、いずれも病理組織学的に癌細胞が確認された。病変組織を採取できなかった1検体は、骨修飾薬投与に伴う病変部の骨硬化が強いため生検針を病変に到達させることができなかった。遺伝子検査を実施した9検体中4検体にEGFR遺伝子変異が認められ、うち2例はT790Mが陽性であった。9例とも骨生検結果の報告後に主科で治療方針の検討が行われ、T790M陽性の2例はいずれも抗悪性腫瘍薬がゲフィチニブからオシメルチニブメシル酸塩へ変更となった。

This study examined the factors that inhibit the therapeutic effects of cognitive behavioral therapy (CBT) and clarify the adaptation judgment criteria of CBT. We included patients with chronic low back pain and allocated them to the adaptation (with visual analog scale [VAS] improvement) or non-adaptation group (without VAS improvement). The patients were analyzed using various psychological tests. CBT improved depressive symptoms and catastrophic thinking; however, they were not correlated with the VAS and did not directly affect low back pain improvement. The non-adaptation group showed an unexplainable/vague sense of anxiety; an excessive focus on searching for pain; a strong intimacy desire; a strong tendency of medical dependency; and fantasy or distortion of the actual experience, especially self-image. Moreover, the patients showed a low ability to objectively express or attribute meaning to pain due to poor language skills, attention-deficit hyperactivity disorder, and emotional value judgment. Individuals with the aforementioned characteristics of pre-CBT psychological tests should select a different treatment approach given the high poor-adaption possibility. Even patients with depressive or anxious symptoms are not necessarily adaptable for CBT. Therefore, pre-CBT tests for treatment suitability are necessary. Future studies should establish a protocol for psychotherapy suitable for the non-adaptation group.

BACKGROUND: Anterior decompression with fusion (ADF) has often been performed for degenerative cervical myelopathy (DCM) in patients with poor cervical spine alignment and/or anterior cord compression. We aimed to identify clinical and radiological predictors associated with neurological recovery after ADF. METHODS: This post-hoc analysis from a prospective multicenter study included patients who were scheduled for ADF for DCM. The patients who received other surgeries (laminoplasty, posterior decompression and fusion) were excluded. The associations between baseline clinical and radiographic variables (age, sex, body mass index, etiology, cervical lordosis, range of motion, C7 slope, C2-7 sagittal vertical axis [SVA], thoracic kyphosis [TK], lumbar lordosis, sacral slope, SVA, pelvic tilt, T1 pelvic angle [TPA], the Japanese Orthopedic Association score for the assessment of cervical myelopathy [C-JOA], European Quality of Life Five Dimensions Scale [EQ-5D], Neck Disability Index [NDI], Physical Component Summary of the SF-36 [PCS], and Mental Component Summary of the SF-36) and the recovery rates as the outcome variables were investigated in the univariate regression analysis. Then, the independent predictors for increased recovery rates were evaluated using a stepwise multiple regression analysis. RESULTS: In total, 37 patients completed the 1 year follow-up. The recovery rate was significantly correlated with SVA (p = 0.001) and TPA (p = 0.03). Univariate regression analyses showed that age (Regression coefficient = - 0.92, p = 0.049), SVA (Regression coefficient  = - 0.57, p = 0.004) and PCS (Regression coefficient = 0.80, p = 0.03) score were significantly associated with recovery rate. Then, a stepwise multiple regression analysis identified the independent predictors of recovery rate after ADF as TK (p = 0.01), PCS (p = 0.03), and SVA (p = 0.03). According to this prediction model, the following equation was obtained: recovery rate = - 8.26 + 1.17 × (TK) - 0.45 × (SVA) + 0.85 × (PCS) (p = 0.002, R2 = 0.44). CONCLUSION: Patients with lower TK, lower PCS score, and higher SVA were more likely to have poor neurological recovery after ADF. Therefore, patients with DCM and these predictors who undergo ADF should be warned about poor recovery and be required to provide adequate informed consent.

Attenuation of the secondary injury of spinal cord injury (SCI) can suppress the spread of spinal cord tissue damage, possibly resulting in spinal cord sparing that can improve functional prognoses. Granulocyte colony-stimulating factor (G-CSF) is a haematological cytokine commonly used to treat neutropenia. Previous reports have shown that G-CSF promotes functional recovery in rodent models of SCI. Based on preclinical results, we conducted early phase clinical trials, showing safety/feasibility and suggestive efficacy. These lines of evidence demonstrate that G-CSF might have therapeutic benefits for acute SCI in humans. To confirm this efficacy and to obtain strong evidence for pharmaceutical approval of G-CSF therapy for SCI, we conducted a phase 3 clinical trial designed as a prospective, randomized, double-blinded and placebo-controlled comparative trial. The current trial included cervical SCI [severity of American Spinal Injury Association (ASIA) Impairment Scale (AIS) B or C] within 48 h after injury. Patients are randomly assigned to G-CSF and placebo groups. The G-CSF group was administered 400 mu g/m(2)/day x 5 days of G-CSF in normal saline via intravenous infusion for five consecutive days. The placebo group was similarly administered a placebo. Allocation was concealed between blinded evaluators of efficacy/safety and those for laboratory data, as G-CSF markedly increases white blood cell counts that can reveal patient treatment. Efficacy and safety were evaluated by blinded observer. Our primary end point was changes in ASIA motor scores from baseline to 3 months after drug administration. Each group includes 44 patients (88 total patients). Our protocol was approved by the Pharmaceuticals and Medical Device Agency in Japan and this trial is funded by the Center for Clinical Trials, Japan Medical Association. There was no significant difference in the primary end point between the G-CSF and the placebo control groups. In contrast, one of the secondary end points showed that the ASIA motor score 6 months (P=0.062) and 1 year (P=0.073) after drug administration tend to be higher in the G-CSF group compared with the placebo control group. Moreover, in patients aged over 65 years old, motor recovery 6 months after drug administration showed a strong trend towards a better recovery in the G-CSF treated group (P=0.056) compared with the control group. The present trial failed to show a significant effect of G-CSF in primary end point although the subanalyses of the present trial suggested potential G-CSF benefits for specific population.

BACKGROUND: According to most of the commonly used classification systems for subaxial spine injuries, unilateral and minimally displaced facet fractures without any sign of a spinal cord injury would be directed to non-operative management. However, the failure rate of non-operative treatment varies from 20 to 80%, and no consensus exists with regard to predictors of failure after non-operative management. CASE PRESENTATION: Case 1 is a patient with a unilateral facet fracture. The patient had only numbness in the right C6 dermatome but failed non-operative treatment, which resulted in severe spinal cord injury. Case 2 is a patient who had a similar injury pattern as case 1 but presented with immediate instability and underwent fusion surgery. Both patients had a minimally displaced unilateral facet fracture accompanied by disc injury and blunt vertebral artery injury, which are possible signs indicating significant instability. CONCLUSIONS: This is the first report of an isolated unilateral facet fracture that resulted in catastrophic spinal cord injury. These two cases illustrate that an isolated minimally displaced unilateral facet fracture with disc injury and vertebral artery injury were associated with significant instability that can lead to spinal cord injury.

BackgroundSeveral authors have reported favorable results in low back pain (LBP) for patients with lumbar disc herniation (LDH) treated with discectomy. However, detailed changes over time in the characteristics and location of LBP before and after discectomy for LDH remain unclear. To clarify these points, we conducted an observational study to determine the detailed characteristics and location of LBP before and after discectomy for LDH, using a detailed visual analog scale (VAS) bilaterally.MethodsWe included 65 patients with LDH treated by discectomy in this study. A detailed VAS for LBP was administered with the patient under 3 different conditions: in motion, standing, and sitting. Bilateral VAS was also administered (affected versus opposite side) for LBP, lower extremity pain (LEP), and lower extremity numbness (LEN). The Oswestry Disability Index (ODI) was used to quantify clinical status. Changes over time in these VAS and ODI were investigated. Pfirrmann grading and Modic change as seen by magnetic resonance imaging (MRI) were reviewed before and 1year after discectomy to determine disc and endplate condition.ResultsBefore surgery, LBP on the affected side while the patients were in motion was significantly higher than LBP while they were sitting (p=0.025). This increased LBP on the affected side in motion was improved significantly after discectomy (p<0.001). By contrast, the residual LBP while sitting at 1year after surgery was significantly higher than the LBP while they were in motion or standing (p=0.015). At 1year following discectomy, residual LBP while sitting was significantly greater in cases showing changes in Pfirrmann grade (p=0.002) or Modic type (p=0.025).ConclusionsImprovement of LBP on the affected side while the patient is in motion suggests that radicular LBP is improved following discectomy by nerve root decompression. Furthermore, residual LBP may reflect increased load and pressure on the disc and endplate in the sitting position.

Advanced glycation end-products (AGEs) have been reported as a possible biomarker of ageing and metabolic diseases; however, its role in the clinical progression of these diseases remains unclear. We aimed to evaluate how AGEs are associated with clinical symptoms and comorbidities in lower back pain (LBP) patients. This prospective cohort study enrolled 636 LBP patients. They were subjected to quantified AGE (qAGE) analysis using skin autofluorescence, and their clinical symptoms and comorbidities, such as diabetes, renal failure with haemodialysis treatment, and osteoporosis, were measured. LBP, lower extremity pain, and numbness were evaluated using a visual analogue scale (VAS). The measured qAGE was significantly higher in subjects with any comorbidity. Age also showed a strong positive correlation with qAGE. qAGE and VAS for leg numbness were positively correlated. Furthermore, in LBP patients under 50-years-old, qAGE was positively correlated with VAS for LBP, lower extremity pain, and numbness. In conclusion, qAGE, as measured by skin autofluorescence measurement, was significantly higher in LBP patients with diabetes and dialysis, as well as in osteoporosis patients. Furthermore, qAGE showed potential as a biomarker for LBP, lower extremity pain, and numbness in patients under 50-years-old. If accumulated AGEs are identified at a young age, researchers should be vigilant for the development of osteoporosis and LBP-related clinical symptoms later in life. (C) 2020 Elsevier Ltd. All rights reserved.

Lumbar lateral interbody fusion (LLIF) has been gaining popularity among the spine surgeons dealing with degenerative spinal diseases while LLIF on L5-S1 is still challenging for its technical and anatomical difficulty. OLIF51 procedure achieves effective anterior interbody fusion based on less invasive anterior interbody fusion via bifurcation of great vessels using specially designed retractors. The technique also achieves seamless anterior interbody fusion when combined with OLIF25. A thorough understanding of the procedures and anatomical features is mandatory to avoid perioperative complications.