古矢 丈雄

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.

Background: The optimal surgical procedure for the treatment of cervical spondylotic myelopathy (CSM) remains controversial because there are few comprehensive studies that have investigated the surgical methods. Therefore, we conducted a systematic review and meta-analysis to evaluate evidence in the literature and to compare the surgical outcomes between anterior decompression with fusion (ADF) and laminoplasty, which are representative procedures for CSM.Methods: An extensive literature search was performed using PubMed, Embase, and the Cochrane Library to identify comparative studies of ADF and laminoplasty for CSM. The language was restricted to English, and the publication period was from January 2001 to July 2019. We only included studies of CSM and excluded studies that involved patients with ossification of the posterior longitudinal ligament and treatments with posterior instrumented fusion. We extracted outcomes from the studies, such as preoperative and postoperative Japanese Orthopaedic Association (JOA) scores, cervical alignment, surgical complications and reoperation rates. Then, a meta-analysis was performed on these surgical outcomes.Results: Nine studies were obtained, and the quality of the studies was acceptable. In the meta-analysis, the preoperative JOA score was similar between the ADF and laminoplasty groups. The postoperative JOA scores and neurological recovery rates were not different between the ADF and laminoplasty groups. ADF exhibited more favorable results than laminoplasty in terms of postoperative cervical alignment. In contrast, overall complications were more frequently observed in the ADF group than in the laminoplasty group, leading to higher rates of reoperation. However, postoperative neck pain was more frequently observed in the laminoplasty group than in the ADF group.Conclusions: This systematic review and meta-analysis showed both the merits and shortcomings of ADF and laminoplasty. ADF and laminoplasty showed similar results in terms of neurological recovery. Postoperative cervical lordosis was better preserved with ADF than with laminoplasty. However, ADF was associated with a higher incidence of surgical complications than laminoplasty. (C) 2020 The Japanese Orthopaedic Association. Published by Elsevier B.V. All rights reserved.

This study aimed to clarify whether ossification predisposition influences clinical symptoms including pain, restriction of activities of daily living, and quality of life in patients with cervical ossification of the posterior longitudinal ligament (OPLL). Cervical ossification predisposition potentially causes neurologic dysfunction, but the relationship between clinical symptoms and radiologic severity of OPLL has not yet been investigated. Data were prospectively collected from 16 institutions across Japan. We enrolled 239 patients with cervical OPLL. The primary outcomes were patient-reported outcomes, including visual analog scale (VAS) pain scores and other questionnaires. Whole-spine computed tomography images were obtained, and correlations were investigated between clinical symptoms and radiologic findings, including the distribution of OPLL, the sum of the levels where OPLL was present (OP-index), and the canal narrowing ratio (CNR) grade. The cervical OP-index was Grade 1 in 113 patients, Grade 2 in 90, and Grade 3 in 36. No significant correlations were found between radiologic outcomes and VAS pain scores. The cervical OP-index was associated with lower extremity function, social dysfunction, and locomotive function. The CNR grade was not correlated with clinical symptoms, but Grade 4 was associated with lower extremity dysfunction. Thickness and extension of ossified lesions may be associated with lower extremity dysfunction in cervical OPLL.

＜文献概要＞はじめに 骨粗鬆症患者で最も骨折が多発する部位は椎体であり,年間140万人に新たな脆弱性椎体骨折が発生していると報告されている.脆弱性椎体骨折を受傷すると,強い疼痛による著しいADL低下(活動制限とそれに伴う廃用)が必発である.さらに,Quality of Life Questionnaire of the European Foundation for Osteoporosis(QUALEFFO)を用いて調査した報告では,脆弱性椎体骨折があると身体機能のみならず,社会機能,全体的健康観までもが低下するとも報告されている.つまり,その影響はQOL低下にまで及ぶといえる.したがって,疼痛のみならずADLおよびQOLの観点からも脆弱性椎体骨折に対する適切な治療介入が重要なのはいうまでもない.そこで本稿では,脆弱性椎体骨折に対する痛み治療のストラテジーについて,(1) 一般的な腰痛治療の観点,(2)脆弱性椎体骨折特有の観点といった2つの面から概説する.