古矢 丈雄

STUDY DESIGN: Observational study. PURPOSE: To evaluate healthy volunteers and patients with spinal canal lesions using apparent diffusion coefficient (ADC) maps with diffusion-weighted imaging. OVERVIEW OF LITERATURE: Decompression surgery for lumbar spinal stenosis (LSS) is selected on the basis of subjective assessment and cross-sectional magnetic resonance imaging (MRI). However, there is no objective standard for this procedure. METHODS: We performed 3T MRI in 10 healthy volunteers and 13 patients with LSS. The ADC values in the spinal canal were evaluated at 46 vertebrae (L4/5 and L5/S1 for each participant), and the reduced and conventional fields of view were compared. RESULTS: The ADC values were 2.72±0.12 at L4/5 in healthy volunteers, 2.76±0.19 at L5/S1 in healthy volunteers, 1.77±0.58 at L4/5 in patients with LSS, and 2.35±0.29 at L5/S1 in patients with LSS. The ADC value at L4/5 in patients with LSS was significantly lower than that at L5/S1 in patients with LSS and that at L4/5 and L5/S1 in healthy volunteers (p <0.05). With an ADC cutoff value of 2.46 to identify LSS, this approach provided an area under the curve of 0.81, sensitivity of 0.92, and specificity of 0.76 (p <0.05). CONCLUSIONS: Preoperative examination using ADC maps permits visualization and quantification of spinal canal lesions, thus proving the utility of ADC maps in the selection of decompression surgery for LSS.

STUDY DESIGN: Prospective multi-center study. OBJECTIVE: The aim of this study was to evaluate the effectiveness of surgical treatment in reducing falls and fall-related neurological deterioration in a prospective cohort of patients undergoing surgery for degenerative cervical myelopathy (DCM). SUMMARY OF BACKGROUND DATA: Current evidence is limited for the effectiveness of surgical interventions for DCM in reducing the risk of fall-related neurological deterioration. METHODS: Patients with DCM scheduled for surgical treatment were enrolled prospectively at eight participating institutes. At the time of enrollment, participants were given diaries to record details of their falls, to be returned at the 1-year postoperative follow-up. In the fall diary, patients were asked whether they had experienced any deterioration in neurological symptoms at each fall episode. Deterioration of neurological symptoms was categorized as follows: only deterioration of sensory function in the limbs; or deterioration of motor deficits. The incidence rate of falls was calculated separately for the preoperative and postoperative periods, as the total number of falls divided by the time over which falls were monitored (100 person-years). Functional outcome was assessed with the Japanese Orthopaedic Association (JOA) score and Neck Disability Index. RESULTS: Of the initial 168 participants, 159 completed the 1-year follow-up, and 132 fall diaries were retrieved and analyzed. Of these 132 patients, 65 (49%) reported at least one fall during the survey period. The incidence rate of falls decreased significantly from 497.4 to 90.3 falls per 100 person-years after surgery. The incidence of motor deterioration per fall decreased significantly from 34% to 8% after surgery. Patients who experienced preoperative fall-related motor deterioration had a significantly lower JOA score compared with patients without fall-related motor deterioration at 1-year follow-up. CONCLUSION: Surgical intervention for DCM is effective not only in reducing the frequency of falls, but also in reducing the risk of fall-related deterioration of motor deficits. LEVEL OF EVIDENCE: 2.

The purpose of this study was to try oblique lateral interbody fusion (OLIF) using percutaneous pedicle screws (PPS) with mobility. Twelve patients who underwent single-level OLIF were observed for at least one year. These included 6 patients with conventional PPS (rigid group), and 6 with movable PPS (semi-rigid group). Mobile PPS used cosmicMIA, which is a load sharing system. The anterior and posterior disc height, screw loosening and bone healing period, and implant failure were evaluated at final observation by CT. Moreover, the stress on the vertebral body-cage, on the vertebral body-screw/rod and on the bone around the screw was estimated using a three-dimensional finite element assessment in both groups. There was no significant difference in surgical time, amount of bleeding, JOA score, or low back pain VAS between groups. There were no differences between groups in anterior and posterior disc height, screw loosening, and implant failure at final observation. The bone healing period was significantly shorter in the semi-rigid screw group (18.3 months vs 4.8 months, p = 0.01). The finite element analysis showed that the lower stress on the rod/screw would contribute to fewer implant fractures and that lower stress on the bone around the screw would reduce screw loosening, and that higher compressive force on the cage would promotes bone healing. OLIF combined with a movable screw accelerated bone healing by nearly 75%. We conclude that mobile PPS in combination with OLIF promotes bone healing and can be a better vertebral fusion technique.

かつて腰痛疾患の85%を占めると謳われた非特異的腰痛の病態は,近年の医学研究の推進とともに解明されつつある。慢性疼痛の機序には腰痛疾患患者の約30%が罹患する神経障害性疼痛の概念が重要であり,特に臀部痛の存在は神経障害性疼痛の可能性を示唆する。椎間板性腰痛は変性椎間板で産生される炎症性サイトカインおよび異常感覚神経の伸長など複数の分子生物学的機序を介して慢性腰痛の一端を担い,これに基づくブロック療法等が報告されている。(著者抄録)

かつて腰痛疾患の85%を占めると謳われた非特異的腰痛の病態は,近年の医学研究の推進とともに解明されつつある。慢性疼痛の機序には腰痛疾患患者の約30%が罹患する神経障害性疼痛の概念が重要であり,特に臀部痛の存在は神経障害性疼痛の可能性を示唆する。椎間板性腰痛は変性椎間板で産生される炎症性サイトカインおよび異常感覚神経の伸長など複数の分子生物学的機序を介して慢性腰痛の一端を担い,これに基づくブロック療法等が報告されている。(著者抄録)

Atlantoaxial rotatory fixation (AARF) in an adult without any trauma is an extremely rare condition. Here we report a case of surgical treatment for existing atlantoaxial rotatory fixation in an adult with spastic torticollis. A 50-year-old man had become aware of torticollis without any cause of injury 6 weeks before he visited our hospital, where he presented with a one-week history of severe neck pain. Based on the local and imaging findings, we diagnosed him as having existing AARF of Fielding classification type I. The AARF was not reduced by 3 weeks of Glisson traction. Thus, we performed C1-C2 posterior fusion surgery 3 months after his initial visit. Although CT findings just after surgery showed that the C1-2 facet subluxation was reduced, the complaint of torticollis was not improved, with scoliosis at the middle to lower cervical level because of left sternocleidomastoid hypertonia. Administration of diazepam was initiated 2 weeks after surgery and botulinum toxin injections to the left sternocleidomastoid were added 2 months after surgery under the neurological diagnosis of spastic torticollis. As a result, the complaint of his torticollis was significantly improved 3 months after surgery. There were no relapses of the torticollis and complete fusion of the C1-C2 laminae was observed at the 2-year final follow-up. Surgical treatment for AARF in an adult should be considered if the diagnosis of AARF is delayed. In addition, appropriate treatment for spastic torticollis applied after surgery resulted in a favorable outcome of this case.

There is no imaging modality to quantitatively evaluate compressed cervical nerve roots in cervical radiculopathy. Here we sought to evaluate the usefulness of simultaneous apparent T2 mapping and neurography with nerve-sheath signal increased with inked rest-tissue rapid acquisition of relaxation-enhancement imaging (SHINKEI-Quant) to evaluate compressed nerves quantitatively in patients with cervical radiculopathy due to cervical disc hernia before microendoscopic surgery. One patient with cervical radiculopathy due to cervical disc hernia before microendoscopic surgery and 5 healthy subjects underwent simultaneous apparent T2 mapping and neurography with SHINKEI-Quant. The patient was a 49-year-old man with severe right upper arm pain and numbness. Based on MRI images, we suspected right C7 radiculopathy due to C6-7 cervical disc hernia. The T2 relaxation times of the cervical dorsal root ganglia of the brachial plexus bilaterally at C5-C8 were measured. We observed no significant differences in T2 relaxation times between the nerve roots on the left and right at each spinal level with values in healthy subjects. In our patient, neurography revealed swelling of the right C7 nerve, and a prolonged T2 relaxation time compared with that of the contralateral, unaffected C7 nerve. We performed microendoscopic surgery and the symptoms improved. We were able to evaluate the injured nerve root quantitatively in a patient with cervical radiculopathy using the SHINKEI-Quant technique, being the first study to our knowledge to show the usefulness of this technique to evaluate cervical radiculopathy quantitatively before microendoscopic surgery.

Previous studies have reported the utility of diffusion tensor imaging (DTI) as an imaging biomarker for the severity of myelopathy and subsequent surgical outcome in patients with degenerative cervical myelopathy (DCM). We hypothesized that DTI may reflect neurological recovery following surgery. The purpose of this study was to evaluate the ability of DTI to assess the post-operative alteration of neural status in patients with DCM as well as to predict post-operative recovery. We enrolled 15 patients with DCM who underwent decompression surgery. The Japanese Orthopaedic Association (JOA) score was evaluated before and 1 year after surgery. The participants were examined using DTI on a 3.0 T magnetic resonance scanner before, and 1 year after surgery. Fractional anisotropy (FA) and mean diffusivity (MD) were assessed for both time points. The correlations between the pre- and post-operative FA and MD values and the pre- and post-operative JOA scores were analyzed. Although the JOA score improved significantly after surgery from 8.9 to 12.3, there was no significant change between the pre- and post-operative FA and MD values. The post-operative outcomes after 1 year moderately correlated with the pre-operative FA values (Spearman's ρ = 0.55, p = 0.03 and Spearman's ρ = 0.56, p = 0.03 for change and recovery rate of the JOA score, respectively). However, there was no correlation between the post-operative FA and post-operative JOA scores nor between MD and clinical outcomes. DTI cannot be utilized as a biomarker for post-operative alterations of neural status of the spinal cord; however, pre-operative DTI may be useful as a predictor of surgical outcomes.

Ossification of the posterior longitudinal ligament (OPLL) can occur throughout the entire spine and can sometimes lead to spinal disorder. Although patients with OPLL sometimes develop physical limitations because of pain, the characteristics of pain and effects on activities of daily living (ADL) have not been precisely evaluated in OPLL patients. Therefore, we conducted a multi-center prospective study to assess whether the symptoms of cervical OPLL are different from those of cervical spondylosis (CS). A total of 263 patients with a diagnosis of cervical OPLL and 50 patients with a diagnosis of CS were enrolled and provided self-reported outcomes, including responses to the Japanese Orthopaedic Association (JOA) Cervical Myelopathy Evaluation Questionnaire (JOACMEQ), JOA Back Pain Evaluation Questionnaire (JOABPEQ), visual analog scale (VAS), and SF-36 scores. The severity of myelopathy was significantly correlated with each domain of the JOACMEQ and JOABPEQ. There was a negative correlation between the VAS score for each domain and the JOA score. There were significantly positive correlations between the JOA score and the Mental Health, Bodily Pain, Physical Functioning, Role Emotional, and Role Physical domains of the SF-36. One-to-one matching resulted in 50 pairs of patients with OPLL and CS. Although there was no significant between-group difference in scores in any of the domains of the JOACMEQ or JOABPEQ, the VAS scores for pain or numbness in the buttocks or limbs were significantly higher in the CS group; however, there was no marked difference in low back pain, chest tightness, or numbness below the chest between the two study groups. The scores for the Role Physical and Body Pain domains of the SF-36 were significantly higher in the OPLL group than in the CS group, and the mean scores for the other domains was similar between the two groups. The results of this study revealed that patients with OPLL were likely to have neck and low back pain and restriction in ADL. No specific type of pain was found in patients with OPLL when compared with those who had CS.

Here, we report a case of spinal tuberculosis without elevation of C-reactive protein (CRP) at the initial visit mimicking spinal metastasis. A 70-year-old woman developed progressive paraplegia without a history of injury and came to our hospital for evaluation. Severe compression to the spinal cord with osteolytic destruction of the spinal vertebrae at T6-7 was observed without elevation of CRP. A T4-9 posterior decompression and fusion were performed. Although the pathology revealed no malignant tumor cells, a positron emission tomography-computed tomography (PET-CT) showed upregulation of the thyroid gland and aspiration cytology revealed a thyroid carcinoma. Thus, we diagnosed her with spinal metastases from thyroid carcinoma. Conservative treatment was chosen with the hope of a significant neurologic recovery; however, 9 months after the primary surgery, she returned to our hospital with reprogressive paraplegia. In addition to progression of osteolytic changes to the T5-7 vertebrae, a coin lesion on the right side of the lung and elevation of CRP were observed. Finally, we diagnosed her with spinal tuberculosis based on the results of a CT-guided needle culture. Two-stage surgeries (posterior and anterior) were performed in addition to administering antituberculosis medications. At the 1-year postoperative follow-up evaluation, both neurologic function and laboratory data were improved with T5-9 complete fusion. It is difficult to determine based on imaging findings alone whether osteolytic vertebrae represent spinal metastases or tuberculosis. Even though inflammatory biomarkers, such as CRP, were not elevated, we should consider the possibility of not only spinal metastases but also tuberculosis when planning surgery involving osteolytic vertebrae. In addition, the combination of neurological, imaging, and pathological findings is important for the diagnosis of spinal tuberculosis.

Background Recent reports indicate that oxidative stress induced by reactive oxygen species is associated with the pathobiology of neurodegenerative disorders that involve neuronal cell apoptosis. Here we conducted a cross-sectional study to evaluate serum levels of oxidative stress in cervical compression myelopathy. Methods Thirty-six serum samples were collected preoperatively from patients treated for acutely worsening compression myelopathy (AM) and chronic compression myelopathy (CM). Serum levels of oxidative stress markers were evaluated by measuring derivatives of reactive oxygen metabolites (ROM), which reflect concentrations of hydroperoxides. ROM in healthy individuals range from 250 to 300 (U. CARR), whereas ROM >340-400 and > 400 define moderate and severe levels of oxidative stress, respectively. Difference of ROM by the cause of disorders whether cervical spondylotic myelopathy (CSM) or cervical ossification of longitudinal ligament (OPLL), correlations between ROM and patient age, body mass index (BMI), history of smoking, existence of diabetes were examined. Neurological evaluations according to Japanese Orthopaedic Association (JOA) scores were performed and correlated with ROM. Results ROM increased to 349.5 +/- 54.8, representing a moderate oxidative stress, in CM samples. ROM increased to 409.2 +/- 77.9 in AM samples, reflecting severe oxidative stress which were significantly higher than for CM samples (p < 0.05). There was no significant difference by the cause of disorders (CSM or OPLL). ROM were significantly increased in AM serum samples from female patients versus AM male and CM patients (p < 0.05). There were no correlations between ROM and age, BMI, history of smoking, and existence of diabetes. A negative correlation between ROM and recovery rate of JOA score (R-2 = 0.454, p = 0.047) was observed in the AM group. Conclusions Although moderate oxidative stress was present in patients with CM, levels of oxidative stress increased in severity in patients with AM. These results suggest that postsurgical neurological recovery is influenced by severe oxidative stress in AM.

Background: A consensus on the optimal surgical procedure for thoracolumbar OVF has yet to be reached due to the previous relatively small number of case series. The study was conducted to investigate surgical outcomes for osteoporotic vertebral fracture (OVF) in the thoracolumbar spine.Methods: In total, 315 OVF patients (mean age, 74 years; 68 men and 247 women) with neurological symptoms who underwent spinal fusion with a minimum 2-year follow-up were included. The patients were divided into 5 groups by procedure: anterior spinal fusion alone (ASF group, n = 19), anterior/ posterior combined fusion (APSF group, n = 27), posterior spinal fusion alone (PSF group, n = 40), PSF with 3-column osteotomy (3CO group, n = 92), and PSF with vertebroplasty (VP + PSF group, n = 137).Results: Mean operation time was longer in the APSF group (p < 0.05), and intraoperative blood loss was lower in the VP + PSF group (p < 0.05). The amount of local kyphosis correction was greater in the APSF and 3CO groups (p < 0.05). Clinical outcomes were approximately equivalent among all groups.Conclusion: All 5 procedures resulted in acceptable neurological outcomes and functional improvement in walking ability. Moreover, they were similar with regard to complication rates, prevalence of mechanical failure related to the instrumentation, and subsequent vertebral fracture. Individual surgical techniques can be adapted to suit patient condition or severity of OVF. (c) 2019 The Japanese Orthopaedic Association. Published by Elsevier B.V. All rights reserved.

＜文献概要＞はじめに 近年のがん患者数の増加により,腫瘍専門医だけでなく一般整形外科医もがん患者を診療する機会や,がん患者の骨転移診療にたずさわる機会が増加している.本稿では,当科で2016年より開始した骨転移専門外来の診療データをもとに,骨転移集学的治療における整形外科へのニーズと役割について考察した.

© The Author(s) 2019. Background: Dural tear and cerebrospinal fluid (CSF) leakage is known to be a complication of anterior thoracic spine surgery. If dural tear occurs on the ventral side of dura in combination with a pleural injury, it potentially becomes a subarachnoid-pleural fistula. The pressure gradient permits continuous flow of CSF from the subarachnoid space into the cavum thorax, resulting in an intractable subarachnoid-pleural fistula. We report two cases of successfully treated subarachnoid-pleural fistula using noninvasive positive-pressure ventilation (NPPV). Methods: Two patients, a 52-year-old man and a 54-year-old woman, underwent anterior thoracic spine surgery to treat thoracic myelopathy caused by spinal tumor and ossification of the posterior longitudinal ligament. During surgery, dural tear and CSF leakage to the cavum thorax due to perforation of the dura was observed. We treated with polyglycolic acid sheet (Neovel®) in combination with fibrin glue; a suction drainage tube was placed at the subfascial level and the wound was drained with negative pressure. However, after removal of the drainage tube, subarachnoid-pleural fistula was proven. We applied NPPV to the patients. Results: We used the application of NPPV for 2 weeks in the first patient and 1 week in the second patient. In both of them, subarachnoid-pleural fistula was attenuated without apparent adverse events. Conclusion: NPPV is noninvasive and potentially useful therapy to attenuate subarachnoid-pleural fistula after thoracic spinal surgery.

腰痛は混合性疼痛の要素を含むが,下肢・臀部痛を呈する場合は神経障害性の可能性が高い。超高齢社会に突入した現代では加えて骨や筋由来の疼痛も着目されつつあり,たとえば骨粗鬆症では骨折等がなくとも病態そのものが惹起する慢性の疼痛発生機序がある。また骨粗鬆症との合併率が高いサルコペニアもADL障害・疼痛をきたしうる。また,腰痛患者の活動データを蓄積・解析した結果,特に急性期での睡眠障害が優位であることが示唆されるなど,運動器慢性疼痛の機序とその評価に対するアプローチは多面化している。(著者抄録)