古矢 丈雄

BackgroundUnilateral laminectomy for bilateral decompression (ULBD) for lumbar spinal stenosis (LSS) is a less invasive technique compared to conventional laminectomy. Recently, several authors have reported favorable results of low back pain (LBP) in patients of LSS treated with ULBD. However, the detailed changes and localization of LBP before and after ULBD for LSS remain unclear. Furthermore, unsymmetrical invasion to para-spinal muscle and facet joint may result in the residual unsymmetrical symptoms. To clarify these points, we conducted an observational study and used detailed visual analog scale (VAS) scores to evaluate the characteristics and bilateral changes of LBP and lower extremity symptoms.MethodsWe included 50 patients with LSS treated with ULBD. A detailed visual analogue scale (VAS; 100mm) score of LBP in three different postural positions: motion, standing, and sitting, and bilateral VAS score (approached side versus opposite side) of LBP, lower extremity pain (LEP), and lower extremity numbness (LEN) were measured. Oswestry Disability Index (ODI) was used to quantify the clinical improvement.ResultsDetailed LBP VAS score before surgery was 51.532.5 in motion, 63.0 +/- 30.1 while standing, and 37.8 +/- 31.8 while sitting; and showed LBP while standing was significantly greater than LBP while sitting (p<0.01). After surgery, LBP while standing was significantly improved relative to that while sitting (p<0.05), and levels of LBP in the three postures became almost the same with ODI improvement. Bilateral VAS scores showed significant improvement equally on both sides (p<0.01).Conclusions ULBD improves LBP while standing equally on both sides in patients with LCS. The improvement of LBP by the ULBD surgery suggests radicular LBP improved because of decompression surgery. Furthermore, the symmetric improvement of LBP by the ULBD surgery suggests unsymmetrical invasion of the paraspinal muscles and facet joints is unrelated to residual LBP.

BackgroundTo date, there have been little published data on surgical outcomes for patients with PD with thoracolumbar OVF. We conducted a retrospective multicenter study of registry data to investigate the outcomes of fusion surgery for patients with Parkinson's disease (PD) with osteoporotic vertebral fracture (OVF) in the thoracolumbar junction.MethodsRetrospectively registered data were collected from 27 universities and their affiliated hospitals in Japan. In total, 26 patients with PD (mean age, 76years; 3 men and 23 women) with thoracolumbar OVF who underwent spinal fusion with a minimum of 2years of follow-up were included (PD group). Surgical invasion, perioperative complications, radiographic sagittal alignment, mechanical failure (MF) related to instrumentation, and clinical outcomes were evaluated. A control group of 296 non-PD patients (non-PD group) matched for age, sex, distribution of surgical procedures, number of fused segments, and follow-up period were used for comparison.ResultsThe PD group showed higher rates of perioperative complications (p<0.01) and frequency of delirium than the non-PD group (p<0.01). There were no significant differences in the degree of kyphosis correction, frequency of MF, visual analog scale of the symptoms, and improvement according to the Japanese Orthopaedic Association scoring system between the two groups. However, the PD group showed a higher proportion of non-ambulators and dependent ambulators with walkers at the final follow-up (p<0.01).ConclusionsA similar surgical strategy can be applicable to patients with PD with OVF in the thoracolumbar junction. However, physicians should pay extra attention to intensive perioperative care to prevent various adverse events and implement a rehabilitation regimen to regain walking ability.

STUDY DESIGN: A retrospective observational study was performed. PURPOSE: We investigated the prevalence of sarcopenia in dropped head syndrome (DHS), and the relationship between biochemical markers, including major advanced glycation end products (AGEs), pentosidine, and DHS in older women. OVERVIEW OF LITERATURE: AGEs have been implicated in the pathogenesis of sarcopenia. METHODS: We studied 13 elderly women with idiopathic DHS (mean age, 77.2 years) and 20 healthy volunteers (mean age, 74.8 years). We used a bioelectrical impedance analyzer to analyze body composition, including appendicular skeletal muscle mass index (SMI; appendicular lean mass [kg]/[height (m)]2). Cervical sagittal plane alignment, including C2-C7 sagittal vertical axis (C2-C7SVA), C2-C7 angle, and C2 slope (C2S), was measured. Biochemical markers, such as serum and urinary pentosidine, serum homocysteine, 1, 25-dihydroxyvitamin D, and 25-hydroxyvitamin D, were measured. The level of each variable was compared between DHS and controls. The relationship between biochemical markers and DHS was examined. RESULTS: Sarcopenia (SMI <5.75) was observed at a high prevalence in participants with DHS (77% compared to 22% of healthy controls). Height, weight, femoral bone mineral density, appendicular lean mass, total lean mass, and SMI all had significantly lower values in the DHS group. Serum and urinary pentosidine, and serum homocysteine were significantly higher in the DHS group compared to controls. Analysis of cervical alignment revealed a significant positive correlation of serum pentosidine with C2-C7SVA and C2S. CONCLUSIONS: Sarcopenia was involved in DHS, and high serum pentosidine levels are associated with severity of DHS in older women.

OBJECTIVEThe purpose of this study was to determine the relationship between vertebral bodies, psoas major morphology, and the course of lumbar nerve tracts using diffusion tensor imaging (DTI) before lateral interbody fusion (LIF) to treat spinal deformities.METHODSDTI findings in a group of 12 patients (all women, mean age 74.3 years) with degenerative lumbar scoliosis (DLS) were compared with those obtained in a matched control group of 10 patients (all women, mean age 69.8 years) with low-back pain but without scoliosis. A T2-weighted sagittal view was fused to tractography from L3 to L5 and separated into 6 zones (zone A, zones 1-4, and zone P) comprising equal quarters of the anteroposterior diameters, and anterior and posterior to the vertebral body, to determine the distribution of nerves at various intervertebral levels (L3-4, L4-5, and L5-S1). To determine psoas morphology, the authors examined images for a rising psoas sign at the level of L4-5, and the ratio of the anteroposterior diameter (AP) to the lateral diameter (lat), or AP/lat ratio, was calculated. They assessed the relationship between apical vertebrae, psoas major morphology, and the course of nerve tracts.RESULTSAlthough only 30% of patients in the control group showed a rising psoas sign, it was present in 100% of those in the DLS group. The psoas major was significantly extended on the concave side (AP/lat ratio: 2.1 concave side, 1.2 convex side). In 75% of patients in the DLS group, the apex of the curve was at L2 or higher (upper apex) and the psoas major was extended on the concave side. In the remaining 25%, the apex was at L3 or lower (lower apex) and the psoas major was extended on the convex side. Significant anterior shifts of lumbar nerves compared with controls were noted at each intervertebral level in patients with DLS. Nerves on the extended side of the psoas major were significantly shifted anteriorly. Nerve pathways on the convex side of the scoliotic curve were shifted posteriorly.CONCLUSIONSA significant anterior shift of lumbar nerves was noted at all intervertebral levels in patients with DLS in comparison with findings in controls. On the convex side, the nerves showed a posterior shift. In LIF, a convex approach is relatively safer than an approach from the concave side. Lumbar nerve course tracking with DTI is useful for assessing patients with DLS before LIF.

INTRODUCTION: To investigate the risk of epidural hematoma after spinous process-splitting laminectomy (SPSL). METHODS: A total of 137 cases (mean age, 72.4 years; 68 men) of SPSL were included. Of these, there were instances (3.7%; mean age, 70.5 years; all male) of postoperative development of new neurologic deficit due to epidural hematoma requiring reoperation. The 133 subjects (72.5 years; 64 men) with normal postoperative course were used as controls, and comparisons were made between both groups using chi-squared and Student's t-tests. Regarding our investigation of risk factors for epidural hematoma, logistic regression was conducted with presence or absence of hematoma as our primary outcome variable, and age, gender, disease duration, number of laminectomies, which levels were decompressed, blood loss, length of case, drain output, coagulopathy, and whether or not there was an intraoperative dural tear were our explanatory variables. RESULTS: All cases of hematoma were single-level laminectomies; there was one case of T9-10 and 3 cases of L2-3. In our direct comparison of both groups (hematoma versus control), the proportion of men was significantly higher in the hematoma group (100% versus 48%, p < 0.05); levels decompressed were also significantly higher (p < 0.05) in the hematoma group, and drain outputs were significantly lower (113 mL versus 234 mL, p < 0.05). From our logistic regression analysis, the levels were significantly higher (χ2 = 15, p = 0.0001) and the drain outputs were smaller (χ2 = 4.6, p = 0.03) in the hematoma group. CONCLUSIONS: Single-level decompression higher than the L2-3 level and reduced drain output were risk factors for spinal epidural hematoma. With this method of spinous process suturing and reconstruction there is less decompression compared with more conventional methods; therefore, the effect of hematoma may be more pronounced at higher vertebral levels with reduced canal width, and drain failure may also occur with this limited space.

INTRODUCTION: Limb muscle mass measurement using dual-energy X-ray absorptiometry (DXA) is considered the gold standard for the diagnosis of sarcopenia. Moreover, bioelectrical impedance analysis (BIA) is also recognized as a beneficial tool considering its high correlation with DXA. However, it remains to be elucidated whether DXA and BIA can accurately measure trunk lean mass. The aim of this study was to investigate the correlation between DXA and BIA measurements of trunk muscle mass and the cross-sectional area (CSA) of trunk muscles measured using magnetic resonance imaging (MRI) and to compare measures of trunk muscle mass obtained using DXA and BIA in patients with low back pain (LBP). METHODS: In total, 65 patients participated in the study. The correlation between DXA and BIA measurements and the CSA of trunk and paraspinal muscles at the L4-5 level were calculated. In addition, the correlation between DXA and BIA measurements of trunk muscle mass and the differences between these two measurements were determined. RESULTS: The correlation coefficient between DXA and BIA trunk muscle mass measurement and trunk muscle CSA was 0.74 and 0.56 for men and 0.69 and 0.44 for women, respectively. DXA and BIA measurement values showed a significantly moderate correlation with the CSA of the erector spinae (ES) and psoas major (PM). The multifidus (MF) CSA did not correlate with measurements of DXA and BIA in both men and women. Although DXA and BIA measurements were significantly correlated, a significant difference between these two measurements was found. BIA overestimated the trunk muscle mass significantly compared with DXA. CONCLUSIONS: Trunk muscle mass measured with DXA and BIA was correlated with the CSA of most trunk muscles. Although the measurement of DXA and BIA showed a high correlation, BIA overestimated trunk muscle mass compared with DXA. Both DXA and BIA are beneficial for measuring trunk muscle mass.

The aim of this study was to investigate the incidence and characteristics of implant failure in posterior cervical long-segment fusion surgery. We retrospectively reviewed 51 cases of posterior cervical long-segment fusion surgery that used pedicle screws, lateral mass screws, or laminar screws. The cranial end of the fusion was C2 or C3, and the caudal end of the fusion was C7 or T1. All patients were observed with CT scans at 6 months postoperatively. We evaluated the loosening and breakage of the implanted screws or rods. In the 51 patients, 257 pedicle screws, 9 laminar screws and 233 lateral mass screws were placed. Implant failure occurred in 25 patients (49.0%). Screw loosening was found in 42 screws (8.4%). Screw breakage occurred in 6 (1.2%) screws. The implant failures were particularly observed in both ends of the fusion level. When C7 was the end of the lower instrumented level, the incidence was 40% without C6 pedicle screws, 33% with unilateral C6 pedicle screws, and 0% with bilateral C6 pedicle screws. The present study revealed that the incidence of implant failures of the screws in long-segment posterior cervical fusion surgery was higher, especially in the caud

Introduction: Approximately 3% of osteoporotic vertebral fractures develop osteoporotic vertebral collapse (OVC) with neurological deficits, and such patients are recommended to be treated surgically. However, a proximal junctional fracture (PJFr) following surgery for OVC can be a serious concern. Therefore, the aim of this study is to identify the incidence and risk factors of PJFr following fusion surgery for OVC.Methods: This study retrospectively analyzed registry data collected from facilities belonging to the Japan Association of Spine Surgeons with Ambition (JASA) in 2016. We retrospectively analyzed 403 patients who suffered neurological deficits due to OVC below T10 and underwent corrective surgery; only those followed up for >= 2 years were included. Potential risk factors related to the PJFr and their cut-off values were calculated using multivariate logistic regression analysis and receiver operating characteristic (ROC) analysis.Results: Sixty-three patients (15.6%) suffered PJFr during the follow-up (mean 45.7 months). In multivariate analysis, the grade of osteoporosis (grade 2, 3: adjusted odds ratio (aOR) 2.92; p=0.001) and lower instrumented vertebra (LIV) level (sacrum: aOR 6.75; p=0.003) were independent factors. ROC analysis demonstrated that lumbar bone mineral density (BMD) was a predictive factor (area under curve: 0.72, p=0.035) with optimal cut-off value of 0.61 g/cm(2) (sensitivity, 76.5%; specificity, 58.3%), but that of the hip was not (p=0.228).Conclusions: PJFr was found in 16% cases within 4 years after surgery; independent risk factors were severe osteoporosis and extended fusion to the sacrum. The lumbar BMD with cut-off value 0.61 g/cm(2) may potentially predict PJFr. Our findings can help surgeons select perioperative adjuvant therapy, as well as a surgical strategy to prevent PJFr following surgery.

Background: Previous studies have shown that patients with cervical ossification of the posterior longitudinal ligament (OPLL) often have co-existing ossification of the nuchal ligament (ONL). However, no studies have focused on ONL and its relevance to the severity of OPLL or ossification of other spinal ligaments, such as anterior longitudinal ligament (OALL), ligamentum flavum (OLF), and supraspinous/interspinous ligament (OSIL).Methods: In this multicenter study, we investigated ossification of the spinal ligaments in the whole spine computed tomography (CT) images of 233 cervical OPLL patients. The severity of ossification was evaluated using ossification index for each spinal ligament, calculated as the sum of the level of ossification. We compared the severity of ossification in each spinal ligament between patients with ONL and those without ONL. Furthermore, we investigated how the number of segments, where ONL exists, affects the severity of ossification in each spinal ligament.Results: One hundred thirty patients (55.8%) had co-existing ONL in the cervical OPLL patients included in this study. The ONL (+) group included more male and aged patients. The cervical ossification indexes of OPLL and OALL were higher in ONL (+) patients than in ONL (-) patients. The thoracolumbar ossification indexes of OALL and OSIL were also higher in ONL (+) patients. Logistic regression analysis revealed that age, gender and cervical OA-index were independent factors correlating to the existence of ONL. In the cervical spine, both the ossification indexes of OALL and OPLL increased as the levels of ONL increased. Similarly, in the thoracolumbar spine, both the ossification indexes of OALL and OSIL were increased as the levels of cervical ONL increased. In the multiple regression analysis, cervical OA-index and thoracolumbar OSI-index showed significant correlation with the number of ONL levels.Conclusions: Co-existence of ONL in cervical OPLL patients was associated with the severity of spinal hyperostosis especially in cervical OPLL, OALL, thoracolumbar OALL and OSIL. (C) 2018 The Japanese Orthopaedic Association. Published by Elsevier B.V. All rights reserved.

脊髄刺激療法は難治性慢性腰下肢痛に対して、疼痛抑制効果および歩行機能改善効果を有する。適応疾患・病態を見極め、心理的サポートなどを併用することにより、さらなる患者満足度の向上が期待できる可能性がある。(著者抄録)

STUDY DESIGN: This was a retrospective multicenter study. OBJECTIVE: To clarify the progression of diffuse idiopathic skeletal hyperostosis (DISH) using whole-spine computed tomography in patients with cervical ossification of the posterior longitudinal ligament (OPLL). SUMMARY OF BACKGROUND DATA: DISH and cervical OPLL frequently coexist, and can cause ankylosing spinal fractures due to biomechanical changes and fragility of the affected vertebrae. The epidemiology and pathophysiology of DISH occurring with cervical OPLL are unclear. MATERIALS AND METHODS: We used whole-spine computed tomography to determine the prevalence of DISH in 234 patients with a diagnosis of cervical OPLL based on plain cervical radiographs. We established a novel system for grading the progression of DISH based on a cluster analysis of the DISH distribution along the spine. We calculated the correlation coefficient between this grading system and patient age. RESULTS: The prevalence of DISH in patients with cervical OPLL was 48.7%. Patients with DISH were significantly older than those who did not have DISH (67.3 vs. 63.4 y; P=0.005). Cluster analysis classified the DISH distribution into 6 regions, based on the levels affected: C2-C5, C3-T1, C6-T5, T3-10, T8-L2, and T12-S1. DISH was observed most frequently at T3-T10. We defined a system for grading DISH progression based on the number of regions involved, from grade 0 to 6. DISH was distributed at T3-T10 in >60% of the grade 1 patients, whereas most patients with DISH at the cervical or lumbar spine were grade 4 or 5. There was a weak but significant correlation between the DISH grade and patient age. CONCLUSIONS: DISH was present in nearly half of the patients with cervical OPLL. DISH was more common in older patients. DISH developed at the thoracic level and progressed into the cervical and/or lumbar spine with age. LEVEL OF EVIDENCE: Level III.

We report two cases of restenosis caused by the progression of thickness of ossification of the posterior longitudinal ligament (OPLL) seven and more years after laminoplasty, resulting in neurological deterioration needed for revision anterior decompressive surgeries. Neurological recovery after revision anterior excision of OPLL was poor. In both cases, the patients had progressive OPLL, with a non-ossified segment of the ossification foci, in common. After laminoplasty, they also both exhibited osseous fusion of the elevated laminae, but there was discontinuity at the interlaminar space at the peak level of OPLL. Discontinuity of the osseous fusion in the elevated laminae might cause mechanical stress increases at the non-ossified segment of the OPLL and could lead to the progression of OPLL. The present cases showed that long-term progression of OPLL can induce neurological deterioration even after sufficient posterior decompression by laminoplasty. Therefore, when considering risk factors that may be predictive of the progression of OPLL after laminoplasty, it is important to perform strict follow-up examination to check for progression to reduce the risk of myelopathy symptoms that are indicative of neurological deterioration.

type:text [要旨] 【目的】ラット筋損傷モデルを用いて圧迫，冷却療法による治療効果を比較した。 【方法】8 週齢雄性SDラットを用いdrop mass 法にてモデル作成し，損傷後3 時間にゴムで損傷部を30分圧迫した圧迫群（n＝36），氷で損傷部を30分冷却した冷却群（n＝36），未治療群（n＝36）の3 群について比較を行った。損傷後3 ， 6 ，18，24時間， 3 日， 1 週， 2 週の腓腹筋をHE染色で評価した。損傷後3 ，6 ，18，24時間の腓腹筋をELISA法にてTNF-α の定量評価を行った。損傷部にフルオロゴールド(FG）を留置し，損傷後3 日のL4 後根神経節でCGRP（疼痛関連ペプチド）による免疫組織化学染色を行った。 【結果】組織では未治療群と比し，圧迫群は損傷後6 時間以降で出血や浮腫が少ない傾向にあった。冷却群は，損傷後6 時間で出血や浮腫は減少するも，損傷後18時間以降で増強した。損傷後1週で未治療群は筋組織の壊死が残存するも，圧迫群，冷却群は筋線維修復が認められた。サイトカインは，圧迫群は未治療群と比し損傷後3 ， 6 ，18時間共に低値を示した。特に損傷後6 時間で有意に低値であった（P＜0.05）。冷却群は未治療群と比し損傷後3 ，6 時間で一過性な上昇を示すも，損傷後18時間では有意に低下した（P＜0.05）。L4 後根神経節でのFG 陽性細胞中のFG とCGRP で二重標識される細胞の割合は，圧迫群，冷却群ともに未治療群と比し有意に低かった（P＜0.05）。 【考察】圧迫，冷却療法は筋組織修復を促進し，疼痛の遷延化を予防するが，急性期では異なる経時的変化を示し，組織修復過程に差異がある可能性が示唆された。 [SUMMARY] Purpose. To compare compression and ice treatments in a rat model of muscle injury. Methods. A model of muscle injury was made in 108 eight-week-old Sprague Dawley male rats by dropping a weight onto their right gastrocnemius muscle. We compared compression and ice treatments after the contusion injury with no treatment. We evaluated the injuries using histology andan enzyme-linked immunosorbent assay for tumor necrosis factor α. We used Fluoro-Gold to traceneural afferents from the region of the contusion injury. The proportion of calcitonin gene-related peptide-immunoreactive neurons in all Fluoro-Gold-labeled neurons was determined to evaluate pain. Results. In the compression treatment group, the injured muscle tended to have less hemorrhage and edema at ? 6 h after the injury. Tumor necrosis factor α levels were lower, and the local acutephase in flammatory reaction was milder than in untreated rats. We found less necrosis of muscle tissue on the third day after injury and the replacement of granulation tissue and regeneration of muscle fibers 1 week after the injury. The proportion of calcitonin gene-related peptide-immunoreactive Fluoro-Gold-labeled neurons in total Fluoro-Gold-labeled neurons was significantly lower than in untreated rats. In the ice treatment group, although injured muscle had decreased hemorrhage and edema 6 h after the injury, hemorrhage and edema increased ?18 h after injury. Tumor necrosis factor α levels were transiently increased compared with those in untreated rats（ 3 h and 6 h after contusion）. On the third day after contusion injury, necrosis of muscle was severe. We observed the replacement of granulation tissue and regeneration of muscle fibers 1 week after the injury. The proportion of calcitonin gene-related peptide-immunoreactive Fluoro-Gold-labeled neurons was significantly lower than in untreated rats. Conclusion. In our study, compression may promote muscle tissue repair by preventing hematoma formation during the repair phase and preventing prolonged pain. On the other hand, ice therapy may prevent prolonged pain through pain relief from the stimulation of cold receptors, enabling animals to proceed with an early range of motion exercise, suppressing hypoactivity and promoting muscle tissue repair during the recovery phase. Overall, our current study indicated that there was a difference between compression and ice treatments during the acute and repair phases of muscle injury.

OBJECTIVE: To validate the relationship between residual walking ability and monthly care cost as well as long-term care insurance (LTCI) certification level in elderly patients after surgical treatment for hip fractures in Japan. METHODS: Elderly patients aged >75 years who underwent surgical treatment for hip fractures in our hospital were included. The preand post-surgical (6-month) walking ability and LTCI certification and the presence or absence of dementia was determined from medical records and questionnaires. Walking ability was classified into 6 levels used in our daily medical practice. Based on these data, we correlated the relationship between walking ability and the LTCI certification level. Further, based on the official statistics pertaining to the average monthly costs per person at each LTCI certification level, we evaluated the relationship between walking ability and monthly care cost. RESULTS: A total of 105 cases (mean age, 80.2 years; 16 men; 39 patients with dementia) were included. The correlation between walking ability and average monthly cost per person as well as LTCI certification level at 6 months postoperatively (r=0.58) was demonstrated. The correlation was found in both groups with and without dementia. CONCLUSION: The ability to walk reduced the cost of care in elderly patients who experienced hip fracture, regardless of the presence of dementia.

【目的】ラット筋損傷モデルを用いて圧迫、冷却療法による治療効果を比較した。【方法】8週齢雄性SDラットを用いdrop mass法にてモデル作成し、損傷後3時間にゴムで損傷部を30分圧迫した圧迫群(n=36)、氷で損傷部を30分冷却した冷却群(n=36)、未治療群(n=36)の3群について比較を行った。損傷後3、6、18、24時間、3日、1週、2週の腓腹筋をHE染色で評価した。損傷後3、6、18、24時間の腓腹筋をELISA法にてTNF-αの定量評価を行った。損傷部にフルオロゴールド(FG)を留置し、損傷後3日のL4後根神経節でCGRP(疼痛関連ペプチド)による免疫組織化学染色を行った。【結果】組織では未治療群と比し、圧迫群は損傷後6時間以降で出血や浮腫が少ない傾向にあった。冷却群は、損傷後6時間で出血や浮腫は減少するも、損傷後18時間以降で増強した。損傷後1週で未治療群は筋組織の壊死が残存するも、圧迫群、冷却群は筋線維修復が認められた。サイトカインは、圧迫群は未治療群と比し損傷後3、6、18時間共に低値を示した。特に損傷後6時間で有意に低値であった(P<0.05)。冷却群は未治療群と比し損傷後3、6時間で一過性な上昇を示すも、損傷後18時間では有意に低下した(P<0.05)。L4後根神経節でのFG陽性細胞中のFGとCGRPで二重標識される細胞の割合は、圧迫群、冷却群ともに未治療群と比し有意に低かった(P<0.05)。【考察】圧迫、冷却療法は筋組織修復を促進し、疼痛の遷延化を予防するが、急性期では異なる経時的変化を示し、組織修復過程に差異がある可能性が示唆された。(著者抄録)

To determine levels of biomarkers reflecting damage to axon, myelin, astrocytes, and neuron in cerebrospinal fluid (CSF) of patients with cervical compression myelopathy.We collected 69 CSF samples from patients before spinal surgery for acutely worsening compression myelopathy (AM, 20), chronic compression myelopathy (CM, 20), and lumbar canal stenosis (LCS 29; control). We measured levels of phosphorylated neurofilament subunit H (pNF-H), tau (reflecting axonal damage), myelin basic protein (MBP) (reflecting demyelination), S100b (reflecting astrocyte damage), and neuron-specific enolase (NSE) (reflecting neuronal damage). Change of neurological function by surgery was determined using a Japanese Orthopaedic Association (JOA) score for cervical myelopathy.Significantly higher levels of pNF-H were detected in AM compared with those in either CM or LCS (P < 0.01). Significantly higher levels of tau were detected in AM compared with those in CM (P < 0.05). Levels of MBP were undetectable in almost all the patients. Levels of S100b were equivalent in the three groups. Levels of NSE in AM and CM were significantly lower than those in LCS (P < 0.01). The recovery rate of JOA score was significantly greater for patients with AM than CM. We found a positive correlation between pNF-H and recovery of JOA score (r = 0.381, P = 0.018).The present results suggest that axonal damage is remarkable compared with demyelination, astrocytic, and neuronal damage in AM. Better clinical outcome in AM with high CSF levels of pNF-H indicates that axonal compensatory plasticity in spinal cord is preserved, and pNF-H can be predictive of good surgical outcome for AM.These slides can be retrieved under Electronic Supplementary Material.[GRAPHICS].

BACKGROUND: Dropped head syndrome (DHS) is a flexion deformity of the neck that is caused by severe weakness of the neck extensor muscles. DHS occurs in combination with not only neuromuscular disorders, but also cervical spondylosis. However, there are few reports of DHS complicated by cervical spondylotic amyotrophy (CSA). Here we report a case of DHS with CSA in a patient who underwent surgical treatment. CASE PRESENTATION: A 79-year-old man became aware of dropped head and gait disturbance in addition to the paralysis of his right upper extremity. At his initial visit, he had a severe chin-on-chest posture. Neurological examination revealed severe paralysis of deltoid, biceps, wrist extensor, finger flexor, extensor, and abductors, in addition to lower extremity spasticity. Nevertheless, sensory dysfunction was not observed. X-ray images showed severe kyphosis at the upper thoracic level. MRI and CT myelography findings revealed spinal canal stenosis at the level of C5-6 and C6 root compression of the right side. Motor neuron disease was excluded because of findings from electromyography. Therefore, we diagnosed this patient as having DHS with cervical spondylotic amyotrophy. A C2-Th5 posterior fusion with C3-C6 laminoplasty and C5-6 foraminotomy on the right side were performed. After surgery, the complaint of dropped head was improved significantly and bilaterally finger motion was improved slightly. His neck position was maintained at the final follow-up at about 1 year after surgery. CONCLUSIONS: Despite the limitation of short-term follow-up, favorable results for the DHS were maintained in the present case. Surgical treatment for similar cases may be a feasible option, but surgery does have some complications.

We used a newly developed, high-porosity unidirectional porous hydroxyapatite spacer (Regenos spacer, not approved by the FDA). The aim of the present study was to elucidate the effectiveness of Regenos laminar spacers for open-door type laminoplasty. The present study included 39 patients who underwent open-door type laminoplasty with Regenos spacers from April 2015 to December 2016 and were followed up for at least 6 months after surgery. We grafted 68 Regenos spacers in 39 patients. Pre- and postoperative neurological status of patients were evaluated using JOA score and recovery rate. Breakage of Regenos spacers, laminar closure, and bone-hydroxyapatite spacer bonding were assessed using 12-month postoperative sagittal and axial CT images. The average preoperative JOA score was 9.5 ± 3.2/17, and the average postoperative JOA score was 12.5 ± 2.9/17. JOA score recovery rate was 34 ± 41% at the latest follow-up visit. The bony fusion rate of the hinge sides was 87%. Breakage and deformity of implanted spacers was observed in 69% of patients and 59% of spacers with a CT sagittal view, and CT axial view at 12 months revealed fine cracks and collapse in 17 spacers

BACKGROUND: The K-line, which is a virtual line between the midpoints of the antero-posterior canal diameter at C2 and C7, can be useful for determination of surgical procedures for cervical ossification of the posterior longitudinal ligament (OPLL). Although K-line is originally measured with plain radiogram, computed tomography multiplanar reconstruction (CT-MPR) is applied for K-line measurement by several surgeons. The purpose of the present study was to analyze whether there is a difference in K-lines obtained from radiographs of standing patients and those obtained from CT-MPR images of supine patients. METHODS: The present study included 65 patients with cervical OPLL underwent surgical treatment. We investigated the K-line (+ or -) before surgery, measured from lateral cervical spine radiographs taken in standing patients in a neutral position (X-P-based K-line) and CT-MPR mid-sagittal images obtained in supine patients (CT-based K-line). The X-P-based and CT-based K-lines were compared and differences between them were assessed. RESULTS: The-X-P-based K-line was found to be (+) in 35 patients and (-) in 30 patients. Four of 35 patients with an X-P-based K-line (11%) showed a change from K-line (+) to (-) in CT-based K-line measurements. One of 30 patients with an X-P-based K-line (3%) showed a change from (-) to (+) in CT-based measurements. CONCLUSIONS: The K-line should be measured with plain radiogram of standing patients because X-P-based K-line and CT-based K-line can be different.

Study Design: Retrospective observational study. Purpose: We considered the relationship between spinal alignment and skeletal muscle mass on clinical outcomes following a surgery for lumbar spinal stenosis (LSS). Overview of Literature: There are no reports of preoperative factors predicting residual low back pain following surgery for LSS. Methods: Our target population included 34 women (mean age, 74.4 years) who underwent surgery for LSS. Prior to and 6 months after the surgery, systemic bone mineral density and lean soft tissue mass were measured using dual-energy X-ray absorptiometry. Skeletal muscle mass index (SMI) was calculated as the sum of the arm and leg lean mass in kilograms divided by height in meters squared. The spinal alignment was also measured. Clinical outcomes were evaluated using the Japanese Orthopedic Association scoring system, leg and low back pain Visual Analog Scale, and Roland-Morris Disability Questionnaire (RDQ). Additionally, we examined the bone mineral density, skeletal muscle mass, and spinal alignment before and after the surgery. We used the Spearman correlation coefficient to examine the associations among clinical outcomes, preoperative muscle mass, and spinal alignment. Results: Sarcopenia (SMI &lt 5.46) was observed in nine subjects (26.5%). Compared with normal subjects (SMI &gt 6.12), RDQ was significantly higher in subjects with sarcopenia (p =0.04). RDQ was significantly negatively correlated with SMI (r =-0.42, p &lt 0.05). There was a significant positive correlation between postoperative RDQ and pelvic tilt (PT r =0.41, p &lt 0.05). SMI and PT were significantly negatively correlated (r =-0.39, r &lt 0.05). Conclusions: Good postoperative outcomes were negatively correlated with low preoperative appendicular muscle mass, suggesting that postoperative outcomes were inferior in cases of decreased appendicular muscle mass (sarcopenia). Posterior PT due to decreased limb muscle mass may contribute to postoperative back pain, showing that preoperatively reduced limb muscle mass and posterior PT are predictive factors in the persistence of postoperative low back pain.

Purpose: Addition of posterior instrumented fusion to laminoplasty (posterior decompression with instrumented fusion: PDF) can improve the surgical outcome of patients with K-line (−) cervical ossification of the longitudinal ligament (OPLL) compared with laminoplasty alone. We sought to elucidate the factors that are significantly associated with a better outcome after PDF for K-line (−) OPLL. Methods: The present study included 38 patients who underwent PDF for K-line (−) OPLL and were followed up for at least 1 year after surgery. Clinical outcome was assessed using Japanese Orthopedic Association (JOA) scores for cervical myelopathy and the recovery rate was calculated. Patients who belonged to the upper quartile of all the patients according to rank order of the JOA score recovery rate were considered to have a good outcome. The correlations between good outcome, patient factors and imaging assessments were analyzed statistically. Results: Univariate analyses showed that postoperative conversion of K-line from (−) to (+) (p = 0.004), no increase in the sagittal vertical axis from the center of gravity of the head to C7 (p = 0.07), and a lower grade of preoperative intramedullary T2-signal intensity (p = 0.03) were candidates for the association. Stepwise logistic regression analysis revealed that postoperative K-line conversion from (−) to (+) is an independent factor that is significantly associated with a better surgical outcome (p = 0.04). Conclusion: Postoperative K-line conversion from (−) to (+) is a factor independently associated with a better surgical outcome. Graphical abstract: These slides can be retrieved under Electronic Supplementary material.

慢性腰痛の病態は多因子からなり、疼痛機序の観点からは全体で約30%の患者に神経障害性疼痛の関与が考えられる。下肢痛や臀部痛のある症例ではその割合は高く、慢性腰痛における特徴の一つと考えられる。また、腰痛患者の活動量の実態をより正確に把握するため行った日常活動度のデータ蓄積と解析によると、特に急性期での睡眠障害の具現化が示唆された。慢性腰痛の病態を検証するうえでは、今後は活動度も含んだより多面的な検証が有用であると考えられる。(著者抄録)

INTRODUCTION: Granulocyte colony-stimulating factor (G-CSF) is generally used for neutropaenia. Previous experimental studies revealed that G-CSF promoted neurological recovery after spinal cord injury (SCI). Next, we moved to early phase of clinical trials. In a phase I/IIa trial, no adverse events were observed. Next, we conducted a non-randomised, non-blinded, comparative trial, which suggested the efficacy of G-CSF for promoting neurological recovery. Based on those results, we are now performing a phase III trial. METHODS AND ANALYSIS: The objective of this study is to evaluate the efficacy of G-CSF for acute SCI. The study design is a prospective, multicentre, randomised, double-blinded, placebo-controlled comparative study. The current trial includes cervical SCI (severity of American Spinal Injury Association (ASIA) Impairment Scale B/C) within 48 hours after injury. Patients are randomly assigned to G-CSF and placebo groups. The G-CSF group is administered 400 µg/m2/day×5 days of G-CSF in normal saline via intravenous infusion for 5 consecutive days. The placebo group is similarly administered a placebo. Our primary endpoint is changes in ASIA motor scores from baseline to 3 months. Each group includes 44 patients (88 total patients). ETHICS AND DISSEMINATION: The study will be conducted according to the principles of the World Medical Association Declaration of Helsinki and in accordance with the Japanese Medical Research Involving Human Subjects Act and other guidelines, regulations and Acts. Results of the clinical study will be submitted to the head of the respective clinical study site as a report after conclusion of the clinical study by the sponsor-investigator. Even if the results are not favourable despite conducting the clinical study properly, the data will be published as a paper. TRIAL REGISTRATION NUMBER: UMIN000018752.

慢性腰痛の原因は多岐に亘るが、その中で特に腰椎椎間板、神経根は、慢性腰痛や坐骨神経痛の主因とされる。歴史的背景から、これらの病態に慢性炎症は深くかかわっていることが示されてきた。椎間板性腰痛の病態は変性した椎間板への感覚神経の侵入とサイトカインを中心とした微小炎症と考えられている。また神経根性疼痛の病態も、慢性炎症と神経のワーラー変性とされている。これ等の機序、新規診断方法、治療法の展開について記載したい。(著者抄録)

Background: In patients with ossification of the posterior longitudinal ligament (OPLL) in the cervical spine, it is well known that the thoracic ossified lesions often coexist with the cervical lesions and can cause severe myelopathy. However, the prevalence of OPLL at each level of the thoracic and lumbar spinal segments is unknown. The aims of this study were to investigate how often OPLL occurs at each level in the thoracolumbar spine in patients with a radiological diagnosis of cervical OPLL and to identify the spinal levels most likely to develop ossification. Methods: Data were collected from 20 institutions in Japan. Three hundred and twenty-two patients with a diagnosis of cervical OPLL were included. The OPLL index (OP index), defined as the sum of the vertebral body and intervertebral disc levels where OPLL is present, was used to determine disease severity. An OP index ≥20 was defined as severe OPLL. The prevalence of OPLL at each level of the thoracic and lumbar spinal segments was calculated. Results: Women were more likely to have ossified lesions in the thoracolumbar spine than men. Severe OPLL was significantly more common in women than in men (20% vs. 4.5%). For thoracic vertebral OPLL, the most frequently affected was the T1 segment in both men and women, followed by the T1/2 and T3/4 intervertebral levels in men and women, respectively. Ossified lesions were frequently seen at the intervertebral and vertebral levels around the cervicothoracic and thoracolumbar junctions in men with severe OPLL, whereas OPLL was more diffusely distributed in the thoracic spine in women with severe OPLL. Conclusion: Thoracolumbar OPLL occurred most often at T1 in men and at T3/4 in women. In severe OPLL cases, although ossified lesions were frequently seen at the intervertebral and vertebral levels around the cervicothoracic and thoracolumbar junctions in men, OPLL could be observed more diffusely in the thoracic spine in women.

Purpose: Advanced glycation end products (AGEs) have been implicated in the pathogenesis of sarcopenia. The objective of the study was to investigate the prevalence of sarcopenia in degenerative lumbar scoliosis (DLS), and the relationship between biochemical markers including major AGEs, pentosidine, and DLS in older women. Methods: Our study participants were 20 elderly women with idiopathic DLS (mean age 76.4 years, range 56–88). Nineteen age- and sex-matched volunteers (mean age 74.0 years, range 62–86) served as controls. Spinal and femoral BMD of all participants was measured using dual-energy X-ray absorptiometry. We used a bioelectrical impedance analyzer to analyze body composition, including appendicular skeletal muscle mass index [SMI appendicular lean mass (kg)/(height (m)]2. SMI OpenSPiltSPi 5.75 was considered diagnostic for sarcopenia. Coronal and sagittal spinal alignments were measured. The following biochemical markers were measured: serum and urinary pentosidine, serum homocysteine, 1,25(OA)2D, and 25(OH)D. The level of each variable was compared between DLS and controls. The relationship between biochemical markers including pentosidine and DLS was examined. Results: Sarcopenia was observed at a high prevalence in participants with DLS: 50% compared with 15.8% of healthy controls. Height, weight, femoral BMI, appendicular lean mass, total lean mass, and SMI all had significantly lower values in the DLS group. Serum pentosidine was significantly higher for the DLS group compared with controls. Correlations with serum pentosidine revealed a significant positive correlation between lumbar scoliosis, pelvic tilt, and pelvic incidence-lumbar lordosis mismatch, and a significantly negative correlation between thoracic kyphosis (P OpenSPiltSPi 0.05). Conclusions: We found that sarcopenia was involved in DLS, and high serum pentosidine levels are associated with severity of coronal and sagittal malalignment in older women, suggesting that high levels of AGEs are a potential biomarker for the progression of lumbar scoliosis and kyphotic deformity. Further studies are needed to clarify the pathogenesis of DLS.