古矢 丈雄

The aim of this study was to elucidate the bone regeneration-inducing capability of Affinos®, a newly developed, high-porosity unidirectional porous β-TCP artificial bone. We compared the ability of Affinos® and OSferion®, a commercially available β-TCP product, to induce bone regeneration following implantation into bony defects left after fibula harvesting for spinal fusion surgery. Study subjects underwent surgery to harvest non-vascularized fibula grafts for spinal fusion surgery and were implanted with either Affinos® (19 patients) or OSferion® (15 patients, control group) at the defect site. The minimal and mean follow up periods were 6 and 11 months after surgery, respectively. X-rays of the lower leg taken 1-2 weeks after surgery and at the final follow-up visit were used to evaluate fibular-β-TCP continuity and fibula defect filling ratio. There was no significant difference in radiographic continuity in the fibula between the two groups. The fibula defect filling ratio for the Affinos® group decreased from 0.94 ± 0.17 at 1-2 weeks to 0.77 ± 0.14 at 10 months. For the OSferion® control group, the fibula defect filling ratio decreased from 0.94 ± 0.14 at 1-2 weeks to 0.52 ± 0.27 at final follow-up. The Affinos® group showed a significantly higher fibula defect filling ratio compared to that for the OSferion® group (p = 0.003). These results indicate that Affinos® has slow absorption rates and significant defect filling activity compared with OSferion®. Thus, Affinos® could be a suitable substitute to fill bony defects induced by fibula harvesting for spinal reconstruction surgery.

BACKGROUND: Intradural extramedullary spinal metastasis is a relatively rare condition. Furthermore, there are few reports with the initial presentation being a neurological symptom from an intradural metastasis. We report a case of a patient with metastasis to the cauda equina from breast cancer found due to neurological symptoms as the initial presentation. CASE PRESENTATION: A 76-year-old Japanese woman who was previously healthy presented to our hospital with bilateral severe buttock and lower extremity pain without any history of injury. A solitary intradural cauda equina mass was found by magnetic resonance imaging at the L2/3 level, and we suspected a schwannoma initially. The patient hoped to undergo surgery due to the severe pain. However, the chest computed tomographic scan obtained to assess the patient's general status showed the suspected breast cancer of the left side and a lung metastasis. Hence, we considered the possibility of cauda equina tumor metastatic from the breast cancer. We performed an L1-3 laminectomy and tumor extirpation. The pathology revealed adenocarcinoma. After surgery, she had relief from pain, and her status remained satisfactory until she died 9 months after surgery. CONCLUSIONS: It is difficult to clarify whether the cauda equina tumor is benign or malignant based only on Magnetic resonance imaging findings. Clinicians should consider the possibility of metastasis when planning the surgery for intradural cauda equina tumor extirpation.

PURPOSE: We investigated the involvement of sarcopenia in middle-aged and elderly women with degenerative lumbar scoliosis (DLS). METHODS: A total of 971 women (mean age 70.4 years) were included in our study. These included 87 cases of DLS (mean 73.8 years) and 884 controls (69.8). Lumbar and femur BMD was measured for all participants 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. We determined bone density and skeletal muscle mass in both groups and determined the prevalence of sarcopenia. We examined the correlation between bone density and appendicular muscle mass in both groups. We also examined factors related to scoliosis using logistic regression analysis. RESULTS: The DLS group showed significantly higher lumbar BMD, lower femur BMD, lower lean mass arm, and lower lean mass leg, and lower lean mass trunk (p < 0.05). Sarcopenia prevalence (SMI < 5.75) was 59.8% in DLS subjects and 42.8% in controls, revealing a high prevalence in DLS (p < 0.05). In both groups, lumbar and femur BMD were positively correlated with appendicular muscle mass. By logistic regression analysis, trunk muscle mass was detected as a risk factor for DLS independent of age (p < 0.05). CONCLUSIONS: In middle-aged and elderly women, prevalence of sarcopenia was 59.8% in DLS cases and 42.8% in controls, which revealed a high prevalence in DLS. A decrease in trunk muscle was a significant risk factor for DLS that was independent of age. These slides can be retrieved under Electronic Supplementary Material.

近年では超高齢社会を背景に、骨粗鬆症に起因する脆弱性骨折に対する手術が多く実施されるようになってきている。そこで本稿では、脆弱性骨折手術後の骨粗鬆症薬物療法について、1)骨癒合促進、2)二次骨折予防の2つの観点から概説する。(著者抄録)

新鮮脆弱性椎体骨折に対しweekly PTH製剤(テリボン56.5μg、週1回皮下注射)を投与した50例を対象に、投与前から投与後10週に日本整形外科学会腰痛評価質問票(JOABPEQ)を患者本人が毎週回答を記載した。得られたデータを集計し、疼痛改善の指標として疼痛関連障害スコア、ADL改善の指標として社会生活障害スコアの変化を調査した。その結果、疼痛関連障害スコアは投与前と比較して経時的に増加し、投与後6週以降に投与前と比較し20ポイント以上の上昇を認めた。また、社会生活障害スコアも投与前と比較して経時的に増加し、投与後8週以降に20ポイント以上の上昇を認めた。新鮮脆弱性椎体骨折はweekly PTH製剤投与により疼痛は6週、ADLは8週で改善すると考えられた。

Study design: A multicenter cross-sectional study. Objectives: To clarify the relationship of trunk muscle mass with low back pain, spinal sagittal balance, and quality of life. Summary of background data: Few reports have investigated the relationship of trunk muscle mass with lumbar spine function and spinal balance, and the clinical significance of trunk muscle mass remains unclear. Methods: Patients attending spinal outpatient clinics at 10 different medical institutions were enrolled in this study. Patient demographics, trunk muscle mass and appendicular skeletal muscle mass (ASM) measured by bioelectrical impedance analysis (BIA), body mass index (BMI), Charlson Comorbidity Index (CCI), the Oswestry Disability Index (ODI), visual analog scale (VAS) for low back pain, sagittal vertical axis (SVA), and EuroQol 5 Dimension (EQ5D) score were investigated. Multivariate nonlinear regression analysis was used to investigate the association of trunk muscle mass with the ODI, VAS score, SVA, and EQ5D score. Results: Of 2551 eligible patients, 1738 (mean age 70.2 ± 11.0 years; 781 men and 957 women) were enrolled. Trunk muscle mass was significantly correlated with the ODI, VAS score, SVA, and EQ5D score (P < 0.001) when adjusted for age, sex, BMI, ASM, CCI, and history of lumbar surgery. Patient deterioration was associated with a decrease in trunk muscle mass, and the deterioration accelerated from approximately 23 kg. Conclusions: Trunk muscle mass was significantly associated with the ODI, VAS score, SVA, and EQ5D score. Trunk muscle mass may assume an important role to elucidate and treat lumbar spinal dysfunction and spinal imbalance. Graphical abstract: These slides can be retrieved under Electronic Supplementary Material.[Figure not available: see fulltext.].

プレガバリンは電位依存性カルシウムチャネルのα2δサブユニットと結合し、興奮性神経伝達物質の遊離を抑制して鎮痛効果をもたらす。本邦では末梢性・中枢性神経障害性疼痛や線維筋痛症に伴う疼痛、帯状疱疹後神経痛、糖尿病性神経障害に伴う痛みやしびれ、脊髄損傷後疼痛などに対して有意な鎮痛効果が示されている。一方でめまいや鎮静、傾眠などの副作用が知られており、最小用量から開始し漸増するなどの処方の工夫によりその発生が抑制されうる。腎機能低下症例、透析症例では慎重投与を心がけることが重要である。神経障害性疼痛に加え侵害受容性疼痛や心理社会的要因など多因子由来の病態である慢性の腰下肢痛に対しては必ずしも全例で効果を示すわけではないが、この場合NSAIDsなどの併用処方が有用である。本剤処方において最も重要なのは入念な診察に基づく確実な神経障害性疼痛の診断であり、臀部痛・下肢痛症例における神経障害性疼痛の関与の報告はその根拠のひとつとなる。(著者抄録)

BACKGROUND: Giant cell tumor is known to be a benign neoplasm that arises most commonly in the long bones, while cases in the spine are rare. Recently, denosumab, a monoclonal antibody that inhibits receptor activator of nuclear factor-kappa β ligand, has been used to treat patients with giant cell tumor. However, there are few reports of total en bloc spondylectomy being used for paravertebral giant cell tumor lesions following denosumab therapy. CASE PRESENTATION: Our patient was a 20-year-old Japanese woman with a 4-month history of lower back pain. A spinal computed tomography scan and magnetic resonance imaging of her lumbar spine revealed an osteolytic lesion involving the L3 vertebral body, and the tumor extended toward the left side of the paravertebral soft tissue and into the left pedicle. The lesion was diagnosed as a giant cell tumor by needle biopsy. Denosumab treatment calcified the paravertebral giant cell tumor lesion and the tumor vertebral body was removed completely by total en bloc spondylectomy. CONCLUSION: This case report describes a patient with a paravertebral giant cell tumor who was successfully treated by preoperative denosumab injection followed by total en bloc spondylectomy.

脊髄刺激療法は難治性腰痛患者の痛みを軽減し、歩行機能を中心とした患者のADL改善につながる治療法である。自験例ではオピオイド等の鎮痛薬減量により患者の身体的負担の軽減や医療経済の改善にも有効な手段であった。近年、デバイス改良によりMRI対応可能となり、さらには自動刺激調整機能が備わった。適応疾患および病態を見極め、心理的サポート等包括的な医療を行うことで更なる効果が期待できる。今後、高齢化社会に伴いさらに増加すると予想される難治性疼痛患者に対する選択肢となり得る治療法である。(著者抄録)

＜文献概要＞超高齢社会における最近のtopicとしてサルコペニアがあり,高齢者の運動機能低下の要因として注目を集め様々な研究が実施されている.加齢性サルコペニアには筋再生能の低下,内分泌機能異常,微小炎症(炎症性サイトカイン),ビタミンDおよびビタミンD受容体,骨粗鬆症など様々な誘因がある.さらにそれらの誘因は相互作用を有しており,複雑な病態をなしていることを理解することが重要である.

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.