古矢 丈雄

Lateral lumbar interbody fusion(LLIF)の特徴は、前方の矯正力が強いため、椎間板性腰痛、腰椎すべり症、成人脊柱変形に応用されている。後側彎症への高い矯正率、狭窄症に対する、間接除圧手術が可能である。術中の神経へ低侵襲で、出血が少ないとされている。ただし、内臓損傷(腹膜、胸膜、大腸、尿管など)、血管損傷などの合併症も報告されており、十分注意すべきである。(著者抄録)

L5の椎体全切除術(以下TS)はその前方に大血管分岐部があるという解剖学的な特徴から困難とされる。さらに椎体切除後の脊椎前方要素の再建材料はL5専用のものはないため腰椎前彎にあわせて材料を形作る必要があり,適した形に成形するのは難しい。そのような中でケージに前彎角をつけることができ,伸縮が可能なエクスパンダブルケージは前方要素の再建に最も適していると考えられる。本症例は68歳男性でL5に発生した原発性悪性腫瘍に対してTSを施行した。患者は初診時,腫瘍による神経根の圧排からの下肢痛を訴えており歩行不可能であった。我々はII期的にTSを計画し,初回手術で後方要素の摘出とスクリューとロッドによる後方要素の固定を施行し2回目手術で前方要素の摘出と再建を行った。再建は前彎角を減ずるためS1頭側終板を楔状に骨切りし,その後にエクスパンダブルケージを挿入し伸長させ固定を行い脊柱の安定性を獲得した。患者は術後6ヵ月で独歩可能となった。L5TSを行う場合,前方要素の再建にエクスパンダブルケージは有用である。解剖学的位置の複雑性や前方再建の困難度,患者の侵襲を考慮するとL5TSを行う際は後方手術,前方手術で日を分けて2期的に行うことも望ましいと考えられる。(著者抄録)

Background: Patients with osteoporosis but no evidence of fracture can sometimes report low back pain. However, few studies have evaluated the nature of osteoporotic low back pain in a clinical situation. Therefore, the aim of this study was to examine the nature of osteoporotic low back pain without fracture, and the analgesic effect of minodronic acid hydrate on such pain. Methods: The current study examined 136 patients with osteoporotic low back pain and no lower extremity symptoms. The following factors were evaluated before and after minodronic acid hydrate administration: the nature of osteoporotic low back pain was evaluated using the painDETECT questionnaire, numeric rating scale (NRS) score for low back pain at rest and in motion, bone mineral density (BMD) of the lumbar spine, and the serum concentration of tartrate-resistant acid phosphatase 5b (TRACP-5b) as a bone metabolism marker. Results: A total of 113 patients were enrolled. The painDETECT questionnaire revealed the percentage of patients with nociceptive pain and neuropathic or mixed pain was approximately 85% and 15%, respectively. the average NRS scores for low back pain at rest decreased significantly 2 months after treatment (p = 0.01), while those in motion decreased significantly 1 month after treatment (p = 0.04). The average lumbar spine BMD tended to increase after treatment, but not significantly. On the other hand, the changes in the average serum concentration of TRACP-5b did significantly decrease 1 month after treatment. There was a significant positive correlation between the rate of NRS score improvement for low back pain at rest, and the rate of improvement in serum concentration of TRACP-5b (p < 0.05). Conclusions: Osteoporotic low back pain consisted of 85% nociceptive pain and 15% neuropathic or mixed pain. The pain is strongly related to pain at rest rather than that in motion. (C) 2017 The Japanese Orthopaedic Association. Published by Elsevier B.V. All rights reserved.

Study Design: Observational study. Purpose: To assess the correlation among inflammatory cytokine expression levels, degree of intervertebral disk (IVD) degeneration, and predominant clinical symptoms observed in degenerative disk disease (DDD). Overview of Literature: Low back pain (LBP) is associated with inflammatory cytokine expression levels, including those of tumor necrosis factor-alpha (TNF-α), interleukin 6 (IL-6), and nerve growth factor (NGF). However, the association between cytokine expression levels and the physiological mechanisms of disk degeneration and clinical pain remain controversial. Methods: Using the enzyme-linked immunosorbent assay, TNF-α, IL-6, and NGF expression levels were analyzed in 58 IVD samples that were harvested from patients with lumbar DDD. Patient samples were grouped according to the degree of IVD degeneration using the Pfirrmann grading system and magnetic resonance imaging, and the correlations between the disease groups and each cytokine expression level were assessed. In addition, on the basis of their predominant preoperative symptoms, the patients were assigned to either an LBP or leg pain group to determine the correlation among these disease manifestations and individual cytokine expression levels. Results: A gradual increase in TNF-α (R=0.391) and IL-6 (R=0.388) expression levels correlated with the degree of IVD degeneration, whereas NGF (R=0.164) expression levels exhibited a minimal decrease with disease progression. Regarding the predominant clinical manifestation, only the LBP group exhibited a significant increase in TNF-α expression levels (p =0.002). Conclusions: These results suggested that TNF-α and IL-6 play an important role in the pathophysiology of IVD degeneration at any stage, whereas NGF plays an important role during the early disease stages. Moreover, because TNF-α expression levels were significantly high in the LBP group, we propose that they are involved in LBP onset or progression.

Study Design: Controlled laboratory study.Purpose: This study aimed to evaluate the efficacy of platelet-rich plasma (PRP) stored at room temperature (RT), frozen, or after freeze-drying. Overview of Literature: PRP enriches tissue repair and regeneration, and is a novel treatment option for musculoskeletal pathologies. However, whether biological activity is preserved during PRP storage remains uncertain.Methods: PRP was prepared from blood of 12 healthy human volunteers (200 mL/person) and stored using three methods: PRP was stored at RT with shaking, PRP was frozen and stored at -80 degrees C, or PRP was freeze-dried and stored at RT. Platelet counts and growth factor content were examined immediately after preparation, as well as 2, 4, and 8 weeks after storage. Platelet activation rate was quantified by flow cytometry. Results: Platelet counts were impossible to determine in many RT samples after 2 weeks, but they remained at constant levels in frozen and freeze-dried samples, even after 8 weeks of storage. Flow cytometry showed approximately 80% activation of the platelets regardless of storage conditions. Almost no growth factors were detected in the RT samples after 8 weeks, while low but significant expression was detected in the frozen and freeze-dried PRP. Over time, the mean relative concentrations of various growth factors decreased significantly or disappeared in the RT group. In the frozen group, levels were maintained for 4 weeks, but decreased significantly by 8 weeks (0.05). The freeze-dried group maintained baseline levels of growth factors for the entire 8-week duration.Conclusions: Freeze-drying enables PRP storage while maintaining bioactivity and efficacy for extended periods.

Study Design: Retrospective case series. Purpose: The purpose of this study was to determine whether discontinuing teriparatide treatment and replacing it with bisphosphonate treatment maintains the volume of the fusion mass after posterolateral fusion (PLF) in women with postmenopausal osteoporosis. Overview of Literature: Clinical data support the efficacy of parathyroid hormone (PTH) for lumbar PLF. However, the use of PTH is limited to 2 years. Methods: We treated 19 women diagnosed with osteoporosis and degenerative spondylolisthesis with teriparatide (20 ug daily subcutaneously). All patients underwent one-level instrumented PLF. Teriparatide was used during 2 months prior to surgery and more than 8 months after surgery. After discontinuing teriparatide treatment, all patients used bisphosphonate (17.5 mg risedronate weekly, oral administration). Area of the fusion mass across the transverse processes at one segment was determined on an anteroposterior radiograph at 1, 2, and 3 years after surgery. Results: We followed 19 patients for 3 years. The average duration of teriparatide treatment was 11.5 months. The bone union rate was 95%. The average area of the bone fusion mass was not significantly different between the right and left sides at 1, 2, or 3 years after surgery (p&gt 0.05). Conclusions: This study showed that replacing teriparatide treatment with bisphosphonate maintained the bone fusion mass volume after PLF in women with postmenopausal osteoporosis. Copyright

Study design. Retrospective multi-center study. Objective. This study was conducted to clarify the incidence and neurological outcomes of fall-related deterioration of subjective symptoms in patients undergoing surgical treatment.Summary of Background Data.The evidence that minor trauma, including falls, increases the risk of worsening cervical myelopathy is insufficient. Methods. A retrospective analysis of patients who had undergone surgery for cervical myelopathy at 12 participating institutes was conducted. Patients who had undergone surgery for symptomatic cervical myelopathy from January 2012 to December 2013 and completed at least 1-year follow-up were included in this study. Data were collected by chart review and a questionnaire that included numbers of recalled falls during the last preoperative year and first postoperative year, circumstances of falls, and whether the patient had experienced fall-related deterioration of subjective symptoms. Results. A total of 360 eligible patients were recruited into the study. Of these, 177 (49%) reported at least one fall during the last preoperative year, and 105 (29%) experienced fall-related deterioration of subjective symptoms. Forty (11%) reported deterioration of numbness in the arms or legs, and 65 (18%) reported deterioration of motor deficits. Incidences of falls and fall-related deterioration of symptoms decreased significantly after surgery. Patients who experienced fall-related deterioration of motor deficits showed significantly worse surgical outcomes as assessed by Japanese Orthopaedic Association (JOA) score compared with those who did not experience deterioration. The optimal cut-off for preoperative JOA score in predicting an increased risk of fall-related deterioration in motor deficits was 8. Conclusion. Patients with cervical myelopathy commonly experienced preoperative fall-related deterioration of subjective symptoms, associated with significantly worse neurological outcomes. Surgical treatment significantly reduced the incidence of both falls and fall-related deterioration of subjective symptoms.

Recently, it has been reported that impairment by an 8th cervical nerve root lesion can cause drop finger, namely C8 drop finger. Here, we report a clinical case series of C8 drop finger to reveal the clinical outcome of surgical treatments to allow for a better choice of treatment. The present study included 17 consecutive patients who were diagnosed as having C8 drop finger, in which muscle strength of the extensor digitorum communis (EDC) showed a manual muscle testing (MMT) grade of 3 or less. We retrospectively investigated the clinical characteristics of C8 drop finger and recovery of muscle power was measured by subtraction of preoperative MMT of the EDC from the final follow-up values. Nine cases showed recovery of muscle power of EDC, whereas the remaining eight cases did not show any recovery including two cases of deterioration. None of the conservatively treated patients showed any recovery. Surgically treated cases included two cases of deterioration. In the cases showing recovery, recovery began 9.9 months after surgery on average and recovery took 13.8 months after surgery on average. There was a significant difference in the recovery of MMT grade between the groups treated conservatively and surgically (p = 0.049). Preoperative MMT grade of EDC showed a moderate correlation with postoperative recovery (r (2) = 0.45, p = 0.003). In other words, the severity of preoperative muscular weakness correlated negatively with postoperative recovery. C8 drop finger is better treated by surgery than conservative therapy.

OBJECTIVE: It is important to develop an easy means of diagnosing lumbar foraminal stenosis (LFS) in a general practice setting. We investigated the use of the Japanese Orthopaedic Association Back Pain Evaluation Questionnaire (JOABPEQ) to diagnose LFS in symptomatic patients. METHODS: Subjects included 13 cases (mean age, 72 years) with LFS, and 30 cases (mean age, 73 years) with lumbar spinal canal stenosis (LSCS) involving one intervertebral disc. The visual analogue scale score for low back pain and leg pain, the JOABPEQ were evaluated. RESULTS: Those with LFS had a significantly lower JOA score (p<0.001), while JOABPEQ scores (p<0.05) for lumbar dysfunction and social functioning impairment (p<0.01) were both significantly lower than the scores in LSCS. The following JOABPEQ questionnaire items (LFS vs. LSCS, p-value) for difficulties in: sleeping (53.8% vs. 16.6%, p<0.05), getting up from a chair (53.8% vs. 6.6%, p<0.001), turning over (76.9% vs. 40%, p<0.05), and putting on socks (76.9% vs. 26.6%, p<0.01) such as pain during rest, and signs of intermittent claudication more than 15 minutes (61.5% vs. 26.6%, p<0.05) were all significantly more common with LFS than LSCS. CONCLUSION: Results suggest that of the items in the JOABPEQ, if pain during rest or intermittent claudication is noted, LFS should be kept in mind as a cause during subsequent diagnosis and treatment. LFS may be easily diagnosed from LSCS using this established patient-based assessment method.