古矢 丈雄

＜文献概要＞頸椎単純X線側面像を用いて,頸椎症,頸椎後縦靱帯骨化症,正常例を鑑別するための畳み込みニューラルネットワーク(CNN)の診断能力を,脊椎外科医の診断能力と比較した.CNNの性能は,脊椎外科医と同等かそれ以上であった.

Although traumatic cervical spine injuries in older adults are commonly caused by minor traumas, such as ground-level falls, their prognosis is often unfavorable. Studies examining the clinical characteristics of cervical spine injuries in older adults according to the external cause of injury are lacking. This study included 1512 patients of ≥ 65 years of age with traumatic cervical spine injuries registered in a Japanese nationwide multicenter database. The relationship between the external causes and clinical characteristics, as well as factors causing unfavorable outcomes at the ground-level falls, were retrospectively reviewed and examined. When fall-induced cervical spine injuries were categorized and compared based on fall height, the patients' backgrounds and injury statuses differed significantly. Of note, patients injured from ground-level falls tended to have poorer pre-injury health conditions, such as medical comorbidities and frailty, compared with those who fell from higher heights. For ground-level falls, the mortality, walking independence, and home-discharge rates at 6 months post-injury were 9%, 67%, and 80%, respectively, with preexisting medical comorbidities and frailty associated with unfavorable outcomes, independent of age or severity of neurological impairment at the time of injury.

BACKGROUND: The 1-year mortality and functional prognoses of patients who received surgery for cervical trauma in the elderly remains unclear. The aim of this study is to investigate the rates of, and factors associated with mortality and the deterioration in walking capacity occurring 1 year after spinal fusion surgery for cervical fractures in patients 65 years of age or older. METHODS: Three hundred thirteen patients aged 65 years or more with a traumatic cervical fracture who received spinal fusion surgery were enrolled. The patients were divided into a survival group and a mortality group, or a maintained walking capacity group and a deteriorated walking capacity group. We compared patients' backgrounds, trauma, and surgical parameters between the two groups. To identify factors associated with mortality or a deteriorated walking capacity 1 year postoperatively, a multivariate logistic regression analysis was conducted. RESULTS: One year postoperatively, the rate of mortality was 8%. A higher Charlson comorbidity index (CCI) score, a more severe the American Spinal Cord Injury Association impairment scale (AIS), and longer surgical time were identified as independent factors associated with an increase in 1-year mortality. The rate of deterioration in walking capacity between pre-trauma and 1 year postoperatively was 33%. A more severe AIS, lower albumin (Alb) and hemoglobin (Hb) values, and a larger number of fused segments were identified as independent factors associated with the increased risk of deteriorated walking capacity 1 year postoperatively. CONCLUSIONS: The 1-year rate of mortality after spinal fusion surgery for cervical fracture in patients 65 years of age or older was 8%, and its associated factors were a higher CCI score, a more severe AIS, and a longer surgical time. The rate of deterioration in walking capacity was 33%, and its associated factors were a more severe AIS, lower Alb, lower Hb values, and a larger number of fused segments.

＜文献概要＞はじめに 日本は超高齢社会に突入し,多くの診療科において治療対象患者の高齢化が進んでいる.整形外科でも同様であり,整形外科手術を受ける患者の半数以上が60歳以上といわれ,今後もその割合が増えると予想される.脊椎脊髄手術も同様であり,2011年の脊椎脊髄手術を受けた患者の最多年齢層は70歳代(28.5%)と報告されている.治療対象の高齢化に伴い,併存基礎疾患に対して,抗血小板薬や抗凝固薬を服用している患者が増加している.冠動脈疾患患者のうち,経皮的冠動脈形成術(percutaneous coronary intervention:PCI)後の患者の5～25%は,PCI後5年以内に非心臓手術を受ける可能性があるが,PCI後の患者は,非心臓手術後早期の心血管イベントのリスクが高いと報告されている.その中で,PCI後の患者を含め,冠動脈疾患患者の非心臓手術を安全に施行するための努力が求められており,脊椎脊髄手術を含む整形外科手術も同様である.そんな中,2020年に日本循環器学会から「冠動脈疾患患者における抗血栓療法ガイドライン」が示され,2022年に「非心臓手術における合併心疾患の評価と管理に関するガイドライン」の改訂版が出された.冠動脈疾患患者の多くは,抗血小板薬や抗凝固薬を内服しているため,非心臓手術の際には休薬するほうが出血のリスクは低下するが,休薬することで,心血管イベントなどのリスクが上昇する.これらの薬剤の休薬の可否について明確なコンセンサスは得られていない.整形外科手術の中でも,脊椎脊髄手術は緊急手術が比較的多く,休薬できない場面も想定され,術後の硬膜外血腫発生に注意が必要である.また,近年では手術侵襲もさまざまである.そこで,整形外科手術のうち,特に脊椎脊髄手術の周術期の抗血小板薬,抗凝固薬の休薬について,文献的考察を行ったので報告する.

＜文献概要＞環椎-軸椎間の前後方向への転位は強靱な横靱帯によって制御されており,その構造が破綻すると不安定性が生じる。ダウン症候群では横靱帯の弛緩により12～24%に環軸椎不安定性が存在するが,ほとんどは無症候性である。歯突起骨を合併すると高度な不安定性を生じやすくなり脊髄症発症のリスクが増す。関節リウマチでは炎症が正中環軸関節に波及して横靱帯が機能不全に陥ると環軸椎亜脱臼を生じる。外側環軸関節の破壊によって関節面が沈下すると軸椎垂直性脱臼に進行する。歯突起骨,環椎頭蓋癒合,頭蓋底陥入,Klippel-Feil症候群などの頭蓋頸椎移行部奇形では不安定性を生じやすい。歯突起骨折,横靱帯断裂などの外傷によっても不安定性が生じる。Grisel症候群では後咽頭の感染が上位頸椎に波及して不安定性が生じる。手術では通常,環軸椎後方固定術または後頭骨頸椎後方固定術が選択される。

OBJECTIVE: The management of cervical spine injuries in the elderly is often complicated by the presence of multiple medical comorbidities, and it is not uncommon for preoperative testing to reveal other conditions that require the postponement of surgery. However, the factors that affect the waiting time from injury to surgery have not been clarified. The purpose of this multicenter database study was to analyze the clinical features and identify the factors affecting the number of days waited between injury and surgery in elderly patients with cervical spine injury. METHODS: We retrospectively reviewed the case histories of 1512 Japanese patients with cervical spinal injury who were seen at among 33 institutions. After excluding patients not initially receiving surgery for cervical spinal injury, 694 patients were ultimately analyzed. Based on a multivariate mixed model, we determined the factors related to the number of days from injury to surgery. RESULTS: The mean time from injury to surgery was 12.3 days. Multivariate analysis revealed delays of 10.7 days for renal disorder, 7.3 days for anticoagulant use, and 15.2 days for non-surgical thoracolumbar fracture as factors prolonging wait time. In contrast, a C3 or lower spine injury was significantly associated with a shortening of 9.5 days to surgery. CONCLUSIONS: This multicenter database study identified several factors influencing the time between injury and cervical spine surgery in elderly patients. While renal impairment, anticoagulant use, and non-surgical thoracolumbar fracture may increase the number of days to surgery, trauma to C3 or lower may expedite surgical treatment.

STUDY DESIGN: A prospective multicenter study. OBJECTIVE: This study aims to evaluate patient-reported outcomes using the Japanese Orthopedic Association Cervical Myelopathy Evaluation Questionnaire (JOACMEQ) and clarify clinical factors that affect the therapeutic effects for patients with cervical ossification of the posterior longitudinal ligament (OPLL). SUMMARY OF BACKGROUND DATA: Although previous studies identified factors that affected the surgical outcomes, their assessment was mainly based on the Japanese Orthopedic Association score, which only includes neurological function. Investigating this pathology through multiple functions and quality of life (QOL) is pivotal to understanding the comprehensive clinical pictures of the cervical OPLL and its therapeutic outcomes. MATERIALS AND METHODS: This study was performed by the Japanese Multicenter Research Organization for Ossification of the Spinal Ligament. A total of 478 patients with myelopathy caused by cervical OPLL from 28 institutions were prospectively registered from 2014 to 2017 and followed up for 2 years. Of the patients, 168 received laminoplasties and fully completed questionnaires. Demographic information, imaging findings, and clinical outcomes were collected. Patients were grouped according to effective or ineffective surgical outcomes as defined by the JOACMEQ using logistic regression analyses. RESULTS: Laminoplasty resulted in functional improvement in the cervical spine and upper extremity around 40% of the patients, while QOL showed only 21.4% ( P <0.01). Multivariable analyses revealed that younger age and a postoperative decrease in arm or hand pain were correlated with significantly improved function of the upper extremities. A reduction in lower limb pain favorably affected the postoperative lower extremity function. A postoperative reduction in upper extremity pain enhanced the QOL recovery. CONCLUSIONS: Surgeons should recognize the diversity of surgical outcomes after laminoplasty and understand the necessity of pain management even after the surgery to enhance bodily functions and QOL in patients with cervical OPLL.

Introduction: In elderly patients with cervical spinal cord injury, comorbidities such as cardiovascular and cerebrovascular diseases are common, with frequent administration of antiplatelet/anticoagulant (APAC) drugs. Such patients may bleed easily or unexpectedly during surgery despite prior withdrawal of APAC medication. Few reports have examined the precise relationship between intraoperative blood loss and history of APAC use regarding surgery for cervical spine injury in the elderly. The present multicenter database survey aimed to answer the question of whether the use of APAC drugs affected the amount of intraoperative blood loss in elderly patients with cervical spinal cord trauma. Methods: The case histories of 1512 patients with cervical spine injury at 33 institutes were retrospectively reviewed. After excluding cases without spinal surgery or known blood loss volume, 797 patients were enrolled. Blood volume loss was the outcome of interest. We calculated propensity scores using the inverse probability of treatment weighting (IPTW) method. As an alternative sensitivity analysis, linear mixed model analyses were conducted as well. Results: Of the 776 patients (mean age: 75.1±6.4 years) eligible for IPTW calculation, 157 (20.2%) were taking APAC medications before the injury. After weighting, mean estimated blood loss was 204 mL for non-APAC patients and 215 mL for APAC patients. APAC use in elderly patients was not significantly associated with surgical blood loss according to the IPTW method with propensity scoring or linear mixed model analyses. Thus, it appeared possible to perform surgery expecting comparable blood loss in APAC and non-APAC cases. Conclusions: This multicenter study revealed no significant increase in surgical blood loss in elderly patients with cervical trauma taking APAC drugs. Surgeons may be able to prioritize patient background, complications, and preexisting conditions over APAC use before injury when examining the surgical indications for cervical spine trauma in the elderly.

＜文献概要＞腰椎疾患は多岐にわたり保存治療が最優先であるが,症状が軽快しない場合,侵襲的な治療が選択される。腰痛や長期的に障害を受けた場合の下肢筋力の低下や萎縮,足底のしびれなどは残存する可能性が高い。また,多数回手術後のfailed back surgery syndromeは難治性であり,注意を要する。

BACKGROUND: The purpose of this study was to clarify the clinical features of ossification of the posterior longitudinal ligament (OPLL) and extreme ossification at multiple sites. METHODS: This prospective study involved patients with a diagnosis of cervical OPLL at 16 institutions in Japan. Patient-reported outcome measures, including responses on the Japanese Orthopaedic Association (JOA) Cervical Myelopathy Evaluation Questionnaire (JOA-CMEQ), JOA Back Pain Evaluation Questionnaire (JOA-BPEQ), and visual analog scale pain score, were collected to investigate clinical status. In each patient, the sum of the levels at which OPLL was located (OP index) was evaluated on whole-spine computed tomography, along with ossification of other spinal ligaments including the anterior longitudinal ligament (OALL), ligament flavum (OLF), supra- and intraspinous ligaments (SSL), and diffuse idiopathic skeletal hyperostosis (DISH). The distribution of OP index values in the study population was investigated, and the clinical and radiologic characteristics of patients in the top 10% were assessed. RESULTS: In total, 236 patients (163 male, 73 female; mean age 63.5 years) were enrolled. Twenty-five patients with OP index ≥ 17 were categorized into a high OP index group and the remainder into a moderate/low OP index group. There were significantly more women in the high OP index group. Patients in the high OP index group also had significantly poorer scores for lower extremity function and quality of life on the JOA-CMEQ and in each domain but not for body pain on the JOA-BPEQ compared with those in the moderate/low OP index group. Patients in the high OP index group had more OALL in the cervical spine and more OLF and SSL in the thoracic spine. The prevalence of DISH was also significantly higher in the high OP index group. In the high OP index group, interestingly, OPLL was likely to be present adjacent to DISH in the cervicothoracic and thoracolumbar spine, especially in men, and often coexisted with DISH in the thoracic spine in women. CONCLUSION: This prospective cohort registry study is the first to demonstrate the clinical and radiologic features of patients with OPLL and a high OP index. In this study, patients with a high OP index had poorer physical function in the lumbar spine and lower extremities and were also predisposed to extreme ossification of spinal ligaments other than the OPLL.

STUDY DESIGN: Retrospective multicenter study. OBJECTIVES: To investigate the neurological outcomes of older individuals treated with surgery versus conservative treatment for cervical spinal cord injury (CSCI) without bone injury. SETTING: Thirty-three medical institutions in Japan. METHODS: This study included 317 consecutive persons aged ≥65 years with CSCI without bone injury in participating institutes between 2010 and 2020. The participants were followed up for at least 6 months after the injury. Individuals were divided into surgery (n = 114) and conservative treatment (n = 203) groups. To compare neurological outcomes and complications between the groups, propensity score matching of the baseline factors (characteristics, comorbidities, and neurological function) was performed. RESULTS: After propensity score matching, the surgery and conservative treatment groups comprised 89 individuals each. Surgery was performed at a median of 9.0 (3-17) days after CSCI. Baseline factors were comparable between groups, and the standardized difference in the covariates in the matched cohort was <10%. The American Spinal Injury Association (ASIA) impairment scale grade and ASIA motor score (AMS) 6 months after injury and changes in the AMS from baseline to 6 months after injury were not significantly different between groups (P = 0.63, P = 0.24, and P = 0.75, respectively). Few participants who underwent surgery demonstrated perioperative complications such as dural tear (1.1%), surgical site infection (2.2%), and C5 palsy (5.6%). CONCLUSION: Conservative treatment is suggested to be a more favorable option for older individuals with CSCI without bone injuries, but this finding requires further validation.

PURPOSE: Correction surgeries for spinal malalignment showed good clinical outcomes; however, there were concerns including increased invasiveness, complications, and impact on medico-economics. Ideally, an early intervention is needed. To better understand the patho-mechanism and natural course of spinal alignment, the effect of factors such as muscle mass and strength on spinal sagittal imbalance were determined in a multicenter cross-sectional study. METHODS: After excluding metal implant recipients, 1823 of 2551 patients (mean age: 69.2 ± 13.8 years; men 768, women 1055) were enrolled. Age, sex, past medical history (Charlson comorbidity index), body mass index (BMI), grip strength (GS), and trunk muscle mass (TM) were reviewed. Spinal sagittal imbalance was determined by the SRS-Schwab classification. Multiple comparison analysis among four groups (Normal, Mild, Moderate, Severe) and multinomial logistic regression analysis were performed. RESULTS: On multiple comparison analysis, with progressing spinal malalignment, age in both sexes tended to be higher; further, TM in women and GS in both sexes tended to be low. On multinomial logistic regression analysis, age and BMI were positively associated with spinal sagittal malalignment in Mild, Moderate, and Severe groups. TM in Moderate and Severe groups and GS in the Moderate group were negatively associated with spinal sagittal malalignment. CONCLUSION: Aging, obesity, low TM, and low GS are potential risk factors for spinal sagittal malalignment. Especially, low TM and low GS are potentially associated with more progressed spinal sagittal malalignment. Thus, early intervention for muscles, such as exercise therapy, is needed, while the spinal sagittal alignment is normal or mildly affected.

STUDY DESIGN: Retrospective Cohort Study. OBJECTIVE: The purpose of this study was to investigate the prognosis of respiratory function in elderly patients with cervical spinal cord injury (SCI) and to identify predictive factors. METHODS: We included 1353 cases of elderly cervical SCI patients collected from 78 institutions in Japan. Patients who required early tracheostomy and ventilator management and those who developed respiratory complications were defined as the respiratory disability group. Patients' background characteristics, injury mechanism, injury form, neurological disability, complications, and treatment methods were compared between the disability and non-disability groups. Multiple logistic regression analysis was used to examine the independent factors. Patients who required respiratory management for 6 months or longer after injury and those who died of respiratory complications were classified into the severe disability group and were compared with minor cases who were weaned off the respirator. RESULTS: A total of 104 patients (7.8%) had impaired respiratory function. Comparisons between the disabled and non-disabled groups and between the severe and mild injury groups yielded distinct trends. In multiple logistic regression analysis, age, blood glucose level, presence of ossification of posterior longitudinal ligament (OPLL), anterior vertebral hematoma, and critical paralysis were selected as independent risk factors. CONCLUSION: Age, OPLL, severe paralysis, anterior vertebral hematoma, hypoalbuminemia, and blood glucose level at the time of injury were independent factors for respiratory failure. Hyperglycemia may have a negative effect on respiratory function in this condition.

Positive association between ossification of the posterior longitudinal ligament of the spine (OPLL) and obesity is widely recognized; however, few studies focused on the effects of obesity on treatment of cervical OPLL. The effects of obesity on surgical treatment of cervical OPLL were investigated by a Japanese nationwide, prospective study. Overall, 478 patients with cervical myelopathy due to OPLL were prospectively enrolled. To clarify the effects of obesity on the surgical treatment for cervical OPLL, patients were stratified into two groups, non-obese (< BMI 30.0 kg/m2) and obese (≥ BMI 30.0 kg/m2) groups. The mean age of the obese group was significantly younger than that of non-obese group. There were no significant differences between the two groups in other demographic information, medical history, and clinical and radiographical findings. Alternatively, the obese group had a significantly higher rate of surgical site infection (SSI) than that of non-obese group. Approach-specific analyses revealed that the SSI was significantly higher in the obese group than in the non-obese group. A logistic regression analysis revealed that age, BMI, and duration of symptoms were significant factors affecting the postoperative minimum clinically important difference success. The result of this study provides useful information for future cervical OPLL treatment.

ラット脊椎固定術モデルを用いて、ロモソズマブによる骨癒合促進および骨強度上昇効果について検討した。対象は、8週目齢のSprague-Dawley雄ラット12匹とした。第10胸椎～第2腰椎までの棘突起から骨移植骨として採取し、左右両側の椎間関節部から横突起までの間に置き、自家骨移植とした。体格差を徐すため、体重を基準にロモソズマブ群(R群)6匹と、Control群(C群)6匹に分類した。R群にはロモソズマブ、C群には生理食塩水を25mg/kg、10週間、毎週2回皮下注射を投与した。術直後と術後10週目にCT装置撮影を行い、両群における椎間関節および横突起間の骨癒合率と骨癒合部の体積を比較検討した。さらに、大腿骨の骨密度の計測と、腰椎後側方固定術を施行した脊椎背側の圧縮強度を評価した。その結果、平均骨癒合率はC群に対し、R群が有意に高かった。骨癒合部の体積は、術後直後は両群間で有意差はなかったが、術後8週目では、R群が有意に大きかった。平均骨密度については、R群が有意に大きかった。脊椎背側の平均圧縮強度は、R群が有意に高かった。破断後のCTで、骨折部位は全例で、椎体軟骨の終板上に認められた。

＜文献概要＞Point ▼脊髄造影の適応,手技を提示する。▼神経根ブロックや神経根造影の適応,手技,治療効果を提示する。▼脊髄造影,神経根ブロック,神経根造影の合併症を提示する。

CASE: A 44-year-old man developed urinary retention due to a spontaneous spinal epidural hematoma (SSEH) at the cervicothoracic junction, without paraplegia. Symptoms improved with surgical treatment. CONCLUSION: SSEH is rare and causes acute neck or back pain and progressive paralysis. Patients with advanced myelopathy due to spinal cord compression lesion including SSEH often present with bladder and bowel disorders after exacerbation of quadriplegia. However, SSEH can cause predominant bladder and bowel disorders without paraplegia or quadriplegia. Physicians should consider that there can be a manifestation of myelopathy with bladder and bowel dysfunction without quadriplegia.

OBJECTIVE: The Hybrid Assistive Limb (HAL) has recently been used to treat movement disorders. Although studies have shown its effectiveness for chronic myelopathy, the immediate effects of HAL gait training on lower limb function have not been clarified. We conducted HAL gait training and examined its immediate effects on a 69-year-old man with re-deterioration of myelopathy in the chronic phase after surgery for compression myelopathy. The HAL intervention was performed every 4 weeks for 10 total sessions. Immediately before and after each session, we analyzed the patient's walking ability using the 10-m walk test. In the 4th HAL session, the gastrocnemius muscle activity was measured bilaterally using a synchronized motion capture-electromyogram system. RESULTS: The training effects became steady after the 2nd session. In sessions 2-10, the step length increased from 0.56 to 0.63 m (mean: 0.031 m) immediately after HAL training. The motion capture-electromyogram analyses showed that considerable amounts of gastrocnemius muscle activity were detected during the stance and swing phases before HAL training. During and immediately after HAL training, gastrocnemius activity during the swing phase was diminished. HAL gait training has an immediate effect for inducing a normal gait pattern with less spasticity in those with chronic myelopathy.

＜文献概要＞【目的】転移性骨腫瘍により脊椎の不安定性が高い症例に対し,骨転移キャンサーボード後に疼痛回避動作指導を中心とした理学療法が効果的であった症例について報告する.【対象】乳癌,脊椎多発転移を呈した52歳女性である.Spinal Instability Neoplastic Scoreによる脊椎の不安定性は16点であった.腰背部の疼痛が増悪し,ADLが困難となった.【方法】骨転移キャンサーボードで多職種連携し,疼痛回避動作指導を中心とした理学療法を施行した.【結果】骨転移キャンサーボードから23日間,骨関連事象が増悪せずにADLの拡大が図れた.【結語】脊椎の不安定性が高い症例に対し,骨転移キャンサーボードで多職種間の連携を強化し疼痛回避動作を中心とした理学療法を施行することで,疼痛を増悪させずにADLの拡大につなげた.

STUDY DESIGN: Retrospective observational study. PURPOSE: We investigated the correlation between T2 relaxation times and clinical symptoms in patients with cervical radiculopathy caused by cervical disk herniation. OVERVIEW OF LITERATURE: There are currently no imaging modalities that can assess the affected cervical nerve roots quantitatively. METHODS: A total of 14 patients with unilateral radicular symptoms and five healthy subjects were subjected to simultaneous apparent T2 mapping and neurography with nerve-sheath signal increased with inked rest-tissue rapid acquisition of relaxation enhancement signaling (SHINKEI-Quant) using a 3-Tesla magnetic resonance imaging. The Visual Analog Scale (VAS) score for neck pain and upper arm pain was used to evaluate clinical symptoms. T2 relaxation times of the cervical dorsal root ganglia of the brachial plexus were measured bilaterally from C4 to C8 in patients with radicular symptoms and from C5 to C8 in healthy controls. The T2 ratio was calculated as the affected side to unaffected side. RESULTS: When comparing nerve roots bilaterally at each spinal level, no significant differences in T2 relaxation times were found between patients and healthy subjects. However, T2 relaxation times of nerve roots in the patients with unilateral radicular symptoms were significantly prolonged on the involved side compared with the uninvolved side (p<0.05). The VAS score for upper arm pain was not significantly correlated with the T2 relaxation times, but was positively correlated with the T2 ratio. CONCLUSIONS: In patients with cervical radiculopathy, the SHINKEI-Quant technique can be used to quantitatively evaluate the compressed cervical nerve roots. The VAS score for upper arm pain was positively correlated with the T2 ratio. This suggests that the SHINKEI-Quant is a potential tool for the diagnosis of cervical nerve entrapment.