稲毛 一秀

STUDY DESIGN: Assessment of pain-related behavior and immunohistology of the dorsal root ganglion in a rat model. OBJECTIVE: To investigate pain-related behavior in a rat model of nerve crush plus inflammation using the CatWalk system. SUMMARY OF BACKGROUND DATA: A definitive method for evaluating animal models of lumbar disease has not been established. Von Frey testing has often been used in this type of study, but the reliability remains in question. The CatWalk system is a computer-assisted apparatus for analyzing gait that provides an automated way to assess gait function during pain. However, there have been few reports using this system for models of lumbar disease. METHODS: Fourteen rats were divided into 2 groups: a treatment group and a sham group. For the treatment group, nucleus pulposus was applied to the sciatic nerve and the sciatic nerve was pinched. Two different methods for assessment of pain-related behavior, von Frey testing and CatWalk analysis, were used before surgery and at 4 and 7 days after surgery. Immunohistochemistry was used to examine calcitonin gene-related peptide expression in L4 to L6 dorsal root ganglia. RESULTS: No significant differences were found between the treatment and sham control groups using von Frey testing. However, significant differences in 4 parameters were found between the 2 groups using the CatWalk system (P < 0.05). The proportion of calcitonin gene-related peptide-immunoreactive neurons was higher in the treatment group than in the control group (P < 0.05). CONCLUSION: Our results demonstrate that the CatWalk system is useful for the measurement of pain-related behavioral change in our rat model in which nociception was indicated at a cellular level. Although further studies are needed, we think that this system is a valid alternative method for the evaluation of models of lumbar disease in rodents.

PURPOSE: The pathological mechanism of lumbar spinal stenosis is reduced blood flow in nerve roots and degeneration of nerve roots. Exercise and prostaglandin E1 is used for patients with peripheral arterial disease to increase capillary flow around the main artery and improve symptoms; however, the ankle-brachial index (ABI), an estimation of blood flow in the main artery in the leg, does not change after treatment. Lumbar spinal nerve roots contain somatosensory, somatomotor, and unmyelinated autonomic nerves. Improved blood flow by medication with prostaglandin E1 and decompression surgery in these spinal nerve roots may improve the function of nerve fibers innervating muscle, capillary, and main vessels in the lower leg, resulting in an increased ABI. The purpose of the study was to examine whether these treatments can improve ABI. MATERIALS AND METHODS: One hundred and seven patients who received conservative treatment such as exercise and medication (n=56) or surgical treatment (n=51) were included. Low back pain and leg pain scores, walking distance, and ABI were measured before treatment and after 3 months of conservative treatment alone or surgical treatment followed by conservative treatment. RESULTS: Low back pain, leg pain, and walking distance significantly improved after both treatments (p<0.05). ABI significantly increased in each group (p<0.05). CONCLUSION: This is the first investigation of changes in ABI after treatment in patients with lumbar spinal stenosis. Improvement of the spinal nerve roots by medication and decompression surgery may improve the supply of blood flow to the lower leg in patients with lumbar spinal stenosis.

【はじめに】高齢者における後彎症は強度の腰痛の原因となりうる。後方矯正骨切術の一つpedicle subtraction osteotomy(PSO)は後彎変形に対し有用な術式であるが,周術期合併症,偽関節,それによる再手術等問題が多い。今回,PSO後のロッド折損,偽関節に対して前後合併手術を施行したので報告する。【対象】68歳女性,腰下肢痛,排尿障害を呈していた。既往として,腰部脊柱管狭窄症に対する除圧固定術,その後の隣接椎間障害による後彎症に対して,PSOを施行されていた。PSO施行6ヵ月後に偽関節とロッド折損をレントゲンで指摘された。【結果】保存療法に抵抗していたため手術を計画した。前後合併手術とした。後方手術には4本のロッドを用い,前方にはメッシュケージと,自家骨移植,さらにロッドとプレートシステムを使用した。腰下肢痛は軽快し,6ヵ月後には骨癒合を認めた。【考察】PSO後のロッド折損,偽関節に対して前後合併手術を施行した。このような非常に不安定がある偽関節には前後合併手術が有用であった。(著者抄録)

STUDY DESIGN: Prospective study. OBJECTIVE: To examine the efficacy of teriparatide or bisphosphonate treatment to reduce pedicle screw (PS) loosening after instrumented lumbar posterolateral fusion in postmenopausal women with osteoporosis. SUMMARY OF BACKGROUND DATA: Failure of fixation caused by loosening of PSs in osteoporosis is a problem in spinal surgery. Oral administration of bisphosphonate or intermittent injection of parathyroid hormone treatment increases bone mass and reduces the risk of osteoporotic vertebral fractures. Although these treatments may be factor in improving bone quality, a clinical study of the efficacy of bisphosphonate or parathyroid hormone for reducing PS loosening that addresses the quality of the bone marrow and pedicle cortex has not yet been reported. METHODS: Sixty-two women with osteoporosis diagnosed with degenerative spondylolisthesis were divided into 3 groups: a teriparatide group (daily subcutaneous injection of 20 μg of teriparatide, n = 20), a bisphosphonate group (daily oral administration 2.5 mg of risedronate, n = 20), and a control group (without medication for osteoporosis, n = 22). All patients underwent decompression and 1- or 2-level instrumented posterolateral fusion with a local bone graft. Loosening of PSs and surgical outcome were evaluated radiographically, clinically, and by computed tomography 12 months after surgery. RESULTS: At 12-month follow-up, the incidence of PS loosening was 7% to 13% in the teriparatide group, 13% to 26% in the risedronate group, and 15% to 25% in the control group. The incidence of PS loosening in the teriparatide group was significantly lower than that in the risedronate or the control group (P < 0.05). In contrast, the extent of PS loosening in the risedronate group was not significantly different from that in the control group (P > 0.05). CONCLUSION: Our findings suggest that administration of teriparatide increased the quality of the lumbar spine bone marrow and pedicle cortex.

STUDY DESIGN: Immunohistochemistry for tumor necrosis factor (TNF)-α in nucleus pulposus of adolescent patients with lumbar disc herniation. OBJECTIVE: To examine whether an inflammatory cytokine is expressed in the nucleus pulposus of adolescent patients with lumbar disc herniation. SUMMARY OF BACKGROUND DATA: TNFα is thought to play a crucial role in the radicular pain caused by lumbar disc herniation in adult patients. However, the expression of TNFα in the nucleus pulposus of adolescent patients with lumbar disc herniation has not been explored. METHODS: Five samples of nucleus pulposus from adolescent patients with lumbar disc herniation (age, 12-16 yr; n = 5) or controls requiring surgery for other back problems (age, 12-16 yr; n = 4; nonpainful scoliosis) were harvested during surgery. Nucleus pulposus specimens were immunostained using TNFα antibodies and immunostained cells in the nucleus pulposus were counted. We compared the expression of TNFα between the 2 groups. RESULTS: In patients with lumbar disc herniation, more TNFα-immunoreactive cells were seen in the nucleus pulposus in comparison with patients with nonpainful scoliosis (P < 0.01). CONCLUSION: The results suggest that TNFα may play a role in adolescent patients with lumbar disc herniation. The TNFα expression may be related with disc degeneration and pain in adolescent patients with lumbar disc herniation.

【はじめに】脊椎圧迫骨折は骨粗鬆症患者における最も問題となる症状の一つである。それ由来の痛みを解決することは,脊椎圧迫骨折の治療においての主眼である。近年諸外国で行われているballoon kyphoplasty(BKP)は疼痛が遷延する脊椎圧迫骨折に対する低侵襲のセメント注入療法である。しかしながら本邦におけるBKPの有用性に関する英語原著による報告は無い。本研究の目的は,日本人骨粗鬆症患者の脊椎圧迫骨折に対する,balloon kyphoplastyの有効性について検討する事である。【対象】骨粗鬆症由来の脊椎圧迫骨折を呈した5症例を対象とした。骨折高位は第12胸椎1症例,第1腰椎4症例であった。3か月以上の保存療法に抵抗して痛みを呈しており,これら5症例に全身麻酔下,BKPを施行した。【結果】全ての症例に関して,術前に比較して,術後12か月間に亘り有効な除痛が得られていた(P<0.05)。また,亀背の程度も,術直後から改善し,12か月間に亘り維持されていた(P<0.05)。しかしながら,1症例において術4か月後に上位隣接椎体の骨折が生じ,同部位にBKPを追加した。【考察】日本人骨粗鬆症患者の脊椎圧迫骨折に対する,balloon kyphoplastyの有効性について検討した結果,12か月間に亘り,除痛,亀背の改善に有用であった。しかしながら,隣接椎体の骨折もあり,その点も留意すべきであると考えられた。(著者抄録)

A 26-year-old paraplegic schizophrenic Japanese woman suffered from severe kyphosis and back pain derived from lumbar burst fractures caused by jumping. She had already undergone resection of the L1 and L2 spinous processes for sharp angular kyphosis, but she still had severe kyphosis and back pain at the L1 and L2. Radiographical examination revealed fused anterior columns at L1 and L2 with severe local kyphosis and a significantly decreased percutaneous distance in the back. The patient underwent anterior instrumented bony resection including an L2 vertebral osteotomy: bilateral L2-L3 facetectomy and partial posterior osteotomy of the L2 vertebrae via a posterior approach followed by an anterior corpectomy of the L2 vertebrae and insertion of a cylindrical cage. No posterior instrumentation was used owing to the presence of atrophied paraspinal soft tissues. Lumbar interbody fusion was performed with vertebral body screws extending from T12 to L4 and corresponding anterior distension and posterior compression. The procedure corrected the kyphosis by 15° and enhanced local stability. Postsurgical visual analogue scale improved from 9.0 to 2.0 and Oswestry Disability Index from 40 to 17.8, respectively. In conclusion, we have demonstrated that anterolateral interbody fusion using extended fixation can compensate for posterior corrective surgery.

Introduction. Spinal scoliosis and kyphosis in elderly people sometimes cause severe low back pain. Surgical methods such as osteotomy are useful for correcting the deformity. However, complications during and after surgery are associated with the osteotomy procedure. In particular, it is difficult to manage deformity correction surgery for patients with Parkinson's disease. Here, we present two cases of combined anterior and posterior surgery for deformity in patients with adult scoliosis and kyphosis due to Parkinson's disease. Case Presentation. Two 70-year-old women had spinal scoliosis and kyphosis due to Parkinson's disease. They had severe low back pain, and conservative treatment was not effective for the pain. Surgery was planned to correct the deformity in both patients. We performed combined posterior and anterior correction surgery. At first, posterior fusions were performed from T4 to the ilium using pedicle screws. Next, cages and autograft from the iliac crest were used in anterior lumbar surgery. The patients became symptom free after surgery. Bony fusion was observed 12 months after surgery. Conclusions. Combined posterior and anterior fusion surgery is effective for patients who show scoliosis and kyphosis deformity, and symptomatic low back pain due to Parkinson's disease.