稲毛 一秀

OBJECTIVES: To examine improvement in acute low back pain (LBP) using ultrasound-guided hydrorelease of the multifidus muscle. METHODS: This prognostic cohort study was conducted in a private clinic on samples of 75 patients with acute LBP diagnosed based on physical and imaging findings. Hydrorelease of the multifidus muscle was performed at the L4/5 level. The LBP visual analog scale (VAS) scores (cm) before and 5 minutes after hydrorelease were statistically evaluated. We defined improvement rate (%) as {LBP VAS scores (cm) immediately before hydrorelease - LBP VAS scores (cm) 5 minutes after hydrorelease} × 100 / LBP VAS scores (cm) immediately before hydrorelease and examined the correlation of the Heckmatt score and average age with the improvement rate. RESULTS: LBP VAS scores (cm) before and 5 minutes after hydrorelease were 7.19 ± 1.01 (mean ± SD) and 2.85 ± 1.25, respectively (p < 0.05). No significant correlations were noted between the LBP improvement rate and the Heckmatt score or age. There were no gender variations in the improvement rate. CONCLUSIONS: Ultrasound-guided hydrorelease of the multifidus muscle led to considerable LBP VAS score improvement at the outpatient level. The improvement rate showed no correlations with the Heckmatt score or age, and there were no significant gender variations in the improvement rate. Therefore, fatty degeneration of muscles and change in muscle echogenicity due to age and gender may not be associated with muscular LBP. These findings suggest that multifidus muscle hydrorelease could be useful in the diagnosis and treatment of acute LBP.

This study examined the factors that inhibit the therapeutic effects of cognitive behavioral therapy (CBT) and clarify the adaptation judgment criteria of CBT. We included patients with chronic low back pain and allocated them to the adaptation (with visual analog scale [VAS] improvement) or non-adaptation group (without VAS improvement). The patients were analyzed using various psychological tests. CBT improved depressive symptoms and catastrophic thinking; however, they were not correlated with the VAS and did not directly affect low back pain improvement. The non-adaptation group showed an unexplainable/vague sense of anxiety; an excessive focus on searching for pain; a strong intimacy desire; a strong tendency of medical dependency; and fantasy or distortion of the actual experience, especially self-image. Moreover, the patients showed a low ability to objectively express or attribute meaning to pain due to poor language skills, attention-deficit hyperactivity disorder, and emotional value judgment. Individuals with the aforementioned characteristics of pre-CBT psychological tests should select a different treatment approach given the high poor-adaption possibility. Even patients with depressive or anxious symptoms are not necessarily adaptable for CBT. Therefore, pre-CBT tests for treatment suitability are necessary. Future studies should establish a protocol for psychotherapy suitable for the non-adaptation group.

We investigated the relationship between trunk muscle mass and spinal pathologies by gender. This multicenter cross-sectional study included patients aged ≥ 30 years who visited a spinal outpatient clinic. Trunk and appendicular muscle mass were measured using bioelectrical impedance analysis. The Oswestry Disability Index (ODI), visual analog scale (VAS) score for low back pain, sagittal vertical axis (SVA), and EuroQol 5 Dimension (EQ5D) score were investigated to evaluate spinal pathology. The association between trunk muscle mass and these parameters was analyzed by gender using a non-linear regression model adjusted for patients' demographics. We investigated the association between age and trunk muscle mass. We included 781 men and 957 women. Trunk muscle mass differed significantly between men and women, although it decreased with age after age 70 in both genders. Lower trunk muscle mass was significantly associated with ODI, SVA, and EQ5D score deterioration in both genders; its association with VAS was significant only in men. Most parameters deteriorated when trunk muscle mass was < 26 kg in men and < 19 kg in women. Lower trunk muscle mass was associated with lumbar disability, spinal imbalance, and poor quality of life in both genders, with significant difference in muscle mass.

【目的】超高齢社会の本邦においては,ロコモティブシンドローム(ロコモ)予防の観点からバランス能力の向上をもたらすことができる確立したトレーニング法の開発が喫緊の課題といえる。そのような状況の中,我々はバランス能力向上の新たなトレーニング法としてスリングセラピーの一種であるredcordを使用したAthlete Tuning Method(ATM)トレーニングに注目した。プレリミナリーな位置付けでまずは安全性を考慮し健常ボランティアを対象とし,その有効性についてロコモ度テストを尺度して検討した。【方法】対象は健常ボランティアとした。これらの被験者に対してバランス能力向上のためにATMトレーニングを同一プロトコール(所要時間:1時間程度,頻度:週2回以上)にて実施した。評価としては,研究開始前および3ヵ月後にロコモ度テスト(立ち上がりテスト,2ステップテスト)と生体インピーダンス法(MC-780A,Tanita社)による骨格筋量指数の変化についての検討を行った。(著者抄録)

Study Design: Retrospective observational study. Purpose: Lumbar spinal stenosis (LSS) has traditionally been evaluated morphologically, there is a paucity of literature on quantitative assessment of LSS. The purpose of this study was to investigate whether intraspinal diffusion tensor imaging (DTI) parameters such as apparent diffusion coefficient (ADC) and fractional anisotropy (FA) are useful for assessing LSS. Overview of Literature: Quantitative assessment of LSS is challenging. Methods: Study participants comprised five healthy volunteers (mean age, 27.2 years) and 27 patients with LSS (mean age, 58.4 years) who were individually assessed using 3.0 Tesla magnetic resonance imaging. Intraspinal ADC and FA values of 10 intervertebral discs from healthy volunteers and 52 intervertebral discs from LSS patients were measured. Also, intraspinal canal area, Schizas classification (A: normal, B: mild stenosis, C: severe stenosis) and correlations with symptoms were investigated. Clinical symptoms were checked for the presence of low back pain (LBP), intermittent claudication (IMC), and bladder and bowel dysfunction (BBD). Results: Compared to healthy individuals, LSS patients had significantly lower ADC (p<0.05) and significantly higher FA values (p<0.01). In Schizas classification, stenosis worsened from A to C. ADC values decreased significantly while FA values increased significantly in that order (p<0.05). A positive correlation was found between intraspinal canal area and ADC values (r=0.63, p<0.01) and a negative correlation between intraspinal canal area and FA values (p=-0.61, p<0.01). No correlations were noted between LBP and ADC or FA values. On the other hand, ADC values were significantly lower (p<0.05) and FA values were significantly higher (p<0.05) in patients with IMC or BBD. Conclusions: Intraspinal DTI parameters such as ADC and FA values were associated with the Schizas classification, intraspinal canal area, and clinical symptoms, suggesting that ADC and FA may be useful for quantitative assessment of LSS.

BACKGROUND: Chronic pain is a highly refractory and complicated condition that persists even without nociception. Several genome-wide gene expression analyses have shown that the immune response and inflammatory cytokines affect chronic pain establishment in the acute pain phase. However, compared with the acute phase, the chronic phase has a poorly elucidated gene expression profile. This study aimed to determine the gene expression profile in the spinal cord of a neuropathic pain mouse model in the chronic phase to elucidate the chronic pain characteristics. METHODS: We established a sciatic nerve cuff mouse model as a neuropathic pain model by placing a 2-mm section of a split PE-20 polyethylene tube around the sciatic nerve. The spinal cord was harvested at the L4-6 level at 28 postoperative days. Next, we examined differentially expressed genes (DEGs) through RNA sequencing (RNA-seq) compared with the sham group; moreover, we conducted enrichment analyses of the expressed genes. To reveal the chronic pain characteristics, we compared the gene expression profiles of the spinal cord between the acute and chronic phases in the neuropathic pain model. Among the chronic pain-related genes categorized in the dendrites, we focused on cyclin-dependent kinase-like 5 (CDKL5). We analyzed CDKL5 expression and function using real-time polymerase chain reaction (PCR), immunohistochemistry, and neurite extension assay in Neuro 2a (N2a) cells. We used three types of CDKL5 plasmids: wild type, nuclear localization signal-attached, and K42R kinase-dead CDKL5. RESULTS: We identified 403 DEGs, including 104 upregulated and 43 downregulated genes (false discovery rate < 0.01). Rather than inflammation or immune response, the most enriched terms in the chronic phase were "regulation of plasma membrane-bounded cell projection organization" and "dendrite." Real-time PCR assay confirmed increased CDKL5 expression in the ipsilateral dorsal horn. CDKL5 was broadly expressed in the ipsilateral dorsal horn across all layers. The neurite extension assay revealed that the cytoplasmic kinase function of CDKL5 was necessary for neurite outgrowth in N2a cells. CONCLUSION: RNA-seq of the spinal cord revealed that the most enriched genes during the chronic pain phase were involved in regulating axon and dendrite morphogenesis, including CDKL5. Our findings suggest that neural remodeling affects chronic pain establishment. Since patients with CDKL5 mutations have shown reduced pain perception, our findings suggest that CDKL5 in the spinal cord could result in neural remodeling during the chronic pain phase through cytoplasmic kinase activity.

BACKGROUND: Several authors have reported favorable results in low back pain (LBP) for patients with lumbar disc herniation (LDH) treated with discectomy. However, detailed changes over time in the characteristics and location of LBP before and after discectomy for LDH remain unclear. To clarify these points, we conducted an observational study to determine the detailed characteristics and location of LBP before and after discectomy for LDH, using a detailed visual analog scale (VAS) bilaterally. METHODS: We included 65 patients with LDH treated by discectomy in this study. A detailed VAS for LBP was administered with the patient under 3 different conditions: in motion, standing, and sitting. Bilateral VAS was also administered (affected versus opposite side) for LBP, lower extremity pain (LEP), and lower extremity numbness (LEN). The Oswestry Disability Index (ODI) was used to quantify clinical status. Changes over time in these VAS and ODI were investigated. Pfirrmann grading and Modic change as seen by magnetic resonance imaging (MRI) were reviewed before and 1 year after discectomy to determine disc and endplate condition. RESULTS: Before surgery, LBP on the affected side while the patients were in motion was significantly higher than LBP while they were sitting (p = 0.025). This increased LBP on the affected side in motion was improved significantly after discectomy (p < 0.001). By contrast, the residual LBP while sitting at 1 year after surgery was significantly higher than the LBP while they were in motion or standing (p = 0.015). At 1 year following discectomy, residual LBP while sitting was significantly greater in cases showing changes in Pfirrmann grade (p = 0.002) or Modic type (p = 0.025). CONCLUSIONS: Improvement of LBP on the affected side while the patient is in motion suggests that radicular LBP is improved following discectomy by nerve root decompression. Furthermore, residual LBP may reflect increased load and pressure on the disc and endplate in the sitting position.

BACKGROUND: According to most of the commonly used classification systems for subaxial spine injuries, unilateral and minimally displaced facet fractures without any sign of a spinal cord injury would be directed to non-operative management. However, the failure rate of non-operative treatment varies from 20 to 80%, and no consensus exists with regard to predictors of failure after non-operative management. CASE PRESENTATION: Case 1 is a patient with a unilateral facet fracture. The patient had only numbness in the right C6 dermatome but failed non-operative treatment, which resulted in severe spinal cord injury. Case 2 is a patient who had a similar injury pattern as case 1 but presented with immediate instability and underwent fusion surgery. Both patients had a minimally displaced unilateral facet fracture accompanied by disc injury and blunt vertebral artery injury, which are possible signs indicating significant instability. CONCLUSIONS: This is the first report of an isolated unilateral facet fracture that resulted in catastrophic spinal cord injury. These two cases illustrate that an isolated minimally displaced unilateral facet fracture with disc injury and vertebral artery injury were associated with significant instability that can lead to spinal cord injury.

PURPOSE: To clarify the impact of anchor type at upper instrumented vertebra (UIV) on postoperative shoulder imbalance in patients with Lenke type 1 adolescent idiopathic scoliosis (AIS) who underwent posterior spinal fusion. METHODS: Subjects were 81 patients with Lenke type 1 AIS who underwent posterior spinal fusion between 2004 and 2013. Twenty-five patients agreed to participate in the study. We divided the patients into two groups: Hook group (15 patients with hooks at UIV who underwent surgery between 2004 and 2011) and PS group (ten patients with pedicle screws at UIV who underwent surgery between 2012 and 2013). To evaluate shoulder balance, first thoracic vertebra tilt angle (T1 tilt), clavicle angle (CA), and radiographic shoulder height (RSH) were measured. RESULTS: There were no significant differences in preoperative T1 tilt, CA, or RSH between the both groups. The postoperative 1-week, 2-year, and most recently observed T1 tilts were significantly smaller in the Hook group than in the PS group. There were no significant differences in postoperative 1-week, 2-year, and most recently observed CAs between the two groups. Although there were no significant differences in 1-week postoperative RSH between the groups, the 2-year postoperative RSH was significantly smaller in the Hook group than in the PS group. The most recently observed RSH tended to be smaller in the Hook group than in the PS group, but the difference was not significant. CONCLUSIONS: In the PS group, poor shoulder balance remained over the long term. The hooks at UIV adjusted postoperative shoulder balance.

Advanced glycation end-products (AGEs) have been reported as a possible biomarker of ageing and metabolic diseases; however, its role in the clinical progression of these diseases remains unclear. We aimed to evaluate how AGEs are associated with clinical symptoms and comorbidities in lower back pain (LBP) patients. This prospective cohort study enrolled 636 LBP patients. They were subjected to quantified AGE (qAGE) analysis using skin autofluorescence, and their clinical symptoms and comorbidities, such as diabetes, renal failure with haemodialysis treatment, and osteoporosis, were measured. LBP, lower extremity pain, and numbness were evaluated using a visual analogue scale (VAS). The measured qAGE was significantly higher in subjects with any comorbidity. Age also showed a strong positive correlation with qAGE. qAGE and VAS for leg numbness were positively correlated. Furthermore, in LBP patients under 50-years-old, qAGE was positively correlated with VAS for LBP, lower extremity pain, and numbness. In conclusion, qAGE, as measured by skin autofluorescence measurement, was significantly higher in LBP patients with diabetes and dialysis, as well as in osteoporosis patients. Furthermore, qAGE showed potential as a biomarker for LBP, lower extremity pain, and numbness in patients under 50-years-old. If accumulated AGEs are identified at a young age, researchers should be vigilant for the development of osteoporosis and LBP-related clinical symptoms later in life.

Introduction: In the aging society, fragility fracture of the pelvis (FFP) has become a problem. Although strong and minimally invasive fixation is required in FFP surgery, reports on relevant surgical results are scarce. Crab-shaped fixation (CSF) is a spinopelvic fixation that involves reconstruction of the posterior pelvic ring using spinal instrumentation. This study aimed to evaluate the walking ability and perioperative complications of patients who underwent CSF for FFP. Methods: We included patients diagnosed with unstable FFPs, including sacral fracture, who required hospitalization. Demographic data, such as age, sex, bone mineral density, and Rommens classification, were evaluated. Surgical findings included estimated blood loss, operation time, and perioperative complications. The improvement in postoperative walking ability was evaluated based on the length of the postoperative period before the initiation of walker training and whether walking aids were required at 6 months post-surgery, compared with those who received conservative treatment for FFP. Results: Our study included 6 cases that received CSF and 16 cases that received conservative treatment, in which all were females and presented with sacral fractures. The average age of the surgical patients, the operation time, and the estimated blood loss were 79.5±14.7 years, 180.7±28.7 min, and 124.2±29.4 mL, respectively. The average length of the postoperative period prior to the initiation of walker training was 10.8±12.3 days, which was significantly shorter than that of conservative treatment. With regard to perioperative complications, poor reduction of fracture dislocation was observed in one case as well as surgical site infection in another case, but the walking ability improved in all cases. Conclusions: We evaluated the results of the posterior pelvic ring reconstruction with CSF for patients with vertically unstable FFPs, including sacral fractures. CSF is minimally invasive and would be useful as it allowed walker training during the early postoperative period, which improved patients' walking ability even during the in situ pelvic ring reconstruction.

Lumbar lateral interbody fusion (LLIF) has been gaining popularity among the spine surgeons dealing with degenerative spinal diseases while LLIF on L5-S1 is still challenging for its technical and anatomical difficulty. OLIF51 procedure achieves effective anterior interbody fusion based on less invasive anterior interbody fusion via bifurcation of great vessels using specially designed retractors. The technique also achieves seamless anterior interbody fusion when combined with OLIF25. A thorough understanding of the procedures and anatomical features is mandatory to avoid perioperative complications.

Introduction: The purpose of the present study was to determine, in a mid-term follow-up 5 years or more after surgery, the forced vital capacity (FVC), forced expiratory volume in 1 s (FEV1), and expiratory flow in patients with adolescent idiopathic scoliosis (AIS) who underwent posterior spinal fusion (PSF) with or without thoracoplasty. Methods: The subjects were 134 patients with AIS who underwent PSF between 2004 and 2013. Forty-five patients agreed to participate in the study. We divided the patients into two groups as follows: 24 patients who underwent PSF with thoracoplasty from 2004 to 2010 in the TP group and 21 patients who underwent PSF without thoracoplasty from 2011 to 2013 in the non-TP group. We evaluated whole spine X-ray imaging and pulmonary function tests (PFTs) in these patients. PFTs measured FVC, FEV1, peak expiratory flow (PEF), maximum expiratory flow at 50% FVC (V50), maximum expiratory flow at 25% FVC (V25), and the ratio of V50 to V25 (V50/V25). Results: The main thoracic curves were 53.6 ± 10.1° before surgery, 19.8 ± 7.6° 1 week after surgery, 22.3 ± 8.3° 2 years after surgery, and 23.3 ± 7.6° at the most recent observation. Compared with preoperative values, FVC, FEV1, and % FEV1 were improved significantly at the most recent observation. No significant difference was observed between % FVC before surgery and at the most recent observation. Compared with preoperative values, PEF, V50, and V25 were improved significantly at the most recent observation. V50/V25 did not change significantly. The changes in PFT values in the TP group and the non-TP group were compared. No significant differences were observed in FVC, % FVC, FEV1, % FEV1, PEF, V50, or V25. Conclusions: Regardless of whether thoracoplasty was performed or not, FVC, FEV1, and expiratory flow were improved 5 years or later after PSF.

Introduction: There are few reports on body composition, particularly muscle mass, in patients with adolescent idiopathic scoliosis (AIS). The purpose of this study was to measure body composition including muscle mass and estimated bone mass of patients with AIS using bioelectrical impedance analysis (BIA) and to clarify the relationship between the degree of scoliosis and body composition. Methods: The subjects were 210 girls (mean age 14.0 years, range 10-18 years) whose body composition was evaluated using BIA (Tanita MC-780). Body mass index (BMI), percent body fat (%BF), lean muscle mass index (LMI: muscle mass/height^2), and estimated bone mass index (eBoneMI: estimated bone mass/height^2) were determined by age and compared with those of previous reports. We divided 111 subjects whose bone maturation was complete into two groups for comparison of body composition metrics: those with Cobb angle <40° (moderate scoliosis group) and those with Cobb angle ≥40° (severe scoliosis group). The relationships between Cobb angle and each body composition parameter were evaluated. Results: Age-adjusted BMI, %BF, and LMI tended to be low at all ages compared with means for the healthy Japanese population as previously reported. BMI, LMI, and eBoneMI were significantly lower in the severe scoliosis group compared with those in the moderate scoliosis group (p<0.05). In addition, all BMI, LMI, and eBoneMI were weakly correlated with Cobb angle (r= -0.20, -0.26, and -0.24). Conclusions: On the basis of the results of this study, patients with AIS are thinner, with lower BMI, %BF, and LMI compared with healthy girls of the same age. Furthermore, factors such as lower BMI, lower muscle mass, and lower estimated bone mass were correlated with progressive scoliosis.

Introduction: Platelet-rich plasma (PRP) is drawing attention as a substance that can promote bone formation. The growth factors present in PRP are stable for a long time after freeze-drying. However, the effects of PRP are inconsistent, and its effects on bone union in spinal surgery remain controversial. The immortalized megakaryocyte cell lines (imMKCLs) derived from human-induced pluripotent stem cells (hiPSCs) have been developed to produce numerous stable and clinically functional platelets. In this study, growth factors present in freeze-dried hiPSC-derived imMKCLs and platelets (iPS-MK/Plts) were evaluated, and their ability to promote bone formation was examined using a rat lumbar artificial bone grafting model. Methods: We prepared freeze-dried iPS-MK/Plts and quantified their growth factors by enzyme-linked immunosorbent assays. Surgical grafting of artificial bone to the lumbar transverse processes was performed in 8-week-old female rats, which were divided into two groups: artificial bone graft (control) and artificial bone graft plus freeze-dried iPS-MK/Plts (iPS group). Transplantation was performed only on the left side. Eight weeks after the surgery, we captured computed tomography images and compared bilateral differences in the bone volume of the graft site in each rat. We also compared the left side/right side bone volume ratio between the two groups. Results: The freeze-dried iPS-MK/Plts contained numerous growth factors. While there was no significant increase in bone volume on the transplanted side than that on the non-grafted side in the control group, bone volume significantly increased on the transplanted side in the iPS group, as evidenced by augmented mean left/right bone volume ratio of the iPS group compared with that of the control group. But the new bone observed in the iPS group was histologically normal. Conclusions: Freeze-dried hiPSC-derived MKCLs and platelets contain several stable growth factors and have the potential for promoting new bone formation.

＜文献概要＞はじめに 骨粗鬆症患者で最も骨折が多発する部位は椎体であり,年間140万人に新たな脆弱性椎体骨折が発生していると報告されている.脆弱性椎体骨折を受傷すると,強い疼痛による著しいADL低下(活動制限とそれに伴う廃用)が必発である.さらに,Quality of Life Questionnaire of the European Foundation for Osteoporosis(QUALEFFO)を用いて調査した報告では,脆弱性椎体骨折があると身体機能のみならず,社会機能,全体的健康観までもが低下するとも報告されている.つまり,その影響はQOL低下にまで及ぶといえる.したがって,疼痛のみならずADLおよびQOLの観点からも脆弱性椎体骨折に対する適切な治療介入が重要なのはいうまでもない.そこで本稿では,脆弱性椎体骨折に対する痛み治療のストラテジーについて,(1) 一般的な腰痛治療の観点,(2)脆弱性椎体骨折特有の観点といった2つの面から概説する.