稲毛 一秀

BACKGROUND: Central sleep apnea (CSA) due to occipitocervical compression myelopathy is an extremely rare condition. Here we report a case of surgical treatment for CSA due to occipitocervical compression myelopathy in a patient with Klippel-Feil syndrome. CASE DESCRIPTION: A 60-year-old man had become aware of a gradually progressive clumsiness and gait disturbance without any cause of injury 5 years before. He had complicated respiratory discomfort during sleep for the previous month and visited our hospital. Neurologic examination revealed severe myelopathy. Polysomnography showed CSA and Cheyne-Stokes respiration. Imaging findings showed C2-3 vertebral fusion and severe spinal cord compression caused by hypoplasia of the C1 posterior arch complicated by an anomaly of the vertebral artery. We diagnosed the patient with CSA due to occipitocervical compression myelopathy complicated by Klippel-Feil syndrome. After a simulation using a full-scale 3-dimensional model, resection of the C1 posterior arch and C4-5 laminoplasty was performed. After surgery, both clumsiness and gait disturbance gradually improved. Polysomnography 1 month after surgery showed that the CSA and the Cheyne-Stokes respiration disappeared. CONCLUSIONS: Although a recent report has indicated the cause of sleep apnea in patients with rheumatoid arthritis and occipitocervical disorders as obstructive sleep apnea, a significant improvement of CSA was observed with decompression surgery in this case. Appropriate surgical planning resulted in a favorable outcome.

＜文献概要＞畳み込みニューラルネットワーク(convolutional neural network:CNN)を用いてMRIによる神経鞘腫と髄膜腫の鑑別を行い,CNNと2人の放射線科医の鑑別能を比較した.組織学的に診断された神経鞘腫と髄膜腫の患者のMRIを学習に用いた.CNNのROC(receiver operating characteristic)曲線下面積はT2強調像に基づく学習で0.88であり,造影後T1強調像に基づく学習で0.87であった.感度は放射線科医のほうが高く,特異度はCNNのほうが高かった.正確度は両者に有意差はなかった.MRIによる神経鞘腫と髄膜腫の鑑別において,CNNの鑑別能は放射線科医と同等に良好であった.

We sought to assess the utility of simultaneous apparent T2 mapping and neurography with the nerve-sheath signal increased by inked rest-tissue rapid acquisition of relaxation-enhancement imaging (SHINKEI-Quant) for the quantitative evaluation of compressed nerves in patients with lumbar radiculopathy. Thirty-two patients with lumbar radiculopathy and 5 healthy subjects underwent simultaneous apparent T2 mapping and neurography with SHINKEI-Quant. Regions of interest (ROIs) were placed in the lumbar dorsal root ganglia (DRG) and the spinal nerves distal to the lumbar nerves bilaterally at L4-S1. The T2 relaxation times were measured on the affected and unaffected sides. The T2 ratio was calculated as the affected side/unaffected side. Pearson correlation coefficients were calculated to determine the correlation between the T2 relaxation times or T2 ratio and clinical symptoms. An ROC curve was used to examine the diagnostic accuracy and threshold of the T2 relaxation times and T2 ratio. We observed no significant differences in the T2 relaxation times between the nerve roots on the left and right at each spinal level in healthy subjects. In patients, lumbar neurography revealed swelling of the involved nerve, and prolonged T2 relaxation times compared with that of the contralateral nerve. The T2 ratio correlated with leg pain. The ROC analysis revealed that the T2 relaxation time threshold was 127 ms and the T2 ratio threshold was 1.07. To our knowledge, this is the first study to show the utility of SHINKEI-Quant for the quantitative evaluation of lumbar radiculopathy.

OBJECTIVE: Laminoplasty is an effective procedure for treating cervical spondylotic myelopathy. We conduct myovascular preserving open-door laminoplasty (MPLP) in combination with a laminoplasty plate to improve the stability of the enlarged lamina. We compare the details of the MPLP technique with conventional open-door laminoplasty. METHODS: We compared 25 cases of MPLP (mean age = 70.5, mean follow-up period = 19 months) with 15 controls who received conventional open-door laminoplasty using hydroxyapatite spacers (mean age = 74, mean follow-up period = 53 months). Regarding surgical outcomes, blood loss, operative time, Japanese Orthopaedic Association score, and postoperative visual analog score for neck pain were measured. Regarding image analysis, preoperative and postoperative range of motion (ROM), C2-7 angle, implant back out, hinge bone fusion time, presence or absence of hinge bone union failure, and posterior neck fat infiltration rate were evaluated. RESULTS: Operative time was significantly shorter for MPLP, and postoperative neck pain was significantly decreased. In image evaluation, %ROM was significantly increased in MPLP, but no difference in C2-7 angle existed between the 2 groups. Implant back out was not recognized in either group. In MPLP, the hinge union period was significantly shortened, and the postoperative fat infiltration rate was significantly decreased. CONCLUSIONS: We were able to reduce neck pain after surgery by an approach entailing longitudinal splitting of the spinous processes. We were able to ensure shorter operation times due to cervical plates and better hinge bone fusion times due to initial stability. LEVEL OF EVIDENCE: 4.

PURPOSE: Diffusion tensor imaging (DTI) is useful to evaluate lumbar nerves visually and quantitatively. Multi-band sensitivity encoding (MB-SENSE) is a technique to reduce the scan time. This study aimed to investigate if super-multi-gradient DTI with multi-band sensitivity encoding (MB-SENSE) is better in evaluating lumbar nerves than the conventional method. METHODS: The participants were 12 healthy volunteers (mean age 33.6 years). In all subjects, DTI was performed using echo planar imaging with different motion probing gradient (MPG) directions (15 without MB, and 15, 32, 64, and 128 with MB) and the lumbar nerve roots were visualized with tractography. In the five groups, we evaluated the resultant DTI both visually and quantitatively. For visual measures, we counted the number of fluffs and disruptions of the nerve fibers. For quantitative measures, the fractional anisotropy (FA) and standard deviation of the fractional anisotropy (FA-SD) values at two regions (proximal and distal) of the lumbar nerve roots were quantified and compared. RESULTS: Among the five groups, the number of fluffs decreased as the number of MPG directions increased. However, the number of disruptions showed no significant differences. The FA-SD values decreased as the number of MPG directions increased, indicating that the signal variation was reduced with multi-gradient directional DTI. CONCLUSION: High-resolution multi-directional DTI with MB-SENSE may be useful to visualize nerve entrapments and may allow for more accurate DTI parameter quantification with opportunities for clinical diagnostic applications.

Objective: Atopic dermatitis (AD) is one of the known risk factors for Staphylococcus aureus infection. The authors report the case of a patient with cervical spondylosis and AD who developed delayed surgical site infection after posterior cervical instrumented surgery. Patient: A 39-year-old male presented to our hospital with paralysis of the left upper extremity without any cause or prior injury. He had a history of severe AD. We performed C3-C7 posterior decompression and instrumented fusion based on the diagnosis of cervical spondylotic amyotrophy. One year after surgery, his deltoid and bicep muscle strength were fully recovered. Nevertheless, his neck pain worsened 2 years after surgery following worsening of AD. One month after that, he developed severe myelopathy and was admitted to our hospital. Radiographic findings showed that all the screws had loosened and the retropharyngeal space had expanded. Magnetic resonance imaging and computed tomography showed severe abscess formation and destruction of the C7/T1 vertebrae. Result: We diagnosed him with delayed surgical site infection. Methicillin-resistant Staphylococcus aureus was identified on abscess culture. The patient responded adequately to treatment with antibiotic therapy and two debridements and the infection subsided. Conclusion: We should consider the possibility of delayed surgical site infection when conducting instrumented spinal surgery in patients with severe AD.

かつて腰痛疾患の85%を占めると謳われた非特異的腰痛の病態は,近年の医学研究の推進とともに解明されつつある。慢性疼痛の機序には腰痛疾患患者の約30%が罹患する神経障害性疼痛の概念が重要であり,特に臀部痛の存在は神経障害性疼痛の可能性を示唆する。椎間板性腰痛は変性椎間板で産生される炎症性サイトカインおよび異常感覚神経の伸長など複数の分子生物学的機序を介して慢性腰痛の一端を担い,これに基づくブロック療法等が報告されている。(著者抄録)

脊椎患者における神経学的所見や機能評価、認知機能の評価などリハビリテーションを進めるうえで知っておくべき代表的な評価法や認知機能評価について概説、さらには骨粗鬆症やサルコペニアなどを含む高齢者をとりまく問題点・特殊性についても述べた。脊椎疾患患者の神経症状を中心とした理学所見の評価の実際やSF-36、RMDQ、ODIやNDI、ならびに新旧JOAスコアなど、機能およびADL・QOL評価を行うための指標、および長谷川式に代表される認知機能評価は高齢者に対する有効な診療を行ううえでは重要かつ不可欠な評価である。本邦が突入した超高齢社会においては、臨床の最前線で運動器疾患に対峙する整形外科、リハビリテーション科をはじめ多分野の連携が重要となってくるものと考えられ、そのためには骨粗鬆症やそれに伴う疼痛、サルコペニアを含む体幹・四肢筋量の低下がもたらす影響とロコモティブシンドロームも念頭に置くことで、より総合的・学際的な運動器診療の実施が可能となる。(著者抄録)

かつて腰痛疾患の85%を占めると謳われた非特異的腰痛の病態は,近年の医学研究の推進とともに解明されつつある。慢性疼痛の機序には腰痛疾患患者の約30%が罹患する神経障害性疼痛の概念が重要であり,特に臀部痛の存在は神経障害性疼痛の可能性を示唆する。椎間板性腰痛は変性椎間板で産生される炎症性サイトカインおよび異常感覚神経の伸長など複数の分子生物学的機序を介して慢性腰痛の一端を担い,これに基づくブロック療法等が報告されている。(著者抄録)