稲毛 一秀

STUDY DESIGN: A multicenter cross-sectional study. OBJECTIVES: To clarify the relationship of trunk muscle mass with low back pain, spinal sagittal balance, and quality of life. Few reports have investigated the relationship of trunk muscle mass with lumbar spine function and spinal balance, and the clinical significance of trunk muscle mass remains unclear. METHODS: Patients attending spinal outpatient clinics at 10 different medical institutions were enrolled in this study. Patient demographics, trunk muscle mass and appendicular skeletal muscle mass (ASM) measured by bioelectrical impedance analysis (BIA), body mass index (BMI), Charlson Comorbidity Index (CCI), the Oswestry Disability Index (ODI), visual analog scale (VAS) for low back pain, sagittal vertical axis (SVA), and EuroQol 5 Dimension (EQ5D) score were investigated. Multivariate nonlinear regression analysis was used to investigate the association of trunk muscle mass with the ODI, VAS score, SVA, and EQ5D score. RESULTS: Of 2551 eligible patients, 1738 (mean age 70.2 ± 11.0 years; 781 men and 957 women) were enrolled. Trunk muscle mass was significantly correlated with the ODI, VAS score, SVA, and EQ5D score (P < 0.001) when adjusted for age, sex, BMI, ASM, CCI, and history of lumbar surgery. Patient deterioration was associated with a decrease in trunk muscle mass, and the deterioration accelerated from approximately 23 kg. CONCLUSIONS: Trunk muscle mass was significantly associated with the ODI, VAS score, SVA, and EQ5D score. Trunk muscle mass may assume an important role to elucidate and treat lumbar spinal dysfunction and spinal imbalance. These slides can be retrieved under Electronic Supplementary Material.

BACKGROUND: Giant cell tumor is known to be a benign neoplasm that arises most commonly in the long bones, while cases in the spine are rare. Recently, denosumab, a monoclonal antibody that inhibits receptor activator of nuclear factor-kappa β ligand, has been used to treat patients with giant cell tumor. However, there are few reports of total en bloc spondylectomy being used for paravertebral giant cell tumor lesions following denosumab therapy. CASE PRESENTATION: Our patient was a 20-year-old Japanese woman with a 4-month history of lower back pain. A spinal computed tomography scan and magnetic resonance imaging of her lumbar spine revealed an osteolytic lesion involving the L3 vertebral body, and the tumor extended toward the left side of the paravertebral soft tissue and into the left pedicle. The lesion was diagnosed as a giant cell tumor by needle biopsy. Denosumab treatment calcified the paravertebral giant cell tumor lesion and the tumor vertebral body was removed completely by total en bloc spondylectomy. CONCLUSION: This case report describes a patient with a paravertebral giant cell tumor who was successfully treated by preoperative denosumab injection followed by total en bloc spondylectomy.

STUDY DESIGN: A basic study using a rodent model of sarcopenia. OBJECTIVE: To elucidate the contribution of oxidative stress to muscle degeneration and the efficacy of antioxidant treatment for sarcopenia using an animal model of neurogenic sarcopenia. SUMMARY OF BACKGROUND DATA: Oxidative stress has been reported to be involved in a number of pathologies, including musculoskeletal disorders. Its relationship with sarcopenia, one of the potential origins of lower back pain, however, is not yet fully understood. METHODS: Myoblast cell lines (C2C12) were treated with H2O2, an oxidative stress inducer, and N-acetyl-L-cysteine (NAC), an antioxidant. Apoptotic effects induced by oxidative stress and the antioxidant effects of NAC were assessed by western blotting, immunocytochemistry, and 3-(4,5-dimethylthiazol-2-yl)-2,5-diphenyltetrazolium bromide (MTT) cell viability assays. An animal model of sarcopenia was produced via axotomy of the sciatic nerves to induce muscle atrophy. Twenty-four male Sprague-Dawley rats were divided into sham, sham+NAC, axotomy, and axotomy+NAC groups. Rats were provided water only or water containing NAC (1 g/L) for 4 weeks. The gastrocnemius muscle was isolated and stained with hematoxylin and eosin (H&E) 2 weeks after axotomy, from which muscle cells were harvested and protein extracted for evaluation. RESULTS: Mitogen-activated protein kinases (MAPKs) were significantly activated by H2O2 treatment in C2C12 cells, which was ameliorated by NAC pretreatment. Furthermore, H2O2 induced apoptosis and death of C2C12 cells, which was prevented by NAC pretreatment. The weight of the gastrocnemius muscle was reduced in the axotomy group, which was prevented by NAC administration. Lastly, although muscle specimens from the axotomy group showed greater reductions in muscle fiber, the oral administration of NAC significantly inhibited amyotrophy via antioxidant effects. CONCLUSION: The current in vitro and in vivo study demonstrated the possible involvement of oxidative stress in sarcopenic pathology. NAC represents a potential anti-sarcopenic drug candidate, preventing amyotrophy and fatty degeneration. LEVEL OF EVIDENCE: 4.

脊髄刺激療法は難治性腰痛患者の痛みを軽減し、歩行機能を中心とした患者のADL改善につながる治療法である。自験例ではオピオイド等の鎮痛薬減量により患者の身体的負担の軽減や医療経済の改善にも有効な手段であった。近年、デバイス改良によりMRI対応可能となり、さらには自動刺激調整機能が備わった。適応疾患および病態を見極め、心理的サポート等包括的な医療を行うことで更なる効果が期待できる。今後、高齢化社会に伴いさらに増加すると予想される難治性疼痛患者に対する選択肢となり得る治療法である。(著者抄録)

BACKGROUND: Unilateral laminectomy for bilateral decompression (ULBD) for lumbar spinal stenosis (LSS) is a less invasive technique compared to conventional laminectomy. Recently, several authors have reported favorable results of low back pain (LBP) in patients of LSS treated with ULBD. However, the detailed changes and localization of LBP before and after ULBD for LSS remain unclear. Furthermore, unsymmetrical invasion to para-spinal muscle and facet joint may result in the residual unsymmetrical symptoms. To clarify these points, we conducted an observational study and used detailed visual analog scale (VAS) scores to evaluate the characteristics and bilateral changes of LBP and lower extremity symptoms. METHODS: We included 50 patients with LSS treated with ULBD. A detailed visual analogue scale (VAS; 100 mm) score of LBP in three different postural positions: motion, standing, and sitting, and bilateral VAS score (approached side versus opposite side) of LBP, lower extremity pain (LEP), and lower extremity numbness (LEN) were measured. Oswestry Disability Index (ODI) was used to quantify the clinical improvement. RESULTS: Detailed LBP VAS score before surgery was 51.5 ± 32.5 in motion, 63.0 ± 30.1 while standing, and 37.8 ± 31.8 while sitting; and showed LBP while standing was significantly greater than LBP while sitting (p < 0.01). After surgery, LBP while standing was significantly improved relative to that while sitting (p < 0.05), and levels of LBP in the three postures became almost the same with ODI improvement. Bilateral VAS scores showed significant improvement equally on both sides (p < 0.01). CONCLUSIONS: ULBD improves LBP while standing equally on both sides in patients with LCS. The improvement of LBP by the ULBD surgery suggests radicular LBP improved because of decompression surgery. Furthermore, the symmetric improvement of LBP by the ULBD surgery suggests unsymmetrical invasion of the paraspinal muscles and facet joints is unrelated to residual LBP.

＜文献概要＞超高齢社会における最近のtopicとしてサルコペニアがあり,高齢者の運動機能低下の要因として注目を集め様々な研究が実施されている.加齢性サルコペニアには筋再生能の低下,内分泌機能異常,微小炎症(炎症性サイトカイン),ビタミンDおよびビタミンD受容体,骨粗鬆症など様々な誘因がある.さらにそれらの誘因は相互作用を有しており,複雑な病態をなしていることを理解することが重要である.

＜文献概要＞超高齢社会の昨今,脊柱後彎変形で日常生活に支障を来す患者は増加している.骨格筋量に着目して,高齢者の後彎変形に伴う腰痛とサルコペニア・骨粗鬆症の関与について述べた.骨盤-腰椎支持機構である体幹・四肢骨格筋量の低下が脊柱変形進行と腰痛増強に関与することが示唆された.骨密度は四肢筋量と相関しており,加齢,力学的負荷の減少,ビタミンD欠乏など骨粗鬆症の病因はサルコペニアにも深く関わっている可能性がある.運動療法,栄養療法(必須アミノ酸),薬物療法(ビタミンD)のような骨格筋維持・増強を促す保存療法の有効性が期待され,さらなる検討を要する.

骨粗鬆症患者79名を、原発性骨粗鬆症(P群)59名(男8名、女51名、平均年齢75.6歳)とステロイド性骨粗鬆症(G群)20名(男4名、女16名、平均年齢73.9歳)に分け、骨代謝マーカー、骨密度、補正四肢・全身筋量、日本整形外科学会腰痛疾患問診票(JOABPEQ)による腰痛スコアを2群間で比較した。骨代謝マーカーの骨型アルカリフォスファターゼ(μg/l)はP群14.3、G群9.3でG群が有意に低値であった。骨質マーカーの総ホモシステイン(nmol/ml)はP群10.9、G群15.1とG群が有意に高値であった。JOABPEQはG群が全体的に低値であり特に腰痛による歩行機能障害スコアが低値であった。G群はP群に比べ骨密度が同等であったが、女性において補正四肢筋肉量と補正体幹筋量が有意に少なかった。ステロイド性骨粗鬆症患者は低骨形成、骨質不良であり、骨密度非依存的に低筋肉量であり腰痛による歩行障害が強い。