稲毛 一秀

BACKGROUND: Autologous vein wrapping (VW) is used in the treatment of recurrent chronic constriction neuropathy and traumatic peripheral nerve injury. However, use of autologous veins is limited by the inability to obtain longer veins of sufficient length for larger sites. Frozen allograft tissue has several advantages, including its availability for large grafts, avoidance of donor-site morbidity, and shorter operation time. Here, we investigated the effect of frozen vein wrapping (FVW) in Wistar rats as a model of sciatic nerve injury. RESULTS: The rats were grouped by treatment as (i) untreated after chronic constriction injury surgery (CCI; control group), (ii) treated with vein wrapping using freshly isolated vein (VW), and (iii) treated with vein wrapping using frozen vein (FVW). Mechanical allodynia was assessed with von Frey filaments on postoperative days (PODs) 1, 3, 5, 7, and 14. Gene expression of HO-1 was evaluated by quantitative polymerase chain reaction (qPCR). The response of heme oxygenase-1 gene, Hmox-1, expression to VW and FVW was assessed by RT-PCR. Both VW and FVW significantly increased withdrawal threshold levels compared to the untreated control group on POD 1, 3, and 5. Both VW and FVW also showed increased HO-1 expression compared to the CCI group. CONCLUSIONS: FVW increased the withdrawal threshold similar to VW in a rat CCI model for short periods. Frozen vein wrapping using vein allograft without donor site morbidity may be an alternative therapeutic option.

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.

PURPOSES: To analyze T2 relaxation times of the facet joint by MRI T2-mapping in patients with degenerative lumbar disorders (DLD), and to determine the correlation with lumbar instability in radiographs. METHODS: We conducted a T2-mapping of the lumbar facet joint using a 1.5 T MRI system. We classified patients with degenerative lumbar disorders scheduled to undergo decompression surgery into groups with stability and instability using radiographs, and compared the T2 relaxation times of the lumbar facet. Lumbar instability was defined as the presence of anterior translation ratio > 5% or disk range of motion (ROM) > 5° in the sagittal plane of SLFE radiographs. RESULTS: Inclusion criteria were met by 22 patients (45 levels, mean age 64.3 years). Facet effusions had high sensitivity (90%) but had low specificity (28%) for diagnosis of lumbar instability. Mean T2 relaxation times of right and left facet joints are significantly longer (98.4 ms) in the instability group than they are (87.6 ms) in the stability group (p < 0.001). Anterior translation ratio was positively correlated with mean T2 relaxation times of facet joint (R2 = 0.493, p < 0.05). From a ROC analysis, the cutoff value of T2 relaxation times for lumbar instability was 98.65 ms (sensitivity 60.0%, specificity 95.7%, AUC 0.763). CONCLUSIONS: The T2 relaxation times were positively correlated with lumbar instability. This new quantitative evaluation of lumbar facet joint using MRI T2-mapping might be useful to determine lumbar instability.

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。

Introduction We compared preoperative skeletal muscle, pre-and post-operative spinal alignment or clinical symptoms between tandem spinal stenosis (TSS) patients who underwent simultaneous cervical and lumbar decompression and lumbar spinal stenosis (LSS) patients who underwent only lumbar decompression and the efficacy of one-stage surgery was examined. Methods This study included 82 patients, identifying 13 patients for the TSS group (mean age 77.2 years) and 69 patients for the LSS group (mean age 72.2 years). One-stage decompression surgery was performed on both groups. The spinal alignments were evaluated using Lumbar scoliosis (LS), Sagittal vertical axis (SVA), Lumbar lordosis (LL), Pelvic tilt (PT), Pelvic incidence (PI), and Sacral slope (SS). The clinical symptoms were evaluated using the visual analogue scale (VAS) score for low back pain (LBP), the Japanese Orthopedic Association scoring system (JOA score), the Roland-Morris Disability Questionnaire (RDQ), the Japanese Orthopedic Association Back Pain Evaluation Questionnaire (JOABPEQ) and Oswestry Disability Index (ODI). Results The amount of bleeding was not significantly different between the two groups (p > .05). SVA, LL, PT, and SS were significantly improved in the LSS group (p < 0.05). In the TSS group, SVA, LL, PT, and SS tended to improve, but without significant differences. The proportion of JOABPEQ gait dysfunction that was difficult to climb stairs was 83% in the TSS group, and social life disturbance that was difficult to engage in ordinary activities was 67% in the TSS group, which was significantly higher than that in the LSS group (p < .05). Although clinical symptoms improved by surgery in both groups (p < .05), there was no significant difference in the degree of clinical symptom improvement before and after surgery (p > .05). Conclusions One-stage surgery for TSS is effective because it has the same intraoperative bleeding volume as LSS alone and is minimally invasive. It also improves forward-leaning posture and clinical symptoms equivalent to LSS alone.

PURPOSE: We investigated changes in skeletal muscle mass and bone mineral density in degenerative lumbar scoliosis (DLS) patients during a 2-year follow-up following diagnosis. METHOD: This study included 418 Japanese women, identifying 50 patients for the DLS group (mean age 76.4 years) and 368 patients for the control group (mean age 73.4 years). Whole-body skeletal muscle mass was measured using a Bioelectrical Impedance Analyzer. Bone mineral density (BMD) was measured using DXA. Skin autofluorescence (SAF), a marker of advanced glycation end products in the skin, was measured using a spectroscope. Spinal alignment, skeletal muscle mass, BMD, grip strength, and SAF were examined and the amount of change 1 and 2 years from the initial examination for each item was compared between groups. RESULTS: Height, body fat mass, grip strength, upper limb muscle mass, and trunk muscle mass in the DLS group were significantly lower, and lumbar spine BMD was significantly greater compared to controls at the first visit (p < 0.05). There was no significant difference in spinal alignment in the DLS group after 2 years compared with baseline. Trunk muscle mass also decreased significantly more in the DLS group (-2.7%) than in the control group (-1.1%) over the 2-year follow-up (p < 0.05). DISCUSSION: In this study, trunk muscle mass in the DLS group decreased about 2.4 times more in 2 years compared with the control group (p < 0.05). It may be possible to clarify the mechanism of kyphoscoliosis progression in the future with large-scale longitudinal studies.

STUDY DESIGN: Retrospective study of magnetic resonance imaging (MRI). OBJECTIVES: To assess the ability of a convolutional neural network (CNN) model to differentiate osteoporotic vertebral fractures (OVFs) and malignant vertebral compression fractures (MVFs) using short-TI inversion recovery (STIR) and T1-weighted images (T1WI) and to compare it to the performance of three spine surgeons. SUMMARY OF BACKGROUND DATA: Differentiating between OVFs and MVFs is crucial for appropriate clinical staging and treatment planning. However, an accurate diagnosis is sometimes difficult. Recently, CNN modeling-an artificial intelligence technique-has gained popularity in the radiology field. METHODS: We enrolled 50 patients with OVFs and 47 patients with MVFs who underwent thoracolumbar MRI. Sagittal STIR images and sagittal T1WI were used to train and validate the CNN models. To assess the performance of the CNN, the receiver operating characteristic (ROC) curve was plotted and the area under the curve (AUC) was calculated. We also compared the accuracy, sensitivity, and specificity of the diagnosis made by the CNN and three spine surgeons. RESULTS: The AUC of ROC curves of the CNN based on STIR images and T1WI were 0.967 and 0.984, respectively. The CNN model based on STIR images showed a performance of 93.8% accuracy, 92.5% sensitivity, and 94.9% specificity. On the other hand, the CNN model based on T1WI showed a performance of 96.4% accuracy, 98.1% sensitivity, and 94.9% specificity. The accuracy and specificity of the CNN using both STIR and T1WI were statistically equal to or better than that of three spine surgeons. There were no significant differences in sensitivity based on both STIR images and T1WI between the CNN and spine surgeons. CONCLUSIONS: We successfully differentiated OVFs and MVFs based on MRI with high accuracy using the CNN model, which was statistically equal or superior to that of the spine surgeons.Level of Evidence: 4.

BACKGROUND: Early-stage spondylolysis (ESS) is one of the common causes of acute low back pain (LBP) in adolescents. Although accurate diagnosis of ESS is important for providing appropriate treatment, differentiating ESS from other low back disorders is difficult by physical signs alone. OBJECTIVES: To elucidate the most common characteristic, namely, motion-provoking LBP, in patients with ESS. DESIGN: Retrospective comparative cohort study. METHOD: We included and categorized adolescents (n = 112; age, <18 years) with acute LBP (<1 month) into the ESS (n = 71) and nonspecific LBP (NS-LBP) (n = 41) groups based on magnetic resonance imaging (MRI) findings. Patients were evaluated using a visual analog scale (VAS), Oswestry Disability Index (ODI), and degree of pain using a numerical rating scale (NRS) provoked by hyperextension, hyperflexion, right and left rotations, and lateral bending in standing position.; the value were compared between the 2 groups. A cut-off value of significance was obtained using receiver operating characteristic (ROC) analysis. RESULTS: The mean scores for VAS and ODI and NRS of each test were as follows (ESS/NS-LBP): VAS, 6.5/6.0; ODI, 19.7/24.6; hyperextension, 4.1/4.1; hyperflexion, 2.4/3.0; rotation, 2.1/2.2; and lateral bending, 2.9/2.2. The ESS group had a significantly greater number of LBP cases provoked by lateral bending than the NS-LBP group. A cut-off lateral bending of 3.5 yielded a diagnosis of ESS. CONCLUSIONS: Our results indicate that lateral bending is the greatest motion-provoking characteristic of LBP in patients with ESS.

＜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。

OBJECTIVE: The authors sought to evaluate the relationship between the difference in lumbar lordosis (DiLL) in the preoperative supine and standing positions and spinal sagittal alignment in patients with lumbar spinal stenosis (LSS) and to determine whether this difference affects the clinical outcome of laminectomy. METHODS: Sixty patients who underwent single-level unilateral laminectomy for bilateral decompression of LSS were evaluated. Spinopelvic parameters in the supine and standing positions were measured preoperatively and at 3 months and 2 years postoperatively. DiLL between the supine and standing positions was determined as follows: DiLL = supine LL - standing LL. On the basis of this determination patients were then categorized into DiLL(+) and DiLL(-) groups. The relationship between DiLL and preoperative spinopelvic parameters was evaluated using Pearson's correlation coefficient. In addition, clinical outcomes such as visual analog scale (VAS) and Oswestry Disability Index (ODI) scores between the two groups were measured, and their relationship to DiLL was evaluated using two-group comparison and multivariate analysis. RESULTS: There were 31 patients in the DiLL(+) group and 29 in the DiLL(-) group. DiLL was not associated with supine LL but was strongly correlated with standing LL and pelvic incidence (PI) - LL (PI - LL). In the preoperative spinopelvic alignment, LL and SS in the standing position were significantly smaller in the DiLL(+) group than in the DiLL(-) group, and PI - LL was significantly higher in the DiLL(+) group than in the DiLL(-) group. There was no difference in the clinical outcomes 3 months postoperatively, but low-back pain, especially in the sitting position, was significantly higher in the DiLL(+) group 2 years postoperatively. DiLL was associated with low-back pain in the sitting position, which was likely to persist in the DiLL(+) group postoperatively. CONCLUSIONS: We evaluated the relationship between DiLL and spinal sagittal alignment and the influence of DiLL on postoperative outcomes in patients with LSS. DiLL was strongly correlated with PI - LL, and in the DiLL(+) group, postoperative low-back pain relapsed. DiLL can be useful as a new spinal alignment evaluation method that supports the conventional spinal sagittal alignment evaluation.

It is challenging to predict neurological outcomes of acute spinal cord injury (SCI) considering issues such as spinal shock and injury heterogeneity. Deep learning-based radiomics (DLR) were developed to quantify the radiographic characteristics automatically using a convolutional neural network (CNN), and to potentially allow the prognostic stratification of patients. We aimed to determine the functional prognosis of patients with cervical SCI using machine learning approach based on MRI and to assess the ability to predict the neurological outcomes. We retrospectively analyzed the medical records of SCI patients (n=215) who had undergone MRI and had an American Spinal cord Injury Association Impairment Scale (AIS) assessment at 1 month after injury, enrolled with a total of 294 MR images. Sagittal T2-weighted MR images were used for the CNN training and validation. The deep learning framework TensorFlow was used to construct the CNN architecture. After we calculated the probability of the AIS grade using the DLR, we built the identification model based upon the random forest using 3 features: the probability of each AIS grade obtained by the DLR method, age, and the initial AIS grade at admission. We performed a statistical evaluation between the actual and predicted AIS. The accuracy, precision, recall and f1 score of the ensemble model based on the DLR and RF were 0.714, 0.590, 0.565 and 0.567, respectively. The present study demonstrates that prediction of the short-term neurological outcomes for acute cervical spinal cord injury based on MRI using machine learning is feasible.

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.

Study Design: Prospective cohort study (open-label, single-arm, and non-blinded). Purpose: This study aims to determine the effects of systemic administration of tocilizumab, an anti-interleukin-6 (IL-6) receptor antibody on refractory low back pain and leg symptoms. Overview of Literature: IL-6 overexpression is associated with neuropathic pain pathogenesis, which is potentially followed by chronic low back pain, including leg pain and numbness. This finding suggest that inhibition of IL-6 at the site of pain or in the transmission pathway could provide novel therapeutic targets for chronic low back pain. Methods: This prospective, single-arm study included 11 patients (eight men; mean age, 62.7 years) with ≥3-months' chronic pain history due to lumbar disease. Subcutaneous TCZ injections were administered twice, at a 2-week interval. We evaluated low back pain, leg pain, and leg numbness using numeric rating scales and the Oswestry Disability Index (ODI; baseline and 6 months postinjection); serum IL-6 and tumor necrosis factor-α levels (baseline and 1 month postinjection); and clinical adverse events. Results: Intractable symptoms reduced after TCZ administration. Low back pain improved for 6 months. Improvements in leg pain and numbness peaked at 4 and 1 month, respectively. Improvements in ODI were significant at 1 month and peaked at 4 months. Serum IL-6 was increased at 1 month. IL-6 responders (i.e., patients with IL-6 increases >10 pg/mL) showed particularly significant improvements in leg pain at 2 weeks, 1 month, and 2 months compared with nonresponders. We observed no apparent adverse events. Conclusions: Systemic TCZ administration improved symptoms effectively for 6 months, with peak improvements at 1-4 months and no adverse events. Changing serum IL-6 levels correlated with leg pain improvements; further studies are warranted to elucidate the mechanistic connections between lumbar disorders and inflammatory cytokines.

This study investigated the effect of romosozumab on bone union in a rat posterolateral lumbar fixation model. Posterolateral lumbar fixation was performed on 8-week-old male Sprague Dawley rats (n=20). For bone grafting, autogenous bone (40 mg) was harvested from the spinous processes of the 10th thoracic vertebra until the 2nd lumbar vertebra and implanted between the intervertebral joints and transverse processes of the 4th and 5th lumbar vertebrae on both sides. Rats were matched by body weight and equally divided into two groups: R group (Evenity®, 25 mg/kg) and control (C) group (saline). Subcutaneous injections were administered twice a week until 8 weeks after surgery. Computed tomography was performed at surgery and week 8 after surgery. The area and percentage of bone trabeculae in the total area of bone fusion were calculated. Statistical analysis was performed using an unpaired t-test (P<0.05). We found that the R group rats had significantly higher mean bone union rate and volume than did the C group rats at all time courses starting week 4 after surgery. The R group had significantly higher increase rates than did the C group at weeks 4 and 6 after surgery. The percentage of bone trabeculae area in the R group was approximately 1.7 times larger than that in the C group. Thus, we demonstrated that romosozumab administration has stimulatory effects on bony outgrowth at bone graft sites. We attribute this to the modeling effect of romosozumab. This article is protected by copyright. All rights reserved.

Introduction: Although strict compliance with brace wearing is important for patients with scoliosis, no study has analyzed the most ideal conditions for temperature logger accuracy. We evaluated the optimal brace position and threshold temperature for the logger and determined the reliability of its measurements in patients with scoliosis. Methods: Five temperature loggers were embedded into holes generated at five different brace positions (right scapula, right chest, left chest, lumbar, and abdomen) within the brace. We compared measurement errors at each position using different threshold temperatures to determine the ideal anatomical position and threshold temperature. Under the ideal conditions determined, we calculated the reliability of the temperature logger readings in three healthy participants. Results: Measurement errors (i.e., differences between the actual and logger-recorded brace wearing times) were the lowest at the 28°C and 30°C threshold temperatures when the logger was positioned at the left chest and at 30°C at the abdomen. Among these three temperature/position combinations, we considered the abdomen to be the least affected by the shape of the brace; thus, the placement of the temperature logger at the abdomen using a threshold temperature of 30°C was the most ideal condition. Conclusions: The placement of the temperature logger at the abdomen using a threshold temperature of 30°C was the most ideal condition, with the reliability of the logger being 97.9%±0.9%. This information might be useful for scoliosis management teams, and this temperature logger provides a valuable clinical tool.

Background: When treating thoracolumbar fractures with severe cranial endplate injury but no or slight caudal endplate injury, it is debatable whether anterior fusion should be performed only for the injured cranial level, or for both cranial and caudal levels. We report an unexpected postoperative correction loss after combined multilevel posterior and single-level anterior fusion surgery in a patient with obesity. Case Description: A 28-year-old male with Class II obesity was brought to the emergency room with an L1 burst fracture with spinal canal involvement. Cranial endplate injury was severe, whereas caudal endplate injury was mild. The first surgery with 1-above 1-below posterior fixation failed to achieve sufficient stability; thus, additional surgeries (3-above 3-below posterior fixation and single-level T12-L1 anterior fusion) were performed. Postoperatively, the local kyphosis angle (LKA) between T12 and L2 was 22° in the lateral lying position and 29° in the standing position. Twenty-one-month post surgery, bony fusion between T12 and L1 was observed, and the LKA was 28° in both the lateral lying and standing positions. After posterior implants were removed 24 months after the surgery, significant correction loss both at the T12-L1 segment (6°) and L1-L2 segment (6°) occurred, and LKA was 40° at the final follow-up. Conclusion: In this patient, an intense axial load due to excessive body weight was at least one of the causes of postoperative correction loss. Postural differences in LKA may be useful to evaluate the stability of thoracolumbar fractures after fusion surgery and to predict postoperative correction loss.

Introduction: Although lateral vertebral translation is associated with inducing curve progression and pain, no study has analyzed risk factors for lateral slip in patients with residual adolescent idiopathic scoliosis (AIS). This study aimed to investigate risk factors for lateral slip in patients with residual AIS. Methods: We included 42 preoperative patients with residual AIS with a thoracolumbar/lumbar (TL/L) curve (3 male, 39 female; age 41.9±18.2 years, TL/L Cobb angle 55.5±10.0°). All patients were >20 years and had been diagnosed with AIS during their adolescence. Lateral slip was defined as more than a 6-mm slip on coronal CT images. Results: Patients were divided into slip (n=22) and nonslip (n=20) groups. Significant differences were observed in age, TL/L Cobb angle, TL/L curve flexibility, lumbar lordosis, thoracolumbar kyphosis, apical vertebral rotation, apical vertebral translation, and L3 and L4 tilt between the groups. Multivariate analyses and receiver operating characteristic curves found that only older age was a significant risk factor for lateral slip (odds ratio: 1.214; 95% confidence interval: 1.047-1.407; P=0.010), with a cutoff value of 37 years old. Conclusions: Older age, especially >37 years, is a risk factor for lateral slip in patients with residual AIS. These findings suggest that surgery for residual AIS should be considered before patients are in their mid-30s to avoid lateral translation.

Introduction Advanced glycation end-products (AGEs) have the potential to serve as biomarkers of aging and metabolic diseases; however, how their expression relates to clinical symptoms is not well defined. In this study, we sought to determine whether the accumulation of pentosidine, one type of AGE, at the peripheral nerve is associated with cutaneous pain or hypersensitivity caused by ovariectomy (OVX). Methods We assigned 12-week-old female Sprague Dawley rats into either the OVX group (n = 6) or the sham group (n = 6). Cutaneous hindpaw sensitivity to mechanical stimuli was measured with von Frey filaments, using Chaplan's adapted method, and the 50% withdrawal threshold was calculated. Then, the accumulation of pentosidine, which represents AGEs, was measured in sciatic nerve fibers after staining with an anti-pentosidine antibody. Results OVX rats showed significantly increased plantar hypersensitivity to mechanical stimuli compared to sham rats 8 weeks after OVX (P = 0.017). Pentosidine-positive sciatic nerves were detected at a higher rate in OVX rats than in sham rats (P = 0.035). The pentosidine positivity rate in sciatic nerve fibers showed a negative correlation with withdrawal threshold (P < 0.001). Conclusions This study showed that higher levels of pentosidine in sciatic nerve fibers are associated with higher plantar hypersensitivity. Accumulation of pentosidine at the sciatic nerve, caused by OVX, may result in cutaneous hindpaw hypersensitivity.

BACKGROUND/AIM: Bone metastasis commonly causes severe pain. Nerve growth factor (NGF) contributes to pain, and promotes the production of pain-associated neuropeptides, such as calcitonin gene-related peptide (CGRP), from sensory nerve endings. We hypothesized that breast cancer cells have NGF levels that promote axonal growth from dorsal root ganglia (DRGs) neurons, and increase their CGRP production associated with pain from spinal metastases. MATERIALS AND METHODS: Expression of NGF by the cultured rat breast adenocarcinoma cell line CRL-1666 was determined using an enzyme-linked immunosorbent assay (ELISA). We constructed a rat model of spinal metastasis by implanting CRL-1666 into L6 vertebrae and determined the change in CGRP expression in DRG neurons innervating vertebrae immunohistochemically. RESULTS: NGF was expressed by CRL-1666. When DRG cells were co-cultured with CRL-1666, there were more CGRP-ir neurons and with a greater average length of axon growth than in cultures without CRL-1666 (p<0.05). In the rat model of metastasis, there were more CGRP-ir DRG neurons innervating vertebra treated with CRL-1666 than in vertebrae from sham surgery control rats (p<0.05). CONCLUSION: NGF from breast cancer may mediate spinal bone pain from metastasis via axonal growth and up-regulation of pain-associated neuropeptides.

INTRODUCTION: Condoliase is a newly approved drug that improves symptoms associated with lumbar disk herniation (LDH) by intradiscal administration. This study aimed to evaluate the mid-term outcomes of condoliase injection, examine the adverse events, including cases that required surgery after condoliase administration, and verify cases in which condoliase could be effective. METHODS: We enrolled patients with LDH who were treated conservatively for at least six weeks and received condoliase. We assessed the visual analog scale (VAS) score, Japanese Orthopaedic Association Back Pain Evaluation Questionnaire, Oswestry Disability Index, disk height, and disk degeneration for up to 6 months, and we examined the complications. Furthermore, a 50% or more improvement in leg pain VAS score was considered effective. Factors related to symptom improvement were investigated by determining whether lower limb pain improved in six months. RESULTS: In total, 84 patients were recruited (52 men, 32 women; mean age, 44.2 ± 17.1 [16-86 years]). The duration of illness was 6.7 ± 6.8 (1.5-30) months. All patient-based outcomes significantly improved at 4 weeks after the administration compared with pretreatment. The intervertebral disc height decreased significantly at four weeks after condoliase administration compared with that before administration. Progression of intervertebral disc degeneration occurred in 50% of the patients. Eleven patients underwent herniotomy due to poor treatment effects. Moreover, treatment in 77.4% of the patients was considered effective. A logistic regression analysis revealed that L5/S1 disk administration (p = 0.029; odds ratio, 5.94; 95% confidence interval, 1.20-29.45) were significantly associated with clinical effectiveness. CONCLUSIONS: Condoliase disk administration improved pain and quality of life over time. Condoliase disk administration was more effective in L5/S1 intervertebral administration.

BACKGROUND: Postoperative changes in lumbar lordosis (LL) after transforaminal lumbar interbody fusion (TLIF) and the related factors are not well-understood. Recently, the preoperative difference in LL between standing and supine positions (DiLL) was proposed as a factor for predicting postoperative radiologic outcomes after short-segment TLIF. This study investigated the influence of DiLL on mid-term radiological outcomes after short-segment TLIF. METHODS: Sixty-six patients with lumbar degenerative disease treated with short-segment TLIF (1-2 levels) who underwent lumbar spine standing radiographs at 3 months, 6 months, 1 year, 2 years, 3 years, 4 years, and 5 years postoperatively were divided into DiLL (+) and DiLL (-) groups (preoperative DiLL ≥0° and <0°, respectively). Associations between the postoperative change in LL and DiLL and clinical outcomes (Oswestry disability index (ODI) and Nakai score) were evaluated. RESULTS: Temporary restoration of LL (+4.5°) until 1 year postoperatively and a subsequent decrease in LL from 1 to 5 years postoperatively (-5.3°) was observed in the DiLL (+) group. No postoperative change in LL was observed in the DiLL (-) group. Postoperative changes in LL were mainly observed in non-fused segments. The postoperative change in LL (ΔLL) until 1 year postoperatively had a significant positive association with DiLL (p = 0.00028), whereas ΔLL from 1 to 5 years postoperatively showed a significant negative association with DiLL (p = 0.010) and a positive association with Nakai score (p = 0.028). ΔLL until 5 years postoperatively showed a significant positive association with postoperative ODI improvement (p = 0.011). CONCLUSIONS: DiLL (+) patients showed a specific time course with temporary LL restoration until 1 year postoperatively and a subsequent decrease in LL from 1 to 5 years postoperatively. Patients with larger postoperative increase in LL until 5 years postoperatively and lesser decrease in LL from 1 to 5 years postoperatively tended to show better mid-term clinical outcomes.

In the current study, multivariate analyses were performed to determine factors associated with low back pain (LBP) in patients with osteoporosis. Aging, high bone turnover, obesity, low trunk muscle mass, spinal global sagittal malalignment, and a high number of previous vertebral fractures were potential independent risk factors of pain-related disorders, gait disturbance, or ADL deficit due to LBP. PURPOSE: Patients with osteoporosis often experience low back pain (LBP) even in the absence of acute fractures. This study identifies factors that may affect questionnaires about LBP. METHODS: The data of 491 patients with osteoporosis were retrospectively reviewed. Data included patient age, sex, body mass index (BMI), bone mineral density of the lumbar spine, tartrate-resistant acid phosphatase 5b level (TRACP5b), trunk muscle mass, sagittal vertical axis (SVA), previous vertebral fractures, secondary osteoporosis, controlling nutritional status score, pain-related disorders and gait disturbance scores from the Japanese Orthopedic Association Back Pain Evaluation questionnaire (JOABPEQ), and Oswestry disability index (ODI) scores for activities of daily living (ADL) deficit. Patients with scores of 100 for each subsection of the JOABPEQ, or an ODI scores < 12 were considered to not have dysfunction (dysfunction (-) group). Multivariate analyses were used to determine variables associated with dysfunction. RESULTS: Pain-related disorders score of JOABPEQ was associated with aging, high BMI, and high SVA. Aging, high TRACP5b, high BMI, low TM, high SVA, and more previous vertebral fractures were associated with gait disturbance score of JOABPEQ. ODI scores were associated with high BMI, low TM, high SVA, and more previous vertebral fractures. CONCLUSIONS: Aging, high bone turnover, obesity, a low TM, spinal global sagittal malalignment, and a high number of previous VFs were potential independent risk factors of pain-related disorders or gait disturbance according to the JOABPEQ or ODI score in patients with osteoporosis.

STUDY DESIGN: A retrospective observational study. PURPOSE: To compare two conservative treatments for acute osteoporotic vertebral fractures (OVFs). OVERVIEW OF LITERATURE: Several studies have reported conservative treatments for OVFs in terms of using a brace, rehabilitation, and bed rest. However, there is no consensus about the conservative treatment for OVFs. METHODS: We evaluated 68 patients with acute OVF treated in our hospital from 2007 to 2011. Thirty-four patients treated in prolonged bed rest (PBR) regimen underwent rehabilitation wearing a Jewett's brace after three weeks of bed rest. In contrast, the other 34 patients underwent rehabilitation wearing a Jewett's brace as soon as possible, which we called a stir-up (SU) regimen. We compared two treatment groups for medical costs, hospital length of stay (LOS), pain according to the numeric rating scale (NRS), the activities of daily living (ADL), and imaging studies. RESULTS: The average hospital LOS was significantly shorter in patients treated by the SU regimen, which resulted in the medical costs reduction. There was no significant difference in the NRS through 6 months between the two groups. Although many patients in both groups experienced at least one level reduction in ADL at 6 months after the injury, patients in the SU group tended to maintain their pre-injury ADL, which almost agrees with past reports. In terms of imaging studies, patients in the PBR group showed milder vertebral compression rate over time. Pseudoarthrosis occurred in 2 patients in the SU group, who presented with mild pain, which had little influence on their daily lives. CONCLUSION: We compared two conservative treatments for OVFs. Early rehabilitation was useful treatment for OVFs to minimize the risk for disuse syndrome, maintain pre-injury ADL status, and reduce the medical costs.

OBJECTIVES: To describe the novel technique of continuous local antibiotic perfusion (CLAP) for a surgical site infection (SSI) after instrumented spinal surgery. METHODS: CLAP was applied to 4 continuous patients at our institution who developed SSI after instrumented spinal surgery. RESULTS: All 4 patients were successfully treated and the infection was controlled. The implant was retained in all patients. The duration of CLAP ranged from 2 to 3 weeks. The blood level of the antibiotic used (gentamicin) at 1 week after the initiation of CLAP did not increase in any patient. No other adverse events occurred in any patient. Dramatic improvements in laboratory parameters, including the white blood cell (WBC) counts and C-reactive protein (CRP) levels were seen in every patient at 1 week after the initiation of CLAP. CONCLUSIONS: CLAP controlled the infection without severe adverse events in all 4 patients, and the implants were retained. Despite its cost and the discomfort of patients, CLAP may become an option for the treatment of SSIs after instrumented spinal surgery. A large number of case series are needed to verify the efficacy of CLAP for patients with SSIs after instrumented spinal surgery.

＜文献概要＞腰痛の生涯罹患率は85%と報告され,本邦の厚生労働省の報告においても,腰痛は男性1位,女性2位にランクされる国民愁訴である。少子高齢化に伴い,高齢者の慢性腰痛の増加,財源・マンパワー不足など,超高齢社会の医療,さらに昨今の新型肺炎に対応するため,遠隔医療のニーズが高まっている。認知行動療法(CBT)は慢性腰痛の治療においても高いエビデンスがあるが,治療には時間とコストがかかりCBTを受けている患者は少ないのが現状である。Apple社のResearchKitを用いてCBTによる腰痛ケアアプリを開発した。本アプリを用いた2週間の短期的なCBT介入で腰痛は改善を示すことがわかった。身につける端末を用いることで,診察以外でも患者の状態を診ることが可能となる。またかつてないほど大規模な腰痛調査が可能となり,フィードバックにより慢性腰痛の予防・改善支援につながることが期待できる。

＜文献概要＞腰痛は国民愁訴の最多を占める愁訴であり,その病態を把握・解析していくことは喫緊の課題であるが,腰痛評価は患者立脚型アウトカムによる主観的評価が主であり,客観的評価に乏しいことが現状である。われわれは,IoTやデバイスの改良が進み,健康を簡便かつ経時的に評価可能とするウェアラブル端末(Micro Motionlogger[米国A. M. I社])を用いて,腰痛に伴う活動量変化に着目し,研究を行ってきた。本稿では,腰痛患者の活動量に影響する因子は何か,さらに慢性腰痛疾患に対する手術治療の経過において活動量はどのように変化していくのかを客観的に評価し,腰痛患者の活動量には社会的背景や体組成が影響すること,手術前後の活動量について主観的評価と客観的評価には乖離があることを報告した。ADL/QOL評価においてウェアラブルデバイスは有用であり,今後より発展した調査・研究が望まれる。

骨粗鬆症性椎体骨折に対して最も広く行われている低侵襲手術はballoon kyphoplasty(BKP)である。しかしながら不安定性が強い骨折や麻痺を伴う場合は除圧固定術の適応となる。除圧固定術には前方除圧固定、後方除圧固定、前後合併除圧固定の3つの方法がある。いずれもある程度の成績は得られているが、高齢である点、また基本に骨粗鬆症があり、アンカーとしてのスクリューの固定性が十分でないための合併症が存在する。本稿では、骨粗鬆症性椎体骨折の手術療法、成功させるためのコツ、さらには合併症などを記載したい。(著者抄録)

Osteoplastic laminectomy is a surgical procedure that enables a wide field during the surgery and enables preservation of the posterior vertebral column structure by refixing the lamina once separated. We performed an osteoplastic laminectomy for resection of a ganglioneuroma at the sacral spine, and improved previous lower limb pain. A 33-year-old woman complained of pain in the nerve root region of the left S1. Examination revealed an epidural tumor at the left S2 level and we planned to remove the tumor. By performing an osteoplastic laminectomy at the level of S1-S3, we could secure a wide view of the surgical site and reliably resect the tumor. Pathological examination revealed that the resected tumor was a ganglioneuroma that had a possibility of malignant conversion. The postoperative course of our patient was favorable and no complaint was heard about surgical site pain postoperatively. There has been no tumor recurrence for more than 2 years. Osteoplastic laminectomy is considered to be a useful technique for epidural tumors at the sacral spine.