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INTRODUCTION: There have been few reports of patients with bilateral cervical facet dislocations that remain untreated for eight weeks or more. We report the case of a 76-year-old man with an old bilateral cervical facet joint dislocation fracture that was treated by posterior-anterior reduction and fixation. CASE PRESENTATION: A 76-year-old Asian man was involved in a road traffic accident. He presented with neck pain and arm pain on his right side, but motor weakness and paralysis were not observed. He was treated conservatively; however, instability and spondylolisthesis at the C5 to C6 joint increased eight weeks after the injury. We performed a posterior-anterior reduction and fixation. After surgery, bony union was achieved, and his neck pain and arm pain disappeared. CONCLUSION: We recommend reduction and fixation surgery if a patient has an old bilateral facet joint dislocation fracture in the cervical spine.

OBJECTIVES: Our aim was to clarify the distribution of hip pain in patients with osteoarthritis of the hip secondary to developmental dysplasia of the hip (DDH). METHODS: We retrospectively studied 443 hips in 369 patients with osteoarthritis secondary to DDH; mean age was 61 years, and follow-up rate was 84 %. Hip pain was defined as preoperative pain that was relieved 3 months after total hip arthroplasty. RESULTS: Distribution of pain originating in the hip was 89 % (393 hips) to the groin, 38 % (170 hips) to the buttock, 33 % (144 hips) to the anterior thigh, 29 % (130 hips) to the knee, 27 % (118 hips) to the greater trochanter, 17 % (76 hips) to the low back, and 8 % (34 hips) to the lower leg. When the groin, buttock, and greater trochanter were combined as the hip region, 95 % (421 hips) of pain was located in the hip region. On the other hand, when the anterior thigh, knee, lower leg, and low back were combined as the referral region, 55 % (242 hips) showed referred pain. CONCLUSIONS: We suggest that rheumatologists be aware of hip disease masquerading as knee pain or low back pain.

Adult presentation of neglected congenital muscular torticollis (CMT) is rare. Therefore, efficacy of surgical treatment for adult CMT is unclear. We experienced a case of neglected CMT in a 28-year-old male patient and report the surgical result here. We conducted unipolar resection at the distal end of the sternocleidomastoid muscle (SCM). After surgery, the range of neck movement and head tilt improved, and his appearance was cosmetically improved despite the long-standing nature of the deformity. We concluded that surgical management of adult patients with neglected congenital muscular torticollis may be a treatment option.

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.

STUDY DESIGN: Case series. OBJECTIVE: To present the difficulty of diagnosing the origin of lower leg pain in patients with lumbar spinal stenosis and hip joint arthritis. SUMMARY OF BACKGROUND DATA: Pain arising from a degenerated hip joint is sometimes localized to the lower leg. Patients with lumbar spinal disease may also show radicular pain corresponding to the lower leg area. If patients present with both conditions and only pain at the lower leg, it is difficult to determine the origin of the pain. METHODS: We reviewed 420 patients who had leg pain with lumbar spinal stenosis diagnosed by myelography, computed tomography after myelography, or magnetic resonance imaging. Pain only at the ipsilateral lateral aspect of the lower leg but slight low back pain or pain around the hip joint was shown in 4 patients who had lumbar spinal stenosis and hip osteoarthritis. The symptoms resolved after L5 spinal nerve block, but remained after lidocaine infiltration into the hip joint. We performed decompression and posterolateral fusion surgery for these 4 patients. RESULTS: Leg pain did not resolve after lumbar surgery in all patients. Conservative treatment was not effective from 6 to 12 months, so ultimately we performed ipsilateral total hip replacement for all patients and they became symptom-free. CONCLUSION: It is difficult to determine the origin of lower leg pain by spinal nerve block and hip joint block in patients with lumbar spinal stenosis and hip osteoarthritis. We take this into consideration before surgery.

STUDY DESIGN: A case report. OBJECTIVE: An elderly patient presented with an acute lumbar spinal pseudogout attack after lumbar instrumented surgery. SUMMARY OF BACKGROUND DATA: Although gout and pseudogout are common diseases causing inflammatory arthropathy in peripheral joints, involvement of the spine is uncommon. Here, we report a patient experiencing an acute lumbar spinal pseudogout attack after lumbar instrumented surgery. METHODS: The patient was treated for lumbar spondylolisthesis at L4 and L5 level and afterward complained of lower back and bilateral leg pain. Conservative treatment was not effective for the patient; therefore, we preformed posterior transforaminal lumbar interbody fusion surgery. RESULTS: The postoperative course was uneventful; however, he experienced lower back pain 4 weeks after surgery. Magnetic resonance image showed changes in signal intensities of vertebra and fluid accumulation in posterior back muscles. A biopsy was performed, but the culture was negative for infection. Calcium pyrophosphate dehydrate was detected in the fluid. Thus, conservative therapy without antibiotics was performed, and the patient's symptoms disappeared within 2 weeks. CONCLUSION: Here, we reported the first case of acute lumbar spinal pseudogout attack after lumbar instrumented surgery. We recommend considering pseudogout before and after surgery.

UNLABELLED: In the present case of postoperative lumbar spinal stenosis after non-instrumented intertransverse fusion with granules of hydroxyapatite (HA), bone union was not completed and the patient felt the recurrence of his symptoms within two years. We performed re-decompression with fusion, and in hematoxylin and eosin staining of HA granulation harvested during revision surgery, fibrous tissue with hyaline degeneration surrounded the cavity where the HA had existed. Multinuclear giant cells and lymphocytes infiltrated some parts of the marginal layer of the cavity, and no obvious bony bridge had regenerated from autologous bone. No tartrate-resistant acid phosphate (TRAP) -positive osteoclasts could be seen in the new bone, suggesting that the activity of osteoclasts in the new bone decreased during the seven years after the primary surgery. VIRTUAL SLIDES: The virtual slide(s) for this article can be found here: http://www.diagnosticpathology.diagnomx.eu/vs/3483360258050263.

STUDY DESIGN: Prospective trial. OBJECTIVE: To examine the clinical efficacy of teriparatide for bone union after instrumented lumbar posterolateral fusion using local bone grafting in women with postmenopausal osteoporosis. SUMMARY OF BACKGROUND DATA: Intermittent parathyroid hormone (PTH) treatment increases bone mass and reduces the risk for osteoporotic vertebral fractures. Recombinant human PTH (1-34) has already been approved as a treatment for severe osteoporosis. Preclinical data support the efficacy of PTH for lumbar spinal fusion. However, clinical results of PTH for spinal fusion have not yet been reported. METHODS: Fifty-seven women with osteoporosis diagnosed with degenerative spondylolisthesis were divided into 2 treatment groups, a teriparatide group (n = 29; daily subcutaneous injection of 20 μg of teriparatide) and a bisphosphonate group (n = 28; weekly oral administration of 17.5 mg of risedronate). All patients underwent decompression and 1- or 2-level instrumented posterolateral fusion with a local bone graft. Fusion rate, duration of bone union, and pain scores were evaluated 1 year after surgery. RESULTS: Pain scores improved after surgery; however, no significant difference was noted between the groups after surgery. The rate of bone union was 82% in the teriparatide group and 68% in the bisphosphonate group. Average duration of bone union was 8 months in the teriparatide group and 10 months in the bisphosphonate group. The rate of bone union and average of duration of bone union in the teriparatide group patients were significantly superior to those in the bisphosphonate group. CONCLUSION: Daily subcutaneous injection of teriparatide for bone union using local bone grafting after instrumented lumbar posterolateral fusion in women with postmenopausal osteoporosis was more effective than oral administration of bisphosphonate.

INTRODUCTION: Interleukin-6 (IL-6) is thought to play a crucial role in the radicular pain caused by lumbar spinal stenosis. However, efficacy of inhibition of IL-6 for sciatica in patients with lumbar spinal stenosis has not been clarified. The purpose of the current study was to examine the effect of the anti-IL-6 receptor monoclonal antibody, tocilizumab, on radicular pain by its epidural administration onto spinal nerves in patients with lumbar spinal stenosis. METHODS: Sixty patients with low back and radicular leg pain caused by spinal stenosis were investigated. In 30 patients, we infiltrated 2.0 mL of lidocaine and 80 mg of tocilizumab onto the affected spinal nerve, and 2.0 mL of lidocaine and 3.3 mg of dexamethasone were used in 30 patients. Low back pain, leg pain, and leg numbness were evaluated during 1 month after spinal nerve infiltration. RESULTS: Infiltration of tocilizumab was more effective than dexamethasone for leg pain (3 days, 1, 2, and 4 weeks), low back pain (3 days, 1, 2 and 4 weeks), and leg numbness (3 days, 1 and 2 weeks). No adverse event was observed in either group. CONCLUSION: Our results indicate that the epidural administration of an anti-IL-6 receptor monoclonal antibody, tocilizumab, onto the spinal nerve produced reduction of radicular leg pain, numbness, and low back pain without adverse event. IL-6 may be one of the inducers of pain caused by spinal stenosis in humans.

It is known that free nerve endings are degenerated after application of shock waves. We therefore hypothesized that the application of shock waves to muscle induces dysfunction of neuromuscular transmission at neuromuscular junctions. We investigated changes in neuromuscular transmission in response to shock wave application. Sprague-Dawley rats were used in this study. Two thousand shock waves at an energy flux density of 0.18 mJ/mm(2) were applied to their right calf muscles. Neuromuscular junctions of gastrocnemius muscles were evaluated using rhodamine-α-bungarotoxin on the day of treatment (n  =  5). Amplitude and latency of compound muscle action potentials were measured on the day of treatment and 1, 2, 4, 6, and 8 weeks after treatment (n  =  10, each group). Degenerated acetylcholine receptors existed in all treated muscles. Although the action potential amplitude on the treated side was significantly less than on the control side from the day of treatment (25.1 ± 7.8 vs. 34.5 ± 9.1, p  =  0.012) to 6 weeks (27.9 ± 7.2 vs. 34.5 ± 7.2, p  =  0.037), there was no significant difference at 8 weeks. There was no significant difference in transmission latency between the groups. The application of shock waves to muscle induced a transient dysfunction of nerve conduction at neuromuscular junctions.

OBJECTIVE: To clarify the sensory innervation and inflammatory cytokines in hypertrophic synovia associated with pain transmission in OA of the hip. METHODS: A piece of the synovium was extracted during reconstruction surgery in 50 patients with OA of the hip as an inflammatory synovium and in 12 patients with femoral neck fracture as a normal synovium. Each sample was immersed in fixative solution, sectioned on a cryostat, and then processed for immunohistochemistry using antibodies as follows: neuron-specific class III β-tubulin (TuJ-1) as a general marker for nerve fibres, calcitonin gene-related peptide (CGRP) for sensory nerve fibres, nuclear factor κB (NF-κB) for the protein complex controlling the transcription of DNA in cellular responses to painful stimuli, and TNF-α for cytokines involved in acute inflammation. The number of immunopositive cells and fibres were counted using a fluorescence microscope. RESULTS: In the inflammatory synovium of OA of the hip, TuJ-1 was positive in 46% (23 hips). Of those positive for TuJ-1, 78% (18 hips) were also positive for CGRP, but 22% (5 hips) were negative for CGRP. NF-κB was positive in 68% (34 hips). Of those positive for NF-κB, 76% (26 hips) were also positive for TNF-α, but 24% (8 hips) were negative for TNF-α. In normal synovia, all four substances were negative. CONCLUSION: We suggest sensory innervation and inflammatory cytokines in hypertrophic synovia are associated with nociception in OA of the hip. TRIAL REGISTRATION: University Hospital Medical Information Network, www.umin.ac.jp, UMIN000001335.

STUDY DESIGN: An immunohistological analysis of the cervical intervertebral disc (IVD). OBJECTIVE: To investigate sensory and autonomic innervation of the rat cervical IVD. SUMMARY OF BACKGROUND DATA: Many clinicians are challenged with treating wide-ranging chronic neck pain. Several authors have reported that sympathetic nerves participate in chronic pain, and various sympathectomy procedures can effectively treat chronic pain. METHODS: The neuro-tracer Fluoro-gold (FG) was applied to the anterior surfaces of C5-C6 IVDs from 10 Sprague-Dawley rats to label the neurons of the innervating dorsal root ganglion (DRG), stellate ganglion (SG; sympathetic ganglion), and nodose ganglion (NG; parasympathetic ganglion). Seven days postsurgery, DRGs from level C1-C8, SG, and NG neurons were harvested, sectioned, and immunostained for calcitonin gene-related peptide (CGRP; a marker for peptide-containing neurons) and isolectin B4 (IB4; a marker for nonpeptide-containing neurons). The proportion of FG-labeled DRG neurons that were CGRP-immunoreactive (CGRP-IR), IB4-binding, and non-CGRP-IR and IB4-binding, and the proportion of FG-labeled SG neurons and NG neurons were calculated. RESULTS: FG-labeled neurons innervating the C5-C6 IVD were distributed throughout the C2-C8 DRGs. The proportions of FG-labeled DRG neurons that were CGRP-IR, IB4-binding, non-CGRP-IR and IB4-binding, as well as SG neurons, and NG neurons were 20.6%, 3.3%, 55.7%, 8.9%, and 11.5%, respectively. The proportion of CGRP-IR FG-labeled DRG neurons was significantly higher than the proportion of IB4-binding FG-labeled DRG neurons at each level (P < 0.05). CONCLUSION: The C5-C6 IVD was innervated multisegmentally from neurons of the C2-C8 DRG, SG, and NG. Overall, 79.6% of the nerve fibers innervating the IVD were sensory nerves and 20.4% were autonomic nerves. Furthermore, 23.9% of the nerve fibers innervating the IVD were afferent sensory pain-related nerves, 8.9% were efferent sympathetic nerves, and 11.5% were efferent parasympathetic nerves. These findings may explain the wide-ranging and chronic discogenic pain that occurs via the somatosensory and autonomic nervous system.

PURPOSE: Chronic low back pain is a common clinical problem. As medication, non-steroidal anti-inflammatory drugs are generally used; however, they are sometimes non-effective. Recently, opioids have been used for the treatment of chronic low back pain, and since 2010, transdermal fentanyl has been used to treat chronic non-cancer pain in Japan. The purpose of the current study was to examine the efficacy of transdermal fentanyl in the treatment of chronic low back pain. MATERIALS AND METHODS: This study included patients (n=62) that suffered from chronic low back pain and were non-responsive to non-steroidal anti-inflammatory drugs. Their conditions consisted of non-specific low back pain, multiple back operations, and specific low back pain awaiting surgery. Patients were given transdermal fentanyl for chronic low back pain. Scores of the visual analogue scale and the Oswestry Disability Index, as well as adverse events were evaluated before and after therapy. RESULTS: Overall, visual analogue scale scores and Oswestry Disability Index scores improved significantly after treatment. Transdermal fentanyl (12.5 to 50 μg/h) was effective in reducing low back pain in 45 of 62 patients; however, it was not effective in 17 patients. Patients who experienced the most improvement were those with specific low back pain awaiting surgery. Adverse events were seen in 40% of patients (constipation, 29%; nausea, 24%; itching, 24%). CONCLUSION: Transdermal fentanyl significantly improved visual analog scale scores and Oswestry Disability Index scores in 73% of patients, especially those with specific low back pain awaiting surgery; however, it did not decrease pain in 27% of patients, including patients with non-specific low back pain or multiple back operations.

PURPOSE: Pain from osteoarthritis (OA) is generally classified as nociceptive (inflammatory). Animal models of knee OA have shown that sensory nerve fibers innervating the knee are significantly damaged with destruction of subchondral bone junction, and induce neuropathic pain (NP). Our objective was to examine NP in the knees of OA patients using painDETECT (an NP questionnaire) and to evaluate the relationship between NP, pain intensity, and stage of OA. MATERIALS AND METHODS: Ninety-two knee OA patients were evaluated in this study. Pain scores using Visual Analogue Scales (VAS), Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC), painDETECT, duration of symptoms, severity of OA using the Kellgren-Lawrence (KL) system, and amount of joint fluid were evaluated and compared using a Spearman's correlation coefficient by rank test. RESULTS: Our study identified at least 5.4% of our knee OA patients as likely to have NP and 15.2% as possibly having NP. The painDETECT score was significantly correlated with the VAS and WOMAC pain severity. Compared with the painDETECT score, there was a tendency for positive correlation with the KL grade, and tendency for negative correlation with the existence and amount of joint fluid, but these correlations were not significant. CONCLUSION: PainDETECT scores classified 5.4% of pain from knee OA as NP. NP tended to be seen in patients with less joint fluid and increased KL grade, both of which corresponded to late stages of OA. It is important to consider the existence of NP in the treatment of knee OA pain.

STUDY DESIGN: Case report. OBJECTIVE: Diagnosis of symptomatic extra-foraminal lumbosacral stenosis using diffusion tensor imaging (DTI). SUMMARY OF BACKGROUND DATA: Conventional magnetic resonance imaging (MRI) has sometimes proved inadequate for evaluating symptomatic spinal nerve lesions. DTI has been developed to visualize anisotropy of nerve-fiber tracts to evaluate nerve degeneration. We report a case of nerve compression causing a far-out lesion diagnosed using DTI. METHODS: A 68-year-old patient presented with an 8-month history of severe right-sided sciatica. Computed tomography and MRI showed right L5-S1 foraminal stenosis and contact of the L5 transverse process and S1 ala without canal stenosis at the L4-L5 level. We evaluated the fractional anisotropy (FA) of the right L5 spinal nerve and compared it with bilateral L3-S1 spinal nerves to determine the L5 spinal nerve compression site. RESULTS: DTI revealed narrowing of the right L5 spinal nerve between the L5 transverse process and S1 ala. FA was significantly decreased in the right L5 spinal nerve between the L5 transverse process and S1 ala. There was no significant difference in the FA of spinal nerves between the right and left sides at L3, L4, or S1. The right L5 spinal nerve from the central spinal canal to the extra-foraminal lumbosacral lesion was exposed during surgery and found to be severely compressed by the L5 transverse process and S1 ala. Postoperatively, the patient's symptoms disappeared immediately. CONCLUSION: We used DTI to diagnose a symptomatic lesion as an extra-foraminal lumbosacral lesion caused by compression of the L5 spinal nerve at the foramina. Because DTI can quantitatively measure damage to nerve fibers, it may be advantageous for the diagnosis of far-out syndrome.

STUDY DESIGN: Immunohistological analysis of dichotomizing sensory nerve fibers projecting to the lumbar multifidus muscles and intervertebral disc (IVD), facet joint (FJ), or sacroiliac joint (SIJ) in rats. OBJECTIVE: To elucidate dichotomizing sensory nerve fibers projecting to the lumbar multifidus muscles and to IVDs, FJs, or SIJs. SUMMARY OF BACKGROUND DATA: Clinically, the origin of low back pain remains unknown. Multiple studies have identified lumbar muscles, IVDs, FJs, and SIJs as sources of low back pain. Pain may originate directly from lumbar muscles or be referred from the spine, or both. Dorsal root ganglion (DRG) neurons with dichotomizing axons have been reported in several species and are thought to be related to referred pain. METHODS: We used 2 neurotracers, 1,1'-dioctadecyl-3,3,3',3'-tetramethyl-indocarbocyanine perchlorate (DiI) and fluorogold (FG), in this double-labeling study involving 30 Sprague Dawley rats. DiI was applied to lumbar multifidus muscles in all rats. Simultaneously, FG was applied to the anterior left portion of L5-L6 IVDs in the IVD group (n = 10), to the left L5-L6 FJs in the FJ group (n = 10), and to the left SIJs in the SIJ group (n = 10). Fourteen days after surgery, left DRGs from L1 to L6 were harvested, sectioned, and observed under a fluorescence microscope. RESULTS: We verified the existence of double-labeled DRG neurons (i.e., dichotomizing sensory nerve fibers) projecting to lumbar multifidus muscles and to IVDs, FJs, or SIJs, depending on the group. The proportion of double-labeled cells in all DiI-labeled DRG neurons was higher in the FJ group (6.8%) and SIJ group (7.1%) than in the IVD group (3.1%) (P < 0.05). CONCLUSION: Our results document the presence of dichotomizing sensory nerve fibers projecting to lumbar multifidus muscles and to IVDs, FJs, and SIJs. Referred low back muscle pain may reflect disorders of lumbar posterior structures, such as FJs and SIJs, rather than disorders of lumbar anterior structures, such as IVDs.

OBJECTIVE: The purpose of the study was to clarify the incidence of alcohol-associated osteonecrosis of the knee using MRI. METHODS: A total of 131 patients (56 women and 75 men) with osteonecrosis of the femoral head were enrolled; 60 patients had a history of alcohol abuse and 71 had previously received steroids. All patients underwent MRI of the knee. The incidence of alcohol-associated osteonecrosis of the knee was compared with that of steroid-associated osteonecrosis of the knee. Predictive factors of alcohol- and steroid-associated osteonecrosis of the knee were also evaluated. RESULTS: The incidence of alcohol-associated osteonecrosis of the knee was lower than that of steroid-associated osteonecrosis of the knee (18.3 vs 54.9%; P < 0.001, Fisher's exact probability test). No significant difference in weekly alcohol consumption was observed between patients with osteonecrosis of the knee and those without osteonecrosis of the knee. No significant difference in daily maximum steroid doses was observed between patients with osteonecrosis of the knee and those without osteonecrosis of the knee. CONCLUSION: The present study revealed that the incidence of alcohol-associated osteonecrosis of the knee is lower than that of steroid-associated osteonecrosis of the knee.

STUDY DESIGN: Prospective randomized trial. OBJECTIVE: To examine the effect of the tumor necrosis factor alpha (TNF-α) inhibitor, etanercept, on radicular pain by its epidural administration onto spinal nerves in patients with lumbar spinal stenosis. SUMMARY OF BACKGROUND DATA: TNF-α is thought to play a crucial role in the radicular pain caused by lumbar disc herniation and spinal stenosis. Intravenous infusion of infliximab for sciatica has been examined in 2 studies; however, the results were equivocal. METHODS: Eighty patients with low back and radicular leg pain were investigated. We diagnosed the patients by physical examination, and X-ray and magnetic resonance imaging. In 40 patients, we epidurally administered 2.0 mL of lidocaine and 10 mg of etanercept onto the affected spinal nerve, and 2.0 mL of lidocaine and 3.3 mg of dexamethasone was used in 40 patients. Low back pain, leg pain, and leg numbness were evaluated using a visual analogue scale (VAS) and Oswestry Disability Index (ODI) score before and for 1 month after epidural administration. RESULTS: Low back pain, leg pain, and leg numbness in the 2 groups were not significantly different before epidural administration. Epidural administration of etanercept was more effective than dexamethasone for leg pain (3 days, and 1, 2, and 4 weeks: P < 0.05), low back pain (3 days, and 1 and 2 weeks: P < 0.05), and leg numbness (3 days, and 1 and 2 weeks: P < 0.05). No adverse event was observed in either group. CONCLUSION: Our results indicate that epidural administration of a TNF-α inhibitor onto the spinal nerve produced pain relief, but no adverse event. TNF-α inhibitors may be useful tools for the treatment of radicular pain caused by spinal stenosis.

Disturbance of blood supply to the femoral head is a risk factor for corticosteroid-associated osteonecrosis. The aim was to measure blood supply of the proximal femur during corticosteroid therapy in systemic lupus erythematosus (SLE) patients. We repeatedly performed 78 dynamic MRIs of 19 hip joints in 19 SLE patients after initiation of corticosteroid administration for one year. Blood supply of the femoral head (epiphysis, growth plate, and metaphysis), the femoral neck, and the medial circumflex femoral artery were measured in terms of peak percent enhancement. At the first month, blood supply of the growth plate was significantly higher in the pediatric group (&lt;15 years old) than in the adolescent and adult group (&gt;15 years old). At the fourth month, blood supply in every part of the femoral head (epiphysis, growth plate, and metaphysis) was significantly higher in the pediatric group than in the adolescent and adult group. Multiple regression analysis revealed that blood supply to the femoral head depended on the number of days after initiation of corticosteroid administration and the age at the time of dynamic MRI. Blood supply to the femoral head is abundant in pediatric patients and is a function of the number of days after initiation of corticosteroid administration.

PURPOSE: Sacroiliac fixation using iliac screws for highly unstable lumbar spine has been reported with an improved fusion rate and clinical results. On the other hand, there is a potential for clinical problems related to iliac fixation, including late sacroiliac joint arthritis and pain. MATERIALS AND METHODS: Twenty patients were evaluated. Degenerative scoliosis was diagnosed in 7 patients, failed back syndrome in 6 patients, destructive spondyloarthropathy in 4 patients, and Charcot spine in 3 patients. All patients underwent posterolateral fusion surgery incorporating lumbar, S1 and iliac screws. We evaluated the pain scores, bone union, and degeneration of sacroiliac joints by X-ray imaging and computed tomography before and 3 years after surgery. For evaluation of low back and buttock pain from sacroiliac joints 3 years after surgery, lidocaine was administered in order to examine pain relief thereafter. RESULTS: Pain scores significantly improved after surgery. All patients showed bone union at final follow-up. Degeneration of sacroiliac joints was not seen in the 20 patients 3 years after surgery. Patients showed slight low back and buttock pain 3 years after surgery. However, not all patients showed relief of the low back and buttock pain after injection of lidocaine into the sacroiliac joint, indicating that their pain did not originate from sacroiliac joints. CONCLUSION: The fusion rate and clinical results were excellent. Also, degeneration and pain from sacroiliac joints were not seen within 3 years after surgery. We recommend sacroiliac fixation using iliac screws for highly unstable lumbar spine.

STUDY DESIGN: Immunohistochemical study. OBJECTIVE: To evaluate invasive surgical approaches by analyzing the number of sensory nerve fibers at 2 back muscle sites in rats and humans and the number of injured nerve fibers innervating these 2 sites after muscle injury in rats. SUMMARY OF BACKGROUND DATA.: Several minimally invasive approaches have recently become popular in the treatment of lumbar spine disorders. Minimally invasive surgery (MIS) is not invasive to back muscle and is thought to reduce low back pain. Muscle damage has been generally evaluated by magnetic resonance imaging (MRI); however, damage to sensory nerve fibers in and around back muscle that is directly related to pain has apparently not been explored. METHODS: Human muscle at L4-L5 was obtained from the paraspinous process (during a midline approach) and from paraspinal back muscle (during a Wiltse paraspinal approach) (n = 10 each). The muscle was sectioned and immunostained for calcitonin gene-related peptide (CGRP). To detect dorsal root ganglion (DRG) neurons innervating back muscle in rats, Fluoro-Gold (FG) was applied to the same 2 sites on the lower back muscle at L4-L5 (only application, n = 12; application of FG + muscle injury, n = 12). DRGs were harvested and immunostained for CGRP and activating transcription factor-3 (ATF-3: marker for nerve injury). The numbers of FG-labeled CGRP-immunoreactive or FG-labeled ATF-3-immunoreactive DRG neurons innervating the 2 sites were counted and compared. RESULTS: CGRP-immunoreactive sensory nerve fibers were found at the 2 sites. The average number of CGRP-immunoreactive sensory nerve fibers in muscle obtained in a midline approach was significantly higher than that in muscle obtained in a Wiltse paraspinal approach (P < 0.01). The numbers of FG-labeled CGRP- and ATF-3-immunoreactive DRG neurons innervating paraspinous process muscle were significantly greater than those innervating paraspinal back muscle in rats (P < 0.01). CONCLUSION: There are more CGRP-immunoreactive sensory nerve fibers and DRG neurons innervating muscle in the midline approach area than in the Wiltse paraspinal approach area in humans and rats. There are more ATF-3-immunoreactive DRG neurons innervating muscle in the midline approach area than in the Wiltse paraspinal approach area after muscle injury in rats. This result may show the differences in sensory nerve injury during the 2 surgical approaches.

STUDY DESIGN: Prospective study of 212 patients with groin pain but without low back pain. OBJECTIVE: To evaluate discogenic groin pain without low back pain or radicular pain. SUMMARY OF BACKGROUND DATA: Patients feel low back pain originating from discogenic disease. It has been reported that the rat lower lumbar discs are innervated mainly by L2 dorsal root ganglion neurons. Thus, it is possible that patients feel referred groin pain corresponding to the L2 dermatome originating from intervertebral discs; however, the referred pain has not been fully clarified in humans. METHODS: We selected 5 patients with groin pain alone for investigation. The patients suffered from groin pain and showed disc degeneration only at 1 level (L4-L5 or L5-S1) on magnetic resonance imaging. Patients did not show any hip joint abnormality on radiography or magnetic resonance imaging. To prove that their groin pain originated in degenerated intervertebral discs, we evaluated changes in groin pain after infiltration of lidocaine into hip joints and examined pain provocation on discography, pain relief by anesthetic discoblock, and finally anterior lumbar interbody fusion surgery. RESULTS: All patients were negative for hip joint block, positive for pain provocation on discography, and positive for pain relief by anesthetic discoblock. Furthermore, bony union was achieved 1 year after anterior interbody fusion surgery in all patients, and visual analogue scale score of groin pain was significantly improved at 1 year after surgery in all patients (P < 0.05). CONCLUSION: In the current study, we diagnosed discogenic groin pain, using magnetic resonance imaging, infiltration of lidocaine into the hip joint, pain provocation on discography, pain relief by anesthetic discoblock, and lumbar surgery. It is important to consider the existence of discogenic groin pain if patients do not show low back pain.

<sec><title>Objectives</title> The purpose of this study was to assess N-acetyl aspartate changes in the thalamus in patients with osteoarthritis of the hip using proton magnetic resonance spectroscopy. </sec><sec><title>Methods</title> Nine patients with osteoarthritis of the hip (symptomatic group, nine women; mean age 61.4 years (48 to 78)) and nine healthy volunteers (control group, six men, three women; mean age 30.0 years (26 to 38)) underwent proton magnetic resonance spectroscopy to assess the changes of N-acetyl aspartate in the thalamus. </sec><sec><title>Results</title> The ratio of N-acetyl aspartate to creatine plus phosphocreatine in the thalamus contralateral to the symptomatic hip in patients with osteoarthritis of the hip was significantly lower than the ratio of N-acetyl aspartate to creatine plus phosphocreatine in the thalamus in the control group (1.611 (1.194 to 1.882) vs 1.355 (1.043 to 1.502), p &lt; 0.001). And, a strong negative correlation was detected between the ratio of N-acetyl aspartate to creatine plus phosphocreatine in the thalamus contralateral to the symptomatic hip in patients with osteoarthritis of the hip and pain duration (r = -0.83, p = 0.018). </sec><sec><title>Conclusions</title> We evaluated the ratio of N-acetyl aspartate to creatine plus phosphocreatine in the thalamus of patients with osteoarthritis of the hip by using proton magnetic resonance spectroscopy. We concluded that the ratio of N-acetyl aspartate to creatine plus phosphocreatine in the thalamus contralateral to the symptomatic hip in patients with osteoarthritis of the hip were significantly lower than those in the thalamus of the control group, and that pain duration was strongly related to the decrease of the ratio of N-acetyl aspartate to creatine plus phosphocreatine. </sec>

STUDY DESIGN: Prospective trial. OBJECTIVE: To examine the bone union and clinical results after unilateral or bilateral instrumented posterolateral fusion surgery using a local bone graft. SUMMARY OF BACKGROUND DATA: The iliac crest bone graft technique for lumbar posterolateral fusion surgery is widely used; however, donor site problems such as pain and sensory disturbance have been reported. Local bone has been used for bilateral multisegment fusion surgery; however, outcomes have been poor because of insufficient amounts of local bone used. This study evaluated unilateral and bilateral posterolateral fusion at 3 levels using a local bone graft. METHODS: Sixty-two patients diagnosed with degenerated spondylolisthesis at 3 levels were divided into 2 groups. All underwent decompression and bilateral instrumented posterolateral fusion. However, a unilateral local bone graft was used in 32 patients and bilateral local bone graft was used in 30 patients. The amount of bone grafting, proportion of patients with bone union, duration of bone union, visual analog scale score, Japanese Orthopedic Association score, and Oswestry Disability Index were evaluated before and 2 years after surgery. RESULTS: Visual analog scale score, Japanese Orthopedic Association score, and Oswestry Disability Index were not significantly different between the 2 groups before and after surgery (P > 0.05). The amount of local bone graft used for each segment was significantly less in the bilateral group (P < 0.05). The proportion of patients with rates of bone union and instability were 86% and 9%, respectively, in the unilateral group, but significantly poorer at 60% and 34% in the bilateral group. CONCLUSION: If multisegment fusion (3-level fusion) is performed, bilateral local bone grafting results in a poor rate of bone union because of an insufficiency of local bone. Unilateral bone grafting is recommended because better rates of bone union and stability are achieved.

BACKGROUND: Drehmann sign is a characteristic clinical feature in slipped capital femoral epiphysis (SCFE). The presence of SCFE indicates an anatomic change of the proximal femur, which induces obligatory hip external rotation with hip flexion. In contrast, a cam-type femoro-acetabular impingement (FAI) is well known as sequelae of SCFE. The purpose of this study was to clarify the relationship between Drehmann sign and radiologic FAI. METHODS: We studied 92 hips of 80 SCFE patients who had been treated with in situ fixation. The occurrence rate of Drehmann sign was analyzed according to the degree of remodeling (the Jones classification) and the radiologic α-angle measured in each class at the final follow-up. At a mean 12.2 years after the final follow-up, the patients' present condition was clinically investigated with a questionnaire using a part of the Harris Hip Rating Scale (HHRS). In addition, 3-dimensional computed tomography analysis was performed to clarify the anatomic relationship between the femoral head and the acetabulum during testing for Drehmann sign. RESULTS: Among the 92 hips in the study, 60 were well remodeled (Jones type A), 24 were type B, and 8 were type C, with 6.5 years of mean follow-up. The mean of the modified α-angles for the 3 groups (A, B, and C) were 61.8, 84.7, and 119.4, respectively (P < 0.05); 25%, 75%, and 100% of the hips in the 3 groups, respectively, exhibited Drehmann sign. The set of hips (n = 41) with a positive Drehmann sign had a mean α-angle of 85.6 versus 63.0 degrees for the set of hips (n = 51) with a negative Drehmann sign (P < 0.05). Seven (13.5%) of 52 patients responding to the questionnaire reported hip pain and/or limp in the positive Drehmann sign group, but no patient in the negative sign group complained of either. Three-dimensional computed tomography delineated FAI at 2 different positions during testing for Drehmann sign. CONCLUSIONS: Drehmann sign is highly valuable for clinically evaluating the existence of FAI and for following up with observation or realignment to prevent early osteoarthritis.

OBJECTIVES: The purpose of this study was to clarify the incidence of (CS)-associated osteonecrosis among different underlying diseases and to evaluate the risk factors for steroid-associated osteonecrosis in a prospective MRI study. METHODS: We prospectively used MRI to study 337 eligible underlying disease patients requiring CS therapy and succeeded in examining 1199 joints (hips and knees) in 302 patients with MRI for at least 1 year starting immediately after the onset of CS therapy (1-year follow-up rate of 90%). The underlying diseases included SLE in 687 joints (173 patients) and a variety of other rheumatological disorders in 512 joints (129 patients). RESULTS: The incidence of osteonecrosis was significantly higher in SLE patients than in non-SLE patients (37 vs 21%, P = 0.001). Logistic regression analysis revealed that adolescent and adult patients had a significantly higher risk of osteonecrosis compared with paediatric patients [odds ratio (OR) = 13.2], that high daily CS dosage (>40 mg/day) entailed a significantly higher risk of osteonecrosis compared with the dosage of <40 mg/day (OR = 4.2), that SLE patients had a significantly higher risk of osteonecrosis compared with non-SLE patients (OR = 2.6) and that male patients had a significantly higher risk of osteonecrosis compared with female patients (OR = 1.6). CONCLUSION: These findings suggest that the incidence of CS-associated osteonecrosis varies among different underlying diseases.

PURPOSE: To evaluate articular cartilage degeneration with transverse relaxation time (T2) mapping in systemic lupus erythematosus (SLE) patients with noncollapsed and asymptomatic osteonecrosis of the femoral head associated with corticosteroids. MATERIALS AND METHODS: T2 mapping with a 1.5-T magnetic resonance imaging system was prospectively performed for 28 normal hips from 14 healthy volunteers (control group) and 15 hips from 10 SLE patients that met the inclusion criteria of noncollapsed and asymptomatic osteonecrosis of the femoral head (osteonecrosis group). Exclusion criteria were past experience of pain, trauma, infection, or prior hip joint surgery. Distribution of T2 values of the femoral head cartilage were compared between the control group and the osteonecrosis group with respect to acetabular dysplasia by center-edge angle (CEA). RESULTS: T2 values of the femoral head cartilage were significantly higher in the osteonecrosis group than in the control group (34.4 msec vs. 30.8 msec, P = 0.001). Multiple regression analysis revealed that the osteonecrosis group and decreased CEA was significantly associated with high T2 values (T2 value = 34.6 + 3.6 × [osteonecrosis] - 0.14 × CEA, R(2) = 0.52, P = 0.003). CONCLUSION: Degeneration of articular cartilage was associated with osteonecrosis of the femoral head in SLE patients and acetabular dysplasia.

The aim of this study was to clarify the reproducibility of the Japanese Ministry of Health, Labor and Welfare (JMHLW) type classification for osteonecrosis of the femoral head. We performed inter-observer and intra-observer trials using 40 sets of magnetic resonance imagings, 20 of which were produced by a 0.5 Tesla (T) superconductive unit and the other 20 produced by a 1.5 T unit, in patients with non-collapsed and asymptomatic osteonecrosis of the femoral head (JMHLW stage 1 or 2). The JMHLW type classification (A, B, C1, or C2) was determined from T1-weighted coronal images at the center of the femoral head. Six orthopedic surgeons independently assessed all 40 images twice, with an interval of 4-5 weeks between sessions. Regarding inter-observer reliability, the percent agreement was 85% and weighted kappa was 0.709 for 0.5 T, versus a percent agreement of 82% and weighted kappa of 0.724 for 1.5 T. Regarding intra-observer reliability, the percent agreement was 82% and weighted kappa was 0.780 for 0.5 T versus a percent agreement of 80% and weighted kappa of 0.800 for 1.5 T. Inter-observer and intra-observer reliabilities did not differ significantly between the 0.5 and 1.5 T units. The JMHLW type classification provided high inter-observer and intra-observer reliabilities.

STUDY DESIGN: Gait analysis and immunohistological analysis in a rat model of myofascial inflammation in low back. OBJECTIVE: To investigate gait in a rat model of myofascial inflammation using the CatWalk gait analysis system. SUMMARY OF BACKGROUND DATA: There are few reports examining low back pain behavior in animal models. The CatWalk is a computer-assisted gait analysis system that provides an automated way to assess gait function and this behavior during pain. METHODS: In a myofascial inflammation group, 0.5 mL of 4% paraformaldehyde buffer and 0.5 mL of 5% Fluoro-Gold (FG) buffer were injected into bilateral multifidus muscles of rats. In a control group, FG buffer alone was injected. Five days after surgery, the gait of rats in both groups was investigated using the CatWalk system. In the present study a total of 36 gait parameters were quantified and used to judge pain-related behavior. Bilateral dorsal root ganglia (DRGs) from L1 to L6 levels were resected, and immunostained for calcitonin gene-related peptide (CGRP). RESULTS: In the myofascial inflammation group, the mean duty cycle (duration of paw contact divided by time between consecutive paw contacts) of each paws (front and hind) were significantly higher and mean stride length (the distance between successive placements of the same paw) of each paws were significantly shorter compared with the control group. Furthermore, mean minimum contact intensity of the complete paw and mean contact intensity of each paws in the myofascial inflammation group were significantly higher compared with the control group. The proportion of CGRP-immunoreactive FG-labeled neurons among all FG-labeled DRG neurons in the myofascial inflammation group was significantly higher than the proportion in the control group. CONCLUSION: These results suggest that myofascial inflammation in low back caused the changes to the rat's gait, including long stands, short stride, and strong paw contact.

STUDY DESIGN: Prospective trial. OBJECTIVE: To examine the difference in bone union and clinical results after one-, two-, and three-level instrumented posterolateral fusion surgery using a local bone graft. SUMMARY OF BACKGROUND DATA: The iliac crest bone graft technique for lumbar posterolateral fusion surgery is widely used; however, donor site problems such as pain and sensory disturbance have been reported. Local bone has been used for fusion surgery; however, its reliability as a graft for multiple segments has not been fully reported. METHODS: One hundred twenty-two patients diagnosed with degenerated spondylolisthesis were divided into three groups [spondylolisthesis at 1 level (n = 42), at 2 levels (n = 40), and at 3 levels (n = 40)]. All patients underwent decompression and instrumented posterolateral fusion with a local bone graft. The amount of bone graft, proportion of patients with (rate) and duration of bone union, Visual Analog Scale (VAS) score, Japanese Orthopedic Association Score (JOAS), and Oswestry Disability Index (ODI) were evaluated before and 2 years after therapy. RESULTS: VAS score, JOA score, and ODI were not significantly different among the three groups before and after surgery (P > 0.05). Average amount of local bone graft used for one segment significantly decreased in proportion to the number of fusion levels (P < 0.05). The rate of bone union was 88% in the one-level group, 85% in the two-level group, and 62.5% in the three-level group, which was significantly lower than that in the one- and two-level groups (P < 0.05). CONCLUSION: If one- and two-level posterolateral fusion were performed, the local bone graft technique provides a good and uniform bone union rate; however, for three-level fusion poor results were obtained because of an insufficient amount of local bone.

BACKGROUND: Surgery for lumbar spondylolisthesis is widely performed. However, there have been no reports comparing posterolateral and anterior interbody fusion prospectively. We compared instrumented posterolateral fusion with anterior interbody fusion for L4 spondylolisthesis in a prospective study. METHODS: Forty-six patients diagnosed with L4 degenerated spondylolisthesis were divided into two groups. Twenty-two consecutive patients underwent non-instrumented anterior interbody fusion using an iliac bone graft (ALIF; L4-L5 level), and 24 consecutive patients underwent instrumented posterolateral fusion with local bone (PLF; L4-L5 level). The rates of bone union, visual analog scale (VAS) score, Japanese Orthopedic Association (JOA) score, Oswestry Disability Index (ODI), surgical invasion, and complications were evaluated before and 2 years after surgery. RESULTS: Age, VAS score, JOA score, and ODI were not significantly different between the two groups before surgery (P > 0.05). Success of bone union between the two groups was not significantly different (P > 0.05). Blood loss during surgery was significantly less; however, periods of bed rest and hospital stay were significantly longer in the ALIF group (P < 0.05). Overall patient satisfaction, and low back and leg pain in both groups were significantly improved after surgery; however, low back pain showed greater improvement in the ALIF group compared with the PLF group (P < 0.05). Complications such as donor site pain (4 patients in the ALIF group) and dural tearing (3 patients in the PLF group) were observed. CONCLUSIONS: If single level fusion for L4 spondylolisthesis is performed, both anterior and posterior methods reduce patients' low back and leg pain. Improvement of low back pain was significantly greater after ALIF; however, periods of hospital stay and of bed rest were significantly longer.

In pathologic radicular pain of lumbar spinal stenosis, cytokines such as tumor necrosis factor-alpha (TNF-α) and interleukins (ILs) play a crucial role in the pathogenesis of nerve degeneration and pain. We investigated TNF-α and IL-6 levels in the cerebrospinal fluid (CSF) of patients with radicular pain caused by lumbar spinal stenosis (LSS). A total of 30 LSS patients and 10 age-matched controls were examined. CSF samples were obtained adjacent to the level of stenosis in 30 LSS patients, and at the L4-L5 level in the 10 control patients. TNF-α and IL-6 levels in the samples were analyzed using enzyme-linked immunosorbent assays (ELISA). We compared the amounts of TNF-α and IL-6 with severity of pain (low back and leg pain), walking ability, and severity of stenosis (cross-sectional area of dural space). The concentration of IL-6 was significantly higher in LSS patients than in controls, but TNF-α levels were beneath the limit of detection. There was no correlation between IL-6 levels and severity of pain or walking ability (p > 0.05). However, there was a significant correlation between IL-6 levels and severity of stenosis (p < 0.05). The current study showed that the increased CSF IL-6 levels in LSS patients with radicular pain were not correlated with pain severity; although not proven in this study, the increase in CSF IL-6 concentration could indicate pathological nerve damage or degeneration of lumbar radiculopathy represented by the severity of stenosis.

The iliac crest bone grafting (ICBG) technique for lumbar posterolateral fusion surgery is widely used; however, donor site problems such as pain and sensory disturbance have been reported. Local bone is available for fusion surgery, but its reliability as a graft has not been fully reported. In the current study, we examined single-level instrumented posterolateral fusion with a local bone graft versus an ICBG in a prospective randomized study. Eighty-two patients diagnosed with L4 degenerated spondylolisthesis were divided into two groups at random. Forty-two patients underwent instrumented posterolateral fusion with a local bone graft (L4-L5 level), and 40 patients underwent instrumented posterolateral fusion with an ICBG (L4-L5 level). Rate and duration of bone union, visual analog scale (VAS) score, Japanese orthopedic association score (JOAS), Oswestry Disability Index (ODI), and complications were evaluated before and 2 years after therapy. VAS score, JOAS, and ODI were not significantly different between the two groups before and after surgery (P > 0.05). Rate and average duration of bone union were 90% and 8.5 months in the local bone graft group, and 85% and 7.7 months in the ICBG group, but without significant difference (P > 0.05). Prolonged surgical time and complications such as donor site pain (8 patients) and sensory disturbance (6 patients) were observed in the ICBG group. If single-level posterolateral fusion was performed, local bone graft technique has the same bone union rate compared with ICBG, requires less surgical time, and has fewer complications.

STUDY DESIGN: retrograde neurotracing and immunohistochemistry were used to investigate the effect of the tumor necrosis factor (TNF)-α inhibitor, etanercept, on calcitonin gene-related peptide (CGRP) expression in dorsal root ganglion (DRG) neurons innervating intervertebral discs in rats. OBJECTIVE: to clarify the action of a TNF-α inhibitor on a sensory neuropeptide in DRG neurons innervating intervertebral discs. SUMMARY OF BACKGROUND DATA: degeneration of lumbar intervertebral discs is a cause of low back pain. TNF-α in the intervertebral disc is a major contributor to discogenie pain. Effects of TNF-α inhibition on CGRP expression in DRG neurons were evaluated. METHODS: the neurotracer FluoroGold was applied to the surfaces of L4/5 discs to label their innervating DRG neurons (n = 30). Of 30 rats, 10 were in a nonpunctured disc sham surgery control group, whereas the other 20 were in experimental groups in which intervertebral discs were punctured with a 23-gauge needle. Etanercept or saline was applied into the punctured discs (n = 10 each treatment). After 14 days of surgery, DRGs from L1 to L6 were harvested, sectioned, and immunostained for CGRP. The proportion of FluoroGold-labeled CGRP-immunoreactive DRG neurons was evaluated in all groups. RESULTS: FluoroGold-labeled neurons innervating the L4/5 disc were distributed throughout L1-L6 DRGs in all groups. Of the FluoroGold-labeled neurons, the proportion of CGRP-immunoreactive neurons was 21% ± 4% in the sham surgery control group, 32% ± 7% in the puncture + saline group, and 23% ± 4% in the puncture + etanercept group. The proportion of CGRP-immunoreactive neurons was significantly greater in the puncture + saline group compared with the sham control and puncture + etanercept groups (P < 0.01). CONCLUSION: in this model, CGRP was upregulated in DRG neurons innervating damaged discs. However, direct intradiscal application of etanercept immediately after disc puncture suppressed CGRP expression in DRG neurons innervating injured discs. This finding may further elucidate the mechanism for the effectiveness of etanercept in upregulation of neuropeptide in DRG neurons innervating intervertebral discs.

STUDY DESIGN: Prospective cohort study. OBJECTIVE: To examine the utility of 18F-fluorodeoxyglucose-positron emission tomography (FDG-PET) to diagnose pyogenic spondylitis in patients showing Modic change. SUMMARY OF BACKGROUND DATA: Vertebral bone marrow infection may appear as Modic type 1 signal on magnetic resonance imaging, so it is difficult to distinguish between common Modic change and infection. In the current study, we aimed to examine the utility of 18F-FDG-PET to diagnose pyogenic spondylitis in patients showing Modic change. METHODS: In a prospective assessment of 312 patients showing low back pain, 18 patients were suspected of having pyogenic vertebral osteomyelitis because of their symptoms, biopsy results, blood analysis, x-ray examination, magnetic resonance imaging, and FDG-PET during a 1-year follow-up. RESULTS: Observers ultimately diagnosed 11 patients with pyogenic spondylitis (group 1 observers). FDG-PET evaluation by 2 radiologists (group 2 observers) showed isotope accumulation in the lumbar spine in 11 patients, and no accumulation in 7 patients. The evaluation by group 1 observers, who did not see the FDG-PET findings, was compared with the evaluation by group 2 observers. No patients were evaluated differently by group 1 and group 2 observers. CONCLUSION: In conclusion, the rate of detecting spondylodiscitis infection was very high if FDG-PET was additionally used. FDG-PET is recommended to distinguish between common Modic change and spinal infection.

BACKGROUND: It has been reported that rat L5/6 lumbar discs are innervated mainly by L2 dorsal root ganglion neurons. We previously reported that L2 spinal nerve infiltration was effective for discogenic low back pain (DLBP) patients, although the diagnosis was based only on the results of physical examination, plain films, and magnetic resonance imaging (MRI). The purpose of the current study was to evaluate L2 spinal nerve block for DLBP patients retrospectively based on MRI findings and surgical results. METHODS: A total of 62 patients with only LBP and no accompanying radicular pain were investigated. Patients had only one level of disc degeneration on MRI. When pain was provoked during discography, we performed surgery at the next stage (40 patients). In all, 22 patients were excluded owing to negative discography results. Of the 40 patients, we evaluated 25 strictly selected patients suffering from DLBP. DLBP was diagnosed when the patient experienced pain relief at least 2 years after anterior lumbar interbody fusion. Fifteen patients who did not show pain relief after surgery were used for the non-DLBP group. L2 spinal nerve infiltration using 1.5 ml of lidocaine was performed in all 40 patients before surgery. The visual analogue scale (VAS) score after L2 spinal nerve infiltration was recorded, and an association of L2 spinal nerve infiltration and DLBP was explored. RESULTS: Low back pain scores assessed using the VAS score, the Japanese Orthopedic Association score, and the Oswestry Disability Index score in the two groups were not significantly different. L 2 spinal nerve infiltration was effective for 27 patients but not effective for 13 patients; the VAS score after 15 min and 2 h improved in the DLBP group compared with that of the non-DLBP group (P < 0. 05). L2 spinal nerve infiltration was more effective in DLBP patients (21 patients, 84%) than in the non-DLBP group (6 patients, 40%) (P < 0.05). CONCLUSIONS: In the current study, L2 spinal nerve infiltration was effective in 84% of selected DLBP patients and is thought to be a useful tool for diagnosing DLBP. However, we should take into consideration that the L2 spinal nerve infiltration was effective in 40% of non-DLBP patients as well.

単純性股関節炎の疫学的傾向を明らかにすることを目的に、股関節痛の発症した日を調査した。対象は2002年4月〜2009年3月の間に千葉県こども病院(千葉県)、国立成育医療センター(東京都)、埼玉県立小児医療センター(埼玉県)を受診した200例211股で、平均年齢は6.3±2.8歳(0.8〜17歳)であった。各施設の発生数が2〜6ヵ月間にわたり同時に増加する時期が認められたが、全期間を通してみると必ずしも一致していなかった。月別では2月に少ない傾向が認められたが、一定の季節性は認められなかった。本研究の結果、明らかな疫学的傾向は認められなかったが、本疾患はある期間に集中して発症する傾向があった。複数病原体による感染症である無菌性髄膜炎と年間の発生件数を比較すると、極めて類似した変動を示しており、共通の病原体の存在が示唆された。(著者抄録)

先天性股関節脱臼後遺残変形に対して当科で10歳代に手術治療を行い2年以上経過観察した13例14股の臨床成績を調査した。手術時年齢は10歳から17歳、平均13.8歳であった。術式は、タナ形成術が8股(2股はWagner法、2股は大腿骨転子部内反骨切り術、1股は大転子下降術を合併)、寛骨臼回転骨切り術が4股、Pemberton骨切り術と大腿骨内反骨切り術の合併手術が2股であった。大腿骨頭壊死は12股86%で術前からみられた。術後経過観察期間は平均6.4年、最終診察時年齢は平均20.2歳であった。Severin分類class I、IIを成績良好とすると11股79%がこれに該当した。しかし9股64%で跛行、疼痛などの症状が断続的または持続的にみられていた。どの術式にも課題が残されていたが、姑息的手術と考えられるタナ形成術は意外に好結果をもたらしていた。(著者抄録)

Pathomechanisms of injured-nerve pain have not been fully elucidated. Radicular pain and chronic constriction injury models have been established; however, producing these models is complicated. A sciatic nerve-pinch injury is easy to produce but the reliability of this model for evaluating pain behavior has not been examined. The current study evaluated pain-related behavior and change in pain markers in the dorsal root ganglion (DRG) of rats in a simple, sciatic nerve-pinch injury model. In the model, the sciatic nerve was pinched for 2 s using forceps (n = 20), but not injured in sham-operated animals (n = 20). Mechanical and thermal hyperalgesia were measured every second day for 2 weeks using von Frey filaments and a Hargreaves device. Calcitonin gene-related peptide (CGRP), activating transcription factor-3 (ATF-3), phosphorylated p38 mitogen activated protein (Map) kinase (p-p38), and nuclear factor-kappa B (NF-κB; p65) expression in L5 DRGs were examined at 4 and 7 days after surgery using immunohistochemistry. The proportion of neurons immunoreactive for these markers was compared between the two groups. Mechanical (during 8 days) and thermal hyperalgesia (during 6 days) were found in the pinch group rats, but not in the sham-operated animals (p < 0.05); however, hyperalgesia was not significant from days 10 to 14. CGRP, ATF-3, p-p38, and NF-κB expression in L5 DRGs was upregulated in the nerve-injured rats compared with the sham-operated rats (p < 0.01). Our results indicate that a simple sciatic nerve pinch produced pain-related behavior. Upregulation of the pain-marker expression in the nerve-injury model suggested it could be used as a model of pain. However, it was not considered as suitable for long-term studies.

The relationship of Modic change to pain and inflammation remains to be unclear. Recently, some authors have reported that Modic type 1 signals are closely related to infection. However, if the patients do not have severe back pain, fever, or an abnormal blood profile, it is difficult to distinguish between common Modic change and infection. The purpose of this study was to examine the prevalence of pyogenic spondylitis in patients who showed Modic type 1 change without other signs of infection. Seventy-one patients with Modic type 1 change were evaluated (average age 55, 32 males and 39 females). X-ray and magnetic resonance imaging (MRI) were performed to investigate low-back pain and leg pain. Body temperature was measured and blood analysis (including white blood cell count and level of C-reactive protein) was conducted for all patents. All 71 patients with Modic type 1 change, but without other signs of infection were followed for 2 years. Low-back pain, X-ray, and blood analyses were performed every 3 months; and MRI was performed every year. Severe low-back pain or abnormal signs developed in four patients during the follow-up. Pyogenic spondylitis was diagnosed in three patients by symptoms, blood results, and imaging, and confirmed by biopsy. Two of the three patients were diabetic. A total of 4.2% of patients with Modic type 1 change, but without other signs of infection were diagnosed as having pyogenic spondylitis during the 2-year follow-up, therefore, it is important to consider this before treating Modic type 1 change.