牧 聡

The aim of this study was to elucidate the bone regeneration-inducing capability of Affinos®, a newly developed, high-porosity unidirectional porous β-TCP artificial bone. We compared the ability of Affinos® and OSferion®, a commercially available β-TCP product, to induce bone regeneration following implantation into bony defects left after fibula harvesting for spinal fusion surgery. Study subjects underwent surgery to harvest non-vascularized fibula grafts for spinal fusion surgery and were implanted with either Affinos® (19 patients) or OSferion® (15 patients, control group) at the defect site. The minimal and mean follow up periods were 6 and 11 months after surgery, respectively. X-rays of the lower leg taken 1-2 weeks after surgery and at the final follow-up visit were used to evaluate fibular-β-TCP continuity and fibula defect filling ratio. There was no significant difference in radiographic continuity in the fibula between the two groups. The fibula defect filling ratio for the Affinos® group decreased from 0.94 ± 0.17 at 1-2 weeks to 0.77 ± 0.14 at 10 months. For the OSferion® control group, the fibula defect filling ratio decreased from 0.94 ± 0.14 at 1-2 weeks to 0.52 ± 0.27 at final follow-up. The Affinos® group showed a significantly higher fibula defect filling ratio compared to that for the OSferion® group (p = 0.003). These results indicate that Affinos® has slow absorption rates and significant defect filling activity compared with OSferion®. Thus, Affinos® could be a suitable substitute to fill bony defects induced by fibula harvesting for spinal reconstruction surgery.

近年では超高齢社会を背景に、骨粗鬆症に起因する脆弱性骨折に対する手術が多く実施されるようになってきている。そこで本稿では、脆弱性骨折手術後の骨粗鬆症薬物療法について、1)骨癒合促進、2)二次骨折予防の2つの観点から概説する。(著者抄録)

新鮮脆弱性椎体骨折に対しweekly PTH製剤(テリボン56.5μg、週1回皮下注射)を投与した50例を対象に、投与前から投与後10週に日本整形外科学会腰痛評価質問票(JOABPEQ)を患者本人が毎週回答を記載した。得られたデータを集計し、疼痛改善の指標として疼痛関連障害スコア、ADL改善の指標として社会生活障害スコアの変化を調査した。その結果、疼痛関連障害スコアは投与前と比較して経時的に増加し、投与後6週以降に投与前と比較し20ポイント以上の上昇を認めた。また、社会生活障害スコアも投与前と比較して経時的に増加し、投与後8週以降に20ポイント以上の上昇を認めた。新鮮脆弱性椎体骨折はweekly PTH製剤投与により疼痛は6週、ADLは8週で改善すると考えられた。

＜文献概要＞一般的な慢性疾患診療と同様,がん診療においても症状の進行とともに全身状態が悪化し,患者の運動機能も低下する。リスク・ベネフィットの観点から,治療継続には一定の身体機能の維持が求められる。昨今のがん治療は外来通院治療も増加しており,通院可能な運動機能を有しているかどうかが治療継続可否に関わる重要なポイントとなる。がん患者の運動器管理はわれわれ整形外科医に求められる重要な役割の一つである。今回,がん患者の運動機能を評価する目的で,外来通院中のがん患者に対しロコモ度テストを施行した。立ち上がりテスト,2ステップテストでは健常ボランティアデータと差を認めなかったが,ロコモ25では有意に高い数値を示した。外来通院レベルの身体機能を有するがん患者においては,実際の運動機能としては健常人と遜色ない能力を有するにもかかわらず,自己の身体の状態に対して抱いている自己評価が低いことが明らかとなった。

プレガバリンは電位依存性カルシウムチャネルのα2δサブユニットと結合し、興奮性神経伝達物質の遊離を抑制して鎮痛効果をもたらす。本邦では末梢性・中枢性神経障害性疼痛や線維筋痛症に伴う疼痛、帯状疱疹後神経痛、糖尿病性神経障害に伴う痛みやしびれ、脊髄損傷後疼痛などに対して有意な鎮痛効果が示されている。一方でめまいや鎮静、傾眠などの副作用が知られており、最小用量から開始し漸増するなどの処方の工夫によりその発生が抑制されうる。腎機能低下症例、透析症例では慎重投与を心がけることが重要である。神経障害性疼痛に加え侵害受容性疼痛や心理社会的要因など多因子由来の病態である慢性の腰下肢痛に対しては必ずしも全例で効果を示すわけではないが、この場合NSAIDsなどの併用処方が有用である。本剤処方において最も重要なのは入念な診察に基づく確実な神経障害性疼痛の診断であり、臀部痛・下肢痛症例における神経障害性疼痛の関与の報告はその根拠のひとつとなる。(著者抄録)

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

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

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

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

Sacral insufficiency fractures (SIFs) are common in the elderly. In patients with SIF, objective neurological abnormalities such as sphincter dysfunction or leg paresthesia are uncommon. We present a case of SIF accompanied by spinopelvic dissociation with late neurological compromise treated by spinopelvic fixation. A 61-year-old woman presented to our hospital with low back pain without obvious trauma history. She had a past history of eosinophilic granulomatosis with polyangiitis and treatment with steroids. Her low back pain became worse, and she started to have radiating left posterior thigh pain and motor weakness in the left ankle and both great toes with symptoms of stress urinary incontinence, constipation, and loss of anal sensation. Magnetic resonance imaging revealed an H-shaped sacrum fracture. We attributed the neurological symptoms to unstable SIF and performed lumbopelvic fixation. After the surgery, her leg pain and symptoms of stress urinary incontinence improved markedly, as did anal sensation. At a 6-month follow-up, the patient reported no low back pain and she was walking independently without pelvic complaints. CT showed bone union was achieved. Even minimally displaced SIF in patients with osteoporosis can be a cause of bowel and bladder disturbance. Lumbopelvic fixation is a treatment option for SIF with spinopelvic dissociation presenting neurological deficit.

Introduction: Limb muscle mass measurement using dual-energy X-ray absorptiometry (DXA) is considered the gold standard for the diagnosis of sarcopenia. Moreover, bioelectrical impedance analysis (BIA) is also recognized as a beneficial tool considering its high correlation with DXA. However, it remains to be elucidated whether DXA and BIA can accurately measure trunk lean mass. The aim of this study was to investigate the correlation between DXA and BIA measurements of trunk muscle mass and the cross-sectional area (CSA) of trunk muscles measured using magnetic resonance imaging (MRI) and to compare measures of trunk muscle mass obtained using DXA and BIA in patients with low back pain (LBP). Methods: In total, 65 patients participated in the study. The correlation between DXA and BIA measurements and the CSA of trunk and paraspinal muscles at the L4-5 level were calculated. In addition, the correlation between DXA and BIA measurements of trunk muscle mass and the differences between these two measurements were determined. Results: The correlation coefficient between DXA and BIA trunk muscle mass measurement and trunk muscle CSA was 0.74 and 0.56 for men and 0.69 and 0.44 for women, respectively. DXA and BIA measurement values showed a significantly moderate correlation with the CSA of the erector spinae (ES) and psoas major (PM). The multifidus (MF) CSA did not correlate with measurements of DXA and BIA in both men and women. Although DXA and BIA measurements were significantly correlated, a significant difference between these two measurements was found. BIA overestimated the trunk muscle mass significantly compared with DXA. Conclusions: Trunk muscle mass measured with DXA and BIA was correlated with the CSA of most trunk muscles. Although the measurement of DXA and BIA showed a high correlation, BIA overestimated trunk muscle mass compared with DXA. Both DXA and BIA are beneficial for measuring trunk muscle mass.

脊髄刺激療法は難治性慢性腰下肢痛に対して、疼痛抑制効果および歩行機能改善効果を有する。適応疾患・病態を見極め、心理的サポートなどを併用することにより、さらなる患者満足度の向上が期待できる可能性がある。(著者抄録)