A nationwide multicenter study of the cost effectiveness of five leading drugs for pharmacological management of cervicobrachial symptoms

BACKGROUND

Cervicobrachial pain frequently affects the quality of life (QOL) of the general public and has a significant economic impact on the health care systems of various countries. There are a number of treatment options for this disease, including widely-used drug therapy, but the effectiveness of each option is indeterminate, and there have been no published cost-effectiveness analysis studies so far. This prospective observational study aimed to examine the cost-effectiveness of drug treatment for cervicobrachial symptoms.

METHODS

A 6-month medication regimen for each of five frequently-prescribed drugs for cervicobrachial symptoms was administered to 322 patients at 24 centers in Japan. Outcome measures, including of the EuroQol Group 5D, Short Form-8, and Visual Analog Scale (VAS), were investigated at baseline and every month thereafter. Incremental cost-effectiveness ratios (ICERs) of the drug cost to quality-adjusted life years (QALYs) were calculated. A stratified analysis of patient characteristics was also performed to identify baseline factors potentially affecting cost-effectiveness.

RESULTS

The ICER of entire drug treatment for cervicobrachial symptoms was 7,491,640 yen. Compared with the reference willingness-to-pay, the ICER was assumed to not be cost-effective. A certain number of QALYs were gained during the first 3 months after the treatment intervention, but almost no QALYs were gained during the following 3 months. Stratified analysis showed that cost-effectiveness was extremely low for patients with high baseline VAS and high QOL.

CONCLUSIONS

The available medications for cervicobrachial symptoms did not have excellent cost-effectiveness. Although a certain number of QALYs were gained during the first 3 months after medication, no QALYs were gained in the latter half of the study period, suggesting that it is not advisable to continue the medication needlessly.

LEVEL OF EVIDENCE

II, prospective cohort study.

Spinal pseudoarthrosis following osteoporotic vertebral fracture: prevalence, risk factors, and influence on patients' activities of daily living 1 year after injury

PURPOSE

To investigate the prevalence and risk factors and influence of pseudoarthrosis on activities of daily living (ADL) of patients with osteoporotic vertebral fracture (OVF).

METHODS

Spinal pseudoarthrosis is defined as the presence of a cleft in the vertebral body on a lateral X-ray image in the sitting position at 1 year after admission. Of the total 684 patients treated for OVF between January 2012 and February 2019 at our institution, 551 patients (mean age, 81.9 years; a male-to-female ratio, 152:399) who could be followed up to 1 year were included in this study. Prevalence, risk factors, and influence of pseudoarthrosis on the ADL of patients as well as fracture type and location were investigated. Pseudoarthrosis was set as the objective variable. Total bone mineral density, skeletal muscle mass index, sex, age, history of osteoporosis treatment, presence of dementia, vertebral kyphosis angle, fracture type (presence of posterior wall injury), degree of independence before admission, history of steroid use, albumin level, renal function, presence of diabetes, and diffuse idiopathic skeletal hyperostosis were set as explanatory variables for multivariate analysis of the influence of pseudoarthrosis on the walking ability and ADL independence before and 1 year after OVF.

RESULTS

In total, 54 (9.8%) patients were diagnosed with pseudarthrosis 1 year after injury (mean age, 81.3 ± 6.5 years; male-to-female ratio, 18:36). BKP was performed in nine patients who did not develop pseudoarthrosis after 1 year. In the multivariate analysis, only the presence of posterior wall injury was significantly correlated with the presence of pseudoarthrosis (OR = 2.059, p = 0.039). No significant difference was found between the pseudarthrosis group and the non-pseudarthrosis group in terms of walking ability and ADL independence at 1 year.

CONCLUSIONS

The prevalence of pseudoarthrosis following OVF was 9.8%, and its risk factor was posterior wall injury. The BKP group was not included in the pseudoarthrosis group, which may have led to an underestimation of the prevalence of pseudoarthrosis. The prevalence, risk factors, and influence of spinal pseudoarthrosis on patients' ADL following osteoporotic vertebral fracture (OVF) were investigated. Pseudoarthrosis occurs in 9.8% 1 year after the injury in patients with OVF. Posterior wall injury was the risk factor of pseudoarthrosis.

Skeletal Muscle and Fat Mass Reflect Chronic Pain in Older Adult

Objectives: The prevalence of chronic pain increases with age. It has been reported that chronic pain is associated with sarcopenia and obesity. Age-related skeletal muscle loss and fat gain are known to occur due to chronic inflammation. The aim of this study was to analyze how skeletal muscle and fat, caused by chronic inflammation due to aging, regulate the development of geriatric chronic pain. Methods: The results of skeletal muscle and fat mass, 412 participants aged ≥65 years with non-specific chronic pain lasting ≥6 months, including low back, neck, and knee pain, was compared with the control without chronic pain. Body composition threshold regulating chronic pain was calculated. Results: A significantly lower skeletal muscle mass index and higher body fat percentage were observed in patients with chronic pain than that in the control. The muscle fat ratio (MFR) was significantly lower in the chronic pain group than in the control group. When the MFR threshold related to chronic pain was calculated by sex, it was 2.984 for men and 1.867 for women. Conclusions: Evaluation of the body composition of elderly patients with non-specific chronic pain revealed that the MFR was useful as an index related to chronic pain.

Bisphosphonate treatment is associated with decreased mortality rates in patients after osteoporotic vertebral fracture

The aim of this study is to investigate the effect of bisphosphonate (BP) on mortality after osteoporotic vertebral fracture (OVF). BP medication (hazard ratios = 0.593; 95%CI: 0.361-0.976) was significantly associated with reduced all-cause mortality after OVF.

PURPOSE

Osteoporotic vertebral fracture (OVF) is the most common type of fragility fracture. Bisphosphonate (BP) medication was suggested to have positive effects on both fracture prevention and recovery outcomes. The aim of this study is to investigate the effect of BP on mortality after OVF.

METHODS

This cohort study involved 535 patients (170 males and 365 females), aged ≥ 65 years (mean age: 82.6 ± 7.0 years, mean follow-up periods: 33.0 ± 25.8 months) who were hospitalized after OVF from January 2011 to December 2019 at a public hospital. Patients treated with PTH (parathyroid hormone), PTH or PTHrp analogues, denosumab, and selective estrogen receptor modulators were excluded. Kaplan-Meier survival curves on mortality of patients with OVF with and without BP treatment were prepared, and log-rank tests were performed. Cox proportional hazards model was used to identify factors associated with mortality after OVF.

RESULTS

This study included 163 (30.5%) patients treated with BP. Kaplan-Meier survival curves showed that the mortality rate after OVF was significantly lower in patients treated with BP (P < 0.001). Cox proportional hazards model showed that older age (hazard ratios [HR] = 1.066; 95%CI:1.035-1.103), male sex (HR = 2.248; 95%CI:1.427-3.542), malnutrition (geriatric nutritional risk index < 92) (HR = 1.691; 95%CI:1.005-2.846), BP medication (HR = 0.593; 95%CI: 0.361-0.976), and Japanese Orthopaedic Association score at discharge (HR = 0.941; 95%CI: 0.892-0.993) were significantly associated with all-cause mortality after OVF.

CONCLUSIONS

BP medication is beneficial not only for fracture prevention but also for mortality after OVF.

Analysis of Dynamic Factors and Spinal Sagittal Alignment in Patients with Thoracic Spondylotic Myelopathy

Introduction

Although thoracic spondylotic myelopathy (TSM) without ossification or disc disorder has been associated with some dynamic factors in the thoracolumbar area, a detailed investigation is yet to be published. Thus, in this study, we investigated the segmental motion and sagittal alignment of the thoracolumbar area in patients with and without TSM.

Methods

Patients with TSM who were treated from 2013 to 2020 were enrolled in this study. The non-TSM group consisted of sex- and age-matched patients with spinal disorders other than TSM. Segmental mobility from T10-L2 during passive maximum flexion and extension following myelography and the sagittal cobb angles of T10-L1 and L1-L5 in the standing position were measured using multidetector computed tomography (CT). The mobility of each segment was set as the difference in the angles between the two positions.

Results

In total, 10 patients (8 males and 2 females, mean age 65.8 years) with TSM and 20 without TSM were enrolled. The most stenotic level was observed at T10-T11 in four cases and T11-T12 in six. The average mobility at this segment in the TSM group (5.8°) was significantly greater than that in the non-TSM group (2.1°) (p<0.001). In the TSM group, the cobb angles of T10-L1 and L1-L5 were 2.3° and 17.4° of lordosis, respectively, which differed significantly from those in the non-TSM group, which were 8° of kyphosis and 32.2° of lordosis, respectively (p<0.001 and p=0.001, respectively).

Conclusions

Compared with those without TSM, patients with TSM were found to have greater segmental mobility at the most stenotic level, thoracolumbar lordosis, and decreased lumbar lordosis.

Elevated red blood cell distribution width is associated with poor outcome in osteoporotic vertebral fracture

INTRODUCTION

Red blood cell distribution width (RDW) has been evaluated as a potential screening marker for cancer and prognostic marker in heart failure and coronary heart disease. Recent studies have been suggested the association of RDW with mortality in patients with hip fracture and arthroplasty. Objective of this study was to investigate whether RDW as a prognostic marker is significant in patients with osteoporotic vertebral fracture (OVF).

MATERIALS AND METHODS

Total of 460 patients with fresh OVF from January 2014 and September 2017 were assessed for a 1-year follow-up period. The cutoff value for RDW was set at 15%, and outcomes of conservative treatment of OVF were evaluated using the Japanese Orthopaedic Association (JOA) scores, Barthel index, and walking state.

RESULTS

Of the total 460 patients, 125 patients (27.2%) had an elevated RDW. RDW value was not correlated with osteoporotic parameters. Both JOA score and Barthel index were significantly lower at 1 year after treatment in the elevated RDW group. In the elevated RDW group, 21 patients died within 1 year (mortality 16.8%) compared with 7 patients (mortality 2.1%) in the non-elevated RDW group; this was statistically significant. Multivariate statistical analysis showed elevated RDW, independent walk before OVF and skeletal muscle mass index (SMI) remained independent factors associated with abasia after OVF affected.

CONCLUSION

Elevated RDW was associated with the poor clinical outcomes of conservative treatment of an OVF, independent of osteoporosis or severity of the OVF. RDW provides prognostic information for risk stratification as a senescence biomarker.

Risk factors of non-union in Anderson-D'Alonzo type III odontoid fractures with conservative treatment

Objective

The purpose of this study was retrospectively to analyze the risk factors for non-union in Anderson-D'Alonzo type III odontoid fractures with conservative treatment.

Methods

25 patients with type III fractures were analyzed. Coronal and sagittal tilt as well as sagittal and lateral mass gaps were measured by using computed tomography.

Results

The non-union group had significantly higher age, greater coronal tilt and lateral mass gap. Especially, the lateral mass gap was >2 mm in all cases with non-union.

Conclusions

Higher age, coronal tilt, and lateral mass gap were significant risk factors for non-union.

Low muscle mass affect hip fracture treatment outcomes in older individuals: a single-institution case-control study

Background

Although sarcopenia has been known as a risk factor for hip fracture, only a few reports have described the impact of muscle mass on hip fracture treatment outcomes. The current study aimed to investigate the impact of muscle mass on hip fracture treatment outcomes.

Methods

This case–control study involved 337 patients (67 males and 270 females) with hip fracture aged ≥65 years (mean age: 84.1 ± 7.1 years) who underwent orthopedic surgery from January 2013 to June 2019. The mean follow-up period was 17.1 (1–60) months. Upon admission, all patients were assessed for low muscle mass according to the Asian Working Group for Sarcopenia criteria (male, SMI < 7.00 kg/m²; female, SMI < 5.40 kg/m²) using dual-energy X-ray absorptiometry. Treatment outcomes (stays at acute care institutions, hospital mortality, the Barthel index at discharge, and home discharge rates, and one-year mortality) were compared between patients with and without low muscle mass by Student’s t-test, Mann-Whitney U test and the Pearson Chi-Square test. A multivariate logistic regression model was used to calculate adjusted odds ratios (ORs) with 95% confidence intervals (CIs) for factors related to low muscle mass. Kaplan–Meier survival curves on one-year mortality of hip fracture patients for those with and without low muscle mass were prepared, and log-rank tests were performed. Furthermore, we determined whether low muscle mass was a risk factor for one-year mortality in hip fracture patients using a Cox proportional hazards model.

Results

The prevalence of low muscle mass in patients with hip fracture was 231(68.5%). Those with low muscle mass had a lower Barthel index (P < 0.0001), hospital discharge rate (P = 0.035) and higher one-year mortality (P = 0.010). Cox proportional hazards regression analysis adjusted for age and sex found that low muscle mass was a risk factor for one-year mortality (hazard ratio, 3.182, 95% confidence interval, 1.097–9.226, P = 0.033).

Conclusions

Patients with hip fracture who had low muscle mass had a lower Barthel index, lower home discharge rate, and higher one-year mortality. Moreover, low muscle mass was identified as a risk factor for one-year mortality among those with hip fracture. The aforementioned findings may help clinicians better manage those with hip fracture.

Surgical results in older patients with lumbar spinal stenosis according to gait speed in relation to the diagnosis for sarcopenia

PURPOSE

The purpose of this study was to evaluate the implication of gait speed, which is a prerequisite for the diagnosis of sarcopenia in older patients with lumbar spinal stenosis (LSS).

METHODS

This study was conducted in a total of 235 patients with LSS who underwent surgical treatment. The state of sarcopenia and pre-sarcopenia, including gait speed, were evaluated before and after the operation.

RESULTS

The proportion of patients with lower than at baseline levels of skeletal muscle mass index (SMI) and gait speed was 27.2% and 17.9%, respectively. Significant changes were observed in gait speed, whereas SMI showed no significant differences between the preoperative and postoperative periods. Sarcopenic patients presented lower levels of activities of daily living preoperatively than pre-sarcopenic patients. However, favorable surgical results were obtained postoperatively. Significant changes were observed in gait speed, whereas grip strength and SMI showed no significant differences between the preoperative and postoperative periods. The postoperative decrease in SMI was not significant.

CONCLUSION

Postoperative gait speed was significantly improved, whereas muscle mass did not increase in the patients in this study. Therefore, low gait speed in patients with LSS seems to be derived from a neurologic disorder. The surgical results in low muscle mass patients without low gait speed were similar to those with low gait speed. Sarcopenia in elderly patients with locomotor disease should be evaluated using muscle mass alone without assessing physical performance.

A systematic review and meta-analysis comparing anterior decompression with fusion and posterior laminoplasty for cervical spondylotic myelopathy

BACKGROUND

The optimal surgical procedure for the treatment of cervical spondylotic myelopathy (CSM) remains controversial because there are few comprehensive studies that have investigated the surgical methods. Therefore, we conducted a systematic review and meta-analysis to evaluate evidence in the literature and to compare the surgical outcomes between anterior decompression with fusion (ADF) and laminoplasty, which are representative procedures for CSM.

METHODS

An extensive literature search was performed using PubMed, Embase, and the Cochrane Library to identify comparative studies of ADF and laminoplasty for CSM. The language was restricted to English, and the publication period was from January 2001 to July 2019. We only included studies of CSM and excluded studies that involved patients with ossification of the posterior longitudinal ligament and treatments with posterior instrumented fusion. We extracted outcomes from the studies, such as preoperative and postoperative Japanese Orthopaedic Association (JOA) scores, cervical alignment, surgical complications and reoperation rates. Then, a meta-analysis was performed on these surgical outcomes.

RESULTS

Nine studies were obtained, and the quality of the studies was acceptable. In the meta-analysis, the preoperative JOA score was similar between the ADF and laminoplasty groups. The postoperative JOA scores and neurological recovery rates were not different between the ADF and laminoplasty groups. ADF exhibited more favorable results than laminoplasty in terms of postoperative cervical alignment. In contrast, overall complications were more frequently observed in the ADF group than in the laminoplasty group, leading to higher rates of reoperation. However, postoperative neck pain was more frequently observed in the laminoplasty group than in the ADF group.

CONCLUSIONS

This systematic review and meta-analysis showed both the merits and shortcomings of ADF and laminoplasty. ADF and laminoplasty showed similar results in terms of neurological recovery. Postoperative cervical lordosis was better preserved with ADF than with laminoplasty. However, ADF was associated with a higher incidence of surgical complications than laminoplasty.

Administration of nusinersen via paramedian approach for spinal muscular atrophy

OBJECTIVE

To assess the success rate, procedure time, and adverse events of intrathecal administration of nusinersen via the paramedian approach in adolescents and adults with spinal muscular atrophy (SMA) associated with scoliosis.

METHODS

Seven patients with genetically confirmed SMA (age, 12-40 years) were included. Intrathecal administration of nusinersen was performed via paramedian approach using fluoroscopy after determination of the largest interlaminal foramen among L2-L3, L3-L4, or L4-L5 by three-dimensional computed tomography. We measured the times for preparation, positioning, and puncture, and the total time of stay. Adverse effects of intrathecal administration were noted.

RESULTS

Intrathecal administration via paramedian approach was successful for all 38 opportunities. The median total time of stay was 44.0 min (interquartile range, 37.3-50.0 min). The total time of stay was significantly longer in patients with SMA type 1 than in those with SMA type 2, but was not different according to the severity of scoliosis. Adverse effects included oxygen supplementation, headache, and back pain. Sedation was correlated with oxygen supplementation and headache.

CONCLUSIONS

Intrathecal administration of nusinersen via the paramedian approach had the advantages of a high success rate and short procedure time with fewer adverse events in SMA patients associated with scoliosis.

Comparison of anterior decompression with fusion and posterior decompression with fusion for cervical spondylotic myelopathy-A systematic review and meta-analysis

BACKGROUND

The optimal surgical procedure for the treatment of cervical spondylotic myelopathy (CSM) remains controversial. Recently, laminectomy/laminoplasty with instrumented fusion (LAMF) has been increasingly applied to treat CSM. However, few comprehensive studies have compared anterior decompression with fusion (ADF) and LAMF. Therefore, we conducted a meta-analysis to evaluate the evidence in the literature and to compare the surgical outcomes between the 2 procedures. Since the surgical outcomes and risks differ between patients with CSM and ossification of the posterior longitudinal ligament (OPLL) and between only posterior decompression and decompression with fusion treatments, we excluded patients with OPLL and patients with only posterior decompression in this review.

METHODS

An extensive literature search was performed using PubMed, Embase, and the Cochrane Library to identify comparative studies of ADF and LAMF for the treatment of CSM. The language was restricted to English, and the publication period was from January 2001 to July 2019. We only included studies about CSM and excluded studies that involved patients with ossification of the posterior longitudinal ligament and with the treatment of posterior decompression without fusion. We extracted outcomes from the studies, such as preoperative and postoperative Japanese Orthopaedic Association (JOA) scores, neck disability index (NDI) scores, cervical alignment data, and surgical complications. Then, a meta-analysis was performed on these surgical outcomes.

RESULTS

Eleven studies were obtained, and the quality of the studies was acceptable. In the meta-analysis, the pre- and postoperative JOA scores were similar between the ADF and LAMF groups. The ADF group exhibited more favorable results than the LAMF group in terms of postoperative cervical alignment and the NDI. Overall complications were similar between the ADF and LAMF groups; however, C5 palsy was more frequently observed in the LAMF group than in the ADF group.

CONCLUSIONS

While the ADF and LAMF groups demonstrated similar results in terms of neurological recovery, postoperative cervical lordosis and NDI scores were more favorable with ADF than with LAMF. The overall complication rate was similar between the ADF and LAMF groups. Surgeons should understand the merits and shortcomings of both procedures when deciding on a surgical procedure.

A double-blind randomized controlled trial of the local application of vancomycin versus ampicillin powder into the operative field for thoracic and/or lumbar fusions

OBJECTIVERetrospective studies have reported that the local application of vancomycin (VCM) powder into the operative field decreases the incidence of surgical site infection (SSI) in thoracic and/or lumbar fusion. Authors of the present study prospectively evaluated the effects of VCM in patients undergoing thoracic and/or lumbar fusion.METHODSIn this randomized double-blind trial, 230 patients undergoing thoracic and/or lumbar fusion were randomly assigned to the local administration of VCM (interventional group, 1 g) or ampicillin (AMP; control group, 1 g) into the surgical field. The primary outcome was SSI results within 1 year of surgery.RESULTSThe trial was prematurely stopped according to predetermined rules. The results showed one superficial infection (0.9%, Staphylococcus aureus) and one deep infection (0.9%, S. aureus) in the VCM group and two superficial infections (1.8%, Staphylococcus epidermidis and culture negative) and one deep infection (0.9%, methicillin-resistant S. aureus) in the AMP group. No significant differences in infection rates were observed between the groups (p = 0.8).CONCLUSIONSThis double-blind randomized controlled trial demonstrated that the local application of VCM or AMP powder into the operative field in short thoracic and/or lumbar fusion procedures resulted in a similar incidence of SSI.■ CLASSIFICATION OF EVIDENCE Type of question: therapeutic; study design: randomized controlled trial; evidence: class III.Clinical trial registration no.: UMIN000009377 (umin.ac.jp/ctr).

Reliability of an Intraoperative Radiographic Anteroposterior View of the Spinal Midline for Detection of Pedicle Screws Breaching the Medial Pedicle Wall in the Thoracic, Lumbar, and Sacral Spine

OBJECTIVE

The purpose of this study was to determine the sensitivity and specificity of using the spinal midline (M line) on a radiographic anteroposterior (AP) view for detecting pedicle screws (PSs) breaching the medial pedicle wall.

METHODS

We retrospectively reviewed 145 patients who underwent fusion surgery using PSs between January 2006 and May 2017. We defined the M line as a line that connected the upper and lower spinous processes through the fixed vertebrae. The M line was positive if the tip of the PS crossed the M line. The reference standard was a computed tomography scan. The reliability of the M line was examined.

RESULTS

The subjects included 145 patients (70 men and 75 women; mean age, 63.4 years). A total of 599 PSs were examined. Most cases were because of spondylolisthesis (66.9%). Most screws were inserted at a lower lumber level (77.6%). Analysis of the diagnostic accuracy of the M line yielded a sensitivity of 74.1% and a specificity of 95.3%. In addition, the positive predictive value of the M line was 42.6%, and the negative predictive value of the M line was 98.7%.

CONCLUSIONS

Assessment of the M line via an intraoperative radiographic AP view is a simple, readily available, complementary method for detecting PSs that have breached the medial pedicle wall in the thoracic, lumbar, and sacral spine. In particular, the M line has a strong negative predictive value, which is much more meaningful.

Psychological Treatment Strategy for Chronic Low Back Pain

Studies have indicated that chronic low back pain (LBP) should be approached according to its morphological basis and in consideration of biopsychosocial interventions. This study presents an updated review on available psychological assessments and interventions for patients with chronic LBP. Psychosocial factors, including fear-avoidance behavior, low mood/withdrawal, expectation of passive treatment, and negative pain beliefs, are known as risk factors for the development of chronic LBP. The Örebro Musculoskeletal Pain Questionnaire, STarT Back Screening Tool, and Brief Scale for Psychiatric Problems in Orthopaedic Patients have been used as screening tools to assess the development of chronicity or identify possible psychiatric problems. The Pain Catastrophizing Scale, Pain Self-Efficacy Questionnaire, and Injustice Experience Questionnaire are also widely used to assess psychosocial factors in patients with chronic pain. With regard to interventions, the placebo effect can be enhanced by preferable patient-clinician relationship. Reassurance to patients with non-specific pain is advised by many guidelines. Cognitive behavioral therapy focuses on restructuring the negative cognition of the patient into realistic appraisal. Mindfulness may help improve pain acceptance. Self-management strategies with appropriate goal setting and pacing theory have proved to improve long-term pain-related outcomes in patients with chronic pain.

Simple presurgical method of predicting C5 palsy after cervical laminoplasty using C5 nerve root ultrasonography

OBJECTIVE

The incidence of C5 palsy after cervical laminoplasty is approximately 5%. Because C5 palsy is related to cervical foraminal stenosis at the C4–5 level, the authors hypothesized that cervical foraminal stenosis can be diagnosed by examining the C5 nerve root (NR) using ultrasonography. The purpose of this study was to investigate whether postoperative C5 palsy could be predicted using ultrasonography.

METHODS

This study used a prospective diagnosis design. In total, 140 patients undergoing cervical laminoplasty were examined with ultrasound. The cross-sectional area (CSA) of the C5 NR was measured on both sides before surgery, and the incidence of postoperative C5 palsy was examined. The difference between the CSA of the patients with and without C5 palsy and the lateral differences in the C5 palsy group were determined.

RESULTS

The incidence of C5 palsy was 5% (7 cases). Symptoms manifested at a median of 5 days after surgery (range 1–29 days). The CSA of the C5 NR on the affected side was significantly enlarged in the C5 palsy group compared with that in the no–C5 palsy group (p = 0.001). In addition, in the patients who had C5 palsy, the CSA of the C5 NR was significantly enlarged on the affected side compared with that on the unaffected side (p = 0.02). Receiver operating characteristic analysis indicated that the best threshold value for the CSA of the C5 NR was 10.4 mm2, which provided 91% sensitivity and 71% specificity.

CONCLUSIONS

C5 palsy may be predicted preoperatively using ultrasound. The authors recommend the ultrasonographic measurement of the CSA of the C5 NR prior to cervical laminoplasty.

Effect of an intensive conservative therapy with daily teriparatide administration and rehabilitation for osteoporotic delayed vertebral collapse and paralysis

Although patients with osteoporotic delayed vertebral collapse (ODVC) have frequently been treated surgically, the efficacy and limitation of conservative treatment for it have not yet been reported. The purpose of this study was to investigate the effectiveness and limitation of further intensive conservative treatment for patients with ODVC.Patients treated for ODVC from 2011 to 2014 with a follow-up period of more than 1 year were eligible. The fundamental treatment strategy consisted of surgical treatment following intensive conservative treatment with daily teriparatide and rehabilitation for 3 months. We conducted a surgical treatment for patients who could not keep standing position by themselves because of prolonged leg paralysis or intolerable back pain. We performed a logistic regression model in which surgical treatment was set as an objective variable, and other related factors including sex, age, the level of affected vertebrae, the quality of paralysis, changing rate (δ) of spinal canal encroachment, local kyphotic angle, mobility of collapsed vertebrae, EuroQol questionnaires (EQ5D), numerical rating scale (NRS), and Frankel grade as explanatory variables. We also plotted receiver operating curves (ROCs) to investigate the cutoff values of parameters at the baseline.Thirty patients (6 males and 24 females, mean age 76.7 years) were enrolled. Eventually 12 out of 30 patients avoided surgical treatment because their symptoms were improved. Logistic regression showed that δ of local kyphotic angle (odds ratio: 1.072), P = .01), mobility of collapsed vertebrae (1.063, 0.01), EQ5D (0.98, 0.04), and NRS (1.113, 0.01) were significantly correlated with the need for surgical treatments. Among the factors at baseline, only the mobility of collapsed vertebrae showed a significant value of area under a curve (AUC = 0.727, P = .008).The results that 40% of patients with ODVC did not need further surgical treatment after the intensive conservative treatment was of great significance. Patients with greater mobility of collapsed vertebrae might be treated surgically as quickly as possible.

Contusional Cerebellar Hemorrhage Related to Placement in the Protrusion Position After Atlantoaxial Fusion

BACKGROUND

Various complications after C1 lateral mass and C2 pedicle screw fusion surgery (C1LM-C2PSFS) have been reported. However, to our knowledge, this is the first report of contusional cerebellar hemorrhage caused by placement in the protrusion (chin-out) position after C1LM-2PSFS.

CASE DESCRIPTION

An 81-year-old woman complaining of gait disturbance and clumsiness of both hands was diagnosed with cervical myelopathy with atlantoaxial subluxation. After we performed C1LM-C2PSFS, her neurologic deficits gradually improved, and there was no radiologic evidence of construct failure. One month after surgery, she had severe headache and vomiting immediately after taking some medications while in the protrusion position. Head computerized tomography scan showed left cerebellar hemorrhage, and titanium rods penetrated the occipital bone on both sides. Flexion/extension radiography showed no loosening of any screws or rods. However, protrusion radiography showed that the tip of the left titanium rod intruded into the intracranial region. We considered that the penetration of the occipital bone by the left titanium rod caused the contusional left cerebellar hemorrhage. We immediately performed revision surgery to replace the titanium rods on each side with shorter rods, and no cerebrospinal fluid leakage was observed. The headache disappeared after the revision surgery.

CONCLUSIONS

We report a case of contusional cerebellar hemorrhage caused by the intrusion of a rod into the occipital bone when the patient was placed in the protrusion position. The rod length on the cranial side must be as short as possible, with careful consideration of placing the head in the protrusion position after C1LM-2PSFS surgery.

Optimal Timing of Surgery for Intramedullary Cavernous Hemangioma of the Spinal Cord in Relation to Preoperative Motor Paresis, Disease Duration, and Tumor Volume and Location

STUDY DESIGN

Prospective study.

OBJECTIVE

Investigate factors associated with preoperative motor paresis, recovery, ambulatory status, and intraoperative neurophysiological monitoring (IONM) among patients with no preoperative paresis (N group), complete preoperative motor recovery (CR group), and no complete recovery (NCR group) in patients with intramedullary spinal cavernous hemangioma to determine the optimal timing of surgery.

METHODS

The study evaluated 41 surgical cases in our institute. Disease duration, tumor lesion, manual muscle testing (MMT), and gait at onset, just before surgery, and final follow-up (FU), tumor and lesion volume, IONM, extent of tumor resection, and tumor recurrence were evaluated among N, CR, and NCR groups.

RESULTS

Motor paresis at onset was found in 26 patients (63%), with 42% of those in CR group. Disease duration from onset negatively affected stable gait just before surgery and FU as well as lower preoperative MMT (P < .05). Thoracic tumors were associated with patients with unstable gait before surgery (P < .05). Tumor volume was larger in NCR group (P < .05). IONM significantly decreased in NCR and CR groups than in N group (P < .05). The NCR group had residual mild motor paresis at FU (P < .05). Stable gait at FU was similar in N group and CR group, though lower in NCR group (P < .05).

CONCLUSIONS

Early surgery is generally recommended for thoracic tumors and large tumors during stable gait without motor paresis before long disease duration. Surgery may be postponed until patients recover from preoperative motor paresis to allow optimal surgical outcome. IONM should be carefully monitored in patients with a history of preoperative paresis even with preoperative complete motor recovery.

Risk Factors for Ineffectiveness of Posterior Decompression and Dekyphotic Corrective Fusion with Instrumentation for Beak-Type Thoracic Ossification of the Posterior Longitudinal Ligament: A Single Institute Study

BACKGROUND: Thoracic ossification of the posterior longitudinal ligament (T-OPLL) is treated surgically with instrumented posterior decompression and fusion. However, the factors determining the outcome of this approach and the efficacy of additional resection of T-OPLL are unknown.

OBJECTIVE: To identify these factors in a prospective study at a single institution.

METHODS: The subjects were 70 consecutive patients with beak-type T-OPLL who underwent posterior decompression and dekyphotic fusion and had an average of 4.8 years of follow-up (minimum of 2 years). Of these patients, 4 (6%; group R) had no improvement or aggravation, were not ambulatory for 3 weeks postoperatively, and required additional T-OPLL resection; while 66 (group N) required no further T-OPLL resection. Clinical records, gait status, intraoperative ultrasonography, intraoperative neurophysiological monitoring (IONM), plain radiography, computed tomography and magnetic resonance imaging findings, and Japanese Orthopaedic Association (JOA) score were compared between the groups.

RESULTS: Preoperatively, patients in group R had significantly higher rates of severe motor paralysis, nonambulatory status, positive prone and supine position test, no spinal cord floating in intraoperative ultrasonography, and deterioration of IONM at the end of surgery (P &lt; .05). In preoperative radiography, the OPLL spinal cord kyphotic angle difference in fused area, OPLL length, and OPLL canal stenosis were significantly higher in group R (P &lt; .05). At final follow-up, JOA scores improved similarly in both groups.

CONCLUSION: Preoperative severe motor paralysis, nonambulatory status, positive prone and supine position test, radiographic spinal cord compression due to beak-type T-OPLL, and intraoperative residual spinal cord compression and deterioration of IONM were associated with ineffectiveness of posterior decompression and fusion with instrumentation. Our 2-stage strategy may be appropriate for beak-type T-OPLL surgery.

Rapid Worsening of Symptoms and High Cell Proliferative Activity in Intra- and Extramedullary Spinal Hemangioblastoma: A Need for Earlier Surgery

STUDY DESIGN

A retrospective analysis of a prospective database.

OBJECTIVE

To compare preoperative symptoms, ambulatory ability, intraoperative spinal cord monitoring, and pathologic cell proliferation activity between intramedullary only and intramedullary plus extramedullary hemangioblastomas, with the goal of determining the optimal timing for surgery.

METHODS

The subjects were 28 patients (intramedullary only in 23 cases [group I] and intramedullary plus extramedullary in 5 cases [group IE]) who underwent surgery for spinal hemangioblastoma. Preoperative symptoms, ambulatory ability on the McCormick scale, intraoperative spinal cord monitoring, and pathologic findings using Ki67 were compared between the groups.

RESULTS

In group IE, preoperative motor paralysis was significantly higher (100 versus 26%, p < 0.005), the mean period from initial symptoms to motor paralysis was significantly shorter (3.5 versus 11.9 months, p < 0.05), and intraoperative spinal cord monitoring aggravation was higher (65 versus 6%, p < 0.05). All 5 patients without total resection in group I underwent reoperation. Ki67 activity was higher in group IE (15% versus 1%, p < 0.05). Preoperative ambulatory ability was significantly poorer in group IE (p < 0.05), but all cases in this group improved after surgery, and postoperative ambulatory ability did not differ significantly between the two groups.

CONCLUSIONS

Intramedullary plus extramedullary spinal hemangioblastoma is characterized by rapid preoperative progression of symptoms over a short period, severe spinal cord damage including preoperative motor paralysis, and poor gait ability compared with an intramedullary tumor only. Earlier surgery with intraoperative spinal cord monitoring is recommended for total resection and good surgical outcome especially for an IE tumor compared with an intramedullary tumor.

Ultrasonography has a diagnostic value in the assessment of cervical radiculopathy: A prospective pilot study

OBJECTIVE

This study investigated the diagnostic accuracy of the difference in the cross-sectional areas (CSAs) of affected cervical nerve roots (NRs) for diagnosing cervical radiculopathy (CR).

METHODS

In total, 102 CR patients and 219 healthy volunteers were examined with ultrasound. The CSA of the cervical NR at each level was measured on the affected side and the contralateral side in CR patients by blinded ultrasonographic technicians. The difference between the CSAs of CR patients and normal volunteers and the difference in the laterality of CSA at the same affected level (ΔCSA) were calculated for each cervical level.

RESULTS

The CSAs of the affected NRs in CR patients were significantly larger than those of the unaffected NRs in CR patients and those of the control group at the C5, C6 and C7 levels (P<0.005). ΔCSA was also significantly larger in the CR group at all levels (P<0.001). A receiver operating characteristic analysis demonstrated that the threshold values were 9.6 mm² (CSA) for C5NR and 15 mm² for both C6NR and C7NR.

CONCLUSIONS

This study revealed that the CSAs of affected NRs were enlarged and that the laterality of the CSA (ΔCSA) was greater in CR patients than in control patients.

KEY POINTS

• Cervical radiculopathy is diagnosed through ultrasonographic measurement of the CSAs. • The CSAs of affected nerve roots were significantly enlarged. • The ΔCSA in the CR group was significantly higher than in the control group. • Diagnostic CSA and ΔCSA thresholds were identified.

Resection of Beak-Type Thoracic Ossification of the Posterior Longitudinal Ligament from a Posterior Approach under Intraoperative Neurophysiological Monitoring for Paralysis after Posterior Decompression and Fusion Surgery

Study Design Prospective clinical study. Objective Posterior decompression and fusion surgery for beak-type thoracic ossification of the posterior longitudinal ligament (T-OPLL) generally has a favorable outcome. However, some patients require additional surgery for postoperative severe paralysis, a condition that is inadequately discussed in the literature. The objective of this study was to describe the efficacy of a procedure we refer to as "resection at an anterior site of the spinal cord from a posterior approach" (RASPA) for severely paralyzed patients after posterior decompression and fusion surgery for beak-type T-OPLL. Methods Among 58 consecutive patients who underwent posterior decompression and fusion surgery for beak-type T-OPLL since 1999, 3 with postoperative paralysis (5%) underwent RASPA in our institute. Clinical records, the Japanese Orthopaedic Association score, gait status, intraoperative neurophysiological monitoring (IONM) findings, and complications were evaluated in these cases. Results All three patients experienced a postoperative decline in Manual Muscle Test (MMT) scores of 0 to 2 after the first surgery. RASPA was performed 3 weeks after the first surgery. All patients showed gradual improvements in MMT scores for the lower extremity and in ambulatory status; all could walk with a cane at an average of 4 months following RASPA surgery. There were no postoperative complications. Conclusions RASPA surgery for beak-type T-OPLL after posterior decompression and fusion surgery resulted in good functional outcomes as a salvage surgery for patients with severe paralysis. Advantages of RASPA include a wide working space, no spinal cord retraction, and additional decompression at levels without T-OPLL resection and spinal cord shortening after additional dekyphosis and compression maneuvers. When used with IONM, this procedure may help avoid permanent postoperative paralysis.

An extremely rare case of a glomus tumor in the popliteal fossa

Glomus tumors are the benign perivascular tumors that typically present with hypersensitivity to cold, paroxysmal severe pain, and pinpoint tenderness. This tumor is usually subungual lesions and accounts for 1.6% of all soft-tissue tumors. However, extradigital glomus tumors are extremely rare and can be difficult to diagnose, as they typically have a diameter of less than about 1 cm. We report a glomus tumor in the popliteal fossa of a 17-year-old male patient who experienced severe posterior knee pain while playing sports. A physical examination did not reveal a mass, although a glomus tumor was identified in the popliteal fossa using magnetic resonance imaging. We successfully performed open excision to remove the tumor, and the patient achieved a restored postoperative gait and could perform sports activities with no pain. These tumors are extremely rare in the knee area, and typically have a diameter of less than about 1 cm, which can complicate their diagnosis and treatment, despite the presence of severe pain. Therefore, we recommend that clinicians be aware of extradigital glomus tumors, as careful imaging can facilitate an early diagnosis and treatment.

The prevalence of diffuse idiopathic skeletal hyperostosis in Japan - the first report of measurement by CT and review of the literature

BACKGROUND

Diffuse idiopathic skeletal hyperostosis (DISH) is prone to be accompanied by a spinal column fracture which is resistant to conservative therapy. This major characteristic of DISH is not recognized adequately by physicians, because the disease's detailed pathological condition has not yet been investigated. Therefore, the purposes of this study were to investigate the prevalence of DISH using computed tomography (CT), and to validate the reliability of CT interpretation.

METHODS

Subjects were 558 patients (300 male and 258 female) who underwent both CT of chest to pelvis and x-ray of chest and abdomen from August 2011 to July 2012 at any department other than orthopedic surgery in our institution. The definition of DISH based on x-ray as well as CT was the presence of consecutive fused vertebral bodies according to Resnick's criteria. The prevalence of DISH based on both modalities was calculated in all subjects. For 107 subjects extracted at random, intra- (Cohen kappa) and inter-observer error (Fleiss kappa) were calculated and the levels of fused segments were investigated.

RESULTS

Ninety-eight of 558 subjects (17.6%) were diagnosed as DISH by x-ray, and 152 (27.2%) by CT. Among males, 70 of 300 subjects (23.3%) were diagnosed by x-ray, and 116 (38.7%) by CT. Among females, 28 of 258 subjects (10.9%) were diagnosed by x-ray and 36 (14.0%) by CT. The levels of fused segments were presented from thoracic spine to lumbar spine, especially the middle and lower thoracic spine. Cohen kappa of x-ray was 0.587, and that of CT was 0.825. Fleiss kappa of x-ray was 0.552, and that of CT was 0.643.

CONCLUSIONS

The prevalence of DISH based on CT was 27.1%, which was higher than that of x-ray. In addition, intra- and inter-observer error by review of CT was less than that of x-ray. CT evaluation would be a better method for precise understanding of the state of DISH.

Prevalence of C7 level anomalies at the C7 level: an important landmark for cervical nerve ultrasonography

BACKGROUND

Recently, various examination and intervention techniques using cervical nerve ultrasonography have been developed. The specific shapes of the C7 transverse process and vertebral artery in front of the C7 transverse process have become landmarks.

PURPOSE

To determine the prevalence of anomalies and anomalous vertebral artery entrances at the C7 transverse process.

MATERIAL AND METHODS

The records of patients who underwent plain or contrast-enhanced neck or cervical spine computed tomography (CT) were reviewed. The examinations were scored for the anomalous presence of anterior tubercles or cervical ribs as well as vertebral artery entrances in the C7 transverse process. The prevalence of anomalies was compared based on patient sex and age.

RESULTS

Evaluating the examinations from 2067 patients (1046 men; 1021 women), 1% of patients exhibited an anomalous presence of anterior tubercles, and 0.3% of patients displayed cervical ribs at the C7 transverse process. The prevalence of anomalies process was significantly higher in men aged less than 40 years than in older men (P < 0.001), whereas the prevalence was not higher in women aged less than 40 years than in older women. The prevalence of vertebral artery entry into the C7 transverse foramen was 0.6%.

CONCLUSION

Although an anomalous vertebral artery entry into the C7 transverse foramen was rare, the prevalence of an anomaly at the C7 transverse process was higher in men aged less than 40 years. Therefore, we recommend performing CT in younger men before cervical nerve ultrasonographic intervention to avoid misinterpretations at the cervical level.

Effect of Denosumab Administration on Lumbar Vertebral Strength of Patients with Vertebral Bony Metastases: Preliminary Study

The purpose of this study was to examine the usefulness of administration of denosumab (antibody against tumor necrosis factor superfamily member 11) as a preventative therapy for skeletal-related events (SREs), such as fracture or paralysis, by computed-tomography (CT)-based on the finite element method (FEM). Patients who had undergone treatment for vertebral metastases with denosumab administration from December 2013 to August 2015 at our Institution were reviewed. We investigated patient data at the time before denosumab administration and at 1, 3 and 6 months using CT. A total of six patients were eligible; four males and two females, with ages ranging from 35 to 73 years, with a mean age of 56 years. Repeated measures analysis of variance showed a significant increase (p=0.0055, F=10.67). To our knowledge, this is the first article to substantiate the effects of the SRE-preventative drug denosumab.

A Compaction Bone Grafting Technique Leads to Early Bone Fusion in Cases of Posterior Lumbar Interbody Fusion

BACKGROUND

The impaction bone grafting technique is a popular approach for achieving complete bone fusion during hip surgery or total knee arthroplasty. We hypothesized that compaction bone grafting (CBG), a modified version of impaction bone grafting, could be applied to lumbar fusion surgery.

OBJECTIVE

To compare the bone fusion rates and durations achieved using the CBG technique and a conventional loose bone grafting technique.

METHODS

We retrospectively reviewed 89 patients who underwent single-level posterior lumbar interbody fusion at the university hospital; 35 other posterior lumbar interbody fusion recipients were excluded due to undergoing multilevel fusion, prior lumbar surgery, trauma, infection, or inadequate computed tomographic data. Computed tomographic-based bone fusion assessments were obtained using the Brantigan, Steffee, and Fraser criteria at 1 and 2 years after surgery.

RESULTS

The baseline characteristics of the CBG (n = 42) and loose bone grafting (n = 47) groups did not significantly differ. Fusion assessments indicated that significantly superior bone fusion rates were achieved at 1 year after surgery in the CBG group than in the loose bone grafting group (P = .04, χ2 test). However, the bone fusion rates of the 2 groups at 2 years after surgery did not significantly differ (P = .3). A nonsymptomatic surgical complication occurred in the CBG group when a spacer was inserted into the intervertebral space; specifically, the spacer slipped out of the right psoas muscle because a large quantity of compaction bone grafts disrupted the cage's pathway.

CONCLUSION

In posterior lumbar interbody fusion surgeries, bone fusion was achieved more quickly with the CBG technique than with the conventional technique.

Lumbar extraforaminal entrapment: performance characteristics of detecting the foraminal spinal angle using oblique coronal MRI. A multicenter study

BACKGROUND CONTEXT

Previous conventional magnetic resonance imaging reports on extraforaminal entrapment (e-FE) on L5-S1 have been problematic because of their complexity or lack of sensitivity and specificity. In this study, we propose a simple diagnostic method for e-FE.

PURPOSE

The purpose of this study was to determine the sensitivity and specificity of using the difference in the foraminal spinal nerve (FSN) angle of the L5 nerve, as determined by oblique coronal T2-weighted imaging (OC-T2WI), for diagnosing L5-S1 unilateral e-FE.

STUDY DESIGN

The study design involves diagnostic accuracy with retrospective case-control study.

PATIENT SAMPLE

Seventy consecutive patients with unilateral L5 radiculopathy who underwent unilateral L5-S1 extraspinal canal decompression for e-FE or 4/5 intraspinal canal decompression for lumbar spinal canal stenosis between 2009 and 2013 were included.

OUTCOME MEASURES

The Japanese Orthopedic Association score, Visual Analog Scale score for leg pain, and OC-T2WI for the FSN angle of the L5 nerve were examined.

METHODS

The 70 patients were divided into two groups: Group A (n=21) with unilateral L5-S1 e-FE and Group B (n=49) with intraspinal canal L4-L5. Group C (n=44) comprised the control group, which included only patients with back pain without leg radiculopathy. All patients underwent OC-T2WI, and the differences in the FSN angle of the fifth lumbar spinal nerve between the symptomatic and asymptomatic sides (ΔFSN angle) were examined and compared among the groups.

RESULTS

There were no significant differences in the patient characteristics among the three groups. The ΔFSN angle was 17° in Group A, 4.8° in Group B, and 6.4° in Group C, and the laterality was significantly larger in Group A than in the other two groups. A receiver-operating characteristic curve showed areas under the curve between groups A and B and between groups A and C of 0.93 and 0.97, respectively. In addition, the cutoff value of the ΔFSN angle (10°) indicated diagnostic accuracies of 94% and 91% (sensitivity and specificity) and of 93% and 95%, respectively.

CONCLUSIONS

Determining differences in the FSN angle between the symptomatic and asymptomatic sides of greater than 10° via OC-T2WI represented a simple, readily available, and complementary diagnostic method for lumbar e-FE.

Diagnostic accuracy of multifidus muscle spontaneous activity by needle electromyography for the detection of lumbar foraminal and lateral exit-zone stenosis

PURPOSE

The medial branch of the posterior ramus of the lumbar spinal nerve is well known to be innervated independently and to end in the multifidus muscle without anastomosis. This prospective cohort study aimed to determine the diagnostic specificity and sensitivity of multifidus muscle denervation (MMD) by needle electromyography (N-EMG) for lumbar foraminal and lateral exit-zone stenosis (LF/LEZS).

METHODS

We enrolled 61 consecutive patients experiencing unilateral dysesthesia and/or leg pain in the L4 or L5 regions with suspicious LF/LEZS. The Japanese Orthopedic Association (JOA) score, Visual Analog Scale (VAS) for leg pain, and N-EMG were examined. In this study protocol, all patients received at least 3 months of conservative therapy. Surgery was performed on patients who experienced less than 50% VAS pain relief compared with their initial score after confirming the responsible level by lumbar nerve root block. The specificity of N-EMG was the proportion of patients who improved with conservative therapies (non-surgery) after 3 months. The sensitivity of N-EMG was the proportion of patients who improved with surgical therapies (surgery) after more than 12 months.

RESULTS

Twenty-three patients underwent surgery. The initial lower JOA, positive Kemp test and motor weakness were significantly higher in the surgery group. The MMD by N-EMG indicated that 34 of 38 patients were negative in the non-surgery group. In the surgery group, 21 of 23 patients were positive. The diagnostic sensitivity and specificity were 91.3 and 92.1%, respectively.

CONCLUSIONS

Needle electromyography is a simple and available additional method for the diagnosis of LF/LEZS.

Large volume inside the cage leading incomplete interbody bone fusion and residual back pain after posterior lumbar interbody fusion

The purpose of this study is to compare intervertebral bone fusion and clinical outcomes in L4-5 posterior lumbar interbody fusion (PLIF) using the same posterior instrumentation with four combinations of one of three types of interbody cage with one of two bone grafts, iliac and local or only local. In 67 patients who underwent L4-5 PLIF, 19 patients had the Brantigan cage and iliac and local bone graft, 18 with the TELAMON C cage and iliac and local bone graft, 16 with the TELAMON C cage and local bone graft (TL), and 14 with the OIC PEEK cage and local bone graft. Clinical assessments were based on Japanese Orthopaedic Association (JOA) scores and on the visual analogue scale (VAS). The bone fusion assessments were based on radiography and CT scans according to the Brantigan, Steffee, and Fraser criteria. More than 2 years after surgery, these assessments were made. In the results, the fusion outcome for the group receiving TL was significantly less than those for the other three groups. In TL, multivariate logistic regression analysis showed that the inside volume of the cage of ≥2.0 mL was the only significant factor for incomplete fusion. Moreover, the VAS (low back pain) score was significantly higher for TL than for the other three groups. In conclusions, we believe that the large volume inside the cage (≥2.0 mL) with local bone graft may lead incomplete interbody bone fusion and residual postsurgical low back pain after PLIF.

A simple, 10-minute procedure for transforaminal injection under ultrasonic guidance to effect cervical selective nerve root block

The aim is to provide a detailed procedure of a simple and 10-minute cervical nerve root block (CNRB) under ultrasonic guidance, and to report the clinical outcomes, disorders, and complications. Records of patients who had undergone CNRB, were reviewed under ultrasonic guidance at the hospital from 2010 through 2012. The procedure is described in detail. Arm and shoulder pain was evaluated by use of the visual analogue scale (VAS). Forty-three patients agreed to undergo CNRB under ultrasonic guidance. Nerve roots from C5 to C8 were affected in 41, and these nerve roots were readily distinguished. Two of the 43 participants did not receive injections because impediments in visualizing the affected nerve root. Of the 41 who received injections, radicular pain immediately disappeared in 39, who continued to feel pain relief 1 month later. However, pain recurred in 15 patients (38%), of whom 11 underwent cervical spine surgery. The rest of 24 patients felt sustained pain relief longer than 3 months after the injection, significantly. Although one patient had recurrent radicular pain 10 months later, the pain could be controlled by medication. At the final follow-up periods, 17.2 (10–24 months), the median VAS score of the patients, 23 (0 to 71 mm), was significantly improvement (P = 0.001) in comparison to before injection 88 (range; 56–100). No complications occurred. The cervical nerve root block under ultrasonic guidance simply, safely, and efficaciously decreased radicular pain for 17.2 months in 62% patients with intolerable radicular pain.

Upper cervical cord compression due to a C-1 posterior arch in a patient with ossification of the posterior longitudinal ligament and a kyphotic cervical spine in the protruded-head position

In this paper the authors report the case of a patient with ossification of the posterior longitudinal ligament (OPLL) below the axial vertebra (C-2) at the kyphotic cervical spine, with an atlas vertebra (C-1) posterior arch that compressed the spinal cord with the head in a pathognomonic position, similar to a protruded position. This condition appears to be very rare. The morphological findings between the kyphotic cervical spine and OPLL, the upper occipitocervical junction, and the protruded-head position are discussed. A 40-year-old man presented with severe pain radiating to both legs when he yawned, sneezed, or extended his jaw (a protruded-head position). A kyphotic cervical spine with OPLL below C-2 was observed using CT and radiography, yet sagittal T2-weighted MRI failed to identify abnormal findings in a neutral or extension position, except for a slight cervical canal stenosis. However, in a pathognomonic protruded-head position, sagittal T2-weighted MRI showed a C-1 posterior arch that severely compressed the spinal cord at the upper cervical level. Therefore, the authors believe that the severe pain radiating to both legs was caused by a spinal canal stenosis due to a C-1 posterior arch impingement. The C-1 posterior arch was resected, and after the surgery, the patient indicated that the intolerable pain had disappeared. In conclusion, in patients with OPLL and a kyphotic cervical spine, the authors propose that the pathognomonic protruded position is valuable for estimating disrupted compensatory mechanisms at the upper cervical junction.

[Bone structure and strength in the proximal femur - changes due to age and medical treatment]

Understanding bone strength scientifically requires knowledge of the material strength of a bone fragment, and understanding the bone strength of a specific part of a bone requires a destruction test using a cadaver bone. Since these tests cannot be used clinically, bone strength evaluation with the advanced medical technology of "predictive estimation of bone strength based on a finite element method using quantitative CT" has been developed to estimate bone strength with consideration of anatomical bone structure of the proximal femur. Today this method has come to be clinically applicable with actual patients. Investigations in our hospital have also led to the finding that while the proximal femur is strong enough for a standing load in daily life, it does not readily withstand the load from falls in accidents, and has a structure such that fractures may be predicted to occur at about one-third that size.

Plasmapore-coated titanium cervical cages induce more rapid and complete bone fusion after anterior cervical discectomy and fusion as compared to noncoated titanium cages

OBJECTIVE

The aim of this study was to examine the solid bone fusion rates between Plasmapore-coated titanium cages (PPC group) and non-Plasmapore-coated titanium cages (N-PPC group) in patients who received anterior cervical decompression and fusion (ACDF).

METHODS

Of 78 patients who received ACDF at the hospital, a follow-up period greater than 2 years was possible for 61 patients, including 30 in the PPC group and 42 in the N-PPC group. Evaluations were performed at 3, 6, 12, and 24 months after surgery. Radiological stabilization (RS) was defined as the restriction of spinous process movement to <3 mm and the absence of a halo around the cages on flexion-extension radiographs. Solid bone fusion (SBF) was defined as the formation of bony bridges between the fixed vertebral bodies in sagittal computed tomography sections. The rates of RS and SBF were compared between both groups.

RESULTS

The differences in RS were not significant between the 2 groups during the follow-up period. However, the SBF rates at 6 and 12 months were significantly higher in the PPC group (26.7% and 56.7%) than in the N-PPC group (5% and 21.4%). Moreover, 63.3% (19 of 30) of patients in the PPC group demonstrated RS at 3 months, and of these patients, SBF was observed in 100% (19 patients) after 24 months, respectively. In comparison, the SBF rates in the N-PPC group were 86%.

CONCLUSIONS

Plasmapore-coated titanium cages enabled more rapid solid bone fusion. We suggest that these types of cages might help to reduce postoperative radiograms.

Bone union rate with autologous iliac bone versus local bone graft in posterior lumbar interbody fusion (PLIF): a multicenter study

PURPOSE

The purpose of this study is to compare bone union rate between autologous iliac bone and local bone graft in patients treated by posterior lumbar interbody fusion (PLIF) using carbon cage for single level interbody fusion.

METHODS

The subjects were 106 patients whose course could be observed for at least 2 years. The diagnosis was lumbar spinal canal stenosis in 46 patients, herniated lumbar disk in 12 patients and degenerative spondylolisthesis in 51 patients. Single interbody PLIF was done using iliac bone graft in 53 patients and local bone graft in 56 patients. Existence of pseudo-arthrosis on X-P (AP and lateral view) was investigated during the same follow up period.

RESULTS

No significant differences were found in operation time and blood loss. Significant differences were also not observed in fusion grade at any follow up period or in fusion progression between the two groups. Donor site pain continued for more than 3 months in five cases (9%). The final fusion rate was 96.3 versus 98.3%.

CONCLUSIONS

Almost the same results in fusion were obtained from both the local bone group and the autologous iliac bone group. Fusion progression was almost the same. Complications at donor sites were seen in 19% of the cases. From the above results, it was concluded that local bone graft is as beneficial as autologous iliac bone graft for PLIF at a single level.

A new criterion for the alarm point for compound muscle action potentials

Object

The purpose of this study was to review the present criteria for the compound muscle action potential (CMAP) alert and for safe spinal surgery.

Methods

The authors conducted a retrospective study of 295 patients in whom spinal cord monitoring had been performed during spinal surgery. The waveforms observed during spinal surgery were divided into the following 4 grades: Grade 0, normal; Grade 1, amplitude decrease of 50% or more and latency delay of 10% or more; Grade 2, multiphase pattern; and Grade 3, loss of amplitude. Waveform grading, its relationship with postoperative motor deficit, and CMAP sensitivity and specificity were analyzed. Whenever any wave abnormality occurred, the surgeon was notified and the surgical procedures were temporarily suspended. If no improvements were seen, the surgery was terminated.

Results

Compound muscle action potential wave changes occurred in 38.6% of cases. With Grade 1 or 2 changes, no paresis was detected. Postoperative motor deficits were seen in 8 patients, all with Grade 3 waveform changes. Among the 287 patients without postoperative motor deficits, CMAP changes were not seen in 181, with a specificity of 63%. The false-positive rate was 37% (106 of 287). However, when a Grade 2 change was set as the alarm point, sensitivity was 100% and specificity was 79.4%. The false-positive rate was 20% (59 of 295).

Conclusions

Neither the Grade 1 nor the Grade 2 groups included patients who demonstrated a motor deficit. All pareses occurred in cases showing a Grade 3 change. Therefore, the authors propose a Grade 2 change (multiphasic waveform) as a new alarm point. With the application of this criterion, the false-positive rate can be reduced to 20%.

Impact of spinal imbalance and back muscle strength on locomotive syndrome in community-living elderly people

BACKGROUND

The Japanese Orthopaedic Association has proposed the term locomotive syndrome ("locomo") to designate a condition of individuals in high-risk groups with musculoskeletal disease who are highly likely to require nursing care. The specific characteristics of "locomo" must still be determined. The spinal column is a major and important component affected by "locomo," but no literature has examined the relationship between spinal factors and "locomo." The current study investigates the influence of spinal factors on "locomo" in the elderly.

METHODS

A total of 135 subjects >70 years old were enrolled in the study (Yakumo study). Those answering yes to least one of the seven categories in the self-assessment checklist for "locomo" were defined as having "locomo." We evaluated lateral lumbar radiographs, sagittal parameters, sagittal balance using the spinal inclination angle (SIA) as an index, spinal mobility as determined with SpinalMouse(®), back muscle strength (BMS), and body mass index (BMI).

RESULTS

Age, BMS, and SIA showed significant correlations with "locomo" and five of the seven self-assessment categories. Multivariate logistic regression analysis indicated that a decrease in BMS (OR 0.971, p < 0.001) and an increase in SIA (OR 1.144, p < 0.05) were significantly associated with "locomo." BMS had significant negative correlations with age (r = -0.363), SIA (r = -0.294), and lumbar kyphosis (r = -0.254), and positive correlations with sacral slope angle (r = 0.194). SIA had significant negative correlations with BMS (r = -0.294), lumbar spinal range of motion (ROM) (r = -0.186) and total spinal ROM (r = -0.180), and positive correlations with age (r = 0.403) and lumbar kyphosis (r = 0.593).

CONCLUSIONS

A decrease in BMS and an increase in SIA may be the most important risk factors for "locomo." Lumbar kyphosis is an important factor related to BMS and SIA. Back muscle strengthening and lumbar spinal ROM exercises could be useful for improving the status of an individual suffering from "locomo."

Effect of back muscle strength and sagittal spinal imbalance on locomotive syndrome in Japanese men

The Japanese Orthopaedic Association has proposed the term locomotive syndrome to designate a condition of individuals in high-risk groups with musculoskeletal disease who are highly likely to require nursing care. This study investigates the influence of spinal factors on locomotive syndrome in Japanese men. A total of 105 men older than 50 years were enrolled in the study. Those answering yes to least 1 of 7 categories in a self-assessment checklist for locomotive syndrome were defined as having locomotive syndrome. The authors evaluated lateral lumbar radiographs, sagittal parameters, sagittal balance using the spinal inclination angle as an index, spinal range of motion as determined with SpinalMouse (Idiag, Volkerswill, Switzerland), back muscle strength, and body mass index. Age, back muscle strength, and spinal inclination angle significantly correlated with locomotive syndrome. Multiple logistic regression analysis indicated that a decrease in back muscle strength (odds ratio, 0.964; P<.01) and an increase in spinal inclination angle (odds ratio, 1.232; P<.05) were significantly associated with locomotive syndrome. Back muscle strength had significant negative correlations with age and spinal inclination angle. Spinal inclination angle had significant negative correlations with back muscle strength and lumbar and total spinal range of motion and significant positive correlations with age, body mass index, sacral slope angle, and lumbar kyphosis. A decrease in back muscle strength and an increase in spinal inclination angle may be the most important risk factors for locomotive syndrome in Japanese men. Back muscle strengthening and spinal range of motion exercises could be useful for improving the symptoms of locomotive syndrome.

Examination of the influence of ossification of the anterior longitudinal ligament on symptom progression and surgical outcome of ossification of the thoracic ligamentum flavum: a multicenter study

Object

The purpose of this study was to provide the first evidence for the influence of an ossified anterior longitudinal ligament (OALL) on the clinical features and surgical outcomes in an ossified ligamentum flavum (OLF) in the thoracic region.

Methods

Sixty-three patients who underwent surgery for a 1-level thoracic OLF were identified, and preoperative symptoms, severity of symptoms and myelopathy, disease duration, MR imaging and CT findings, surgical procedure, intraoperative findings, complications, and postoperative recovery were investigated in these patients. Entities of OALLs were found on sagittal CT images to be adjacent to or at the same vertebral level as the OLF were classified into 4 types: no discernible type (Type N), one-sided (Type O), discontinuous (Type D), and continuous (Type C).

Results

The duration of symptoms was especially long for Types D and C OALLs. Patients with Type D OALLs had a significantly worse percentage of recovery, as well as worse preoperative JOA scores.

Conclusions

The authors' results showed that a Type D OALL had strong associations with preoperative severity of symptoms and surgical outcomes. These findings may allow surgeons to determine the severity of preoperative symptoms and the probable surgical outcomes from the OALL classifications. Moreover, surgery with instrumentation for Type D OALLs may produce better surgical outcomes.

Progression of cervical instabilities in patients with rheumatoid arthritis 5.7 years after their first lower limb arthroplasty

We reviewed 101 rheumatoid arthritis (RA) patients who had undergone their first lower limb arthroplasty between 1990 and 2002. None of the patients had received immunosuppressant or biological drugs. Preoperative and follow-up cervical spine radiographs had been performed (more than 2 years after the arthroplasty). Cervical spine instabilities were found in 62 and 82 patients, and a posterior atlantodental interval (PADI) of <14 mm was present in 20 and 22 patients in the respective radiographs. The presence of cervical spine instabilities and PADI <14 mm were correlated with a higher modified Lansbury index (LI) both preoperatively and at final follow-up. Patients with no cervical spine instability throughout the follow-up had a lower average LI. Patients with atlantoaxial subluxation (AAS), vertical subluxation (VS), and subaxial subluxation (SAS) had more joint arthroplasties at final follow-up compared with other patients. The percentage of patients with single and multiple cervical instabilities increased at final follow-up. The incidence of cervical spine instabilities in RA patients requiring a lower limb arthroplasty is extremely high, with progression of these instabilities after the procedure. There is a correlation between the severity of RA activity in peripheral joints and the severity of cervical spine instabilities.

Human dental pulp-derived stem cells promote locomotor recovery after complete transection of the rat spinal cord by multiple neuro-regenerative mechanisms

Spinal cord injury (SCI) often leads to persistent functional deficits due to loss of neurons and glia and to limited axonal regeneration after injury. Here we report that transplantation of human dental pulp stem cells into the completely transected adult rat spinal cord resulted in marked recovery of hind limb locomotor functions. Transplantation of human bone marrow stromal cells or skin-derived fibroblasts led to substantially less recovery of locomotor function. The human dental pulp stem cells exhibited three major neuroregenerative activities. First, they inhibited the SCI-induced apoptosis of neurons, astrocytes, and oligodendrocytes, which improved the preservation of neuronal filaments and myelin sheaths. Second, they promoted the regeneration of transected axons by directly inhibiting multiple axon growth inhibitors, including chondroitin sulfate proteoglycan and myelin-associated glycoprotein, via paracrine mechanisms. Last, they replaced lost cells by differentiating into mature oligodendrocytes under the extreme conditions of SCI. Our data demonstrate that tooth-derived stem cells may provide therapeutic benefits for treating SCI through both cell-autonomous and paracrine neuroregenerative activities.