Incisura angularis belongs to fundic or transitional gland regions in Helicobacter pylori-naïve normal stomach: Sub-analysis of the prospective multi-center study.

OBJECTIVE: Incisura angularis is one of the important parts for evaluating mucosal atrophy and cancer risk. We determined the type of mucosa at incisura angularis in Helicobacter pylori-naïve normal stomach. METHODS: Subjects aged 40 years or older who underwent esophagogastroduodenoscopy for dyspepsia or a routine health checkup were recruited in 24 facilities between March 2008 and February 2009. Serum antibody to H. pylori was measured. Endoscopic atrophy was evaluated according to Updated Kimura-Takemoto classification. Five biopsy specimens were taken from the incisura angularis and greater and lesser curvatures of the antrum and corpus. These specimens were histologically classified as fundic, pyloric or transitional. H. pylori-naïve normal stomach was defined with the strictest criterion among various combinations of histological, endoscopic and serum findings. We determined histological type of mucosa at incisura angularis in H. pylori-naïve normal stomach. RESULTS: A total of 270 subjects (122 men, mean 64.6 yo) were analyzed. The strictest criterion consists of serum antibody ≤ 3.0 U/mL, endoscopic atrophy C-1 and histological grade 0 in all of the five items in Updated Sydney System. The numbers having fundic, transitional and pyloric mucosa at incisura angularis under the strictest criterion were 13 (50%), 13 (50%) and 0, respectively. The probability that the type of mucosa at incisura angularis would be pyloric was almost zero (97.5% confidence interval 0-0.132). CONCLUSIONS: Incisura angularis of the stomach may not belong to pyloric, but fundic or transitional mucosa in H. pylori-naïve normal stomach. UMIN000018218.

Mapping occipital bone thickness using computed tomography for safe screw placement.

OBJECT Safe and effective insertion of occipital bone screws requires morphological analysis of the occipital bone, which is poorly documented in the literature. The authors of this study present morphological data for determining the area of screw placement for optimal internal fixation. METHODS The subjects of this institutional review board-approved retrospective study were 105 individuals without head and neck disease who underwent CT imaging at the authors' hospital. There were 55 males and 50 females, with a mean age of 57.1 years (range 20-91 years). Measurements using CT were taken according to a matrix of 55 points following a grid with 1-cm spacing based on the external occipital protuberance (EOP). RESULTS The maximum thickness of the occipital bone was at the level of the EOP at 16.4 mm. Areas with thicknesses > 8 mm were more frequent at the EOP and up to 2 cm in all directions, as well as up to 1 cm in all directions at a height of 1 cm inferiorly, and up to 3 cm from the EOP inferiorly. The male group tended to have a thicker occipital bone than the female group, and the differences were significant around the EOP. The ratio of the trabecular bone to the occipital bone thickness was > 30% in the central region. At positions more than 2 cm laterally, the ratio was < 15%, and the ratio gradually decreased further laterally. CONCLUSIONS Screws that are 8 mm long can be placed in the area extending 2 cm laterally from the EOP at the level of the superior nuchal line and approximately 3 cm inferior to the center. These results suggest that it may be possible to effectively insert a screw over a wider area than the conventional reference range.

Analysis of chronic low back pain with magnetic resonance imaging T2 mapping of lumbar intervertebral disc.

BACKGROUND: Magnetic resonance imaging (MRI) T2 mapping utilizes the T2 values for quantification of moisture content and collagen sequence breakdown. Recently, attempts at quantification of lumbar disc degeneration through MRI T2 mapping have been reported. We conducted an analysis of the relationship between T2 values of degenerated intervertebral discs (IVD) and chronic low back pain (CLBP). METHODS: The subjects who had CLBP comprised 28 patients (15 male, 13 female; mean age 48.9 ± 9.6 years; range 22-60 years). All subjects underwent MRI and filled out the low back pain visual analog scale (VAS) and Japanese Orthopaedic Association Back Pain Evaluation Questionnaire (JOABPEQ). The disc was divided into the anterior annulus fibrosus (AF), the nucleus pulposus (NP), and the posterior AF, and each T2 value was measured. This study involved 25 asymptomatic control participants matched with the CLBP group subjects for gender and age (13 male, 12 female; mean age 43.8 ± 14.5 years; range 23-60 years). These subjects had no low back pain, and constituted the control group. RESULTS: T2 values for IVD tended to be lower in the CLBP group than in the control group, and these values were significantly different within the posterior AF. The correlation coefficients between the VAS scores and T2 values of anterior AF, NP and posterior AF were r = 0.30, -0.15 and -0.50. The correlation coefficient between the JOABPEQ scores (low back pain) and T2 values of anterior AF, NP and posterior AF were r = -0.0041, 0.11 and 0.42. Similarly, the JOABPEQ scores (lumbar function) were r = -0.22, -0.12 and 0.57. CONCLUSIONS: The results indicated a correlation between posterior AF degeneration and CLBP. This study suggests that MRI T2 mapping could be used as a quantitative method for diagnosing discogenic pain.

Investigation of intervertebral disc and facet joint in lumbar spondylolisthesis using T2 mapping.

PURPOSE: We measured T2 relaxation time of the intervertebral discs (IVD) and facet joints (FJ) in patients with degenerative spondylolisthesis (DS) and no spondylolisthesis (NS) and investigated the characteristics of these parts in DS. METHODS: In 40 patients with DS and 40 patients with NS, we measured T2 relaxation time of the IVD and FJ and compared them between groups. In the group with DS, we also examined the relationship between the degree of slippage using Meyerding grade and T2 relaxation of each part in the IVD and FJ. RESULTS: T2 relaxation time of the IVD tended to be lower in the DS than NS group and differed significantly (P < 0.01) within the anterior annulus fibrosus. T2 relaxation time in the FJ was significantly higher in the DS than NS group. T2 relaxation time in the FJ was significantly higher for those assessed Meyerding Grade II than Grade I, although we observed no significant differences in T2 relaxation time in any area of the IVD. CONCLUSION: T2 relaxation time decreased in the anterior annulus fibrosus of the IVD and increased in the FJ in patients with DS, suggesting an association of IVD and FJ degeneration with the development of lumbar DS.

Endoscopic diagnosis of gastric mucosal atrophy: multicenter prospective study.

BACKGROUND AND AIM: Gastric atrophy is one of the important pathological states that cause gastric cancer. As atrophic gastritis is related to the risk of gastric cancer, it is important to diagnose atrophic gastritis. In the present study, we tried to establish endoscopic criteria for atrophic gastritis. METHODS: A multicenter study of prospectively collected patients was conducted in 24 participating facilities. Two hundred and seventy-five patients received endoscopic examination and 15 endoscopic features, including diffuse redness, swelling of areae gastrica, and mucosal swelling, were evaluated. Biopsy specimens were taken from five points recommended by the Updated Sydney System, and evaluated by a single pathologist for atrophy. Sensitivity, specificity, positive predictive value, negative predictive value, area under the receiver operating characteristic curve (AUC/ROC) of each endoscopic finding to histological atrophy were calculated. Pepsinogen I/II ratios of these patients were measured and compared to the endoscopic features. RESULTS: There was no single endoscopic feature that is highly specific for histological atrophy. In the corpus, the combination of visibility of vascular pattern and swelling of areae gastrica by indigocarmine chromoendoscopy showed the highest AUC/ROC (0.83). In the antrum, the combination of visibility of vascular pattern and mucosal swelling showed the highest AUC/ROC (0.70). These endoscopic findings correlated very well to the pepsinogen I/II ratio. CONCLUSIONS: Combination of endoscopic findings can improve diagnostic accuracy, and endoscopic diagnosis of atrophy is improved especially with new endoscopic criteria, such as swelling of areae gastrica or mucosal swelling.

Atypical fungal vertebral osteomyelitis in a tsunami survivor of the Great East Japan Earthquake.

STUDY DESIGN: Case report. OBJECTIVE: We report a rare case of fungal vertebral osteomyelitis in a tsunami survivor of the Great East Japan Earthquake. SUMMARY OF BACKGROUND DATA: Fungal vertebral osteomyelitis due to Scedosporium apiospermum (S. apiospermum) is extremely rare. We describe the case of a 45-year-old male who developed vertebral osteomyelitis by S. apiospermum 1 month after near drowning in the huge tsunami after the Great East Japan Earthquake. METHODS: The patient was treated with a combination of percutaneous posterolateral endoscopic debridement and antifungal therapy. The case was evaluated with radiography and computed tomography, and his white blood cell count and C-reactive protein level in serum were measured 20 months after initiation of treatment. RESULTS: The patient had no low back pain and both white blood cell count and C-reactive protein had remained normal. Radiographs and computed tomography of lumbar spine demonstrated sclerotic change of endplates and spur formation bridging the L3 and L4 vertebral bodies. CONCLUSION: We report a rare case of the fungal vertebral osteomyelitis caused by S. apiospermum. If a patient develops severe back pain after a near-drowning episode in dirty water such as a swamp or a river, the clinician should be suspicious of the possibility of fungal spondylitis by S. apiospermum.

Microendoscopic discectomy for far lateral lumbar disk herniation: less surgical invasiveness and minimum 2-year follow-up results.

STUDY DESIGN: A retrospective review of data collected prospectively on 24 consecutive patients who underwent microendoscopic discectomy (MED) for far lateral lumbar disk herniation. OBJECTIVE: To evaluate the level of surgical invasiveness of the procedure and clinical results with a follow-up of at least 2 years. SUMMARY OF BACKGROUND DATA: To the best of our knowledge, there have only been 2 small-size and short-term clinical studies reporting the feasibility of MED for far lateral lumbar disk herniation, despite its relatively long history. Moreover, these 2 articles did not include detailed evaluations of surgical invasiveness and did not comprise any cases with disk herniation at L5-S1, which should account for a considerable proportion of cases. METHODS: Twenty-four consecutive patients, including L5-S1 patients, who underwent MED for far lateral lumbar disk herniation participated in this study. Ninety-three consecutive patients with intracanalicular disk herniation, who underwent MED also participated as control subjects. Operative time, intraoperative blood loss, serum C-reactive protein and creatine kinase, visual analog scale, and Japanese Orthopaedic Association score were evaluated. RESULTS: The procedure was successfully performed in all cases. The operative time in patients with far lateral disk herniation (143.9 min) was significantly longer than in patients with intracanalicular disk herniation (90.2 min) (P<0.01). There were no differences between the groups in terms of intraoperative blood loss (39.6 and 40.4 mL, respectively), serum C-reactive protein level on postoperative day 3 (0.71 and 0.73 mg/dL), serum creatine kinase level on postoperative day 1 (161.8 and 225.7 IU/L), visual analog scale scores to assess surgical site pain on the first postoperative day (19.4 and 24.0 mm), or improvement rate in Japanese Orthopaedic Association score at final follow-up (76.0% and 77.0%). CONCLUSIONS: MED is a well-balanced technique which offers both reduced invasiveness and good clinical results without sacrificing reliability.

Microendoscopy-assisted muscle-preserving interlaminar decompression for lumbar spinal stenosis: clinical results of consecutive 105 cases with more than 3-year follow-up.

STUDY DESIGN: A retrospective review of data collected prospectively on patients who underwent microendoscopy-assisted muscle-preserving interlaminar decompression (MILD) for lumbar spinal stenosis. OBJECTIVE: To evaluate the clinical results including surgical invasiveness and reduction rate of facet joint with a follow-up of more than 3 years. SUMMARY OF BACKGROUND DATA: Hatta et al reported microscopic posterior decompression procedure, MILD for lumbar spinal stenosis with reference to the cervical central approach put forth by Shiraishi. Mikami et al applied spinal microendoscopy to MILD procedure (microendoscopy-assisted MILD). METHODS: One hundred five consecutive patients, who underwent microendoscopy-assisted MILD, participated in this study. Operative time, blood loss, visual analogue scale (VAS), serum creatine kinase and C-reactive protein, surgical complications, reduction rate of the facet joint, Japanese Orthopaedic Association score, and Short-Form 36 were evaluated. RESULTS: The operative time was 99.3 minutes and the intraoperative bleeding was 15.7 mL on average. The mean VAS score to assess surgical site pain was 20.6 mm on postoperative day 1. The mean serum creatine kinase on postoperative day 1 and C-reactive protein on postoperative day 3 were 145.4 IU/L and 2.7 mg/dL, respectively. Surgical complications were identified in 2 cases, cauda equina injury and dural tear. The mean reduction rate of the facet joint was 3%. The follow-up rate was 83.3% and the mean follow-up period was 52.7 months. The Japanese Orthopaedic Association score improved significantly from 14.8 to 23.7 points on average. Significant improvements in Short-Form 36 were observed in all subscales except in General Health. Revision surgical procedures were performed in 8 cases at the operated level including 4 of juxtafacet cyst, 3 of disc herniation, and 1 of insufficient decompression. CONCLUSION: Microendoscopy-assisted MILD is a minimally invasive procedure and favorable clinical results can be expected for lumbar spinal stenosis. LEVEL OF EVIDENCE: 4.

Effect of cryotherapy after spine surgery.

STUDY DESIGN: Historical controlled trial. PURPOSE: To clarify the usefulness of cryotherapy after spine surgery. OVERVIEW OF LITERATURE: Cryotherapy has generally been performed subsequent to surgery on joints and in this application its clinical effects are well understood. However, cryotherapy has yet to be used following spine surgery. Its clinical efficacy in this context is unknown. METHODS: Thirty six patients had undergone one level microendoscopic surgery. Sixteen were enrolled into the cooling group, with the remaining 20 making up the no postoperative cryotherapy control group. Cryotherapy was performed at 5℃ using an icing system. A silicone balloon catheter with a thermo sensor on the tip was placed in the surgical wound. The temperature in the wound was recorded every 30 minutes until the next morning. The relationship between the depth of the sensor and the temperature in the wound were investigated using simple linear regression analysis. Laboratory data, visual analogue scale (VAS) for wound pain and postoperative bleeding were investigated. RESULTS: The mean temperature in the surgical wound was 37.0 in the control group and 35.0℃ in the cooling group (p<0.001). There was a positive correlation between the depth of the thermo sensor and the temperature in the wound in the cooling group (y=0.91x+30.2, r=0.67, p=0.004). There were no significant differences between the groups in terms of laboratory data, VAS or postoperative bleeding. CONCLUSIONS: The temperature in the wound was decreased significantly by spinal surgery cryotherapy.

Microendoscopic discectomy in athletes.

BACKGROUND: Management of lumbar disc herniation in athletes is challenging because a prolonged period of postoperative rehabilitation prevents the athlete from participating in sporting activity, resulting in loss of competitive form. No study reporting the clinical results of microendoscopic discectomy (MED) in athletes was identified in a literature search through PubMed, in spite of the relatively long history of this treatment. The objective of this study was to evaluate the efficacy of MED for athletes, focusing on their ability to quickly resume their sports activity. METHODS: Twenty-five competitive athletes, who underwent MED participated in this study. The level of sporting activity patients were capable of achieving, and the time until complete return to competitive level were assessed. The Japanese Orthopaedic Association (JOA) score and short form 36 (SF-36) were also evaluated. RESULTS: Two patients did not return to sporting activity for reasons unrelated to the lumbar diseases. Among the remaining 23 cases, 19 (82.6 %) successfully returned to their original levels of sporting activity. One patient (4.4 %) could not return to his pre-injury level of sporting activity because of residual pain. He changed his field from a high school sports team to a low-level sports society. The mean period until complete return to competition was 10.8 weeks (range 5-16 weeks). Three patients (13.0 %) could not resume sporting activity because of residual pain. The mean improvement rate of JOA score at final follow-up was 80.4 %. Significant improvements in SF-36 were observed in all subscales except in general health perceptions. CONCLUSIONS: MED is a well-balanced technique which offers a high probability of return and an early return to the same level of sporting activity, both of which are optimal aims in treatment of athletes with lumbar disc herniation.

Efficacy of diffusion-weighted magnetic resonance imaging in diagnosing spinal root disorders in lumbar disc herniation.

STUDY DESIGN: Prospective study based on magnetic resonance imaging for lumbar disc herniation. OBJECTIVE: In this study, we captured diffusion-weighted imaging (DWI) of dorsal root ganglion (DRG) of the affected nerve root in lumbar disc herniation and examined the relationship between apparent diffusion coefficient (ADC) and clinical symptoms to evaluate the efficacy of DWI in the diagnosis of lumbar spinal disorders. SUMMARY OF BACKGROUND DATA: DWI captures diffusion of water molecules in intracellular or extracellular fluid, allowing visualization of edematous changes, and is therefore used in diagnosis of hyper-acute cerebral infarction. In addition, it is possible to quantify the degree of diffusion using ADC calculated from the DWI data. Meanwhile in lumbar disc herniation, edematous changes occur in DRG of affected nerve root. If DWI enables visualization of these edematous changes, it will be possible to diagnose objectively the affected level. METHODS: The subjects were 30 patients who underwent surgery of unilateral radiculopathy and a single level lumbar disc herniation. We analyzed the relationship between morbidity duration, visual analogue scale (VAS) score of leg symptoms, and ADC. In addition, we investigated any correlation between VAS recovery ratio (i.e., VAS preoperative - VAS postoperative)/VAS preoperative × 100) with ADC. RESULTS: When compared with the contralateral side, ADC of the affected DRG was observed to increase in 18 and decrease in 12 subjects, and thus no definite trend was observed. The relationship between morbidity duration, VAS score, and ADC had no observed correlation. A positive correlation between ADC and VAS recovery ratio was statistically observed (P < 0.01, leg pain: r = 0.707, leg numbness: r = 0.738). CONCLUSION: This study showed that patients with decreased ADC tended to show poor improvement of leg symptoms, which may suggest the possibility that ADC of DRG is related to neuronal plasticity. LEVEL OF EVIDENCE: 2.

Endoscopic diagnosis of gastric mucosal activity and inflammation.

AIM: Gastritis is an important pathological state that causes gastric atrophy and cancer. The Sydney System is a well-used classification for histological evaluation for gastritis. However, there is no concordance with endoscopic findings. In the present study, we tried to establish endoscopic criteria and diagnosis for the inflammation activity of gastric mucosa. METHODS: A prospective multicenter study was conducted and 24 facilities participated. Two hundred and seventy patients received endoscopic examinations and 15 endoscopic features were evaluated. Biopsy specimens were taken from five points, and evaluated by a single pathologist for mononuclear cell infiltration and polymorphonuclear cell infiltration. Sensitivity, specificity, positive predictive value, negative predictive value, area under curve of receiver operating characteristics (AUC/ROC) of each endoscopic finding to histological gastritis were calculated. RESULTS: There was no single endoscopic finding that was highly specific for mononuclear cell infiltration and polymorphonuclear cell infiltration. In the corpus, the combination of swelling of areae gastrica by the indigo carmine contrast method (IC method) and lack of a regular arrangement of collecting venules (RAC) in angle for mononuclear cell infiltration (0.887), and the combination of swelling of areae gastrica by the IC method and diffuse redness for polymorphonuclear cell infiltration (0.851) showed the highest AUC/ROC. In the antrum, the combination of diffuse redness and visibility of a vascular pattern for mononuclear cell infiltration (0.780), and the combination of visibility of vascular pattern and swelling of areae gastrica by the IC method for polymorphonuclear cell infiltration (0.795) showed the highest AUC/ROC. CONCLUSION: Combination of endoscopic findings can improve diagnostic accuracy, and sensitivity of examination for inflammation.

Endoscopic diagnosis of gastric intestinal metaplasia: a prospective multicenter study.

BACKGROUND: Intestinal metaplasia (IM) of the gastric mucosa has long attracted attention as a premalignant lesion involved in gastric carcinogenesis. However, endoscopic diagnosis of IM has remained unclear for a long time. In recent years, the methylene blue staining technique and narrow-band imaging (NBI) magnifying endoscopy have facilitated clinical diagnosis of IM, although these methods have some problems due to their complexity. Simple methods for diagnosis of IM using conventional endoscopy and the indigo carmine contrast (IC) method are necessary. PATIENTS AND METHODS: This study was a multicenter, prospective, randomized, comparative study involving 10 facilities. The appearance of IM was examined using conventional and IC methods with an electronic endoscope. RESULTS: Subjects included 163 patients, of whom 87 and 76 underwent conventional and IC methods, respectively. Sensitivity, specificity, and receiver operating characteristic/area under thecurve (ROC/AUC) of conventional and IC methods for the detection of IM in the gastric antrum showed that diagnostic performance of the conventional method was higher, but not significantly, than that of the IC method. Sensitivity, specificity and ROC/AUC of conventional and IC methods for the detection of IM in the gastric body showed that the IC method yielded better (but not significantly better) results than the conventional method. CONCLUSION: The diagnostic performance of the conventional method did not significantly differ from that of the IC method. A villous appearance, whitish mucosa, and rough mucosal surface, as observed by both methods, and areae gastricae pattern, as observed by the IC method, were useful indicators for endoscopic diagnosis of IM.

Diagnosis of Helicobacter pylori infection in gastric mucosa by endoscopic features: a multicenter prospective study.

BACKGROUND: Endoscopic features corresponding to pathological findings in the Sydney System have not been identified, and endoscopic diagnosis of chronic gastritis has not yet been established. To establish the diagnosis of Helicobacter pylori (H. pylori) infection in gastric mucosa by endoscopic features, a prospective multicenter study was carried out. PATIENTS AND METHODS: Two hundred and ninety-seven registered patients from 24 facilities between March 2008 and February 2009 were enrolled. Association between endoscopic findings (conventional findings and indigocarmine contrast (IC) method findings) and diagnosis of H. pylori infection made by microscopic observation of biopsy specimens was investigated in the corpus and antrum and their diagnostic accuracies were investigated. RESULTS: Two hundred and seventy-five patients were analyzed. The area under the receiver operating characteristic (ROC) curve for H. pylori infection of conventional endoscopy was 0.811 in thecorpus and 0.707 in the antrum (P = 0.006). Evaluation of diffuse redness, spotty redness and mucosal swelling by conventional endoscopy and swelling of areae gastricae by the indigocarmine contrast (IC) method were useful for diagnosing H. pylori infection. Regular arrangement of collecting venules (RAC) in the angle, fundic gland polyposis, hemorrhagic erosion and bleeding spot in the corpus and red streaks, and erosions (flat, raised, hemorrhagic and bleeding spot) in the antrum may be used as diagnostic features suggesting negative H. pylori infection. CONCLUSION: It is suggested that endoscopic diagnosis of H. pylori infection in gastric mucosa by conventional endoscopy and the IC method is mostly possible.

Changes in endoscopic findings of gastritis after cure of H. pylori infection: multicenter prospective trial.

BACKGROUND AND AIM: Successful eradication of H. pylori changes pathological findings of gastritis dramatically. However, change of endoscopic mucosal findings is not fully understood. To clarify the short-term changes of endoscopic mucosal findings after cure of H. pylori infection, a multicenter prospective trial was conducted. METHODS: One hundred and forty-seven patients with H. pylori infection from 12 institutions were enrolled into this prospective cohort trial. Nineteen endoscopic findings using high-resolution white light electronic endoscopy were assessed before and 2-4 months after eradication treatment of H. pylori. H. pylori infection was diagnosed by pathology of three stomach sites using hematoxylin-eosin stain or H. pylori-specific immunostaining. Endoscopic features of the successful eradication group and the failed eradication group were compared. The change of severity of endoscopic features before and after H. pylori eradication were compared between successful eradication and failed eradication. RESULTS: One hundred and twenty-six patients were analyzed. Eradication rate was 81% (102/126). Non-transparency of gastric juice, diffuse redness of fundic mucosa, enlarged fold, spotty redness of fundic mucosa, flat erosion of stomach, and hemoglobin index of fundic mucosa were significantly different between the successful eradication group and the failed eradication group. Gastric flat erosion was of higher frequency in the successful eradication group. When eradication was successful, spotty redness of fundic gland improved significantly. CONCLUSION: Assessment of endoscopic findings of spotty redness after eradication treatment is useful in the diagnosis of H. pylori eradication.

Minimum invasive posterior decompression for cervical spondylotic amyotrophy.

BACKGROUND: Cervical spondylotic amyotrophy (CSA), characterized by amyotrophy and muscular weakness of the upper limbs, is caused by damage to anterior spinal root or anterior horn of the spinal cord. Formerly, anterior decompression and fusion were performed for treatment of CSA, but it has recently been reported that posterior decompression is also effective. However, a consensus on the choice of procedure has not yet been reached. Selective laminoplasty as minimally invasive surgery is a posterior decompression procedure that alleviates axial neck pain. Because, for CSA patients, the responsible lesion level is localized, this procedure combined with foraminotomy enables simultaneous spinal cord and root decompression. Therefore, we report the results of this treatment for CSA. METHODS: Subjects were 28 patients (25 males, 3 females), average age 50.6 years and average follow-up 43.5 months. The muscles involved were deltoid for 14 patients, biceps for 11, and extensor digitorum communis and/or intrinsic muscles of the hand for 9. MMT scores were grade 2 for 23 cases and grade 3 for 5 cases. To evaluate the results of minimally invasive surgery, cervical ROM (C2-7) and postoperative neck pain (VAS) on the first postoperative day and 1 week after surgery were evaluated. RESULTS: Muscle strength improvement was rated as "excellent" for 18 patients, "good" for 9, and "fair" for 1, with none rated "poor". Four of 10 patients whose muscle strength did not fully improve had distal type CSA and/or had preoperative MMT scores of 2. Average %ROM was 91.2 % and almost complete cervical ROM was maintained. The average postoperative VAS score was 2.6 on the first postoperative day and 1.2 1 week after surgery. CONCLUSIONS: Selective laminoplasty with segmental decompression is advantageous for minimizing postoperative neck pain and for simultaneous decompression of the affected spinal cord segment and nerve root.

SYT-SSX breakpoint peptide vaccines in patients with synovial sarcoma: a study from the Japanese Musculoskeletal Oncology Group.

In the present study, we evaluated the safety and effectiveness of SYT-SSX-derived peptide vaccines in patients with advanced synovial sarcoma. A 9-mer peptide spanning the SYT-SSX fusion region (B peptide) and its HLA-A*2402 anchor substitute (K9I) were synthesized. In Protocols A1 and A2, vaccines with peptide alone were administered subcutaneously six times at 14-day intervals. The B peptide was used in Protocol A1, whereas the K9I peptide was used in Protocol A2. In Protocols B1 and B2, the peptide was mixed with incomplete Freund's adjuvant and then administered subcutaneously six times at 14-day intervals. In addition, interferon-α was injected subcutaneously on the same day and again 3 days after the vaccination. The B peptide and K9I peptide were used in Protocols B1 and B2, respectively. In total, 21 patients (12 men, nine women; mean age 43.6 years) were enrolled in the present study. Each patient had multiple metastatic lesions of the lung. Thirteen patients completed the six-injection vaccination schedule. One patient developed intracerebral hemorrhage after the second vaccination. Delayed-type hypersensitivity skin tests were negative in all patients. Nine patients showed a greater than twofold increase in the frequency of CTLs in tetramer analysis. Recognized disease progression occurred in all but one of the nine patients in Protocols A1 and A2. In contrast, half the 12 patients had stable disease during the vaccination period in Protocols B1 and B2. Of note, one patient showed transient shrinkage of a metastatic lesion. The response of the patients to the B protocols is encouraging and warrants further investigation.

Correlation between T2 relaxation time and intervertebral disk degeneration.

OBJECTIVE: Magnetic resonance T2 mapping allows for the quantification of water and proteoglycan content within tissues and can be used to detect early cartilage abnormalities as well as to track the response to therapy. The goal of the present study was to use T2 mapping to quantify intervertebral disk water content according to the Pfirrmann classification. MATERIALS AND METHODS: This study involved 60 subjects who underwent lumbar magnetic resonance imaging (a total of 300 lumbar disks). The degree of disk degeneration was assessed in the midsagittal section on T2-weighted images according to the Pfirrmann classification (grades I to V). Receiver operating characteristic (ROC) analysis was performed among grades to determine the cut-off values. RESULTS: In the nucleus pulposus, T2 values tended to decrease with increasing grade, and there was a significant difference in T2 values between each grade from grades I to IV. However, there was no significant difference in T2 values in the anterior or posterior annulus fibrosus. T2 values according to disk degeneration level classification were as follows: grade I (>116.8 ms), grade II (92.7-116.7 ms), grade III (72.1-92.6 ms), grade IV (<72.0 ms). CONCLUSION: T2 values decreased with increasing Pfirrmann classification grade in the nucleus pulposus, likely reflecting a decrease in proteoglycan and water content. Thus, T2 value-based measurements of intervertebral disk water content may be useful for future clinical research on degenerative disk diseases.

Pyogenic spondylitis in the elderly: a report from Japan with the most aging society.

Pyogenic spondylitis can be life-threatening for elderly patients. To discuss the characteristics of the disease in the elderly, medical records of 103 consecutive cases of pyogenic spondylitis were reviewed. Of these, 45 cases were 65 years of age or older, and these 45 cases were enrolled into further study. In this study, the proportion of elderly patients among the total number with pyogenic spondylitis was 43.7%, and this figure has increased with the passing of time as follows: 37.5% (1988-1993), 44.4% (1994-1999), and 55.5% (2000-2005). The microorganisms were isolated in 16 cases: Staphylococcus aureus in 13 cases (including methicillin-resistant Staphylococcus aureus in nine) and others in three. Twenty-five patients had associated diseases: diabetes in 18 patients and malignant tumors in seven. Thirty patients were treated conservatively, and 15 patients underwent surgery. Twenty-six patients had paralysis. All 15 patients treated surgically, and eight of the 11 patients treated conservatively showed improvement in paralysis. Bone union was achieved in all cases except one. Our results indicate that a good outcome can be expected from conservative treatment in elderly patients as well as the young.

Symptomatic relevance of intravertebral cleft in patients with osteoporotic vertebral fracture.

OBJECT: The present study was designed to determine clinical and radiographic characteristics of unhealed osteoporotic vertebral fractures (OVFs) and the role of fracture mobility and an intravertebral cleft in the regulation of pain symptoms in patients with an OVF. METHODS: Patients who had persistent low-back pain for 3 months or longer and a collapsed thoracic or lumbar vertebra that had an intervertebral cleft and abnormal mobility were referred to as having unhealed OVFs. Twenty-four patients with an unhealed OVF and 30 patients with an acute OVF were compared with regard to several clinical and radiographic features including the presence of an intravertebral fluid sign. Subsequently, the extent of dynamic mobility of the fractured vertebra was analyzed for correlation with the patients' age, duration of symptoms, back pain visual analog scale (VAS) score, and performance status. Finally, in cases of unhealed OVFs, the subgroup of patients with positive fluid signs was compared with the subgroup of patients with negative fluid signs. RESULTS: Patients with an unhealed OVF were more likely to have a crush-type fracture, shorter vertebral height of the fractured vertebra, and a fracture with a positive fluid sign than those with an acute OVF. The extent of dynamic mobility of the vertebra correlated significantly with the VAS score in patients with an unhealed OVF. In addition, a significant correlation with the extent of dynamic vertebral mobility with performance status was seen in patients with an unhealed OVF and those with an acute OVF. Of the 24 patients with an unhealed OVF, 14 had a positive fluid sign in the affected vertebra. Patients with a positive fluid sign exhibited a statistically significantly greater extent of dynamic vertebral mobility, a higher VAS score, a higher performance status grade, and a greater likelihood of having a crush-type fracture than those with a negative fluid sign. All but 1 patient with an unhealed OVF and a positive fluid sign had an Eastern Cooperative Oncology Group Performance Status Grade 3 or 4 (bedridden most or all of the time). In sharp contrast, all 10 patients with an unhealed OVF and a negative fluid sign were Grade 1 or 2. CONCLUSIONS: Unhealed OVFs form a group of fractures that are distinct from acute OVFs regarding radiographic morphometry and contents of the intravertebral cleft. Dynamic vertebral mobility serves as a primal pain determinant in patients with an unhealed OVF and potentially in those with an acute OVF. Fluid accumulation in the intravertebral cleft of unhealed OVFs likely reflects long-term bedridden positioning of the patients in daily activity.