Impact of surgical treatment on patient reported outcome in patients with spinal metastases from prostate cancer.

OBJECTIVE: This study aimed to elucidate postoperative outcomes in patients with spinal metastases of prostate cancer, with a focus on patient-oriented assessments. METHODS: This was a prospective multicenter registry study involving 35 centers. A total of 413 patients enrolled in the Japanese Association for Spine Surgery and Oncology Multicenter Prospective Study of Surgery for Metastatic Spinal Tumors were evaluated for inclusion. The eligible patients were followed for at least 1 year after surgery. The Frankel Classification, Eastern Cooperative Oncology Group Performance Status, visual analog scale for pain, face scale, Barthel Index, vitality index, indications for oral pain medication, and the EQ-5D-5L questionnaire were used for evaluating functional status, activities of daily living, and patient motivation. RESULTS: Of the 413 eligible patients, 41 with primary prostate cancer were included in the study. The patient-oriented assessments indicated that the patients experienced postoperative improvements in quality of life and motivation in most items, with the improvements extending for up to 6 months. More than half of the patients with Frankel classifications B or C showed improved neurological function at 1 month after surgery, and most patients presented maintained or improved their classification at 6 months. CONCLUSION: Surgical intervention for spinal metastases of prostate cancer significantly improved neurological function, quality of life, and motivation of the patients. Consequently, our results support the validity of surgical intervention for improving the neurological function and overall well-being of patients with spinal metastases of prostate cancer.

Risk Factors for Postoperative Loss of Correction in Thoracolumbar Injuries Caused by High-Energy Trauma Treated via Percutaneous Posterior Stabilization without Bone Fusion.

Background and Objectives: Percutaneous pedicle screws were first introduced in 2001, soon becoming the cornerstone of minimally invasive spinal stabilization. Use of the procedure allowed adequate reduction and stabilization of spinal injuries, even in severely injured patients. This decreased bleeding and shortened surgical time, thereby optimizing outcomes; however, postoperative correction loss and kyphosis still occurred in some cases. Thus, we investigated cases of percutaneous posterior fixation for thoracolumbar injury and examined the factors affecting the loss of correction. Materials and Methods: Sixty-seven patients who had undergone percutaneous posterior fixation for thoracolumbar injury (AO classifications A3, A4, B, and C) between 2009 and 2016 were included. Patients with a local kyphosis angle difference ≥10° on computed tomography at the postoperative follow-up (over 12 months after surgery) or those requiring additional surgery for interbody fusion were included in the correction loss group (n = 23); the no-loss group (n = 44) served as the control. The degree of injury (injury level, AO classification, load-sharing score, local kyphosis angle, cuneiform deformity angle, and cranial and caudal disc injury) and surgical content (number of fixed intervertebral vertebrae, type of screw used, presence/absence of screw insertion into the injured vertebrae, and presence/absence of vertebral formation) were evaluated as factors of correctional loss and compared between the two groups. Results: Comparison between each group revealed that differences in the wedge-shaped deformation angle, load-sharing score, degree of cranial disc damage, AO classification at the time of injury, and use of polyaxial screws were statistically significant. Logistic regression analysis showed that the differences in wedge-shaped deformation angle, AO classification, and cranial disc injury were statistically significant; no other factors with statistically significant differences were found. Conclusion: Correction loss was seen in cases with damage to the cranial intervertebral disc as well as the vertebral body.

Osteochondroma causing cervical spinal cord compression.

Osteochondromas are the most common benign tumors of the bone. They occur in young adolescent patients and are frequently located in the metaphyses of the long bones; they do not grow after skeletal maturity. The incidence of osteochondroma in the spine is reported to be rare. Moreover, patients with spinal osteochondroma who develop symptoms of myelopathy are extremely rare. We report the case of an 8-year-old girl who experienced myelopathy due to spinal compression of the cervical osteochondroma. This case suggests that if a cartilage cap is observed on the spinal canal with magnetic resonance imaging (MRI), the tumor may extend to the spinal canal, resulting in neurologic dysfunction. Therefore, careful follow-up until bone maturity should be performed.

Prospective Registration Study for Establishing Minimal Clinically Important Differences in Patients Undergoing Surgery for Spinal Metastases.

STUDY DESIGN: Multicenter, prospective registry study. OBJECTIVE: To clarify minimal clinically important differences (MCIDs) for surgical interventions for spinal metastases, thereby enhancing patient care by integrating quality of life (QoL) assessments with clinical outcomes. SUMMARY OF BACKGROUND DATA: Despite its proven usefulness in degenerative spinal diseases and deformities, the MCID remains unexplored regarding surgery for spinal metastases. METHODS: This study included 171 (out of 413) patients from the multicenter "Prospective Registration Study on Surgery for Metastatic Spinal Tumors" by the Japan Association of Spine Surgeons. These were evaluated preoperatively and at 6 months postoperatively using the Face scale, EuroQol-5 Dimensions-5 Levels (EQ-5D-5L), including the visual analog scale (VAS), and performance status. The MCIDs were calculated using an anchor-based method, classifying participants into the improved, unchanged, and deteriorated groups based on the Face scale scores. Focusing on the improved and unchanged groups, the change in the EQ-5D-5L values from before to after treatment was analyzed, and the cutoff value with the highest sensitivity and specificity was determined as the MCID through receiver operating characteristic curve analysis. The validity of the MCIDs was evaluated using a distribution-based calculation method for patient-reported outcomes. RESULTS: The improved, unchanged, and deteriorated groups comprised 121, 28, and 22 participants, respectively. The anchor-based MCIDs for the EQ-5D-5L index, EQ-VAS, and domains of mobility, self-care, usual activities, pain/discomfort, and anxiety/depression were 0.21, 15.50, 1.50, 0.50, 0.50, 0.50, and 0.50, respectively; the corresponding distribution-based MCIDs were 0.17, 15,99, 0.77, 0.80, 0.78, 0.60, and 0.70, respectively. CONCLUSION: We identified MCIDs for surgical treatment of spinal metastases, providing benchmarks for future clinical research. By retrospectively examining whether the MCIDs are achieved, factors favoring their achievement and risks affecting them can be explored. This could aid in decisions on surgical candidacy and patient counseling.

Ten-year trends in the treatment and intervention timing for patients with metastatic spinal tumors: a retrospective observational study.

BACKGROUND: Cancer treatment has recently evolved due to the advances in comprehensive therapies, including chemotherapy and radiotherapy. The aspect of cancer-related bone metastasis has undergone a paradigm shift with the transformation of orthopedic interventions for spinal metastasis. We performed this retrospective observational study to investigate the changes in patient status and metastatic spine-tumor treatment over the past decade. METHODS: We included 186 patients (122 men and 64 women; mean age: 67.6 years) who were referred to our hospital between 2009 and 2018 and were diagnosed and treated for metastatic spinal tumors. We classified the patients into early (81 patients from 2009 to 2013) and late (105 patients from 2014 to 2018) groups. The following components were investigated and compared between the groups: primary tumor, time taken from subjective-symptom onset to hospital visit, primary tumor evaluation during the visit, walking capacity due to lower paralysis during the visit, local treatment details, and post-treatment functional prognosis. RESULTS: Predominant primary tumors with similar trends in both groups included lung cancer, multiple myeloma, and prostate cancer. The percentage of non-ambulatory patients during the consultation was significantly lower in the late group (28% vs. 16%, P = 0.04). Among non-ambulatory patients at the time of hospital visit, the mean time from the primary doctor consultation to our hospital visit was 2.8 and 2.1 days in the early and late groups, respectively. In both groups, surgical procedures were performed promptly on the non-ambulatory patients; however, postoperative lower function did not improve in approximately half of the patients. CONCLUSIONS: Our findings demonstrated that in recent years, patients tended to be referred promptly from their previous doctors under a favorable collaboration system. However, the effectiveness of lower paralysis treatment remains limited, and it is important to raise awareness regarding the importance of early consultation among the general public for earlier detection.

Effects and limitations of home-based motor-control exercise for chronic low back pain: A single center prospective study.

STUDY DESIGN: Prospective single-center observational study. OBJECTIVE: To investigate the effects and limitations of self-motor-control exercise in patients with chronic low back pain. SUMMARY OF BACKGROUND DATA: Although exercise therapy and physical therapy have been shown to be effective in treating chronic low back pain, these therapies are often discontinued due to patients' non-compliance, and their effectiveness cannot be fully demonstrated. METHODS: Fifteen patients with low back pain, no apparent organic disease, who had been symptomatic for at least three months, and could continue motor-control exercise at home for at least six months were included in the study. Low back pain (visual analog scale [VAS]), locomotor 25, stand-up test, two-step test, trunk and total body muscle mass by the impedance method, and spinal sagittal alignment were examined before the intervention to establish a baseline, and at two and six months after the intervention. RESULT: Significant improvement was observed in the back pain VAS (p<0.01), stand-up test (p = 0.03), two-step test (p = 0.01), and locomotor 25 (p = 0.04) before and after the intervention. In contrast, there were no significant changes in muscle mass and sagittal alignment. The effect of long-term exercise was more pronounced in patients without spinal deformity. CONCLUSIONS: Self-exercise for patients with chronic low back pain was effective in improving pain and function, although it did not directly affect muscle mass or alignment. Moreover, strength training of the lumbar back muscles alone was not found to be effective in patients with spinal deformities.

Osteophyte Bridge Formation Correlates with Vascular Calcification and Cardiovascular Disease in Diffuse Idiopathic Skeletal Hyperostosis.

Diffuse idiopathic skeletal hyperostosis (DISH) is a noninflammatory spondyloarthropathy characterized by ectopic calcification of spinal cord tissue. Its etiology is possibly polygenic. However, its pathogenesis and systemic effects remain unclear. Recent studies have reported a high prevalence of DISH in heart failure patients. The authors investigated how the incidence and severity of DISH are associated with vascular calcification and the occurrence of cardiovascular events. In this retrospective chart review study, 500 patients with cardiovascular disease who underwent surgery (cardiovascular events group) and 500 patients with non-cardiovascular disease who underwent computed tomography scans (non-cardiovascular events group) were randomly selected to investigate the degree of ossification of the anterior longitudinal ligament and the incidence of DISH. We found that the incidence of DISH was higher in patients with cardiovascular events and that patients with DISH had more calcification of the coronary arteries and aorta. Next, we examined the relationship between the degree of coronary and aortic calcification, the incidence of DISH, and the degree of ossification of the anterior longitudinal ligament in the non-cardiovascular event group. The prevalence of DISH in the cardiovascular and non-cardiovascular groups was 31.4% and 16.5%, respectively (p = 0.007). Aortic calcification and a predominant degree of vascular calcification with a certain level of ossification of the anterior longitudinal ligament suggest some correlation between DISH and cardiovascular events. This study is important in understanding the pathophysiology and pathogenesis of DISH.

Broad and Asymmetric Lower Extremity Myotomes: Results from Intraoperative Direct Electrical Stimulation of the Lumbosacral Spinal Roots.

STUDY DESIGN: Retrospective review of prospectively collected data. OBJECTIVE: This study aimed to accurately map the lower extremity muscles innervated by the lumbar spinal roots by directly stimulating the spinal roots during surgery. SUMMARY OF BACKGROUND DATA: Innervation of the spinal roots in the lower extremities has been estimated by clinical studies, anatomical studies, and animal experiments. However, there have been discrepancies between studies. Moreover, there are no studies that have studied the laterality of lower limb innervation. MATERIALS AND METHODS: In 73 patients with lumbar degenerative disease, a total of 147 spinal roots were electrically stimulated and the electromyographic response was recorded at the vastus medialis (VM), gluteus medius (GM), tibialis anterior (TA), biceps femoris (BF), and gastrocnemius (GC). The asymmetry index (AI) was obtained using the following equation to represent the left-right asymmetry in the CMAP amplitude. Paired t-tests were used to compare CMAP amplitudes on the right and left sides. Differences in the AI among the same spinal root groups were determined using one-way analysis of variance. RESULTS: The frequency of compound muscle action potentials (CMAP) elicitation in VM, GM, TA, BF, and GC were 100%, 75.0%, 50.0%, 83.3%, and 33.3% in L3 spinal root stimulation, 90.4%, 78.8%, 59.6%, 73.1%, and 59.6% in L4 spinal root stimulation, 32.2%, 78.0%, 93.2%, 69.5%, and 83.1% in L5 spinal root stimulation, and 40.0%, 100%, 80.0%, 70.0%, and 80.0% in S1 spinal root stimulation, respectively. The most frequent muscle with maximum amplitude of the CMAP in L3, L4, L5, and S1 spinal root stimulation was the VM, GM, TA, and GM respectively. Unilateral innervation occurred at high rates in the TA in L4 root stimulation and the VM in L5 root stimulation in 37.5% and 42.3% of patients, respectively. Even in patients with bilateral innervation, a 20-38% asymmetry index of CMAP amplitude was observed. CONCLUSIONS: The spinal roots innervated a much larger range of muscles than what is indicated in general textbooks. Furthermore, a non-negligible number of patients showed asymmetrical innervation of lower limb by the lumbar spinal roots.

Evaluation of segmental mobility in patients with lumbar spondylolisthesis : A comparison of images from standing flexion-extension and standing/supine slippage.

PURPOSE: To evaluate segmental mobility with degenerative lumbar spondylolisthesis (DLS), upright lateral flexion-extension radiographs (FE) are widely used. However, some authors have described that a combination of lateral radiographs in the standing position and supine sagittal image (SS) reveal more segmental mobility than FE. The purpose of this study was to investigate the optimal method for evaluating segmental mobility with DLS. METHODS: We included 92 consecutive Japanese patients diagnosed with DLS. Sagittal translation (ST) determined by FE and SS were compared. Pathological instability was defined as ST more than 8% of the upper vertebra. Patients were divided into those diagnosed with pathological instability in FE (PI-FE) and those diagnosed with SS (PI-SS), and lumbar lordosis (LL) in the standing position in each group were compared. RESULTS: ST in FE was significantly greater than in SS. Of 92 patients, 31 had pathological instability in FE or SS ; 17 patients had PI-FE, and 10 patients had PI-SS. LL in the standing position in PI-FE was significantly smaller than in PI-SS. CONCLUSIONS: ST in FE was greater than that in SS, contrary to previous studies' reports on Caucasians. Since Japanese individuals have smaller LL than Caucasians, FE tends to reveal more segmental mobility than SS. J. Med. Invest. 70 : 135-139, February, 2023.

Degenerative Lumbar Spondylolisthesis Patients With Movement-related Low Back Pain Have Less Postoperative Satisfaction After Decompression Alone.

STUDY DESIGN: Retrospective analysis of prospectively collected multicenter observational data. OBJECTIVE: The aim was to examine the preoperative factors affecting postoperative satisfaction following posterior lumbar interbody fusion (PLIF) and microendoscopic muscle-preserving interlaminar decompression (ME-MILD) in patients with degenerative lumbar spondylolisthesis (DLS). SUMMARY OF BACKGROUND DATA: The technique involved in DLS surgery may either be decompression alone or decompression-fixation. Poor performance may occur after either of these surgical treatments. The author hypothesized that evaluating the correlation between preoperative quality of life and postoperative performance would aid in determining the optimal procedure. MATERIALS AND METHODS: This study included 138 patients who underwent surgery for 1-level mild DLS. The authors performed PLIF for 79 patients and ME-MILD for 59 patients. When the satisfaction subscale of the Zurich Claudication Questionnaire exceeded 2 points, postoperative satisfaction was considered poor. The clinical characteristics were investigated. Responses to preoperative health-related quality of life questionnaires, such as the Japanese Orthopedic Association Back Pain Evaluation Questionnaire (JOABPEQ), short form-36 health survey (SF-36), and visual analog scale, were compared between the satisfied and unsatisfied groups. RESULTS: In the PLIF group, no endogenous factors influenced postoperative satisfaction. The ME-MILD cohort's satisfied and unsatisfied patients differed significantly in terms of preoperative lumbar spine dysfunction ( P <0.001) items of the JOABPEQ, role physical ( P =0.03), and role emotional ( P =0.03) items of the SF-36. A strong correlation ( r =-0.609 P =0.015) was found between preoperative lumbar spine dysfunction and postoperative satisfaction. CONCLUSIONS: In the ME-MILD group, preoperative lumbar spine function was correlated with postoperative satisfaction. Decompression alone may be ineffective in cases with decreased lumbar spine function prior to surgery. The degree of low back pain on movement should be considered before selecting the surgical method. LEVEL OF EVIDENCE: 3.

Effect of Minimally Invasive Selective Laminectomy for Cervical Spondylotic Myelopathy on Degenerative Spondylolisthesis.

STUDY DESIGN: Retrospective analysis of prospectively collected observational data. OBJECTIVE: This study aimed to evaluate the slippage, sagittal alignment, and range of motion (ROM) after selective laminectomy (SL) in patients who had cervical spondylotic myelopathy (CSM) with degenerative spondylolisthesis (DS). SUMMARY OF BACKGROUND DATA: Clinical outcomes have been reported for both decompression and fusion surgeries for DS of the lumbar spine. However, only a few reports have examined cervical spine spondylolisthesis. MATERIALS AND METHODS: This study included 178 patients who underwent SL for CSM. Those with ossification of the posterior longitudinal ligament were excluded. Slippage >2 mm was defined as spondylolisthesis, and spondylolisthesis progression was defined as an additional displacement >2 mm on a neutral radiograph. The slippage, translational motion, C2-C7 angle, local kyphosis, and ROM were examined before and ≥2 years after surgery. Radiologic parameters were evaluated according to the slip direction and the number of laminae removed. RESULTS: DS was observed in 29 patients (16.3%); 24 patients, comprising 9 and 15 in the anterolisthesis and retrolisthesis groups, respectively, were successfully followed up for more than 2 years. Preoperative and postoperative radiologic changes in slippage, translational motion, C2-C7 angle, local kyphosis, and ROM were not remarkable in either group regardless of the number of laminae removed. Revision surgery for the progression of DS and alignment deterioration was not required in any patient of either group. CONCLUSIONS: SL does not affect DS, sagittal alignment, or ROM irrespective of the slip direction and the number of laminae removed, even after >2 years after surgery. Given the preservation of the posterior elements, SL may be an effective treatment for CSM with DS. LEVEL OF EVIDENCE: Level IV.

Prevalence of Multiple-Level Spondylolysis and the Bone Union Rates among Growth-Stage Children with Lower Back Pain.

INTRODUCTION: Lumbar spondylolysis is usually single level, and only a few multiple-level cases have been reported. We investigated the frequency of multiple-level spondylolysis and the bone union rates among growth-stage children with lower back pain (LBP). METHODS: The subjects were growth-stage children examined for LBP between April 2013 and December 2018. All patients with LBP persisting for at least 2 weeks and severe enough to make playing sports difficult underwent lumbar plain radiogram, computed tomography, and magnetic resonance imaging. The cases diagnosed as multiple-level spondylolysis and classified as early or progressive stage received conservative treatment to achieve bone union. RESULTS: A total of 782 growth-stage children were examined for LBP. Of them, 243 children (31.1%) were diagnosed with lumbar spondylolysis. Of these 243 children, 23 (9.5%) children had multiple-level spondylolysis. Of the children diagnosed with multiple-level spondylolysis, most children (87.0%) had pars defects in the early or progressive stage in which bone union could be expected. Most children (78.3%) had pars defects in the terminal stage and combined with these defects, had pars defects in the early or progressive stage at a different spinal level. Twenty children diagnosed with multiple-level spondylolysis who also had pars defects in the early or progressive stage received conservative treatment for bone union, which was achieved in 31 of 39 sites (79.5%). The bone union rate by stage was 92.9% (26 of 28 sites) in the early stage and 45.5% (5 of 11 sites) in the progressive stage. CONCLUSIONS: In cases of multiple-level spondylolysis, bone union is likely to be achieved with conservative treatment when the pars defects are in the early or progressive stage. Therefore, the first choice of treatment should be conservative treatment to achieve bone union, the same for single-level spondylolysis.

Reconstruction after Subtotal Sacrectomy for Sacral Ewing's Sarcoma Using Tibial Allograft Strut Grafting: A Case Report.

We present the case of a 15-year-old girl. Two months after becoming aware of pain, she was diagnosed with a sacral tumor and referred to our department. She was diagnosed with a sacral Ewing's sarcoma; after chemotherapy, it was determined that the tumor could be resected, so surgical treatment was performed. The sacrum and ilium were partially resected at the lower end of S1, and the lumbar vertebrae and pelvis were fixed with a pedicle screw and two iliac screws on each side of L3, and the sacral resection was reconstructed with a tibial strut allograft. No tumor recurrence or metastasis has been observed 1 year postoperatively. She developed bladder and rectal dysfunction, but she remained independent in activities of daily living and her daily life was not limited. The bone fusion in the reconstructed area confirmed the lack of instrumentation looseness. Surgical treatment for sacral Ewing's sarcoma was performed to cure the patient. We believe that the tibial allograft contributed to the patient's ability to walk on her own due to its high mechanical stability. Postoperative bone healing was observed with the same material, suggesting that the tibial allograft is useful for similar procedures.

Comparison of the sacral table angles by progression stage of lumbar spondylolysis.

STUDY DESIGN: Retrospective study. OBJECTIVES: The purpose of this study was to investigate sacral table angle (STA) values in early-stage spondylolysis. Several studies suggested that the STA of patients with L5 spondylolysis or spondylolisthesis was significantly lower than that of healthy controls. Separation of the pars interarticularis creates shear stress between the upper sacral end plate and L5 vertebra. This was considered the cause of low STA in patients with spondylolysis or spondylolisthesis. However, if a low STA value is obtained in the early stage of L5 spondylolysis, it suggests that low STA does not result in the remodeling of the sacral end plate. METHODS: Patients with L5 spondylolysis and those with low back pain without pars defect were retrospectively identified from a hospital database in 2014-2016. Pars defect of the spondylolysis was classified into three categories based on CT and MRI results: early, progressive, or terminal stage. The STA difference between groups was calculated using one-way analysis of variance and Scheffe F test, which were used for post hoc testing. RESULTS: A total of 84 cases of L5 spondylolysis and 70 cases of low back pain were identified. No significant difference was found between the STAs of the early- or progressive-stage spondylolysis and the terminal-stage L5 spondylolysis and low back pain patients. The STA of the terminal-stage L5 spondylolysis was significantly lower than that of low back pain patients. CONCLUSIONS: In conclusion, patients with early- or progressive-stage spondylolysis do not have low STA. Low STA is seen only in patients with terminal-stage spondylolysis, suggesting that low STA is associated with remodeling changes in response to shear force after onset of spondylolysis. STA value might not important as a prognostic parameter about development of the spondylolysis. LEVEL OF EVIDENCE: Level IV.

Glossopharyngeal and Hypoglossal Nerve Paralysis Secondary to Prevertebral Phlegmon.

A 50-year-old man presented to the clinic with severe neck pain, fever, and difficulty breathing and was subsequently admitted to the local orthopedics department with possible retropharyngeal abscess and pyogenic spondylitis. Antibiotic therapy was initiated; however, due to poor oxygenation, he was referred and transferred to our department and admitted. Magnetic resonance imaging showed signal changes at the left C1/2 lateral atlantoaxial joint, posterior pharynx, longus colli muscle, carotid space, and medial deep cervical region, predominantly on the left side. In addition, despite lymph node enlargement from the posterior pharynx to the deep cervical region, there was no abscess formation. There were no signs of a space-occupying lesion or signal changes in the jugular foramen. One day postadmission, the patient's temperature had risen to 39.1°C and his SpO2 had fallen. His neck pain had also worsened, and emergency surgery was decided. Preoperatively, we suspected retropharyngeal abscess and pyogenic spondylitis. On day 13 postadmission, the patient exhibited dysphagia, deviated tongue protrusion, and the curtain sign. Glossopharyngeal and hypoglossal nerve paralysis were diagnosed. The patient's swallowing functions recovered and he was discharged on day 36. We experienced a case of glossopharyngeal and hypoglossal nerve paralysis secondary to pyogenic cervical facet joint arthritis.

Do We Have Adequate Flexion-extension Radiographs for Evaluating Instability in Patients With Lumbar Spondylolisthesis?

STUDY DESIGN: A retrospective cohort study of consecutive patients. OBJECTIVE: To investigate whether adequate flexion-extension was acquired in standard functional radiographs in lumbar spondylolisthesis. SUMMARY OF BACKGROUND DATA: In lumbar spondylolisthesis, flexion-extension radiographs taken in the standing position are most commonly used to evaluate spinal instability. However, these functional radiographs occasionally depend on the patient's effort and cooperation, they can provide different results. METHODS: This study included 92 consecutive patients diagnosed with L4-5 degenerative lumbar spondylolisthesis. We analyzed the flexion-extension radiographs taken with the patient being led by the hand (LH) and those taken without LH (NLH). Sagittal translation (ST), segmental angulation (SA), posterior opening (PO), and lumbar lordosis (LL) were measured on functional radiographs taken in both tests. Then, ST, SA, PO, detection rate of instability, and LL observed in LH were compared with those observed in NLH. Furthermore, the correlation of the difference was evaluated between ST, lumbar angulation, and LL. RESULTS: A relative value of ST was 9.5% ±â€Š4.3% in LH and 5.6% ±â€Š3.3% in NLH, which differed significantly (P < 0.001). SA and PO were also significantly greater in LH than in NLH. The detection rate of instability was 71.7% in LH and 30.4% in NLH (P < 0.001). LL measurement on flexion showed 17.6°â€Š±â€Š13.5° in LH and 28.2°â€Š±â€Š12.2° in NLH, which differed significantly (P < 0.001). However, no significant difference was found in LL on extension between LH and NLH. There was a moderate correlation between the difference of ST, SA, PO, and LL on flexion. CONCLUSION: Flexion with physical assistance was useful for the detection of abnormal lumbar mobility. Taking radiation exposure into consideration, physical assistance such as using a table in front of a patient could lead the similar evaluation of the segmental instability. LEVEL OF EVIDENCE: 2.

Mid-term Clinical Results of Microendoscopic Decompression for Lumbar Foraminal Stenosis.

INTRODUCTION: There have been several reports on surgical techniques involving microendoscopy or percutaneous endoscopy for treating lumbar foraminal stenosis (LFS). However, no studies have assessed the mid-term clinical results of endoscopic techniques in spite of their relatively long history. In this study, we report 20 consecutive cases of LFS treated by our microendoscopic technique focusing on clinical results with a follow-up of at least two years. METHODS: Twenty consecutive cases of LFS treated with microendoscopic decompression were followed up at 1, 2, 6, and 12 months postoperatively and annually thereafter. The patients were 14 males and 6 females, and the mean age at the time of surgery was 64.7 years. The Japanese Orthopaedic Association (JOA) score was used as the clinical outcome index. RESULTS: Of the 20 patients, 16 were monitored successfully for more than 2 years. The follow-up rate was 80.0%, and the mean follow-up period was 66.3 months. The JOA score improved from 13.8 points before surgery to 24.6 points at final follow-up. Revision fusion surgeries were performed in two cases for LFS recurrence. CONCLUSIONS: The microendoscopic technique effectively treats LFS.

Analysis of Neuropathic Pain Using Magnetic Resonance Imaging T2 Mapping of Intervertebral Disc in Chronic Low Back Pain.

STUDY DESIGN: Cross sectional study. PURPOSE: The study aimed to analyze mechanisms underlying chronic low back pain (CLBP) using magnetic resonance imaging (MRI) T2 mapping of the intervertebral disc (IVD). OVERVIEW OF LITERATURE: MRI T2 mapping utilizes the T2 values for quantifying moisture content and collagen sequence breakdown. We previously used MRI T2 mapping for quantifying the extent of IVD degeneration (IVDD) and showed a correlation between the degeneration of the posterior annulus fibrosus (AF) and CLBP. METHODS: We enrolled 40 patients with CLBP (17 males, 23 females; mean age, 50.8±1.6 years; range, 22-60 years). IVDs were categorized as the anterior AF, nucleus pulposus (NP), and posterior AF, and T2 value for each disc was measured. T2 values, assessed using the Japanese neuropathic pain (NeP) screening questionnaire, of the NeP and nociceptive pain (NocP) groups were compared. RESULTS: T2 values of the NocP and NeP groups were 64.7±5.6 ms and 58.1±2.3 ms for the anterior AF; 67.0±4.6 ms and 59.6±2.1 ms for NP; and 70.7±4.6 ms and 51.0±1.2 ms for the posterior AF, respectively. T2 values for IVDD were significantly lower in the NeP group than those in the NocP group (p<0.01). CONCLUSIONS: The results indicate a correlation between the degeneration of posterior AF and NeP. MRI T2 mapping may be beneficial for detecting NeP caused by IVDD and can help formulate targeted analgesic therapies.

Spindle cell rhabdomyosarcoma in a lumbar vertebra with FUS-TFCP2 fusion.

A 70-year-old woman developed severe buttock pain that progressed to a walking disturbance. Radiographs and computed tomography scans revealed an osteolytic lesion with osteosclerosis extending from the body to the arch of the fifth lumbar vertebra. Magnetic resonance imaging showed multinodular masses in the fifth lumbar vertebral body extending into the spinous processes and right transverse process. The masses were hypointense to isointense on T1-weighted images and hypointense to hyperintense on T2-weighted images. Histologic examination of biopsy specimens showed destruction of the trabecula of the vertebral bone by a fascicular and solid proliferation of spindle tumor cells and scattered rhabdomyoblasts, in a fibrotic background. The tumor cells were immunoreactive for keratins, vimentin, desmin, MyoD1, myogenin, and anaplastic lymphoma kinase. Fluorescence in situ hybridization detected split signals for FUS and TFCP2 in 80% and 64% of the tumor cells, respectively, suggesting FUS-TFCP2 fusion. Reverse transcription-polymerase chain reaction revealed a FUS-TFCP2 fusion. The final diagnosis was spindle cell rhabdomyosarcoma of a lumbar vertebra with a FUS-TFCP2 fusion. A spindle cell rhabdomyosarcoma with a FUS-TFCP2 fusion in a vertebral bone is rare and should be differentiated from metastatic carcinoma, particularly in the elderly.

Comparison of Health-related Quality of Life Between Double-door Laminoplasty and Selective Laminoplasty for Degenerative Cervical Myelopathy, With a Minimum Follow-up of 5 Years.

STUDY DESIGN: A retrospective analysis of prospectively collected multicenter observational data. OBJECTIVE: The aim of this study was to compare the health-related quality of life (HR-QOL) of double-door laminoplasty (DDL) and selective laminoplasty (SL) in patients with degenerative cervical myelopathy (DCM) in two institutions, with a minimum follow-up of 5 years. SUMMARY OF BACKGROUND DATA: No study has compared DDL and SL regarding postoperative HR-QOL with a follow-up of more than 5 years. METHODS: One-hundred ninety patients who underwent DDL (n = 77) or SL (n = 113) participated in this study. Short-form 36 (SF-36), Japanese Orthopedic Association Cervical Myelopathy Evaluation Questionnaire (JOACMEQ), Neck Disability Index (NDI), and visual analog scale (VAS) values were compared between the groups. RESULTS: Thirty-seven DDL and 52 SL patients were evaluated. The mean follow-up period was 8 years and the follow-up rate was 46.8%. No significant differences were found regarding age and JOA score at baseline. At the follow-up, there were no significant differences in SF-36, JOACMEQ, and VAS score, while the NDI score for headache and sleeping were higher in the SL group. After dividing the SL group into short and long SL subgroups, the long SL subgroup showed a significantly lower score in bodily pain in SF-36, lower and bladder function in JOACMEQ, and pain intensity, personal care, headaches, and sleeping in NDI compared with the other groups. CONCLUSION: No significant differences were found in SF-36, JOA score, and NDI, except for the NDI subscale of headache and sleeping. The subgroup analysis showed that the long SL group showed a decreased QOL compared with the short SL and DDL groups. LEVEL OF EVIDENCE: 3.