Central sensitization as a predictive factor for the surgical outcome in patients with lumbar spinal stenosis: a multicenter prospective study.

PURPOSE: The impact of central sensitization (CS) on neurological symptoms and surgical outcomes in patients with lumbar spinal stenosis (LSS) remains unknown. This study aimed to investigate the influence of preoperative CS on the surgical outcomes of patients with LSS. METHODS: A total of 197 consecutive patients with LSS (mean age 69.3) who underwent posterior decompression surgery with or without fusion were included in this study. The participants completed the CS inventory (CSI) scores and the following clinical outcome assessments (COAs) preoperatively and 12 months postoperatively: the Japanese Orthopaedic Association (JOA) score for back pain, JOA back pain evaluation questionnaire, and Oswestry Disability Index (ODI). The association between preoperative CSI scores and preoperative and postoperative COAs was analyzed, and postoperative changes were statistically evaluated. RESULTS: The preoperative CSI score significantly decreased at 12 months postoperatively and was significantly correlated with all COAs preoperatively and 12 months postoperatively. Higher preoperative CSI showed worse postoperative COAs and inferior postoperative improvement rates in the JOA score, VAS score for neurological symptoms, and ODI. Multiple regression analysis demonstrated that preoperative CSI was significantly associated with postoperative low back pain (LBP), mental health, quality of life (QOL), and neurological symptoms at 12 months postoperatively. CONCLUSIONS: Preoperative CS evaluated by CSI had a significantly worse impact on surgical outcomes, including neurological symptoms, disability, and QOL, especially related to LBP and psychological factors. CSI can be used clinically as a patient-reported measure for predicting postoperative outcomes in patients with LSS.

The Relationship of BMD Increases Between the First 12 Months and the Latter 12 Months by Daily Teriparatide Treatment.

The degree of correlation between the first 12 months and the latter 12 months of increased bone mineral density (BMD) with teriparatide treatment is unknown. We retrospectively investigated the correlation between the first 12 months and the latter 12 months of increased BMD owing to teriparatide treatment. We retrospectively analyzed 357 patients (mean age, 78 years) with osteoporosis treated with teriparatide 20 µg/day for 24 months. The primary efficacy measure was the correlation between lumbar spine (LS) and femoral neck (FN) BMD increases from baseline to 12 months and from 12 to 24 months. The correlation between the first 12 months and the latter 12 months of increased BMD was evaluated. We investigated the correlation between the increases in BMD and the baseline procollagen type I N-terminal propeptide (PINP) concentration. LS BMD significantly increased by 9.7 ± 8.3 % in the first 12 months and 3.5 ± 4.8 % in the latter 12 months. FN BMD increased by 2.2 ± 8.4 % in the first 12 months and 1.3 ± 4.9 % in the latter 12 months. Increased LS and FN BMD were not significantly correlated between the first 12 months and the latter 12 months. The serum baseline PINP concentration was correlated with the LS BMD in the first 12 months, and similarly, the PINP concentration at 12 months was correlated with the latter 12 months of increased LS BMD. Increased BMD by teriparatide treatment in the first 12 months and the latter 12 months was not significantly correlated.

Evaluation of Central Sensitization Inventory in Patients Undergoing Elective Spine Surgery in a Multicenter Study.

STUDY DESIGN: This study is a retrospective review. OBJECTIVE: Central sensitization (CS) is a neurological phenomenon that involves hypersensitivity of the central nervous system. The central sensitization inventory (CSI) was developed as a screening tool to assess CS-related symptoms. The purpose of this study was to evaluate the association of preoperative CSI scores with patient-reported outcome measures (PROMs) including neurological symptoms for patients who underwent spine surgeries in a multicenter study. METHODS: A consecutive 673 patients who underwent spine surgery at 8 different institutions were included in this study. Preoperative CSI scores were assessed for all subjects. The participants completed the following PROMs: the Oswestry Disability Index (ODI), the Japanese Orthopaedic Association (JOA) back pain evaluation questionnaire (JOABPEQ) for lumbar spinal diseases, and the JOA cervical myelopathy evaluation questionnaire (JOACMEQ) for cervical spinal diseases. The association of CSI scores with PROMs was statistically evaluated. RESULTS: The average CSI score for the total subjects was 23.6 ± 13.5. The subjects with CS-related symptoms (CSI ≥ 40) were 13.2% (n = 89). The CSI score showed a significant and weak-to-moderate correlation with the PROMs including neurological symptoms that included all the domains of the JOACMEQ for cervical spinal diseases, and JOABPEQ and ODI for lumbar spinal diseases. Among these, psychological factors had the most influence on the correlation with CSI score. CONCLUSION: Central sensitization evaluated by the CSI is related to neurological symptoms and health-related quality of life in patients undergoing elective spine surgery.

Does Central Sensitization Influence Outcomes of Lumbar Discectomy Surgery in Patients With Lumbar Disc Herniation? A Multicenter Prospective Study.

STUDY DESIGN: Multicenter prospective study. OBJECTIVE: Patients with central sensitization (CS) are reported to be at high risk of poor outcomes after spinal surgery. However, the influence of CS on surgical outcomes for lumbar disc herniation (LDH) remains unknown. This study aimed to examine the association between preoperative CS and surgical outcomes in LDH patients. METHODS: A total of 100 consecutive patients with LDH (mean age 51.2) who underwent lumbar surgery were included in this study. The extent of CS was evaluated using the central sensitization inventory (CSI), a screening tool for CS-related symptoms. The patients completed the following CSI and clinical outcome assessments (COAs) preoperatively and 12 months postoperatively: the Japanese Orthopaedic Association (JOA) score for back pain, JOA back pain evaluation questionnaire (JOABPEQ), and Oswestry Disability Index (ODI). The association between preoperative CSI scores, and preoperative and postoperative COAs was analyzed, and the postoperative changes were statistically evaluated. RESULTS: The preoperative CSI score significantly decreased 12 months postoperatively. Preoperative CSI scores showed a significant correlation with most COAs; however, a significant correlation was only identified in the social function and mental health domains of JOABPEC postoperatively. Higher preoperative CSI showed worse preoperative COAs; however, all COAs significantly improved regardless of CSI severity. There were no significant differences in any COAs among the CSI severity groups 12 months postoperatively. CONCLUSIONS: The results of this study showed that lumbar surgeries significantly improved the COAs regardless of preoperative severity of CS in patients with LDH.

Second rebound-associated vertebral fractures after denosumab discontinuation.

Here, we report the case of a 69-year-old female who discontinued denosumab to undergo dental treatment. She subsequently suffered rebound-associated vertebral fractures (RVFs) twice. Denosumab is approved in several countries for osteoporosis treatment. Its discontinuation can result in bone turnover rebound increase and rapid bone mineral density loss. Rebound-associated vertebral fractures (RVFs) after discontinuing denosumab have been widely reported. We previously reported the case of a patient who suffered RVFs after discontinuing denosumab to undergo dental treatment. A 69-year-old female suffered five acute VFs 10 months after the last denosumab injection. The current report identifies the risks associated with denosumab discontinuation to undergo dental treatment. The patient described in this report also underwent an additional clinical course after the first RVFs. Next month after the first RVFs, she developed severe back pain when she changed her posture. Magnetic resonance imaging showed new RVFs at T9 and T12 levels. This case indicates that RVFs may occur more than once. In addition, it suggests that additional denosumab injections do not completely eliminate the risk of RVFs.

Efficacy of Switching From Teriparatide to Bisphosphonate or Denosumab: A Prospective, Randomized, Open-Label Trial.

There is no consensus on an optimal treatment after daily teriparatide (TPTD). We performed a prospective, randomized, open-label, 12-month trial to investigate the efficacy of follow-up treatment after daily TPTD treatment for Japanese patients. Three-hundred patients were enrolled in this study. Patients received oral bisphosphonate (BP) including alendronate (ALN; 35 mg/week) and minodoronate (MINO; 50 mg/month), or subcutaneous denosumab (60 mg/6 month). The primary efficacy measure was bone mineral density (BMD) responses in the lumbar spine (LS) and femoral neck (FN). Lumbar spine BMD increased by 1.3 ± 5.1% in the ALN subgroups, 0.5 ± 4.6% in the MINO subgroups, and 4.3 ± 3.5% in the denosumab subgroups. Femoral neck BMD increased by 0.7 ± 4.6% in the ALN subgroups, 0.2 ± 4.6% in the MINO subgroups, and 1.4 ± 3.4% in the denosumab subgroups. Lumbar spine BMD increases were significantly greater in the denosumab subgroup than the BP subgroups. There were no significant differences in FN BMD increases among the three subgroups. Lumbar spine BMD increases were significantly greater in the denosumab subgroup than the BP subgroups, whereas FN BMD increases were not significant. Denosumab treatment was more effective in increasing BMD and therefore has the potential benefit of fracture prevention. Further research is warranted to determine the optimal treatment after daily TPTD. © 2018 The Authors. JBMR Plus published by Wiley Periodicals, Inc. on behalf of American Society for Bone and Mineral Research.

Efficacy of Daily Teriparatide Treatment in Low Levels of Walking State Patients.

INTRODUCTION: Little is known about the efficacy of osteoporosis medication in patients with low levels of walking state, namely, influence by immobilization levels. We retrospectively compared the efficacy of the daily teriparatide therapy in patients with low and high levels of walking state to detect possible immobilization-related differences. METHODS: We analyzed 661 patients treated with 20 µg/day of teriparatide for 24 months. We measured the changes in the bone mineral density (BMD) of the lumbar spine (LS) and of the femoral neck (FN), the changes in serum procollagen type I N-terminal propeptide (PINP) levels and urinary N-telopeptide (uNTX) excretion. To compare the results of BMD and bone turnover marker, the patients were divided into two subgroups, low levels of walking state and high levels of walking state. RESULTS: Compared with baseline, in the low levels of walking state subgroup, the percent LS BMD and FN BMD increased significantly by 12.8 ± 8.9% and 5.0 ± 13.8% at 24 months, respectively (p < 0.01 vs baseline for LS and FN, respectively); the mean absolute LS BMD and FN BMD change was 0.101 ± 0.067 g/cm2 and 0.017 ± 0.063 g/cm2 at 24 months, respectively. In the high levels of walking state subgroup, the percent LS BMD and FN BMD increased significantly by 13.4 ± 9.5% and 3.1 ± 7.8% at 24 months, respectively; the mean absolute LS BMD and FN BMD change was 0.104 ± 0.068 g/cm2 and 0.017 ± 0.042 g/cm2 at 24 months, respectively. The increases in percent and absolute BMD in LS and FN, and the changes in PINP and uNTX were similar between the subgroups. CONCLUSIONS: The efficacy of the daily teriparatide treatment is similar between low levels of walking state patients and high levels of walking state patients and was not influenced by immobilization levels.

Cortical thickness of the femur and long-term bisphosphonate use.

Femoral cortical thickening has been mentioned in reports of atypical subtrochanteric/femoral shaft (ST/FS) fractures, which are associated with long-term bisphosphonate (BP) use. However, whether thickening precedes BP use or results from BP use, as well as the role BPs may play in cortical thickening remain unclear. The purpose of this study was to investigate the relationship between cortical thickness and BP use. We enrolled 142 patients (mean age 79 years) who had taken BPs for more than 5 years, and enrolled 426 osteoporosis patients who had not used BPs as controls. We performed a case-control study of patients with long-term BP use and controls matched for age, sex, and levels of activities of daily living (ADLs) (1:3 ratio). On femoral radiographs, we measured femoral cortical thickness in three regions: 5 cm and 12.5 cm below the lesser trochanter and in the region of maximal cortical thickness. We compared cortical thicknesses between patients taking BP and controls and evaluated longitudinal changes in cortical thickness. There were no significant differences in cortical thickness between long-term BP users and controls. In addition, after further use of BP for a minimum of 1 year, we observed no significant differences in the changes in cortical thickness at any level of the femur. In conclusion, our study did not find evidence of cortical thickening at the ST/FS area of the femur with long-term BP use.

Determinants associated with bone mineral density increase in response to daily teriparatide treatment in patients with osteoporosis.

INTRODUCTION: Several factors associated with bone mineral density (BMD) increase are reported with daily teriparatide treatment, but there has been no systematic analysis to summarize these associations. The purpose of this study was to investigate the clinical determinants associated with BMD increase to daily teriparatide treatment. METHODS: This was a retrospective study. We performed an analysis of 306 patients diagnosed with osteoporosis. Teriparatide was administered at 20µg/day for 12months. The primary efficacy measure was a change in lumbar spine (LS) BMD from baseline at 12months. To determine the response variables of BMD changes, we investigated the clinical determinants using univariate and multivariate analyses. RESULTS: There was a 9.8±8.2% increase in LS BMD after 12months. Prior bisphosphonate treatment and baseline procollagen type I N-terminal propeptide (PINP) concentration were significantly associated with LS BMD absolute response by univariate analyses. In the multiple regression model, patients with higher baseline PINP concentration had a significantly greater LS BMD absolute increase. Prior bisphosphonate use lost its correlation in the multiple regression models. CONCLUSION: Our results showed that baseline PINP concentration was a useful predictor of LS BMD absolute increase regardless of prior treatment.

Primary Ewing sarcoma of the spine mimicking a psoas abscess secondary to spinal infection.

STUDY DESIGN: A case of primary Ewing sarcoma of the lumbar spine is presented. OBJECTIVE: To present and review a rare case of primary Ewing sarcoma of the lumbar spine that required differentiation from spinal infection. SUMMARY OF BACKGROUND DATA: Primary Ewing sarcoma originating from the spinal column is very rare. Because Ewing sarcoma is one of the most aggressive bone tumors with high proliferative and invasive potential, its clinical symptoms and variety of imaging manifestations can mimic the pathologic findings of other diseases, including infectious diseases. METHODS: The clinical course, radiologic features, pathology and treatment outcome of a patient with primary Ewing sarcoma of the lumbar spine was documented. RESULTS: The magnetic resonance imaging findings showed an abnormal marrow signal at the L2 vertebra and significant enlargement of the unilateral iliopsoas muscle. Immunologic and molecular analysis of the surgical specimen provided a diagnosis of Ewing sarcoma. Laminotomy followed by multidisciplinary therapy including chemotherapy and radiation therapy was effective for treating this case. CONCLUSION: We report a case of Ewing sarcoma that mimicked a psoas abscess secondary to spinal infection. Abnormal magnetic resonance imaging images, as well as a confusing clinical course, made diagnosis difficult. When enlargement of the iliopsoas with a vertebral lesion is detected in a child with low back pain, Ewing sarcoma should be included in the differential diagnosis.

Thoracic myelopathy with alkaptonuria.

STUDY DESIGN: A case of thoracic myelopathy with alkaptonuria (ochronotic spondyloarthropathy) is presented. OBJECTIVE: To present and review the first reported case of an alkaptonuric patient with concomitant thoracic myelopathy. SUMMARY OF BACKGROUND DATA: Alkaptonuria, a rare hereditary metabolic disease, is characterized by accumulation of homogentistic acid, ochronosis, and destruction of connective tissue resulting in degenerative spondylosis and arthritis. Despite the high incidence of intervertebral disc diseases among patients with alkaptonuria, neurologic symptoms caused by spinal disease are rare. Thoracic myelopathy in a patient with alkaptonuria has not been previously reported. METHODS: The clinical course, radiologic features, pathology, and treatment outcome of an alkaptonuria patient with thoracic myelopathy was documented. RESULTS: Myelopathy of the patient was caused by rupture of a thoracic intervertebral disc. The neurologic symptoms of the patient were markedly improved after surgery. CONCLUSION: We have reported for the first time, that an alkaptonuria patient showed thoracic myelopathy caused by rupture of a thoracic intervertebral disc. Decompression followed by the instrumented fusion of the thoracic spine was effective for improving the neurologic symptoms.