Systematic reduction of gray matter volume in anorexia nervosa, but relative enlargement with clinical symptoms in the prefrontal and posterior insular cortices: a multicenter neuroimaging study.

Although brain morphological abnormalities have been reported in anorexia nervosa (AN), the reliability and reproducibility of previous studies were limited due to insufficient sample sizes, which prevented exploratory analysis of the whole brain as opposed to regions of interest (ROIs). Objective was to identify brain morphological abnormalities in AN and the association with severity of AN by brain structural magnetic resonance imaging (MRI) in a multicenter study, and to conduct exploratory analysis of the whole brain. Here, we conducted a cross-sectional multicenter study using T1-weighted imaging (T1WI) data collected between May 2014 and February 2019 in Japan. We analyzed MRI data from 103 female AN patients (58 anorexia nervosa restricting type [ANR] and 45 anorexia nervosa binge-purging type [ANBP]) and 102 age-matched female healthy controls (HC). MRI data from five centers were preprocessed using the latest harmonization method to correct for intercenter differences. Gray matter volume (GMV) was calculated from T1WI data of all participants. Of the 205 participants, we obtained severity of eating disorder symptom scores from 179 participants, including 87 in the AN group (51 ANR, 36 ANBP) and 92 HC using the Eating Disorder Examination Questionnaire (EDE-Q) 6.0. GMV reduction were observed in the AN brain, including the bilateral cerebellum, middle and posterior cingulate gyrus, supplementary motor cortex, precentral gyrus medial segment, and thalamus. In addition, the orbitofrontal cortex (OFC), ventromedial prefrontal cortex (vmPFC), rostral anterior cingulate cortex (ACC), and posterior insula volumes showed positive correlations with severity of symptoms. This multicenter study was conducted with a large sample size to identify brain morphological abnormalities in AN. The findings provide a better understanding of the pathogenesis of AN and have potential for the development of brain imaging biomarkers of AN. Trial Registration: UMIN000017456. https://center6.umin.ac.jp/cgi-open-bin/icdr/ctr_view.cgi?recptno=R000019303 .

Comprehensive elucidation of resting-state functional connectivity in anorexia nervosa by a multicenter cross-sectional study.

BACKGROUND: Previous research on the changes in resting-state functional connectivity (rsFC) in anorexia nervosa (AN) has been limited by an insufficient sample size, which reduced the reliability of the results and made it difficult to set the whole brain as regions of interest (ROIs). METHODS: We analyzed functional magnetic resonance imaging data from 114 female AN patients and 135 healthy controls (HC) and obtained self-reported psychological scales, including eating disorder examination questionnaire 6.0. One hundred sixty-four cortical, subcortical, cerebellar, and network parcellation regions were considered as ROIs. We calculated the ROI-to-ROI rsFCs and performed group comparisons. RESULTS: Compared to HC, AN patients showed 12 stronger rsFCs mainly in regions containing dorsolateral prefrontal cortex (DLPFC), and 33 weaker rsFCs primarily in regions containing cerebellum, within temporal lobe, between posterior fusiform cortex and lateral part of visual network, and between anterior cingulate cortex (ACC) and thalamus (p < 0.01, false discovery rate [FDR] correction). Comparisons between AN subtypes showed that there were stronger rsFCs between right lingual gyrus and right supracalcarine cortex and between left temporal occipital fusiform cortex and medial part of visual network in the restricting type compared to the binge/purging type (p < 0.01, FDR correction). CONCLUSION: Stronger rsFCs in regions containing mainly DLPFC, and weaker rsFCs in regions containing primarily cerebellum, within temporal lobe, between posterior fusiform cortex and lateral part of visual network, and between ACC and thalamus, may represent categorical diagnostic markers discriminating AN patients from HC.

Middle cluneal nerve entrapment sites in the surgical field.

INTRODUCTION: Middle cluneal nerve (MCN) entrapment around the sacroiliac joint elicits low back pain (LBP). For surgical decompression to be successful, the course of the MCN must be known. We retrospectively studied the MCN course in 15 patients who had undergone MCN neurolysis. METHODS: Enrolled in this retrospective study were 15 patients (18 sides). We inspected their surgical records and videos to determine the course of the entrapped MCN. The area between the posterior superior- and the posterior inferior iliac spine was divided into areas A-D from the rostral side. The MCN transit points were identified at the midline and the lateral edge connecting the posterior superior- and posterior inferior iliac spine. Before and 6 months after surgery, the patients recorded the degree of LBP on the numerical rating scale and the Roland-Morris Disability Questionnaire. RESULTS: We decompressed 24 MCNs. The mean number was 1.3 nerves per patient (range 1-2). The MCN course was oblique in the cranio-caudal direction; the nerve tended to be observed in areas C and D. In six patients (40%), we detected two MCN branches, they were in the same area and adjacent. Postoperatively, LBP was improved significantly in all patients. CONCLUSION: Between the posterior superior- and the posterior inferior iliac spine, the MCN ran obliquely in the cranio-caudal direction; it was prominent in areas on the caudal side. In six (40%) patients, we decompressed two adjacent MCNs. Our findings are useful for MCN decompression surgery.

Associations of conservatism and jumping to conclusions biases with aberrant salience and default mode network.

AIM: While conservatism bias refers to the human need for more evidence for decision-making than rational thinking expects, the jumping to conclusions (JTC) bias refers to the need for less evidence among individuals with schizophrenia/delusion compared to healthy people. Although the hippocampus-midbrain-striatal aberrant salience system and the salience, default mode (DMN), and frontoparietal networks ("triple networks") are implicated in delusion/schizophrenia pathophysiology, the associations between conservatism/JTC and these systems/networks are unclear. METHODS: Thirty-seven patients with schizophrenia and 33 healthy controls performed the beads task, with large and small numbers of bead draws to decision (DTD) indicating conservatism and JTC, respectively. We performed independent component analysis (ICA) of resting functional magnetic resonance imaging (fMRI) data. For systems/networks above, we investigated interactions between diagnosis and DTD, and main effects of DTD. We similarly applied ICA to structural and diffusion MRI to explore the associations between DTD and gray/white matter. RESULTS: We identified a significant main effect of DTD with functional connectivity between the striatum and DMN, which was negatively correlated with delusion severity in patients, indicating that the greater the anti-correlation between these networks, the stronger the JTC and delusion. We further observed the main effects of DTD on a gray matter network resembling the DMN, and a white matter network connecting the functional and gray matter networks (all P < 0.05, family-wise error [FWE] correction). Function and gray/white matter showed no significant interactions. CONCLUSION: Our results support the novel association of conservatism and JTC biases with aberrant salience and default brain mode.

Tissue damage between barbed suture and conventional sutures in animal laboratory model using scanning electron microscopy.

This study aimed to compare the tissue damage caused by barbed sutures and conventional sutures using scanning electron microscopy (SEM). Porcine myocardium was incised and sutured using different thread types: barbed suture, (STRATAFIX® Spiral PDS PLUS) and conventional sutures, (VICRYL® and PDS Plus®). Needle hole shapes were examined at magnifications of 30×-100×. VICRYL® suture damaged the tissue and created large gaps around the needle holes. The tissue around the needle holes was smoother and less damaged in the single suture ligations with PDS®; however, a large gap had formed. In the continuous suture with STRATAFIX®, the tissue around the needle holes was significantly smoother and minimally damaged, with no noticeable gaps around the needle holes. Barbed sutures reduced the load on needle holes and minimised tissue damage owing to the dispersion of traction forces by the barbs compared with conventional sutures.

Long-term outcome after surgery for middle cluneal nerve entrapment neuropathy.

PURPOSE: Entrapment of the middle cluneal nerve (MCN-E) can elicit low back pain (LBP). Patients whose LBP responds only transiently to the analgesic effects of MCN blockage may be candidates for surgery. This study addresses its long-term efficacy. METHODS: We initially subjected 34 MCN-E patients (48 sides) to surgical release. Of these, 4 were excluded from this study because their follow-up was shorter than 24 months. The mean age of the 30 included patients was 71.5 years; the mean postoperative follow-up period was 40.4 months. Clinical outcomes were assessed on the Numerical Rating Scale (NRS) for LBP and the Roland Morris Disability Questionnaire (RDQ) before surgery and at the latest follow-up visit. RESULTS: The 30 patients (44 sides) reported severe LBP, leg symptoms were elicited by 32 sides. A mean of 1.4 MCN branches were surgically released, 32 sides were addressed by neurolysis, 7 by neurectomy, and 5 underwent both procedures due to the presence of 2 nerve branches. There were no complications. In the course of a mean follow-up of 26.3 months, MCN-E elicited recurrent symptoms on 6 sides; all had undergone neurolysis or neurectomy and a second operation improved the symptoms. All patients showed significant improvement at the last follow-up visit. Postoperatively both their NRS for LBP and their RDQ scores were improved (pre- vs. postoperative scores, p < 0.05). CONCLUSIONS: While surgical release of MCN-E is expected to yield long-term symptom relief, on 6 of 32 sides (18.8%) treated by neurolysis the patients reported pain recurrence. Whether neurectomy effectively prevents the recurrence of MCN-E in the long term requires further study.

Dual Antiplatelet Therapy Using Cilostazol With Aspirin or Clopidogrel: Subanalysis of the CSPS.com Trial.

Background and Purpose: Although dual antiplatelet therapy (DAPT) with aspirin and clopidogrel reduces the recurrence of ischemic stroke while significantly increasing the bleeding events compared with monotherapy, the CSPS.com trial (Cilostazol Stroke Prevention Study combination) showed that DAPT using cilostazol was more effective without the bleeding risk. In the CSPS.com trial, aspirin or clopidogrel was used as the underlying antiplatelet drug. The effectiveness and safety of each combination were examined and clarified. Methods: In the CSPS.com trial, a multicenter, open-label, randomized controlled study, patients with high-risk, noncardioembolic ischemic stroke 8 to 180 days after onset treated with aspirin or clopidogrel alone at the discretion of the physician in charge were recruited. Patients were randomly assigned to receive either monotherapy or DAPT using cilostazol and followed for 0.5 to 3.5 years. The primary efficacy outcome was first recurrence of ischemic stroke. The safety outcome was severe or life-threatening bleeding. The analysis was based on the underlying antiplatelet agents. Results: A total of 763 patients taking aspirin and 1116 taking clopidogrel were included in the intention-to-treat analysis. Although the clopidogrel group had more risk factors than the aspirin group, the primary efficacy outcome and safety outcome did not differ significantly between the 2 groups. In the aspirin group, the primary efficacy outcome and safety outcome did not differ significantly between the DAPT group and the aspirin-monotherapy group. In the clopidogrel group, the primary end point occurred at a rate of 2.31 per 100 patient-years in the DAPT group and 5.19 per 100 patient-years in the clopidogrel-monotherapy group (hazard ratio, 0.447 [95% CI, 0.258­0.774]). Safety outcome did not differ significantly between groups (0.51 per 100 patient-years versus 0.71 per 100 patient-years, respectively; hazard ratio, 0.730 [95% CI, 0.206­2.588]). Conclusions: The combination of cilostazol and clopidogrel significantly reduced the recurrence of ischemic stroke without increasing the bleeding risk in noncardioembolic, high-risk patients. Registration: URL: https://www.clinicaltrials.gov; Unique identifier: NCT01995370. URL: https://www.umin.ac.jp/ctr/; Unique identifier: UMIN000012180.

Set-shifting-related basal ganglia deformation as a novel familial marker of obsessive-compulsive disorder.

The symptoms of obsessive-compulsive disorder (OCD) are suggestive of cognitive rigidity, and previous work identified impaired flexible responding on set-shifting tasks in such patients. The basal ganglia are central to habit learning and are thought to be abnormal in OCD, contributing to inflexible, rigid habitual patterns of behaviour. Here, we demonstrate that increased cognitive inflexibility, indexed by poor performance on the set-shifting task, correlated with putamen morphology, and that patients and their asymptomatic relatives had common curvature abnormalities within this same structure. The association between the structure of the putamen and the extradimensional errors was found to be significantly familial in OCD proband-relative pairs. The data implicate changes in basal ganglia structure linked to cognitive inflexibility as a familial marker of OCD. This may reflect a predisposing heightened propensity toward habitual response patterns and deficits in goal-directed planning.

Clinical features of middle cluneal nerve entrapment neuropathy.

BACKGROUND: Entrapment of the middle cluneal nerve (MCN), a peripheral nerve in the buttock, can elicit low back pain (LBP). We examined the epidemiology, clinical course, and treatment of MCN entrapment (MCN-EN). METHODS: Among 383 LBP patients who visited our institute, 105 were admitted for intractable LBP. They were 42 men and 63 women; their average age was 64 years. Based on clinical symptoms, palpation, and the effects of MCN block, we suspected MCN-EN in these 105 patients, 50 of whom are our study subjects. Their treatment outcomes were assessed at the time of discharge and at follow-up visits. RESULTS: MCN-EN was diagnosed in 50 of the 383 patients (13.1%) and they were hospitalized. In 43 (11.2%), MCN-EN was associated with other diseases (superior cluneal nerve entrapment, n = 21, sacroiliac joint pain, n = 9, other, n = 13). At the time of discharge, the symptoms of patients with LBP due to MCN-EN were significantly improved by repeat MCN blocks. In 7 of the 383 patients (1.8%), LBP was improved by only MCN blocks; 5 of them had reported leg symptoms in the dorsal part of the thigh. After discharge, 22 of the 50 hospitalized patients required no additional treatments after 2-5 blocks; 19 required only conservative treatment, and 9 underwent microsurgical release of the MCN. CONCLUSIONS: We confirmed MCN-EN in 50 of 105 patients admitted for intractable LBP. Repeat MCN blocks were effective in 22 patients; 19 required additional conservative treatment, and 9 underwent surgery. Buttock pain radiating to the posterior thigh was an MCN-EN symptom that has been diagnosed as pseudo-sciatica. Before subjecting patients with intractable LBP to surgery, the presence of MCN-EN must be ruled out.

Correlation between the number of laparoscopy-qualified gynecologists and the proportion of laparoscopic surgeries for benign gynecological diseases in Japan: An ecological study.

AIM: We aimed to evaluate regional disparities in the proportion of the three main laparoscopic surgeries for benign gynecological diseases among 47 prefectures in Japan and their correlation with the number of laparoscopy-qualified gynecologists per population. METHODS: In this retrospective ecological study, we collected the data of patients from 47 prefectures in 2017 using "The National Database of Health Insurance Claims and Specific Health Checkups of Japan" Open Data from the Ministry of Health, Labor and Welfare in Japan. The primary outcome of the study was the proportion of laparoscopic surgeries conducted for benign gynecologic diseases (hysterectomy, myomectomy and surgery for the benign ovarian diseases). The main exposure was the number of laparoscopy-qualified gynecologists per 100 000 females. RESULTS: The average proportion of laparoscopic hysterectomies, myomectomies and surgeries for the benign ovarian disease were 38% (standard deviation (SD) 16, range 12-74), 48% (SD 18, range 9-81) and 60% (SD 11, range 36-79), respectively. Multiple regression analysis showed a significant correlation between the number of laparoscopy-qualified gynecologists per 100 000 females and the proportion of the three main laparoscopic surgeries. CONCLUSION: There are obvious regional disparities in the proportion of the three main laparoscopic procedures for benign gynecological diseases among 47 prefectures. The number of laparoscopy-qualified gynecologists correlated significantly with these regional disparities. The academic society should monitor these regional disparities and make an effort to reduce these regional disparities by increasing laparoscopy-qualified gynecologists in areas where the widespread use of laparoscopic techniques is lagging.

The number of overall hysterectomies per population with the perimenopausal status is increasing in Japan: A national representative cohort study.

AIM: This study aimed to investigate the trends in overall hysterectomy and other alternative therapies for benign uterine diseases per population aged 40-54 years in Japan. METHODS: We conducted a national representative cohort study in Japan. We obtained data from 'The National Database of Health Insurance Claims and Specific Health Checkups of Japan' Open Data. The primary outcome was the number of overall hysterectomies for benign gynecologic diseases per population aged 40-54 years, from 2014 to 2017 in Japan. The secondary outcome was the number of alternative surgical and drug therapies to hysterectomy per population. We also analyzed the correlation between the number of laparoscopy-qualified gynecologists and the number of overall hysterectomies per population among 47 prefectures in 2017. RESULTS: The number of overall hysterectomies for benign gynecological diseases per 100 000 females aged 40-54 years gradually increased from 320 in 2014 to 344 in 2017 (7.5% increase overall). Moreover, there was a significant increase in the use of levonorgestrel intrauterine systems. We could not explain the reason for this increase in the rate of overall hysterectomies by summarizing the increase or decrease of alternative therapies to hysterectomy. Multiple regression analysis showed a significant correlation between the number of laparoscopy-qualified gynecologists and the number of overall hysterectomies among 47 prefectures. CONCLUSION: Despite the spread of alternative therapies to hysterectomy, there was an increasing trend for overall hysterectomies in Japan. The reason was not clear but may be related to the spread of laparoscopic hysterectomy.

Abnormalities of striatal morphology in gambling disorder and at-risk gambling.

OBJECTIVE: The clinical phenotype of gambling disorder (GD) is suggestive of changes in brain regions involved in reward and impulse suppression, notably the striatum. Studies have yet to characterize striatal morphology (shape) in GD and whether this may be a vulnerability marker. AIMS: To characterize the morphology of the striatum in those with disordered gambling (at-risk gambling and GD) versus controls. METHOD: Individuals aged 18-29 years were classified a priori into those with some degree of GD symptoms (at-risk gambling and GD) or controls. Exclusion criteria were a current mental disorder (apart from GD), history of brain injury, or taking psychoactive medication within 6 weeks of enrollment. History of any substance use disorder was exclusionary. Participants completed an impulsivity questionnaire and structural brain scan. Group differences in volumes and morphology were characterized in subcortical regions of interest, focusing on the striatum. RESULTS: Thirty-two people with GD symptoms (14 at-risk and 18 GD participants) and 22 controls completed the study. GD symptoms were significantly associated with higher impulsivity and morphological alterations in the bilateral pallidum and left putamen. Localized contraction in the right pallidum strongly correlated with trait impulsivity in those with GD symptoms. CONCLUSIONS: Morphologic abnormalities of the striatum appear to exist early in the disease trajectory from subsyndromal gambling to GD and thus constitute candidate biological vulnerability markers, which may reflect differences in brain development associated with trait impulsivity. Striatal morphology and associated impulsivity might predispose to a range of problematic repetitive behaviors.

Middle cluneal nerve entrapment mimics sacroiliac joint pain.

BACKGROUND: Sacroiliac joint (SIJ)-related pain is associated with low back- and buttock pain and the SIJ score is diagnostically useful because it helps to differentiate between SIJ-related pain and pain due to other factors such as lumbar disc herniation and lumbar spinal canal stenosis. Middle cluneal nerve (MCN) entrapment (MCN-E) can produce pain involving the lower back and buttocks. Therefore, the origin of the pain must be identified. We successfully treated patients with a high SIJ score whose pain was attributable to MCN-E. METHODS: Between August 2016 and June 2017, we treated 40 patients with non-specific low back pain. Among them, 18 (45%) presented with a positive SIJ score. Although SIJ treatment was unsuccessful in 4 of these patients, they responded to MCN-E treatment. RESULTS: All 4 patients reported tenderness at the site of the sacrotuberous ligament (STL); 3 were positive for the one-finger test and experienced pain while sitting in a chair. The effect of SIJ block was inadequate in the 4 patients. As they reported severe pain at the trigger point in the area of the MCN, we performed MCN blockage. It resulted in pain control. However, in 1 patient, the effect of MCN block was transient and required MCN neurolysis. At the last visit, our patients' symptoms were significantly improved; their average numerical rating scale score fell from 8.3 to 1.0, their Roland-Morris Disability Questionnaire score fell from 12.8 to 0.3, and their average Japanese Orthopaedic Association score rose from 12.5 to 19.5. CONCLUSIONS: In patients with suspected SIJ-related pain, the presence of MCN-E must be considered when the effect of SIJ block is unsatisfactory.

Gluteus medius muscle decompression for buttock pain: a case-series analysis.

BACKGROUND: The causes of low back and buttock pain are variable. Elsewhere, we presented a surgical technical note addressing the gluteus medius muscle (GMeM) pain that elicited buttock pain treatable by surgical decompression. Here, we report minimum 2-year surgical outcomes of GMeM decompression for intractable buttock pain. METHODS: Between January 2014 and December 2015, we surgically treated 55 consecutive patients with a GMeM pain. Of these, 39 were followed for at least 2 years; they were included in this study. Their average age was 69.2 years; 17 were men and 22 were women. The affected side was unilateral in 24 patients and bilateral in the other 15 (total 54 sites). The mean follow-up period was 40.0 months (range 25-50 months). The severity of pre- and post-treatment pain was recorded on the numerical rating scale (NRS) and the Roland-Morris Disability Questionnaire (RDQ). RESULTS: Of the 39 patients, 35 also presented with leg symptoms. They were exacerbated by walking in all 39 patients and by prolonged sitting in 33 patients; 19 had a past history of lumbar surgery and 4 manifested failed back surgery syndrome. Repeat surgery for wider decompression was performed in 5 patients due to pain recurrence 15.8 months after the first operation. At the last follow-up, the symptoms were significantly improved; the average NRS fell from 7.4 to 2.1 and the RDQ score from 10.5 to 3.3 (p < 0.05). CONCLUSIONS: When diagnostic criteria are met, GMeM decompression under local anesthesia is a useful treatment for intractable buttock pain.

A Case of Juvenile Stroke due to Carotid Artery Dissection from an Elongated Styloid Process-Revisiting Conservative Management.

Carotid artery dissection is a significant etiology of juvenile stroke. Blunt trauma from an elongated styloid process can rarely cause carotid artery dissection, which is one of well-known clinical presentations of Eagle's syndrome as known as stylocarotid syndrome. Growing number of publications contributed improved awareness and diagnostic modalities for this clinical entity, thus the carotid artery dissection from an elongated styloid process is often diagnosed appropriately. The management of carotid artery dissection in stylocarotid syndrome tends to be nonconservative (ie, removal of the process or carotid stenting) presumably due to a publication bias prone to surgical intervention. However, the compression of elongated styloid process to carotid artery is usually difficult or even dangerous to directly prove. Furthermore, stent fracture with subsequent stent and carotid artery occlusion has been reported as a complication of the treatment. Here, we report a male presenting with acute embolic stroke due to carotid artery dissection with the ipsilateral elongated styloid process who has been managed conservatively for more than 1.5 years without any sequelae. We will discuss the management strategy and emphasize the importance of patient education of daily life, since the surgical intervention seems not always necessary in this clinical setting.

Low back pain due to superior cluneal nerve entrapment: A clinicopathologic study.

INTRODUCTION: We studied the clinical and nerve pathologic features in 6 patients whose low back pain (LBP) was relieved by superior cluneal nerve (SCN) neurectomy to determine whether nerve compression was the mechanism underlying this type of LBP. METHODS: All 6 patients (7 nerves) underwent SCN neurectomy for intractable LBP. Their clinical outcomes and the pathologic features of 7 nerves were reviewed. RESULTS: All patients reported LBP relief immediately after SCN neurectomy. Pathologic study of the 7 resected nerves showed marked enlargement, decreased myelinated fiber density, an increase in thinly myelinated fibers (n = 2), perineurial thickening (n = 5), subperineurial edema (n = 4), and Renaut bodies (n = 4). At the distal end of 1 enlarged nerve, we observed a moderate reduction in the density and marked reduction in the number of large myelinated fibers. DISCUSSION: The pathologic findings and effectiveness of neurectomy suggest that, in our patients, SCN neuropathy likely elicited LBP via nerve compression. Muscle Nerve 57: 777-783, 2018.

The Safety and Effectiveness of Abdominal Radical Trachelectomy for Early-Stage Cervical Cancer During Pregnancy.

OBJECTIVES: Cervical cancer is one of the most frequently diagnosed cancers in pregnancy. Our aim was to evaluate the safety and efficacy of abdominal radical trachelectomy (ART) for pregnant women with early-stage cervical cancer who strongly desire to preserve their pregnancies. METHODS/MATERIALS: A retrospective observational study was performed for stage IB1 cervical cancer patients who underwent ART or radical hysterectomy (RH) at our hospital between February 2013 and June 2017. We compared differences in perioperative findings and oncologic outcomes among ART during pregnancy (ART-DP), ART, and RH groups. RESULTS: A total of 38 patients were included in this analysis. Six, 10, and 22 patients were assigned to the ART-DP, ART, and RH groups, respectively. There were no significant differences in the distribution of pathological TNM classifications, histology, tumor size, stromal invasion, and lymph-vascular space invasion among the 3 groups. The patients in the ART-DP group were younger than those in the RH group (P = 0.014). The ART-DP group was associated with more blood loss and prolonged surgery compared with the RH group (P = 0.017 and P = 0.014). The number of total lymph nodes in the ART-DP group was lower than that in the RH group (P = 0.036). However, there were no significant differences in age, surgical time, blood loss, or lymph node count between the ART-DP and ART groups. There were no significant differences in progression-free and overall survival times among the 3 groups, and no recurrence was observed in the ART-DP group. CONCLUSIONS: Abdominal radical trachelectomy may be a tolerable treatment option for pregnant women with early-stage cervical cancer who strongly desire a baby.

Low back pain due to middle cluneal nerve entrapment neuropathy.

PURPOSE: The etiology of low back pain (LBP) is complicated and the diagnosis can be difficult. Superior cluneal nerve entrapment neuropathy (SCN-EN) is a known cause of LBP, although the middle cluneal nerve (MCN) can be implicated in the elicitation of LBP. METHODS: A 76-year-old woman with a 4-year history of severe LBP was admitted to our department in a wheelchair. She complained of bilateral LBP that was exacerbated by lumbar movement. Her pain was severe on the right side and she also suffered right leg pain and numbness. Based on palpation and nerve blocking findings we diagnosed SCN-EN and MCN entrapment neuropathy (MCN-EN). RESULTS: Her symptoms improved with repeated SCN and MCN blocking; the MCN block was the more effective and her symptoms improved. As her right-side pain around the MCN -EN with severe trigger pain recurred we performed microscopic right MCN neurolysis under local anesthesia. This led to dramatic improvement of her LBP and leg pain and the numbness improved. At the last follow-up, 7 months after surgery, she did not require pain medication. CONCLUSIONS: The MCN consists of sensory branches from the dorsal rami of S1-S4. It sandwiches the sacral ligament between the posterior superior and inferior iliac spine as it courses over the iliac crest. Its entrapment at this hard orifice can lead to severe LBP with leg symptoms. An MCN block effect is diagnostically useful. Less invasive MCN neurolysis under local anesthesia is effective in patients who fail to respond to observation therapy.

Effect of phase-encoding direction on group analysis of resting-state functional magnetic resonance imaging.

AIM: Echo-planar imaging is a common technique used in functional magnetic resonance imaging (fMRI); however, it suffers from image distortion and signal loss because of large susceptibility effects that are related to the phase-encoding direction of the scan. Despite this relation, the majority of neuroimaging studies has not considered the influence of phase-encoding direction. Here, we aimed to clarify how phase-encoding direction can affect the outcome of an fMRI connectivity study of schizophrenia (SCZ). METHODS: Resting-state fMRI using anterior to posterior (A-P) and posterior to anterior (P-A) directions was used to examine 25 patients with SCZ and 37 matched healthy controls (HC). We conducted a functional connectivity (FC) analysis using independent component analysis and performed three group comparisons: (i) A-P versus P-A (all participants); (ii) SCZ versus HC for the A-P and P-A datasets; and (iii) the interaction between phase-encoding direction and participant group. RESULTS: The estimated FC differed between the two phase-encoding directions in areas that were more extensive than those where signal loss has been reported. Although FC in the SCZ group was lower than that in the HC group for both directions, the A-P and P-A conditions did not exhibit the same specific pattern of differences. Further, we observed an interaction between participant group and the phase-encoding direction in the left temporoparietal junction and left fusiform gyrus. CONCLUSION: Phase-encoding direction can influence the results of FC studies. Thus, appropriate selection and documentation of phase-encoding direction will be important in future resting-state fMRI studies.

[Treatment Results of Low Back and Leg Pain Considering Para-Lumbar Spine Disease and Peripheral Nerve Neuropathy].

INTRODUCTION: Here we report our treatment results of low back and leg pain(LBLP)considering para-lumbar spine disease(PLSD)and peripheral nerve neuropathy(PNN). MATERIALS AND METHODS: We enrolled 103 patients who were admitted to our institute for LBLP treatment between January and December in 2014. For the treatment, we preferentially performed intensive block therapy for PLSD. RESULT: Among 103 patients, 89 patients had PLSD. In 85 patients, we performed intensive block therapy and 82 patients experienced short-term improvement of symptoms. In 35 of these 82 patients, lumbar spine and/or PNN surgical treatment was required as the effect of block therapy was transient. Intensive block therapy was effective in 47 of 103 patients(45.6%), and the remaining patients required surgical treatment(PLSD and/or PNN:31 cases, lumbar spine:13 cases, both:8 cases). CONCLUSION: Among 103 patients with LBLP, intensive block therapy for PLSD and PNN was useful for short-term symptom improvement in 82 patients(79.6%), and for long-term symptom improvement in 47 patients(45.6%)as evaluated at the final follow-up. Surgical treatment of PLSD and/or PNN was required in 39 patients(37.9%). These results suggested that treatment of PLSD and PNN might yield good results for patients with LBLP.