Radiographic knee osteoarthritis severity has no impact on fall risk: the locomotive syndrome and health outcomes in the aizu cohort study (LOHAS): a cross-sectional study.

BACKGROUND: To investigate factors that have an impact on the risk of falls and determine whether radiographic knee osteoarthritis (KOA) is a factor involved in falls independent of knee pain, psychological factors, and physical function. METHODS: A cross-sectional analysis was conducted on 1083 subjects for the 2009 Locomotive Syndrome and Health Outcomes in the Aizu Cohort Study (LOHAS). A logistic regression analysis was performed to examine the relationship between radiographic KOA and fall history. RESULTS: Fall history was significantly associated with the severity of knee pain. Compared to subjects with no knee pain, the odds ratio (OR) was 1.53 times higher in the subjects with mild knee pain (95% confidence interval [CI]: 1.04-2.25), 1.69 times higher in those with moderate knee pain (95%CI: 1.03-2.79), and 2.98 times higher in those with severe knee pain (95%CI: 1.67-5.30). In subjects with depression, the OR was 1.91 (95%CI: 1.25-2.92), and in those with decreased mobility, the OR was 1.70 (95%CI: 1.08-2.69). Age, gender, knee crepitus, BMI, OLST, and sleeping pill use were not significantly associated with fall risk. In a multivariate analysis, radiographic KOA severity was not significantly associated with fall risk (OR 0.81, 95%CI 0.44-1.50 in mild OA; OR 1.10, 95%CI 0.57-2.14 in severe OA). CONCLUSION: Knee pain, decreased mobility, and depression, but not the radiographic KOA severity, were significantly associated with a fall risk. Regardless of the individual's radiographic KOA severity, the risk of falls may be reduced by treating his/her knee pain, mobility problems, and/or psychological factors.

Time Course of Asymptomatic Stenosis in Multiple Lumbar Spinal Stenosis-Five-Year Results of Selective Decompression of Symptomatic Levels.

Background: In the diagnosis of lumbar spinal stenosis (LSS), finding stenosis with magnetic resonance imaging (MRI) does not always correlate with symptoms such as sciatica or intermittent claudication. We perform decompression surgery only for cases where the levels diagnosed from neurological findings are symptomatic, even if multiple stenoses are observed on MRI. The objective of this study was to examine the time course of asymptomatic stenosis in patients with LSS after they underwent decompression surgery for symptomatic stenosis. Materials and Methods: The participants in this study comprised 137 LSS patients who underwent single-level L4-5 decompression surgery from 2003 to 2013. The dural sac cross-sectional area at the L3-4 disc level was calculated based on preoperative MRI. A cross-sectional area less than 50 mm2 was defined as stenosis. The patients were grouped, according to additional spinal stenosis at the L3-4 level, into a double group (16 cases) with L3-4 stenosis, and a single group (121 cases) without L3-4 stenosis. Incidences of new-onset symptoms originating from L3-4 and additional L3-4-level surgery were examined. Results: Five years after surgery, 98 cases (72%) completed follow-up. During follow-up, 2 of 12 patients in the double group (16.7%) and 9 of 86 patients in the single group (10.5%) presented with new-onset symptoms originating from L3-4, showing no significant difference between groups. Additional L3-4 surgery was performed for one patient (8.3%) in the double group and three patients (3.5%) in the single group; again, no significant difference was shown. Conclusion: Patients with asymptomatic L3-4 stenosis on preoperative MRI were not prone to develop new symptoms or need additional L3-4-level surgery within 5 years after surgery when compared to patients without preoperative L3-4 stenosis. These results indicate that prophylactic decompression for asymptomatic levels is unnecessary.

Lumbar spinal stenosis is a risk factor for the development of dementia: locomotive syndrome and health outcomes in the Aizu cohort study.

PURPOSE: It remains unclear whether musculoskeletal diseases are risk factors for dementia development. This prospective cohort study of community-dwelling residents aimed to clarify the impact of lumbar spinal stenosis (LSS) on dementia development. METHODS: We included participants aged ≥ 65 years from the Locomotive Syndrome and Health Outcomes in the Aizu cohort study. LSS was diagnosed using the validated LSS diagnostic support tool. Dementia development between 2008 and 2015 was investigated using official long-term care insurance certification data. We analysed the effects of LSS on dementia development after adjusting for potential confounders, like age, sex, diabetes, depressive symptoms, hip and knee joint osteoarthritis, daily activity, and smoking habit. RESULTS: We included 1220 patients in the final analysis. The incidence of dementia was significantly higher in the LSS group [48 of 444 (10.8%)] than in the control group [34 of 776 (4.4%)]. Multivariable analysis using multiple imputations revealed that the confidence interval for the adjusted odds ratio of LSS for dementia development was 1.87 (95% confidence interval; 1.14-3.07). CONCLUSION: We clarified that LSS is an independent risk factor for dementia development. Our findings suggest the importance of considering the risk of dementia in the decision-making process for the treatment of LSS.

Generalization of a clinical diagnosis support tool for lumbar spinal stenosis: Can the ankle brachial pressure index be replaced by palpation of the posterior tibial artery in the lumbar spinal stenosis diagnostic support tool? (DISTO project).

BACKGROUND: The Japanese Society for Spine Surgery and Related Research previously developed a diagnostic support tool for lumbar spinal stenosis (LSS-DST). Using the LSS-DST, general physicians can identify potential cases of LSS. However, in the LSS-DST, measurement of the ankle brachial pressure index (ABI) is required to exclude peripheral artery lesions in the lower limbs. We can expect further application of the LSS-DST if we can identify a simpler and easier method than ABI measurement. Therefore, in this large-scale, multicenter, cross-sectional study, we verified whether palpation of the posterior tibial (PT) artery could be used instead of ABI in the LSS-DST. METHODS: This survey was conducted at 2177 hospitals and included 28,883 participants. The sensitivity and specificity of the original LSS-DST method using the ABI and that of the LSS-DST ver2.0 with PT artery palpation were assessed to screen their ability for diagnosing LSS, using the physicians' final diagnosis based on the patients' history, physical examination and radiographic findings as the gold standard. RESULTS: The sensitivity and specificity [95%CI] of the LSS-DST were 88.2% [87.5, 88.8] and 83.9% [83.4, 84.5], respectively, whereas the sensitivity and specificity of the LSS-DST ver2.0 were 87.7% [87.0, 88.3] and 78.3% [77.7, 78.9], respectively, indicating that LSS-DST ver2.0 is a useful screening tool for LSS with good sensitivity. CONCLUSION: When the item of ABI in the LSS-DST is replaced by palpation of the PT artery (LSS-DST ver2.0), its sensitivity is maintained as a screening tool for LSS. LEVEL OF EVIDENCE: Level 3.

Gender differences on preoperative psychologic factors affecting acute postoperative pain in patients with lumbar spinal disorders.

BACKGROUND: Psychosexual factors are one of the preoperative factors influencing acute postoperative pain. Because of gender differences in pain, the preoperative factors that influence acute postoperative pain may also differ between males and females. However, there have been no reports on such factors in patients with spinal disorders that focused on gender differences. Therefore, the purpose of this study was to examine the preoperative factors that influence acute postoperative pain, focusing on gender differences. METHODS: The subjects were 75 males and 60 females admitted for surgery for lumbar spinal disorders. Preoperatively, the following were assessed: low back pain using the Numeric Rating Scale (NRS); anxiety and depression using the Japanese version of the Hospital Anxiety and Depression Scale (HADS); catastrophic thinking using the Pain Catastrophizing Scale (PCS); psychiatric problems using the Brief Scale for Psychiatric Problems in Orthopaedic Patients (BS-POP); and neurological assessments. Acute postoperative pain was also assessed using the NRS within 48 h, postoperatively. Based on these data, we analyzed gender differences in preoperative factors affecting acute postoperative pain in patients with lumbar spinal disorders. RESULTS: Postoperative NRS and preoperative PCS scores were higher in females compared to males. In the males, the coefficient of determination of the multiple regression equation was 0.088, and PCS (ß = 0.323, p = 0.015) was extracted as a significant factor. In the females, the coefficient of determination of the multiple regression equation was 0.075, and BS-POP (ß = 0.300, p = 0.019) was extracted as a significant factor. CONCLUSION: Preoperative factors influencing acute postoperative pain for patients with lumbar spinal disorders vary by gender. It was suggested that males should be screened using PCS. In females, on the other hand, PCS alone is not sufficient for evaluation. It was suggested that evaluation using BS-POP should be considered in addition to PCS.

Formulation of Japanese Orthopaedic Association (JOA) clinical practice guideline for the management of low back pain- the revised 2019 edition.

BACKGROUND: The latest clinical guidelines are mandatory for physicians to follow when practicing evidence-based medicine in the treatment of low back pain. Those guidelines should target not only Japanese board-certified orthopaedic surgeons, but also primary physicians, and they should be prepared based entirely on evidence-based medicine. The Japanese Orthopaedic Association Low Back Pain guideline committee decided to update the guideline and launched the formulation committee. The purpose of this study was to describe the formulation we implemented for the revision of the guideline with the latest data of evidence-based medicine. METHODS: The Japanese Orthopaedic Association Low Back Pain guideline formulation committee revised the previous guideline based on a method for preparing clinical guidelines in Japan proposed by Medical Information Network Distribution Service Handbook for Clinical Practice Guideline Development 2014. Two key phrases, "body of evidence" and "benefit and harm balance" were focused on in the revised version. Background and clinical questions were determined, followed by literature search related to each question. Appropriate articles were selected from all the searched literature. Structured abstracts were prepared, and then meta-analyses were performed. The strength of both the body of evidence and the recommendation was decided by the committee members. RESULTS: Nine background and nine clinical qvuestions were determined. For each clinical question, outcomes from the literature were collected and meta-analysis was performed. Answers and explanations were described for each clinical question, and the strength of the recommendation was decided. For background questions, the recommendations were described based on previous literature. CONCLUSIONS: The 2019 clinical practice guideline for the management of low back pain was completed according to the latest evidence-based medicine. We strongly hope that this guideline serves as a benchmark for all physicians, as well as patients, in the management of low back pain.

Usefulness of Lateral Lumbar Interbody Fusion Combined with Indirect Decompression for Degenerative Lumbar Spondylolisthesis: A Systematic Review.

Background and Objective: The aim of this review was to analyze the existing literature and investigate the outcomes or complications of lateral lumbar interbody fusion (LLIF) combined with indirect decompression for degenerative lumbar spondylolisthesis (DS). Materials and Methods: A database search algorithm was used to query MEDLINE, COCHRANE, and EMBASE to identify the literature reporting LLIF with indirect decompression for DS between January 2010 and December 2021. Improvements in outcome measures and complication rates were pooled and tested for significance. Results: A total of 412 publications were assessed, and 12 studies satisfied the inclusion criteria after full review. The pooled data available in the included studies showed that 438 patients with lumbar spondylolisthesis (mean age 65.2 years; mean body mass index (BMI) 38.1 kg/m2) underwent LLIF. A total of 546 disc spaces were operated on. The most frequently treated levels were L4-L5 and L3-L4. Clinically, the average improvement was 32.5% in ODI, 46.3 mm in low back pain, and 48.3 mm in leg pain estimated from the studies included. SF-36 PCS improved by 51.5% and MCS improved by 19.5%. For radiological outcomes, a reduction in slippage was seen in 6.3%. Disc height increased by 55%, foraminal height increased by 21.1%, the foraminal area on the approach side increased by 21.9%, and on the opposite side it increased by 26.1%. The cross-sectional spinal canal area increased by 20.6% after surgery. Post-operative complications occurred in 5-40% of patients with thigh symptoms, such as anterior thigh numbness, dysesthesia, discomfort, pain, and sensory deficits. Conclusions: Indirect decompression by LLIF for DS is an effective method for improving pain and dysfunction with less surgical invasion. In addition, it has the effect of significantly improving disc height, foraminal height and area, and segmental lordosis on radiological outcomes compared to the posterior approach.

Minimally Invasive Spinal Treatment (MIST)-A New Concept in the Treatment of Spinal Diseases: A Narrative Review.

In the past two decades, minimally invasive spine surgery (MISS) techniques have been developed for spinal surgery. Historically, minimizing invasiveness in decompression surgery was initially reported as a MISS technique. In recent years, MISS techniques have also been applied for spinal stabilization techniques, which were defined as minimally invasive spine stabilization (MISt), including percutaneous pedicle screws (PPS) fixation, lateral lumbar interbody fusion, balloon kyphoplasty, percutaneous vertebroplasty, cortical bone trajectory, and cervical total disc replacement. These MISS techniques typically provide many advantages such as preservation of paraspinal musculature, less blood loss, a shorter operative time, less postoperative pain, and a lower infection rate as well as being more cost-effective compared to traditional open techniques. However, even MISS techniques are associated with several limitations including technical difficulty, training opportunities, surgical cost, equipment cost, and radiation exposure. These downsides of surgical treatments make conservative treatments more feasible option. In the future, medicine must become "minimally invasive" in the broadest sense-for all patients, conventional surgeries, medical personnel, hospital management, nursing care, and the medical economy. As a new framework for the treatment of spinal diseases, the concept of minimally invasive spinal treatment (MIST) has been proposed.

Dose-response relationship between spino-pelvic alignment determined by sagittal modifiers and back pain-specific quality of life.

PURPOSE: To determine whether abnormalities of the sagittal modifiers (SMs) of the Scoliosis Research Society (SRS)-Schwab classification truly reflect back pain (BP)-specific quality of life (QOL), it is necessary to examine their dose-response relationships and to determine clinically impactful thresholds for declines in BP-specific QOL. This study aimed to analyse the continuous dose-response relationship between each SM and BP-specific QOL. METHODS: This cross-sectional study, using data from a Japanese population-based cohort study, included 519 community-dwelling residents aged ≥ 50 years who participated in the annual health examination. The participants completed the Roland-Morris Disability Questionnaire (RDQ) on BP-specific QOL. Spino-pelvic alignment based on SMs was assessed by whole-spine X-ray examinations. We fitted general linear models with or without nonlinear terms to estimate the dose-response relationship between each SM and BP-specific QOL. RESULTS: Pelvic tilt, pelvic incidence minus lumbar lordosis (PI-LL), and sagittal vertical axis showed dose-response relationships with BP-specific QOL measured as the RDQ score. PI-LL was most likely to predict a minimally clinically important RDQ score when its value exceeded the 90th percentile. A nonlinear relationship between PI-LL and the BP-specific QOL score was found. RDQ increased when PI-LL exceeded 10°. CONCLUSION: PI-LL might be the most sensitive of the three modifiers of the SRS-Schwab classification for determining BP-specific QOL. Moreover, BP-specific QOL worsens rapidly when the compensatory mechanism against malalignment exceeds a critical value. Therefore, we suggest that traditional classifications and surgical strategies should be re-examined regarding the dose-dependent abnormalities of the SMs to develop a more reliable classification strategy.

Sagittal imbalance and symptoms of depression in adults: Locomotive Syndrome and Health Outcomes in the Aizu Cohort Study (LOHAS).

PURPOSE: With spinal deformities, mental health can deteriorate due to sagittal imbalance of the spine. The purpose of this study was to clarify the relationship between sagittal imbalance and symptoms of depression among local residents in the community. METHODS: This study used data from the Locomotive Syndrome and Health Outcomes in Aizu Cohort Study (LOHAS) in 2010. The sagittal vertical axis (SVA) was identified as an indicator of sagittal imbalance. Symptoms of depression were assessed using the 5-item version of the Mental Health Inventory. Participants were classified into three categories based on the SVA balance as normal (< 40 mm), moderate imbalance (40-95 mm), and severe imbalance (> 95 mm). To evaluate the relationship between sagittal imbalance of the spine and symptoms of depression, the adjusted risk ratio (RR) and the 95% confidence interval (CI) were calculated using a generalized linear model with Poisson link. RESULTS: There were 786 participants included in the statistical analysis. Overall, the mean age was 68.1 y (standard deviation, 8.8 y), and 39.4% were men. The prevalence of symptoms of depression by SVA category was 18.6% for normal, 23.8% for moderate, and 40.6% for severe. On multivariate analysis, the RR of SVA for symptoms of depression compared to the normal category was 1.12 (95% CI 0.7-1.70) for the moderate category and 2.29 (95% CI 1.01-5.17) for the severe category. CONCLUSION: In local community residents, sagittal imbalance had a significant association with symptoms of depression.

Development of a severity discrimination scale based on physical quality of life for patients with chronic pain.

BACKGROUND: Deterioration of quality of life in patients with chronic pain is difficult to treat. Chronic pain in patients with low quality of life may be "severe" and require multidisciplinary treatments. This study aimed to develop an objective severity discrimination scale based on quality of life measurements to identify patients with "severely disabling" chronic pain. METHODS: Subjects were 156 patients with chronic pain whose numerical rating pain score was ≥1 and who had pain for ≥3 months. Diseases associated with chronic pain included spinal diseases, joint diseases, concomitant diseases, complex regional pain syndromes, and other musculoskeletal diseases. Patients were divided into low, middle, and high groups based on physical quality of life summary scores on the Short Form-36. The mental component summary, painDETECT, Japanese version of the Pain Catastrophizing Scale, Brief Scale for Psychiatric Problems in Orthopaedic Patients, and factors related to degree/quality of pain during the past 4 weeks were analyzed to identify components in the low group. The score weighting factor for discriminating between the high and low groups was determined by discriminant analysis. RESULTS: Factor analysis identified 4 factors representing features of chronic pain patients with low QOL: enhanced perception of pain, pain catastrophic thoughts, depressive sleep disorder, and pain intensity. For discriminant analysis, patients were defined as those with low physical quality of life if each factor's total score multiplied by a factor plus a constant value of 2.6 was ≥0, and high quality of life if it was <0. The receiver operating characteristic curve area used to determine the cut-off value was 0.71, with 67.3% sensitivity and specificity. CONCLUSIONS: We developed a 33-question severity discrimination scale to define "severely disabling" chronic pain based on physical quality of life. "Severely disabling" patients identified on this scale could represent chronic pain patients needing focused multidisciplinary treatment.

The Change of Lumbar Spinal Stenosis Symptoms over a Six-Year Period in Community-Dwelling People.

Background and Objectives: The high prevalence of lumbar spinal stenosis (LSS) and its negative impact on quality of life in the elderly is well known. However, the longitudinal time course of LSS symptoms remains unclear. The purpose of this study was to clarify the longitudinal time course and associated factors of LSS symptoms over a period of six years in a community. Materials and Methods: This study was conducted with data prospectively collected in 2004 and 2010 under a retrospective design. In 2004, 1578 subjects (age range: 40 to 79 years) were interviewed on LSS symptoms using a specially designed and validated questionnaire. In 2010, a follow-up study was performed by mail, to which 789 subjects of the 2004 study population responded. Considering that the presence of osteoarthritis (OA) of the knee or hip may influence the participants' answers in the questionnaire, analysis was performed in all 789 subjects with and 513 subjects without either knee or hip OA. Changes in LSS symptoms between the initial and the 6-year survey were investigated. Multiple logistic regression analysis was used for detecting the risk factors for LSS symptom presence at the six-year follow-up. Results: 1. At the six-year follow-up, more than half of the subjects who showed LSS symptoms at the initial analysis became LSS-negative, and 12-15% of those who were LSS-negative became LSS-positive. 2. From the multiple logistic regression analysis, a lower Roland-Morris Disability Questionnaire (RDQ) score and a positive LSS symptom at the initial analysis were detected as predictive factors of the presence of LSS symptoms at the six-year follow-up in the total number of subjects, as well as just in those who did not have either knee or hip OA. Conclusions: More than half of the subjects who were LSS-positive at their initial assessment still experienced improvement in their symptoms even after 6 years. This means that both LSS symptoms and their time course vary from person to person. Predictive factors for the presence of LSS symptoms during the six-year follow-up period were RDQ score and positive LSS symptoms.

Reference values of the Japanese Orthopaedic Association Back Pain Evaluation Questionnaire in patients with lumbar spinal stenosis and characteristics of deterioration of QOL: Lumbar Spinal Stenosis Diagnosis Support Tool: DISTO project.

BACKGROUND: The reference values of the Japanese Orthopaedic Association Back Pain Evaluation Questionnaire (JOABPEQ) in patients with lumbar spinal stenosis (LSS) are still unknown. This multicenter cross-sectional survey was performed to determine the reference values and disease-specific characteristics of deterioration of QOL caused by LSS itself, not by aging, through comparison of patients with and without LSS who had an outpatient visit for low back pain by age and sex groups. METHODS: The present study was performed at 564 medical centers and clinics. The JOABPEQ was measured for 8338 patients aged 20 years or over who came to an outpatient clinic for low back pain (LBP) and were examined for whether they had LSS using the LSS diagnosis support tool (LSS-DST). Scores in the five JOABPEQ domains were compared between the LSS group and the LBP without LSS group (LBP group) for each age and sex group. RESULTS: Scores for Pain-related disorder, Gait disturbance, Social life disturbance, and Psychological disorders were significantly lower in the LSS group than in the LBP group. CONCLUSION: The percentiles of JOABPEQ scores in patients with LSS were clarified and could be used as reference values. Deterioration of QOL caused by LSS itself, not by aging, are characterized by Pain-related disorder, Gait disturbance, Social life disturbance, and Psychological disorders.

Correction to: Attenuation of cortical activity triggering descending pain inhibition in chronic low back pain patients: a functional magnetic resonance imaging study.

Inadvertently, the Fig. 7 was published incorrectly in the original publication of the article. The correct figure should be as below.

Bowel/bladder dysfunction and numbness in the sole of the both feet in lumbar spinal stenosis - A multicenter cross-sectional study.

BACKGROUND: Numbness in the soles of both feet at rest or bowel/bladder dysfunction can occur in patients with lumbar spinal stenosis (LSS), especially in patients with cauda equina lesions. The purpose of this study was to clarify the relationship between cauda equina symptoms at rest and quality of life (QOL) in LSS patients using standardized questionnaires developed for the Japanese population. METHODS: A survey was conducted in 564 hospitals and general practice clinics nationwide from December 1, 2011 to December 31, 2012. All patients who visited hospital or clinic because of low back pain were included. Patients were diagnosed with LSS using the LSS-Diagnostic Support Tool (LSS-DST), and the severity of the disease was measured using the Japanese Orthopaedic Association Back Pain Evaluation Questionnaire (JOABPEQ) for quality of life. Presence of both sole numbness and/or bowel/bladder dysfunction were determined by medical interview. 3647 patients were diagnosed with LSS according to the results of the LSS-DST. 1294 of these patients (35.5%) had symptoms at rest. Of these patients, 359 patients with sole numbness, 135 patients with bowel/bladder dysfunction, and 52 patients with both numbness and bowel/bladder dysfunction were compared to the patients without rest symptoms (n = 2182). Comparisons between groups with or without sole numbness and bowel/bladder dysfunction were performed using statistical analysis of JOABPEQ responses in the categories of pain-related disorder, lumbar spine disorder, gait disturbance, social life disturbance, and psychological disorder. RESULTS: All groups with sole numbness and/or bowel/bladder dysfunction had statistically lower (worse) scores in all categories of the JOABPEQ compared to the group without these symptoms at rest. CONCLUSION: LSS patients having numbness in the soles of both feet at rest or bowel/bladder dysfunction had lower measurements of QOL and activities of daily living than those patients without symptoms at rest. These symptoms appear to be related to QOL of LSS patients.

Attenuation of cortical activity triggering descending pain inhibition in chronic low back pain patients: a functional magnetic resonance imaging study.

PURPOSE: A considerable portion of chronic low back pain (cLBP) patients lack anatomical abnormality, resist conventional therapeutic interventions, and their symptoms are often complicated with psychological and social factors. Such patients have been reported to show cerebral abnormalities both in anatomy and function by neuroimaging studies. Here we examined differences in cerebral reactivity to a simulated low back pain stimulus between cLBP patients and healthy controls by functional magnetic resonance imaging (fMRI), and their behavioral correlates from a psychophysical questionnaire. METHODS: Eleven cLBP patients and 13 healthy subjects (HS) were enrolled in this study. After psychophysical evaluation on-going pain with McGill Pain Questionnaire Short Form (MPQ), they underwent whole-brain fMRI in a 3-Tesla MRI scanner while receiving three blocks of 30-s mechanical pain stimuli at the left low back with a 30-s rest in between, followed by a three-dimensional anatomical imaging. Functional images were analyzed with a multi-subject general linear model for blood oxygenation level-dependent (BOLD) signal changes associated with pain. Individual BOLD signal amplitudes at activated clusters were examined for correlation with psychophysical variables. Two in the cLBP and five data sets in the HS groups were excluded from analysis because of deficient or artifactual data or mismatch in age. RESULTS: The HS group showed LBP-related activation at the right insular cortex, right dorsolateral prefrontal cortex (DLPFC), left anterior cingulate cortex (ACC), and left precuneus; and deactivation in a large area over the parietal and occipital cortices, including the bilateral superior parietal cortex. On the other hand, the cLBP group did not show any significant activation at those cortical areas, but showed similar deactivation at the bilateral superior parietal cortex and part of the premotor area. An HS > cLBP contrast revealed significantly less activity at the ACC and DLPFC in the cLBP group, which was negatively correlated with higher MPQ scores. CONCLUSIONS: The cLBP patients showed attenuated reactivity to pain at the ACC and DLPFC, known cortical areas mediating affective component, and top-down modulation, of pain. The present results might be associated with possible dysfunction of the descending pain inhibitory system in patients with chronic low back pain, which might possibly play a role in chronification of pain.

Relationship between lumbar spinal stenosis and psychosocial factors: a multicenter cross-sectional study (DISTO project).

INTRODUCTION: Lumbar spinal stenosis (LSS) is a lumbar spinal disorder that causes leg symptoms and intermittent claudication. It is reported that the risk factors for low back pain include age, family history, smoking, obesity, work-related physical load, exercise, and depression. This was a multicenter, cross-sectional survey, and the aim of this study was to investigate the prevalence of LSS by age and the relationships between LSS and psychosocial factors and job satisfaction. METHODS: This study enrolled subjects aged 50 years and over from a survey of LSS in 2177 hospitals and general practices nationwide. The clinical characteristics of the LSS and non-LSS groups were compared using the χ2 test, and the multivariate logistic regression analysis was performed to examine associations between exercise, perceived stress, strenuous use of the low back or legs, job satisfaction, and LSS. RESULTS: In total, 18,642 patients (8338 males, 10,267 females) were analyzed. The rate of LSS was 38.3% and it increased with age. Regular exercise was less common among those in the LSS group than those in the non-LSS group (p<0.001). Satisfaction in all job-related items was less in the LSS group than in the non-LSS group (p<0.001). The odds for having LSS were higher in subjects having perceived stress and strenuous use of the low back or legs (p=0.001). The odds ratios of heart diseases and hypertension (p<0.001) were higher in the LSS group. CONCLUSION: This study investigated factors associated with LSS. The prevalence of LSS increased with age. Perceived stress and strenuous use of the low back or legs might be associated with LSS, and job satisfaction was lower with LSS.

Diagnostic accuracy of the Self-administered, Self-reported History Questionnaire for lumbar spinal stenosis patients in Japanese primary care settings: a multicenter cross-sectional study (DISTO-project).

BACKGROUND: Diagnostic support tools for lumbar spinal stenosis such as the Self-administered, Self-reported History Questionnaire have been developed in Japan, but no report has demonstrated the diagnostic accuracy of this questionnaire in Japanese primary care settings. This multicenter, cross-sectional survey was performed to evaluate and improve the diagnostic accuracy of this questionnaire for lumbar spinal stenosis patients in Japanese primary care settings. METHODS: The lumbar spinal stenosis diagnosis support tool project was conducted in 1657 hospitals to evaluate the diagnostic accuracy of the Self-administered, Self-reported History Questionnaire in Japan from 2011 to 2012. Consecutive adults (≥50 years old) from physicians, including non-orthopedic general practitioners and orthopedic general practitioners, were considered for enrollment. Consecutive adults (≥50 years old) with low back pain from hospital-based orthopedic surgeons were also considered for enrollment. The diagnostic accuracy of the Self-administered, Self-reported History Questionnaire with initial and several new cutoff points in classifying patients according to the presence of lumbar spinal stenosis was assessed in terms of sensitivity, specificity and negative predictive values. RESULTS: Among the 33,545 patients, 10,199 (30.4 %) were diagnosed with lumbar spinal stenosis by the physicians. The Self-administered, Self-reported History Questionnaire version 1.1 with a new cutoff point was more sensitive than the Self-administered, Self-reported History Questionnaire version 1.0 with the initial cutoff point (79.8 vs. 68.3 %) and less specific (68.8 vs. 75.1 %) for lumbar spinal stenosis diagnosis. The respective negative predictive values were 88.5 and 84.3 %. CONCLUSIONS: The Self-administered, Self-reported History Questionnaire version 1.1 with the new cutoff was more sensitive and had higher negative predictive value than version 1.0 with the initial cutoff. Therefore, the improved Self-administered, Self-reported History Questionnaire version 1.1 can be used for lumbar spinal stenosis screening, and its use may improve the quality of lumbar spinal stenosis diagnostic practice in Japanese primary care settings.

Atypical Fracture of the Scapular Spine: A Case Report.

Atypical fractures are gaining attention as a severe potential side effect of long-term treatment with bone-modifying agents (e.g., bisphosphonate and denosumab) for osteoporosis. Most atypical fractures occur in weight-bearing bones; the femur is the most frequent site. Atypical fractures occurring in non-weight-bearing bones are extremely rare. We describe an atypical fracture of the scapular spine in a 92-year-old Japanese woman with osteoporosis who had been treated with minodronate for ~7 years. Although the dislocation of the fracture site remained after conservative treatment, there was no obstacle to her daily life.

Thoracic spinal epidural hematoma misdiagnosed as conversion paralysis: A case report.

A woman with a history of psychiatric hospitalization was misdiagnosed with conversion paralysis despite lower extremity paralysis due to a thoracic epidural hematoma, leaving her with severe neurological deficits. Conversion paralysis is a diagnosis of exclusion and should never be made unless all possible organic causes have been ruled out.