Mapping the Japanese orthopedic association national registry (JOANR) to the international classification of health interventions (ICHI).

BACKGROUND: The Japanese Orthopedic Association launched the Japanese Orthopedic Association National Registry (JOANR), Japan's first large-scale nationwide musculoskeletal disease registry, in 2020. The World Health Organization released the International Classification of Health Interventions (ICHI) Beta-3 version in the same year. This concurrence served as an impetus to examine the relationship between domestic and international classification for orthopedic interventions. Our objective was to evaluate the possibility of utilizing JOANR for international comparison and the potential usage of ICHI in the domestic medical fee reimbursement system. This study is a novel attempt at mapping a domestic orthopedic scheme to the ICHI. METHODS: We mapped 149 codes out of 581 orthopedic surgical codes, on JOANR's registration form, to the ICHI, and then classified the nature of JOANR codes' relationship, to both ICHI single stem codes and stem codes accompanied by other additional stem codes, extension codes, and International Classification of Diseases for Mortality and Morbidity Statistics (ICD) codes, into five categories: Equivalent (exact match), Narrower (compared to ICHI; can be smoothly incorporated into ICHI), Broader (compared to ICHI), Slipped (combination of both Narrower and Broader), and None (no appropriate code). Finally, debatable issues that arose during the mapping operation were noted. RESULTS: The domestic codes' relationship to ICHI single stem code by category were Equivalent: 27 (18.1%) and Narrower: 65 (43.6%), respectively. Further, the rate of Equivalent rose to 120 (80.5%) on adding other stem codes, extension codes, and ICD codes. Additionally, certain domestic titles, which were unsuitable for classification as they included diagnostic information, and arthroscopic surgeries without corresponding ICHI codes, were recoded. CONCLUSIONS: JOANR can be converted to an international comparison standard via ICHI to a certain extent, and ICHI accompanied by ICD codes has potential for deployment in the domestic medical fee reimbursement system.

Analysis of the relationship between spinal alignment and retrocrural space area in adult spinal deformity surgery: Potential risk factors for acute celiac artery compression syndrome.

PURPOSE: This study was designed to reveal the association between spinal parameters and RCS area in patients with adult spinal deformities treated with spinal correction surgery. We hypothesized that reduction of the retrocrural space (RCS) area is related to thoracolumbar alignment, which may cause acute celiac artery compression syndrome (ACACS). METHODS: Eighty-nine patients (age: 68.4 ± 7.6 years; sex: 7 male/82 female) with ASD treated by spinal correction surgery were enrolled. Preoperative and postoperative spinal parameters were measured, and the differences between these parameters were calculated. Postoperative T12 translation was measured and RCS area was evaluated using reconstructed computed tomography. The change of RCS area after surgery was defined as ΔRCS. Patients were divided into increased and decreased RCS groups by the ΔRCS value, and spinal parameters were compared between groups. The correlation between spinal parameters and ΔRCS was calculated. RESULTS: The patients in the decreased RCS group had greater anterior T12 translation than those in the increased RCS group (p < 0.001). T12 translation was significantly correlated with ΔRCS (ß = -0.31, p = 0.017). There were no correlations between ΔRCS and other spinal parameters. CONCLUSION: Thoracolumbar alignment was associated with RCS area. Consistent with the hypothesis, overcorrection of the thoracolumbar junction was associated with reduced RCS area and might be one risk factor for ACACS.

Does vacuum phenomenon at non-fused discs affect the postoperative course after transforaminal lumbar interbody fusion in patients showing a positive value of difference in lumbar lordosis?

INTRODUCTION: Preoperative difference in lumbar lordosis (DiLL) was associated with surgical outcomes after single-level transforaminal lumbar interbody fusion (TLIF). Patients with DiLL>0 (DiLL (+)) tended to show worse clinical outcomes and postoperative greater restoration of lumbar lordosis (LL). However, some patients with DiLL (+) showed relatively good outcomes and no postoperative LL restration. This study aimed to elucidate whether the lumbar intervertebral disc vacuum phenomenon (VP) influences clinical course after single-level TLIF in patients with DiLL (+) and DiLL (-). METHODS: Patients with lumbar spinal stenosis and degenerative spondylolisthesis treated with single-level TLIF were included. Pre- and postoperative LL were measured, and postoperative LL improvement was calculated. Preoperative DiLL was calculated as preoperative supine LL minus standing LL. Severity of VP at the non-fused discs (SVP (non-FS)) was evaluated using preoperative reconstructed computed tomography imaging. Clinical outcomes were assessed using the Oswestry disability index, visual analogue scale (VAS; low back pain (LBP), lower-extremity pain, numbness, and the Japanese Orthopaedic Association Back Pain Evaluation Questionnaire. Patients were stratified by the median preoperative SVP (non-FS) score into severe and mild VP groups in patients with DiLL (+) or DiLL (-), and their surgical outcomes were compared. RESULTS: Overall, 89 patients were included. In patients with DiLL (+) (n = 37), patients with severe VP showed worse clinical outcomes, particulary for LBP and DiLL (+) patients with mild VP showed greater LL improvement (6.5° ± 10.0°). In patients with DiLL(-) (n = 52), patients with severe VP showed worse clinical outcomes, particularly for LBP and no differences in preoperative, postoperative, and improvement of LL were observed between two groups. CONCLUSION: Patients with DiLL (+) and DiLL (-) showed different clinical courses depending on VP severity at the non-fused discs after single-level TLIF.

Quantitative evaluation of the lumbar ligamentum flavum using MRI T2-mapping: Efficacy of its clinical application in patients with lumbar spinal stenosis.

OBEJECTIVE: To perform a magnetic resonance imaging T2-mapping of the ligamentum flavum in healthy individuals and patients with lumbar spinal stenosis scheduled for surgery and compare the T2 relaxation times. SUBJECTS AND METHODS: The T2 relaxation time of the ligamentum flavum was compared among 3 groups, healthy young individuals (H group (age< 50)), healthy middle-aged and older individuals (H group (age≥50)), and patients with lumbar spinal stenosis (L group). Additionally, the thickness of the ligament was measured in the axial image plane, and the occupied area ratio of each fiber was measured by staining the surgically obtained ligament, and each was correlated with the T2 relaxation time. We also evaluated the adhesion of the ligamentum flavum with the dura mater during the surgery. RESULTS: The T2 relaxation times were significantly prolonged in H group (age ≥50) and L group (P < 0.001) compared to H group (age<50). The relationship between collagen fiber and T2 relaxation times was significantly positive (r = 0.720, P < 0.001). Moreover, the relaxation times were significantly prolonged in those with adhesion of the ligamentum flavum with the dura mater (P < 0.05). The cut-off for the relaxation time was 50 ms (sensitivity: 62.50%, false positive rate: 10.8%). CONCLUSION: Healthy middle-aged and older individuals and patients with lumbar spinal stenosis and adhesion of the ligamentum flavum with the dura mater have prolonged T2 relaxation times. Hence, the adhesion between the ligamentum flavum and dura mater should be considered in cases with a relaxation time ≥50 ms.

Characteristics and comparative study of thoracolumbar spine injury and dislocation fracture due to tertiary trauma.

PURPOSE: Thoracolumbar spine injury is frequently seen with high-energy trauma but dislocation fractures are relatively rare in spinal trauma, which is often neurologically severe and requires urgent treatment. Therefore, it is essential to understand other concomitant injuries when treating dislocation fractures. The purpose of this study is to determine the differences in clinical features between thoracolumbar spine injury without dislocation and thoracolumbar dislocation fracture. METHODS: We conducted an observational study using the Japan Trauma Data Bank (2004-2019). A total of 734 dislocation fractures (Type C) and 32,382 thoracolumbar spine injuries without dislocation (Non-type C) were included in the study. The patient background, injury mechanism, and major complications in both groups were compared. In addition, multivariate analysis of predictors of the diagnosis of dislocation fracture using logistic regression analysis were performed. RESULTS: Items significantly more frequent in Type C than in Non-type C were males, hypotension, bradycardia, percentage of complete paralysis, falling objects, pincer pressure, accidents during sports, and thoracic artery injury (P < 0.001); items significantly more frequent in Non-type C than in Type C were falls and traffic accidents, head injury, and pelvic trauma (P < 0.001). Logistic regression analysis showed that younger age, male, complete paralysis, bradycardia, and hypotension were associated with dislocation fracture. CONCLUSION: Five associated factors were identified in the development of thoracolumbar dislocation fractures. LEVEL OF EVIDENCE: III.

Associated factors and effects of coronal vertebral wedging angle in thoracic adolescent idiopathic scoliosis.

BACKGROUND: Adolescent idiopathic scoliosis (AIS) causes vertebral wedging, but associated factors and the impact of vertebral wedging are still unknown. We investigated associated factors and effects of vertebral wedging in AIS using computed tomography (CT). METHODS: Preoperative patients (n = 245) with Lenke types-1 and 2 were included. Vertebral wedging, lordosis, and rotation of the apical vertebra were measured by preoperative CT. Skeletal maturity and radiographic global alignment parameters were evaluated. Multiple regression analysis was performed on associated factors for vertebral wedging. Side-bending radiographs were evaluated using multiple regression analysis to calculate the percentage of reduction of Cobb angles to determine curve flexibility. RESULTS: The mean vertebral wedging angle was 6.8 ± 3.1°. Vertebral wedging angle was positively correlated with proximal thoracic (r = 0.40), main thoracic (r = 0.54), and thoracolumbar/lumbar curves (r = 0.38). By multiple regression, the central sacral vertical line (p = 0.039), sagittal vertical axis (p = 0.049), main thoracic curve (p = 0.008), and thoracolumbar/lumbar curve (p = 0.001) were significant factors for vertebral wedging. In traction and side-bending radiographs there were positive correlations between curve rigidity and the vertebral wedging angle (r = 0.60, r = 0.59, respectively). By multiple regression, thoracic kyphosis (p < 0.001), lumbar lordosis (p = 0.013), sacral slope (p = 0.006), vertebral wedging angle (p = 0.003), and vertebral rotation (p = 0.002) were significant factors for curve flexibility. CONCLUSIONS: Vertebral wedging angle was found to be highly correlated to coronal Cobb angle, with larger vertebral wedging indicating less flexibility.

Deaths caused by osteoporotic fractures in Japan: An epidemiological study.

BACKGROUND: Osteoporosis is a global issue with a worldwide prevalence of 18.3%, and the presence of coexisting fragility fractures can reduce the survival rate by approximately 20%. In Japan, the prevalence of osteoporosis is estimated to be 12.8 million, and the annual occurrence of hip fractures is approximately 193,400. Remarkably, coexisting hip or spinal fragility fractures caused by slight external force meet the Japanese diagnostic criterion for osteoporosis regardless of bone mineral density. However, only 191 deaths due to osteoporosis were published in 2021 in Japan. With the concern that some cases of hip and spinal fragility fractures were assigned an underlying cause of death of traumatic fracture instead of osteoporosis, this study aimed to elucidate the actual number of deaths due to osteoporosis in Japan. METHODS: We used the data from Japan in 2018. First, the number of deaths due to osteoporosis and hip or spinal fractures was reviewed using published vital statistics. Second, we calculated the number of elderly deaths (age ≥80 years) resulting from hip or spinal fractures caused by falls on the same level using data from approximately 1.4 million annual individual death certificates. Combining the above data, the actual number of deaths due to osteoporosis was estimated. RESULTS: Only 190 deaths due to osteoporosis were reported in the published data. The individual certificate data revealed 3437 elderly deaths due to hip or spinal fractures caused by falls on the same level, which could meet the criteria of osteoporotic fragility fractures. Accordingly, the estimated number of deaths caused by osteoporosis was calculated as 3,627, approximately 19 times the published value. CONCLUSIONS: After researching the individual death certificate data focusing on the coexisting hip or spinal fragility fracture, it was implied that osteoporosis may have a higher mortality rate in Japan than what is published.

Risk factors for celiac artery and superior mesenteric artery stenosis in preoperative lumbar and thoracolumbar spinal surgery patients.

BACKGROUND: Ischemic necrosis of the abdominal organs caused by compression of the celiac artery (CA) and superior mesenteric artery (SMA) by the median arcuate ligament (MAL) after correction surgery has been recognized as acute celiac artery compression syndrome (ACACS). Here, using contrast-enhanced computed tomographic (CT) images, we sought to determine the prevalence and degree of CA and SMA stenosis in spinal patients preoperatively, and the risk factors associated with the stenosis. METHODS: We retrospectively examined contrast-enhanced abdominal CT of 90 patients with preoperative lumbar degenerative disease, lumbar burst fracture, or adult spinal deformity. The trunks of the CA and SMA were detected using three-dimensional reconstructed CT. To investigate their degree of stenosis, we determined the ratio of the narrowest diameter of the stenotic segment to the distal normal lumen's diameter. Patients with a degree of stenosis ≥35% were defined as being in the group with stenosis and the remainder as in the group without. To determine the risk factors for stenosis of these arteries, the relationship between the stenosis and CA and SMA calcification or the median arcuate ligament (MAL) crossing the proximal portion of the celiac axis (MAL overlap) was also investigated. RESULTS: The average degree of stenosis of the CA trunk was 12.1% ± 13.9% and that for the SMA trunk was 8.5% ± 8.8%. There were 8 patients (8.9%) in the group with CA stenosis and 2 patients (2.2%) in the group with SMA stenosis. The number of patients in the group with CA stenosis was significantly greater than the number with MAL overlap or CA calcification (P < 0.05). DISCUSSION: The prevalence of CA or SMA stenosis was 11.2% of preoperative patients due to undergo thoracolumbar fusion surgery. Calcifications of the CA trunk and MAL overlap are risk factors for CA stenosis.

Postoperative change in lumbopelvic alignment after short-segment transforaminal lumbar interbody fusion is related to preoperative postural difference in lumbar lordosis.

BACKGROUND: Postoperative changes in lumbar lordosis (LL) after transforaminal lumbar interbody fusion (TLIF) and the related factors are not well-understood. Recently, the preoperative difference in LL between standing and supine positions (DiLL) was proposed as a factor for predicting postoperative radiologic outcomes after short-segment TLIF. This study investigated the influence of DiLL on mid-term radiological outcomes after short-segment TLIF. METHODS: Sixty-six patients with lumbar degenerative disease treated with short-segment TLIF (1-2 levels) who underwent lumbar spine standing radiographs at 3 months, 6 months, 1 year, 2 years, 3 years, 4 years, and 5 years postoperatively were divided into DiLL (+) and DiLL (-) groups (preoperative DiLL ≥0° and <0°, respectively). Associations between the postoperative change in LL and DiLL and clinical outcomes (Oswestry disability index (ODI) and Nakai score) were evaluated. RESULTS: Temporary restoration of LL (+4.5°) until 1 year postoperatively and a subsequent decrease in LL from 1 to 5 years postoperatively (-5.3°) was observed in the DiLL (+) group. No postoperative change in LL was observed in the DiLL (-) group. Postoperative changes in LL were mainly observed in non-fused segments. The postoperative change in LL (ΔLL) until 1 year postoperatively had a significant positive association with DiLL (p = 0.00028), whereas ΔLL from 1 to 5 years postoperatively showed a significant negative association with DiLL (p = 0.010) and a positive association with Nakai score (p = 0.028). ΔLL until 5 years postoperatively showed a significant positive association with postoperative ODI improvement (p = 0.011). CONCLUSIONS: DiLL (+) patients showed a specific time course with temporary LL restoration until 1 year postoperatively and a subsequent decrease in LL from 1 to 5 years postoperatively. Patients with larger postoperative increase in LL until 5 years postoperatively and lesser decrease in LL from 1 to 5 years postoperatively tended to show better mid-term clinical outcomes.

Frozen vein wrapping for chronic nerve constriction injury reduces sciatic nerve allodynia in a rat model.

BACKGROUND: Autologous vein wrapping (VW) is used in the treatment of recurrent chronic constriction neuropathy and traumatic peripheral nerve injury. However, use of autologous veins is limited by the inability to obtain longer veins of sufficient length for larger sites. Frozen allograft tissue has several advantages, including its availability for large grafts, avoidance of donor-site morbidity, and shorter operation time. Here, we investigated the effect of frozen vein wrapping (FVW) in Wistar rats as a model of sciatic nerve injury. RESULTS: The rats were grouped by treatment as (i) untreated after chronic constriction injury surgery (CCI; control group), (ii) treated with vein wrapping using freshly isolated vein (VW), and (iii) treated with vein wrapping using frozen vein (FVW). Mechanical allodynia was assessed with von Frey filaments on postoperative days (PODs) 1, 3, 5, 7, and 14. Gene expression of HO-1 was evaluated by quantitative polymerase chain reaction (qPCR). The response of heme oxygenase-1 gene, Hmox-1, expression to VW and FVW was assessed by RT-PCR. Both VW and FVW significantly increased withdrawal threshold levels compared to the untreated control group on POD 1, 3, and 5. Both VW and FVW also showed increased HO-1 expression compared to the CCI group. CONCLUSIONS: FVW increased the withdrawal threshold similar to VW in a rat CCI model for short periods. Frozen vein wrapping using vein allograft without donor site morbidity may be an alternative therapeutic option.

A 2-year longitudinal study of skeletal muscle mass in women over 40 years of age with degenerative lumbar scoliosis.

PURPOSE: We investigated changes in skeletal muscle mass and bone mineral density in degenerative lumbar scoliosis (DLS) patients during a 2-year follow-up following diagnosis. METHOD: This study included 418 Japanese women, identifying 50 patients for the DLS group (mean age 76.4 years) and 368 patients for the control group (mean age 73.4 years). Whole-body skeletal muscle mass was measured using a Bioelectrical Impedance Analyzer. Bone mineral density (BMD) was measured using DXA. Skin autofluorescence (SAF), a marker of advanced glycation end products in the skin, was measured using a spectroscope. Spinal alignment, skeletal muscle mass, BMD, grip strength, and SAF were examined and the amount of change 1 and 2 years from the initial examination for each item was compared between groups. RESULTS: Height, body fat mass, grip strength, upper limb muscle mass, and trunk muscle mass in the DLS group were significantly lower, and lumbar spine BMD was significantly greater compared to controls at the first visit (p < 0.05). There was no significant difference in spinal alignment in the DLS group after 2 years compared with baseline. Trunk muscle mass also decreased significantly more in the DLS group (-2.7%) than in the control group (-1.1%) over the 2-year follow-up (p < 0.05). DISCUSSION: In this study, trunk muscle mass in the DLS group decreased about 2.4 times more in 2 years compared with the control group (p < 0.05). It may be possible to clarify the mechanism of kyphoscoliosis progression in the future with large-scale longitudinal studies.

MRI T2-mapping of lumbar facet joints is effective for quantitative evaluation of lumbar instability in patients with degenerative lumbar disorders.

PURPOSES: To analyze T2 relaxation times of the facet joint by MRI T2-mapping in patients with degenerative lumbar disorders (DLD), and to determine the correlation with lumbar instability in radiographs. METHODS: We conducted a T2-mapping of the lumbar facet joint using a 1.5 T MRI system. We classified patients with degenerative lumbar disorders scheduled to undergo decompression surgery into groups with stability and instability using radiographs, and compared the T2 relaxation times of the lumbar facet. Lumbar instability was defined as the presence of anterior translation ratio > 5% or disk range of motion (ROM) > 5° in the sagittal plane of SLFE radiographs. RESULTS: Inclusion criteria were met by 22 patients (45 levels, mean age 64.3 years). Facet effusions had high sensitivity (90%) but had low specificity (28%) for diagnosis of lumbar instability. Mean T2 relaxation times of right and left facet joints are significantly longer (98.4 ms) in the instability group than they are (87.6 ms) in the stability group (p < 0.001). Anterior translation ratio was positively correlated with mean T2 relaxation times of facet joint (R2 = 0.493, p < 0.05). From a ROC analysis, the cutoff value of T2 relaxation times for lumbar instability was 98.65 ms (sensitivity 60.0%, specificity 95.7%, AUC 0.763). CONCLUSIONS: The T2 relaxation times were positively correlated with lumbar instability. This new quantitative evaluation of lumbar facet joint using MRI T2-mapping might be useful to determine lumbar instability.

Decreased muscle mass and strength affected spinal sagittal malalignment.

PURPOSE: Correction surgeries for spinal malalignment showed good clinical outcomes; however, there were concerns including increased invasiveness, complications, and impact on medico-economics. Ideally, an early intervention is needed. To better understand the patho-mechanism and natural course of spinal alignment, the effect of factors such as muscle mass and strength on spinal sagittal imbalance were determined in a multicenter cross-sectional study. METHODS: After excluding metal implant recipients, 1823 of 2551 patients (mean age: 69.2 ± 13.8 years; men 768, women 1055) were enrolled. Age, sex, past medical history (Charlson comorbidity index), body mass index (BMI), grip strength (GS), and trunk muscle mass (TM) were reviewed. Spinal sagittal imbalance was determined by the SRS-Schwab classification. Multiple comparison analysis among four groups (Normal, Mild, Moderate, Severe) and multinomial logistic regression analysis were performed. RESULTS: On multiple comparison analysis, with progressing spinal malalignment, age in both sexes tended to be higher; further, TM in women and GS in both sexes tended to be low. On multinomial logistic regression analysis, age and BMI were positively associated with spinal sagittal malalignment in Mild, Moderate, and Severe groups. TM in Moderate and Severe groups and GS in the Moderate group were negatively associated with spinal sagittal malalignment. CONCLUSION: Aging, obesity, low TM, and low GS are potential risk factors for spinal sagittal malalignment. Especially, low TM and low GS are potentially associated with more progressed spinal sagittal malalignment. Thus, early intervention for muscles, such as exercise therapy, is needed, while the spinal sagittal alignment is normal or mildly affected.

Analgesic effects and arthritic changes following intra-articular injection of diclofenac etalhyaluronate in a rat knee osteoarthritis model.

BACKGROUND: Diclofenac etalhyaluronate (DF-HA) is a recently developed analgesic conjugate of diclofenac and hyaluronic acid that has analgesic and anti-inflammatory effects on acute arthritis. In this study, we investigated its analgesic effect on osteoarthritis, using a rat model of monoiodoacetate (MIA). METHODS: We injected MIA into the right knees of eight 6-weeks-old male Sprague-Dawley rats. Four weeks later, rats were randomly injected with DF-HA or vehicle into the right knee. Seven weeks after the MIA injection, fluorogold (FG) and sterile saline were injected into the right knees of all the rats. We assessed hyperalgesia with weekly von Frey tests for 8 weeks after MIA administration. We took the right knee computed tomography (CT) as radiographical evaluation every 2 weeks. All rats were sacrificed 8 weeks after administration of MIA for histological evaluation of the right knee and immunohistochemical evaluation of the DRG and spinal cord. We also evaluated the number of FG-labeled calcitonin gene-related peptide (CGRP)-immunoreactive(ir) neurons in the dorsal root ganglion (DRG) and ionized calcium-binding adapter molecule 1 (Iba1)-ir microglia in the spinal cord. RESULTS: Administration of DF-HA significantly improved pain sensitivity and reduced CGRP and Iba1 expression in the DRG and spinal cord, respectively. However, computed tomography and histological evaluation of the right knee showed similar levels of joint deformity, despite DF-HA administration. CONCLUSION: DF-HA exerted analgesic effects on osteoarthritic pain, but did not affect joint deformity.

Assessment of locomotive syndrome in patients with visceral cancer, the comparison with non-cancer patients using propensity score matching.

BACKGROUND: When treating cancer patients, the progression of symptoms is accompanied by the deterioration of systemic conditions and motor function. From a risk-benefit perspective, a certain level of physical function must be maintained to continue cancer treatment. Recently, outpatient cancer treatment has become more common. Motor function is important to determine the feasibility of continuing cancer treatment. The study aimed to evaluate the motor function of patients with visceral cancer using locomo tests established by Japanese Orthopaedic Association. METHODS: Locomo tests were performed, and the results were compared with data from non-cancer individuals. Background data were matched by propensity score matching. Data from 53 cancer patients (group C) were compared with that of 75 non-cancer patients (group N). RESULTS: The average score in the two-step test of group C was lower than that of group N (1.27: 1.37, p = 0.004). The average function in the stand-up test of group C was worse than that of group N (p = 0.001). The average score in the 25-question geriatric locomotive function scale (GLFS) of group C was significantly higher than that of group N (19.92: 5.29, SE 2.21, p < 0.001). Higher 25-question GLFS scores indicate reduced mobility. The proportion of the locomo stage 2 in group C was significantly higher than in group N (51%: 13%, p < 0.001). The results of the two field tests revealed a clinically minimal difference between the two groups, but a statistically significant difference. Locomo tests may be detect potential motor dysfunction in outpatient cancer patients with apparently maintained motor function. CONCLUSIONS: Even in cancer patients who attend outpatient clinics, their motor functions could be potentially impaired. Therapeutic interventions to maintain and enhance motor function for cancer patients could be useful for continuing cancer treatment, and furthermore, improving prognosis.

Effect of Ultrasound-Guided Hydrorelease of the Multifidus Muscle on Acute Low Back Pain.

OBJECTIVES: To examine improvement in acute low back pain (LBP) using ultrasound-guided hydrorelease of the multifidus muscle. METHODS: This prognostic cohort study was conducted in a private clinic on samples of 75 patients with acute LBP diagnosed based on physical and imaging findings. Hydrorelease of the multifidus muscle was performed at the L4/5 level. The LBP visual analog scale (VAS) scores (cm) before and 5 minutes after hydrorelease were statistically evaluated. We defined improvement rate (%) as {LBP VAS scores (cm) immediately before hydrorelease - LBP VAS scores (cm) 5 minutes after hydrorelease} × 100 / LBP VAS scores (cm) immediately before hydrorelease and examined the correlation of the Heckmatt score and average age with the improvement rate. RESULTS: LBP VAS scores (cm) before and 5 minutes after hydrorelease were 7.19 ± 1.01 (mean ± SD) and 2.85 ± 1.25, respectively (p < 0.05). No significant correlations were noted between the LBP improvement rate and the Heckmatt score or age. There were no gender variations in the improvement rate. CONCLUSIONS: Ultrasound-guided hydrorelease of the multifidus muscle led to considerable LBP VAS score improvement at the outpatient level. The improvement rate showed no correlations with the Heckmatt score or age, and there were no significant gender variations in the improvement rate. Therefore, fatty degeneration of muscles and change in muscle echogenicity due to age and gender may not be associated with muscular LBP. These findings suggest that multifidus muscle hydrorelease could be useful in the diagnosis and treatment of acute LBP.

Minimally displaced unilateral facet fracture of cervical spine can lead to spinal cord injury: a report of two cases.

BACKGROUND: According to most of the commonly used classification systems for subaxial spine injuries, unilateral and minimally displaced facet fractures without any sign of a spinal cord injury would be directed to non-operative management. However, the failure rate of non-operative treatment varies from 20 to 80%, and no consensus exists with regard to predictors of failure after non-operative management. CASE PRESENTATION: Case 1 is a patient with a unilateral facet fracture. The patient had only numbness in the right C6 dermatome but failed non-operative treatment, which resulted in severe spinal cord injury. Case 2 is a patient who had a similar injury pattern as case 1 but presented with immediate instability and underwent fusion surgery. Both patients had a minimally displaced unilateral facet fracture accompanied by disc injury and blunt vertebral artery injury, which are possible signs indicating significant instability. CONCLUSIONS: This is the first report of an isolated unilateral facet fracture that resulted in catastrophic spinal cord injury. These two cases illustrate that an isolated minimally displaced unilateral facet fracture with disc injury and vertebral artery injury were associated with significant instability that can lead to spinal cord injury.

Characteristics of relief and residual low back pain after discectomy in patients with lumbar disc herniation: analysis using a detailed visual analog scale.

BACKGROUND: Several authors have reported favorable results in low back pain (LBP) for patients with lumbar disc herniation (LDH) treated with discectomy. However, detailed changes over time in the characteristics and location of LBP before and after discectomy for LDH remain unclear. To clarify these points, we conducted an observational study to determine the detailed characteristics and location of LBP before and after discectomy for LDH, using a detailed visual analog scale (VAS) bilaterally. METHODS: We included 65 patients with LDH treated by discectomy in this study. A detailed VAS for LBP was administered with the patient under 3 different conditions: in motion, standing, and sitting. Bilateral VAS was also administered (affected versus opposite side) for LBP, lower extremity pain (LEP), and lower extremity numbness (LEN). The Oswestry Disability Index (ODI) was used to quantify clinical status. Changes over time in these VAS and ODI were investigated. Pfirrmann grading and Modic change as seen by magnetic resonance imaging (MRI) were reviewed before and 1 year after discectomy to determine disc and endplate condition. RESULTS: Before surgery, LBP on the affected side while the patients were in motion was significantly higher than LBP while they were sitting (p = 0.025). This increased LBP on the affected side in motion was improved significantly after discectomy (p < 0.001). By contrast, the residual LBP while sitting at 1 year after surgery was significantly higher than the LBP while they were in motion or standing (p = 0.015). At 1 year following discectomy, residual LBP while sitting was significantly greater in cases showing changes in Pfirrmann grade (p = 0.002) or Modic type (p = 0.025). CONCLUSIONS: Improvement of LBP on the affected side while the patient is in motion suggests that radicular LBP is improved following discectomy by nerve root decompression. Furthermore, residual LBP may reflect increased load and pressure on the disc and endplate in the sitting position.

Anchor type at upper instrumented vertebra and postoperative shoulder imbalance in patients with Lenke type 1 adolescent idiopathic scoliosis.

PURPOSE: To clarify the impact of anchor type at upper instrumented vertebra (UIV) on postoperative shoulder imbalance in patients with Lenke type 1 adolescent idiopathic scoliosis (AIS) who underwent posterior spinal fusion. METHODS: Subjects were 81 patients with Lenke type 1 AIS who underwent posterior spinal fusion between 2004 and 2013. Twenty-five patients agreed to participate in the study. We divided the patients into two groups: Hook group (15 patients with hooks at UIV who underwent surgery between 2004 and 2011) and PS group (ten patients with pedicle screws at UIV who underwent surgery between 2012 and 2013). To evaluate shoulder balance, first thoracic vertebra tilt angle (T1 tilt), clavicle angle (CA), and radiographic shoulder height (RSH) were measured. RESULTS: There were no significant differences in preoperative T1 tilt, CA, or RSH between the both groups. The postoperative 1-week, 2-year, and most recently observed T1 tilts were significantly smaller in the Hook group than in the PS group. There were no significant differences in postoperative 1-week, 2-year, and most recently observed CAs between the two groups. Although there were no significant differences in 1-week postoperative RSH between the groups, the 2-year postoperative RSH was significantly smaller in the Hook group than in the PS group. The most recently observed RSH tended to be smaller in the Hook group than in the PS group, but the difference was not significant. CONCLUSIONS: In the PS group, poor shoulder balance remained over the long term. The hooks at UIV adjusted postoperative shoulder balance.

Does the increased motion probing gradient directional diffusion tensor imaging of lumbar nerves using multi-band SENSE improve the visualization and accuracy of FA values?

PURPOSE: Diffusion tensor imaging (DTI) is useful to evaluate lumbar nerves visually and quantitatively. Multi-band sensitivity encoding (MB-SENSE) is a technique to reduce the scan time. This study aimed to investigate if super-multi-gradient DTI with multi-band sensitivity encoding (MB-SENSE) is better in evaluating lumbar nerves than the conventional method. METHODS: The participants were 12 healthy volunteers (mean age 33.6 years). In all subjects, DTI was performed using echo planar imaging with different motion probing gradient (MPG) directions (15 without MB, and 15, 32, 64, and 128 with MB) and the lumbar nerve roots were visualized with tractography. In the five groups, we evaluated the resultant DTI both visually and quantitatively. For visual measures, we counted the number of fluffs and disruptions of the nerve fibers. For quantitative measures, the fractional anisotropy (FA) and standard deviation of the fractional anisotropy (FA-SD) values at two regions (proximal and distal) of the lumbar nerve roots were quantified and compared. RESULTS: Among the five groups, the number of fluffs decreased as the number of MPG directions increased. However, the number of disruptions showed no significant differences. The FA-SD values decreased as the number of MPG directions increased, indicating that the signal variation was reduced with multi-gradient directional DTI. CONCLUSION: High-resolution multi-directional DTI with MB-SENSE may be useful to visualize nerve entrapments and may allow for more accurate DTI parameter quantification with opportunities for clinical diagnostic applications.