Nocturnal Leg Cramps and Lumbar Spinal Stenosis: A Cross-Sectional Study in the Community.

Purpose: Nocturnal leg cramps are considered to be a symptom of lumbar spinal stenosis (LSS). However, the relationship between LSS and nocturnal leg cramps in the general population remains unclear. The purpose of this study was to investigate the prevalence and characteristics of nocturnal leg cramps in LSS in the community. Patients and Methods: 328 voluntary participants were enrolled in this study. The presence of LSS was assessed by a validated and self-administered diagnostic support tool. The presence of nocturnal leg cramps and neurological findings were evaluated by one experienced spine surgeon. To investigate the relationship between leg cramps and anatomical factors, the participants underwent an MRI scan, and the dural sac cross-sectional area (DCSA) at each lumbar intervertebral disc level was measured. Results: A total of 214 participants (65.2%) had nocturnal leg cramps, and 94 of 328 participants (28.7%) showed typical LSS symptoms. In the typical LSS symptom group, 31 participants (33.0%) had nocturnal leg cramps. In the atypical LSS symptom group, 83 participants (35.5%) had nocturnal leg cramps. There was no statistically significant difference in the prevalence of nocturnal leg cramps between the two groups. The narrowest DCSA (<25 mm2 and 25-49.4mm2) was statistically related to the presence of nocturnal leg cramp. Statistically significant differences in sensory disturbance and motor weakness were not observed between the subjects with and those without nocturnal leg cramps. Moreover, impaired PTR was statistically related to the presence of nocturnal leg cramp. Conclusion: The prevalence of nocturnal leg cramps did not differ with or without typical LSS symptoms in the community. The degree of dural tube compression that is determined by DCSA had a direct effect on the presence of nocturnal leg cramps. Neurological impairment, such as PTR abnormalities, was associated with the presence of nocturnal leg cramps.

Bow hunter's syndrome: temporary obstruction of blood flow in the affected vertebral artery during posterior occipitocervical fusion. Illustrative case.

BACKGROUND: Bow hunter's syndrome (BHS) is a rare condition characterized by mechanical impingement of a vertebral artery (VA) during neck rotation followed by vertebrobasilar insufficiency. Posterior fusion is a typical surgical method for BHS. OBSERVATIONS: The case of a 70-year-old Japanese man who presented with presyncope that occurred during right cervical rotation is reported. Given the possibility of vertebrobasilar insufficiency, digital subtraction angiography and computed tomography angiography were performed and showed a hypoplastic right VA and severe stenosis of the left VA over the occiput (O)-C2 level. The blood flow of the left VA was interrupted by right cervical rotation, with resumption of blood flow on left cervical rotation. BHS was diagnosed, and posterior fusion at the O-C2 level was performed. Immediately after implant fixation, selective arteriography confirmed disruption of blood flow in the left VA. The rods were removed immediately; resumption of blood flow was confirmed; and the rods were refixed, anatomically bent with slight left cervical rotation. Then, sustained blood flow in the left VA was confirmed. LESSONS: Posterior fixation for BHS can induce VA occlusion due to minor changes in cervical spine alignment. Intraoperative selective arteriography is a necessary tool to identify occlusion of the affected VA.

Usefulness of the Brief Scale for Psychiatric Problems in Orthopaedic Patients (BS-POP) for Predicting Poor Outcomes in Patients Undergoing Lumbar Decompression Surgery.

BACKGROUND: The Brief Scale for Psychiatric Problems in Orthopaedic Patients (BS-POP) is an original questionnaire that evaluates psychosocial problems in orthopaedic patients. The purpose of this study was to clarify the relationship between BS-POP scores and surgical outcomes in patients with lumbar spinal stenosis (LSS). METHODS: From our database, a total of 157 patients with LSS who had undergone decompression surgery and completed a 1-year follow-up were retrospectively observed. The primary outcome was the numerical rating scale (NRS) score for satisfaction with surgery (from 0: not satisfied to 10: completely satisfied). Patients with an NRS score ≥8 were classified into the satisfied group. The secondary outcomes were NRS scores for low back pain, leg pain, and leg numbness and scores on the Roland-Morris Disability Questionnaire (RDQ). BS-POP was used to detect psychiatric problems before surgery. A BS-POP score ≥11 on the physician version or a combination of 10 on the physician version and ≥15 on the patient version was considered to indicate the presence of psychiatric problems. The patients were classified into two groups and compared based on preoperative BS-POP scores at the 1-year follow-up. RESULTS: Preoperatively, 22 and 135 patients showed high and low BS-POP scores, respectively. No significant differences in preoperative symptoms were found between the two groups. At 1 year after surgery, patients with high BS-POP scores showed significantly lower satisfaction with surgery, higher NRS scores for low back pain, leg pain, and leg numbness, and lower RDQ deviation scores than did the low BS-POP group (p < 0.05). The results of the multivariable analysis indicated that preoperative high BS-POP scores were independently associated with low satisfaction with surgery (odds ratio: 5.2, 95% confidence interval: 1.9-15.1). CONCLUSION: High preoperative BS-POP scores were associated with poor outcomes for decompression surgery in patients with LSS at 1 year after surgery. These results suggest that BS-POP is a useful tool for predicting surgical outcomes in patients with LSS.

Development of a self-administered questionnaire for the screening of cervical myelopathy. Part 2, investigation of its characteristics in surgical cases.

BACKGROUND: Our previous report described the development of a self-administered questionnaire to screen patients for cervical myelopathy (SQC). For clinical application, the characteristics of the SQC should be verified. METHODS: Participants comprised 129 patients (94 men, 35 women) with cervical myelopathy who underwent operative treatment. SQC score was calculated before surgery and patients were divided into a positive group (score ≥6) and negative group (score <6). Sex, age, pathologies of cervical myelopathy, Japanese Orthopaedic Association (JOA) score, 10-s grip-and-release test (10-s test), grip strength, number of levels decompressed, most cranial level of damage, and presence of diabetes mellitus (DM) were compared between groups. RESULTS: The sensitivity was 89.9% with 116 positive cases and 13 negative cases (10.1%). JOA score was significantly higher and 10-s test and grip strength significantly better in the negative group than in the positive group. No significant differences in sex, age, pathologies of cervical myelopathy, number of spinal levels decompressed, most rostral level of damage, or presence of DM were seen between groups. CONCLUSIONS: Screening for cervical myelopathy using SQC had a high sensitivity of 89.9%. However, SQC should be used with caution because it may miss mild cervical myelopathy with low JOA scores.

Grip Strength as a Screening Index for Severe Degenerative Cervical Myelopathy in Primary Care: Development of Cutoff Values Using Receiver Operating Curve Analysis.

PURPOSE: Early diagnosis of degenerative cervical spondylosis (DCM) is desirable because late treatment can lead to irreversible sequelae. No screening method has yet been established. Grip strength is commonly used in primary care settings to evaluate disease activity and diagnose sarcopenia. This single-center, cross-sectional study aimed to determine the diagnostic accuracy of grip strength for cervical myelopathy (DCM) and cutoff values for primary care DCM screening using area under the curve (AUC) and sensitivity values. PATIENTS AND METHODS: The DCM group comprised 249 consecutive participants (165 males, 84 females; mean age, 65.1 years) with DCM who had undergone surgery at the affiliated hospital. The control group comprised 735 (280 males, 455 females; mean age, 65.8 years) participants undertaking a local government health checkup. Stratifying by age and sex, receiver operating characteristic (ROC) analyses were constructed for each group using minimum grip strength values for both hands. Based on ROC analysis, cut-off values were established so that the screening sensitivity would be 90% for either sex or age group, respectively. RESULTS: According to age group and sex (males/females [M/F]), AUC values for a diagnosis of DCM in M/F were as follows: 40-59 years, 0.92/0.87; 60-69 years, 0.94/0.89; 70-79 years, 0.89/0.91; and 80-89 years, 0.97/0.97. Calculated M/F cutoff values were 41/24.5, 27/16, 27/15, and 20/10 kg, which were similar to cutoff scores for sarcopenia in M/F patients aged 60-69 and 70-79 years. M/F sensitivities in each age groups were 0.94/0.91, 0.92/0.90, 0.95/0.96, and 0.92/0.93. M/F specificities were 0.62/0.59, 0.84/0.83, 0.61/0.71, and 0.83/0.88. CONCLUSION: Grip strength had moderate-to-high diagnostic accuracy for DCM between participants in the control and DCM groups. We developed easily applicable cutoff values for primary care DCM screening with ≥90% sensitivity. In patients with sarcopenia, DCM should be differentially diagnosed in primary care.

Headache in Patients with Cervical Spondylotic Myelopathy.

Purpose: The anatomical mechanisms of cervicogenic headache caused by upper cervical lesions have been reported. However, the pathomechanisms of headache caused by lower cervical spine disorders remain unknown. The purpose of the current study was to clarify the prevalence and pathogenesis of headaches in patients with cervical spondylotic myelopathy (CSM). Methods: In this retrospective study, a questionnaire regarding preoperative and postoperative symptoms was sent to 147 patients with CSM who were surgically treated in our hospital during the previous 10 years. All of the surgical procedures were decompression surgeries between the C3 and C7 levels. Data from 74 patients (50.3%) were available for analysis. Subjects were divided into four groups according to the presence or absence of preoperative and postoperative headache. The severity of pain, severity of neuropathic pain symptoms, depression, severity of myelopathy, and quality of life (QOL) were also evaluated using questionnaires. The scores of these questionnaires were then compared between the four groups. Kruskal-Wallis tests with Dunn-Bonferroni post hoc tests were used for comparisons. Results: Of the patients with CSM, 31% had headaches preoperatively, and 43% of these headaches disappeared postoperatively. Type 4 (preoperative headache-positive/postoperative headache-positive) patients had more severe pain and neuropathic pain symptoms and lower QOL scores compared with type 1 (preoperative headache-negative/postoperative headache-negative) patients. Conclusions: Approximately one-third of all patients with CSM had headaches preoperatively. Headache in patients with CSM may be neuropathic pain. A proportion of headaches in patients with CSM can be treated by decompression surgery.

Abdominal oblique muscle injury at its junction with the thoracolumbar fascia in a high school baseball player presenting with unilateral low back pain.

Abdominal oblique muscle injury is characterized by acute pain and localized tenderness over the lateral trunk. This injury is particularly common among throwing athletes, and usually presents as anterolateral abdominal wall pain. Imaging evidence is scarce in regard to whether oblique muscle injury at its junction with the thoracolumbar fascia can instead present with low back pain. A high school baseball player with unilateral low back pain was referred to us with a different diagnosis.　Careful palpation and magnetic resonance imaging guided our care, and the patient returned to high-level competition after 7 weeks of conservative treatment, with no report of recurrence in the subsequent 12 months. Oblique muscle injury at its junction with the thoracolumbar fascia should be added to the differential diagnosis for throwing athletes with unilateral low back pain following a torque movement.

The Natural Polyphenol Epigallocatechin Gallate Protects Intervertebral Disc Cells from Oxidative Stress.

Oxidative stress-related phenotypic changes and a decline in the number of viable cells are crucial contributors to intervertebral disc degeneration. The polyphenol epigallocatechin 3-gallate (EGCG) can interfere with painful disc degeneration by reducing inflammation, catabolism, and pain. In this study, we hypothesized that EGCG furthermore protects against senescence and/or cell death, induced by oxidative stress. Sublethal and lethal oxidative stress were induced in primary human intervertebral disc cells with H2O2 (total n = 36). Under sublethal conditions, the effects of EGCG on p53-p21 activation, proliferative capacity, and accumulation of senescence-associated ß-galactosidase were tested. Further, the effects of EGCG on mitochondria depolarization and cell viability were analyzed in lethal oxidative stress. The inhibitor LY249002 was applied to investigate the PI3K/Akt pathway. EGCG inhibited accumulation of senescence-associated ß-galactosidase but did not affect the loss of proliferative capacity, suggesting that EGCG did not fully neutralize exogenous radicals. Furthermore, EGCG increased the survival of IVD cells in lethal oxidative stress via activation of prosurvival PI3K/Akt and protection of mitochondria. We demonstrated that EGCG not only inhibits inflammation but also can enhance the survival of disc cells in oxidative stress, which makes it a suitable candidate for the development of novel therapies targeting disc degeneration.

The effect of serotonin-noradrenaline reuptake inhibitor duloxetine on the intervertebral disk-related radiculopathy in rats.

INTRODUCTION: Neuropathic pain, commonly related to intervertebral disk (IVD) degeneration, responds poorly to standard pain treatments. Serotonin-noradrenaline reuptake inhibitors (SNRIs) have been reported to reduce neuropathic pain; however their effect on radiculopathy induced by lumbar disk herniation remains unclear. The aim of this study was to investigate the effect of SNRI duloxetine in rat model of IVD-related neuropathic pain. MATERIALS AND METHODS: Effects of SNRI duloxetine were tested in Sprague-Dawley rats (n = 135). Neuropathic pain was induced by applying autologous nucleus pulposus (NP) on the left L5 dorsal root ganglion (DRG). Duloxetine in concentrations 0.4 mg/kg (low dose) and 1.2 mg/kg (high dose) or saline were administered orally for 10 days. Von Frey test was carried out on post-operative days 2, 7, 14, 21, and 28 to test pain sensitivity. Immunohistochemistry of L5 DRG and L5 segment of spinal cord (SC) was performed on days 7 and 21 to examine expressions of tumor necrosis factor alpha (TNF), nerve growth factor (NGF), brain-derived neurotrophic factor (BDNF), and ionized calcium-binding adapter molecule 1 (Iba1). On days 14, 21, and 28, expressions of TNF in DRG as well as NGF and BDNF in SC were tested by immunoblotting. Sham-operated rats and naive rats were used as controls. RESULTS: Duloxetine in both concentrations significantly improved pain threshold from postoperative day 21 onward, compared to the NP + saline group (p < 0.05). High-dose duloxetine significantly inhibited the expression of TNF in DRG (day 28, p < 0.05). Both duloxetine concentrations reduced the expression of NGF in SC (day 21, p < 0.05), but the expression of BDNF remained unchanged. CONCLUSION: SNRI duloxetine inhibited neuropathic pain in rats possibly via down-regulating TNF, NGF, and microglia activation. We conclude that duloxetine, and most likely other SNRIs, may be used for the management of lumbar neuropathic pain.

Four-year follow-up of pregnancy-associated osteoporosis: a case report.

A 22-year-old woman presented with complaints of severe pain in a wide region of the thoracolumbar spine. She developed severe pain in the thoracolumbar spine region 2 months after her first delivery and was referred 1 month later. A lateral thoracic X-ray showed depressed degenerative vertebrae (T7, T9). One month after the initial examination, thoracic sagittal magnetic resonance imaging showed low intensity areas on T1-weighted imaging and iso-high intensity areas on T2-weighted imaging at T5, 7, 8, 9 and 11. Bone mineral density measured by ultrasound was low (%YAM 76%). The bone metabolic markers were high, suggesting accelerated osteoclast activity. These findings prompted a diagnosis of pregnancy-associated osteoporosis. She was asked to stop breastfeeding and to wear a lumbar brace, and treatment with nutritional calcium, activated vitamin D3, and risedronate sodium was started. Her low back pain almost disappeared after treatment. Bone metabolic markers showed normalization 8 months after the initial examination. Risedronate sodium was stopped 2 years and 2 months after the initial examination. Teriparatide treatment was started because her bone mineral density remained low; however, the osteoblast marker P1NP was not increased 5 months after the start of teriparatide treatment.