Impact of Bone Mineral Density and Bone Structural Properties on Postmenopausal Women With Rheumatoid Arthritis in Japan: A Cross-Sectional Study.

Introduction There has been no study on bone structural properties in postmenopausal women with rheumatoid arthritis (RA) in Japan. This study investigated bone mineral density (BMD) and bone structural properties in Japanese postmenopausal women with RA. Methods The study had a cross-sectional design and included 119 postmenopausal women aged 50-80 years with RA symptoms for more than five years. BMD, trabecular bone score (TBS), and results of hip structure analysis (HSA) were measured on dual-energy X-ray absorptiometry scans. The control group consisted of 288 women aged 50-80 years without RA. The RA group and control group using bisphosphonates were compared after propensity score matching for age, body mass index, and fracture history. Women in the RA group were also compared according to the use of glucocorticoids (GCs). Results After the propensity matching score, there were no other significant differences in BMD, TBS, and HSA parameters between the RA group and the control group. In the RA group, the TBS was lower in patients on GCs than those not on GCs (1.272 vs 1.313, p=0.008). There were no other significant differences in BMD and HSA parameters between patients in the RA group according to the use of GCs. Conclusion Although there were no differences in BMD, the TBS was lower in patients on GCs than those not on GCs in the RA group. It is thus important for physicians who administer GCs to treat patients with RA to be aware of not only BMD but also TBS.

Relation between spine alignment and scapular position by plain radiograph examination.

Background: Both scapular dynamics and static scapular position are important in the treatment of shoulder dysfunction. This study aimed to create an index that can evaluate scapular position on plain radiographs and evaluate the relation between scapular position and posture accurately. Methods: Using four fresh frozen cadavers, we developed a glenoid angle grade based on the degree of overlap between the shadow of the coracoid inflection point and the upper edge of the scapula on frontal plain radiographs: grade 1, no overlap; grade 2, overlaps by less than half of the shadow; grade 3, overlaps by more than half. We then performed a retrospective cohort study that included 329 shoulders of 329 patients who underwent spine surgery. Spine alignment parameters (SPAPs), including cervical lordosis (CL), thoracic kyphosis (TK), lumbar lordosis (LL), pelvic incidence, pelvic tilt, sacral slope, and sagittal vertical axis were measured on standing lateral plain radiographs. Glenoid anterior tilt (GAT) and glenoid anteversion angle (GAVA) were calculated on frontal radiographs and three-dimensional computed tomography scans. Correlations between SPAPs and each angle were investigated, and independent influencing factors were sought in multivariate analysis. Individual factors, GAT, GAVA, and SPAPs were compared among the grades. Results: SPAPs associated with GAT were sagittal vertical axis (R = 0.14, P = .011), TK (R = 0.12, P = .026), and LL (R = -0.11, P = .046). Multivariate analysis identified TK and LL as independent influencing factors (TK, P = .001; LL, P = .008). SPAPs associated with GAVA were CL (R = 0.17, P = .002), TK (R = 0.29, P < .001), and LL (R = 0.25, P < .001). Multivariate analysis identified CL, TK, and LL as independent influencing factors (CL, P = .01; TK, P = .03; LL, P = .03). There were 183, 127, and 19 cases categorized as grades 1, 2, and 3. GAT (grade 1, 24.0 ± 7.8; 2, 32.4 ± 7.0; 3, 41.0 ± 7.8), GAVA (1, 29.3 ± 7.6; 2, 33.7 ± 9.5; 3, 31.5 ± 8.3), and TK (1, 30.6 ± 13.6; 2, 35.1 ± 14.2; 3, 43.1 ± 20.4) differed significantly according to grade. Conclusion: We identified factors that influence scapular position and demonstrated that scapular position can be estimated by a grading system using plain radiographs.

Comparison of Percutaneous Endoscopic Transforaminal Discectomy, Chemonucleolysis, Microdiscectomy, and Microendoscopic Discectomy for Symptomatic Lumbar Disc Herniation: One-year Follow-up Clinical Results and Disc Degeneration.

This study compared the 1-year clinical outcomes and disc degeneration rates after transforaminal full-endoscopic lumbar discectomy (TF-FED), condoliase injection, open discectomy (OD), and microendoscopic discectomy (MED) for lumbar disc herniation (LDH). In total, 279 patients with LDH were divided into four treatment groups: TF-FED, OD, MED, and condoliase injection. Outcomes were evaluated on the basis of the complication rate, Japanese Orthopaedic Association Back Pain Evaluation Questionnaire (JOABPEQ), visual analog scale (VAS) scores, and the modified MacNab criteria. Surgical and hospital costs were assessed. Disc degeneration and endplate bone marrow edema were evaluated using magnetic resonance images. The mean postoperative JOABPEQ, VAS, or modified MacNab scores among the four groups had no significant differences. Additionally, the nerve injury or reoperation rate among the TF-FED, OD, and MED groups had no significant difference. However, the reoperation rate with condoliase injection was high because of residual disc herniation. Surgical and hospital costs were lower with condoliase injection and higher with OD and MED than those with TF-FED. With TF-FED and condoliase injection, the Pfirrmann grade progressed, and the disc height was significantly smaller than that with OD and MED. Endplate bone marrow edema was more common with condoliase injection and TF-FED. All groups had good outcomes. TF-FED and condoliase injection may reduce the burden of surgery because they can be performed under local anesthesia with little blood loss and low medical costs but tend to be associated with disc degeneration and endplate bone marrow edema. A randomized controlled study with a larger sample is needed.

Real-world effects, safety, and predictors of the effectiveness of romosozumab in primary and secondary osteoporosis: An observational study.

Romosozumab is an anti-sclerostin antibody that increases bone formation and decreases bone resorption. It became available for patients at high risk of osteoporotic fractures in Japan in 2019. The aim of this study was to clarify the clinical effects, safety, and predictors of the effectiveness of 12 months of romosozumab therapy. The study had an observational pre-post design and included 460 patients. Romosozumab was administered at a dose of 210 mg subcutaneously every 4 weeks for 12 months. The incidence of new fractures, safety, and changes in bone mineral density (BMD) and bone turnover markers were recorded. New fractures occurred in 11 cases (3.0 %). Nine patients (2.0 %) experienced cardiovascular events, which were fatal in 3 (0.65 %). Percent changes in BMD at the spine and total hip at 12 months from baseline were +7.7 % and +1.8 %, respectively. Romosozumab had better effects in patients with good renal function, low spine BMD, and high TRACP-5b at baseline and low TRACP-5b or high P1NP after 1 month of treatment. The percent change in spine BMD at 12 months was significantly lower in patients transitioning from denosumab than in those not previously treated with other anti-osteoporosis agents. Romosozumab is considered to be relatively safe in patients with primary osteoporosis compared to those with secondary osteoporosis. Romosozumab resulted in larger increases in spine BMD in patients with primary osteoporosis who were not previously treated with other anti-osteoporosis therapies and those with low spine BMD at the start of treatment.

Prevalence of osteochondritis dissecans of the capitellum in elementary school baseball players based on ultrasonographic screening: a 15-year overview in Tokushima, Japan.

Background: Although several operative procedures have evolved for capitellar osteochondritis dissecans (OCD), the best outcome is achieved by early detection and conservative treatment. The objective of this study was to clarify changes in the prevalence of capitellar OCD in young baseball players over a long-term period based on consistent criteria in Tokushima, Japan between 2006 and 2020. Methods: The number of players who underwent screening and the discovery rate of capitellar OCD during the study period were investigated. School grade and radiographic stage were also evaluated. Results: The confirmation rate was significantly higher when ultrasonographic screening was performed than when screening was based on physical findings (65.8% vs. 1.9%, P < .001). The overall incidence of OCD in elementary school players based on ultrasonographic screening was 1.4% during the 10-year study period. Twenty-one (10.8%) of the 195 players identified to have OCD had experienced lateral elbow pain. When classified radiographically, the lesion was stage I in 73.3% of cases, stage II in 24.1%, and stage III in 2.6%. No cases of OCD were diagnosed before the fourth grade. The prevalence rates increased gradually from the fourth grade to the sixth grade. Conclusion: Ultrasonographic screening could be more effective for detecting capitellar OCD than screening based on physical findings. The overall prevalence of OCD among elementary school players was 1.4% over 10 years. The prevalence rates increased gradually from the fourth grade onwards.

Mismatch between Augmented Reality Navigation Images and Actual Location of a Cauda Equina Tumor:A Case Report.

BACKGROUND: Augmented reality navigation is the one of the navigation technologies that allows computer-generated virtual images to be projected onto a real-world environment. Augmented reality navigation can be used in spinal tumor surgery. However, it is unknown if there are any pitfalls when using this technique. CASE PRESENTATION: The patient in this report underwent complete resection of a cauda equina tumor at the L2-L3 level using microscope-based augmented reality navigation. Although the registration error of navigation was <1 mm, we found a discrepancy between the augmented reality navigation images and the actual location of the tumor, which we have called "navigation mismatch". This mismatch, which was caused by the mobility of the spinal tumor in the dura mater, seems to be one of the pitfalls of augmented reality navigation for spinal tumors. CONCLUSIONS: Combined use of intraoperative ultrasound and augmented reality navigation seems advisable in such cases. J. Med. Invest. 71 : 174-176, February, 2024.

Full-endoscopic spine surgery in oldest old patients aged over 90 years:A case report.

BACKGROUND: Transforaminal full-endoscopic spine surgery (FESS) is the least invasive spinal surgery and can be performed under local anesthesia. In Japan, the population is rapidly aging and the number of spinal surgeries performed in the elderly is also increasing. OBJECT: In this report, we describe 3 patients aged 90 years or older in whom we performed FESS under local anesthesia. CASE: The first case was a 90-year-old man who presented with severe leg pain. He had multiple medical comorbidities and was unsuitable for general anesthesia. We performed FESS. After surgery, the leg pain resolved with full recovery of muscle strength. He was discharged with no perioperative complications. The second case was a 90-year-old man who presented with severe leg pain. MRI showed a herniated nucleus pulposus and foraminal stenosis at L4/5. We performed FESS. The leg pain improved immediately after surgery. The third case was a 91-year-old woman in whom we diagnosed left L5 radiculopathy due to foraminal stenosis at L5/S1. After surgery, her leg pain was relieved. CONCLUSION: FESS is a good surgical procedure for elderly patients who are in a poor general condition because it is minimally invasive and can be performed under local anesthesia with early mobilization. J. Med. Invest. 71 : 169-173, February, 2024.

Full-Endoscopic Foraminal Decompression for Foraminal Stenosis Following Osteoporotic Vertebral Fracture in an Elderly Woman Under Local Anesthesia:A Case Report.

Osteoporotic vertebral fracture (OVF) is common in the elderly population. In this report, we describe a case with radiculopathy due to foraminal stenosis caused by OVF in a very elderly patient that was treated successfully by full-endoscopic foraminotomy under local anesthesia. The patient was an 89-year-old woman who presented with a chief complaint of left leg pain for 5 years. She visited a couple of hospitals and finally consulted us to determine the exact cause of the pain. Computed tomography scans were obtained and selective nerve root block at L3 was performed. The diagnosis was radiculopathy at L3 due to foraminal stenosis following OVF. The patient had severe heart disease, so we decided to avoid surgery under general anesthesia and planned full-endoscopic spine surgery under local anesthesia. We performed transforaminal full-endoscopic lumbar foraminotomy at L3-L4 to decompress the L3 nerve root. The leg pain disappeared completely immediately after surgery. Postoperative computed tomography confirmed appropriate bone resection. The leg pain did not recur during a year of postoperative follow-up. OVF may cause lumbar radiculopathy as a result of foraminal stenosis, and transforaminal full-endoscopic lumbar foraminotomy under local anesthesia would be the best option in an elderly patient with poor general condition. J. Med. Invest. 71 : 179-183, February, 2024.

Return-to-play outcomes after full-endoscopic spine surgery under local anesthesia in professional baseball players: Comparison by timing of surgery.

BACKGROUND: Full-endoscopic spine surgery via a transforaminal approach (TF-FESS) is minimally invasive and could help athletes quickly return to play. When treating professional athletes, we have to consider their season schedule. In this study, we investigated the characteristics of Japanese professional baseball players who underwent TF-FESS and examine how the timing of surgery influenced their postoperative course. METHODS: Ten players who underwent TF-FESS (discectomy, foraminoplasty, or thermal annuloplasty according to their diagnosis) under local anesthesia were analyzed. Multilevel surgeries were performed at the same time in patients with lesions at multiple levels. The patients were divided into three groups according to timing of surgery (pre/during/post-season). Time to complete return to play and duration of official game loss were compared between the three groups. RESULTS: All players (100 %) could return to their original level of professional play after FESS surgery. Seven of the 10 patients underwent two-level surgery. The mean time until complete return to play was 4.6 months (range, 2-8 months) and the mean duration of game loss was 1.5 months (range, 0-4 months). The mean duration of game loss was shorter in the post-season group than in the other groups (0.9 vs 2,4 months), and 4 of 6 patients in the post-season group did not miss any games. CONCLUSIONS: TF-FESS is a good technique for achieving a quick return to play in professional baseball players. In particular, surgery performed during the post-season could allow players to return to play after adequate rehabilitation with no game loss.

Robotic-assisted minimally invasive repair surgery for progressive spondylolysis in a young athlete: a technical note.

Presently, the invasiveness of direct repair surgery for lumbar spondylolysis is relatively high. Thus, high school and junior high school students who play sports often cannot return to sports before graduation because of the invasiveness. The use of a robotic system enabled an accurate and minimally invasive procedure. Robotic-assisted minimally invasive direct pars repair surgery is useful for young patients with progressive spondylolysis.

Biomechanical Effects of Thoracic Flexibility and Stiffness on Lumbar Spine Loading: A Finite Element Analysis Study.

OBJECTIVE: To determine the effects of thoracic stiffness on mechanical stress in the lumbar spine during motion. METHODS: To evaluate the effect of preoperative thoracic flexibility, stiff and flexible spine models were created by changing the material properties of ligaments and discs in the thoracic spine. Total laminectomy was performed at L4/5 in stiff and flexible models. A biomechanical investigation and finite element analysis were performed preoperatively and postoperatively. A hybrid loading condition was applied, and the range of motion (ROM) at each segment and maximum stress in the discs and pars interarticularis were computed. RESULTS: In the preoperative model with the stiff thoracic spine, lumbar disc stress, lumbar ROM, and pars interarticularis stress at L5 increased. In contrast, as the thoracic spine became more flexible, lumbar disc stress, lumbar ROM, and pars interarticularis stress at L5 decreased. All L4/5 laminectomy models had increased instability and ROM at L4/5. To evaluate the effect of thoracic flexibility on the lumbar spine, differences between the stiff and flexible thoracic spine were examined: Differences in ROM and intervertebral disc stress at L4/5 in flexion between the stiff and flexible thoracic spine were respectively 0.7° and 0.0179 MPa preoperatively and 1.5° and 0.0367 MPa in the L4/5 laminectomy model. CONCLUSIONS: Biomechanically, disc stress and pars interarticularis stress decrease in the flexible thoracic spine. Flexibility of the thoracic spine reduces lumbar spine loading and could help to prevent stress-related disorders.

Morphological Evaluation of Lumbar Facet Joints in Professional Baseball Players.

Background: Many professional baseball players experience low back pain, a major cause of which is lumbar facet joint arthropathy. Purpose: To evaluate the relationship between the dominant hand side and facet joint morphology in baseball movement. Study Design: Cross-sectional study; Level of evidence, 3. Methods: Participants were 25 Japanese professional baseball players (11 pitchers and 14 fielders) with low back pain and lower limb symptoms. Player age, hand dominance, and length of professional playing experience were recorded, and the lateral diameter of all lumbar facet joints was determined from the axial computed tomography scans. We defined the facet joints ipsilateral and contralateral to the dominant hand as dominant and nondominant, respectively. The nondominant-to-dominant (N/D) ratio of the lateral diameter was calculated, and differences between the pitchers and fielders were analyzed using the unpaired t test. Results: The average player age and length of professional playing experience were 26.9 years (range, 19-37 years) and 7.2 years (range, 1-15 years), respectively. The right hand was dominant in 9 pitchers and 5 fielders, while the left hand was dominant in 2 pitchers and 9 fielders. In pitchers, the average lateral facet joint diameter on the nondominant side was significantly larger than on the dominant side at all vertebral levels except L1 to L2 (P < .05 for all). The N/D ratio for each facet joint was 1.06 (L1-L2), 1.11 (L2-L3), 1.10 (L3-L4), 1.12 (L4-L5), and 1.12 (L5-S1). In fielders, the average lateral facet joint diameter on the dominant side was significantly larger than on the nondominant side at L3 to L4 (P < .05), with N/D ratios of 0.98 (L1-L2), 0.96 (L2-L3), 0.94 (L3-L4), 0.97 (L4-L5), and 0.98 (L5-S1). The N/D ratio was significantly larger in pitchers than in fielders at all levels (P < .05 for all). Conclusion: The facet joints of professional baseball players were enlarged asymmetrically, with different tendencies observed between pitchers and fielders. Although pitching and batting are movements that transmit the rotation from the lower limbs to the upper limbs, the effects of rotation and lateral flexion were associated significantly with facet joint hypertrophy.