Surgical outcomes of anterior column reconstruction for spinal fractures caused by minor trauma-preoperative examination of the number of intervertebral bone bridges is key to obtaining good bone fusion.

BACKGROUND: To achieve good bone fusion in anterior column reconstruction for vertebral fractures, not only bone mineral density (BMD) and bone metabolism markers but also lever arms due to bone bridging between vertebral bodies should be evaluated. However, until now, no lever arm index has been devised. Therefore, we believe that the maximum number of vertebral bodies that are bony and cross-linked with the contiguous adjacent vertebrae (maxVB) can be used as a measure for lever arms. The purpose of this study is to investigate the surgical outcomes of anterior column reconstruction for spinal fractures and to determine the effect of bone bridging between vertebral bodies on the rate of bone fusion using the maxVB as an indicator of the length of the lever arm. METHODS: The clinical data of 81 patients who underwent anterior column reconstruction for spinal fracture between 2014 and 2022 were evaluated. The bone fusion rate, back pain score, between the maxVB = 0 and the maxVB ≥ 2 patients were adjusted for confounding factors (age, smoking history, diabetes mellitus history, BMD, osteoporosis drugs, surgical technique, number of fixed vertebrae, materials used for the anterior props, etc.) and analysed with multivariate or multiple regression analyses. The bone healing rate and incidence of postoperative back pain were compared among the three groups (maxVB = 0, 2≦maxVB≦8, maxVB ≧ 9) and divided by the maxVB after adjusting for confounding factors. RESULTS: Patients with a maxVB ≥ 2 had a significantly higher bone fusion rate (p < 0.01) and postoperative back pain score (p < 0.01) than those with a maxVB = 0. Among the three groups, the bone fusion rate and back pain score were significantly higher in the 2≦maxVB≦8 group (p = 0.01, p < 0.01). CONCLUSIONS: Examination of the maxVB as an indicator of the use of a lever arm is beneficial for anterior column reconstruction for vertebral fractures. Patients with no intervertebral bone bridging or a high number of bone bridges are in more need of measures to promote bone fusion than patients with a moderate number of bone bridges are.

Number of contiguous vertebral cross-links in the spine indicates bone formation: a cross-sectional study.

BACKGROUND: As an indicator to evaluate the risk of fracture in diffuse idiopathic skeletal hyperostosis, the maximum number of vertebral bodies' bone cross-linked with contiguous adjacent vertebrae (max VB) was developed. This study retrospectively investigates the relationship between max VB, bone mineral density (BMD), and bone metabolic markers (BMM). METHODS: In this cross-sectional study (from April 2010 to January 2022), males (n = 114) with various max VB from the thoracic vertebra to the sacrum, measured using computed tomography scans, were selected to assess femur BMD and BMM. The association of max VB with the total type I procollagen N-terminal propeptide (P1NP), tartrate-resistant acid phosphatase 5b (TRACP-5b), and bone turnover ratio (BTR = TRACP-5b/P1NP) as well as its relationship with femur BMD with P1NP and TRACP-5b, were investigated. Furthermore, the relationship between P1NP and TRACP-5b was investigated. RESULTS: P1NP increased in proportion to max VB and TRACP-5b increased in proportion to P1NP. Moreover, BTR was inversely proportional to max VB. Finally, femur BMD was inversely proportional to P1NP and TRACP-5b. CONCLUSION: As max VB increased with P1NP-a potential osteogenesis indicator-and BTR was inversely proportional to max VB with compensatory TRACP-5b increase, max VB can be considered as a possible predictor of bone fusion.

Does the degree of preoperative gait disturbance remain after tumor resection in patients with intradural extramedullary spinal cord tumors?

STUDY DESIGN: Retrospective comparative study. OBJECTIVE: This study aimed to determine whether the degree of preoperative gait disturbance remains following surgical resection in patients with intradural extramedullary spinal cord tumors (IDEMSCTs), and to investigate any factors that may influence poor improvement in postoperative gait disturbance. SETTING: The single institution in Japan. METHODS: In total, 78 IDEMSCTs patients who required surgical excision between 2010 and 2019 were included. According to the degree of preoperative gait disturbance using modified McCormick scale (MMCS) grade, they were divided into the Mild and Severe groups. The mean postoperative follow-up period was 50.7 ± 17.9 months. Data on demographic and surgical characteristics were compared between the two groups. RESULTS: There was no significant difference in terms of age at surgery, sex, tumor size, surgical time, estimated blood loss, tumor histopathology, and postoperative follow-up period between the Mild and Severe groups. At the final follow-up, 84.6% of IDEMSCTs patients were able to walk without support. Gait disturbance improved after surgery in most of the patients with preoperative MMCS grades II-IV, but remained in approximately half of patients with preoperative MMCS grade V. Age at surgery was correlated with poor improvement in postoperative gait disturbance in the Severe group. CONCLUSIONS: Regardless of the degree of preoperative gait disturbance, it improved after tumor resection in most of the IDEMSCTs patients. However, in the preoperative MMCS grade III-V cases, older age at surgery would be an important factor associated with poor improvement in postoperative gait disturbance.

Effects of Bone Cross-Link Bridging on Fracture Mechanism and Surgical Outcomes in Elderly Patients with Spine Fractures.

STUDY DESIGN: This study adopted a cross-sectional study design. PURPOSE: This study was designed to investigate the effects of bone cross-link bridging on fracture mechanism and surgical outcomes in vertebral fractures using the maximum number of vertebral bodies with bony bridges between adjacent vertebrae without interruption (maxVB). OVERVIEW OF LITERATURE: The complex interplay of bone density and bone bridging in the elderly can complicate vertebral fractures, necessitating a better understanding of fracture mechanics. METHODS: We examined 242 patients (age >60 years) who underwent surgery for thoracic to lumbar spine fractures from 2010 to 2020. Subsequently, the maxVB was classified into three groups: maxVB (0), maxVB (2-8), and maxVB (9-18), and parameters, including fracture morphology (new Association of Osteosynthesis classification), fracture level, and neurological deficits were compared. In a sub-analysis, 146 patients with thoracolumbar spine fractures were classified into the three aforementioned groups based on the maxVB and compared to determine the optimal operative technique and evaluate surgical outcomes. RESULTS: Regarding the fracture morphology, the maxVB (0) group had more A3 and A4 fractures, whereas the maxVB (2-8) group had less A4 and more B1 and B2 fractures. The maxVB (9-18) group exhibited an increased frequency of B3 and C fractures. Regarding the fracture level, the maxVB (0) group tended to have more fractures in the thoracolumbar transition region. Furthermore, the maxVB (2-8) group had a higher fracture frequency in the lumbar spine area, whereas the maxVB (9-18) group had a higher fracture frequency in the thoracic spine area than the maxVB (0) group. The maxVB (9-18) group had fewer preoperative neurological deficits but a higher reoperation rate and postoperative mortality than the other groups. CONCLUSIONS: The maxVB was identified as a factor influencing fracture level, fracture type, and preoperative neurological deficits. Thus, understanding the maxVB could help elucidate fracture mechanics and assist in perioperative patient management.

Incidence and predictive factors of shoulder imbalance after selective anterior spinal fusion surgery in Lenke type 5C adolescent idiopathic scoliosis.

Background: No study has assessed the incidence or predictors of postoperative shoulder imbalance (PSI) in patients with Lenke type 5C adolescent idiopathic scoliosis (AIS) who underwent selective anterior spinal fusion (ASF). This study evaluated the incidence and predictors of shoulder imbalance after selective ASF for Lenke type 5C AIS. Methods: In total, 62 patients with Lenke type 5C AIS (4 men and 58 women, mean age at surgery of 15.5 ± 1.5 years) were included and divided into the following two groups according to the radiographic shoulder height (RSH) at the final follow-up: PSI and non-PSI groups. All patients in this study underwent a whole-spine radiological evaluation. Various spinal coronal and sagittal profiles on radiographs were compared between the 2 groups. The clinical outcomes were assessed using the Scoliosis Research Society (SRS)-22 questionnaires. Results: The mean final follow-up duration was 8.6 ± 2.7 years. PSI was observed in 10 patients (16.1%) immediately after surgery; however, in the long-term follow-up period, PSI improved in 3 patients spontaneously, whereas the remaining 7 patients had residual PSI. The preoperative RSH and correction rates of the major curve immediately after surgery or at the final follow-up were significantly larger in the PSI group than in the non-PSI group (p=.001, p=.023, and p=.019, respectively). Receiver operating characteristic curve analysis indicated that the cutoff values for preoperative RSH and the correction rates immediately after surgery and at the final follow-up were 11.79 mm (p=.002; area under the curve [AUC], 0.948), 71.0% (p=.026; AUC, 0.822), and 65.4% (p=.021; AUC, 0.835), respectively. No statistically significant difference was observed in the preoperative and final follow-up SRS-22 scores in any domain between the PSI and non-PSI groups. Conclusions: Paying attention to the preoperative RSH and avoiding excessive correction of the major curve can prevent the occurrence of shoulder imbalance after selective ASF for Lenke type 5C AIS.

Surgical Outcomes of Selective Laminectomy for Patients With Cervical Kyphosis: A Retrospective Study of 379 Cases.

STUDY DESIGN: A retrospective study. OBJECTIVES: This study aimed to investigate the impact of cervical kyphosis on patients with cervical spondylotic myelopathy (CSM) following selective laminectomy (SL) regarding posterior spinal cord shift (PSS), and a number of SLs. METHODS: We evaluated 379 patients with CSM after SL. The patients with kyphosis (group K) were compared with those without kyphosis (group L). Moreover, groups K and L were divided into subgroups KS and KL (SLs ≤ 2) and LS and LL (SLs ≥ 3), respectively, and analyzed. Receiver operating characteristic (ROC) curve analysis was performed to determine the cut-off value of the C2-C7 angle for satisfactory surgical outcomes, which was defined as a Japanese Orthopaedic Association (JOA) recovery rate of ≥50% in group KS. RESULTS: The average PSS (mm) in group K was smaller than that in group L (.8 vs 1.4; P < .01), but the JOA recovery rate was comparable between the 2 groups. Meanwhile, the mean PSS and JOA recovery rate (%) in group KS was lower than those in group KL, respectively (.3 vs 1.0; P < .01, 35.1 vs 52.3; P = .047). Moreover, the average PSS of group KS (.6) was smaller than those of other subgroups ( < .01). In addition, the ROC curve analysis showed that the C2-C7 angle of -14.5° could predict satisfactory surgical outcomes in group KS. CONCLUSION: Selective laminectomy is not contraindicated for patients with kyphosis, but a larger number of SLs may be indicated for the patients with C2-C7 angles of ≤ -14.5°.

Assessment of the Necessity of Osteoporosis Treatment for Patients with Low Bone Density in Diffuse Idiopathic Skeletal Hyperostosis.

Introduction: Although patients with diffuse idiopathic skeletal hyperostosis (DISH) do not have low bone density, it is a risk factor for spine fractures associated with DISH. We investigated the characteristics and bone metabolism markers of patients with DISH having low bone density to assess whether osteoporosis medication is necessary to prevent fractures. Methods: A cross-sectional study was conducted between April 1, 2008, and March 31, 2019. The 86 patients included were divided into two groups according to their T-scores-one group had low bone density and DISH, and the other group did not. Group A (T-score≤-1) and B (T-score>-1) data were adjusted for confounding factors and compared for differences in age, body weight, maximum number of vertebral bodies with bony bridges between adjacent vertebrae (max VB), and previous history (hypertension, malignant tumors, diabetes mellitus, cardiac diseases, chronic renal failure, and spinal fractures). In Group A, multiple linear regression was used to investigate relationships among max VB, femur bone mineral density (BMD), total type I procollagen N-terminal propeptide (P1NP), and tartrate-resistant acid phosphatase 5b (TRACP-5b). Results: Group A had 36, and Group B had 50 male patients with DISH. Patients in Group B were heavier than those in Group A. The mean femur BMD in Group A was age-appropriate, and that in Group B was higher than the age-appropriate femur BMD. The mean values of P1NP and TRACP-5b were within the normal range. Max VB was positively correlated with total P1NP in Group A. Total P1NP was significantly and positively correlated with TRACP-5b. Conclusions: The DISH group with a T-score of ≤-1 was age-appropriate. The group with a T-score of >-1 had higher BMD because of their higher body weight. The group with a T-score of ≤-1 had good bone metabolism and did not require aggressive osteoporosis treatment.

Normal pressure hydrocephalus due to an iatrogenic giant lumbar pseudomeningocele after posterior lumbar interbody fusion: illustrative case.

BACKGROUND: Iatrogenic pseudomeningocele incidence after lumbar surgery is 0.068%-2%, and most lumbar pseudomeningoceles are smaller than 5 cm; however, in rare cases, "giant" pseudomeningoceles greater than 8 cm in size may develop. Normal pressure hydrocephalus (NPH) is another rare condition in which the ventricles expand despite the presence of normal intracranial pressure. To date, pseudomeningocele associated with NPH has not been reported. OBSERVATIONS: An 80-year-old woman underwent L3-5 laminectomy and posterior lumbar interbody fusion, and her symptoms improved after surgery. However, dementia appeared 1 month after surgery. Repeated brain computed tomography showed ventricular enlargement, and lumbar magnetic resonance imaging showed a long pseudomeningocele in the subcutaneous tissues at the L4 level. Here, the authors report a rare case of an iatrogenic giant pseudomeningocele accompanied by NPH after lumbar surgery. The symptoms of NPH in the present case occurred after spinal surgery and recovered after dural repair surgery, indicating that the changes in cerebrospinal fluid circulation and/or pressure due to pseudomeningoceles may cause NPH. LESSONS: The prevention of dural tears through precise surgical technique and primary repair of dural tears are the best approaches to prevent pseudomeningocele incidence and subsequent events.

Selective Anterior Fusion Surgery Does Not Influence Global Spinal Sagittal Alignment in Lenke Type 5 Adolescent Idiopathic Scoliosis Patients.

STUDY DESIGN: Retrospective comparative study. OBJECTIVE: The aim of this study was to evaluate the changes in global spinal sagittal alignment (GSSA) following selective anterior spinal fusion (ASF) in patients with Lenke type 5 adolescent idiopathic scoliosis (AIS). SUMMARY OF BACKGROUND DATA: Few studies have assessed the changes in postoperative GSSA, including cervical, thoracic, and lumbosacral sagittal alignment in AIS patients with major thoracolumbar/lumbar (TL/L) curve who underwent selective ASF. METHODS: Fifty-two patients with Lenke type 5 AIS (two males and 50 females, mean age at surgery of 16.4 ±â€Š3.1 years) were included in this study. The average final follow-up was 8.3 ±â€Š3.1 years after surgery. The variations of outcome variables were analyzed in various spinal sagittal profiles using radiographic outcomes (pre-operation, immediate post-operation, and final follow-up). The clinical outcomes at the final follow-up were assessed using Scoliosis Research Society (SRS)-22 and Oswestry Disability Index (ODI) questionnaires. RESULTS: The mean Cobb angle of the main TL/L and minor thoracic curve was significantly improved after selective ASF, which was maintained up to the final follow-up. However, in all cases, the various sagittal parameters examined (sagittal vertical axis [SVA], C2-7 SVA, C2-7 lordosis, T1 slope, thoracic kyphosis, T10-L2 kyphosis, lumbar lordosis, pelvic incidence, pelvic tilt, and sacral slope), did not significantly change in the immediate postoperative period, and all GSSA parameters were maintained up to the final follow-up. Furthermore, the magnitude of coronal curve correction and fused levels did not affect each GSSA parameter postoperatively. During the period up to the final follow-up, no significant clinical symptoms were observed. The final SRS-22 global score was 4.5 ±â€Š0.3, and ODI scored 0.8 ±â€Š2.4. CONCLUSION: Selective ASF did not influence various GSSA parameters postoperatively and could maintain excellent correction for coronal deformity with satisfactory final functional and clinical outcomes confirmed by long-term follow-up.Level of Evidence: 4.

Association of Continuous Vertebral Bone Bridges and Bone Mineral Density with the Fracture Risk in Patients with Diffuse Idiopathic Skeletal Hyperostosis.

STUDY DESIGN: Cross-sectional study. PURPOSE: To examine whether the number of continuous vertebral bone bridges and bone mineral density (BMD) influence the fracture risk in diffuse idiopathic skeletal hyperostosis (DISH) patients. OVERVIEW OF LITERATURE: Bone bridges connecting through the intervertebral body in DISH create long lever arms that can increase the risk of fractures from minor trauma. DISH patients have a BMD that is higher than or comparable to those of age-matched healthy subjects. METHODS: We examined the computed tomography scans from the thoracic vertebra to the sacrum used to diagnose DISH in 140 patients (98 men and 42 women; average age, 78.6 years). We compared patients who did (n=52) and did not have (n=88) fractures at the continuous vertebral bodies fused by bone bridges. The relationship between the vertebral fractures and the maximum number of vertebrae that are bony cross-linked with contiguous adjacent vertebrae (max VB) from the thoracic vertebra to the sacrum or from the lumbar vertebra to the sacrum and proximal femur BMD were analyzed using a logistic regression model. RESULTS: We found that after adjusting for the confounding factors, higher max VB, both from the thoracic vertebrae to the sacrum and the lumbar vertebrae to the sacrum, was associated with a higher risk of vertebral fractures. This difference was statistically significant. The risk was higher when only the lumbar vertebrae to the sacrum was considered (thoracic vertebrae to the sacrum: odds ratio, 1.21; p<0.05; lumbar vertebrae to the sacrum: odds ratio, 2.78; p<0.01). Moreover, low proximal femur BMD in DISH patients raises the fracture risk (odds ratio, 0.47; p<0.01). CONCLUSIONS: Many continuous vertebral bone bridges, especially those that extend to the lumbar spine and low proximal femur BMD, are risk factors for fracture in DISH patients.

Maximum number of bone cross-linked vertebrae: an index for BMD in diffuse idiopathic skeletal hyperostosis.

INTRODUCTION: The maximum number of vertebral bodies with bony bridges between adjacent vertebrae (max VB) helps assess the risk of fracture in diffuse idiopathic skeletal hyperostosis (DISH). In addition to max VB, the maximum thickness of bone cross-bridges (max TB) may be an index of bone mineral density (BMD). Therefore, this study investigated the relationship among max VB, max TB, and BMD. MATERIALS AND METHODS: The participants in this cross-sectional study were male patients (n = 123) with various max VB from the thoracic vertebrae to the sacrum without sacroiliac ankylosis. The participants were grouped by max VB. For example, a group with max VB from 4 to 8 would be listed as max VB (4-8). The relation between femur proximal BMD and mean max TB and max VB was assessed. Femur proximal BMD was then compared after adjusting for confounding factors. RESULTS: The results indicated that max VB was correlated with femur proximal BMD in max VB (0-8) and max VB (9-18) groups. The mean max TB was correlated only with femur proximal BMD in max VB (0-8). After adjusting, max VB (4-8) showed a significantly higher femur proximal BMD than max VB (0-3) and max VB (9-18). CONCLUSION: Femur proximal BMD and mean max TB showed different trends after max VB = 9, which suggests that max VB is an index of BMD, and that DISH has at least two possible populations in terms of BMD and bone cross-link thickness.

Femur Bone Mineral Density and Pentosidine Level Distinguish Ankylosing Spinal Disorder Patients with and without Sacroiliac Ankylosis.

INTRODUCTION: When spinal fracture occurred in ankylosing spinal disorder (ASD) patients, it is important to evaluate not only the long lever arm but also bone density and bone quality for the determination of treatment strategies. This case-controlled study examined bone mineral density (BMD), bone metabolism markers, and pentosidine levels in patients with ASD. METHODS: Subjects with bridging of minimum four contiguous vertebral bodies were classified into ASD group and the rest into non-ASD group. The former was further divided into two subgroups based on the presence/absence of sacroiliac joint ankylosis (SJA). We compared BMD, bone metabolism markers, and pentosidine levels in these groups. RESULTS: The BMD T and Z scores of the femur proximal extremity were lower in the ASD with SJA group than those in the ASD without SJA group. When groups were matched for age, weight, and eGFR, compared with the non-ASD group, the ASD with SJA group had lower BMD of the lumbar spine and femur proximal extremity and the ASD without SJA group had significantly higher BMDs of the lumbar spine and femur proximal extremity. After matching, the ASD without SJA group showed a significantly higher pentosidine level than the non-ASD group. CONCLUSIONS: Patients with SJA have low femur proximal extremity BMD, whereas those with ASD without SJA have a higher BMD of the femur proximal extremity with high pentosidine level. Investigating the presence or absence of SJA is important for the determination of treatment strategies in fractured ASD patients.

Surgical Results of Microscopic Cervical Foraminotomy for Cervical Radiculopathy Presenting Drop Finger and Proposal of Classification Based on Drop Finger Patterns.

INTRODUCTION: In drop finger, the extension of the finger is limited, although the wrist can be flexed dorsally. There have been no well-organized reports on drop finger pattern caused by cervical nerve root disorder. Moreover, diagnosis and treatment are delayed because of the inability to distinguish cervical radiculopathy from peripheral nerve disease. This study aimed to clarify the operative outcome of microscopic cervical foraminotomy (MCF) for cervical radiculopathy presenting drop finger and to investigate whether our classification based on drop finger patterns is useful retrospectively. METHODS: Overall, 22 patients with drop finger who underwent MCF were included. Grip power (GP) and longitudinal manual muscle test (MMT) score of each finger were examined. Drop finger patterns were classified as types I, II, and III. In type I, the extension disorders of the middle and ring fingers are severe and those of index and little fingers are mild. In type II, the extension disorders are severe from the little finger and slightly to index finger. In type III, the extension disorder is consistently severe in all fingers. Perioperative nerve root disorder and paralysis degree were investigated for all types. RESULTS: The mean GP was significantly postoperatively improved in all 22 patients. The mean MMT score would benefit from exact data for almost all muscles, except the abductor pollicis brevis at the last follow-up. However, pre- and postoperative paralyses were severe in type III patients. C7 nerve root disorder was confirmed in 5/6 type I patients and C8 nerve root disorder in 12/13 type II and 3/3 type III patients. CONCLUSIONS: The operative results of MCF were relatively good, except in type III patients. As a certain tendency was confirmed between the drop finger types and injured nerve roots, our classification may be useful in reducing misdiagnosis and improving the operative results to some extent.

The characteristics of the patients with radiologically severe cervical ossification of the posterior longitudinal ligament of the spine: A CT-based multicenter cross-sectional study.

BACKGROUND: Ossification of the posterior longitudinal ligament of the spine (OPLL) is characterized by heterotopic bone formation in the posterior longitudinal ligament of the spine. We know that the size and distribution of the ossified lesions in patients with OPLL are different in each case. However, the characteristics of the patients with radiologically severe cervical OPLL remain unknown. METHODS: The participants of our study were symptomatic patients with cervical OPLL who were diagnosed by standard radiographs of the cervical spine. Whole-spine CT data and demographic data such as age and sex were obtained from 20 institutions belonging to the Japanese Multicenter Research Organization for Ossification of the Spinal Ligament. According to the number of the levels involved by OPLL, we stratified the patients into two subgroups: severe group (S-group) and non-severe group (NS-group) to delineate the characteristics of radiologically severe patients with cervical OPLL. We also evaluated the most compressed level and the degree of occupying ratio of cervical spinal canal by OPLL at the most compressed level. RESULTS: A total of 234 patients with a mean age of 65 years were recruited. The S-group consisted of 48 patients (21%, 12 females and 36 males) and the NS-group consisted of 92 patients (79%, 22 females and 70 males). The mean age of males in the S-group (68 years old) was significantly higher than that of males in the NS-group (64 years old); however there was no significant difference in the mean age in females between the S-group (69 years old) and the NS-group (66 years old). No significant difference of body mass index, ossification of the nuchal ligament-positivity and presence of diabetes mellitus were found between the S- and the NS-group. CONCLUSIONS: It is likely that the manner of extension of cervical OPLL is different between male and female patients.

Co-existence of ossification of the nuchal ligament is associated with severity of ossification in the whole spine in patients with cervical ossification of the posterior longitudinal ligament -A multi-center CT study.

BACKGROUND: Previous studies have shown that patients with cervical ossification of the posterior longitudinal ligament (OPLL) often have co-existing ossification of the nuchal ligament (ONL). However, no studies have focused on ONL and its relevance to the severity of OPLL or ossification of other spinal ligaments, such as anterior longitudinal ligament (OALL), ligamentum flavum (OLF), and supraspinous/interspinous ligament (OSIL). METHODS: In this multicenter study, we investigated ossification of the spinal ligaments in the whole spine computed tomography (CT) images of 233 cervical OPLL patients. The severity of ossification was evaluated using ossification index for each spinal ligament, calculated as the sum of the level of ossification. We compared the severity of ossification in each spinal ligament between patients with ONL and those without ONL. Furthermore, we investigated how the number of segments, where ONL exists, affects the severity of ossification in each spinal ligament. RESULTS: One hundred thirty patients (55.8%) had co-existing ONL in the cervical OPLL patients included in this study. The ONL (+) group included more male and aged patients. The cervical ossification indexes of OPLL and OALL were higher in ONL (+) patients than in ONL (-) patients. The thoracolumbar ossification indexes of OALL and OSIL were also higher in ONL (+) patients. Logistic regression analysis revealed that age, gender and cervical OA-index were independent factors correlating to the existence of ONL. In the cervical spine, both the ossification indexes of OALL and OPLL increased as the levels of ONL increased. Similarly, in the thoracolumbar spine, both the ossification indexes of OALL and OSIL were increased as the levels of cervical ONL increased. In the multiple regression analysis, cervical OA-index and thoracolumbar OSI-index showed significant correlation with the number of ONL levels. CONCLUSIONS: Co-existence of ONL in cervical OPLL patients was associated with the severity of spinal hyperostosis especially in cervical OPLL, OALL, thoracolumbar OALL and OSIL.

Vascular Complication after Collagenase Injection and Manipulation for Dupuytren's Contracture: A Case Report.

A case of a vascular complication after collagenase injection and manipulation for Dupuytren's contracture in a 57-year-old Japanese man is described. The patient presented with a 10-year history of worsening primary Dupuytren's contracture. The metacarpophalangeal joint of his left little finger had a flexion contracture of 40° and was treated by collagenase injection. When the patient returned to our hospital for manipulation 24 hours later, however, his left little finger was almost completely improved because he hit his finger on the car's gear lever. Then, 9 months after collagenase injection, in the first winter, he complained of a painful and pale left little finger occurring a few times a day, lasting for about 10 minutes. Now, two years after collagenase injection, the episodes of Raynaud's phenomenon remain. Although Raynaud's phenomenon after collagenase injection and manipulation for Dupuytren's contracture is considered rare, it is a complication to be noted.

Prevalence and Distribution of Diffuse Idiopathic Skeletal Hyperostosis on Whole-spine Computed Tomography in Patients With Cervical Ossification of the Posterior Longitudinal Ligament: A Multicenter Study.

STUDY DESIGN: This was a retrospective multicenter study. OBJECTIVE: To clarify the progression of diffuse idiopathic skeletal hyperostosis (DISH) using whole-spine computed tomography in patients with cervical ossification of the posterior longitudinal ligament (OPLL). SUMMARY OF BACKGROUND DATA: DISH and cervical OPLL frequently coexist, and can cause ankylosing spinal fractures due to biomechanical changes and fragility of the affected vertebrae. The epidemiology and pathophysiology of DISH occurring with cervical OPLL are unclear. MATERIALS AND METHODS: We used whole-spine computed tomography to determine the prevalence of DISH in 234 patients with a diagnosis of cervical OPLL based on plain cervical radiographs. We established a novel system for grading the progression of DISH based on a cluster analysis of the DISH distribution along the spine. We calculated the correlation coefficient between this grading system and patient age. RESULTS: The prevalence of DISH in patients with cervical OPLL was 48.7%. Patients with DISH were significantly older than those who did not have DISH (67.3 vs. 63.4 y; P=0.005). Cluster analysis classified the DISH distribution into 6 regions, based on the levels affected: C2-C5, C3-T1, C6-T5, T3-10, T8-L2, and T12-S1. DISH was observed most frequently at T3-T10. We defined a system for grading DISH progression based on the number of regions involved, from grade 0 to 6. DISH was distributed at T3-T10 in >60% of the grade 1 patients, whereas most patients with DISH at the cervical or lumbar spine were grade 4 or 5. There was a weak but significant correlation between the DISH grade and patient age. CONCLUSIONS: DISH was present in nearly half of the patients with cervical OPLL. DISH was more common in older patients. DISH developed at the thoracic level and progressed into the cervical and/or lumbar spine with age. LEVEL OF EVIDENCE: Level III.

Distribution of ossified spinal lesions in patients with severe ossification of the posterior longitudinal ligament and prediction of ossification at each segment based on the cervical OP index classification: a multicenter study (JOSL CT study).

BACKGROUND: In patients with ossification of the posterior longitudinal ligament (OPLL) in the cervical spine, it is well known that the thoracic ossified lesions often coexist with the cervical lesions and can cause severe myelopathy. However, the prevalence of OPLL at each level of the thoracic and lumbar spinal segments is unknown. The aims of this study were to investigate how often OPLL occurs at each level in the thoracolumbar spine in patients with a radiological diagnosis of cervical OPLL and to identify the spinal levels most likely to develop ossification. METHODS: Data were collected from 20 institutions in Japan. Three hundred and twenty-two patients with a diagnosis of cervical OPLL were included. The OPLL index (OP index), defined as the sum of the vertebral body and intervertebral disc levels where OPLL is present, was used to determine disease severity. An OP index ≥20 was defined as severe OPLL. The prevalence of OPLL at each level of the thoracic and lumbar spinal segments was calculated. RESULTS: Women were more likely to have ossified lesions in the thoracolumbar spine than men. Severe OPLL was significantly more common in women than in men (20% vs. 4.5%). For thoracic vertebral OPLL, the most frequently affected was the T1 segment in both men and women, followed by the T1/2 and T3/4 intervertebral levels in men and women, respectively. Ossified lesions were frequently seen at the intervertebral and vertebral levels around the cervicothoracic and thoracolumbar junctions in men with severe OPLL, whereas OPLL was more diffusely distributed in the thoracic spine in women with severe OPLL. CONCLUSION: Thoracolumbar OPLL occurred most often at T1 in men and at T3/4 in women. In severe OPLL cases, although ossified lesions were frequently seen at the intervertebral and vertebral levels around the cervicothoracic and thoracolumbar junctions in men, OPLL could be observed more diffusely in the thoracic spine in women.

Prevalence and distribution of ossification of the supra/interspinous ligaments in symptomatic patients with cervical ossification of the posterior longitudinal ligament of the spine: a CT-based multicenter cross-sectional study.

BACKGROUND: Supra/interspinous ligaments connect adjacent spinous processes and act as a stabilizer of the spine. As with other spinal ligaments, it can become ossified. However, few report have discussed ossification supra/interspinous ligaments (OSIL), so its epidemiology remains unknown. We therefore aimed to investigate the prevalence and distribution of OSIL in symptomatic patients with cervical ossification of the posterior longitudinal ligament (OPLL). METHODS: The participants of our study were symptomatic patients with cervical OPLL who were diagnosed by standard radiographs of the cervical spine. The whole spine CT data as well as clinical parameters such as age and sex were obtained from 20 institutions belong to the Japanese Multicenter Research Organization for Ossification of the Spinal Ligament (JOSL). The prevalence and distribution of OSIL and the association between OSIL and clinical parameters were reviewed. The sum of the levels involved by OPLL (OP-index) and OSIL (OSI-index) as well as the prevalence of ossification of the nuchal ligament (ONL) were also investigated. RESULTS: A total of 234 patients with a mean age of 65 years was recruited. The CT-based evidence of OSIL was noted in 68 (54 males and 14 females) patients (29%). The distribution of OSIL showed a significant thoracic preponderance. In OSIL-positive patients, single-level involvement was noted in 19 cases (28%), whereas 49 cases (72%) presented multi-level involvement. We found a significant positive correlation between the OP-index grade and OSI-index. ONL was noted at a significantly higher rate in OSIL-positive patients compared to negative patients. CONCLUSIONS: The prevalence of OSIL in symptomatic patients with cervical OPLL was 29%. The distribution of OSIL showed a significant thoracic preponderance.

Smad2/3 Proteins Are Required for Immobilization-induced Skeletal Muscle Atrophy.

Skeletal muscle atrophy promotes muscle weakness, limiting activities of daily living. However, mechanisms underlying atrophy remain unclear. Here, we show that skeletal muscle immobilization elevates Smad2/3 protein but not mRNA levels in muscle, promoting atrophy. Furthermore, we demonstrate that myostatin, which negatively regulates muscle hypertrophy, is dispensable for denervation-induced muscle atrophy and Smad2/3 protein accumulation. Moreover, muscle-specific Smad2/3-deficient mice exhibited significant resistance to denervation-induced muscle atrophy. In addition, expression of the atrogenes Atrogin-1 and MuRF1, which underlie muscle atrophy, did not increase in muscles of Smad2/3-deficient mice following denervation. We also demonstrate that serum starvation promotes Smad2/3 protein accumulation in C2C12 myogenic cells, an in vitro muscle atrophy model, an effect inhibited by IGF1 treatment. In vivo, we observed IGF1 receptor deactivation in immobilized muscle, even in the presence of normal levels of circulating IGF1. Denervation-induced muscle atrophy was accompanied by reduced glucose intake and elevated levels of branched-chain amino acids, effects that were Smad2/3-dependent. Thus, muscle immobilization attenuates IGF1 signals at the receptor rather than the ligand level, leading to Smad2/3 protein accumulation, muscle atrophy, and accompanying metabolic changes.