Influence of Diabetes Mellitus on Surgical Outcomes in Patients with Cervical Myelopathy: A Prospective, Multicenter Study.

STUDY DESIGN: Multicenter, prospective study. PURPOSE: To investigate the effects of diabetes mellitus (DM) on surgical outcomes in patients with cervical myelopathy. OVERVIEW OF LITERATURE: To date, few studies have investigated the influence of postoperative blood glucose or glycated hemoglobin (HbA1c) levels on surgical outcomes. METHODS: The participants were patients who underwent surgery for the treatment of cervical spondylotic myelopathy and ossification of the posterior longitudinal ligament. The 61 cases were evaluated preoperatively and 1 year postoperatively using the Japanese Orthopaedic Association (JOA) scores and the JOA Cervical Myelopathy Evaluation Questionnaire (JOACMEQ). The study variables included fasting blood glucose and HbA1c levels measured preoperatively and at 1 week, 4 weeks, and 1 year postoperatively; the F-wave conduction velocity, latency, rate of occurrence, and M-wave latency in the ulnar and tibial nerves were measured preoperatively and at 1 year postoperatively. The patients were divided into a group without diabetes (N group, 42 patients) and a group with diabetes (DM group, 19 patients). We then assessed the associations between the surgical outcomes and each of the study variables. RESULTS: JOA scores significantly improved in both groups; however, no significant between-group differences were found. There was no significant improvement in the JOACMEQ scores, which assessed cervical function, upper and lower limb function, and bladder function in both groups. We then subdivided the DM group into those with a good control of HbA1c after 1 year (DMG group, 12 patients) and those with HbA1c deterioration after 1 year (DMB group, seven patients), prior to comparing the surgical outcomes. The JOACMEQ scores for upper and lower limb function significantly improved in the DMG group (p<0.01). Compared with the DMB group, there were no significant increases in upper or lower limb function scores in the DMG group. CONCLUSIONS: Poor glycemic control might prevent postoperative functional recovery of the spinal cord.

Morphological and volumetric analysis of the development of atlantoaxial vertical subluxation in rheumatoid arthritis.

BACKGROUND: Cervical disorders in rheumatoid arthritis (RA) patients have been an important problem for a long time. Although the recent progression of the treatment strategies for RA might change the progression of atlantoaxial vertical subluxation (VS) in RA patients, to reveal the risk factors for VS progression should be important at present. Osteoporosis (OP) and RA share the same risk factors. The purposes of this study were to identify the progression of VS in RA, and to evaluate the relationship between the VS development and OP. METHODS: Eighty female patients with RA and 18 female patients with OP were retrospectively analyzed. The RA patients were divided into VS (10 patients) and non-VS groups (70 patients). Morphological parameters on coronal reconstructed computed tomography images were evaluated. Three-dimensional analysis was used to measure volumes and volumetric bone mineral densities (vBMDs) at the upper cervical spine (UCS). RESULTS: The VS group had higher age, longer RA symptom duration, and lower BMD at the lumbar spine compared to the non-VS group. Volumes and vBMDs at the UCS in RA group were greater than those in the OP group. In accordance with VS development, the lateral masses at the UCS became shorter, the C1 facet angle became sharper, and the volumes at the UCS decreased. However, there was no statistically significant relationship between vBMDs at the UCS and the VS development. CONCLUSION: The C1 facet angle became sharper with VS progression. Although 3-dimensional analysis revealed that decreases in the volumes at the UCS were associated with VS development, no significant relationship between OP and the VS development was observed.

Clinical features and surgical outcomes of lumbar spinal stenosis in patients aged 80 years or older: a multi-center retrospective study.

INTRODUCTION: With increased aging of the population, spine surgeons have more opportunity to treat elderly patients for lumbar spinal stenosis (LSS). The purpose of this study was to clarify the clinical features and surgical outcomes for LSS in the elderly aged 80 years or older. MATERIALS AND METHODS: We retrospectively reviewed 702 consecutive patients with LSS who underwent decompression surgery without fusion between 2006 and 2010. Patients with other conditions that could affect functional status were excluded from this study. Of the remaining 304 patients, 241 with LSS whose condition could be evaluated 6 months at least after surgery were analyzed. The mean follow-up period was 14.4 months (range 6-60 months). There were 144 males and 97 females aged 45-93 years old (average: 72.2 years old). Patients were divided into two age groups: 80 years or older (Group A, 46 patients) and under 80 years of age (Group B, 195 patients). We evaluated differences in the clinical features and surgical outcomes between the two groups. RESULTS: There were no significant differences in surgical levels, the number of operation levels, operation times, or the amount of intraoperative bleeding between Groups A and B. The percentages of patients with comorbidities were 73.9 % in Group A and 60.0 % in Group B, which were not significantly different. There were no significant differences in Japanese Orthopaedic Association scores preoperatively, 6 months postoperatively, and at the final follow-up between the two groups. Furthermore, recovery ratios 6 months postoperatively and at final follow-up were similar between the two groups. The percentages of patients with postoperative complications were 19.6 % in Group A and 13.3 % in Group B, which were not significantly different. CONCLUSIONS: This multi-center retrospective study demonstrated that the benefits and risks of decompression surgery for LSS were similar between patients aged over 80 years and those under 80 years. Therefore, decompression surgery is a reasonable treatment even for elderly patients aged over 80 years.

Influence of spinous process spacers on surgical outcome of laminoplasty for OPLL.

Expansive laminoplasty for ossification of the posterior longitudinal ligament (OPLL) has had favorable outcomes. Many modifications of expansive laminoplasty have been developed, including expansive laminoplasty with and without spinous process spacers (SPS). The purpose of this study was to determine whether surgical outcomes were similar between expansive laminoplasty surgeries with and without SPS.Of 109 consecutive patients undergoing surgery for OPLL, 68 patients undergoing expansive laminoplasty were included in the study after excluding patients with other conditions affecting their functional status. The patients were divided into 2 groups based on their K-line, which connects the midpoints of the spinal canal at C2 and C7. Patients were further divided into 2 subgroups: those undergoing expansive laminoplasty without SPS (without SPS group) and those undergoing expansive laminoplasty with SPS (with SPS group). Surgical outcomes were evaluated between K-line (+) and K-line (-) groups. After dividing those groups further into the with SPS and without SPS groups, the differences in surgical outcomes were evaluated again.No significant difference existed in the recovery rate between the with SPS and without SPS groups and between the K-line (+) and K-line (-) groups. When the surgical outcome was only evaluated in the K-line (+) group, the recovery rate 1 year postoperatively was higher in patients without SPS than in those with SPS. Therefore, for patients with K-line (+), the possibility exists that SPS can restrict the posterior shift of the spinal cord and affect the surgical outcome.

Early surgical intervention for spinal infection in patients with malignancy requiring chemotherapy: report of two cases and review of the literature.

Advances in chemotherapy for various malignancies have contributed to the increased life expectancy of patients. If such a patient has a concurrent infection, his/her oncologist would hesitate to perform prompt chemotherapy owing to the risk of inducing sepsis. Therefore, the treatment of infection would have priority over initiating chemotherapy for the malignancy. We present a 69-year-old female with malignant lymphoma requiring prompt chemotherapy who also demonstrated spinal infection with Mycobacterium tuberculosis and a 66-year-old male with esophageal cancer who also demonstrated spinal infection with Staphylococcus aureus. Anterior debridement and interbody fusion were performed for both patients. One patient died of malignant lymphoma 4 years after surgery, and the other is still alive and has remained disease-free 4 years after surgery. Saving the life of a patient with malignancy would be difficult without prompt chemotherapy. Conservative treatment for spinal infection requires prolonged antibiotic treatment, and there is no guarantee that the spinal infection would be controlled only with antibiotics. Therefore, early surgical intervention would be an alternative option under such a condition.

Clinical features of spinal infection in individuals older than eighty years.

PURPOSE: Japan has one of the most rapidly increasing numbers of elderly individuals; therefore, future trends in spinal infections in the elderly in other countries may be predicted by studying such characteristics in Japan. The purposes of this study were to identify whether the incidence of spinal infection in individuals more than 80 years old is increasing and to define its clinical characteristics. METHODS: We retrospectively reviewed the medical records of 98 patients treated in our hospital for spinal infection between 1999 and 2008. Patients were divided into two groups: those admitted to our hospital during the initial five year period, and those admitted during the latter five year period. We evaluated changes in the percentage of individuals over the age of 80 years. To define the clinical characteristics of spinal infection, patients were also divided into another set of two groups: those over 80 years and those around the age of 80 years. RESULTS: The percentage of patients over 80 years with spinal infection was significantly increasing. There was no significant difference in the gender distribution, prevalence of immunocompromised hosts, common involved levels, or mortality rate between the two age groups. The pathogenic organism was isolated in 78.6%, and of these, the rate of methicillin-resistant Staphylococcus aureus or epidermidis was 2.46 times higher in the elderly group than in the younger group. CONCLUSIONS: The number of patients over 80 years with spinal infection is expected to rapidly increase in aging societies. This advanced age group is more susceptible to infection with drug-resistant organisms, which makes infection management more difficult.

Surgical outcomes and prognostic factors of cervical spondylotic myelopathy in diabetic patients.

BACKGROUND: There have been a few reports on the surgical outcomes of cervical myelopathy in diabetic patients; however, those studies included ossification of the posterior longitudinal ligament. This study investigated whether surgical outcome of expansive laminoplasty (ELAP) for diabetic patients with cervical spondylotic myelopathy (CSM) differs from that for non-diabetic patients and determined prognostic factors in diabetic patients. METHODS: We retrospectively reviewed 78 patients with CSM after excluding the cases with other medical conditions, which could affect surgical outcome from 222 consecutive patients who had undergone ELAP between 2000 and 2008 in our hospital. The patients were divided into two groups: diabetic patients (Group 1) and non-diabetic patients (Group 2). We evaluated differences in age, gender, pre- and postoperative Japanese Orthopaedic Association (JOA) score, recovery rate (RR), symptom duration, and postoperative complications between the two groups. In Group 1, the correlation between RR and factors indicating the severity of diabetes mellitus was assessed. RESULTS: There were 13 patients in Group 1 and 65 in Group 2. There was no significant difference in age, gender, JOA score before or after surgery, or symptom duration between the two groups. Group 1 showed poorer recovery of sensory and motor function in the lower extremities. A negative correlation was observed between RR and the preoperative hemoglobin A(1c) (HbA(1c)) level in Group 1. CONCLUSIONS: Diabetic patients experienced benefits from ELAP similar to non-diabetic patients. A negative correlation between RR and preoperative HbA(1c) level suggests that strict blood sugar control is recommended before surgery.

Clinical features and surgical outcomes of cervical spondylotic myelopathy in patients aged 80 years or older: a multi-center retrospective study.

With the aging of the population in developed countries, spine surgeons have recently been more likely to encounter elderly patients in need of treatment. This study investigated whether decompression surgery for cervical spondylotic myelopathy (CSM) in elderly patients aged 80 years or older would likely be a reasonable treatment. We retrospectively reviewed 605 consecutive patients with cervical myelopathy who underwent decompression surgery between 2004 and 2008. Patients with other conditions that could affect functional status or compression factors other than spondylosis were excluded from this study. Of the remaining 189 patients, 161 with CSM whose condition could be evaluated 6 months after surgery were analyzed. The patients were divided into two age groups: 80 years or older (Group A, 37 patients) and younger than 80 years of age (Group B, 124 patients). We evaluated the differences in symptom duration, clinical data, involved levels, surgical outcome, comorbidities, and postoperative complications between the two groups. The symptom duration was significantly shorter in Group A. The average JOA scores preoperatively and 6 months postoperatively were significantly lower in Group A; however, there was no significant difference in the recovery ratio. There were no significant differences in the percentages of patients with comorbidities or those with postoperative complications. Elderly patients aged 80 years or older regained approximately 40% of their function postoperatively, and the incidence of postoperative complication was similar to that in younger patients. Since this age group shows a rapid deterioration after onset, prompt decompression surgery is required.

Spinal subdural haematoma concurrent with cranial subdural haematoma: Report of two cases and review of literature.

Subdural haematomas co-existing in the cranium and spine are considered extremely rare. We report 2 cases demonstrating the condition described here with a review of literature. One of these 2 patients was the first case in which the spinal lesion was found before the cranial lesion. A 66-year-old man without trauma presented with paraparesis accompanied by severe leg pain. The patient was diagnosed as having spinal subdural haematoma extending from L1 to S1 vertebral levels with magnetic resonance images (MRI). Two days after admission, the patient developed disorientation and abnormal behavior; therefore, computed tomography (CT) of brain was performed, and chronic cranial subdural haematoma was observed. A 60-year-old man who developed headache showing gradually progressive was diagnosed as having cranial subdural haematoma on CT. Three days after admission, he became insomnolent due to severe low back pain radiating to ankle. On MRI, subdural haematoma was found extending from L3/4 to S2 vertebral levels. Only brain surgery was performed for all cases by the neurosurgeons. Paraparesis and severe leg pain, which were derived from spinal lesions, showed recovery approximately 2 weeks after onset and spinal subdural haematoma was completely resolved on MRI obtained 2 or 5 months after onset, respectively. There is a possibility that the incidence of spinal subdural haematoma concurrent with cranial subdural haematoma could be underestimated because the doctor had not obtained CT or MRI of the brain. Doctors should aware of such a condition and check patients with spinal subdural haematoma for neurological signs derived from brain lesions. Spontaneous resolution of spinal subdural haematoma was observed; therefore, surgery for this condition should be indicated only for patients with moderate or severe paraparesis or paraparesis deteriorated.

High-resolution nuclear magnetic resonance spectroscopic study of metabolites in the cerebrospinal fluid of patients with cervical myelopathy and lumbar radiculopathy.

There have been few reports describing substances related to oxidative and intermediary metabolism in the cerebrospinal fluid (CSF) in patients with spinal degenerative disorders. This study investigated whether the concentrations of metabolites in the CSF differed between patients with spinal degenerative disorders and controls, and whether the concentrations of these metabolites correlated with the severity of symptoms. CSF samples were obtained from 30 patients with cervical myelopathy (Group M), 30 patients with lumbar radiculopathy (Group R), and 10 volunteers (control). Metabolites in these CSF samples were measured by nuclear magnetic resonance spectroscopy. There were no differences in the concentrations of lactate, alanine, acetate, glutamate, pyruvate, or citrate between Groups M and R, between Group M and the control, or between Group R and the control. In Group M, neither symptom duration nor the Japanese Orthopaedic Association score correlated with the concentration of any metabolite. In Group R, the symptom duration positively correlated with the concentration of lactate, glutamate, and citrate in CSF. The duration of nerve root block showed a negative correlation with the concentrations of acetate in CSF of the patients in Group R. In patients with lumbar radiculopathy, there is a possibility of increased aerobic metabolic activity or decreased gluconeogenic activity in patients with shorter symptom duration, and increased aerobic metabolic activity in patients with severe inflammation around a nerve root.

Recent trends in spinal infections: retrospective analysis of patients treated during the past 50 years.

We retrospectively reviewed the medical charts of 210 consecutive patients treated for spinal infection in Tottori University Hospital in Japan between 1956 and 2005. Until 1995, spinal infection was under control in this series; however, during the last decade, it has been on the rise. Male predominance had been gradually progressing, and 69% of the patients were male during the last decade. Patients with spinal infection were aging, and the ratio of immunocompromised hosts dramatically increased to 53%. Until 1995, the percentage of patients with tuberculous spondylitis had been declining; however, the incidence has been on the rise during the last ten years. The organism was detected in 64% of patients treated between 1996 and 2005, of which Staphylococcus aureus was detected in 49%. Moreover, methicillin-resistant S. aureus was detected in 61% of patients with S. aureus. There were no immigrants or cases with human immunodeficiency virus in this series.

Tumor necrosis factor-alpha, interleukin-1beta, and interleukin-6 in the cerebrospinal fluid of patients with cervical myelopathy and lumbar radiculopathy.

There have been few reports describing cytokines in the cerebrospinal fluid (CSF) of patients with spinal degenerative disorders. This study investigated whether interleukin-1beta (IL-1beta), interleukin-6 (IL-6), and tumor necrosis factor-alpha (TNF-alpha) could be detected in CSF of patients with cervical myelopathy or lumbar radiculopathy and whether the concentrations of those cytokines correlated with the severity of disease conditions. CSF samples were obtained from 21 patients with cervical myelopathy (Group M) and 19 patients with lumbar radiculopathy (Group R), and six volunteers (control). The concentration of IL-6 was significantly higher in Groups M and R than in the control, possibly demonstrating spinal cord and nerve root damage, respectively. However, TNF-alpha was lower than the detection limit. IL-1beta was detected in only five samples from three patients in Group M and two volunteers in the control. The concentrations of IL-6 did not show any correlation with symptom duration, the scoring system by the Japanese Orthopaedic Association, or the duration of nerve root block. There is a possibility that the concentration of inflammatory cytokines in CSF can indicate certain pathological aspects of cervical myelopathy or lumbar radiculopathy.

Correlation between bone mineral density and intervertebral disk degeneration in pre- and postmenopausal women.

The purpose of this study was to investigate the relationship between intervertebral disk degeneration and bone mass. Magnetic resonance imaging was performed to evaluate lumbar disk degeneration according to Thompson's classification (grades 1 and 2, normal disk; grades 3, 4, and 5, degenerated disk), and bone mineral density (BMD) in the lumbar vertebrae, radius, and calcaneus was measured by dual-energy X-ray absorptiometry for 90 women (22-74 years old). The relationship between the grade of intervertebral disk degeneration and the BMD ( Z score) was analyzed in pre- and postmenopausal women. In premenopausal women, BMD was significantly higher at all measured sites in the degenerated disk group judged at the L5-S1 level than in the normal disk group ( P < 0.05). In postmenopausal women, BMD was significantly higher at the anteroposterior L2-L4, lateral L3, and calcaneus in the degenerated disk group judged at the L2-L3 level than in the normal disk group ( P < 0.05). BMD at the anteroposterior L2-L4 and calcaneus was significantly higher in the degenerated disk group judged at the L3-L4 level than in the normal disk group ( P < 0.05). In conclusion, the BMD of not only the lumbar vertebrae but also the calcaneus and radius was mutually related to lumbar intervertebral disk degeneration from an early stage of degeneration.