Comparison of surgical outcomes of posterior surgeries between cervical spondylotic myelopathy and ossification of the posterior longitudinal ligament.

STUDY DESIGN: Retrospective multicenter study. OBJECTIVE: To compare the surgical outcomes and complications of posterior decompression between individuals with cervical spondylotic myelopathy (CSM) and those with ossification of the posterior longitudinal ligament (OPLL). SETTING: Seventeen medical institutions in Japan. METHODS: This study included 814 individuals with CSM (n = 636) and OPLL (n = 178) who underwent posterior decompression. Propensity score matching of the baseline characteristics was performed to compare surgical outcomes and perioperative complications between the CSM and OPLL groups. RESULTS: Before propensity score matching, the OPLL group had higher percentage of male individuals, body mass index, and number of stenosis levels and longer duration of symptoms (P < 0.01, P < 0.01, P < 0.01, and P < 0.01, respectively). After matching, the baseline characteristics were comparable between the CSM (n = 98) and OPLL (n = 98) groups. The postoperative Japanese Orthopaedic Association (JOA) scores, preoperative-to-postoperative changes in the JOA scores, and JOA score recovery rates were not significantly different between the groups (P = 0.42, P = 0.47, and P = 0.09, respectively). The postoperative visual analog scale (VAS) score for neck pain and preoperative-to-postoperative changes in the VAS score for neck pain were not significantly different between the groups (P = 0.25 and P = 0.50, respectively). The incidence of perioperative complications was comparable between groups. CONCLUSION: Neurological improvement and complication rates after surgery were comparable between individuals with CSM and those with OPLL, suggesting similar effectiveness and safety of posterior decompression for both conditions.

Changes in cross-sectional areas of posterior extensor muscles in thoracic spine: a 10-year longitudinal MRI study.

Age-related changes in the posterior extensor muscles of the cervical and lumbar spine have been reported in some studies; however, longitudinal changes in the thoracic spine of healthy subjects are rarely reported. Therefore, this study aimed to evaluate changes in the cross-sectional areas (CSAs) of posterior extensor muscles in the thoracic spine over 10 years and identify related factors. The subjects of this study were 85 volunteers (mean age: 44.7 ± 11.5) and the average follow-up period was about 10 years. The CSAs of the transversospinalis muscles, erector spinae muscles, and total CSAs of the extensor muscles from T1/2 to T11/12 were measured on magnetic resonance imaging. The extent of muscle fat infiltration was assessed by the signal intensity (luminance) of the extensor muscles' total cross-section compared to a section of pure muscle. We applied a Poisson regression model, which is included in the generalized linear model, and first examined the univariate (crude) association between each relevant factor (age, sex, body mass index, lifestyle, back pain, neck pain, neck stiffness, and intervertebral disc degeneration) and CSA changes. Then, we constructed a multivariate model, which included age, sex, and related factors in the univariate analysis. The mean CSAs of the transversospinalis muscles, erector spinae muscles, and total CSAs of the extensor muscles significantly increased over 10 years. Exercise habit was associated with increased CSAs of the erector spinae muscles and the total area of the extensor muscles. The cross-section mean luminance significantly increased from baseline, indicating a significant increase of fat infiltration in the posterior extensor muscles. Progression of disc degeneration was inversely associated with increased fat infiltration in the total extensor muscles.

Effect of low body mass index on clinical recovery after fusion surgery for osteoporotic vertebral fracture: A retrospective, multicenter study of 237 cases.

A retrospective multicenter study. Body mass index (BMI) is recognized as an important determinant of osteoporosis and spinal postoperative outcomes; however, the specific impact of BMI on surgery for osteoporotic vertebral fractures (OVFs) remains inconclusive. This retrospective multicenter study investigated the impact of BMI on clinical outcomes following fusion surgery for OVFs. 237 OVF patients (mean age, 74.3 years; 48 men and 189 women) with neurological symptoms who underwent spinal fusion were included in this study. Patients were grouped by World Health Organization BMI categories: low BMI (<18.5 kg/m2), normal BMI (≥18.5 and <25 kg/m2), and high BMI (≥25 kg/m2). Patients' backgrounds, surgical method, radiological findings, pain measurements, activities of daily living (ADL), and postoperative complications were compared after a mean follow-up period of 4 years. As results, the proportion of patients able to walk independently was significantly smaller in the low BMI group (75.0%) compared with the normal BMI group (89.9%; P = .01) and the high BMI group (94.3%; P = .04). Improvement in the visual analogue scale for leg pain was significantly less in the low BMI group than the high BMI group (26.7 vs 42.8 mm; P = .046). Radiological evaluation, the Frankel classification, and postoperative complications were not significantly different among all 3 groups. Improvement of pain intensity and ADL in the high BMI group was equivalent or non-significantly better for some outcome measures compared with the normal BMI group. Leg pain and independent walking ability after fusion surgery for patients with OVFs improved less in the low versus the high BMI group. Surgeons may want to carefully evaluate at risk low BMI patients before fusion surgery for OVF because poor clinical results may occur.

The Long-term Impact of Whiplash Injuries on Patient Symptoms and the Associated Degenerative Changes Detected Using MRI: A Prospective 20-year Follow-up Study Comparing Patients with Whiplash-associated Disorders with Asymptomatic Subjects.

STUDY DESIGN: A longitudinal, 20-year comparative study of patients with whiplash-associated disorders (WAD). OBJECTIVE: The aim of this study was to clarify the long-term impact of WAD on patient symptoms and on magnetic resonance imaging (MRI) findings of the cervical spine, in comparison with asymptomatic volunteers. SUMMARY OF BACKGROUND DATA: The long-term impact of WAD has not been fully elucidated. METHODS: Between 1993 and 1996, we conducted a cross-sectional comparative study of 508 acute WAD patients and 497 asymptomatic volunteers, all of whom underwent MRI on cervical spine and physical examinations. For this 20-year follow-up comparative study, 75 WAD patients and 181 control subjects aged <60 years were recruited from the original cohort. The MRI findings, including discs' signal intensities, posterior disc protrusions, anterior dural compressions, spinal cord disc space narrowing, and foraminal stenoses, were evaluated using two to four numerical grades. The results of the WAD patients and control subjects were compared. RESULTS: In this follow-up, the prevalence of shoulder stiffness (72.0% vs. 45.9%), headache (24.0% vs. 12.2%), and arm pain (13.3% vs. 3.9%) were significantly greater in WAD patients than in control subjects. The multiregression analysis revealed that a history of WAD was associated with shoulder stiffness (odds ratio [OR]: 3.36), headache (OR: 2.39), and arm pain (OR: 3.82). Although MRI findings in WAD patients were more degenerated than in control subjects in the initial study, all MRI findings were similar at the 20-year follow-up. There were no significant correlations between clinical cervical symptoms and progression in each MR finding in either group. CONCLUSION: After 20 years, whiplash injuries significantly impacted the residual symptoms of shoulder stiffness, headache, and arm pain when compared with initially asymptomatic volunteers. The progression of degenerative changes in the cervical intervertebral discs after 20 years revealed no association with existing whiplash injuries, neither did the residual cervical-related symptoms.Level of Evidence: 3.

Diabetes Does Not Adversely Affect Neurological Recovery and Reduction of Neck Pain After Posterior Decompression Surgery for Cervical Spondylotic Myelopathy: Results From a Retrospective Multicenter Study of 675 Patients.

STUDY DESIGN: Retrospective multicenter study. OBJECTIVE: The aim of this study was to identify the impact of diabetes on surgical outcomes of posterior decompression for cervical spondylotic myelopathy (CSM). SUMMARY OF BACKGROUND DATA: Although some previous studies have reported surgical outcomes of posterior decompression for CSM in diabetic patients, their results were inconsistent. METHODS: We included 675 patients with CSM who underwent posterior decompression. Patients were divided into diabetic (n = 140) and nondiabetic (n = 535) groups according to the diabetic criteria for glucose intolerance. Surgical outcomes as assessed by the Japanese Orthopedic Association (JOA) scores and visual analog scale (VAS) for neck pain were compared between groups. Subsequently, the functional outcomes of diabetic patients were compared between the mild (n = 131) and moderately severe (n = 9) groups. All patients were followed up for at least 1 year after surgery. RESULTS: Compared with the nondiabetic group, the diabetic group showed lower pre- and postoperative JOA scores (P = 0.025 and P = 0.001, respectively) and a lower JOA score recovery rate (RR) (P = 0.009). However, the preoperative-to-postoperative changes in JOA scores in the diabetic and nondiabetic groups were not significantly different (P = 0.988). Pre- and postoperative VAS for neck pain and postoperative reduction of neck pain were comparable between groups (P = 0.976, P = 0.913 and P = 0.688, respectively). Although statistical analysis was not performed due to the small underpowered sample size, functional outcomes assessed by the JOA score RR (43.3 ±â€Š37.1% vs. 45.3 ±â€Š33.9%) and preoperative-to-postoperative changes in JOA scores (3.0 ±â€Š2.2 vs. 2.7 ±â€Š2.5) were similar between the mild and moderately severe diabetes groups. CONCLUSION: CSM patients with diabetes experienced improvements in neurological function and neck pain as a result of posterior decompression to the same extent seen in patients without diabetes.Level of Evidence: 3.

The Surgical Outcomes of Spinal Fusion for Osteoporotic Vertebral Fractures in the Lower Lumbar Spine with a Neurological Deficit.

INTRODUCTION: Osteoporotic vertebral fracture (OVF) is the most common osteoporotic fracture, and some patients require surgical intervention to improve their impaired activities of daily living with neurological deficits. However, many previous reports have focused on OVF around the thoracolumbar junction, and the surgical outcomes of lumbar OVF have not been thoroughly discussed. We aimed to investigate the surgical outcomes for lumbar OVF with a neurological deficit. METHODS: Patients who underwent fusion surgery for thoracolumbar OVF with a neurological deficit were enrolled at 28 institutions. Clinical information, comorbidities, perioperative complications, Japanese Orthopaedic Association scores, visual analog scale scores, and radiographic parameters were compared between patients with lower lumbar fracture (L3-5) and those with thoracolumbar junction fracture (T10-L2). Each patient with lower lumbar fracture (L group) was matched with to patients with thoracolumbar junction fracture (T group). RESULTS: A total 403 patients (89 males and 314 females, mean age: 73.8 ± 7.8 years, mean follow-up: 3.9 ± 1.7 years) were included in this study. Lower lumbar OVF was frequently found in patients with lower bone mineral density. After matching, mechanical failure was more frequent in the L group (L group: 64%, T group: 39%; p < 0.001). There was no difference between groups in the clinical and radiographical outcomes, although the rates of complication and revision surgery were still high in both groups. CONCLUSIONS: The surgical intervention for OVF is effective in patients with myelopathy or radiculopathy regardless of the surgical level, although further study is required to improve clinical and radiographical outcomes. LEVEL OF EVIDENCE: Level III.

Surgical Treatment of Osteoporotic Vertebral Fracture with Neurological Deficit-A Nationwide Multicenter Study in Japan.

INTRODUCTION: The prevalence of patients with osteoporosis continues to increase in aging societies, including Japan. The first choice for managing osteoporotic vertebral compression fracture (OVF) is conservative treatment. Failure in conservative treatment for OVF may lead to non-union or vertebral collapse, resulting in neurological deficit and subsequently requiring surgical intervention. This multicenter nationwide study in Japan was conducted to comprehensively understand the outcomes of surgical treatments for OVF non-union. METHODS: This multicenter, retrospective study included 403 patients (89 males, 314 females, mean age 73.8 ± 7.8 years, mean follow-up 3.9 ± 1.7 years) with neurological deficit due to vertebral collapse or non-union after OVF at T10-L5 who underwent fusion surgery with a minimum 1-year follow-up. Radiological and clinical outcomes at baseline and at the final follow-up (FU) were evaluated. RESULTS: OVF was present at a thoracolumbar junction such as T12 (124 patients) and L1 (117 patients). A majority of OVF occurred after a minor trauma, such as falling down (55.3%) or lifting objects (8.4%). Short segment fusion, including affected vertebra, was conducted (mean 4.0 ± 2.0 vertebrae) with 256.8 minutes of surgery and 676.1 g of blood loss. A posterior approach was employed in 86.6% of the patients, followed by a combined anterior and posterior (8.7%), and an anterior (4.7%) approach. Perioperative complications and implant failures were observed in 18.1% and 41.2%, respectively. VAS scores of low back pain (74.7 to 30.8 mm) and leg pain (56.8 to 20.7 mm) improved significantly at FU. Preoperatively, 52.6% of the patients were unable to walk and the rate of non-ambulatory patients decreased to 7.5% at FU. CONCLUSIONS: This study demonstrated that substantial improvement in activity of daily living (ADL) was achieved by fusion surgery. Although there was a considerable rate of complications, fusion surgery is beneficial for elderly OVF patients with non-union.

Complications after spinal fixation surgery for osteoporotic vertebral collapse with neurological deficits: Japan Association of Spine Surgeons with ambition multicenter study.

BACKGROUND: There have been few reports on the incidence and risk factors of the complications after spinal fixation surgery for osteoporotic vertebral collapse (OVC) with neurological deficits. This study aimed to identify the incidence and risk factors of the complications after OVC surgery. METHODS: In this retrospective multicenter study, a total of 403 patients (314 women and 89 men; mean age 73.8 years) who underwent spinal fixation surgery for OVC with neurological deficits between 2005 and 2014 were enrolled. Data on patient demographics were collected, including age, sex, body mass index, smoking, steroid use, medical comorbidities, and surgical procedures. All postoperative complications that occurred within 6 weeks were recorded. Patients were classified into two groups, namely, complication group and no complication group, and risk factors for postoperative complications were investigated by univariate and multivariate analyses. RESULTS: Postoperative complications occurred in 57 patients (14.1%), and the most common complication was delirium (5.7%). In the univariate analysis, the complication group was found to be older (p = 0.039) and predominantly male (p = 0.049), with higher occurrence rate of liver disease (p = 0.001) and Parkinson's disease (p = 0.039) compared with the no-complication group. In the multivariate analysis, the significant independent risk factors were age (p = 0.021; odds ratio [OR] 1.051, 95% confidence interval [CI] 1.007-1.097), liver disease (p < 0.001; OR 8.993, 95% CI 2.882-28.065), and Parkinson's disease (p = 0.009; OR 3.636, 95% CI 1.378-9.599). CONCLUSIONS: Complications after spinal fixation surgery for OVC with neurological deficits occurred in 14.1%. Age, liver disease, and Parkinson's disease were demonstrated to be independent risk factors for postoperative complications.

Association of Susceptibility Genes for Adolescent Idiopathic Scoliosis and Intervertebral Disc Degeneration With Adult Spinal Deformity.

STUDY DESIGN: Genetic case-control study of single nucleotide polymorphisms (SNPs). OBJECTIVE: To examine the association of previously reported susceptibility genes for adolescent idiopathic scoliosis (AIS) and intervertebral disc (IVD) degeneration with adult spinal deformity (ASD). SUMMARY OF BACKGROUND DATA: ASD is a spinal deformity that develops and progresses with age. Its etiology is unclear. Several ASD susceptibility genes were recently reported using a candidate gene approach; however, the sample sizes were small and associations with ASD development were not determined. METHODS: ASD was defined as structural scoliosis with a Cobb angle more than 15° on standing radiographs, taken of patients at age 40 to 75 years in this study. Subjects in whom scoliosis was diagnosed before age 20 were excluded. We recruited 356 Japanese ASD subjects and 3341 healthy controls for case-control association studies of previously reported SNPs. We genotyped four known AIS-associated SNPs (rs11190870 in LBX1, rs6570507 in GPR126, rs10738445 in BNC2, and rs6137473 in PAX1) and three IVD degeneration-associated SNPs (rs1245582 in CHST3, rs2073711 in CILP, and rs1676486 in COL11A1) by the Invader assay. RESULTS: Among the AIS-associated SNPs, rs11190870 and rs6137473 showed strong and nominal associations with ASD (P = 1.44 × 10, 1.00 × 10, respectively). Of the IVD degeneration-associated SNPs, rs1245582 and rs2073711 showed no association with ASD, while rs1676486 showed a nominal association (P = 1.10 × 10). In a subgroup analysis, rs11190870 was significantly associated with a Cobb angle more than 20° in the minor thoracic curve (P = 1.44 × 10) and with a left convex lumbar curve (P = 6.70 × 10), and nominally associated with an apical vertebra higher than L1 (P = 1.80 × 10). CONCLUSION: rs11190870 in LBX1, a strong susceptibility SNP for AIS, may also be a susceptibility SNP for ASD. Thus, ASD and AIS may share a common genetic background. LEVEL OF EVIDENCE: 4.

Ten-year Longitudinal Follow-up MRI Study of Age-related Changes in Thoracic Intervertebral Discs in Asymptomatic Subjects.

STUDY DESIGN: Prospective longitudinal study. OBJECTIVE: The aim of this study was to evaluate long-term degenerative changes in intervertebral discs in the thoracic spine in healthy asymptomatic subjects. SUMMARY OF BACKGROUND DATA: Longitudinal magnetic resonance imaging (MRI) studies of intervertebral disc degeneration have been reported for the cervical and lumbar but not the thoracic spine. METHODS: In this longitudinal study (average follow-up 10.0 ±â€Š0.6 years), we assessed degenerative changes in the thoracic spine of 103 volunteers (58 men) of 223 healthy volunteers in the initial MRI study of the thoracic spine (follow-up rate 46.2%). The mean age at the initial study was 45.0 ±â€Š11.5 years (24-77 years). Initial and follow-up thoracic-spine MRIs were graded for the following 4 factors of degenerative changes: decrease in signal intensity of intervertebral disc (DSI), posterior disc protrusion (PDP), anterior compression of dura and spinal cord (AC), and disc-space narrowing (DSN) from T1-2 to T12-L1. We assessed associations between changes in MRI grade and demographical factors such as age, sex, body mass index, smoking habits, sports activities, and disc degeneration in the cervical spine. RESULTS: MRIs revealed that 63.1% of the subjects had degenerative changes in the thoracic intervertebral discs that had progressed at least one grade during the follow-up period. DSI progressed in 44.7% of subjects, PDP in 21.4%, and AC in 18.4% during the 10-year period. No DSN progression was seen. DSI was frequently observed in the upper thoracic spine (T1-2 to T4-5). Disc degeneration was relatively scarce in the lower thoracic spine (T9-10 to T12-L1). PDP was frequently observed in the middle thoracic spine (T5-6 toT8-9). We found significant associations between DSI and cervical-spine degeneration (P = .004) and between AC and smoking (P = .04). CONCLUSION: Progressive thoracic disc degeneration, observed in 63.1% of subjects; was significantly associated with smoking and with cervical-spine degeneration. LEVEL OF EVIDENCE: 2.

Does Posterior Cervical Decompression Conducted by Junior Surgeons Affect Clinical Outcomes in the Treatment of Cervical Spondylotic Myelopathy? Results From a Multicenter Study.

STUDY DESIGN: Retrospective multicenter study. OBJECTIVES: To evaluate the outcomes of posterior cervical decompression for cervical spondylotic myelopathy (CSM) when performed by board-certified spine (BCS) or non-BCS (NBCS) surgeons. METHODS: We reviewed outcomes for 675 patients who underwent surgery for CSM, were followed at least 1 year after surgery, and were assessed preoperatively and at final follow-up by Japanese Orthopaedic Association (JOA) scores and by the visual analog scale (VAS) for the neck. Cervical alignment was assessed on radiographs by C2-C7 angles, and range of motion (ROM) by extension minus flexion C2-C7 angles. We compared outcomes for BCS surgeons, who must meet several requirements, including experience in more than 300 spinal surgeries, and for NBCS surgeons. RESULTS: BCS surgeons performed 432 of 675 laminoplasties. NBCS surgeons were primary in 243 surgeries, of which 187 were directly supervised by a BCS surgeon. BCS surgeons required significantly less time in surgery (98.0 ± 39.5 vs 108.1 ± 49.7 min; P < .01). BCS and NBCS surgeons had comparable perioperative complications rates, and preoperative-to-postoperative changes in JOA scores (2.9 ± 2.1 vs 3.1 ± 2.3; P = .40) and VAS (-1.5 ± 2.9 vs -1.4 ± 2.5; P = .96). Lordotic cervical alignment and ROM were maintained after operations by both groups. CONCLUSIONS: Surgical outcomes such as functional recovery, complication rates, and cervical dynamics were comparable between the BCS and NBCS groups. Thus, posterior cervical decompression for CSM is safe and effective when performed by junior surgeons who have been trained and supervised by experienced spine surgeons.

Modic changes in the cervical spine: Prospective 20-year follow-up study in asymptomatic subjects.

BACKGROUND: Few studies have characterized the development of Modic changes in the cervical spine over time. We evaluated Modic changes of the cervical spine that developed over a 20-year period in a healthy cohort, and sought to clarify the relationship between Modic changes and the development of clinical symptoms. METHODS: For this multicenter prospective cohort study, we recruited 193 subjects from an original cohort of asymptomatic volunteers who underwent MRI of the cervical spine between 1993 and 1996. Each cervical level from C2/3 to C7/T1 (total n = 1158 intervertebral levels) was assessed on current MRIs as normal or showing type 1, 2, or 3 Modic change, and we asked about symptoms related to the cervical spine. Relationships between the presence of Modic changes and patient characteristics, pre-existing disc degenerations or clinical symptoms were evaluated by logistic regression analysis. RESULTS: After 20-year follow-up, Modic changes affected 31 subjects (16.1%) at 47 intervertebral disc levels. Of these 47 intervertebral disc levels, type 2, found at 30 levels (63.8%), was the most frequent, followed by type 1 at 15 levels (31.9%) and type 3 at two levels (4.3%). The most frequent changes were observed at the C5/6 segment with type 2 Modic changes. The presence of Modic changes correlated with pre-existing posterior disc protrusion (odds ratio 3.31, 95% confidence interval 1.21-9.05) and neck pain (odds ratio 2.71, 95% confidence interval 1.08-6.80). CONCLUSIONS: In the cervical spine over a 20-year period, type 2 Modic changes were most frequent at the C5/6 segment. The Modic changes were associated with pre-existing disc degeneration and neck pain but not with age, BMI, smoking, shoulder stiffness, arm pain or numbness.

A 20-year prospective longitudinal MRI study on cervical spine after whiplash injury: Follow-up of a cross-sectional study.

BACKGROUND: Some patients suffer from long-lasting symptoms after whiplash injury. However, there are few reports on the long-term changes in the cervical spine after whiplash injury using imaging tests. The purpose of this longitudinal study was to determine the changes on MRI of the cervical spine 20 years after whiplash injury, and to examine the relationships between changes in the cervical spine on MRI and changes in related clinical symptoms. METHODS: Eighty-one subjects finally participated in this study (follow-up rate 16%). The mean follow-up duration was 21.7 years. All subjects filled out a questionnaire about their clinical symptoms. The MRI findings were assessed using numerical grading system applied in the original study. Statistic analyses were used to investigate whether the progression of each MRI finding was associated with the severity of neck pain, stiff shoulders, dizziness and tinnitus. RESULTS: All subjects had complained of some clinical symptoms in the original study: 71 had neck pain, 53 stiff shoulders, and others. In the present study, 66 subjects (81.5%) complained of some clinical symptoms: 57 had stiff shoulders, 20 neck pain, and others. The progression of degeneration on MRI was observed in 95% of the subjects, with C4/5 and 5/6 being the most frequently involved levels. Changes in the severity of neck pain, stiff shoulders, dizziness and tinnitus over 20 years were not significantly associated with the progression of degenerative changes in the cervical spine on MRI. CONCLUSIONS: Twenty years after whiplash injury, 95% of the subjects showed a progression of degeneration in the cervical spine. The progression of the intervertebral disc degeneration in the cervical spine on MRI after whiplash injury was not significantly associated with changes in the severity of related clinical symptoms, indicating that the degenerative changes on MRI may reflect the physiological aging process rather than post-traumatic sequelae.

Twenty-year Longitudinal Follow-up MRI Study of Asymptomatic Volunteers: The Impact of Cervical Alignment on Disk Degeneration.

STUDY DESIGN: A 20-year longitudinal study. OBJECTIVE: To evaluate the long-term effect of sagittal alignment of the cervical spine on intervertebral disk degeneration in healthy asymptomatic subjects. SUMMARY OF BACKGROUND DATA: This study continues a previous 10-year longitudinal study to determine whether sagittal alignment affects disk degeneration during normal aging. MATERIALS AND METHODS: We assessed 90 healthy subjects (30 men and 60 women) from among 497 volunteers who underwent magnetic resonance imaging (MRI) and plain radiographs of the cervical spine between 1994 and 1996 (follow-up rate 18.1%). The mean age at the initial study was 35.5±13.4 years (11-65 y). We compared initial MRIs and follow-up MRIs, conducted at an average of 21.6 years after the initial study, for (1) decreased signal intensity of the intervertebral disks, (2) posterior disk protrusion, and (3) disk-space narrowing from C2-3 to C7-T1. Subjects were grouped by age at follow-up (under 40 vs. 40 y and older) and by a lordotic or nonlordotic cervical sagittal alignment at baseline. We assessed neck pain, stiff shoulders, and upper-arm numbness at follow-up, and examined associations between clinical symptoms and MRI parameters. RESULTS: Progressive changes during the 20-year period included a decrease in disk signal intensity (84.4% of subjects), posterior disk protrusion (86.7%), and disk-space narrowing (17.8%). No significant association was observed between sagittal alignment and decreased disk signal intensity, posterior disk protrusion, or disk-space narrowing. Among subjects over the age of 40, progressive degenerative changes at C7-T1 were significantly more frequent in nonlordotic subjects (90.9%) compared with those with cervical lordosis (54.2%, P=0.032). The prevalence of clinical symptoms was similar in lordotic and nonlordotic subjects at follow-up. CONCLUSIONS: Nonlordotic cervical alignment was related to the progression of disk degeneration at C7-T1 but not other levels. Cervical alignment did not affect the development of clinical symptoms in healthy subjects. LEVEL OF EVIDENCE: Level III.

A 20-Year Prospective Longitudinal Study of Degeneration of the Cervical Spine in a Volunteer Cohort Assessed Using MRI: Follow-up of a Cross-Sectional Study.

BACKGROUND: Few studies have addressed in detail long-term degenerative changes in the cervical spine. In this study, we evaluated the progression of degenerative changes of the cervical spine that occurred over a 20-year period in an originally healthy cohort. We also sought to clarify the relationship between the progression of cervical degenerative changes and the development of clinical symptoms. METHODS: For this prospective follow-up investigation, we recruited 193 subjects from an original cohort of 497 participants who had undergone magnetic resonance imaging (MRI) of the cervical spine between 1993 and 1996. The subjects were asked about the presence or absence of cervical spine-related symptoms. Degenerative changes of the cervical spine were assessed on MRI using an original numerical grading system. The relationship between the progression of degenerative changes and the onset of clinical symptoms was evaluated by logistic regression analysis. RESULTS: Degeneration in the cervical spine was found to have progressed in 95% of the subjects during the 20-year period. The finding of a decrease in signal intensity of the intervertebral disc progressed in a relatively high proportion of the subjects in all age groups and occurred with similar frequency (around 60%) at all intervertebral disc levels. The rate of progression of other structural failures on MRI increased with age and was highest at C5-C6. The progression of foraminal stenosis was associated with the onset of upper-limb pain (odds ratio, 4.71 [95% confidence interval, 1.02 to 21.7]). CONCLUSIONS: A progression of degenerative changes in the cervical spine on MRI over the 20-year period was detected in nearly all subjects. There was no relationship between the progression of degeneration on MRI and the development of clinical symptoms, with the exception of an association found between foraminal stenosis and upper-limb pain. LEVEL OF EVIDENCE: Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Significant differences of brain blood flow in patients with chronic low back pain and acute low back pain detected by brain SPECT.

BACKGROUND: The aim of this study was to examine and compare the areas of brain blood flow in patients with chronic low back pain (CLBP) without structural abnormality and acute low back pain (ALBP) with lumber disc herniation (LDH). Functional neuroimaging studies provide evidence of abnormalities in the regional cerebral blood flow during low back pain. Recent studies have shown that CLBP is associated with plastic, pathophysiological changes in the brain. However, there has been no report yet statistically or by neuro-images on the compared brain single photon-emission computed tomography (SPECT) findings between CLBP and ALBP patients. METHODS: The subjects comprised 14 patients, 7 CLBP and 7 ALBP patients. The CLBP group included the patients who had no or minor structural abnormality in the lumbar spine on magnetic resonance imaging (MRI) and met the criteria for a classification of "pain disorder" (chronic) according to the Diagnostic and Statistical Manual of Mental Disorders, 4th Edition, Text Revision. The ALBP group included the patients who had symptoms within 3 months of onset and LDH revealed by MRI. All patients were assessed using brain SPECT. We then performed a two-tailed view analysis using the easy Z score imaging system, determined the mean Z scores, and performed vBSEE software (Fujifilm RI Pharma, Tokyo, Japan) for both CLBP and ALBP patients. RESULTS: The CLBP group showed significantly reduced blood flow in the bilateral prefrontal cortex of the frontal lobe and increased blood flow in the bilateral posterior lobe of the cerebellum. CONCLUSIONS: SPECT images and statistical analyses revealed the brain blood flow alterations in the patients with ALBP and CLBP. These results may suggest that the dysfunction of the prefrontal cortex could lead to the appearance of unconscious pain behavior controlled by the cerebellum in the patients with CLBP.

Vertebra collapse due to primary amyloidosis causing neurological compromise.

In primary amyloidosis (AL), a fibrillar protein (amyloid light chain) is deposited in many organs; however, it is rare to have involvement of the vertebral bodies. Multiple myeloma is a well-known systemic amyloid disease that frequently has vertebral involvement. However, the pathology of vertebral involvement of these two clinical entities differs significantly. We report a patient with L4 vertebral collapse because of primary AL, causing neurological compromise that improved with surgical treatment. Deposition of amyloid and following demineralisation caused the vertebral collapse. Primary AL needs to be taken into consideration as a cause of pathological vertebral fracture.

Mucosal lesions may be a minor complication of SAPHO syndrome: a study of 11 Japanese patients with SAPHO syndrome.

Since the term synovitis-acne-pustulosis-hyperostosis-osteitis (SAPHO) syndrome was proposed by Chamot et al. (Rev Rhum Mal Osteoartic 54:187-196, 1987), clinical reviews concerning this syndrome have been mainly reported from Europe. We carried out a retrospective analysis of 11 Japanese patients with SAPHO syndrome, and reviewed the clinical features of our series in comparison with those in a European large case study. In this study the major features of SAPHO syndrome were chronic osteitis of the anterior chest wall and pustulotic arthro-ostitis with middle age onset, and mucosal lesions seemed to be a minor complication of SAPHO syndrome. The non-erosive peripheral large joints arthritis and the particular HLA types (HLA-B51, B52, or A26), which had been reported to be increased in Behcet's disease, were frequently seen in SAPHO syndrome with mucosal lesions. This study also suggests that SAPHO syndrome with mucosal lesions may be part of a broader disease spectrum including Behcet's disease.

Open-door laminoplasty for cervical myelopathy resulting from adjacent-segment disease in patients with previous anterior cervical decompression and fusion.

STUDY DESIGN: This is a retrospective study of patients with cervical myelopathy resulting from adjacent-segment disease who were treated by open-door expansive laminoplasty. OBJECTIVES: The purpose of this study was to evaluate the effectiveness of laminoplasty for cervical myelopathy resulting from adjacent-segment disease. SUMMARY OF BACKGROUND DATA: Adjacent-segment disease is one of the problems associated with anterior cervical decompression and fusion. However, the optimal surgical management strategy is still controversial. METHODS: Thirty-one patients who underwent open-door expansive laminoplasty for cervical myelopathy resulting from adjacent-segment disease and age- and sex-matched 31 patients with myelopathy who underwent laminoplasty as the initial surgery were enrolled in the study. The pre- and postoperative Japanese Orthopedic Association scores (JOA scores) and the recovery rate were compared between the two groups. RESULTS: The average JOA scores in the patients with adjacent-segment disease and the controls were 9.2 +/- 2.6 and 9.4 +/- 2.3 before the expansive laminoplasty and 11.9 +/- 2.8 and 13.3 +/- 1.7 at the follow-up examination, respectively; the average recovery rates in the two groups were 37.1 +/- 22.4% and 50.0 +/- 21.3%, respectively (P = 0.04). The mean number of segments covered by the high-intensity lesions on the T2-weighted magnetic resonance images was 1.87 and 0.9, respectively (P = 0.001). CONCLUSIONS: Moderate neurologic recovery was obtained after open-door laminoplasty in patients with cervical myelopathy resulting from adjacent-segment disc disease, although the results were not as satisfactory as those in the control group. This may be attributed to the irreversible damage of the spinal cord caused by persistent compression at the adjacent segments.