Meclozine ameliorates skeletal muscle pathology and increases muscle forces in mdx mice.

We screened pre-approved drugs for the survival of the Hu5/KD3 human myogenic progenitors. We found that meclozine, an anti-histamine drug that has long been used for motion sickness, promoted the proliferation and survival of Hu5/KD3 cells. Meclozine increased expression of MyoD, but reduced expression of myosin heavy chain and suppressed myotube formation. Withdrawal of meclozine, however, resumed the ability of Hu5/KD3 cells to differentiate into myotubes. We examined the effects of meclozine on mdx mouse carrying a nonsense mutation in the dystrophin gene and modeling for Duchenne muscular dystrophy. Intragastric administration of meclozine in mdx mouse increased the body weight, the muscle mass in the lower limbs, the cross-sectional area of the paravertebral muscle, and improved exercise performances. Previous reports show that inhibition of phosphorylation of ERK1/2 improves muscle functions in mouse models for Emery-Dreifuss muscular dystrophy and cancer cachexia, as well as in mdx mice. We and others previously showed that meclozine blocks the phosphorylation of ERK1/2 in cultured cells. We currently showed that meclozine decreased phosphorylation of ERK1/2 in muscles in mdx mice but not in wild-type mice. This was likely to be one of the underlying mechanisms of the effects of meclozine on mdx mice.

Effect of race, age, and gender on lumbar muscle volume and fat infiltration in the degenerative spine.

BACKGROUND: The quantity and quality of spinal muscles in patients with degenerative spinal diseases and various backgrounds such as age, gender, or race is unclear. We quantitatively evaluated the cross-sectional area (CSA) and fatty degeneration of the muscles around the spine, using magnetic resonance imaging (MRI) in patients with degenerative spinal disease, and studied the effects of age, gender, and race in multicenter retrospective study. METHODS: The subjects were Caucasian and Asian patients with degenerative lumbar disease who underwent L4-5 single level spinal fusion surgery at centers in the United States and Japan. Using preoperative axial T2 MRI at the L4-5 disc level, the cross-sectional areas of the psoas and paraspinal muscles were measured. Fat infiltration was measured using the threshold method, and percent fat area (%FA) was calculated for each muscle. The muscle/disc area ratio (MDAR) was used to control for size differences per patient. T-test, Pearson's correlation coefficient, partial correlation, and multiple linear regression were used for statistical analysis. RESULTS: In total, 140 patients (53 men; 87 women; mean age, 69.2 years) were analyzed. Age was similar in Caucasians (n = 64) and Asians (n = 76). MDARs were larger in Caucasians for paraspinal and psoas muscles (p < 0.005). Percent FA of psoas was similar in Caucasians and Asians, but greater in the paraspinal muscles of Asians (p < 0.05). After controlling for race and gender, age was correlated negatively with MDAR (p < 0.001) and positively with %FA (p < 0.001). In the multiple linear regression analysis, age, gender, and race were independently affected by MDAR and %FA. CONCLUSIONS: Lumbar muscle mass and quality were affected by age, gender, and race, independently, in patients with degenerative lumbar disease.

Increasing postural sway in balance test is related to locomotive syndrome risk: A cross-sectional study.

BACKGROUND: Locomotive syndrome risk level has been recently proposed to evaluate physical ability. Impaired balance control is one of the most important risk factors for falls. However, the relationship between locomotive syndrome risk and postural sway according to the balance test is unclear. This study aimed to investigate the relationship between locomotive syndrome risk and balance test results, including muscle mass and physical function, in a large-scale prospective general health checkup. METHODS: We enrolled 292 participants who underwent a basic health checkup and conducted a two-step test, stand-up test, evaluation using a 25-question geriatric locomotive function scale for the locomotive syndrome risk test, balance test, appendicular skeletal muscle mass measurement by bioelectrical impedance analysis, evaluation of physical function by the timed-up-and-go test, and back muscle and grip strength evaluation. A statistical comparative study was then conducted between normal and locomotive syndrome risk groups. Subsequently, significant factors for locomotive syndrome risk were investigated by multivariate analysis. RESULTS: The comparative study was conducted by adjusting age and sex using a generalized linear model. No significant difference in muscle mass existed, but postural sway in the balance test significantly increased in the people at locomotive syndrome risk. Among the four posturographic variables by balance test, increase in back-and-forth sway was the most remarkable variable associated with locomotive syndrome risk together with back muscle strength, body mass index, and the timed-up-and-go test by logistic regression analysis. This posturographic variable was significantly related to the timed-up-and-go test and leg skeletal muscle mass by multiple regression analysis. CONCLUSIONS: A relationship was recognized between locomotive syndrome risk and postural sway. In particular, increase in back-and-forth sway was an important factor for locomotive syndrome risk. If the balance test shows an increase in back-and-forth sway, attention should be paid to locomotive syndrome risk for possible intervention and early treatment.

Relationship between locomotive syndrome and body composition among community-dwelling middle-age and elderly individuals in Japan: The Yakumo study.

OBJECTIVES: Locomotive syndrome (LS) is a condition requiring nursing care for musculoskeletal disorders. Our aim was to evaluate the correlation between body composition, measured by bioelectrical impedance analysis (BIA), and LS, measured using the 25-question Geriatric Locomotive Functional Scale (GLFS-25). METHODS: We enrolled 286 individuals who were undergoing regular health follow-up. All individuals completed the GLFS-25, body composition analysis by BIA, and five physical performance tests related to LS: timed up-and-go test, 10-m gait time, maximum stride length, back strength, and grip strength. Measured variables and demographic data were compared between individuals with and without LS. RESULTS: The extracellular water ratio, the extracellular water/total body water (ECW/TBW) ratio differentiated the LS and non-LS groups (p=.005), with all physical function measures being lower among individuals with a high, compared to low, ECW/TBW ratio. The risk ratio for LS among individuals with a high ECW/TBW ratio was 2.31, with an odds ratio of 2.67. CONCLUSION: The ECW/TBW ratio is predictive of LS. Based on our results, we propose that BIA should routinely be performed, with follow-up and intervention, as needed, for individuals with a high ECW/TBW ratio, as they are at risk for developing LS.

The decrease in phase angle measured by bioelectrical impedance analysis reflects the increased locomotive syndrome risk in community-dwelling people: The Yakumo study.

OBJECTIVES: The locomotive syndrome (LS) risk test has recently been advocated for the evaluation of physical ability. Phase angle measurement by bioelectrical impedance analysis (BIA) is an indicator of cellular health and muscle mass. We aimed to investigate how muscle mass and phase angle are related to LS risk stage. METHODS: A prospective cohort study was conducted in 311 patients who were undergoing a health checkup. All participants performed the two-step test, stand-up test, and 25-question geriatric locomotive function scale components of the LS risk test. Muscle mass and phase angle were measured using BIA. A comparison study was conducted among the three LS risk stages. RESULTS: In the trend test, phase angle decreased significantly as the LS risk stage progressed, whereas muscle mass did not show a significant difference. After adjusting for age and sex, phase angle showed a significant difference among all LS risk stages. Muscle mass did not show a significant difference between no risk and stage 1. CONCLUSION: Compared to muscle mass, phase angle more strongly reflects LS risk and becomes significantly reduced at later LS risk stages. Phase angle can be a useful screening tool for LS risk.

Surgical intervention for a pediatric isolated intramedullary spinal aneurysm.

PURPOSE: To report the case of a pediatric patient with intramedullary spinal aneurysm. METHODS: A 9-year-old boy presented with low back pain and subsequent gait disturbance. He had no history of trauma. After admission, MRI revealed an intramedullary spinal cord mass lesion surrounded by hemorrhage at the cervical-thoracic junction. Initial treatment was started with intravenous methylprednisolone and bed rest. Neurological deficit disappeared under careful observation for a few months. Surgical intervention was applied for diagnosis and resection of the mass lesion to prevent recurrent hemorrhage. RESULTS: Intraoperative ultrasound sonography helped to diagnose the lesion as a spinal cord aneurysm, prior to midline myelotomy. Monitoring of transcranial muscle evoked potentials helped to avoid spinal cord damage during surgery. There has been no evidence of spinal aneurysm on MRI for 3 years after surgery and no neurological deterioration. CONCLUSION: To our knowledge, this is a first report of an intramedullary spinal cord aneurysm at the cervical-thoracic junction in a pediatric patient. Careful observation after initial symptoms followed by surgical intervention was favorable in this case.

Sarcopenia and physical function are associated with inflammation and arteriosclerosis in community-dwelling people: The Yakumo study.

OBJECTIVES: Sarcopenia reduces physical function, while chronic inflammation causes arteriosclerosis and decreases skeletal muscle. We conducted a cross-sectional study to elucidate the associations among sarcopenia, physical function, arteriosclerosis, and inflammation in community-dwelling people. METHODS: We recruited 335 participants in an annual health checkup. We diagnosed sarcopenia based on appendicular skeletal muscle mass index (aSMI) assessed by bioelectrical impedance analysis. We measured several physical function tests, blood pressure, and serum levels of high-sensitivity C-reactive protein (hs-CRP), total cholesterol, and low-density lipoprotein cholesterol. RESULTS: After controlling for age, sex, and BMI, participants in the sarcopenia group showed lower performance in all measured physical tests than the normal group. Arteriosclerosis risk factors, including blood pressure, cholesterol levels, and hs-CRP, were significantly higher in the sarcopenia group than in the normal group. hs-CRP and total cholesterol levels were significant risk factors of sarcopenia. The aSMI, grip strength, and maximum stride length were negatively related to hs-CRP level. CONCLUSIONS: Community-dwelling people with sarcopenia had higher levels of hs-CRP and a higher risk for arteriosclerosis. The serum level of hs-CRP was an independent risk factor for sarcopenia and was associated with physical function. These findings indicate that chronic inflammation may relate arteriosclerosis and sarcopenia simultaneously.

Serum cystatin C level is associated with locomotive syndrome risk and can be an early predictor in community-living people: The Yakumo study.

OBJECTIVES: The locomotive syndrome (LS) risk has been recently proposed as a criterion for evaluating physical ability. Serum cystatin C level is an early renal function marker and a cardiovascular disease predictor. This study aimed to evaluate the relationship between serum cystatin C level and LS risk. METHODS: We enrolled 54 participants and conducted the two-step test, stand-up test, 25-question geriatric locomotive function scale, LS risk test, Timed Up and Go test, back muscle strength, grip strength, blood test and serum cystatin C level measurement. A comparative study was conducted in participants with and without LS risk and in subgroups aged <60 and ≥60 years. RESULTS: No significant difference was found in the serum cystatin C level in subgroups aged <60 years and without LS risk. However, it was significantly higher in subjects with LS risk and aged ≥60 years. The area under the curve of the serum cystatin C level for LS risk was 0.824. CONCLUSION: The serum cystatin C level is significantly related to LS risk and can be an early predictor. In middle-aged and elderly people with high serum cystatin C levels, it is strongly recommended to enforce LS risk test and intervention.

Prevention of spinal cord injury using brain-evoked muscle-action potential (Br(E)-MsEP) monitoring in cervical spinal screw fixation.

PURPOSE: The goal of the study was to examine waveform deterioration in intraoperative monitoring during posterior fusion with a cervical screw. This surgery is useful for alignment correction, but worsening of neurological symptoms may occur in association with screw insertion and rod installation. Therefore, spinal cord monitoring is important for safe surgery. METHODS: The study included 25 cases treated with posterior fusion with a cervical screw. Waveform deterioration was defined as an intraoperative amplitude <50% of the control waveform. Comparisons were made between cases with normal and deteriorated waveforms. RESULTS: Intraoperative waveform deterioration occurred in nine cases, including after screw insertion in 8 and after rod installation in one. The nine patients with deteriorated waveforms had a significantly lower preoperative JOA score (8.8 vs. 11.2, P < 0.05) and a tendency for more frequent high signal intensity on MRI [67% (6/9) vs. 31% (5/16), P = 0.087]. Cases in which stenosis was greatest at the apex of the cervical lordosis had significantly more frequent intraoperative waveform deterioration [46% (6/13) vs. 0% (0/8), P < 0.05]. In cases in which the narrowest segment was at the apex of the cervical lordosis, screw insertion before compared to after decompression significantly increased waveform deterioration [67% (6/9) vs. 0% (0/4), P < 0.05]. CONCLUSION: Intraoperative waveform deterioration in posterior cervical screw fixation is associated with severe preoperative symptoms, location of the narrowest segment, and screw insertion before decompression. It is particularly desirable to perform decompression before screw insertion in cases with the narrowest segment at the apex of the cervical lordosis.

Discrimination between spinal extradural meningioma and both intra and extradural meningioma: Case Report.

Meningiomas are common spinal tumor and mostly located at intradura. Recurrence rate after surgery for extradural meningioma was higher than intradural meningioma. A patient with intra and extradural spinal meningioma was treated and discussed its features and clinical management. A 41-year-old woman noted numbness of bilateral legs, gait disturbance, and mild bladder disturbance for over the two-month period. Magnetic resonance imaging revealed an epidural mass at T8-9 involving the dura mater from the left side. Intraoperatively, ultrasonography showed extradural tumor suppress the dura from the left side and no subarachnoid space. Therefore, it was difficult to diagnose the tumor was located at only extradural or both intra and extradural. The extradural tumor was resected as much as possible, then ultrasonography was performed for the second time. The spinal cord was decompressed and subarachnoid space was appeared with intradural tumor. The dura mater was opened in the midline for intradural exploration, and the intradural tumor appeared beside the spinal cord. The dura mater with attachment to the tumor was rescected. To prevent a recurrence, ultrasonography after removing extradural tumor is recommended to detect intra dural tumor and invasion of tumor into dura mater. In such case, removing only extradural meningioma is not enough, and gross total resection including intradural meningioma and dura mater is required.

Intrawound Vancomycin powder as the prophylaxis of surgical site infection after invasive spine surgery with a high risk of infection.

Surgical site infections (SSIs) are one of the most serious complications in spine surgery. We investigated the efficacy of locally administered vancomycin (VCM) powder for prophylaxis on SSI after invasive spine surgery. We retrospectively studied 174 consecutive patients who underwent spine surgery. In patients of the VCM group (n = 81), VCM powder was administered in the wound before closing wound. Patients who did not receive VCM treatment were set as a control group (n = 93). We compared the patients' background, operation time, intraoperative blood loss, usage of implants, presence of deep SSI, and side effects between the two groups. There were no significant differences between the groups in age, gender, and BMI. The operation time and the intraoperative blood loss were longer and greater in the VCM group than in the control group (P < 0.005, P < 0.001, respectively). Implants were used in 85% of the VCM group, and in 31% of the control group (P < 0.001). Deep SSI was not observed in the VCM group, whereas it was observed in 4 patients in the control group. No side effects were observed in any of the cases. In conclusion, surgeons applied VCM for cases which were invasive or had a high risk of infection. However, deep SSI was not observed in anyone in the VCM group. The intrawound administration of VCM might be effective to prevent SSI in cases with high risks of infection.

Clinical outcome of lumbar spinal stenosis based on new classification according to hypertrophied ligamentum flavum.

BACKGROUND: The ligamentum flavum hypertrophy is considered to be one of the important causes of development of lumbar spinal stenosis (LSS). Several histologic and biologic mechanisms in hypertrophied flavum have proposed. However, no study that investigated the relationship between clinical outcome and ligamentum flavum hypertrophy has been published. The purpose of this study was to identify a new classification of LSS, in ligamentous and nonligamentous stenosis, according to the cutoff value of the area proportion of the ligamentum flavum in the spinal canal, and to assess the value of surgical and conservative treatments for LSS based on the classification of the ligamentous stenosis. METHODS: A total of 230 surgical patients with LSS were evaluated based on the cross-sectional area and intraoperative findings of the ligamentum flavum. LSS was classified as ligamentous or nonligamentous stenosis, according to the cutoff value of the proportion of the ligamentum flavum in the spinal canal. Based on the classification, the results of 234 surgical patients (103 patients with spinal fusion surgery and 131 patients with spinal decompression) and 191 patients under conservative treatment with prostaglandin E1 were evaluated, 1 year after treatments. RESULTS: ROC analysis revealed that the area under the curve for the cutoff value of the proportion of the ligamentum flavum in the spinal canal was 0.4275 (sensitivity = 0.861, specificity = 0.854). Based on these criteria, ligamentous and nonligamentous stenoses were 115 and 119 in surgical patients, 97 and 94 in conservative patients, respectively. In the surgical treatment group, no significant difference was found in any of the evaluations conducted for the group with ligamentous and nonligamentous stenosis. However, in the conservative treatment group, the patients with ligamentous stenosis showed significant improvement compared with patients with nonligamentous stenosis. CONCLUSIONS: Ligamentous stenosis in LSS patients had favorable outcome on conservative treatment with prostaglandin E1 derivative.

Staged decrease of physical ability on the locomotive syndrome risk test is related to neuropathic pain, nociceptive pain, shoulder complaints, and quality of life in middle-aged and elderly people - The utility of the locomotive syndrome risk test.

OBJECTIVES: A locomotive syndrome (LS) risk test for evaluation of physical ability is recently proposed. The objective of this study is to evaluate the utility of this test by examining physical ability, neuropathic pain, nociceptive pain, shoulder complaints, and quality of life (QOL). METHODS: A prospective cohort study was conducted in 523 subjects (240 males, 283 females; mean age: 63.3 years) at a health checkup. Data collected using visual analog scales (VAS) for shoulder pain, low back pain, sciatica, and knee pain, neuropathic pain, shoulder complaint, body mass index (BMI), osteoporosis, and SF-36 were compared among three LS risk stages. RESULTS: Subjects in LS risk stage 1 (24%) had significantly more osteoporosis, slower gait speed, weaker muscle strength and higher VAS, with no difference in age and BMI compared to those with no LS risk (50%). Subjects in stage 2 (26%) had significantly poorer results for all items. Shoulder complaint, neuropathic pain and QOL differed significantly among all three groups and worsened with decline in mobility on the LS risk test. CONCLUSIONS: LS risk test is easy and useful screening tool for evaluation of mobility and for screening for pain and complaint associated with activity of daily living and QOL.

Sarcopenia and sarcopenic leg as potential risk factors for acute osteoporotic vertebral fracture among older women.

PURPOSE: Sarcopenia-related falls and fractures among women with osteoporosis are becoming an emerging problem because of rapid aging worldwide. We aimed to investigate the association between sarcopenia, given by the muscle mass of the arms and legs, and osteoporotic vertebral fracture (OVF) among female patients. METHODS: This cross-sectional study examined 216 women with fresh OVF (OVF group) diagnosed by magnetic resonance imaging and 1,608 women from an outpatient clinic who did not have a OVF [non-fracture (NF) group]. We performed whole-body dual-energy X-ray absorptiometry to analyze body composition, including skeletal muscle mass index (SMI; lean mass/height2) and bone mineral density (BMD). We used stepwise logistic regression analysis to determine the risk factors associated with OVF. RESULTS: After controlling for age, the OVF group showed lower appendicular SMI (5.62 vs. 5.97 kg/m2, P < 0.001), lower arm SMI (1.36 vs. 1.42 kg/m2, P = 0.004), lower leg SMI (4.27 vs. 4.55 kg/m2, P < 0.001), and higher prevalence of sarcopenia (42.3 vs. 25.9 %, P < 0.001), compared with the NF group. Reduced leg muscle mass and presence of sarcopenia were independent risk factors for acute OVF in multivariate analysis (odds ratio = 1.4, P = 0.002; odds ratio = 1.96, P < 0.001, respectively). CONCLUSIONS: We found higher prevalence of sarcopenia and lower leg muscle mass among patients with acute OVF compared with patients who did not have an OVF. These results suggest that sarcopenia may be a risk factor for OVF.

Analysis of cervical kyphosis and spinal balance in young idiopathic scoliosis patients classified by the apex of thoracic kyphosis.

PURPOSE: Sagittal balance has recently been the focus of studies aimed at understanding the correction force required for both coronal and sagittal malalignment. However, the correlation between cervical kyphosis and sagittal balance in AIS patients has yet to be thoroughly investigated. This study aimed to clarify the correlation between cervical alignment and spinal balance in patients with adolescent idiopathic scoliosis (AIS). Here, we hypothesized that cervical kyphosis patients can be classified into groups by the apex of thoracic kyphosis. METHODS: This study included 92 AIS patients (84 females, 8 males; mean age, 15.1 years). Patients were divided into the cervical lordosis (CL), cervical sigmoid (CS), or cervical kyphosis (CK) groups and further classified according to the apex of thoracic kyphosis into High (above T3), Middle (T4-T9), and Low (below T10) groups. RESULTS: There were 17 (18.5 %), 22 (23.9 %), and 53 (57.6 %) patients with CL, CS, and CK, respectively. In the CK group, 13 had CK-High, 35 had CK-Middle, and 5 had CK-Low. The C7 sagittal vertical axis (C7SVA) measurements were most backward in CK-High and most forward in CK-Low. The T5-12 kyphosis (TK) measurement was significantly lower in CK-High. CONCLUSIONS: Most AIS patients had kyphotic cervical alignment. Patients with CK can be classified as having CK-High, CK-Middle, or CK-Low according to the apex of thoracic kyphosis. CK-High is due to thoracic hypokyphosis with a backward balanced C7SVA. CK-Middle is well-balanced cervical kyphosis. CK-Low has forward-bent global kyphosis of the cervicothoracic spine that positioned the C7SVA forward.

Intrathecal morphine for postoperative pain control after laminoplasty in patients with cervical spondylotic myelopathy.

OBJECTIVES: To examine the clinical efficacy of intrathecal morphine as postoperative analgesia for cervical laminoplasty. SUMMARY OF BACKGROUND DATA: Patients who undergo posterior cervical spinal surgery frequently experience significant postoperative pain. Postoperative pain contributes to patient morbidity because of decreasing early voluntary mobilization and delayed rehabilitation. Intrathecal morphine is known to be a simple and effective analgesia. However, the effectiveness of intrathecal morphine for cervical spinal surgery has not yet been reported. METHODS: Seventy-eight patients with cervical spondylotic myelopathy were divided into two groups prospectively, a diclofenac suppository (DS) group who received 50 mg diclofenac suppository at the end of the surgery, and an intrathecal morphine (ITM) group who were preoperatively administered 0.3 mg of morphine chloride, intrathecally, via a lumbar puncture. All patients underwent double-door laminoplasty of C3-6 or C3-7 level. Visual analog scale (VAS) of cervical pain, self-rating pain impression, supplemental analgesic usage, and complication rate were evaluated until the seventh postoperative day. RESULTS: Thirty-one patients in the DS group and 32 patients in the ITM group were finally assessed. No baseline variable differences between the two groups were observed. The VAS was significantly lower in the ITM group at 4 h and 24 h until the seventh postoperative day. Self-rating pain impression was significantly better in the ITM group. No significant difference was observed in complication rate. CONCLUSIONS: Intrathecal morphine was an effective and safe analgesic method for cervical laminoplasty in patients with cervical spondylotic myelopathy.

Predictive factors for a distal adjacent disorder with L3 as the lowest instrumented vertebra in Lenke 5C patients.

OBJECTIVE: To investigate what type of Lenke 5C patient benefits most from a fusion to L3 as the LIV. METHODS: The subjects were 16 patients who underwent fusion surgery to L3 as the lowest instrumented vertebra (LIV), and who were then observed for a minimum of 2 years postoperatively. We considered an unsatisfactory radiologic outcome for the distal adjacent curve (DAD) to be an L3 or L4 tilt angle less than 10° or L3/4 disc wedging less than 10°. Patients were divided into 2 groups based on the radiologic outcome of the distal curve: the distal adjacent disorder+ (DAD+) and the distal adjacent disorder-(DAD-). We compared global balance, Cobb angles (thoracic and lumbar), L3 and L4 tilt angles and L3/4/5 disc angles between the 2 groups on preoperative, postoperative and final radiographs. RESULTS: Seven patients (43.8 %) met the criteria for the DAD+ group. On preoperative radiographs, there was a significant difference in the L3/4 disc angle: the DAD+ group opened to the preoperative convex side (-2.1° ± 3.0°) and the DAD- group opened to the preoperative concave side (4.7° ± 5.1°). The standing L3- and L4-CSVL and the L4-CSVL under traction were significantly different. CONCLUSIONS: In Lenke 5C patients who underwent fusion surgery to L3 as the LIV, preoperative LIV (L3), LIV + 1 (L4) translation and L3/4 disc angle on standing, plus LIV + 1 translation under traction were very important parameters correlating with postoperative global coronal balance.

Pharmacological management of chronic low back pain in older patients: a randomized controlled trial of the effect of pregabalin and opioid administration.

PURPOSE: Pregabalin and opioids are used to treat chronic low back pain (LBP). No previous investigations have compared the efficacy of pregabalin and that of opioids for chronic LBP. METHODS: We performed a randomized controlled trial of pregabalin and opioids in 65 consecutive patients aged 65 years or older who had chronic LBP. Each agent was administered randomly in different phases. Pain and activities of daily living (ADL) were evaluated after 4 weeks of treatment using the visual analog scale, Japanese Orthopaedic Association score, Roland Morris Disability Questionnaire, short-form McGill Pain Questionnaire, EuroQol quality-of-life scale, and geriatric depression scale. Neuropathic pain was evaluated using a neuropathic pain screening questionnaire. RESULTS: The effectiveness rate was 73.3% for pregabalin and 83.3% for opioid, showing no significant difference. The mean durations until the onset of effect were 10.2 and 6.1 days, respectively, albeit without significant difference. Pregabalin was effective for LBP with neuropathic pain, whereas opioids were effective for non-neuropathic pain. The improvement of ADL was greater with opioids than with pregabalin. Pregabalin was effective for LBP in patients with lower limb symptoms, whereas opioids were effective for those without lower limb symptoms. CONCLUSIONS: Aside from screening tests, consideration of neuropathic pain and lower extremity symptoms may be an integral component in the selection of the appropriate medication for chronic LBP. Moreover, the therapeutic objectives, including pain relief and/or improvement of ADL, should be specified.

Utility of a 3-dimensional full-scale NaCl model for rib strut grafting for anterior fusion for cervicothoracic kyphosis.

In severe spinal deformity, pain and neurological disorder may be caused by spinal cord compression. Surgery for spinal reconstruction is desirable, but may be difficult in a case with severe deformity. Here, we show the utility of a 3D NaCl (salt) model in preoperative planning of anterior reconstruction using a rib strut in a 49-year-old male patient with cervicothoracic degenerative spondylosis. We performed surgery in two stages: a posterior approach with decompression and posterior instrumentation with a pedicle screw; followed by a second operation using an anterior approach, for which we created a 3D NaCl model including the cervicothoracic lesion, spinal deformity, and ribs for anterior reconstruction. The 3D NaCl model was easily scraped compared with a conventional plaster model and was useful for planning of resection and identification of a suitable rib for grafting in a preoperative simulation. Surgery was performed successfully with reference to the 3D NaCl model. We conclude that preoperative simulation with a 3D NaCl model contributes to performance of anterior reconstruction using a rib strut in a case of cervicothoracic deformity.

Tuberculous meningitis with dementia as the presenting symptom after intramedullary spinal cord tumor resection.

Early-stage TB meningitis has no specific symptoms in patients, potentially leading to delayed diagnosis and consequently worsening prognosis. The authors present the fatal case with a delayed diagnosis of tuberculous (TB) meningitis with dementia as the presenting symptom after intramedullary spinal cord tumor resection. The medical records, operative reports, and radiographical imaging studies of a single patient were retrospectively reviewed. A 77-year-old man who underwent thoracic intramedullary hemangioblastoma resection for 2 times. The postoperative course was uneventful, but 1.5 months after surgery, the patient suffered from dementia with memory loss and diminished motivation and speech in the absence of a fever. No abnormalities were detected on blood test, brain computed tomography and cerebrospinal fluid (CSF) analysis. A sputum sample was negative for Mycobacterium tuberculosis in the QuantiFERON®-TB Gold (QFT-G) In-Tube Test and the tuberculin skin test was also negative. The patient was diagnosed with senile dementia by a psychiatrist. However, the patient's symptoms progressively worsened. Despite the absence of TB meningitis findings, we suspected TB meningitis from the patient's history, and administered a four-drug regimen. However the patient died 29 days after admission, subsequently M. tuberculosis was detected in the CSF sample. This case is a rare case of TB meningitis initially mistaken for dementia after intramedullary spinal cord tumor resection. Symptoms of dementia after intramedullary spinal cord tumor resection should first be suspected as one of TB meningitis, even if the tests for meningitis are negative. We propose that anti-tuberculosis therapy should be immediately initiated in cases of suspected TB meningitis prior to positive identification on culture.