Hiroyasu Fujiwara

Effect of Biological Agents on Cervical Spine Lesions in Rheumatoid Arthritis

Study Design. A retrospective cohort analysis. Objective. To determine the effect of biological agents (BAs) on the development and progression of cervical spine lesions and identify predictors of lesion progression. Summary of Background Data. The introduction of BAs has facilitated advances in the treatment of rheumatoid arthritis (RA). BAs reduce disease activity and limit structural joint damage. However, the effect of BAs on cervical spine lesions remains unclear. Methods. Thirty-eight subjects who received more than 2 years of continuous BA treatment were enrolled. The mean x-ray interval was 4.4 years. RA activity was evaluated by disease activity score (DAS)-C reactive protein (CRP) and matrix metalloproteinase (MMP)-3. Radiographical definitions of cervical lesions were atlanto-dental interval (ADI) more than 3 mm for atlanto-axial subluxation (AAS), Ranawat value less than 13 mm for vertical subluxation (VS), and anterior or posterior listhesis more than 2 mm for subaxial subluxation (SS). Definitions of radiographical progression were an increase of ADI more than 2 mm for AAS, a decrease of both Ranawat and Redlund-Johnell values more than 2 mm for VS, and an increase of listhesis more than 2 mm for SS. Results. RA activity responded dramatically to BA therapy (DAS-CRP from 4.3 to 2.3, P < 0.01; MMP-3 from 207.9 ng/mL to 105.6 ng/mL, P < 0.01). Baseline radiographical evaluation showed no pre-existing cervical spine lesions in 12 cases, AAS in 15 cases, and VS in 11 cases. Radiological progression was found in 1 (8%) patient in the no lesion group, 12 patients (80%) in the AAS group, and 9 patients (80%) in the VS group. The incidence of progression was significantly lower in the no lesion group compared with the other groups. Multivariate regression analysis showed that the presence of pre-existing cervical lesions was the single greatest predictor of progression. Conclusion. BAs prevented the development of de novo cervical spine lesions in patients with RA, but failed to inhibit progression of pre-existing RA lesions.

Predictors for the progression of cervical lesion in rheumatoid arthritis under the treatment of biological agents.

Study Design. Retrospective cohort analysis. Objective. To clarify the effect of biological agents (BAs) on the development and progression of cervical lesions in patients with rheumatoid arthritis (RA) and to identify biomarkers that accurately predict disease progression. Summary of Background Data. The introduction of BAs changed the paradigm of RA treatment. However, their effects on cervical lesions in patients with RA have not been studied. Methods. Ninety-one subjects who had received BAs for 2 years or more were enrolled. Mean radiographical interval was 3.9 years. Disease activity was evaluated by disease activity score–C-reactive protein levels, and matrix metalloproteinase-3 levels. Cervical lesions were defined as an atlantodental interval more than 3 mm for atlantoaxial subluxation (AAS), Ranawat value less than 13 mm for vertical subluxation (VS), and anterior or posterior listhesis more than 2 mm for subaxial subluxation. Disease progression was defined radiographically as an increase in the atlantodental interval more than 2 mm for AAS, a decrease in both Ranawat and Redlund-Johnell values more than 2 mm for VS, and an increase in listhesis more than 2 mm for subaxial subluxation. We used multivariate regression techniques to assess predictors of disease progression. Results. Baseline radiographical evaluation showed no pre-existing cervical lesion in 44 patients, AAS in 29, and VS in 18. Radiological progression occurred in 7% patients without baseline lesions, 79% in the AAS group, and 72% in the VS group. The incidence of progression was significantly lower in patients without lesions at baseline. Multivariate regression analysis demonstrated pre-existing cervical lesions, disease activity score–C-reactive protein levels at baseline and metalloproteinase-3 levels at final visit as good predictors of RA progression. Conclusion. BAs prevented de novo cervical lesions in patients with RA but failed to control progression in patients with pre-existing cervical lesions. Disease activity score–C-reactive protein levels at baseline were related to pre-existing joint destruction, and metalloproteinase-3 levels accurately predicted ongoing bone destruction during BA treatment. Level of Evidence: 3

Does fusion status after posterior lumbar interbody fusion affect patient-based QOL outcomes? An evaluation performed using a patient-based outcome measure

BackgroundAlthough delayed union or pseudoarthrosis after lumbar arthrodesis has been recognized as a major radiographic complication, little has been known about the effect of fusion status on the patient’s quality-of-life (QOL) outcome. The purpose of this study was to investigate the effects of fusion status after posterior lumbar interbody fusion (PLIF) on QOL outcomes by using the Japanese Orthopaedic Association Back Pain Evaluation Questionnaire (JOABPEQ).MethodsAmong 100 patients who underwent single level PLIF for spinal canal stenosis, 29 who had not achieved fusion (incomplete fusion group) and 29 age- and sex ratio-matched patients who had achieved fusion (fusion group) 6xa0months after surgery were enrolled. Overall clinical evaluation was performed before and 6xa0months after surgery: the physician determined the Japanese Orthopaedic Association Score for Low Back Pain (JOA score); the JOABPEQ and visual analogue scale (VAS) values were collected. The recovery rate of the JOA score, changes in all JOABPEQ subdomain scores and in the VAS values were calculated. All variables were compared between the groups.ResultsThe preoperative JOA scores, JOABPEQ scores of all subdomains, and VAS values of all categories did not differ between the groups. The recovery rate was higher in the fusion group than the incomplete fusion group (pxa0=xa00.0185). The changes in the JOABPEQ scores for walking ability and social life function were significantly greater in the fusion group than the incomplete fusion group (walking ability, pxa0=xa00.0172; social life function, pxa0=xa00.0191). The postoperative VAS values and changes in the VAS values for all categories did not differ between the groups.ConclusionsIncomplete fusion after PLIF correlated with poor improvement in walking ability and social life function. Therefore, the achievement of fusion after PLIF is essential to obtain better patient QOL outcomes.

Lumbar scoliosis in rheumatoid arthritis : epidemiological research with a DXA cohort

Study Design. A retrospective cross-sectional study. Objective. The aim of this study was to identify the prevalence of and risk factors for lumbar scoliosis in patients with rheumatoid arthritis (RA) using lumbar images obtained from dual-energy x-ray absorptiometry (DXA). Summary of Background Data. The prevalence of lumbar scoliosis in the normal adult population has been reported, but that in patients with RA remains unclear. Methods. Subjects comprised 241 patients with RA who underwent annual DXA. Cobb angles of the lumbar spine were measured by lumbar anteroposterior DXA and the prevalence of lumbar scoliosis (curvature ≥10°) was calculated. Correlations between lumbar scoliosis and potential risk factors (age, sex, duration of RA, T score of lumbar spine and hip, medications for RA [daily predonisolone dose, use of biological agents] and osteoporosis, disease activity score-C-reactive protein, progression stage and functional classification of RA, and severity of hand deformity were analyzed. Results. The prevalence of lumbar scoliosis in patients with RA was 32.0%. Mean Cobb angle was 7.1º ± 5.5º among all subjects, compared with 13.6º ± 4.4º (range, 10º–32º) among subjects with scoliosis. Subjects with scoliosis were significantly older (67.8 yr) than those without (61.6 yr, P < 0.0001). The daily prednisolone dose was significantly higher in subjects with scoliosis (4.14 mg) than in those without (3.46 mg, P = 0.0389). The T score of the hip was significantly smaller in subjects with scoliosis (−1.79) than in those without (−1.26, P = 0.0005). A multivariate logistic regression analysis revealed age as the sole risk factor for lumbar scoliotic changes in patients with RA (odds ratio, 1.068; 95% confidence interval, 1.031–1.107; P = 0.0003). Conclusion. The prevalence of lumbar scoliosis in patients with RA was 32.0%, about 3- or 4-times higher than its prevalence as obtained from previous reports of DXA cohorts irrespective of RA. Increased age represented an independent risk factor for lumbar scoliosis in patients with RA. Level of Evidence: 4

Thoracic spinal epidural angiolipoma: report of two cases and review of the literature.

AIMnSpinal angiolipoma is a benign uncommon neoplasm composed of mature lipocytes admixed with abnormal blood vessels, and accounts for only 0.14-1.2% of all spinal tumors.nnnMATERIAL AND METHODSnRetrospective data analysis.nnnRESULTSnWe report two cases of a 64-year-old woman and a 65-year-old man with thoracic myelopathy due to spinal angiolipoma. Magnetic resonance imaging showed isointensity on T1-weighted imaging and hyperintensity on T2-weighted imaging and enhance with gadolinium administration. In one case, angiography elucidated the vascularity of the tumor and the relationship with concomitant hemangioma. Laminoplasty was performed to achieve tumor resection, and the postoperative course was uneventful with neurological improvement. Histopathological examination of the resected tumors revealed angiolipomas.nnnCONCLUSIONnAlthough extremely rare, thoracic spinal epidural angiolipoma should be considered in the differential diagnosis of thoracic spinal lesions. Prognosis after surgical management of this lesion is favorable. Angiography was useful for preoperative evaluation of vascularity and the relationship with concomitant tumors.

Late-onset deep surgical-site infection after posterior lumbar interbody fusion in a patient treated with tocilizumab; unusual changes in inflammatory markers

PurposeTo describe a case of late-onset deep surgical-site infection (SSI) after posterior lumbar interbody fusion in a patient treated with tocilizumab (TCZ) for rheumatoid arthritis (RA), with emphasis on the clinical symptoms and changes in inflammatory markers such as white blood cell (WBC) count and C-reactive protein (CRP) level.Case reportA 74-year-old woman with 3-year history of RA underwent posterior lumbar interbody fusion at the L4/5/S1 level. After confirmation of no clinical symptom of SSI postoperatively, we decided to use TCZ for the patient after 2xa0months postoperatively. At 8xa0months after beginning of TCZ, she suffered from sudden onset of severe low back pain (LBP) with fever (38xa0°C) 1xa0day after administration of TCZ. Local tissues around the operative wound showed no sign of redness, warmth, or swelling. Increases in body temperature, WBC count, and CRP level were well suppressed by TCZ. Magnetic resonance imaging performed 2xa0weeks after onset of LBP revealed deep SSI. After surgical debridement and administration of the sensitive antibiotics, no clinical signs of recurrent spondylitis or osteolysis of vertebral body have been seen for 3xa0years.ConclusionsAs TCZ strongly suppresses inflammatory reactions, detecting deep SSI based on local and systemic findings and laboratory data is quite difficult. Care must be taken regarding SSI when patients treated with TCZ complain of long-lasting LBP after lumbar surgery.

Positional occlusion of the vertebral artery in a case of rheumatoid atlantoaxial subluxation presenting with multiple cerebral and cerebellar infarction

We report an uncommon case of positional occlusion of the vertebral artery associated with rheumatoid arthritis (RA). Plain radiography showed reducible atlantoaxial subluxation, and dynamic vertebral arteriography demonstrated positional occlusion of the left vertebral artery. The patient was treated with C1-2 posterior fusion and has since experienced no recurrent symptoms. Insufficiency of the vertebrobasilar artery is a relatively uncommon complication with cervical lesions in RA patients. However, when RA patients manifest recurrent cerebral and cerebellar symptoms, this condition should be kept in mind and actions taken to avoid further irreversible cerebral damage. Recommended imaging methods include vertebral dynamic lateral plain radiography of the cervical spine and vertebral arteriography at multiple cervical positions.

Risk factors for poor patient-reported quality of life outcomes after posterior lumbar interbody fusion: An analysis of two-year follow-up.

Study Design. A retrospective review of prospectively collected data. Objective. The present study aimed to identify risk factors for poor patient-reported quality of life (QOL) outcomes, based on five categories (pain-related disorders, lumbar spine dysfunction, gait disturbance, social life dysfunction, and psychological disorders) of the Japanese Orthopaedic Association Back Pain Evaluation Questionnaire (JOABPEQ), after posterior lumbar interbody fusion (PLIF) at the 2-year follow-up. Summary of Background Data. Many studies have been reported on patient QOL outcomes after lumbar surgery; however, few reports have focused on risk factors for poor postoperative QOL outcomes in terms of the various disabilities and dysfunctions after PLIF. Methods. One hundred consecutive patients (39 men and 61 women; mean age 69.6 [44–84] yr) who underwent single- or two-level PLIF for degenerative spondylolisthesis and/or foraminal stenosis with a 2-year follow-up were included. The effectiveness of surgery in each category of the JOABPEQ was evaluated. Demographic and clinical data and radiographic parameters were reviewed. Risk factors for poor postoperative QOL outcomes in each category of the JOABPEQ were investigated by multivariate logistic regression analysis. Results. Older age and spinopelvic malalignment (preoperative high pelvic tilt or postoperative decrease in lumbar lordosis [=postoperative increase in the mismatch between pelvic incidence and lumbar lordosis]) were risk factors for poor postoperative QOL outcomes in all categories of the JOABPEQ, except for lumbar spine dysfunction. In contrast, increase in number of PLIF segments, non-union, and radiographic adjacent segment degeneration were risk factors for poor postoperative QOL outcomes in lumbar spine dysfunction and gait disturbance. Conclusion. The risk factors for poor QOL outcomes after PLIF differed among the five categories of the JOABPEQ. In particular, surgery-related factors (e.g., increase in number of PLIF segments, nonunion, and radiographic adjacent segment degeneration) had a negative effect on the improvement of lumbar spine dysfunction and gait disturbance. Level of Evidence: 4

Morphometric analysis using multiplanar reconstructed CT of the lumbar pedicle in patients with degenerative lumbar scoliosis characterized by a Cobb angle of 30° or greater

OBJECTnAlthough the anatomy of the thoracic pedicle in adolescent idiopathic scoliosis is well known, that of the lumbar pedicle in degenerative lumbar scoliosis is not. The morphometric differences between the pedicles on the concave and convex sides can result in an increased risk of malpositioned pedicle screws. The purpose of this study was to analyze the lumbar pedicle morphology in degenerative lumbar scoliosis using multiplanar reconstructed CT.nnnMETHODSnThe study group comprised 16 consecutive patients (1 man and 15 women, mean age 70.9 ± 4.5 years) with degenerative lumbar scoliosis characterized by a Cobb angle of at least 30° who underwent preoperative helical CT scans. The CT data in DICOM format were reconstructed, and the following parameters were measured for each pedicle inside the curves: the inner cortical transverse pedicle width (TPWi) and outer cortical transverse pedicle width (TPWo) and axial angle, all on an axial plane, and the inner cortical minimum pedicle diameter (MPDi) and outer cortical minimum pedicle diameter (MPDo) and cephalocaudal inclination of the pedicle, all on the plane perpendicular to the pedicle axis. The cortical thickness and cortical ratio of the pedicles on the axial plane and the plane perpendicular to the pedicle axis were calculated. Data were obtained for a total of 124 pedicles; L-1, 26 pedicles in 13 patients; L-2, 32 pedicles in 16 patients; L-3, 32 pedicles in 16 patients; L-4, 28 pedicles in 14 patients; and L-5, 6 pedicles in 3 patients.nnnRESULTSnAmong the target vertebrae, the TPWi, MPDi, and MPDo were significantly smaller and the axial angle was significantly larger on the concave side than on the convex side (TPWi, 6.37 vs 6.70 mm, p < 0.01; MPDi, 5.15 vs 5.67 mm, p < 0.01; MPDo, 7.91 vs 8.37 mm, p < 0.05; axial angle, 11.79° vs 10.56°, p < 0.01). The cortical ratio of the pedicles was larger on the concave side than on the convex side (on the axial plane, 0.29 vs 0.26, p < 0.05; on the plane perpendicular to the pedicle axis, 0.36 vs 0.32, p < 0.01). These differences were most evident at L-4.nnnCONCLUSIONSnThis study demonstrated lumbar pedicle asymmetry in degenerative lumbar scoliosis. The authors speculate that these asymmetrical changes were attributed to the remodeling caused by axial load imbalance and the limited space available for pedicles on the concave side. On the concave side, because of the narrower pedicle diameter and larger axial angle, surgeons should carefully determine screw size and direction when inserting pedicle screws to prevent possible pedicle wall breakage and neural damage.

Incidence and risk factors for cervical lesions in patients with rheumatoid arthritis under the current pharmacologic treatment paradigm

Abstract Objective: To elucidate the incidence and risk factors for cervical lesions in patients with rheumatic arthritis (RA) under the current pharmacologic treatment paradigm. Methods: Of patients with RA onset after 2000, 151 who introduced biologic agents (BAs) because of high disease activity and underwent cervical radiography more than 5 years after onset were included. Incidence of those with cervical lesions and predictors of cervical lesions were analyzed. Mean disease duration was 8.5 years. The radiographic definitions of cervical lesions were as follows: atlantoaxial subluxation (AAS), atlantodental interval >3u2009mm; vertical subluxation (VS), Ranawat value <13u2009mm; and subaxial subluxation (SS), and listhesis >2u2009mm. Results: Radiographic evaluation indicated AAS in 43 cases (28%), VS in 10 (7%), and SS in 6 (4%). The incidence of those with any cervical lesion was 32% (48/151). Univariate analysis showed that disease duration, time from onset to BA use, and onset before 2005 were significant predictors of cervical lesions, while multivariate regression analysis showed that disease duration and Steinbrocker stage were predictors. Conclusion: The incidence of cervical lesions in patients with RA onset after 2000 was still high (32%). In addition, disease duration and Steinbrocker stage were predictors of cervical lesions.