Ichiro Kikkawa

Posterior Spinal Shortening for Paraplegia After Vertebral Collapse Caused by Osteoporosis

Study Design. Case report of a patient who underwent a new surgical procedure for paraplegia after vertebral collapse due to osteoporosis. Objectives. To propose a new approach to posterior spinal fusion surgery for osteoporotic patients. Summary of Background Data. Surgical treatment was performed on a paraplegic patient after vertebral collapse due to osteoporosis. However, the surgery was difficult because implants such as hooks and screws often dislodged during the treatment. The poor holding power of these implants to the osteoporotic spine is a challenging problem in this treatment. Methods. When a fractured vertebra is shortened by resecting the posterior part of the spine and the application of a compression force, a short vertebra is produced. As a result, the thoracic kyphosis decreases and the force pushing the upper thoracic spine inferio-ventrally also decreases. Results. A 74-year-old woman with T12 vertebral collapse was treated with this new method. Lateral Cobb angle (T10–L2) was reduced from 26 to 4° after surgery. The shortened vertebral body united, and after 33 months, the implant had not dislodged and no loss of correction was seen. Conclusion. The posterior spinal shortening can be a choice for treating delayed paraplegia after osteoporotic vertebral fracture.

Femur fracture during abdominal breech delivery

BackgroundWhile vaginal breech delivery, although rare, can cause femur fracture, abdominal breech delivery is not expected to cause it.CaseA 2,490-g female infant was delivered at term by elective cesarean section for breech presentation. She sustained a fracture of the femur shaft. A simple splinting led to a complete healing of the fracture without sequelae.ConclusionAlthough abdominal breech delivery reduces the risk of birth trauma, we must be aware that femur fracture can occur regardless of the mode of delivery.

Lipopolysaccharide (LPS) Stimulates the Production of Tumor Necrosis Factor (TNF)‐α and Expression of Inducible Nitric Oxide Synthase (iNOS) by Osteoclasts (OCL) in Murine Bone Marrow Cell Culture

Osteoclasts (OCL) resorb bone. They are essential for the development of normal bones and the repair of impaired bones. The function of OCL is presumed to be supported by cytokines and other biological mediators, including tumor necrosis factor (TNF)‐α and nitric oxide (NO). Bacterial lipopolysaccharide (LPS) is a potent inducer of TNF‐α and inducible nitric oxide synthase (iNOS), which is the specific enzyme for synthesizing NO from L‐arginine. To obtain direct evidence on LPS‐induced TNF‐α production and iNOS expression by OCL, OCL‐enriched cultures were prepared by 7‐day cocultures of bone marrow cells of adult BALB/c mice and osteoblastic cells (OBs) derived from calvaria of newborn BALB/c mice, and the generation of TNF‐α and iNOS in OCL stimulated with LPS was examined immunocytochemically. When the cultured cells were stimulated with 100 ng/ml of LPS, OCL clearly showed TNF‐α and iNOS expression. Without LPS‐stimulation, no expression was observed. TNF activity in the culture supernatants of the OCL‐enriched cultures in the presence of LPS was also detected by cytotoxic assay that used TNF‐sensitive L929 cells. The dentin resorption activity of OCL was estimated by area and number of pits formed on dentin slices, which were covered by the OCL fraction and cultured in the presence or absence of LPS, sodium nitroprusside (SNP; a NO generating compound), NG‐monomethyl L‐arginine acetate (L‐NMMA; a competitive inhibitor of NO synthase (NOS)), or LPS plus L‐NMMA. Pit formation was obviously inhibited in the presence of SNP and slightly inhibited in the presence of L‐NMMA, but it was not affected in the presence of LPS or LPS plus L‐NMMA. These findings indicate that OCL produces TNF and expresses iNOS in response to LPS, but the LPS‐activation of OCL scarcely affects pit formation by them.

Changes in blood coagulation-fibrinolysis markers by pneumatic tourniquet during total knee joint arthroplasty with venous thromboembolism.

This study investigated changes in blood coagulation-fibrinolysis markers during total knee arthroplasty (TKA). Preoperative 16-row multidetector row computed tomography (MDCT) revealed no asymptomatic venous thromboembolism (VTE) in the 42 patients recruited. Using MDCT postoperatively, patients were divided into thrombus (asymptomatic VTE, 19 patients) and no-thrombus (23 patients) groups. Blood taken at intervals before and after pneumatic tourniquet release revealed increased plasminogen activator inhibitor type-1 (PAI-1) at 30s for both groups and at 90s (both P=0.01) in the thrombus group. D-dimer levels were highest at 30 and 90s for both groups (P = 0.01). PAI-1 and D-dimer levels were strongly correlated at both time points in the thrombus group. Inactivating fibrinolysis due to PAI-1 may lead to asymptomatic VTE after TKA.

Histological investigation of resected dura mater attached to spinal meningioma.

Study Design. Histological observational study of patients with spinal meningioma. Objective. To clarify the status of tumor cell invasion into the dura mater and to provide fundamental information for appropriate management of dural attachment. Summary of Background Data. Histological appearance of the dura attached to spinal meningioma has not been sufficiently evaluated. Methods. Dura mater resected in a Simpson Grade 1 manner from 25 consecutive patients with spinal meningiomas (World Health Organization grade 1) was histologically observed to determine the status of tumor cell invasion. As no clear borders such as a tumor capsule between tumor and dura mater were observed, histological findings of the dura mater were classified into the following 3 categories: grade 1, no dural invasion, with only inflammation of the dura; grade 2: dural invasion below the zone between the inner and outer layers; and grade 3, dural invasion into or over the zone between the inner and outer layers (full-thickness invasion). Results. In our microscopic study, 19 of the 25 cases of spinal meningioma showed evidence of dural invasion and 15 cases showed full-thickness invasion. Conclusion. This histological investigation of resected dura mater attached to spinal meningioma showed a high rate of full-thickness tumor invasion into the dura mater.

Regional difference in the appearance of apoptotic cell death in the ligamentum flavum of the human cervical spine.

Ossification or calcification of the ligamentum flavum (LF) is relatively common in the middle and lower cervical, thoracic, and lumbar spine but extremely rare in the upper cervical region. This clinical fact suggests that there exist local factors promoting or preventing ossification or calcification of LF. However, little is known about the differences in the ultrastructure and cellular alterations of the LF between the different spinal levels, even in the cervical spine. With electron microscopy, we examined samples of LF collected surgically from the upper and lower cervical spine regions; we then studied the apoptotic appearance of ligament cells using a preferential labeling method. We found direct evidence of apoptosis of ligament cells in the LF. Apoptosis was more apparent in the upper region samples than in the lower region samples. The spaces around the normal fibroblasts were filled with thick collagen fibrils, but the collagen fibrils disappeared around the apoptotic bodies and thin fibrils were formed. The difference of the level of apoptosis may correlate to the ultrastructual difference of LF, and our data will benefit further investigations seeking to clarify the mechanism of various pathological conditions in the human LF.

Radiological results of treatment using an extensive anterolateral approach for developmental dysplasia of the hip: minimum 5-year follow-up.

To investigate the radiological results using the extensive anterolateral approach in patients with developmental dysplasia of the hip. A total of 16 hips with developmental dysplasia of the hip treated by the extensive anterolateral approach were retrospectively reviewed after a minimum follow-up of 5 years. For evaluation, we considered the Severin classification and postoperative complications. At the final follow-up (mean 75.6 months), 14 hips (87.5%) were satisfactory in the Severin classification. Reoperation was performed in only one hip (6.3%) because of redislocation. No femoral head necrosis was observed. Our results were more favorable than those using conventional surgical methods.

Evaluation of the association between locomotive syndrome and depressive states : a cross-sectional study

ABSTRACT The Japanese Orthopaedic Association has proposed the term “locomotive syndrome” to designate a condition that places a person at high risk for long-term care. However, in daily clinical practice, even when a diagnosis of locomotive syndrome is made, exercise therapy often cannot be successfully performed in some patients owing to their lack of motivation. We speculated that locomotive syndrome and depressive states co-exist in elderly people. The purpose of this study was to determine the presence or absence of depressive states in older patients aged ≥ 65 years who were diagnosed with locomotive syndrome. A questionnaire survey, the 25-Question Geriatric Locomotive Function Scale and Self-Rating Questionnaire for Depression was conducted. The items of the interview survey were sex, age, and history of treatment for hypertension or diabetes mellitus. For somatometry, height and body weight were measured. Patients diagnosed with locomotive syndrome (LS group) were compared with those without locomotive syndrome (non-LS group). The LS group included 99 patients, mean age was 79.4 years old, while the non-LS group included 101 patients, mean age was 76.3 years old. The number of patients with depressive states and number of females were significantly higher in the LS group. In addition, the LS group was significantly older and shorter. Multivariate analysis revealed depressive states and age to be independent factors. Therapy for patients with LS should include evaluation and, if necessary, treatment for concomitant depression.

Langerhans cell histiocytosis case with dense metaphyseal band sign

Eosinophilic granuloma, a type of Langerhans cell histiocytosis, exhibits a classic vertebral collapse, which is called vertebra plana (Calves disease) and it manifests as a solitary bony lesion. Vertebra plana can cause severe pain in patients. Bisphosphonates (clodronate, pamidronate and zoledronic acid) have been recently used to treat osteolytic bone lesions of LCH. Zoledronic acid has 100 times relative potency that of pamidronate. We report a case of a 10‐year‐old girl who had zoledronic acid treatment for severe back pain due to vertebra plana. X‐ray photographs of the patients body showed dense metaphyseal band sign, which can be found in lead poisoning, treated leukemia, healing rickets, recovery from scurvy, vitamin D hypervitaminosis, congenital hypothyroidism and hypoparathyroidism. Increased biological potent zoledronic acid deprived her of severe back pain due to vertebra plana and might cause dense metaphyseal band sign of her skeleton. Conclusion; We have cured the severe back pain of a 10‐year‐old girl case of eosinophilic granuloma with zoledronic acid. After that treatment, X‐ray photographs of the patients body showed dense metaphyseal band sign. There have been few such cases reported until now.

Imaging Diagnosis of Thoracic OPLL and OLF

Although ossifi cation of the posterior longitudinal ligament (OPLL) is often detected on cervical radiographs, OPLL can also develop in the thoracic spine. It is important to note that the incidence of ossifi cation of the ligamentum fl avum (OLF) of the thoracic spine is high. Because ossifi cation of the spinal ligaments is a disease involving systemic ossifi cation of the ligaments, it often occurs in multiple locations simultaneously. The symptoms associated with compressive spinal cord lesions in the neck usually fi rst appear in the upper extremities, and thoracic or lumbar spine lesions should be suspected if gait disorders or sensory disorders of the lower extremities occur. When lower extremity tendon refl exes are exaggerated without any symptoms in the upper extremity, the probability of lumbar myelopathy is low, whereas that of thoracic myelopathy is high.