Kyoji Hayashi

Prognosis of Patients With Upper Cervical Lesions Caused by Rheumatoid Arthritis : Comparison of Occipitocervical Fusion Between C1 Laminectomy and Nonsurgical Management

Study Design. A matched controlled comparative study of patients with upper cervical lesions caused by rheumatoid arthritis was performed at two different hospitals to evaluate occipitocervical fusion associated with C1 laminectomy and nonsurgical treatment. Objectives. To evaluate the long-term results and advantages of occipitocervical fusion associated with C1 laminectomy, and to compare these results with those of nonsurgical management of patients with myelopathy related to rheumatoid arthritis. Summary of Background Data. Few studies have reported the prognosis of patients with rheumatoid arthritis managed by occipitocervical fusion associated with C1 laminectomy. Methods. In this study, 40 patients with rheumatoid arthritis and myelopathy caused by irreducible atlantoaxial dislocation with or without upward migration of the odontoid process were studied. Of these 40 patients, 19 were treated by occipitocervical fusion using a rectangular rod associated with C1 laminectomy at one hospital, whereas 21 matched patients were treated conservatively at another hospital. The patients were observed by the same protocol to assess the radiologic and clinical results, including functional recovery and survival rate. All the patients were followed until their death. Results. The atlantodental interval was reduced immediately after surgery, and this result had been well maintained at the final follow-up assessment. Redlund-Johnell values did not vary significantly throughout the course of the study. As for neural assessment with the Ranawat classification system, improvement was found in 13 (68%) of the 19 patients who underwent surgery. The survival rate was 84% 5 years after surgery, and 37% in the first 10 years. In the patients who did not undergo surgical treatment, atlantodental interval and Redlund- Johnell values were aggravated. These patients showed no neural improvement, and aggravation was found in 16 (76%) of the 21 cases during the follow-up period. All the patients were bedridden within 3 years after the onset of myelopathy. The survival rate was 0% in the first 8 years. Conclusions. The findings lead to the conclusion that occipitocervical fusion associated with C1 laminectomy for patients with rheumatoid arthritis is useful for decreasing nuchal pain, reducing myelopathy, and improving prognosis.

Psychologic management of brace therapy for patients with idiopathic scoliosis

Study Design. A trial of brace therapy modified by a measured personality pattern of patients with idiopathic scoliosis was performed. Objective. To evaluate the effectiveness of performing personality tests for patients with idiopathic scoliosis who undergo brace therapy. Summary of Background Data. Brace therapy has often been used for the treatment of scoliosis. However, emotional distress can result from this therapy. Few attempts have been made to reduce such stress. Methods. A test using the Maudsley Personality Inventory was performed on 145 adolescent females with idiopathic scoliosis, treated with brace therapy alone, before the start of brace therapy and 1 month after the start of brace therapy. On the basis of test results, the patients were rated as normal type and four abnormal types. Brace therapy was continued considering the personality pattern of patients. For all patients, changes in psychologic test results, compliance with braces wearing instructions, and correction of scoliosis were analyzed. Result. Of the 134 patients rated as normal before the start of therapy, 108 patients were rated as abnormal pattern when tested 1 month after the start of therapy. After performing autogenic training for patients with E−N+ and E−N− personalities, and giving advice to school teachers to decrease the emotional stress for patients with E+N+ personality, 47 patients were finally rated as abnormal pattern. In total, 12 (8%) of the 145 patients dropped out. In dropouts, the average pretreatment deformity of 29° (range: 21°–37°) had increased to an average of 37° (range, 31°–48°). Conclusion. Psychologic tests may be useful and provide a means of modifying brace therapy tailored to the psychologic conditions of individual patients.

Sortilin is upregulated during osteoblastic differentiation of mesenchymal stem cells and promotes extracellular matrix mineralization.

Osteoblasts and adipocytes are derived from a common precursor in bone marrow, the mesenchymal stem cell (MSC). Factors driving human MSCs (hMSCs) to differentiate down the two lineages play important roles in determining bone density because it has been shown that bone volume loss associated with osteoporosis and aging is accompanied by reduced osteoblastic bone formation and increased marrow adipose tissue. The genes upregulated in hMSCs during osteogenic differentiation were screened using cDNA microarrays and were semi‐quantitated by real‐time RT‐PCR. One of the genes identified was sortilin, which was upregulated one day after osteogenic induction and remained upregulated for a week. The overexpression of sortilin in hMSCs using an adenovirus vector resulted in the acceleration of mineralization during osteogenic differentiation without affecting alkaline phosphatase activity. Lipoprotein lipase (LPL), produced by adipocytes, is bound by sortilin, which may mediate its endocytosis. By adding LPL to osteogenic induction medium, osteoblastic mineralization was inhibited in a dose‐dependent manner. Interestingly, sortilin overexpression abolished the LPL‐mediated suppression of osteogenic differentiation. hMSCs exist in marrow where LPL‐producing adipose cells are abundant and where osteogenesis is negatively regulated by LPL. Sortilin has a counter effect of promoting osteogenesis by acting as a scavenger of LPL. J. Cell. Physiol. 193: 73–79, 2002.

Quality of life in elderly patients with ossification of the posterior longitudinal ligament

Study Design. A longitudinal cohort study of 216 elderly patients with ossification of the posterior longitudinal ligament for an average of 13 years was performed. Objective. To know the quality of life experienced by patients after treatment. Summary of Background Data. No report is available on the quality of life experienced by elderly patients with ossification of the posterior longitudinal ligament. Because the life prognosis of patients with this condition is relatively good, the quality of life experienced by elderly patients with this disease is an important subject. Methods. The study participants were 216 elderly patients with ossification of the posterior longitudinal ligament. Conservative therapy was performed for 126 patients, and surgical therapy for 90 patients. Surgery was basically indicated for patients with myelopathy, who were classified using Nurick’s grading system. The cumulative survival rate of these patients and their disabilities in daily living were reviewed. The occurrence of fracture resulting from osteoporosis was surveyed, and the relation of such fractures to bone mineral density was examined. Results. The cumulative survival rate of 70-year-old patients exhibiting Nurick Grade 5 severe myelopathy before treatment was 20%, whereas that of patients without myelopathy or those with Grades 1, 2, 3, or 4 myelopathy before treatment was 80%. Patients who underwent surgical therapy for Grade 3 or 4 myelopathy were statistically more likely to be independent of assistance with activities of daily living than those with similar degrees of myelopathy who underwent conservative therapy. The final quality of life was poor for patients with Grade 5 myelopathy at the first examination, regardless of therapeutic method. The prevalence of complication by fracture in patients with ossification of the posterior longitudinal ligament was 1.4% for men and 8.6% for women. The bone mineral density in these patients without myelopathy was significantly higher than in healthy subjects of the same age. Conclusion. The study data suggest that surgical treatment should be chosen for patients exhibiting moderate myelopathy to obtain satisfactory quality of life for them over a long period.

Occupational recovery after open-door type laminoplasty for patients with ossification of the posterior longitudinal ligament.

Study Design. A cross-sectional survey of occupational recovery after surgery with patients who had ossification of the posterior longitudinal ligament. Objectives. To evaluate occupational recovery after open-door type laminoplasty for patients with ossification of the posterior longitudinal ligament. Summary of Background Data. The literature contains numerous reports on the surgical results of laminoplasty for ossification of the posterior longitudinal ligament, but very few reports are available on postoperative quality of life, and even fewer on occupational recovery after laminoplasty. Methods. A cross-sectional survey was conducted of 301 patients with ossification of the posterior longitudinal ligament in the cervical spine who were employed before open-door type laminoplasty. Presurgical occupations were classified into three categories: light sedentary labor, light standing labor, and heavy labor. High-rise workers and professional drivers were analyzed separately. The subjects were rated by occupational category for determining the occupational recovery ratio. Factors analyzed for impact on recovery were pre- and postsurgery severity of myelopathy, duration of myelopathy, age at surgery, gender, and type of ossification of the posterior longitudinal ligament. Results. Of the 301 patients studied, 160 (53%) returned to work. Poor recovery rates were observed for heavy labor, high-rise workers, and professional drivers. The period required for return to work did not significantly differ among occupational categories. Occupation, presurgery severity of myelopathy, and postsurgery severity of myelopathy were significantly correlated with occupational recovery. Conclusion. Patients’ occupations should be carefully considered when designing postsurgery occupational rehabilitation programs, and patients should receive postoperative advice regarding the suitability of occupation.

Lateral Approach to C2 Root Schwannoma Located Ventral to the Spinal Cord: A Case Report

脊髄腹側にあるC2前根糸由来の神経症腫に対し側方進入にて手術施行したので報告する．（症例）31歳男性．2003年2月上位頚椎のdumb-bell腫瘍に対し，後方進入にて環椎後弓切除・腫瘍摘出術施行．病理はschwannomaであった．myelopathyは軽快するも，MRI上脊柱管内に腫瘍は遺残．2004年9月左上肢の筋力低下出現．手術目的にて2005年6月入院．四肢DTRの亢進，左上下肢の筋力低下を認め，JOA scoreは11/17．脊髄は環椎レベルで腹側から著明に圧迫されており，側方進入摘出術を施行．胸鎖乳突筋後方より進入，腫瘍を内減圧し骨削除は行わずに全摘し得た．腫瘍はC2神経根前根と連続していた．術後大後頭神経領域の知覚低下出現するもmyelopathyは軽快した．（考察）上位頚椎部の脊髄腫瘍は呼吸麻痺や重篤な麻痺を来しうるため，特に良性の場合全摘が望ましい．腫瘍が脊髄腹側に存在する場合，側方進入摘出術は有用な方法と考える．

Posterior Surgical Procedure for Ossification of the Posterior Longitudinal Ligament of the Thoracic Spine

We studied 22 patients (seven men and fifteen women) with ossification of the posterior longitudinal ligament (OPLL) of the thoracic spine.Posterior approach was performed on all patients, laminoplasty on nine patients, and laminectomy on thirteen patients. The mean JOA score of all patients improved from 3.6 points to 6.3 points. The improvement rate (Hirabayashimethod) was 35.4%.In four patients, paralysis of the lower extremities progressed temporarily, but at the end of the study it had improved. In conclusion, satisfactory results were observed by posterior surgical procedure for thoracic OPLL.

Treatment of Femoral Fracture with MRSA Myelitis

We treated an 81-year-old female who had femoral fracture with osteomyelitis by MRSA. She underwent osteosynthesis of the femoral neck fracture in 2000. Two years after the operation, her thigh became infected, for which she underwent operations such as removal of prosthesis, continuous irrigation, and plugging of PMMA cement beads with VCM. Unfortunately, she suffered a femoral fracture again. We performed osteosynthesis using the gamma-nail and grafted calcium phosphate cement (Biopex) with VCM to the bone defect, and obtained good results Biopex is useful for grafting to the bone defect when osteosynthesis is required for the treatment of fractures with osteomyelitis by MRSA.

Video-assisted Thoracoscopic Surgery (VATS) with Posterior Surgery for Thoracic Dumbbell Tumor.

We performed video-assisted thoracoscopic surgery (VATS) combined with posterior surgery for two patients with dumbbell tumor at the thoracic level. The patients were a 35-year-old male and a 51-year-old female. Following the resection of the intra-spinal-canal portion of the tumor with posterior approach, the intra-thoracic lesion was resected using VATS instead of conventional approach in both patients. Complete resection of tumor was successfully performed without neurological complication. VATS is useful for the treatment of dumbbell tumor at the thoracic level.

3:59 Pathogenesis of myelopathy in patients with ossification of the posterior longitudinal ligament in the cervical spine

Abstract Purpose of study: The pathogenesis of myelopathy in ossification of the posterior longitudinal ligament (OPLL) in the cervical spine remains unknown. It is believed that myelopathy develops because of spinal compression by the ossified ligament. However, some patients with little ossifications exhibit myelopathy, whereas others with marked ossification do not. Static factors alone cannot account for the pathogenesis of myelopathy. The goal of this study was to clarify pathogenesis of myelopathy in patients with OPLL in the cervical spine based on the relationship between static compression factors and dynamic factors. Methods used: This was a prospective study with an average 11-year follow-up review. There was a total of 247 patients, including 167 patients who were conservatively followed for a mean of 11 years and 2 months and 80 patients who had myelopathy at initial consultation and underwent surgery. Clinical changes with time and radiographical changes of development of ossification were observed periodically in the 167 patients who did not undergo surgery and were conservatively followed. The relationship between minimal diameter of space available for spinal cord (SAC) and the whole range of motion (ROM) of the cervical spine was examined in 247 patients, including those who were conservatively followed and those who underwent surgery. of findings: During the natural course of OPLL in the cervical spine, 37 of 167 patients (22%) developed or aggravated spinal symptoms. All of the patients with minimal diameter of space available for spinal cord (SAC) less than 6 mm had myelopathy, whereas the patients with an SAC diameter of 14 mm or greater did not. No correlation was found between presence or absence of myelopathy in patients whose SAC diameter ranged from 6 mm to less than 14 mm. In patients with myelopathy whose minimal SAC diameter ranged from 6 mm to less than 14 mm, ROM was significantly greater. Relationship between findings and existing knowledge: In the patients with a minimal SAC diameter of 6 mm to less than 14 mm, the whole ROM in the group with myelopathy was significantly greater than that in the group without myelopathy. These results support the importance of the restriction of motion of cervical spine as a dynamic factor for development of myelopathy in patients with moderate OPLL. Overall significance of findings: Pathological compression by the ossified ligament above a certain critical point may be the most significant factor in inducing myelopathy, whereas below that point dynamic factors may be largely involved in inducing myelopathy. Disclosures: No disclosures. Conflict of interest: Shunji Matsunaga, grant research support, Ministry of Health and Welfare, Japan.