Makoto Takazawa

Difficulty of Diagnosing the Origin of Lower Leg Pain in Patients With Both Lumbar Spinal Stenosis and Hip Joint Osteoarthritis

Study Design. Case series. Objective. To present the difficulty of diagnosing the origin of lower leg pain in patients with lumbar spinal stenosis and hip joint arthritis. Summary of Background Data. Pain arising from a degenerated hip joint is sometimes localized to the lower leg. Patients with lumbar spinal disease may also show radicular pain corresponding to the lower leg area. If patients present with both conditions and only pain at the lower leg, it is difficult to determine the origin of the pain. Methods. We reviewed 420 patients who had leg pain with lumbar spinal stenosis diagnosed by myelography, computed tomography after myelography, or magnetic resonance imaging. Pain only at the ipsilateral lateral aspect of the lower leg but slight low back pain or pain around the hip joint was shown in 4 patients who had lumbar spinal stenosis and hip osteoarthritis. The symptoms resolved after L5 spinal nerve block, but remained after lidocaine infiltration into the hip joint. We performed decompression and posterolateral fusion surgery for these 4 patients. Results. Leg pain did not resolve after lumbar surgery in all patients. Conservative treatment was not effective from 6 to 12 months, so ultimately we performed ipsilateral total hip replacement for all patients and they became symptom-free. Conclusion. It is difficult to determine the origin of lower leg pain by spinal nerve block and hip joint block in patients with lumbar spinal stenosis and hip osteoarthritis. We take this into consideration before surgery.

Influence of pelvic incidence-lumbar lordosis mismatch on surgical outcomes of short-segment transforaminal lumbar interbody fusion.

BackgroundThe importance of pelvic incidence-lumbar lordosis (PI-LL: PI minus LL) mismatch is emphasized in long-segment fusion for adult spinal deformity; however, there are few studies evaluating the influence of PI-LL on surgical outcomes after short-segment fusion. In this study, we have examined the effects of PI-LL mismatch on surgical outcomes of short-segment lumbar intervertebral fusion for lumbar degenerative diseases.MethodsPatients with lumbar degenerative disease treated by short-segment (1 or 2 levels) transforaminal lumbar interbody fusion were divided into Group A (PI-LLu2009≤u200910°: nu2009=u200922) and Group B (PI-LLu2009≥u200911°: nu2009=u200930). Pre-and post-operative patient symptoms were assessed by the visual analogue scale (VAS: scores 0-100xa0mm; for LBP, lower-extremity pain, and lower-extremity numbness), a detailed VAS for LBP while in motion, standing, and sitting, and the Oswestry disability index (ODI). Surgical outcomes were evaluated by the Nakai score (3u2009=u2009excellent to 0u2009=u2009poor. Post-operative data were acquired for at least one year following surgery and were compared between the two groups. Multiple regression analyses were used to evaluate the relative influence of PI-LL on each pre-and post-operative parameter (VAS, detailed VAS and ODI) adjusted for age, sex, fusion levels, body mass index, presence of scoliosis, diabetes mellitus and depression.ResultsThe surgical outcomes in Group A were significantly better than those of Group B. Group A showed better post-operative VAS scores for LBP, particularly LBP while standing (11.9 vs. 25.8). The results of the multivariate analyses showed no significant correlation between PI-LL and pre-operative symptoms, but did show a significant correlation between PI-LL and the post-operative VAS score for LBP, lower extremity pain, and numbness.ConclusionsThis study is the first to find that PI-LL mismatch influences post-operative residual symptoms, such as LBP, lower extremity pain and numbness. Among the three types of LBP examined in the detailed VAS, LBP while standing was most strongly related to PI-LL mismatch. The importance of maintaining spinopelvic alignment is emphasized, particularly when treating patients with adult spinal deformity using long-segment fusion surgery. However, our results indicate that surgeons should pay attention to sagittal spinopelvic alignment and avoid post-operative PI-LL mismatch even when treating patients with short-segment lumbar interbody fusion.

The incidence of alcohol-associated osteonecrosis of the knee is lower than the incidence of steroid-associated osteonecrosis of the knee: an MRI study

OBJECTIVEnThe purpose of the study was to clarify the incidence of alcohol-associated osteonecrosis of the knee using MRI.nnnMETHODSnA total of 131 patients (56 women and 75 men) with osteonecrosis of the femoral head were enrolled; 60 patients had a history of alcohol abuse and 71 had previously received steroids. All patients underwent MRI of the knee. The incidence of alcohol-associated osteonecrosis of the knee was compared with that of steroid-associated osteonecrosis of the knee. Predictive factors of alcohol- and steroid-associated osteonecrosis of the knee were also evaluated.nnnRESULTSnThe incidence of alcohol-associated osteonecrosis of the knee was lower than that of steroid-associated osteonecrosis of the knee (18.3 vs 54.9%; Pu2009<u20090.001, Fishers exact probability test). No significant difference in weekly alcohol consumption was observed between patients with osteonecrosis of the knee and those without osteonecrosis of the knee. No significant difference in daily maximum steroid doses was observed between patients with osteonecrosis of the knee and those without osteonecrosis of the knee.nnnCONCLUSIONnThe present study revealed that the incidence of alcohol-associated osteonecrosis of the knee is lower than that of steroid-associated osteonecrosis of the knee.

Inter-observer and intra-observer reliabilities of the Japanese Ministry of Health, Labor and Welfare type classification system for osteonecrosis of the femoral head

The aim of this study was to clarify the reproducibility of the Japanese Ministry of Health, Labor and Welfare (JMHLW) type classification for osteonecrosis of the femoral head. We performed inter-observer and intra-observer trials using 40 sets of magnetic resonance imagings, 20 of which were produced by a 0.5xa0Tesla (T) superconductive unit and the other 20 produced by a 1.5xa0T unit, in patients with non-collapsed and asymptomatic osteonecrosis of the femoral head (JMHLW stage 1 or 2). The JMHLW type classification (A, B, C1, or C2) was determined from T1-weighted coronal images at the center of the femoral head. Six orthopedic surgeons independently assessed all 40 images twice, with an interval of 4–5xa0weeks between sessions. Regarding inter-observer reliability, the percent agreement was 85% and weighted kappa was 0.709 for 0.5xa0T, versus a percent agreement of 82% and weighted kappa of 0.724 for 1.5xa0T. Regarding intra-observer reliability, the percent agreement was 82% and weighted kappa was 0.780 for 0.5xa0T versus a percent agreement of 80% and weighted kappa of 0.800 for 1.5xa0T. Inter-observer and intra-observer reliabilities did not differ significantly between the 0.5 and 1.5xa0T units. The JMHLW type classification provided high inter-observer and intra-observer reliabilities.

Increase of nerve growth factor levels in the human herniated intervertebral disc: can annular rupture trigger discogenic back pain?

IntroductionNerve growth factor (NGF) has an important role in the generation of discogenic pain. We hypothesized that annular rupture is a trigger for discogenic pain through the action of NGF. In this study, the protein levels of NGF in discs from patients with disc herniation were examined and compared with those from discs of patients with other lumbar degenerative disc diseases.MethodsPatients (n = 55) with lumbar degenerative disc disease treated by surgery were included. Nucleus pulposus tissue (or herniated disc tissue) was surgically removed and homogenized; protein levels were quantified using an enzyme-linked immunosorbent assay (ELISA) for NGF. Levels of NGF in the discs were compared between 1) patients with herniated discs (herniated group) and those with other lumbar degenerative disc diseases (non-herniated group), and 2) low-grade and high-grade degenerated discs. Patient’s symptoms were assessed using a visual analog scale (VAS) and the Oswestry disability index (ODI); the influence of NGF levels on pre- and post-operative symptoms was examined.ResultsMean levels of NGF in discs of patients were significantly higher in herniated discs (83.4xa0pg/mg total protein) than those in non-herniated discs (68.4xa0pg/mg).No significant differences in levels of NGF were found between low-grade and high-grade degenerated discs. Multivariate analysis, adjusted for age and sex, also showed significant correlation between the presence of disc herniation and NGF levels, though no significant correlation was found between disc degeneration and NGF levels. In both herniated and non-herniated groups, pre-operative symptoms were not related to NGF levels. In the herniated group, post-operative lower extremity pain and low back pain (LBP) in motion were greater in patients with low levels of NGF; no significant differences were found in the non-herniated group.ConclusionsThis study reports that NGF increased in herniated discs, and may play an important role in the generation of discogenic pain. Analysis of patient symptoms revealed that pre-operative NGF levels were related to post-operative residual lower extremity pain and LBP in motion. The results suggest that NGF in the disc is related to pain generation, however, the impact of NGF on generation of LBP varies in individual patients.

Pain‐related behavior and the characteristics of dorsal‐root ganglia in a rat model of hip osteoarthritis induced by mono‐iodoacetate

The principal aim of this study was to clarify the time course of pain‐related behavior and pain‐related sensory innervation in a rat model of hip osteoarthritis (OA) induced by intra‐articular injection of mono‐iodoacetate (MIA). Using 6‐week‐old male Sprague Dawley rats, 25u2009μl of sterile saline of 1% Fluoro‐Gold solution (FG) (control group; nu2009=u200930) and 25u2009μl of sterile saline of 1% FG with 2u2009mg of MIA (MIA group; nu2009=u200930) was injected into the right hip joints. Gait function was evaluated using a CatWalk system after 7, 14, 28, 42, and 56 days (nu2009=u20095, respectively). Neurons in the dorsal root ganglion (DRG) between L1 and L5 were immunostained for calcitonin gene‐related peptide (CGRP) and activating transcription factor‐3 (ATF3). Gait analysis revealed the mean six parameters of hind paws at all time points were significantly lower in the MIA group (pu2009=u20090.05). The number of CGRP‐immunoreactive (‐IR) DRG neurons was significantly increased on days 7, 14, 28, and 42 peaking at 14 days in the MIA group. By contrast, expression of ATF3‐IR in FG‐labeled DRG neurons was significantly increased on days 42 and 57. The FG‐labeled DRG neurons were distributed between L1 and L5, mainly at the L4 level. Pain‐related behavior indicated by gait disturbance was observed in a MIA model of hip OA in rat. Early elevation of CGRP expression and late expression of ATF‐3 were demonstrated in DRG neurons, possibly reflecting inflammatory pain and neuropathic pain in hip OA.

Predictive factors for acetabular labral lesions in osteoarthritis of the hip with radial magnetic resonance imaging--a cross-sectional study.

Abstract Objectives. To document the reliability of Abes classification and to clarify the predictive factors for acetabular labral lesions in osteoarthritis of the hip with radial magnetic resonance (MR) imaging. Methods. Reliability trial for the classification of acetabular labral lesion was performed by six orthopedic surgeons, grading 20 radial MR images in a blinded fashion at an interval of 4–5 weeks. Radial MR images of 275 hips in 263 patients were prospectively analyzed to determine the relationship between acetabular labral lesions, their distribution, age, and the acetabular coverage. Results. Cohens quadratic weighted kappa of inter-observer reliability was 0.784 for the grade and 0.812 for the shape category. The weighted kappa of intra-observer reliability was 0.852 for the grade and 0.90 for the shape category. Multiple regression analysis revealed that both the grade and the shape were associated with age, acetabular coverage, and location of the labrum. Conclusions. Abes classification of labral lesions was reliable for both the grade and shape categories. Aging, acetabular dysplasia, and the anterosuperior portion would be predictive factors for degeneration of the acetabular labrum using radial MR imaging.

Inflammatory pain-related traits of sensory DRG neurons innervating the hip joints

BACKGROUNDnHip pain is transmitted to the dorsal horn of the spinal cord via the dorsal root ganglion (DRG), which contains two types of neurons with differential sensitivity to neurotrophic factors. If either type predominantly innervates the hip joint, it may represent a good target for hip joint pain treatment.nnnMETHODSnInflammation was induced in the left hip joint of rats (nxa0=xa010) by using complete Freunds adjuvant. Fluoro-Gold (FG) was applied to the hip joint after 7 days, and T12-L6 DRGs were double-stained for calcitonin gene-related peptide (CGRP) and isolection-IB4 1 week later.nnnRESULTSnFG-labeled neurons in the control group were distributed throughout the left DRG from T13 to L5, primarily in L2 to L4, and CGRP-positive neurons were significantly more frequent than IB4-binding neurons. In the inflammatory group, FG-labeled neurons were similarly distributed, primarily at L3 and L4, and CGRP-positive neurons were significantly more frequent than IB4-binding neurons. The percentage of CGRP-positive neurons was significantly greater in the inflammatory group (Pxa0<xa00.05).nnnCONCLUSIONSnMost small neurons innervating the hip joint express CGRP. Furthermore, hip joint inflammation caused an increase in CGRP-positive neurons, but not in IB4-binding neurons. Our results suggest that CGRP-expressing nerve growth factor-dependent neurons are primarily responsible for hip joint pain and may represent therapeutic targets.

Less invasive lumbopelvic fixation technique using a percutaneous pedicle screw system for unstable pelvic ring fracture in a patient with severe multiple traumas.

Pelvic ring fractures are defined as life-threatening injuries that can be treated surgically with external or internal fixation. The authors report on an 81-year-old woman with an unstable pelvic fracture accompanying multiple traumas that was successfully treated with a less invasive procedure. The patient was injured in a traffic accident and sustained a total of 20 fractures, including pelvic ring, bilateral rib, and lumbar transverse processes fractures, and multiple fractures of both upper and lower extremities. The pelvic ring fracture was unstable with fractures of the bilateral sacrum with right sacroiliac disruption, right superior and inferior pubic rami, left superior pubic ramus, and ischium. During emergency surgery, bilateral external fixation was applied to the iliac crest to stabilize the pelvic ring. Second and third surgeries were performed 11 and 18 days after the first emergency surgery, respectively, to treat the multiple fractures. At the third surgery, the pelvic ring fracture was stabilized surgically using a less invasive posterior fixation technique. In this technique, 2 iliac screws were inserted on each side following an 8-cm midline posterior incision from the S-1 to S-3 spinous process, with the subcutaneous tissue detached from the fascia of the paraspinal muscles. The S-2 spinous process was removed and 2 rods were connected to bilateral iliac screws to stabilize the bilateral ilium in a switchback fashion. A crosslink device was applied to connect the 2 rods at the base of the S-2 spinous process. Following pelvic fixation, percutaneous pedicle screws were inserted into L-4 and L-5 vertebral bodies on both sides, and connected to the cranial rod connecting the bilateral iliac screws, thus completing the lumbopelvic fixation. The postoperative course was favorable with no postoperative complications. At the 10-month follow-up, bone union had been achieved at the superior ramus of the pubis, the patient did not complain of pain, and her activities of daily life returned to preinjury status. Unstable pelvic ring fractures need to be sufficiently stabilized for good surgical outcome. However, to avoid postoperative complications, a less invasive treatment is preferred, particularly in cases with poor general condition. This procedure is less invasive and provides sufficient stabilization to the unstable pelvic ring fracture, and thus is the ideal surgical procedure for such cases.

Response to ‘Increase of nerve growth factor levels in the human herniated intervertebral disc: can annular rupture trigger discogenic back pain?’ – authors’ reply

We appreciate the interest and attention paid by Agilli and Ekinci, and we agree with their point that nerve growth factor (NGF) levels could be affected by multiple factors [1]. As pointed out, the paper would be improved by considering the effects of these factors; thus the data were re-examined. This analysis found that the number of patients who had neuropsychiatric diseases and use medications (one patient in the herniated group and two patients in the nonherniated group) and had diabetes mellitus (two patients in each group) were similar between the two groups. As Bullo and colleagues described, obesity is one of the important factors affecting NGF levels in blood samples [2]. These authors also indicated the influence of body mass index (BMI) on NGF levels; thus, the BMI of our patients was analyzed and included in the multivariate analysis. The BMI of the two groups showed no significant difference (24.0u2009±u20094.0 in the herniated group and 25.3u2009±u20093.2 in the nonherniated group, Pu2009=u20090.20), and Pearson’s correlation analysis showed no significant correlation between the level of NGF and BMI (Pu2009=u20090.91). The multivariate analysis adjusted for age, sex, disc degeneration and BMI still showed a significant correlation between disc herniation and NGF levels (Pu2009=u20090.018). n nA previous report of a rat study described that disc injury induced an inflammatory response and NGF upregulation in the disc [3]. It has also been reported that inflammatory mediators including NGF were increased in human symptomatic discs [4,5]. The intervertebral disc is avascular, and metabolic transport depends on diffusion through the vertebral endplates [6]. This limited molecular transport may explain why NGF did not increase in discs from our obese patients. These observations suggest that the significant increase of NGF in herniated discs was due to local tissue reaction following annular rupture. Because there may be many factors affecting NGF levels in the disc, it would be difficult to include them all in a multivariate analysis. However, as Agilli and Ekinci indicated, several important factors should be taken into account when studying NGF levels in the disc.