Tsuneaki Takao

Immunohistochemistry of chondromodulin-I in the human intervertebral discs with special reference to the degenerative changes.

The expression of the matrix protein chondromodulin-I has been studied in human intervertebral discs of 101 people using immunohistochemical analyses. The purpose of this report is to present data on the metabolic changes that were found to occur in the chondrocytes of intervertebral discs during development and aging. Chondromodulin-I was highly expressed during the gestational period and gradually decreased after maturation. It was detected in both the extracellular matrix and chondrocytes in the zone of hypertrophic cartilage, the zone of proliferative cartilage and the zone of resting cartilage in fetal discs. It was also present in the annulus fibrosus, nucleus pulposus and end-plate cartilage in mature discs. In degenerative discs, chondromodulin-I immunoreactivity tended to be elevated in the remaining chondrocytes. Our findings suggest that the expression of the protein is developmentally regulated and upregulated through a defense mechanism against the degenerative processes of the aged intervertebral disc.

Analysis of the risk factors for tracheostomy in traumatic cervical spinal cord injury.

Study Design. A retrospective, consecutive case series. Objective. To determine the risk factors that have a statistically significant association with the need of tracheostomy in patients with cervical spinal cord injury (CSCI) at the acute stage. Summary of Background Data. Respiratory complications remain a major cause of further morbidity and mortality in patients with CSCI. Although several risk factors for tracheostomy have been postulated in these patients, no definitive factors have yet been established according to a multivariate analysis. The use of vital capacity was considered as a single global measure of respiratory function in patients with spinal cord injury, but there are very few studies in which the forced vital capacity was investigated as a risk factor for tracheostomy. Methods. This study that reviewed the clinical data of 319 patients with CSCI, who were evaluated for their neurological impairment within 2 days after injury, was performed. We analyzed the factors postulated to increase the risk for tracheostomy, including patients age, neurological impairment scale grade and level, smoking history, pre-existing medical comorbidities, respiratory diseases, Injury Severity Score, forced vital capacity, and percentage of vital capacity to the predicted value (%VC), using a multiple logistic regression model and classification and regression tree analysis. Results. Of 319 patients, 32 patients received tracheostomy (10.03%). The factors identified using a multiple logistic regression model were high age (69 years of age or older), severe neurological impairment scale, low forced vital capacity (⩽500 mL), and low percentage of vital capacity to the predicted value (<16.3%). The decision tree analysis demonstrated that forced vital capacity, the severe neurological impairment scale, and high patient age were predictive of need for tracheostomy on 94.4% occasions. Conclusion. The measurement of forced vital capacity is indispensable to predict the need for tracheostomy in patients with CSCI at the acute stage.

A comparative study of localization of heat shock protein 27 and heat shock protein 72 in the developmental and degenerative intervertebral discs.

STUDY DESIGN The lumbar intervertebral discs of 135 subjects after autopsy were immunostained with antihuman heat shock protein 27 (HSP27) monoclonal antibody and antihuman heat shock protein 72 (HSP72) polyclonal antibody. OBJECTIVES To present the data on metabolic changes that occurred in the chondrocytes of intervertebral discs during development and aging. SUMMARY OF BACKGROUND DATA Heat shock proteins have been implicated in the progressive degeneration of articular cartilage in joint disease, such as rheumatoid arthritis and osteoarthritis. However, the role and expression of heat shock proteins in human intervertebral discs have received little study. METHODS One hundred thirty-five specimens of human intervertebral discs were stained with hematoxylin and eosin, alcian blue, and Massons trichrome and were immunostained with HSP27 and HSP72 by an indirect immunoperoxidase method. The relative amounts of HSP27 and HSP72 deposition were graded according to a semiquantitative scoring system. RESULTS Heat shock protein 72 accumulated in the cytoplasm of the chondrocytes of both endplate cartilage and nucleus pulposus during gestation and thereafter decreased with aging (age, </=60 years), and HSP72 immunoreactivity increased in the chondrocytes of degenerative discs. In addition, HSP72 was located in the nuclei of certain chondrocytes of the degenerated nucleus pulposus and anulus fibrosus, was highly expressed in the chondrocytes of endplate cartilage during gestation and childhood, and thereafter decreased with aging. Furthermore, with the progressive degeneration of the endplate cartilage, HSP27 immunoreactivity increased. The degree of HSP27 immunoreactivity did not change significantly according to age in either the nucleus pulposus or the anulus fibrosus. CONCLUSIONS Heat shock protein 27 and HSP72 are thus considered to be useful molecular indicators for degenerative change in intervertebral discs. Both HSP27 and HSP72 are presumed to play a role in cell protection from stress that is induced by mechanical and biologic factors causing intervertebral disc degeneration.

The potential for functional recovery of upper extremity function following cervical spinal cord injury without major bone injury

Study Design:This was a retrospective observational study.Objectives:The objectives were to describe the prognosis of upper extremity function following cervical spinal cord injury (CSCI), and to identify prognostic factors for functional recovery.Setting:Spinal Injuries Center, Japan.Methods:Sixty patients with C3–4 CSCI without major bone injury participated in the study. Patients were treated nonsurgically and evaluated using the American Spinal Injury Association (ASIA) scales for the upper and lower extremities, their residual cervical motor functions, the modified Frankel grade and an upper extremity function scale. We compared the findings for the upper extremity function scale at 6 months with those for the residual cervical motor functions and modified Frankel grade obtained 3 days after injury.Results:Most patients with CSCI who could flex their hip and knee from a supine position (95%) or who showed some active elbow extension (86%) 3 days after their injury could use a spoon at 6 months. We compared patients who used their fingers at 6 months to those who could not, and observed significant differences in age and ASIA scores for the upper and lower extremities obtained 3 days after injury. A strong correlation was observed between the initial motor scores and the extent of functional recovery at 6 months.Conclusion:Hip and knee flexion from the supine position and elbow extension 3 days after injury significantly predicted a positive prognosis for upper extremity function. Younger age and higher ASIA motor scores obtained 3 days after injury were factors associated with neurological recovery.

Clinical Influence of Cervical Spinal Canal Stenosis on Neurological Outcome after Traumatic Cervical Spinal Cord Injury without Major Fracture or Dislocation

Study Design Retrospective case series. Purpose To clarify the influence of cervical spinal canal stenosis (CSCS) on neurological functional recovery after traumatic cervical spinal cord injury (CSCI) without major fracture or dislocation. Overview of Literature The biomechanical etiology of traumatic CSCI remains under discussion and its relationship with CSCS is one of the most controversial issues in the clinical management of traumatic CSCI. Methods To obtain a relatively uniform background, patients non-surgically treated for an acute C3–4 level CSCI without major fracture or dislocation were selected. We analyzed 58 subjects with traumatic CSCI using T2-weighted mid-sagittal magnetic resonance imaging. The sagittal diameter of the cerebrospinal fluid (CSF) column, degree of canal stenosis, and neurologic outcomes in motor function, including improvement rate, were assessed. Results There were no significant relationships between sagittal diameter of the CSF column at the C3–4 segment and their American Spinal Injury Association motor scores at both admission and discharge. Moreover, no significant relationships were observed between the sagittal diameter of the CSF column at the C3–4 segment and their neurological recovery during the following period. Conclusions No relationships between pre-existing CSCS and neurological outcomes were evident after traumatic CSCI. These results suggest that decompression surgery might not be recommended for traumatic CSCI without major fracture or dislocation despite pre-existing CSCS.

Influence of spinal cord compression and traumatic force on the severity of cervical spinal cord injury associated with ossification of the posterior longitudinal ligament.

Study Design. Retrospective review. Objective. To evaluate the influence of static compression factors and dynamic factors based on the various degrees of traumatic force on the cervical spinal cord injury (SCI) in patients with ossification of the posterior longitudinal ligament. Summary of Background Data. Spinal cord disorder occurs as a result of various factors, including static factors and traumatic force. Discussions about the severity of paralysis resulting from SCI must therefore focus on dynamic factors based on the traumatic force as well as on static compression factors. However, the past reports did not describe the influence of traumatic force in detail. Methods. Fifty patients presenting with cervical SCI associated with ossification of the posterior longitudinal ligament were included in this study. The American Spinal Injury Association motor score 3 days after injury, the degree of the traumatic force, and the spinal cord compression rate were investigated, and the relationships among these factors were investigated. Results. Paralysis at the time of injury was not determined by static factors alone or by traumatic force alone. The severity of paralysis at the time of injury was determined on the basis of a combination of both the static factors and the degree of traumatic force. Conclusion. Both the degree of spinal cord compression and the degree of traumatic force were found to be important factors associated with the severity of cervical SCI in patients with ossification of the posterior longitudinal ligament. Level of Evidence: 4

The dosage and administration of long-term intrathecal baclofen therapy for severe spasticity of spinal origin

Study designRetrospective chart audit.ObjectiveTo indicate the appropriate baclofen dosage to control severe spasticity of spinal origin and to develop the optimal administration protocol for long-term intrathecal baclofen (ITB) therapy.SettingDepartment of Orthopaedic Surgery, Spinal Injuries Center, Japan.MethodsThirty-four people with spasticity of various spinal origins who were consistently treated at our hospital were included. The median follow-up period was 6 years and 11 months. Measures of Ashworth score were taken before and after surgical implant of baclofen pump. We decided not to increase the baclofen dosage after the Ashworth score reached 1. We recorded the control of spasticity, changes in the baclofen dose, and the incidence of complications.ResultsThe average Ashworth score was 3.31 (1.75–4.0) before implant surgery, 1.38 (1.0–2.25) after implant surgery, and 1.39 (1.0–2.25) at the final follow-up, while the average baclofen dose (therapeutic/optimal dose) was 230.6 μg/day (50–450). The incidence of each complication was as follows: 8.8% (n = 3) catheter-related, 2.9% (n = 1) pump-related and 5.9% (n = 2) drug tolerance. No patients experienced withdrawal syndrome. Dose fluctuation with changes in the pathology of the original disease was observed in three cases.ConclusionsThe usage of the Ashworth score as a guide for dose adjustment was found to be a good objective indicator for ITB therapy. The administration based on this objective indicator made it possible to effectively manage patients with a relatively low dose of baclofen and a low rate of drug-related complications.

A radiographic evaluation of facet sagittal angle in cervical spinal cord injury without major fracture or dislocation

Study Design:A retrospective radiographic study with a minimum 2-year follow-up.Objective:To evaluate the relationships between the cervical articular facets’ morphology and the incidence of traumatic cervical spinal cord injury (CSCI) without major fracture or dislocation.Setting:Spinal Injuries Center, Japan.Methods:This study included 113 patients with traumatic CSCI without major fracture or dislocation. Eighty-four healthy volunteers without neurological deficits or cervical cord pathology on magnetic resonance imaging (MRI) were defined as control subjects. We used a plain sagittal radiograph to measure the facet sagittal angles (FSA) at four cervical segments in all the CSCI patients and controls. We defined the FSA as the angle between the inferior margin of the superior cervical spinal body and the inferior articular process of the superior vertebra.Results:Most frequent incidence of CSCI was seen at C3–4 segment (54%). With respect to CSCI at C3–4 segment, 55.7% of the subjects showed smallest FSA at C3–4 segment.Conclusion:Most of the traumatic CSCI at C3–4 segment showed raised cervical articular facets at C3–4 segment. On the basis of our results, we hypothesized that the raised cervical articular facets might have an important role in the etiology of traumatic CSCI. The cervical spinal cord at the C3–4 segment might receive the highest load during acute hyperextension of the cervical spine because of the C3–4 articular facets’ morphology.

Local Sagittal Alignment after Indirect Reduction and 2-Level Short-Segment Pedicle Screw Fixation of Thoracolumbar Burst Fractures

Local Sagittal Alignment after Indirect Reduction and 2-Level Short-Segment Pedicle Screw Fixation of Thoracolumbar Burst Fractures The treatment of thoracolumbar burst fractures with short-segment pedicle screw fixation alone has been associated with progressive loss of correction and instrumentation failure. However, some burst fractures can be treated successfully by this technique without correction loss or implant failure.