Yasunori Sorimachi

Cervical malalignment after laminoplasty : relationship to deep extensor musculature of the cervical spine and neurological outcome

OBJECT The goal of this study was to investigate the relationship between preservation of the insertion of the deep extensor musculature of the cervical spine at C-2 and postoperative cervical alignment, especially differences between cases involving male and female patients, as well as the relationship between the loss of cervical lordosis and neurological outcome after laminoplasty. METHODS The authors reviewed the records of 50 patients who underwent laminoplasty to elevate the C-3 lamina with repair of the deep extensor musculature (Group A) and 31 patients who underwent laminoplasty by C-3 dome laminotomy or laminectomy (Group B). They compared the degree of cervical lordosis after laminoplasty with preoperative measurements. Neurological function at last follow-up was also compared with preoperative assessments. RESULTS In Group A, the mean values for pre- and postoperative cervical lordosis were 14.5 and 10.9 degrees, respectively (p > 0.18). In female patients, however, the pre- and postoperative means were 14.4 and 3.7 degrees, respectively (p < 0.004). In Group B, the overall means for pre- and postoperative cervical lordosis were 17.3 and 19.1 degrees, respectively (p > 0.48); the corresponding means for female patients were 15.0 and 14.1 degrees (p > 0.83). The mean percentages of neurological recovery were 54.1% in Group A and 54.8% in Group B. CONCLUSIONS Preservation of the insertion of the deep extensor musculature to the C-2 spinous process prevented significant changes in cervical alignment after laminoplasty, even among female patients. Neurological recovery was not affected by the loss of cervical lordosis.

Foot drop due to lumbar degenerative conditions: mechanism and prognostic factors in herniated nucleus pulposus and lumbar spinal stenosis

OBJECT The aim of this study was to analyze the mechanism and prognostic factors of foot drop caused by lumbar degenerative conditions. METHODS The authors retrospectively reviewed the charts of 28 patients with foot drop due to a herniated nucleus pulposus (HNP) or lumbar spinal stenosis (LSS), scoring between 0 and 3 on manual muscle testing for the tibialis anterior muscles. They analyzed the mechanism of foot drop and whether the duration before the operation, preoperative tibialis anterior and extensor hallucis longus strength, age, gender, and diabetes mellitus were all found to be prognostic factors for postoperative tibialis anterior recovery. They also investigated whether the diagnosis had any influence on the prognosis. RESULTS The compression of double roots and a sequestrated fragment were observed, respectively, in 9 and 13 of 16 patients with HNP. Multiple levels including the L4-5 segment were decompressed in 8 of 12 patients with LSS. Analysis did not demonstrate any prognostic factor in surgically treated HNP, but significant associations with prognosis were observed with respect to preoperative tibialis anterior (p = 0.033) and extensor hallucis longus (p = 0.020) strength in patients with LSS. In addition, the postoperative muscle recovery in patients with HNP was significantly superior to that in patients with LSS (p = 0.011). CONCLUSIONS Double root compression was the most common condition associated with foot drop due to HNP. The diagnosis and preoperative tibialis anterior and extensor hallucis longus strength in LSS were factors that influenced recovery following an operation.

Diagnosis of a previously unidentified primary site in patients with spinal metastasis: diagnostic usefulness of laboratory analysis, CT scanning and CT-guided biopsy

When the primary site is unknown in patients with spinal metastases, there can be problems in locating the site of tumor origin. Most previous reports on metastases of unknown origin have not been limited to the spine. The purpose of this study is to assess the usefulness of laboratory analysis, chest, abdominal and pelvic CT and CT-guided biopsy in patients with spinal metastases of unknown origin (SMUO). A retrospective review of the clinical histories of 27 patients with SMUO was done. A total of 43 patients with SMUO were seen at our institution between 2002 and 2007. Of the 43 patients, 27 who underwent all 3 tests (laboratory analysis including M protein and tumor markers, chest, abdominal and pelvic CT and CT-guided biopsy) were included in this study. We retrospectively assessed the diagnostic usefulness of those 3 tests in the 27 patients. In 27 patients, the final diagnosis was obtained in 26 patients. Myeloma was the most common malignancy followed by lung carcinoma. M protein was positive in all 7 patients with myeloma and negative in patients with other malignancies. The level of tumor markers was elevated in 16 of 17 patients with a solid tumor and in all 3 with lymphoma. CA15-3 was elevated in 4 of 27 patients, CA19-9 in 5 of 27 patients, CA125 in 2 of 27 patients, CEA in 6 of 27 patients, SCC in 2 of 27 patients, NSE in 7 of 27 patients, AFP in 1 of 27 patients, PIVKA-II in 1 of 27 patients, TPA in 6 of 27 patients, IAP in 3 of 12 patients, thyroglobulin in 2 of 27 patients, sIL-2R in 3 of 24 patients, and PSA in 5 of 17 male patients. Myeloma, lymphoma and prostate carcinoma had a marker with high sensitivity and specificity (M protein, sIL-2R and PSA). Eleven primary tumor sites (40.7%) were detected (6 lung, 1 prostate, 1 kidney, 1 thyroid, 1 liver, and 1 pancreas) by chest, abdominal and CT scanning. Biopsy led to determination of the final diagnosis in 12 (44.4%) of 27 patients (5 myelomas, 3 lymphomas, 2 prostate carcinomas, 1 renal-cell carcinoma, 1 thyroid carcinoma). In the remaining 15 patients, biopsy did not lead to determination of the final diagnosis, because the histological diagnosis was either an adenocarcinoma or an undifferentiated carcinoma, the tissue sample was not diagnostic. A laboratory analysis limited to specific tumor markers such as PSA and protein electrophoresis is considered to be useful in making a final diagnosis. Chest, abdominal and pelvic CT is considered to be useful for making a final diagnosis in solid tumors, but not for hematologic tumors. A CT-guided biopsy had a low determination rate in the final diagnosis in comparison to a laboratory analysis and CT scanning for solid tumors and it is not considered to be essential for the diagnosis of hematologic tumors.

Evaluation of neck pain by using a visual analog scale before and after laminoplasty in patients with cervical myelopathy: relationship with clinical results.

OBJECT In this study the authors investigated the neck pain of patients with cervical myelopathy by using a visual analog scale (VAS) before and after laminoplasty, and they analyzed the association of amount of neck pain with the clinical results. METHODS A retrospective review was conducted in 41 patients with cervical myelopathy who underwent cervical laminoplasty. The patients were assessed using questionnaires to evaluate the neck pain intensity before surgery, and 2 years after surgery, the outcome was assessed using a VAS. The degree of cervical lordosis and range of motion (ROM) of the cervical spine were evaluated before and after laminoplasty. The neurological status was also evaluated before and after surgery. RESULTS The patients were classified into 2 groups according to their preoperative neck pain: 1) the pain (PA) group, which included patients whose preoperative VAS score was more than 1 mm; and 2) the no pain (NP) group, which included patients whose preoperative VAS score was 0 mm. Inclusion in the PA group indicated a restriction of the cervical ROM before laminoplasty; however, the improvement of neck pain in this group and the deterioration of pain status in the NP group eliminated this difference after laminoplasty. Thereafter, the PA group was classified into 2 subgroups according to the improvement of the preoperative neck pain: 1) the improved group, which included patients whose postoperative VAS score decreased; and 2) the no improvement group, which included patients who were not in the improved group. No significant differences were observed in the average recovery and radiographic results between these 2 subgroups. CONCLUSIONS Neck pain before surgery in the PA group indicated a restriction of the cervical ROM; however, the improvement of neck pain in this group and the deterioration of pain status in the NP group indicated the disappearance of this difference postoperatively. Moreover, improvement of preoperative neck pain was not associated with the radiographic results and the neurological recovery rate.

Effect of Obesity and Being Overweight on Disability and Pain After Lumbar Fusion: An Analysis of 805 Patients.

Study Design. Prospective follow-up study. Objective. To investigate the influence of obesity and being overweight on disability and pain of patients undergoing lumbar spinal fusion. Summary of Background Data. Although spinal fusion surgery has been shown to relieve symptoms in several spinal disorders, the influence of obesity on the results remains controversial. Methods. Since January 1, 2008, all patients undergoing lumbar fusion in two hospitals have been invited to participate in a prospective follow-up database. At the end of 2014, the preoperative and 1-year follow-up data of 805 patients were available. Disability was evaluated using the Oswestry Disability Index and back and leg pain by the visual analogue scale. In addition, the working status, smoking, physical activity, duration of symptoms, and indication for surgery were captured. According to the World Health Organization classification of preoperative body mass index, patients were divided into three groups: normal weight (<25.0 kg/m2), overweight (25.0–29.9 kg/m2), and obese (≥30.0 kg/m2). Results. Of the 805 patients, 204 (25.3%) were normal weight, 365 (45.3%) were overweight, and 236 (29.3%) were obese. The patients in the obese group exercised significantly less per week (P < 0.001). Preoperatively, the body mass index groups did not differ with regard to disability and pain. At the 1-year follow-up, the change in the Oswestry Disability Index was −25 in normal, −24 in overweight, and −23 in obese patients (P = 0.013), and disability was severe in 14.7% of the normal group, 17.0% of the overweight group, and 24.2% of the obese group (P = 0.0052). Back and leg pain improved more in the normal weight group compared with the overweight or obese groups (P < 0.05). Conclusion. Although lumbar spine fusion is also effective in obese patients, the present large follow-up study demonstrates that their outcome results are slightly poorer than patients with normal weight at 1 year after surgery. Level of Evidence: 3

Bone turnover markers and the factors associated with atypical femur fractures among Japanese patients

Many previous reports have indicated that atypical femur fractures (AFFs) are associated with the administration of bisphosphonates (BPs). A number of risk factors and hypotheses regarding the pathogenesis of AFFs have been reported to date. The purpose of the present study was to identify the factors associated with AFFs in Japanese individuals and to elucidate the association between bone metabolism and AFFs by evaluating bone turnover markers (BTMs). We prospectively reviewed all patients with femur fractures and identified the patients with AFFs and typical femur fractures (TFFs). We collected the demographic and clinical data that were relevant to the present study, namely age, gender, affected side, affected site, concomitant medical history, and comorbid conditions, and measured the levels of BTMs within 24h after trauma. Welchs test and Fishers exact probability test were used for the statistical analyses. A total of 338 patients, including 10 patients with AFFs and 328 patients with TFFs, were analyzed under the inclusion criteria. The use of BPs (p<0.001) and collagen disease and chronic granulomatous disease (CD/CGD) (p=0.025) were more frequently observed in patients with AFFs than in patients with TFFs, while the levels of BTMs, including N-terminal propeptides of type 1 procollagen (P1NP), isoform 5b of tartrate-resistant acid phosphatase (TRACP-5b) and undercarboxylated osteocalcin (ucOC) were significantly lower in patients with AFFs than in patients with TFFs. Furthermore, the level of TRACP-5b was found to be significantly lower in patients with atypical subtrochanteric fractures than in atypical diaphyseal fractures (p=0.025). Moreover, the levels of P1NP (p=0.016) and TRACP-5b (p=0.015) were found to be significantly lower in patients with AFFs than in patients with TFFs in a subgroup analysis of BPs users. The use of BPs was considered to be a factor associated with AFFs. Our comparison of the BTMs in patients with AFFs and TFFs indicated that the severe suppression of bone turnover was associated with the pathogenesis of AFFs. The extent of the influence of suppressed turnover on the pathogenesis of AFFs may differ depending on the fracture site.

A Retrospective Analysis of Subaxial Subluxation Following Atlanto-axial Arthrodesis in Patients with Rheumatoid Arthritis Based on Annual Radiographs Obtained for Five Years.

Study Design: Retrospective study. Objective: The purpose of this study was to investigate the incidence of subaxial subluxation (SAS) after atlanto-axial arthrodesis in rheumatoid arthritis (RA) patients using annual radiographs obtained for 5 years and clarify the characteristics of SAS after surgery. Summary of Background Data: Rheumatoid SAS has been reported to occur after atlanto-axial arthrodesis. Many authors have noted that excessive correction of the atlanto-axial angle (AAA) results in a decrease in subaxial lordosis, thereby inducing SAS; therefore, we paid special attention to acquiring a suitable AAA in patients with atlanto-axial arthrodesis. Methods: Twenty-five patients with AAS treated with surgery were reviewed. In all patients, lateral cervical radiographs were obtained in neutral, maximal flexion, and maximal extension positions every year for 5 years after surgery. We investigated the occurrence and progression of SAS using these annual radiographs. Results: There were no significant differences between preoperative and postoperative value in AAA and subaxial angle (SAA), respectively. Before surgery, SAS was found in 10 patients. The occurrence and progression of SAS after surgery was found in 12 cases (SAS P+ group). There were no significant differences in age, sex, or the duration of RA between the SAS P+ group and the remaining 13 cases. We also found no differences in the preoperative and postoperative AAA and SAA between the 2 groups. Conclusions: Although SAA was maintained after atlanto-axial arthrodesis in RA-AAS patients, 12 of 25 patients (48%) with AAS developed SAS after atlanto-axial fusion. Further surgery was not needed for SAS up to 5 years after the initial surgery. We did not find any relationship between the occurrence of SAS and the AAA and SAA before and after surgery. Therefore, our findings suggest that proper reduction of AAA in patients with atlanto-axial arthrodesis does not affect the occurrence of SAS at 5 years after surgery.