Relationship Between Clinical Symptoms and Skin Autofluorescence in Hemodialysis Patients as a Measure of Advanced Glycation End-Product Accumulation.

Background The purpose of this study was to investigate the relationship between skin autofluorescence (SAF), as a measure of advanced glycation end-product (AGE) accumulation and osteoporosis and clinical symptoms in hemodialysis patients. Methodology The study participants were 156 hemodialysis patients (97 males, 59 females, mean = 66.9 years, range = 25-92 years) who visited our hospital between October 2019 and March 2020. The average dialysis period was 10.4 years (range = 1-40 years). Age, years of dialysis, bone mineral density, bone metabolism markers (Ca, P, intact parathyroid hormone, total N-terminal propeptide of type 1 collagen, tartrate-resistant acid phosphatase-5b), clinical symptoms, and SAF were evaluated. Clinical symptoms were evaluated using the visual analog scale (VAS) score for low back pain (LBP) and leg pain ranging from 10 mm (extreme amount of pain) to 0 mm (no pain); the Japanese Orthopaedic Association Back Pain Evaluation Questionnaire (JOABPEQ; 0-100 points); and the Roland-Morris Disability Questionnaire (RDQ; 0-24 points). We calculated Pearson correlation coefficients to assess the correlation of SAF with age, years of hemodialysis, bone density, bone metabolism markers, clinical symptoms, and biochemical markers. Results The SAF of dialysis patients averaged 4.11, higher than previous reports for non-dialysis patients. Age (r = 0.435, p = 0.0001) was moderately positively correlated and hemodialysis period (r = 0.214, p = 0.00907) was weakly positively correlated with SAF. Among the clinical symptoms measured by the JOABPEQ, social life dysfunction (r = -0.257, p = 0.0108) had a weak negative correlation with SAF. Conclusions The level of AGEs implied by SAF was elevated in hemodialysis patients. SAF correlated with social life disorders, suggesting that SAF may be involved in disorders of activities of daily living in hemodialysis dialysis patients.

The nature of osteoporotic low back pain without acute vertebral fracture: A prospective multicenter study on the analgesic effect of monthly minodronic acid hydrate.

BACKGROUND: Patients with osteoporosis but no evidence of fracture can sometimes report low back pain. However, few studies have evaluated the nature of osteoporotic low back pain in a clinical situation. Therefore, the aim of this study was to examine the nature of osteoporotic low back pain without fracture, and the analgesic effect of minodronic acid hydrate on such pain. METHODS: The current study examined 136 patients with osteoporotic low back pain and no lower extremity symptoms. The following factors were evaluated before and after minodronic acid hydrate administration: the nature of osteoporotic low back pain was evaluated using the painDETECT questionnaire, numeric rating scale (NRS) score for low back pain at rest and in motion, bone mineral density (BMD) of the lumbar spine, and the serum concentration of tartrate-resistant acid phosphatase 5b (TRACP-5b) as a bone metabolism marker. RESULTS: A total of 113 patients were enrolled. The painDETECT questionnaire revealed the percentage of patients with nociceptive pain and neuropathic or mixed pain was approximately 85% and 15%, respectively. the average NRS scores for low back pain at rest decreased significantly 2 months after treatment (p = 0.01), while those in motion decreased significantly 1 month after treatment (p = 0.04). The average lumbar spine BMD tended to increase after treatment, but not significantly. On the other hand, the changes in the average serum concentration of TRACP-5b did significantly decrease 1 month after treatment. There was a significant positive correlation between the rate of NRS score improvement for low back pain at rest, and the rate of improvement in serum concentration of TRACP-5b (p < 0.05). CONCLUSIONS: Osteoporotic low back pain consisted of 85% nociceptive pain and 15% neuropathic or mixed pain. The pain is strongly related to pain at rest rather than that in motion.

Perioperative Complications in 155 Patients Who Underwent Oblique Lateral Interbody Fusion Surgery: Perspectives and Indications From a Retrospective, Multicenter Survey.

STUDY DESIGN: A retrospective multicenter survey. OBJECTIVE: To investigate the perioperative complications of oblique lateral interbody fusion (OLIF) surgery. SUMMARY OF BACKGROUND DATA: OLIF has been widely performed to achieve minimally invasive, rigid lumbar lateral interbody fusion. The associated perioperative complications are not yet well described. METHODS: The participants were patients who underwent OLIF surgery under the diagnosis of degenerative lumbar diseases between April 2013 and May 2015 at 11 affiliated medical institutions. The collected data were classified into intraoperative and early-stage postoperative (≤1 mo) complications. The intraoperative complications were then subcategorized into organ damage (neural, vertebral, vascular, and others) and other complications, mainly related to instrumental failure. The collected data were also divided and analyzed based on whether the surgeon was certified to perform the surgery and the incidence of complications in the early (April 2013-March 2014) and late stages (April 2014-May 2015) of OLIF introduction. RESULTS: In the 155 included patients, 75 complications were reported (incidence rate, 48.3%). The most common complication was endplate fracture/subsidence (18.7%), followed by transient psoas weakness and thigh numbness (13.5%) and segmental artery injury (2.6%). Almost all these complications were transient, except for three patients who had permanent damage: one had ureteral injury and two had neurological injury. Postoperative complications included surgical site infection (1.9%) and reoperation (1.9%). Whether the primary operator was experienced did not affect the incidence of complications. Regarding the introductory stage, the incidence of complications was 50% in the early stage and 38% in the late stage. CONCLUSION: The overall incidence of perioperative complications of OLIF surgery reached 48.3%, of which only 1.9% resulted in permanent damage. Our analysis based on surgeon experience indicated that the OLIF procedure could be performed without increasing incidence of complications, under the guidance of experienced supervisors. LEVEL OF EVIDENCE: 3.

Efficacy of TachoSil, a Fibrin-Based Hemostat, for Anterior Lumbar Spine Surgery.

STUDY DESIGN: Retrospective case series. PURPOSE: To examine the efficacy of TachoSil for vessel injury in 6 patients who underwent anterior lumbar fusion surgery (ALF). OVERVIEW OF LITERATURE: ALF for the lumbar spine has a high rate of success, although intraoperative concerns and iatrogenic complications are known, and injury of a major vessel is sometimes a complication. The efficacy of TachoSil, a fibrin-based hemostat, has been reported for several types of surgery; however, use of TachoSil for ALF surgery has not been described. Here, we report on the efficacy of TachoSil in 6 patients, who underwent ALF after vascular surgeons having difficulty in repairing vessels. METHODS: Two man and 4 women with average age of 50.8±10.9 (mean±standard deviation) were diagnosed with a vertebral tumor (2 patients), L4 degenerative spondylolisthesis (2 patients), and L5 spondylolytic spondylolisthesis (2 patients) and underwent ALF. The blood vessels injured included the common iliac vein in 2 patients and a branch of a segmental artery from the aorta in 4 patients. We consulted a vascular surgeon to suture or repair the vessels during surgery, and although the vascular surgeon attempted to address the injuries, suturing or repair was not possible in these cases. For this reason, we used TachoSil to repair the injury in the vessels walls or to stop the bleeding. RESULTS: Time to pressure hemostasis using TachoSil was 34±12 minutes, and total blood loss was 1,488±1,711 mL. Nevertheless, all vessel injuries were controlled by the use of TachoSil. CONCLUSIONS: We recommend the use of TachoSil for vessel injuries that vascular surgeons cannot suture or repair during ALF surgery.

Pregabalin for Refractory Radicular Leg Pain due to Lumbar Spinal Stenosis: A Preliminary Prospective Study.

We investigated the efficacy of pregabalin (PGB) for neuropathic leg pain in lumbar spinal stenosis (LSS) patients with disturbed activities of daily living (ADL)/quality of life (QOL) in a prospective observational study. Subjects were a total of 104 LSS patients with neuropathic pain (NeP) in leg and neurological intermittent claudication (IMC) refractory to nonsteroidal anti-inflammatory drugs (NSAIDs) for at least a month. NeP was identified using screening tool, Pain DETECT questionnaire. Visual analog scale (VAS) scores and responses to the Japanese Orthopaedic Association Back Pain Evaluation Questionnaire (JOABPEQ) were assessed before and 6 weeks after PGB treatment initiation. Changes in IMC distance and adverse events were also recorded. PGB significantly improved their VAS scores for pain and sleep quality (P < 0.001). With respect to JOABPEQ, significant improvements were observed with regard to the following dimensions: pain-related disorders (P < 0.01), lumbar spine dysfunction (P = 0.031), gait disturbance (P = 0.028), and psychological disorders (P = 0.014). The IMC distance showed an improvement tendency after PGB treatment, albeit with no significance (P = 0.063). Minor adverse events such as dizziness were observed. PGB can be effective for neuropathic leg pain refractory to NSAIDs in LSS patients, resulting in not only pain control but also improving lower back pain-related ADL/QOL scores.

Miniopen oblique lateral L5-s1 interbody fusion: a report of 2 cases.

Extreme lateral interbody fusion (XLIF) has been widely used for minimally invasive anterior lumbar interbody fusion (ALIF), but an approach to L5-S1 is difficult because of the iliac crest. In the current study, we present 2 cases using minimally invasive oblique lateral interbody fusion (OLIF) of L5-S1. The patients showed foraminal stenosis between L5 and S1 and severe low back and leg pain. The patients were placed in a lateral decubitus position and underwent OLIF surgery (using a cage and bone graft from the iliac crest) without posterior decompression. Posterior screws were used in the patients. Pain scores significantly improved after surgery. There was no spinal nerve, major vessel, peritoneal, or urinary injury. OLIF surgery was minimally invasive and produced good surgical results without complications.

Incidence of nocturnal leg cramps in patients with lumbar spinal stenosis before and after conservative and surgical treatment.

PURPOSE: To examine the effects of conservative and surgical treatments for nocturnal leg cramps in patients with lumbar spinal stenosis (LSS). Nocturnal leg cramps is frequently observed in patients with peripheral neuropathy. However, there have been few reports on the relationship between nocturnal leg cramps and LSS, and it remains unknown whether conservative or surgical intervention has an impact on leg cramps in patients with LSS. MATERIALS AND METHODS: The subjects were 130 LSS patients with low back and leg pain. Conservative treatment such as exercise, medication, and epidural block was used in 66 patients and surgical treatment such as decompression or decompression and fusion was performed in 64 patients. Pain scores and frequency of nocturnal leg cramps were evaluated based on self-reported questionnaires completed before and 3 months after treatment. RESULTS: The severity of low back and leg pain was higher and the incidence of nocturnal leg cramps was significantly higher before treatment in the surgically treated group compared with the conservatively treated group. Pain scores improved in both groups after the intervention. The incidence of nocturnal leg cramps was significantly improved by surgical treatment (p=0.027), but not by conservative treatment (p=0.122). CONCLUSION: The findings of this prospective study indicate that the prevalence of nocturnal leg cramps is associated with LSS and severity of symptoms. Pain symptoms were improved by conservative or surgical treatment, but only surgery improved nocturnal leg cramps in patients with LSS. Thus, these results indicate that the prevalence of nocturnal leg cramps is associated with spinal nerve compression by LSS.

Conservative and surgical treatment improves pain and ankle-brachial index in patients with lumbar spinal stenosis.

PURPOSE: The pathological mechanism of lumbar spinal stenosis is reduced blood flow in nerve roots and degeneration of nerve roots. Exercise and prostaglandin E1 is used for patients with peripheral arterial disease to increase capillary flow around the main artery and improve symptoms; however, the ankle-brachial index (ABI), an estimation of blood flow in the main artery in the leg, does not change after treatment. Lumbar spinal nerve roots contain somatosensory, somatomotor, and unmyelinated autonomic nerves. Improved blood flow by medication with prostaglandin E1 and decompression surgery in these spinal nerve roots may improve the function of nerve fibers innervating muscle, capillary, and main vessels in the lower leg, resulting in an increased ABI. The purpose of the study was to examine whether these treatments can improve ABI. MATERIALS AND METHODS: One hundred and seven patients who received conservative treatment such as exercise and medication (n=56) or surgical treatment (n=51) were included. Low back pain and leg pain scores, walking distance, and ABI were measured before treatment and after 3 months of conservative treatment alone or surgical treatment followed by conservative treatment. RESULTS: Low back pain, leg pain, and walking distance significantly improved after both treatments (p<0.05). ABI significantly increased in each group (p<0.05). CONCLUSION: This is the first investigation of changes in ABI after treatment in patients with lumbar spinal stenosis. Improvement of the spinal nerve roots by medication and decompression surgery may improve the supply of blood flow to the lower leg in patients with lumbar spinal stenosis.

Associations between proinflammatory cytokines in the synovial fluid and radiographic grading and pain-related scores in 47 consecutive patients with osteoarthritis of the knee.

BACKGROUND: One of the sources of knee pain in osteoarthritis (OA) is believed to be related to local chronic inflammation of the knee joints, which involves the production of inflammatory cytokines such as tumor necrosis factor alpha (TNFα), interleukin (IL)-6, and nerve growth factor (NGF) in the synovial membrane, and these cytokines are believed to promote pathological OA. In the present study, correlations between proinflammatory cytokines in knee synovial fluid and radiographic changes and functional scores and pain scores among OA patients were examined. METHODS: Synovial fluid was harvested from the knees of 47 consecutive OA patients, and the levels of TNFα, IL-6, and NGF were measured using enzyme-linked immunosorbent assays. Osteoarthritic knees were classified using Kellgren-Lawrence (KL) grading (1-4). The Western Ontario and McMaster University Osteoarthritis Index (WOMAC) was used to assess self-reported physical function, pain, and stiffness. RESULTS: TNFα and IL-6 were detectable in knee synovial, whereas NGF was not. TNFα was not correlated with the KL grade, whereas IL-6 had a significantly negative correlation. We observed differences in the correlations between TNFα and IL-6 with WOMAC scores and their subscales (pain, stiffness, and physical function). TNFα exhibited a significant correlation with the total score and its 3 subscales, whereas IL-6 exhibited a moderately significant negative correlation only with the subscale of stiffness. CONCLUSIONS: The present study demonstrated that the concentrations of proinflammatory cytokines are correlated with KL grades and WOMAC scores in patients with knee OA. Although TNFα did not have a significant correlation with the radiographic grading, it was significantly associated with the WOMAC score. IL-6 had a significant negative correlation with the KL grading, whereas it had only a weakly significant correlation with the subscore of stiffness. The results suggest that these cytokines play a role in the pathogenesis of synovitis in osteoarthritic knees in different ways: TNFα is correlated with pain, whereas IL-6 is correlated with joint function.

Evaluation of low back pain using the Japanese Orthopaedic Association Back Pain Evaluation Questionnaire for lumbar spinal disease in a multicenter study: differences in scores based on age, sex, and type of disease.

BACKGROUND: The Japanese Orthopaedic Association (JOA) has investigated the JOA Back Pain Evaluation Questionnaire (JOABPEQ) to evaluate several aspects of low back pain in patients. The score includes five categories (25 items) selected from the Roland Morris Disability Questionnaire and Short Form 36, and a visual analogue scale. Japanese physicians have recently used these scores to evaluate back pain; however, the efficacy has not been fully explored in large-scale studies. In the current study, we used the JOABPEQ to evaluate lumbar spinal disease in 555 patients (with lumbar disc herniation, lumbar spinal stenosis, and lumbar disc degeneration/spondylosis) in multiple spine centers and compared the results based on age, sex, and type of disease. METHODS: A total of 555 patients who had low back or leg pain were selected in 22 hospitals in Chiba Prefecture. Spine surgeons diagnosed their disease type based on symptoms, physical examination, radiography images, and magnetic resonance imaging. In all, 486 patients were diagnosed with spinal stenosis (239 patients), disc degeneration/spondylosis (143 patients), or disc herniation (104 patients). The other 69 patients were diagnosed with spondylolysis (16 patients) or other diseases (53 patients). The pain score in all patients was evaluated using the JOABPEQ (from 0 to 100, with 0 indicating the worst pain). RESULTS: The age of the patients was 56.1 +/- 13.3 years (mean +/- SD); the age of patients in the disc herniation and disc degeneration/spondylosis group was significantly lower than that in the spinal stenosis group. The average JOABPEQ scores in all patients were, for low back pain, 47.1; lumbar function, 53.6; walking ability, 54.8; social life function, 48.7; and mental health, 48.3. The low back pain score in men was significantly worse than that in women. In contrast, the mental health score in women was significantly higher than that in men. The low back pain score in patients <40 years old and the walking ability score in patients >65 years old were significantly lower than those scores in other patients. Based on the disease type, low back pain, lumbar function, social life function, and mental health scores for patients with disc herniation were significantly worse than for those with spinal stenosis. CONCLUSION: JOABPEQ scores were evaluated for several lumbar diseases. The average of five categories of JOABPEQ scores in all patients was similarly distributed. However, the average scores in the five categories were significantly different depending on age, sex, and type of disease. Compared with prior mass data (baseline data on the observational cohort of the Spine Patient Outcomes Research Trial in the United States), many data were similar based on the type of disease in the current study. Furthermore, the JOABPEQ is easy to use compared with the SF-36. Hence, we concluded that the JOABPEQ could be used worldwide as a tool for evaluating low back pain.

Osteochondroma in the lumbar spinal canal causing sciatic pain: report of two cases.

A search of the English-language medical literature found only two cases in which expansion of an osteochondroma into the lumbar spinal canal caused sciatica. We report another two cases of spinal nerve root compression by solitary lumbar spinal canal osteochondromas: in a 56-year-old man and a 55-year-old woman with no history of hereditary multiple exostoses. Osteochondromas compressing the spinal nerve root were seen at the inferior articular processes of the lumbar vertebrae by computed tomography (CT), three-dimensional reconstruction of CT scans, myelography, and magnetic resonance imaging. The symptoms disappeared after surgical removal of the lesions. Histopathologic examination confirmed the diagnosis of benign osteochondroma.

The knee-spine syndrome. Association between lumbar lordosis and extension of the knee.

Degenerative changes of the knee often cause loss of extension. This may affect aspects of posture such as lumbar lordosis. A total of 366 patients underwent radiological examination of the lumbar spine in a standing position. The knee and body angles were measured by physical examination using a goniometer. Limitation of extension of the knee was significantly greater in patients whose lumbar lordosis was 30 degrees or less. Lumbar lordosis was significantly reduced in patients whose limitation of extension of the knee was more than 5 degrees. It decreased over the age of 70 years, and the limitation of extension of the knee increased over the age of 60 years. Our study indicates that symptoms from the lumbar spine may be caused by degenerative changes in the knee. This may be called the 'knee-spine syndrome'.

Changes in lumbar lordosis in young patients with low back pain during a 10-year period.

Height and muscle strength have reportedly changed among Japanese youth during the past 10 years. Height has increased, and the back muscles have become weaker than 10 years ago. We compared the lumbar lordosis of youth today (113 men and 76 women) and of 10 years ago (85 men and 62 women). Lumbar lordosis and sacral inclination were measured on lateral standing radiographs of the lumbar spine. We also measured the same parameters among adults today (63 men and 63 women) and 10 years ago (56 men and 73 women) to study postural changes in another generation. In both men and women, the lumbar lordosis and the sacral inclination of youth today were approximately 10 degrees larger than they were 10 years ago ( P < 0.0001). However, there was no significant difference between the values among adults today and those of the same generation 10 years ago.

Changes in scoliotic curvature and lordotic angle during the early phase of degenerative lumbar scoliosis.

STUDY DESIGN: Longitudinal radiographic measurements of the lumbar alignment in clinical cases were performed. OBJECTIVE: To clarify the progressive process of degenerative lumbar scoliosis during its early phase by conducting a longitudinal study. SUMMARY OF BACKGROUND DATA: Previous studies on the alignment changes of degenerative lumbar scoliosis have been conducted only on patients with seriously symptomatic lumber scoliosis, such as those who have undergone surgical treatment. With these patients, who manifest wedging at several levels, it is difficult to determine where the curving initially begins, and to understand the wedging process. Thus, there is much to clarify regarding the process of this symptom's early phase. Furthermore, such data may be useful in anticipating future symptoms. METHODS: The subjects selected for this study were 243 patients who had low back pain without lumbar scoliosis at the initial examination, which took place between 1985 and 1989. Anteroposterior and lateral radiographic examinations of the lumber spine were performed with the subject in a standing position. All of these patients went through at least three sets of examinations. The Cobb method was used to measure the scoliotic angle, defined as the largest angle between any two lines of the lumbar vertebrae. The 47 subjects who manifested a scoliotic angle increase exceeding 10 degrees were reselected for further prospective analyses. The scoliotic and lordotic wedging of these remaining 47 subjects were studied prospectively. RESULTS: The degree of change in scoliotic and lordotic wedging was studied in the 47 patients who manifested a scoliotic angle increase of 10 degrees or more. Of the 47 subjects, 8 showed initial wedging at L1-L2, 9 at L2-L3, 7 at L3-L4, 10 at L4-L5, and 16 at L5-S. During later examinations, 69 discs of 34 patients showed initial wedging exceeding 3 degrees, both in progression and retrogression. On the other hand, changes in the segmental lordotic wedging also were observed during these examinations. Of the 79 discs that showed more than a 5 degrees decrease in segmental lordotic wedging, progression of scoliotic wedging at the same level was observed in 56 cases, either simultaneously or at previous examinations. CONCLUSIONS: Degenerative lumbar scoliosis was triggered by any disc degeneration at the lumbar level. Loss of segmental lordosis usually occurs at the same disc level as segmental wedging. In the early phase of degenerative lumbar scoliosis, the scoliotic curvature not only progresses, but also may retrogress.