Comparison of facet fusion rates and clinical outcomes between cortical bone trajectory screw and percutaneous pedicle screw fixation for degenerative lumbar spondylolisthesis.

BACKGROUND CONTEXT: Cortical bone trajectory (CBT) screws have been introduced as an alternative technique for pedicle screw (PS) insertion because they have greater contact with the cortex and a greater uniaxial pullout load than traditional PS. CBT screwing can also minimize muscle dissection. However, CBT screws and traditional PSs have not yet been compared in terms of fusion rates and clinical outcomes for particular operative procedures. PURPOSE: This study aimed to assess the fusion rate and clinical outcomes of facet fusion (FF) fixed with CBT screws (CBT-FF) and to compare them with those of FF fixed with percutaneous PS (PPS-FF). STUDY DESIGN: Retrospective study. PATIENT SAMPLE: Records of 68 patients who underwent CBT-FF for single-level degenerative lumbar spondylolisthesis (DLS) with at least 1 year of follow-up were retrospectively reviewed. The control group comprised 143 patients who underwent PPS-FF under the same conditions. OUTCOME MEASURES: Computed tomography was performed to confirm fusion. Therapeutic effectiveness was assessed as a clinical outcome using the Japanese Orthopaedic Association Back Pain Evaluation Questionnaire (JOABPEQ), Roland-Morris Disability Questionnaire (RMDQ), and visual analog scale (VAS) preoperatively and 1 year postoperatively. The rate of revision surgery was also calculated. Intraoperative blood loss was measured. METHODS: Fusion rate, clinical outcomes, revision surgery rate, and intraoperative blood loss of CBT-FF and PPS-FF were compared. RESULTS: The CBT-FF and PPS-FF fusion rates were 91.2% and 90.1%, respectively. The JOABPEQ category scores demonstrated therapeutic effectiveness in 74.5% and 77.1% of the patients for low back pain; the corresponding proportions for walking ability were 84.7% and 89.3%, respectively. No significant differences in therapeutic effectiveness were observed for any category, including the RMDQ and VAS scores for buttock and lower limb pain. Three patients required revision surgery for adjacent segment disease between 6 months and 3.5 years after CBT-FF (revision surgery rate, 4.4%), whereas the revision surgery rate for PPS-FF was 6.3% (9/143 cases). Average intraoperative blood loss was significantly less in the CBT-FF group than in the PPS-FF group. CONCLUSIONS: Both procedures were equally useful in terms of fusion rate and clinical outcomes for DLS management.

Good 5-year postoperative outcomes after facet fusion using a percutaneous pedicle screw system for degenerative lumbar spondylolisthesis.

Many authors have reported no significant differences in clinical outcomes between posterolateral fusion (PLF) and interbody fusion, as well as satisfactory long-term outcomes after PLF. Facet fusion (FF), a minimally invasive evolution of PLF, has also resulted in good clinical outcomes. This study aimed to assess the clinical outcomes 5 years after FF for degenerative lumbar spondylolisthesis (DLS) and determine whether good clinical outcomes were maintained after FF. Records of 115 patients who underwent FF for single-level DLS with at least 5 years of follow-up were retrospectively studied. The therapeutic effectiveness of FF was assessed as a clinical outcome using the Japanese Orthopaedic Association Back Pain Evaluation Questionnaire (JOABPEQ), the Roland-Morris Disability Questionnaire (RMDQ), and the visual analogue scale (VAS) preoperatively and at 1 and 5 years postoperatively. Computed tomography was performed for fusion confirmation. The revision surgery rate was also evaluated. The JOABPEQ category scores demonstrated therapeutic effectiveness in 81.7% of patients at 1 year postoperatively and 81.4% of patients at 5 years postoperatively for low back pain; the corresponding proportions for walking ability were 93.8% and 86.6%, respectively. There were no significant differences in therapeutic effectiveness at 1 and 5 years postoperatively for any category, including the RMDQ and VAS scores. The fusion rate was 90.4% at the final follow-up. Four patients required revision surgery for adjacent segment disease 1-5 years after the first surgery (revision surgery rate, 3.5%). Good clinical outcomes were maintained 5 years after FF, and FF had an extremely low revision surgery rate.

Mechanism of Chronic Pain of Symptomatic Hip Osteoarthritis by Association of its Distribution, Nociceptive, Neuropathic, Nociplastic, or Mixed-pain Screening, and the Prevalence of Lumbar Spinal Stenosis: A Cross-sectional Study.

OBJECTIVES: The pain of hip osteoarthritis (OA) is generally recognized as nociceptive in origin because of the local pathology. However, some patients with OA experience a neuropathic pain component as an essential part of some nociplastic pain subtype. Here, we sought to examine the mechanism of chronic pain of symptomatic hip OA by the association of its distribution, complex pain mechanism screening, and the prevalence of lumbar spinal stenosis. MATERIALS AND METHODS: We conducted a prospective cross-sectional study of 100 hips in 100 patients with symptomatic hip OA in a chronic state. We examined all baseline clinical characteristics including clinical and functional score, location of pain and numbness, and pain score (PainDETECT questionnaire and the Leeds Assessment of Neuropathic Symptoms and Signs), and magnetic resonance imaging of the hip and lumbar spine. RESULTS: The PainDETECT questionnaire and Leeds Assessment of Neuropathic Symptoms and Signs revealed that 23% of the patients had a neuropathic pain component. There were 24 variations of the pain pattern. By contrast, the pain localized around the hip joint was only 15%. Pain distal to the thigh and any numbness was significantly more frequent in the group with neuropathic pain (P<0.001). Lumbar spinal stenosis grade was not significantly different between patients with nociceptive pain and those with neuropathic pain. Pain score was significantly correlated with the pain in clinical and functional scores. DISCUSSION: Among patients with symptomatic hip OA, the distribution of pain was various, and about 23% of patients had neuropathic, nociplastic, or mixed pain as a possibility for somatosensory system disturbances.

Good clinical outcomes in nonunion cases after facet fusion with a percutaneous pedicle screw system for degenerative lumbar spondylolisthesis.

There are many satisfactory long-term outcomes after posterolateral fusion (PLF) for degenerative lumbar spondylolisthesis (DLS); nonunion cases have also achieved good clinical outcomes. Facet fusion (FF), a minimally invasive evolution of PLF, also resulted in good clinical outcomes. We aimed to assess the course of nonunion cases after FF and determine whether the nonunion cases achieved good clinical outcomes. We retrospectively reviewed the records of 136 patients who underwent FF for DLS. Range of motion (ROM) at the fused level was measured using a flexion-extension lateral radiograph preoperatively and 1 year postoperatively. Patients were classified into the Fusion or Unconfirmed Fusion group by computed tomography (CT) 1 year postoperatively. Furthermore, patients in the Unconfirmed Fusion group were classified into the Delayed Union or Nonunion group depending on the confirmation status of FF upon the following CT. The average preoperative ROM and clinical outcomes were compared between the three groups. The Fusion, Delayed Union, and Nonunion groups had 109, 14, and 13 patients, respectively. In the Nonunion group, the average ROM significantly decreased from 13.0° preoperatively to 4.9° postoperatively. There was a significant difference in the average preoperative ROM between the groups. The larger the preoperative ROM, the fewer facets fused. There was no significant difference in clinical outcomes between the groups. Five patients (3.7%) required revision surgery for adjacent segment disease 1-5.5 years after FF. Even nonunion cases after FF achieved good clinical outcomes, likely because the unstable spondylolisthesis was stabilized. FF did not require revision surgery for nonunion itself.

A simple formula for predicting diameter of safely inserted cortical bone trajectory screws for fixation of the lower lumbar spine.

BACKGROUND: Cortical bone trajectory (CBT) screws are popular for spinal fixation, but their ideal diameter has not been determined. Studies using postoperative computed tomography (CT) have revealed ample bone marrow space around 5.5-mm screws, which are commonly used. However, evidence indicates that a larger screw diameter provides a greater fixation strength. This study aimed to develop a generalizable formula for computing the diameter of CBT screws that could be inserted safely for fixation of the lower lumbar spine. METHODS: Records of 44 consecutive patients who had undergone posterior fusion with CBT screws for single-level degenerative lumbar spondylolisthesis were retrospectively reviewed. We estimated the maximum diameter for conventional pedicle screws by the minimum diameter of the pedicle using preoperative CT (PSD). We measured the minimum endosteal diameter of the pedicle on the reconstructed plane of the postoperative CT which passed through the cannula used for the screw and estimated the maximum diameter for the CBT screws that could be inserted within the bone marrow space of the pedicle (CBTD). RESULTS: Among the 176 pedicles measured, there were 151 (85.8%) with a PSD of 8.5 mm and 13, 7.5 mm. Because of a slight pedicle wall breach, 13 screws were excluded from the sample. There were 64 (39.3%) screws with a CBTD of 8.5 mm; 45, 7.5 mm; and 40, 6.5 mm. Of 163 screws, 156 (95.7%) had PSD minus CBTD ≤2 mm for each pedicle. PSD minus the minimum outer cortical diameter was ≤1 mm for each pedicle in 155 (95.1%) screws. CONCLUSION: Our results show that CBT screws with a diameter 1 mm smaller than the endosteal diameter of the pedicle were inserted safely. STUDY: Design: Clinical study.

Effect of Al Content in the Mg-Based Alloys on the Composition and Corrosion Resistance of Composite Hydroxide Films Formed by Steam Coating.

Mg alloys are expected to be used in fields of the transportation industry because of their lightweight property, however, they show low corrosion resistance. To improve the corrosion resistance, preparation of the protective film on Mg alloys is essential. In this study, composite hydroxide films were prepared on three types of Mg alloys with different aluminum contents-that is, AZ31, AZ61, and AZ91D-by steam coating to investigate the relationship between the Mg-Al layered double hydroxide (LDH) content in the film and the Al content in the Mg alloys. Scanning electron microscopy (SEM) observation demonstrated that films were formed densely on all Mg alloy surfaces. X-ray diffraction (XRD) analyses revealed that all films prepared on AZ61 and AZ91D were composed of Mg(OH)2, AlOOH, and Mg-Al LDH, while the film containing Mg(OH)2 and Mg-Al LDH were formed only on AZ31. The Mg-Al LDH content in the film prepared on AZ61 was relatively higher than those prepared on AZ31 and AZ91D. The content of AlOOH in the film increased with an increase in the Al content in the Mg alloys. The film thickness changed depending on the treatment time and type of Mg alloy. Polarization curve measurements in 5 mass% NaCl solution demonstrated that the film prepared on the AZ61 showed complete passive behavior within the potential range of -1.0 to -0.64 V. In addition, immersion tests in 5 mass% NaCl aqueous solution for 480 h demonstrated that the film on the AZ61 had superior durability against 5 mass% NaCl aqueous solution. These results indicated that the film on the AZ61 had the most superior corrosion resistance among all samples. The results obtained in this study suggest that the LDH content in the film could be related to the corrosion resistance of the film.

Pedicle screw shift without loosening following instrumented posterior fusion: limitations of pedicle screw fixation.

The disc angle at the fused segment is extended in operative prone position, but eventually returns to preoperative neutral position within 6 months to 1 year. This study aimed to assess pedicle screw (PS) shift without loosening to identify the mechanism of the change in disc angle after posterior fusion for degenerative lumbar spondylolisthesis (DLS). Sixty-three consecutive patients who underwent facet fusion for L4 single-level DLS were retrospectively reviewed using computed tomography (CT) immediately after surgery and 6 months postoperatively. Twenty-two patients (88 PSs) in whom the disc angle had decreased by more than 4° at 6-month postoperative radiographic follow-up were selected to more readily identify and quantify PS shift. Six patients with PS loosening and/or nonunion were excluded. We reconstructed a CT plane, vertical to the cranial endplate of the vertebrae and passing through the cannula used for percutaneous PSs. Angle α, which is formed by the cranial endplate and the cannula on this plane, was measured. A change in angle α of more than 2° between the immediate postoperative period and the 6-month follow-up was defined as a PS shift. Angle α did not change by more than 2° in any of the 44 PSs in the upper vertebrae of the fused segment. In the lower vertebrae, angle α changed by more than 2° in 22 of 44 PSs. The change in angle α in the lower vertebrae (average, 2.3°) was significantly greater than that in the upper vertebrae (average, 0.2°) (P < 0.0001). The change in the disc angle was not relevant to clinical outcomes assessed by the Japanese Orthopaedic Association Back Pain Evaluation Questionnaire, the Roland-Morris Disability Questionnaire, and the visual analogue scale. The disc angle at the fused segment returned to preoperative neutral position due to PS shift without loosening, mainly in the lower vertebrae. PS shift is caused by bone remodeling in response to biomechanical load, similar to that in orthodontic tooth movement. As PS has limited ability to maintain a lordotic disc angle, even with the insertion of a cage, lumbar alignment will return to preoperative neutral position owing to cage subsidence or adjacent segment disease. These findings might indicate that it is not necessary to correct the spinal alignment for DLS.

Effect of Vapor Pressure During the Steam Coating Treatment on Structure and Corrosion Resistance of the Mg(OH)2/Mg-Al LDH Composite Film Formed on Mg Alloy AZ61.

Corrosion resistant films with almost the same film thickness were prepared on the magnesium alloy AZ61 by steam coating at different vapor pressure and treatment times. The effect of the vapor pressure on the structures and the corrosion resistance of the films was investigated by using FE-SEM, SEM-EDX, GAXRD, and potentiodynamic polarization curve measurements in a 3.5 mass percentage NaCl aqueous solution. These studies clarified that the interlayers of Mg-Al Layered Double Hydroxide (LDHs) increased and its structure became non-uniform with an increase in the vapor pressure. The corrosion current density slightly increased with an increase in the vapor pressure during the treatment, but pitting corrosion occurred at both low and high vapor pressures. These results indicate that water molecules were pushed into an interlayer of Mg-Al LDHs by high vapor pressure. Consequently, the interlayer distance of Mg-Al LDH was widened and the cracks were generated in the anti-corrosive film. On the other hand, the Mg-Al LDH with an insufficiently large interlayer distance could not fill the cracks in the Mg(OH)2 crystallites and caused pitting corrosion when the vapor pressure was low.

Baastrup's Disease Is Associated with Recurrent of Sciatica after Posterior Lumbar Spinal Decompressions Utilizing Floating Spinous Process Procedures.

STUDY DESIGN: Retrospective case-control study. PURPOSE: To determine whether kissing spine is a risk factor for recurrence of sciatica after lumbar posterior decompression using a spinous process floating approach. OVERVIEW OF LITERATURE: Kissing spine is defined by apposition and sclerotic change of the facing spinous processes as shown in X-ray images, and is often accompanied by marked disc degeneration and decrement of disc height. If kissing spine significantly contributes to weight bearing and the stability of the lumbar spine, trauma to the spinous process might induce a breakdown of lumbar spine stability after posterior decompression surgery in cases of kissing spine. METHODS: The present study included 161 patients who had undergone posterior decompression surgery for lumbar canal stenosis using a spinous process floating approaches. We defined recurrence of sciatica as that resolved after initial surgery and then recurred. Kissing spine was defined as sclerotic change and the apposition of the spinous process in a plain radiogram. Preoperative foraminal stenosis was determined by the decrease of perineural fat intensity detected by parasagittal T1-weighted magnetic resonance imaging. Preoperative percentage slip, segmental range of motion, and segmental scoliosis were analyzed in preoperative radiographs. Univariate analysis followed by stepwise logistic regression analysis determined factors independently associated with recurrence of sciatica. RESULTS: Stepwise logistic regression revealed kissing spine (p=0.024; odds ratio, 3.80) and foraminal stenosis (p<0.01; odds ratio, 17.89) as independent risk factors for the recurrence of sciatica after posterior lumbar spinal decompression with spinous process floating procedures for lumbar spinal canal stenosis. CONCLUSIONS: When a patient shows kissing spine and concomitant subclinical foraminal stenosis at the affected level, we should sufficiently discuss the selection of an appropriate surgical procedure.

Dropped head syndrome after cervical laminoplasty: A case control study.

Dropped head syndrome (DHS) is characterized by apparent neck extensor muscle weakness and difficulty extending the neck to raise the head against gravity. The aim of the present study was to elucidate possible risk factors for DHS after cervical laminoplasty. Five patients who developed DHS after cervical laminoplasty (DHS group) and twenty age-matched patients who underwent laminoplasty without DHS after surgery (control group) were compared. The surgical procedure was single-door laminoplasty with strut grafting using resected spinous processes or hydroxyapatite spacers from C3 to C6 or C7. Analyses of preoperative images including the C2-C7 angle, C7-T1 kyphosis, T1 tilt, center of gravity line from the head-C7 sagittal vertical axis (CGH-C7 SVA) were performed on lateral plain cervical spine radiographs. Preoperative T2-weighted MRI at the C5 vertebral level was used to measure the cross-sectional area of the deep extensor muscles. Widths of the lateral gutters were assessed postoperatively using CT scans of the C5 vertebral body. The average preoperative C2-C7 angle was significantly smaller in the DHS group compared with the control group. The average preoperative C7-T1 angle was significantly larger in the DHS group compared with the control group. The average preoperative CGH-C7 SVA was significantly larger in the DHS group compared with the control group. In conclusion, patients with more pronounced preoperative C2-C7 kyphosis, C7-T1 kyphosis, and CGH-C7 SVA are more likely to develop DHS following laminoplasty.

Good clinical outcomes and fusion rate of facet fusion with a percutaneous pedicle screw system for degenerative lumbar spondylolisthesis: minimally invasive evolution of posterolateral fusion.

STUDY DESIGN: A retrospective clinical and radiographical study. OBJECTIVE: To assess the clinical outcomes and fusion rate of facet fusion (FF) for degenerative lumbar spondylolisthesis (DLS). SUMMARY OF BACKGROUND DATA: On the basis of the long-term clinical and radiological follow-up studies of posterolateral fusion (PLF)-that is, intertransverse process fusion with pedicle screw instrumentation-for DLS, we recognized that FF alone would be sufficient for spinal fusion. METHODS: Eighty-eight patients who underwent FF for single-level DLS were retrospectively reviewed after at least 1 year of follow-up. The control group comprised 21 patients who underwent conventional PLF. The operative technique involved a 5-cm midline skin incision, bilateral laminar fenestration, and FF with autologous bone harvested from the spinous process. Percutaneous pedicle screws were then inserted through the fascia. The fusion rate of FF was evaluated using computed tomography, and the change in the range of motion at the fused level was assessed on flexion-extension lateral radiographs. The Japanese Orthopaedic Association Back Pain Evaluation Questionnaire was used to assess the therapeutic effectiveness of FF. The results of the Roland-Morris Disability Questionnaire and the visual analogue scales of low back pain, buttock and lower limb pain, and buttock and lower limb numbness were evaluated. RESULTS: The fusion rate was 88.6% (78/88 cases). Among 10 patients with inadequate fusion, the average range of motion significantly decreased from 14.4° preoperatively to 4.3° postoperatively. The Japanese Orthopaedic Association Back Pain Evaluation Questionnaire category scores demonstrated therapeutic effectiveness in 93.0% of the patients for walking ability and in 73.0% of the patients for low back pain. The average preoperative scores of the Roland-Morris Disability Questionnaire and the visual analogue scales of low back pain, buttock and lower limb pain, and buttock and lower limb numbness were significantly reduced postoperatively in the FF group. CONCLUSION: FF achieved good clinical outcomes that were superior to those of conventional PLF with a comparable fusion rate. It is useful for managing DLS and is a minimally invasive evolution of PLF. LEVEL OF EVIDENCE: 3.

Animated respiratory movement of a spinal intradural arachnoid cyst visualized by intraoperative ultrasonography.

This study aims to describe the animated respiratory movement of a spinal intradural arachnoid cyst visualized by intraoperative ultrasonography. A 69-year-old man with a spinal arachnoid cyst of the thoracic spine presented with gait disturbance. Magnetic resonance images showed a mild anterior displacement and flattening of the spinal cord at T4-T5. We performed ultrasonography before incision of the dura during the operation and observed the movement of the cyst consisting of not only pulsation in accordance with the cardiac cycle but also rhythmic expansion and contraction in accordance with the respiratory cycle. In the inspiratory phase, the cyst gradually expanded and pulsated in accordance with the cardiac cycle. In the expiratory phase, the cyst gradually contracted with the same pulsation. After resection of the cyst, the patient's neurological improvements were excellent. To our knowledge, this is the first report of animated respiratory movement of a spinal arachnoid cyst visualized by intraoperative ultrasonography. Although cine magnetic resonance imaging can detect spinal intradural arachnoid cysts preoperatively, intraoperative ultrasonography is useful for close analysis of their movement and pathology. Considering the dynamic compression mechanism revealed in this study, we think that an early operation should be performed for such cysts.

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.

Multicenter prospective nonrandomized controlled clinical trial to prove neurotherapeutic effects of granulocyte colony-stimulating factor for acute spinal cord injury: analyses of follow-up cases after at least 1 year.

STUDY DESIGN: An open-labeled multicenter prospective nonrandomized controlled clinical trial. OBJECTIVE: To confirm the feasibility of using granulocyte colony-stimulating factor (G-CSF) for treatment of acute spinal cord injury (SCI). SUMMARY OF BACKGROUND DATA: We previously reported that G-CSF promotes functional recovery after compression-induced SCI in mice. On the basis of these findings, we conducted a multicenter prospective controlled clinical trial to assess the feasibility of G-CSF therapy for patients with acute SCI. METHODS: The trial ran from August 2009 to March 2011, and included 41 patients with SCI treated within 48 hours of onset. Informed consent was obtained from all patients. After providing consent, patients were divided into 2 groups. In the G-CSF group (17 patients), G-CSF (10 µg/kg/d) was intravenously administered for 5 consecutive days, and in the control group (24 patients), patients were similarly treated except for the G-CSF administration. We evaluated motor and sensory functions using the American Spinal Cord Injury Association score and American Spinal Cord Injury Association impairment scale at 1 week, 3 months, 6 months, and 1 year after onset. RESULTS: Only 2 patients did not experience American Spinal Cord Injury Association impairment scale improvement in the G-CSF group. In contrast, 15 patients in the control group did not experience American Spinal Cord Injury Association impairment scale improvement. In the analysis of increased American Spinal Cord Injury Association motor score, a significant increase in G-CSF group was detected from 1 week after the administration compared with the control group. After that, some spontaneous increase of motor score was detected in control group, but the significant increase in G-CSF group was maintained until 1 year of follow-up. CONCLUSION: Despite the limitation that patient selection was not randomized, the present results suggest the possibility that G-CSF administration has beneficial effects on neurological recovery in patients with acute SCI. LEVEL OF EVIDENCE: 3.

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.

Spontaneous reduction of a floated ossification of the ligamentum flavum after posterior thoracic decompression (floating method); report of a case (abridged translation of a primary publication).

BACKGROUND CONTEXT: Although complete resection is the preferred surgical treatment for ossification of the ligamentum flavum (OLF), it sometimes results in the floating method because of adhesion to, or ossification of, the dura mater. It is difficult to anticipate the degree of floating, and if the floated ossification is large, decompression of the spinal cord may not be sufficient. PURPOSE: To describe a case of spontaneous reduction of a floated OLF after posterior decompression. STUDY DESIGN: Case report and review of the literature. METHODS: A 70-year-old woman with OLF of the thoracic spine presented with gait disturbance. A computed tomographic myelogram showed a large ossification and severe spinal canal stenosis at T10-T11. It also showed slight spinal cord compression by ossification at T9-T10. RESULTS: We performed a laminectomy with floating ossification at T9-T11 and posterior fusion with a pedicle screw system at T10-T11. After the operation, the patient's neurologic improvement was excellent. Five weeks after the operation, a computed tomogram showed reduction of the floated ossification. Improvement progressed up to 3 months after the operation, bringing a sufficient decompression of the spinal cord, whereas it was insufficient immediately after the operation. CONCLUSIONS: Our present study is the first report that showed OLF was reduced after the floating method. Reduction of the floated ossification was observed 5 weeks after the operation.

Granulocyte colony-stimulating factor (G-CSF) protects oligodendrocyte and promotes hindlimb functional recovery after spinal cord injury in rats.

BACKGROUND: Granulocyte colony-stimulating factor (G-CSF) is a protein that stimulates differentiation, proliferation, and survival of cells in the granulocytic lineage. Recently, a neuroprotective effect of G-CSF was reported in a model of cerebral infarction and we previously reported the same effect in studies of murine spinal cord injury (SCI). The aim of the present study was to elucidate the potential therapeutic effect of G-CSF for SCI in rats. METHODS: Adult female Sprague-Dawley rats were used in the present study. Contusive SCI was introduced using the Infinite Horizon Impactor (magnitude: 200 kilodyne). Recombinant human G-CSF (15.0 µg/kg) was administered by tail vein injection at 1 h after surgery and daily the next four days. The vehicle control rats received equal volumes of normal saline at the same time points. RESULTS: Using a contusive SCI model to examine the neuroprotective potential of G-CSF, we found that G-CSF suppressed the expression of pro-inflammatory cytokine (IL-1 beta and TNF- alpha) in mRNA and protein levels. Histological assessment with luxol fast blue staining revealed that the area of white matter spared in the injured spinal cord was significantly larger in G-CSF-treated rats. Immunohistochemical analysis showed that G-CSF promoted up-regulation of anti-apoptotic protein Bcl-Xl on oligpodendrocytes and suppressed apoptosis of oligodendrocytes after SCI. Moreover, administration of G-CSF promoted better functional recovery of hind limbs. CONCLUSIONS: G-CSF protects oligodendrocyte from SCI-induced cell death via the suppression of inflammatory cytokines and up-regulation of anti-apoptotic protein. As a result, G-CSF attenuates white matter loss and promotes hindlimb functional recovery.

Multiple neck operations in a patient with severe motor tics because of Tourette's syndrome: a case report.

INTRODUCTION: In patients with Tourette's syndrome who have severe motor tics, involuntary neck movements can enhance degenerative changes in the cervical spine, occasionally causing myelopathy. There have been a limited number of reports on surgical treatment for cervical myelopathy caused by Tourette's syndrome, and a consensus for surgical treatment has not been fully established. To the best of our knowledge, this is the first report that describes a case of cervical myelopathy in a patient with Tourette's syndrome with severe motor tics who has undergone multiple surgeries of the cervical spine. CASE PRESENTATION: A 44-year-old Asian man with severe motor tics due to Tourette's syndrome presented with cervical myelopathy. Previously, he had undergone an anterior discectomy and spinal fusion with ceramics at the C3-C4 and C5-C6 levels, but required further surgery because of displacement of the ceramics. After the second operation, he developed compression myelopathy at the sandwiched (C4-C5) disc level, and had to undergo a C4-C5 anterior discectomy and spinal fusion, which was unsuccessful.As a salvage operation, we performed a C3-C7 decompression and spinal fusion from both the anterior and posterior approaches. By thorough postoperative external immobilization of his neck, our patient's spinal fusion was successful and his neurological improvements were maintained for more than 10 years. CONCLUSIONS: Patients with Tourette's syndrome with cervical myelopathy are at risk of having multiple neck operations to correct their symptoms. Postoperative immobilization and the correct selection of surgical procedure are quite important for successful spinal fusion and for avoiding complications at adjacent levels in these patients.

Neuroprotective therapy using granulocyte colony-stimulating factor for patients with worsening symptoms of thoracic myelopathy: a multicenter prospective controlled trial.

STUDY DESIGN: An open-labeled multicenter prospective controlled clinical trial. OBJECTIVE: To confirm the feasibility of granulocyte colony-stimulating factor (G-CSF) administration for patients with thoracic myelopathy. SUMMARY OF BACKGROUND DATA: Although G-CSF is best known as an important cytokine commonly used to treat neutropenia, it also has nonhematopoietic functions. Previous experimental studies have shown that G-CSF can enhance tissue regeneration of several organs, such as the heart and the brain. We previously reported that G-CSF promotes functional recovery after spinal cord injury in rodents. On the basis of those findings, we started a clinical trial of neuroprotective therapy, using G-CSF for patients with worsening symptoms of thoracic myelopathy. METHODS: Patients whose Japanese Orthopaedic Association (JOA) score for thoracic myelopathy had decreased 2 points or more during a recent 1-month period were eligible for entry. After giving informed consent, patients were assigned to G-CSF and control groups. The G-CSF group (n = 10) received G-CSF 10 µg/kg per day intravenously for 5 consecutive days. The control group (n = 14) received similar treatments as the G-CSF group except for G-CSF administration. The primary outcome was JOA recovery rate at 1 month after G-CSF administration or initial treatment. RESULTS: There was greater improvement in neurological functioning between baseline and 1-month follow-up in the G-CSF group (JOA recovery rate: 29.1 ± 20.5%) than in the control group (JOA recovery rate: 1.1 ± 4.2%) (P < 0.01). No serious adverse events occurred during or after the G-CSF administration. CONCLUSION: The results provide evidence that G-CSF administration caused neurological recovery in patients with worsening symptoms of thoracic compression myelopathy.