Impairment-driven cancer rehabilitation in patients with neoplastic spinal cord compression using minimally invasive spine stabilization.

BACKGROUND: Neoplastic spinal cord compression is a cause of severe disability in cancer patients. To prevent irreversible paraplegia, a structured strategy is required to address the various impairments present in cancer patients. In this study, we aimed to identify the status where rehabilitation with minimally invasive spine stabilization (MISt) effectively improves ADL. METHODS: We retrospectively reviewed 27 consecutive patients with neoplastic spinal compression who were treated with MISt. We classified the impairments of patients through our multidisciplinary tumor board based on spine-specific factors, skeletal instability, and tumor growth. The neurological deficits, progress of pathological fracture, incidence of vertebral collapse, and postoperative implant failure were examined. Changes of the Barthel index (BI) scores before and after surgery were investigated throughout the clinical courses. RESULTS: The average duration to ambulation was 7.19 ± 11 days, and we observed no collapse or progression of paralysis except in four cases of complete motor paraplegia before the surgery. Neurological deficiency was improved to or maintained at Frankel's grade E in 16 patients, remained unchanged in 6 patients (in grades B, C, D), and worsened in 5 patients. BI score comparisons before and after surgery in all patients showed statistically significant increments (p < 0.05). On further analysis, we noted good functional prognosis in patients capable of ambulation within 7 days (p < 0.05) and in patients who could survive longer than 3 months after the surgery (p < 0.05). CONCLUSIONS: In various cancer patients with neoplastic spinal cord compression, skeletal instability as the primary impairment is a good indication for MISt, as the patients showed early ambulation with improved BI scores.

Reliability Comparison between "Distal Radius and Ulna" and "Simplified Tanner-Whitehouse III" Assessments for Patients with Adolescent Idiopathic Scoliosis.

STUDY DESIGN: This is a retrospective clinical study. PURPOSE: In this study, we aim to evaluate the reliability of the distal radius and ulna assessment (DRU) and simplified Tanner-Whitehouse III classification (sTW3) in Japanese patients with adolescent idiopathic scoliosis (AIS). OVERVIEW OF LITERATURE: The greatest curvature of a scoliotic spine occurs at peak-height velocity (PHV), which is the time during which an individual's height increases at the maximum rate. Diagnosing and appropriately treating AIS before PHV is the most effective way in order to prevent unnecessary deterioration of the scoliosis curve. Although it is difficult to detect scoliosis before PHV, DRU and sTW3, which involve evaluations using a left-hand radiograph, have been reported to be effective. METHODS: We retrospectively evaluated 54 hands of 40 girls with AIS who visited Nara Medical University Hospital from 2000 to 2015 using previously collected radiographs. The examiners included a spine surgeon and a pediatric orthopedic surgeon, each with over 10 years of experience. The reliability of the DRU and sTW3 was evaluated using the kappa coefficient. RESULTS: The left-hand radiographs of 40 female patients with AIS (mean age, 13.9±1.7 years; N=54 hands) were evaluated by two blinded examiners using the sTW3 and DRU methods. The highest inter-observer and intra-observer reliabilities (kappa, 0.64 and 0.62, respectively) for radius evaluation were determined. Radius evaluation by the DRU showed the highest agreement rate and smallest error between the inter- and intra-observer examinations. CONCLUSIONS: The DRU was the most reliable assessment tool, and it has the potential to be useful for precisely determining the stage of skeletal maturity in outpatient clinics.

Muscle-evoked Potentials After Electrical Stimulation to the Brain in Patients Undergoing Spinal Surgery are Less Affected by Anesthetic Fade With Constant-voltage Stimulation Than With Constant-current Stimulation.

STUDY DESIGN: A prospective, within-subject study was conducted. OBJECTIVE: We aimed to compare the influence of anesthetic fade under maximum stimulation conditions between constant-current and constant-voltage stimulation techniques. SUMMARY OF BACKGROUND DATA: The monitoring of muscle-evoked potentials after electrical stimulation to the brain [Br(E)-MSEP)] is useful for assessing the integrity of spinal cord motor tracts during major spine surgery. Nonetheless, Br(E)-MSEP responses are known to deteriorate over the duration of surgeries performed under general anesthesia. This phenomenon is known as anesthetic fade. METHODS: We recruited 117 patients undergoing various spinal surgeries from the cervical to the lumbar level. We excluded 29 cases with insufficient data. The decrease rate of the Br(E)-MSEP amplitude for each muscle was examined. Br(E)-MSEP monitoring with constant-current and constant-voltage stimulations at the C3 and C4 electrode positions was applied. Compound muscle action potentials (CMAPs) were bilaterally recorded from the abductor pollicis brevis, deltoid, abductor hallucis, tibialis anterior, gastrocnemius, and quadriceps muscles. We defined the decrease rate as follows: (initial CMAPs-final CMAPs)/initial CMAPs × 100. Differences in the decrease rate were evaluated between stimulators, limbs (upper vs. lower), and operative time group (lowest quartile vs. highest quartile). RESULTS: The overall decrease rate (across all muscles) increased as the operative time increased, and the rate was higher in the lower limbs than in the upper limbs. In addition, the overall decrease rate was lower with constant-voltage stimulation than with constant-current stimulation. Furthermore, the decrease rate for constant-current stimulation was significantly higher than that for constant-voltage stimulation, regardless of the operative time. CONCLUSION: The CMAP waveform with constant-voltage stimulation is less susceptible to anesthetic fade than that with constant-current stimulation, even during long surgeries. LEVEL OF EVIDENCE: 3.

Evaluating Cervical Sagittal Alignment in Cervical Myelopathy: Are Sitting Cervical Radiographs and Standing Whole-Spine Radiographs Equally Useful?

STUDY DESIGN: Retrospective review of medical charts and radiographic data. OBJECTIVES: We aimed to clarify the differences in cervical alignment findings between sitting cervical lateral radiographs and standing whole-spine lateral radiographs with clavicle positioning in cervical spondylotic myelopathy (CSM) patients. METHODS: We retrospectively evaluated the radiographs of 50 consecutive patients who underwent cervical surgery for CSM in our hospital. Cervical sagittal alignment was evaluated based on the C0-2 angles and C2-7 Gore and Cobb angles. Head position was evaluated in terms of the center of gravity of the head to C7 (CGH-C7) angle and the McGregor angle (ie, the angle between the McGregor line and a horizontal line). The T1-slope was also evaluated. RESULTS: The mean values of the CGH-C7 angle and T1-slope were significantly lower, while the mean value of the McGregor angle was significantly higher on whole-spine lateral radiographs with clavicle positioning than on sitting cervical lateral radiographs. The mean values of the C0-2 and C2-7 angles did not differ significantly between the 2 radiographic positioning approaches. CONCLUSIONS: Using whole-spine lateral radiographs with clavicle positioning may result in a significantly lower T1-slope and a posterior tilt of the head. In the absence of a compensatory change in cervical alignment, clavicle positioning may force patients to adopt an upward gazing position of the head. These compensatory mechanisms should be considered while evaluating cervical alignment on whole-spine lateral radiographs with clavicle positioning. Surgical planning should take into account the effect of posture on the radiographic appearance of cervical alignment.

An aneurysmal bone cyst at T1 treated with bone grafts containing calcitonin and methylprednisolone.

Aneurysmal bone cysts (ABCs) rarely trigger pathological fractures. Various surgical and nonsurgical treatments have been reported for this condition. Herein, we present the examination findings and treatment for a 15-year-old girl who initially presented with adolescent idiopathic scoliosis and mild back pain, but subsequently experienced severe back pain. Magnetic resonance imaging revealed an ABC at T1, with an associated pathological fracture. We successfully treated the patient using posterior fixation with instrumentation, curettage, and bone grafts combined with calcitonin and methylprednisolone (mPSL). At 3 years post-surgery, there was no ABC recurrence and only mild back pain persisted. To our knowledge, this is the first report of open surgery (curettage and fixation) with local intralesional administration of calcitonin and mPSL for an ABC-induced pathological spinal fracture. We believe that this treatment is an effective option for ABCs associated with a pathological spinal fracture.

Loco-check presents a useful tool to determine health-related quality of life in elderly people with lumbar spinal stenosis.

BACKGROUND: Locomotive syndrome (LS) is a condition of decreased mobility caused by disorders of the locomotive organs. Lumbar spinal stenosis (LSS) is an LS disorder. The loco-check is a simple questionnaire comprising seven questions that can detect LS. The differences between the health-related quality of life (HRQoL) of elderly persons without LSS and those with LSS remain unclear. The primary aim of this study was to clarify these differences using the European quality of life (EuroQoL) scale. The secondary aim was to clarify the differences between the groups based on loco-check questionnaire responses. METHODS: We recruited patients aged ≥65 years. Our age- and sex-matched case/control cohorts included 28 elderly patients with LSS and 28 without LSS. The study participants were evaluated by the number of "yes" answers on the loco-check, the HRQoL using EuroQoL-5 dimension (EQ-5D) utility values, and the EuroQoL-visual analog scale (EQ-VAS). We compared differences between patients with and without LSS regarding HRQoL using EQ-5D utility values, EQ-VAS scores, the number of "yes" answers on the loco-check, and details of the loco-check. RESULTS: Patients with LSS had significantly lower EQ-5D utility values (p < 0.01) and more "yes" answers on the loco-check (p < 0.01) than those without LSS. There were no significant differences in EQ-VAS scores between groups (p = 0.09). There were statistically significant differences between groups in all questions except two: You often trip up or slip around the house and You can't make it across the road before the light turns red. CONCLUSIONS: Elderly patients with LSS had lower EQ-5D utility values and more "yes" answers on the loco-check than elderly persons without LSS. Our results may clarify differentiating features of elderly patients with and without LSS.

Biceps-Related Physical Findings Are Useful to Prevent Misdiagnosis of Cervical Spondylotic Amyotrophy as a Rotator Cuff Tear.

STUDY DESIGN: Case-control study. PURPOSE: The aim of the present study was to identify physical findings useful for differentiating between cervical spondylotic amyotrophy (CSA) and rotator cuff tears to prevent the misdiagnosis of CSA as a rotator cuff tear. OVERVIEW OF LITERATURE: CSA and rotator cuff tears are often confused among patients presenting with difficulty in shoulder elevation. METHODS: Twenty-five patients with CSA and 27 with rotator cuff tears were enrolled. We included five physical findings specific to CSA that were observed in both CSA and rotator cuff tear patients. The findings were as follows: (1) weakness of the deltoid muscle, (2) weakness of the biceps muscle, (3) atrophy of the deltoid muscle, (4) atrophy of the biceps muscle, and (5) swallow-tail sign (assessment of the posterior fibers of the deltoid). RESULTS: Among 25 CSA patients, 10 (40.0%) were misdiagnosed with a rotator cuff tear on initial diagnosis. The sensitivity and specificity of each physical finding were as follows: (1) deltoid weakness (sensitivity, 92.0%; specificity, 55.6%), (2) biceps weakness (sensitivity, 80.0%; specificity, 100%), (3) deltoid atrophy (sensitivity, 96.0%; specificity, 77.8%), (4) biceps atrophy (sensitivity, 88.8%; specificity, 92.6%), and (5) swallow-tail sign (sensitivity, 56.0%; specificity, 74.1%). There were statistically significant differences in each physical finding. CONCLUSIONS: CSA is likely to be misdiagnosed as a rotator cuff tear; however, weakness and atrophy of the biceps are useful findings for differentiating between CSA and rotator cuff tears to prevent misdiagnosis.

Lymphocyte Count at 4 Days Postoperatively: A Reliable Screening Marker for Surgical Site Infection After Posterior Lumbar Decompression Surgery.

STUDY DESIGN: Case-control study. OBJECTIVE: To identify laboratory markers for surgical site infection (SSI) in posterior lumbar decompression surgery, which are not affected by operative factors, and to determine the diagnostic cutoffs of these markers. SUMMARY OF BACKGROUND DATA: Numerous laboratory markers are used for the early detection of SSI; however, these markers may be affected by operative factors. METHODS: The study included 182 participants. They were divided into an SSI group (patients who developed deep SSI; n = 8) and a no-SSI group (n = 174). We reviewed data on the C-reactive protein level and total white blood cell count and differential count before posterior lumbar decompression surgery and 1 and 4 days postoperatively. We determined which markers differed significantly between the groups and identified the markers that were not affected by operative factors (operative time, intraoperative blood loss, and number of operative segments) in the no-SSI group. We then determined the diagnostic cutoffs of these unaffected markers using receiver operating characteristic curves. RESULTS: We identified the lymphocyte percentage at 4 days postoperatively (cutoff, <19.4%; sensitivity, 80.0%; specificity, 62.5%; area under the curve, 0.78) and lymphocyte count at 4 days postoperatively (cutoff, <1010/µL; sensitivity, 93.7%; specificity, 62.5%; area under the curve, 0.78) as reliable markers. CONCLUSION: Lymphocyte percentage and count at 4 days postoperatively are reliable markers for SSI after posterior lumbar decompression surgery. Lymphocyte count at 4 days postoperatively can be considered as a superior marker for screening because it has a high sensitivity and can be measured early. LEVEL OF EVIDENCE: 4.

Post-tetanic transcranial motor evoked potentials augment the amplitude of compound muscle action potentials recorded from innervated and non-innervated muscles.

BACKGROUND CONTEXT: Transcranial electrical stimulation used to produce motor evoked potentials (TES-MEPs) and subsequent compound muscle action potential (CMAP) recording is widely used to monitor motor function during surgery when there is risk of damaging the spinal cord. Nonetheless, some muscles do not produce CMAP amplitudes sufficient for intraoperative monitoring. PURPOSE: This study aimed to investigate the utility of tetanic stimulation at single and multiple peripheral nerve sites for augmenting CMAP amplitudes recorded from innervated and non-innervated muscles. STUDY DESIGN/SETTING: A retrospective study was carried out. PATIENT SAMPLE: The study sample comprised 24 patients with cervical myelopathy who underwent decompression surgery at our department between November 2005 and March 2007. OUTCOME MEASURES: Compound muscle action potential amplitude was a physiological measure. METHODS: We used two patterns of tetanic peripheral nerve stimulation for each patient. The first pattern consisted of tetanic stimulation of the left tibial nerve only (Pattern 1), and the second pattern consisted of tetanic stimulation of the bilateral median nerves and left tibial nerve (Pattern 2). RESULTS: Compound muscle action potential amplitudes from all muscles were augmented by both tetanic stimulation patterns compared with conventional TES-MEP recording; however, Pattern 2 elicited the greatest augmentation of CMAP amplitudes, especially for CMAPs recorded from the bilateral abductor pollicis brevis muscles. CONCLUSIONS: Although tetanic stimulation of a single peripheral nerve increased CMAP amplitudes recorded from both innervated and non-innervated muscles, CMAP amplitudes were best augmented when the corresponding nerve received tetanic stimulation. Additionally, tetanic stimulation of multiple nerves rather than a single nerve appears to provide better augmentation.

Comparison of neutrophil and lymphocyte at 1 and 4 days postoperatively: reliable and early detection markers for surgical site infection following instrumented spinal fusion.

INTRODUCTION: To identify the temporal comparison of biochemical markers for early detection of surgical site infection (SSI) following instrumented spinal fusion that are not affected by operative factors. METHODS: We reviewed data on C-reactive protein level and total white blood cell count and differential count before instrumented spinal fusion and at 1, 4, and 7 days postoperatively. The 141 patients in our sample were divided into an SSI group (patients who developed deep SSI) and a non-SSI group. We investigated the peak or nadir value day and identified those not affected by operative circumstances (operating time, intraoperative blood loss, and number of fusion segments) in the non-SSI group. If there was a significant difference between the peak or nadir value day and the next survey day, we considered the temporal comparison between these unaffected markers as an indicator of SSI and examined the usefulness of these indicators by calculating sensitivity and specificity. Furthermore, we investigated the usefulness of the combination of these markers (if even each one marker was recognized, we considered it positive). RESULTS: Four biochemical markers of SSI were selected: neutrophil percentage at postoperative day 4 more than day 1 (sensitivity 36%, specificity 95%), neutrophil count at postoperative day 4 more than day 1 (sensitivity 46%, specificity 93%), lymphocyte percentage at postoperative day 4 less than day 1 (sensitivity 36%, specificity 90%), and lymphocyte count at postoperative day 4 less than day 1 (sensitivity 36%, specificity 90%). The combination of these markers showed sensitivity 100%, specificity 80%, respectively. CONCLUSIONS: Four markers are reliable indicators for early detection of SSI following spinal instrumented fusion because they are not affected by operative factor. The combination of each indicator had both high sensitivity and specificity. Therefore, it is reliable and much useful for early detection of SSI.

Preliminary algorithm for differential diagnosis between spinal meningioma and schwannoma using plain magnetic resonance imaging.

BACKGROUND: Preoperative differential diagnosis between spinal meningioma and schwannoma is critical due to the characteristic differences of the surgical treatments. Thus, we aimed to develop an algorithm for the differential diagnosis of these two lesions based on plain MRI findings. METHODS: We retrospectively reviewed plain MR images from patients who had undergone surgical treatment for meningiomas and schwannomas in our hospital between 2002 and 2016. Seven findings characteristic of meningioma or schwannoma were considered: (a) low or equal signal intensity on T2-weighted images, (b) obtuse angle from the dura mater, (c) anterior location in the spinal canal, (d) cystic degeneration, (e) lumbar occurrence, (f) oval or round shape, and (g) dumbbell type. We calculated the sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), and accuracy of each MRI finding, following which the algorithm was developed using decision tree analysis. Finally, we examined the usefulness of the algorithm for differential diagnosis between the two lesions. RESULTS: Twenty four patients with meningiomas and 56 with schwannomas were enrolled. The sensitivity, specificity, PPV, NPV, and accuracy of each finding were as follows: (a) [58%, 100%, 100%, 85%, 88%], (b) [67%, 89%, 73%, 86%, 83%], (c) [29%, 88%, 50%, 74%, 70%], (d) [30%, 96%, 94%, 37%, 50%], (e) [43%, 96%, 96%, 42%, 59%], (f) [33%, 88%, 73%, 57%, 60%], and (g) [25%, 96%, 93%, 35%, 46%]. Significant differences were observed with regard to (a), (b), (d), (e), and (g). The algorithm was developed using these five findings, all of which exhibited high specificity and reliability. Accuracy of the algorithm was 91.3%. CONCLUSIONS: Our results indicated that plain MRI findings can be used to differentiate between spinal meningiomas and schwannomas. Furthermore, our novel algorithm exhibited high accuracy, suggesting that this algorithm may aid in the differential diagnosis of these two lesions.

Higher success rate with transcranial electrical stimulation of motor-evoked potentials using constant-voltage stimulation compared with constant-current stimulation in patients undergoing spinal surgery.

BACKGROUND CONTEXT: During spine surgery, the spinal cord is electrophysiologically monitored via transcranial electrical stimulation of motor-evoked potentials (TES-MEPs) to prevent injury. Transcranial electrical stimulation of motor-evoked potential involves the use of either constant-current or constant-voltage stimulation; however, there are few comparative data available regarding their ability to adequately elicit compound motor action potentials. We hypothesized that the success rates of TES-MEP recordings would be similar between constant-current and constant-voltage stimulations in patients undergoing spine surgery. PURPOSE: The objective of this study was to compare the success rates of TES-MEP recordings between constant-current and constant-voltage stimulation. STUDY DESIGN: This is a prospective, within-subject study. PATIENT SAMPLE: Data from 100 patients undergoing spinal surgery at the cervical, thoracic, or lumbar level were analyzed. OUTCOME MEASURES: The success rates of the TES-MEP recordings from each muscle were examined. MATERIALS AND METHODS: Transcranial electrical stimulation with constant-current and constant-voltage stimulations at the C3 and C4 electrode positions (international "10-20" system) was applied to each patient. Compound muscle action potentials were bilaterally recorded from the abductor pollicis brevis (APB), deltoid (Del), abductor hallucis (AH), tibialis anterior (TA), gastrocnemius (GC), and quadriceps (Quad) muscles. RESULTS: The success rates of the TES-MEP recordings from the right Del, right APB, bilateral Quad, right TA, right GC, and bilateral AH muscles were significantly higher using constant-voltage stimulation than those using constant-current stimulation. The overall success rates with constant-voltage and constant-current stimulations were 86.3% and 68.8%, respectively (risk ratio 1.25 [95% confidence interval: 1.20-1.31]). CONCLUSIONS: The success rates of TES-MEP recordings were higher using constant-voltage stimulation compared with constant-current stimulation in patients undergoing spinal surgery.

Bone marrow stromal cell sheets may promote axonal regeneration and functional recovery with suppression of glial scar formation after spinal cord transection injury in rats.

OBJECTIVE Transplantation of bone marrow stromal cells (BMSCs) is a theoretical potential as a therapeutic strategy in the treatment of spinal cord injury (SCI). Although a scaffold is sometimes used for retaining transplanted cells in damaged tissue, it is also known to induce redundant immunoreactions during the degradation processes. In this study, the authors prepared cell sheets made of BMSCs, which are transplantable without a scaffold, and investigated their effects on axonal regeneration, glial scar formation, and functional recovery in a completely transected SCI model in rats. METHODS BMSC sheets were prepared from the bone marrow of female Fischer 344 rats using ascorbic acid and were cryopreserved until the day of transplantation. A gelatin sponge (GS), as a control, or BMSC sheet was transplanted into a 2-mm-sized defect of the spinal cord at the T-8 level. Axonal regeneration and glial scar formation were assessed 2 and 8 weeks after transplantation by immunohistochemical analyses using anti-Tuj1 and glial fibrillary acidic protein (GFAP) antibodies, respectively. Locomotor function was evaluated using the Basso, Beattie, and Bresnahan scale. RESULTS The BMSC sheets promoted axonal regeneration at 2 weeks after transplantation, but there was no significant difference in the number of Tuj1-positive axons between the sheet- and GS-transplanted groups. At 8 weeks after transplantation, Tuj1-positive axons elongated across the sheet, and their numbers were significantly greater in the sheet group than in the GS group. The areas of GFAP-positive glial scars in the sheet group were significantly reduced compared with those of the GS group at both time points. Finally, hindlimb locomotor function was ameliorated in the sheet group at 4 and 8 weeks after transplantation. CONCLUSIONS The results of the present study indicate that an ascorbic acid-induced BMSC sheet is effective in the treatment of SCI and enables autologous transplantation without requiring a scaffold.

Increased Segmental Range of Motion Is Correlated With Spondylolisthesis in the Cervical Spine After Laminoplasty.

STUDY DESIGN: A retrospective study. OBJECTIVE: The aim of this study was to determine the incidence of increased segmental range of motion (ROM) after laminoplasty and to clarify whether increased ROM is associated with spondylolisthesis. Finally, we explored the effect of increased segmental ROM on clinical results. SUMMARY OF BACKGROUND DATA: Cervical laminoplasty for cervical spondylotic myelopathy causes reduced ROM, possibly due to the unintended contracture of the facet joint or a bony union. Although it is rarely studied, ROM may also increase following laminoplasty. Thus far, there are no reports describing the correlation between increased segmental ROM and segmental spondylolisthesis after laminoplasty. METHODS: We evaluated 187 segments from 39 cervical spondylotic myelopathy patients who underwent bilateral open door laminoplasty from C2 to C7. The segmental ROM and spondylolisthesis were measured using dynamic radiographs that were obtained preoperatively and 2 years postoperatively. The Japanese Orthopedic Association (JOA) score was used for clinical evaluation. To compare the clinical results, we compared the cases with increased ROM in at least one segment with the remaining cases. RESULTS: Increased segmental ROM (i.e., ≥5° increase) was observed in 25 of 187 segments (13.4%) from 14 cases. There was a strong correlation between increased ROM and spondylolisthesis. A high preoperative disc height was associated with increased segmental ROM 2 years postoperation. Regardless of the correlation with spondylolisthesis, there was no statistically significant correlation between increased segmental ROM and JOA score. CONCLUSION: The decrease in segmental ROM after laminoplasty was not uniform. Approximately 13.4% of all segments showed increased ROM. The preoperative disc height might influence the risk for increased segmental ROM. Furthermore, increased ROM was correlated with spondylolisthesis in the segment, though it was not correlated with clinical results. LEVEL OF EVIDENCE: 4.

Lymphopenia at 4 Days Postoperatively Is the Most Significant Laboratory Marker for Early Detection of Surgical Site Infection Following Posterior Lumbar Instrumentation Surgery.

STUDY DESIGN: Case control study. PURPOSE: To identify the most significant laboratory marker for early detection of surgical site infection (SSI) using multiple logistic regression analysis. OVERVIEW OF LITERATURE: SSI is a serious complication of spinal instrumentation surgery. Early diagnosis and treatment are crucial. METHODS: We retrospectively reviewed the laboratory data of patients who underwent posterior lumbar instrumentation surgery for degenerative spinal disease from January 2003 to December 2014. Six laboratory markers for early SSI detection were considered: renewed elevation of the white blood cell count, higher at 7 than 4 days postoperatively; renewed elevation of the C-reactive protein (CRP) level, higher at 7 than 4 days postoperatively; CRP level of >10 mg/dL at 4 days postoperatively; neutrophil percentage of >75% at 4 days postoperatively; lymphocyte percentage of <10% at 4 days postoperatively; and lymphocyte count of <1,000/µL at 4 days postoperatively. RESULTS: Ninety patients were enrolled; five developed deep SSI. Multivariate regression analysis showed that a lymphocyte count of <1,000/µL at 4 days postoperatively was the sole significant independent laboratory marker for early detection of SSI (p=0.037; odds ratio, 11.9; 95% confidence interval, 1.2-122.7). CONCLUSIONS: A lymphocyte count of <1,000/µL at 4 days postoperatively is the most significant laboratory marker for early detection of SSI.

Lymphopenia and Elevated Blood C-Reactive Protein Levels at Four Days Postoperatively Are Useful Markers for Early Detection of Surgical Site Infection Following Posterior Lumbar Instrumentation Surgery.

STUDY DESIGN: Case-control study. PURPOSE: To identify the characteristics of candidate indexes for early detection of surgical site infection (SSI). OVERVIEW OF LITERATURE: SSI is a serious complication of spinal instrumentation surgery. Early diagnosis and treatment are crucial for the welfare of the patient postoperation. METHODS: We retrospectively reviewed laboratory data of patients who underwent posterior lumbar instrumentation surgery for degenerative spine disease. The sensitivity and specificity of six laboratory markers for early detection of SSI were calculated: greater elevation of the white blood cell count at day 7 than at day 4 postoperatively, greater elevation of the C-reactive protein (CRP) level at day 7 than at day 4 postoperatively, a CRP level of >10 mg/dL at 4 days postoperatively, neutrophil percentage of >75% at 4 days postoperatively, a lymphocyte percentage of <10% at 4 days postoperatively, and a lymphocyte count of <1,000/µL at 4 days postoperatively. Statistical analysis was via Fisher's exact test and a p-value of <0.05 was considered significant. RESULTS: In total, 85 patients were enrolled. Of these, five patients developed deep SSI. The sensitivity and specificity of each index were as follows: index 1, 20.0% and 77.5%; index 2, 20.0% and 83.8%; index 3, 40.0% and 97.5%; index 4, 40.0% and 86.3%; index 5, 0% and 96.3%; and index 6, 80.0% and 80.0%. A significant difference was noted for indexes 3 and 6. CONCLUSIONS: A CRP level of >10 mg/dL at 4 days postoperatively would be useful for definitive diagnosis of SSI, and a lymphocyte count of <1,000/µL at 4 days postoperatively would be a useful screening test for SSI. Although laboratory markers for early detection of SSI have been frequently reported, we believe that it is important to understand the characteristics of each index for a precise diagnosis.

Lymphocyte Count at 4 Days Postoperatively and CRP Level at 7 Days Postoperatively: Reliable and Useful Markers for Surgical Site Infection Following Instrumented Spinal Fusion.

STUDY DESIGN: A case-control study. OBJECTIVE: The objective of this study is to identify biochemical markers for surgical site infection (SSI) in posterior instrumented spinal fusion that are not affected by operative circumstances and to determine diagnostic cutoffs for these markers. SUMMARY OF BACKGROUND DATA: Numerous biochemical markers may be used for early detection of SSI; however, these markers may be affected by operative factors. METHODS: We reviewed data on C-reactive protein level and total white blood cell count and differential count before instrumented spinal fusion and at 1, 4, and 7 days postoperatively. The 141 patients in our sample were divided into an SSI group (patients who developed deep SSI) and a no-SSI group. We determined which markers differed significantly between groups and identified those not affected by operative circumstances (operating time, intraoperative blood loss, number of fusion segments) in the no-SSI group. Then, we determined diagnostic cutoffs for these unaffected markers by using receiver-operating characteristic curves. RESULTS: Three markers were selected: lymphocyte count at 4 days postoperatively (cutoff 1180/µL, sensitivity 90.9%, specificity 65.4%, area under the curve [AUC] 0.80), lymphocyte count of at 7 days postoperatively (cutoff <1090/µL, sensitivity 63.6%, specificity 78.5%, AUC 0.77), and C-reactive protein level at 7 days postoperatively (cutoff >4.4 mg/dL, sensitivity 90.9%, specificity 89.2%, AUC 0.95). CONCLUSION: Lymphocyte count at 4 and 7 days postoperatively and C-reactive protein level at 7 days postoperatively are reliable markers for SSI following instrumented spinal fusion. Lymphocyte count at 4 days should be useful for screening because of its high sensitivity and because it can be measured early. C-reactive protein level at 7 days should be useful for definitive diagnosis given its high sensitivity and specificity and large AUC. LEVEL OF EVIDENCE: 4.

Maternal dietary patterns in pregnancy and fetal growth in Japan: the Osaka Maternal and Child Health Study.

Maternal nutritional status during pregnancy is an important determinant of fetal growth. Although the effects of several nutrients and foods have been well examined, little is known about the relationship of overall maternal diet in pregnancy to fetal growth, particularly in non-Western populations. We prospectively examined the relationship of maternal dietary patterns in pregnancy to neonatal anthropometric measurements at birth and risk of small-for-gestational-age (SGA) birth among 803 Japanese women with live-born, singleton, term deliveries. Maternal diet in pregnancy was assessed using a validated, self-administered diet history questionnaire. Dietary patterns from thirty-three predefined food groups (g/4184 kJ) were extracted by cluster analysis. The following three dietary patterns were identified: the 'meat and eggs' (n 326), 'wheat products', with a relatively high intake of bread, confectioneries and soft drinks (n 303), and 'rice, fish and vegetables' (n 174) patterns. After adjustment for potential confounders, women in the 'wheat products' pattern had infants with the significantly lowest birth weight (P = 0·045) and head circumference (P = 0·036) among those in the three dietary patterns. Compared with women in the 'rice, fish and vegetables' pattern, women in the 'wheat products' pattern had higher odds of having a SGA infant for weight (multivariate OR 5·2, 95 % CI 1·1, 24·4), but this was not the case for birth length or head circumference. These results suggest that a diet high in bread, confectioneries, and soft drinks and low in fish and vegetables during pregnancy might be associated with a small birth weight and an increased risk of having a SGA infant.

A1C but not serum glycated albumin is elevated because of iron deficiency in late pregnancy in diabetic women.

OBJECTIVE We have already reported that A1C is elevated because of iron deficiency in late pregnancy among nondiabetic pregnant women. This report examined whether the same phenomenon is observed in pregnant women with diabetes. RESEARCH DESIGN AND METHODS This longitudinal study was conducted in 17 pregnant women with diabetes (20-35 weeks of pregnancy). A1C, serum glycated albumin, erythrocyte indexes, and iron metabolism indexes were measured. RESULTS A1C levels were significantly increased in late pregnancy, whereas serum glycated albumin showed no significant changes. Glycated albumin/A1C ratio, mean corpuscular hemoglobin, serum transferrin saturation, and serum ferritin were significantly decreased in late pregnancy. Serum transferrin saturation showed a significant positive correlation with glycated albumin/A1C ratio. CONCLUSIONS A1C levels, but not serum glycated albumin levels, are elevated in late pregnancy because of iron deficiency in diabetic women. Serum glycated albumin may offer an adequate marker for glycemic control during pregnancy.

Effects of pitavastatin on serum lipids and high sensitivity C-reactive protein in type 2 diabetic patients.

AIM: Previous studies have been inconsistent results about the effects of statins on serum triglyceride (TG), high-density lipoprotein cholesterol (HDL-C) and high sensitivity C-reactive protein (hsCRP) levels. We therefore investigated the effects of pitavastatin on serum lipid profiles and hsCRP levels in patients with type 2 diabetes mellitus. METHODS: The study population was 65 Japanese type 2 diabetic patients who had been administered 2 mg daily of pitavastatin and completed a 6-month follow-up. Serum lipids and hsCRP were measured before and after treatment for 1, 3, and 6 months. RESULTS: Total cholesterol (TC), low-density lipoprotein cholesterol (LDL-C) and TG had significantly reduced after 1 month and remained reduced for 6 months, while HDL-C levels had significantly increased after 1 month and remained at the higher level for 6 months. Baseline median levels of hsCRP were 0.49 mg/L and showed a significant reduction to 0.37 mg/L at 6 months' treatment (p<0.001). Six-month changes in hsCRP levels were not associated with those in TC, LDL-C, HDL-C or TG. CONCLUSION: Pitavastatin improved serum lipid profiles and reduced serum hsCRP levels in type 2 diabetic patients with relatively low inflammation. The effect on hsCRP was not related to the effects on serum lipid profiles.