Effect of acute high-intensity intermittent exercise on serum brain-derived neurotrophic factor concentrations.

BACKGROUND: This study aimed to examine changes in serum brain-derived neurotrophic factor (BDNF) concentrations after exhaustive high-intensity intermittent exercise (HIIE) and non-exhaustive HIIE, and to compare the two conditions. METHODS: Eight healthy male college students (age: 22±1 year) participated in exhaustive (sets: 6-7) and non-exhaustive (sets: 5) HIIE. In both conditions, participants repeated sets of 20 seconds of exercise at 170% V̇O2max with 10 seconds of rest between sets. Serum BDNF was measured 8 times in each condition: 30 minutes after resting, 10 minutes after sitting, immediately after HIIE, and 5, 10, 30, 60, and 90 minutes after main exercise. Changes in serum BDNF concentrations over time and between measurement points in both conditions were measured using a two-way repeated measures ANOVA. RESULTS: Serum BDNF concentrations were measured, revealing significant interaction between two factors (conditions and measurement points) (F=3.482, P=0.027). In the exhaustive HIIE, there were significant increases at 5 minutes (P<0.01) and 10 minutes (P<0.01) after exercise compared to after resting. In the non-exhaustive HIIE, there was a significant increase immediately after (P<0.01) and 5 minutes after (P<0.01) exercise compared to resting. Comparison of the serum BDNF concentrations at each measurement point showed a significant difference at 10 minutes after exercise, with significantly higher values for the exhaustive HIIE condition (P<0.01, r=0.60). CONCLUSIONS: Exhaustive and non-exhaustive HIIE are time-efficient exercises that increase serum BDNF concentrations in healthy adults.

A Case of Idiopathic Thoracic Spinal Subdural Hematoma With Bilateral Lower Limb Paralysis.

Subdural hemorrhage is rare and is mostly triggered non-traumatically due to intracranial surgery, lumbar puncture, anticoagulant therapy, blood diseases, vascular malformations, and tumors. We experienced a case of idiopathic subdural hematoma with acute bilateral lower limb paralysis on postoperative day 4 after laparoscopic hysteromyomectomy. The patient was a 40-year-old woman with uterine myoma who took no medication nor had history of trauma or abnormalities such as vascular malformations. Four days after laparoscopic surgery, sudden chest and back pain and bilateral lower limb paralysis appeared. Muscle weakness was found predominantly on the left side. In manual muscle test (MMT), the quadriceps femoris was 5/5 on both sides, but the tibialis anterior, extensor pollicis longus and flexor pollicis longus were 5/5 only on the right, and 2/5 on the left side. Warm pain sensation was decreased below Th4 (Fourth thoracic vertebra), and the right side showed a greater decrease of deep sensation than the left. Excretion was difficult and dysuria was also apparent. There were no abnormalities in blood biochemical tests or in the blood coagulation system. Using the results of diagnostic imaging, as preoperative diagnosis of the patient, spinal subdural hematoma was suspected. Conservative treatment was initially conducted but the emergency surgery for hematoma removal was performed at 14 hours after the onset because of progression of paralysis. This resulted in improvement of neurological symptoms including lower limb paralysis, bladder-rectal disorder and hypoesthesia. If subdural hematoma is suspected regardless of the cause, it is important to observe neurological findings over time and make a quick decision to treat with surgery.

Acromegaly presenting with myelopathy due to ossification of posterior longitudinal ligament: a case report.

BACKGROUND: Acromegaly is a rare disease caused by high serum levels of growth hormone (GH) and insulin-like growth factor 1 (IGF-1), often originating from a pituitary adenoma. Spinal and peripheral joint abnormalities are caused by these hormonal hypersecretions. In particular, the response to GH is involved in the onset of ossification of the spinal ligament in vitro, especially ossification of the posterior longitudinal ligament (OPLL). However, because acromegaly and OPLL are rare diseases, we seldom encounter them in combination. To the best of our knowledge in the English-language literature, this is the first reported case of acromegaly presenting with thoracic myelopathy due to OPLL. CASE PRESENTATION: A 47-year-old woman presented with lower extremity weakness and paresthesia, gait disorder, and bladder disorder without any trauma. The patient's most remarkable symptom was paraplegia, and we diagnosed myelopathy due to cervical and thoracic OPLL. Furthermore, we suspected acromegaly because of the characteristic facial features, and we found a pituitary adenoma by contrast-enhanced MRI. Cervical and thoracic decompression, posterior fixation, and pituitary adenoma resection were performed. CONCLUSION: We report a case of acromegaly that was detected after the diagnosis of OPLL. The main challenge in acromegaly is delayed in diagnosis. Even in this case, the facial features characteristic of acromegaly had appeared at least 9 years ago. Early diagnosis and treatment of acromegaly improve prognosis and reduce exposure to GH and IGF-1 through early intervention and seem to suppress the progression of ligament ossification. Orthopedic surgeons and neurosurgeons need to keep in mind that acromegaly is associated with bone/joint lesions and ossification of the spinal ligament and should aim to diagnose acromegaly early.

Adult Morquio syndrome requiring occipito-thoracic fusion.

Morquio syndrome is a relatively rare entity that is often associated with atlantoaxial instability from early childhood due to odontoid dysplasia based on a mucopolysaccharoidal disorder. Here, we present the case of a 55-year-old male patient with Morquio syndrome who developed cervical myelopathy, which is an extremely rare condition in the older population. Myelopathy developed gradually with upper-limb paresthesia and clumsiness of both hands. The patient had a characteristic "gargoyle-like" coarse face with a trunk shortening-type short stature. Imaging of the cervical spine demonstrated several problems, including diminutive structures called platyspondyly with small pedicles and fragile bone quality, hypoplasia of the C1 posterior arch that migrated into the spinal canal, and os odontoideum with atlantoaxial instability. With intraoperative navigation guidance, posterior decompression of C1 followed by occipito-cervico-thoracic spinal fusion was successfully performed in this complicated case. Clinical and radiographic outcomes were both excellent and have been maintained for 2 years postoperatively.

A Case of a Spinal Extradural Arachnoid Cyst.

The patient was a 49-year-old woman with a chief complaint of hip and buttock pain that had persisted for 3 years. She visited our hospital for aggravation of the pain. Percussion tenderness of the spinous process was observed and a T1-low, T2-high cystic lesion was detected on the dorsal side of the dural canal at the 12th thoracic vertebral level on MRI performed by a previous physician. Plane CT showed severe scalloping at the same level. During laminectomy for the 11th and 12th thoracic vertebrae, a cystic lesion of about 60 × 25 mm was noted on the dorsal side of the dural canal, with a communication pathway with the cyst present near the left 12th nerve root bifurcation. This pathway was ligated and the cyst was excised. The histopathological diagnosis was an arachnoid cyst. Pain improved after surgery, and as of 10 months after surgery, the cystic lesion has not recurred. A spinal extradural arachnoid cyst (SEAC) is a relatively rare disease. This case shows that surgical ligation of a communicating tract and cystectomy are necessary and contrast-enhanced CT was useful for the identification of the position of the communication pathway before surgery.

Use of intrawound vancomycin powder against postoperative infection after spine surgery.

Local application of vancomycin has recently become widely used in spine surgery. However, local application is not included in the indication and has not been approved by the US Food and Drug Administration (FDA). Thus, we searched for reports with "intra wound-vancomycin" and "SSI" as keywords in the MEDLINE database, and investigated the efficacy, problems with use, and future prospects based on these reports. Intrawound vancomycin was described as effective in most of the reports, but was found to have no effect or to aggravate the condition in some reports. A toxic effect on osteoblasts due to a high local concentration was described in some reports, whereas local application was found to be safe in other studies. The amount of vancomycin used and the administration method varied among the reports. Overall, the results suggest that intrawound vancomycin is clinically effective, but this has yet to be established in a randomized controlled trial. There is a need to identify cases that should be selected for this treatment and to investigate the dose and optimum concentration of vancomycin for clinical use.

Solitary Spinal Epidural Metastasis from Gastric Cancer.

Solitary epidural space metastasis of a malignant tumor is rare. We encountered a 79-year-old male patient with solitary metastatic epidural tumor who developed paraplegia and dysuria. The patient had undergone total gastrectomy for gastric cancer followed by chemotherapy 8 months priorly. The whole body was examined for suspected metastatic spinal tumor, but no metastases of the spine or important organs were observed, and a solitary mass was present in the thoracic spinal epidural space. The mass was excised for diagnosis and treatment and was histopathologically diagnosed as metastasis from gastric cancer. No solitary metastatic epidural tumor from gastric cancer has been reported in English. Among the Japanese, 3 cases have been reported, in which the outcome was poor in all cases and no definite diagnosis could be made before surgery in any case. Our patient developed concomitant pneumonia after surgery and died shortly after the surgery. When a patient has a past medical history of malignant tumor, the possibility of a solitary metastatic tumor in the epidural space should be considered.

Evaluation of antimicrobial prophylaxis against postoperative infection after spine surgery: Limit of the first generation cephem.

In our department, first-generation cephem (CEZ) are generally administered for 2 days as antimicrobial prophylaxis (AMP) for spinal surgery. However, the incidence of surgical site infection (SSI) has recently increased, particularly cases involving coagulase-negative Staphylococci (CNS) as an etiologic agent. The objective was to elucidate the problems with the current AMP and the risk factors of SSI through a retrospective investigation of affected cases. The subjects were patients who underwent spine surgery at our department between August 2007 and June 2013. The subjects were divided into those who developed SSI (S group) and who did not develop SSI (non-SSI (N) group), patients who developed CNS infection in the S group was subdivided as C group, and the risk factors were investigated. The significance of each factor was analyzed using cross tabulation, and multivariate logistic regression analyses were performed with 22 of the investigation factors as explanatory variables. The incidence of SSI was 2.55%, and the etiologic agent was CNS in 17 patients. Upon comparison between the S and N groups, the presence of 3 or more underlying diseases and blood loss were extracted as significant risk factors. Upon comparison between the C and N groups, emergency surgery and intra- and postoperative steroid administration were extracted as significant risk factors, in addition to the presence of 3 or more underlying diseases and blood loss. The effect of the current AMP using first generation cephem is limited, and reconsideration of the protocol may be necessary.

Comparison of the invasiveness of conventional discectomy and microendoscopic discectomy for lumbar disc herniation: Differences in the methods of approach.

INTRODUCTION: The aim of this study was to investigate whether differences in the methods of approach to the vertebral arch influence the invasiveness of conventional discectomy and microendoscopic discectomy (MED). METHODS: In this study, 41 Wistar rats were divided into four groups: controls (no surgery) (n = 10), shams (skin incision only) (n = 11), MED (n = 10), and conventional discectomy (n = 10). We performed ethological and blood biochemical examinations for three of the groups, excluding the control group, and a histological examination for three of the groups, excluding the sham group. In the ethological examination, we measured the threshold of postoperative pain using the von Frey test. In the blood chemical examination, we measured blood creatine phosphokinase and inflammatory cytokines, and compared the severity of tissue damage by histological examination using hematoxylin-eosin and immunohistochemical staining. RESULTS: The conventional discectomy group showed a significantly lower threshold of postoperative pain, compared with the MED group (P < 0.05). Blood biochemical investigation revealed that the creatine phosphokinase (P < 0.05) and tumor necrosis factor-α levels (P < 0.05) of the conventional discectomy group were significantly higher than those in the MED group. In the histological examination, it was found that a wide range of paraspinal muscle damage occurred in the conventional discectomy group (P < 0.05) and that the damage was mostly confined to the periosteum and nearby nerve endings. CONCLUSION: MED was found to be less invasive than conventional discectomy based on ethological, blood biochemical, and histological examinations.

Spontaneous symptomatic pseudoarthrosis at the l2-l3 intervertebral space with diffuse idiopathic skeletal hyperostosis: a case report.

Pseudoarthrosis at the intervertebral space in patients with ankylosing spondylitis has occasionally been reported, but symptomatic pseudoarthrosis at the intervertebral disc level is rare in patients with diffuse idiopathic skeletal hyperostosis (DISH). Here, we report a case of symptomatic pseudoarthrosis at the L2-L3 intervertebral space that was diagnosed based on clinical history. We first performed L1-L5 fixation, but back-out of the pedicle screw occurred in the early postoperative phase and may have been caused by a short fixation range and concomitant Parkinson's disease. However, the prognosis of the case was favorable after a second surgery. This case indicates that a fixation range of at least 3 above and 3 below is necessary for bone fracture of a thoracolumbar vertebra and pseudoarthrosis in patients with DISH.

Incidence of venous thromboembolism after spine surgery.

BACKGROUND: The incidence of venous thromboembolism (VTE) has varied among studies of patients undergoing elective spine surgery. This may be because of differences in prophylaxis for VTE and differences in methods of observation. Furthermore, some studies have reported symptomatic deep vein thrombosis (DVT) or pulmonary thromboembolism (PE), whereas others have included asymptomatic DVT or PE, making comparisons difficult. Therefore, the objective of this study was to determine the incidence of symptomatic and asymptomatic PE in patients undergoing elective spine surgery and to evaluate therapeutic methods for these conditions. METHODS: The subjects were 1975 patients who underwent spine surgery in our hospital from 1990 to 2011. Patients treated from January 1990 to November 1996 (n = 541, Group A) did not receive prophylaxis whereas those treated from January 2000 to February 2011 (n = 1,434, Group B) used a foot pump during and after surgery and subsequently wore elastic stockings. All subjects in Group A began ambulation ≥2 weeks after surgery whereas those in Group B began to walk earlier-within 3 days for patients who underwent decompression and within 1 week for those treated with fusion. From June 2010 to February 2011, contrast-enhanced computed tomography (CT) was performed 1 week after surgery for 100 patients to evaluate the presence of DVT and PE. Since March 2004, D-dimer was measured 1 week after surgery and patients with a level ≥10 µg/mL were followed up. RESULTS: The incidence of symptomatic PE was significantly higher in Group A than in Group B (8/541, 1.5% vs. 3/1,434, 0.2%). In 3 patients in Group B, PE developed within 1 week postoperatively and D-dimer values at onset were ≤10 µg/mL. In the 100 cases examined by contrast-enhanced computed tomography (CT), asymptomatic PE and VTE were detected in 18 and 19%, respectively. The D-dimer level 1 week after surgery was ≥10 µg/mL in 105 of 841 patients; however, none of these patients had clinically symptomatic VTE for at least 3 months postoperatively. CONCLUSIONS: Mechanical prophylaxis and early ambulation may be effective in reducing the incidence of symptomatic PE after spine surgery. Asymptomatic PE developed in 18% of patients who received mechanical prophylaxis, but the incidence of symptomatic PE was only 0.2%. Prompt diagnosis and treatment are required for patients who develop symptomatic PE.

Isolated neck extensor myopathy causing a dropped head: a case report.

This report is of a 71-year-old woman who presented with a dropped head and difficulty in extending her neck. She was diagnosed with isolated neck extensor myopathy. Conservative treatment (use of a cervical collar and muscular strength training) temporarily improved her symptoms. However, destruction of cervical vertebrae and myelopathy progressed secondary to repeated microfractures from mechanical stress. The patient underwent 2-stage combined anterior and posterior decompression and fusion using autografts. At one-year follow-up, numbness of the bilateral upper limbs had resolved, and bone union was achieved. The patient was able to look straight ahead and was very satisfied with the outcome.

Antimicrobial prophylaxis for spinal surgery.

BACKGROUND: The concept of antimicrobial prophylaxis (AMP) did not exist in Japan until recently. Therefore, postoperative administration of antimicrobial drugs has long been practiced under the pretext of prophylaxis against surgical site infection (SSI). In recent years, however, the concept of AMP and prophylactic countermeasures against SSI, based on evidence of the effectiveness of AMP, has gradually spread in Japan. From 2000 onward, we have undertaken prophylactic countermeasures against SSI in patients undergoing spinal surgery referring to the Guideline for Prevention of Surgical Site Infection published by the Centers for Disease Control and Prevention in 1999. The purpose of this study was to investigate the type of AMP that would be appropriate for spinal surgery and the manner in which it should be used. METHODS: The subjects were 1415 patients who underwent spinal surgery at our department from January 1990 to March 2008. The patients were classified into four groups according to the method of AMP administration: group 1, AMP was employed for 7 days, only postoperatively; group 2, initial AMP dosing was administered at the time of anesthesia induction, followed by administration of AMP for 5 days, including the day of the operation; group 3, initial AMP dosing was administered at the time of anesthesia induction, and AMP was administered for 3 days, including the day of the operation; group 4, the initial dosing was administered at the time of anesthesia induction, and AMP was administered for 2 days, including the day of the operation. The frequency of SSI was assessed in the four groups. RESULTS: The frequencies of SSI in groups 1-4 were 2.6% (14/539), 0.9% (5/536), 0% (0/257), and 0% (0/83), respectively. Thus, the frequency of SSI decreased as the duration of the AMP administration period decreased. CONCLUSIONS: As a result of thorough implementation of preventive measures against perioperative occurrence of infections, which included additional preoperative and intraoperative administration of AMP, the incidence of SSI could be decreased despite shortening the duration of AMP administration to 2 days.