Locomotive Syndrome: Operational Definition Based on a Questionnaire, and Exercise Interventions on Mobility Dysfunction in Elderly People.

The increasing elderly population has a great impact on public health, and it is important to understand the progression of musculoskeletal disorders seen in this population. To establish useful preventative methods for such locomotive disorders, we must detect early changes in these individuals and identify those at risk in order to implement early interventions. The purpose of this review was: (1) to introduce an operational definition of locomotion dysfunction to prevent a care-need condition, and to verify its validity through a prospective cohort study, and (2) to review the indication of exercise intervention for multiple musculoskeletal involvements from the preceding literature. We developed a measurement scale called the Geriatric Locomotive Function Scale (GLFS)-25, which clearly reflects the degree of functional deterioration. We used it in a prospective cohort study of 314 patients recruited from 5 clinics or nursing care facilities and investigated the relationship of the GLFS-25 with 46 variables covering various clinical manifestations. The results clearly revealed that the change in the GLFS-25 classification reflected a common pattern seen in those with locomotive dysfunction. Recently, several important movements regarding physical activity and its public promotion have been advocated by international health organizations and journal publishers. Though it has not been confirmed yet that complex musculoskeletal diseases can be treated using therapeutic exercise, the promotion of physical activity appears promising. The degree of activity limitation in aged individuals with locomotive disorders can be evaluated using this scale, which may be useful in predicting the effectiveness of future interventions.

Osteoarthritis development in novel experimental mouse models induced by knee joint instability.

OBJECTIVE: Although osteoarthritis (OA) is induced by accumulated mechanical stress to joints, little is known about the underlying molecular mechanism. To apply approaches from mouse genomics, this study created experimental mouse OA models by producing instability in the knee joints. METHODS: The models were of four types: severe, moderate, mild, and medial, depending on the severity and direction of instability imposed by combinations of ligament transection and menisectomy. OA development was evaluated by X-ray and histology by Safranin-O staining, and quantified using our original gradings. Expressions of type II, IX and X collagens and matrix metalloproteinase (MMP)-2, -3, -9 and -13 were further examined by immunohistochemistry and in situ hybridization (ISH). RESULTS: The severe, moderate and mild models exhibited OA development in the posterior tibial cartilage. The severe model showed cartilage destruction at 2 weeks and osteophyte formation at 4-8 weeks after surgery; however, the mild model showed only a partial cartilage destruction at 8 weeks. The grading confirmed that the OA disorders progressed depending on the severity of joint instability. In the medial model, the OA development in the medial tibial cartilage was similar to that in the posterior cartilage of the mild model. Among the collagens and MMPs, type X collagen and MMP-13 were markedly induced and colocalized in the early stage OA cartilage. CONCLUSION: We established four types of mouse models exhibiting various speeds of OA progression. By applying a mouse genomics approach to the models, molecular backgrounds in various stages of OA development can be clarified.

Image-guided surgery for cervical disorders in rheumatoid arthritis.

Abstract This study demonstrated that frameless stereotaxy can be applied safely to cervical disorders caused by rheumatoid arthritis (RA). Sixteen patients with cervical instability including atlantoaxial instability due to RA underwent instrumentation surgery under an image-guidance system from February 2000 through May 2001. Neural and vascular injuries were evaluated, and postoperative computed tomography (CT) was used to determine the accuracy of screw placement. There were no neurovascular complications, and screw placement was highly accurate. Image-guidance systems are useful tools for preoperative planning and application of transarticular and pedicular screw placement in the cervical spine of patients with RA.

Insulin secretory response is positively associated with the extent of ossification of the posterior longitudinal ligament of the spine.

BACKGROUND: Glucose intolerance is frequently found in patients with ossification of the posterior longitudinal ligament of the spine. This study was undertaken to examine the relationship between glucose intolerance and the extent of ossification in patients with ossification of the posterior longitudinal ligament. METHODS: A total of 100 patients with ossification of the posterior longitudinal ligament (the overall study group), including fifty-two inpatients who were scheduled to have an operation (the inpatient group) and forty-eight outpatients who had undergone an operation, were analyzed. Indices of glucose metabolism-fasting plasma glucose and serum insulin levels, hemoglobin A1c level, and insulinogenic index (a ratio of the increment of the serum level of insulin to that of glucose)-as well as age and body-mass index were correlated with the extent of ossification, as determined by the number of vertebral levels affected with ossification of the posterior longitudinal ligament (extent of ossification), in the inpatient group. In addition, a similar analysis was performed in twenty-eight inpatients (the selected inpatient group) whose ages and body-mass indices were within one standard deviation of the mean values of those of the inpatient group. Association of a polymorphism in the gene of insulin receptor substrate-1, an essential substrate in insulin signaling, with the extent of ossification was evaluated with genomic DNA extracted from the overall study group. RESULTS: Multiple-regression analysis revealed direct correlations of age (p = 0.038), body-mass index (p = 0.006), and insulinogenic index (p = 0.0003) with the extent of ossification of the posterior longitudinal ligament in the inpatient group. The fasting plasma glucose level, the hemoglobin A1c level, and the stage of glucose tolerance were not associated with the extent of ossification. In the analysis of the selected inpatient group, only the insulinogenic index was correlated with the extent of ossification (p = 0.002). However, no significant association was seen between the insulin receptor substrate-1 polymorphism and the extent of ossification. CONCLUSIONS: The insulin secretory response was associated with the extent of ossification of the posterior longitudinal ligament. Since insulin receptor substrate-1 is expressed both in the spinal ligament and in the tissues regulating glucose metabolism, we speculate that some other molecules related to insulin signaling that are impaired only in the tissues regulating glucose metabolism may be responsible for the progression of ossification. We also speculate that the upregulation of insulin production due to the impairment of insulin action may stimulate osteoprogenitor cells in the ligament to induce ossification. CLINICAL RELEVANCE: The insulinogenic index may be useful as a serum marker for the prediction of progression of ossification of the posterior longitudinal ligament. This study may serve as a stimulus for evaluation of the use of various drugs that may improve the response to insulin in the tissues regulating glucose metabolism to prevent the progression of ossification.

A new bisphosphonate treatment option for giant cell tumors.

Treatment of giant cell tumors (GCT) especially in the vertebrae remains controversial. With multidisciplinary treatments, their results are still insufficient. Moreover, GCT shows the potential for malignant transformation and metastasis, additional options such as adjuvant medication must be considered. We report favorable results in three consecutive cases diagnosed with GCT of the spine which were treated with radiotherapy and bisphosphonate (BP) as a new treatment option, and present a review of the literature and a comparison with these case reports.

Long-term results of double-door laminoplasty for cervical stenotic myelopathy.

STUDY DESIGN: A retrospective study of the long-term results from double-door laminoplasty (Kurokawa's method) for patients with myelopathy caused by ossification of the posterior longitudinal ligament and cervical spondylosis was performed. OBJECTIVE: To know whether the short-term results from double-door laminoplasty were maintained over a 10-year period and, if not, the cause of late deterioration. SUMMARY OF BACKGROUND DATA: There are few long-term follow-up studies on the outcome of laminoplasty for cervical stenotic myelopathy. METHODS: In this study, 35 patients with cervical myelopathy caused by ossification of the posterior longitudinal ligament in the cervical spine and 25 patients with cervical spondylotic myelopathy, including 5 patients with athetoid cerebral palsy, underwent double-door laminoplasty from 1980 through 1988 and were followed over the next 10 years. The average follow-up period was 153 months (range, 120-200 months) in patients with ossification of the posterior longitudinal ligament and 156 months (range, 121-218 months) in patients with cervical spondylotic myelopathy. Neurologic deficits before and after surgery were assessed using a scoring system proposed by the Japanese Orthopedic Association (JOA score). Patients who showed late deterioration received further examination including computed tomography scan and magnetic resonance imaging of the cervical spine. RESULTS: In 32 of the patients with ossification of the posterior longitudinal ligament and 23 of the patients with cervical spondylotic myelopathy, myelopathy improved after surgery. The improvement of Japanese Orthopedic Association scores was maintained up to the final follow-up assessment in 26 of the patients with ossification of the posterior longitudinal ligament and 21 of the patients with cervical spondylotic myelopathy. Late neurologic deterioration occurred in 10 of the patients with ossification of the posterior longitudinal ligament an average of 8 years after surgery, and in 4 of the patients with cervical spondylotic myelopathy, including the 3 patients with athetoid cerebral palsy, an average of 11 years after surgery. The main causes of deterioration in patients with ossification of the posterior longitudinal ligament were a minor trauma in patients with residual cervical cord compression caused by ossification of the posterior longitudinal ligament and thoracic myelopathy resulting from ossification of the yellow ligament in the thoracic spine. CONCLUSIONS: The short-term results of laminoplasty for cervical stenotic myelopathy were maintained over 10years in 78% of the patients with ossification of the posterior longitudinal ligament, and in most of the patients with cervical spondylotic myelopathy, except those with athetoid cerebral palsy. Double-door laminoplasty is a reliable procedure for individuals with cervical stenotic myelopathy.

Partial functional recovery of paraplegic rat by adenovirus-mediated gene delivery of constitutively active MEK1.

Spinal cord injury in adult mammals results in little axonal regeneration, although the mechanism of regeneration failure still remains elusive. Recent research has revealed that activation of the extracellular-signal-regulated kinases (ERKs) plays an important role in the neurite outgrowth. In the present study, we constructed a replication-defective adenovirus vector carrying mutated form of MEK1 (CA-MEK virus), which constitutively activate ERK pathway, and investigated its effect on thoracic spinal cord injury model in young adult rats as well as neurite outgrowth in vitro. In rat pheocromocytoma cell line PC12 cells, CA-MEK virus infection induced sustained activation of ERKs and stimulated neurite outgrowth in the absence of neurotrophic factors. In rat spinal cord transection model, injection of CA-MEK virus into the completely transected spinal cord efficiently activated ERKs in the supraspinal neurons and induced axonal regeneration across the transection site, which was confirmed by anterograde labeling with wheat-germ-agglutinin conjugated peroxidase (WGA-HRP). Spinal cord evoked potentials (SCEP) showed that these regenerated axons were electroconductive. Most importantly, CA-MEK virus-treated rats showed significant recovery of hind limb function 2 weeks after operation compared to the control rats treated with no virus or LacZ virus. These results suggest that adenovirus-mediated CA-MEK gene transduction offers a novel strategy for the gene therapy of spinal cord injury.

Comparison of spinal cord evoked potentials and peripheral nerve evoked potentials by electric stimulation of the spinal cord under acute spinal cord compression in cats.

STUDY DESIGN: Spinal cord evoked potentials and peripheral nerve evoked potentials after spinal cord stimulation were recorded under acute spinal cord compression in 19 cats. OBJECTIVES: To investigate the effects of acute compression upon grey matter and white matter by comparing both potentials. METHODS: We compared peripheral nerve evoked potentials, recorded at the biceps brachii branch of the musculocutaneous nerve, with descending spinal cord evoked potentials, recorded from the lumbar spinal cord, by stimulation to the C2 level, under compression of the C6 segment. RESULTS: The amplitude of both potentials decreased with increased compression. The second wave of peripheral nerve evoked potentials, which are motor fibre action potentials, decreased sooner than those of the spinal cord evoked potentials. CONCLUSION: These findings indicate that peripheral nerve evoked potentials are sensitive to acute damage of the segmented compression. This suggests that grey matter is more vulnerable to compression than white matter.

Psoas abscess complicating Crohn's disease: report of a case.

We describe herein the case of a psoas abscess complicating Crohn's disease, and present a review of the literature on this unusual disease entity. A 22-year-old Japanese man with a 5-year history of Crohn's ileocolitis presented with right lower abdominal and hip pain, and a diagnosis of right psoas abscess was subsequently made by abdominal computed tomography (CT). Following the administration of antibiotics and CT-guided percutaneous drainage of the abscess, the patient's symptoms temporarily improved; however, 2 weeks later, the abscess cavity was found to have extended around the periarticular tissue of the right hip joint. To prevent the development of septic arthritis of the hip joint, surgical drainage of the abscess cavity and ileocecal resection were immediately performed, after which the patient's condition greatly improved. The resected specimen showed Crohn's ileocolitis with an external fistula in the terminal ileum which was considered to have caused the psoas abscess. Since psoas abscess in Crohn's disease can result in serious complications such as septic arthritis of the hip joint if left untreated, aggressive treatment should be initiated without delay.

Intraoperative radiation therapy for metastatic spinal tumors.

STUDY DESIGN: Retrospective examination of 37 patients with metastatic spinal tumors treated with intraoperative radiation therapy. OBJECTIVE: To propose a new technique for local control of metastatic spinal tumors. SUMMARY OF BACKGROUND DATA: No reports of intraoperative radiation therapy for metastatic spinal tumors have been published as of the time of this writing. METHODS: Between December 1992 and April 1996, intraoperative radiation therapy was performed in 37 patients with spinal metastasis. In all but one patient, the spinal cord was protected during intraoperative radiation therapy by a lead shield to prevent radiation myelopathy. In addition to intraoperative radiation therapy, 22 of the 37 patients received external radiation therapy, either before or after their operation. Although the authors had recommended a dose of approximately 30 Gy of external radiation therapy after wound suture removal to patients who did not receive preoperative radiation therapy, the remaining 15 patients did not receive external radiation therapy, either by choice or because they received alternative therapy. Adjuvant chemotherapy for various cancers was administered to 9 of the 37 patients, including 4 of the aforementioned 15. RESULTS: All patients attained clinical improvement in pain, neurologic function status, or both, with no evidence of local recurrence. Radiation myelopathy developed in the one patient whose spinal cord was not protected during intraoperative radiation therapy. Eleven patients experienced metastasis in vertebrae that were not surgically treated. CONCLUSION: Intraoperative radiation therapy appears to achieve good palliation and may be useful for local control of spinal metastases.

A report on the safety of unilateral vertebral artery ligation during cervical spine surgery.

STUDY DESIGN: This study retrospectively analyzed the outcome of unilateral vertebral artery ligation during cervical spine surgery. OBJECTIVES: To examine the influence of unilateral vertebral artery ligation on the function of brain and spinal cord. SUMMARY OF BACKGROUND DATA: There was little published information about the outcome of a vertebral artery ligation except for several reports from the field of neurosurgery. METHODS: Unilateral vertebral artery ligation was used in 15 patients with cervical tumors of the spine or the spinal cord (age range, 13-71 years; nine male patients and six female). The authors ligated the involved vertebral artery only when the tumor appeared on the minor or equal diameter artery side measured by pre-operative angiogram. The patient's condition was examined regarding signs of dysfunction of the brain stem, the cerebellum, or the spinal cord. RESULTS: Preoperative angiogram showed that the involved vertebral artery had a smaller diameter in four patients and had an equal diameter in 11 patients compared with the one not involved. The involved vertebral artery was severed at single site in four patients and was resected between two distant sites of ligation in 11 patients. Examination after surgery of the patient's condition (follow-up periods ranged from 10 months to 7 years) revealed that unilateral vertebral artery ligation did not provoke any symptoms of damage resulting from ischemia of the brain stem, the cerebellum, or the spinal cord. CONCLUSION: A vertebral artery could be ligated uneventfully when the diameter of the vertebral artery was not larger than the one not involved. Where vertebral artery ligation could not be avoided, it should be confirmed by preoperative angiogram that the other vertebral artery is large enough and that simultaneous occlusion testing of the involved vertebral artery is uneventful.

Cervical spinal cord atrophy associated with spina bifida.

We treated three patients with spina bifida who had atrophy of the cervical spinal cord. One patient presented with a gradually progressive paresis of the upper right extremity, and two patients developed tetraparesis. MRI (magnetic resonance imaging) of the cervical spine demonstrated cord atrophy with enlargement of the subarachnoid space. The three patients were treated by releasing the tethered spinal cord in the lumbosacral area. Two of the three patients had neurological recovery soon after the operation, but this was transient and was followed by later deterioration; and the third patient showed no recovery. The transient recovery suggests that the tethering in the lumbosacral region affects the entire spinal cord and causes atrophy of the cervical spinal cord.

The role of calcium metabolism abnormalities in the development of ossification of the posterior longitudinal ligament of the cervical spine.

To study the role of calcium metabolism in the development of ossification of the posterior longitudinal ligament of the cervical spine, 39 patients with affected cervical spines were investigated using an oral calcium tolerance test and followed by cervical spinal radiography to evaluate disease progression. The average follow-up was 6 years. The patients were divided into two groups according to their responsiveness to an oral calcium load: a group of 14 patients with decreased calciuric responses and another group of 25 with normal responses. The incidence of the development of cervical ossification of the posterior longitudinal ligament in the decreased-response group was significantly higher than that in the normal group. Because these patients were managed operatively by laminoplasty, however, the incidence was low irrespective of their calciuric responses. These results suggest that the development of cervical ossification of the posterior longitudinal ligament is associated with decreased intestinal calcium absorption but that treatment with laminoplasty alters the mechanical environment of the cervical spine (eg, range of motion of the cervical spine is limited). The development of cervical ossification of the posterior longitudinal ligament may be controlled by this procedure.

Laminopediculoplasty: a new method of reconstructing the posterior elements of the thoracic spine.

We describe a new method of reconstructing the posterior elements of the thoracic spine following decompression of the cord through a wide posterior approach. Osteoperiosteal corticocancellous grafts are harvested from the iliac wing, then bent into a semicircle with the periosteum on the inside and inserted between the resected vertebral pedicles where they act as a base for further grafting. The posterior spinoligamentous complex is preserved and reattached. This technique permits circumferential decompression of the thoracic cord through a posterior approach and posterior thoracic interbody fusion. Fifteen patients were treated by this method and a solid fusion achieved in each case. No bony ingrowth into the spinal canal was observed.