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A 45-year-old male patient diagnosed as stage IVa pancreatic cancer received anti-cancer treatment with chemotherapy and radiotherapy. During the treatment, he complained of nausea, appetite loss, and fatigue. He received a Kampo diagnosis of qi deficiency, blood stasis, and heat with phlegm; consequently, qi supplementation, smoothing blood, and relieving fever were initiated using Juzentaihoto and Keppuchikuoto. After this treatment, the symptoms showed remarkable improvement. However, computed tomography revealed multiple lung nodules. We prescribed crude drugs with anti-cancer effects, including Scutellaria barbata and Oldenlandia diffusa. These drugs led to slowed development of lung metastases that could be surgically resected. He survived for 7 years after the advanced diagnosis without loss of quality of life. Kampo medicine may be useful for disease control and supportive care in advanced pancreatic cancer patients.

Introduction: Osteoporotic vertebral fracture (OVF) is the most common osteoporotic fracture, and some patients require surgical intervention to improve their impaired activities of daily living with neurological deficits. However, many previous reports have focused on OVF around the thoracolumbar junction, and the surgical outcomes of lumbar OVF have not been thoroughly discussed. We aimed to investigate the surgical outcomes for lumbar OVF with a neurological deficit. Methods: Patients who underwent fusion surgery for thoracolumbar OVF with a neurological deficit were enrolled at 28 institutions. Clinical information, comorbidities, perioperative complications, Japanese Orthopaedic Association scores, visual analog scale scores, and radiographic parameters were compared between patients with lower lumbar fracture (L3-5) and those with thoracolumbar junction fracture (T10-L2). Each patient with lower lumbar fracture (L group) was matched with to patients with thoracolumbar junction fracture (T group). Results: A total 403 patients (89 males and 314 females, mean age: 73.8 ± 7.8 years, mean follow-up: 3.9 ± 1.7 years) were included in this study. Lower lumbar OVF was frequently found in patients with lower bone mineral density. After matching, mechanical failure was more frequent in the L group (L group: 64%, T group: 39%; p < 0.001). There was no difference between groups in the clinical and radiographical outcomes, although the rates of complication and revision surgery were still high in both groups. Conclusions: The surgical intervention for OVF is effective in patients with myelopathy or radiculopathy regardless of the surgical level, although further study is required to improve clinical and radiographical outcomes. Level of evidence: Level III

Aims: The present report aims to investigate the use of Kampo medicine for advanced pancreatic cancer patients in order to prolong survival.Methods: We retrospectively reviewed medical records of patients with pancreatic cancer who presented to our Shimizu Clinic from 2000 to 2020. Patients who survived at least twice as long as the initial prognostic estimate were selected and their treatment was reviewed. The Kampo formula and crude drugs were selected according to the Kampo diagnosis and treatment strategy, which included qi and blood supplementation; qi, blood and water smoothing; and inflammation (termed “heat”) and cancer suppression.Results: Ten patients aged 45–80 years (six males and four females) with stage IV advanced cancer were selected. All patients received hozai, which is a tonic formula, of juzentaihoto (JTT) or hochuekkito (HET) decoction. Anti-cancer crude drugs were included in the decoctions of nine patients. At the first visit, the estimated life expectancy for all patients was no more than 1 year; however, treatment with Western and Kampo medicine led to a relatively long survival period of over 2 years. Three patients were still living at the time of this writing, more than 2, 6, and 14 years after treatment initiation.Conclusion: Our results suggest that Kampo medicine may be useful for disease control and supportive care for patients with advanced pancreatic cancer.

Introduction: Approximately 3% of osteoporotic vertebral fractures develop osteoporotic vertebral collapse (OVC) with neurological deficits, and such patients are recommended to be treated surgically. However, a proximal junctional fracture (PJFr) following surgery for OVC can be a serious concern. Therefore, the aim of this study is to identify the incidence and risk factors of PJFr following fusion surgery for OVC. Methods: This study retrospectively analyzed registry data collected from facilities belonging to the Japan Association of Spine Surgeons with Ambition (JASA) in 2016. We retrospectively analyzed 403 patients who suffered neurological deficits due to OVC below T10 and underwent corrective surgery; only those followed up for ≥2 years were included. Potential risk factors related to the PJFr and their cut-off values were calculated using multivariate logistic regression analysis and receiver operating characteristic (ROC) analysis. Results: Sixty-three patients (15.6%) suffered PJFr during the follow-up (mean 45.7 months). In multivariate analysis, the grade of osteoporosis (grade 2, 3: adjusted odds ratio (aOR) 2.92; p=0.001) and lower instrumented vertebra (LIV) level (sacrum: aOR 6.75; p=0.003) were independent factors. ROC analysis demonstrated that lumbar bone mineral density (BMD) was a predictive factor (area under curve: 0.72, p=0.035) with optimal cut-off value of 0.61 g/cm(2) (sensitivity, 76.5%; specificity, 58.3%), but that of the hip was not (p=0.228). Conclusions: PJFr was found in 16% cases within 4 years after surgery; independent risk factors were severe osteoporosis and extended fusion to the sacrum. The lumbar BMD with cut-off value 0.61 g/cm(2) may potentially predict PJFr. Our findings can help surgeons select perioperative adjuvant therapy, as well as a surgical strategy to prevent PJFr following surgery.

STUDY DESIGN Retrospective cohort study. OBJECTIVE To clarify the poor patient satisfaction after lumbar spinal surgery in elderly patients. SUMMARY OF BACKGROUND DATA As the global population continues to age, it is important to consider the surgical outcome and patient satisfaction in the elderly. No studies have assessed patient satisfaction in elderly patients undergoing surgical treatment and risk factors for poor satisfaction in elderly patients after lumbar spinal surgery. MATERIALS AND METHODS A retrospective multicenter survey was performed in 169 patients aged above 80 years who underwent lumbar spinal surgery. Patients were followed up for at least 1 year after surgery. We assessed patient satisfaction from the results of surgery by using a newly developed patient questionnaire. Patients were assessed by demographic data, surgical procedures, complications, reoperation rate, pain improvement, and risk factors for poor patient satisfaction with surgery for lumbar spinal disease. RESULTS In total, 131 patients (77.5%, G-group) were satisfied and 38 patients (22.5%, P-group) were dissatisfied with surgery. The 2 groups did not differ significantly in baseline characteristics and surgical data. Postoperative visual analog scale score for low back pain and leg pain were significantly higher in the P-group than in the G-group (low back pain: G-group, 1.7±1.9 vs. P-group, 5.2±2.5, P

Case series Patients: Male, 72-year-old • Male, 70-year-old Final Diagnosis: Acute respiratory distress syndrome (ARDS) • COVID-19 • COVID-19 pneumonia Symptoms: Cough • fever • malaise • nausea • respiratory distress • vomiting Medication: — Clinical Procedure: — Specialty: Critical Care Medicine • Infectious Diseases • Radiology Objective: Rare disease Background: Patients with coronavirus disease 2019 (COVID-19) caused by the severe acute respiratory syndrome corona-virus 2 can rapidly progress to acute respiratory distress syndrome (ARDS). Because clinical diagnosis of ARDS includes several diseases, understanding the characteristics of COVID-19-related ARDS is necessary for precise treatment. We report 2 patients with ARDS due to COVID-19-associated pneumonia. Case Report: Case 1 involved a 72-year-old Japanese man who presented with respiratory distress and fever. Computed tomography (CT) revealed subpleural ground-glass opacities (GGOs) and consolidation. Six days after symptom onset, reverse transcription-polymerase chain reaction (RT-PCR) testing confirmed the diagnosis of COVID-19-associated pneumonia. He was intubated and received veno-venous extracorporeal membrane oxygenation (ECMO) 8 days after symptom onset. Follow-up CT revealed large diffuse areas with a crazy-paving pattern and consolidation, which indicated progression of COVID-19-associated pneumonia. Following treatment with antiviral medications and supportive measures, the patient was weaned off ECMO after 20 days. Case 2 involved a 70-year-old Asian man residing in Canada who presented with cough, malaise, nausea, vomiting, and fever. COVID-19-associated pneumonia was diagnosed based on a positive result from RT-PCR testing. The patient was then transferred to the intensive care unit and intubated 8 days after symptom onset. Follow-up CT showed that while the initial subpleural GGOs had improved, diffuse GGOs appeared, similar to those observed upon diffuse alveolar damage. He was administered systemic steroid therapy for ARDS and extubated after 6 days. Conclusions: Because the pattern of symptom exacerbation in COVID-19-associated pneumonia cases seems inconsistent, individual treatment management, especially the CT-based treatment strategy, is crucial.

Background Vertebroplasty with posterior spinal fusion (VP + PSF) is one of the most widely accepted surgical techniques for treating osteoporotic vertebral collapse (OVC). Nevertheless, the effect of the extent of fusion on surgical outcomes remains to be established. This study aimed to evaluate the surgical outcomes of short- versus long-segment VP + PSF for OVC with neurological impairment in thoracolumbar spine. Methods We retrospectively collected data from 133 patients (median age, 77 years; 42 men and 91 women) from 27 university hospitals and their affiliated hospitals. We divided patients into two groups: a short-segment fusion group (S group) with 2- or 3-segment fusion (87 patients) and a long-segment fusion group (L group) with 4- through 6-segment fusion (46 patients). Surgical invasion, clinical outcomes, local kyphosis angle (LKA), and complications were evaluated. Results No significant differences between the two groups were observed in terms of neurological recovery, pain scale scores, and complications. Surgical time was shorter and blood loss was less in the S group, whereas LKA at the final follow-up and correction loss were superior in the L group. Conclusion Although less invasiveness and validity of pain and neurological relief are secured by short-segment VP + PSF, surgeons should be cautious regarding correction loss.

Background The optimal treatment of osteoporosis after reconstruction surgery for osteoporotic vertebral fractures (OVF) remains unclear. In this multicentre retrospective study, we investigated the effects of typically used agents for osteoporosis, namely, bisphosphonates (BP) and teriparatide (TP), on surgical results in patients with osteoporotic vertebral fractures. Methods Retrospectively registered data were collected from 27 universities and affiliated hospitals in Japan. We compared the effects of BP vs TP on postoperative mechanical complication rates, implant-related reoperation rates, and clinical outcomes in patients who underwent posterior instrumented fusion for OVF. Data were analysed according to whether the osteoporosis was primary or glucocorticoid-induced. Results A total of 159 patients who underwent posterior instrumented fusion for OVF were included. The overall mechanical complication rate was significantly lower in the TP group than in the BP group (BP vs TP: 73.1% vs 58.2%, p = 0.045). The screw backout rate was significantly lower and the rates of new vertebral fractures and pseudoarthrosis tended to be lower in the TP group than in the BP group. However, there were no significant differences in lumbar functional scores and visual analogue scale pain scores or in implant-related reoperation rates between the two groups. The incidence of pseudoarthrosis was significantly higher in patients with glucocorticoid-induced osteoporosis (GIOP) than in those with primary osteoporosis; however, the pseudoarthrosis rate was reduced by using TP. The use of TP also tended to reduce the overall mechanical complication rate in both primary osteoporosis and GIOP. Conclusions The overall mechanical complication rate was lower in patients who received TP than in those who received a BP postoperatively, regardless of type of osteoporosis. The incidence of pseudoarthrosis was significantly higher in patients with GIOP, but the use of TP reduced the rate of pseudoarthrosis in GIOP patients. The use of TP was effective to reduce postoperative complications for OVF patients treated with posterior fusion.

It is generally recognized that the main thoracic curve Cobb angle threshold for surgical correction is approximately 50 degrees in patients with adolescent idiopathic scoliosis (AIS). Although AIS with a Cobb angle of50 degrees is sometimes treated surgically to improve cosmesis, the precise outcomes are unclear. This study analyzed the postoperative results for AIS with a main thoracic curve of 50 degrees.Thirty-nine consecutive patients with Lenke type 1-2 curves underwent posterior spinal fusion for AIS. These subjects were divided into the50 degrees of main thoracic curve group (n = 14) and the ≥50 degrees group (n = 25). Clinical and radiographic data were compared.The mean Cobb angle of the main thoracic curve before and at 2 years after surgery for the50 degrees and ≥50 degrees groups was 44.5 and 60.3 degrees (p 0.001) and 14.0 and 19.5 degrees (p = 0.016), respectively. Preoperatively, both groups had comparable Scoliosis Research Society-22 (SRS-22) scores (all p 0.05). Patients with a Cobb angle of50 degrees displayed significantly milder postoperative pain (4.7 vs. 4.3, p = 0.031), with no remarkable differences in other SRS-22 domain scores. These patients also had a significantly shorter operative time (194 vs. 235 min, p = 0.021) and fused level (9.2 vs. 10.8 vertebrae, p = 0.006) along with similar correction rate (68.1 vs. 65.8%, p = 0.622) and blood loss volume (932 vs. 1009 ml, p = 0.715).Surgical correction of AIS with50 degrees of main thoracic curve may less invasively achieve results that are comparable with those for AIS with 50 degrees or more, including improvements in self-image.

Study design A retrospective chart review. Objective The aim of this study was to investigate the incidence and characteristics of screw loosening in surgically treated adolescent idiopathic scoliosis (AIS) patients. Summary of background data Pedicle screws are widely used in posterior spinal fusion for AIS, although postoperative loosening can occur. However, few reports exist on screw loosening after pedicle screw fixation in young scoliosis patients and the etiology of loosening is not well known. Methods One hundred twenty AIS patients (9 males, 111 females; mean age: 15.0 years) who had received pedicle screw fixation were retrospectively reviewed. All patients underwent routine computed tomography (CT) reconstruction scans at 6 months postoperatively to assess screw position, bony fusion, and the presence of screw loosening. The perforation status of each pedicle screw was assigned a grade of 0 to 3 using Rao classification. Results Forty-three of 1624 (2.6%) screws showed evidence of loosening on CT. Screw loosening rates according to vertebral insertion level were upper instrumented vertebra (UIV): 9.6%; lower instrumented vertebra (LIV): 5.4%; one vertebra below the UIV: 1.8%; one vertebra above the LIV: 0.5%; two vertebrae below the UIV: 1.2%; and three vertebrae below the UIV: 0.9%. Screw loosening rates based on screw perforation grade were Grade 0: 1.4%; Grade 1: 3.1%; Grade 2: 15.5%; and Grade 3: 15.2%. Multivariate analysis revealed a distance from the UIV or LIV of one vertebra as well as the presence of major perforation to be independent factors affecting screw loosening. The odds ratios (ORs) of UIV/LIV insertion and major perforation were 73.4 and 17.2, respectively. When major perforations occurred in the UIV or LIV, the OR for loosening approached 1262. Conclusion Pedicle screw loosening after posterior spinal fusion in AIS patients tend to occur in the UIV or LIV. Major screw perforation is also significantly associated with screw loosening. The risk of loosening becomes compounded when major perforations are present in the UIV or LIV. Level of evidence 4.

Introduction: With an aging population, the proportion of patients aged 80 years requiring cervical surgery is increasing. Surgeons are concerned with the high incidence of complications in this population, because “age” itself has been reported as a strong risk factor for complications. However, it is still unknown which factors represent higher risk among these elderly patients. Therefore, this study was conducted to identify the risk factors related to surgical complications specific to elderly patients by analyzing the registry data of patients aged 80 years who underwent cervical surgery. Methods: We retrospectively studied multicenter collected registry data using multivariate analysis. Sixty-six patients aged 80 years who underwent cervical surgery and were followed up for more than one year were included in this study. Preoperative patient demographic data, including comorbidities and postoperative complications, were collected from multicenter registry data. Complications were considered as major if they required invasive intervention, caused prolonged morbidity, or resulted in prolongation of hospital stay. Logistic regression analysis was performed to analyze the risk factors for complications. A p-value of

A retrospective single-center and single-surgeon study.This study investigated the clinical and radiological results of skip pedicle screw fixation for adolescent idiopathic scoliosis (AIS).At present, the generally used technique for pedicle screw fixation for the surgical correction of AIS entails inserting a pedicle screw into every segment on the corrective side and into every or every other segment on the supportive side. To reduce operation time, blood loss, and cost, we developed skip pedicle screw fixation to achieve correction of AIS using fewer pedicle screws.We evaluated 62 consecutive patients who had undergone computer-assisted skip pedicle screw fixation from August 2005 to June 2014. All patients were followed up for at least two years. We investigated the clinical results of skip pedicle screw fixation for AIS.The mean number of fused vertebrae was 10.3 ± 2.0, the mean surgical time was 242 ± 78 min, and the mean blood loss volume was 1060 ± 688 ml. The mean Cobb angle of main thoracic (MT) curve two years after surgery improved significantly compared with that before surgery (p 0.01). The mean correction rate of MT curve immediately after surgery was 62.4 ± 12.4% and correction loss of MT curve at two years after surgery was 1.9 ± 5.8°. The SRS-22 subtotal score two years after surgery improved significantly compared to that before surgery (p 0.01). Although no patients experienced major complications, eight (12.9%) encountered minor complications (two [3.2%] had massive blood loss [3000 ml], three [4.8%] had a broken screw, one [1.6%] had a set-screw that dropped out, one [1.6%] experienced deep vein thrombosis, one [1.6%] experienced acute renal failure, and one [1.6%] experienced intercostal neuralgia). Revision surgery was not performed.Subjects with AIS who underwent skip pedicle screw fixation had significantly improved clinical and radiological parameters at two years after surgery, indicating that skip pedicle screw fixation could be used to successfully treat AIS.Level 4.

There have been few reports on the incidence and risk factors of the complications after spinal fixation surgery for osteoporotic vertebral collapse (OVC) with neurological deficits. This study aimed to identify the incidence and risk factors of the complications after OVC surgery.In this retrospective multicenter study, a total of 403 patients (314 women and 89 men; mean age 73.8 years) who underwent spinal fixation surgery for OVC with neurological deficits between 2005 and 2014 were enrolled. Data on patient demographics were collected, including age, sex, body mass index, smoking, steroid use, medical comorbidities, and surgical procedures. All postoperative complications that occurred within 6 weeks were recorded. Patients were classified into two groups, namely, complication group and no complication group, and risk factors for postoperative complications were investigated by univariate and multivariate analyses.Postoperative complications occurred in 57 patients (14.1%), and the most common complication was delirium (5.7%). In the univariate analysis, the complication group was found to be older (p = 0.039) and predominantly male (p = 0.049), with higher occurrence rate of liver disease (p = 0.001) and Parkinson's disease (p = 0.039) compared with the no-complication group. In the multivariate analysis, the significant independent risk factors were age (p = 0.021; odds ratio [OR] 1.051, 95% confidence interval [CI] 1.007-1.097), liver disease (p 0.001; OR 8.993, 95% CI 2.882-28.065), and Parkinson's disease (p = 0.009; OR 3.636, 95% CI 1.378-9.599).Complications after spinal fixation surgery for OVC with neurological deficits occurred in 14.1%. Age, liver disease, and Parkinson's disease were demonstrated to be independent risk factors for postoperative complications.

Background To date, there have been little published data on surgical outcomes for patients with PD with thoracolumbar OVF. We conducted a retrospective multicenter study of registry data to investigate the outcomes of fusion surgery for patients with Parkinson’s disease (PD) with osteoporotic vertebral fracture (OVF) in the thoracolumbar junction. Methods Retrospectively registered data were collected from 27 universities and their affiliated hospitals in Japan. In total, 26 patients with PD (mean age, 76 years; 3 men and 23 women) with thoracolumbar OVF who underwent spinal fusion with a minimum of 2 years of follow-up were included (PD group). Surgical invasion, perioperative complications, radiographic sagittal alignment, mechanical failure (MF) related to instrumentation, and clinical outcomes were evaluated. A control group of 296 non-PD patients (non-PD group) matched for age, sex, distribution of surgical procedures, number of fused segments, and follow-up period were used for comparison. Results The PD group showed higher rates of perioperative complications (p

Study Design Multicenter analysis of two groups of patients surgically treated for degenerative L4 unstable spondylolisthesis. Purpose To compare the clinical and radiographic outcomes of posterolateral fusion (PLF) and posterior lumbar interbody fusion (PLIF) for degenerative L4 unstable spondylolisthesis. Overview of Literature Surgery for lumbar degenerative spondylolisthesis is widely performed. However, few reports have compared the outcome of PLF to that of PLIF for degenerative L4 unstable spondylolisthesis. Methods Patients with L4 unstable spondylolisthesis with Meyerding grade II or more, slip of >10° or >4 mm upon maximum flexion and extension bending, and posterior opening of >5 degree upon flexion bending were studied. Patients were treated from January 2008 to January 2010. Patients who underwent PLF (n=12) and PLIF (n=19) were followed-up for >2 years. Radiographic findings and clinical outcomes evaluated by the Japanese Orthopaedic Association (JOA) score were compared between the two groups. Radiographic evaluation included slip angle, translation, slip angle and translation during maximum flexion and extension bending, intervertebral disc height, lumbar lordotic angle, and fusion rate. Results JOA scores of the PLF group before surgery and at final follow-up were 12.3±4.8 and 24.1±3.7, respectively; those of the PLIF group were 14.7±4.8 and 24.2±7.8, respectively, with no significant difference between the two groups. Correction of slip estimated from postoperative slip angle, translation, and maintenance of intervertebral disc height in the PLIF group was significantly (p

Case report.We report here on an 18-month-old boy with brachytelephalangic chondrodysplasia punctata (BCDP), whose atlantoaxial instability was successfully managed with occipitocervical instrumented fusion (OCF) using screw and rod instrumentations.Recently, there have been a number of reports on BCDP with early onset of cervical myelopathy. Surgical OCF is a vital intervention to salvage affected individuals from the life-threatening morbidity. Despite recent advancement of instrumentation techniques, however, rigid OCF is technically demanding in very young children with small and fragile osseous elements. To our best knowledge, this is the first report on application of the instrumentation technique to a toddler patient with BCDP.A 16-month-old boy with BCDP presented with tetraplegia and swallow obstacle. Hypoplasia of the odontoid process and atlantoaxial instability were present in lateral radiographs. T2-weighted magnetic resonance (MR) images revealed a high signal region in the spinal cord at the C1-2 and C7-T1 levels. Cervical computed tomography (CT) showed that the pedicles and lateral masses in the cervical spine were small and immature, but the laminae were comparatively thick.One week before surgery, the patient was fitted with a Halo-body jacket. We performed plate-rod placement with occipital cortical screws and C2/C3 interlaminar screws, and added an autogenous bone graft using the right 8 and 9 ribs. Rigid fixation of the occipito-cervical spine was completed successfully without major complications. Postoperative halo-body jacket immobilization was continued for 3 months, after which Aspen collar was fitted. CT confirmed occipitocervical bone fusion at 6 months after surgery. Mild clinical improvements in motor power of the affected muscles and swallowing were witnessed at 1 year postoperatively.Rigid fixation using screw, rod, and occipital plate instrumentation was successful in an 18-month-old toddler with BCDP and atlantoaxial instability. Bone fusion was achieved at postoperative 6 months.5.

Study design A retrospective study. Purpose The present study aimed to evaluate mid-term results of cervical pedicle screw (CPS) fixation for cervical instability. Overview of literature CPS fixation has widely used in the treatment of cervical spinal instability from various causes; however, there are few reports on mid-term surgical results of CPS fixation. Methods Record of 19 patients who underwent cervical and/or upper thoracic (C2-T1) pedicle screw fixation for cervical instability was reviewed. The mean observation period was 90.2 months. Evaluated items included Japanese Orthopaedic Association (JOA) score and C2-7 lordotic angle before surgery and at 5 years after surgery. Postoperative computerized tomography was used to determine the accuracy of screw placement. Visual analog scale (VAS) for neck pain and radiological evidence of adjacent segment degeneration (ASD) at the 5-year follow-up were also evaluated. Results Mean JOA score was significantly improved from 9.0 points before surgery to 12.8 at 5 years after surgery (p=0.001). The C2-7 lordotic angle of the neutral position improved from 6.4° to 7.8° at 5 years after surgery, but this was not significant. The major perforation rate was 5.0%. There were no clinically significant complications such as vertebral artery injury, spinal cord injury, or nerve root injury caused by any screw perforation. Mean VAS for neck pain was 49.4 at 5 years after surgery. The rate of ASD was 21.1%. Conclusions Our mid-term results showed that CPS fixation was useful for treating cervical instability. Severe complications were prevented with the assistance of a computed tomography-based navigation system.

Study design Seventy-five patients who had been treated for lumbar spinal stenosis (LSS) were reviewed retrospectively. Purpose Invasion into the paravertebral muscle can cause major problems after laminectomy for LSS. To address these problems, we performed spinous process-splitting laminectomy. We present a comparative study of decompression of LSS using 2 approaches. Overview of literature There are no other study has investigated the lumbar spinal instability after spinous process-splitting laminectomy. Methods This study included 75 patients who underwent laminectomy for the treatment of LSS and who were observed through follow-ups for more than 2 years. Fifty-five patients underwent spinous process-splitting laminectomy (splitting group) and 20 patients underwent conventional laminectomy (conventional group). We evaluated the clinical and radiographic results of each surgical procedure. Results Japanese Orthopaedic Association score improved significantly in both groups two years postoperatively. The following values were all significantly lower, as shown with p-values, in the splitting group compared to the conventional group: average operating time (p=0.002), postoperative C-reactive protein level (p=0.006), the mean postoperative number of days until returning to normal body temperature (p=0.047), and the mean change in angulation 2 years postoperatively (p=0.007). The adjacent segment degeneration occurred in 6 patients (10.9%) in the splitting group and 11 patients (55.0%) in the conventional group. Conclusions In this study, the spinous process-splitting laminectomy was shown to be less invasive and more stable for patients with LSS, compared to the conventional laminectomy.

A cross-sectional study of the data retrospectively collected by chart review. This study aimed to clarify screw perforation features in 129 consecutive patients treated with computer-assisted cervical pedicle screw (CPS) insertion and to determine important considerations for computer-assisted CPS insertion. CPS fixation has been criticized for the potential risk of serious injury to neurovascular structures. To avoid such serious risks, computed tomography (CT)-based navigation has been used during CPS insertion, but screw perforation can occur even with the use of a navigation system. The records of 129 consecutive patients who underwent cervical (C2–C7) pedicle screw insertion using a CT-based navigation system from September 1997 to August 2013 were reviewed. Postoperative CT images were used to evaluate the accuracy of screw placement. The screw insertion status was classified as grade 1 (no perforation), indicating that the screw was accurately inserted in pedicle; grade 2 (minor perforation), indicating perforation of less than 50 % of the screw diameter; and grade 3 (major perforation), indicating perforation of 50 % or more of the screw diameter. We analyzed the direction and rate of screw perforation according to the vertebral level. The rate of grade 3 pedicle screw perforations was 6.7 % (39/579), whereas the combined rate of grades 2 and 3 perforations was 20.0 % (116/579). No clinically significant complications, such as vertebral artery injury, spinal cord injury, or nerve root injury, were caused by the screw perforations. Of the screws showing grade 3 perforation, 30.8 % screws were medially perforated and 69.2 % screws were laterally perforated. Of the screws showing grades 2 and 3 perforation, 21.6 % screws were medially perforated and 78.4 % screws were laterally perforated. Furthermore, we evaluated screw perforation rates according to the vertebral level. Grade 3 pedicle screw perforation occurred in 6.1 % of C2 screws; 7.5 % of C3 screws; 13.0 % of C4 screws; 6.5 % of C5 screws; 3.2 % of C6 screws; and 4.0 % of C7 screws. Grades 2 and 3 pedicle screw perforations occurred in 12.1 % of C2 screws, 22.6 % of C3 screws, 31.5 % of C4 screws, 22.2 % of C5 screws, 14.4 % of C6 screws, and 12.1 % of C7 screws. C3–5 screw perforation rate was significantly higher than C6–7 (p = 0.0024). Careful insertion of pedicle screws is necessary, especially at C3 to C5, even when using a CT-based navigation system. Pedicle screws tend to be laterally perforated.

Study design A retrospective single-center study. Summary and background We routinely have used C1-C2 transarticular and cervical pedicle screw fixations to reconstruct highly destructed unstable rheumatoid arthritis (RA) cervical lesions. However, there is little data on midterm results of surgical reconstruction for rheumatoid cervical disorders, particularly, cervical pedicle screw fixation. Objectives The purpose of this study was to evaluate the mid-term surgical results of computer-assisted cervical reconstruction for such lesions. Methods Seventeen subjects (4 men, 13 women; mean age, 61 +/- 9 years) with RA cervical lesions who underwent C1-C2 transarticular screw fixation or occipitocervical fixation, with at least 5 years follow-up were studied. A frameless, stereotactic, optoelectronic, CT-based image-guidance system, was used for correct screw placement. Variables including the Japanese Orthopaedic Association (JOA) score, Ranawat class, EuroQol (EQ-5D), atlantodental interval, and Ranawat values before, and at 2 and 5 years after surgery, were evaluated. Furthermore, screw perforation rates were evaluated. Results The lesions included atlantoaxial subluxation (AAS, n = 6), AAS + vertical subluxation (VS, n = 7), and AAS + VS + subaxial subluxation (n = 4). There was significant neurological improvement at 2 years after surgery, as evidenced by the JOA scores, Ranawat class, and the EQ-5D utility weight. However, at 5 years after surgery, there was a deterioration of this improvement. The Ranawat values before, and at 2 and 5 years after surgery, were not significantly different. Major screw perforation rate was 2.1 %. No neural and vascular complications associated with screw insertion were observed. Conclusions Subjects with rheumatoid cervical lesions who underwent C1-C2 transarticular screw fixation or occipitocervical fixation using a pedicle screw had significantly improved clinical parameters at 2 years after surgery. However, there was a deterioration of this improvement at 5 years post surgery., Article, JOURNAL OF ORTHOPAEDIC SCIENCE. 18(6):916-925 (2013)

BACKGROUND CONTEXT: The EuroQol (EQ-5D) is a widely used comprehensive measure of health-related quality of life. There has been no study that has evaluated the health-related quality of life before and after the surgical reconstruction of rheumatoid arthritis (RA) cervical spine lesions using EQ-5D. PURPOSE: The present study aimed to evaluate the improvement of quality of life before and after surgical reconstruction of rheumatoid cervical spine using EQ-5D, and the surgical outcomes of cervical spine affected by RA. STUDY DESIGN: A retrospective study of the patients who underwent surgical reconstruction of cervical disorders in RA. PATIENT SAMPLE: Twenty-five patients (seven men, 18 women, mean age 62.2 years) who underwent surgical reconstruction of cervical disorders in RA were enrolled. OUTCOME MEASURES: Japanese Orthopaedic Association (JOA) score and EQ-5D. METHODS: Clinical symptoms were evaluated before surgery and at 2 years after surgery by measuring the JOA score. We also investigated health-related quality of life before surgery and outcome at 2 years after surgery using the EQ-5D questionnaire. RESULTS: Mean observation period was 46.3 months. Mean JOA score significantly improved from 9.1 +/- 4.5 points before surgery to 12.4 +/- 2.8 at the 2 years after surgery (p=.0001). All the EQ-5D data were improved at the 2 years after surgery, compared with the data before surgery; especially, pain (p=.005), usual activity (p=.005), mobility (p=.008), and anxiety/depression (p=.02) were significantly improved. Utility weight was 0.37 +/- 0.27 before surgery and 0.56 +/- 0.26 at the 2 years after surgery, showing significant improvement at the 2 years after surgery compared to before surgery (p=.002). CONCLUSIONS: The surgical reconstruction of rheumatoid cervical spine has been demonstrated to improve patients' health-related quality of life., Article, SPINE JOURNAL. 13(4):391-396 (2013)

Background Context Pedicle screw fixation is commonly employed for the surgical correction of scoliosis but carries a risk of serious neurovascular or visceral structure events during screw insertion. To avoid these complications, we have been using a computed tomography (CT)-based navigation system during pedicle screw placement. As this could also prolong operation time, multilevel registration for pedicle screw insertion for posterior scoliosis surgery was developed to register three consecutive vertebrae in a single time with CT-based navigation. The reference frame was set either at the caudal end of three consecutive vertebrae or at one or two vertebrae inferior to the most caudal registered vertebra, and then pedicle screws were inserted into the three consecutive registered vertebrae and into the one or two adjacent vertebrae. Objectives This study investigated the perforation rates of vertebrae at zero, one, two, three, or four or more levels above or below the vertebra at which the reference frame was set. Study Design This is a retrospective, single-center, single-surgeon study. Patient Sample One hundred sixty-one scoliosis patients who had undergone pedicle screw fixation were reviewed. Outcome Measures Screw perforation rates were evaluated by postoperative CT. Materials and Methods We evaluated 161 scoliosis patients (34 boys and 127 girls; mean±standard deviation age: 14.6±2.8 years) who underwent pedicle screw fixation guided by a CT-based navigation system between March 2006 and December 2015. Results A total of 2,203 pedicle screws were inserted into T2–L5 using multilevel registration with CT-based navigation. The overall perforation rates for Grade 1, 2, or 3, Grade 2 or 3 (major perforations), and Grade 3 perforations (violations) were as follows: vertebrae at which the reference frame was set: 15.9%, 6.1%, and 2.5%; one vertebra above or below the reference frame vertebra: 16.5%, 4.0%, and 1.2%; two vertebrae above or below the reference frame vertebra: 20.7%, 8.7%, and 2.3%; three vertebrae above or below the reference frame vertebra: 23.8%, 7.9%, and 3.5%; and four vertebrae or more above/below the reference frame vertebra: 25.4%, 9.5%, and 4.1%, respectively. Fisher exact test was performed to detect significant differences among the above five groups. With regard to Grade 1, 2, or 3 perforations, the rates of screw perforation for three and four vertebrae or more above or below the reference frame vertebra were significantly larger than that for vertebrae at the reference frame (both p Conclusions In multilevel registration of three consecutive vertebrae, the accuracy of screw insertion into vertebrae at which the reference frame was not set was not significantly inferior to that in vertebrae at which the reference frame was set with regard to major perforation rate. Including minor perforations, however, a distance of three vertebrae or more above or below the reference frame vertebra produced significantly more frequent perforations.

Background Context Osteoid osteoma of the thoracic spine is relatively uncommon and is often difficult to diagnose, especially when patients do not complain of pain. Purpose This study aims to describe an unusual case of scoliosis caused by osteoid osteoma of the thoracic spine that was challenging to diagnose. Study Design/Setting A case report of a 12-year-old girl who presented with scoliosis caused by osteoid osteoma of the thoracic spine without apparent pain was carried out. Methods Diagnosis of the lesion was made using computed tomography (CT) and magnetic resonance imaging as well as the Scoliosis Research Society-22 (SRS-22) patient-based questionnaire. Results A preoperative CT myelogram revealed a mass lesion in the lamina of the 10th thoracic vertebra that was considered to be osteoid osteoma. This diagnosis was histologically confirmed following tumor excision. The patient's spinal deformity and SRS-22 scores were both improved at 5 months postoperatively. Conclusions Osteoid osteoma of the thoracic spine may present as non-painful scoliosis. Tumor resection is effective. Clinicians should bear this uncommon lesion in mind during recommended CT examination before scoliosis surgery.

Background The advanced trauma life support guidelines suggest that, in primary care, the chest tube should be placed posteriorly along the inside of the chest wall. A chest tube located in the posterior pleural cavity is of use in monitoring the volume of hemothoraces. However, posterior chest tubes have a tendency to act as nonfunctional drains for the evacuation of pneumothoraces, and additional chest tube may be required. Thus, it is not always necessary to insert chest tubes posteriorly. The purpose of this study was to determine whether posterior chest tubes are unnecessary in trauma care. Methods We reviewed the volume of hemothoraces from 78 chest drains emergently placed posteriorly at a primary trauma care in 75 blunt chest trauma patients who were consecutively admitted over a 6-year period, excluding those with cardiopulmonary arrest and occult pneumothoraces. Massive acute hemothorax (MAH), in which the chest tube should be inserted posteriorly, was defined as the evacuation of more than 500 mL of blood or the need for hemostatic intervention within 24 hours of trauma admission. Demographics, interventions, and outcomes were analyzed. We also reviewed the malpositioning of 74 chest tubes based on anterior and posterior insertion directions in patients who subsequently underwent computed tomography. Results The overall incidence of MAH was 23% (n = 18). In the univariate analysis, the presence of multiple rib fractures, shock, pulmonary opacities on chest x-ray, and the need for intubation were found to be independent predictors for the development of MAH. If all 4 independent predictors were absent, none of the patients developed MAH. The incidence of nonfunctional chest drains that required reinsertion or the addition of a new drainage was 27% (n = 20). The rates of both radiologic and functional malposition in chest tubes with posterior insertion were significantly higher than in patients with anterior insertion (64% and 43% vs 13% and 6%, respectively; P Conclusions Chest tubes did not need to be directed posteriorly in many trauma cases. Posterior chest tubes have a high incidence of being malpositioned. This malpositioning may be prevented by judging the necessity for posterior insertion.

We describe a case of type-2 bronchial artery endoleak after endovascular aortic repair of Kommerell diverticulum (KD) involving right-sided aortic arch and aberrant left subclavian artery (LSA). A 68-year-old woman underwent an endovascular repair of KD with an aberrant LSA in our hospital. Follow-up computed tomography (CT) at 6 months after the procedure showed an endoleak. Digital subtraction angiography revealed a type-2 endoleak from a bronchial artery, but no type-1 or type-2 endoleak from the aberrant left subclavian artery. We performed coil embolization of the KD and the left subclavian artery. The endoleak disappeared in the postoperative CT.

We developed a new multilevel registration technique for pedicle screw (PS) insertion that has the capability of registering three consecutive vertebrae simultaneously, using a reference frame set to one of the caudal vertebrae. PSs are inserted in the consecutive and adjacent one or two vertebrae. This study aimed to investigate the perforation rates of the registered and unregistered adjacent vertebrae and compare the perforation rate of the PS and insertion time per PS between the conventional and new techniques. Sixty-nine consecutive scoliosis patients who underwent PS insertion using multilevel registration were enrolled. The conventional and new techniques were used in 29 subjects, and in 40 subjects, respectively. The total numbers of PSs used were 375 and 492, respectively. Of the 492 PSs, 301 were inserted to the registered vertebrae and 191 were inserted to the unregistered adjacent vertebrae. The PS malposition on postoperative axial computed tomography was classified as grades 2 and 3 perforation, using the Rao classification. The perforation rate and insertion time per PS were compared between the conventional and new techniques. The perforation rates did not significantly differ between the registered and unregistered vertebrae (10.3 vs. 6.3 %,), and between the new and conventional techniques (8.7 vs. 9.6 %). The insertion time per PS was significantly shorter in the new technique than in the conventional technique (3.9 ± 1.0 vs. 4.9 ± 1.3 min; p

Skin hyperpigmentation and itching are characteristic findings in systemic sclerosis (SSC) patients. Stem cell factor (SCF, c-kit ligand) is a multifunctional cytokine which can promote melanocyte and mast cell development. We investigated the SCF expression histopathologically in normal and SSC skin, and compared the expression with the serum SCF levels measured with a specific enzyme-linked immunosorbent assay. The epidermal and dermal immunoreactive SCF expression was markedly higher in the forearm skin of edematous phase SSC patients than in that of normal subjects. Tissue SCF expression declined from the sclerotic phase to the atrophic phase, where it was close to the normal level. In contrast, the elevated serum SCF level seen in the edematous phase samples was further increased in the sclerotic phase samples. The serum SCF level decreased in the atrophic phase, but it still remained at a level higher than that of the normal controls. Itching and increase of dermal mast cell number are characteristic of edematous phase SSC, and are in bears a parallel to the presently observed dermal SCF expression profile. Pigmentation is significant in sclerotic phase SSC and lasts to the atrophic phase, which may correspond to the serum SCF level observed here. These results indicate a contribution of the fibroblast membrane integral SCF in dermal mast cell development, and of the soluble serum SCF to melanocyte activation in SSC.

Interleukin 1alpha (IL-1alpha) is thought to play a central role in inflammatory reactions of the skin. Its excessive production and discharge by keratinocytes has been implicated in psoriasis, bullous diseases and other skin diseases. In addition to the type 2 IL-1 receptor and the IL-1 receptor antagonist, anti-IL-1 antibody in human serum has been proposed as a potential means to down regulate systemic responses attributable to IL-1. However, the relationship of these antibodies to disease and particularly to disease pathogenesis is still unclear. To understand this relationship, we characterized the anti-IL-1 autoantibody in sera from various skin diseases. IL-1alpha and IL-1beta radioimmunoassay, and immuno-blotting study showed the existence of IL-1alpha autoantibody but not autoantibodies to IL-1beta or pro-IL-1beta. High titer of anti-IL-1alpha autoantibodies were detected in the sera from inflammatory skin diseases with epidermal injury, including psoriasis, palmoplantar pustulosis, pustular psoriasis, pemphigus and lichen planus. In contrast, few samples from non-epidermodestructive bullous pemphigoid, atopic dermatitis and healthy normal controls had autoantibodies. The titer of anti-IL-1alpha autoantibodies showed some relation to the clinical course of psoriasis and pemphigus. Anti-IL-1 autoantibody neutralized rhIL-1alpha in D10.G4 assay and inhibited receptor binding of FITC-rhIL-1alpha. Taken together present data, the keratinocyte derived IL-1alpha could be a source of autoantigen that provokes production of endogenous anti-IL-1alpha autoantibody, which may regulate IL-1alpha mediated cutaneous inflammation.

Four patients with systemic scleroderma (SSc), 4 patients with morphea, and 4 patients with hypertrophic scar were treated with topical tocoretinate for 6 months to 3 years and studied clinically and histopathologically. Clinically, all of the lesions responded to this therapy. The stiffness of the skin lesions, glossy appearance of the lesions, and telangiectasia improved. Histopathologically, the proliferated collagen fibers decreased in thickness, and the inter-fiber spaces increased. Immunoreactive tenascin-C expressed in the proliferated deep dermal fibers of the SSc and hypertrophic scar lesions was markedly decreased compared with the level before the topical tocoretinate therapy. Topical tocoretinate has been used for the treatment of ulcers; it is also a potent treatment for sclerotic skin diseases.

Background: A new antibacterial quinolone, sparfloxacin (SPFX), frequently causes photosensitive dermatitis and sometimes induces a treatment-resistant lichenoid tissue reaction (LTR). Objective: We attempted to determine the factors that induce LTR in SPFX-induced photodermatitis. Methods: Thirteen patients with SPFX photosensitive dermatitis were studied clinically and histopathologically. Results: Six of the 13 patients had acute dermatitis with epidermal spongiosis and focal epidermal HLA-DR and intercellular adhesion molecule–1 (ICAM-1) expression with CD4 + cell infiltration. The other seven displayed LTR with basal cell liquefaction degeneration and diffuse epidermal HLA-DR and ICAM-1 expression associated with CD8 + cells. The seven patients with LTR were exposed to UV and SPFX for more than 2 weeks after the appearance of their initial eruption, whereas the six patients with acute dermatitis were treated within 2 weeks. The acute dermatitis lesions cleared significantly within 2 weeks, but the LTR lesions persisted for more than 6 weeks. Conclusion: Patients with quinolone-induced photosensitivity should be treated within 2 weeks of onset to prevent LTR. (J Am Acad Dermatol 1998;38:945-9.)

We report a case of renal crisis in a patient with elderly onset systemic scleroderma (SSc). A sixty-one-year-old woman was diagnosed as having SSc with rapidly advancing generalized skin sclerosis. After experiencing an upper respiratory infection, she suddenly developed renal failure, hemolytic anemia and malignant hypertension. Laboratory examination revealed uremia with a significantly high plasma renin level. Ophthalmologic study revealed Keith-Wagner's retinopathy Grade IV. Combination therapy including captopril, systemic corticosteroid and prostaglandin E1 venous infusion for the hemolytic uremic syndrome was effective and saved her from the renal crisis. However, her renal function deteriorated and she needs permanent hemodialysis. Rapidly progressive skin sclerosis in SSc, especially in elderly onset cases, suggests a high risk for renal crisis and indicates the need for careful consideration of hypertension and renal function.

We reported a cace of a 61-year-old man with squamous cell carcinoma (SCC) on the external ear, which metastasized to the parotid lymph node, although the tumor was 2cm in diameter at an elrly stage. During past 10 years, we have experienced 13 patients with SCC on the external ear. All patients were male with a mean age of 76.8 years. The tumor were located mostly on the helix. Two patients developed lymph nodes metastasis, but no distal metastasis. SCC of the external ear is an aggressive cancer with higher metasiatic rates than cutaneous SCC as seen in other parts of the body. Poor prognotic facters included specific growth pattern and perineural invasion.

We reported a case of a 68 year-old man with Merkel cell carcinoma. He noticed a tumor on his left leg about seven months previously. As the tumor expanded gradually, he visited Mie University Hospital. At his first visit, the lesion composed of a smooth, easily bleeding tumor in the center and a violet plaque around the tumor. Light microscopy showed two diffirent parts in the lesion, which are Merkel cell carcinoma and squamous cell carcinoma. Immunohistochemical examination showed positive reaction of CEA on the part of Merkel cell carcinoma.

Objective Antegrade central perfusion for acute Stanford type A aortic dissection prevents malperfusion and retrograde cerebral embolism during cardiopulmonary bypass. Prompt establishment of antegrade perfusion via the ascending aorta may improve surgical results of type A dissections, especially in situations of hemodynamic instability. Thus, we evaluated the safety and efficacy of cannulation of the dissected ascending aorta in acute type A dissection. Methods We reviewed the medical charts of patients undergoing repair of acute ascending aortic dissection (n = 52) from April 2010 to April 2013. Cannulation was accomplished in 29 patients via the ascending aorta (central) and in 23 patients via the femoral or axillary artery (peripheral). The ascending aorta was routinely cannulated using Seldinger technique under epiaortic ultrasound guidance. Comorbidities, mortality, complications, and durations of hospital stays were compared for the groups. Results In all cases, routine cannulation of the ascending aorta was safely performed with no resultant malperfusion or thromboembolism. Mean operative duration, cardiopulmonary bypass time, intubation time, and intensive care unit stay were significantly shorter in the central group. Two patients (6.8 %) in the central group died compared with four patients (17.3 %) in the peripheral group (P = 0.005). Conclusions Antegrade central perfusion via the ascending aorta, a simple and safe technique that enables rapid establishment of antegrade systemic perfusion, was as safe as peripheral cannulation in patients with type A acute aortic dissection.

BackgroundThe Scoliosis Research Society-22 (SRS-22) is a widelyused instrument to measure clinical outcomes inpatients with scoliosis. The comparison of domainscores in the SRS-22 between thoracic curve and lum-bar/thoraco-lumbar curve has not been previouslyreported.AimThe purpose of this study is to evaluate the comparisonof domain scores in the SRS-22 between thoracic curveand lumbar/thoraco-lumbar curve in patients with ado-lescent idiopathic scoliosis (AIS).MethodsThis is a cohort of 43 patients (all female) with AIS whounderwent posterior spine fusion. The patients weredivided into two group which were thoracic curve group(n=30, Lenke 1, 2, 3, 4) with a mean age of 14.6 years anda mean Cobb angle of 54° and lumbar/thoraco-lumbargroup (n=14, Lenke 5, 6) with a mean age of 14.6 yearsand a mean Cobb angle of 56° Each was compared for pre-operative SRS-22 domain scores.ResultsIn the thoracic curve group, the pre-operative mean valuesof appearance, activity, pain, mental, and sub-total were asfollows: 2.8±0.5, 4.4±0.5, 4.1±0.4, 3.8±0.9, and 3.8±0.4,respectively. In the lumbar/thoraco-lumbar curve group,the preoperative mean values of appearance, activity, pain,mental, and sub-total were as follows: 2.7±0.5, 4.0±0.8,3.8±0.9, 3.9±0.9, and 3.6±0.5, respectively. The pre-operative mean domain score of activity in the lumbar/thoraco-lumbar curve group was significantly smallercompare with that in the thoracic curve group (p=0.04).ConclusionThe pre-operative domain scores of appearance, painand mental were almost the same; however, the pre-operative mean domain score of activity in the lumbar/thoraco-lumbar curve group was significantly smallercompared with that in the thoracic curve group.

A 29-year-old man with a furuncle-like lesion brought in a maggot on the next day after his first visit to our clinic. He said it moved out from the eruption spontaneously. He had previously visited Parana and Sao Paulo in Brazil before he noticed the symptom. The maggot was confirmed to be a third instar larva of Dermatobia hominis. Japanese cases of cutaneous myiasis are reviewed.

症例1: 68歳の女性約2ヵ月前, 口腔内と肛門周囲に軽度のそう痒と疼痛を伴う皮疹が出現し次第に拡大した。初診時, 腋窩, 足背, 臀部に, 周囲に紅暈と膿胞を伴う疣贅状に隆起する境界明瞭な皮疹が認められた。粘膜疹も認められた。ステロイド内服(ブレドニゾロン50mg/day)にて軽快し経過良好であったが, 4年後結腸癌にて死亡した。症例2: 62歳の男性。約1年前に顔面, 前腕等に無症候性皮疹が出現した。初診時, 口角部, 躯幹, 四肢に粟粒大の膿胸を伴う浸潤性紅斑と, 粘膜疹も認められた。S字状結腸癌と間質性肺炎を合併していた。2例とも病理組織学的に, 表皮内への好酸球浸潤と棘融解が認められ, 病変部の免疫螢光抗体直接法所見で表皮細胞間にIgGとC3, の沈着が認められ, Hallopeau型増殖性天疱瘡と考えた。中等量以下のステロイド内服により皮疹は色素沈着を残し軽快した。

We report a 29-year-old female OKT4 epitope deficiency patient with primary Sjögren's syndrome and psoriasis vulgaris. Immunological investigations during the prolonged clinical course of her herpes zoster revealed that she has OKT4 epitope deficiency and primary Sjögren's syndrome. She had been treated for psoriasis vulgaris for 17 years without systemic immunosuppressive therapy. Flow cytometric study revealed that her OKT4 deficiency is heterogeneous and excluded interference with the OKT4 epitope by anti OKT4 autoantibodies. The rare coexistence of primary Sjögren's syndrome and psoriasis implicates an immune disturbance due to an unusual phenotype of CD4.

79歳の男性。初診2ヵ月前に上眼瞼浮腫性紅斑出現, 初診1ヵ月前に嚥下困難出現, 近医受診し消化管障害の診断にて上部消化管造影を施行された後, 当科紹介となった。初診時バリウム誤飲による嚥下性肺炎を生じており, 両眼瞼部, 頬部, 頚部, 前腕に帯紫色浮腫性紅斑, 背部ではpoikilodermaを認めた。筋脱力症状を認め, 筋生検にて筋線維の変性を認め, 筋電図に異常なく検査所見で筋原性酵素の上昇を認めた。以上より皮膚筋炎と診断。プレドニゾロン, 抗生剤等の治療にて一旦症状軽快傾向を示したがプレドニゾロン漸減中, 皮疹の再燃をきたしメソトレキセート併用を行い現在, 経過観察中である。

Despite remarkable improvement in Cobb angle after surgery for scoliosis, many patients have a residual rib hump. We studied the factors responsible for this hump and their influence on patient satisfaction.We recruited 2 men and 38 women (mean age 14.9 years) who underwent skip pedicle screw fixation combined with direct vertebral body derotation for adolescent idiopathic scoliosis with Lenke type 1 and 2 curves. Hump size was evaluated by measuring apical trunk rotation (ATR). Patients with postoperative ATR ≤10° were categorized as group A and those with postoperative ATR10° as group B. We analyzed postoperative self-image and satisfaction subscores of the SRS-22 questionnaire. We also compared the rate of postoperative improvement in ATR between patients who underwent additional Ponte osteotomy and those who did not.Preoperative ATR, preoperative apical translation, and preoperative and postoperative apical rotation significantly differed between groups A and B. In contrast, Cobb angles before and after surgery, Cobb angle correction rates, apical translation after correction, and postoperative self-image and satisfaction scores did not differ significantly between the groups. However, the rate of improvement in ATR showed a strong correlation with self-image (correlation coefficient 0.64) and satisfaction (correlation coefficient 0.52). This improvement rate did not differ significantly between subjects who underwent additional Ponte osteotomy and those who did not.Preoperative apical rotation and ATR were clearly related to postoperative residual hump. For decreasing the postoperative rib hump, removal of the deformation by apical rotation was considered more important than correction of Cobb angle. Patient satisfaction and self-image scores were not significantly related to postoperative residual hump size, but they were influenced by improvement in ATR.

Cervical spine fixation using cervical pedicle screw (CPS) was first reported by Abumi [1] and Jeanneret [2] in 1994. Both reports described cases of cervical instability caused by cervical trauma. Cervical spine fixation by CPS was introduced as a procedure for the cervical instability of middle and/or lower cervical spine caused by trauma, and the importance of fixation by CPS for posterior cervical decompression and reconstruction was later reported [3,4]. Cervical pedicle screws can achieve rigid fixation compared to other cervical pedicle fixation methods [5, 6], and enable posterior cervical cord decompression. However, cervical pedicle screw insertion is technically demanding because of the narrow pedicle diameter and the risk of serious neurovascular complications including vertebral artery tear, spinal cord injury, and nerve root injury [7]. To achieve more accurate and safe pedicle screw insertion, navigation by two-dimensional imaging system or CT has been employed in recent years [9-12]. However, CPS insertion from C3 to C6 is technically demanding. The purpose of this study was to evaluate the perforation rates and direction of screw perforations in these insertions using CT-based navigation system.

Study Design: A retrospective study. Purpose: To evaluate the surgical results of cervical pedicle screw (CPS) fixation combined with laminoplasty for treating cervical spondylotic myelopathy (CSM) with instability. Overview of Literature: Cervical fixation and spinal cord decompression are required for CSM patients with instability. However, only a few studies have reported on CPS fixation combined with posterior decompression for unstable CSM patients. Methods: Thirteen patients that underwent CPS fixation combined with laminoplasty for CSM with instability were evaluated in this study. We assessed the clinical and radiological results of the surgical procedures. The Japanese Orthopedic Association (JOA) scoring system was used to evaluate the clinical results. The percentages of slip, difference in slip angle between maximum flexion and maximum extension of unstable intervertebrae, and perforation rate of CPS were evaluated. Results: The mean JOA scores before surgery, immediately after surgery, and at final follow-up were 9.1, 13.3, and 12.6, respectively. The mean percentages of slip before surgery, immediately after surgery, and at final follow-up were 9.1%, 3.2%, and 3.5%, respectively; there were significant improvements immediately after surgery and at final follow-up. The difference in slip angle between the maximum flexion and maximum extension of the unstable intervertebrae changed from 9.0° before surgery to 1.6° at the final follow-up. The perforation rate of CPS was 10.9%. Conclusions: The results suggest that CPS fixation combined with laminoplasty is an effective surgical procedure for treating CSM with instability.

Multi-walled carbon nanotubes (MWCNTs) promote calcification during hydroxyapatite (HA) formation by osteoblasts. Primary cultured osteoblasts are incubated with MWCNTs or carbon black. After culture for 3 weeks, the degree of calcification is very high in the 50 μg mL(-1) MWCNT group. Transmission electron microscopy shows needle-like crystals around the MWCNTs, and diffraction patterns reveal that the peak of the crystals almost coincides with the known peak of HA.

The purpose of this case report was to report a rare case of pyogenic spondylodiscitis caused by Campylobacter fetus. A 37-year-old male presented with fever and low back pain. By lumbar magnetic resonance imaging (MRI), no abnormal finding was observed at the first presentation. However, low back pain was aggravated, and fever did not improve. Thus, lumbar MRI was repeated on the 26 day after the onset of symptoms, showing abnormal signals at vertebrae and disc spaces, and pyogenic spondylitis was diagnosed. The possibility of pyogenic spondylodiscitis should be taken into account if a patient presents with low back pain and fever, and areas of low signal intensity on a T1-weighted MRI should be carefully examined. When initial MRI does not reveal abnormal findings, repeated MRI after one or two weeks or, more favorably, immediate gadolinium enhancement MRI, are important for patients who have persistent low back pain and fever.