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青木真美教授定年退職記念号(Special issue in commemoration of Prof. Mami Aoki's retirement)

Study Design: Human ligamentum flavum–derived cells (HFCs) were obtained from surgical samples for a basic experimental study.Purpose: We sought to evaluate the inflammatory response of human ligamentum flavum cells to investigate hypertrophic changes occurring in the ligamentum flavum.Overview of Literature: Lumbar spinal stenosis (LSS) is a disease commonly observed in the elderly. The number of patients with LSS has increased over time, yet the pathomechanisms of LSS still have not been fully elucidated. One of the clinical features of LSS is hypertrophy of the ligamentum flavum, which results in narrowing of the lumbar spinal canal. Some reports have suggested that ligamentum flavum hypertrophy is associated with inflammation and fibrosis; meanwhile, the p38 mitogen-activated protein (MAP) kinase is involved in the hypertrophy of human ligamentum flavum cells.Methods: HFCs were obtained from patients with LSS who underwent surgery. HFCs were stimulated by tumor necrosis factor-α (TNF-α) and a p38 MAP kinase inhibitor, SB203580. Phosphorylation of the p38 MAP kinase was analyzed by western blotting. The concentration of interleukin-6 (IL-6) in the conditioned medium was measured by enzyme-linked immunoassay and IL-6 messenger RNA expression levels were determined by real-time polymerase chain reaction.Results: TNF-α induced the phosphorylation of p38 MAP kinase in a time-dependent manner, which was suppressed by the p38 MAP kinase inhibitor, SB203580. TNF-α also stimulated IL-6 release in both a time- and dose-dependent manner. On its own, SB203580 did not stimulate IL-6 secretion from HFCs; however, it dramatically suppressed the degree of IL-6 release stimulated by TNF-α from HFCs.Conclusions: This is the first report suggesting that TNF-α stimulates the gene expression and protein secretion of IL-6 via p38 MAP kinase in HFCs. A noted association between tissue hypertrophy and inflammation suggests that the p38 MAP kinase inflammatory pathway may be a therapeutic molecular target for LSS.

Objective This study was conducted to clarify the validity of the short posterior arch screw (S-PAS). The S-PAS is inserted only in the pedicle-analogue portion of the posterior arch. The S-PAS screw length is almost half that conventional C1 lateral mass screws inserted via the posterior arch (via-PAS). S-PAS reduces the risk of vertebral artery injury (VAI) because it never reaches the transverse foramen. Although the biomechanical validity of various C1 lateral mass screws (C1LMS) analyzed in young specimens have been published, that of unicortically inserted C1LMS such as the unicortical Harms screw, S-PAS, and via-PAS for elderly patients is concerning because of the high prevalence of osteoporosis in the elderly. Methods Nine fresh frozen cadavers (average age at death, 72.1 years) were used for pullout testing. The bone mineral density of each specimen was evaluated using quantitative computed tomography. Results The pullout strength of via-PAS (1,048.5 N) was significantly greater than that of the unicortical Harms screw (257.9 N) (p

Study Design: A cadaveric study.Purpose: To investigate the anatomical features of segmental arteries and veins in the anterior part of the spinal column to prevent segmental vessel injury.Overview of Literature: The lateral transpsoas approach to the lumbar intervertebral discs (IVD) is associated with the risk of segmental vessel injury. Previous studies have described the vascular anatomy on the lateral part of the vertebral body. However, there are no studies that describe the segmental vessels on its anterior aspect. Here, we report the important anatomical features of the segmental arteries and veins that can intersect the anterior part of the IVD. These vessels are considered at risk of vascular injury when placing the anterior retractors during lateral lumbar interbody fusion or cutting the anterior longitudinal ligament during anterior column realignment.Methods: Five formalin-embalmed human cadavers were used. We assessed the proportion of segmental arteries and veins that intersected the IVD in the L2–L5 range and their course on the anterior part of the spinal column.Results: The segmental arteries and veins commonly intersect the anterior part of the IVD (artery, 28.1%; vein, 42.1%). Seven of 10 (70%) segmental arteries at L2 intersected the IVD, but only one artery intersected the IVD at L3 and L4. The proportions of segmental veins that intersected the IVD were 60%, 50%, and 16.7% at L2, L3, and L4, respectively.Conclusions: The segmental arteries and veins frequently intersect the IVD in the anterior part of the spinal column. Therefore, it is necessary to consider these individual anatomical features to prevent vascular damage during lateral lumbar interbody fusion surgery.

[Purpose] Sports activity has been shown to improve postural stability and vestibular function in healthy older adults. The hypothesis was that healthy young adults undertaking sports activity will also have better postural stability and vestibular function compared with healthy young adults who do not undertake sports activity. The purpose of this study was to investigate the differences in postural stability and vestibular function between healthy young adults who undertake sports activity and those who do not undertake such activity. [Participants and Methods] Thirty-nine healthy young adults were recruited and divided into sports and non-sports groups on the basis of their response to a questionnaire concerning regular participation in sports activities over the past 12 months. In both groups, postural stability was measured during quiet standing and standing during head rotation, and dynamic visual acuity was assessed during head rotation. [Results] The results showed significant differences in postural stability during head rotation and dynamic visual acuity between the two groups, whereas no significant differences were found in postural stability during quiet standing. [Conclusion] The results suggest that healthy young adults who undertake sports activity have better postural stability during head rotation and better dynamic visual acuity. The causal effect of these differences is not clear and further investigation is warranted.

Background: Arthroscopy is a widely used minimally invasive technique. Nevertheless, no report describes the arthroscopic anatomy of the proximal interphalangeal (PIP) joint for portal creation. To facilitate arthroscopy, this study elucidated the anatomy of the lateral bands of the extensor mechanism and collateral ligaments of PIP joints. Methods: A total of 39 fingers from the right hands of 10 cadavers (4 males, 6 females) were evaluated in this study. We defined the extension line from the proximal interphalangeal volar crease as the C-line. We also defined an imaginary line along the distal edge of the proximal phalanx, which is parallel to the C-line, as the J-line. The distance between J-line and C-line was measured. On the C-line and J-line, we measured the following: from the dorsal skin to the lateral edge of the lateral band (LB), the dorsal edge of the collateral ligament (CL) and from the lateral band and the collateral ligament (D), the width of the finger (W). The finger half-width (M) was measured on the J-line. Comparison between the digits and comparison between radial and ulnar distance were measured and statistical analysis was performed. Results: All PIP joint spaces were distal from the C-line, except for one ring finger. The average distances between the J-line and C-line were 1.8–3.2 mm. On the C-line, only 11 cases (14.1%) showed an interval between the lateral bands and the collateral ligaments, but, on the J-line 72, cases (92.3%) had such an interval. The interval was located 1.6–2.9 mm in a dorsal direction from the midlateral on the J-line. Conclusions: Portal creation at the J-line is safer than at the C-line. This study revealed that safe portals for arthroscopy of the PIP joint are 2 mm dorsal to the midlateral line of the finger on the J-line.

Early active mobilization after hand surgery is extremely important for preventing scar tissue and adhesion. We examined four patients for whom continuous peripheral nerve blocks (CPNB) were used during and after hand surgery. This method was used for three median nerves and one ulnar nerve. A 2-cm incision was made at distal one-third of the forearm with local analgesia. The catheter tip was placed in the distal one-fourth of the forearm, and the hand surgery was begun. Early active mobilization and the self-rehabilitation exercise started immediately after the operation. The VAS scores during exercise were 0–2 (mean: 1.3); pain was controlled sufficiently. Regarding ROM, excellent results were obtained for tenolysis, with good results for arthrolysis. No infection or postoperative nerve compression was found. This method, using CPNB with a portable infusion pump, is effective and safe for use at home for postoperative pain control.

The goal of fixation surgery for atlantoaxial instability is to achieve solid bony fusion. Achieving bony fusion as early as possible is beneficial for patients. Although placement of a transverse cross-link connector (XL) provides greater biomechanical strength, XLs have not been able to be placed when performing the Goel/Harms procedure. Recently, placing a XL on the screw head (on-the-head XL [OH-XL]) has become a viable option during the Goel/Harms procedure. However, there is little evidence demonstrating whether applying an OH-XL achieves early solid bony union. A matched-control study was conducted to investigate whether placing an OH-XLs in C1/2 fixation surgery provides earlier bone union or not. Eighteen patients who underwent atlantoaxial fusion with OH-XLs (X-group), and 17 age and sex-matched patients without OH-XLs (NX-group) were compared. Bony union was assessed using reconstructed sagittal and coronal computed tomography images. Six months after surgery, six patients in the X-group and one patient in the NX-group achieved bony union (p = .0338). One year after surgery, 14 patients in the X-group and 4 patients in the NX-group achieved bone union (p = .0010). Two years after surgery, 17 patients in the X-group and 9 patients in the NX-group achieved bony union (p = .0011). This is the first report of the clinical application of OH-XLs for the Goel/Harms procedure. OH-XLs yield earlier bony fusion; thus, placing OH-XLs is beneficial for atlantoaxial fixation surgery using lateral mass screws of the atlas.

The purpose of this study is to clarify the impact of low cost carriers (LCCs) on non-aeronautical revenues in 26 UK airports from 1999 to 2008. Increasingly non-aeronautical revenues have become an important source for airport revenue. Our literature review highlights that there is little consensus in empirical results concerning LCC impact on non-aeronautical revenues, some of these report positive impact while others show negative impact. We estimate a non-aeronautical revenue function which includes frequency share of LCC, Air Transport Movements (ATMs), number of passengers and population of hinterland of each observed airports as explanatory variables. In addition to this, we produce marginal revenue estimates for both the case of capacity constrained and capacity unconstrained circumstance in airports. As a result, in the case of a non-capacity constrained airport, on average, the marginal revenue of an additional LCC ATM is £147 while for non-LCC ATM it is £226. On the other hand, in the case of a capacity constrained airport, on average, substituting one non-LCC ATM with an LCC ATM reduces revenue by £79.

Study Design: Retrospective cohort study. Objective: Determine the indications, complications, and clinical outcomes in patients requiring fusions from the cervical spine to the pelvis. Several investigators have examined fusions from the thoracic spine to the sacrum, but no similar study has been performed for cervical-to-pelvis fusions. Methods: Patients from 2003 to 2014 with an upper instrumented vertebrae (UIV) in the cervical spine (any level) and a lower instrumented vertebrae (LIV) in the sacrum or pelvis were included in the study. Those with infectious or acute trauma-related deformities were excluded. Patient demographics, medical history, diagnosis, operative procedure, and health-related quality of life measures were analyzed. Student’s t test, Kruskal-Wallis test, and χ2 test were used as appropriate; significance was set at P < .05 for all tests. Results: Fifty-five patients met inclusion criteria for the study. Average follow-up was 2.8 years. Proximal junctional kyphosis was the most common indication for cervical-to-pelvis fusions (36%). The most common UIV was C2 (29%) followed by C7 (24%). There was an average 31° correction in maximum kyphosis and a 3.3 cm improvement in sagittal vertical axis. In adults, the rate of complication was 71.4%, with a major complication rate of 39.3% and reoperation rate of 53.6%. There was significant improvement in the Scoliosis Research Society (SRS-22r) score (3.0 to 3.5; P < .01). Conclusion: Proximal junctional kyphosis is the most common indication for patients requiring fusion to the cervical spine. Adult patients incur a significant risk of major complications and reoperations. However, significant improvement in SRS-22r outcomes are noted in these patients.

An intratendinous ganglion of the hand is a rare entity, and only one case report of flexor tendon has been published in the English literature. We herein report two cases of an intratendinous ganglion occurring in the extensor digitorum communis and flexor digitorum superficialis tendon, respectively.

OBJECTIVE Lateral interbody fusion (LIF) with percutaneous screw fixation can treat adult spinal deformity (ASD) in the coronal plane, but sagittal correction is limited. The authors combined LIF with open posterior (OP) surgery using facet osteotomies and a rod-cantilever technique to enhance lumbar lordosis (LL). It is unclear how this hybrid strategy compares to OP surgery alone. The goal of this study was to evaluate the combination of LIF and OP surgery (LIF+OP) for ASD. METHODS All thoracolumbar ASD cases from 2009 to 2014 were reviewed. Patients with < 6 months follow-up, prior fusion, severe sagittal imbalance (sagittal vertical axis > 200 mm or pelvic incidence-LL > 40°), and those undergoing anterior lumbar interbody fusion were excluded. Deformity correction, complications, and outcomes were compared between LIF+OP and OP-only surgery patients. RESULTS LIF+OP (n = 32) and OP-only patients (n = 60) had similar baseline features and posterior fusion levels. On average, 3.8 LIFs were performed. Patients who underwent LIF+OP had less blood loss (1129 vs 1833 ml, p = 0.016) and lower durotomy rates (0% vs 23%, p = 0.002). Patients in the LIF+OP group required less ICU care (0.7 vs 2.8 days, p < 0.001) and inpatient rehabilitation (63% vs 87%, p = 0.015). The incidence of new leg pain, numbness, or weakness was similar between groups (28% vs 22%, p = 0.609). All leg symptoms resolved within 6 months, except in 1 OP-only patient. Follow-up duration was similar (28 vs 25 months, p = 0.462). LIF+OP patients had significantly less pseudarthrosis (6% vs 27%, p = 0.026) and greater improvement in visual analog scale back pain (mean decrease 4.0 vs 1.9, p = 0.046) and Oswestry Disability Index (mean decrease 21 vs 12, p = 0.035) scores. Lumbar coronal correction was greater with LIF+OP surgery (mean [± SD] 22° ± 13° vs 14° ± 13°, p = 0.010). LL restoration was 22° ± 13°, intermediately between OP-only with facet osteotomies (11° ± 7°, p < 0.001) and pedicle subtraction osteotomy (29° ± 10°, p = 0.045). CONCLUSIONS LIF+OP is an effective strategy for ASD of moderate severity. Compared with the authors' OP-only operations, LIF+OP was associated with faster recovery, fewer complications, and greater relief of pain and disability.

In Japan, the yardstick regulation was implemented as an incentive only for large private railway companies, in 1997. This study examined the effects of yardstick regulation on productivity of private railway companies by comparing TFP (Total Factor Productivity) of a large private railway group with that of a small private railway group in Kansai metropolitan area. We interpreted a railway's service to conduct the stratified 3T activities; Track, Train and Transport and estimated TFP for individual and total 3T activities. Estimation results showed that both railway groups had increased their TFP of total 3T activities contributed by productivity improvements of track and train activities since 1997. On the other hand, we could not find obvious evidences to show that the yardstick regulation for large railway companies had generated productivity improvements compared with small railway companies to which the traditional rate of return regulation is applied.

This study evaluated experimentally the influence of the swirling inflow condition upon the flow field in the cold leg piping, which comprises three 90 ° elbows, of the primary cooling system of Japan sodium-cooled fast reactor. Flow visualization experiment was conducted to reveal the velocity fields of the flow in the piping with swirling flow generator. When comparing to the developed turbulent inflow case, the flow separations in the intrados of the 1st elbow became smaller and the swirling flow downstream of the 2nd elbow became stronger, and there appeared separated regions downstream of the 2nd elbow which was not observed in developed turbulent inflow case. Since the flow separation can be considered as the source of the separated vortices which induce pressure fluctuations, these results imply the possibility that pressure fluctuations downstream of the 1st elbow are reduced and those of the 2nd elbow are enhanced by swirling flows as the inlet condition. The separated region is strongly reduced when a suitable swirling inflow enters the 3rd elbow.

In Japan, High Speed Rail (HSR) extended its network in 2011 and 2015, and Low Cost Carriers (LCC) entered into the domestic airline market in 2012. We compared the effects of the extension of the HSR network and the entry of LCCs on the airfares of the incumbent Full Service Carriers (FSC). We conducted Difference in Differences analysis with passenger level data to evaluate these market changes, and found that the effects of the HSR extension on FSC's airfares were consistently negative and larger in the short haul markets, while the effects of the entry of LCCs were inconsistent. HSR seems to be a stronger competitor than LCC to FSC and this finding could be affected by capacity, which is large for HSR while small for the LCCs.

When Japanese National Railways was privatized and separated in 1987, the government established a new freight train operation scheme where rail tracks were owned by six JR Passenger companies, and JR-Freight was allowed access to the JR Passenger company's tracks by paying an access charge under the avoidable cost rule, regulated by the national government. The aim of this scheme was to reduce the track costs for JR-Freight. We found that rail freight infrastructure investment had not been high enough because it was only conducted by JR-Freight, and it only included investment in a few facilities owned by JR-Freight but excluded investment in the rail tracks owned by the JR passenger companies. Additionally, the track access charges, calculated by the avoidable cost rule, could not compensate for the track maintenance costs and would induce an undersupply of rail tracks for rail freight traffic. In conclusion, the track access charges paid from JR-Freight to the JR Passenger companies were too low, causing difficulties in the promotion of a modal shift to rail freight.

Recurrence after wide excision or residual tumor after an unplanned excision of a malignant soft tissue sarcoma (STS) is a complex problem, due to a higher recurrence rate and poorer survival rate compared with primary resection. Regional hyperthermia was used, with the expectation that it will enhance the anti-tumor effects of chemotherapy and radiotherapy. This study aimed to assess the efficacy of neoadjuvant concomitant radiotherapy, hyperthermia, and chemotherapy (RHC) for salvage of recurrent or residual malignant STS.We identified 64 patients with recurrent or residual STS treated between 1994 and 2013. After excluding those with low-grade malignancy, with recurrent bone tumor in the soft tissues, with truncal STS, and who declined to participate, 23 patients (7 with recurrence and 16 with residual tumor) underwent RHC. The histologic diagnoses were undifferentiated pleomorphic sarcoma (n = 11), synovial sarcoma (n = 3), leiomyosarcoma and myxoid liposarcoma (n = 2 each), and other histologic types. As primary outcomes, the 5-year overall survival (OS), distant metastasis-free survival (D-MFS), and local control (LC) rates were evaluated by Kaplan-Meier analysis.The median follow-up period was 112.3 months. The 5-year OS, D-MFS, and LC were 86.4%, 77.4%, and 86.7%, respectively. In the univariate analysis, tumor depth was considered as a negative prognostic factor for OS and D-MFS, and a positive margin was also a negative prognostic factor for OS, D-MFS LC with retained on Cox proportional hazards model in OS, and D-MFS.RHC is an effective option for salvage treatment of recurrent and residual STS.

Background Although aneurysmal bone cysts (ABCs) are benign tumours, they have the potential to be locally aggressive. Various treatment approaches, such as en bloc resection, open curettage, radiotherapy, sclerotherapy, and embolization have been proposed, but the most appropriate treatment should be selected after considering the risk of tumour recurrence and treatment complications. Endoscopic curettage (ESC) may be a less invasive alternative to open curettage for ABC treatment. We aimed to describe the use of ESC for the treatment of ABCs and to report our clinical outcomes, including the incidence rate of recurrence, radiological appearance at final follow-up, time to solid union, complications, and postoperative function. Methods Between 1998 and 2015, 30 patients (18 men and 12 women; mean age, 17.4 years) underwent ESC for the treatment of primary ABCs at our hospital (mean postoperative follow-up, 55 months). ESC was performed under arthroscopic guidance for direct visualization, and curettage extended until normal bone was observed in the medullary cavity. To investigate bone healing after ESC, we evaluated the consolidation of cysts at the final evaluation (based on the modified Neer classification) and time to solid union after surgery, which was defined as sufficient cortical bone thickness to prevent fracture and allow physical activities. Results Recurrence was identified in 3 cases (10%). Curative outcomes were obtained after repeated ESC or open curettage. A log-rank analysis indicated that age

Resveratrol is a naturally occurring polyphenol that possesses health‑related properties, and is predominantly found in grapes and berries. Bone morphogenetic protein‑4 (BMP‑4) stimulates osteocalcin synthesis via p38 mitogen‑activated protein (MAP) kinase in osteoblast‑like MC3T3‑E1 cells. The present study aimed to investigate the effects of resveratrol on BMP‑4‑induced osteoprotegerin (OPG) synthesis in MC3T3‑E1 cells. Resveratrol alone had no effect on OPG expression levels, but significantly enhanced BMP‑4‑induced OPG release. In addition, resveratrol markedly amplified the mRNA expression levels of BMP‑4‑induced OPG. SB203580 is an inhibitor of p38 MAP kinase, which was shown to suppress BMP‑4‑stimulated OPG release. BMP‑4‑induced phosphorylation of p38 MAP kinase was also enhanced by resveratrol. Furthermore, SB203580 significantly reduced the resveratrol‑induced amplification of BMP‑4‑stimulated OPG release. These results suggested that resveratrol was able to upregulate BMP‑4‑stimulated OPG synthesis via the amplification of p38 MAP kinase activity in osteoblasts.

Regional hyperthermia is considered to enhance the antitumor effects of chemotherapy and radiotherapy. In this study, we confirmed the efficacy of concomitant radiotherapy, hyperthermia, and chemotherapy (RHC) for neoadjuvant treatment of malignant soft tissue sarcoma (STS). From 1994 to 2013, we performed RHC in 150 patients. This study was limited to 60 patients using the following exclusion criteria: salvage for recurrence or unplanned excision, trunk location, metastasis at initiation, non‐STS, and no definitive surgery. As a control group, we collected data from 11,031 patients in the Bone and Soft Tissue Tumor Registry in Japan (BSTT). We performed multivariate logistic regression analysis, and propensity scores were created for comparisons between groups. The primary outcome of this study was to compare oncologic outcomes (5‐year local control rate [LC] and overall survival rate [OS]). In the RHC group, two local recurrences (3.3%) occurred, and no patients underwent amputation. Margins of definitive surgery were not identical between groups [wide margins (60.0% vs. 85.3%), marginal margins (28.3% vs. 10.5%), and intralesional margins (7.4% vs. 4.2%), RHC and BSTT groups, respectively, P

Objective Dizziness is one of the most common symptoms in the general population. Patients with dizziness experience balance problems and anxiety, which can lead to decreased physical activity levels and participation in their daily activities. Moreover, recovery of vestibular function from vestibular injury requires physical activity. Although there are reports that decreased physical activity is associated with handicap, anxiety, postural instability and reduced recovery of vestibular function in patients with chronic dizziness, these data were collected by self-report questionnaires. Therefore, the objective data of physical activity and the relationships between physical activity, handicap, anxiety and postural stability in patients with chronic dizziness are not clear. The purpose of this research was to objectively measure the physical activity of patients with chronic dizziness in daily living as well as handicap, anxiety and postural stability compared to healthy adults. Additionally, we aimed to investigate the relationships between physical activity, handicap, anxiety and postural stability in patients with chronic dizziness. Methods Twenty-eight patients with chronic dizziness of more than 3 months caused by unilateral vestibular hypofunction (patient group) and twenty-eight age-matched community dwelling healthy adults (healthy group) participated in this study. The amount of physical activity including time of sedentary behavior, light physical activity, moderate to vigorous physical activity and total physical activity using tri-axial accelerometer, self-perceived handicap and anxiety using questionnaires, and postural stability were measured using computerized dynamic posturography. Results The results showed worse handicap, anxiety and postural stability in the patient group compared to the healthy group. Objective measures of physical activity revealed that the patient group had significantly longer time of sedentary behavior, shorter time of light physical activity, and shorter time of total physical activity compared to the healthy group; however, time of moderate to vigorous physical activity was not significantly different between groups. Moreover, there were correlations between physical activity and postural stability in the patient group, while there were no correlations between physical activity, handicap or anxiety in the patient group. Conclusion These results suggest that objectively measured physical activity of the patients with chronic unilateral vestibular hypofunction is lower compared to the healthy adults, and less active patients showed decreased postural stability. However, the details of physical activity and causal effect between physical activity and postural stability were not clear and further investigation is needed.

Author(s): Mizutani, Jun; Strom, Russell; Abumi, Kuniyoshi; Endo, Kenji; Ishii, Ken; Yagi, Mitsuru; Tay, Bobby; Deviren, Vedat; Ames, Christopher | Abstract: BACKGROUND:There have been no reports describing how cervical reconstruction surgery affects global spinal alignment (GSA). OBJECTIVE:To elucidate the effects of cervical reconstruction for GSA through a retrospective multicenter study. METHODS:Seventy-eight patients who underwent cervical reconstruction surgery for cervical kyphosis were divided into a Head-balanced group (nn=n42) and a Trunk-balanced group (nn=n36) according to the values of the C7 plumb line (PL). We also divided the patients into a cervical sagittal balanced group (CSB group, nn=n18) and a cervical sagittal imbalanced group (CSI group, nn=n60) based on the C2 PL-C7 PL distance. Various sagittal Cobb angles and the sagittal vertical axes were measured before and after surgery. RESULTS:Cervical alignment was improved to achieve occiput-trunk concordance (the distance between the center of gravity [COG] PL, which is considered the virtual gravity line of the entire body, and C7 PLnln30 mm) despite the location of COG PL and C7PL. A subsequent significant change in thoracolumbar alignment was observed in Head-balanced and CSI groups. However, no such significant change was observed in Trunk-balanced and CSB groups. We observed 1 case of transient and 1 case of residual neurological worsening. CONCLUSION:The primary goal of cervical reconstruction surgery is to achieve occiput-trunk concordance. Once it is achieved, subsequent thoracolumbar alignment changes occur as needed to harmonize GSA. Cervical reconstruction can restore both cervical deformity and GSA. However, surgeons must consider the risks and benefits in such challenging cases.

Retrospective nationwide questionnaire-based survey of complications.To elucidate the incidence of complications and risk factors associated with lateral interbody fusion (LIF).After its introduction to Japan in February 2013, the numbers of LIF cases have increased substantially because of the advantages of this minimally invasive procedure. However, LIF has the potential risk of several complications unique to the procedure. Although there are many reports of complications, no nationwide survey has been conducted.Questionnaires were sent to all Japanese Society for Spine Surgery and Related Research (JSSR) members. Questionnaires requested information about surgical procedures (XLIF or OLIF), patient characteristics, preoperative diagnosis, complications, salvage procedures, final outcomes, and the surgeon's experience of LIF. The data from replies received between March 2013 and April 2015 were recorded on a web site and the details of complications were analyzed by a JSSR research team.Seventy-one institutions (12.3%) answered "yes" to LIF experience and 2998 cases (1995 XLIF and 1003 OLIF) were enrolled in this study. The response rate was 86.1%. A total of 540 complications were reported, of which 474 (84.8%) could be further analyzed. The overall complication rate was 18.0%. The most frequent complications were sensory nerve injury (5.1%) and psoas weakness (4.3%) and the majority resolved spontaneously. The rates of major vascular injury, bowel injury, and surgical site infection were 0.03%, 0.03%, and 0.7%, respectively. The overall reoperation rate was 2.2%. Higher rates of sensory nerve injury and psoas weakness were reported for XLIF and higher rates of peritoneal laceration and ureteral injury were reported for OLIF.A nationwide survey of complications associated with LIF was conducted. Although the majority of complications were minor, a relatively high rate of complications was reported. Approach-related specific features of the two procedures were identified.4.

It is firmly established that resveratrol, a natural food compound abundantly found in grape skins and red wine, has beneficial properties for human health. In the present study, we investigated the effect of basic fibroblast growth factor (FGF-2) on osteoprotegerin (OPG) synthesis in osteoblast-like MC3T3-E1 cells and whether resveratrol affects the OPG synthesis. FGF-2 stimulated both the OPG release and the expression of OPG mRNA. Resveratrol significantly suppressed the FGF-2-stimulated OPG release and the mRNA levels of OPG. SRT1720, an activator of SIRT1, reduced the FGF-2-induced OPG release and the OPG mRNA expression. PD98059, an inhibitor of upstream kinase activating p44/p42 mitogen-activated protein (MAP) kinase, had little effect on the FGF-2-stimulated OPG release. On the other hand, SB203580, an inhibitor of p38 MAP kinase, SP600125, an inhibitor of stress-activated protein kinase/c-Jun N-terminal kinase (SAPK/JNK), and Akt inhibitor suppressed the OPG release induced by FGF-2. Resveratrol failed to affect the FGF-2-induced phosphorylation of p44/p42 MAP kinase, p38 MAP kinase or SAPK/JNK. The phosphorylation of Akt induced by FGF-2 was significantly suppressed by resveratrol or SRT1720. These findings strongly suggest that resveratrol down-regulates FGF-2-stimulated OPG synthesis through the suppression of the Akt pathway in osteoblasts and that the inhibitory effect of resveratrol is mediated at least in part by SIRT1 activation.

We have previously shown that glycoprotein Ib/IX/V activation stimulates the release of the soluble CD40 ligand (sCD40L) via the generation of thromboxane A2 from human platelets. In the present study, the role of Rac, which is a member of the Rho family, was investigated in the thromboxane A2‑stimulated release of platelet‑derived growth factor (PDGF)‑AB and sCD40L in human platelets. U46619, a thromboxane receptor agonist, stimulated the activation of Rac time‑dependently in human platelets, and NSC23766, a selective inhibitor of the Rac‑guanine nucleotide exchange factor interaction, reduced the U46619‑induced platelet aggregation. NSC23766 markedly suppressed the U46619‑induced p38 mitogen-activated protein (MAP) kinase phosphorylation. The thromboxane A2‑induced release of PDGF‑AB and sCD40L was significantly suppressed by NSC23766 in a dose‑dependent manner. In addition, NSC23766 reduced the sCD40L release stimulated by ristocetin, a glycoprotein Ib/IX/V activator. These results indicate that Rac regulates the thromboxane A2‑induced stimulation of PDGF‑AB secretion and sCD40L release via the p38 MAP kinase in human platelets.

Introduction Gait disturbance of Parkinsonian syndrome is characterized by dysrhythmic gait cycle including freezing, small steps and slowness. These symptoms are often not sufficiently responsive to dopaminergic therapy. Recently, we developed new rehabilitation system using non-invasive closed–circuit brain stimulation targeting on dysrhythmic gait dysfunction. Methods The objective of this study is to investigate whether the oscillatory closed-circuit brain stimulation mimicking the appropriate gait cycle can modulate the gait speed and cycle in patients with parkinsonian syndrome. Six patients with Parkinsonian syndrome participated in this study. Three were diagnosed as Parkinson’s disease, two as corticobasal syndrome and one as vascular parkinsonism. Before gait rehabilitation, we decided optimal brain stimulation frequency to each subject as 1/averaged gait cycle when they were best on condition. All participants performed gait rehabilitation for total ten days which contained 4 sessions (4 min. walk and 3 min. rest) per each day. During gait rehabilitation, slow oscillatory DC stimulation (current intensity 0–2 mA) was applied over ipsilateral cerebellum as symptom dominant side, which was triggered by their flat foot switch attached to the ipsilateral heels. Closed-circuit system enabled the implementation of the oscillatory brain stimulation with a fixed pre-set phase lag with respect to the intrinsic gait cycle. Ten m gait speed, cadence, laterality of gait cycle and frozen of gait questionnaire (FOGQ) were evaluated before and after gait rehabilitation. Results Gait speed and cadence were significantly increased after gait rehabilitation (speed: 98 ± 39 cm/s before and 116 ± 38 cm/s after, cadence: 114 ± 18 steps/min before and 124 ± 20 steps/min after). Laterality of gait cycle and FOGQ were significantly decreased after the rehabilitation (laterality: 0.07 ± 0.05 before and 0.0021 ± 0.004 after, FOGQ: 10 ± 7 before and 7 ± 5 after). Conclusion Closed-circuit brain stimulation during walking is useful method to parkinsonian gait disturbance possibly by normalizing dysrhythmic and lateralized gait control system in patients with Parkinsonian syndrome. This new system may provide the personalized rehabilitation in patients with Parkinson related disorders.

Resveratrol is well known as a natural polyphenol abundantly found in red wine. We previously reported that bone morphogenetic protein-4 (BMP-4) stimulates vascular endothelial growth factor (VEGF) synthesis via p70 S6 kinase in osteoblast-like MC3T3-E1 cells. In the present study, we investigated the effect of resveratrol on the BMP-4-stimulated VEGF synthesis in MC3T3-E1 cells. Resveratrol significantly suppressed BMP-4-stimulated release and expression levels of VEGF mRNA. SRT1720, an activator of SIRT1 with potencies greater than resveratrol, also reduced VEGF release and the mRNA levels. Both resveratrol and SRT1720 markedly attenuated the BMP-4-induced phosphorylation of p70 S6 kinase without affecting the BMP-4-induced phosphorylation of Smad1/5/8. These findings strongly suggest that resveratrol attenuates BMP-4-stimulated VEGF synthesis through suppression of the activation of p70 S6 kinase in osteoblasts, and that the inhibitory effect is mediated at least in part by SIRT1 activation.

Resveratrol, a natural polyphenol abundantly found in grape skins and red wine, possesses various beneficial properties for human health. In the present study, we investigated the mechanism underlying the effects of prostaglandin F2α (PGF2α) on osteoprotegerin (OPG) synthesis and of resveratrol on the OPG synthesis in osteoblast-like MC3T3-E1 cells. PGF2α stimulated both the release of the OPG protein and the expression of OPG mRNA. Treatment with PD98059, SB203580 and SP600125, specific inhibitors of MEK1/2, p38 mitogen-activated protein (MAP) kinase and stress-activated protein kinase/c-jun N-terminal kinase (SAPK/JNK) all suppressed the OPG release induced by PGF2α. Resveratrol also significantly reduced the PGF2α-stimulated OPG release and the mRNA levels of OPG. Similarly, treatment with SRT1720, an activator of SIRT1, also suppressed the PGF2α-stimulated OPG release. Resveratrol and SRT1720 both attenuated the phosphorylation of p44/p42 MAP kinase, MEK1/2, Raf-1, p38 MAP kinase and SAPK/JNK induced by PGF2α. These findings strongly suggest that resveratrol suppresses PGF2α-stimulated OPG synthesis by inhibiting the MAP kinase pathways in osteoblasts, and that the effect is mediated via SIRT1 activation.

Soft tissue coverage around the knee has persisted as a challenge for plastic and reconstructive surgeons. The distally-based anterolateral thigh flap is often used for coverage. Nevertheless, few anatomical studies have investigated the retrograde vascular pedicle. This report clarifies the anatomy of the connection between the descending branch of the lateral circumflex femoral artery and the lateral superior genicular artery. This study examined 38 lower limbs from cadavers and recorded the numbers and locations of perforating vessels. Proximal and distal pivot points were also recorded. The proximal pivot point was 1.0-12.1 cm (average = 6.0 cm) from the inguinal ligament. The distal pivot point, found under the vastus lateralis muscle in all 38 specimens, was 4.0-13.6 cm (average = 9.8 cm) from the lateral superior edge of the patella. The most distal perforator was 8.2-28.0 cm (average = 18.9 cm) from the proximal pivot point. The most proximal perforator was 3.0-19.5 cm (average = 8.7 cm) from the distal pivot point. Details of the anastomosis of the descending branch and the superior lateral genicular artery were clarified. The distally-based anterolateral thigh flap presents one option for reconstruction around the knee.

We previously reported that interleukin-1 (IL-1), a potent bone resorptive cytokine, stimulates the synthesis of interleukin-6 (IL-6) via activation of p44/p42 mitogen-activated protein (MAP) kinase and p38 MAP kinase in osteoblast-like MC3T3-E1 cells, and that AMP-activated protein kinase (AMPK) negatively regulates the IL-1-induced IL-6 synthesis through the inhibitor of κB (IκB)/nuclear factor-κB (NF-κB) pathway. On the other hand, it is recognized that catechin possesses a beneficial property for bone metabolism. Among them, (-)-epigallocatechin gallate (EGCG) is an abundant and major bioactive component. In the present study, we investigated the effect of EGCG on the IL-1 stimulated IL-6 synthesis in osteoblast-like MC3T3-E1 cells. EGCG significantly enhanced the IL-1-stimulated IL-6 synthesis in a dose-dependent manner in the range between 50 and 100 μM. EGCG increased the mRNA levels of IL-6 stimulated by IL-1. IL-1-induced phosphorylation of IκB and NF-κB were suppressed by EGCG. On the other hand, EGCG failed to affect the IL-1-induced phosphorylation of p44/p42 MAP kinase, p38 MAP kinase and AMPK. These results strongly suggest that EGCG enhances IL-1-stimulated IL-6 synthesis through inhibiting the AMPK-IκB/NF-κB pathway at the point between AMPK and IκB/NF-κB in osteoblasts.

The present study describes a case of leg lymphedema due to iliopectineal bursitis associated with rheumatoid arthritis (RA), which was satisfactorily controlled by surgery and combination therapy with methotrexate (MTX) and tacrolimus. A 68-year-old male, who had a six-year history of RA, developed an iliopectineal bursa associated with destruction of the hip joint. The mass gradually increased in size, and there was swelling in his right lower extremity. The patient was subsequently hospitalized with increasing right hip pain and leg edema. A colorless transparent lymph fluid leaked from his leg, and leg lymphedema was thus diagnosed. The patient also had a 20-year history of myelodysplastic syndrome. Therefore, the extensive or total resection of the bursa was considered to be too invasive, so a partial bursal excision was performed via an anterior approach. Following the partial bursal excision, total hip arthroplasty (THA) was performed using the Hardinge approach. The leg lymphedema disappeared following the surgery, and the iliopectineal bursa was no longer enlarged. MTX and tacrolimus were postoperatively administered to strictly control the RA. The RA was subsequently well controlled, without any increases in the levels of inflammatory markers, such as C-reactive protein and matrix metalloproteinase-3. This case demonstrated that iliopectineal bursitis was resolved following THA, without complete excision of the intrapelvic bursa, and that strict RA control led to a good clinical course without recurrent inflammation of the bursa. Similar procedures may be beneficial in other patients contraindicated for resection of the entire bursa.