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A retrospective review of a case series of five participants.To elucidate the effects of post-cervical laminoplasty on the clinical pathophysiology of traumatic CSCI. Cervical laminoplasty has been widely performed with good results in individuals for cervical myelopathy. However, no reports have thus far referred to the incidence of traumatic cervical spinal cord injury (CSCI) after previous history of cervical laminoplasty.Spinal Injuries Center, Japan.From 2008 to 2017, 999 cervical myelopathy individuals were treated by cervical laminoplasty in our institution. Of these, only five participants were subsequently emergency transported to our institution caused by traumatic CSCI. The pathology of five participants were cervical ossification of posterior longitudinal ligament (C-OPLL). The changes of cervical sagittal range of motion (ROM) and the morphology of OPLL were radiologically evaluated. Moreover, the mechanism of injury, the level of injury, and neurological evaluations were discussed.All of the participants demonstrated ankylosed cervical spine due to developing OPLL and spontaneous bony facet and laminar fusion on post-laminoplasty. A significant difference in cervical ROM was observed between pre-laminoplasty and 6 months post-laminoplasty (p = 0.0065). Three participants were extension injury and the other two were flexion injury.All of the five traumatic CSCI participants had a history of previous cervical laminoplasty for C-OPLL. Cervical laminoplasty for C-OPLL might lead to cervical spine with rigidity and ankylosing due to developing OPLL and bony facet and laminar fusion, and might have a risk for traumatic CSCI.

Study design: Retrospective cohort study. Objective: To investigate the characteristics of cervical spinal cord injury in patients over 65 years and examine the factors influencing their discharge home. Setting: Spinal Injuries Center, Fukuoka, Japan. Methods: We referred to past medical records and our database to extract data regarding consecutive cervical spinal cord injury cases between 2005 and 2020. Patients over 65 years old who were admitted to the hospital within 14 days of injury were selected. A univariate analysis was performed between the home discharge and out-of-home discharge groups. Multiple logistic regression analysis of admission findings and patient background was also performed to examine independent factors influencing home discharge. Results: Over 15 years, we included 219 patients in the study, of whom 41.1% were eventually discharged home. A two-group comparison between the home discharge and out-of-home discharge groups showed significant differences in age at injury, length of hospital stay, rate of American Spinal Injury Association (ASIA) Impairment Scale (AIS:A), cohabitants, ASIA motor score (AMS), and Spinal Cord Independence Measure (SCIM) at initial visit and discharge. Multivariate logistic regression analysis revealed that age at injury (OR: 0.88, 95% CI: 0.83–0.93, pConclusion: More than half the older adult patients with cervical cord injury were discharged outside the home. Age, percentage of AIS:A, and AMS values at admission were independent factors influencing home discharge.

Study design: Retrospective clinical study.Objectives: To evaluate annual changes in the pathology of conus medullaris injury (CMI) and investigate its precise pathophysiology.Setting: Hospital in Iizuka, Japan.Methods: From January 2012 to January 2020, 16 individuals with complete spinal cord injury caused by vertebral fracture at the level of T12 or L1 were included in this study. We collected American Spinal Injury Association Impairment Scale (AIS), Lower-Extremity Motor Score (LEMS), and modified Frankel classification (mFr) data at admission and at 24 months postoperatively. Results: At the final evaluation, 3 of the 16 participants (18.75%) showed neurological improvement from AIS A to AIS C or D. Furthermore, LEMS significantly improved during the postoperative 24 months (p < 0.05). In the mFr, 12 of the 16 participants (75.0%) showed improvement. Moreover, three individuals (18.75%) acquired independent walking ability (higher than mFr D3) at 24 months postoperatively.Conclusion: Even in cases of complete CMI only, the recovery of lower extremity muscle strength varies among individuals.

Many algorithms to detect copy number variations (CNVs) using exome sequencing (ES) data have been reported and evaluated on their sensitivity and specificity, reproducibility, and precision. However, operational optimization of such algorithms for a better performance has not been fully addressed. ES of 1199 samples including 763 patients with different disease profiles was performed. ES data were analyzed to detect CNVs by both the eXome Hidden Markov Model (XHMM) and modified Nord's method. To efficiently detect rare CNVs, we aimed to decrease sequencing biases by analyzing, at the same time, the data of all unrelated samples sequenced in the same flow cell as a batch, and to eliminate sex effects of X-linked CNVs by analyzing female and male sequences separately. We also applied several filtering steps for more efficient CNV selection. The average number of CNVs detected in one sample was

Background: Angelman syndrome (AS) is a neurodegenerative disorder caused by functional loss of the maternal ubiquitin-protein ligase 3A gene. Nonepileptic myoclonus, also described as tremulous movement, often occurs during puberty and increasesin adulthood. The involuntary movement in AS has not been defined patho-physiologically and the drugs used such as levetiracetamand piracetamare not alwayseffective. Recently, the alpha-amino-3-hydroxy-5-methyl-4-isoxazole propionate (AMPA) receptorantagonist, perampanel (PER), was used to alleviate myoclonus in progressive myoclonus epilepsy. Herein, we tested the efficacyof PER for nonepileptic myoclonus.Methods and results: Four patients with AS, aged from 20 to 40 years at the beginning of treatment, were enrolled in our study.All patients reported disruption to their daily lives from the myoclonus movement. They experienced mild to moderate improvementwith the starting dose of 2 mg. The dose was increased to 4 mg in one patient to achieve sufficient efficacy, while two had their dosereduced to 1 mg due to dizziness or possible exacerbation of myoclonus. The last patient continued to take the starting dose. Follow-up over 16?20 months revealed a significant reduction in the severity of nonepileptic myoclonus in all patients.Conclusion: Our study suggests that PER could be one of the promising drugs for nonepileptic myoclonus in AS.O2020 The Japanese Society of Child Neurology. Published by Elsevier B.V. All rights reserved.

STUDY DESIGN: Retrospective comparative clinical study. OBJECTIVE: To establish eligible diagnostic criteria for traumatic cervical spinal cord injury (TCSCI) without major fracture or dislocation and create a definitive clinical protocol by comparing the pathophysiology of CSCI in both traumatic and degenerative disorders. SETTING: Fukuoka, Japan. METHODS: A total of 21 TCSCI patients and 16 rapid progressive clinical deterioration of cervical spondylotic myelopathy (rp-CSM: additional cervical spinal cord injury with an existing cervical myelopathy) patients with impairment graded as C or D on the American Spinal Injury Association (ASIA) Impairment Scale were included in the study. Magnetic resonance (MR) images and ASIA motor scores were evaluated for all of the patients at the time of admission and 12 months postoperatively. RESULTS: The T2-weighted MR images for all patients showed an abnormally high intramedullary signal in the area of the injured segment at the first examination. At 12 months post-surgery, 47.62% of patients with TCSCI and none with rp-CSM had an abnormally low intramedullary signal change on T1-weighted MR images. The neurological improvement with rp-CSM was significantly greater than that with TCSCI at 12 months postoperatively. CONCLUSIONS: Our results suggest that the pathophysiology of CSCI between traumatic injury and degenerative disorder are similar, but not identical. The most important factor in the early pathophysiological differential diagnosis between these two pathologies is the presence of an existing cervical myelopathy. We believe that early prognosis with eligible diagnosis for CSCI may lead to early preparations for social rehabilitation in each case.

To elucidate the incidence and risk factors for pneumonia after acute traumatic cervical spinal cord injury (CSCI).Retrospective cohort study.From the 167 individuals who met the criteria, 30 individuals (18%) had pneumonia; in 26 (87%) of these individuals, pneumonia was aspiration related, defined as Dysphagia Severity Scale ≤ 4. The median occurrence of aspiration pneumonia was 11.5 days after injury. A logistic regression analysis revealed that severe AIS and severe Dysphagia Severity Scale scores were significant risk factors of pneumonia after CSCI.It was highly likely that the pneumonias following CSCI were related to aspiration based on the Dysphagia Severity Scale. In addition, most of the patients developed aspiration pneumonia within 1 month after injury. Aspiration and severe paralysis were significant risk factors for pneumonia. The treatment of dysphagia in the acute phase should be considered an important indicator to prevent pneumonia.

A retrospective clinical study.To elucidate the usefulness of the patellar tendon reflex (PTR), bulbocavernosus reflex (BCR), and plantar response (PR) as factors in the prognostic prediction of motor function in complete paralysis due to cervical spinal cord injuries (CSCIs) at the acute phase.Department of Orthopedic Surgery, Spinal Injuries Center, Japan.99 patients assessed as the American Spinal Injury Association Impairment Scale (AIS) grade A (AIS A) were included in this study. The PTR, BCR, and PR were evaluated respectively as positive or negative at the time of injury. We classified the patients into two groups based on their neurological recovery at 3 months after injury: "recovered" group was defined as AIS C, D, or E; "non-recovered" group was defined as AIS A or B.Eight patients demonstrated positive PTR, while 91 demonstrated negative. Three out of eight patients with positive PTR (37.5%) were R group, while 83 out of 91 patients with negative PTR (91.2%) were N group. A significant difference was observed (p = 0.043). For BCR, no significant difference was observed (p 0.05). Twenty-six patients demonstrated positive PTR, while 73 demonstrated negative. Nine out of twenty-six patients with positive PR (34.6%) were R group, while 71 out of 73 patients with negative PR (97.3%) were N group. A significant difference was observed (p = 0.000068).The PTR and PR are useful for poor prognostic prediction of motor function in CSCI at the acute phase.

Objective: To investigate the usefulness of the combination of neurological findings and magnetic resonance imaging (MRI) as a prognostic predictor in patients with motor complete cervical spinal cord injury (CSCI) in the acute phase. Design: A cross-sectional analysis Setting: Department of Orthopaedic Surgery, Spinal Injuries Center Participants/Methods: Forty-two patients with an initial diagnosis of motor complete CSCI (AIS A, n = 29; AIS B, n = 13) within 72 h after injury were classified into the recovery group (Group R) and the non-recovery group (Group N), based on the presence or absence of motor recovery (conversion from AIS A/B to C/D) at three months after injury, respectively. The Neurological Level of Injury (NLI) at the initial diagnosis was investigated and the presumptive primary injured segment of the spinal cord was inferred from MRI performed at the initial diagnosis. We investigated whether or not the difference between the presumptive primary injured segment and the NLI exceeded one segment. The presence of a difference between the presumptive primary injured segment and the NLI was compared between Groups R and N. Results: The number of cases with the differences between the presumptive primary injured segment and the NLI was significantly higher in Group N than in Group R. Conclusion: The presence of differences between the presumptive primary injured segment and the NLI might be a poor improving prognostic predictor for motor complete CSCI. The NLI may be useful for predicting the recovery potential of patients with motor complete CSCI when combined with the MRI findings.

Traumatic cervical spinal cord injury (SCI) is a devastating condition leading to respiratory failure that requires permanent mechanical ventilation, which is the main driver of increased medical costs. There is a great demand for establishing therapeutic interventions to treat respiratory dysfunction following severe cervical SCI.We present a 24-year-old man who sustained a cervical displaced C2-C3 fracture with SCI due to a traffic accident. As the patient presented with tetraplegia and difficulty in spontaneous breathing following injury, he was immediately intubated and placed on a ventilator with cervical external fixation by halo orthosis. The patient then underwent open reduction and posterior fusion of the cervical spine 3 weeks after injury. Although the patient showed significant motor recovery of the upper and lower limbs over time, only a slight improvement in lung capacity was observed.At 1.5 years after injury, a diaphragmatic pacing stimulator was surgically implanted to support the patient's respiratory function. The mechanical ventilator support was successfully withdrawn from the patient 14 weeks after implantation. We observed that both the vital capacity and tidal volume of the patient were significantly promoted following implantation. The patient finally returned to daily life without any mechanical support.The findings of this report suggest that diaphragmatic pacing implantation could be a promising treatment for improving respiratory function after severe cervical SCI. To our knowledge, this is the first SCI patient treated with a diaphragm pacing implantation covered by official medical insurance in Japan.

OBJECTIVE Numerous studies have reported on synovial facet joint cysts of the spine as a primary lesion. The exact pathogenesis of those cysts is still controversial, but degeneration and destabilization seem to be underlying mechanisms. However, only a few reports have thus far investigated synovial cysts of the spine as postoperative complications of decompression surgery. In this retrospective clinical study, the authors focused on synovial cysts of the lumbar facet joints as complications after lumbar decompression surgery, with the aim of elucidating their pathophysiology. METHODS A total of 326 patients with 384 segments treated with posterior decompression surgery without fusion were included in the study. Of these segments, 107 were surgically decompressed unilaterally and 277 were decompressed bilaterally. After surgery, 18 of the 384 segments developed a complication of symptomatic facet synovial cyst. The anatomical and morphological evaluations of these segments were performed using functional plain radiographs, CT scans, and MR images. RESULTS All of the 18 segments with postoperative lumbar facet synovial cyst were treated with bilateral lumbar posterior decompression. There was no significant radiological lumbar spinal instability in any segments, although 17 of 18 segments demonstrated facet articular spondylotic changes. Moreover, 12 of 18 patients demonstrated lumbar retrolisthesis in the neutral position. CONCLUSIONS Based on the authors’ results, they propose that patients with lumbar degenerative disease who have a potential biomechanical lumbar instability such as disruption of the facet articular surface and hydrarthrosis or lumbar facet tropism might have a high risk for formation of lumbar facet synovial cyst after bilateral posterior decompression surgery.

Swallowing dysfunction, which may cause aspiration pneumonia, is one of the most important complications of treatment of traumatic cervical spinal cord injury (CSCI); however, the mechanism of dysphagia is not well understood. No previous studies have reported the association between morphological changes of the soft tissue and dysphagia. We aimed to determine the factors associated with severity of dysphagia after CSCI and elucidate its mechanism. We conducted a prospective analysis of patients with acute traumatic CSCI who were admitted within 2 weeks of the injury. Dysphagia was evaluated using the Dysphagia Severity Scale (DSS) 2 weeks after the injury. The widths of the retropharyngeal and retrotracheal spaces were measured to assess soft tissue damage owing to the injury using sagittal images of computed tomography. We also assessed age, surgery of the injured cervical spine, presence of tracheostomy, osteophyte behind the pharynx, level of injury, and motor score 2 weeks after the injury. A total of 136 persons met our criteria. Given that 44 persons were categorized under grades

Rationale: Spontaneous spinal subdural hematoma (SSDH) is a rare disease that can cause severe permanent neurological dysfunction. Here we present a case of spontaneous SSDH, in which a series of magnetic resonance images (MRIs) taken through the course of the disease facilitated understanding of the resolution process of the hematoma and the diagnosis of SSDH. Patient concerns: A 59-year-old male presented with sudden severe back pain and rapid onset of paraplegia. This symptom had continued developing while he was transferred to the emergency department. Initial physical examination showed flaccid paralysis of both lower limbs with areflexia and loss of all sensation below T6 bilaterally. MRI images showed an anterior subdural hematoma from C7 to T7 with spinal cord compression. Diagnosis: Based on MRI findings, the diagnosis was SSDH. Interventions: We chose conservative treatment of 1-week bed rest and intensive rehabilitation for the patient due to the presence of sacral sparing and the slight motor recovery at 24 hours after the onset. Outcomes: Frequent MRI images demonstrated that the spinal cord compression was surprisingly mitigated only 2 days and mostly absorbed 4 days after the onset. The patient's motor function was recovered completely and he was discharged after 8 weeks of hospitalization. Lessons: Our chronological MRI findings provide crucial information for diagnosing SSDH and also suggest that spinal surgeons should consider the potential option of a conservative approach for treating SSDH. Although prompt selection of a therapeutic strategy for SSDH could be challenging, the surgeons could observe the course of the patient's neurological status for a few days to detect signs of spontaneous recovery.

Background: We herein report the usefulness of two types of talc pleurodesis for secondary pneumothorax of elderly patients with persistent air leak who have severe pulmonary emphysema. Methods: We assessed 17 elderly patients with persistent air leak who received talc pleurodesis for secondary pneumothorax from April 2013 to March 2017. Thoracoscopic talc poudrage (TTP) (n=11) was performed in patients whose general condition was thought to sufficiently stable to tolerate for general anesthesia. Talc slurry pleurodesis (TSP) (n=6) via a chest tube was performed in patients whose general condition was thought to be insufficiently stable to tolerate general anesthesia. Results: The median drainage period after pleurodesis was 6 days in patients who received TTP and 12 days in patients who received TSP. Complications associated with talc pleurodesis included atrial fibrillation (n=1) in the thoracoscopic poudrage group, while the slurry pleurodesis group showed chest pain (n=2), asthmatic attack (n=1), and pneumonia (n=1). All patients who received thoracoscopic poudrage were able to leave the hospital after removal of the chest tube. Five of the six patients who received slurry pleurodesis were able to leave the hospital, but one of them died of acute exacerbation of interstitial pneumonia (IP) on the 45th day after pleurodesis. The success rate was 94% (16/17). There were no cases of recurrence during the observation period. Conclusions: TTP was deemed likely to be safe and effective for patients able to tolerate general anesthesia. In patients with IP, especially those treated with steroids, the indication of talc pleurodesis should be cautiously considered.

Previous studies have reported that the expressions of specific proteins may predict the efficacy of chemotherapy agents for non-small cell lung cancer (NSCLC) patients. The present study evaluated the expression of proteins hypothesized to be associated with the effect of chemotherapeutic agents in 38 NSCLC patients with pathological stage II and IIIA. The subjects received carboplatin plus paclitaxel (CP) or S-1 as adjuvant chemotherapy following complete resection. The protein expressions evaluated were those of thymidylate synthase (TS), dihydropyrimidine dehydrogenase (DPD) and orotate phsphoribosyltransferase (OPRT), which were suspected to be associated with the effect of S-1 agents, excision repair cross-complementation group 1 (ERCC1), which was suspected to be associated with the effect of platinum-based agents, and class III β-tubulin (TUBB3), which was suspected to be associated with the effect of taxane-based agents. The positive rate of TS was 55.3% (n=21/38), DPD was 57.9% (n=22/38), OPRT was 42.1% (n=16/38), ERCC1 was 47.4% (n=18/38) and TUBB3 was 44.7% (n=17/38). Among the patients who received S-1 adjuvant chemotherapy, TS-negative cases demonstrated a significantly better disease-free survival than positive cases. Thus, TS protein expression may have been a factor that predicted the effect of S-1 agent as adjuvant chemotherapy.

Immune checkpoint inhibitors (ICIs) targeting the PD-1/PD-L1 pathway are expected to be a novel therapy for combating future increases in numbers of malignant pleural mesothelioma (MPM) patients. However, the PD-L1 expression, which is a predictor of the response to ICIs, is unclear in MPM. We studied the PD-L1 expression using four immunohistochemical assays (SP142, SP263, 28-8 and 22C3) in 32 MPM patients. The PD-L1 expression in tumor cells and immune cells was evaluated to clarify the rate of PD-L1 expression and the concordance among the four assays in MPM. The positivity rate of PD-L1 expression was 53.1% for SP142, 28.1% for SP263, 53.1% for 28-8, and 56.3% for 22C3. Nine cases were positive and 10 were negative for all assays. Discordance among the four assays was found in 13 cases. The concordance rates between SP142 and 22C3 and between 28-8 and 22C3 were the highest (84.4%). The concordance rates between SP263 and the other three assays were low (71.9% to 75.0%). The PD-L1 expression in MPM was almost equivalent for three of the assays. Given the cut-off values set in our study, these findings suggested that these assays, except for SP263, can be used for accurate PD-L1 immunostaining in MPM.

Currently, four immunohistochemical assays are registered with the US Food and Drug Administration to detect the expression of PD-L1. We investigated the PD-L1 expression in thymic carcinomas using these four diagnostic assays. The cases of 53 patients were reviewed and their specimens were subjected to four PD-L1 assays with different antibodies (SP142, SP263, 22C3, and 28-8). The PD-L1 expression in tumor cells (TCs) and immune cells (ICs) was evaluated. In TCs, the four assays showed similar scores in each case. Histopathologically, high TC scores were observed in squamous cell carcinomas (SqCCs). Meanwhile, there were no significant relationships among the IC scores in the four assays. In SqCCs, the high expression of PD-L1 (defined as ≥50% TC score) in TCs tended to be associated with early stage cancer. The patients with high expression levels of PD-L1 tended to show longer overall survival in the 22C3 assays (p=0.0200). In thymic carcinomas, the staining pattern showed high concordance among the four assays when TCs – rather than ICs – were stained. High PD-L1 positivity in TCs, especially in SqCCs, indicated that PD-1/PD-L1 targeted therapy may be a promising therapeutic approach.

Importance The optimal management for acute traumatic cervical spinal cord injury (SCI) is unknown. Objective To determine whether early surgical decompression results in better motor recovery than delayed surgical treatment in patients with acute traumatic incomplete cervical SCI associated with preexisting canal stenosis but without bone injury. Design, Setting, and Participants This multicenter randomized clinical trial was conducted in 43 tertiary referral centers in Japan from December 2011 through November 2019. Patients aged 20 to 79 years with motor-incomplete cervical SCI with preexisting canal stenosis (American Spinal Injury Association [ASIA] Impairment Scale C; without fracture or dislocation) were included. Data were analyzed from September to November 2020. Interventions Patients were randomized to undergo surgical treatment within 24 hours after admission or delayed surgical treatment after at least 2 weeks of conservative treatment. Main Outcomes and Measures The primary end points were improvement in the mean ASIA motor score, total score of the spinal cord independence measure, and the proportion of patients able to walk independently at 1 year after injury. Results Among 72 randomized patients, 70 patients (mean [SD] age, 65.1 [9.4] years; age range, 41-79 years; 5 [7%] women and 65 [93%] men) were included in the full analysis population (37 patients assigned to early surgical treatment and 33 patients assigned to delayed surgical treatment). Of these, 56 patients (80%) had data available for at least 1 primary outcome at 1 year. There was no significant difference among primary end points for the early surgical treatment group compared with the delayed surgical treatment group (mean [SD] change in ASIA motor score, 53.7 [14.7] vs 48.5 [19.1]; difference, 5.2; 95% CI, −4.2 to 14.5;P = .27; mean [SD] SCIM total score, 77.9 [22.7] vs 71.3 [27.3];P = .34; able to walk independently, 21 of 30 patients [70.0%] vs 16 of 26 patients [61.5%];P = .51). A mixed-design analysis of variance revealed a significant difference in the mean change in ASIA motor scores between the groups (F1,49 = 4.80;P = .03). The early surgical treatment group, compared with the delayed surgical treatment group, had greater motor scores than the delayed surgical treatment group at 2 weeks (mean [SD] score, 34.2 [18.8] vs 18.9 [20.9]), 3 months (mean [SD] score, 49.1 [15.1] vs 37.2 [20.9]), and 6 months (mean [SD] score, 51.5 [13.9] vs 41.3 [23.4]) after injury. Adverse events were common in both groups (eg, worsening of paralysis, 6 patients vs 6 patients; death, 3 patients vs 3 patients). Conclusions and Relevance These findings suggest that among patients with cervical SCI, early surgical treatment produced similar motor regain at 1 year after injury as delayed surgical treatment but showed accelerated recovery within the first 6 months. These exploratory results suggest that early surgical treatment leads to faster neurological recovery, which requires further validation. Trial Registration ClinicalTrials.gov Identifier:NCT01485458; umin.ac.jp/ctr Identifier:UMIN000006780

Several prognostic studies looked for an association between the degree of spinal cord injury (SCI), as depicted by primary magnetic resonance imaging (MRI) within 72 hours of injury, and neurologic outcome. It was not clearly demonstrated whether the MRI at any time correlates with neurologic prognosis.The purpose of the present study was to investigate the relationship between acute MRI features and neurologic prognosis, especially walking ability of patients with cervical spinal cord injury (CSCI). Moreover, at any point, MRI was clearly correlated with the patient's prognosis.Retrospective image study.From January 2010 to October 2015, 102 patients with CSCI were treated in our hospital. Patients who were admitted to our hospital within 3 days after injury were included in this study. The diagnosis was 78 patients for CSCI with no or minor bony injury and 24 patients for CSCI with fracture or dislocation. A total of 88 men and 14 women were recruited, and the mean patient age was 62.6 years (range, 16-86 years). Paralysis at the time of admission was graded as A in 32, B in 15, C in 42, and D in 13 patients on the basis of the American Spinal Injury Association (ASIA) impairment scale. Patients with CSCI with fracture or dislocation were treated with fixation surgery and those with CSCI with no or minor bony injury were treated conservatively. Patients were followed up for an average of 168 days (range, 25-496 days).Neurologic evaluation was performed using the ASIA motor score and the modified Frankel grade at the time of admission and discharge.Magnetic resonance imaging was performed for all patients at admission. Using the MRI sagittal images, we measured the vertical diameter of intramedullary high-intensity changed area with T2-weighted images at the injured segment. We studied separately the patients divided into two groups: 0-1 day admission after injury, and 2-3 days admission after injury. We evaluated the relationship between the vertical diameter of T2 high-intensity changed area in MR images and neurologic outcome in these two groups. This study does not contain any conflict of interest.In the group admitted at 0-1 day after injury, there was a relationship between the vertical diameter of T2 high-intensity area in MR image and the ASIA motor score at admission and at discharge, but correlation coefficient was low (0.3766 at admission and 0.4239 at discharge). On the other hand, in the group admitted at 2-3 days after injury, there was a significant relationship between the vertical diameter of T2 high-intensity area in MR image and the ASIA motor score at admission and at discharge, and correlation coefficient was very high (0.6840 at admission and 0.5293 at discharge). In the group admitted at 2-3 days after injury, a total of 17 patients (68%) recovered to walk with or without a cane. Receiver operating characteristic (ROC) curve analysis demonstrated that the optimal vertical diameter of T2 high-intensity area cutoffvalue for patients who were able to walk at discharge was 45.8 mm. If the vertical diameter of T2 high-intensity area cutoff value was 45 mm, there was a significant positive correlation with being able to walk at discharge (p.0001).From our study, 2-3 days after injury, a significant relationship was observed between the vertical diameter of T2 high-intensity area and the neurologic prognosis at discharge. Zero to 1 day after injury, the relationship between the vertical diameter of T2 high-intensity area and the neurologic prognosis at discharge was weak. Neurologic prognosis is more correlated with MRI after 2-3 days after the injury. If the vertical diameter of T2 high-intensity area was45 mm, the patients were able to walk with or without a cane at discharge. T2 high-intensity changed area can reflect the neurologic prognosis in patients with CSCI.

Tracheal resection followed by reconstruction is one of the most difficult procedures in the field of thoracic surgery. Right thoracotomy performed via a posterolateral incision is selected for middle and lower tracheal resection under general anesthesia. In order to develop a novel less invasive surgical procedure, it is necessary to devise methods to keep the operating field clear and to use better methods of anesthesia. Thoracic surgeons have attempted to improve surgical techniques, the approach, and methods of anesthesia in order to minimize the trauma to the patient and to reduce the incidence of postoperative complications, including respiratory complications.

Patients with smoking-independent lung cancer mainly consist of females, yet the molecular background of this epidemiological feature, other than epidermal growth factor receptor (EGFR) mutation, remains unclear. Several studies have revealed the association between female hormone-associated factors and the prognosis of lung cancer, however the data remain inconsistent. The present study focused on the expression of estrogen receptor (ER)α in order to elucidate this association in smoking-independent lung cancer. Immunohistochemistry staining (IHC) of aromatase, ERα and ERβ was performed against formalin-treated tissues from 38 patients who had never-smoked who underwent complete surgical resection between 2012 and 2013. Among them, adequate RNA of the tumor and adjacent normal lung cancer was extracted from 31 matching deep frozen samples. Considering the IHC results, reverse transcription-quantitative polymerase chain reaction (RT-qPCR) was performed to measure the expression level of 2 different exons of ERα, exon 6 and exon 7, which are part of the ligand binding domain of ERα, using the Taqman gene expression assay. Extra-nuclear expression of ERα using IHC demonstrated a statistically significant association with pathological invasiveness. RT-qPCR results exhibited a decreased expression of ERα exon 7 in invasive tumor tissues, compared with their adjacent normal tissues. This is consistent with the findings of previous in vitro studies indicating that extra-nuclear ERα were exon 7 splicing variants. No difference was observed in ERα exon 7 expression between normal and tumor tissues in non-invasive lung cancer tissues. When considering the EGFR mutation status, EGFR wild-type lung cancers exhibited decreased ERα exon 7 expression levels compared with EGFR mutated lung cancers. Extra-nuclear expression of ERα, which may represent exon 7 splicing variants of ERα, showed statistical association with pathological invasiveness in smoking-independent lung cancer. The post-translational splicing mechanism of ERα may be involved in the acquired invasiveness of smoking independent lung cancer.

Retrospective chart audits. To investigate the optimal timing at which permanent complete cervical spinal cord injury (CSCI) can be confirmed when evaluating paralysis caused by traumatic CSCI. Department of Orthopedic Surgery, Spinal Injuries Center, Japan. Two-hundred and three patients with CSCI that was classified with an American Spinal Injury Association (ASIA) Impairment Scale (AIS) grade A (AIS A) within 72 h of the initial diagnosis of traumatic CSCI were included in the present study. Neurological data from the time of the initial diagnosis to 1 year after the injury were extracted. The number of those with recovery from AIS A and changes of AIS in the recovery were examined. Thirty-five of 203 (17%) patients whose injuries were initially classified with an AIS A showed recovery from AIS A. Thirty-four of 35 (97%) patients showed recovery from AIS A within 8 weeks after injury. If CSCI patients with AIS A have not recovered by 8 weeks, the likelihood that they will recover from AIS A is marginal. However, this conversely means that we must consider the possibility that a patient with a traumatic CSCI classified with an AIS A may still show recovery from AIS A within the first 8 weeks after injury.

Introduction Compressive-flexion type cervical spine fracture is typically accompanied by apparent dislocation of the facet joints, undesirable cervical alignment, and devastating neurological dysfunction, which provides strong rationale for rendering prompt operative treatment. However, the validity of conservative treatment for compressive-flexion cervical spine injury in cases with preserved congruity of the facet joints has yet to be elucidated. The purpose of this study is to evaluate the long-term outcome of cervical alignment following conservative treatment for compressive-flexion cervical spine injury with preserved congruity of the facet joints. Methods A total of 662 patients who experienced spinal cord injury from 2007 to 2017 were included and underwent retrospective review in a single institute. Thirteen patients were identified as receiving conservative therapy following compressive-flexion cervical spine fractures with spinal cord injury. Clinical and radiological results were collected, including vertical fractures of the vertebral column, laminar fractures, progression of local kyphosis, and neurological status. The degree of the local cervical kyphosis was evaluated with two methods: the posterior tangent method and the endplate method. Results All 13 patients were male, and the mean age at the time of injury was 28.4 years. The mean follow-up period was 3 years. Although none of the patients presented neurological deterioration after the injury, the degree of local kyphosis was increased at the time of final follow-up compared to what was observed at the time of injury. Patient age at the time of injury and concurrent vertical fracture of vertebral body could have been influencing factors for the progression of the kyphosis. While laminar fracture affected the kyphosis at the time of injury, it was not a strong influencing factor of the overall progression of local kyphosis. Conclusions The conservative option for the compressive-flexion cervical injury allowed us to treat without exacerbating neurological symptoms as long as the facet joints are preserved. However, in terms of cervical alignment, surgical stabilization may have been desirable for these patients. Notably, the younger patients and the patients with vertical fracture of the cervical vertebral column in this type of injury required closer observation to help prevent the progression of local kyphosis.

Prospective cohort study. To elucidate serial changes in dysphagia and elucidate the critical period for dysphagia following acute traumatic cervical spinal cord injury (CSCI). Spinal Injuries Center, Fukuoka, Japan. We prospectively examined individuals with acute traumatic CSCI admitted within 2 weeks after injury. Severity of dysphagia was evaluated using both the dysphagia severity scale (DSS) and functional oral intake scale (FOIS) at 2 weeks, 1 month, 2 months, and 3 months after injury. Condition of oral intake before injury was assessed by history taking. American Spinal Injury Association (ASIA) impairment scale grade and motor scores were also assessed at the same timepoints, and the correlation between dysphagia and paresis was analyzed. Sixty-five individuals with CSCI were assessed consecutively for 3 months after injury. Swallowing function, evaluated using both the DSS and FOIS, was significantly decreased at 2 weeks after injury, but significantly improved thereafter. Significant correlations between severity of dysphagia (DSS and FOIS scores) and motor scores were found at 2 weeks after injury (rs = 0.66 and 0.61; p

Background: Pure red cell aplasia (PRCA) associated with thymoma is relatively rare, and relevant reports are limited. We investigated the clinical features and outcomes of PRCA associated with thymoma in this study. Methods: A retrospective review of all PRCA patients who underwent surgical resection of thymoma from April 1, 2004, to December 31, 2015, was performed. Results: We experienced eight patients with PRCA among 146 patients who underwent surgical resection of thymoma. Extended thymectomy (n=4) and thymectomy (n=4) were performed for thymoma. Regarding the WHO classification of thymoma, the subtypes were type B2 or B3 in seven patients, and the stage of thymoma was advanced in seven patients. Complete resection was achieved macroscopically in only five patients. Recurrence of thymoma occurred in four patients who underwent complete resection. PRCA was diagnosed after surgical resection of thymoma in six patients (range 1–101 months, median 56.5 months). Cyclosporine was used for PRCA in six patients. Pneumonia of treatment-related complications due to cyclosporine occurred in all patients. The follow-up period ranged from 13–147 months (median 54.5 months) after the PRCA diagnosis. Three patients obtained complete remission of anemia by cyclosporine. Although one patient was able to stop taking cyclosporine because of complete remission of anemia, transfusion was needed due to relapse of PRCA. Five patients died, with the main causes of death diagnosed as pneumonia (n=4) and cardiac failure (n=1). Conclusions: PRCA associated with thymoma was diagnosed postoperatively in three-quarter of patients. We should be alert for the occurrence of PRCA even after resection of thymoma, especially in patients with incomplete resection or advanced disease. Cyclosporine was effective for PRCA, but treatment-related complications occurred, particularly pneumonia. As treatment for PRCA associated with thymoma and its complications were combined in a complex manner, treating PRCA associated with thymoma can be quite difficult.

Retrospective chart audit. To indicate the appropriate baclofen dosage to control severe spasticity of spinal origin and to develop the optimal administration protocol for long-term intrathecal baclofen (ITB) therapy. Department of Orthopaedic Surgery, Spinal Injuries Center, Japan. Thirty-four people with spasticity of various spinal origins who were consistently treated at our hospital were included. The median follow-up period was 6 years and 11 months. Measures of Ashworth score were taken before and after surgical implant of baclofen pump. We decided not to increase the baclofen dosage after the Ashworth score reached 1. We recorded the control of spasticity, changes in the baclofen dose, and the incidence of complications. The average Ashworth score was 3.31 (1.75–4.0) before implant surgery, 1.38 (1.0–2.25) after implant surgery, and 1.39 (1.0–2.25) at the final follow-up, while the average baclofen dose (therapeutic/optimal dose) was 230.6 μg/day (50–450). The incidence of each complication was as follows: 8.8% (n = 3) catheter-related, 2.9% (n = 1) pump-related and 5.9% (n = 2) drug tolerance. No patients experienced withdrawal syndrome. Dose fluctuation with changes in the pathology of the original disease was observed in three cases. The usage of the Ashworth score as a guide for dose adjustment was found to be a good objective indicator for ITB therapy. The administration based on this objective indicator made it possible to effectively manage patients with a relatively low dose of baclofen and a low rate of drug-related complications.