論文

STUDY DESIGN: An anatomic study of the associations between the fifth lumbar spinal nerve (L5 spinal nerve) and a lumbosacral tunnel, consisting of the fifth lumbar vertebral body (L5 vertebral body), the lumbosacral ligament, and sacral ala, and clinical case reports of four patients with lumbar radiculopathy secondary to entrapment of the L5 spinal nerve in the lumbosacral tunnel. OBJECTIVES: To delineate the anatomic, clinical, and radiologic features and surgical outcome of patients with entrapment of the L5 spinal nerve in the lumbosacral tunnel. SUMMARY OF BACKGROUND DATA: Although several cadaveric studies on a lumbosacral tunnel as a possible cause of L5 radiculopathy have been reported, few studies had focused on osteophytes of the L5-S1 vertebral bodies as the major component of this compressive lesion, and clinical reports on patients with this disease have been rare. METHODS: Lumbosacral spines from 29 geriatric cadavers were examined with special attention to the associations between osteophytes of the L5-S1 vertebral bodies and the L5 spinal nerve. Four patients with a diagnosis of the entrapment of the L5 spinal nerve by osteophytes at the lumbosacral tunnel were treated surgically, and their clinical manifestations and surgical results were reviewed retrospectively. RESULTS: The anatomic study demonstrated osteophytes of the L5-S1 vertebral bodies in seven of the 29 cadavers. Entrapment of the L5 spinal nerve in the lumbosacral tunnel was observed in six of the seven cadavers with L5-S1 osteophytes but in only one of the 22 cadavers without such osteophytes (P < 0.05, chi2 test). All four patients had neurologic deficits in the L5 nerve root distribution. MRI and myelography showed no abnormal findings in the spinal canal, but CAT scans demonstrated prominent osteophytes on the lateral margins of L5-S1 vertebral bodies in all four. Selective L5 nerve block completely relieved all patients of pain but only temporarily. Three patients were treated via a posterior approach by resecting the sacral ala along the L5 spinal nerve, and the other patient was treated by laparoscopic anterior resection of the osteophytes. Pain relief was obtained in the four patients immediately after surgery, but one patient experienced recurrence of pain 1 year after the first surgery and was successfully treated by additional posterior decompression and fusion. CONCLUSIONS: Extraforaminal entrapment of L5 spinal nerve in the lumbosacral tunnel can cause L5 radiculopathy, and osteophytes of L5-S1 vertebral bodies are a major cause of the entrapment.

Intervertebral disc (IVD) consists of a soft gelatinous material in its center, the nucleus pulposus (NP), bounded peripherally by fibrocartilage, annulus fibrosus (AF). Despite the number of patients with IVD degeneration, gene expression analysis has not been undertaken in NP and therefore little is known about the molecular markers expressed in NP. Here, we undertook a microarray screen in NP with the other nine tissues to identify the specific cell surface markers for NP. Five membrane associating molecules out of 10,490 genes were identified as highly expressing genes in NP compared with the other tissues. Among them, we identified CD24, a glycosylphosphatidylinositol (GPI) anchor protein as a cell surface marker for NP. CD24 expression was also detected in the herniated NP and chordoma, a malignant primary tumor derived from notochordal cells, while it was absent in chondrosarcoma. Therefore, CD24 is a molecular marker for NP as well as the diseases of IVD. © 2005 Elsevier Inc. All rights reserved.

Measurement of the morphological dimensions of the pedicles of the lumbar spine was conducted using computed tomography (CT) to clarify the difference in pedicle morphology among different lumbar degenerative diseases. The subjects were 136 patients with lumbar spinal disorders who underwent myelography followed by CT scans. They were divided into four groups, that is a group of 25 patients with degenerative spondylolisthesis (DS group), a group of 54 patients with lumbar canal stenosis (LCS group), a group of 42 patients with lumbar disc herniation (LDH group), and a control group of 15 patients with spinal cord tumor in cervicothoracic region but without lumbar diseases (control group). Measurements of the transverse diameter, axial length, and axial angle of the pedicles were performed on CT slices obtained at the middle of the pedicle. The transverse diameter was the width of the isthmus, the axial length was the distance between the anterior of the vertebral body and the posterior of the vertebral arch on a line perpendicular to the line bisecting the isthmus, and the axial angle was the angle between the line perpendicular to the line bisecting the isthmus and the midline of the vertebral body. While there were no significant differences in the mean transverse diameter or axial length among the four groups, the mean axial angle was significantly smaller in the DS and LCS groups when compared to that in the LDH and control groups. In the DS and LCS groups, the pedicles were more sagitally oriented than in the LDH and control groups. Such difference in the axial angle of the pedicles in different lumbar diseases should be taken into consideration when placing at the insertion of pedicle screws, because precise orientation of screw insertion would scarcely allow penetration of the pedicle wall. © Springer-Verlag 2005.

In conventional laminectomy for lumbar canal stenosis (LCS), intraoperative damage of posterior supporting structures can lead to irreversible atrophy of paraspinal muscles. In 2001, the authors developed a new procedure for lumbar laminectomy, the lumbar spinous process-splitting laminectomy (LSPSL). In this new procedure, the spinous process is split longitudinally in the middle and then divided at its base from the posterior arch, leaving the bilateral paraspinal muscles attached to the lateral aspects. Ample working space for laminectomy is obtained by retracting the split spinous process laterally together with its attached paraspinal muscles. After successfully decompressing nerve tissues, each half of the split spinous process is reapproximated using a strong suture. Thus, the supra- and interspinous ligaments are preserved, as is the spinous process, and damage to the paraspinal muscles is minimal. Eighteen patients with LCS underwent surgery in which this new technique was used. Twenty patients in whom conventional laminectomy was undertaken were chosen as controls. At 2 years, the clinical outcomes (as determined using the Japanese Orthopaedic Association [JOA] scores and recovery rate) and the rate of measured magnetic resonance imaging-documented paravertebral muscle atrophy were evaluated and compared between the two groups. The mean JOA score recovery rates were 67.6 and 59.2%, respectively, for patients treated with LSPSL and conventional laminectomy; the mean rates of paravertebral muscle atrophy were 5.3 and 23.9%, respectively (p = 0.0005). Preservation of posterior supporting structures and satisfactory recovery rate after 2 years indicated that this technique can be a useful alternative to conventional decompression surgery for lumbar canal stenosis.

OBJECT: The segmental-type of ossification of the posterior longitudinal ligament (OPLL) of the cervical spine is distinct from other types in its morphological features. Whether the results of expansive open-door laminoplasty for the segmental-type are different from those for other types remains unclear. To clarify this issue, the long-term results after surgical treatment of segmental-type OPLL were compared with those of other types. METHODS: Clinical results were documented in 57 patients who underwent expansive open-door laminoplasty and were followed for a minimum of 7 years, results were quantified using the Japanese Orthopaedic Association (JOA) scoring system to determine function. Segmental-type OPLL was observed in 10 patients (Group 1) and other types in 47 patients (Group 2). Preoperative JOA scores were not significantly different between the two groups. As many as 5 years after surgery, clinical results were favorable and maintained in both groups, and no significant intergroup difference in postoperative JOA scores was observed; however, after 5 years postoperatively, JOA scores decreased in both groups. The decrease was greater in Group 1, and a significant intergroup difference in JOA scores was demonstrated when analyzing final follow-up data. In Group 1, the authors found that the degree of late-onset deterioration relating to cervical myelopathy positively correlated with the cervical range of motion. CONCLUSIONS: The long-term results of expansive open-door laminoplasty in the treatment of segmental-type OPLL were inferior to those for other types. Cervical mobility may contribute to the development of late deterioration of cervical myelopathy.

We report excellent outcomes in two patients with cystic lesions in the lumbar spinal canal who underwent resection using the METRx™ microendoscopic discectomy (MED) system. Pathological examinations revealed the diagnoses of a synovial cyst and a discal cyst, respectively. Both of them were allowed to walk the next day after surgery with complete pain relief. Microendoscopic surgery provides excellent visualization of the spinal canal and allows minimally invasive removal of the pathological lesions. This technique can be an effective alternative to conventional open surgery for cystic lesions in the lumbar spine. © Georg Thieme Verlag KG Stuttgart.

OBJECT: Although neurological examination is the key step to reaching a correct diagnosis of cervical compressive myelopathy (CCM), the accuracy of diagnosis of the affected spinal level for CCM has not yet been tested. METHODS: The authors conducted a prospective study to elucidate how accurately the affected intervertebral level can be determined and decompressed based on neurological examination. Fifty patients who underwent successful decompressive surgery for cervical myelopathy caused by single-level disc herniation or spondylosis were included in this study (38 men and 12 women, mean age 60 years). Three board-certified spine surgeons participated in establishing the neurological diagnoses. One of the three surgeons made a diagnosis of CCM, and the other two conducted the neurological examination including deep tendon reflex, pinprick response, muscle weakness, and numbness in the hand only, knowing that the patient had CCM, and established the neurological-level diagnosis. A single intervertebral level responsible for patient's symptoms was determined concordantly based on magnetic resonance imaging and myelography findings by two spine surgeons, and this served as the standard. Agreement between neurological and neuroimaging/radiological level diagnoses was determined. The rate of agreement between neurological and neuroimaging diagnosis was 66%. Among the neurological tests, patient-perceived location of numbness in the hands was the most useful for establishing the affected level. For the other three tests the agreement rate was lower than 50% and thus each individual test may not be reliable for diagnosing the affected level. CONCLUSIONS: The results of this study suggested that neurological examination in patients with CCM is moderately accurate and reliable for determining the neurological level of disease.

The pedicle screw and hook have become popular instruments in treating spinal deformity and disease. This study gathered morphological data on thoracic and lumbar spines in a Japanese population that should serve as useful reference for posterior instrumentation surgery. One hundred and three dry bones were used to investigate the morphology of pedicle and facet in thoracic and lumbar spines. Measurements included the diameter and axial length of pedicle from T8 to L5, height and width of facets and thickness of articular processes from T1 to T12, and axial angle of pedicle from T1 to L5. The diameter and axial length of pedicle were smallest at T8, diameter was largest at L5 and axial length was largest at L3. Height of facets and thickness of articular processes were largest at T12. Men tended to have larger pedicles and facets than women. Transverse angle of pedicle was smallest at T12. These precise data may provide useful information when performing posterior instrumentation surgery and when developing new spinal implant systems for Asians. © Springer-Verlag 2005.

OBJECT: Structural interlaminar graft materials were used for atlantoaxial transarticular screw fixation (TSF), and its impact on the fusion status was investigated. METHODS: Forty-two patients (10 men, 32 women, mean age 51 years, mean follow-up period 45 months; 30 with rheumatoid arthritis, and 12 with os odontoideum) underwent TSF and modified Brooks posterior wiring involving titanium cables. As interlaminar graft materials, autologous bone from posterior iliac crest alone was used in 20 patients (Group A), and a structural spacer (13 ceramic spacers, nine titanium mesh cages) in 22 (Group B). Lateral radiographs were evaluated to determine bone fusion, alignment of the cervical spine, and wire loosening. Solid osseous fusion was obtained in 95% of Group A and 96% of Group B patients. The mean atlantoaxial angle was 19.1+/-9.7 degrees and 16.7+/-10.4 degrees before surgery (p = 0.45), and 27.4+/-7.8 degrees and 22.1+/-5.5 degrees after surgery (p = 0.02) in Groups A and B, respectively. Atlantoaxial hyperlordosis (atlantoaxial angle > or = 30 degrees) was observed in 32% of Group A and 18% of Group B patients (p = 0.26). Postoperative kyphosis occurred in 40% of Group A and 23% of Group B patients (p = 0.28). Loosening of the cable was demonstrated in 50% of Group A and 36% of Group B patients(p = 0.37). In Group B patients maintenance of cervical lordosis was more likely than in those in Group A, although the differences did not reach statistical significance. CONCLUSIONS: These results indicate that structural interlaminar spacers can maintain proper cervical alignment without a decease in the fusion rate; the authors recommend their use in conjunction with TSF.

The biological properties of using two kinds of cells, MC3t3-E1 of an osteoblastic cell line and the rat bone-marrow cell (RBMC) as mesenchymal stem cell model were discussed. The HAp fiber was synthesized via a homogeneous precipitation method using urea. The HAp fiber was mixed with the spherical carbon beads having a diameter of ∼ 150 μm in the mixed solvent. The single HAp phase was present in the S0, S1000, and S2000 scaffolds with porosity of 95% over. The results show that the high porosity and large pore size fulfilled by S2000 could provide an excellent environment for enhancing bone marrow cell activity.

The effectiveness of hydroxyapatite fibers (HAF) as a scaffold of osteoblastic cells for bone generation was investigated. Three types of HAF with different diameters of pores and porosity were used in the study. The results showed that HAF is degradable and can be eventually replaced by bone tissue in vivo. The results suggested that HAF can be used as an effective scaffold for osteoblast-like cells having capability for bone conduction and that HAF with larger pore sizes can be replaced by newly formed bone tissue in vivo.