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Background The latest clinical guidelines are mandatory for physicians to follow when practicing evidence-based medicine in the treatment of low back pain. Those guidelines should target not only Japanese board-certified orthopaedic surgeons, but also primary physicians, and they should be prepared based entirely on evidence-based medicine. The Japanese Orthopaedic Association Low Back Pain guideline committee decided to update the guideline and launched the formulation committee. The purpose of this study was to describe the formulation we implemented for the revision of the guideline with the latest data of evidence-based medicine. Methods The Japanese Orthopaedic Association Low Back Pain guideline formulation committee revised the previous guideline based on a method for preparing clinical guidelines in Japan proposed by Medical Information Network Distribution Service Handbook for Clinical Practice Guideline Development 2014. Two key phrases, "body of evidence" and "benefit and harm balance" were focused on in the revised version. Background and clinical questions were determined, followed by literature search related to each question. Appropriate articles were selected from all the searched literature. Structured abstracts were prepared, and then meta-analyses were performed. The strength of both the body of evidence and the recommendation was decided by the committee members. Results Nine background and nine clinical qvuestions were determined. For each clinical question, outcomes from the literature were collected and meta-analysis was performed. Answers and explanations were described for each clinical question, and the strength of the recommendation was decided. For background questions, the recommendations were described based on previous literature. Conclusions The 2019 clinical practice guideline for the management of low back pain was completed according to the latest evidence-based medicine. We strongly hope that this guideline serves as a benchmark for all physicians, as well as patients, in the management of low back pain.

Masumi Iwabuchi,1 Ryoji Tominaga,1 Jun Komatsu,1,2 Osamu Shirado1 1Department of Orthopaedic and Spinal Surgery, Aizu Medical Center at Fukushima Medical University, Aizuwakamatsu, Fukushima, Japan; 2Department of Medicine for Motor Organs, Juntendo University Graduate School of Medicine, Tokyo, JapanCorrespondence: Masumi Iwabuchi, Department of Orthopaedic and Spinal Surgery, Aizu Medical Center at Fukushima Medical University, Aizuwakamatsu, Fukushima, 969-3492, Japan, Tel +81-242-75-2100, Fax +81-242-75-2568, Email bucci@fmu.ac.jpPurpose: To investigate whether the minimally invasive spinal fusion can provide the better outcome than conventional fusion surgery in the treatment of degenerative lumbar spinal diseases.Patients and Methods: One hundred and thirteen patients who had undergone single-level fusion surgery for degenerative lumbar spinal diseases were examined with a minimum of one-year follow-up. There were 56 men and 57 women with a median age of 70s ranging 47– 88. The following three-types of fusion surgery were performed; minimally invasive transforaminal interbody fusion after microscopic decompression through a unilateral approach with percutaneous pedicle screwing (MTLIF), transforaminal interbody fusion after microscopic decompression through a unilateral approach (TLIF), and posterior lumbar interbody fusion with posterolateral fusion after open decompression through a bilateral approach (PLIF). The purpose for limiting on single level degenerative spinal disease was that it would be easy to compare the surgical outcomes among the three groups.Results: There were no statistically significant differences among three groups in terms of VAS scores, RDQ scores, and all of the domains in the JOABPEQ scores at the baseline. The JOABPEQ score for pain-related disorders at 6 months after surgery was statistically significantly higher in MTLIF group than the other two groups (P = 0.023). There were no statistically significant differences in the scores of the other outcome measures among three groups in whole follow-up period.Conclusion: The current study demonstrated that the JOABPEQ score for pain-related disorders at 6 months postoperatively was significantly better in MTLIF group than in the other groups. Since lumbar degenerative diseases mostly consisted in elderly patients, less invasive surgeries are desirable. MTLIF resulted in a better health-related QOL at 6 months after surgery, and its outcomes at the final follow-up were non-numerical inferiority. The results strongly indicate that MTLIF is desirable surgery especially for elderly patients with degenerative spinal diseases.Keywords: minimally invasive spinal fusion surgery, transforaminal lumbar interbody fusion, posterior lumbar interbody fusion, posterolateral fusion, health-related QOL, surgical outcome, percutaneous pedicle screwing, CT-based navigation system

Purpose To determine whether abnormalities of the sagittal modifiers (SMs) of the Scoliosis Research Society (SRS)-Schwab classification truly reflect back pain (BP)-specific quality of life (QOL), it is necessary to examine their dose–response relationships and to determine clinically impactful thresholds for declines in BP-specific QOL. This study aimed to analyse the continuous dose–response relationship between each SM and BP-specific QOL. Methods This cross-sectional study, using data from a Japanese population-based cohort study, included 519 community-dwelling residents aged ≥ 50 years who participated in the annual health examination. The participants completed the Roland–Morris Disability Questionnaire (RDQ) on BP-specific QOL. Spino-pelvic alignment based on SMs was assessed by whole-spine X-ray examinations. We fitted general linear models with or without nonlinear terms to estimate the dose–response relationship between each SM and BP-specific QOL. Results Pelvic tilt, pelvic incidence minus lumbar lordosis (PI-LL), and sagittal vertical axis showed dose–response relationships with BP-specific QOL measured as the RDQ score. PI-LL was most likely to predict a minimally clinically important RDQ score when its value exceeded the 90th percentile. A nonlinear relationship between PI-LL and the BP-specific QOL score was found. RDQ increased when PI-LL exceeded 10°. Conclusion PI-LL might be the most sensitive of the three modifiers of the SRS-Schwab classification for determining BP-specific QOL. Moreover, BP-specific QOL worsens rapidly when the compensatory mechanism against malalignment exceeds a critical value. Therefore, we suggest that traditional classifications and surgical strategies should be re-examined regarding the dose-dependent abnormalities of the SMs to develop a more reliable classification strategy.

The purpose of this study was to evaluate the gait posture of patients with adult spinal deformity (ASD) using a 3-dimensional motion analysis system (3DMAS) and to investigate whether it affects gait endurance.Fifty-one patients with ASD aged 50 years or older who were admitted to our hospital between March 2016 and March 2018 were included in the study. The subjects completed the 6-min walking test, which is an indicator of gait endurance. Static standing posture was assessed by whole-spine x-ray examination (coronal cobb angle, CCA; sagittal vertical axis, SVA; pelvic tilt, PT; and pelvic incidence minus lumbar lordosis, PI-LL). In addition, the gait posture was evaluated by a 3DMAS (dynamic trunk tilt angle, DTA; and dynamic pelvic tilt angle, DPA). The relationship between standing and gait postures and gait endurance was investigated by multivariable analysis.In univariable analysis, SVA, PI-LL, and DTA were associated with gait endurance. Furthermore, in the multivariable analysis, DTA showed the strongest association among the static and dynamic parameters (RAn association was found between gait posture and gait endurance in patients with ASD. These findings can be useful to health care providers treating patients with ASD. It is advisable to assess the gait posture of patients with ASD because they present postural abnormalities during gait.

This study aims to investigate the relationship between dynamic alignment of the spine and pelvis during gait and quality of life (QOL) in lumbar spinal canal stenosis (LSS) patients. We evaluated QOL using the Oswestry Disability Index (ODI), trunk and hip muscle strength as physical function, static spinal alignment, and dynamic spinal/pelvic alignment during gait. The relationship between the ODI score and physical function or static and dynamic alignment were examined. A total of 30 preoperative patients with LSS were participated in this study. ODI score significantly correlated with trunk extension strength (r = -0.559, p = 0.002), hip extension strength (r = -0.473, p = 0.011), maximum flexion angle of spine during gait (r = -0.551, p = 0.002) and maximum anterior tilt angle of pelvis (r = 0.528, p = 0.004). Multiple regression analysis showed that trunk extension strength (standardized β; - 0.35), maximum spinal flexion angle (standardized β; - 0.51) and hip extension strength (standardized β; - 0.40) significantly affected the ODI score, with adjusted coefficient of determination of 0.62. The results of this study showed that the LSS patients with weak hip or trunk extensor muscles, a greater angle of pelvic tilt or a less spinal flexion during gait had a lower QOL.

Purpose This study was to evaluate clinical outcomes using a patient-oriented test that scores health-related quality of life (HRQOL) for patients after minimally invasive surgery using microendoscopic discectomy (MED) for lumbar disc hernia. Few studies regarding MED in terms of disease-specific quality of life measures using Japanese Orthopaedic Association Back Pain Evaluation Questionnaire (JOABPEQ) have been published. Methods Retrospective analysis of the surgical and clinical outcomes with regard to reducing pain and improving the functional status for 31 patients who underwent MED for lumbar disc hernia was conducted. These patients were evaluated at 3-year follow-up. The evaluations were based on a visual analogue scale (VAS), the Japanese Orthopaedic Association (JOA) scoring system, and the JOABPEQ, which is an objective, patient-oriented test that assesses HRQOL in patients with lumbar disorders. Results A low rate of improvement was seen only in mental health until 1 year, the low rate of improvement in mental health and was independently correlated with body mass index (BMI), pre-operative scores on the Brief Scale for Psychiatric problems in Orthopaedic Patients (BS-POP), and scores on the BS-POP at 12 months post-operatively. Conclusions All categories of VAS, JOA scores, and all domains of JOABPEQ were significantly higher over 3 years than those obtained pre-operatively. But only mental health domain showed mild improvement until 1 year. Moreover, BMI showed a negative correlation with improvements in the mental health domain post-operatively. As patients may be mentally exhausted from lumbar disc herniation, pre-operative mental health may be improved by surgical treatment.

Study Design: Single-hospital cross-sectional study.Purpose: The aim of the present study was to investigate the physical functions influencing dynamic postural change in patients with adult spinal deformity (ASD).Overview of Literature: Dynamic postural change leading to increased forward lean during gait is a problem in patients with ASD; however, the relationship between this change and trunk and hip extensor strength is unclear.Methods: Thirty patients with ASD aged ≥50 years who were admitted to our hospital between July 2016 and September 2019 were included in this study. X-ray parameters (i.e., sagittal vertical axis, pelvic tilt, and pelvic incidence minus lumbar lordosis) were evaluated from the full-length standing radiographs of the subjects. Trunk and hip extensor strength was evaluated using a hand-held dynamometer. Dynamic postural changes (i.e., sagittal trunk shift during standing, sagittal trunk shift during gait, and delta sagittal trunk shift) were assessed using a three-dimensional motion analysis system. The relationships between dynamic postural change and various X-ray parameters, as well as trunk and hip extensor strength, were examined using multivariable analysis.Results: Multivariable analysis showed that hip extensor strength is the factor most strongly associated with dynamic postural change among the X-ray parameters and physical functions assessed in this study (β=−0.41, R2=0.12).Conclusions: We demonstrated the association between dynamic postural change and hip extensor strength in patients with ASD. Our results may be useful to healthcare providers treating patients with ASD. Interventions for dynamic postural change in patients with ASD should focus on hip extensor strength.

Background Patient-reported outcome measures are widely utilized to assess health-related quality of life (HRQOL) in patients with adolescent idiopathic scoliosis (AIS). However, the association between HRQOL and curve severity is mostly unknown. The aim of this study is to clarify the association between HRQOL and curve severity, and to determine the optimal cutoff values of patient-reported outcomes for major curve severity in female patients with AIS. Methods Female patients with AIS treated conservatively were recruited. The patients’ HRQOL outcomes were examined using the revised Scoliosis Research Society-22 (SRS-22r) and the Scoliosis Japanese Questionnaire-27 (SJ-27). The correlations of the SRS-22r and SJ-27 scores with the major Cobb angle were assessed using Spearman’s correlation coefficient analysis. The association between HRQOL issues in the SJ-27 and the major Cobb angle was evaluated by calculating Akaike’s Information Criterion (AIC). Furthermore, the optimal cutoff values of the SRS-22r and SJ-27 scores for the major Cobb angle were determined by AIC analysis. Results The study cohort comprised 306 female patients with AIS. The SRS-22r and SJ-27 scores were significantly correlated with the major Cobb angle. Questions in the SJ-27 regarding discomfort when wearing clothes showed a lower AIC value in patients with severe scoliosis. The optimal cutoff values were a SRS-22r score of 3.2 for the discrimination of severe scoliosis (Cobb angle ≥48°), and a SJ-27 score of 32 for the discrimination of moderate scoliosis (Cobb angle ≥33°). Conclusion Discomfort when wearing clothes was the most important HRQOL problem caused by severe scoliosis. The SRS-22r and SJ-27 scores are useful for the discrimination of clinical status in female patients with severe scoliosis or moderate scoliosis.

To determine whether abnormalities of the sagittal modifiers (SMs) of the Scoliosis Research Society (SRS)-Schwab classification truly reflect back pain (BP)-specific quality of life (QOL), it is necessary to examine their dose-response relationships and to determine clinically impactful thresholds for declines in BP-specific QOL. This study aimed to analyse the continuous dose-response relationship between each SM and BP-specific QOL.This cross-sectional study, using data from a Japanese population-based cohort study, included 519 community-dwelling residents aged ≥ 50 years who participated in the annual health examination. The participants completed the Roland-Morris Disability Questionnaire (RDQ) on BP-specific QOL. Spino-pelvic alignment based on SMs was assessed by whole-spine X-ray examinations. We fitted general linear models with or without nonlinear terms to estimate the dose-response relationship between each SM and BP-specific QOL.Pelvic tilt, pelvic incidence minus lumbar lordosis (PI-LL), and sagittal vertical axis showed dose-response relationships with BP-specific QOL measured as the RDQ score. PI-LL was most likely to predict a minimally clinically important RDQ score when its value exceeded the 90th percentile. A nonlinear relationship between PI-LL and the BP-specific QOL score was found. RDQ increased when PI-LL exceeded 10°.PI-LL might be the most sensitive of the three modifiers of the SRS-Schwab classification for determining BP-specific QOL. Moreover, BP-specific QOL worsens rapidly when the compensatory mechanism against malalignment exceeds a critical value. Therefore, we suggest that traditional classifications and surgical strategies should be re-examined regarding the dose-dependent abnormalities of the SMs to develop a more reliable classification strategy.

BACKGROUND AND OBJECTIVE Identifying risks for older adults who will require healthcare resources is critical for the government, healthcare providers, and consumers. The objective of this study was to examine the relationship between the results of the single limb standing (SLS) test and healthcare costs among community-dwelling older adults. METHODS We used data obtained from a population-based prospective cohort study of the residents of Tadami town in Fukushima Prefecture, Japan. The participants were above 60 years of age and had undergone annual health check-ups, and data on their healthcare costs over the two-year study period were available. A censored regression model adjusted for potential confounders was used to estimate the mean difference in total healthcare costs between participants who could remain standing on a single limb for at least 30 s and those who could not. RESULTS Healthcare costs of participants who passed the SLS test were significantly lower than those who did not. The mean difference between the two groups' healthcare costs was 4064 USD (95 % confidence interval: 2661-5467 USD, p

Background A progressive deformity associated with adolescent idiopathic scoliosis (AIS) negatively affects a patient’s health-related quality of life (HRQOL). Although the Scoliosis Research Society-22 (SRS-22) is the standard measurement tool for assessing HRQOL in patients with AIS, it is partially suboptimal for evaluating HRQOL in Japanese patients with AIS because of cultural differences. The purpose of this study was to develop a novel patient-reported outcome measure for Japanese female patients with AIS and to evaluate the reliability and validity of this questionnaire in comparison with the SRS-22 tool. Methods We developed 27 questions based on the psychosocial problems in the daily life of young female patients with AIS in Japan, the Scoliosis Japanese Questionnaire-27 (SJ-27). To evaluate its reliability, the internal consistency was assessed using Cronbach’s alpha coefficient. Concurrent validity was evaluated using Spearman’s correlation coefficient between the SJ-27 and the SRS-22. To investigate the construct validity of the SJ-27, the correlation between the SJ-27 questions was assessed using Akaike’s information criterion (AIC). Results We analyzed 384 female patients with AIS. Cronbach’s alpha coefficients were 0.914 and 0.829 for the SJ-27 and the SRS-22, respectively. Spearman’s correlation coefficient between the SJ-27 and the SRS-22 was 0.692 (p

Therapy for chronic, nonspecific low back pain is mainly conservative: medication and/or exercise. Pharmacotherapy, however, has side effects, and the quantities of concomitant drugs in older persons require attention. Although exercise promises improved function, its use to alleviate pain is controversial. Thus, we compared the efficacy of pharmacotherapy versus exercise for treating chronic nonspecific low back pain. The pharmacotherapy group (n=18: 8 men, 10 women) were prescribed celecoxib monotherapy. The exercise group (n=22: 10 men, 12 women) undertook stretching exercises. Because of drop-outs, the NSAID group (n=15: 7 men, 8 women) and the exercise group (n =18: 8 men, 10 women) were finally analyzed. We applied a visual analog scale, Roland–Morris disability scores, and the 36-Item Short Form Health Survey. We used a paired t-test for within-group analyses and an unpaired t-test for between-group analyses. Pain relief was achieved after 3 months of pharmacotherapy or exercise. Quality of life improved only in the exercise group. Recovery outcomes for the two groups were not significantly different. Efficacy of exercise therapy for strictly defined low back pain was almost equivalent to that of pharmacotherapy and provided better quality of life.

Background The pathological mechanisms of lumbar spinal stenosis are unclear. Family doctors in the primary care setting may perform medical examinations of patients with lumbar spinal stenosis. Our aim was to use the painDETECT questionnaire to quantify the pathological mechanisms of low back pain and/or leg pain caused by lumbar spinal stenosis. Methods We enrolled 102 patients (37 men, 65 women) who had been newly diagnosed with lumbar spinal stenosis at 2 facilities. The patients’ conditions were evaluated using the painDETECT questionnaire, Numerical Rating Scale, Roland-Morris Disability Questionnaire, Japanese Orthopaedic Association Back Pain Evaluation Questionnaire, and 36-Item Short-Form Health Survey. The pathological mechanisms of low back pain and/or leg pain caused by lumbar spinal stenosis were classified based on results of the painDETECT questionnaire as nociceptive pain, neuropathic pain, or unclear type of pain (mixed pain). Statistical analyses were performed using the Kruskal–Wallis test. A value of p

Study design Prospective, randomized, controlled trial. Objective To investigate the effectiveness of home-based exercise on pain, dysfunction, and quality of life (QOL) in Japanese individuals with chronic low back pain (CLBP). Summary of background data Exercise therapy is a widely used treatment for CLBP in many countries. The studies on its effectiveness have been performed only in Western industrialized countries. The existence of cross-cultural differences and heterogeneity of patients in each country may influence the outcome of interventions for CLBP. Data that would enable researchers to compare the effectiveness of interventions between widely different societies is lacking. Methods A total of 201 patients with nonspecific CLBP were randomly assigned to either the control or exercise therapy group: 89 men and 112 women with a mean age of 42.2 years. The control group was treated with nonsteroidal anti-inflammatory drugs (NSAIDs), and the exercise group performed trunk muscle strengthening and stretching exercises. The primary outcome measures were pain intensity (visual analogue scale) and dysfunction level (Japan Low back pain Evaluation Questionnaire [JLEQ] and Roland-Morris Disability Questionnaire [RDQ]) over 12 months. The secondary outcome measure was FFD (Finger-floor distance). Statistical analysis was performed using Wilcoxon signed-ranks and Mann-Whitney U tests, and estimation of the median with 95% CI was calculated. Results In both groups, significant improvement was found at all points of follow-up assessment. However, JLEQ and RDQ were significantly more improved in the exercise group compared to the control group (P = 0.021 in JLEQ, P = 0.023 in RDQ). The 95% CI for the difference of medians of the change ratio between exercise and NSAID groups, [Exercise] - [NSAID], was -0.25 to -0.02 in JLEQ, -0.33 to 0.00 in RDQ, and -0.20 to 0.06 in visual analogue scale. Conclusion The home-based exercise prescribed and monitored by board-certified orthopedic surgeons was more effective than NSAIDs for Japanese patients with CLBP.

1 Laboratory of Statistics, Osaka City University Faculty of Medicine, Osaka, Japan 2 Department of Orthopaedic Surgery, Keio University, 35 Shinanomachi, Shinjuku, Tokyo 160-8582, Japan 3 Department of Orthopaedic Surgery, Wakayama Medical University, Wakayama, Japan 4 Department of Orthopaedic Surgery, School of Medicine, Fukushima Medical University, Fukushima, Japan 5 Department of Orthopedic Surgery, Nippon Medical School, Tokyo, Japan 6 Department of Orthopaedic Surgery, The University of Tokyo, Tokyo, Japan 7 Department of Orthopaedic Surgery, Iwate Medical University School of Medicine, Morioka, Japan 8 Department of Orthopaedic Surgery, Saitama Medical School. Saitama, Japan 9 Department of Orthopedic Surgery, Yamaguchi University School of Medicine, Yamaguchi, Japan 10 Department of Orthopedic Surgery, Graduate School of Medicine, Chiba University, Chiba, Japan 11 Department of Orthopaedics, Kochi Medical School, Kochi, Japan 12 Department of Orthopaedic Surgery, Hoshigaoka Koseinenkin Hospital, Osaka, Japan 13 National Hospital Organization, Osaka-Minami Medical Center, Osaka, Japan 14 Department of Internal Medicine, Houai Hospital, Osaka, Japan 15 Department of Public Health, Osaka City University Faculty of Medicine, Osaka, Japan

Background The Japanese Orthopaedic Association decided to revise the JOA score for low back pain and to develop a new outcome measure. In February 2002, the first survey was performed with a preliminary questionnaire consisting of 60 evaluation items. Based on findings of that survey, 25 items were selected for a draft of the JOA Back Pain Evaluation Questionnaire (JOABPEQ). The second survey was performed to confirm the reliability of the draft questionnaire. This article further evaluates the validity of this questionnaire and establishes a measurement scale. Methods The subjects of this study consisted of 355 patients with low back disorders of any type (201 men, 154 women; mean age 50.7 years). Each patient was asked to fill in a self-administered questionnaire. Superficial validity was checked in terms of the completion rate for filling out the entire questionnaire. Factor analysis was then performed to evaluate the validity of the questionnaire and establish a measurement scale. Results As a result of the factor analysis, 25 items were categorized into five factors. The factors were named based on the commonality of the items: social function, mental health, lumbar function, walking ability, and low back pain. To establish a measurement scale for each factor, we determined the coefficient for each item so the difference between the maximum factor scores and minimum factor scores was approximately 100. We adjusted the formula so the maximum for each factor score was 100 and the minimum was 0. Conclusions We confirmed the validity of the JOA Back Pain Evaluation Questionnaire and est ablished a measurement scale.

BackgroundTo establish a patient-oriented outcome measure for cervical myelopathy, a subcommittee of the Japanese Orthopaedic Association (JOA) developed a new scoring system to evaluate the overall clinical status of patients, which could be completed by patients themselves. The subcommittee completed three large-scale studies to select and modify questions derived from various preexisting outcome measures including Short Form-36, and then finalized and validated the questionnaire, which comprised 24 questions.MethodsThe finalized questionnaire was administered to 369 patients with cervical myelopathy due to disc herniation, spondylosis, or ossification of posterior longitudinal ligament by randomly selected board-certified spine surgeons. Patients with different severities of myelopathy were included to insure accuracy and responsiveness of this questionnaire against patients’ different neurological status.ResultsData of 236 patients were employed and were subjected to rigorous statistical analyses. There was no question that was difficult to answer and distribution of answers for each question was not concentrated to one choice, indicating the appropriateness of all 24 questions. Results of factor analysis suggested that the 24 questions could be divided into five different factors or functional domains. The factors were defined as follows: factor 1, lower extremity function; factor 2, quality of life; factor 3, cervical spine function; factor 4, bladder function; and factor 5, upper extremity function. Finally, equations that would yield scores for the five factors were assembled. The score to be used to represent the degree of patients’ disability or status in each domain can be calculated by multiplying prefixed numbers of selected answers to questions by preassigned coefficients. Coefficients were defined to make the minimum score 0 and the maximum score 100.ConclusionsWe have successfully established a questionnaire that is able to demonstrate the status of patients suffering cervical myelopathy from five different aspects represented by five intuitive numerical scores. The final issue to be confirmed is the responsiveness of this questionnaire to changes in patients’ status after various surgical and nonsurgical treatments.

Study design Development of a nationwide patient-based outcome measure for patients with chronic low back pain (CLBP). Objective The purpose of this study was to develop and introduce a new means of measuring outcomes for Japanese individuals with CLBP (the Japan Low Back Pain Evaluation Questionnaire [JLEQ]), and to examine its validity and reliability by comparison with the Roland-Morris Disability Questionnaire (RDQ). Summary of background data CLBP is a serious problem affecting the health and welfare of workers, especially laborers. The severity and disability it causes vary depending on cultural background and the psycho-emotional aspect of the patients. Methods The following items were tested for the JLEQ and the RDQ using psychometric analyses: content validity, construct validity, criterion validity, internal-consistency reliability, and test and retest reliability. Results A total of 195 patients with CLBP participated in this study. There were no floor and ceiling effects in the JLEQ. Cronbach's alpha coefficient was 0.971 and 0.893 for the JLEQ and RDQ, respectively. The test-retest interclass correlation coefficient in the JLEQ was 0.886, indicating good test-retest reliability. Categorical principal component analysis showed that the construct structure consisted of 3 item clusters in the JLEQ. The factor loading patterns indicated that the JLEQ items were separated into 3 domains, i.e., a moderately loaded group, a less loaded group, and psychological conditions. The degree of correlation between the question items in the JLEQ and RDQ was evaluated using Akaike Information Criteria. Conclusion The JLEQ was shown to be a valid and reliable questionnaire scale for measurement of patient-based outcomes in CLBP patients.

Background The project to develop a new Japanese Orthopaedic Association (JOA) score rating system for low back disorders, the JOA Back Pain Evaluation Questionnaire (JOABPEQ), is currently in progress. Part 1 of the study selected 25 “candidateȝ items for use on the JOABPEQ. The purpose of this current Part 2 of the study was to verify the reliability of the questionnaire. Methods A total of 161 patients with low-back disorders of any type participated in the study. Each patient was interviewed twice at an interval of 2 weeks using the same questionnaire. The reliability of the questionnaire was evaluated by determining the extension of the kappa and weighted kappa coefficients. Results Both kappa and weighted kappa were more than 0.50 for all but one item, which was 0.48. The lower 95% confidence interval exceeded 0.4 in all but two items, which was 0.39. This implied that the test–retest reliability of JOABPEQ was acceptable as a measure of outcome. Conclusions The tentative questionnaire of the JOABPEQ with 25 items was confirmed to be reliable enough to describe the quality of life of patients who suffer low back disorders.

BackgroundThe manner of measuring the outcome of cervical myelopathy must be patient-oriented and have sufficient reliability and validity. The current Japanese Orthopaedic Association (JOA) scoring system for cervical myelopathy is widely used but has not met this requirement. The first- and second-round surveys established 24 items for inclusion on a new questionnaire for cervical myelopathy. The purpose of this study (the third-round survey A) was to confirm the reproducibility of patient responses to the selected questions.MethodsA total of 201 patients with cervical myelopathy and with no change of symptoms between the two interviews were included. Each patient was interviewed twice using the same questionnaire at an interval of 4 weeks. The reliability of the questionnaire was evaluated by determining the extension of the weighted kappa coefficients.ResultsThe weighted kappa coefficient for each item was >0.4, confirming that the test–retest reliability was acceptable.ConclusionsThe newly developed JOA Cervical Myelopathy Evaluation Questionnaire was proven to have sufficient reliability.

There are three questions to be addressed in lumbar disc herniation with separation of the ring apophysis: does this lesion occur only in adolescents, does any trauma predispose this lesion, and is removal of the detached apophyses mandatory to achieve satisfactory results? We prospectively investigated 32 consecutive patients (22 men, 10 women; mean age, 25.4 years; mean followup, 4 years 8 months). This lesion occurred not only in adolescents, but also in adults older than 30 years. Eight patients (25%) were younger than 20 years, whereas 14 patients (43.8%) were in the third decade, and 10 (31.2%) were in the fourth decade. Only five patients (15.6%) had antecedent traumatic episodes. Resection of the fragment did not influence the clinical results. Excision of the herniated disc and mobile bony fragment was done in 11 patients (34.4%). Discectomy alone was done in 21 patients (65.6%) with immobile bony fragments. Satisfactory results were obtained in both groups. Lumbar disc herniation with detachment of the ring apophysis can occur, without any relationship to trauma, in adults and adolescents. Removal of the bony fragment is not always needed to achieve satisfactory results.

✓ Sarcoidosis is a systemic disease commonly affecting lung, skin, or eye. Sarcoidosis involved with osseous structures occurs in approximately 5% of patients, usually involving small bones. Spinal sarcoidosis is extremely rare. The authors report on a man in whom examination of a subclavicular lymph node biopsy specimen and its spinal involvement had established a diagnosis of sarcoidosis and who had undergone steroid therapy. Despite intensive conservative treatment, the authors observed progressive collapse of L-2 requiring spinal decompressive and reconstructive surgeries. Histological evaluation of the collapsed vertebra did not show the typical noncaseating granuloma; rather, the authors observed osteonecrosis of the entire L-2 structure without reactive cellular activities. Other potential diagnoses including infectious disease, metastatic spinal tumor, and osteoporotic vertebral collapse were excluded based on laboratory data, imaging studies, and pathological findings. Complete necrosis of the entire L-2 vertebra in this case can be considered as a rare clinical manifestation of spinal sarcoidosis. Because of osteopenia and systemic bone fragility, combined anterior—posterior spinal reconstructive surgery was performed to restabilize the severely damaged spine.

Shirado O, Kawase M, Minami A, Strax TE. Quantitative evaluation of long sitting in paraplegic patients with spinal cord injury. Arch Phys Med Rehabil 2004;85:1251–6. Objectives To evaluate the characteristics of long sitting (ie, sitting with legs extended) in patients with spinal cord injury (SCI) and to compare these results with able-bodied control subjects. Design A kinematic study using a video camera and forceplate with a strain-gauge type load cell. Setting A referral center for patients with SCI in Japan. Participants Twenty-four subjects, including 11 able-bodied, matched control subjects and 13 SCI patients with complete paraplegia. Interventions Not applicable. Main outcome measures Sitting posture in the sagittal plane as well as the movement pattern and distance of the center of pressure (COP). Results Patients with SCI kept their pelvis tilted posteriorly and the lumbar spine was less lordotic during long sitting. The changing COP pattern during long sitting differed in able-bodied subjects as compared patients with SCI. During long sitting with arms outstretched over the thighs, COP movement in the subjects with SCI was significantly greater than that in the able-bodied subjects. When the arms were outstretched over the thighs, the COP shifted anteriorly in the able-bodied subjects and posteriorly in the patients with SCI. Conclusions Long sitting in the paraplegic patients with SCI was unstable compared with the able-bodied subjects. The COP distribution pattern differed significantly between the 2 groups. The support and function of the upper extremities may influence balance during long sitting in the patients with SCI. The method of seating evaluation using a video camera and gravicorder was easy to use and appeared to provide an objective measurement of dynamic seating function in the patients with SCI.

The retinoblastoma protein (pRB) and its homologues, p107 and p130, prevent cell cycle progression from G(0)/G(1) to S phase by forming complexes with E2F transcription factors. Upon phosphorylation by G(1) cyclin-cyclin-dependent kinase (Cdk) complexes such as cyclin D1-Cdk4/6 and cyclin E-Cdk2, they lose the ability to bind E2F, and cells are thereby allowed to progress into S phase. Functional loss of one or more of the pRB family members, as a result of genetic mutation or deregulated phosphorylation, is considered to be an essential prerequisite for cellular transformation. In this study, we found that pRB family proteins have the ability to stimulate cyclin D1 transcription by activation of the NF-kappaB transcription factor. The cyclin D1-inducing activity of pRB is abolished by adenovirus E1A oncoprotein but not by the deletion of the A-box, the B-box, or the C-terminal region of the pocket, indicating that multiple pocket sequences are independently involved in cyclin D1 activation. Intriguingly, tumor-derived pRB pocket mutants retain the cyclin D1-inducing activity. Our results reveal a novel role of pRB family proteins as potential activators of NF-kappaB and inducers of G(1) cyclin. Certain pRB pocket mutants may give rise to a cellular situation in which deregulated E2F and cyclin D1 cooperatively promote abnormal cell proliferation.

Background: It has been suggested that the principal mechanism of nystagmus suppression in the nystagmus blockage syndrome is either adduction of the eye or convergence. We examined this issue using the nystagmus of the vestibulo-ocular reflex (VOR) as a model. Methods: A motorized, computer-controlled rotary chair was used to produce VOR in darkness, using either sinusoidal or velocity step stimulation. Left eye position was monitored and horizontal slow-phase eye velocity was calculated. Subjects were cued to converge or perform other gaze tasks. Results: Convergence suppressed nystagmus. With sinusoidal stimulation, nystagmus was nearly extinguished in extreme lateroversion, probably due to mechanical tethering of the eye. However, VOR gain suppression of 47% during convergence was observed even when the monitored eye was close to primary position. With velocity step stimulation, nystagmus was nearly extinguished at moderate angles of adduction. Conclusions: Convergence is sufficient to suppress nystagmus, without vision and without regard to whether the eye is adducted.

The clinical presentation of a herniated lumbar disc depends on which nerve root is affected. Therefore, the diagnosis of the level of herniation is initially based on the neurological symptoms and signs and is confirmed by a radiographic examination. Herniation of a disc at a level between the first and fourth lumbar vertebrae usually causes compression of the second, third, or fourth lumbar nerve roots. In addition, the herniation is associated with characteristic findings, including pain and sensory loss over the anterior portion of the thigh or the medial aspect of the leg, or both; a positive femoral-nerve-stretch test; weakness of the quadriceps or the iliopsoas muscle, or both; and a diminished or absent patellar ligament reflex3. Our report describes a patient who had a herniated disc between the first and second lumbar vertebrae with sciatica and a monoradiculopathy of the fifth lumbar nerve root. A sixty-seven-year-old woman was admitted to the hospital because of low-back pain, sciatica on the left, and weakness of the left lower extremity. For two months she had had low-back pain, and for three weeks pain had radiated from the left buttock to the lateral aspect of the thigh, the anterolateral portion of the leg, and the dorsal part of the foot. She had slight difficulty walking because of muscular weakness. She had no bowel or bladder incontinence. The pain was aggravated with movement of the trunk, especially forward bending, and was relieved by bed rest. The initial physical examination revealed diffuse tenderness over the low back and localized tenderness over the posterior portion of the left thigh and calf. A straight-leg-raising test was positive at 60 degrees on the left, and the femoral-nerve-stretch test was negative. No atrophy or fasciculation of the muscles was found. A neurological examination demonstrated weakness (grade 4 …

The purpose of this study was to analyze the ability of the patients with idiopathic scoliosis to transfer the body weight in the frontal plane.Randomized and controlled study.A referral center and institutional practice and outpatient care.Fifty patients with idiopathic scoliosis (three men and forty-seven women; average age 15.3 years) and 15 normal women (average age 17.3 years) participated in this study. Thirty patients were treated with underarm braces.Computer-assisted force plates were used to evaluate the laterally shifted weight and the time period during side-shift on sitting.During both slow and fast side-shifts, shifted weight in the patients with idiopathic scoliosis was significantly less than in the normal controls (p0.05). The shifted weight was less on the concave side than on the convex one. The time for the shift to the concave side was longer in the patients than in the normal controls (p0.05). The brace was effective in correcting the imbalance of shifted weight in the patients with idiopathic scoliosis.The current study demonstrated the different patterns of weight side-shift between normal subjects and patients with idiopathic scoliosis. The patients transferred less weight laterally than the normal subjects during slow and fast random movements. The patients also showed slower side-shift patterns than the normal subjects during the fast random movement.

Posture to avoid hyperextension of the lumbar spine during isometric trunk muscle exercises has been widely recommended. However, there are no common standards for cervical and pelvic alignment during exercises. To investigate the effects of four different techniques regarding cervical and pelvic alignment, electromyographic (EMG) and radiological studies were performed on 30 healthy subjects. The four different postures were: (1) maximally extended neck, (2) neutral neck, (3) maximally flexed neck, and (4) maximally flexed neck with pelvic stabilization through muscle contraction. During flexion exercises, the largest increase in EMG activity in the abdominal muscles was observed with the flexed neck with pelvic stabilization (p < .01). During extensor exercises, the largest increase in EMG activity in the erector spinae was also obtained in the same position (p < .01). An increase of EMG activity in antagonist muscles (eg, erector spinae on flexion, and rectus and oblique muscles on extension) was also greatest with the flexed neck and pelvic stabilization. From the radiographic study, degrees of lumbar lordosis were least with the flexed neck and pelvic stabilization (p < .01). This study showed that neck and pelvic alignment can influence the EMG activity of trunk flexors and extensors during isometric trunk exercises. For isometric trunk muscle exercises, a maximum flexed neck with pelvic stabilization through muscle contraction seems to be the most optimal posture for decreasing the lumbar lordosis and for activating trunk flexors and extensors most effectively.

Study Design. This in vitro analysis defines biomechanical properties of the Triumph Lumbar Disc (TLD) for posterolateral lumbar disc arthroplasty. Objectives. To quantify segmental kinematics afforded by the TLD, determine whether intervertebral positional changes of the device affect spinal kinematics, and compare kinematics following TLD reconstruction with historical CHARITE data. Summary of Background Data. As an alternative to arthrodesis, total disc arthroplasty serves to restore the biomechanical properties of the spine. However, there are kinematic and clinical concerns regarding posterior lumbar column destabilization and reconstruction using motion-preserving technology. Methods. Seven human lumbosacral spines were biomechanically evaluated under the following conditions: (1) Intact; (2) Unilateral facetectomy; (3) Facetectomy and discectomy; (4) TLD-posterior; (5) TLD-central; (6) TLD-anterior. Centers of intervertebral rotation (COR) and intradiscal pressures were compared at the operative/adjacent levels. Results. In axial rotation, L4-L5 range of motion (ROM) increased to 110% ± 15.3% following unilateral facetectomy and 134.3% ± 26.9% following facet/discectomy. Implanting the TLD in 3 positions—posterior, central, and anterior-demonstrated no significant differences in ROM (P > 0.05). Trends were similar in flexion/extension and lateral bending. The neutral zone increased under the facet/discectomy condition and TLD reconstructions compared to the intact condition (P < 0.05). CORs were dispersed at the operative level following destabilization. TLD in posterior and central positions restored loci to near the intact condition, whereas the anterior position produced more diffuse CORs. Adjacent level intradiscal pressures decreased in flexion-extension following destabilization and reconstruction. Conclusion. Axial rotation ROM following TLD reconstruction (central position) was 131.5% of intact, compared to historical controls for the CHARITE device (162.0%). This indicates that lumbar disc arthroplasty performed using a posterolateral approach may offer biomechanical advantages over the anterior approach. Moreover, this approach may minimize surgical complications and allow simultaneous decompression of the neural elements. Intervertebral positional changes of the TLD were not shown to affect spinal kinematics.

In order to clarify the pathomechanism of thoracolumbar burst fractures and to evaluate the influence of disc degeneration and bone mineral density, a biomechanical study was performed using cadaveric spines. Eleven motion segments of thoracolumbar spines from human cadavers were compressed vertically until a fracture occurred. In addition, bone mineral density and degree of disc degeneration were determined for each specimen. Compression of 7 of 11 specimens resulted in the typical burst fracture characterized by retropulsion of a bony fragment into the spinal canal and an increase of the interpedicular distance. All seven specimens showed disruptions of the middle end plate and disc materials in the vertebral body. The fracture line was located between the middle of the end plate and the middle of the posterior wall cortex. No burst fractures were seen in the specimens with severely degenerated discs and osteoporosis. In order to confirm the stress state in a vertebra that induces the burst fracture, finite element analysis of one motion segment was also carried out under the same mechanical conditions as the experiments in this study. As a result of calculation for the healthy disc, the highest stresses under axial compression were concentrated in the following areas: the middle of the end plate, the cancellous bone under the nucleus pulposus, and the middle of the posterior wall cortex. This implies that the above regions are more vulnerable to vertical compressive load. In the analysis of specimens with severely degenerated discs, stresses were very low at the end plate and cancellous bone under the nucleus.(ABSTRACT TRUNCATED AT 250 WORDS)

Rheumatoid arthritis often involves the cervical spine, especially the atlantoaxial joint. Although any cervical lesion can induce myelopathy in patients with rheumatoid arthritis, it is difficult to precisely predict if the lesion will progress and produce the myelopathy in a prospective fashion. The diagnostic imaging studies including plain radiographs, computed tomography, and magnetic resonance imaging are not always of sufficient quality to identify and predict the instability in the cervical spine in an rheumatoid arthritis patient. This article presents a patient with rheumatoid arthritis who had an acute collapse of a seemingly stabilized C5-6 segment, followed by severe quadriparesis resulting in death.

Thoracic hyperkyphosis, or loss of lumbar lordosis, is often equated with osteoporosis because vertebral fractures are assumed to be a major causative factor. However, recent evidence suggests that up to one-half of the patients with hyperkyphosis have no evidence of underlying vertebral fracture. The shape characteristics of the intervertebral discs and their role in determining kyphotic curvature have been investigated. The spinal sagittal parameters and segmental disc angles of elderly subjects were examined during a longitudinal follow-up.A total of 53 subjects (20 men, 33 women) without vertebral fractures during a more than 10-year follow-up were included in this study, undergoing standing lateral radiographs of the spine using 36-inch film at baseline and final follow-up. The mean age of the subjects was 63 years (range 50-77 years) at baseline and 75 years (range 62-88 years) at follow-up; and the mean follow-up period was 11 years 11 months.The lumbar lordosis and the sacral inclination angle decreased and the C7-plumbline distance increased with age. Among a total of 664 discs, 70 discs (10.5%) showed anterior wedging over 5 degrees at follow-up. In contrast, 39 discs (5.9%) showed posterior wedging over 5 degrees . The subjects had only discs with anterior wedging, decreased total lumbar lordosis, and the C7 plumbline displaced anteriorly. However, when the subjects had discs with posterior wedging, the C7 plumbline and sagittal spinal balance tended to be maintained. This compensatory mechanism was seen in younger subjects.A decrease in the total lumbar lordosis and the sacral inclination angle occurred with age. Increasing age correlated with a more forward sagittal vertical axis, depending on a decrease in the total lumbar lordosis. The cause of loss of lumbar lordosis in the subjects without vertebral fracture was anterior wedging of the segmental discs. Posterior wedging of the thoracic and lumbar segmental discs then could occur, compensating for the loss of lumbar lordosis.

Background To establish a patient-oriented outcome measure for cervical myelopathy, a subcommittee of the Japanese Orthopaedic Association (JOA) developed a new scoring system to evaluate the overall clinical status of patients, which could be completed by patients themselves. The subcommittee completed three large-scale studies to select and modify questions derived from various preexisting outcome measures including Short Form-36, and then finalized and validated the questionnaire, which comprised 24 questions. Methods The finalized questionnaire was administered to 369 patients with cervical myelopathy due to disc herniation, spondylosis, or ossification of posterior longitudinal ligament by randomly selected board-certified spine surgeons. Patients with different severities of myelopathy were included to insure accuracy and responsiveness of this questionnaire against patients’ different neurological status. Results Data of 236 patients were employed and were subjected to rigorous statistical analyses. There was no question that was difficult to answer and distribution of answers for each question was not concentrated to one choice, indicating the appropriateness of all 24 questions. Results of factor analysis suggested that the 24 questions could be divided into five different factors or functional domains. The factors were defined as follows: factor 1, lower extremity function; factor 2, quality of life; factor 3, cervical spine function; factor 4, bladder function; and factor 5, upper extremity function. Finally, equations that would yield scores for the five factors were assembled. The score to be used to represent the degree of patients’ disability or status in each domain can be calculated by multiplying prefixed numbers of selected answers to questions by preassigned coefficients. Coefficients were defined to make the minimum score 0 and the maximum score 100. Conclusions We have successfully established a questionnaire that is able to demonstrate the status of patients suffering cervical myelopathy from five different aspects represented by five intuitive numerical scores. The final issue to be confirmed is the responsiveness of this questionnaire to changes in patients’ status after various surgical and nonsurgical treatments.

A case report and review of the literature are presented.To describe the clinical course and treatment of a patient with athetoid cerebral palsy who had quadriparesis due to an intraspinal cyst, following a failed occipitocervical fusion using sublaminar wires and rods.Intraspinal cyst as a cause of quadriparesis in a patient with athetoid cerebral palsy is extremely rare. To our knowledge, there have been no publications on this issue.A 60-year-old man with athetoid cerebral palsy and a history of posterior occipitocervical fusion presented with quadriparesis. Salvage surgery for cervical myelopathy and pseudarthrosis was performed with laminectomy and rearthrodesis using the pedicle screw system. An intraspinal cyst was identified as the main cause of the paraparesis.Solid bony fusion and the improvement of paraparesis were achieved 2 years and 1 month after the surgery. He is now able to feed himself and to walk with a cane, both without assistance.A physician managing patients with athetoid cerebral palsy should always be aware that an intraspinal cyst in the cervical spine may be the cause of cervical myelopathy.