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We investigated the prevalence of and risk factors for the progression of upper cervical lesions (UCLs) in patients with rheumatoid arthritis (RA). A retrospective analysis of 49 patients with RA (4 males, 45 females) was conducted. The UCLs included atlanto-axial subluxation and vertical subluxation. We investigated the clinical factors including the Disease Activity Score 28 based on C-reactive protein (DAS28-CRP) and the modified Health Assessment Questionnaire-Disability Index as well as radiographic changes between the baseline (at May 2010 to April 2013) and final follow-up. Forty patients (81.6%) were classified as the non-progressive group, and the other 9 patients (18.4%) comprised the progressive group. The progressive group’s final CRP values, baseline or final MMP-3 levels, DAS28-CRP, and rate of pre-existing lesions at baseline were all significantly higher than those of the non-progressive group (p=0.017, p=0.043, p=0.002, p=0.008, p

Introduction: Although modulation of atrial fibrillation (AF) drivers and/or substrates has been proposed as one of the effective ablation strategies for non-paroxysmal AF (Non-PAF), previous meta-analyses showed that ablation, targeting complex fractionated atrial electrogram (CFAE) indirectly-reflecting Non-PAF drivers, had no additional benefit for post-pulmonary vein isolation (PVI) Non-PAF. As an alternative ablation strategy for Non-PAF, rotor ablation has been proposed as one of the potentiated ablation strategies for Non-PAF. However, the optimal ablation strategy is still unclear because reliable method detecting AF drivers remain unsettled in clinical practice. Hypothesis: Because rotors are known as key mechanisms for Non-PAF, we might open the possibility of Non-PAF control by the real-time visualization of wave dynamics during AF ablation. Methods: Consecutive 140 Non-PAF patients were enrolled in this study. The clinically-available online and real-time AF imaging system with high-spatiotemporal density (ExTRa Mapping TM ) developed by our group was applied in case Non-PAF was remained after PVI. Then, we detected and ablated non-passively-activated areas where rotational activations in the form of meandering rotors and/or multiple wavelets assumed to contain Non-PAF drivers were frequently observed (figure, top). The recurrence rate of Non-PAF or atrial tachycardia (AT) after the ablation was compared to that in patients underwent PVI-alone at our hospital. Results: The propensity scores selected each 34 people from ExTRa-strategy group and PVI-alone group (figure, middle). The 24-month freedom ratio from Non-PAF/AT in the matched-ExTRa-strategy group was higher than the matched-PVI-alone group, which was close to significance (p = 0.056) (figure, bottom). Conclusion: The ExTRa Mapping-guided ablation for PVI-refractory Non-PAF might be superior to PVI-alone.

Study DesignCross sectional study.PurposeTo clarify the difference in position of the psoas muscle between adult spinal deformity (ASD) and lumbar spinal stenosis (LSS).Overview of LiteratureAlthough it is known that the psoas major muscle deviates in ASD patients, no report is available regarding the difference in comparison with LSS patients.MethodsThis study investigates 39 patients. For evaluating spinal alignment, pelvic tilt (PT), pelvic incidence (PI), sacral slope, lumbar lordosis (LL), PI–LL, Cobb angle, and the convex side, the lumbar curves were measured. For measuring the position of the psoas major at the L4/5 disk level, magnetic resonance imaging was used. The displacements of psoas major muscle were measured separately in the anterior–posterior and lateral directions. We examined the relationship between the radiographic parameters and anterior displacement (AD) and lateral displacement (LD) of the psoas major muscle.ResultsAD was demonstrated in 15 cases with ASD and nine cases with LSS (p>0.05). LD was observed in 13 cases with ASD and no cases with LSS (pp=0.04). PT, LL, PI–LL, and Cobb angle were significantly greater in cases with LD (ppConclusionsDespite AD being observed in LSS as well, LD was observed only in the ASD group. Radiographic parameters were worse when LD was seen, rather than AD.

This is a retrospective case series.To avoid lateral misplacement of midcervical pedicle screws, T.T., one of our authors, developed a method for minimally invasive cervical pedicle screw (MICEPS) fixation by a posterolateral approach. We reviewed our initial experience with this fixation for trauma cases.Excellent clinical results with cervical screws have been reported for trauma cases. Although cervical pedicle screw fixation can be an essential part of reconstruction in spinal disorders, there is also a risk for injury to the vertebral artery.This study included 56 consecutive patients who received surgery for cervical fractures. We inserted a total of 203 cervical pedicle screws. Nineteen patients were treated by conventional methods. Thirty-seven patients were treated by MICEPS fixation. According to the MICEPS fixation, 12 patients were treated by unilateral fusion, 25 patients by bilateral fusion. All pedicle screws were inserted using spinal navigation system in the both groups.The average surgical time was 217 minutes with the conventional pedicle screw fixation and 165 minutes with the MICEPS fixation (P=0.0014). The average intraoperative bleeding was 560 mL in the conventional fixation and 140 mL in the MICEPS fixation (P0.0001). Clinically significant screw deviation was significantly lower in the MICEPS fixation group than in the conventional cervical pedicle screw group (P=0.0039). There was not any deep wound infection in both groups.This intramuscular approach allows for horizontal pedicle screw insertion. This technique is probably useful for reducing intraoperative bleeding. In this study, incidence of screw perforation was significantly lower in the MICEPS fixation group than in the conventional cervical pedicle screw group. In particular, neither of the misplaced screws was laterally deviated in the MICEPS group.

Study DesignRetrospective analysis using magnetic resonance imaging (MRI).PurposeTo identify MRI features that could discriminate benign from malignant vertebral fractures.Overview of LiteratureDiscrimination between benign and malignant vertebral fractures remains challenging, particularly in patients with osteoporosis and cancer. Presently, the most sensitive means of detecting and assessing fracture etiology is MRI. However, published reports have focused on only one or a few discriminators.MethodsTotally, 106 patients were assessed by MRI within six weeks of sustaining 114 thoracic and/or lumbar vertebral fractures (benign, n=65; malignant, n=49). The fractures were pathologically confirmed if malignant or clinically diagnosed if benign and were followed up for a minimum of six months. Seventeen features were analyzed in all fractures' magnetic resonance images. Single parameters were analyzed using the chi-square test; a logit model was established using multivariate logistic regression analysis.ResultsThe chi-square test revealed 11 malignant and 4 benign parameters. Multivariate logistic regression analysis selected (i) posterior wall diffuse protrusion (odds ratio [OR], 48; 95% confidence interval [CI], 4.2–548; p=0.002), (ii) pedicle involvement (OR, 21; 95% CI, 2.0–229; p=0.01), (iii) posterior involvement (OR, 21; 95% CI, 1.5–21; p=0.02), and (iv) band pattern (OR, 0.047; 95% CI, 0.0005–4.7; p=0.19). The logit model was expressed as P=1/[1+exp (x)], x=−3.88×(i)−3.05×(ii)−3.02×(iii)+3.05×(iv)+5.00, where P is the probability of malignancy. The total predictive value was 97.3%. The only exception was multiple myeloma with features of a benign fracture.ConclusionsAlthough each MRI feature had a different meaning with a variable differentiation power, combining them led to an accurate diagnosis. This study identified the most relevant MRI features that would be helpful in discriminating benign from malignant vertebral fractures.

Background Although a multidisciplinary approach is often recommended to treat intractable pain, this approach does not completely prevent uncontrolled pain in some patients. The aim of this retrospective study was to investigate the exacerbating factors of prolonged, intractable pain among patients being treated at a pain liaison clinic. Methods The participants of this study were 94 outpatients (32 men, 62 women) with chronic intractable pain who visited our hospital between April 2013 and February 2015. Demographic and clinical information was obtained from all patients at baseline. Experts in various fields, including anesthesia, orthopedic surgery, psychiatry, physical therapy, and nursing, were involved in the treatment procedures. All patients were assessed before and after a 6-month treatment period using the following measures: the Numeric Rating Scale (NRS); the Pain Catastrophizing Scale (PCS); the Hospital Anxiety and Depression Scale (HADS); the Pain Disability Assessment Scale (PDAS); and the Oswestry Disability Index (ODI). All participants were then divided into two groups based on their self-reported pain after treatment: a pain relief group ( n = 70) and a prolonged pain group ( n = 24). The exacerbating factors of prolonged pain after treatment in the pain liaison outpatient clinic were analyzed using univariate and multiple logistic regression analysis. Results A significant improvement in NRS scores was observed after the 6-month follow-up period. After treatment, 24 (25.5%) of the 94 patients reported having prolonged pain. Significant improvements were seen in the PCS, PDAS, and ODI scores in the pain relief group, and in the HADS depression scores in the prolonged pain group. On univariate and multiple regression analysis, HADS depression scores were identified as a factor related to prolonged pain after treatment. Conclusions The results of the present study suggest that severe depression at the initial visit to the liaison outpatient clinic was an exacerbating factor for prolonged pain after treatment.

Introduction Denosumab specifically inhibits the receptor activator for nuclear factor-kappa B ligand (RANKL), and prevents osteoporotic fractures. Several reports have analyzed the effects of denosumab and alendronate alone on bone mineral density (BMD) or reduction of fracture risk. The objective of this study was to analyze the effects of antiresorptive osteoporosis pharmacotherapy on pain relief in patients with fresh vertebral fracture. Methods This retrospective, single-center study included 80 patients (10 males, 70 females) with fresh osteoporotic vertebral fractures treated using denosumab at a dose of 60 mg subcutaneously every 6 months (40 patients) or alendronate at a dose of 35 mg orally every week (40 patients) for 6 months in our hospital. The mean age of subjects was 77 years (range, 55–92 years). The primary outcome was duration of back pain. Secondary outcomes included changes in BMD, serum type 1 collagen cross-linked N-telopeptide (NTX), and serum N-terminal propeptide of type 1 collagen (P1NP) from baseline to 6 months. Pain catastrophizing due to back pain was assessed using the Pain Catastrophizing Scale (PCS). The incidences of further vertebral fracture and adverse events were also assessed. Results Pain relief was obtained at a mean of 3.3 weeks with denosumab and 5.4 weeks with alendronate. Pain relief was achieved significantly earlier with denosumab than with alendronate. At 6 months, change in BMD was higher with denosumab (6.1%) than with alendronate (0.8%). No significant differences in changes in NTX and P1NP were observed between groups. Scores for PCS were significantly lower for denosumab than for alendronate. The incidence of further vertebral fractures was 5% with denosumab and 10% with alendronate. Adverse event rates were similar between groups. Conclusions Denosumab enabled earlier pain relief than alendronate and avoided catastrophizing in patients with osteoporotic vertebral fractures after 6 months of treatment.

Introduction It is reported that for patients with non-paroxysmal (persistent or long-standing persistent) atrial fibrillation (Non-PAF), extended ablation to atrial walls in addition to pulmonary vein isolation (PVI) did not improve the long-term outcome. On the other hand, modulation of Non-PAF drivers (or perpetuators) has been proposed as one of the alternative effective ablation strategies for Non-PAF. Purpose To clarify whether the rotor ablation under online real-time high-density phase mapping system is effective for PVI-refractory Non-PAF ablation. Methods Under such circumstances, our academic group had recently developed the online real-time high-density phase mapping system (ExTRa Mapping™) by industrial alliance. The phase map moving images were based on 41 intra-atrial bipolar signals recorded by a 20-pole spiral-shaped catheter (2.5 cm in diameter) and on in silicorapid prediction of spatio-temporal atrial excitations (artificial intelligence system). Then we applied the ExTRa Mapping to clinical practice in order to directly visualize rotors in patients with Non-PAF, and investigated the middle- to long-term outcome of the ExTRa Mapping-guided rotor ablation (ExTRa-ABL). Results Thirty-eight patients (63±8 y/o, 30 males) with Non-PAF demonstrating refractoriness to PVI were enrolled in this study. Ablation for cavo-tricuspid isthmus and/or superior vena cava isolation was additionally performed at physicians' discretion. After these procedures, the ExTRa-ABL was performed in order to modify Non-PAF substrates, causing rotor control. The modification of the rotors was evaluated by re-mapping with the use of the ExTRa Mapping at the end of each ablation session. Patients were followed at 1, 3, 6 months and every year after the procedure. All of them were followed for 21±8 months. During the follow-up period, Non-PAF was recurred in only 8 of 38 (21%). Furthermore, we found if PVI-refractory Non-PAF duration was shorter than 6 years, the non-recurrence rate remained ≥80% (see Figure), which was markedly better outcome comparing with previous reports with regard to Non-PAF ablation. Figure 1 Conclusion Comparing with conventional Non-PAF ablation strategies, our novel approach with the use of the online real-time high-density phase mapping system might improve medium- to long-term outcome of PVI-refractory Non-PAF treatment.

A 44-year-old man with a 3-day history of limited range of motion of the bilateral shoulders, neck pain, dysphagia and mild fever presented to our emergency department. He had no previous significant medical history. He also denied any other neurological problems. He had normal levels of consciousness and orientation. On physical examination, the patient exhibited limited range of motion in rotation, severe nuchal rigidity without meningeal irritation, including Kernig’s sign and Brudzinski’s sign. Cervical CT …

Vertical sacral fracture is one of the most difficult fractures to treat. Posterior fixation using spinal dual rods is a novel method for treating this fracture, but its biomechanical strength has not yet been reported. The aim of this study was to evaluate the biomechanical strength produced by posterior fixation using spinal instrumentation. Sacral fractures were created in eight pelvic bone models and classifi ed into a posterior plate fixation group [P group, n＝4] and a spinal instrumentation group [R group, n＝4]. The biomechanical strength was tested by pushing down on the S1 vertebra from the top. The mean maximum loads were 1,057.4 N and 1,489.4 N in the P and R groups, respectively (p＝ 0.014). The loads applied to the construct at displacements of 5mm and 7.5mm from the start of the universal testing machine loading were also significantly higher in the R group. The mean stiffness levels in the P and R groups were 88.3N/mm and 119.6N/mm, respectively (p＝0.014). Posterior fixation using spinal instrumentation is biomechanically stronger than conventional posterior plate fixation. This procedure may be the optimal method for treating unstable sacral fracture fixation.

Study design Retrospective case series of one institute database. Objective To investigate the differences in the metallic strength of rods used for implant failure in the dual growing rod technique and evaluate clinical outcomes. Summary of background data The dual growing rod technique in which implanted rods extend with the growth of the spine is a useful treatment for early onset scoliosis. However, many complications, particularly those associated with rods, exist. Especially, the implant failure of growing rod focused on metallic strength is unknown. Methods Thirteen patients (42 lengthening surgeries) who underwent surgery by this technique at our hospital from 2007 were divided into a titanium rod plus titanium connector group (T group, n = 4, 26 lengthening surgeries) and cobalt-chromium rod plus titanium connection group (C group, n = 9, 16 lengthening surgeries). The incidence of implant failure and the site of fracture were retrospectively investigated. Results Implant failure occurred in three patients in the T group, because of rod fracture in two patients and connector fracture in one. In the C group, implant failure occurred in six patients, because of rod fracture in one patient and connector fracture in seven. Fracture occurred twice in two patients. The rod fracture rate decreased with the use of cobalt-chromium rods but the rate of connector fracture increased. We performed a stress distribution analysis using the finite element method to clarify the mechanisms underlying implant failure in both groups. Regardless of the rod type, the greater load was placed on the distal rod. However, differences in the metallic strength caused the rod to fracture when titanium rods were used and connectors (weak metallic strength) to fracture when cobalt-chromium rods were used. Conclusion Rod fractures occurred more commonly with titanium rods and connector fractures with cobalt-chromium rods.

The presence of preoperative kyphosis has been identified as a risk factor for laminar closure (LC). We have been performing modified open-door laminoplasty with reattachment of the spinous processes and extensor musculature for patients with reduced cervical lordosis because this procedure can prevent progression of cervical kyphosis. This procedure may also prevent LC. The purpose of this study was to evaluate the rate of LC after the modified open-door laminoplasty. A total of 104 patients who underwent open-door laminoplasty were retrospectively reviewed. Of these patients, 18 underwent modified open-door laminoplasty (group M), whereas the other 86 underwent Hirabayashi open-door laminoplasty (group H). Group H was divided into two classes according to the preoperative cervical lordosis angle (group H1 ≤ 10° vs. group H2 ≥ 11°). All 18 patients in group M had a preoperative lordosis angle ≤10°. The outcomes were assessed using the rate of LC, the cross-sectional area (CSA) of the erector muscle on magnetic resonance imaging, and the Japanese Orthopaedic Association score (JOA score). The rate of laminar closure was significantly lower in group M (39 %) than in group H1 (76 %) (P

Background Stroke is one of the leading causes of disability and mortality in Japan. The aim of the present analysis was to determine the non-acute survival rate after first-ever stroke using data from a large-scale population-based stroke registry in Japan. Methods and Results: Shiga Stroke Registry is an ongoing population-based registry of stroke, which covers approximately 1.4 million residents of Shiga Prefecture in central Japan. A total of 2,176 first-ever stroke patients, who were registered in 2011, were followed up until December 2013. The 2-year cumulative survival rates were estimated using Kaplan-Meier method according to index stroke subtype. Cox proportional hazards models were used to assess predictors of all-cause death. During a 2-year follow-up period, 663 patients (30.5%) died. The 2-year cumulative survival rate after first-ever stroke was 69.5%. There was heterogeneity in 2-year cumulative survival according to stroke subtype: lacunar infarction, 87.2%; large artery infarction, 76.1%; cardioembolic infarction, 55.4%; intracerebral hemorrhage, 65.9%; and subarachnoid hemorrhage, 56.7%. Older age, male sex, medical history, higher Japan coma scale score on admission, and stroke subtype were associated with risk of all-cause death in ≤2 years. Conclusions In the present population-based stroke registry with a real-world setting in Japan, 2-year cumulative mortality after first-ever stroke is still high (>30%), particularly for cardioembolic infarction, subarachnoid hemorrhage and intracerebral hemorrhage.

Background and Purpose Most available scoring system to predict outcome after acute ischemic stroke (AIS) were established in Western countries. We aimed to develop a simple prediction score of 1-month severe disability/death after onset in AIS patients ineligible for recanalization therapy based on readily and widely obtainable on-admission clinical, laboratory and radiological examinations in Asian developing countries. Methods Using the Shiga Stroke Registry, a large population-based registry in Japan, multivariable logistic regression analysis was conducted in 1617 AIS patients ineligible for recanalization therapy to yield s-coefficients of significant predictors of 1-month modified Rankin Scale score of 5-6, which were then multiplied by a specific constant and rounded to nearest integer to develop 0-10 points system. Model discrimination and calibration were evaluated in the original and bootstrapped population. Results Japan Coma Scale score (J), age (A), random glucose (G), untimely onset-to-arrival time (U), atrial fibrillation (A), and preadmission dependency status according to the modified Rankin Scale score (R), were recognized as independent predictors of outcome. Each of their β-coefficients was multiplied by 1.3 creating the JAGUAR score. Its area under the curve (95% confidence interval) was .901 (.880- .922) and .901 (.900- .901) in the original and bootstrapped population, respectively. It was found to have good calibration in both study population (P = .27). Conclusions The JAGUAR score can be an important prediction tool of severe disability/death in AIS patients ineligible for recanalization therapy that can be applied on admission with no complicated calculation and multimodal neuroimaging necessary, thus suitable for Asian developing countries.

Recent studies have recognized the involvement of microRNAs (miRNAs) in the development of osteoporosis, which regulate the balance between osteogenesis and osteoclasis. In this study, we investigated the regulation by miRNA-133a-5p on the osteoblast differentiation-associated markers in the mouse osteoblast-like MC3T3-E1 cells by RUNX2. First, we manipulated the miRNA-133a level in the MC3T3-E1 cells with 20 or 40 nM miR-133a-5p mimics, miR-133a-5p inhibitor, or scramble miRNA. Then, we quantified with real-time polymerase chain reaction (qRT-PCR) the expression of Collagen I, osteocalcin (OCN), and osteopontin (OPN) in the miR-133a-5p-manipulated MC3T3-E1 cells. And the confocal microscopy was also utilized to confirm the regulation by miR-133a-5p on the expression of the three molecules. We also investigated the extracellular matrix (ECM) mineralization and the alkaline phosphatase (ALP) activity in the miR-133a-5p-manipulated MC3T3-E1 cells. In addition, we explored the possible targeting by miR-133a-5p on RUNX2, which was a well-recognized promoter to osteoblast differentiation, with luciferase reporter, qRT-PCR, and Western blotting assay. Results demonstrated that the miRNA-133a-5p mimics markedly reduced, whereas the miRNA-133a-5p inhibitor significantly promoted the expression of Collagen I, OCN, and OPN, the ECM mineralization, and the ALP activity in MC3T3-E1 cells. The alignment analysis demonstrated a high homology between miRNA-133a-5p and the 3' UTR of RUNX2. Moreover, the luciferase reporter assay demonstrated that miRNA-133a-5p targeted the 3' UTR of RUNX2, and inhibited the expression of RUNX2 in both mRNA and protein levels. In conclusion, we identified the inhibition by miRNA-133a-5p to the expression of osteoblast differentiation markers, to the ECM mineralization, and to the ALP activity in MC3T3-E1 cells, by targeting the 3' UTR of RUNX2. Our study suggests that miRNA-133a-5p might be an important target to inhibit osteoblast differentiation in osteoporosis.

Aim Although renal dysfunction has been identified as a novel risk factor affecting stroke prognosis, few have analyzed the association within large-scale population-based setting, using wide-range estimated glomerular filtration rate (eGFR) category. We aimed to determine the association of admission eGFR with acute stroke outcomes using data from a registry established in Shiga Prefecture, Japan. Methods Following exclusion of patients younger than 18 years, with missing serum creatinine data, and with onset more than 7 days prior to admission, 2,813 acute stroke patients registered in the Shiga Stroke Registry year 2011 were included in the final analysis. The Japanese Society of Nephrology equation was used to estimate GFR. Multivariable logistic regression was performed to analyze the association of eGFR with all-cause in-hospital death (modified Rankin Scale [mRS] 6), and at-discharge death/disability (mRS 2-6). Separate analyses were conducted within stroke subtypes. Results Compared to eGFR 60-89 mL/min/1.73 m2, adjusted odds ratios (ORs) and 95% confidence interval [95% CI] for in-hospital death (in the order of eGFR ＜45, 45-59, and ≥90 mL/min/1.73 m2) were 1.54 [1.04-2.27], 1.07 [0.72-1.58], and 1.04 [0.67-1.59]. Likewise, adjusted ORs [95% CI] for at-discharge death/disability were 1.54 [1.02-2.32], 0.97 [0.73-1.31], and 1.48 [1.06-2.05]. Similar pattern was further evident in the eGFR ＜45 mL/min/1.73 m2 group for both outcomes within acute ischemic stroke patients. Conclusions Our study has ascertained that in acute stroke, particularly ischemic stroke, low eGFR was significantly associated with in-hospital death and at-discharge death/disability. Additionally, high eGFR was found to be associated with at-discharge death/disability.

Although a C2 pedicle screw and a C1–2 transarticular screw are the most rigid anchors, these screws cannot be used in cases with bilateral high-riding vertebral arteries. The authors describe their recent experience using a novel method of C2–3 transuncovertebral joint screw placement for occipitocervical fixation. A 67-year-old patient suffered myelopathy due to instability at C1–2. The patient had bilateral high-riding vertebral arteries that precluded the use of a C2 pedicle screw or a C1–2 transarticular screw. A C2–3 transuncovertebral joint screw was applied bilaterally under 3D navigation guidance. The patient’s postoperative course was uneventful, and his neurological status improved after the surgery. Bony fusion was achieved after the surgery. This is the first report to describe the technique of transuncovertebral joint screw. Using a C2–3 transuncovertebral joint screw, a long screw could be used, and it provided an anchor at C3 and C2 from a posterior approach.

Primary spinal osteosarcoma is quite rare, and the 5-year survival rate is very low. Because of its rarity, successful treatment experience with spinal osteosarcoma is limited. The purpose of this study is to report the effect of therapy of primary osteosarcoma of spine by carbon-ion radiotherapy (CIRT) and long-term follow. A 70-year-old with primary spinal osteosarcoma who received CIRT underwent combined anterior artificial vertebral body replacement and posterior lumbar fusion (L1–L5) 3 years later. According to the surgical resection of tumoral lesion, pathological results showed that the intertrabecular space previously filled with tumor cells on the initial biopsy sample now contained necrotic tissue without tumor cells. This means that primary osteosarcoma of the spine was completely eliminated and achieved local control with CIRT, with a 7-year follow-up after the initial treatment. Carbon ion beam treatment is an effective local treatment for patients with spinal osteosarcoma for whom surgical resection is not a feasible option, especially for elderly patients. However, more patients need to be evaluated over a longer term to assess the curative effect of CIRT.

Background We established a patient-oriented biobank, BioBank Japan, with information on approximately 200,000 patients, suffering from any of 47 common diseases. This follow-up survey focused on 32 diseases, potentially associated with poor vital prognosis, and collected patient survival information, including cause of death. We performed a survival analysis for all subjects to get an overview of BioBank Japan follow-up data. Methods A total of 141,612 participants were included. The survival data were last updated in 2014. Kaplan–Meier survival analysis was performed after categorizing subjects according to sex, age group, and disease status. Relative survival rates were estimated using a survival-rate table of the Japanese general population. Results Of 141,612 subjects (56.48% male) with 1,087,434 person-years and a 97.0% follow-up rate, 35,482 patients died during follow-up. Mean age at enrollment was 64.24 years for male subjects and 63.98 years for female subjects. The 5-year and 10-year relative survival rates for all subjects were 0.944 and 0.911, respectively, with a median follow-up duration of 8.40 years. Patients with pancreatic cancer had the least favorable prognosis (10-year relative survival: 0.184) and patients with dyslipidemia had the most favorable prognosis (1.013). The most common cause of death was malignant neoplasms. A number of subjects died from diseases other than their registered disease(s). Conclusions This is the first report to perform follow-up survival analysis across various common diseases. Further studies should use detailed clinical and genomic information to identify predictors of mortality in patients with common diseases, contributing to the implementation of personalized medicine., Highlights • 141,612 participants with any of 32 diseases were included in the follow-up survey. • Subject characteristics at enrollment for the follow-up survey were identified. • The relative survival analysis showed the worst prognosis in pancreatic cancer. • The most common cause of death in all subjects was malignant neoplasms.

Background To implement personalized medicine, we established a large-scale patient cohort, BioBank Japan, in 2003. BioBank Japan contains DNA, serum, and clinical information derived from approximately 200,000 patients with 47 diseases. Serum and clinical information were collected annually until 2012. Methods We analyzed clinical information of participants at enrollment, including age, sex, body mass index, hypertension, and smoking and drinking status, across 47 diseases, and compared the results with the Japanese database on Patient Survey and National Health and Nutrition Survey. We conducted multivariate logistic regression analysis, adjusting for sex and age, to assess the association between family history and disease development. Results Distribution of age at enrollment reflected the typical age of disease onset. Analysis of the clinical information revealed strong associations between smoking and chronic obstructive pulmonary disease, drinking and esophageal cancer, high body mass index and metabolic disease, and hypertension and cardiovascular disease. Logistic regression analysis showed that individuals with a family history of keloid exhibited a higher odds ratio than those without a family history, highlighting the strong impact of host genetic factor(s) on disease onset. Conclusions Cross-sectional analysis of the clinical information of participants at enrollment revealed characteristics of the present cohort. Analysis of family history revealed the impact of host genetic factors on each disease. BioBank Japan, by publicly distributing DNA, serum, and clinical information, could be a fundamental infrastructure for the implementation of personalized medicine., Highlights • The BioBank Japan Project (BBJ) annually collected clinical information. • Analysis of the clinical information at enrollment characterized the BBJ cohort. • Analysis of family history revealed impacts of host genetic factors on the diseases.

The anti-seizure drug pregabalin is currently used for peripheral neuropathic pain, including degenerative lumbar disease with a neuropathic component. Although there are many reports associated with pregabalin, treatment outcome in low back pain (LBP) patients with depression remains uncertain. This study investigated the outcomes of pregabalin in LBP patients with depression.We assessed 64 patients (29 men and 35 women) using a Visual Analogue Scale, a Self-Rating Depression Scale (SDS) and the Oswestry Disability Index (ODI). Mean age was 63.3 years (range 20-81), and mean duration of disease was 69.8 months (range 3-576). The patients were divided into two groups according to SDS: normal (n = 37) and depressed group (n = 27).Pregabalin significantly reduced both SDS and ODI in the depressed group (p0.05). Effect size was larger for both SDS and ODI in the depressed group than in the normal group. Pain was significantly relieved, even in the depressed group (p0.01). Pain reduction was achieved by the direct effect of pregabalin, as well as indirect effects attributed to change in depressive symptoms. Although both somnolence and dizziness were detected, the use of hypnotic agents was decreased in half of cases. Somnolence did not influence the analgesic effects of the drug or psychotic state.This investigation indicated that pregabalin is safe and effective for reducing both LBP and mood disturbance in patients with depression.

Background To avoid lateral misplacement of midcervical pedicle screws, we developed a method for Minimally Invasive Cervical Pedicle Screw (MICEPS) fixation via a posterolateral approach. This intramuscular approach allows for horizontal pedicle screw insertion and reduced intraoperative bleeding. We reviewed our initial experience with MICEPS fixation for patients with cervical metastases. Methods This study included 18 consecutive patients who received cervical spinal surgery for metastatic tumor. We treated 12 patients with conventional cervical pedicle screw fixation, and 6 patients with the MICEPS fixation technique. Average follow-up was 14 months (range 3 to 34). We inserted 117 pedicle screws using the navigation system. Average fusion area was 4.9 vertebrae (range 3 to 8). Alpha-angles between a line perpendicular to the posterior cortex of the vertebral body and the screw trajectory in the transverse plane were also measured. Results The average surgical time was 250 min (range 151 to 420 min) with the conventional pedicle screw fixation and 234 min (range 154 to 300 min) with the MICEPS fixation. The average total blood loss was 780 mL (range, 180-1430 mL) in the conventional pedicle screw fixation group and 180 mL (range, 70-400 mL) in the MICEPS fixation group. At the level of midcervical (C3-5), average alpha-angles was 52 degrees (range 43 to 62) in MICEPS fixation group, and 39 degrees (range 19 to 55) in conventional cervical pedicle screw group. Conclusions The MICEPS fixation technique uses an intramuscular approach, which is minimally invasive and reduces intraoperative bleeding. Intramuscular approach allows for horizontal pedicle screw insertion, and reduced critical screw deviation.

Background Cardiovascular disease (CVD) is a leading cause of death in Japan. The present study aimed to develop new risk prediction models for long-term risks of all-cause and cardiovascular death in patients with chronic phase CVD. Methods Among the subjects registered in the BioBank Japan database, 15,058 patients aged ≥40 years with chronic ischemic CVD (ischemic stroke or myocardial infarction) were divided randomly into a derivation cohort (n = 10,039) and validation cohort (n = 5019). These subjects were followed up for 8.55 years in median. Risk prediction models for all-cause and cardiovascular death were developed using the derivation cohort by Cox proportional hazards regression. Their prediction performances for 5-year risk of mortality were evaluated in the validation cohort. Results During the follow-up, all-cause and cardiovascular death events were observed in 2962 and 962 patients from the derivation cohort and 1536 and 481 from the validation cohort, respectively. Risk prediction models for all-cause and cardiovascular death were developed from the derivation cohort using ten traditional cardiovascular risk factors, namely, age, sex, CVD subtype, hypertension, diabetes, total cholesterol, body mass index, current smoking, current drinking, and physical activity. These models demonstrated modest discrimination (c-statistics, 0.703 for all-cause death; 0.685 for cardiovascular death) and good calibration (Hosmer-Lemeshow χ2-test, P = 0.17 and 0.15, respectively) in the validation cohort. Conclusions We developed and validated risk prediction models of all-cause and cardiovascular death for patients with chronic ischemic CVD. These models would be useful for estimating the long-term risk of mortality in chronic phase CVD., Highlights • We developed risk prediction models for death after cardiovascular disease (CVD). • Performances of these models were validated in an independent cohort. • Our models may be used to estimate mortality risk in chronic CVD patients.

Craniometaphyseal dysplasia is a rare genetic condition characterized by progressive thickening of bones in the skull and metaphyseal abnormalities in the long bones. This disorder often causes progressively symptomatic cranial nerve compression, but in rare cases foramen magnum stenosis may lead to quadriplegia. Chiari I malformation with craniometaphyseal dysplasia is extremely rare. The authors report on a 25-year-old woman with myelopathy due to Chiari I malformation along with craniometaphyseal dysplasia. There are only four previous case reports of this condition. The authors present here the fifth case report of this rare condition and summarize its characteristics.

Depression can exacerbate symptoms of chronic pain and worsen disability. The symptoms of lumbar disease may be particularly sensitive to psychological state, but statistical associations between low back pain (LBP) severity and mental health status have not been established.Of the 151 patients with LBP, 122 completed questionnaires probing depressive symptoms, LBP severity, and degree of disability. In addition to completing self-report questionnaires, patients provided demographic and clinical information. A self-rating depression scale (SDS) was used to screen for depression. Pain and disability were assessed by the visual analog scale (VAS) and the Roland-Morris disability questionnaire (RDQ), respectively. Overall clinical severity was assessed using the Japanese Orthopaedic Association (JOA) score. Kendall's tau correlation coefficients were calculated to examine the relationships among these variables.Ninety-four patients (77 %) were in a depressive state as indicated by SDS score ≥40, including mild depression group (47 patients, SDS score from 40 to 49) and depression group (47 patients, SDS score ≥50). There were only 28 patients in the no depression group (SDS score ≤39). There was no significant difference in both age and pain duration among the three groups. The mean VAS score in the depression group (70 ± 19 mm) was higher than both no depression (41 ± 24 mm) and mild depression groups (52 ± 21 mm). The mean JOA score in the no depression group (14 ± 5.0 points) was higher than both mild depression (12 ± 4.0 points) and depression groups (10 ± 6.0 points). The mean RDQ in the depression group (15.1 ± 6.0 points) was higher than both no depression (6.4 ± 5.0 points) and mild depression groups (10.9 ± 5.4 points). Factors significantly correlated with SDS score included VAS, JOA score, and RDQ score. In contrast, SDS did not correlate with patient age or pain duration.The majority of chronic LBP patients examined were in a depressed state and the severity of depression correlated with pain severity, degree of self-rated disability, and clinical severity.

Background The BioBank Japan (BBJ) Project was launched in 2003 with the aim of providing evidence for the implementation of personalized medicine by constructing a large, patient-based biobank (BBJ). This report describes the study design and profile of BBJ participants who were registered during the first 5-year period of the project. Methods The BBJ is a registry of patients diagnosed with any of 47 target common diseases. Patients were enrolled at 12 cooperative medical institutes all over Japan from June 2003 to March 2008. Clinical information was collected annually via interviews and medical record reviews until 2013. We collected DNA from all participants at baseline and collected annual serum samples until 2013. In addition, we followed patients who reported a history of 32 of the 47 target diseases to collect survival data, including cause of death. Results During the 5-year period, 200,000 participants were registered in the study. The total number of cases was 291,274 at baseline. Baseline data for 199,982 participants (53.1% male) were available for analysis. The average age at entry was 62.7 years for men and 61.5 years for women. Follow-up surveys were performed for participants with any of 32 diseases, and survival time data for 141,612 participants were available for analysis. Conclusions The BBJ Project has constructed the infrastructure for genomic research for various common diseases. This clinical information, coupled with genomic data, will provide important clues for the implementation of personalized medicine., Highlights • The BioBank Japan Project (BBJ) enrolled 200,000 patients with 47 target diseases. • The BBJ is one of the largest patient-based biobanks in the world. • The BBJ may allow for personalized medicine in the future.

STUDY DESIGN Retrospective case series. OBJECTIVE We present a minimally invasive spinopelvic fixation technique for unstable bilateral sacral fractures and describe a technical report. SUMMARY OF BACKGROUND DATA Unstable sacral fractures are severe injuries with high mortality and morbidity due to pain and malunion. Galveston technique is useful for rigid fixation of an unstable sacral fracture. However, wound-related complications with this technique have been relatively common because of extensive contusion of the skin or poor blood supply after embolization. MATERIALS AND METHODS There were 34 patients with unstable pelvic fractures between 2005 and 2012. We performed conventional open surgery between 2005 and 2009. Minimally invasive spinopelvic fixation was performed between 2009 and 2012. Minimally invasive technique needs 4 small, lateral incisions for percutaneous lumbar pedicle screw insertion. We pushed a pure titanium rod into the paravertebral muscle. RESULTS The average surgical time was 345 minutes in the conventional fixation and 208 minutes with the minimally invasive fixation. The average intraoperative bleeding was 520 mL in the conventional fixation and 290 mL in minimally invasive fixation. When comparing deep wound infection, 3 of 8 (38%) patients who received conventional fixation had methicillin-resistant Staphylococcus aureus infections, whereas nobody who received the minimally invasive fixation acquired infection. Bony union was achieved in 15 of the 16 patients. CONCLUSIONS In this study, minimally invasive spinopelvic fixation required a shorter surgical time, incurred less bleeding, and had a lower infection rate than fixation with the conventional Galveston technique.

The increasing prevalence of extended-spectrum β-lactamase (ESBL)-producing Escherichia coli has been associated with the emergence of the CTX-M-producing sequence type 131 (ST131) pandemic clonal group, a member of the O25b serogroup and the B2 phylogenetic group. To assess the clonal spread of ESBL-producing E. coli in Japan, a regional surveillance programme was conducted.A total of 581 ESBL-producing clinical specimen E. coli isolates were collected between 2001 and 2010. Clonal groups, including ST131, D-ST405, D-ST393 and D-ST69, were determined using the PCR O type, phylogenetic grouping by triplex PCR, allele-specific PCR and multilocus sequence typing (MLST). A subset of clonal groups underwent PFGE.Among clonal strains, 215 isolates (37%) were identified as belonging to the ST131 group, 185 as B2-ST131-O25b (32%), 26 as B2-ST131-O16 (4%), 3 as B1-ST131-O25b (0.5%) and 1 as B2-ST131-O-non-typeable (0.1%). Forty-one isolates (7%) were identified as belonging to the D-ST405 clonal group, seven (1%) as D-ST69 and two (0.3%) as D-ST393. The B2-ST131-O16 clonal group was characterized by CTX-M-14 and a significantly lower ciprofloxacin resistance rate than the B2-ST131-O25b clonal group. The B2-ST131-O16 and B2-ST131-O25b clonal groups each made up a single PFGE cluster, with 65% similarity. The rate of ESBL-producing E. coli increased over the years (0.2% in 2001 to 9.7% in 2010) and corresponded to increases in the numbers of the B2-ST131-O25b, B2-ST131-O16 and D-ST405 clonal groups.The B2-ST131-O25b, B2-ST131-O16 and D-ST405 clonal groups have contributed to the spread of ESBL-producing E. coli in Japan.

There are a variety of treatment options for patients with spinal metastasis, and predicting prognosis is essential for selecting the proper treatment. The purpose of the present study was to identify the significant prognostic factors for the survival of patients with spinal metastasis. We retrospectively reviewed 143 patients with spinal metastasis. The median age was 61 years. Eleven factors reported previously were analyzed using the Cox proportional hazards model:gender, age, performance status, neurological deficits, pain, type of primary tumor, metastasis to major organs, previous chemotherapy, disease-free interval before spinal metastasis, multiple spinal metastases, and extra-spinal bone metastasis. The average survival of study patients after the first visit to our clinic was 22 months. Multivariate survival analysis demonstrated that type of primary tumor (hazard ratio [HR] = 6.80, p0.001), metastasis to major organs (HR = 2.01, p = 0.005), disease-free interval before spinal metastasis (HR = 1.77, p = 0.028), and extra-spinal bone metastasis (HR = 1.75, p = 0.017) were significant prognostic factors. Type of primary tumor was the most powerful prognostic factor. Other prognostic factors may differ among the types of primary tumor and may also be closely associated with primary disease activity. Further analysis of factors predicting prognosis should be conducted with respect to each type of primary tumor to help accurately predict prognosis.

Background: Spontaneous coved ST-segment elevation ≥2mm followed by a negative T-wave in the right precordial leads (type 1 Brugada ECG) is diagnostic of Brugada syndrome (BS), but there is a false-positive rate. Methods and Results: Computer-processed analysis of a 12-lead ECG database containing 49,286 females and 52,779 males was performed to select patients with a spontaneous type 1 Brugada ECG for an examination of the association of this ECG characteristic with long-term prognosis. There were 185 patients with a spontaneous type 1 Brugada ECG and of these, 16 (15 males; mean age, 46.7±14.0 years) were diagnosed with BS and 15 patients (all males; mean age, 50.1±13.4 years) were undiagnosed. The PQ interval was significantly longer in the diagnosed patients than in the undiagnosed patients (187.4±28.3ms vs. 161.2±21.5ms; P=0.0073). The T-wave in lead V1 was more negative in the diagnosed patients than in the undiagnosed patients (-170.2±174.6μV vs. -43.2±122.3μV, P=0.027). Multivariate analysis revealed that a PQ interval ≥170ms and T-wave amplitude

Correct screw placement is especially difficult in the upper thoracic vertebrae. At the cervicothoracic junction (C7-T2), problems can arise because of the narrowness of the pedicle and the difficulty of using a lateral image intensifier there. Other upper thoracic vertebrae (T3-6) pose a problem for screw insertion also because of the narrower pedicle. We inserted 154 pedicle screws into 78 vertebrae (C7 to T6) in 38 patients. Screws were placed using intraoperative data acquisition by an isocentric C-arm fluoroscope (Siremobile Iso-C3D) and computer navigation. Out of 90 pedicle screws inserted into 45 vertebrae between C7 and T2, 87 of the 90 (96.7%) screws were classified as grade 1 (no perforation). Of 64 pedicle screws inserted into 33 vertebrae between T3 and T6, 61 of 64 (95.3%) screws were classified as grade 1. In this study, we reduced pedicle screw misplacement at the level of the C7 and upper thoracic (T1-6) vertebrae using the three-dimensional fluoroscopy navigation system.

Cervical pedicle screws, when misplaced, tend to perforate laterally. One of the reasons for lateral perforation is vertebral rotation during screw insertion. However, actual vertebral rotation during pedicle screw insertion is unknown. In this study, we measured vertebral rotation during pedicle screw insertion in patients with cervical injury.We inserted 76 pedicle screws into 38 vertebrae (C2 to C7) in 17 patients. All patients had some type of cervical injury. Screws were placed using intraoperative acquisition of data acquired with the isocentric C-arm fluoroscope (Iso-C3D) and computer navigation. We made screw holes using an image-guided awl, and we took images of cervical vertebrae in the neutral and rotational positions using navigation. Images of 76 insertions and rotational positions were taken while each cervical vertebra was under maximum stress at the time we were making the pedicle hole by awl.Average cervical vertebra rotation was 10.6 degrees (range 6 to 17) at C2, 9.1 degrees (5 to 13) at C3, 7.8 degrees (6 to 9) at C4, 6.7 degrees (4 to 11) at C5, 4.9 degrees (2 to 8) at C6, and 2.8 degrees (0 to 4) at C7. Vertebrae in the upper and middle cervical spine rotated more than the lower cervical spine vertebrae. Of the 76 pedicle screws inserted into vertebrae between C2 and C7, 74 screws (97.4%) were classified as grade 1 (no pedicle perforation).In this study, upper and middle cervical vertebrae in patients with neck injuries rotated more than the lower vertebrae. We should be especially careful of cervical rotation during screw insertion from C2 to C6, so as to prevent vertebral artery injury.

The instrumentation of the osteoporotic spine may sometimes result in failure due to the loosening or pullout of the conventional pedicle screw. Moreover, augmentation of screws with polymethylmethacrylate (PMMA) has risks of complications. We developed a new and original pedicle nail system with PMMA for osteoporotic vertebral fractures. A clinical evaluation of this novel pedicle nail system utilized in patients with an osteoporotic vertebral collapse was performed to determine the effectiveness and safety of this technique. Thirty-four elderly patients who suffered from osteoporotic compression fractures were treated by posterolateral fusion using the pedicle nail system. The mean follow-up period was 37 months. Of the 25 patients with neurological symptoms, two patients improved two stages at the Frankel level. Fifteen patients improved one stage at the Frankel level, and eight other patients improved, however, their improvement did not exceed a Frankel level. Nine cases with neuralgia symptoms improved from 4.4 to 2.2 points on average on the Denis pain scale (p

頚椎症性脊髄症の初期症状は両手 指のしびれと歩行障害であり,それ ぞれ64%,16%とした報告がある. 本症では下肢の筋力低下を伴うこと は少なく,むしろ痙性歩行や失調性 歩行を訴える.痙性歩行が明らかな 症例では両下肢の反射は亢進し, Babinski 反射や足クローヌスが高 率に陽性となる.失調性歩行のある 場合には閉眼によってこの傾向は悪 化し,Romberg 徴候は陽性となる. 一方,上肢においては圧迫高位の髄 節支配の筋の腱反射は低下し,それ より下位の髄節支配の筋の腱反射は 亢進し,Hoffmann 徴候陽性となる. Hoffmann 徴候の本疾患に対する感 度は58%,特異度は78%である. 手の巧緻性障害も特徴的な症状であ り,手指のすばやい把握動作とその 解除や内転,外転動作が障害され, myelopathy hand と呼ばれる.客観 的指標としては finger escape sign (小,環,中指の内転および伸展の 障害により5段階に分類)と10秒テ スト(10秒間に20回以下しか手指の 把握動作とその解除ができなければ 異常)がある. 頚椎症性脊髄症の高位診断は画像 診断,電気生理的検査ならびに神経 学的所見から総合的に判断する.神 経学的所見の中でも深部腱反射,筋 力低下,感覚障害および手指の知覚 障害が診断には重要である.重症度 の評価には日本整形外科頚髄症治療 判定基準(JOA スコア)が頻用され ており,ある程度成績とも相関す る. 画像診断では単純X線像で発育性 脊柱管狭窄症が関与しており,男性 では14mm以下,女性では13mm以下と 定義される.頚椎症性脊髄症の患者 では82%がこの発育性脊柱管狭窄症 を認めたとする報告がある.MRI における脊髄の圧迫や扁平化は重要 な所見である.MRI のT1強調横断 像で脊髄の前後径/横径の比率が 頚椎症性脊髄症の診療ガイドライン 田 中 雅 人*,杉 本 佳 久,三 澤 治 夫,高 畑 智 宏,尾 﨑 敏 文

Study design Consecutive cohort study. Objective To reconsider effects of the Second National Acute Spinal Cord Injury Study. Summary of background data High dose methylprednisolone sodium succinate (MPSS) for the patients with acute spinal cord injury has been considered standard treatment in the several countries. However, many authors have criticized the effect of MPSS because of lack of evidence about neurologic improvement and the high incidence of complications. Methods During 2-year, all patients with cervical cord injury were treated with MPSS within 8 hours of their injuries based on the Second National Acute Spinal Cord Injury Study protocol (MPSS group). During the next 2-year, all patients were treated without MPSS (non-MPSS group). There were 38 patients in the MPSS group and 41 in the non-MPSS. Early spinal decompression and stabilization was performed as soon after injury in both the groups. Results According to The American Spinal Injury Association (ASIA) motor score, there was an average improvement by 3 months postinjury of 12.4 points in the MPSS group and 13.8 points in the non-MPSS group. In patients with complete motor loss, average ASIA motor score improved 9.0 points in the MPSS group and 12.6 points in the non-MPSS group. For patients with incomplete motor loss, average ASIA motor score improvement was 14.1 and 15.5 points in the MPSS and non-MPSS groups, respectively.In the MPSS group, 19 patients developed pneumonia, 13 developed urinary tract infections, and 5 developed wound infections. Incidence of pneumonia was significantly increased with the use of MPSS medication. Conclusion We found no evidence supporting the opinion that high-dose MPSS administration facilitates neurologic improvement in patients with spinal cord injury. We believe MPSS should be used under limited circumstances because of the high incidence of pulmonary complication.

The purpose of this study was to examine the correlation between the changes in the lateral pillar grades and the factors influencing such changes. We reviewed 102 patients with Perthes' disease. Changes were observed in 32 (31%) hips. The percentage of the changes in each treatment group showed significant differences. Patients with extensive involvement showed significantly more changes. There was no difference in the age at the onset. We recommend that treatment methods be used that more effectively relieve the mechanical force on the capital femoral epiphysis for patients with extensive involvement regardless of the age at the onset.

Postoperative outcomes of segmental pedicle screw fixation were evaluated in posterior scoliosis surgery with the use of navigation system.We report the usefulness of a navigation system and a segmental pedicle screw fixation in surgery for scoliosis.Few reports on a segmental pedicle screw fixation method for scoliosis surgery using a navigation system have been published. This is the report on the usefulness of a navigation system in segmental pedicle screw fixation.We targeted 16 cases in which segmental pedicle screw fixation had been performed using a navigation system at our hospital. We inserted 264 pedicle screws in total, and we did not perform registration for each corpus vertebrate in order to shorten the duration of the surgery. We reviewed screw deviation among the items for review using Neo classification with postoperative CT images (1.25 mm). For screw deviation in this case, grade 2 or higher in the Neo classification system was designated as total deviation. Furthermore, we evaluated the registration period per corpus vertebrae, the complications, duration of surgery, blood loss, Cobb angle, and the correction rate.In terms of screw deviation, 11 (4.2%) of the 264 inserted screws were classified as total deviation. However, there were no neurovascular complications during or after surgery in any cases, and all cases maintained strong internal fixation. In the relationship between the use or nonuse of registration and the deviation, four screws (3.2%) in the corpus vertebrae for which registration was performed and seven screws (5.0%) in the adjacent corpus vertebrae for which registration was not performed had deviated. The duration of registration per corpus vertebrate averaged 4 min and 24 s (58-791 s), but registration also requires a learning curve, so the duration of registration per corpus vertebrae averaged 1 min and 14 s in more recent cases, thus marking a significant shortening.Segmental pedicle screw fixation are excellent in regard to their fixing and correction force and have been clinically applied even in surgery for scoliosis, but the potential risk of neurovascular complications is unavoidable. The adoption of a navigation system in surgery for scoliosis is useful to increase the safety and certainty of the insertion of pedicle screws.

Background context Because posterior decompression and fusion for vertebral collapse in an osteoporotic spine sometimes results in a pullout of the pedicle screw. Several authors reported that fixation of pedicle screws in severely osteoporotic bone could be improved by inserting polymethylmethacrylate (PMMA) into the hole before inserting the screw. However, pedicle screws were not designed to be used with PMMA. Purpose To report a patient with vertebral collapse who were treated using a novel-concept, pedicle nail using with PMMA. Study design Case report. Methods The patient was a 74-year-old female who experienced back pain after some heavy lifting 3 months before. She was laid up for 2 months because of the back pain and weakness of her lower legs. Radiographs and magnetic resonance imaging showed vertebral collapse and neural severe compression from the posterior wall of vertebra T12. The pedicle nail consists of an outer sheath with evenly spaced holes and an internal, removable, threaded component. The outer sheath and the internal component were connected before insertion. The pedicle nail attaches to and is bound by the PMMA through the holes of the outer sheath. We performed a T11–L1 posterior fusion and laminectomy using the pedicle nail, and we used a hydroxyapatite block to perform a transpedicular vertebroplasty of T12. Results Bone union was observed on a lateral radiograph without pedicle nail loosening. Conclusions The authors speculate that posterior spinal fusion and vertebroplasty using the pedicle nail will be a reasonable choice for delayed paraplegia after osteoporotic vertebral fracture.