Evaluating Spinal Canal Lesions Using Apparent Diffusion Coefficient Maps with Diffusion-Weighted Imaging

Kanamoto Hirohito,Norimoto Masaki,Eguchi Yawara,Oikawa Yasuhiro,Orita Sumihisa,Inage Kazuhide,Abe Koki,Inoue Masahiro,Kinoshita Hideyuki,Umimura Tomotaka,Matsumoto Koji,Masuda Yoshitada,Furuya Takeo,K 대한척추외과학회 2020 Asian Spine Journal Vol.14 No.3

Study Design: Observational study.Purpose: To evaluate healthy volunteers and patients with spinal canal lesions using apparent diffusion coefficient (ADC) maps with diffusion-weighted imaging.Overview of Literature: Decompression surgery for lumbar spinal stenosis (LSS) is selected on the basis of subjective assessment and cross-sectional magnetic resonance imaging (MRI). However, there is no objective standard for this procedure.Methods: We performed 3T MRI in 10 healthy volunteers and 13 patients with LSS. The ADC values in the spinal canal were evaluated at 46 vertebrae (L4/5 and L5/S1 for each participant), and the reduced and conventional fields of view were compared.Results: The ADC values were 2.72±0.12 at L4/5 in healthy volunteers, 2.76±0.19 at L5/S1 in healthy volunteers, 1.77±0.58 at L4/5 in patients with LSS, and 2.35±0.29 at L5/S1 in patients with LSS. The ADC value at L4/5 in patients with LSS was significantly lower than that at L5/S1 in patients with LSS and that at L4/5 and L5/S1 in healthy volunteers (<i>p</i> <0.05). With an ADC cutoff value of 2.46 to identify LSS, this approach provided an area under the curve of 0.81, sensitivity of 0.92, and specificity of 0.76 (<i>p</i> <0.05).Conclusions: Preoperative examination using ADC maps permits visualization and quantification of spinal canal lesions, thus proving the utility of ADC maps in the selection of decompression surgery for LSS.

Diffusion Tensor Imaging of the Spinal Canal in Quantitative Assessment of Patients with Lumbar Spinal Canal Stenosis

Norimoto Masaki,Eguchi Yawara,Kanamoto Hirohito,Oikawa Yasuhiro,Matsumoto Koji,Masuda Yoshitada,Furuya Takeo,Orita Sumihisa,Inage Kazuhide,Maki Satoshi,Shiga Yasuhiro,Kinoshita Hideyuki,Abe Koki,Inoue 대한척추외과학회 2021 Asian Spine Journal Vol.15 No.2

Study Design: Retrospective observational study. Purpose: Lumbar spinal stenosis (LSS) has traditionally been evaluated morphologically, there is a paucity of literature on quantitative assessment of LSS. The purpose of this study was to investigate whether intraspinal diffusion tensor imaging (DTI) parameters such as apparent diffusion coefficient (ADC) and fractional anisotropy (FA) are useful for assessing LSS. Overview of Literature: Quantitative assessment of LSS is challenging. Methods: Study participants comprised five healthy volunteers (mean age, 27.2 years) and 27 patients with LSS (mean age, 58.4 years) who were individually assessed using 3.0 Tesla magnetic resonance imaging. Intraspinal ADC and FA values of 10 intervertebral discs from healthy volunteers and 52 intervertebral discs from LSS patients were measured. Also, intraspinal canal area, Schizas classification (A: normal, B: mild stenosis, C: severe stenosis) and correlations with symptoms were investigated. Clinical symptoms were checked for the presence of low back pain (LBP), intermittent claudication (IMC), and bladder and bowel dysfunction (BBD). Results: Compared to healthy individuals, LSS patients had significantly lower ADC (p <0.05) and significantly higher FA values (p <0.01). In Schizas classification, stenosis worsened from A to C. ADC values decreased significantly while FA values increased significantly in that order (p <0.05). A positive correlation was found between intraspinal canal area and ADC values (r =0.63, p <0.01) and a negative correlation between intraspinal canal area and FA values (p =−0.61, p <0.01). No correlations were noted between LBP and ADC or FA values. On the other hand, ADC values were significantly lower (p <0.05) and FA values were significantly higher (p <0.05) in patients with IMC or BBD. Conclusions: Intraspinal DTI parameters such as ADC and FA values were associated with the Schizas classification, intraspinal canal area, and clinical symptoms, suggesting that ADC and FA may be useful for quantitative assessment of LSS.

Elevated Levels of Serum Pentosidine Are Associated with Dropped Head Syndrome in Older Women

Yawara Eguchi,Toru Toyoguchi,Kazuhide Inage,Kazuki Fujimoto,Sumihisa Orita,Kazuyo Yamauchi,Miyako Suzuki,Hirohito Kanamoto,Koki Abe,Masaki Norimoto,Tomotaka Umimura,Masao Koda,Takeo Furuya,Yasuchika A 대한척추외과학회 2019 Asian Spine Journal Vol.13 No.1

Study Design: A retrospective observational study was performed. Purpose: We investigated the prevalence of sarcopenia in dropped head syndrome (DHS), and the relationship between biochemical markers, including major advanced glycation end products (AGEs), pentosidine, and DHS in older women. Overview of Literature: AGEs have been implicated in the pathogenesis of sarcopenia. Methods: We studied 13 elderly women with idiopathic DHS (mean age, 77.2 years) and 20 healthy volunteers (mean age, 74.8 years). We used a bioelectrical impedance analyzer to analyze body composition, including appendicular skeletal muscle mass index (SMI; appendicular lean mass [kg]/[height (m)]2). Cervical sagittal plane alignment, including C2–C7 sagittal vertical axis (C2–C7SVA), C2–C7 angle, and C2 slope (C2S), was measured. Biochemical markers, such as serum and urinary pentosidine, serum homocysteine, 1, 25-dihydroxyvitamin D, and 25-hydroxyvitamin D, were measured. The level of each variable was compared between DHS and controls. The relationship between biochemical markers and DHS was examined. Results: Sarcopenia (SMI <5.75) was observed at a high prevalence in participants with DHS (77% compared to 22% of healthy controls). Height, weight, femoral bone mineral density, appendicular lean mass, total lean mass, and SMI all had significantly lower values in the DHS group. Serum and urinary pentosidine, and serum homocysteine were significantly higher in the DHS group compared to controls. Analysis of cervical alignment revealed a significant positive correlation of serum pentosidine with C2–C7SVA and C2S. Conclusions: Sarcopenia was involved in DHS, and high serum pentosidine levels are associated with severity of DHS in older women.

Assessment of Clinical Symptoms in Lumbar Foraminal Stenosis Using the Japanese Orthopaedic Association Back Pain Evaluation Questionnaire

Yawara Eguchi,Munetaka Suzuki,Hajime Yamanaka,Hiroshi Tamai,Tatsuya Kobayashi,Sumihisa Orita,Kazuyo Yamauchi,Miyako Suzuki,Kazuhide Inage,Hirohito Kanamoto,Koki Abe,Yasuchika Aoki,Masao Koda,Takeo Fur 대한척추신경외과학회 2017 Neurospine Vol.14 No.1

Objective: It is important to develop an easy means of diagnosing lumbar foraminal stenosis (LFS) in a general practice setting. We investigated the use of the Japanese Orthopaedic Association Back Pain Evaluation Questionnaire (JOABPEQ) to diagnose LFS in symptomatic patients. Methods: Subjects included 13 cases (mean age, 72 years) with LFS, and 30 cases (mean age, 73 years) with lumbar spinal canal stenosis (LSCS) involving one intervertebral disc. The visual analogue scale score for low back pain and leg pain, the JOABPEQ were evaluated. Results: Those with LFS had a significantly lower JOA score (p<0.001), while JOABPEQ scores (p<0.05) for lumbar dysfunction and social functioning impairment (p<0.01) were both significantly lower than the scores in LSCS. The following JOABPEQ questionnaire items (LFS vs. LSCS, p-value) for difficulties in: sleeping (53.8% vs. 16.6%, p<0.05), getting up from a chair (53.8% vs. 6.6%, p<0.001), turning over (76.9% vs. 40%, p<0.05), and putting on socks (76.9% vs. 26.6%, p<0.01) such as pain during rest, and signs of intermittent claudication more than 15 minutes (61.5% vs. 26.6%, p<0.05) were all significantly more common with LFS than LSCS. Conclusion: Results suggest that of the items in the JOABPEQ, if pain during rest or intermittent claudication is noted, LFS should be kept in mind as a cause during subsequent diagnosis and treatment. LFS may be easily diagnosed from LSCS using this established patient-based assessment method.

Diagnosis of Lumbar Foraminal Stenosis using Diffusion Tensor Imaging

Yawara Eguchi,Seiji Ohtori,Munetaka Suzuki,Yasuhiro Oikawa,Hajime Yamanaka,Hiroshi Tamai,Tatsuya Kobayashi,Sumihisa Orita,Kazuyo Yamauchi,Miyako Suzuki,Yasuchika Aoki,Atsuya Watanabe,Hirohito Kanamoto 대한척추외과학회 2016 Asian Spine Journal Vol.10 No.1

Diagnosis of lumbar foraminal stenosis remains difficult. Here, we report on a case in which bilateral lumbar foraminal stenosis was difficult to diagnose, and in which diffusion tensor imaging (DTI) was useful. The patient was a 52-year-old woman with low back pain and pain in both legs that was dominant on the right. Right lumbosacral nerve compression due to a massive uterine myoma was apparent, but the leg pain continued after a myomectomy was performed. No abnormalities were observed during nerve conduction studies. Computed tomography and magnetic resonance imaging indicated bilateral L5 lumbar foraminal stenosis. DTI imaging was done. The extraforaminal values were decreased and tractography was interrupted in the foraminal region. Bilateral L5 vertebral foraminal stenosis was treated by transforaminal lumbar interbody fusion and the pain in both legs disappeared. The case indicates the value of DTI for diagnosing vertebral foraminal stenosis.

Long-Term Outcomes of In Situ Fusion for Treating Dysplastic Spondylolisthesis

Kazuhide Inage,Sumihisa Orita,Kazuyo Yamauchi,Miyako Suzuki,Yoshihiro Sakuma,Go Kubota,Yasuhiro Oikawa,Takeshi Sainoh,Jun Sato,Kazuki Fujimoto,Yasuhiro Shiga,Koki Abe,Hirohito Kanamoto,Masahiro Inoue 대한척추외과학회 2017 Asian Spine Journal Vol.11 No.2

Study Design: Retrospective, observational, single-center study. Purpose: To investigate the long-term outcomes of in situ fusion procedures for treating dysplastic spondylolisthesis. Overview of Literature: In situ fusion performed in patients with dysplastic spondylolisthesis avoids the development of nerve complications. Methods: In total, 12 of 28 patients who underwent in situ fusion for treating dysplastic spondylolisthesis at Chiba University Hospital from 1974 to 2004 were followed up in August 2013. Surgical complications were evaluated. Low back pain and leg pain were assessed using a visual analog scale (VAS). Vertebral alignment, including the lumbosacral angle and lumbar lordosis angle measurement on radiographic images (profile view in the neutral standing position), was evaluated during preoperative, postoperative, and final examinations. Results: The mean follow-up duration, patient age at the final examination, and patient age at operation were 20.0±7.2, 42.3±13.3, and 22.3±11.4 years, respectively. No complications were reported. Mean VAS scores for low back pain and leg pain were significantly lower at the final examination than at the preoperative examination (p <0.05). At the preoperative, postoperative, and final examinations, the mean lumbosacral angle was 32.3°±14.2°, 33.7°±11.8°, and 36.5°±16.4°, while the mean lumbar lordosis angle was 51.0°±14.8°, 48.6°±18.8°, and 49.6°±15.5°, respectively. No significant differences were noted among these values across the different time periods (p <0.05). Conclusions: In situ fusion performed in patients with dysplastic spondylolisthesis avoids the development of nerve complications such as nerve paralysis that may occur after repositioning operation and maintains appropriate long-term sagittal alignment, even 20 years after operation.

Dose Optimization for Single Intradiscal Administration of the Tumor Necrosis Factor-α Inhibitor, Etanercept, in Rat Disc Injury Models

Kazuhide Inage,Sumihisa Orita,Kazuyo Yamauchi,Takane Suzuki,Miyako Suzuki,Yoshihiro Sakuma,Go Kubota,Yasuhiro Oikawa,Takeshi Sainoh,Jun Sato,Kazuki Fujimoto,Yasuhiro Shiga,Koki Abe,Hirohito Kanamoto,M 대한척추외과학회 2016 Asian Spine Journal Vol.10 No.4

Study Design: Experimental animal study. Purpose: We aimed to determine the optimal dose of a single direct injection of the tumor necrosis factor (TNF)-α inhibitor, etanercept, by using the rat model of degenerative intervertebral disc from injury. Overview of Literature: The pain-related peptide expression was suppressed in the etanercept (100 μg and 1,000 μg)-administered groups in a dose-dependent manner. Methods: The neurotracer FluoroGold (FG) was applied to the surfaces of L4/5 discs to label their innervating dorsal root ganglion (DRG) neurons (n=50). Ten rats were included in the nonpunctured disc sham surgery control group, whereas the other 40 were included in the experimental group in which intervertebral discs were punctured with a 23-gauge needle. Saline or etanercept (10 μg, 100 μg, or 1,000 μg) was injected into the punctured discs (n=10 for each treatment). After 14 days of surgery, DRGs from L1 to L6 were harvested, sectioned, and immunostained for calcitonin gene-related peptide (CGRP). The proportion of FG-labeled CGRPimmunoreactive DRG neurons was evaluated in all the groups. Results: There were no significant differences between the puncture+saline group and the puncture+10-μg etanercept group (p >0.05). However, a significant decrease in the percentage of FG and CGRP double-positive cells in FG-positive cells was observed in the etanercept (100 μg and 1,000 μg)-administered groups in a dose-dependent manner (p <0.05). Conclusions: When a low dose of the TNF-α inhibitor (10 μg of etanercept) was directly administered to the rat intervertebral disc in the rat model of degenerative intervertebral disc from injury, no suppressive effect on the pain-related peptide expression was observed. However, when a higher dose of etanercept (100 μg and 1,000 μg) was administered, the pain-related peptide expression was suppressed in a dose-dependent manner.

Does Discontinuing Teriparatide Treatment and Replacing It with Bisphosphonate Maintain the Volume of the Bone Fusion Mass after Lumbar Posterolateral Fusion in Women with Postmenopausal Osteoporosis?

Seiji Ohtori,Sumihisa Orita,Kazuyo Yamauchi,Yawara Eguchi,Yasuchika Aoki,Junichi Nakamura,Miyako Suzuki,Gou Kubota,Kazuhide Inage,Yasuhiro Shiga,Koki Abe,Kazuki Fujimoto,Hirohito Kanamoto,Masahiro Ino 대한척추외과학회 2017 Asian Spine Journal Vol.11 No.2

Study Design: Retrospective case series. Purpose: The purpose of this study was to determine whether discontinuing teriparatide treatment and replacing it with bisphosphonate treatment maintains the volume of the fusion mass after posterolateral fusion (PLF) in women with postmenopausal osteoporosis. Overview of Literature: Clinical data support the efficacy of parathyroid hormone (PTH) for lumbar PLF. However, the use of PTH is limited to 2 years. Methods: We treated 19 women diagnosed with osteoporosis and degenerative spondylolisthesis with teriparatide (20 μg daily subcutaneously). All patients underwent one-level instrumented PLF. Teriparatide was used during 2 months prior to surgery and more than 8 months after surgery. After discontinuing teriparatide treatment, all patients used bisphosphonate (17.5 mg risedronate weekly, oral administration). Area of the fusion mass across the transverse processes at one segment was determined on an anteroposterior radiograph at 1, 2, and 3 years after surgery. Results: We followed 19 patients for 3 years. The average duration of teriparatide treatment was 11.5 months. The bone union rate was 95%. The average area of the bone fusion mass was not significantly different between the right and left sides at 1, 2, or 3 years after surgery (p >0.05). Conclusions: This study showed that replacing teriparatide treatment with bisphosphonate maintained the bone fusion mass volume after PLF in women with postmenopausal osteoporosis.

Discrimination between Lumbar Intraspinal Stenosis and Foraminal Stenosis using Diffusion Tensor Imaging Parameters: Preliminary Results

Yawara Eguchi,Seiji Ohtori,Munetaka Suzuki,Yasuhiro Oikawa,Hajime Yamanaka,Hiroshi Tamai,Tatsuya Kobayashi,Sumihisa Orita,Kazuyo Yamauchi,Miyako Suzuki,Yasuchika Aoki,Atsuya Watanabe,Hirohito Kanamoto 대한척추외과학회 2016 Asian Spine Journal Vol.10 No.2

Study Design: Retrospective observational study. Purpose: To examine fractional anisotropy (FA) values and apparent diffusion coefficient (ADC) values of damaged nerves to discriminate between lumbar intraspinal stenosis (IS) and foraminal stenosis (FS) using diffusion tensor imaging (DTI) Overview of Literature: It is important in the selection of surgical procedure to discriminate between lumbar IS and FS, but such discrimination is difficult. Methods: There were 9 cases of IS, 7 cases of FS, and 5 healthy controls. The regions of interest were established in the lumbar intraspinal zone (Iz), nerve root (N), and extraforaminal zone (Ez). The FA and ADC values were measured on the affected and unaffected sides of the nerves. The FA ratio and the ADC ratio were calculated as the affected side/unaffected side ×100 (%). Results: In the Ez, the FA value was significantly lower in FS than in IS (p <0.01). FA ratio was significantly lower in FS than in IS for the Ez (p <0.01). In the Iz, the ADC value was significantly higher in IS than FS (p <0.01). ADC ratio was significantly higher in FS than in IS for the N and Ez (p <0.05). For the Ez, receiver operating characteristic analysis of parameters revealed that the FA values showed a higher accuracy for the diagnosis of FS than the ADC values, and the FA value cut-off value was 0.42 (sensitivity: 85.7%, false positive: 11.1%) and the FA ratio cut-off value was 83.9% (sensitivity: 85.7%, false positive: 22.2%). Conclusions: The low FA value in the extraforaminal zone suggests the presence of foraminal stenosis. When the FA value and FA ratio cut-off value were established as 0.42 and 83.9%, respectively, the accuracy was high for the diagnosis of foraminal stenosis. It may be possible to use DTI parameters to help in the discrimination between IS and FS.

Influence of Skeletal Muscle Mass and Spinal Alignment on Surgical Outcomes for Lumbar Spinal Stenosis

Yawara Eguchi,Munetaka Suzuki,Hajime Yamanaka,Hiroshi Tamai,Tatsuya Kobayashi,Sumihisa Orita,Kazuyo Yamauchi,Miyako Suzuki,Kazuhide Inage,Kazuki Fujimoto,Hirohito Kanamoto,Koki Abe,Masaki Norimoto,Tom 대한척추외과학회 2018 Asian Spine Journal Vol.12 No.3

Study Design: Retrospective observational study. Purpose: We considered the relationship between spinal alignment and skeletal muscle mass on clinical outcomes following a surgery for lumbar spinal stenosis (LSS). Overview of Literature: There are no reports of preoperative factors predicting residual low back pain following surgery for LSS. Methods: Our target population included 34 women (mean age, 74.4 years) who underwent surgery for LSS. Prior to and 6 months after the surgery, systemic bone mineral density and lean soft tissue mass were measured using dual-energy X-ray absorptiometry. Skeletal muscle mass index (SMI) was calculated as the sum of the arm and leg lean mass in kilograms divided by height in meters squared. The spinal alignment was also measured. Clinical outcomes were evaluated using the Japanese Orthopedic Association scoring system, leg and low back pain Visual Analog Scale, and Roland–Morris Disability Questionnaire (RDQ). Additionally, we examined the bone mineral density, skeletal muscle mass, and spinal alignment before and after the surgery. We used the Spearman correlation coefficient to examine the associations among clinical outcomes, preoperative muscle mass, and spinal alignment. Results: Sarcopenia (SMI <5.46) was observed in nine subjects (26.5%). Compared with normal subjects (SMI >6.12), RDQ was significantly higher in subjects with sarcopenia (p =0.04). RDQ was significantly negatively correlated with SMI (r =−0.42, p <0.05). There was a significant positive correlation between postoperative RDQ and pelvic tilt (PT; r =0.41, p <0.05). SMI and PT were significantly negatively correlated (r =−0.39, r <0.05). Conclusions: Good postoperative outcomes were negatively correlated with low preoperative appendicular muscle mass, suggesting that postoperative outcomes were inferior in cases of decreased appendicular muscle mass (sarcopenia). Posterior PT due to decreased limb muscle mass may contribute to postoperative back pain, showing that preoperatively reduced limb muscle mass and posterior PT are predictive factors in the persistence of postoperative low back pain.