Vacuum phenomenon of sacroiliac joint

Study Design: A radiologic study of sacropelvic morphology and vacuum phenomenon of sacroiliac joint in subjects unrelated to low back pain. Purpose: The aim of this study is to describe the relationship between sacropelvic morphology and vacuum phenomenon of the sacroiliac joint. Overview of Literature: Lumbopelvic alignment and sacropelvic morphology are associated with the pathomechanisms of various spinal disorders. The vacuum phenomena of the sacroiliac joint (SJVP) are often observed in clinical practice, but the relationships between these phenomena and sacropelvic morphology have not been investigated. This study examined the prevalence of SJVP in computed tomography (CT) images and the relationship between sacropelvic morphology and SJVP. Methods: We analyzed multiplanar CT images of 93 subjects (59 men, 34 women). Pelvic incidence (PI), pelvic tilt (PT), sacral slope (SS), and lumbar lordosis (LL) were measured using the three-dimensional reconstruction method. The prevalence of SJVP in multiplanar CT images were reviewed. Roland-Morris Disability Questionnaire (RDQ) scores and the modified Japanese Orthopedic Association (JOA) score, which focuses on subjective symptoms and restriction of activities of daily living, were also obtained from all the subjects. Results: Thirty-six of the 93 subjects had SJVP (39%), with marked female predominance (91% women, 8.5% men). Men with SJVP had significantly lower PI than men without SJVP (35.1° vs. 46.3°, p<0.05). There was no correlation between SJVP and the modified JOA or RDQ scores. Conclusions: These data suggest that differences in sacropelvic morphology can influence the biomechanical environment and contribute to SJVP in men. Presence of SJVP did not affect JOA or RDQ scores

Association between BRCA Gene Variants and the Response to Modified FOLFIRINOX in Patients with Unresectable Pancreatic Cancer

We investigated the effect of modified FOLFIRINOX (mFFX) in unresectable pancreatic cancer by retrospectively analyzing the cases of 43 patients who underwent BRCA testing (germline, n=11; somatic, n=26; both germline and somatic, n=6). The association between BRCA mutations and therapeutic effect was clarified. Six patients tested positive for germline pathogenic variants. Familial pancreatic cancer (33% vs. 3%, p=0.006) and peritoneal disseminated lesions (66% vs. 8%, p<0.001) were significantly more common in patients with germline pathogenic variants. The partial response (PR) rate was 100% in the germline BRCA-positive patients, and 27% in the germline BRCA-negative patients (p<0.001). The median progression-free survival (PFS) was not reached for any germline BRCA-positive patients but was 9.0 months for the germline BRCA-negative patients (p=0.042). Patients with stage IV BRCA-associated pancreatic cancer had better overall survival than those with non-BRCA-associated pancreatic cancer, although the difference was nonsignificant (not reached vs. 655 days, p=0.061). Our results demonstrate that a PR and prolonged PFS can be expected in germline BRCA-positive patients after treatment with mFFX. Our findings also suggest that germline BRCA pathogenic variants may be useful as biomarkers for the therapeutic effect of mFFX in patients with pancreatic cancer

発育期分離すべりモデルラットにおける下位椎体変形修復の骨化様式

Study design: A study using rat spondylolisthesis models. Objective: To elucidate the mechanism for correction of vertebral rounding deformity. Summary of Background Data: Vertebral rounding deformity is the strongest risk factor for high-grade slippage associated with spondylolisthesis in adolescents. We previously reported that inadequate endochondral ossification of the anterior upper corner of the vertebral growth plate in response to mechanical stress could be the pathological mechanism of vertebral rounding deformity. Methods: We created a model of spondylolisthesis using 4-week-old rats. They were divided into a tail suspension group that underwent tail suspension to decrease mechanical stress starting at 2 weeks postoperatively and a ground control group with no intervention. Radiographs and micro-computed tomography scans were obtained once weekly for 6 weeks postoperatively. The lumbar spines were then harvested for histological analysis. Immunohistochemical studies detected types I, II, and X collagen in the growth plate cartilage. Bone histomorphometrical analysis was also performed. Results: Radiological and histological evidence in the ground control group showed progress the rounding deformity with time as previously reported. Formation of normal cancellous bone was observed radiologically over time in the tail suspension group, indicating correction of rounding deformity. Histologically, the site showing radiological evidence of correction was derived from cartilage tissue. After starting tail suspension, the growth plate stained positive for type X collagen and the corrected site stained for types II and X collagen in a mosaic pattern. Chondrocytes expressing types I and II collagen and tartrate-resistant acid phosphatase-positive cells were also present at the corrected site. Histomorphometrically, more endochondral bone was detected at the corrected site than in the posterior aspect of the normal growth plate. Conclusion: Correction of vertebral rounding deformity was associated with improvement of chondrocyte differentiation, furthermore, there is possible involvement of a third mechanism, namely transchondroid bone ossification.It is possible to correct the rounding deformity of the vertebral body associated with isthmus slippage by decrease the load on the vertebral body in pediatric patients. In addition to improved chondrocyte differentiation and promotion of redifferentiation, there is possible involvement of a third mechanism, namely transchondroid bone ossification

Optimal Entry Point for Lateral Mass Screwing

Study Design: Retrospective study of 37 consecutive female patients with cervical spondylotic myelopathy who underwent reconstructed computed tomography (CT) scanning of the cervical spine. Purpose: The purpose of this study was to investigate whether the vertebral lateral notch of the cervical spine is an effective landmark to determine the entry point for lateral mass screwing. A modified Roy-Camille technique was used to determine the entry point associated with the lateral notch of the cervical spine. Overview of Literature: The Roy-Camille technique has been a popular technique for the posterior fixation of the cervical spine. A problem with this technique is determining the entry point on the lateral mass via visual inspection, such as in cases with degenerative or destructive cervical facet joints. Methods: Thirty-three female patients with cervical spondylotic myelopathy underwent reconstructed CT scanning of the cervical spine. Overall, 132 vertebrae from C3 to C6 were reviewed using reconstructed CT. The probable trajectory using a modified Roy-Camille technique was determined using reconstructed CT scans, and the optimal entry point was identified. Horizontal and vertical distances from the vertebral lateral notch were measured. Results: The entry point determined using the modified Roy-Camille technique was significantly superior and medial compared with that determined using the conventional Roy-Camille technique. At C3 and C4 levels, the entry point using the modified technique was 1.4 mm below and 4.4 mm medial to the lateral notch, and at C5 and C6 levels, it was 2.3 mm below and 4.9 mm medial to the lateral notch. Conclusions: The vertebral lateral notch of the cervical spine was an effective landmark to determine the entry point for lateral mass screwing. The modified Roy-Camille technique proposed here may prevent surgical complications and poor outcomes

横断像と矢状断像における椎間関節角度の加齢性変化 : 変性すべり症症例との比較

Background: Despite facet joints being three-dimensional structures, previous computed tomography and magnetic resonance imaging studies have evaluated facet joint orientation in only the axial plane. Facet joint orientation in the sagittal plane has rarely been studied using these imaging techniques. The aim of this study was to elucidate facet joint orientation in both the axial and sagittal planes on computed tomography. Methods: A total of 568 patients (343 men, 225 women) (excluding orthopedic outpatients) for whom abdominal and pelvic computed tomography scans were obtained at our hospital between September 2010 and October 2012 were included. Mean age was 63 (range 21-90) years. Patients were divided into a degenerative spondylolisthesis group (67 patients; 30 men, 37 women) and a control group (313 patients; 313 men, 188 women). Facet joint orientation was evaluated in the control group according to patient age (≤50, 51-60, 61-70, or ≥71 years). The findings in the control group were then compared with those in the degenerative spondylolisthesis group. The orientation of the lumbar facet joints at each level was measured in the axial and sagittal planes on computed tomography images. Results: Facet joint angles decreased with age at L4/5 and L5/S1 in women in the axial plane and at L4/5 in men and L3/4 and L4/5 in women in the sagittal plane. The variation in facet joint angle was greatest at L4/5 in women. Patients with degenerative spondylolisthesis showed more sagittally and horizontally oriented facet joints in the axial and sagittal planes; facet tropism showed an association with degenerative spondylolisthesis in the axial plane. Conclusions: The axial and sagittal orientation of facet joints in the lower lumbar vertebra, especially L4/5, was negatively correlated with age. This finding could help to explain why older people are more prone to degenerative spondylolisthesis

Revision percutaneous endoscopic lumbar discectomy under the local anesthesia for the recurrent lumbar herniated nucleus pulposus in a high class athlete : A case Report

Percutaneous endoscopic discectomy (PED) is a minimally invasive spinal technique and has several advantages compared with open surgery. We describe repeat PED surgery for recurrent herniated nucleus pulposus (HNP). The patient was a 33-year-old handball high level player. Previously, he underwent transforaminal PED under local anesthesia for intracanalicular HNP at L4-5 level about 2 years ago. He could return to his original competitive level. Two years later, he felt low back and right leg pain again when he was playing handball. Magnetic resonance imaging revealed the recurrence of HNP at the same level. We conducted transforaminal PED again using the exact same route as the previous surgery. Although there was a little adhesion around the L5 nerve root, we could easily identify and remove the herniated mass using endoscopic forceps. Immediately after the surgery, the low back and leg pain disappeared. Repeat PED surgery for recurrence of lumbar disc herniation is effective especially for athletes because of the benefits of PED, including surgery under local anesthesia, preservation of normal posterior structures, less postoperative pain, early discharge, and faster return to sports

Optimal liver drainage rate for survival in patients with unresectable malignant hilar biliary obstruction using 3D-image volume analyzer

Background: Drainage exceeding 50% of total liver volume is a beneficial prognostic factor in patients with unresectable malignant hilar biliary obstruction (UMHBO). However, it is unclear what threshold percentage of total liver volume drained ('liver drainage rate') significantly improves survival in patients with UMHBO who received systemic chemotherapy. Objectives: We aimed to assess the optimal liver drainage rate that improves survival in patients with UMHBO receiving chemotherapy using a three-dimensional (3D)-image volume analyzer. Design: This study was a single-center retrospective cohort study. Methods: Data from 90 patients with UMHBO who received chemotherapy after endoscopic biliary drainage using metal stents at Okayama University Hospital from January 2003 to December 2020 were reviewed. The liver drainage rate was calculated by dividing the drained liver volume by the total liver volume using a 3D-image volume analyzer. The primary endpoint was overall survival by liver drainage rate. The secondary endpoints were time to recurrent biliary obstruction (TRBO) and prognostic factors. Results: The median total liver volume was 1172 (range: 673-2032) mL, and the median liver drainage rate was 83% (range: 50-100). Overall survival was 376 (95% CI: 271-450) days, and patients with >80% drainage (n = 67) had significantly longer survival than those with 80% liver drainage [hazard ratio (HR): 0.35, 95% CI: 0.20-0.62, p = 0.0003] and hilar cholangiocarcinoma (HR: 0.30, 95% CI: 0.17-0.50, p Conclusion: In patients with UMHBO scheduled for chemotherapy, >80% drainage is associated with improved survival. Further prospective multicenter studies are needed to verify the results of this study

Gastric linitis plastica with autoimmune pancreatitis diagnosed by an endoscopic ultrasonography-guided fine-needle biopsy: A case report

BACKGROUND Gastric linitis plastica (GLP) is a subset of gastric cancer with a poor prognosis. It is difficult to obtain a definitive diagnosis by endoscopic mucosal biopsies, and the usefulness of an endoscopic ultrasonography-guided fine-needle biopsy (EUS-FNB) for GLP has been recently reported. Meanwhile, autoimmune diseases are occasionally known to coexist with malignant tumors as paraneoplastic syndrome. We herein report the usefulness of an EUS-FNB for detecting GLP and the possibility of paraneoplastic syndrome coexisting with GLP. CASE SUMMARY An 81-year-old man was admitted to our hospital for a 1-mo history of epigastric pain that increased after eating. His laboratory data revealed high levels of serum carbohydrate antigen 19-9 and immunoglobulin-G4. Endoscopic examinations showed giant gastric folds and reddish mucosa; however, no epithelial changes were observed. The gastric lumen was not distensible by air inflation, suggesting GLP. Computed tomography showed the thickened gastric wall, the diffuse enlargement of the pancreas, and the peripancreatic rim, which suggested autoimmune pancreatitis (AIP) coexisting with GLP. Because the pathological findings of the endoscopic biopsy showed no malignancy, he underwent an EUS-FNB and was diagnosed with GLP. He received chemotherapy for unresectable gastric cancer due to peritoneal metastasis, after which both the gastric wall thickening and diffuse enlargement of the pancreas were improved. CONCLUSION An EUS-FNB for GLP with a negative endoscopic biopsy is useful, and AIP may develop as a paraneoplastic syndrome

X線透視による医療者及び患者の被曝量の検討 : 未固定遺体を用いた研究

Study Design. Using fresh cadavers, real-time dosimeters were used to estimate the radiation exposure dose from C-arm fluoroscopy to surgeons, medical staff, and patients during various procedures. Objective. To evaluate the radiation exposure dose from C-arm fluoroscopy, which is used to generate real-time images of the human body, under a variety of conditions and in different areas. Summary of Background Data. Awareness of the harmful effects of long-term low-dose radiation is rising. There are no all-inclusive reports evaluating the radiation exposure dose to medical staff associated with fluoroscopic procedures which can accurately simulate the real clinical situation. Methods. Seven fresh cadavers were irradiated for 1, 3, and 5 min with C-arm fluoroscopy. The X-ray source was positioned under the table, over the table, and laterally. Radiation exposure doses were measured at different simulated areas such as the center area, and the surgeon’s hand or thyroid gland. Results. There were significant differences in the radiation exposure dose under different conditions and for different irradiated areas. The risk of direct and scatter radiation exposure was the greatest with the lateral position, which increased by more than 200 times and more than 30 times, respectively, compared with that from a position under the table. Direct radiation was attenuated to less than one-hundredth after passing through the body of the cadaver. All radiation exposure doses were positively correlated with total exposure time. Conclusions. Our study revealed the direct and scatter radiation exposure dose from C-arm fluoroscopy to different areas under a variety of conditions when fluoroscopy is used to generate real-time images of the human body. Our results serve as a guide for medical staff to understand the risk of radiation exposure during each fluoroscopic procedure. Medical staff, especially surgeons, should consider how to protect themselves and reduce radiation exposure by using appropriate shielding

The reduction and direct repair of isthmic spondylolisthesis using the smiley face rod method in adolescent athlete : Technical note

Presently, lumbar spondylolisthesis did not have the indication of direct repair surgery because of the difficulty to reduce the slippage. In this report, we presented a case and described a minimally invasive direct repair surgery to reduce and repair the pars interarticularis defects of lumbar spondylolisthesis. First, curettage and removal of the synovium of the pars interarticularis and decompression of nerve root are conducted. Next, cancellous bone is harvested from the iliac crest. And then the Percutaneous Pedicle Screws are inserted bilaterally. A rod is bended and placed just caudal to the spinous process. We can make reposition of slipped vertebra and stabilize the loose lamina more firmly using a reduction tool and a rod pusher. Finally, bone grafts are implanted onto the pars defects. The Smiley face rod method is very useful to reduce the slippage and repair the pars defects in the lumbar spondylolisthesis especially in adolescent athletes