Accurate diagnosis of low back pain

Background : There is few reports evaluated accurately the pain generator of low back pain in elite athletes. The purpose of this report was to show case series and to investigate the cause of unidentified low back pain of elite athletes. Methods : Twenty-three adult elite athletes consulted our sports spine clinic to seek a second opinion for low back pain between April 2013 and March 2016. Their cause of low back pain had not been identified by nearby doctor. Spine surgeons had diagnosed using diagnostic injection and STIR-MRI and the final diagnosis made by the spine surgeon were collected. Results : The mean age of 23 patients (16 male, 7 female) was 30.4 years. The most common sport played was baseball. The final diagnosis made by a spine surgeon was as follows : disc related low back pain (n = 12), facet joint arthritis (n = 5), vertebral endplate injury (n = 4), early-stage lumbar spondylolysis (n = 1), supraspinous ligament injury (n = 1). Conclusions : A thorough medical interview, careful physical examination, appropriate diagnostic imaging, and injection block examination can effectively identify the cause of low back pain

Lumbar Spondylolysis and vascular supply

INTRODUCTION : The pathology of lumbar spondylolysis is generally thought to begin with a stress fracture in adolescence. Stress fractures of the lower extremities occur in watershed areas with a poor vascular supply because of an inability to respond to stress and heal. This pathology has not been well researched in the lumbar spine. The aim of this study was to evaluate the distribution of the spinal arteries in patients with lumbar spondylolysis. METHODS : The extraosseous distribution of the arteries around the pars interarticularis was retrospectively investigated in 14 patients with colon cancer who underwent abdominal contrast-enhanced computed tomography (CE-CT) as part of a preoperative assessment at our hospital and were found to have spondylolysis at L5. RESULTS : All patients were found to have terminal-stage spondylolysis at L5 (1 unilateral, 13 bilateral). L5 segmental artery was absent in all cases. However, separate spinal arteries supplying the pars interarticularis at L5 were found above and below the transverse process at this level. CONCLUSION : All the patients had two separate arteries originating from the cranial and caudal sides that distributed to the superior and inferior articular processes, suggesting that the pars interarticularis is a posterior element containing a vascular watershed area

Early return activity after endoscopic surgery in medical doctors

Full endoscopic surgery including discectomy (FED) and ventral facetectomy (FEVF) is a minimally invasive lumbar decompression surgery that only requires an 8 mm skin incision and can be done under the local anesthesia and sedation. Six male medical doctors underwent the endoscopic decompression (FED/FEVF) for common degenerative lumbar spine problems. Their age ranged from 27 to 63 years of age with a mean of 40 years. Five doctors underwent FED surgery for herniated nucleus pulposus (HNP), and the remaining one physician had FEVF for lumbar lateral recess stenosis. There were no surgery related complications. Postoperatively, 5 out of the 6 physician patients returned the original job within a week because they had clinical duties. The shortest duration to return to work was reported by a 63-year-old orthopedic surgeon resumed working in his clinic 2 days after the FEVF surgery. The longest duration to return to work occurred in general medicine resident who took almost 2 weeks for the sick leave because he did not have clinical duties. The mean duration for the returning to work was 5.8 days after the surgery. At final follow-up ranging from 6 to 30 months, all physician patients were working without any residual pain. In the hands of the authors, the full endoscopic transforaminal decompression surgery is the preferred surgical option and allowed early return to work—an observation that is not the norm in Japan

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

FED surgery for L5 radiculopathy

In this report, we presented a 65 year-old male case having right leg pain due to L5 radiculopathy. Based on the radiological examination including CT, MRI and radiculography, double crash impingement of L5 nerve root due to L4-5 lateral recess and L5-S foraminal stenosis was diagnosed. Because of the strong pain, he could not work anymore. His job was a general manager of big hospital, he needed to return to job as soon as possible. We decided to conduct the full-endoscopic decompression surgery of ventral facetectomy (FEVF) for L4-5 lateral recess stenosis and foraminoplasty (FELF) for L5-S foraminal stenosis. The technique can be done under the local anesthesia with only 8 mm skin incision; thus, it must be the least invasive spine surgery. Soon after the surgery, he could return to the original job as a general manager. In conclusion, the full-endoscopic decompression surgery for the spinal canal stenosis such as FELF and FEVF would be minimally invasive procedure and it enable patients the quick return to the original activity

Retrospective Cohort Study Showing Clinical Equivalence of Microendoscopic Laminotomy to Open Fenestration for Patients with Lumbar Spinal Stenosis

Objective Despite the popularity of microendoscopic disectomy, there is currently insufficient studies about microendoscopic laminotomy (MEL) for lumbar spinal stenosis. The purpose of this study was to compare the clinical and radiographic outcomes of MEL and fenestration (laminotomy in open procedure) for lumbar spinal stenosis. Methods This study included 30 patients in the MEL group and 46 patients in the open fenestration group between 2012 and 2016 (follow-up period ≥1 year). The Japanese Orthopedic Association Back Pain Evaluation Questionnaire(JOABPEQ), a visual analog scale(VAS), surgical outcomes, blood test outcomes, and radiographic parameters were studied. Results Mean age was 67 years old in the MEL group and 70 years old in the open fenestration group (p=0.1). There were no significant differences in score change of either domain of JOABPEQ between MEL and fenestration. The 95% confidence intervals of the between-group differences in score change were within clinical important difference (±20 point) in all the domains of JOABPEQ. The MEL group had significantly shorter hospital stays (9 days vs 13 days; p<0.001), smaller increase in C-reactive protein (1.7 mg/dL vs 2.9 mg/dL; p=0.009), and longer operating time (122 min vs 39 min; p<0.001) than the fenestration group. There was no significant difference in hemoglobin level, total protein, albumin, creatine kinase between the groups. The MEL group had one case of dural tear and the fenestration group had two cases(p=1.0). There was no significant differences in complication rate between the groups. There were no significant between-group differences in change of disc height or ROM. Conclusion In the treatment of lumbar spinal stenosis, the clinical effectiveness and safety of MEL was equivalent to that of fenestration, with less invasiveness

Transforaminal endoscopic surgery in professional baseball players

Transforaminal endoscopic discectomy has been established as the least minimally invasive spine surgical procedure because it avoids the surgical morbidity from surgical dissection and denervation of normal anatomy responsible for the functional stability of the spine. There have been few reports on endoscopic spine surgery for professional athletes who are dependent on the preservation of vital anatomy to maintain the highest level of function. This report is on five Japanese professional baseball players who underwent transforaminal endoscopic foraminoplasty-discectomy with pulsed radiofrequency thermal annuloplasty under the local anesthesia. There were no adverse surgical events nor complications. Three athletes suffered from discogenic back pain, one from symptomatic herniated nucleus pulposus (HNP), and another player from sciatica due to foraminal stenosis. Three players decided to undergo surgery at the beginning of the off-season. Therefore, they returned to professional play at the beginning of the following season. The remaining two players underwent surgery just before the beginning of the next season. They all returned to play sooner than with traditional open decompression. Two players returned to play about one month after the start of the season. All five players quickly returned to their sport within three months despite the rigors required of their sport to maintain high proficiency and were able to complete the season

TE-LUL for lumbar central canal stenosis

Full-endoscopic spinal surgery was first developed for the lumbar herniated nucleus pulposus. Mainly, there are two types in the full-endoscopic lumbar surgery : i.e., transforaminal (TF) and interlaminar approach. The surgery can be done under the local anesthesia for the TF approach ; therefore, we need to further develop the TF approach to variety of the spinal disorders. Recently, the TF full-endoscopic surgery has been applied for the spinal canal stenosis. First, transforaminal full-endoscopic lumbar foraminoplasty for the foraminal stenosis ; then, transforaminal lumbar lateral recess decompression for the lateral recess stenosis has been developed. Finally, we have developed the surgical technique to decompress the central stenosis via TF approach under the local anesthesia. Prior to initiate the clinical case, we have attempted the lumbar undercutting laminectomy using a fresh cadaveric spine. After we technically confirmed that the transforaminal full-endoscopic lumbar undercutting laminectomy (TE-LUL) is possible, we applied the technique to the patient whose lung capacity did not allow general anesthesia. The 72 years old female patient with central canal stenosis could be improved her left leg pain and muscle weakness after TE-LUL under the local anesthesia. In this paper, we introduce the surgical technique of the TE-LUL and discuss of the efficacy of the TE-LUL

Bony fragment of apophyseal ring fracture

In this paper, we present 2 cases of herniated nucleus pulposus (HNP) combined with the residual bony fragment of apophyseal ring fracture. HNP typically exists at the narrow lateral recess formed by the bony fragment, and so it has been reported that symptoms may persist. Case 1 was a 22-year-old man, a high-level javelin thrower and Paralympic athlete. He had a history of persistent pain for 4 years due to HNP, and so we performed surgical removal. Case 2 was a 23-year-old male professional baseball player. He was referred to us only 17 days after the onset of pain and presented with muscle weakness, a feature which may prolong the clinical course in addition other features such as pain. Thus, we performed a comparatively quick intervention of surgical removal. In both cases, we had excellent clinical outcomes and better function and performance. In conclusion, in cases with HNP and apophyseal ring separation, surgical intervention in the comparatively early phase can be recommended, particularly if the patients desire quick return to their original level of activity

Biomass production and nutrient removal by spontaneous grown green algae oedogonium sp. from a pond in University of Tsukuba

As one of the methods for nutrient removal from eutrophicated lakes and ponds affected by nonpoint nutrient pollution, the conversion of nutrients into aquatic plant biomass (APB) has drawn increasing attention. In this study, the acquisition and sequestration of nutrients by APB and the application of APB as a resource were discussed. The study site was an eutrophicated inland pond at the University of Tsukuba, Amano-Gawa, which is occasionally covered with the submerged macrophyte green alga Oedogonium sp. This species was found to produce 1048 kg of total biomass in dry weight and 13.1 kg of lipid per harvest