竹下 克志

Purpose. The purpose of this paper is to investigate the efficacy of the Milwaukee brace and its psychological impact and to define whether its use is still acceptable today by a review of literature. Method. A bibliographic search on PubMed and Medline database using keywords, 'scoliosis and brace' was performed. Results. Milwaukee brace 23-hours wearing protocol was most effective for the treatment of adolescent idiopathic scoliosis. However, 23-hours wearing protocol has some drawbacks, and even the patients using thoraco-lumbo-sacral orthosis wore their brace only for around 60% of the time prescribed as their wearing protocol. Our Milwaukee brace part-time wearing treatment was effective, and by its use combined with physical therapy, better results than the natural history were obtained. Conclusion. With part-time wearing protocol, the Milwaukee brace can survive today as a treatment option for idiopathic scoliosis with thoracic curve or double curve. © 2008 Informa UK Ltd All rights reserved.

Background. There is no widely accepted objective evaluation for lumbar spine disorders. New outcome measures should be patient-oriented and should measure symptoms and self-reported functional status in multiple dimensions. The aim of this study was to identify items to be included in the disease-specific quality of life (QOL) questionnaire for the assessments of patients with lumbar spine disorders. Methods. The draft of the QOL questionnaire that consisted of a total of 60 items, including 24 items derived from the Japanese version of the Roland Morris Disability Questionnaire (RDQ) and 36 items derived from the Japanese version of Short Form 36 (SF-36), were administered to patients and controls. After obtaining written informed consent, the following data were collected from the patient group (n = 328) and the control group (n = 213): (1) background characteristics, including age, diagnosis, Japanese Orthopaedic Association (JOA) score, and finger to floor distance; (2) responses to the questionnaire; (3) the identification rate by discrimination analysis to select the candidates for adoption and by adopting explanatory variables. The items to be excluded were determined by examining the explanatory variables, which were selected after the discrimination analysis, by setting the candidate to-be-excluded items as an objective variable. Results. Based on the distribution of the responses, two items, RDQ-15 and RDQ-19, were excluded. From the results of the correlation coefficient calculation for each question in the patient group, 33 items were excluded and 27 candidate items were adopted. Based on the adoption explanatory variable used in the discrimination analysis, 25 of the 27 candidate items for adoption were accepted. Conclusions. This study identified the 25 specific questionnaire items that should be included in the questionnaire to evaluate QOL of patients with various lumbar spine disorders.

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

Background An outcome measure to evaluate the neurological function of cervical myelopathy was proposed by the Japanese Orthopaedic Association in 1975 (JOA score), and has been widely used in Japan. However, the JOA score does not include patients' satisfaction, disability, handicaps, or general health, which can be affected by cervical myelopathy. The purpose of this study was to develop a new outcome measure for patients with cervical myelopathy. Methods This study was conducted in eight university hospitals and their affiliated hospitals from February to May 2002. The questionnaire included 77 items. Forty-one questions, which were originally listed by the authors, were for evaluation of the physical function of the cervical spine and spinal cord. The Medical Outcome Study Short-Form 36-Item Health Survey (SF-36) was used to examine health-related quality of life (QOL). Patients with cervical myelopathy and healthy volunteers were recruited at each institution. After analysis of the answers from patients and volunteers, irrelevant questions using the following criteria were excluded: (1) a question 80% of answers for which were concentrated on one choice, (2) a question whose answer was highly correlated with that of other questions, (3) a question that could be explained by other questions, and (4) a question for which the distribution of the answers obtained from the patients was not different from that obtained from the normal volunteers. Results The patients comprised 164 men and 86 women, and the healthy volunteers 96 men and 120 women. Thirteen items from the questions about the physical functions of the cervical spine and the spinal cord and 11 items from SF-36 remained as candidates that should be included in the final outcome measure questionnaire. Conclusions Twenty-four questions remained as candidates for the final questionnaire. This new self-administered questionnaire might be used to evaluate the outcomes in patients with cervical myelopathy more efficiently.

Background A new self-administered questionnaire as an outcome measure for patients with cervical myelopathy was drawn up in Part 1 (Japanese Orthopaedic Association Cervical Myelopathy Evaluation Questionnaire, JOACMEQ). Because a question with regard to driving a car (C-41) was not suitable for this patient group, the authors composed an alternative question related to neck motion (C-41-2). The purposes of the present study were to perform a secondary survey on patients with cervical myelopathy and to statistically analyze the responses to validate the JOACMEQ, and also to determine if it was possible to convert item C-41 to the alternative question. Methods A member of the Subcommittee on Low Back Pain and Cervical Myelopathy Evaluation from each hospital administered the questionnaire to more than 50 patients with cervical myelopathy in each hospital. The questionnaire consisted of 25 questions, 24 of which were extracted in the primary survey. The authors statistically examined whether it was possible to convert question C-41 to C-41-2. Results Three hundred and sixty-eight patients with cervical myelopathy were enrolled in the present study. No questions elicited no answer or "I am not sure" in more than 5% of patients except question C-41. There were no questions that the patients answered with difficulty. There was no tendency that was concentrated on one option as an answer to questions. There was a high correlation between questions C-41 and C-41-2. Spearman's correlation coefficient and kappa value showed that there was high coincidence between the two questions C-41 and C-41-2. It is possible to convert the question C-41 to the alternative question C41-2. Conclusions The questionnaire has sufficient reliability for clinical use. It is possible that the JOACMEQ will prevail and become a global standard to evaluate outcomes in patients with cervical myelopathy.

Contribution of genetic backgrounds to the etiology of lumbar spondylosis has been suggested by epidemiological studies. This study was designed to determine the association of restriction fragment length polymorphisms (RFLPs) of estrogen receptor (ER), vitamin D receptor (VDR), parathyroid hormone (PTH) and interleukin-1 beta (IL-1 beta) genes with the radiological severity of lumbar spondylosis at the disk level from L1/2 to L5/S1 in Japanese post-menopausal women. ER and VDR RFLP haplotypes were associated with the severity of spondylosis in the upper levels (L1/2 and L2/3) more than in the lower levels. Association of ER genotype was more pronounced in the group younger than average than in the older group, while that of VDR genotype was more significant in the older group. Neither PTH nor IL1-beta RFLP was associated with the severity at any levels in either stratified group. We thus conclude that ER and VDR genes may contribute to lumbar spondylosis in a distinct manner: estrogen sensitivity influences the severity in the early phase after menopause while vitamin D plays an important role at older ages when the contribution of estrogen loss is weaker.

Purpose. The aim of this study was to assess the feasibility of an original reformation method of cervical myelographic computed tomography (CT) using the Bezier surface technique. Material and methods. Presurgical myelographic computed tomography (CT) scans using a multidetector row CT scanner were performed in 25 patients with avulsion injury of the cervical nerve roots. Each volumetric data set was reformatted using Bezier surface technique to depict the individual nerve root in a single image. In the reformatted images, visualization of the dorsal and ventral nerve roots between C4 and T1 on the uninjured side (300 nerves) was rated. Results. Bezier surface reformation (BSR) images depicted the dorsal and the ventral nerve roots between C4 and C8 in 125 (100%) and 125 (100%) of 125 nerves, respectively. The dorsal and the ventral nerve roots of T1 were depicted in 25 (100%) and 22 (88%) in 25 nerves, respectively. Conclusion. The BSR technique of cervical myelographic CT enables simultaneous display of multiple cervical nerve roots in one image. BSR is a feasible technique for the assessment of the cervical nerve roots. © 2006 Japan Radiological Society.

Study Design. Descriptive case series. Objective. To determine whether fusionless, multiple vertebral wedge osteotomy can safely obtain correction of the deformity with adolescent idiopathic scoliosis (AIS). Summary of Background Data. To our knowledge, no such attempts to manage the AIS with fusionless, vertebral osteotomies have been reported. Methods. A total of 20 consecutive patients were treated since 1987. Deformity correction, complications, respiratory function, and patient-oriented outcome were investigated. Results. There were 20 patients (17 females and 3 males), including 19 with idiopathic and 1 with syringomyelia scoliosis, who underwent surgery at an average age of 16.4 years and were followed for 8.9 years (range 2-17) on average. There were no neurologic complications. One superficial wound infection necessitated debridement. There were 2 patients converted to posterior instrumentation surgery because of deterioration of the deformity. The average Cobb angle of 64.0 degrees before surgery was corrected to 48.2 degrees at 8.9 years after surgery. Decline of the pulmonary function test after surgery was not statistically significant. The patients' responses to questions about function and pain were favorable. Conclusion. Deformity with AIS was safely corrected with fusionless, multiple vertebral wedge osteotomy.

Study Design. Retrospective case-control study. Objectives. To compare patients treated with and without intraoperative halo-femoral traction to assess neuromuscular spinal deformity correction as well as the safety of the technique. Summary of Background Data. Optimal sitting balance can be achieved in nonambulatory neuromuscular patients with pelvic obliquity by maneuvering a Galveston-type rod or inserting screws into the iliac wings; however, this is often clinically challenging because of the small, soft bonestock in the pelvis of these patients. Methods. A total of 40 patients with nonambulatory neuromuscular scoliosis were treated surgically with a T2 or T3-sacrum instrumented posterior spinal fusion. There were 20 patients (12 who underwent posterior spinal fusionalone and 8 anterior/posterior spinal fusion) who had intraoperative halo-femoral traction performed unilaterally on the high side iliac wing compared to a control group of 20 patients (15 who underwent posterior spinal fusion-alone and 5 anterior/posterior spinal fusion) operatively treated without halo-femoral traction. Each group had 14 patients with spastic (cerebral palsy) scoliosis, and 6 with flaccid (muscular dystrophy) scoliosis deformities. Minimum follow-up for all patients was 2 years (range 3-12). Results. Preoperative lumbar scoliosis averaged 87 (range 30-141) in the halo-femoral traction group and 67 (range 28-108) in the control group (P = 0.012). Postoperative lumbar Cobb decreased to 35 (range 15 60) in the halo-femoral traction group and 32 (range 4-66) in the control group (P = 0.181). Preoperative pelvic obliquity averaged 26 (range 8-47) in the halofemoral traction group and 17 (range 8-44) in the control group (P = 0.017); postoperative averaged 6 (range 1-23) in the halo-femoral traction group and 7 (range 0-27) in the control group. Average pelvic obliquity correction was 78% in the halo-femoral traction group and 52% in the control group (P = 0.001). There were no intraoperativeor postoperative halo-femoral traction apparatusrelated complications noted (pin cut-out, femoral fractures, pin-sight infections, etc.). Conclusions. Intraoperative use of halo-femoral traction during the surgical treatment of patients with nonambulatory neuromuscular scoliosis provided significantly improved lumbar curve and pelvic obliquity correction. Intraoperative halo-femoral traction had no associated perioperative complications.

Study Design. A cross-sectional analysis. Objective. To elucidate the accuracy of neurologic level diagnosis of cervical stenotic myelopathy. Summary of Background Data. Neurologic level diagnosis in cervical myelopathy has not been well established. Methods. A total of 106 patients with cervical stenotic myelopathy, with a single-level intramedullary high-intensity area confirmed on both preoperative and postoperative T2-weighted magnetic resonance imaging (MRI), were included in this study. We performed a level diagnosis on the basis of neurologic signs (the uppermost muscle with weakness, diminished or exaggerated deep tendon reflex, the uppermost level of sensory disturbance of the upper extremities) and compared it with a level diagnosis made by T2-weighted MRI. The sensitivity, specificity, and accuracy of neurologic signs on our index corresponding to each intervertebral level were calculated. Results. The averages of sensitivity, specificity, and accuracy were 42%, 80%, and 70%, respectively, in the uppermost muscle with weakness, 66%, 89%, and 83% in deep tendon reflex, and 74%, 91%, and 87% in the sensory disturbance area. The positive and negative predictive values were 40% and 91%, respectively, in the uppermost muscle with weakness, 66% and 89% in deep tendon reflex, and 74% and 91% in the sensory disturbance area. Accuracy of a diagnosis based on muscle weakness was less high, the reason being that in many patients, the uppermost muscle with weakness was extensor digiti communis or the intrinsic muscles of the hands, and this led to a lower sensitivity. Conclusions. The average accuracy of neurologic level diagnosis based on the index we proposed was >= 70%. The level diagnosis by a sensory disturbance area showed the highest accuracy (87%).

Background. The exact insertion of a cervical screw is technically demanding, especially when normal anatomic landmarks have been obscured and are difficult to identify, such as in revision surgery. The purpose of this study was to evaluate the efficacy of an image-guidance system to aid placement of transarticular and pedicular screws for revision cervical spine surgery. Methods. Ten patients with recurrent myelopathy, including seven with cerebral palsy, two with a giant cell tumor, and one with rheumatoid arthritis, underwent computer-aided reconstruction surgery. The authors used a frameless stereotactic image-guidance system with simultaneous fluoroscopy. Postoperative computed tomography was used to determine the accuracy of the screw placement. Results. There were no neurovascular complications and no correction loss. All patients showed solid bony union. All four C1/2 transarticular screws were exactly placed inside the pedicles. Of 47 pedicular screws, 11 showed a slight breach of the cortex. When a reference arc could not be attached to the relevant vertebra, the rate of cortical perforation of screws was high (5/10; 50%) compared with the rate when a reference arc was attached to the relevant vertebra (6/37; 16%). Conclusion. Although more advanced technology is hopeful, a computer-assisted image-guidance system with simultaneous fluoroscopy is useful for aiding revision surgery to achieve rigid fixation and ensure safety.

Study Design. Retrospective case- controlled study of cervical laminoplasty. Objective. To evaluate the alignment and clinical result by laminoplasty when the C2 lamina is contained or retained. Summary of Background Data. Resection of the C2 lamina was reported to progress to kyphosis after laminectomy. Laminoplasty was reported to inhibit kyphosis. But no study has ever shown if the alignment is retained when laminoplasty also included the C2 lamina. Methods. Seventy- two patients with cervical spondylotic myelopathy undergoing laminoplasty were analyzed. Follow- up averaged 4.0 years. The outcome was assessed by the Cobb angle between C2 and C7, and the motor function scores of the upper and lower extremities for cervical myelopathy were made by the Japanese Orthopedic Association. Patients were stratified into three groups depending on the handling of the C2 lamina: fully split ( S group; n = 17), C2 dome- like laminotomy ( D group; n = 19), and intact ( I group; n = 36). Change of the C2 - C7 angle was compared by the analysis of variance and post hoc test. The association between the alignment and the motor scores was analyzed. Results. Upper/ lower score increased from 2.4/ 2.0 to 3.4/ 2.9, respectively. The C2 - C7 angle decreased in S group: - 8.3 °, D group: - 5.2 °, and I group: - 1.5 °. The cervical alignment deteriorated significantly in S group compared with the I group ( P < 0.01). The C2 - C7 angle change or postoperative C2 - C7 angle had no significant correlation with the postoperative upper and lower m-JOA scores or score change. Conclusions. Subaxial laminoplasty maintained the alignment. But if laminoplasty included the C2 lamina, the alignment worsened.

The management of grade I lumbar degenerative spondylolisthesis remains controversial. There have been few reports comparing any form of surgery with conservative treatment. As for surgical management, the need for arthrodesis with instrumentation has not been established. A series of 53 patients with single-level spinal stenosis at L4/5 due to grade I degenerative spondylolisthesis entered into a study to compare outcomes of two surgical methods of treatment with those of a control group treated conservatively: group 1, 19 patients treated by decompression laminectomy combined with posterolateral fusion and pedicle screw instrumentation; group 2, 18 patients treated by decompression of the spinal canal using a laminoplasty technique to preserve the integrity of the midline structure; group 3, 16 patients treated conservatively after being recommended that they have surgery. We compared the 2-year results among the three groups. A leviation of symptoms was noted in groups 1 and 2, whereas the controls (group 3) showed no improvement. There was no significant difference in the degree of clinical improvement between groups 1 and 2. Spondylolisthesis was controlled in group 1, but it did not lead to better clinical results than those achieved in group 2. Our findings indicate that the technique for decompressing the spinal canal with preservation of the posterior elements of its roof can be useful for treating patients with grade I degenerative spondylolisthesis with symptoms of spinal stenosis.

Study Design. An analysis of computed tomography images of patients with adolescent idiopathic scoliosis. Objectives. To evaluate the spatial relations between the vertebral body and the thoracic aorta and to verify the safety of anterior instrumentation surgery. Summary of Background Data. Recent studies have suggested that the aorta is positioned more laterally and posteriorly in patients with idiopathic scoliosis than in normal patients; however, no study used rib heads as references in the analysis. Methods. Computed tomography images of the whole thoracic spine of 10 patients with adolescent idiopathic scoliosis were analyzed. A line that passed the anterior edge of the bilateral rib heads was regarded as the virtual passage of the screw used for anterior instrumentation surgery. Whether this line crossed the aorta was investigated. A distance between the vertebral body and the aorta was measured along this line. Results. The aorta was located more posteriorly between T6 and T9. At these levels, the virtual passage of the screw crossed the aorta in 33 of 40 vertebrae (83%). At seven vertebrae in 5 patients, this passage crossed the aorta and the distance was less than 2 mm. Of these, four were T6, two T7, and one T8. Conclusion. In some patients with adolescent idiopathic scoliosis, the aorta can be located in the direction of the screw passage and close to the vertebral body. Accordingly, when planning anterior instrumentation surgery for right thoracic curve, surgeons should pay attention to these spatial relations.

Object. The purpose of this study was to evaluate the advantages of using an image guidance system to aid in the resection of ossified of the ligamentum flavum (OLF) in the thoracic spine. The procedure and surgery-related outcome are discussed. Methods. Ten patients with myelopathy underwent laminotomy with medial facetectomy and an image guidance system was used to remove the OLF. No neurological deterioration occurred, and postoperative computerized tomography scanning demonstrated successful decompression and good preservation of the lateral parts of the facet joints. Conclusions. The image guidance system allows accurate resection of the OLF while preserving as much as possible the facet joints and posterior elements of the thoracic spine.

Since 1986, the authors have been conducting conservative treatment for idiopathic scoliosis with the combination of brace treatment and physical treatment (side shift exercise and hitch exercise). A total of 328 female patients with adolescent idiopathic scoliosis who were at least 10 years of age at the first visit, with Cobb angle of 10° at the minimum and followed until after 15 years of age or skeletal maturity were included. The average Cobb angle was 32.4° and the average age was 13.8 years at the first visit. Surgery was recommended when curvature progressed to &gt 50°. Twenty of 328 patients (6.1%) with more severe curves to begin with (mean Cobb angle at admission of 48.5 ± 9.3°) progressed to 62.2 ± 8.5° and were treated with spinal fusion by the age of 16.0 ± 2.6 years. The remaining 308 patients, of comparable age at inception of treatment but with a smaller original mean Cobb angle (32.4 ± 11.1°), showed no significant increase in magnitude of curvature (mean 33.6 ± 11.5°) by the time of discharge (18.6 ± 3.1 years). The fact that curvature magnitude was maintained at &lt 35° means that these patients will have a good prognosis for avoiding dramatic progression during adulthood.

A total of 69 patients with idiopathic SCOl∼OS∼S who were treated only by side shift exercise after their skeletal maturity were reviewed. The average age at the beginning of the side shift was 16.3 years and the average follow-up period was 4.2 years. Size ofthe curve was 31.5°+11.2 at the beginning ofthe side shift and 3O.3∼il2.3 at the final follow-up. The side shift exercise can be a useful treatment option for the management of idiopathic scoliosis after skeletal maturity.