佐久間 康成

PURPOSE: Osteoarthritic pain is largely considered to be inflammatory pain. Sensory nerve fibers innervating the knee have been shown to be significantly damaged in rat models of knee osteoarthritis (OA) in which the subchondral bone junction is destroyed, and this induces neuropathic pain (NP). Pregabalin was developed as a pain killer for NP; however, there are no reports on pregabalin use in OA patients. The purpose of this study was to investigate the efficacy of pregabalin for pain in OA patients. MATERIALS AND METHODS: Eighty-nine knee OA patients were evaluated in this randomized prospective study. Patients were divided into meloxicam, pregabalin, and meloxicam+pregabalin groups. Pain scores were evaluated before and 4 weeks after drug application using a visual analogue scale (VAS), and Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC). Pain scales among groups were compared using a Kruskal-Wallis test. RESULTS: Before drug application, there was no significant difference in VAS and WOMAC scores among the three groups (p>0.05). Significant pain relief was seen in the meloxicam+pregabalin group in VAS at 1, 2, and 4 weeks, and WOMAC score at 4 weeks, compared with the other groups (p<0.05). No significant pain relief was seen in the meloxicam only group in VAS during 4 weeks and WOMAC score at 4 weeks compared with the pregabalin only group (p>0.05). CONCLUSION: Meloxicam+pregabalin was effective for pain in OA patients. This finding suggests that OA pain is a combination of inflammatory and NP.

PURPOSE: The pathological mechanism of lumbar spinal stenosis is reduced blood flow in nerve roots and degeneration of nerve roots. Exercise and prostaglandin E1 is used for patients with peripheral arterial disease to increase capillary flow around the main artery and improve symptoms; however, the ankle-brachial index (ABI), an estimation of blood flow in the main artery in the leg, does not change after treatment. Lumbar spinal nerve roots contain somatosensory, somatomotor, and unmyelinated autonomic nerves. Improved blood flow by medication with prostaglandin E1 and decompression surgery in these spinal nerve roots may improve the function of nerve fibers innervating muscle, capillary, and main vessels in the lower leg, resulting in an increased ABI. The purpose of the study was to examine whether these treatments can improve ABI. MATERIALS AND METHODS: One hundred and seven patients who received conservative treatment such as exercise and medication (n=56) or surgical treatment (n=51) were included. Low back pain and leg pain scores, walking distance, and ABI were measured before treatment and after 3 months of conservative treatment alone or surgical treatment followed by conservative treatment. RESULTS: Low back pain, leg pain, and walking distance significantly improved after both treatments (p<0.05). ABI significantly increased in each group (p<0.05). CONCLUSION: This is the first investigation of changes in ABI after treatment in patients with lumbar spinal stenosis. Improvement of the spinal nerve roots by medication and decompression surgery may improve the supply of blood flow to the lower leg in patients with lumbar spinal stenosis.

INTRODUCTION: In Japan, ABO-incompatible (ABO-IC) living kidney transplantation (LKT) has been performed among more than 2000 patients between 1989 and 2010 seeking to compensate for the shortage of donor organs. In addition, many patients lack a genetically living related donor (LRD); therefore, volunteer spouses (unrelated, LURD) have been considered since about 1990. PATIENTS AND METHODS: We performed 112 LKT between April 2003 and March 2011, including 44 (39%) spousal and two other LURD. The other 66 cases received LRD kidneys. We divided patients into two groups: 44 patients (group 1) received a kidney from a spouse (LURD) and 66 (group 2) from LRD. During the induction phase, tacrolimus or cyclosporine, mycophenolate mofetil, and methylprednisolone were prescribed for immunosuppression. Basiliximab was administered on postoperative days 0 and 4. For ABO-IC LKT, plasmapheresis was performed to remove anti-AB antibodies prior to LKT. Splenectomy was performed at the time of or before LKT. Since March 2010, rituximab administration was performed before transplantation instead of splenectomy. RESULTS: Death-censored graft survival rates were 97.7% in group 1 and 98.5% in group 2, respectively. The incidences of acute rejection episodes were 31.8% and 24.2% in groups 1 and 2, respectively. There were three cases of antibody-mediated rejection in group 1. No patient experienced a lethal infectious complication. CONCLUSIONS: Our results demonstrated that spousal LKT (LURD) was equivalent to LRD. In response to the shortage of deceased donors and genetically LRD, LKT between married couples or from ABO-IC donors will spread in Japan.

2001年〜2011年に施行した大腿ヘルニア手術症例52例を検討した。全例でCT施行し、大腿ヘルニアの術前診断は41例(CT正診率80%)だった。嵌頓群は37例(71%)で、イレウス症状は20例(嵌頓群の54%)で認め、全例緊急手術を要した。ヘルニア内容は小腸27例(73%)が最も多かった。腸切除は16例(43%)で施行した。発症から手術までの経過時間は、切除群と非切除群で平均値は同等で有意差を認めなかった(P=0.621)。後壁補強はMcVay法が37例(95%)で施行され、非嵌頓群では各種メッシュ法が53%で選択されていた。術後合併症は嵌頓群で有意に多かったが、腸切除の有無では有意差を認めなかった。腸切除を避けるためには、早期診断・治療が必要であり、発症からできるだけ早いタイミングでの介入が有効と考えられた。(著者抄録)

胆膵領域の診断に用いられる画像診断装置の進歩は著しい。これら画像診断装置から得られる高精細の情報を、系統的に活用する手法の開発が必要である。われわれは、画像情報を処理することによるvirtual 3D model(仮想三次元モデル)を作成した。さらに、産業界で用いられる3次元プリンタのrapid prototyping法によりreal 3D model(実体3次元モデル)を作成する手法を開発した。本手法により患者の個人情報を直接反映した臓器モデルが作成可能である。Virtual 3D modelは、コンピューター上での加工、処理が容易である。Real 3D modelは直接の大きさの把握や曲面の理解などに寄与する。デジタルとアナログの組み合わせにより、より詳細な理解や情報共有が得られる。今後は臨床のみならず、教育や患者コミュニケーションツールとしての活用も期待される。(著者抄録)

STUDY DESIGN: Case series. OBJECTIVE: To present the difficulty of diagnosing the origin of lower leg pain in patients with lumbar spinal stenosis and hip joint arthritis. SUMMARY OF BACKGROUND DATA: Pain arising from a degenerated hip joint is sometimes localized to the lower leg. Patients with lumbar spinal disease may also show radicular pain corresponding to the lower leg area. If patients present with both conditions and only pain at the lower leg, it is difficult to determine the origin of the pain. METHODS: We reviewed 420 patients who had leg pain with lumbar spinal stenosis diagnosed by myelography, computed tomography after myelography, or magnetic resonance imaging. Pain only at the ipsilateral lateral aspect of the lower leg but slight low back pain or pain around the hip joint was shown in 4 patients who had lumbar spinal stenosis and hip osteoarthritis. The symptoms resolved after L5 spinal nerve block, but remained after lidocaine infiltration into the hip joint. We performed decompression and posterolateral fusion surgery for these 4 patients. RESULTS: Leg pain did not resolve after lumbar surgery in all patients. Conservative treatment was not effective from 6 to 12 months, so ultimately we performed ipsilateral total hip replacement for all patients and they became symptom-free. CONCLUSION: It is difficult to determine the origin of lower leg pain by spinal nerve block and hip joint block in patients with lumbar spinal stenosis and hip osteoarthritis. We take this into consideration before surgery.

STUDY DESIGN: Prospective trial. OBJECTIVE: To examine the clinical efficacy of teriparatide for bone union after instrumented lumbar posterolateral fusion using local bone grafting in women with postmenopausal osteoporosis. SUMMARY OF BACKGROUND DATA: Intermittent parathyroid hormone (PTH) treatment increases bone mass and reduces the risk for osteoporotic vertebral fractures. Recombinant human PTH (1-34) has already been approved as a treatment for severe osteoporosis. Preclinical data support the efficacy of PTH for lumbar spinal fusion. However, clinical results of PTH for spinal fusion have not yet been reported. METHODS: Fifty-seven women with osteoporosis diagnosed with degenerative spondylolisthesis were divided into 2 treatment groups, a teriparatide group (n = 29; daily subcutaneous injection of 20 μg of teriparatide) and a bisphosphonate group (n = 28; weekly oral administration of 17.5 mg of risedronate). All patients underwent decompression and 1- or 2-level instrumented posterolateral fusion with a local bone graft. Fusion rate, duration of bone union, and pain scores were evaluated 1 year after surgery. RESULTS: Pain scores improved after surgery; however, no significant difference was noted between the groups after surgery. The rate of bone union was 82% in the teriparatide group and 68% in the bisphosphonate group. Average duration of bone union was 8 months in the teriparatide group and 10 months in the bisphosphonate group. The rate of bone union and average of duration of bone union in the teriparatide group patients were significantly superior to those in the bisphosphonate group. CONCLUSION: Daily subcutaneous injection of teriparatide for bone union using local bone grafting after instrumented lumbar posterolateral fusion in women with postmenopausal osteoporosis was more effective than oral administration of bisphosphonate.