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1.  Comparison between Bilateral C2 Pedicle Screwing and Unilateral C2 Pedicle Screwing, Combined with Contralateral C2 Laminar Screwing, for Atlantoaxial Posterior Fixation 
Asian Spine Journal  2014;8(6):777-785.
Study Design
A retrospective study.
To compare clinical and radiological outcomes between bilateral C2 pedicle screwing (C2PS) and unilateral C2PS, combined with contralateral C2 laminar screwing (LS), for posterior atlantoaxial fixation.
Overview of Literature
Posterior fixation with C1 lateral mass screwing (C1LMS) and C2PS (C1LMS-C2PS method) is an accepted procedure for rigid atlantoaxial stabilization. However, conventional bilateral C2PS is not always allowed in this method due to anatomical variations of C2 pedicles and/or asymmetry of the vertebral artery. Although unilateral C2PS plus contralateral LS (C2PS+LS) is an alternative in such cases, the efficacy of this procedure has not been evaluated in controlled studies (i.e., with bilateral C2PS as a control).
Clinical and radiological records of patients who underwent the C1LMS-C2PS method, using unilateral C2PS+LS (n=9), and those treated using conventional bilateral C2PS (n=10) were compared, with a minimum two years follow-up.
Postoperative complications related to the unilateral C2PS+LS technique included one case of spontaneous spinous process fracture of C2. A C1 anterior arch fracture occurred after a fall in one patient, who underwent bilateral C2PS and C1 laminectomy. No significant differences were seen between the groups in reduction of neck pain after surgery or improvement of neurological status, as evaluated using the Japanese Orthopaedic Association score. A delayed union occurred in one patient each of the groups, with the final fusion rate being 100% in both groups.
Clinical and radiological outcomes of unilateral C2PS+LS were comparable with those of the bilateral C2PS fixation technique for the C1LMS-C2PS method.
PMCID: PMC4278983  PMID: 25558320
Cervical spine; Atlantoaxial instability; Laminar screw; Pedicle screw
2.  Syncope caused by congenital anomaly at the craniovertebral junction: a case report 
Anomalies in the craniovertebral junction may be a rare cause of syncope. The mechanisms of syncope related to craniovertebral junction anomaly remain unknown.
We present an extremely rare case with anomaly in the craniovertebral junction and syncope, and discuss the mechanism of the syncope.
Case presentation
A 10-year-old Japanese boy with a congenital anomaly in the craniovertebral junction presented with recurrent syncope. A physical examination showed generalized hyperreflexia, but motor and sensory examinations were normal. Computed tomography and magnetic resonance imaging showed basilar invagination and spinal cord compression at his craniovertebral junction. Three-dimensional computed tomography angiography revealed an anomalous course of his bilateral vertebral arteries, both of which showed a persistent first intersegmental artery that entered the spinal canal at the caudal portion of the C1 posterior arch. In this case, the arteries were nearly pinched between the C1 posterior arch and the pars interarticularis of the C2. C1 laminectomy and occiput-cervical fusion (O-C2) was performed using an instrumentation system. After surgery, the syncope was not observed.
Syncope can be related to compression of extracranial arteries within the neck. In this case, transient brain ischemia caused by the anomalous course of vertebral arteries that were pinched between the C1 posterior arch and the pars interarticularis of C2 in cervical motion was the suspected cause of the syncope.
PMCID: PMC4196201  PMID: 25296768
Craniovertebral junction; Syncope; Vertebral artery
3.  Combined effect of teriparatide and low-intensity pulsed ultrasound for nonunion: a case report 
BMC Research Notes  2014;7:317.
Low-intensity pulsed ultrasound is a pain-free therapy performed daily at home by the patient and has been shown to promote fracture healing. Teriparatide is a parathyroid hormone preparation that activates osteoblastic bone formation and is also reported to be effective in promoting bony union.
Case presentation
We report the case of a 56-year-old Japanese male with a femoral shaft fracture who underwent intramedullary osteosynthesis nailing initially. He had no radiologic or clinical sign of healing 3 months later and low-intensity pulsed ultrasound was initiated at that time. He was reassessed in another 3 months, with evidence of mild bone consolidation but the fracture gap persisted. Subsequent treatment with human parathyroid hormone was initiated in combination with low-intensity pulsed ultrasound. Full fracture healing was present 6 months after beginning the combination low-intensity pulsed ultrasound and teriparatide. It is hypothesized that the potential additive effects of low-intensity pulsed ultrasound and teriparatide therapy ultimately triggered sufficient bone formation to support osseous union.
The case reported herein is a femoral shaft atrophic nonunion in which traditional interventions failed. Successful fracture healing was finally achieved with low-intensity pulsed ultrasound and teriparatide therapy. This is the first reported case of diaphyseal nonunion with deterioration of bone quality in long bones resolved with teriparatide and low-intensity pulsed ultrasound.
PMCID: PMC4059730  PMID: 24886079
Teriparatide; Low-intensity pulsed ultrasound (LIPUS); Nonunion; Bone quality
4.  Congenital lumbar spinal stenosis with ossification of the ligamentum flavum in achondroplasia: a case report 
Achondroplasia is a genetic disorder of bone growth. Congenital spinal stenosis is a well-known complication of this disease, but, to the best of our knowledge, no cases involving combined stenosis with congenital lumbar spinal stenosis and ossification of the ligamentum flavum in achondroplasia have been reported previously. In this report, we describe a case of a patient with congenital spinal stenosis with achondroplasia combined with ossification of the ligamentum flavum at the lumbar spine, which we treated with decompressive surgery.
Case presentation
A 75-year-old Japanese woman with achondroplasia was unable to walk due to a neurological deficit of the lower extremities caused by congenital spinal stenosis that resulted from achondroplasia and ossification of the ligamentum flavum at the lumbar spine. Congenital spinal stenosis was observed from L1 to L5, and ossification of the ligamentum flavum was identified from L1/2 to L3/4. A decompressive laminectomy from L1 to L5 and removal of the ossification of the ligamentum flavum were performed. The patient’s neurological symptoms improved after surgery. She could walk with T-cane at the time of her four-year follow-up examination.
In this report, we describe what is, to the best of our knowledge, the first known published case of ossification of the ligamentum flavum in congenital spinal stenosis associated with achondroplasia at the lumbar spine. Although resection of the ossification of the ligamentum flavum at the congenital spinal stenosis at the lumbar spine was technically difficult because of congenital narrowing of the spinal canal, thickening of the lamina and adhesion of the ossified ligamentum flavum, a wide laminectomy and resection of the ossification of the ligamentum flavum resulted in acceptable improvement of the patient’s neurological symptoms.
PMCID: PMC3973881  PMID: 24597928
Achondroplasia; Lumbar spinal stenosis; Ossification of the ligamentum flavum
5.  Neural Basis of Impaired Cognitive Flexibility in Patients with Anorexia Nervosa 
PLoS ONE  2013;8(5):e61108.
Impaired cognitive flexibility in anorexia nervosa (AN) causes clinical problems and makes the disease hard to treat, but its neural basis has yet to be fully elucidated. The purpose of this study was to evaluate the brain activity of individuals with AN while performing a task requiring cognitive flexibility on the Wisconsin Card Sorting Test (WCST), which is one of the most frequently used neurocognitive measures of cognitive flexibility and problem-solving ability.
Participants were 15 female AN patients and 15 age- and intelligence quotient-matched healthy control women. Participants completed the WCST while their brain activity was measured by functional magnetic resonance imaging during the task. Brain activation in response to set shifting error feedback and the correlation between such brain activity and set shifting performance were analyzed.
The correct rate on the WCST was significantly poorer for AN patients than for controls. Patients showed poorer activity in the right ventrolateral prefrontal cortex and bilateral parahippocampal cortex on set shifting than controls. Controls showed a positive correlation between correct rate and ventrolateral prefrontal activity in response to set shifting whereas patients did not.
These findings suggest dysfunction of the ventrolateral prefrontal cortex and parahippocampal cortex as a cause of impaired cognitive flexibility in AN patients.
PMCID: PMC3651087  PMID: 23675408
6.  Surgical treatment and intraoperative spinal cord monitoring in scoliosis associated with chronic inflammatory demyelinating polyneuropathy: A case report 
Upsala Journal of Medical Sciences  2013;118(2):134-137.
There has been only one reported case of neuromuscular scoliosis following chronic inflammatory demyelinating polyneuropathy (CIDP). However, no cases of scoliosis that were treated with surgery secondary to CIDP have been previously described. A 16-year-old boy with CIDP was consultant due to the progression of scoliosis with the coronal curve of 86° from T8 to T12. Posterior correction and fusion with segmental pedicle screws were performed under intraoperative spinal cord monitoring with transcranial electric motor-evoked potentials. Although the latency period was prolonged and amplitude was low, the potential remained stable. Coronal curve was corrected from 86° to 34° without neurological complications. We here describe scoliosis associated with CIDP, which was successfully treated with surgery under intraoperative spinal cord monitoring.
PMCID: PMC3633329  PMID: 23311940
Chronic inflammatory demyelinating polyneuropathy; intraoperative spinal cord monitoring; scoliosis; transcranial electric motor-evoked potentials
7.  Posteriorly migrated thoracic disc herniation: a case report 
Posterior epidural migration of thoracic disc herniation is extremely rare but may occur in the same manner as in the lumbar spine.
Case presentation
A 53-year-old Japanese man experienced sudden onset of incomplete paraplegia after lifting a heavy object. Magnetic resonance imaging revealed a posterior epidural mass compressing the spinal cord at the T9-T10 level. The patient underwent emergency surgery consisting of laminectomy at T9-T10 with right medial facetectomy, removal of the mass lesion, and posterior instrumented fusion. Histological examination of the mass lesion yielded findings consistent with sequestered disc material. His symptoms resolved, and he was able to resume walking without a cane 4 weeks after surgery.
Pre-operative diagnosis of posterior epidural migration of herniated thoracic disc based on magnetic resonance imaging alone may be overlooked, given the rarity of this pathology. However, this entity should be considered among the differential diagnoses for an enhancing posterior thoracic extradural mass.
PMCID: PMC3582544  PMID: 23402642
Intervertebral disc herniation; Posterior migration; Thoracic spine
8.  Symptomatic cervical disc herniation in teenagers: two case reports 
The development of a symptomatic herniated cervical disc before the age of 20 is extremely rare. Sporadically reported cases of patients with cervical disc herniation under the age of 20 usually have had underlying disease.
Case presentation
Case 1: A 19-year-old Asian man visited our clinic and presented with progressive pain in his upper left scapula and weakness of the left deltoid and biceps brachii muscles. C5 radiculopathy by soft disc herniation at C4-C5 without calcification was diagnosed. Microsurgical posterior foraminotomy was performed and he recovered completely eight weeks after the surgery.
Case 2: A 15-year-old Asian man presented with difficulty in lifting his arm and neck pain on the right side. Neurological examination showed weakness of the right deltoid and biceps brachii muscles. A magnetic resonance imaging scan demonstrated a herniated intervertebral disc in the right C4-C5 foramen. The patient was treated conservatively and put under observation only, and had completely recovered eight weeks after admission.
Although extremely rare, symptomatic cervical disc herniations may occur even in the younger population under the age of 20 without any trauma or underlying disease. Favorable outcomes can be achieved by conventional treatments for cervical disc herniation.
PMCID: PMC3599747  PMID: 23402661
9.  Amelioration of pregnancy-associated osteoporosis after treatment with vitamin K2: a report of four patients 
Upsala Journal of Medical Sciences  2012;117(3):336-341.
We demonstrate for the first time therapeutic effects of vitamin K2 (menatetrenone) on pregnancy-associated osteoporosis with multiple vertebral fractures in four cases. Due to its safety, vitamin K2 presents itself as a treatment option for women with pregnancy-associated osteoporosis. Desirably, future controlled studies should verify these findings.
PMCID: PMC3410294  PMID: 22746299
Pregnancy-associated osteoporosis; vertebral fracture; vitamin K2
10.  Asian Consensus Report on Functional Dyspepsia 
Environmental factors such as food, lifestyle and prevalence of Helicobacter pylori infection are widely different in Asian countries compared to the West, and physiological functions and genetic factors of Asians may also be different from those of Westerners. Establishing an Asian consensus for functional dyspepsia is crucial in order to attract attention to such data from Asian countries, to articulate the experience and views of Asian experts, and to provide a relevant guide on management of functional dyspepsia for primary care physicians working in Asia.
Consensus team members were selected from Asian experts and consensus development was carried out using a modified Delphi method. Consensus teams collected published papers on functional dyspepsia especially from Asia and developed candidate consensus statements based on the generated clinical questions. At the first face-to-face meeting, each statement was reviewed and e-mail voting was done twice. At the second face-to-face meeting, final voting on each statement was done using keypad voting system. A grade of evidence and a strength of recommendation were applied to each statement according to the method of the GRADE Working Group.
Twenty-nine consensus statements were finalized, including 7 for definition and diagnosis, 5 for epidemiology, 9 for pathophysiology and 8 for management. Algorithms for diagnosis and management of functional dyspepsia were added.
This consensus developed by Asian experts shows distinctive features of functional dyspepsia in Asia and will provide a guide to the diagnosis and management of functional dyspepsia for Asian primary care physicians.
PMCID: PMC3325300  PMID: 22523724
Asia; Diagnosis; Epidemiology; Functional dyspepsia; Management; Pathophysiology
11.  A placebo-controlled trial of acotiamide for meal-related symptoms of functional dyspepsia 
Gut  2011;61(6):821-828.
To determine the efficacy of acotiamide, an acetylcholinesterase inhibitor, in patients with functional dyspepsia (FD) in a 4-week trial
A multicentre, randomised, placebo-controlled, parallel-group, phase III trial was carried out, in which patients with FD received 100 mg of acotiamide or placebo three times a day for 4 weeks, with 4 weeks post-treatment follow-up. The primary efficacy end points were global assessment of overall treatment efficacy (OTE) and elimination rate of all three meal-related symptoms (postprandial fullness, upper abdominal bloating and early satiation), as derived from daily diaries. Secondary efficacy end points were individual symptom scores and quality of life. Adverse events were monitored.
52.2% of those receiving acotiamide and 34.8% in the placebo group (p<0.001) were classified as responders according to a global assessment of OTE. Over 4 weeks, the elimination rate for all three meal-related symptoms was 15.3% among patients receiving acotiamide compared with 9.0% in the placebo group (p=0.004). The significant benefit of acotiamide over placebo in OTE and elimination rate was maintained during the 4 week post-treatment follow-up. All other secondary efficacy end points, including quality of life, were significantly improved with 100 mg of acotiamide as compared with placebo. The number needed to treat was 6 for OTE and 16 for symptom elimination rate. The incidence of adverse events was similar between the acotiamide group and placebo group and no significant cardiovascular effects due to treatment were seen.
Over 4 weeks, acotiamide significantly improved symptom severity and eliminated meal-related symptoms in patients with FD.
Trial registration number number, NCT00761358.
PMCID: PMC3345932  PMID: 22157329
Gastro-oesophageal reflux disease; enteric nervous system; irritable bowel syndrome; appetite; gastrointestinal motility; visceral sensitivity; gastric emptying; dyspepsia; gastroduodenal motility; functional dyspepsia; functional bowel disorder; achalasia; pancreatic cancer; neurogastroenterology; hepatobiliary cancer
12.  Prevalence, Spinal Alignment, and Mobility of Lumbar Spinal Stenosis with or without Chronic Low Back Pain: A Community-Dwelling Study 
Pain Research and Treatment  2011;2011:340629.
Although lumbar spinal stenosis (LSS) occurs almost universally with aging, little is known regarding its actual prevalence and relationships to chronic low back pain (CLBP) in the general population. The presence of CLBP in subjects with LSS may have negative impacts on spinal alignment and mobility. This study evaluated the prevalence of LSS using a self-administered, self-reported history questionnaire in 630 community-dwelling individuals ≥50 years old. Subjects with LSS were further divided into LSS+CLBP and LSS alone groups, and spinal alignment and mobility were compared using a computer-assisted device. Prevalence of LSS was 10.8% in this cohort. Subjects in the LSS+CLBP group (n = 46) showed a significantly more kyphotic lumbar spinal alignment with limited lumbar extension (P < .05), resulting in a stooped trunk compared to subjects in the LSS alone group (n = 22). However, no significant difference in spinal mobility was seen between groups.
PMCID: PMC3195391  PMID: 22110922
13.  Biomechanical evaluation of a new fixation device for the thoracic spine 
European Spine Journal  2009;18(8):1213-1219.
The technology used in surgery for spinal deformity has progressed rapidly in recent years. Commonly used fixation techniques may include monofilament wires, sublaminar wires and cables, and pedicle screws. Unfortunately, neurological complications can occur with all of these, compromising the patients’ health and quality of life. Recently, an alternative fixation technique using a metal clamp and polyester belt was developed to replace hooks and sublaminar wiring in scoliosis surgery. The goal of this study was to compare the pull-out strength of this new construct with sublaminar wiring, laminar hooks and pedicle screws. Forty thoracic vertebrae from five fresh frozen human thoracic spines (T5–12) were divided into five groups (8 per group), such that BMD values, pedicle diameter, and vertebral levels were equally distributed. They were then potted in polymethylmethacrylate and anchored with metal screws and polyethylene bands. One of five fixation methods was applied to the right side of the vertebra in each group: Pedicle screw, sublaminar belt with clamp, figure-8 belt with clamp, sublaminar wire, or laminar hook. Pull-out strength was then assessed using a custom jig in a servohydraulic tester. The mean failure load of the pedicle screw group was significantly larger than that of the figure-8 clamp (P = 0.001), sublaminar belt (0.0172), and sublaminar wire groups (P = 0.04) with no significant difference in pull-out strength between the latter three constructs. The most common mode of failure was the fracture of the pedicle. BMD was significantly correlated with failure load only in the figure-8 clamp and pedicle screw constructs. Only the pedicle screw had a statistically significant higher failure load than the sublaminar clamp. The sublaminar method of applying the belt and clamp device was superior to the figure-8 method. The sublaminar belt and clamp construct compared favorably to the traditional methods of sublaminar wires and laminar hooks, and should be considered as an alternative fixation device in the thoracic spine.
PMCID: PMC2899515  PMID: 19404687
Thoracic vertebrae; Scoliosis; Orthopedic fixation devices; Biomechanics
14.  Effect of Multiple Freeze-Thaw Cycles on Intervertebral Dynamic Motion Characteristics in the Porcine Lumbar Spine 
Journal of biomechanics  2008;41(4):916-920.
Fresh frozen spine specimens are commonly used in biomechanical investigations of the spine. Since many study designs require staged preparation and testing, the effect of multiple freeze-thaw cycles on motion behavior should be understood. The objective of this study was to investigate the effect of multiple freeze-thaw cycles on the biomechanical parameters measured during dynamic pure moment loading. Ten porcine lumbar motion segments were harvested immediately after death and potted in acrylic fixtures. Specimens were tested in continuous pure moment flexion-extension, lateral flexion, and rotation cycles up to a limit of ±5 Nm. Moment-angular displacement data were analyzed and parameters quantified including range of motion, elastic zone, transitional zone (neutral region) size and slope, and width of the hysteresis loop. All specimens were tested at baseline and after each of 3 subsequent cycles of freezing and thawing. The transitional zone size decreased and the transitional zone slope increased during flexion-extension and lateral bending after the initial freeze-thaw cycle. These parameters were not altered after subsequent cycles. No significant change was observed in the elastic zone or width of hysteresis loop. Although freezing porcine spine specimens increased the stiffness in the neutral region of motion, up to three subsequent cycles of freezing and thawing did not further affect these motion characteristics. This suggests that data obtained from porcine spines which have been frozen and thawed multiple times are stable after initial freezing.
PMCID: PMC2278038  PMID: 18078942
lumbar spine; biomechanics; freeze; intervertebral disk; porcine; specimen handling
15.  Translation and validation of a Japanese version of the irritable bowel syndrome-quality of life measure (IBS-QOL-J) 
To compare quality of life (QOL) for patients with irritable bowel syndrome (IBS) between the U.S. and Japan, it is indispensable to develop common instruments. The IBS-QOL, which is widely used in Western countries, was translated into Japanese as there has been a lack of Japanese disease-specific QOL measures for IBS.
The original 34 items of the IBS-QOL were translated from English into Japanese through two independent forward translations, resolution, back translation, and resolution of differences. Forty nine patients who had GI symptoms but did not have any organic diseases (including 30 IBS patients diagnosed by Rome II criteria) were recruited from Tohoku University Hospital in Sendai, Japan and completed a Japanese version of the IBS-QOL (IBS-QOL-J) concomitant with a Japanese version of the IBS severity index (IBSSI-J) twice within 7–14 days.
The IBS-QOL-J demonstrated high internal consistency (Cronbach's alpha; 0.96) and high reproducibility (intraclass correlation coefficient; 0.92, p < 0.001). Convergent analyses confirmed that the overall score of IBS-QOL-J was significantly correlated with overall severity of IBS symptoms on the IBSSI-J (r = -0.36, p = 0.01) and with the individual items on the IBSSI-J that assess interference with life in general (r = -0.47, p = 0.001) and dissatisfaction with bowel habits (r = -0.32, p < 0.05). Eight patients who reported continuous abdominal pain in the past 6 months had significantly lower scores in the IBS-QOL-J than those who did not (53.7 +- 12.7 vs. 73.6 +- 19.5, p < 0.01). Age, sex, education or marital status did not affect scores on the measure.
The IBS-QOL-J is a reliable instrument to assess the disease-specific QOL for IBS. Considering cross-cultural comparison, this measure is likely to be a valuable tool to investigate the QOL in Japanese patients with IBS.
PMCID: PMC1832201  PMID: 17371576

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