Japan Orthopedic Association Score Research Articles

硬膜内膿ようの１症例

A 68-year old man had been suffering low back pain and a slight fever for two months. He also had hemorrhoid fistulae and used to puncture them using a needle. Pain on both lower extremities started one month later and he had occasional fever around 38 C. When he visited our hospital, he was slightly febrile (37.8 C) and drowsy. He also presented clinical symptoms of meningeal irritation, as well as pollakisuria and hyperreflexia of the patella and Achilles tendon reflex. Sensory disturbance distal to inguinal band was also seen. The Japan Orthopedic Association (JOA) score for lumbar lesion was 8/29. WBC was 12100/ml, CRP was 12.3mg/dl, and ESR was 71mm/1h in blood exams. MRI revealed a mass in isointesity on T1, high intensity on T2 posterior to the 5th vertebral body, suggesting subdural abscess. Emergency incision and drainage were performed. Surgery revealed adhesion between the cauda equina and arachnoid and cauda equina encased abscess. After irrigation and placement of the draining catheter, the wound was closed and antibiotics were administered.Metithiline sensitive staphylococcus aureus was identified from the abscess. After drainage and administration of AB-PC, clinical symptoms and blood test values improved, except for the episode of high fever with skin rush due to allergy to AB-PC. At 10 months after surgery, his JOA score improved to 26/29 and the values of blood test values were within the normal range.

Vertical ground reaction force shape is associated with gait parameters, timed up and go, and functional reach in elderly females.

The aim of this study was to evaluate the relationship between knee pain and various indicators of the combined performance of the lower extremity (including gait parameters, functional performance such as timed up and go, and functional reach test) and to determine whether the classification of vertical ground reaction forces correlates with gait parameters and functional performance. Simultaneous analysis of gait, time-distance parameters and vertical ground reaction force. Timed up and go, and functional reach test were examined in 130 elderly women. The vertical component of the ground reaction force was grouped into 2 categories: M-shaped and non-M-shaped. No significant association was found between knee pain and timed up and go, functional reach test, or gait parameters in elderly female participants. There were significant differences between subjects with M- and non-M-shaped vertical ground reaction forces with regard to timed up and go, functional reach test and Japan Orthopaedic Association score. There were also significant differences between the 2 groups (M shaped and non-M-shaped) in gait parameters. Evaluation of the vertical ground reaction force to determine its shape may be a useful and simple tool in the analysis of gait and functional performance.

Clinicopathological study of "snake-eye appearance" in compressive myelopathy of the cervical spinal cord.

The goal of this study was to elucidate the pathophysiological features and clinical significance of the magnetic resonance imaging-documented small intramedullary high signal intensity known as "snake-eye appearance" (SEA) in cases of compressive myelopathy such as cervical spondylosis or ossification of the posterior longitudinal ligament. One hundred forty-four patients with compression myelopathy who underwent surgery between 1998 and 2000 were selected. Intramedullary high signal intensity was found in 79 cases and was divided into two types, SEA and non-SEA (NSEA). The Japan Orthopaedic Association (JOA) scoring system was used for evaluation of pre- and postoperative neurological status. In nine cases of SEA autopsy was performed and specimens were histologically analyzed. The improvement ratio determined by JOA score was 32.2 +/- 15.1% in SEA, 47.1 +/- 12.1% in NSEA, and 50 +/- 18.3% (p < 0.01) in control cases in which high signal intesity was absent. There were significant differences among SEA, NSEA, and control groups. In a separate group of nine patients who died of unrelated causes, histological examination showed small cystic necrosis in the center of the central gray matter of the ventrolateral posterior column and significant neuronal loss in the flattened anterior horn. Snake-eye appearance was found to be a product of cystic necrosis resulting from mechanical compression and venous infarction. Destruction of the gray matter accompanying significant neuronal loss in the anterior horn suggested that SEA is an unfavorable prognostic factor for the recovery of upper-extremity motor weakness.

腰椎椎間板外側ヘルニアに対する手術成績の検討

We studied 33 cases of lateral lumbar disc herniation (LLDH) retrospectively. In radiological examinations, coronary view by magnetic resonance imaging (MRI) proved most useful. Selective radiculography and root block were effective for the diagnosis of the LLDH level. Discography and CT-discography were useul for diagnosis of the occupied region. On the other hand, lateral fenestration was considered the best surgical method for LLDH because it was comparatively easy and reguired no fusion. The details of this study are as follows. We performed lateral fenestration on 19 patients. The locations of disc hernia were intraforaminal type (IF) in 4 cases, extraforaminal type (EF) in 11 cases, intara and extraforaminal type (IEF) in 5 cases. The average recovery rate of the JOA score (Japan Orthopedic Association score, Assessment of Treatment for Low Back Pain) was 97.1% for IF, 80.8% for EF, and 84.8% for IEF. The results were not significantly different, and were satisfactory. We believe that lateral fenestration is effective for not only the EF type, but for the IF and IEF types, as well.

Quantitative assessment of surgical decompression of the cervical spine with cine phase contrast magnetic resonance imaging.

We measured cerebrospinal fluid flow velocity by use of cine phase contrast magnetic resonance imaging to quantitate the effectiveness of surgical decompression in patients with cervical myelopathy. Forty-seven patients with cervical myelopathy attributable to either spondylosis or ossification of the posterior longitudinal ligament were studied. Thirty-five patients underwent anterior cervical decompression and fusion; 12 others underwent expansive laminoplasty. Patients were examined preoperatively and postoperatively by use of a 1.5-T scanner with a pulse-gated cine phase contrast sequence. Cerebrospinal fluid flow direction and velocity in the ventral subarachnoid space were determined at the C1 and T1 levels. Forty-four healthy control subjects were examined to determine normal flow velocity parameters. Severity of cervical myelopathy was evaluated preoperatively and postoperatively by use of Japan Orthopedic Association scores to calculate the extent of recovery. Preoperatively, cerebrospinal fluid flow velocity in the caudal direction was significantly lower at both C1 and T1 than velocities measured in healthy controls. Both decompressive procedures essentially returned patient velocities to control values. Clinical recovery from myelopathy did not differ between anterior and posterior decompression. Postoperative increase in flow velocity correlated with clinical recovery after posterior (P < 0.0008) but not anterior decompression. Cine phase contrast magnetic resonance imaging provides quantitative assessment of cervical spine decompression, with particularly good clinical applicability to posterior procedures.

Anterior decompression for cervical spondylosis associated with an early form of cervical ossification of the posterior longitudinal ligament

The goal of this study was to determine the appropriate surgical strategy for cervical spondylosis associated with an early form of ossification of the posterior longitudinal ligament (EOPLL) of the cervical spine. Patients with EOPLL-associated cervical spondyosis were selected for treatment. Medical records and radiographs were retrospectively reviewed. Specimens taken at the time of operation were histologically examined. There were 24 men and six women ranging in age from 39 to 74 years (mean 57.6 years). Symptoms consisted of myelopathy in 28 cases and radiculopathy in two cases. Anterior decompressive surgery was performed. The EOPLL, hypertrophy of the posterior longitudinal ligament (HPLL), and the disc-PLL complex were directly resected. The mean preoperative Japan Orthopaedic Association score was 12.6, and the mean postoperative score was 14.4. Histologically, EOPLL was consistent with foci of compact lamellar bone in the degenerative thickening of the PLL. Appropriate corpectomy should follow direct removal of EOPLL associated with HPLL compressing the spinal cord to achieve good outcomes.

Dorsal root ganglia morphologic features in patients with herniation of the nucleus pulposus: assessment using magnetic resonance myelography and clinical correlation.

Morphologic features of the dorsal root ganglia were investigated in patients with herniation of the nucleus pulposus by means of magnetic resonance myelography. This study was undertaken to assess morphologic changes of the dorsal root ganglia in patients with herniation of the nucleus pulposus and to determine the relations between the morphologic features of the dorsal root ganglia and clinical features. It has recently been reported that application of the nucleus pulposus to a nerve root induces edema in the rat dorsal root ganglion. Edema in the human dorsal root ganglion resulting from lumbar disc herniation has not been discussed in the literature, to the authors' knowledge. Eighty-three consecutive patients (average age 42.1 years; range 17 to 77 years) with monoradicular symptoms were examined. Dorsal root ganglion morphologic features, i.e., indentations and swelling, were evaluated by magnetic resonance myelography. The dorsal root ganglion swelling at each level was quantitatively expressed as a ratio of the dorsal root ganglion width on the involved side to that of the contralateral side and was termed dorsal root ganglion ratio. Eighty-three uninvolved levels were chosen as controls in a randomized manner. Factors possibly contributing to the morphologic changes in the dorsal root ganglion were investigated. Neurologic symptoms, evaluated by the Japan Orthopaedic Association scoring system, were correlated to the morphologic changes. The morphologic features were followed up for 1 year after treatment in a small group of patients. Dorsal root ganglion indentations were always found in the narrowed intervertebral foramens. The incidence of indentations was significantly higher at the involved nerve roots (10.8%) than at the uninvolved nerve roots (4.0%) (P = 0.026). Patients with dorsal root ganglion indentations were significantly older (P = 0.0008). Leg pain scores in patients with indentations were significantly poor (P = 0.007). The dorsal root ganglion ratios were significantly higher at the involved levels than at the uninvolved levels (P = 0.001); the means +/- SD were 1.19 +/- 0.25 and 1.08 +/- 0.13, respectively. Patients with lateral herniated nucleus pulposus had significantly higher dorsal root ganglion ratios than those with central herniated nucleus pulposus (P = 0.0001); the mean ratios +/- SD were 1.48 +/- 0.32 and 1.10 +/- 0.12, respectively. A moderate positive correlation was found between dorsal root ganglion ratio and age (Pearson's correlation coefficient = 0.313). There was moderate negative correlation between the dorsal root ganglion ratio and leg pain, gait, motor, and total Japan Orthopaedic Association score (correlation coefficients were = -0.385, -0.350, -0.422, and -0.358, respectively). The dorsal root ganglion ratios were significantly diminished at 1-year follow-up (P = 0.001); the means +/- SD were 1.22 +/- 0.22 and 1.09 +/- 0.07, respectively. Indentations observed before treatment disappeared after treatment. Swelling and impingement in the involved dorsal root ganglion were clearly visualized by magnetic resonance myelography. The swelling and indentations were well correlated with severity of leg pain. These findings have important value in understanding the pathophysiology of the nerve roots in herniated nucleus pulposus.

Developmental and dynamic canal stenosis as radiologic factors affecting surgical results of anterior cervical fusion for myelopathy.

The correlation between preoperative and postoperative lateral functional radiograms and clinical results was analyzed in 74 cases of myelopathy treated by anterior cervical fusion. To clarify the correlation between clinical results and radiologic findings (developmental and dynamic stenosis). Although radiologic changes have been reported at the disc level adjacent to anterior cervical fusion, the question of whether these radiologic findings affect the clinical results of anterior fusion has not been resolved. The "deteriorated" results group (28 cases) was composed of cases with deterioration of 2 points or more in the Japan Orthopedic Association score at follow-up compared with the postoperative best score. The "good" results group (46 cases) exhibited a recovery rate of > or = 50%. The two groups were compared in lateral functional roentgenograms on which the sagittal canal diameter in each vertebra and the diameter between the inferoposterior lip of the vertebral body and the anterior margin of the lamina of the distal vertebra in the extended neck were measured. A diameter of less than 12 mm was defined as developmental canal stenosis or dynamic canal stenosis. Fifty-four percent of the cases in the deteriorated results group had developmental canal stenosis, whereas the same findings were identified in only 2% of the cases in the good results group (P < 0.01). Preoperative dynamic canal stenosis at the disc level adjacent to the fusion was found in 64% of the patients in the deteriorated results group and in only 4% of the patients in the good results group (P < 0.01). Patients in the deteriorated results group showed a higher incidence of preoperative developmental and/or dynamic canal stenosis at the adjacent disc level than those in the the good results group. These results indicate that patients with preoperative developmental canal stenosis are not suitable candidates for anterior cervical fusion. When dynamic canal stenosis is found below or above the level of fusion, simultaneous fusion is recommended to avoid deterioration of the myelopathy.

人工股関節置換術におけるサポートリングの経験

Acetabular reconstructions using acetabular reinforcement ring with hook were analyzed after an average follow-up period of 19.6 months (range: 2-28 months) in 9 patients/hips. The deficiencies, according to the American Academy of Orthopaedic Surgeons classification, were 2 segmental, 4 cavitary and 3 combined cavitary and segmental. Bone grafts were packed into bone defects, a hook was placed around the bone in the acetabular notch and then a reinforcement ring was fixed with cancellous screws. Postoperative management was with partial weight-bearing on 2 crutches usually starting one week after surgery. Radiographic evaluation revealed acetabular component migration of more than 2mm in 1 hip. The overall Japan Orthopaedic Association score (JOA score) of 36.5 points improved to a follow-up examination score of 73.6 points. Short-term results were good. In arthroplasty with bone stock of poor quality and quantity, the reinforcement ring with hook serres as a good method for reconstructing the acetabulum.

Atlantoaxial dislocation. A follow-up study of surgical results.

The cases of 47 patients with atlantoaxial dislocation exclusive of rheumatoid arthritis, cerebral palsy, and tumors as causative pathologies were reviewed after surgical treatment, which was performed between 1979 and 1993. To investigate the surgical results of atlantoaxial dislocation itself without any systemic factors affected by rheumatoid arthritis, cerebral palsy, and tumors. Neck pain (or occipitalgia) and extent of myelopathy at follow-up evaluation were compared with that present before surgery. The results were classified into four groups: excellent (no pain or recovery rate in myelopathy of more than 50%), good (decreased pain or recovery rate of 25% to 50%), fair (no improvement of pain or recovery rate of zero to 25%), and poor (aggravation of pain or recovery rate less than zero). The average follow-up period was 4 years and 2 months. Of the patients evaluated, 51% were assessed as excellent, 23% as good, 7% as fair, and 19% as poor. Pain relief was achieved in 95% of patients with non myelopathy. Extent of myelopathy, pathology of atlantoaxial dislocation (ligamentous or osseous instability), loss of reduction after surgery, and surgical procedures were recognized as the major factors affecting surgical results. Better surgical results were obtained in mild myelopathy cases (> 10 points in Japan Orthopaedic Association scoring), ligamentous instability, and cases without loss of reduction. The incidence of pseudarthrosis and loss of reduction was low in Brooks' method for atlantoaxial fusion and in Luque's segmental sublaminal wiring method for occipitocervical fusion. The best results occurred in patients with no myelopathy, and the worst results occurred in patients with severe myelopathy; therefore, surgery is best indicated for atlantoaxial dislocation with intractable pain or with mild myelopathy. To avoid pseudarthrosis and loss of reduction, a strong fixation method, such as Brooks' or Luque's segmental sublaminal wiring method, should be selected.