Although postoperative recurrent lumbar disc herniation (rec-LDH) is uncommon, it is a challenging situation that requires revision surgery when conservative treatment fails. Recently, an agent inducing chemical dissolution of the nucleus pulposus using condoliase has been approved as a novel intradiscal treatment for LDH. To date, no evidence has been reported regarding its effectiveness in the treatment of postoperative rec-LDH. A 25-year-old man with a history of LDH in L4/5, who underwent transforaminal full endoscopic lumbar discectomy when he was 17 years old, complained of severe pain radiating to his left leg since 1 month. The straight leg-raising test was limited to 25° on the left side. Lumbar T2-weighted magnetic resonance imaging (MRI) showed intracanal, left-sided transligamentous disc herniation at L4/5 with high-signal intensity. Because the conservative treatment with oral analgesics and selective left L5 nerve root block failed, the patient requested intradiscal condoliase injection instead of revision surgery. There were no adverse events reported after the condoliase treatment, and the pain radiating to the left leg improved within 2 weeks. A lumbar MRI performed 2 months after treatment revealed that the disc herniation had significantly decreased in size. The straight leg-raising test examined 3 months after treatment was negative. In this case, the disc herniation was of the transligamentous type and showed a high-signal intensity on T2-weighted MRI which could be suitably treated by condoliase injection therapy. This case report is the first to suggest that intradiscal condoliase injection could be a useful and novel conservative treatment option to treat postoperative rec-LDH.

A 56-year-old obese man with a body mass index of 30.9 kg/m2 presented with left sciatica and intermittent claudication. Computed tomography scans showed a posterior vertebral scalloping change in L3, L4, and L5. Meanwhile, magnetic resonance imaging revealed epidural mass posterior to the L3, L4, and L5 vertebral bodies. The solitary mass was isosignal to subcutaneous fat and asymmetrically compressed to the left side of the dural sac and L4 nerve root, as observed on axial T1- and T2-weighted images. To the best of our knowledge, there have been few reports of a solitary epidural lipoma causing lumbar radiculopathy. The patient underwent transforaminal lumbar interbody fusion at L4–L5, and his symptoms then resolved. Thus, we recommend decompression and fixation as appropriate management for lumbar radiculopathy caused by epidural lipoma located on the ventral side of the dura and intervertebral foramen.

OBJECTIVE:The goal of this study was to clarify the clinical utility of paravertebral foramen screws (PVFSs) and to determine intraoperative indicators for appropriate screw placement during posterior cervical fusion surgery to improve its safety.METHODS:The authors included data from 46 patients (29 men and 17 women, mean age 61.7 years) who underwent posterior cervical spine surgery with 94 PVFSs. Of the 94 PVFSs, 77 were used in C6, 9 in C3, 5 in C4, and 3 in C5. According to the cervical lateral radiographic view, the authors divided the 94 PVFSs into 3 groups as follows: a longer group, in which the tip of PVFS was located anteriorly from the line of the posterior wall of the vertebral body (> +0 mm); an intermediate group, in which the screw tip was located up to 2 mm posteriorly to the posterior wall of the vertebral body (-2 to 0 mm); and a shorter group, in which the screw tip was located more than 2 mm posteriorly (< -2 mm). The accuracy of screw placement was assessed using CT imaging in the axial plane, and the proportion of screws penetrating a vertebral foramen or a transverse foramen was compared between the 3 groups. Screw loosening was defined as a lucent zone around the screw evaluated on cervical radiography at 1 year after surgery. Complications related to PVFS insertion and revision surgery related to PVFS were evaluated.RESULTS:The authors classified 25 PVFSs into the longer group, 43 into the intermediate group, and 26 into the shorter group. The proportion of screws penetrating a vertebral foramen was largest in the shorter group, and the proportion penetrating a transverse foramen was largest in the longer group. Screw loosening was confirmed for 3 of 94 PVFSs. One PVFS inserted in C6 unilaterally within a long construct from C2 to C7 showed loosening, but it did not cause clinical symptoms. Revision surgery was required for 2 PVFSs inserted in C3 bilaterally as the lower instrumented vertebra in occiput-cervical fusion because they pulled out. There was no neurovascular complication related to PVFS insertion.CONCLUSIONS:PVFSs are useful for posterior cervical fusion surgery as alternative anchor screws, and the line of the posterior wall of the cervical body on lateral fluoroscopic images is a potential intraoperative reference to indicate an appropriate trajectory for PVFSs.

Abstract Background: Prediction of postoperative complications and management based on that prediction are important for improving outcomes. The surgical Apgar score, a simple score for surgical outcomes, has been used to predict postoperative complications. The purpose of this study was to investigate the usefulness of the surgical Apgar score to predict major complications after thoracic spinal surgery. Methods: The subjects were 104 patients who underwent thoracic spinal surgery at a single institution from 2014 to 2018. Background patient and disease characteristics assessed included age, gender, body mass index (BMI), comorbidities (diabetes, hypertension or coronary artery disease), anticoagulant and antiplatelet medications, preoperative hemoglobin, controlling nutritional status (CONUT) score, and American Society of Anesthesiologists-Physical Status (ASA-PS) classification. Surgical factors evaluated were operative time, approach, presence of instrumentation, and multiple intervertebral surgery. The surgical Apgar score was calculated from intraoperative estimated blood loss, minimum heart rate, and minimum mean blood pressure. Major complications were defined as unexpected elongation of intubation for more than 48 hours, postoperative blood transfusion (bleeding) of more than 4U in 72 hours, coronary artery disease, renal failure, cerebrovascular disease, sepsis, pneumonia, severe delirium, deep vein thrombosis, pulmonary embolism (PE), or wound complications. Postoperative hospitalization days were also investigated. A multivariate statistical analysis was performed using stepwise logistic regression. The occurrence of complications and the duration of postoperative hospitalization were compared using a t-test. A p-value of <0.05 was considered significant.Results: Major complications were observed in 19 (18.3%) patients; these were bleeding (8 patients), delirium and wound complications (4 patients each) PE (2 patients) and pneumonia and acute kidney injury (1 patient each). The multivariate analysis revealed that the surgical Apgar score (odds ratio=0.3) was significantly associated with major complications. Postoperative hospital stay was significantly longer in patients with complications (59 days) than in patients without complications (36 days; p=0.0015).Conclusion: The surgical Apgar score is an objective index that can be easily calculated from anesthesia records, and this study suggests that it may be useful in predicting major complications after thoracic spinal surgery.

Background The use of platelet-rich plasma has been increasing in spinal fusion surgery. However, the efficacy of platelet-rich plasma in lateral lumbar interbody fusion is unclear. In Japan, Affinos,® (Kuraray Co., Tokyo, Japan), a β-tricalcium phosphate artificial bone, has been increasingly used for spinal fusion. The purpose of this trial is to demonstrate whether Affinos® impregnated with platelet-rich plasma can achieve a higher fusion rate and better clinical outcomes than Affinos® alone. Methods The current study is a prospective randomized controlled trial. This trial will include consecutive patients scheduled for lateral lumbar interbody fusion. An intervertebral cage for lateral lumbar interbody fusion has two spaces for bone grafts. As a consequence, two bone grafts are inserted at each intervertebral level. In this study, an artificial bone with platelet-rich plasma will be inserted into one space, and an artificial bone without platelet-rich plasma will be inserted into the other space. We will compare the fusion rates between the bone grafts with and without platelet-rich plasma. Our primary endpoint will be the interbody fusion rate at 1 year after surgery. Discussion This trial will verify the efficacy of platelet-rich plasma with Affinos® for bony fusion in lateral lumbar interbody fusion. It will also provide substantial evidence for the effectiveness and safety of platelet-rich plasma in spinal fusion surgery. Trial registration Japan Registry of Clinical Trials (jRCT) jRCTb032200199 . First registered on 13 November 2020. jRCT is approved as a member of the Primary Registry Network of WHO ICTRP.

IntroductionThe purpose of the present study was to elucidate a potential predictive factor for poor clinical outcomes in the conservative treatment of osteoporotic vertebral fractures.Materials and MethodsThis is a study of the vertebrae of 41 patients selected from 63 patients with recent osteoporotic fractures admitted to our hospital from April 2013 to March 2015. Patients with dementia were excluded. We analyzed visual analog scale (VAS: 0‒100 mm) scores and dynamic radiographic images over time for up to 12 weeks after admission. Our statistical analyses were designed to identify factors that were significantly associated with pain prolongation.ResultsLogistic regression analysis using a stepwise method revealed that the independent factor significantly associated with failure for 50% pain reduction at the final follow-up visit was VAS reduction rate at week 3 (OR = 9.0, 95% CI 0.5–17.6, p = 0.04).ConclusionsPatients who responded well to treatment reported a reduction in pain during the first 3 weeks of treatment versus nonresponders who did not. It may be possible to predict the prognosis of osteoporotic vertebral fractures early during the first 3 weeks after hospital admission.

Nutritional screening scores, including Controlling Nutritional Status (CONUT) Score and Surgical Apgar Score (SAS), which reflect intraoperative hemodynamics, have been reported to be useful for predicting major postoperative complications in various kinds of surgery. We assessed independent risk factors for major complications after cervical spine surgery using those scoring measurements. We retrospectively reviewed medical records of patients who underwent cervical spine surgery at our institution from 2014 to 2019. Baseline clinical information, including the CONUT Score, and surgical factors, including the SAS, were assessed as risk factors for major postoperative complications. We analyzed 261 patients. Major postoperative complications occurred in 40 cases (15.3%). In the multivariate analysis, SAS (odds ratio [OR], 0.42; P < 0.01), CONUT (OR, 1.39; P < 0.01), and operative time (OR, 1.42; P < 0.01) were significant independent risk factors of major complications. The area under the SAS curve was 0.852 in the receiver operating characteristic curve analysis. Postoperative hospitalization duration was significantly longer in major complications group. Evaluating preoperative nutritional condition and intraoperative hemodynamics with CONUT score and SAS was useful for predicting major postoperative complications of cervical spine surgery. In addition, both scoring measurements are easily calculated, objective evaluations. Perioperative management utilizing those scoring measurements may help prevent them.

This study aimed to investigate whether fat infiltration in lumbar paravertebral muscles assessed by magnetic resonance imaging (MRI) could be related to dynamic sagittal spino-pelvic balance during gait in adult spinal deformity (ASD). This is a retrospective analysis of 28 patients with ASD. The fat infiltration rate of lumbar erector spinae muscles, multifidus muscles and psoas major muscles was measured by T2 weighted axial MRI at L1-2 and L4-5. Dynamic sagittal spinal and pelvic angles during gait were evaluated using 3D motion analysis. The correlation between fat infiltration rate of those muscles with variations in dynamic kinematic variables while walking and static radiological parameters was analyzed. Spinal kyphosis and pelvic anteversion significantly increased during gait. Fat infiltration rate of erector spinae muscles at L1-2 was positively correlated with thoracic kyphosis ( r = 0.392, p = 0.039) and pelvic tilt ( r = 0.415, p = 0.028). Increase of spinal kyphosis during walking was positively correlated with fat infiltration rate of erector spinae muscles both at L1-2 ( r = 0.394, p = 0.038) and L4-5 ( r = 0.428, p = 0.023). Qualitative evaluation of lumbar erector spinae muscles assessed by fat infiltration rate has the potential to reflect dynamic spino-pelvic balance during gait.

Objectives: To describe the novel technique of continuous local antibiotic perfusion (CLAP) for a surgical site infection (SSI) after instrumented spinal surgery. Methods: CLAP was applied to 4 continuous patients at our institution who developed SSI after instrumented spinal surgery. Results: All 4 patients were successfully treated and the infection was controlled. The implant was retained in all patients. The duration of CLAP ranged from 2 to 3 weeks. The blood level of the antibiotic used (gentamicin) at 1 week after the initiation of CLAP did not increase in any patient. No other adverse events occurred in any patient. Dramatic improvements in laboratory parameters, including the white blood cell (WBC) counts and C-reactive protein (CRP) levels were seen in every patient at 1 week after the initiation of CLAP. Conclusions: CLAP controlled the infection without severe adverse events in all 4 patients, and the implants were retained. Despite its cost and the discomfort of patients, CLAP may become an option for the treatment of SSIs after instrumented spinal surgery. A large number of case series are needed to verify the efficacy of CLAP for patients with SSIs after instrumented spinal surgery. (c) 2021 Elsevier Ltd. All rights reserved.

Background: Several authors have reported favorable results in low back pain (LBP) for patients with lumbar disc herniation (LDH) treated with discectomy. However, detailed changes over time in the characteristics and location of LBP before and after discectomy for LDH remain unclear. To clarify these points, we conducted an observational study to determine the detailed characteristics and location of LBP before and after discectomy for LDH, using a detailed visual analog scale (VAS) bilaterally. Methods: We included 65 patients with LDH treated by discectomy in this study. A detailed VAS for LBP was administered with the patient under 3 different conditions: in motion, standing, and sitting. Bilateral VAS was also administered (affected versus opposite side) for LBP, lower extremity pain (LEP), and lower extremity numbness (LEN). The Oswestry Disability Index (ODI) was used to quantify clinical status. Changes over time in these VAS and ODI were investigated. Pfirrmann grading and Modic change as seen by magnetic resonance imaging (MRI) were reviewed before and 1 year after discectomy to determine disc and endplate condition. Results: Before surgery, LBP on the affected side while the patients were in motion was significantly higher than LBP while they were sitting. This increased LBP on the affected side in motion was improved significantly after discectomy. By contrast, the residual LBP while sitting at 1 year after surgery was significantly higher than the LBP while they were in motion or standing. At 1 year following discectomy, residual LBP while sitting was significantly greater in cases showing changes in Pfirrmann grade or Modic type. Conclusions: Improvement of LBP on the affected side while the patient is in motion suggests that radicular LBP is improved following discectomy by nerve root decompression. Furthermore, that residual LBP is found while the patient is sitting is reflective of the load and pressure put on the disc and endplate.

Background A high-riding vertebral artery (HRVA) is an intraosseous anomaly that narrows the trajectory for C2 pedicle screws. The prevalence of a HRVA is high in patients who need surgery at the craniovertebral junction, but reports about HRVAs in subaxial cervical spine disorders are limited. We sought to determine the prevalence of HRVAs among patients with subaxial cervical spine disorders to elucidate the potential risk for VA injury in subaxial cervical spine surgery. Methods We included 215 patients, 94 were with a main lesion from C3 to C7 (subaxial group) and 121 were with a main lesion from T1 to L5 (thoracolumbar group). A HRVA was defined as a maximum C2 pedicle diameter of < 3.5 mm on axial CT. The sex, age of patients, body mass index (BMI), osteoarthritis of the atlantoaxial (C1-2) facet joints, and prevalence of a HRVA in the 2 groups were compared and logistic regression was used to identify the factors correlated with a HRVA. Results The patients in the subaxial group were younger than those in the thoracolumbar group, but their sex and BMI did not differ significantly between the 2 groups. The mean osteoarthritis grade of the C1-2 facet joints of patients in the subaxial group was significantly higher than that in those in the thoracolumbar group. A HRVA was found in 26 patients of 94 (27.7 %) in the subaxial group and in 19 of 121 (15.7 %) in the thoracolumbar group. The prevalence of a HRVA in the subaxial group was significantly higher and osteoarthritis of C1-2 facet joints correlated significantly with a HRVA. Conclusions The prevalence of a HRVA in patients with subaxial cervical spine disorders is higher than in those without and osteoarthritis of the C1-2 facet joints is correlated with a HRVA.

We report a case of cardiac arrest, which occurred during C1 laminectomy for irreducible atlantoaxial subluxation, with return of spontaneous circulation (ROSC) upon interruption of the laminectomy. A 60-year-old woman with rheumatoid arthritis presented with neck pain, bilateral finger numbness, and bladder-rectal disturbance. Simple radiograph images showed that the atlantodental interval (ADI) was enlarged to 8 mm, and magnetic resonance imaging revealed severe spinal stenosis at C1. She was diagnosed with cervical spondylotic myelopathy due to atlantoaxial subluxation. Cardiac arrest occurred twice during the C1 laminectomy and occipito-cervical fusion (Occ-C3), and ROSC occurred without any treatment. There was no postoperative worsening of neurological symptoms, and the improvement of sensory and motor palsy was favorable. The pathogenic mechanism was presumed to be trigeminocardiac reflex. Cardiac arrest during upper cervical spine surgery is an important intraoperative complication of which operators should be made aware.

BACKGROUND:The penetrating end plate screw (PES) technique improved the fixation strength of the pedicle screw by penetrating the end plate in posterior fusion. The "double" PES, which is a trajectory that penetrates both the upper end plate of the corresponding vertebra and the lower end plate of the upper adjacent vertebral body, provides a stronger tricortical fixation but requires a stricter trajectory. The purpose of this study was to measure the cephalad angles from T7-L5 that would allow a safe trajectory for "double" PES.METHODS:We analyzed 1078 pedicles of 539 vertebral bodies of 50 consecutive cases (27 males and 23 females, mean age, 63.3 years) who underwent computed tomography (CT) myelography for evaluation of spinal disorders. The mean cephalad angle to obtain the double PES trajectory of each vertebra was examined, except for cases in which the appropriate trajectory would perforate the pedicles.RESULTS:The cephalad angle for the appropriate trajectory of "double" PES ranged from 23.4 to 37.6 degrees in the thoracic spine and 34.8 to 40.8 degrees in the lumbar spine. The ratio of pedicle perforation was significantly higher at T7 (16%), L4 (26%), and L5 (52%).CONCLUSIONS:It is important to measure the optimal cephalad angle by preoperative computed tomography imaging according to the vertebral level. In L4 and L5, "double" PES should be avoided because it is often unsafe.

Objective: Whether or not emergent decompression/fusion surgery for paralysis caused by metastatic spinal tumors of unknown origin improves patient neurological outcome and survival remains unclear. This study aimed to evaluate the clinical outcomes of emergent decompression/fusion surgery for paralysis caused by spinal tumors of unknown or not previously diagnosed origin. Patients and Methods: Data from the medical records of 11 patients with spinal tumors of unknown origin (study group) were compared with those of 15 patients with metastatic spinal tumors of known origin (control group). The outcome measures were postoperative performance status, motor function evaluated with the Frankel grade, and actual survival after surgery as compared with the estimated survival calculated using the Tokuhashi score. χ2 analyses were performed to evaluate differences between the groups. Results: The mean performance status was 3.6 preoperatively, which improved to 2.9 postoperatively (P<0.05), in the unknown origin group and 3.6 preoperatively, which improved to 2.7 postoperatively (P<0.05), in the control group. Seven patients (64%) in the unknown origin group showed improvement in paralysis by ≥1 Frankel grade. By contrast, only 4 patients (27%) in the control group showed improvement in paralysis. The unknown origin group tended to show better improvement (P=0.05). All the patients in the unknown origin group underwent adjuvant therapy after definitive diagnosis following surgery. The unknown origin group showed a slight tendency toward better survival than toward the estimated survival. Conclusion: Emergent decompression/fusion surgery for patients with paralysis caused by metastatic tumors of unknown origin is potentially useful for diagnosing tumor origin and improving neurological outcomes and performance status, and thus for extending survival.

Lateral lumbar disc herniation (LLDH) accounts for 7%-12% of all lumbar disc herniations [1][2][3] and is more likely to occur in middle-aged to older adults 4) .It is typically resistant to conservative therapy and often requires surgery due to compression on the dorsal root ganglion of the exiting nerve root 2) .An agent that induces chemical dissolution of the nucleus pulposus using condoliase (Hernicore Ⓡ , Kaken Pharmaceutical Co.) 5) was recently approved as a novel intradiscal treatment for LDH 6,7) .However, there is little information about its effectiveness in LLDH.

Background: Percutaneous endoscopic discectomy (PED) has been reported to be an effective procedure and minimally invasive surgical therapy for various spinal pathologies. Objective: To evaluate the clinical outcome of patients with pyogenic spondylitis who were treated with PED. Methods: Twenty-four patients with pyogenic spondylitis who underwent PED were evaluated for medical history, level of the affected intervertebral space, mode of onset, plain radiographs, epidural or psoas abscesses on MRI, results of blood and intraoperative sample cultures, preoperative C-reactive protein (CRP) level, time until postoperative CRP normalization (CRP < 0.3), and any additional surgery. Patients who underwent additional surgery and showed uncontrollable inflammation were considered to have “failed” PED for pyogenic spondylitis. To elucidate the factors that were significantly associated with a failure of PED for pyogenic spondylitis, statistical analyses were conducted by univariate analysis. Results: Control of inflammation was achieved in 19 of 24 patients (76%) after PED for pyogenic spondylitis. The remaining five patients failed to achieve infection control by PED. One such patient was not able to control the infection after PED, and another patient developed an epidural abscess 2 weeks after PED. Remaining three “failed” patients had exacerbations of their infections during the postoperative course and required additional surgery. Univariate analyses demonstrated that diabetes mellitus (DM; p = 0.05), hemodialysis due to DM-induced renal failure (p = 0.02), concomitant malignant disease (p = 0.09), and acute onset (p = 0.05) were possibly correlated with PED failure. Stepwise logistic regression analysis revealed that hemodialysis due to DM-induced renal failure was an independent factor associated with PED failure (p = 0.03). Conclusions: PED might be considered as one of the alternative therapeutic options before invasive radical surgeries for pyogenic spondylitis after failure of standard conservative therapy. Even by less invasive PED, pyogenic spondylitis patients with DM-hemodialysis showed poor outcome.

Background: Dural tear and cerebrospinal fluid (CSF) leakage is known to be a complication of anterior thoracic spine surgery. If dural tear occurs on the ventral side of dura in combination with a pleural injury, it potentially becomes a subarachnoid-pleural fistula. The pressure gradient permits continuous flow of CSF from the subarachnoid space into the cavum thorax, resulting in an intractable subarachnoid-pleural fistula. We report two cases of successfully treated subarachnoid-pleural fistula using noninvasive positive-pressure ventilation (NPPV). Methods: Two patients, a 52-year-old man and a 54-year-old woman, underwent anterior thoracic spine surgery to treat thoracic myelopathy caused by spinal tumor and ossification of the posterior longitudinal ligament. During surgery, dural tear and CSF leakage to the cavum thorax due to perforation of the dura was observed. We treated with polyglycolic acid sheet (Neovel®) in combination with fibrin glue; a suction drainage tube was placed at the subfascial level and the wound was drained with negative pressure. However, after removal of the drainage tube, subarachnoid-pleural fistula was proven. We applied NPPV to the patients. Results: We used the application of NPPV for 2 weeks in the first patient and 1 week in the second patient. In both of them, subarachnoid-pleural fistula was attenuated without apparent adverse events. Conclusion: NPPV is noninvasive and potentially useful therapy to attenuate subarachnoid-pleural fistula after thoracic spinal surgery.

The use of methotrexate (MTX) to treat rheumatoid arthritis (RA) is increasing. Recently, MTX-associated lymphoproliferative disorder (MTX-LPD) has been frequently reported as lymphoma occurring during MTX therapy. The authors report their experience with a relatively rare case of MTX-LPD presenting in the lumbar spine. The patient, a 73-year-old woman who experienced low-back pain while receiving MTX therapy for RA, was suspected of having developed MTX-LPD based on her medical history, images of the L1 vertebra, and transpedicular biopsy results. One week after discontinuing MTX, the patient's low-back pain reportedly improved. The woman was diagnosed with MTX-LPD based on histopathological findings. MTX discontinuation alone coincided with spontaneous tumor regression. Because MTX-LPD can occur in tissues other than lymph nodes, such as in bones and joints, it is a disease that should be considered when diagnosing spinal tumors in patients receiving MTX therapy.

General MedicineVolume 13, Issue 1 p. 5-10 Special ArticleOpen Access Clinical Problem Solving: What Causes Tachycardia in a Hip Injury? Toshikazu Abe MD, MPH, Corresponding Author Toshikazu Abe MD, MPH mican-philia@sunny.ocn.ne.jp Department of Emergency Medicine, Mito Kyodo General Hospital, University of Tsukuba, Mito City, Ibaraki, Japan Author for Corresponding: Toshikazu Abe, MD, MPH Mito Kyodo Hospital, University of Tsukuba, Mito City, Ibaraki, 3–2–7, Miyamachi, Mito-city, Ibaraki, 310–0015 E-mail: mican-philia@sunny.ocn.ne.jpSearch for more papers by this authorKazuya Fujihara MD, Kazuya Fujihara MD Department of Medicine, Mito Kyodo General Hospital, University of Tsukuba, Mito City, Ibaraki, JapanSearch for more papers by this authorMamoru Kono MD, Mamoru Kono MD Department of Orthopedic Surgery, Mito Kyodo General Hospital, University of Tsukuba, Mito City, Ibaraki, JapanSearch for more papers by this authorRyo Kumagai MD, Ryo Kumagai MD Department of Emergency Medicine, Mito Kyodo General Hospital, University of Tsukuba, Mito City, Ibaraki, JapanSearch for more papers by this authorKanako Ono MD, Kanako Ono MD Department of Emergency Medicine, Mito Kyodo General Hospital, University of Tsukuba, Mito City, Ibaraki, JapanSearch for more papers by this authorYasuharu Tokuda MD, MPH, Yasuharu Tokuda MD, MPH Department of Medicine, Mito Kyodo General Hospital, University of Tsukuba, Mito City, Ibaraki, JapanSearch for more papers by this author Toshikazu Abe MD, MPH, Corresponding Author Toshikazu Abe MD, MPH mican-philia@sunny.ocn.ne.jp Department of Emergency Medicine, Mito Kyodo General Hospital, University of Tsukuba, Mito City, Ibaraki, Japan Author for Corresponding: Toshikazu Abe, MD, MPH Mito Kyodo Hospital, University of Tsukuba, Mito City, Ibaraki, 3–2–7, Miyamachi, Mito-city, Ibaraki, 310–0015 E-mail: mican-philia@sunny.ocn.ne.jpSearch for more papers by this authorKazuya Fujihara MD, Kazuya Fujihara MD Department of Medicine, Mito Kyodo General Hospital, University of Tsukuba, Mito City, Ibaraki, JapanSearch for more papers by this authorMamoru Kono MD, Mamoru Kono MD Department of Orthopedic Surgery, Mito Kyodo General Hospital, University of Tsukuba, Mito City, Ibaraki, JapanSearch for more papers by this authorRyo Kumagai MD, Ryo Kumagai MD Department of Emergency Medicine, Mito Kyodo General Hospital, University of Tsukuba, Mito City, Ibaraki, JapanSearch for more papers by this authorKanako Ono MD, Kanako Ono MD Department of Emergency Medicine, Mito Kyodo General Hospital, University of Tsukuba, Mito City, Ibaraki, JapanSearch for more papers by this authorYasuharu Tokuda MD, MPH, Yasuharu Tokuda MD, MPH Department of Medicine, Mito Kyodo General Hospital, University of Tsukuba, Mito City, Ibaraki, JapanSearch for more papers by this author First published: 09 July 2012 https://doi.org/10.14442/general.13.5AboutPDF ToolsRequest permissionExport citationAdd to favoritesTrack citation ShareShare Give accessShare full text accessShare full-text accessPlease review our Terms and Conditions of Use and check box below to share full-text version of article.I have read and accept the Wiley Online Library Terms and Conditions of UseShareable LinkUse the link below to share a full-text version of this article with your friends and colleagues. Learn more.Copy URL Share a linkShare onFacebookTwitterLinkedInRedditWechat References 1Kondo, Y.; Abe, T.; Kohshi, K.; Tokuda, Y.; Cook, E. F.; Kukita, I. Revised trauma scoring system to predict in-hospital mortality in the emergency department: Glasgow Coma Scale, Age, and Systolic Blood Pressure score. Crit Care. 2011, vol. 15, no. 4, p. R191. 2Kirkpatrick, A. W.; Ball, C. G.; D'Amours, S. K.; Zygun, D. Acute resuscitation of the unstable adult trauma patient: bedside diagnosis and therapy. Can J Surg. 2008, vol. 51, no. 1, p. 57– 69. 3Chien, S. Role of the sympathetic nervous system in hemorrhage. Physiological reviews. 1967, vol. 47, no. 2, p 214– 288. 4Teixeira, P. G.; Inaba, K.; Hadjizacharia, P.; Brown, C.; Salim, A.; Rhee, P. et al. Preventable or potentially preventable mortality at a mature trauma center. J Trauma. 2007, vol. 63, no. 6, p. 1338– 1346. 5Bahn Chair, R. S.; Burch, H. B.; Cooper, D. S.; Garber, J. R.; Greenlee, M. C.; Klein, I. et al. Hyperthyroidism and other causes of thyrotoxicosis: management guidelines of the American Thyroid Association and American Association of Clinical Endocrinologists. Thyroid. 2011, vol. 21, no. 6, p. 593– 646. 6Bassett, J. H.; O'Shea, P. J.; Sriskantharajah, S.; Rabier, B.; Boyde, A.; Howell, P. G. et al. Thyroid hormone excess rather than thyrotropin deficiency induces osteoporosis in hyperthyroidism. Mol Endocrinol. 2007, vol. 21, no. 5, p. 1095– 1107. Volume13, Issue1July 2012Pages 5-10 ReferencesRelatedInformation