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Kazunori Yone, Kyoji Hayashi, Takuya Yamamoto, Yoshimi Nagatomo, Masah ...
2006 Volume 55 Issue 3 Pages
293-296
Published: 2006
Released on J-STAGE: December 01, 2006
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The purpose of this study was to clarify the efficacy and benefits of surgical treatment in elderly patients with cervical myelopathy. Postoperative JOA score and neurological improvement rate were lower in elderly patients than in younger adult patients. In most elderly patients with cervical myelopathy who did not undergo surgical treatment, however, neurological deficits worsened gradually. Moreover, the survival rate at five years after the first admission to our clinic was 0.915 in elderly patients who were treated surgically, but 0.745 in those who did not undergo surgical treatment, suggesting that surgical treatment should be performed even on elderly patients with cervical myelopathy.
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Hironobu Koseki, Takahiko Aoyagi, Itaru Furuichi, Yasuhiro Hirota, Yos ...
2006 Volume 55 Issue 3 Pages
297-300
Published: 2006
Released on J-STAGE: December 01, 2006
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We experienced a rare case of 64-year-old male with a traumatic dissection of common iliac artery with concurrent lumbar spine fracture. In his first visit, he had severe pain in his lower back. Initial examination demonstrated a pale and cool left lower extremity with paralysis. The left femoral, dorsalis pedis, and posterior tibial pulses were absent. Plain radiographs revealed vertebral body fracture of L4 due to hyperextension force. CT scan showed occlusion of the left common iliac artery. Emergency laparotomy revealed disruption of the anterior abdominal wall and multiple hollow viscus injuries. Aortotomy showed an intimal flap type injury with dissection. The intimal flap was resected, and a femoro-femoral bypass was performed. Thirteen months later, bone union was obtained and normal peripheral Doppler studies were documented.
Our case suggests the mechanism of this injury to be application of distractive force to the aorta lying anterior to the anterior longitudinal ligament, which causes aortic intimal tear. CT scan was an important and useful imaging modality. Intimal dissection with occlusion should be managed operatively. With distractive lumbar spine fractures, traumatic injury of artery needs to be considered.
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Kazuaki Fukuda, Akira Sei, Hiroshi Mizuta, Takuya Taniwaki, Masaya Miz ...
2006 Volume 55 Issue 3 Pages
301-305
Published: 2006
Released on J-STAGE: December 01, 2006
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Patients with LSCS mainly complain of intermittent claudication. But our patient (63-year-old male) complained of limited muscular atrophy and sural fasciculation several months ago. Neurogists suspected motor neuron disease (MND) at first, but no sensory dist and motor paralysis were recognized. His arch of left foot showed severe muscular atrophy and sural fasciculation was also observed. He could only walk intermittently for 300 meters. EMGs showed neurogenic changes and NCV was normal. MRI and CT myelography showed lumbar canal spinal stenosis at L4/5 and 5/S1.
We could not completely deny MND, however, because his symptoms aggravated, we operated on him with partial laminectomy at L4/5 and 5/S1.
Two and a half year follow-up observation should improvement of intermittent claudication and fasciculation, and no recurrence of muscular atrophy and myodynamia.
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Taka-aki Sagara, Koji Akasaki, Makoto Kimura, Takumi Fukumoto, Yoshihi ...
2006 Volume 55 Issue 3 Pages
306-312
Published: 2006
Released on J-STAGE: December 01, 2006
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We experienced three patients with paralysis due to non-neoplastic intramedullary spinal cord lesion. Case 1 was a 66-year-old man who was diagnosed with spinal infarction. Case 2 was a 63-year-old woman with intramedullary spinal hemorrhage. Case 3 was a 32-year-old woman with spinal infarction with hemorrhage. Only case 3 remained completely paralysed. These cases were followed up by spinal MRI. For accurate diagnosis at early stage from onset, MRI is very useful for detecting intramedullary spinal cord lesion.
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Koichiro Toyoda, Hiroyoshi Ogasa, Eiichi Shiiki, Tetsuya Oikawa, Masak ...
2006 Volume 55 Issue 3 Pages
313-315
Published: 2006
Released on J-STAGE: December 01, 2006
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We report a rare case of pseudoarthrosis of the thoraco-vertebral spine with ankylosing spinal hyperostosis. At 84 years of age, he fell backwards and experienced weakness of the lower limb and back pain. He was brought toour hospital by ambulance. The X-ray showed open-wedge deformity of the T12 vertebra in the spine position, which was diagnosed as non-union of the T12 vertebra with late paralysis of the bilateral lower limb. MRI showed a fracture line between the vertebra and lamina, and fluid-like collection of the T12 vertebra. We performed shortening of the T12 vertebra with pedicle screw fixation and posterolateral fusion. Four months later, he died due to aspiration pneumonia in another hospital. Pseudo-arthrosis of the spine with ASH was unstable, so early diagnosis by MRI and CT was required. Early diagnosis and treatment are important.
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Takuya Yamamoto, Kazunori Yone, Shunji Matsunaga, Kyoji Hayashi, Fumih ...
2006 Volume 55 Issue 3 Pages
316-319
Published: 2006
Released on J-STAGE: December 01, 2006
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We used lateral approach to C2 anterior root schwannoma located ventral to the cord. A 31 year-old man who was operated to treat upper cervical dumbbell tumor by the posterior approach in December 2003, suffered recurrence of myelopathy because of residual tumor regrowth. In July 2005 we performed lateral approach and extirpated completely. This approach is useful for treating ventral lesion to the spinal cord.
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Shunji Matsunaga, Kyoji Hayashi, Takuya Yamamoto, Yoshimi Nagatomo, Ma ...
2006 Volume 55 Issue 3 Pages
320-322
Published: 2006
Released on J-STAGE: December 01, 2006
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Some individuals over 80 years of age have no cervical symptoms and lead healthy lives. Observing the cervical X-rays of these healthy elders provides the key to identifying the difference between physiological degeneration and degeneration that induces neurological symptoms. Two groups of subjects were selected: 50 super healthy elders over 80 years who had no past history of cervical related symptoms and who still lead independent, healthy lives without receiving any aid and a neurological symptom group of 50 elderly patients over 80 years. The two groups were compared for cervical X-ray findings. Degeneration of the cervical spine was noted in "super-healthy elders" as well as in the neurological symptom group. The average diameter of the spinal canal at level C5 was 13.2 mm for men and 12.4 mm for women in the neurological symptom group, but was significantly larger in the "super- healthy elders", with an average of 16.7 mm for men and 15.3 mm for women. Research on induction of physiological degeneration is just as important as research on suppression of cervical degeneration caused by aging.
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Ryo Date, Tatsuhiko Miyamoto, Seiji Sumiura, Manabu Yamamoto, Kimio Ni ...
2006 Volume 55 Issue 3 Pages
323-327
Published: 2006
Released on J-STAGE: December 01, 2006
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We investigated the effects of preventing venous thromboembolism (VTE) in our hospital. We divided 75 knees of 66 samples undergoing VTE prevention after total knee arthroplasty (TKA) into three groups by according to the unit of unfractionated heparin (UFH). We injected UFH 1000IU, 2000IU, or 5000IU subcutaneously to each group twice on the first day after the operation. We investigated changes of D-dimer, APTT, Hb, and blood platlet between the three groups. We compared risk factors of VTE with non-VTE. No significant differences were seen between the three groups in terms of the four measurements. The incidence of VTE decreased in the 5000IU group. D-dimer before the operation was significantly high in VTE patients.
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Hiroto Ota, Katushi Kudo, Dai Tatsushiro, Masanori Matsumoto, Hiroyuki ...
2006 Volume 55 Issue 3 Pages
328-332
Published: 2006
Released on J-STAGE: December 01, 2006
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We treated osteoarthritis of the knee (medial type) with unicompartmental knee arthroplasty (UKA), and evaluated short-term clinical results.
Five cases (five knee) were treated with UKA. The mean age was 72.0 years (1 male, 4 female), and mean follow-up period was 12 months. The mean JOA score improved from 50.0 preoperatively to 83.7 at the final follow-up period. The mean range of motion improved 123.8° to 136.2°. Partial radiolucent lines were not noted in all patients, and no components were thought to be clinically loose in the latest follow-up evaluation. UKA allows excellent short-term results with strict indications and requires careful longer term follow-up evaluation.
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Hideki Yamashita, Toru Okano, Hideki Nagashima, Ryota Teshima, Michiya ...
2006 Volume 55 Issue 3 Pages
333-338
Published: 2006
Released on J-STAGE: December 01, 2006
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A 76-year-old woman experienced low back pain, and left inguinal and thigh pain after falling down. Physical examination revealed knock pain of the thocic spinous process and hip pain, radiating into the iliac wing and down the antero-lateral aspect of the left thigh. The hip pain on motion and limited range of motion were also revealed. On radiographic examination, X-ray showed burst fracture of the thoracic spine. No obvious changes around the pubis and proximal femur were detected on X-ray. A trial consisting of conservative therapy and vertebroplasty of the thoracic spine for these symptoms failed. Magnetic resonance imaging (MRI) of the hips showed distended iliopsoas bursa. Aspiration was performed under computed tomography (CT). Leakage of pale yellow serous content was seen. No bacterial organisms were detected in the culture. Aspiration provided temporary relief of symptoms for two weeks. After the second aspiration, the patient remained symptom free at one-year follow-up.
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Akiko Hori, Hisaaki Miyahara, Yukio Esaki, Kazumasa Terada, Nobuo Koha ...
2006 Volume 55 Issue 3 Pages
339-344
Published: 2006
Released on J-STAGE: December 01, 2006
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The purpose of the study was to evaluate the femoral offset change in total hip arthroplasty (THA) with high-offset stem. Forty-one hips of 36 patients who underwent cementless THA with high-offset stem from March 2004 to August 2005 were enrolled. There were 25 hips of 22 patients with osteoarthritis (OA), and 16 hips of 14 patients with rheumatoid arthritis (RA). Intraoperative impingement test revealed that the range of motion with high-offset stem was larger than that with standard offset stem. Postoperative radiographs demonstrated that femoral offset increased in 80% of hips in the OA group, and in 56% of hips in the RA group, although actual increase of the femoral offset from the pelvis was smaller in both groups. No excessive offset lengthening was seen in postoperative radiograph, and no patient had complaints around the greater trochanter. High-offset stem is useful for the restoration of femoral offset, which improves abductor muscle strength, and increases the range of motion.
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Masaru Higo, Shinji Yoshino, Masahiro Nakamura
2006 Volume 55 Issue 3 Pages
345-347
Published: 2006
Released on J-STAGE: December 01, 2006
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This study was undertaken to reveal radiographically each alignment of the lower extremity in 16 children with unilateral coxa vara by full-length standing anteroposterior roentogenograms. Residual coxa vara included 13 Perthes' disease, two congenital dislocation of the hip and one purulent arthritis of the hip. The average age at presentation was 13 years (range 8 to 15 years). The width of the proximal tibial epiphysis was divided equally into five zones with mechanical axis of the lower extremity. The mid-zone is normally in 13 lower extremities, the zones of physiologic range including the adjacent mid-zone were considered to be normal variance in two lower extremities, and the lateral zone was considered to be pathologic in one lower extremity. Fifteen lower extremities with mechanical axis in normal and physiologic range had no angular deformity of the knee. One patient with congenital dislocation of the hip had lateral shift of the mechanical axis line and genu valugum deformity. We believe that malalignment of the lower extremity rarely developes in children with residual coxa vara after treatment of hip disease.
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Shinji Yoshino, Masaru Higo, Masahiro Nakamura
2006 Volume 55 Issue 3 Pages
348-350
Published: 2006
Released on J-STAGE: December 01, 2006
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We examined the curative effects on patients with congenital clubfoot treated by the Ponseti method at least 6 months previously. We reviewed 14 feet in 9 patients. After plaster casting 6 times on average, we performed percutaneous fendoachilles tenotomy. We evaluated the deformity radiographically, and examined the talo-first metatarsal angle (T-1stMTA) and talo-calcaneal angle (TCA) on anteroposterior radiographs, as well as the TCA and tibio-calcaneal angle (Ti-CA) in the dorsiflexion on lateral radiographs. At 6 months of age, T-1stMTA was −10° on average, anteroposterior TCA 34°, lateral TCA 33°, and Ti-CA 67°, indicating good correction. In most cases, the correction was maintained until the patient was 1 year of age. The deformity remained in 3 feet (21%), and posterior release was required in 2 feet and postero-medial release in 1 foot.
Adduction deformity of the forefoot is corrected early and roll-in of the calcaneus in the hindfoot is naturally corrected by the Ponseti method. We conclude that the Ponseti method is useful and can decrease the need for extensive open release surgery at an early stage of disease.
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Hidehiko Matsushita, Tatsuro Yamauchi, Saburo Nakashima, Tetsuji Inoue ...
2006 Volume 55 Issue 3 Pages
351-354
Published: 2006
Released on J-STAGE: December 01, 2006
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From January 1996 to April 2005, we operated on 28 cases of the subtrochanteric fracture of the femur, using the intramedullary nail on 26 cases and CHS on two. In this study, we evaluated the post-operative results of the ambulation status and alteration in X-rays. Sixteen (67%) of the 24 patients who could walk before injury regained the ability to walk. In 23 patients (82%), bone union was obtained. In the other five patients with delayed union (all of them were operated with intramedullary nail), three were re-operated because of nail fracture or cut out. And two suffered from dynamization. Finally, all cases obtained bone union. We concluded that if good reduction cannot be obtained in the operation using intramedullary nail for the subtrochanteric fracture of the femur, we should add open reduction, and perform dynamization on cases of delayed union.
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Yuichi Maeda, Haruhiko Chuma, Ichiro Seike, Hidetoshi Horiuchi
2006 Volume 55 Issue 3 Pages
355-357
Published: 2006
Released on J-STAGE: December 01, 2006
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A man suffered transient cortical blindness during embolization of veins to spinal tumor. Immediate MRI showed right putaminal hemorrhage, which was suspected to have been present for a week. CT on the next day showed nothing. His vision was restored gradually. We suspect that the disorder was self-limiting.
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Yasunori Tome, Hikaru Tashima, Yo Mintaku
2006 Volume 55 Issue 3 Pages
358-362
Published: 2006
Released on J-STAGE: December 01, 2006
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Seven consecutive ligament reconstructions by extensor carpi radialis longus tendon for the instability of the thumb CM joint were reviewed in seven patients. They consisted of two males and five females, and their age ranged from 15 to 67 years. Postoperative follow-up periods ranged from six months to six yeas three months (average 2.5 years). According to Eaton's radiographic classification, there were four cases in stage I and three in stage II.
The procedure was performed in accordance with University of Ryukyu's method. The half slip of ECRL tendon is passed through the bony tunnel made at the base of the first and second metacarpal, then it was sutured to itself under sufficient tension.
Each case was evaluated by Eaton's clinical criteria, thumb CM joint range of motion, pinch power, grip power, and radiographic estimation.
Overall results were excellent in five cases, good in one, and failed in one. The failed case was re-injured by traffic accident postoperatively. Except for this case, all cases achieved good results in terms of relief of pain. There were no significant differences with regard to thumb CM joint range of motion, pinch power, and grip power pre-and post-operatively. The operative radiographic stage did not progress in all cases, although one had minimum laxity.
Ligament reconstruction by ECRL tendon may be a useful surgical procedure for unstable thumb CM joint.
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Yukio Abe, Kazunari Tsue, Kenzo Fujii, Ryuta Iwanaga
2006 Volume 55 Issue 3 Pages
363-367
Published: 2006
Released on J-STAGE: December 01, 2006
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The distal radioulnar joint (DRUJ) is a substantially unstable joint, and the dorsal and palmar radioulnar ligaments (RUL) are considered to play an important role for the stability. We investigated six cases of acute or subacute DRUJ instability. All were males which age ranged from 15 to 44 years (average: 23 years). Instability was examined using manual test, lateral X-ray of the wrist, and computed tomography (CT) including radio-ulnar line method and congruity method. Accompanied bone injuries were one Galeazzi fracture-dislocation, one perilunate transscaphoid fracture-dislocation, five ulnar styloid fractures, and one ulnar styloid non-union.
Soft tissue injuries were variable: there were two lacerations between dorsal RUL and dorsal DRUJ capsule, two TFCC dorsal tears, two avulsions of RUL from the fovea, one laceration of dorsal DRUJ capsule, one tear of dorsal RUL, and one palmar dislocation of extensor carpi ulnaris tendon. There were two patterns of ulnar head instability. One was straightforward instability to the dorsal and the other was external rotational instability. Diagnosis using only the radio-ulnar line method is sometimes unreliable, thus total judgement including manual test, roentogenography, and congruity method in CT is necessary.
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Yukihiro Furue, Makoto Sasaki, Ikuhumi Nagayoshi, Tatsuo Motoyama, Tat ...
2006 Volume 55 Issue 3 Pages
368-371
Published: 2006
Released on J-STAGE: December 01, 2006
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We report a case of Galeazzi-equivalent lesion. This injury is characterized by complete distal ulnar epiphyseal separation instead of dislocation of the distal radio-ulnar joint. A 11-year-old boy was injured by falling from a moving bicycle. X-ray showed greenstick fracture of the distal radius with volar angulation, and Salter-Harris type II fracture of the distal ulna with dorsal displacement of the proximal metaphyseal fragment. Closed reduction under general anesthesia was unsuccessfully attempted. Open reduction and internal fixation were performed. Torn periosteum was interposed at the fracture site, blocking reduction. In spite of removal of the periosteum, reduction was difficult, and after obtaining reposition, the instability of the fracture site in pronation of the forearm remained. We fixed with tension band wiring with full knowledge that it was epiphyseal injury. Neither growth arrest nor loss of range of motion occurred at seven months after operation. We will continue follow-up to prevent growth disturbance of the distal ulnar physis.
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Kenichi Masuda, Kenji Yoshida, Kenji Tanaka, Hidetomo Nakamura, Toshih ...
2006 Volume 55 Issue 3 Pages
372-374
Published: 2006
Released on J-STAGE: December 01, 2006
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Twelve patients with fractures of the distal end of the humerus treated in the last two years were reviewed retrospectively. The subjects included four males and eight females, with age ranging from 15 to 82 average age: 56.9 years. According to the AO/ASIF classification system, three cases were classified as type A2, three type B2, two type C1, C2, and two type C3. The operative procedures performed were open reduction and internal fixation, using tension band wiring on two cases, and plate fixation on ten.
The follow-up period ranged from 6 to 18 months, with an an average of 11.9 months.
The average flexion of the elbow was 107 degrees and extension of the elbow was -17 degrees. The JOA score at final evaluation was 82.2 points ranging from 65 to 91. The results in this study showed that this surgical procedure provides relatively satisfactory functional results for the fracture of the distal end of the humerus.
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Ryuji Ichimura, Hidehiko Horiuchi, Tsuyoshi Okudaira
2006 Volume 55 Issue 3 Pages
375-379
Published: 2006
Released on J-STAGE: December 01, 2006
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A consecutive series of patients aged 60 and over with unstable fractures of the distal radius were treated by external fixator (n=11) or non-operative treatment (n=21). Outcome of the treatment was assessed by Saito's scoring system. Patients treated by the external fixator had a statistically significant improvement in radial inclination (mean 21.5°), and volar tilt (mean 10°), as compared with the group treated by cast alone. However, there were no significant differences in functional outcome in terms of range of movement, grip strength, complications, and patients' satisfaction between both groups. A significant number of patients had good functional outcome and were satisfied with their results, even when malunion existed. We concluded that non-operative treatment is appropriate for unstable fracture of the distal radius in elderly patients.
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Hisato Tanaka, Mitsunori Komine, Hiroaki Kurokawa
2006 Volume 55 Issue 3 Pages
380-384
Published: 2006
Released on J-STAGE: December 01, 2006
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Conservative treatment for proximal humeral fracture is common particularly in the elderly.
Results were good if bone union is achieved, but dementia patients are prove to pseudarthrosis and often suffer displaced proximal humeral fracture. To solve these problems, we attempted intrafocal pinning for proximal humeral fractures among the elderly with dementia. The K-wire was inserted intramedullary and via intrafocal. Then the dorsum and ventral fragment were sandwitched, and a third pin was added if necessary from the outside. The K-wire was buried subcutaneously, and rehabilitation started immediately after surgery. The pins were removed at eight weeks and the patients were able to return to full activity. Bone union was obtained in all cases and postoperative alignment was maintained. The results suggest that the method is useful and reliable with less fragment complications in the treatment of common fractures, particularly in dementia cases.
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Kazutaka Matsunaga, Hidetoshi Onoue, Kazuo Kimura, Tetsu Yamaguchi, No ...
2006 Volume 55 Issue 3 Pages
385-388
Published: 2006
Released on J-STAGE: December 01, 2006
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We reviewed seven humeral shaft fractures treated by locked intramedullary nail. The patients were three males and four females. The mean age at operation was 67 years (range 40 to 91). AO classification of the fractures was: type A2 : 2, B1 : 1, B2 : 2, and B3 : 1. All fractures were located at the shaft (mid 1/3). The follow-up periods averaged l2 months (4 to 18) Bone union were observed in six fractures, but one fracture had nonunion. No cases complained of shoulder pain, or complication of radial nerve palsy after operation. This study suggests antegrade locked intramedullary nail to be an effective surgical method for humeral shaft fractures in elderly patients.
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Hiroto Tsukano, Takashi Ikeda, Shinichi Miyazaki, Yasuhiro Kawazoe, To ...
2006 Volume 55 Issue 3 Pages
389-392
Published: 2006
Released on J-STAGE: December 01, 2006
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We report a 73-year-old man who was referred to our hospital because of left hip pain. There were considerable nodes in the hip bursa on X-ray film and CT, and he was treated surgically. Surgery revealed multiple free osteochondral nodes in the hip brusa.
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Masahiro Yokouchi, Yoshiya Arishima, Kohei Yamasaki, Ichiro Kawamura, ...
2006 Volume 55 Issue 3 Pages
393-396
Published: 2006
Released on J-STAGE: December 01, 2006
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We report here two patients with soft tissue sarcoma who were treated with radio-hyperthermo-chemotherapy (RHC). One patient was a 53-year-old man, who underwent excision of the left thigh myxoid liposarcoma twice and had local recurrence. The recurrent tumor was very close to the nerves and blood vessels. The other patient was a 28-year-old woman, who had huge mass with pain in the right thigh. Biopsy was performed and pathological diagnosis was primitive neuroectodermal tumor (PNET). This patient underwent initial chemotherapy, then admitted in our department for operation.
In both cases, extensive resection necessitates the sacrifice of nerves and blood vessels, so we performed RHC before surgery. Both tumors shrinked clearly.
We then performed marginal resection. Histological response of both tumors was achievement of CR.
Our experience indicates that RHC for soft tissue sarcoma could be considered in clinical situations where no acceptable surgical option is available.
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Kimiaki Sato, Kensei Nagata, Jin Soo Park, Kei Yamada, Kimiaki Yokosuk ...
2006 Volume 55 Issue 3 Pages
397-399
Published: 2006
Released on J-STAGE: December 01, 2006
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We report the mid-term follow-up findings of 12 patients (two males and 10 females) after surgery to treat calcification in the ligamentum flavum (CLF) of the cervical spine. Their mean age was 69.8 (range from 54 to 80) years at operation. Initially, the mean anteroposterior diameter of the spinal canal at the C5 level was 12.3 (10.0-14.0) mm on lateral radiogram. There was combined CLF or other compressive lesions such as disc herniation in five patients, spondylolisthesis in another two, and combined ossification in the posterior longitudinal ligament (OPLL) in another. All patients had objective neural deficits consistent with cervical myelopathy. Each underwent expansive laminoplasty by sagittal splitting of the spinous process. Preoperative calcification was observed at the C3/4 level in six patients, at the C4/5 level in nine, C5/6 in nine, and at the C6/7 in eight. The operative results were evaluated according to the Japanese Orthopaedic Association (JOA) score, after a mean follow-up period of 31.2 (range from six to 100) months. The mean JOA score was 9.0 points before surgery, and was 13.2 points in the most recent follow-up. The overall mean recovery rate by JOA score was 53.5%.
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Minoru Kashihara
2006 Volume 55 Issue 3 Pages
400-402
Published: 2006
Released on J-STAGE: December 01, 2006
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We performed double-door cervical laminoplasty without preservation of posterior elements between 1998 and 2005. This report is based on 31 subjects consisting of 23 cases of cervical spondylotic myelopathy and eight cases of ossification of the posterior longitudinal ligament. Cervical alignment and nuchal symptoms are investigated before operation and at follow-up. Postoperative axial pain was defined as different from preoperative nuchal symptoms. The average preoperative lordosis angle which was 12.6 degrees between C2 and C7 decreased to 8.6 degrees at follow-up. Patients were divided into two groups: Group A consisting of patients without preoperative nuchal symptoms and Group B with the symptoms. In Group A, all patients had no nuchal symptoms at follow-up. In Group B, the rate of symptom relief of the patients with postoperative axial pain was worse than that of patients without postoperative axial pain.
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