Exercise therapy is useful for low back pain. Exercise therapy aims to improve postural alignment, muscle strength, and endurance, and also contributes to pain relief and the prevention of recurrences.Furthermore, exercise therapy helps to reduce the psychological burden in chronic low back pain patients. Exercise therapy for low back pain is divided into two major categories : stretching for flexibility and motor control for lumbar spine and pelvic stability. Patients with low back pain reportedly have less trunk and lower limb flexibility. Flexibility can be enhanced with trunk and lower limb stretching, which contributes to the maintenance of postural alignment under gravity. Trunk stability exercises using the inner unit have been widely applied for nervous, skeletal,and muscular system coordination as well as lumbar spine dynamic stability

  Introduction : Transcranial motor evoked potentials (TcMEPs) and free-running electromyography (FR-EMG) are used for all microscopic spinal surgeries in our institute. During monitoring, characteristic spontaneous EMG (S-EMG) waves are observed, as well as false positive waves ; these are not easily differentiated. However, there is still no evidence of an association between S-EMG waves and neurological damage. In this paper, we describe the classification of S-EMG waves and the differentiation between dangerous and false positive waves.

  Method : S-EMG waves were classified into 7 types by their frequency and duration : single pulse, transient, intermittent, continuous, cyclic, sporadic, and mixed. The FR-EMG was monitored in 160 spinal surgical cases performed between September 1, 2015 and June 30, 2016. There were 47 cases of cervical spondylosis (CS), 7 of cervical ossification of the posterior longitudinal ligament (OPLL), 60 of lumbar canal stenosis (LCS), 22 of lumbar disc herniation (LDH), 13 of lumbar spondylolisthesis (LS), 13 of spinal tumor (ST), and 8 of spinal injury.

  Result : False positive waves were detected when the observer was aware of every aspect of the operation using both the FR-EMG and monitoring of the operative field. Abnormal waves were detected in 80% of LCS cases and 68% of CS cases. Short-duration waves were predominant in LCS surgery, and long duration waves were predominant in CS cases.

  Conclusion : Understanding of the wave types is essential for smooth communication between the operator and observer. FR-EMG should be used to avoid complications in spinal surgery.

  Objective : Methods for intraoperative electrophysiological mapping in thoracic outlet syndrome have not yet been established, despite the potential severity of surgical complications. A method for intraoperative electrophysiological mapping in the supraclavicular approach for thoracic outlet syndrome was developed. The purpose of the study was to verify the usefulness and validity of this method.

  Methods : Twelve patients underwent surgery for thoracic outlet syndrome using this mapping method. The region of interest in an operative field was electrically stimulated, and evoked electromyography was recorded from the deltoid, biceps, triceps, and abductor pollicis brevis for the brachial plexus, the diaphragm for the phrenic nerve, and the serratus anterior for the long thoracic nerve. Cathodal stimulation was performed using a monopolar electrode. The stimulus rate was fixed at 3/s, and 0.2-ms biphasic square waves were applied. The stimulus current ranged from 0.5 mA to 2 mA. Whether this method enabled identification of important anatomical landmarks by referring to the evoked electromyography pattern was retrospectively investigated.

  Results : In 10 of 12 cases, clinical improvement was obtained. In all cases, important landmarks related to the brachial plexus and phrenic nerve were identified with this mapping method. In 5 of 12 cases, the course of the long thoracic nerve in the middle scalene muscle was identified.

  Conclusion : This monitoring method was useful for confirming the distribution of important nerves in the surgical field of thoracic outlet syndrome, and has great significance by enabling management of the anatomical variations seen in thoracic outlet syndrome.

  Metastases of malignant cervical spine tumors often cause posterior cervical pain. We report a case of rapidly progressive multiple myeloma of the third cervical vertebra in a patient who presented with cervical pain but without any abnormal findings on plain radiography in the early stages of diagnosis.

  A 72-year-old man with a 1-month history of posterior cervical pain visited our outpatient clinic. We did not identify any abnormal findings on plain radiography except for a degenerative change in the C5-C6 disk space. The patient was treated using conservative measures. Six weeks later, the patient returned with gradual development of the cervical and mandibular pains during swallowing. Plain radiography revealed destruction of the C3 vertebral body. Computed tomography revealed osteolytic changes and a C3 compression fracture. The magnetic resonance imaging scan demonstrated a tumor extending from the C3 vertebral body to the retropharyngeal space. Fludeoxyglucose positron-emission tomography revealed abnormal accumulation only in C3. Moreover, Bence-Jones protein expression was detected in the patient’s urine. We performed laminectomy of C3, biopsy of the tumor, and posterior fixation.

  The tumor was diagnosed as a myeloma. Stereotactic radiotherapy (Cyberknife 25 Gy/5 fractions) and chemotherapy (lenalidomide, bortezomib, and dexamethasone) were administered and resulted in the regression of the C3 tumor.

  In cases of cervical pain without any abnormal findings on plain radiography, magnetic resonance imaging or computed tomography should not be performed on the basis of suspicion of a malignant spinal tumor. However, in cases of malignancy, rapid destruction of bone may occur. Therefore, in patients with chronic cervical pain and worsening of this pain while resting or at night, complete examination should be repeatedly performed.

  A 70-year-old woman presented with right leg pain induced by walking and standing retention. The symptoms were improved by bending forward. We suspected L5 nerve injury on the basis of neurological findings. We found no lesions in the spinal canal on magnetic resonance imaging and myelography.

  Flow of contrast medium from the foramen into the spinal canal in the right L5 nerve root was smooth. However, the flow was horizontal in the distal nerve root. At the time of contrast medium injection, the patient felt leg pain, but the pain disappeared when xylocaine root block was performed at the same time.

  The L5 nerve root was compressed by the L5S1 osteophytes of the vertebral body with a hernia, L5 transverse process, and sacral wing (kissing area). We diagnosed the patient with L5 nerve root compression or the so-called “far-out syndrome”. We used the percutaneous endoscopic laminectomy (PEL) technique for treating the patient under general anesthesia. An 8-mm skin incision was made just above the kissing area, and then the PEL-dedicated 3.5-mm ultra-long bar was used for partial resection of the sacral wing and transverse process. After peeling off the surrounding soft tissue, we identified the nerve root and removed the fragment.

  Two hours after the operation, the patient was relieved of the leg pain and could walk. She was discharged on the following day post surgery. In this case, we could approach the lesion using the PEL technique without performing a bone elimination of the facet joint. The PEL technique is minimally invasive to the lumbar spine fascia and erector muscle of the spine.