Three-dimensional phase-contrast magnetic resonance imaging for the detention of a small communicating defect in a patient with a spinal extradural arachnoid cyst: illustrative case.

BACKGROUND: Spinal extradural arachnoid cysts are thought to be pouches that communicate with the intraspinal subarachnoid space through a dural defect. The treatment for these cysts is resection of the cyst wall followed by obliteration of the communicating defect, which is often elusive. OBSERVATIONS: The authors report the case of a 22-year-old man with an extradural arachnoid cyst with claudication and progressive motor weakness. Regular magnetic resonance imaging (MRI) and computed tomography did not reveal the location of the defect in the cyst. However, three-dimensional (3D) phase-contrast MRI clearly indicated the location of the defect and the flow of cerebrospinal fluid into the cyst. These findings allowed the authors to perform the least invasive surgery; the patient recovered motor function and could walk more smoothly. LESSONS: 3D phase-contrast MRI can reveal a subtle dural defect in patients with spinal extradural arachnoid cysts.

Medicine at mass gatherings: current progress of preparedness of emergency medical services and disaster medical response during 2020 Tokyo Olympic and Paralympic Games from the perspective of the Academic Consortium (AC2020).

Mass gatherings are events characterized by "the concentration of people at a specific location for a specific purpose over a set period of time that have the potential to strain the planning and response resources of the host country or community." Previous reports showed that, as a result of the concentration of people in the limited area, injury and illness occurred due to several factors. The response plan should aim to provide timely medical care to the patients and to reduce the burden on emergency hospitals, and to maintain a daily emergency medical services system for residents of the local area. Although a mass gathering event will place a significant burden on the local health-care system, it can provide the opportunity for long-term benefits of public health-care and improvement of daily medical service systems after the end of the event. The next Olympic and Paralympic Games will be held in Tokyo, during which mass gatherings will occur on a daily basis in the context of the coronavirus disease (COVID-19) epidemic. The Academic Consortium on Emergency Medical Services and Disaster Medical Response Plan during the Tokyo Olympic and Paralympic Games in 2020 (AC2020) was launched 2016, consisting of 28 academic societies in Japan, it has released statements based on assessments of medical risk and publishing guidelines and manuals on its website. This paper outlines the issues and countermeasures for emergency and disaster medical care related to the holding of this big event, focusing on the activities of the academic consortium.

Surgical Results of Microscopic Cervical Foraminotomy for Cervical Radiculopathy Presenting Drop Finger and Proposal of Classification Based on Drop Finger Patterns.

INTRODUCTION: In drop finger, the extension of the finger is limited, although the wrist can be flexed dorsally. There have been no well-organized reports on drop finger pattern caused by cervical nerve root disorder. Moreover, diagnosis and treatment are delayed because of the inability to distinguish cervical radiculopathy from peripheral nerve disease. This study aimed to clarify the operative outcome of microscopic cervical foraminotomy (MCF) for cervical radiculopathy presenting drop finger and to investigate whether our classification based on drop finger patterns is useful retrospectively. METHODS: Overall, 22 patients with drop finger who underwent MCF were included. Grip power (GP) and longitudinal manual muscle test (MMT) score of each finger were examined. Drop finger patterns were classified as types I, II, and III. In type I, the extension disorders of the middle and ring fingers are severe and those of index and little fingers are mild. In type II, the extension disorders are severe from the little finger and slightly to index finger. In type III, the extension disorder is consistently severe in all fingers. Perioperative nerve root disorder and paralysis degree were investigated for all types. RESULTS: The mean GP was significantly postoperatively improved in all 22 patients. The mean MMT score would benefit from exact data for almost all muscles, except the abductor pollicis brevis at the last follow-up. However, pre- and postoperative paralyses were severe in type III patients. C7 nerve root disorder was confirmed in 5/6 type I patients and C8 nerve root disorder in 12/13 type II and 3/3 type III patients. CONCLUSIONS: The operative results of MCF were relatively good, except in type III patients. As a certain tendency was confirmed between the drop finger types and injured nerve roots, our classification may be useful in reducing misdiagnosis and improving the operative results to some extent.

Selective Thoracic Fusion for King-Moe Type II/Lenke 1C Curve in Adolescent Idiopathic Scoliosis: A Comprehensive Review of Major Concerns.

INTRODUCTION: Controversies still exist in the surgical indications and outcomes of selective thoracic fusion (STF) for a primary thoracic curve with a compensatory large lumbar curve (King-Moe type II/Lenke 1C curve) in adolescent idiopathic scoliosis (AIS). Issues of the greatest concern regarding this curve type include curve criteria that indicate STF to prevent postoperative coronal decompensation and postoperative radiographic outcomes, including curve correction, coronal balance, and thoracolumbar kyphosis, after STF. METHODS: This review comprehensively documents the issues raised in the literature regarding surgical indications and radiographic outcomes of STF for King-Moe type II/Lenke 1C curve in AIS. RESULTS: Studies suggest that radiographic curve criteria indicating STF for this curve type include the preoperative dominance of the thoracic curve to the lumbar curve in the Cobb angle and the characteristics of the lumbar curve in magnitude and flexibility. Studies warn the need for a careful clinical evaluation of the thoracic and lumbar rotational prominences. Documented radiographic outcomes of importance include the postoperative behavior of the unfused lumbar curve, coronal or sagittal decompensation after STF, and factors associated with these issues. A comprehensive review of the literature suggests that the use of a segmental pedicle screw construct and better instrumented thoracic curve correction achieve better spontaneous lumbar curve correction. Although the causes of postoperative coronal decompensation remain multifactorial, preoperative coronal decompensation to the left and an inappropriate selection of the lowest instrumented vertebra are consistently reported to be the major causative factors. CONCLUSIONS: STF has been validated in general for the treatment of King-Moe type II or Lenke 1C curve in AIS; however, controversies remain regarding the surgical indications and outcomes. Long-term impacts of residual lumbar curve, coronal decompensation, and mild thoracolumbar kyphosis on clinical outcomes after STF, along with optimal indications and strategy for STF, should further be assessed.

Discography aids definitive diagnosis of posterior epidural migration of lumbar disc fragments: case report and literature review.

BACKGROUND: Posterior epidural migration of lumbar disc fragments (PEMLDF) is extremely rare. It is often confused with other posterior lesions and is usually diagnosed intraoperatively. We here describe the use of preoperative discography in the diagnosis of PEMLDF. CASE PRESENTATION: A 78-year-old man presented with acute low back pain, gait disturbance, and paresthesia in both legs. Magnetic resonance imaging showed a mass located posteriorly and laterally to the left aspect of the dural sac at the L3 level. The initial diagnosis indicated PEMLDF, malignancy, spontaneous hematoma, or epidural abscess. L3/4 discography clearly showed leakage of the contrast medium into the posterior dural space, indicating PEMLDF. The lesion was identified intraoperatively as a herniated-disc fragment, consistent with the preoperative discography. CONCLUSION: PEMDLF is difficult to diagnose preoperatively. Discography is useful for the definitive diagnosis of PEMDLF prior to surgery.

[A case of a metastatic spine tumor treated using a multidisciplinary approach].

A 5 0-year-old man who was a hepatitis B carrier was admitted with back pain due to bone metastasis of the 12 th thoracic vertebra(Th12)in November 2011. He had been diagnosed with liver cancer in January 2010 and underwent liver resection following hepatic arterial chemoembolization. He presented with performance status(PS)2 and a numeric rating scale(NRS) pain score of 8 out of 10 at the time of admission. We started the patient on radiation and drug therapy, but lower limb muscle weakness(manual muscle test[MMT]grade 4 out of 5, Frankel D classification)occurred on day 12 after admission. Therefore, we immediately consulted the orthopedician, and the patient underwent posterior decompression fixation on day 15, followed by radiation therapy and rehabilitation. Even after discontinuation of all analgesics, his pain level on the NRS was 0, and he had no progressive muscle weakness. We ensured long-term care as well as nursing home visits. The patient was discharged on day 61. We have a variety of criteria for the selection of surgery for spinal metastasis, including Tokuhashi, Tomita, and Katagiri scores. The patient's general condition and prognosis are important factors to consider when selecting surgical therapy. In the present case, because of selection of the appropriate treatment and timely cooperation with specialists, it was possible to effectively relieve symptoms and discharge the patient to home care.

Risk factors for adjacent segment disease after posterior lumbar interbody fusion and efficacy of simultaneous decompression surgery for symptomatic adjacent segment disease.

STUDY DESIGN: A retrospective study. SUMMARY OF BACKGROUND DATA: Posterior lumbar interbody fusion (PLIF) increases mechanical stress and can cause degenerative changes at the adjacent segment. However, the precise causes of adjacent segment disease (ASD) after PLIF are not known, and it is unclear whether simultaneous decompression surgery for symptomatic ASD is effective. OBJECTIVE: To study, radiographically and symptomatically, the risk factors for adjacent segment disease (ASD) in the lumbar spine after L4/5 PLIF and to examine whether decompression surgery for the adjacent segment (L3/4) reduces the occurrence of symptomatic ASD. METHODS: Fifty-four patients who underwent L4/5 PLIF for L4 degenerative spondylolisthesis and could be followed up for at least 2 years were included. Of these, 37 were treated simultaneously with decompression surgery at L3/4. We measured radiographic changes and assessed symptoms from the cranial adjacent segment. RESULTS: Thirty-one patients (57.4%) met radiologic criteria for ASD. The length of follow-up (P=0.004) and simultaneous decompression surgery at L3/4 (P=0.009) were statistically significant factors for radiologic diagnosis of ASD. Seven patients (13.0%) had symptomatic ASD: 6 in the decompression group (16.2%) and 1 in the PLIF-only group (5.9%). Simultaneous decompression surgery did not reduce the incidence of symptomatic ASD (P=0.256). Local lordosis at the fused segment (P=0.005) and the sagittal angle of the facet joint at L3/4 (P=0.024) were statistically significant predictors of symptomatic ASD, which was accompanied by postoperative anterior listhesis above the fused segment (S group, 8.4%±8.0%; nonsymptomatic group: -0.7%±5.0%, P=0.024). CONCLUSIONS: Patients whose facet joint at the adjacent segment had a more sagittal orientation had postoperative anterior listhesis, which caused symptomatic ASD. Simultaneous decompression surgery without fusion at the adjacent level was not effective for these patients, but rather, there was a possibility that it induced symptomatic ASD.

High preoperative hemoglobin A1c is a risk factor for surgical site infection after posterior thoracic and lumbar spinal instrumentation surgery.

BACKGROUND: Diabetes mellitus (DM) is reported to be a risk factor for surgical site infection (SSI), which is a serious complication after spinal surgery. The effect of DM on SSI after instrumented spinal surgery remains to be clarified. The aim was to elucidate perioperative risk factors for infection at the surgical site after posterior thoracic and lumbar spinal arthrodesis with instrumentation in patients with DM. METHODS: Consecutive patients who underwent posterior instrumented thoracic and lumbar spinal arthrodesis during the years 2005-2011, who could be followed for at least 1 year after surgery, were included. These included 36 patients with DM (19 males and 17 females; mean age 64.3 years). The patients' medical records were retrospectively reviewed to determine the SSI rate. The characteristics of the DM patients were examined in detail, including the levels of serum glucose and HbA1c, which indicate the level of diabetes control. RESULTS: Patients with DM had a higher rate of SSI (6 of 36 patients, 16.7 %) than patients without DM (10 of 309 patients, 3.2 %). Although the perioperative serum glucose level did not differ between DM patients that did or did not develop SSI, the preoperative HbA1c value was significantly higher in the patients who developed SSI (7.6 %) than in those who did not (6.9 %). SSI developed in 0.0 % of the patients with controlled diabetes (HbA1c <7.0 %) and in 35.3 % of the patients with uncontrolled diabetes (HbA1c ≥7.0 %). CONCLUSIONS: DM patients whose blood glucose levels were poorly controlled before surgery were at high risk for SSI. To prevent SSI in DM patients, we recommend lowering the HbA1c to <7.0 % before performing surgery.

Surgical treatment of spinal extradural arachnoid cysts in the thoracolumbar spine.

BACKGROUND: Because an idiopathic spinal extradural arachnoid cyst (SEAC) is rare, its optimal surgical treatment remains controversial. OBJECTIVE: To evaluate the results of surgical treatments for SEACs and to clarify features of the disease associated with poor outcomes. METHODS: Twelve patients with SEACs who underwent surgery at our hospital between 1988 and 2008 were examined retrospectively. The mean follow-up period was 4.7 years. Total resection of the cyst was performed in 7 patients and closure of the dural defect without cyst resection in 5 patients. Surgical outcomes were evaluated with regard to the duration of symptoms, the size of the cyst, and the surgical procedure used. RESULTS: Neurological recovery was observed in all patients, and there was no recurrence. Poor outcomes were observed in patients with a long duration of symptoms (>1 year, P < .01) and large cyst size (>5 vertebrae, P < .05). The surgical procedure had no significant association with the postoperative neurological recovery. However, there was a significant difference in the degree of the mean postoperative kyphotic angle between the patients treated by total resection of the cyst (9.7 degrees) and those treated by closure of the dural defect without cyst resection through selective laminectomy (2.2 degrees) (P < .01). CONCLUSION: There was no significant difference in postoperative neurological recovery between the 2 surgical procedures. However, closure of the dural defect without cyst resection was less invasive, preventing postoperative kyphotic deformity of the thoracolumbar spine.

Association of the tag SNPs in the human SKT gene (KIAA1217) with lumbar disc herniation.

Lumbar disc herniation (LDH) is one of the most common musculo-skeletal diseases. Recent studies have indicated that LDH has strong genetic determinants, and several susceptibility genes have been reported to associate with LDH; however, its etiology and pathogenesis still remain unclear. KIAA1217 (alias SKT, the human homolog of murine Skt [Sickle tail]) is a good candidate for an LDH susceptibility gene because SKT is specifically expressed in nucleus pulposa of intervertebral discs (IVDs) in humans and mice, and Skt(Gt) mice, which are established through a large-scale gene-trap mutagenesis, exhibit progressive, postnatal onset abnormality of the IVDs. Here, we report the association of SKT with LDH. Using tag SNPs, we examined the association in two independent Japanese case-control populations and found a significant association with SKT rs16924573 in the allele frequency model (p = 0.0015). The association was replicated in a Finnish case-control population (p = 0.026). The combined p value of the two population by meta-analysis is 0.00040 (OR, 1.34; 95% CI, 1.14-1.58). Our data indicate that SKT is involved in the etiology of LDH.

A functional polymorphism in COL11A1, which encodes the alpha 1 chain of type XI collagen, is associated with susceptibility to lumbar disc herniation.

Lumbar disc herniation (LDH), degeneration and herniation of the nucleus pulposus of the intervertebral disc (IVD) of the lumbar spine, is one of the most common musculoskeletal diseases. Its etiology and pathogenesis, however, remain unclear. Type XI collagen is important for cartilage collagen formation and for organization of the extracellular matrix. We identified an association between one of the type XI collagen genes, COL11A1, and LDH in Japanese populations. COL11A1, which encodes the alpha 1 chain of type XI collagen, was highly expressed in IVD, but its expression was decreased in the IVD of patients with LDH. The expression level was inversely correlated with the severity of disc degeneration. A single-nucleotide polymorphism (c.4603C-->T [rs1676486]) had the most significant association with LDH (P=3.3 x 10(-6)), and the transcript containing the disease-associated allele was decreased because of its decreased stability. These observations indicate that type XI collagen is critical for IVD metabolism and that its decrease is related to LDH.

Open-door laminoplasty for cervical myelopathy resulting from adjacent-segment disease in patients with previous anterior cervical decompression and fusion.

STUDY DESIGN: This is a retrospective study of patients with cervical myelopathy resulting from adjacent-segment disease who were treated by open-door expansive laminoplasty. OBJECTIVES: The purpose of this study was to evaluate the effectiveness of laminoplasty for cervical myelopathy resulting from adjacent-segment disease. SUMMARY OF BACKGROUND DATA: Adjacent-segment disease is one of the problems associated with anterior cervical decompression and fusion. However, the optimal surgical management strategy is still controversial. METHODS: Thirty-one patients who underwent open-door expansive laminoplasty for cervical myelopathy resulting from adjacent-segment disease and age- and sex-matched 31 patients with myelopathy who underwent laminoplasty as the initial surgery were enrolled in the study. The pre- and postoperative Japanese Orthopedic Association scores (JOA scores) and the recovery rate were compared between the two groups. RESULTS: The average JOA scores in the patients with adjacent-segment disease and the controls were 9.2 +/- 2.6 and 9.4 +/- 2.3 before the expansive laminoplasty and 11.9 +/- 2.8 and 13.3 +/- 1.7 at the follow-up examination, respectively; the average recovery rates in the two groups were 37.1 +/- 22.4% and 50.0 +/- 21.3%, respectively (P = 0.04). The mean number of segments covered by the high-intensity lesions on the T2-weighted magnetic resonance images was 1.87 and 0.9, respectively (P = 0.001). CONCLUSIONS: Moderate neurologic recovery was obtained after open-door laminoplasty in patients with cervical myelopathy resulting from adjacent-segment disc disease, although the results were not as satisfactory as those in the control group. This may be attributed to the irreversible damage of the spinal cord caused by persistent compression at the adjacent segments.

A functional SNP in CILP, encoding cartilage intermediate layer protein, is associated with susceptibility to lumbar disc disease.

Lumbar disc disease (LDD) is caused by degeneration of intervertebral discs of the lumbar spine. One of the most common musculoskeletal disorders, LDD has strong genetic determinants. Using a case-control association study, we identified a functional SNP (1184T --> C, resulting in the amino acid substitution I395T) in CILP, which encodes the cartilage intermediate layer protein, that acts as a modulator of LDD susceptibility. CILP was expressed abundantly in intervertebral discs, and its expression increased as disc degeneration progressed. CILP colocalized with TGF-beta1 in clustering chondrocytes and their territorial matrices in intervertebral discs. CILP inhibited TGF-beta1-mediated induction of cartilage matrix genes through direct interaction with TGF-beta1 and inhibition of TGF-beta1 signaling. The susceptibility-associated 1184C allele showed increased binding and inhibition of TGF-beta1. Therefore, we conclude that the extracellular matrix protein CILP regulates TGF-beta signaling and that this regulation has a crucial role in the etiology and pathogenesis of LDD. Our study also adds to the list of connective tissue diseases that are associated with TGF-beta.

[The antiemetic effect of dexamethasone during continuous subcutaneous infusion of morphine for postoperative pain relief].

BACKGROUND: Dexamethasone is known to reduce the incidence of postoperative nausea and vomiting, associated with perioperative intrathecal, epidural, or intravenous morphine. However, the effect of dexamethasone on subcutaneous morphine is unclear. Therefore, we evaluated the antiemetic effect of intravenous dexamethasone during continuous subcutaneous infusion of morphine for postoperative pain relief. METHODS: Twenty patients scheduled for spinal surgery under general anesthesia were enrolled in this randomized, double-blind, and placebo-controlled study. The dexamethasone group (n=10) received dexamethasone 8 mg and the saline group (n=10) received the same amount of saline before the induction of anesthesia. Anesthesia was maintained with propofol and fentanyl. Postoperative pain was treated with continuous subcutaneous morphine via a patient-controlled analgesia device. Postoperatively patients were assessed during 48 hours for nausea and vomiting. RESULTS: Nausea or vomiting ascribable to the subcutaneous morphine developed in 40% of the patients in each group (P:NS). CONCLUSIONS: Our results suggest that the single dose of dexamethasone (8 mg) does not reduce postoperative nausea and vomiting associated with continuous subcutaneous infusion of morphine after spinal surgery.