Cervical Myelopathy Secondary to Combined Ossification of Ligamentum Flavum and Posterior Longitudinal Ligament-A Case Report.

In the cervical spine, the combined ossification of the ligamentum flavum (OLF) and posterior longitudinal ligament is rarely seen. Patients are usually treated with cervical laminectomy or laminoplasty with OLF resection. In most of the cases, OLF is adhered to the dura and there is a risk of dural tear or cerebrospinal fluid (CSF) leakage during its resection. In this case report, the authors present results of laminectomy with debulking instead of complete excision of OLF for spinal cord decompression in a cervical myelopathy case in which OLF was adhered to the dura. A 69-year-old man presented with insidious onset weakness in bilateral lower limbs and unsteady gait, which he had experienced 1 month. He has a history of neck pain with left upper limb radiation for the last 2 years. Magnetic resonance imaging showed C5-6 severe central canal stenosis with underlying myelomalacia. Computed tomography showed ossification posterior longitudinal ligament and OLF contributing to severe central canal stenosis at the C5-6 level. The patient underwent C4-C6 laminectomy, debulking of OLF, posterior instrumentation, and fusion with autogenous bone graft from C3 to C6. A histological specimen showed osseous tissue within the ligamentum flavum. After surgery the patient's symptoms improved and no recurrence was observed at 4 years after surgery. The symptoms of myelopathy were successfully treated with debulking instead of complete excision of OLF, thus reducing the risk of dural tear or CSF leakage.

A case report of 3-level degenerative spondylolisthesis with spinal canal stenosis.

INTRODUCTION: Lumbar degenerative spondylolisthesis is a major cause of impaired quality of life and diminished functional capacity in the elderly. Degenerative spondylolisthesis often involves only one or two level and tend to present with one or two level spinal canal stenosis. CASE REPORT: The authors describe an unusual case of degenerative spondylolisthesis involving 3 levels of the lumbar spine from L2 to L5. The patient was a 58-year-old woman who suffered chronic back pain and neurogenic claudication. Plain radiography revealed grade I degenerative spondylolisthesis at L2-L3, L3-L4 and L4-L5. Elevated pedicle-facet joint angles and W-type facet joints at the lumbar spine was observed. Magnetic resonance imaging showed L2-S1 spinal cord compression at the lumbar spine. Patient underwent L2-S1 decompression laminectomy and posterior lateral fusion of L2-S1 with posterior instrumentation and bone grafting. Symptoms improved significantly at 4 months follow-up. CONCLUSION: Thorough evaluation for multilevel segmental involvement in degenerative spondylolisthesis is important because of the frequency of severe symptomatic spinal stenosis or foraminal encroachment. Good surgical outcome can be expected from decompression and stabilisation. The pathogenesis of multi-level lumbar degenerative spondylolisthesis can be complex and heterogeneous.

Patellar instability with and without trochlear dysplasia: new arthroscopic medial soft tissue plication with pullout technique.

The aim of this study was to analyze clinical and radiologic results of an arthroscopic medial plication with the pullout technique and to define indications and limitations of this procedure for patellar instability. Records of 45 patients treated for patellar instability with arthroscopic medial plication with the pullout technique were reviewed. The mean patient age was 22.8±8.3 years. The tibial tuberosity-trochlear groove distance, trochlear depth (TD), and Insall-Salvati ratio were measured using magnetic resonance imaging taken preoperatively. Patients were evaluated clinically by the Insall and Kujala score and radiographically by measuring the congruence angle, lateral patellofemoral angle, and lateral patellar translation pre- and postoperatively. Patients were classified into 2 groups: group 1 comprised 23 patients with TD greater than or equal to 3.0 mm and group 2 comprised 22 patients with TD less than 3.0 mm. A significant improvement (P=.007) in postoperative clinical scores compared with preoperative values was observed. The congruence angle improved to 11.0°±20.6° (P=.006), the lateral patellofemoral angle improved to -1.6°±7.7° (P≤.0001), and the lateral patellar translation improved to 8.7±5.3 mm (P≤.0001) postoperatively. There were 5 (11%) failure cases. No significant difference existed in the number of failure cases and clinical scores between the 2 groups. This arthroscopic medial soft tissue pullout technique showed good clinical and radiologic results for patellar instability even in the presence of mild to moderate trochlear dysplasia. However, the technique showed limited success in severe trochlear dysplasia cases.

Isolated percutaneous thoracoplasty procedure for skeletally mature adolescent idiopathic scoliosis patients, with rib deformity as their only concern: short-term outcomes.

STUDY DESIGN: Prospective case series study. OBJECTIVE: To study the effect of percutaneous thoracoplasty-only procedure on curve pattern in mature adolescent idiopathic scoliosis (AIS). SUMMARY OF BACKGROUND DATA: The rib hump prominence on the convex side is the major cosmetic concern among patients with AIS. Thoracoplasty combined with spinal fusion is a commonly used procedure in scoliosis. However, there are no studies regarding the effect of isolated thoracoplasty procedure on curve pattern in skeletally matured patients with AIS. METHODS: The study involved 7 skeletally matured female patients with AIS. The convex rib hump deformity was measured preoperatively using hump height and hump angle. We performed thoracoplasty without spinal fusion in patients with the Cobb angle less than 40° but with prominent hump deformity. Thoracoplasty was performed percutaneously using 1 or 2 transverse incisions along the rib hump, and apex portions of the deformed ribs were resected. The Cobb angle was measured before surgery, immediately after surgery, and at final follow-up visit. In all cases, clinical satisfaction was assessed using the Scoliosis Research Society Instrument (SRS-22 questionnaires) and trunk appearance perception scale before surgery and at final follow-up visit. RESULTS: The mean patient age was 20.24 years and an average of 4 ribs were resected. The mean preoperative hump height and hump angle of 38.14 mm and 14.14° improved to 11.70 mm and 11.42° respectively, after surgery (P = 0.018 and 0.042). Preoperative and the final follow-up mean Cobb angles were 35.43° and 45.00°, respectively (P = 0.028). On average, the mean thoracic curve progressed by 9.57°. Preoperative Scoliosis Research Society Instrument SRS-22 questionnaires and trunk appearance perception scale scores of 4.09 and 2.57 respectively improved to and 4.26 and 3.66 after surgery (P = 0.126 and 0.014). CONCLUSION: Percutaneous thoracoplasty-only procedure gives significant rib humps correction and satisfactory clinical outcome. However, progression of the curve was observed after surgery. This suggests that the convex ribs function as a buttress for curve progression.

Effect of soft tissue thickness over the posterior border of the vertebral body and disc space on cage placement during posterior lumbar interbody fusion: a cadaveric study.

In the present study, we investigated whether there is a difference between visual depth (VD) and radiological image depth (RD) of cages (i.e., structural interbody support devices) placed in disc spaces during posterior lumbar interbody fusion and whether soft tissues covering the posterior border of the vertebral body and associated disc space are the cause of any observed differences. Using digital calipers, cages were inserted at a depth of 5 mm from the soft tissues covering the posterior border of the vertebral body and disc space under direct vision; this depth was defined as VD. After insertion, RD was measured in triplicate. The reliability of RD measurements was evaluated using an intraclass coefficient test. To identify the cause of differences between VD and RD, the thicknesses of soft tissues were measured microscopically. A total of 40 lumbar intervertebral disc spaces with cages were evaluated. The mean RD of cages was 3.12 mm, while the mean difference between the VD and RD of cages (DVRD) was 1.91 mm. On histological examination, the mean thickness of the soft tissue was 2.02 mm. Comparative analysis between histological values and DVRD showed no statistical difference (P = 1.14, 1.55, 0.06). There was a significant difference between VD and RD during cage placement, and soft tissue structure appeared to be responsible for the DVRD of inserted cages. Therefore, cages should be inserted deeper to account for differences between visual and radiological image depths.

Improvement in reflux gastroesophagitis in a patient with spinal muscular atrophy after surgical correction of kyphoscoliosis: a case report.

BACKGROUND: Scoliosis, a three-dimensional deformity, has secondary effects on the gastrointestinal system. Reflux gastroesophagitis with hiatus hernia in patients with scoliosis is difficult to manage. We present a patient in whom primary correction of a spinal deformity was associated with resolution of symptoms of reflux. CASE DESCRIPTION: A 15-year-old girl with severe thoracolumbar kyphoscoliosis visited our scoliosis research institute complaining of back pain, positional imbalance, intermittent respiratory tract infections, and gastrointestinal discomfort such as pain, dysphagia, and heartburn for several years. On preoperative CT, her abdominal organs were in a deviant position, and esophagogastroduodenoscopy revealed severe reflux gastroesophagitis, Los Angeles classification (LA) Grade D, and a sliding hiatus hernia. After kyphoscoliosis correction, the patient's truncal balance and pain improved. Postoperatively, the patient reported abdominal pain and dysphagia that gradually subsided after 3 weeks. At 1 year, the patient had no abdominal complaints secondary to reflux gastroesophagitis, and episodes of recurrent respiratory tract infections were substantially reduced. Postoperative evaluation showed the reflux gastroesophagitis had improved to LA Grade A. Postoperative CT showed the abdominal cavity had expanded and the abdominal organs were more centered. LITERATURE REVIEW: The association between scoliosis and reflux gastroesophagitis is well documented. However, the secondary effects of scoliosis correction on gastrointestinal symptoms caused by reflux gastroesophagitis have not been investigated in detail. PURPOSE AND CLINICAL RELEVANCE: This patient illustrates the relationship between spinal deformity and gastrointestinal symptoms. Postural balance correction resulted in the alleviation of reflux gastroesophagitis symptoms secondary to hiatus hernia.