Long-term surgical outcome and risk factors in patients with cervical myelopathy and a change in signal intensity of intramedullary spinal cord on Magnetic Resonance imaging.

OBJECT: The goal of this study was to determine the long-term clinical significance of and the risk factors for intramedullary signal intensity change on MR images in patients with cervical compression myelopathy (CCM), an entity most commonly seen with cervical spondylotic myelopathy and ossification of the posterior longitudinal ligament (OPLL). METHODS: One hundred seventy-four patients with CCM but without cervical disc herniation, severe OPLL (in which the cervical canal is < 10 mm due to OPLL), or severe kyphotic deformity (> 15 degrees of cervical kyphosis) who underwent surgery were initially selected. One hundred eight of these patients were followed for > 36 months, and the 71 patients who agreed to MR imaging examinations both pre- and postsurgery were enrolled in the study (the mean follow-up duration was 60.6 months). All patients underwent cervical laminoplasty. The authors used the Japanese Orthopaedic Association (JOA) score and recovery ratio for evaluation of pre- and postoperative outcomes. The multifactorial effects of variables such as age, sex, a history of smoking, diabetes mellitus, duration of symptoms, postoperative expansion of the high signal intensity area of the spinal cord on MR imaging, sagittal arrangement of the cervical spine, presence of ventral spinal cord compression, and presence of an unstable cervical spine were studied. RESULTS: Change in intramedullary signal intensity was observed in 50 of the 71 patients preoperatively. The pre- and postoperative JOA scores and the recovery ratio were significantly lower in the patients with signal intensity change. The mean JOA score of the upper extremities was also significantly lower in these patients. Twenty-one patients showed hypointensity in their T1-weighted images, and a nonsignificant correlation was observed between intensity in the T1-weighted image and the mean JOA score and recovery ratio. The risk factors for signal intensity change were instability of the cervical spine (OR 8.255, p = 0.037) and ventral spinal cord compression (OR 5.502, p < 0.01). Among these patients, 16 had postoperative expansion of the high signal intensity area of the spinal cord. The mean JOA score and the recovery ratio at the final follow-up were significantly lower in these patients. The risk factor for postoperative expansion of the high signal intensity area was instability of the cervical spine (OR 5.509, p = 0.022). No significant correlation was observed between signal intensity on T1-weighted MR images and postoperative expansion of the intramedullary high signal intensity area on T2-weighted MR images. CONCLUSIONS: Long-term clinical outcome was significantly worse in patients with intramedullary signal intensity changes on MR images. The risk factors were instability of the cervical spine and severe ventral spinal compression. The long-term clinical outcome was also significantly worse in patients with postoperative expansion of the high signal intensity area. The fact that cervical instability was a risk factor for the postoperative expansion of the high signal intensity indicates that this high signal intensity area occurred, not only from necrosis secondary to ischemia of the anterior spinal artery, but also from the repeated minor traumas inflicted on the spinal cord from an unstable cervical spine. The long-term neurological outcome found in the preliminary study of patients with CCM who had cervical instability and intramedullary signal intensity changes on MR images suggests that surgical treatment should include posterior fixation along with cervical laminoplasty or anterior spinal fusion.

Mucosal lesions may be a minor complication of SAPHO syndrome: a study of 11 Japanese patients with SAPHO syndrome.

Since the term synovitis-acne-pustulosis-hyperostosis-osteitis (SAPHO) syndrome was proposed by Chamot et al. (Rev Rhum Mal Osteoartic 54:187-196, 1987), clinical reviews concerning this syndrome have been mainly reported from Europe. We carried out a retrospective analysis of 11 Japanese patients with SAPHO syndrome, and reviewed the clinical features of our series in comparison with those in a European large case study. In this study the major features of SAPHO syndrome were chronic osteitis of the anterior chest wall and pustulotic arthro-ostitis with middle age onset, and mucosal lesions seemed to be a minor complication of SAPHO syndrome. The non-erosive peripheral large joints arthritis and the particular HLA types (HLA-B51, B52, or A26), which had been reported to be increased in Behcet's disease, were frequently seen in SAPHO syndrome with mucosal lesions. This study also suggests that SAPHO syndrome with mucosal lesions may be part of a broader disease spectrum including Behcet's disease.

Symptomatic osteochondroma of the spine in elderly patients. Report of 3 cases.

Whereas osteochondroma is a common benign bone tumor in adolescence, it is rarely observed in elderly patients. It is unknown why osteochondromas, which usually develop during skeletal growth, rarely develop in elderly patients. The authors report 3 cases of symptomatic spinal osteochondroma in elderly patients and discuss the possible reasons for the onset of the enlargement of osteochondromas in elderly patients. Clinical history, radiographs, MR images, and CT myelography studies were obtained in each patient and are described. A review of the relevant literature is also presented. In the first case, the cervical osteochondroma caused spinal canal compression and occipital nerve irritation. It was totally excised, which successfully relieved the pain and allowed the patient to return to normal neurological function. In the second case, total removal of the tumor was effective in alleviating clinical symptoms. In the last case, ablation of the articular facet joint partially relieved the patient's lower-back pain. In the first 2 cases, the patients suffered from psoriasis and associated psoriatic arthritis and in the last case, the patient suffered from HIV-associated psoriatic arthritis. The psoriatic arthritis was characterized as asymmetric chronic multiple-joint arthritis and was HLA B27 positive. The pathology of psoriatic arthritis was the accelerating bone turnover and ankylosis. Symptomatic osteochondroma of the spine in elderly patients is extremely rare since it typically develops during skeletal growth. In this report, the authors show that pathological accelerating bone turnover such as psoriatic arthritis may be a possible mechanism for the onset of the enlargement of osteochondromas in elderly patients. The age of the patients in this report suggests that growth of the osteochondroma continues after skeletal development.

Postoperative outcome after modified unilateral-approach microendoscopic midline decompression for degenerative spinal stenosis.

OBJECT: The object of this study was to assess the feasibility and efficacy of a novel, minimally invasive spinal surgery technique to correct degenerative lumbar spinal stenosis involving a modified unilateral-approach microendoscopic midline decompression. METHODS: In this prospective study, 41 patients with lumbar stenosis were randomly assigned to undergo either a novel, median-approach microendoscopic laminectomy (20 patients) or a conventional laminectomy (21 patients). Spinal anteroposterior diameter, cross-sectional area, lateral recess distance, spinal stability, postoperative back pain, functional outcomes, and muscle trauma were evaluated. Follow-up ranged from 16 to 24 months, with a mean of 17.8 months for the novel procedure group and 18.6 months for the conventional laminectomy group. RESULTS: Compared with patients in the conventional laminectomy group, patients who received the novel procedure had a reduced mean duration of hospital stay, a lower mean creatine phosphokinase muscular-type isoenzyme level, a lower visual analog scale score for back pain at 1-year follow-up, and a faster recovery rate. These patients also had less mean blood loss compared with the conventionally treated group. Satisfactory neurological decompression and symptom relief were achieved in 90% of these patients. There was no significant clinical difference compared with the conventional laminectomy group's results. There was no evidence of spinal instability in any patient, and no patient required a follow-up conventional laminectomy. CONCLUSIONS: This novel procedure provides effective spinal decompression. Although this method requires more operating time than a conventional method, it requires only minimal muscle trauma and spinal stability maintenance, and allows for early mobilization. This shortens the hospital stay, reduces postoperative back pain, and leads to satisfactory neurological and functional outcomes. Moreover, with the midline approach, decompression was accomplished without compromising the facet joints, even with a narrow width of lamina.

Two cases of SAPHO syndrome accompanied by classic features of Behcet's disease and review of the literature.

We describe two patients with SAPHO (synovitis-acne-pustulosis-hyperostosis-ostitis) syndrome who presented some of the classic features of Behcet's disease. The first case is a man diagnosed as SAPHO at 74 years old. His major complaint is pain and swelling of the bilateral sterno-clavicular region for more than 14 years. Another conspicuous complication was bilateral glaucoma and episodes of iritis were recognized during the follow-up period. The second case is a 65-year-old woman, who first consulted us with right knee pain. As she had a past history of palmoplantar pustulosis and anterior chest pain, her sterile knee arthritis was diagnosed as SAPHO. She also had been suffering from recurrent oral aphthous ulceration since 6 months before visiting our hospital. Considering the clinical courses of our two cases and a review of five previously reported cases, these conditions may imply that classic features of Behcet's disease are minor complications of SAPHO syndrome. Human leukocyte antigen typing and frequent association of sacroiliitis in our cases and in the review of the literature for SAPHO syndrome with some of the classic features of Behcet's disease may indicate this condition to be a closely related disease with seronegative spondylo-arthritis.