Clinical features of multiple spinal schwannomas without vestibular schwannomas.

BACKGROUND: Multiple spinal cord tumors in a single patient are very rare and most often seen in cases of neurofibromatosis and associated disorders. Schwannomatosis, which is characterized by the development of multiple schwannomas without vestibular schwannomas, has been newly defined as a distinct form of neurofibromatosis. The purpose of the present study was to describe and review the clinical and radiological features and the management of patients with multiple spinal schwannomas without vestibular schwannomas. METHODS: Between 1986 and 2016, 19 patients with multiple spinal schwannomas without vestibular schwannoma were diagnosed and treated. Of the 19 patients, 13 were males, and 6 were females. The mean age at the first surgery for spinal schwannoma was 45.2 years old. The mean follow-up period was 123.4 months. The clinical features and radiological findings of the patients with multiple spinal schwannomas were retrospectively reviewed. RESULTS: Among the 19 patients, there were more than 140 spinal schwannomas. The most common area of spinal schwannoma was the thoracolumbar-lumbar region. Initial symptoms and chief complaints caused by spinal schwannomas were primarily pain in the trunk or extremities in 17 (89.5%) of 19 patients. More than 60 spinal schwannomas were surgically resected. Multiple spinal surgeries were required in six patients. In all 19 patients, surgical treatment has provided successful relief of symptoms and neurological recovery. CONCLUSIONS: Surgical treatment was safe and effective in patients with multiple spinal schwannomas without vestibular schwannomas. After surgery, we recommend that all patients be followed with magnetic resonance imaging to monitor for asymptomatic tumors or detect new tumors early.

Prone position surgery for a professional sumo wrestler with thoracic ossification of the posterior longitudinal ligament resulting in intraoperative brachial plexus injury by hypertrophic pectoral muscles.

Surgery in the prone position is associated with a variety of complications due to the positioning, including the widely recognized peripheral nerve compression injuries and brachial plexus neuropathy. Previous studies have reported that thin body habitus is a predisposing risk factor for the compressive peripheral nerve injuries due to the prone position surgery. However, prone-position-related brachial plexus injury in patients who are overweight due to hypertrophic muscles have never been reported. Here we report a case of a professional sumo wrestler with severe thoracic ossification of the posterior longitudinal ligament (OPLL). Thoracic OPLL was successfully treated by posterior spinal fusion and decompression surgery. Despite a preoperative simulation and intraoperative inspection of the patient's surgical positioning, he suffered from bilateral upper extremity paralysis immediately after the surgery. Postoperative axillary MRI image revealed a high-intensity area on both sides of his pectoral muscles and axillary fossa, which implied that the pectoral muscles between the ribs and chest pad were pushed out toward the axillary fossa, resulting in compressive brachial plexus injury. His upper extremity motor paralysis was fully recovered in 6 months, but he still has mild tingling sensation even after 12 months of his surgery. In conclusion, overweight patients with hypertrophic muscles pose a risk for brachial plexus entrapment injury by pectoral muscles during prone-position surgery, and therefore it would be more effective to use a wide chest pad to reduce the pressure on the pectoral muscles to prevent it from being pushed out toward the axillary fossa.

Clinical Outcome and Prognostic Factors of Malignant Spinal Dumbbell Tumors.

INTRODUCTION: To investigate the clinical outcome and prognostic factors of malignant spinal dumbbell tumors (m-SDTs). METHODS: We retrospectively reviewed the clinical outcome of 22 consecutive cases of m-SDTs and analyzed the prognostic factors associated with worse outcome. RESULTS: Nineteen of the 22 cases were managed with surgery (86%), and gross total resection (GTR) was achieved in four cases (21%). The duration of overall survival (OS) ranged from 3 to 140 months, with a median survival time of 15.3 months. The 5 year OS rate was 55.6%. In multivariate analysis, histological subtype (high-grade malignant peripheral nerve sheath tumor) (hazard ratio [HR] 14.9, p = 0.0191), GTR (HR 0.07, p = 0.0343), and presence of local recurrences (HR 11.2, p = 0.0479) were significant and independent predictors of OS. CONCLUSIONS: On the basis of clinical data, we propose that GTR and prevention of local recurrence may improve the clinical outcome of m-SDTs.

Radiological Examination of Postoperative Cervical Alignment and Stability in Patients with Dialysis-Associated Spondylosis Excluding Destructive Spondyloarthropathy: Comparison with Patients with Cervical Spondylotic Myelopathy.

INTRODUCTION: Several reports have demonstrated the surgical treatment strategy for patients with dialysis-associated spondylosis in the cervical spine (CDAS) with destructive spondyloarthropathy (DSA). However, studies focusing on the clinical outcome of patients with CDAS without DSA remain scarce. We aimed to review the treatment strategy of patients with CDAS but without DSA. METHODS: The clinical data and surgical records of consecutive patients with CDAS without DSA (n = 9; D-group) and cervical spondylotic myelopathy (CSM) (n = 30; C-group) who underwent modified double-door laminoplasty(DDL) were reviewed retrospectively. We investigated four radiologic factors in the pre-and postoperative periods that have been reported to be the risk factors for worsening of clinical symptoms in various studies and examined statistical comparison between the D and C groups. RESULTS: In the D group, the pre- versus postoperative C2-C7 sagittal angles were not significantly different, and only two patients (22%) had kyphosis postoperatively. There was a significant difference in the pre- and postoperative C2-C7 angles in the two groups (P = 0.031). Regarding the change in segmental alignment, the local open angle increased at the C4/C5 level in the D group. Also there was a significant difference in the local angles between the two groups at C4/5 and C5/6 (P = 0.00038, and 0.037), suggesting that postoperative segmental mobility at C4/5 and C5/6 was higher in the D group than in the C group. CONCLUSIONS: In the present study, DDL in patients with CDAS without DSA did not adversely affect the postoperative alignment and stability compared with CSM patients with CSM. However, patients in the D group may have a chance to develop DSA change at the C4/5 level in the future, and careful long-term follow-up is warranted.

Can the acute magnetic resonance imaging features reflect neurologic prognosis in patients with cervical spinal cord injury?

BACKGROUND CONTEXT: Several prognostic studies looked for an association between the degree of spinal cord injury (SCI), as depicted by primary magnetic resonance imaging (MRI) within 72 hours of injury, and neurologic outcome. It was not clearly demonstrated whether the MRI at any time correlates with neurologic prognosis. PURPOSE: The purpose of the present study was to investigate the relationship between acute MRI features and neurologic prognosis, especially walking ability of patients with cervical spinal cord injury (CSCI). Moreover, at any point, MRI was clearly correlated with the patient's prognosis. STUDY DESIGN: Retrospective image study. PATIENT SAMPLE: From January 2010 to October 2015, 102 patients with CSCI were treated in our hospital. Patients who were admitted to our hospital within 3 days after injury were included in this study. The diagnosis was 78 patients for CSCI with no or minor bony injury and 24 patients for CSCI with fracture or dislocation. A total of 88 men and 14 women were recruited, and the mean patient age was 62.6 years (range, 16-86 years). Paralysis at the time of admission was graded as A in 32, B in 15, C in 42, and D in 13 patients on the basis of the American Spinal Injury Association (ASIA) impairment scale. Patients with CSCI with fracture or dislocation were treated with fixation surgery and those with CSCI with no or minor bony injury were treated conservatively. Patients were followed up for an average of 168 days (range, 25-496 days). OUTCOME MEASURES: Neurologic evaluation was performed using the ASIA motor score and the modified Frankel grade at the time of admission and discharge. METHODS: Magnetic resonance imaging was performed for all patients at admission. Using the MRI sagittal images, we measured the vertical diameter of intramedullary high-intensity changed area with T2-weighted images at the injured segment. We studied separately the patients divided into two groups: 0-1 day admission after injury, and 2-3 days admission after injury. We evaluated the relationship between the vertical diameter of T2 high-intensity changed area in MR images and neurologic outcome in these two groups. This study does not contain any conflict of interest. RESULTS: In the group admitted at 0-1 day after injury, there was a relationship between the vertical diameter of T2 high-intensity area in MR image and the ASIA motor score at admission and at discharge, but correlation coefficient was low (0.3766 at admission and 0.4239 at discharge). On the other hand, in the group admitted at 2-3 days after injury, there was a significant relationship between the vertical diameter of T2 high-intensity area in MR image and the ASIA motor score at admission and at discharge, and correlation coefficient was very high (0.6840 at admission and 0.5293 at discharge). In the group admitted at 2-3 days after injury, a total of 17 patients (68%) recovered to walk with or without a cane. Receiver operating characteristic (ROC) curve analysis demonstrated that the optimal vertical diameter of T2 high-intensity area cutoffvalue for patients who were able to walk at discharge was 45.8 mm. If the vertical diameter of T2 high-intensity area cutoff value was 45 mm, there was a significant positive correlation with being able to walk at discharge (p<.0001). CONCLUSIONS: From our study, 2-3 days after injury, a significant relationship was observed between the vertical diameter of T2 high-intensity area and the neurologic prognosis at discharge. Zero to 1 day after injury, the relationship between the vertical diameter of T2 high-intensity area and the neurologic prognosis at discharge was weak. Neurologic prognosis is more correlated with MRI after 2-3 days after the injury. If the vertical diameter of T2 high-intensity area was <45 mm, the patients were able to walk with or without a cane at discharge. T2 high-intensity changed area can reflect the neurologic prognosis in patients with CSCI.

Effects of posterior pelvic tilt on anterior instability in total hip arthroplasty: a parametric experimental modeling evaluation.

BACKGROUND: Anterior dislocation is one of the concerns of patients with posterior pelvic tilt undergoing total hip arthroplasty. This study aimed to evaluate the magnitude of posterior pelvic tilt constituting a risk for anterior dislocation by measuring the range of motion until impingement and dislocation under various pelvic tilt. METHODS: Using a jig mounted prosthetic hip model, the ranges of external rotation at extension and internal rotation at flexion until reaching dislocation were tested. The site of impingement prior to dislocation was also recorded. Posterior pelvic tilt and the cup version were changed with 10° increments from 0° to 40° and from 10° retroversion to 30° anteversion, respectively. Effects of increasing femoral offset were also tested. We defined a required range of motion as having 30° external rotation at extension and 40° internal rotation at 90° flexion. FINDINGS: External rotation decreased in a posterior pelvic tilt-dependent manner. In the case with more than 20° posterior pelvic tilt, available external rotation extended beyond required range with the cup anteversion of 20°. Decreasing cup anteversion improved external rotation, however, internal rotation decreased simultaneously. In the case with posterior pelvic tilt more than 20°, only cup anteversion with 0° or 10° satisfied the required range of motion. A +4 mm horizontal offset improved external rotation by 10° with delaying bony impingement. INTERPRETATION: More than 20° of posterior pelvic tilt may cause anterior instability and diminish the optimal range of cup version. Increasing the femoral offset improved external rotation without reducing internal rotation.

A Gustilo type IIIB open forearm fracture treated by negative pressure wound therapy and locking compression plates: a case report.

A 91-year-old female sustained injuries to her left forearm while walking across a crosswalk. X-rays showed left radial shaft and ulna shaft fractures, and the injury was a type IIIB open fracture. On the day of admission, irrigation and debridement of the open wound, and temporary fixation of the radius and ulna using an external fixator and a Kirschner wire were peformed. Six days after the surgery, we used negative pressure wound therapy (NPWT) using the V.A.C.ATS system for the open wound. Thirteen days after the first surgery, definitive fixation was performed by using locking compression plates, and full thickness skin grafting was undertaken for the open wound. NPWT is a treatment that accelerates the wound healing process through the delivery of continuous subatmospheric pressure within a closed environment. In our case, we could reduce the healing period of the soft tissue and could convert to the definitive fixation in a timely fashion. NPWT is thought to be a useful adjunct in the management of the soft tissues of open fractures.

Modular necks improve the range of hip motion in cases with excessively anteverted or retroverted femurs in THA.

BACKGROUND: Anteversion of an acetabular component often is difficult to ascertain in patients with THA in whom excessively anteverted or retroverted femurs may result in limited ROM or risk of dislocation. Restriction of motion, however, is determined by the combination of version of both components. QUESTIONS/PURPOSES: We therefore determined the combined anteversion values that provide adequate ROM. We varied acetabular version by differing implantations and varied femoral version with modular necks. METHODS: ROM was tested by changing cup anteversion after setting the femoral version to 20° or 60° anteversion or 20° retroversion. The angle of the modular neck was adjusted in 11 increments of 5° each. Range of internal rotation (IR) at 90° flexion, external rotation (ER) at 0° extension, and flexion (Flex) were measured when any impingement occurred before dislocation. We defined a required ROM as having 40° IR, 30° ER, and 110° Flex. RESULTS: At 60° anteversion, ER was less than 10° even when the acetabular component was set at 10° retroversion because of posterior impingement. When a modular neck with 25° retroversion was used, ER improved to greater than 30°. At 20° retroversion, IR was 31° even when the acetabular component was opened to 35° anteversion. IR improved to 34° and 40° with 20° and 25° anteverted modular necks, respectively. CONCLUSIONS AND CLINICAL RELEVANCE: In cases with excessive femoral anteversion or retroversion, the required ROM could not be achieved by simply changing the version of acetabular components. The adjustment of femoral versions using the modular necks allowed additional improvement of ROM.

Acetabular retroversion in developmental dysplasia of the hip.

BACKGROUND: Patients with developmental dysplasia of the hip are prone to the development of degenerative changes in the affected hip. The aim of this study was to evaluate the prevalence, morphological features, and clinical relevance of acetabular retroversion in these patients. METHODS: We investigated the version and morphological features of the acetabulum using pelvic radiographs and computed tomography images of ninety-six hips in fifty-nine patients with developmental dysplasia of the hip. A diagnosis of acetabular retroversion was based on the presence of a positive cross-over sign on the pelvic radiograph. Using computed tomography images, we determined the acetabular anteversion angle at various levels in the axial plane. The acetabular sector angle served as an indicator of acetabular coverage of the femoral head. We evaluated the association between acetabular version and the patient's age at the onset of pain. Fifty normal hips were examined as controls. RESULTS: We observed acetabular retroversion in 18% (seventeen) of the ninety-six hips in the patients with developmental dysplasia of the hip. The mean acetabular anteversion angle in the hips with acetabular retroversion was significantly smaller, at all levels, than that in the hips with acetabular anteversion; this tendency was more evident at proximal levels. There was significantly less posterior and posterosuperior coverage in the hips with acetabular retroversion than in those with acetabular anteversion, but superior acetabular coverage did not differ between the groups. Multivariate analysis showed that the onset of pain occurred at a significantly earlier age in patients with acetabular retroversion (27.9 years) than in those with acetabular anteversion (40.5 years), regardless of the severity of the dysplasia (p = 0.003). CONCLUSIONS: In patients with developmental dysplasia of the hip, acetabular retroversion results from relatively deficient coverage by the posterior portion of the acetabulum. Developmental dysplasia with acetabular retroversion is associated with an earlier onset of pain than is developmental dysplasia with anteversion, suggesting a correlation between deficiency of the posterior acetabular wall and the earlier onset of pain.

Effects of the femoral offset and the head size on the safe range of motion in total hip arthroplasty.

The purpose of this study was to quantify the effects of femoral offset and head size on range of motion (ROM) after total hip arthroplasty. Modular prostheses were implanted into 11 cadaveric hips using a posterolateral approach and tested for ROM with 3 different offsets and 5 different femoral head sizes. Increasing the femoral offset to 4 and 8 mm resulted in 21.1 degrees and 26.7 degrees of improved flexion, and 13.7 degrees and 21.2 degrees of improved internal rotation, respectively. The ROM improved in a head size-dependent manner primarily because of increasing the jumping distance of the femoral head rather than delaying any impingement. In contrast, the effectiveness of femoral offset was driven by delayed osseous impingement.