Repair of cervical esophageal perforation using longus colli muscle flap: a case report of a patient with cervical spinal cord injury.

BACKGROUND CONTEXT: Perforation of the esophagus after anterior cervical spine surgery is a rare, but well-recognized complication. The management of esophageal perforation is controversial, and either nonoperative or operative treatment can be selected. PURPOSE: Several reports have described the use of a sternocleidomastoid muscle flap for esophageal repair. In this case report, we describe a longus colli muscle flap as a substitute for a sternocleidomastoid flap in a patient with an esophageal perforation. STUDY DESIGN: Case report. PATIENT SAMPLE: A 20-year-old man sustained cervical spinal cord injury, on diving and hitting his head against the bottom of a pool. A C6 burst fracture was observed with posterior displacement of a bone fragment into the spinal canal. The patient exhibited complete paralysis below the C8 spinal segment level. METHODS: The patient underwent subtotal corpectomy of the sixth cervical vertebra with the iliac bone graft and augmented posterior spinal fixation (C5-7) with pedicle screws. After the primary operation, the patient showed signs of infection such as throat pain, a high fever, and osteolytic change of the grafted bone by cervical radiograph. A second operation was performed to replace the graft bone using fibula. On the day after the operation, food residue was confirmed in the suction drainage tube, suggesting esophagus perforation. A third operation was immediately performed to confirm and treat esophagus perforation, although apparent esophageal perforation could not be detected at the second operation. Because the erosion around the perforation of the esophageal posterior wall was extensive, a longus colli muscle flap transposition was accordingly performed into the interspace between the esophageal posterior wall and the grafted bone in addition to simple suturing of the perforation. RESULTS: Neither high fever nor pharyngeal pain has recurred at latest follow-up, 5 years after surgery. CONCLUSIONS: To the best of our knowledge, this is the first report concerning the use of a longus colli muscle flap for esophageal perforation after anterior cervical spine surgery.

Surgical strategy for cervical myelopathy due to ossification of the posterior longitudinal ligament: Part 1: Clinical results and limitations of laminoplasty.

STUDY DESIGN: Retrospective study of 66 patients who underwent laminoplasty for treatment of cervical myelopathy due to ossification of the posterior longitudinal ligament (OPLL). OBJECTIVES: The present study describes surgical results of laminoplasty for treatment of cervical myelopathy due to OPLL and aims to clarify 1) factors predicting outcome and 2) limitations of laminoplasty. SUMMARY OF BACKGROUND DATA: During the period 1986 and 1996, laminoplasty was the only surgical treatment selected for cervical myelopathy at our institutions. METHODS: We reviewed data obtained in 66 patients who underwent laminoplasty for treatment of cervical myelopathy due to OPLL. Mean duration of follow-up was 10.2 years (range, 5-20 years). Surgical outcomes were assessed using the Japanese Orthopaedic Association (JOA) scoring system for cervical myelopathy. RESULTS: Surgical outcome was significantly poorer in patients with occupying ratio greater than 60%. Multiple regression analysis showed that the most significant predictor of poor outcome after laminoplasty was hill-shaped ossification, followed by lower preoperative JOA score, postoperative change in cervical alignment, and older age at surgery. CONCLUSIONS: Laminoplasty is effective and safe for most patients with occupying ratio of OPLL less than 60% and plateau-shaped ossification. However, neurologic outcome of laminoplasty for cervical OPLL was poor or fair in patients with occupying ratio greater than 60% and/or hill-shaped ossification.

Surgical strategy for cervical myelopathy due to ossification of the posterior longitudinal ligament: Part 2: Advantages of anterior decompression and fusion over laminoplasty.

STUDY DESIGN: Retrospective study of 27 patients who underwent anterior decompression and fusion (ADF) for treatment of cervical myelopathy due to ossification of the posterior longitudinal ligament (OPLL). OBJECTIVES: To compare surgical outcome of ADF with that of laminoplasty. SUMMARY OF BACKGROUND DATA: During the period 1986 and 1996, laminoplasty was the only surgical treatment selected for cervical myelopathy at our institutions. According to surgical results of laminoplasty performed during this period, we have performed either laminoplasty or ADF for patients with OPLL since 1996. METHODS: We reviewed clinical data obtained in 27 patients who underwent ADF between 1996 and 2003. Mean duration of follow-up was 6.0 years (range, 2-10 years). Surgical outcomes were assessed using the Japanese Orthopedic Association (JOA) scoring system for cervical myelopathy. Surgical results of ADF were compared with those of laminoplasty, which was performed in 66 patients during the period 1986 and 1996. RESULTS: ADF yielded a better neurologic outcome at final follow-up than laminoplasty in patients with occupying ratio > or =60%, although graft complications occurred in 15% and additional surgical intervention was required in 26%. Neither occupying ratio of OPLL, sagittal shape of ossification, nor cervical alignment was found to be related to surgical outcome of ADF. CONCLUSIONS: Although ADF is technically demanding and has a higher incidence of surgery-related complications, it is preferable to laminoplasty for patients with occupying ratio of OPLL > or =60%.

Risk factors for adjacent segment degeneration after PLIF.

STUDY DESIGN: A retrospective study of 87 patients who underwent posterior lumbar interbody fusion (PLIF) at L4-L5 for L4 degenerative spondylolisthesis. OBJECTIVE: To clarify: 1) the correlation between radiologic degeneration of cranial adjacent segment and clinical results, 2) risk factors for radiologic degeneration of cranial adjacent segment, and 3) preoperative radiologic features of patients who underwent additional surgery with cranial adjacent segment degeneration. SUMMARY OF BACKGROUND DATA: Whereas PLIF with pedicle screw fixation has shown satisfactory clinical results, a solid fusion has been reported to accelerate a degenerative change at unfused adjacent levels, especially in the cranial level. Although several authors have reported the adjacent segment degeneration after PLIF, there are no previous reports of risk factors for adjacent segment degeneration after PLIF. MATERIALS AND METHODS: Eighty-seven patients who underwent PLIF for L4 degenerative spondylolisthesis and could be followed for at least 2 years were included in this study. We measured lumbar lordosis, scoliosis, laminar inclination angle at L3, facet sagittalization at L3-L4, facet tropism at L3-L4, preexisting disc degeneration at L3-L4, and lordosis at the fused segment. Progression of L3-L4 segment degeneration was defined as a condition in which disc narrowing, posterior opening, and progress of slippage in comparison with preoperative dynamic lateral radiographs. Patients were divided into three groups according to postoperative progression of L3-L4 degeneration: Group 1 with neither progression of L3-L4 degeneration nor neurologic deterioration, Group 2 with progression of L3-L4 degeneration but no neurologic deterioration, and Group 3 with an additional surgery required for neurologic deterioration. Correlation between clinical results and radiologic progression of L3-L4 degeneration, and risk factors for progression of radiologic degeneration were investigated. Further, preoperative radiologic features of Group 3 were studied to detect risk factors for clinical deterioration. RESULTS: There were 58 (67%) patients classified into Group 1, 25 (29%) patients into Group 2, and 4 (4%) patients into Group 3. There was no significant difference in average age in each group. No obvious difference was observed in recovery rate between Groups 1 and 2. Laminar inclination angle and facet tropism in Group 3 were more significant than those in Groups 1 and 2. Further, apparent lamina inclination and facet tropism coexisted in Group 3. There were no obvious differences in other factors between each group. CONCLUSION: 1) There was no correlation between radiologic degeneration of cranial adjacent segment and clinical results. 2) Risk factors for postoperative radiologic degeneration could not be detected in terms of each preoperative radiologic factor. 3) Coexistence of horizontalization of the lamina at L3 and facet tropism at L3-L4 may be one of the risk factors for neurologic deterioration resulting from accelerated L3-L4 degenerative change after L4-L5 PLIF.

Mechanical stress-induced apoptosis of endplate chondrocytes in organ-cultured mouse intervertebral discs: an ex vivo study.

STUDY DESIGN: Various amounts of static mechanical load were applied to mouse intervertebral discs in organ cultures. The apoptosis then was examined using nick end labeling. Two mitogen-activated protein kinase (MAPK) inhibitors were added to the medium. OBJECTIVES: To establish an experimental model for detecting factors regulating chondrocyte apoptosis induced by mechanical stress, and to determine the role of MAPK and p38 in the stress-induced apoptotic pathway of endplate chondrocytes. SUMMARY OF BACKGROUND DATA: The cause of degenerative change in the cartilaginous endplate (CEP) remains unclear. The authors' previous findings using a mouse model suggested that apoptosis in the cartilaginous endplate may play a role in intervertebral disc degeneration, and that mechanical stress may induce apoptosis. If apoptosis of endplate chondrocytes is involved in the cascade of intervertebral disc degeneration, then how apoptosis is induced by mechanical stress should be important in preventing disc degeneration. However, the mechanism of apoptosis induced by mechanical stress remains unclear. METHODS: Mouse coccygeal discs were harvested and organ cultured. Various static compression loads (0, 0.2, 0.4, 0.8, and 1.0 MPa) were applied on intervertebral discs placed in culture bottles for 24 hours. Paraffin-embedded sections of the harvested discs were stained using Safranin-O and the nick end labeling procedure. The apoptotic cells were counted in the cartilaginous endplate and junctional anulus fibrosus of each intervertebral disc. In addition, U0126 (MAPK inhibitor) and SB202190 (p38 inhibitor) were added to the culture medium to determine their regulatory roles in the apoptosis of endplate chondrocytes induced by mechanical load. RESULTS: Histologically, loaded discs became bulged, and the disc space became narrow. Apoptosis was absent in discs without load, but was particularly noticeable in loaded discs (load weight, 1.0 MPa). The number of apoptotic cells increased depending on the weight of the load. The two MAPK inhibitors significantly increased the number of apoptotic cells. CONCLUSIONS: Chondrocyte apoptosis was induced using a static mechanical load especially in the cartilaginous endplate in an organ culture. Apoptosis occurred similarly to previous findings using an in vivo model. This culture system thus reflected the apoptosis demonstrated in vivo. Because biologically active reagents such as MAPK inhibitors can be simply added to culture media, this system may be a useful method for detecting factors that influence apoptosis induced by mechanical stress. Both MAPK inhibitors increased the occurrence of apoptosis. This suggests that these two MAPKs can counteract the apoptotic pathway induced by mechanical stress.