Efficacy of Minimally Invasive Trans-Sacral Canal Plasty between Patients with and without Failed Back Surgery Syndrome.

Background and Objectives: Clinicians are required to manage a growing number of elderly patients with several medical comorbidities, and invasive surgical treatments are sometimes not advisable for these patients. The aim of this study was to evaluate the efficacy of minimally invasive intraspinal canal treatment, trans-sacral canal plasty (TSCP), for patients with and without failed back surgery syndrome (FBSS). Materials and Methods: A multicenter analysis was conducted. TSCP was performed in patients with chronic low back pain and leg pain due to lumbar spinal disorders. An adhesiolysis by TSCP was carried out, then a mixture of steroid and local anesthesia was injected. Visual Analog Scales (VAS) for low back pain and leg pain, and complications were evaluated. Results: A total of 271 patients with a minimum 6-month follow-up were enrolled. There were 80 patients who had a history of previous lumbar spinal surgery (F group), and 191 patients without previous lumbar spinal surgery (N group). There were no significant differences in sex and age between the two groups. VAS scores for low back pain (N group/F group) preoperatively, immediately postoperatively, and 1 month, 3 months and 6 months postoperatively, were 51/52 mm, 24/26 mm, 33/34 mm, 30/36 mm, and 30/36 mm, respectively. VAS scores for leg pain were 69/67 mm, 28/27 mm, 39/41 mm, 36/43 mm, and 32/40 mm, respectively. Both VAS scores for low back pain and leg pain were significantly decreased from baseline to final follow-up in both groups (p < 0.01). However, VAS scores for leg pain at 3 months and 6 months postoperatively were significantly higher in F group (p < 0.05). There were three catheter breakages (2/3 in F group), and one dural tear in F group. Conclusions: TSCP significantly reduced both VAS scores for low back and leg pain in patients with and without FBSS. However, co-existence of intractable epidural adhesion might be associated with less improvement in FBSS.

Ponte Osteotomy During Dekyphosis for Indirect Posterior Decompression With Ossification of the Posterior Longitudinal Ligament of the Thoracic Spine.

STUDY DESIGN: Retrospective clinical study. PURPOSE: To investigate the outcomes after indirect posterior decompression and dekyphosis using multilevel Ponte osteotomies for ossification of the posterior longitudinal ligament (OPLL) of the thoracic spine. SUMMARY OF BACKGROUND DATA: There are no previous reports on the use of Ponte osteotomy to treat thoracic OPLL. METHODS: The subjects were 10 patients with an average age at surgery of 47 years, who underwent indirect posterior decompression and dekyphosis using multilevel Ponte osteotomies at our institute. Minimum follow-up period was 2 years, and averaged 2 year 6 months. Using radiographs and CT images, we investigated fusion range, preoperative and postoperative Cobb angles of thoracic fusion levels, intraoperative ultrasonography, and clinical results. RESULTS: The mean fusion area was 9.8 vertebraes, with average laminectomy of 7.3 laminas. The mean preoperative thoracic kyphosis of fusion levels on standing radiograph measured 35 degrees and was changed to 21 degrees after surgery. The mean number of Ponte osteotomies was 3 levels. The mean preoperative and postoperative (at the 1 y follow-up) JOA scores were 3.5 and 7.5 points, respectively, and the recovery rate was 56%. On intraoperative ultrasonography, 7 of the cases were included in the floating (+) and 3 in the floating (-) groups, and the recovery rates were 66.0% and 33.4%, respectively. CONCLUSIONS: "The Ponte procedure for indirect spinal cord decompression" is a novel concept used for the first time with thoracic OPLL in our study, and we consider it a useful method to achieve more effectively dekyphosis and indirect spinal cord decompression if there is not the spinal cord free from OPLL on intraoperative ultrasonography after only laminectomies.

Nogo receptor 1 is expressed in both primary cultured glial cells and neurons.

Nogo receptor (NgR) is common in myelin-derived molecules, i.e., Nogo, MAG, and OMgp, and plays important roles in both axon fasciculation and the inhibition of axonal regeneration. In contrast to NgR's roles in neurons, its roles in glial cells have been poorly explored. Here, we found a dynamic regulation of NgR1 expression during development and neuronal injury. NgR1 mRNA was consistently expressed in the brain from embryonic day 18 to postnatal day 25. In contrast, its expression significantly decreased in the spinal cord during development. Primary cultured neurons, microglia, and astrocytes expressed NgR1. Interestingly, a contusion injury in the spinal cord led to elevated NgR1 mRNA expression at the injury site, but not in the motor cortex, 14 days after injury. Consistent with this, astrocyte activation by TGFß1 increased NgR1 expression, while microglia activation rather decreased NgR1 expression. These results collectively suggest that NgR1 expression is enhanced in a milieu of neural injury. Our findings may provide insight into the roles of NgR1 in glial cells.

Fatal case of cervical blunt vascular injury with cervical vertebral fracture: a case report.

Blunt cerebrovascular injury (BCVI) is usually caused by neck trauma that predominantly occurs in high-impact injuries. BCVI may occur due to damage to both the vertebral and carotid arteries, and may be fatal in the absence of appropriate treatment and early diagnosis. Here, we describe a case of cerebral infarction caused by a combination of a lower cervical spinal fracture and traumatic injury to the carotid artery by a direct blunt external force in a 52-year-old man. Initially, there was no effect on consciousness, but 6 hours later loss of consciousness occurred due to traumatic dissection of the carotid artery that resulted in a cerebral infarction. Brain edema was so extensive that decompression by emergency craniectomy and internal decompression were performed by a neurosurgeon, but with no effect, and the patient died on day 7. This is a rare case of cerebral infarction caused by a combination of a lower cervical spinal fracture and traumatic injury to the carotid artery. The case suggests that cervical vascular injury should be considered in a patient with a blunt neck trauma and that additional imaging should be performed.

Appropriate timing of surgical intervention for the proximal type of cervical spondylotic amyotrophy.

PURPOSE: The purposes of this study were to evaluate the clinical outcome after surgical treatment of patients with the proximal type of cervical spondylotic amyotrophy (CSA) and to explore the appropriate timing for surgical intervention. MATERIALS AND METHODS: A retrospective review was performed on a consecutive cohort of 41 patients who underwent surgical treatment for the proximal type of CSA between 1995 and 2011 at the Nagoya Spine Group Hospitals. We collected information regarding age, type of muscle atrophy, preoperative and final manual muscle test, duration of symptoms, high-intensity areas on T2-weighted MRI images, low-intensity areas on T1-weighted MRI images, levels of spinal canal stenosis, the compression lesion site, cervical kyphosis and surgical procedures (laminoplasty, anterior spinal fusion and posterior spinal fusion). Univariate analyses and multivariate logistic regression analysis were performed to identify correlates of a poor outcome. To explore the appropriate timing for performing surgery, we analyzed the data using receiver operating characteristic (ROC) analysis. RESULTS: The duration of CSA symptoms was 11.6 months on average. The surgical results were excellent for 25 patients, good for six, fair for nine and poor for one. On multivariate logistic regression analysis, the duration of symptoms was statistically associated with a poor surgical outcome (OR 1.393, p = 0.011). ROC analysis demonstrated that 4.3 months from the onset of CSA symptoms was the appropriate time to undergo surgery. CONCLUSIONS: Our results indicate that we should recommend surgical intervention to patients with the proximal type of CSA within about 4 months after the onset of symptoms if conservative treatment has not been successful.

Intradural disc herniation: radiographic findings and surgical results with a literature review.

OBJECTIVE: To report a series of four cases of intradural disc herniation (IDH) with a review of the literature. SUMMARY OF BACKGROUND DATA: IDH is a rare type of disc herniation. Preoperative diagnosis is difficult and IDH is only confirmed during surgery in most cases. Here, we describe four cases of IDH, including three with lumbar hernia and one with thoracic hernia. METHODS: A retrospective chart review, surgical database query, and review of radiology reports are presented for each case, along with a literature review of IDH. RESULTS: Two of the four patients had a history of surgery at the same spinal level. Ring enhancement in gadolinium-enhanced MRI, an air image in computed tomography, and complete block in myelography were observed in the series. Surgery was performed with a transdural approach in all patients. One patient underwent transforaminal lumbar interbody fusion after postoperative recurrence. Three patients with lumbar involvement had nerve root symptoms preoperatively, but showed symptomatic improvement in the early postoperative period. In contrast, the patient with thoracic involvement had preoperative muscle weakness due to myelopathy symptoms, and had residual symptoms after surgery. CONCLUSIONS: IDH is a rare disease and characteristic imaging findings can be useful for diagnosis. Intraoperative findings lead to a definitive diagnosis in many cases and recognition of the pathological characteristics of IDH is important.

Recurrence of solitary fibrous tumor of the cervical spinal cord.

Solitary fibrous tumor (SFT) mostly originates from the pleura because of proliferation of fibroblast cells. It is extremely rare for the tumor to originate from the spinal cord. Here, we report a rare case of SFT in the spinal cord that recurred repeatedly and progressed from intramedullary to extramedullary. A 40-year-old man underwent C4-5 intramedullary and extramedullary tumor resection in another hospital. Eighteen years later, he experienced symptoms of myelopathy because of tumor recurrence; therefore, he consulted with our hospital and underwent tumor resection again. During surgery, we found that the tumor had an intramedullary and extramedullary location. Only partial resection was possible because of intraoperative deterioration in the compound motor action potential (CMAP). After resection, the pathological diagnosis was SFT. The postoperative course was good. However, two years later, a third tumor resection was required because of dysuria and tumor growth. In this surgery, total resection of the tumor was possible without intraoperative deterioration of the CMAP. The tumor has not subsequently recurred. However, SFT recurrence is relatively common and careful follow-up is required for early detection of recurrence, even after successful removal of the tumor.

Radiologic evaluation after posterior instrumented surgery for thoracic ossification of the posterior longitudinal ligament: union between rostral and caudal ossifications.

STUDY DESIGN: Retrospective clinical study. OBJECTIVE: To investigate, using multislice CT images, how thoracic ossification of the posterior longitudinal ligament (OPLL) changes with time after thoracic posterior fusion surgery. SUMMARY OF BACKGROUND DATA: Few studies have evaluated thoracic OPLL preoperatively and post using computed tomography (CT). METHODS: The subjects included 19 patients (7 men and 12 women) with an average age at surgery of 52 years (38-66 y) who underwent indirect posterior decompression with corrective fusion and instrumentation at our institute. Minimum follow-up period was 1 year, and averaged 3 years 10 months (12-120 mo). Using CT images, we investigated fusion range, preoperative and postoperative Cobb angles of thoracic fusion levels, intraoperative and postoperative blood loss, operative time, hyperintense areas on preoperative MRI of thoracic spine and thickness of the OPLL on the reconstructed sagittal, multislice CT images taken before the operation and at 3 months, 6 months and 1 year after surgery. The basic fusion area was 3 vertebrae above and below the OPLL lesion. RESULTS: The mean operative time was 7 hours and 48 min (4 h 39 min-10 h 28 min), and blood loss was 1631 mL (160-11,731 mL). Intramedullary signal intensity change on magnetic resonance images was observed at the most severe ossification area in 18 patients. Interestingly, the rostral and caudal ossification regions of the OPLLs, as seen on sagittal CT images, were discontinuous across the disk space in all patients. Postoperatively, the discontinuous segments connected in all patients without progression of OPLL thickness by 5.1 months on average. CONCLUSIONS: All patients needing surgery had discontinuity across the disk space between the rostral and caudal ossified lesions as seen on CT. This discontinuity was considered to be the main reason for the myelopathy because a high-intensity area on magnetic resonance imaging was seen in 18 of 19 patients at the same level. Rigid fixation with instrumentation may allow the discontinuous segments to connect in patients without a concomitant thickening of the OPLL.

Characteristics and surgical results of the distal type of cervical spondylotic amyotrophy.

OBJECT: Cervical spondylosis that causes upper-extremity muscle atrophy without gait disturbance is called cervical spondylotic amyotrophy (CSA). The distal type of CSA is characterized by weakness of the hand muscles. In this retrospective analysis, the authors describe the clinical features of the distal type of CSA and evaluate the results of surgical treatment. METHODS: The authors performed a retrospective review of 17 consecutive cases involving 16 men and 1 woman (mean age 56.3 years) who underwent surgical treatment for the distal type of CSA. The condition was diagnosed on the basis of cervical spondylosis in the presence of muscle impairment of the upper extremity (intrinsic muscle and/or finger extension muscles) without gait disturbance, and the presence of a compressive lesion involving the anterior horn of the spinal cord, the nerve root at the foramen, or both sites as seen on axial and sagittal views of MRI or CT myelography. The authors assessed spinal cord or nerve root impingement by MRI or CT myelography and evaluated surgical outcomes. RESULTS: The preoperative duration of symptoms averaged 11.8 months. There were 14 patients with impingement of the anterior horn of the spinal cord and 3 patients with both anterior horn and nerve root impingement. Twelve patients were treated with laminoplasty (plus foraminotomy in 1 case), 3 patients were treated with anterior cervical discectomy and fusion, and 2 patients were treated with posterior spinal fixation. The mean manual muscle testing grade was 2.4 (range 1-4) preoperatively and 3.4 (range 1-5) postoperatively. The surgical results were excellent in 7 patients, good in 2, and fair in 8. CONCLUSIONS: Most of the patients in this series of cases of the distal type of CSA suffered from impingement of the anterior horn of the spinal cord, and surgical outcome was fair in about half of the cases.

Unilateral instrumented fixation for cervical dumbbell tumors.

PURPOSE: The purpose of this study was to describe the radiological outcomes in patients with unilateral instrumented fixation for cervical dumbbell tumors. PATIENTS AND METHODS: Fourteen consecutive individuals were included in the present study. We included Eden type II and III tumors in this cohort study and analyzed fixed segment fusion rates, screw failure with multiplanar reconstruction computed tomography (CT) scan radiographs and lateral radiographs with flexion-extension dynamic views, and immediate postoperative and last follow-up radiographs after surgery. RESULTS: The mean follow-up was 105.4 months. There were six men and eight women ranging in age from 32 to 70 years (mean age, 48 years). Twenty pedicle screws (PSs) and 11 lateral mass screws (LMSs) were used in total. There were seven patients with only PSs, four with only LMSs, and three with PSs at C2 and LMSs at C3. PS misplacement occurred in three screws of insertions including two screws with grade 1 misplacement and one screw with grade 2 misplacement, and no grade 3 misplacement occurred. All screws breached the lateral wall with no apparent superior or inferior misplacement. None of the LMSs were misplaced. Fortunately, no complication could be directly attributed to screw insertion. Radiological evidence showed that all patients achieved successful fusion with no screw loosening or breakage. However, two patients who received only LMS fixation had degenerative spondylolisthesis at the upper fusion segment at the last follow-up. CONCLUSIONS: Grade 2 PS misplacement occurred in one screw of insertions. Unilateral pedicle screw fixation for cervical dumbbell tumors is a useful surgical method that can successfully fuse vertebrae with good postoperative alignment.

Acute pancreatitis after spine surgery: a case report and review of literature.

Although acute postoperative pancreatitis is a relatively frequent complication after open biliary tract surgery and gastric surgery, acute pancreatitis after spine surgery is a rare complication. We report the first case of acute pancreatitis after posterior lumbar interbody fusion (PLIF) for spondylolisthesis that resolved with conservative treatment. A 53-year-old female patient received a PLIF from L3 to L5. The patient presented with persistent mild abdominal pain, nausea and vomiting several hours after the surgery. An abdominal CT revealed swelling of the head of the pancreas and free fluid around the pancreas. A gastroenterologist diagnosed acute pancreatitis and prescribed nafamostat mesilate, antibiotics and intravenous fluid therapy. The patient recovered gradually, and clinical symptoms disappeared. At 6 months after the operation, she had experienced no recurrence of abdominal symptoms, and solid spinal fusion was achieved. In previous studies, acute pancreatitis was reported as a complication after spine surgery for various spine diseases such as scoliosis and lumbar disorders. The procedures performed included anterior/posterior scoliosis surgery and anterior/posterior lumbar fusion surgery. We must consider the possibility of acute pancreatitis when unusual abdominal symptoms with elevated serum amylase levels occur after spine surgery. Prompt diagnosis and supportive therapy are essential to minimize morbidity and mortality.

Atlantoaxial rotatory fixation in a child after bilateral otoplastic surgery.

Atlantoaxial rotatory fixation (AARF), which is a dislocation or subluxation of the atlantoaxial joint, is a well-recognized condition in children. We present a case of AARF after otoplastic surgery for bilateral cryptotia performed by plastic surgeons. The pediatric patient presented with neck pain and torticollis after the surgery, and an orthopedic surgeon diagnosed AARF. The patient was treated successfully with conservative treatment incorporating mild manual manipulation, neck traction, and a collar for 1.5 months. Physicians should consider the possibility of AARF when a patient presents with neck pain and torticollis after otoplastic surgery; diagnosis and treatment should be started immediately.

Progressive relapse of ligamentum flavum ossification following decompressive surgery.

Thoracic ossification of the ligamentum flavum (T-OLF) is a relatively rare spinal disorder that generally requires surgical intervention, due to its progressive nature and the poor response to conservative therapy. The prevalence of OLF has been reported at 3.8%-26%, which is similar to that of cervical ossification of the posterior longitudinal ligament (OPLL). The progression of OPLL after cervical laminoplasty for the treatment of OPLL is often shown in long-term follow-up. However, there have been no reports on the progression of OLF following surgery. We report a case of thoracic myelopathy secondary to the progressive relapse of OLF following laminectomy.

Primary cauda equina lymphoma: case report and literature review.

The central nervous system, in particular the spinal cord, is a rare site for primary lymphoma occurrence, with very few published cases. We report an extremely rare primary lymphoma in the cauda equina in a single case with literature review. An immunocompetent 59-year-old male, who complained of progressive low back and bilateral leg pain for 7 months, was studied. Magnetic resonance imaging (MRI) revealed an intradural space-occupying lesion from T12 to S1, poorly demarcated to the normal cauda equina. The intradural lesion showed T1 low intensity, T2 low isointensity, and marked homogeneous enhancement with gadolinium-diethylenetriaminepentaacetic acid on MRI. We performed spinal tap to obtain additional information about the intradural lesion. Large-sized atypical lymphoid cells were found during pathological examination. Fluorodeoxyglucose accumulation was found only in the lumbar area, which corresponded with the MRI findings, and the primary lymphoma site was defined as the cauda equina area. For further detailed pathological diagnosis, we performed surgical biopsy of the cauda equina. Morphological and immunohistochemical assessment made a diagnosis of diffuse large B-cell lymphoma of the cauda equina. The patient received radiotherapy to the lumbosacral area (50 Gy) and methotrexate (MTX) therapy after surgery. The patient was able to walk without help after the therapies. Follow-up MRI performed 1 year after biopsy showed remission of the lesion. MRI and spinal tap were effective tools for the early definitive diagnosis of cauda equina lymphoma. Combined treatment with radiotherapy and MTX should be performed as early as possible.