Long-term Radiological Evidence of Affected and Adjacent Segment Disease after Anterior Cervical Foraminotomy.

Anterior cervical foraminotomy (ACF) is a surgical procedure for cervical radiculopathy to avoid fusion and adjacent segment disease (ASD), but its long-term outcome has yet to be investigated. It is also unclear whether ACF enables preservation of range of motion (ROM) and decreases ASD compared with anterior cervical discectomy and fusion (ACDF). This study included nine patients who underwent ACF, and 12 who underwent ACDF and with follow-up period of at least 5 years (average follow-up: 8.7 years). Preoperative and postoperative radiological findings were investigated, comparing the changes in ACF versus ACDF. All disc height (DH) levels (C2/3-C7/Th1) were measured preoperatively and postoperatively in all 21 patients to compare with the change due to the natural history. The ACF group experienced significant loss of DH (0.6 mm, 13.5%, p <0.01) and ROM (p <0.01) at the operated level postoperatively. However, loss of DH was not significantly different from natural changes at unaffected levels, and ROM was maintained. The ACDF group experienced a significant increase in the ROM of the cranial adjacent segment from 6.46 mm to 7.45 mm (p <0.01), and the dislocation in dynamic X-ray was also significantly increased from 1.61 mm to 2.89 mm (p <0.01), indicating radiological ASD. The ACF group had no significant increase in ROM and dislocation. ACF causes significant loss of DH and ROM, but this change is not significantly different compared with natural changes at unaffected levels. Furthermore, ACF causes less ASD than ACDF in the long term.

Investigation of Radiologic Landmarks Used to Decide the Appropriate Surgical Approach for Upper Thoracic Ventral Degenerative Disorders.

BACKGROUND: Ventral lesions of upper thoracic spinal cord due to degenerative diseases are rare and often have poor operative outcomes. Anterior decompression of the lesion is difficult because of the local anatomy. This retrospective study aimed to evaluate reproducible anatomic measurements for selecting the best surgical approach for anterior decompression of ventral lesions of upper thoracic spinal cord. METHODS: Cases of anterior decompression of ventral lesions of upper thoracic spinal cord due to degenerative diseases at our institution from 2004 to 2015 were assessed. Several lines were drawn on magnetic resonance imaging and computed tomography scans of midsagittal sections of the upper thoracic spine to evaluate the most optimal approach for treating upper thoracic lesions. A line from the suprasternal notch to the vertebral body (suprasternal notch to vertebral body [SV] line) was accepted as baseline. RESULTS: The caudal edge of the lesion was above the SV line in 10 cases, each of which was treated via an anterior approach without sternotomy. The caudal edge was below the SV line in 7 cases, 5 of which underwent surgery with the sternum-splitting or transthoracic approach. The other 2 lesions were approached via an obliquely deviated route without sternotomy. The SV line sometimes changed with patients' posture alterations. CONCLUSIONS: The SV line, a useful landmark for upper thoracic lesions, is not sufficiently reliable because it changes according to the patient's posture. By leaning in the direction of the surgical microscope, more caudal upper thoracic lesions can be reached than when using the SV line as a surgical landmark.

Morphological Patterns of the Anterior Median Fissure in the Cervical Spinal Cord Evaluated by Computed Tomography After Myelography.

OBJECTIVE: Computed tomography following myelography (CTM) revealed an unusual flow of contrast dye into the anterior median fissure (AMF) in a patient with cervical spondylotic myelopathy. Since then, several AMF configurations have been observed on CTM. Therefore, we evaluated morphological patterns of the AMF on CTM and investigated the significance and mechanisms of contrast dye flow into the AMF. METHODS: Morphological patterns of the AMF on CTM were examined in 79 patients. Group A (24 patients) underwent surgery because of symptomatic cervical myelopathy. Group B (43 patients) had no clinical symptoms but showed spinal cord compression on CTM. Group C (12 patients), who showed neither clinical symptoms nor cord changes, underwent CTM for lumbar lesion evaluation. AMF patterns were classified into 4 types according to their configurations on CTM (reversed T, Y, V, and O types). RESULTS: In group B, the reversed T type and Y type appeared significantly more often near the compressed portion (p<0.001). A similar tendency was seen in group A. The V and O types were most frequently observed in group C (p<0.001). CONCLUSION: On CTM, contrast dye tends to flow into the AMF of the cervical cord when the spinal cord is compressed. We speculate that there may be 3 possible mechanisms for this phenomenon: deformation of the epipial layer of the AMF due to cervical cord compression, AMF dilatation due to atrophy of the anterior funiculus or anterior horn, and temporary AMF dilatation when it becomes an alternative route for cerebrospinal fluid circulation.

Precocious Solitary Cervical Metastasis from Endometrial Cancer Presenting as Cervical Radicular Pain.

BACKGROUND: Bone metastases from endometrial cancer are rare. To our knowledge, only 2 cases of solitary vertebral metastases from endometrial cancer presenting with osseous and/or neurologic symptoms before the diagnosis of the primary endometrial cancer have been reported; however, in both cases, the metastases were thoracic. Thus, cervical vertebral metastases are extremely rare. CASE DESCRIPTION: We describe the case of a 55-year-old woman who presented with right C6 radicular and neck pain. Neurologic imaging showed destruction of the C6 vertebral body by an extradural mass with kyphotic changes in the cervical spine. Fluorodeoxyglucose positron emission tomography showed increased uptake in the enlarged body of the uterus as well as the C6 vertebral body. Additional pelvic magnetic resonance images and endometrial biopsy confirmed endometrial cancer. The patient underwent excision of the cervical tumor with anterior reconstruction and posterior fixation followed 1 month later by semiradical hysterectomy and bilateral salpingo-oophorectomy with pelvic and para-aortic lymph node dissection. The cervical and endometrial histopathologic findings were similar, and the final diagnosis made was cervical metastatic adenocarcinoma originating from an endometrial cancer. CONCLUSIONS: We describe an extremely rare case of a precocious solitary cervical metastasis from an endometrial cancer presenting as cervical radicular pain. In our review of published reports, we found that solitary spinal metastases are significantly associated with longer overall survival than are multiple lesions. Resection of the spinal lesion with rigid spinal reconstruction followed by radical hysterectomy may be beneficial in such patients.

Analysis of Revision Surgery of Microsurgical Lumbar Discectomy.

STUDY DESIGN: A retrospective study. PURPOSE: Our objectives were to determine the association between the pathological changes of disc herniation and the interval between primary and revision surgeries and to investigate the frequency and site of the dural laceration in the primary and revision surgeries. OVERVIEW OF LITERATURE: Among 382 patients who underwent microsurgical lumbar discectomy, we investigated 29 who underwent revision surgery to analyze recurrent herniation pathologies and complications to determine the manner in which lumbar disc herniation can be more efficiently managed. METHODS: Of 29 patients, 22 had recurrent disc herniation at the same level and site. The pathological changes associated with compression factors were classified into the following two types depending on intraoperative findings: (1) true recurrence and (2) minor recurrence with peridural fibrosis (>4 mm thickness). The sites of dural laceration were examined using video footage and operative records. RESULTS: The pathological findings and days between the primary and revision surgeries showed no statistical difference (p=0.14). Analysis of multiple factors, revealed no significant difference between the primary and revision surgery groups with regard to hospital days (p=0.23), blood loss (p=0.99), and operative time (p=0.67). Dural lacerations obviously increased in the revision surgery group (1.3% vs. 16.7%, p<0.01) and were mainly located near the herniated disc in the primary surgery group and near the root shoulder in the revision surgery group, where severe fibrosis and adhesion were confirmed. To avoid dural laceration during revision surgery, meticulous decompressive manipulation must be performed around the root sleeve. CONCLUSIONS: We recommend that meticulous epidural dissection around the scar formation must be performed during revision surgery to avoid complications.

[Investigation of Repeatability of Residual Urine Volume Measurement for Lower Urinary Tract Disorder in Patients with Lumbar Degenerative Disorders].

STUDY DESIGN: prospective study OBJECTIVE:To evaluate repeatability of residual urine(RU)volume measurement(RUM)in patients with lumbar degenerative disorders. SUMMARY OF BACKGROUND DATA: RUM by abdominal echo is a non-invasive modality to evaluate lower urinary tract disorder(LUTD), repeatability of which is not found in urological disorders. Additionally, its repeatability has not been confirmed in spinal disorders. The authors examined repeatability of RUM for evaluation of LUTD in patients with lumbar degenerative disorders. METHODS: Thirty-four patients with lumbar degenerative disorders and 7 normal adult volunteers entered our study. RUM was performed at least twice(two to seven times; average 3.6 times). According to urological guidelines, RU over 50 cc is defined as abnormal. Thirty-four patients were divided into two groups:the U+group with lower urinary tract lesion(16 patients)and the U-group without such a lesion(18 patients). RESULTS: In normal adult volunteers:In all volunteers, there was no abnormal RU. Repeatability of RUM was 100%. Average RU volume was 1.6 cc. In patients with lumbar degenerative disorders:Repeatability of RUM was 94.4% in the U-group(average RU volume was 35.2 cc)and 50% in the U+group(average RU volume was 50.1 cc). In all patients with lumbar degenerative disorders, repeatability of RUM was 73.5%(average RU volume was 43.0 cc). CONCLUSIONS: Repeatability of RUM in patients with lumbar degenerative disorders was 73.5%. Especially, in patients without lower urinary tract lesion, high repeatability of RUM was confirmed. According to the present study, RUM seemed to be a dependable modality to evaluate LUTD in patients with lumbar degenerative disorders.

Current Status of Lumbar Interbody Fusion for Degenerative Spondylolisthesis.

Instrumented lumbar fusion can provide immediate stability and assist in satisfactory arthrodesis in patients who have pain or instability of the lumbar spine. Lumbar adjunctive fusion with decompression is often a good procedure for surgical management of degenerative spondylolisthesis (DS). Among various lumbar fusion techniques, lumbar interbody fusion (LIF) has an advantage in that it maintains favorable lumbar alignment and provides successful fusion with the added effect of indirect decompression. This technique has been widely used and represents an advancement in spinal instrumentation, although the rationale and optimal type of LIF for DS remains controversial. We evaluated the current status and role of LIF in DS treatment, mainly as a means to augment instrumentation. We addressed the basic concept of LIF, its indications, and various types including minimally invasive techniques. It also has acceptable biomechanical features, and offers reconstruction with ideal lumbar alignment. Postsurgical adverse events related to each LIF technique are also addressed.

Indication for Partial Vertebral Osteotomy and Realignment in Posterior Spinal Fixation for Osteoporotic Thoracolumbar Vertebral Collapse with Neurological Deficits.

Instrumented spinal fixation is ordinarily required in patients who present with myelopathy or cauda equina syndrome secondary to vertebral collapse following osteoporotic thoracolumbar fracture. Posterior spinal fixation is a major surgical option, and partial vertebral osteotomy (PVO) through a posterior approach is occasionally reasonable for achievement of complete neural decompression and improvement of excessive local kyphosis. However, the indications and need for PVO remain unclear. The objectives of this retrospective study were to determine the efficacy and safety of posterior spinal fixation with or without PVO for osteoporotic thoracolumbar vertebral collapse and identify patients who require neural decompression and alignment correction by PVO. We retrospectively reviewed the clinical records of 20 patients (13 females, 7 males; mean age, 67.1 years) who underwent instrumented posterior fixation for osteoporotic thoracolumbar vertebral fracture. Clinical outcomes were assessed by the Japanese Orthopedic Association score and visual analog scale scores in the lumbar and leg areas. PVO was added with posterior spinal fixation in eight patients because neural decompression was incomplete after laminectomy as indicated by intraoperative echo imaging. Neurological and functional recovery significantly improved during follow-up. Clinical outcomes in patients who underwent PVO were similar to those in patients who did not undergo PVO. However, correction of the local kyphotic angle and improvement of spinal canal compromise after surgery was significant in patients who underwent PVO. The patients who required PVO had a less local kyphotic angle in the supine position and higher occupation rate of the fractured fragment in the spinal canal in the preoperative examination.

Three Case Reports of Donor Site Iliac Bone Fracture as a Complication of Anterior Cervical Fixation Surgery.

Although intervertebral implants have been advocated for cervical fixation surgery, classic Cloward's method or Smith-Robinson's methods using autologous iliac bone has been performed in our clinic for about 30 years. In most cases, the postoperative clinical course is uneventful with satisfactory result. However, the authors experienced three cases of donor site iliac bone fracture in the patients who performed anterior cervical fixation surgery. All three patients were female, elderly, short, and lean with low bone mineral density. Iliac bone fractures manifested with sudden pain in the vicinity of donor site. For the iliac bone fracture, two patients received invasive plate fixation surgery and the other was managed conservatively. As to the mechanism of donor site iliac bone fracture, the share stress during bone donation is speculated to cause iliac crest fragile. After beginning of walking after surgery, tractive force of the muscles attaching to the iliac crest play an important role in promoting the fracture cleft. Several clinical factors were analyzed to investigate the cause and prevention of this troublesome complication of cervical anterior fixation surgery. Age, female gender, lean, and small structure were risk factors for such iliac donor site fracture.

Lumbar alignment and clinical outcome after single level asymmetrical transforaminal lumbar interbody fusion for degenerative spondylolisthesis with local coronal imbalance.

Transforaminal lumbar interbody fusion (TLIF) is widely accepted for the treatment of lumbar arthrodesis. However, the exact characteristics of TLIF depend on the number, location, shape, or materials of the interbody implants, and the type of posterior instrument. Clinical and biomechanical characteristics of each TLIF procedure are still unclear. The present study investigated the clinical and radiological improvements after single level asymmetrical TLIF, in which a single box-shaped spacer was obliquely inserted into the intervertebral space, for lumbar degenerative spondylolisthesis in patients with or without local coronal imbalance (LCI) at the operated level. The clinical records of 60 patients who underwent single level asymmetrical TLIF augmented with the pedicle screw fixation system from January 2005 to January 2011, were retrospectively reviewed. The patients were divided into the LCI group (n = 19) and non-LCI group (n = 41), based on segmental lateral translation or disc wedging at the operated site. Clinical recovery was significantly good in both groups at 2 years after surgery, but improvement of low back pain was significantly worse in the LCI group. Radiological examination revealed that the mean lumbar scoliotic angle was significantly worse in the LCI group postoperatively. Preoperative greater scoliotic angle and coronal off balance of the lumbar spine were related to unfavorable radiological outcomes. The present study showed that single level asymmetrical TLIF is an acceptable method for achieving good clinical and radiological outcomes for patients with symptomatic degenerative spondylolisthesis, however, the clinical benefits and realignment are limited if the patient has LCI at the operated site with greater scoliotic angle or coronal off balance of the lumbar spine.

[Systematic review of complications for proper informed consent(12)decompression or fixation surgery of the lumbar spine].

A systematic review of the English- and Japanese-language literature related to complications and reoperation rates of spinal surgery for degenerative lumbar disease was undertaken for articles published between 1993 and 2012. From these references, key articles were selected to determine the incidence of clinical perioperative and postoperative adverse events for different types of degenerative lumbar diseases. The mortality rate after lumbar degenerative spinal surgery was 0.20% in the large-scale clinical studies evaluated. In this review series, the complication rates for lumbar canal stenosis(LCS), degenerative spondylolisthesis(DS), and lumbar disc herniation(LDH)were 7.6%, 8.5%, and 3.5%, respectively. The reoperation rates for LCS, DS, and LDH were 8.1%, 8.0%, and 6.2%, respectively. These data are helpful for spinal surgeons to apprise patients who have spinal surgery for degenerative lumbar disease of the possible risks of surgical procedures and reoperation rates.