Morphologic Changes in Contralateral Lumbar Foramen in Unilateral Cantilever Transforaminal Lumbar Interbody Fusion Using Kidney-type Intervertebral Spacers.

STUDY DESIGN: A retrospective study of 58 patients undergoing cantilever transforaminal lumbar interbody fusion (c-TLIF). OBJECTIVES: To evaluate morphologic changes in the intervertebral foramen (IVF) on the side contralateral to spacer insertion in patients undergoing c-TLIF using plain x-ray films and computed tomography scan. SUMMARY OF BACKGROUND DATA: The morphologic changes in the contralateral lumbar foramen in c-TLIF using unilateral insertion of spacers have not been well studied. MATERIALS AND METHODS: Fifty-eight consecutive patients with lumbar dysplastic changes or degenerative disk diseases underwent c-TLIF using 96 kidney-type spacers with local bone grafts. Radiographic findings (sagittal disk angle), computed tomography scan findings (coronal disk angle, disk height, foraminal height (FH), foraminal width, and cross-sectional area of IVF in contralateral lumbar foramen) were compared between preoperative period and 6 months after surgery. The correlations between contralateral lumbar foraminal dimensions and disk height, sagittal disk angle, and coronal disk angle were analyzed. RESULTS: After c-TLIF, sagittal angle, disk height, FH, foraminal width, and cross-sectional area of the IVF were significantly increased. Increase in posterior disk height showed a positive correlation with increases in FH, foraminal width, and cross-sectional area of IVF (r=0.235-0.511). However, the increase in sagittal disk angle showed a negative correlation with changes in foraminal width and cross-sectional area of IVF (r=-0.256 to -0.206). CONCLUSIONS: Lumbar foraminal dimensions on the side contralateral to spacer insertion increased significantly after c-TLIF, suggesting that c-TLIF enables indirect decompression of the contralateral nerve root. Although increase in posterior disk height was shown to be an important factor to increase contralateral foraminal size, segmental lordosis was a risk factor for a decrease in contralateral foraminal size.

Alterations in axial curvature of the cervical spine with a combination of rotation and extension in the conventional anterior cervical approach.

PURPOSE: Alterations of three-dimensional cervical curvature in conventional anterior cervical approach position are not well understood. The purpose of this study was to evaluate alignment changes of the cervical spine in the position. In addition, simulated corpectomy was evaluated with regard to sufficiency of decompression and perforation of the vertebral artery canal. METHODS: Fifty patients with cervical spinal disorders participated. Cervical CT scanning was performed in the neutral and supine position (N-position) and in extension and right rotation simulating the conventional anterior approach position (ER-position). Rotation at each vertebral level was measured. With simulation of anterior corpectomy in a vertical direction with a width of 17 mm, decompression width at the posterior wall of the vertebrae and the distance from each foramen of the vertebral artery (VA) were measured. RESULTS: In the ER-position, the cervical spine was rotated rightward by 37.2° ± 6.2° between the occipital bone and C7. While the cervical spine was mainly rotated at C1/2, the subaxial vertebrae were also rotated by several degrees. Due to the subaxial rotation, the simulated corpectomy resulted in smaller decompression width on the left side and came closer to the VA canal on the right side. CONCLUSIONS: In the ER-position, the degrees of right rotation of subaxial vertebrae were small but significant. Therefore, preoperative understanding of this alteration of cervical alignment is essential for performing safe and sufficient anterior corpectomy of the cervical spine.

In vivo measurement of lumbar foramen during axial loading using a compression device and computed tomography.

STUDY DESIGN: In vivo measurement of lumbar foramen using computed tomography and an axial loading device in healthy young subjects. OBJECTIVE: To investigate the effects of axial loading on the morphology of the lumbar foramen in vivo. SUMMARY OF BACKGROUND DATA: In vitro studies have shown morphologic changes in the lumbar foramen in response to axial loading. The effects of axial loading on foraminal dimensions in vivo, however, are poorly understood. MATERIALS AND METHODS: The study population consisted of 12 asymptomatic healthy young volunteers [6 men and 6 women; age range, 22-34 y (mean, 27 y)]. Lumbar computed tomography images were compared with and without axial loading using a compression device (DynaWell), and differences in disk height (DH), foraminal height (FH), foraminal width (FW), and the cross-sectional area (CSA) of the intervertebral foramen (IVF) were determined. RESULTS: During axial loading, the FHs at L1/L2, L2/L3, L3/L4, and L4/L5 each decreased significantly (P<0.01 each), by 4.0%, 6.6%, 6.6%, and 5.1%, respectively. Maximum FW decreased significantly (P<0.05 each) at L2/L3 (7.2%) and L3/L4 (5.7%), and increased significantly (P<0.05) at L5/S1 (8.9%). The CSAs of the IVF decreased significantly (P<0.01 each) at L2/L3 (10.8%) and L3/L4 (10.7%) and increased significantly (P<0.01) at L5/S1 (23.3%). Changes in FH, maximum and minimum FW, and CSA of the IVF significantly (P<0.01) correlated with change in posterior DH. CONCLUSIONS: FH, FW, and CSA of the IVF, except for L5/S1, decreased significantly during axial loading. Changes in posterior DH correlated well with the changes in foraminal dimensions.

Compensatory Pelvic Retro-Rotation Associated with a Decreased Quality of Life in Patients with Normal Sagittal Balance.

STUDY DESIGN: Cross-sectional observational study. PURPOSE: To examine whether pelvic rotation as a compensatory mechanism for sagittal imbalance is related to quality of life (QOL). OVERVIEW OF LITERATURE: Poor sagittal alignment is associated with compensatory pelvic retroversion and decreased QOL. Whether the compensatory pelvic tilt (PT) influences QOL is unclear. METHODS: Overall, 134 subjects aged ≥20 years with lower back pain were included (104 females; mean age, 70±9.8 years). Sagittal vertical alignment (SVA) and PT were analyzed radiographically. Patients were stratified into three groups based on SVA values: good alignment (group G), intermediate alignment (group I), and poor sagittal alignment (group P). Patients in group I were further categorized into two groups: low PT and high PT. The Japanese Orthopaedic Association Back Pain Evaluation Questionnaire (JOABPEQ) was used for clinical assessment, and the scores were compared between groups. RESULTS: As SVA increased, PT and lumbar lordosis (LL) increased and decreased, respectively. PT and LL differed significantly between groups G and P (p<0.01 for each comparison). Within group I, there was no significant difference in SVA between the high PT and low PT groups, suggesting that the high PT group had acquired a compensated sagittal balance. Importantly, all domains in the JOABPEQ (except for lower back pain) were significantly lower in the high PT group than in the low PT group (p<0.05 for every comparison). CONCLUSIONS: This study showed that focusing solely on SVA as a single indicator can cause important losses in QOL to be overlooked in patients with lumbar disorders. Although pelvic retroversion can compensate for sagittal balance, it is associated with a significant decrease in QOL. To improve the assessment of patients with lumbar disorders, PT should be considered besides SVA.

Test-retest repeatability of lumbar sagittal alignment and disc height measurements with or without axial loading: a computed tomography study.

STUDY DESIGN: In vivo study using young healthy volunteers, CT scan, and an axial compression device. OBJECTIVE: This study was conducted to evaluate the test-retest repeatability of the measurements of sagittal alignment and disc height of the lumbar spine with and without an axial compression device in the supine position. SUMMARY OF BACKGROUND DATA: Dynamic radiologic examinations have been used to investigate the relationships between disc degeneration and lumbar kinematics or disc height changes under different loading conditions in vivo. There have been a number of investigations of axial loading changes in the lumbar spine during CT and MRI using axial compression devices. Axial compression devices are widely used for simulation of standing position during magnetic resonance imaging (MRI) or computed tomography (CT) scans of the lumbar spine. However, the test-retest repeatability of lumbar morphological changes using axial loading devices is not well understood. METHODS: The study population consisted of 14 asymptomatic healthy young volunteers (7 men, 7 women: age 21 to 32, mean 27 y). Lumbar CT scan with axial loading using a DynaWell compression device (axial loading condition), and CT scan without loading (lying down condition) were carried out. Each participants was evaluated on 2 occasions, 1 month apart at about the same time of the day. Lumbar spinal length, disc height, disc angles, and total lumbar angle were measured by a single observer. Test-retest repeatability was assessed using the intraclass correlation coefficients (ICC). The dependability coefficient ranged between 0 and 1, in which 0 implies null repeatability and 1 implies perfect repeatability. A value of ~0.75 indicates good repeatability, a value between 0.50 and 0.75 indicates moderate repeatability, and values under 0.5 indicate poor repeatability. Test-retest repeatability (intraclass correlation coefficients: ICC) in spinal length, lumbar disc height, disc angle, total lumbar angle, and pelvic angle in both conditions were assessed between the first and second examinations. To evaluate the effects of the device, these parameters under axial loading and lying down conditions were compared statistically using the paired t test. RESULTS: Although spinal length was significantly decreased with axial loading, test-retest ICC of spinal length under lying down and axial loading conditions was ≥0.995, suggesting good repeatability. Although the average disc height showed a significant decrease at L5/S, test-retest ICC of disc heights under lying down and axial loading conditions was ≥0.739, suggesting moderate to good repeatability. Although disc angles at L2/3 and 3/4 showed a significant increase and disc angle at L5/S and pelvic angle showed significant decreases in axial loading, test-retest ICC of these angle parameters were ≥0.877, suggesting good repeatability. The differences in these parameters between lying down and axial loading conditions showed the same tendencies in the first and second examinations. CONCLUSIONS: Spinal length was significantly decreased under conditions of axial loading. Segmental lordotic angle at L2/3 and L3/4 was significantly increased under axial loading conditions. However, disc lordotic angle at L5/S and the pelvic angle were significantly decreased under conditions of axial loading. Axial loading CT of the lumbar spine, and CT without axial loading, provided reproducible measurements of lumbar spinal anthropometric parameters within a 1-month test-retest interval. Axial compression devices are potentially reliable to examine lumbar spinal alignment changes.

Spondylolysis of the second lumbar vertebra treated with segmental wiring and bone grafting.

Spondylolysis affects mostly the lower lumbar spine and rarely the upper lumbar spine. In a literature research, we found that the descriptions of spondylolysis of the upper lumbar spine had been reported mainly with the outcomes of conservative treatment using lumbosacral supports. However, an indication of surgical treatment has rarely been reported. Ravichandran et al reported 2 cases of spinal fusion, decompression or a combination of these procedures, but the procedures have not proved satisfactory in cases of upper lumbar spondylolysis. We found no reports of segmental wire fixation and bone grafting for upper lumbar spondylolysis. Herein, we report spondylolysis of the second lumbar vertebra in a 27-year-old man. He presented with pain and tenderness at the L2 spinous process, and swollen paravertebral muscles. The patient first became aware of lumbago at age 24 years. Much of his work involved heavy labor. He was diagnosed with spondylolysis of L2 and treated conservatively by a general orthopedist from age 25 to 27 years, but without improvement. We performed segmental wire fixation of the transverse and spinous processes of L2, followed by a bone graft. Six months after surgery, the lumbago had resolved and the patient was able to return to work. Three years after surgery, his pain is completely resolved. This is the first report in the English literature in which a successful indication for symptomatic spondylolysis in the upper lumbar spine is described.

Sagittal Alignment of a Strut Graft Affects Graft Subsidence and Clinical Outcomes of Anterior Cervical Corpectomy and Fusion.

STUDY DESIGN: Retrospective study. PURPOSE: The purpose of this study was to investigate the influence of sagittal alignment of the strut graft on graft subsidence and clinical outcomes after anterior cervical corpectomy and fusion (ACCF). OVERVIEW OF LITERATURE: ACCF is a common technique for the treatment of various cervical pathologies. Although graft subsidence sometimes occurs after ACCF, it is one cause for poor clinical results. Malalignment of the strut graft is probably one of the factors associated with graft subsidence. However, to the best of our knowledge, no prior reports have demonstrated correlations between the alignment of the strut graft and clinical outcomes. METHODS: We evaluated 56 patients (33 men and 23 women; mean age, 59 years; range, 33-84 years; 45 with cervical spondylotic myelopathy and 11 with ossification of the posterior longitudinal ligament) who underwent one- or two-level ACCF with an autogenous fibular strut graft and anterior plating. The Japanese Orthopaedic Association (JOA) score recovery ratio for cervical spondylotic myelopathy was used to evaluate clinical outcomes. The JOA score and lateral radiograms were evaluated 1 week and 1 year postoperatively. Patients were divided into two groups (a straight group [group I] and an oblique group [group Z]) based on radiographic assessment of the sagittal alignment of the strut graft. RESULTS: Group I showed a significantly greater JOA score recovery ratio (p<0.05) and a significantly lower graft subsidence than group Z (p<0.01). CONCLUSIONS: Our findings suggest that a straight alignment of the strut graft provides better clinical outcomes and lower incidence of graft subsidence after ACCF. In contrast, an oblique strut graft can lead to significantly increased strut graft subsidence and poor clinical results.

Two-level posterior lumbar interbody fusion for degenerative disc disease: improved clinical outcome with restoration of lumbar lordosis.

BACKGROUND CONTEXT: Although posterior lumbar interbody fusion (PLIF) for degenerative lumbar diseases is routine, there are few reports on double-level PLIF. PURPOSE: To evaluate the clinical outcomes of double-level PLIF. STUDY DESIGN/SETTING: A retrospective study of operated cases in Gifu, Japan. PATIENT SAMPLE: Nineteen patients (8 men and 11 women, 59.5+/-10.2 years) who underwent double-level PLIF between 1996 and 2001. OUTCOME MEASURES: Operation time, blood loss, complications, the Japanese Orthopaedic Association (JOA) score for back pain and lumbar sagittal alignment were evaluated. METHODS: Patients were examined retrospectively at follow-ups of 3.6+/-1.7 years. Primary diseases were spondylolisthesis, spinal canal stenosis, degenerative scoliosis and herniated intervertebral disc. Fusion areas were L3 to L5 in 15 cases and L4 to S1 in 4 cases. RESULTS: The mean JOA score increased from an initial score of 12.9+/-3.5 to 21.3+/-4.9 at the final follow-up. There was a positive correlation (R=0.718, p<.001) between the increase in lordotic angle and the increase in the JOA score. Several parameters suggested that the surgical invasiveness was not minimal. CONCLUSION: Double-level PLIF provided satisfactory results and preserved lumbar spine lordosis.

Clinical Outcomes of Surgical Treatments for Traumatic Spinal Injuries due to Snowboarding.

STUDY DESIGN: Retrospective study. PURPOSE: To assess treatment outcomes of snowboarding-related spinal and spinal cord injuries. OVERVIEW OF LITERATURE: Snowboarding-related spinal or spinal cord injury have a great impact on social and sporting activities. METHODS: A retrospective review of 19 cases of surgically treated snowboard-related injury was done. Analyzed parameters included site of injury, type of fracture, peri- and postoperative complications, pre- and postoperative neurological status, activities of daily living, and participation in sports activities at the final follow-up. RESULTS: The major site of injury was the thoracolumbar junction caused by fracture-dislocation (13/19 cases). The remaining 6 cases had cervical spine injuries. Over 60% of the patients had Frankel A and B paralysis. All patients were surgically treated by posterior fusion with instrumentation. Five underwent additional anterior fusion. Surgical outcome was restoration of ambulatory capacity in 12 patients (63.2%). Ultimately, 15 patients (78.9%) could return to work. Patients with complete paralysis upon admission showed reduced ambulatory capacity compared to those with incomplete paralysis. None of the patients again participated in any sports activities, including snowboarding. CONCLUSIONS: Snowboarding-related spinal or spinal cord injury has a great impact on social as well as sports activities. It is necessary to enhance promotion of injury prevention emphasizing the snowboarders' responsibility code.

Trachea-thoracic vertebral body fistula causing spinal cord injury: a case report.

STUDY DESIGN: A case report and review of the literature. OBJECTIVE: To discuss the significance of identifying trachea-thoracic vertebral body fistula. SUMMARY OF BACKGROUND DATA: Several authors have reported the occurrence of communication between the trachea and the spinal canal or paraspinal abscess. However, trachea-thoracic vertebral body fistulas have not been reported. METHODS: A 77-year-old male experienced gradually worsening lower-extremity palsy. Fifteen years before presentation, he had undergone retrosternal esophageal reconstruction with a gastric tube for esophageal cancer. RESULTS: Computed tomographic scan revealed compression of the Th5 vertebral body; the trachea and the Th5 vertebral body were connected by a fistula, and air seemed to enter Th5 from the trachea. Magnetic resonance image showed severe spinal canal stenosis. Posterior thoracic decompression and fusion was performed. Five months after the procedure, he regained the ability to walk with a cane, and computed tomographic scan revealed closure of the fistula and the bony fusion. CONCLUSION: To our knowledge, this is the first case report of a trachea-thoracic vertebral body fistula. Because the trachea is adjacent to the anterior aspect of the thoracic vertebrae, in cases of retrosternal esophageal reconstruction, trachea-vertebral body fistula should be a differential diagnosis for destructive changes in thoracic vertebrae without any signs of trauma.

Cervical symmetric dumbbell ganglioneuromas causing severe paresis.

We report an extremely rare case with bilateral and symmetric dumbbell ganglioneuromas of the cervical spine in an elderly patient. A 72-year-old man came by ambulance to our hospital due to progressive incomplete paraplegia. Magnetic resonance imaging demonstrated bilateral symmetric dumbbell tumors at the C1/2 level. We performed total resection of the intracanalar tumor, aiming at complete decompression of the spinal cord, and partial and subtotal resection of foraminal outside portions. Histopathological examination of the surgical specimen indicated the tumor cells to be spindle cells with the presence of ganglion cells and no cellular pleomorphism, suggesting a diagnosis of ganglioneuroma. Although the surgery was not curative, the postoperative course was uneventful and provided a satisfactory outcome. This is the fourth known case of cervical ganglioneuromas of the bilateral symmetric dumbbell type.

Successful antibiotic treatment for subdural empyema and seizure due to methicillin-resistant Staphylococcus aureus as a complication of halo orthosis usage: a case report.

Halo orthosis is used for cervical spine fixation after spinal surgery or injury. Although superficial infection at pin sites occurs frequently, intracranial development of infection, including brain abscesses, is very rare. We experienced subdural empyema due to methicillin-resistant Staphylococcus aureus (MRSA) caused by intracranial penetration of halo pins. A 38-year-old woman with a 4-year history of rheumatoid arthritis experienced severe myelopathy due to atlanto-axial dislocation and vertical subluxation. Reduction and immobilization using a halo vest resulted in neurologic improvement; she later underwent occipital bone to C2 fusion using posterior instrumentation. Three months after halo orthosis fixation, she complained of a headache, experienced a generalized tonic-clonic seizure, and became unconscious for 10 min. Computed tomography revealed pneumoencephalus, and Gd-enhanced magnetic resonance imaging revealed edema, enhancement of the overlying dura in the left partial lobe, and subdural and subarachnoidal empyema. Following removal of the halo vest, there was a purulent discharge from the left-posterior pin site. Culture of the discharge was positive for MRSA. The patient was treated with intravenous vancomycin for 2 weeks, followed by cefozopran hydrochloride for 4 weeks. Her symptoms improved, and additional surgery was not required. At latest follow-up, 10 years after the seizure, she is neurologically stable without any recurrence of the infection.

Repair of pars defects by segmental transverse wiring for athletes with symptomatic spondylolysis: relationship between bony union and postoperative symptoms.

STUDY DESIGN: Retrospective study of surgery for spondylolysis patients. OBJECTIVE: To assess clinical outcome of bony union using multislice computed tomography after segmental wiring fixation. SUMMARY OF BACKGROUND DATA: How bony union affects surgical outcome of spondylolysis repair is unclear. METHODS: Forty-four athletes with symptomatic spondylolysis (33 men and 11 women; mean age, 24.2 ± 5.4 years) who underwent segmental wiring fixation were evaluated retrospectively at a mean follow-up of 85 ± 17 months. The level of spondylolysis was L5 in 42 cases, and both L4 and L5 in 2 cases, giving a total of 46 operative levels of vertebrae. Bony union using axial and sagittal reconstruction images of computed tomography, the Japanese Orthopaedic Association (JOA) score for back pain, and complications were reviewed. State of bony union was classified as bilateral union, unilateral union, or nonunion. The total score and the improvement ratio of the JOA score were compared among the 3 groups. RESULTS: Bilateral bony union was obtained in 29 cases (31 of 46 vertebrae, 67.4%). Six cases (13%) showed unilateral union, and 9 cases (19.6%) showed nonunion. JOA score increased significantly after surgery in all groups, average improvement rate was 78.9% in the bilateral group, 63.6% in the unilateral group, and 29.8% in the nonunion group; differences among the 3 groups were significant (P < 0.05). JOA score was significantly higher in the bilateral group than in the other 2 groups. CONCLUSION: Although symptoms were significantly ameliorated in all groups, the bilateral group showed the greatest improvement ratio in JOA score showing bony union to be an important factor in clinical outcome. However, there were a few exceptional cases with contradictory clinical and radiological outcomes. Thus, further studies are required to gain a better understanding of the other multiple factors affecting clinical outcome after spondylolysis repair.

Cantilever transforaminal lumbar interbody fusion for upper lumbar degenerative diseases (minimum 2 years follow up).

PURPOSE: To evaluate the clinical outcomes of cantilever transforaminal lumbar interbody fusion (c-TLIF) for upper lumbar diseases. MATERIALS AND METHODS: Seventeen patients (11 males, 6 females; mean ± SD age: 62 ± 14 years) who underwent c-TLIF using kidney type spacers between 2002 and 2008 were retrospectively evaluated, at a mean follow-up of 44.1 ± 12.3 months (2 year minimum). The primary diseases studied were disc herniation, ossification of posterior longitudinal ligament (OPLL), degenerative scoliosis, lumbar spinal canal stenosis, spondylolisthesis, and degeneration of adjacent disc after operation. Fusion areas were L1-L2 (5 patients), L2-L3 (9 patients), L1-L3 (1 patient), and L2-L4 (2 patients). Operation time, blood loss, complications, Japanese Orthopaedic Association (JOA) score for back pain, bone union, sagittal alignment change of fusion level, and degeneration of adjacent disc were evaluated. RESULTS: JOA score improved significantly after surgery, from 12 ± 2 to 23 ± 3 points (p < 0.01). We also observed significant improvement in sagittal alignment of the fusion levels, from - 1.0 ± 7.4 to 5.2 ± 6.1 degrees (p < 0.01). Bony fusion was obtained in all cases. One patient experienced a subcutaneous infection, which was cured by irrigation. At the final follow-up, three patients showed degenerative changes in adjacent discs, and one showed corrective loss of fusion level. CONCLUSION: c-TLIF is a safe procedure, providing satisfactory results for patients with upper lumbar degenerative diseases.

Lumbar axial loading device alters lumbar sagittal alignment differently from upright standing position: a computed tomography study.

STUDY DESIGN: A study was performed using an axial loading device in healthy young subjects. OBJECTIVE: To determine whether sagittal alignment during axial loading using a compression device can accurately simulate the standing posture. SUMMARY OF BACKGROUND DATA: Axial compression devices are widely used for simulation of standing position during magnetic resonance imaging (MRI) or computed tomography (CT) scans. However, images taken during axial loading have not been compared with those obtained in a standing posture. METHODS: The study population comprised 14 asymptomatic healthy volunteers (7 men and 7 women: age 21-32, mean 27 years). Lumbar lateral radiograph films obtained in the standing posture (standing condition), lumbar CT images with axial loading using a DynaWell compression device (axial loading condition), and CT images without loading (control) were compared. Changes in spinal length, lumbar disc height, segmental lordotic angle, and total lumbar lordotic angle were compared among the conditions. RESULTS: Spinal length was significantly decreased in both the axial loading and standing conditions compared with controls. The magnitude of the changes was greater in the standing condition than in the axial loading condition. Segmental lordotic angle at L2/3 and L3/4 was significantly increased in both axial loading and standing conditions. However, disc lordotic angle at L5/S was significantly decreased in the axial loading condition, while the standing condition showed no significant change. Consequently, the pelvic angle showed a significant decrease in the axial loading condition. CONCLUSION: The compression device simulates the lumbar segmental alignment change from supine to standing posture in L1/2, L2/3, L3/4, and L4/5. However, in L5/S, axial loading using the DynaWell altered lumbar segmental alignment with a kyphotic change, while no significant difference was observed in this level between standing and supine positions. Awareness of these phenomena are essential for accurate interpretation of imaging results.

Two-staged decompression for thoracic paraparesis due to the combined ossification of the posterior longitudinal ligament and the ligamentum flavum: a case report.

STUDY DESIGN: A case report of ossification of the posterior longitudinal ligament (OPLL) combined with ossification of the ligamentum flavum, or yellow ligament (OYL), in the upper thoracic spine. OBJECTIVE: To describe a rare clinical entity and its management pitfalls in a patient with upper thoracic myelopathy due to combined OPLL and OYL. METHODS: A 52-year-old woman developed paresthesia and paraparesis of both legs. One month prior to admission she fell and became unable to walk. She was diagnosed as having upper thoracic myelopathy due to combined OPLL and OYL and was treated by two-stage anterior and posterior spinal decompression. Posterior decompression was achieved first by laminoplasty at C3-Th1 and laminectomy of Th2 and Th3. RESULTS: After posterior decompression, her symptoms immediately and dramatically improved. However, symptoms recurred after she was able to achieve a sitting or standing position. We then performed anterior decompression at Th2, which again improved her symptoms. At two years post-surgery, she is ambulatory with the use of a cane. CONCLUSION: Upper thoracic myelopathy due to OPLL and OYL was treated by combined 2-staged anterior and posterior decompression. In this case, posterior decompression alone was inadequate to relieve the symptoms of this pathological condition.

Two-stage decompression for combined epiconus and cauda equina syndrome due to multilevel spinal canal stenosis of the thoracolumbar spine: a case report.

INTRODUCTION: A case of combined epiconus and cauda equina syndrome due to multilevel spinal canal stenosis of the thoracolumbar spine is reported. METHODS: A 76-year-old man with multilevel spinal canal stenosis of the thoracolumbar spine (Th11-12, L2-S) who showed symptoms of epiconus syndrome was reported. First, we performed anterior decompression and fusion at the thoracolumbar junction (decompression: Th11-12, fusion: Th10-L2), which ameliorated his symptom partially. However, he presented cauda equina symptoms. Then, he underwent posterior spinal decompression (L3-5) and fusion (Th12-L5). RESULTS: After anterior decompression, several symptoms disappeared. However, motor and sensory disturbance below L4 and bladder-bowel disturbance remained. We then performed a secondary operation. At three years' follow-up, he was able to walk with the aid of a cane. CONCLUSIONS: Combined epiconus and cauda equina syndrome due to multilevel spinal canal stenosis was treated by combined two-stage anterior and posterior decompression. In this case, multilevel decompression via anterior and posterior approaches was necessary to relieve the symptoms.

Two-stage (posterior and anterior) surgical treatment of spinal osteomyelitis due to atypical mycobacteria and associated thoracolumbar kyphoscoliosis in a nonimmunocompromised patient.

STUDY DESIGN: A case report of atypical mycobacterial spinal osteomyelitis. OBJECTIVE: To describe a rare case of spinal osteomyelitis and associated thoracolumbar kyphoscoliosis caused by atypical mycobacteria, and successful treatment by a 2-stage surgical intervention. SUMMARY OF BACKGROUND DATA: Vertebral osteomyelitis caused by atypical mycobacteria is very rare. METHODS: The patient was an 18-year-old woman with vertebral osteomyelitis of Th12-L1 caused by Mycobacterium avium complex. Plain radiographs revealed vertebral collapse of Th12, scoliosis, and kyphosis. RESULTS: Two-stage surgical treatment (first: posterior instrumentation; second: anterior debridement and bone graft) was performed. At 5 years after surgery, the patient is almost free of the preoperative symptoms with no evidence of disease recrudescence. Plain radiograph film demonstrated amelioration of scoliosis and kyphosis, and consolidation of the anterior bone graft. CONCLUSION: A rare case of intractable spinal osteomyelitis due to atypical mycobacteria in a nonimmunocompromised patient was treated successfully with 2-stage surgical treatment.