Histopathological explanation of the MRI target sign in extra-axial schwannomas.

BACKGROUND: To better understand the nature of magnetic resonance imaging (MRI) findings in schwannomas, especially in the "target sign" of these findings, the histopathological investigation was performed. METHODS: The MRI findings were correlated with histopathological features in 22 samples of schwannomas, which were mostly resected from the extremities. The histopathological analyses included alcian blue staining and immunohistochemical staining for S-100 protein, proliferating cell nuclear antigen (PCNA) and epithelial membrane antigen (EMA). RESULTS: Seven of the 22 samples of schwannomas of the extremities exhibited target signs including a peripheral zone of homogeneously high signal intensity and a central zone of heterogeneous signal intensity in T2-weighted images. Gadolinium-enhanced T1-weighted images demonstrated a central heterogeneous enhancement and a peripheral ring of homogeneously low signal intensity. Histopathologically, S-100 and PCNA were positive only in the central heterogeneous signal area. In contrast, EMA was only stained on the degenerative epi/perineurium in the peripheral zone. CONCLUSION: In schwannomas of the extremities showing target sign in T2-weighted images, histopathologically, the peripheral areas were suggested to be mucinous degeneration of the epineurium or perineurium, while the central areas were composed of truly neoplastic cells.

Clinical output of the rheumatoid cervical spine in patients with mutilating-type joint involvement: for better activities of daily living and longer survival.

STUDY DESIGN: Retrospective study. OBJECTIVE: To gain an insight for the final clinical output of surgically managed cervical lesions in seropositive rheumatoid arthritis (RA) patients with mutilating-type joint involvement (mutilating-RA patients), these patients was followed up until either death or complete bedridden. SUMMARY OF BACKGROUND DATA: There has been no study reporting the final clinical output of surgically managed cervical lesion in mutilating-RA patients. In our previous study, we reported short- to middle-term result of such patient. The present study further traced those patients and reports the final clinical output. METHODS: Seventeen seropositive mutilating-RA patients extracted from 504 RA patients were enrolled. Eleven patients underwent surgical treatments, whereas six patients did not. All patients, who underwent operation, have received occipitocervical or occipitocervicothoracic fusion. Neck pain, neurological symptoms and ADL score were completely followed up (i.e., follow-up period>10 years). RESULTS: The six patients of non-operated group worsened ADL score and resulted in either complete bedridden or death within 3 years. Contrary, 11 operated patients either improved or maintained ADL until their death. Survival rate in 6.2 years was 0% in non-operated group and 27% in operated group, respectively. The present study suggests that the seropositive mutilating-RA patients worsen cervical lesions once they become affected, and are likely to lose their ADL activity. CONCLUSION: Once seropositive mutilating-RA patients develop major spinal involvement(s), they are likely to undergo a life-threatening stage of the disease during the next 5-10 years. Surgical intervention is advocated not only to treat the neurological compromise but also to sustain their ADL levels during end stage of disease. The sustained ADL, in turn, may contribute to the longevity of these patients by preventing other major life-threatening events.

Osteochondritis dissecans of the talus treated with the mosaicplasty technique: a case report.

The authors present the use of osteochondral autografting with mosaicplasty technique performed on a 20-year-old man for a large osteochondral talar dome lesion. The patient had sustained a right ankle sprain many times while playing rugby football. The lesion measured 15 mm in diameter and encompassed more than one-third of the articular surface. After exposing the talus to a medial malleolar osteotomy, 3 osteochondral grafts taken from the medial femoral condyle of the ipsilateral knee were press-fit into the lesion. One year postoperatively, the patient has returned to playing rugby football. Radiographically, there was incorporation of the grafts. The authors believe that the mosaicplasty technique presents a promising new option in the treatment of osteochondritis dissecans of the talus.

Evaluation of standard nucleotomy for lumbar disc herniation using the Love method: results of follow-up studies after more than 10 years.

A retrospective analysis of long-term follow-up results more than 10 years after a standard nucleotomy for lumbar disc herniation with the Love method was done to determine the effectiveness of this procedure. Nucleotomy according to Love was the standard treatment for lumbar disc herniation before the various minimally invasive alternatives were recently introduced. Without long-term follow-up analysis of Love operations, evidence-based evaluation of those new methods is impossible. We believe that the standard nucleotomy procedure should now be evaluated precisely. In this study we present a comparison of 1-year follow-up results to the results more than 10 years after lumbar nucleotomy. Seventy-six consecutive patients who had undergone lumbar nucleotomy were identified. It was possible to assess 54 (71.1%) of the cases more than 10 years after surgery. The initial and final outcomes were assessed using the MacNab classification and the Japanese Orthopaedic Association (JOA) score. With the MacNab classification a successful outcome 1 year after surgery was achieved in 87.0% of the cases. At the final follow-up, this result was reduced to 74.1%. Seven patients required a second operation and patients under 21 years of age were at risk for reoperation. Patient overall satisfaction with the results of the standard nucleotomy was high. The disc height of the operation site significantly decreased after surgery; nevertheless, this did not affect the clinical outcome. A standard lumbar nucleotomy according to Love is a safe and reliable method of treating selected patients with lumbar disc herniations.

Bath ankylosing spondylitis functional index (BASFI) evaluation of postoperative patients with OPLL.

Although surgical decompression of the involved spinal cord achieves a good recovery of neurological conditions, one of the most important complaints of patients with ossification of the posterior longitudinal ligament (OPLL) is disability as a result of spinal immobility. The activities of daily living (ADL) of postoperative patients with OPLL were examined. To evaluate the ADL of postoperative patients with OPLL in the cervical spine, we utilized the Bath Ankylosing Spondylitis Functional Index (BASFI), one of the most widely used functional indexes for ankylosing spondylitis. We investigated consecutive cases that underwent surgery for OPLL of the cervical spine in our department from 1978 to 1998. The latest and postoperative scores were compared to the preoperative Japanese Orthopaedic Association (JOA) scores (range, 0-17) to assess neurological recovery. We also evaluated ADL at the latest follow-up, using BASFI scores. Significant recoveries of JOA scores were confirmed; however, 77% of patients complained of disability. In BASFI, questions that seemed to reflect spinal condition received low scores in the present study. BASFI scoring was not sufficient in the present form; however, it is one of the candidate functional indexes for evaluating ADL in postoperative patients with OPLL. Establishment of an ideal functional index for such evaluation is needed.

Evaluation of posterior long fusion versus conservative treatment for the progressive rheumatoid cervical spine.

STUDY DESIGN: Results of the posterior long fusion performed for the progressive cervical lesions of rheumatoid arthritis were compared with the outcomes of those who did not undergo surgical treatment. OBJECTIVE: To provide a clue as to whether posterior long fusion improves or maintains the impaired daily life activity of the patients with rheumatoid arthritis with progressive, mutilating-type joint involvements. SUMMARY OF BACKGROUND DATA: To provide optimal treatments for the cervical lesions of patients with rheumatoid arthritis, the natural courses of cervical lesions should be taken into account. In the authors' preliminary study they have retrospectively investigated natural courses of cervical rheumatoid arthritis lesions and have found that the seropositive patients with rheumatoid arthritis with mutilating-type joint involvement are at a high risk of deteriorating the cervical lesion once their cervical spine becomes affected. METHODS: In the present study 17 seropositive patients with rheumatoid arthritis with mutilating-type joint involvements were studied. Eleven patients underwent surgical treatments (operated group), whereas six patients did not (nonoperated group). All of the operated patients underwent occipitocervical or occipitocervicothoracic fusion supplemented by the Luque's sublaminar wiring and preoperative and postoperative usage of halo-jacket. RESULTS: The six patients of the nonoperated group worsened the activities of daily living score and resulted in either complete bedridden or in death by the time point of final follow-up. In contrast, all of the 11 operated patients either improved or maintained the activities of daily living score: those operated because of neurologic compromise due to myelopathy improved at least one class in the activities of daily living score, and those operated because of severe occipitocervical pain maintained the activities of daily living with relief of pain. CONCLUSION: The present study suggests that posterior long fusion may achieve an improvement of activities of daily living, at least, for a certain time period. However, the newly emerging lesions adjacent to the fused segments, which may result from the increased mechanical loads, may finally lead to the impairment of activities of daily living.

Expression of E-cadherin in chordomas: diagnostic marker and possible role of tumor cell affinity.

Chordoma is a relatively rare malignant bone tumor thought to arise from the remnants of the fetal notochord. Chordomas express epithelial cell markers such as cytokeratin and epithelial membrane antigen (EMA), which strongly suggests that the tumor cells grow via the mechanism of epithelial characterized cell-cell interactions. However, there are no known reports that have studied epithelial characterized cell-adhesion molecules such as E-cadherin or epithelial cell adhesion molecule (Ep-CAM) in chordomas. An immunohistochemical investigation was performed in seven cases of chordoma to determine the expression of pan-cytokeratin, Ep-CAM, and E-cadherin. Histological specimens showed the typical appearance of conventional chordoma but for two cases of chondroid chordoma. Cytokeratin was constantly expressed in conventional chordomas, but it was detected among a few cells with physaliphorous appearance in chondroid chordoma cases. Although no Ep-CAM expression was noted, E-cadherin was detected in most chordoma cells irrespective of histological subtypes. The expression of E-cadherin was negative among chondrosarcoma cells in this study as previously reported, and thus constant E-cadherin expression of chordoma cells suggests a role as a useful diagnostic marker to distinguish chondroid chordoma from chondrosarcoma. Furthermore, we speculate that E-cadherin may play a role in tumor cell adhesion and is also involved with histological and clinical features in chordomas.

Sex discrepancy in the canal/body ratio of the cervical spine implicating the prevalence of cervical myelopathy in men.

STUDY DESIGN: A radiographic analysis of the cervical spine in healthy young adults. OBJECTIVES: To investigate the size correlations among the vertebral height, the anteroposterior diameter of the vertebral body, and the anteroposterior diameter of the spinal canal and to investigate the sex discrepancy of the canal/body ratio. SUMMARY OF BACKGROUND DATA: Narrow spinal canal, large vertebral body, and male gender have been thought to be risk factors for cervical myelopathy. However, the association among those risk factors has been seldom analyzed. METHODS: The height and the anteroposterior diameter of the vertebral body as well as the anteroposterior diameter of the spinal canal were measured on the lateral radiographs of healthy young adults (105 men and 114 women) using a distance-measuring tool of computer software. The canal/body ratio was compared between men and women. RESULTS: The height and the anteroposterior diameter of the vertebral body were both larger in males than in females throughout C3-C7, but the anteroposterior diameter of the spinal canal was similar for both sexes. The height of the vertebral body was not correlated with the spinal canal size at any measured segment in both sexes, whereas the anteroposterior diameter of the vertebral body was significantly correlated with the size of the spinal canal in males but not in females. The canal/body ratio was significantly larger in women than in men. CONCLUSIONS: A significantly small canal/body ratio in men may implicate the male prevalence of cervical myelopathy.

Traumatic bilateral locked facet at L4-5: report of a case associated with incorrect use of a three-point seatbelt.

We present a case of traumatic L4-5 bilateral facet dislocation, without neurological deficit, in a 32-year-old female patient, as an unusual seatbelt injury caused by positioning the shoulder harness improperly under her armpit. Open reduction, posterior interbody fusion, and posterior segmental instrumentation were carried out. The aim of this report is to describe this rarely encountered condition and speculate regarding automotive shoulder harness misuse as a potential cause of bilateral locked facet at L4-5, and to emphasize the importance of multidirectional X-ray on first examination. The unusual L4-5 level facet interlocking was attributed to misuse of the automobile shoulder harness. We propose the importance of recognizing this injury and following up on such clues as transverse process fractures and/or widened posterior elements.