Postoperative Airway Management after Anterior Cervical Spine Surgery: Retrospective Neurosurgical Multicenter Study.

Airway complications that occur after anterior cervical spine surgery pose a life-threatening risk, which encompasses complications including prolonged intubation, unplanned reintubation, and/or necessity of tracheostomy. The present study aimed to identify the surgical risks associated with postoperative airway complications in neurosurgical training institutes. A retrospective, multicenter, observational review of data from 365 patients, who underwent anterior cervical spine surgery between 2018 and 2022, at three such institutes was carried out. Postoperative airway complication was defined as either the need for prolonged intubation on the day of surgery or the need for unplanned reintubation. The perioperative medical information was obtained from their medical records. The average age of the cohort was over 60 years, with males comprising approximately 70%. Almost all surgeries predominantly involved anterior cervical discectomy and fusion or anterior cervical corpectomy and fusion, with most surgeries occurring at the level of C5/6. In total, 363 of 365 patients (99.5%) were extubated immediately after surgery, and the remaining two patients were kept under intubation because of the risk of airway complications. Of the 363 patients who underwent extubation immediately after surgery, two (0.55%) required reintubation because of postoperative airway complications. Patients who experienced airway complications were notably older and exhibited a significantly lower body mass index. The results of this study suggested that older and frailer individuals are at an elevated risk for postoperative airway complications, with immediate postoperative extubation generally being safe but requiring careful judgment in specific cases.

Statistical model of trajectories of reduced mobility in older people with locomotive disorders: a prospective cohort study with group-based trajectory model.

BACKGROUND: Today we experience "Super-aged society", and a drastic increase in the number of older people needing assistance is an urgent matter for everyone from medical and socio-economical standpoints. Locomotive organ dysfunction due to musculoskeletal disorders is one of the main problems in these patients. Although the concepts of frailty and sarcopenia have been proposed for functional decline, pain remains the main and non-negligible complaint in these of such disorders. This prospective cohort study aimed to observe the changes of reduced mobility in patients with locomotive disorders and to determine the risk factors for functional deterioration of those patients using statistical modeling. METHODS: A cohort of older adults with locomotive disorders who were followed up every 6 months for up to 18 months was organized. Pain, physical findings related to the lower extremities, locomotive function in performing daily tasks, and Geriatric Locomotive Function Scale-25 (GLFS-25) score were collected to predict the progress of deterioration. Group-based trajectory analysis was used to identify subgroups of changes of GLFS-25 scores, and multinomial logistic regression analysis was performed to investigate potential predictors of the GLFS-25 trajectories. RESULTS: Overall, 314 participants aged between 65 and 93 years were included. The participants were treated with various combinations of orthopedic conservative treatments on an outpatient basis. The in-group trajectory model analysis revealed a clear differentiation between the four groups. The mild and severe groups generally maintained their GLFD-25 scores, while the moderate group included a fluctuating group and a no change group.　This study showed that comorbidity of osteoporosis was related to GLFS-25 score over 18 months. Age was a weak factor to be moderate or severe group, but gender was not. In addition, the number of pain locations, number of weak muscles, one-leg standing time, grip strength and BMI significantly contributed to the change in GLFS-25 score. CONCLUSIONS: This study proposes an effective statistical model to monitor locomotive functions and related findings. Pain and comorbid osteoporosis are significant factors that related to functional deterioration of activities. In addition, the study shows a patient group recovers from the progression and their possible contributing factors.

Facet joint thickness and lumbar instability documented on myelo-computed tomography studies in patients with lumbar degenerative disease.

Background: Various indicators of vertebral instability in patients with lumbar degenerative disease can be identified in myelo-computed tomography (CT) studies. Methods: Of 120 patients, 45 with lumbar degenerative spondylolisthesis (LDS; 53 lumbar lesions) and 75 with lumbar spinal stenosis alone (LSS; 105 lesions) (2015-2019) myelo-CT studies and surgery confirmed the presence of lumbar instability. Myelo-CT findings indicative of instability included facet joint thickness (FJT), fluid in the facet joint, facet tropism, and air in the facet and/or disc. Results: For the 120 study patients, FJT was significantly elevated in both the LDS and LSS groups. Conclusion: FJT on myelo-CT is more specific for lumbar instability than other imaging parameters when evaluating LDS. An increase in FJT suggests vertebral instability likely warranting fusion.

The Safety of Spine Surgery in the Late-Stage Elderly of 75 Years of Age or Older: A Retrospective Multicenter Study.

OBJECTIVE: The objective of this study was to verify that spine surgery for late-stage elderly (LSE) (age 65-74 years) is as safe as that for early-stage elderly (ESE) (age 65-74 years). METHODS: This retrospective multicenter study included elderly patients aged ≥65 years who underwent spine surgery between 2018 and 2021. The medical information for individual patients was obtained from medical records. Activities of daily living (ADL) were estimated using a 5-grade scale based on the Eastern Cooperative Oncology Group performance status. Good outcome was defined as ADL grade 0 or 1 at discharge; poor outcome was defined as ADL grade 2 to 4 at discharge. The postoperative complications were listed with reference to the Common Terminology Criteria for Adverse Events v5.0. RESULTS: There were 311 patients in the ESE group and 395 patients in the LSE group. Reoperation during hospitalization was significantly higher in the LSE group (4.6%) than in the ESE group (1.6%). The total number of days of hospitalization was significantly longer in the LSE group than in the ESE group. However, there was no significant difference in the postoperative complications or ADL at discharge between the 2 groups. In the statistical analysis, preoperative American Society of Anesthesiologists physical status class 3-6, underlying heart or renal disease, and cervical or thoracic spine level of surgical procedures were significantly associated with poor ADL outcomes at discharge. CONCLUSIONS: Spine surgery even for LSE can be safely done, if perioperative risk factors are appropriately managed.

Immediate effect of mechanical lumbar traction in patients with chronic low back pain: A crossover, repeated measures, randomized controlled trial.

BACKGROUND: Lumbar traction is a treatment method traditionally used for chronic low back pain (CLBP) in many countries. However, its clinical effectiveness has not been proven in medical practice. The purpose is to conduct a multi-center, crossover, randomized controlled trial (RCT) to prove the efficacy and safety of traction on CLBP patients, using equipment capable of precise traction force control and of reproducibility of the condition based on the previous biomechanical and pre-clinical studies. METHODS: Ninety-five patients with non-specific CLBP from 28 clinics and hospitals were randomly assigned to either the intermittent traction with vibration (ITV) first group (A: sequence ITV to ITO) or the intermittent traction only (ITO) first group (B: sequence ITO to ITV); the former was treated with repeated traction and vibration force added to preload. All patients were followed up weekly for 2 periods after study-initiation. The primary outcome measures were disability level including pain and quality of life (based on Japan Low back pain Evaluation Questionnaire; JLEQ), and JLEQ was measured repeatedly. Statistical analysis was performed using linear mixed model. RESULTS: Comparing to pre-traction data, both traction modes significant improvement except the first intervention of ITO treatment. The differences in JLEQ scores over time showed significant improvements in the treatment to which vibrational force was added in contrast to the conventional traction treatment; Mean difference was significant to compare ITV treatment and ITO treatment (-1.75 (p = 0.001), 95% CI; -2.69 to -0.80). However, neither difference between the two sequences (p = 0.884) nor carryover effect (p = 0.527) was observed. CONCLUSIONS: Altogether, the results indicate that lumbar traction was able to improve the pain and functional status immediately in patients with CLBP. This study contributes to add some evidence of the efficacy of lumbar traction.

Prospective, Multicenter Clinical Study of Microvascular Decompression for Hemifacial Spasm.

BACKGROUND: Microvascular decompression (MVD) is the most effective procedure for hemifacial spasm (HFS). MVD results from nonspecialized or low-volume institutes are not always reliable. Most studies on MVD for HFS are retrospective and single centered; to the best of our knowledge, no prospective, multicenter studies exist. OBJECTIVE: To evaluate short- and long-term outcomes and complications in patients who underwent MVD for HFS in specialized Japanese institutions, in this multicenter, prospective, cohort study. METHODS: Included patients had undergone MVD for HFS in study centers between April 2012 and March 2015. Patients' postoperative grade of involuntary movements and complications were recorded postoperatively at 7 d (short-term) and at 1 (mid-term) and 3 (long-term) yr. RESULTS: A total of 486 patients (150 men, 336 women; mean age 53.9 yr with 181 patients over 60 yr) were enrolled during the study period. Neuromonitoring was used in 96.3% of the cases. The complete cure rate of symptom relief, mortality rate, and complication rate at short-term follow-up were 70.6%, 0%, and 15%, respectively. The long-term follow-up was completed by 463 patients (95.3%); the complete cure rate of symptom relief and complication rate were 87.1% and 3.0%, respectively. CONCLUSION: Our study revealed that under expert guidance and intraoperative neuromonitoring, the long-term curative effect rate of MVD for HFS is high, while complications are uncommon and usually transient. Our results indicate that MVD is an effective and safe treatment for patients with HFS, including elderly patients.

Effect and usability of anti-inflammatory drug plasters for knee osteoarthritis: A crossover, double-blind, repeated measures, randomized controlled trial.

BACKGROUND: The use of plasters is a well-accepted treatment with high adherence. However, the characteristics such as its cool feeling or extensibility favored by elderly have a possibility to contribute to clinical utility. The purpose is to examine the effect of anti-inflammatory drug plasters for knee osteoarthritis and the clinical preference of the patients for using plasters. We conducted a crossover, double-blind, randomized controlled trial (RCT) recruited 168 patients with knee osteoarthritis. METHODS: We included a "run-in-period" to evaluate the patients' preference among A (first-generation; methyl salicylate), B (second-generation; indomethacin), and N (base substrate for B) before the crossover sequence of two treatment periods with A and B plasters; four arms (N-A-B, A-A-B, N-B-A, and B-B-A) were made to compare the assessment of A, B, and N plasters. We used two measures: The Japanese Knee Osteoarthritis Measure (JKOM), for clinical functions, and the usability questionnaire to evaluate the clinical value of plasters. RESULTS: At baseline, there were no significant differences in characteristics. The subjects in groups A and B showed improved overall JKOM scores at the end of each intervention. Comparison of the change of the mean difference showed that A and B were statistically significant improvement over N (-2.40, (95%CI = -3.58 to -1.21), -2.52, (-3.65 to -1.40)) but no significant difference between A and B - 0.13, (-1.14 to 0.89)). In network analysis for usability, twelve items were independent of JKOM's network structure and consisted of two domains. The analysis of usability showed that N and B were preferred over A significantly. CONCLUSION: Both the first- and second-generation plasters were statistically superior to the base only, but no significant difference between two generations. The patient is surely aware of the effect of the drug itself, but the two feelings are important in the preference.

A case report of microvascular decompression for cervical myelopathy and radiculopathy caused by tortuous and abnormal bilateral vertebral artery.

BACKGROUND: Tortuous/abnormal vertebral arteries (VAs) sometimes cause neurovascular compression syndromes (NVCs), such as trigeminal neuralgia, hemifacial spasm, and, rarely, myelopathy/radiculopathy. Abnormalities/tortuosity of the VA at the level of the atlas and axis are of particular note; these may be characterized by a persistent first intersegmental artery (PFIA) and C2 segmental type of VA. Herein, we report a 72-year-old male who presented with cervical myelopathy/radiculopathy due to bilateral tortuosity of the PFIA resulting in spinal cord compression at the craniocervical junction. CASE DESCRIPTION: A 72-year-old male presented with cervical pain when turning his neck and progressive gait disturbance. The neurological examination demonstrated a moderate myeloradicular syndrome (Nurick Grade III). The magnetic resonance revealed compression of the medulla and spinal cord due to tortuosity of both dorsal VA at the C1 vertebral level. The three-dimensional computed tomography angiogram confirmed bilateral PFIA running medially. In addition, the left side of VA forms fenestration. Surgery through a C1 laminectomy and midline small suboccipital craniectomy, both VAs were transposed and tethered to the ipsilateral dura utilizing Aron Alpha and vinyl prostheses. In addition, a large vinyl prosthesis was inserted between both VAs to protect them from contacting the spinal cord. Following this decompressive procedure, the patient's symptoms fully resolved, and he remains asymptomatic 10 years later exhibiting no recurrent vascular pathology. CONCLUSION: Microvascular decompression of anomalous VAs contributing to cord compression at the C1 level was safe and effective in a 72-year-old male.

Lumbar mechanical traction: a biomechanical assessment of change at the lumbar spine.

BACKGROUND: Lumbar traction is a traditional treatment modality for chronic low back pain (CLBP) in many countries. However, its effectiveness has not been demonstrated in clinical practice because of the following: (1) the lack of in vivo biomechanical confirmation of the mechanism of lumbar traction that occurs at the lumbar spine; (2) the lack of a precise delivery system for traction force and, subsequently, the lack of reproducibility; and (3) few randomized controlled trials proving its effectiveness and utility. METHODS: This study was planned as a preparatory experiment for a randomized clinical trial, and it aimed (1) to examine the biomechanical change at the lumbar area under lumbar traction and confirm its reproducibility and accuracy as a mechanical intervention, and (2) to reconfirm our clinical impression of the immediate effect of lumbar traction. One hundred thirty-three patients with non-specific CLBP were recruited from 28 orthopaedic clinics to undergo a biomechanical experiment and to assess and determine traction conditions for the next clinical trial. We used two types of traction devices, which are commercially available, and incorporated other measuring tools, such as an infrared range-finder and large extension strain gauge. The finite element method was used to analyze the real data of pelvic girdle movement at the lumbar spine level. Self-report assessments with representative two conditions were analyzed according to the qualitative coding method. RESULTS: Thirty-eight participants provided available biomechanical data. We could not measure directly what happened in the body, but we confirmed that the distraction force lineally correlated with the movement of traction unit at the pelvic girdle. After applying vibration force to preloading, the strain gauge showed proportional vibration of the shifting distance without a phase lag qualitatively. FEM simulation provided at least 3.0-mm shifting distance at the lumbar spine under 100 mm of body traction. Ninety-five participants provided a treatment diary and were classified as no pain, improved, unchanged, and worsened. Approximately 83.2% of participants reported a positive response. CONCLUSION: Lumbar traction can provide a distractive force at the lumbar spine, and patients who experience the application of such force show an immediate response after traction. TRIAL REGISTRATION: University Hospital Medical Information Network - Clinical Trial Registration: UMIN-CTR000024329 (October 13, 2016).

[Relationship between the extent of subarachnoid hemorrhage and intraocular hemorrhages in patients with subarachnoid hemorrhage].

PURPOSE: To examine the relationship between the extent of subarachnoid hemorrhage and intraocular hemorrhages in patients with subarachnoid hemorrhage. SUBJECTS AND METHOD: A total, of 63 patients (25 men and 38 women, mean age 58 years). The subarachnoid hemorrhage quantity was graded according to the Fisher scale and compared with hemorrhages in the ocular fundus. RESULTS: Either vitreous or preretinal hemorrhages in either one or both eyes (vitreous hemorrhages) were present in 16 patients (25%). Retinal hemorrhages in either one or both eyes (retinal hemorrhages) were present in 12 patients (19%). Intraocular hemorrhage was absent in the other 35 patients (56%). The incidence of vitreous hemorrhage tended to be higher than the incidence of retinal hemorrhage or of the absence of hemorrhage as the rate of subarachnoid hemorrhage increased (Kruskal-Wallis, p < 0.05). There was no significant correlation between retinal hemorrhages and the absence of hemorrhage in the Fisher grade IV chi2, p > 0.05). CONCLUSION: The onset of vitreous hemorrhage appears to be related to the extent of subarachnoid hemorrhage but the onset of retinal hemorrhage is not.

A proposal for standardized analysis of the results of microvascular decompression for trigeminal neuralgia and hemifacial spasm.

BACKGROUND: The purpose of this study was to evaluate and analyze overall postoperative results from microvascular decompression (MVD) by combining the cure rate of symptoms with the complication rate. A new scoring system for obtaining objective surgical results from MVD for trigeminal neuralgia (TN) and hemifacial spasm (HFS) is proposed to document treatment results using consistent criteria in a standardized manner. METHOD: Surgical results combining complications , if any, were obtained from a questionnaire sent to patients who had undergone surgery for TN or HFS in recent years and had been followed-up for more than 1 year after surgery (TN patients, n = 54; HFS patients, n = 81) When surgical outcome is complete resolution of symptoms, the efficacy of surgery (E) is designated E-0, but when moderate symptoms are still persist postoperatively, the score is designated E-2. When no complications are seen after surgery, the complication score (C) is C-0, while the score is C-2 if troublesome complications remain. In addition, total evaluation of the results (T) is judged by combining the E and C scores. For example, when E is 0, and C is C-2, the total evaluation is scored as T-2, which is diagnosed as fair. FINDINGS: The response rate of the questionnaire was 80.7% (109/135). Overall surgical data were evaluated and analyzed using our new scoring system. Analysis of the collected data revealed an outcome of T-0 was 70% (35/50 patients) and T-1 was 24% (12/50) and T-2 was 6% (3/50) in TN, whereas in HFS, T-0 was 61% (36/59) and T-1 was 27.1% (16/59) and T-2 was 6.8% (4/59) and T-3 was 5.1% (3/59). CONCLUSION: The total results of MVD should be evaluated and analyzed by combining the cure rate of symptoms together with the complication rate. This new scoring system could allow much more objective analysis of the results of following MVD. Adopting this scoring system to objectively judge treatment results for TN and HFS, individual surgeons can compare their own overall surgical results with those of other institutes. Comparative results of MVD can also be provided to patients considering therapy to allow informed decision-making on the basis of good quality evidence.

Intrinsic arteriovenous malformation embedded in the trigeminal nerve of a patient with trigeminal neuralgia.

A 66-year-old man presented with typical right trigeminal neuralgia. Neuroimaging showed a small arteriovenous malformation (AVM) in the right cerebellopontine angle. Suboccipital craniotomy verified that the AVM was almost completely embedded in the root entry zone of the trigeminal nerve and the nerve axis was tilted infero-posteriorly. The patient obtained complete pain relief without sequelae after surgery by transposition of the superior cerebellar artery and correction of the tilted nerve axis. The nidus of the unresected AVM was obliterated by gamma knife radiosurgery.

Trigeminal neuralgia associated with an anomalous artery originating from the persistent primitive trigeminal artery.

A 31-year-old man presented with typical trigeminal neuralgia caused by an anomalous variant type of anterior inferior cerebellar artery (AICA) directly branching from the primitive trigeminal artery (PTA). Three-dimensional computed tomography angiography, magnetic resonance angiography, and magnetic resonance cisternography disclosed that this anomalous artery originated from the PTA and coursed to the AICA territory of the cerebellum. Microvascular decompression surgery disclosed the trigeminal nerve compressed by this AICA variant together with the superior cerebellar artery. These arteries were successfully transpositioned to decompress the nerve. Careful and thorough inspection around the trigeminal nerve verified that the PTA did not conflict with the nerve. This unusual case was caused by compression of the trigeminal nerve from the AICA directly originating from the PTA, without the more common involvement of the PTA.

[Microvascular decompression for refractory neurogenic hypertension: case report].

It is noted that the increased central sympathetic nerve activity caused by neurovascular compression at the rostral ventrolateral medulla (RVLM) is closely related to the genesis of neurogenic hypertension. The authors present the case of a 49-year-old female with refractory neurogenic hypertension to be uncontrolled even with all kinds of oral antihypertensive medications. After approval by the Ethical Committee in a hospital, she had received an intravenous introduction of calcium antagonist and beta-blocker at home for three years. The subsequent examination detail showed increased sympathetic nerve activity and compression of the left vertebral artery (VA) at the left RVLM on magnetic resonance imaging, and therefore microvascular decompression (MVD) underwent through a left lateral suboccipital approach. The left VA was seen indenting the left RVLM. To ensure the complete decompression, the distal part of VA was moved away from RVLM to fix to the dura of the petrous bone with a glue. Her blood pressure became normalized afterwards without drugs and remained normotensive for 23 months after MVD. In order to decide the surgical indication for pure neurogenic hypertension due to neurovascular compression, a strict differential diagnosis is necessary.

Boron neutron capture therapy for recurrent malignant meningioma. Case report.

Malignant meningioma is a rare brain tumor with a high risk of recurrence. If this tumor recurs after complete resection and adjuvant radiotherapy, there is no optimal treatment to control it. The authors report the first case of recurrent malignant meningioma treated using boron neutron capture therapy (BNCT). This 25-year-old pregnant woman presented with a large frontal tumor. After her baby was born, she underwent gross-total resection of the tumor. A second resection and three Gamma Knife surgeries could not control progression of the enhancing mass; therefore, the authors applied BNCT based on their experience with it in the treatment of malignant gliomas. The minimum tumor dose and maximum brain tissue dose were estimated as 39.7 Gy-Eq and less than 9.0 Gy-Eq, respectively. Before BNCT the patient was mobile by wheelchair only, whereas 1 week after therapy she was able to walk. Twenty-two weeks later she underwent a second BNCT for tumor regrowth on the contralateral side, and the lesion was subsequently reduced. The tumor volume was markedly decreased from 65.6 cm3 at the time of the first BNCT to 31.8 cm3 at 26 weeks thereafter. The treatment of recurrent malignant meningioma is difficult and has been discouraging thus far. Data in the present case indicate that BNCT may be a promising treatment option for this challenging tumor.

Surgically treated aneurysm of the trunk of the persistent primitive trigeminal artery--case report.

A 62-year-old man presented with a very rare cerebral aneurysm arising from the trunk of the persistent primitive trigeminal artery (PPTA) manifesting as subarachnoid hemorrhage. Angiography showed a saccular aneurysm at the curved mid-section of the trunk of the left PPTA of the adult type. The patient underwent surgery via the left subtemporal approach, and the aneurysm was successfully eliminated by clipping without sequelae. Aneurysm formation at this point was probably due to hemodynamic stress. The perforating arteries from the PPTA may be important in supply of the hindbrain, so PPTA patency should be preserved if possible.

[Combined therapy with surgery and stereotactic radiosurgery for facial schwannoma: case report].

The authors report the successful case of combined therapy using surgery and stereotactic radiosurgery for facial schwannoma in the middle cranial fossa, and discuss the surgical strategy for preservation of facial nerve function. This 27-year-old man presented with a 9-year history of right facial palsy and spasm. CT scan and MR imaging demonstrated a tumor 3 x 3 x 4 cm in size extending to the intradural middle cranial fossa from the petrous bone. After total removal of the intradural tumor, gamma knife radiosurgery was performed for residual tumor in the petrous bone. The marginal dose to the tumor was 12 Gy. Facial spasm disappeared, but facial palsy is unchanged 14 months after the radiosurgery.