Cerebral Syphilitic Gumma Can Arise Within Months of Reinfection: A Case of Histologically Proven Treponema pallidum Strain Type 14b/f Infection With Human Immunodeficiency Virus Positivity.

A 44-year-old man with human immunodeficiency virus positivity developed cerebral gumma 6 months after appropriate therapy for secondary syphilis. It was surgically resected and histologically, Treponema pallidum (14b/f, a relatively rare strain type) was proven. A complete set of modern techniques was performed to depict rare complication of this classic disease.

Novel Technique for Rapid and Accurate Insertion of a Microguidewire Tail Into Low-Profile Devices During Endovascular Procedures: The Paper Rail Method.

PURPOSE: To report a novel technique ("paper rail") to facilitate inserting the tail of a microguidewire into the tip of a low-profile device during endovascular procedures. TECHNIQUE: A sterilized nonwoven fabric tape with a smooth glossy paper backing is used. The tape has several linear folds ideal for a paper rail. Holding each piece of equipment about 5 cm from its respective tip, both the tail of the guidewire and the tip of the catheter are navigated at a 30° angle toward each other in the crease until the guidewire enters the catheter. The paper rail technique was compared with the conventional freehand method under varying luminosities found in an operating room. The paper rail technique was most effective in suboptimal lighting, where the mean time was reduced from 83 seconds with the conventional method to 20 seconds with the paper rail maneuver. The times required to insert the wire with the paper rail method were comparable (~22 seconds) at all light levels. CONCLUSION: The paper rail method may help improve the speed and accurate insertion of the tail of a microguidewire into the tip of low-profile devices during endovascular procedures. It may be particularly useful for physicians in a low-light environment or trainees.

Pseudoprogression successfully treated with bevacizumab in a child with spinal pilocytic astrocytoma.

CLINICAL CASE: We report on a 7-year-old female with spinal pilocytic astrocytoma complicated by pseudoprogression 1 month after completion of radiation therapy. Although she was initially treated with high-dose steroids, her clinical symptoms did not completely resolve, and magnetic resonance imaging (MRI) revealed extension of the lesions into the medulla oblongata. Treatment with bevacizumab was commenced, followed by rapid resolution of the clinical symptoms and improvements in the MRI findings. CONCLUSION: This case highlights the efficacy and tolerability of bevacizumab for the treatment of pseudoprogression in children with spinal low-grade gliomas.

Posterior Meningeal Artery Origin Patterns among 300 Cases and Their Clinical Importance.

BACKGROUND AND PURPOSE: The posterior meningeal artery (PMA) is known as a dura mater-nourishing vessel. We encountered a patient with Wallenberg syndrome during transarterial embolization of the PMA associated with the dural arteriovenous fistula (DAVF). METHODS: After development of Wallenberg syndrome in the patient, we assessed origins of the PMA patterns in 300 cases and divided them into 3 types. CASE PRESENTATION: A 63-year-old man was incidentally diagnosed as having transverse-sigmoid sinus DAVF with a cortical venous reflux. During the transarterial embolization, the patient complained of vertigo and numbness of the right extremities. Postoperatively, the patient exhibited Wallenberg syndrome. Diffusion-weighted magnetic resonance imaging showed a high-intensity area on the lateral side of the right medulla. CONCLUSIONS: While performing arterial embolization of the PMA that directly originates from the intracranial vertebral artery, the possibility of deficient brainstem nourishment must be considered.

Novel Vertebral Artery Flow Reversal Method for Preventing Ischemic Complication during Endovascular Intervention.

BACKGROUND AND PURPOSE: We report a secure endovascular approach for the treatment of vascular lesions of the posterior circulation. Even if a large profile guide catheter is wedged in the unilateral vertebral artery (VA), our VA flow reversal method can prevent ischemic complications, including the spinal cord infarction. CASE PRESENTATION: The patient was a 64-year-old woman who had been followed up for arteriovenous malformation (AVM) and an unruptured aneurysm of the basilar artery-superior cerebellar artery bifurcation. Endovascular treatment was performed because minor bleeding occurred from the AVM. When a 6-French guide catheter was navigated into the right VA, the guide catheter became completely wedged, and blood flow between the tip of the catheter and the VA union was fully stagnated. Because ischemia of the anterior spinal artery and right posterior inferior cerebellar artery could persist for a few hours during the endovascular procedure, we built a continuous reversal circulation from the guiding catheter tip to the femoral vein. The flow stagnation disappeared immediately. There was no complication during embolization of both the AVM and aneurysm. CONCLUSIONS: The VA flow reversal method was secure in this case in which the tip of the guide catheter became wedged in the VA during the endovascular procedure.

Ultrasonography has a diagnostic value in the assessment of cervical radiculopathy: A prospective pilot study.

OBJECTIVE: This study investigated the diagnostic accuracy of the difference in the cross-sectional areas (CSAs) of affected cervical nerve roots (NRs) for diagnosing cervical radiculopathy (CR). METHODS: In total, 102 CR patients and 219 healthy volunteers were examined with ultrasound. The CSA of the cervical NR at each level was measured on the affected side and the contralateral side in CR patients by blinded ultrasonographic technicians. The difference between the CSAs of CR patients and normal volunteers and the difference in the laterality of CSA at the same affected level (ΔCSA) were calculated for each cervical level. RESULTS: The CSAs of the affected NRs in CR patients were significantly larger than those of the unaffected NRs in CR patients and those of the control group at the C5, C6 and C7 levels (P<0.005). ΔCSA was also significantly larger in the CR group at all levels (P<0.001). A receiver operating characteristic analysis demonstrated that the threshold values were 9.6 mm2 (CSA) for C5NR and 15 mm2 for both C6NR and C7NR. CONCLUSIONS: This study revealed that the CSAs of affected NRs were enlarged and that the laterality of the CSA (ΔCSA) was greater in CR patients than in control patients. KEY POINTS: • Cervical radiculopathy is diagnosed through ultrasonographic measurement of the CSAs. • The CSAs of affected nerve roots were significantly enlarged. • The ΔCSA in the CR group was significantly higher than in the control group. • Diagnostic CSA and ΔCSA thresholds were identified.

Expression of the JAK/STAT signaling pathway in the ligamentum flavum of patients with lumbar spinal canal stenosis.

BACKGROUND: Ligamentum flavum (LF) hypertrophy is an important cause of lumbar spinal canal stenosis (LSS), one of the most common spinal disorders in the elderly. Although many cytokines are reported to be associated with LF hypertrophy, the intracellular signaling system is rarely discussed. The purpose of this study was to identify the JAK/STAT signaling pathway and to examine the role of the JAK/STAT systems in the hypertrophied LF. METHODS: The LF of 10 LSS patients was analyzed and the expression of JAK1, STAT3, phosphorylated (p)-STAT3, and actin was examined by Western blot analysis. The expression of p-STAT3 was also examined by immunostaining and its positive cell ratio was compared between LSS and non-LSS samples. We measured the thickness of the LF on magnetic resonance images and studied the relationship between its thickness and the expression of p-STAT3. RESULTS: JAK1, STAT3, and p-STAT3 were detected in almost all samples by Western blot analysis. Immunoreactivity against p-STAT3 was observed mainly in endothelial- and fibroblast-like cells. The expression of p-STAT3 was significantly higher in LSS than non-LSS samples; it was significantly stronger on the dorsal than the dural side of the LF and positively correlated with the thickness of the LF on the dorsal side. CONCLUSIONS: The JAK/STAT signaling pathway is positively correlated with the thickness of the LF. Our findings suggest that JAK1 and STAT3 molecules are involved in and regulate LF hypertrophy.

Interleukin-6, MCP-1, IP-10, and MIG are sequentially expressed in cerebrospinal fluid after subarachnoid hemorrhage.

BACKGROUND: Interleukin-6 (IL-6), an inflammatory cytokine, plays important roles in cerebrospinal fluid (CSF) after subarachnoid hemorrhage (SAH). Chemokines are chemoattractant cytokines that regulate trafficking of monocytes/macrophages and lymphocytes to sites of inflammation. However, no studies have been reported regarding the temporal expression of these cytokines in CSF after SAH. FINDINGS: The concentrations of IL-6, monocyte chemoattractant protein-1 (MCP-1), interferon-γ-inducible protein-10 (IP-10), and monokine induced by interferon-γ (MIG) in the CSF of ten patients with SAH were measured using ELISA kits over a period of 14 days. All aneurysms were located in the anterior circulation. CSF samples from patients with unruptured aneurysms were used as controls. The concentration of IL-6 significantly increased during the acute stage of the disease. The concentration of MCP-1 increased from days 1 to 5, peaking on day 3, and decreased thereafter. The concentrations of IP-10 and MIG progressively increased, peaked on day 5, and then gradually decreased. There were strong correlations between the maximum levels of IL-6 and MCP-1 and IP-10 and MIG on day 5. The maximum level of IL-6 was much higher in poor outcome patients than in good outcome patients. CONCLUSIONS: The present investigation demonstrated that increases in IL-6 levels may induce the expression of MCP-1 in CSF after SAH, followed by increases in the expression of IP-10 and MIG. Dynamic changes in the levels of these cytokines may induce inflammation and may be closely associated with the development of delayed ischemic neurological deficits after SAH.

Prevalence of C7 level anomalies at the C7 level: an important landmark for cervical nerve ultrasonography.

BACKGROUND: Recently, various examination and intervention techniques using cervical nerve ultrasonography have been developed. The specific shapes of the C7 transverse process and vertebral artery in front of the C7 transverse process have become landmarks. PURPOSE: To determine the prevalence of anomalies and anomalous vertebral artery entrances at the C7 transverse process. MATERIAL AND METHODS: The records of patients who underwent plain or contrast-enhanced neck or cervical spine computed tomography (CT) were reviewed. The examinations were scored for the anomalous presence of anterior tubercles or cervical ribs as well as vertebral artery entrances in the C7 transverse process. The prevalence of anomalies was compared based on patient sex and age. RESULTS: Evaluating the examinations from 2067 patients (1046 men; 1021 women), 1% of patients exhibited an anomalous presence of anterior tubercles, and 0.3% of patients displayed cervical ribs at the C7 transverse process. The prevalence of anomalies process was significantly higher in men aged less than 40 years than in older men (P < 0.001), whereas the prevalence was not higher in women aged less than 40 years than in older women. The prevalence of vertebral artery entry into the C7 transverse foramen was 0.6%. CONCLUSION: Although an anomalous vertebral artery entry into the C7 transverse foramen was rare, the prevalence of an anomaly at the C7 transverse process was higher in men aged less than 40 years. Therefore, we recommend performing CT in younger men before cervical nerve ultrasonographic intervention to avoid misinterpretations at the cervical level.

[Multi-Layered Closure of Transorbital Penetrating Brain Injury without Bone Reconstruction: A Case Report].

A 26-year-old man was injured in a motor vehicle accident. He sustained a compound orbital fracture with brain contusion. The brain tissue protruded through the orbit. Computed tomography showed a long contusion with a moderate amount of hematoma in the right frontal lobe. No foreign body was observed in the cranium. On 3D CTA, the major cerebral vessels were found to be intact. An urgent surgery was first performed by neurosurgeons and subsequently by ophthalmologists. The periosteum was left on the skull. A frontal periosteal, a right temporal fascial, and a right temporal muscular flap were prepared. After debridement and irrigation, the dural tear was closed with the right periosteal and fascial flaps. Finally, the frontal fascia was used to cover the orbital defect. The patient's clinical course was favorable. The patient was able to walk when discharged 46 days after the surgery. A penetrating brain injury through the orbit is rare, and its treatment is not established. A key to successful management of this injury is immediate assessment. Foreign bodies in the cranium, especially metal, should be checked for immediately. The cerebral vessels should also be evaluated. Usually, a surgical intervention is necessary. Since bone reconstruction can be associated with a risk of infection, a multi-layered closure, as described in this report, could prevent leakage of cerebrospinal fluid and subsequent meningitis.

Large volume inside the cage leading incomplete interbody bone fusion and residual back pain after posterior lumbar interbody fusion.

The purpose of this study is to compare intervertebral bone fusion and clinical outcomes in L4-5 posterior lumbar interbody fusion (PLIF) using the same posterior instrumentation with four combinations of one of three types of interbody cage with one of two bone grafts, iliac and local or only local. In 67 patients who underwent L4-5 PLIF, 19 patients had the Brantigan cage and iliac and local bone graft, 18 with the TELAMON C cage and iliac and local bone graft, 16 with the TELAMON C cage and local bone graft (TL), and 14 with the OIC PEEK cage and local bone graft. Clinical assessments were based on Japanese Orthopaedic Association (JOA) scores and on the visual analogue scale (VAS). The bone fusion assessments were based on radiography and CT scans according to the Brantigan, Steffee, and Fraser criteria. More than 2 years after surgery, these assessments were made. In the results, the fusion outcome for the group receiving TL was significantly less than those for the other three groups. In TL, multivariate logistic regression analysis showed that the inside volume of the cage of ≥2.0 mL was the only significant factor for incomplete fusion. Moreover, the VAS (low back pain) score was significantly higher for TL than for the other three groups. In conclusions, we believe that the large volume inside the cage (≥2.0 mL) with local bone graft may lead incomplete interbody bone fusion and residual postsurgical low back pain after PLIF.

Diagnostic accuracy of multifidus muscle spontaneous activity by needle electromyography for the detection of lumbar foraminal and lateral exit-zone stenosis.

PURPOSE: The medial branch of the posterior ramus of the lumbar spinal nerve is well known to be innervated independently and to end in the multifidus muscle without anastomosis. This prospective cohort study aimed to determine the diagnostic specificity and sensitivity of multifidus muscle denervation (MMD) by needle electromyography (N-EMG) for lumbar foraminal and lateral exit-zone stenosis (LF/LEZS). METHODS: We enrolled 61 consecutive patients experiencing unilateral dysesthesia and/or leg pain in the L4 or L5 regions with suspicious LF/LEZS. The Japanese Orthopedic Association (JOA) score, Visual Analog Scale (VAS) for leg pain, and N-EMG were examined. In this study protocol, all patients received at least 3 months of conservative therapy. Surgery was performed on patients who experienced less than 50% VAS pain relief compared with their initial score after confirming the responsible level by lumbar nerve root block. The specificity of N-EMG was the proportion of patients who improved with conservative therapies (non-surgery) after 3 months. The sensitivity of N-EMG was the proportion of patients who improved with surgical therapies (surgery) after more than 12 months. RESULTS: Twenty-three patients underwent surgery. The initial lower JOA, positive Kemp test and motor weakness were significantly higher in the surgery group. The MMD by N-EMG indicated that 34 of 38 patients were negative in the non-surgery group. In the surgery group, 21 of 23 patients were positive. The diagnostic sensitivity and specificity were 91.3 and 92.1%, respectively. CONCLUSIONS: Needle electromyography is a simple and available additional method for the diagnosis of LF/LEZS.

Expression of suppressor of cytokine signaling 3 in cerebrospinal fluid after subarachnoid hemorrhage.

BACKGROUND: IL-6 is a proinflammatory cytokine reported to play an important role in the induction of cerebral vasospasm after subarachnoid hemorrhage (SAH). Suppressor of cytokine signaling 3 (SOCS3) is known to act as an inhibitor of signal transduction of IL-6. However, there have been no reports on the expression of SOCS3 in cerebrospinal fluid (CSF) after SAH. FINDINGS: The concentration of IL-6 was measured serially up until day 10, in CSF of eight patients with SAH. CSF samples obtained from patients suffering from an unruptured aneurysm were used as controls. The expression of SOCS3 in CSF was further examined by immunoprecipitation methods. Concentrations of IL-6 in CSF increased immediately after the onset of SAH and remained chronically elevated over control values. SOCS3 was significantly expressed in CSF on days 1 to 3 after SAH. CONCLUSIONS: Our findings suggest that SOCS3 regulates IL-6 signaling as an antagonist in CSF, immediately following SAH. As the expression of SOCS3 decreases after day 5, IL-6 signals might then be more easily transmitted, presumably resulting in cerebral vasospasm.

Vertebral artery variations and osseous anomaly at the C1-2 level diagnosed by 3D CT angiography in normal subjects.

INTRODUCTION: The craniovertebral junction is anatomically complicated. Representative vertebral artery (VA) variations include the persistent first intersegmental artery (FIA), fenestration of the VA above and below C1 (FEN), posterior inferior cerebellar artery (PICA) from C1/2, and high-riding VA (HRVA). The ponticulus posticus (PP) is a well-known osseous anomaly at C1. Although those anomalies are frequent in patients with cervical deformity, the prevalence of these in subjects with normal cervical spines is still unknown. The aim of this study is to investigate the variations and prevalence of vascular and osseous anomalies based on three-dimensional computed tomographic (3D CT) angiography in patients without any cervical diseases, such as rheumatoid arthritis, Klippel-Feil syndrome, or Down syndrome. METHODS: Eligible subjects were patients who underwent 3D CT angiography by the Department of Otorhinolaryngology and Internal Medicine from January 2009 to October 2013 in our institution. The authors defined a HRVA as a C2 pedicle with a maximum diameter of 4 mm or less. RESULTS: Among 480 subjects with a mean age of 63.1 years, 387 patients were eligible. One hundred and eighteen subjects were female, and 269 were male. HRVA was observed in 10.1% of patients (39 out of 387 cases), FIA in 1.8% (7 cases), FEN in 1.3% (5 cases), and PICA in 1.3% (5 cases). PP was observed in 6.2% of patients (24 cases). CONCLUSION: According to past reports, many VA anomalies could be attributed to congenital or acquired conditions (e.g., rheumatoid arthritis). However, VA anomalies appear to exist even in patients without any such cervical diseases.

The surgical treatment method for an adult posttraumatic thoracolumbar kyphosis patient with osteogenesis imperfecta.

Osteogenesis imperfecta (OI) is an inheritable bone disorder characterized by osseous fragility and ligamentous laxity. It is sometimes difficult to obtain bone union in patients with OI. The purpose of this report is to present a rare case of posttraumatic kyphosis due to a L1 burst fracture in a patient with OI, and to discuss how to treat it to achieve an adequate correction and circumferential fusion. The patient was a 29-year-old man with OI (Sillence type-IA) who had sustained an L1 fracture when he dived head first into a river. After 3 months of conservative therapy with a body cast, he showed disability at work because of his persistent low back pain and fatigue in his whole back. He showed no neurological disorder. Diagnostic imaging revealed localized kyphotic deformity at L1. Therefore, lumbar lordosis and thoracic kyphosis worsened. Anterior release and fusion, and posterior fusion were conducted. Three months after surgical treatment, circumferential fusion was obtained. His low back pain and fatigue in the whole back disappeared, and he could resume work without any difficulty. From the bone union standpoint, the surgical strategy for spinal correction in OI patients is still controversial because of the intractableness of bone union and fragility of the bone itself. The authors achieved circumferential union using anterior fusion and posterior fusion, in which wide bone bed is available owing to spared posterior elements of the spinal column.

Comparative Study of Surgical Outcomes of Occipitocervical and Atlantoaxial Fusion for Retro-Odontoid Pseudotumor.

OBJECTIVE: To compare the surgical and radiographic outcomes of occipitocervical fusion (OCF) with those of atlantoaxial fusion (AAF) in patients with cervical myelopathy caused by retroodontoid pseudotumors (ROPs). METHODS: This retrospective, comparative study included 26 patients; 12 underwent occipitocervical fusion (OCF) (group O) and 14 retroodontoid pseudotumor (AAF) (group A) with a minimum 2-year follow-up. Neurologic outcomes were evaluated using the Japanese Orthopedic Association (JOA) score. Radiologic assessment included the maximum anteroposterior (AP) diameter of the anteroposterior-retroodontoid pseudotumor (AP-ROP), C2-7 angle, O-C2 angle, C1-2 angle, atlantodental interval (ADI), range of motion (ROM) of the ADI, C2-C7 sagittal vertical axis (C2-7 SVA), and T1 slope. Global spinal alignments (pelvic incidence [PI] minus lumbar lordosis [LL] [PI-LL], pelvic tilt, sacral slope, and C7 sagittal vertical axis) were also compared between the groups. RESULTS: Both groups had equally good clinical outcomes with equal complication rates. Three patients had a three-level fusion, 5 cases had a four-level fusion, and 4 cases had more than five-level fusion in group O. All cases had a single-level fusion in group A. Surgical time was significantly shorter in group A. AP-ROP was significantly downsized postoperatively in both groups and was more prominent in group O. C2-7 SVA was significantly increased and C2-7A ROM was significantly reduced in group O at the final follow-up. The PI-LL showed a significant increase in group O at the final follow-up. CONCLUSIONS: Although OCF and AAF were similarly effective for cervical myelopathy with ROP, AAF was less invasive, and spinal alignment was better maintained postoperatively in AAF than OCF.

Surgical Outcomes of Common Peroneal Nerve Entrapment Neuropathy Associated with L5 Radiculopathy.

Impingement of the common peroneal nerve, a branch of the L5 nerve root, causes common peroneal nerve entrapment neuropathy (CPNE). Although there are cases of CPNE associated with L5 radiculopathy, surgical intervention's effectiveness remains to be elucidated. This retrospective case-control study aimed to evaluate the efficacy of surgery in patients with CPNE associated with L5 radiculopathy. Twenty-two patients (25 limbs) with surgically treated CPNE between 2015 and 2022 were retrospectively reviewed. The limbs were classified into two groups: group R (limbs of CPNE associated with L5 radiculopathy) and group O (limbs of CPNE without L5 radiculopathy). The durations from onset to surgery, the nerve conduction studies (NCSs), and postoperative improvement rates for motor weakness, pain, and dysesthesia were compared between the groups. Group R included 15 limbs (13 patients), and group O included 10 limbs (9 patients). There were no significant differences in the duration from onset to surgery or abnormal findings of NCS between the two groups. The postoperative improvement rates were 88% and 100% (p = 0.62) for muscle weakness, 87% and 80% (p = 0.53) for pain, and 71% and 56% (p = 0.37) for dysesthesia in group R and group O, respectively, without significant differences between groups. CPNE associated with L5 radiculopathy is common, and the results of the present study showed that the surgical outcomes in such cases were satisfactory and comparable to those in CPNE without L5 radiculopathy.

Comparative Study of Anterior Transvertebral Foraminotomy and Anterior Cervical Discectomy and Fusion for Unilateral Cervical Spondylotic Radiculopathy.

OBJECTIVE: To study the compared surgical and radiographic outcomes of Transvertebral foraminotomy (TVF) with anterior cervical discectomy and fusion (ACDF) in patients with unilateral cervical spondylotic radiculopathy (CSR). METHODS: We performed a retrospective comparative study of 72 consecutive patients with 1- or 2-level CSR treated with ACDF or TVF. 27 patients who underwent TVF (group T) and 45 patients who underwent ACDF (group A) with a minimum 2-year follow-up were enrolled. We evaluated clinical outcomes and radiological assessment. Clinical outcome included Visual analog scale (VAS) scores for axial, arm pain at preoperatively and final follow-up. VAS score for painful swallowing was also evaluated 1 week after surgery. Radiological assessment included C2-7 sagittal Cobb angle (C2-7 CA), range of motion (ROM) of C2-7 CA, the height, angle and ROM of the functional spinal unit (FSU), and tip of the spinous process of the operated segment. We also evaluated the disc height, FSU angle, and ROM of the FSU at the cranial adjacent segment. RESULTS: Both groups had good clinical outcomes. Soft tissue swelling was significantly less prominent in group T than that for group A. VAS scores for painful swallowing is lower in group T without significant difference. The ROM of C2-7 CA, FSU, and spinous processes demonstrated a significant reduction in group A compared with group T.(P < 0.05). Disc height at the cranial adjacent segment was maintained in group T. CONCLUSIONS: TVF is as effective as ACDF for unilateral CSR and preserves whole cervical spine and segmental alignment.