[Treatment for Pyogenic Spondylodiscitis and Spinal Epidural Abscess].

Spontaneous spinal infections, such as pyogenic spondylodiscitis(PSD)and spinal epidural abscess(SEA), are relatively rare, but the number of patients is increasing because of the increase in the older population with chronic comorbidities. Magnetic resonance imaging is the most useful tool for identifying PSD or SEA, with high sensitivity and specificity. Effective antibiotic medication is essential to treat the infection, and selection of antibiotics should be based on not only sensitivity to the causative bacteria, but also ability to penetrate bone tissues. Medication should be continued for at least 6 weeks while monitoring C-reactive protein levels. Surgical treatment is indicated when neurological symptoms or severe spinal instability cannot be managed conservatively. Percutaneous endoscopic surgery enables simultaneous tissue sampling for diagnosis and curative debridement without injury to the spinal supporting tissues. Anterior debridement and interbody fusion(ADIF)with autologous bone grafts have been frequently used for PSD. ADIF can be applied more easily to the lumbar spine using techniques and devices for lateral interbody fusion. Posterior decompression is frequently performed in patients with SEA without severe spinal instability. Percutaneous posterior instrumentation, with or without posterior decompression, is a useful option for PSD, especially in the thoracic spine.

[Standard Techniques of Spinal Fusion for Lumbar Degenerative Diseases].

Recently, many neurospinal surgeons are utilizing spinal fusion techniques for lumbar degenerative diseases. This paper aims to summarize the standard techniques of lumbar spinal fusion. Lumbar spinal fusion is categorized into posterolateral fusion(PLF)and interbody fusion(IF)based on the location of bone grafting. PLF needs wide dissection of paraspinal muscles beyond the synovial joints. It is often utilized for long fusion at the thoraco-lumbar junction with open posterior instrumentation. Techniques for IF include posterior lumbar interbody fusion(PLIF)or transforaminal lumbar interbody fusion(TLIF)via the posterior approach, and anterior lumbar interbody fusion(ALIF), lateral lumbar interbody fusion(LLIF), and oblique lumbar interbody fusion(OLIFTM)performed via the anterior approach. PLIF/TLIF procedures include laminectomy and/or facetectomy for direct neural decompression, and local bone grafting into the interbody space through the interlaminar space or the vertebral foramen. ALIF/LLIF/OLIFTM are usually performed via the retroperitoneal approach. ALIF has an advantage of obtaining lordosis with insertion of a large angled cage from the anterior aspect of the intervertebral space. LLIF/OLIFTM are less invasive methods, in which bone grafting is performed through or beside the psoas muscle. As a larger cage can be plated between the bilateral edge of the intervertebral space, LLIF/OLIFTM has an advantage in the correction of scoliosis.

Psoriasis vulgaris of the skin caused a L3-L4 lumbar epidural spinal abscess.

Background: In a 31-year-old male, psoriasis vulgaris (PV) of the skin caused paraparesis attributed to a L3-L4 epidural spinal abscess that required emergent surgical decompression. Case Description: A 31-year-old male presented with lower back pain and cauda equina compression attributed to a magnetic resonance-documented L34 enhancing lesion consistent with a spinal epidural abscess (SEA). The skin over the L3-L4 level revealed severe PV that proved to be the likely etiology of the right-sided paraspinal muscle abscess, infected right L3-L4 facet joint, and SEA. At surgery, the foci of infection were excised/decompressed, and cultures grew methicillin-susceptible Staphylococcus aureus. Following surgery, the patient was improved and was treated with appropriate antibiotic therapy. Conclusion: PV caused a L3-L4 epidural spinal abscess and cauda equina compression in a 31-year-old male who was successfully treated with operative decompression and appropriate antibiotic management.

Technique for Recanalization of Sheath Introducer Occlusion due to Captured Thrombus during Mechanical Thrombectomy for Acute Ischemic Stroke: A Technical Note.

Objective: Mechanical thrombectomy (MT) is the gold standard treatment for acute ischemic stroke. During these interventions, a thrombus frequently obstructs a guiding catheter. The obstructed guiding catheter should be withdrawn before distal embolism occurs; however, albeit infrequently, the thrombus occludes even a sheath introducer (SI). While conventionally new SI placement is required for continuation of treatment, we propose a viable alternative for recanalization of the occluded SI, termed vacuum-assisted delivery of thrombus (VADT), with a clinical report of our cases. The usefulness of this technique was also evaluated in simulation experiments. Case Presentations: The VADT procedure is as follows: 1) insert a peel-away sheath, originally attached to a balloon-guiding catheter (BGC), into the SI to continuously open the hemostatic valve; 2) advance the BGC into the peel-away sheath while applying mechanical aspiration; and 3) remove the peel-away sheath/BGC assembly slowly. In a simulation environment using an artificial thrombus, we repeated the VADT procedure five times and reproducibly achieved SI reopening within only 10-20 seconds. From March 2013 to September 2022, 204 patients were treated with MT at our stroke center and SI occlusion occurred in three patients (1.5%). These events occurred exclusively in patients with extracranial internal carotid artery occlusion. All three patients with SI occlusion underwent successfully thrombus extraction in the SI using the VADT on the first try. Conclusion: The results of clinical experience and simulation experiments strongly support VADT as a reliable option for recanalization of an occluded SI.

Combined C1-2 transarticular screw fixation and C1 laminoplasty with interlaminar bone transplant for retro-odontoid pseudotumor: illustrative case.

BACKGROUND: The surgical treatment for retro-odontoid pseudotumor (ROP) remains controversial. Posterior C1 laminectomy without fixation occasionally leads to postoperative enlargement of ROP. Because its pathogenesis is associated with atlantoaxial instability, atlantoaxial fixation with C1 laminectomy is commonly performed. Atlantoaxial fixation usually includes transarticular fixation and screw-rod fixation. However, these methods have some issues. That is, in transarticular fixation with C1 laminectomy, the bone grafting area is challenging to obtain. In screw-rod fixation with C1 laminectomy, extensive bleeding occurs at times if the lateral atlantoaxial joint is exposed to the transplant bone grafts. OBSERVATIONS: Herein, the authors report a case of ROP treated with combined C1-2 transarticular screw fixation and C1 laminoplasty with interlaminar bone transplant, which can help achieve adequate spinal cord decompression and can simultaneously secure the bone grafting area between the laminae. In addition, the volume of intraoperative blood loss decreased. Postoperative magnetic resonance imaging showed sufficient decompression of the spinal cord at the C1 level, and computed tomography performed after 6 months revealed bone union between the C1 and C2 laminae. LESSONS: Combined C1-2 transarticular screw fixation and C1 laminoplasty with interlaminar bone transplant is a useful method for ROP.

Diffuse Idiopathic Skeletal Hyperostosis with Severely Displaced Spine Fracture Managed with Posterior Approach Alone: Case Reports and Literature Review.

Diffuse idiopathic skeletal hyperostosis (DISH) is a condition in which minor trauma can cause extremely unstable vertebral fractures. Spinal fractures associated with DISH are prone to instability due to the large moment of lever arm and secondary neurological deterioration; hence, surgical internal fixation is considered necessary. On the other hand, some reports suggest that patients with DISH have a high osteogenic potential. In this report, we describe three patients with DISH. These patients had spinal injuries that resulted in a large gap, for which anterior fixation with bone graft would generally be considered due to comminuted fractures. However, we achieved good bony fusion with posterior fixation alone, without forcible correction.

Case of Syringomyelia Associated with Ossified Yellow Ligament and Arachnoid Web.

Syringomyelia is often associated with Chiari malformation, trauma, infection, and spinal cord tumor. Although they are relatively rare diseases, arachnoid cysts and its related pathology, "arachnoid web" can sometimes lead to syrinx formation at the thoracic vertebral level. However, syrinx formation caused by degenerative spinal disorders, particularly at the thoracic vertebral levels, has rarely been reported. Herein, we present a case of syringomyelia with thoracic ossified yellow ligament (OYL) in a 79-year-old man, who underwent initial posterior decompression followed by arachnoid web removal. Posterior decompression via laminectomy of thoracic vertebra 2 and removal of the OYL improved the syrinx partially, but dorsal indentation of the spinal cord and a remnant syrinx were observed in post-operative magnetic resonance images, subsequent to the second surgery's successful removal of the arachnoid web, which had dorsally compressed the spinal cord. After the second operation, the syrinx shrunk further, and the patient could walk independently at 5 months after the operations. In our case, both the OYL and arachnoid web were responsible for syrinx formation. Therefore, the coincidence of degenerative vertebral diseases with a syrinx might indicate the coexistence of an underlying lesion. Furthermore, the arachnoid web in this case might have formed due to the denaturation of the arachnoid cyst triggered by the OYL.

Lateral Lumbar Interbody Fusion Using Bone Graft Substitute for Lumbar Vertebral Fracture Associated Radiculopathy.

This study aims to present our surgical technique of lateral lumbar interbody fusion (LLIF) without corpectomy for lumbar vertebral fracture (LVF) associated radiculopathy. This study includes three patients treated with LLIF (mean age of 77.3 years, Group L) and three patients treated with PLIF (mean age of 75.7 years, Group P) to compare the surgical outcomes. The cartilage on the fractured vertebrae was aggressively resected with attention to avoid injury to the ring apophysis. The central cavity of the fractured endplate was filled with a bone graft substitute made of hydroxyapatite and collagen composite, followed by interbody fusion achieved by utilizing of a cage with sufficient length spanning the bilateral edges of the fractured vertebra. PLIF was performed with a standard technique using two interbody cages, and vertebroplasty was combined in one patient. Comparing to PLIF, LLIF could be performed with less estimated blood loss in shorter surgical time. Local kyphotic angle improved in all cases of Group L immediately after the surgery, but correction loss was observed at the final examination. The lordotic angle was lost in Group P postoperatively. Arthrodesis was achieved in all the cases. The mean VAS score for leg pain was 85.3 mm in Group L and 82.0 mm in Group P at preoperation and decreased to 8.7 mm and 11.3 mm, respectively, at postoperation. LLIF is an effective surgical option that enables stabilization of the fractured vertebra and reduces radicular pain by indirect neural decompression.

Atlantoaxial Intradural Synovial Cyst Mimicking an Extradural Lesion Adjacent to a Retro-odontoid Pseudotumor: A Case Report.

Atlantoaxial synovial cysts can very rarely penetrate the dura mater into the thecal sac and cause direct neural compression. Several case reports have been available on "intradural synovial cysts" (IDSCs). In this study, we report on a case with an atlantoaxial IDSC mimicking an extradural lesion. A 90-year-old man was diagnosed with a cystic lesion located laterally to the atlantoaxial joint adjacent to the retro-odontoid pseudotumor (ROP) causing cervical spinal cord compression. Thus, surgical removal was planned. On preoperative examination, the cyst, which had a two-layer structure showing a T2-isointense small mass inside a T2-hyperintense lesion, was thought to be located in the extradural region. However, operative findings showed that the cyst was located inside the dura mater. Histopathological examination suggested a synovial cyst. No recurrence of the cyst was observed until the latest follow-up after 3 years, and the ROP decreased in size. Almost all IDSCs reported previously were observed in the medial site of the atlantoaxial joint. In our case, however, the cyst was observed adjacent to the posteromedial site of the right atlantoaxial joint and the ROP, mimicking an extradural lesion. We had no knowledge regarding the IDSC before the surgery and assumed an extradural lesion. Albeit rare, the existence of such a condition should be considered.

Vertebral Endplate Cyst Formation in Relation to Properties of Interbody Cages.

OBJECTIVE: This retrospective study aimed to compare vertebral endplate cyst formation (VECF), an early predictor for pseudoarthrosis, in different types of interbody cages. METHODS: We reviewed 84 cases treated with single-level posterior/transforaminal lumbar interbody fusion. We utilized a polyetheretherketone cage in 20 cases (group P), a titanium cage in 16 cases (group Ti), a titanium-coating polyetheretherketone cage in 13 cases (group TiP) and a porous tantalum cage in 35 cases (group Tn). VECF was evaluated comparing the computed tomography scans taken at day 0 and 6-month postoperation. We defined VECF (+) as enlargement of a pre-existing cyst or de novo formation of a cyst with the diameter over 2 mm. We calculated the adjusted odds ratio (OR) and 95% confidence intervals (CIs) as an indicator of association between different types of cages and VECF using a logistic regression model. RESULTS: VECF was observed in 13 (65%), 7 (44%), 9 (69%), and 8 (23%) cases in groups P, Ti, TiP and Tn, respectively. VECF correlated with the type of cage (p = 0.04). In comparison with group P, the proportion of VECF (+) cases was lower in group Tn (OR, 0.16; 95% CI, 0.04-0.60) but not different in group Ti (OR, 0.47; 95% CI, 0.10-2.20) and group TiP (OR, 1.06; 95% CI, 0.21-5.28). No patient underwent additional surgery for the fused spinal level during the follow-up periods (average, 37.9 months; range, 6-76 months). CONCLUSION: VECF was the least in the porous Tn cage, suggesting its potential superiority for initial stability.

[Lateral fenestration combined with spinal canal decompression through contralateral laminotomy for radiculopathy caused by lumbar canal stenosis and lumbar foraminal stenosis: a case report].

Lumbar canal stenosis (LCS) and lumbar foraminal stenosis (LFS) are frequently observed in elder patients. For patients with radiculopathy caused by both LCS and LFS, surgical manipulations require nerve root decompression from its exit zone to the lateral part of the vertebral foramen, and often need spinal instrumentation. In the present report, we performed a new strategy of surgical decompression without spinal fixation. An 81-year-old woman suffered from bilateral buttock pain, left leg pain and right leg numbness in the L4 and L5 nerve root distribution. MRI and CT scans showed LCS at L3-5 levels and left LFS at L4-5 level. Although the L5 radiculopathy diminished with conservative treatment for 3 weeks, she could not walk due to residual L4 radiculopathy. We tried to perform surgical decompression as follows; the left L4 nerve root was decompressed by lateral fenestration on the left L4 lamina and simultaneously by bilateral spinal canal decompression through right laminotomy for LCS. This method can achieve decompression of the left L4 nerve root from the spinal canal to the vertebral foramen under direct observation while preserving the continuity of the lamina. The patient was relieved from the radicular pain after the operation, and returned to her previous activity of daily living. One-year after the operation, she was free from the radiculopathy, and radiograms showed no fracture in the preserved left L4 lamina. Lateral fenestration combined with bilateral spinal canal decompression through contralateral laminotomy is potentially a surgical option for radiculopathy caused by both LSC and LFS.

Early Development of Syringomyelia after Spinal Cord Injury: Case Report and Review of the Literature.

We report a case of post-traumatic syringomyelia (PTS), which developed 2 months after spinal cord injury (SCI). A 20-year-old man who was involved in a motorcycle accident sustained a complete SCI resulting from a burst fracture of the T5 vertebral body. He underwent posterior fixation with decompression at another hospital 2 days after the injury. Postoperative imaging suggested that spinal stenosis endured at the T4 level and swelling of the spinal cord above that level. Two months later, he felt dysesthetic pain in his forearms and hands, but the cause of the pain was not examined in detail. Four months after the injury, he presented with motor weakness in the upper extremities. Magnetic resonance imaging (MRI) showed syringomyelia ascending from the T3 level to the C1 level, and he was referred to our hospital immediately. The imaging studies suggested that PTS was caused by congestion of the cerebrospinal fluid (CSF) at the T3 level. The patient was treated with syringosubarachnoid (SS) shunt at the T1-T2 level, whereby neurological symptoms of the upper extremities were immediately relieved. Postoperative MRI showed shrinkage of the syrinx. At the latest follow-up 2 years postoperatively, there was no sign of recurrence. It is noteworthy that PTS potentially occurs in the early phase after severe SCI. We discuss relevant pathology and surgical treatment through a review of previous literature.

[Case with L5 radiculopathy caused by far-out syndrome and lumbar canal stenosis].

Far-out syndrome (FOS) is caused by L5 nerve root entrapment at the L5-S1 extraforaminal area surrounded by the sacral alar and the transverse process. Here, we report a case with right L5 radiculopathy caused by L4-5 lumbar canal stenosis (LCS) and FOS. A 57-year-old man suffered from progressing right sciatica and leg pain in the L5 nerve root distribution. MR images showed canal stenosis and a slight disc herniation at the L4-5 level. He underwent surgical decompression for LCS, but he only obtained partial pain relief. Multiplanner reformatted CT scans showed that the right L5 nerve root was entrapped by the sacral alar and lateral disc bulging at the L5-S1 level. Selective radiculograpy demonstrated L5 nerve root compression in the far-lateral area, and a nerve root block provided temporary pain relief. He received a second operation for decompression of the L5 nerve root in the far-lateral zone by partial removal of the sacral alar and the transverse process. He was relieved completely from pain after the operation. He left our hospital on the 9th postoperative day, and returned to work on the 16th day. Visual analogue scales of pain and numbness were 8.7 and 8.7 respectively at first examination. These scores decreased to 5.5 and 3.7 two months after the first operation for LCS, and to 0 and 0 one month after the second operation for FOS. We recommend that more attention be paid to FOS when patients with L5 radiculopathy are diagnosed.

[Posttraumatic syringomyelia developing soon after spinal cord injury. A case report].

We report a case of posttraumatic syringomyelia (PTS) that developed 10 months after spinal cord injury (SCI), A 46-year-old man was involved in a motorcycle accident, in which he received a severe spinal cord injury due to a burst fracture at the T6 level. The patient underwent posterior fixation without decompression at another hospital, and was transferred to our hospital for rehabilitation. Ten months after the SCI, he complained of back and neck pain caused by bending his head backward. MRI showed syringomyelia shaped like a cone extending from the T6 to the C6 level, enlarged by cerebrospinal fluid (CSF) flow toward the syringomyelia at the T6 level. Pain was relieved by syringosubarachnoid shunt implantation and the syrinx disappeared after the operation. PTS emerging 10 months after spinal cord injury is relatively rare. From the radiological and operative findings, PTS was enlarged by the CSF flow, which was hindered at the T6 level by compression of the vertebral body to the spinal cord. In cases of SCI in patients who undergo posterior fixation with insufficient decompression, close attention to PTS is required in the postoperative follow-up.

Cervical osteogenic degeneration in Japanese professional wrestlers and its relationship to cervical spine injury.

OBJECTIVEThis study aimed to investigate the characteristics of cervical degeneration in Japanese professional wrestlers and its relationship with the risk of cervical spine injury (CSI).METHODSSince 2012, 27 Japanese male wrestlers belonging to a professional wrestling association have undergone periodical medical examinations of the cervical spine. If neurological symptoms were observed in the wrestlers, the resident trainers urged them to undergo a brief examination at the authors' institutions. In addition to this prospective research study, the mechanisms of the CSIs that occurred in 5 wrestlers, including 2 with CSI before 2012 and 3 who were independent from the professional wrestling association, were retrospectively investigated by reviewing the circumstances of the injury and the wrestlers' imaging studies.RESULTSThe mean age of the wrestlers was 36.9 years (range 23-56 years) at the initial examination. An anterior giant ossifying lesion (AGOL) was observed in the anterior aspect of the cervical spine of 11 wrestlers (41%). The AGOLs tended to grow and spread to multiple spinal levels as the wrestlers aged. Of the 12 wrestlers with osteogenic lesions, 10 older than 40 years of age (83%) had an AGOL, which is frequently accompanied by osseous spinal canal stenosis. Two wrestlers presented with spinal cord compression with intramedullary intensity change on MRI. However, during the follow-up period, no spinal cord injury (SCI) occurred in the wrestlers, although thoracolumbar injury occurred in 2 wrestlers during a match. In examining the 5 wrestlers with CSI, the injury occurred at the spinal levels without an AGOL. The most frequent pathology of CSI (60%) was SCI at the spinal level adjacent to the multilevel AGOL.CONCLUSIONSAGOL is a peculiar cervical degeneration of Japanese professional wrestlers, especially in aged wrestlers. The AGOL appears to be a biological reaction to reinforce the anterior aspect of the cervical spine of professional wrestlers, who routinely defend themselves in a flexed neck posture against their opponent. The present results suggest that the risk of CSI is not increased by spinal canal stenosis accompanied by AGOL. Further studies are needed to investigate the relationship between the wrestlers' cervical degeneration and the risk of CSI in more detail.

Adult Case of Atlantoaxial Rotatory Fixation Treated with In Situ Fixation Using an Unusual Posterior Instrumentation Construct.

Atlantoaxial rotatory fixation (AARF) occurs commonly in children who have undergone trauma. It is usually corrected with conservative therapy. In this report, however, the patient was an adult with AARF who was treated surgically. A 64-year-old woman presented with a 1-year history of spastic gait and hand clumsiness. Imaging studies revealed the presence of AARF, os odontoideum, and severe spinal cord compression at that spinal level. As the AARF had not been responded to head traction with a halo device, we decided to treat the patient with in situ posterior fixation. Because the rigid dislocation was present between the atlas and the axis, we were forced to make an unusual instrumentation construct. Neurological symptoms other than hand numbness diminished after the surgery, and arthrodesis was obtained between the occiput and the axis. It should be noted that surgical planning for posterior instrumentation construct is required when rigid AARF is treated surgically.

Report of a familial case of proatlas segmentation abnormality with late clinical onset.

Although proatlas segmentation abnormalities as developmental remnants around the foramen magnum have been reported in postmortem studies, they are rarely documented in a clinical setting. This report details the clinical and radiological characteristics of a rare case of proatlas segmentation abnormalities with clinical onset during the seventh decade of life. This case was suspected to have a familial factor. We also review the literature regarding this condition.

Expression of MAGE-D4, a novel MAGE family antigen, is correlated with tumor-cell proliferation of non-small cell lung cancer.

PURPOSE: MAGE-D4, originally termed MAGE-E1, is a novel MAGE family gene that is expressed at high levels in malignant tumors as compared to normal tissue. The present study was conducted to assess the clinical significance of MAGE-D4 expression in non-small cell lung cancer (NSCLC). EXPERIMENTAL DESIGN: Expression of MAGE-D4 protein was estimated by immunohistochemistry and MAGE-D4 mRNA expression was investigated using quantitative reverse transcription-PCR (RT-PCR). RESULTS: We assessed MAGE-D4 expression in NSCLC tissues and was found to be up-regulated in tumor tissues compared with normal lung tissues (mean MAGE-D4/GAPDH values, 0.035 for tumor tissues and 0.009 for normal lung tissues; p=0.002). However, there was no significant difference in MAGE-D4 expression among different pathological stages. The proliferative activity of tumor cells was significantly higher in high MAGE-D4 tumors (mean proliferative indices, 58.3 for high MAGE-D4 tumor levels and 34.0 for low MAGE-D4 tumor levels; p<0.001). In addition, a high MAGE-D4 expression was more frequently seen in squamous cell carcinoma than in adenocarcinoma (p=0.008), and less frequently in well-differentiated tumors than in moderately to poorly differentiated tumors (p=0.036). There was no difference in the postoperative survival between low and high MAGE-D4 patients (5-year survival rates, 65% and 69%, respectively; p=0.742). CONCLUSIONS: MAGE-D4 plays some roles in tumor cells proliferation in NSCLC, but MAGE-D4 expression status did not provided a prognostic significance.

Microscopic bilateral decompression through unilateral laminotomy for lumbar canal stenosis in patients undergoing hemodialysis.

OBJECT: Microscopic bilateral decompression through a unilateral laminotomy (MBDUL) is a minimally invasive technique used to treat lumbar canal stenosis (LCS). In the present study, MBDUL was performed to treat LCS in eight patients undergoing hemodialysis. METHODS: Surgical outcomes were evaluated using the Japanese Orthopaedic Association (JOA) scale (highest possible score 29). The JOA scale was administered preoperatively, at 1 month and 3 months postoperatively, and at the final follow-up examination. One patient refused to undergo the postoperative assessment after the 1-month examination; the mean follow-up duration of the remaining seven patients was 24 months (range 18-31 months). The mean age at the time of surgery was 62 years (range 48-76 years), and the mean duration of hemodialysis therapy was 21.4 years (range 3-28 years). All patients could walk within 2 days of surgery. The mean angle of the straight leg-raising (SLR) test was 53.8 degrees preoperatively, and this increased to 69.4 degrees postoperatively. Six patients felt enhancement of sciatica or leg pain when performing the SLR test preoperatively, a finding that was absent postoperatively at least until the final follow-up examination. The mean preoperative JOA score was 11.6 (range 4-22), and the score markedly improved to 19.8 (range 15-23) at 1 month and 20.6 (range 16-25) at 3 months. The mean JOA score decreased to 17.1 (range 12-25) at the final follow-up examination, but this decrease was attributed to other physical disorders. CONCLUSIONS: The authors conclude that MBDUL is a safe and effective surgical treatment for patients undergoing hemodialysis who are suffering from LCS.