Nonsuture dural repair using polyglycolic acid mesh and fibrin glue: clinical application to spinal surgery.

BACKGROUND: In spinal surgery, repair of the dura is difficult when it is torn or fragile or is ossified as in cases with ossification of posterior longitudinal ligament. We report our experience with a nonsuture dural repair technique in patients undergoing spinal surgery; it uses a dura substitute composed of polyglycolic acid (PGA) mesh and fibrin glue. Here, we report the efficacy and safety of nonsuture duroplasty using PGA mesh and fibrin glue (PGA-fibrin sheet). METHODS: The artificial dura mater is composed of a PGA-fibrin sheet. The dural defect is covered with a patch sprayed with fibrin glue without suturing to the dura mater. We first evaluated this technique in an experimental study by performing water leakage tests. Between May 2001 and January 2005, we used it in 160 spinal surgeries that required intraoperative dura repair. RESULTS: Our preliminary tests showed that the threshold for water pressure without leakage was 161 +/- 42 and 96.5 +/- 32 mm Hg when the unsprayed margin around the perimeter of the patch was 5 and 2 mm, respectively. Of the 160 operated patients, 10 (6.3%) experienced subcutaneous cerebrospinal fluid (CSF) leakage. Of these, 6 required a second operation; in the other 4, the CSF collection diminished spontaneously. There were no other complications such as allergic reaction, adhesion, or infection. CONCLUSION: In combination with CSF diversion, the PGA-fibrin sheet is a viable alternative method for dural repair in spinal surgery.

Ligamentum flavum hematoma in the lumbar spine.

A 62-year-old male presented with a rare case of ligamentum flavum hematoma manifesting as low back pain and gait difficulty beginning 1 month before consulting our institute. He had no history of lumbar spine surgery or lumbar puncture. However, he might have suffered forgotten back injury while practicing martial arts. Magnetic resonance imaging showed a heterogeneous intensity mass lesion with a cystic component at the L3-4 levels. The lesion was totally removed through a hemilaminectomy. Intraoperative and histological findings confirmed the diagnosis of old hematoma with granulomatous change in the ligamentum flavum. Postoperatively, his low back pain and gait difficulty resolved within a few days.

Acute cervical cord injury associated with ossification of the posterior longitudinal ligament.

OBJECTIVE: Patients with ossification of the posterior longitudinal ligament (OPLL) sometimes present with acute spinal cord injury caused by only minor trauma. In the present study, we reviewed our experience of acute cervical cord injury associated with OPLL to understand the pathomechanisms and to provide clinical information for management of this disorder. METHODS: Twenty-eight patients were retrospectively analyzed. There were 26 men and 2 women, aged 45 to 78 years (mean, 63.0 yr). Most patients experienced incomplete spinal cord injury (Frankel Grade A, 3; B, 1; C, 15; and D, 9). RESULTS: Radiological studies revealed continuous- or mixed-type OPLL in 14 patients and segmental-type OPLL in 14 patients. The sagittal diameter of the spinal canal was reduced to 4.1 to 10 mm at the narrowest level as a result of OPLL. Developmental size of the spinal canal was significantly smaller in the group with segmental OPLL. Magnetic resonance imaging scans revealed that spinal cord injury occurred predominantly at the caudal edge of continuous-type OPLL or at the disc levels. Surgery was performed in 24 patients either by posterior (18 patients) or anterior (6 patients) decompression at various time intervals after the trauma. Twenty patients (71%) displayed improvement in Frankel grade. CONCLUSION: The present study demonstrates the preexisting factors and pathomechanisms of acute spinal cord injury associated with cervical OPLL. Magnetic resonance imaging is useful to understand the level and mechanism of injury. Further investigation will be needed to elucidate the role of surgical decompression.

Spinal subdural hematoma: a sequela of a ruptured intracranial aneurysm?

BACKGROUND: A case of spinal subdural hematoma (SSDH) following subarachnoid hemorrhage (SAH) because of a ruptured internal carotid aneurysm is described. Such a case has never been reported. CASE DESCRIPTION: A 52-year-old woman underwent a craniotomy for a ruptured internal carotid aneurysm. A computed tomography scan showed that SAH existed predominantly in the posterior fossa and subdural hematoma beneath the cerebellar tentorium. Intrathecal administration of urokinase, IV administration of fasudil hydrochloride, and continuous cerebrospinal fluid (CSF) evacuation via cisternal drainage were performed as prophylactic treatments for vasospasm. On the sixth postoperative day, the patient complained of severe lower back and buttock pain. Magnetic resonance imaging showed a subdural hematoma in the lumbosacral region. Although the mass effect was extensive, the patient showed no neurologic symptoms other than the sciatica. She was treated conservatively. The hematoma dissolved gradually and had diminished completely 15 weeks later. Her pain gradually subsided, and she was discharged 7 weeks later without any neurologic deficit. CONCLUSION: Although the exact mechanism of SSDH in this case is unclear, we speculate that this SSDH was a hematoma that migrated from the intracranial subdural space. Low CSF pressure because of continuous drainage and intrathecal thrombolytic therapy may have played an important role in the migration of the hematoma through the spinal canal. It is important to recognize the SSDH as a possible complication of the SAH accompanied with intracranial subdural hematoma.

[A case of thoracic disc herniation with sudden onset paraplegia on toilet straining: case report].

Thoracic disc herniation is less common rather than cervical or lumbar herniation. Cases of sudden onset without trauma are especially rare. Generally, the neurological onset of disc herniation is caused by mechanical cord compression due to a protruded disc, and its onset is usually gradual. Ischemia is also considered as a factor of neurological onset. We report a case of a 78-year-old male with sudden paraplegia while straining at the toilet. T2 weighted MR image on admission showed mild disc protrusion at the level of Th8-9 and intramedullary high signal intensity below the Th8-9 level. We speculate that Valsalva-like maneuver had led to the congestion of vertebral venous plexus or compression of the anterior spinal artery, and spinal ischemia occurred.

Clinical and radiographic characteristics of upper lumbar disc herniation: ten-year microsurgical experience.

Upper and lower lumbar disc herniation apparently have different background, symptoms, and operative results. This retrospective study reviewed the clinical records of 403 patients (409 discs) who underwent lumbar microdiscectomy performed by different surgeons at our institute between 1999 and 2009. The 290 male (72.0%) and 113 female (28.0%) patients were aged from 19 to 77 years (mean 44 years). Demographics, symptoms, and static and dynamic radiographic and magnetic resonance images obtained at the L1-2, L2-3, L3-4, L4-5, and L5-S1 intervertebral levels were analyzed. Of the 409 herniations, 3 were at L1-2, 9 at L2-3, 21 at L3-4, 166 at L4-5, and 210 at L5-S1. The mean age at herniation at L1-2 and L2-3 levels was 55.7 years. Patients with herniation of discs at L3-4 or above were significantly older than patients who suffered herniation at L4-5 or below (p < 0.0001), and the incidence of urinary disturbance was significantly higher in patients with herniation at L1-2 and L2-3 levels (p = 0.0013). The incidence of degenerative scoliosis was significantly higher in patients with herniation at L1-2 and L2-3 than in those with herniated discs at L3-4 or below (p < 0.0001). Patients with upper lumbar disc herniation were older and manifested a higher incidence of urinary disturbance. A high incidence of degenerative scoliosis was noted in the course of prolonged degenerative processes.

Detection of residual disc hernia material and confirmation of nerve root decompression at lumbar disc herniation surgery by intraoperative ultrasound.

The aim of lumbar disc herniation surgery is the removal of herniated disc material (HDM) and complete decompression of the nerve root. As some patients present with residual HDM, we examined the ability of intraoperative ultrasound (IOUS) to detect this material. Between February 2006 and June 2007, we used IOUS in 30 patients undergoing surgery for lumbar disc herniation. They were 17 men and 13 women; their ages ranged from 22 to 63 y (mean 44.0 y). The level surgically addressed was L3/4 in 1, L4/5 in 14 and L5/S1 in 15 patients; they were operated in the prone position. After placing a 3-4 cm midline skin incision, partial hemi-semilaminotomy was performed. HDM was removed through a bone window; a surgical microscope was used during the operation. After removal was judged as adequate, IOUS was performed; 17 patients also underwent IOUS before removal of the herniated disc. For the acquisition of IOUS images, we used LOGIQ 9 and 8c microconvex probes (GE Healthcare, Wauwatosa, WI, USA). The normal anatomical structures were well visualized. HDM was iso- to hyperechoic compared with normal nerve tissue. In three of 17 patients, the dural sac and nerve root could not be distinguished from HDM before removal, although in all 30, the decompressed dural sac, intradural cauda equina and nerve root were well visualized. We posit that the echogenicity of nerve tissue was raised due to compression, rendering it similar to that of the herniated disc. In two patients, IOUS detected residual disc material; the surgical procedure was resumed and sufficient removal was accomplished. IOUS monitoring is safe, convenient and inexpensive. It is also highly useful for the detection of residual HDM and the confirmation of adequate nerve root decompression.

Cervical myelopathy by C1 posterior tubercle impingement in a patient with DISH.

STUDY DESIGN: A unique case of a patient with diffuse idiopathic skeletal hyperostosis (DISH) associated with C1 posterior tubercle impingement resulting in spinal canal stenosis and cervical myelopathy. OBJECTIVE: To describe an uncommon mechanism of spinal cord compression in patient with DISH. SUMMARY OF BACKGROUND DATA: The neurologic deficits due to cervical DISH are relatively rare and a few cases of cervical spinal cord compression due to atlantoaxial subluxation, odontoid fracture, pseudotumor, ligamentous hypertrophy, and basilar impression have been reported. To the best of our knowledge, there has been no other report of a patient with DISH causing C1 posterior tubercle impingement and cervical myelopathy. METHODS: A 75-year-old Japanese man, first diagnosed as hyperostosis of anterior and posterior longitudinal ligament 25 years ago, presented with gradual progression of numbness in both lower extremities, disturbed precise hand motion and urinary function. DISH, OPLL, and C1 posterior tubercle impingement was diagnosed by radiograph, CT, and MRI. Hyperintense signal in the C1 spinal cord on T2 weighted sequence was observed. RESULT: Laminectomy from C1-C3 was performed. Myelocompression and myelopathy improved after the surgical intervention. Multilevel fusion of the subaxial cervical spine and increase of the mechanical stress on the craniocervical segment may leads to partial damage of the ligaments and resulted in C1 posterior arch impingement. CONCLUSION: This is the first report of unique C1 posterior tubercle impingement and myelopathy caused by DISH. We should keep it in mind that DISH can cause serious problems in the upper cervical spine even after 25 years of interval.

Long-term follow-up results in patients with cervical disk disease treated by cervical anterior fusion using titanium cage implants.

This study is a retrospective analysis of 146 patients, 85 males and 61 females aged 21-80 years (mean 52 years), with cervical disk disease who underwent anterior fusion and titanium cage implantation with follow-up periods of no less than 72 months after surgery. All patients underwent the conventional anterior cervical approach. After removing the protruded disk and osteophyte, cylindrical titanium cages were placed. Single, two, and three level fusion was performed in 76 (52%), 64 (44%), and 6 (4%) patients, respectively. Functional assessment used the Neurosurgical Cervical Spine Scale (NCSS). The curvature index and range of motion were evaluated pre- and postoperatively. The clinical outcomes were satisfactory and there were no significant complications. The mean NCSS was 9.7 before and 12.7 at 1 year after the operation, and 12.1 at final examination. No postoperative cage extrusion or pseudoarthrosis occurred, but the cages descended in 10 patients (7%) although alignment was satisfactory. At 5 years after the operation, 140 of the 146 patients (96%) had solid fusion. The long-term results of anterior fusion with titanium cage implantation in patients with cervical disk disease were satisfactory. Titanium cage placement is a highly useful alternative to the conventional treatment method in these patients.

Radiculopathy caused by lumbar epidural venous varix: case report.

A 33-year-old man presented with a rare case of lumbar epidural venous varix causing radiculopathy manifesting as sciatica exacerbated during bowel movements. The left straight-leg raising test was positive and patellar tendon reflex was lost. Lumbar magnetic resonance imaging showed a mass lesion in the epidural space at the L4 level just anterior to the dural sac on the left, appearing as hypointense on T(1)- and hyperintense on T(2)-weighted images, with ring-like enhancement with gadopentetate dimeglumine. He underwent surgery under a preoperative diagnosis of cystic nerve sheath tumor. After left hemilaminectomy, intraoperative ultrasonography showed a low echoic mass lesion ventral to the L4 nerve root. The mass was dark blue with a smooth wall. Tearing of the wall resulted in continuous bleeding. After removal of the lesion, we confirmed that the dura of the nerve root was intact. Histological examination of the surgical specimen confirmed venous tissue. The postoperative course was excellent. Lumbar epidural varix is difficult to diagnose preoperatively. Lumbar epidural varix should be considered if the lesion is smaller on preoperative than intraoperative imaging, or disappears with bleeding cessation, as this may avoid unnecessary widening of the operative field. The correct preoperative diagnosis remains difficult, so we recommend surgical removal and histological confirmation.

A new ceramic interspinous process spacer for lumbar spinal canal stenosis.

OBJECTIVE: Because surgery in elderly patients should be minimally invasive, interspinous process distraction has been widely used in this group to treat lumbar canal stenosis. We developed a new interspinous process distraction spacer composed of hydroxyapatite ceramic. In this work, we demonstrate the usefulness of this novel device. METHODS: Since 2003, we operated on 19 elderly patients with lumbar canal stenosis, including 14 men and five women. Their mean age was 70.1 years. We compared the intervertebral angle, posterior disc height, and interspinous process distance on midsagittal magnetic resonance images obtained before and after the surgery. We also assessed clinical outcomes by using the Visual Analog Scale and the Zurich Claudication Questionnaire. RESULTS: The average operation time per level was 44.7 minutes. Postoperatively, there were significant changes in the angle (from 12.5 to 8.6 degrees, P < 0.0001), the posterior disc height (from 10.6 to 13.1 mm, P < 0.0001), and the interspinous process distance (from 9.7 to 14.1 mm, P < 0.0001). The clinical outcomes, which we assessed by using the Visual Analog Scale and the Zurich Claudication Questionnaire, were considered satisfactory. (Visual Analog Scale, from 6.88 to 3.00; Zurich Claudication Questionnaire, symptom severity domain from 2.94 to 1.92, physical function from 2.51 to 1.73.) CONCLUSION: Our ceramic spacer is useful in the treatment of elderly patients with lumbar canal stenosis. Treatment comprises an easy surgical procedure and produces no metal artifact on radiological evaluations, such as magnetic resonance imaging and computed tomographic scans.

Surgical treatment of cervical spondylosis in the elderly: surgical outcomes, risk factors, and complications.

The incidence of cervical spondylosis in the elderly is increasing with the higher proportion of elderly individuals among the Japanese population. The present study retrospectively analyzed the clinical and radiological features of this clinical entity in 107 patients with cervical spondylosis aged 70 years or older surgically treated between 1995 and 2005. The patients were divided into Group 1 (n = 60) aged between 70 and 74 years, and Group 2 (n = 47) 75 years or older. Patients with localized compression within 2 levels responsible for the neurological symptoms underwent anterior fusion, and patients with a narrow spinal canal were treated by laminoplasty. The pre- and postoperative neurological status (Neurosurgical Cervical Spine Scale) and postoperative complications were compared. More patients in Group 2 required laminoplasty but most patients underwent single-level anterior fusion. There was no statistically significant difference in the surgical results. Group 2 had a much higher ratio of anterior fusion at the C3-4 level. Many of the aged patients had multiple risk factors. Surgical decompression for cervical spondylosis is beneficial even in elderly patients. Single-level anterior fusion to treat the lesion most responsible for the symptoms is the least invasive choice. Elderly patients tend to present with multiple risk factors so require careful perioperative management.

A case of pediatric thoracic SCIWORA following minor trauma.

CASE REPORT: A case of spinal cord injury without radiological abnormality (SCIWORA) at the thoracic level is reported. A 14-year-old girl fell backwards from a low chair and hit her back on the floor. It left her bent forward markedly. After taking a nap, she found herself unable to walk. Neurological examination revealed flaccid paraparesis, hypalgesia below the L-1 level, and bladder and bowel dysfunction. MR imaging revealed marked edema in the thoracic spinal cord. RESULTS AND CONCLUSION: The patient was treated conservatively and showed gradual improvement in her symptoms, finally becoming independently ambulant. The spinal cord edema was less pronounced on the follow-up MR imaging. The clinical course and findings of MR imaging in this case demonstrated mid-thoracic SCIWORA caused by hyperflexion of the thoracic spine.

Nicked beta2-glycoprotein I: a marker of cerebral infarct and a novel role in the negative feedback pathway of extrinsic fibrinolysis.

BEta(2)-glycoprotein I (beta(2)-GPI) is proteolytically cleaved by plasmin in domain V (nicked beta(2)-GPI), being unable to bind to phospholipids. This cleavage may occur in vivo and elevated plasma levels of nicked beta(2)-GPI were detected in patients with massive plasmin generation and fibrinolysis turnover. In this study, we report higher prevalence of elevated ratio of nicked beta(2)-GPI against total beta(2)-GPI in patients with ischemic stroke (63%) and healthy subjects with lacunar infarct (27%) when compared to healthy subjects with normal findings on magnetic resonance imaging (8%), suggesting that nicked beta(2)-GPI might have a physiologic role beyond that of its parent molecule in patients with thrombosis. Several inhibitors of extrinsic fibrinolysis are known, but a negative feedback regulator has not been yet documented. We demonstrate that nicked beta(2)-GPI binds to Glu-plasminogen with K(D) of 0.37 x 10(-6) M, presumably mediated by the interaction between the fifth domain of nicked beta(2)-GPI and the fifth kringle domain of Glu-plasminogen. Nicked beta(2)-GPI also suppressed plasmin generation up to 70% in the presence of tissue plasminogen activator, plasminogen, and fibrin. Intact beta(2)-GPI lacks these properties. These data suggest that beta(2)-GPI/plasmin-nicked beta(2)-GPI controls extrinsic fibrinolysis via a negative feedback pathway loop.