The efficacy and safety of decompression with interspinous fixation for lumbar spondylolisthesis when compared with posterior lumbar interbody fusion: A pilot study.

Posterior lumbar interbody fusion (PLIF) is widely used to treat degenerative spondylolisthesis because it provides definitive decompression and fixation. Although it has several advantages, it has some disadvantages and risks, such as paraspinal muscle injury, potential intraoperative bleeding, postoperative pain, hardware failure, subsidence, and medical comorbidity. Lumbar decompressive bilateral laminectomy with interspinous fixation (DLISF) is less invasive and can be used on some patients with PLIF, but this has not been reported. To compare the efficacy and safety of DLISF in the treatment of low-grade lumbar spondylolisthesis with that of PLIF. We retrospectively analyzed the medical records of 81 patients with grade I spondylolisthesis, who had undergone PLIF or DLISF and were followed up for more than 1 year. Surgical outcomes, visual analog scale, radiologic outcomes, including Cobb angle and difference in body translation, and postoperative complications were assessed. Forty-one patients underwent PLIF, whereas 40 underwent DLISF. The operative times were 271.0 ±â€…57.2 and 150.6 ±â€…29.3 minutes for the PLIF and DLISF groups, respectively. The estimated blood loss was significantly higher in the PLIF group versus the DLISF group (290.7 ±â€…232.6 vs 122.2 ±â€…82.7 mL, P < .001). Body translation did not differ significantly between the 2 groups. Overall pain improved during the 1-year follow-up when compared with baseline data. Medical complications were significantly lower in the DLISF group, whereas perioperative complications and hardware issues were higher in the PLIF group. The outcomes of DLISF, which is less invasive, were comparable to PLIF outcomes in patients with low-grade spondylolisthesis. As a salvage technique, DLISF may be a good option when compared with PLIF.

Normal Functional Local Alignment and Segmental Motion at the Thoracolumbar Junction: A Cross-Sectional Study of Healthy Subjects.

OBJECTIVE: Several studies have investigated the mechanical behavior of the thoracolumbar spine. However, finding an accurate reference for the normal functional local alignment and segmental motion (SM) at the thoracolumbar junction (TLJ) is challenging. Therefore, this study aimed to assess age- and sex-related changes and differences in local alignment and SM at the TLJ. METHODS: The study recruited healthy subjects aged 20 to 79 without complaints of back pain. Healthy subjects (60 males and 60 females) with appropriate imaging results were enrolled in the study. The subjects were divided into age groups (20-29, 30-39, 40-49, 50-59, 60-69, and 70-79 years); each group included 10 subjects of each sex. RESULTS: The SM at the TLJ was small but noticeable, and the motion gradually increased toward the lower level of the TLJ, closer to the lumbar region. No significant differences were observed between male and female subjects in any SM measurements at the TLJ. The SM at the TLJ gradually decreased with age, while local kyphosis of TLJ progressed. The results also showed that the thoracolumbar slope value did not change with age and remained at a mean of -12.8 ± 7.2° (P = 0.893). CONCLUSIONS: This study's results provide valuable guidance for appropriate surgical planning and rehabilitation of patients with spinal diseases or trauma. Furthermore, the results can be the basis for categorizing accurate criteria to evaluate the degree of disability after treatment.

Neurenteric cyst of the craniovertebral junction treated to reduce recurrence using different strategies: Two case reports and a literature review.

RATIONALE: Neurenteric cysts are rare benign lesions that are usually located in the lower cervical and upper thoracic spine and extremely rare in the craniovertebral junction. It is generally challenging to completely remove the neurenteric cysts of the craniovertebral junction. We report the cases of 2 patients with neurenteric cyst in the ventral craniovertebral junction managed using different treatment strategies. PATIENT CONCERNS: The first patient was a 64-year-old man. He man was admitted with headache, posterior neck pain, and a tingling sensation in both the forearms. The second patient was a 53-year-old woman. She was admitted with tingling sensations and numbness in both the hands and feet. DIAGNOSES: Cervical spine magnetic resonance imaging showed 2 intradural extramedullary cystic lesions in case 1 and a C2 to C3 intradural extramedullary cystic mass in case 2. INTERVENTIONS AND OUTCOMES: The patient of the case 1 underwent a left C1 to C2 hemi-laminectomy and the cysts were completely removed. Eleven years after the surgery, there was no recurrence. In case 2, we performed a left C2 to C3 hemi-laminectomy and removed only a part of the outer membrane to enable sufficient communication with the surrounding normal subarachnoid space. After removing the cyst wall, the patient underwent C1 to 2 trans articular screw fixation to prevent cervical instability. Ten years after surgery, there was no recurrence of the cyst or new lesions. LESSONS: Clinicians should consider neurenteric cyst in the differential diagnosis of arachnoid cyst or epidermoid cyst. If performing a complete surgical removal is difficult, partial surgical removal, using a cysto-subarachnoid shunt and stabilization, such as screw fixation, could be an alternative treatment option to reduce the risk of mortality and morbidity.

Iatrogenic atlantoaxial rotatory subluxation after thyroidectomy in a pediatric patient: A case report.

BACKGROUND: Atlantoaxial rotatory subluxation (AARS) is an uncommon disease with a greater prevalence among children than adults, and it is mostly associated with trauma. Iatrogenic spinal injury accounts for a low percentage of injuries. However, in AARS, 20%-40% of cases are associated with surgery, and 48% are caused by infection. Here, we describe our experience with a case of iatrogenic AARS after general anesthesia. CASE SUMMARY: A 12-year-old girl presented with right-sided torticollis and cervical motion limit. The patient had undergone thyroidectomy 2 mo ago. Computed tomography revealed AARS with bilateral locked facets. Following the failure of repeated external reduction under general anesthesia, the patient underwent an open surgical reduction. The patient gained atlantoaxial alignment without any complications. Follow-up radiographs showed a normal appearance without instability. The cervical spine of children is more predisposed to injury due to anatomical and biomechanical differences. AARS secondary to infection and surgery is known as Grisel's syndrome, which involves non-traumatic AARS. Several cases of AARS after surgery and other procedures with no evidence of inflammation have been reported. Our experience shows that surgery requiring hyperextension of the neck after general anesthesia should also be included as a risk factor. CONCLUSION: Surgeons and anesthesiologists should be careful not to excessively extend the neck during pediatric surgery. Moreover, clinicians caring for pediatric patients with recent head and neck procedures must be aware of common AARS presentations.

Occipital artery bypass importance in unsuitable superficial temporal artery: Two case reports.

BACKGROUND: Superficial temporal artery-middle cerebral artery (STA-MCA) bypass helps treat cerebral ischemia. However, the STA is not available for bypass in some conditions. Therefore, with some technical tips, the authors introduced a bypass technique using the occipital artery (OA). CASE SUMMARY: Two female patients complained of hemiparesis. Brain magnetic resonance imaging (MRI) indicated contralateral infarction from the MCA steno-occlusion. On Diamox single photon emission computed tomography or perfusion MRI, the contralateral front parietotemporal reserve was diminished. On transfemoral cerebral angiography, the STA was thin with a weak flow; however, the OA was prominent. Direct OA-MCA end-to-side extracranial-intracranial bypass surgery was implemented instead of STA because the caliber was too narrow. The postoperative course was uneventful in both cases, with well-maintained bypass patency and neurological stability during follow-up. CONCLUSION: OA might be an acceptable alternative for MCA cerebral ischemic cases with an unsuitable STA.

Minimally invasive fibrinolytic treatment and drainage in patients with acute subdural hemorrhage and underlying comorbidities.

The incidence of acute subdural hemorrhage (ASDH), which is often caused by head trauma, is steadily increasing due to an increase in the elderly population and the use of anticoagulants. Urgent surgical treatment is recommended if the patient has impaired consciousness, worsening neurological symptoms, or brain midline shift (MLS) due to large hematomas on brain computed tomography (CT). Although large craniotomy is traditionally recommended for ASDH removal, old age, comorbidities, and antiplatelet drugs are considered risk factors for surgical complications, many neurosurgeons hesitate to perform aggressive surgical procedures in these patients. In this study, we introduced a method that can quickly and effectively remove ASDH without general anesthesia. We retrospectively reviewed 11 cases of patients with ASDH who underwent hematoma drainage between June 2019 and December 2020. We measured the maximum subdural hematoma thickness and MLS on brain CT of patients and recorded the Glasgow Coma Scale scores before and after the surgical procedure. All patients had multiple comorbidities, and seven patients received anticoagulant or antiplatelet therapy. On initial brain CT, the median subdural hemorrhage thickness was 21.36 mm, median MLS was 10.09 mm, and mean volume of the subdural hematoma was 163.64 mL. The mean evacuation rate of the subdural hematoma after drainage was 83.57%. There was no rebleeding or operation-related infection during the aspiration procedure, and the median MLS correction after the procedure was 7.0 mm. Our treatment strategies can be a reliable, less invasive, and alternative treatment option for patients at high risk of complications due to general anesthesia or patients who are reluctant to undergo a large craniotomy due to a high bleeding tendency.

Spontaneous regression of colloid cyst on the third ventricle: a case report with the review of the literature.

BACKGROUND: Colloid cyst (CC) is a rare and benign cyst found in the third ventricle near the foramen of Monro. Although the role of surgical resection is well established in symptomatic large-sized CC, it remains debatable whether surgical removal of CC with no symptoms or minimal symptoms is necessary. CASE PRESENTATION: A 49-year-old male patient visited our institute for incidentally detected intracranial mass. MRI demonstrated typical, 12 mm-sized CC located in the third ventricle. It was noticed that the cyst spontaneously decreased in size from 12 mm to 4 mm on MRI at 18 months after the first visit. CONCLUSION: Although spontaneous regression is a very rare phenomenon in CC, regular imaging study and frequent neurologic examination can be an alternative option for well-selected, asymptomatic cases.

Vertical split fracture of the vertebral body following oblique lumbar interbody fusion: A case report.

RATIONALE: Oblique lumbar interbody fusion (OLIF) is an effective and safe surgical technique widely used for treating spondylolisthesis; however, its use is controversial because of several associated complications, including endplate injury. We report a rare vertebral body fracture following OLIF in a patient with poor bone quality. PATIENT CONCERNS: A 72-year-old male patient visited our clinic for 2 years with lower back pain, leg radiating pain, and intermittent neurogenic claudication. DIAGNOSES: Lumbar magnetic resonance imaging revealed L4-5 stenosis. INTERVENTION: We performed OLIF with percutaneous pedicle screw fixation and L4 subtotal decompressive laminectomy. We resected the anterior longitudinal ligament partially for anterior column release and inserted a huge cage to maximize segmental lordosis. No complications during and after the operation were observed. Further, the radiating pain and back pain improved, and the patient was discharged. Two weeks after the operation, the patient visited the outpatient department complaining of sudden recurred pain, which occurred while going to the bathroom. Radiography and computed tomography revealed a split fracture of the L5 body and an anterior cage displacement. In revision of OLIF, we removed the dislocated cage and filled the bone cement between the anterior longitudinal ligament and empty disc space. Further, we performed posterior lumbar interbody fusion L4-5, and the screw was extended to S1. OUTCOMES: After the second surgery, back pain and radiating pain in the left leg improved, and he was discharged without complications. LESSON: In this case, owing to insufficient intervertebral space during L4-5 OLIF, a huge cage was used to achieve sufficient segmental lordosis after anterior column release, but a vertebral body coronal fracture occurred. In patients with poor bone quality and less flexibility, a huge cage and over-distraction could cause a vertebral fracture; hence, selecting an appropriate cage or considering a posterior approach is recommended.

The Tumor Control According to Radiation Dose of Gamma Knife Radiosurgery for Small and Medium-Sized Brain Metastases from Non-Small Cell Lung Cancer.

OBJECTIVE: The effectiveness of gamma knife radiosurgery (GKR) in the treatment of brain metastases is well established. The aim of this study was to evaluate the efficacy and safety of maximizing the radiation dose in GKR and the factors influencing tumor control in cases of small and medium-sized brain metastases from non-small cell lung cancer (NSCLC). METHODS: We analyzed 230 metastatic brain tumors less than 5 mL in volume in 146 patients with NSCLC who underwent GKR. The patients had no previous radiation therapy for brain metastases. The pathologies of the tumors were adenocarcinoma (n=207), squamous cell carcinoma (n=18), and others (n=5). The radiation doses were classified as 18, 20, 22, and 24 Gy, and based on the tumor volume, the tumors were categorized as follows : small-sized (less than 1 mL) and medium-sized (1-3 and 3-5 mL). The progression-free survival (PFS) of the individual 230 tumors and 146 brain metastases was evaluated after GKR depending on the pathology, Eastern Cooperative Oncology Group (ECOG) performance score (PS), tumor volume, radiation dose, and anti-cancer regimens. The radiotoxicity after GKR was also evaluated. RESULTS: After GKR, the restricted mean PFS of individual 230 tumors at 24 months was 15.6 months (14.0-17.1). In small-sized tumors, as the dose of radiation increased, the tumor control rates tended to increase (p=0.072). In medium-sized tumors, there was no statistically difference in PFS with an increase of radiation dose (p=0.783). On univariate analyses, a statistically significant increase in PFS was associated with adenocarcinomas (p=0.001), tumors with ECOG PS 0 (p=0.005), small-sized tumors (p=0.003), radiation dose of 24 Gy (p=0.014), synchronous lesions (p=0.002), and targeted therapy (p=0.004). On multivariate analyses, an improved PFS was seen with targeted therapy (hazard ratio, 0.356; 95% confidence interval, 0.150-0.842; p=0.019). After GKR, the restricted mean PFS of brain at 24 months was 9.8 months (8.5-11.1) in 146 patients, and the pattern of recurrence was mostly distant within the brain (66.4%). The small and medium-sized tumors treated with GKR showed radiotoxicitiy in five out of 230 tumors (2.2%), which were controlled with medical treatment. CONCLUSION: The small-sized tumors were effectively controlled without symptomatic radiation necrosis as the radiation dose was increased up to 24 Gy. The medium-sized tumors showed potential for symptomatic radiation necrosis without signifcant tumor control rate, when greater than 18 Gy. GKR combined targeted therapy improved the tumor control of GKR-treated tumors.

Solitary Fibrous Tumor/Hemangiopericytoma Metastasizes Extracranially, Associated with Altered Expression of WNT5A and MMP9.

Solitary fibrous tumor/hemangiopericytoma (SFT/HPC) is a mesenchymal tumor originating from various soft tissues and meninges, which carries the NAB2-STAT6 fusion gene. Meningeal/intracranial SFT/HPCs (icSFT/HPC) have a poor clinical outcome with metastatic behavior compared to soft tissue/extracranial SFT/HPCs (exSFT/HPC), but the underlying genetic factors are unclear. Differentially expressed genes (DEGs) were analyzed by NanoString nCounter assay using RNA extracted from formalin-fixed paraffin-embedded (FFPE) tissue samples. Additionally, immunohistochemistry (IHC) was performed on 32 cases of exSFT/HPC, 18 cases of icSFT/HPC, and additional recurrent or metastatic cases to verify the findings. Pathway analysis revealed that the WNT signaling pathway was enriched in exSFT/HPC. Analysis of DEGs showed that expression of WNT5A was lower and that of MMP9 was higher in icSFT/HPC than in exSFT/HPC (p = 0.008 and p = 0.035, respectively). IHC showed that WNT5A and CD34 expression was high in exSFT/HPC (p < 0.001, both), while that of MMP9 was high in icSFT/HPC (p = 0.001). Expression of CLDN5 in tumoral vessels was locally decreased in icSFT/HPC (p < 0.001). The results suggested that decreased WNT5A expression, together with increased MMP9 expression, in icSFT/HPC, may affect vascular tightness and prompt tumor cells to metastasize extracranially.

Is the Agricultural Work a Risk Factor for Koreans Elderly Spinal Sagittal Imbalance?

OBJECTIVE: A primary degenerative sagittal imbalance has been considered because of unique lifestyles such as the prolonged crouched posture during agricultural work and performing activities of daily living on the floor. Previous papers have reported that sagittal imbalance disease is often seen distinctly in the farming districts of "oriental" countries such as Korea and Japan. However, this finding was only evaluated with the use of X-ray, and other factors such as magnetic resonance imaging (MRI), muscle volume, compression fracture, and laboratory results were not considered. Thus, using these, we evaluate the agricultural work-associated factors for Korean elderly spinal sagittal imbalance. METHODS: We recruited 103 Korean participants who had a sagittal vertical axis (SVA) of >5 cm in this Korean Elderly Sagittal Imbalance Cohort Study. The following were evaluated : radiological parameters, MRI, compression fracture, vitamin D, parathyroid hormone, C-terminal telopeptide, osteocalcin, bone mineral density and muscle fatty change, muscle volume, and health-related quality of life from patients' survey. Moreover, in this survey, the farmers' annual working hours were investigated. Subsequently, we analyzed the associated factors for spinal sagittal imbalance depending on occupation. RESULTS: A total of 46 participants were farmers, and the others were housewives, sellers, and office workers. The farmer group had more SVA (141 vs. 99 mm, p=0.001) and pelvic tilt (31° vs. 24°, p=0.004) and lesser lumbar lordosis (20° vs. 30°, p=0.009) and thoracic kyphosis (24° vs. 33°, p=0.03) than non-farmer group. A significantly positive correlation was noted between the working hour and SVA in the farmer group (p=0.014). The visual analogue scale score for back pain (8.26 vs. 6.96, p=0.008) and Oswestry Disability Index (23.5 vs. 19.1, p=0.003) in the farmer group were higher than that in the non-farmer group, but the Short Form-36 score was not significantly different between the two groups. The Mini-Mental State Exam score was significantly lower in the farmer group than in the non-farmer group (24.85 vs. 26.98, p=0.002). CONCLUSION: The farmer group had more sagittal imbalance and back pain in proportion to the working hours even though the muscle and bone factors and general laboratory condition were not significantly different between the two groups. These results supported that the long hours spent in the crouched posture while performing agricultural work were a risk factor for severe sagittal imbalance.

Retropharyngeal Granulation: Delayed Complication of Anterior Cervical Diskectomy and Fusion in C2-3.

BACKGROUND: A 26-year-old man presented with acute quadriparesis owing to a traffic accident. A computed tomography scan revealed a hangman fracture and locking of the left facet joint at C2-3. Magnetic resonance imaging showed a high signal change of the spinal cord on T2-weighted image and hemorrhage in the C2-3 level. CASE DESCRIPTION: An emergency closed reduction after anterior cervical diskectomy and fusion were performed for spinal stability and decompression of the dural sac. Five months postoperatively, C1-2-3 posterior wiring using an iliac bone graft with the Brook method was performed due to nonunion of C2-3. After using the posterior cervical approach, the patient began complaining about the difficulty in swallowing. A 5 × 2 × 1-cm-sized posterior pharyngeal wall mass was detected on an endoscopic examination. Despite conservative management, the retropharyngeal mass progressed and dysphagia worsened, so the retropharyngeal wall granulation mass was resected by a laryngologist. Despite removal of the granulation mass, dysphagia and throat discomfort persisted for about 2 years. The plate and screws were removed considering their possible correlation with the granulation tissue. One month after plate removal, the retropharyngeal granulation tissue resolved almost spontaneously. At the last follow-up, the radiologic examination showed well-fused C1-2-3 with good alignment. The patient had no residual neurologic deficits or dysphagia. CONCLUSIONS: Retropharyngeal granulation can occur as a late complication associated with plate fixation after anterior cervical diskectomy and fusion. Recurrent retropharyngeal wall granulation caused by plate irritation might only be resolved after plate and screw removal.

Diverse Ischemic Postconditioning Protocols Affect the Infarction Size in Focal Ischemic Stroke.

OBJECTIVE: Ischemic postconditioning (IPostC), consisted of transient brain ischemia/reperfusion cycles, is considered to have neuroprotective effect. However, there is no best single protocol of IPostC, because varied factors like species tested and characteristics of the tissue may affect the efficacy of IPostC. Thus, we investgated whether different protocols of IPostC affect neuroprotective effects in experimental animal models. MATERIALS AND METHODS: Through occlusion of middle cerebral artery (MCA) with intraluminal suture, stroke was induced in a transient focal ischemia model in mice. We conducted IPostC via brief and repeated MCA occlusion, 2 minutes after reperfusion, followed by different ischemia and reperfusion protocols. After procedure, functional neurological score and histological examination were evaluated. RESULTS: IPostC with different protocols resulted in diverse effects. Among them, a protocol that consists of 3 cycle of IPostC significantly reduced the infarction size 3 days after stroke. CONCLUSION: IPostC was confirmed to reduce infarction size. The effects of IPostC are definitely affected by differences in the protocol used, including the number of cycles, the duration of individual ischemia/reperfusion episode and the entire duration of the IPostC stimuli.