[Cervical Spine and Spinal Cord Injury:Keys for Diagnosis and Treatment].

Spinal cord injuries are not rare in neurosurgical practice. As cervical spine injuries are frequently associated with head injuries, neurosurgeons have critical roles of immediate evaluation and treatment in an emergency room in Japan. It is crucial to make a correct initial diagnosis and provide appropriate treatment for cervical spine injuries because missed injuries or delayed diagnosis might result in unwarranted neurological sequelae. This paper focuses on tips regarding 1)screening for cervical spine injury in head injury patients, 2)diagnosis and treatment of cranio-vertebral junction injuries, and 3)diagnosis and treatment of acute traumatic central cord syndrome because these conditions are most likely encountered by neurosurgery residents and fellows in their practice.

Early experience of single level full endoscopic posterior cervical foraminotomy and comparison with microscope-assisted open surgery.

BACKGROUND: Posterior cervical foraminotomy (PCF) is one of the standard surgeries for treatment of cervical spondylotic radiculopathy. Full endoscopic application for PCF has recently applied to minimize traumatization of the surgical access. Here we present our early experience of full endoscopic PCF (FEPCF) and compared with results of microscope-assisted open PCF (OPCF) surgery. METHODS: Seven cases of one level FEPCF were carried out during March and November of 2019, and seven cases of previously performed one level OPCF were included for comparison in this study. Operating time, foraminotomy area calculating from postoperative reconstructed 3D-computed tomography (3D-CT) scan, improvement of Oswestry neck disability index (ONDI) at 1 month after surgery, and use of postoperative PRN medication were compared. Mann-Whitney's U-test was used for statistical analysis. RESULTS: Operating time of FEPCF and OPCF was 70.9 and 85.0 min respectively and not statistically different (P=0.37). Foraminotomy area of FEPCF was 51.67 cm2, significantly smaller than that of OPCF of 93.47 cm2 (P=0.025). Improvement of ONDI 1 month after surgery was not significantly different (50.4% for FEPCF and 41.0% for OPCF, P=0.72). Use of postoperative PRN pain medication was significantly less in FEPCF, 0.57 times as compared with OPCF, 8.71 times (P=0.0022). CONCLUSIONS: One level FEPCF is as effective as OPCF in alleviation of radiculopathy related symptoms and requires similar operating time as OPCF. In addition, FEPCF significantly reduces foraminotomy area requires for nerve root decompression, and use of postoperative pain medication compared with OPCF. FEPCF is technically feasible and considered as less invasive treatment options for cervical spondylotic radiculopathy as compared with OPCF.

Double Crush of L5 Spinal Nerve Root due to L4/5 Lateral Recess Stenosis and Bony Spur Formation of Lumbosacral Transitional Vertebra Pseudoarticulation: A Case Report and Review.

We present a case of double-crushed L5 nerve root symptoms caused by inside and outside of the spinal canal with spur formation of the lumbosacral transitional vertebra (LSTV). A 78-year-old man presented with 7-year history of moderate paresis of his toe and left leg pain when walking. Magnetic resonance imaging (MRI) revealed spinal stenosis at the L3/4 and 4/5 spinal levels and he underwent wide fenestration of both levels. Leg pain disappeared and 6-min walk distance (6MWD) improved after surgery, however, the numbness in his toes increased and 6MWD decreased 9 months after surgery. Repeated MR and 3D multiplanar reconstructed computed tomography (CT) images showed extraforaminal impingement of the L5 root by bony spur of the left LSTV. He underwent second decompression surgery of the L5/S via the left sided Wiltse approach, resulting in the improvement of his symptoms. The impingement of L5 spinal nerve root between the transverse process of the fifth lumbar vertebra and the sacral ala is a rare entity of the pathology called "far-out syndrome (FOS)". Especially, the bony spur formation secondary to the anomalous articulation of the LSTV (LSPA) has not been reported. These articulations could be due to severe disc degeneration, following closer distance and contact between the transverse process and the sacral ala. To our knowledge, this is the first report describing a case with this pathology and may be considered in cases of failed back surgery syndromes (FBSS) of the L5 root symptoms.

Prevalence of spinal meningeal cyst in the sacrum.

Spinal meningeal cysts in the sacrum (SMC) are known to be occasionally symptomatic with low back pain as well as leg pain, but no distinct prevalence of this pathological entity including asymptomatic lesions has been described. This prospective study investigated the prevalence of SMCs based on magnetic resonance (MR) myelography in 102 consecutive Japanese women with gynecological problems, who underwent pelvic conventional MR imaging. Ten of 102 patients were suspected of being positive for SMC (9.8%), but pseudo-positive findings were possible. A high probability of positive SMC was found in 7/102 (6.9%). MR myelography was better to detect SMCs than conventional MR imaging. Multiplicity and female preponderance may be other features of SMC. The speculated prevalence of SMCs in Japanese females ranged from 6.9% to 9.8%.

A unique device, the disc space-fitted distraction device, for anterior cervical discectomy and fusion: early clinical and radiological evaluation.

OBJECT: To perform interbody distraction and to obtain spinal curvature correction during anterior cervical discectomy and fusion (ACDF), the authors recently adopted a new stand-alone device, a disc space-fitted distraction device (DFDD). In this preliminary report the authors introduce this unique device and discuss some advantages in terms of short-term clinical and radiological evaluations. METHODS: The most unique aspect of the DFDD is the function of gentle distraction at anterior disc space with maximum lordotic correction of up to 8 degrees while rotating a screw at the front of the device. Additional advantages are related to its configuration such as disc space-matched shape in all dimensions, tapering contour for easy insertion into the disc space, multiple spikes to avoid dislodgment, wider contact area to the vertebral endplate for diminishing sinking process, and sufficient space for accommodation of bone-conductive materials. Twenty-four patients who have been observed more than 12 months after ACDF were involved in this evaluation. RESULTS: The objective clinical outcome, measured by the Neurological Cervical Spine Scale, was significantly improved. In radiological evaluation, statistically significant improvement compared with preoperative values was noted on the curvature index, C2-7 curvature, and disc angle (p < 0.01) throughout the entire postoperative period, up to 12 months. A high fusion rate and remodeling process around the implants were also observed. CONCLUSIONS: The DFDD may have some advantages over other devices-its distraction action, diminished sinking, and early solid bone union resulted in maintaining sufficient correction of the spinal curvature. This corrected spinal curvature may play an important role in preventing progressive adjacent-disc degeneration subsequent to ACDF in the long term.

New titanium spacer for cervical laminoplasty: initial clinical experience. Technical note.

Many commercially available hydroxyapatite (HA) spacers for cervical laminoplasty have been introduced but have disadvantages such as lack of plasticity, easy cracking, and occasional difficulty in fixation by sutures. Here we present the short-term results of a newly designed titanium spacer (Laminoplasty Basket) in open-door cervical laminoplasty, and evaluated clinically and radiologically. The titanium box-shaped spacer with two arms for fixation was easily inserted and fixed into the laminoplasty space with 4-mm or 5-mm length screws after the posterior cervical arch was repositioned for the canal expansion. Twenty-one patients with cervical myelopathy due to spondylosis or ossification of the longitudinal ligament or developmental narrow canal observed for more than 6 months postoperatively were enrolled in this study. The neurological condition of these patients improved from 9.4 points on the Japanese Orthopaedic Association scale preoperatively to 13.5 points at 6 months after surgery. Postoperative radiological evaluation showed no laminar closure or implant failure and cervical spine curvature was maintained. These results seemed to have no significant difference compared with those using HA spacers. This titanium spacer is a potential substitute for conventional HA or other similar devices in cervical laminoplasty.

Spinal epidural cavernous hemangioma in an HIV-positive patient.

BACKGROUND: Spinal epidural cavernous hemangioma is rare. PURPOSE: Here, we report a case of spinal epidural cavernous hemangioma in an HIV-positive patient. STUDY DESIGN: Single case report. METHOD: A 40-year-old known HIV-positive woman presented with a 6-month history of slowly progressive bilateral leg weakness and pain. Neuroimaging showed an epidural mass lesion, which was isointense on T1-WI, hyperintense on T2-WI, and homogenously enhanced with gadolinium diethylenetriamine pentaacetate (Gd-DTPA), from T8 to T10. RESULTS: The patient underwent T8-T10 laminectomy and removal of this lesion. Pathological diagnosis was cavernous hemangioma. CONCLUSION: Although soft-tissue tumors such as Kaposi's sarcoma and lymphomas have been well documented in association with HIV infection, this is the first reported case of spinal epidural cavernous hemangioma. This may be an incidental finding or perhaps a causal relationship exists, suggesting that cavernous hemangioma could be a differential diagnosis of a spine lesion in HIV-positive patients.

Cortical laminar necrosis caused by critically increased intracranial pressure in an infant: case report.

A 3-month-old boy presented with critically elevated intracranial pressure (ICP) due to bilateral subdural hematomas, which resulted in diffuse cortical laminar necrosis, manifesting as a 1-week history of appetite loss, fever, and intermittent seizure. Initial computed tomography revealed bilateral subdural fluid collections. Burr hole drainage was carried out to control the ICP. T(1)-weighted magnetic resonance imaging on day 26 revealed diffuse linear hyperintense lesions, which suggested cortical laminar necrosis. This is an extremely unusual case of cortical laminar necrosis caused by elevated ICP due to subdural hematoma in an infant.

Simulation of sound field in a tissue medium generated by a concave spherically annular transducer.

The concave spherically annular transducer is regarded as a negative and a positive concave spherical transducer, and the spheroidal beam equation is used to simulate the linear and nonlinear sound field in a tissue medium generated by this transducer. It is found that the acoustic focus of the ring does not coincide with the acoustic focus of its central part. If the width of the ring increases, its acoustic focus will move toward the geometric focus and the amplitudes of nonlinear harmonics will increase obviously. If there are several coaxial rings placed on the concave spherical surface, more than one peak will appear along the axial direction for the fundamental, and high harmonics focus better. The distribution of sound field will change with the number and the excited signals of rings, so it maybe is a potential approach to treat locally big tumors.

Role of endothelial NO synthase phosphorylation in cerebrovascular protective effect of recombinant erythropoietin during subarachnoid hemorrhage-induced cerebral vasospasm.

BACKGROUND AND PURPOSE: In the present study, the effect of subarachnoid hemorrhage (SAH) on the phosphorylation of endothelial NO synthase (eNOS) and the ability of recombinant erythropoietin (Epo) to augment this vasodilator mechanism in the spastic arteries were studied. METHODS: Recombinant adenoviral vectors (10(9) plaque-forming units per animal) encoding genes for human Epo (AdEpo), and beta-galactosidase were injected immediately after injection of autologous arterial blood into the cisterna magna (day 0) of rabbits. Cerebral angiography was performed on day 0 and day 2, and basilar arteries were harvested for Western blots, measurement of cGMP levels, and analysis of vasomotor functions. RESULTS: Injection of autologous arterial blood into cisterna magna resulted in significant vasospasm of the basilar arteries. Despite the narrowing of arterial diameter and reduced expression of eNOS, expressions of phosphorylated protein kinase B (Akt) and phosphorylated eNOS were significantly increased in spastic arteries. Gene transfer of AdEpo reversed the vasospasm. AdEpo-transduced basilar arteries demonstrated significant augmentation of the endothelium-dependent relaxations to acetylcholine, whereas the relaxations to an NO donor, 2-(N,N-diethylamino)diazenolate-2-oxide sodium salt, were not affected. Transduction with AdEpo further increased the expression of phosphorylated Akt and eNOS and elevated basal levels of cGMP in the spastic arteries. CONCLUSIONS: Phosphorylation of eNOS appears to be an adaptive mechanism activated during development of vasospasm. The vascular protective effect of Epo against cerebral vasospasm induced by SAH may be mediated in part by phosphorylation of Akt/eNOS.

[Paradoxical worsening of cavernous sinus dural arteriovenous fistula: case report with serial angiograms].

We report, with serial angiograms, a case worsening of dural arteriovenous fistulae (DAVFs) located at the hypoplastic right cavernous sinus and draining into the left superior ophthalmic vein across the inter-cavernous sinus. The patient presented with sudden onset of external ophthalmoplegia and deterioration of visual acuity on the left. An imaging work-up at the day of admission included contrast-enhanced computed tomography and conventional catheter angiography, which demonstrated complete thrombosis of the left cavernous sinus. There was no strong evidence to suggest DAVFs other than small faint opacification of the posterior cavernous sinus on the right at the late arterial phase. For this reason a diagnosis of left cavernous sinus thrombosis was made, followed by aggressive anticoagulation therapy with intravenous administration of antibiotics. Although the patient's eye symptoms improved significantly after the anticoagulation therapy, the follow-up angiogram obtained 5 days after admission demonstrated small right cavernous sinus DAVFs, which drained into the left superior ophthalmic vein. The patient was followed up conservatively at the out-patient clinic. Three-month follow up angiograms demonstrated spontaneous cure of the DAVF. Also noted was a complete recovery of external ophthalmoplegia with significant improvement of left visual acuity. The alternation of clinical and angiographic findings in this case may help to understand the etiology of paradoxical worsening of cavernous sinus DAVF. In selected cases, anticoagulation therapy may help to improve the prognosis of paradoxical worsening.

Expression and function of recombinant S1179D endothelial NO synthase in human pial arteries.

BACKGROUND AND PURPOSE: Mutation of serine 1179 to aspartate on the endothelial NO synthase (eNOS) increases NO production in the absence of stimulation by agonists. The present study was designed to determine the effect of recombinant S1179DeNOS gene expression on the vasomotor function of human pial arteries. METHODS: Pial arteries were isolated from 28 patients undergoing temporal lobectomy for intractable seizures. Adenoviral vectors (10(10) pfu/mL) encoding beta-galactosidase (AdCMVLacZ) or S1179DeNOS (AdCMVS1179DeNOS) were used for ex vivo gene transfer, and vasomotor function was evaluated in control and transduced arteries. RESULTS: Contractions to cumulative additions of U46619 were not affected by expression of LacZ or S1179DeNOS. Endothelium-dependent relaxations to bradykinin or endothelium-independent relaxations to Diethylaminodiazen-1-ium-1,2-dioate were significantly reduced in arteries expressing S1179DeNOS. A superoxide dismutase mimetic, manganese (III) tetrakis (4-benzoic acid) porphyrin chloride, failed to improve the reduced relaxations to bradykinin. The levels of cGMP were significantly elevated in arteries expressing S1179DeNOS. CONCLUSIONS: Our results support the concept that high local production of NO in pial arterial wall causes adaptive reduction of vasodilator reactivity to NO.

Protective effect of chronic vitamin C treatment on endothelial function of apolipoprotein E-deficient mouse carotid artery.

Endothelium-dependent relaxations are impaired in carotid artery of apolipoprotein E-deficient (apoE-/-) mice. This impairment seems to be due to increased formation of superoxide anions and inactivation of endothelial nitric oxide (NO). In the present study, we tested hypothesis that chronic treatment with vitamin C may prevent endothelial dysfunction by increasing release of NO from endothelial cells. C57BL/6 and apoE-/- mice were treated for 26 weeks with Western-type fat diet with and without 1% vitamin C. Vasomotor function of isolated carotid arteries was studied by video dimension analyzer. Expression of endothelial NO synthase (eNOS) and platelet-endothelial cell adhesion molecule-1 (PECAM-1) protein were evaluated by Western blotting. Levels of cGMP and cAMP were measured by radioimmunoassay. In apoE-/- mice, vitamin C significantly augmented relaxations to acetylcholine (10-9-10-5 mol/l), but did not affect relaxations to NO donor diethylammonium-(Z)-1-(N,N-diethylamino) diazen-1-1,2-diolate (DEA-NONOate; 10-9-10-5 mol/l). In contrast, vitamin C reduced relaxations to acetylcholine and DEA-NONOate in C57BL/6 mice. Interestingly, vitamin C significantly increased basal cGMP levels in C57BL/6 mice but did not affect cGMP formation in apoE-/-. Vitamin C treatment did not affect expression of eNOS protein, whereas elevated expression of PECAM-1 protein in apoE-/- mice was returned to normal level. Our findings demonstrate that chronic treatment with vitamin C prevents endothelial dysfunction of carotid artery induced by hypercholesterolemia. This effect seems to be mediated by preservation of NO bioavailability in endothelial cells.

Can transcranial ultrasonication increase recanalization flow with tissue plasminogen activator?

BACKGROUND AND PURPOSE: In thrombolytic therapy for acute ischemic stroke, it is essential to obtain rapid thrombolysis before ischemic neuronal injury occurs. To develop a new technique of thrombolysis for acute ischemic stroke, the effect of transcranially applied ultrasound (TUS) on thrombolysis was examined. METHODS: An occlusion model of rabbit femoral artery was produced with thrombin after establishment of stenotic flow and endothelial damage. After stable occlusion was confirmed, monteplase (mtPA) was administered intravenously, and ultrasound (490 kHz, 0.13 W/cm2) was applied through a piece of temporal bone (TUS group; n=9). The control group received mtPA alone (tissue plasminogen activator [tPA] group; n=12). To verify the efficacy of TUS, femoral artery flow was measured during the procedure. RESULTS: The recanalization ratio was 16.7% (2 of 12) in the tPA group and 66.7% (6 of 9) in the TUS group. The recanalization ratio in the TUS group was higher than that in the tPA group (P=0.03). Patency flow ratio, which was defined as recanalization flow divided by baseline flow, of the TUS group (44.6+/-13.9%) was significantly greater than that of the tPA group (9.9+/-6.8%) at 60 minutes (P=0.025). Patency flow ratio became higher in the TUS group than in the tPA group between 20 and 30 minutes from the start of thrombolysis. CONCLUSIONS: Low-frequency and low-intensity TUS enhanced thrombolysis by mtPA in a rabbit femoral artery occlusion model. This technique should be clinically useful for thrombolysis in acute ischemic stroke.

Expression and function of recombinant S1179D endothelial nitric oxide synthase in canine cerebral arteries.

BACKGROUND AND PURPOSE: Bovine endothelial nitric oxide synthase (eNOS) is phosphorylated directly by the protein kinase Akt at serine 1179. Mutation of this residue to the negatively charged aspartate (S1179DeNOS) increases nitric oxide (NO) production constitutively in the absence of agonist stimulus. The present study was designed to determine the effect of mutant S1179DeNOS gene expression on vasomotor function of canine cerebral arteries. METHODS: Isolated basilar and middle cerebral arteries were exposed ex vivo (30 minutes at 37 degrees C) to an adenoviral vector (10(10) plaque-forming units per milliliter) encoding the S1179DeNOS gene (AdCMVS1179DeNOS), the wild-type eNOS gene (AdCMVeNOS), or the green fluorescent protein (GFP) reporter gene (AdCMVGFP). Twenty-four hours after transduction, arteries were suspended in an organ chamber for isometric force recording, and levels of cGMP were measured by radioimmunoassay. RESULTS: Transgene protein expression was detected mainly in the vascular adventitia. In AdCMVS1179DeNOS-transduced arteries, basal levels of cGMP were significantly elevated compared with those in control (nontransduced), AdCMVGFP-, or AdCMVeNOS-transduced vessels (n=8; P<0.01). The elevation of cGMP was abolished by a NOS inhibitor, N(G)-nitro-L-arginine methyl ester (L-NAME), or by incubation in the calcium-free medium in the presence of calcium chelators. In AdCMVS1179DeNOS-transduced arteries, contractions to endothelin-1 (10(-10) to 10(-8) mol/L) were significantly reduced compared with those in control and AdCMVGFP-transduced arteries (n=7; P<0.05). The vasoconstrictor effect of endothelin-1 was restored in the presence of the NOS inhibitor L-NAME. CONCLUSIONS: Our results suggest that in cerebral arteries, expression of recombinant S1179DeNOS increases basal production of NO and inhibits the vasoconstrictor effect of endothelin-1. This effect may have therapeutic application in prevention and treatment of cerebrovascular diseases.

[A case of falcotentorial meningioma with visual allesthesia].

Visual allesthesia, in which visual images are transposed from one homonymous half-field of visual field to another, is a rare phenomenon. Palinopsia is the persistence or recurrence of visual images after the exciting stimulus object has been removed. Some authors have reported these phenomena, but these pathophysiology has not been understood. We report a right-handed 63-year-old woman, with a right falcotentorial meningioma. She paroxysmally experienced illusory transpositions of objects viewed in the right homonymous visual field into the left, and she recognized her face in it. The illusory images were palinoptic, persisting for up to a few minutes after the real objects were no longer in view. Administration of anticonvulsant medications resulted in the decrease of frequency of this phenomenon. Radiological and surgical findings revealed that the tumor was compressing the very localized visual cortex, especially the Brodmann's area 18 and 19. After resection of the tumor, visual allesthesia and palinopsia completely disappeared. These areas are associated with memory and recognition of visual images as visuopsychic area. This case provides some insight into the mechanisms of this phenomenon, and we consider that it could be caused by seizure activity in this lesion.