Large-Scale Comparative Study Between Microendoscopic Laminectomy and Full-Endoscopic Laminectomy for the Treatment of Single-Level Lumbar Spinal Canal Stenosis.

BACKGROUND: We previously compared the operative outcomes of microendoscopic laminectomy (MEL) and full-endoscopic laminectomy (FEL) for single-level lumbar spinal canal stenosis (LSCS). In this initial report, the operative outcomes of FEL were not inferior to those of MEL. OBJECTIVE: The purpose of this study is to compare the outcomes of MEL and FEL for single-level LSCS on a large scale using widely used multiple evaluation methods. METHODS: MEL was performed using a 16 mm tubular retractor and an endoscope, while FEL was performed using a 6.4 mm working channel endoscope. A retrospective study was performed on patients with LSCS treated with MEL (n = 355) or FEL (n = 154). Patient background and operative data were also collected. The Oswestry Disability Index (ODI), European Quality of Life-5 Dimensions (EQ-5D), and 36-item Short Form Survey (SF-36) scores were recorded preoperatively and 1-year postoperatively. RESULTS: Background data of the two groups and the mean operation time (MEL, 72.1 m; FEL, 74.2 m) were not significant (p>0.2). The mean volumes of intraoperative bleeding (MEL, 25.2 ml; FEL, 10.3 ml) were significantly different (p<0.001). The mean postoperative hospital stays (MEL, 3.9 days; FEL, 2.1 days) were significantly different (p<0.001). Fifteen dural tears (MEL, 11; FEL, 4) and 1 surgical site infection (MEL, 1; FEL, 0) were observed but not significant (p>0.5). Reoperation was required for postoperative hematoma in five patients (MEL, 3; FEL, 2). Although the ODI, EQ-5D, and SF-36 scores improved significantly at one year postoperatively in the MEL and FEL groups (p<0.001), there were no significant differences between the two groups (p>0.1). CONCLUSION: The operative outcomes and minimal invasiveness were no statistical difference between the MEL and FEL groups. Further development of the operative techniques and the instruments of FEL are required to shorten the operation time.

Comparison of the Outcomes of Microendoscopic Cervical Foraminotomy versus Full-endoscopic Cervical Foraminotomy for the Treatment of Cervical Radiculopathy.

This study aimed to compare the outcomes of microendoscopic cervical foraminotomy (MECF) versus full-endoscopic cervical foraminotomy (FECF) for treating cervical radiculopathy (CR).A retrospective study was performed on patients with CR treated using MECF (n = 35) or FECF (n = 89). A 16-mm tubular retractor and endoscope was used for MECF, while a 4.1-mm working channel endoscope was used for FECF. Patient background and operative data were collected. The numerical rating scale (NRS) and the Neck Disability Index scores were recorded preoperatively and at 1 year postoperatively. Postoperative subjective satisfaction was also assessed.Although the NRS, and NDI scores, as well as postoperative satisfaction at 1 year considerably improved in both groups, one of the background data (number of operated vertebral level) was significantly different. Therefore, we separately analyzed single- and two-level CR. In single-level CR, operation time, intraoperative bleeding, postoperative stay, NDI after 1 year, and reoperation rate were statistically superior in FECF group. In two-level CR, the postoperative stay was statistically superior in FECF group. Three postoperative hematomas were observed in the MECF group, while none was observed in the FECF group.Operative outcomes did not significantly differ between groups. We did not observe postoperative hematoma in FECF even without placement of a postoperative drain. Therefore, we recommend FECF as the first option for the treatment of CR as it has a better safety profile and is minimally invasive.

Comparison of the Interlaminar and Transforaminal Approaches for Full-endoscopic Discectomy for the Treatment of L4/5 Lumbar Disc Herniation.

This study aims to compare the outcomes of interlaminar and transforaminal approaches for full-endoscopic discectomy (FED) for treating L4/5 lumbar disc herniation (LDH).A retrospective study of patients with L4/5 LDH treated with interlaminar endoscopic lumbar discectomy (IELD, n = 19) or transforaminal endoscopic lumbar discectomy (TELD, n = 105) was conducted. Patient background, radiological findings, and operative data were collected. Oswestry Disability Index (ODI) and European Quality of Life-5 Dimension (EQ-5D) scores were recorded preoperatively and 1 and 2 years postoperatively.Although ODI and EQ-5D scores 1 and 2 years postoperatively improved statistically in the IELD and TELD groups, there were no statistical differences between the groups. IELD was predominantly performed in patients who were taller and heavier. The mean operative times and the frequency of laminectomy for IELD and TELD were 67.2 and 44.6 min and 63.2 and 17.1%, respectively (P < 0.001). The radiological findings showed that the concave configuration of the L4 lamina, interlaminar space width, and foraminal width were statistically different between the groups. There were no complications in either of the groups. Reoperation was required for recurrence in two and five patients in the IELD and TELD groups (P = 0.29), respectively.Operative outcomes were identical between the two groups. Although the operative time was longer in the IELD group, both approaches were safely and effectively performed. Depending on the patient's physique and preoperative radiological findings, the more suitable approach for L4/5 LDH should be chosen.

Spinal cord infarction six months after thoracic endovascular aortic repair- A case report.

Spinal cord infarction is reported to account for less than 1% of all strokes and is a relatively rare disease. In recent years, thoracic endovascular aortic repair (TEVAR) has become a common treatment for aortic aneurysms, and spinal cord ischemia is one of its complications. Most cases occur in the perioperative period; however, a few cases have been reported in the chronic stage. Here, we report a case of spinal cord infarction, 6 months after TEVAR. A 77-year-old man experienced sudden onset paraparesis following dumbbell exercises and defecation. He had a history of an infectious thoracoabdominal aortic aneurysm treated by TEVAR 6 months prior. Paralysis and disturbance of the thermal pain and tactile sensations of the lower limbs were observed, but proprioception and deep sensation were preserved. Computed tomography (CT) showed no evidence of intraspinal hemorrhage, new aortic dissection, or endoleak around the aortic stent placed from Th11 to L3. Magnetic resonance imaging (MRI) showed intramedullary hyperintensity from Th11 to the conus 2 days after onset. Anticoagulant therapy and rehabilitation were performed, and the lower-limb muscle strength gradually improved. After aortic stenting, particularly including the level of the Adamkiewicz artery, the risk of spinal cord ischemia must be monitored, because spinal circulation depends on collateral circulation.

Tumoral Calcinosis of Thoracic Spine Associated with Vertebral Fracture and Inflammatory Reactions.

Tumoral calcinosis involving the spine is rare. The involvement of the thoracic spine is rarer than that of the cervical or lumbar spine. We report a case of thoracic tumoral calcinosis accompanied by vertebral fracture with increased concentrations of inflammatory markers and no abnormalities in serum calcinosis and phosphorus concentration. A 60-year-old woman presented with complete paraplegia. Her white blood cell count and C-reactive protein (CRP) concentration were elevated. The thoracic magnetic resonance imaging revealed vertebral fracture and an epidural mass that demonstrated low intensity on both T2- and T1-weighted images at the T9/10 dorsal side of the central canal. This lesion is larger in size than that observed in the previous 2 months. Her laboratory data showed signs of infection, and only decompression surgery without fixation for treatment and diagnosis was performed. Histopathological examination was consistent with tumoral calcinosis. Postoperatively, the patient's white cell count and CRP concentration were normalized. We found that tumoral calcinosis can occur at the thoracic level on the basis of the spinal instability due to the vertebral compression fracture and the accompanying increase in inflammation indicated by increased white blood cell count and CRP concentration.

Spinal Subdural Abscess following Transforaminal Lumbar Interbody Fusion.

Spinal subdural abscesses are rare lesions. We report the case of surgical site infection complicated with meningitis and rapidly progressive spinal subdural abscess caused by P. aeruginosa following transforaminal lumbar interbody fusion (TLIF). A 72-year-old woman was admitted to our hospital complaining of drop foot syndrome and sciatica caused by stenosis of the L5/6 intervertebral foramen accompanied by L5 lumbar vertebral fracture. Accordingly, TLIF of L5-L6 and balloon kyphoplasty of L5 were performed. On the 3rd postoperative day (POD), she was diagnosed with surgical site infection complicated with bacterial meningitis. Subcutaneous fluid, blood, and cerebrospinal fluid cultures indicated P. aeruginosa. On the 7th POD, a repeat MRI showed a large dorsal fluid collection consistent with a subdural infection and massive cauda equina compression. We performed debridement and instrument removal and found a dural laceration that was not observed during the first operation. An intraoperative insensible dural laceration may cause bacteria intrusion into the subdural space.

A Rapidly Growing Cervical Meningeal Melanocytoma with a Dumbbell-Shaped Extension.

BACKGROUND: Meningeal melanocytoma is a rare benign lesion found in the central nervous system. Preoperative diagnosis of meningeal melanocytoma is often a diagnostic challenge, as the clinical and neurologic features are often nonspecific. Various characteristics, including the natural course of this tumor, remain poorly understood. We report a case of a rapidly growing dumbbell-shaped melanocytoma compressing the spinal cord that manifested 2 years after a tumor was identified at the right C2-C3 foramen. CASE DESCRIPTION: A 40-year-old, right-handed man presented with a 2-month history of right palm and left leg numbness. Magnetic resonance imaging of the cervical spine showed a dumbbell-shaped tumor at the right C2-C3 foramen with extension into the central canal. The lesion was hyperintense on T1-weighted images and hypointense to isointense on T2-weighted images. Contrast enhancement was not visualized clearly. Fluorodeoxyglucose-positron emission tomography with computed tomography showed intense uptake in the lesion. The patient's history included a small lesion that had been localized at the right C2-C3 foramen 2 years before admission. The pathologic findings were consistent with melanocytoma. CONCLUSIONS: It is important to include meningeal melanocytoma in the differential diagnosis of dumbbell tumors, as meningeal melanocytomas may show rapid progression.

Isolated Posterior Spinal Artery Aneurysm Presenting with Spontaneous Thrombosis After Subarachnoid Hemorrhage.

BACKGROUND: The cause of subarachnoid hemorrhage is more likely to be intracranial than spinal. Bleeding, although common with spinal arteriovenous malformations and spinal cord tumors, rarely occurs with ruptured isolated spinal artery aneurysms. Here, we report a case of isolated thoracic posterior spinal artery aneurysm presenting with thrombosis after subarachnoid hemorrhage. CASE DESCRIPTION: A 67-year-old woman presented with sudden-onset nausea and low back and right thigh pain that worsened with movement. Computed tomography (CT) and magnetic resonance imaging (MRI) scans of the head suggested a small subarachnoid hemorrhage in the high-convexity sulcus, and lumbar puncture showed bloody cerebrospinal fluid. There was no apparent intracranial aneurysm on CT angiography; however, spinal MRI showed a lesion on the right side of the spinal cord at Th10. Contrast-enhanced CT showed an enhancing lesion at this site on day 7 that was not present on day 15. Selective right Th10 intercostal artery angiography on day 22 showed no evidence of aneurysm. The lesion was suspected to be a thrombotic spinal artery aneurysm. Given the unclear natural history of this entity, surgery was performed on day 36. After right Th10 hemilaminectomy and opening the dura, the arachnoid and adhesions were found to be thickened. A fusiform-shaped thrombosed aneurysm continuous with the radiculopial artery was removed. The patient was discharged without neurologic deterioration. CONCLUSIONS: Isolated spinal artery aneurysm is a rare cause of subarachnoid hemorrhage. It is expected that additional cases will clarify the natural history and indications for treatment.

Lumbar Ganglioneuroma from the Paravertebral Body Presenting in Continuity Between Intradural and Extradural Spaces.

BACKGROUND: Ganglioneuroma is a well-differentiated benign tumor that develops from the ganglion cells of the posterior mediastinum, retroperitoneum, cervical spine, and adrenal glands. The paravertebral body, in which the sympathetic trunk exists, is a common tumor site, and tumor sometimes invades the spinal canal through the intervertebral foramen. There have been no reports regarding tumors with intradural and extradural continuity. We report a paravertebral ganglioneuroma extending between the intradural and extradural spaces and its surgical treatment. CASE DESCRIPTION: A 33-year-old man was admitted to the hospital with progressive left lower limb numbness. A dumbbell-type tumor progressing to the spinal canal via the left intervertebral foramen from the paravertebral body at L1-2 was detected, and intradural calcified lesions were found. Pathologic examination of a computed tomography-guided biopsy sample revealed a ganglioglioma. The extradural tumor was removed; however, the left lower limb pain gradually worsened. As complete block was observed on myelography, the intradural tumor was removed 8 months later. Intraoperative findings revealed that the intradural and extradural tumors were continuous through the L1 nerve root. CONCLUSIONS: This is the first known reported case of paravertebral ganglioneuroma presenting in continuity between the intradural and extradural spaces.

The Transspinal Canal Screwing Technique for Atlantoaxial Anomalies: A Technical Note and 2 Case Reports.

It is difficult to treat atlantoaxial instability in patients with a high-riding vertebral artery or anomalies of the craniocervical junction. We report 2 successful cases in which the transspinal canal screwing technique was used because of difficulties performing conventional fixation methods. Case 1: A 78-year-old woman suffered from progressive myelopathy due to severe spinal cord compression with a congenital anomaly of the craniovertebral junction. Bilateral transspinal canal screws from the axis body with spondylolisthesis to the dens were inserted by retracting the dural sac medially after foramen magnum decompression and cervical laminoplasty. Case 2: A 20-year-old man with a spinal deformity due to Loeys-Dietz syndrome presented to our hospital for treatment of syringomyelia. He had no obvious neurological deficits, but spinal cord compression due to right atlantoaxial rotating dislocation was observed. A screw was inserted from the vertebral body of the axis to the right lateral mass of the atlas via the spinal canal after laminectomy of the atlas. The transspinal canal screwing technique is useful for treating atlantoaxial instability in cases where other fixation methods are difficult.

[Availability of Early Balloon Kyphoplasty for the Treatment of Osteoporotic Compression Fractures].

INTRODUCTION: Japan has many patients with osteoporosis; however, only about one-fifth of these patients receive treatment. Although some treatment guidelines exist for osteoporosis, the number of newly diagnosed patients with osteoporotic compression fractures is increasing and protocols for treatment of osteoporotic compression fractures vary from one hospital to another. This study aims to investigate the availability of early balloon kyphoplasty(BKP)in relation to our treatment strategy for osteoporotic compression fractures. METHODS: In our hospital, patients diagnosed with osteoporotic compression fractures were treated conservatively with a corset and rehabilitation. In cases where pain was prolonged and computed tomography(CT)imaging revealed formation of a cavity, we performed BKP. We divided the patients admitted between April 2016 and December 2016 with osteoporotic compression fractures into 2 groups, based on whether they received conservative treatment or BKP. We assessed the patients' age, fracture site, CT and MRI findings, bone density, Numerical Rating Scale(NRS), duration of hospital stay, and outcomes. RESULTS: In the BKP group, the number of Th12 and L1 compression fractures was higher than fractures to other vertebral bodies. No difference was observed in bone density, improvement of NRS, and outcomes between groups. CT cavity signs were more frequently observed in the BKP group than in the conservative group. CONCLUSIONS: This study establishes a correlation between the appearance of CT cavity sign and prolonged pain, which increases the likelihood of a patient undergoing BKP. The CT cavity sign and prolonged pain could be indicators of pre-stage pseudoarthrosis. BKP performed in the early stages of a fracture is safe and does not result in complications. However, BKP should be performed according to appropriate indications, including delayed neurological deficit, pain, and reduced bone adhesion.

[Functional mapping using subdural electrodes combined with monitoring during awake craniotomy enabled preservation of function and extensive resection of a glioma adjacent to the parietal lobe language sites: a case report].

INTRODUCTION: Surgical resection of gliomas located in the dominant parietal lobe is difficult because this lesion is surrounded by multiple functional areas. Although functional mapping during awake craniotomy is very useful for resection of gliomas adjacent to eloquent areas, the limited time available makes it difficult to sufficiently evaluate multiple functions, such as language, calculative ability, distinction of right and left sides, and finger recognition. Here, we report a case of anaplastic oligodendroglioma, which was successfully treated with a combination of functional mapping using subdural electrodes and monitoring under awake craniotomy for glioma. CASE PRESENTATION: A 32-year-old man presented with generalized seizure. Magnetic resonance imaging revealed a non-enhanced tumor in the left angular and supramarginal gyri. In addition, the tumor showed high accumulation on 11C-methionine positron emission tomography(PET)(tumor/normal brain tissue ratio=3.20). Preparatory mapping using subdural electrodes showed absence of brain function on the tumor lesion. Surgical removal was performed using cortical mapping during awake craniotomy with an updated navigation system using intraoperative magnetic resonance imaging(MRI). The tumor was resected until aphasia was detected by functional monitoring, and the extent of tumor resection was 93%. The patient showed transient transcortical aphasia and Gerstmann's syndrome after surgery but eventually recovered. The pathological diagnosis was anaplastic oligodendroglioma, and the patient was administered chemo-radiotherapy. The patient has been progression free for more than 2 years. CONCLUSION: The combination of subdural electrode mapping and monitoring during awake craniotomy is useful in order to achieve preservation of function and extensive resection for gliomas in the dominant parietal lobe.