The diagnostic value of single-photon emission computed tomography/computed tomography for severe sacroiliac joint dysfunction.

PURPOSE: We aimed to evaluate the value of single-photon emission computed tomography (SPECT)/computed tomography (CT) for the diagnosis of sacroiliac joint (SIJ) dysfunction. METHODS: SPECT/CT was performed in 32 patients with severe SIJ dysfunction, who did not respond to 1-year conservative treatment and had a score of >4 points on a 10-cm visual analog scale. We investigated the relationship between the presence of severe SIJ dysfunction and tracer accumulation, as confirmed by SPECT/CT. In cases of bilateral SIJ dysfunction, we also compared the intensity of tracer accumulation on each side. Moreover, we examined the relationship between the intensity of tracer accumulation and the different treatments the patients subsequently received. RESULTS: All 32 patients with severe SIJ dysfunction had tracer accumulation with a standardized uptake value (SUV) of >2.2 (mean SUV 4.7). In the 19 patients with lateralized symptom intensity, mean SUVs of the dominant side were significantly higher than those of the nondominant side. In 10 patients with no lateralization, the difference in the SUVs between sides was <0.6. Patients exhibiting higher levels of tracer accumulation required more advanced treatment. CONCLUSION: Patients with higher levels of tracer accumulation had greater symptom severity and also required more advanced treatment. Thus, we believe that SPECT/CT may be a suitable supplementary diagnostic modality for SIJ dysfunction as well as a useful technique for predicting the prognosis of this condition.

Percutaneous drainage combined with hyperbaric oxygen therapy for pyogenic spondylitis with iliopsoas abscess.

STUDY DESIGN: A retrospective study. PURPOSE: The purpose of this study was to evaluate outcomes in patients with pyogenic spondylitis accompanied by iliopsoas abscess who were treated by percutaneous drainage combined with hyperbaric oxygen (HBO) therapy. OVERVIEW OF LITERATURE: To the best of our knowledge, there have been no previous reports of the use of percutaneous drainage combined with HBO therapy for the treatment of this condition. METHODS: Twenty-three patients (13 men, 10 women; mean age, 69.0 years; range, 45-85 years) were treated with percutaneous drainage combined with HBO therapy in addition to commonly used conservative therapy. Mean follow-up duration was 27.7 months (range, 12-48 months). Clinical outcomes and imaging examinations were retrospectively investigated. RESULTS: Symptoms such as low back pain, radicular pain, and hip pain resolved in all patients immediately after treatment. Mean time from the start of treatment to the return of C-reactive protein levels to normal or baseline values recorded before the onset of spondylitis was 28.3 days (range, 8-56 days). In the final set of follow-up radiographic studies, all patients were free from progressive destructive changes. Follow-up magnetic resonance images or computed tomography with contrast enhancement confirmed the disappearance or near-total resolution of the iliopsoas abscess cavity with healing of the pyogenic spondylitis in all 23 patients. No recurrences were observed during follow-up. CONCLUSIONS: The present study suggests that patients with pyogenic spondylitis accompanied by iliopsoas abscess can be cured without a prolonged period of therapy or recurrence using this treatment.

Distractive flexion injuries of the subaxial cervical spine treated with a posterior procedure using cervical pedicle screws or a combined anterior and posterior procedure.

The purpose of this study was to compare the clinical and radiographic outcomes of patients with distractive flexion (DF) injuries of the subaxial cervical spine who had undergone a posterior procedure using cervical pedicle screw (CPS) fixation with those who had undergone a combined anterior and posterior procedure. Recommendations for the surgical treatment of DF injuries of the subaxial cervical spine remain controversial. There are few clinical reports of posterior CPS fixation for DF injuries. We retrospectively reviewed the clinical records and radiographs of 50 consecutive patients with DF injuries of the subaxial cervical spine treated at the Imakiire General Hospital. Group 1 consisted of 24 patients who underwent posterior wiring fixation and fusion with additional anterior decompression and fusion. Group 2 consisted of 26 patients who underwent posterior decompression and fusion with CPS fixation. Group 1 had a significantly longer operation time (295.4 minutes) than Group 2 (163.3 minutes). Group 1 had significantly higher blood loss (689.1g) than Group 2 (313.7 g). No patient in Group 1 or 2 developed postoperative neurological worsening. The mean loss of kyphotic correction was 1.6° and 0.1° in Groups 1 and 2, respectively, and the loss of kyphotic correction in Group 2 was significantly less than that of Group 1. We suggest that posterior procedures with CPS fixation are reasonable for the management of cervical DF injuries.

The use of antibiotic-impregnated fibrin sealant for the prevention of surgical site infection associated with spinal instrumentation.

PURPOSE: The purpose of this study was to determine if the use of antibiotic-impregnated fibrin sealant (AFS) was effective in preventing surgical site infections (SSI) associated with spinal instrumentation. METHODS: In a preliminary study, five pieces of vancomycin-impregnated fibrin sealant, five nuts that were not treated with the sealant, and five nuts that were treated with the sealant were subjected to agar diffusion testing. In a clinical study, the rates of deep SSI were compared between 188 patients who underwent procedures involving spinal instrumentation without AFS (group 1) and 196 patients who underwent procedures involving spinal instrumentation with AFS (group 2). RESULTS: All five pieces of vancomycin-impregnated fibrin sealant and the five nuts treated with the sealant exhibited antimicrobial efficacy, while the five untreated nuts did not exhibit antimicrobial efficacy in the agar diffusion test. In the clinical study, 11 (5.8 %) of the 188 patients in group 1 acquired a deep SSI, while none (0 %) of the 196 patients in group 2 acquired a deep SSI. CONCLUSION: The present study demonstrated that the application of AFS to spinal instrumentation yielded good clinical outcomes in terms of the prevention of postoperative spinal infections. It is hoped that limiting AFS use to patients requiring spinal instrumentation and those with risk factors for SSI will reduce the overall costs while preventing SSIs.

Subdural spread of injected local anesthetic in a selective transforaminal cervical nerve root block: a case report.

INTRODUCTION: Although uncommon, selective cervical nerve root blocks can have serious complications. The most serious complications that have been reported include cerebral infarction, spinal cord infarction, transient quadriplegia and death. CASE PRESENTATION: A 40-year-old Japanese woman with a history of severe right-sided cervical radicular pain was scheduled to undergo a right-sided C6 selective cervical nerve root block using a transforaminal approach under fluoroscopic guidance. An anterior oblique view of the C5-C6 intervertebral foramen was obtained, and a 23-gauge spinal needle, connected to the normal extension tube with a syringe filled with contrast medium, was introduced into the posterior-caudal aspect of the C5-C6 intervertebral foramen on the right side. In the anteroposterior view, the placement of the needle was considered satisfactory when it was placed no more medial than halfway across the width of the articular pillar. Although the spread of the contrast medium along the C6 nerve root was observed with right-sided C6 radiculography, the subdural flow of the contrast medium was not observed with real-time fluoroscopy. The extension tube used for the radiculography was removed from the spinal needle and a normal extension tube with a syringe filled with lidocaine connected in its place. We performed a negative aspiration test and then injected 1.5 mL of 1.0% lidocaine slowly around the C6 nerve root. Immediately after the injection of the local anesthetic, our patient developed acute flaccid paralysis, complained of breathing difficulties and became unresponsive; her respiratory pattern was uncoordinated. After 20 minutes, she regained consciousness and became alert, and her muscle strength in all four limbs returned to normal without any sensory deficits after receiving emergent cardiorespiratory support. CONCLUSIONS: We believe that confirming maintenance of the appropriate needle position in the anteroposterior view by injecting local anesthetic is important for preventing central needle movement. Because the potential risk of serious complications cannot be completely eliminated during the use of any established selective cervical nerve root block procedure, preparation for an emergency airway, ventilation and cardiovascular support is indispensable in cases of high spinal cord anesthesia.

Facet arthrography of a cervical synovial cyst.

A rare case is presented of a synovial cyst located at the level of C3-C4 that caused cervical myelopathy and that was preoperatively diagnosed by facet arthrography. A woman in her late seventies experienced muscle weakness and numbness in her right upper extremity and gait disturbance. MRI revealed an extradural lesion located dorsolaterally on the right side of the spinal cord at the level of C3-C4. CT facet arthrography revealed continuity of the extradural lesion with the right C3-C4 facet joint and infiltration of contrast medium into the lesion. Postoperatively, histological examination of the cyst showed fibrous tissue with calcium deposits and the presence of synovial lining. Preoperatively, cervical synovial cysts are often difficult to distinguish from other extradural lesions. In this case, facet arthrography allowed the preoperative determination of communication between the extradural lesion and the facet joint, leading to the diagnosis of a synovial cyst.

Cervical pedicle screw insertion using a gutter entry point at the transitional area between the lateral mass and lamina.

PURPOSE: The purpose of this study was to describe a free-hand pedicle screw insertion technique and to evaluate the accuracy of pedicle screw placement and validity of pedicle screw fixation in patients with subaxial cervical spine injuries. METHODS: We retrospectively reviewed 32 consecutive patients with subaxial cervical spine injuries who underwent posterior cervical fixation using our cervical pedicle screw (CPS) insertion technique. We also assessed the clinical and radiological outcomes and the accuracy of pedicle screw placement. RESULTS: The mean preoperative kyphosis was 4.0°, which was corrected to -5.2° after the operation, and the mean kyphosis angle was -4.4° at the final follow-up. The mean preoperative disc height ratio was 81.9%, and it improved to 105.4% after the operation, which was maintained until the final follow-up measurement of 103.4%. Bony union was achieved, and there were no instrumentation failures in any patient. Overall, 127 pedicle screws were inserted, of which 112 (88.1%) were classified as grade 1 (exact intrapedicular screw positioning), 10 (7.8%) as grade 2 (perforation <50% of the screw diameter), and 5 (3.9%) as grade 3 (perforation more than 50% of the screw diameter). CONCLUSION: In our technique, a gutter is created using a high-speed burr at the transitional area between the lateral mass and lamina similar to the procedure in double-door laminoplasty to identify an entry point for CPS insertion. It is easy for general spine surgeons to identify a CPS insertion entry point using our technique.

Combined posterior and delayed staged mini-open anterior short-segment fusion for thoracolumbar burst fractures.

STUDY DESIGN: A prospective study. OBJECTIVES: To assess the outcome of patients with a single thoracolumbar burst fracture treated with circumferential short-segment fusion consisting of posterior reduction, short-segment fusion, and delayed staged mini-open anterior short-segment fusion. SUMMARY OF BACKGROUND DATA: The surgical treatment of thoracolumbar burst fractures remains controversial. In attempting to combine the advantages of posterior procedures, including initial correction of kyphosis and early decompression, and those of anterior procedures, including direct decompression and restoration of anterior column support, a combined posterior and delayed staged anterior procedure seems to be a reasonable choice. However, conventional combined procedures are invasive. METHODS: We prospectively selected 28 consecutive patients with single thoracolumbar burst fracture for circumferential short-segment fusion consisting of posterior reduction, short-segment fusion, and delayed staged mini-open anterior short-segment fusion. The pedicle screw systems were removed after confirmation of posterior bony fusion to preserve as many motion segments as possible in those patients who could be treated with circumferential monosegmental fusion. Radiographic and clinical assessment of 28 patients who received this treatment was carried out. RESULTS: The mean loss of correction of kyphosis between the time of the combined procedure and final follow-up was 3.7 degrees (range, 0 to 10.2 degrees). Bony fusion was eventually achieved in all patients. There were 15 cases with monosegmental and 13 cases with bisegmental circumferential fusion. All 10 patients with initial neurological deficit improved by at least 1 Frankel grade: 3 improved by 1 grade, 5 improved by 2 grades, and 2 improved by 3 grades. In total, 27 patients, who were P1 or P2 on the Denis pain scale, were considered to have obtained clinically satisfactory results. CONCLUSIONS: This combined procedure is less invasive than the conventional combined one, and finally achieves shorter stabilization, resulting in preservation of motion segments. It thus seems to be a reasonable treatment option for thoracolumbar burst fractures.

Facet arthrography in an unusual presentation of a lumbar hemorrhagic synovial cyst.

An 84-year-old man experienced right buttock pain that radiated gradually to his right lower extremity over a few months before admission. MRI revealed a space occupying intraspinal lesion that was close to the right-sided L4-L5 facet joint and an extraspinal lesion posterior to the right-sided L5 lamina. The lesions appeared as hyperintense areas on T1 weighted images and heterogeneous areas on T2 weighted images. Facet arthrography under CT guidance revealed peripheral infiltration of the contrast medium only in the intraspinal lesion at early stages; subsequently, the contrast medium diffused into the extraspinal lesion, establishing a continuity of the right L4-L5 facet joint with both lesions, which were connected through the interlaminar space. A connection between the intraspinal and extraspinal lesions at the right-sided interlaminar space at the L4-L5 level was clearly noted during intraoperative examination. Histological examination revealed a hemorrhagic synovial cyst.

Traumatic lumbosacral dislocation treated with posterior lumbar interbody fusion using intersomatic cages.

A 35-year-old man was struck by a car on his right side and presented with paraparesis of both lower extremities. Radiographic examination revealed multiple transverse process fractures and anterior displacement of L5 on S1. Computed tomography revealed a bilateral anterior facet dislocation of the fifth lumbar vertebra on the sacrum. MRI showed rupture of the posterior ligamentous complex. A posterior lumbar interbody fusion using two intersomatic cages and pedicle screw instrumentation and posterior fusion were performed. Although no major disc lesion was found at the level of L5-S1 on preoperative MRI, a severely collapsed L5-S1 disc was found intraoperatively. Two years after surgery, the patient was asymptomatic with normal neurological findings, and has resumed normal activity. We believe that lumbosacral dislocation can be considered a three-column injury with an L5-S1 disc lesion, and, therefore, requires a solid circumferential segmental arthrodesis to improve fusion rate.

L2-L3 flexion-distraction injury treated by posterior fusion using ultra-high molecular weight polyethylene tape in a 7-year-old boy.

A 7-year-old boy was sitting in the back seat of a car wearing a lap seatbelt when the car was involved in a head-on collision with another vehicle. Radiographs revealed mild scoliosis, anterior column compression of L3 and enlargement of both the intervertebral foramen and interspinous distance between L2 and L3. Computed tomography revealed bilateral L2-L3 facet joint disruption with fracture of the L2 spinous process. Magnetic resonance imaging revealed rupture of the posterior ligamentous complex. An open reduction and posterior fusion with autologous bone graft using 5-mm-wide ultra-high molecular weight polyethylene tape sublaminar wiring was performed. Three months after surgery, bony fusion of L2-L3 was observed. At 6 months after surgery, the patient was asymptomatic and had resumed previous activities.

Dorsally sequestered cervical disc herniation.

STUDY DESIGN: A case report of dorsally sequestered cervical disc herniation. OBJECTIVE: To present an unusual case of dorsally sequestered cervical disc herniation and to briefly review the literature on this condition. SUMMARY OF BACKGROUND DATA: There have been few reports of migration of cervical disc herniation to the posterior surface of the spinal canal. METHODS: A 72-year-old man experienced a sudden episode of weakness of both lower extremities after playing golf, which gradually progressed, resulting in inability to walk without aid. Magnetic resonance imaging revealed a well-defined, oval mass lesion on the left dorsal aspect of the spinal canal, which compressed the dural sac at the level of C7. The mass lesion was isointense on T1-weighted images and heterogeneously hyperintense on T2-weighted images, and contrast-enhanced magnetic resonance imaging demonstrated peripheral enhancement of the mass lesion. RESULTS: The patient underwent surgery consisting of decompressive laminoplasty of C6 to C7, partial laminectomy of T1, and removal of the mass lesion. Histologically, the mass lesion was diagnosed as a dorsally sequestered disc herniation. After surgery, the weakness of both lower extremities gradually resolved, and the patient was able to walk without assistance at 2 weeks after surgery. CONCLUSION: It is important to appropriately differentiate dorsally sequestered disc herniation from other epidural mass lesions such as extradural tumor before operation and essential to perform early and sufficient surgical decompression of the spinal cord to prevent poor postoperative course in cases of acute onset and rapid progression of the paralysis caused by disc herniation.

Continuous irrigation in pyogenic spondylitis accompanied by iliopsoas abscess.

STUDY DESIGN: A retrospective assessment of 12 patients with pyogenic spondylitis accompanied by iliopsoas abscess treated by continuous irrigation with our new method between March 2003 and July 2005. OBJECTIVES: To present our method of treatment and to evaluate outcomes of 12 patients undergoing it. SUMMARY OF BACKGROUND DATA: Since patients with pyogenic spondylitis accompanied by iliopsoas abscess who require surgery are often immunocompromised hosts, open surgery may be excessively invasive. A less invasive operative procedure is therefore desirable for them. Percutaneous drainage is often used for secondary iliopsoas abscess due to pyogenic spondylitis. However, some authors have emphasized the importance of spondylitis as the primary source of infection for secondary iliopsoas abscess and have considered it essential to combine abscess drainage with curative treatment of the primary focus of infection. METHODS: We describe our treatment, which involves continuous irrigation using a saline infusion tube inserted into the infectious spondylitic disc as the primary lesion and insertion of a drainage tube into the iliopsoas abscess communicating with the primary lesion. Clinical and radiographic assessment of all 12 patients who received this treatment was performed. RESULTS: Ten (83%) of the 12 patients responded well to this treatment, with clinical results overall. Back pain, a major symptom, was relieved a mean of 9 days after the start of continuous irrigation. The mean duration to remission of C-reactive protein was 30.2 days. Follow-up MRI and CT with enhancement revealed disappearance or near-total resolution of the iliopsoas abscess cavity with healing of pyogenic spondylitis in all 10 patients who responded well to our treatment. CONCLUSION: This treatment is minimally invasive and useful in carefully selected patients with pyogenic spondylitis complicated by iliopsoas abscess.

Spontaneous regression of symptomatic lumbar epidural varix: a case report.

STUDY DESIGN: A case report of spontaneous regression of symptomatic lumbar epidural varix. OBJECTIVES: To present a case of spontaneous regression of lumbar epidural varix itself and to briefly review the literature. SUMMARY OF BACKGROUND DATA: It has previously been reported that some cases of lumbar epidural varix exhibit complete resolution of symptoms without surgery. However, the natural history of lumbar epidural varix is still unclear. To our knowledge, spontaneous regression of lumbar epidural varix itself has not been previously reported in the literature. METHODS: A 57-year-old woman experienced a sudden episode of low back pain radiating to the right lower extremity during physical exercise. Magnetic resonance imaging revealed a mass lesion in the ventral right epidural space, extending from the L2-L3 intervertebral disc space inferiorly, along the posterior aspect of the L3 vertebral body, to the L3-L4 intervertebral disc space, which was isointense on T1-weighted images and hyperintense on T2-weighted images compared with the L2-L3 disc. RESULTS: Repeat magnetic resonance imaging every 2 weeks revealed that the patient's lumbar epidural varix spontaneously regressed with corresponding changes in clinical symptoms, that it extended from the epidural venous plexus, consistent with epidural varix, and that it exhibited a gradual decrease in size. CONCLUSION: Although surgical treatment is often performed for symptomatic lumbar epidural varices, the findings of the present case suggest the usefulness of conservative treatment of these lesions in selected patients without major neurologic deficits.

HAS3-related hyaluronan enhances biological activities necessary for metastasis of osteosarcoma cells.

Several studies have suggested that increased production of hyaluronan (HA) is associated with metastatic behavior in various malignant tumors. To our knowledge, HA molecular weights required for metastasis are still unsolved in osteosarcoma. We examined the size of HA and hyaluronan synthase (HAS) isoforms related to biological functions required for metastasis in the LM8 stably highly metastatic osteosarcoma cell line. We found that HA of molecular weight which HAS3 produces enhanced biological functions related to metastasis such as cell proliferation, invasion, and degradation of extracellular matrix. Moreover, cell proliferation and invasion were inhibited by suppressing the activity of HAS3 expressed in LM8 cells, using hyaluronan synthase suppressor, 4-methylumbelliferone (MU). HA with the molecular weight related to HAS2 was the most adherent to CD44 in LM8 cells, suggesting that HAS2 may play an important role in pericellular coat formation. These results suggest that HAS3-related HA enhances crucial biological activities necessary for metastasis and that HAS2-related HA offers an advantageous environment for osteosarcoma cells.