New radiological parameters for the assessment of atlantoaxial instability in children with Down syndrome: the normal values and the risk of spinal cord injury.

AIMS: To determine the normal values and usefulness of the C1/4 space available for spinal cord (SAC) ratio and C1 inclination angle, which are new radiological parameters for assessing atlantoaxial instability in children with Down syndrome. PATIENTS AND METHODS: We recruited 272 children with Down syndrome (including 14 who underwent surgical treatment), and 141 children in the control group. All were aged between two and 11 years. The C1/4 SAC ratio, C1 inclination angle, atlas-dens interval (ADI), and SAC were measured in those with Down syndrome, and the C1/4 SAC ratio and C1 inclination angle were measured in the control group. RESULTS: The mean C1/4 SAC ratio in those requiring surgery with Down syndrome, those with Down syndrome not requiring surgery and controls were 0.63 (standard deviation (sd) 0.1), 1.15 (sd 0.13) and 1.29 (sd 0.14), respectively, and the mean C1 inclination angles were -3.1° (sd 10.7°), 15.8° (sd 7.3) and 17.2° (sd 7.3), in these three groups, respectively. The mean ADI and SAC in those with Down syndrome requiring surgery and those with Down syndrome not requiring surgery were 9.8 mm (sd 2.8) and 4.3 mm (sd 1.0), and 11.1 mm (sd 2.6) and 18.5 mm (sd 2.4), respectively. CONCLUSION: The normal values of the C1/4 SAC ratio and the C1 inclination angle were found to be about 1.2° and 15º, respectively. Cite this article: Bone Joint J 2016;98-B:1704-10.

Dorsal root ganglia morphologic features in patients with herniation of the nucleus pulposus: assessment using magnetic resonance myelography and clinical correlation.

STUDY DESIGN: Morphologic features of the dorsal root ganglia were investigated in patients with herniation of the nucleus pulposus by means of magnetic resonance myelography. OBJECTIVES: This study was undertaken to assess morphologic changes of the dorsal root ganglia in patients with herniation of the nucleus pulposus and to determine the relations between the morphologic features of the dorsal root ganglia and clinical features. SUMMARY OF BACKGROUND DATA: It has recently been reported that application of the nucleus pulposus to a nerve root induces edema in the rat dorsal root ganglion. Edema in the human dorsal root ganglion resulting from lumbar disc herniation has not been discussed in the literature, to the authors' knowledge. METHODS: Eighty-three consecutive patients (average age 42.1 years; range 17 to 77 years) with monoradicular symptoms were examined. Dorsal root ganglion morphologic features, i.e., indentations and swelling, were evaluated by magnetic resonance myelography. The dorsal root ganglion swelling at each level was quantitatively expressed as a ratio of the dorsal root ganglion width on the involved side to that of the contralateral side and was termed dorsal root ganglion ratio. Eighty-three uninvolved levels were chosen as controls in a randomized manner. Factors possibly contributing to the morphologic changes in the dorsal root ganglion were investigated. Neurologic symptoms, evaluated by the Japan Orthopaedic Association scoring system, were correlated to the morphologic changes. The morphologic features were followed up for 1 year after treatment in a small group of patients. RESULTS: Dorsal root ganglion indentations were always found in the narrowed intervertebral foramens. The incidence of indentations was significantly higher at the involved nerve roots (10.8%) than at the uninvolved nerve roots (4.0%) (P = 0.026). Patients with dorsal root ganglion indentations were significantly older (P = 0.0008). Leg pain scores in patients with indentations were significantly poor (P = 0.007). The dorsal root ganglion ratios were significantly higher at the involved levels than at the uninvolved levels (P = 0.001); the means +/- SD were 1.19 +/- 0.25 and 1.08 +/- 0.13, respectively. Patients with lateral herniated nucleus pulposus had significantly higher dorsal root ganglion ratios than those with central herniated nucleus pulposus (P = 0.0001); the mean ratios +/- SD were 1.48 +/- 0.32 and 1.10 +/- 0.12, respectively. A moderate positive correlation was found between dorsal root ganglion ratio and age (Pearson's correlation coefficient = 0.313). There was moderate negative correlation between the dorsal root ganglion ratio and leg pain, gait, motor, and total Japan Orthopaedic Association score (correlation coefficients were = -0.385, -0.350, -0.422, and -0.358, respectively). The dorsal root ganglion ratios were significantly diminished at 1-year follow-up (P = 0.001); the means +/- SD were 1.22 +/- 0.22 and 1.09 +/- 0.07, respectively. Indentations observed before treatment disappeared after treatment. CONCLUSIONS: Swelling and impingement in the involved dorsal root ganglion were clearly visualized by magnetic resonance myelography. The swelling and indentations were well correlated with severity of leg pain. These findings have important value in understanding the pathophysiology of the nerve roots in herniated nucleus pulposus.

[Intra-arterial chemotherapy for locally advanced bladder cancer].

A total of 83 patients with locally advanced bladder cancer (T1, n = 5; T2, n = 28; T3a, n = 21; T3b, n = 21; T4, n = 8) were treated with intra-arterial (i.a.) cisplatin and adriamycin (or epirubicin) chemotherapy. In 51 of the 83 cases, we combined this treatment with radiotherapy. The pathological complete response (CR) rate was 68% for all patients, 84% for i.a. chemotherapy combined with radiotherapy and only 41% for i.a. chemotherapy. The 5-year survival rate was 57% for all patients, 71% for i.a. chemotherapy combined with radiotherapy and only 44% for i.a. chemotherapy. The 5-year survival as a function of the clinical stage was 82% for T1 + T2, 66% for T3a, 28% for T3b, 25% for T4 (T1 + T2 vs: T3b: p < 0.001, T1 + T2 vs. T4: p < 0.0001, T3a vs. T3b: p < 0.0263, T3a vs. T4: p < 0.0214, T3b vs. T4: p < 0.029). In 46% of all patients, we succeeded in preserving the bladder; especially noteworthy, is that in 65% of the patients undergoing i.a. chemotherapy combined with radiotherapy, we succeeded in preserving the bladder. These results demonstrate that i.a. chemotherapy combined with radiotherapy is a useful method for locally advanced bladder cancer which may make preservation of the bladder function feasible.

Presurgical identification of extradural nerve root anomalies by coronal fat-suppressed magnetic resonance imaging: a report of six cases and a review of the literature.

In an attempt to depict the anatomy of the nerve roots, we obtained magnetic resonance (MR) images of the lumbar spine in the coronal plane with the frequency-selective fat-suppression technique. With this technique, extradural anomalies were identified in 20 (6.7%) of 300 patients. We report the appearance on coronal MR images of six surgically confirmed extradural anomalous nerve roots together with the myelography findings. These include type Ia, type Ib, and type 3 anomalies. These are readily recognized and allow detailed evaluation of the type of nerve root anomaly.

Postfusion instability at the adjacent segments after rigid pedicle screw fixation for degenerative lumbar spinal disorders.

Sixty-five patients who underwent wide laminectomy, Cotrel-Dubousset instrumentation, and fusion for lumbar degenerative disorders were reviewed radiographically to investigate the incidence and contributing factors of the postfusion instability at the adjacent segments immediately above or below the level of fusion. Thirty-four were men and 31 were women. The mean age was 55.8 years. The average follow-up time was 39 months. Postfusion instability was studied at a total of 107 adjacent segments in 65 patients. The incidence of postfusion instability noted at final follow-up was 24.6% (15 of 61 patients). The incidence was significantly more often observed in the adjacent segments above the fusion than below the fusion, at rates of 25.5 and 2.6%, respectively. The most common instability was posterior translation (9 of 15 patients). Regarding contributing factors for instability at the adjacent segment above the fusion levels, the age of patients was the most significant factor. The incidence was 36.7% (11 of 30 patients) in older patients (> 55 years old) and 12% (3 of 25 patients) in younger patients (< 55 years old). In four patients with a preoperative of > 3 mm anterior translation, instability progressed further postoperatively. To prevent postoperative instability, attention must be paid especially above the fusion levels of the elderly and the preoperative minimal anterior translation.

Somatoform pain disorder in a case of Klinefelter's syndrome with multiply operated lower back.

We report a case of Klinefelter's syndrome with multiply operated low back (MOB). Psychological and/or psychosocial problems related to MOB have been of recent interest in the field of orthopedic surgery. Based on psychiatric interviews, this case was diagnosed as a somatoform pain disorder of the DSM-III-R somatoform disorders. In addition to psychological problems, the pain was partly explicable by severe osteoporosis, which was prematurely caused by endocrinological disturbances associated with Klinefelter's syndrome. Patients with this syndrome are more likely to develop severe osteoporosis. In the presenile period of Klinefelter's syndrome with severe osteoporosis, liaison psychiatrists may pay attention to somatoform disorders (e.g. somatoform pain disorder and conversion disorder) linked with the MO.

Reduction of lumbar spondylolisthesis using a CDI pedicle screw system.

To evaluate reduction methods using two of the several types of Cotrel-Dubousset instrumentation (CDI), 39 patients with low-grade (Meyerding grades I and II [12]) lumbar spondylolisthesis were followed clinically and radiologically for a minimum of 6 months. Our surgical methods were classified into three types as follow: reduction by 2-level assembly using double-threaded screws (type I); reduction by single-level assembly using the double-threaded screws (type II); and reduction by single-level assembly using tulip screws (type III). We found that satisfactory reduction could be achieved by single-level assembly using either the double-threaded or tulip screw without resection of disc material or the posterior leverage method. We found that the tulip screw was superior in obtaining stable reduction. We discuss the mechanism of reducing spondylolisthesis in comparison with that of previously reported methods.

Pedicle screws and bone mineral density.

STUDY DESIGN: Thirty-five consecutive patients who underwent surgeries for decompression, and one-level fusions with Cotrel-Dubousset pedicle screws for spinal canal stenosis were included in this study. The relationship between bone mineral density of the lumbar spine and the rate of successful fusion and screw problems was studied. OBJECTIVES: Bone mineral density of the third lumbar vertebral body was measured by quantitative computed tomography preoperatively, and the degree of osteoporosis was graded by radiographic films of lumbar spines. The films were followed with anteroposterior and lateral dynamic radiographic examinations of lumbar spines. These examinations were evaluated clinically after surgery. Follow-up duration was at least 19 months, with a mean of 28 months. SUMMARY OF BACKGROUND DATA: The mean bone mineral density of all the patients was 117.1 mg/mL (SD = 42.5). The rate of successful fusion was 88.6%, the non-union rate was 5.7%, and the rate of fusions that were undetermined was 5.7%. The incidence of screw loosening occurred in 5.7% of the patients, screw breakage occurred in 5.7% of patients, and symptomatic screws related to non-union were present in 5.7% of patients. The degree of bone mineral density or radiographic gradings of osteoporosis and the successful fusion or the incidence of symptomatic screws, which were defined as screws related to non-union, were not related. METHODS: The patients were divided into two groups. One group consisted of 12 patients who had less than 100 mg/mL of bone mineral density, with a mean of 72.0 mg/mL (SD = 21.2). The other group consisted of 23 patients who had more than 100 mg/mL of bone mineral density, with a mean of 140.6 mg/mL (SD = 30.0). The rate of successful fusion or non-union and the rate of screw problems such as screw loosening or screw breakage were compared in the two groups. The presence of bony trabeculation in grafted bone is the most important criterion for successful fusion. RESULTS: A statistical difference did not occur between the two groups. Non-union, screw breakage, and screw loosening were observed in patients with both increased and decreased bone mineral density and those with increased and decreased grade osteoporosis. Radiographic grading of osteoporosis was not correlated to bone mineral density, but patients with unexpected bone mineral density were frequent in this series. CONCLUSIONS: The use of decompression and pedicle screws for spinal canal stenosis due to degenerative lumbar disorders can be done safely with one-level fusion in patients with decreased bone mineral density if patients with grade III osteoporosis are excluded. Bone mineral density is more reliable than radiographic grading to evaluate the degree of osteoporosis and should be included in the preoperative evaluation of patients with osteoporosis.

Two cases of ganglion cysts in the lumbar spinal canal.

Two cases of ganglion cysts in the lumbar spinal canal: MR findings. Ganglion cysts in the spinal canal are rare. To our knowledge, only 12 cases have been reported. In addition, ganglion cysts depicted by MR are extremely rare. We report the MR findings in two cases of ganglion cysts in the lumbar spinal canal. In both cases, the ganglion cysts were slightly higher in intensity than CSF on T2-weighted images. In addition, a thin band of low intensity was depicted around the ganglion in both cases. This finding may help to diagnose ganglion in the spinal canal. On T1-weighted images, the signal intensity of the ganglion was very similar to that of the intervertebral disc in both cases. In summary, although ganglion mimics disc hernia or sequestrated disc on both T2- and T1-weighted images, the possibility of a ganglion should be considered whenever an extradural mass showing high signal intensity surrounded by a thin band of low intensity is identified on T2-weighted images.

[Results of treatment for advanced non-seminomatous germ cell tumors of the testis based on Indiana University classification].

From 1980 to 1990, we treated 45 patients with non-seminomatous germ cell tumors of greater than or equal to stage II according to the Japanese general rule for clinical and pathological studies on testicular tumors. The patients were divided into 2 groups based on the Indiana University Classification: 26 good risk patients (score < or = 6) and 19 poor risk patients (score > or = 7). The clinical results, the % dose intensity of Cisplatin and half-lives of tumor makers were analyzed in the two groups. The per cent dose intensity of Cisplatin of the induction chemotherapy was 61 +/- 24% in 1980-1985 and 87 +/- 18% in 1986-1990. The NED rate improved from 66.7% (10/15) to 81.8% (9/11) in the good risk patients and from 33.3% (3/9) to 50.0% (5/10) in the poor risk patients between the above two periods. When the % dose intensity of Cisplatin exceeded 80%, the NED rate increased from 66.7% (10/15) to 90.0% (9/10) in good risk patients and from 33.3% (2/6) to 45.5% (5/11) in poor risk patients. The NED rate was only 25.0% (4/16) in the poor risk patients whose residual tumors were not resected. The half-lives of AFP and beta-HCG from the latter part of the first course to the second course were 6.8 +/- 1.9 days and 4.4 +/- 1.4 days, respectively, in the patients with a good prognosis, while they were 6.5 +/- 1.5 days and 4.4 +/- 2.9 days, respectively, in with a poor prognosis.(ABSTRACT TRUNCATED AT 250 WORDS)

Microdiscectomy and second operation for lumbar disc herniation.

To prevent recurrence and avoid the second operation, the authors analyzed the clinical features and surgical outcome of 214 patients (157 males and 57 females) who underwent lumbar microdiscectomy, 16 of whom required second operation. The mean age was 34.6 years (range, 12-62 years). The average follow-up period was 4 years 5 months. The overall incidence of second operation was 7.5%. Second operation was performed because of recurrence of herniation in nine patients, and residual bony compression at the lateral recess in two. The incidence of second operation was significantly higher in teenagers than in patients in other age decades (P < 0.01), and in patients with protrusion-type herniation than in those with extrusion-type or sequestration-type herniation (P < 0.01). To prevent the necessity for second operation, careful and thorough discectomy, especially deep to the posterior longitudinal ligament, and decompression at the lateral recess are useful.

[A case of prostatic carcinoma presenting as abdominal mass].

A 69-year-old man was admitted to the hospital on August 7, 1991 because of a lower abdominal mass. On physical examination, firm, rough-surfaced, unmovable masses of over fist size were palpable in the lower abdomen along with some small masses in the bilateral inguinal regions. On rectal examination the prostate was rough, hard and stony and larger than a chicken's egg in size. The serum prostatic acid phosphatase and prostatic specific antigen levels were elevated. A computerized tomography scan disclosed a large mass in the pelvis. Both a needle biopsy of the prostate and resection of an inguinal mass revealed moderately differentiated adenocarcinoma. Bone scintigram disclosed multiple metastases. Treatment with diethylstilbestrol diphosphate, etoposide, peplomycin and ifosfamide was effective, resulting in regressed intrapelvic masses and decreased serum prostatic acid phosphatase and prostatic specific antigen levels close to the normal limits. In November 1991, the patient was discharged and was surviving with the tumor as of August 1992.

[The study on intravesical instillation of THP in the treatment of in-situ and superficial bladder cancers].

The efficacy and safety of Pirarubicin (THP), administered by intravesical instillation, have been studied in recurrent multiple superficial bladder cancer patients and patients who tested positive by urine cytology but lacked protuberant legions (CIS). The average age and range of the 19 patients (M 15, F4) studied were 63.3 (37-84). Twelve patients had protuberant, multiple cancer and 7 patients had CIS. Sixteen of the cases were recurrent disease. Twenty mg THP, delufed in 40 ml of 5% glucose solution were instilled for 2 hours once or twice a week. Each patients received 8 treatments. One week after the last treatment, the therapeutic result was evaluated on the bases of cystoscopy and urine cytology. Before and after administration, CBC and biochemical blood tests were run. Nine of the 12 patients (75%) with multiple recurrent tumor and all the 7 patients with CIS showed complete response. The total outcome for CR was 84.2% in this study. Intravesical instillation with THP did not cause any serious side effects.

[Clinical study of estramustine phosphate (Estracyt) on prostatic cancer].

Clinical effect of Estracyt was investigated in prostatic cancer patients. Twenty seven patients had been previously treated and 20 had not received prior treatment. Improvement rate of subjective symptoms was 85% in the previously untreated patients and that of objective findings was 85%, while those rates were 44% and 50% in the previously treated patients, respectively. Most of the adverse reactions were changes in mamma and mammary papilla which were considered to be due to the estrogenic activity.

[Multivariate evaluation of survival factors and postoperative adjuvant chemotherapy in patients with bladder cancer treated by radical cystectomy].

Multivariate analysis by Cox's proportional hazard model was performed on 71 bladder cancer patients treated by radical cystectomy to clarify factors affecting survival and to evaluate the efficacy of postoperative adjuvant chemotherapy. Clinicopathologic data included in the analysis were age, sex, interval from onset of symptoms to first consultation, prior tumor history, year of operation and tumor characteristics: size, number, growth pattern, stage, grade, mode of infiltration, lymphatic invasion, lymph-node metastasis and lymphocyte infiltration around tumors. Analysis revealed that stage is the most statistically significant factor for survival (p less than 0.0001); followed by year of operation (p less than 0.05) and lymph node metastasis (p less than 0.1). The above three determinants yielded hazard ratios of 16.6 for stage (pT3a-pT4 vs. pTis-pT2), 2.7 for year of operation (1978-1982 vs. 1983-1987) and 2.4 for lymph node metastasis (positive vs. negative). Postoperative adjuvant chemotherapy consisting of cisplatin, peplomycin and mitomycin C (PPM therapy) seemed to improve survival, when the influence of the major prognostic factors were adjusted by the proportional hazards model. The authors conclude that stage and lymph node metastasis should be considered when postoperative adjuvant treatment is selected for patients with bladder cancer treated by radical cystectomy, and that further prospective randomized trials are mandatory to confirm the efficacy of postoperative adjuvant PPM therapy suggested by the present retrospective multivariate analysis.

[A study of postoperative adjuvant chemotherapy of advanced urinary epithelial cancer].

The effect of postoperative adjuvant chemotherapy was studied in 22 cases of advanced urinary epithelial cancer. Vincristine, mitomycin C and bleomycin (VMB) was administered in combination to 9 prophase cases from December, 1980 to March, 1982 and cis-dichlorodiamine platinum, peplomycin and mitomycin C (PPM) in combination to 13 anaphase cases from April, 1982 to November, 1984. The site was renal pelvic cancer in 3 cases, cancer of the ureter in 3 cases, cancer of the bladder in 13 cases, cancer of the pelvis, ureter, and bladder in 1 case, and recurrence of pelvic cancer following bladder cancer in 2 cases. The degree of invasion was pTa in 2 cases, pT1 in 1 case, pT2 in 1 case, pT3 in 11 cases and pT4 in 5 cases. Lymph node metastasis had occurred in 9 cases, no metastasis in 8 cases and it was unclear in the remaining 6 cases. The mean observation period was 16.5 months; 10 patients were alive without any tumors, one patient was alive with a tumor, 11 patients died of cancer, and one patient died intercurrently. The mean postoperative survival period in the mortality cases was 14.5 months. According to the classified type of chemotherapy received, there were 3 out of 9 cases (33.3%) who survived without tumors after receiving VMP and 7 out of 13 cases (53.8%) in the PPM group who survived without tumors. Although a simple comparison cannot be made, it appears that PPM therapy is superior. No severe side-effects were observed.

[A case of leiomyosarcoma of the kidney].

A case of renal leiomyosarcoma seen in a 65-year-old man is reported. On November 15, 1985, he complained of right flank pain and high fever. On right renal angiography and computed tomography showed a mass on lower pole of the right kidney. On December 10, 1985, the patient underwent right radical nephrectomy. The histological diagnosis was leiomyosarcoma probably originating from the right renal capsule. Forty-six cases of renal leiomyosarcoma, including this case, in the Japanese literature have been reviewed and are discussed.