Intramedullary spinal cord metastasis of ovarian tumor.

STUDY DESIGN: Case report. OBJECTIVES: To report a case of a thoracic intramedullary spinal cord metastasis of ovarian tumor in a 59-year-old woman. SETTING: Shiga, Japan. CASE REPORT: A case of a thoracic intramedullary spinal cord metastasis of ovarian tumor in a 59-year-old woman is reported. She received abdominal ovariectomy for the ovarian adenocarcinoma 4 years before she suffered from back pain and showed neurological symptoms. The thoracic intramedullary lesion was confirmed by preoperative magnetic resonance imaging. She showed complete paralysis before operation. The excision of the tumor was achieved through the posterior approach. Histologically, the diagnosis of metastasis of adenocarcinoma was made. CONCLUSION: Although she did not show any postoperative neurologic recovery, her general condition was good and there was no evidence of recurrence 24 months after surgery.

Kyphotic malalignment after anterior cervical fusion is one of the factors promoting the degenerative process in adjacent intervertebral levels.

The aim of this study was to determine whether postoperative malalignment of the cervical spine after anterior interbody fusion surgery promotes degenerative changes in the neighboring intervertebral discs. Forty-two patients who underwent anterior interbody fusion surgery for cervical spondylosis and disc herniation (34 men, 8 women) were followed for an average of 9.8 years. The average age at surgery was 50.2 years. Twenty-three patients underwent a single-level fusion, 17 underwent two-level fusion, and 2 had three levels fused. The Japanese Orthopaedic Association cervical myelopathy score, with a normal score 17 points, was 11.7 before surgery and 14.9 at follow-up. Neurological status was significantly improved postoperatively, and the improvement was preserved thereafter in most cases (paired t-test, P<0.001). Degenerative changes were evident on radiological examination in the levels adjacent to the fused segment in 21 of the 42 (50%) patients. Eight of these 21 patients demonstrated neurological deterioration caused by an adjacent disc lesion. A total of 43% of the patients with adjacent-level degeneration had malalignment of the cervical spine, such as kyphosis or sigmoid curvature. In addition, degenerative change in adjacent intervertebral levels was observed in 77% of kyphoses of the fused segment. These were statistically significant (Fisher exact method, P<0.05, P<0.04, respectively). Our findings suggest that one of the factors promoting degenerative change in adjacent intervertebral levels after anterior cervical fusion for degenerative disorders is postoperative kyphotic change in the cervical spine and the fused segment.

Spontaneous atlantoaxial rotatory fixation in old age after cerebral infarction: case report.

STUDY DESIGN: Case report of spontaneous Fielding and Hawkins Type I atlantoaxial rotatory fixation in a 78-year-old man after hemiplegia and homonymous hemianopsia caused by cerebral infarction. OBJECTIVES: To describe a case of spontaneous atlantoaxial rotatory fixation in old age and review previous adult cases of atlantoaxial rotatory fixation without fracture. SUMMARY OF BACKGROUND DATA: Atlantoaxial rotatory fixation in adults is a relatively rare finding and is mainly caused by trauma. To the author's knowledge, there has been no previous report of spontaneous atlantoaxial rotatory fixation in old age. METHODS: The patient's head was fixed in a 40 degrees left-rotated position. Left hemiplegia and homonymous left-side hemianopsia developed due to cerebral infarction. Computed tomography of the cervical spine clearly showed rotatory fixation of the atlas on the axis. RESULTS: Successful reduction was obtained after 1 day of skull traction. CONCLUSIONS: It was hypothesized that repeated left-rotational stress due to homonymous hemianopsia loaded to the atlantoaxial joint caused abnormal laxity of the joint.

A migrated lumbar disc herniation simulating a dumbbell tumor.

We report a case of a migrated lumbar disc hemiation, which on magnetic resonance imaging (MRI) simulated a dumbbell tumor in a 44-year-old woman who had severe pain in her right buttock and leg. A large epidural mass mimicking a dumbbell tumor was detected at the L5 vertebral level by MRI and computed tomography over myelography. Surgical fenestration of the L4/L5 interlaminar space revealed a dorsolateral epidural mass connected to the L5/S1 intervertebral disc extending laterally through the right L5/S1 intervertebral foramen. Histologically, it was degenerative disc material without active inflammation. Reevaluation of the MRI suggested some clues that might be useful in differentiating such a herniated disc from an epidural tumor.

A long-term follow-up study of cervical spondylotic myelopathy treated by "French window" laminoplasty.

We investigated 30 patients with multilevel cervical spondylotic myelopathy (22 males and 8 females) treated by "French window" laminoplasties from 1979 to 1988. Patients averaged 62.6 years of age, and were followed an average of 5 years and 2 months. The average preoperative and postoperative Japanese Orthopaedic Association (JOA) scores were assessed, rising from the original 8.8 +/- 3.4 to 11.9 +/- 3.3 (p < 0.001). Patients were divided into two groups, demonstrating poor alignment and no malalignment after surgery. There was no statistical difference regarding improvement in the neurological examinations between these two groups. The "French window" laminoplasty achieved good clinical results in the management of cervical spondylotic myelopathy irrespective of whether or not alignment deteriorated in the postoperative period.

Clinical outcomes of cervical spinal cord injuries without radiographic evidence of trauma.

We investigated 33 cervical spinal cord injury patients (25 males and eight females) without bony injury. Patients whose neurologic recovery had reached a plateau and who had evidence on imaging of persistent spinal cord compression were considered candidates for surgical decompression. When imaging did not show spinal cord compression or patients were maintaining a good neurologic recovery from the early days after injury, we pursued conservative treatment. Age at injury varied from 20 to 76 years (mean, 55.6). Average follow-up was 31 months. Twelve patients were treated conservatively (Group 1). Groups 2 and 3 had surgery. Group 2 (14 cases) had multi-level compression of spinal cord due to pre-existing cervical spine conditions such as ossification of posterior longitudinal ligament, cervical canal stenosis, and cervical spondylosis. Group 3 (7 cases) patients existed single-level compression of spinal cord by cervical disc herniations or spondylosis. We evaluated clinical results according to the Frankel classification, the American Spinal Injury Association (ASIA) scales and Japanese Orthopaedic Association (JOA) scores. Overall improvement of JOA and ASIA scores after treatment was 56.3 +/- 35.5% and 67.1 +/- 38.0%, respectively. Patients in Group 1 showed very good recovery after conservative treatment, with improvement of JOA and ASIA scores being 70.4 +/- 40.2% and 77.4 +/- 34.2%, respectively. The average interval between injury and operation was 4.3 +/- 4.4 months. The improvement of the surgically treated patients (Groups 2 and 3) in JOA and ASIA score was 48.2 +/- 30.7% and 61.2 +/- 39.6% respectively. We obtained good neurological recovery after operation, with significantly more improvement in Group 3 than in Group 2. No significant neurologic recovery had occurred preoperatively in these groups. In such patients operative intervention is essential for neurologic recovery.

Anterior cervical plate used in degenerative disease can maintain cervical lordosis.

The aim of this study was to show whether anterior cervical plate stabilization is able to maintain cervical lordosis or not when used for cervical degenerative disease. Thirty cases that underwent anterior fusion at multiple levels without cervical plating before 1986 were compared with 44 cases treated with cervical plating since 1986. Changes in the alignment of the total cervical spine and of the fused segment were studied in both groups. Collapse of the grafted bone, which was observed in 9 of 30 cases in the nonplate group, was not observed in the plate group. Alignment of the cervical spine was corrected and well maintained in the plated group, compared with the nonplate group. Anterior cervical plate stabilization could maintain the normal alignment of the cervical spine damaged by degenerative processes, whereas anterior cervical fusion without plating could not.

Cervical myelopathy caused by calcium pyrophosphate dihydrate crystal deposition in facet joints. A case report.

STUDY DESIGN: This report illustrates a case of cervical myelopathy caused by degenerative changes of the facet joints in which calcium pyrophosphate dihydrate crystals were found histologically. OBJECTIVES: To evaluate the treatment of this patient, which involved the principles of laminoplasty and posterolateral fusion, and to analyze surgical specimens and preoperative radiographs taken after the patient's surgery. SUMMARY OF BACKGROUND DATA: Calcium pyrophosphate dihydrate deposition occurs in cartilage, ligaments, tendons, and joint capsules. Radiographic changes of the cervical facet joints caused by such deposition have already been reported in cadaveric studies. Cases with neurologic compromise rarely occur. METHODS: Surgical specimens that were obtained from the cervical facet joints, i.e., capsule and synovium, were analyzed histopathologically. RESULTS: The preoperative radiographic study showed severe degenerative changes of the cervical facet joints, and analysis of the surgical specimens indicated the presence of calcium pyrophosphate dihydrate crystals. CONCLUSIONS: The cervical facet joints can be involved in calcium pyrophosphate dihydrate crystal deposition and this involvement may accelerate the degenerative changes of the facet joints.

Intermedilysin, a novel cytotoxin specific for human cells secreted by Streptococcus intermedius UNS46 isolated from a human liver abscess.

A novel cytotoxin (intermedilysin) specific for human cells was identified as a cytolytic factor of Streptococcus intermedius UNS46 isolated from a human liver abscess. Intermedilysin caused human cell death with membrane blebs. Intermedilysin was purified from UNS46 culture medium by means of gel filtration and hydrophobic chromatography. The purified toxin was resolved into major and minor bands of 54 and 53 kDa, respectively, by sodium dodecyl sulfate-polyacrylamide gel electrophoresis. These proteins reacted with an antibody against intermedilysin. Five internal peptide fragments of intermedilysin were sequenced and found to have 42 to 71% homology with the thiol-activated cytotoxin pneumolysin. However, the action of intermedilysin differed from that of thiol-activated cytotoxins, especially in terms of a lack of activation by dithiothreitol and resistance to treatments with N-ethylmaleimide and 5,5'-dithio-bis-(2-nitrobenzoic acid), although cholesterol inhibited the toxin activity. Intermedilysin was potently hemolytic on human erythrocytes but was 100-fold less effective on chimpanzee and cynomolgus monkey erythrocytes. Intermedilysin was not hemolytic in nine other animal species tested. Since human erythrocytes treated with trypsin were far less sensitive to intermedilysin than were the intact cells, a cell membrane protein(s) may participate in the intermedilysin action. These data demonstrated that intermedilysin is distinguishable from all known bacterial cytolysins.

Alternating sciatica while jogging: an early symptom of cauda equina tumor.

Three athletic patients with cauda equina or lumbosacral cord tumor noticed, as an early symptom of the disease, alternating bilateral sciatica synchronized with each stride while jogging. Comparison with athletic patients who developed lumbar disc hernia suggested that this symptom was significant. The authors speculated that the mechanism producing this symptom is the inertial force induced while jogging, which acts on the tumor in its early stage, when it is still quite mobile in the intradural space. The diagnostic role of this symptom in cauda equina and lumbosacral cord tumor should be recognized.

Large vertebral body, in addition to narrow spinal canal, are risk factors for cervical myelopathy.

It is well known that a narrow spinal canal is frequently associated with cervical spondylotic myelopathy. However, few investigators have studied the relationship between the size of the cervical spinal canal and that of the cervical spinal cord. Moreover, no studies mention the correlation between the size of the vertebral body and that of the spinal canal in the pathogenesis of cervical myelopathy. In the present study, we used computed tomographic myelography to measure the size of the vertebral body, spinal canal, and spinal cord in patients who had classic cervical myelopathy and in control subjects. We found that patients with cervical spondylotic had a narrow spinal canal as well as a slender spinal cord in the cervical region. Moreover, the vertebral body is significantly larger in the myelopathy group than in controls. A large vertebral body is thought to be associated with a large osteophyte and large disc protrusion. We conclude that a large vertebral body is another risk factor for cervical myelopathy, along with a narrow spinal canal.

Lumboperitoneal shunt for cauda equina syndrome in ankylosing spondylitis.

Cauda equina syndrome is a rare complication in the late stage of ankylosing spondylitis, for which approximately 60 cases have been reported in the literature. The cause of the syndrome is unclear, and there is no effective treatment. Recently lumboperitoneal shunt was reported to have been effective in two patients. In our study, we performed lumboperitoneal shunt in a patient and evaluated the condition after the operation compared with that preoperatively. Some alleviation of neurologic symptoms was observed for 6 months after operation. Histopathologic examination of the dural diverticulum revealed a residual change after old inflammation. Lumboperitoneal shunt was an effective surgical treatment for cauda equina syndrome in this patient with ankylosing spondylitis, but its effects were not extreme. Arachnoiditis is suggested to be involved in the pathogenesis of cauda equina syndrome.

Immunohistochemical study of matrix metalloproteinase-3 and tissue inhibitor of metalloproteinase-1 human intervertebral discs.

STUDY DESIGN: Immunohistologic staining of human intervertebral discs collected at the time of surgery (100 intervertebral discs from 80 patients) and 10 discs collected from 7 cadavers within 12 hours of death was performed using antimatrix metalloproteinase-3 monoclonal antibody and antitissue inhibitor of metalloproteinase-1 monoclonal antibody. OBJECTIVES: To examine the relationship between matrix destruction and staining for matrix metalloproteinase-3 and tissue inhibitor of metalloproteinase-1 in intervertebral disc degeneration. SUMMARY OF BACKGROUND DATA: Matrix metalloproteinase-3, which decomposes aggregating proteoglycans, has attracted research attention as a substance contributing to matrix destruction in the articular cartilage and intervertebral disc. However, except for a few in vitro studies, the relationship between matrix destruction of the intervertebral disc and matrix metalloproteinase-3 has been little studied. METHODS: Immunohistologic staining was performed to examine the relationship between matrix metalloproteinase-3 and tissue inhibitor of metalloproteinase-1 in the intervertebral disc, and the relationship of these two agents to magnetic resonance imaging, radiographic, and surgical findings. RESULTS: Those cases testing positive for matrix metalloproteinase-3 and negative for tissue inhibitor of metalloproteinase-1 accounted for most of the surgical specimens. The matrix metalloproteinase-3-positive cell ratio was significantly correlated with the magnetic resonance imaging grade of intervertebral disc degeneration, and the matrix metalloproteinase-3-positive cell ratio observed in prolapsed lumbar intervertebral discs was significantly higher than that in nonprolapsed discs. In cervical intervertebral discs, the matrix metalloproteinase-3-positive cell ratio and staining of cartilaginous endplate were correlated with the size of osteophyte formation. CONCLUSIONS: These findings suggested that intervertebral disc degeneration is caused by disturbance in the equilibrium of matrix metalloproteinase-3 and tissue inhibitor of metalloproteinase-1, and that matrix metalloproteinase-3 contributes to degeneration of the cartilaginous endplate.

Experimental study of intervertebral disc allografting in the dog.

STUDY DESIGN: An investigation of the use of intervertebral disc allografting as a potential alternative to intervertebral fusion was performed. In 13 adult mongrel dogs, intervertebral disc units cryopreserved after slow freezing were grafted. OBJECTIVES: To evaluate the morphologic and biosynthetic damage caused by cryopreserving the canine intervertebral disc before allografting. SUMMARY OF BACKGROUND DATA: Cryopreservation did not alter the normal histologic appearance. The metabolic activity, measured by 35S-sulfate incorporation, was observed to be 44% of the fresh control. METHODS: Transplanted intervertebral discs were examined histologically and radiographically at 12, 24, and 48 weeks after surgery. RESULTS: The allografted disc had preserved anular and nuclear architecture with moderate loss of chondrocytes 12 weeks after grafting. However, the intervertebral disc showed evidence of progressive disc degeneration 1 year after transplantation. CONCLUSIONS: More investigation of storage methods is needed to enhance the viability of the intervertebral disc for successful intervertebral disc allografting.

Experimental study on acute aggravating factors of cervical spondylotic myelopathy.

Systemic arterial hypotension, systemic arterial hypertension, cervical hyperflexion, cervical hyperextension, and cervical instability were induced in experimental animal with cervical spondylotic myelopathy, and their effects on spinal cord pathology were investigated. An experimental animal model of cervical spondylotic myelopathy was produced by combining anterior cervical cord compression with occlusion of the cervical vertebral arteries in dogs. Spinal cord pathology at the site of compression was characteristically different and depended on the type of load; that is, peripheral necrosis of the central gray matter in systemic hypotension, capillary congestion and subarachnoid hemorrhage in systemic hypertension, and linear necrosis of the transversely elongated central gray matter combined with occluded anterior spinal artery in cervical hyperflexion, and the pathologic severity was proportional to the number of loadings. This study suggests that cervical spondylotic myelopathy might progress stepwise rather than linearly when these aggravating factors are loaded.