Psoriasis vulgaris of the skin caused a L3-L4 lumbar epidural spinal abscess.

Background: In a 31-year-old male, psoriasis vulgaris (PV) of the skin caused paraparesis attributed to a L3-L4 epidural spinal abscess that required emergent surgical decompression. Case Description: A 31-year-old male presented with lower back pain and cauda equina compression attributed to a magnetic resonance-documented L34 enhancing lesion consistent with a spinal epidural abscess (SEA). The skin over the L3-L4 level revealed severe PV that proved to be the likely etiology of the right-sided paraspinal muscle abscess, infected right L3-L4 facet joint, and SEA. At surgery, the foci of infection were excised/decompressed, and cultures grew methicillin-susceptible Staphylococcus aureus. Following surgery, the patient was improved and was treated with appropriate antibiotic therapy. Conclusion: PV caused a L3-L4 epidural spinal abscess and cauda equina compression in a 31-year-old male who was successfully treated with operative decompression and appropriate antibiotic management.

Atlantoaxial Intradural Synovial Cyst Mimicking an Extradural Lesion Adjacent to a Retro-odontoid Pseudotumor: A Case Report.

Atlantoaxial synovial cysts can very rarely penetrate the dura mater into the thecal sac and cause direct neural compression. Several case reports have been available on "intradural synovial cysts" (IDSCs). In this study, we report on a case with an atlantoaxial IDSC mimicking an extradural lesion. A 90-year-old man was diagnosed with a cystic lesion located laterally to the atlantoaxial joint adjacent to the retro-odontoid pseudotumor (ROP) causing cervical spinal cord compression. Thus, surgical removal was planned. On preoperative examination, the cyst, which had a two-layer structure showing a T2-isointense small mass inside a T2-hyperintense lesion, was thought to be located in the extradural region. However, operative findings showed that the cyst was located inside the dura mater. Histopathological examination suggested a synovial cyst. No recurrence of the cyst was observed until the latest follow-up after 3 years, and the ROP decreased in size. Almost all IDSCs reported previously were observed in the medial site of the atlantoaxial joint. In our case, however, the cyst was observed adjacent to the posteromedial site of the right atlantoaxial joint and the ROP, mimicking an extradural lesion. We had no knowledge regarding the IDSC before the surgery and assumed an extradural lesion. Albeit rare, the existence of such a condition should be considered.

Case of Syringomyelia Associated with Ossified Yellow Ligament and Arachnoid Web.

Syringomyelia is often associated with Chiari malformation, trauma, infection, and spinal cord tumor. Although they are relatively rare diseases, arachnoid cysts and its related pathology, "arachnoid web" can sometimes lead to syrinx formation at the thoracic vertebral level. However, syrinx formation caused by degenerative spinal disorders, particularly at the thoracic vertebral levels, has rarely been reported. Herein, we present a case of syringomyelia with thoracic ossified yellow ligament (OYL) in a 79-year-old man, who underwent initial posterior decompression followed by arachnoid web removal. Posterior decompression via laminectomy of thoracic vertebra 2 and removal of the OYL improved the syrinx partially, but dorsal indentation of the spinal cord and a remnant syrinx were observed in post-operative magnetic resonance images, subsequent to the second surgery's successful removal of the arachnoid web, which had dorsally compressed the spinal cord. After the second operation, the syrinx shrunk further, and the patient could walk independently at 5 months after the operations. In our case, both the OYL and arachnoid web were responsible for syrinx formation. Therefore, the coincidence of degenerative vertebral diseases with a syrinx might indicate the coexistence of an underlying lesion. Furthermore, the arachnoid web in this case might have formed due to the denaturation of the arachnoid cyst triggered by the OYL.

Combined C1-2 transarticular screw fixation and C1 laminoplasty with interlaminar bone transplant for retro-odontoid pseudotumor: illustrative case.

BACKGROUND: The surgical treatment for retro-odontoid pseudotumor (ROP) remains controversial. Posterior C1 laminectomy without fixation occasionally leads to postoperative enlargement of ROP. Because its pathogenesis is associated with atlantoaxial instability, atlantoaxial fixation with C1 laminectomy is commonly performed. Atlantoaxial fixation usually includes transarticular fixation and screw-rod fixation. However, these methods have some issues. That is, in transarticular fixation with C1 laminectomy, the bone grafting area is challenging to obtain. In screw-rod fixation with C1 laminectomy, extensive bleeding occurs at times if the lateral atlantoaxial joint is exposed to the transplant bone grafts. OBSERVATIONS: Herein, the authors report a case of ROP treated with combined C1-2 transarticular screw fixation and C1 laminoplasty with interlaminar bone transplant, which can help achieve adequate spinal cord decompression and can simultaneously secure the bone grafting area between the laminae. In addition, the volume of intraoperative blood loss decreased. Postoperative magnetic resonance imaging showed sufficient decompression of the spinal cord at the C1 level, and computed tomography performed after 6 months revealed bone union between the C1 and C2 laminae. LESSONS: Combined C1-2 transarticular screw fixation and C1 laminoplasty with interlaminar bone transplant is a useful method for ROP.

[Treatment for Pyogenic Spondylodiscitis and Spinal Epidural Abscess].

Spontaneous spinal infections, such as pyogenic spondylodiscitis(PSD)and spinal epidural abscess(SEA), are relatively rare, but the number of patients is increasing because of the increase in the older population with chronic comorbidities. Magnetic resonance imaging is the most useful tool for identifying PSD or SEA, with high sensitivity and specificity. Effective antibiotic medication is essential to treat the infection, and selection of antibiotics should be based on not only sensitivity to the causative bacteria, but also ability to penetrate bone tissues. Medication should be continued for at least 6 weeks while monitoring C-reactive protein levels. Surgical treatment is indicated when neurological symptoms or severe spinal instability cannot be managed conservatively. Percutaneous endoscopic surgery enables simultaneous tissue sampling for diagnosis and curative debridement without injury to the spinal supporting tissues. Anterior debridement and interbody fusion(ADIF)with autologous bone grafts have been frequently used for PSD. ADIF can be applied more easily to the lumbar spine using techniques and devices for lateral interbody fusion. Posterior decompression is frequently performed in patients with SEA without severe spinal instability. Percutaneous posterior instrumentation, with or without posterior decompression, is a useful option for PSD, especially in the thoracic spine.

Lateral Lumbar Interbody Fusion Using Bone Graft Substitute for Lumbar Vertebral Fracture Associated Radiculopathy.

This study aims to present our surgical technique of lateral lumbar interbody fusion (LLIF) without corpectomy for lumbar vertebral fracture (LVF) associated radiculopathy. This study includes three patients treated with LLIF (mean age of 77.3 years, Group L) and three patients treated with PLIF (mean age of 75.7 years, Group P) to compare the surgical outcomes. The cartilage on the fractured vertebrae was aggressively resected with attention to avoid injury to the ring apophysis. The central cavity of the fractured endplate was filled with a bone graft substitute made of hydroxyapatite and collagen composite, followed by interbody fusion achieved by utilizing of a cage with sufficient length spanning the bilateral edges of the fractured vertebra. PLIF was performed with a standard technique using two interbody cages, and vertebroplasty was combined in one patient. Comparing to PLIF, LLIF could be performed with less estimated blood loss in shorter surgical time. Local kyphotic angle improved in all cases of Group L immediately after the surgery, but correction loss was observed at the final examination. The lordotic angle was lost in Group P postoperatively. Arthrodesis was achieved in all the cases. The mean VAS score for leg pain was 85.3 mm in Group L and 82.0 mm in Group P at preoperation and decreased to 8.7 mm and 11.3 mm, respectively, at postoperation. LLIF is an effective surgical option that enables stabilization of the fractured vertebra and reduces radicular pain by indirect neural decompression.

Diffuse Idiopathic Skeletal Hyperostosis with Severely Displaced Spine Fracture Managed with Posterior Approach Alone: Case Reports and Literature Review.

Diffuse idiopathic skeletal hyperostosis (DISH) is a condition in which minor trauma can cause extremely unstable vertebral fractures. Spinal fractures associated with DISH are prone to instability due to the large moment of lever arm and secondary neurological deterioration; hence, surgical internal fixation is considered necessary. On the other hand, some reports suggest that patients with DISH have a high osteogenic potential. In this report, we describe three patients with DISH. These patients had spinal injuries that resulted in a large gap, for which anterior fixation with bone graft would generally be considered due to comminuted fractures. However, we achieved good bony fusion with posterior fixation alone, without forcible correction.

[Standard Techniques of Spinal Fusion for Lumbar Degenerative Diseases].

Recently, many neurospinal surgeons are utilizing spinal fusion techniques for lumbar degenerative diseases. This paper aims to summarize the standard techniques of lumbar spinal fusion. Lumbar spinal fusion is categorized into posterolateral fusion(PLF)and interbody fusion(IF)based on the location of bone grafting. PLF needs wide dissection of paraspinal muscles beyond the synovial joints. It is often utilized for long fusion at the thoraco-lumbar junction with open posterior instrumentation. Techniques for IF include posterior lumbar interbody fusion(PLIF)or transforaminal lumbar interbody fusion(TLIF)via the posterior approach, and anterior lumbar interbody fusion(ALIF), lateral lumbar interbody fusion(LLIF), and oblique lumbar interbody fusion(OLIFTM)performed via the anterior approach. PLIF/TLIF procedures include laminectomy and/or facetectomy for direct neural decompression, and local bone grafting into the interbody space through the interlaminar space or the vertebral foramen. ALIF/LLIF/OLIFTM are usually performed via the retroperitoneal approach. ALIF has an advantage of obtaining lordosis with insertion of a large angled cage from the anterior aspect of the intervertebral space. LLIF/OLIFTM are less invasive methods, in which bone grafting is performed through or beside the psoas muscle. As a larger cage can be plated between the bilateral edge of the intervertebral space, LLIF/OLIFTM has an advantage in the correction of scoliosis.

Vertebral Endplate Cyst Formation in Relation to Properties of Interbody Cages.

OBJECTIVE: This retrospective study aimed to compare vertebral endplate cyst formation (VECF), an early predictor for pseudoarthrosis, in different types of interbody cages. METHODS: We reviewed 84 cases treated with single-level posterior/transforaminal lumbar interbody fusion. We utilized a polyetheretherketone cage in 20 cases (group P), a titanium cage in 16 cases (group Ti), a titanium-coating polyetheretherketone cage in 13 cases (group TiP) and a porous tantalum cage in 35 cases (group Tn). VECF was evaluated comparing the computed tomography scans taken at day 0 and 6-month postoperation. We defined VECF (+) as enlargement of a pre-existing cyst or de novo formation of a cyst with the diameter over 2 mm. We calculated the adjusted odds ratio (OR) and 95% confidence intervals (CIs) as an indicator of association between different types of cages and VECF using a logistic regression model. RESULTS: VECF was observed in 13 (65%), 7 (44%), 9 (69%), and 8 (23%) cases in groups P, Ti, TiP and Tn, respectively. VECF correlated with the type of cage (p = 0.04). In comparison with group P, the proportion of VECF (+) cases was lower in group Tn (OR, 0.16; 95% CI, 0.04-0.60) but not different in group Ti (OR, 0.47; 95% CI, 0.10-2.20) and group TiP (OR, 1.06; 95% CI, 0.21-5.28). No patient underwent additional surgery for the fused spinal level during the follow-up periods (average, 37.9 months; range, 6-76 months). CONCLUSION: VECF was the least in the porous Tn cage, suggesting its potential superiority for initial stability.

Early Development of Syringomyelia after Spinal Cord Injury: Case Report and Review of the Literature.

We report a case of post-traumatic syringomyelia (PTS), which developed 2 months after spinal cord injury (SCI). A 20-year-old man who was involved in a motorcycle accident sustained a complete SCI resulting from a burst fracture of the T5 vertebral body. He underwent posterior fixation with decompression at another hospital 2 days after the injury. Postoperative imaging suggested that spinal stenosis endured at the T4 level and swelling of the spinal cord above that level. Two months later, he felt dysesthetic pain in his forearms and hands, but the cause of the pain was not examined in detail. Four months after the injury, he presented with motor weakness in the upper extremities. Magnetic resonance imaging (MRI) showed syringomyelia ascending from the T3 level to the C1 level, and he was referred to our hospital immediately. The imaging studies suggested that PTS was caused by congestion of the cerebrospinal fluid (CSF) at the T3 level. The patient was treated with syringosubarachnoid (SS) shunt at the T1-T2 level, whereby neurological symptoms of the upper extremities were immediately relieved. Postoperative MRI showed shrinkage of the syrinx. At the latest follow-up 2 years postoperatively, there was no sign of recurrence. It is noteworthy that PTS potentially occurs in the early phase after severe SCI. We discuss relevant pathology and surgical treatment through a review of previous literature.

Cervical osteogenic degeneration in Japanese professional wrestlers and its relationship to cervical spine injury.

OBJECTIVEThis study aimed to investigate the characteristics of cervical degeneration in Japanese professional wrestlers and its relationship with the risk of cervical spine injury (CSI).METHODSSince 2012, 27 Japanese male wrestlers belonging to a professional wrestling association have undergone periodical medical examinations of the cervical spine. If neurological symptoms were observed in the wrestlers, the resident trainers urged them to undergo a brief examination at the authors' institutions. In addition to this prospective research study, the mechanisms of the CSIs that occurred in 5 wrestlers, including 2 with CSI before 2012 and 3 who were independent from the professional wrestling association, were retrospectively investigated by reviewing the circumstances of the injury and the wrestlers' imaging studies.RESULTSThe mean age of the wrestlers was 36.9 years (range 23-56 years) at the initial examination. An anterior giant ossifying lesion (AGOL) was observed in the anterior aspect of the cervical spine of 11 wrestlers (41%). The AGOLs tended to grow and spread to multiple spinal levels as the wrestlers aged. Of the 12 wrestlers with osteogenic lesions, 10 older than 40 years of age (83%) had an AGOL, which is frequently accompanied by osseous spinal canal stenosis. Two wrestlers presented with spinal cord compression with intramedullary intensity change on MRI. However, during the follow-up period, no spinal cord injury (SCI) occurred in the wrestlers, although thoracolumbar injury occurred in 2 wrestlers during a match. In examining the 5 wrestlers with CSI, the injury occurred at the spinal levels without an AGOL. The most frequent pathology of CSI (60%) was SCI at the spinal level adjacent to the multilevel AGOL.CONCLUSIONSAGOL is a peculiar cervical degeneration of Japanese professional wrestlers, especially in aged wrestlers. The AGOL appears to be a biological reaction to reinforce the anterior aspect of the cervical spine of professional wrestlers, who routinely defend themselves in a flexed neck posture against their opponent. The present results suggest that the risk of CSI is not increased by spinal canal stenosis accompanied by AGOL. Further studies are needed to investigate the relationship between the wrestlers' cervical degeneration and the risk of CSI in more detail.

Adult Case of Atlantoaxial Rotatory Fixation Treated with In Situ Fixation Using an Unusual Posterior Instrumentation Construct.

Atlantoaxial rotatory fixation (AARF) occurs commonly in children who have undergone trauma. It is usually corrected with conservative therapy. In this report, however, the patient was an adult with AARF who was treated surgically. A 64-year-old woman presented with a 1-year history of spastic gait and hand clumsiness. Imaging studies revealed the presence of AARF, os odontoideum, and severe spinal cord compression at that spinal level. As the AARF had not been responded to head traction with a halo device, we decided to treat the patient with in situ posterior fixation. Because the rigid dislocation was present between the atlas and the axis, we were forced to make an unusual instrumentation construct. Neurological symptoms other than hand numbness diminished after the surgery, and arthrodesis was obtained between the occiput and the axis. It should be noted that surgical planning for posterior instrumentation construct is required when rigid AARF is treated surgically.

Report of a familial case of proatlas segmentation abnormality with late clinical onset.

Although proatlas segmentation abnormalities as developmental remnants around the foramen magnum have been reported in postmortem studies, they are rarely documented in a clinical setting. This report details the clinical and radiological characteristics of a rare case of proatlas segmentation abnormalities with clinical onset during the seventh decade of life. This case was suspected to have a familial factor. We also review the literature regarding this condition.

Spontaneous Regression of Inflammatory Pseudotumor in the Cauda Equina: A Case Report.

Spinal intradural extramedullary inflammatory pseudotumor (IPT) is an extremely rare entity. Spontaneous shrinking of a spinal IPT has never been reported. A case of an IPT of the cauda equina that regressed spontaneously is presented. A 78-year-old woman presented with hypoesthesia of both lower legs in the L4 nerve root distribution and motor weakness of the right leg. Preoperative CT myelography and MRI showed two tumor-like lesions located at T12-L1 and L2-3. The lesion at the T12-L1 level appeared to encase several nerve roots. The preoperative diagnosis was ependymoma, schwannoma, or malignant lymphoma. The tumors were biopsied. In the operation, the lesion turned out to consist of swollen and adherent nerve roots. On histopathological examination of the biopsied nerve roots, they were diagnosed as IPT. The patient's symptoms improved gradually without any treatment after the operation. The IPTs regressed on the postoperative MR images and disappeared at one year. This is the first report of spontaneous regression of an IPT in the spinal region. IPT should be considered in the differential diagnosis of a tumor that appears to involve several nerve roots on preoperative imaging, but surgery is necessary for diagnosis. Complete resection is not absolutely required if an intraoperative pathological diagnosis of the frozen section reveals IPT.

Middle-term surgical outcomes of microscopic posterior decompression for far-out syndrome.

OBJECTIVE: Far-out syndrome (FOS) is a rare incident caused by L5 nerve root entrapment in the far-out area, the L5-S1 extraforaminal area between the transverse process and the sacral ala. The purpose of this study is to disclose the middle-term surgical outcomes of microscopic posterior decompression in the far-out area (MPDFA). MATERIAL AND METHODS: From June 2008 to November 2010, eight patients with FOS (six men and two women, mean age 65.4 years) were treated with MPDFA. Their chief complaint was leg pain in the L5 nerve root distribution area. Nerve root impingements in the far-out area were confirmed by magnetic resonance imaging, computed tomography and selective radiculography. Indications for MPDFA were given when pain was uncontrollable with conservative treatments for more than 1 month. MPDFA was performed according to the following procedure: a 4-to-5-cm skin incision was made just above the far-out area. The far-out area was exposed using Wiltse's intermuscular approach. The nerve root was decompressed with partial resection of the transverse process and the sacral ala, and removal of the iliolumbar ligament. Surgical outcomes were evaluated at periodical examinations with the Japanese Orthopedic Score (JOA) and a Visual Analogue Scale (VAS) of the leg pain. The mean follow-up period was 24.3 months (ranging from 12 to 40 months). RESULTS: All patients had reduced radicular leg pain after their operations. The mean postoperative hospital stay was 11.4 days, and the patients returned to their normal activities of daily living immediately after discharge. Both JOA and the VAS scores improved after surgery. The scores temporarily worsened in two patients with degenerative scoliosis; the worsening was attributed not to recurrence of the radiculopathy but to pain arising from knee arthropathy. The scores were maintained in the other patients at least until the final examinations during the follow-up. CONCLUSION: MPDFA is a less-invasive surgery for treating FOS and can provide a good middle-term surgical outcome.

Anterior transarticular screw fixation as a conventional operation for rigid stabilization.

BACKGROUND: Anterior transarticular screw (ATS) fixation is a useful surgical option for atlantoaxial (AA) stabilization. This report presents a revised ATS method for AA fusion. METHODS: A 79-year-old male presented with AA instability attributed both to an old odontoid fracture and severe degeneration of the lateral atlantoaxial joints (LAAJs). ATS fixation was performed through the conventional anterior cervical approach. The longest screw trajectories were planned preoperatively using multiplanar reconstruction computed tomography (CT) scans, with entry points of the screws situated at the midpoint on the inferior border of the axial body. The surgical exposure was limited to opening at the entry points alone. Our retractor of choice was the Cusco speculum; it sufficiently secured space for utilizing the required instruments for screw placement while offering sufficient protection of soft tissues. Cannulated full-threaded bicortical screws stabilized the LAAJs. Screw insertion required a significant amount of coronal angulation up to the superior articular process of the atlas under open-mouth and lateral fluoroscopy image guidance. After ATS fixation, bone grafting was performed between the posterior laminae of the axis and the atlas through a conventional posterior approach. RESULTS: Bony fusion between the atlas and the axis was confirmed radiographically. Arthrodesis of the LAAJs occurred despite no bone grafting. CONCLUSIONS: Rigid fixation of the LAAJs was obtained by our ATS technique, indicating that it is an alternative method for AA fixation when posterior rigid internal fixation is not applicable.

Mobile schwannoma of the cauda equina incarcerated following caudal migration after trauma--case report.

A 56-year-old man presented with a very rare case of mobile schwannoma of the cauda equina incarcerated following caudal migration after trauma, manifesting as attack of severe back pain and bilateral sciatica which developed just after a fall. Magnetic resonance imaging demonstrated a large intradural tumor at the L4-5 level with redundant nerve roots below that. Two days before the surgery, his pain unexpectedly lessened without additional treatment. Computed tomography showed that the tumor had migrated cranially and was now located at the L3-4 level. These findings suggest that the severe symptoms were caused by incarceration of a mobile tumor at the L4-5 level following the trauma. The tumor was successfully removed using minimally invasive procedures with guidance provided by the intraoperative myelography. The patient was relieved from pain postoperatively. The histological diagnosis was schwannoma. This case suggests that intraoperative myelography is a useful method for guiding the removal of mobile tumors.

Radiculopathy caused by osteoporotic vertebral fractures in the lumbar spine.

The clinical features of radiculopathy caused by osteoporotic vertebral fractures (OVFs) in the lumbar spine were investigated in 66 patients treated for pain caused by OVFs from January 2006 to December 2009. Ten of the patients complained of persistent radiculopathy. The cause of radiculopathy was initially diagnosed as lumbar canal stenosis (LCS) in seven patients, lumbar foraminal stenosis (LFS) in two, and both in one. One patient with LFS had reduced pain with conservative treatment, and the other nine needed surgical treatments. LCS was treated with posterior decompression, and LFS complicated with LCS at the same spinal level was treated with posterior lumbar interbody fusion (PLIF). Vertebroplasty was performed for one patient with LFS to attain indirect nerve root decompression achieved as a result of vertebral reconstruction and stabilization. Four of the patients treated with posterior decompression for LCS suffered from residual radiculopathy postoperatively, which was caused by LFS at the same level or the level below the treated level. Two patients underwent second operative procedure (PLIF) for recurrent radiculopathy. The Japanese Orthopedic Association and Visual Analogue Scale scores of the pain improved after operations, but the scores of the patients treated without spinal fusion gradually worsened during the follow-up period, whereas the scores of the patients treated with PLIF remained stable at various levels. Seven of the ten patients developed LFS following OVF, suggesting that radiculopathy following OVF involves LFS with high frequency.

Spray-irrigation system attached to high-speed drills for simultaneous prevention of local heating and preservation of a clear operative field in spinal surgery.

Heat generation due to drilling during spinal surgery is potentially hazardous to nerves. Saline irrigation is often performed to prevent such local heating, but sometimes floods and obscures the operative field. We have developed a spray-irrigation system for attachment to high-speed drills, which sprays saline solution with an air-jet in the direction of the surface cut by the drill. We anticipated that this air jet would create a clearer operative view by displacing excess fluid, and would also provide an added cooling effect greater than that of irrigation with saline. This study was designed to evaluate these predicted effects of the spray-irrigation system compared to conventional irrigation. A thermography study was performed to confirm the cooling effect of the spray-irrigation system. A plaster board coated with adhesives was drilled at 100,000 rpm along a 10-cm line for a duration of 20 seconds. Thermograms were recorded every minute, without cooling, with irrigation, and with the spray-irrigation system. To examine the operative views, continuous drilling for a period of seconds was performed with conventional irrigation and with the spray-irrigation system. Local heating was inhibited by the spray-irrigation system to 14-30% of that with irrigation. A clear operative field was maintained during continuous drilling using the spray-irrigation system through the air-jet action of the system. The spray-irrigation system can simultaneously provide effective cooling and a clear operative field during surgical manipulations with high-speed drills.