Charcot spinal disease after spinal cord injury.

OBJECT: The authors investigated the background, risk factors, and treatment strategies for Charcot spinal disease (CSD) after spinal cord injury (SCI). METHODS: The authors retrospectively examined the clinical and radiological findings in 9 patients with a total of 10 Charcot spine lesions that occurred after SCI. The mean age of the 9 patients was 54 years, and all patients presented with complete SCIs. In all but 1 patient, symptoms did not develop until 10 years postinjury. All 10 Charcot spine lesions were located below the thoracolumbar junction. Surgical treatment was performed in 7 patients (7 lesions), and the mean duration of postoperative follow-up was 84 months. RESULTS: All patients reported audible noises when changing posture, 5 of 9 patients reported low-back pain, and 7 patients displayed increasing instability while sitting. In 8 patients, spasticity disappeared and limbs became flaccid several years after SCI. Two patients had associated bacterial infections in the Charcot spine lesions, and 1 patient complained of autonomic dysreflexic symptoms associated with trunk movements. Although postoperative complications occurred in 3 patients, all patients who underwent surgical treatment made a good recovery and were able to return to daily life in a wheelchair. On lateral radiography, the mean range of motion at the lesion site was 43 degrees , and fluid collections between the involved vertebrae were observed in 8 patients on MR images; ankylosing spinal hyperostosis was observed in 7 patients. Charcot spine lesions tended to occur at the junction between or at the end of an ankylosing spinal hyperostotic lesion. Postoperatively, solid arthrodesis was obtained within 6 months in all surgically treated lesions. CONCLUSIONS: Disappearance of spasticity in the lower extremities is thought to be an important physical sign suggestive of CSD after SCI. Sitting imbalance and the fluid volume of the Charcot spinal lesions are related to range of motion at the lesion site. In addition to a combined approach, a single posterior approach with acquisition of anterior support is an option for surgical treatment even in cases of infected CSD.

Lumbosacral reconstruction for intractable pyogenic spondylitis using a total leg flap with a vascularized tibia graft.

This report describes an effective technique of using a total leg flap for treating a 57-year-old male paraplegic patient with intractable sacral pyogenic spondylitis caused by methicillin-resistant Staphylococcus aureus. Spondylitis was accompanied by severe instability of the lumbosacral area, a large lumbosacral ulcer, and a large bone and muscle defect, which made it difficult for the patient to maintain a sitting position. A total leg flap procedure, a modification of the total thigh flap procedure, was performed as a 1-stage salvage surgery. The vascularized tibia and fibula were grafted between the lumbar and sacral vertebrae, and a musculocutaneous flap was used to cover the extensive ulceration in the lumbosacral skin defect. The intractable lesion of the lumbosacral spine, which had not been cured for more than 2 years despite repeated debridement, intravenous antibiotic injections, sugar treatment, pyoktanin treatment, and hyperbaric O(2) treatment, subsided and stabilized within 1 year of surgery. The patient returned to activities of daily living using a wheelchair, and was very satisfied with the results. Use of a total leg flap with a vascularized tibia graft is an effective treatment for intractable pyogenic spondylitis accompanied by a large bone defect and large lumbosacral ulcers.

Expression of parsley flavone synthase I establishes the flavone biosynthetic pathway in Arabidopsis thaliana.

Arabidopsis thaliana lacks the flavone biosynthetic pathway, probably because of a lack or low activity of a flavone synthase. To establish this biosynthetic pathway in Arabidopsis, we subjected this model plant to transformation with the parsley gene for flavone synthase type I (FNS-I). Transgenic seedlings expressing FNS-I were cultured in liquid medium with or without naringenin, and plant extracts were then analyzed by high-performance liquid chromatography. In contrast to wild-type seedlings, the transgenic seedlings accumulated substantial amounts of apigenin, which is produced from naringenin by FNS-I, and the apigenin level correlated with the abundance of FNS-I mRNA in three different transgenic lines. These results indicate that the FNS-I transgene produces a functional enzyme that catalyzes the conversion of naringenin to apigenin in Arabidopsis. These FNS-I transgenic lines should prove useful in investigating the in vivo functions of enzymes that mediate the synthesis of the wide variety of flavones found in other plants.

Repair of cervical esophageal perforation using longus colli muscle flap: a case report of a patient with cervical spinal cord injury.

BACKGROUND CONTEXT: Perforation of the esophagus after anterior cervical spine surgery is a rare, but well-recognized complication. The management of esophageal perforation is controversial, and either nonoperative or operative treatment can be selected. PURPOSE: Several reports have described the use of a sternocleidomastoid muscle flap for esophageal repair. In this case report, we describe a longus colli muscle flap as a substitute for a sternocleidomastoid flap in a patient with an esophageal perforation. STUDY DESIGN: Case report. PATIENT SAMPLE: A 20-year-old man sustained cervical spinal cord injury, on diving and hitting his head against the bottom of a pool. A C6 burst fracture was observed with posterior displacement of a bone fragment into the spinal canal. The patient exhibited complete paralysis below the C8 spinal segment level. METHODS: The patient underwent subtotal corpectomy of the sixth cervical vertebra with the iliac bone graft and augmented posterior spinal fixation (C5-7) with pedicle screws. After the primary operation, the patient showed signs of infection such as throat pain, a high fever, and osteolytic change of the grafted bone by cervical radiograph. A second operation was performed to replace the graft bone using fibula. On the day after the operation, food residue was confirmed in the suction drainage tube, suggesting esophagus perforation. A third operation was immediately performed to confirm and treat esophagus perforation, although apparent esophageal perforation could not be detected at the second operation. Because the erosion around the perforation of the esophageal posterior wall was extensive, a longus colli muscle flap transposition was accordingly performed into the interspace between the esophageal posterior wall and the grafted bone in addition to simple suturing of the perforation. RESULTS: Neither high fever nor pharyngeal pain has recurred at latest follow-up, 5 years after surgery. CONCLUSIONS: To the best of our knowledge, this is the first report concerning the use of a longus colli muscle flap for esophageal perforation after anterior cervical spine surgery.

Surgical outcomes of posterior lumbar interbody fusion in elderly patients. Surgical technique.

BACKGROUND: We are aware of no reports on the surgical results of posterior lumbar interbody fusion in elderly patients. The purpose of this study was to investigate the clinical and radiographic results of posterior lumbar interbody fusion with pedicle screws in patients older than seventy years of age and compare them with results in younger patients. We also investigated the association between the clinical and radiographic results. METHODS: The study included 101 patients who had been followed for at least three years after posterior lumbar interbody fusion with pedicle screws for the treatment of L4-L5 degenerative spondylolisthesis. The average follow-up period was fifty months. The patients were divided into two groups according to their age at the time of the operation: Group 1 included thirty-one patients who were seventy years of age or older (average age, seventy-four years) at the time of the operation, and Group 2 included seventy patients who were less than seventy years old (average age, fifty-nine years). Preoperative and postoperative status (according to the Japanese Orthopaedic Association scoring system) and postoperative complications were compared between the two groups. Postoperative radiographic features, including fusion status and segmental lordosis, were also examined. RESULTS: No significant differences in preoperative and postoperative scores were observed between the two age groups, with the numbers available. General complications were found in Group 1. However, the prevalence of adjacent segment degeneration in Group 1 was lower than that in Group 2. The radiographic results revealed no significant difference in the prevalence of segmental lordosis, with the numbers available. There was no nonunion in either group. Although the prevalence of either collapsed union or delayed union in Group 1 was significantly higher than that in Group 2 (p = 0.034), the fusion results such as union in situ, collapsed union, and delayed union did not appear to affect the postoperative clinical results in this study. CONCLUSIONS: No obvious differences in the clinical results were observed between the age groups with the numbers available. Postoperative adjacent segment degeneration was less frequent and collapsed union and delayed union were more common in the elderly group. The fusion results did not appear to affect the postoperative clinical results in this study.

Surgical outcomes of posterior lumbar interbody fusion in elderly patients.

BACKGROUND: We are aware of no reports on the surgical results of posterior lumbar interbody fusion in elderly patients. The purpose of this study was to investigate the clinical and radiographic results of posterior lumbar interbody fusion with pedicle screws in patients older than seventy years of age and compare them with results in younger patients. We also investigated the association between the clinical and radiographic results. METHODS: The study included 101 patients who had been followed for at least three years after posterior lumbar interbody fusion with pedicle screws for the treatment of L4-L5 degenerative spondylolisthesis. The average follow-up period was fifty months. The patients were divided into two groups according to their age at the time of the operation: Group 1 included thirty-one patients who were seventy years of age or older (average age, seventy-four years) at the time of the operation, and Group 2 included seventy patients who were less than seventy years old (average age, fifty-nine years). Preoperative and postoperative status (according to the Japanese Orthopaedic Association scoring system) and postoperative complications were compared between the two groups. Postoperative radiographic features, including fusion status and segmental lordosis, were also examined. RESULTS: No significant differences in preoperative and postoperative scores were observed between the two age groups, with the numbers available. General complications were found in Group 1. However, the prevalence of adjacent segment degeneration in Group 1 was lower than that in Group 2. The radiographic results revealed no significant difference in the prevalence of segmental lordosis, with the numbers available. There was no nonunion in either group. Although the prevalence of either collapsed union or delayed union in Group 1 was significantly higher than that in Group 2 (p = 0.034), the fusion results such as union in situ, collapsed union, and delayed union did not appear to affect the postoperative clinical results in this study. CONCLUSIONS: No obvious differences in the clinical results were observed between the age groups with the numbers available. Postoperative adjacent segment degeneration was less frequent and collapsed union and delayed union were more common in the elderly group. The fusion results did not appear to affect the postoperative clinical results in this study.

Surgical complications of posterior lumbar interbody fusion with total facetectomy in 251 patients.

OBJECT: Previous studies of surgical complications associated with posterior lumbar interbody fusion (PLIF) are of limited value due to intrastudy variation in instrumentation and fusion techniques. The purpose of the present study was to examine rates of intraoperative and postoperative complications of PLIF using a large number of cases with uniform instrumentation and a uniform fusion technique. METHODS: The authors reviewed the hospital records of 251 patients who underwent PLIF for degenerative lumbar disorders between 1996 and 2002 and who could be followed for at least 2 years. Intraoperative, early postoperative, and late postoperative complications were investigated. Intraoperative complications occurred in 26 patients: dural tearing in 19 patients and pedicle screw malposition in seven patients. Intraoperative complications did not affect the postoperative clinical results. Early postoperative complications occurred in 19 patients: brain infarction occurred in one, infection in one, and neurological complications in 17. Of the 17 patients with neurological complications, nine showed severe motor loss such as foot drop; the remaining eight patients showed slight motor loss or radicular pain alone, and their symptoms improved within 6 weeks. Late postoperative complications occurred in 17 patients: hardware failure in three, nonunion in three, and adjacent-segment degeneration in 11. Postoperative progression of symptomatic adjacent-segment degeneration was defined as a condition that required additional surgery to treat neurological deterioration. CONCLUSIONS: The most serious complications of PLIF were postoperative severe neurological deficits and adjacent-segment degeneration. Prevention and management of such complications are necessary to attain good long-term clinical results.

Risk factors for adjacent segment degeneration after PLIF.

STUDY DESIGN: A retrospective study of 87 patients who underwent posterior lumbar interbody fusion (PLIF) at L4-L5 for L4 degenerative spondylolisthesis. OBJECTIVE: To clarify: 1) the correlation between radiologic degeneration of cranial adjacent segment and clinical results, 2) risk factors for radiologic degeneration of cranial adjacent segment, and 3) preoperative radiologic features of patients who underwent additional surgery with cranial adjacent segment degeneration. SUMMARY OF BACKGROUND DATA: Whereas PLIF with pedicle screw fixation has shown satisfactory clinical results, a solid fusion has been reported to accelerate a degenerative change at unfused adjacent levels, especially in the cranial level. Although several authors have reported the adjacent segment degeneration after PLIF, there are no previous reports of risk factors for adjacent segment degeneration after PLIF. MATERIALS AND METHODS: Eighty-seven patients who underwent PLIF for L4 degenerative spondylolisthesis and could be followed for at least 2 years were included in this study. We measured lumbar lordosis, scoliosis, laminar inclination angle at L3, facet sagittalization at L3-L4, facet tropism at L3-L4, preexisting disc degeneration at L3-L4, and lordosis at the fused segment. Progression of L3-L4 segment degeneration was defined as a condition in which disc narrowing, posterior opening, and progress of slippage in comparison with preoperative dynamic lateral radiographs. Patients were divided into three groups according to postoperative progression of L3-L4 degeneration: Group 1 with neither progression of L3-L4 degeneration nor neurologic deterioration, Group 2 with progression of L3-L4 degeneration but no neurologic deterioration, and Group 3 with an additional surgery required for neurologic deterioration. Correlation between clinical results and radiologic progression of L3-L4 degeneration, and risk factors for progression of radiologic degeneration were investigated. Further, preoperative radiologic features of Group 3 were studied to detect risk factors for clinical deterioration. RESULTS: There were 58 (67%) patients classified into Group 1, 25 (29%) patients into Group 2, and 4 (4%) patients into Group 3. There was no significant difference in average age in each group. No obvious difference was observed in recovery rate between Groups 1 and 2. Laminar inclination angle and facet tropism in Group 3 were more significant than those in Groups 1 and 2. Further, apparent lamina inclination and facet tropism coexisted in Group 3. There were no obvious differences in other factors between each group. CONCLUSION: 1) There was no correlation between radiologic degeneration of cranial adjacent segment and clinical results. 2) Risk factors for postoperative radiologic degeneration could not be detected in terms of each preoperative radiologic factor. 3) Coexistence of horizontalization of the lamina at L3 and facet tropism at L3-L4 may be one of the risk factors for neurologic deterioration resulting from accelerated L3-L4 degenerative change after L4-L5 PLIF.

Cervical kyphosis: predictive factors for progression of kyphosis and myelopathy.

STUDY DESIGN: A retrospective study of 13 patients with cervical kyphosis. The authors propose new methods of measuring spinal cord compression and predicting the progression of kyphosis. OBJECTIVES: To ascertain predictive factors for progression of cervical kyphosis and myelopathy. SUMMARY OF BACKGROUND DATA: Cervical kyphosis may be congenital, result from decompression surgery, or occur as a posttraumatic deformity. Although there is the potential for progressive deformity and the development of myelopathy in all these situations, there are few previous reports of predictive factors for progression of cervical kyphosis and myelopathy in patients with cervical kyphosis. METHODS: The authors studied radiographs and magnetic resonance imaging scans of 13 patients with cervical kyphosis, including 9 who had been operated on and had postsurgical secondary kyphosis, and 4 with idiopathic kyphosis without any of the above causes. Compression of the spinal cord at the apex of the cervical kyphosis was evaluated by magnetic resonance imaging of the ratio between the anteroposterior diameter of the medulla-pons junction and the spinal cord at the apex. RESULTS: The mean ratio between the anteroposterior diameter of the medulla-pons junction and the spinal cord at the apex in five patients in whom myelopathy did not develop was 0.37, and was 0.21 in the patients in whom myelopathy developed. Progression of cervical kyphosis was associated with osteophyte formation at the anterior aspect of the vertebral body. CONCLUSION: A ratio below 0.3 between the anteroposterior diameter of the medulla-pons junction and the spinal cord at the apex was a risk factor for cervical myelopathy. One of the most predictable risk factors of progression of the cervical kyphosis was osteophyte formation at the anterior aspect of the vertebral body.