Endoscopic endonasal extreme far-medial approach for a lower clivus osteochondroma in a patient with hereditary multiple exostoses: illustrative case.

BACKGROUND: The authors reported on the use of endoscopic endonasal surgery (EES) for clivus osteochondroma in a patient with hereditary multiple exostoses (HME), a rare pediatric disorder characterized by the formation of osteochondromas adjacent to the growth plates of the axial and appendicular skeletal elements. OBSERVATIONS: A 26-year-old man with a family history of HME reported progressive hoarseness and dysphagia over the previous 6 months. He was referred to us after magnetic resonance imaging (MRI) showed a bone tumor in the lower clivus. MRI revealed tumor proliferation in the lower clivus and its extension to the bilateral occipital condyle and jugular tubercle. The hypoglossal canal and jugular foramen were encased on the right side, whereas the medulla oblongata was compressed. The tumor was subtotally resected with EES, and the brainstem was successfully decompressed. The pathological diagnosis was exostoses. Transient postoperative worsening of dysphagia improved within 1 month without other neurological deficits. The patient underwent posterior occipitoaxial fixation 3 months after EES to correct instability and local lateral tilt of the right atlanto-occipital joint. LESSONS: The authors' experience showed that EES is effective for resection of lower clivus osteochondromas, including the cartilaginous cap, and may improve clinical outcomes in patients with HME.

Third primary branch of the posterior ramus of the spinal nerve at the thoracolumbar region: a cadaveric study.

PURPOSE: Spinal column procedures require an accurate understanding of neural pathways relative to the anatomic structure. Since Bogduk's report in 1982, it has been known that the human lumbar posterior ramus of the spinal nerve (PRSN) comprise not two but three primary branches at least in some lumbar segments. The purpose of the current study was to examine the existence of the three primary branches in the thoracic and lumbar segments. METHODS: In this study, we investigated the anatomy of the human PRSN in the thoracic and lumbar segments. Ventral dissection was performed in eight cadavers to determine the anatomy of the PRSN between T1 and L5. RESULTS: At the distal end of a given PRSN, the PRSN divided into three primary branches-medial, intermediate and lateral-in 196 out of 272 segments in the thoracic and lumbar regions in eight cadavers. The medial branch supplied the spinalis compartment, and reached the skin. The lateral branch supplied the iliocostalis muscle compartment, and reached skin. The intermediate branch supplied the longissimus muscle and the area between the medial and the lateral branch, which was a seemingly shorter branch. CONCLUSION: The triplication of the primary branch of the PRSN is considered not uncommon. The third branch should be recognized in the literature and in textbooks.

Posterior inferior cerebellar artery with an extradural origin from the V3 segment: higher incidence on the nondominant vertebral artery.

OBJECTIVE The posterior inferior cerebellar artery (PICA) and the vertebral artery (VA) often exhibit anatomical variations at the craniovertebral junction (CVJ). An example of this is the PICA originating extradurally from the V3 segment of the VA. To date, some cadaveric investigations have been reported, but the incidence and relationship of this variation to the VA and the atlas as observed on clinical imaging have not been discussed. This study evaluated the prevalence of PICAs originating from the V3 on CT scanning. Other variations of the atlas and VA were also analyzed. METHODS CT images from a series of 153 patients who underwent 3D CT angiography (CTA) were analyzed, and variations of the PICA, VA, and atlas were investigated. RESULTS A total of 142 patients (284 sides) were analyzed; 11 patients (7.2%) were excluded due to poor image quality. The most common VA variation was the PICA originating from V3 (9.5% of 284 sides), which was more frequently observed on the nondominant VA than the dominant VA (22.5% vs 6.25%, p = 0.0005). A VA with a PICA end was identified in 4 sides (1.4%), which is the same incidence as observed in the persistent first intersegmental VA (1.4%). VA fenestration was only found in 1 side (0.35%). Regarding the atlas, ponticulus posticus was observed in 24 sides (8.5%). There was no relationship between the incidence of ponticulus posticus and the variations of the VA. CONCLUSIONS A PICA originating from V3 was the most common VA variation at the CVJ and was more common on the nondominant VA. Three-dimensional CTA is useful for the evaluation of this variance. Surgeons should be mindful of this variation during operations.

Expression of the JAK/STAT signaling pathway in the ligamentum flavum of patients with lumbar spinal canal stenosis.

BACKGROUND: Ligamentum flavum (LF) hypertrophy is an important cause of lumbar spinal canal stenosis (LSS), one of the most common spinal disorders in the elderly. Although many cytokines are reported to be associated with LF hypertrophy, the intracellular signaling system is rarely discussed. The purpose of this study was to identify the JAK/STAT signaling pathway and to examine the role of the JAK/STAT systems in the hypertrophied LF. METHODS: The LF of 10 LSS patients was analyzed and the expression of JAK1, STAT3, phosphorylated (p)-STAT3, and actin was examined by Western blot analysis. The expression of p-STAT3 was also examined by immunostaining and its positive cell ratio was compared between LSS and non-LSS samples. We measured the thickness of the LF on magnetic resonance images and studied the relationship between its thickness and the expression of p-STAT3. RESULTS: JAK1, STAT3, and p-STAT3 were detected in almost all samples by Western blot analysis. Immunoreactivity against p-STAT3 was observed mainly in endothelial- and fibroblast-like cells. The expression of p-STAT3 was significantly higher in LSS than non-LSS samples; it was significantly stronger on the dorsal than the dural side of the LF and positively correlated with the thickness of the LF on the dorsal side. CONCLUSIONS: The JAK/STAT signaling pathway is positively correlated with the thickness of the LF. Our findings suggest that JAK1 and STAT3 molecules are involved in and regulate LF hypertrophy.

Improved Vision from Severe Compressive Optic Neuropathy by Apical Cavernous Hemangioma.

A 59-year-old woman had a 1-year history of right vision loss. Her visual acuity was then 0.01 OD, and the critical flicker frequency (CFF) was 8 Hz OD. Goldmann perimetry examination showed inferior suppression of the right visual field center. Funduscopic examination revealed normal coloring of the right optic disc. Imaging studies showed an apical oval tumor. The optic nerve was compressed by both the tumor and the superior rectus muscle/levator palpebrae superioris complex. The tumor was dissected from the surrounding tissues and completely extracted. Histopathologic examination confirmed a cavernous hemangioma. The patient underwent three cycles of postoperative steroid pulse therapy. One year after the surgery, her visual acuity and CFF improved to 1.0 and 32 Hz OD, respectively. Her right visual field was within the normal range.

[Multi-Layered Closure of Transorbital Penetrating Brain Injury without Bone Reconstruction: A Case Report].

A 26-year-old man was injured in a motor vehicle accident. He sustained a compound orbital fracture with brain contusion. The brain tissue protruded through the orbit. Computed tomography showed a long contusion with a moderate amount of hematoma in the right frontal lobe. No foreign body was observed in the cranium. On 3D CTA, the major cerebral vessels were found to be intact. An urgent surgery was first performed by neurosurgeons and subsequently by ophthalmologists. The periosteum was left on the skull. A frontal periosteal, a right temporal fascial, and a right temporal muscular flap were prepared. After debridement and irrigation, the dural tear was closed with the right periosteal and fascial flaps. Finally, the frontal fascia was used to cover the orbital defect. The patient's clinical course was favorable. The patient was able to walk when discharged 46 days after the surgery. A penetrating brain injury through the orbit is rare, and its treatment is not established. A key to successful management of this injury is immediate assessment. Foreign bodies in the cranium, especially metal, should be checked for immediately. The cerebral vessels should also be evaluated. Usually, a surgical intervention is necessary. Since bone reconstruction can be associated with a risk of infection, a multi-layered closure, as described in this report, could prevent leakage of cerebrospinal fluid and subsequent meningitis.

Exploitation of Simple Classification and Space Created by the Tumor for the Treatment of Foramen Magnum Meningiomas.

OBJECTIVE: The resection of foramen magnum meningiomas (FMMs) presents neurosurgical challenges. We propose a simple classification of the tumor location and the operating space created by the tumor to help treatment planning. METHODS: We retrospectively analyzed 16 FMMs and divided them into 3 groups based on the tumor location--clival, foraminal, and atlantal tumors. The distance between the condyle and the neuraxis at the level of the foramen magnum was measured and defined as the available operative space (AOS). We also reviewed intraoperative video recordings to assess the surgical exposure of the tumor by the space created by the FMM and compared it with the AOS. RESULTS: There were 4 clival, 8 foraminal, and 4 atlantal tumors. The AOS of the clival tumors was 10 mm ± 1.7, the AOS of the foraminal tumors was 18 mm ± 3.7, and the AOS of the atlantal tumors was 12 mm ± 2.1. All foraminal and atlantal tumors could be detached without a brain retractor. Because a major portion of the clival tumors was covered by the spinomedullary junction, a brain spatula was needed to obtain the required surgical space. The difference in AOS between clival and foraminal/atlantal tumors was statistically significant (P = 0.044). Although 4 patients experienced postoperative complications, the average postoperative Karnofsky performance scale score improved. The surgical complication rate was significantly lower in foraminal and atlantal FMMs than in clival FMMs (P = 0.027). CONCLUSIONS: The simple classification of the tumor location helped to assess surgical difficulties. Knowledge of the space created by the FMMs between the condyle and the neuraxis is useful for planning the approach strategy, especially for estimating the available working space without resection of the occipital condyle.

Pitfalls in the Management of Atlanto-Occipital Dislocation.

Atlanto-occipital dislocation (AOD) is rarely seen in clinic because it is characteristically immediately fatal. With recent progress in the pre-hospital care, an increasing number of AOD survivors have been reported. However, because the pathophysiology of AOD is not clearly understood yet, the appropriate strategy for the initial management remains still unclear. We report a case of successful AOD treatment and describe important points in the management of this condition. It is important to note that abducens nerve palsy is a warning sign of AOD and that AOD can result in a life-threatening distortion of the arteries and the brain stem. We recommend the application of a halo vest to protect the patient's neural and vascular competence as the immediate initial step in the treatment of AOD. Horn's grading system is useful in assessing indications for surgery. Finally, when performing posterior fixation, C2 should be included because of the anatomy of the ligamentous architecture.

Long-term progressive deterioration of visual function after papilledema improved by embolization of a dural arteriovenous fistula in the sigmoid sinus: a case report.

INTRODUCTION: It is generally believed that people affected by papilledema will not have progressive damage to their eyesight if they receive adequate medical care to treat the underlying cause of the papilledema. We present a case that appears to contradict this widely accepted belief. CASE PRESENTATION: A 53-year-old Japanese man with tinnitus visited our hospital. His initial best-corrected visual acuity in either eye was not impaired, although they both exhibited papilledema. Magnetic resonance imaging did not reveal a mass or hemorrhagic lesion in our patient's brain. Nevertheless, his best-corrected visual acuity gradually deteriorated over the following three months. Angiography demonstrated a dural arteriovenous fistula in his sigmoid sinus. After embolization therapy, the papilledema improved in both eyes. However, over the subsequent four years, his best-corrected visual acuity progressively deteriorated due to an unknown cause, despite the successful embolization of the dural arteriovenous fistula. CONCLUSION: There may be delayed onset of an unknown pathophysiology in the visual system after treatment for the underlying cause of papilledema, implying an uncertain visual prognosis for patients with this condition.

Trumpet laminectomy microdecompression for lumbal canal stenosis.

Microsurgery techniques are useful innovations towards minimizing the insult of canal stenosis. Here, we describe the trumpet laminectomy microdecompression (TLM) technique, advantages and disadvantages. Sixty-two TLM patients with lumbar disc herniation, facet hypertrophy or yellow ligament or intracanal granulation tissue. The symptoms are low back pain, dysesthesia and severe pain on both legs. Spine levels operated Th11-S1; the patients who had trumpet-type fenestration, 62.9% had hypertrophy of the facet joint, 11.3% had intracanal granulation tissue, 79.1% had hypertrophy of the yellow ligament and 64.5% had disc herniation. The average of procedure duration was 68.9 min and intraoperative blood loss was 47.4 mL. Intraoperative complications were found in 3.2% of patients, with dural damage but without cerebrospinal fluid leakage. The TLM can be performed for all ages and all levels of spinal canal stenosis, without the complication of spondilolistesis. The TLM has a shorter duration, with minimal intraoperative blood loss.

Radiographic measurements of C-2 in patients with atlas assimilation.

OBJECT: The object of this study was to evaluate the radiographic characteristics of C-2 using multiplanar CT measurements for anchor screw placement in patients with C-1 assimilation (C1A). Insertion of a C-2 pedicle screw in the setting of C1A is relatively difficult and technically demanding, and there has been no report about the optimal sizes of the pedicles and laminae of C-2 for screw placement in C1A. METHODS: An institutional database was searched for all patients who had undergone cervical CT scanning and cervical spine surgery between April 2006 and December 2012. Two neurosurgeons reviewed the CT scans from 462 patients who met these criteria, looking for C1A and other anomalies of the craniocervical junction such as high-riding vertebral artery (VA), basilar invagination, and VA anomaly. The routine axial images were reloaded on a workstation, and reconstruction CT images were used to measure parameters: the minimum width of bilateral pedicles and laminae and the length of bilateral laminae of the atlas. RESULTS: Seven patients with C1A were identified, and 14 sex-matched patients without C1A were randomly selected from the same database as a control group. The mean minimum pedicle width was 5.21 mm in patients with C1A and 7.17 mm in those without. The mean minimum laminae width was 5.29 mm in patients with C1A and 6.53 mm in controls. The mean minimum pedicle and laminae widths were statistically significantly smaller in the patients with C1A (p < 0.05). CONCLUSIONS: In patients with C1A, the C-2 bony structures are significantly smaller than normal, making C-2 pedicle screw or translaminar screw placement more difficult.

Expression of the JAK/STAT3/SOCS3 signaling pathway in herniated lumbar discs.

The inflammatory cytokine interleukin-6 (IL-6) plays an important role in causing symptoms of lumbar disk herniation. The present study clarifies the expression of the signaling pathway of IL-6 in herniated discs. Homogenates prepared from lumbar herniated discs from 10 patients were assessed. The expression of janus kinase 1 (JAK1), signal transducer and activator of transcription 3 (STAT3), phosphorylated (p)-STAT3 at Tyr(705), suppressor of cytokine signaling 3 (SOCS3) and actin was examined by Western blot analysis. The expression of JAK1, STAT3, and p-STAT3 at Tyr(705) was also examined by immunostaining. JAK1, STAT3, p-STAT3 at Tyr(705) and SOCS3 were detected in almost all cases. Immunoreactivity against JAK1 and STAT3 was observed mainly in chondrocytes, whereas immunoreactivity against p-STAT3 at Tyr(705) was observed in the nuclei of chondrocytes. The JAK/STAT signaling pathway might be activated by IL-6 and transmit messages from the cell surface to the nucleus, and the pathway is negatively regulated by SOCS3. These JAK1, STAT3 and SOCS3 molecules might tightly regulate and play a role in the degeneration of chondrocytes within herniated discs.

A simple, 10-minute procedure for transforaminal injection under ultrasonic guidance to effect cervical selective nerve root block.

The aim is to provide a detailed procedure of a simple and 10-minute cervical nerve root block (CNRB) under ultrasonic guidance, and to report the clinical outcomes, disorders, and complications. Records of patients who had undergone CNRB, were reviewed under ultrasonic guidance at the hospital from 2010 through 2012. The procedure is described in detail. Arm and shoulder pain was evaluated by use of the visual analogue scale (VAS). Forty-three patients agreed to undergo CNRB under ultrasonic guidance. Nerve roots from C5 to C8 were affected in 41, and these nerve roots were readily distinguished. Two of the 43 participants did not receive injections because impediments in visualizing the affected nerve root. Of the 41 who received injections, radicular pain immediately disappeared in 39, who continued to feel pain relief 1 month later. However, pain recurred in 15 patients (38%), of whom 11 underwent cervical spine surgery. The rest of 24 patients felt sustained pain relief longer than 3 months after the injection, significantly. Although one patient had recurrent radicular pain 10 months later, the pain could be controlled by medication. At the final follow-up periods, 17.2 (10-24 months), the median VAS score of the patients, 23 (0 to 71 mm), was significantly improvement (P = 0.001) in comparison to before injection 88 (range; 56-100). No complications occurred. The cervical nerve root block under ultrasonic guidance simply, safely, and efficaciously decreased radicular pain for 17.2 months in 62% patients with intolerable radicular pain.

Cervical radiculopathy due to disc herniation with adjacent facet hypertrophy: case report.

We report a rare case of cervical radiculopathy associated with facet hypertrophy and disc herniation. The patient was a 38-year-old woman with sudden-onset left arm pain. As conservative therapy failed to alleviate her symptoms she was referred to us. On physical examination she manifested no neurological deficits except pain and dysesthesia in the left C7 territory. Computed tomography revealed hypertrophic ossified changes in the left T1 facet joint with encroachment on the spinal canal. Magnetic resonance imaging showed compression of the spinal cord at C6/7 by disc herniation at C6/7. Anterior cervical decompression and fusion by corpectomy (C7 corpectomy and C6/T1 fixation with a titanium cage) ameliorated her pain. Facet hypertrophy in a morphologically normal cervicothoracic spine is extremely rare and its etiology is unknown. We speculate the possibility that our patient harbored a congenital anomaly and that the morphologic changes were the consequence of an injury she sustained in a traffic accident.

Plasmapore-coated titanium cervical cages induce more rapid and complete bone fusion after anterior cervical discectomy and fusion as compared to noncoated titanium cages.

OBJECTIVE: The aim of this study was to examine the solid bone fusion rates between Plasmapore-coated titanium cages (PPC group) and non-Plasmapore-coated titanium cages (N-PPC group) in patients who received anterior cervical decompression and fusion (ACDF). METHODS: Of 78 patients who received ACDF at the hospital, a follow-up period greater than 2 years was possible for 61 patients, including 30 in the PPC group and 42 in the N-PPC group. Evaluations were performed at 3, 6, 12, and 24 months after surgery. Radiological stabilization (RS) was defined as the restriction of spinous process movement to <3 mm and the absence of a halo around the cages on flexion-extension radiographs. Solid bone fusion (SBF) was defined as the formation of bony bridges between the fixed vertebral bodies in sagittal computed tomography sections. The rates of RS and SBF were compared between both groups. RESULTS: The differences in RS were not significant between the 2 groups during the follow-up period. However, the SBF rates at 6 and 12 months were significantly higher in the PPC group (26.7% and 56.7%) than in the N-PPC group (5% and 21.4%). Moreover, 63.3% (19 of 30) of patients in the PPC group demonstrated RS at 3 months, and of these patients, SBF was observed in 100% (19 patients) after 24 months, respectively. In comparison, the SBF rates in the N-PPC group were 86%. CONCLUSIONS: Plasmapore-coated titanium cages enabled more rapid solid bone fusion. We suggest that these types of cages might help to reduce postoperative radiograms.

Activation of JAK-STAT3 signaling pathway in chronic subdural hematoma outer membranes.

Chronic subdural hematoma (CSDH) is an inflammatory disease, the mechanism of which still remains to be elucidated. Interleukin-6 (IL-6), one of the inflammatory cytokines regulating janus kinase (JAK)-signal transducer and activator of transcription (STAT) signaling pathway, is expressed in human CSDH fluid. The status of this signaling pathway in human CSDH outer membranes was examined in the present study using outer membranes obtained during trepanation surgery. Concentrations of IL-6 in human CSDH fluids were measured using an enzyme immuno-assay kit. Expression patterns of JAK1, STAT1, phosphorylated (p)-STAT1 at Tyr(701) and at Ser(727), STAT3, p-STAT3 at Tyr(705) and at Ser(727) and actin in outer membranes were examined by Western blot analysis and immunohistochemistry. IL-6 is significantly expressed in human CSDH fluids compared with control cerebrospinal fluid. JAK1, STAT1 and STAT3 were detected in all cases. The expression of p-STAT3 at Tyr(705) is more significant compared with that of p-STAT1 at Tyr(701). In some cases, p-STAT3 at Ser(727) could also be detected, while p-STAT1 at Ser(727) could not. The localizations of STAT1 and STAT3 were revealed to be present in fibroblasts in human CSDH outer membranes, especially when p-STAT3 at Tyr(705) was in the nuclei of fibroblasts. These findings suggest that JAK1-STAT3 signaling is dominantly activated in fibroblasts of human CSDH outer membranes compared with STAT1 and indicate the possibility that this JAK1-STAT3 pathway might be activated by IL-6 and play a critical role in progression of human CSDH.

Transvertebral anterior key hole foraminotomy without fusion for the cervicothoracic junction.

BACKGROUND: Various surgical procedures have been used to repair disc herniations and osteophytes at the cervicothoracic junction. Among these procedures, transvertebral anterior foraminotomy without fusion is a relatively less invasive, safe and useful method, although the majority of spinal surgeons remain unfamiliar with this method. We describe the surgical procedure for a transvertebral anterior keyhole foraminotomy without fusion at the cervicothoracic junction, and we assess the middle-term clinical and radiological outcomes. METHODS: Of 118 patients undergoing this surgery in our institute between 2007 and 2010, five (4.2 %) had C8 radiculopathy causing C7/T1 disc herniations or osteophytes. We studied five patients who underwent trans-C7 vertebral keyhole foraminotomy without fusion. We retrospectively examined clinical data, pre- and postoperative neurological status. RESULTS: In all cases, surgical decompression was successfully achieved without difficulty when accessing the pathology. No complications related to the surgical procedure were reported. The follow-up period was 12-28 (mean 20) months. In all patients, the visual analogue scale (VAS) due to radicular pain immediately decreased after the operation and did not increase thereafter. The mean VAS decreased from 7.8 (4.5-9.6) to 1.0 (0-2.1). The Cobb angle at C2-T1 in a neutral position improved from -12.6 (-2.8 to -24.7) degrees to -6.9 (4.2 to -25.4). The postoperative C7/T1 disc height decreased from 5.4 to 4.9 mm, indicating minimal loss. CONCLUSIONS: This procedure allows for direct access to the pathology and is less invasive. In this study, we clarified that this technique yields excellent radiological and clinical outcomes.