Combined cervical laminoplasty and foraminotomy for coexistence of cervical myelopathy and unilateral radiculopathy: case series and preliminary results.

BACKGROUND: The clinical outcomes and radiographic changes of a one-stage procedure combining cervical laminoplasty and unilateral cervical foraminotomy for patients with coexisting cervical myelopathy and unilateral radiculopathy were evaluated. METHODS: Seven patients (two females and five males) with coexisting cervical myelopathy and unilateral cervical radiculopathy were included in this study. The mean age was 58.4 years (range 45-77 years). Cervical laminoplasty and unilateral cervical foraminotomy were performed on the recruited patients in a single stage. The quantitative clinical changes between the preoperative and 6-month postoperative assessment were analyzed using the Japanese Orthopedic Association (JOA) score, the JOA Cervical Myelopathy Evaluation Questionnaire (JOA-CMEQ), visual analog scale (VAS), and Neck Disability Index (NDI). Moreover, the preoperative and 6-month postoperative radiographic changes were assessed using the C2-7 angle and range of motion (ROM) between flexion and extension angle. RESULTS: There were significant differences in QOL in the JOA-CMEQ between the groups. Furthermore, the postoperative VAS values in the arms and hands generally improved, although not significantly, between the groups. CONCLUSIONS: The aforementioned surgical procedure may be safe and efficient for patients with coexisting cervical myelopathy and radiculopathy.

Intraoperative cone-beam CT with metal artifact reduction for assessment of the electrode position and the intracranial structures during deep brain stimulation procedure.

BACKGROUND: In deep brain stimulation (DBS) for Parkinson's disease (PD), the clinical outcome largely depends on the appropriate position of the electrode implanted in the targeted structure. In intraoperative cone-beam computed tomography (CT) performed for the evaluation of the electrode position, the metal artifact induced by the implanted electrode can prevent the precise localization of the electrode. Metal artifact reduction (MAR) techniques have been recently developed that can dramatically improve the visualization of objects by reducing metal artifacts after performing cone-beam CT. Hence, in this case series, we attempted to clarify the usefulness and accuracy of intraoperative cone-beam CT with MAR (intraCBCTwM) by comparing with both intraoperative cone-beam CT without MAR (intraCBCTwoM) and conventional postoperative CT (post-CT) for the assessment of the implanted electrode position and the intracranial structures during DBS procedures. METHODS: Between November 2019 and December 2020, 10 patients with PD who underwent DBS at our institution were recruited, and the images of 9 patients (bilateral: n = 8, unilateral: n = 1) were analyzed. The artifact index (AI) in intraCBCTwM or intraCBCTwoM, and conventional post-CT were retrospectively assessed using the standard deviation of the region-of-interest around the implanted electrodes and background noise. Additionally, the Euclidean distances gap of electrode tip based on post-CT in each fusion image was compared between intraCBCTwM and intraCBCTwoM. RESULTS: The AI was significantly lower in intraCBCTwM than in intraCBCTwoM (P < 0.01). The mean Euclidean distance between the tip of the electrode in intraCBCTwM and in post-CT was significantly shorter compared to that in intraCBCTwoM (P < 0.05). CONCLUSIONS: The results reported here suggest that intraCBCTwM is a more useful and accurate method than intraCBCTwoM to assess the implanted electrode position and intracranial structures during DBS.

Flexible endoscopically assisted evacuation of acute and subacute subdural hematoma through a small craniotomy: preliminary results.

BACKGROUND: The first choice to treat acute subdural hematoma (SDH) is a large craniotomy under general anesthesia. However, increasing age or comorbid burden of the patients may render invasive treatment strategy inappropriate. These medically frail patients with SDH may benefit from a combination of small craniotomy and endoscopic hematoma removal, which is less invasive and even available under local anesthesia. Although hematoma evacuation with a rigid endoscope for acute or subacute SDHs has been reported in the literature, use of a flexible endoscope may have distinct advantages. In this article, we attempted to clarify the utility of small craniotomy evacuation with a flexible endoscope for acute and subacute SDH in the elderly patients. METHOD: Between November 2013 and September 2016, a total of 17 patients with acute SDH (15 patients), subacute SDH (1 patient), or acute aggravation of chronic SDH (1 patient) underwent hematoma evacuation with a flexible endoscope at our hospital and were enrolled in this retrospective study. Either under local or general anesthesia, the SDH was removed with a flexible suction tube with the aid of the flexible endoscope through the small craniotomy (3 × 4 cm). Hematoma evacuation rate, improvement of clinical symptoms, and procedure-related complications were evaluated. RESULTS: Hematoma evacuation rate was satisfactory, and statistically significant clinical improvement was observed in postoperative Glasgow Coma Scale in all cases compared to the preoperative assessment. No procedure-related hemorrhagic complications were observed. CONCLUSIONS: The results reported here suggest that small craniotomy evacuation with a flexible endoscope is a safe, effective, and minimally invasive treatment for acute and subacute SDH in selected cases.

Histological Examination of Trousseau Syndrome-Related Thrombus Retrieved Through Acute Endovascular Thrombectomy: Report of 2 Cases.

The mechanism of thrombus formation in Trousseau syndrome remains unclear. The purpose of this study was to investigate specific pathological findings of the thrombi in Trousseau syndrome. The authors report on 2 cases of thrombi in Trousseau syndrome from large cerebral vessels removed by endovascular therapy and compared with thrombi in atherosclerosis or cardiac embolism. The first patient, a 67-year-old man, was transferred to our hospital for sudden onset consciousness disturbance and tetraparesis. He had been diagnosed with stage IV lung cancer. The magnetic resonance (MR) angiography demonstrated basilar artery occlusion. An endovascular thrombectomy was performed. The second patient, an 84-year-old woman, was transferred to our hospital for sudden onset motor aphasia and right-sided motor weakness. She has a history of stage IV pancreatic body cancer. The MR angiography demonstrated left middle cerebral artery occlusion. An endovascular thrombectomy was performed for the floating thrombus. Macroscopic findings of retrieved thrombi were observed immediately after thrombectomy. The thrombi in Trousseau syndrome were white in color and solid against manual compression, whereas thrombi from other causes were red and fragile. In terms of microscopic findings, the thrombi in Trousseau syndrome mainly contained fibrin. On the other hand, thrombi associated with atherosclerosis or cardiac embolism had smaller area of fibrin with a considerable amount of red and white blood cells. The thrombi in Trousseau syndrome, which caused occlusion of large cerebral vessel, almost exclusively consisted of fibrin.

[Three Cases of Moyamoya Disease with a History of Kawasaki Disease].

Here, we report three cases of moyamoya disease with a history of Kawasaki disease. A 33-year-old man was found to have stenotic lesions of the internal carotid arteries(ICAs)on both sides at a nearby hospital where he visited complaining of headache and lisping. He had received immunoglobulin therapy for Kawasaki disease at the ages of 1, 2, and 6 years. MRI showed only a chronic ischemic lesion in the white matter. Angiography showed occlusion at the terminal portion of the ICAs on both sides. He was diagnosed with moyamoya disease, but as he had no symptoms and preserved cerebral blood flow (CBF), he was kept under observation. An 8-year-old boy was diagnosed with moyamoya disease and underwent right encephaloduroarteriosynangiosis at a nearby hospital. He had received immunoglobulin therapy for Kawasaki disease at the age of 1 year. His ischemic symptoms worsened. Although MRI detected no apparent ischemic lesion, angiography revealed severe stenosis at the terminal portions of the ICAs on both sides, and 123I-IMP SPECT showed CBF impairment. Bilateral direct bypass was performed. His father was subsequently also diagnosed with moyamoya disease. A 4-year-old girl with epilepsy was diagnosed with moyamoya disease at a nearby hospital. She had been treated with aspirin for Kawasaki disease at the age of 1 year. MRI detected no remarkable ischemic lesions, but angiography revealed mild stenosis at the terminal portions of the ICAs on both sides. Five months later, her ischemic symptoms were worsening with progressing stenotic lesions, and she underwent bilateral direct bypass.

Primary extranodal marginal zone mucosa-associated lymphoid tissue-type B-cell lymphoma involving the dura: A case report.

Background: Primary extranodal marginal zone mucosa-associated lymphoid tissue-type B-cell lymphoma (EMZMBCL), which presents as a dural mass, is a rare intracranial tumor that mimics a subdural hematoma or meningioma. Case Description: A 49-year-old woman presented to our hospital with transient right upper limb paresis, dysarthria for 10 min, and ongoing right upper-limb numbness. Computed tomography (CT) of the head revealed extra-axial lesions in the left frontal and parietal lobes. Based on the initial CT findings in the emergency room, an acute subdural hematoma was suspected. However, meningiomas and other intracranial tumors were also listed as differential diagnoses because there was no history of head trauma or coagulation abnormalities on blood examination, and further imaging studies were performed. Imaging findings suggested a subdural neoplastic lesion. A partial resection was performed for the lesion. Based on histopathological and immunohistochemical examinations, the patient was diagnosed with EMZMBCL. Whole-brain and intensity-modulated radiation therapies were administered as adjuvant therapies. The patient was discharged without neurological deficits. Conclusion: EMZMBCL is a rare disease that should be considered in the differential diagnosis of subdural lesions, especially when there is no history of trauma or abnormalities in the coagulation system. The patient had a favorable outcome after selecting radiotherapy as the adjuvant therapy.

Tailor-Made Surgical Strategy for Coexistent Cervical Myelopathy and Bilateral Radiculopathy. Combined Laminoplasty, Laminectomy, and Foraminotomy: Report of Two Cases.

Cervical spondylosis is a common and degenerative disease consisting of myelopathy and radiculopathy. Surgical treatment can be considered for patients with cervical spondylosis resulting in severe pain, motor weakness, ambulation difficulty, and urination disorder. As myelopathy and radiculopathy often coexist, two-staged anterior and posterior fixation/decompression surgery can be selected to resolve those two pathologies. However, due to the invasiveness of that management, posterior surgery in a single session seems favorable. In this study, we present two cases of cervical spondylosis. A 67-year-old man was complaining of pain in the neck and right upper extremity. Radiographically, cervical canal stenosis was concurrently diagnosed with the foraminal stenosis of the left C3/4 and right C6/7. Laminoplasty from C3 to C6 (left open; C3 to C5, right open; C6) and foraminotomy of the left C3/4 and right C6/7 were performed in a single session. Another 43-year-old man was bothered by pain in the neck and bilateral upper extremities resulting from cervical canal stenosis and bilateral foraminal stenosis of C6/7. Laminoplasty from C3 to C5, laminectomy of C6, and foraminotomy of bilateral C6/7 were performed in a single session. Preoperative symptoms were remitted in both cases. As described in our cases, a tailor-made combination of laminoplasty, laminectomy, and foraminotomy can effectively resolve cervical spondylosis in a single session.

A Progressive Spontaneous Cervical Compression Fracture Over Years Following Long-Term Corticosteroid Use.

Spontaneous vertebral compression fractures in the cervical region can have a significant impact on a patient's condition even after surgical management. Due to the rarity of spontaneous cervical vertebral compression fractures and the lack of a comprehensive description of this condition, the establishment of a clear understanding of its natural course remains incomplete. In this case study, a 73-year-old woman on long-term corticosteroid therapy underwent combined anterior and posterior fixation for a spontaneous vertebral compression fracture at the C3-C4 level. The vertebral compression fracture gradually worsened over a span of four years. Following the surgery, the patient experienced a temporary improvement in her neurological symptoms. However, seven months after the second operation, an instrumentation failure resulted in the patient becoming bedridden. This highlights the importance of considering the potential long-term implications and monitoring patients closely even after surgical intervention.

Cervical dumbbell-type tumor spontaneously shrinking following an ischemic stroke.

Background: Asymptomatic cervical dumbbell-type tumors can be incidentally diagnosed. Notably, the chronological changes in the size of these tumors have not been satisfactorily described. Case Description: A 57-year-old man was clinically followed for an asymptomatic cervical dumbbell-type tumor that had the appearance of a schwannoma on magnetic resonance (MR) images obtained over a 7-year period. Notably, the tumor compressed both the spinal cord and the right vertebral artery. At the end of the 7-year period, the patient sustained a cerebral infarction due to atherosclerosis of the right vertebral artery; the angiogram revealed both atherosclerosis and the tumor compressing the right vertebral artery. After the stroke/ischemic event, the tumor progressively shrunk on MR images obtained for the following 4 years, and the spinal cord compression was similarly relieved. Conclusion: Here, we report on a 57-year-old man with cervical MR images revealing that a cervical dumbbell schwannoma was progressively compressing both the spinal cord and the right vertebral artery. However, following a cerebral infarction, the tumor underwent spontaneous shrinkage over the next 4 years, thus relieving the compression.

A case of anterior arch fracture of the atlas associated with C1 laminectomy.

Background: Spontaneous anterior arch fracture of the atlas after a C1 laminectomy (CIL) is an extremely rare complication. Case Description: A 72-year-old male presented with the sudden onset of neck pain. His prior history included; a CIL for atlantoaxial subluxation, shunt closure for a spinal dural arteriovenous fistula at C3, a cervical laminoplasty from C3 to C6 for stenosis, and a prior anterior C4/5 and C5/6 fusion 14 years ago. Once the computed tomography documented a right C1 anterior arch fracture, and occipital-cervical fusion was performed utilizing C2 laminar screws and C4 pedicle screws with halo-vest placement. Postoperatively, the neck pain resolved and he remained stable. Conclusion: Neurosurgeons should be aware of the risk of anterior arch fractures following a CIL and may alternatively consider a C1 laminoplasty in the future.

Intractable hiccups and neck pain due to left C4 radiculopathy decreased with posterior foraminotomy.

BACKGROUND: Intractable hiccups can last for more than 1-2 months and can occur, as shown in this case study, due to cervical nerve root compression. CASE DESCRIPTION: A 76-year-old male presented with intractable hiccups and neck pain of 7 months' duration. The patient underwent magnetic resonance imaging studies of the entire neuraxis. The only abnormality found was on the cervical magnetic resonance images that demonstrated left C4 nerve root compression due to the C3- C4 lateral/foraminal osteophyte. Following a left-sided C3-C4 laminoforaminotomy, the hiccups and the neck pain improved. CONCLUSION: A 76-year-old male presented with intractable hiccups and neck pain attributed to a left C3/C4 lateral/foraminal spondylotic ridge. Following a left C3-C4 laminoforaminotomy, the frequency of hiccup attacks remained the same, but their duration was markedly shortened to 30 s, while the neck pain improved.

Cauda equina syndrome after L5-S1 posterior decompression surgery showing a "convexity sign" caused by engorgement of the ventral epidural venous plexus: A case series.

Background: Cauda equina syndrome (CES) following posterior lumbar decompression is rare. Here, we present four postoperative cases of L5S1 surgery resulting in CES attributed to engorged ventral epidural veins that decreased spontaneously in three cases, while the fourth warranted a laminoplasty. Case Description: Four patients underwent posterior lumbar decompressions at the L5-S1 level, but developed postoperative symptoms/signs of CES. Interestingly, in all four cases, cauda equina compression was attributed to engorgement of the ventral epidural venous plexus documented on magnetic resonance images (MRI) by the "convexity sign." Postoperatively, three patients' CES compression decreased spontaneously, but one required a laminoplasty. Conclusion: Postoperative CES occurred in four patients undergoing L5-S1 lumbar surgery. This deficit was attributed to marked engorgement of the ventral epidural plexus (i.e., yielding the "convexity sign" on MRI) that resolved spontaneously in three patients, but warranted a laminoplasty in the fourth.

Pathological Examination of Radiologically Fused Interbody Tissue Five Years After Anterior Cervical Discectomy and Fusion Using the Titanium Cage System: A Report of Two Cases.

This case report aimed to identify potential relationships between pathological and radiological assessments of bony fusion after anterior cervical discectomy and fusion (ACDF). ACDF can resolve neurological symptoms related to cervical spondylosis, such as myelopathy and radiculopathy. Intervertebral bony fusion is a key outcome for successful ACDF, often assessed on radiography and computed tomography (CT) images. However, the pathological findings of tissues demonstrating bony fusion after ACDF have not been well studied. This report presents the cases of two female patients, aged 62 and 40 years, who underwent additional ACDFs for recurrent cervical radiculopathy. Findings from CT imaging identified intervertebral calcification in the titanium spacers placed in the first ACDF. In both cases, recurrent compression of nerve roots was observed radiologically. Cervical nerve root block identified habitual symptoms related to recurrent radiculopathy. To resolve the clinical symptoms, additional ACDFs were performed in two cases. In the second ACDF, the titanium cases from the prior ACDF were removed. Histopathological examination of the tissues from the removed cages revealed growth of cartilage tissue. This is the first report concerning the histopathological evaluation of the tissue in titanium spacers placed in ACDF. Completion of intervertebral calcification in titanium spacers placed in ACDF may not signify completion of intervertebral bony fusion after ACDF.

Early postoperative sacral fracture after short-segment posterior lumbar interbody fusion for L5/S1 isthmic spondylolisthesis: A case report.

Background: Early postoperative sacral fractures are extremely rare complications of single-level posterior lumbar interbody fusions (PLIFs). Case Description: A 71-year-old female presented with lower back pain and right S1 radiculopathy attributed to MR-documented L5/S1 isthmic spondylolisthesis. Following a L5 laminectomy and bilateral L5/S1 PLIF, she experienced sacral pain while sitting. When the MR showed a sacral insufficiency fracture with anterolisthesis at L5/S1, a secondary posterior fusion was extended to the pelvis, utilizing bilateral iliac screws. Following this reoperation, the patient did well and went on to achieve arthrodesis. Conclusion: Early postoperative sacral fractures that occur following single-segment L5/S1 PLIF for isthmic spondylolisthesis warrant fusion to the pelvis with bilateral iliac screws.

Asymptomatic spinal subdural epiarachnoid hygroma after lumbar laminectomy for lumbar spinal canal stenosis: illustrative case.

BACKGROUND: Spinal subdural epiarachnoid hygroma (SSEH) after lumbar laminectomy is an extremely rare complication. OBSERVATIONS: An 84-year-old man presented to the hospital with lower back pain, radicular pain, and numbness in the lateral aspect of the left leg. Magnetic resonance imaging (MRI) revealed anterior lumbar spondylolisthesis at L3, severe disc herniation at L3-4, and severe lumbar spinal canal stenosis at L3-4 and L4-5. Lumbar laminectomy at L3-4 and L4-5 and discectomy at L3-4 were performed without complications such as cerebrospinal fluid (CSF) leakage and durotomy intraoperatively. Although lower back pain and numbness at the lateral aspect of the left leg were resolved postoperatively, postoperative MRI showed spinal nerve deviation to the ventral side due to SSEH from T12 to S1. Conservative therapy was performed for asymptomatic SSEH, and MRI 1 week postoperatively indicated improved ventral spinal nerve deviation and reduced SSEH. LESSONS: SSEHs after posterior decompression without durotomy are extremely rare. Asymptomatic SSEHs may resolve with conservative treatment. However, surgery should be performed to decompress hygroma in patients with symptomatic SSEH.

Embolization of a vertebral artery encased in a regrowth cervical meningioma before resection.

Background: Managing intraoperative bleeding may be challenging when a cervical tumor encases the vertebral artery (VA). Here, a patient with a recurrent cervical meningioma between the C1/2 and C3/4 levels and encasement of the right VA injury developed intraoperative bleeding that was endovascularly embolized postoperatively. Case Description: A 30-year-old female presented with a progressive quadriparesis, most markedly involving the right upper extremity. Six years ago, she had a cervical meningioma resected at the C2/3 level. The new MR revealed regrowth of intraspinal tumor between the C1/2 to C4/5 levels accompanied by extradural encasement of the right VA within the C2/3 and C3/4 foramina. Before the first surgery, the right VA was embolized (i.e., after a balloon occlusion test proved negative). During the attempted resection of the intradural/extradural tumor, bleeding from the right VA was encountered; it was temporarily controlled. After complete occlusion of the right VA was angiographically confirmed, a second-stage procedure to fully resect the extradural remanent of the tumor was undertaken. Conclusion: Endovascular embolization of the right VA before the attempted resection of a recurrent intraspinal/extraspinal cervical meningioma failed to occlude the vessel entirely. The VA bleeding encountered intraoperatively was temporarily controlled. Delayed total VA occlusion was angiographically observed before full tumor resection could be completed.

An interdural spinal cyst in the cervicothoracic spine: a review and proposal for a revised classification of spinal meningeal cysts. Illustrative case.

BACKGROUND: Spinal cysts in the interdural space are extremely rare and are not included in the standard classification of spinal meningeal cysts. OBSERVATIONS: A 60-year-old female presented to our hospital with a spastic gait and numbness in both palms. Magnetic resonance imaging (MRI) revealed a spinal cyst from C4 to T4 compressing the spinal cord. Computed tomography myelography revealed a fistula at C4-5 and C5-6 that connected the cyst along the right C5 and C6 root sleeves. The cyst was located within the dura mater, and communication with the arachnoid space was achieved using a shunt tube. There was partial spastic gait amelioration after the procedure, but the patient experienced a relapse 2 months postoperation. A repeat procedure was performed without a shunt tube to allow greater communication between the cyst and the subarachnoid space. After this, marked improvement in gait function was observed, and MRI showed a significant reduction in cyst volume. LESSONS: Interdural spinal meningeal cysts are rare. When the interdural cyst cannot be removed entirely, surgery may be appropriate for providing a shunt tube or establishing communication between the cyst and arachnoid space to maintain the circulation of cerebrospinal fluid collected in the cyst cavity.

Primary intramedullary spinal cord pilocytic astrocytoma with anaplasia in an adult: illustrative case.

BACKGROUND: Primary intramedullary spinal cord (IMSC) pilocytic astrocytoma (PA) with anaplasia is extremely rare. OBSERVATIONS: A 50-year-old man presented to our hospital with numbness of the left posterior rib region, back, and bilateral lower limbs. Contrast-enhanced T1-weighted magnetic resonance imaging (MRI) revealed an intramedullary lesion at T2-T3 with no contrast enhancement. The patient opted for conservative treatment. Eighteen months after the first consultation, the patient presented with slowly progressive numbness of the bilateral upper limbs, paraparesis, and dysuria, with rapid deterioration over the following 3 months. T1- and T2-weighted MRI revealed expansion of the intramedullary lesion, which extended from C7 to T5, and syringomyelia at C5-C6. Contrast-enhanced T1-weighted MRI revealed an enhancing intramedullary lesion at C7-T5. Open biopsy and C5-T5 laminectomy were performed for diagnosis and decompression. PA with anaplasia was diagnosed based on pathological and immunohistochemical findings. The patient received postoperative radiotherapy and chemotherapy. LESSONS: Rapidly progressive IMSC PA with a change in contrast enhancement is extremely rare in adults. PA may undergo a spontaneous malignant transformation during its natural clinical course. In this case, the change in contrast enhancement may have been associated with the malignant transformation of the PA.

Effect of choice of treatment modality on the incidence of shunt-dependent hydrocephalus after aneurysmal subarachnoid hemorrhage.

OBJECTIVE: Shunt-dependent hydrocephalus (SDHC) may arise after aneurysmal subarachnoid hemorrhage (aSAH) as CSF resorptive mechanisms are disrupted. Using propensity score analysis, the authors aimed to investigate which treatment modality, surgical clipping or endovascular treatment, is superior in reducing rates of SDHC after aSAH. METHODS: The authors' multicenter SAH database, comprising 3 stroke centers affiliated with Kyoto University, Japan, was used to identify patients treated between January 2009 and July 2016. Univariate and multivariate analyses were performed to characterize risk factors for SDHC after aSAH. A propensity score model was generated for both treatment groups, incorporating relevant patient covariates to detect any superiority for prevention of SDHC after aSAH. RESULTS: A total of 566 patients were enrolled in this study. SDHC developed in 127 patients (22%). On multivariate analysis, age older than 53 years, the presence of intraventricular hematoma, and surgical clipping as opposed to endovascular coiling were independently associated with SDHC after aSAH. After propensity score matching, 136 patients treated with surgical clipping and 136 with endovascular treatment were matched. Propensity score-matched cohorts exhibited a significantly lower incidence of SDHC after endovascular treatment than after surgical clipping (16% vs 30%, p = 0.009; OR 2.2, 95% CI 1.2-4.2). SDHC was independently associated with poor neurological outcomes (modified Rankin Scale score 3-6) at discharge (OR 4.3, 95% CI 2.6-7.3; p < 0.001). CONCLUSIONS: SDHC after aSAH occurred significantly more frequently in patients who underwent surgical clipping. Strategies for treatment of ruptured aneurysms should be used to mitigate SDHC and minimize poor outcomes.