Akira Hioki

Two-stage (posterior and anterior) surgical treatment of spinal osteomyelitis due to atypical mycobacteria and associated thoracolumbar kyphoscoliosis in a nonimmunocompromised patient.

Study Design. A case report of atypical mycobacterial spinal osteomyelitis. Objective. To describe a rare case of spinal osteomyelitis and associated thoracolumbar kyphoscoliosis caused by atypical mycobacteria, and successful treatment by a 2-stage surgical intervention. Summary of Background Data. Vertebral osteomyelitis caused by atypical mycobacteria is very rare. Methods. The patient was an 18-year-old woman with vertebral osteomyelitis of Th12–L1 caused by Mycobacterium avium complex. Plain radiographs revealed vertebral collapse of Th12, scoliosis, and kyphosis. Results. Two-stage surgical treatment (first: posterior instrumentation; second: anterior debridement and bone graft) was performed. At 5 years after surgery, the patient is almost free of the preoperative symptoms with no evidence of disease recrudescence. Plain radiograph film demonstrated amelioration of scoliosis and kyphosis, and consolidation of the anterior bone graft. Conclusion. A rare case of intractable spinal osteomyelitis due to atypical mycobacteria in a nonimmunocompromised patient was treated successfully with 2-stage surgical treatment.

In vivo measurement of lumbar foramen during axial loading using a compression device and computed tomography.

Study Design: In vivo measurement of lumbar foramen using computed tomography and an axial loading device in healthy young subjects. Objective: To investigate the effects of axial loading on the morphology of the lumbar foramen in vivo. Summary of Background Data: In vitro studies have shown morphologic changes in the lumbar foramen in response to axial loading. The effects of axial loading on foraminal dimensions in vivo, however, are poorly understood. Materials and Methods: The study population consisted of 12 asymptomatic healthy young volunteers [6 men and 6 women; age range, 22–34 y (mean, 27 y)]. Lumbar computed tomography images were compared with and without axial loading using a compression device (DynaWell), and differences in disk height (DH), foraminal height (FH), foraminal width (FW), and the cross-sectional area (CSA) of the intervertebral foramen (IVF) were determined. Results: During axial loading, the FHs at L1/L2, L2/L3, L3/L4, and L4/L5 each decreased significantly (P<0.01 each), by 4.0%, 6.6%, 6.6%, and 5.1%, respectively. Maximum FW decreased significantly (P<0.05 each) at L2/L3 (7.2%) and L3/L4 (5.7%), and increased significantly (P<0.05) at L5/S1 (8.9%). The CSAs of the IVF decreased significantly (P<0.01 each) at L2/L3 (10.8%) and L3/L4 (10.7%) and increased significantly (P<0.01) at L5/S1 (23.3%). Changes in FH, maximum and minimum FW, and CSA of the IVF significantly (P<0.01) correlated with change in posterior DH. Conclusions: FH, FW, and CSA of the IVF, except for L5/S1, decreased significantly during axial loading. Changes in posterior DH correlated well with the changes in foraminal dimensions.

Morphologic Changes in Contralateral Lumbar Foramen in Unilateral Cantilever Transforaminal Lumbar Interbody Fusion Using Kidney-type Intervertebral Spacers.

Study Design: A retrospective study of 58 patients undergoing cantilever transforaminal lumbar interbody fusion (c-TLIF). Objectives: To evaluate morphologic changes in the intervertebral foramen (IVF) on the side contralateral to spacer insertion in patients undergoing c-TLIF using plain x-ray films and computed tomography scan. Summary of Background Data: The morphologic changes in the contralateral lumbar foramen in c-TLIF using unilateral insertion of spacers have not been well studied. Materials and Methods: Fifty-eight consecutive patients with lumbar dysplastic changes or degenerative disk diseases underwent c-TLIF using 96 kidney-type spacers with local bone grafts. Radiographic findings (sagittal disk angle), computed tomography scan findings (coronal disk angle, disk height, foraminal height (FH), foraminal width, and cross-sectional area of IVF in contralateral lumbar foramen) were compared between preoperative period and 6 months after surgery. The correlations between contralateral lumbar foraminal dimensions and disk height, sagittal disk angle, and coronal disk angle were analyzed. Results: After c-TLIF, sagittal angle, disk height, FH, foraminal width, and cross-sectional area of the IVF were significantly increased. Increase in posterior disk height showed a positive correlation with increases in FH, foraminal width, and cross-sectional area of IVF (r=0.235–0.511). However, the increase in sagittal disk angle showed a negative correlation with changes in foraminal width and cross-sectional area of IVF (r=–0.256 to –0.206). Conclusions: Lumbar foraminal dimensions on the side contralateral to spacer insertion increased significantly after c-TLIF, suggesting that c-TLIF enables indirect decompression of the contralateral nerve root. Although increase in posterior disk height was shown to be an important factor to increase contralateral foraminal size, segmental lordosis was a risk factor for a decrease in contralateral foraminal size.

Cantilever transforaminal lumbar interbody fusion for upper lumbar degenerative diseases (minimum 2 years follow up).

Purpose To evaluate the clinical outcomes of cantilever transforaminal lumbar interbody fusion (c-TLIF) for upper lumbar diseases. Materials and Methods Seventeen patients (11 males, 6 females; mean ± SD age: 62 ± 14 years) who underwent c-TLIF using kidney type spacers between 2002 and 2008 were retrospectively evaluated, at a mean follow-up of 44.1 ± 12.3 months (2 year minimum). The primary diseases studied were disc herniation, ossification of posterior longitudinal ligament (OPLL), degenerative scoliosis, lumbar spinal canal stenosis, spondylolisthesis, and degeneration of adjacent disc after operation. Fusion areas were L1-L2 (5 patients), L2-L3 (9 patients), L1-L3 (1 patient), and L2-L4 (2 patients). Operation time, blood loss, complications, Japanese Orthopaedic Association (JOA) score for back pain, bone union, sagittal alignment change of fusion level, and degeneration of adjacent disc were evaluated. Results JOA score improved significantly after surgery, from 12 ± 2 to 23 ± 3 points (p < 0.01). We also observed significant improvement in sagittal alignment of the fusion levels, from - 1.0 ± 7.4 to 5.2 ± 6.1 degrees (p < 0.01). Bony fusion was obtained in all cases. One patient experienced a subcutaneous infection, which was cured by irrigation. At the final follow-up, three patients showed degenerative changes in adjacent discs, and one showed corrective loss of fusion level. Conclusion c-TLIF is a safe procedure, providing satisfactory results for patients with upper lumbar degenerative diseases.

Lumbar axial loading device alters lumbar sagittal alignment differently from upright standing position: a computed tomography study.

Study Design. A study was performed using an axial loading device in healthy young subjects. Objective. To determine whether sagittal alignment during axial loading using a compression device can accurately simulate the standing posture. Summary of Background Data. Axial compression devices are widely used for simulation of standing position during magnetic resonance imaging (MRI) or computed tomography (CT) scans. However, images taken during axial loading have not been compared with those obtained in a standing posture. Methods. The study population comprised 14 asymptomatic healthy volunteers (7 men and 7 women: age 21–32, mean 27 years). Lumbar lateral radiograph films obtained in the standing posture (standing condition), lumbar CT images with axial loading using a DynaWell compression device (axial loading condition), and CT images without loading (control) were compared. Changes in spinal length, lumbar disc height, segmental lordotic angle, and total lumbar lordotic angle were compared among the conditions. Results. Spinal length was significantly decreased in both the axial loading and standing conditions compared with controls. The magnitude of the changes was greater in the standing condition than in the axial loading condition. Segmental lordotic angle at L2/3 and L3/4 was significantly increased in both axial loading and standing conditions. However, disc lordotic angle at L5/S was significantly decreased in the axial loading condition, while the standing condition showed no significant change. Consequently, the pelvic angle showed a significant decrease in the axial loading condition. Conclusion. The compression device simulates the lumbar segmental alignment change from supine to standing posture in L1/2, L2/3, L3/4, and L4/5. However, in L5/S, axial loading using the DynaWell altered lumbar segmental alignment with a kyphotic change, while no significant difference was observed in this level between standing and supine positions. Awareness of these phenomena are essential for accurate interpretation of imaging results.

Two-stage decompression for combined epiconus and cauda equina syndrome due to multilevel spinal canal stenosis of the thoracolumbar spine: a case report.

IntroductionA case of combined epiconus and cauda equina syndrome due to multilevel spinal canal stenosis of the thoracolumbar spine is reported.MethodsA 76-year-old man with multilevel spinal canal stenosis of the thoracolumbar spine (Th11–12, L2–S) who showed symptoms of epiconus syndrome was reported. First, we performed anterior decompression and fusion at the thoracolumbar junction (decompression: Th11–12, fusion: Th10–L2), which ameliorated his symptom partially. However, he presented cauda equina symptoms. Then, he underwent posterior spinal decompression (L3–5) and fusion (Th12–L5).ResultsAfter anterior decompression, several symptoms disappeared. However, motor and sensory disturbance below L4 and bladder–bowel disturbance remained. We then performed a secondary operation. At three years’ follow-up, he was able to walk with the aid of a cane.ConclusionsCombined epiconus and cauda equina syndrome due to multilevel spinal canal stenosis was treated by combined two-stage anterior and posterior decompression. In this case, multilevel decompression via anterior and posterior approaches was necessary to relieve the symptoms.

Neurological deterioration due to missed thoracic spinal stenosis after decompressive lumbar surgery: A report of six cases of tandem thoracic and lumbar spinal stenosis

There have been a few reports of patients with a combination of lumbar and thoracic spinal stenosis. We describe six patients who suffered unexpected acute neurological deterioration at a mean of 7.8 days (6 to 10) after lumbar decompressive surgery. Five had progressive weakness and one had recurrent pain in the lower limbs. There was incomplete recovery following subsequent thoracic decompressive surgery. The neurological presentation can be confusing. Patients with compressive myelopathy due to lower thoracic lesions, especially epiconus lesions (T10 to T12/L1 disc level), present with similar symptoms to those with lumbar radiculopathy or cauda equina lesions. Despite the rarity of this condition we advise that patients who undergo lumbar decompressive surgery for stenosis should have sagittal whole spine MRI studies pre-operatively to exclude proximal neurological compression.

Repair of Pars Defects by Segmental Transverse Wiring for Athletes With Symptomatic Spondylolysis : Relationship Between Bony Union and Postoperative Symptoms

Study Design. Retrospective study of surgery for spondylolysis patients. Objective. To assess clinical outcome of bony union using multislice computed tomography after segmental wiring fixation. Summary of Background Data. How bony union affects surgical outcome of spondylolysis repair is unclear. Methods. Forty-four athletes with symptomatic spondylolysis (33 men and 11 women; mean age, 24.2 ± 5.4 years) who underwent segmental wiring fixation were evaluated retrospectively at a mean follow-up of 85 ± 17 months. The level of spondylolysis was L5 in 42 cases, and both L4 and L5 in 2 cases, giving a total of 46 operative levels of vertebrae. Bony union using axial and sagittal reconstruction images of computed tomography, the Japanese Orthopaedic Association (JOA) score for back pain, and complications were reviewed. State of bony union was classified as bilateral union, unilateral union, or nonunion. The total score and the improvement ratio of the JOA score were compared among the 3 groups. Results. Bilateral bony union was obtained in 29 cases (31 of 46 vertebrae, 67.4%). Six cases (13%) showed unilateral union, and 9 cases (19.6%) showed nonunion. JOA score increased significantly after surgery in all groups, average improvement rate was 78.9% in the bilateral group, 63.6% in the unilateral group, and 29.8% in the nonunion group; differences among the 3 groups were significant (P < 0.05). JOA score was significantly higher in the bilateral group than in the other 2 groups. Conclusion. Although symptoms were significantly ameliorated in all groups, the bilateral group showed the greatest improvement ratio in JOA score showing bony union to be an important factor in clinical outcome. However, there were a few exceptional cases with contradictory clinical and radiological outcomes. Thus, further studies are required to gain a better understanding of the other multiple factors affecting clinical outcome after spondylolysis repair.

Two-staged decompression for thoracic paraparesis due to the combined ossification of the posterior longitudinal ligament and the ligamentum flavum: a case report

Study designA case report of ossification of the posterior longitudinal ligament (OPLL) combined with ossification of the ligamentum flavum, or yellow ligament (OYL), in the upper thoracic spine.ObjectiveTo describe a rare clinical entity and its management pitfalls in a patient with upper thoracic myelopathy due to combined OPLL and OYL.MethodsA 52-year-old woman developed paresthesia and paraparesis of both legs. One month prior to admission she fell and became unable to walk. She was diagnosed as having upper thoracic myelopathy due to combined OPLL and OYL and was treated by two-stage anterior and posterior spinal decompression. Posterior decompression was achieved first by laminoplasty at C3–Th1 and laminectomy of Th2 and Th3.ResultsAfter posterior decompression, her symptoms immediately and dramatically improved. However, symptoms recurred after she was able to achieve a sitting or standing position. We then performed anterior decompression at Th2, which again improved her symptoms. At two years post-surgery, she is ambulatory with the use of a cane.ConclusionUpper thoracic myelopathy due to OPLL and OYL was treated by combined 2-staged anterior and posterior decompression. In this case, posterior decompression alone was inadequate to relieve the symptoms of this pathological condition.

Cervical Symmetric Dumbbell Ganglioneuromas Causing Severe Paresis

We report an extremely rare case with bilateral and symmetric dumbbell ganglioneuromas of the cervical spine in an elderly patient. A 72-year-old man came by ambulance to our hospital due to progressive incomplete paraplegia. Magnetic resonance imaging demonstrated bilateral symmetric dumbbell tumors at the C1/2 level. We performed total resection of the intracanalar tumor, aiming at complete decompression of the spinal cord, and partial and subtotal resection of foraminal outside portions. Histopathological examination of the surgical specimen indicated the tumor cells to be spindle cells with the presence of ganglion cells and no cellular pleomorphism, suggesting a diagnosis of ganglioneuroma. Although the surgery was not curative, the postoperative course was uneventful and provided a satisfactory outcome. This is the fourth known case of cervical ganglioneuromas of the bilateral symmetric dumbbell type.