Hideo Hosoe

Two-stage (posterior and anterior) surgical treatment using posterior spinal instrumentation for pyogenic and tuberculotic spondylitis.

Study Design. A retrospective analysis was performed of the clinical outcomes of patients with pyogenic or tuberculotic spondylitis who were treated with two-stage surgery (first stage: placement of posterior instrumentation; second stage: anterior debridement and bone grafting). Objective. To evaluate the clinical outcomes of the abovementioned two-stage surgical treatment for pyogenic or tuberculotic spondylitis. Summary of Background Data. Although several methods of surgical treatment for pyogenic and tuberculotic spondylitis have been reported, there have been few reports of two-stage surgical treatment. Methods. Eight patients (7 male, 1 female) with pyogenic or tuberculotic spondylitis (pyogenic: 6; tuberculotic: 2) were treated by two-stage surgery (first: placement of posterior instrumentation, second: anterior debridement and bone graft). Age at the time of surgery was 63.5 ± 9.91 years (average ± SD) (range: 47 to 77 years). Most of the patients had systemic problems, such as pneumonia, diabetes mellitus, or chronic renal failure. First, posterior spinal instrumentation was placed. Then, anterior debridement and bone grafting were performed. Patients were evaluated before and after surgery in terms of pain level, hematologic parameters, neurologic status, and Barthel index. Results. Average duration of surgery for both procedures was less than 4 hours. Changes in the pain level, blood parameters, and Barthel index demonstrated significant clinical improvement in all patients. Posterior wound infection occurred in two patients who were in poor general condition. Conclusions. This two-stage surgical treatment for pyogenic or tuberculotic spondylitis provided satisfactory results and can also be used in patients who are in poor general condition.

Surgical Outcome of 2-stage (posterior and Anterior) Surgical Treatment Using Spinal Instrumentation for Tuberculous Spondylitis

Study Design A prospective study on the clinical outcomes in patients with tuberculous spondylitis treated by a 2-stage operation (posterior and anterior) using posterior spinal instrumentation. Objective To evaluate the clinical outcomes of the 2-stage surgical treatment (first stage: placement of posterior instrumentation and second stage: anterior debridement and bone grafting) for tuberculous spondylitis. Summary of Background Data There have been few reports describing the effects of 2-stage surgical treatment for tuberculous spondylitis. Methods Ten patients (5 men and 5 women) with tuberculous spondylitis were treated by 2-stage operations. Age at the initial operation was 64.6±14.8 years (average±SD) (range: 47 to 83 y). The clinical outcomes were evaluated before and after the surgery in terms of hematologic examination, pain level, and neurologic status. Bone fusion and changes in sagittal alignment were examined radiographically. Results All patients showed suppression of infection, bony fusion, relief of pain, and recovery of neurologic function. No significant changes were observed in kyphosis angle at the final follow-up. There were no incidences of severe complications or recurrence. Conclusions Our results showed that posterior and anterior 2-stage surgical treatment for tuberculous spondylitis is a viable surgical option for cases in which conservative treatment has failed. However, the changes in sagittal alignment showed that this strategy provides limited kyphosis correction.

Acute Cervical Spinal Cord Injury Complicated by Preexisting Ossification of the Posterior Longitudinal Ligament : A Multicenter Study

Study Design. Retrospective multicenter study. Objective. To review the clinical characteristics of traumatic cervical spinal cord injury (SCI) associated with ossification of the posterior longitudinal ligament (OPLL). Summary of Background Data. Despite its potentially devastating consequences, there is a lack of information about acute cervical SCI complicated by OPLL. Methods. This study included consecutive patients with acute traumatic cervical SCI (Frankel A, B, and C) who were admitted within 48 hours of injury to 34 spine institutions across Japan. For analysis of neurologic outcome, patients who had completed at least a 6-month follow-up were included. Neurologic improvement was defined as at least one grade conversion in Frankel grade. Results. A total of 453 patients were identified (367 men, 86 women; mean age, 59 years). OPLL was found in 106 (23%) patients (87 men, 19 women; mean age, 66 years). Most of the patients with OPLL (94 of 106) were without bone injury, presenting with incomplete SCI. The prevalence of OPLL reached 34% in SCI without bone injury. The cause of SCI was predominantly falls (74%). Only 25% of the patients were aware of OPLL. Half of the OPLL patients reported gait disturbance before injury. Forty-eight (52%) OPLL patients without bone injury underwent surgery (median, 13.5 days after injury), mostly laminoplasty. Overall, no significant difference was noted in neurologic improvement between surgery group and conservative group. However, further stratification showed that surgery was associated with greater neurologic recovery in patients who had gait disturbance before injury (P = 0.04). Conclusion. Prevalence of OPLL among cervical SCI was alarmingly high, especially in those without bone injury. Most of cervical SCI associated with OPLL were incomplete, without bone injury, and caused predominantly by low-energy trauma. The majority of the patients were unaware of OPLL. Surgery produced better neurologic recovery in patients who had gait disturbance before injury.

Neurological complications of cervical laminoplasty for patients with ossification of the posterior longitudinal ligament - A multi-institutional retrospective study

Study Design. Retrospective multi-institutional study. Objective. To investigate the incidence of neurological deficits after cervical laminoplasty for ossification of the posterior longitudinal ligament (OPLL). Summary of Background Data. According to analysis of long-term results, laminoplasty for cervical OPLL has been reported as a safe and effective alternative procedure with few complications. However, perioperative neurological complication rates of laminoplasty for cervical OPLL have not been well described. Methods. Subjects comprised 581 patients (458 men and 123 women; mean age: 62 ± 10 years; range: 30–86 years) who had undergone laminoplasty for cervical OPLL at 27 institutions between 2005 and 2008. Continuous-type OPLL was seen in 114, segmental-type in 146, mixed-type in 265, local-type in 24, and not judged in 32 patients. Postoperative neurological complications within 2 weeks after laminoplasty were analyzed in detail. Cobb angle between C2 and C7 (C2/C7 angle), maximal thickness, and occupying rate of OPLL were investigated. Pre- and postoperative magnetic resonance imaging was performed on patients with postoperative neurological complications. Results. Open-door laminoplasty was conducted in 237, double-door laminoplasty in 311, and other types of laminoplasty in 33 patients. Deterioration of lower-extremity function occurred after laminoplasty in 18 patients (3.1%). Causes of deterioration were epidural hematoma in 3, spinal cord herniation through injured dura mater in 1, incomplete laminoplasty due to vertebral artery injury while making a trough in 1, and unidentified in 13 patients. Prevalence of unsatisfactory recovery not reaching preoperative level by 6-month follow-up was 7/581 (1.2%). Mean occupying rate of OPLL for patients with deteriorated lower-extremity function was 51.2 ± 13.6% (range, 21.0%–73.3%), significantly higher than the 42.3 ± 13.0% for patients without deterioration. OPLL thickness was also higher in patients with deterioration (mean, 6.6 ± 2.2 mm) than in those without deterioration (mean, 5.7 ± 2.0 mm). No significant difference in C2/C7 lordotic angle was seen between groups. Conclusion. Although most neurological deterioration can be expected to recover to some extent, the frequency of short-term neurological complications was higher than the authors expected.

Lower incidence of adjacent segment degeneration after anterior cervical fusion found with those fusing C5-6 and C6-7 than those leaving C5-6 or C6-7 as an adjacent level.

Study Design Retrospective analysis of adjacent disc degeneration (ADD) after anterior cervical decompression and fusion (ADF). Objectives To elucidate the influence of the number of levels fused in ADF on the incidence of ADD. Summary of Background Data ADD is known as a complication associated with ADF. However, how the number of levels fused affects the incidence of ADD is not well understood. Methods One hundred and two patients with cervical degenerative disease, who underwent ADF and were followed for more than 24 months, were retrospectively analyzed. They were classified into 2 groups, a long group (L group) consisting of 50 cases with ADF of 4 or more disc levels, and a short group (S group) consisting of 52 cases with ADF of 3 or fewer disc levels. Furthermore, the patients were also divided into 2 groups according to inclusion or exclusion of C5-6 and C6-7 (C group: including both, NC group: not including both). The incidence of ADD, and that of symptomatic ADD (sADD), was compared between the 2 classifications. Results In the L group, there were 13 cases of ADD (26.0%), including 1 case of sADD (2.0%), whereas in the S group, there were 22 cases of ADD (42.3%), including 11 cases of sADD (21.2%). The incidence of sADD was significantly lesser in the L group (P=0.024). Three cases with sADD in the S group required revision surgery, whereas no additional surgery related to ADD was performed on patients in the L group. In addition, in the C group, ADD occurred in 20 of 71 cases (28.2%) and sADD occurred in 4 of 71 cases (5.6%), whereas in the NC group, ADD occurred in 15 of 31 cases (48.4%) and sADD occurred in 8 of 31 cases (25.8%). The incidence of ADD and sADD were significantly lesser in the C group (P=0.048). Conclusions ADD occurs less frequently among patients in whom C5-6 and C6-7 are fused than among those in whom C5-6 or C6-7 is left at an adjacent level, irrespective of the length of the fusion.

One-staged combined cervical and lumbar decompression for patients with tandem spinal stenosis on cervical and lumbar spine: analyses of clinical outcomes with minimum 3 years follow-up.

Study Design Retrospective study of clinical outcomes of 1-staged combined cervical and lumbar decompression for patients with tandem spinal stenosis (TSS). Objective To describe middle-term clinical outcomes of this procedure. Summary and Background Data Little is known with regard to the clinical outcomes of 1-staged combined cervical and lumbar decompression for TSS. Method Surgical intervention, perioperative complications, and clinical outcomes were reviewed in 17 TSS patients who underwent 1-staged combined cervical and lumbar decompression and were followed-up for more than 3 years. Clinical symptoms were evaluated using the Japan Orthopaedic Association Score for back pain (JOA-B) and cervical myelopathy (JOA-C) and activity of daily life, before surgery, at 6 months postoperatively, and at final follow-up. Patient satisfaction was determined at final follow-up. Results The JOA-B, JOA-C scores, and activities of daily life improved significantly 6 months after surgery, but ultimately deteriorated. At 6 months, the improvement ratios in JOA-B and JOA-C scores were positively correlated. Complications involving other parts of the body significantly influenced clinical deterioration. Twelve patients (71%) were satisfied. Conclusions One-staged combined cervical and lumbar decompression for TSS provided fair results, even for elderly patients. Although reasons other than spinal pathology affected symptom deterioration at final follow-up, most patients expressed satisfaction at middle-term follow-up periods.

Clinical outcome after segmental wire fixation and bone grafting for repair of the defects in multiple level lumbar spondylolysis.

The aim of this retrospective study was to assess clinical outcomes after segmental wire fixation and bone grafting for repair of pars defects in patients with multiple-level lumbar spondylolysis. Subjects were 7 patients (5 men and 2 women, mean age 26.7 y) with multiple-level lumbar spondylolysis treated by segmental wire fixation and bone grafting at one of our affiliated institutions between 1983 and 2004. Clinical outcomes were determined by comparing preoperative and postoperative Japanese Orthopaedic Association scores and Mancab criteria, and healing of pars defects was evaluated by radiographic and computed tomography study. The condition involved 2 levels in 5 cases and 3 levels in 2 cases. The mean postoperative follow-up period was 51.0 months. The mean Japanese Orthopaedic Association score improved significantly from 21.29 before surgery to 27.86 after surgery, and the recovery rate was 85.21%. An “excellent” result was achieved in 5 cases, a “good” result in 1 case and a “fair” result in 1 case according to the Macnab criteria. Postoperative radiographs revealed healing of all defects in 4 cases, healing of 3 out of 4 defects in 2 cases, and no healing of any defect in 1 case. Pseudoarthrosis was related to wire breakage, and patients who did not obtain complete healing were patients who did not fully comply with instructions to wear a lumbar corset or restrict activity postoperatively. Segmental wire fixation and bone grafting were shown to be effective for multiple-level lumbar spondylolysis.

Kyphectomy Using a Surgical Threadwire (t-saw) for Kyphotic Deformity in a Child With Myelomeningocele

Study Design. A 9-year-old boy with severe myelomeningocele kyphosis was treated by kyphectomy using a surgical threadwire. Objective. To describe a new method of kyphectomy for severe kyphotic deformity in a child with myelomeningocele using a surgical threadwire. Summary of Background Data. Although several methods of kyphectomy for severe kyphotic deformity in children with myelomeningocele have been reported, few of these methods allow preservation of the nonfunctioning dural sac and cerebrospinal fluid flow, with the aim of reducing complications. Methods. The preoperative kyphotic angle was 113°. There was repeated skin ulceration over the apex of the kyphos. Kyphectomy at the Th12 to L3 vertebral levels was performed using a surgical threadwire (T-saw, developed by Tomita and colleagues in 1996), preserving the entire dural sac. Results. The T-saw allowed anterior dissection of the dural sac over the length of the planned resection, thus preserving cerebrospinal fluid flow throughout the entire subarachnoid space. The kyphotic angle was decreased to 10° after the operation, and the postoperative clinical course was uneventful. At the 2-year follow-up assessment, the kyphotic angle was 10° according to plain radiograph. At this writing, the boy is able to maintain a sitting position without any difficulty. Conclusions. For this child with myelomeningocele, kyphectomy using a surgical threadwire (T-saw) provided a satisfactory result without any major complication.

Spinal arachnoid cysts associated with syringomyelia: report of two cases and a review of the literature.

We describe two cases of spinal arachnoid cyst associated with syringomyelia and report the clinical results after surgical treatment using excision of the cyst without a shunt operation for the syringomyelia. Case 1 is a 73-year-old woman who presented with a spastic gait and numbness of her bilateral lower extremities. Magnetic resonance imaging (MRI) showed the presence of a spinal arachnoid cyst extending from T3 to T8 and syringomyelia from T8 to T10. The cyst had compressed the spinal cord anteriorly. We excised the cyst without applying a shunt tube for the syringomyelia. Case 2 is a 68-year-old woman who presented with gait disturbance and numbness of her left lower extremity. MRI indicated that the spinal cord had been compressed anteriorly by a spinal arachnoid cyst extending from T10 to T11. Syringomyelia existed just caudal to the cyst at T11. In our surgical treatment, we excised only the cyst. In both cases, neurologic examination after the operation showed amelioration of the condition. Postoperative MRI indicated that the spinal cord had moved to the center, its original position, and the syringomyelia had decreased in size. Conclusively, spinal arachnoid cyst associated with syringomyelia can be treated by simple excision of the cyst without shunting the syrinx if the decompression effect resulting from removal of the cyst is sufficient.

Anterior decompression and fusion for multiple thoracic disc herniation

Multiple thoracic disc herniations are rare and there are few reports in the literature. Between December 1998 and July 2002, we operated on 12 patients with multiple thoracic disc herniations. All underwent an anterior decompression and fusion through a transthoracic approach. The clinical outcomes were assessed using the Frankel neurological classification and the Japanese Orthopaedic Association (JOA) score. Under the Frankel classification, two patients improved by two grades (C to E), one patient improved by one grade (C to D), while nine patients who had been classified as grade D did not change. The JOA scores improved significantly after surgery with a mean recovery rate of 44.8% +/- 24.5%. Overall, clinical outcomes were excellent in two patients, good in two, fair in six and unchanged in two. Our results indicate that anterior decompression and fusion for multiple thoracic disc herniations through a transthoracic approach can provide satisfactory results.