Hirofumi Nishimoto

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.

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.

Dropped head syndrome associated with cervical spondylotic myelopathy

We report a case of an 80-year-old woman with dropped head syndrome associated with cervical spondylotic myelopathy. She could not keep her cervical spine in a neutral position for >1 minute. She had a disturbed gait and severe kyphotic deformity in her thoracic spine. Magnetic resonance imaging revealed severe compression of the spinal cord due to cervical spondylotic change. Laminoplasty from C2 through C6 levels was performed. One year after operation, she could keep her cervical spine in a neutral position easily. Her gait was also improved. The symptoms did not recur during 4 years of follow-up. We surmise that to maintain daily activities, she had to extend her cervical spine owing to the thoracic kyphotic deformity, resulting in compression of the spinal cord. The compression led to weakening of the cervical extensor muscles. Cervical laminoplasty was effective.

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.

Surgical treatment for cervical myelopathy in patients aged > 80 years.

The surgical outcomes of 13 patients who were diagnosed with cervical spondylotic myelopathy were reviewed retrospectively. Mean patient age at surgery was 83 years. The severity of cervical spondylotic myelopathy was evaluated using the Japanese Orthopaedic Association score. Daily activities were evaluated using the Barthel index. The preoperative JOA score and Barthel index were 7.8 and 63.5, respectively. The mean JOA score and Barthel index maximum recovery rate were 35% and 24%, respectively. The results of this study imply that surgery for patients with cervical spondylotic myelopathy aged > 80 years is warranted.

Spontaneous symptomatic pseudoarthrosis at the T11-T12 intervertebral space with diffuse idiopathic skeletal hyperostosis: a case report.

Study Design. We report on a 69-year-old male who had severe back pain due to spontaneous symptomatic pseudoarthrosis at the T11–T12 intervertebral space with diffuse idiopathic skeletal hyperostosis. Objective. To describe a rare clinical entity and successful treatment by spinal fusion with a 4-year follow-up. Summary of Background Data. There have been a few reports of spontaneous symptomatic pseudoarthrosis of an intervertebral space associated with diffuse idiopathic skeletal hyperostosis, but there have been no reports of surgical treatment for this clinical condition. Methods. Plain radiographs of the patient, who was admitted to our hospital with severe back pain but no history of trauma, revealed manifestations of diffuse idiopathic skeletal hyperostosis and a pseudoarthrosis at the T11–T12 intervertebral space. Posterior instrumentation from T9 to L2 and anterior bone grafting at the T11–T12 intervertebral space were performed. Results. The patient has been followed for 4 years and is currently asymptomatic. Conclusions. A rare case of spontaneous symptomatic pseudoarthrosis at the T11–T12 intervertebral space with diffuse idiopathic skeletal hyperostosis was treated successfully by spinal fusion.

Scoliosis in a patient with Alexander disease.

Alexander disease is a rare, degenerative disorder of the central nervous system. It is characterized clinically by spasticity, seizures, dementia, loss of developmental milestones, and macrocephaly. Here we describe a 13-year-old boy with Alexander disease and severe scoliosis. The patient initially presented at 9 months of age, with profound mental retardation and a history of seizures. When he was 7 years old, a pediatrician had diagnosed Alexander disease (hypotonia, macrocephaly, and progressive low-density white matter predominantly in the frontal region on computed tomography examination). From the age of 10, thoracolumbar scoliosis had gradually become severe. Because treatment using a corrective brace would have produced major problems because of the patients mental retardation, the scoliosis was successfully treated surgically, by careful posterior spinal fusion with instrumentation, and an autologous iliac crest bone graft. A 64 degrees curve was corrected to 18 degrees (72% correction). Scoliosis with Alexander disease is considered to be very rare because patients with the disease seldom survive long enough to develop spinal deformities.

Transforaminal lumbar interbody fusion for failed Graf ligamentoplasty: a report of two cases

We report 2 cases of transforaminal lumbar interbody fusion for failed Graf ligamentoplasty. Both patients had residual or recurrent low back pain and leg pain after Graf ligamentoplasty, caused by lumbar segmental instability or narrowing of their intervertebral foramens. The pain improved markedly after the revision surgery. We recommend transforaminal lumbar interbody fusion for failed Graf ligamentoplasty, as it provides rigid interbody bony fusion and obviates complete exposure of the dural sac or dural tube.

Postoperative cervical kyphosis after atlantoaxial fixation and cervical expansive laminoplasty at one time.

Cervical kyphotic deformity is one of the well-known complications after atlantoaxial fixation or cervical expansive laminoplasty, but to our knowledge there is no information about postoperative cervical kyphosis after performing these operations simultaneously. The aims of this study were to evaluate the changes in the cervical alignment after simultaneous atlantoaxial fixation and cervical expansive laminoplasty, and to discuss the risk factors of this deformity. Five patients (1 man and 4 women) who underwent the simultaneous procedure were examined. Their mean age at surgery was 68.4±3.4 years, and the mean follow-up period was 30.8±9.5 months. Their underlying diseases were rheumatoid arthritis, and one of them had athetosis, too. On neutral lateral cervical radiographs, tangents were drawn to the inferior endplates of C2 to C5, respectively, and we measured the angles between C2 and C3, C3 and C4, C4 and C5, and C2 and C5 just after surgery and at the latest follow-up. The mean angles were 2.1, −1.9, 1.8, and 1.2 degrees, respectively, just after surgery; and 2.1, −3.5, −2.6, and −5.8 degrees, respectively, at the latest follow-up. Although the mean angle between C2 and 3 hardly changed postoperatively, the mean angle between C2 and C5 significantly decreased postoperatively. In summary, atlantoaxial fixation and cervical expansive laminoplasty may be an unsuitable combination because cervical kyphosis after the simultaneous procedure developed as a complication during the short-term follow-up.