Hirotaka Kodama

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.

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.

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.

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.

Total spondylectomy of a symptomatic hemangioma of the lumbar spine

A vertebral hemangioma with dural compression and neurological deficit is rare. We report a symptomatic lumbar vertebral hemangioma which was successfully managed with total spondylectomy. The patient was a 31-year-old man whose chief complaint was low back pain. He had a slight sensory disturbance in the right thigh. Plain radiography and magnetic resonance imaging (MRI) revealed a tumor in the second lumbar vertebra, which extended into the spinal canal, compressing the dura. A percutaneous needle biopsy did not provide a pathological diagnosis. Before surgery, the arteries feeding the tumor were embolized using coils. We performed a total spondylectomy of the second lumbar vertebra with anterior reconstruction with a glass ceramic spacer and posterior instrumentation. The intraoperative pathological examination revealed a hemangioma of the lumbar spine. At the 4-year follow-up examination, the patient is completely asymptomatic without evidence of tumor recurrence.

Cervical clear cell meningioma mimicking a vertebral metastasis

Cervical vertebral involvement of clear cell meningioma is very rare. We report a case of clear cell meningioma in the cervical vertebral body in a 72-year old male. Seven years prior to this presentation, the patient underwent palliative surgery and posterior instrumentation for a cervical vertebral tumor at C5, which had been diagnosed as a metastatic renal cell carcinoma. On this admission, the patient presented with severe neck pain. Examination revealed hypesthesia on the left in a C6 nerve root distribution. Plain X-rays and MRI revealed an enlarging tumor in the C5 and C6 vertebral bodies. The tumor was resected via an anterior approach followed by fusion using a strut bone graft. Histological examination of the surgical specimen diagnosed a clear cell meningioma. Postoperatively, the patient achieved pain relief and resolution of the neurological deficit. At follow-up two years postoperatively, he remains asymptomatic. We emphasize that cervical clear cell meningioma with involvement of the vertebral bodies may mimic metastatic renal cell carcinoma.

Calpain inhibition by cerebrospinal fluid and effects of calpain on intrathecal nerve tissue.

Study Design. The effects of calpain on intrathecal nerve tissue in the rabbit were investigated. Objective. To evaluate the chemonucleolytic side effect of calpain on nerve tissue in the event of accidental intrathecal calpain injection. Summary of Background Data. Calpain has a degradative effect on proteoglycans, and as previously shown, it is associated with chemonucleolytic action in the rabbit. However, its effect on nerve tissue in the event of accidental intrathecal injection is not clear. Methods. The inhibitory activity of cerebrospinal fluid against calpain was measured in human cerebrospinal fluid using &mgr;-calpain, and in different cerebrospinal fluid fractions separated by molecular filtration. The presence of the endogenous calpain inhibitor, calpastatin, in human cerebrospinal fluid was examined by Western blotting with anticalpastatin antibody. After intrathecal application of calpain in rabbits, the spinal cord nerve tissue was examined by light microscopy. Results. Cerebrospinal fluid inhibited the enzyme reaction of calpain at its normal concentration. Immunoblotting with anticalpastatin antibody did not yield positive staining. After the intrathecal application of calpain, there was no evidence of degeneration in the nerve tissue of the spinal cord. Conclusions. This study suggests that in the event of accidental intrathecal injection of calpain for chemonucleolysis, the enzyme activity of calpain will be neutralized by cerebrospinal fluid, and the calpain should not cause unwanted side effects in chemonucleolysis.