Itaru Yuge

Tortuosity of the vertebral artery in patients with cervical spondylotic myelopathy: Risk factor for the vertebral artery injury during anterior cervical decompression

Study Design The case report presented herein shows tortuosity of the vertebral artery in a patient with cervical myelopathy. This case led the authors to evaluate 22 other patients who also had undergone anterior cervical fusion. They were studied before operation by either magnetic resonance imaging angiography or selective vertebral angiography. Objectives To analyze the radiographs, computed tomography, magnetic resonance imaging, and angiography findings to detect any tortuosity of the vertebral artery in patients with cervical myelopathy to show the risk factors of vertebral artery injury during anterior decompression. Summary of Background Data Complications of vertebral artery laceration during cervical anterior decompression are rare, so this injury and abnormality in the course of vertebral artery in patients with cervical myelopathy receive little attention. Methods The tortuosity of the vertebral artery was assessed by angiography, magnetic resonance imaging, and computed tomography. Results Mild vertebral artery tortuosity was observed in 10 patients and loop formation in three associated with cervical spondylotic changes. Conclusions This study suggests that vertebral artery loop formation is developed associated with cervical spondylotic changes. During the anterior decompression of cervical spondylotic myelopathy or radiculopathy, the looped vertebral artery could be injured by an excessive wide rejection of the bone or disc material. In the case of vertebral artery migration, the looped vertebral artery can even be injured by routine procedures.

Cerebrospinal fluid concentrations of nitric oxide metabolites in spinal cord injury.

Study Design. Multiple center study to evaluate cerebrospinal fluid (CSF) concentrations of nitric oxide metabolites [NOx] in relation to neurologic severity and prognosis in spinal cord injury (SCI). Objective. To examine whether CSF [NOx] correlates with neurologic severity and recovery in SCI. Summary of Background Data. Inducible nitric oxide synthase is expressed in rat spinal cord immediately after SCI. Excessive nitric oxide production is cytotoxic, causing neuronal apoptosis with subsequent neurodysfunction in the spinal cord. We previously reported a significant correlation between initial [NOx] after incomplete cervical cord injury (CCI) and neurologic recovery at the final follow-up in 25 cases. Methods. Ninty-six cases (SCI group), including 76 patients with CCI and 20 patients with thoracic cord injury were examined. Mean follow-up period was 11 months. The control group comprised 40 cases (3 healthy volunteers and 37 patients with neither pain nor neurologic disorders). CSF [NOx] were measured using the Griess method. Severity of neurologic impairment was assessed using Frankels classification and the American Spinal Injury Association motor score (ASIA MS). Degree of neurologic recovery was assessed using Frankels classification and the ASIA motor recovery percentage. Results. CSF [NOx] did not differ significantly among the control, CCI, and thoracic cord injury groups at the initial examination. In the CCI group, [NOx] in the Frankel A and B classes were significantly higher than [NOx] in the control group at 5 to 14 days, in the Frankel A and B classes at 0 to 4 days, and in the Frankel C and D classes at 5 to 14 days. Also, in the CCI group at 5 to 14 days, [NOx] correlated significantly with ASIA MS and motor recovery percentage. Conclusion. There was a significant correlation between CSF [NOx] at the pathologic early subacute stage (approximately 5–14 days) and neurologic severity and recovery in SCI.

Surgical Treatment of Metastatic Tumors of Long Bones and the Spine

We have operated on 42 patients with bone metastasis from various primary tumors over the past fourteen years. The number of operated cases of metastasis secondary to thyroid and breast carcinoma was especially high, since patients with such types of cancer have prolonged life expectancies in general. The sites of these operation were as follows: 27 in the spine, 12 in the femur, 2 in the tibia, and 1 in the humerus.

Can the acute magnetic resonance imaging features reflect neurologic prognosis in patients with cervical spinal cord injury

BACKGROUND CONTEXT Several prognostic studies looked for an association between the degree of spinal cord injury (SCI), as depicted by primary magnetic resonance imaging (MRI) within 72 hours of injury, and neurologic outcome. It was not clearly demonstrated whether the MRI at any time correlates with neurologic prognosis. PURPOSE The purpose of the present study was to investigate the relationship between acute MRI features and neurologic prognosis, especially walking ability of patients with cervical spinal cord injury (CSCI). Moreover, at any point, MRI was clearly correlated with the patients prognosis. STUDY DESIGN Retrospective image study. PATIENT SAMPLE From January 2010 to October 2015, 102 patients with CSCI were treated in our hospital. Patients who were admitted to our hospital within 3 days after injury were included in this study. The diagnosis was 78 patients for CSCI with no or minor bony injury and 24 patients for CSCI with fracture or dislocation. A total of 88 men and 14 women were recruited, and the mean patient age was 62.6 years (range, 16-86 years). Paralysis at the time of admission was graded as A in 32, B in 15, C in 42, and D in 13 patients on the basis of the American Spinal Injury Association (ASIA) impairment scale. Patients with CSCI with fracture or dislocation were treated with fixation surgery and those with CSCI with no or minor bony injury were treated conservatively. Patients were followed up for an average of 168 days (range, 25-496 days). OUTCOME MEASURES Neurologic evaluation was performed using the ASIA motor score and the modified Frankel grade at the time of admission and discharge. METHODS Magnetic resonance imaging was performed for all patients at admission. Using the MRI sagittal images, we measured the vertical diameter of intramedullary high-intensity changed area with T2-weighted images at the injured segment. We studied separately the patients divided into two groups: 0-1 day admission after injury, and 2-3 days admission after injury. We evaluated the relationship between the vertical diameter of T2 high-intensity changed area in MR images and neurologic outcome in these two groups. This study does not contain any conflict of interest. RESULTS In the group admitted at 0-1 day after injury, there was a relationship between the vertical diameter of T2 high-intensity area in MR image and the ASIA motor score at admission and at discharge, but correlation coefficient was low (0.3766 at admission and 0.4239 at discharge). On the other hand, in the group admitted at 2-3 days after injury, there was a significant relationship between the vertical diameter of T2 high-intensity area in MR image and the ASIA motor score at admission and at discharge, and correlation coefficient was very high (0.6840 at admission and 0.5293 at discharge). In the group admitted at 2-3 days after injury, a total of 17 patients (68%) recovered to walk with or without a cane. Receiver operating characteristic (ROC) curve analysis demonstrated that the optimal vertical diameter of T2 high-intensity area cutoffvalue for patients who were able to walk at discharge was 45.8 mm. If the vertical diameter of T2 high-intensity area cutoff value was 45 mm, there was a significant positive correlation with being able to walk at discharge (p<.0001). CONCLUSIONS From our study, 2-3 days after injury, a significant relationship was observed between the vertical diameter of T2 high-intensity area and the neurologic prognosis at discharge. Zero to 1 day after injury, the relationship between the vertical diameter of T2 high-intensity area and the neurologic prognosis at discharge was weak. Neurologic prognosis is more correlated with MRI after 2-3 days after the injury. If the vertical diameter of T2 high-intensity area was <45 mm, the patients were able to walk with or without a cane at discharge. T2 high-intensity changed area can reflect the neurologic prognosis in patients with CSCI.

Spinal Surgery for Misdiagnosed Amyotrophic Lateral Sclerosis in Spinal Diseases

Spinal operations were performed on 4 cases with Amyotrophic Lateral Sclerosis (ALS), in which 3 cases were wrongly diagnosed with cervical spondylotic myelopathy, 1 with L4 degenarative spodylolisthsis, and 1 with L1/2 disc herniation. (In 1 case, operation was performed two times for cervical lesion and lumbar lesion.) The chief complaint of all cases with obvious sensory disturbance, were muscle weakness, dullness, and numbness of the extremity. Sensory disturbance and MRI/CTM showed spinal compression slightly presenting spondylotic degenerative change were misdiagnosed. We must be careful in the evaluation of cases who have simultaneously spondylotic degenerative lesion and ALS. In all cases, post-operational symptoms were worse than pre operational itself. We believe that the operation deteriorated the neurological states progressively and gave no benefit. In conclusion, spinal disease, with ALS or those for which ALS cannot be ruled out should not be operated.