Junichi Mizuno

Surgery for acute subaxial traumatic central cord syndrome without fracture or dislocation.

Twenty-two patients with subaxial acute traumatic central cord syndrome (CCS) without fracture or dislocation who underwent surgery between 1995 and 2002 were reviewed, retrospectively. There were 13 males and nine females ranging in age from 24 to 84 years (mean 61.2). Falls were the most common injury (68%), followed by motor vehicle accidents (32%). All patients had dynamic cervical lateral radiographs and magnetic resonance imaging (MRI). Cord compression was present in all cases and cervical instability in 11. Associated pathology included disc herniation in seven patients, cervical spondylosis (CS) in 11 and ossification of the posterior longitudinal ligament (OPLL) in four. Anterior decompression and fusion was performed in 12 patients with 1- or 2-level lesions. Posterior decompression and fusion was performed for multilevel lesions in 11 patients, including one patient who required re-operation. The interval between injury and surgery ranged from 1 to 37 days (mean 8.0). Postoperatively, all patients improved clinically. We conclude that surgical management of subaxial acute traumatic CCS without fracture or dislocation improved neurological status and prevented delayed neurological deterioration in our patients.

Analysis of hypertrophy of the posterior longitudinal ligament of the cervical spine, on the basis of clinical and experimental studies.

OBJECTIVEThe goal of this study was to elucidate the pathophysiological features and treatment of hypertrophy of the posterior longitudinal ligament (HPLL) of the cervical spine. HPLL is defined as a pathological thickening of the posterior longitudinal ligament (PLL), causing spinal cord compression. Incomplete decompression via removal of only coexisting herniated intervertebral discs or spondylotic spurs might be performed, resulting in unsatisfactory surgical outcomes, when the PLL becomes abnormally thickened and contributes to myelopathy. METHODSPatients with HPLL who underwent cervical decompression surgery were selected. Medical records and radiographs were retrospectively reviewed, to obtain data on the pre- and postoperative clinical conditions of the patients. Autopsy cases with HPLL proven by low-energy x-ray examinations were chosen for assessment of the pathological characteristics. RESULTSSeventeen men and three women with HPLL underwent treatment via an anterior approach, with direct removal of HPLL. Nineteen patients developed myelopathy, whereas one patient developed radiculopathy. Radiologically, all HPLL cases exhibited coexisting herniated intervertebral discs and 10 exhibited small segmental ossifications of the PLL. Magnetic resonance imaging or computed tomographic myelography revealed extensive cord compression across the vertebral endplate level. The average preoperative Benzel modified Japanese Orthopaedic Association score was 10.8, and the average postoperative score was 13.2. Histological examinations revealed thickening of the PLL with proliferation of chondrocytes, together with various degenerative changes. CONCLUSIONPatients with HPLL can benefit from an anterior approach with direct removal of the HPLL and associated herniated intervertebral discs or ossification of the PLL. Cervical polytomography, computed tomography, and magnetic resonance imaging are useful in establishing a diagnosis of HPLL.

Airway obstruction caused by cerebrospinal fluid leakage after anterior cervical spine surgery. A report of two cases.

Cerebrospinal fluid leakage is a relatively rare complication after an anterior cervical spine operation1, except when the diagnosis includes ossification of the posterior longitudinal ligament. In patients with such a diagnosis, the dura is usually thin because of long-standing compression by the ossification; furthermore, there may be a dural defect or dural ossification2. Although cerebrospinal fluid leakage may cause wound dehiscence and subsequent infection, it has not been recognized as a cause of airway problems, to our knowledge. In this report, we present two cases of postoperative cerebrospinal fluid leakage that caused acute airway obstruction, requiring emergency treatment.The patients were informed that data concerning the cases could be submitted for publication. Case 1. A sixty-one-year-old man presented with mild sensory abnormalities of the upper extremities and a gait disturbance. Cervical spine radiographs, computed tomography scans, and magnetic resonance images showed segmental ossification of the posterior longitudinal ligament compressing the spinal cord at the C3-C4, C4-C5, and C5-C6 levels. The patient underwent anterior cervical decompression with inter-body fixation with cages. During this procedure, a dural tear with cerebrospinal fluid leakage occurred at the C5-C6 level and was repaired with a muscle patch and fibrin glue. The evening of the next day, the patient showed signs of upper airway obstruction with rapidly progressive dyspnea. A cervical spine radiograph demonstrated enlargement of the prevertebral soft-tissue shadow (Fig. 1). Computed tomography of the cervical spine showed a large prevertebral mass with low density. After a failed attempt at fiberscopic intubation, we performed an emergency tracheostomy, and the patient underwent surgical exploration of the wound. When we opened the sutures in the platysma, cerebrospinal fluid flowed briskly out from the prevertebral space, decreasing the tension of the wound. We …

Primary amyloidoma of the thoracic spine presenting with acute paraplegia

BACKGROUND Primary solitary amyloidoma of the spine is a rare disease characterized by localized deposition of amyloid. To the best of our knowledge, there have been only 14 cases previously reported in the literature. Patients with focal spinal amyloidoma usually have relatively long symptomatic periods preoperatively, ranging from 3 weeks to 6 years (mean: 12 months). Only two reported patients had acute paraplegia. We add a third case of a thoracic spine amyloidoma presenting with acute paraplegia. CASE DESCRIPTION A 65-year-old man presented with a three-day history of progressive paraplegia and urinary retention. He was found to have severe cord compression at T2 on magnetic resonance imaging. He underwent emergent decompressive laminectomy with instrumentation for spinal stabilization. Histopathology revealed abundant amyloid deposits. A systemic work-up was negative for amyloidosis. The patient showed marked neurological improvement with residual mild spastic gait after 1 year. CONCLUSIONS Primary spinal amyloidoma with acute paraplegia is rare. One-stage surgery combining prompt decompression and stabilization of the spinal column is mandatory in cases of spinal amyloidoma with acute myelopathy, because primary solitary amyloidoma carries a good prognosis.

Clinical and radiological analysis of ossification of the anterior longitudinal ligament causing dysphagia and hoarseness.

OBJECTIVE:We retrospectively analyzed the clinical and radiological characteristics of ossification of the anterior longitudinal ligament (OALL). METHODS:Seventeen patients with OALL who underwent surgery between 1995 and 2003 were reviewed. Symptomatic OALL was found in four patients. In 13 asymptomatic OALL patients who experienced mild to severe myelopathy, no swallowing difficulty was noted. The OALL was classified into three types by sagittal computed tomographic (CT) scans as segmental, continuous, and mixed and three types on axial CT scans as flat, nodular, and globular type. The thickness, numbers of involved vertebral bodies, and type and shape for symptomatic OALL were analyzed and compared with those for asymptomatic OALL. RESULTS:The mean thickness of 13.5 mm for symptomatic OALL was significantly higher than that of 6.5 mm for asymptomatic OALL (P = 0.0009). A globular shape on axial CT was common for symptomatic OALL. There were no differences in the numbers of involved vertebral bodies and types of OALL on sagittal CT scans. Surgical excision of OALL was performed for all cases of symptomatic OALL. In 7 of 13 asymptomatic cases, OALL was simultaneously removed during anterior decompressive surgery for the associated pathology. CONCLUSION:The thickness on axial CT scans was an important contributing factor to dysphagia and hoarseness as was the shape of the OALL. The type of OALL on sagittal CT scans was similar to that of ossification of the posterior longitudinal ligament but did not influence the development of dysphagia. Good relief from symptoms was achieved for symptomatic OALL after removal of OALL.

Symptomatic ossification of the anterior longitudinal ligament with stenosis of the cervical spine: A REPORT OF SEVEN CASES

Seven men with a mean age of 63.9 years (59 to 67) developed dysphagia because of oesophageal compression with ossification of the anterior longitudinal ligament (OALL) and radiculomyelopathy due to associated stenosis of the cervical spine. The diagnosis of OALL was made by plain lateral radiography and classified into three types; segmental, continuous and mixed. Five patients had associated OALL in the thoracic and lumbar spine without ossification of the ligamentum flavum. All underwent removal of the OALL and six had simultaneous decompression by removal of ossification of the posterior longitudinal ligament or a bony spur. All had improvement of their dysphagia. Because symptomatic OALL may be associated with spinal stenosis, precise neurological examination is critical. A simultaneous microsurgical operation for patients with OALL and spinal stenosis gives good results without serious complications.

Pathology of spinal cord lesions caused by ossification of the posterior longitudinal ligament, with special reference to reversibility of the spinal cord lesion.

This report describes pathological findings of the spinal cord damage, with ossification of the posterior longitudinal ligament (OPLL), with special reference to reversibility of such lesions. Twenty-five autopsy cases associated with OPLL were examined, and the spinal cord damage was pathologically classified into four categories based on degree of destruction (stage 0-3). In stage 0 and stage 1, major pathological changes in the gray matter and the degree of compression on the spinal cord were well correlated to deformity of the anterior horn. In stage 2 and stage 3, neurons were almost completely obliterated and necrosis with cavitation were frequently observed. Destruction of the spinal cord in stage 2 and stage 3 is considered to be irreversible; therefore, surgical treatment is recommended at stage 0 or stage 1.

Ganglioglioma of the cerebellum: case report

The authors report a rare case of a cerebellar ganglioglioma. A review of 12 previously reported cases and our case suggest that surgical removal of this neoplasm carries a good prognosis.

Unilateral ossification of the ligamentum flavum in the cervical spine with atypical radiological appearance

We report a case of symptomatic unilateral ossification of the ligamentum flavum with unusual radiological presentation in the cervical spine. The patient was a 64 year old man with numbness and weakness of the left upper extremity who was admitted to our hospital. Computerized tomography revealed a triangular-shaped high density mass severely compressing the spinal cord at C6. Concomitant small ossification of the posterior longitudinal ligament was noted from C3 to C6. The ossified mass was completely removed via a unilateral osteoplastic laminectomy of the left C6 and C7.

Surgery for dural ossification in association with cervical ossification of the posterior longitudinal ligament via an anterior approach

STUDY DESIGN Direct removal of an ossified mass via an anterior approach carries good decompression, to one- or two-level ossification of the posterior longitudinal ligament (OPLL) of the cervical spine. Ossification occasionally involves not only the posterior longitudinal ligament (PLL) but also the underlying dura mater. Defect of the dura mater by resection of the dural ossification (DO) can cause cerebrospinal fluid leakage or neural injury. The technique of resection of OPLL with floating of DO provides satisfactory decompression and avoids dural defect or neural injury in OPLL associated with DO. METHODS Four patients developed cervical myelopathy. Radiological examination revealed cord compression due to OPLL associated with DO. RESULTS All patients underwent anterior procedures. After the necessary discectomies and corpectomies, OPLL was resected using a high-speed drill with a 4-mm steel burr and then with a 4-mm diamond burr. When the OPLL became paper-thin, it was separated from the dura mater using a microdissector and a Kerrison rongeur. There was a thin layer of the nonossified degenerated PLL between the residual OPLL and DO. Meticulous dissection of the residual OPLL over the DO was performed without removing the DO at this layer. Fixation was performed with a titanium cylindrical cage. CONCLUSION This technical note describes the successful decompression of the spinal cord by removing OPLL only, and avoidance of dural defect or neural injury in cases of OPLL associated with DO.