Kunio Yokoyama

In Not Only Vertebroplasty but Also Kyphoplasty, the Resolution of Vertebral Deformities Depends on Vertebral Mobility

BACKGROUND AND PURPOSE: It has not been clarified whether the postoperative resolution of vertebral deformities achieved by KP are superior to those achieved by VP. We compared the outcomes of KP and VP, taking into account the presence of vertebral mobility, to determine whether the balloon inflation in KP may contribute to postoperative resolution of the vertebral deformities in patients with VCFs. MATERIALS AND METHODS: The subjects had 34 vertebral bodies treated by VP, and 43 vertebral bodies treated by KP. In all patients, preoperative dynamic imaging was performed to assess the presence of vertebral mobility. First, the vertebral height restoration and kyphotic change were compared between the VP and KP groups. Then, the patients were further divided into 2 groups on the basis of the presence of vertebral mobility, and they were compared within and between the VP and KP groups in relation to the presence of vertebral mobility. RESULTS: Overall, no significant differences were observed in either the vertebral height restoration or kyphotic change between the VP and KP groups (P > .20). Preoperative dynamic imaging identified 19 vertebral bodies each with vertebral mobility in the VP (56%) and KP groups (44%) (P = .21). Within the VP and KP groups, the vertebral height restoration and kyphotic changes were significantly better in patients with vertebral mobility than in those without (P < .01). There were no significant differences between the 2 treatment groups after adjustment for the presence of vertebral mobility (P > .30). CONCLUSIONS: In both the VP and KP groups, the vertebral height restoration and kyphotic change largely depended on the preoperative vertebral mobility. The use of the balloon itself contributed little to resolution of the vertebral deformities.

Comparative Study of Percutaneous Vertebral Body Perforation and Vertebroplasty for the Treatment of Painful Vertebral Compression Fractures

BACKGROUND AND PURPOSE: Percutaneous vertebral body perforation is a new technique for treating painful VCFs. Herein, we compare the therapeutic effect of vertebral perforation and conventional vertebroplasty for treating VCFs. MATERIALS AND METHODS: One hundred eight patients with single painful VCFs were assigned to undergo vertebral perforation (perforation group) or vertebroplasty (PVP group). Clinical outcomes were assessed by using the VAS. The associations of analgesic effect and clinical factors were also analyzed by multivariate regression. Plain radiographs were used to quantify the progression of vertebral body compression after surgery and to evaluate cement leakage and new vertebral fractures. The median follow-up time was 10 months. RESULTS: Baseline characteristics were similar in the 2 groups. No factors correlated with analgesic effects in the PVP group. The analgesic effect of vertebral perforation was, however, related to the preoperative severity of vertebral compression and was low in patients with severe deformity (P < .05). Among patients with preoperative vertebral percentage of compression below 30%, there were no significant differences between the 2 groups in analgesic effect at any postoperative intervals. Progression of vertebral compression after surgery occurred in 22.2% and 16.0% of treated vertebrae in the perforation and PVP groups, respectively (P = .38). Respectively, 3.7% and 20.0% of the perforation and PVP groups had new postoperative fractures during follow-up (P < .05). There were no other complications. CONCLUSIONS: Vertebral perforation was safe and effective for painful VCFs with slight compression. However, vertebroplasty should be considered for patients with marked vertebral body compression.

Age-related variations in global spinal alignment and sagittal balance in asymptomatic Japanese adults

Abstract Objectives: The global spinal sagittal alignment varies widely among healthy individuals as it is affected by not only race, but also aging. We investigated age-related changes in the spinal alignment in asymptomatic Japanese individuals. Methods: The subjects comprised 220 individuals without any spine-related neurological symptoms or treatment history thereof who visited our outpatient clinic. Lateral radiographs of the whole spine were taken for all subjects in the standing position. Based on the images obtained, spino-pelvic parameters were calculated using Jackson’s method so as to analyze any correlations with age. Results: TIA, TK, and C2–C7A were found to markedly increase with age from late middle age (P < 0.05). No correlation with aging was found for lumbosacral parameters or sagittal balance (P > 0.05). However, there were 22 subjects (10%) with C7SVA > 50 mm, with those aged 70 years or older accounting for half of this subpopulation. Sagittal balance tended to be retained even in elderly subjects if lumbosacral lordosis was large enough to compensate for thoracic kyphosis. A very strong correlation was found between the L1 slope and whole-spine sagittal balance (P < 0.0001, r = −0.497). Conclusions: Increases in cervicothoracic curvature occurring along with thoracic deformation underlie age-related changes in the spine. In contrast, the lumbosacral spine compensates in such a manner so as to maintain the sagittal balance. The whole-spine sagittal balance can deteriorate if the compensatory changes in the lumbosacral spine are insufficient. The L1 slope is a central parameter that defines the whole-spine sagittal balance. Abbreviations: PI; pelvic incidence; SS; sacral slope; PT; pelvic tilt; LL; lumbar lordosis; C7SVA; C7 sagittal vertical axis; SSA; spinosacral angle; TK; thoracic kyphosis; C2–C7SVA; C2–C7 sagittal vertical axis; C2–C7A; C2–C7 Angle; TIA; thoracic inlet angle; NT; neck tilt.

Validity of Intervertebral Bone Cement Infusion for Painful Vertebral Compression Fractures Based on the Presence of Vertebral Mobility

BACKGROUND AND PURPOSE: It is uncertain whether analgesic effects of vertebroplasty in patients with painful VCF are actually attributable to intervertebral cement infusion. This study aims to assess the validity of cement infusion performed for pain relief based on the presence or absence of pseudoarthrosis. MATERIALS AND METHODS: We compared therapeutic effects between PVP and vertebral perforation without bone cement infusion in patients with painful VCF. The subjects were 64 patients undergoing PVP (PVP group) and 67 undergoing vertebral perforation (perforation group). In all patients, preoperative dynamic radiography was performed to assess the presence of vertebral mobility. Patients were classified into 2 groups, those with and those without vertebral mobility, and changes in VAS and ADL scores before and after surgery were compared between the PVP and perforation groups. RESULTS: Regarding patients with vertebral mobility, VAS improved during the 3 months immediately after surgery in the PVP group compared with the perforation group (P < .05). Although no significant difference in postoperative ADL scores was observed between the 2 treatment groups, the scores 3 months after surgery were better in the PVP group than in the perforation group. Meanwhile, in the subgroup of patients without vertebral mobility, both treatments produced marked pain relief, but the difference was not significant (P > .05). Moreover, there was no difference in ADL scores between the 2 treatment groups. CONCLUSIONS: Intervertebral cement infusion exerts analgesic effects in patients with VCF with pseudoarthrosis. However, in those without vertebral mobility, the analgesic effects of vertebroplasty are the same regardless of bone cement infusion.

Clinical Significance of Postoperative Changes in Redundant Nerve Roots After Decompressive Laminectomy for Lumbar Spinal Canal Stenosis

OBJECTIVE The postoperative time course of redundant nerve roots (RNRs) in patients with lumbar spinal canal stenosis (LSCS) is currently unknown. The purpose of this study is to investigate the relationship between postoperative morphologic changes in detected RNRs and the clinical outcome of patients with LSCS. METHODS A total of 33 symptomatic patients with LSCS who demonstrated RNRs on magnetic resonance imaging (MRI) were treated with decompressive laminectomy alone. On the basis of the MRI scans obtained 7 days after surgery, patients were stratified into two groups: group 1 included patients with resolution of RNRs and group 2 included patients with persistent RNRs. Comparative parameters were examined between the two groups of patients. RESULTS We found that 24 of the 33 patients showed resolution of RNRs and 9 showed persistent RNRs. Although there was no difference in the Japanese Orthopedic Association score between the two groups before treatment, group 1 showed a greater recovery of Japanese Orthopedic Association score 1 month postoperatively. MRI demonstrated that the cross-sectional area of the preoperative dural sac at the stenotic lesion was smaller in group 2 than in group 1; however, there was no difference in cross-sectional area of the postoperative dural sac between the two groups. Within 12 months, there was no evidence of RNRs in six of the nine cases in group 2. CONCLUSION Although most patients with LSCS show postoperative resolution of RNRs detected on MRI, some show persistent RNRs postoperatively. The functional outcome of these patients remains poor even if sufficient expansion of the dural sac is achieved postoperatively.

Long-term therapeutic effects of vertebroplasty for painful vertebral compression fracture: a retrospective comparative study

Abstract As a treatment for painful vertebral compression fractures (VCFs), vertebral perforation does not require bone cement infusion. Here, we retrospectively assessed the long-term therapeutic effects of vertebroplasty in a comparison with those of vertebral perforation. The subjects were 64 patients who underwent percutaneous vertebroplasty (PVP group) and 67 patients who underwent vertebral perforation (Perforation group) between 2006 and 2011 at Takeda general hospital. We compared the analgesic effects of the treatments and the incidences of new VCFs between the groups at 15 months postsurgery. The pain scores on a visual analog scale 15 months postsurgery were 2.3 ± 2.0 in the PVP group and 2.1 ± 1.4 in the Perforation group, a nonsignificant difference (p = .90). The presence of vertebral mobility did not influence the analgesic effect in either group. New VCFs developed at a significantly higher rate in the PVP group (n = 27, 52%) compared to the Perforation group (n = 11, 24%; p = .0017). This difference was even greater within 3 months of the surgery, in 19 PVP patients (38%) and two Perforation patients (3.0%; p < .0001). However, the incidence after 3 months was eight PVP patients and nine Perforation patients, a nonsignificant difference (p = .50). The Kaplan–Meier analysis suggested that the new fractures after surgery in both treatment groups may occur at the same frequency at around 31 months postoperatively. Vertebroplasty is more effective than vertebral perforation in relieving pain early in the course of treatment, but over the long term, no significant difference in pain was seen between the two treatments. The complication of new fractures seen with cement vertebroplasty is only seen after the procedure.

Cystic dilation of the ventriculus terminalis

The ventriculus terminalis (VT) is a virtual cavity of the conus medullaris that appears during embryonic life. We presented a case with the cystic dilation of the ventriculus terminalis (CDVT) in a symptomatic patient. A 66-year-old female suffered from disturbance while walking evolving for the past 2 years. An MR image revealed a cystic dilatation of ventriculus terminalis. The patient experienced marked improvement of lower extremity strength by a fenestration of cyst and cyst-subarachnoid shunt. Treatment for asymptomatic patients seems to be the best conducted conservatively, whereas patients with focal neurological deficits seem to be best handled surgically.

Cervical disc herniation manifesting as a Brown-Sequard syndrome.

Brown-Sequard syndrome is commonly seen in the setting of spinal trauma or an extramedullary spinal neoplasm. The clinical picture reflects hemisection of the spinal cord. We report a rare case of Brown-Sequard syndrome caused by a large cervical herniated disc. A 63-year-old man presented with progressive right hemiparesis and disruption of pain and temperature sensation on the left side of the body. Magnetic resonance imaging showed large C3-C4 disc herniation compressing the spinal cord at that level, with severe canal stenosis from C4 through C7. Decompressive cervical laminoplasty was performed. After surgery, complete sensory function was restored and a marked improvement in motor power was obtained.

Microsurgical Resection of Thoracic Meningioma: 2-Dimensional Operative Video

The primary goal of surgery with spinal meningioma is complete safe tumor removal and decompression of the spinal cord. For the surgical removal of spinal meningioma, internal debulking before dissection of the tumor capsule is essential. Intraoperative ultrasonography to localize the tumor is recommended by some authors, but we use indocyanine green (ICG) videography to visualize the localization of tumor before dural incision. ICG videography allows safe and complete delineation of intradural tumors before dural opening. This technique is quick, cost-effective, and simple to use, especially with its integration into the surgical microscope.  Herein, we present a case of a 54-yr-old female patient presenting with a 1-yr history of numbness of the right lower limb. Neurological examinations demonstrated temperature pain disorder of right lower limb and slight dysuria. Magnetic resonance images demonstrated intradural extramedullary tumor at the level of Th6. Preoperative diagnosis was spinal meningioma.  In this surgical video, we show ICG angiography before dural opening, in addition to the basic surgical procedure of the thoracic meningioma. We believe this operative video will be useful for those in training as well as practicing surgeons. We received written informed consent from the patient for this publication.

Microsurgery of Spinal Dural Arteriovenous Fistula Using Indocyanine Green Video Angiography: 2-Dimensional Operative Video

Spinal dural arteriovenous fistulas (SDAVF) develop by direct abnormal arteriovenous connection between both sides of the spinal dura matter. In this condition, there is no intervening nidus between a meningeal segmental artery and a radiculomedullary vein. Open microsurgery is one of the choices for patients with SDAVF. When the AVF is on the inner dural surface, we can easily block the radiculomedullary vein in a microscopic view. We herein report a 50-yr-old woman who presented with low back pain, was diagnosed with an SDAVF, and underwent surgical treatment under a microscopic view. The spinal angiography demonstrated abnormal arteriovenous connections between intercostal arteries at the level of Th11 to 12 and the intradural radiculomedullary vein. Operative indocyanine green (ICG) microangiography demonstrated the blood flow in meningeal vessels and their anastomoses between both sides of the dural surface. We easily identified the radiculomedullary vein fed by the surrounding meningeal feeding arteries and block completely under a direct microscopic view. We detected the change in hemodynamic during feeder ligation by Flow 800 (Zeiss Penteto Flow 800 microscope; Zeiss Corporation, Tokyo, Japan). After surgery, the patients symptoms disappeared and no recurrence of the disease has been noted in the past 23 mo. We have received the informed consent of this patient for the publication of this case report.