Kuniyoshi Tsuchiya

Minimum 5-year analysis of L5-S1 fusion using sacropelvic fixation (bilateral S1 and iliac screws) for spinal deformity.

Study Design. Clinical radiographic and outcomes investigation. Objective. To investigate clinical and radiographic outcomes for lumbosacral fusion (in patients with spinal deformity) using a combination of bilateral sacral and iliac screws with a minimum 5-year follow-up. Summary of Background Data. To our knowledge, long-term results (>5 years of follow-up) of bilateral S1 screw/bilateral iliac screw fixation have never been published or presented. Materials and Methods. A total of 67 patients (from an initial consecutive cohort of 81) undergoing lumbosacral fusion with bilateral sacral and iliac screws with a minimum follow-up of 5 years (range 5–10 + 5, average 6 + 3) were analyzed for radiographic outcome and clinical course by an outcome questionnaire (administered at ultimate follow-up) analysis. Patients were divided into 2 groups: group 1, 34 patients with mostly high-grade spondylolisthesis; and group 2, 33 with adult scoliosis fused mostly from the thoracic spine to the sacrum. A true anteroposterior pelvis film was obtained in all patients to assess for sacroiliac joint arthritis, as were standard spine radiographs. Patients were administered Oswestry and directed buttock pain questionnaires at latest follow-up. Results. There were no cases of sacral screw failure (i.e., screw loosening, partial screw pullout, or fracture of the sacral screw). There were 5 cases of nonunion at L5–S1. Of the 5 cases, 3 did not have anterior column support at L5–S1. Four of the 5 cases were revised, and, subsequently, 3 achieved union. Iliac screws were removed electively on 1 or both sides in 23 of the patients after 2 years postoperatively because of prominence. There were 7 cases of iliac screw breakage. Iliac screw halos were observed in 29 patients. No sacroiliac osteoarthritis was observed on the true anteroposterior pelvis films. At ultimate follow-up, average visual analog painscale (0–10) score to assess buttock pain was 2.4, and average Oswestry score was 20.1. Conclusions. For high-grade spondylolisthesis and long adult deformity fusions to the sacrum, a montage of bilateral S1 screws and iliac screws were effective in protecting the sacral screws from failure. Pseudarthrosis at L5–S1 was manifested by rod breakage at that level. We saw no evidence of a long-term effect of the iliac screws predisposing the sacroiliac joints to degeneration at follow-up ranging from 5 to 10 years.

Bacterial spondylodiscitis in the patients with hemodialysis.

Study Design. Retrospective clinical and laboratory data analyses were performed on hemodialysis (HD) patients with bacterial spondylodiscitis. Objectives. The purpose of this study was to investigate clinical characteristics and related problems for the diagnosis and treatment of spondylodiscitis in patients on maintenance HD. Possible factors for the development of spondylodiscitis were also discussed. Summary of Background Data. Although bacterial spondylodiscitis is one of most serious complications that can occur in HD patients, few reports are seen describing its clinical course and treatment in HD patients. Methods. A total of 9 HD patients were diagnosed as having bacterial spondylodiscitis at our institute. The onset of infection, characteristics of clinical symptoms, and clinical course were reviewed retrospectively. Results. Latent form occurrence was most frequent, and only 1 in 9 cases presented high-grade fever at the beginning of treatment. Many complications were encountered both in conservatively treated and operated cases. Three patients were operated on, 1 of whom died 2 days after operation. Two of six patients in the conservatively treated group also died during the treatment period. Conclusions. The presence of bacterial spondylodiscitis must be considered when treating back pain of HD patients even when they are afebrile. Careful observation of general status in addition to local conditions is essential. Indication of operation should be considered carefully because of the poor general status and bone quality of HD patients. MRI, in addition to plain radiographs, was necessary to differentiate destructive spondylarthropathy from bacterial spondylodiscitis.

Discovertebral lesion in ankylosing spondylitis: differential diagnosis with discitis by magnetic resonance imaging.

Abstract  Ankylosing spondylitis (AS) is occasionally accompanied by erosive changes in the vertebral endplate at one or more restricted levels (Andersson lesions). The radiographic findings of this lesion are similar to those of bacterial discitis, and a differential diagnosis between them is often difficult. These diseases must be diagnosed correctly because they require different treatments. In order to evaluate the prevalence of Andersson lesions in the Japanese population, we examined 31 cases of AS which were treated in our department, and Andersson lesions were found in three (9.7%) of them. All these three cases developed Andersson lesions in the earlier phase of the AS, and differentiating the lesions from bacterial discitis was difficult. The details of these three cases are reviewed, and the importance of differentiating between Andersson lesions and bacterial discitis is discussed. Plain radiographs showed no clear difference between these conditions, but magnetic resonance imaging (MRI) was found to be more efficient.

Effect of cartilaginous endplates on extruded disc resorption in lumbar disc herniation

Objective The aim of this study was to investigate the clinicopathologic features of lumbar disc herniation (LDH) with endplate degeneration and the association between cartilaginous fragments and inflammatory response to the herniated disc. Summary of background data LDH often involves hyaline cartilage fragments pulled from the vertebral endplates. Modic changes are closely associated with LDH that contains hyaline cartilage, and cartilaginous endplates seem to affect resorption of the herniated disc. Methods A total of 78 patients who underwent microscopic discectomy between 9 and 16 weeks after an occurrence of LDH were reviewed. Modic changes, disc degeneration, high-intensity zone, and vertebral corner defect were evaluated using magnetic resonance imaging (MRI). Histopathological observations of cartilaginous endplates and inflamed granulation tissue in the herniated disc were made. In cases with inflamed granulation tissue, neovascularization and macrophage infiltration were also evaluated using immunohistochemical analysis. Results Modic changes were observed in approximately one-third of the patients (26 cases: type 1, 7; type 2, 17; and type 3, 2). Cartilaginous endplates were observed in 32 cases (41%) and in the majority of cases with Modic changes compared with cases without Modic changes (65%, p = 0.001). Although inflamed granulation tissue was observed in 60 cases (77%), no significant differences were detected in patient age and the composition of the herniated material. Immunohistochemical analysis showed that fewer CD34-positive capillaries and CD68-positive cells were found in cases with cartilaginous fragments compared with those without cartilaginous fragments (p < 0.001). In addition, a higher immunoreactivity to CD34 and CD68 was found in herniated discs <25% of whose area was occupied by cartilaginous endplates compared with discs whose area was occupied at 25% or more (p < 0.001). Conclusion There is an association between LDH with endplate degeneration and cartilaginous herniation, with Modic type 2 predominating. Furthermore, neovascularization and macrophage infiltration, especially if the amount of cartilage is high, are likely to be less frequent in cartilaginous herniation, leading to failure in the spontaneous remission of clinical symptoms.

Clinical features and surgical management of rare cases of thoracic intraspinal cysts: Report of 3 cases

Intraspinal cysts can cause myelopathy or radiculopathy by compressing the spinal cord or nerve root. These cysts occur commonly in the lumbar or cervical spine and rarely at the thoracic level, because spinal instability is considered to be the cause of intraspinal cysts. Intraspinal cysts include synovial cysts, ganglion cysts, ligamentum flavum cysts, neurenteric cysts, arachnoid cyst. Among them, the most common types are synovial and ganglion cysts, which arise from facet joints. Synovial cysts are pathologically distinguished from ganglion cysts by having a thick wall lined by synovial cells. Diagnosis of ganglion cysts also can be made on the basis of the characteristic jelly-like fluid content. The ligamentum flavum also can form cysts when hemorrhage occurs inside, and these are called ligamentum flavum cysts. In this report, we present 3 cases of rare thoracic intraspinal cysts that were successfully treated by surgical resection; discuss the features of these cysts on preoperative images, the intraoperativefindings, treatment options, and pathological findings; and review the relevant literature.

Application of Ultrasonic Bone Scalpel for Spinal Surgery

脊椎疾患133例の手術に超音波骨切除装置を使用した．超音波骨メスの使用により骨切除が容易かつ安全に施行可能であった．特に有用であった術式は頚椎椎弓形成の正中縦割，頚椎前方除圧固定，胸椎レベルの靭帯骨化に対する除圧術，腰椎では骨形成的椎弓切除術であった．2例に硬膜損傷を経験した．これらはハンドピースの先端部のフックで機械的に硬膜を挟み込んだものと推定され，手技的なものと考えられた．その他超音波骨メスは硬膜露出後の追加骨切除の際に有用であった．超音波骨メスは削開スピード自体はエアトームに劣るが術者の負担軽減が期待でき，脊椎手術の際有用であることが示された．

Assessment of Femoral Neck Fracture in Hemodialytic Patients.

In order to examine the pathogenesis and related problems of femoral neck fracture in hemodialytic patients, 16 patients with hemodialysis (HD) who were operated on for femoral neck fracture from November 1998 to December 2000 were reviewed. Average age at operation was 71 years and the average duration of HD was 17.4 years. Two out of the 16 cases had no obvious history of trauma. Thirteen cases had subcapital fracture and three cases had trochanteric fracture. All three cases with trochanteric fracture showed severe anemia and required blood transfusion before operation, whereas all cases of subcapital fracture did not. Subcapital fracture seemed more likely to occur in patients with HD presumably due to bone fragility and anatomical weakness of the femoral neck. In addition, appropriate volume control and early transufusion, when necessary, are considered very important for patients with HD, because they lack self-regulatory capacity.