Rinsei Tei

Two-stage management for vertebral osteomyelitis and epidural abscess: technical note.

OBJECTIVE:The incidence of spinal infections has increased in recent years, and vertebral osteomyelitis and epidural abscess are issues of great concern for spine surgeons. We retrospectively reviewed our cases treated by two-stage management for vertebral osteomyelitis and epidural abscess. METHODS:The series consisted of nine patients (five men and four women); their ages ranged from 49 to 77 years (mean age, 60.6 yr). Coexisting medical conditions were diabetes mellitus in one case and long-term steroid intake in another. Myelopathy or radicular pain was caused by osteomyelitis and an epidural abscess in all patients. Cervical, thoracic, and lumbar osteomyelitis was detected in three, four, and two patients, respectively; epidural abscess was pyogenic in four patients, tuberculous in three, and unknown in two patients. Our surgical strategy involved anterior debridement or drainage and application of an external orthosis postoperatively during the first stage. After clinical control of the infection by using organism-specific intravenous antibiotics as far as possible, as confirmed by normal erythrocyte sedimentation rate and/or C-reactive protein, second stage surgery was performed. This included complete debridement of all necrotic bone and soft tissues, and stable reconstruction with or without instrumentation (six and three patients, respectively). RESULTS:The postoperative course was uneventful with relief of the symptoms after the second surgery. No evidence of recurrence or residual infection was observed in any patient, as shown by erythrocyte sedimentation rate and/or C-reactive protein levels during a follow-up period averaging 26.6 months (range, 2–56 mo). CONCLUSION:Without denying the efficacy of the single-stage surgery, two-stage management can be a reasonable alternative for carefully selected patients who have spinal infection.

Delayed reconstruction by titanium mesh-bone graft composite in pyogenic spinal infection: a long-term follow-up study.

Objective: Use of instrumentation in spinal osteomyelitis remains controversial because of the perceived risk of persistent infection related to a devitalized graft and spinal hardware. Particularly, limited information is available regarding the long-term follow-up of patients. We retrospectively reviewed the use of titanium mesh-bone graft composite after corpectomy in pyogenic spinal infection with a minimum 3-year follow-up outcome. Methods: Four patients, two men and two women, with cervical and thoracic myelopathy caused by cervical (two cases) and thoracic (two cases) osteomyelitis and epidural abscess, were treated. Their age ranged from 49 to 74 years (mean age 58 years). In one case, the coexisting medical condition was diabetes. Neurologic deficits caused by direct spinal cord compression due to epidural abscess, segmental deformity, and instability were observed in all cases. After infection was clinically controlled by intravenous antibiotics, anterior debridement and fusion using titanium mesh cage along with anterior plate were performed. Two-stage treatment was performed in two cases. Results: The postoperative course was uneventful; all patients experienced relief of symptoms. No evidence of recurrence or residual infection was observed in any patient during the average follow-up period of 42-56 months (average 49.0 months). Conclusions: Once infection is clinically controlled, a titanium mesh-bone graft composite and plate in combination with aggressive debridement might provide an effective therapy for spinal osteomyelitis requiring surgery. Despite studying a small number of patients, we can conclude that titanium mesh reconstruction can be useful as a surgical method in selected low-risk patients with vertebral osteomyelitis.

Secondary spinal cord hypoperfusion of circumscribed areas after injury in rats

Abstract Objectives: The evaluation of the spatial spread of ischemia following spinal cord injury (SCI) is important for planning therapeutic strategies for secondary injury. The purpose of this study was to investigate in detail the change in regional spinal cord blood flow (rSCBF) after SCI. Methods: Thirty-four male Wistar rats were used, for which laminectomies of the T11–13 vertebrae were performed. SCI was produced by a directed impact through a laminectomy site at the level of the Th12 using a pneumatic impact device. We measured the sequential and spatial changes of rSCBF using a laser Doppler scanning technique before and after SCI in rats not only at the injured myelomere but also at the circumferent myelomeres. SCBF mapping was carried out before and after SCI on each site. Results: After SCI, the rSCBF value gradually decreased for each site for the SCI group (n=26), while it globally decreased at the epicenter. Moreover, a decrease in SCBF was observed at the caudal and rostral sites. The mean value of the %SCBF 120 minutes after SCI for each site was 63.6±2.3% (Th11), 74.4±4.5% (Th12), 75.8±3.2% (Th13), and was significantly lower for the rostral site compared with the caudal site (p<0.05, one-way analysis of variance). Discussion: This study found that SCBF is significantly decreased not only at the injured myelomere but also at the circumferent myelomeres. Circumferentially extending ischemia after SCI is related to secondary injury after SCI. The improvement in SCBF after SCI, therefore, can be attributed to the treatment of SCI.

Protective effect of C1 esterase inhibitor on acute traumatic spinal cord injury in the rat

Abstract Objective: The complement system and activated neutrophils are thought to play a major role in initiating some of the inflammatory events that occur in spinal cord injury. The aim of the present study was to assess the effects of C1 esterase inhibitor (C1-INH) on traumatic spinal cord injury (SCI) in the rat. Methods: Thirty-eight male Wistar rats were used. Just after SCI by a pneumatic impact device, C1-INH (n=16, C1-INH group) or saline (n=16, saline group) was administered. Sham operated animals (n=6, sham group) received only laminectomy. Eighteen (six from each group) rats were killed and an assessment of leukocyte infiltration by myeloperoxidase (MPO) activity and immunoreactivity of MPO were performed 24 hours after SCI. Twenty (ten from each of C1-INH and saline groups) rats were examined using behavioral function on post-operative days. They were also examined after 7 days by histologic analysis using Luxol fast blue for axons and myelin. Lesion volume was calculated by considering a lesion as being composed of two cones with juxtaposed bases. During the experiment, sequential changes in regional spinal cord blood flow (rSCBF) were measured using the laser Doppler (LD) scanning technique. Results: The recovery of motor function was better in the C1-INH group than in the saline group. In the C1-INH group, immunoreactivity of MPO showed a tendency to be smaller than that of the saline group. Lesion volume was significantly smaller in the C1-INH group than in the control group (p<0.01) and MPO activity was also significantly smaller in the C1-INH group than in the control group (p<0.01). After SCI, the rSCBF value decreased gradually and significantly in both injured groups. Significant differences were observed from 30 to 120 minutes after SCI (p<0.05). Discussion: The results of this study provided the first evidence that C1-INH reduced accumulation of polymorphonuclear leukocytes (PMLs) and neuronal damage in acute stage after SCI. This protection was not related to an improvement in rSCBF.

Course of the Hemorrhagic Type Moyamoya Disease: Based on the Data of Re-hemorrhage and Collateral Circulation

We analyzed the effect of superficial temporal to middle cerebral artery (STA-MCA) bypass to prevent future strokes based on the data of the clinical course and the course of the collateral circulation. Thirty-five patients with hemorrhagic type moyamoya disease were examined during the follow-up period with a mean of 6.3 years after the initial intracranial hemorrhage. Eighteen patients were conservatively managed, 12 patients underwent STA-MCA bypass, and the last 5 patients underwent encephaloduroarteriosynangiosis (EDAS). The ophthalmic artery flow was examined as the collateral circulation using the color Doppler flow imaging (CDFI). During the follow-up period, 13 patients (43%, 5.86%/patient/year) experienced a cerebral event such as ischemia or rebleeding. The incidence of a future stroke event in the patients treated with STA-MCA bypass (ppp Clinical symptoms and ophthalmic artery CDFI findings confirmed that STA-MCA bypass in patients with hemorrhagic type moyamoya disease prevents future strokes.

Early Decompressive Surgery for Spinal Cord Injury: Rationale Based on Experimental Study

The use of hypothermia to treat patients with severe TBI was first reported by Fay in 1943, and Sedzimir in the 1950’s [1,2]. These clinicians thought that cooling patients to as low as 27°C for 1–5 days after injury led to better than expected outcomes in some patients. Lundberg reported that hypothermia was as effective as osmotic diuretics for reducing elevated ICP, and had a more prolonged effect than hyperventilation [3]. James et al found that hypothermia caused a reduction of ICP in at least half of 40 patients with severe TBI they studied, and that the average decrease associated with hypothermia treatment was 41% [4]. However, concerns about