Takako Kanatani

Influence of macrophage infiltration of herniated disc tissue on the production of matrix metalloproteinases leading to disc resorption.

Study Design. Herniated lumbar disc specimens were cocultured with peripheral blood mononuclear cells, and cells isolated from extruded disc were cultured to study the production of matrix metalloproteinases. Objective. To investigate the role of peripheral blood mononuclear cells infiltrating extruded discs and disc-derived cells in the production of matrix metalloproteinases. Summary of Background Data. Magnetic resonance imaging analysis of herniated disc patients revealed a progressive decrease in the size of herniated discs. Spontaneous regression of herniated disc is associated with infiltrating macrophages, and matrix metalloproteinases have been implicated in this phenomenon. However, the correlation between infiltrating macrophages and the production of matrix metalloproteinases has received little research attention. Methods. Each disc specimen was incubated with homologous peripheral blood mononuclear cells. The numbers of peripheral blood mononuclear cells attached to the surfaces of herniated discs were counted and the culture media was assayed for MMP-3. The cells isolated from herniated discs were incubated with cytokines and the production of matrix metalloproteinases was measured. Total RNA was extracted from herniated discs and RT-PCR was carried out. Results. Significantly larger numbers of peripheral blood mononuclear cells were attached to the surfaces of extruded discs, and higher amounts of MMP-3 were detected than those of control discs. The culture medium of extruded discs showed higher MMP-1 and MMP-3 production than those from controls. Significant enhancement of MMP-1 and MMP-3 mRNA expression was observed in the disc-derived cells stimulated with cytokines. Conclusion. These results suggest that peripheral blood mononuclear cells infiltrating extruded discs may secrete a variety of biologic materials capable of further recruiting monocytes into herniated discs in an autocrine fashion. Disc cells stimulated with cytokines showed enhanced production of matrix metalloproteinases, which might play an important role in spontaneous regression of disc materials.

Prospective study and multivariate analysis of the incidence of C5 palsy after cervical laminoplasty.

Study Design. A prospective comparative study about the incidence of postoperative C5 palsy and multivariate analysis of the risk factors of C5 palsy. Objective. To clarify the risk factors of occurrence of C5 palsy after laminoplasty (LP) by comparing the 2 surgical procedures of open-door and double-door LP prospectively. Summary of Background Data. The incidence of C5 palsy has been reported to average 4.6%, and there has been no difference of the incidence among surgical procedures. However, there were only indirect retrospective studies. Methods. A total of 146 patients who underwent the LP procedure between 2006 and 2007 were studied prospectively. In 2006, the patients were assigned to undergo the open-door LP, and in 2007, they were assigned to undergo the double-door LP. The incidence of postoperative C5 palsy was compared prospectively between these 2 LP procedures, and the risk factors of C5 palsy were detected with multivariate logistic regression analysis. Results. Postoperative C5 palsy occurred in 7 of 73 cases after open-door LP (9.6%) and in 1 of 73 cases after double-door LP (1.4%). The incidence of C5 palsy after open-door LP was statistically higher than the one after double-door LP (P = 0.029), and open-door LP was recognized as a significant risk factor for postoperative C5 paralysis (odds ratio: 69.6, P = 0.043). In addition, ossification of posterior longitudinal ligament (OPLL) was recognized as a significant risk factor for postoperative C5 paralysis (odds ratio: 43.8, P = 0.048). Conclusion. This study showed significant evidence indicating the higher risk of postoperative C5 palsy in open-door LP than double-door LP. Because OPLL as well as open-door LP were recognized as the risk factors of C5 palsy, asymmetric decompression by open-door LP might introduce imbalanced rotational movement of spinal cord and result in C5 palsy. We recommend double-door LP to minimize the postoperative C5 palsy, in particularly, if the patient has OPLL.

Delayed electrophysiological recovery after carpal tunnel release for advanced carpal tunnel syndrome: a two-year follow-up study.

Summary: Advanced carpal tunnel syndrome presents severe thenar atrophy with the absence of electrophysiological motor and sensory responses. Because of severity of these conditions, a substantial period of recovery after surgery is required before improvement becomes evident. In this electrophysiological-based study, the reappearance of distal motor latency (DML) at the abductor pollicis brevis and/or sensory nerve conduction velocity (SCV) after wrist stimulation were evaluated 1 year and 2 years after carpal tunnel release . To categorize outcomes, the following grading scale was used: stage I, normal DML and SCV; stage II, DML ≥ 4.5 ms and normal SCV; stage III, DML ≥ 4.5 ms and SCV < 40.0 ms; stage IV, DML ≥ 4.5 ms and nonmeasurable SCV; stage V: nonmeasurable DML and SCV. The authors found measurable DML and/or SCV and significant improvement both 1 year and 2 years postoperatively. Furthermore, the percentage of patients who recovered to the extent that they presented as mild carpal tunnel syndrome (stage I or II) increased significantly. They conclude that electrophysiological assessment of DML and SCV of advanced carpal tunnel syndrome using the above grading scale was effective as an objective evaluation tool of recovery after carpal tunnel release.

Electrophysiological Assessment of Carpal Tunnel Syndrome in Elderly Patients: One-Year Follow-Up Study

PURPOSE To objectively assess elderly patients with carpal tunnel syndrome to characterize their preoperative severity and prognosis after carpal tunnel release using a electrophysiological severity scale. METHODS Electrophysiologic assessment was performed preoperatively and 1 year postoperatively following carpal tunnel release in 112 hands in patients over 70 years of age prospectively by the use of the following electrophysiological severity scale: stage 1, normal distal motor latency (DML) and normal sensory conduction velocity (SCV); stage 2, DML ≥ 4.5 milliseconds and normal SCV; stage 3, DML ≥ 4.5 milliseconds and SCV < 40.0 m/s; stage 4, DML ≥ 4.5 milliseconds and non-measurable SCV; stage 5; non-measurable DML and non-measurable SCV. Additionally, the outcomes of clinical symptoms of pain, nocturnal symptoms, numbness, loss of 2-point discrimination in the median nerve territory, and thenar atrophy were assessed. RESULTS The mean age of patients was 77 years at the time of the operation. Preoperatively, the most common severity was stage 5 (70 of 112 hands, 63%), and clustering stage 4 and 5 together as severe resulted in 103 hands (92%). One year postoperatively, 97 hands (87%) demonstrated at least one stage improvement, and the numbers of mild (stage 1 or 2) increased from 3 (3%) to 45 hands (40%). Parallel with the electrophysiological improvement, pain and nocturnal symptoms resolved in 17 of 17 hands and 11 of 11 hands, respectively, in whom they were present preoperatively. Numbness, loss of 2-point discrimination, and thenar atrophy demonstrated the improvement in 96 of 112 (86%) hands, in 58 of 112 (52%) hands, and in 80 of 96 (83%) hands. CONCLUSIONS We observed electrophysiologic improvement in 86% of elderly patients following carpal tunnel release. Electrophysiologic outcomes correlated with improvement in clinical variables. TYPE OF STUDY/LEVEL OF EVIDENCE Therapeutic IV.

The vanishment of an intramedullary high-signal intensity lesion at the craniocervical junction after surgical treatment: a case report of the presyrinx state.

Study Design. A case report of the presyrinx state at the craniocervical junction with vanishment of an intramedullary high-signal lesion followed by decompression and fixation. Objective. To report the reversible change of an intramedullary high-signal lesion on T2-weighted MRI as a presyrinx state. Summary of Backgroud Data. The pathology of a T2-weighted high-signal intensity area in the spinal cord has not yet been described in detail. The case presented here showed the vanishment of this lesion after the surgical procedure, which implies that some high-signal intensity lesions might be reversible as a presyrinx state. Methods. A 75-year-old man presented with severe cervical myelopathy. Neurologic findings and observations on various images indicated compression myelopathy due to both a pseudotumor at the craniocervical junction and spondylosis at C3–C4 disc level due to Klippel-Feil syndrome. The most obvious finding was a vast high-signal intensity lesion at the craniocervical junction, which was speculated to be a syringomyelia before surgery. Results. The MRI at 1 month after surgical treatment (occipito-spinal fusion with the decompression by enlargement of foramen magnum) revealed complete vanishment of the vast high intensity lesion at the craniocervical junction, which remained undetected at the 2 years and 8 months follow-up and corresponded with improvement in the clinical symptoms of myelopathy. Conclusion. The vanishment of these signal changes on MRI after surgery was interpreted as a presyrinx state, demonstrating this reversible pathology in the spinal cord.

Assessment of vascularized free fibula transplantation revealing a congenital aplastic posterior tibial artery: a case report

IntroductionAnatomical abnormalities in the lower limb vessels are uncommon. However, the preoperative evaluation of the anatomical variations is very important for planning the operation procedure to prevent jeopardizing the donor leg.Case presentationIn this case report, a 23-year-old Asian woman who was scheduled to have vascularized free fibula transplantation for reconstruction of her wrist after excision of bone tumor in her distal radius, was found to have congenital aplastic posterior tibial arteries in both legs. These findings were found on magnetic resonance angiography (our preferred methodology due to its simplicity). We planned testing the sufficiency of her pedal pulses after temporarily clamping her peroneal artery but prior to harvesting, to ensure minimal risk to the longevity of her donor leg. During the operation, after dissection of a 10cm segment of her fibula with the peroneal artery, the peroneal artery proximal to the graft was temporarily clamped and the tourniquet was released. As adequate sustainable pedal pulses were confirmed, the graft was harvested and transplanted to her wrist. There was no morbidity in her right leg postoperatively and the union of the grafted fibula was substantiated 10 months postoperatively.ConclusionsWe concluded two findings: firstly, for accurate preoperative planning of a vascularized free fibula procedure, examination of the bilateral lower leg vasculature either by angiography or other imaging should be performed. Secondly, abnormalities are not in themselves reason to abandon the vascularized free fibula procedure. We contend that pedal pulses should be evaluated preoperatively and provided that adequate foot circulation can be confirmed (by temporarily clamping the vessels and releasing the tourniquet during the operation prior to harvesting the free vascularized fibula) the procedure should be successful without jeopardizing the donor leg.

Usefulness of distal motor latency measurement after palmar stimulation in advanced carpal tunnel syndrome.

Summary: The measurement of distal motor latency (DML) after palmar stimulation distal to the carpal tunnel (Palmar-DML) was investigated before carpal tunnel release (CTR) in 48 advanced carpal tunnel syndrome (CTS) with thenar atrophy and absence of motor and sensory responses after wrist stimulation. This allowed measurement of the direct effects of stimulation, in assessing the pathologic condition of the median nerve. Palmar-DML was measurable in 47 of 48 hands preoperatively, which responded to CTR with improvement of thenar atrophy at 1 year postoperatively. Also, electrophysiologic recovery presenting reappearance of DML after wrist stimulation was shown in 43 hands of those 47 hands. Furthermore, sensory nerve conduction velocity was measurable in 24 hands. In contrast, in one hand with the absence of Palmar-DML, CTR neither relieved thenar atrophy nor induced measurable Palmar-DML. This study demonstrated that Palmar-DML was measurable in most advanced CTS, which suggested the major abnormality was focal demyelination. This was confirmed by electrophysiologic and clinical improvement obtained after CTR. Palmar-DML measurement was useful to elucidate the median nerve condition in advanced CTS.

CARPAL TUNNEL SYNDROME ASSOCIATED WITH A FRACTURE OF A SILICONE IMPLANT FOR KIENBÖCK'S DISEASE: TWO CASE REPORTS

In this report, two cases presenting with CTS including a fracture of the silicone implant for Kienböcks disease after replacement over 20 years postoperatively where CTR ceased the symptoms of CTS. The major symptom characteristic was the median nerve impairment with less emphasis on the limited range of motion of the wrist or wrist pain due to a fracture of the silicone implant. There was an unlikely association between the fracture of the implant and CTS, which was confirmed by the operative findings of tenosynovitis and thickness of the degenerated transverse ligament without a significant protrusion of the silicone implant.

Re: metastatic oesophageal carcinoma presenting in a finger.

authors use the term Wassel IV for a complete duplication of the proximal phalanx, but many authors use Wassel’s original scheme with its ambiguous drawing for type IV (Buck-Gramcko, 1981; Dobyns et al., 1988; Ikuta, 1984). In their modification of Wassel’s classification, Tada et al. (1983) defined type IV as a duplication at the MCPJ level, and in the accompanying drawing the epiphyses of the proximal and distal phalanges were omitted, thus avoiding Wassel’s mistake. Wood (1978) expanded Wassel’s classification with respect to the triphalangeal thumb, drawing type IV correctly with two proximal phalanges and two epiphyses. Horii et al. (1997) further subdivided type IV duplication by the type of connection between the bases of the proximal phalanges by either cartilage, joint or fibrous tissue. They did not, however, mention a bony connection, which would again represent a Wassel type III duplication. It is difficult to speculate whether Wassel really intended to define type IV duplication the way he did, or whether it was an error. Following the principle Wassel used in defining types I to VI, it would seem there was an error both in his definition and in the drawing that has unfortunately been repeated in various journals and books for the last four decades.

Medial Migration of the Lag Screw in Gamma Nailing System: A Case Report

Medial lag screw migration in Gamma nail system is an uncommon complication. In 92-year-old woman, the medial lag screw migration into the pelvic with nonunion oftrochanteric fractureat 4 months after the osteosynthesis. The computed tomography scan did not reveal intestinal organs injury by the protruded screw and the removal of the implant eased her right hip pain. During the operation, the lag screw migration by the incorrect engagement of the set screw outside of the groove on the lag screw was observed, which was considered the reason. To avoid such a hazardous complication in Gamma nail system for trochanteric fracture, correct engagement of the set screw into the groove on the lag screw should be confirmed after tightening the set screw.