Toshio Matsubara

Microsurgical anatomy of the lower cervical spine and cord.

The authors dissected the cervical spine and its surrounding structures from 40 adult cadavers under a surgical microscope. The anterior part of the spine and spinal cord was examined after vertebrectomy. The posterior longitudinal ligament (PLL) consists of two layers; the anterior one is termed the deep layer, and the posterior one is termed the superficial layer. These two layers adhered together loosely. In the lateral portion of the spinal canal, the superficial layer joined the periradicular sheath at the level of the intervertebral disc spaces and joined the dura mater at the level of the vertebral bodies. After the removal of the deep layer, the anterior internal vertebral venous plexus was seen on top of the lateral part of the superficial layer. The venous plexus was embedded between the double-layered PLLs, was not located in the epidural space, and was not seen in the medial part of the PLL. The PLL without venous channels on top of it was about 10 mm in width at the levels of the intervertebral disc and about 5 mm at the levels of the vertebral body. The anterior root exit zone (AREZ) was an elliptical shape; the transverse length of the AREZ was about 2 mm, and the longitudinal length was 10 to 15 mm. The average number of anterior rootlets on the AREZ was 17 to 25 and tended to decrease in the lower cervical spinal cord. The posterior structures were examined after en bloc laminectomy.(ABSTRACT TRUNCATED AT 250 WORDS)

Thoracic spinal angiomyolipoma with extracanal extension to the thoracic cavity : A case report

Study Design. Case report and review of the literature. Objective. To describe a 72‐year‐old man with thoracic spinal angiomyolipoma in the ventral aspect of the epidural space and extracanal extension to the posterior mediastinum, to discuss the clinical and radiologic features and unique biologic behavior of this entity, and to review of the literature on angiolipoma and angiomyolipoma. Summary of Background Data. Spinal angiolipoma and angiomyolipoma are rare tumors, which are localized almost exclusively in the dorsal epidural space of the thoracic spine. Most reported cases have no tendency to involve the surrounding tissue. Methods. The authors describe the radiologic, surgical, and pathologic findings of this patient and review the findings from other reported cases. Results. Anterior decompression was performed using a right transthoracic incision, and the neurologic symptoms improved immediately. There were no signs of recurrence of the tumor or neurologic deficit within a 2‐year follow‐up period. Conclusion. Results of a literature survey of these tumors support management by prompt and radical surgical intervention for long‐term cure, even in cases in which the infiltrating nature is recognized.

Surgical treatment of ossification of the posterior longitudinal ligament in the thoracic spine

Thoracic ossification of the posterior longitudinal ligament (OPLL) is a rare entity causing thoracic myelopathy. Its surgical decompression is still challenging. Three patients admitted with progressive myelopathy due to thoracic OPLL are described. A transthoracic anterolateral approach was used in the first and second cases, in which OPLL was located at the T3-T4 and T5-T6 and at the T7-T8 levels, respectively. In the third case, a transsternal approach was adopted for OPLL at the T1-T2 level. The OPLL, including dural ossification, was removed by microsurgical techniques as extensively as possible. Myelopathy in all three cases became relieved or stable postoperatively. Operative procedures are described in detail. From the viewpoint of surgical anatomy, the selection of operative approach depends on the level of the OPLL. The authors emphasize that a transthoracic anterolateral approach is the treatment of choice for extensive anterior pathology such as OPLL involving more than two thoracic bodies below the T4. A transsternal approach can provide excellent access to a lesion at the upper three thoracic bodies.

Recurrent melanotic neuroectodermal tumor in the orbit successfully treated with resection followed by pediculated periosteal flaps.

Melanotic neuroectodermal tumor of infancy (MNTI) is a rare tumor arising mainly in the orofacial bones. Among more than 200 cases described in articles, only seven cases involved orbital regions. We present a case of newborn with recurrent MNTI in the lateral wall of right orbit. The patient underwent complete surgical resections at onset and relapse. The bone defects following the second surgery were successfully reconstituted with pediculated periosteal flaps from parietofrontal bones. In this article, we describe clinical course of recurrent MNTI in the orbit and discuss management of the tumor involving the orbit. Pediatr Blood Cancer 2008;51:430–432.

MRI findings of atypical meningioma with microcystic changes

A 54-year-old woman presented with visual disturbance and consulted with a physician at our hospital. Neurological examination revealed left hemianopsia. MRI of the brain revealed an extraaxial tumor with a markedly low T1 signal and a markedly high T2 signal in the right occipital region (Figs. 1a, 1b). Peritumoral edema was visible on the T2-weighted images (Fig. 1b). Contrast-enhanced T1-weighted images showed inhomogeneous and less intense enhancement (Fig. 1c). Diffusion-weighted imaging (DWI) was performed and an apparent diffusion coefficient (ADC) map (Fig. 1d) revealed much higher diffusion of the tumor (1.41 · 10 mm/s) than normal white matter (0.70 · 10 mm/s), equivalent to that of adjacent peritumoral edema (1.40 · 10 mm/s). A diagnosis of microcystic meningioma was considered. Subsequently, the patient underwent total tumor resection. Intraoperatively, the tumor attached to the dura matter was soft and moist, resembling a jellyfish. No invasion into adjacent brain parenchyma was apparent. Histological examination showed that the tumor comprised neoplastic meningothelial cells with abundant cysts of various size (Fig. 2a). Histological diagnosis was atypical meningioma with microcystic changes (WHO grade II) because the tumor features increased cellularity and prominent nucleoli (Fig. 2b), and foci of geographic necrosis (Fig. 2c). However, mitotic activity was not high and the MIB1 labeling index was 3%. The patient had a good postoperative course and has been under follow-up for six months.

Chronic hydrocephalus presenting with bilateral ptosis after minor head injury: case report.

OBJECTIVE AND IMPORTANCE Some patients with hydrocephalus may exhibit various signs of oculomotor dysfunction. However, ptosis has not previously been described in chronic hydrocephalus patients. CLINICAL PRESENTATION We report a 50-year-old woman who was diagnosed with chronic hydrocephalus based on an evaluation for bilateral ptosis after a minor head injury. She exhibited bilateral ptosis and upward gaze paralysis, but other oculomotor functions were normal. Neuroimages revealed chronic hydrocephalus with no traumatic abnormalities. INTERVENTION The eyelid dysfunction resolved after placement of a right ventriculoperitoneal shunt with a programmable pressure valve. CONCLUSION The resolution of eyelid dysfunction by cerebrospinal fluid diversion suggests that chronic hydrocephalus was involved in the development of ptosis after the minor head injury. A mild but sudden cerebrospinal fluid pressure change at the time of minor head injury might induce functional impairment at the level of vulnerable periaqueductal structures, which barely withstood the longstanding ventriculomegaly, resulting in the clinical features observed in our patient.

An immuno-wall microdevice exhibits rapid and sensitive detection of IDH1-R132H mutation specific to grade II and III gliomas

Abstract World Health Organization grade II and III gliomas most frequently occur in the central nervous system (CNS) in adults. Gliomas are not circumscribed; tumor edges are irregular and consist of tumor cells, normal brain tissue, and hyperplastic reactive glial cells. Therefore, the tumors are not fully resectable, resulting in recurrence, malignant progression, and eventual death. Approximately 69–80% of grade II and III gliomas harbor mutations in the isocitrate dehydrogenase 1 gene (IDH1), of which 83–90% are found to be the IDH1-R132H mutation. Detection of the IDH1-R132H mutation should help in the differential diagnosis of grade II and III gliomas from other types of CNS tumors and help determine the boundary between the tumor and normal brain tissue. In this study, we established a highly sensitive antibody-based device, referred to as the immuno-wall, to detect the IDH1-R132H mutation in gliomas. The immuno-wall causes an immunoreaction in microchannels fabricated using a photo-polymerizing polymer. This microdevice enables the analysis of the IDH1 status with a small sample within 15 min with substantially high sensitivity. Our results suggested that 10% content of the IDH1-R132H mutation in a sample of 0.33 μl volume, with 500 ng protein, or from 500 cells is theoretically sufficient for the analysis. The immuno-wall device will enable the rapid and highly sensitive detection of the IDH1-R132H mutation in routine clinical practice.

Skull Meningioma Associated with Intradural Cyst: A Case Report

We present the first report of intraosseous meningioma accompanied by intradural cyst formation. A 76-year-old woman had previously undergone breast cancer treatment, so the preoperative diagnosis was metastatic breast cancer. This case reminds us that the possibility of meningioma should be kept in mind in patients with breast cancer, irrespective of neuroimaging findings.

Efficacy of Seprafilm® in Abdominal Surgery for Ventriculoperitoneal Shunt Malfunction: A Report of Two Pediatric Cases

Temporary external drainage with adequate antibiotic treatment followed by ventriculoperitoneal (VP) shunt reinsertion is necessary to treat VP shunt malfunction with infection. In surgeries for VP shunt reinsertion, the key factors that determine whether the reinserted VP shunt will function sufficiently are adequate adhesiolysis and safe placement of the VP shunt within a satisfactory peritoneal location. Based on these factors, the prevention of postoperative adhesions after surgery for VP shunt malfunction is very important. We present two cases of shunt malfunction related to infection and report their successful treatment using Seprafilm®. Seprafilm may improve the safety of VP shunt reinsertion and preserve the function of the reinserted VP shunt after VP shunt malfunction with infection.