Yasuo Saruhashi

Clinical outcomes of cervical spinal cord injuries without radiographic evidence of trauma

We investigated 33 cervical spinal cord injury patients (25 males and eight females) without bony injury. Patients whose neurologic recovery had reached a plateau and who had evidence on imaging of persistent spinal cord compression were considered candidates for surgical decompression. When imaging did not show spinal cord compression or patients were maintaining a good neurologic recovery from the early days after injury, we pursued conservative treatment. Age at injury varied from 20 to 76 years (mean, 55.6). Average follow-up was 31 months. Twelve patients were treated conservatively (Group 1). Groups 2 and 3 had surgery. Group 2 (14 cases) had multi-level compression of spinal cord due to pre-existing cervical spine conditions such as ossification of posterior longitudinal ligament, cervical canal stenosis, and cervical spondylosis. Group 3 (7 cases) patients existed single-level compression of spinal cord by cervical disc herniations or spondylosis. We evaluated clinical results according to the Frankel classification, the American Spinal Injury Association (ASIA) scales and Japanese Orthopaedic Association (JOA) scores. Overall improvement of JOA and ASIA scores after treatment was 56.3±35.5% and 67.1±38.0%, respectively. Patients in Group 1 showed very good recovery after conservative treatment, with improvement of JOA and ASIA scores being 70.4±40.2% and 77.4±34.2%, respectively. The average interval between injury and operation was 4.3±4.4 months. The improvement of the surgically treated patients (Groups 2 and 3) in JOA and ASIA score was 48.2±30.7% and 61.2±39.6% respectively. We obtained good neurological recovery after operation, with significantly more improvement in Group 3 than in Group 2. No significant neurologic recovery had occurred preoperatively in these groups. In such patients operative intervention is essential for neurologic recovery.

Evaluation of posterior long fusion versus conservative treatment for the progressive rheumatoid cervical spine.

Study Design. Results of the posterior long fusion performed for the progressive cervical lesions of rheumatoid arthritis were compared with the outcomes of those who did not undergo surgical treatment. Objective. To provide a clue as to whether posterior long fusion improves or maintains the impaired daily life activity of the patients with rheumatoid arthritis with progressive, mutilating-type joint involvements. Summary of Background Data. To provide optimal treatments for the cervical lesions of patients with rheumatoid arthritis, the natural courses of cervical lesions should be taken into account. In the authors’ preliminary study they have retrospectively investigated natural courses of cervical rheumatoid arthritis lesions and have found that the seropositive patients with rheumatoid arthritis with mutilating-type joint involvement are at a high risk of deteriorating the cervical lesion once their cervical spine becomes affected. Methods. In the present study 17 seropositive patients with rheumatoid arthritis with mutilating-type joint involvements were studied. Eleven patients underwent surgical treatments (operated group), whereas six patients did not (nonoperated group). All of the operated patients underwent occipitocervical or occipitocervicothoracic fusion supplemented by the Luque’s sublaminar wiring and preoperative and postoperative usage of halo-jacket. Results. The six patients of the nonoperated group worsened the activities of daily living score and resulted in either complete bedridden or in death by the time point of final follow-up. In contrast, all of the 11 operated patients either improved or maintained the activities of daily living score: those operated because of neurologic compromise due to myelopathy improved at least one class in the activities of daily living score, and those operated because of severe occipitocervical pain maintained the activities of daily living with relief of pain. Conclusion. The present study suggests that posterior long fusion may achieve an improvement of activities of daily living, at least, for a certain time period. However, the newly emerging lesions adjacent to the fused segments, which may result from the increased mechanical loads, may finally lead to the impairment of activities of daily living.

A migrated lumbar disc herniation simulating a dumbbell tumor.

We report a case of a migrated lumbar disc hemiation, which on magnetic resonance imaging (MRI) simulated a dumbbell tumor in a 44-year-old woman who had severe pain in her right buttock and leg. A large epidural mass mimicking a dumbbell tumor was detected at the L5 vertebral level by MRI and computed tomography over myelography. Surgical fenestration of the L4/L5 interlaminar space revealed a dorsolateral epidural mass connected to the L5/S1 intervertebral disc extending laterally through the right L5/S1 intervertebral foramen. Histologically, it was degenerative disc material without active inflammation. Reevaluation of the MRI suggested some clues that might be useful in differentiating such a herniated disc from an epidural tumor.

Effects of serotonin 1A agonist on acute spinal cord injury

Study design: We evaluated the effects of serotonin (5-HT) agonists on in vitro models of spinal cord compressive injury. Evoked potentials in injured rat spinal cords (n=24) were recorded during perfusion with 5-HT agonists.Objectives: To evaluate the therapeutic effects of 5-HT agonists on the recovery of compound action potentials in injured spinal cords.Methods: Rat dorsal columns were isolated, placed in a chamber, and injured by extradural compression with a clip. Conducting action potentials were activated by supramaximal constant current electrical stimuli and recorded during perfusion with 5-HT agonists and antagonists.Results: After inducing compression injuries, mean action potential amplitudes were reduced to 33.9±5.4% of the pre-injury level. After 120 min of perfusion with Ringers solution, the mean amplitudes recovered to 62.8±8.4% of the pre-injury level. At a concentration of 100 μM, perfusion with tandospirone (a 5-HT1A agonist) resulted in a significantly greater recovery of mean action potential amplitudes at 2 h after the injury (86.2±6.9% of pre-injury value) as compared with the control Ringers solution (62.8±8.4% of pre-injury value, P<0.05). In contrast, quipazine (a 5-HT2A agonist) accelerated the decrease of amplitude (54.5±11.7% of pre-injury value). 5-HT1A and 5-HT2A agonist did not consistently alter latencies of the action potentials.Conclusion: The 5-HT1A receptor agonist was effective for the recovery of spinal action potential amplitudes in a rat spinal cord injury model.

Spinal degenerative lesions and spinal ligamentous ossifications in ancient Chinese populations of the Yellow River Civilization

Rheumatological diseases, whether inflammatory or degenerative, are ubiquitous among modern Asian people but very few palaeopathological studies have been performed in Asia on this subject. Since 1996, we have been carrying out a palaeoepidemiological survey of rheumatic diseases in ancient Chinese and Japanese skeletal populations. Findings on the spinal column in ancient Chinese populations (ca. 5000 bc–ad 1644) in Henan Province (centre of the Yellow River Civilization) are reported in this study. The examined number of the people over 20 years old was 365 (185 males, 169 females and 11 unsexed). Of these, 248 were young adults, 98 were middle adults and 19 were old adults. Crude prevalence (number/100) in total population of vertebral osteophytosis/facet osteoarthritis was 17.5/7.7, 17/3.7 and 44.6/21.1 at the cervical, thoracic and lumbar spine, respectively. That of ossified anterior longitudinal ligament (OALL) or Forestiers disease was around 3 at each of the cervical, thoracic and lumbar spine. Ossification of the posterior longitudinal ligament (OPLL) of the cervical spine was observed in five out of 114 skeletons with cervical spine preserved, while it did not exist in any thoracic and lumbar segment. Ossification of the ligamentum flavum (OLF) was predominantly observed in the thoracic spine, the crude prevalence of which was 36.7. Overall spinal degenerative lesions seemed to have been more prevalent and spinal ligament ossifications less prevalent in ancient Chinese populations than in modern people. None of the inflammatory lesions like rheumatoid spondylitis, as well as seronegative spondyloarthropathies, were detected. This is the first palaeopathological study in which the prevalence of OPLL and OLF, the two clinically important spinal ligamentous ossifications causing myelopathy in modern mankind, was surveyed in ancient skeletons. Copyright

Percutaneous aspiration of spinal terminal ventricle cysts using real-time magnetic resonance imaging and navigation.

Study Design. Clinical case series. Objective. To present a new innovative treatment option for cysts of the terminal ventricle. Summary of Background Data. Invasive surgery including laminectomy and cyst fenestration has been the sole reported method of treatment for this rare pathology. Methods. Four cases of symptomatic cyst of the terminal ventricle of the spinal cord were treated by percutaneous aspiration using real-time guidance with magnetic resonance imaging (MRI) and optically-tracking navigation. Results. Three patients were treated successfully by this percutaneous method, and for 1 patient the treatment was converted to conventional surgery after a single unsuccessful trial of percutaneous puncture. All patients were relieved of their symptoms without any complication. Follow-up MRI revealed continued shrinkage of the cysts after both surgery and MRI-guided percutaneous fenestration. Conclusion. MRI-navigated percutaneous aspiration can be a minimally-invasive treatment option for symptomatic cysts of the terminal ventricle, and therefore, can be indicated before more invasive surgery might be scheduled.

Parosteal (juxtacortical) chondrosarcoma of the humerus associated with regional lymph node metastasis. A case report.

Recurring parosteal (juxtacortical) chondrosarcoma of the humerus occurred in a 79-year-old man. Roentgenograms of the left humerus showed minimal cortical irregularity and a large soft tissue mass without calcification or periosteal reaction. Magnetic resonance imaging (MRI) showed a multilobular tumor of high intensity (T2-weighted imaging) without marrow involvement. During the left shoulder disarticulation an enlarged axillary lymph nodes was discovered and removed. Macroscopic examination of the disarticulated humerus showed a large yellow parosteal mass, which looked like cartilage, completely surrounding the humeral shaft. The marrow cavity was almost normal except for a small erosion at the site of the olecranon fossa. The histologic diagnosis of the mass was Grade 2 chondrosarcoma of parosteal (juxtacortical or periosteal) origin associated with regional lymph node metastasis. The features that made this case unique were a long history of the tumor (for 32 years), minimal cortical destruction of the bone by the tumor, and regional lymph node metastasis. This case illustrates the differential diagnosis of the parosteal chondrosarcoma from periosteal osteosarcoma and extraskeletal myxoid chondrosarcoma.

Percutaneous transthoracic fenestration of an intramedullary neurenteric cyst in the thoracic spine with intraoperative magnetic resonance image navigation and thoracoscopy.

Neurenteric cysts are rare congenital cysts typically located in the anterior cervical or thoracic spinal canal. The authors report on their experience with the successful treatment of a midthoracic neurenteric cyst in an 8-year-old boy. Percutaneous fenestration via a transthoracic, transvertebral approach with combined thorascopy and intraoperative MR imaging guidance was used, and the cyst showed lasting shrinkage. The authors discuss this minimally invasive technique and its limitations.

Traumatic bilateral locked facet at L4-5: report of a case associated with incorrect use of a three-point seatbelt

Abstract. We present a case of traumatic L4-5 bilateral facet dislocation, without neurological deficit, in a 32-year-old female patient, as an unusual seatbelt injury caused by positioning the shoulder harness improperly under her armpit. Open reduction, posterior interbody fusion, and posterior segmental instrumentation were carried out. The aim of this report is to describe this rarely encountered condition and speculate regarding automotive shoulder harness misuse as a potential cause of bilateral locked facet at L4-5, and to emphasize the importance of multidirectional X-ray on first examination. The unusual L4-5 level facet interlocking was attributed to misuse of the automobile shoulder harness. We propose the importance of recognizing this injury and following up on such clues as transverse process fractures and/or widened posterior elements.

Long-term clinical outcome of sacral chondrosarcoma treated by total en bloc sacrectomy and reconstruction of lumbosacral and pelvic ring using intraoperative extracorporeal irradiated autologous tumor-bearing sacrum: a case report with 10 years follow-up

BACKGROUND CONTEXT Primary malignant tumors of the sacrum are rare. Chondrosarcoma is one of the common malignant tumors arising from the sacrum. Chondrosarcoma is often invasive, and there is a high propensity for local recurrence. Surgical resection is often the only effective treatment; however, the treatment of malignant sacral tumors can be challenging, both because of the anatomy of the spinopelvic complex and the frequently large tumor size. PURPOSE We report a case of sacral chondrosarcoma that was successfully treated by total en bloc sacrectomy and reconstruction of the lumbosacral and pelvic ring using intraoperative extracorporeal irradiated autologous tumor-bearing sacrum. STUDY DESIGN A case report with 10 years follow-up. METHODS A 51-year-old man presented with right lower leg pain. Plain radiographs and computed tomography (CT) showed an osteolytic lesion at the sacrum that extended to the sacroiliac joint. Magnetic resonance imaging demonstrated that the tumor mass was localized from S1 to S2 with an epidural lesion at L5-S1 disc level. Histopathologic evaluation by open biopsy revealed that the lesion was chondrosarcoma. Total en bloc sacrectomy of the tumor-bearing sacrum was performed. The removed tumor-bearing sacrum was extracorporeally irradiated at 200 Gy during the operation and returned to the original position as a bone graft and fixed with instruments thereafter. RESULTS We needed two revision surgeries during the first 3 years because of the implant failures; however, 10 years after the initial surgery, CT revealed that the irradiated sacrum had remodeled into living bone and integrated with surrounding iliac bone without radiological evidence of tumor recurrence. The patient ambulates without any support and there was no clinical and radiological evidence of tumor recurrence. CONCLUSIONS The advantages of our method include the availability of high dose of radiation because of extracorporeal irradiation, excellent fit between graft and host bone, reduction of the dead space, no immunological rejection, no need for a bone bank, availability of the sacrum not only for the augmentation of the large defect but also for the scaffold for the other bone grafts. Our report is of only one case; however, we consider that it could be one option for the treatment of sacral malignant bone tumors, such as chondrosarcoma.