Elevated plasma fibronectin concentrations in patients with ossification of the posterior longitudinal ligament and ossification of the ligamentum flavum

Fibronectin is a glycoprotein involved in a wide variety of cellular activities, including the development of bone tissues. To study the relevance of fibronectin to the development of ossification of the posterior longitudinal ligament (OPLL) and ossification of the ligamentum flavum (OLF), plasma fibronectin concentrations in 30 consecutive patients with OPLL or OLF and 20 age-and-sex-matched control subjects were measured with an immunonephelometric method. Plasma fibronectin concentrations were significantly elevated in the patients with OPLL or OLF, independently of associated endocrinologic abnormalities, when compared with the control subjects. Because fibronectin is one of the essential factors in endochondral ossification, it is probable that the higher fibronectin concentration in plasma acts as a promoter of the development of OPLL and OLF.

Longitudinal study of spinal deformity in Duchenne muscular dystrophy

To investigate the natural course of the spinal deformity in Duchenne muscular dystrophy (DMD) and its clinical relevance, longitudinal series of spinal radiographs and medical records of 46 patients with DMD were reviewed. The natural course of the deformity was classified into three types; type 1 (n = 21), unremittent progression of scoliosis with kyphosis; type 2 (n = 18), transition from kyphosis to lordosis before age 15 years; and type 3 (n = 7), less deformity without prominent longitudinal changes. Age at loss of ambulatory ability was not a predictor of type. Neither was the age at which the Cobb angle was 30 degrees correlated with the rate of subsequent progression. Because the spinal deformity always progresses, we consider spinal surgery justifiable in type 1, when a certain strict indication exists, such as spinal deformity > 30 degrees and age < 15 years in patients with > 35% predicted value of vital capacity. In type 2, operation may be necessary in patients in whom Cobb angle will progress unremittently. There is no surgical indication for patients with type 3.

Epidural migration of hemostatic agents as a cause of postthoracotomy paraplegia. Report of two cases

Paraplegia secondary to pulmonary surgery occurred in two patients because of epidural migration of hemostatic agents. Computerized tomography following myelography revealed the lesion clearly. Both patients achieved satisfactory neurological recovery through prompt diagnosis and treatment.

Laminoplasty versus subtotal corpectomy. A comparative study of results in multisegmental cervical spondylotic myelopathy

A comparative study of surgical results was used to determine the treatment of choice for multisegmental cervical spondylotic myelopathy. Forty-one patients who received subtotal corpectomy and strut grafting (SCS) and forty-two undergoing laminoplasty were followed up for at least 2 years after surgery. Regarding factors known to affect surgical prognosis (age at surgery, duration of symptoms, severity of neurologic deficit, anteroposterior canal diameter, transverse area of the cord at the site of maximum compression, number of levels involved), the two groups were statistically comparable with each other. The severity of neurologic deficits was assessed by the Japanese Orthopaedic Association scale. Results were evaluated in terms of postoperative score and recovery rate. The difference between the recovery rate and final score between the two groups was not statistically significant. Surgical complications were more frequent in the subtotal corpectomy and strut grafting group than in the laminoplasty group. The most frequent complications encountered in the subtotal corpectomy and strut grafting group were related to bone grafting. Spinal alignment worsened in six patients of the laminoplasty group, but none of them suffered from neurologic deterioration. Another disadvantage of subtotal corpectomy and strut grafting was the longer postoperative period of bed rest needed to secure graft stability. We conclude that laminoplasty should be the treatment of choice for multisegmental cervical spondylotic myelopathy when neurologic results, incidence of complications, and postoperative treatment are taken into consideration.

Ossification of the ligamentum flavum induced by bone morphogenetic protein. An experimental study in mice

Ossification of the ligamentum flavum and secondary spinal-cord compression were produced experimentally in mice by implanting bone morphogenetic protein (BMP) in the lumbar extradural space. The ligamentum flavum became hypertrophied and ossified, and protruded into the spinal canal. The thickness of the ossified ligament increased gradually with time, leading to compression and deformation of the spinal cord which showed various degrees of degeneration. Demyelination occurred in the posterior and lateral white columns and neuronal loss or chromatolysis in the grey matter. The pathological findings in the experimental animals closely resemble those found in the human disease and suggest that BMP may be a causative factor of ossification of the ligamentum flavum in man. This experimental model may be useful for the study of myelopathy caused by gradual spinal-cord compression.

Neurologic complications of surgery for cervical compression myelopathy

Neurologic complications resulting from surgery for 384 cases of cervical myelopathy (cervical soft disc herniation, spondylosis, ossification of the posterior longitudinal ligament) were reviewed. Surgical procedures performed included 134 anterior interbody fusions (Cloward or Robinson-Smith technique), 70 subtotal corpectomies with strut bone graft, 85 laminectomies, and 95 laminoplasties. Twenty-one patients (5.5%) sustained neurologic deterioration related to surgery. The deterioration was classified into two types on the basis of the neurologic signs observed: deterioration of spinal cord function or of nerve root function. Manifestations of the former varied from weakness of the hand to tetraparesis. Paralysis of the deltoid and biceps brachii muscles was an exclusive feature of deterioration in the nerve root group. Causes of this paralysis included malalignment of the spine related to graft complications, and a tethering effect on the nerve root following major shifting of the spinal cord after decompression. The causes of deterioration of the cord function included spinal cord injury during surgery, malalignment of the spine associated with graft complication, and epidural hematoma.

Cineradiographic motion analysis of atlantoaxial instability in os odontoideum

Cineradiography was used to study six patients with os odontoideum. Atlantoaxial kinematics was analyzed with the relative motion of the atlas on the axis. In all cases, the tracing of the anterior arch was straight in the sagittal plane, whereas the posterior arch moved in two different configurations: straight and S-shaped. In cases of S-shaped configurations, the anterior translation occurred in the neutral position. Such translation could threaten the stability of the atlantoaxial complex fixed with posterior wiring because circumferential wires allow the laminas to rotate in the sagittal direction. In patients with os odontoideum, pathomechanics of the atlantoaxial joint should be examined with cineradiography in order biomechanically to determine the soundest fixation.

Experimental cervical spondylosis in the mouse

A reproducible experimental model of cervical spondylosis in mice was established by means of detachment of the posterior paravertebral muscles from the vertebrae and resection of the spinous processes along with the supraspinous and interspinous ligaments. Mechanical instability in the cervical spine elicited by this surgical intervention accelerated the process of intervertebral disc degeneration, and when extended over a 6-12-month period, induced cervical spondylosis in the mice. The pathologic findings in the cervical intervertebral discs of this experimental model varied: proliferation of cartilaginous tissue and fissures in the anulus fibrosus, shrinkage of the nucleus pulposus, herniation of disc material, and osteophyte formation. The availability of this experimental model should be valuable for biochemical and biomechanical understanding of the pathogenesis of cervical spondylosis.

Breast cancer with bone-only metastases. Visceral metastases-free rate in relation to anatomic distribution of bone metastases

The medical records of 82 patients with breast cancer with bone-only metastases were reviewed. According to the distribution of the metastases by bone scan at the time they were first documented, the patients were divided into three groups: Group A (patients who had bone metastases exclusively cranial to the lumbosacral junction), Group B (patients who had bone metastases exclusively caudal to the junction), and Group C (patients who had bone metastases both cranial and caudal to the junction). Group A had a significantly higher visceral metastases-free rate than Groups B or C. Serial bone scans and radiographs of Group A patients revealed that bone lesions cranial to the junction rarely developed into visceral metastases and that bone lesions extending caudal to the junction frequently developed into visceral metastases. These results indicate that the presence of bone metastases caudal to the lumbosacral junction is predictive of visceral metastases.

Os odontoideum with posterior atlantoaxial instability

Nine patients who had os odontoideum with posterior atlantoaxial instability are reviewed. Three parameters were measured on the lateral radiographs: the distance from the os odontoideum to the spinous process of the axis in extension (Dext), the distance from the os odontoideum to the posterior arch of the atlas (Datl), and the degree of instability (Inst). Patients were classified into four groups: Group I, local symptoms (N = 3); Group II, transient myelopathy (N = 0); Group III, progressive myelopathy (N = 6); and Group IV, cerebral symptoms (N = 0). The development of cervical myelopathy was not related to degree of instability but to distance from the os to the spinous process of the axis (Dext). Dext was more than 16 mm in Group I and less than or equal to 16 mm in Group III. Five of six patients in Group III underwent myelography. Based on myelographic findings, Group III was further subdivided into two groups, Group IIIA (N = 2) and Group IIIB (N = 3), according to the following characteristics: In Group IIIA, the distance from the os to the posterior arch of the atlas was more than 13 mm, and the spinal cord was impinged between the os odontoideum and the lamina of the axis in extension and reduced in flexion. In Group IIIB, Datl was less than or equal to 13 mm, and the spinal cord was compressed at the level of the atlas during flexion and extension. Stenotic Datl of 13 mm or less specifically defined severe cervical myelopathy. Surgical treatment for cervical myelopathy in os odontoideum with posterior instability is suggested as follows: in the absence of canal stenosis of the atlas (Group IIIA), atlantoaxial fusion in a reduced position is indicated; when associated with canal stenosis of the atlas (Group IIIB), laminectomy of the atlas followed by occiput-to-C2 arthrodesis is indispensable.

Thoracic myelopathy caused by ossification of the ligamentum flavum. Clinicopathologic study and surgical treatment

The authors reviewed 14 patients with thoracic myelopathy caused by ossification of the ligamentum flavum (OLF). The predominant locality of symptomatic OLF was at the thoracolumbar junction, particularly at T10-11 followed by T11-12. At the level of the thickest OLF in each patient, there were three types of OLF from computed tomography and operative findings: a lateral type in 3 patients, diffuse in 8, and thickened nodular in 3. The diagnosis of OLF-related thoracic spinal canal stenosis was best made by enhanced computed tomography. Histologic study revealed that the developmental mode of OLF was mainly endochondral ossification. Numerous fibrocartilaginous cells were found in the increased and swollen collagen fibers forming the hypertrophic ligamentum flavum (HLF). Ossification extended along the superficial layer of HLF. The size or extension of OLF was relevant to the corresponding diathesis of spinalhyperostosis. Results of laminectomy for OLF were poor because of the high occurrence of complications early on or later deterioration. Therefore, laminoplasty is recommended as a successful procedure for OLF-related thoracic myelopathy, avoiding further local mechanical stress due to tensile force.

Lateral rhachotomy for thoracic spinal lesions

Capener's "Lateral Rhachotomy" was modified by additional excision of the pedicle, articular facets, part of the lamina, and a posterior half of the vertebral bodies on one side through a transpleural approach to the thoracic spine, and a retroperitoneal approach to the lumbar spine. The aim was to excise a space-occupying lesion, which exists in front of the thoracic or lumbar spinal cord, safely. This modification enable the authors to expose more than 50% of the spinal canal, and decompress it from its anterior, lateral, and posterior compressing mass. The utmost important point of this procedure is the excision of the lesion under the direct visualization of the dura. In ossification of the posterior longitudinal ligament (OPLL), the dura is usually indented by the thick bony mass, and the lesion extends over a few segment with adhesion. Using "Modified Lateral Rhachotomy," it was possible to explore three or four vertebral levels in continuity through the same skin incision. In the present report, the authors described their "Modified Lateral Rhachotomy" procedure, and reviewed the case material.

Unstable cervical spine in athetoid cerebral palsy

The manifestations and pathomechanism of cervical instability of the athetoid neck in cerebral palsy (CP) patients was clarified in this study by means of static and dynamic x-ray analysis. Instability was defined as follows: 1) listhesis indicating anterior or posterior slip of more than 3 mm and/or 2) sagittal rotation between two vertebrae beyond the normal range measured by Penning. Cervical instability fitting this definition mainly took place in the upper and middle cervical disc levels, such as C3-4, C4-5, and/or occasionally C5-6. These coincide with the disc levels adjacent to the apex of the lordotic curve and/or those around the transitional vertebrae between the two reversed curves that render the cervical spine S-shaped in athetoid CP. A large facet angle at the apex vertebra facilitated anterior and/or posterior listhesis of the vertebrae. Conversely, a sudden decrease in the facet angle around the transitional vertebra in S-shaped curves precipitated deflection of the spine and increased sagittal rotation at this level. In addition to these structural abnormalities, rapid and repetitious neck movements seemed to accelerate the progression of cervical instability in athetoid CP patients.

The prognosis of surgery for cervical compression myelopathy. An analysis of the factors involved

We have studied the morphometry of the spinal cord in 50 patients with cervical compression myelopathy. Computed tomographic myelography (CTM) showed that the transverse area of the cord at the site of maximum compression correlated significantly with the results of surgery. In most patients with less than 30 mm2 of spinal cord area, the results were poor; the cord was unable to survive. Several factors, such as chronicity of disease, age at surgery and multiplicity of involvement are said to influence the results of surgery, but the transverse area of the cord at the level of maximum compression provides the most reliable and comprehensive parameter for their prediction.

Morphometry of the cervical spinal cord and its relation to pathology in cases with compression myelopathy

The purpose of this study was to determine whether or not computerized tomography myelography (CTM) gave an actual size and shape of the cervical spinal cord, and whether such dimensions reflected pathology of the spinal cord in cases suffering from compression myelopathy. Spinal cord transverse area and compression ratio (sagittal diameter divided by transverse diameter) were measured as indicators of spinal cord morphology. As a basis for this study, we first performed CTM of cadaveric cervical columns and compared the actual dimensions of the spinal cord of the cadaveric specimens with the CTM image. Second, the correlations between these dimensions and pathology of the affected spinal cord were investigated. The results showed that CTM provided a precise image of the actual cross-section of the spinal cord. In 12 cadaveric specimens of cervical myelopathy examined, the transverse area and compression ratio were in good correlation with the severity of observed pathological changes.

Desmoplastic fibroma of the axis. A case report

Desmoplastic fibroma of the bone appears in a wide variety of bones but rarely involves the spine. A 24-year-old male with desmoplastic fibroma of the axis treated by complete resection and posterior spinal fusion is reported. There was no recurrence of the tumor three years after surgery. Complete resection and reconstructive surgery for spinal instability are recommended for this benign spinal tumor.

Prosthetic replacement surgery for cervical spine metastasis

Since 1972, 18 patients suffering from metastatic cancer in the cervical spine were treated with prosthetic replacement surgery. The surgery enabled the authors to decompress the spinal cord and the nerve roots and at the same time restore stability in the affected spine. Patients suffering from severe pain and spinal cord and/or nerve root compression secondary to involvement of a single vertebral body particularly benefited from this surgery. The rates of positive recovery were as follows: 94.1% for pain relief, 91.7% for motor recovery, and 87.5% for ambulation. The surgical efficacy was maintained until the terminal stage. Tumor recurrence took place in five cases--two anterior, and three posterior. Anterior recurrence caused a marked instability, whereas posterior recurrence did not affect stability.

Myelopathy hand characterized by muscle wasting. A different type of myelopathy hand in patients with cervical spondylosis

While the authors have often observed the hand presenting spastic dysfunction and deficient pain sensation in patients with cervical compression myelopathy, which has been termed "Myelopathy hand," they have occasionally seen a different type of myelopathy hand characterized by muscle wasting and motor dysfunction in patients with cervical spondylosis. This type of myelopathy hand they have termed "amyotrophic type of myelopathy hand." Because it is similar to the hand of a patient suffering from motor neuron disease, and yet is treatable, the authors thought it worthwhile to report this type of hand in detail. The main clinical features are localized wasting and weakness of the extrinsic and intrinsic hand muscles, but not accompanied by either sensory loss or spastic quadriparesis. For an accurate diagnosis, attention should be paid to the narrow anteroposterior (AP) canal diameter of the cervical spine (less than 13mm), multisegmental spondylosis in C5-6 and C6-7 disc levels and a reduced transectional area of the spinal cord at the C7, C8, or T1 spinal cord segments. To date the authors have seen 15 patients with this hand; seven underwent either spondylectomy or laminoplasty. In six patients who were satisfied with surgical results, recovery from muscle wasting and weakness was seen.

Cervical radiculopathy or myelopathy secondary to athetoid cerebral palsy

Radiculopathy or myelopathy often occurs during adult life in patients who have athetosis. Herniation of an intervertebral disc, spondylosis, malalignment or instability of the cervical spine, or a combination of these lesions, can develop because of the athetoid hyperactivity. We reviewed the cases of ten patients who had cervical radiculopathy or myelopathy, or both, secondary to athetosis and who were surgically treated between the ages of thirty and fifty-eight years. The surgery consisted of discectomy, removal of osteophytes, and anterior interbody fusion. When several segments were involved, an extensive subtotal resection of the vertebrae and discs, followed by strut bone-grafting, was done.

Thoracic myelopathy secondary to ossification of the spinal ligament

The authors describe their experience with 26 cases of thoracic myelopathy secondary to hypertrophic ossification of the spinal ligament (posterior longitudinal ligament and/or ligamentum flavum). The clinical manifestations of this condition and results of its surgical treatment are described. The commonest symptoms were numbness or tingling in the legs and feet and gait disturbance. Most of the patients with involvement of the upper thoracic spine showed typical features of thoracic myelopathy: that is, sensory and motor deficits in both the trunk and lower extremities, sphincter disturbance, and exaggerated tendon reflexes. Several patients with involvement of the thoracolumbar junction presented with atypical symptoms of thoracic myelopathy and were sometimes misdiagnosed and treated inappropriately. Surgical treatment, particularly laminectomy, was not always successful. Inconsistencies in the surgical outcome were caused by either operative complications or reversal of the initial improvement during the follow-up period. The results of anterior surgery for the condition were more favorable; however, use of this procedure was rarely indicated.

Myelopathy hand. New clinical signs of cervical cord damage

A characteristic dysfunction of the hand has been observed in various cervical spinal disorders when there is involvement of the spinal cord. There is loss of power of adduction and extension of the ulnar two or three fingers and an inability to grip and release rapidly with these fingers. These changes have been termed "myelopathy hand" and appear to be due to pyramidal tract involvement. The characteristic nature of the signs permit the distinction between myelopathy and changes due to nerve root or peripheral nerve disorder. The clinical significance of these signs has been assessed against other tests and their value in management is discussed.

Interspinous wiring without bone grafting for nonunion or delayed union following anterior spinal fusion of the cervical spine

Nine patients who had unsuccessful anterior interbody fusion or subtotal spondylectomy and fusion for cervical spondylosis were treated by interspinous wiring without bone grafting. Bone union was confirmed during a mean postoperative period of 2 years and 2 months in seven patients by the disappearance of clear zones observed preoperatively in the disc space, and by continuity of the trabeculae in radiograms. One of the two patients in whom the procedure failed to unite the site of nonunion had received technically inadequate wiring with slight mobility at the wiring site; in the other patient, the grafted bone had collapsed and no sclerotic shadow of the nonunion site was seen at the time of surgery. Both patients underwent wiring after considerable intervals from the time of the initial anterior spinal fusion. We found that satisfactory bone union can be obtained for nonunion or delayed union following anterior cervical spinal fusion by interspinous wiring without further bone grafting if applied to properly selected patients.

Elongation of brachymetatarsy with ceramic implant: a roentgenographic evaluation of its utility

The metatarsal bone was elongated by intercalary implantation of a single-crystal alumina ceramic in 7 patients with brachymetatarsy. The implants were encased with new bone 24 months after surgery and resulted in 5.2 to 9.2 mm elongation of the metatarsal bone. The response of the bone to the ceramic implant was observed roentgenographically. No resorption or pseudoarthrosis of the bones, nor loosening or breakage of the implants, were observed. The alumina ceramic implant proved to be a useful substitute for a bone graft, because of its biocompatibility and strength.

Causes of neurologic deterioration following surgical treatment of cervical myelopathy

Neurologic deterioration was analyzed in 110 patients with surgically treated cervical myelopathy secondary to soft disc hernia or spondylosis. Follow-up periods ranged from 2 to 14 years, with an average of 6 years. Of 110 patients, 29 suffered neurologic deterioration. In most of the patients, deterioration occurred within the first year after surgery. Causes of deterioration were divided into three categories: direct trauma to neural tissue during surgery (a preventable complication); instability of the spine, progression of spondylotic changes above or below the level of fusion, and non-union (apparently unpreventable but treatable); and nonsurgery-related accidental trauma (unavoidable and often irreversible). Countermeasures for the deterioration are discussed.

Choice of surgical treatment for multisegmental cervical spondylotic myelopathy

Three surgical procedures for multisegmental cervical spondylotic myelopathy were evaluated on the basis of a follow-up study (12-157 months) of 95 patients. Twenty-four patients were treated by extensive laminectomy, 50 by anterior interbody fusion by the Cloward and/or Smith-Robinson techniques, and 21 by subtotal spondylectomy and fusion. Results of subtotal spondylectomy were significantly (P less than 0.01) better when compared with those of the other two procedures. It was concluded that spondylosis up to three disc levels should be treated by subtotal spondylectomy and fusion regardless of the canal diameter. When involvement extended four or more levels, extensive laminectomy was recommended.

Atlantoaxial rotatory fixation. Radiographic study of its mechanism

The mechanism of atlantoaxial rotatory fixation was investigated by means of CT scanning. During the acute stage, there was a common rotatory displacement of the occiput and atlas complex in relation to the axis. As symptom subsided spontaneously or with treatment, the displacement was reduced and the occiput and atlas complex was in normal alignment with the axis. In a few cases where survey x-ray presented persistence of a typical displacement between C1/2, there was a persistent rotatory displacement of the atlas within the occiput-atlas-axis (C0-C1-C2) complex. Here, the occiput faced in nearly the same direction as the axis and the rest of the cervical spine. This meant an interlocking of the rotated atlas between C0 and C2. Either one of the lateral mass articulation of the rotated atlas was anteriorly dislocated and interlocked. Compensatory derotation of the occiput and a hypermobility of the C0/1 articulation, limited to younger children, presumably produced such a rotatory displacement of the atlas within the C0-C1-C2 complex. Restriction of rotation and a residual postural deformity resulted from unilateral dislocation of the lateral mass articulation between C1/2 and residual rotatory displacement between C0/2, respectively. Difficulty in reducing such a postural deformity can be attributed to the fact that any manipulative force often fails to unlock the atlas within C0-C1-C2 complex because of an excessive mobility between the C0/C1, and a ligamentocapsular contracture can be established in the lateral mass articulation of the interlocked atlas in an ignored case.

Congenital constriction band syndrome

Eighty-three patients with congenital constriction band syndrome were reviewed. Clinical manifestations and associated anomalies were analyzed with attention directed to distribution of the involvement. Constriction bands, amputation, and acrosyndactyly were the main clinical manifestations of this syndrome. Involvement of the distal portions of the extremity was most common. In the hand, the central digits were involved most frequently, and the thumb was only minimally affected in most cases. Of the 19 cases with an associated clubfoot deformity, 10 were proven to be a paralytic clubfoot due to compression neuropathy of the peroneal nerve caused by a deep constriction band below the knee, whereas 9 had a normal peripheral nerve.

Ulnar ray deficiency: its various manifestations

Eighty-eight upper extremities of 65 patients with ulnar ray deficiency were reviewed with regard to clinical manifestations. Based on the findings, a subclassification into four types was established: type I, hypoplasia or partial defect of the ulna; type II, total defect of the ulna; type III, total or partial defect of the ulna with humeroradial synostosis; and type IV, ulnar defect with congenital amputation at the wrist. Various manifestations of deficiency were evident not only within the ulnar ray but also in other rays. Hypoplasia of the shoulder and/or proximal part of the humerus was present in some cases of types III and IV. Elbow involvement varied from functioning (type I) to acute flexion contracture (type II) to fusion (type III). In 57 hands the digits and carpal bones in the radial ray showed hypoplasia and/or defect. Central digits and carpal bones were also influenced by ulnar ray deficiency, presenting carpal bone fusion, syndactyly, and delta phalanx.

Arthrogryposis of the hand

Forty-five cases of arthrogryposis multiplex congenita were reviewed with respect to deformities and function of the hand. A distal predominance of the involvement and severity was apparent; hand deformity was a common manifestation in the arthrogrypotic patients. The majority of the hand deformities consisted of two types: one was a thumb-in-palm deformity with the fingers in intrinsic plus position, and another type was flexion contractures of the fingers at the interphalangeal joints. Regardless of type, hand function was impaired with severe or moderate deformity. Twenty-nine hands of 17 patients were successfully treated by surgery. Surgical methods are discussed based on an analysis of hand deformity and function.

Avascular necrosis of the carpal scaphoid associated with progressive systemic sclerosis

We treated a patient with avascular necrosis of the carpal scaphoid associated with progressive systemic sclerosis. Aetiology and histology of this unusual condition are discussed in relation to the underlying disease and the anatomical characteristics of the carpal scaphoid. Resection of the carpal scaphoid and replacement were successful.

Duplication of the thumb. A retrospective review of two hundred and thirty-seven cases

Over a twenty-two-year period, 237 patients (261 hands) with duplication of the thumb were seen in the Hand Clinic of Osaka University Hospital. Two groups were identified: Group A, 141 patients without previous surgical treatment, and Group B, ninety-six patients with residual deformity despite previous surgical treatment. Using a modification of Wassel's classification, seven types of deformity were defined. In Group A these types were identified on the basis of the observed duplications of bone and soft tissue. In all but ten of the Group-B patients preoperative roentgenograms were not available and the type of deformity had to be deduced from the residual duplicated bone, the surgical scar, and the residual deformity. Surgery, performed on 193 hands (125 in Group A and sixty-eight in Group B), attempted to restore normal anatomical relationships. The results could be evaluated in 130 hands according to the range of motion, joint stability, and alignment of the remaining thumb after an average follow-up of 35.0 months. According to the rating system described, the results were rated as good in 75.5 per cent, fair in 20.2 per cent, and poor in 4.3 per cent of the ninety-four hands in Group-A patients who were followed. In the thirty-six hands of Group-B patients who could be followed, the preoperative and postoperative scores were compared. Thirteen were not improved while the other twenty-three, sixteen improved from fair to good and seven improved from poor to fair, to give a good result in 63.9 per cent of the Group-B patients who were followed. The results in these 130 Group-A and B hands emphasize the importance of providing muscle balance and, in young patients, of performing an arthroplasty of the interphalangeal or metacarpophalangeal joint when indicated, although arthrodesis was indicated as a salvage operation for Group-B patients who were more than fifteen years old.

Canal diameter, anteroposterior compression ratio, and spondylotic myelopathy of the cervical spine

Nine patients with cervical spondylotic myelopathy, diagnosed during life, were subjected to detailed clinicopathologic study. The degree of cord destruction was in good correlation with the ratio of the anteroposterior diameter to the transverse diameter, designated as an anteroposterior compression ratio. Within the factors responsible for decrease in the ratio, developmental narrowing of the spinal canal was the most significant, and multiplicity of spondylotic protrusion less so. The former resulted in an extensive demyelination of the posterolateral funiculus and infarction of the gray matter. Recurrent trauma proved to cause distinct manifestations and cord pathology. Clinicopathologic correlations were also examined from the neurologic findings at the terminal stage.

Apert's syndrome--a report of five cases

This report presents five cases of Apert's syndrome with features of acrocephaly, characteristic face and complete syndactyly of the hand and foot with bony fusion. Three cases out of five showed preaxial polydactylies of the foot, considered to be one of the characteristic features of Carpenter's syndrome. In the remaining two cases, the first digital ray of the foot was broad and deformed. In addition one case had a postaxial polydactyly of the hand. Three cases showed severe deformity of the shoulder; two had dysplasia and one had synchondrosis of the glenohumeral joint. On the basis of our findings in this, we feel that there is much phenotypic overlap between Apert's and Carpenter's syndrome. A polydactylous presentation of the hand and foot can be found in not a few cases of Apert's syndrome and it is not always an exclusive feature of Carpenter's syndrome.

Mirror hand anomaly: reconstruction of the thumb, wrist, forearm, and elbow

Surgical procedures and the results of reconstruction of the mirror hand anomaly are presented. The thumb was reconstructed by pollicization of the radial third finger and multiple muscle transfer. The function of wrist, forearm, and elbow improved with arthroplasty of the affected joints. The results of the follow-up are satisfactory. We believe that surgical treatment of the mirror hand should be started in early life.

Congenital central ray deficiency in the hand- a survey of 59 cases and subclassification

Eighty-nine hands were studied in 59 patients with central ray deficiency. A subclassification into two subgroups was established based on the clinical and radiological findings-subgroup I: typical type and subgroup II: (atypical type) with type a, syndactylous type, and type b, polydactylous type. In subgroup I, the sequential severity of deficiency ranged from a partial defect of phalanges of the middle finger to a monodigit hand. The central digital elements were fused to adjacent digital rays in subgroup II-type a. Supernumerary bony elements were seen in subgroup II-type b. The close relationship between central ray deficiency, syndactyly, and polydactyly was discussed from the standpoint of development of the hand. The classification of central ray deficiency into the longitudinal deficiency category of the International Classification of Congenital Limb Malformations was recommended.

[The topographical localization of spinal motoneurons of the rat and its numerical alternation in regard to development (author's transl)]

The topographical localization of spinal motoneurons innervating the forelimb muscles of the rat and its numerical alternation in regard to development was observed by HRP (horseradish peroxidase) method. HRP method is a histochemical technique to trace the cellular origin of axon terminal net work. When HRP is injected into the muscles, the enzyme is taken up by nerve endings and transported retrogradely by the axoplamic flow to the original cell body, and does not transported hematogenously and does not cross the synapse. The spinal motoneurons were found in spindle-shape longitudinal cell columns according to its innervation. The motoneurons supplying the biceps brachii muscle were located in the dorso-lateral nucleus on the anterior horn of the 4th cervical segment, and extended downward to the ventral nucleus in 8th cervical segment, forming a spindle-shape cell column. The thick spindle-shape cell column consisting of cells which innervated the triceps brachii muscle lied in the ventro-medial nucleus of the 6th, 7th and 8th cervical segment. The neurons innervating the flexor carpi ulnaris muscle were located in 7th and 8th cervical segment, but few in number compared to those of the biceps and triceps. The motoneurons innervating the biceps brachii muscle decreased in number with increasing age according to exponential curve. The total number of HRP-labeled neurons in two week old rat ranged from 2,932 to 2,017 and markedly decreased during first eight weeks, in eight week old rat ranged from 1,637 to 603. After this, they gradually decreased to 312 in 50 weeks on an average, where the number corresponded to about 13% of those of two week old rat. The data indicate that ventral horn has a great deal of excess neurons which has a distinct neuromuscular connection as suggested by Prestige, in the developmental stage of Xenopus laevis. In young rats (ten days to two weeks of age), HRP-labeled neurons were also present in the ventral horn on the non-injected side. These large and multigonal contralateral HRP-labeled neurons constituted a characteristic feature of spinal motoneurons, and distributed through the same segment as those on injected side. The total number of HRP-labeled neurons within non-injected side ranged from 563 to 197 and corresponded from one-fifth to one-tenth of that in the injected side. In five weeks or elder rat, no HRP-labeled neurons could be observed in non-injected side. This indicates that in immature rats the muscles are innervated bilaterally by the spinal nerve, since HRP is transported by retrograde axoplasmic flow and does not cross the synapse, and the bilateral motor innervation has disappeared with maturation. The bilateral motor innervation is therefore, presumed to be an immature mode of innervation limited to the early stage of life. Although bilateral motor innervation following the nerve injury in the limb at the early stage of life has been confirmed by ourselves, the significance of the immature mode of innervation is still hard to explain.

Development of spinal motoneuron innervation of the upper limb muscle in the rat

Horseradish peroxidase was injected into the biceps brachii muscle of rats at various stages of development, from 10 days to 50 weeks. The retrogradely labeled neurons were found in the ipsilateral ventro-lateral column of the cervical cord, C4--C8, of all stages studied, but the number of labeled neurons decreased according to exponential curve as the age advanced. A striking finding was that the contralateral ventral horn cells were also labeled in the 10- and 14-day-old rats.