Subaxial sagittal alignment and adjacent-segment degeneration after atlantoaxial fixation performed using C-1 lateral mass and C-2 pedicle screws or transarticular screws

Object

The purpose of this study was to evaluate the effect of a fixed atlantoaxial angle on subaxial sagittal alignment, and that of atlantoaxial fixation on adjacent-segment motion and degeneration.

Methods

The authors retrospectively reviewed 65 patients in whom atlantoaxial instability was treated with atlantoaxial fixation by C-1 lateral mass and C-2 pedicle screw fixation (30 patients, Goel-Harms [GH] group) or a combination of transarticular screw fixation and posterior wiring (35 patients, Magerl-Brooks [MB] group). Angles of Oc–C1, C1–2, C2–3, and C2–7 were determined based on an upright lateral radiograph in flexion, neutral, and extension positions. The range of motion (ROM) at Oc–C1 and C2–3 was also determined. All patients were examined before and 2 years after surgery.

Results

The mean preoperative atlantoaxial angles in the GH and MB groups were 20.9 ± 8.3° and 18.3 ± 7.2°, respectively, and the mean postoperative atlantoaxial angles in the same groups were 23.5 ± 5.6° and 29.7 ± 6.3°, respectively, with a statistically significant difference between the 2 groups (p < 0.05). The mean preoperative angles of C2–7 in the GH and MB groups were 15.4 ± 7.8° and 13.7 ± 9.5°, respectively, and after surgery, the angles were 11.8 ± 12° and 2.48 ± 12°, respectively, with a statistically significant difference between the 2 groups (p < 0.05). The postoperative angle of C1–2 showed a negative correlation with the extent of change observed in the C2–7 angle preand postoperatively in each of these 2 surgical procedures. The Oc–C1 ROM increased after surgery in both groups, but the difference was not statistically significant (p = 0.38). The C2–3 ROM decreased after surgery in both groups, and the difference was statistically significant (p < 0.05).

Conclusions

Atlantoaxial fixation in a hyperlordotic position produced kyphotic sagittal alignment after surgery in both GH and MB groups. Reduction of the atlantoaxial joint can be easily achieved through screw fixation at an optimal angle, thereby ameliorating the risk for subsequent subaxial kyphosis. Degeneration of lower adjacent segments appeared to be less with this procedure compared with using a combination of transarticular screw fixation and posterior wiring.

A prospective randomized study for postoperative pain relief of lower extremity fractures: efficacy of intrathecal morphine administration

Systemic opioids are known to be effective for controlling postoperative pain. Intrathecal morphine administration can be performed in a simple manner concurrently with spinal anesthesia. The purpose of this study was to investigate the efficacy of intrathecal morphine administration for the postoperative analgesia of lower extremity fractures. A prospective randomized study for postoperative pain relief was conducted. Fifty consecutive patients with a lower extremity fracture who underwent osteosynthesis under spinal anesthesia were enrolled. The patients were divided into two groups for comparative results. No baseline variable differences between the groups were observed. Twenty-two patients were assigned to a morphine group and were administered intrathecal bupivacaine combined with a single intrathecal injection of morphine. The other 28 patients were assigned to a control group and administered intrathecal bupivacaine alone. Pain intensity was assessed using the Visual Analog Scale (VAS). The use of supplemental analgesics, time of first request for supplemental analgesics, and side effects were investigated. During the initial 12 h after surgery, the VAS score was significantly lower in the morphine group (p < 0.05). The use of supplemental analgesic drugs was significantly less in the morphine group (p < 0.05). The time of first request of the control group was shorter than that of the morphine group (p < 0.001). Side effects were seen more frequently in the morphine group though there was no significant difference. Although the use of morphine requires appropriate postoperative care, an intrathecal morphine injection can be an attractive analgesic for the postoperative pain of lower extremity fractures.

Combined posteroanterior surgery for osteoporotic delayed vertebral fracture and neural deficit in patients with Parkinson's disease

Osteoporotic thoracolumbar compression fracture occasionally occurs in patients with Parkinson's disease and can lead to neural compromise due to delayed vertebral body collapse, requiring surgical treatment. Surgical treatment and postoperative care are difficult because of poor bone quality, involuntary exercise, and postural imbalance. Due to such difficulties in treatment, few reports exist about surgery for osteoporotic thoracolumbar compression fracture in patients with Parkinson's disease. Anterior decompression and posteroanterior reconstructive stabilization were performed for 3 patients with Parkinson's disease and osteoporotic vertebral body collapse. To prevent instrument-related complications, it is important to achieve initial rigid stability. Regarding the stabilization of the posterior elements, laminar hooks were used. Two pedicle screws and 1 hook were placed at 1 level above and 1 level below the injured vertebra. As for the stabilization of the anterior part, a titanium cage was used. All patients resumed their activities of daily living postoperatively. Two of 3 patients experienced sinking of the rib cage after commencement of ambulation with a hard brace postoperatively. After these patients wore a body cast for 2 months, they were able to resume activities of daily living under careful treatment. In all patients, junctional kyphosis improved postoperatively and progressed postoperatively. None experienced recurrent neural deterioration or backache related to the fracture through >3 years of postoperative follow-up. Combined posteroanterior reconstruction surgery was useful for osteoporotic thoracolumbar compression fracture with Parkinson's disease. However, maintenance of postoperative alignment was difficult to achieve. Careful postoperative management was important for good clinical results.

Image classification of idiopathic spinal cord herniation based on symptom severity and surgical outcome: a multicenter study

Object

The purpose of this study was to provide the first evidence for image classification of idiopathic spinal cord herniation (ISCH) in a multicenter study.

Methods

Twelve patients who underwent surgery for ISCH were identified, and preoperative symptoms, severity of paralysis and myelopathy, disease duration, plain radiographs, MR imaging and CT myelography findings, surgical procedure, intraoperative findings, data from spinal cord monitoring, and postoperative recovery were investigated in these patients. Findings on sagittal MR imaging and CT myelography were classified into 3 types: a kink type (Type K), a discontinuous type (Type D), and a protrusion type (Type P). Using axial images, the location of the hiatus was classified as either central (Type C) or lateral (Type L), and the laterality of the herniated spinal cord was classified based on correspondence (same; Type S) or noncorrespondence (opposite; Type O) with the hiatus location. A bone defect at the ISCH site and the laterality of the defect were also noted.

Results

Patients with Type P herniation had a good postoperative recovery, and those with a Type C location had significant severe preoperative lower-extremity paralysis and a significantly poor postoperative recovery. Patients with a bone defect had a significantly severe preoperative myelopathy, but showed no difference in postoperative recovery.

Conclusions

The authors' results showed that a Type C classification and a bone defect have strong relationships with severity of symptoms and surgical outcome and are important imaging and clinical features for ISCH. These findings may allow surgeons to determine the severity of preoperative symptoms and the probable surgical outcome from imaging.

Effect of 8-MHz radiofrequency-capacitive regional hyperthermia with strong superficial cooling for unresectable or recurrent colorectal cancer

A well-known disadvantage of a radiofrequency-capacitive device for deep-seated tumours is preferential heating of the subcutaneous fat tissue. The authors previously developed the hyperthermia with their own external cooling unit and achieved strong superficial cooling, and reported its usefulness for the reduction of the preferential heating. The purpose of the present study was to evaluate the effect of hyperthermia with strong superficial cooling on the treatment results for unresectable or recurrent colorectal cancers. From 1986 to 2002, 44 patients with primary unresectable or locally recurrent colorectal cancer treated with thermoradiotherapy were analysed retrospectively. The patients with obesity as a subcutaneous fat thickness more than 3 cm, a high age or other serious complications did not undergo therapy. The results were compared between 17 cases with strong superficial cooling treated after 1997 (Group A) and 27 cases without strong superficial cooling treated before 1996 (Group B). Significant differences in thermometry data of T(max), T(ave) and T(min) were noted between Groups A (45.3, 44.4 and 43.6 degrees C, respectively) and B (42.9, 42.0 and 41.1 degrees C, respectively) (p<0.01). Complete response plus partial response rates were better for Group A than for Group B (59 versus 26%, p = 0.05). Multivariate analysis by logistic regression to evaluate the effects of certain factors on complete response plus partial response was strongly correlated with strong superficial cooling (p<0.05). The median survival times for overall survival were 24.3 months for Group A and 17.1 months for Group B (p<0.05). Eight-megahertz radiofrequency-capacitive regional hyperthermia with strong superficial cooling is potentially useful for improving treatment results in unresectable or recurrent colorectal cancers.

Placement and complications of cervical pedicle screws in 144 cervical trauma patients using pedicle axis view techniques by fluoroscope

Cervical pedicle screw fixation is an effective procedure for stabilising an unstable motion segment; however, it has generally been considered too risky due to the potential for injury to neurovascular structures, such as the spinal cord, nerve roots or vertebral arteries. Since 1995, we have treated 144 unstable cervical injury patients with pedicle screws using a fluoroscopy-assisted pedicle axis view technique. The purpose of this study was to investigate the efficacy of this technique in accurately placing pedicle screws to treat unstable cervical injuries, and the ensuing clinical outcomes and complications. The accuracy of pedicle screw placement was postoperatively examined by axial computed tomography scans and oblique radiographs. Solid posterior bony fusion without secondary dislodgement was accomplished in 96% of all cases. Of the 620 cervical pedicle screws inserted, 57 (9.2%) demonstrated screw exposure (<50% of the screw outside the pedicle) and 24 (3.9%) demonstrated pedicle perforation (>50% of the screw outside the pedicle). There was one case in which a probe penetrated a vertebral artery without further complication and one case with transient radiculopathy. Pre- and postoperative tracheotomy was required in 20 (13.9%) of the 144 patients. However, the tracheotomies were easily performed, because those patients underwent posterior surgery alone without postoperative external fixation. The placement of cervical pedicle screws using a fluoroscopy-assisted pedicle axis view technique provided good clinical results and a few complications for unstable cervical injuries, but a careful surgical procedure was needed to safely insert the screws and more improvement in imaging and navigation system is expected.

Anterior cervical pedicle screw and plate fixation using fluoroscope-assisted pedicle axis view imaging: a preliminary report of a new cervical reconstruction technique

Anterior procedures in the cervical spine are feasible in cases having anterior aetiologies such as anterior neural compression and/or severe kyphosis. Halo vests or anterior plates are used concurrently for cases with long segmental fixation. Halo vests are bothersome and anterior plate fixation is not adequately durable. We developed a new anterior pedicle screw (APS) and plate fixation procedure that can be used with fluoroscope-assisted pedicle axis view imaging. Six patients (3 men and 3 women; mean age, 54 years) with anterior multisegmental aetiology were included in this study. Their original diagnoses comprised cervical myelopathy and/or radiculopathy (n = 4), posterior longitudinal ligament ossification (n = 1) and post-traumatic kyphosis (n = 1). All patients underwent anterior decompression and strut grafting with APS and plate fixation. Mean operative time was 192 min and average blood loss was 73 ml. Patients were permitted to ambulate the next day with a cervical collar. Local sagittal alignment was characterised by 3.5 degrees of kyphosis preoperatively, which improved to 6.8 degrees of lordosis postoperatively and 5.2 degrees of lordosis at final follow-up. Postoperative improvement and early bony union were observed in all cases. There was no serious complication except for two cases of dysphagia. Postoperative imaging demonstrated screw exposure in one screw, but no pedicle perforation. APS and plate fixation is useful in selected cases of multisegmental anterior reconstruction of cervical spine. However, the adequate familiarity and experience with both cervical pedicle screw fixation and the imaging technique used for visualising the pedicle during surgery are crucial for this procedure.

Postoperative changes in spinal cord signal intensity in patients with cervical compression myelopathy: comparison between preoperative and postoperative magnetic resonance images

Object

Increased signal intensity of the spinal cord on magnetic resonance (MR) imaging was classified pre- and postoperatively in patients with cervical compressive myelopathy. It was investigated whether postoperative classification and alterations of increased signal intensity could reflect the postoperative severity of symptoms and surgical outcomes.

Methods

One hundred and four patients with cervical compressive myelopathy were prospectively enrolled. All were treated using cervical expansive laminoplasty. Magnetic resonance imaging was performed in all patients preoperatively and after an average of 39.7 months postoperatively (range 12–90 months). Increased signal intensity of the spinal cord was divided into 3 grades based on sagittal T2-weighted MR images as follows: Grade 0, none; Grade 1, light (obscure); and Grade 2, intense (bright). The severity of myelopathy was evaluated according to the Japanese Orthopedic Association (JOA) score for cervical myelopathy and its recovery rate (100% = full recovery).

Results

Increased signal intensity was seen in 83% of cases preoperatively and in 70% postoperatively. Preoperatively, there were 18 patients with Grade 0 increased signal intensity, 49 with Grade 1, and 37 with Grade 2; postoperatively, there were 31 with Grade 0, 31 with Grade 1, and 42 with Grade 2. The respective postoperative JOA scores and recovery rates (%) were 13.9/56.7% in patients with postoperative Grade 0, 13.2/50.7% in those with Grade 1, and 12.8/40.1% in those with Grade 2, and these differences were not statistically significant. The postoperative increased signal intensity grade was improved in 16 patients, worsened in 8, and unchanged in 80 (77%). There was no significant correlation between the alterations of increased signal intensity and surgical outcomes.

Conclusions

The postoperative increased signal intensity classification reflected postoperative symptomatology and surgical outcomes to some extent, without statistically significant differences. The alteration of increased signal intensity was seen postoperatively in 24 patients (23%) and was not correlated with surgical outcome.

Laminoplasty and skip laminectomy for cervical compressive myelopathy: range of motion, postoperative neck pain, and surgical outcomes in a randomized prospective study

STUDY DESIGN

A prospective randomized clinical trial in surgical treatment for cervical compressive myelopathy.

OBJECTIVE

We prospectively compared modified laminoplasty and skip laminectomy in terms of surgical invasiveness, postoperative range of cervical motion, axial pain, and surgical outcomes.

SUMMARY OF BACKGROUND DATA

Laminoplasty is an established procedure for the decompression of multisegmental cervical compressive myelopathy. However, it often induces postoperative problems, such as axial pain, restriction of neck motion, and loss of lordotic alignment. Skip laminectomy was recently developed as a minimally invasive procedure.

METHODS

Forty-one patients with cervical spondylotic myelopathy (CSM), excluding developmental stenosis, were randomized to modified double-door laminoplasty (Lamino group; n = 21) or skip laminectomy (Skip group; n = 20), and followed for more than 1 year (average, 28.1 months). Of these patients, radiographs were taken in neutral, extension, and flexion positions before surgery and after surgery. The cervical alignment of C2-C7 curvature and range of motion (ROM) were calculated. After surgery patients were asked to rate their neck pain, using the visual analogue scale (VAS) periodically. Clinical outcomes were estimated with the Japanese Orthopedic Association scoring system (JOA score).

RESULTS

There was no significant difference about operative time and blood loss between Lamino and Skip groups. The C2-C7 lordosis of neutral position in both groups was decreased by a few degrees at final follow-up. The final ROMs were 77.4/88.6% of preoperative ROM, respectively. At all collection times, no significant difference in VAS score of axial pain was seen in either group. There was no significant difference in JOA score between both groups before and after surgery.

CONCLUSION

No significant differences were seen between Lamino and Skip groups, in terms of operative invasiveness, axial neck pain, cervical alignment, and ROM, and clinical results in the patients of CSM without developmental stenosis.

MR T2 image classification in cervical compression myelopathy: predictor of surgical outcomes

STUDY DESIGN

Prospective imaging study of patients undergoing surgery for cervical compressive myelopathy. OBJECTIVES.: To investigate whether the classification of increased signal intensity (ISI) on magnetic resonance imaging (MRI) in patients with cervical compressive myelopathy reflects the severity of symptoms and surgical outcome.

SUMMARY OF BACKGROUND DATA

The association between ISI and surgical outcome in cervical myelopathy remains controversial. The degree of ISI has not been well discussed.

METHODS

A total of 104 patients with cervical compressive myelopathy were prospectively enrolled. All were treated with cervical expansive laminoplasty. MRI was performed in all patients before surgery. ISI of spinal cord was classified into three groups based on sagittal T2-weighted images as follows: Grade 0, none; Grade 1, light (obscure); and Grade 2, intense (bright). The severity of myelopathy was evaluated according to the Japanese Orthopedic Association (JOA) score for cervical myelopathy.

RESULTS

Eighty-six patients (83%) showed ISI before surgery. Patients with ISI were significantly older, and had a longer duration of disease, a lower postoperative JOA score, and a worse postoperative recovery rate of JOA score than those without ISI. Preoperative MRI showed 18 patients in Grade 0, 49 patients in Grade 1, and 37 in Grade 2. Duration of disease was the shortest in Grade 0 and longest in Grade 2. Although there was no significant difference in preoperative JOA scores among the three groups, Grade 0 patients had a higher postoperative JOA score and the best postoperative recovery, and Grade 2 had a lower postoperative JOA score and the worst postoperative recovery.

CONCLUSION

Preoperative ISI on T2-weighted sagittal MRI was correlated with patient age, duration of disease, postoperative JOA score, and postoperative recovery rate. Patients with the greatest ISI had the worst postop erative recovery. Classification of ISI can be a predictor of surgical outcome.

Codeine presynaptically inhibits the glutamatergic synaptic transmission in the nucleus tractus solitarius of the guinea pig

Although codeine is the most prominent and centrally acting antitussive agent, the precise sites and mode of its action have not been fully understood yet. In the present study, we examined the effects of codeine on synaptic transmission in second-order neurons of the nucleus tractus solitarius (NTS), which is the first central relay site receiving tussigenic afferent fibers, by using whole-cell patch-clamp recordings in guinea-pig brainstem slices. Codeine (0.3-3 mM) significantly decreased the amplitude of excitatory postsynaptic currents (EPSCs) evoked by electrical stimulation of the tractus solitarius in a naloxone-reversible and concentration-dependent manner, but it had no effect on the decay time of evoked EPSCs (eEPSCs). The inhibition of eEPSCs was accompanied by an increased paired-pulse ratio of two consecutive eEPSCs. The inward current induced by application of AMPA remained unchanged after codeine application. A voltage-sensitive K+ channel blocker, 4-aminopyridine (4-AP) attenuated the inhibitory effect of codeine on eEPSCs. These results suggest that codeine inhibits excitatory transmission from the primary afferent fibers to the second-order NTS neurons through the opioid receptors that activate the 4-AP sensitive K+ channels located at presynaptic terminals.

Cervical pedicle screw fixation in 100 cases of unstable cervical injuries: pedicle axis views obtained using fluoroscopy

Object

The authors conducted a study to introduce the imaging technique in which pedicle axis views are obtained using fluoroscopy to match the screw entry point with pedicle orientation and to report the clinical results and safety of cervical pedicle screw fixation (PSF) in patients treated for unstable cervical injuries.

Methods

One hundred consecutive patients with unstable cervical injuries underwent PSF in which the authors used fluoroscopic imaging to acquire pedicle axis views. There were 87 men and 13 women whose mean age was 42.5 years. The accuracy of PS placement was examined postoperatively using axial computed tomography (CT) and oblique radiography. Screw malpositioning was classified either as screw exposure (< 50% of the screw outside the pedicle) or pedicle perforation (> 50% of the screw outside the pedicle boundaries).

The mean operative time was 97.6 minutes, and the mean estimated blood loss was 221 ml. Local vertebral alignment around the injured segment measured 6.0° of kyphosis preoperatively and 6.7° of lordosis postoperatively. Solid posterior bone fusion was achieved in all but three patients who died shortly after surgery. There was no secondary dislodgment of instrumentation in 95% of these 97 cases. Of the 419 cervical PSs, 43 (10.3%) were of the screw-exposure type and 17 (4.0%) of the pedicle-perforation type. There were two surgery-related complications: one penetration of a probe into the vertebral artery and one radiculopathy. There were six postoperative complications: two cases of instrumentation failure associated with loss of correction, three cases of correction loss (> 10°), and one case of deep wound infection.

Conclusions

Solid posterior fusion without secondary dislodgment of hardware was demonstrated in 95% of the cases. The incidence of complications associated with cervical PSF was not high. Postoperative CT scanning showed that 17 (4.0%) of 419 screws perforated the pedicle. It appears that fluoroscopy performed using pedicle axis views improves the accuracy and safety of cervical PS insertion.

Radiotherapy with 8 MHz radiofrequency-capacitive regional hyperthermia for pain relief of unresectable and recurrent colorectal cancer

PURPOSE

The purpose of this study was to assess the pain relief in patients with unresectable and recurrent colorectal cancer treated with radiation plus 8 MHz radiofrequency-capacitive regional hyperthermia and to identify predictors of the good outcome.

METHODS

Between February 1986-May 2003, 41 patients with primarily unresectable and recurrent colorectal cancer that caused pain were treated with thermoradiotherapy at the hospital and retrospectively analysed. Radiotherapy was administered with a mean total radiation dose of 56 Gy. Hyperthermia was usually applied within 30 min after radiotherapy once or twice a week. For cooling of the skin surface, the overlay boluses were applied in addition to regular boluses. The external cooling unit has been used to reinforce the cooling ability of the overlay bolus and achieve strong surface cooling to reduce the preferential heating of the subcutaneous fat tissue and treat with more RF-output in 17 patients since January 1997.

RESULTS

Pain relief was obtained in 83% of the patients. Multi-variate analysis by logistic regression to evaluate the effects of certain factors on pain relief (complete response + good response) was strongly correlated with the presence of radiating pain to leg(s) (p < 0.05). The median follow-up was 18 months. The median duration of pain relief was 7.0 months. For the 27 patients in whom the tumour temperature was estimated, the median duration of pain relief was 14.6 months for the patients with a mean average tumour temperature of > 42.5 degrees C and 5.7 months for those of < 42.5 degrees C (p < 0.05). In the 18 patients with radiating pain to leg(s), use of strong superficial cooling and the higher numbers of hyperthermia treatments were better prognostic factors for the duration of pain relief (p < 0.01 and p < 0.05, respectively).

CONCLUSIONS

Radiotherapy with 8 MHz radiofrequency-capacitive regional hyperthermia provided an efficient, effective means on pain relief of treating unresectable and recurrent colorectal cancer. The duration of pain relief can be prolonged, if an adequate heating is achieved, especially in the patients with radiating pain to the leg(s).

Extraction efficiency of phosphate from pre-coagulated sludge with NaHS

The recovery of phosphorus from sewage and sludge treatment systems is particularly important because it is a limited resource and a large proportion of the phosphorus currently used in Japan must be imported. We have been experimentally evaluating recovery methods with sulphide. In this study, we focussed on the extraction of phosphate from the sludge, and sought to achieve a greater extraction efficiency and to validate the extraction mechanism. We conducted three experiments, i.e. a sludge-type experiment, a coagulant ratio of pre-coagulated sludge experiment, and a concentration of pre-coagulated sludge experiment. Phosphate was extracted not with normal sewage sludge but with pre-coagulated sludge and FePO4 reagent at S/Fe = 1.0-2.0. A coagulant ratio of 23mg Fe L(-1) was required in the precoagulation process to effectively extract phosphate. A high concentration of pre-coagulated sludge was required for the phosphate extraction. The mass balance was calculated, and 44.0% of phosphorus was extracted to supernatant, and 98.5% of iron and 98.3% of sulphur (44.1% of sulphur was sulphide). Thus, phosphate can be selectively separated from iron by the phosphate extraction method with NaHS, and phosphorus and iron can be recovered and reused at sewage treatment plants using ferric chloride as a coagulant.

A prospective randomized study of preemptive analgesia for postoperative pain in the patients undergoing posterior lumbar interbody fusion: continuous subcutaneous morphine, continuous epidural morphine, and diclofenac sodium

STUDY DESIGN

A prospective randomized clinical trial in preemptive analgesia for postoperative pain was conducted.

OBJECTIVE

To compare the efficacy of three preemptive analgesics combined with local anesthesia: continuous subcutaneous morphine (SC), continuous epidural morphine (ED), and diclofenac sodium (DS).

SUMMARY OF BACKGROUND DATA

Systemic opioids are known to be effective methods of postoperative pain control. The use of epidural morphine for postoperative analgesia has been a standard treatment in spinal surgery. Only a few studies in the literature have investigated the efficacy of preemptive analgesia using morphine. This is the first prospective randomized clinical trial to assess both subcutaneous and epidural continuous administration of opioids for preemptive analgesia.

METHODS

For this study, 73 patients were assigned randomly to one of three treatment groups: SC, ED, or DS. All patients underwent posterior lumbar interbody fusion with instrumentation. Pain management was assessed using the visual analogue scale (VAS). Usage of supplemental analgesics, the time to first request of them, and side effects were also investigated.

RESULTS

Twenty-two patients were randomized to SC, 23 to ED, and 27 to DS. No baseline variable differences among the three groups were seen. The results showed no significant difference in analgesic effects among those three preemptive analgesics. Only immediately after surgery (at 0 hours), the VAS of the DS group was lowest among three groups. But the DS group took more supplemental analgesic drugs until 72 hours, and the time to first request of this group was shorter than that of the other two groups. High rates of minor side effects were seen in both the ED and DS groups. SC gave moderate analgesic effects as well as the other two groups with few adverse effects.

CONCLUSIONS

DS provided a favorable effect immediately after surgery, but the effective time was short and the patient needed more supplemental drugs after that. ED did not give the expected effect, with comparatively high rates of side effects. Continuous epidural anesthesia did not seem to be suitable for preemptive analgesia. Continuous subcutaneous morphine brought some analgesic effects with a low rate of complications. It can be an attractive method for postoperative analgesia with technical ease.

Natural history of patients with lumbar disc herniation observed by magnetic resonance imaging for minimum 7 years

OBJECTIVE

The aim of this work was to elucidate the relation between the clinical course and morphologic changes of lumbar disc herniation on magnetic resonance imaging (MRI).

METHODS

Twenty-one patients with lumbar disc herniation treated nonsurgically were followed for a minimum of 7 years and investigated with regard to their clinical outcome and the initial, 2-year, and final stage MRI findings. The space-occupying ratio of herniation to the spinal canal and the degree of disc degeneration were evaluated on serial MRI.

RESULTS

The mean space-occupying ratio of herniation showed significant reduction both on the 2-year and on the final scans. Progression of degeneration of the intervertebral disc was seen in all patients at the final investigation. Comparing patients with and without symptoms, no factors were detected on the initial and 2-year MR images capable of distinguishing patients who were and were not destined to develop lumbago and/or sciatica in the future. Morphologic changes of lumbar disc herniation continued to occur even after 2 years.

CONCLUSIONS

Clinical outcome did not depend on the size of herniation or the grade of degeneration of the intervertebral disc in the minimum 7-year follow-up.

[Primary pulmonary meningioma; report of a case]

Primary pulmonary meningiomas are quite rare, and their occurrence has been reported only sporadically. A 49-year-old, asymptomatic female was hospitalized for the evaluation of a coin lesion in the left lung radiography. She has no history of previous neoplasm or symptom referable to the central nervous system. Chest computed tomography (CT) demonstrated a 9 x 14 mm, round, noncalcified, well-demarcated lesion in the left upper lobe of the lung (S(1+2)). For diagnostic purposes, enucleation of the tumor was performed. The resected specimen revealed histologically classical typical meningioma. Because postoperative magnetic resonance imaging (MRI) of the brain did not show any intracranial mass, this case was and diagnosed as a primary pulmonary meningioma. The patient was discharged with no complication, and alive without recurrence of disease 14 months after surgery.

[Thoracoscopy and intraoperative upper gastrointestinal endoscopy was effective for Boerhaave syndrome; report of a case]

Boerhaave syndrome is a rare disease and needs an exact diagnosis and a proper treatment plan because of its terrible clinical course. We experienced a case of Boerhaave syndrome that thoracoscopy and intraoperative upper gastrointestinal (GI) endoscopy was very effective. Sixty-four-year-old man realized chest and back pain after vomitting. Esophageal perforation was suspected, but 64 hours had passed already when we started a surgical treatment. By the thoracoscopy and intraoperative endoscopy, lower esophageal perforation and infectious pleural effusion were found. Therefore, we selected a surgical treatment under the assistance of thoracoscopy. Secondly, a simple closure and intracostal muscle overlapping was performed with small incisional thoracotomy. Postoperative complication, such as mediastinal abscess, has not occurred. Thoracoscopy and intraoperative upper GI endoscopy was effective for an appropriate diagnosis and treatment of Boerhaave syndrome.

[Diaphragmatic eventration resulting from phrenicectomy treated with surgical method; report of a case]

The case was a 59-year-old man who has a history of left mediastinal tumor resection with left phrenicectomy. The elevated diaphragm revealed by chest X-ray 7 years after the operation led to diagnosis of diaphragmatic eventration. Since any symptom was seen in the early period, "wait and watch" strategy was done for management. Both the abdominal enlarged feeling and the dyspnea on effort were appeared 10 years after the operation. Under the speculation of these symptoms related to the elevated abdominal organs came up with diaphragmatic eventration, surgical method the plication of the diaphragm was performed. The diaphragm was plicated by interrupted suture as opening the diaphragm to avoid injury the abdominal organs, and reinforced with the Marlex mesh. We used artificial mesh to reinforce the thin diaphragm with exceptation of prevent the postoperative recurrence, because a result of the etiological process of the case was considered as disuse atrophy of diaphragm after phrenicectomy.

Early and transient increase in spontaneous synaptic inputs to the rat facial motoneurons after axotomy in isolated brainstem slices of rats

Section of motor nerve fibers (axotomy) elicits a variety of morphofunctional responses in the motoneurons in the motor nuclei. Later than the fifth post-operational day after section of the facial nerve, synapse elimination occurs in the facial motoneuron pool, leading to gradual abolishment of synaptic input-driven activities of the axotomized motoneurons. However, it remains unknown how the amount of synaptic input changes during this period between the axotomy and the synaptic elimination. Here we examined a hypothesis that axotomy of the motoneurons itself modifies the synaptic inputs to the motoneurons. One day after axotomy, the postsynaptic currents, mostly mediated by non-N-methyl-D-aspartic acid (non-NMDA) receptors, recorded from the axotomized facial motoneurons in the acute slice preparations of the rats were of higher frequency and larger amplitude than those in the intact motoneurons. This difference was not observed after the third post-operational day and appeared earlier than the changes in the electrophysiological properties and increase in the number of dead neurons in the axotomized motor nucleus. The larger postsynaptic current frequency of the axotomized motoneurons was observed both in the absence and in the presence of tetrodotoxin citrate, suggesting that increased excitability and facilitated release underlie the postsynaptic current frequency increase. These results suggest that synaptic re-organization occurs in the synapses of motoneurons at an early stage following axotomy.

Reduction by sevoflurane of adenosine 5'-triphosphate-activated inward current of locus coeruleus neurons in pontine slices of rats

Increasing evidence indicates that volatile general anesthetics exert their effects by affecting various types of membrane conductance expressed in the central nervous system (CNS), such as ligand-gated receptor-channels. The most recently identified family of the receptor-channels in the CNS are the extracellular ATP-gated channels (P2X purinoceptors). In the present study, we tested whether volatile anesthetics can affect P2X receptor function in the CNS network. We recorded whole-cell currents of locus coeruleus (LC) neurons in pontine slices from young rats. Adenosine 5'-triphosphate (ATP) sodium (0.03-3 mM) evoked a rapidly rising and moderately desensitizing inward current (50-200 pA) in a dose-dependent manner in LC neurons at a holding potential of -80 mV. Perfusion with clinically relevant concentration of sevoflurane (0.1-0.5 mM) reduced the ATP-induced inward current in a dose-dependent manner (to 56.8+/-5.9% of control with 0.5 mM sevoflurane; mean+/-S.E.M., n=13). Estimated IC(50) of sevoflurane was 0.59 mM. We conclude that the attenuation of extracellular ATP-mediated signaling in the central nervous system might be one of the multiple actions of volatile anesthetics.

Determination of indomethacin polymorphic contents by chemometric near-infrared spectroscopy and conventional powder X-ray diffractometry

A chemoinfometric method for the quantitative determination of the crystal content of indomethacin (IMC) polymorphs, based on Fourier-transform near-infrared (FT-NIR) spectroscopy, was established. A direct comparison of the data with those collected using the conventional powder X-ray diffraction method was performed. Pure alpha and gamma forms of IMC were prepared using published methods. Powder X-ray diffraction profiles and NIR spectra were recorded for six kinds of standard material with various contents of the gamma form of IMC. Principal component regression (PCR) analyses were performed on the basis of the normalized NIR spectral sets of standard samples with known contents of the gamma form of IMC. A calibration equation was determined to minimize the root mean square error of the prediction. The predicted gamma form contents were reproducible and had a relatively small standard deviation. The values of the gamma form contents predicted by the two methods were in close agreement. The results indicated that NIR spectroscopy provides an accurate quantitative analysis of crystallinity in polymorphs compared with the results obtained by conventional powder X-ray diffractometry.