Optimal Treatment of C3 Lamina in Cervical Laminoplasty

STUDY DESIGN

Results of C4-C6 laminoplasty with C3 laminectomy and C3-C6 laminoplasty were compared retrospectively.

OBJECTIVES

To clarify the difference between C3 laminectomy and C3 laminoplasty in cervical laminoplasty.

SUMMARY OF BACKGROUND DATA

Intraoperative damage to the semispinalis cervicis has been shown to lead to postoperative axial symptoms and reduced range of motion (ROM). To prevent this event, C3 laminectomy in cervical laminoplasty is considered superior to C3 laminoplasty.

METHODS

A total of 36 patients were included in this study: 20 patients (GroupA) of C3 laminectomy, C4-C6 laminoplasty compared with 16 patients (GroupB) of C3-C6 laminoplasty. We collected patient's background data, operative time, Japanese Orthopaedic Association (JOA) score, VAS score, and radiologic findings such as C2-C7 Cobb angle, ROM, C2 inter-spinous angle, and use of postoperative PRN medication were compared.

RESULTS

There was no statistically significant difference in the C2-C7 Cobb angles between the 2 groups before and after surgery (P = 0.315). In ROM, there was a 17.7% decrease from 31.5 preoperatively to 25.9 postoperatively in Group A, and a 6.1% decrease from 29.3 preoperatively to 27.5 postoperatively in Group B. There was no statistically significant difference in ROM (P = 0.683). Postoperative neck pain (VAS) was significantly lower in Group A than in Group B both at 1 week (P = 0.015) and 1 month (P = 0.035) after surgery. The C2 inter-spinous angle was statistically significantly smaller in Group A than in Group B (P = 0.004). Clinical outcomes and surgical outcomes did not differ significantly between groups.

CONCLUSIONS

If the C2 interspinous angle is wide and intraoperative semispinalis capitis damage can be minimized, it is worth trying C3 laminoplasty, but if the C2 inter-spinous angle is narrow, C3 laminectomy is recommended from the beginning.

[Three cases of mechanical thrombectomy in patients over 100 years old]

BACKGROUND

While several cases involving mechanical thrombectomy in patients >90 years old have been reported, only 1 case involving a patient >100 years old has been described. We herein report 3 cases of mechanical thrombectomy performed in patients >100 years old, along with a review of the literature.Case 1: A 102-year-old woman with a National Institute of Health Stroke Scale (NIHSS) score of 20 and diffusion weighted imaging (DWI)-Alberta Stroke Program Early Computed Tomography Score (ASPECTS) of 8 points showed M1 occlusion. She was treated with tissue plasminogen activator followed by mechanical thrombectomy. Recanalization of thrombosis in cerebral infarction (TICI)-3 was obtained at 1 pass. After 90 days, her modified Rankin Scale (mRS) was 2, and she returned to living independently.Case 2: A 104-year-old woman with a NIHSS score of 13 and DWI-ASPECTS of 9 points showed M1 occlusion, so mechanical thrombectomy was performed. Recanalization of TICI-3 was obtained. She was admitted with an mRS of 5.Case 3: A 101-year-old woman with an NIHSS score of 8 and DWI-ASPECTS of 10 points showed right internal carotid artery occlusion, so mechanical thrombectomy was performed. Direct puncture of the right common carotid artery was performed due to access difficulties. Recanalization of TICI-3 was obtained. She was admitted with an mRS of 5.

CONCLUSION

In all cases, occlusion access using techniques such as direct carotid puncture was possible, but two of the three patients had an mRS of 5, resulting in a poor prognosis. The indication for treatment in patients >100 years old should be carefully considered.

Spinal subarachnoid hemorrhage after percutaneous kyphoplasty: a case report and literature review

Background

Spinal intradural (subdural and subarachnoid) hematoma following percutaneous kyphoplasty is an extremely rare complication. In this report, we describe a case of subarachnoid hemorrhage with delayed paralysis after kyphoplasty and review the literature on similar cases to describe the complications of kyphoplasty and vertebroplasty (VP).

Case Description

An 80-year-old man underwent percutaneous kyphoplasty at a local hospital an osteoporotic vertebral fracture (OVF) at the T12 and L1 level. On the second day after kyphoplasty for T12 OVF, he developed paralysis of the lower limbs. At his initial visit to our clinic, he had a complete loss of sensation below T11 and complete paralysis of both lower extremities. Thoracolumbar magnetic resonance imaging revealed an intradural hematoma on the ventral side of the spinal cord, in the spinal canal from T5 to T12, compressing the spinal cord. Thoracolumbar computed tomography showed a fracture line in the medial cortex of the right pedicle at T12 and a tract from the spinal canal to the vertebral body. An emergency posterior decompression from T11 to L1 was performed. A small hole was found on the right side of the pedicle at T12, and tear of the nerve and subarachnoid hematoma were observed in the vicinity of the T11 nerve root. The subarachnoid hematomas were removed. Postoperatively, the neurological symptoms improved rapidly. Eventually, he was able to walk and was transferred for rehabilitation.

Conclusions

Percutaneous surgery through the pedicle might cause hematoma and bone cement leakage into the spinal canal. This can be a serious complication: hence prevention is important.

Closure of a dural defect as a cause of superficial siderosis: does early dural repair lead to a better outcome? Illustrative case

BACKGROUND

Superficial hemosiderosis (SS) of the central nervous system is a rare condition that is caused by chronic, repeated hemorrhage into the subarachnoid space. The subsequent deposition of hemosiderin in the brain and spinal cord causes neurological deterioration. In this report, the authors describe a repair procedure for SS associated with a dural defect in the thoracic spine.

OBSERVATIONS

A 75-year-old man presented with tinnitus symptoms that began about 1 year prior. Subsequently, his hearing loss progressed, and he gradually became unsteady on walking. Magnetic resonance imaging (MRI) of the head showed diffuse hemosiderin deposition on the surface of the cerebellum. Thoracic MRI showed ventral cerebrospinal fluid leakage of T2-7, and computed tomography myelography showed leakage of contrast medium that appeared to be a dural defect. Dural closure was successful, and MRI showed decreased fluid collection ventral to the dura. The patient's symptoms of wobbliness on walking and tinnitus improved dramatically from the postoperative period.

LESSONS

Dural abnormalities of the spine must always be considered as one of the causes of SS. Early dural closure is an effective means of preventing the progression of symptoms.

Horizontal stenting via retrograde route for recurrent ruptured posterior communicating artery aneurysm after clipping: A case report and literature review

Treatment of recurrent ruptured aneurysms incorporating a branch vessel arising from the dome is challenging. Here, we attempted horizontal stent-assisted coil embolization via a retrograde route from the contralateral internal carotid artery to treat a small ruptured posterior communicating artery aneurysm incorporating a fetal variant posterior cerebral artery after clipping.

Dysphagia after occipital cervical fusion for retro-odontoid pseudotumor with ossification of the anterior longitudinal ligament

Background:

Ossification of the anterior longitudinal ligament (OALL) of the cervical spine is a relatively rare disease. If patients present with dysphagia, hoarseness, and/or dyspnea, they may require surgery.

Case Description:

Over a 7-month period, a 55-year-old female with a history of cerebral palsy developed a progressive quadriparesis accompanied by diffuse sensory loss (i.e., clumsiness of the hand/legs and gait disturbance). The cervical spine X-rays showed atlanto-axial subluxation with instability, while the cervical MRI demonstrated “pseudotumor in the retro-odontoid” region. Following an occipital cervical fusion (C0-C2) surgery, her quadriparesis resolved. Nevertheless, she had persistent dysphagia that worsened over 6 months. Video fluoroscopy revealed severe mechanical stenosis of the pharynx, which was attributed to OALL extending from the C3-C6 levels. Following OALL resection through a right anterior approach utilizing diamond burrs and an ultrasonic bone curette, the dysphagia rapidly resolved.

Conclusion:

We report a rare case of retro-odontoid pseudotumor successfully treated with a posterior C0-C2 cervical fusion. Additional symptomatic C3-C6 OALL, responsible for progressive dysphagia, was later managed with focal anterior OALL resection.

Repeated-Manual Aspiration with Maximum Pressure (r-MAX): A New Technique of Mechanical Thrombectomy Using Syringe Aspiration

Objective

We report a new contact aspiration technique using syringe aspiration called repeated-manual aspiration with maximum pressure (r-MAX).

Case Presentation

From January 2020 to May 2021, 18 patients underwent mechanical thrombectomy with r-MAX for occlusion of the internal carotid artery, the first division of the middle cerebral artery (M1), and basilar artery occlusion. In this method, the aspiration catheter is first guided to the occlusion site, and then, two VacLok syringes are connected to the aspiration catheter. Next, the three-way stopcock is released in one direction. After 15 seconds, the direction of the three-way stopcock is switched. In the meantime, negative pressure is reapplied through the syringe, and the direction of the three-way stopcock is switched again. After reapplying negative pressure through the syringe and switching the three-way stopcock two more times, the aspiration catheter is removed. First-pass thrombolysis in cerebral infarction (TICI) scale 3 recanalization was achieved in 11 out of 18 patients (61.1%). In all, 11 patients (61.1%) achieved modified Rankin Scale scores of 0-2 at 90 days. Asymptomatic hemorrhage was observed in two patients (11.1%), and no patients had symptomatic hemorrhage.

Conclusion

The r-MAX technique using syringe aspiration can be employed as one of the methods of contact aspiration.

Successful Endovascular Trapping for Symptomatic Thrombosed Giant Unruptured Aneurysms of the V1 and V2 Segments of the Vertebral Artery: Case Report and Literature Review

A thrombosed giant aneurysm of the V1 and V2 segments of the vertebral artery (VA) is rare. Therefore, there is controversy regarding its optimal treatment. A case of a symptomatic giant VA aneurysm located in the V1 to V2 segments on the left treated successfully by endovascular trapping of the VA is reported. A 68-year-old woman presented with swelling in the left anterior neck. Computed tomography angiography (CTA) showed a giant aneurysm measuring 47 × 58 × 47 mm³ in the left neck. Ten days after her first visit, she presented with sudden onset of left anterior neck pain. Repeated CTA showed a partial thrombus in the aneurysm. Angiography showed two thrombosed giant aneurysms located in the V1 to V2 segments of the left VA. After endovascular trapping for the aneurysms, the anterior neck pain resolved and the aneurysm gradually shrank. This case demonstrates that endovascular surgery is better than open surgery because it is less invasive. When performing endovascular treatment, trapping will be an alternative strategy for a symptomatic giant thrombotic aneurysm of the V1 and V2 segments of the VA if the patient can tolerate ischemia.

Delayed Tentorial Subdural Hematoma Caused by Traumatic Posterior Cerebral Artery Aneurysm: A Case Report and Literature Review

BACKGROUND Subdural hematoma (SDH) caused by traumatic intracranial aneurysm (TICA) is rare. TICAs are known to rupture easily, resulting in a high morbidity and mortality rate. Therefore, accurate diagnosis and treatment are crucial for preserving life. We describe a case of delayed SDH in the setting of posterior cerebral artery (PCA) aneurysm. CASE REPORT A 42-year-old man presented with sustained head injury from a traffic accident, and was being followed-up conservatively for traumatic SDH and subarachnoid hemorrhage. Three weeks after the head trauma, the patient developed a sudden deterioration of mental status and disorientation. Computed tomography revealed de novo SDH at the cerebellar tentorium. Computed tomography angiography and magnetic resonance imaging demonstrated TICA in the PCA. The patient was diagnosed with SDH due to a ruptured PCA aneurysm at the quadrigeminal segment. To avoid SDH growth due to re-rupture of the aneurysm, parent artery occlusion was subsequently performed with no complications. The patient was discharged home 2 months after endovascular treatment, with moderate disability. Follow-up angiography 2 years after the operation showed no recanalization, and the patient had returned to work. CONCLUSIONS TICA in the PCA can cause tentorial SDH with or without the presence of subarachnoid hemorrhage. Routine cerebrovascular assessment is crucial for head trauma with hematoma adjacent to the cerebellar tentorium. Parent artery occlusion via an endovascular procedure is an alternative treatment for TICA in the PCA that is less invasive than other approaches.

[Technical "Tips" for Epidural Tenting Using DuraGen^® for Surgical Management of Large Dural Defects:A Technical Note]

DuraGen^®, an absorbable, engineered collagen-based artificial graft was introduced in Japan in September 2019 for cranial, transsphenoidal, and spinal surgeries. In addition to its efficacy and safety profile, owing to sutureless dural repair, DuraGen^® is widely accepted by neurosurgeons. Direct tenting with DuraGen^® is occasionally required in patients with large dural defects, particularly in cases of tumors adherent to the dura. To overcome this limitation, we introduced a surgical technique for epidural tenting using DuraGen^®. A 78-year-old man with a history of alexia underwent craniotomy for resection of a left temporal lobe metastatic tumor. We completely removed the recurrent tumor, which was strongly adherent to the dura in the middle cranial fossa. A layer of DuraGen^® was used as a subdural underlay beneath the autologous dura to close the wide dural defect. To avoid postoperative epidural fluid collection, we retracted the DuraGen^® from the epidural aspect and interposed several pieces of muscle, which were sutured on the subdural aspect to ensure that the muscle pieces securely plugged the dural defect. We placed an additional overlay of DuraGen^® along the autologous dura. The patient's postoperative course was uneventful without cerebrospinal fluid leakage, tension pneumocephalus, or wound infection. Reoperations for tumor resection, particularly surgical procedures for refractory meningiomas and malignant tumors cause increasing fragility and wide defects of the dura. DuraGen^® placement enables sutureless closure and is less time-consuming. Our technique of epidural direct tenting with DuraGen^® using muscle pieces sutured on the subdural aspect could be useful in patients with significantly large dural defects and can prevent postoperative epidural fluid collection to ensure complete dural sealing.

Bone mineral measurement in Japan

Various methods for evaluating bone mineral in appendicular, and axial bone or in the whole skeleton have recently become available. As bone mineral is one of the major determinants of bone strength, its exact measurement should be useful for the diagnosis of osteoporosis, as well as for the prediction of fracture risk and monitoring of therapeutical response. The aims of this paper are to review the fundamental performance of bone mineral measurements, the improvements in DXA systems, and the progress in site-specific bone mineral instruments for the radius and calcaneus used in Japan, and to introduce diagnostic criteria for primary osteoporosis, and report on annual rates of bone loss in Japanese females.

Scleroderma-like changes in a patient with insulin-dependent diabetes mellitus

A 38-year-old Japanese woman with diabetes showed sclerosis of the hands, a short sublingual frenulum, and hypomotility of the esophagus. She had been on insulin therapy for insulin-dependent diabetes mellitus since the age of 15. For the previous one year, the proximal interphalangeal joints had become painful and swollen with sclerosis of the hands. Although these findings are also seen in PSS, this case was assumed to be due to diabetes mellitus. The patient had a high serum level of HbA1c, which may reflect a poor control of diabetes and non-enzymatic glycosylation of collagen fibers, resulting in an accumulation of collagen in the dermis.

Febrile ulceronecrotic Mucha-Habermann's disease

Febrile ulceronecrotic Mucha-Habermann's disease (FUMH) was first described by Degos in 1966. In the literature, nine cases of FUMH have been reported in both children and adults. We report a 16-year-old boy with the febrile ulceronecrotic type. A review of the nine cases in the literature showed acute necrotic lesions, as well as rare complications such as fever, superinfected lesions and viral infection which are not as common in pityriasis lichenoides et varioliformis acuta. There is no definitive treatment, but systemic corticosteroid, methotrexate, antibiotics (tetracycline, erythromycin), aciclovir, and 4,4-diaminodiphenyl sulfone (DDS) have been frequently used. The most common histologic feature is mononuclear perivascular infiltrates consisting of T lymphocytes. The etiology is not known, but a hypersensitivity reaction, possibly to an infectious agent, is suggested.

Fournier's gangrene: report of a case associated with paralytic and mechanical ileus throughout the management of the gangrene

A 65-year-old Japanese male, who was treated for Fournier's gangrene, developed an enlarged erythema over the right thigh and right lower quadrant. The area was surgically debrided, and he was given antibiotics. However, he complained of abdominal swelling with a metallic bowel sound, pain, and vomiting and was then treated for paralytic ileus. Although his symptoms initially improved, he complained again of the same symptoms and underwent surgery for mechanical ileus occurring at the site of a surgical scar from an appendectomy 43 years earlier. This is a very rare case of Fournier's gangrene which caused mechanical ileus of the small intestine and adherence to a peritoneal scare after paralytic ileus due to inflammation of the abdominal fascia following scrotal gangrene.

A case of CD8+ T cell lymphoma occurring during treatment for in situ malignant melanoma of the palate

A 53-year-old Japanese male noticed pigmented lesions on his right upper gingiva and hard palate in February of 1986. Histological examination revealed in situ malignant melanoma. Chemotherapy, beta-interferon, and oral BCG were given. However, tumors subsequently developed in the nasal cavity in March of 1989. The patient died in April of 1990 after developing Garcin's syndrome and the syndrome of inappropriate secretion of antidiuretic hormone (SIADH). Autopsy revealed aggressively infiltrating, whitish tumor masses invading the hard palate, the nasal cavity, the paranasal sinuses, the base of the skull, cranial nerves I-X, and the pituitary body, as well as severe necrosis of the soft palate. However, there was no evidence of malignant melanoma. Instead, these oval tumor cells had atypical nuclei and scanty cytoplasm. They contained no melanin granules, were negative for S-100 protein, and were also negative for various melanoma-associated antigens. They were positive for CD2, CD3, and CD8 by avidin-biotin-peroxidase complex immunohistochemistry. It was concluded that the patient had CD8+ non-Hodgkin's malignant lymphoma (diffuse, large cell type) of the nasopharyngeal region, which was preceded by in situ malignant melanoma of the palate.

A case of progressive systemic sclerosis associated with sarcoidosis and esophageal adenocarcinoma

A 50-year-old Japanese female with progressive systemic sclerosis (PSS, CREST syndrome) is reported. During treatment for PSS, she was diagnosed by clinical and laboratory findings as having sarcoidosis, which was confirmed by histological examination of the skin and lymph nodes in July of 1991. She complained of back pain in August of 1991. Reflux esophagitis and Barrett's esophagus, found by endoscopy, progressed into a well-differentiated tubular adenocarcinoma. This is a very rare case of PSS associated with sarcoidosis and esophageal adenocarcinoma developing from Barrett's esophagus.

BCC-associated amyloidosis with a peculiar pattern of deposition

An 83-year-old Japanese woman with lepromatous leprosy had been treated in a leprosarium. More than 10 years ago, she developed a dome-like brown tumor on the dorsum of the nose which showed the histology of basal cell carcinoma. The lesion was a well bordered, rounded tumor with tumor cell nests on its periphery extending toward the center as cords of tumor nest and with amyloid depositions between the cords. The tumor nests and amyloid lessened toward the center of the tumor, being replaced by collagen fibers. Amyloidosis showing this peculiar pattern of transition was reported with a review of published cases.

A case of dermatomyositis associated with pseudomyxoma peritonei originating from mucinous adenocarcinoma of the appendix

A 69-year-old Japanese woman with erythema, severe edema on the face, Gottron's papules and poikiloderma was diagnosed as having dermatomyositis. She also noticed muscle weakness in her extremities, although her electromyogram showed neurogenic patterns. Her levels of CA19-9 and CEA were elevated and a CT of her abdomen revealed a giant, multilobular, cystic lesion in the pelvis. This tumor was diagnosed as pseudomyxoma peritonei originating from a mucinous adenocarcinoma of the appendix.

Squamous-cell carcinoma arising in solar keratosis of a leprosy patient: relationship with positive skin smear examination

A 70-year-old Japanese female with lepromatous leprosy developed squamous-cell carcinoma within a long standing area showing solar keratoses on her head. Alopecia had been present at least for the preceding 34 years on her forehead and frontal area of the head, and solar keratoses had existed at least for the previous 9 years. Skin smear examination for acid-fast bacilli which had continually been negative for the previous 2 years (during which 8 examinations were done) became positive. We assume that there may be some relationship between the onset of the tumor and the positive skin smear examination, although the exact connection remains unclarified.

Purification of a 51 kDa endo-beta-N-acetylglucosaminidase from Staphylococcus aureus

A bacteriolytic enzyme obtained from the culture fluid of Staphylococcus aureus FDA 209P was purified to homogeneity utilizing dye-ligand affinity column chromatography, hydrophobic interaction high pressure liquid chromatography (HPLC) and hydroxyapatite HPLC. Subsequent characterizations indicated that the purified enzyme acted as endo-beta-N-acetylglucosaminidase. The molecular weight determined by sodium dodecyl sulphate polyacrylamide gel electrophoresis (SDS-PAGE) was 51,000 and the isoelectric point was higher than 10. The optimum pH for the enzyme activity on whole cells of Micrococcus luteus as a substrate was 8.0. Some heavy metal cations (Cu2+ and Zn2+) inhibited the enzyme activity at a concentration of 0.1 mM and others (Ba2+, Mg2+ and Co2+) showed a stimulating effect at a concentration of 1 mM.

Glycosaminoglycan content in the media of cultured dermal fibroblasts derived from burn scar and normal skin

The glycosaminoglycan (GAG) content of the extracellular matrix of burn scar in humans has been reported to differ from that of normal skin. In order to investigate whether the GAG content altered as a result of functional changes in fibroblasts, the GAG content was determined in culture media of fibroblasts derived from growing burn scar, mature scar, and normal skin tissue. No statistical differences were observed in the population doubling-times of scar and normal skin. Mature scar showed significantly higher values for all the concentrations of uronic acid, hexosamine, and sulfate measured in the glycosaminoglycan, as compared with normal skin values, and the concentrations from growing scar were slightly higher than those for normal skin. The above results may suggest an increase in glycosaminoglycan sulfate synthesis following the hyperplasia of the matrix in burn scar tissue.

Complicating systemic amyloidosis in dystrophic epidermolysis bullosa, recessive type

An autopsy case of dystrophic epidermolysis bullosa, recessive type, complicated by systemic secondary amyloidosis is described. The patient had developed multiple bullous lesions and erosions from birth, followed by repeated infection. At autopsy, chronic persistent inflammation was observed in the skin and in various visceral organs, accompanied by systemic amyloidosis. By the peroxidase-antiperoxidase (PAP) method, amyloid deposits stained positively for anti-AA-protein antiserum. In the present case, we concluded that the systemic amyloidosis was of the AA type, and developed secondarily to the chronic persistent inflammation in the prolonged course of dystrophic epidermolysis bullosa, recessive type.

Immunochemical properties of glucosyltransferases from Streptococcus mutans

Antiserum against purified mutansynthetase (EC 2.4.1.?) of Streptococcus mutans 6715 (serotype g), which is responsible for the synthesis of water-insoluble glucan (ISG) in the presence of both sucrose and water-soluble glucan, was prepared. The specificity of the antiserum was tested by using crude enzyme preparations (CEPs) of S. mutans strains of various serotypes. On immunodiffusion, the antiserum cross-reacted with CEPs from strains of serotypes a (HS-6 and AHT), d (OMZ176), and g (OMZ65 and KIR), but not with those from strains of serotypes b (BHT and FA-1) and c (GS-5 and Ingbritt). The antiserum inhibited the synthesis of ISG by crude or purified mutansynthetase of S. mutans 6715. The activities of ISG synthesis by CEPs from the strains antigenically related in the foregoing immunodiffusion were inhibited by the antiserum against strain 6715 mutansynthetase. The antiserum, however, also inhibited the enzyme activity of the strains of serotype b. The finding that the antiserum against purified dextransucrase of S. mutans HS-6 inhibited ISG synthesis by a CEP of strain HS-6 and also by CEPs of antigenically related strains suggested that dextransucrase activity is involved in ISG synthesis.