Neurological deterioration due to missed thoracic spinal stenosis after decompressive lumbar surgery

There have been a few reports of patients with a combination of lumbar and thoracic spinal stenosis. We describe six patients who suffered unexpected acute neurological deterioration at a mean of 7.8 days (6 to 10) after lumbar decompressive surgery. Five had progressive weakness and one had recurrent pain in the lower limbs. There was incomplete recovery following subsequent thoracic decompressive surgery.

The neurological presentation can be confusing. Patients with compressive myelopathy due to lower thoracic lesions, especially epiconus lesions (T10 to T12/L1 disc level), present with similar symptoms to those with lumbar radiculopathy or cauda equina lesions. Despite the rarity of this condition we advise that patients who undergo lumbar decompressive surgery for stenosis should have sagittal whole spine MRI studies pre-operatively to exclude proximal neurological compression.

Cite this article: Bone Joint J 2013;95-B:1388–91.

The surgical treatment of pyogenic spondylitis using posterior instrumentation without anterior debridement

There have been few reports regarding the efficacy of posterior instrumentation alone as surgical treatment for patients with pyogenic spondylitis, thus avoiding the morbidity of anterior surgery. We report the clinical outcomes of six patients with pyogenic spondylitis treated effectively with a single-stage posterior fusion without anterior debridement at a mean follow-up of 2.8 years (2 to 5). Haematological data, including white cell count and level of C-reactive protein, returned to normal in all patients at a mean of 8.2 weeks (7 to 9) after the posterior fusion. Rigid bony fusion between the infected vertebrae was observed in five patients at a mean of 6.3 months (4.5 to 8) post-operatively, with the remaining patient having partial union. Severe back pain was immediately reduced following surgery and the activities of daily living showed a marked improvement. Methicillin-resistant Staphylococcus aureus was detected as the causative organism in four patients.

Single-stage posterior fusion may be effective in patients with pyogenic spondylitis who have relatively minor bony destruction.

Degenerative lumbosacral spondylolisthesis: possible factors which predispose the fifth lumbar vertebra to slip

We have analysed a number of radiological measurements in an attempt to clarify the predisposing factors for degenerative spondylolisthesis of the lumbosacral junction. We identified 57 patients with a slip and a control group of 293 patients without any radiological abnormality apart from age-related changes. The relative thickness of the L5 transverse process, the sacral table angle and the height of the iliac crest were measured and evaluated. The difference in these measurements between men and women was analysed in the control group. We found that the transverse process of L5 was extremely slender, the sacral table more inclined, and the L5 vertebra was less deeply placed in the pelvis in patients with a slip compared with the control group. The differences in these three parameters were statistically significant. We believe that the L5 vertebra is predisposed to slip when these factors act together on a rigidly-stabilised sacrum. This occurs more commonly in women, probably as a result of constitutional differences in the development of the male and female spine.

Clinical outcomes of multilevel anterior corpectomy and fusion as a revision surgery of the cervical spine: report of seven cases

STUDY DESIGN

Report of seven cases.

OBJECTIVE

There is no general consensus on the best surgical procedures for late-onset complications of cervical operations. We reported seven patients who had been treated effectively by multilevel anterior corpectomy and fusion (ACF) as revision surgery of the cervical spine.

SETTING

Gifu University Hospital, Gifu, Japan.

METHOD

Multilevel ACF using autogenous fibular strut graft as revision surgery was performed on seven patients: four patients having disorders of adjacent discs after anterior discectomy and fusion and three patients having postlaminoplasty disorders. Japanese Orthopedic Association scores (JOA scores) of the cervical myelopathy and severity of radicular and axial pains were used to evaluate outcomes.

RESULTS

Rigid osseous fusion was achieved in all patients. JOA scores of the cervical myelopathy and the radicular pain, which had worsened just before the revision surgery, were improved significantly.

CONCLUSION

In the present seven patients who had variety of pathological conditions with various previous surgeries, multilevel ACF using strut graft was effective as a revision procedure in ameliorating their symptoms.

Transoral anterior approach for extensive anterior decompression at the C3 vertebra level in a patient with severe atlantoaxial vertical subluxation and rheumatoid arthritis

STUDY DESIGN

We report a successful extensive transoral anterior decompression for an elderly patient with myelopathy and occipitalgia due to severe atlantoaxial vertical subluxation and posterior subluxation of the axis associated with rheumatoid arthritis (RA).

OBJECTIVE

To describe the treatment of an exceptional pathological condition involving severe vertical subluxation.

SETTING

University-affiliated hospital in Gifu, Japan.

METHODS

A 73-year-old woman was referred to our clinic because of myelopathy and occipitalgia due to severe atlantoaxial vertical subluxation and posterior subluxation of the axis associated with RA. Plain radiographs revealed severe atlantoaxial vertical subluxation and sagittal magnetic resonance (MR) imaging revealed severe compression of the spinal cord at the level of the C2/3 disc space due to both posterior subluxation of C2 and rheumatoid pannus at the C2/3 disc space. As MR images demonstrated that the C2/3 disc space was located just behind the retropharyngeal wall, we performed successful anterior decompression from C2 to C3 via the standard transoral approach without mandibular osteotomy.

RESULTS

The patient has been followed for 4 years and her symptoms are currently much improved without further surgical treatment.

CONCLUSIONS

The present case illustrates that severe atlantoaxial vertical subluxation and posterior subluxation of the axis associated with RA can be treated successfully by anterior decompression of C2 and C3 via the standard transoral approach.

Anterior decompression and fusion for multiple thoracic disc herniation

Multiple thoracic disc herniations are rare and there are few reports in the literature. Between December 1998 and July 2002, we operated on 12 patients with multiple thoracic disc herniations. All underwent an anterior decompression and fusion through a transthoracic approach. The clinical outcomes were assessed using the Frankel neurological classification and the Japanese Orthopaedic Association (JOA) score. Under the Frankel classification, two patients improved by two grades (C to E), one patient improved by one grade (C to D), while nine patients who had been classified as grade D did not change. The JOA scores improved significantly after surgery with a mean recovery rate of 44.8% +/- 24.5%. Overall, clinical outcomes were excellent in two patients, good in two, fair in six and unchanged in two. Our results indicate that anterior decompression and fusion for multiple thoracic disc herniations through a transthoracic approach can provide satisfactory results.

Tetraparesis due to exostotic osteochondroma at upper cervical cord in a patient with multiple exostoses–mental retardation syndrome (Langer–Giedion syndrome)

STUDY DESIGN

Case report of a severe upper cervical cord compression and tetraparesis by a massive cervical exostotic osteochondroma in a patient with multiple exostoses-mental retardation syndrome (Langer-Giedion syndrome; LGS).

OBJECTIVE

To describe this very rare pathological condition and the results of surgical intervention.

SETTING

Gifu, Japan.

METHODS

A 23-year-old man was referred to our clinic because of progressing tetraparesis. He had previously been diagnosed with hereditary multiple exostoses and mental retardation. As he had not complained of any symptoms, his family only noticed the tetraparesis after advanced deterioration. His face possessed the pathognomic features of LGS. A postmyelogram CT scan demonstrated an exostotic mass arising from the left-side C2 pedicle with associated severe spinal cord compression. He was diagnosed with LGS. Hemilaminectomy on the left side and resection of the osteochondroma were performed.

RESULTS

At 5 years postoperatively, a neurological examination showed the full return of all motor functions. The CT scan revealed no intracanalar recurrence of the tumor.

CONCLUSION

In this case of severe tetraparesis due to cervical osteochondroma, decompression by hemilaminectomy provided excellent results. In patients with LGS and intracanalar osteochondroma, the neurological deficit may be masked by mental retardation. Hence, awareness of this pathological condition will help clinicians diagnose it at an early stage.

Foramen magnum decompression for the treatment of Arnold Chiari malformation type I with associated syringomyelia in an elderly patient

STUDY DESIGN

Report of a rare case of an elderly patient with late onset of Arnold Chiari malformation type I with associated syringomyelia that was successfully treated with foramen magnum decompression.

OBJECTIVE

To report this rare case along with a literature review.

SETTING

Gifu, Japan.

METHODS

A 69-year-old woman with a 4-year history of dull pain in her right arm was referred to the clinic. After physical and radiographical examinations, she was diagnosed with Arnold Chiari malformation type I with associated syringomyelia. A foramen magnum decompression by the removal of the outer layer of the dura mater was performed.

RESULTS

At 2 years postoperatively, MRI revealed a decrease in the size of the syringomyelia. Her symptoms had also remarkably improved.

CONCLUSIONS

A rare case of symptomatic Arnold Chiari malformation type I with associated syringomyelia in an elderly woman was successfully treated with foramen magnum decompression by the removal of the outer layer of the dura mater.

Spinal subarachnoid hematoma compressing the conus medullaris and associated with neurofibromatosis type 2

STUDY DESIGN

Report of a case of subarachnoid hematoma associated with neurofibromatosis type 2 (NF2) in a 10-year-old girl.

OBJECTIVE

To report a rare case of subarachnoid spontaneous hematoma associated with NF2, with no evidence of trauma.

SETTING

Gifu, Japan.

METHODS

The patient presented with severe leg pain. MRI revealed a subarachnoid hematoma at the level of L2 and a spinal cord tumor at the level of T6. The subarachnoid hematoma had low and high heterogeneous signal intensity on the T1-weighted image and low signal intensity on the T2-weighted image, indicating the presence of extracellular methemoglobin. The tumor and hematoma were resected.

RESULTS

Pathological analysis demonstrated that the surgical specimen removed from the area of L2 was a hematoma and the specimen from T6 was a neurinoma. At follow-up 1 year after surgery, the girl remained neurologically asymptomatic.

CONCLUSIONS

This rare case of spinal subarachnoid hematoma was associated with NF2. MRI was useful in establishing the diagnosis.

Sudden onset of paraparesis caused by hypertrophy of the thoracic posterior longitudinal ligament

STUDY DESIGN

Case report of a rare form of hypertrophy of the thoracic posterior longitudinal ligament (HPLL), causing paraparesis.

OBJECTIVE

To describe this very rare pathological condition in the thoracic spine and the results of surgical intervention.

SETTING

A department of orthopaedic surgery in Japan.

METHODS

A 61-year-old man presented with acute paraparesis associated with HPLL in the thoracic region. A radiographic and pathological review of the case was conducted. Anterior decompression was performed, and he was followed for 3 years after the operation.

RESULTS

Pathologic examination of the surgical specimen revealed proliferation of fibrocartilage and calcification. The patient's paraparesis ameliorated after the operation.

CONCLUSION

For this case of myelopathy due to HPLL in the thoracic spine, urgent decompression gave excellent results. Clinical awareness of HPLL may aid correct diagnosis and prompt therapy.

Intramedullary teratoma of the spine: report of two adult cases

STUDY DESIGN

Two case reports of intramedullary teratoma in the spinal cord of adults, and a review of the literature.

OBJECTIVE

To investigate and describe unusual cases of spinal teratoma using MRI to define features that may be used to avoid misdiagnosis.

SETTING

A department of orthopedic surgery in Japan.

METHODS

One patient, a 37-year-old woman, was referred because of gait disturbance. She was evaluated by myelography, CT scan with myelography, and MRI. T12 through L1 laminoplasty was performed and the tumor was subtotally removed. The other patient, a 56-year-old man, was referred because of muscle weakness and sensory disturbance. MRI revealed multiple spinal tumors. C4 through C6 laminoplasty and T12 through L2 laminoplasty were performed, and the tumors in these regions were subtotally removed.

RESULTS

In Case 1, the postoperative course was excellent, and histological examination of the resected specimen revealed a spinal teratoma consisting of ectodermal and mesodermal elements. In Case 2, the symptoms were resolved after surgery, and ectodermal, mesodermal and endodermal elements were revealed.

CONCLUSIONS

Although intramedullary teratomas are very rare in adults, they need to be considered in differential diagnosis.

Removal of broken pedicle screws. Technical note

The authors describe a simple, new method for removing broken pedicle screws. Under microscopic visualization a straight, narrow slot is etched in the broken surface of the pedicle screw by using a power drill with a 2-mm diamond burr. A minus screwdriver is then inserted into the slot, and the broken screw is rotated and removed. There is no need to enlarge the screw hole around the broken screw or to use any special devices. The authors succeeded in removing broken screws in two cases, and there were no complications. This method allows preservation of both the pedicle and the screw hole. Consequently, it is possible to insert new pedicle screws into the same hole without losing the strength and stability of pedicle screw fixation. The authors recommend this simple and new method for removal of broken pedicle screws.

Protective effect of erdosteine against hypochlorous acid-induced acute lung injury and lipopolysaccharide-induced neutrophilic lung inflammation in mice

The effect of erdosteine, a mucoactive drug, on hypochlorous acid (HOCl)-induced lung injury, and the lipopolysaccharide (LPS)-induced increase in tumour necrosis factor-alpha (TNF-alpha) production and neutrophil recruitment into the airway, was investigated. Male BALB/c mice were orally administered erdosteine (3-100 mgkg(-1)), ambroxol hydrochloride (ambroxol) (3-30 mgkg(-1)), S-carboxymethyl-L-cysteine (S-CMC) (100-600 mgkg(-1)) or prednisolone (10 mgkg(-1)), 1 h before intratracheal injection of HOCl or LPS. In the HOCl-injected mice, erdosteine markedly suppressed increases in the ratios of lung wet weight to bodyweight and lung dry weight to bodyweight, whereas the other mucoactive drugs ambroxol and S-CMC had little effect. Erdosteine also inhibited the LPS-induced neutrophil influx, although it did not affect the increased level of TNF-alpha in the bronchoalveolar lavage fluid. The results suggest that attenuation of reactive oxygen species and neutrophil recruitment is involved in the clinical efficacy of erdosteine in the treatment of chronic bronchitis.

Fatal acute alcohol intoxication in an ALDH2 heterozygote: a case report

On an evening in November, a 25-year-old man was found dead in his bedroom. There were many empty snap-out sheets for flunitrazepam tablets in the trash at his bedside. He had been beaten by a gang of young people earlier in the morning of the same day. At the medico-legal autopsy, although there were many bruises and/or abrasions on the whole body, only slight subdural hemorrhage was observed, and none of them was thought to be the cause of death. Flunitrazepam and its metabolites were not detected in his body fluid by gas chromatography-mass spectrometry (GC-MS). Marked lung edema and a severe congestion of organs were observed. His blood alcohol concentration from the femoral vein was 2.00 mg/ml. Fatal cases of acute alcohol intoxication usually have shown higher alcohol concentration (2.25-6.23 mg/ml). Although the genotype of aldehyde dehydrogenase 2 (ALDH2) has not previously been mentioned as a contributing factor in determining the cause of death, in this case the genotype of ALDH2 was ALDH2*1/2 and thus is important. Those who possess the ALDH2*2 gene show high concentrations of acetaldehyde (AcH) at even comparatively lower alcohol levels. Consequently, the cause of death was considered to be acute alcohol intoxication including AcH poisoning.

Radiographic evaluation of the lumbosacral disc height

OBJECTIVE

To establish criteria for the radiographic evaluation of narrowing of the L5-S1 disc height, which varies widely with transition of the L5 vertebra.

DESIGN AND PATIENTS

Nondegenerated disc heights of L3-4 to L5-S1 and the thickness and length of the L5 transverse process were measured on plain radiographs of the lumbar spine in 166 outpatients, aged 18-35 years (mean 26.3 years), in whom at least the L3-4 and L5-S1 discs both showed normal signal intensity on magnetic resonance imaging. The level of the iliac crest was recorded semiquantitatively. The disc height was expressed as a percentage of the L3-4 disc height, namely "relative disc height". The ratio of disc height to the sagittal diameter of the overlying vertebral body was termed the "disc height index".

RESULTS AND CONCLUSION

The relative disc height and disc height index of L5-S1 showed strong negative correlations with two anatomic variables, which were the relative thickness of the transverse process and the level of the iliac crest (P<0.0001). The results of linear regression analysis suggest that narrowing of the L5-S1 disc height can be evaluated on plain radiographs alone in relation to these anatomic variables.

Mucolytic and antitussive effects of erdosteine

To investigate the influence of erdosteine, a new homocysteine-derived expectorant, on airway clearance we studied the effects of the drug on the viscosity of mucin, on the mucociliary transport rate in quails, on airway secretion in rats and on the cough reflex in guinea-pigs. The active metabolite of erdosteine, M1 (10 microM to 1 mM), significantly reduced the viscosity of porcine stomach mucin. Erdosteine by itself did not reduce viscosity. Erdosteine significantly promoted mucociliary transport in quails and increased airway secretion in rats. The effect was still apparent 24h after administration. Erdosteine significantly suppressed citric acid-induced cough reflexes in guinea-pigs but did not suppress mechanical stimuli-induced cough reflexes. Erdosteine suppressed the reduction of the recovery volume of bronchoalveolar lavage fluid and albumin leakage into the fluid in citric acid-exposed guinea-pigs. These results indicate that erdosteine removes sputum by reducing its viscosity, and by promoting mucociliary transport and sustained enhancement of airway secretion. It also suppressed the chemical stimulation-induced cough reflex and plasma leakage into the airway. These results suggest that erdosteine is an excellent expectorant with several modes of action.

[A sudden death case in the bath with peculiar scald]

A 60-year-old man was found dead in the bathtub of his house on the 2nd of February. Erythema with a clear border was observed on the right side of the face, trunk and around the knees, though the left side of the face, the hips and the feet were normal. The water heater was set outside of the bath, and the heated water flowed from the heater to the bath through the upper pipe. In order to determine the mechanism of the peculiar scalding, changes in the water temperature in the bathtub were measured under the same conditions. An hour after turning on the water heater, the surface water temperature of the bath was 73 degrees C. Zonal gradation of the temperature was observed. At the level of the opening for the lower intake pipe, it was 50 degrees C. The border of the scalding was consistent with the water layer above 50 degrees C.

The effect of erdosteine and its active metabolite on reactive oxygen species production by inflammatory cells

OBJECTIVE

We examined the effect of erdosteine (KW-9144), an expectorant, and related compounds on inflammatory cell-derived reactive oxygen species which are involved in airway inflammation.

METHODS

Neutrophils were isolated from peritoneal lavages of casein-injected rats and from peripheral blood of healthy human donors. Eosinophils were isolated from peritoneal lavages of horse serum-injected guinea pigs. These cells were stimulated with phorbol 12-myristate 13-acetate (PMA) and the production of reactive oxygen species was measured with luminol-dependent chemiluminescence (LDCL).

RESULTS

M1, an active metabolite of erdosteine, significantly inhibited PMA-induced LDCL of the all cell populations with treatment before stimulation. The effects of S-carboxymethylcysteine (S-CMC), ambroxol and N-acetylcysteine (NAC) on the LDCL response were weaker than those of M1. Furthermore, PMA-induced LDCL was decreased by posttreatment with M1.

CONCLUSION

These results suggest that M (an active metabolite of erdosteine) may exert an antiinflammatory effect by scavenging inflammatory cells-derived reactive oxygen species.

Erdosteine enhances mucociliary clearance in rats with and without airway inflammation

Erdosteine is a new homocysteine-derived expectorant and has been reported to have many mucolytic effects. In this report, we studied the activities of erdosteine on mucociliary clearance in normal and airway-inflammation-induced rats. In normal rats, erdosteine at doses of 100-600 mg/kg significantly promoted mucociliary clearance. However, erdosteine did not change the concentrations of mucopolysaccharides in bronchoalveolar lavage fluid (BALF). In the LPS-instillated rats, the mucociliary clearance was inhibited and the number of inflammatory cells, albumin concentration, and mucopolysaccharides concentration in BALF were increased. Erdosteine at doses of 100-600 mg/kg significantly attenuated the inhibition of mucociliary clearance and the increase of inflammatory cells, however, it did not prevent the increase of albumin and mucopolysaccharides. Other mucolytic drugs which are ambroxol and S-carboxymethylcysteine, had no effect. These results indicate that erdosteine promotes the mucociliary clearance in normal and airway-inflammation-induced rats.

[Shotshell injuries--single or multiple shots?--a case report]

The case of a 64-year-old hunter who was accidentally shot at a distance of 40 meters with a shotgun by a member of hunting group was reported. At the scene, the victim was found dead and showed two bullet wounds in the left lateral chest and thigh, and a penetrated wound in the left knee. Autopsy findings revealed that the former two wounds were discharged from the left side of the body, and the last one in the knee from the right. The assailant and comrades who happened to be on the scene of the accident deposed that the only one shot sound was heard at that time. Whether quite different directions of these three wound tracks could be explained with single shot or multiple ones, we discussed the locus of the bullets in consideration of the posture of the victim.

Distribution of fluoride in cortical bone of human rib

We describe a detailed study of fluoride distribution with age in the human cortical rib bone. Human ribs were obtained from 110 subjects (M:68, F;42) aged 20-93 years. The fluoride distribution from the periosteal to endosteal surfaces of the ribs was determined by sampling each specimen using an abrasive micro-sampling technique, and the samples were analyzed using the fluoride electrode, as described by Weatherell et al. [1]. The concentration of fluoride was highest in the periosteal region, decreased gradually towards the interior of the tissue where the concentration of fluoride tended toward the plateau, and then rose again towards the endosteal surface. Patterns of fluoride distribution changed with age, and the difference between periosteal and endosteal fluoride levels increased with age. Although average fluoride concentrations increased with age in both sexes, there was a significant difference between males and females at the age of about 55 years (P < 0.05).

A novel synthesis and potent antiinflammatory activity of 4-hydroxy-2(1H)-oxo-1-phenyl-1,8-naphthyridine-3-carboxamides

New antiinflammatory agents 4-hydroxy-2(1H)-oxo-1-phenyl-1,8-naphthyridine-3- carboxamides 7 were designed and synthesized via a valuable intermediate, 1-phenyl-2H-pyrido[2,3-d][1,3]oxazine-2,4(1H)-dione (9). The nature of substituents on the amide nitrogen had a pronounced effect on antiinflamatory activity. Studies of structure-activity relationships led to compounds 33 and 34 bearing a pyridine ring on the amide nitrogen. Compounds 33 and 34 were active against carrageenin-, zymosan-, and arachidonic acid-induced rat paw edemas and also potently inhibited the reversed passive Arthus reaction in rats. Thus, they possess a broader spectrum of antiinflammatory activity than the classical nonsteroidal antiinflammatory drugs (NSAIDs) such as indomethacin and piroxicam.

Numerical evaluation of symptoms in cervical myelopathy by quantification theory III (Hayashi)

The authors applied Hayashi's quantification theory III, a mathematical approach for quantification of qualitative data to evaluate cervical myelopathy in 81 patients who had been surgically treated. More of these patients recovered from sensory disturbances than from motor disturbance. The size of the spinal canal was correlated with the severity of the preoperative symptoms of the myelopathy, but not with the surgical results. The surgical results were correlated with the duration of the disease but not with the age of the patient. The most predictable surgical result obtained by the use of multiple regression analysis was that of the leg motor symptom.