Lateral Extracavitary Approach to Thoracic Cord Tumor and Disc Herniation

We treated 9 patients of ventrally or ventrolaterally located thoracic lesions with lateral extracavitary approach, six cases of ventrally located thoracic cord tumor, and three cases of central disc herniation. After operation, the patients' neurological symptoms were effectively improved and there were no signigicant postoperative c omplications. Compared to transthoracic approach, this approach is less invasive and enable simultaneous vertebral reconstruction and posterior spinal fixation. Although relatatively small in number experienced, lateral extracavitry approach is considered to be a alternative method to transthoracic approach for the treatment of ventrally and ventrolaterally located thoracic lesion.ope

Clinical Results of Chemonucleolysis for the Far Lateral Lumbar Disc Herniation

The far lateral lumbar disc herniation occurs ten times less often than the classic posterolateral disc herniations. Its clinical presentation, the anatomy involved, and difficulty of surgical treatment are not well understood. The surgical approach and results also have not been clearly defined. Although there are limited number of reports and series in the literature, there is still no general consensus on the approach to surgical treatment. However, chymopapain, even with a history of controversy and troubling complications, has endured the test of time to show 30 years of clinical success in the treatment of herniated nucleus pulposus. Strict attention to indications, contraindications, and technique ensures safety and efficacy of treatment. Between 1984 and 1997, we treated with chymopapain injection in 69 patients with severe lumbar radiculopathy secondary to far lateral disc herniation. Average patient age was 38.5 years in the 47 male and 22 female patients involved. The L4-5 disc was the most commonly herniated level(44.9%) followed by L3-4(37.8%), L5-S1(13.0%), and L2-3(4.3%). They were assessed using standardized forms as well as the Mcnab classification and questioner. They were reviewed at an average of 5 years 8 months postoperatively. Relief of symptoms was obtained in 63 patients(91.3%) after injection. No one subsequently relapsed requiring operation. All 69 patients available for long-term follow-up had considerable and sustained relief from their symptoms. For ADL(activity of daily living), 50 patients(81.3%) answered that they had no limitation, and regarding the office or house work, 49 patients(71.0%) returned previous work without any difficulties. Based on these findings we recommend the chymopapain injection as the primary treatment for patients with severe radiculopathy secondary to far lateral herniation of a lumbar disc.ope

ongenital Intraspinal Epidermoid Cyst: Case Report

The epidermoid cyst is formed as the result of inclusion of epithelial elements at the time of closure of the neural tube. The incidence of this tumor is less than 3% of all spinal canal tumors in children, The authors have experienced a 6-year old child with intraspinal epidermoid cyst which presented with symptom of back and abdominal pain. The magnetic resonance imaging study showed intraspinal mass lesion from level of T12 to S1. The patient had no history of previous lumbar puncture. We have removed totally the pearly-like intradural mass with laminoplastic laminotomy from T12 to L5. The pathological findings were compatible with epidermoid cyst. The postoperative course was uneventful without any neurologic deficit. Characteristics of this lesion with a pertinent literature is reviewed.ope

Real-time CT Fluoroscopy (CTF)-Guided Vertebroplasty in Osteoporotic Spine Fractures

The purpose of this study was to evaluate the clinical feasibility, benefits, and limitations of CT fluoroscopy (CTF)-guided percutaneous vertebroplasty (PVP). PVP under the guidance of CTF without additional guidance by conventional C-arm fluoroscopy was performed in a total of 29 vertebral bodies in 21 patients with vertebral compression fractures. While monitoring sectional CTF images, the needle was advanced from the skin to the target vertebra. Contrast media and polymethylmethacrylate (PMMA) were injected into the target vertebra with careful monitoring of their distribution. After the procedure, an evaluation was conducted to determine whether extraosseous leakage of PMMA occurred and whether sufficient filling of PMMA had been achieved. Needle placement into the target vertebra was easily achieved with both the transpedicular and posterolateral approaches. Injection of PMMA and venous leakage of contrast media were carefully monitored in all patients, and early detection of PMMA leaking was achieved in 5 patients. Extraosseous leakage that had not been detected during the procedure was not found upon postoperative evaluation. Pain scales were significantly decreased after the procedure, and no obvious complications occurred following the procedure. CTF-guided PVP without the combined use of C-arm fluoroscopy was feasible and showed definite benefits. We believe that, in spite of some limitations, CTF-guided PVP provides an alternative technique appropriate in certain situations

Cell Death in Acute Spinal Cord Injury

OBJECTIVE: In acute spinal cord injury, biomechanical and pathological changes in the cord may worsen after injury. To explain these phenomena, the concept of the secondary injury has evolved and numerous pathophysiological mechanisms have postulated. These, however, have mainly focused only on the cell necrosis. The aim of present study is to verify whether apoptosis plays a role in the animal model of secondary injury of spinal cord. MATERIALS AND METHODS: Adult male Sprague-Dawley rats were laminectomized and spinal cord injury was induced using NYU spinal impactor at T9 segment. The animals were sacrificed periodically and tissue specimen was obtained at the injury segment, adjacent segments, and remote segments to observe the secondary injury ultimately for the observation of the spatial and temporal distribution and the related cells for the appearance of apoptosis, if present. RESULTS: In the spatial distribution of apoptosis, the apoptotic cells were located at gray matter of spinal cord and the number of apoptotic cells were significantly higher in adjacent segments than in the injured segment. In the temporal distribution of apoptosis, the number of apoptotic cells were maximal at 4 hours after injury and decreased subsequently. No apoptotic cells were found at remote segments which implies that there were no influence of apoptosis on transneuronal degeneration. CONCLUSION: These results suggest that the lesioned area of spinal cord expanded over time in acute spinal cord injury and apoptosis contributed to the spinal cord neuronal and glial cell loss. In conclusion, apoptosis is thought to have an important role in secondary injury of acute spinal cord injury.ope

Thoracic Stenosis Secondary to Ossification of the Ligamentum Flavum

The thoracic portion of the spinal cord is susceptible to compression by hypertrophic ossification of the spinal ligament in the thoracic spinal canal. Unlike ossification of the posterior longitudinal ligament(OPLL) in the cervical spine, however, thoracic myelopathy due to ossification of the ligamentum flavum(OLF) may be overlooked, misdiagnosed, or treated inappropriately. This is mainly because of lack of knowledge of this condition. We therefore describe our experience with 22 cases of thoracic myelopathy secondary to ossification of the ligamentum flavum among 45 cases of thoracic stenosis. The clinical manifestations of this condition and the results of its surgical treatment are described. The most common cause of thoracic stenosis was OLF(48.9%) and the most common symptoms were numbness or tingling in the legs(81.8%) and motor weakness of the lower extremities(72.7%). Radiologically, OLF occurred mainly at intervertebral segments T9-T10 through T12-L1(86.2%), the most prevalent site was T11-T12(31.0%). Most OLF involved multiple intervertebral segments(81.8%) particularly two or three segments (59.1%). Eleven of the 22 patients were also suffering from other ossified conditions such as OPLL(45.5%) at other spinal sites, suggesting that ossification has a common underlying etiology. According to the authors' experience, surgical treatment, particularly laminectomy, was usually successful and outcomes were very promising(excellent, 27.3% ; good, 45.5%). OLF of the thoracic spine is no longer an uncommon condition and the authors believe that early diagnosis and appropriate surgical treatment, before irreversible damage to the spinal cord has occurred, may be the key to better results.ope

Three Cases of Spinal Mesenchymal Chondrosarcoma

Mesenchymal chondrosarcoma arising in the central nervous system is extremely rare and most of case described are intracranial. During the last ten years, the authors have encountered three cases of spinal mesenchymal chondrosarcoma; These involved a four-year-old boy, a 29-year-old man, and a 36-year women. Their location was lumbosacral, at the cervicothoracic junction, and in the midcervical area, respectively. The three patients underwent surgery, and microscopic examination revealed mesenchymal chondrosarcoma. The postoperative result was good. The related literature is also reviewed.ope

Surgical Treatment for Ossification of the Posterior Longitudinal Ligament of the Cervical Spine

Ossification of the posterior longitudinal ligament(OPLL) is a degenerative disease of the spine, usually found in the cervical vertebrae. The etiology and pathogenesis have not been clarified, and its natural course is still unknown. The choice of operative approach, anterior vs. posterior, is still controversial. During the past 13 years, we have operated on 116 patients with myelopathy associated with cevical OPLL; 34 cases(29.3%) were of the continuous type, 30(25.9%) were segemental, 37(31.9%) were mixed, and 15(12.9%) were other type respectively. Forty-six patients underwent anterior cervical decompression by corpectomy, disectomy, and removal of the OPLL, and in these patients, segmental and other types of OPLL were more common and were found in 73% of these cases. On the other hand, 70 patients underwent posterior cervical decompression by cervical laminectomy or expansive laminoplasty; among them, the continuous and mixed type were more common and accounted for 84% of these cases. Surgical outcome was better in patients in whom the duration of pre-operative symptoms was shorter(p<0 .05). Age at surgery, trauma history and surgical approach did not, however, significantly affect the outcome. In conclusion, anterior cervical decompression was seen to give the best results, but was limited to patients with segmental or other types of OPLL, single or two levels of OPLL, and OPLL with herniated cervical disc. The posterior approach, on the other hand, was palliative, and gave better results in patients with continuous or mixed type of OPLL, OPLL of more than level three, and generally compromised patients.ope

Surgical Treatment of Foramen Magnum & High Cervical Spinal Cord Tumor

Objective：The authors reviewed 51 patients of spinal cord tumor located at the craniovertebral junction and high cervical area to determine which factors influenced resectability, complications, and postoperative outcomes. Methods：Radiological examinations, clinical data, and operation notes were evaluated, and additional follow-up information was obtained from outpatient examinations. The mean follow-up period was 3.5 years Results：The most common neurological findings were motor deficit(72.5%) and sensory change(47.1%). There was no clinical finding that is considered as pathognomic. Meningioma(18 cases, 35.3%) was the most common tumor in this region. Total removal was achieved in 45 patients. There was no surgical mortality. Immediate postoperative motor weakness were encounted in 11 cases(21.6%) which improved in long term follow-up except two patients. Conclusions：The location and relationship of the tumor to surrounding struncture determine its resectability. Postoperative results were related to the preoperative neurological status and pathological findings.ope

Posterior Fossa Decompression in Syringomyelia with Chiari Malformation

Chiari malformation is a condition characterized by herniation of the posterior fossa contents below the level of the foramen magnum : The main pathologic change is downward displacement of the cerebellar tonsils to occlude the subarachnoid space at the level of the foramen magnum. For this reason, the practice of posterior fossa decompression in the treatment of syringomyelia with Chiari malformation has been widely accepted. In order to evaluate the usefulness of the procedure in the treatment of this condition, clinical data and surgical outcome in 20 patients who underwent posterior fossa decompression during the last five years were analyzed. The average age at presentation was 35.9(range 17 to 61) years. Chiari I malformation was found in 14 patients, and Chiari II malformation in six : weakness and pain were the most common symptoms. The most useful preoperative imaging study was magnetic resonance imaging. In order to expose the outlet of the fourth ventricle, all patients underwent suboccipital craniectomy and C1 or C1-2 laminectomy with the supportive procedure consisting of adhesiolysis and tonsillar elevation. Postoperatively, 75% of patients showed improvement, and the condition of 15% stabilized. Postoperative MRI was performed in 12 patients, and revealed that in 11 of these, the syrinx cavity had become smaller. Transient headache and vomiting was the most frequent postoperative complication. Patients with pain and numbness had a better prognosis than those with weakness and sensory loss, and it appears that in cases of syringomyelia with Chiari malformation, posterior fossa decompression is beneficial.ope