Kinematic Analysis of the Cervical Cord and Cervical Canal by Dynamic Neck Motion

Study DesignNormal cervical sagittal length patterns were measured by magnetic resonance imaging (MRI).PurposeThe aim of this study was to evaluate the relationship of sagittal length patterns between the cervical cord and the cervical canal in flexion-extension kinematics.Overview of LiteratureCervical dynamic factors sometimes cause a cervical spondylotic myelopathy in elderly subjects and an overstretching myelopathy in juvenile subjects. Previous studies showed the length changing of the cervical cord in flexion and extension. However, there is no detailed literature about the relationship between cervical vertebral motion and cord distortion yet.MethodsSixty-two normal subjects (28 male and 34 female, 42.1±8.5 years old) without neck motion disturbances and abnormalities on cervical X-ray and MRI were enrolled in this study.ResultsThe cervical cord length was significantly longer in flexion and significantly shorter in extension in all cervical cord sagittal lines. The cervical canal length pattern was also the same as the cervical cord. The elongation of the cervical cord and canal was the largest at the site of the posterior cervical canal and the shortest at the anterior canal site. The positions of the cerebellar tonsils were verified at each neck position.ConclusionsThe posterior elements of the cervical canal were most affected by neck motion. Movement directions of the upper cervical cord were verified among the various neck positions

Postoperative Radiographic Early-Onset Adjacent Segment Degeneration after Single-Level L4–L5 Posterior Lumbar Interbody Fusion in Patients without Preoperative Severe Sagittal Spinal Imbalance

Study Design Retrospective study. Purpose To investigate the relationship between preoperative total spinal sagittal alignment and the early onset of adjacent segment degeneration (ASD) after single-level posterior lumbar interbody fusion (PLIF) in patients with normal sagittal spinal alignment. Overview of Literature Postoperative early-onset ASD is one of the complications after L4–L5 PLIF, a common surgical procedure for lumbar degenerative disease in patents without severe sagittal imbalance. A better understanding of the preoperative characteristics of total spinal sagittal alignment associated with early-onset ASD could help prevent the condition. Methods The study included 70 consecutive patients diagnosed with lumbar degenerative disease who underwent single-level L4–L5 PLIF between 2011 and 2015. They were divided into two groups based on the radiographic progression of L3–L4 degeneration after 1-year follow-up: the ASD and the non-ASD (NASD) group. The following radiographic parameters were preoperatively and postoperatively measured: sagittal vertebral axis (SVA), thoracic kyphosis (TK), lumbar lordosis, pelvic tilt, and pelvic incidence (PI). Results Eight of the 70 patients (11%) experienced ASD after PLIF (three males and five females; age, 64.4±7.7 years). The NASD group comprised 20 males and 42 females (age, 67.7±9.3 years). Six patients of the ASD group showed decreased L3–L4 disc height, one had L3–L4 local kyphosis, and one showed both changes. Preoperative SVA, PI, and TK were significantly smaller in the ASD group than in the NASD group (p <0.05). Conclusions A preoperative small SVA and TK with small PI were the characteristic alignments for the risk of early-onset ASD in patients without preoperative severe sagittal spinal imbalance undergoing L4–L5 single-level PLIF

Complications Associated With Spine Surgery in Patients Aged 80 Years or Older: Japan Association of Spine Surgeons with Ambition (JASA) Multicenter Study

Study Design:Retrospective study of registry data.Objectives:Aging of society and recent advances in surgical techniques and general anesthesia have increased the demand for spinal surgery in elderly patients. Many complications have been described in elderly patients, but a multicenter study of perioperative complications in spinal surgery in patients aged 80 years or older has not been reported. Therefore, the goal of the study was to analyze complications associated with spine surgery in patients aged 80 years or older with cervical, thoracic, or lumbar lesions.Methods:A multicenter study was performed in patients aged 80 years or older who underwent 262 spinal surgeries at 35 facilities. The frequency and severity of complications were examined for perioperative complications, including intraoperative and postoperative complications, and for major postoperative complications that were potentially life threatening, required reoperation in the perioperative period, or left a permanent injury.Results:Perioperative complications occurred in 75 of the 262 surgeries (29%) and 33 were major complications (13%). In multivariate logistic regression, age over 85 years (hazard ratio [HR] = 1.007, P = 0.025) and estimated blood loss ≥500 g (HR = 3.076, P = .004) were significantly associated with perioperative complications, and an operative time ≥180 min (HR = 2.78, P = .007) was significantly associated with major complications.Conclusions:Elderly patients aged 80 years or older with comorbidities are at higher risk for complications. Increased surgical invasion, and particularly a long operative time, can cause serious complications that may be life threatening. Therefore, careful decisions are required with regard to the surgical indication and procedure in elderly patients

Bacille Calmette-Guérin (BCG) spondylitis with adjacent mycotic aortic aneurysm after intravesical BCG therapy: a case report and literature review

Abstract Background Although intravesical bacille Calmette-Guérin (BCG) therapy is accepted as an effective treatment for bladder cancer, serious complications may occur in rare cases. To date, only 4 cases have been reported in which the patient developed a combination of mycotic aortic aneurysm and BCG spondylitis. Accurate diagnosis of BCG spondylitis is important because it is an iatrogenic disease, and its treatment is different from usual tuberculous spondylitis. However, distinguishing BCG spondylitis from usual tuberculous spondylitis is very difficult and takes a long time. In this study, we were able to suspect BCG spondylitis at an early stage from the result of the interferon-gamma release assay (IGRA). Case presentation We encountered a case of BCG spondylitis with adjacent mycotic aortic aneurysm after intravesical BCG therapy in a 76-year-old man. We performed a 2-stage operation to obtain spine stabilization and replace the aneurysm with a synthetic graft. We started multidrug therapy with antituberculosis medication, excluding pyrazinamide, because the patient’s history of BCG therapy, negative IGRA, and positive of tuberculosis-polymerase chain reaction (Tb-PCR) suggested that the pathogenic bacteria of the spondylitis was BCG. Eventually the bacterial strain was identified as BCG by PCR-based genomic deletion analysis. Conclusions BCG infection should be considered in patients who have been treated with BCG therapy, even if the treatment was performed several months to several years previously. In the case of a patient with a history of BCG therapy, a positive Tb-PCR result and negative IGRA result probably suggest BCG infections, if the possibility of false-negative IGRA result can be excluded

A Case of Rapidly-Progressing Cervical Spine Subependymoma with Atypical Features

This was a study of the case of a 60-year-old woman who presented with a six-month history of headache and numbness radiating to the right arm. MRI revealed a fusiform intramedullary spinal tumor spanning C2 to C5 at the hospital where she first presented. As her right upper limb weakness had presented gradually, she visited our hospital after one and a half years. Neurological examination revealed muscle weakness in the right deltoid, but no sensory disturbance. The patient underwent a C2-C6 total laminectomy and posterior midline myelotomy from the posterior median fissure of the spinal cord. The intraoperative histological diagnosis was glioma. Pathological findings in low magnification demonstrated clusters of small uniform nuclei embedded in a dense and fibrillary matrix in hematoxylin-eosin staining (H.E.). On immunohistochemical staining, the tumor cells were weakly positive for glial fibrillary acidic protein (GFAP), but negative for the epithelial membrane antigen (EMA). The histopathological findings were consistent with the diagnosis of a subependymoma. However, the MIB-1 labeling index was of moderately high level up to approximately 8%. In this case, we performed total resection because the tumor had rapidly increased in size and was of atypical form in histological findings. It should be minded that some of subependymomas have a possibility of rapidly increasing in size with progressing neurological deficits

Cervical Kyphotic Deformity after Laminoplasty in Patients with Cervical Ossification of Posterior Longitudinal Ligament with Normal Sagittal Spinal Alignment

Background: Preoperative cervico-thoracic kyphosis and cervical regional positive imbalance are the risk factors for postoperative cervical kyphosis after expansive laminoplasty (ELAP). However, the relationship between preoperative global sagittal spinal alignment and postoperative cervical kyphosis in patients with cervical ossification of the posterior longitudinal ligament (OPLL) is unclear. The purpose of this study was to investigate the relationship between the onset of postoperative cervical kyphosis after ELAP and the preoperative global spinal sagittal alignment in patients with OPLL with normal sagittal spinal alignment. Methods: Sixty-nine consecutive patients without preoperative cervical kyphosis who underwent ELAP for OPLL and cervical spondylotic myelopathy (CSM) were enrolled. The global sagittal alignment radiography preoperatively and 1 year postoperatively were examined. The subjects were divided into a postoperative cervical lordosis group (LG) or a kyphosis group (KG) at 1 year postoperatively. The preoperative global sagittal spinal alignment between LG and KG in CSM and OPLL was compared. Results: The occurrence of cervical kyphosis after ELAP was 7 of 27 cases (25.9%) in OPLL and 13 of 42 cases (31.0%) in CSM. In patients with CSM in the KG, C7 the sagittal vertical axis (SVA) was smaller than in the LG. In patients with cervical OPLL in the KG, C2-C7 angle, C2-C7 SVA, and thoracic kyphosis (TK) were smaller than those in the LG. In OPLL, the age of the KG was younger than that of LG; however, this was not a significant difference in CSM. Conclusion: In patients with cervical OPLL without preoperative global spinal sagittal imbalance, preoperative small C2-C7 angle, C2-C7 SVA, TK, and younger age were typical characteristics of postoperative cervical kyphosis after ELAP

Radiographic Assessment of Spinopelvic Sagittal Alignment from Sitting to Standing Position

Introduction: Most people in modern societies spend the majority of their time sitting. However, sagittal spinal alignment is usually analyzed in the standing position. For understanding the symptoms associated with postural changes, this alignment is better to be analyzed in various positions. The purpose of this study was to investigate lumbo-pelvic relationships between standing up and sitting (sit-to-stand) motion. Methods: The study subjects were 25 healthy young adult volunteers without any spinal symptoms. The following parameters were measured, namely, intervertebral range of motion (IV ROM), lumbar lordotic angle (L1L5), sacral slope (SS), pelvic tilt (PT), and pelvic incidence (PI), on lateral whole-spine radiographs while sitting upright, sitting anterior flexed (anteflexed), standing anteflexed, and standing upright. Results: The measurements of spinopelvic parameters during sit-to-stand motion (sitting upright, sitting anteflexed, standing anteflexed, standing upright, respectively) were as follows: L1L5 (7.9, −4.4, 3.1, 31.9) and PT (31.5, 26.5, 11.9, 7.7). Regarding IV ROM, the lumbar segmental ROM after seat-off was wider than before seat-off (sitting anteflexed). In particular, the L4-L5 segments had a wide ROM from standing anteflexed to standing upright. Conclusions: The pelvis was retroverted in the sitting upright position and gradually anteverted during sit-to-stand motion. Lumbar lordosis decreased in the sitting upright position, temporarily decreased further (sitting anteflexed), and then increased in the standing position (standing anteflexed and standing upright). The mechanical loads on lumbosacral segments were greater after seat-off due to the reverse movement between upper lumbar and pelvic segments

Salvage carbon ion radiotherapy for recurrent solitary fibrous tumor: A case report and literature review

Background:Malignant solitary fibrous tumor (MSFT) arising from the spinal cord is extremely rare and poorly understood mesenchymal neoplasms: only a few MSFT in the spinal canal has been described. We describe the clinical course of the patient with MSFT arising from the thoracic spinal cord.Case report:We describe the clinical course of the patient and the radiological and pathological findings of the tumor. The tumor had been resected by microscopic posterior approach and video-assisted thoracic surgery, but local recurrence was observed by MRI at 1-year follow-up period. No metastatic lesion was confirmed. Then, carbon ion radiotherapy (CIRT) was administered to the recurrent lesion. Local suppression has been observed for 40 months after irradiation.Conclusion:Dumbbell-shaped MSFT arising from thoracic spinal cord is a highly unusual presentation. CIRT might be effective for treatment of recurrent tumors