The goal of “bloodless surgery” or the normovolemic hemodilution (NH) technique is to minimize intraoperative blood loss and to limit or eliminate preoperative blood donation and postoperative homologous transfusion. Risks associated with autologous or homologous blood transfusion include receiving the wrong unit, the potential for predonated blood contamination or infection in homologous blood, the progressive crenation of red corpuscles maintained over weeks prior to surgery, and the loss of coagulation factors and platelets. The NH technique was utilized in 40 patients averaging 49 years of age undergoing multilevel lumbar laminectomies with instrumented fusions. All patients had normal preoperative cardiac stress tests. Early in our series, 6 patients predonated from 1-3 units of blood ; the latter 34 patients did not. Immediately prior to surgery, an average of 563.5 cc of autologous blood was removed after which patients received an average of 4585 mL of crystalloid. Preoperative hematocrits averaged 41. Decompressive laminectomies (average 3.6 levels) and fusions (average 1.3 levels) required an average of 5.0 hours of operating time. Intraoperative blood loss (average 719 cc) resulted in average postoperative hematocrits of 27.5 five days postoperatively. Only 12 (30%) of 40 patients had enough autologous blood in the cell saver (average of 303 mL, range 100 cc-680 mL) to warrant reinfusion. Utilizing the normovolemic hemodilution technique, only 6 patients (15%) required postoperative homologous blood transfusions. For those wishing to predonate blood, more complete screening would allow unused units to be returned to the blood bank for use in the overall population.

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Patients undergoing long-term hemodialysis often develop spinal canal stenosis caused by β2-microglobulin amyloid deposition in the synovial joints, the intervertebral discs and the ligamentum flavum. Minimally invasive surgery is essential to treat these patients because of their poor general condition and spinal fragility. Bilateral spinal decompression through unilateral laminotomy is one of the minimally invasive surgical techniques for lumbar canal stenosis. This surgical method can accomplish bilateral nerve root decompression without injury of supra- / inter-spinous ligament complex or contralateral paraspinal muscles. In the present study, lumbar canal stenosis of the seven patients undergoing long-term hemodialysis was treated by this technique, and the surgical outcome was evaluated using the Japanese Orthopedic Association score (JOA score) excluding the assessment of urinary function (highest possible score, 29 points). The JOA score ranged preoperatively from 4 to 22 points (mean, 10.9 points), and was improved postoperatively ranging form 16 to 25 points (mean, 20.7 points). The increase in points was equivalent to that of non-dialyzed patients receiving the same operation for lumbar canal stenosis: preoperative scores ranged from 13 to 21 points (mean, 16.7 points), and postoperative scores ranged from 24 to 29 points (mean, 26.7 points). Patients could walk and start rehabilitation training on the next day after their operation, and the postoperative hospital stay ranged from 17 to 39 days (mean, 25.7 days). The technique of bilateral spinal decompression through unilateral laminotomy provides a less invasive operation with an excellent outcome for lumber canal stenosis associated with long-term hemodialysis.

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Intraspinal juxta-facet cysts of the cervical spine are rare. We report two cases of juxta-facet cysts of the upper cervical spine, one of which was arising after cervical spinal surgery and the other that involved the cruciform ligament of the odontoid process. The first case was a 65-year-old male who had received C1 laminectomy and C3-C6 laminoplasty for myelopathy. Follow-up MRIs after 2 months showed a small cystic lesion at the dorsal below right lateral atlanto-axial joint. It had grown gradually and consequently it had compressed the spinal cord with symptoms of right neck and shoulder pain. The second case was a 70-year-old female who presented sensory disturbance in the left arm and leg. MRIs of the cervical spine revealed an extradural mass located posteriorly to the dens. Both of them were removed by transdural approach and then their symptoms were resolved. Based on the MRIs and pathological findings, diagnosis of juxta-facet cysts, which rarely occur at the cervical spine, were made. We present these very rare cases of upper cervical juxta-facet cysts and their successful treatment with surgical management.

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Superficial siderosis (SS) of the central nervous system (CNS) is characterized by the deposition of hemosiderin on the surface of the CNS due to chronic and recurrent subarachnoid hemorrhage. This results in irreversible neurological deficits. We present a case of SS associated with an idiopathic meningeal cyst, dural ectasia, and scalloping of the vertebral bodies. A 51-year-old male presented with drowsiness and bloody cerebrospinal fluid. His medical records revealed perceptive hearing impairment that had developed in his early teens; generalized motor weakness, hypesthesia, and ataxia which had progressed over 10 years; and frequent episodes of transient disturbance of consciousness (drowsiness) since the age of 46. MRI revealed atrophy of the cerebellum, the brain stem, and the spinal cord with low signal intensity on their surfaces. This low signal intensity, indicating the deposition of hemosiderin, was more detectable by gradient echo T2^*-weighted MRI than by other MRI conditions. A meningeal cyst at the level of Th1-2 and dural ectasia with scalloping of the C2-Th3 vertebral bodies were also revealed. It was considered that either of these two conditions could have led to the bleeding, because no other lesions were exposed. We did not continue with follow-up treatment, because he was bedridden and it was considered that no treatment would be effective in reversing his condition.

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In atlantoaxial transarticular screw fixation, two screws are usually used to fix both sides of the joint, but not in all cases. We have experienced two cases in which one of the two screws was not able to be applied, because of the high-riding of a vertebral artery and a severe deformity of C2/3 facet. In order to increase the stability, we used the Trois-X system (3XS), which is a rod and clamp system having a transverse bar, for posterior interlaminar fixation. Contrary to our expectation, we had a complication with this device. In the atlantoaxial transarticular screw fixation, C1/2 joints were fixed in neutral position in contrast to the posterior interlaminar fixation that fixes C1/2 in an extended position. So less room is available between the occiput and C1 posterior arch for the screw fixation. Since some parts of 3XS extend over the C1 posterior arch, the room between the C1 and the occiput was reduced and the device came in contact with the occipital bone in extension. The contact induced osteolysis of the C1 lateral mass that required a second operation. In atlantoaxial transarticular screw fixation, this bulky device should be used carefully for interlaminar fixation, especially for the patients having a short distance between the occiput and C1 posterior arch.

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The palmar cutaneous branch of the median nerve arises from the radial side of the main trunk in the distal forearm. It travels distally in close association with the flexor carpi radialis tendon and pierces the superficial palmar fascia, sending sensory branches to the palmar skin. We have treated two patients with entrapment of the palmar cutaneous branch in its course. Two patients, 34 and 44-year-old women, presented with dysesthesia and paresthesia in the palmar side of the first and second fingers up to the wrist crease. Tinel's sign was positive a few centimeters proximal to the wrist crease, while the nerve conduction velocity of the median nerve through the carpal tunnel was normal. These findings were compatible with isolated entrapment of the palmar cutaneous branch, and decompression of the palmar cutaneous branch of the median nerve generated favorable results. This clinical entity should be distinguished from carpal tunnel syndrome.

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Because of the lack of guidelines for management of spinal cord injury (SCI), surgical tactics and perioperative management of patients with SCI vary in each hospital. There are broad management approaches including prolonged bedresting with a solid external orthosis or skull-traction, and anterior arthrodesis or posterior arthorodesis. With the advent of spinal instrumentation, internal fixation with combinations of various titanium implants and bone graft without a heavy external orthosis is increasing in popularity for early rehabilitation and an early return to work. In this paper, several cases are presented for consideration and selection of operative procedures.

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Cervical spondylosis is a common spinal disorder associated with degenerative changes of the cervical spine. The symptoms originate from multiple factors such as compressions of the nerve roots and spinal cord, contraction of the paravertebral muscles or degenerative joints of the spine. Precise neurological examinations and appropriate preoperative imaging studies are important in making decisions about the course of treatment. Recent advances in cervical instruments and surgical techniques have provided a variety of surgical options both in anterior and posterior decompression procedures. This article describes the current standards of diagnosis and selection of surgical treatment in cervical spondylosis based both on my clinical experience and a literature review.

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