In cervical spondylosis, the dynamics of the cervical spine plays an important role in the cord insult. In this regard, it is well recognized that the extension of the cervical spine aggravates narrowing of the spinal canal, thereby resulting in cord compression, a phenomenon termed the pincers mechanism. In patients with this condition, long tract signs such as spasticity in the legs are among the clinically predominant symptoms. In contrast, however, very little attention has been paid to neck flexion, and when the neck is flexed, the spinal cord elongates and compresses against the anterior structure of the spinal canal. Under certain conditions, such elongation and compression can exceed the range of physiological tolerance and results in a cord insult. When this occurs, the intramedullary pressure of the spinal cord increases and ischemic changes are liable to take place, thereby causing a scenavio in which the grey matter can be greatly affected by this impedment. On the other hand, the dynamics of the thoracic spine are limited when compared to the dynamics of the cervical or lumbar spine. However, even though the thoracic dynamics are considered negligible the author presents three cases of a thoracic extramedullary tumor in which the dynamics of the thoracic spine played an important role in aggravating the long tract signs. The author concludes by stating that when treating patients with spinal cord disorders, the pathophysiological factors should be considered, especially the dynamics of the spine and the spinal cord.

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The surgical management of cervical injuries is based on restabilization of the injured cervical spine with decompression if necessary, and early rehabilitation. Before the era of spinal instrumentation, treatment usually consisted of one-stage surgery, combining anterior and posterior approaches, and the use of a halo brace. However, patients with a halo brace often complain of limited shoulder movement and discomfort, so that rehabilitation proceeds more slowly. With the advent of spinal instrumentation, however, internal fixation of an unstable cervical spine is being achieved without the need of a halo brace, so that rehabilitation is more rapid. Further, since the material used for this instrumentation is magnetic resonance compatible, radiographic follow-up has been simplified. The most common indication for the use of spinal instrumentation is spinal instability after sustaining a trauma. Spinal instability can also result from a laminectomy, a tumor, an infection and or pseudoarthrosis. When treating a spinal injury by surgery, a choice must be made with regard to using an anterior and or posterior approach on the basis of the neurological menifestations of the patient and the radiologic findings. Although the choice of spinal instrumentation is wide, the most commonly used techniques include interlaminar clamps, wires, lateral mass plates and screws, and Synthes anterior plating. This paper discusses the use of spinal instrumentation, with regard to its indications, techniques, and complications that may occur.

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The emphasis of this report is the surgical technique for a disease of the cervical disc. In addition to the Smith-Robinson method, there are many other operative methods that can be considered, such as the Cloward method, a corpectomy or without a bone graft using an anterior approach, and a laminectomy or an expansive laminoplasty for posterior decompression. However, it appears that is generally agreed that an anterior approach is more effective than posterior decompression. At our institute, our first choice is usually the Smith-Robinson method under microscopy. When using this method, great attention should be taken, not only to avoid a cord injury but also to prevent postoperative hoarseness due to an injury that may occur to the recurrent laryngeal nerve and/or a sensory disturbance of the thigh due to a lateral femoral cutaneous nerve injury. Therefore, the surgeon performing this operation must be well acquainted with the anatomical structure concerned. As for cases manifesting multilevel regions and a severely narrowed spinal canal, posterior decompression is the method selected, and we have recently been using an expansive laminoplasty as the surgical approach. This is because an expansive laminoplasty, unlike a laminectomy, has additional merits, such as postoperative stabilization of the cervical spine and protection against an over-tethering injury of the nerve roots.

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Ossification of the posterior longitudinal ligament (OPLL) is a well known cause of cervical radiculomyelopathy, and although an OPLL is commonly seen in Japanese with a cervical myelopathy, the incidence of an OPLL has been increasing among North Americans. The surgical treatment of a cervical OPLL is approached from a variety of anterior and posterior routes. However, the choice of surgical procedure used, which include a laminectomy, laminoplasty, or anterior decompression with fusion, stil1 remains a topic of controversy. Between 1983 and 1993, the authors have performed an anterior decompression with interbody fusion for 51 patients with a cervical radiculomyelopathy due to an OPLL. To briefly, describe this surgical method, after nasotracheal fiberoptic intubation, with the patient's head resting on a Mayfield padded horseshoe, a skin incision is made along the anteromedial border of the right sternocleidomastoid muscle. This approach thus allows ample exposure of the cervical spine from the C3 to T1 levels. Plain X-ray confirmation of the spinal level is then mandatory before vertebral dissection is initiated with an air drill. The multilevel vertebrectomy should be initiated under direct vision with a Midas Rex drill, so as to remove the majority of the bodies down to the posterior cortical margin. Once the posterior cortical margin is reached, all subsequent drilling should be conducted under operative microscopy using a diamond burr, since a diamond burr minimizes trauma to the dura and spinal cord and reduces bleeding. The egg-shell like, residual OPLL is then completed to remove with microkerrison punches and other microinstruments. After the complete decompression of the spinal cord, the dural theca almost always. begins to protrude anteriorly with good pulsation. At this point a bone graft of an appropriate length from iliac crest is inserted in an in an inlay fashion. Postoperatively, in patients' in whom more than 2 bodies are re removed, a halo vest is applied for about 12 weeks. In conclusion, cervical cord compression caused by the lesions located principally in the anterior aspect of the spinal canal should be completely relieved by using an anterior approach.

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Although some reports have indicated that adoptive immunotherapy (AIT) is beneficial for patients with malignant astrocytomas and glioblastomas, however some clinical cases have failed to show AIT's effectiveness as had been expected from in vitro cytotoxicity studies. In this paper, we report on our attempts to clarify the benefits and limitations of AIT. To do so, we have investigated the following : the cytotoxic activity of autologous stimulated lymphocytes (ASLs) on glioma cell culture supernatants (GCSs), changes in CT or MRI imagings of patients receiving ASLS for AIT, the pathological findings of specimens obtained from such reoperated AIT patients, and the Kaplan-Meier survival rates of these AIT patients. Ten malignant glioma patients receiving ASLS for their AIT were studied, 6 of these cases involving glioblastomas and 4 presenting malignant astrocytomas. Among these 10 patients, 6 underwent reoperation. With regard to the cytotoxicity of ASL cells and lymphokine-activated killer cells on GCSs from 7 patients and on the glioma cavity cystic fluid from 1 patient, results of a ^<51>chromium release assay revealed that out a total of 10 evaluated GCSs, only 2 showed ASL inhibition. Further, the pathological findings revealed that although some ASLS injected into the cavity of the tumor migrated into the residual glioma tissue, most of the injected ASLS stayed on the surface of the cavity. A complete remission through the use of AIT is very rare and only a single report has been found in the literature. However, we have experienced 2 cases of a recurrent glioblastoma in which, after repeated ASL administrations by a device that provided access to the tumoral cavity, the lesion disappeared. Of these 2 cases, a complete remission was confirmed by MRI in 1 case and by a histological study in the other. In both these cases, the tumoral extension had been local, and the overall mean survival rate from the start of AIT was 51.8 weeks. The best survival-time correlation was seen in cases of a localized tumor, and on identifying the tumor, local AIT administrations increased the length of the patient's survival, the mean survival time of such cases amounting to 85.4 weeks. We thus have concluded that for patients with a localized malignant glioma, a surgical resection and radiotherapy followed by AIT is associated with a longer survival.

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Reported herein are the computed tomographic (CT) features of a ruptured distal middle cerebral artery (MCA) aneurysm, considered a rare occurrence, and the clinical course of 5 MCA aneurysm patients. The CT findings revealed an associated dense, sylvian hematoma rather than a subarachnoid hemorrhage. One patient prior to cerebral angiography had been misdiagnosed as showing a hypertensive putaminal hemorrhage on the basis of the CT findings. Four of the 5 aneurysms had arisen in the insular portion of the MCA and the remaining aneurysm in an opercular portion of the MCA. The aneurysms were successfully clipped and the sylvian clot was removed as much as possible. An increasing awareness that a ruptured distal MCA aneurysm may be associated with a dense, sylvian hematoma enables the achievement of a more accurate diagnosis and care should be taken not to injure the fine vessels while removing the hematoma within the sylvian fissure.

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The authors report a ruptured iatrogenic internal carotid artery aneurysm case, after clipping a basilar bifurcation aneurysm. A 40-year-old female had an attack of subarachnoid hemorrhage, which was caused by a ruptured basilar-tip aneurysm. The aneurysm neck was successfully clipped by the pterional approach. However, she had reattacks of subarachnoid hemorrhage caused by a ruptured internal carotid aneurysm, 8 and 15 days after surgery. Postoperative angiograms disclosed an aneurysm adjacent to the initial clip-head, which was not present in the original angiography. It was thought that the iatrogenic aneurysm had appeared due to not only the arterial injury caused by the spatula and clip-head, but also the hemodynamic changes induced by hypertension therapy.

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Discussed is the case of a 61-year-old male with a remote history of having undergone a pulmonary lobectomy for a lung cancer who now had developed a visual field defect with hypopituitarism. Neuro-imaging studies disclosed a pituitary mass with a suprasellar extension, and thorough preoperative examinations revealed no evidence of a recurrent disease and/or a metastasis to other organs. After a trans-sphenoidal removal of this pituitary tumor, it was found to be an adenocarcinoma. Postoperately, he then was given radiotherapy of the pitultary region and the whole brain. However, 11 months after surgery, he developed meningitis carcinomatosa and died. Although a metastatic pituitary carcinoma on presentation occasionally mimics a pituitary adenoma, unlike the prognosis of a pituitary adenoma, its prognosis is poor.

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The authors report a case of an upper cervical spine metastasis from a hepatocellular carcinoma at the C2 and C3 levels. The patient, a 54-year-old male, was admitted to hospital because of a severe neck pain and a neck movement disturbance. X-rays of the cervical spine indicated erosion of the C2 and C3 vertebral body and the arch. CT and MRI inspection revealed that the tumor was mainly sited in the left posterolateral compartment of the axis and that it had invaded the epidural space of the spinal canal. Abdominal CT showed multiple lesions in the liver. The serum level of α FP was 320 ng/ml and the PIVKA-II was 7.3 AU/ml. Based on these findings, the diagnosis was an upper cervical spine metastasis from a hepatocellular carcinoma. Prior to surgery, the primary lesion in the liver was treated by a transarterial embolization using farmorubicin and gel foam. The subsequent operation was performed by posterior decompression of the C2 and C3 region, followed by tumor removal and occipito-cervical stabilization using Cotrel-Dubousset instrumentation (CDI). After the surgery, the patient received radiotherapy totaling 60 Gy. The postoperative course proved uneventful and the severe neck pains he had experienced were disappeared, although the radiculopathy of C5 and C6 level was temporalily found. Excellent and strong internal stabilization of CDI with posterior decompression permitted early improvement in activities of daily living and allowed for good palliative care. On the hook setting of CDI, the special care was needed to prevent the injury of spinal radicular nerves.

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Two cases of depressed fracture of the posterior fossa were reported. Case 1; A 46-year-old female, had fallen backward against the edge of the hood of the car. She showed cardiac arrest. There were no brain stem reflexes at all. Plain skull film revealed a depressed fracture in the posterior fossa. CT showed high density areas in the cerebellem and supratentorial acute subdural hematoma. Case 2; A 17-year-old female, was thrown out several meters together with the motorcycle. Neurological examination revealed consciousness disturbance and increased deep tendon reflexes. Plain skull film revealed a depressed fracture in the posterior fossa. CT revealed traumatic subarachnoid hemorrhage in the perimesencephalic cistern. Depressed fracture in the posterior fossa occurred in only 1.5% of all patients admitted with skull fractures in our hospital. This kind of fracture occurs more often in females and children. The depressed fracture in the posterior fossa is rare because the posterior fossa is protected by thick muscles. In supratentorial cranial vault, it is often caused by contact injury with not only projecting mass but also even mass. However contact injury with projecting mass is essential to cause depressed fracture in the posterior fossa. Patients with depressed fracture in the posterior fossa show many symptoms including tetraparesis, cerebellar signs, and cranial nerve palsy due to primary brain stem injury and/or diffuse axonal injury. Management should be chosen carefully.

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Reported is the case of a 50-year-old female who suddenly developed severe headaches and vomiting. On hospital admission, a neurological examination revealed only a mild nuchal stiffness. However, a CT scan showed a mild, diffuse subarachnoid hemorrhage with an intracerebral hematoma sited in the left frontal lobe. Further, a left carotid angiogram revealed an abnormal vessel with a vascular pouch in the anterior cranial fossa that was being fed by the left anterior ethmoidal artery and drained by the olfactory vein into the basal vein of Rosenthal. Based on the diagnosis of a dural arteriovenous fistula (AVF) of the anterior cranial fossa, a left frontal craniotomy was performed and the vascular pouch, including its feeder and drainer, was resected. Histologically, the wall of the vascular pouch showed reactive hyperplasia. Dural AVFS of the anterior cranial fossa are rare, only 37 cases having been reported in detail. The authors review the literature and discuss the clinical features of a dural AVF of the anterior cranial fossa.

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