Lateral Lumbar Interbody Fusion (LLIF) has been getting popular. Anterior column realignment (ACR) is also to be introduced in Japan. However, potential complications due to the specificity of this technique has been arising. The purpose of this study is to investigate anatomical features of the anterior part of segmental artery to prevent the injury on LLIF and ACR tequnique.

Thirty patients who underwent CT angiography for the purpose of the preparation of spine surgery were included in this study. Whether segmental artery may across the disc at anterior part were investigated. If the segmental artery across the disc, the distance from most lateral side of the disc to the intersection point of the disc was measured to investigate the depth of anterior retractor can insert safely. The distance from branching part of aorta to the intersection point of the disc was also measured to know the reason why the segmental artery intersect the disc.

One hundred eighteen of 221 (53.4%) segmental artery from L1 to L5 have intersect the disc at anterior part, 49 of 55 at L1/2, 47 of 58 at L2/3, 20 of 58 at L3/4 and 2 of 44 at L4/5. The distance from most lateral side of the disc to the intersection point of the disc was 25.8 mm in average. The distance from branching site of aorta to the intersection point of the disc was 8.2 mm in average.

Anterior part of segmental artery at disc level has not been reported, but to insert the anterior retractor or to do ACR technique, it is very important to know many of segmental arteries intersect the disc at anterior part of disc especially at L1/2, L2/3 and L3/4.

In lumbar interbody fusion procedure, the beneficial effects of sagittal alignment improvement and an increase in disc height in lateral lumbar interbody fusion (LLIF) have recently been reported. On the other hand, in posterior lumbar interbody fusion (PLIF), number of good results from sagittal alignment improvement and an increase in disc height have also been reported. In this study, we compared the results between LLIF and PLIF.

We compared cases of LLIF (49 cases) and PLIF (42 cases) at the L4-5 level, in our hospital between February 2014 and August 2017. These cases included cases of multiple disc level fixation; we did not distinguish how many disc levels were fixed. The average age was 70.4 years in LLIF cases and 70.7 years in PLIF cases. We analyzed the lordotic angle and disc height gained through the procedures and bone union at one year after surgery in both LLIF and PLIF cases at the L4-5 level.

The average postoperative lordotic angle and disc height at the anterior disc rim of LLIF cases were significantly larger than those of PLIF cases. Furthermore, the increased lordotic angle and disc height at the anterior and posterior disc rim of LLIF cases were also significantly larger than those of PLIF cases. At one year after surgery, the average lordotic angle and disc height at the anterior disc rim of LLIF cases was larger than that of PLIF cases. On the other hand, the decrease in lordotic angle and disc height at the anterior disc rim of LLIF cases was larger than that of PLIF cases. Furthermore, the rate of bone union in LLIF cases was lower than that in PLIF cases at one year after surgery.

In this study, improvement in the lordotic angle and disc height was more in LLIF cases than in PLIF cases. On the other hand, we should pay attention to the loss of lordotic angle and disc height, and the bone union in LLIF cases.

Purpose: The purpose of this study was to evaluate the clinical feature and perioperative complication of osteoporotic vertebral fracture (OVF) in thoraco-lumbar transitional vertebra (T group) compared to middle-lower lumbar vertebra (L group).

Materials and Methods: 38 patients (13 men and 25 women) with OVF in T group (20 cases) and L group (18 cases) were evaluated in this study from 2010 to 2017. The mean age of patients was 76.9 years, and the mean follow-up period was 29.5 months.

Results: Lumbar degenerative disease was significantly observed in L group (13 cases) compared with T group (5 cases) (P<0.05). Surgical date was not significantly different in the average of operative time (T: 235 min, L: 260 min) and which of blood loss (T: 544 ml, L: 602 ml) and which of fusion range (T: 5 levels, L: 4.4 levels). Perioperative complications (T: 9 cases, L: 8 cases) and additional surgery (T: 2 cases, L: 5 cases) were not significantly different. Middle-column injury was significantly observed in T group (16 cases) compared with L group (9 cases) (P<0.05). The mean correction angle (T: 14.7°, L: 20.7°) and the mean loss of correction angle (T: 7.6°, L: 11°) were not significantly different. Preoperative neurological deficits (T: 13 cases, L: 10 cases) and postoperative neurological improvements (T: 13 cases, L: 8 cases) were not significantly different.

Conclusion: It was suggested that the cause of neurological deficit following OVF in T group was due to the vertebral fracture site and which in L group was due to the intervertebral site adjacent to OVF besides fracture site.

In our institute, we perform herniotomy for extraforaminal lumbar disc herniation via paramedian approach using QUADRANT retractor. Twenty-three patients had been treated with this procedure and followed up at least six months. Twelve patients were excellent, six were good, two were fair and three were poor. Three patients of poor postoperative course were all underwent reoperation combined with interbody fusion. Surgical outcome of herniotomy without fixation via paramedian approach is generally good.

For the treatment of the tuberculous spondylitis, adequate curettage of the involved lesion and restoring spinal stability are mandated. It, however, may be difficult to take bone graft that correspond to replace large defect after curettage. We performed vascularized rib graft for anterior fusion of the thoracolumbar spine. The case was an 80-year-old female with spinal tuberculosis at the L1-2 level. She was presented to our hospital with low back pain. Magnetic resonance imaging (MRI) demonstrated a huge mass compressing spinal cord at the L1-2 vertebral level. We performed posterior spinal fixation using percutaneous pedicle screws, followed by anterior spinal fusion with vascularized rib graft one month after the initial surgery. A 16 cm vascularized graft was carried from the 10th rib. The graft was folded into two pieces to a length adequate to fill the defect and inserted as a pedicled vascularized graft from Th12 to L3. After 3 months, she was able to regain movement with relieved pain. No recurrence of the tuberculous spondylitis was noted in the follow-up period. We conclude that vascularized rib graft is a useful treatment for cases with destruction involving multiple vertebral bodies.

A 66-year-old man complained of back pain and night fever for 2 weeks. He had a medical history of bladder carcinoma treated with intravesical BCG therapy. Pyogenic spondylitis was suspected when he visited our hospital. Needle biopsy of the vertebral body of L4 was performed, and cefazolin and clindamycin were administered intravenously. After 2 weeks, Mycobacterium tuberculosis was proven by culture, and the antibiotics were changed to antituberculous drugs consisting of isoniazid, rifampicin, ethambutol, and pyrazinamide. However, spondylitis progressed. Debridement was planned. The curettage of the infected vertebral body of L4, the transplantation of iliac bone autograft, and percutaneous pedicle screw fixation were performed. Antituberculous drugs were continuously administered postoperatively, but magnetic resonance imaging showed no improvement. The specimen obtained from the surgery was susceptible to those drugs. Further debridement was required. During the second surgery, the curettage of the epidural abscess by posterior approach was performed. Subsequently, after 1 week, the curettage of the iliac bone graft, the vertebral body of L5, paravertebral abscess, transplantation of fibula strut and pedicle flap of the greater omentum into the dead space by transabdominal approach were performed. The antibiotics were administered continuously for 18 months, and the spondylitis eventually healed.

Vertebral osteomyelitis caused by non-tuberculous mycobacteria is uncommon, and there are only few reports in the literatures to date. It is characterized by progressive bony destruction and abscess formation. We report two patients who suffered from vertebral osteomyelitis caused by Mycobacterium Avium Complex (MAC). Those patients were successfully treated by two-staged posterior-anterior surgeries, i.e. posterior stabilization with spinal instrument followed by anterior debridement and autogenous strut bone grafting. After the surgery, infection was effectively controlled with apparent reduction of paravertebral abscess.

Patients of hemophilia are normally diagnosed after unusual subcutaneous bleeding at infants. After acquired self-walk and getting active to run, some patients are diagnosed after intracranial hemorrhage since they still tend to fall. In orthopaedic clinic situation, it is reported that osteoarthritis after repeated joint hemorrhage is a major problem for hemophilia patients. However, there are very few reports that patients develop epidural hematoma before diagnosis of hemophilia.

Here, we report one extremely rare case of 3-month-old infant of hemophilia who was diagnosed after epidural hematoma. The parents found that the patient did not move his legs very well and looked displeased. After they visit a pediatric clinic, they went to a hospital to take MRI which revealed epidural mass at thoracic level. The mass looked like an epidural hematoma or abscess. The blood examination suggested no infection regarding WBC and CRP. But the only outlier was APTT that indicates some abnormality in blood coagulation. The patient did not show any recovery so that we decided to perform surgery. Surgery was one-side open wedge laminoplasty from Th8 to L2. The mass was hematoma. Right after surgery, the muscle strength recovered. After surgery, he was diagnosed as hemophilia A. At the moment, he does not have any growth problem including gait-disturbance and scoliosis. He acquired self-walk at 11-month-old. At one year after surgery, MRI shows no mass in spinal canal and that the dura spreads widely enough in spinal canal.

While there are reports that lumbar puncture to hemophilia patients should be avoided because of the risk of epidural hematoma, the treatment of epidural hematoma of hemophilia patients is not enough established because clinical cases are rare. Some authors report that their patients recovered after conservative treatment and some report good recovery after surgery. If patients any recovery before surgery, it may be good by conservative treatment. However, without any recovery surgery should be considered. Recently treatment of hemophilia has developed so well that patients could take only one shot of clotting factor monthly. And the blood coagulation is now able to be controlled strictly, the risk of bleeding can be controlled well, too. Surgery can be one optional treatment for epidural hematoma of hemophilia patients.

We report a case of benign metastasizing leiomyoma (BML) in the sacrum. A 42-year-old woman with a history of myomectomy for a uterine myoma presented with severe right leg pain. An MRI showed right sided epidural lesion at S1 level. This lesion was diagnosed with meningioma by under fluoroscopy-guided percutaneous biopsy. Her symptom progressed during follow-up. Partial resection of the epidural lesion was performed for both a definitive diagnosis and a pain relief. After the surgery, her pain was relieved.

Histopathology of the surgical specimen revealed features consistent with a benign smooth muscle tumor. We consulted gynecologists and an oophorectomy for hormone control was scheduled to prevent regrowth of residual tumor and further metastasis.

A 10-year-old boy complaining of neck pain without any inducement was referred to our hospital. Images at the first visit showed an atlantoaxial rotatory fixation (AARF). He received conservative treatment for 14 months with a cervical collar, Glisson traction and halo vest fixation after manual reduction under general anesthesia. However, residual rotational position and cervical pain recurred. Finally, he required surgical intervention with posterior C1-2 fixation. An atlantoaxial rotation with O-C1 joint lesion (OAARF) may result in worse treatment outcome as conservative treatment compared to AARF. It is necessary to evaluate the pathological condition at an early stage of OAARF and consider decision making including the surgical treatment.

A 32-year-old female with paresis of the right lower limb due to sequela of cerebral palsy. She was consulted to our hospital with chief complaints of weakness of limbs and difficulty walking. She had a surgical history of laminoplasty for cervical spondylosis myelopathy three years ago, and suffered from paresis of limbs 2 weeks ago. MRI showed compression of cervical spinal cord due to postoperative lamina migration into canal and extensive edema of the cervical spinal cord. The serum anti-aquaporin 4 antibody was positive. Since she had no optic neuritis, she was diagnosed with neuromyelitis optica spectrum disorder. She was able to walk with walking assistive devices 5 months after medical treatment.

A 27-year-old female was referred to our department because of unbearable low back pain and sagittal imbalance. She received an initial diagnosis of scoliosis at the age of 12 years old, and posterior spinal fusion was performed at 17 years of age. As several instrumentation failure caused unbearable low back pain and sagittal imbalance, the revision surgery was performed twice. However, her complaints continued and she couldn't lie down on supine position. The coronal and sagittal balance was ignored at the time of the first and revision surgery. We performed the staged spinal reconstructive surgery: anterior and posterior corrective spinal fusion with fusion mass osteotomy and asymmetrical pedicle subtraction osteotomy, and in consequence, her complaints and sagittal imbalance improved.

Surgical strategy to obtain both coronal and sagittal good balance should be made even in the primary spinal deformity surgery.

We report a rare case of bladder and rectal disturbance due to restenosis of the fixed vertebrae in one year after single level transforaminal lumbar interbody fusion by the cortical bone trajectory (CBT) method, resulting in reoperation. At reoperative findings, ligament-like tissues formed in the epidural space from under the muscular layer adhered to the dura and became the cause of cauda equina compression. Pathological findings were ligament-like tissue hyperplasia with necrotic tissue. The instability due to delayed union, the mechanical stimulation of the paravertebral muscles around the implant, etc. may have contributed to the growth of the ligament-like tissues.