Thigh abscesses are relatively rare with only a few cases previously reported in Japan. We report a case of thigh abscess occurring in a 31-year-old female, who complained of pain and swelling in her right thigh. MRI showed an abscess within the quadriceps femoris. Surgical excision of the abscess was carried out and Staphylococcus aureus was identified from the culture. The patient remains sympton-free seven months after surgery, with no recurrence.
We report three cases of Cat Scratch Disease (CSD). Patients were diagnosed based on a history of cat scratches, followed by typical symptoms including painful regional lymphadenitis. In Case 1 and 2, antibiotic therapy and resection of swollen lymph nodes was performed. Pathological findings were typical as CSD. In Case 3, the symptoms were relieved with only antibiotic therapy.
To establish a basis for the treatment of open injuries, a bacteriological study of fresh open and festering wounds following trauma was performed. Clinical specimens were directly collected from the wounds by inserting TranswabR into the wounds, followed by bacteriological examinations. Of 213 fresh open wounds, 131 cases were polluted by bacteria and compared to the control group of 57 cases of festering wounds. All 4 of the fresh open wounds that became festered were bacteriologically polluted on their first examination. Of these 4 cases, three were open fractures. On the other hand, no case festered when the wound was proven to be aseptic on the first examination. Bacteria were detected from the wounds more frequently in summer than winter. Coagulase-negative Staphylococcus was most frequently detected and Bacillus cereus, the next. Other species with clinical importance were S. aureus, S. epidermidis, S. milleri, E. faecalis, Aeromonas species, and Clostridium species. Compared with fresh wounds, S. aureus and GNR were detected more frequently in festering wounds.
We have treated 10 children with pyogenic coxarthrosis during a 10-year period. Over half of the cases were caused by Staphylococcus aureus. Seven cases had other diseases originally, such as atopic dermatitis, chronic hepatitis, and tonsillitis, Atopic dermatitis was observed in four cases, and it is considered to be important for the development of pyogenic coxarthrosis in children. Proper surgical procedures are required when pyogenic coxarthrosis is strongly suspected, because the cases whose surgical treatments were delayed showed poor results and sever sequellae.
We report a case with a necrotizing fasciitis-like disease in the bilateral lower extremities of an 83-year-old woman which developed in the course of treating her pyogenic arthritis of both knees. The patient had her left leg amputated above the left knee and her right leg skin grafted following currettage of the right lower leg. Magnetic resonance imaging (MRI) was very useful for providing details of the extent of this disease.
Bacterial meningitis associated with continuous epidural anesthesia is a rare event. We report a case of a patient who developed a bacterial meningitis during continuous epidural catheterization for management of direct traction for an acute slipped capital femoral epiphysis. The cause of the meningitis is not certain, although cellulitis from the site of the epidural catheter is the best possibility.
We experienced three cases who survived non-clostridial gas gangrene in association with diabetes mellitus. All cases had surgery: one metatarsal open amputation, one above knee amputation, one Lisfranc open amputation and stump plasty. Post-operatively all cases were treated with insulin and intravenous administration of antibiotics.
A contaminated lower extremity fracture was treated by reconstruction with a peroneal osteocutaneous flap. The patient was a 43 year old male who was injured in a traffic accident. His left leg was fractured and contaminated by E. coli, progressing to gas gangrene. He received hyperbaric oxygen therapy and achieved successful local control of infection. Then, we reconstructed the limp with a peroneal osteocutaneous flap. Five months after surgery bone union was achieved and he could stand with full-weight bearing.
We observed 4 cases of so-called Brodie's abscess. All patients were male, and two were adults. Diagnosis was made by blood examination, roentgenogram, tomogram, CT, scintiphotograph, bactenological culture, and clinical symptoms. Patients were treated by surgical evacuation of the abscess and with antibiotics. In the 2 adult cases, the focus was relatively large, therefore we initially evacuated the abscess surgically and inserted antibiotic mixed cement beads. Secondly we performed a bone graft. No recurrences were seen. We believe that surgical evacuation of the lesion, followed by antibiotics, is an appropriate treatment, and that use of antibiotic mixed cement beads would decrease recurrence of this abscess.
A new V-Y advancement flap using the gluteus maximus fasciocutaneous flap is described. The skin, subcutaneous fat and gluteus maximus fascia are cut, but not the muscle belly. Thirteen patients with sacral pressure sores and radionecrosis underwent surgery using this method. Eleven of 13 patients experienced complete wound healing. In comparison with the conventional V-Y gluteus maximus musclocutaneous flap, this technique is easier and can achieve a better functional prognosis.
Recently, various techniques have been used to cover sacral pressure sores. These include skin grafts, local flaps, musculocutaneous flaps and fasciocutaneous flaps. We investigated how to decide which technique should best be used for managing sacral pressure sores of individual patients. The points are (1) confidence, (2) damage to patient, (3) surgical technique, (4) infection, (5) sore size, and (6) recurrence of sore. Our first option has been the use of local flaps where possible. However, when local flaps cannot be applied, we recommend the use of musculocutaneous flaps.
Decubitus ulcers is a disease which clinicians frequently have to treat. Measures, such as medical and surgical treatment, nursing and rehabilitation have been established to some extent to treat this problem. However, no clear cut consensus is available at present for the treatment of decubitus ulcers. We added hyperbaric oxygen therapy to the above treatments and obtained good results. Hyperbaric oxygen therapy is said to be useful for treatment of central and distal circulatory disturbances as well as that of gas poisoning and decompression disease, and was also sufficiently effective for treating decubitus ulcers, an ischemic disease. We feel that hyperbaric oxygen therapy is to be stressed more in the treatment guidelines for decubitus disease.
Clinical results following treatment for spinal infections in nine patients were evaluated. Three children and one adult who showed only slight disc space narrowing and slight erosion of vertebral endplate radiologically were successfully treated only by administration of antibiotics. Five adults who showed advanced vertebral destruction required surgery in order to reduce the infection. Two of these five cases, who showed neurological compromise with severe cervical kyphosis, were successfully treated with Luque SSI, anterior debridement and iliac bone grafting. Children and adults with minimum radiological changes respond well to antibiotic administration. Adults with advanced radiological changes and neurological compromise can be successfully treated with posterior instrumentation and anterior bone grafting not only sufficient for correction of kyphosis but also for rigid fixation.
We studied 19 cases with pyogenic vertebral osteomyelitis, and evaluated these using MR imaging and markers of inflammation. Infectious vertebrae, 7 days after onset already showed irregularity of end plates and abnormalities of signal intensity or MR imaging. Although CRP had been negative, on MR imaging, infectious vertebrae showed signs of inflammation and abscess, with paravertebral abscess still present. We concluded that MR imaging is useful for following-up patients with pyogenic vertebral osteomyelitis.
The effect of chymopapain treatment on the rabbit intervertebral disc was studied in vivo. Different doses of chymopapain (0.3 to 80pKunits/10μl) were injected into the intervertebral disc of 18 Japanese white rabbits. One week after injection, disc heights had decreased in the groups receiving 2.5 pKunits/10μl or more. Twelve weeks after injection, disc heights had recovered only in the group receiving 2.5pKunits/10μl. Histologically, only 2.5pKunits/10μl injected discs showed disc regeneration. The loss of safranin-O staining was observed in the groups injected with 5pKunits/10μl or more chymopapain, and a large defect in the bony end-plate was seen in the discs injected with over 20pKunits/10μl. It was concluded that disc regeneration depends upon the dose of injected chymopapain. Also clinically, more desirable results may be expected by control of the injection dose.
Fourteen cases of cauda equina lesions were treated surgically. Three of the four-teen cases were dumbbell tumors which are rare. These were all neurinomas. For these cases we carried out reconstruction using only bone grafting without instrumentation.
We present a case of a 49 year-old man who visited our hospital for low back pain and numbness of the right leg. An intramedullary spinal cord tumor at the Th12 to L1 portion was suspected by magnetic resonance imaging. His muscle power rapidly weakened and he could not walk after admission. Laminectomy of Th12 to L1 lamina was performed and we found the tumor in the spinal cord. The tumor was histologically diagnosed as metastatic adenocarcinoma. After the operation, irradiation therapy of about 5000cGy was carried out. The lung tumor was found by chest roentgenogram in the left upper field, large cell carcinoma of the lung was detected by transverse bronchial lung biopsy. In general, intramedullary metastatic tumors are very rare, with an incidence reported of 2 to 3% of all central nervous system metastatic tumors. This case reminds us that we must consider the possibility of metastatic tumor in the spinal cord when patients complain of rapid deterioration of the nervous system.
Case 1. A fifty-four-year-old man reported a severe pair from the perineum radiating to the left leg. A hepatocellular carcinoma and a metastatic tumor of the sacrum was diagnosed by his local doctor. The patient was admitted to our hospital for treatment of the hepatocellular carcinoma. He was treated with transcatheter hepatic arterial embolization and was irradiated with 50Gy to his pelvis. Two years later, he began complaining of severe low back pain when in a sitting position. He received surgical intervention for decompression of the cauda equina, as well as stabilization of the pelvic ring with CDI. Postoperatively the severe low back pain disappeared. Case 2. A fifty-year-old women noted severe pain radiating from the perinuem to the left leg. She had been operated on in 1977, 1981, 1984 and 1988 for pelvic chondrosarcoma. X-rays examination showed lytic destruction from the fifth lumbar vertebra, sacrum to the iliac bone. Recurrence of the pelvic chondrosacoma was diagnosed and intralesional resection of the pelvic tumor and reconstruction of the pelvic ring with CDI was performed. Limb salvage for patients with malignant pelvic tumors remains a problem from the reconstructive standpoint. CDI consists of a rod, and hooks and screws and the transverse traction device and dominos. CDI achieve stable vertebral and pelvic osteosynthesis.
From May 1989 to May 1992, twenty patients were surgically treated for metastatic spinal tumors. Metastasis was from primary lesions of the breast in seven cases, kidney in four cases, liver in three cases, digestive tract in two cases and others in four cases. Nineteen cases had pain and 16 cases showed neurologic deficits. Two cases were treated by posterior fixation, ten cases by posterior fixation and decompression, and 12 cases by a combined anterior and posterior procedure. As a result, all cases had pain relief, and neurological improvement was obtained in seven cases. Ten cases (breast: six, kidney: three, other: one) survived, while the remaining ten cases died. If the primary lesion is one of low malignancy, surgical treatment is recommended because of the improvement of QOL and life expectancy.
A fifty-two-year-old woman suffered from spinal cord injury (paraplegia) following by a Th9 dislocation fracture. She immediately underwent reduction and posterior thoracic fusion with CD system. Eight days after surgery, when the central venous catheter was removed from the right femoral vein, she immediately complained of chest pain, fell into unconsciousness and died. Autopsy revealed complete obstruction of the lumen of both pulmonary arteries due to thromboembolism. The cause of death was recorded as pulmonary thromboembolism resulting from detachment of thrombus which had developed at the femoral vein catheter site. The importance of screening for complications in patients with complete lesions and injuries is discussed.
There is a great controversy as to the exact anatomy of the lumbar nerve roots at the intra and extraforaminal zones. We report an anatomical study of the position of dorsal root ganglia (DRG). Seventeen human cadavers, aged 49-90 years (average 75.3 years) were studied. After laminectomy and facetectomy at L1 to L5, myelography and radiculography were performed to confirm the anatomy of the nerve roots. Although most DRG existed at the intraforaminal site, some DRG existed at intraspinal or extraforaminal sites. Developmental factors play an important role in the location of DRG.
Since Adams reported a case of scoliosis relieved by surgery on the transverse process of one of the vertebra in 1910, the clinical significance of lumbosacral transitional vertebrae has been disputed. 22 patients with low back pain and lumbosacral transitional vertebrae with local tenderness over the anomalous lumbosacral articulation were studied. Steroid and local anesthetic injection was performed in the anomalous articulation using fluoroscopy. There was immediate total relief of pain in 19 patients (86.4%). We conclude that lumbosacral transitional vertebrae can be a cause of low back pain.
The Kin-Com 3 machine was used to measure trunk strength in 145 normal subjects, 71 males 74 females and 44 patients with lumbar spine disease, 22 males 22 females. Both extension and flexion stops were set at 30°. Testing was performed with three reciprocal repetitions at 10°, 30°/second isokinetic speed. Normal subjects and patients were divided by age into 6 groups and were compared. The study showed ext./flex. rations of an average torque were obtained in consideration of sex, age, weight, and height at the same time. Normal female values of flexor force decreased at random with ages and showed a tendency to obesity. Normal male values of flexor force decreased at random with ages and did not have a tendency to obesity. Abnormal females over 40 years of age decreased at random with ages in the ratio of extensors to flexors, and others increased at random with ages in the ratio of extensors to flexors. Abnormal males of all ages increased at random with ages in the ratio of extensors to flexors, and others were increased at random with ages in the ratio of extensors to flexors and had a tendency to obesity. The trunk muscle strength was different among individuals and was different at the ages, sex, and individuals, but the ratio of extensors to flexors was fixed in general consideration of sex, age, weight, and height etc. at the same time. We concluded that this ratio could be used as a general index.
Autologous blood transfusion was used for 44 patients undergoing spinal surgery. In all patients, predeposit autologous transfusion was performed and in 23 patients requiring postero-lateral fusion for thoracic or lumbar spine, intraoperative autologous transfusion was added. The success rate for avoiding the use of homologous blood was 97.7%. Intraoperative autologous transfusion was useful for anemic patients worried about the large volume of blood loss.
Since 1984, cervical spinal canal enlargement has been performed in 41 patients with cervical myelopathy. Expansive open-door laminoplasty and double-door have been done. Clinical results were evaluated using the JOA score for cervical myelopathy and recovery rate using Hirabayashi's method. Radiologically, cervical measurement of antero-posterior movement by plane lateral films was carried out. We evaluated significant differences between the two different operative methods.
We studied 69 patients with cervical spondylotic myelopathy, and 33 patients with cervical ossification of the posterior longitudinal ligament with a mean age of 65.5 years and an average follow-up period of 4 years and 5 months. Clinical results were evaluated using the JOA score for cervical myelopathy and recovery rates using Hirabayashi's method. The overall mean recovery rate was 58%. There was no significant difference between recovery rate and age, duration of symptoms or preoperative JOA score.Moreover, we radiographically investigated changes in cervical alignment and rate of enlargement, antero-posterior movement, and instability in 50 cases.
Eighteen cervical myelopathy patients who had combined lumbar canal stenosis underwent one stage decompression surgery, between 1989 and 1993. There were 14 males and 4 females, with a mean age of 69 years. The underlying causative condition was cervical spondylosis in 13 patients, OPLL in 5, lumbar spondylosis in 16, and lumbar degenerative spondylolisthesis in 2. The method of cervical operation was expansive laminoplasty using sagittal splitting of the spinous process, and the lumbar operation performed was wide laminectomy. Operative results were evaluated according to the modified Japanese Orthopaedic Association (JOA) score, after a mean follow-up period of 1 year 2 months. The mean recovery rate was 39%, with a recovery of 50% or more achieved in 7 patients (39%). An advantage of the one stage operation was shortening the period of treatment. For establishing an accurate indication of one stage operation, a detailed history and also neurologic examination are most important. Image diagnosis is useful for supporting rather than confirmatory evidence.
Two cases of cervical intervertebral disk calcification in children are presented. Case 1: A 7-year-old boy landed on his head, and complained of neck pain several days later. Physical examination revealed tenderness on the front and right of his neck and limitation of neck motion. Neurological examination revealed no abnormality. Radiograms of the cervical spine showed calcification in the C6/7 intervertebral disc space. He was treated with collar fixation, and was completely free of symptoms after two weeks. Eighteen months later, the calcification had almost disappeared. Case 2: A 4-year-old boy visited our clinic complaining of neck pain without trauma. Physical examination revealed tenderness on the back of his neck and limitation of neck motion. Radiograms of the cervical spine showed calcification in the C5/6 intervertebral disc space. He was admitted to hospital and treated with antiinflammatory drugs and bed rest. The next day he was completely free from symptoms. Five months later, the calcification showed partial resolution.
The effects of surgical treatment for cervical spine lesions were clinically evaluated in 8 patients with Rheumatoid Arthritis (RA); mutilans type. Six patients complained of pain in the nape and occipital region, and myelopathy was noted in 3 patients. Upper cervical spine lesions were shown in 7 cases and lower in 4 cases. We performed posterior spinal fusion (CO-C2: 5 cases, C1-C2: 2 cases, below C3: 4 cases) for all patients. Posterior decompression was accompanied with posterior spinal fusion in 2 of these cases who had subaxial subluxation with cervical stenosis. Occipitocervical fusion was carried out in 1 patient with atlanto-axial subluxation in the upper cervical spine because vertical subluxation was progressing. After operation immobilization was continued using a halo-vest for an average period of 11 weeks in 7 patients with upper cervical lesions. Solid union was demonstrated radiographically in 7 except 1 patient who had died 8 months after surgery. The condition of all patients improved on early follow-up. Understanding the severity of mutilans RA, could be a better determinant for choosing the appropriate surgical treatment.
Preoperative radiological findings and surgical results of 13 bidirectional anterior and posterior atlantoaxial subluxation (AAS) cases and 11 unidirectional anterior AAS cases were compared. Bidirectional AAS showed more angular instability of the atlantoaxial joint than anterior AAS (p<0.005). Four bidirectional AAS cases and 4 anterior AAS cases, who were treated using the modified McGraw method combined with Magerl's transarticular fixation of C1/2, achieved solid union except for three cases with hypoplastic C1 posterior arches. This combined method was useful for a RA patient, whose spinal cord was compressed statically by synovitis of the odontoid process even when the neck was in a neutral position.
Since 1988, we have carried out mass screening of scoliosis for children in elementary schools and junior high schools in Nagasaki city. Every year about 33, 000 elementary school children and 17, 500 junior high school children were examined by the respective school doctors or nursing staff as a first screen. Suspected scoliosis cases were then examined by orthopaedists for the second screening. X-rays were taken in those hump proprietors who had more than eight mm differences, measured by a hump meter. Scoliosis was diagnosed in 0.77% of elementary school children and 1.79% of junior high school children on average. The average incidence of scoliosis with curves more than ten degrees were 0.04% in elementary schools and 0.35% in junior high schools. There was a significant correlation between the height of the hump and Cobb's angle in junior high school children. The incidence of scoliosis in the first screening was lower than that found in previous reports. This may be due to great variations between schools in the first screening in this study. It is important to educate school doctors and nursing staff for the proper screening of scoliosis.
In order to stereoscopically evaluate scoliosis, three-dimensional analysis of the deformity was carried out. Top views of the spine were obtained by stereoscopic AP and lateral radiographs. A new progressive factor was three-dimensionally established, and prediction of the progression of scoliotic deformity with juvenile and adolescent idiopathic scoliosis was carried out. These top views were divided into 5 groups by the order of its progressive risk degree according to the progressive standard of scoliotic deformity that we established. Progression of scoliotic angle in all cases in 2 groups with high progressive risk degree of scoliotic deformity was confirmed. It was considered that progressive scoliotic deformity may be further accurately predicted by evaluation of a new progressive factor that was obtained by analysis of top views in addition to studying progressive factors revealed by AP and lateral radiographs because this top view of the scoliotic deformity had not been previously studied.
Seven cases with severe scoliosis (three adult idiopathic scoliosis, one neurofibromatosis, two Marfan's syndrome, one infantile idiopathic scoliosis) were treated using Cotrel-Dubousset Instrumentation (CDI). Preoperatively, the major curves measured an average of 101 degrees, and on the best side bend they average 74 degrees, a 27% degree of flexibility. Postoperatively, curves improved to an average of 57 degrees, a correction of 44%. Four of seven cases were treated by two-staged anterior and posterior spinal fusion. A correction of 50% was obtained in this group. Three curves less than 60 degrees were treated with derotation manuever and four curves more than 60 degrees were treated by the 3 rod method. We concluded that two stage anterior and posterior fusion is of value for the treatment of cases with severe rigid curves.
As a result of severe deformity caused by ankylosing spondylitis, patients may be able to see only a few feet beyond their toes. Several surgical methods have been used for treating deformities caused by ankylosing spondylitis. Reported cases were operated on before the age of 50 years. We surgically treated a patient aged 72 years. Wedge osteotomy in the lumbar region was carried out and a manipulative procedure achieved good correction, but we abandoned instrumentation because of marked osteoporosis. He received further bone grafting due to delayed union and following surgery was able to see straight ahead. No major complications such as rupture of the great vessels occurred during surgery.
Free epidural fat-grafting was performed to prevent adhesion between scar tissue of the epidural space and dura and nerve root after lumbar laminectomy. The results were evaluated using MRI. 15 cases were operated upon with an average follow-up period of 7.5 months. MRI was recorded and the findings were classified into four types as follows; I, equally high signal case; II, slight fibrosis case; III, severe fibrosis case; IV, high signal disappeared case. The results showed 3 cases of type I, 7 cases of type II 3 of type III 2 cases of type IV. According to MRI findings, free epidural fat is supposed to be still viable and alive, although slightly fibrosed but the dural side remains a high signal area. Free epidural fat-grafting was useful for preventing adhesion around the epidural space. There was high relation ship to age and sex with regard to viability of the free fat graft.
We reviewed the contrast-enhanced MR images of 47 chronic compressive myelopathy cases (28 cervical OPLL and 19 cervical spondylotic myelopathy). In 5 cases, there were correlated areas of enhancement within the spinal cord on T1 weighted images with areas of increased signal intensity on T2 weighted images. Areas of enhancement within the spinal cord were classified into three types; enhancement area resembled fried eggs in the gray matter (two cases), enhancement of the white matter (one case), entire spinal enhancement (two cases). Following decompressive surgery, most of the symptoms improved except for numbness of the upper extremities and motor weakness of hands in the two cases showing enhancement which resembled fried eggs in the gray matter.
We examined the lumbar spine MRI results of 42 elderly people and assessed any nerve symptoms of their lower extremities. We found high rates of unusual forms of spinal canal cross section, brightness changes in the endplate and degeneration of discs in LCS. However, at present it is difficult to believe there is any connection between these high rates and nerve symptoms.
The peridiscal and nuclear (nucleus pulposus and inner layer of annulus fibrosus) signal intensities in 1773 discs of adult patients were compared with common degenerative lumbar disc disease. Images were taken with a 7mm slice thickness and T2 weighted (TE 80-90mS, TR 2000-2200mS) midsagittal and parasagittal imaging. We have reported the correlation between these intensities of teen-age patients in the previous WJSOT. In adults the signal intensity primarily decreased in the peridiscal vertebrae (osseous end plate) and secondarily decreased in the nucleus pulposus. These findings suggest that degenerative changes of the nucleus pulposus originate from peridiscal (osseous endplate) disorders. But correlation of these intensities in adult patients was lower than in teen-age patients.
The laser speckle method is a new technique for evaluation of tissue blood flow using the dynamic laser speckle effect. In 1987, Fujii proposed a new system to visualize the microcirculation map using the laser speckle method. Blood flow of subchondral bone in the femoral condyles of ten rabbits was measured simultaneously by this system and by the hydrogen washout method. Analysis of regression showed that blood flow measured by the lasr speckle method and by the hydrogen washout method was significantly correlated (r=0.777, p=0.0001). The results showed that subchondral bone blood flow could be measured through the articular cartilage by the laser speckle method. The laser speckle method is a non-contact, simple and rapid technique for evaluation of bone blood flow. It is confirmed that this method is useful for the detection of necrotic areas during the surgery for osteonecrosis of the femoral head.
Fractal is mathematical theory advocated by Mandelbrot in 1985. He made it possible to analyze complicated patterns using the fractal dimension, that is, the index of complexity of a certain pattern. This study investigated the fractal dimension of trabecular pattern and the difference in fractal dimension between normal and osteoporotic cancellous bone. Normal rats and osteoporotic talcum model rats were compared. Fractal dimension in the proximal portion of the tibia of both groups was evaluated using the box counting method. Results showed that there are significant characteristics of fractal in trabecular bone and the fractal dimension of normal and osteoporotic bone was 1.76 and 1.59, respectively. The difference in fractal dimension between normal bone and osteoporotic bone means that not only bone loss but also change in trabecular pattern occurs in osteoporosis. Fractal analysis will provide a new tool for image diagnosis and enable us to evaluate the complexity of patterns quantitatively.
We developed a new computerized program for analyzing strain distribution of the intervertebral discs, and used it to clarify the mechanism underlying progressin of ossification of posterior longitudinal ligaments (OPLL). Biomechanical analysis was performed in 101 patients who had OPLL by putting their dynamic lateral X-ray films of the cervical spine into a microcomputer. The progression of OPLL was investigated after a minimum 5 years follow up. Correlation between progression of OPLL and the concentration of strain of intervertebral discs existed in 79% of patients with continuous type OPLL, 78% with mixed type, 65% with segmental type. Biomechanical factors play an important role in progression of OPLL.
In order to clarify the relationship between mechanical stress and hypertrophy of the yellow ligament, thickness of the ligament in the unstable lumber spine was compared with that in the stable lumber spine. Furthermore collagen ratio and histological findings were obsereved in those two groups. In the unstable group, the ligament was obviously thicker and the collagen ratio was higher than that in the stable group. Fibrocartilaginous cells increased at the enthesis in the unstable group. Therefore mechanical stress seemed to make the ligament hypertrophic. Some authors report that hypertrophy of the ligament is a precursor of ossification, but our study did not prove this.
We investigated the clinical results and progression of ossification in 113 patients with cervical OPLL. For analysis, patients were divided into two groups dependent on type of management those who recuved conservative treatment (natural history group: N-group), and the other group which recuved surgical treatment (Op-group). N-group consisted of 43 patients with a mean age of 58 years, and the Op-group of 70 patients who underwent expansive laminoplasty using sagittal splitting of the spinous process (Kurokawa method) had a mean age of 59 years. The mean follow-up period was 6 years and 2 months in N-group, and 2 years and 11 months in Op-group. In N-gruop, improvement of subjective symptoms was found in 26 patients (66.5%). However, improvement was found in only 21% of the patients with myelopathy. In Op-group, a recovery rate of 50% or more by JOA score was achieved in 38 patients (54.3%). Progressive OPLL was seen in 18 patients (41.9%) of N-group, and in 24 patients (34.3%) of Op-group. There was no significant difference in clinical results between those patients still having progressive OPLL and those patients with no progression.
We evaluated the operative results in 32 cases with ossification of the yellow ligament (OYL) in the thoracic spine using JOA score and Hirabayashi's method. All patients had had laminectomy at least a year previously. Preoperative average JOA score was 4.3 points, postoperative average JOA score was 8.0 points with an average improvement rate of 61.8%. We devised four types of classification according to neurological symptoms, namely spastic spinal paralysis, flaccid paralysis, combined type and normal reflex type depending on the variety of deep tendon reflexes of the lower extremities. We then discussed the causative mechanisms such as various types of paralysis originating at the thoracolumbar junction. In addition, we referred to the surgical indications for OYL by analysing the operative results.
We reviewed 57 patients who were operated on for degenerative lumbar canal stenosis and evaluated them clinically and radiographically. The surgical method was decompressive wide laminectomy with posterolateral fusion (28 patients) and without posterolateral fusion (29 patients). The mean age of patients at operation was 53 years in the cases with fusion and was 59 years in the cases without fusion. They were followed up for an age of 103 months. The average postoperative JOA score of patients with fusion was 15.5 points and that without fusion was 15.5 points. There was no statistical significance of JOA score between with the groups and without fusion. Acquired spondylolysis was found in 5 patients in the group without fusion, but there were no cases of acquired spondylolysis in patients with fusion. The width of decompression in 5 patients with spondylolysis was greater than that in patients without spondylolysis. We suggest that posterolateral fusion is a useful method for preventing postoperative instability in patients with excessive bony decompression.
We studied the solidity of PLF after surgery in 67 patients using Roentgenographs, CT, 3D-CT, and MRI findings. We found that CT using 2mm slices was the best method for determining solidity of PLF. MRI (T1. T2 weighted images) was not so useful, because its sensitivity was low and width of slice was limited to 7mm.
We studied the clinical results of 86 patients who were followed up for more than three years after percutaneous discectomy for lumbar disc herniation. They consisted of 61 males and 25 females aged 13-66 years (mean, 35.9 years). Results were evaluated according to the questionnaire based on JOA score and Macnab's criteria. Treatment was considered to have been effective when the evaluation was “excellent” or “good”. In this study, percutaneous discectomy was effective in 55 patients (64.0%). A salvage operation was added to 13 patients who were resistant to percutaneous discectomy.
Before surgery, we performed MRI on 20 patients who had multiple level herniated nucleus pulposus, compared with 54 patients who had single level herniated nucleus pulposus. The single level group was deviled into two groups, one of multiple and the other of single protruded disc which was seen by MRI. The multiple level group had multiple neurological signs, and the same incidences of protruded and degenerated lmber vertebral discs seen on MRI as the multiple protruded group. In particular, there were high incidences of protruded and degenerated discs seen on MRI on upper and lower level of the operated discs. For that reason, the multiple protruded discs seen on MRI maybe related with congenital factors. For diagnosis of multiple protruded discs seen on MRI, we carefully examined neurological signs, and the effect of nerve root infiltration.
During the past 5 years, we have operated on 10 patients with lateral lumbar disc herniation. Of these, 5 were male and 5 were female ranging in age from 42-62 years (mean; 52 years). The level of hernition was L3/4 in 1, L4/5 in 3, L5/S in 6 cases. All patients complained of severe pain in the lower extremities. Axial views of MRI, CT and selective root block were useful for accurate diagnosis of place of lateral herniation. Facetectomy and removal of disc herniation were performed in all cases, but posterolateral fusion was not added. Problems of instability in the lumbar spine did not occur. Excellent results were achieved in all cases.