We reviewed 19 patients with cervical myelopathy treated with anterior decompression and fusion. Etiology of cervical myelopathy was cervical disc herniation (CDH) in 13 patients and cervical spondylosis (CSM) in 6. Clinical recovery rate (%) was calculated from preoperative cervical myelopathy score (JOA) and the score at follow-up. Correlation between the clinical recovery rate and MRI findings (area and flatness at the narrowest part of the spinal cord), age at surgery, duration of myelopathy and pre-operative clinical score were analyzed separately in the CDH and CSM groups. Clinical recovery rate averaged 69% in the CDH group and 75% in the CSM group. In the CDH group, average clinical recovery rate in patients younger than 60 years was 80 and in patients over 60 years was 60. There was a significant negative correlation between the clinical recovery rate and age at surgery (p<0.05). No significant correlation was found between the clinical recovery rate and other factors investigated.
Herniation of cervical discs often reveals radiculopathy which can usually be cured with conservative therapy. On the other hand, surgical treatment will be required for aggravating myelopathy when conservative therapy has been unsuccessful. We reviewed cases with herniation of a cervical disc and myelopathy who required surgical treatment. We performed 172 cases of cervical anterior spinal fusion from 1988 to 1993 including 41 cases (28 males and 13 females) of cervical disc hernia with myelopathy. We excluded cases caused by trauma, and of the 35 cases in the study, 32 gained excellent or good results with a good improving JOA score rate of 86%. Considering the relationship between preoperative factors and the improving JOA score rate, elderly patients gained less improvement, and patients with only a short duration of the disorder gained more improvement.
Cervical spondylosis with muscle atrophy in the shoulder girdle is called cervical spondylotic amyotrophy. Pathophysiology in this condition is not well resolved. Muscle action potential after stimulation of the cortex by magnetic stimulation (MEP) in biceps brachii and T-response muscle action potential after tapping of biceps tendon were recorded in 10 patients who presented with deltoid and biceps paresis. Latency difference between the affected and unaffected side were also measured. Latency differences were more evident in T-response compared to MEP. The results showed that pathological lesions in cervical spondylotic amyotrophy are not localized to the anterior root but also found in the spinal cord or posterior root.
T-reflex waves were carefully researched in the lower limbs but not in the upper limbs. We recorded T-reflex waves of biceps and triceps brachii muscles from 14 normal subjects and 18 patients whose symptoms were mainly radiculopathy of the cervical nerve, and individually compared (through measurements) the lateral differentials of latency and amplitude. Based upon the examination of the normal subjects, we defined pathological T-waves as those with lateral differential of latency ≥1.5ms and lateral differential of amplitude ≥50%. Among the patients, pathological latency was found in 11 individuals (61% of total) and pathological amplitude in 12 individuals (67% of total). Pathological T-wave response was found in 14 patients (88% of total). From our study the correlation of the T-reflex wave of the biceps to C5 and C6 function and the correlation of the T-reflex wave of the triceps to C7 function were reconfirmed. Through cervical radiculopathy, it was shown that there is a high rate of occurrence of the pathological tendon reflex. T-reflex waves can measure the tendon reflexes objectively and are useful in the diagnosis of cervical root lesions.
Upper cervical lesions were investigated with three-dimensional computed tomography (3D-CT) in 12 patients with rheumatoid arthritis. MRI findings are very useful for evaluating soft tissues, but are less useful than 3D-CT imaging for assessing cervical bone lesions. Although 3D-CT imaging is far superior to other methods in the resolution of lateral atlantoaxial joints, it is necessary for clear imaging to estimate appropriately the threshold, especially the lower limit.
We reviewed the radiographic evaluation of patients with OPLL, especially in the thoracic spine. Subjects included 398 patients with OPLL (278 male, 120 female who ranged in age from 29 to 90 years (mean 59 years). Sixty nine of 398 patients had thoracic OPLL (29 male, 40 female). Thoracic OPLL was observed radiographically in 33.3% of all female patients in contrast to 10.4% of all male patients. In the cervical spine, the male to female ratio was 3:1, but the ratio was reversed in the thoracic spine. We think this difference in ratio results from hereditary factors and in our latest study, we postulate that thoracic OPLL may be different from cervical OPLL.
A follow-up study was done on occipito-cervical fusion using a recto-angular rod in eight children. Three subjects had congenital dysplasia of the odontoid, three had sustained atlanto-axial dislocation due to Down's syndrome, and two suffered from atlanto-axial rotatory fixation. The mean age of patients at the time of surgery was 8 years 4 months, and mean follow-up period was 5 years 6 months. In all children, symptoms remarkably improved after the operation. Cervical lordosis was slightly progressive, but no problems were seen in activities of daily living. We believe that occipito-cervical fusion using a recto-angular rod is useful even in children.
We evaluated changes in cervical alignment after laminoplasty using biomechanical method. Twenty-four patients with cervical ossification of the posterior longitudinal ligament were analyzed. The postoperative “A” value was useful for estimating postoperative malalignment. The frequency of decrease in the “A” value was less in OPLL than in CSM.
We investigated tha potential relationships between clinical results, radiological changes and local symptoms in 70 patients with cervical myelopathy who underwent expansive laminoplasty, since 1985. These 70 patients included 44 males and 26 females, with an average age of 63 years. The operative results were evaluated according to their JOA score, and their local symptoms of neck and shoulder pain, after a mean follow-up period of 3 years (range from 1 to 8 years). The cervical sagittal-plane motion was measured on a flexion-extension radiogram. Local symptoms were seen in 20 patients (29%) after the operation. These local symptoms did not correlate with the recovery rate according to the JOA score nor to the measurements on the radiogram. However, we found that local symptoms occurred in about 50% of patients who had previously had a malalignment or an instability in their cervical spine.
Between 1992 and 1994, 24 patients with cervical spinal disorders were treated with posterior laminaplasty using an autogenous spinous process bone grafting technique. This simple and inexpensive technique was reported by Yabuki in 1984. Subjects included 18 males and 6 females with a mean age of 61.6 years (range: 31-78 years), mean follow-up was 11.4 months (range: 3-30 months). All patients obtained excellent results with enlargement of the laminae averaging 153% (range: 138%-174%).
Since 1982 We have operated on 142 cases of cervical myelopathy using Hattori's method of cervical laminoplasty. This operation was performed on 14 patients with kyphotic deformity and minstability (segmental instability and olisthetic instability). This pater evaluates the patients with these instabilities.
We report on 5 cases treated by posterior arthrodesis of the cervical spine using a plate fixed with screws to the lateral masses. Of 3 patients with cervical spine injuries, all had solid fusion. These cases had injuries of the spinous processes, laminaes, and facets. This technique is particularly advantageous in these conditions. Of 2 patients with cervical myelopathy associated with athetoid cerebral palsy who had carvical laminoplasty and posterior arthrodesis, all had solid fusion and achieved good chinical results. All cases maintained good cervical alignment. There were no neurologic or vascular complications.
We evaluated anatomical variations of the tibia measuring two indices. The first index was the difference between the central line of the tibial shaft and the center of the proximal tibia. The second index was the difference between the tibial tubercle rotational angle and the malleolar line angle relative to the most posterior edge of teh medial and lateral femoral condyle. In total knee arthropalsty, variations may affect the rotational and/or varus/valgus position of the tibial component, especially when the proximal tibia is cut with a posterior slope. It is recommended that the operative technique be modified according to the variation of the tibial configuration.
Total knee arthroplasty is indicated for the treatment of osteoarthritis. The number of operated cases is increasing, and we report our experience with failed total knee prostheses. We had 9 failed total knee joints, of which 3 were Porous coated anatomic (PCA) type, 2 were Miller-Galante (MG) type. 3 were unicompartmental (UKA), and 1 was the Kinematic type. Failure included patellar subluxation, patellar fracture, and tibial subsidence with loosening in the PCA prostheses; instability and patellar subluxation with metallosis in the MG prostheses; loosening and dislodgement of the component in UKA and deep infection in a Kinematic prosthesis. Some failures after TKA might result from inappropriate component designs and/or inadequate surgical techniques.
Steroid arthropathy is a difficult problem to treat because of significant instability due to bone defects and ligamentous laxity. Long-term results of total knee arthroplasty (TKA) for treating steroid arthropathy of three knee joints with supplementation of medial tibial condyle defects is reported. Two knees were replaced by a kinematic stabilizer prosthesis (semiconstrained type), one with supplementation by bone cement and the other by bone graft. Another knee needed a kinematic rotating hinge prosthesis (constrained type) because of instability even after supplementation using bone cement. The mean age at surgery was 74 years and follow-up averaged 8 years 7 months. Knee function score according to the “Three Universities Scoring System” averaged 51 points (range 39-58) before surgery which improved to 87 points (range 80-92) at follow-up. Satisfactory surgical results for steroid arthropathy of the knee joint can be obtained using a semiconstrained type TKA with a thick tibial component following the supplementation of the bone defect. In cases with an unstable knee joint even after supplementation, a constrained type TKA could provide satisfactory long term results.
We evaluated 38 porous-coated anatomic total knee arthroplasties in 32 patients with osteoarthritis, performed from 1985 to 1992. Anterior subsidence shown by radiographic assessment of tibial components occurred in 14 knees (36.8%), all of which were arthroplasties without cement. Anterior subsidence occurred significantly more frequently in groups in which the tibial component crossed at an almost vertical angle of 87°-90° with the tibial shaft axis in the lateral view, and also in those subjects whose bone mineral density of the distal radius (1/6 site) was low. There was a tendency for the tibial component to be covered incompletely with the anterior cortical bone of the proximal tibia.
We reviewed 6 patients who were treated by unicompartmental knee arthroplasty (UKA) for osteonecrosis of the femoral condyle. Age of patients at surgery ranged from 57 to 78 years (mean: 69.5 years), and all cases were female. Clinical evaluation was carried out for a mean follow-up period of 24 months. Pain on walking and pain on ascending and descending stairs was remarkably improved. Loss of the flexion angle of the knee was minimal. UKA has a definite effect on relieving pain, and also has the advantages of maintaining the range of motion of the knee, and requiring only a short period for postoperative rehabilitation. We believe that UKA is useful for treating osteonecrosis of the femoral condyle in elderly patients.
We performed 199 total knee arthroplasties (TKA) in 149 patients with rheumatoid arthritis and osteoarthritis from 1982 to 1994. From 1982 we used kinematic or mark 2 prostheses for TKA, KOM or KC-1 (ceramic type) from 1984, PCA from 1985, MG-1 from 1986 and PFC since 1992. We shidied 8 revision TKA (4%) performed in 8 patients with failed knees. The mean interval from initial to revision TKA was 5.8 years (range; 4.5 to 9.3 years). The most common reasons for failure were tibial component sinking due to technical failure, tibial component sinking due to bone weakness with RA, breakage of metal back patella component (MG-1) and loosening due to arthritis mutilans. When we used cementless porous coating total knee arthroplasty, more and more bone source was lost revision.
Out of 670 total knee arthroplasties performed at our institution until 1993, eighteen were followed by revision. The major reasons for revision were loosening, dislocation, and infection. Eight of the eighteen knees were revised using a kinematic rotating hinge. Results using this prosthesis were good following revision. We examined the causes of dislocation which occurred in 6 cases and there were 3 cases with post operative infection following the revision surgery at our institution.
We performed revision surgery following total knee arthroplasty complicated by patellar component failure in 6 knees (4 cases). The best surgical approach was the tibial tubercle osteotomy. It was very difficult to remove the patellar plate from the bone due to strong bone ingrowth and the airtome was very useful for removing the patellar plate. Total knee arthroplasty with patellar component failure always has some femoral component wear making it necessary to revise not only the patellar component but also the femoral component.
Resection arthroplasty was done as a salvage procedure in four cases of infected total knee replacements. All patients were women. Two patients had multiarticular rheumatoid arthritis and two had osteoarthritis. The patients were followed for an average of three years and ten months (range, six months to six years). Knee function was evaluated using the JOA (Japanese Orthopaedic Association) knee score. The mean JOA score for RA knees was 56 and 58 points in OA knees. All patients could walk with one or two canes. Three patients could walk without pain, and two of them did not need a brace. However the remaining pain-free patient and a patient who experienced pain while walking needed both canes and a brace. We concluded that resection arthroplasty was an efficient salvage procedure for treating infected total knee replacements in patients who were not suitable for re-implantation.
High tibial osteotomy (HTO) is a common surgical procedure used to correct axial malalignment and the pathomechanics of the knee. Among 40 knees 35 cases treated by HTO between 1991 and 1993 had pre- and postoperative measurements performed. The purpose of this study was to determine the factors which are related to the results achieved following HTO. Postoperative results are excellent, but there is a tendency for those with a large correction angle (over fifteen degrees) to worsen leading to varus and valgus deformities. The following changes in FTA factors should be measured (1) FTA of the preoperative supine position, (2) correction angle, (3) FTA of postoperative standing position.
An accelerometric technique was performed on 21 osteoarthritic (OA) and 21 normal knees to analyze the lateral thrust (sideways movemant of the knee in the early stance phase) for the purpose of evaluating the influence of changes in the foot angle upon gait. The lateral thrust was measured under the following conditions 1) usual walking; 2) toe-in gait; 3) toe-out gait; 4) tip-toe gait; 5) heel gait. Both in the OA and normal groups, the lateral thrust was significantly decreased during toe-ingait and tip-toe gait and it was in creased during the toe-out and heel gaits. OA patients were recommended to walk using the toe-in gait to avoid knee pain produced in the early stance phase.
The outcome of arthrodesis of the knee was evaluated, including investigation of postoperative problems in activities of daily living (ADL). Eight knees in eight patients were treated by arthrodesis with external fixation. All patients achieved solid fusion, at an average of 4.7 months after surgery. Fusions were aligned in 12.1±6.5 degrees of flexion and in 5.4±2.1 degrees of valgus angulation. The average shortening in all eight patients was 3.2 centimeters. Analysis of ADL revealed a high percentage of patients who had difficulty using the toilet or bathing themselves postoperatively. In all patients, however, pain was relieved completely and the fused knee provided adequate support to the loads imposed. All arthrodesed knees were completely functional and all patients were highly satisfied with the results of the operation.
Spontaneous haemarthrosis of the knee joint is rare. We report the case of a sixty-three year old woman with recurrent bleeding into her right knee with no apparent cause. On sixth May, arthroscopy and synovectomy were performed. The bleeding seemed to settle, but ten days after the first operation, spontaneous haemarthrosis again appeared while lying on the bed. At the same time, her blood pressure was 240/130mmHg. On the twenty fifth of May, we perfomed open synovectomy and resected osteophytes of the patella and the femoral condyles. Six months post-operatively she has no recurrence of bleeding into her right knee and has no pain. It has been suggested that hypertension has a great influence upon spontaneous haemarthrosis. It is also important to resect synovial lesions accurately as part of the surgical treatment of this disorder.
We performed 3 revision cases following reconstruction of the anterior cruciate ligament with a Dacron prosthesis. One patient had only used a dacron prosthesis, while the other cases used both a dacron prosthesis and iliotibial band. All cases required revision due to reinfury whici occurred over a months after surgery. Revisions were very difficult a little and post-operatively one has instability and the other two have good stability and enjoy sports. We consider anterior cruciate ligament reconstruction using one-third of patellar ingament a very useful procedure.
We studied changes in patellar ligament length after reconstruction of the anterior cruciate ligament using either the middle of the patellar ligment as an autogenous graft or a Dacron prosthesis wrapped into the ilio-tibial tract. The mean change in length in the ligament graft group was 1.9%; in the Dacron group it was 1.5%. The change in length was no significanat in both groups. There was shortening of 7% or more in these groups.
A rare case of a hand injury caused by breakage of a the rmometer is reported. A 39-year-old female injured her right hand and mercury entered into her hand from the palmar side. The sublimis tendon of her ring finger and median nerve were partially cut by the head of the thermomrter, and mercury balls entered into her Capitatum. We tried to remove the mercury with suction, but were unable to remove all of it. X-rays taken at follow-up revealed that the amount of was decreasing. Medical symptoms due to the mercury did not appear and there was no increase in her blood mercury concentration.
We experienced a relatively rare case of rupture of the flexor pollicis tendon resulting from an nonunited scaphoid fracture. A seventy-two year old man suddenly lost the ability to flex the interphalangeal joint of his right thumb while he was writing. On examination, there was no active flexion of the interphalangeal joint of his right thumb. No neurological deficits could be found. Roentgenograms revealed an old scaphoid nonunion. We recognized the rupture of his flexor pollicis longus tendon in the preoperative MRI and echograhy. It can be suggested that MRI and echogram investigations are valuable for distinguishing between rupture of the flexor pollicis longus tendon and an incomplete type of anterior interosseous nerve palsy.
The authors report three cases of suprascapular nerve entrapment occurring as the nerve passed around the lateral border of the spine of the scapula. The cardinal finding included shoulder pain, weakness and wasting of the infraspinal muscle, as well as a positive electromyogram showing fibrillation, polyphasic potential, giant spike, and delayed distal latency. Ultrasonography was a very useful diagnostic test in cases caused by ganglion. All cases were operated on. Ganglion were extirpated in 2 cases and the inferior transverse scapular ligament was excised in the other case. The shoulder pain disappeared postoperatively and at follow-up external rotation strength of the affected shoulder had almost returned to normal.
Five patients with axillary nerve injuries and four patients with suprascapular nerve entrapment were treated. Diagnosis was confirmed by physical examination and electromyographic studies. As an ancillary test, myelography of the cervical spine and arthrography and MRI of the shoulder joint were performed. Two patients with isolated axillary nerve injuries, in whom the nerve was in continuity, were treated by neurolysis. Three patients with axillary and suprascapular nerve injuries required nerve grafts. One patient operated upon up to one year two months after trauma required trapezius and latissimus dorsi transfer. In three patients with suprascapular nerve entrapment, we performed a release of the transverse scapular ligament and spinoglenoid notch resection. One patient with suprascapular nerve entrapment due to spinoglenoid notch ganglion was treated by removal of the ganglion. All patients achieved good results.
Adjunctive internal neurolysis of the median nerve followed by release of the transverse carpal ligament is widely performed for treating carpal tunnel syndrome. However, the efficacy of internal neurolysis is still controversial. In this series, eleven hands in eleven patients had internal neurolysis of the median nerve and carpal tunnel release, twelve hands in eleven patients had standard ligament release alone. Thenar muscle strength and bulk were recorded in all hands. Median nerve function was evaluated using the two-point discrimination test and electromyography. Preoperatively, all hands had severe thenar muscle atrophy with no motor response to stimulation. Analysing the postoperative data, the majority of hands in both groups achieved satisfactory results and there was no significant difference between the results of the two groups. Results of this study indicate that standard surgical release of the transverse carpal ligament is equally effective in patients with severe carpal tunnel syndrome. Therefore, it can be suggested that internal neurolysis is not necessary in the treatment of carpal tunnel syndrome.
Carpal Tunnel Syndrome caused by a calcified mass has rarely been described. We report a 51 year-old female, with carpal tunnel syndrome caused by a calcified mass in the carpal tunnel. Terminal latency of her median nerve was delayed to 10.9ms. Plain X-ray films revealed a calcified mass not only on the floor of the carpal tunnel but also in both shoulders. Laboratory results were within normal limits. Carpal tunnel decompression was done and a nodular white mass attached to the capitate and moderate synovitis were seen. Histological section revealed a calcified deposit surrounded by fibrous tissue and nonspecific, chronic inflammatory synovitis. Although X-ray analysis could not been done to identify the content of the calcified mass, radiological and histological findings were compatible with calcific periarthritis caused by basic calcium phosphate. After surgery, the patient had immediate relief of symptoms. 1 year after surgery, atrophy of abductor pollicis brevis is recovering and terminal latency has recovered to 5.1ms.
Median and ulnar sensory nerve conduction velocities and amplitudes were measured orthodromically on the ring finger in 10 normal hands and in 64 hands with numbness (31 hands with carpal tunnel syndrome (CTS), 16 hands with cubital tunnel syndrome (CubTS), 8 hands with paresthesia due to cervical spondylosis (CS) and 9 hands with diabetic neuropathy (DN)). Of 31 hands with CTS, 13 hands had slow conduction velocities (35.6±7.3m/s) and 18 hands had no sensory nerve action potential (SNAP) in the median nerve. Of 16 hands with CubTS, 12 hands had no SNAP and 4 had normal ulnar nerve conduction velocities. Nine hands with DN had low amplitudes and slow conduction velocities in both nerves. Eight hands with CS had normal SNAPs in both nerves. We concluded that measurement of SNAP of the ring finger is easy and useful for diagnosing numbness in hands.
We report four cases of entrapment neuropathy of the lateral dorsal cutaneuos nerve that were operated on. The cardinal findings included pain and dysesthesia along the lateral border of the foot and tenderness at the entrapment point. Infiltration of a local anesthetic at the entrapment point is both a very useful diagnostic test and treatment. Conservative treatment was unsuccessful in all cases and neurolysis was performed. The lateral dorsal cutaneuos nerve was released and covered with a pedicle fat flap. The postoperative course was uneventful in three cases, who became completely symptom-free. In the other patient pain returned one year after the operation and resection of the nerve was performed. After the second operation the patient was completely symptom-free.
We evaluated the operative results in 8 cases with delayed paraparesis resulting from osteoporotic vertebral fractures. Two cases were treated by anterior decompression and fusion, six were treated by posterior decompression and fusion with instrumentation. All cases were evaluated using the JOA score, walking ability and radiologic findings regarding postoperative progression of kyphosis, bone union and instrument failure. All cases showed neurologic recovery, but the progression of kyphosis after surgery could not be prevented. The pathogenesis of neurologic deficits was via compression of neural tissue due to retropulsion of the posterior part of the collapsed vertebral body into the spinal canal and the increasingly-unstable kyphosis. In cases with neurologic deficits due to increasingly-unstable kyphosis and in patients who are in a worse clinical condition, we should also consider the posterior Surgical approach.
During the past 7 years, we have surgically treated 3 patients with upper thoracic spinal lesions using the anterior approach. 2 of these cases had the sternum-splitting approach, one for C7-T3 anterior decompression and interbody fusion due to spinal caries, the other for T2-T3 fusion for disc herniation. The last case had the transpleural approach for T3-T6 fusion to treat spinal caries. Regarding sternal splitting, we were able to achieve a satisfactory operating field by only cutting the manubrium.
Some patients with ossification of the yellow ligament of the thoracic spine (OYL) have been reported as achieving poor results following surgery. We investigated the factors affecting postoperative prognosis of OYL in our cases. Since 1984, ten patients with OYL have been operated in our hospital. Nine were available for follow-up. Four were male and five were female. The age at operation ranged from 34 to 77 years (mean age 58.4 years). Average symptomatic period prior to surgery was 22 months. The JOA score improved from a mean of 4.6 pre-operatively to 7.6 after surgery. Patients who were either elderly or had a long period of symptoms tended to achieve poorer results after surgery. Severe stenosis on CT (or CTM) and combined OPLL of cervical or thoracic spine seemed to influence their prognosis to some degree.
Since 1978, chemonucleolysis and percutaneous discectomy have been employed for treating dise herniation, with their efficacy recognized for some types of herniation. Recently, a new method of intradiscal vaporization using laser irradiation has been developed. We report our investigation into the experimental efficacy of this new method, particularly with respect to its effect on intradiscal pressure. We measured the effects both radiographically and histologically on intradiscal ablation in rabbits, and obtained successful ablation of the nucleus pulposus with a decrease in the intradiscal pressure. However, excess laser irradiation also caused ablation in the annulus, with carbonization, but with no adverse effects seen on the disc periphery or canal.
During the period from 1989 to 1993 we operated on 16 cases of upper lumbar disc herniation involving the intervertebral discs at L1/2, L2/3 and L3/4. Mean age (46.3 years) of patients operated on for upper lumbar disc herniations is higher than that of other patients (36.8 years) operated on for lower lumbar disc herniations. Diagnosis was difficult with few characteristic signs and features. Myelography was a helpful method of localizing herniated upper lumbar discs. The lumbar root block and discographic exploration were the most helpful methods.
We investigated the clinical results of continuous epidural block for 40 patients with lumbar disc herniations from 1989 to 1993 in our hospital. This block was effective for 17 patients, but not for the other 23. The result showed a definite correlation between horizontal position and the form of disc herniation. This treatment achieved good results for central herniation but terded to be ineffective for treating partial herniation near the intervertebral foramen or protruded herniation.
Eighteen patients ranging in age between 28-67 years (mean, 44.8) underwent surgery for herniated intervertebral disk of the lumbar spine extruded to the posterior epidural space from 1977 to 1994. Twelve patients could not walk because of their leg pain, numbness and muscle weakness. Half of the patients had urine incontinence. The levels of the herniated discs were L2/3 in two patients, L3/4 in five patients, L4/5 in six patients and L5/S1 in five patients. 39% were above the L3/4 levels. Severe patients were operated on within eight days. In most of the patients, large fragments extruded to the posterior epidural space and in four patients fragments extruded below the nerve root of S1. Follow-up ranged from 6 months to 12 years. All of the patients except two showed good results. One patient took a long time from the onset of pain and numbness to the operation, and another patient suffered severe paralysis.
Thirty-seven patients (32 men and 16 women) who received decompressive surgery extending to the foraminal region between December 1989 and December 1993 were studied. The average age at the time of operation was 63 years, and the average postoperative follow-up period was 20 months, with 22 patients (60%) being followed for over one year. On preoperative investigation, latefal displacement and nerve block as determined by selective radiculograhy (SRG) as well as a marked reduction or absence of perineural fat tissue in the intervertebral foraminal region on MRI, were considered abnormal. In general en block laminectomy (laminoplasty) was performed for nevrve root canal decompression. Fifty nerve root canal decompressive procedures were performed, since nine patients required surgery at two or more sites. The operative findings included 37 cases of osteophyte and or disc protrusion and six cases of ala-transverse impingement. Postoperatively, 35 patients (94%) were either pain-free or had slight residual pain in the lower extremities. In patients with lower extremity pain due to degenerative lumbar disease, it is important to detect abnormalities of the interforamina on MRI and SRG. En block laminectomy (laminoplasty) is an effective procedure because it does not result in structural failure and it allows adequate observation of the nerve root pathway.
We evaluated the lumbar spinal alignment of patients treated by fenestration for lumbar canal stenosis. Twenty-three patients were analyzed using computerized program. Alignment value (A value) is the index of the degree of malalignment. Abnormal A values were found in 10 patients preoperatively. The relationship between A values and surgical outcome was evaluated. Operative results were poor in 9 of 10 patients with abnormal A values. We believe that it is important to estimate spinal alignment when treating patients with lumbar canal stenosis.
The function of disordered lumbosacral nerve roots in cases of transitional vertebrae was studied from the viewpoint of neurological findings. There were 25 cases who had a single neve root disorder. The level of the transitional vertebrae (T. V.) was calculated from the cephalic side, which were classified into 2 groups; (1) S Type (lumbar number 4+T. V.), (2) L Type (lumbar number 5+T. V.). The function of the transitional nerve roots were S type in 10 cases and L type in 15 cases In addition there were a lot of mixed nerve root disordered cases which were composed of both L5 and S1 factors. Moreover in the L type, the function of the transitional nerve roots was influenced by the shape of the transverse process and the level of the iliac crest. From these results, it was suggested that the function of the nerve roots was influenced by the shape of the bone.
This study investigated the features of lumbo-sacral transitional vertebrae (LSTV) in younger patients. 50 teenagers were examined and compared with 237 patients from all generations (ISTV group). In addition 408 patients with low back pain who visited our clinic (LBP group) were reviewed. Patients with ISTV were selected who had Type II (articular type) and Type III (fusion type) of posterior elements according to our classification system and type 1-3 for anterior elements. The frequency of LSTV in the LBP group was higher in younger patients. Spondylolysis and spondylolisthesis were almost the same frequency in the 3 groups. Posterior slip had the highest frequency in the younger group (64%), followed by the ISTV group (50%), and 23% in the LBP group. ISTV was seen in younger groups more frequently than in other age groups. In conclusion, patients with ISTV were frequently seen in the teenage age group.
Neurogenic bladder is one of the most important neurological symptoms associated with lumbar spinal disease. However it is difficult to evaluate it objectively. We reviewed thirty patients who had various lumbar spinal diseases using a urodynamic study. Sixteen patients (53.3%) had urinary symptoms, all of which were of an obstructive nature, such as difficulty of urination, urinary retention and a sense of residual urine, except for one patient who complained of pollakisuria. The existence of urinary symptoms did not always agree with abnormalities in the urodynamic study which was very useful for investigating true complications of neurogenic bladder in lumbar spinal disease. Urodynamic study should be selected in lumbar spinal desease to objectively evaluate urinary function because the patients subjective complaints of urinary symptoms can be vague.
Twenty-two patients with spinal disorders who were treated by instrumentation surgery were reviewed. In this series, there were fracture dislocations in 7 cases, spinal canal stenosis in 6 cases, herniated intervertebral disks in 4 cases, spondylolisthesis in 4 cases and spondylolysis with spondylolisthesis in 1 case. The type of instrumentation systems were Hokudai system (10 cases), Harrington (3 cases), Dick (8 cases) and Diapason (2 cases). Clinical and radiographic evaluation were carried out in these patients, with a mean follow-up of two years and four months (range 1-4 years) . The JOA score of the fifteen patients without a fracture dislocation improved from 12.6 to 22.6 points. Five patients with fracture dislocations had marked deformity and the angulation of the inferior surface of the vertebral body of the upper vertebra and that of the lower vertebra of the affected vertebrae improved from 25.3° to 11.4°. Fifteen patients underwent removal of the instruments and all achieved bone fusion. Instrumentation failures were noticed in four patients using the Hokudai system, one of whom had revision surgery using Harrington instrumentation. Considering reduction, the Dick system was the most effective. However, due to the size of the instrument and the anatomical shape of the spine four patients complained of back pain in the lordotic potion of their vertebral column. In cases with osteoporosis, care should be taken during pedicular screw insertion to avoid fracture of the vertebral arch.
A new internal fixation system, the Simmons plating system, for immobilization of the spine has been devised, which is composed of bolts (or screws), washers and plates. The authors have used the system for fixation of the lumbar or thoracolumbar spine in 154 operative procedures performed over 30 months (December 1991-June 1994). Patients were followed clinically and radiographically over 2-30 months. Fusion was achieved in 93.6% of cases with few complications noted. There were only two semirigid fixation failures. Results from this study show that the Simmons plating system is a desirable addition for internal fixation of the spine. Furthermore, the system offers the surgeon many advantages in ease and simplicity of insertion as well as safety and confidence in fixation performance and capability.
We used cannulated screws to fix spinal laminae when performing osteoplastic laminectomy or segmental fixation for surgical treatment of lumbar spinal diseases. We report our experience using these screws in 15 patients. The screws are 3.5mm in diameter and made of titanium. Kirschner wires are used as guide wires before inserting the screws. It is possible to insert this screw more safely and with greater accuracy than what has been available up to this time. Because they are made of titanium it is also possible to follow the post-operative course with MRI. Althaugh in the preliminary stages we believe that this method offers many potential advantages.