37 knee joints of 37 patients suspected as having cruciate ligamentous or meniscal tears were evaluated with magnetic resonance imaging (MRI) and arthroscopy. For ACL tears, sensitivity of MRI compared with arthroscopy was 100%, specificity was 92% and accuracy was 94.6%. For PCL tears, the results were 100%, 100%, and 100% respechvely. For medial meniscus tears, 87.5%, 93.1% and 91.9%. For lateral meniscus, 85.7%, 100% and 97.3%. Almost all results were satisfactory but a few cases had false positive and false negative findings on MRI. The cause of diagnostic pitfalls using MRI were MRI artifactsunder or over reading by radiologist, and inability to visualize with arthroscopy.
We studied the accuracy of magnetic resonance imaging (MRI) of the knee in fifty-six patients who were also examined arthroscopically. The accuracy, sensitivity, and specificity were 96%, 100%, and 95% for medial meniscal tears, and 91%, 67%, and 100% for lateral meniscal tears respectively. Two MRIs of the medial meniscus were false-positives. These MRI findings were both meniscocapsular separation of the medial meniscus, but the arthroscopic findings were normal. One case was an ACL injury and the other PCL and MCL injury. Hemorrhage and edema of the medial capsule caused by valgus stress at injury may look like a meniscal pseudo-tear on MRI. Five MRIs of the lateral meniscus were false-negatives. All menisci showed normal signal and shape on MRI but traumatic and stable tears of the lateral meniscus were identified arthroscopically. All were associated with ACL tears and lateral condylar bone bruise. The traumatic and stable tear of the meniscus tended to be overlooked on MRI because a meniscus without degeneration shows a normal signal.
We evaluated the effectiveness of magnetic resonance imaging in 7 cases with Legg-Calvé-Perthes disease by comparing the MRI findings with radiograms taken within 6 months. It was not easy to predict the extent of necrosis of the femoral head by evaluating the initial magnetic resonance imaging. However, we found that it was possible to know the reparative stage earlier by using MRI compared to radiograms.
During past 7 years from 1988 to 1994, microsurgical replantations have been performed for 37 complete finger tip amputations in 34 patients. These fingers were classified according to Allen's criteria (type III-15, type IV-22). 5 of the 37 fingers resulted in failure, six fingers had partial necrosis, however the remaining 26 had no necrosis. Survival rate was 100% in clean cut amputation, 90% in blunt amputation, 60% in crush amputation and 50% in avulsion amputation. Postoperative results were evaluated in 25 fingers of 22 patients with a follow-up period more than 1 year. The paresthesia of the finger tip was present in 9 finger tips and cold intolerance was present in 8 finger tips. The average static 2 point discrimination test was 5.8mm, renging from 2-10mm. Nail deformity was seen in 3 finger tips and mallet deformity in 3 fingers. 8 finger tips had mild atrophy. Functional results by Tamai's criteria vudged 21 patients to be excellent and 1 patient good. Almost all patients wete satisfied with the results. From this study, we concluded that replantation with microvascular anastomosis is the first choice for finger tip amputation.
We have heated 31 patients with intraarticular fractures of the distal radius in a ten year penod. Fractures were classified according to Saito's classification. Gartland's criterion was employed for the clinical evaluation; Sakagami's criterion for morphological evaluation, and Knirk's criterion for evaluation of the remaining displacement of the articular surface. In general, clinical results were excellent or good in those reduced by open reduction and fixed internally. Morphological evaluation and the remaining displacement of the articular surface interfers with the clinical results. Osteoarthritic changes were observed in 75% of the patients with remaining displacement more than 2mm. Therefore permissible displacement was supposed to be within 2mm. In simple intraarticular fractures, clinical results in the conservatively treated group were similar to those in operatively treated group. However, in the comminuted intraarticular fractures, clinical results were distinctively successful in the group reduced by open reduction and fixed internally compared to other groups. Especially in the dorsal split depression or central depression fractures, reductions of the depressed fragment were insufficient with external fixation only. Although correct reduction is extremely difficult, open reduction with anatomical restoration of the articular surface and fixation is important in this type of fracture.
We treated 16 patients (10 men and 6 women) with intra-articular fractures of the distal radius by intrafocal pinning which was reported by Kapandji at 1976. The age at surgery range from 17 to 77 years, mean 41.3 years. There were 12 communited Colles fractures, 2 volar Barton fractures, and 2 comminuted Smith fractures. Follow-up ranged from 2 to 33 months with a mean of 12.3 months. The roentgenographic changes of radial inclination, palmar tilt, ulnar variance, and step-off were measured just after pinning and at final follow-up. Roentgenographic results and clinical results were evaluated using Saito's criteria. Radial inclination averaged 24.6° after reduction and 22.6° at follow-up. Palmar tilt averaged 8.3° after reduction, changing to 9.0° at follow-up. Mean ulnar variance was 0.6mm and mean step-off was 2mm. These values did not change after reduction and at follow-up. Those values were within acceptable range after Saito's criteria. Clinical results were excellent in 7, good in 9. None showed fair or poor results. Intrafocal pinning has only been indicated for extra-articular fractures and intra-articular fractures with moderate dorsal comminution. Our surgical results justify our expanded indication for other comminuted fractures of the distal radius. We think that intrafocal pinning is the method of choice for extra-and intra-articular fractures of the distal radius.
We report on our treatment with percutaneous pinning in 40 cases of supracondylar fractures of the humerus in children, between 1989 and 1994. In our hospital, percutaneous pinning techniques have become the treatment of choice for displaced supracondylar fractures. There are no grave complications, and in most cases, there is adequate reduction and a good range of elbow motion. It is necessary to have primary adequate fixation and good alignment to prevent a cubitus varus deformity.
Cubitus varus deformity after supracondylar fracture in children is caused by varus angulation and internal rotation of the distal fragment. An ultrasonographic measurement has been reported as a method of measuring the rotational deformity of the humerus. Yamamoto measured the rotation angle of the glenohumeral joint to clarify the rotational deformity of the distal fragment (Yamamoto's method). This paper presents a comparison of the ultrasonographic measurement and Yamamoto's method. Twenty-five patients with supracondylar fractures were examined for rotational deformity of the humerus using both methods. They were followed for an average of 8 years (2-13 years). The ultrasonographically measured angle of the sound side subtracted from the affected side (HT') was on average 6.9±8.8°, and that of Yamamoto's method (IR') -1.4±16.9°. If HT' and IR' both measured the rotational deformity of the distal fragment, then both angles should be the same. However, there was a distinct difference between them, as IR' was affected by limitation of internal rotation of the glenohumeral joint. From this study, when we recommend that when evaluating rotational deformity of the distal fragment by Yamamoto's method, it is important to remember that IR' is affected by glenohumeral movement.
The relationship between clinical results and electrophysical parameters of 23 hands (22 patients) were examined. There were seven men and 15 women. The average age of the patients was 56.9 years (range: 32 to 72 years). The average length of followup was one year and five months (range: 4 months to 3 years and 7 months). Distal motor latency (DML), amplitude of compound muscle action potential of Abductor pollicis brevis (CMAPa), distal sensory latency (DSL) and amplitude of sensory nerve action potential (SNAPa) were examined as the electrophysical parameters. CMAPa and SNAPa seem to be reasonable markers to evaluate the postoperative recovery of the median nerve.
Distal latency and sensory conduction velocity were measured in 23 patients (30 hands) with carpal tunnel syndrome before and after transverse carpal ligament release under endoscopic two portal teschnique. The average age of subjects was 53.3 years. The distal latency of median nerve was 6.32±1.90 msec preoperatively and 5.33±1.38 msec after surgery. The sensory conduction velocity was 36.1±6.8m/sec in the preoperatively and 39.0±6.7m/sec postoperatvely. A complication of this endoscopic release of the transverse ligament was seen in only one case with rupture of a superficial palmer arch.
Thirty three patients with cubital tunnel syndrome were evaluated pre and post operatively. They were followed up for an average period of 85 months, andthe mean age at surgery was 51 years (range: 6-75 years). The causes of disease were osteoarthritis in 17, cubitus valgus in 9, ganglion in 2, and other causes in 5. Pre and post operative status was evaluated according to our criteria which included MCV of ulnar nerve, hypesthesia of 4th and 5th fingers, muscle atrophy of first dorsal interossei muscle, muscle strength of abductor digiti minimi and deformity of fingers with a total score of 16 points indicating absenceof palsy. The average score was 9.7±2.9 before surgery and 12.7±2.9 at follow-up. The average preoperative MCV was 26.3±17.2m/s which improved to 34.7±16.6m/s at follow-up. There were significant relationships between before and aftersurgery in both resulfs. Age at surgery, the duration from onset to operationand preoperative status influenced the operative result. The duration of follow-up did not have and effect on the final outcome.
We conducted a critical review of the use of autologous transfusions in elective hip surgery at Fukuoka University School of Medicine. There were 37 cases who deposited blood before operation on an outpatient basis. Four-hundred milliliters of blood were collected at each donation and the amount of autologous blood donated was two or three units in all cases. Four patients had some difficulty donating autologous blood preoperatively. Although these patients actually fainted and needed medical attention, none of the symptoms were serious. Seven patients developed gastritis because of ferrous citrate administered orally and recovered uneventfully. Autologous blood transfusion eliminated the risks of blood-transmissible infections and avoids sensitization to redblood-cell, white-blood-cell, and platelet antigens in donor blood. It is generally considered to be the safest type of transfusion and can be done safely on an outpatient-basis.
We report the radiation exposure dose received by the anesthesiologist and nurse in the orthopaedic operating room, when a fluoroscopic image intensifier is in use. This study was done in 12 femoral neck fracture operations performed from January to May 1995. Radiation was monitored with the MYDOSE MINIX PDM 107 made by Aloka Co. which were attached in front and behind the nurse's lead apron, in front of the lead apron of the anesthesiologist. The average imaging time was 9.78min. The average radiation dose in front of the anesthesiologist is lead apron was 2.08μ SV, and in front and behind the nurse's lead apron were 5.67μ SV, 0.08μ SV respectively. This study and review of the literature indicate that the operating room anesthesiologist and nurse receive a lower exposure than the orthopaedist. We can disregard the problem of radiation exposure to the anesthesiologist and nurse during an orthopaedic operation when they wear lead aprons and stand far from the patient.
We observed the healing process of ruptured Achilles tendons in a series using magnetic resonance imaging. In six cases, tendons were repaired percutaneously with limited skin incisions. Seven cases were treated conservatively using unique functional braces. MR imaging revealed two different modes of conjoining. In the conservatively treated group, tendons inclined to conjoin in a dumbbell shape. In the surgically treated group, they inclined to conjoin in a spindle shape. The diameters of the ruptured part are wider in the spindle shapecompared to the dumbbell shape at all stages. These findings suggest that surgkal treatment is favorable for acquiring earlier strength.
We surgically treated 15 tibial condylar fractures from 1991 to 1995. Fractures were classified into undisplaced type (1 case), central depression type (2), split depression type (5), total depression type (4), split type (1), comminuted type (2) as defined by Hohl. We only used the cancellous screw in all cases and bone grafting was necessary in 5 cases. Clinical results were evaluated according to Hohl & Luck's score. Anatomic results were excellent in 12 cases and good in 3. Functional results were excellent in 8 cases, good in 6 and fair in 1. When we performed this operation screw fixation was less invasive than plate fixation and made early rehabilitation possible. This fixation achieved sahsfactory results.
We reviewed 26 cases of tibial pilon fractures treated operativery in the last 12 years. Twenty-four cases achieved good or excellent results and two cases had fair clinical results. As the grade of fractures became higher, clinical results tended to worsen alond with the reduction shown on the X-ray. However, range of motion post-operatively was not related to the grade of fracture. We concluded that firm internal fixation and early exercise allow acquisition of a satisfactory range of motion in the ankle joint.
Dislocation of metatarsophalangeal (MTP) joint is infrequent. We present a case of an old dorsal dislocation of the fourth MTP joint. At surgery the capsule of the MTP joint and lateral collateral ligament were elongated and attenuated and the medial collateral ligament disappeared. The plantar plate did not interpose into the MTP joint. The medial collateral ligament was reconstructedusing the plantar interosseous muscle. The lateral collateral ligament and the dorsal capsule were tightened. The MTP joint was fixated with a Kirschner wire. After 6 months' follow up, the MTP joint was stable and painless and had good movement.
We reviewed nine cases of hallux valgus that were treated using the Hammond procedure. We used the cannulated Herbert bone screw (Herbert screw) for internal fixation at the osteotomy site of the first metatarsal bone. In our experience, using the Herbert screw is superior for rigid fixation, providing an easy and exact surgical technique. Clinical results were excellent in all cases with the M1M2 angle corrected exactly. In some cases, the Hallux valgus angle was increased at follow up compared with immediately after surgery and correction of the sesamoid deviation was slightly incomplete. We believe this is due to a technical issue in the treatment of the medial soft tissue of the metatarsophalangeal joint.
Dislocation of both ends of the clavicle is a rare injury. We experienceda case of bipolar clavicular dislocation in a 42-year-old man with a floating clavicle who required surgical treatment. Ten months postoperatively, the patient reported a good recovery, with no complaints of pain or subjective difference in range of motion and strength between the normal and injured shoulder. His only complaint concerned a mild deformity-a small anterior bulge of the clavicle at the sternoclavicular joint.
Complete dislocation of the acromioclavicular joint should be treated surgically. We have used the modified Weaver's procedure to reduce dislocation of the acromioclavicular joint since 1992. In this procedure, the acromioclavicular joint is reduced and fixed by two Kirshner wires and then the coracoacromial ligament is transferred to the clavicle. We operated on 13 cases of complete dislocation of the acromioclavicular joint using this procedure. The time of follow up ranged from 5 months to 43 months with an average of 22.6 months. Cases were 12 males and 1 female, and ages ranged from 25 to 66 years with a mean of 47.2 years. Eight cases were on the right side and five on the left. Postoperative results were evaluated according to Kawabe's scores. Eight cases were excellent, one was good, one was fair and three were poor. The fair and poor results were caused by persistence of pain and easy fatiguability.
There are several methods for treatment of acromioclavicular luxation and distal clavicular fracture. We report our experience using the Wolter Clavicular Plates for these injuries. Subjects included six patients; 4 luxations and 2 fractures. After using this plate, all of these patients reported good results with no complaint such as pain and limitation of ROM. We concluded that wolter clavicular plates are useful for treatment of acromioclavicular luxation and distal clavicular fracture.
Nine cases with displaced fractures of the distal end of the clavicle (Neer type II) and six cases with acromioclavicular separation (Tossy grade III) were treated using the Wolter plate. All cases had good reduction and bone union. In addition, all cases except one had an almost full range of motion at the shoulder joint. The Wolter plate provided stable fixation which allowed an early range of motion of the shoulder joint without impairing the acromiocravicular joint.
We report a rare case of a 4-part dislocation fracture of the bilateral proximal end of the humerus. A-58-year-old man with a history of alcohol abuse had a grand mal seizure, resulting in such a fracture. A hemiarthroplasty was performed with satisfactory results. Cases with these fractures are very rare with only one other case reported in the previous literature.
We experienced a rare case of stiff shoulder with traumatic neuroma. The patient was a 52 year old male who presented complaining of pain and motion disturbance in his shoulder joint. In May 1994 he fell down the stairs hitting the upper side of his right shoulder and developed a bruise and shoulder pain. When he came to our hospital, active flexion of his shoulder was 95 degrees and active abduction was 80 degrees. Arthrogram and MRI did not show a rotator cuff tear, except for a contrast finding on the arthrography. 50% of his shoulder pain was relieved by injection into the glenohumeral joint, subacromial bursa and acromio-clavicular joint with local anesthetic. In March 1995 arthroscopic surgery which released the coraco-acromial ligament and the joint capsule was performed. However, post-operatively, his shoulder discomfort continued and he could not tolerate the rehabilitation program. One month after his first surgery, the local anesthetic test was repeated. His pain was not relieved by injection into the joint capsule and the subacromial bursa. The injected agent flowed out from the acromio-clavicular joint. In 1995 surgery was performed and a traumatic neuroma recognized outside of the clavicle. After resection of the neuroma, his shoulder discomfort significantly improved and it was possible for him to perform the rehabilitation program.
A case of unilateral idiopathic accessory nerve palsy is described. A 45-year-old woman sought medical help in July 1994 because of dysphagia and hoarseness, and was diagnosed as having recurrent nerve paralysis. Several days later she developed severe pain in the left side of her neck and shoulder. Despite the pain subsiding over several days, she noticed increasing difficulty in elevating her left arm. Physical examination two months following the onset of the illness showed obvious atrophy of the trapezius muscle and mild atrophy of the sternocleidomastoid muscle on the left side. She was unable to abduct her arm above the horizontal position. Electrophysiological evaluations demonstrated slowing of the accessory nerve conduction and evidence of denervation of the trapezius muscle. Hematological evaluations showed slightly increasing white blood cells and herpes simplex viral titer. The remainder of the examinations were normal. On the basis of the above findings, it was possible to diagnose Schmidt syndrome due to idiopathic accessory nerve palsy. A trial of conservative treatment for a year produced a significant improvement. This syndrome should be considered in the differential diagnosis of shoulder gridle weakness and impairment.
We report neuropathic arthropathy of the shoulder joint caused by syringomyelia and discuss the method of diagnosis and treatment. Three patients were treated and their ages were 41, 52 and 55 years respectively. In case No 1, there was swelling and the rapid destruction of the shoulder joint. Synovectomy was performed, however the ROM decreased markedly. Six months later, a shoulder joint replacement was carried out and a temporaly improvement of ROM was noticed. However it became worse gradually again and after ten years later she can abduct her arm only 40 degrees. In case No. 2, the synovectomy was performed, but the destruction of the joint progressed rapidly and the joint was dislocated anteriorly 6 months later. At present she has poor abduction of 60 degrees. In case No. 3, osteosynthesis was carried out for the humeral shaft fracture 5 years ago, however non-union and neuropathic arthropathy of the shoulder joint were diagnosed 3 years. later. Present ab-duction angle is 30 degrees. All these three cases had characteristics of massive swelling, rapid and progressive destruction of humeral head with slight pain. So far in Japan, 36 cases out of 42 cases of neuropathic arthropathy of the shoulder joint was caused by syringomyelia. However, the results of these cases were not satisfactory, even after performing synovectomy, prosthesis or arthrodesis because almost all the syringomyelia cases are slow and progressive and leads to the destruction of the joint.
In cases of rotator cuff tear, the scapulo-humeral rhythm is usually disturbed, however, the patient is able to elevate the arm to a certain extent. This paper presents an analysis of the scapulo-humeral rhythm and clarifies the function of the cuff during elevation. Five unilateral cuff tear patients with an average age of 55 years were examined on both sides. The sizes of cuff rupture ranged from 12mm to 40mm which were confirmed at surgery. To analyze the rhythm, two roentgenograms were taken with a distance of 1 and 2 meters between the X-ray source and the film. The three landmarks of the scapula were determined and the tilting angles of the scapula in three dimensions were considered to be the medially tilting angle, downward tilting angle and upward rotation angle and they were calculated. The patient was asked to elevate both arms in the scapular plane in front of the roentgenofluoscopy (field diameter: 31cm). The movements were recorded on a video recorder and then analyzed by micro-computer. The medial tilting angle remained almost constant at about 35 degrees during elevation, and the downward tilting angle inclined posteriorly as elevation progressed but these angles were not markedly different from those of the sound side. However, the upward rotation angle was different from that of sound side. In a patient who could elevate the arm only 30 degrees, there was only upward rotational movement of the scapula but no gleno-humeral motion. The other four patients could elevate the arm above 100 degrees, but the upward rotational movement of the scapula took the major role in the elevation compared to the sound side. These results suggest that the cuff function in stabilizing the head on the glenoid cavity is disturbed during elevation in patients with cuff tear.
Since 1967, we have carried out the modified Bristow procedure for treating 110 patients with anterior shoulder dislocation. We focused on patients older than 40 years and investigated the pathology and clinical results in these patients. Clinical records and examination results were available in 10 patients, aged from 40 to 66 years. We found Bankart lesion in 7 patients, Hill-Sachs lesion in 9 and rotator cuff tear in 4. 7 patients were interviewed and examined by the authors. The follow-up period ranged from 5 months to 17 years and one month, with a mean of five years and ten months. The average JOA score was 90.1 points. Rowe's criteria was excellent in 5 patients, good in one and poor in one. From the above mentioned results it can be suggested that, recurrent anterior shoulder dislocation after age forty may be associated with Bankart lesion and Hill-Sachs lesion at the same rate as for younger patients. In addition there is a moderate incidence of this lesion being complicated with a rotator cuff tear.
Imaging of the Bankart lesion for the patients with reccurent dislocation of the shoulder is useful for making the pre-operative planning. We compared CT arthrography (CTA) with MR arthrography (MRA), and investigated the usefulness of CTA and MRA for the diagnosis. 6 patients (6 shoulders) with reccurent anterior dislocation of the shoulder were evaluated with CTA and MRA. There were 5 males and one female, their age ranged from 17 to 40 years (average age 28 years at the time of operation). CT was taken after injecting 20ml of air in the joint space. MRA was done with itraarticular injection of 20ml of Gd-DTPA and T1 images were taken in transverse and oblique sagittal plane. All of them underwent arthroscopy follwed by modified Bristow's operation. The findings of both MRA and CTA were verified with the arthroscopic and operative findings. Absence of labrum in one case and displacement of the labrum in three cases could be seen in both CTA and MRA. In two cases there was only tear without any displcement, both these cases could be diagnosed by MRA, however, CTA missed one case. On the other hand, considering two osseous Bankart lesions, MRA could not detect one case, whereas CTA could diagnose the both. In four cases there was detachment of the anterior capsule, which could be seen in both CTA and MRA. However, MRA has an upper hand in detecting the anterior inferior glenohumeral ligament.
Traumatic anterior dislocation of the shoulder in elderly patients is not very common. Furthermore, few papers are reported which describe MRI findings associated with anterior dislocation in elderly patients. In this study, we report MRI findings of 6 patients with traumatic anterior dislocation of the shoulder whose ages were 60 years old or more. Subjects comprised one male and 5 females ranging in age from 64 to 91 years. In 4 cases, MRI was obtained at the time of initial dislocation. In 2 cases of recurrent anterior dislocation, MRI was performed 3 years postoperatively T1 weighted, T2 weighted and FE MR images were evaluated with respect to imaging of the humeral head, anterior labrum and anterior capsular insertion and rotator cuff. Hill-Sack lasions were shown in all cases. In two cases, a Bankart lesion was revealed. Rotator cuff tear was found in all but one case who had fracture of the greater tuberosity. Rotator cuff tear occurred at the supraspinatus tendinous insertion in all cases. In one case the tear expanded from the subscapularis to supraspinatus tendon. McLaughlin reported that the coincidence of rotator cuff tear and acute dislocation of the shoulder was as high as 70% in patients over 40 years. It is well known that glenoid labral detachment is common in the young generation with acute dislocation of the shoulder. In the elderly patients of our series, however, rupture of the capsule and damage at the subscapularis tendenous area were revealed by MRI.
We performed arthroscopic surgery on 10 labral tears of the shoulder resulting from baseball overhand activities. The average age of patients was 19 years and the average history of baseball activities was 8 years and 8 months. Mean follow-up period was 15 months. All patients have returned to baseball activities after the arthroscopic surgery. 9 of 10 patients had no pain in throwing a ball and 1 patient had only a small amount of pain when throwing a ball. Arthroscopic surgery is an effective treatment for patients who have shoulder pain from sports injuries. The indications for arthroscopic surgery and post operative rehabilitation are important for patients to be able to return to sports.
We investigated the effect of limaprost alfadex in fifty patients with lumbar canal stenosis. The 28 men and 22 women in this study had a mean age of 63 years. Limaprost alfadex was effective in 34 patients (68%), especially in those with numbness and cold sensation of lower extremities. Limaprost alfadex was effective in patients with lumbar canal stenosis in the early stage.
We examined the lumbar spine MRI results of 76 elderly people and assessed any nerve symptoms in 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 that there is any connection between these high rates and nerve symptons.
Sixty three patients were treated with posterior lumbar interbody fusion (PLIF) by and total facetectomy (TF) for lumbar degenerative disorders. Patients were followed clinically and radiographically over one year. Fusion was achieved in 90.6% of cases with few complications, and good clinical results were shown in most patients with low back pain and leg pain. Apart from 13 patients that were treated with both PLF and PLIF, the remaining 70% of cases were operated on using excised strut laminar bone, without grafted bone gathered from the ilium. PLIF could prevent pain caused by picked ilium bone. We believe that PLIF by TF offers spinal surgeon many advantages in surgical technique and clinical status.
Posterior lumbar interbody fusion is biomechanically a good procedure. Though recommended many years ago by Cloward, PLIF (posterior lumbar interbody fusion), was not widely used for many years. Recently, many authors have recognized PLIF as a preferred technique for lumbar stabilization. The use of this newfusion device provides immediate stabilization, preservation of discheight due to highly resistant material, and long term fusion with autogenous bone. Nine cases of posterior lumbar interbody fusion using this new fusion device were evaluated. Subjects included eight males and one female with a mean age of 49.3 years, ranging from twenty-four to seventy-four years. Diagnosis was degenerative spondylolisthesis in two cases, herniated disc disease in two, disc degeneration in three, degenerative lumbar scoliosis in two. Seven of nine cases achieved solid union, but union was delayed in three cases. If you select cases carefully, this implant is very useful because it acts as an interbody spacer with its own stabilizing capacity, without reguiring additional fixation.
We report on the short term results using the Graf flexible stabilizing system for surgery on the lumbar spine. The concept of flexible stabilizing is comparatively new in Japan. Between 1993 to 1995, 43 patients were operated on using with this method. The patients included 26 males and 17 females with a mean age of 58 years. Preoperative diagnoses were degenerative spondylolisthesis in 18 patients, lumbar disc herniation in 17 patients and lumbar spinal canal stenosis in 8 patients. Nerve decompression was performed in all cases proceeding stabilization with the Graf system. 98% of the patients were evaluated as achieving excellent or good results. Post operative X-ray films showed improvement in the functional stability of the lumbar spine but structural displacement was not corrected. In conclusion, flexible stabilization using the Graf system seems to be effective for patients with remarkable functional instability of the lumbar spine.
Recently, lumbar degenerative disease with instability or malalignment has been treated using various internal fixation systems. The Simmons plating system offers the surgeon many advantages in ease and simplicity of insertion as well as safety and confidence in fixation performance and capability. In this series, fifty-nine patients with spondylolisthesis causing instability were treated using this system. Patients were followed clinically and radiographically over 16-45 months. Fusion rate was 96.4% and only one case showed a broken screw. This study obtained acceptable clinical results in most of the patients withlow back pain and leg pain. We recommend instrumental surgery using this system for treating instability caused by spondylolisthesis. We now await long term follow-up results.
The purpose of this study is to evaluate the location and time of appearance for the clear zone around pedicle screws and to investigate the relationship between appearance time and bone union (P. L. F.). Subjects included 33 patients examined from July to Sep 1995 who were investigated radiographically. They consisted of 18 men and 15 women, ranging in age from 22-73 years with a mean of 51 years. Follow-up duration was 7 months. Evaluation of bone union was carried out according to modified Matsuzaki's criteria. Excellent or good cases achieved sucressful bone union while possible or nonunion on cases failed to achieve bone union. 8 patients had a clear zone which appeared within 6 months after surgery, mean 3.8 months. 8 patients had sacral stabilization performed and there were 3 patients with sacral clear zone. 25 patients without a clear zone were classified as successfu. 2 of 8 patients with a clear zone were classified as failure. In regard to development of the clear zone, 6 months after surgery is the important period. If a clear zone is not observed within 6 months after surgery, the possibility of successful bone union is high.
We studied the MRI findings and results of conservative treatment in 8 patients with central spinal cord injury. Function was categorised according to the classification by Usui et al., the clinical results to Nisseikai's criteria for cervical myelopathy (JOA) and the improvement rate in accordance with the Hirabayashi method. The injuries were classifed as the following types: upper limb in 5, Schneider in 1 and incomplete transverse in 2. Although MRI did not show changes in the upper limb type, it revealed spinal cord compression and intramedullary signal changes in the other patients. The presence or absence of intramedullary signal changes and the range of the area correlated with clinical results and prognosis. We believe that it is difficult to improve the symptoms and prognosis is unfavorable in patients in whom MRI reveals strong intramedullary changes.
Pressure ulcers are one of the most serious complications for the spinal cord injury patient. One hundred and eighty one patients with spinal cord injuries (96 patients with cervical injury and 85 with thoracic and lumbar injury) received a range of medical treatments in our hospital duning a 7 years period. This study evaluated the treatment results, the relationship between severity of the pressure ulcer and the level of motor paralysis, the interval of pressure ulcer and the mean time sitting each day. The results were as follows. The total pressure ulcer morbidity rate was 58.6% (106/181), cervical spinal cord injury was 46.9% (45/96), thoracic and lumbar spinal cord injury was 71.8% (61/85). High morbidity in terms of the region of pressure ulcers was observed in long term patients with cervical cord injuries. There was no clear correlation between the sitting time and the morbidity rate of the pressure ulcer. We concluded that self-management is the best method of preventing pressure ulcers in patients with spinal cord injuries.
A-fifty-four year old man was admitted to our hospital on June 12, 1986. He was unable to walk and had 96 degrees of kyphosis. He had suffered from tuberculosis of the spine when he was nine years old. From that time he had had no complaints although retained a level of kyphosis. Forty years later he had weakness in the lower limbs and eventually became unable to walk. Surgery for anterior debridement and spinal fusion with strut bone grafts was carried out with Halo-Pelvic traction, and followed by treatment with INH, RF, SM, EB. He was able to walk again and worked regularly after discharge. Eight years later the spine remained fused and the degree of kyphosis was 83°. Anterior decompression and fusion with strut bone grafts is a good treatment for Pott's Palsy with severe kyphosis.
We reviewed the surgical results of 18 patients suffering from thoracic myelopathy caused by ossification of the yellow ligament (OYL) and investigated the factors affecting postoperative results. The percentage of clinical recovery, which was calculated from the JOA score before and after surgery, averaged 54.9%. Factors investigated were age at surgery, delay of surgery after onset of symptoms, JOA score before surgery and percentage of narrowing of spinal canal calculated from CT myelography. Correlation between percentage of clinical recovery and these factors were analyzed. There was a significant negative correlation between the percentage of clinical recovery and delay of surgery. No significant correlation was found between the other factors. Therefore, we recommend early diagnosis and early surgery without delay.
We surgically treated 20 cases of thoracic myelopathy caused by ossification of the yellow ligament (OYL) and combined OPLL. Subjects included 10 males and 10 females. The duration between the occurrence of symptoms and time of surgery ranged from 1 month to 2 years (average 8.3 months). The average age at surgery was 58 years. All patients had had laminectomy. We found difficulty in some cases in performing decompression of the ossified spinal lesions.
We have operated on 5 patients with thoracic disc herniation since 1988. Patients included 3 males and 2 females with a mean age of 58.8 years. All patients presented with onset of numbness and muscle weakness of lower limbs, and progression of myelopathy progressed. Of these patients, 4 were operated on with anterior spinal fusion and 1 with posterior decompression. The clinical results was excellent in 3 patients and good in 2 patients.
The purpose of this experimental study was to investigate the effects of spinal external fixation in scoliosis. Four ribs on the right side of growing rabbits were partially resected. Four to 6 weeks later, moderate right-convex thoracic scoliosis had developed. Then, in Group I, an Orthofix mini-model or fixano fixator was attached by Kischner wires to T9/10 and to L1/2. In Group II, percutaneous discectomy (PD) was performed at T12/L1 followed by external fixation. In both groups, the mean initial correction was 11 degrees (44%). The initial effect of spinal external fixation for scoliosis was due to correction in the axial rotation at the apical vertebra rather than to the traction force. The fixators were removed after 17 weeks of age. In Group I, relatively good prevention of progression was seen compared to controls. However, moderate or severe progression in scoliosis was seen after removal of the fixator, due to theloss of correction at T12/L1 in some cases. In Group II, severe progression inscoliosis was not seen after removal of the fixator, due to ankylosis at T12/L1.
Primary spinal glioblastoma is very rare. This document describes a case of a 44-year-old female who had a history of gait disturbance and low back pain at first admission. Though myelography, metorizamide CT, and MRI showed an intramedullary mass, the expansion of the mass was not identified. Laminectomy and dural decompression were performed at the level of Th1 to Th12, and a necrotic and invasive intramedullary tumor was found. The histological examination revealed glioblastome multiforma. The patient died 2 months after surgery due to respiratory arrest. The course was extraordinarily rapid.
We report a 22-year-old woman with features of schwannomatosis. She had been operated on for a cervical tumor when she was twelve years old and for two cutaneous tumors in the medial lower leg when fifteen years old. Pathological findings of both tumors were that of neurinoma. Since then, she had been followed in our hospital. Her mother died when she was thirty four yeas old and her cousin was operated on for multiple spinal tumors pathologically diagnosed as neurinoma. The patient visited our hospital complaining of lumbago in January 1992. MRI of the lumbal spine showed multiple extradural tumors and she was operated on in October 1992. The pathological finding was neurinoma. Two weeks after surgery, she developed spastic paralysis and 4 months later involuntary movement in both of her legs appeared. In July 1994, MRI showed a tumor in the cervical cord and the cerebellopontine angle, but there was no indication for neurosurgery. The patient died in July 1995.
A rare case of thoracic intradural extramedullary tumor with an apoplectic onset is reported. A 37-year-old female complained of sudden backache. The patient was treated surgically after which she showed improvement in symptoms.