Cubitus varus deformity is a common complication after supracondylar fracture of the humerus. The reason of this complication is thought to be due to the varus and internal rotation of the distal fragment. The varus position of the distal fragment can be controlled, but not by X-ray examination, and the internal rotation by ultrasonographical examination of the humeral torsion. However it has been reported that humeral torsion changes with age. Consequently we measured the humeral torsion using ultrasonography to investigate the changes in the humeral torsion with age as well as laterality. 103 males and 98 females, aged between 2 to 18 with a mean age of 10.7 years, were investigated. The results show that humeral torsion increases with age, and there exists no significant difference in laterality and gender in humeral torsion. These results are considered useful for the treatment humeral shaft fracture and the correction of internal rotational deformity after supracondylar fracture of the humerus by measuring the contra lateral side.
The incidence of neurovascular complication after the fracture of the clavicle is very low. We experienced a case of delayed neurovascular complication about 3 months after the fracture of the clavicle. The patient was a 45-year-old man who fell down and was injured while riding a motorcycle. Initially, he showed no symptoms in his upper extremity, and was treated with a clavicle brace. Later, numbness and muscle weakness appeared in the segmental area from C5 to Th1 of the upper extremity. Osteotomy, autologous bone graft, and internal fixation by plate led to good results, and the symptoms gradually disappeared. The patients has returned to his profession as a carpenter.
Fracture of the Capitulum humeri is rare, and opinions on the preferred surgical management of this injury differ. We studied 12 patients who underwent surgical treatment for fractures with a mean follow-up of 3 years (7 months to 10 years 3 months). In 11 cases, open reduction and internal fixation were performed, while in 1 case, the fracture fragment was removed. Kirschner wire and soft wire are used in our method for open reduction. Open reduction is stable and produces the best results, especially when performed immediately after the trauma. Early open reduction is thus recommended as the treatment for fracture of the capitulum humeri.
Numerous problems are encounterd in the surgical treatment of communuted fractures of the radial head. We reviewed 12 patients to determine the surgical treatment. Both radial head excision and complex fracture-dislocations around the elbow did not yield satisfactory results, suggesting that these cases need to be treated surgically with Judet floating prosthesis, and complex injuries require immediate surgical treatment.
We treated 2 cases of posterior dislocation of the elbow joint accompanied with the fracture of the cronoid process by internal fixation. After the operation, no signs of instability and ROM limitation of the elbow joint were seen. Treatment by internal fixation is considered necessary for the next two cases, as reduction by manipulation is not possible in one, and the reduced region cannot be kept at the 90 degrees flexion of the elbow joint in the other.
Between 1986 and 1997, 28 forearm open fractures were treated at the Tamana Central Hospital. The fracture type was classified according to Gustilo et al.: 2 type I, 14 type II, 6 type III-A, 3 type III-B, and 3 type III-C fractures. All fractures were treated surgically within 6 hours. Immediate internal fixation was performed for 17 fractures, and 8 fractures were treated with delayed fixation. The rate of infection in this series was 7.1%. All fractures showed bony union eventually. One type II patient and 1 type III-C had delayed union, and bone graft and replating were added for these patients. The fracture of the type I and type II cases, healed in an average of 90 days, and that of type III, in an average of 162 days. Patients were clinically evaluated according to a rating system based on fracture union and pronation-supination of the forearm (Grace and Eversmann). Ninety-two per cent (11) of the type II fractures showed excellent or good results and 1 poor. Sixty per cent (6) of the type III fractures showed excellent or good results and 5 fractures acceptable or poor. Patients, except type III-C fractures, had good functional results.
The simultaneous occurrence of ipsilateral humerus and forearm fractures is common. During a 16 year period, we prospectively studies 22 children with fractures of the humerus and forearm. They consisted of 17 males and 5 females with an average age of 8.1 years (range; 1 to 14). Clinical and radiographical results were acceptable in 21 children, fair in, and poor in 2. The poor cases were cubitus varus deformity treated with rubber traction and external immobilization.
We reviewed 3 cases with humeral shaft fracture treated with TRUE FLEX. All 3 cases were female, with a mean age of 50 years at the time of surgery. According to AO classification, the cases were a 12-A3 fracture, a 12-B2 fracture (delayed union), and a 12-C1 fracture. All were closed fractures. None showed neurological nor vascular complications. ROM exercise began 1 week after postoperative fixation. All the cases achieved good bone union. 2 out of the 3 cases showed no limitation of motion in the shoulder and elbow joints, while the third case had limitation of motion in the shoulder joint, possibly due to insufficient insertion of the rod cap. In conclusion, TRUE FLEX which achieves bone union without the use of interlocking screws, is an effective device for the fixation of fractures.
This paper investigated the recent trends in the incidence of distal radius and proximal humerus fractures in Tottori Prefecture. Between 1992 and 1995, a survey was conducted on all distal radius and proximal humerus fractures treated at all hospitals and clinics in Tottori Prefecture. Among patients 35 years old and above, the survey found 1015 distal radius and 307 proximal humerus fractures during the observation period. The mean age-and gender-specific incidences were compared by chi-square test with data collected between 1986 and 1988 when we performed the same survey in Tottori Prefecture. The incidence of distal radius fractures in women increased significantly between 1986 to 1988 and 1992 to 1995 (P<0.01), while that of proximal humerus fractures increased significantly in both genders (P<0.01).
Intrafocal pinning first described by Kapandji was originally indicated for extra-articular fractures of the distal radius in young patients. We Modified the procedure for application to elderly patients. Three Kirschner wires were inserted through small incisions. The dorsal intramedullary pin was inserted first through the fourth dorsal compartment. The radial pin was then inserted between the first and second dorsal compartments. Finally the palmar pin was inserted from the radial side of the radial artery. The ends of the Kirschner wires were bent and impacted to the cortex to avoid skin irritation. We observed 27 (16 original procedures and 11 modified procedures) patients aged over 65. The number of patients within the normal range of the palmar tilt (0 to 22 degrees) was 7 for the original procedure and 10 for the modified procedure. That within the normal range of the radial inclination (16 to 22 degrees) was 7 and 11 respectively. 11 patients were evaluated by the Saito's demerit point system. There were 1 excellent and 5 good for the original procedure and 5 excellent for the modified procedure. The number of patients with complications caused by the Kirschner wires was 8 for the original procedure and 1 for the modified procedure. The results suggest modified intrafocal pinning method maintains better reduction and reduces complications by the Kirschner wires.
We treated 23 fractures of the distal end of radius with the dynamic external fixator. 4 patients were over 65 years old and 19 were below 65. The average immobilization period was 27 days (range; 12 to 46 days). The average follow-up period was 19.5 months (range; 3 to 62 months). Postoperative results were evaluated using Saito's criteria, correlation between the postoperative results and age at injury, immobilization period, and follow-up period was then investigated. 11 cases were excellent, 11 cases were good, and 1 was fair. Only the immobilization period showed a significant correlation with the postoperative results. Lesser displacement was found for the addition of percutaneous pinning. From the above results, it can be concluded that early exercise and percutaneous pinning are important in the treatment of the fracture of the distal end of the radius with the dynamic external fixator.
We studied functional changes after surgery of unstable distal radial fractures and clarified the factors affecting early functional recovery in this retrospective study of 29 patients. 29 patients, 8 males and 21 females with a mean age of 60 years (range: 16 to 86 years), were available for evaluation. The patients were divided into several groups according to age, side (dominant or nondominant), maintenance of reduction, method of surgery, and immobilization period after surgery. For 6 months after beginning the rehabilitation program, each patient's flexion-extension of the wrist, forearm rotation, and grip strength were recorded every month and the functional recovery was compared in each group. Forearm rotation was normally recovered in 1 month and flexion-extension of the wrist was fully recovered in 3 months. Grip strength, however averaged 70.6±23.0% of the contralateral side. Recovery of flexion-extension of the wrist was affected by the maintenance of reduction, but recovery of forearm rotation and grip strengh was irrespective of all factors.
4 cases of humeral neck practures which we treated with the hook plate from 1995 to 1997 are reported. The patients were all female with a man age of 63.8 years. According to the Neer classification, 2 were two part, and the other 2 were three-part. All the fractures were evaluated by the JOA score of the Shoulder joint. The score of all the cases totaled 73 to 89 points (mean 82.3). The hook plate was thus cinsidered more useful than other types of plates for the fracture of the humeral neck.
We experienced a 26-year-old male who suffered from post-traumatic recurrent dislocation of the peroneal tendons over the past 3 years. The patient was injured during sports. Transposition of the peroneal tendons under the calcaneofibular ligament was chosen from the many different surgical techniques to treat the peroneal tendon dislocation. The ruptured superior peroneal retinaculum was reconstructed by rerouting of the calcaneofibular ligament to the lateral side of the peroneal tendons. The calcaneal insertion of the calcaneofibular ligament was mobilized with a small bone block and reinserted in its bed after the transposition. After the operation, the ankle joint was immobilized for 6 weeks in a short-leg plaster cast. Partial weight-bearing was allowed after 2 weeks. After 4 months post-operatively, the patient was able to resume sports. He sometimes suffered from swelling and slight pain around the lateral malleolus but was satisfied with the good results.
There are two types of porximal femoral fractures; cervical and trochanteric. The risk factors related to these types of fractures were examined. 15 women aged 66 to 99 (mean age; 81.5 years) with cervical fractures and age- and sex-matched controls aged 73 to 95 (mean age; 82.7 years) with trochanteric fractures were analyzed by the Wilcoxon signed-ranks test. Height, weight and body mass index were not considered risk factors. The bone mineral density of the neck region divided by that of the trochanteric region (NT value) was a significant risk factor. The average NT value was 1.27 for cervical fractures and 1.57 for trochanteric ones. The neck axis length (NAL) of the proximal femur was also a significant risk factor. The average NAL was 10.3cm for cervical fractures and 9.6cm for trochanteric.
Clinical examinations were performed on 16 elderly patients (over 90 years of age) who were treated surgically during the past 2 years and 9 months for femoral neck fracture. Patients aged over 90 account for 15.7% (16 cases) of the population aged over 65 (102 cases). Cardiac failure was the most frequent preoperative complication. Principal complications seen during operation were hypotention and arrythmia. 9 patients regained walking ability and 7 could move by wheelchair. Walking ability afteroperation was lower than before trauma, but no patients remained bedridden. 8 of the 13 patients who lived in their own homes befor trauma could return. But 1 patient needed to stay in a health care facility, while 4 patients had to be taken to other hospitals. Early surgical treatment and early postoperative rehabilitation are also important for preventing complications and improving the quality of life in elderly patients (over 90). We felt the need to prepare the patients to return back to their normal lives after hospitalization.
We conducted a randomised prospective comparison of the Compression Hip Screw(CHS) and gamma nail for internal fixation of 60 intertrochanteric femoral fractures in elderly patients. The gamma nail group showed shorter convalescence and earlier full weight-bearing. There were however no significant differences in the operative time, blood loss, stay in hospital' and patien's mobility at the final review. Intra-operative lateral cortex fracture and post-operative cutting cut were recorded in the gamma nail group. Use of the gamma nail is thus not recommended for these complications considering the good results of CHS.
We reviewed the radiographs of 216 trochanteric fractures treated with a compression hip screw. In 2 cases, rotational displacement of the proximal fragment with the sliding of the screw was observed within 4 weeks after surgery. Both cases were categorized into type 1, grade 4 fractures according to Evans' classification. The reduction was inadequate, and the axis of the screw was not parallel to that of the femoral neck in the lateral view of the rediograph. Using a fracture model we demonstrated the mechanism of the rotational displacement of the proximal fragment simultaneously with the sliding of the screw. When using the compression hip screw, reduction of the flexion or extension displacement and placement of the screw parallel to the femoral neck is necessary to avoid such displacements after surgery.
We treated 303 cases of peritrochanteric fractures with the gamma nail from 1992 to 1997. 11 cases showed post-operative complications requiring second-time surgical procedures. 4 cases showed the complications of cutouts, 4 fractures of the femoral shafts, 1 aseptic necrosis of the femoral head, 1 infection of the operative site, and 1 non-union. Incorrect indication of the gamma nail inadequate positioning of the lag screw were major causes of cutouts, and reaming apparently affected the fractures of the femoral shafts, since they were caused even by the slightest force on the femoral bone during walking and falling. Inserting the nail into the fracture line, which poses as an unavoidable disadvantage of the gamma nail, drawback was the cause of the diastasis of the fractures, resulting in the non-union.
We report a new surgical elderly method for femoral condylar or supracondylar fractures in elderly patients. The cases studied consisted of 4 females with an average age of 81 years (range; 67 to 92 years), 2 were Grade 1 and 2 were Grade 2 according to Singh's classification. The surgical methods consisted of cross screwing after the fixation of the intramedullary supracondylar nail. Bone union was achiered in all cases without external fixations after surgery. The results indicate that the new surgical method serve as favorable treatment for femoral condylar or supracondylar fractures in elderly patients.
A case Salter-Harris type-III fracture of the distal femoral epiphysis is reported. A 12 year-old boy was fractured during skiing. As the fractur did not reduce after the injury, initial routine X-rags were taken studied. We reduced the fracture, and immobilized it for 6 weeks using a plastic cast. The epipyseal line was obserred in X-rags for 5 months, after which the fracture healed satisfactorily.
5 children with femoral shaft fractures were treated by external fixation. Their ages at fracture were 6 to 11 yeras. The mean time until partial weight bearing was 3.2 weeks. The mean duration of admission was 5.2 weeks. All cases had bone union without malunion or limb shortening, and showed full range of motion at the knee joint. External fixation is a useful method for treating femoral shaft fractures in children from elementary school, allowing early crutch-assisted gait and early return to school.
The llizarov external fixator with a hinge is useful for treatment of joint contractures and correction of deformities. We use it in the treatment of two cases of fractures around the knee for the purpose of enabling ROM exercise using CPM. Excellent results were obtained in terms of ROM. The construction of the llizarov external fixator with a hinge is complicated and time consuming, so the frame must be preconstructed and disinfected before the operation. During the operation, the hinges should be placed at the estimated center of motion of the knee joint, about 2cm from the articular edge, at the posterior third of the femoral condyle. The actual procedures used in positioning the hinge are demonstrated in detail in this article. We hope for further development and refinement of the hinged distraction llizarov external fixator for application to other joints, specifically the elbow, wrist and ankle.
Twenty-four patients (24 knees) who underwent open reduction at our department during the past five years (14 males and 10 females; mean age 58.8 years) were enrolled in this study. The fracture types were determind according to Hohl's classification. The therapeutic results were assessed using the therapeutic result judgment criteria of Hohl and Luck and JOA score. Accordingly, the factors determine the therapeutic outcome were invenstigated. The therapeutic results of fracture types 2, 3, 4 and 5 were good or excellent by functional assessment with JOA score of over 90 for all patients. However, the therapeutic results of fracture type 6 (2 patients) were fair by functional assessment with JOA score of 75, indicating the a poor outcome of the reduction. This deterioration of the therapeutic results was attributed to the poor alignment of the lower limb owing to the complexity of type 6 fracture.
In the past 3 years from 1994 to 1997, we treated 21 patients with pychiatric disorder. 9 patients were male and 12 were female, and their mean age was 56.9 years. There were many problems which could not be managed with in the orthopedic ward. Preoperatively, all patient received intensive phychiatric medication. Minor wound infection in 3 patients and pseudoarthrosis in 1 patient were obserred. At the time of operation, the pre-operative period and pre-operative management of tranquilizers imposed various effects on the results of operations and rehabilitation. Moreover, post-operative care proved difficult as the patients did not recognize their disorders. As 3 patients were predisposed to infections and wound related complications, it suggested the importance of cooperation between the phychiatrist and orthopaedic surgeon during the pre- and post-operative periods in the orthopedic treatment of patients with psychiatric disorders.
5 patients with posterior rim acetabular fractures were treated with absorbable screws. Open reduction and internal fixation were performed on these patients due to the instability of the fracture following closed reduction. All 5 patients healed without complications and showed good results, indicating that the absorbable screws provided sufficient stability for the fixation of this type of fracture. In addition, the absorbable implants did not require removal and produced no artifacts in postoperative CT and 3-DCT images, permitting excellent analysis of the fracture aligment and union. These results indicate that the absorbable screws may be a viable alternative to metalic implants for the treatment of unstable posterior rim acetabular fractures.
We reviewed the clinical results of 17 cases that had been treated for traumatic posterior fracture-dislocation of the hip at our hospital. Of these cases, 14 were male and 3 were female, their ages ranging from 17 to 67 years (mean; 34.3 years). The follow-up period was 6 months to 5 years and 8 months (mean; 2 years and 6 months). The results of 15 of these cases were classified by the Thompson and Epstein classification. 3 were “exellent”, 11 were “good”, and only 1 was “fair”. There was no “poor” case, nor any cases with avascularnecrosis of the femoral head and osteoarthritis. The other 2 cases received prosthetic replacement of the hip due to femoral neck fracture that occured during the reduction procedure. We recommend that dislocation of the hip be reduced as soon as possible, but carefully.
We report on the usefulness and safety of thoracodrainage for patients with traumatic hemopneumothorax who had fractures of the extremities and trunk. Traffic accident was the most common cause of hemopneumothorax. 20 in 47 patients (42.6%) had multiple bone fractures, and so orthopedic operations were conducted on 23 patients (48.9%). A thoracic drain was inserted for 42 patients (89.3%) including 1 patient who underwent thoracodrainage in both lungs. The outcome of all the patients was satisfactory.
We reviewed 19 patients with tibial shaft fracture treated with ACE tibial nail from December 1992 to August 1997. There were 13 males and six females with a mean age of 36.2 years (range: 18-78 years). The average follw-up period was 19 months (range: 5 to 40 months). Bone union was achieved in all cases. Some complications were however seen breakage of distal interlocking screw: 1 case, fibula head erosion by proximal interlocking screw: 1 case, and tibial shaft fracture during removal of the nail: 1 case. The ace tibial nail proved to be a favorable apparatus, but presented some problems during removal.
We report the postoperative outcomes following the treatment of open tibial shaft fractures including Gustilo type IIIa fractures, with primary fixation using an unreamed intramedullary nail within the goledn hour. 11 fractures that were treated primarily with intramedullary nails with more than 6 months follow-up were studied. the average patient age at injury was 30.7 years (range: 14 to 55 years). There were 10 males and 1 female. The average follow-up was 9.8 months (range: 6 to 17 months). Fractures were classified as Gustilo type I: 2 cases, type II: 7 cases, type IIIa: 2 cases. AO classification showed type A: 4 cases, type B: 5 cases, and type C: 2 cases. No complications were observed in all the patients. Callus showed clearly in 10 out of 11 cases after an average of 12.6 weeks (range: 6 to 19). The remaining case showed malunion but no other clinical complications. We found that primary unreamed nailing is a safe and useful tretment for open tibial shaft fractures, as long as sufficient wound debridement is performed to prevent infection.
Fractures of the ankle are common injuries. We reviewed the results of 74 fractures of the ankle treated from 1991 to 1997. The ages of the patients ranged from 13 to 83 years with a mean age of 44 years. The fractures werw grouped into four types according to the Lauge-Hansen classification. Clinical results were good in 68 cases, fair in 6 cases, and poor in 0 cases based on the Burwells x-p classification. We compared the group with less than 1mm longitudinal displacement of the medial and lateral malleoli with the group with 1mm to 2mm displacement. It was found that longitudinal displacements less than 1mm produced good clinical results.
The purpose of this study is to show that the adequate reduction and repair of soft tissue in distal tibiofibuler syndesmosis including interosseous ligament is necessary for achieving an ankle stability following pronation-external rotation injury (PER) stage III, IV, pronation-abduction injury (PA) stage III. 19 cases of displaced bimalleolar and trimalleolar fractures of the ankle treated at our hospital were reviewed clinically. There were 14 males and 5 females with an average age of 40.8 years (range; 15 to 77 years). The average follow-up period was 6 years and 8 months (range; 1 to 11 years). PER stage III was seen in 3 cases, PER stage IV in 13 cases, and PA in 3 cases. Though all cases were treated by surgical intervention, treatment for distal tibiofibuler syndesmosis was varied by internal static fixation (I. F.), or repair of soft tissue (R. S.). Both I. F. and R. S. were performed on 5 cases, only I. F. on 8 cases, only R. S. on 3 cases, and neither I. F. nor R. S. on 3 cases. We evaluated the width of the syndesmotic space in all initial and post operation roentgenogrms using the criteria of Leed, et al., in addition to physical examination. The correlation between I. F. and R. S. was then investigated. Postoperative tibiofibuler diastasis was not significant in the R. S. group (p<0.05). Moreover, the restriction of the range of motion and pain at weight bearing was relatively low in the I. F. group.
A 37-year-old woman experienced pain in the dorsum of the right foot while running on a sports field, after which she was unable to walk on her right foot. Radiograms, computed tomography, and tomography revealed fracture and medial shift of the medial cuneiform of the right foot. 9 days after injury, we performed open reduction and fixtation with small cannulated screws. the results were excell ant; she resumed most of her activities with little pain or discomfort 28 months after the operation.
24 cases of patients over 60 years of age treated by anterior cervidal body fusion (AVBF) were clinically studied and compared with 50 casses of patients under 60 yeares of age treated by AVBF. The follow-up time was more than 1 year (15 to 71 months) and the mean age was 65.8 years. In elderly patients and young patients, the mean preoperative JOA scores were 12.6 points and 12.3 points, the post operative JOA scores were 14.7 points and 15.5 points, and the recovery rates evaluated by Hirabayasi's method were 60% and 66.2%, respectively. In the elderly patients, preoperative X-rays of the lower cervical spine showed decrease of the range of motion (ROM) due to severe degenerative spondylotic changes, and relatively percent ROM increase of the upper cervival spine major involved level was seen. These findings suggest that instability of the upper cervical spine may pose as a risk factor particularly for cervical spondylotic myelopathy in elderly patients.
13 patients were examined for cervical spondylotic myelopathy by postoperative magnetic resonance imaging. All patients were male and the operative procedure was open door laminoplasty. On the saggital scans, a low or high signal intensity lesion within the spinal cord, the distance from the posterior edge of the vertebral body to the spinal cord and spinal atrophy were investigated their relationship with the JOA score improvement rate was analyzed. On T2-weighted scans, a high signal intensity loesion was observed in 5 cases. And 2 of them had a low signal intensity lesion on T1-weigthed scans. Postoperative results of patients with T2 high signal intensity lesions were poor and their mean improvement rate was 18.4%, while those without T2 high signal intensity was 64.7%. There was a relationship between distance and improvement rate of those without T2 high signal intensity lesions. We concluted that the T2 high signal intensity lesion and the distance from the posterior edge of the vertebral body to the spinal cord carry prgnostic significance in postoperative magnetic resonance imaging.
Expansive laminoplasty can be performed to treat cervical myelopathy in the ossification of posterior longutitional ligament (OPLL) and cervical spondylotic myelopathy (CSM). Our retrospective study used 18 patients' CT films and measured spinal canal area, spinal canal distance, and the respective evaluations (used by JOA-Score). The result shows that the expansion of the spinal canal was not related to the JOA-Score, but expantion of the spinal canal area and spinal canal distance has a significant relation. The lower cervical vertebrae has a wide spinal canal by nature, and so expansion is shignt compared the other spines. This operative method involves cutting off the procesus and openning the lamina. Use of a small spacer will not provide sufficient expansion due to a small lamina angle.
We present 4 cases of cervical myelopathy caused by the calcification of the yellow ligament. All cases were female and teir average age was 62 (range: 53 to 73) years. Plain radiographs showed round-shaped calcification in the spinal canal; 2 between C5/6, Ibetween C6/7, and 1 between C3/4, C4/5, and C5/6 from the lateral view. Computed Tomography (CT) clearly showed high density tumor-like mass at the sites corres pording to the plain radiographs which compressed the spinal cord. Laminoplasty from C3 to C7 was employed for operative treatment and produced good result in all cases.
Patients with ossification of the anterior longitudinal ligament of the cervical spine rarely show clinical symptoms. The patient in this study with this disease complained of dysphagia and underwent surgical treatment. After the removal of the OALL at the C6, C7, and T1 regions. disphagia improved.
5 patients requiring posterior fusion for the fracture-dislocation of cervical spine were treated with Halifax interlaminar clamps for internal fixation. 4 patients had unilateral and another patient had bilateral facet dislocation. Fusion was at the C3-4 level in 1 case, the C4-5 level in 3, and the C6-7 level in 1. Facetectomy for reduction at the locked facet was required in 3 cases. Autogenous iliac bone grafting was performed in 1 case with bilateral facet dislocation. Satisfactory stabilization without complication was achieved in all patients. Halifax interlaminar clamps are effective for the posterior stabilization of traumatic lower cervical spinal instability.
A 60-year-old man with cervical myelopathy due to Arnold-Chiari malformation and atlanto axial dislocation (AAD) who underwent mnltiple operations was reported. 20 years ago, he had undergone laminectomy of C1 and C2.5 years after the initial surgery, posterior cerviczl spinal fusion following laminectomy of C3 and C4 were performed. However, he complained of severe neck pain and gait disturbance' and visited our hospital. On the cervical X-ray, a broken wire and AAD (ADI 8mm) were observed. MRI examination revealed compressed spinal cord due to Arnold Chiari malformation type I. Occipito-cervical fusion with rest angular rod following decompression of Foramen magnum was performed. 6 months after the surgery, improvement of neck pain and gait disurbance was seen.
We studied the surgical results of 26 cases diagnosed the spinal cord tumor. 13 cases were treated in microsurgical technique and other 13 cases were not used the microscope at the time of surgery. There were 20 cases of schwannoma, 3 cases of meningioma, 2 cases of lipoma and one case of neurofibroma. Microsurgical technique were used for 8 cases of schwannoma, 2 cases of meningioma, 2 cases of lipoma and one case of neurofibroma. We compared the surgical results of the two groups using the microscope or not. Follow up study which was done 6 months to 8 years post operatively revealed the acceptable results in both groups except the urinary dysfunction in two cases. All cases in both groups had normal daily activities at the time of follow up study. Of course, the microsurgical technique were chose to the spinal cord tumors which were severe space taking lesions to the neural tissues. But, we think that we prefer to use the microscope at the time of surgery to all spinal cord tumors as the atraumatic technique.
We have experienced 3 cases of dumb-bell tumor of the cervical spine. According to Eden's classification, there was 1 case of type 2, 1 type 3, and 1 type 4. Type 2 and type 4 cases were operated by the posterior approach. The type 3 case was operated on by both the posterior and lateral approach. Pathological diagnoses indicated pseudotumor in type 2, Schwannoma in type 3, and fibrous tissue tumor in type 4. There were no postoperative complications in all cases, but the type 3 case showed postoperative instability of the cervical spine.
A case of spinal dural arteriovenous fistula is discussed. The patient was a 52-year-old female. The symptoms were intermittent loss of muscular strength and hypoesthesia of the lower extremities. MRI findings indicated swelling of the spinal cord in the T1 weighted image, high signal intensity of the spinal cord, and flow void of the surface of the spinal cord in the T2 weighted image. The final diagnosis was made by selective spinal arterial angiography. She was treated using transcatheter arterial embolization. The swelling of the spinal cord and high intensity area seen in MR imaging disappeared after embolization. Her symptoms were found to disappear completely one year after the treatment.
We experienced a 70-year-old male case suffering L3 and L4 roots impairment due to L2/3 disc hernia, and L4 root impairment due to dumbbell tumor. He complained of severe low back pain, right femoral neuralgia, weakness, and urinary infection. MRI revealed two lesions; one was a tumor in the psoas muscle at the L3-L5 level originating from the L4 root ans the other was a downward sequestrated mass from the L3/4 disc. We operated two-stages from the anterior to posterior. The anterior tumor was histologically neurinoma and the sequestarted hernia mass impinged both the L3 and L4 roots.
We have experienced acase of extradural cyst in the thoracolumbar resion. The case was a 61 year old female suffering from urinary disturbance and palsy of the perineal area. MRI and myelogram showed a cystic lesion located at the posterior part of the spinal canal and compressing the spinal cord at the Th12 L3 levels. Intra-operative findings, indicated that the cyst communicated with the subaracnoid space. After extirpating the cyst, it is necessary to clear the communicating fissure and repair the weakend or defected dura to prevent the recurrence of the cyst. The patient fully recovered from her palsy and urinary disturbance.
A patient with mobile neurioma of the cauda equina is described in this report. This 31-year-old man was hospitalized because of low back and gluteal pain. Neurological examination failed to reveal any abnormalities. MRI scan after injection of Gd-DTPA showed an area of high signal intensity at the L2 level. Myelogram demonstrated an almost complete block with characteristics of a well circumscribed intradural extramedullary tumor. It also showed that the level of the tumor varied between L2 and L4 according to the patient's position. After induction of anesthesia and placing the patient in the prone position, myelography was repeated. This was useful for identifying the tumor location. A recapping laminoplasty of L2 was performed, the dura a was opened, and the tumor was exposed. The tumor was mobile but originated from a single elongated nerve of the cauda equina. Pathological examination revealed neurinoma.
Thoracoscopic interbody fusion of the thoracic spine was performed on patient and the results and relevant literature are discussed in this report. The case was a 38-year-old man who visited our hospital complaining of back pain. He was found to develop radiating pain to the intercostal nerve with positional changes. MRI revealed degenerative and herniated intervertebral disk at TH7/8. Operation was performed under general anesthesia at the left lateral position. Small skin incisions were made at 4 points and thoracic spinal interbody fusion was performed using a thoracoscope by lateral insertion of a threaded fusion cage. The chest drain was removed 2 days after operation and the patient started walking after 4 days with a body cast. 5 weeks after operation, the patient was allowed to wear an elastic corset. The course was uneventful with no findings of postoperative complications and back pain was alleviated. This mode of surgical technique is concidered to minimize surgical scar, reduce pain after surgery, and decrease respiratory complications as compared to thoracotomy, enabling early commencement of rehabilitation and early return to society. The technique may be used widely in the future for spinal operations.
In this report, we discuss two cases of upper thoracic myelopathy, treated successfully with anterior decompression and fusion utilizing sternum manubrium splitting approach. When considering surgical approach to lesions around the spinal canal, lesions existing in the anterior of spinal canal can basically be treated more effectively from the anterior approach. This is especially true at the thoracic level, because of physiological kyposis of the thoracic spine. Since the conventional anterior approach is difficult for the upper thoracic spine, this approach proves very useful for the treatment of intracanal lesions at the upper thoracic level localized at the anterior of the spinal canal.
We experienced a 12-year-old female exhibiting paralysis caused by the dislocation fracture of the vertebrae without obvious history of trauma. She showed dislocation between the 10th and 11th thoracic vertebrae and kyphotic deformation at 56°. Surgery was performed immediately by the posterior approach. After resection of the 10th and 11th thoracic laminae, decompression and pulsation of the dura mater were observed. The vertebral bodies were dislocated rotating around the spinal canal and continuity of the canal was retained. The spinal cord was bent in a manner escaping backwards. Posterior fusion with the Luque rod and wire was performed in the closest possible position for restoration. Paralysis started to subside from the 3rd week after the operation. 6 months later now, sensory and motor paralyses have more or less disappeared. In this case, dislocation fracture appeared to occur because of fragile bone tissues without any obvious trauma. Since the spinal cord moved backward as if to avoid injuries, paralysis was eliminated by decompression and fusion, and close observations were implemented.
We experienced 31 cases of anterior spinal reconstructive surgery using the Kanede device in the past 10 years. The cases consisted of 14 compression fractures (12 progrssive vertebral body collapses), 11 burst fractures, 2 old thoracolumbar fractutre-dislocations, 2 metastatic spinal tumors, and 2 spondylitis. Clinical and radiological investigation were conducted on the operated cases. The results showed that; 1) Evaluating by Frankel's classification, 77.8% of the cases had obtained improvment rates over 1 step According to Denis' pain score, pain relief was seen in 96.8%. The improvment rates of ambulance and urinary dysfunctions were 87.5 and 54.5% respectively. 2)Radiological solid fusion was achieved in 93.5 % and the mean correction ratio for Kyphosis was 62.4%.