Between 1976 and 1998, we experienced ten cases of well-differentiated liposarcomas. In all cases surgical treatment was performed. In the first operation, we performed marginal resection in eight cases, wide resection in one case, and intralesional resection in one case. Local recurrence appeared in three cases. Two cases underwent marginal resection and one case underwent intralesional resection. The prognosis of well-differentiated liposarcomas is comparatively good. Metastasis does not appear except when they are dedifferentiated. Moreover, sometimes it is clinically difficult to distinguish them from some benign fatty soft tissue tumors. It should be better to preserve the nerves and vessels which are attached to the tumor and to resect the other tissues which are attached to the tumor with a wide margin as much as possible in the first operation.
The management of patients with soft tissue sarcomas exhibiting metastases at the time of initial presentation is a difficult problem. The purpose of this study is to describe the treatment outcome in such patients at our institution. Eleven patients with a mean age of 55 years were included in the study. There were 6 male and 5 female patients. The mean follow-up period was 1 year and 9 months. The predominant histological diagnosis was malignant fibrous histiocytomas in 4 patients. The most common metastatic site was the lung, which was seen in 8 patients. The survival rate, calculated using the kaplan-Meier method, was 61% at 1 year, and 19% at 4 years after the initial presentation. Univariate analysis of the prognostic factors showed a significant influence of the tumor size and interval between onset and presentation. Chemotherapy and radiotherapy were not effective for both the primary and metastatic lesions in all patients. Despite multimodal therapy, long-term prognosis remains poor for most soft tissue sarcoma patients with metastatic disease. Further advancement modality of treatment such as new chemotherapeutic agents needs to be developed.
A case of metastatic carcinomatosis of the bone marrow with hyperphosphatasia is reported. Even if patients with marked hyperphosphatasia have no symptom and no abnormal findings of skeletal radiographs, it is possible that their hyperphosphatasia is caused by metastatic carcinomatosis of the bone marrow due to adenocarcinoma. Bone scintigram is useful for the diagnosis of metastatic carcinomatosis of the bone marrow.
A case of malignant lymphoma of bone, which originated in the right talus, is reported. A 68-year-old man complained of increasing pain and swelling in the right ankle joint. Radiograph of the ankle demonstrated a diffuse, destructive lesion in the talus. On magnetic resonance imaging, the talus, the anterior soft part of the talus demonstrated abnormal signal. Bone scintigram showed increased uptake in the talus. The pathological diagnosis of biopsy specimen from the talus was non-Hodgkin's lymphoma, B cell type. Radiotherapy and chemotherapy were carried out. He has been in remission for 6 months after diagnosis.
Case 1: A 12-year-old boy complained of right buttock pain and high fever. Radiographic examinations demonstrated osteolytic lesion in his right iliac bone. He was treated with several antibiotics and his symptoms disappeared for two months. However, the fever increased again and atypical lymphocytes appeared in peripheral blood. Acute lymphoblastic leukemia (ALL) was diagnosed by myelocentesis. Case 2: A 3-year-old girl complained of right leg pain and high fever. Radiographic examinations demonstrated osteolytic lesion and periosteal reaction in her right tibia. She was treated with several antibiotics and her symptoms disappeared for two months. However, she suffered both fever and forearm pain again. Radiographic examinations revealed osteolytic lesions with periosteal reactions in both radius and ulna, which resembled Caffey's disease. Abnormal findings were not seen by bone biopsy and her symptom did not respond to antibiotic therapy. Atypical lymphocytes appeared in peripheral blood one week after bone biopsy and ALL was confirmed by myelocentesis. Both patients responded well to chemotherapy and have kept remission.
A consecutive series of 17 patients underwent extirpation of intramedullary spinal cord tumor between January, 1990 and January, 1999. The patients were 11 men and 6 women with an average age of 42.6. Their histology was ependymoma in 5 cases, cavernous hemangioma in 3 cases, neurilemoma and astrocytoma in 2 cases, glioblstoma, lipoma and intramedullary metastatic tumor in 1 case. Preoperative neurological evaluation was very good in 5 cases, good in 4, fair in 4 and poor in 4. Neurological evaluation revealed deterioration just after surgery in many cases and gradual improvement with time in somecases. In 10 cases we could follow-up more than a year. Recent neurologicalstates were functional improvement from the preoperative status in 3 patients, no remarkable change in 2 patients, and deterioration in 5 patients. This experience suggests that surgery can not always produce satisfactory result for intramedullary spinal tumor.
The patient was a 64-year-old female. Past history: She underwent laminoplasty from C3 to C7 for cervical spondylotic myelopathy at another hospital in 1988. Present illness: She feels numbness of left upper extremity from 1989. She was diagnosed with spinal cord tumor at the C1 level in MRI and course observed. She has been experiencing power loss and motor disturbance of the left upper extremity since 1993. She was referred to our hospital on 29th September in 1998. MRI demonstrated a intramedullary tumor (T1: low, T2: high) at the C1 level and syrinx from C1/2 to C6/7. She underwent a tumor resection, after which she felt power loss of the left upper and lower extremities, which improved markedly after 1 month.
A 24 year-old woman with thoracic myelopathy due to spinal angiolipoma is reported. Plain radiographs showed distinct, coarse trabecular patterns with vertical striations extending throughout the vertebral bodies of T4-6. CT and MRI revealed epidural tumor at levels of T3-9, which compressed the spinal cord. The patient underwent thoracic laminectomy and tumor resection. Pathologic findings indicated that the tumor was an angiolipoma. Four months after surgery, the myelopathy had completely improved.
A case of candida spondylitis affecting the lumber spine is reported. An eighty-one-year old man underwent colectomy for sigmoid colon cancer. Three months after the abdominal surgery, he had high fever and low back pain. Roentogenographic examination and MR imaging demonstrated abscess of the third to fourth intervertebral disk space and psoas abscess. Microbiological examination of a specimen obtained by needle biopsy revealed infection of candida tropicalis. Intravenous elimination of the furuconazole and cast immobilization rapidly improved his clinical symptom, although the C-reactive protein and erythrocyte sedimentation continued to be high for one year because of recurrent bacterial pneumonia. Thus MR imaging proved to be very useful for detecting the bone condition and inspecting diminishment of the abscess.
Neurological complications of myeloma are relatively common, and include those associated with various metabolic disturbances, hyperviscosity, amyloidosis, peripheral neuropathy, and, occasionally, cranial nerve palsies. Spread to the central nervous system most commonly presents as compression of the spinal cord or cauda equina. We report a relative rare case presenting acute paraparesis initially due to thoracic cord compression by extramedullary extradural plasmacytoma. This 70 year-old man complained of epigastralgia, back pain, and gait disturbance. He fulfilled the diagnostic criteria of myeloma, and later experienced sphincter disturbance. Magnetic resonance imaging showed the tumor compressing the spinal cord at the Th4 level, so, decompressive laminectomy was performed. The tumor extended extramedullary from the Th4 lamina and compressed the dural sac from behind. Microscopic examination indicated plasmacytoma.
We reviewed the middle-term results of 68 rotational acetabular osteotomies (RAO) that had been performed for subluxated osteoarthritis of the hip with less than 5 degrees of the center-edge (CE) angle. Subjects comprised of 56 females (63 hips) and 5 males (5 hips); the mean age at the time of the operation was 38.3 years (range; 13 to 59 years). The average duration of follow-up was 6.3 years (range; 3 to 11 years). All hips were evaluated preoperatively and at the time of the latest follow-up according to the Japanese Orthopaedic Association (JOA) clinical hip scoring system. Measurement of CE angle was corried out on preoperative radiograph. We classified the degree of the subluxation by CE angle and evaluate the clinical results using the JOA score. The average JOA clinical score at the time of the latest follow-up did not differ among 34 patients with early stage osteoarthritis of the hip (5-1 degree CE angle: 95.8 points, 0--4 degree: 92.9 points, -5--9 degree: 94.5 points, less than -10 degree: 96.0 points). The average JOA clinical score of the patients with less than -10 degree CE angle on the preoperative radiograph was however 60.6 points which was poor compared with 82.0 points (5-1 degree of CE angle), 72.5 points (0--4 degree), 88.0 points (-5--9 degree) in 34 patients with advanced stage coxarthrosis. The clinical results of patients with advanced stage coxarthrosis associated with less than -10 degree CE angle were not satisfactory.
We measured blood flow of the osteotomized acetabulum during curved periacetabular osteotomy (CPO), which is our modification of the Bernese periacetabular osteotomy derived by Ganz et al. Twelve female and one male patients, who had residual hip dysplasia, underwent CPO. The average age at the time of operation was 36 years old (16-59). At operation, the bone blood flow at the acetabulum was measured before osteotomy and after redirection with a laser flowmeter. The bone blood flow at the acetabulum averaged 3.2±1.6 FLOW (arbitrary units) before osteotomy. After redirection, the bone blood flow at the acetabulum averaged 2.4±1.3 FLOW. Consequently, the CPO caused decrease of the bone blood flow at the acetabulum by 18.7±31.7%. The CPO did not significantly change the bone blood flow of the transferred acetabulum. In rotational acetabular osteotomy, collapse and necrosis of the transferred acetabulum has been reported as a disastrous complication. In CPO, the external portion of the ilium can be left undissected. Bone union and relief of pain were obtained in all hips.
We treated a patient who had been suffering from a wide range of deep venous thrombosis (DVT) in the lower right extremity after the right transfer of the acetabulum. The patient noticed swelling and pain in the lower right extremity two weeks after the operation. The defects of the contrast medium were seen between the right common iliac vein and calf venula when venography was performed. A slight wedgeshaped defect was also seen in the lower left lung when lung blood flow scintigram was performed. The patient was diagnosed as DVT with slight pulmonary embolism (PE). Immediately we routinely treated this patient with anticoagulant therapy that consists of intravenous heparin medication. In order to prevent lethal PE during the therapy, we implanted a percutaneous infra vena cava filter (IVC filter) capable of trapping large thrombus and inducing spontaneous fibrinolysis at this site. Furthermore, fibrinolytic therapy consisting of intravenous urokinase medication was added. During the therapy, swelling and pain of the lower right extremity improved with the decreasing in the serum D-dimer. The IVC filter seems to be useful for preventing acute lethal PE following a wide range of DVT after hip surgery. However, long term follow-up of this patient seems to be required.
We evaluated the clinical results of transtrochanteric rotational osteotomy using the F-system as an internal fixation device. Group I with F-system fixation consisted of six hips in six patients. In this group, the average age at operation was thirty years old and the average post-operative follow-up period was twenty-five months. The clinical results of group I were compared with that of the control group (group II) using other screws. Bone-nonunion was observed in three hips of group II, and the neck-shaft angle in group II decreased 3.5 degrees on the average in plain roentgenograms one year after the operation. On the other hand, there was no bone-nonunion and the progression of varus deformity was only 1.5 degrees in group I. The mechanical strength of the F-system was found to be superior to other devices in compression tests. The difference in the time and blood loss during operations between the two groups was insignificant. Fracture of the proximal femur occurred intraoperatively in two hips of group I. The F-system is useful, but the operative technique and the design of the device require certain improvements.
The subjects were 7 cases (3 males, 4 females). The mean age was 62 years (range; 45 to 75 years) and the mean follow-up period was 13.1 months (range; 7 to 25 months) postoperatively. Bone defects of the femur were type II (1 case); and type III (6 cases) according to AAOS classification. Cortical bone defects were covered with autogenous iliac cortical bone, and cancellous bone or allograft were inlay grafted to the intramedullary cavity. Long extensively porous coated stems and proximally porous coated stems were employed in 4 cases and 3 cases respectively. Allograft was used in 3 cases. These cases were evaluated clinically using the JOA score and evaluated radiographically based on Engh's criteria. All the cases improved clinically, and 6 cases were stable on the radiographic evaluation. In one case with marked bone defect in which femoral reconstruction was performed with the proximally porous coated stem, stem subsidence occurred in on early period after the operation. Only this case was evaluated as unstable. For the revision of the femur with severe bone defect, femoral reconstruction with cementless stem is considered desirable.
Three revision hip hemiarthroplasties were performed. In all cases, primary hip hemiarthroplasties were performed previously for femoral neck fractures. All cases were caused by mechanichal loosening. They were classified into type I (one case) and type II (two cases) according to Gustilo classification. The JOA hip score improved from 64, 62, 67 to 93, 96, 96. It is important to perform hip hemiarthroplasty with the appropriate skill and technique and to follow up the case periodically.
Autogenous bone grafting has been used to reconstruct acetabulum in dysplastic hips during primary Total Hip Arthroplasty (THA). We experienced 5 joints in 5 patients (1 male and 4 females) and examined the results of cases where more than 3 years have passed after THA combined with an autogenous bone graft. The mean age at the time of surgery was 63.8 years. Clinical evaluation by JOA score and radiographic evaluation were carried out. JOA score improved from the preoperative mean of 34.4 points to the postoperative mean of 86.6 points. Bone fusion was established in all the bone grafts and neither migration of the cup nor crush of the bone grafts were found. Bone resorption was observed in some bone grafts but no clinical problems were raised. Our study indicates that acetabular bone graft is useful for obtaining the stability of the cup.
The linear wear measurement of inner articulation for bipolar hemiarthroplasty (BHA) was performed on 28 hips by using the changed radiographic condition. There were two types of innerheads; 22mm (15 hips) and 28mm (13 hips). The average annual linear wear rate was 0.07mm/y in the 22mm head, and 0.04mm/y in the 28mm head. The wear rate of the inner articulation in BHA was less than that of THA. Osteolysis was observed in 7 hips in the 22mm head group (46%). There was no significant difference in the linear wear regardless of whether osteolysis was present.
Total hip arthroplasty (THA) for high positioned dislocated hips was performed on six cases. All patients were women. The mean patient age was 55.0 years (range; 37 to 68). Attempts were made to correct the leg-length discrepancy to an appropriate length in each case. The greatest lengthening was 45mm (12.5% femoral lengthening) in the series reported. There were no major complications with severe nerve palsy due to overlengthening of the femur, but a patient with 40mm (10.4%) femoral lengthening complained of numbness in the lateral sural cutaneous nerve area. We consider that the appropriate leg-lengthening should be within 10% of femoral lengthening.
Between January 1996 and December 1998, we treated 76 cases of trochanteric femoral fracture. The patients included 16 males and 60 females, with a mean age of 82 years. 22 cases with stable fracture were treated using a compression hip screw (CHS), and the other 54 cases with unstable fracture were treated using an intramedullary hip screw (IMHS). As post operative complications, osteomyelitis occurred in 2 cases after IMHS. They were delayed infections, occurring approximately at 5 months and at 15 months after IMHS. For treatment, we performed removal of the implant, curettage of the focus, closed continuous irrigation, followed by general infusion of antibiotics. In one case, the organism was Methicillin-resistant Staphylococcus aureus (MRSA), and in another case, the organism was Acinetobacter calcoaceticus in laboratory cultures. The case with MRSA additionally underwent local irrigation and hyperbaric oxygenation (HBO) therapy because the wound was dehiscent and a marrow cavity in the femur was exposed. A split-thickness skin graft was performed after filling up the dead space with granulation tissue. 2 cases were successfully treated.
Osteomyelitis of the pubis is a rare condition. We experienced a case of osteomyelitis of the pubis after urologic surgery. A sixty-nine-year old man who developed lower abdominal pain and gait disturbance after urologic surgery of total prostectomy was referred to us. Computed tomography scan showed the pubic bone was slightly destructed and MR imaging disclosed an abscess of the pubic symphysis. Surgical treatment with debridement and curettage of the lesion was performed. The culture yielded Pseudomonas aeruginosa. Two weeks after curettage, the pain was diminished and C-reactive protein value and erythrocyte sedimentation rate became normal.
We report a case of epidural abscess complicating epidural anesthesia. A 64-year-old woman developed a hemopneumothorax after multiple rib fractures, and an epidural catheter was inserted at L1-2 for pain relief. Five days later she complained of severe back pain and temperature elevated to more than 39.0°C. Nine days later MRI showed an epidural abscess of the ventral epidural space between T8 and L4. Because femoral nerve pain was experienced, laminectomy at T12-L2 and closed irrigation were performed. Epidural pus grew Staphylococcus aureus. Follow-up MRI 3 months after surgery showed disappearance of the epidural abscess completely. The patient recovered completely without neurological sequela.
It is said that calcified intervertebral disc was confirmed anatomically by Luschka in 1858, and Benke proved it radiologically with cadaver in 1897. In 1922, calcified nucleus pulposus was found by Calve and Galland, and they named it “calcification du nucleus pulposus”. Then Bársony renamed it “calcification intervertebralis”, because calcification was not seen only in nucleus pulposus but everywhere in the intervertebra. On the other hand, pediatric disc calcification was described by Báron in 1924. Since then, about 200 cases of children have been reported. In Japan Calcified intervertebral disc is considered rare. In 1932, the cases of a 13-year-old girl and 68-year-old female were described by Mizumachi. Since then, there have been sereval case reports of adults with especially intervertebral thoracial discs, but few reports of children. This paper reports the case of a 12-year-old boy with a calcified intervertebral disc at C 4-5 discovered by neck pain. With conservative treatment, X-rays 18 months later showed complete resolution of the calcification.
We experienced a case of dysphasia and dysphonia due to Ankylosing spinal hyperostosis (ASH) of the cervical spine. The patient was a 78-year-old man who was admitted to the department of internal medicine in our hospital for the examination and treatment of dysphasia and Mendelson syndrome. Dysphonia appeared later. X-rays of the cervical spine showed ossification of the anterior longitudinal ligament (OALL) at the C2 to C7 regions. The patient received surgical treatment. After the removal of OALL, dysphasia and dysphonia improved. The causes of these ASH symptom are examined in this study.
The authors report a rare case of spinal epidural hematoma due to arteriovenous malformation. The patient was a 26-year-old male who experienced severe back pain and incomplete lower extremity paralysis. His condition improved at one point but the same symptoms reappeared. Eemergency operation was thus performed. Tumor with hematoma was resected under the surgical microscope. Pathological examination confirmed arteriovenous malformation.
We investigated the correlation between the severity of cervical myelopathy and MRI findings. Anterior cervical decompression and fusion in 70 patients with cervical myelopathy were prospectively assessed with MRI. The degree of compressed deformities in the cervical cord on sagittal T1-weighted MRI was classified into three groups: retraction (54%), improvement (39%), or unchanged (7%). Good correlation was observed between the severity of the cervical myelopathy (the Japanese Orthopaedic Association score, recovery rate and duration of symptoms) and the deformity of the cervical cord on sagittal T1-weighted MRI (p<0.05). Additionally, the cross-sectional area of the cord was measured at the site of maximum compression in 24 patients. The postoperative cross-sectional area of the cord was then divided by the preoperative cross-sectional area to obtain the enlargement ratio. No correlation was observed between the preoperative Japanese Orthopaedic Association score and preoperative cross-sectional area of the cord, duration of symptoms or enlargement ratio. The findings in the cervical cord on sagittal T1-weighted MRI proved useful in the assessment of the surgical results.
The purpose of this study was to investigate the relationship between the restoration of the spinal cord just after decompression surgery and preoperative MRI findings. 13 patients underwent posterior decompression surgery at the cervical and thoracic level. The frontal diameter of the spinal cord was measured using pre-operative MRI and intra-operative ultrasonography. The restoration rate was calculated according to Kataoka's method from the pre and intra-operative diameters. Clinical results were also recorded using the Japanese Orthopedic Association score. Correlation between the restoration rate, clinical results, and MRI findings was evaluated. Significant correlation was observed between the restoration rate and clinical results (R=0.61). Also the spinal cord which indicated high signal intensity on the T2 WI preoperative MRI had a tendency to show a low restoration rate. These results suggest that the combination of the low restoration rate and high signal intensity of the spinal cord indicates severe spinal cord damage.
We studied the accuracy of MRI in lumbar disc herniation, comparing the results with the operative findings in the assessment of the rupture of the posterior longitudial ligament (PLL), and type of herniation. The MRI findings in 47 subjects who were operated on for lumbar disc herniation were retrospectively studied. The accuracy rate was 75.2% for the rupture of the PLL and 40.4% for the type of herniation respectively. It was hard to differentiate subligamentous extrusion from transligamentous extrusion on MRI.
This study reviewed an over one-year follow-up results of 18 cases who underwent posterior lumbar interbody fusion with Brantigan I/F cage. The clinical success was defined according to Hirabayashi's scale. 9 cases were categorized as excellent, 4 cases as good, 2 cases as fair, and the remaining 3 cases as poor. Plane X-ray radiographs revealed bone union in 18 out of 20 levels (union rate 90.0%), and non-union in only one level. The remaining cases could be concluded as neither union nor non-union because of interrueted bone trabeculae. Assessment results of X-ray radiographs were most or less satisfactory and correction loss was not observed. X-rays of some patients treated for degenerative spondylolisthesis showed carbon fiber cages buried deep in the upper vertebral bodies. A reaming device could be slipped onto the edges of the lower vertebral bodies, so pre-shaving them would be important. It is important that the autologous bone graft harvested from the lamina by laminectomy be unrelated with any donor site pain from the ilium. However it should be borne in mind that of MOB patients have poor bone quality after the autologous bone graft, the possibility of non-union is high. We concluded that the Brantigan I/F cage is an useful implant, but certain characteristics should be clarified for clinical and union success.
The purpose of this study was to evaluate the clinical outcome of posterior lumber interbody fusion (PLIF) with the interbody fusion cage for L5/S1. PLIF was performed on 18 patients consisting of 12 males and 6 females. 8 were diagnosed as disc degeneration, 7 as spondylolisthesis, 3 as spondylolytic spondylolisthesis. The average patients age was 38.2 years. The mean JOA score improved to 25.3 on the last follow-up from the preoperative score of 14.2. Posterior elements were preserved as much as possible, and two cages were then inserted into both sides. Low back pain and leg pain recurred in all patients. No breakage, displacement, backout of cage, progress of slipping, nor sinking was observed. In all cases, the interbody height was enlarged. Four cases showed clear zones less than 1mm around the cages. No motion was seen at the fusion level in all cases on dynamic radiographs. We believe that PLIF with interbody fusion cage for L5/S1 is useful for cases with diminished disc space.
To find out if we can predict postoperative instability before an operation, we measured the preoperative radiographic factors we proposed for inducing spondylolisthesis. Thirty-three patients who underwent lumbar decompression without fusion for acquired lumbar spinal canal stenosis between 1983 and 1997 were included in this study. The mean time of the postoperative observation was 30 months. Degenerative spondylolisthesis was seen in 14 patients. Postoperative slipping was seen in 5 patients. We found no relationship between each preoperative radiographic factor and the progression of slipping after lumbar decompression. Postoperative slipping had a tendency to increase if a preoperative narrowing of the disc space was present. We concluded that it is difficult to predict postoperative slipping by preoperative roentgenogram.
Between November 1989 and October 1998, 20 degenerative lumbar spondylolisthesis patients over 65-years were treated with posterior decompression surgery. The mean age at surgery was 70.5 years (range, 65 to 80) and the length of follow-up was 26.7 months (range, 7 to 40). These patients were divided into three groups (without fusion, posterolateral fusion (PLF), and PLF and pedicular screw system). The clinical scores were evaluated retrospectively with the Japanese Orthopedic Asssociation low back pain rating score (JOA score). The JOA score was 13.0 preoperatively and 22.4 postoperatively (rate of improvement: 61.1%) on average. Relatively good results were obtained in all groups. The best and consistent results in the group with PLF and pedicular screw system, the rate of improvement of which was over 50% in all cases.
We reviewed the clinical outcome of patients with entrapment radiculopathy at the foraminal and/or extraforaminal lesions, who underwent osteoplastic hemilaminectomy. The patients were eight men, aged 20 to 73 years (mean, 53.6 years), and the mean follow-up time was 7 months (3 to 16 months). The diagnoses were lumbar canal stenosis for 6, combined for 4, post laminectomy for 1, spondylolytic for 1, and lateral lumbar disc herniation for 2. Seven patients reported low back pain, and 8 had sciatica. The nerve roots involved were L4 in 1, and L5 in 7. In all the patients, osteoplastic hemilaminectomy was performed using an absorbable screw made from poly-L-lactic acid for the fixation of the osteotomized lamina. The mean preoperative JOA score of 11.0 was increased to 24.1 at the final follow-up. The recovery ratio was 50% or more for all the patients with a mean value of 73.8%. Two patients gained fusion of the osteotomized lamina, but 6 had not in the short follow-up period. Osteoplastic hemilaminectomy allows appropriate decompression for nerve roots involved under a wide visual field and preservation of posterior structures.
We report a rare case of intracanal and extraforaminal disc herniation at L5/S1. A 30 year-old woman had left low leg pain and motor loss of left M. TA, EHL, Gastrocutaneous and FHL. It was diagnosed as the radiculopathy of L5 and S1. Myelogram and CTM showed only intracanal disc herniation at L5/S1. MRI findings showed evident intracanal disc herniation at L5/S1, but extraforaminal disc herniation unclearly. CTD finding showed intracanal and extraforaminal disc herniation at L5/S1. We performed discectomy with resection of the left facet at L5/S1 and PLIF with the steffy VSP. She had no leg pain and no motor lossseven months postoperatively. According to extraforaminal disc herniation literature, interacanal and extra-foraminal disc hemiation has been seen in 2 out of 178 cases against extraforaminal disc herniation.
We report a very rare case with bilateral hypoplasia of the lumbar vertebral arch. A twenty-year-old man consulted us complaining of low back pain. The patient did not remember any severe trauma causing the low back and had never engaged in strenuous sports activities. Neurological examination was normal. X-ray of the anteroposterior view detected bone defect on the bilateral vertebral arch of the second lumbar vertebra. The tomography and 3D-CT clearly demonstrated that the lumbar vertebral arch did not connect to the vertebral body. There was clear instability between the second and third lumbar vertebras. We performed laminectomy of the second lumbar vertebral arch and postero-lateral fusion of L2-L3. In this case, the hypoplasia of the lumbar vertebral arch was caused by the failure of the ossification process.
We report a case of a nine-year-old girl with scoliosis and Williams syndrome (WS) which rapidly progressed to 75' and required surgical stabilization. Common features of WS include elfin face, mental retardation, and supravalvular aortic stenosis. Orthopaedic manifestations are hallux valgus, little-finger clinodactyly etc, not to mention scoliosis. Spine surgeons should be particularly careful of scoliosis due to the possible rapid progress of WS.
We report a case of paraparesis caused by hematoma of the ligamentum flavum. A 72-year-old man complcined of back and leg pain after lifting a heavy pack. 10 days later, the patient suffered from gait disturbance. On examination, the patient had showed 3/4 of normal strength in the lower extremity. Sensation and reflexes were normal. MRI demonstrated a severe spinal stenosis at L3-L4, caused by a posterior mass. Within the mass, areas of high signal intensity were noted. At operation, the right lamina at L3 noted brown and fragile. A solid mass was found, firmly adhered, posteriorly to the dural sac at L3-L4, and oozy tissue was identified around the mass. Initially we suspected the mass to be a metastatic epidural tumor. Pathological examination, however, revealed hemorrhage within the ligament. There was no evidence of neoplasm or infection.
We report a prospective double-blind trial of the efficacy and safety of a single epidural dose of buprenorphine on pain after lumbar surgery. Postoperative pain was assessed by a face scale chart and by the additional requirement for analgesia. The patients receiving buprenorphine were more comfortable and required less analgesia in the first 24 hours after operation than the control group. This suggests that the method is effective and safe for reducing pain.
Pulmonary embolism is well known as a serious postoperative complication in orthopaedic surgery. We experienced two cases of pulmonary embolism after spinal surgery. Although rare, the occurrence of pulmonary embolism requires aggressive management to prevent death. Anticoagulation therapy after the development of pulmonary embolism in patients undergoing spinal surgery causes a high rate of complications. Decompression of the nerve causes hematoma in the epidural space, which results in paralysis and infection. Neurological symptoms showld be observed carefully, and operations performed immediately when paralysis occurs.
We report a case of coracoid process fracture with clavicle fracture. A 32-year-old-male was injured and suffered open clavicle fracture by a direct blow. He also suffered a coracoid process fracture. Initially a correct diagnosis could not be made. When contusions around the shoulder are seen, the possibility of a coracoid process fracture should always be kept in mind.
Two unusual cases of the fracture of the first rib resulting from traffic injury are reported. There were no fracture of other ribs, clavicle fracture of the same side, and thoracic injury complications in these cases. We reviewed the mechanism of fracture of these cases. It is suggested that fracture is caused by direct force from the anterior at the posterior portion of the first rib in Case 1, and by the traction force of the muscle in the thinnest portion of the rib in Case 2.
We treated three cases of shaft fractures of both bones of the forearm with the TRUE/FLEX intramedullary nailing system. The patients were evaluated by the Grace & Eversmann's rating system. All of these fractures united and all three patients achieved excellent functional results. Rotational stability of the forearm was obtained and early active motion was possible. Damages to the soft tissue and scars from the operation were small. We therefore concluded that this method is effective for treating shaft fractures of the forearm.
We reviewed 20 patients with 20 humeral fractures treated by flexible intramedullary nailing. The average follow-up period was 17 months (rang; 5 to 45 months). There were 8 males and 12 females. The age of the patients ranged from 19 to 80 years (average; 47.3 years). We used Ender nails for 15 patients and Rush pins for 5 patients. We examined union, malunion and the range of motion in the shoulder and elbow. Union was obtained in 18 patients. There was 1 patient with malunion and 1 with nonunion of the humerus. Both cases were treated using 1 to 3 Rush pins due to the narrow intramedullary space. The range of motion was disturbed in 2 patients around the shoulder. In conclusion, the flexible intramedullary nailing is a useful method for humeral shaft fractures except for cases with narrow intramedullary space which cannot be inserted with more than two Ender nails.
We studied the postoperative displacement after each intrafocal pinning procedure (Kapandji) and conventional cross or parallel pinning for Colles' fracture. Fifty-eight cases of Colles' fracture were treated by percutaneous pinning in our hospital from 1994 to 1998. The rate of postoperative displacement after intrafocal pinning was 28% (7 cases of 25 intrafocal-pinning cases) and conventional cross or parallel pinning was 48% (16 cases of 33 conventional cases). The common causes of the displacement in conventional procedures are malreduction and loosening of the Kirschner wire. On the other hand, the intrafocal pinning procedure enables good reduction but tends to result in hyperreduction, which causes volar flexion deformity. We concluded that percutaneous pinning should not be performed if good reduction cannot be obtained and fixation by osteotaxis is necessary to maintain reductin.
14 patients (15 wrists) who had been treated for fracture of the distal end of the radius and had not been treated for ulnar styloid fracture at Sasebo Kyousai Hospital between January 1994 to December 1998 were studied for tenderness, ulno carpal stress test, bone union, and ulnar variance. According to Hauck et al., ulnar styloid fractures were classificd into tip fractures (type I) and base fractures (type II) There were 10 type I and 5 type II, 3 men and 11 women, and 6 right and 9 left wrists. The mean age was 58 years. 2 wrists (20%) showed ulnar side pain for type I, and 3 wrists (60%) for type II. Non-union was seen in 1 wrist (10%) for type I, and 4 wrists (80%) for type II. Wrists with both pain and non-union were 0 for type I, and 2 for type II. In 5 wrists with pain, 3 showed ulnar variance (more than 3mm) and the other 2 tested positive for ulnocarpal stress. Type II fractures tend to be accompanied with pain and be non-union, while type I does not. Procedures such we pinning are thus recommended for type II fractures.
We report three cases of Panner's disease defined as avascular necrosis of the capitellum of the humerus. Case 1; A boy aged eight complained of right elbow pain. The roetgenograms of the right elbow showed of irregularity of contour and a transparent zone in the capital epiphysis. Two months later, epiphysis became flat. Two years later, it changed completely. Case 2; A boy aged eleven complained of right elbow pain. Roentgenograms of the right elbow showed irregularity of contour of the capital epiphysis. Ten months later, it remodeled alwost completely. Case 3; A boy aged seven years was hospitalized for Perthes disease. The roentgenograms of the right elbow showed abnormal shade, irregularity of contour and a transparent zone of the capital epiphysis. Three months later, epiphysis became flat, but the contour smoothed. It is usually easy to distinguish Panner's disease from osteochoudritis dissecans, but occasionally difficult. We define a part of the osteochoudritis dissecans as Panner's disease.
In most cases, the fracture of the redial neck is the primary displacement of the proximal fragment, and has been classified according to the level of the displacement of the proximal fragment or location. In this particular case, we experienced the fracture of the radial neck with normal location of the proximal fragment, but with the primary displacement of the distal fragment to the ulnar side, and performed an openreduction.
We report two Monteggia fractures. Case 1 was an 8-year-old boy injured with Bado type 1 Monteggia fracture after falling off the balance beam. The dislocated radius head could not be reduced. Surgical exposure revealed interposition of the torn capsule. Open reduction and osteosynthesis of the ulna were performed. He regained stable elbow with full range of motion. Case 2 was an 11-year-old boy without previous injury around the elbow joint. He noticed pain and prominence of a bony mass at the anterior aspect of the elbow after throwing a dodge ball. On examination, neither swelling nor pain of the ulna were seen and the elbow joint showed valgus instability. X-ray showed the anterior dislocation of the hypertrophied radius head and traumatic bowing of the ulna. It was speculated that the anteriorly subluxated radius head by a previous traumatic bowing fell into complete dislocation by the traction of the biceps when throwing a ball. We performed an osteotomy of the ulna with bone graft. Although subluxation of the radius head remained because of insufficient osteotomy, bony prominence disappeared and he regained stable elbow with full range of motion of the elbow with full supination and 60 degrees pronation.
We report the effects of circumferential capsulotomy on the treatment for hip dislocation in cerebral palsy patients. The former operation method combined with anterior capsulotomy has sometimes showed unsatisfactory concentric reduction and adduction deformity. Since the remaining posterior part of the capsule is suspected to cause incomplete reduction, we introduced circumferential capsulotomy to the open reduction for the hip dislocation of cerebral palsy patients. Five spastic quadriplegia patients aged 7 to 14 years (3 males and 2 females) were operated by this modified method since April of 1998. The operation involves muscle release, open reduction with circumferential capsulotomy, and femoral osteotomy (detorsion/varus/shortening). 8 to 14 months follow-up study showed satisfactory concentric reduction, and range of abduction. We are planning to introduce this modified method to ambulatory cerebral palsy patients.