Neurologia medico-chirurgica
Online ISSN : 1349-8029
Print ISSN : 0470-8105
ISSN-L : 0470-8105
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Volume 53, Issue 12
Displaying 1-15 of 15 articles from this issue
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Original Articles
  • Acetyl Salicylic Acid Locally Enhances Functional Recovery After Sciatic Nerve Transection in Rat
    Rahim MOHAMMADI, Keyvan AMINI, Mehdi ABDOLLAHI-PIRBAZARI, Alireza YOUS ...
    2013 Volume 53 Issue 12 Pages 839-846
    Published: 2013
    Released on J-STAGE: December 25, 2013
    Advance online publication: October 21, 2013
    DOIhttps://doi.org/10.2176/nmc.oa2012-0330
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    Local effect of acetyl salicylic acid (ASA) on peripheral nerve regeneration was studied using a rat sciatic nerve transection model. Forty-five male healthy White Wistar rats were divided into three experimental groups (n = 15), randomly: Sham-operation (SHAM), control (SIL), and ASA-treated (SIL/ASA) groups. In SHAM group after anesthesia left sciatic nerve was exposed through a gluteal muscle incision and after homeostasis the muscle was sutured. In SIL group the left sciatic nerve was exposed the same way and transected proximal to tibio-peroneal bifurcation leaving a 10-mm gap. Proximal and distal stumps were each inserted into a silicone tube and filled with 10 μl phosphate buffered solution. In SIL/ASA group defect was bridged using a silicone tube filled with 10 μl acetyl salisylic acid (0.1 mg/ml). Each group was subdivided into three subgroups of five animals each and were studied 4, 8, and 12 weeks after surgery. Data were analyzed statistically by factorial analysis of variance (ANOVA) and the Bonferroni test for pair-wise comparisons. Functional study confirmed faster and better recovery of regenerated axons in SIL/ASA than in SIL group (p < 0.05). Gastrocnemius muscle mass in SIL/ASA was significantly more than in SIL group. Morphometric indices of regenerated fibers showed that the number and diameter of the myelinated fibers in SIL/ASA were significantly higher than in control group. In immuohistochemistry, location of reactions to S-100 in SIL/ASA was clearly more positive than in SIL group. Response to local treatment of ASA demonstrates that it influences and improves functional recovery of peripheral nerve regeneration.
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  • Surgical Treatment of Chiari I Malformation With Ventricular Dilation
    Xiaofeng DENG, Liang WU, Chenlong YANG, Xianzeng TONG, Yulun XU
    2013 Volume 53 Issue 12 Pages 847-852
    Published: 2013
    Released on J-STAGE: December 25, 2013
    Advance online publication: October 21, 2013
    DOIhttps://doi.org/10.2176/nmc.oa2012-0206
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    Ventricular dilation affects 7% to 10% of patients with Chiari type I malformation (CIM), but the choice of surgical treatment is controversial. To study the surgical approaches for treating CIM with ventricular dilation and to evaluate the efficacy of posterior fossa decompression (PFD), clinical and imaging data of 38 adult patients who received surgical correction performed at the authors’ department from 2004 to 2011 were reviewed. Ventricular dilation was defined as Evans’ index > 0.30. Preoperative fundus examinations were done on all patients and no papilledema was found. Surgical procedures included a sub-occipital decompression and a C1 laminectomy, followed by a duraplasty with an autologous graft. Evans’ index was measured before and after surgery respectively, and a paired samples t-test was performed to examine the difference. Factors predicting outcomes were investigated using logistic regression analysis. Follow-up was done to all patients with an average duration of 43 months. All postoperative magnetic resonance (MR) images showed a relief of cervicomedullary compression and recreation of the cisterna magna. Symptoms improved in 33 patients (86.8%), remained stable in 5 (13.2%), and no patient deteriorated. No significant change in ventricular size was observed after surgery (P = 0.257). Regression analysis showed duration of illness had a significant effect on clinical outcome (P = 0.034, OR = 12.5, 95% CI: 1.214, 128.661). Our study suggests that the intracranial pressure (ICP) of patients with CIM and ventricular dilation is usually normal. PFD with duraplasty is an effective and safe treatment for CIM with ventricular dilation. Treatment of ventricular dilation is unnecessary before PFD as long as there is no persistent headache, vomiting, and papilledema.
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  • The Pitfalls in Surgical Management of Lumbar Canal Stenosis Associated With Rheumatoid Arthritis
    Tetsuryu MITSUYAMA, Motoo KUBOTA, Masahito YUZURIHARA, Masaki MIZUNO, ...
    2013 Volume 53 Issue 12 Pages 853-860
    Published: 2013
    Released on J-STAGE: December 25, 2013
    Advance online publication: October 21, 2013
    DOIhttps://doi.org/10.2176/nmc.oa2012-0299
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    There have been few clinical studies in the area of cervical spine that focused on surgery for treating degenerative lumbar disease in patients with rheumatoid arthritis (RA). High rates of wound complications and instrumentation failure have been reported more for RA than for non-RA patients, although clinical outcomes are similar between the two groups. Lumbar canal stenosis in RA is caused not only by degeneration but also by RA-related spondylitis, which includes facet arthritis and inflammation around the vertebral endplate. The pitfalls in surgical management of lumbar canal stenosis in RA patients are highlighted in this study. The study reviewed 12 patients with RA, who were surgically treated for lumbar canal stenosis. Two out of five patients with pulmonary fibrosis died of worsened pulmonary condition, even though there were no perioperative pulmonary complications. Two patients with pedicle screw fixation showed no instrumentation failure, but two patients with spinous process fixation needed re-operation or vertebral fracture. Surgical treatment for lumbar canal stenosis in RA patients needs to be individually adjusted. Preoperative assessments and treatments of pulmonary fibrosis and osteopenia are essential. Surgery for lumbar canal stenosis with RA should be deferred for patients with advanced pulmonary fibrosis because of its potential life-threatening risk. Fusion surgery is indicated only in patients with kyphosis or severe symptoms caused by intervertebral instability. Pedicle screw fixation with hydroxyapatite granules or sublaminar tape is recommended. Closer follow-up after surgery is necessary because of possible delayed wound infection, instrumentation failure, pathological fracture, and respiratory deterioration.
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  • Surgical Management of Minimally Invasive Anterior Lumbar Interbody Fusion With Stand-Alone Interbody Cage for L4-5 Degenerative Disorders: Clinical and Radiographic Findings
    Yasuo HIRONAKA, Tetsuya MORIMOTO, Yasushi MOTOYAMA, Young-Su PARK, Hir ...
    2013 Volume 53 Issue 12 Pages 861-869
    Published: 2013
    Released on J-STAGE: December 25, 2013
    Advance online publication: October 21, 2013
    DOIhttps://doi.org/10.2176/nmc.oa2012-0379
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    Surgical treatment for degenerative spinal disorders is controversial, although lumbar fusion is considered an acceptable option for disabling lower back pain. Patients underwent instrumented minimally invasive anterior lumbar interbody fusion (mini-ALIF) using a retroperitoneal approach except for requiring multilevel fusions, severe spinal canal stenosis, high-grade spondylolisthesis, and a adjacent segments disorders. We retrospectively reviewed the clinical records and radiographs of 142 patients who received mini-ALIF for L4-5 degenerative lumbar disorders between 1998 and 2010. We compared preoperative and postoperative clinical data and radiographic measurements, including the modified Japanese Orthopaedic Association (JOA) score, visual analog scale (VAS) score for back and leg pain, disc height (DH), whole lumbar lordosis (WL), and vertebral wedge angle (WA). The mean follow-up period was 76 months. The solid fusion rate was 90.1% (128/142 patients). The average length of hospital stay was 6.9 days (range, 3–21 days). The mean blood loss was 63.7 ml (range, 10–456 ml). The mean operation time was 155.5 min (range, 96–280 min). The postoperative JOA and VAS scores for back and leg pain were improved compared with the preoperative scores. Radiological analysis showed significant postoperative improvements in DH, WL, and WA, and the functional and radiographical outcomes improved significantly after 2 years. The 2.8% complication rate included cases of wound infection, liquorrhea, vertebral body fractures, and a misplaced cage that required revision. Mini-ALIF was found to be associated with improved clinical results and radiographic findings for L4-5 disorders. A retroperitoneal approach might therefore be a valuable treatment option.
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  • Decompression Only Versus Fusion Surgery for Lumbar Stenosis in Elderly Patients Over 75 Years Old: Which is Reasonable?
    Chang-Hyun LEE, Seung-Jae HYUN, Ki-Jeong KIM, Tae-Ahn JAHNG, Hyun-Jib ...
    2013 Volume 53 Issue 12 Pages 870-874
    Published: 2013
    Released on J-STAGE: December 25, 2013
    Advance online publication: October 29, 2013
    DOIhttps://doi.org/10.2176/nmc.oa2012-0415
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    As the population ages, more elderly patients suffer from spinal stenosis requiring lumbar fusion. However, there are few and conflicting results regarding the clinical outcome of lumbar fusion. The purpose of this study is to evaluate the safety and efficiency of posterior lumbar interbody fusion (PLIF) in over 75-year-old patients and analyze the relative effectiveness of lumbar spinal fusion surgery compared with decompression surgery for spinal stenosis. This retrospective review evaluated 25 patients aged 75 to 93 who were diagnosed with spinal stenosis and underwent PLIF for 24 months. The control group included 25 patients who were matched for age, gender, level, race, and severity of stenosis, and who underwent decompressive laminectomy and flavectomy without fusion (DLF). The fusion rate in the PLIF group was 32.0%, 84.0%, and 96.0% at 6, 12, and 24 months, respectively. During the follow-up period, 4 (16%) and 2 (8%) patients underwent revision surgery in the DLF and PLIF groups, respectively. The back pain in the DLF group decreased from 5.6 to 2.1 at 6 months and then substantially increased to 3.4 at 24 months. The decrease in back pain score after treatment was greater in the PLIF group compared to the DLF group (P < 0.01) with a statistically significant difference in the trend in the two groups over time (P < 0.01). Even in elderly patients, lumbar surgery appears to be a safe and justifiable treatment for spinal stenosis. Lumbar fusion surgery rather than decompressive surgery was recommended for those patients who mainly complained of back pain.
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  • The Efficacy of Hydroxyapatite for Screw Augmentation in Osteoporotic Patients
    Sang Hoon JANG, June Ho LEE, Ji Young CHO, Ho-Yeon LEE, Sang-Ho LEE
    2013 Volume 53 Issue 12 Pages 875-881
    Published: 2013
    Released on J-STAGE: December 25, 2013
    Advance online publication: November 08, 2013
    DOIhttps://doi.org/10.2176/nmc.oa2012-0346
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    The stability of screw constructs is of considerable importance in determining the outcome, especially in spinal osteoporosis. Polymethylmethacrylate (PMMA) has been proven as an effective material for increasing the pullout strength of pedicle screws inserted into the osteoporotic bones. However, PMMA has several disadvantages, such as its exothermic properties, the risk of neural injury in the event of extravasation, and difficulties in performing revision surgery. In the current study, we used hydroxyapatite (HA) cement for screw augmentation in spinal osteoporosis. We conclude that HA cement is a useful tool for screw augmentation and recommend it as a promising option for spinal instrumentation in osteoporotic patients.
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Case Reports
  • Posterior Fixation for Atlantoaxial Subluxation in a Case With Complex Anomaly of Persistent First Intersegmental Artery and Assimilation in the C1 Vertebra
    Daisuke UMEBAYASHI, Masahito HARA, Yasuhiro NAKAJIMA, Yusuke NISHIMURA ...
    2013 Volume 53 Issue 12 Pages 882-886
    Published: 2013
    Released on J-STAGE: December 25, 2013
    Advance online publication: October 07, 2013
    DOIhttps://doi.org/10.2176/nmc.cr2012-0135
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    We report a very rare case of atlantoaxial subluxation (AAS) with persistent first intersegmental artery (PFIA) and assimilation in the atlas (C1) vertebra. This case demonstrates the difficulty of deciding on a surgical strategy for complex anomalies. A 63-year-old man presented with gait disturbance, neck pain, and severe dysesthesia in his left arm. Past history included a whiplash injury. Dynamic X-ray studies demonstrated an irreducible AAS and assimilation of C1. This subluxation was slightly deteriorated in an extended position. A three-dimensional computed tomography angiography (3DCTA) indicated that the PFIA was located on the left side. We performed a C1 posterior arch resection and C1 lateral mass–axis pedicle screw (C1LM–C2PS) fixation using the modified technique of skewering the occipital condyle and C1 lateral mass. The patient had no postoperative morbidity and his symptoms disappeared immediately after operation. Complex anomalies cause difficulty in determining surgical strategy although several surgical methods for simple craniovertebral junction anomaly have been reported. To avoid significant morbidities associated with vertebral artery injury, surgical strategies for these complex conditions are discussed. The modified technique of a C1 lateral mass screw penetrating the occipital condyle is a viable treatment option.
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  • Unusual Traumatic Midthoracic Spondyloptosis and its Surgical Management: Case Report
    Askin Esen HASTURK, Kemal ILIK, Ilker COVEN, Ozgur OZDEMIR
    2013 Volume 53 Issue 12 Pages 887-889
    Published: 2013
    Released on J-STAGE: December 25, 2013
    Advance online publication: October 07, 2013
    DOIhttps://doi.org/10.2176/nmc.cr2012-0248
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    Posttraumatic spondyloptosis develops as a result of complete subluxation of the vertebral bodies and causes complete transection of the spinal cord. Severe trauma-related spondyloptosis of the upper-mid thoracic region is a rare form of spinal trauma. Traumatic midthoracic spondyloptosis is quite rare, and radiology plays an important role in the diagnosis and treatment of this condition. Surgical reconstruction and stabilization are required for early mobilization and rehabilitation of patients with this injury. Here, we report the clinical features, radiographic findings, and management of an unusual case of traumatic midthoracic spondyloptosis that showed complete spinal cord transection and was operated.
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  • Cauda Equina Intradural Extramedullary Cavernous Haemangioma—Case Report and Review of the Literature
    Mihai POPESCU, Valentin TITUS GRIGOREAN, Crina JULIETA SINESCU, Cristi ...
    2013 Volume 53 Issue 12 Pages 890-895
    Published: 2013
    Released on J-STAGE: December 25, 2013
    Advance online publication: October 07, 2013
    DOIhttps://doi.org/10.2176/nmc.cr2012-0309
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    Cavernous haemangioma (cavernoma) is a benign vascular lesion, exceptionally located in cauda equina. We report a case, diagnosed and operated in the Department of Neurosurgery from Pitesti County Emergency Hospital, of a 60-year-old woman with history of lumbar region distress, who presented with low back pain, paravertebral muscle contracture, and bilateral lumbar radiculopathy, with sudden onset after lifting effort. The preoperative diagnosis was done using computed tomography (CT) and magnetic resonance imaging (MRI), and the patient underwent surgery—two level laminectomy, dural incision, and tumor dissection from the cauda equina nerve roots under operatory microscope. Histopathological examination confirmed the positive diagnosis of cavernoma of cauda equina. The patient’s outcome was favorable, without postoperative neurological deficits.
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  • Spinal Epidural Arteriovenous Fistulas With Unusual Manifestation of Sudden Onset of Severe Neurological Deficits: Case Report
    Naoko MIYAMOTO, Isao NAITO, Shin TAKATAMA, Tomoyuki IWAI, Shinichiro T ...
    2013 Volume 53 Issue 12 Pages 896-901
    Published: 2013
    Released on J-STAGE: December 25, 2013
    Advance online publication: October 07, 2013
    DOIhttps://doi.org/10.2176/nmc.cr2012-0269
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    Spinal epidural arteriovenous fistulas with perimedullary venous drainage cause venous hypertension, and usually manifest as slowly progressive myelopathy. We treated two patients presenting with sudden onset of severe neurological deficits. Moreover, in Case 1, the venous drainage was exclusively epidural and no perimedullary venous drainage was present. Angiographic findings of this patient were characterized by a slow-flow fistula with marked retention of the epidural venous drainage. Rapidly progressing thrombosis of the epidural venous plexus may have caused the sudden onset of the symptoms. In Case 2, hematomyelia may also be possibly associated with the sudden onset of the symptoms. Early diagnosis and treatment are essential to achieve favorable outcome in such cases because venous congestion results in irreversible venous infarction within a short period.
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  • Intraoperative Computed Tomography for Cervicomedullary Decompression of Foramen Magnum Stenosis in Achondroplasia: Two Case Reports
    —Case Report—
    Hidetaka ARISHIMA, Kenzo TSUNETOSHI, Toshiaki KODERA, Ryuhei KITAI, Hi ...
    2013 Volume 53 Issue 12 Pages 902-906
    Published: 2013
    Released on J-STAGE: December 25, 2013
    Advance online publication: October 21, 2013
    DOIhttps://doi.org/10.2176/nmc.cr2012-0421
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    The authors report two cases of cervicomedullary decompression of foramen magnum (FM) stenosis in children with achondroplasia using intraoperative computed tomography (iCT). A 14-month-old girl with myelopathy and retarded motor development, and a 10-year-old girl who had already undergone incomplete FM decompression was presented with myelopathy. Both patients underwent decompressive sub-occipitalcraniectomy and C1 laminectomy without duraplasty using iCT. It clearly showed the extent of FM decompression during surgery, which finally enabled sufficient decompression. After the operation, their myelopathy improved. We think that iCT can provide useful information and guidance for sufficient decompression for FM stenosis in children with achondroplasia.
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Technical Notes
  • Novel Method for Analyzing Locomotor Ability After Spinal Cord Injury in Rats: Technical Note
    Munehisa SHINOZAKI, Akimasa YASUDA, Satoshi NORI, Nobuhito SAITO, Yosh ...
    2013 Volume 53 Issue 12 Pages 907-913
    Published: 2013
    Released on J-STAGE: December 25, 2013
    Advance online publication: October 07, 2013
    DOIhttps://doi.org/10.2176/nmc.tn2012-0223
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    In the research for the treatment of spinal cord injury (SCI), the evaluation of motor function in model rats must be as objective, noninvasive, and ethical as possible. The maximum speed and acceleration of a mouse measured using a SCANET system were previously reported to vary significantly according to severity of SCI. In the present study, the motor performance of SCI model rats was examined with SCANET and assessed for Basso–Beattie–Bresnahan (BBB) score to determine the usefulness of the SCANET system in evaluating functional recovery after SCI. Maximum speed and acceleration within the measurement period correlated significantly with BBB scores. Furthermore, among several phased kinematic factors used in BBB scores, the capability of “plantar stepping” was associated with a drastic increase in maximum speed and acceleration after SCI. Therefore, evaluation of maximum speed and acceleration using a SCANET system is a useful method for rat models of SCI and can complement open field scoring scales.
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  • C2 Nerve Root Resection to Achieve Safe and Wide Exposure of Lateral Atlantoaxial Joints in Posterior C1-2 Instrumented Fixation: Technical Note
    Toru YAMAGATA, Toshihiro TAKAMI, Kentaro NAITO, Kenji OHATA
    2013 Volume 53 Issue 12 Pages 914-919
    Published: 2013
    Released on J-STAGE: December 25, 2013
    Advance online publication: October 07, 2013
    DOIhttps://doi.org/10.2176/nmc.tn2012-0288
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    Posterior atlantoaxial (C1-2) fixation with individual screw placement in C1 and C2 has been one of the technical options to treat C1-2 subluxation or instability. In the present study, we demonstrate the surgical technique of C2 nerve root resection to avoid the troublesome bleeding from the perivertebral venous plexus and achieve full exposure of the lateral C1-2 joints. The present study includes a series of 16 consecutive patients who underwent posterior C1-2 instrumented fixation with individual screw placement in C1 and C2. All patients underwent unilateral or bilateral C2 nerve root resection at the sensory ganglion. Screw malposition resulting in vascular or neural injury was not encountered. Sensory pain scale analysis indicated that the mean score before surgery was 2.4, which significantly improved to 1.4 after surgery. No patients reported allodynia or C2 distribution neuropathic pain during the follow-up. C2 nerve root resection resulted in early postoperative dysesthesia in all 16 patients; however, neurological examination during the follow-up revealed that only 12.5% of all analyzed patients did not demonstrate satisfactory recovery of C2 sensory disturbance. Postoperative radiologic analysis revealed solid osseous or partial fusion at the lateral C1-2 joints in all cases during the follow-up. No case demonstrated non-union with pseudoarthrosis. Although C2 nerve root resection is still under debate and not fully justified, the present study suggests that C2 nerve root resection does not always result in significant morbidity and can be an option for surgical resolution to achieve safe and wide exposure of lateral C1-2 joints.
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  • Posterolateral Sulcus Approach for Spinal Intramedullary Tumor of Lateral Location: Technical Note
    Toshihiro TAKAMI, Toru YAMAGATA, Kenji OHATA
    2013 Volume 53 Issue 12 Pages 920-927
    Published: 2013
    Released on J-STAGE: December 25, 2013
    Advance online publication: October 29, 2013
    DOIhttps://doi.org/10.2176/nmc.tn2012-0419
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    Posterolateral sulcus (PLS) approach of the spinal cord, being equivalent to the dorsal root entry zone myelotomy, may offer the satisfactory exposure of the spinal intramedullary tumor if applied appropriately. Eight consecutive patients with spinal intramedullary tumors of lateral location underwent the surgery of PLS approach in our institute. There were 6 male and 2 female patients, ranging in age from 34 to 72 years (mean, 57 years). PLS approach was indicated for the intramedullary tumor situated laterally in the spinal cord and that do not contact the posterior or lateral surfaces on magnetic resonance (MR) images before surgery. Total removal of the tumor was achieved in 6 cases except of 2 cases of anaplastic astrocytoma. All 6 patients with total removal of the tumor demonstrated the modest or mild deterioration of motor function on the approach side early after surgery, which resolved within 1 month after surgery. Average grade of the modified McCormick functional schema was 3.5 before surgery and improved to 3.0 at 3 months after surgery. These 6 patients demonstrated satisfactory pain relief early after surgery. Average grade of the sensory pain scale was 2.7 before surgery and improved to 1.7 at 3 months after surgery. PLS approach can be one of the surgical choices to the spinal intramedullary tumors, if applied appropriately. Better indication for PLS approach may be the tumors of the uneven location within the spinal cord associated with moderate or severe local pain.
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