Neurologia medico-chirurgica
Online ISSN : 1349-8029
Print ISSN : 0470-8105
ISSN-L : 0470-8105
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Volume 56, Issue 8
Displaying 1-9 of 9 articles from this issue
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Review Articles
  • Basic Principles and Recent Trends of Transcranial Motor Evoked Potentials in Intraoperative Neurophysiologic Monitoring
    Shunji TSUTSUI, Hiroshi YAMADA
    2016 Volume 56 Issue 8 Pages 451-456
    Published: 2016
    Released on J-STAGE: August 15, 2016
    Advance online publication: March 02, 2016
    DOIhttps://doi.org/10.2176/nmc.ra.2015-0307
    JOURNAL OPEN ACCESS
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    Transcranial motor evoked potentials (TcMEPs), which are muscle action potentials elicited by transcranial brain stimulation, have been the most popular method for the last decade to monitor the functional integrity of the motor system during surgery. It was originally difficult to record reliable and reproducible potentials under general anesthesia, especially when inhalation-based anesthetic agents that suppressed the firing of anterior horn neurons were used. Advances in anesthesia, including the introduction of intravenous anesthetic agents, and progress in stimulation techniques, including the use of pulse trains, improved the reliability and reproducibility of TcMEP responses. However, TcMEPs are much smaller in amplitude compared with compound muscle action potentials evoked by maximal peripheral nerve stimulation, and vary from one trial to another in clinical practice, suggesting that only a limited number of spinal motor neurons innervating the target muscle are excited in anesthetized patients. Therefore, reliable interpretation of the critical changes in TcMEPs remains difficult and controversial. Additionally, false negative cases have been occasionally encountered. Recently, several facilitative techniques using central or peripheral stimuli, preceding transcranial electrical stimulation, have been employed to achieve sufficient depolarization of motor neurons and augment TcMEP responses. These techniques might have potentials to improve the reliability of intraoperative motor pathway monitoring using TcMEPs.
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  • Surgical and Endovascular Treatment for Spinal Arteriovenous Malformations
    Toshiki ENDO, Hidenori ENDO, Kenichi SATO, Yasushi MATSUMOTO, Teiji TO ...
    2016 Volume 56 Issue 8 Pages 457-464
    Published: 2016
    Released on J-STAGE: August 15, 2016
    Advance online publication: March 04, 2016
    DOIhttps://doi.org/10.2176/nmc.ra.2015-0327
    JOURNAL OPEN ACCESS
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    Spinal arteriovenous malformation (AVM) is a broad term that constitutes diverse vascular pathologies. To date, various classification schemes for spinal AVM have been proposed in literature, which helped neurosurgeons understand the pathophysiology of the disease and determine an optimal treatment strategy. To discuss indications and results of surgical and endovascular interventions for spinal AVM, this article refers to the following classification proposed by Anson and Spetzler in 1992: type I, dural arteriovenous fistula (AVF); type II, glomus intramedullary AVM; type III, juvenile malformations; and type IV, perimedullary AVF. In general, complete obliteration of the fistula is a key for better outcome in type I dural and type IV perimedullary AVFs. On the other hand, in type II glomus and type III juvenile malformations, functional preservation, instead of pursuing angiographical cure, is the main goal of the treatment. In such cases, reduction of the shunt flow can alleviate clinical symptoms. Proper management of spinal AVM should start with neurological examination and understanding of angioarchitectures, which provide critical information that guides the indication and modality of intervention. Finally, close collaboration of the microsurgical and endovascular teams are mandatory for successful treatment.
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  • Surgical Intervention for Instability of the Craniovertebral Junction
    Masakazu TAKAYASU, Masahiro AOYAMA, Masahiro JOKO, Mikinobu TAKEUCHI
    2016 Volume 56 Issue 8 Pages 465-475
    Published: 2016
    Released on J-STAGE: August 15, 2016
    Advance online publication: April 04, 2016
    DOIhttps://doi.org/10.2176/nmc.ra.2015-0342
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    Surgical approaches for stabilizing the craniovertebral junction (CVJ) are classified as either anterior or posterior approaches. Among the anterior approaches, the established method is anterior odontoid screw fixation. Posterior approaches are classified as either atlanto-axial fixation or occipito-cervical (O-C) fixation. Spinal instrumentation using anchor screws and rods has become a popular method for posterior cervical fixation. Because this method achieves greater stability and higher success rates for fusion without the risk of sublaminar wiring, it has become a substitute for previous methods that used bone grafting and wiring. Several types of anchor screws are available, including C1/2 transarticular, C1 lateral mass, C2 pedicle, and translaminar screws. Appropriate anchor screws should be selected according to characteristics such as technical feasibility, safety, and strength. With these stronger anchor screws, shorter fixation has become possible. The present review discusses the current status of surgical interventions for stabilizing the CVJ.
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  • Current Status of Lumbar Interbody Fusion for Degenerative Spondylolisthesis
    Toshiyuki TAKAHASHI, Junya HANAKITA, Yasufumi OHTAKE, Yusuke FUNAKOSHI ...
    2016 Volume 56 Issue 8 Pages 476-484
    Published: 2016
    Released on J-STAGE: August 15, 2016
    Advance online publication: May 11, 2016
    DOIhttps://doi.org/10.2176/nmc.ra.2015-0350
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    Instrumented lumbar fusion can provide immediate stability and assist in satisfactory arthrodesis in patients who have pain or instability of the lumbar spine. Lumbar adjunctive fusion with decompression is often a good procedure for surgical management of degenerative spondylolisthesis (DS). Among various lumbar fusion techniques, lumbar interbody fusion (LIF) has an advantage in that it maintains favorable lumbar alignment and provides successful fusion with the added effect of indirect decompression. This technique has been widely used and represents an advancement in spinal instrumentation, although the rationale and optimal type of LIF for DS remains controversial. We evaluated the current status and role of LIF in DS treatment, mainly as a means to augment instrumentation. We addressed the basic concept of LIF, its indications, and various types including minimally invasive techniques. It also has acceptable biomechanical features, and offers reconstruction with ideal lumbar alignment. Postsurgical adverse events related to each LIF technique are also addressed.
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Original Articles
  • Indication for Partial Vertebral Osteotomy and Realignment in Posterior Spinal Fixation for Osteoporotic Thoracolumbar Vertebral Collapse with Neurological Deficits
    Toshiyuki TAKAHASHI, Junya HANAKITA, Taigo KAWAOKA, Yasufumi OHTAKE, H ...
    2016 Volume 56 Issue 8 Pages 485-492
    Published: 2016
    Released on J-STAGE: August 15, 2016
    Advance online publication: March 28, 2016
    DOIhttps://doi.org/10.2176/nmc.oa.2015-0261
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    Instrumented spinal fixation is ordinarily required in patients who present with myelopathy or cauda equina syndrome secondary to vertebral collapse following osteoporotic thoracolumbar fracture. Posterior spinal fixation is a major surgical option, and partial vertebral osteotomy (PVO) through a posterior approach is occasionally reasonable for achievement of complete neural decompression and improvement of excessive local kyphosis. However, the indications and need for PVO remain unclear. The objectives of this retrospective study were to determine the efficacy and safety of posterior spinal fixation with or without PVO for osteoporotic thoracolumbar vertebral collapse and identify patients who require neural decompression and alignment correction by PVO. We retrospectively reviewed the clinical records of 20 patients (13 females, 7 males; mean age, 67.1 years) who underwent instrumented posterior fixation for osteoporotic thoracolumbar vertebral fracture. Clinical outcomes were assessed by the Japanese Orthopedic Association score and visual analog scale scores in the lumbar and leg areas. PVO was added with posterior spinal fixation in eight patients because neural decompression was incomplete after laminectomy as indicated by intraoperative echo imaging. Neurological and functional recovery significantly improved during follow-up. Clinical outcomes in patients who underwent PVO were similar to those in patients who did not undergo PVO. However, correction of the local kyphotic angle and improvement of spinal canal compromise after surgery was significant in patients who underwent PVO. The patients who required PVO had a less local kyphotic angle in the supine position and higher occupation rate of the fractured fragment in the spinal canal in the preoperative examination.
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  • Image-guided Spine Stabilization for Traumatic Or Osteoporotic Spine Injury: Radiological Accuracy and Neurological Outcome
    Nobuyuki SHIMOKAWA, Junya ABE, Hidetoshi SATOH, Hironori ARIMA, Toshih ...
    2016 Volume 56 Issue 8 Pages 493-500
    Published: 2016
    Released on J-STAGE: August 15, 2016
    Advance online publication: April 11, 2016
    DOIhttps://doi.org/10.2176/nmc.oa.2015-0334
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    Significant progress has been made in image-guided surgery (IGS) over the last few decades. IGS can be effectively applied to spinal instrumentation surgery. In the present study, we focused our attention on the feasibility and safety of image-guided spine stabilization for traumatic or osteoporotic spine injury. The IGS spine fixation with or without minimally invasive surgery (MIS) techniques such as percutaneous screw placement, balloon kyphoplasty (BKP), or vertebroplasty (VP) were accomplished in 80 patients with traumatic or osteoprotic spine injury between 2007 and 2015. The injured vertebral levels included the following: cervical spine, 41; thoracic spine, 22; and lumbar spine, 17. Neurological condition before and after surgery was assessed using the American Spinal Injury Association Impairment Scale (AIS). A total of 419 pedicle, lateral mass, or laminar screws were placed, and 399 screws (95.2%) were found to be placed correctly based on postoperative computed tomography scan. Although 20 screws (4.8%) were found to be unexpectedly placed incorrectly, no neural or vascular complications closely associated with screw placement were encountered. Neurological outcomes appeared to be acceptable or successful based on AIS. The IGS is a promising technique that can improve the accuracy of screw placement and reduce potential injury to critical neurovascular structures. The integration of MIS and IGS has proved feasible and safe in the treatment of traumatic or osteoporotic spine injury, although a thorough knowledge of surgical anatomy, spine biomechanics, and basic technique remain the most essential aspects for a successful surgery.
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  • Early Cerebral Circulation Disturbance in Patients Suffering from Severe Traumatic Brain Injury (TBI): A Xenon CT and Perfusion CT Study
    Mitsuru HONDA, Ryo ICHIBAYASHI, Hiroki YOKOMURO, Katsunori YOSHIHARA, ...
    2016 Volume 56 Issue 8 Pages 501-509
    Published: 2016
    Released on J-STAGE: August 15, 2016
    Advance online publication: June 29, 2016
    DOIhttps://doi.org/10.2176/nmc.oa.2015-0341
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    Traumatic brain injury (TBI) is widely known to cause dynamic changes in cerebral blood flow (CBF). Ischemia is a common and deleterious secondary injury following TBI. Detecting early ischemia in TBI patients is important to prevent further advancement and deterioration of the brain tissue. The purpose of this study was to clarify the cerebral circulatory disturbance during the early phase and whether it can be used to predict patient outcome. A total of 90 patients with TBI underwent a xenon-computed tomography (Xe-CT) and subsequently perfusion CT to evaluate the cerebral circulation on days 1–3. We measured CBF using Xe-CT and mean transit time (MTT: the width between two inflection points [maximum upward slope and maximum downward slope from inflow to outflow of the contrast agent]) using perfusion CT and calculated the cerebral blood volume (CBV) using the AZ-7000W98 computer system. The relationships of the hemodynamic parameters CBF, MTT, and CBV to the Glasgow Coma Scale (GCS) score and the Glasgow Outcome Scale (GOS) score were examined. There were no significant differences in CBF, MTT, and CBV among GCS3–4, GCS5–6, and GCS7–8 groups. The patients with a favorable outcome (GR and MD) had significantly higher CBF and lower MTT than those with an unfavorable one (SD, VS, or D). The discriminant analysis of these parameters could predict patient outcome with a probability of 70.6%. During the early phase, CBF reduction and MTT prolongation might influence the clinical outcome of TBI. These parameters are helpful for evaluating the severity of cerebral circulatory disturbance and predicting the outcome of TBI patients.
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Review Article
  • The Importance of Recognizing Diffuse Idiopathic Skeletal Hyperostosis for Neurosurgeons: A Review
    Masatoshi YUNOKI, Kenta SUZUKI, Atsuhito UNEDA, Shuichi OKUBO, Koji HI ...
    2016 Volume 56 Issue 8 Pages 510-515
    Published: 2016
    Released on J-STAGE: August 15, 2016
    Advance online publication: March 28, 2016
    DOIhttps://doi.org/10.2176/nmc.ra.2016-0013
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    Diffuse idiopathic skeletal hyperostosis (DISH) is characterized by calcification and ossification of the soft tissues, mainly ligaments and entheses. The spines of patients with DISH generally become increasingly rigid and osteoporotic, and fractures may occur after even a relatively minor traumatic event such as a ground-level fall. Moreover, the prevalence of DISH may be rapidly increasing in affluent societies. Thus, awareness of this condition is becoming more important for neurosurgeons when assessing trauma patients. For the present article, a literature review was conducted to summarize the current clinical, pathogenetic, and therapeutic knowledge of this disease. Furthermore, current treatment strategies for DISH-related spine injuries are also reviewed. Although the recommended treatment for spinal injuries in DISH patients is surgical, mainly through long-segment posterior fusion, rather than conservative options, stable fractures without any associated neurologic deficits have often been successfully managed with immobilization alone. Percutaneous instrumentation and the use of teriparatide may be useful depending on the surgical risks and patient neurological status.
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Editorial Committee
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