頭蓋内脳腫瘍による続発性脊髄障害について病理解剖所見を中心にその病態について述べた.続発性脊髄障害の原因として, 1)髄膜播腫, 2)腫瘍の硬膜外転移, 3)脊髄実質内のびまん性浸潤, 4)脳原発の悪性リンパ腫による脊髄障害を挙げた.髄膜播腫では神経根障害が強いこと, 実質内への腫瘍細胞浸潤と二次的な循環障害による脊髄障害を強調した.硬膜外転移については血行性と, 髄膜播腫からの神経根に沿っての転移経路を病理学的に明らかにした.またgliomatosis cerebriの脊髄障害の病理所見として脊髄全長にわたるびまん性の腫瘍細胞浸潤を記載した.脳原発悪性リンパ腫の脊髄障害は基本的に髄膜リンパ肉腫症の所見と同一である事を強調した.以上から頭蓋内脳腫瘍の治療中または治療後の経過の中で, 臨床的に脊髄症状, 神経根症状に注目すべきであり, また画像診断との関連についても今後, 臨床的観察が重要である事を指摘した.

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Direct anterior screw fixation for type II and type III (Anderson & D'Alonzo) odontoid fracture is a new alternative to posterior atlanto-axial (A-A) arthrodesis in that normal upper cervical motion can be preserved. Thirteen patients of Type II and three of Type III odontoid fractures were treated with anterior odontoid screw stabilization during the past four years. The fractured odontoid fragments were displaced anteriorly (3-8mm) in nine patients and posterior displacement (4-15mm) was seen in six patients. No displacement was seen in one case. Three of these patients had concomitant Jefferson's fracture. Preoperative reduction of the displaced odontoid fragment and postoperative stability of the A-A complex were obtained in fourteen cases. They were followed for a minimum of 5 months (mean 27 months). In two patients, the odontoid fused with permissible displacement (3, 4mm) due to incomplete preoperative reduction. No neurological complications related to the procedure were seen. Another two patients showed fracture resolution delayed to over 8 months and 10 months respectively, probably due to the significant anterior fracture gap resulted from excessive posterior angulation during screw fixation and extreme instability of the fracture site. The anterior screw fixation of odontoid fracture is an ideal method of treatment, but it should be performed in selected patients by a surgeon with experience.

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There are various surgical strategies for the treatment of ventral or ventrolateral thoracic or thoracolumbar pathology. Standard laminectomy with manipulation of the spinal cord can cause significant spinal cord injury. Transthoracic approach requires violation of pleural space, manipulation of the lungs and mediastinal structures, and chest tube drainage. We have performed posterolateral approach for 3 years for ventral or ventrolateral thoracolumbar disease in 22 patients; 6 tumor cases, 7 thoracic disc herniation cases and 9 fracture cases. We have performed 16 cases of transpedicular approach, 2 cases of costotransversectomy, 3 cases of lateral extracavitary approach and 1 case of lateral parascapular extrapleural approach. Bilateral transpedicular routes were used in 3 patients and supplemental laminectomies in 6. The final outcome was measured by Prolo's Functional-Economic Outcome Rating Scale. Final functional outcomes were; good in 13, moderate in 6, and poor in 3 cases. Spinal canal decompression was confirmed with follow up CT scan or MRI. There were three operative complications-two CSF leakages and one delayed wound infection. Compared to transthoracic approach, the posterolateral approach has few potential complications such as violation of the pleural space, manipulation of the mediastinal structure, and it enables immediate posterior stabilization, if necessary. In conclusion, the posterolateral approach to ventral or ventrolateral thoracolumbar pathology is an effective procedure which allows adequate decompression of ventral encroachment without further spinal cord injury.

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The generally accepted procedure for the removal of a large cervical dumbbell-shaped neurinoma is that a posterior approach is carried out first for the removal of the intraspinal tumor and then the remaining extraspinal tumor is explored through an anterior approach. We have achieved total resection of these tumors at one-stage operation by an anterolateral transforaminal approach. In the supine position, a linear skin incision along the anterior margin of the sternocleidomastoid muscle is made. This muscle and external jugular vein are retracted laterally and the longus capitis muscles medially. This step gives exposure of the extraspinal portion of the tumor as well as cervical nerves distal to the tumor just above the scalenus muscular groups. After an intracapsular decompression of the tumor, these two muscular layers are dissected and retracted medially to identify the vertebral artery, which is mobilized upward to expose the intraforaminal portin of the tumor. The intradural part of the tumor is then removed through this enlarged foramen. After the removal of tumor, the dura is closed and no bone graft is required. This approach dealt with a series of 11 cases. Satisfactory surgical results were achieved in 10 cases. In discussion, we compare this transforaminal approach with other anterolateral approaches such as transuncodiscal and oblique transcorporeal ones.

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Fifty-three patients with spinal nerve tumors, including 9 neurofibromas and 44 schwannomas were operated on in our clinics between 1962 and 1997. Frequent initial symptoms were neuralgic pain in 26 cases, weakness of the region of the involved nerve(s) in 12, and the dysesthesia or numbness in 8. Patients showing only neuralgic pain or weakness of the involved nerve(s) or asymptomatic were classified as Stage I (5 patients); those presenting neurological dysfunction but were able to walk by themselves were classified as Stage II (21 patients); those presenting paraplegia and consequently were unable to walk were classified as Stage III (23 patients); and those presenting tetraplegia and were unable to sit were classified as Stage IV (4 patients). All patients in Stage IV had cervical tumors and 2 of them were neurofibromas. The presence of vesico-urinary disturbance was closely correlated with the exacerbation of neurological dysfunction : In Stage I, there was no vesico-urinary dysfunction, in Stage II 9.5%, in Stage III 78.3%, and in Stage IV 100%. Location of the tumors in relation to the dura mater revealed 36 tumors were intradural, 7 were purely extradural, and 10 were dumbbell type. The follow-up review of these 53 cases showed good functional recovery except for 1 case of neurofibroma in Stage IV who is now bedridden. Postoperative neurological recovery is satisfactory in all cases, and even if the tumor originated from anterior roots of C5 and/or C6, risks of neurological deficit after resection of the involved nerves were negligible.

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The authors have used the technique called the oblique transcorporeal approach to achieve spinal cord decompression in four patients with ossification of the posterior longitudinal ligament. The procedure consists of posterior displacement of the vertebral artery and obliquely drilling out the postero-lateral part of the vertebral bodies and intervertebral discs up to the beginning of the contralateral nerve root. This technique permits easy access to the anterior aspect of the spinal cord from the antero-lateral direction, and safe removal of ossification of the posterior longitudinal ligament. Because most of the disc is undisturbed, it does not require bone fusion or postoperative immobilization. The surgical results have been excellent, with all cases showing marked improvement of their neurological signs, and no spinal instability developing over the follow up period of from 6 months to three years. The details of this approach are described and the advantage of this technique over the anterior or posterior approach is discussed.

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We reported two cases of cervical disk disease who demonstrated cervical radiculopathy of the unilateral upper extremities. Their CT myelogram in the neutral position did not demonstrate any evidence of cord compression or narrowing of the intervertebral foramen. However, these patients showed a rotation of the involved vertebral body on the CT myelogram in the extending position and their neurological deficit was aggravated in this special position. With a diagnosis of cervical disk disease, they were successfully treated by anterior fusion or decompression. In such cases, CT myelography in the extending position showed substantial evidence of abnormality even if their usual CT myelograph in the neutral position demonstrated normal findings. The possible mechanism of their neurological symptoms was also discussed.

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The authors have performed 134 microsurgical anterior cervical platings (MACPs) for degenerative cervical spine diseases using various systems with successful results. More than 95.5% of the patients showed improvement of their clinical manifestations and no aggravation was observed. No complications, such as injury of the nomal structures, system related problems or infection, were experienced. Symptomatic progression of degeneration of the adjacent spines has not been observed. MACP provides immediate strong fixation, maintaining physiological lordosis soon after operation. This procedure is not very invasive so long as it is carried out appropriately and it is applicable even to aged patients. MACP is indicated under the conditions which are discussed and keys for secure, rapid and accurate procedure are also mentioned.

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We studied the clinical and radiological follow-up of patients with double door laminoplasty, splitting the spinous processes, but preserving the posterior supporting structures and using a hydroxyapatite spacer for cervical degenerative diseases. In our hospital standard double door laminoplasty, splitting the spinous processes and using a hydroxyapatite spacer has been performed on 44 patients from July 1994 to September 1995. This standard procedure has gradually produced favorable clinical results. However the partial removal of the spinal posterior structures, as happens in this method, might possibly spoil the stability of the cervical spine. Because of this danger, we incorporated into our standerd method the preservation of the maximum amount of the posterior supporting structures. This modified procedure has been performed on 69 patients since November 1995. Among them, 41 patients who had been followed-up for more than 1 year were selected. Thirty patients had cervical spondylotic myelopathy, 6 had ossification of the posterior longitudinal ligament and 5 had cervical myelopathy due to disc herniation. The average age at operation was 60.0 years old. The average follow-up period was 18.1 months. Preoperative and postoperative clinical assessments were evaluated by Neurosurgical Cervical Spine Scale (NCSS). Radiological courses were examined by the cervical range of motion on the lateral flexion and extension radiographs and the cervical curvature index calculated by Ishihara's method. The improvement of the postoperative clinical courses by NCSS was maintained over 1 year, including cases where the patients were over 70 years old. Radiologically, the cervical range of motion decreased after the operation, but the cervical curvature was generally maintained better after the operation, compared with results obteined by the former standard procedure. We emphasize that double door laminoplasty splitting the spinous processes but preserving the posterior supporting structures is a useful posterior approach, which is easily and safely performed and produces good clinical results for cervical degenerative diseases. However, it should be noted that follow-up periods were short.

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We report a case of cerebrospinal fluid hypotension probably caused by lumbosacral meningeal rupture due to injury. This 19-year-old male was admitted to our clinic on July 31, 1989, after involvement in a motor vehicle accident. On admission neurological examination revealed no abnormalities except for his altered consciousness level. Physical examination on admission demonstrated a skin abrasion on his back and head. Cranial CT scan showed an epidural hematoma in the right side without evidence of midline shift. Three days after admission the patient complained of a postural headache worsened by taking up a sitting position. Observation revealed the patient had lumbar subcutaneous fluid retention suggesting cerebrospinal fluid leakage. Plain lumbar X-ray revealed L5 spondylosis and S1 spina bifida occulta. In order to confirm the diagnosis and determine the location of the dural tear a myelography was performed, but there was no evidence of abnormalities. Although an accurate leak point could not be detected, he was diagnosed as having cerebrospinal fluid hypotension due to a lumbosacral meningeal rupture. He was kept in bed and received autologous epidural blood patch three times followed by closed continuous drainage of cerebrospinal fluid. He made a good recovery and was free of after-effects. Traumatic lumbar subcutaneous cerebrospinal fluid leakage without traumatic avulsion of lumbosacral nerve roots is extremely rare. The diagnosis and treatment of this condition are discussed here.

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