We retrospectively review the results of treatment of a series of nine patients with spinal spondylitis. Nine consecutive patients with tubecular or pyogenic spinal spondylitis were treated between 1989 and 1999. Nonsurgical management is indicated for patients with minimal or no neurological deficits and absence of significant localized kyphotic deformities. Surgical indications included the presence or development of motor deficits with epidural compression and/or localized kyphotic deformities, or the failure of medical therapy. Seven patients underwent surgery. Five patients were treated using full instrumentation. Conservative therapy was conducted on 2 patients. After a minimal follow-up period of 6 months, all patients showed neurological improvement. Early surgical decompression results in rapid improvement of neurological deficits and stabilization with bony fusion. The presence of active infection does not preclude the use of internal fixation.

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<Object> This study was conducted to determine the optimal surgical intervention associated with performing vertebral reconstruction in cases of fracture and dislocation of C1 and C2. <Methods> Between 1984 and 1999 twenty-five patients underwent surgical treatment for correction of traumatic C1 and C2 lesions. There were 21 men and 4 women, with ages ranging from 17 years to 62 years (mean age : 36 years). The pattern of C1 and C2 injury included 4 complex C1-2 fractures, 13 C2 odontoid fractures, 3 hangman's fractures of C2 and 5 atlantoaxial dislocations (AAD) (3 irreducible AAD and 2 reducible AAD). Seven patients underwent posterior fixation with monofilament wire and an iliac bone graft in the pre-instrumentation era. Four patients underwent posterior fusion with an interlaminar clamp and an iliac bone graft, four underwent posterior fusion with multifilament wire and an iliac bone graft, three of the hangman's fracture cases underwent anterior fusion with anterior plating and an iliac bone graft, three underwent posterior fusion with a transarticular screw, multifilament wire and an iliac bone graft, in four odontoid screws were placed (two of which needed an additional transarticular screw) and three underwent one staged-transoral decompression and posterior fusion. There were no operative deaths or neurological sequelae following surgery. <Conclusion> Surgical correction of traumatic C1 and C2 lesions has an important role to avoid progressive neurological sequelae. Tailored surgery should be performed taking into consideration the pattern of injury, the degree of instability, reducibility and the severity of cord compression.

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We studied the frequency and clinical consequences of vertebral artery injuries and the relationship between the type of vertebral artery injury and bone abnormalities in patients with acute cervical spine trauma. One hundred and eleven patients who had acute nonpenatrating cervical spine trauma were examined with MR angiography and/or 3D-CT angiography, within 24 hours after the injury. From findings of MR angiography and/or 3D-CT, we classified vertebral artery injury as "displacement", "stenosis" and "occlusion". Findings concerning the vertebral artery in MR angiography and/or 3D-CT angiography demonstrated abnormalities in 22 patients (19.8%). 5 of the cases (4.5%) had displacement of the vertebral artery, 7 cases (6.3%) had stenosis and 10 cases (9.0%) had occlusion of the vertebral artery. Patients without bone dislocation had no vertebral artery injuries. Patients with bone displacement had a high incidence (71.0%) of vertebral artery injury. Neurological deficits due to ischemia of the brain appeared in 5 cases (16.1%). We should consider the possibility of vertebral artery injury especialy in patients with subluxation or dislocation of the cervical spine.

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In cases of anterior reconstruction of the cervical spine, we compared, retrospectively, the surgical results and the average hospitalization time of 121 patients who underwent instrumentation surgery with a group of 115 patients who underwent non instrumentation surgery. CERLOCK and BAK Interbody Fusion Cage Cervical were used for interbody fusion cages, and Cervical Spine Locking Plate and Pylamesh were used for internal fixation devises from 1997 to 1999. In the group with instrumentation, the fusion rate was 94% and the average hospitalization time was 18 days. In the group without instrumentation, the results were 89% and 27 days, respectively. The results of this study demonstrate that the use of instrumentation may raise the cost of the operation, but it provides immediate stabilization, and, by shortening the hospitalization time, enables a quicker return to work. Sufficient follow-up periods for assessment is mandatory.

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Conventional laminectomy is normally performed in patients with lumbar hernia, degenerative lumbar canal stenosis, and spinal tumors. Postoperative CT scans show moderate to severe atrophy of the posterior lumbar muscles. Preservation and reconstruction of the bony components has been the primary consideration with certain types of laminoplasty indicated including expansive open-door laminoplasty, the spinous-process-splitting method and en bloc laminoplasty. On the other hand, associated soft tissues such as muscles and ligaments have not been considerated an important element of the spine. In this study, we report on multi-level lumbar laminectomy to preserve the maximum amount of posterior suppporting tissue. The period of this study was from July 1996 to December 1999, during which this method was performed on 58 patients (mean age 62.8 years, ages ranging from 48-78) with 8 lumbar disc hernia, and 50 lumbar canal stenosis. In conclusion, our method causes minimal injury to soft tissue (supra and inter-spinous ligaments), and will help prevent distortion of the spine and instability. Facetectomy is minimized compared with hemilaminectomy and bilateral facetectomy. This method brings an improvement to the daily quality of life of the patient and shortens the period during which a lumbar corset must be worn.

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The term mini ALIF (mini-anterior lumbar interbody fusion) was created to described by Dr Mayer in Germany as a new anterior approach to the lumbar spine for the purpose of performing interbody fusion. This approach is based on conventional surgical techniques for exposure of the anterior parts of the lumbar spine to which the general principles of microsurgery have been applied. We developed a more minimal use of this new method, so we report our experience with mini ALIF in 36 cases for lumbar degenerative spondylolisthesis. The fusion rate was 95% and no major complication occurred. The average correction of % slip and slip angle was 12.3% and 12.0 degree, respectively. The recovery rate on the JOA score averaged 63.3%. We regard this new method as an excellent surgical procedure for lumbar degenerative spondylolisthesis.

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A 46-year-old male was admitted to our hospital presenting with subarachnoid hemorrhage. A computed tomography revealed subarachnoid hemorrhage in the prepontine cistern. Vertebral angiography showed a dural arteriovenous fistula at the craniovertebral junction. This dural arteriovenous fistula had two meningeal arteries from both vertebral arteries and a vein drainging into the intracranial venous system. Clipping of the draining vein was performed using the transcondylar approach. Ten days after the operation, the feeding arteries were still alive, but 2 months after the operation, the dural arteriovenous fistula was shown by angiography to have been eliminated completely. Dural arteriovenous fistula at the craniovertebral junction presenting with subarachnoid hemorrhage is a very rare entitiy. We discussed the clinical features, diagnostic problems, therapeutic strategies, and operative approach of our case and the previously reported 11 cases of dural arteriovenous fisutla at the craniovertebral junction in the literature.

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Multiple lesions of the calcified cervical ligamentum flavum are quite rare and no detailed studies have been done in the past, although approximately 100 cases of calcified ligamentum flavum have been reported. We report two cases of such lesions which caused cervical myelopathy. The first case was a 68-year-old woman with a 3 months history of gradually progressing gait disturbance. Plain cervical X-ray revealed narrowing of the spinal canal with thin nodular calcifications in the posterior part of the spinal canal at the level of C4/5, 5/6 and 6/7. Three dimensional (3D) CT scan clearly demonstrated the round, calcified masses situated on the ventral part of the vertebral laminae at same levels. MRI and computed tomography (CT) myelogram disclosed severe compression of the spinal cord by the masses. The second case was a 71-year-old woman with a one month history of an increasing severe neck pain and symptoms of cervical myelopathy, who also harbored the same kind of masses at the level of C3/4, 4/5 and 5/6. In both cases, the masses within the ligamentum flavum were removed surgically from the inner surface of C4, 5, 6, 7 laminae. The masses appeared to have no continuity with the dura mater, and the calcification per se was confined within the ligament. Postoperative imaging studies revealed complete decompression of the spinal cord and the symptoms in both patients decreased. The 3D-CT scan was very useful in understanding the anatomical relationship between the calcified masses and the spinal structures, in making the treatment strategies, and also in differentiating the calcified ligamentum flavum from ossified ligamentum flavum, each of which seemed to be a distinct clinical entity.

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We present 2 comparatively rare cases of spinal cord decompression sickness (SCDS) associated with scuba (self-contained underwater breathing apparatus) -diving. A 39-year-old man and a 43-year-old man, both professional divers, presented with neurological deficits after over 1 hour from the beginning of a scuba-diving session. Neurological deficits occurred acutely in one case, and in the other case appeared gradually. We gave both patients emergency hyperbaric oxygen (HBO) therapy within 24 hours. They were almost completely ADL (activity of daily living) after a long rehabilitation. The pathophysiology of SCDS is not completely understood, but is behaved to be mainly due to arterial gas embolism and venous infarction. It is difficult to understand how venous congestion could be origin, if the white matter of the upper or middle thoracic cord segment is affected most frequently. We describe herein MRI evaluated SCDS.

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Endoscopic microsurgery for spinal disorders has become a well-established, valuable approach during the past decade. We report on a patient with herniated thoracic discs which were removed using thoracoscopy. A 56-year-old man noted acute onset of burning pain at the right lateral abdomen. Two weeks later, he also presented with gait disturbance. Neurological examination revealed left spastic gait and increased deep tendon reflexes in both lower extremities. Magnetic resonance imagings indicated mild compression of the spinal cord caused by protruded thoracic discs at the T6/7 and T7/8 levels. A double-lumen endotracheal tube was inserted to allow intraoperative single-lung ventilation. The patients was placed in a lateral position and four flexible portals were inserted into the thoracic cavity. Following that procedrue, the proximal ribs were removed. Discectomy was performed at the T6/7 and T7/8 levels. Upon discharge, the patient had no neurological deficit except right T7 neuralgia. It was considered that video-assisted thoracoscopic surgery was useful for thoracic surgery.

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We report a unique case with thoracic extradural mesenchymoma. A sixty-three-year old male had complained of progressive gait disturbance due to motor weakness and sensory disturbance under Th 5 level. Computed tomography showed an ossifying lesion in the thoracic spinal canal with slight osteoclastic change in the lamina. Magnetic resonance images (MRI) revealed an ellipsoid tumor at the level of Th 5 and Th 7 which appeared buried in the thoracic epidural adipose tissure. The tumor was compressing the thoracic cord anteriorly. We performed Th 4-Th 8 osteoplastic laminotomy and achieved total resection of the ossified tumor. The pathological findings indicated hamartomatous and mesenchymal characteristics, which contained fat tissue, bone trabeculae, fibrous tissue, and haematopoietic tissue. Benign mesenchymomas in the spine are extremely rare and have a high recurrent rate of about 20% in the literature. The treatment of choice is the total resection followed by long-term clinical follow-up.

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