Expansive laminoplasty has been widely used for treatment in patients with cervical compressive myelopathy. We evaluated the usefulness of expansive laminoplasty for patients with cervical canal stenosis due to multisegmental cervical spondylosis (CS) and ossification of the posterior longitudinal ligament (OPLL), and analyzed how the preoperative prognostic factors affect the outcome in both diseases. The authors reviewed 57 patients with CS and 25 patients with OPLL, who underwent expansive open-door laminoplasty. Pre- and post-operative clinical symptoms were evaluated by the Japan Orthopedic Association (JOA) disability score. The influences of predictive factors on the clinical outcome were analyzed by evaluating the recovery rate. The mean functional recovery rate in JOA score was 60.5% in the CS group and 63.8% in the OPLL group, showing no significant difference between the two groups. While improvement in the lower limbs' motor function was better than that in the upper limbs in both groups, all the patients showed an improvement or reduction in symptoms of myelopathy. The mean recovery rate of sensory function was approximately 50% in both groups. In the CS group, the duration of symptoms and severity of preoperative disability singnificantly (p<0.05) affected the operative outcome. In the OPLL group, the severity of preoperative disability and severity of canal stenosis showed significant influences on the operative outcome. Open-door expansive laminoplasty in patients with cervical compressive myelopathy due to multisegmental CS or OPLL showed promising improvement of myelopathy. In order to improve the patient's disability, early decompressive surgery following proper diagnosis must be done in these patients.

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The case reports were reviewed 164 patients who had died subsequent to surgeries for metastatic spine tumors. Excisional procedures were performed in 23 patients, and palliative procedures were carried out in 141. The surgical indications for these procedures were pain or paralysis due to spinal instability or direct invasion of the tumors, or pain associated with radioresistent tumors. Excisional procedures for the purpose of local cure were rarely indicated in patients with long life expectancy. As for the results, though improvement in paralysis was neither always good nor maintained, pain relief was effectively achieved and maintained. A maximum 15 point scoring system based on six items was developed for the preoperative evaluation of the prognosis, and the surgical procedures was decided based on this scoring system. The total score obtained for each patient could be correlated with the prognosis : when related with survival it was proposed that patients who scored under 8 points would survive for less than 6 months ; patients who scored from 9 to 11 points would survive for over 6 months ; and patients who scored 12 or more points would survive for over 12 months. These point-based prognoses held true for 77.4% of the patients. Therefore, it would be reasonable to state that an excisional procedure would be indicated for patients with a total score of 12 or more. On the other hand, in patients with scores of less than 8, selected conservative treatment or less invasive palliative procedures should be considered. For the group scoring between 9 and 11, an excisional procedure should be indicated with the provision that the tumoral lesion and borders could be aggressively removed. Metastatic spine tumors are considered as a general disease and these patients have limits of their life expectancy, so this scoring system was useful in the decision whether or not to subject the patient to surgery and in the selection of the most appropriate surgical procedure.

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The purpose of this study was to evaluate the use of titanium mesh cage (filled with morselized local bone from a corpectomy) and locking plate after anterior corpectomy for multi-level disease of the cervical spine. With this procedure, since 1999, we treated 16 patients (6 men and 10 women with a mean age of 61.6 years) for cervical myelopathy caused by OPLL (8 cases), vertebral tumors (3 cases), spondylosis (3 cases), and osteomyelitis (2 cases). Corpectomy was performed in one (8 cases), two (7 cases), and three vertebrae (1 case). Autologous bone fragment were taken from the removed vertebra, except in any cases complicated by tumor and infection. The improved rate as scored on the Neurosurgical Cervical Spine Scale (NCSS) was on average 68.8%, and stable bone union was obtained in 13 cases in an average follow-up period 18.7-months (range of from 12 to 29 months), except in cases complicated by metastatic tumors. Postoperative complications included dyspnea (1 patient) and cerebrospinal fluid leakage treated by lumbar drainage (1 patient) without any additional repair operation. There were no hardware complications. This technique presents good clinical results and helps to avoid complications associated with harvesting bone from the iliac crest donor site.

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Specific characteristics, such as variable angle screw or screw translation, and advantages and/or possibilities of three newly developed anterior cervical plate systems are introduced based on the author's preliminary clinical experience. Spinal instrumentation is widely accepted and far more promising as one of the therapeutic modalities for various spinal disorders, such as tumor, trauma, anomaly or degenerative disease. However, surgeons must take care that implantation of metal into a living body may give rise to serious system-related medicolegal matters.

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Recently, the use of hydroxyapatite as a substitute for an iliac bone graft in anterior cervical fusion has been reported, but is associated with some problems, such as a slip out of the hydroxyapatite plugs or the development of a radiolucent zone around the implant on postoperative X-rays. While porous hydroxyapatite promotes bony ingrowth, a significant number of implant collapses have been reported. To avoid these complications, anterior titanium plates or cages are used. Patients treated with an anterior plate, however, run the risk of not only hardware complications but also a decreased fusion rate for single-level fusion. On the other hand, the use of the titanium cages occasionally leads to vertebral body collapse. Moreover, cages cause an artifact on magnetic resonance T2-weighted axial imaging. We have developed a new implant in order to avoid all those drawbacks and complications. The device, which we call the K-CHAS, is made of dense hydroxyapatite and β-tricalcium phosphate (β-TCP) composite, is 11mm in length, 8mm in anterior diameter and 7mm in posterior diameter, and is threaded. The K-CHAS can withstand a compression force of 501kg/cm^2. β-TCP actively promotes osteogenesis and can be eventually replaced by bone. The Smith-Robinson's procedure is indicated, in which two implants are screwed into the intervertebral space in parallel. There is no need to harvest or collect bone. We have used this implant at 42 levels in 37 patients, with mean age of 55.4 years. Patients were placed in a hard cervical collar for 1 to 2 weeks after operation. They were allowed to walk on the second postoperative day. There were no intraoperative complications. Radiological follow-up showed neither instability nor any radiolucent zones. The K-CHAS provides immediate, solid stability of the cervical spine and brings about early fusion in the anterior cervical spine surgery.

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The author presents a study on the primary operative techniques in cases of cervical degenerative disease (CDD : spondylosis, disc hernia, and ossification of the posterior longitudinal ligament) requiring re-operation. Re-operation was required in 30 cases from a total of 539 operations for CDD in the period from April 1996 to December 2000. The age range at re-operation was from 22yr to 79yr, with 18 males and 12 females comprising the 30 patients. The period between the primary procedure and reopration ranged from 4 months to 18yr. Primary operation via the anterior approach was performed in 23 of the 30 patients. Deterioration of the nervous system was caused by a new stenosis in 15 patients, restenosis at the first level in 5 cases and non-union in 3 cases. The anterior approach was employed for re-operation in 8 patients, and the posterior approach in the remaining 14 patients combined approach in one case. In seven patients, deterioration was seen yet again, caused by kyphotic cervical spine in 5 patients and restenosis in 2. Re-operation was once again performed via the anterior approach in 5 patients and via the posterior approach in 2. In order to forestall re-operation, there are twe important considerations. First, an operation via the anterior approach is effective for stenosis of the lateral spine canal, but in cases involving stenosis of multiple segments, the posterior approach is required. Second, in cases of spinal column stenosis the procedure of chive is via the posterior approach, but in patients with cervical kyphosis the anterior approach should be considerd.

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Two elderly patients, who had undergone expansive laminoplasty (EL) for cervical spondylotic myelopathy associated with developmental canal stenosis, presented with recurrent myelopathy and severe dysesthesic pain in the bilateral upper limbs. The computed imaging study showed posterior displacement and deformity of the cervical cord at the site of the EL, indicating the presence of traction being applied to the cervical cord and root (lets). Both patients underwent antero-lateral partial vertebrectomies (ALPVs) and showed satisfactory improvement of the symptoms in a space of a couple of months. ALPVs, in which the posterior longitudinal ligament was widely excised, facilitated the anterior movement of the cervical cord and worked against the pulling force. Beta-tricalcium phosphate (Beta-TCP) was implanted into the site of the vertebrectomy in both patients. New bone formation was evident on the surface of beta-TCP four months after the surgery in one patient. Beta-TCP seemed to be a useful material to strengthen the cervical column which was reduced in volume by ALPV.

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Clinical symptoms and diagnostic features with operative indication are investigated in 111 cases (15 male and 96 female) of carpal tunnel syndrome (CTS) seen at our institution, of which 53 cases had bilateral CTS. CTS was detected in the non-dominant side hand in 50 cases. Conservative care was selected in 58 cases with favorable recovery, whereas operative treatment was indicated in 53 severely affected cases with excellent result after direct microscopic surgery. Atypical patterns of sensory disturbance were shown in 50% of our series. The positive rate was 50% with Tinel's sign and approximately 90% with Phalen's sign. Nerve conduction studies are the most reliable method for diagnosis of CTS by detecting demyelination and axonopathy. MRI showed decreased volume of the carpal tunnel with T1 weighted images and increased signal intensity of the flattened median nerve at the affected wrists with T2 weighted images. These findings showed a favorable improvement in T2 weighted images with normalized signal intensity of the round-shaped median nerve in the increased space of the carpal tunnel after surgery.

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We evaluated surgery for thoracic outlet syndrome (TOS). Forty patients had undergone surgery for TOS. The surgical methods consisted of the anterior approach for scalenectomy (AAS), the lateral approach for scalenectomy (LAS), and transaxillary first rib resection (FR). Preoperative symptoms disappeared in 23/26 (88%), 5/7 (71%), and 10/12 (83%) operations in AAS, LAS, and FR, respectively. Postoperative complications occurred in 1/26, 0/7, and 2/12 in AAS, LAS, and FR, respectively. We discuss the feature of these three operative methods, and conclude that LAS is the procedure of choice in surgery for TOS.

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Degenerative changes in the spine can produce osteophytic spurs on the anterior part of the cervical vertebrae. Cervical spondylosis or ankylosing hyperostosis is usually asymptomatic. Dysphagia caused by cervical osteophytic formation is quite rare. The following cases are the reports and reviews of the literature with striking radiographic findings. Their ages were little younger than previous reports and all were male patients. A massive anterior cervical osteophyte was resected without discectomy and fusion via the anterior approach followed by excellent relief of symptoms.

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Tumors at the craniovertebral junction are uncommon and difficult to diagnose clinically. We report on the case of a 79-year-old woman who presented with a history of progressive cervical myelopathy. Neuroimaging studies demonstrated a tumor behind the odontoid vertebra and ventral compression of the rostral spinal cord by this retro-odontoid mass. Histopathologically, the surgical specimen was a non-neoplastic fibrocartilaginous mass. Since the tumor was not neoplastic and amenable to surgical excision, differential diagnosis of this "pseudotumor", a new pathological entity recently described by Sze and Crockard, is important.

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The authors report a rare case of renal cell carcinoma with metastasis to the cauda equina. A 68-year old male was evaluated for a two-year history of increasing low back pain. His medical history included a renal cell carcinoma diagnosed seven years earlier and treated by right nephrectomy. He then underwent partial pneumonectomies on three occasions for metastatic lung tumors from the primary lesion. On admission, he showed radicular pain projecting into the right L5 region, but he exhibited no sensorimotor deficits. Lumbosacral MR imaging revealed an intradural extramedullary mass at the level of L3. He underwent L2-4 laminectomy. The tumor had not infiltrated into the subarachnoid space and involved only one spinal nerve that was excised during surgery. The tumor was removed successfully and was confirmed by the pathology to be a metastasis from a renal cell carcinoma. His postoperative course was satisfactory. He noticed relief from radicular pain and left hospital on the twelfth postoperative day without neurological deficits. The majority of cauda equina tumors are primary tumors, and metastases from outside of the central nerves system are extremely rare. To our knowledge, only a few cases have been reported in detail in the literature. The literature is reviewed with reference to tumor pathology, diagnostic future and modes of metastasis to the cauda equina.

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We report an extremely rare case of composite gliofibroma and pilocytic astrocytoma. An 11-year-old girl had a 2-month history of back pain. A marked swelling of the cervical region of the spinal cord was seen on magnetic resonance (MR) imaging. Ring-like enhancement within the spinal cord at C4-C7 and heterogenous enhancement at the dorsal aspect of the C1-C7 section of the cord were seen following administration of gadolinium diethylenetriamine pentaacetic acid. Positron emission tomography scans revealed a high uptake of ^<18>F-fluorodeoxyglucose and ^<11>C-methionine. The patient underwent an expansive laminoplasty and a biopsy of the dorsal cervical tumor. The histopathological finding was consistent with gliofibroma. Postoperatively the patient had remained stable for 3 months, after which back pain returned. MR images showed that the tumor had developed to involve the cord from the medullo-cervical junction to T4. Radiation therapy was then started, and three months later, the second surgery was performed. On performing an incision of the dorsal lesion, we encountered cystic cavities surrounding by a grayish soft tumor. Following a biopsy, draining tubes were inserted into the cavities at the level of C5 and the cervico-medullary junction. The histopathological diagnosis was pilocytic astrocytoma. Gliofibroma is a benign tumor composed of cells exhibiting both glial and mesenchymal differentiation. The neoplastic glial differentiation is highlighted by positive immunohistological staining with glial fibrillary acidic protein, S-100 protein, and MIB-1, while the mesenchymal one is characterized by a dense proliferation of fibroblastic spindle cells. Combined pilocytic astrocytoma and gliofibroma of the spinal cord in the present case seems to be first report in the literature and should be added to differential diagnosis of intramedullary spinal cord tumors.

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