In this study, we express numerically the thickness of the yellow ligament at the level of L3/4, L4/5 and L5/S1 in degenerative lumbar canal stenosis caused by thickened yellow ligament. The thickness of the yellow ligament in patients with degenerative lumbar canal stenosis (stenosis group) and age-matched lumbar disc herniation patients (hernia group; as a control) were measured on CT myelography. In the stenosis group, the mean thickness of the yellow ligament were 4.2±1.5 mm (L3/4), 5.3±1.9 mm (L4/5) and 5.6±2.2 mm (L5/S1). In the hernia group, the mean thickness of the yellow ligament were 3.0±2.0 mm (L3/4) and 3.8±2.4 mm (L4/5) and 4.8±2.7 mm (L5/S1). Statistically differences were observed between the stenosis group and the hernia group in all three levels (p<0.05).

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The transoral surgery is the most direct operative approach for pathology ventral to the upper cervical spinal cord and the medulla oblongata. However, many spinal surgeons still hesitate to use this approach because of the prejudiced view of invasiveness and high surgical risks in the transoral surgery such as infection, postoperative dysphagia and so on. As a matter of fact, the transoral approach can be performed as a minimally invasive approach by avoiding tracheostomy and incision of soft palates or hard palates, and by performing other little means. We describe surgical tips for minimally invasive transoral surgery. Wider indications would be considered for such less invasive transoral approach.

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The surgical treatment of thoracolumbar spinal injuries remains controversial. Recently we have performed vertebroplasty and posterior lateral fusion by posterior approach exclusively. This report describes 10 patients with thoracic and lumbar fractures who were treated successfully with vertbroplasty in combination with posterior fixation using pedicle screws or hooks. Vertebroplasty with polymethylmethacrylate or hydroxyapatite may offer immediate spinal stability in patients with thoracolumbar fractures and reduce the instrument failure rate compared to those achieved by procedures without vertebroplasty. For certain patients, this technique may be a useful option for overcoming the pitfalls of conventional thoracolumbar fracture treatment.

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The treatment of vertebral osteomyelitis and epidural abscess represents one of the greatest challenges to the spine surgeons. These diseases are complex and difficult to manage and often result in acute neurological deterioration and require a combination of adequate surgical and conservative treatments. We reviewed the surgical management and outcome of 14 patients with pyogenic or tuberculous osteomyelitis and epidural abscess. The series consisted of 14 patients (8 males and 6 females); their ages ranged from 49 to 77 years. Myelopathy or radicular pain was caused by osteomyelitis and an epidural abscess in all patients. Cervical, thoracic, and lumbar osteomyelitis was detected in 5, 6, and 3 cases, respectively; epidural abscess was pyogenic in 11 and tuberculous in 3 cases. Among them, two-stage managements were performed in 10 cases. The pathogen was identified in 9 of the 14 cases: S. aureus in 5 cases, M. tuberculosis in 3 cases and MRSA in 1 case. The postoperative course was uneventful with relief of the symptoms. No evidence of recurrence or residual infection was observed in any patient as shown by ESR and/or CRP levels during the follow-up period of an average of 27.3 months (range, 6 to 56 months). In conclusion, the strategy for osteomyelitis and abscess of the spine must provide timely neural decompression, spinal stabilization, and clearance of infection. Two-stage management appears suitable in selected patients for emergent decompression and organism-specific antibiotic treatment. The antibiotic therapy should be tailored on the basis of the culture and sensitivity results, which are the key factors in the treatment of this disease. Instrumentation can be used safely even in cases of spinal infection after the infection has been controlled with a normal CRP; however, the use should be limited only in the cases with the advantage being superior to the risk.

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Compared with the simple decompression procedures, lumbar fixation procedures are essentially invasive. Spinal instrumentation is used for fixation in degenerative lumbar disease cases. But there is a considerable debate with regard to whether instrumentation is needed or not and if needed, which procedure should be performed. It is possible to accomplish the firm lumbar fixation using pedicle screws (PS), but the procedure is invasive. Intraoperative nerve root injury or paraspinal muscle damage is sometimes reported as one of the complication of PS fixation. The aim of this paper is to clarify the invasiveness of posterior lumbar interbody fusion (PLIF) using interbody spacers and a Lumbar Alligator Spinal System (LA) which is a kind of a clamping plate for the spinous process. A total of 17 patients underwent PLIF for single level spondylolisthesis in our institute from 2002 to 2004. Stand-alone PLIF was carried out in 4 patients, PLIF with PS in 10 patients, and PLIF with LA in 3 patients. We compared the duration of surgery, volume of blood loss, procedure-related complications, postoperative neurological findings, and postoperative hospitalization among 3 techniques. A LA was employed in 1 patient age more than 80 years and in 2 patients with osteoporosis. In the LA group, the duration of the surgery was significantly shortened in comparison to the PS group. In the LA and stand-alone PLIF group, the volume of blood loss was significantly lower than that in the PS group. After surgery, there was no neurological deterioration in any patient in LA group, and the main preoperative symptoms, such as lumbago and intermittent claudication, improved in all patients. In this study the fixation with LA was appreciated to be safer and less invasive method than PS. For the case which need the less invasive procedure such as aged people and the case who has osteoporosis, it is a useful fixation method for PLIF instead of the PS fixation.

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Vertebroplasty with bone cement for vertebral compression fracture has been increasing, recently. However, serious complications, such as pulmonary embolism or paraplegia, have been reported. We performed vertebroplasty using hydroxyapatite blocks for vertebral compression or burst fracture for 25 patients, 26 vertebral bodies since February 2003 and gained good results. In our institution, we use 2.5ml disposable syringes and operate percutaneously using fluoroscope because of a little invasion. Preoperative average visual analogue scale (VAS) was 6.9 and postoperative average VAS was 1.0. Postoperatively vertebral body height decreased around 13% as compared to just after operation, but there have been no symptomatical complications and no recurrence of pain until now. Though we think this method is still improving, we show our present procedure of this operation.

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Ossification of the yellow ligament (OYL) is considered an uncommon cause of syringomyelia, and single case has been described (11). We encountered simply 1 case of syringomyelia associated with cervical OYL out of more than 320 surgically treated syringomyelia cases.The 66-year-old female patient underwent cervical laminoplasty and displayed good postoperative course. Long-standing blockage of CSF circulation is considered one of the main factors for syringomyelia associated with degenerative disease of the cervical spine [2,3,4,5,6,7,10,11,15]. However this speculation warrants further discussion. We therefore obtained more dynamic and objective data using analytical methods described by Marmarou in 1975 [9]. The clinical course of this patient is discussed with reference to the literature and the results of a CSF dynamic study.

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In the literature ten cases of ligamentum flavum hematoma have been reported. Authors report here two cases of ligamentum flavum hematoma, showing their image studies and clinical features as to the mechanisms of hematoma formation, some speculations were suggested. The first case was a 64 year-old male who had had lower back pain for 8 years. He complained of severe pain from the left calf to the dorsal aspect of his first toe soon after suspension from a horizontal bar. When the left L4-5 partial hemilaminectomy was performed, a brown serous hematoma was found in the ligamentum flavum. His symptoms dramatically improved after surgery. The second case was a 75 year-old male who had had lower back pain for the last two years without an obvious history of trauma. When the right L3 partial hemilaminectomy was done, old hematoma with peripheric fibers intensely compressing the L4 nerve root were detected in the ligamentum flavum. His symptoms improved soon after surgery. One case showed acute progression and the other exhibited a chronic one. Hematoma in the first case bled from small arteries of the posterior spinal canal branch which might play an important role in the pathological mechanism. The second case was suspected to be caused by repeated injury of small capillary vesseles in sublaminar space.

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