The morbidity associated with allograft or demineralized bone matrix utilized to supplement autograft in spinal fusions has prompted the search for the ideal artificial bone volume expander. One artificial supplement, Beta Tricalcium Phosphate [Vitoss, Orthovita, Malvern, PA, USA], was prospectively utilized to supplement lamina autograft [50:50 mix] in 30 consecutive patients undergoing multilevel laminectomies [average 5.1 levels] and 1 [16 patients] or 2 [14 patients] level non-instrumented posterolateral fusions. These older patients averaged 71.4 years of age, with 28 of 30 patients over 65 years old. The series included 21 females and 9 males. Major comorbidities included osteoporosis [24 patients], hypertension [20 patients], obesity [20 patients], elevated cholesterol [12 patients], coronary artery disease [9 patients], diabetes [7 patients], and smoking [8 patients]. Seven of 30 patients had prior surgery including far lateral disc excision in 4 patients, and laminectomy for stenosis in 3 patients. Preoperatively, dynamic X-rays documented degenerative spondylolisthesis [25 patients], spondylolysis [1 patient], and instability secondary to prior surgery [4 patients]. Preoperative MR and CT studies predominantly demonstrated multilevel stenosis [30 patients] and hypertrophy/ossification of the yellow ligament [OYL] [24 patients]. Multilevel laminectomies and non-instrumented fusions resulted in both dynamic X-ray and 2D-CT documented fusion in 27 patients [average 6.5 months]. Two patients exhibited fusion on dynamic X-rays [no motion] but not on the 2D-CT studies obtained up to 18 months postoperatively; neither was symptomatic and no second operations were required. Only one patient exhibited symptomatic dynamic X-ray and 2D-CT documented pseudarthrosis 1 year following surgery, and required a second operation. Patients were followed a minimum of 1 postoperative year [average 20 months]. Utilizing Odom's criteria, recovery assessed 1 year postoperatively revealed 26 excellent, 3 good, and 1 fair outcome(s). SF-36 questionnaire data obtained preoperatively and 6 weeks, 3 months, 6 months, and 1 year postoperatively demonstrated maximal improvement by the 6th postoperative month at which time patients demonstrated moderate improvement on 2 Health Scales [General Health, Social Function], and marked improvement on the remaining 6 Health Scales [Physical Function, Role Physical, Bodily Pain, Vitality, Role Emotional, Mental Health].

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Recently, there has been a increased use of box-designed titanium cages for anterior cervical interbody fusion (ACIF). Their advantages include ease of insertion, and we have been using them since 2001. In this study, we evaluatede radiographs in patients underwent ACIF with box-designed titanium cages. Twenty five patients at 34 levels were analyzed. The preoperative and immediate postoperative lateral X-ray films were compared with films obtained during the follow up periods (15.1±11.6 months) respectively. All X-ray films were scanned and saved as TIFF image on computer. The sinking was calculated from the difference of the vertebral heights between before and after operation. Segmental alignment was measured as the angle between the posterior borders of the two vertebral bodies using NIH image. In most cases, increased vertebral height and segmental lordosis obtained immediately after operation changed to almost same level as preoperation winthin a couple of months after ACIF. After that, no progress in subsidence and kyphosis was detected. Our data demonstrated that box-design titanium cage is a safe and effective device for ABIF.

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Iliac crest bone graft harvesting is commonly used for anterior cervical fusion, but the donor site problem must not be ignored. Various techniques were developed to avoid donor site morbidity. In this study we introduced manubrium bone graft harvesting in anterior cervical fusion with a titanium cage. In 41 patients who underwent anterior cervical fusion, we harvested bone grafts for filling up the titanium cage from the manubrium bone. There was no donor site complication. Good fusion was obtained in all patients after six months. In this procedure, we must pay great attention to avoid injuries of adjacent major vessels and organs. A disadvantage of this method is the cosmetic matter for women because of the low-necked scarring. In conclusion, we think that the manubrium bone is a preferable graft harvesting site for anterior cervical fusion with titanium cage from the point of view of avoiding donor site morbidity.

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Subependymoma is considered a relatively slow growing benign tumor that is usually found at autopsy. It is difficult to differentiate from astrocytoma or ependymoma on the basis of morphologic or radiographic findings. 33-year-old female patient presented with a 16-year history of left lower extremity pain followed by numbness of the same area as well as both upper extremities. Spinal MRI revealed an enhanced abnormal intra-medullary mass extending from Th3 to Th7 and accompanied by a cystic mass lesion. No specific findings were apparent todifferentiate this tumor from astrocytoma or ependymoma. The patient underwent total resection, resulting in good neurologic recovery. Histopathologic analysis demonstrated findings typical of subependymoma. Clinical course, pathological features, treatment and prognosis of 41 published cases are reviewed in the discussion

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A 54-year-old female complained progressive severe neck pain and restricted neck movement after making lots of deep bows. Her axial CT showed calcification around the atlanto-axial joint. Under a diagnosis of acute crystal-induced periarthritis, we treated her by prednisolone (15mg per day for one week). Her severe neck pain improved quickly after two days. Calcification around the atlanto-axial joint on the CT vanished after one month. So we suspected it was acute inflammatory change induced by hydroxyapatite crystal. Acute crystal periarthritis of this portion is very rare. It is important to treat by steroid quickly, when calcification around atlanto-axial joint with severe neck pain and restricted neck movement is diagnosed by CT scan.

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A case of delayed onset of secondary syringomyelia associated with spinal surgery is presented and the mechanism of syrinx formation and surgical treatment are discussed. This 59 year old woman had an intradural thoracic Schwannoma and developed a thoracic syrinx 25 years after surgery on the thoracic Schwannoma. She complained of paresthesiae below the lower thoracic level. There was mild weakness in both legs. Hypalgesia was presented below T9. MRI showed a syrinx with adhesive arachnoiditis in the thoracic levels at the operated site. We performed a syrinx-subarachnoid shunt after microsugical lysis between the dura and the adhesive arachnoid membrane. An expanded polytetrafluoroethylene sheet (Gore-Tex^® sheet) was inserted to maintain CSF flow. Postoperative neurological deterioration did not occur for 1 year postoperatively, but postoperative MRI showed a recurrence of the syrinx. These results suggest that postoperative adhesive spinal cord arachnoiditis can cause syrinx formation, and this procedure may be inappropriate surgical treatment for patient with longitudinally extensive arachnoiditis.

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