The efficacy of the CyberKnife [Accuracy, Inc., Sunnyvale CA], a new stereotactic radiosurgery device utilized in the treatment of benign and malignant spinal tumors, is reviewed. The study assesses the number and type of spinal tumors safely and effectively treated with CyberKnife radiosurgery. Most reports concerning the utilization of CyberKnife stereotactic radiosurgery [CSR] for the treatment of malignant [primary, metastatic] or benign spinal lesions have been published within the last 5 years. CSR may be administered alone or in conjunction with surgery and external beam radiation therapy. A major benefit of CSR is that it can be completed within 1 week [1-5 fractions] as compared with the several weeks required for external beam radiotherapy, with limited toxicity. A frameless device, the CSR’s accuracy is +/- 1 mm. Additionally, the Xsight program now allows the cervical and lumbar spine to be treated without fiducial marker placement; however, this is still required to accurately target thoracic lesions. CyberKnife radiosurgery is effective in treating both benign and malignant lesions. For benign tumors, the CSR successfully arrests tumor progression and minimizes pain. It is unique for the management/palliation of malignant metastatic disease where it functions as an adjunct or alternative to invasive surgery and/or routine external beam radiotherapy. In summary, CyberKnife stereotactic radiosurgery, approved by the Federal Drug Administration [USA 2001], may be safely and effectively administered within 1 week’s time to treat both benign and malignant spinal lesions with limited toxicity.

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The morbidity for dynamic plating [ABC Aesculap, Tuttlingen, Germany] of 116 single level anterior cervical corpectomy/fusion [1 ACF] procedures included delayed graft fractures [2 of 7 surgical], graft/plate extrusion [one], pseudarthroses [two], and adjacent segment disease warranting secondary surgery [one][6]. Here we asked what morbidity would be encountered utilizing dynamic plates for 31 single level anterior diskectomy and fusion procedures. Thirty-one patients undergoing 1 level ADF averaged 45 years of age and included 18 males, 13 females, and 12 smokers [Table I]. Patients exhibited moderate myelopathy attributed to MR/CT documented disc herniations [ten], spurs/ossification of the posterior longitudinal ligament [OPLL] [seven], or both [fourteen]. Iliac crest autografts, dynamic plates, and cervicothoracic orthoses [CTO] were utilized [until fused]. Patients were followed an average of 2.6 years [minimum 1 year]. Two independent neuroradiologists confirmed fusion utilizing both dynamic X-rays and 2D-CT studies [2.5-12 mo postoperatively]. SF-36 outcomes were also assessed [preoperatively- 1 year postoperatively]. Postoperatively, patients’ myelopathy improved an average of 3 Nurick Grades. Although all patients fused [dynamic X-ray/2D-CT] an average of 3.6 months postoperatively, 2 female smokers demonstrated delayed fusions [7, 8 months], and one required secondary surgery 5 years later for adjacent level disease. Utilizing dynamic plates, although all 31 single level ADF patients fused [average 3.6 months postoperatively], 2 demonstrated delayed fusions [7, 8 months], and one developed adjacent segment disease 5 years later warranting secondary arthrodesis. None, however, developed the delayed fractures, graft/plate extrusion, or pseudarthroses observed in the previous dynamic-plated 1 level ACF series.

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Study Design: This is a retrospective analysis of 3 patients with MR-documented lumbar spinal stenosis found to have myelopathy and distal thoracic cord compression. Objectives: To emphasize that some patients lumbar stenosis/radiculopathy may also be myelopathic, and should undergo MR evaluations of the cervical/ thoracic spine. Summary of Background Data: Patients presenting with the diagnosis of lumbar spinal stenosis supported by MR studies should be fully examined to determine whether thoracic myelopathy is superimposed on lumbar radiculopathy. Methods: Three patients presented with MR-documented lumbar spinal stenosis/spondyloarthrosis, and ossification of the yellow ligament [OYL]. However, when all 3 also exhibited severe thoracic myelopathy/parapareses, they underwent thoracic MR/CT studies which documented; [1] T10/11 right-sided disc, and severe stenosis/OYL T9-T12 OYL [mild/moderate L3-S1 OYL was not operated upon-1 patient], [2] T9/10 and T10/11 synovial cysts, and severe stenosis T8-S1 OYL [1 patient], and [3] T10/11 synovial cyst and severe stenosis/OYL T10-S1 [1 patient]. Results: The first patient underwent a T10/11 right-sided diskectomy, and T9-T12 laminectomy alone. Two patients had thoracic laminectomies for synovial cysts/OYL, and lumbar laminectomies for severe stenosis/OYL; T8-S1 and T9-S1. Utilizing Odom’s criteria, 2 patients exhibited excellent outcomes 6 and 9 months, while 1 demonstrated a fair/good recovery [T8-S1 laminectomy] 3 months postoperatively. Conclusions: A subset of patients with MR-documented lumbar spinal stenosis/radiculopathy may exhibit simultaneous thoracic myelopathy. Where thoracic cord compression is documented, thoracic/thoracolumbar laminectomies may become warranted.

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Object: The authors investigated patients’ self assessments of lumbar surgery and evaluated the short-term results. Materials and Methods: Our center had 251 lumbar surgeries from July, 2005 to February, 2006 and we investigated all cases. Patients assessed Visual Analog Scale (VAS), Japan Orthopedic Assosiation Scale (JOA), Oswestry Disability Questionaire Index (ODI), Short Form36 (SF36)v2 at preoperation, 2 weeks, 3 months, and 6months of postoperation. Data were analyzed by one-way ANOVA, and then defferences among means were analyzed using the Scheffe method (P<0.05). Results: 244 patients (151 men and 93 women) responsed to the scales at preoperation, and returned 645 answers for 10 months. The mean age was 60.8 years (17-88). The mean follow-up period was 3.09 months (range, 0.5-11). The results showed 3 patterns. We observe that VAS, JOA, ODI and SF36-PF improved significantly (P<0.01) from 2 weeks after the operations. SF36-RP, BP, SF, MH and VT significantly(P<0.05) improved from after 3 months. SF36-RP and GH didn’t improve. Conclusions: VAS, JOA, ODI and SF36-PF had significantly improved from after 2 weeks with the lumbar operations. The mental component of SF-36 improved from after 3 months, but the recovery of the mental component was small compared with the recovery of the physical component.

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The cage has recently been used as the graft of anterior fusion to treat cervical spondylosis, hernia, and OPLL, whose short and middle term result is not gained sufficiently. We treated 114 cases by using threaded and cylindrical cages filled with hydroxapatite. The purpose of the follow up study in these patients was to investigate the height between upper and lower vertebral body inserted cage, loss of lordosis and clinical assessment for 1-7 years. These patients had mild and moderate cases with 8-14 points of the JOA score. Postoperative JOA score revealed some recovery within one year. Excellent and good assessment on 4 stage self-evaluation occupied 95%. However, vertebral height was reduced an additional 2mm in average in 90% of the cases. In the same time, lordosis (Cobb angle between C2 and C7) also decreased (average-2.7 degree). This assessment was not correlative between one and two level fusion. Furthermore, the relationship between clinical assessment and radiological appearance as subsidence of vertebral height and loss of lodosis was not correlative. Only one case had new symptoms due to focal lordosis after anterior fusion of C5/6. The cause of sinking cage was due to operative method with which the endplate was drilled away until cancelous bone was partially exposed. This method did not result in poor outcome in our study. The sufficient decompressing of the nerve root and the spinal cord was accomplished and adjacent vertebral penetration by the cylindrical cage resulted in significant straining of the hydroxapatite which may have invited early fusion.

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We have treated 205 Syringomyelia patients associated with Chiari Type 1 malformation. We then investigated the relationship between factors such as gender, age, preoperative complications, and the degree of postoperative improvement to ascertain the factors with a high probability of influencing improvement by univariate and multivariate analyses. The results of univariate analysis indicated that patients with scoliosis, difficult labor, and intraoperatively confirmed arachnoiditis potentially minimized their positive surgical outcome and required greater care in their management. The results of multivariate analysis showed that Abe’s grade 1a, 2, 3a, and 4 patients could expect their symptomatic improvement in the maximum value of their own grade.

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The author presents the transforaminal interbody fusion at thoracolumbar and conus levels with polyaxial pedicle screws and rods systems. Materials and Methods: Seven patients with ages ranging from 40-80 showed conus medullaris syndrome due to thoracolumbar problems. Thoracic disc herniation: 2, Failed back syndrome: 2. Adjacent problems after PLIF: 2. Both cord decompression and insertion of interbody fusion cages could safely be completed by unilateral facetectomy using distraction force on the pedicle screws. Results: All patients showed improvement of urinary and gait disturbance without complications. Bony fusion was checked and followed by postoperative CT and the vertebral intensity around cages became higher within one month. Conclusions: This approach is an application of "TLIF (transforaminal lumbar interbody fusion)" reported by Harms(Germany). This safe and solid fusion with decompression technique has no necessity for the opening of abdominal and thoracic cavities and it is very useful for aged and patients.

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OBJECTIVE: As for the operation of lumbar spondylolysis and spondylolysic spondylolthesis combination of decompression and fixation is generic. However, we will report our results in a series of 26 patients who underwent decompression without fusion treated for spondylolysis and spondylolysic spondylolisthesis. PATIENTS AND METHOD: In 26 patients (mean age 54.2 years) who underwent decompression without fusion treated for spondylolysis and spondylolysic spondylolisthesis, the postoperative follow-up time was 16.8 months. We divided them into A group and B group. The A group performed subtotal resection of floating lamina, the B group performed total resection of floating lamina. The following were clinical outcome(the recovery rate of JOA score), lower back pain (JOA score) and use of anti-inflammatory agents. RESULTS: The symptom recovery rate of Group A, assessed on the JOA score was 66.8%, and 84.3% for the B group. We performed re-operation in 2 patients of the A group. It was thought that the remaining floating lamina was caused by the recompression of the nerve root. We performed re-operation that removed the remaining floating lamina and the right amount of ambient fibrous tissue. As for the lower back pain, both groups had improvement tendency. Use of postoperative anti-inflammatory agents disappeared in 18 patients, and all patients had improvement tendency. CONCLUSION: In the short-term, we obtained good operation results of decompression without fusion treated for spondylolysis and spondylolysic spondylolisthesis. On the occasion of an operation, it is important to perform enough decompression by resection of floating lamina.

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Intraspinal extradural meningeal cysts are uncommon causes of spinal cord and nerve root compression. We report our experience of a 32-year-old male presented with progressive intermittent back pain. Magnetic resonance image and computed tomography myelography showed an extradural meningeal cyst extending at the T11-12 levels in the thoracic area. The cyst was confirmed as a Type I spinal meningeal cyst via the hemilaminotomy. Total resection of the cyst was not performed because the separation of the cystic bottom was difficult due to adhesion in the surgery. Surgical partial resection of the cyst wall and closure of the dural defect provided a favorable result.

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Do higher graft/plate complication rates occur in morbidly obese patients undergoing single level anterior corpectomy fusion [ACF] alone, and do these patients, therefore, warrant simultaneous posterior fusion? To assess whether initial circumferential surgery should be performed in this unique population, the experience with 5 morbidly obese patients undergoing single level [ACF] performed with [3 patients] and without [2 patients] simultaneous posterior fusion [PF] and halo application were reviewed. Patients averaged 51 years of age and exhibited average Bone Mass Indices [BMI=kg/M2] of 46.8 [BMI=kg/m2]. Neurological examinations reflected moderate to severe spastic cervical myeloradicular syndromes [average Nurick Score of 4]. Two-level [adjacent] cervical pathology [with retrovertebral extension], included disc disease [2 patients], spondyloarthrosis/stenosis [5 patients], ossification of the posterior longitudinal ligament [OPLL] [4 patients], and olisthy [2 patients]. Medical comorbidities included morbid obesity [5 patients], osteoporosis [5 patients], hypertension [5 patients], diabetes [3 patients], and coronary artery disease [2 patients]. Five patients underwent initial single level ACF consisting of two-level adjacent diskectomy with removal of the intervening vertebral body. Two patients originally underwent single level ACF alone and received hard cervico-thoracic orthoses [CTO]. The remaining 3 patients initially had simultaneous posterior fusions [PF] performed with halo immobilization [circumferential surgery]. The 3 patients undergoing initial circumferential surgery fused 4-8 months postoperatively. Two patients undergoing single level ACF alone, however, developed plate/graft extrusions one day and three weeks postoperatively. Both of these patients required secondary multilevel anterior corpectomy/fusion with posterior fusion and the application of a halo device. These latter patients fused within 7 and 9 postoperative months respectively. Odom’s criteria 1 year postoperatively revealed 2 excellent, 2 good, and 1 fair outcome. Conclusions: Morbidly obese patients undergoing single level ACF are at increased risk for plate/graft extrusion and should be considered candidates for initial simultaneous single-level ACF with posterior fusion and halo immobilization.

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A case of hangman fracture treated with polyaxial & rod systems is presented. This 16-year-old boy with severe neck pain was hospitalized after an accident in which he fell forming a scrum during rugby football. Radiological imaging on admission showed a typical hangman fracture of C2 with interspinous and disc damage at C2-4 level(Effendi Type 2). A week after his admission, C2 anterior slipping and dislocation of fracture deteriorated and he underwent C2-4 posterior fixation using polyaxial screw and rod systems. This system has no necessity for sharp and long K-wire, and an easy and safe rod connection could be completed in case of long fusion. And it will be easy for removal of this system after bony fusion. This patient was discharged on foot without a neck brace and obtained good bony fusion confirmed by CT scan.

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We report two cases of hematomyelia. Both patients developed rapidly progressing paralysis. Spinal MR imaging showed characteristic hematomas with massive peripheral edema. We carefully resected the hematomas in both cases. There was no evidence of angioma observed in either case. The patients showed gradual improvement of their neurological symptoms.

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