Spinal Surgery

The symptoms of the cervical spondylosis are various because of the complexity of the relationship between the causative degeneration and the nerve root. One of these symptoms, severe pain, is caused by an impaired root in the intervertebral foramen and demands an accurate and rapid diagnosis. Clear imaging of the affected root in the vertebral foramen is difficult to obtain with conventional X-ray, CT scan, CT myelography and/or MRI. Accordingly, we have used 3.0T MRI for detecting the root in the intervertebral foramen since July 2007. The various imaging methods and assorted clinical cases are demonstrated and discussed. Methods: For our 3.0T MRI, an Achieva 3.0T (Philips, the Netherlands) was used. Sequences for imaging the nerve root were: Balanced Fast Field Echo (B. FFE), T2 multiple fast field echo (T2) and T2 turbo spin echo (T2 TSE). Each image can be further reconstructed for acquiring a more visible view. Results: Physical examinations, MRI views and surgical findings corresponded well with each other. Very small degenerations which compressed the nerve roots, could also be detected with the MRI. Conclusions: 3.0T MRI has definite diagnostic advantage. Operative indication and method, especially for minimally invasive surgery would be reconsidered with 3.0T MRI.

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Recently, practice of vertebroplasty using injection material into the vertebral body has been increasing in Japan. But the exact methods and results of this procedure are not clear. We have investigated and analyzed vertebroplasty practiced by neurosurgeons, using survey questionnaires for all of the neurosurgical institutions in Japan. Questionnaires were sent to 1195 neurosurgical institution, 564 of which responded Analysis was performed based on the replies of these 564 institutions. Among them, 65 perform vertebroplasty. Approximately 50% of the institutions who do not perform this operation have interest to adopt this technique. As to the injection material, PMMA is most frequently used. Ninety percent of the indication was osteoporotic compression fracture. Incidence of new vertebral fracture occurring at the adjacent level was about 6% per year. The result shows that this operation has been performed in relatively a small group of neurosurgical institutions so far, however, there is a growing interest. Rate of complications is low. It remains desirable to develop a new method which effectively reduces incidence of de novo adjacent body fractures.

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The optimal treatment strategy for cervicogenic headache (CeH) remains controversial, possibly because the pathophysiology of this disease entity is unclear. The present study describes a case of alleviation of severe CeH that was alleviated after cervical open-door laminoplasty and reviews magnetic resonance imaging (MRI) data from a series of patients with CeH. In our case study, a 63-year-old male with severe headache underwent cervical open-door laminoplasty and his headache resolved postoperatively. In our MRI review, since preoperative MRI showed moderate, not severe, compression of the spinal cord by the surrounding tissues (bones, discs, and ligaments), the relationship between the degree of cervical spondylosis and headache was analyzed in patients with cervical spondylosis who were identified between November 2005 and December 2006 in the Department of Neurosurgery of our hospital. MRI data was compared between patients with and without headache. The number of cervical spinal levels in which there was either moderate or severe compression was significantly greater in the group without headache (at least 4 levels) than in the group with headache (at most 3 levels), All patients with pain who subsequently underwent open-door laminoplasty experienced alleviation of their symptoms. These data suggest that moderate cervical spondylosis may result in CeH and that cervical open-door laminectomy may be an effective therapeutic modality for treating this phenomenon.

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A high incidence of cervical spine instability after resection of dumbbell type cervical neurinoma with laminectomy has been reported. Intraoperative disruption of the muscles and ligaments attached to the C2 process is relevant to the significant loss in the range of movement (ROM) and the malalignment that manifest late postoperatively. A case of C2 neurinoma in a 48-year-old female that was successfully managed with maximal preservation of the surrounding supportive tissue is presented. She was admitted with a six-month history of progressive tetraparesis, bilateral paresthesia of the limbs, bowel and bladder dysfunction. Imaging studies revealed a large extradural dumbbell shaped tumor at C1/2, extending postero-laterally, that was severely compressing the spinal cord. The vertebral artery was displaced antero-laterally, the C1-C2 intervertebral space extended, and the C2 lamina partially eroded. The tumor appeared to be enclosed by the rectus capitis posterior major and inferior oblique muscle. Thus, a midline posterior approach without laminectomy was adopted and the tumor extirpated without detaching the surrounding muscle and ligament from their insertion. Neither nuchal pain nor loss of ROM developed postoperatively. During a 6-month follow-up period, no sign of the surrounding muscle atrophy was detected on the follow-up MRI, and the cervical alignment was well preserved as confirmed on a plain X-radiography. The preservation of the surrounding supportive tissue during the surgical intervention of the cervical spine is important to avoid instability. Our technical adaptation of the posterior approach to the C2 neurinomas is discussed and the literature regarding the approaches to C2 dumbbell tumors is reviewed.

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