Objective : Pyogenic spondylitis (PS) is rare but serious condition. Delayed treatment may lead to increased morbidity and mortality. Authors focus on the prompt diagnosis and management of PS and present the clinical outcome in consecutive 10 patients.

  Methods : Ten cases of PS treated over the past 6 years were analyzed retrospectively. There were 9 males and 1 female with the mean age of 67.1 years old. Six of 10 cases were clearly immunocompromised, including 3 cases of chronic renal failure, 1 of advanced gastric cancer, 1 of liver dysfunction and 1 of diabetes mellitus. All cases received surgical drainage of infection affected area to isolate the pathogens early after systemic evaluation, and underwent surgical decompression with/without the posterior stabilization with spinal instrumentation. Antibiotic treatment was maintained until the infection was controlled completely.

  Results : Cervical spine was affected in 7 of 10 cases (70%). Clinical course of infection spread was acute in 7 cases, subacute in 2 cases and gradual in 1 case. Surgical culture isolated the pathogens in 7 of 10 cases. Early surgery followed by antibiotic treatment appeared to result in spinal cord decompression and neurological recovery.

  Conclusion : Early diagnosis is crucial in the management of PS. Once the presence of PS has been established, all appropriate cultures, including surgical drainage, need to be obtained without delay. Surgical decompression with/without the posterior instrumented stabilization of the spine may play a role in the cases of neurological deficit with spinal cord compression.

  Objective : Central cord syndrome is the more common incomplete type of spinal cord injury in patients of middle and older age associated with hyper-extention of the cervical spine. We summarized the treatment outcome of patients with central cervical cord injury (CCCI) and evaluated recovery of neurological function.

  Methods : Sixty-one patients of CCCI were treated. The clinical characteristics including age, gender, cause and mechanism of trauma, neurological symptoms, treatment were retrospectively obtained from medical records and statistically analyzed as prognostic factors for better outcome. Patients received thirty-one of 61 steroids as the NASCIS-Ⅱ protocol just after admission. Seventeen patients were treated surgically. NCSS (Neurological Cervical Spine Scale) was used for the evaluation of neurological symptoms and singns estimation of the rate of recovery.

  Results : Male were 43 cases and female were 18, averaged age was 60.1 years (ranged 25-86 years, median age was 63 years). Improvement was obtained in all cases but complete resolution of neurological deficit was obtained in only 2 of 61. The average rate of recovery in NCSS scoring was 59.1%. Neurological signs and recovery of lower extremities were statistically better than those of upper extremities. Treatment-related death was not experienced. The clinical characteristics of patients were statistically analyzed, males demonstrated better outcome than femals and the group of traffic accident better than that of falling patients group. The averaged rate of recovery was not statistically different between medical and surgical treatment groups, 59.6% and 57.6%. The duration from onset of trauma to the surgical treatment was not influencing for the outcome.

  Conclusion : Treatment outcome in patients with CCCI was having acceptable resnlts, but complete resolution of neurological signs was difficult. Neurological symptoms and recovery of upper extremities were worse than that of lower extremities. Surgical treatment for CCCI could improve the outcome even on the conservative treatment group.

  Introduction : In order to determine the onset mechanisms responsible for upper extremities unilateral or asymmetrical neurological symptoms in cervical spondylosis, we performed 3 Dimensional Computed Tomography (3D-CT) in the neutral and extending positions. Then we examined the association between cervical vertebra dynamic factors and the onset of neurological symptoms.

  Materials and Methods : We selected 12 patients with unilateral or asymmetrical neurological symptoms in their upper extremities from 48 patients who underwent anterior decompression and fusion or posterior decompression to treat cervical spondylosis between January 2007 and September 2009. Subjects comprised 11 males and 1 female between the age of 28 and 78 (average 49.9). They induded 5 cases of mono-segmental fusion and 7 cases of bi-segmental fusion, and surgery was performed for 2 cases at C4-5 level, 10 cases at C5-6 level, and 7 cases at C6-7 level. Aquilion 16 TSX-101A/GB (Toshiba Medical Systems) was used for the 3D-CT imaging. CT was performed at a 0.5 mm slice thickness for neutral and retroflexed positions, after which we performed volume rendering. The degree of affection of every particular in intervertebral level was assessed according to clinical symptoms and MRI results. The inclination between vertebral bodies was measured and compared (unilateral spondylolisthesis) by drawing a line perpendicular to the line which connected the transverse processes of each vertebral body on the 3D-CT frontal view. We also examined instabilities such as misalignment or gaps of facet joints in the neutral and extending positions.

  Results : Of a total of 19 facet joints, instabilities or unilateral facet joints spondylolisthesis were observed in 11 facet joints in the extending position.

  Conclusions :

1. We investigated the mechanisms involved in the onset of unilateral or asymmetrical neurological symptoms in upper extremities in patients with cervical disk diseases using 3D-CT in the neutral and extending positions.

2. We conclude that instabilities or unilateral spondylolisthesis in unilateral facet joints in the extending position can influence the onset of neurological symptoms.

  Background and Purpose : Surgical indication of lumbar interbody fusion (LIF) in elderly patients remains controversial because of potential risks such as inferior bone quality and a higher rate of postoperative complications. However, clinical efficacy and operative risk of LIF in elderly patients have not been estimated sufficiently. The aim of this study was to investigate clinical effect and safety of LIF for lumbar degenerative disease with segmental instability in patients who were seventy years of age or older.

  Methods : The authors retrospectively reviewed the results of 37 patients with mean age 74.8 years (range 70-86) who underwent one or two-level LIF augmented with pedicle screw fixation system. The preoperative diagnosis included degenerative or isthmic spondylolisthesis with instability. Clinical outcomes were assessed by the JOA (Japanese Orthopaedic Association) score, VAS (visual analog scale), and patient's satisfaction. Radiological fusion rate was also investigated. Clinical and radiological results were compared with those of younger patients and adverse factor related to poor clinical results were also analyzed.

  Results : Clinical outcome measures were significantly improved after operation in elderly patients, but improvement rates were statistically lower than those of younger patients. Fusion rate was similar in both groups. Overall postopetrative complications were increased in aged patients, although the prevalence of complications directly related to surgery was not significant. Postoperative complications not related surgery and reoperation were affecting factors resulting in poor results.

  Conclusion : LIF is thought to be an accepted method of achieving lumbar fusion with high radiographic fusion success even in elderly patients, although clinical benefits were limited compared with those of younger patients. Postoperative morbidity was mainly related to general or non-lumbar site complications.

  Objective : Endoscopic thoracic sympathectomy (ETS) is an effective treatment for palmar hyperhidrosis. Inspite of side effects such as compensate sweating, satisfactory rate of ETS is high. However, this evaluations is mainly due to subjective. We used thermographic evaluation of the skin temperature for patients with palmar hyperhidrosis before and after ETS.

  Methods : We performed ETS (T2 and 3) to 109 patients (205 sides, Average 28.6 years old±11.9) with palmar hyperhidrosis since January 2000. And time course thermography of the skin temperature including face, upper limbs, chest, abdomen and lower limbs was recorded to the 15 patients since July 2007.

  Results : Every ETS was effective and satisfactory rate was high except for only two patients suffered excessive compensate sweating. Increased temperature was observed in the operated-side skin after ETS. Higher temperature was observed during from immediately to 3-6 months after ETS. The area of higher temperature was detected typically in operation-side face, upper limb and precordium, but not detected in lower limb and foot.

  Conclusion : Thermographic observation of skin temperature was useful for objective evaluation in patients before and after ETS. And this method could be adaptable to the evaluation of the patients with spinal region such as cervical spondylosis, disc hernia and lumbar canal stenosis.

  Object : Assessment of the usefulness of discography for correct diagnosis of lumbar discogenic pain and determination of causative disc levels.

  Methods : Between January 2006 and January 2009, we performed 66 discographies in 44 patients whose neuroimaging data did not clearly show the location of the pain generating site. We retrospectively assessed the correlation between of discography findings and the surgical results and other neuroimaging data.

  Results : Twenty-seven out of a total of 38 patients were diagnosed with discogenic pain ; concordant pain was elicited by infusion of contrast agents into their discs. Twenty of these 27 patients were treated by transforaminal lumbar interbody fusion (TLIF) or posterior lumbar interbody fusion (PLIF) and pedicle screw fixation. Their Japanese orthopedic association (JOA) score postoperatively improved by 54%, which is a higher improvement than the reported results of surgeries performed according to other diagnostic methods including MRI. Discogram type and disc degenerative change in MRI seemed to correlate to the provocation rate of concordant pain by discography.

  Conclusion : Discography is an invasive technique, but it still has a diagnostic significance even in an MRI era. It provides important information as to which patients should undergo fusion and the appropriate disc levels to be fused.

  Objective : The use of spinal instruments in the elderly remains controversial because of the potential fragility of their bones. The purpose of this article is to show our views about spinal instrumentation surgery for unstable cervical lesions in elderly patients over the age of 80 years.

  Methods : 31 patients underwent a total of 32 spinal instrumentation surgeries. The vertebral plate system was used in most cases of unstable subaxial cervical spine lesions. Posterior screw fixation system was used for subluxation or dislocation in the upper cervical spine. For odontoid fracture odontoid screw was inserted anteriorly. Bone fusion was evaluated by dynamic plain radiographs 3 months after surgery.

  Results : The patients underwent surgery for spinal injury in 18 cases, cervical spondylosis in 12 cases and spinal tumors in one case. In 25 of 31 case initial fixation remained intact during follow-up period and bone fusion was confirmed. Bony fusion could not be evaluated in 3 cases because of bed-rest following postoperative complications and in one case of cervical metastatic tumor. In two patients, instrumentation failure were occurred. In one case, anterior vertebral plate system placed for vertebral dislocation broke down three weeks after surgery. In this case, an instrument could not support vertebral column that had been destroyed entirely. In another case, bony union was not achieved because of unskillful odontoid screwing. Complications occurred in a total of 6 cases. Respiratory failure was most frequent and occurred in 4 cases, 3 of there died. Confusion or other mental complication, occurred in 2 cases, were transient.

  Conclusion : Spinal instrumentation is a safe and useful method for unstable cervical spinal lesions in elderly patients when the surgical strategy is strict and instrument devices are used with precision.

  The Currarino triad was first described by Currarino et al as a combination of presacral mass, bony sacral defect, and anorectal malformation. Neuroanatomic malformations associated with this hereditary syndrome are anterior sacral meningocele, teratoma, tethered cord syndrome and Chiari malformation. In this paper the authors report four surgically treated cases of Currarino triad. The patients' age at first admission was between 1 month and 8 months, 3 patients were female and one was male. Initial symptoms were meningitis, periproctal abscess, constipation and abdominal mass. The indication for surgery was different in each case. The combination of the pathological findings of the presacral mass and the tethered cord in our cases were different in all patients. All patients showed tethered cord in our cases, although tethered cord was reported in only approximately 18% of the patients with the Currarino triad reported in the literature. The Currarino triad is categorized as a of hereditary abnormality but each case shows various combination of anomaly. It is therefore necessary to understand the condition of each individual case and to determine the proper strategy for treatment accordingly.

  Acute calcific tendinitis of the longus colli muscle presenting as an acute neck pain is not common. The present unusual case is a thirty eight year-old man who complained of an acute onset of neck pain. Lateral aspect of a plain X-ray of the neck showed a retropharyngeal space being dilated by 13.9 mm. CT/MRI delineated a partly calcified longus colli muscle with an effusion at the retropharyngeal space. Calcific tendinitis of the longus colli can be clinically misdiagnosed as retropharyngeal abscess, traumatic sequelae or infectious spondylitis. Correct radiographical diagnosis can be made by the presence of a calcified shadow anterior to C1-2 body, prevertebral soft tissue swelling and retropharyngeal effusion. His neck pain gradually ameliorated within 1 week by an administration of NSAIDs and neck rest. We present an uncommon case of acute calcific tendinitis of the longus colli muscle diagnosed by on unusual neck pain and the pathognomonic findings on the neuroimaging.

  The adequate expansion of C1 and C2 spinal canal is required for the treatment for upper cervical spinal cord lesion. Conventional axial laminectomy and laminoplasty can cause postoperative cervical malalignment and axial neck pain. These complications are serious, especially for younger patients, who can be subjected to progressive kyphotic deformities. Complete opening of these laminae is not necessarily demanded for the degenerative cervical disease such as cervical spondylosis, disc hernia and ossification of posterior longitudinal ligament. C2 decompression can be achieved by bell-shape osteotomy through large C2 spinous process, or undermining one of C2 from caudal edge. However, complete laminar opening is needed for upper cervical spinal tumor, especially large intradural spinal tumor or intramedullary cord tumor. The authors developed the laminar opening and reconstruction with all the muscular attachment undisturbed for upper cervical spinal cord lesion including C1-2. The secure of intermuscular space for lateral gutter is key procedure after midline splitting of C1-2. In C1, the lateral gutter is secured between rectus capitis posterior major (RCPMa) and minor muscle, or between RCPMa and obliquus capitis inferior muscle (OCI). In C2, it is secured between OCI and semispinalis cervicis muscle. The laminar flap is opened with all the muscular attachment maintained. Sufficient operative field was acquired, and make intradural manipulation easier. Muscle-preserving laminoplasty is completed with or without hydroxyapatite implant. We introduced these procedures in detail, and verified the concept of musculo-skeletal preservation under the pre-and post-operative evaluation of muscular layers related with C1 and C2.

  Inadvertent dural tears are not uncommon in spinal surgery. It is not too difficult to fix dural tears in a normal setting, but they can prove problematic especially under minimally invasive surgery. We report a case of dural tear under a narrow operative field, and explain how to deal with such a case.

  An 83-year-old man presented with intermittent claudication, and felt discomfort in his thigh. An MR imaging study showed canal stenosis at the L3-5 level. During an operation at another hospital, a punch coused a dural tear and his cauda equina prolapsed from this small hole. This prolapsed cauda equina remgined herniated, and this patient was ther referred to our hospital. He could not move or even get up due to severe lumbago. Two weeks after the first operation, a second operation was performed at our hospital. When the laminectomy was enlarged from the L3 to L5 level, the dural sac tension of the dural sac was decompressed. The prolapsed cauda equina was carefully repositioned into dural sac. The patient recovered well neurologically soon after the operation. Imaging studies showed that the dural sac was decompressed sufficiently as well.

  In this case, the most important technical point was to gain enough decompression of the dural sac by enlarging the laminectomy space. The more common minimally invasive surgery becomes, the more frequently difficult cases to deal are encountered. In order to minimize iatrogenic complications, we have to carefully consider the 3D anatomical architecture of the spinal process, laminar arch, pedicle, yellow ligament, articular process and so on before each operation.