Background : Terminal myelocystocele is a rare type of skin-covered lumbosacral mass, which is often associated with the OEIS complex, a combination of Omphalocele, cloacal Exstrophy, Imperforate anus, and Spinal cord abnormalities. Due to its rarity, the long-term outcome and postoperative course are poorly understood.

  Material and Methods : We retrospectively reviewed seven patients with terminal myelocystocele who underwent surgery at our hospital between 1996 and 2019.

  Resurts : The OEIS complex was observed in four patients. All three patients without OEIS complex achieved ambulation, in contrast with only one of the four patients with OEIS complex. All the patients without OEIS complex had normal urinary function.

  Conclusion : Although the prognosis of lower limb function is often poor in patients with terminal myelocystocele in the presence of OEIS complex, patients treated with optimal timing may achieve ambulation. The long-term postoperative course is generally uneventful.

  Background : While microscopic lumbar disc herniation (LDH) surgery has been performed at our institution for >20 years, full-endoscopic lumbar discectomy (FELD) was introduced in 2019 to further minimize invasiveness. We aimed to analyze and compare short-term results of patients who first underwent FELD with those of patients who underwent microscopic LDH surgery during the same period.

  Methods : FELD was performed in 10 patients over an 18-month period (FELD group, male : female ratio, 6 : 4 ; mean age, 57.2 ± 13.3 years). Of the 10 patients, interlaminar and transforaminal approaches were adopted in five and five patients, respectively. During the same period, microscopic LDH surgery was performed in 19 patients (microdiscectomy group). Japanese Orthopaedic Association (JOA) scores, visual analog scale (VAS) scores, operation time, bleeding volume, complications, and recurrence of symptoms were investigated and compared between the groups.

  Results : In the FELD group, the preoperative VAS score was significantly lower than that in the microdiscectomy group as was the preoperative JOA score. There was a significant improvement in both groups in terms of the JOA and VAS scores postoperatively. No serious complications were observed, and no differences in operation times or recurrence rates were noted between the groups.

  Conclusions : Adequate short-term results were confirmed for the initial FELD group ; however, preoperative severity in the FELD group was milder than that in the microdiscectomy group. We intend to expand the adaptation of this surgery to include more severe cases through increasing the number of surgical cases and improving our surgical technique.

  Spinal arachnoid web is a rare condition that causes various neurological symptoms due to direct spinal cord compression by a thickened arachnoid membrane and subsequent cerebrospinal fluid (CSF) flow blockage, occasionally leading to presyrinx, which may precede syringomyelia. Magnetic resonance imaging (MRI) is helpful for establishing diagnosis. Although the “scalpel sign” is considered a characteristic finding, the arachnoid web is a fine lesion that is often difficult to visualize.

  We have described a case of a 63-year-old woman with complaints of progressive numbness in both her upper and left lower limbs for 10 years and progressive right axillary and upper back pain.

  MRI at the previous hospital revealed an intramedullary hypersignal lesion at the T2 level. Heavy T2-weighted sagittal imaging and cine-mode MRI performed at our hospital revealed the “scalpel sign” and a membrane-like structure that was impeding CSF flow on the dorsal side of the spinal cord. She was diagnosed with a spinal arachnoid web ; hence, T1-3 laminectomy was performed to remove arachnoid.

  Postoperatively, her neurological symptoms improved remarkably. Her numbness decreased, and the right axillary and back pain disappeared. Furthermore, the “scalpel sign” and intramedullary hypersignal lesion had disappeared. Postoperative cine-mode MRI revealed an improvement in CSF flow. Pathological examination of the resected arachnoid membrane showed normal tissue without any evidence of inflammatory or malignant lesion.

  Here, we have reported a case of arachnoid web with presyrinx, a reversible intramedullary lesion. The arachnoid web must be identified as a cause of presyrinx. Even in cases with a long course, surgical treatment should be considered to improve the presyrinx state and ameliorate the neurological condition.

  During anterior cervical discectomy and fusion (ACDF), injuries to the internal ramus of the superior laryngeal nerve (Ir-SLN), which can cause postoperative dysphasia, have rarely been reported. Here, we present a case of dysphasia post-ACDF due to Ir-SLN paresis and discuss the diagnosis and the need for preservation of this nerve.

  A 69-year-old woman underwent ACDF of the second and third cervical bodies after a hangman’s fracture and developed swallowing difficulties postoperatively. Laryngoscopy and laryngography findings indicated paresis of the Ir-SLN. She underwent dysphasia rehabilitation and subsequently fully recovered normal swallowing function.

  In this patient with dysphasia post-ACDF, the cause of Ir-SLN injury during ACDF might have been missed because of the complicated method for diagnosing Ir-SLN injury. Dysphasia can be due to several factors such as : mechanical compression of the pharynx following pharyngeal ischemia ; cervical fixation due to malposition of the plate, screws, and transplanted bone in the disc space ; and peripheral neuropathy. In this case, excluding other possible causes of dysphasia might have helped with the diagnosis. The Ir-SLN runs superior-laterally to inferior-medially within the muscle layer at the second and third cervical body. The Ir SLN is a sensory nerve at the pharynx. While dysphasia following Ir-SLN injury has previously been reported, little attention has been paid to the Ir-SLN during spinal surgery. To avoid post-ACDF dysphagia, preservation of the Ir-SLN is important.

  This complication should be considered when performing ACDF surgery.

  We report a rare and therapeutically challenging case of a retroperitoneal lymphocele that developed after oblique lumbar interbody fusion (OLIF).

  A 74-year-old woman underwent spinal canal decompression between L2 and S1, OLIF between L2 and L5, and posterior lumbar interbody fusion (PLIF) at the L5/S1 level for management of severe lumbar pain secondary to lumbar kyphosis and intermittent claudication. Follow-up magnetic resonance imaging (MRI) performed 4 months postoperatively revealed a left-sided retroperitoneal cyst (maximum diameter 11 cm). The cyst did not communicate with the ureter, and the patient was asymptomatic ; therefore, she was followed up as an outpatient. The patient developed left lower leg pain 2 years postoperatively. We performed computed tomography (CT) guided cyst puncture and drainage, and the cyst was diagnosed as a lymphocele. Continuous drainage reduced the cyst volume, and the patient’s symptoms disappeared on day 5 ; however, she was not completely cured. She underwent lymphatic embolization using lipiodol and sclerotherapy using 5% povidone-iodine, which were ineffective. Subsequently, we performed laparoscopic fenestration ; however, we observed a recurrent infected cyst. She underwent repeat sclerotherapy using 1% pyoktanin ; however, she was unresponsive to this treatment and was finally cured following continuous drainage for approximately 8 months overall.

  Lymphatic vessels tend to become thicker toward the proximal side ; therefore, postoperative lymphatic leakage may occur following operative procedures performed near large vessels. In our case, lymphocele was attributed to the hemostatic procedure performed in the vicinity of the common iliac artery. Surgeons should remain mindful of the possibility of postoperative lymphocele formation even with the use of a lumbar lateral approach, following surgical procedures performed in close proximity to the abdominal aorta or common iliac artery.

  We report a case of a 92-year-old female who presented with a sudden onset of right hemiparesis and neck pain mimicking ischemic stroke without trauma.

  She was initially suspected to have ischemic stroke ; thus, imaging examination of her brain was performed.

  Magnetic resonance imaging (MRI) of the head demonstrated a high diffusion-weighted imaging (DWI) signal in the left occipital lobe. In addition, magnetic resonance angiography (MRA) of the head demonstrated a severe stenosis in the left middle cerebral artery (M1).

  At the emergency room, however, her condition could not be correctly diagnosed.

  One day after admission, MRI of the cervical spine revealed an acute cervical epidural hematoma from the C2 to C5 levels.

  The axial image showed an epidural hematoma that shifted to the left in the spinal canal, compressing the spinal cord and causing hemiparesis and neck pain.

  She underwent surgical evacuation of the epidural hematoma in the emergency room and recovered.

  Recently, spontaneous cervical epidural hematoma has been indicated to mimic ischemic stroke.

  Spontaneous cervical epidural hematoma is generally a rare disease and its diagnosis is often difficult, so patients with a sudden onset of hemiparesis can be misdiagnosed as cerebral infarction even if they have neck pain.

  In this case, the patient was within the time window for acute ischemic stroke treatment, so it would have been possible to administer recombinant tissue plasminogen activator (rt-PA) had she not complained of neck pain.

  We should keep in mind that spontaneous cervical epidural hematoma may present as a stroke mimic, and it is important to evaluate physical and neurological findings in detail.

  The incidence of fragility sacral fractures has been increasing with the increase in the number of patients with osteoporosis. In sacral fractures, the fourth and fifth lumbar and sacral nerves can be injured through compression or extension. Herein, we report two cases of foot drop due to fragility sacral fractures.

  Case 1 : A 71-year-old woman complained of buttock pain after bumping her right buttock with a shopping cart. One week later, her buttock pain worsened and she could not walk. Severe paralysis of the right anterior tibial muscle and numbness in the right lower leg were observed. A U-shaped sacral fracture was detected across the right sacral foramen and sacral ala. The patient was treated with adequate bed rest and teriparatide. Although there was little improvement in the drop foot, the patient was discharged with a short leg brace.

  Case 2 : A 55-year-old woman had no injury but complained of pain in the right buttock and lower limb. Paresis of the right anterior tibial muscle was observed. A U-shaped sacral fracture, including the bilateral sacral ala, was detected. Far-lateral type lumbar disc herniation at the L5/S1 level was accompanied by a sacral fracture. Endoscopic removal of the disc herniation was performed to relieve lower limb pain.

  For sacral fractures, attention should be paid to the evaluation of the fractured part and neurological examination. In our cases, foot drop developed owing to the extension or compression of the fifth lumbar nerve triggered by the sacral fracture. Sacral fractures may occur in an increasing number of patients and should be considered as a differential diagnosis of foot drop.

  Objectives : Spinal epidural lipomatosis (SEL) is a relatively rare disease characterized by an overgrowth of epidural adipose tissue within the spinal canal. SEL can be asymptomatic, and patients often present with symptoms related to nerve or spinal cord compression.

  Case Presentation : A 50-year-old man was admitted to our hospital with pain in the lumbar region and leg, in 2020. He was self-reliant in his daily life, but had a history of lumbar surgery. MRI showed compression of the spinal nerve of the cauda equina within the spinal tube due to lumbar SEL. The “lateral I” sign of thecal sac compression was seen at L2/3 and L3/4 levels.

  A full endoscopic interlaminar approach for L3/4 and L4/5 was performed a month after admission. This surgery included placing the patient in the prone position, full endoscopic spinal surgery, interlaminar approach, dissection of the yellow ligament, and removal of the epidural hypertrophic adipose tissue. After post-surgical rehabilitation, the patient made a full recovery at discharge, and returned to his life.

  Discussion : SEL is a relatively rare disease. To date, SEL and secondary SEL require long periods of exogenous steroid use.

  Distinctive features of idiopathic SEL is the common occurrence in men, mostly in the lumbar region.

  MRI showed compression of the spinal nerve of the cauda equina within the spinal tube due to lumbar SEL. The “lateral I” sign at L2/3 and L3/4 levels, and the typical “Y” sign at L4/5 and L5/S1 levels of thecal sac compression were seen.

  In general, the removal of SEL produces good results, with or without microscopic surgery. We believe that full endoscopic spinal surgery for symptomatic lumbar SEL is a good choice of minimally invasive surgery. This requires the accumulation of the cases before this procedure is standardized.

  Conclusions : We report our experience with symptomatic idiopathic lumbar SEL with a “lateral I” sign on axial MRI, and effective full endoscopic spinal surgery.

  The patient was a 46-year-old man who presented with fatigue for 6 months. His activities of daily living (ADL) gradually worsened and he was transported to our hospital’s emergency room because of difficulty in walking due to muscle weakness in the extremities. His weight had decreased by 20 kg in 6 months, and he was almost bedridden. Upon arrival, he presented with emaciation, hypotension, and muscle weakness predominantly in the proximal portions. However, he showed no clumsiness in the hands, pain, sensory disorders, or bladder-rectal disturbances. Only Hoffman’s reflex was positive. Deep tendon reflexes were almost normal in his upper limbs but flaccid in his lower limbs. The Japan Orthopaedic Association (JOA) score was 14/17. Images of the cervical spine showed a developmental narrow canal, cervical spondylotic changes at C4-7 levels, and cervical spinal cord compression with myelomalacia at C4-6 levels. These findings suggested cervical spondylotic myelopathy (CSM). However, laboratory data showed mild hyponatremia (sodium 135 mmol/L) and hypothyroidism (free thyroxine [T4] 1.00 ng/ml, thyroid-stimulating hormone [TSH] 6.62 µIU/ml). Based on radiology, endocrinology, and neurology consultations, the patient was diagnosed with an isolated adrenocorticotropic hormone (ACTH) deficiency. Hydrocortisone (20 mg/day) administration dramatically improved his symptoms and ADL. The JOA score improved to 17/17 over a few months, and the patient returned to his daily life. He has been followed-up without surgery until now.

  Several differential diagnoses other than CSM involve muscle weakness of the extremities. Even if there is a clear cervical spine lesion on imaging, it is important to consider whether it is a lesion actually responsible for the symptoms. Cooperation with other departments is also necessary. In particular, if a patient has endocrine diseases, such as in this case, it can cause fatal complications during surgery. Therefore, we should pay attention to these patients and initiate prophylactic measures if the patient needs surgery.