The median survival of patients with spinal metastases has substantially improved over the last decade owing to advances in oncological treatment options. However, spinal paralysis induced by metastatic spinal cord compression remains a devastating problem that worsens activities of daily living (ADL) in patients with spinal metastasis and may subsequently shorten survival time. Radiotherapy failure, delayed referrals from medical oncologists, and delay in the transmission of medical imaging diagnostic reports were the major factors associated with the incidence of spinal paralysis in providing medical treatment services for spinal metastasis. Medical oncologists, radiation oncologists, and spinal surgeons must collaborate to provide the best supportive care for these patients ; therefore, a multidisciplinary treatment strategy was designed in our hospital to prevent the onset of spinal paralysis. The spinal instability neoplastic score (SINS), a diagnostic tool used to assess spinal neoplasia-related instability, was introduced in routine clinical practice among radiation oncologists to increase awareness of instability, expedite collaboration between spinal surgeons, and prevent radiotherapy failure. Furthermore, an early transfer system for medical imaging diagnostic reports that represent impending paralysis was developed to guide medical oncologists for earlier and more appropriate referrals to spinal surgeons and radiation oncologists. This multidisciplinary treatment strategy will help patients with spinal metastasis receive radiotherapy and/or surgery before the onset of spinal paralysis and subsequently result in long-term preservation of the patient’s ADL.

  Cervical spondylotic amyotrophy, which causes upper limb muscle atrophy due to cervical spondylosis, results from compression lesions and circulatory disorders in the anterior horn of the spinal cord, the anterior root, or both. In the proximal type, the main symptom is the deltoid muscle and biceps brachii muscle atrophy, whereas the distal type involves muscle atrophy of the fingers. Several studies have reported various treatment outcomes concerning conservative treatment, anterior surgery, and posterior surgery for these pathologies ; however, treatment options remain controversial.

  Here, we report surgical treatment outcomes concerning 29 consecutive patients with proximal cervical spondylotic amyotrophy who had been treated at our hospital between January 2005 and December 2020 (23 males, 79% ; six females, 21% ; average age at surgery, 67.0±10.4 years). Although the operative procedures mainly involved an anterior approach (anterior cervical discectomy and fusion [ACDF] and anterior keyhole foraminotomy), laminoplasty+posterior foraminotomy was performed in patients with multiple lesions and strong posterior elements. In total, 16 patients underwent ACDF, 4 underwent anterior keyhole foraminotomy, and 9 underwent laminoplasty+posterior foraminotomy. For 3 (10.3%) patients, there was no improvement in paralysis, while in 26 (89.7%) patients, manual muscle testing (MMT) indicated that paralysis had improved. We investigated the associations between age at surgery, time from onset to surgery, degree of paralysis before surgery, method of surgery, and improvement in paralysis. Weak correlations were found between the pre-operative degree of paralysis, age at surgery, and the post-operative degree of paralysis. No association was found between the duration from onset to surgery, the surgical approach, or the post-operative degree of paralysis.

  Our findings indicate that in patients with mild paralysis, conservative treatment should be prioritized. If the paralysis does not improve after conservative treatment following the onset of mild paralysis, surgical treatment may be effective.

  Objective : The Kihoku-Super Early Ambulation Program (K-SEAP), started in June 2020, enables patients undergoing minimally invasive spinal surgery for a single vertebra, microendoscopic laminotomy (MEL), microendoscopic discectomy (MED), or percutaneous balloon kyphoplasty (BKP), to become mobile and ambulatory 3 h post-operation. We evaluated K-SEAP efficacy and safety.

  Methods : Patients treated under the K-SEAP from June to December 2021 (K-SEAP group) were compared with those who became mobile on day 1 postoperatively from April 2019 to March 2020 (control group). Bedridden patients and those unable to complete a questionnaire were excluded from the study. We evaluated data in relation to surgical information (operative technique, site, and time ; blood loss ; and intraoperative complications), postoperative management (urethral balloon and drain management, opioid and steroid use, postoperative complications, and falls), pain assessment using a numerical rating scale (NRS), length of postoperative hospital stay, functional independence measure (FIM) score, duration of toileting, independent walking with a walker, walking independently, and transfer to another hospital.

  Results : The K-SEAP and control groups comprised 27 patients (females, 59.3% ; mean age, 70.1 years) and 80 patients (females, 53.8% ; mean age, 67.6 years), respectively. There were no differences in terms of surgical technique (K-SEAP vs. control : BKP, 14 vs. 30 ; MED, 5 vs. 24 ; MEL, 8 vs. 26), surgical site, operative time, or blood loss between the groups. The NRS scores did not differ between the groups at the time of admission, and there was no difference in postoperative management between the groups. Both groups showed significant improvement immediately post-operation (K-SEAP group : 6.2 at admission vs. 1.2 at discharge, p＜0.05 ; control group : 5.1 at admission vs. 1.4 at discharge, p＜0.05). Postoperative hospital stays (K-SEAP/control : 5.8/15.5 days ; toileting independence, 1.0/4.8 days ; walking independently, 1.4/5.5 days ; and independent walking with a walker, 3.2/7.5 days) were significantly faster in the K-SEAP group (p＜0.05) and the FIM score gain was greater in the K-SEAP group (12.6 vs 2.7 points, p＜0.05).

  Conclusion : There was no difference in safety between very early mobilization 3 h after minimally invasive spinal surgery for one vertebral segment and mobilization on day 1 postoperatively. The K-SEAP allowed early activities of daily living recovery and discharge, suggesting that it is an effective treatment program.

  Background : Carcinoids are neuroendocrine tumors that typically occur in the gastrointestinal and respiratory systems. Carcinoid tumors in the middle ear are rare. Herein, we report a case of middle ear carcinoid that developed spinal metastasis and required decompression surgery more than 20 years after the initial surgery.

  Case description : A 75-year-old woman underwent gross total removal of a right middle ear tumor that had been identified 25 years earlier owing to right-sided hearing loss and was pathologically diagnosed as an adenomatous tumor. Six years ago, right facial nerve palsy revealed local recurrence from the mastoid air cells to the middle cranial fossa, which was additionally resected as feasible. Histopathological examination revealed a homogeneous cuboidal epithelial cord structure with little atypia, synaptophysin positivity, CD56 positivity, and a Ki-67 index of 0.1%, and a diagnosis of middle ear carcinoid (neuroendocrine tumor ; NET) was made. A lumbar epidural mass was found while evaluating her paraplegia that began one month prior to presentation, and the patient was referred to our department. Magnetic resonance imaging revealed a mass lesion with suspected metastasis to the L3 high vertebral body and severe stenosis of the spinal canal. Following L3 laminectomy and L2/L4 partial laminectomy, the epidural tumor was removed. Histopathological examination showed glandular and cord-like growth of atypical cells, chromogranin A negativity, synaptophysin positivity, and a Ki-67 index of approximately 5% ; therefore, NET grade 2 was diagnosed. Postoperative rehabilitation was performed, and the patient’s lower limb paralysis became less severe and she was ambulatory.

  Conclusion : Middle ear carcinoids are rare neuroendocrine tumors, and cases of distant metastasis are extremely rare. Although middle ear carcinoids are considered to follow a slow course in most cases, there have been reports of distant metastasis after a long period of time. As exemplified in this case, long-term follow-up is necessary.

  Perineural cysts are often found incidentally in the sacral region of the spine. Most cases are asymptomatic or mildly symptomatic and are treated conservatively. Few cases are symptomatic and require surgical intervention. Although several surgical treatments for perineural cysts have been described, including cyst fenestration, wrapping, fibrin glue injection, and cyst-peritoneal shunt, there is no consensus on the operating procedures with respect to their success or recurrence rates. The presence of a check-valve mechanism indicates the growth of perineural cysts. A “delayed filling” appearance via computed tomographic myelography was considered to show the mechanism of cyst formation ; thus, it may be a prognostic factor of effective post-treatment outcomes.

  We present the case of a patient with perineural cysts who was successfully treated with endoscopic cyst puncture, followed by a wrapping surgery. Percutaneous endoscopic cyst puncture is a minimally invasive procedure and may be useful for assessing the therapeutic effect prior to open surgery.

  Case : A 72-year-old man with a 20-years-standing ventriculoperitoneal (VP) shunt after subarachnoid hemorrhage visited our department for cervical myelopathy treatment. MRI resonance imaging revealed an extra-axial mass in the anterior cervical spinal cord, compressing the cervical spinal cord with edema. Angiography revealed a markedly dilated epidural venous plexus in the cervical spinal canal with bilateral relative stenosis of the internal jugular vein.

  Diagnosis : A shunt tap and lumbar puncture were performed without spontaneous flow of cerebrospinal fluid (CSF). The shunt systems were functional, but the intracranial pressure (ICP) was low. We speculated that the dilated epidural venous plexus would compress the cervical spinal cord because of low CSF pressure.

  Therapy : A new shunt was placed, and a programmable valve was set at a higher pressure for gradual acclimatization to higher ICPs.

  Results : Postoperatively, the patient experienced gradual clinical improvement, and the spinal cord compression improved on imaging.

  Conclusions : Intracranial low ICP due to CSF overshunting can cause the rare complication of cervical myelopathy from a dilated epidural venous plexus. Low ICP can be treated by surgical revision of the VP shunt with a pressure-programmable valve.

  We present a case study of a patient with spinal instability due to pseudoarthrosis following posterior lumbar interbody fusion (PLIF) who was successfully treated with lateral lumbar interbody fusion (LLIF). A 58-year-old woman underwent PLIF from L2 to S1, followed by removal of the posterior spinal implant 2 years after the fusion surgery. However, she complained of back pain and severe right leg pain in the L3 nerve root distribution after the implant removal. Despite receiving conservative treatments, the patient was unable to walk without the aid of a cane due to severe leg pain. Four years after implant removal, she sought treatment at our hospital. Plain radiographs showed the progression of degenerative scoliosis compared to previous radiographic images. Lateral spondylolisthesis of the L3 vertebral body was worse in the standing position relative to the supine position. Furthermore, the interbody cage at the L3-4 level protruded to the left lateral side of the intervertebral space. Computed tomography (CT) scans showed right intervertebral foramen stenosis at the L3-4 level. Temporary pain relief was obtained through selective right L3 nerve root infiltration. Therefore, we considered the severe pain to be caused by right foraminal stenosis at the L3-4 level due to spinal instability. Consequently, we performed LLIF via the left retroperitoneal approach as a salvage surgery. The previously implanted PLIF cages were safely removed and replaced with large LLIF cages at the L2-3 and L3-4 levels. The patient had immediate pain relief in the right leg after the operation. A week later, percutaneous posterior instrumentation at the L2-L4 levels was performed. The patient regained the ability to walk without a cane shortly after the procedure. Clinical evaluation using Visual Analog Scales and the Japanese Orthopaedic Association Back Pain Evaluation Questionnaire demonstrated reduced pain and improvement in the patient’s activities of daily living postoperatively. Radiological assessments revealed that Cobb’s angle at the L2-4 levels decreased from 21 degrees preoperatively to 11 degrees postoperatively. CT scans at the 12-month follow-up visit showed bony fusion at the L2-3 and L3-4 levels without correction loss. In conclusion, LLIF is a convenient and valuable option for salvage surgery in cases of pseudoarthrosis after PLIF.