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歩行障害により発症した脊髄くも膜嚢腫の1例を経験したので報告する．症例は59歳，女性．2ヶ月前より痙性歩行，下肢脱力，歩行障害が出現したため当センター入院となる．58歳時に小脳橋角部くも膜嚢腫手術の既往があった．著明な痙性歩行．Th12以下で痛覚，触覚は低下し，両第1足趾の位置覚は消失．両下肢腱反射は亢進．左下肢筋力に低下を認めた．CTMでは左Th8/9，9/10レベルでの脊髄の圧迫が著明であった．この症例に対しTh8-10椎弓切除術，嚢腫摘出術，経くも膜下腔的嚢腫壁開放術，くも膜下腔―くも膜下腔bypass術を施行した．術後は筋力，下肢の位置覚共に回復し，独歩可能となった．くも膜嚢腫の発生には何らかの先天性素因の関与が示唆された．

Sixty-three patients with delayed neurologic deficit due to post-traumatic osteoporotic burst fractutes underwent various kinds of operative methods. Anterior decompression and fusion was performed on eleven patients, posterior decompression and fusion on twenty-five patients, posterior fusion on six patients, posterior spinal shortening on five patients, and vertebroplasty on sixteen patients. Neurologic deficit recovered in all groups but posterior decompression and fusion provided the best results statistically. Posterior spinal shortening improved the correction rate of kyphosis, which did not differ significantly in other groups. Postoperative back pain was less in all patients even though kyphosis remained. Posterior fusion and vertebroplasty provided less blood loss and shorter operative time than other groups. We recommend posterior fusion with vertebroplasty in the absence of posterior compression of the spinal cord. Anterior decompression / fusion or posterior spinal shortening is recommended over surgery for this disease.

Intramedullary cavernous haemangioma is very rare, and often diagnosed before intramedullary bleeding. We experienced six cases (five female, two male) from 1980 to 2001 in our hospital. Their ages ranged from 24 to 60 years. Lesions were located from the lower cervical to middle thoracic medulla. Magnetic resonance imaging (MRI) showed T2: low indicating intramedullary bleeding in most cases. We used the Frankel scale for neurological assessments. Five at of the six cases underwent laminectomy and microscopic tumor extirpation. Two operated cases suffered complicated posterior cord disturbance. However, five cases except one preoperative Frankel A nainfained Frankel D at the end of follow-up (from one month to seven yers, eight months). The changes in hemoglobin lead to MRI findings: T1; isointensity/T2; hypointensity at acute bleeding, T1; hyperintensity/T2; hyperintensity at subacufe bleeding, and T1; hypointensity/T2; hypointensity at over one month after bleeding. The most important findings of cavernous haemangioma are not enhanced at Gd-DTPA, and there are no abnormal findings by angiography. We recommend patients with symptoms to undergo operation as early as possible when diagnosed as cavernous haemangioma.

Intraspinal cysts are rarely observed in patients. They are distinguished from neoplasm using magnetic resonance imaging (MRI) or computed tomography (CT) because they rarely cause bony erosive changes. We treated three cases of intraspinal cysts causing bony erosion. Patients ranged from fifty-five to seventy-one years, and symptoms and signs resembled disc herniation. Signal-intensity patterns and pathological finding of these lesions were variable. They were adjacent to degenerated facet joints. Treatment involved surgical excision of the cysts. Many lumbar intraspinal cysts may be associated with significantly degenerated facet joints. Bleeding into or around the cysts may invade the vertebral body.

We reviewed 7 cases of scoliosis combined with syringomyelia and or Arnold-Chiari malformation. Foramen magmun was decompressed in 5 cases, of which spinal deformities were followed conservatively in 3, and by surgical correction in 1. In the another case, scoliosis had been treated operatively before foramen magnum decompression. In 2 patients who were observed conservatively, the curve of scoliosis was progrssed.

Between 1979 and 1996, 99 lumbar canal stenosis patients over 65-years were treated with posterior decompression surgery. The mean age at surgery was 71.6 years (range, 65 to 83) and the length of follow-up was an average of 23.7 months (range, 6 to 90). These patients were divided into two groups (with fusion or without fusion). The clinical scores were evaluated retrospectively with the Japanese Orthopedic Association low back pain rating score (JOA-score). The JOA-score was an average of 8.9 preoperatively and 15.9 postoperatively (improving rate: 49.6%). There was no significant difference between these two groups. However, low back pain improved in fusion groups more than in the no-fusion groups.

［症例］46歳女性．15年前に左小指の屈曲変形出現し，手の手術を施行するも軽快せず．徐々に手足のシビレ，歩行障害出現．近医MRIにて脊髄空洞症と診断され当院紹介．Chiari奇形に伴う脊髄空洞症に対して，後頭孔減圧術施行し，歩行障害が軽快した．［考察］くも状指は脊髄空洞症の他に様々な脊髄疾患で起こりうる．今回の症例のように筋萎縮から発症する場合は診断が遅れることがある．空洞による不可逆的な障害が起こると術後空洞が縮小しても症状の改善がみられないこともあり，不可逆的な障害に陥る以前に早期診断治療が重要であると思われる．

頚椎前方脱臼の整復の要は椎間関節嵌合の整復処置である．今回後方からの整復が困難であった稀な症例を経験したので報告する．15歳男性．後頭部を強打し近医にてC5前方脱臼を指摘され当科搬送．初診時所見はFrankel分類：Aであった．画像所見はCTにてfacetの両側嵌合とMRI矢状面にてC5/6に椎間板ヘルニア認めた．同日緊急手術を施行．後方からの術中所見ではC5/6facetは両側とも深く嵌合しており，上関節突起の一部をエアトームにて切除し整復を試みるも，弾力的な抵抗が存在し，十分な整復は困難であった．前方の椎間板軟骨終板が阻害因子と考え，前方進入を追加すると完全に整復できた．通常頚椎脱臼の整復操作は後方からの進入のみで可能であるが，本症例では軟骨終板が整復阻害因子であり，後方侵入だけでは整復困難であった．無理な整復力は脊髄への障害を引き起こす可能性があるため症例に応じた整復を考慮しなければならない．

A 29-year-old man lost consciousness briefly after falling from a height. Initial examination revealed complete quadriplegia, with normal strength in trapezius and at the C5 sensory level. Cranial nerves were intact. Cervical spine X-ray demonstrated a fracture dislocation of C4, and he underwent C4-5 posterior wiring and fusion. Postoperatively he became unresponsive and two days later, experienced locked-in syndrome. Vertebral angiography demonstrated complete occlusion of the right vertebral artery 2cm proximal to the fracture site, and the mid one-third portion of basilar artery was completely obstructed. We concluded that the thrombus of the vertebral artery caused the thromboembolism of the basilar artery and pontine-infarction during surgery.

We evaluated the location of 748 pedicle screws in a random sampling of 160 patients, and assessed the incidence of neurological complication in 685 consective patients who underwent lumbar and sacral spinal fusion using the Zielke transpedicular fixation system. 93% of 748 screws were right in the pedicle, while 6.2% penetrated the cortex of the pedicle, and 0.8% were completely misplaced from the pedicle. Neural injury relating to screw displacement occured in 11 of 685 cases, giving a neurological complication rate of 1.6%, all of which were nerve root injuries. This figure is consistant with other reports. 8 of these 11 cases had revision surgery with retrieval of the misplaced screw. 6 of 8 cases achieved satisfactory recovery and the remaining two cases resulted in some neurological deficits. 3 cases who did not require revision surgery because of minimum neurological deficits showed complete recovery.

Severe spasticity of spinal origin has been proven to be a good indication for intrathecal baclofen (ITB) infusion. ITB is nondestructive, reversible, and can be titrated precisely, allowing retention of extant function while diminishing spasticity. It is also associated with few complications. In our hospital, a patient with spinal cord injury underwent implantation using a programmable pump and intrathecal catheter designed to deliver baclofen directly to the spinal cord. Rigidity (tone) decreased from a mean prebolus Ashworth score of 3.75 to a mean postbolus Ashworth score of 2.13. But during the course, the pump was removed due to MRSA infection, which resulted in reoccurrence of severe spasticity although the infection healed. Reimplantation was carried out due to the patients continuous request. Ashworth scores reduced to an acceptable level after reimplantation.Intrathecal therapy showed a statistically significant improvement of tone and spasms, and seems to be an effective treatment for patients with severe spasticity.

The lumbosacral plexus innervation is variable, making the diagnosis of lumbar spinal disease according to lower extremity symptoms complicated. We investigated lower extremity myotomes by recording the compound muscle action potential (CMAP) during lumbar spinal surgery in six L4 roots, twenty-four L5 roots and fourteen S1 roots. At L4 root, innervation to only Quadriceps is 33%, to Quadriceps and Tibialis Anterior is 50%, to Quadriceps, Tibialis Anterior and Gastrocnemius is 17%. At L5 root, the innervation to only Tibialis Anterior is 41%, to Tibialis Anterior and Gastrocnemius is 59%. At S1 root, the innervation to only Gastrocnemius is 57%, to Gastrocnemius and Tibialis Anterior is 43%. Knowledge of the relationship of L4 root to Quadriceps, L5 root to Tibialis Anterior, S1 root to Gastrocnemius are required. 3 out of 9 cases also had different innervation between their right and left sides.

Large curves between 50 and 80 degrees progress after skeletal maturity in untrated idiopathic scoliosis. In patients treated surgically for idiopathic scoliosis, curves sometime progress after removal of spinal instrumentation. Twenty-seven patients were evaluated to quantitate curve progression after removal of spinal instrumentation and identify factors leading to curve progression. Curve progressed in nine out of the twenty-seven patients. Curve progression is related to only curve magnitude, and not to correction rate, interval between operation and removal of spinal instrumentation, age, Rissers sign, type of scoliosis (adolescent, juvenile, infantile) , and spinal balance.

We report on 5 cases treated by posterior arthrodesis of the cervical spine using a plate fixed with screws to the lateral masses. Of 3 patients with cervical spine injuries, all had solid fusion. These cases had injuries of the spinous processes, laminaes, and facets. This technique is particularly advantageous in these conditions. Of 2 patients with cervical myelopathy associated with athetoid cerebral palsy who had carvical laminoplasty and posterior arthrodesis, all had solid fusion and achieved good chinical results. All cases maintained good cervical alignment. There were no neurologic or vascular complications.

Helical volume computed tomography (CT) involves continuous patient translation during x-ray source rotation and scan data acquisition. As a result, high-quality three-dimensional images can be produced from the continuous volume data sets in a relatively short period of time. Helical CT scanning and three-dimensional surface reconstruction of the spinal lesions were performed. In fracture and dislocation of the spine, three-dimensional CT provides excellent images of posterior aspects of the lesion and demonstrates sharp sagittal images of vertebral fractures compared with magnetic resonance imaging. In degenerative spinal disorders, three-dimensional CT is helpful in evaluating patients with ossification or calcification of ligaments. Three-dimensional images with helical volume scanning may be useful for the diagnosis of spinal disorders.

Although disc injury is common in cervical spinal fractures the mechanism of disc herniation in cervical fracture dislocations is not known. This study evaluated the pathogenesis of disc hernia in cervical fracture dislocations. Twenty-two patients who underwent anterior and posterior spinal fixation were studied. Findings of preoperative magnetic resonance imaging (MRI) were compared with surgical findings. During surgery, cervical disk hernia were found in six patients (27%), and the MRI findings of these patients were evaluated in detail. We concluded that the characteristic MRI findings of cervical disc hernia are as follows.1) discontinuity of injured disc2) anterior indentation of spinal cord at the site of dislocated vertebral body3) signal irregularity at the site of interspace between dislocated vertebral body and spinal cord.

The MRI findings in 61 subjects who were operated on for lumbar disc herniation were retrospectively studied, to diagnose rupture of the posterior longitudinal ligament(PLL). The accuracy rate of diagnosing rupture of the 66.7%. False negative cases were found in herniated discs with only a small rupture of the PLL. False positives were seen in cases with large extruded disc herniation.

Magnetic resonance imaging (MRI) was performed on 18 patients with acute cervical cord injury using T2-weighted images of a 1.0-T magnet. Three different types of MRI signal patterns were detected in association with these cervical cord injuries. A classification was developed using these three patterns. Type I, seen in six patients, demonstrated a low signal intensity consistent with acute intraspinal hemorrhage. Type II, seen in seven patients, demonstrated a high signal intensity consistent with acute cord edema. Thpe III, seen in five patients, demonstrated no abnormal signal intensity. Type I patterns showed complete quadriplegia except for one and no improvement in their Frankel classification. In comparison, Type II and III patterns improved at least one Frankel classification. MR at 1.0T in extremely useful in the diagnosis of acute cord injury and also demonstrates potential in predicting neurologic recovery.

The operative results of cervical myelopathy were evaluated in twenty-eight patients who were more than sixty-five years old. The mean age of the patients was seventy-one years (range, sixty-six to seventy-nine) at the time of operation (older patients group). Cervical disorders included CSM in 16 cases, CDH in 4 cases, OPLL in 6 cases, and OYL in 2 cases. We compared older patients group with non-older patients group (less than fifty-four years old) in the operative results, as well as a good-result group (more than 50% recovary ratio) with a poor-result group (less than 49% recovary ratio) in the older patients. The results were as follows; 1) the older patients group were greater than the non-older patients group in the severity of symptoms and duration of symptoms before surgery, worse than in the recovery of symptoms after surgery; and 2) the severity of symptoms before surgery of the poor-result group was greater than that of the good-result group.

We reviewed 32 cases of acute injuries of the upper and middle thoracic spines associated with paraplegia.Spinal injuries were distributed with peaks at T3/4 and T7/8 In 27 cases a fracture-dislocation was present: were twenty were anteriorly dislocated: six were lateraly dislocated; and one was posteriorly dislocated. On CAT scan, a separation of pedicle adjacent to the vertebral body was seen characteristically. All fracture-dislocations with incomplete spinal cord injury were accompanied with the charactaristic pedicle separation.

We have reviewed 11 procedures in 9 patients with metastatic malignant tumor of the spine. An anterior decompressive spinal fusion was performed in 3 cases, a posterior spinal fixation alone in 5 csses, a posterior spinal fixation with laminectomy in 2 cases, and a laminectomy alone in the other.All patients were suffering from pain and they all had relief of pain after operation. 10 cases of 9 patients had neurological deficits and neurological return was achieved in 8 cases. In these 8 cases, 2 cases was perfomed posterior spinal fixation only.Spinal instability is one of the main causes for pain and neurological deficits in the patients with metastatic malignant spinal tumor, and rigid internal stabilization is the first choice for the surgical treatment of these patients.

We have had experience in treating 18 cases of Chance type fractures. The dominant feature of this fracture is a horizontal fracture involving the posterior element with little or no compression of the vertebral body. In our cases, 4 cases had bony fragments retropulsed from posterior wall. These may be classified to burst fracture. Two cases had rotation and displacement of the vertebral body. These may be classified to fracture dislocation. Surgical treatment with transpedicular fixation was done in 9 cases. For cases with burst fracture, combined anterior decompression and fusion was done.

We clinically evaluated 45 patients who underwent anterior spinal fusion for treatment of lumbar disc herniation. Fusion rate was 80%, with all but one patient gaining relief of pain. Thirty-three (73%) patients were able to continue in the same occupation, eleven were able to be employed doing jobs requiring less physical work and one retired. Despite the relief of pain, there remained a high rate of occupational turnover. We suggest that psychogenic and social factors shoud be considered in the assessment of patients with chronic lumbar disc herniation.

Postoperative evaluation was performed on fifty-two patients with the ossification of the posterior longitudinal ligament (OPLL) after decompressive laminectomy or anterior decompression and fusion. OPLLs with cervical cord trauma showed poor results, thus these cases had better be excluded.Twenty-one cases with posterior approach gained 48.4% recovery rate, and eigteen cases with anterior approach 51.7%.In severe narrow cases (narrow ratio>40%), posterior decompressive laminectomy was performed on eighteen cases and anterior decompression under microscopy on four cases.Four anterior cases gained 58.5% recovery rate, whereas 18 posterior cases 48.7%.Anterior resection of OPLL and fusion was a good procedure for compressive myelo pathy due to OPLL, especially cases with kyphosis or cases with locally located big OPLL.In order to perform this operation safely, it is essential to use the microscopy during operation.

MRI studies of fifty-two cases with OPLL in the cervical spine showed some interesting facts. Firstly, twenty-five percents of these cases had iso-or high signal intensity in the area of the OPLL, which indicated the pre-OPLL stage. Then, MRI could show us the change of the spinal cord between pre-operation and post-operation. The volume of the spinal cord is usually increased by posterior decompressive laminectomy than by anterior operation. However, some cases were observed in which the volume did not increase sufficiently or did not increase at all (atrophic type) or increased too much on the contrary. Finally, in OPLL with spinal cord injury, low intensity area in the spinal cord was observed at the edge of the OPLL. It suggested that a dynamic factor was more important than a static factor such as a narrow canal.