Search

Case: A 74-year-old woman presented with severe trunk deformity. Radiographs revealed severe sagittal and coronal imbalance with spinal canal stenosis at L4 to L5. Anterior cages were placed at L2 to L3, L3 to L4, and L4 to L5. Three days later, posterior correction surgery from T5 to the ilium with decompression at L4 to L5 was performed. At 30 minutes after surgery, leg muscle strength severely deteriorated. Emergency surgery revealed disc fragments protruding into the spinal canal at L2 to L3. Conclusion: Because posteriorly placed extreme lateral interbody fusion (XLIF) cages can be a risk factor for disc protrusion into the spinal canal, computed tomographic evaluation or prophylactic posterior decompression should be considered before the correction procedure. [ABSTRACT FROM AUTHOR]

Study Design: Retrospective multicenter study.Objective: We aimed to assess the outcomes following posterior cervical decompression for cervical spondylotic myelopathy (CSM) in a large sample of patients older than 80 years.Summary Of Background Data: Although age is a predictor of surgical outcomes for CSM, most previous studies have only investigated the effect of age for patients aged 65 to 75 years, and surgical outcomes remain unclear for older patients.Methods: Patients older than 50 years who underwent posterior cervical decompression for CSM were enrolled from 17 institutions. The patients were grouped into a young-old group (<80 yrs old) and an old-old group (≥80 yrs). Clinical information, comorbidities, perioperative complications, Japanese Orthopaedic Association (JOA) scores, Japanese Orthopaedic Association Cervical Myelopathy Evaluation Questionnaire (JOACMEQ), visual analog scale (VAS) scores, and radiographic parameters were compared between the two groups. All patients were followed for at least 1 year after surgery.Results: The young-old and old-old groups included 491 and 77 patients, respectively. The JOA score and quality of life measured by JOACMEQ improved significantly after surgery in both groups. Compared with the young-old group, the old-old group had lower preoperative JOA scores (9.6 vs. 11.0), lower final JOA scores (12.6 vs. 14.0), and lower recovery rates (42% vs. 50%). However, there were no significant differences in perioperative complications or in the VAS scores at the final assessments. The old-old group had a higher mean preoperative sagittal Cobb angle at C2-C5, though this was not statistically significant postoperatively.Conclusion: Posterior decompression surgery is safe and beneficial for patients older than 80 years with CSM, despite having a more limited neurological recovery compared with younger patients.Level Of Evidence: 3. [ABSTRACT FROM AUTHOR]

Solitary bone cysts of the lumbar vertebrae are extremely rare. We report a 20-year-old man, who presented with a 5-year history of persistent low back pain. Radiographic examination, magnetic resonance imaging, and subsequent computed tomography revealed a well-circumscribed osteolytic and cystic lesion at the right pedicle of the L3 vertebra. On the basis of the radiologic findings, a simple bone cyst was considered the most probable diagnosis. The patient underwent a minimally invasive operation with the assistance of an endoscope. The gross total curettage resection of the lesion including the cyst walls was accomplished, followed by a combined graft consisting of granulated β-tricalcium phosphate and autologous iliac crest cancellous bone. At the 1-year follow-up, the patient’s symptoms were resolved, bone union at the lesion site had been achieved, and he had returned to his previous level of physical activity. [ABSTRACT FROM AUTHOR]

To describe patients with cervical myelopathy due to cervical disc herniation (CDH) who showed spontaneous regression, we conducted a retrospective study.A review of clinical records since 1990 identified 19 patients (12 male and 7 female; mean age, 42.4 y) with mild cervical myelopathy due to CDH who exhibited spontaneous CDH regression after conservative treatment.The mean Japanese Orthopaedic Association scores were 13.7±1.4 before conservative treatment, 14.8±1.2 at 3 months, and 15.9±0.7 at final follow-up. On magnetic resonance imaging (MRI), the CDH regression was observed at 7.5 months on average. Intramedullary high-signal intensity was observed in 15 patients (78.9%) before treatment and 9 patients (47.4%) at follow-up. The mean area of the spinal cord was 58.4±8.3 mm2 before treatment and 62.4±9.7 mm2 at follow-up.Spontaneous regression of the CDH in 19 patients with mild cervical myelopathy was observed, with improvements in neurological status and in intramedullary high-signal intensity on MRI. [ABSTRACT FROM AUTHOR]

The article focuses on a study which investigated the risk factors for developing subaxial subluxations (SAS) following C1-C2 arthrodesis for atlantoaxial (AA) subluxation in patients with rheumatoid arthritis (RA). The study included 58 patients with RA who underwent C1-C2 arthrodesis. The patients preoperative and sequential postoperative radiographs were evaluated. Study authors concluded that excessive correction of AA angle can cause loss of cervical lordosis.

Objective: To examine the effect of suppressive oligodeoxynucleotides (ODNs) on the pulmonary inflammation induced by immunostimulatory CpG DNA.Design: Prospective, randomized, controlled study.Setting: Research laboratories.Subjects: RAW 264.7 murine macrophage-like cell line and BALB/c mice.Interventions: RAW 264.7 cells were incubated with bacterial DNA or CpG ODN, alone or combined with suppressive ODN. The in vivo effect of suppressive ODN was determined using an acute lung injury model. CpG ODN alone or combined with suppressive ODN was instilled into the mouse lung.Measurements and Main Results: Production of tumor necrosis factor (TNF)-alpha and macrophage inflammatory protein (MIP)-2 by RAW 264.7 cells were measured by enzyme-linked immunosorbent assay (ELISA), whereas their messenger RNA levels were determined by reverse transcriptase-polymerase chain reaction. Synthetic ODN containing CpG motifs (CpG ODN) mimicked the ability of bacterial DNA to stimulate the production of TNF-alpha and MIP-2. Suppressive ODN significantly inhibited the activation of RAW 264.7 cells by both bacterial DNA and CpG ODN. In the lung injury model, production of proinflammatory cytokines (TNF-alpha and IL-6) and chemokines (MIP-2 and KC) in bronchoalveolar lavage (BAL) fluids was measured by ELISA. Neutrophil accumulation in the alveolar spaces was also evaluated. Instillation of CpG ODN into the lungs of normal mice triggered the synthesis of TNF-alpha, IL-6, MIP-2, and KC. Suppressive ODN significantly blocked the production of these proinflammatory cytokines and chemokines and also reduced neutrophil mobilization into the alveolar spaces by CpG DNA.Conclusions: Proinflammatory cytokines and chemokines are up-regulated by CpG motifs in bacterial DNA. Suppressive ODN significantly inhibits the inflammatory response induced by CpG DNA in murine macrophages and the lung. This study supports the use of suppressive ODN to reduce the deleterious inflammatory responses induced by bacterial DNA. [ABSTRACT FROM AUTHOR]

A retrospective multicenter study. Body mass index (BMI) is recognized as an important determinant of osteoporosis and spinal postoperative outcomes; however, the specific impact of BMI on surgery for osteoporotic vertebral fractures (OVFs) remains inconclusive. This retrospective multicenter study investigated the impact of BMI on clinical outcomes following fusion surgery for OVFs. 237 OVF patients (mean age, 74.3 years; 48 men and 189 women) with neurological symptoms who underwent spinal fusion were included in this study. Patients were grouped by World Health Organization BMI categories: low BMI (<18.5 kg/m2), normal BMI (≥18.5 and <25 kg/m2), and high BMI (≥25 kg/m2). Patients' backgrounds, surgical method, radiological findings, pain measurements, activities of daily living (ADL), and postoperative complications were compared after a mean follow-up period of 4 years. As results, the proportion of patients able to walk independently was significantly smaller in the low BMI group (75.0%) compared with the normal BMI group (89.9%; P = .01) and the high BMI group (94.3%; P = .04). Improvement in the visual analogue scale for leg pain was significantly less in the low BMI group than the high BMI group (26.7 vs 42.8 mm; P = .046). Radiological evaluation, the Frankel classification, and postoperative complications were not significantly different among all 3 groups. Improvement of pain intensity and ADL in the high BMI group was equivalent or non-significantly better for some outcome measures compared with the normal BMI group. Leg pain and independent walking ability after fusion surgery for patients with OVFs improved less in the low versus the high BMI group. Surgeons may want to carefully evaluate at risk low BMI patients before fusion surgery for OVF because poor clinical results may occur., Competing Interests: The authors have no funding and conflicts of interest to disclose., (Copyright © 2022 the Author(s). Published by Wolters Kluwer Health, Inc.)

Study Design: Retrospective multicenter study., Objective: The aim of this study was to identify the impact of diabetes on surgical outcomes of posterior decompression for cervical spondylotic myelopathy (CSM)., Summary of Background Data: Although some previous studies have reported surgical outcomes of posterior decompression for CSM in diabetic patients, their results were inconsistent., Methods: We included 675 patients with CSM who underwent posterior decompression. Patients were divided into diabetic (n = 140) and nondiabetic (n = 535) groups according to the diabetic criteria for glucose intolerance. Surgical outcomes as assessed by the Japanese Orthopedic Association (JOA) scores and visual analog scale (VAS) for neck pain were compared between groups. Subsequently, the functional outcomes of diabetic patients were compared between the mild (n = 131) and moderately severe (n = 9) groups. All patients were followed up for at least 1 year after surgery., Results: Compared with the nondiabetic group, the diabetic group showed lower pre- and postoperative JOA scores (P = 0.025 and P = 0.001, respectively) and a lower JOA score recovery rate (RR) (P = 0.009). However, the preoperative-to-postoperative changes in JOA scores in the diabetic and nondiabetic groups were not significantly different (P = 0.988). Pre- and postoperative VAS for neck pain and postoperative reduction of neck pain were comparable between groups (P = 0.976, P = 0.913 and P = 0.688, respectively). Although statistical analysis was not performed due to the small underpowered sample size, functional outcomes assessed by the JOA score RR (43.3 ± 37.1% vs. 45.3 ± 33.9%) and preoperative-to-postoperative changes in JOA scores (3.0 ± 2.2 vs. 2.7 ± 2.5) were similar between the mild and moderately severe diabetes groups., Conclusion: CSM patients with diabetes experienced improvements in neurological function and neck pain as a result of posterior decompression to the same extent seen in patients without diabetes.Level of Evidence: 3., (Copyright © 2020 Wolters Kluwer Health, Inc. All rights reserved.)

Study Design: Multicenter retrospective study., Objective: To validate and improve the predictive model for proximal junctional failure (PJF) with or without the bone mineral density (BMD) score., Summary of Background Data: PJF is a serious complication of surgery for adult spinal deformity (ASD). A predictive model for PJF was recently reported that has good accuracy, but does not include BMD, a known PJF risk factor, as a variable., Methods: We included 145 surgically treated ASD patients who were older than 50 at the time of surgery and had been followed up for at least 2 years. Variables included age, sex, body mass index (BMI), fusion level, upper and lower instrumented vertebral (UIV and LIV) level, primary or revision surgery, pedicle subtraction osteotomy (PSO), Schwab-SRS type, and BMD. PJF was defined as a ≥ 20° increase from baseline (immediately postoperative) of the proximal junctional angle with concomitant deterioration of at least 1 SRS-Schwab sagittal modifier grade, or any proximal junctional kyphosis requiring revision. Decision-making trees were constructed using the C5.0 algorithm with 10 different bootstrapped models, and validated by a 7:3 data split for training and testing; 112 patients were categorized as training and 33 as testing samples., Results: PJF incidence was 20% in the training samples. Univariate analyses showed that BMD, BMI, pelvic tilt (PT), UIV level, and LIV level were PJF risk factors. Our predictive model was 100% accurate in the testing samples with an AUC of 1.0, indicating excellent fit. The best predictors were (strongest to weakest): PT, BMD, LIV level (pelvis), UIV level (lower thoracic), PSO, global alignment, BMI, pelvic incidence minus lumbar lordosis, and age., Conclusion: A successful model was developed for predicting PJF that included BMD. Our model could inform physicians about patients with a high risk of developing PJF in the perioperative period., Level of Evidence: 4.

Study Design: Single-center retrospective analysis of consecutively collected data., Objective: To determine the clinical characteristics of idiopathic spinal epidural lipomatosis (SEL)., Summary of Background Data: SEL is associated with the overt accumulation of nonencapsulated adipose tissue in the epidural space, leading to spinal cord or nerve root compression. The etiology of this condition is currently not completely understood., Methods: Data of 166 male patients who underwent primary surgery for lumbar spinal canal stenosis (LSS) from May 2013 to February 2016 were retrospectively reviewed. Participants were divided into three groups based on the degree of epidural lipomatous lesion. Patient data of age at surgery, body mass index, prevalence of common noncommunicable diseases, blood tests, arteriosclerotic index, and preoperative clinical scores (assessed using the Japanese Orthopedic Association Back Pain Evaluation Questionnaire) were evaluated. Multivariate analysis was performed to assess the potential associated factors for idiopathic SEL., Results: Patients with LSS with severe SEL had a significantly higher body mass index and elevated serum levels of total cholesterol and triglyceride compared with those without SEL. Analysis of preoperative clinical scores revealed that patients with SEL experienced pain more frequently and showed less walking ability than did those without SEL. Multivariate analysis revealed that hyperlipidemia was significantly associated with idiopathic SEL (odds ratio = 3.74, 95% confidence interval = 1.31-10.64)., Conclusion: Our data suggest that aberrant lipid metabolism is related to the pathogenesis of idiopathic SEL and that patients with LSS with idiopathic SEL have more severe pain than do those without SEL., Level of Evidence: 3.

Study Design: A propensity-matched comparison of risk factors for proximal junctional failure (PJF), which is a symptomatic proximal junctional kyphosis developing after corrective surgery for adult spinal deformity (ASD)., Objective: To elucidate the role of bone strength for developing PJF., Summary of Background Data: PJF, a devastating complication of corrective surgery for ASD, often recurs even after revision surgery. Most studies of risk factors for PJF are retrospective and have a selection bias in surgical strategy, making it difficult to identify modifiable PJF risk factors., Methods: We conducted propensity-matched comparisons of 113 surgically treated ASD patients who were followed for at least 2 years, to elucidate whether low bone-mineral density (BMD) was a true risk factor for PJF in a uniform population from a multicenter database. Patients were grouped as having mildly low to normal BMD (M group; T-score≧ - 1.5) or significantly low BMD (S group; T-score <  -1.5), and were propensity-matched for age, upper and lower instrumented vertebrae, history of spine surgery, and Schwab-Scoliosis Research Society (SRS) ASD classification. PJF was defined as a ≥20° increase from the baseline proximal junction angle with a concomitant deterioration of at least one SRS-Schwab sagittal modifier grade, or any type of proximal junctional kyphosis requiring revision., Results: PJF developed in 22 of 113 patients (19%). There were 48 propensity-matched patients in the M and S groups (24 in each) with similar parameters for age, body mass index, number of vertebrae involved, C7SVA, pelvic incidence  - LL, and SRS-Schwab type. In this propensity-matched population, the incidence of PJF was significantly higher in the S group (33% vs. 8%, P < 0.01, odds ratio 6.4, 95% CI: 1.2-32.3)., Conclusion: Low BMD was a significant risk factor for PJF in this propensity-matched cohort (odds ratio 6.4). Surgeons should consider prophylactic treatments when correcting ASD in patients with low BMD., Level of Evidence: 3.

Study Design: Laboratory study., Objective: To elucidate the potential involvement of the interleukin-6 (IL-6)/Janus kinase (JAK)/signal transducers and activator of transcription (STAT3) pathway in the development of intervertebral disc (IVD) degeneration., Summary of Background Data: IL-6 plays a crucial role in IVD degeneration; however, the downstream intracellular signaling of IL-6 in the IVD is not fully understood., Methods: The expression levels of IL-6 and suppressors of cytokine signaling 3 (SOCS3), a target gene of the IL-6/JAK/STAT3 pathway, were evaluated in rat and human degenerated IVD samples. The effects of IL-6 on primary rat annulus fibrosus (AF) cells were analyzed using quantitative PCR, immunocytochemistry, and Western blotting. The potential efficacy of a JAK inhibitor, CP690,550, in neutralizing the effect of IL-6 was evaluated in vitro., Results: A high expression of IL-6 and SOCS3 was observed in both rat and human degenerated IVD samples. In rat AF cells, IL-6 markedly induced the phosphorylation of STAT3 and the expression of cyclooxygenase-2 and matrix metalloprotease-13. CP690,550 significantly suppressed the phosphorylation of STAT3 and offset the catabolic effect of IL-6 in rat AF cells., Conclusion: Our results suggest that the IL-6/JAK/STAT3 pathway is involved in the pathogenesis of IVD degeneration and that CP690,550 suppresses the catabolic effect of the IL-6 in the IVD., Level of Evidence: N/A.

Study Design: Case report and systematic review of the literature., Objective: To describe a rare case of remodeling of the cervical facet joint after the microendoscopic resection of an osteoid osteoma., Summary of Background Data: Osteoid osteoma, the third most common benign bone tumor, is often treated by image-guided percutaneous removal of the nidus. However, percutaneous resection poses technical difficulties when the tumor is located near the spinal cord or nerve roots. To our knowledge, there are no reports describing postoperative remodeling of the cervical facet joint after surgical resection of an osteoid osteoma., Methods: A 13-year-old boy was presented with neck pain that became worse at night. Computed tomography showed an osteoid osteoma in the right 7th cervical superior articular process. We successfully resected the nidus of the osteoid osteoma using minimally invasive microendoscopy., Results: The patient was symptom-free at the 1-year follow up, and computed tomography images showed new bone formation at the C6/7 facet joint., Conclusion: This case indicates that microendoscopic resection is safe and effective for treating a cervical osteoid osteoma. This technique allowed total resection of the nidus with only minimal damage to the adjacent soft tissue and bone, and induced remodeling of the resection site.Level of Evidence: 4., (Copyright © 2016 Wolters Kluwer Health, Inc. All rights reserved.)

Study Design: Retrospective study., Objective: To examine the reliabilities of sagittal spino-pelvic alignment measurements using whole spine-pelvic and local pelvic radiographs and to determine whether spinal deformity affects these reliabilities., Summary of Background Data: Sagittal spino-pelvic alignment is important in adult spinal deformity patients (ASD). Spino-pelvic parameters are closely related to health-related quality of life and indispensable for surgical planning. However, few studies have focused on the reliability of these measurements., Methods: Three spino-pelvic parameters, pelvic incidence (PI), pelvic tilt (PT), and sacral slope (SS) were measured in 2 patient groups: 33 adult scoliosis (AS) and 33 nondeformity (ND) patients, using whole spine-pelvic lateral radiographs (whole spine radiographs) and local pelvic lateral radiographs (local pelvic radiographs), by 5 experienced spine surgeons. Intra- and interobserver reliabilities for each procedure were evaluated by intraclass correlation coefficients (ICC). The interobserver reliability differences between the 2 procedures were statistically evaluated. The difference between the largest and smallest measurements among the 5 observers was also evaluated in the AS and ND groups., Results: Measurement of the 3 parameters using whole spine or local pelvic radiographs showed good to excellent intraobserver reliability (range of ICC: 0.820-0.935). The interobserver reliabilities of PI and PT from local pelvic radiographs were significantly higher than those from whole spine radiographs (P < 0.002). The intraobserver reliabilities of PI and PT from pelvic radiographs tended to be higher than those from whole spine radiographs, but the differences were not statistically significant. The reliability of SS was comparable between the 2 methods. The differences between the highest and lowest PI and PT measurements were smaller with the pelvic compared to whole spine radiographs. These findings were consistent in the AS and ND groups., Conclusion: Local pelvic radiography is more reliable than whole spine radiography for determining spino-pelvic parameters, and we recommend its use for evaluating ASD patients., Level of Evidence: 3.

Study Design: Retrospective case series., Objective: To evaluate the treatment strategies for spinal meningioma., Summary of Background Data: Although previous studies have demonstrated favorable surgical outcomes for spinal meningioma, with a low incidence of tumor recurrence, few have examined long-term surgical outcomes., Methods: The influence of patient age, surgical margin status (Simpson grade), tumor location, and histological subtype on tumor recurrence were examined retrospectively. In addition, the resected dura mater from Simpson grade I cases was examined for invasive tumor cells and compared with the presence or absence of a dural tail sign on magnetic resonance image., Results: Complete resection (Simpson grades I and II) was performed in 62 patients. Among them, the tumor recurrence rate was 9.7%, all in patients who underwent grade II resection for ventral spinal lesions. The mean duration to reoperation in these patients was 12.2 ± 5.2 years. Of the 6 patients who underwent incomplete resection (Simpson grade III/IV), all required reoperation for tumor recurrence or regrowth, 5 years later on average. Patients younger than 50 years at the initial surgery had a significantly higher recurrence rate than those aged 50 years or older. Histologic examination of 43 dura mater specimens from Simpson grade I-resection patients revealed tumor cell invasion between the inner and outer layers in 15 patients. This invasion was noted in 8 (29%) of 28 patients who were negative for the dural tail sign on magnetic resonance image, and in 7 (47%) of 15 patients who showed a positive dural tail sign. The MIB-1 index reached about 10% for dumbbell-type meningiomas invading the vertebral body; these were associated with repeated recurrence and unfavorable prognosis., Conclusion: Long-term follow-up after surgery for meningiomas indicated that Simpson grade I resection should be selected whenever practicable when treating younger patients or dumbbell-type meningiomas. Tumors recurred at 12 years, on average, in approximately 30% of patients who underwent grade II resection.

Study Design: Case report., Objective: To report an extremely rare case of spinal dumbbell-type tanycyticependymoma., Summary of Background Data: Only two previous cases of a dumbbell-type tanycyticependymoma in the spinal cordhave been reported., Methods: A 40-year-old female presented with low back pain and numbness of the left leg. Magnetic resonance imaging revealed a dumbbell tumor at the Th10-11 level that compressed the spinal cord extensively. The diagnosis of extradural dumbell spinal tumor was made, and a total tumor excision was performed with a thoracic 10-11 laminectomy., Results: After surgery, the patient's low back pain and numbness disappeared. Detailed immunohistological examinations confirmed the diagnosis of tanycyticependymoma. At 16 months, there was no evidence of tumor recurrence and no further treatment was needed., Conclusion: A rare case of spinal dumbbell-type tanycyticependy-moma was presented. Detailed histologic examinations are essential to differentiate tanycyticependymoma from other tumors such as schwannoma and pilocyticastrocytoma.

Background: Shprintzen-Goldberg syndrome (SGS) is characterized by craniosynostosis and marfanoid habitus. The clinical findings of SGS include neurological, cardiovascular, connective tissue, and skeletal abnormalities. Among these skeletal findings, developmental scoliosis is recognized in half of all patients with SGS. However, no earlier reports have described the surgical treatment of scoliosis associated with SGS., Methods: Four patients (2 boys and 2 girls; mean age at the time of surgery, 7.3±4.4 y) with SGS who underwent surgical treatment for progressive scoliosis were reviewed. The radiologic findings, operative findings, and perioperative complications were evaluated., Results: The mean preoperative Cobb angle was 102.8±16.9 degrees. The curve patterns were a double curve in 2 cases and a triple curve in 2 cases. Local kyphosis at the thoracolumbar area was recognized in all the cases with a mean kyphosis angle of 49±16 degrees. Growing rod procedures were performed in 2 patients, and posterior correction and fusion were performed in 2 patients. The mean correction rate was 45% in the patients who underwent the growing rod procedures at the time of growing rod placement and 51% in the patients who underwent posterior correction and fusion. Dislodgement of the proximal anchors occurred in 3 of the 4 patients. One patient developed pseudoarthrosis. Two patients developed deep wound infections, and implant removal was necessary in 1 patient., Conclusions: Surgical treatment for scoliosis in patients with SGS was associated with a high incidence of perioperative and postoperative complications including implant dislodgements and deep wound infections attributable to poor bone quality and a thin body habitus, which are characteristic clinical features of this syndrome. Careful preoperative surgical planning and postoperative care are critical for the surgical treatment of scoliosis associated with SGS, especially in infants requiring multiple surgeries., Level of Evidence: Level IV.

Study Design: Case report., Objective: To report 3 cases of malignant tumors in the upper cervical spine that were treated surgically by a combination of posterior tumor resection and stabilization and anterior tumor resection through a mandible-splitting approach after failed ion-beam radiation therapy., Summary of Background Data: Few clinical reports have described in detail the postoperative complications associated with transoral surgical resection of tumors in the upper cervical spine after unsuccessful ion-beam radiation therapy., Methods: Three patients with malignant tumors in the upper cervical spine who had undergone ion-beam radiotherapy and experienced tumor recurrence were treated by a combination of posterior and anterior surgery through a mandible-splitting approach. One patient (patient 1, a 32-year-old man) had a hemangioendothelioma at the C2 and C3 level, whereas the other 2 patients (patient 2, a 66-year-old woman and patient 3, a 65-year-old man) had a chordoma at the C2 and C3 level., Results: The intralesional but macroscopic total resection of the tumors was achieved in all 3 patients. However, serious complications developed after surgery, including deep wound infection, cerebrospinal fluid leakage, and meningitis in patient 1, prolonged swallowing difficulty, subsidence of the strut graft, and recurrence in patient 2, and deep wound infection and discitis causing progressive paralysis in patient 3. All patients underwent salvage surgery, including debridement of the wound in patient 1, posterior reinforcement using instrumentation and posterior tumor resection for the recurrent tumor in patient 2, and anterior debridement of the wound with a pedicle flap using the pectoral major muscle in patient 3 to address these problems. Patients 1 and 3 had no signs of recurrence at the time of a follow-up examination., Conclusion: Severe complications, mainly associated with the disturbance in healing of the retropharyngeal wall, were observed in all 3 patients. A preventive method, such as primary repair of the retropharyngeal wall using muscular/musculocutaneous flaps, should be considered for patients undergoing resection through a transoral approach after ion-beam irradiation.

STUDY DESIGN.: A case report. OBJECTIVES.: To report a case of progressive kyphoscoliosis associated with a tethered cord that was corrected by posterior vertebral column resection after complicated untethering surgery. SUMMARY OF BACKGROUND DATA.: There have been few clinical reports on posterior vertebral column resection conducted for severe deformity associated with a tethered cord. METHODS.: A patient with progressive kyphoscoliosis associated with a tethered cord first underwent untethering surgery, resulting in neurologic deterioration. Posterior vertebral column resection was performed to correct the kyphoscoliosis while shortening the spinal column to prevent the spinal cord from stretch injury. RESULTS.: Good correction of kyphoscoliosis was obtained without further neurologic deterioration. The Cobb angles of scoliosis was 103 degrees before surgery and 25 degrees after surgery (correction rate; 75.7%), and that of kyphosis was 90 degrees and 36 degrees , respectively (correction rate; 60.0%). CONCLUSION.: Correction of progressive kyphoscoliosis associated with a tethered cord can be achieved successfully by posterior vertebral column resection even after complicated untethering surgery.

Study Design: Retrospective case series., Objective: To evaluate our treatment strategy for myxopapillary ependymomas of the cauda equina., Summary of Background Data: Some patients with myxopapillary ependymoma develop cerebrospinal fluid (CSF) dissemination leading to poor prognosis. Because of the rarity of this tumor, there is no consensus on its optimal treatment options and prognosis., Methods: We reviewed 25 cases of myxopapillary ependymomas, treated surgically between 1972 and 2005. The mean postoperative follow-up period was 10.4 years. The effects of surgical margins at surgery and postoperative radiotherapy on tumor recurrence and prognosis were investigated., Results: In 15 patients, total resection achieved (6 cases of en bloc resection without postoperative radiation, and in 9 cases piecemeal resection) was followed by whole brain and spinal cord radiation or local irradiation. Fourteen of these patients survived without tumor recurrence. In 1 case of total resection without radiotherapy, the tumor capsule was violated intraoperatively and local recurrence occurred 2 years after surgery. In 4 patients, the tumors were removed subtotally. Of these, 2 patients who received radiation (24 Gy) only to the whole brain and spinal cord developed recurrence, and 2 who received whole brain and spinal cord radiation (24 Gy) supplemented with local radiation (46 Gy) developed no recurrence. The remaining 6 patients received partial resection after local radiation (40-50 Gy) alone, and all 6 died of CSF dissemination., Conclusion: The results of the present study indicate that the surgical margin obtained at the initial surgery and the extent and amount of postoperative radiation can be crucial factors determining the prognosis of patients with myxopapillary ependymoma. Although this tumor is histologically benign, CSF dissemination can occur once tumor capsule is violated, before or during surgery. Therefore, early diagnosis is essential, and a therapeutic strategy including radiotherapy, on the assumption that this tumor is malignant, should be established.

Study Design: Questionnaire survey on leg cramps for patients with lumbar spinal canal stenosis (LCS)., Objective: To evaluate the prevalence of leg cramps in patients with LCS treated surgically and the relationship between leg cramps and the surgical outcomes., Summary of Background Data: Although it has been anecdotally reported that LCS patients have suffered from leg cramps, the true prevalence remains unknown., Methods: One hundred twenty LCS patients who underwent decompression surgery (men 85, women 35, mean age 73.5) and 370 elderly subjects from the general population (men 162, women 208, mean age 75.6) were enrolled in the study. The participants filled in a questionnaire regarding: (all participants) (1) experience of leg cramps, (2) frequency and time of the day of the cramp attacks; (for LCS patients only), (3) changes in cramps before and after surgery, (4) activities of daily living disturbance because of leg cramps, (5) satisfaction with surgery and walking ability, (6) the Roland-Morris Disability Questionnaire, and (7) the Oswestry Disability Index., Results: Eighty-five (70.8%) patients with LCS and 137 (37.2%) of the control population experienced leg cramps (age and sex adjusted odds ratio; 4.6, P < 0.01). Leg cramps occurred once or twice a week in 34.9% of the LCS group and once in several months in 44.5% of the control group, and occurred nocturnally in 73.3% of the LCS patients and in 91.6% of the control group. In LCS patients, leg cramps improved after surgery in 18.2%, remained unchanged in 45.5%, and worsened in 26.1%, and activities of daily living were disturbed in 47.6%. There was no significant difference in satisfaction with surgery, the Oswestry Disability Index, the Roland-Morris Disability Questionnaire scores, or walking ability between the LCS patients with or without leg cramps., Conclusion: LCS patients had significantly more frequent attacks of nocturnal leg cramps than the control population, and leg cramps disturbed the quality of the patients' life, and they rarely improved after decompression surgery. Leg cramps should be recognized as one of the symptoms of LCS, which disturb the patients' quality of life.