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OBJECTIVEThis study investigated neurological improvements after conservative treatment in patients with complete motor paralysis caused by acute cervical spinal cord injury (SCI) without bone and disc injury.METHODSThis study was retrospective. The authors evaluated neurological outcomes after conservative treatment of 62 patients with complete motor paralysis caused by cervical SCI without bone and disc injury within 72 hours after trauma. The sequential changes in their American Spinal Injury Association Impairment Scale (AIS) grades were reviewed at follow-up 24–72 hours, 1 week, and 1, 3, and 6 months after treatment.RESULTSOf the 31 patients with a baseline AIS grade of A, 2 (6.5%) patients improved to grade B, 5 (16.1%) improved to grade C, and 2 (6.5%) improved to grade D by the 6-month follow-up. The 22 (71.0%) patients who remained at AIS grade A 1 month after injury showed no neurological improvement at the 6-month follow-up. Of the 31 patients with a baseline AIS grade of B, 12 (38.7%) patients showed at least a 1-grade improvement at the 1-month follow-up; 11 (35.5%) patients improved to grade C and 16 (51.6%) patients improved to grade D at the 6-month follow-up.CONCLUSIONSEven in patients with complete motor paralysis caused by cervical SCI without bone and disc injury within 72 hours after trauma, approximately 30% of the patients with an AIS grade of A and 85% of the patients with an AIS grade B improved neurologically after conservative treatment. It is very important to recognize the extent of neurological improvement possible with conservative treatment, even for severe complete motor paralysis.

Study DesignRetrospective review.PurposeTo describe a safe and effective surgical procedure for old distractive flexion (DF) injuries of the subaxial cervical spine.Overview of LiteratureSurgical treatment is required in old cases when a progression of the kyphotic deformity and/or persistent neck pain and/or the appearance of new neurological symptoms are observed. Since surgical treatment is more complicated and dangerous in old cases than in acute distractive-flexion cases, the indications for surgery and the selection of the surgical procedure must be carefully conducted.MethodsTo identify a safe and effective surgical procedure, the procedure selected, reason(s) for its selection, and associated neurological complications were investigated in 13 patients with old cervical DF injuries.ResultsNo neurological complications were observed in nine patients (DF stage 2 or 3) who underwent the anterior-posterior-anterior (A-P-A) method and two patients (DF stage 1) who underwent the posterior method. It was initially planned that two patients (DF stage 2) who underwent the P-A method would be treated using the Posterior method alone; however, anterior discectomy was added to the procedure after the development of a severe spinal cord disorder.ConclusionsThe A-P-A method (anterior discectomy, posterior release and/or partial facetectomy, reduction and instrumentation, anterior bone grafting) is considered to be a suitable surgical procedure for old cervical DF injuries.

Several prognostic studies looked for an association between the degree of spinal cord injury (SCI), as depicted by primary magnetic resonance imaging (MRI) within 72 hours of injury, and neurologic outcome. It was not clearly demonstrated whether the MRI at any time correlates with neurologic prognosis.The purpose of the present study was to investigate the relationship between acute MRI features and neurologic prognosis, especially walking ability of patients with cervical spinal cord injury (CSCI). Moreover, at any point, MRI was clearly correlated with the patient's prognosis.Retrospective image study.From January 2010 to October 2015, 102 patients with CSCI were treated in our hospital. Patients who were admitted to our hospital within 3 days after injury were included in this study. The diagnosis was 78 patients for CSCI with no or minor bony injury and 24 patients for CSCI with fracture or dislocation. A total of 88 men and 14 women were recruited, and the mean patient age was 62.6 years (range, 16-86 years). Paralysis at the time of admission was graded as A in 32, B in 15, C in 42, and D in 13 patients on the basis of the American Spinal Injury Association (ASIA) impairment scale. Patients with CSCI with fracture or dislocation were treated with fixation surgery and those with CSCI with no or minor bony injury were treated conservatively. Patients were followed up for an average of 168 days (range, 25-496 days).Neurologic evaluation was performed using the ASIA motor score and the modified Frankel grade at the time of admission and discharge.Magnetic resonance imaging was performed for all patients at admission. Using the MRI sagittal images, we measured the vertical diameter of intramedullary high-intensity changed area with T2-weighted images at the injured segment. We studied separately the patients divided into two groups: 0-1 day admission after injury, and 2-3 days admission after injury. We evaluated the relationship between the vertical diameter of T2 high-intensity changed area in MR images and neurologic outcome in these two groups. This study does not contain any conflict of interest.In the group admitted at 0-1 day after injury, there was a relationship between the vertical diameter of T2 high-intensity area in MR image and the ASIA motor score at admission and at discharge, but correlation coefficient was low (0.3766 at admission and 0.4239 at discharge). On the other hand, in the group admitted at 2-3 days after injury, there was a significant relationship between the vertical diameter of T2 high-intensity area in MR image and the ASIA motor score at admission and at discharge, and correlation coefficient was very high (0.6840 at admission and 0.5293 at discharge). In the group admitted at 2-3 days after injury, a total of 17 patients (68%) recovered to walk with or without a cane. Receiver operating characteristic (ROC) curve analysis demonstrated that the optimal vertical diameter of T2 high-intensity area cutoffvalue for patients who were able to walk at discharge was 45.8 mm. If the vertical diameter of T2 high-intensity area cutoff value was 45 mm, there was a significant positive correlation with being able to walk at discharge (p.0001).From our study, 2-3 days after injury, a significant relationship was observed between the vertical diameter of T2 high-intensity area and the neurologic prognosis at discharge. Zero to 1 day after injury, the relationship between the vertical diameter of T2 high-intensity area and the neurologic prognosis at discharge was weak. Neurologic prognosis is more correlated with MRI after 2-3 days after the injury. If the vertical diameter of T2 high-intensity area was45 mm, the patients were able to walk with or without a cane at discharge. T2 high-intensity changed area can reflect the neurologic prognosis in patients with CSCI.

Retrospective chart audits. To investigate the optimal timing at which permanent complete cervical spinal cord injury (CSCI) can be confirmed when evaluating paralysis caused by traumatic CSCI. Department of Orthopedic Surgery, Spinal Injuries Center, Japan. Two-hundred and three patients with CSCI that was classified with an American Spinal Injury Association (ASIA) Impairment Scale (AIS) grade A (AIS A) within 72 h of the initial diagnosis of traumatic CSCI were included in the present study. Neurological data from the time of the initial diagnosis to 1 year after the injury were extracted. The number of those with recovery from AIS A and changes of AIS in the recovery were examined. Thirty-five of 203 (17%) patients whose injuries were initially classified with an AIS A showed recovery from AIS A. Thirty-four of 35 (97%) patients showed recovery from AIS A within 8 weeks after injury. If CSCI patients with AIS A have not recovered by 8 weeks, the likelihood that they will recover from AIS A is marginal. However, this conversely means that we must consider the possibility that a patient with a traumatic CSCI classified with an AIS A may still show recovery from AIS A within the first 8 weeks after injury.

Introduction Compressive-flexion type cervical spine fracture is typically accompanied by apparent dislocation of the facet joints, undesirable cervical alignment, and devastating neurological dysfunction, which provides strong rationale for rendering prompt operative treatment. However, the validity of conservative treatment for compressive-flexion cervical spine injury in cases with preserved congruity of the facet joints has yet to be elucidated. The purpose of this study is to evaluate the long-term outcome of cervical alignment following conservative treatment for compressive-flexion cervical spine injury with preserved congruity of the facet joints. Methods A total of 662 patients who experienced spinal cord injury from 2007 to 2017 were included and underwent retrospective review in a single institute. Thirteen patients were identified as receiving conservative therapy following compressive-flexion cervical spine fractures with spinal cord injury. Clinical and radiological results were collected, including vertical fractures of the vertebral column, laminar fractures, progression of local kyphosis, and neurological status. The degree of the local cervical kyphosis was evaluated with two methods: the posterior tangent method and the endplate method. Results All 13 patients were male, and the mean age at the time of injury was 28.4 years. The mean follow-up period was 3 years. Although none of the patients presented neurological deterioration after the injury, the degree of local kyphosis was increased at the time of final follow-up compared to what was observed at the time of injury. Patient age at the time of injury and concurrent vertical fracture of vertebral body could have been influencing factors for the progression of the kyphosis. While laminar fracture affected the kyphosis at the time of injury, it was not a strong influencing factor of the overall progression of local kyphosis. Conclusions The conservative option for the compressive-flexion cervical injury allowed us to treat without exacerbating neurological symptoms as long as the facet joints are preserved. However, in terms of cervical alignment, surgical stabilization may have been desirable for these patients. Notably, the younger patients and the patients with vertical fracture of the cervical vertebral column in this type of injury required closer observation to help prevent the progression of local kyphosis.

Prospective cohort study. To elucidate serial changes in dysphagia and elucidate the critical period for dysphagia following acute traumatic cervical spinal cord injury (CSCI). Spinal Injuries Center, Fukuoka, Japan. We prospectively examined individuals with acute traumatic CSCI admitted within 2 weeks after injury. Severity of dysphagia was evaluated using both the dysphagia severity scale (DSS) and functional oral intake scale (FOIS) at 2 weeks, 1 month, 2 months, and 3 months after injury. Condition of oral intake before injury was assessed by history taking. American Spinal Injury Association (ASIA) impairment scale grade and motor scores were also assessed at the same timepoints, and the correlation between dysphagia and paresis was analyzed. Sixty-five individuals with CSCI were assessed consecutively for 3 months after injury. Swallowing function, evaluated using both the DSS and FOIS, was significantly decreased at 2 weeks after injury, but significantly improved thereafter. Significant correlations between severity of dysphagia (DSS and FOIS scores) and motor scores were found at 2 weeks after injury (rs = 0.66 and 0.61; p

Study design Retrospective review. Objective To evaluate the influence of static compression factors and dynamic factors based on the various degrees of traumatic force on the cervical spinal cord injury (SCI) in patients with ossification of the posterior longitudinal ligament. Summary of background data Spinal cord disorder occurs as a result of various factors, including static factors and traumatic force. Discussions about the severity of paralysis resulting from SCI must therefore focus on dynamic factors based on the traumatic force as well as on static compression factors. However, the past reports did not describe the influence of traumatic force in detail. Methods Fifty patients presenting with cervical SCI associated with ossification of the posterior longitudinal ligament were included in this study. The American Spinal Injury Association motor score 3 days after injury, the degree of the traumatic force, and the spinal cord compression rate were investigated, and the relationships among these factors were investigated. Results Paralysis at the time of injury was not determined by static factors alone or by traumatic force alone. The severity of paralysis at the time of injury was determined on the basis of a combination of both the static factors and the degree of traumatic force. Conclusion Both the degree of spinal cord compression and the degree of traumatic force were found to be important factors associated with the severity of cervical SCI in patients with ossification of the posterior longitudinal ligament. Level of evidence 4.

Study design A retrospective imaging and clinical study. Objective To evaluate the extraneural soft-tissue damage and its clinical relevance in patients with traumatic cervical spinal cord injury (SCI) without major bone injury. Summary of background data To date, various kinds of cervical discoligamentous injuries have been demonstrated on magnetic resonance images in patients with SCI without bony injury. However, it has not been clear whether these magnetic resonance imaging abnormalities are actually related to spinal segmental instability and the patients' neurological status. Methods Eighty-eight adult patients with acute traumatic cervical SCI without major bone injury were examined by flexion-extension lateral radiographs and magnetic resonance images within 2 days after trauma. We excluded patients with flexion recoil injury; therefore, most of the patients included were considered to have sustained a hyperextension injury. Instability of the injured cervical segment was defined when there was more than 3.5-mm posterior translation and/or more than a 11° difference in the intervertebral angle between the site of interest and adjacent segments. The neurological status was evaluated according to the American Spinal Injury Association motor score. Results On magnetic resonance images, the damage to the anterior longitudinal ligament and intervertebral disc were apparent in 44 and 37 patients, respectively. Various degrees of prevertebral fluid collection (prevertebral hyperintensity) were demonstrated in 76 patients. These magnetic resonance imaging abnormalities were significantly associated with initial cervical segmental instability as judged by flexion-extension radiographs. Interestingly, the American Spinal Injury Association motor score had a significant association with either magnetic resonance imaging abnormalities or segmental instability but not with the cervical canal diameter. Conclusion A considerable proportion of the patients with traumatic cervical SCI without major bone injury were shown to have various types of soft-tissue damage associated with cervical segmental instability at the early stages of the injury. The severity of paralysis greatly depended on these discoligamentous injuries.

The fully human monoclonal antibody KMTR2 acts as a strong direct agonist for tumor necrosis factor-related apoptosis-inducing ligand (TRAIL) receptor 2 (TRAIL-R2), which is capable of inducing apoptotic cell death without cross-linking. To investigate the mechanism of direct agonistic activity induced by KMTR2, the crystal structure of the extracellular region of TRAIL-R2 and a Fab fragment derived from KMTR2 (KMTR2-Fab) was determined to 2.1 Å resolution. Two KMTR2-Fabs assembled with the complementarity-determining region 2 of the light chain via two-fold crystallographic symmetry, suggesting that the KMTR2-Fab assembly tended to enhance TRAIL-R2 oligomerization. A single mutation at Asn53 to Arg located at the two-fold interface in the KMTR2 resulted in a loss of its apoptotic activity, although it retained its antigen-binding activity. These results indicate that the strong agonistic activity, such as apoptotic signaling and tumor regression, induced by KMTR2 is attributed to TRAIL-R2 superoligomerization induced by the interdimerization of KMTR2.

A retrospective radiographic study with a minimum 2-year follow-up.To evaluate the relationships between the cervical articular facets' morphology and the incidence of traumatic cervical spinal cord injury (CSCI) without major fracture or dislocation.Spinal Injuries Center, Japan.This study included 113 patients with traumatic CSCI without major fracture or dislocation. Eighty-four healthy volunteers without neurological deficits or cervical cord pathology on magnetic resonance imaging (MRI) were defined as control subjects. We used a plain sagittal radiograph to measure the facet sagittal angles (FSA) at four cervical segments in all the CSCI patients and controls. We defined the FSA as the angle between the inferior margin of the superior cervical spinal body and the inferior articular process of the superior vertebra.Most frequent incidence of CSCI was seen at C3-4 segment (54%). With respect to CSCI at C3-4 segment, 55.7% of the subjects showed smallest FSA at C3-4 segment.Most of the traumatic CSCI at C3-4 segment showed raised cervical articular facets at C3-4 segment. On the basis of our results, we hypothesized that the raised cervical articular facets might have an important role in the etiology of traumatic CSCI. The cervical spinal cord at the C3-4 segment might receive the highest load during acute hyperextension of the cervical spine because of the C3-4 articular facets' morphology.

STUDY DESIGN A retrospective, consecutive case series. OBJECTIVE To determine the risk factors that have a significant correlation with the severity of neurologic impairment in thoracolumbar and lumbar burst fractures. SUMMARY OF BACKGROUND DATA The correlation between spinal canal stenosis due to bony fragments and the severity of neurologic deficits in thoracolumbar and lumbar burst fractures remains controversial. Moreover, there have so far been no reports in the literature in which the risk factors (spinal canal stenosis and the disruption of posterior ligamentous complex) causing a severe neurologic deficit were analyzed using a multiple logistic regression model. METHODS A review of the clinical data (neurologic impairments on admission and a finding of posterior ligamentous complex disruption at the time of operation), axial computed tomography, and plain lateral radiography of 216 patients in thoracolumbar (T11-L1) and lumbar (L2-L5) burst fractures was performed. The factors related to neurologic impairments were analyzed using a multiple logistic regression model. RESULTS In all cases, both the spinal canal stenosis (P < 0.01) and disruption of posterior ligamentous complex (P < 0.01) were significant risk factors. Interestingly, these two risk factors varied according to the injury levels: at thoracic level, the spinal canal stenosis (P < 0.01); at the first lumbar spine, the disruption of the posterior ligamentous complex (P < 0.01); and at the lumbar spine below L2, both of the spinal canal stenosis (P < 0.01) and the disruption of posterior ligamentous complex (P < 0.05) were significant risk factors, respectively. CONCLUSION In the patients with thoracolumbar and lumbar burst fractures, the significance of the two important risk factors related to clinical results, namely, the stenosis ratio of spinal canal and the disruption of posterior ligamentous complex, were found to vary depending on the level of injury.

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．

When human antibody genes were expressed in the methylotrophic yeast Ogataea minuta, the secreted antibody became partially degraded. To suppress the degradation, a vacuolar protease-deficient strain was constructed and its antibody production was evaluated. Although antibody productivity was improved in the vacuolar protease-deficient strain, the secreted antibody still became partially degraded. Peptide sequencing revealed that the cleavage occurred in the CH1 region of the heavy chain, implying that the cleavage was caused by an aspartic protease, Yps1p. To inhibit this cleavage, Yps1p-deficient strains were constructed and their antibody production was evaluated. As a result, the partial degradation of the antibody was suppressed in the O. minuta multiple-protease-deficient strains.

Study design Retrospective case series. Purpose To clarify the influence of cervical spinal canal stenosis (CSCS) on neurological functional recovery after traumatic cervical spinal cord injury (CSCI) without major fracture or dislocation. Overview of literature The biomechanical etiology of traumatic CSCI remains under discussion and its relationship with CSCS is one of the most controversial issues in the clinical management of traumatic CSCI. Methods To obtain a relatively uniform background, patients non-surgically treated for an acute C3-4 level CSCI without major fracture or dislocation were selected. We analyzed 58 subjects with traumatic CSCI using T2-weighted mid-sagittal magnetic resonance imaging. The sagittal diameter of the cerebrospinal fluid (CSF) column, degree of canal stenosis, and neurologic outcomes in motor function, including improvement rate, were assessed. Results There were no significant relationships between sagittal diameter of the CSF column at the C3-4 segment and their American Spinal Injury Association motor scores at both admission and discharge. Moreover, no significant relationships were observed between the sagittal diameter of the CSF column at the C3-4 segment and their neurological recovery during the following period. Conclusions No relationships between pre-existing CSCS and neurological outcomes were evident after traumatic CSCI. These results suggest that decompression surgery might not be recommended for traumatic CSCI without major fracture or dislocation despite pre-existing CSCS.

OBJECT Axial neck pain after C3–6 laminoplasty has been reported to be significantly lesser than that after C3–7 laminoplasty because of the preservation of the C-7 spinous process and the attachment of nuchal muscles such as the trapezius and rhomboideus minor, which are connected to the scapula. The C-6 spinous process is the second longest spinous process after that of C-7, and it serves as an attachment point for these muscles. The effect of preserving the C-6 spinous process and its muscular attachment, in addition to preservation of the C-7 spinous process, on the prevention of axial neck pain is not well understood. The purpose of the current study was to clarify whether preservation of the paraspinal muscles of the C-6 spinous process reduces postoperative axial neck pain compared to that after using nonpreservation techniques. METHODS The authors studied 60 patients who underwent C3–6 double-door laminoplasty for the treatment of cervical spondylotic myelopathy or cervical ossification of the posterior longitudinal ligament; the minimum follow-up period was 1 year. Twenty-five patients underwent a C-6 paraspinal muscle preservation technique, and 35 underwent a C-6 nonpreservation technique. A visual analog scale (VAS) and VAS grading (Grades I–IV) were used to assess axial neck pain 1–3 months after surgery and at the final follow-up examination. Axial neck pain was classified as being 1 of 5 types, and its location was divided into 5 areas. The potential correlation between the C-6/C-7 spinous process length ratio and axial neck pain was examined. RESULTS The mean VAS scores (± SD) for axial neck pain were comparable between the C6-preservation group and the C6-nonpreservation group in both the early and late postoperative stages (4.1 ± 3.1 vs 4.0 ± 3.2 and 3.8 ± 2.9 vs 3.6 ± 3.0, respectively). The distribution of VAS grades was comparable in the 2 groups in both postoperative stages. Stiffness was the most prevalent complaint in both groups (64.0% and 54.5%, respectively), and the suprascapular region was the most common site in both groups (60.0% and 57.1%, respectively). The types and locations of axial neck pain were also similar between the groups. The C-6/C-7 spinous process length ratios were similar in the groups, and they did not correlate with axial neck pain. The reductions of range of motion and changes in sagittal alignment after surgery were also similar. CONCLUSIONS The C-6 paraspinal muscle preservation technique was not superior to the C6-nonpreservation technique for preventing postoperative axial neck pain.

Tumor necrosis factor-related apoptosis-inducing ligand (TRAIL) specifically induces apoptosis in tumor cells but may be toxic to human hepatocytes. Although hepatocytes are susceptible to apoptotic signals mediated by TRAIL-receptor 2 (TRAIL-R2), we previously reported that some anti-TRAIL-R2 monoclonal antibodies (mAbs) produce little hepatocyte toxicity. Those mAbs neutralized the cytotoxic activity of TRAIL by inhibiting receptor–ligand binding. The hepatocyte-toxic mAbs did not compete with TRAIL for binding to TRAIL-R2, and potentiated ligand activity in both cancer cells and hepatocytes. A neutralizing antibody to TRAIL inhibited hepatocyte death by anti-TRAIL-R2 mAbs, suggesting that the toxicity may reflect their ability to potentiate membrane-bound TRAIL on hepatocytes.

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.

Monoclonal antibodies have already established a secure position as a very promising strategy for anti-tumor therapeutics. High specificity and high affinity are attractive characteristics of antibodies which make them suitable for clinical applications. Advances in genetic engineering have enabled to generate recombinant antibodies which circumvent the problems of using murine antibodies in human therapy. Immunological effects, specific delivery of antibody conjugated-toxins to target cancer cells, and direct effects through receptor engagement by antibodies have been exploited as mechanisms which generate anti-tumor activity.Tumor necrosis factor (TNF)-related apoptosis-inducing ligand (TRAIL) is a member of the TNF superfamily and can induce apoptosis in a wide variety of human cancer cell lines via its interactions with TRAIL receptor 1 (TRAIL-R1) and TRAIL receptor 2 (TRAIL-R2), but does not affect most normal human cells. From the clinical viewpoint, the use of a recombinant soluble form of TRAIL and agonistic antibodies specific for TRAIL-R1 and TRAIL-R2 as anti-tumor agents have been investigated. These promising therapeutic agents are now undergoing clinical investigations.In this review, we summarize the characteristics of recently developed anti-tumor therapeutic antibodies and discuss the current status of therapeutic approaches targeting TRAIL receptors, both by application of TRAIL and by treatment with agonistic monoclonal antibodies. Both these strategies show great promise as therapeutic agents for treatment of cancer patients.

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.

A retrospective imaging and clinical study.To evaluate the relationship between magnetic resonance imaging (MRI) features and neurological prognosis in patients with traumatic cervical spinal cord injury (CSCI) without major bone injury.A total of 72 patients with CSCI without major bone injury were treated conservatively in our hospital. MRI was performed for all patients at admission and 1 month following injury. We measured the antero-posterior and cranio-caudal diameter of intramedullary intensity changed area with T1-weighted images at the injured segment. Neurological evaluations were performed using the American Spinal Injury Association (ASIA) motor score and the modified Frankel grade at the time of admission and discharge.There was a significant relationship between the antero-posterior diameter ratio of the T1-weighted low-intensity area on MRI at the subacute stage and the ASIA motor score. The optimal threshold of the T1-weighted low-intensity diameter ratio for predicting the patient's ability to walk with or without assistance at discharge was determined to be 46%. Moreover, 96.8% of the patients with50% T1-weighted low-intensity area recovered to walk with or without a cane at discharge.The T1-low intensity area may be an important predictive factor for the neurological recovery of CSCI without major bone injury.

Local Sagittal Alignment after Indirect Reduction and 2-Level Short-Segment Pedicle Screw Fixation of Thoracolumbar Burst Fractures The treatment of thoracolumbar burst fractures with short-segment pedicle screw fixation alone has been associated with progressive loss of correction and instrumentation failure. However, some burst fractures can be treated successfully by this technique without correction loss or implant failure.

In mammalian cells, the p38 mitogen-activated protein kinase (MAPK) pathway is activated in response to a variety of environmental stresses and inflammatory stimuli. However, the role of p38 MAPK signaling in unchallenged conditions remains largely unknown. We have isolated mutations in a Drosophila p38 MAPKK gene homolog, licorne (lic), and show that during oogenesis, lic is required in the germ line for correct asymmetric development of the egg. In lic mutant egg chambers, oskar mRNA posterior localization is not properly maintained, resulting in anteroposterior patterning defects in the embryo. Furthermore, lic loss-of-function in the germ line leads to reduced EGF receptor activity in dorsal follicle cells and ventralization of the egg shell. Both these defects are associated with a diminution of gurken protein levels in the oocyte. Our phenotypic data argue for a role of lic in a post-transcriptional regulation of the grk gene. Furthermore, they show that in addition to the well-characterized Ras/Raf/ERK MAPK pathway acting in the follicle cells, another related signaling cascade, the p38 MAPK pathway, is required in the germ line for correct axes determination. These results provide the first genetic demonstration of an essential function for a p38 pathway during development.

Seven cases of vertebral body fractures adjacent to the instrumented vertebral were observed after posterior spinal instrumentation surgery. All patients were females and their ages ranged from 51 to 68 years (mean, 69 years). The interval between surgery and fracture recognized radiographically ranged from two months (mean, 3.5 years). This case report presents the possibility of biomechanical stress on the porotic spine adjacent to the instrumented rigid spinal segments.

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．

The present study was designed to investigate the effects of centrally administered morphine and opioid peptides on the discriminative stimulus properties of pentazocine in the rat. Rats were trained to discriminate 3 mg/kg (s.c.) of pentazocine from vehicle in a shock avoidance paradigm. A 3 mg/kg (s.c.) dose of pentazocine produced stimulus effects in common with those induced by a training dose (3 mg/kg, s.c.) of pentazocine. Morphine (0·1–3 μg, i.c.v.) produced a dose-dependent increase in responding appropriate for pentazocine lever. The μ-selective opioid receptor agonist [D-Ala2,NMePhe4,Gly-ol] enkephalin (DAMGO) (0·0003–0·03 μg, i.c.v.) generalized to pentazocine cue. d-Pen2, l-Pen5] enkephalin (DPLPE) (3 and 10 μg, i.c.v.), a δ-selective opioid receptor agonist, produced partial generalization to pentazocine cue. However, the κ-selective opioid receptor agonist dynorphin A-(1–13) (3 and 10 μg, i.c.v.) did not generalize to pentazocine cue. The pentazocine-like discriminative stimulus effects of morphine (3 μg, i.c.v.) and DAMGO (0·03 μg, i.c.v.) were fully reversed by intracerebroventricular injection of the μ-selective opioid receptor antagonist β-funaltrexamine (5 μg, i.c.v.). These results suggest that μ-opioid receptors play a major role in the discriminative stimulus effects of pentazocine, while δ-opioid receptors only partially contribute to them. © 1998 John Wiley & Sons, Ltd.

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.

The purpose of the study was to evaluate the clinical relationship between cervical spinal canal stenosis (CSCS) and incidence of traumatic cervical spinal cord injury (CSCI) without major fracture or dislocation, and to discuss the clinical management of traumatic CSCI.Forty-seven patients with traumatic CSCI without major fracture or dislocation (30 out of 47 subjects; 63.83 %, had an injury at the C3-4 segment) and 607 healthy volunteers were measured the sagittal cerebrospinal fluid (CSF) column diameter at five pedicle and five intervertebral disc levels using T2-weighted midsagittal magnetic resonance imaging. We defined the sagittal CSF column diameter of less than 8 mm as CSCS based on the previous paper. We evaluated the relative and absolute risks for the incidence of traumatic CSCI related with CSCS.Using data from the Spinal Injury Network of Fukuoka, Japan, the relative risk for the incidence of traumatic CSCI at the C3-4 segment with CSCS was calculated as 124.5:1. Moreover, the absolute risk for the incidence of traumatic CSCI at the C3-4 segment with CSCS was calculated as 0.00017.In our results, the relative risk for the incidence of traumatic CSCI with CSCS was 124.5 times higher than that for the incidence without CSCS. However, only 0.017 % of subjects with CSCS may be able to avoid developing traumatic CSCI if they undergo decompression surgery before trauma. Our results suggest that prophylactic surgical management for CSCS might not significantly affect the incidence of traumatic CSCI.

This was a retrospective observational study.The objectives were to describe the prognosis of upper extremity function following cervical spinal cord injury (CSCI), and to identify prognostic factors for functional recovery.Spinal Injuries Center, Japan.Sixty patients with C3-4 CSCI without major bone injury participated in the study. Patients were treated nonsurgically and evaluated using the American Spinal Injury Association (ASIA) scales for the upper and lower extremities, their residual cervical motor functions, the modified Frankel grade and an upper extremity function scale. We compared the findings for the upper extremity function scale at 6 months with those for the residual cervical motor functions and modified Frankel grade obtained 3 days after injury.Most patients with CSCI who could flex their hip and knee from a supine position (95%) or who showed some active elbow extension (86%) 3 days after their injury could use a spoon at 6 months. We compared patients who used their fingers at 6 months to those who could not, and observed significant differences in age and ASIA scores for the upper and lower extremities obtained 3 days after injury. A strong correlation was observed between the initial motor scores and the extent of functional recovery at 6 months.Hip and knee flexion from the supine position and elbow extension 3 days after injury significantly predicted a positive prognosis for upper extremity function. Younger age and higher ASIA motor scores obtained 3 days after injury were factors associated with neurological recovery.

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.

The present study was designed to investigate the effects of centrally administered neuropeptides on the discriminative stimulus properties of cocaine in the rat. Rats were trained to discriminate 10.0 mg/kg of cocaine from vehicle in a shock avoidance paradigm. The mu-selective opioid agonist [D-Ala2,NMePhe4,Gly-ol]enkephalin (DAMGO) (0.03-0.3 microgram, ICV) or the kappa-selective opioid agonist dynorphin A-(1-13) (1.0-10.0 micrograms, ICV) did not generalize to cocaine cue, although the delta-selective opioid agonist [D-Pen2,L-Pen5]enkephalin (DPLPE) (10.0 micrograms, ICV) reportedly generalizes to it through the mediation of delta-opioid receptors. Thyrotropin-releasing hormone (10.0-56.0 micrograms, ICV), somatostatin (0.3-3.0 micrograms, ICV), substance P (3.0-17.5 micrograms, ICV), or neurotensin (3.0-17.5 micrograms, ICV) did not produce any stimulus effects in common with cocaine. It appears that neuropeptides other than the delta-selective opioid do not play a major role in the discriminative stimulus properties of cocaine.

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.

STUDY DESIGN A retrospective, consecutive case series. OBJECTIVE To determine the risk factors that have a statistically significant association with the need of tracheostomy in patients with cervical spinal cord injury (CSCI) at the acute stage. SUMMARY OF BACKGROUND DATA Respiratory complications remain a major cause of further morbidity and mortality in patients with CSCI. Although several risk factors for tracheostomy have been postulated in these patients, no definitive factors have yet been established according to a multivariate analysis. The use of vital capacity was considered as a single global measure of respiratory function in patients with spinal cord injury, but there are very few studies in which the forced vital capacity was investigated as a risk factor for tracheostomy. METHODS This study that reviewed the clinical data of 319 patients with CSCI, who were evaluated for their neurological impairment within 2 days after injury, was performed. We analyzed the factors postulated to increase the risk for tracheostomy, including patient's age, neurological impairment scale grade and level, smoking history, pre-existing medical comorbidities, respiratory diseases, Injury Severity Score, forced vital capacity, and percentage of vital capacity to the predicted value (%VC), using a multiple logistic regression model and classification and regression tree analysis. RESULTS Of 319 patients, 32 patients received tracheostomy (10.03%). The factors identified using a multiple logistic regression model were high age (69 years of age or older), severe neurological impairment scale, low forced vital capacity (≤ 500 mL), and low percentage of vital capacity to the predicted value (