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A 62-year-old male presented with a thoracic intradural-extramedullary metastasis from lung cancer. He complained of walking difficulty and bilateral lower leg numbness. He had a past history of lung adenocarcinoma three years prior. Thoracic spine magnetic resonance imaging showed that the tumor occupied the right subarachnoid space and spinal nerve roots had shifted to the left side at Th12. He was diagnosed with cauda equina syndrome by an intradural-extramedullary tumor. Surgery was performed (Th12 laminectomy) and we opened the dura mater and arachnoid membrane. The tumor was in the right side and was removed. After the operation, his neurological condition soon improved and he could walk with a cane. By four moths postoperatively, a metastatic brain tumor occurred and he had to use a wheel chair. He died one year after surgery. Immunohistochemical staining was positive for thyroid transcription factor-1 in both the lung adenocarcinoma and intradural-extramedullary tumor. We diagnosed a metastatic tumor. Including the present case, 102 cases of a metastatic intradural-extramedullary tumor have been reported and, thus, the condition may not be rare. In more than twenty years there have only been two case studies, which recommended both operative and non-operative methods. We reviewed the validity of an operation base on the prognosis and surgical results of previous reports. The average life expectancy was 8.6 months. The functional improvement rate was 78%. We recommend an operation for an intradural-extramedullary metastatic tumor because it improves the quality of a patients’ short life.

Low transverse sacral fractures are rare, with only two published reports regarding their surgery. The complication associated with surgery for sacral fractures is the prominence of implants. In addition, screw fixation below S3 is impractical. We performed posterior sacral fixation using S2 alar iliac (S2AI) screws and sacral sublaminar wires for low transverse sacral fractures. Case 1 was 65-year-old male with an S2-3 transverse sacral fracture. We performed laminectomy (S2-3) and passed ultrahigh molecular weight polyethylene (UHMWPE) cables from laminectomy area to the third posterior sacral foramina. We inserted S2AI screws and connected rods. We also tightened the UHMWPE cables. The implants did not protrude into skin. One year after surgery, the sacral fracture healed without any displacement. Case 2 was a 42-year-old female with an S2 transverse sacral fracture. We performed laminectomy (S1–3) and passed UHMWPE cables from laminectomy area to the third and fourth posterior sacral foramina. We inserted S1 pedicular screws and S2AI screws and connected rods. We also tightened UHMWPE cables. The implants did not protrude into skin. One year after surgery, the sacral fracture healed without any displacement. We consider sacral sublaminar wires to be useful bone anchors in lower sacrum.

Spontaneous thoracic spinal subarachnoid hemorrhage is rare, and thus no useful radiological findings for preoperative diagnosis have been reported. We experienced a patient with spontaneous thoracic spinal subarachnoid hemorrhage. A 37-year-old female presented with sudden-onset paraplegia and numbness in the trunk and bilateral lower extremities. The patient had no past history of trauma, lumbar puncture and bleeding disorder. T2-weighted sagittal magnetic resonance imaging (MRI) of the cervical and thoracic spines showed a mass occupied in the ventral space of spinal cord that was dorsally shifted. The mass extended from C6 to Th6 levels, with its largest size at Th2 level. Thoracic spine T2-weighted sagittal and axial MRI showed that the mass compressed spinal cord and was located in the intradural space. There was no spinal cord tumor and no spinal vascular malformation around the mass. Brain computed tomography (CT) showed a high-density area in the subarachnoid space, indicating the possibility of subarachnoid hemorrhage. Brain MRI showed no ruptured aneurysm. The patient was diagnosed as a spontaneous thoracic spinal subarachnoid hemorrhage and emergency surgery was selected. We performed right-side hemilaminectomy at Th1-Th6 and opened dura mater and arachnoid membrane. Hematoma was found in the ventral space of spinal cord and was removed. One year after surgery, numbness in the trunk and bilateral lower extremities had disappeared but paraplegia remained unchanged. Thoracic spine T2-weighted MRI confirmed no hematoma but showed a newly formed intradural cyst. Preoperative combination of brain CT and thoracic MRI is useful to diagnose thoracic spinal subarachnoid hemorrhage.

The incidence of lumbar spinal canal stenosis (LSCS) is increasing in Japan. Posterior lumbar decompression surgery, wide fenestration and laminectomy, for LSCS is a common treatment modality. Compared with posterior fusion surgery, posterior decompression surgery has been considered as less invasive. However, no reports regarding postoperative anemia following posterior decompression surgery have been published. In this retrospective study, we evaluated changes in hemoglobin values following wide fenestration in 80 patients with LSCS based on the number of operated levels, and also analyzed the differences between intraoperative and postoperative bleeding volume. Two patients required allogenic transfusion. The mean preoperative hemoglobin values were 13.6 g/dL and the mean postoperative minimum hemoglobin values were 11.2 g/dL. The mean hemoglobin values decreased by 1.8 g/dL in patients with one operated level (n = 15); 2.2 g/dL in those with two operated levels (n = 31); 2.6 g/dL in those with three operated levels (n = 23); and 3 g/dL in those with four operated levels (n = 11). The mean decrease in hemoglobin values was calculated as follows: 1.8 + 0.4 × (X - 1), where X was the number of operated levels. The mean intraoperative bleeding volume was 94 ml and the mean postoperative bleeding volume was 418 ml. Postoperative bleeding volume was significantly larger than intraoperative bleeding volume. Accordingly, postoperative hemoglobin values can be predicted in patients undergoing wide fenestration. Effective management of postoperative bleeding is necessary to prevent postoperative anemia.

While 22 articles have reported on sacral stress fractures, it is a rare injury and its etiology is not well known. We present the case of a 16-year-old male who presented with low back pain in 2015. He was a high school soccer player with a previous history of a bilateral L5 lumbar spondylolysis in 2014. The patient refrained from soccer and wore a brace for six months. Two months after restarting soccer, he again complained of low back pain. After 1 year, a lumbar spine computed tomography revealed the bone union of the spondylolysis. At his first visit to our hospital, his general and neurological conditions were normal and laboratory data were within the normal range. Sacral coronal magnetic resonance imaging (MRI) of the left sacral ala revealed an oblique lineal signal void surrounding bone marrow edema. Based on his symptoms, sports history, and MRI, he was diagnosed with a sacral stress fracture. He again refrained from soccer; his low back pain soon improved, and, after 1 year, the abnormal signal change had disappeared on sacral MRI. Recurrent low back pain case caused by a sacral stress fracture occurring after the bone union of lumbar spondylolysis is uncommon.

Introduction. Degenerative lumbar spinal disorder is common in Japan, and the L5 nerve root is commonly involved in this disorder. The symptoms of L5 radiculopathy are irradiating lateral leg pain, and numbness and weakness of tibialis anterior and the hip abductor muscle. There has been only one report on the results of surgery for hip abductor muscle weakness caused by degenerative lumbar spinal disorder. Patients and methods. In this study, we analyzed the strength of the hip abductor muscle before and after decompressive surgery in 26 cases and the relationship between the lumbar disc herniation (LDH) and lumbar spinal canal stenosis (LSCS) groups. Results. Of the total 26 cases, muscle strength improved in 23 cases (88%), with complete recovery in 17 cases (65%). In the LDH group, the improvement rate was 92%. In the LSCS group, the improvement rate was 68%. Although the improvement rate for the LDH group was higher than that for the LSCS group, the difference was not significant (P = 0.054). Discussion. Decompressive surgery may be an effective method to improve hip abductor muscle weakness in degenerative lumbar spinal disorder.

Many studies have been reported on recurrent lumbar disc herniations covering several pathological conditions. In those studies, reoperation rate of revised disc excisions was calculated by simple division between the number of reoperations and that of the total primary disc excisions. To determine the real reoperation rate, strict definition of pathologies, a large number of patients, a long observation period, and survival function method are necessary.Between 1988 and 2007, 5,626 patients with disc excision were enrolled by the spine registration system of the Department of Orthopaedic Surgery, Tohoku University, Japan. Among them, 192 had revised disc surgery, and we obtained data of 186 patients whose clinical features were assessed and reoperation rates analyzed using the Kaplan-Meier method.In total, 205 disc herniations were excised in the revision surgery (including contralateral herniation at the same level and new herniation at a different level), and 101 were real recurrent herniations (recurrence at the same level and side as the primary herniation). The kappa coefficient of the spinal level and side between the primary and revision surgeries was 0.41, indicting moderate correlations. Real recurrent herniations showed shorter intervals between primary and revision surgeries. Male patients with surgery at a younger age carried a higher risk of reoperation. In the revision surgery, transligamentous extrusion was significantly more common than other types of herniation. On Kaplan-Meier analysis, the reoperation rate of overall revised excisions was 0.62% at 1 year, 2.4% at 5 years, 4.4% at 10 years, and 5.9% after 17 years. That of real recurrent herniations was 0.5%, 1.4%, and 2.1%, respectively, and 2.8% after 15.7 years.Reoperation rate of real recurrent herniations calculated using survival function method gradually increased year by year, from 0.5% at 1 year after primary surgery to 2.8% at 15.7 years.

Staphylococcus aureus Pyogenic spondylitis is a common infectious disease caused by various microorganisms. It is difficult to predict the infecting microorganism at the time of initiation of treatment. Pneumonia is generally clarified into community or hospital-acquired types based on where the infection was acquired, and the infecting microorganisms are different for each type. We retrospectively analyzed 20 cases of pyogenic spondylitis treated in our hospital and categorized the cases into community and hospital-acquired types. We also identified the infecting microorganisms and the rate of sepsis in each type. There were 12 cases of community-acquired and 8 of hospital-acquired infection. The major infecting microorganisms responsible for the community-acquired type were Gram-positive cocci, and those responsible for the hospital-acquired type were methicillin-resistant Staphylococcus aureus and Gram-negative bacilli. The rate of sepsis was significantly different for both groups: 16% for the community-acquired type and 75% for the hospital-acquired type. The classification of pyogenic spondylitis based on where the infection was acquired may be useful for predicting which microorganisms are responsible for the disease.

Intradural extra-arachnoid lumbar disc herniation is a rare disease. Few MRI findings have been reported. We experienced an intradural extra-arachnoid lumbar disc herniation. We reviewed the preoperative MRI findings. Lumbar spine T2-weighted sagittal MRI showed that one line of the ventral dura was divided into two by a disc herniation. We speculated that the two lines comprised the dura and arachnoid and that a disc herniation existed between them. We believe that division of the ventral dural line on T2-weighted sagittal images is a characteristic finding of intradural extra-arachnoid lumbar disc herniation. The division of ventral dural line seemed to be a “Y,” and, thus, we called it the “Y sign.” The “Y sign” may be useful for diagnosing intradural extra-arachnoid lumbar disc herniation.