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Atsushi Seichi, Susumu Nakajima, Katsushi Takeshita, Tomoaki Kitagawa, Toru Akune, Hiroshi Kawaguchi and Kozo Nakamura

Object

The purpose of this study was to evaluate the advantages of using an image guidance system to aid in the resection of ossified of the ligamentum flavum (OLF) in the thoracic spine. The procedure and surgery-related outcome are discussed.

Methods

Ten patients with myelopathy underwent laminotomy with medial facetectomy and an image guidance system was used to remove the OLF. No neurological deterioration occurred, and postoperative computerized tomography scanning demonstrated successful decompression and good preservation of the lateral parts of the facet joints.

Conclusions

The image guidance system allows accurate resection of the OLF while preserving as much as possible the facet joints and posterior elements of the thoracic spine.

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Atsushi Seichi, Katsushi Takeshita, Hiroshi Kawaguchi, Naohiro Kawamura, Akiro Higashikawa and Kozo Nakamura

✓ The authors describe an anterior decompression procedure for thoracic ossification of the posterior longitudinal ligament (PLL) in which they used an image guidance system in three cases. To make registration possible in anterior thoracic surgery, they devised a surgical reference frame that could be connected to a rod and attached to an external fixation device, which was then attached to the thoracic VB.

The mean fiducial error at the registration was acceptable (range 0.5–0.8 mm). They were able to confirm the success of decompression on postoperative computerized tomography scans. In the removal of an ossified thoracic PLL, an image guidance system has been shown to be a useful tool.

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Ko Matsudaira, Takashi Yamazaki, Atsushi Seichi, Kazuto Hoshi, Nobuhiro Hara, Satoshi Ogiwara, Sei Terayama, Hirotaka Chikuda, Katsushi Takeshita and Kozo Nakamura

The authors developed an original procedure, modified fenestration with restorative spinoplasty (MFRS) for the treatment of lumbar spinal stenosis. The first step is to cut the spinous process in an L-shape, which is caudally reflected. This procedure allows easy access to the spinal canal, including lateral recesses, and makes it easy to perform a trumpet-style decompression of the nerve roots without violating the facet joints. After the decompression of neural tissues, the spinous process is anatomically restored (spinoplasty). The clinical outcomes at 2 years were evaluated using the Japanese Orthopaedic Association (JOA) scale and patients' satisfaction. Radiological follow-up included radiographs and CT.

Between January 2000 and December 2002, 109 patients with neurogenic intermittent claudication with or without mild spondylolisthesis underwent MFRS. Of these, 101 were followed up for at least 2 years (follow-up rate 93%). The average score on the self-administered JOA scale in 89 patients without comorbidity causing gait disturbance improved from 13.3 preoperatively to 22.9 at 2 years' follow-up. Neurogenic intermittent claudication disappeared in all cases. The patients' assessment of treatment satisfaction was “satisfied” in 74 cases, “slightly satisfied” in 12, “slightly dissatisfied” in 2, and “dissatisfied” in 1 case. In 16 cases (18%), a minimum progression of slippage occurred, but no symptomatic instability or recurrent stenosis was observed. Computed tomography showed that the lateral part of the facet joints was well preserved, and the mean residual ratio was 80%. The MFRS technique produces an adequate and safe decompression of the spinal canal, even in patients with narrow and steep facet joints in whom conventional fenestration is technically demanding.

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Motoaki Murakami, Atsushi Seichi, Hirotaka Chikuda, Katsushi Takeshita, Kozo Nakamura and Atsushi Kimura

The authors report the case of a man with cervical ossification of the posterior longitudinal ligament (OPLL) who was observed for more than 26 years. Initial symptoms consisted of subtle numbness of the hands, and initial radiography showed small, segmental-type OPLL in the cervical spine. Lateral radiography of the cervical spine was performed every few years. Ossification accelerated for about 4 years during the follow-up. Segmental-type OPLL developed into mixed-type extensive OPLL. This case shows an accelerating maturation process of OPLL over the course of a few years. Segmental-type OPLL appears to represent an initial stage of extensive OPLL.

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Atsushi Seichi, Hirotaka Chikuda, Atsushi Kimura, Katsushi Takeshita, Shurei Sugita, Yuichi Hoshino and Kozo Nakamura

Object

The aim in this prospective study was to determine the morphological limitations of laminoplasty for cervical ossification of the posterior longitudinal ligament (OPLL) by using intraoperative ultrasonography and to investigate correlations between ultrasonographic findings and 2-year follow-up results.

Methods

Included in this study were 40 patients who underwent double-door laminoplasty for cervical myelopathy due to OPLL. Intraoperative ultrasonography was used to evaluate posterior shift of the spinal cord after the posterior decompression procedure. To determine the decompression status of the cord, the authors classified ultrasonographic findings into 3 types on the basis of the presence or absence of spinal cord contact with OPLL after decompression: Type 1, noncontact; Type 2, contact and apart; and Type 3, contact. Patients were divided accordingly into Group 1, showing Type 1 or 2 findings, representing sufficient decompression; and Group 2, showing Type 3 findings with insufficient decompression. Preoperative sagittal alignment of the cervical spine (C2–7 angle) and preoperative maximal thickness of OPLL were compared between groups. The authors also investigated the morphological limitations of laminoplasty and 2-year follow-up results by using the Japanese Orthopedic Association (JOA) scoring system.

Results

According to receiver operating characteristic curve analysis, an OPLL maximal thickness > 7.2 mm was a cutoff value for insufficient decompression. However, sufficient or insufficient decompression did not correlate with 2-year results, as determined by JOA scores. The C2–7 angle had no impact on ultrasonographic findings.

Conclusions

Laminoplasty has a morphological limitation for thick OPLLs, and a thickness > 7.2 mm represents a theoretical cutoff for residual cord compression after laminoplasty. According to 2-year results, however, laminoplasty can remain the first choice for any type of multiple-level OPLL.

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Morio Matsumoto, Yoshiaki Toyama, Hirotaka Chikuda, Katsushi Takeshita, Tsuyoshi Kato, Shigeo Shindo, Kuniyoshi Abumi, Masahiko Takahata, Yutaka Nohara, Hiroshi Taneichi, Katsuro Tomita, Norio Kawahara, Shiro Imagama, Yukihiro Matsuyama, Masashi Yamazaki and Akihiko Okawa

Object

The aim of this study was to evaluate the outcomes of fusion surgery in patients with ossification of the posterior longitudinal ligament in the thoracic spine (T-OPLL) and to identify factors significantly related to surgical outcomes.

Methods

The study included 76 patients (34 men and 42 women with a mean age of 56.3 years) who underwent fusion surgery for T-OPLL at 7 spine centers during the 5-year period from 2003 to 2007. The authors evaluated the patient demographic data, underlying disease, preoperative comorbidities, history of spinal surgery, radiological findings, surgical methods, surgical outcomes, and complications. Surgical outcomes were assessed using the Japanese Orthopaedic Association (JOA) scale score for thoracic myelopathy (11 points) and the recovery rate.

Results

The mean JOA scale score was 4.6 ± 2.1 points preoperatively and 7.7 ± 2.5 points at the time of the final follow-up examination, yielding a mean recovery rate of 45.4% ± 39.1%. The recovery rates by surgical method were 38.5% ± 37.8% for posterior decompression and fusion, 65.0% ± 35.6% for anterior decompression and fusion via an anterior approach, 28.8% ± 41.2% for anterior decompression via a posterior approach, and 57.5% ± 41.1% for circumferential decompression and fusion. The recovery rate was significantly higher in patients without diabetes mellitus (DM) than in those with DM. One or more complications were experienced by 31 patients (40.8%), including 20 patients with postoperative neurological deterioration, 7 with dural tears, 5 with epidural hematomas, 4 with respiratory complications, and 10 with other complications.

Conclusions

The outcomes of fusion surgery for T-OPLL were favorable. The absence of DM correlated with better outcomes. However, a high rate of complications was associated with the fusion surgery.

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Shurei Sugita, Hirotaka Chikuda, Katsushi Takeshita, Atsushi Seichi and Sakae Tanaka

Object

Despite its potential clinical impact, information regarding progression of thoracic ossification of the posterior longitudinal ligament (OPLL) is scarce. Posterior decompression with stabilization is currently the primary surgical treatment for symptomatic thoracic OPLL; however, it remains unclear whether thoracic OPLL increases in size following spinal stabilization. It is also unknown whether patients' clinical symptoms worsen as OPLL size increases. In this retrospective case series study, the authors examined the postoperative progression of thoracic OPLL.

Methods

Nine consecutive patients with thoracic OPLL who underwent posterior decompression and fixation with a minimum follow-up of 3 years were included in this study. Thin-slice CT scans of the thoracic spine obtained at the time of surgery and the most recent follow-up were analyzed. The level of the most obvious protrusion of ossification was determined using the sagittal reconstructions, and the ossified area was measured on the axial reconstructed scan at the level of the most obvious protrusion of ossification using the DICOM (digital imaging and communications in medicine) software program. Myelopathy severity was assessed according to the Japanese Orthopaedic Association (JOA) scale score for lower-limb motor function on admission, at postoperative discharge, and at the last follow-up visit.

Results

The OPLL area was increased in all patients. The mean area of ossification increased from 83.6 ± 25.3 mm2 at the time of surgery to 114.8 ± 32.4 mm2 at the last follow-up visit. No patients exhibited any neurological deterioration due to OPLL progression.

Conclusions

The present study demonstrated that the size of the thoracic OPLL increased after spinal stabilization. Despite diminished local spinal motion, OPLL progression did not decrease or stop. Physicians should pay attention to ossification progression in patients with thoracic OPLL.

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Akitake Mukasa, Shunsuke Yanagisawa, Kuniaki Saito, Shota Tanaka, Keisuke Takai, Junji Shibahara, Masachika Ikegami, Yusuke Nakao, Katsushi Takeshita, Masao Matsutani and Nobuhito Saito

Primary spinal germ cell tumors are rare, and spinal nongerminomatous germ cell tumors represent an even rarer subset for which no standard therapy has been established. The authors report the case of a 24-year-old woman with multifocal primary spinal germ cell tumors scattered from T-12 to L-5 that consisted of yolk sac tumor and mature teratoma. After diagnostic partial resection, the patient was treated with 30 Gy of craniospinal irradiation and 30 Gy of local spinal irradiation, followed by 8 courses of chemotherapy based on ifosfamide, cisplatin, and etoposide (ICE). Salvage surgery was also performed for residual mature teratoma components after the third course of ICE chemotherapy. Chemotherapy was continued after the operation, but ifosfamide was entirely eliminated from the ICE regimen because severe myelosuppression was observed after previous courses. The patient remains recurrence free as of more than 5 years after the completion of chemotherapy. This case suggests that this treatment strategy is an effective option for primary spinal yolk sac tumor.

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Shuhei Murase, Yasushi Oshima, Yujiro Takeshita, Kota Miyoshi, Kazuhito Soma, Naohiro Kawamura, Junichi Kunogi, Takashi Yamazaki, Dai Ariyoshi, Shigeo Sano, Hirohiko Inanami, Katsushi Takeshita and Sakae Tanaka

OBJECTIVE

Interbody fusion cages are widely used to achieve initial fixation and secure spinal fusion; however, there are certain technique-related complications. Although anterior cage dislodgement can cause major vascular injury, the incidence is extremely rare. Here, the authors performed a review of anterior cage dislodgement following posterior lumbar interbody fusion (PLIF) surgery.

METHODS

The authors retrospectively reviewed the cases of 4625 patients who had undergone PLIF at 6 institutions between December 2007 and March 2015. They investigated the incidence and causes of surgery-related anterior cage dislodgement, salvage mechanisms, and postoperative courses.

RESULTS

Anterior cage dislodgement occurred in 12 cases (0.26%), all of which were caused by technical errors. In 9 cases, excessive cage impaction resulted in dislodgement. In 2 cases, when the cage on the ipsilateral side was inserted, it interacted and pushed out the other cage on the opposite side. In 1 case, the cage was positioned in an extreme lateral and anterior part of the intervertebral disc space, and it postoperatively dislodged. In 3 cases, the cage was removed in the same operative field. In the remaining 9 cases, CT angiography was performed postoperatively to assess the relationship between the dislodged cage and large vessels. Dislodged cages were conservatively observed in 2 cases. In 7 cases, the cage was removed because it was touching or compressing large vessels, and an additional anterior approach was selected. In 2 patients, there was significant bleeding from an injured inferior vena cava. There were no further complications or sequelae associated with the dislodged cages during the follow-up period.

CONCLUSIONS

Although rare, iatrogenic anterior cage dislodgement following a PLIF can occur. The authors found that technical errors made by experienced spine surgeons were the main causes of this complication. To prevent dislodgement, the surgeon should be cautious when inserting the cage, avoiding excessive cage impaction and ensuring cage control. Once dislodgement occurs, the surgeons must immediately address this difficult complication. First, the possibility of a large vessel injury should be considered. If the patient’s vital signs are stable, the surgeon should continue with the surgery without cage removal and perform CT angiography postoperatively to assess the cage location. Blind maneuvers should be avoided when the surgical site cannot be clearly viewed. When the cage compresses or touches the aortic artery or vena cava, it is better to remove the cage to avoid late-onset injury to major vessels. When the cage does not compress or touch vessels, its removal is controversial. The risk factors associated with performing another surgery should be evaluated on a case-by-case basis.

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Takeshi Oichi, Yasushi Oshima, Hiroyuki Oka, Yuki Taniguchi, Hirotaka Chikuda, Yoshitaka Matsubayashi, Katsushi Takeshita and Sakae Tanaka

OBJECTIVE

Several investigators have reported the occurrence of interlaminar bony fusion after cervical laminoplasty, which is reportedly associated with reduced postoperative cervical range of motion (ROM). However, to the authors’ knowledge, no previous study has investigated the characteristics of patients who were likely to develop interlaminar bony fusion after cervical laminoplasty. Therefore, the objective of this study was to investigate the risk factors for interlaminar bony fusion in patients with cervical spondylotic myelopathy (CSM) following cervical laminoplasty and to investigate the effect of interlaminar bony fusion on surgical outcomes.

METHODS

The authors retrospectively reviewed data from 92 patients with CSM (63 men and 29 women) after cervical laminoplasty. The presence of interlaminar bony fusion was evaluated by functional radiographs 2 years after surgery. The patients were divided into 2 groups according to the presence of postoperative interlaminar bony fusion: a fusion group (at least 1 new postoperative interlaminar bony fusion) and a nonfusion group (no new interlaminar bony fusion). Potential risk factors for postoperative interlaminar bony fusion were assessed, including diabetes mellitus, smoking status, whether the C-2 lamina was included in the surgical treatment, C2–7 Cobb angle in each cervical position, preoperative cervical ROM, and T-1 slope. The differences in each variable were compared between the fusion and nonfusion groups. Thereafter, multivariate logistic regression analysis was performed to identify the risk factors for postoperative interlaminar bony fusion. For surgical outcomes, the recovery rate based on Japanese Orthopaedic Association scores and the reduction rate of cervical ROM were evaluated 2 years after surgery.

RESULTS

Interlaminar bony fusion was observed in 60 cases, 52 of which were observed at the C2–3 level. Patients in the fusion group were significantly older, had a significantly larger C2–7 angle in flexion, and had a significantly lower preoperative cervical ROM than those in the nonfusion group. A high T-1 slope was significantly more frequent in the fusion group. Multivariate analysis revealed that the significant risk factors for postoperative interlaminar bony fusion were high T-1 slope (odds ratio 4.81; p = 0.0015) and older age (odds ratio 1.05; p = 0.025). The Japanese Orthopaedic Association recovery rate in patients with interlaminar bony fusion did not differ significantly from those without bony fusion (45% vs 48%; p = 0.73). However, patients with bony fusion showed significantly reduced postoperative cervical ROM compared with those without bony fusion (50% vs 25%; p < 0.001).

CONCLUSIONS

High T-1 slope and older age were significant risk factors for developing interlaminar bony fusion after cervical laminoplasty in patients with CSM. Interlaminar bony fusion was associated with reduced postoperative cervical ROM, but it did not affect neurological outcomes.