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  • Author or Editor: Shiro Imagama x
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Yukihiro Matsuyama, Yoshihito Sakai, Yoshito Katayama, Shiro Imagama, Zenya Ito, Norimitsu Wakao, Koji Sato, Mitsuhiro Kamiya, Yasutsugu Yukawa, Tokumi Kanemura, Makoto Yanase and Naoki Ishiguro

Object

The authors investigated the outcome of intramedullary spinal cord tumor surgery, focusing on the effect of preoperative neurological status on postoperative mobility and the extent of tumor excision guided by intraoperative spinal cord monitoring prospectively.

Methods

Intramedullary spinal cord tumor surgery was performed in 131 patients between 1997 and 2007. The authors compared the pre- and postoperative neurological status and examined the type of surgery in 106 of these patients. A modified McCormick Scale (Grades I–V) was used to assess ambulatory ability (I = normal ambulation; II = mild motor sensory deficit, independent without external aid; III = independent with external aid; IV = care required; and V = wheelchair required). The type of surgery was classified into 4 levels: total resection, subtotal resection, partial resection, and biopsy.

Results

The 106 patients consisted of 47 females and 59 males, whose average age was 42.5 years (range 6–75 years). The mean follow-up period was 7.3 years (range 2.5 months–21 years). The tumor types included astrocytoma (12 cases), ependymoma (46 cases), hemangioblastoma (16 cases), cavernous hemangioma (17 cases), and others (15 cases overall: gangliocytoma, 1; germ cell tumor, 1; lymphoma, 3; neurinoma, 1; meningioma, 1; oligodendroglioma, 1; sarcoidosis, 2; glioma, 1; and unknown, 4). Initial total excision, subtotal resection, partial resection, biopsy, and duraplasty were performed in 59, 12, 22, 12, and 1 patients, respectively. According to the preoperative McCormick Scale, ambulatory status was classified as Grades I, II, III, IV, and V in 41(38%), 30 (28%), 14 (13%), 19 (19%), and 2 (2%) patients, respectively. Thirty-three (31%) of 106 patients suffered postoperative neurological deterioration. The number of patients who did not lose ambulatory ability or who achieved an ambulatory status of Grade I or II postoperatively was 33 (80%), 21 (70%), 10 (71%), 8 (42%), and 1 (50%) in patients with preoperative Grades I, II, III, IV, and V, respectively. Total excision was performed in 31 (79%) of 39 patients with preoperative Grade I, 12 (40%) of 30 patients with Grade II, 7 (50%) of 14 patients with Grade III, and 9 of 21 patients (38%) with Grade IV or V, indicating that the rate of total excision was significantly higher in patients with Grade I status.

Conclusions

The postoperative ambulatory ability was excellent in patients with a good preoperative neurological status. Total excision in patients with Grade I or II ambulation was associated with a good prognosis for postoperative mobility. However, the rate of postoperative deterioration was 31.5%, which is relatively high, and patients should be fully informed of this concern prior to intramedullary spinal cord tumor surgery.

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Shiro Imagama, Yukihiro Matsuyama, Yoshihito Sakai, Hiroshi Nakamura, Yoshito Katayama, Zenya Ito, Norimitsu Wakao, Koji Sato, Mitsuhiro Kamiya, Fumihiko Kato, Yasutsugu Yukawa, Yasushi Miura, Hisatake Yoshihara, Kazuhiro Suzuki, Kei Ando, Kenichi Hirano, Ryoji Tauchi, Akio Muramoto and Naoki Ishiguro

Object

The purpose of this study was to provide the first evidence for image classification of idiopathic spinal cord herniation (ISCH) in a multicenter study.

Methods

Twelve patients who underwent surgery for ISCH were identified, and preoperative symptoms, severity of paralysis and myelopathy, disease duration, plain radiographs, MR imaging and CT myelography findings, surgical procedure, intraoperative findings, data from spinal cord monitoring, and postoperative recovery were investigated in these patients. Findings on sagittal MR imaging and CT myelography were classified into 3 types: a kink type (Type K), a discontinuous type (Type D), and a protrusion type (Type P). Using axial images, the location of the hiatus was classified as either central (Type C) or lateral (Type L), and the laterality of the herniated spinal cord was classified based on correspondence (same; Type S) or noncorrespondence (opposite; Type O) with the hiatus location. A bone defect at the ISCH site and the laterality of the defect were also noted.

Results

Patients with Type P herniation had a good postoperative recovery, and those with a Type C location had significant severe preoperative lower-extremity paralysis and a significantly poor postoperative recovery. Patients with a bone defect had a significantly severe preoperative myelopathy, but showed no difference in postoperative recovery.

Conclusions

The authors' results showed that a Type C classification and a bone defect have strong relationships with severity of symptoms and surgical outcome and are important imaging and clinical features for ISCH. These findings may allow surgeons to determine the severity of preoperative symptoms and the probable surgical outcome from imaging.

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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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Kei Ando, Shiro Imagama, Norimitsu Wakao, Kenichi Hirano, Ryoji Tauchi, Akio Muramoto, Fumihiko Kato, Yasutsugu Yukawa, Noriaki Kawakami, Koji Sato, Yuji Matsubara, Tokumi Kanemura, Yukihiro Matsuyama and Naoki Ishiguro

Object

The purpose of this study was to provide the first evidence for the influence of an ossified anterior longitudinal ligament (OALL) on the clinical features and surgical outcomes in an ossified ligamentum flavum (OLF) in the thoracic region.

Methods

Sixty-three patients who underwent surgery for a 1-level thoracic OLF were identified, and preoperative symptoms, severity of symptoms and myelopathy, disease duration, MR imaging and CT findings, surgical procedure, intraoperative findings, complications, and postoperative recovery were investigated in these patients. Entities of OALLs were found on sagittal CT images to be adjacent to or at the same vertebral level as the OLF were classified into 4 types: no discernible type (Type N), one-sided (Type O), discontinuous (Type D), and continuous (Type C).

Results

The duration of symptoms was especially long for Types D and C OALLs. Patients with Type D OALLs had a significantly worse percentage of recovery, as well as worse preoperative JOA scores.

Conclusions

The authors' results showed that a Type D OALL had strong associations with preoperative severity of symptoms and surgical outcomes. These findings may allow surgeons to determine the severity of preoperative symptoms and the probable surgical outcomes from the OALL classifications. Moreover, surgery with instrumentation for Type D OALLs may produce better surgical outcomes.

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Hiroaki Nakashima, Yasutsugu Yukawa, Shiro Imagama, Tokumi Kanemura, Mitsuhiro Kamiya, Makoto Yanase, Keigo Ito, Masaaki Machino, Go Yoshida, Yoshimoto Ishikawa, Yukihiro Matsuyama, Naoki Ishiguro and Fumihiko Kato

Object

The cervical pedicle screw (PS) provides strong stabilization but poses a potential risk to the neurovascular system, which may be catastrophic. In particular, vertebrae with degenerative changes complicate the process of screw insertion, and PS misplacement and subsequent complications are more frequent. The purpose of this study was to evaluate the peri- and postoperative complications of PS fixation for nontraumatic lesions and to determine the risk factors of each complication.

Methods

Eighty-four patients who underwent cervical PS fixation for nontraumatic lesions were independently reviewed to identify associated complications. The mean age of the patients was 60.1 years, and the mean follow-up period was 4.1 years (range 6–168 months). Pedicle screw malpositioning was classified on postoperative CT scans as Grade I (< 50% of the screw outside the pedicle) or Grade II (≥ 50% of the screw outside the pedicle). Risk factors of each complication were evaluated using a multivariate analysis.

Results

Three hundred ninety cervical PSs and 24 lateral mass screws were inserted. The incidence of PS misplacement was 19.5% (76 screws); in terms of malpositioning, 60 screws (15.4%) were classified as Grade I and 16 (4.1%) as Grade II. In total, 33 complications were observed. These included postoperative neurological complications in 11 patients in whom there was no evidence of screw misplacement (C-5 palsy in 10 and C-7 palsy in 1), implant failure in 11 patients (screw loosening in 5, broken screws in 4, and loss of reduction in 2), complications directly attributable to screw insertion in 5 patients (nerve root injury by PS in 3 and vertebral artery injury in 2), and other complications in 6 patients (pseudarthrosis in 2, infection in 1, transient dyspnea in 1, transient dysphagia in 1, and adjacent-segment degeneration in 1). The multivariate analysis showed that a primary diagnosis of cerebral palsy was a risk factor for postoperative implant failure (HR 10.91, p = 0.03) and that the presence of preoperative cervical spinal instability was a risk factor for both Grade I and Grade II screw misplacement (RR 2.12, p = 0.03), while there were no statistically significant risk factors for postoperative neurological complications in the absence of evidence of screw misplacement or complications directly attributable to screw insertion.

Conclusions

In the present study, misplacement of cervical PSs and associated complications occurred more often than in previous studies. The rates of screw-related neurovascular complications and neurological deterioration unrelated to PSs were high. Insertion of a PS for nontraumatic lesions is surgically more challenging than that for trauma; consequently, experienced surgeons should use PS fixation for nontraumatic cervical lesions only after thorough preoperative evaluation of each patient's cervical anatomy and after considering the risk factors specified in the present study.

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Hiroaki Nakashima, Shiro Imagama, Yasutsugu Yukawa, Tokumi Kanemura, Mitsuhiro Kamiya, Makoto Yanase, Keigo Ito, Masaaki Machino, Go Yoshida, Yoshimoto Ishikawa, Yukihiro Matsuyama, Nobuyuki Hamajima, Naoki Ishiguro and Fumihiko Kato

Object

Postoperative C-5 palsy is a significant complication resulting from cervical decompression procedures. Moreover, when cervical degenerative diseases are treated with a combination of decompression and posterior instrumented fusion, patients are at increased risk for C-5 palsy. However, the clinical and radiological features of this condition remain unclear. Therefore, the purpose of this study was to clarify the risk factors for developing postoperative C-5 palsy.

Methods

Eighty-four patients (mean age 60.1 years) who had undergone posterior instrumented fusion using cervical pedicle screws to treat nontraumatic lesions were independently reviewed. The authors analyzed the medical records of some of these patients who developed postoperative C-5 palsy, paying particular attention to their plain radiographs, MRI studies, and CT scans. Risk factors for postoperative C-5 palsy were assessed using multivariate logistic regression analysis. The cutoff values for the pre- and postoperative width of the intervertebral foramen (C4–5) were determined by receiver operating characteristic curve analysis.

Results

Ten (11.9%) of 84 patients developed postoperative C-5 palsy. Seven patients recovered fully from the neurological complications. The pre- and postoperative C4–5 angles showed significant kyphosis in the C-5 palsy group. The pre- and postoperative diameters of the C4–5 foramen on the palsy side were significantly smaller than those on the opposite side in the C-5 palsy group and those bilaterally in the non–C5 palsy group. Risk factors identified by multivariate logistic regression analysis were as follows: 1) ossification of the posterior longitudinal ligament (relative risk [RR] 7.22 [95% CI 1.03–50.55]); 2) posterior shift of the spinal cord (C4–5) (RR 1.73 [95% CI 1.00–2.98]); and 3) postoperative width of the C-5 intervertebral foramen (RR 0.33 [95% CI 0.14–0.79]). The cutoff values of the pre- and postoperative widths of the C-5 intervertebral foramen for C-5 palsy were 2.2 and 2.3 mm, respectively.

Conclusions

Patients with preoperative foraminal stenosis, posterior shift of the spinal cord, and additional iatrogenic foraminal stenosis due to cervical alignment correction were more likely to develop postoperative C-5 palsy after posterior instrumentation with fusion. Prophylactic foraminotomy at C4–5 might be useful when preoperative foraminal stenosis is present on CT. Furthermore, it might be useful for treating postoperative C-5 palsy. To prevent excessive posterior shift of the spinal cord, the authors recommend that appropriate kyphosis reduction should be considered carefully.

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Zenya Ito, Shiro Imagama, Yoshihito Sakai, Yoshito Katayama, Norimitsu Wakao, Kei Ando, Kenichi Hirano, Ryoji Tauchi, Akio Muramoto, Hany El Zahlawy, Yukihiro Matsuyama and Naoki Ishiguro

Object

The purpose of this study was to review the present criteria for the compound muscle action potential (CMAP) alert and for safe spinal surgery.

Methods

The authors conducted a retrospective study of 295 patients in whom spinal cord monitoring had been performed during spinal surgery. The waveforms observed during spinal surgery were divided into the following 4 grades: Grade 0, normal; Grade 1, amplitude decrease of 50% or more and latency delay of 10% or more; Grade 2, multiphase pattern; and Grade 3, loss of amplitude. Waveform grading, its relationship with postoperative motor deficit, and CMAP sensitivity and specificity were analyzed. Whenever any wave abnormality occurred, the surgeon was notified and the surgical procedures were temporarily suspended. If no improvements were seen, the surgery was terminated.

Results

Compound muscle action potential wave changes occurred in 38.6% of cases. With Grade 1 or 2 changes, no paresis was detected. Postoperative motor deficits were seen in 8 patients, all with Grade 3 waveform changes. Among the 287 patients without postoperative motor deficits, CMAP changes were not seen in 181, with a specificity of 63%. The false-positive rate was 37% (106 of 287). However, when a Grade 2 change was set as the alarm point, sensitivity was 100% and specificity was 79.4%. The false-positive rate was 20% (59 of 295).

Conclusions

Neither the Grade 1 nor the Grade 2 groups included patients who demonstrated a motor deficit. All pareses occurred in cases showing a Grade 3 change. Therefore, the authors propose a Grade 2 change (multiphasic waveform) as a new alarm point. With the application of this criterion, the false-positive rate can be reduced to 20%.