✓ A 51-year-old man presenting with radiculopathy with a rare cervical dural arteriovenous fistula (AVF) is reported. Angiography revealed that the cervical dural AVF was fed mainly by the left C-3 and C-4 radicular arteries and drained into the internal vertebral venous plexus with no communication with intradural structures. The dural AVF was treated surgically after embolization therapy. Although the AVF showed mass effect on computerized tomography (CT) scanning, abnormal vessels, which were suspected to drain the AVF, were observed intraoperatively to compress the left C-4 and C-5 nerve root sleeves. After resection of these abnormal epidural vessels, monoparesis of the left proximal upper extremity was markedly improved. In this patient, dynamic CT scanning was useful in the initial diagnosis, and the preoperative embolization therapy was very effective.
Michihiro Kohno, Hiroshi Takahashi, Katsuhisa Ide, Buichi Ishijima, Katsuhiro Yamada, and Shigeru Nemoto
Katsuhisa Yamada, Hideki Sudo, Kiyoshi Kaneda, Yasuhiro Shono, Yuichiro Abe, and Norimasa Iwasaki
The aim of this retrospective study was to analyze the influence of upper instrumented vertebra (UIV) translation from the C7 plumb line (C7PL) on the long-term postoperative results of patients with main thoracic (MT) adolescent idiopathic scoliosis (AIS).
Twenty-five patients had been treated surgically for AIS with a Lenke type 1 curve and had been followed up for a mean period of 18.2 years. Radiographic parameters, pulmonary function measurements, and clinical outcomes were compared between the patients (n = 15) with UIV translation < 20 mm and those (n = 10) with UIV translation ≥ 20 mm at the final follow-up. Correlations between UIV translation and radiographic or pulmonary function parameters were analyzed.
Patients with ≥ 20 mm UIV translation at the final follow-up had a significantly larger preoperative UIV translation than that in the patients with < 20 mm UIV translation at follow-up. The former group also had a significantly lower correction rate of the MT curve, higher chest cage ratio, and lower radiographic shoulder height (p = 0.01, 0.005, and 0.025, respectively) at the final follow-up. The Scoliosis Research Society (SRS)–30 Questionnaire scores were equivalent between the two groups. Correlation analysis showed that the following parameters were significantly associated with UIV translation: MT curve correction rate (r = -0.481, p = 0.015), chest cage ratio (r = 0.673, p < 0.001), and percent-predicted forced expiratory volume in 1 second (r = -0.455, p = 0.033).
The UIV translation should be considered an important factor that influences postoperative results. In MT AIS patients whose preoperative upper end vertebra (UEV) is distant from the C7PL, the UIV should be selected above the UEV to prevent large UIV translation at the postoperative follow-up.
Akira Iwata, Hideki Sudo, Kuniyoshi Abumi, Manabu Ito, Katsuhisa Yamada, and Norimasa Iwasaki
Controversy exists regarding the effects of lowest instrumented vertebra (LIV) tilt and rotation on uninstrumented lumbar segments in adolescent idiopathic scoliosis (AIS) surgery. Because the intraoperative LIV tilt from the inferior endplate of the LIV to the superior sacral endplate is not stable after surgery, the authors measured the LIV angle of the instrumented thoracic spine as the LIV angle of the construct. This study aimed to evaluate the effects of the LIV angle of the construct and the effects of LIV rotation on the postoperative uninstrumented lumbar curve and L4 tilt in patients with thoracic AIS.
A retrospective correlation and multivariate analysis of a prospectively collected, consecutive, nonrandomized series of patients at a single institution was undertaken. Eighty consecutive patients with Lenke type 1 or type 2 AIS treated with posterior correction and fusion were included. Preoperative and 2-year postoperative radiographic measurements were the outcome measures for this study. Outcome variables were postoperative uninstrumented lumbar segments (LIV tilt, LIV translation, uninstrumented lumbar curve, thoracolumbar/lumbar [TL/L] apical vertebral translation [AVT], and L4 tilt). The LIV angle of the construct was measured from the orthogonal line drawn from the upper instrumented vertebra to the LIV. Multiple stepwise linear regression analysis was conducted between outcome variables and patient demographics/radiographic measurements. There were no study-specific biases related to conflicts of interest.
Predictor variables for postoperative uninstrumented lumbar curve were the postoperative LIV angle of the construct, number of uninstrumented lumbar segments, and flexibility of TL/L curve. Specifically, a lower postoperative uninstrumented lumbar curve was predicted by a lower absolute value of the postoperative LIV angle of the construct (p < 0.0001). Predictor variables for postoperative L4 tilt were postoperative LIV rotation, preoperative L4 tilt, and preoperative uninstrumented lumbar curve. Specifically, a lower postoperative L4 tilt was predicted by a lower absolute value of postoperative LIV rotation (p < 0.0001).
The LIV angle of the construct significantly affected the LIV tilt, uninstrumented lumbar curve, and TL/L AVT. LIV rotation significantly affected the LIV translation and L4 tilt.