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Yuki Yamamuro, Satoru Demura, Hideki Murakami, Satoshi Kato, Noritaka Yonezawa, Noriaki Yokogawa, and Hiroyuki Tsuchiya

Acute progressive adolescent idiopathic cervical kyphosis (AICK) is rare, and its treatment strategy is controversial. The authors present a case of AICK successfully treated with preoperative halo-gravity traction, followed by combined anterior-posterior surgery. A 15-year-old girl with no relevant past or family history presented with axial neck pain without any cause. A few months after the development of cervical myelopathy, cervical kyphosis progressed to 71° despite conservative treatment. CT scanning demonstrated osteophyte formation at the anterior aspect of the vertebral body. MRI showed a forward migration of the spinal cord with a ratio (C/M ratio) between the anteroposterior diameter of the medulla-pons junction and the spinal cord at the apex of the kyphosis of 0.27. After 2 weeks of preoperative halo-gravity traction, anterior release and posterior fusion was performed. After surgery, cervical kyphosis was corrected to 0°, and cervical myelopathy improved. One year after surgery, the patient was neurologically intact, and bony union and improved cervical alignment were observed. Preoperative halo-gravity traction followed by combined anterior-posterior surgery led to safe and effective correction. Osteophyte formation at the anterior aspect of the vertebral body and the C/M ratio were useful in predicting the progression of AICK.

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Hideki Murakami, Norio Kawahara, Satoru Demura, Satoshi Kato, Katsuhito Yoshioka, and Katsuro Tomita

Object

Total en bloc spondylectomy (TES) for thoracic spinal tumors may in theory produce neurological dysfunction as a result of ischemic or mechanical damage to the spinal cord. Potential insults include preoperative embolization at 3 levels, intraoperative ligation of segmental arteries, nerve root ligation, and circumferential dural dissection. The purpose of this study was to assess neurological function after thoracic TES.

Methods

The authors performed a retrospective review of 79 patients with thoracic-level spinal tumors that had been treated with TES between 1989 and 2006. Neurological function was retrospectively analyzed according to the Frankel grading system. Of the 79 cases, 26 involved primary tumors and 53 involved metastatic tumors. The number of excised vertebrae was 1 in 60 cases, 2 in 13, and ≥ 3 in 6. The Frankel grade before surgery was B in 1 case, C in 16, D in 29, and E in 33.

Results

At the follow-up, the Frankel grade was C in 2 cases, D in 24, and E in 53. Of 46 cases with neurological deficits before surgery, neurological improvement of at least 1 Frankel grade was achieved in 25 cases (54.3%). Although the Frankel grade did not change in 21 patients, improvement in neurological symptoms within the same Frankel grade did occur in these patients. There were no cases of neurological deterioration.

Conclusions

There was no neurological deterioration due to preoperative embolization, ligation of segmental arteries, or ligation of thoracic nerve roots. Each of the cases with preoperative neurological deficits showed improvement in neurological symptoms. Data in the current study clinically proved that TES is a safe operation with respect to spinal cord blood flow. In TES, the spinal cord is circumferentially decompressed and the spinal column is shortened. An increase in spinal cord blood flow due to spinal shortening in addition to decompression was considered to have brought about a resolution of neurological symptoms with TES.

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Satoshi Kato, Hideki Murakami, Satoru Demura, Katsuhito Yoshioka, Hiroyuki Hayashi, Noriaki Yokogawa, Xiang Fang, and Hiroyuki Tsuchiya

OBJECT

Several surgical procedures have been developed to treat thoracic OPLL (ossification of the posterior longitudinal ligament). However, favorable surgical results are not always achieved, and consistent protocols and procedures for surgical treatment of OPLL in this region have not been established. Beak-type OPLL in the thoracic spine is known to be the most complicated form of OPLL to treat surgically. In this study, the authors examine the clinical outcomes after anterior decompression via a posterolateral approach for beak-type OPLL in the thoracic spine and address the gradual spinal cord decompression caused by migration of the floated plaques after surgery.

METHODS

Between 2011 and 2013, a total of 12 patients with thoracic myelopathy due to OPLL were surgically treated at the authors’ institute. The study group for this paper comprises 6 of those 12 patients. These 6 patients, who had beak-type OPLL, underwent with anterior decompression and instrumented fusion via the authors’ posterolateral approach-based surgical technique. The other 6 patients, who exhibited other types of OPLL, underwent posterior decompression and instrumented fusion. In the study group (the 6 patients with beak-type OPLL), half of the patients (the 3 patients who were treated first) were treated with removal of the ossified ligament. These patients are referred to as the removal group. The other 3 patients were treated by means of “floating” the OPLL plaques and are referred to as the floating group. Clinical and radiographic outcomes were evaluated in these 6 cases.

RESULTS

The recovery rates were 52.4% in the removal group and 60.0% in the floating group. Two patients in the removal group had operative complications, including a dural tear and temporary neurological deterioration. No operative complications were encountered in the floating group. In all 3 cases in the floating group, floating of the ossified ligament was completely achieved, and the floated plaque gradually migrated into the ventral bone resection areas. The mean migration distances of the floated plaque were 2.4 mm, 4.3 mm, 4.7 mm, and 4.8 mm at 1, 3, 6, and 12 months after surgery.

CONCLUSIONS

Treatment of beak-type OPLL in the thoracic spine via the posterolateral approach-based floating plaque technique was safe and effective in this small case series. Gradual migration of the floated plaques provided additional spinal cord decompression during the postoperative course.

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Satoshi Kato, Hideki Murakami, Satoru Demura, Katsuhito Yoshioka, Hiroyuki Hayashi, and Hiroyuki Tsuchiya

Several surgical procedures have been developed to treat thoracic ossification of the posterior longitudinal ligament (OPLL). However, favorable surgical results are not always achieved, and consistent protocols and procedures for surgical treatment of thoracic OPLL have not been established. This technical note describes a novel technique to achieve anterior decompression via a single posterior approach. Three patients with a beak-type thoracic OPLL underwent surgery in which the authors' technique was used. Complete removal of the ossified PLL was achieved in all cases. With the patient in the prone position, the authors performed total resection of the posterior elements at the anterior decompression levels. This maneuver included not only laminectomies but also removal of the transverse processes and pedicles, which allowed space to be created bilaterally at the sides of the dural sac for the subsequent anterior decompression. The thoracic nerves at the levels of anterior decompression were ligated bilaterally and lifted up to manipulate the ossified ligament and the dural sac. An anterior decompression was then performed posteriorly. The PLL was floated without any difficulty. After exfoliation of the adhesions between the ossified ligament and the ventral aspect of the dural sac, the ossified PLL was removed. In every step of the anterior decompression, the space created in the bilateral sides of the dural sac allowed the surgeons to see the OPLL and anterolateral aspect of the dural sac directly and easily. After removal of the ossified PLL, posterior instrumented fusion was performed. This surgical procedure allows the surgeon to perform, safely and effectively, anterior decompression via a posterior approach for thoracic OPLL.

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Hideki Murakami, Norio Kawahara, Satoru Demura, Satoshi Kato, Katsuhito Yoshioka, and Katsuro Tomita

Object

The prognosis in patients with a distant spinal metastasis from the lung is dismal. The role of radical surgery in such cases has been questioned because of the excessive morbidity, blood loss, and operative time as well as the tumor's extreme malignancy. The purpose of this study was to evaluate the surgical results and the prognosis associated with radical surgery for lung cancer metastasis to the spine in carefully selected patients and to clarify whether there is an indication for radical surgery such as total en bloc spondylectomy (TES) in lung cancer metastasis.

Methods

The author performed a retrospective review of patients with lung cancer spinal metastasis treated by TES during a 10-year period. Total en bloc spondylectomy for lung cancer metastasis to the spine was performed in 6 patients without visceral or other bony metastases. Outcome measures were prognostic score, mean survival time, and perioperative complications. The histological type was adenocarcinoma in all 6 cases. In 4 cases the surgical strategy prognostic score was 5. In the other 2 cases the score was 6 because there were skip metastases to adjacent vertebra. In the 2 cases with adjacent vertebral metastasis, the adjacent vertebra was excised en bloc together.

Results

The mean estimated blood loss was 1076 ml and the mean operative time was 7 hours 20 minutes. Perioperative complications were found in 2 cases. One was deep infection after CSF leakage, and the other was paralysis due to postoperative hematoma. At the end of follow-up period, 4 of 6 patients are still living after a mean of 46.3 months (range 36–62 months). In the other 2 cases, 1 patient died of a heart attack and the other of mediastinitis due to surgical site infection by methicillin-resistant Staphylococcus aureus. In this series, local recurrence was not found.

Conclusions

Total en bloc spondylectomy has been shown to be associated with excessive morbidity, blood loss, and operative time; however, the procedure is becoming less invasive. The authors conclude that TES is appropriate in selected cases with controllable primary lung cancer, localized spinal metastasis, and no visceral metastasis. In such patients, improvement in the prognosis can be expected after TES. However, even in selected cases and with skilled surgical technique, the complication rate remains high. Total en bloc spondylectomy should be performed after a thorough discussion of the risks and benefits.

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Naoko Araya, Hiroyuki Inose, Tsuyoshi Kato, Masanori Saito, Satoshi Sumiya, Tsuyoshi Yamada, Toshitaka Yoshii, Shigenori Kawabata, and Atsushi Okawa

Hyperimmunoglobulin E syndrome (HIES) is a rare primary immunodeficiency syndrome characterized by recurrent staphylococcal infections in the skin and lungs, with an incidence of less than one case per million persons. Skeletal and connective tissue abnormalities, such as scoliosis, osteoporosis, pathological fractures, and hyperextensive joints, are other manifestations of HIES. However, only one report documents the use of implants to treat spinal deformity caused by HIES, which was discovered following corrective surgery resulting in postoperative infection. In this case report, the authors describe a 16-year-old male with low-back pain and infections of the soft tissue. Radiological findings showed deteriorated kyphotic deformity due to the pathological compression fracture of T-11 with intensive conservative treatment. Anterior and posterior fixation surgery was performed. Thereafter, the patient showed no signs of infection. An investigation was conducted to avoid any postoperative infection.

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Satoru Demura, Norio Kawahara, Hideki Murakami, Mohamed E. Abdel-Wanis, Satoshi Kato, Katsuhito Yoshioka, Katsuro Tomita, and Hiroyuki Tsuchiya

Object

Thyroid carcinoma generally has a favorable prognosis, and patients rarely present with distant metastases. Authors of several studies have proposed piecemeal resection for spinal metastases in thyroid carcinoma; however, few have analyzed the impact of local curative surgery such as total en bloc spondylectomy (TES) for thyroid carcinoma. The purposes of the present study are to determine the strategy of surgical treatment for spinal metastases of thyroid carcinoma and to evaluate the surgical results of and the prognosis associated with TES.

Methods

Twenty-four cases of spinal metastases were retrospectively reviewed. The patients included 16 women and 8 men, with a mean age of 60.7 years. Histological examination showed follicular carcinoma in 15 cases, papillary carcinoma in 8, and medullary carcinoma in 1. Total en bloc spondylectomy was performed in 10 cases; debulking surgery, such as piecemeal excision or eggshell curettage, was performed in 14. The average follow-up time was 55 months (12–180 months).

Results

Four patients had no evidence of disease, 8 were alive with the disease, and 12 had died of the disease. The overall survival rate from the time of surgery was 74% at 5 years. Patients with visceral metastases had a significant, higher risk of death. The survival rate of patients following TES was 90% at 5 years, which was higher than the rate in patients who underwent debulking surgery (63%). However, no significant difference was observed between the 2 types of surgery. There was a local recurrence after debulking surgery in 8 (57%) of 14 cases. Because of the recurrences, reoperation was required after a mean of 41 months. In contrast, there was a local recurrence after TES in only 1 (10%) of 10 cases. The difference between debulking surgery and TES regarding local recurrence was statistically significant.

Conclusions

Total en bloc spondylectomy with enough of a margin provided favorable local control of spinal metastases of thyroid carcinoma during a patient's lifetime.

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Takaki Inoue, Satoshi Maki, Toshitaka Yoshii, Takeo Furuya, Satoru Egawa, Kenichiro Sakai, Kazuo Kusano, Yukihiro Nakagawa, Takashi Hirai, Kanichiro Wada, Keiichi Katsumi, Kengo Fujii, Atsushi Kimura, Narihito Nagoshi, Tsukasa Kanchiku, Yukitaka Nagamoto, Yasushi Oshima, Kei Ando, Masahiko Takahata, Kanji Mori, Hideaki Nakajima, Kazuma Murata, Shunji Matsunaga, Takashi Kaito, Kei Yamada, Sho Kobayashi, Satoshi Kato, Tetsuro Ohba, Satoshi Inami, Shunsuke Fujibayashi, Hiroyuki Katoh, Haruo Kanno, Shiro Imagama, Masao Koda, Yoshiharu Kawaguchi, Katsushi Takeshita, Morio Matsumoto, Seiji Ohtori, Masashi Yamazaki, Atsushi Okawa, and

OBJECTIVE

It is unclear whether anterior cervical decompression and fusion (ADF) or laminoplasty (LMP) results in better outcomes for patients with K-line–positive (+) cervical ossification of the posterior longitudinal ligament (OPLL). The purpose of the study is to compare surgical outcomes and complications of ADF versus LMP in patients with K-line (+) OPLL.

METHODS

The study included 478 patients enrolled in the Japanese Multicenter Research Organization for Ossification of the Spinal Ligament and who underwent surgical treatment for cervical OPLL. The patients who underwent anterior-posterior combined surgery or posterior decompression with instrumented fusion were excluded. The patients with a follow-up period of fewer than 2 years were also excluded, leaving 198 patients with K-line (+) OPLL. Propensity score matching was performed on 198 patients with K-line (+) OPLL who underwent ADF (44 patients) or LMP (154 patients), resulting in 39 pairs of patients based on the following predictors for surgical outcomes: age, preoperative Japanese Orthopaedic Association (JOA) score, C2–7 angle, and the occupying ratio of OPLL. Clinical outcomes were assessed 1 and 2 years after surgery using the recovery rate of the JOA score. Complications and reoperation rates were also investigated.

RESULTS

The mean recovery rate of the JOA score 1 year after surgery was 55.3% for patients who underwent ADF and 42.3% (p = 0.06) for patients who underwent LMP. Two years after surgery, the recovery rate was 53.4% for those who underwent ADF and 38.7% for LMP (p = 0.07). Although both surgical procedures yielded good results, the mean recovery rate of JOA scores tended to be higher in the ADF group. The incidence of surgical complications, however, was higher following ADF (33%) than LMP (15%; p = 0.06). The reoperation rate was also higher in the ADF group (15%) than in the LMP group (0%; p = 0.01).

CONCLUSIONS

Clinical outcomes were good for both ADF and LMP, indicating that ADF and LMP are appropriate procedures for patients with K-line (+) OPLL. Clinical outcomes of ADF 1 and 2 years after surgery tended to be better than LMP, but the analysis did not detect any significant difference in clinical outcomes between the groups. Conversely, patients who underwent ADF had a higher incidence of surgery-related complications. When considering indications for ADF or LMP, benefits and risks of the surgical procedures should be carefully weighed.