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Yoshihiro Mukai, Shota Takenaka, Noboru Hosono, Toshitada Miwa and Takeshi Fuji

Object

This randomized study was designed to elucidate the time course of the perioperative development of intramuscular multifidus muscle pressure after posterior lumbar interbody fusion (PLIF) and to investigate whether the route of pedicle screw insertion affects this pressure and resultant low-back pain. Although several studies have focused on intramuscular pressure associated with posterior lumbar surgery, those studies examined intramuscular pressure generated by the muscle retractors during surgery. No study has investigated the intramuscular pressure after PLIF.

Methods

Forty patients with L4–5 degenerative spondylolisthesis were randomly assigned to undergo either the mini-open PLIF procedure with pedicle screw insertion between the multifidus and longissimus muscles (n = 20) or the conventional PLIF procedure via a midline approach only (n = 20). Intramuscular pressure was measured 5 times (at 30 minutes and at 6, 12, 24, and 48 hours after surgery) with an intraoperatively installed sensor. Concurrently, the FACES Pain Rating Scale score for low-back pain and the total dose of postoperative analgesics were recorded.

Results

With the patients in the supine position, for both groups the mean pressure values were consistently 40–50 mm Hg, which exceeded the critical capillary pressure of the muscle. With the patients in the lateral decubitus position, the pressure decreased over time (from 14 to 9 mm Hg in the mini-open group and from 20 to 10 mm Hg in the conventional group). Among patients in the mini-open group, the pressure was lower, but the difference was not statistically significant. Postoperative pain and postoperative analgesic dosages were also lower .

Conclusions

To the authors' knowledge, this is the first study to evaluate postoperative intramuscular pressure after PLIF. Although the results did not demonstrate a significant difference in the intramuscular pressure between the 2 types of PLIF, mini-open PLIF was associated with less pain after surgery. Clinical trial registration no.: UMIN000010069 (www.umin.ac.jp/ctr/index.htm).

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Shota Takenaka, Noboru Hosono, Yoshihiro Mukai, Toshitada Miwa and Takeshi Fuji

Object

No previous hypothesis has attempted to fully account for the occurrence of upper-limb palsy (ULP) after cervical laminoplasty. The authors propose that friction-generated heat from a high-speed drill may cause thermal injury to the nerve roots close to the drilled bone, which may then lead to ULP. The authors investigated the effect of cooling the saline used for irrigation during the drilling on the incidence of upper-limb (C-5) palsy following cervical laminoplasty.

Methods

The irrigation saline for drilling was used at room temperature (RT, average temperature of 25.6°C) in operations of 79 patients (the RT group) and cooled to an average of 12.1°C in operations of 80 patients (the low-temperature [LT] group). The authors used a hand-held dynamometer to precisely assess muscle strength presurgery and 2 weeks postsurgery.

Results

There was a 7.6% and 1.9% decrease in the strength of the deltoid muscle, a 10.1% and 4.4% decrease in the strength of the biceps brachii, a 1.3% and 0.6% decrease in the strength of the triceps brachii, and a 7.6% and 3.1% decrease in grip strength in the RT and LT groups, respectively. Multivariate analysis revealed that a significant predictor for decreased deltoid muscle strength was the use of irrigation saline at RT.

Conclusions

Using cooled irrigation saline during bone drilling significantly decreased the incidence of ULP and can thus be recommended as a simple method for the prevention of ULP.

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Noboru Hosono, Hironobu Sakaura, Yoshihiro Mukai, Takahiro Ishii and Hideki Yoshikawa

Object. Although conducting cervical laminoplasty in patients with multisegmental cord compression provides good neurological results, it is not without shortcomings, including C-5 palsy, axial neck pain, and undesirable radiologically detectable changes. Postoperative kyphosis and segmental instability can cause neurological problems and are believed mainly to result from neck muscle disruption. The authors developed a new laminoplasty technique, with the aim of preserving optimal muscle function.

Methods. The present technique is a modification of unilateral open-door laminoplasty. By using an ultrasonic osteotome in small gaps of muscle bellies, a gutter is made without disrupting muscles, spinous processes, or their connections on the hinged side. Ceramic spacers are then positioned between elevated laminae and lateral masses at C-3, C-5, and C-7 on the opened side, which is exposed in a conventional manner.

This new procedure was used to treat 37 consecutive patients with compression myelopathy. Postoperative computerized tomography (CT) scanning revealed a significant difference in a cross-sectional area of muscles between the hinged and opened side. The mean follow-up period was 40.2 months (range 24–54 months). Changes in alignment were observed in only one patient, and vertebral slippage developed in two. Performed at regular intervals, CT scanning demonstrated that the elevated laminae remained in situ throughout the study period.

Conclusions. In using the present unilateral open-door laminoplasty technique, deep extensor muscles are left intact along with their junctions to spinous processes on the hinged side. Radiologically documented changes were minimal because the preserved muscles functioned normally immediately after the operation.

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Shota Takenaka, Kosuke Tateishi, Noboru Hosono, Yoshihiro Mukai and Takeshi Fuji

OBJECT

In this study, the authors aimed to identify specific risk factors for postdecompression lumbar disc herniation (PDLDH) in patients who have not undergone discectomy and/or fusion.

METHODS

Between 2007 and 2012, 493 patients with lumbar spinal stenosis underwent bilateral partial laminectomy without discectomy and/or fusion in a single hospital. Eighteen patients (herniation group [H group]: 15 men, 3 women; mean age 65.1 years) developed acute sciatica as a result of PDLDH within 2 years after surgery. Ninety patients who did not develop postoperative acute sciatica were selected as a control group (C group: 75 men, 15 women; mean age 65.4 years). Patients in the C group were age and sex matched with those in the H group. The patients in the groups were also matched for decompression level, number of decompression levels, and surgery date. The radiographic variables measured included percentage of slippage, intervertebral angle, range of motion, lumbar lordosis, disc height, facet angle, extent of facet removal, facet degeneration, disc degeneration, and vertebral endplate degeneration. The threshold for PDLDH risk factors was evaluated using a continuous numerical variable and receiver operating characteristic curve analysis. The area under the curve was used to determine the diagnostic performance, and values greater than 0.75 were considered to represent good performance.

RESULTS

Multivariate analysis revealed that preoperative retrolisthesis during extension was the sole significant independent risk factor for PDLDH. The area under the curve for preoperative retrolisthesis during extension was 0.849; the cutoff value was estimated to be a retrolisthesis of 7.2% during extension.

CONCLUSIONS

The authors observed that bilateral partial laminectomy, performed along with the removal of the posterior support ligament, may not be suitable for lumbar spinal stenosis patients with preoperative retrolisthesis greater than 7.2% during extension.

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Shota Takenaka, Yoshihiro Mukai, Noboru Hosono, Kosuke Tateishi and Takeshi Fuji

Vertebral cystic lesions may be observed in pseudarthroses after lumbar fusion surgery. The authors report a rare case of pseudarthrosis after spinal fusion, accompanied by an expanding vertebral osteolytic defect induced by cellulose particles. A male patient originally presented at the age of 69 years with leg and low-back pain caused by a lumbar isthmic spondylolisthesis. He underwent a posterior lumbar interbody fusion, and his neurological symptoms and pain resolved within a year but recurred 14 months after surgery. Radiological imaging demonstrated a cystic lesion on the inferior endplate of L-5 and the superior endplate of S-1, which rapidly enlarged into a vertebral osteolytic defect. The patient underwent revision surgery, and his low-back pain resolved. A histopathological examination demonstrated foreign body–type multinucleated giant cells, containing 10-μm particles, in the sample collected just below the defect. Micro–Fourier transform infrared spectroscopy revealed that the foreign particles were cellulosic, presumably originating from cotton gauze fibers that had contaminated the interbody cages used during the initial surgery. Vertebral osteolytic defects that occur after interbody fusion are generally presumed to be the result of infection. This case suggests that some instances of vertebral osteolytic defects may be aseptically induced by foreign particles. Hence, this possibility should be carefully considered in such cases, to help prevent contamination of the morselized bone used for autologous grafts by foreign materials, such as gauze fibers.

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Yoshihiro Mukai, Noboru Hosono, Hironobu Sakaura, Takahiro Ishii, Tsuyoshi Fuchiya, Keiju Fijiwara, Takeshi Fuji and Hideki Yoshikawa

Object. Although controversy exists regarding surgical treatment for rheumatoid subaxial lesions, no detailed studies have been conducted to examine the efficacy of laminoplasty in such cases. To discuss indications for laminoplasty in rheumatoid subaxial lesions, the authors retrospectively investigated clinical and radiological outcomes in patients who underwent laminoplasty for subaxial lesions.

Methods. Thirty patients (11 men and 19 women) underwent laminoplasty for rheumatoid subaxial lesions. The patients were divided into those with mutilating-type rheumatoid arthritis (RA) and those with nonmutilating-type RA according to the number of eroding joints. As of final follow-up examination laminoplasty resulted in improvement of myelopathy in 24 patients (seven with mutilating- and 17 with nonmutilating-type RA) and transient or no improvement in six (five with mutilating- and one with nonmutilating-type RA). In the group with mutilating-type RA, significantly poorer results were displayed (p < 0.05). In most patients preoperative radiographs demonstrated vertebral slippage less than or equal to 5 mm at only one or two levels. Postlaminoplasty deterioration of subaxial subluxation and unfavorable alignment change occurred significantly more often in patients with mutilating-type RA (p < 0.05).

Conclusions. Patients with nonmutilating-type RA can benefit from laminoplasty for myelopathy due to subaxial lesions.

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Takashi Kaito, Noboru Hosono, Yoshihiro Mukai, Takahiro Makino, Takeshi Fuji and Kazuo Yonenobu

Object

Spinal fusion at the L4–5 disc space alters the normal biomechanics of the spine, and the loss of motion at the fused level is compensated by increased motion and load at the other unfused segments. This may lead to deterioration of the adjacent segments of the lumbar spine, called adjacent-segment disease (ASD). In this study, the authors investigate the distracted disc height of the fused segment, caused by cage or bone insertion during surgery, as a novel risk factor for ASD after posterior lumbar interbody fusion (PLIF).

Methods

Radiographic L3–4 ASD is defined by development of spondylolisthesis greater than 3 mm, a decrease in disc height of more than 3 mm, or intervertebral angle at flexion smaller than −5°. Symptomatic ASD is defined by a decrease of 4 points or more on the Japanese Orthopaedic Association scale. Eighty-five patients with L-4 spondylolisthesis treated by L4–5 PLIF underwent follow-up for more than 2 years (mean 38.8 ± 17.1 months). The patients were divided into 3 groups according to the final outcome. Group A comprised those patients without ASD (58), Group B patients had radiographic ASD (14), and Group C patients had symptomatic ASD (13).

Results

The L4–5 disc space distraction by cage insertion was 3.1 mm in the group without ASD, 4.4 mm in the group with radiographic ASD, and 6.2 mm in the group with symptomatic ASD, as measured using lateral spinal radiographs just after surgery. Multivariate analysis showed that distraction was the most significant risk factor.

Conclusions

The excessive distraction of the L4–5 disc space during PLIF surgery is a significant and potentially avoidable risk factor for the development of radiographic, symptomatic ASD.