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ABSTRACT: Object The origin of posttraumatic syringomyelia is not completely understood. With respect to posttraumatic syringomyelia, the optimum management strategy for patients with spinal cord injury has also not been established. The authors hypothesized that reconstruction of the subarachnoid channels would reestablish CSF flow, thereby addressing the underlying cause of the syrinx formation. The authors performed a new type of surgery, subarachnoid-subarachnoid bypass (S-S bypass), in which an attempt was made to reestablish normal CSF circulation around the spinal cord. The purpose of this study was to evaluate the effectiveness of S-S bypass for posttraumatic syringomyelia. Methods Twenty consecutive patients with symptomatic posttraumatic syringomyelia who had progressive neurological symptoms and underwent S-S bypass were included in the study. The surgical procedure was as follows: a laminectomy was performed at the level of trauma, and a midline dural opening was made under a microscope. The arachnoid was exposed up to the area of normal arachnoid mater with normal CSF circulation. After dissection of the normal arachnoid mater at the cephalic and caudal sites, 1 or 2 tubes made of medical-grade silicone were inserted into the cephalic and caudal ends of the normal subarachnoid space. Bypass tubes were laid in the subdural space, and a watertight dural closure was accomplished using running sutures. The mean follow-up period was 48.2 months (range 12-93 months). The preoperative status and postoperative clinical course were assessed according to 3 grading systems: the Frankel grading system for global neurological status, the American Spinal Injury Association motor score for motor weakness, and the Klekamp system for bladder function. The major presenting symptoms or signs were assessed in terms of symptom improvement, stabilization, or deterioration. Preoperative and postoperative MRI was used to analyze the size and craniocaudal extension of the cavity. Results Twelve patients showed clinical improvement, 4 were stable, and 4 showed deterioration. The mean length of the syrinx observed on preoperative MRI was 9.9 spinal levels, and the mean Vaquero index was 62.3%. The mean length of the syrinx observed on postoperative MRI was 5.3 spinal levels, and the mean Vaquero index was 28.4%. These values were significantly lower than the preoperative values (p = 0.01 and p < 0.01, respectively). Conclusions This study showed that interference with CSF flow was the major cause of syrinx development and that reconstruction of CSF flow is the most important treatment strategy based on the cause of the syrinx. Subarachnoid-subarachnoid bypass, which can be performed without myelotomy, was not only a safe and effective surgical technique, but may also be a more physiological way of treating posttraumatic syringomyelia.
Journal of neurosurgery. Spine 02/2013; · 1.61 Impact Factor
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Itaru Yugué,
Seiji Okada, Takayoshi Ueta,
Takeshi Maeda,
Eiji Mori,
Osamu Kawano,
Tsuneaki Takao,
Hiroaki Sakai,
Muneaki Masuda,
Tetsuo Hayashi,
Yuichiro Morishita,
Keiichiro Shiba
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ABSTRACT: STRUCTURED ABSTRACT: Study Design. A retrospective, consecutive case series.Objective. To determine the risk factors that have a statistically significant association with the need of tracheostomy in the patients with cervical spinal cord injury (CSCI) at the acute stage.Summary of Background Data. Respiratory complications remain major cause of further morbidity and mortality in patients with CSCI. Although several risk factors for tracheostomy have been postulated in these patients, no definitive factors have yet been established according to a multivariate analysis. The use of vital capacity was considered as a single global measure of respiratory function in spinal cord injury patients but there are very few studies in which the forced vital capacity was investigated as a risk factor for tracheostomy.Methods. This study reviewed the clinical data of 319 patients with CSCI, who were evaluated for their neurological impairment within 2 days after injury, was performed. We analyzed the factors postulated to increase the risk for tracheostomy, including patient age, neurological impairment scale grade and level, smoking history, preexisting medical comorbidites, respiratory diseases, Injury severity score (ISS), force vital capacity (FVC), and percentage of vital capacity to the predicted value (%VC) using a multiple logistic regression model and classification and regression tree analysis.Results. Of 319 patients, 32 patients received a tracheostomy (10.03%). The factors identified using a multiple logistic regression model were high age (≥69 years old), severe neurological impairment scale, low forced vital capacity (≤500ml) and low percentage of vital capacity to the predicted value (<16.3%). The decision tree analysis demonstrated that FVC, the severe neurological impairment scale, and high patient age were predictive of need for tracheostomy on 94.4% occasions.Conclusions. The measurement of forced vital capacity is indispensable to predict the need for tracheostomy in cervical spinal cord injury patients at the acute stage.
Spine 09/2012; · 2.08 Impact Factor
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ABSTRACT: Study Design. A retrospective imaging and clinical studyObjective. To evaluate the extraneural soft tissue damage and its clinical relevance in patients with traumatic cervical spinal cord injury (SCI) without major bone injury.Summary of Background Data. So far, various kinds of cervical discoligamentous injuries have been demonstrated on magnetic resonance imaging (MRI) in patients with SCI without bony injury. However, it has not been clear if these MRI abnormalities are actually related to spinal segmental instability and the patients' neurological status.Methods. Eighty-eight adult patients with acute traumatic cervical SCI without major bone injury were examined by flexion-extension lateral radiographs and MRI within 2 days after trauma. We excluded patients with flexion recoil injury, therefore, most of the patients included were considered to have sustained a hyperextension injury. Instability of the injured cervical segment was defined when there was more than 3.5 mm posterior translation, and/or more than a 11° difference in the intervertebral angle between the site of interest and adjacent segments. The neurological status was evaluated according to the American Spinal Injury Association (ASIA) motor score.Results. On MRI, the damage to the anterior longitudinal ligament and intervertebral disc were apparent in 44 and 37 patients respectively. Various degrees of prevertebral fluid collection (prevertebral hyperintensity) were demonstrated in 76 patients. These MRI abnormalities were significantly associated with initial cervical segmental instability as judged by flexion-extension radiographs. Interestingly, the ASIA motor score had a significant association with either MRI abnormalities or segmental instability, but not with the cervical canal diameter.Conclusion. A considerable proportion of the patients with traumatic cervical SCI without major bone injury were shown to have various types of soft tissue damage associated with cervical segmental instability at the early stages of the injury. The severity of paralysis greatly depended on these discoligamentous injuries.
Spine 09/2012; · 2.08 Impact Factor
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ABSTRACT: A prospective radiographical trial.
To elucidate effects of loading associated with spinal canal encroachment (SCE) in patients with insufficient bone union after vertebral fractures in the elderly, using computed tomography-myelography in 2 different positions.
In elderly patients with vertebral fractures, influence of loading would be involved in SCE, but the details are not well understood.
Seventeen patients (mean age, 77.4 ± 8 yr; range, 62-91 yr) with various degrees of neurological deficit due to insufficient bone union at both vertebral body and posterior vertebral wall were included in this study. Computed tomography-myelography was performed in both semisitting and supine positions. Kyphotic angle, rate of dural compression, ratio of occupation by bony fragments, and posterior vertebral body height ratio were measured and compared between positions.
Mean ratio of occupation by bony fragments was significantly higher in the semisitting position (47.9 ± 9.2%) than in the supine position (33.9 ± 10.0%, P, 0.001). Similarly, mean posterior vertebral body height ratio was significantly lower in the semisitting position (67.8 ± 10.8%) than in the supine position (76.3 ± 13.3%), indicating a significant loss of vertebral height in the semisitting position (P, 0.001). Mean rate of dural compression was likewise significantly higher in the semisitting position (48.6 ± 13.3%) than in the supine position (33.3 ± 16.5%; P, 0.001). Mean change in ratio of occupation by bony fragments, change in posterior vertebral body height ratio, and angular instability between positions were 13.9 ± 8.6%, 8.5 ± 6.7%, and 13° ± 5.7°, respectively. A significant correlation was identified between change in ratio of occupation by bony fragments and change in posterior vertebral body height ratio (P = 0.001).
Our study demonstrated that collapse of the nonunited posterior vertebral wall and intracanal protrusion of vertebral fragments would occur simultaneously with axial loading, causing SCE. Computed tomographic scan obtained in semisitting position seems quite useful to evaluate the amount of SCE by an unstable posterior wall.
Spine 05/2012; 37(19):E1203-8. · 2.08 Impact Factor
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ABSTRACT: The conventional open pedicle screw fusion (PSF) requires an extensive detachment of the paraspinal muscle from the posterior aspect of the lumbar spine, which can cause muscle injury and subsequently lead to "approach-related morbidity". The spinous process-splitting (SPS) approach for decompression, unilateral laminotomy for bilateral decompression, and the Wiltse approach for pedicle screw insertion are considered to be less invasive to the paraspinal musculature. We investigated whether SPS open PSF combined with the abovementioned techniques attenuates the paraspinal muscle damage and yields favorable clinical results, including alleviation in the low back discomfort, in comparison to the conventional open PSF.
We studied 53 patients who underwent single-level PSF for the treatment of degenerative spondylolisthesis (27 patients underwent SPS open PSF and the other 26 underwent the conventional open PSF). The clinical outcomes were assessed using the Japanese Orthopedic Association (JOA) score, the Roland-Morris disability questionnaire (RDQ), and the visual analog scale (VAS) for low back pain and low back discomfort (heavy feeling or stiffness). Postoperative multifidus (MF) atrophy was evaluated using MRI. Follow-up examinations were performed at 1 and 3 years after the surgery.
Although there was no significant difference in the JOA and RDQ score between the two groups, the VAS score for low back pain and discomfort after the surgery were significantly lower in the SPS open PSF group than in the conventional open PSF group. The extent of MF atrophy after SPS open PSF was reduced more significantly than after the conventional open PSF during the follow-up. The MF atrophy ratio was found to correlate with low back discomfort at the 1-year follow-up examination.
In conclusion, SPS open PSF was less damaging to the paraspinal muscle than the conventional open PSF and had a significant clinical effect, reducing low back discomfort over 1 year after the surgery.
European Spine Journal 01/2012; 21(4):745-53. · 1.97 Impact Factor
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Journal of Orthopaedic Science 05/2011; 17(3):319-22. · 0.84 Impact Factor
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ABSTRACT: A retrospective, consecutive case series.
To determine the risk factors that have a significant correlation with the severity of neurologic impairment in thoracolumbar and lumbar burst fractures.
The correlation between spinal canal stenosis due to bony fragments and the severity of neurologic deficits in thoracolumbar and lumbar burst fractures remains controversial. Moreover, there have so far been no reports in the literature in which the risk factors (spinal canal stenosis and the disruption of posterior ligamentous complex) causing a severe neurologic deficit were analyzed using a multiple logistic regression model.
A review of the clinical data (neurologic impairments on admission and a finding of posterior ligamentous complex disruption at the time of operation), axial computed tomography, and plain lateral radiography of 216 patients in thoracolumbar (T11-L1) and lumbar (L2-L5) burst fractures was performed. The factors related to neurologic impairments were analyzed using a multiple logistic regression model.
In all cases, both the spinal canal stenosis (P < 0.01) and disruption of posterior ligamentous complex (P < 0.01) were significant risk factors. Interestingly, these two risk factors varied according to the injury levels: at thoracic level, the spinal canal stenosis (P < 0.01); at the first lumbar spine, the disruption of the posterior ligamentous complex (P < 0.01); and at the lumbar spine below L2, both of the spinal canal stenosis (P < 0.01) and the disruption of posterior ligamentous complex (P < 0.05) were significant risk factors, respectively.
In the patients with thoracolumbar and lumbar burst fractures, the significance of the two important risk factors related to clinical results, namely, the stenosis ratio of spinal canal and the disruption of posterior ligamentous complex, were found to vary depending on the level of injury.
Spine 01/2011; 36(19):1563-9. · 2.08 Impact Factor
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Seiji Okada,
Takeshi Maeda,
Yasuyuki Ohkawa,
Katsumi Harimaya,
Hirokazu Saiwai,
Hiromi Kumamaru,
Yoshihiro Matsumoto,
Toshio Doi, Takayoshi Ueta,
Keiichiro Shiba,
Yukihide Iwamoto
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ABSTRACT: Retrospective outcome measurement study.
The purpose of this study is to assess whether ossification of the posterior longitudinal ligament (OPLL) affects neurologic outcomes in patients with acute cervical spinal cord injury (SCI).
There have so far been few reports examining the relationship between OPLL and SCI and there is controversy regarding the deteriorating effects of OPLL-induced canal stenosis on neurologic outcomes.
To obtain a relatively uniform background, patients nonsurgically treated for an acute C3-C4 level SCI without any fractures or dislocations of the spinal column were selected, resulting in 129 patients. There were 110 men and 19 women (mean age was 61.1 years), having various neurologic conditions on admission (American Spinal Injury Association [ASIA] impairment scale A, 43; B, 16; C, 58; D, 12). The follow-up period was the duration of their hospital stay and ranged from 50 to 603 days (mean, 233 days). The presence of OPLL, the cause of injury, the degree of canal stenosis (both static and dynamic), and the neurologic outcomes in motor function, including improvement rate, were assessed.
Of the 129 patients investigated in this study, OPLL was identified at the site of the injury in 13 patients (10.1%). In this OPLL+ group, the static and dynamic canal diameters at C3 and C4 were significantly smaller than those of the remaining 116 patients (OPLL- group). However, no significant difference was observed between the 2 groups in terms of ASIA motor score both at the time of administration and discharge, and the mean improvement rate in ASIA motor score was 55.5 +/- 9.0% in OPLL+ group, while it was 43.1 +/- 2.8% in the OPLL-group. Furthermore, no significant correlation was observed between the static/dynamic canal diameters and neurologic outcome in all 129 patients.
No evidence was found for OPLL to have any effect on the initial neurologic status or recovery in motor function after traumatic cervical cord injury, suggesting that the neurologic outcome is not significantly dependent on canal space.
Spine 06/2009; 34(11):1148-52. · 2.08 Impact Factor
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Takayoshi Ueta
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ABSTRACT: Spasticity is often observed in patients with brain or spinal cord injuries. Patients with severe spasticity experience considerable difficulty in performing the activities of daily living (ADLs). Baclofen is an agonisit at gamma-aminobutyric acid (GABA) receptors, and is, therefore, a neuroinhibitor, and decreases spasticity. However, because of blood-brain-barrier (BBB) sufficient concentrations of baclofen do not reach the spinal cord. Intrathecal administration of baclofen enables its direct infiltration into the spinal cord, and drastically reduce spasticity. In Japan, the government approved intrathecal baclofen (ITB) treatment in April, 2006. Thus far we have 40 patients administered ITB treatment. Further, we have implanted a pump that delivers baclofen in 22 patients who nevertheless require baclofen administration. All patients implanted with the pump are satisfied with the reduction in spasticity which has improved the performance of activities among wheelchair users and facilitates locomotion. In 2 patients, the implants were removed; in 1, the reason for the removal infection, and in the other was disruption of catheter. Re-implantation surgery was performed on both patients and baclofen treatment was continued.
Brain and nerve = Shinkei kenkyū no shinpo 01/2009; 60(12):1415-20.
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ABSTRACT: Retrospective single-center study.
To evaluate the recovery of motor function and the early complications in patients with acute cervical spinal cord injury after receiving a high dose of methylprednisolone sodium succinate (MPSS) within 8 hours of injury.
High-dose MPSS therapy has been demonstrated to improve the neurologic recovery in patients with acute spinal cord injury. However, it remains a controversial treatment.
Seventy patients were included in this study: 37 in the MPSS group who were treated with MPSS within 8 hours of their injury according to the Second National Acute Spinal Cord Injury Study protocol, and 33 in non-MPSS group who were not administered with MPSS. Improvements in the American Spinal Injury Association motor score were compared between the MPSS group and the non-MPSS group. In patients with complete motor loss at admission and follow-up periods, improvements of myotomal levels between the MPSS (n = 15) and non-MPSS groups (n = 21) were compared. Early complications within 6 weeks of high-dose MPSS therapy were compared with those of no MPSS therapy.
Among the patients with incomplete paralysis at admission, the American Spinal Injury Association motor scores in the MPSS group were improved more significantly than those in the non-MPSS group at 6 weeks and 6 months after injury. Meanwhile, among the patients with complete paralysis at admission, the patients in the MPSS group did not show significantly more change in motor score than those in the non-MPSS group. Improvement in myotomal level had no significant difference between the MPSS and non-MPSS groups. The MPSS group had 10 patients with early complications, while the non-MPSS group had 14. The differences between the 2 groups showed no statistical significance.
MPSS should be administered to patients with incomplete cervical spinal cord injury according to the Second National Acute Spinal Cord Injury Study protocol.
Spine 01/2007; 31(26):2992-6; discussion 2997. · 2.08 Impact Factor
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ABSTRACT: A cross-sectional study was performed to elucidate the usefulness of a new clinical evaluation, and a prospective study was performed to detect hysterical paralysis using this evaluation method.
To make a correct diagnosis of hysterical paralysis, a new clinical evaluation was developed.
Hysterical paralysis is a conversion disorder. Its diagnosis must be ruled out when encountering a patient with paralysis, therefore imaging and electrophysiological studies are often necessary, but costly. The principal salient diagnostic features for diagnosing hysterical paralysis are thought to be the preservation of a normal reflex pattern, normal rectal sensation, and normal bladder and bowel functions; however, these features are not always successfully identified.
A new clinical evaluation named the "Spinal Injuries Center" test was developed. The lower extremities of the patients were divided into two groups as follows: in group A, the patients were able to lift up the knee; in group B, the patients were unable to lift up the knee. The 96 legs of the 48 patients who had obvious myelomalacia were randomly chosen. All legs were investigated using the Spinal Injuries Center test, and the association between each group and the Spinal Injuries Center test was examined. The 28 legs of the 14 patients in whom hysterical paralysis was diagnosed were prospectively evaluated using the Spinal Injuries Center test, and the association between the groups and the Spinal Injuries Center test was examined.
Forty-eight legs were classified as group A, and 48 legs were classified as group B. In group A, 45 legs were judged to be positive for the Spinal Injuries Center test, and 3 legs were negative. In group B, 1 leg was judged to be positive for the Spinal Injuries Center test, and 47 legs were negative. All legs of the patients with hysterical paralysis were classified as group B; however, all legs were positive for the Spinal Injuries Center test.
The Spinal Injuries Center test is a new clinical evaluation method that can help make a correct diagnosis of hysterical paralysis. When a patient is unable to lift up his knees by himself, the result of the Spinal Injuries Center test is considered to be positive, and hysterical paralysis is diagnosed in such patients. The diagnosis of hysterical paralysis must be ruled out when encountering patients with paralysis, and as a result, imaging and electrophysiological studies are often necessary. Unfortunately, such tests are costly. Thus, a new clinical evaluation for the diagnosis of hysterical paralysis, named the Spinal Injuries Center test, was developed. When patients who are unable to lift up their knees by themselves test positive using the Spinal Injuries Center test, then they are considered to have ether hysterical or simulated paralysis.
Spine 10/2004; 29(17):1910-3; discussion 1913. · 2.08 Impact Factor
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ABSTRACT: The authors report four cases of traumatic neuroma in the cervical nerve root in patients with no history of trauma. In one case the patient presented with intractable pain in the left upper extremity and motor paresis of the left shoulder, and in another case the patient suffered neuropathic pain in the left forearm. In both cases, magnetic resonance (MR) imaging revealed an intradural extramedullary mass lesion in the ipsilateral cervical nerve root; these MR imaging signals were similar to the intensity of the spinal cord. Intraoperatively, fusiform enlargement of the anterior cervical nerve root was detected in the subarachnoid space. Histological examination showed a meandering change of axons accompanied by mild axonal swelling and a thin myelin sheath, which are consistent with the typical pathological features of traumatic neuroma. Postoperatively, pain resolved in both cases. The authors also investigated two traumatic neuromas of the anterior cervical nerve root in autopsy cases in which there was no history of trauma and no significant neurological signs suggestive of traumatic neuroma. The authors conclude that traumatic neuroma of the anterior cervical nerve root may develop following an unnoticed minor brachial plexus injury at birth or a forgotten traction injury of the upper extremity in childhood, and the lesion may be accompanied by various case-specific clinical features.
Journal of Neurosurgery 11/2002; 97(3 Suppl):393-6. · 2.96 Impact Factor
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ABSTRACT: Study Design: Sixty-five patients who underwent transpedicular fixation for thoracolumbar and lumbar injuries were studied for type of injury, the severity of paralysis, the degree of postoperative correction, and instrumentation failures.
Objectives: To evaluate the surgical approaches and the selection of instrumentation to determine indications for using the transpedicular fixation procedure.
Summary of Background Data: Various transpedicular fixation devices have been used for different type of injuries, and satisfactory postoperative results were not obtained in some studies.
Methods: Forty patients had burst fraetures, 19 had fracture dislocations, and six had chance-type fractures. An anterior decompression procedure was used for most cases of burst fracture and some cases of fractures dislocation where anterior compression factors were present. The Zielke or modified Zielke system was used as an internal fixator for posterior segmental fixation.
Results: No patient had neurologica deterioration after surgery. Twenty of 28 patients with incomplete lesions improved postoperatively according to Frankel grades. The instrumentation failed in only one patient, in whom a nonunion developed.
Conclusion: With transpedicular fixation, it is possible to provide solid internal fixation that is circumsribed to the injured vertebral segments. The elasticity of the Zielka rod makes it an excellent transpedicular fixation devices because it is easily attached and reduction is easily performed. Anterior decompression with fusion needs to be used with transpedicular fixation in the treatment of injuries (especially burst fractures).
(C) Lippincott-Raven Publishers.
Spine 08/1994; 19(17). · 2.08 Impact Factor
