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Study Design: Cross-sectional observational study.Purpose: To examine whether pelvic rotation as a compensatory mechanism for sagittal imbalance is related to quality of life (QOL).Overview of Literature: Poor sagittal alignment is associated with compensatory pelvic retroversion and decreased QOL. Whether the compensatory pelvic tilt (PT) influences QOL is unclear.Methods: Overall, 134 subjects aged ≥20 years with lower back pain were included (104 females; mean age, 70±9.8 years). Sagittal vertical alignment (SVA) and PT were analyzed radiographically. Patients were stratified into three groups based on SVA values: good alignment (group G), intermediate alignment (group I), and poor sagittal alignment (group P). Patients in group I were further categorized into two groups: low PT and high PT. The Japanese Orthopaedic Association Back Pain Evaluation Questionnaire (JOABPEQ) was used for clinical assessment, and the scores were compared between groups.Results: As SVA increased, PT and lumbar lordosis (LL) increased and decreased, respectively. PT and LL differed significantly between groups G and P (pp

Some patients developed shoulder imbalance after selective anterior correction of lumbar scoliosis with spontaneous rebalances later on. We conducted this retrospective radiographic analysis study to study the effect of selective anterior correction of thoracolumbar and lumbar scoliosis on shoulder balance. Standing X-ray films of 15 patients with lumbar scoliosis operated by anterior correction at preoperative, 3, 6 & 12 months postoperative were used. Spine and shoulder balance parameters were measured. Correlations between changes in shoulder balance and spine parameters were evaluated. Shoulder height parameters showed early postoperative change from positive or neutral to negative shoulder balance, Lumbar and thoracic Cobb angles showed immediate postoperative improvement with a slight later increase contributing to shoulder rebalance mechanisms. Changes in T1 tilt was correlated to change in thoracic Cobb angle at 3 months post op. (r= 0.515 p =.049), CRCI was correlated to difference between changes in lumbar Cobb angle and changes in thoracic Cobb angle (r= 0.56 p= 0.030), close correlation between Correction change ratio and T1 tilt, FRA, CA and CPH was shown (p=0.008, 0.016, 0.011 & 0.012). Spontaneous Correction of shoulder balance after anterior correction of lumbar scoliosis is likely to occur during the first postoperative year. Flexibility of the thoracic curve was a major determinant in the shoulder re-balance, ratio between correction of lumbar curve and correction of thoracic curve may have a prognostic value in shoulder rebalance after anterior correction surgery. Clavicle angle has the best predictor for postoperative shoulder balance improvement.

Background Ectopic gas in the graft is occasionally encountered upon follow-up computed tomography (CT) after anterior cervical corpectomy and fusion (ACCF). However, most cases lack inflammatory responses and manifestations of infection. Although the clinical significance of ectopic gas in the graft has not yet been established, to the best of our knowledge, no previous studies have described ectopic gas in the graft after ACCF. This study evaluated ectopic gas in the fibular graft upon follow-up CT after ACCF. Methods We reviewed 112 patients who underwent ACCF and follow-up CT, with a minimum follow-up period of 3 years. CT images were retrospectively reviewed to confirm the presence of ectopic gas in the graft and bone fusion. Bone fusion was defined as follows: mobility less than 2 mm between spinous processes on the flection-extension radiograph or a bone bridge on CT images. Results Of the 112 patients, 30 (27%) patients had ectopic gas in the fibular grafts. Among them, ectopic gas was initially observed 3 months after surgery (early onset) in 23 (77%) patients and 6 months after surgery (late-onset) in the remaining seven (23%) patients. Upon the latest follow-up CT, ectopic gas more frequently remained in late-onset (4/7, 57%) rather than in early-onset (3/23, 13%) cases (p = 0.033). Bone fusion was not observed when CT images exhibited ectopic gas in the graft, whereas ectopic gas was not observed when CT images exhibited bone fusion. Conclusion Ectopic gas in the fibular graft was observed at both early and late-onset after ACCF; late-onset gas remained significantly. The remaining gas was strongly associated with pseudoarthrosis; therefore, pseudoarthrosis should be considered when ectopic gas in the graft is observed on CT images.

While it is known that the degenerated intervertebral disc (IVD) is one of the primary reasons for low-back pain and subsequent need for medical care, there are currently no established effective methods for direct treatment. Nuclear factor-κB (NF-κB) is a transcription factor that regulates various genes’ expression, among which are inflammatory cytokines, in many tissues including the IVD. NF-κB decoy is an oligodeoxynucleotide containing the NF-κB binding site that entraps NF-κB subunits, resulting in suppression of NF-κB activity. In the present preclinical study, NF-κB decoy was injected into degenerated IVDs using the rabbit anular-puncture model. In terms of distribution, NF-κB decoy persisted in the IVDs up to at least 4 weeks after injection. The remaining amount of NF-κB decoy indicated that it fit a double-exponential-decay equation. Investigation of puncture-caused degeneration of IVDs showed that NF-κB decoy injection recovered, dose-dependently, the reduced disc height that was associated with reparative cell cloning and morphological changes, as assessed through histology. Gene expression, by quantitative real-time polymerase chain reaction (qRT-PCR), showed that NF-κB decoy attenuated inflammatory gene expression, such as that of interleukin-1 and tumor necrosis factor-α, in rabbit degenerated IVDs. NF-κB decoy also reduced the pain response as seen using the “pain sensor” nude rat xenograft-radiculopathy model. This is the first report demonstrating that NF-κB decoy suppresses the inflammatory response in degenerated IVDs and restores IVD disc height loss. Therefore, the intradiscal injection of NF-κB decoy may have the potential as an effective therapeutic strategy for discogenic pain associated with degenerated IVDs.

Background Although many complications of the spinal implant have been reported previously, to the best of our knowledge, this is the first report on a delayed implant complication of the ilium, leading to buttock pain and aggravated scoliosis. Case description A 78-year-old woman underwent transforaminal lumbar interbody fusion with pedicle screws at the L4–L5 level at another institution. Preoperative symptoms, left leg pain, disappeared soon after surgery. However, 6 months post surgery, she experienced severe pain in her left buttock and sacroiliac joint area, which was treated only at our pain clinic. Based on our initial consultation 5 years after the operation, her plain radiography findings showed a 29° convex left-sided scoliosis spanning from the L1–L5. Computed tomography scan revealed apparent iliac bone erosion at the point of contact with the left-side screw head and rod at L5. The patient had painful scoliosis owing to implant irritation. Soon after the removal of the left implant, the pain was relieved and the degree of scoliosis decreased to 17°. Conclusion This study reports the presence of an unexpected complication caused by pedicle screw fixation at the L4–L5 level. Although the implant was far from the iliac bone, at the L4–L5 fusion, it could cause erosion of the bone after the progression of L3–L4 and L5–S1 disk degeneration and aggravate scoliosis. Neurosurgeons should be aware that patients may present with buttock pain and unprecedented scoliosis by hardware irritation.

Aim: Spinal cord injury in elderly populations has increased in recent years. This study aimed to investigate the pathology, severity, efficacy of the surgery, and complications of cervical spinal cord injury in extremely elderly patients aged >80 years. Methods: Sixty-three patients who underwent surgical treatment for cervical spinal cord injury were enrolled in this retrospective multicenter study. Forty patients were aged

Human dental pulp cells (DPCs), adherent cells derived from dental pulp tissues, are potential tools for cell transplantation therapy. However, little work has been done to optimize such transplantation. In this study, DPCs were treated with fibroblast growth factor-2 (FGF2) for 5–6 consecutive serial passages and were transplanted into the injury site immediately after complete transection of the rat spinal cord. FGF2 priming facilitated the DPCs to promote axonal regeneration and to improve locomotor function in the rat with spinal cord injury (SCI). Additional analyses revealed that FGF2 priming protected cultured DPCs from hydrogen-peroxide–induced cell death and increased the number of DPCs in the SCI rat spinal cord even 7 weeks after transplantation. The production of major neurotrophic factors was equivalent in FGF2-treated and untreated DPCs. These observations suggest that FGF2 priming might protect DPCs from the post-trauma microenvironment in which DPCs infiltrate and resident immune cells generate cytotoxic reactive oxygen species. Surviving DPCs could increase the availability of neurotrophic factors in the lesion site, thereby promoting axonal regeneration and locomotor function recovery.

Study DesignRetrospective study.PurposeThe purpose of this study was to investigate the influence of sagittal alignment of the strut graft on graft subsidence and clinical outcomes after anterior cervical corpectomy and fusion (ACCF).Overview of LiteratureACCF is a common technique for the treatment of various cervical pathologies. Although graft subsidence sometimes occurs after ACCF, it is one cause for poor clinical results. Malalignment of the strut graft is probably one of the factors associated with graft subsidence. However, to the best of our knowledge, no prior reports have demonstrated correlations between the alignment of the strut graft and clinical outcomes.MethodsWe evaluated 56 patients (33 men and 23 women; mean age, 59 years; range, 33–84 years; 45 with cervical spondylotic myelopathy and 11 with ossification of the posterior longitudinal ligament) who underwent one- or two-level ACCF with an autogenous fibular strut graft and anterior plating. The Japanese Orthopaedic Association (JOA) score recovery ratio for cervical spondylotic myelopathy was used to evaluate clinical outcomes. The JOA score and lateral radiograms were evaluated 1 week and 1 year postoperatively. Patients were divided into two groups (a straight group [group I] and an oblique group [group Z]) based on radiographic assessment of the sagittal alignment of the strut graft.ResultsGroup I showed a significantly greater JOA score recovery ratio (ppConclusionsOur findings suggest that a straight alignment of the strut graft provides better clinical outcomes and lower incidence of graft subsidence after ACCF. In contrast, an oblique strut graft can lead to significantly increased strut graft subsidence and poor clinical results.

STUDY DESIGN: Retrospective study. PURPOSE: To assess treatment outcomes of snowboarding-related spinal and spinal cord injuries. OVERVIEW OF LITERATURE: Snowboarding-related spinal or spinal cord injury have a great impact on social and sporting activities. METHODS: A retrospective review of 19 cases of surgically treated snowboard-related injury was done. Analyzed parameters included site of injury, type of fracture, peri- and postoperative complications, pre- and postoperative neurological status, activities of daily living, and participation in sports activities at the final follow-up. RESULTS: The major site of injury was the thoracolumbar junction caused by fracture-dislocation (13/19 cases). The remaining 6 cases had cervical spine injuries. Over 60% of the patients had Frankel A and B paralysis. All patients were surgically treated by posterior fusion with instrumentation. Five underwent additional anterior fusion. Surgical outcome was restoration of ambulatory capacity in 12 patients (63.2%). Ultimately, 15 patients (78.9%) could return to work. Patients with complete paralysis upon admission showed reduced ambulatory capacity compared to those with incomplete paralysis. None of the patients again participated in any sports activities, including snowboarding. CONCLUSIONS: Snowboarding-related spinal or spinal cord injury has a great impact on social as well as sports activities. It is necessary to enhance promotion of injury prevention emphasizing the snowboarders' responsibility code. Language: en

Alterations of three-dimensional cervical curvature in conventional anterior cervical approach position are not well understood. The purpose of this study was to evaluate alignment changes of the cervical spine in the position. In addition, simulated corpectomy was evaluated with regard to sufficiency of decompression and perforation of the vertebral artery canal.Fifty patients with cervical spinal disorders participated. Cervical CT scanning was performed in the neutral and supine position (N-position) and in extension and right rotation simulating the conventional anterior approach position (ER-position). Rotation at each vertebral level was measured. With simulation of anterior corpectomy in a vertical direction with a width of 17 mm, decompression width at the posterior wall of the vertebrae and the distance from each foramen of the vertebral artery (VA) were measured.In the ER-position, the cervical spine was rotated rightward by 37.2° ± 6.2° between the occipital bone and C7. While the cervical spine was mainly rotated at C1/2, the subaxial vertebrae were also rotated by several degrees. Due to the subaxial rotation, the simulated corpectomy resulted in smaller decompression width on the left side and came closer to the VA canal on the right side.In the ER-position, the degrees of right rotation of subaxial vertebrae were small but significant. Therefore, preoperative understanding of this alteration of cervical alignment is essential for performing safe and sufficient anterior corpectomy of the cervical spine.

We report a unique case of lumbar disc herniation, in particular, with end-plate and surrounded by extensive ossification, mimicking a tumor with calcification. A 69-year-old female suffered from right buttock and leg pain. Computed tomography (CT) showed an intracanalar mass with calcification or ossification, which most likely originated from the vertebral body at the L1/2 level epidural space. On a T1-weighted gadolinium magnetic resonance image, the capsule of the mass was enhanced and not only the content of the mass but also that of the L2 vertebral body were partially and slightly enhanced. The final pathological diagnosis was disc herniation with end-plate fracture and secondary ossification. A combination of these pathological conditions as accompanied by both end-plate fractures and extensive secondary ossifications has not been previously reported. This rare pathological condition needs to be recognized as a differential diagnosis.

Anterior decompression with fusion (ADF) for patients with cervical ossification of the posterior longitudinal ligament (OPLL) is reportedly associated with a higher incidence of complications than is laminoplasty. However, the frequency of perioperative complications associated with ADF for cervical OPLL has not been fully established. The purpose of this study was to investigate the incidence of perioperative complications, especially neurological complications, following ADF performed to relieve compressive cervical myelopathy due to cervical OPLL.Study participants comprised 150 patients who had undergone ADF for cervical OPLL at 27 institutions between 2005 and 2008. Perioperative--especially neurological--complications occurring within 2 weeks after ADF were analyzed. Preoperative imaging findings, including Cobb angle, between C2 and C7 and occupying ratio of OPLL were investigated. Multivariate analysis with logistic regression was performed to identify independent risk factors for neurological complications.Three patients (2.0 %) showed deterioration of lower-extremity function after ADF. One of the three patients had not regained their preoperative level of function 6 months after surgery. Upper-extremity paresis occurred in 20 patients (13.3 %), five of whom had not returned to preoperative levels 6 months after surgery. Patients with upper-extremity paresis showed significantly higher occupying ratios of OPLL, greater blood loss, longer operation times, fusion of more segments, and higher rates of cerebrospinal fluid leakage than those without paresis. Independent risk factors for upper-extremity paresis were a high occupying ratio of OPLL and large blood loss during surgery.The incidences of deterioration in upper- and lower-extremity functions were 13.3 % and 2.0 %, respectively. Patients with a high occupying ratio of OPLL are at higher risk of developing neurological deterioration.

There have been few reports regarding the efficacy of posterior instrumentation alone as surgical treatment for patients with pyogenic spondylitis, thus avoiding the morbidity of anterior surgery. We report the clinical outcomes of six patients with pyogenic spondylitis treated effectively with a single-stage posterior fusion without anterior debridement at a mean follow-up of 2.8 years (2 to 5). Haematological data, including white cell count and level of C-reactive protein, returned to normal in all patients at a mean of 8.2 weeks (7 to 9) after the posterior fusion. Rigid bony fusion between the infected vertebrae was observed in five patients at a mean of 6.3 months (4.5 to 8) post-operatively, with the remaining patient having partial union. Severe back pain was immediately reduced following surgery and the activities of daily living showed a marked improvement. Methicillin-resistant Staphylococcus aureus was detected as the causative organism in four patients. Single-stage posterior fusion may be effective in patients with pyogenic spondylitis who have relatively minor bony destruction.

Halo orthosis is used for cervical spine fixation after spinal surgery or injury. Although superficial infection at pin sites occurs frequently, intracranial development of infection, including brain abscesses, is very rare. We experienced subdural empyema due to methicillin-resistant Staphylococcus aureus (MRSA) caused by intracranial penetration of halo pins. A 38-year-old woman with a 4-year history of rheumatoid arthritis experienced severe myelopathy due to atlanto-axial dislocation and vertical subluxation. Reduction and immobilization using a halo vest resulted in neurologic improvement; she later underwent occipital bone to C2 fusion using posterior instrumentation. Three months after halo orthosis fixation, she complained of a headache, experienced a generalized tonic-clonic seizure, and became unconscious for 10 min. Computed tomography revealed pneumoencephalus, and Gd-enhanced magnetic resonance imaging revealed edema, enhancement of the overlying dura in the left partial lobe, and subdural and subarachnoidal empyema. Following removal of the halo vest, there was a purulent discharge from the left-posterior pin site. Culture of the discharge was positive for MRSA. The patient was treated with intravenous vancomycin for 2 weeks, followed by cefozopran hydrochloride for 4 weeks. Her symptoms improved, and additional surgery was not required. At latest follow-up, 10 years after the seizure, she is neurologically stable without any recurrence of the infection.

STUDY DESIGN Retrospective analysis of factors related to kidney-type interbody spacer subsidence (SS) in transforaminal interbody fusion (TLIF). OBJECTIVE To determine the risk factors for SS in TLIF using kidney-type spacers. SUMMARY OF BACKGROUND DATA SS into the vertebral body, a major complication of TLIF, has not been studied extensively. METHODS Between July 2004 and May 2006, 54 consecutive patients with lumbar dysplastic changes or degenerative disc diseases underwent TLIF using 82 kidney-type spacers with iliac bone grafts. All were followed-up for more than 2 years (mean, 2 y, 11 mo). SS was defined as disc height loss >2 mm. Risk factors analyzed for SS included spacer location in the intervertebral space (IVS, anterior, center, and posterior), sex, age, body mass index, and disease (spondylolisthesis, degenerative disc disease). Clinical outcomes were assessed using the Japanese Orthopedic Associated Score for back pain, as were adjacent segment disorder and nonunion. RESULTS Of the 82 spacers, 66 were located in the center of the IVS and 16 anteriorly. There were 18 SS. Spacer position at the center of the IVS (P

Meningeal melanocytoma is a rare benign tumor of the central nervous system (CNS) that develops in the cranial and spinal leptomeninges. Symptomatic subarachnoid hemorrhage associated with this tumor has been rarely reported. We describe a patient with a sudden onset of paraplegia due to a subarachnoid hemorrhage associated with an intradural extramedullary meningeal melanocytoma. As both the meningeal melanocytoma and hematoma in the subacute phase are black in color, their co-occurrence was difficult to distinguish in the surgical field. Following a subtotal resection, there has been no evidence of local recurrence after one year, although careful follow-up with radiation therapy is essential. Clinicians should be aware of meningeal melanocytoma as an intradural neoplasm.

Study Design. Comparison of magnetic resonance imaging (MRI) and computed tomography-myelography (CTM) for cervical intracanalar dimensions. Objective. To compare the capability and reproducibility of MRI and CTM in measuring the cross-sectional morphology of intracanalar lesions of the cervical spine. Summary of Background Data. The relative advantages and disadvantages of MRI and CTM in measuring cervical intracanalar dimensions are poorly understood. Methods. MRI and CTM were used to measure cervical disc levels in 45 subjects with various cervical spinal diseases. Measurements included dural area, dural anteroposterior (A-P) diameter, dural right-left (RL) diameter, cord area, cord anteroposterior (A-P) diameter, cord right-left (RL) diameter and cerebrospinal fluid (CSF) space (anterior and posterior). Each section was graded by 2 orthopedic surgeons for degree of stenosis (Grades, 0-3), and the intra- and interobserver reproducibility of these measurements (intraclass correlation coefficients: ICC) was assessed. Results. In both CTM and MRI, intra- and interobserver reproducibility (ICC) ranged from 0.702 to 0.989, suggesting that both imaging methods are reproducible. Importantly, CTM measurements of dural area, dural A-P diameter, dural RL diameter, and CSF space (anterior and posterior) were slightly, but significantly (P < 0.001), larger than MRI measurements. In contrast, MRI measurements of cord area, cord A-P diameter, and cord RL diameter were slightly, but significantly (P < 0.001), larger than CTM measurements. Degree of stenosis was significantly more severe in MRI than in CTM. Conclusion. Both CTM and MRI provided reproducible measurements of cervical intracanalar dimensions. Measurements of dura were slightly larger in CTM, whereas measurements of spinal cord were slightly larger in MRI, making stenosis more severe in MRI than in CTM. The clinical relevance of these slight differences requires further examination.

Retrospective analyses of six cases. To describe six patients with previous failed laminoplasty who were subsequently managed by anterior cervical decompression and fusion (ACDF) using fibular strut as revision surgeries. While several complications and unsatisfactory results of cervical laminoplasty have been reported, there is no general consensus on how to best surgically treat these pathological conditions. Six patients, who had been treated by laminoplasty for cervical spondylotic myelopathy (n = 2) or ossification of posterior longitudinal ligament (OPLL, n = 4) and had unfavorable outcomes, underwent ACDF using autogenous fibular strut grafts. The pathological factors associated with the poor outcomes were intraforaminal spur, slip, spondylotic change, disc herniation, and increase of OPLL in size. Clinical outcomes were assessed by evaluating the modified Japanese Orthopedic Association score (JOA score) of cervical myelopathy, severity of radicular pains, axial pains, and perioperative complications. In addition, C2–7 angle and the presence of bony union were analyzed. The revision ACDF significantly increased the mean ± SD. JOA score, from 10.3 ± 3.9 to 13.5 ± 2.7 points (p = 0.028), with a recovery rate of 47.1 ± 26.7%. Radicular pain and axial pain also improved. C2–7 angle was not changed significantly. Solid fusion was achieved in all patients at 12.2 ± 4.2 months after revision surgery. ACDF with fibular strut graft was effective as a revision procedure for failed laminoplasty.

The number of participants in thoracic or abdominal examinations using multi-detector-row CT (MDCT) has been increasing recently. If the degree of progress of osteoporosis can be estimated using these images, it may be useful as it will allow predictions of vertebral fractures without an additional radiation exposure. The aims of this study were to investigate segmental variations in bone mineral density (BMD) distributions of thoracic and lumbar vertebral bodies and to show specific differences according to age and gender. A large database including 1,031 Japanese subjects for whom MDCT was used to examine various organs and tissues was utilized in this study for trabecular BMD at thoracic and lumbar vertebrae. In relationship to vertebral level, L3 had the lowest trabecular BMD. BMD tended to gradually increase from L3 to T1 in all age categories. Also, there was a moderate correlation between vertebrae whose distance from each other was great whereas there was a high correlation between adjacent vertebrae. It may be appropriate to use an arbitrary vertebra as a first approximation for assessing vertebrae that are in the area of predilection for the fracture; however, to better understand their behavior, it may be necessary to measure BMD directly in this region. This study showed trabecular BMD distribution at healthy thoracic and lumbar vertebrae in Japanese subjects and specific differences in age and gender. Improved knowledge about vertebral BMD may help with the diagnosis of primary osteoporosis using MDCT.

Study design Retrospective study of clinical outcomes of 1-staged combined cervical and lumbar decompression for patients with tandem spinal stenosis (TSS). Objective To describe middle-term clinical outcomes of this procedure. Summary and background data Little is known with regard to the clinical outcomes of 1-staged combined cervical and lumbar decompression for TSS. Method Surgical intervention, perioperative complications, and clinical outcomes were reviewed in 17 TSS patients who underwent 1-staged combined cervical and lumbar decompression and were followed-up for more than 3 years. Clinical symptoms were evaluated using the Japan Orthopaedic Association Score for back pain (JOA-B) and cervical myelopathy (JOA-C) and activity of daily life, before surgery, at 6 months postoperatively, and at final follow-up. Patient satisfaction was determined at final follow-up. Results The JOA-B, JOA-C scores, and activities of daily life improved significantly 6 months after surgery, but ultimately deteriorated. At 6 months, the improvement ratios in JOA-B and JOA-C scores were positively correlated. Complications involving other parts of the body significantly influenced clinical deterioration. Twelve patients (71%) were satisfied. Conclusions One-staged combined cervical and lumbar decompression for TSS provided fair results, even for elderly patients. Although reasons other than spinal pathology affected symptom deterioration at final follow-up, most patients expressed satisfaction at middle-term follow-up periods.

Although cervical anterior osteophytes accompanying diffuse idiopathic skeletal hyperostosis (DISH) are generally asymptomatic, large osteophytes sometimes cause swallowing disorders. Surgical resection of the osteophyte has been reported to be an effective treatment; however, little study has been given to the recurrences of osteophytes. A prospective study was performed for seven patients who underwent surgical resection of cervical anterior osteophytes for the treatment of recalcitrant dysphagia caused by osteophytes that accompanied DISH. The seven patients were six men and one woman ranging in age from 55 to 78 years (mean age = 65 years). After a mean postoperative follow-up period of 9 years (range: 6–13 years), surgical outcomes were evaluated by symptom severity and plain radiographs of the cervical spine. On all operated intervertebral segments, the effect of postoperative intervertebral mobility (range of movement >1 degree) on the incidence of recurrent osteophytic formation (width >2 mm) was analyzed by Fisher’s exact test. Complete relief of the dysphagia was obtained within one month postoperatively in five patients, while it was delayed for 3 months in two patients. All of the patients developed recurrent cervical osteophytic formation, with an average increase rate of approximately 1 mm/year following surgical resection. Of the 20 operated intervertebral segments, the incidence of recurrent osteophytes was significantly higher (P = 0.0013) in the 16 segments with mobility than in the four segments without mobility. Five of the seven patients remained asymptomatic, although radiological recurrence of osteophytes was seen at the final follow-up. The two remaining patients complained of moderate dysphagia 10 and 11 years after surgery, respectively; one of these two required re-operation due to progressive dysphagia 11 years postoperatively. In patients with cervical DISH and dysphagia, surgical resection of osteophytes resulted in a high likelihood of the recurrence of osteophytes. Therefore, attending surgeons should continue to follow these patients postoperatively for more than 10 years in order to assess the regrowth of osteophytes that may contribute to recurrent symptoms.

Study Design. A case report describing thoracic intervertebral disc degeneration and spondylolisthesis associated with a Schmorl node in a young athlete, which was successfully treated by anterior interbody fusion (AIF). Objective. To describe a rare pathologic condition with a clinical outcome of a surgical intervention. Summary of Background Data. Intervertebral degeneration and spondylolisthesis of the lower thoracic spine associated with a Schmorl node in a young athlete has not been reported. Methods. A 19-year-old male amateur soccer player presented with severe back pain during motion. This pain was associated with intervertebral disc degeneration, spondylolisthesis, and a Schmorl node at the Th11/12 level. He was surgically treated by AIF. Results. The AIF resulted in a solid fusion, an improvement in sagittal alignment, and amelioration of symptoms. Conclusion. The AIF procedure was effective for lower thoracic symptomatic intervertebral disc degeneration and spondylolisthesis associated with a Schmorl node.

Background Several mechanisms of how abdominal belts affect the trunk have been postulated, but very little is known about how the belts affect the cross-sectional shape of the trunk during trunk muscle exertions. Methods To evaluate the effects of abdominal belts on the cross-sectional shape of the trunk during contraction of the trunk muscles, CT images at the third lumbar vertebra level of 20 healthy males (age: 23–45 years) under 8 different conditions (combinations of performing or not performing the Valsalva maneuver after full inhalation or at neutral respiratory state, while wearing or not wearing a 100-mm-wide abdominal belt) were evaluated. The cross-sectional shapes of the trunk seen on CT images taken at the level of the 3rd lumbar vertebra were compared using three-way ANOVA. Findings Wearing the belt decreased the cross-sectional area of the trunk, and wearing it while performing the Valsalva maneuver and during inhalation compressed the postero-lateral part of the trunk and made the trunk nearly round by increasing the ratio of the anterior–posterior width to the right–left width. Interpretation A wide belt cinched around the abdomen exerts external hoop tension on the trunk and stiffens the trunk. When the belt is worn during the Valsalva maneuver after deep inhalation, the posterolateral portion of the trunk is compressed and the trunk becomes circular.

Spinal injuries resulting from entering into water usually occur in the cervical region, with few reported in the thoracolumbar region. Although the mechanism of cervical spine injury caused by diving is known, less is known regarding the mechanism of upper lumbar spine injury.The study subjects were five patients (mean age, 32.8 years), inexperienced in diving from heights, who were referred for burst fractures (Denis type B) at L1 caused while jumping into a river from a 12-m-high bridge between 2004 and 2005. Three patients were treated surgically and two were treated conservatively. Their clinical outcomes were reviewed and the mechanism of upper lumbar spine injury was discussed.No patient experienced neurological deficit or low back pain after treatment, and all returned to their previous activities within 1 year. Impact with the surface of the river with back and hip flexed may be a major cause of upper lumbar spine injury.To minimize the incidence of upper lumbar burst fracture during recreational high jumping into water, it is important that jumpers, especially inexperienced jumpers, should be instructed to jump with their backs and hips straight.

STUDY DESIGN A case report of atypical mycobacterial spinal osteomyelitis. OBJECTIVE To describe a rare case of spinal osteomyelitis and associated thoracolumbar kyphoscoliosis caused by atypical mycobacteria, and successful treatment by a 2-stage surgical intervention. SUMMARY OF BACKGROUND DATA Vertebral osteomyelitis caused by atypical mycobacteria is very rare. METHODS The patient was an 18-year-old woman with vertebral osteomyelitis of Th12-L1 caused by Mycobacterium avium complex. Plain radiographs revealed vertebral collapse of Th12, scoliosis, and kyphosis. RESULTS Two-stage surgical treatment (first: posterior instrumentation; second: anterior debridement and bone graft) was performed. At 5 years after surgery, the patient is almost free of the preoperative symptoms with no evidence of disease recrudescence. Plain radiograph film demonstrated amelioration of scoliosis and kyphosis, and consolidation of the anterior bone graft. CONCLUSION A rare case of intractable spinal osteomyelitis due to atypical mycobacteria in a nonimmunocompromised patient was treated successfully with 2-stage surgical treatment.

Spinal shortening is indicated for osteoporotic vertebral collapse. However, this surgical procedure has not been indicated for more than two vertebral levels that are not adjacent. We experienced a rare case of paraparesis due to osteoporotic vertebral collapse of two vertebral bodies with a normal vertebra in between and treated successfully by the double-level posterior shortening procedure.A 79-year-old woman suffered from delayed paraparesis 2 years after L1 and Th11 vertebral body compression fracture. Plain X-ray photographs showed Th11 and L1 vertebral body collapse, Th7 compression fracture and a kyphosis angle of 30 degrees from Th10 to L2. Plain magnetic resonance imaging showed spinal canal stenosis at Th11 and L1 vertebral body levels. She was treated by double-level posterior spinal shortening using pedicle screw and hook systems.After the procedure, the patient's kyphosis angle decreased to 10 degrees and her back pain, leg pain, and sensory deficits improved. She was able to walk by herself. Although new vertebral compression fractures occurred at L4 and L5 in the follow-up period, there has been no deterioration of the neurological symptoms 5 years after the operation.Delayed paraparesis after double-level thoracolumbar vertebral collapse due to osteoporosis was treated successfully by double-level posterior spinal shortening using a pedicle screw and hook system.

A case of combined epiconus and cauda equina syndrome due to multilevel spinal canal stenosis of the thoracolumbar spine is reported. A 76-year-old man with multilevel spinal canal stenosis of the thoracolumbar spine (Th11–12, L2–S) who showed symptoms of epiconus syndrome was reported. First, we performed anterior decompression and fusion at the thoracolumbar junction (decompression: Th11–12, fusion: Th10–L2), which ameliorated his symptom partially. However, he presented cauda equina symptoms. Then, he underwent posterior spinal decompression (L3–5) and fusion (Th12–L5). After anterior decompression, several symptoms disappeared. However, motor and sensory disturbance below L4 and bladder–bowel disturbance remained. We then performed a secondary operation. At three years’ follow-up, he was able to walk with the aid of a cane. Combined epiconus and cauda equina syndrome due to multilevel spinal canal stenosis was treated by combined two-stage anterior and posterior decompression. In this case, multilevel decompression via anterior and posterior approaches was necessary to relieve the symptoms.

Recently, solitary fibrous tumors occurring in spine-related lesions have been reported. However, the destruction of vertebral bodies by this type of tumor has not been reported. A 71-year-old female presented with pain from a mass on the right side of her neck. Plain radiographs of the cervical spine showed collapse of the C5 vertebral body and dislocation of the C4 vertebral body. The MRI image showed a large mass surrounding C4 and C5, which had low signal intensity in the T1W image and high signal intensity in the T2W image. At first, resection of the tumor and spinal fusion was performed by anterior approach. Histology revealed a solitary fibrous tumor with proliferating spindle cells. Immunohistochemistry showed positive stains for vimentin and CD34. One year postoperatively, a local recurrence manifested extensive destruction of the C4 and C5 vertebral bodies. Then, palliative surgery with posterior cervical instrumentation and radiation therapy were performed. Because the destruction proceeded and the rods were broken 2 years after, she underwent additional occipito-cervical instrumentation. This is the first report of a solitary fibrous tumor that involves the destruction of the spinal structure. An extensive destruction of the vertebral body by the solitary fibrous tumor needs to be aware in treating this tumor with spinal involvement.

We report the case of a 7-year-old boy with thoracolumbar scoliosis and central core disease who had a history of malignant hyperthermia. He had scoliosis with Cobb's angle deteriorating to 67 degrees (thoracic) and 59 degrees (lumbar). A provocation test of general anesthesia was performed to confirm no hyperthermic reaction. Then, he underwent surgical correction by a posterior approach. The thoracic curve was reduced to 38 degrees and the lumbar curve to 42 degrees . He has been followed up for 2 years without any complications. This is the first report with a detailed description of perioperative management on surgical treatment of scoliosis associated with central core disease.

Study design The axonal growth potential of dorsal root ganglion (DRG) neurons in an organ culture system was investigated. Objective To examine the effects of neuronal injury and tumor necrosis factor-alpha (TNF-alpha) on the axonal growth potential of 2 types of nociceptive DRG neurons: nerve growth factor (NGF)-sensitive and glial cell line-derived neurotrophic factor (GDNF)-sensitive neurons. Summary of background data Nerve ingrowth into the disc is recognized to be one of the causes of discogenic pain. Almost all of these disc-innervating neurons are NGF-sensitive. The axonal growth potential of NGF-sensitive neurons has not been investigated. Methods Adult Sprague-Dawley rats were used for immunohistochemistry (n = 7) and cell viability studies (n = 6). Bilateral L3-L5 DRGs, which were successfully removed without damage, were noncultured or cultured in serum-free medium containing TNF-alpha at 0, 0.01, 0.1, and 1 ng/mL for 48 hours (n = 5, each treatment). The DRGs were then immunostained for activating transcription factor 3 (ATF3, a marker for injured neurons) or double-stained for growth-associated protein 43 (GAP-43, a marker for axonal growth) with calcitonin gene-related peptide (CGRP, a marker for NGF-sensitive neurons) or isolectin B4 (IB4, a marker for GDNF-sensitive neurons). Cell viability was assessed by a lactate dehydrogenase (LDH) assay and an MTS assay (n = 6, each treatment). Results Immunoreactive evidence of injured neurons (ATF3 positive) was frequently observed in cultured DRGs, but never in noncultured DRGs. The percentage of neurons exhibiting axonal growth potential (GAP-43 immunoreactive) was significantly higher for NGF-sensitive neurons than for GDNF-sensitive neurons at any concentration of TNF-alpha. More than 95% of the cultured neurons were viable. Conclusions The results suggest that the cultured DRG neurons exhibit pathologic changes similar to those found in injured neurons. NGF-sensitive neurons, which include disc-innervating neurons, may have a greater potential to extend their axons in response to neuronal injury under pathologic conditions in the presence of TNF-alpha than GDNF-sensitive neurons.

STUDY DESIGN This is a report of a 12-year-old girl treated surgically for scoliosis associated with bilateral hip dislocation in Larsen syndrome. OBJECTIVE To describe a rare case of scoliosis associated with Larsen syndrome and bilateral hip dislocation that was treated surgically with follow-up for 15 years. SUMMARY OF BACKGROUND DATA There are few reports of the long-term follow-up of cases involving surgically treated scoliosis associated with bilaterally dislocated hips. METHODS The patient's spine showed a right thoracic curve (T5-T12) with a Cobb angle of 77 degrees and did not show pelvic obliquity on an anterior-posterior radiograph film. On the sagittal alignment of her spine, the thoracic spine showed an abnormal lordosis (T5-T12: 19 degrees), and the lumbar spine had a hyperlordosis (L1-S1: 57 degrees) with a large lumbosacral angle (72 degrees ). We performed a posterior spinal fusion between T4 and L2 using Cotrel-Dubousset Instrumentation, anticipating the restoration of normal lumbar and cervical lordosis, as well as thoracic kyphosis. RESULTS The Cobb angle of thoracic scoliosis improved from 77 degrees to 28 degrees, and a thoracic kyphosis of 12 degrees (T5-T12) was obtained. Subsequently, on the sagittal plane, the lumbosacral angle (sacral anteflexion) decreased from 72 degrees to 52 degrees, comparable to that of patients with hip dislocation, and the lumbar lordotic angle increased from 57 degrees to 66 degrees. The restoration of thoracic kyphosis resulted in an increase of lumbar lordosis and decrease of sacral anteflexion. At the 15-year follow-up,although the thoracic scoliosis (T5-T12) had increased to 36 degrees, good coronal and sagittal balance had been maintained. The patient is asymptomatic in her spine and hip. CONCLUSIONS A case of scoliosis associated with dislocated hips in a patient with Larsen syndrome was successfully treated with posterior correction surgery. Fusion surgery between T4 and L2 provided an ideal sagittal balance of the total spine, while preserving 4 lumbar mobile segments.

STUDY DESIGN An in vivo study on the effects of an agent for scar prevention in a dog laminectomy model. OBJECTIVE To examine the anti-adhesion properties of a thrombin-based hemostatic gelatin (FLOSEAL; Baxter International Inc., Deerfield, IL). SUMMARY OF BACKGROUND DATA Postlaminectomy dural adhesion sometimes causes symptomatic problems. Although a new type of hemostatic agent, a thrombin-based hemostatic gelatin, has been developed, its effect on postlaminectomy scar prevention is unknown. METHODS A 4-level lumbar laminectomy was performed on 11 adult mongrel dogs. There were 2 levels randomly chosen to receive the thrombin-based hemostatic gelatin treatment, while the remaining levels were untreated (control). Dogs were euthanized 8 weeks after surgery. To assess the tenacity of adhesion between the dura and scar, peel-off testing was performed. Gross, biochemical, and histologic analyses were then used to examine the samples. RESULTS Peel-off stiffness was significantly decreased in the treatment group (64.8% of the control, P = 0.032; 2-tailed unpaired t test). Histologically, there was significantly less scar tissue formation in the treatment group (P = 0.04). The gross analyses showed a trend toward a smaller amount of scar tissue and tenacity of adhesion between the dura and scar in the treatment group. Biochemically, there was a trend toward a lower collagen cross-links content in the treatment group (P = 0.07). CONCLUSIONS The thrombin-based hemostatic gelatin decreases the tenacity of adhesion between the dura and scar at laminectomy sites.

Report of seven cases. There is no general consensus on the best surgical procedures for late-onset complications of cervical operations. We reported seven patients who had been treated effectively by multilevel anterior corpectomy and fusion (ACF) as revision surgery of the cervical spine. Gifu University Hospital, Gifu, Japan. Multilevel ACF using autogenous fibular strut graft as revision surgery was performed on seven patients: four patients having disorders of adjacent discs after anterior discectomy and fusion and three patients having postlaminoplasty disorders. Japanese Orthopedic Association scores (JOA scores) of the cervical myelopathy and severity of radicular and axial pains were used to evaluate outcomes. Rigid osseous fusion was achieved in all patients. JOA scores of the cervical myelopathy and the radicular pain, which had worsened just before the revision surgery, were improved significantly. In the present seven patients who had variety of pathological conditions with various previous surgeries, multilevel ACF using strut graft was effective as a revision procedure in ameliorating their symptoms.

Although posterior lumbar interbody fusion (PLIF) for degenerative lumbar diseases is routine, there are few reports on double-level PLIF.To evaluate the clinical outcomes of double-level PLIF.A retrospective study of operated cases in Gifu, Japan.Nineteen patients (8 men and 11 women, 59.5+/-10.2 years) who underwent double-level PLIF between 1996 and 2001.Operation time, blood loss, complications, the Japanese Orthopaedic Association (JOA) score for back pain and lumbar sagittal alignment were evaluated.Patients were examined retrospectively at follow-ups of 3.6+/-1.7 years. Primary diseases were spondylolisthesis, spinal canal stenosis, degenerative scoliosis and herniated intervertebral disc. Fusion areas were L3 to L5 in 15 cases and L4 to S1 in 4 cases.The mean JOA score increased from an initial score of 12.9+/-3.5 to 21.3+/-4.9 at the final follow-up. There was a positive correlation (R=0.718, p.001) between the increase in lordotic angle and the increase in the JOA score. Several parameters suggested that the surgical invasiveness was not minimal.Double-level PLIF provided satisfactory results and preserved lumbar spine lordosis.

STUDY DESIGN In vitro study on the effects of pulsed low intensity ultrasound on the cellular metabolism of bovine intervertebral disc cells. OBJECTIVE To determine whether pulsed low intensity ultrasound has effects on cell proliferation and extracellular matrix metabolism by bovine intervertebral disc cells. SUMMARY OF BACKGROUND DATA The application of pulsed low intensity ultrasound is known to be effective in stimulating fracture and cartilage repair. However, the effects of pulsed low intensity ultrasound on intervertebral disc cells are not known. METHODS Cells of the nucleus pulposus and inner and outer anulus fibrosus were enzymatically isolated from bovine coccygeal tissue and precultured in alginate beads for 14 days. In the ultrasound group, pulsed low intensity ultrasound was administered to the culture for 20 minutes daily for an additional 20 days. The control group was cultured in the same way but without administration of ultrasound. Cell viability, DNA content, proteoglycan and collagen synthesis, and proteoglycan content at days 10 and 20 after the initiation of treatment were evaluated. Characterization of newly synthesized collagen and proteoglycan was performed. RESULTS No significant differences in cell viability and DNA content were observed between the two groups. On day 20, proteoglycan synthesis was increased by the application of pulsed low intensity ultrasound in nucleus pulposus and inner and outer anulus fibrosus cells (24%-26% increase, P < 0.001). The application of pulsed low intensity ultrasound increased proteoglycan content in alginate beads containing inner and outer anulus fibrosus cells (P < 0.05). Collagen synthesis by cells isolated from all three zones of the intervertebral disc was increased by the application of pulsed low intensity ultrasound (16%-19% increase, P < 0.05-0.0001). CONCLUSIONS The application of pulsed low intensity ultrasound stimulated extracellular matrix metabolism in intervertebral disc cells. Pulsed low intensity ultrasound may prove useful for the physical stimulation of cell metabolism for tissue engineering of intervertebral disc tissue.

Background context A case of spondyloepiphyseal dysplasia congenita (SEDC) with thoracolumbar kyphosing scoliosis and a clinical outcome of the patient's surgical treatment are reported. Purpose We report a rare case and the effect of surgical treatment on the kyphosing scoliosis with SEDC with a review of literature. Study design/setting SEDC is a rare disease and has a variety of spinal deformities. To our knowledge, a case of surgical treatment for the kyphosing scoliosis with SEDC was not reported before. Methods The patient, a 27-year-old woman, complained of severe back pain and dyspnea. She was operated on in 1997 for severe kyphosing scoliosis, using segmental spinal instrumentation and strut bypass graft. She was followed for 6 years, and clinical symptoms and plain X-ray films were investigated. Results Her kyphosis was corrected from 116 degrees to 86 degrees at the final follow-up; otherwise, her scoliosis was almost unchanged. Her symptoms were relieved. Conclusions A case of SEDC with thoracolumbar kyphosing scoliosis was successfully treated by segmental spinal instrumentation and anterior strut bypass graft.

Multiple thoracic disc herniations are rare and there are few reports in the literature. Between December 1998 and July 2002, we operated on 12 patients with multiple thoracic disc herniations. All underwent an anterior decompression and fusion through a transthoracic approach. The clinical outcomes were assessed using the Frankel neurological classification and the Japanese Orthopaedic Association (JOA) score. Under the Frankel classification, two patients improved by two grades (C to E), one patient improved by one grade (C to D), while nine patients who had been classified as grade D did not change. The JOA scores improved significantly after surgery with a mean recovery rate of 44.8% ± 24.5%. Overall, clinical outcomes were excellent in two patients, good in two, fair in six and unchanged in two. Our results indicate that anterior decompression and fusion for multiple thoracic disc herniations through a transthoracic approach can provide satisfactory results.

The purpose of this randomized controlled study was to elucidate effects of music listening on postoperative pain and/or stress in elderly orthopaedic patients. Forty–four patients over 60 years old participated in this study. Patients were randomly assigned to a music listening group (group M) and a control group (group C). The patients in group M were given a choice of listening to either Western classical music, Gagaku, Noh songs, or Enka, and listened to music for 20 minutes in private rooms. Effects on pain were evaluated using a Visual Analogue Scale (VAS) and the Wong/Baker Faces Scale (FS). As indicators of stress, systolic and diastolic blood pressure, heart rate, and skin temperature and blood flow at the finger tip were measured. In group M, both VAS and FS decreased significantly (p < 0.01) after 10 (VAS: decrease to 79.1%; FS: decrease to 77.6%) and 20 minutes (VAS: decrease to 59.1%; FS: decrease to 53.6%) of music listening, whereas there was no effect on the autonomic nervous system measur...

Case report of a severe upper cervical cord compression and tetraparesis by a massive cervical exostotic osteochondroma in a patient with multiple exostoses–mental retardation syndrome (Langer–Giedion syndrome; LGS). To describe this very rare pathological condition and the results of surgical intervention. Gifu, Japan. A 23-year-old man was referred to our clinic because of progressing tetraparesis. He had previously been diagnosed with hereditary multiple exostoses and mental retardation. As he had not complained of any symptoms, his family only noticed the tetraparesis after advanced deterioration. His face possessed the pathognomic features of LGS. A postmyelogram CT scan demonstrated an exostotic mass arising from the left-side C2 pedicle with associated severe spinal cord compression. He was diagnosed with LGS. Hemilaminectomy on the left side and resection of the osteochondroma were performed. At 5 years postoperatively, a neurological examination showed the full return of all motor functions. The CT scan revealed no intracanalar recurrence of the tumor. In this case of severe tetraparesis due to cervical osteochondroma, decompression by hemilaminectomy provided excellent results. In patients with LGS and intracanalar osteochondroma, the neurological deficit may be masked by mental retardation. Hence, awareness of this pathological condition will help clinicians diagnose it at an early stage.

We report a case of an 80-year-old woman with dropped head syndrome associated with cervical spondylotic myelopathy. She could not keep her cervical spine in a neutral position for >1 minute. She had a disturbed gait and severe kyphotic deformity in her thoracic spine. Magnetic resonance imaging revealed severe compression of the spinal cord due to cervical spondylotic change. Laminoplasty from C2 through C6 levels was performed. One year after operation, she could keep her cervical spine in a neutral position easily. Her gait was also improved. The symptoms did not recur during 4 years of follow-up. We surmise that to maintain daily activities, she had to extend her cervical spine owing to the thoracic kyphotic deformity, resulting in compression of the spinal cord. The compression led to weakening of the cervical extensor muscles. Cervical laminoplasty was effective.

STUDY DESIGN An observational study of the changes in thickness of the erector spinae (ES) muscle in three different trunk postures. OBJECTIVE To use ultrasonography to evaluate the thickness of the ES muscle in three different trunk postures. BACKGROUND Although there has been extensive study of the morphology of the ES muscle during prolonged trunk flexion, we have little information about the changes in thickness of these muscles in various postures of the lumbar spine. Ultrasonography has never been used to measure the thickness of ES muscle. METHODS We studied 30 volunteers with no history of lower back problems. We used ultrasonography to measure the thickness of the ES muscle at each lumbar level (L1, L2, L3, L4, and L5) in maximum flexion, neutral posture, and maximum extension. We tested the reliability of this method by evaluating intraobserver and interobserver differences in 13 subjects. RESULT The high correlation between intraobserver and interobserver measurements in the 13 subjects demonstrated that the method provides sufficient reproducibility. When the trunk was flexed maximally, the thickness of the ES muscle was significantly decreased at each lumbar vertebral level. When the trunk was extended maximally, the thickness of the ES muscle was significantly increased at each lumbar vertebral level. CONCLUSION The thickness of the ES muscle decreases as the lumbar spine flexes and increases as it extends. We used ultrasonography successfully for quantitative evaluation of changes in thickness of the ES muscle with postural changes in the lumbar spine.

✓ The authors discuss the cases of three patients in whom thoracic paraplegia developed after lumbar spinal decompressive surgery for slight lumbar spinal canal stenosis. Careful computerized tomography myelography and magnetic resonance imaging examination of the thoracic spine revealed another compressive lesion (spinal cord tumor, disc herniation, osteophyte of vertebral body, and ossification of the ligamentum flavum). Additional thoracic decompressive surgery provided partial amelioration of each patient's neurological condition. The authors suggest that to avoid such a complication physical and radiographic examination of the thoracic spine should be performed preoperatively if the lumbar imaging is inconclusive.

The surgical outcomes of 1 3 patients who were diagnosed wirh cervical spondylotic myelopathy were reviewed retrospectively. Mean patient age at surgery was 83 years. The severity of cervical spondylotic myelopathy was evaluated using the Japanese Orthopaedic Association score. Daily activities were evaluated using the Barthel index. The preoperative JOA score and Barthel index were 7.8 and 63.5, respectively. The mean JOA score and Barthel index maximum recovery rate were 35% and 24%, respectively. The results of this study imply that surgery for patients with cervical spondylotic myelopathy aged >80 years is warranted.

Study design This study focused on the effects of leg length discrepancy on the motion of the normal spine during gait in healthy male volunteers who wore a heel-raising orthotic device on the right foot. Objective To evaluate the effect of leg length discrepancy on the changes in curvature of the normal spine during gait. Summary of background data There are few published data on the effects of leg length discrepancy on the motion of the normal spine during gait. Methods An orthotic device that raised the heel by 3 cm was used to simulate leg length discrepancy. Twenty-two healthy male volunteers participated (age: 28.2 +/- 6.1 years, average +/- SD). The dynamic curvatures of the spine under two conditions (without and with a heel-raising orthotic device; normal gait and heel-raising gait) were evaluated during gait. The leg length discrepancy values without and with the device were measured and analyzed using a VICON system (Oxford Metrics, United Kingdom). Results The spine showed an asymmetrical lateral-bending motion during heel-raising gait as compensation for the leg length discrepancy. Maximum lateral bending angle of the thoracic spine was 4.2 +/- 1.4 degrees in heel-raising gait, whereas it was 3.0 +/- 1.0 degrees in normal gait. Maximum lateral bending angle of the lumbar spine was 8.1 +/- 2.8 degrees in heel-raising gait, whereas it was 6.1 +/- 2.1 degrees in normal gait. The maximum bending angle and bending velocity were significantly larger in the heel-raising gait than in normal gait. Conclusion Patients who have leg length discrepancy due to disorders in the lower extremities are at greater risk of developing disabling spinal disorders due to exaggerated degenerative change. Therefore, treatment for leg length discrepancy may be helpful in preventing degenerative spinal changes.

Study design A retrospective analysis was performed of the clinical outcomes of patients with pyogenic or tuberculotic spondylitis who were treated with two-stage surgery (first stage: placement of posterior instrumentation; second stage: anterior debridement and bone grafting). Objective To evaluate the clinical outcomes of the abovementioned two-stage surgical treatment for pyogenic or tuberculotic spondylitis. Summary of background data Although several methods of surgical treatment for pyogenic and tuberculotic spondylitis have been reported, there have been few reports of two-stage surgical treatment. Methods Eight patients (7 male, 1 female) with pyogenic or tuberculotic spondylitis (pyogenic: 6; tuberculotic: 2) were treated by two-stage surgery (first: placement of posterior instrumentation, second: anterior debridement and bone graft). Age at the time of surgery was 63.5 +/- 9.91 years (average +/- SD) (range: 47 to 77 years). Most of the patients had systemic problems, such as pneumonia, diabetes mellitus, or chronic renal failure. First, posterior spinal instrumentation was placed. Then, anterior debridement and bone grafting were performed. Patients were evaluated before and after surgery in terms of pain level, hematologic parameters, neurologic status, and Barthel index. Results Average duration of surgery for both procedures was less than 4 hours. Changes in the pain level, blood parameters, and Barthel index demonstrated significant clinical improvement in all patients. Posterior wound infection occurred in two patients who were in poor general condition. Conclusions This two-stage surgical treatment for pyogenic or tuberculotic spondylitis provided satisfactory results and can also be used in patients who are in poor general condition.

STUDY DESIGN A 9-year-old boy with severe myelomeningocele kyphosis was treated by kyphectomy using a surgical threadwire. OBJECTIVE To describe a new method of kyphectomy for severe kyphotic deformity in a child with myelomeningocele using a surgical threadwire. SUMMARY OF BACKGROUND DATA Although several methods of kyphectomy for severe kyphotic deformity in children with myelomeningocele have been reported, few of these methods allow preservation of the nonfunctioning dural sac and cerebrospinal fluid flow, with the aim of reducing complications. METHODS The preoperative kyphotic angle was 113 degrees. There was repeated skin ulceration over the apex of the kyphos. Kyphectomy at the Th12 to L3 vertebral levels was performed using a surgical threadwire (T-saw, developed by Tomita and colleagues in 1996), preserving the entire dural sac. RESULTS The T-saw allowed anterior dissection of the dural sac over the length of the planned resection, thus preserving cerebrospinal fluid flow throughout the entire subarachnoid space. The kyphotic angle was decreased to 10 degrees after the operation, and the postoperative clinical course was uneventful. At the 2-year follow-up assessment, the kyphotic angle was 10 degrees according to plain radiograph. At this writing, the boy is able to maintain a sitting position without any difficulty. CONCLUSIONS For this child with myelomeningocele, kyphectomy using a surgical threadwire (T-saw) provided a satisfactory result without any major complication.

We report a case of atlantoaxial vertical subluxation with mandibular micrognathia associated with juvenile rheumatoid arthritis. The patient was treated by odontoidectomy via the transoral approach and required a sagittal split mandibular osteotomy because of the mandibular micrognathia. The clinical outcome was excellent.