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This study is the first attempt to examine anatomical characteristics using three-dimensional computed tomography (3DCT) bone images with some parameters, in order to achieve correct and uncomplicated accesses. In addition, the study addresses a long-standing problem in the field and evaluates whether the trigonum sacrale forms an equilateral triangle or not. A detailed anatomic study of the sacral region was carried out on 91 patient 3DCT images. The CT data, in DICOM format, was read into VINCENT software from Fuji Film, with a slice thickness of 0.5 mm. The average length of sacral hiatus was 28.6 ± 8.4 (range 13.8-45.2 mm). The average width of sacral hiatus at the level of sacral cornua was 10.9 ± 2.7 (range 3.8-16.5 mm). The ratio between the length of the oblique and base line formed by the sacral triangle was 0.81 ± 0.12 (range 0.54-1.00). Using 3DCT images translated by the volume rendering technique, we can remove soft tissue from bones virtually. A slice thickness of 0.5 mm makes it a fine image, and permits meticulous measurement, which is different from previous cadaveric studies. Interestingly, our data showed that the ratio between oblique and base line on sacral triangle was 1.0, average 0.81. Findings demonstrated that the trigonum sacrale is not an equilateral triangle. This is useful information for the identification of the sacral hiatus when the landmark-based technique is employed.

The authors reported a 58-year-old male who suffered from severe low back pain due to kyphoscoliosis associated with congenital contractural arachnodactyly (CCA), a subset of Marfan syndrome. Posterior spinal corrective fusion surgery from T8 to the pelvis with pedicle subtraction osteotomy at L4 was conducted. Because of long upper extremities due to CCA, we had no choice but to keep his shoulders abducted 90°, horizontal flexed 30°, and elbow flexed 120° with the conventional arm table during the surgery. Immediately after the surgery, he complained of numbness on the lateral aspect of his right forearm, difficulty of elbow flexion, and supination. Postoperative upper arm magnetic resonance imaging revealed evidence of coracobrachialis, brachialis, and biceps brachii myositis resulted from denervation by musculocutaneous nerve. We diagnosed his symptoms as postoperative isolated musculocutaneous neuropathy (MCNP) based on physical and radiological findings. Weakness and numbness began to be resolved 1.5 months after the surgery. Active motion of the elbow started to recover two months after the surgery and completely recovered six months postoperatively. The potential cause of our patient’s pathology was regarded to be intraoperative malposition of the abnormal long arms. In conclusion, we reported a case of isolated MCNP after thoracolumbar spine surgery under prone position, which is extremely rare and not well known among surgeons. Therefore, spine surgeons should take care of arm position and joint angle even though prone surgery to prevent MCNP, particularly in the patient with long arm span because of Marfanoid.

Study Design Clinical and basic study. Objectives This study aimed to investigate whether transforaminal lumbar interbody fusion (TLIF) using 2 banana-shaped cages leads to good clinical outcomes. Methods First, we conducted a clinical study to compare outcomes among patients who underwent TLIF using different types or numbers of cages. Propensity matched patients in each group were reviewed. Thirty-four patients who underwent surgery with 2 bullet-shaped cages (group A), 34 with a banana-shaped cage (group B), and 34 with 2 banana-shaped cages (group C) were compared. Twelve months after the surgery, bony fusion and cage subsidence were evaluated. Results The mean amount of cage subsidence was 14.9% in group A, 19.9% in group B, and 11.8% in group C. Subsidence in group B was significantly greater than that in group C ( P < .01). Radiological bony fusion was not achieved in 2 cases in group B. Second, we performed a finite element model (FEM) analysis to determine the biomechanical stress of the vertebral endplate by comparing the single-banana cage construct with a double banana-shaped cage construct. FEM analysis showed that the maximum stress of the endplate in the single-cage model was 1.72-times greater than the maximum stress in the double-cage model. Furthermore, the maximal stress in the single-cage model was significantly higher than in the double-cage model during lumbar extension and side bending. Conclusion This study showed that TLIF with double banana-shaped cages led to good clinical outcomes with less cage subsidence, probably because of decreased mechanical stress on the vertebral endplate.

We report a rare case of a rigid spinal deformity with severe pelvic obliquity (PO) resulting from hip ankylosis caused by childhood tuberculosis (TB). A 66-year-old woman presented with left knee pain, chronic low back pain, and fatigability during walking. She presented with leg length discrepancy (LLD) due to an ankylosed right hip joint, severe PO, and secondary lumbar scoliosis. Total hip arthroplasty (THA) and adductor tendonectomy were performed prior to spine surgery, and posterior spinal correction and fusion were performed from T10 to the pelvis. Prior to spinal correction surgery, we predicted that it would be impossible to make the pelvis perfectly horizontal. Therefore, we positioned a prosthetic acetabular cup at a small inclination angle at the upper limit of anteversion; spinal correction and fusion were then performed. Her symptoms including fatigability during walking resolved and the sagittal spinal balance on standing improved dramatically. The preoperative and postoperative values of the thoracolumbar Cobb angle was 40° and 25°, lumbosacral Cobb angle was 60° and 14°, C7 plumb line shift was 24 and 0 mm, pelvic tilt was 15° and 19°, lumbar lordosis (LL) was 23° and 60°, pelvic incidence minus lumbar lordosis (PI-LL) was 38° and 1°, the sagittal vertical axis was 80 and 0 mm, and PO was 28° and 15°, respectively. We present a case of rigid spinal deformity accompanied by hip joint ankylosis and PO. Performing THA prior to spinal correction surgery is an alternative and feasible option for the treatment of this challenging pathology.

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.

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

Osteoid osteoma occasionally occur in the spine, but their malignant transformation is not common. We present an extremely rare case of the malignant transformation of an osteoid osteoma to high-grade osteosarcoma that formed in the pedicle and spread to the lateral mass of the cervical spine.We report the case of an 18-year-old man who suffered from neck pain as an initial symptom. The size of the radiolucent lesion was 12 mm in diameter at the time of diagnosis. Intralesional tumour resection and autologous bone grafting were performed. The remaining tumour grew gradually for 40 months after the surgery; therefore, the tumour had grown rapidly till 51 months after the initial diagnosis. At this stage, the tumour size was approximately 6-fold larger than the initial size, and resulted in progressive paraplegia. A biopsy revealed that the tumour had transformed into a high-grade osteosarcoma. Heavy charged particle irradiation was performed to control tumour growth.There is a possibility of malignant transformation of osteoid osteoma. Patients with osteoid osteoma or osteoblastoma should be carefully observed, especially for recurrent tumours after an intralesional resection.

Background Traumatic occipitocervical dislocation (OCD) occurs due to fatal high-energy injury. Modern screw-based constructs enable successful reduction and stabilisation. In view of this, there are no previous reports on the spontaneous remodelling of the O-C1 joint after posterior fusion. We report the first case of postoperative spontaneous remodelling and stabilisation of the O-C1 joint after traumatic OCD. Case description: A 9-year-old girl suffered from traumatic OCD, accompanied by complete rupture of the O-C1-C2 ligamentous complex. Halo-vest fixation, and subsequently posterior fusion surgery from the occipital bone to C2, with autologous iliac crest bone graft and an allograft were performed. However, we could not achieve complete reduction of the O-C1 joint during surgery owing to extremely severe instability. Postoperative X-ray and computed tomography scan showed incomplete reduction of the O-C1 joint. Insufficient congruity of the O-C1 joint persisted. Afterwards, gradual spontaneous remodelling of the O-C1 joint occurred, both anteriorly and posteriorly 3 months postoperatively. Solid union was achieved 6 months postoperatively. Two years later, bilateral O-C1 joints in the patient were completely reformed and restabilised by incredible vigorous remodelling. Insufficient reduction and persisting poor joint congruence after surgery for OCD was probably restabilised by further spontaneous remodelling of articular morphology in such a young patient. Conclusions Postoperative spontaneous remodelling of the O-C1 joint after posterior reconstruction for OCD may occur in young patients. Incomplete reduction of the O-C1 joint during surgery may be acceptable due to the possibility of postoperative bone remodelling and restabilisation.

Sagittal lumbar apex has been demonstrated to be a key parameter in sagittal plane morphology. Our aim was to understand its behavior with postural changes, analyzing two different concepts of lumbar apex. Prospective observational study with a cohort of patients presenting sagittal malalignment identified from a monocenter database of adult spinal deformities (ASD). Inclusion criteria were age > 30 years, SVA > 40 mm, and/or PT > 20. All patients had full-spine EOS radiographs in 2 different positions: (P1: natural position) and position 2 (P2: compensated position). Sagittal alignment, spinopelvic values, and two different methods of assessing lordosis apex location were analyzed in both P1 and P2 positions. Changes between P1 and P2 were compared using a paired t test with a significance level at p

Attenuation of the secondary injury of spinal cord injury (SCI) can suppress the spread of spinal cord tissue damage, possibly resulting in spinal cord sparing that can improve functional prognoses. Granulocyte colony-stimulating factor (G-CSF) is a haematological cytokine commonly used to treat neutropenia. Previous reports have shown that G-CSF promotes functional recovery in rodent models of SCI. Based on preclinical results, we conducted early phase clinical trials, showing safety/feasibility and suggestive efficacy. These lines of evidence demonstrate that G-CSF might have therapeutic benefits for acute SCI in humans. To confirm this efficacy and to obtain strong evidence for pharmaceutical approval of G-CSF therapy for SCI, we conducted a phase 3 clinical trial designed as a prospective, randomized, double-blinded and placebo-controlled comparative trial. The current trial included cervical SCI [severity of American Spinal Injury Association (ASIA) Impairment Scale (AIS) B or C] within 48 h after injury. Patients are randomly assigned to G-CSF and placebo groups. The G-CSF group was administered 400 μg/m2/day × 5 days of G-CSF in normal saline via intravenous infusion for five consecutive days. The placebo group was similarly administered a placebo. Allocation was concealed between blinded evaluators of efficacy/safety and those for laboratory data, as G-CSF markedly increases white blood cell counts that can reveal patient treatment. Efficacy and safety were evaluated by blinded observer. Our primary end point was changes in ASIA motor scores from baseline to 3 months after drug administration. Each group includes 44 patients (88 total patients). Our protocol was approved by the Pharmaceuticals and Medical Device Agency in Japan and this trial is funded by the Center for Clinical Trials, Japan Medical Association. There was no significant difference in the primary end point between the G-CSF and the placebo control groups. In contrast, one of the secondary end points showed that the ASIA motor score 6 months (P = 0.062) and 1 year (P = 0.073) after drug administration tend to be higher in the G-CSF group compared with the placebo control group. Moreover, in patients aged over 65 years old, motor recovery 6 months after drug administration showed a strong trend towards a better recovery in the G-CSF treated group (P = 0.056) compared with the control group. The present trial failed to show a significant effect of G-CSF in primary end point although the subanalyses of the present trial suggested potential G-CSF benefits for specific population., Koda et al. present the results of a randomized phase 3 trial comparing granulocyte colony-stimulating factor versus placebo in patients with acute spinal cord injury. While the primary endpoint was not met, a sub-analysis revealed a trend towards superior efficacy of G-CSF versus placebo in an elderly population.

Background Neurogenic acute respiratory failure is usually caused by either infection or vascular insufficiency. We report the case of a patient who developed acute respiratory failure secondary to a spinal tumor. Case Presentation A 32‐year‐old man, presenting with numbness and muscle weakness in his legs for 2 weeks, was transferred to our hospital with worsening quadriplegia and development of respiratory symptoms. We carried out emergent spinal decompression and initiated steroid pulse therapy, with no resolution of symptoms; a tumor incision biopsy after contrast cervical magnetic resonance imaging revealed an intraspinal tumor with a pathological diagnosis of World Health Organization grade IV glioma. The patient developed bradycardia, severe sepsis, status epilepticus, and cardiopulmonary arrest due to hypoxemia and was treated with chemoradiotherapy under mechanical ventilation. He was later transferred to another hospital for subacute care. Conclusion Acute respiratory failure caused by spinal tumors is uncommon. However, acute care practitioners should be mindful of neoplastic lesions as a potential cause., Neurogenic acute respiratory failure caused by spinal tumors is uncommon. However, acute care practitioners should be mindful of neoplastic lesions as a potential cause.

To report a patient with bilateral vocal cord palsy following cervical laminoplasty, who survived following a tracheotomy and intensive respiratory care. Acute respiratory distress is a fatal complication of cervical spinal surgery. The incidence of bilateral vocal cord palsy after posterior cervical decompression surgery is extremely rare. The authors report a 71-year-old woman who suffered from cervical myelopathy due to ossification of the posterior longitudinal ligament. Open-door laminoplasty from C2 to C6 and laminectomy of C1 were performed. Following surgery, extubation was successfully conducted. Acute-onset dysphagia and stridor had occurred 2 h following extubation. A postoperative fiber optic laryngoscope revealed bilateral vocal cord palsy. After a tracheotomy and intensive respiratory care, she had completely recovered 2 months after surgery. One potential cause of this pathology was an intraoperative hyper-flexed neck position, which likely induced mechanical impingement of the larynx, resulting in swelling and edema of the vocal cords and recurrent laryngeal nerve paresis. Direct trauma of the vocal cords during intubation and extubation could have also induced vocal cord paralysis. We reported a case of bilateral vocal cord palsy associated with posterior cervical laminoplasty. Airway complications following posterior spinal surgery are rare, but they do occur; therefore, spine surgeons should be aware of them and take necessary precautions against intraoperative neck position, intubation technique, even positioning of the intratracheal tube.

STUDY DESIGN Retrospective study. OBJECTIVE To analyze the clinical outcomes of anterior and posterior spinal fusion (APSF) using a fibular strut autograft (FSAG) and to investigate the morphological changes in the reconstructed spinal column of dystrophic deformities in neurofibromatosis (NF)-1. SUMMARY OF BACKGROUND DATA APSF is desirable for dystrophic deformities in NF-1 with more than 50° of dystrophic kyphosis. There are few reports regarding the clinical outcomes of APSF in which the morphological changes over time of the anterior strut graft have been investigated. METHODS The clinical and radiographic outcomes of APSF with FSAG were investigated in 10 consecutive patients with dystrophic deformity in NF-1. For qualitative and quantitative analyses, the chronological changes in the FSAG configuration, length, and diameter were evaluated. RESULTS The mean follow-up period was 9 years, 9 months (range, 1-30 years). Graft bone erosion and postoperative curve progression were not observed in any patient. In quantitative analyses of the anterior strut, the mean ratio of the latest and immediately postoperative FSAG lengths was 0.98 (0.93-1.09). The mean central/peripheral ratios of the FSAG diameter (central portion/[upper end + lower end]/2) were 1.02 (0.92-1.10) immediately after surgery, and 1.01 (0.92-1.07) at the latest follow-up, with no significant change between these 2 time points (P = 0.937). The mean preoperative cross-sectional area of the apical vertebral body and its mean virtual cross-sectional area at the final follow-up were 3.80 (1.83-5.43) and 4.87 (2.46-7.00) cm(2), respectively, with a significant difference between these 2 parameters (P = 0.0078). The mean final/preoperative ratio was 1.31 (1.10-1.43). CONCLUSION APSF with FSAG for dystrophic deformity in NF-1 successfully reconstructed a reliable spinal column with a rich bone stock. The FSAG and surrounding vertebral bodies were free from postoperative erosion due to dystrophic changes and maintained their stability for a long time.

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.

Introduction Granulocyte colony-stimulating factor (G-CSF) is generally used for neutropaenia. Previous experimental studies revealed that G-CSF promoted neurological recovery after spinal cord injury (SCI). Next, we moved to early phase of clinical trials. In a phase I/IIa trial, no adverse events were observed. Next, we conducted a non-randomised, non-blinded, comparative trial, which suggested the efficacy of G-CSF for promoting neurological recovery. Based on those results, we are now performing a phase III trial. Methods and analysis The objective of this study is to evaluate the efficacy of G-CSF for acute SCI. The study design is a prospective, multicentre, randomised, double-blinded, placebo-controlled comparative study. The current trial includes cervical SCI (severity of American Spinal Injury Association (ASIA) Impairment Scale B/C) within 48 hours after injury. Patients are randomly assigned to G-CSF and placebo groups. The G-CSF group is administered 400 µg/m 2 /day×5 days of G-CSF in normal saline via intravenous infusion for 5 consecutive days. The placebo group is similarly administered a placebo. Our primary endpoint is changes in ASIA motor scores from baseline to 3 months. Each group includes 44 patients (88 total patients). Ethics and dissemination The study will be conducted according to the principles of the World Medical Association Declaration of Helsinki and in accordance with the Japanese Medical Research Involving Human Subjects Act and other guidelines, regulations and Acts. Results of the clinical study will be submitted to the head of the respective clinical study site as a report after conclusion of the clinical study by the sponsor-investigator. Even if the results are not favourable despite conducting the clinical study properly, the data will be published as a paper. Trial registration number UMIN000018752.

A prospective study on the clinical outcomes in patients with tuberculous spondylitis treated by a 2-stage operation (posterior and anterior) using posterior spinal instrumentation.To evaluate the clinical outcomes of the 2-stage surgical treatment (first stage: placement of posterior instrumentation and second stage: anterior debridement and bone grafting) for tuberculous spondylitis.There have been few reports describing the effects of 2-stage surgical treatment for tuberculous spondylitis.Ten patients (5 men and 5 women) with tuberculous spondylitis were treated by 2-stage operations. Age at the initial operation was 64.6+/-14.8 years (average+/-SD) (range: 47 to 83 y). The clinical outcomes were evaluated before and after the surgery in terms of hematologic examination, pain level, and neurologic status. Bone fusion and changes in sagittal alignment were examined radiographically.All patients showed suppression of infection, bony fusion, relief of pain, and recovery of neurologic function. No significant changes were observed in kyphosis angle at the final follow-up. There were no incidences of severe complications or recurrence.Our results showed that posterior and anterior 2-stage surgical treatment for tuberculous spondylitis is a viable surgical option for cases in which conservative treatment has failed. However, the changes in sagittal alignment showed that this strategy provides limited kyphosis correction.