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9. Effect of Early vs Delayed Surgical Treatment on Motor Recovery in Incomplete Cervical Spinal Cord Injury With Preexisting Cervical Stenosis

Author

Chikuda, Hirotaka, Koyama, Yurie, Matsubayashi, Yoshitaka, Ogata, Toru, Ohtsu, Hiroshi, Sugita, Shurei, Sumitani, Masahiko, Kadono, Yuho, Miura, Toshiki, Tanaka, Sakae, Akiyama, Toru, Ando, Kei, Anno, Masato, Azuma, Seiichi, Endo, Kenji, Endo, Toru, Fujiyoshi, Takayuki, Furuya, Takeo, Hayashi, Hiroyuki, Higashikawa, Akiro, Hiyama, Akihiko, Horii, Chiaki, Iimoto, Seiji, Iizuka, Yoichi, Ikuma, Hisanori, Imagama, Shiro, Inokuchi, Koichi, Inoue, Hirokazu, Inoue, Tomoo, Ishii, Keisuke, Ishii, Masayoshi, Ito, Takui, Itoi, Akira, Iwamoto, Kohei, Iwasaki, Motoki, Kaito, Takashi, Kato, Tsuyoshi, Katoh, Hiroyuki, Kawaguchi, Yoshiharu, Kawano, Osamu, Kimura, Atsushi, Kobayashi, Kazuyoshi, Koda, Masao, Komatsu, Miki, Kumagai, Gentaro, Maeda, Takeshi, Makino, Takahiro, Mannoji, Chikato, Masuda, Kazuhiro, Masuda, Keisuke, Matsumoto, Koji, Matsumoto, Morio, Matsunaga, Shunji, Matsuyama, Yukihiro, Mieda, Tokue, Miyoshi, Kota, Mochida, Joji, Moridaira, Hiroshi, Motegi, Hiroyuki, Nakagawa, Yukihiro, Nohara, Yutaka, Oae, Kazunori, Ogawa, Shinji, Okazaki, Rentaro, Okuda, Akinori, Onishi, Eijiro, Ono, Atsushi, Oshima, Masashi, Oshita, Yusuke, Saita, Kazuo, Sasao, Yutaka, Sato, Kimiaki, Sawakami, Kimihiko, Seichi, Atsushi, Seki, Shoji, Shigematsu, Hideki, Suda, Kota, Takagi, Yasutaka, Takahashi, Masahito, Takahashi, Ryosuke, Takasawa, Eiji, Takenaka, Shota, Takeshita, Katsushi, Takeshita, Yujiro, Tokioka, Takamitsu, Tokuhashi, Yasuaki, Tonosu, Juichi, Uei, Hiroshi, Wada, Kanichiro, Watanabe, Masahiko, Yahata, Tadashi, Yamada, Kei, Yasuda, Taketoshi, Yasui, Keigo, and Yoshii, Toshitaka

Subjects
Online Only, Neurology, Research, Original Investigation
Abstract

Key Points Question Does early surgical treatment yield better motor recovery than delayed surgical treatment for patients with preexisting cervical canal stenosis sustaining acute traumatic spinal cord injury? Findings In this randomized clinical trial that included 72 patients with motor-incomplete cervical spinal cord injury, there was no statistically significant difference between groups in mean improvement in American Spinal Injury Association motor score, total score in the spinal cord independence measure, or patients’ ability to walk at 1 year. Early surgical treatment was associated with higher motor scores than delayed surgical treatment in the first 6 months. Meaning These findings suggest that among patients with motor-incomplete cervical spinal cord injury, early surgical treatment did not significantly improve motor recovery at 1 year compared with delayed surgical treatment but showed accelerated recovery., This randomized clinical trial assesses motor recovery outcomes in early vs delayed surgical treatment for patients with acute traumatic incomplete cervical spinal cord injury associated with preexisting canal stenosis., Importance The optimal management for acute traumatic cervical spinal cord injury (SCI) is unknown. Objective To determine whether early surgical decompression results in better motor recovery than delayed surgical treatment in patients with acute traumatic incomplete cervical SCI associated with preexisting canal stenosis but without bone injury. Design, Setting, and Participants This multicenter randomized clinical trial was conducted in 43 tertiary referral centers in Japan from December 2011 through November 2019. Patients aged 20 to 79 years with motor-incomplete cervical SCI with preexisting canal stenosis (American Spinal Injury Association [ASIA] Impairment Scale C; without fracture or dislocation) were included. Data were analyzed from September to November 2020. Interventions Patients were randomized to undergo surgical treatment within 24 hours after admission or delayed surgical treatment after at least 2 weeks of conservative treatment. Main Outcomes and Measures The primary end points were improvement in the mean ASIA motor score, total score of the spinal cord independence measure, and the proportion of patients able to walk independently at 1 year after injury. Results Among 72 randomized patients, 70 patients (mean [SD] age, 65.1 [9.4] years; age range, 41-79 years; 5 [7%] women and 65 [93%] men) were included in the full analysis population (37 patients assigned to early surgical treatment and 33 patients assigned to delayed surgical treatment). Of these, 56 patients (80%) had data available for at least 1 primary outcome at 1 year. There was no significant difference among primary end points for the early surgical treatment group compared with the delayed surgical treatment group (mean [SD] change in ASIA motor score, 53.7 [14.7] vs 48.5 [19.1]; difference, 5.2; 95% CI, −4.2 to 14.5; P = .27; mean [SD] SCIM total score, 77.9 [22.7] vs 71.3 [27.3]; P = .34; able to walk independently, 21 of 30 patients [70.0%] vs 16 of 26 patients [61.5%]; P = .51). A mixed-design analysis of variance revealed a significant difference in the mean change in ASIA motor scores between the groups (F1,49 = 4.80; P = .03). The early surgical treatment group, compared with the delayed surgical treatment group, had greater motor scores than the delayed surgical treatment group at 2 weeks (mean [SD] score, 34.2 [18.8] vs 18.9 [20.9]), 3 months (mean [SD] score, 49.1 [15.1] vs 37.2 [20.9]), and 6 months (mean [SD] score, 51.5 [13.9] vs 41.3 [23.4]) after injury. Adverse events were common in both groups (eg, worsening of paralysis, 6 patients vs 6 patients; death, 3 patients vs 3 patients). Conclusions and Relevance These findings suggest that among patients with cervical SCI, early surgical treatment produced similar motor regain at 1 year after injury as delayed surgical treatment but showed accelerated recovery within the first 6 months. These exploratory results suggest that early surgical treatment leads to faster neurological recovery, which requires further validation. Trial Registration ClinicalTrials.gov Identifier: NCT01485458; umin.ac.jp/ctr Identifier: UMIN000006780

Published
2021

13. The usefulness and safety of the simultaneous parallel anterior and posterior combined lumbar spine surgery using intraoperative 3D fluoroscopy-based navigation (SPAPS)

Author

Ikuma, Hisanori, Hirose, Tomohiko, Takao, Shinichiro, Otsuka, Kazutoshi, Kawasaki, Keisuke, Ikuma, Hisanori, Hirose, Tomohiko, Takao, Shinichiro, Otsuka, Kazutoshi, and Kawasaki, Keisuke

Abstract

Background The combined anterior-posterior surgery in the lateral decubitus position generally needs the intraoperative repositioning. However, prolonged surgical time and increased medical costs due to intraoperative repositioning have been problematic. In recent years, there have been reports of combined anterior-posterior procedure with a single position performing anterior and posterior fixation consecutively where the patient remains in the lateral decubitus position (single surgeon method-SS method). We had further advanced this method, and have adopted the Simultaneous Parallel Anterior and Posterior combined lumbar spine Surgery using intraoperative 3D fluoroscopy-based navigation (SPAPS method), where anterior and posterior procedure are performed independently by two spine surgeons. Methods 66 cases that underwent SPAPS method (n=37) and SS method (n=29) from 2015 to 2019 at single institution were concluded in this study. The pre- and post-operative changes in the following were compared retrospectively between the two groups: surgical factors and clinical evaluations including JOA back pain evaluation questionnaire (JOABPEQ), visual analogue scale (VAS) on lower back pain, buttock/lower limb pain, and buttock/lower limb numbness, and Roland-Morris disability questionnaire (RDQ). Results The SPAPS method was able to significantly reduce the surgical time (p=0.0025) compared to the SS method, and allowed a reduction of approximately 24.4 minutes per segment. The estimated blood loss were similar in both groups, and with regards to post-operative outcomes, both groups improved equally well. The rates of screw deviation and fusion were also similar. Conclusions In the case of performing the combined anterior-posterior surgery under a single position, the anterior and posterior procedure can be performed independently and simultaneously by two spine surgeons by utilizing the 3D fluoroscopy-based navigation. The surgical ti

Published
2021

17. Radiation Exposure to the Hand of a Spinal Interventionalist during Fluoroscopically Guided Procedures

Author

Yamashita, Kazuta, Ikuma, Hisanori, Tokashiki, Takuya, Maehara, Takashi, Nagamachi, Akihiro, Takata, Yoichiro, Sakai, Toshinori, Higashino, Kosaku, Sairyo, Koichi, Yamashita, Kazuta, Ikuma, Hisanori, Tokashiki, Takuya, Maehara, Takashi, Nagamachi, Akihiro, Takata, Yoichiro, Sakai, Toshinori, Higashino, Kosaku, and Sairyo, Koichi

Abstract

Study Design: Prospective study. Purpose: During fluoroscopically guided spinal procedure, the hands of spinal surgeons are placed close to the field of radiation and may be exposed to ionizing radiation. This study directly measured the radiation exposure to the hand of a spinal interventionalist during fluoroscopically guided procedures. Overview of Literature: Fluoroscopically guided spinal procedures have been reported to be a cause for concern due to the radiation exposure to which their operators are exposed. Methods: This prospective study evaluated the radiation exposure of the hand of one spinal interventionalist during 52 consecutive fluoroscopic spinal procedures over a 3-month period. The interventionalist wore three real-time dosimeters secured to the right forearm, under the lead apron over the chest, and outside the lead apron over the chest. Additionally, one radiophotoluminescence glass dosimeter was placed under the lead apron over the left chest and one ring radiophotoluminescence glass dosimeter was worn on the right thumb. The duration of exposure and radiation dose were measured for each procedure. Results: The average radiation exposure dose per procedure was 14.9 µSv, 125.6 µSv, and 200.1 µSv, inside the lead apron over the chest, outside the lead apron over the chest, and on the right forearm, respectively. Over the 3-month period, the protected radiophotoluminescence glass dosimeter over the left chest recorded less than the minimum reportable dose, whereas the radiophotoluminescence glass ring dosimeter recorded 368 mSv for the thumb. Conclusions: Our findings indicated that the cumulative radiation dose measured at the dominant hand may exceed the annual dose limit specified by the International Commission on Radiological Protection. Spinal interventionalists should take special care to limit the duration of fluoroscopy and radiation exposure.

Published
2017

21. Dominant vertebral artery injury during posterior atlantoaxial transarticular screw fixation in a juvenile rheumatoid arthritis patient with atlantoaxial subluxation

Author

Zhang, Wei, Tanaka, Masato, Sugimoto, Yoshihisa, Ikuma, Hisanori, Nakanishi, Kazuo, and Misawa, Haruo

Subjects
rheumatoid arthritis, Adult, Atlanto-Axial Joint, atlantoaxial subluxation, Bone Screws, vertebral artery injury, Joint Dislocations, Humans, Female, Arthritis, Juvenile, Vertebral Artery, transarticular screw
Abstract

Many authors have reported on iatrogenic vertebral artery (VA) injury, but, to our knowledge, this is the first report of a dominant VA injury with compensatory blood flow from the hypoplastic VA. A 23-year-old woman with juvenile rheumatoid arthritis and atlantoaxial subluxation sustained injury to her dominant VA after occipitocervical fusion using transarticular screws. This did not result in lethal consequences due to compensation from her hypoplastic contralateral VA. Postoperative angiography, however, illustrated occlusion of the dominant left side, while the hypoplastic VA of the right side was enlarged. The patient experienced vertigo and loss of consciousness several times during rehabilitation. At the 4-year follow-up exam, bony fusion was observed, with no neurological deficits or correction loss. She had had no episodes of unconsciousness and no recurrence of any symptoms over the previous 3 years.

Published
2012

23. Surgical results of sacral perineural (Tarlov) cysts

Author

Tanaka, Masato, Nakahara, Shinnosuke, Ito, Yauo, Nakanishi, Kazuo, Sugimoto, Yoshihisa, Ikuma, Hisanori, and Ozaki, Toshifumi

Subjects
meningeal cyst, Adult, Male, Sacrum, sacral radiculopathy, sacral perineural cyst, meningeal diverticulum, Middle Aged, Magnetic Resonance Imaging, Tarlov cyst, Tarlov Cysts, Treatment Outcome, Humans, Female, Tomography, X-Ray Computed, Myelography, Aged, Retrospective Studies
Abstract

The purpose of this study was to investigate the surgical outcomes and to determine indicators of the necessity of surgical intervention. Twelve consecutive patients harboring symptomatic sacral perineural cysts were treated between 1995 and 2003. All patients were assessed for neurological deficits and pain by neurological examination. Magnetic resonance of imaging, computerized tomography, and myelography were performed to detect signs of delayed filling of the cysts. We performed a release of the valve and imbrication of the sacral cysts with laminectomies in 8 cases or recapping laminectomies in 4 cases. After surgery, symptoms improved in 10 (83%) of 12 patients, with an average follow-up of 27 months. Ten patients had sacral perineural cysts with signs of positive filling defect. Two (17%) of 12 patients experienced no significant improvement. In one of these patients, the filling defect was negative. In conclusion, a positive filling defect may become an indicator of good treatment outcomes.

Published
2006

28. The impact of the lateral decubitus position in the perioperative period on posterior fixation for thoracolumbar fracture with ankylosing spinal disorder.

Author

Ikuma H, Hirose T, Takao S, Ueda M, Yamashita K, Otsuka K, and Kawasaki K

Abstract

Objective: Patients with ankylosing spinal disorders (ASDs), such as ankylosing spondylitis and diffuse idiopathic skeletal hyperostosis, often have rigid kyphosis of the spine. The fracture site is sometimes unintentionally displaced when surgery is conducted with the patient prone. To prevent this incident, the authors adopted the lateral decubitus position for patients intraoperatively for this pathology. The aim of this study was to retrospectively assess the impact of the lateral decubitus position in the perioperative period on posterior fixation for thoracolumbar fractures with ASD., Methods: Thirty-seven consecutive patients who underwent posterior instrumentation for thoracolumbar fracture with ASD at the authors' institute were divided into 15 lateral decubitus positions (group L) and 22 prone positions (group P). Surgical time, estimated blood loss (EBL), number of levels fused, perioperative complications, length of stay (LOS), ratio of fracture voids, and ratio of anterior wall height were investigated. The ratio of fracture void and the ratio of anterior wall height were the radiological assessments showing a degree of reduction in vertebral fracture on CT., Results: Age, sex, BMI, fracture level, and LOS were similar between the groups. Levels fused and EBL were significantly shorter and less in group L (p < 0.001 and p = 0.04), but there was no significant difference in surgical time. The complication rate was similar, but 1 death within 90 days after surgery was found in group P. The ratio of fracture voids was 85.4% ± 12.8% for group L and 117.5% ± 37.3% for group P. A significantly larger number of patients with a fracture void ratio of 100% or less was found in group L (86.7% vs 36.4%, p = 0.002). The ratio of anterior wall height was 107.5% ± 12.3% for group L and 116.9% ± 18.8% for group P. A significantly larger number of patients with the anterior wall height ratio of 100% or less was also found in group L (60.0% vs 27.3%, p = 0.046)., Conclusions: The results of this study suggest that the lateral decubitus position can be expected to have an effect on closing or maintaining the fracture void or a preventive effect of intraoperative unintentional extension displacement of the fractured site, which is often seen in the prone position during surgery for thoracolumbar fractures involving ASD.

Published
2021
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29. The usefulness and safety of the simultaneous parallel anterior and posterior combined lumbar spine surgery using intraoperative 3D fluoroscopy-based navigation (SPAPS).

Author

Ikuma H, Hirose T, Takao S, Otsuka K, and Kawasaki K

Abstract

Background: The combined anterior-posterior surgery in the lateral decubitus position generally needs the intraoperative repositioning. However, prolonged surgical time and increased medical costs due to intraoperative repositioning have been problematic. In recent years, there have been reports of combined anterior-posterior procedure with a single position performing anterior and posterior fixation consecutively where the patient remains in the lateral decubitus position (single surgeon method-SS method). We had further advanced this method, and have adopted the S imultaneous P arallel A nterior and P osterior combined lumbar spine S urgery using intraoperative 3D fluoroscopy-based navigation (SPAPS method), where anterior and posterior procedure are performed independently by two spine surgeons., Methods: 66 cases that underwent SPAPS method (n=37) and SS method (n=29) from 2015 to 2019 at single institution were concluded in this study. The pre- and post-operative changes in the following were compared retrospectively between the two groups: surgical factors and clinical evaluations including JOA back pain evaluation questionnaire (JOABPEQ), visual analogue scale (VAS) on lower back pain, buttock/lower limb pain, and buttock/lower limb numbness, and Roland-Morris disability questionnaire (RDQ)., Results: The SPAPS method was able to significantly reduce the surgical time (p=0.0025) compared to the SS method, and allowed a reduction of approximately 24.4 minutes per segment. The estimated blood loss were similar in both groups, and with regards to post-operative outcomes, both groups improved equally well. The rates of screw deviation and fusion were also similar., Conclusions: In the case of performing the combined anterior-posterior surgery under a single position, the anterior and posterior procedure can be performed independently and simultaneously by two spine surgeons by utilizing the 3D fluoroscopy-based navigation. The surgical time can be significantly reduced by approximately 24.4 minutes per segment comparing to the SS method., Competing Interests: For all authors, there are no conflicts of interest to declare., (© 2020 The Authors. Published by Elsevier Ltd on behalf of North American Spine Society.)

Published
2020
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30. Novel magnetic resonance imaging evaluation for valgus instability of the knee caused by medial collateral ligament injury.

Author

Ikuma H, Abe N, Uchida Y, Furumatsu T, Fujiwara K, Nishida K, and Ozaki T

Subjects
Adolescent, Adult, Female, Humans, Joint Instability classification, Male, Middle Aged, Severity of Illness Index, Joint Instability pathology, Magnetic Resonance Imaging methods, Medial Collateral Ligament, Knee injuries
Abstract

Instability of the knee after the medial collateral ligament (MCL) injury is usually assessed with the manual valgus stress test, even though, in recent years, it has become possible to apply magnetic resonance imaging (MRI) to the assessment of the damage of the ligament. The valgus instability of 24 patients (12 isolated injuries and 12 multiple ligament injuries) who suffered MCL injury between 1993 and 1998 was evaluated with the Hughston and Eilers classification, which involves radiographic assessment under manual valgus stress to the injured knees. We developed a novel system for classifying the degree of injury to the MCL by calculating the percentage of injured area based on MRI and investigated the relationship between this novel MRI classification and the magnitude of valgus instability by the Hughston and Eilers classification. There was a significant correlation between the 2 classifications (p=0.0006). On the other hand, the results using other MRI based classification systems, such as the Mink and Deutsch classification and the Petermann classification, were not correlated with the findings by the Hughston and Eilers classification in these cases (p0.05). Since MRI is capable of assessing the injured ligament in clinical practice, this novel classification system would be useful for evaluating the stability of the knee and choosing an appropriate treatment following MCL injury.

Published
2008
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