阿部 幸喜

Cerebellar hemorrhage remote from the site of surgery can complicate neurosurgical procedures. However, this complication after lumbar surgery is rare. Furthermore, hemorrhage in both the cerebellum and the temporal lobe after spine surgery is rarer still. Herein we present a case of remote hemorrhage in both the cerebellum and the temporal lobe after lumbar spine surgery. A 79-year-old woman with a Schwannoma at the L4 level presented with low back and bilateral leg pain refractory to conservative management. Surgery was undertaken to remove the Schwannoma and to perform posterior fusion. During the surgery, the dura mater was removed in order to excise the Schwannoma. Reconstruction of the dura mater was performed; postoperatively the patient had a cerebrospinal fluid leak. Five days after surgery, clouding of consciousness started gradually, and hemorrhage in the cerebellum and the temporal lobe was revealed by computed tomography. Emergent evacuation of the hemorrhage was performed and the patient recovered consciousness after the surgery. Leakage of cerebrospinal fluid may have induced this hemorrhage. While rare, intracranial hemorrhage after spine surgery can occur, sometimes requiring emergent intervention.

Extreme lateral interbody fusion (XLIF) has been widely used for minimally invasive anterior lumbar interbody fusion (ALIF), but an approach to L5-S1 is difficult because of the iliac crest. In the current study, we present 2 cases using minimally invasive oblique lateral interbody fusion (OLIF) of L5-S1. The patients showed foraminal stenosis between L5 and S1 and severe low back and leg pain. The patients were placed in a lateral decubitus position and underwent OLIF surgery (using a cage and bone graft from the iliac crest) without posterior decompression. Posterior screws were used in the patients. Pain scores significantly improved after surgery. There was no spinal nerve, major vessel, peritoneal, or urinary injury. OLIF surgery was minimally invasive and produced good surgical results without complications.

Background: Many patients with intravertebral vacuum cleft after osteoporotic vertebral fracture have persistent back pain, but few reports examine the course for intravertebral vacuum cleft with conservative treatment. We studied risk factors for persistent back pain and persistent pseudarthrosis based on radiographic findings. Methods: Sixty-two patients with intravertebral vacuum cleft after osteoporotic vertebral fractures, suffering from P4 or P5 back pain on the Denis pain scale, were analyzed. We obtained data on age, sex, cause of fracture, levels of fractured vertebrae, neurological findings, and neutral lateral, supine lateral, and standing or sitting lateral radiographs. After conservative treatment between 4 and 12 months, we reviewed the radiographs and pain levels. The effect of each parameter on persistent pain and pseudarthrosis were evaluated using multiple logistic regression analysis. Results: On final examination, 20 patients still had severe pain (pain scale: P4, P5) and 42 had pain that was not severe (pain scale: P1, P2, P3), 46 had pseudarthrosis, and 16 had union. Differences in the wedge rate of the vertebral body between the supine lateral and standing/sitting lateral radiographs and neurologic deficits significantly affected pain levels. The odds ratios for the two parameters were 1.05 and 29.91, respectively. Twenty-six of 46 patients with persistent pseudarthrosis did not have severe pain on final examination. Conclusions: Severe back pain decreased in more than two-thirds of patients with conservative treatment. Early surgical treatment is recommended for patients with an intravertebral vacuum cleft with over 35% difference in wedge rate or with neurologic deficits. © 2013 Wolters Kluwer Health.

A woman with rheumatoid arthritis (RA) experienced glottic stenosis approximately two months after switching from etanercept to tocilizumab. Cricoarytenoid joint (CAJ) arthritis due to RA was diagnosed. An awake tracheostomy saved the relievable airway, and the administration of methylprednisolone and infliximab ameliorated the flare-up and glottic stenosis. A follow-up examination revealed the recovery of the patient's normal voice and good control of RA with infliximab and methotrexate. Although general physicians do not frequently encounter patients with symptomatic CAJ arthritis, this condition should be considered as it can be life-threatening. Therefore, when detected, it should be diagnosed and treated immediately.

A 68-year-old man with a 3-year history of rheumatoid arthritis (RA) developed gynecomastia 3 months after beginning oral low-dose methotrexate (MTX) therapy. Four months after MTX therapy was discontinued, the gynecomastia symptoms improved. Only eight cases of gynecomastia resulting from low-dose MTX administration have been reported worldwide, and no cases have previously been reported in Japan. Although it occurs infrequently, gynecomastia resulting from low-dose MTX therapy should be considered in male patients with RA.