古矢 丈雄

A 60-year-old man presented with thoracic myelopathy due to ossification of the posterior longitudinal ligament (OPLL). His spinal cord was severely impinged anteriorly by a beak-type OPLL and posteriorly by ossification of the ligamentum flavum at T4/5. He underwent surgical posterior decompression with instrumented fusion (PDF). Immediately after surgery, he developed a Brown-Sequard-type paralysis, which spontaneously resolved without requiring the addition of OPLL extirpation. This example highlights that the risk of postoperative neurological deterioration cannot be eliminated even when PDF is selected as the surgical procedure for thoracic OPLL, especially in instances in which the spinal cord is severely compressed. (C) 2010 Elsevier Ltd. All rights reserved.

We evaluated the feasibility and reliability of open source Digital Imaging and COmmunication in Medicine (DICOM) imaging software, OsiriX (Antoine Rosset, 2003-2009), in spine surgery. CT data were used and processed with OsiriX and with commercial software for comparison. Images were reconstructed and compared in volume rendering (VR) and multi-planar reconstruction (MPR) mode. When all images were compared, the three-dimensional (3D) reconstructed images from both software packages showed considerable consistency in VR mode. Measurements in MPR mode also showed similar values with no statistically significant difference. These results demonstrate that OsiriX has approximately equivalent values to commercial software and provides reliable preoperative 3D information for the surgical field. In addition, any clinician, can obtain information using OsiriX at any time. Thus, OsiriX is a helpful tool in preoperative planning for spine surgery. (C) 2009 Elsevier Ltd. All rights reserved.

We evaluated the clinical results of posterior decompression with instrumented fusion (PDF) for thoracic myelopathy due to ossification of the posterior longitudinal ligament (OPLL). A total of 24 patients underwent PDF, and their surgical outcomes were evaluated by the Japanese Orthopaedic Association (JOA) scores (0-11 points) and by recovery rates calculated at 3, 6, 9 and 12 months after surgery and at a mean final follow-up of 4 years and 5 months. The mean JOA score before surgery was 3.7 points. Although transient paralysis occurred immediately after surgery in one patient (3.8%), all patients showed neurological recovery at the final follow-up with a mean JOA score of 8.0 points and a mean recovery rate of 58.1%. The mean recovery rate at 3, 6, 9 and 12 months after surgery was 36.7, 48.8, 54.0 and 56.8%, respectively. The median time point that the JOA score reached its peak value was 9 months after surgery. No patient chose additional anterior decompression surgery via thoracotomy. The present findings demonstrate that despite persistent anterior impingement of the spinal cord by residual OPLL, PDF can result in considerable neurological recovery with a low risk of postoperative paralysis. Since neurological recovery progresses slowly after PDF, we suggest that additional anterior decompression surgery is not desirable during the early stage of recovery.

Study Design. Case report.Objective. To describe the usefulness of simulated surgery for evaluation of a patient with neurofibromatosis type-1 (NF-1) who had severe cervicothoracic kyphoscoliosis and an anomalous vertebral artery (VA).Summary of Background Data. Several surgical procedures have been used in the treatment of cervicothoracic kyphoscoliosis associated with myelopathy in patients with NF-1. However, to our knowledge, there has been no report that describes a surgical procedure for NF-1 patients with anomalous VA at the cervical spine.Methods. A 45-year-old man with NF-1 developed cervical myelopathy. Preoperative examinations revealed severe cervicothoracic kyphoscoliosis, dystrophic changes of the cervical vertebrae, and the anomalous course of a VA and VA aneurysms. To assist in the preoperative planning and intraoperative navigation, we created 3-dimensional (3D) full-scale models of the patient's spine. Using a model, we performed a simulation of the planned surgery for spinal cord decompression with spinal fusion through both anterior and posterior approaches.Results. Through the simulation, we could evaluate the risk of VA injury at the process of corpectomy, and altered the surgical procedure for the spinal cord decompression with spinal fusion from a posterior approach and a bone graft alone from an anterior approach. We accomplished the surgery successfully without any neurovascular complications. After surgery, the patient experienced relief from myelopathy.Conclusion. Preoperative surgical simulation using a 3D full-scale model was useful for improving the accuracy and safety of the surgery for cervicothoracic kyphoscoliosis with NF-1.

Study Design. Case report.Objective. To report a surgically treated case of cervical ossification of the posterior longitudinal ligament (OPLL), in which a spinal subarachnoid hematoma (SSAH) developed intraoperatively but was successfully treated.Summary of Background Data. Previous reports have indicated that trauma, lumbar puncture, vascular lesions such as arteriovenous malformation, neoplastic lesions, and coagulopathy can cause SSAH. To the best of our knowledge, there has been no report that describes the occurrence of SSAH during anterior decompression surgery of the cervical spine.Methods. A 52-year-old man with cervical myelopathy caused by OPLL underwent surgery for anterior decompression from C2/3 to C6/7. Immediately after the OPLL floating procedure, cerebrospinal fluid leakage and massive bleeding occurred at right edge of the OPLL at the C3-C4 level. After hemostasis, the dura mater at the C5-C6 levels bulged rapidly and became cyanotic. Intraoperative ultrasonographic images showed a high-intensity mass lesion on the ventral side of the spinal cord, indicating an intrathecal hematoma.Results. We incised the dura, found the hematoma under the intact arachnoid, and removed it. We then found that the bleeding occurred from the radicular artery along the right C4 root. After hemostasis, we performed anterior spine fusion from C2-C7. After surgery, the patient's myelopathy was improved, and no neurologic deficit related to the subarachnoid hematoma was found.Conclusion. This experience suggests that when anterior decompression surgery is performed for cervical OPLL patients, we should consider the possible occurrence of an SSAH. Intraoperative ultrasonography is a useful tool for detecting SSAHs.

We studied 27 patients with cervical ossification of the posterior longitudinal ligament (OPLL) but no clinical symptoms of myelopathy. We investigated the occupation ratio of the spinal canal by OPLL with cervical radiographs, assessed the morphological types of OPLL, and measured the segmental range of motion (ROM) at the level of maximum cord compression on flexion and extension radiographs. Patients were classified as having continuous-type OPLL (17 patients), mixed-type OPLL (seven patients), or segmental-type OPLL (three patients). The segmental ROM was negatively correlated with the OPLL occupation ratio (r = -0.49, p < 0.01). No patient developed myelopathy during the study period. Three patients with massive OPLL did not develop myelopathy and the mobility of their cervical spine was highly suggesting that dynamic factors such as the segmental ROM preferentially contribute to the restricted, development of myelopathy in patients with cervical OPLL. Thus, by controlling the dynamic factors (hypermobility), we might be able to reduce neurological deterioration in patients with cervical OPLL. (C) 2009 Elsevier Ltd. All rights reserved.

We have started a Phase I and IIa clinical trial to assess the safety and feasibility of neuroprotective therapy using granulocyte colony-stimulating factor (G-CSF) for patients with acute spinal cord injury (SCI). Six patients with acute SCI were received intravenous G-CSF injection (5μg/kg per day) for 5 days. After injection, we had neurological evaluations with American Spinal Cord Injury Association (ASIA) score, and confirmed side effects for medication with physical findings and laboratory data. In all 6 patients, some neurological improvement was obtained after medication. Mean white blood cell (WBC) counts were 25.2 to 38.4 (&amp times 103/μl) 1 days after medication that was higher than previous counts. From 1 day to 5 days after the medication, during the administration, WBC counts kept higher than previous counts, and 1 days after the end of medication, WBC counts returned to the previous rate. No severe adverse effects were seen in all patients after G-CSF injection.

In light of reports that the administration of fasudil, a Rho-kinase inhibitor, improved rats locomotor abilities following spinal cord injury, we hypothesized that combining fasudil with another type of therapy, such as stem cell transplantation, might further improve the level of locomotor recovery. Bone marrow stromal cells (BMSCs) are readily available for stem cell therapy. in the present study, we examined whether fasudil combined with BMSC transplantation would produce synergistic effects on recovery. Adult female Sprague-Dawley rats were subjected to spinal cord contusion injury at the T10 vertebral level using an IH impactor (200 Kdyn). Immediately after contusion, they were administrated fasudil intrathecally for 4 weeks. GFP rat-derived BMSCs (2.5x10(6)) were injected into the lesion site 14 days after contusion. Locomotor recovery was assessed for 9 weeks with BBB scoring. Sensory tests were conducted at 8 weeks. Biotinylated dextran amine (BDA) was injected into the sensory-motor cortex at 9 weeks. In addition to an untreated control group, the study also included a fasudil-only group and a BMSC-only group in order to compare the effects of combined therapy vs. single-agent therapy. Animals were perfused transcardially 11 weeks after contusion, and histological examinations were performed. The combined therapy group showed statistically better locomotor recovery than the untreated control group at 8 and 9 weeks after contusion. Neither of the two single-agent treatments improved open field locomotor function. Sensory tests showed no statistically significant difference by treatment. Histological and immunohistochemical studies provided some supporting evidence for better locomotor recovery following combined therapy. The average area of the cystic cavity was significantly smaller in the fasudil+BMSC group than in the control group. The number of 5-HT nerve fibers was significantly higher in the fasudil+BMSC group than in the control group on the rostral side of the lesion site. BDA-labeled fibers on the caudal side of the lesion epicenter were observed only in the fasudil+BMSC group. on the other hand, only small numbers of GFP-labeled grafted cells remained 9 weeks after transplantation, and these were mainly localized at the site of injection. Double immunofluorescence studies showed no evidence of differentiation of grafted BMSCs into glial cells or neurons. The Rho-kinase inhibitor fasudil combined with BMSC transplantation resulted in better locomotor recovery than occurred in the untreated control group. However, the data failed to demonstrate significant synergism from combined therapy compared with the levels of recovery following single-agent treatment. (C) 2009 Elsevier B.V. All rights reserved.

Study Design. To report a new index, the K-line, for deciding the surgical approach for cervical ossification of the posterior longitudinal ligament (OPLL). Objective. To analyze the correlation between the K-line-based classification of cervical OPLL patients and their surgical outcome. Summary of Background Data. Previous studies showed that kyphotic alignment of the cervical spine and a large OPLL are major factors causing poor surgical outcome after laminoplasty for cervical OPLL patients. However, no report has evaluated these 2 factors in 1 parameter. Methods. The K-line was defined as a line that connects the midpoints of the spinal canal at C2 and C7. Twenty-seven patients who had cervical OPLL and underwent posterior decompression surgery were classified into 2 groups according to their K-line classification. OPLL did not exceed the K-line in the K-line (+) group and did exceed it in the K-line (+) group. By intraoperative ultrasonography, we evaluated the posterior shift of the spinal cord after the posterior decompression procedure. The Japanese Orthopedic Association scores before surgery and 1 year after surgery were evaluated, and the recovery rate was calculated. Results. Eight patients were classified as K-line (+), and 19 patients were classified as K-line (+). The mean recovery rate was 13.9% in the K-line (+) group and 66.0% in the K-line (+) group (P < 0.01). Ultrasonography showed that the posterior shift of the spinal cord was insufficient in the K-line (+) group. Conclusion. The present results demonstrate that a sufficient posterior shift of the spinal cord and neurologic improvement will not be obtained after posterior decompression surgery in the K-line (+) group. Our new index, the K-line, is a simple and practical tool for making decisions regarding the surgical approach for cervical OPLL patients.