田中 雅人

We performed fixation using laminar screws in 2 patients in whom lateral mass screws, pedicle screws or transarticular screws could not be inserted. One was a 56-year-old woman who had anterior atlantoaxial subluxation (AAS). When a guide wire was inserted using an imaging guide, the hole bled massively. We thought the re-insertion of a guide wire or screw would thus increase the risk of vascular injury, so we used laminar screws. The other case was an 18-year-old man who had a hangman fracture. Preoperative magnetic resonance angiography showed occlusion of the left vertebral artery. A laminar screw was inserted into the patent side (i.e., the right side of C2). Cervical pedicle screws are the most biomechanically stable screws. However, their use carries a high risk of neurovascular complications during screw insertion, because the cervical pedicle is small and is adjacent laterally to the vertebral artery, medially to the spinal cord, and vertically to the nerve roots. Lateral mass screws are also reported to involve a risk of neurovascular injuries. The laminar screw method was thus thought to be useful, since arterial injuries could thus be avoided and it could also be used as a salvage modality for the previous misinsertion.

Surgical treatment of metastatic spinal cord compression is controversial. The purpose of this study was to investigate the effectiveness of our current surgical treatments and the use of spinal instrumentation. In this retrospective study covering the years between 1990 and 2006, 100 patients with spinal metastases which were secondary to various cancers underwent posterior and/or anterior decompression with spinal stabilization for the purposes of reduction of pain, and/or to help correct or improve neurological deficits. The group was made up of 60 men and 40 women whose ages ranged from 16 to 83 years (average of 60 years), and the average follow-up period was 14 months. The effect of treatment upon pain relief and neural deficits was assessed, and the cumulative survival rate was calculated by the Kaplan-Meier method. The average surgical time was 185min. This was calculated based on the following times, listed here with the surgery type:178min for posterior surgery;245min for anterior surgery;465 min for combined surgery;and 475min for total en bloc spondylectomy. Average blood loss during surgery was 1,630 ml for posterior surgery, 1,760 ml for anterior surgery, 1,930 ml for combined surgery, and 3,640 ml for total en bloc spondylectomy. Preoperative pain and paralysis were improved by 88% and 53%, respectively. In regards to surgical complications, postoperative epidural hematoma was observed in 2 patients, and instrumentation-related infection was observed in 1. Only 2 patients died within 2 months of surgery. In conclusion, posterior and/or anterior decompression with spinal stabilization is a safe and effective treatment for patients with spinal metastases, and can improve their quality of life.

Scoliosis is a common clinical manifestation of Rett syndrome, a neurodevelopmental disorder that almost exclusively affects females. The spinal curve in patients with Rett syndrome is typically a long C curve of a neuromuscular type. As the onset of the scoliosis is very early and shows rapid progression, early surgical intervention has been recommended to prevent a life-threatening collapsing spine syndrome. However, there are high perioperative risks in Rett syndrome patients who undergo spinal surgery, such as neurological compromise and respiratory dysfunction due to rigid spinal curve. We herein report the surgical result of treating severe rapid progressive thoracic scoliosis in a 16-year-old girl with Rett syndrome. Posterior segmental pedicle screw fixation was performed from T1 to L3 using a computer-assisted technique. Post-operative radiography demonstrated a good correction of the curve in both the sagittal and coronal alignment. There were no postoperative complications such as neurological compromise. The patient had maintained satisfactory spinal balance as of the 3-year follow-up examination.

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.