Little information is available about the incidence and outcome of incidental dural tears associated with microendoscopic lumbar decompressive surgery. We prospectively examined the incidence of dural tears and their influence on the outcome six months post-operatively in 555 consecutive patients (mean age 47.4 years (13 to 89)) who underwent this form of surgery. The incidence of dural tears was 5.05% (28/555). The risk factors were the age of the patient and the procedure of bilateral decompression via a unilateral approach. The rate of recovery of the Japanese Orthopaedic Association score in patients with dural tears was significantly lower than that in those without a tear (77.7% vs 87.6%; p < 0.02), although there were no significant differences in the improvement of the Oswestry Disability Index between the two groups. Most dural tears were small, managed by taking adequate care of symptoms of low cerebrospinal fluid pressure, and did not require direct dural repair. Routine MRI scans were undertaken six months post-operatively; four patients with a dural tear had recurrent or residual disc herniation and two had further stenosis, possibly because the dural tear prevented adequate decompression and removal of the fragments of disc during surgery; as yet, none of these patients have undergone further surgery.

Cite this article: Bone Joint J 2014;96-B:641–5.

We retrospectively examined the prevalence and natural history of asymptomatic lumbar canal stenosis in patients treated surgically for cervical compressive myelopathy in order to assess the influence of latent lumbar canal stenosis on the recovery after surgery. Of 214 patients who had undergone cervical laminoplasty for cervical myelopathy, we identified 69 (32%) with myelographically documented lumbar canal stenosis. Of these, 28 (13%) patients with symptomatic lumbar canal stenosis underwent simultaneous cervical and lumbar decompression. Of the remaining 41 (19%) patients with asymptomatic lumbar canal stenosis who underwent only cervical surgery, 39 were followed up for ≥ 1 year (mean 4.9 years (1 to 12)) and were included in the analysis (study group). Patients without myelographic evidence of lumbar canal stenosis, who had been followed up for ≥ 1 year after the cervical surgery, served as controls (135 patients; mean follow-up period 6.5 years (1 to 17)). Among the 39 patients with asymptomatic lumbar canal stenosis, seven had lumbar-related leg symptoms after the cervical surgery.

Kaplan–Meier analysis showed that 89.6% (95% confidence interval (CI) 75.3 to 96.0) and 76.7% (95% CI 53.7 to 90.3) of the patients with asymptomatic lumbar canal stenosis were free from leg symptoms for three and five years, respectively. There were no significant differences between the study and control groups in the recovery rate measured by the Japanese Orthopaedic Association score or improvement in the Nurick score at one year after surgery or at the final follow-up.

These results suggest that latent lumbar canal stenosis does not influence recovery following surgery for cervical myelopathy; moreover, prophylactic lumbar decompression does not appear to be warranted as a routine procedure for coexistent asymptomatic lumbar canal stenosis in patients with cervical myelopathy, when planning cervical surgery.

A dural tear is a common but troublesome complication of endoscopic spinal surgery. The limitations of space make repair difficult, and it is often necessary to proceed to an open operation to suture the dura in order to prevent leakage of cerebrospinal fluid. We describe a new patch technique in which a small piece of polyglactin 910 is fixed to the injured dura with fibrin glue. Three pieces are generally required to obtain a watertight closure after lavage with saline. We have applied this technique in seven cases. All recovered well with no adverse effects. MRI showed no sign of leakage of cerebrospinal fluid.

By 1998, 10 patients had undergone 12 revision total knee arthroplasties at our institute. One patient died three weeks after surgery due to cerebral infarction, leaving 11 knees of nine patients for evaluation. Average follow-up was 4.8 years (1 to 9 years). All components were subjected to revision surgery in five knees, the tibial tray and insert in four knees, and only the insert in two knees. Patients were evaluated with clinical examinations, radiographs, and the Knee Society Clinical Rating System.

After revision surgery, the Knee Scores and ROMs were restored to almost the same level as just after the first TKA. Re-revision was performed on two patients, one 103 months and the other 82 months after revision TKA. In those two patients, huge bone loss of the proximal tibial canal was filled with cement without bone graft. The other patients, however whose tibial trays were fixed with cement on adequate grafted bone obtained good results.

The femoral components that were not treated with revision surgery despite small flaws or scratches due to wear and tear of the tibial insert did not cause marked wear of the new tibial insert.

Conclusion: Bone loss of the proximal tibial canal should be filled with bone graft, not with cement only. Femoral components with small flaws or scratches, and without other ploblems, need not to be treated with revision surgery.

Patients with Lumbar Degenerative Kyphosis and Kyphoscoliosis (LDK) complain of stooped gait, persistent low back pain and weakness. Because operative treatment of LDK imposes considerable operative intervention for aged patients, an indication should be strictly limited; those have severe low back pain with lumbar kyphosis which afflicts upright walking disturbing house keeping, patients aged less than 70 as a rule and have no critical general complication as well. Purpose of this paper is to compare factors that affect the results of operative treatment of LDK.

19 patients were reviewed retrospectively in these series (av. aged 62.7, all female except one), who were followed-up for 3.0 years in average (14 months-8 years.) after the last surgery. Number of fused vertebra comprised 3 in 4 cases, 4 in 5, 5 in 3, 6 in 2, 7 in 2, 8 in 1, 9 in 2 respectively. In these cases 8 (av. aged 60.4) had no interbody fusion at all, one segment in one, 2 segments in 4, and 3 and more in 6 either anterior or posteriorly. Results were evaluated as excellent, good, fair and poor based on a correction rates of C7 plumb line and T1 tilt angle, as well as correction of lumbar kyphosis angle.

The result was evaluated as excellent in 2 cases, good in 6, fair in 6 poor in 5. No co-relation was found between the results and number of fused vertebra at the last stage. However, patients whose operation include interbody fusion (IBF) of 3 and more contiguous segments showed either excellent or good, but all cases with single segment or no IBF groop showed either poor or fair, where those with 2 segments had good in 2 cases and fair in 2 respectively. There were relatively many poor results due to instrument failures (6 cases), insufficient correction of the deformity, compression fracture and increase of kyphosis above and below IBF level, possibly caused by progression of osteoporosis and degeneration. Four patients were found nerve root symptom after surgery, but almost healed by revision in several weeks.

In order to obtain good result correction should include interbody fusion of at least 3 contiguous lumbar segments for multilevel anterior support and rigid instrumentation in sufficient length. Accurate planning before operation and careful surgical procedure should be emphasized to avoid nerve entrapment and instrument failure.

We have reported that most of lower cervical cord injury patients had either improved or remained the same neurology following early operative stabilization done in our hospital. However, a few patients deteriorated with ascending paralysis in acute stage. Purpose of this paper is to present such cases and discuss the outcomes.

Methods: 1) We have analyzed 10 pts of acute lower cervical cord injury who had deteriorated neurologic symptom ascending above C4 and complicated with respiratory quadriplegia. They accounted for 3.7 % out of 271 patients with bony injury. 2) They were 8 males and 2 females, aged 17~76, injury type C5/6 fracture-dislocation (Fx/Dx) in 4, C6/7 Fx/Dx in 4, C7/T1 in 1, and one C5 flexion tear drop Fx. 3) 2 patients were treated conservatively and 8 had operative reduction and fusion with careful technique.

Results: 1) All patients had complete quadriplegia. 2) 3 pts could not wean out of ventilator and other 2 of them eventually died. 3) Paralysis started to ascend in 3 days after injury needed ventilator in 24 hours thereafter. 4) 2 out of 10 patients underwent an excessive distraction being treated conservatively. 8 patients had operative fixation for bony injuries, 7 of them obtained solid spine with single operation, but one had redislocated in a few days after the operation and received restabilisation surgery.

Conclusion: 1) There are a few patients of acute lower cervical injury with complete quadriplegia deteriorated neurology ascending paralysis with respiratory distress. 2) Comparing to other cases an operative treatment would not a cause of such neurologic deterioration. 3) In most cases paralysis of diaphragm was passing symptom, but quite a few patients(1%) could not wean off ventilator. 4) Cause of ascending paralysis in such injury could not be identified definitely, therefore careful observation and prompt treatment such as tracheotomy should be recommended.

Charcot spondyloarthropathy is one of the late complications of traumatic spinal cord injury that produces further disability. Purpose of this paper is to introduce 5 patients who developed Charcot spine after traumatic spinal cord injury treated surgically in our hospital (SIC) and discuss the result.

Methods: 1) We experienced 7 pts who presented characteristic clinical and radiographic findings of Charcot spine treated in SIC for 20 years (an incidence < 1%). 2) 5 out of 7 pts underwent surgical fusion. They were 4 males, 1 female, aged: 39~66, previous injury comprises of: C6 Fracture-dislocation(Fx/Dx) in 1, T11 Fx/Dx in 2, T12 Fx/Dx in 2. respectively, 3) 4 pts had complete paraplegia, 0ne incomplete(Frankel B) and the Charcot spine occurred below fusion mass under the injured level. 4) Posterior spinal fusions combined with kyphosis correction were performed in 3, the same with posterior shortening osteotomy using TSRH instruments in 2. Fusions were extended to L4 in 1, L5 in 2, S1 in 2 respectively.

Results: 1) 4 pts who had been followed-up over one year showed ultimate osseous union. Another one showed loosening of screws resulted in non-union at 5 months postoperatively. 2) Cobb angle of kyphosis were improved from 67.7 degrs. in av.(58~82) to 13.7 degrs in av. (15~36) by the operation. 3) All pts could have restored a good sitting balance tolerated a long time wheelchair sitting without any localized back pain.

Conclusion: It is important for physicians who treat spinal cord injury patients to be aware of posttraumatic Charcot spine. As longevity of the people with paralysis is increasing, this phenomenon may occur more apparently. Special attention should be given to the spinal segments just below the fused level in patients with previous spinal fusion. For the unstable and symptomatic Charcot spine, a surgical correction and fusion should be considered. The correction of kyphosis is essential, but too much correction should be avoided, because it may worsen a sitting balance of the patient. We now recommend a posterior shortening osteotomy and rigid fusion using a solid pedicle screw instrumentation like TSRH.

In cases above C4 cervical cord injury a respiratory distress and serious pulmonary complications occur with frequent obstruction of air way by increased excretion and difficult evacuation. Long term tracheal intubation often provides many general complications. We analized advantage and demerit of early tracheotomy in such cases of cervical cord injury patients.

Material and Methods: 1) We proposed early tracheotomy to prevent complications and ease respiration when pts showed low vital capacity (v.c.) less than 500cc showing deltoid/biceps palsy and respiratory distress with much excretion and difficult evacuation. 2) We have analysed 91 patients who needed ventilator out of 845 cervical cord injury patients who admitted in our hospital. 2) 25 pts were treated by tracheotomy from the beginning of treatment, and others were switched over from management of tracheal intubation. 3) We used a double cuff tracheotomy tube to prevent continuous pressure to the tracheal wall. 4) Weaning from ventilator was done when Fi02< 0.3, PEEP< 5cmH2O and PaO2> 80mmHg in room air.

Results: 1) 4 (16%) out of 25 pts who had been treated with tracheotomy from the beginning had atelectasis, whereas 15 (23%) out of 66 pts treated with intubation occurred that symtome, and 20% of the pts suffered pneumonia. 2) Out of 46 pts treated with intratracheal intubation in the beginning and then changed to tracheotomy within 4 days 7(15%) had atelectasis, whereas 20 (29%) of the pts who underwent tracheotomy after 5 days occurred the complication. 3) As complication of tracheotomy? Infection and? tracheal stenosis were observed but all uneventful healed.

Discussion/Conclusion: 1) Acutecervical cord injury pts showing deltoid/biceps palsy have impending respiratory distress. Examination of spirometer is essential. In such cases low v.c. < 500 tracheotomy should be indicated. 2) Continuing respiratory distress > 4days of intubation it is advised tracheotomy in order to prevent genera l complications. 3) Combination with frequent position changing and chest tapping is also essential for evacuation.

There are increasing opportunity of operative treatment for advanced aged patients with degenerative spinal disease aiming for better quality of life. We have studied such patients concerning operative result, complication and problem in pre- and peri- operative management, and achievement of their aims.

Patients and Results: 1) 26 patients were analyzed; 16 males and 10 females, av. aged 82.3, pts of 19 lumbar canal stenosis with marked intermittent claudication and 7 disc herniation. 2) Low back pain and neurogenic disabilities are evaluated on JOA scoring criteria excepting ADL points (full score:15).

Results: 1) 25 of 26 pts had following complications before operation; hypertension in 16, neurogenic bladder 7, arrhythmia 6, prostata hypertrophy 6, cardiac ischemic disease 4, DM 3, cerebral infarction 3, advanced OA of the knee joints 3. asthma 2, pulmonary emphysema 2, Parkinsonism 1, respectively. 2) All patients underwent laminectomy of av. 2.2 segments(1~4), and 3 pts had PL fusion. 3) One had postlaminectomy haematoma complicated with neurologic deterioration 3 hrs after operaion. He underwent immediate revision which resulted complete recovery of neurology. 4) One pt with pulmonary emphysema was operated successfully with lumbar anaesthesia as general anaesthesia was refused. 5) Improvement evaluated with modified JOA pain score accounted for as follows; av. preoperative score showed 7.16 improved to 10.73 (45.8%), objective symptoms 4.23–4.66, subjective symptome 3.0–6.08 (51.3%), ambulant ability improved from 0.35–2.0 (62.3%), and pain ± numbness of L/E 0.96–2.04 (52.9%) resp. 6) 2 patient