Masahiro Morita

Retrospective case series. To investigate the clinical features and surgical outcomes of patients with intraspinal epidermoid tumor of the cauda equina region. Intraspinal epidermoid tumor of the cauda equina region is very rare, and the majority of the existing literature of this condition comprises case reports with a few case series. The clinical features and surgical outcomes of 7 patients (2 males, 5 females; age range, 4-66 y) with intraspinal epidermoid tumor of the cauda equina region were retrospectively studied, and a literature review was performed. All patients complained of neurologic symptoms and underwent microscope-assisted surgery. The mean duration of postoperative follow-up was 126 months (range, 52-209 mo). Antecedent lumbar puncture had been performed on 3 patients, and 4 cases thought to be of congenital origin without a past history of lumbar puncture had no associated anomalies, such as spina bifida or dermal sinus. Postoperatively, complications occurred in 3 patients concerning cauda equina symptom. Two patients (29%) had tumor recurrence, diagnosed 1 and 13 years after surgery, respectively. Immediately after additional surgery for tumor recurrence, both patients had severe paresis of the hemilateral foot. Complete removal without tear of the tumor was difficult in our case series, because the capsule of the tumor was thin and often adhered to the cauda equina nerve roots or dura mater. However, total resection of the capsule is important, because patients with epidermoid tumor are at risk for recurrence. On the other hand, aggressive resection of the capsule adhering to the neural elements can cause a high rate of neurological complications postoperatively, especially after surgery for tumor recurrence.

A retrospective case-control study. To investigate differences between number of levels of decompression surgery for lumbar spinal canal stenosis (LSCS) as decided by magnetic resonance imaging (MRI) and myelography with computed tomographic myelography (CTM), and to investigate intraobserver reliability and interobserver reproducibility of MRI and myelography with CTM. Although the decision to carry out decompression surgery for LSCS largely depends on the severity of stenosis on imaging along with clinical findings, no universally accepted imaging criteria have been defined for determining severity of LSCS. The decision to carry out decompression surgery for LSCS thus seems relatively subjective, and would differ according to both observer and the findings of preoperative imaging. We retrospectively selected 50 patients with LSCS who underwent decompression surgery. Mean patient age was 69 years, and mean number of levels carried out decompression surgery was 2. Each of 4 spine surgeons retrospectively decided levels of decompression surgery 4 times, according to the findings of MRI or myelography with CTM (MRI-1, MRI-2, CTM-1, CTM-2). We investigated differences between number of levels of decompression surgery decided by MRI and myelography with CTM, and also investigated intraobserver reliability and interobserver reproducibility of MRI and myelography with CTM. The number of levels of decompression surgery as decided by myelography with CTM was significantly greater than that by MRI. κ coefficients for intraobserver reliability and interobserver reproducibility revealed myelography with CTM as more reliable and reproducible than MRI. The number of levels of decompression surgery for LSCS as decided by MRI would be less than that by myelography with CTM. Myelography with CTM is more reliable and reproducible than MRI for preoperative evaluation of LSCS.

The purpose of this paper was to inform the reader that prolonged upper airway obstruction after posterior cervical spine surgery is a possible complication for patients with metastatic tumor of upper cervical spine. A 49-year-old man presented severe neck pain during posture changes due to metastatic spinal tumor of C2. Occipitocervical fusion following removal of the posterior arch of C1 and laminectomy of C2 via the single posterior approach was performed 2 weeks after radiation therapy. After the surgery, life-threatening airway obstruction due to pharyngeal oedema occurred immediately after extubation that required emergency tracheostomy. The airway obstruction did not improve well during the patient's postoperative course. Once pharyngeal oedema occurs in patients with metastatic tumor of upper cervical spine who undergo posterior cervical spine surgery following radiation therapy to the neck, the pharyngeal oedema may be constant for a long period of time.

We report the case of a 50-year-old man presenting symptoms of autonomic dysreflexia associated with Charcot spine following complete C8 spinal cord injury. After posterior lumbar interbody fusion of L2/3 with simultaneous posterior instrumentation from L1 to L5, the patient recovered from the symptoms of autonomic dysreflexia. Although the patient began to faint when he sat up and transferred after surgery, it began to be resolved by continuous urinary catheterization, setting a limit to activity and prescription of alpha-, beta-stimulants. Within a few weeks after performing these treatment strategies, he could return to active wheelchair life, and no recurrence of any symptoms was noted at the 6-year follow-up. Although there are only a small number of cases with Charcot spine presenting autonomic dysreflexia, surgical stabilization of the affected lesion for patients with this condition should be recommended.

A case report with a review of the literature. To describe an unusual case of primary lymphoma of the cauda equina and provide a review of the literature of this condition. Primary lymphoma of the cauda equina is extremely rare, and has been reported in 8 cases previously. This report is the first to describe a case of primary nasal type NK/T-cell lymphoma of the cauda equina. We report the case of a 67-year-old man presenting the symptoms of cauda equina syndrome caused by primary lymphoma of the cauda equina. After laminectomy and removal of the tumor, the patient recovered from the symptoms of cauda equina syndrome except for bladder and bowel dysfunction. Further investigations including immunohistochemical stains made a diagnosis of primary nasal type NK/T-cell lymphoma of the cauda equina, and the patient received radiotherapy to the lumbosacral area. Brain metastasis was detected 8 months after surgery, and the patient died 14 months after his initial clinical presentation despite additional treatments including whole-brain radiotherapy and oral chemotherapy. Although primary lymphoma of the cauda equina is extremely rare, the prognosis of this condition is thought to be poor. Early definitive diagnosis with examination of the cerebrospinal fluid followed by combined treatment with radiotherapy and high-dose methotrexate should be considered.

Object: The authors investigated the background, risk factors, and treatment strategies for Charcot spinal disease (CSD) after spinal cord injury (SCI).Methods: The authors retrospectively examined the clinical and radiological findings in 9 patients with a total of 10 Charcot spine lesions that occurred after SCI. The mean age of the 9 patients was 54 years, and all patients presented with complete SCIs. In all but 1 patient, symptoms did not develop until 10 years postinjury. All 10 Charcot spine lesions were located below the thoracolumbar junction. Surgical treatment was performed in 7 patients (7 lesions), and the mean duration of postoperative follow-up was 84 months.Results: All patients reported audible noises when changing posture, 5 of 9 patients reported low-back pain, and 7 patients displayed increasing instability while sitting. In 8 patients, spasticity disappeared and limbs became flaccid several years after SCI. Two patients had associated bacterial infections in the Charcot spine lesions, and 1 patient complained of autonomic dysreflexic symptoms associated with trunk movements. Although postoperative complications occurred in 3 patients, all patients who underwent surgical treatment made a good recovery and were able to return to daily life in a wheelchair. On lateral radiography, the mean range of motion at the lesion site was 43°, and fluid collections between the involved vertebrae were observed in 8 patients on MR images; ankylosing spinal hyperostosis was observed in 7 patients. Charcot spine lesions tended to occur at the junction between or at the end of an ankylosing spinal hyperostotic lesion. Postoperatively, solid arthrodesis was obtained within 6 months in all surgically treated lesions.Conclusions: Disappearance of spasticity in the lower extremities is thought to be an important physical sign suggestive of CSD after SCI. Sitting imbalance and the fluid volume of the Charcot spinal lesions are related to range of motion at the lesion site. In addition to a combined approach, a single posterior approach with acquisition of anterior support is an option for surgical treatment even in cases of infected CSD.