広範脊柱管狭窄症

BACKGROUND CONTEXT: Ossification of the posterior longitudinal ligament (OPLL) involving the C2 segment poses significant surgical challenges due to anatomical complexity and limited exposure. PURPOSE: This report describes a novel application of the Expanded Shelter Technique to overcome C3-level exposure constraints in the management of continuous C2-C6 OPLL. STUDY DESIGN: This study used a clinical case report. RESULTS: A 60-year-old male presented with progressive neck/shoulder discomfort, right upper limb numbness, and weakness (MRC grade 2 right vs. grade 4 left). Imaging showed multi-level OPLL from C2 to C6, severe canal stenosis, and disc herniations. The Expanded Shelter Technique was performed. Neurological symptoms in the right upper limb resolved on the first postoperative day, with no new neurological symptoms emerging. At the six-month follow-up, neurological symptoms remained absent, and solid bony fusion was confirmed at the graft-vertebral interface. Direct spinal cord decompression was achieved. Subtotal resection of the C3 vertebral body effectively widened the surgical corridor and reduced procedural complexity. CONCLUSIONS: We report a case of continuous cervical OPLL spanning C2-C6 managed with the Expanded Shelter Technique. This approach successfully overcomes C3 exposure constraints through subtotal vertebral body resection and mesh reconstruction, providing a viable anterior decompressive solution for this challenging OPLL subtype.

INTRODUCTION: Transforaminal epidural steroid injection (TFESI) is commonly applied for lumbar radicular pain. High-level evidence supports the use in disc-related radiculopathy, while evidence for TFESI in neuroforaminal stenosis remains consensus-based. METHODS: A retrospective repeated cross-sectional study was conducted covering January 2013-December 2022. The dataset comprised 11,208 unique patients reimbursed for TFESI. Trends in clinical indications were analyzed using automated keyword-based text recognition. Representative cohorts from 2014 (n = 266) and 2022 (n = 299) were randomly selected for clinical and radiologic reviews. Imaging was reassessed according to established grading systems. Pain intensity and global perceived effect were evaluated approximately 6 weeks post-injection. Parametric and non-parametric statistics, linear regression, and ordinal logistic regression were applied. A two-sided p < 0.05 was considered statistically significant. RESULTS: Mean patient age and the proportion of stenosis-related indications both increased steadily between 2013 and 2022 (p < 0.001). In the studied cohorts, short-term pain decreased significantly after TFESI across all phenotypical subcategories, except for moderate-to-severe central canal compression in 2014. Neuroforaminal stenosis predicted greater pain improvement regardless of its nature in 2014 (p = 0.006), whereas disco-osteophyte abnormalities and chronic or recurrent symptoms were associated with less pain reduction in 2022 (p < 0.05). Female patients showed less short-term improvement than males. At one-year follow-up, central canal stenosis predicted a lower likelihood of being pain-free (OR = 0.63, p = 0.022). CONCLUSIONS: This retrospective study found an upward trend in patient age and a growing proportion of non-discogenic neuroforaminal stenosis as indications for TFESI. While modest short-term pain reduction was observed, outcomes were slightly negatively influenced by central compression, disco-osteophyte abnormalities, chronic symptoms, and female sex.

Rabies is a universally fatal acute zoonotic disease caused by rhabdovirus, and postexposure prophylaxis (PEP) remains the mainstay of prevention. Patients who sustain animal bites may require urgent or elective surgical interventions for unrelated conditions while simultaneously undergoing rabies prophylaxis. The perioperative team often faces uncertainty regarding the safety of anesthesia and surgery in patients receiving rabies vaccines or rabies immunoglobulin (RIG). This report discusses such a scenario in a patient posted for elective lumbar spine surgery. We report the case of a male in his mid-60s with chronic low back pain and bilateral lower limb radiculopathy, with the left side more involved, diagnosed with a prolapsed intervertebral disc at the L5-S1 level with lumbar canal stenosis. Following failed conservative management for six weeks, he was planned for decompression and transforaminal lumbar interbody fusion (TLIF) at the L5-S1 level. On the day before surgery, he received a scratch from a monkey, classified as a Grade III wound, which was managed, and PEP was initiated, including human RIG and a four-dose intradermal vaccine regimen. Surgery was deferred till completion of PEP, following which he underwent TLIF at the L5-S1 level. There were no intraoperative adverse events. The immediate postoperative course was uneventful, with significant symptomatic improvement. The surgical site was found to be healthy on postoperative day 2, and the patient was discharged on the next postoperative day. Our case shows that timely administration of rabies PEP in the form of RIG and vaccine, along with postponement of elective surgery, does not preclude the patient from safely undergoing elective spine surgery in the future, provided vaccination schedules are not interrupted and adequate time is allowed after immunoglobulin administration. In our patient, lumbar TLIF was performed after completion of the PEP schedule, and he had an uneventful intraoperative and postoperative course, with a good clinical recovery. This highlights the importance of appropriate coordination between infectious disease management and individualized surgical planning, along with careful perioperative and postoperative monitoring, to balance the urgency of spinal disease and the need for effective rabies prevention for optimal surgical outcomes.

PURPOSE: Minimally invasive tubular lumbar microdiscectomy (MIS-MCD) is used for lumbar disc herniation (LDH) in adults, but pediatric data remain limited. This study aimed to evaluate clinical presentation, perioperative outcomes, and recovery patterns after MIS-MCD, and to explore risk factors for reherniation and reoperation in a pediatric cohort. METHODS: We performed a retrospective case series of consecutive pediatric patients undergoing primary single-level MIS-MCD for LDH from 2014-2024 at a tertiary center by a single surgeon. Patients with primarily traumatic, neoplastic, or infectious pathology were excluded. Primary outcomes included early symptom improvement, return to activities, reherniation, and reoperation. Risk factors for reherniation were explored using Fisher's exact tests. RESULTS: Thirty-four patients were included (mean age 16.7 ± 1.7 years; 55.9% male; mean BMI 30.6 ± 7.4 kg/m2). Most participated in organized sports (58.9%), with sport/exertional mechanisms being the most common identifiable cause (41.2%). Congenital spinal stenosis (CSS) was present in 20.6%. Mean symptom-to-surgery interval was 9.2 ± 8.3 months. Length of stay was 0.5 ± 0.6 days, median blood loss was 15 mL, and no durotomies occurred. Initial symptom improvement was reported by 94.1%, and 79.4% returned to prior activities. Over a median follow-up of 20.4 months, reherniation occurred in 8 patients (23.5%) and reoperation in 6 (17.6%). Reherniation was significantly associated with CSS (62.5% vs. 7.7%; p < 0.001). All reoperations were repeat MIS-MCD; none required fusion. CONCLUSION: MIS-MCD is safe and effective in pediatric patients. Reherniation is concentrated in patients with CSS, suggesting preoperative canal narrowing identification may guide counseling and surveillance.

BACKGROUND: A previous single-case study has demonstrated that a modified time-spatial labeling inversion pulse (Time-SLIP) technique, specifically Deep Abdominal Breathing-induced CSF Flow Imaging with Time-SLIP (DAB Time-SLIP), successfully visualized dynamic cerebrospinal fluid (CSF) flow during deep breathing with superior contrast compared to conventional Time-SLIP. However, it is unclear whether this occurs consistently across healthy individuals. PURPOSE: To investigate CSF flow dynamics during deep breathing in healthy volunteers with the DAB Time-SLIP. STUDY TYPE: Prospective. POPULATION: 10 healthy participants (7 men; mean age, 29.5 years). FIELD STRENGTH/SEQUENCE: 1.5-Tesla, Time-SLIP. ASSESSMENT: Midsagittal Time-SLIP imaging was performed using a 9 s repetition interval. A labeling pulse was applied at four vertebral levels (Th11-L1-L3-L5 or Th12-L2-L4-S1), and images were acquired after a 2 s delay. Separate imaging sessions were conducted during shallow breathing and during a structured 8 s deep abdominal breathing cycle. During deep-abdominal-breathing, an intentional phase shift between the 9 s imaging interval and the 8 s respiratory cycle enabled visualization of CSF movement across the entire cycle within 72 s. This protocol for CSF dynamics during deep-breathing was designated as DAB Time-SLIP. Images acquired under these two breathing conditions were compared with the reference label images obtained during breath-holding, and CSF flow velocity and displacement range were quantified based on the resulting positional changes. STATISTICAL TESTS: Wilcoxon signed-rank test and simple linear regression analysis. A p < 0.05 was considered significant. RESULTS: Cranial flow occurred during inhalation, whereas caudal flow was observed during exhalation. Both the magnitude and the displacement range of CSF flow velocity and CSF movement of range progressively decreased toward the caudal direction (rS = -0.9479). Compared with free breathing, the range of CSF movement using DAB Time-SLIP was significantly greater. DATA CONCLUSION: DAB Time-SLIP demonstrated cranial CSF flow during deep inspiration and caudal CSF flow during deep expiration. TECHNICAL EFFICACY: Stage 1.