We will a present new modification for situations where the spine is osteoporotic. At cranial area to osteotomy the combination of pedicle screw without tightening set screw and sublaminar wiring with nesplon-cable is used. This system has a telescoping function by screw and cableʼs sliding on the rod.

We will show two examples. This new modification with a telescoping mechanism seems to be effective cases where there is loss of height of the vertebral body.

Postural deformity and camptocormia in patients with Parkinsonʼs disease (PD) cause spinal imbalance, leading to significant disability. If the deformity is long term and well established with secondary degenerative changes, patients might complain of difficulty lying flat in bed. We performed corrective spinal osteotomy with posterior thoracolumbar multilevel fusion in PD patients with severe rigid spinal deformity. Five patients with PD who underwent spinal fusion surgery were included in this study. We report the method of surgery, X-p findings and treatmen complications. The study included 4 female and 1 male PD patient aged 68-79 and follow-up of 8-16 months who underwent posterior thoracolumbar multilevel fusion with spinal osteotomy (3 vertebral column resections and 2 pedicle subtraction osteotomies). Intraoperative blood loss and operation time were 1322-2200ml and 397-439min., respectively. Sagittal vertical axis was 221mm anterior preoperatively, which was decreased to 143mm postoperatively. We noted medical complications in two patients, namely temporal worsening of PD and postoperative delirium. Our surgical intervention in patients suffering from spinal deformity with PD resulted in improved spinal balance. Surgically invasive procedures and medical control of PD are important to acquire good clinical results by this method.

Purpose：After posterior spinal instrumentation, we sometimes need to extend the fusion levels, because of junctional spondylosis, fracture, and deviation or loosening of pedicle screws. In such situation, we performed salvage surgery using the anterior cross connector.

Subjects and Methods：We operated on 17 patients and followed them up for an average of 13.9 months(1-25), and investigated clinical findings.

The causes for the second surgery were instrumentation failure in 9 patients, breakdown of the adjacent segment in 6 patients and adjacent vertebral fracture in 2 patients.

Salvage surgeries included the extension of the fusion instruments by using the anterior cross connector.

Results：4 cases extended to upper level, and 13 cases extended to lower level. In 4.9(2-6)cases the anterior cross connector was used. Mean operative time was 282minutes, and mean operative blood loss was 466ml.

Discussion：Salvage posterior spinal instrumentation using the anterior cross connector offers a useful less invasive surgical technique for the treatment of spinal diseases, and improves the stability for adjacent segment disease.

Recently, anterior procedures for thoracic and lumbar spines seem to be avoided because of possible perioperative complications. However, the actual risk factors causing surgical complications have not yet been evaluated. The purpose of this study was to clarify the perioperative complications in elderly patients with anterior approach to the thoracic or lumbar spine. From 1997 to 2010, 45 anterior procedures (thoracic extrapleural and/or retroperitoneal approaches) were performed in patients older than 70 years and operative time, blood loss, and perioperative complications in them were evaluated. The operative time and blood loss were 123 to 373 minutes, 185 to 1627ml, respectively. 10 of the 45 patients had at least one perioperative complication.
However, no major complications occurred. Our results suggest that the anterior procedure, especially extrapleural and／or retroperitoneal approaches, was less-invasive and suitable for patients of all ages.

Introduction：It is common practice to use first-generation cephalosporins (CEZ) empirically for
pyogenic spondylitis before infectious organisms are isolated. The objective of this study is to review infectious organisms causing pyogenic spondylitis and to clarify what kind of antibiotics we should use empirically.

Methods：We retrospectively reviewed cases of pyogenic spondylitis in 117 patients who were treated in our hospital from 1997 to 2011, including 75 men and 42 women with a mean age of 66.5 years.

Results and Discussion：62 patients (53%) had conditions causing immunocompromise (diabetes mellitus, cancer, steroid use, hemodialysis and aothers). Organisms were isolated from 70 patients(42 immunocompromise and 28 non-immunocompromised patients). Organisms in 22 of 70 cases(31%) had no sensitivity for CEZ. In non-immunocompromised hosts, 6 of 28 cases (21%)had no sensitibity to CEZ. On the other hand, in immunocompromised hosts, 16 of 42 cases (38%)had no sensitivity to CEZ. 6 cases required broad spectrum antibiotics and 10 needed anti-MRSA drugs. Antibiotic-resistant organisms were more commonly isolated from immunocompromised patients.

This study suggests that broad spectrum antibiotics and anti-MRSA drugs should be used empirically for pyogenic spondylitis in immunocompromised patients before isolating causative organisms.

Purpose：We will present our irrigation method for Lumbar Spondylodiscitis using EndoFinger. Primarily CottonFinger was a simple metal cylinder used to grasp the swab in the thoracoscope operation.

Method：We curettaged the infected discs with Hijikataʼs percutaneus discectomy set and inserted the f3.0mm drain tubes bilaterally into the disc using CottonFinger under local or general analgesia. The discs were irrigated with natural serum at 1000ml/day.

Objectives：We performed this method in  cases,  discs(seven male and one female, 55 to 86 years old, average 75.6 years old). The duration of irrigation duration was 13.1±7.4 days. In cases out of 7, decompression or epidural abscess removal were combined with this method under general analgesia.

Results：In  cases out of 7, the spondylodiscitis resolved after irrigation. One case who had been treated for septic shock during his hospital admission died during irrigation.

In one case, where the adjacent vertebral body had an extensive T1 low intensity area on MRI, the adjacent endplates collapsed and resulted in vertical instability and kyphosis. In our cases, there were no obvious nerve or vessel injuries.

Conclusion：In this simple method, it is not necessary to use special or costly devices. We think this method is a good choice for treatment of acute Spondylodiscitis.

In cases of pyogenic vertebral osteomyelitis and discitis, surgery is indicated when appropriate
medical management fails, the patient develops neurological deterioration, or spinal instability/deformity becomes apparent. We report a single-stage anterior debridement and autologous bone graft followed by posterior instrumented fixation for pyogenic vertebral osteomyelitis and discitis of the lumbar spine in 2 cases. The first case was postoperative infection at L4/5 and the second case was hematogeneous spread of infection at L2/3. Careful and meticulous medical management failed to control the infection, and these two patients underwent surgery. Diagnositc images after surgery revealed complete control of infection and osseous bony fusion. Single-stage anterior debridement and autologous bone graft followed by posterior instrumented fixation of the lumbar spine presented here is not altogether novel and rather than less invasive, it may offer a more thorough solution for the condition of pyogenic vertebral osteomyelitis and discitis.

We reported technical feasibility and clinical outcomes of TLIF procedures through METRx tubular retractor (MTLIF) using our newly developed devices for microscopic surgery. This procedure was performed successfully with acceptable OR time, blood loss and few complications, although there was concern about bone union.

Attention should be paid to bone union following this procedure over the longer term.

Objective：From 2008 to 2012, microendoscopic posterior lumbar interbody fusion was performed in 546 patients with lumbar degenerative disorders. Since 2011, C-Shape cage has been used for ME-TLIF. The purpose of this study was to introduce the operative technique of ME-TLIF and investigate the area of both grafted bone and C-Shape cage using postoperative CT axial images.

Methods：Fourteen patients suffering from lumbar degenerative disorders underwent ME-TLIF using C-Shape cage (MILESTONE PEEK CAGE^®, Medtronic) with percutaneous pedicle screw fixation. After sufficient endplate preparation, local bone graft was performed and a cage was inserted and placed through 18mm tubular retractor under the microendoscope. The grafted bone area(B-area) and the upper vertebral body area(V-area)of ME-TLIF were measured by CT axial images.

Results：The ratio of B-area(760.3mm)and V-area (1389.8mm) was 0.55. In ME-TLIF, the average operation time was 84.4 minutes and the operative blood loss was 75.1ml.

Conclusion：ME-TLIF allows for safe and efficient minimally invasive treatment of lumbar

Background：Cervical pedicle screw (CPS) fixation has superior mechanical strength to other fixation techniques. However, this technique has the potential risk of vertebral artery injury.

Materials and methods：17 patients with cervical spinal injury and degenerative disease were included. CPS fixation was performed via a small posterolateral skin incision and iliac bone grafting was also performed. Deviation of screws, surgery time, amount of bleeding, and complications were investigated.

Results：No lateral deviation of CPS, which is thought to be the risk factor for vertebral artery injury, was occurred. Average surgery time was 201 minutes and average amount of bleeding was 122ml.

Conclusion：Posterolateral approach for CPS fixation has the potential to reduce vertebral artery injury.

Purpose：Percutaneous Endoscopic Lumbar Discectomy(PELD)is minimally invasive spinal surgery requiring only a one night stay. PELD can be applied to complicated Lumbar Disc Herniations (LDHs), such as central large herniations (CLH), high-migrated herniations, cases combined with bone-abnomalities (posterior osteophytes, central calcifications, lateral recess osteospurs, foraminal stenosis, ring apophyseal separation etc.), and cysts. Until recently, it has been difficult to perform.

Method：PELD was performed on the following types of lumbar lesions.

　1. Various techniques at each different disc level were used on 156 CLHs.

　2. 256 migrated LDHs over six zones were operated on using advanced techniques.

　3.The drill was necessary for 144 bone-related cases.

　4. Nine cysts were resected in similar fashion to discectomy.

Results：Of all our PELD cases, there was an 86％ satisfaction rate after initial operation, with 10％ requiring revisions. The reasons for revision were mainly nucleus remnants, recurrences, nerve adhesions, ganglion damage, and osteospur remnants. The final satisfaction rate was 94％ after all operations.

Conclusions：Our advanced techniques for central large hernia, high-migrated hernia and other complicated cases are minimally invasive and therefore the most patient-friendly. Great care should be taken with complications in the initial stage of the learning curve.

We compared minimally invasive surgery transforaminal lumbar interbody fusion (MIS-TLIF) and minimally invasive spinous process splitting posterior lumbar interbody fusion (MISPS-PLIF) for one level lumbar fusion to determine which approach resulted in the least amount of postoperative multifidus muscle injury. The preoperative and postoperative cross-sectional area, and T2 signal change of the multifidus muscle were measured by MRI. MISPS-PLIF group had less muscle atrophy and T2 signal change. MISPS-PLIF induced less multifidus muscle damage caused by direct trauma and denervation associated with the surgical approach.

Objective：Postoperative complications including lumbago, hematoma and deep infection due to the wide exposure at the posterior lumbar interbody fusion (PLIF) are sometimes critical problems. We have attempted to minimize the invasiveness of PLIF procedures with pedicle screw fixation via intermuscular approach using double C arm technique and Jackson table since 2008.

Methods：Eighty-eight patients who had undergone PLIF were retrospectively studied. They were divided into two groups (group 1：37 cases receiving conventional PLIF；group 2：51 cases receiving minimally invasive PLIF). We compared 1) operative duration 2) blood loss 3) drainage volume at 1 post-operative day (POD) 4) damaged area of paraspinal muscles at the level of interbody fusion by T2-weighted magnetic resonance(MR)images at 3 months after surgery between group 1 and 2.

Results：Drainage volume of group 2 was significantly less than group 1. MRI showed that the damaged are of paraspinal muscles of group 2 was significantly less than that of group 1.

Conclusions：We consider that minimally invasive PLIF via intermuscular approach is a useful procedure with less blood loss and less damage to the paraspinal muscles.

Objective：To compare the efficacy of anterior cervical discectomy and fusion using cage only (ACDF-CO) with cage plus plate (ACDF-CPP) in regards to radiologic outcomes.

Methods：A total 101 consecutive patients, from June 2005 to June 2011, who underwent 1 level ACDF-CO or ACDF-CPP with 4 different titanium implants (Affinity, DFDD, Syncage-C, Conerstone) suffering from cervical radiculopathy were divided into 2 groups；Group A (n=22) post operative immediate subsidence was greater than 5.6mm；Group B (n=79) was smaller than 5.5mm. Subsidence, segmental angle, and C2-7 angle were assessed by radiographs.

Result：Group A were all Affinity which was a cylindrical typed cage. Plate construction had a tendency to preserve a segmental angle(p<0.10)but had no influence on subsidence and C2-7 angle.

Group B were almost all box typed cage. Cage plus plate decreased subsidence significantly (p< 0.01) and had a tendency to preserve a segmental angle. (p<0.10)

There was no relation between with/without plating and C2-7 angle. (p=0.50)

DFDD had a lower subsidence rate than Affinity.(p<0.10)

Conclusion：The use of cage and plate construction in 1 level ACDF results in a lower subsidence and preservation of segmental angle compared with cage only. However, the overall alignment between C2 and C7 did not change significantly.

We started to use polyetheretherketone (PEEK) cages (CORNERSTONE, Medtronic) for singlelevel anterior cervical discectomy and fusion (ACDF) in the year 2011. Nine patients with either radiculopathy or myelopathy underwent ACDF using the PEEK cage between September 2011 and May 2012. Patient ages ranged from 40 to 78 (mean age 60.5) years. Of the 8 patients, 6 were male and 2 were female. Five patients underwent a C5/6 fusion, one patient a C3/4 fusion, one patient a C4/5 fusion, and one patient a C6/7 fusion.

A right-side anterior cervical approach was performed in all cases. Segmental decompression was performed using a high resolution microscope and a high-speed burr. After discectomy, removal of osteophytes, and end plate preparation, a PEEK cage filled with a hydroxyapatite block was inserted into the intervertebral space, with the help of a Casper distractor.

Fusion was assessed as present if trabecular continuity across the disc space was present. Bony fusion had occurred in 6/8 (75%) by 6 months. Subsidence (>1.5mm) was observed in one patient.

We found a better fusion rate and less subsidence for PEEK cages, compared to titanium cages which we previously used for ACDF.

Cortical bone trajectory screw (CBTs) was designed to primarily utilize cortical bone of the lamina and pedicle, and to be placed in the medial to lateral direction as compared to conventional pedicle screw (Ps) which utilize cancellous bone in the pedicle and vertebral body by screw placement in the lateral to medial direction The entry point on the lamina is located more medial by CBTs than that by Ps. Therefore, wide exposure is unnecessary for the placement of CBTs, minimizing surgical damage to the back muscles. To reveal that PLIF with CBTs can reduce muscle damage, we conducted a study by comparing surgical outcomes of single-level PLIF between 5 patients with CBTs (CBT group)and 6 with Ps (Ps group). Average blood loss at surgery was less in CBT group than in Ps group. Postoperativelly, all patients in Ps group had an increased level of Creatine Phosphokinase, compared with only 2 in CBT group. There was no significant difference in average recovery rate with JOA scores. The results suggest that PLIF with CBTs successfully reduced surgical damage to the back muscles.

Biomechanical and clinical effectiveness on pedicle screw and hook-rod technique for spondylosis have been reported. We present a novel hook-rod insertion technique for minimally invasive spondylosis repair surgery. The most important point of this technique is connecting the hook with extender which enables easy rod insertion to preserve back muscles. The operation is done with a small midline incision. The pars interarticularis defect is curetted and bone graft is placed. Percutaneous pedicle screws are inserted on each side through small skin incisions. The hook connected with extender is attached to the caudal site of the lamina and the rod is inserted caudally from screw to hook extender. This technique was performed on 3 patients. Mean operative time was 105 minutes and mean intraoperative blood loss was 22g. In all cases, their back pain disappeared and they gradually returned to full activities at 6 months. The advantages of this technique are minimally invasive in reducing back muscle damage, correct rod length sizing, and smooth rod insertion. This is effective especially in active sports players with a large back muscle mass.

Introduction：Fluoroscopy is commonly used to check the position of tubular retractors : However, it comes with the problem of X-ray exposure. We performed microendoscopic discectomy (MED) by stabbing a 1.6mm K-wire guide into a spinous process without using fluoroscopy during surgery.

Methods：The patients were 20 men and 7 women, whose mean age was 38.7 (range 15-71 years old). The surgery level was at L4-5 in 17 cases and L5-S in 10 cases. (1) We stabbed a 15cm K-wire into a spinous process parallel to the disc space using fluoroscopic guidance before hand scrubbing. (2) We produced a hard copy image of the K-wire and the disc. We then inserted a tubular retractor parallel to the K-wire using the image for guidance. (3) If imaging was unclear, we could confirm the position of the tubular retractor using lateral X-ray imaging.

Results and Discussion：There was no need to confirm the position of the tubular retractor using lateral X-ray imaging. There were no errors in surgical level. This MED method is useful for the early stage of surgery level without fluoroscopy.

Anterior transarticular fixation of the atlantoaxial joint was performed using computer navigation system Iso-C 3D in four cases. Subjects were 4 patients；three cases had unstable odontoid fracture with severe osteoporosis and one suffered from C1/2 subluxation due to rheumatoid arthritis. Age at operation ranged from 69 to 93, average 82.5 years old. One of three odontoid fractures showed Frankel C spinal cord injury. Before starting surgery, patients were placed on carbon table with Mayfield three points skull fixator and posture-reduction of the atlantoaxial displacement was applied. The surgical approach started from the right anterior neck. In two cases fixation of the right AA joint failed. In the last a small skin incision was added on the left anterior neck and a lag screw was put in the right AA joint. Two cases where there was fixation of bilateral AA joints obtained good bony union. This method could be considered a viable option in cases of elderly osteoporotic odontoid fractures where vascular and osseous anomalies are contraindications to bilateral posterior fixation.

Introduction：Atlantoaxial rotatory fixation (AARF) occurs primarily in children, and is often improved by cervical collar or skin traction. But in some cases it is difficult to treat. In these cases we treat using manipulation under general anesthesia.

Materials and methods：Four cases(one boy and three girls)were treated. Their mean age at operation was 7.5 years (range 4 to 10). The periods from the onset to manipulation were 1-3 months. Classification of Fielding was type I：3 cases, type II：1 case. All cases were cock-robin position. Duration of postoperative observation varied between 9 months and 5 years.

Results：We treated using manipulation under general anesthesia in all cases. We performed manipulation with limited range of motion. Confirmation of the reduction was done using perioperative CT. We used halo traction and halo-vest in two cases. All cases gave good results.

Conclusions：Manipulation of atlantoaxial rotatory fixation gave good results.

We reviewed the surgical results of 19 patients (12 men, 7 women) who underwent surgery for thoracic myelopathy caused by ossification of the ligament flavum (OLF) by analyzing sagittal CT images. OLF was mainly located at the T10/11 levels. The most of the ossified ligaments in this series were classified into mountain・prop type.

Regarding lower limb function, the mean preoperative JOA score improved from 4.9 to 7.5, and the average recovery rate was 48.2%.

Sagittal CT images were useful for safer and mor precise decompression of OLF.

Objective：We have chosen the translaminar approach (TLA) or the lateral (transmuscular) approach (LA) to foraminal lumbar disc herniations (FDH). The purpose of this study was to evaluate the efficacy of these procedures.

Methods：4 patients underwent a TLA (2 at L4/5, 2 at L5/S1) and 2 patients (at L4/5) underwent a LA.

Results：Appreciation of the pinched exiting nerve roots and resection of disc fragments were able to perform in all 6 cases. In all cases symptoms improved, and neither complications nor recurrences were reported.

Discussion and conclusions：The LA is a technique in which the approach is lateral to a lesion with resection of the lateral rim of the isthmus. On the contrary, the TLA is a technique where the approach is medial to a lesion after making a bony window at the pars interarticularis. Because FDH usually exist medial to or behind the exiting nerve root, a TLA seems easier to remove disc fragments. Also, in the lower lumbar region, the spinal process is shorter and the pars interarticularis is wider than those in the upper lumbar region. Those anatomical characteristics make a TLA easier. The TLA is thought to be a more useful approach than the LA to L4/5 and L5/S1 FDH.

[Objective] To investigate the rate of postoperative occurrence of juxtafacet cysts (facet cyst) and the rate of incidence of symptoms associated with this lesion after hemilaminectomy (hemi group) and bilateral laminectomy (bilateral group) of the lumbar spine.

[Method] The subjects were 133 patients who underwent magnetic resonance imaging after hemilaminectomy or laminectomy of the lumbar spine between July 2006 and February 2011. Of the 133 patients, 98 had lumbar canal stenosis, 34 had lumbar spondylolisthesis, and 1 had hemorrhage of the yellow ligament.

[Result] Among all patients, facet cysts were observed in 14(13.9％)patients in the hemi group and 10 (31.3%) patients in the bilateral group. Among patients with decompressed facet joints, 14 (4.2%) cysts were observed in the hemi group and 13(7.9％)in the bilateral group. Symptoms associated with facet cysts were occurred in 10(71.4%)patients in the hemi group and 1 (10.0%) patient in the bilateral group.

[Conclusion] Postoperative facet cysts occurred more frequently in the bilateral group than in the hemi group；further, the rate of incidence of symptoms associated with postoperative facet cyst was higher in the hemi group than that in bilateral group.

We report a case of a 2-year old girl, who sustained an odontoid basilar synchondosis fracture with marked flexion-displacement in an automobile accident. There was no neurological complications. Initially, conservative treatment with a halo vest orthosis was prescribed. However, even after four months of observation, fusion was still not obtained and instability persisted. Her cervical anatomy was thoroughly examined with CT and MRA, confirming the path of her vertebral artery and width of pedicles. Seven months after injury, atlantoaxial transarticular screw fixation and sublaminar wiring of C1/C2 was done. Auto-graft bone from her rib and iliac were harvested and transplanted. Postoperatively, a halo vest orthosis was also used for stabilisation. Two months after operation, bony fusion was confirmed by CT and a halo vest orthosis was discontinued. One year after operation, the internal fixation devises were removed. There was no surgical complications. Two years following the injury, there are no detectable signs of neurological complications, but slightly loss of range of motion of the neck. We have experienced the case of a 2-year old girl, who was treated by atlantoaxial posterior fixation for an odontoid fracture with flexion-displacement.

Osteoid osteoma (OO) is a benign bone tumor. Curative treatment for OO is complete removal of the nidus；however this can sometime be difficult. Therapeutic modalities have been proposed including radiofrequency thermal coagulation. Spinal OOs, however, may not allow straightforward application of these techniques because of the latent risk of damaging the adjacent structures. Thus, establishment of an ideal treatment for spinal OOs remains undetermined.

We report the efficacy of a navigation system in excising OO localizing adjacent to the facet joint of C2. Complete and pin-point removal of the nidus was achieved. The navigation system was used to depict the lesion and to confirm its consequent excision. This technique also prevented excessive removal of the bone which can lead to spinal instability and possible damage of nearby structures.

Case Presentation：A 30-year-old male presented with pain in the left lower limb lasting for six months. Physical examination revealed slight weakness in his right quadriceps muscle. Computed tomography (CT) and MRI showed bony mass arising from the posterior wall of L1 vertebral body, which caused dural sac compression. The continuity of this lesion with the underlying native bone cortex and medullary canal suggested osteochondroma. Additionally, multiple lesions of osteochondroma in limbs and ribs were revealed by radiograph. The removal of the mass and L1/2 anterior fusion were successfully performed. Postoperative histopathology confirmed the diagnosis of osteochondroma with no malignancy.

Discussion：Osteochondroma is one of the most common primary bone tumors and can originate as solitary lesions or in the context of hereditary multiple osteochondroma(HMO). In this case, his brother and maternal relative also have similar multifocal bone tumors, which suggest the presence of HMO. Osteochondroma of the vertebral column with spinal cord compression is reported to be uncommon, especially in the lumbar spine. If accompanied by neurological symptoms, complete resection of the tumor is recommended to prevent local recurrence. Although postoperative CT confirmed complete excision and decompression, improvement of the pain was poor in the early postoperative period.

We report two cases of infectious spondylitis following major surgery. The first case was spondylitis after AAA rupture, where there was a skip lesion from T6 to T8 and T11/12. The second case was spondylitis after CABG, and the level was T8 to T10. In both cases, conservative therapy was selected at first, but failed. Both cases had severe collapse of vertebral body, and kyphotic deformity. Radical operation was performed. In the first case, a two staged operation was performed. The first stage was anterior debridement and reconstruction from T6 to T8 followed by posterior instrumentation and fusion from T4 to T10. The second stage was anterior debridement and fusion at T11/12 followed by posterior instrumentation and fusion from T4 to L2. On the other hand, posterior VCR was selected in the second case because of the history of thoracotomy. Postoperative clinical course was good in both cases. The diagnosis of spondylitis tended to be delayed, and the thoracotomy or laparotomy of the previous surgery made treatment of the spondylitis difficult.