Surgical simulation of circumferential osteotomy and correction of cervico-thoracic kyphoscoliosis for an irreducible old C6–C7 fracture dislocation

Background  Many different surgical procedures have been employed in the treatment of fracture dislocation at the middle to lower cervical spine. However, consistent protocols and procedures have not been fully established for the surgical correction of an irreducible old cervical fracture dislocation associated with spinal deformity. Methods  We report a case of irreducible cervical fracture dislocation and kyphoscoliosis, in which surgical simulation using a three-dimensional full-scale model was useful for circumferential corrective osteotomy at the C6–C7 level. A 56-year-old man was diagnosed with an irreducible fracture dislocation at the C6–C7 level 2 months after a motor vehicle accident. He showed torticollis, and complained of severe pain in his neck and left upper arm. Radiographic examinations revealed that the C6 vertebra was translated anteriorly and laterally to the C7 vertebra. A bony union had progressed at the fracture site, showing rigid cervico-thoracic kyphoscoliosis. To assist in the preoperative planning, we created a three-dimensional, full-scale model from the patient's computed tomography data. Using the model, we performed a simulation of the planned circumferential corrective osteotomy at the C6–C7 level. Results  Through the simulation, we could evaluate the deformed bony structures around the vertebral arteries at the C6–C7 level accurately. At the time of the actual surgery, corrective osteotomy combined with spinal fusion (C5–T2) with a pedicle screw-rod system was accomplished successfully without any neurovascular complications. After surgery, the patient experienced relief from pain, and his neck posture became normal. Conclusions  Surgical simulation using a three-dimensional, full-scale model was useful for improving the accuracy and safety of circumferential corrective osteotomy of the cervical spine.     

A case report of port-site metastasis of pancreatic cancer after laparoscope assistted distal pancreatectomy

Laparosopic port-site metastasis is rare, but a well recognized outcome following surgery in gastroenterological surgery for gastric cancer, colon cancer and gallbladder cancer with its etiology was not clearly understood. We report a port-site metastasis of pancreatic cancer diagnosed by position emission tomography( PET). A 49-year-old man was diagnosed as splenic tumor with pancreatic tail invasion due to malignant lymphoma, and received a laparoscope assisted distal pancreatectomy. Unsuspected pancreatic cancer was discovered with histological result of moderate differentiated invasive ductal adenocarcinoma of the pancreas infiltrating spleen. Systemic chemotherapy with 1,000 mg/m2 of gemcitabine (GEM) was performed for six months. Unfortunately, our patients relapsed one year after the surgery with multiple lesions in the peritoneum, abdominal wall, as well as a laparoscopic port-site metastasis. He was started on 100 mg/body of S-1 daily, subsequently, combined chemotherapy with GEM( 80 mg/m2) and S-1( 80 mg/body) was also performed. Furthermore, he underwent palliative radiation therapy( 40 Gy) to care the pain. Fortunately, a long-term survival of 3 years was elicited by these systemic treatments and radiography. Laparoscopic port-site metastases are associated with presence of advanced cancer. Therefore, we should carefully precede a laparoscopic resection against pancreatic cancer.     

Ependymal and choroid plexus tumors. Cytokeratin and GFAP expression

Twenty-six ependymal and 15 choroid plexus tumors were examined with monoclonal antibody against cytokeratin using the avidin-biotin-peroxidase complex (ABC) technique. Serial sections were examined with antisera to glial fibrillary acidic protein (GFAP). In five ependymal tumors (one ependymoma, two papillary ependymomas, and two primitive neuroectodermal tumors [PNET] with ependymal cells), a variable number of cytokeratin-positive cells were present. Most tumor cells (except two PNET) were positive with GFAP antisera. Many cytokeratin-positive cells were present in all choroid plexus tumors. GFAP-positive cells were present focally in six of 11 papillomas and in one of four carcinomas. Although their staining patterns and distribution were clearly different, focal coexistence of cytokeratin and GFAP was observed in six papillomas and two ependymal tumors. Thus, some ependymal tumors (especially papillary ependymomas and occasional PNET) and many choroid plexus tumors have demonstrable positivity with antibody to cytokeratin, suggesting a transitional cell type with features of both ependyma and choroid plexus.     

Neuronal and glial proteins in medulloblastomas. I. Immunohistochemical study

Neuronal and glial specific proteins were studied in 35 cases of medulloblastomas, using immunohistochemical methods and antibodies to neurofilament triplet proteins (NF68Kd, NF160Kd, NF210Kd), gamma-enolase, GFAP, S-100 protein, and myelin basic protein. NF160Kd positive cells were observed in 12 of the 35 cases. NF160Kd positive cells were noted in 2, but NF210Kd positive cells were not detected. Gamma-enolase positive cells were observed in 23 cases. GFAP and S-100 protein positive cells were seen in 25 and 28 cases respectively; many of these cells were reactive astrocytes. The myelin basic protein positive cells could not be identified. The expression of neuronal and glial proteins had no relation to the postoperative survival of patients with medulloblastoma, but gamma-enolase may be one factor for evaluating prognosis.     

Postoperative paralysis following posterior decompression with instrumented fusion for thoracic myelopathy caused by ossification of the posterior longitudinal ligament

A 60-year-old man presented with thoracic myelopathy due to ossification of the posterior longitudinal ligament (OPLL). His spinal cord was severely impinged anteriorly by a beak-type OPLL and posteriorly by ossification of the ligamentum flavum at T4/5. He underwent surgical posterior decompression with instrumented fusion (PDF). Immediately after surgery, he developed a Brown-Séquard-type paralysis, which spontaneously resolved without requiring the addition of OPLL extirpation. This example highlights that the risk of postoperative neurological deterioration cannot be eliminated even when PDF is selected as the surgical procedure for thoracic OPLL, especially in instances in which the spinal cord is severely compressed.