Purpose: Cervical laminoplasty has been used for the treatment of cervical arthrosic myelopathy in Japan. The purpose of this work was to assess clinical and radiological outcome at more than two years follow-up.

Material: Thirty-one patients underwent laminoplasty of three levels or more for cervical arthrosic myelopathy and were reviewed more than two years after surgery.

Methods: The Japanese Orthopaedic Association score was used to assess function preoperatively and at last follow-up. Preoperative and last follow-up standard strict lateral and flexion and extension x-rays of the cervical spine were available for all patients. The curvature was assessed on the lateral view in the neutral position (C2–C7 Cobb angle). Overall mobility was assessed on the dynamic views.

Results: The mean preoperative score was 9.7, improving to 138 at last follow-up (p < 0.0001, paired t test). Mean relative gain was 52.9%. The mean Cobb angle was 17° preoperatively and 8.9° at last follow-up. Cervical spine curvature and overall mobility had no influence on the score at last follow-up. The postoperative Cobb score was only influenced by the preoperative angle (p < 0.0001). There were no reoperations for instability.

Discussion: Guigui has demonstrated that mean loss of cervical lordosis in a series of extended laminectomies was 14°. In our series, mean loss of cervical lordosis was 8.1°. Laminoplasty enables a better preservation of cervical lordosis than laminectomy. Guigui also reported three patients requiring reoperation because of an unstable spine after laminectomy. Inversely, we did not have any cases requiring reoperation. During laminoplasty, a gutter is fashioned in a medial quarter of the articular masses to open the lamina, producing their fusion. This unexpected fusion diminishes overall mobility but also has a less destabilising effect on the spine than laminectomy.

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