Transforaminal lumbar interbody fusion (TLIF) is widely accepted for the treatment of lumbar arthrodesis. However, the exact characteristics of TLIF depend on the number, location, shape, or materials of the interbody implants, and the type of posterior instrument. Clinical and biomechanical characteristics of each TLIF procedure are still unclear. The present study investigated the clinical and radiological improvements after single level asymmetrical TLIF, in which a single box-shaped spacer was obliquely inserted into the intervertebral space, for lumbar degenerative spondylolisthesis in patients with or without local coronal imbalance (LCI) at the operated level. The clinical records of 60 patients who underwent single level asymmetrical TLIF augmented with the pedicle screw fixation system from January 2005 to January 2011, were retrospectively reviewed. The patients were divided into the LCI group (n = 19) and non-LCI group (n = 41), based on segmental lateral translation or disc wedging at the operated site. Clinical recovery was significantly good in both groups at 2 years after surgery, but improvement of low back pain was significantly worse in the LCI group. Radiological examination revealed that the mean lumbar scoliotic angle was significantly worse in the LCI group postoperatively. Preoperative greater scoliotic angle and coronal off balance of the lumbar spine were related to unfavorable radiological outcomes. The present study showed that single level asymmetrical TLIF is an acceptable method for achieving good clinical and radiological outcomes for patients with symptomatic degenerative spondylolisthesis, however, the clinical benefits and realignment are limited if the patient has LCI at the operated site with greater scoliotic angle or coronal off balance of the lumbar spine.

An intramedullary spinal cord abscess, which is usually associated with discitis, is an uncommon but potentially important complication of vertebral osteomyelitis. The authors describe a rare case of an intramedullary conus medullaris abscess and lumbar osteomyelitis sparing the intervertebral discs and without discitis. The patient also developed a granuloma in the cauda equina during treatment. Diffusion-weighted MRI was useful for differentiating the granulomatous lesion from the relapse of infection. A 65-year-old immunocompetent man with moderately controlled diabetes presented with progressive lowerextremity numbness and weakness with urinary dysfunction. He had progressive paraparesis, bilateral leg paresthesia, and sphincter compromise. Magnetic resonance imaging revealed an intramedullary ring-enhanced lesion, which was hyperintense on diffusion-weighted images. The lesion, an intramedullary spinal cord abscess, was surgically drained. During antibiotic treatment, serial MRI showed an enlarging enhanced lesion in the cauda equina, and a recurrent infection was suspected. A second-look surgery confirmed the formation of a granuloma and the absence of a relapse of the abscess. Although the enhanced lesion increased in size, its intensity on diffusion-weighted images remained unchanged. After 3 months of antibiotic treatment, all enhanced lesions were diminished. An intramedullary spinal cord abscess is a rare but important complication of vertebral osteomyelitis, and it requires immediate treatment. Diffusion-weighted MRI was useful for the initial diagnosis as well as for monitoring treatment efficacy.

Cobb syndrome is a rare, noninherited, neurocutaneous disease characterized by vascular abnormality of the spinal cord and is associated with vascular lesions in the skin at the same metamere. The majority of spinal vascular lesions are arteriovenous malformations, and skin lesions are mostly port-wine angiomas. The authors report the first case of multiple intramedullary cavernous angiomas (CAs) accompanied by skin CAs within the same metamere. A 42-year-old man presented with an acute onset of gait disturbance, low-back pain, and urinary incontinence. Magnetic resonance imaging of the thoracolumbar spine showed homogeneously enhanced lesions on a contrast-enhanced T1-weighted image and a hypointense area on a T2*-weighted image surrounding this enhanced lesion, between the T-12 and S-1 levels. Purple protruding skin lesions were detected on the left side of his gluteal region. The patient received a laminectomy followed by evacuation of a hematoma and partial removal of the tumor, which completely resolved his neurological symptoms. Pathological examinations showed that the spinal and skin lesions were CAs, suggesting that these vascular lesions developed congenitally. Cavernous angiomas associated with Cobb syndrome present with multiple lesions spanning more than 3 vertebral levels, making it difficult to completely resect these tumors. Although Cobb syndrome is an uncommon disease entity, it should be considered if a patient manifesting with neurological deficits has skin vascular lesions, including CAs.

Objective: Recently, dual-antiplatelet therapy (DAPT) including clopidogrel (CLP) with endovascular treatment for unruptured cerebral aneurysm has been widely accepted. However, patients who are poor metabolizers of CLP (CLPPMs) are more frequent in East Asians than in Caucasians, and an adequate antiplatelet effect may not be achieved with a normal dose in such patients. Prasugrel, which is a novel thienopyridine antiplatelet drug that is less likely to be poorly metabolized than CLP, is used widely for percutaneous coronary intervention, but its efficacy and safety with neuroendovascular treatment have not been elucidated. From this point of view, the purpose of this study was to elucidate the safety and efficacy of prasugrel with endovascular treatment for unruptured cerebral aneurysm. Methods:We investigated 108 consecutive patients with an unruptured cerebral aneurysm who underwent endovascular treatment from March 2015 to January 2016 in our hospital. All patients received DAPT with 100 mg aspirin and 75 mg CLP daily, and antiplatelet function was evaluated by VerifyNow (Accumetrics, San Diego, CA, USA). In patients with P2Y12 reaction units (PRU) over 230, prasugrel was administered with a loading dose of 20 mg and a maintenance dose of 3.75 mg daily.Results: Prasugrel was administered to 12 patients in our series. Of these patients, the mean age was 63.1 ± 13.0 years, and the mean PRU was 272 ± 20. Eleven patients received endovascular treatment with intracranial stents, of which four patients received treatment with flow diverters. The mean observational period was 5-13 months (median: 6.5), and no symptomatic hemorrhagic and ischemic complications occurred. Mean PRU was decreased to 159 ± 63 in the six patients in which PRU were re-examined. Conclusion:Prasugrel is safe and effective with endovascular treatment for unruptured cerebral aneurysm in CLP-PMs.

Objective: Intracranial hemorrhage (ICH) after endovascular revascularization (ER) for acute ischemic stroke is associated with poor outcome. In this study, we examined the risk factors for postoperative ICH in patients who underwent ER in our hospital. Methods:We investigated the incidence/type of postoperative ICH and risk factors in 157 patients who underwent ER in our hospital from July 2011 to June 2015.Results: Postoperative ICH, including asymptomatic ICH, was observed in 57 (36.3%) patients. Symptomatic ICH occurred in seven patients (4.5%). According to the Safe Implementation of Thrombolysis in Stroke-Monitoring Study classification, hemorrhagic infarction type 2 and parenchymal hematoma type 2 were observed in 27 (47.4%) and 4 (7.0%) patients, respectively, of all patients with ICH. The frequency of patients with functional independence (score of 0-2 on the modified Rankin scale) 90 days after ER was significantly lower in patients with than without ICH (p <0.01).We performed a multivariate analysis of factors associated with postoperative ICH. The oral administration of anticoagulants prior to onset (p = 0.019; odds ratio [OR], 3.17; 95% confidence interval [CI], 1.22-8.54) and a prolonged onset-to-recanalization time (p = 0.043; OR, 1.11; 95% CI, 1.01-1.24) were associated with poor outcome.Conclusion: ICH after ER may lead to an unfavorable outcome. Risk factors for ICH after ER included the oral administration of anticoagulants prior to onset and a prolonged onset-to-recanalization time.