Published papers

Adolescent idiopathic scoliosis is a pediatric spinal deformity affecting 2-3% of school-age children worldwide. Genetic factors have been implicated in its etiology. Through a genome-wide association study (GWAS) and replication study involving a total of 1,376 Japanese females with adolescent idiopathic scoliosis and 11,297 female controls, we identified a locus at chromosome 10q24.31 associated with adolescent idiopathic scoliosis susceptibility. The most significant SNP (rs11190870; combined P = 1.24 × 10 -19; odds ratio (OR) = 1.56) is located near LBX1 (encoding ladybird homeobox 1). The identification of this susceptibility locus provides new insights into the pathogenesis of adolescent idiopathic scoliosis. © 2011 Nature America, Inc. All rights reserved.

Previous studies have revealed various extrinsic stimuli and factors involved in the regulation of hematopoiesis. Among these, Notch-mediated signaling has been suggested to be critically involved in this process. Herein, we show that conditional inactivation of ADAM10, a membrane-bound protease with a crucial role in Notch signaling (S2 cleavage), results in myeloproliferative disorder (MPD) highlighted by severe splenomegaly and increased populations of myeloid cells and hematopoietic stem cells. Reciprocal transfer of bone marrow cells between wild-type and ADAM10 mutant mice revealed that ADAM10 activity in both hematopoietic and nonhematopoietic cells is involved in the development of MPD. Notably, we found that MPD caused by lack of ADAM10 in nonhematopoietic cells was mediated by G-CSF, whereas MPD caused by ADAM10-deficient hematopoietic cells was not. Taken together, the present findings reveal previously undescribed nonredundant roles of cell-autonomous and non-cell-autonomous ADAM10 activity in the maintenance of hematopoiesis. © 2011 by The American Society of Hematology.

Background: Lumbar spinal canal stenosis (LSCS) is one of the most common spinal disorders in the elderly, and ligamentum flavum (LF) hypertrophy is an important cause of LSCS. Matrix metalloproteinase 13 (MMP13) can degrade fibrillar collagens and elastic microfibrils, and is involved in inflammation and fibrosis. The purpose of this study was to compare the expression of MMP13 in the LF from LSCS patients with diabetes mellitus [DM (+)] with that in the LF from patients without DM [DM (-)] and to analyze the relationship among DM, MMP13 expression, and LF hypertrophy. Methods: LFs from 11 DM (+) and 24 DM (-) LSCS patients were analyzed in this study. Histology analysis using hematoxylin and eosin and Masson's trichrome stain was performed for each LF. The expression of MMP13 was analyzed by quantitative real-time PCR. The thickness of LF was measured by CT. Results: In the LF from DM (+) LSCS patients, the elastic fibers were more disorganized and had lower volumes than in the LF from DM (-) LSCS patients, while more fibrotic tissue was observed in the LF from DM (+) than from DM (-) LSCS patients. MMP13 expression was significantly higher in the LF from DM (+) LSCS patients (0.46 ± 0.61 vs. 0.05 ± 0.09, P = 0.002). The LF from the DM (+) LSCS patients was significantly thicker than that from the DM (-) LSCS patients (5.0 ± 0.9 vs. 3.1 ± 0.8 mm, P < 0.01), and the thickness was correlated with the expression of MMP13 (correlation coefficient = 0.43, P = 0.01, Pearson's correlation test). Conclusion: DM-related MMP13 expression can be one of the factors contributing to fibrosis and hypertrophy of the LF. Further research on the mechanism of this process may lead to new therapies for LF hypertrophy. © 2011 The Japanese Orthopaedic Association.

To clarify the mechanism of osteoporosis in adolescent idiopathic scoliosis (AIS), we investigated radiological and histological changes in the cervical vertebrae of a chicken thoracic scoliosis model. Forty newly hatched broiler chicks were randomly divided into four equal groups: sham-operated chickens serving as control (CON), pinealectomized chickens (PNX), sham-operated (CON + MLT) and pinealectomized chickens (PNX + MLT) that received intraperitoneal administration of melatonin. Pinealectomy was performed at the age of 3 days, and the chickens were killed at 2 months of age. Postmortem X-rays were examined for the presence of scoliosis, and micro-computed tomography (micro-CT) images were taken to evaluate the microstructure of the cervical vertebrae. Histological specimens of the scanned cervical vertebra were prepared, and a midsagittal section was stained with hematoxylin and eosin and tartrate-resistant acid phosphatase to evaluate the numbers of osteoblasts and osteoclasts, respectively. Scoliosis developed at the thoracic spine in all chickens of the PNX and in two of the PNX + MLT group. Micro-CT data revealed that chickens in the PNX group had a greater degree of generalized osteoporosis compared with the other birds. The number of osteoblasts was significantly decreased in the PNX group, while no significant difference was observed among chickens in the numbers of osteoclasts. Our results suggest that melatonin deficiency reduces osteoblast proliferation and leads to the development of scoliosis and osteoporosis. The restoration of melatonin prevented the development of scoliosis and osteoporosis, indicating that melatonin levels may be crucial to the development of deformity and osteoporosis in AIS. © 2011 John Wiley & Sons A/S.

Object. The aim of this study was to evaluate the outcomes of fusion surgery in patients with ossification of the posterior longitudinal ligament in the thoracic spine (T-OPLL) and to identify factors significantly related to surgical outcomes. Methods. The study included 76 patients (34 men and 42 women with a mean age of 56.3 years) who underwent fusion surgery for T-OPLL at 7 spine centers during the 5-year period from 2003 to 2007. The authors evaluated the patient demographic data, underlying disease, preoperative comorbidities, history of spinal surgery, radiological findings, surgical methods, surgical outcomes, and complications. Surgical outcomes were assessed using the Japanese Orthopaedic Association (JOA) scale score for thoracic myelopathy (11 points) and the recovery rate. Results. The mean JOA scale score was 4.6 ± 2.1 points preoperatively and 7.7 ± 2.5 points at the time of the final follow-up examination, yielding a mean recovery rate of 45.4% ± 39.1%. The recovery rates by surgical method were 38.5% ± 37.8% for posterior decompression and fusion, 65.0% ± 35.6% for anterior decompression and fusion via an anterior approach, 28.8% ± 41.2% for anterior decompression via a posterior approach, and 57.5% ± 41.1% for circumferential decompression and fusion. The recovery rate was significantly higher in patients without diabetes mellitus (DM) than in those with DM. One or more complications were experienced by 31 patients (40.8%), including 20 patients with postoperative neurological deterioration, 7 with dural tears, 5 with epidural hematomas, 4 with respiratory complications, and 10 with other complications. Conclusions. The outcomes of fusion surgery for T-OPLL were favorable. The absence of DM correlated with better outcomes. However, a high rate of complications was associated with the fusion surgery.

There has been no prospective study on agerelated changes of the extensor muscles of the cervical spine in healthy subjects. This study was conducted to elucidate any association between the changes in cross-sectional area of the extensor muscles of the cervical spine on MRIs and cervical disc degeneration or the development of clinical symptoms. Sixty-two subjects who underwent MR imaging by a 1.5-Tesla machine between 1993 and 1996 as asymptomatic volunteers in a previous study were recruited again 10 years later for this follow-up study. The mean interval between the studies was 11.0 ± 0.7 years. The cross-sectional areas of the multifidus, semispinalis cervicis, semispinalis capitis, and splenius capitis at C3-C4, C4-C5, and C5-C6 intervertebral levels were measured on T2-weighted axial images using Image J 1.42. The mean cross-sectional areas of the deep extensor muscles were 1,396.8 ± 337.6 mm 2 at the C3-C4 level, 1,514.7 ± 381.0 mm 2 at the C4-C5 level, and 1,542.8 ± 373.5 mm2 at the C5-C6 level in the previous investigation. The cross-sectional areas were 1,498.7 ± 374.4 mm2 at the C3-C4 level, 1,569.9 ± 390.9 mm 2 at the C4-C5 level, and 1,599.6 ± 364.3 mm 2 at the 10-year follow-up. An increase in the cross-sectional area of the muscles was more frequently observed in subjects in their tens to thirties in the initial study, while a decrease was more frequently observed in those in their forties and older in the initial study. Disc degeneration was not correlated with a change in extensor muscle volume. Development of shoulder stiffness during follow-up was significantly negatively correlated with a change in the cross-sectional area of the deep extensor muscles. © Springer-Verlag 2011.

Object. The object of this study was to investigate failures after spinal reconstruction following total en bloc spondylectomy (TES), related factors, and sequelae arising from such failures in patients with malignant spinal tumors. Methods. Fifteen patients (12 males and 3 females, with a mean age of 46.5 years) with malignant spinal tumors who underwent TES and survived for more than 1 year were included in this analysis (mean follow-up 41.5 months). Seven patients had primary tumors, including giant cell tumors in 4 patients, chordoma in 2, and Ewing sarcoma in 1. Eight patients had metastatic tumors, including thyroid cancer in 6 and renal cell cancer and malignant fibrous histiocytoma in 1 patient each. Seven patients without prominent paravertebral extension of the tumor were treated using a posterior approach alone, and 8 patients who exhibited prominent anterior or anterolateral extension of the tumors into the thoracic or abdominal cavity were treated using a combined anterior and posterior approach. Spinal reconstruction after tumor resection was performed using a combination of anterior structural support and posterior instrumentation. The relationship between instrumentation failure and clinical and radiographic factors, including age, sex, history of previous surgery, preoperative radiotherapy, tumor histology, tumor level, surgical approach, number of resected vertebrae, rod diameter, number of instrumented vertebrae, and cage subsidence, was investigated. Results. Six patients (40%) with spinal instrumentation failure were identified: rod breakage occurred in 3 patients, and breakage of both the rod and the cage, combined cage breakage and screw back-out, and endplate fracture arising from cage subsidence occurred in 1 patient each. All of these patients experienced acute or chronic back pain, but only 1 patient with a tumor recurrence experienced neurological deterioration upon instrumentation failure. Cage subsidence (≥ 5 mm), preoperative irradiation, and the number of instrumented vertebrae (≤ 4 vertebrae) were significantly related to late instrumentation failure. Conclusions. Late instrumentation failure was a frequent complication after TES. Although patients with instrumentation failure experienced back pain, the neurological sequelae were not catastrophic. For prevention, meticulous preparation of the graft site and a longer posterior fixation should be considered.

Background: Because of the lack of long-term postoperative follow-up studies of idiopathic spinal cord herniation (ISCH), there is little information about the long-term effectiveness and complications of the dural defect enlargement in patients with ISCH. The purpose of this study is to determine the long-term effectiveness of this procedure. Methods: Sixteen patients with ISCH were treated surgically by enlargement of the dural defect. The patient's neurological status and surgical outcome were evaluated by the JOA scores for thoracic myelopathy and the recovery rate (mean follow-up period 9.6 years). Correlations between the surgical outcomes and patients' age and duration of disease were assessed retrospectively. The patients were also divided into two groups based on the location of the dural defect: the ventro-lateral (VL) group and the ventral (V) group. The difference in the duration of disease, preoperative JOA score, and the recovery rate were compared between the two groups. Results: There was no recurrence of ISCH after surgery. The mean recovery rate was 42.6%. There was a significant correlation between the patient's age and the recovery rate, and between the duration of disease and the recovery rate. The median recovery rate was significantly lower in the V group than in the VL group. There were no complications related to CSF leakage after surgery. Conclusions: Long-term surgical outcomes of enlargement of the dural defect for ISCH were stable and favorable without recurrences or any complications. This procedure should be considered for patients with ISCH before their neurological deficit worsens, especially for the patients in whom the dural defect is located at the ventral part of the dural canal. © 2011 The Author(s).

Adolescent idiopathic scoliosis (AIS) is a spinal deformity most commonly arising in apparently healthy girls around puberty. AIS has a strong genetic predisposition. Several genetic associations between AIS and single nucleotide polymorphisms (SNPs) have been reported; common SNPs in the genes for matrilin 1 (MATN1), melatonin receptor 1B (MTNR1B), tryptophan hydroxylase 1 (TPH1), and insulin-like growth factor 1 (IGF1) are reported to be associated with AIS in Chinese. However, these associations have not been replicated so far. To confirm the associations, we compared these SNPs with AIS predisposition and curve severity in a population of Japanese females consisting of 798 AIS patients and 1,239 controls. All the subjects were genotyped using the PCR-based Invader assay. We found no association of any of the SNPs with AIS predisposition or curve severity. Considering the statistical power and sample size of the present study, we concluded that these SNPs are not associated with either AIS predisposition or curve severity in Japanese. © 2011 Orthopaedic Research Society Published by Wiley Periodicals, Inc.

STUDY DESIGN.: Retrospective multi-institutional study. OBJECTIVE.: To investigate the incidence of neurological deficits after cervical laminoplasty for ossification of the posterior longitudinal ligament (OPLL). SUMMARY OF BACKGROUND DATA.: According to analysis of long-term results, laminoplasty for cervical OPLL has been reported as a safe and effective alternative procedure with few complications. However, perioperative neurological complication rates of laminoplasty for cervical OPLL have not been well described. METHODS.: Subjects comprised 581 patients (458 men and 123 women; mean age: 62 ± 10 years; range: 30-86 years) who had undergone laminoplasty for cervical OPLL at 27 institutions between 2005 and 2008. Continuous-type OPLL was seen in 114, segmental-type in 146, mixed-type in 265, local-type in 24, and not judged in 32 patients. Postoperative neurological complications within 2 weeks after laminoplasty were analyzed in detail. Cobb angle between C2 and C7 (C2/C7 angle), maximal thickness, and occupying rate of OPLL were investigated. Pre- and postoperative magnetic resonance imaging was performed on patients with postoperative neurological complications. RESULTS.: Open-door laminoplasty was conducted in 237, double-door laminoplasty in 311, and other types of laminoplasty in 33 patients. Deterioration of lower-extremity function occurred after laminoplasty in 18 patients (3.1%). Causes of deterioration were epidural hematoma in 3, spinal cord herniation through injured dura mater in 1, incomplete laminoplasty due to vertebral artery injury while making a trough in 1, and unidentified in 13 patients. Prevalence of unsatisfactory recovery not reaching preoperative level by 6-month follow-up was 7/581 (1.2%). Mean occupying rate of OPLL for patients with deteriorated lower-extremity function was 51.2 ± 13.6% (range, 21.0%-73.3%), significantly higher than the 42.3 ± 13.0% for patients without deterioration. OPLL thickness was also higher in patients with deterioration (mean, 6.6 ± 2.2 mm) than in those without deterioration (mean, 5.7 ± 2.0 mm). No significant difference in C2/C7 lordotic angle was seen between groups. CONCLUSION.: Although most neurological deterioration can be expected to recover to some extent, the frequency of short-term neurological complications was higher than the authors expected. Copyright © 2011 Lippincott Williams & Wilkins.

Adolescent idiopathic scoliosis (AIS) is a common disorder with a strong genetic predisposition. Associations between AIS and common single nucleotide polymorphisms (SNPs) in estrogen receptor genes have been reported. rs9340799 in the gene for estrogen receptor α (ESR1) is reported to be associated with curve severity in Japanese and with AIS predisposition and curve severity in Chinese. In addition, rs1256120 in the gene for estrogen receptor β (ESR2) is reported to be associated with AIS predisposition and curve severity in Chinese. However, the sample sizes of these previous studies were small, and the associations of these SNPs have not been replicated. To examine the association between AIS and estrogen receptor genes, we investigated the association of rs9340799 and rs1256120 with AIS predisposition and curve severity using a large Japanese population, consisting of 798 AIS patients and 637 sex-matched controls. We found no association of either SNP with AIS predisposition or curve severity in the Japanese population. Considering the statistical power of the present study and the limitations of the previous reports, we conclude that the associations of rs9340799 and rs1256120 with AIS predisposition and curve severity are negative. © 2010 Orthopaedic Research Society Published by Wiley Periodicals, Inc.

Primary spinal primitive neuroectodermal tumors (PNETs) are very rare conditions. Most of these tumors occur in children and young adults. A 63-year-old man with a primary spinal PNET in the conus medullaris from the L1 to L2 level is presented in this report. The optimal treatment of primary spinal PNETs is yet unknown. Surgical resection, radiation therapy, and chemotherapy have been advocated for the treatment of spinal PNET based on PNETs at other sites. However, the outcome is very poor. There are a few reports of cases with long-term survival and no recurrence. In these patients, en bloc resections were performed. Copyright © 2011 S. Karger AG, Basel.

An association between progression of cervical disc degeneration and that of lumbar disc degeneration has been considered to exist. To date, however, this association has not yet been adequately studied. Age-related changes in the cervical intervertebral discs were evaluated by magnetic resonance imaging (MRI) in patients with lumbar disc herniation, and compared with the MRI findings of healthy volunteers without lower back pain. The purpose of this study was to clarify whether the prevalence of asymptomatic cervical disc degeneration is higher in patients with lumbar disc herniation than in healthy volunteers. The study was conducted on 51 patients who were diagnosed as having lumbar disc herniation and underwent cervical spine MRI. The patients consisted of 34 males and 17 females ranging in age from 21-83 years (mean 46.9 ± 14.5 years) at the time of the study. The control group was composed of 113 healthy volunteers (70 males and 43 females) aged 24-77 years (mean 48.9 ± 14.7 years), without neck pain or low back pain. The percentage of subjects with degenerative changes in the cervical discs was 98.0% in the lumbar disc herniation group and 88.5% in the control group (p = 0.034). The presence of lumbar disc herniation was associated significantly with decrease in signal intensity of intervertebral disc and posterior disc protrusion in the cervical spine. None of the MRI findings was significantly associated with the gender, smoking, sports activities, or BMI. As compared to healthy volunteers, patients with lumbar disc herniation showed a higher prevalence of decrease in signal intensity of intervertebral disc and posterior disc protrusion on MRI of the cervical spine. The result of this study suggests that disc degeneration appears to be a systemic phenomenon. © Springer-Verlag 2010.

Purpose: Wedging of the vertebral body on radiological examination is a valuable indicator of a vertebral compression fracture, although it can also be observed in subjects with no history of trauma. The purpose of this study was to elucidate the normative value of vertebral wedging at the thoracolumbar junction in asymptomatic healthy subjects for differential diagnosis of vertebral compression fractures using MRI. Methods: A total of 115 subjects without back pain at the time of the examination and without history of spinal trauma was included (68 males, 47 females, mean age 49.5 years). They underwent MRI of the thoracic and lumbar spine, and the ratio of anterior vertical height to posterior vertical height of the vertebral body (APR) was determined from T10 to L2 on T2 weighted sagittal images. Results: APR was 0.92 ± 0.08 at T10, 0.92 ± 0.08 at T11, 0.90 ± 0.06 at T12, 0.89 ± 0.06 at L1, and 0.90 ± 0.07 at L2, indicating that vertebral bodies at the thoracolumbar junction appear wedge-shaped rather than rectangular. Males, thinner subjects, smokers, and subjects with abnormalities of the endplates such as a Schmorl nodule had a significantly smaller APR than females, fatter subjects, non-smokers, and those without endplate abnormalities. Conclusion: The normative values of APR obtained in the present study can represent a valuable reference in the diagnosis of vertebral compression fracture to help prevent confusion with physiological vertebral wedging. © 2010 Springer-Verlag.

Study Design.: Case report. OBJECTIVE:: To report an extremely rare case of spinal dumbbell-type tanycyticependymoma. Summary of Background Data.: Only two previous cases of a dumbbell-type tanycyticependymoma in the spinal cordhave been reported. Methods.: A 40-year-old female presented with low back pain and numbness of the left leg. Magnetic resonance imaging revealed a dumbbell tumor at the Th10-11 level that compressed the spinal cord extensively. The diagnosis of extradural dumbell spinal tumor was made, and a total tumor excision was performed with a thoracic 10-11 laminectomy. Results.: After surgery, the patient's low back pain and numbness disappeared. Detailed immunohistological examinations confirmed the diagnosis of tanycyticependymoma. At 16 months, there was no evidence of tumor recurrence and no further treatment was needed. Conclusion.: A rare case of spinal dumbbell-type tanycyticependy-moma was presented. Detailed histologic examinations are essential to differentiate tanycyticependymoma from other tumors such as schwannoma and pilocyticastrocytoma. © 2011, Lippincott Williams & Wilkins.

A 32-year-old woman was referred to our hospital for a refractory ulcer on her back. She had a history of myelomeningocele with spina bifida that was treated surgically at birth. The ulcer was located at the apex of the kyphosis. An X-ray film revealed a kyphosis of 154° between L1 and 3 and a scoliosis of 60° between T11 and L5. Computed tomography, magnetic resonance imaging and laboratory data indicated the presence of a pyogenic spondylitis at L2/3. To correct the kyphosis and remove the infected vertebrae together with the skin ulcer, kyphectomy was performed. Pedicle screws were inserted from T8 to T12 and from L4 to S1. The dural sac was transected and ligated at L2, followed by total kyphectomy of the L1-L3 vertebrae. The spinal column was reconstructed by approximating the ventral wall of the T12 vertebral body and the cranial endplate of the L4 vertebra. Postoperatively, the kyphosis was corrected to 61° and the scoliosis was corrected to 22°. In the present case, we treated the skin ulcer and pyogenic spondylitis successfully by kyphectomy, thereby, preventing recurrence of the ulcer and infection, and simultaneously obtaining sufficient correction of the spinal deformity. © 2011 Yoshioka et al; licensee BioMed Central Ltd.

Background: Shprintzen-Goldberg syndrome (SGS) is characterized by craniosynostosis and marfanoid habitus. The clinical findings of SGS include neurological, cardiovascular, connective tissue, and skeletal abnormalities. Among these skeletal findings, developmental scoliosis is recognized in half of all patients with SGS. However, no earlier reports have described the surgical treatment of scoliosis associated with SGS. Methods: Four patients (2 boys and 2 girls; mean age at the time of surgery, 7.3±4.4 y) with SGS who underwent surgical treatment for progressive scoliosis were reviewed. The radiologic findings, operative findings, and perioperative complications were evaluated. Results: The mean preoperative Cobb angle was 102.8±16.9 degrees. The curve patterns were a double curve in 2 cases and a triple curve in 2 cases. Local kyphosis at the thoracolumbar area was recognized in all the cases with a mean kyphosis angle of 49±16 degrees. Growing rod procedures were performed in 2 patients, and posterior correction and fusion were performed in 2 patients. The mean correction rate was 45% in the patients who underwent the growing rod procedures at the time of growing rod placement and 51% in the patients who underwent posterior correction and fusion. Dislodgement of the proximal anchors occurred in 3 of the 4 patients. One patient developed pseudoarthrosis. Two patients developed deep wound infections, and implant removal was necessary in 1 patient. Conclusions: Surgical treatment for scoliosis in patients with SGS was associated with a high incidence of perioperative and postoperative complications including implant dislodgements and deep wound infections attributable to poor bone quality and a thin body habitus, which are characteristic clinical features of this syndrome. Careful preoperative surgical planning and postoperative care are critical for the surgical treatment of scoliosis associated with SGS, especially in infants requiring multiple surgeries. Level of evidence: Level IV. © 2011 by Lippincott Williams & Wilkins.

Cavernous hemangioma consists mainly of congenital vascular malformations present before birth and gradually increasing in size with skeletal growth. A small number of patients with cavernous hemangioma develop scoliosis, and surgical treatment for the scoliosis in such cases has not been reported to date. Here we report a 12-year-old male patient with severe progressive scoliosis due to a huge subcutaneous cavernous hemangioma, who underwent posterior correction and fusion surgery. Upon referral to our department, radiographs revealed a scoliosis of 85° at T6-L1 and a kyphosis of 58° at T4-T10. CT and MR images revealed a huge hemangioma extending from the subcutaneous region to the paraspinal muscles and the retroperitoneal space and invading the spinal canal. Posterior correction and fusion surgery using pedicle screws between T2 and L3 were performed. Massive hemorrhage from the hemangioma occurred during the surgery, with intraoperative blood loss reaching 2800 ml. The scoliosis was corrected to 59°, and the kyphosis to 45° after surgery. Seven hours after surgery, the patient suffered from hypovolemic shock and disseminated intravascular coagulation due to postoperative hemorrhage from the hemangioma. The patient developed sensory and conduction aphasia caused by cerebral hypoxia during the shock on the day of the surgery. At present, two years after the surgery, although the patient has completely recovered from the aphasia. This case illustrates that, in correction surgery for scoliosis due to huge subcutaneous cavernous hemangioma, intraoperative and postoperative intensive care for hemodynamics should be performed, since massive hemorrhage can occur during the postoperative period as well as the intraoperative period.© 2011 Ogura et al; licensee BioMed Central Ltd.

A butterfly vertebra is a congenital anomaly often associated with a series of syndromic diseases and is often recognized incidentally without any presenting symptoms. The authors report the case of a 13-year-old girl with lumbar scoliosis and mild spondylolisthesis associated with a butterfly vertebra at L-6 causing radiculopathy. The L-5 and L-6 nerve roots were entrapped at the intervertebral foramina between L-5 and the butterfly vertebra (L-6) and between L-6 and S-1 in the concave side. To decompress and preserve the two nerve roots, correct the deformity, and obtain a solid bone fusion, surgery involving the thorough removal of the facet joints between L-5 and L-6 and between L-6 and S-1 in the concave side was performed, with a partial resection of the butterfly vertebra and the placement of a titanium mesh cage between the L-5 and S-1 pedicles dorsal to the nerve roots. Complete pain relief and correction of the deformity with solid bone fusion was obtained after a 2-year follow-up period.