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1.  Factors affecting disability and physical function in degenerative lumbar spondylolisthesis of L4–5: evaluation with axially loaded MRI 
European Spine Journal  2009;18(12):1851-1857.
Few studies have investigated the factors related to the disability and physical function in degenerative lumbar spondylolisthesis using axially loaded magnetic resonance imaging (MRI). Therefore, we aimed to investigate the effect of axial loading on the morphology of the spine and the spinal canal in patients with degenerative spondylolisthesis of L4–5 and to correlate morphologic changes to their disability and physical functions. From March 2003 to January 2004, 32 consecutive cases (26 females, 6 males) with degenerative L4–5 spondylolisthesis, grade 1–2, intermittent claudication, and low back pain without sciatica were included in this study. All patients underwent unloaded and axially loaded MRI of the lumbo-sacral spine in supine position to elucidate the morphological findings and to measure the parameters of MRI, including disc height (DH), sagittal translation (ST), segmental angulation (SA), dural sac cross-sectional area (DCSA) at L4–5, and lumbar lordotic angles (LLA) at L1–5 between the unloaded and axially loaded condition. Each patient’s disability was evaluated by the Oswestry Disability Index (ODI) questionnaire, and physical functioning (PF) was evaluated by the Physical Function scale proposed by Stucki et al. (Spine 21:796–803, 1996). Three patients were excluded due to the presence of neurologic symptoms found with the axially loaded MRI. Finally, a total of 29 (5 males, 24 females) consecutive patients were included in this study. Comparisons and correlations were done to determine which parameters were critical to the patient’s disability and PF. The morphologies of the lumbar spine changed after axially loaded MRI. In six of our patients, we observed adjacent segment degeneration (4 L3–L4 and 2 L5–S1) coexisting with degenerative spondylolisthesis of L4–L5 under axially loaded MRI. The mean values of the SA under pre-load and post-load were 7.14° and 5.90° at L4–L5 (listhetic level), respectively. The mean values of the LLA under pre-load and post-load were 37.03° and 39.28°, respectively. There were significant correlations only between the ODI, PF, and the difference of SA, and between PF and the post-loaded LLA. The changes in SA (L4–L5) during axial loading were well correlated to the ODI and PF scores. In addition, the LLA (L1–L5) under axial loading was well correlated to the PF of patients with degenerative L4–L5 spondylolisthesis. We suggest that the angular instability of the intervertebral disc may play a more important role than neurological compression in the pathogenesis of disability in degenerative lumbar spondylolisthesis.
PMCID: PMC2899437  PMID: 19526378
Degenerative lumbar spondylolisthesis; Axially loaded MRI; Disability; Physical functioning; Segmental angulation
2.  Biomechanical analysis of the lumbar spine on facet joint force and intradiscal pressure - a finite element study 
Finite element analysis results will show significant differences if the model used is performed under various material properties, geometries, loading modes or other conditions. This study adopted an FE model, taking into account the possible asymmetry inherently existing in the spine with respect to the sagittal plane, with a more geometrically realistic outline to analyze and compare the biomechanical behaviour of the lumbar spine with regard to the facet force and intradiscal pressure, which are associated with low back pain symptoms and other spinal disorders. Dealing carefully with the contact surfaces of the facet joints at various levels of the lumbar spine can potentially help us further ascertain physiological behaviour concerning the frictional effects of facet joints under separate loadings or the responses to the compressive loads in the discs.
A lumbar spine model was constructed from processes including smoothing the bony outline of each scan image, stacking the boundary lines into a smooth surface model, and subsequent further processing in order to conform with the purpose of effective finite element analysis performance. For simplicity, most spinal components were modelled as isotropic and linear materials with the exception of spinal ligaments (bilinear). The contact behaviour of the facet joints and changes of the intradiscal pressure with different postures were analyzed.
The results revealed that asymmetric responses of the facet joint forces exist in various postures and that such effect is amplified with larger loadings. In axial rotation, the facet joint forces were relatively larger in the contralateral facet joints than in the ipsilateral ones at the same level. Although the effect of the preloads on facet joint forces was not apparent, intradiscal pressure did increase with preload, and its magnitude increased more markedly in flexion than in extension and axial rotation.
Disc pressures showed a significant increase with preload and changed more noticeably in flexion than in extension or in axial rotation. Compared with the applied preloads, the postures played a more important role, especially in axial rotation; the facet joint forces were increased in the contralateral facet joints as compared to the ipsilateral ones at the same level of the lumbar spine.
PMCID: PMC2913991  PMID: 20602783
3.  Mini-open anterior spine surgery for anterior lumbar diseases 
European Spine Journal  2008;17(5):691-697.
Minimally invasive surgeries including endoscopic surgery and mini-open surgery are current trend of spine surgery, and its main advantages are shorter recovery time and cosmetic benefits, etc. However, mini-open surgery is easier and less technique demanding than endoscopic surgery. Besides, anterior spinal fusion is better than posterior spinal fusion while considering the physiological loading, back muscle function, etc. Therefore, we aimed to introduce the modified “mini-open anterior spine surgery” (MOASS) and to evaluate the feasibility, effectiveness and safety in the treatment of various anterior lumbar diseases with this technique. A total of 61 consecutive patients (46 female, 15 male; mean age 58.2 years) from 1997 to 2004 were included in this study, with an average follow-up of 24–52 (mean 43) months. The disease entities included vertebral fracture (20), failed back surgery (13), segmental instability or spondylolisthesis (10), infection (8), herniated disc (5), undetermined lesion for biopsy (4), and hemivertebra (1). Lesions involved 13 cases at T12–L1, 18 at L1–L2, 18 at L2–L3, 22 at L3–L4 and 11 at L4–L5 levels. All patients received a single stage anterior-only procedure for their anterior lumbar disease. We used the subjective clinical results, Oswestry disability index, fusion rate, and complications to evaluate our clinical outcome. Most patients (91.8%) were subjectively satisfied with the surgery and had good-to-excellent outcomes. Mean operation time was 85 (62–124) minutes, and mean blood loss was 136 (minimal-250) ml in the past 6 years. Hospital stay ranged from 4–26 (mean 10.6) days. Nearly all cases had improved back pain (87%), physical function (90%) and life quality (85%). Most cases (95%) achieved solid or probable solid bony fusion. There were no major complications. Therefore, MOASS is feasible, effective and safe for patients with various anterior lumbar diseases.
PMCID: PMC2367411  PMID: 18327620
Mini-open anterior spine surgery; Mini-open; Anterior lumbar interbody fusion; Techniques; Lumbar fusion; ALIF
4.  Rare clinical experiences for surgical treatment of melanoma with osseous metastases in Taiwan 
Malignant melanoma occurs infrequently in Taiwan. Once it has progressed into osseous metastases, the prognosis is poor. There are no reported clinical experiences of surgical management in this area.
To improve our understanding of the rare clinical experiences, we retrospectively investigated clinical characteristics, radiological findings, treatment modalities, survival outcomes and prognoses of 11 Taiwanese patients with osseous metastasis of melanoma treated surgically at two national medical centers, National Taiwan University Hospital and National Cheng Kung University Hospital from January 1983 to December 2006.
Six patients suffered from acral-lentiginous melanoma. Nine patients sustained multiple osseous metastases and most lesions were osteolytic. Nine patients also had sustained metastases to other organs including liver, lungs, lymph nodes, brain and spleen. Second malignancies including lung cancer, thyroid papillary carcinoma, renal cell carcinoma and cervical cancer co-existed in four patients. The interval from the initial diagnosis of melanoma to the clinical detection of osseous metastases varied from 0–37.8 months (mean 9.75 months). Metastatic melanoma was invariably fatal; the mean survival time from bone metastases to death was 5.67 months.
Due to the high morbidity and poor survival of Taiwanese patients with osseous metastases of melanoma, surgical treatment should be directed towards pain relief and the prevention of skeletal debilitation in order to maintain their quality of life.
PMCID: PMC1945025  PMID: 17650346

Results 1-4 (4)