A 13-year-9-month-old female child presented with congenital kyphoscoliosis along with progressive paraparesis. Radiographs confirmed kyphoscoliosis and magnetic resonance imaging revealed a stretched and flattened spinal cord over the kyphotic deformity and a T7 hemivertebra. She underwent a posterior correction of the curve along with posterior decompression and a posterior to anterior excision of T7 hemivertebra to relieve her of the deteriorating neurology. While carrying out the excision of T7 hemivertebra, her trans cranial electrical motor evoke potential dropped. Consequently, she was administered a mega dose steroid therapy. After a positive wake-up test, the excision was discontinued and surgery was concluded by in situ fixation of the deformity with short rods. Thereafter, a gradual deterioration in the neurologic status was observed and patient became paraplegic on the fourth post operative day. In this case report, we try to analyze various causes for gradual deterioration in neurologic status.
Kyphosis; Paraparesis; Paraplegia; Motor evoked potentials
Retrospective comparative study.
To study and compare the surgical outcomes of muscular dystrophy (MD) and spinal muscle atrophy (SMA).
Overview of Literature
There are few reports that have evaluated and compared the surgical outcomes of MD and SMA patients.
The patients (n = 35) were divided into two groups: a MD group with 24 patients and a SMA group with 11 patients. The average follow-up period was 21 months. All patients were operated for scoliosis correction using posterior instrumentation and fusion. In the immediate postoperative period, all efforts were made to reduce the pulmonary complications using non-invasive positive pressure ventilation and a coughing assist devices. The patients were evaluated by radiograph in terms of the Cobb's angle, pelvic obliquity, T1 translation, thoracic kyphosis and lumbar lordosis. The pulmonary function and self-image satisfaction were also assessed.
There was a lower correction rate in the MD group (41.5%) than in the SMA group (48.3%), even though the curves were smaller in the MD group. The correction in the pelvic obliquity was significantly better in the SMA group (p = 0.03). The predicted vital capacity showed a 4% reduction in the MD group 1 year after surgery, while the SMA group showed a 10% reduction. The peak cough flow and end tidal PCO2 did not deteriorate and were well maintained. The average score for the improvement in self-image satisfaction postoperatively was 3.96 and 4.64 for the MD and SMA groups, respectively. The total complication rate was 45.7%; 14.3% of which were respiratory-related.
Surgical intervention for MD and SMA may be performed safely in patients with a very low forced vital capacity (< 30%) through aggressive preoperative and postoperative rehabilitation efforts.
Muscular dystrophy; Spinal muscular atrophy; Neuromuscular scoliosis; Surgical correction; Pulmonary function
There are no reports of a 7-day delay in the onset of neurological deterioration because of a spinal epidural hematoma (SEH) after a spinal fracture. A hematoma was detected from the T12 to L2 area in a 36-year-old male patient with a T12 burst fracture. On the same day, the patient underwent in situ posterior pedicle instrumentation on T10-L3 with no additional laminectomy. On the seventh postoperative day, the patient suddenly developed weakness and sensory changes in both extremities, together with a sharp pain. A MRI showed that the hematoma had definitely increased in size. A partial laminectomy was performed 12 hours after the onset of symptoms. Two days after surgery, recovery of neurological function was noted. This case shows that spinal surgeons need to be aware of the possible occurrence of a delayed aggravated SEH and neurological deterioration after a spinal fracture.
Spinal epidural hematoma; Spine fracture; Neurology
The incidence of adolescent idiopathic scoliosis (AIS) has rapidly increased, and with it, physician consultations and expenditures (about one and a half times) in the last 5 years. Recent etiological studies reveal that AIS is a complex genetic disorder that results from the interaction of multiple gene loci and the environment. For personalized treatment of AIS, a tool that can accurately measure the progression of Cobb's angle would be of great use. Gene analysis utilizing single nucleotide polymorphism (SNP) has been developed as a diagnostic tool for use in Caucasians but not Koreans. Therefore, we attempted to reveal AIS-related genes and their relevance in Koreans, exploring the potential use of gene analysis as a diagnostic tool for personalized treatment of AIS therein.
Materials and Methods
A total of 68 Korean AIS and 35 age- and sex-matched, healthy adolescents were enrolled in this study and were examined for 10 candidate scoliosis gene SNPs.
This study revealed that the SNPs of rs2449539 in lysosomal-associated transmembrane protein 4 beta (LAPTM4B) and rs5742612 in upstream and insulin-like growth factor 1 (IGF1) were associated with both susceptibility to and curve severity in AIS. The results suggested that both LAPTM4B and IGF1 genes were important in AIS predisposition and progression.
Thus, on the basis of this study, if more SNPs or candidate genes are studied in a larger population in Korea, personalized treatment of Korean AIS patients might become a possibility.
Adolescent idiopathic scoliosis; gene; single nucleotide polymorphism
Infective spondylodiscitis usually occurs in patients of older age, immunocompromisation, co-morbidity, and individuals suffering from an overall poor general condition unable to undergo reconstructive anterior and posterior surgeries. Therefore, an alternative, less aggressive surgical method is needed for these select cases of infective spondylodiscitis. This retrospective clinical case series reports our novel surgical technique for the treatment of infective spondylodiscitis.
Between January 2005 and July 2011, among 48 patients who were diagnosed with pyogenic lumbar spondylodiscitis or tuberculosis lumbar spondylodiscitis, 10 patients (7 males and 3 females; 68 years and 48 to 78 years, respectively) underwent transpedicular curettage and drainage. The mean postoperative follow-up period was 29 months (range, 7 to 61 months). The pedicle screws were inserted to the adjacent healthy vertebrae in the usual manner. After insertion of pedicle screws, the drainage pedicle holes were made through pedicles of infected vertebra(e) in order to prevent possible seeding of infective emboli to the healthy vertebra, as the same instruments and utensils are used for both pedicle screws and the drainage holes. A minimum of 15,000 mL of sterilized normal saline was used for continuous irrigation through the pedicular pathways until the drained fluid looked clear.
All patients' symptoms and inflammatory markers significantly improved clinically between postoperative 2 weeks and postoperative 3 months, and they were satisfied with their clinical results. Radiologically, all patients reached the spontaneous fusion between infected vertebrae and 3 patients had the screw pulled-out but they were clinically tolerable.
We suggest that our method of transpedicular curettage and drainage is a useful technique in regards to the treatment of infectious spondylodiscitic patients, who could not tolerate conventional combined anterior and posterior surgery due to multiple co-morbidities, multiple level infectious lesions and poor general condition.
Spondylodiscitis; Curettage; Drainage; Surgery; Transpedicular
The objectives of this study are to describe the outcome of adolescent idiopathic scoliosis (AIS) patients treated with Video Assisted Thoracoscopic Surgery (VATS) plus supplementary minimal incision in the lumbar region for thoracic and lumbar deformity correction and fusion.
Materials and Methods
This is a case series of 13 patients treated with VATS plus lumbar mini-open surgery for AIS. A total of 13 patients requiring fusions of both the thoracic and lumbar regions were included in this study: 5 of these patients were classified as Lenke type 1A and 8 as Lenke type 5C. Fusion was performed using VATS up to T12 or L1 vertebral level. Lower levels were accessed via a small mini-incision in the lumbar area to gain access to the lumbar spine via the retroperitoneal space. All patients had a minimum follow-up of 1 year.
The average number of fused vertebrae was 7.1 levels. A significant correction in the Cobb angle was obtained at the final follow-up (p = 0.001). The instrumented segmental angle in the sagittal plane was relatively well-maintained following surgery, albeit with a slight increase. Scoliosis Research Society-22 (SRS-22) scores were noted have significantly improved at the final follow-up (p < 0.05).
Indications for the use of VATS may be extended from patients with localized thoracic scoliosis to those with thoracolumbar scoliosis. By utilizing a supplementary minimal incision in the lumbar region, a satisfactory deformity correction may be accomplished with minimal post-operative scarring.
Scoliosis; VATS; mini-open retroperitoneal approach
This is a prospective randomized cohort study.
We intended to evaluate the efficacy of a 48 hour antibiotic microbial prophylaxis (AMP) protocol as compared with a 72 hour AMP protocol.
Overview of Literature
The current guideline for the prevention of surgical site infection (SSI) suggests the AMP should not exceed 24 hours after clean surgery like spinal surgery. But there exist some confusion in real clinical practice about the duration of postoperative antibiotic administration because the evidence of the guideline was not robust.
The subjects were 548 patients who underwent spinal surgery at our department from April 2007 to December 2008. The patients were classified into two groups according to the prophylaxis protocol: group A, for which AMP was employed for 72 hours postoperatively and group B, for which AMP was employed for 48 hours postoperatively. Five hundred two patients out of 548 patients were followed until 6 months postoperatively. The incidence of SSI in the two groups was analyzed.
The overall infection rate was 0.8%. There was no significant difference in infection rate between the two groups. The overall infection rate for the patients who underwent instrumented fusion was 0.9%. There was no significant difference in the infection rate between the patients of the two groups who underwent instrumented fusion.
AMP for 48 hours is as efficient as AMP for 72 hours.
Spine; Surgical site infection; Anti-bacterial agents
The purpose of this study is to report the comparative results of thoracoscopic correction achieved via cantilever technique using a 4.5 mm thin rod and the poly-axial reduction screw technique using a 5.5 mm thick rod in Lenke type 1 adolescent idiopathic scoliosis (AIS).
Materials and Methods
Radiographic data, Scoliosis Research Society (SRS) patient-based outcome questionnaires, and operative records were reviewed for forty-nine patients undergoing surgical treatment of scoliosis. The study group was divided into a 4.5 mm thin rod group (n = 24) and a 5.5 mm thick rod group (n = 25). The radiographic parameters that were analyzed included coronal curve correction, the most caudal instrumented vertebra tilt angle correction, coronal balance, and thoracic kyphosis.
The major curve was corrected from 49.8° and 47.2° pre-operatively to 24.5° and 18.8° at the final follow-up for the thin and thick rod groups, respectively (50.8% vs. 60.2% correction). There were no significant differences between the two groups in terms of kyphosis, coronal balance, or tilt angle at the time of the final follow-up. The mean number of levels fused was 6.2 in the thin rod group, compared with 5.9 levels in the thick rod group. There were no major intraoperative complications in either group.
Significant correction loss was observed in the thin rod system at the final follow-up though both groups had comparable correction immediately post-operative. Therefore, the thick rod with poly axial screw system helps to maintain post-operative correction.
Instrumentation; rod; scoliosis; thoracoscopic surgery
Surgical treatment in the case of thoracolumbar burst fractures is very controversial. Posterior instrumentation is most frequently used, however, but the number of levels to be instrumented still remains a matter of debate.
Materials and Methods
A total of 94 patients who had a single burst fracture between T11 and L2 were selected and were managed using posterior instrumentation with anterior fusion when necessary. They were divided into three groups as follows; Group I (n = 28) included patients who were operated by intermediate segment fixation, Group II (n = 32) included patients operated by long segment fixation, and Group III (n = 34) included those operated by intermediate segment fixation with a pair of additional screws in the fractured vertebra. The mean follow-up period was twenty one months. The outcomes were analyzed in terms of kyphosis angle (KA), regional kyphosis angle (RA), sagittal index (SI), anterior height compression rate, Frankel classification, and Oswestry Disability Index questionnaire.
In Groups II and III, the correction values of KA, RA, and SI were much better than in Group I. At the final follow up, the correction values of KA (6.3 and 12.1, respectively) and SI (6.2 and 12.0, respectively) were in Groups II and III found to be better in the latter.
The intermediate segment fixation with an additional pair of screws at the fracture level vertebra gives results that are comparable or even better than long segment fixation and gives an advantage of preserving an extra mobile segment.
Thoracolumbar burst fracture; posterior instrumentation; intermediate segment fixation; fixation length; selective anterior fusion
We report here on an unusual case of multiple levels of asymmetric lumbar spondylolysis in a 19-year-old woman. The patient had severe low back pain of increasing intensity with lumbar instability, which was evident on the dynamic radiographs. MRI demonstrated the presence of abnormalities and the three dimensional CT scan revealed asymmetric complete spondylolysis at the left L2, L3 and L4 levels and the right L1, L2 and L3 levels. This case was treated surgically by posterior and posterolateral fusion at L2-3-4 with intersegmental fixation using pedicle screws and an auto iliac bone graft. The patient was relieved of her low back pain after the surgery.
Lower back pain; Multiple spondylolysis; Fusion
First, to examine the association between bone mineral density (BMD) and the halo phenomenon, and second, to investigate risk factors predisposing to the halo phenomenon and its correlation with clinical outcomes.
Overview of Literature
The few in vivo studies regarding the relationship between pedicle screw stability and BMD have shown conflicting results.
Forty-four female patients who underwent spine fusion surgery due to spinal stenosis were included in this study. The halo phenomenon and fusion state were evaluated through plain radiographs performed immediately after surgery and through the final outpatient follow-up examination. BMD, osteoarthritis grade in the hip and knee joints, and surgical outcome were also evaluated.
BMD was not related to the halo phenomenon, but age, absence of osteoarthritis in the knee, and non-union state were found to be significant risk factors for the halo phenomenon. However, the radiological halo phenomenon did not correlate with clinical outcome (visual analogue scale for back pain and leg pain).
The halo phenomenon is a simple phenomenon that can develop during follow-up after pedicle screw fixation. It does not influence clinical outcomes, and thus it is thought that hydroxyapatite coating screws, expandable screws, cement augmentation, and additional surgeries are not required, if their purpose is to prevent the halo phenomenon.
Halo phenomenon; Pedicle screw; Bone mineral density
To more accurately determine the incidence and clarify risk factors.
Overview of Literature
Superior mesenteric artery syndrome is one of the possible complications following correctional operation for scoliosis. However, when preliminary symptoms are vague, the diagnosis of superior mesenteric artery syndrome may be easily missed.
We conducted a retrospective study using clinical data from 118 patients (43 men and 75 women) who underwent correctional operations for scoliosis between September 2001 and August 2007. The mean patient age was 15.9 years (range 9~24 years). The risk factors under scrutiny were the patient body mass index (BMI), change in Cobb's angle, and trunk length.
The incidence of subjects confirmed to have obstruction was 2.5%. However, the rate increased to 7.6% with the inclusion of the 6 subjects who only showed clinical symptoms of obstruction without confirmative study. The BMI for the asymptomatic and symptomatic groups were 18.4±3.4 and 14.6±3, respectively. The change in Cobb's angle for the asymptomatic and symptomatic groups were 24.8±13.6° and 23.4±9.1°, respectively. The change in trunk length for the asymptomatic and symptomatic groups were 2.3±2.1 cm and 4.5±4.8 cm, respectively. Differences in Cobb's angle and the change in trunk length between the two groups did not reach statistical significance, although there was a greater increase in trunk length for the symptomatic group than for the asymptomatic group.
Our study shows that the incidence of superior mesenteric artery syndrome may be greater than the previously accepted rate of 4.7%. Therefore, in the face of any early signs or symptoms of superior mesenteric artery syndrome, prompt recognition and treatment are necessary.
Scoliosis; Superior mesenteric artery syndrome; Body mass index; Trunk length
A retrospective study.
We evaluated the results of the use of anterior debridement and interbody fusion followed by posterior spinal instrumentation.
Overview of Literature
An early diagnosis of pyogenic spondylitis is difficult to obtain. The disease can be treated with various surgical methods (such as anterior debridement and bone graft, anterior instrumentation, and posterior instrumentation).
This study included 20 patients who received anterior debridement and interbody fusion with strut bone graft followed by posterior spinal fusion for pyogenic spondylitis between 1996 and 2005. We analyzed the culture studies, the correction of the kyphotic angle, blood chemistry, the bony union period, and the amount of symptom relief.
In terms of clinical symptoms relief, eight patients were grouped as "excellent", eleven patients as "good", and one patient as "fair". The vertebral body cultures were positive in 14 patients showing coagulase (-) streptococcus and S. aureus. The average times for normalization of the erythrocyte sedimentation rate and C-reactive protein level were 3.3 and 1.9 months, respectively. Four months was required for bony union. For complications, meralgia paresthetica was found in two
Due to early ambulation and the correction of the kyphotic angle, anterior interbody fusion with strut bone graft and posterior instrumentation could be another favorable method for the treatment of pyogenic spondyulitis.
Pyogenic spondylitis; Anterior interbody fusion; Posterior instrumentation
To identify the incidence of new vertebral compression fractures in women after kyphoplasty and to analyze influential factors in these patients.
Materials and Methods
One hundred and eleven consecutive female patients with osteoporotic vertebral compression fractures (VCFs) underwent kyphoplasty at 137 levels. These patients were followed for 15.2 months postoperatively. For the survey of new vertebral compression fractures, medical records and x-rays were reviewed, and telephone interviews were conducted with all patients.
During that time 20 (18%) patients developed new VCFs. The rate of occurrence of new VCFs in one year was 15.5% using a Kaplan-Meier curve. Body mass index (BMI), symptom duration and kyphoplasty level were the statistically significant factors between the patient groups both with and without new VCFs after kyphoplasty. In the comparison between the adjacent and remote new VCF groups, the adjacent new VCF group showed a larger amount of polymethyl methacrylate (PMMA) use during kyphoplasty (p < 0.05). Before kyphoplasty, 9.9% of the patients had been prescribed medication for osteoporosis, and 93.7% of the patients started or continued medication after kyphoplasty. The development of new VCFs was affected by the number of vertebrae involved in the kyphoplasty. However, the lower incidence rate (15.5%) of new compression fractures might be due to a greater percentage (93.7% in our study) of patients taking anti-osteoporotic medication before and/or after kyphoplasty.
When kyphoplasty is planned for the management of patients with osteoporotic VCFs, the application of a small amount of PMMA can be considered in order to lower the risk of new fractures in adjacent vertebrae. The postoperative use of anti- osteoporotic medication is recommended for the prevention of new VCFs.
Kyphoplasty; compression fracture; influencing factor
Radiographic sagittal plane analysis of VATS (video-assisted thoracoscopic surgery) anterior instrumentation for adolescent idiopathic scoliosis. This is retrospective study. To report, in details about effects of VATS anterior instrumentation on the sagittal plane. Evaluations of the surgical outcome of scoliosis have primarily studied in coronal plane correction, functional, and cosmetic aspects. Sagittal balance, as well as coronal balance, is important in functional spine. Recently, scoliosis surgery applying VATS has been increasingly performed. Its outcome has been reported several times; however, according to our search of the literature, the only one study partially mentioned. The study population was a total of 42 cases of idiopathic scoliosis patients (8 male, 34 female). Their mean age was 15.6 years (13 to 18 years). The 18 cases were Lenke IA type, 16 cases were Lenke IB type, and 8 cases were Lenke IC type. The preoperative Cobb's angle was 54.5 ± 13.9°. All patients were followed up for a minimum of 2 years and implanted, on average, at the 5.9 level (5 to 8 levels). The most proximal implant was the 4th thoracic spine, and the most distal implant was the 1st lumbar spine. Whole spine standing PA and lateral radiographs were taken before surgery, 2 months after surgery, and at the last follow up (range 24-48 months, mean 35 months). The C7 plumbline proximal junctional measurement (PJM), distal junctional measurement (DJM), thoracic kyphosis, and lumbar lordosis angles were measured and compared. In all cases, follow-ups were possible and survived till the last follow up. The Cobb's angle in coronal plane at the last follow up was 19.7 ± 9.3° and was corrected to 63.8% on average. The preoperative C7 sagittal plumbline before surgery was -13.9 ± 29.1 mm, the final follow up was -9.9 ± 23.8 mm, and the average positive displacement was 4 mm. Thoracic kyphosis was increased from preoperative 18.2 ± 7.7° to 22.4 ± 7.2° on average at the last follow up, and the increase was, on average, 4.2°. The PJM angel was increased from 6.2 ± 4.3° preoperative to 8.8 ± 3.7° at the last follow up, and the increment was, on the average, 2.6°. The DJM angle before surgery was 6.8 ± 5.1° and 6.7 ± 4° at the last follow up, and did not change noticeably. Preoperative lumbar lordosis was 42 ± 10.7° and 43.5 ± 11.1° after surgery. Similarly, it did not change greatly. The scoliosis surgery applying VATS displaced the C7 sagittal plumb line by 4 mm to the anteriorly, increased thoracic kyphosis by 4.2°, and increased PJM by 2.6°. DJM and lumbar lordosis, before and after operation, were not significantly different. Although the surgical technique of VATS thoracic instrumentation is difficult to make the normal thoracic kyphosis, an acceptable sagittal balance can be obtained in Lenke type I adolescent idiopathic scoliosis using VATS.
Scoliosis; VATS; sagittal balance
Autologous transfusion has been used to overcome adverse effects of homologous transfusion. Clinical studies evaluating general orthopaedic postoperative results have been designed to compare these transfusion methods. However, few studies have evaluated postoperative results in spinal fusion surgeries, which have larger blood loss volumes. The purpose of this study is to determine if there are differences in postoperative infection and clinical results of spinal fusion with autologous, as compared to homologous, blood transfusion. A total of 62 patients who underwent instrumented spinal fusion and received autologous (n = 30) or homologous (n = 32) transfusions were reviewed. Information on gender, age, preoperative and 3-day postoperative hematologic features, total transfused units, segmental estimated blood loss, transfused units, and surgery time were collected. In addition, postoperative infection data on wound infection, pneumonia, urinary tract infection, cellulitis, and viral disease, incidence and duration of fever, as well as clinical results, fusion rates, and patient feedback were collected. No differences in postoperative infection and clinical results were found between the two types of transfusions; however, homologous transfusion was associated with an increased number of total units transfused, longer duration of fever, and decreased patient satisfaction regarding the transfusion.
Spinal fusion; autologous transfusion
To date, there have been no prospective, objective studies comparing the accuracy of the MRI, myelo-CT and myelography. The purpose of this study is to compare the diagnostic and predictive values of MRIs, myelo-CTs, and myelographies. Myelographies with dynamic motion views, myelo-CTs, MRIs and exercise treadmill tests were performed in 35 cases. The narrowest AP diameter of the dural sac was measured by myelography. At the pathologic level, dural cross-sectional area (D-CSA) was calculated in the MRI and Myelo-CT. The time to the first symptoms (TAF) and the total ambulation time (TAT) were measured during the exercise treadmill test and used as the standard in the comparison of correlation between radiographic parameters and walking capacity. The mean D-CSA by CT was 58.3 mm2 and 47.6 mm2 by MRI. All radiographic parameters such as AP diameters and D-CSA have no correlation to TAF or TAT (p>0.05). Our data showed no statistically significant differences in the correlation of the patients' walking capacity to the severity of stenosis as assessed by myelography, myelo-CT and MRI.
Spinal stenosis; myelography; spiral computed tomography; magnetic resonance imaging; exercise test; predictive value of tests
Chronic lower back pain is one of the most common musculoskeletal problems; it is also the most expensive industrial injury. Not surprisingly, many treatments have been developed to combat this expensive and debilitating condition. One of these, intradiscal electrothermal treatment (IDET), was developed for patients with chronic discogenic lower back pain who failed to improve with any of the wide variety of non-surgical treatments. The present study sought to evaluate the efficacy of IDET for patients with chronic lower back pain. Twenty-five patients were enrolled in this prospective study; the patients received IDET between June 2001 and June 2003. MRI was used to confirm the diagnosis of internal disc disruption in all patients. The patients then underwent a pre-operative provocative test and discography. The follow-up duration was at least 1 year in all cases, and the visual analogue scale, recovery rate, and satisfaction of each patient were evaluated. The average age of the patients was 32 years (age range 18 to 49 years), and the patient group was 33% male and 67% female. Of the 25 patients, 5 underwent lumbar fusion surgery within 1 year of IDET. After IDET, 8 patients (32%) reported more pain than before, 14 patients (56%) reported less pain, and 3 patients (12%) experienced no change. Twelve patients (48%) were satisfied with IDET, 11 (44%) were dissatisfied, and 2 (8%) were undecided about the treatment. At least 1 year after IDET, nearly half the study patients were dissatisfied with their medical outcome. Consequently, 5 patients (20%) underwent fusion surgery at 1 year after IDET. Although other studies have shown good results with IDET for at least 2 years, this investigation suggests the IDET may be somewhat less effective. In order to firmly establish the efficacy of IDET for treating chronic discogenic lower back pain, additional studies with larger numbers of patients evaluated over longer time periods are recommended.
Intradiscal electrothermal treatment (IDET); internal disc disruption; back pain