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issn:1976-78.6
1.  Effects of Methylprednisolone on Neuroprotective Effects of Delay Hypothermia on Spinal Cord Injury in Rat 
Asian Spine Journal  2015;9(1):1-6.
Study Design
A retrospective study.
Purpose
The aim of this study was to evaluate the effects of delayed hypothermia on spinal cord injuries in rats. In addition, the effect of methylprednisolone on therapeutic window of hypothermia was evaluated.
Overview of Literature
Several studies have demonstrated that early hypothermia is the most effective neuroprotective modality. However, delayed hypothermia seems to be more practical for patients with traumatic spinal cord injuries. A combination of hypothermia and other neuroprotective methods, such as using methylprednisolone, may help extend the therapeutic window of hypothermia.
Methods
One hundred and twenty male rats were categorized into six groups. The rats in five groups were subjected to spinal cord injury using the weight drop method, followed by treatment, consisting of early hypothermia, late hypothermia, late hypothermia plus methylprednisolone, or methylprednisolone only. Biochemical tests including catalase, malondialdehyde, and superoxide level were evaluated in the injured spinal cord. Behavioral functions of the hind limb were evaluated by Basso-Battle-Bresnaham locomotor rating scale and tail-flick tests.
Results
Functional and biochemical evaluation showed both early and late hypothermia had significant neuroprotective effects. The treated groups did not differ significantly from one another in the behavioral tests. Hypothermia had better biochemical results compared to methylprednisolone. Also, methylprednisolone was shown to extend the therapeutic window of delayed hypothermia.
Conclusions
Hypothermia showed a significant neuroprotective effect, which can be improved with further studies optimizing the duration of hypothermia and the rewarming period. Moreover, the therapeutic effect of the delayed hypothermia can be extended by methylprednisolone.
doi:10.4184/asj.2015.9.1.1
PMCID: PMC4330203
Hypothermia; Spinal cord injury; Methylprednisolone; Hypothermia
2.  Spinal Stenosis Presenting with Scrotal and Perianal Claudication 
Asian Spine Journal  2015;9(1):103-105.
A 63-year-old gentleman presented with a one-year duration of progressive neurogenic claudication. However, unlike most patients who presents with leg symptoms, his pain was felt in his scrotal and perianal region. This was exacerbated with walking and standing, but he had immediate relief with sitting. An magnetic resonance imaging (MRI) was performed which showed severe central canal stenosis. An L3/4 and L4/5 surgical decompression and a transforaminal lumbar interbody fusion was performed, and the patient made good recovery with immediate resolution of symptoms. Although rare, spinal stenosis should be considered a differential when approaching a patient with perianal and scrotal claudication, even in the absence of leg claudication. An MRI is useful to confirm the diagnosis. This rare symptom may be a sign of severe cauda equina compression and we recommend decompression with predictable good results.
doi:10.4184/asj.2015.9.1.103
PMCID: PMC4330204
Spinal; Stenosis; Atypical; Claudication
3.  Cervical Ossification of Posterior Longitudinal Ligament in X-Linked Hypophosphatemic Rickets Revealing Homogeneously Increased Vertebral Bone Density 
Asian Spine Journal  2015;9(1):106-109.
There is no report that describes in detail the radiological and intraoperative findings of rickets with symptomatic cervical ossification of the posterior longitudinal ligament. Here, we describe a case of X-linked hypophosphatemic rickets with cervical ossification of the posterior longitudinal ligament presenting unique radiological and intraoperative findings. The patient presented progressive tetraparesis. Magnetic resonance imaging studies revealed severe cervical spinal cord compression caused by ossification of the posterior longitudinal ligament. Computed tomography scans revealed homogeneously increased vertebral bone density. An expansive laminoplasty was performed. At surgery, homogeneously hard lamina bone was burdened in drilling and opening of the laminae. The patient's neurological symptoms were improved postoperatively. Bony fusion of the hinges occurred postoperatively. Therefore, expansive laminoplasty could be performed for symptomatic cervical ossification of the posterior longitudinal ligament with X-linked hypophosphatemic rickets. However, unusual bone characters should be taken into consideration for careful operation during surgery.
doi:10.4184/asj.2015.9.1.106
PMCID: PMC4330205
Laminoplasty; Rickets; Ossification of posterior longitudinal ligament
4.  Brown Tumor of the Cervical Spines: A Case Report with Literature Review 
Asian Spine Journal  2015;9(1):110-120.
To report a rare case of axis brown tumor and to review literature of cervical spine brown tumor. Brown tumor is a rare bone lesion, incidence less than 5% in primary hyperparathyroidism. It is more common in secondary hyperparathyroidism with up to 13% of cases. Brown tumor reactive lesion forms as a result of disturbed bone remodeling due to long standing increase in parathyroid hormones. Cervical spine involvement is extremely rare, can be confused with serous spine lesions. To date, only four cases of cervical spine involvement have been reported. Three were due to secondary hyperparathyroidism. Only one was reported to involve the axis and was due to secondary hyperparathyroidism. This is the first reported case of axis brown tumor due to primary hyperparathyroidism. A case report of brown tumor is presented. A literature review was conducted by a Medline search of reported cases of brown tumor, key words: brown tumor, osteoclastoma and cervical lesions. The resulting papers were reviewed and cervical spine cases were listed then classified according to the level, cause, and management. Only four previous cases involved the cervical spine. Three were caused by secondary hyperparathyroidism and one was by primary hyperparathyroidism which involved the C6. Our case was the first case of C2 involvement of primary hyperparathyroidism and it was managed conservatively. Brown tumor, a rare spinal tumor that presents with high PTH and giant cells, requires a high level of suspicion.
doi:10.4184/asj.2015.9.1.110
PMCID: PMC4330206
Osteitis fibrosa cystica; Axis neoplasm; Osteoclastoma; Brown tumor; Hyperparathyroidism
5.  Horner's Syndrome Secondary to Epidural Anaesthesia Following Posterior Instrumented Scoliosis Correction 
Asian Spine Journal  2015;9(1):121-126.
An 11-year-old girl underwent T4 to L1 posterior instrumented scoliosis correction for adolescent idiopathic scoliosis. Postoperative clinical examination revealed left-sided Horner's syndrome which was preceded by left-sided C8 paraesthesia. The Horner's syndrome resolved after 14 hours following weaning and removal of the epidural catheter. Horner's syndrome following posterior instrumented scoliosis correction associated to epidural use is extremely rare. Surgeons must be aware of the risks of epidural placement and the need for close monitoring of associated complications. Alternative aetiology producing a Horner's syndrome must always be considered because of its devastating long term sequela if missed.
doi:10.4184/asj.2015.9.1.121
PMCID: PMC4330207
Epidural; Horner syndrome; Scoliosis
6.  Combat-Related Intradural Gunshot Wound to the Thoracic Spine: Significant Improvement and Neurologic Recovery Following Bullet Removal 
Asian Spine Journal  2015;9(1):127-132.
The vast majority of combat-related penetrating spinal injuries from gunshot wounds result in severe or complete neurological deficit. Treatment is based on neurological status, the presence of cerebrospinal fluid (CSF) fistulas, and local effects of any retained fragment(s). We present a case of a 46-year-old male who sustained a spinal gunshot injury from a 7.62-mm AK-47 round that became lodged within the subarachnoid space at T9-T10. He immediately suffered complete motor and sensory loss. By 24-48 hours post-injury, he had recovered lower extremity motor function fully but continued to have severe sensory loss (posterior cord syndrome). On post-injury day 2, he was evacuated from the combat theater and underwent a T9 laminectomy, extraction of the bullet, and dural laceration repair. At surgery, the traumatic durotomy was widened and the bullet, which was laying on the dorsal surface of the spinal cord, was removed. The dura was closed in a water-tight fashion and fibrin glue was applied. Postoperatively, the patient made a significant but incomplete neurological recovery. His stocking-pattern numbness and sub-umbilical searing dysthesia improved. The spinal canal was clear of the foreign body and he had no persistent CSF leak. Postoperative magnetic resonance imaging of the spine revealed contusion of the spinal cord at the T9 level. Early removal of an intra-canicular bullet in the setting of an incomplete spinal cord injury can lead to significant neurological recovery following even high-velocity and/or high-caliber gunshot wounds. However, this case does not speak to, and prior experience does not demonstrate, significant neurological benefit in the setting of a complete injury.
doi:10.4184/asj.2015.9.1.127
PMCID: PMC4330208
Gunshot wound; Foreign body; Spinal cord injury; Laminectomy; Recovery of function
7.  Treatment of Thoracolumbar Fracture 
Asian Spine Journal  2015;9(1):133-146.
The most common fractures of the spine are associated with the thoracolumbar junction. The goals of treatment of thoracolumbar fracture are leading to early mobilization and rehabilitation by restoring mechanical stability of fracture and inducing neurologic recovery, thereby enabling patients to return to the workplace. However, it is still debatable about the treatment methods. Neurologic injury should be identified by thorough physical examination for motor and sensory nerve system in order to determine the appropriate treatment. The mechanical stability of fracture also should be evaluated by plain radiographs and computed tomography. In some cases, magnetic resonance imaging is required to evaluate soft tissue injury involving neurologic structure or posterior ligament complex. Based on these physical examinations and imaging studies, fracture stability is evaluated and it is determined whether to use the conservative or operative treatment. The development of instruments have led to more interests on the operative treatment which saves mobile segments without fusion and on instrumentation through minimal invasive approach in recent years. It is still controversial for the use of these treatments because there have not been verified evidences yet. However, the morbidity of patients can be decreased and good clinical and radiologic outcomes can be achieved if the recent operative treatments are used carefully considering the fracture pattern and the injury severity.
doi:10.4184/asj.2015.9.1.133
PMCID: PMC4330209
Thoracolumbar spine; Fracture; Treatment; Minimally invasive surgery
8.  Repair Using Conventional Implant for Ruptured Annulus Fibrosus after Lumbar Discectomy: Surgical Technique and Case Series 
Asian Spine Journal  2015;9(1):14-21.
Study Design
A retrospective review of annulus fibrosus repair (AR) using a novel technique with a conventional implant.
Purpose
The purpose of this study was to present the feasibility and clinico-radiological outcomes of a novel AR technique using a conventional implant to minimize recurrence following a lumbar discectomy (LD).
Overview of Literature
Conventional repair techniques to prevent recurrence following LD have several drawbacks. The AR surgical technique has received little attention as an adjunct to LD.
Methods
A total of 19 patients who underwent novel AR following LD, and who were available for follow-up for at least three years, were enrolled in this study. Several variables, including the type and size of disc herniation, and the degree of disc degeneration, were evaluated preoperatively. Postoperatively, the presence of clinical and radiological recurrence of disc herniation was evaluated from pain intensity and functional statuses, as well as an enhanced L-spine magnetic resonance imaging at the final follow-up. The presence of a peripheral hollow rim and inserted anchor mobilization were also evaluated during the follow-up.
Results
During follow-ups, there were no recurrences of disc herniation or complications, including neurovascular complications. Pain and functional disability improved significantly after surgery, and the improvement was maintained throughout the three-year follow-up period. No mobilization or implant peripheral hollow rim was observed during the follow-up.
Conclusions
This study examined the feasibility of a novel and easily available annulus implant technique following LD. These results suggest performing AR with this technique may be a valuable alternative for optimizing outcomes, if the procedure is performed in proper candidates.
doi:10.4184/asj.2015.9.1.14
PMCID: PMC4330210
Annulus fibrosus; Repair; Intervertebral disc displacement; Lumbar vertebrae
13.  A Comparison of Computed Tomography Measures for Diagnosing Cervical Spinal Stenosis Associated with Myelopathy: A Case-Control Study 
Asian Spine Journal  2015;9(1):22-29.
Study Design
Retrospective comparative study.
Purpose
To assess differences in computed tomography (CT) imaging parameters between patients with cervical myelopathy and controls.
Overview of Literature
There is a lack of information regarding the best predictor of symptomatic stenosis based on osseous canal dimensions. We postulate that smaller osseous canal dimensions increase the risk of symptomatic central stenosis.
Methods
CT images and medical records of patients with cervical myelopathy (19 patients, 8 males; average age, 64.4±13.4 years) and controls (18 patients, 14 males; average age, 60.4±11.0 years) were collected. A new measure called the laminar roof pitch angle (=angle between the lamina) was conducted along with linear measures, ratios and surrogates of canal perimeter and area at each level C2-C7 (222 levels). Receiver-operator curves were used to assess the diagnostic value of each. Rater reliability was assessed for the measures.
Results
The medial-lateral (ML) diameter (at mid-pedicle level) and calculated canal area (=anterior-posterior.×ML diameters) were the most accurate and highly reliable. ML diameter below 23.5 mm and calculated canal area below 300 mm2 generated 82% to 84% sensitivity and 67% to 68% sensitivity. No significant correlations were identified between age, height, weight, body mass in dex and gender for each of the CT measures.
Conclusions
CT measures including ML dimensions were most predictive. This study is the first to identify an important role for the ML dimension in cases of slowly progressive compressive myelopathy. A ML reserve may be protective when the canal is progressively compromised in the anterior-posterior dimension.
doi:10.4184/asj.2015.9.1.22
PMCID: PMC4330215
Cervical cord; Cervicle vertebrae; Spinal stenosis; Spinal cord compression; Spinal cord diseae
14.  A Prospective Randomized Clinical Trial Comparing Bone Union Rate Following Anterior Cervical Discectomy and Fusion Using a Polyetheretherketone Cage: Hydroxyapatite/B-Tricalcium Phosphate Mixture versus Hydroxyapatite/Demineralized Bone Matrix Mixture 
Asian Spine Journal  2015;9(1):30-38.
Study Design
Prospective randomized noninferiority trial.
Purpose
To evaluate whether the union rate of anterior cervical discectomy and fusion (ACDF) using a polyetheretherketone (PEEK) cage filled with a mixture of hydroxyapatite (HA) and demineralized bone matrix (DBM) is inferior to that of a mixture of β-tricalcium phosphate (β-TCP) and HA.
Overview of Literature
There have been no clinical trials investigating the outcomes of a mixture of HA and DBM in a PEEK cage in ACDF.
Methods
Eighty-five eligible patients were randomly assigned to group B (n=43), in which a PEEK cage with a mixture of HA and DBM was used, or group C (n=42), in which a PEEK cage with a mixture of HA and β-TCP was used. The primary study endpoint was the fusion rate, which was assessed with dynamic radiographs and computed tomography (CT) scans. Secondary endpoints included pain intensity using a visual analogue scale, functional outcome using a neck disability index score, laboratory tests of inflammatory profiles, and the infection rate.
Results
Seventy-seven patients (38 in group B and 39 in group C) were included in the final analysis. One year postoperatively, bone fusion was achieved in 87% of group B patients and 87% of group C patients on dynamic radiographs, and 87% of group B patients and 72% of group C patients on CT scans (p=1.00 and 0.16, respectively). There were also no between-groups differences with respect to the secondary endpoints.
Conclusions
A HA/DBM mixture inside a PEEK cage can provide noninferior outcomes compared to a HA/TCP mixture in ACDF.
doi:10.4184/asj.2015.9.1.30
PMCID: PMC4330216
Anterior cervical discectomy and fusion; Polyetheretherketone cage; Hydroxyapatites; Demineralized bone matrix; Beta-tricalcium phosphate
15.  Analysis of Postoperative Pain at the Anterior Iliac Crest Harvest Site: A Prospective Study of the Intraoperative Local Administration of Ropivacaine 
Asian Spine Journal  2015;9(1):39-46.
Study Design
This was a prospective randomized comparative study.
Purpose
The aim of this study was to objectify donor site-related pain following anterior iliac crest graft harvesting, in patients who have undergone multilevel anterior cervical discectomy and fusion with plating (ACDFP); and to assess the effect of an intraoperative local single injection of ropivacaine on postoperative pain.
Overview of Literature
Multilevel ACDFP can be associated with a high non-union rate. Autogenous iliac bone has been used to increase union rates, although a high incidence of donor site-related pain has been reported.
Methods
Forty consecutive patients who required 3-level or 4-level ACDFP were prospectively assessed for donor site-related pain. Pain levels were assessed daily for five days postoperative using the visual analog scale (VAS). Patients were randomly assigned to group A or B. In group A patients, 7-10 mL of ropivacaine (0.2%) was injected into the iliac crest after iliac crest graft harvesting. Morphine usage via patient controlled analgesia was calculated. At six months postoperative, patient complaints at the harvest site were documented.
Results
Patients were randomly assigned to group A or B. In group A, ropivacaine was locally administered at the site of the iliac crest graft harvest after fascia closure. In group B, no additional treatments were administered. The average patient age in group A was 56±7.6 years, whereas the average age of patients in group B was 52.6±10.4 years. Group A had an average of 0.6±0.7 previous surgeries per patient, whereas group B had an average of 0.8±1.0 previous surgeries per patient. The average number of levels fused in group A was 3.6±0.7, whereas the average number of levels fused in group B was 3.7±0.9 (all p>0.05). In group A, the mean ropivacaine volume administered was 8.4±1.5 mL. No patient complaints regarding chronic pain, were reported six months postoperatively. No complications were encountered from the harvest site, and all patients underwent successful 3-level and 4-level ACDFP. Statistical analysis showed significant differences for VAS on postoperative day 1 (p=0.004) and day 2 (p=0.005).
Conclusions
VAS assessment showed overall moderate perioperative morbidity in terms of donor site-related pain, which was reduced by administering ropivacaine.
doi:10.4184/asj.2015.9.1.39
PMCID: PMC4330217
Spine; Bone grafting; Complications; Local anesthetics; Pain assessment
16.  Comparison of the Japanese Orthopaedic Association Score and the Japanese Orthopaedic Association Cervical Myelopathy Evaluation Questionnaire Scores: Time-Dependent Changes in Patients with Cervical Spondylotic Myelopathy and Posterior Longitudinal Ligament 
Asian Spine Journal  2015;9(1):47-53.
Study Design
Prospective cohort study.
Purpose
To identify differences in time-dependent perioperative changes between the Japanese Orthopaedic Association (JOA) score and the JOA Cervical Myelopathy Evaluation Questionnaire (JOACMEQ) score in patients with cervical spondylotic myelopathy (CSM) and posterior longitudinal ligament (OPLL) who underwent cervical laminoplasty.
Overview of Literature
The JOA score does not take into consideration patient satisfaction or quality of life. Accordingly, the JOACMEQ was designed in 2007 as a patient-centered assessment tool.
Methods
We studied 21 patients who underwent cervical laminoplasty. We objectively evaluated the time-dependent changes in JOACMEQ scores and JOA scores for all patients before surgery and at 2 weeks, 3 months, 6 months, and 1 year after surgery.
Results
The average total JOA score and the recovery rate improved significantly after surgery in both groups, with a slightly better recovery rate in the OPLL group. Cervical spine function improved significantly in the CSM group but not in the OPLL group. Upper- and lower-extremity functions were more stable in the CSM group than in the OPLL group. The effectiveness rate of the JOACMEQ for measuring quality of life was quite low in both groups. In both groups, the Spearman contingency coefficients were dispersed widely except for upper- and lower-extremity function.
Conclusions
Scores for upper- and lower-extremity function on the JOACMEQ correlated well with JOA scores. Because the JOACMEQ can also assess cervical spine function and quality of life, factors that cannot be assessed by the JOA score alone, the JOACMEQ is a more comprehensive evaluation tool.
doi:10.4184/asj.2015.9.1.47
PMCID: PMC4330218
Questionnaires; Spinal cord diseases; Spondylosis; Ossification of posterior longitudinal ligament; Quality of life
17.  Foramen Magnum Meningioma: Some Anatomical and Surgical Remarks through Five Cases 
Asian Spine Journal  2015;9(1):54-58.
Study Design
Foramen magnum meningioma foramen magnum meningioma (FMM) represents 2% all of meningiomas. The clinical symptomatology is usually insidious and consists of headache, neck pain and hypoesthesia in C2 dermatome. Because of their location, the management is challenging.
Purpose
The purpose of this paper is to present our experience in the surgery of FMM.
Overview of Literature
Since 1938, numerous series have been published but they are very heterogeneous with high variability of location and surgical approaches.
Methods
During two years, we operated 5 patients with FMM. All the patients had magnetic resonance imaging (MRI) with angio-MRI to study the relationship between tumour and vertebral artery (VA). In all the cases, we used prone position.
Results
In one case, considering the tumour localization (posterior and pure intradural) the tumour was removed via a midline suboccipital approach with craniotomy and C1-C2 laminectomy. In all other cases, meningiomas were posterolateral (classification of George) with extradural extension in one case. In all cases, VA was surrounded by tumor. So, we opted for a modified postero-lateral approach with inverted L incision, craniotomy and C1-C2 laminectomy without resect occipital condyle. Epidural part of VA was identified and mobilized laterally. Once VA was identified we opened dura mater and began to remove the tumour.
Conclusions
In this paper, we present five cases of operated FMM, describe our approaches, the reason of each approach and propose some surgical remarks.
doi:10.4184/asj.2015.9.1.54
PMCID: PMC4330219
Craniocervical; Foramen magnum; Meningioma; Surgical approach; Neurosurgery; Posterior cranial fossa
18.  Total Disc Arthroplasty for Treating Lumbar Degenerative Disc Disease 
Asian Spine Journal  2015;9(1):59-64.
Study Design
Lumber disc arthroplasty is a technological advancement that has occurred in the last decade to treat lumbar degenerative disk diseases.
Purpose
The aim of this retrospective study was to establish the impact and outcomes of managing patients with lumbar degenerative disk disease who have been treated with lumbar total disc arthroplasty (TDA).
Overview of Literature
Several studies have shown promising results following this surgery.
Methods
We reviewed the files of 104 patients at the Department of Neurosurgery in Colmar (France) who had been operated on by lumbar spine arthroplasty (Prodisc) between April 2002 and October 2008.
Results
Among the 104 patients, 67 were female and 37 were male with an average age of 33.1 years. We followed the cases for a mean of 20 months. The most frequent level of discopathy was L4-L5 with 62 patients (59.6%) followed by L5-S1 level with 52 patients (50%). Eighty-three patients suffered from low back pain, 21 of which were associated with radiculopathy. The status of 82 patients improved after surgery according to the Oswestry Disability Index score, and 92 patients returned to work.
Conclusions
The results indicate that TDA is a good alternative treatment for lumbar spine disk disease, particularly for patients with disabling and chronic low back pain. This technique contributes to improve living conditions with correct patient selection for surgery.
doi:10.4184/asj.2015.9.1.59
PMCID: PMC4330220
Low back pain; Lumbar vertebrae; Intervertebral disk degeneration
19.  Surgical Correction in Patients with Lumbar Degenerative Kyphosis Who Had Low Bone Mineral Density: An Analysis of 40 Patients with a Minimum Follow-Up of Two Years 
Asian Spine Journal  2015;9(1):65-74.
Study Design
Retrospective study.
Purpose
To investigate influence of bone mineral density (BMD) on the surgical correction of lumbar degenerative kyphosis (LDK).
Overview of Literature
No studies so far have reported the influence of BMD on the surgical correction of LDK.
Methods
Forty LDK patients with more than 2 years follow-up were studied. Pelvic incidence (PI), pelvic tilt, sacral slope, sagittal vertical axis (SVA), lumbar lordosis (LL), and thoracic kyphosis were measured preoperatively, immediate postoperatively and at final follow-up. Adverse outcomes: proximal adjacent fractures, sagittal decompensation, pseudoarthrosis, and cage subsidence were documented.
Results
There were 37 females and 3 males. Average age was 65.1±4.5 years and mean follow-up was 34.2±16.7 months. 42.5% were Takemitsu type 3 curves, 27.5% type 2, 20.0% type 4 and 10.0% type 1. 37.5% had osteopenia, 40.0% osteoporosis and 22.5% had severe osteoporosis. SVA improved from 237.0±96.7 mm preoperatively to 45.3±41.8 mm postoperatively (p=0.000). LL improved from 10.5°±14.7° to -40.6°±10.9° postoperatively (p=0.000). At final follow-up SVA deteriorated to 89.8±72.2 mm and LL to 34.7°±15.8° (p=0.000). The association between late sagittal decompensation, pseudoarthrosis, or proximal adjacent fractures and osteoporosis was insignificant. The difference between immediate postoperative LL and PI (PIDiff) had a significant association with sagittal decompensation and pseudoarthrosis.
Conclusions
Osteoporosis did not influence the degree of correction, late sagittal decompensation, proximal adjacent fractures, and pseudoarthrosis in LDK. PIDiff had a significant association with sagittal decompensation and pseudoarthrosis.
doi:10.4184/asj.2015.9.1.65
PMCID: PMC4330221
Lumbar degenerative kyphosis; Bone mineral density; Surgery; Outcome; Osteoporosis
20.  Expression of Hyaluronidase-4 in a Rat Spinal Cord Hemisection Model 
Asian Spine Journal  2015;9(1):7-13.
Study Design
Examination of hyaluronidase-4 (Hyal-4) expression in a rat spinal cord hemisection model.
Purpose
To determine the status of Hyal-4 expression after hemisection of the spinal cord, and the relationship between its expression and that of chondroitin sulfate proteoglycans (CSPGs).
Overview of Literature
CSPGs are expressed at the site of spinal cord injury and inhibit axon regeneration. Administration of exogenous chrondroitinase ABC (ChABC), derived from bacteria, digested CSPGs and promoted axonal regrowth. Using a rat hemisection model, we have demonstrated peak CSPGs levels at by 3 weeks after injury but then decreased spontaneously. Could there be an endogenous enzyme similar to ChABC in the spinal cord? It has been suggested that Hyal-4 is involved in CSPG degradation.
Methods
A rat hemisection model was prepared and spinal cord frozen sections were prepared at 4 days and 1, 2, 3, 4, 5, and 6 weeks post-cordotomy and stained for CSPGs and Hyal-4 and subjected to Western blotting.
Results
CSPGs appeared at the injury site at 4 days after hemisection, reached a peak after 3 weeks, and then decreased. Hyal-4 was observed around the injury site from 4 days after cordotomy and increased until after 5-6 weeks. Double staining showed Hyal-4 around CSPGs. Western blotting identified a band corresponding to Hyal-4 from 4 days after hemisection.
Conclusions
Hyal-4 was expressed in a rat hemisection model in areas surrounding CSPGs, and as its peak was delayed compared with that of CSPGs. These results suggest the involvement of Hyal-4 in the digestion of CSPGs.
doi:10.4184/asj.2015.9.1.7
PMCID: PMC4330222
Spinal cord injury; Chondroitin sulfate proteoglycans; Hyaluronidase
21.  The Efficacy of Intramuscular Calcitonin Injection in the Management of Lumbar Spinal Stenosis 
Asian Spine Journal  2015;9(1):75-82.
Study Design
A prospective, cross-sectional, non-randomized study.
Purpose
To assess the effectiveness of intramuscular calcitonin injection in the treatment of lumbar spinal stenosis (LSS).
Overview of Literature
LSS, manifesting as chronic low back pain and neurogenic claudication, is a chronic condition with an increasing incidence in the elderly population having inadequate effective conservative treatment options.
Methods
In this study, 36 patients with LSS who were diagnosed based on the clinical findings and magnetic resonance imaging were included. Patients received 100 IU of calcitonin per week for one month and were evaluated before and after treatment using the Oswestry disability index (ODI) questionnaire and visual analogue scale (VAS). Before treatment, the patients were divided into two subgroups based on their ODI results: patients with mild to moderate low back pain (disability, 0%-40%) and patients with severe or very severe low back pain (disability, 40%-100%).
Results
In patients with mild to moderate low back pain, there were no significant changes in the ODI and VAS after calcitonin injection. But in patients with severe or very severe low back pain, pain severity, personal functions, ability to lift and carry objects, time interval between standing and initiation of pain, social life, disability percentage, and VAS were significantly improved after treatment with calcitonin.
Conclusions
It seems that an intramuscular injection of low dose of calcitonin may have some beneficial effects on the pain due to LSS, especially in patients who suffer from severe or very severe low back pain.
doi:10.4184/asj.2015.9.1.75
PMCID: PMC4330223
Lumbar spinal stenosis; Calcitonin; Intramuscular injection
22.  An Evaluation of the Effectiveness of Hyaluronidase in the Selective Nerve Root Block of Radiculopathy: A Double Blind, Controlled Clinical Trial 
Asian Spine Journal  2015;9(1):83-89.
Study Design
Prospective, double-blind, randomized controlled trial.
Purpose
To determine the ability of hyaluronidase to provide longer lasting pain relief and functional improvement in patients with lumbar radiculopathy.
Overview of Literature
Selective nerve root block (SNRB) is a good treatment option in lumbar radiculopathy. We studied the effectiveness of hyaluronidase when added to the traditional SNRB regimen.
Methods
A sample size of 126 patients per group was necessary. A sample of 252 patients who underwent an injection procedure with or without hyaluronidase due to radiculopathy was included in this study. The patients were randomly divided into two groups: the control (C) group and the hyaluronidase (H) group. After SNRB due to radiculopathy, the visual analog scale (VAS) was compared at 2, 4, 6, 8, and 12 weeks between the two groups, and the Oswestry disability index (ODI) was compared at 12 weeks between the two groups.
Results
Both groups seemed to have general improvement in VAS, but in C group, the VAS was higher than the H group 2 and 4 weeks after the surgery, and the difference in time-group change between 2 groups was statistically significant (p <0.05). ODI improved in both groups, and the difference in time-group change between 2 groups was not statistically significant (p >0.05).
Conclusions
The rebound pain (the re-occurrence of pain within 2-4 weeks after injection) that occurs within 2-4 weeks after the injection of the routine regimen can be reduced when hyaluronidase is added to the routine SNRB regimen.
doi:10.4184/asj.2015.9.1.83
PMCID: PMC4330224
Nerve block; Hyaluronidase; Visual analog scale
23.  Clinical Outcomes of Surgical Treatments for Traumatic Spinal Injuries due to Snowboarding 
Asian Spine Journal  2015;9(1):90-98.
Study Design
Retrospective study.
Purpose
To assess treatment outcomes of snowboarding-related spinal and spinal cord injuries.
Overview of Literature
Snowboarding-related spinal or spinal cord injury have a great impact on social and sporting activities.
Methods
A retrospective review of 19 cases of surgically treated snowboard-related injury was done. Analyzed parameters included site of injury, type of fracture, peri- and postoperative complications, pre- and postoperative neurological status, activities of daily living, and participation in sports activities at the final follow-up.
Results
The major site of injury was the thoracolumbar junction caused by fracture-dislocation (13/19 cases). The remaining 6 cases had cervical spine injuries. Over 60% of the patients had Frankel A and B paralysis. All patients were surgically treated by posterior fusion with instrumentation. Five underwent additional anterior fusion. Surgical outcome was restoration of ambulatory capacity in 12 patients (63.2%). Ultimately, 15 patients (78.9%) could return to work. Patients with complete paralysis upon admission showed reduced ambulatory capacity compared to those with incomplete paralysis. None of the patients again participated in any sports activities, including snowboarding.
Conclusions
Snowboarding-related spinal or spinal cord injury has a great impact on social as well as sports activities. It is necessary to enhance promotion of injury prevention emphasizing the snowboarders' responsibility code.
doi:10.4184/asj.2015.9.1.90
PMCID: PMC4330225
Snowboarding; Spinal injury; Surgical treatment; Clinical outcomes
24.  Diastematomyelia: A Surgical Case with Long-Term Follow-Up 
Asian Spine Journal  2015;9(1):99-102.
Few reports have described the involvement of syringomyelia associated with diastematomyelia in the etiology of neurological deficits. We reported a case with syringomyelia associated with diastematomyelia. A female patient with diastematomyelia was followed up clinically over 14 years. At the age of 8, she developed clubfoot deformity with neurological deterioration. Motor function of the right peroneus demonstrated grade 2 in manual muscle tests. Continuous intracanial bony septum and double cords with independent double dura were observed at upper thoracic spine. Magnetic resonance imaging revealed a tethering of the spinal cord and syringomyelia distal to the level of diastematomyelia. Extirpation of the osseum septum and duralplasty were performed surgically. She grew without neurological deterioration during 7 years postoperatively. A long-term followed up case with syringomyelia that was possibly secondary to the tethering of the spinal cord associated with diastematomyelia, and effective treatment with extirpation of the osseum septum and duralplasty was described.
doi:10.4184/asj.2015.9.1.99
PMCID: PMC4330226
Diastematolyelia; Syringomyelia; Tethered cord syndrome
25.  Coccygectomy as a Surgical Option in the Treatment of Chronic Traumatic Coccygodynia: A Single-Center Experience and Literature Review 
Asian Spine Journal  2014;8(6):705-710.
Study Design
Retrospective cohort study.
Purpose
Trauma is the most common cause for chronic coccygodynia. The present study aims at presenting our results after complete removal of the coccyx for refractory traumatic coccygodynia in terms of pain level, complication rates, and patients' overall satisfaction.
Overview of Literature
There is limited extant literature describing the success rate and complications in refractory isolated traumatic coccygodynia.
Methods
From January 2011 to January 2012, 10 consecutive patients with posttraumatic coccygodynia (six males and four females; mean age, 42 years) were enrolled in our study. Conservative treatment of the condition had failed in all patients. The same surgeon performed a complete coccygectomy on all patients. Postoperative outcomes included measurements of pain relief and degree of patient satisfaction with the procedure's results.
Results
In our selected cohort, all patients indicated complete pain relief or significant pain improvement in follow up-care and would recommend this procedure. One patient developed a subcutaneous hematoma that required surgical intervention.
Conclusions
Our results suggest that complete removal of the coccyx relieves pain in patients with refractory chronic traumatic coccygodyniaand is therefore a reasonable treatment option after conservative treatment failure.
doi:10.4184/asj.2014.8.6.705
PMCID: PMC4278974  PMID: 25558311
Coccygectomy; Coccyx

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