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issn:1976-78.6
1.  Gait Analysis in Cervical Spondylotic Myelopathy 
Asian Spine Journal  2015;9(3):321-326.
Study Design
Gait analysis of patients with cervical spondylotic myelopathy (CSM) by using a sheet-type gait analysis system.
Purpose
The aim of this study was to compare the gait patterns of patients with CSM, evaluated by the Nurick grades, and to determine the threshold values of gait parameters predicting the occurrence of a fall by using a gait recorder.
Overview of Literature
Gait disorder due to CSM may progress to severe paraplegia, following even a minor trauma such as a fall. The indications for the surgery of CSM without severe paralysis remain controversial. The quantitative gait analysis and the decision for decompressive surgery in patients with CSM are important in order to prevent severe paraplegia from a fall.
Methods
One hundred thirty-two subjects (normal, 34; CSM, 98) underwent gait analysis by using a sensor sheet. Measurements of gait cycle parameters included the step and stride length, step width, foot angle, swing phase, and stance phase. CSM was assessed by Nurick grade.
Results
Although the clinical symptoms were lacking, Nurick grade 1 had significant abnormalities in the parameters of velocity, step length, and step angle (p<0.05). Regarding the Nurick grade and walking phase, the length of the stance phase was increased to more than 70% of the entire walking cycle in Nurick grade 4.
Conclusions
Gait analysis was an objective tool for evaluating the gait stability. Our results suggested that when the percentage of the stance phase in the gait cycle increases to above 70%, the CSM patients have an increased fall risk.
doi:10.4184/asj.2015.9.3.321
PMCID: PMC4472579  PMID: 26097646
Gait; Movement disorders; Physical examination; Spinal cord diseases
2.  Detecting Facet Joint and Lateral Mass Injuries of the Subaxial Cervical Spine in Major Trauma Patients 
Asian Spine Journal  2015;9(3):327-337.
Study Design
Radiologic imaging measurement study.
Purpose
To assess the accuracy of detecting lateral mass and facet joint injuries of the subaxial cervical spine on plain radiographs using computed tomography (CT) scan images as a reference standard; and the integrity of morphological landmarks of the lateral mass and facet joints of the subaxial cervical spine.
Overview of Literature
Injuries of lateral mass and facet joints potentially lead to an unstable subaxial cervical spine and concomitant neurological sequelae. However, no study has evaluated the accuracy of detecting specific facet joint injuries.
Methods
Eight spinal surgeons scored four sets of the same, randomly re-ordered, 30 cases with and without facet joint injuries of the subaxial cervical spine. Two surveys included conventional plain radiographs series (test) and another two surveys included CT scan images (reference). Facet joint injury characteristics were assessed for accuracy and reliability. Raw agreement, Fleiss kappa, Cohen's kappa and intraclass correlation coefficient statistics were used for reliability analysis. Majority rules were used for accuracy analysis.
Results
Of the 21 facet joint injuries discerned on CT scan images, 10 were detected in both plain radiograph surveys (sensitivity, 0.48; 95% confidence interval [CI], 0.26-0.70). There were no false positive facet joint injuries in either of the first two X-ray surveys (specificity, 1.0; 95% CI, 0.63-1.0). Five of the 11 cases with missed injuries had an injury below the lowest visible articulating level on radiographs. CT scan images resulted in superior inter- and intra-rater agreement values for assessing morphologic injury characteristics of facet joint injuries.
Conclusions
Plain radiographs are not accurate, nor reliable for the assessment of facet joint injuries of the subaxial cervical spine. CT scans offer reliable diagnostic information required for the detection and treatment planning of facet joint injuries.
doi:10.4184/asj.2015.9.3.327
PMCID: PMC4472580  PMID: 26097647
Zygapophyseal joint; Spine; Spinal injuries; Diagnostic imaging; Reproducibility of results
3.  The Time Course Changes in Bone Metabolic Markers after Administering the Anti-Receptor Activator of Nuclear Factor-Kappa B Ligand Antibody and Drug Compliance among Patients with Osteoporosis 
Asian Spine Journal  2015;9(3):338-343.
Study Design
Retrospective study.
Purpose
We conducted a study to investigate the time course changes in bone metabolic markers after the administration of the anti-receptor activator of nuclear factor-kappa B ligand (RANKL) antibody and to assess drug compliance among osteoporotic patients.
Overview of Literature
The anti-RANKL antibody is expected to provide an improvement in those with a bone metabolism disorder. However there are only a few clinical reports available on the effect of treatment.
Methods
We included 40 post-menopausal osteoporotic patients who received the anti-RANKL antibody. To determine the time course changes in the bone metabolic markers, we measured the serum tartrate-resistant acid phosphatase 5b (TRACP 5b; a bone resorption marker) and the serum N-terminal propeptide of type 1 collagen (P1NP; a bone formation marker) levels prior to and 1 month after administrating the anti-RANKL antibody. To evaluable drug compliance, we assessed the dropout rate during treatment and at 6 months after treatment.
Results
The average TRACP 5b level significantly decreased from 574.8 mU/dL before treatment to 153.2 mU/dL 1 month after treatment (p<0.05). There was no significant difference in the average P1NP level, which was 56.9 µG/L and 35.1 µG/L before and 1 month after treatment, respectively (p>0.05). As for drug compliance, we did not have any dropouts during the treatment or after 6 months (dropout rate: 0%).
Conclusions
Our study suggests that anti-RANKL antibody treatment suppresses bone resorption and maintains bone formation.
doi:10.4184/asj.2015.9.3.338
PMCID: PMC4472581  PMID: 26097648
Tartrate-resistant acid phosphatase; Receptor activator of nuclear factor-kappa B ligand
4.  Demographics of Thoracolumbar Fracture in Indian Population Presenting to a Tertiary Level Trauma Centre 
Asian Spine Journal  2015;9(3):344-351.
Study Design
Prospective, cross-sectional, observational study.
Purpose
Spine traumata are devastating injuries, which may result in serious disabilities and dire consequences. The current study involves a detailed analysis and description of patients, who were operated at a tertiary care, urban level 1 Spine Centre in India.
Overview of Literature
Various studies in literature have discussed the epidemiology and patterns of these injuries in trauma patients. However, literature describing the demographic profile and distribution of these traumata in the Indian population is scarce.
Methods
The current study was conducted as a prospective trial involving patients, who were treated at our Spine Centre in India between July 2009 to December 2012. We studied 92 patients with thoraco-lumbar spine fracture, who were operated with short or long segment posterior stabilization. Epidemiological details, pre- and post-hospitalisation care received and other injury pattern factors were studied.
Results
Fall from height (46 patients, 50%) was the most common mechanism observed in the patients. Sixty-three percent injuries belonged to AO type A fractures, while 16.2% and 19.4% of the patients had suffered from AO types B and C injuries, respectively.
Conclusions
We identified interesting epidemiological data and prevailing inadequacies in Emergency Spine care management in the study patients. These observations could facilitate implementation of the changes required to improve current standards of patient care.
doi:10.4184/asj.2015.9.3.344
PMCID: PMC4472582  PMID: 26097649
Spinal fractures; Thoracic vertebrae injuries; Demography; Trauma center; India
5.  Restoration of Lumbar Lordosis in Flat Back Deformity: Optimal Degree of Correction 
Asian Spine Journal  2015;9(3):352-360.
Study Design
A retrospective comparative study.
Purpose
To provide an ideal correction angle of lumbar lordosis (LL) in degenerative flat back deformity.
Overview of Literature
The degree of correction in degenerative flat back in relation to pelvic incidence (PI) remains controversial.
Methods
Forty-nine patients with flat back deformity who underwent corrective surgery were enrolled. Posterior-anterior-posterior sequential operation was performed. Mean age and mean follow-up period was 65.6 years and 24.2 months, respectively. We divided the patients into two groups based on immediate postoperative radiographs-optimal correction (OC) group (PI-9°≤LL
Results
Patients in OC group had significantly less correction loss and maintained normal sagittal alignment (sagittal vertical axis<5 cm), as compared to patients in UC group (p<0.05). LL of low PI group significantly maintained within 9° better than high PI group (p<0.05). Oswestry disability index (ODI) significantly decreased at last follow-up, as compared to preoperative state. However, there was no significant difference in last follow-up ODI between the groups.
Conclusions
In flat back deformity, correction of LL to within 9° of PI will result in better sagittal balance. Thus, we recommend sufficient LL to prevent correction loss, especially in patients with high PI.
doi:10.4184/asj.2015.9.3.352
PMCID: PMC4472583  PMID: 26097650
Flat back deformity; Lumbar lordosis; Pelvic incidence
Asian Spine Journal  2015;9(3):361-369.
Study Design
Retrospective study.
Purpose
To evaluate the radiological and clinical results of three different methods in the deformity correction of a degenerative flat back.
Overview of Literature
There are no comparative studies about different procedures in the treatment of degenerative flat back.
Methods
Sixty-four patients who consecutively underwent corrective surgery for degenerative flat back were reviewed. The operations were performed by three different methods: posterior-only (group P, n=20), one-stage anterior-posterior (group AP, n=12), and two-stage anterior-posterior with iliac screw fixation (group AP-I, n=32). Medical and surgical complications were examined and radiological and clinical results were compared.
Results
The majority of medical and surgical complications were found in group AP (5/12) and group P (7/20). The sagittal vertical axes were within normal range immediately postoperatively in all groups, but only group AP-I showed normal sagittal alignment at the final follow-up. Postoperative lumbar lordosis was also significantly higher in group AP-I than in group P or group AP and the finding did not change through the last follow-up. The Oswestry disability index was significantly lower in groups AP and AP-I than in group P at the final follow-up. Meanwhile, the operating time was the longest in group AP-I, and total amount of blood loss was larger in group AP-I and group AP than in group P.
Conclusions
Anterior-posterior correction showed better clinical results than posterior-only correction. Two-staged anterior-posterior correction with iliac screw fixation showed better radiological results than posterior-only or one-staged anterior-posterior correction. Two-staged anterior-posterior correction with iliac screw fixation also showed a lower complication rate than one-staged anterior-posterior correction.
doi:10.4184/asj.2015.9.3.361
PMCID: PMC4472584  PMID: 26097651
Lumbar vertebrae; Kyphosis; Surgical procedures; Treatment outcome
Asian Spine Journal  2015;9(3):370-385.
Study Design
This is a prospective, randomized, controlled study designed and conducted over 10 years from 2002 to 2012.
Purpose
The study aimed to monitor the effect of suction drains (SD) on the incidence of epidural fibrosis (EF) and to test, if the use of SD alone, SD with local steroids application, SD combined with fat grafts and local steroids application, or SD combined with fat grafts and without local steroids application, would improve outcome.
Overview of Literature
EF contributes to significant unsatisfactory failed-back syndrome. Efforts have been tried to reduce postoperative EF, but none were ideal.
Methods
Between September 2002 and 2012, 290 patients with symptomatic unilateral or bilateral, single-level lumbar disc herniation were included in the study. Two groups were included, with 165 patients in group I (intervention group) and 125 patients in group II (control group). Group I was subdivided into four subgroups: group Ia (SD alone), group Ib (SD+fat graft), group Ic (SD+local steroids), and group Id (SD+fat graft+local steroids).
Results
The use of SD alone or combined with only fat grafts, fats grafts and local steroids application, or only local steroids application significantly improved patient outcome and significantly reduced EF as measured by magnetic resonance imaging (MRI).
Conclusions
This study has clearly demonstrated the fact that the use of suction drainage alone or combined with only fat grafts, fats grafts and local steroids application, or only local steroids application significantly improved patient outcome with respect to pain relief and functional outcome and significantly reduced EF as measured by an MRI. A simple grading system of EF on MRI was described.
doi:10.4184/asj.2015.9.3.370
PMCID: PMC4472585  PMID: 26097652
Epidural fibrosis; Suction drain; Lumbar; Failed back; Prevention
Asian Spine Journal  2015;9(3):386-393.
Study Design
Descriptive cases series.
Purpose
To evaluate clinical findings and results of conventional surgery in patients with spinal osteoid osteoma (OO).
Overview of Literature
OO is a rare benign tumor with spinal involvement rate of about 10%-20%.
Methods
This descriptive study was conducted on 19 patients (11 males and 8 females with an average age of 19.8 years) with documented histopathological and imaging findings of OO referred to a university hospital. Neurologic symptoms and pain were scored before and after the open surgical excision. Data were analyzed by SPSS ver. 16 software using chi-square and significance level of 0.05.
Results
The most common complaint was back or neck pain (84.2%) and in 68.4% spinal deformity (mostly scoliosis) shown with an average cobb angle of 21° at presentation. The sites of involvement were 35% in the lumbar, 35% in the thoracic, 25% in the cervical, and 5% in the sacrum. Lamina was the most common site (50%) of involvement with predilection for the right side (p=0.001). All patients were treated by conventional surgical excision with a complete recovery of pain and deformity. No recurrence occurred after a mean follow up of 44.5 months, but 4 of 19 cases instrumented because of induced instability. In one case there were two levels of involvement (C7-T1) simultaneously. Interestingly, 10 out of 19 of our cases belonged to a specific race (Bakhtiari).
Conclusions
Surgical intra-lesional curettage is potentially an effective method without any recurrence, which can lead to spontaneous scoliosis recovery and pain relief. Race may be a potential risk factor for spinal (OO).
doi:10.4184/asj.2015.9.3.386
PMCID: PMC4472586  PMID: 26097653
Osteoid osteoma; Bone tumor; Surgical outcoms; Spine
Asian Spine Journal  2015;9(3):394-398.
Study Design
A retrospective chart review.
Purpose
In endemic resource poor countries like Pakistan, most patients are diagnosed and treated for Potts disease on clinical and radiological grounds without a routine biopsy. The purpose of this study was to evaluate the use and effect of computed tomography (CT)-guided biopsy in the management of Potts disease since the technique is becoming increasingly available.
Overview of Literature
CT-guided biopsy of spinal lesions is routinely performed. Literature on the utility of the technique in endemic resource poor countries is little.
Methods
This study was conducted at the Neurosurgery section of Aga Khan University Hospital Karachi. All the patients with suspected Potts disease who underwent CT-guided biopsy during the 7 year period from 2007 to 2013 were included in this study. Details of the procedure, histopathology and microbiology were recorded.
Results
One hundred and seventy-eight patients were treated for suspected Potts disease during the study period. CT-guided biopsies of the spinal lesions were performed in 91 patients (51.12%). Of the 91 procedures, 22 (24.2%) were inconclusive because of inadequate sample (10), normal tissue (6) or reactive tissue (6). Sixty-nine biopsies were positive (75.8%). Granulomatous inflammation was seen in 58 patients (84.05%), positive acid-fast bacillus (AFB) smear in 4 (5.7%) and positive AFB culture in 12 patients (17.3%). All 91 cases in which CT-guided biopsy was performed responded positively to antituberculosis therapy (ATT).
Conclusions
75.8% of the specimens yielded positive diagnoses. Granulomatous inflammation on histopathology was the commonest diagnostic feature. In this series, the rates of positive AFB smear and culture were low compared to previous literature.
doi:10.4184/asj.2015.9.3.394
PMCID: PMC4472587  PMID: 26097654
Potts disease; Computed tomography; Aspiration biopsy
Asian Spine Journal  2015;9(3):399-406.
Study Design
Case-control study.
Purpose
To design a new tool for classifying lumbar spinal canal stenosis (CLSCS).
Overview of Literature
Grading of patients with lumbar spinal canal stenosis (LSCS) is controversial.
Methods
The Oswestry disability index (ODI) and the neurogenic claudication outcome score (NCOS) were recorded. Four parameters, which indicate the severity of LSCS disease, including Hufschmidt-grade, grading of magnetic resonance imaging, self-paced walking test, and stenosis ratio (SR) were employed. For the SR, quartile analysis was applied for classifying LSCS and the Hufschmidt-grade was modified into a 4-grade score. An initial score was assigned to each metric based on the severity of LSCS. Using the inverse-variance weighting method, the relative weights of these domains and their categories were determined. The score for all of the cases was obtained based on their weight by summing up the points of the four variables. Quartile analysis was used and a CLSCS score was proposed. Finally, intra- and interobserver reliability, and validity were assessed.
Results
A total of 357 patients were studied. The final CLSCS score for each case ranged from 4 to 16.5. Based on the quartile analysis, using the new criteria set, the CLSCS score was divided into four categories: CLSCS<7 (grade 0); 7≤CLSCS<10 (grade 1); 10≤CLSCS<13 (grade 2); and 13≤CLSCS≤16.5 (grade 3). The kappa values of for the CLSCS score indicated a perfect agreement. The CLSCS was correlated with the ODI and NCOS. All patients with grade 3 CLSCS were observed in the surgical group.
Conclusions
The CLSCS score can be helpful for classifying LSCS patients and in the decision-making process.
doi:10.4184/asj.2015.9.3.399
PMCID: PMC4472588  PMID: 26097655
Lumbar spinal canal stenosis; New tool; Classification; Classifying lumbar spinal canal stenosis
Asian Spine Journal  2015;9(3):407-415.
Study Design
Retrospective cross-sectional study.
Purpose
To determine the prevalence of idiopathic scoliosis, define the distribution of the curve magnitude, evaluate the accuracy of Moiré topography as a screening tool, and investigate the cost-effectiveness of our screening system.
Overview of Literature
Early detection of idiopathic scoliosis provides the opportunity for conservative treatment before the deformity is noticeable. We believe that scoliosis screening in schools is useful for detection; however, screening programs are controversial owing to over referral of students who do not require further testing or follow-up. In Japan, school scoliosis screening programs are mandated by law with individual policies determined by local educational committees. We selected Moiré topography as the scoliosis screening tool for schools in Nara City.
Methods
We selected Moiré topography as the scoliosis screening tool for schools in Nara City. We screened boys and girls aged 11-14 years and reviewed the school scoliosis screening results from 1990 to 2012.
Results
A total of 195,149 children aged 11-14 years were screened. The prevalence of scoliosis (defined as ≥10° curvature) was 0.057%, 0.010%, and 0.059% in fifth, sixth, and seventh grade boys and 0.337%, 0.369%, and 0.727% in fifth, sixth, and seventh grade girls, respectively. The false-positive rate of our Moiré topography was 66.7%. The minimum cost incurred for scoliosis detection in one student was 2,000 USD.
Conclusions
The overall prevalence of scoliosis was low in the students of Nara City schools. Over 23 years, the prevalence of scoliosis in girls increased compared to that in the first decade of the study.
doi:10.4184/asj.2015.9.3.407
PMCID: PMC4472589  PMID: 26097656
Scoliosis; Mass screening; Prevalence; Moiré topography; Costs and cost analysis
Asian Spine Journal  2015;9(3):416-422.
Study Design
A cross-sectional, descriptive study.
Purpose
This study aimed to investigate the relationship between kyphosis and lordosis measured by using a flexible ruler and musculoskeletal pain in students of Hamadan University of Medical Sciences.
Overview of Literature
The spine supports the body during different activities by maintaining appropriate body alignment and posture. Normal alignment of the spine depends on its structural, muscular, bony, and articular performance.
Methods
Two hundred forty-one students participated in this study. A single examiner evaluated the angles of lumbar lordosis and thoracic kyphosis by using a flexible ruler. To determine the severity and frequency of pain in low-back and inter-scapular regions, a tailor-made questionnaire with visual analog scale was used. Finally, using the Kendall correlation coefficient, the data were statistically analyzed.
Results
The mean value of lumbar lordosis was 34.46°±12.61° in female students and 22.46°±9.9° in male students. The mean value of lumbar lordosis significantly differed between female and male students (p<0.001). However, there was no difference in the level of the thoracic curve (p=0.288). Relationship between kyphosis measured by using a flexible ruler and inter-scapular pain in male and female students was not significant (p=0.946). However, the relationship between lumbar lordosis and low back pain was statistically significant (p=0.006). Also, no significant relationship was observed between abnormal kyphosis and frequency of inter-scapular pain, and between lumbar lordosis and low back pain.
Conclusions
Lumbar lordosis contributes to low back pain. The causes of musculoskeletal pain could be muscle imbalance and muscle and ligament strain.
doi:10.4184/asj.2015.9.3.416
PMCID: PMC4472590  PMID: 26097657
Kyphosis; Lordosis; Pain
Asian Spine Journal  2015;9(3):423-426.
Study Design
A prospective, randomized, controlled study.
Purpose
The objective of this study was to evaluate the effectiveness of two techniques of skin preparation with povidone-iodine.
Overview of Literature
Preoperative skin preparation is important for preventing surgical site infection by reducing the bacteria in the surgical area. Povidone-iodine is a commonly used agent for preoperative skin preparation, and further decrease in surgical site infections can be expected by understanding how to apply it more effectively.
Methods
Eighty-nine spine surgery patients were randomly allocated to two groups. In group A, povidone-iodine was applied to the surgical site just before starting the operation; in group B, povidone-iodine was applied several minutes prior to starting the operation and was allowed to dry. We collected samples from the wound edge before suturing, and we compared the rates of positive culture between the two groups.
Results
The rate of positive culture was 30.2% (13 out of 43 patients) in group A, and 6.5% (3 out of 46 patients) in group B. This indicates that there was a significant difference in postoperative infection rates between group A and group B.
Conclusions
Because bacteria on the skin appeared significantly reduced by allowing povidone-iodine to dry for several minutes prior to surgery, we recommend this approach to reduce the incidence of postoperative infections.
doi:10.4184/asj.2015.9.3.423
PMCID: PMC4472591  PMID: 26097658
Surgical wound; Infection; Povidone-iodine
Asian Spine Journal  2015;9(3):427-432.
Study Design
Retrospective study.
Purpose
To evaluate the radiological outcome of the surgical treatment of thoracolumbar burst fractures by using short segment posterior instrumentation (SSPI) and fusion.
Overview of Literature
The optimal surgical treatment of thoracolumbar burst fractures remains a matter of debate. SSPI is one of a number of possible choices, yet some studies have revealed high rates of poor radiological outcome for this SSPI.
Methods
Patients treated using the short segment instrumentation and fusion technique at the Spinal Injuries Center (Iizuka, Fukuoka, Japan) from January 1, 2006 to July 31, 2012 were selected for this study. Radiographic parameters such as local sagittal angle, regional sagittal angle, disc angle, anterior or posterior height of the vertebral body at admission, postoperation and final observation were collected for radiological outcome evaluation.
Results
There were 31 patients who met the inclusion criteria with a mean follow-up duration of 22.7 months (range, 12-48 months). The mean age of this group was 47.9 years (range, 15-77 years). The mean local sagittal angles at the time of admission, post-operation and final observation were 13.1°, 7.8° and 14.8°, respectively. There were 71% good cases and 29% poor cases based on our criteria for the radiological outcome evaluation. The correction loss has a strong correlation with the load sharing classification score (Spearman rho=0.64, p<0.001).
Conclusions
The loss of kyphotic correction following the surgical treatment of thoracolumbar burst fracture by short segment instrumentation is common and has a close correlation with the degree of comminution of the vertebral body. Patients with high load sharing scores are more susceptible to correction loss and postoperative kyphotic deformity than those with low scores.
doi:10.4184/asj.2015.9.3.427
PMCID: PMC4472592  PMID: 26097659
Short segment instrumentation; Thoracolumbar burst fractures; Correction loss; Degree of comminution; Load sharing classification
Asian Spine Journal  2015;9(3):433-439.
Study Design
A randomized, controlled animal study.
Purpose
To investigate the effectiveness of fusion and new bone formation induced by demineralized bone matrix (DBM) strips with jelly strengths.
Overview of Literature
The form of the DBM can make a difference to the outcome. The effect of different jelly strengths on the ability of DBM to form new bone is not known.
Methods
Forty-eight rabbits were randomized into a control group and two experimental groups. In the control group (group 1), 1.4 g of autologous iliac crest bone was placed bilaterally. In the experimental groups, a high jelly strength DBM-hyaluronic acid (HA)-gelatin strip (group 2) and a low jelly strength DBM-HA-gelatin strip (group 3) were used. The fusion was assessed with manual manipulation and radiographs. The volume of the fusion mass was determined from computed tomographic images.
Results
The fusion rates as determined by manual palpation were 37.5%, 93.8% and 50.0% in group 1, group 2, and group 3, respectively (p<0.05). By radiography, the fusion rate of High jelly strength DBM strip was statistically significantly greater than that of the other alternatives (p<0.05). The mean bone volume of the fusion mass as determined by computed tomography was 2,142.2±318.5 mm3, 3,132.9±632.1 mm3, and 2,741.5±380.4 mm3 in group 1, group 2, and group 3, respectively (p<0.05).
Conclusions
These results indicate that differences in the structural and mechanical properties of gelatin that are associated with jelly strength influenced cellular responses such as cell viability and bony tissue ingrowth, facilitating greater bone fusion around high jelly strength implants.
doi:10.4184/asj.2015.9.3.433
PMCID: PMC4472593  PMID: 26097660
Demineralized bone matrix; Spinal fusion
Asian Spine Journal  2015;9(3):440-448.
Study Design
Case-control study.
Purpose
To evaluate clinical and radiological results of transforaminal lumbar interbody fusion (TLIF) performed with cortical bone trajectory (CBT) pedicle screw insertion with those of TLIF using 'conventional' or percutaneous pedicle screw insertion.
Overview of Literature
CBT is a new trajectory for pedicle screw insertion in the lumbar spine; clinical and radiological results of TLIF using pedicle screws inserted with CBT are unclear.
Methods
In total, 26 patients (11 males, 15 females) were enrolled in this retrospective study and divided into three groups: TLIF with pedicle screw insertion by conventional minimally invasive methods via the Wiltse approach (M-TLIF, n=10), TLIF with percutaneous pedicle screw insertion (P-TLIF, n=6), and TLIF with pedicle screw insertion with CBT (CBT-TLIF, n=10). Surgical results and preand postoperative radiological findings were evaluated and compared.
Results
Intraoperative blood loss was significantly less with CBT-TLIF (p=0.03) than with M-TLIF. Postoperative lordotic angles did not differ significantly among the three groups. Complete fusions were obtained in 10 of 12 levels (83%) with M-TLIF, in seven levels (100%) with P-TLIF, and in 10 of 11 levels (91%) with CBT-TLIF. On postoperative computed tomography, correct positioning was seen in 84.1% of M-TLIF screws, 88.5% of P-TLIF screws, and 90% of CBT-TLIF screws.
Conclusions
CBT-TLIF resulted in less blood loss and a shorter operative duration than M-TLIF or P-TLIF. Postoperative rates of bone union, maintenance of lordotic angles, and accuracy of pedicle screw positions were similar among the three groups.
doi:10.4184/asj.2015.9.3.440
PMCID: PMC4472594  PMID: 26097661
Transforaminal lumbar interbody fusion; Cortical bone trajectory; Conventional trajectory; Percutaneous insertion; Computed tomography
Asian Spine Journal  2015;9(3):449-451.
Herein, we report on an inferior migration of an intervertebral disc C6-7 to the cervicothoracic junction manifesting as acute paraplegia. The patient showed a remarkable recovery after the surgery. The diagnostic dilemma and management difficulties of such an entity are briefly discussed.
doi:10.4184/asj.2015.9.3.449
PMCID: PMC4472595  PMID: 26097662
Cervical disc prolapse; Disc herniation; Cervico thoracic junction; Disc migration
Asian Spine Journal  2015;9(3):452-455.
Hemophilia A is a hereditary coagulation disorder. Most cases are diagnosed at birth or at least during childhood. A spontaneous spinal epidural hematoma was developed in a 74-year-old male patient who hadn't had a family or past medical history of bleeding disorders. On magnetic resonance imaging, epidural hematoma at L1-2 was accompanied by spinal stenosis at L4-5 and spondylolytic spondylolisthesis at L5. Hematoma evacuation and surgery for distal lumbar lesions were performed at once. After transient improvement, complete paraplegia was developed due to redevelopment of large epidural hematomas at L1-2 and L4-S1 which blocked epidural canal completely. Emergency evacuation was performed and we got to know that he had a hemophilia A. Factor VIII was 28% of normal value. Mild type hemophilia A could have not been diagnosed until adulthood. Factor VIII should have been replaced before the surgical decompression.
doi:10.4184/asj.2015.9.3.452
PMCID: PMC4472596  PMID: 26097663
Hemophilia A; Hematoma; Epidural; Spinal; Spontaneous; Senior
Asian Spine Journal  2015;9(3):456-460.
To date, no reports have presented radiculopathy secondary to heterotopic ossification following lumbar total disc arthroplasty. The authors present a previously unpublished complication of lumbar total disk arthroplasty (TDA) secondary to heterotopic ossification (HO) in the spinal canal, and they propose a modification to the McAfee classification of HO. The patient had undergone an L5/S1 lumbar TDA two years prior due to discogenic back pain. His preoperative back pain was significantly relieved, but he developed new, atraumatic onset radiculopathy. Radiographs and a computed tomography myelogram revealed an implant malposition posteriorly with heterotopic bone formation in the canal, causing an impingement of the traversing nerve root. Revision surgery was performed with implant extraction, L5/S1 anterior lumbar interbody fusion, supplemental posterior decompression, and pedicle screw fixation. The patient tolerated the procedure well, with complete resolution of the radicular leg pain. At a two-year follow up, the patient had a solid fusion without subsidence or recurrence of heterotopic bone. This case represents a novel pattern of heterotopic ossification, and it describes a previously unreported cause for implant failure in lumbar disc replacement surgery-reinforcing the importance of proper intraoperative component positioning. We propose a modification to the existing McAfee classification of HO after TDA with the addition of Class V and VI HO.
doi:10.4184/asj.2015.9.3.456
PMCID: PMC4472597  PMID: 26097664
Heterotopic ossification; Total disc arthroplasty; Radiculopathy
Asian Spine Journal  2015;9(3):461-464.
The breakage of an epidural catheter is an extremely rare complication. We describe a unique case where a retained epidural catheter fragment after epidural anesthesia was treated by surgery. The epidural catheter broke during its removal, requiring surgery to remove the retained catheter. Intraoperatively, the removal of the catheter was attempted by simple traction, but was impossible because of the adhesion. The adhesion of the dura mater surface was carefully exfoliated and the successful removal of the catheter was accomplished. Conventionally, it was said that this follow-up was enough for the retained catheter. However, if a catheter is retained within the spinal canal, surgical removal should thus be considered before the adhesion advances.
doi:10.4184/asj.2015.9.3.461
PMCID: PMC4472598  PMID: 26097665
Epidural; Catheter; Complication; Surgery
Asian Spine Journal  2015;9(3):465-470.
Atlanto-occipital dislocation (AOD) is rarely seen in clinic because it is characteristically immediately fatal. With recent progress in the pre-hospital care, an increasing number of AOD survivors have been reported. However, because the pathophysiology of AOD is not clearly understood yet, the appropriate strategy for the initial management remains still unclear. We report a case of successful AOD treatment and describe important points in the management of this condition. It is important to note that abducens nerve palsy is a warning sign of AOD and that AOD can result in a life-threatening distortion of the arteries and the brain stem. We recommend the application of a halo vest to protect the patient's neural and vascular competence as the immediate initial step in the treatment of AOD. Horn's grading system is useful in assessing indications for surgery. Finally, when performing posterior fixation, C2 should be included because of the anatomy of the ligamentous architecture.
doi:10.4184/asj.2015.9.3.465
PMCID: PMC4472599  PMID: 26097666
Atlanto-occipital joint; External fixators; Internal fixators
Asian Spine Journal  2015;9(3):471-482.
Cervical disc replacement (CDR) has emerged as an alternative surgical option to cervical arthrodesis. With increasing numbers of patients and longer follow-ups, complications related to the device and/or aging spine are growing, leaving us with a new challenge in the management and surgical revision of CDR. The purpose of this study is to review the current literature regarding reoperations following CDR and to discuss about the approaches and solutions for the current and future potential complications associated with CDR. The published rates of reoperation (mean, 1.0%; range, 0%-3.1%), revision (mean, 0.2%; range, 0%-0.5%), and removal (mean, 1.2%; range, 0%-1.9%) following CDR are low and comparable to the published rates of reoperation (mean, 1.7%; range; 0%-3.4%), revision (mean, 1.5%; range, 0%-4.7%), and removal (mean, 2.0%; range, 0%-3.4%) following cervical arthrodesis. The surgical interventions following CDR range from the repositioning to explantation followed by fusion or the reimplantation to posterior foraminotomy or fusion. Strict patient selection, careful preoperative radiographic review and surgical planning, as well as surgical technique may reduce adverse events and the need for future intervention. Minimal literature and no guidelines exist for the approaches and techniques in revision and for the removal of implants following CDR. Adherence to strict indications and precise surgical technique may reduce the number of reoperations, revisions, and removals following CDR. Long-term follow-up studies are needed, assessing the implant survivorship and its effect on the revision and removal rates.
doi:10.4184/asj.2015.9.3.471
PMCID: PMC4472600  PMID: 26097667
Spine; Cervical vertebra; Intervertebral disc; Arthroplasty; Complications; Reoperations; Options
Asian Spine Journal  2015;9(3):483-491.
Despite their benign nature some symptomatic aggressive vertebral haemangiomas (AVH) require surgery to decompress spinal cord and/or stabilise pathological fractures. Preoperative embolisation may reduce the considerable blood loss during surgical decompression. This systematic review investigated whether preoperative embolisation reduced surgical blood loss during treatment of symptomatic AVH. PubMed Medline, Web of Science, and Ovid Medline were searched for case reports and clinical studies on surgical AVH treatment. Included were cases from all publications on surgical treatment of AVH where the amount of surgical blood loss and the use of preoperative embolisation were documented. 51 cases with surgically treated AVH were retrieved from the included studies. Blood loss in the embolised treatment group (980±683 mL) was lower than the non-embolised control group (1,629±946 mL). This systematic review found that embolisation prior to AVH resection reduced surgical blood loss (level of evidence, very low) and can be recommended (strong recommendation).
doi:10.4184/asj.2015.9.3.483
PMCID: PMC4472601  PMID: 26097668
Spinal cord compression; Hemangioma; Therapeutic embolisation; Surgical blood loss
Asian Spine Journal  2015;9(3):493-494.
doi:10.4184/asj.2015.9.3.493
PMCID: PMC4472603  PMID: 26097670

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