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2.  Stable reconstruction using halo vest for unstable upper cervical spine and occipitocervical instability 
European Spine Journal  2011;21(2):295-303.
Introduction
Upper cervical or occipitocervical disorders such as rheumatoid arthritis present as atlantoaxial subluxation, vertical subluxation of the axis, and subaxial subluxation, which produce myelopathy and severe pain. In such cases, occipitocervical reconstruction surgery may be indicated, and several reports have described reduction of subluxation by fixing the halo vest before this surgery.
Purpose
The purpose of this study was to evaluate the efficacy of using the halo vest before the surgery for unstable upper cervical spine and for occipitocervical instability.
Methods
Twenty-eight patients (9 men and 19 women; mean age, 61.8 years at surgery) who presented with atlantoaxial or occipitocervical fusion were studied. In all cases, the halo vest was fixed in the conscious condition, and subluxation was reduced before the surgery. The mean follow-up period was 45 months. Roentgenologic measurement and clinical evaluation were performed before the surgery and at the final follow-up.
Results
Using the halo vest resulted in significant reductions in the atlantodental interval, the space available for the spinal cord, and the Ranawat value (p < 0.05), and these were maintained until the final follow-up. The mean Japanese Orthopedic Association score significantly improved from 9.5 before surgery to 12.2 at the final follow-up (p = 0.01). Nineteen cases (68%) improved by more than 1 grade by Ranawat’s classification after surgery and 16 cases (57%) maintained the same at the follow-up visit.
Conclusion
Conscious preoperative reduction using the halo vest for occipitocervical disorders is a useful and safe technique.
doi:10.1007/s00586-011-1973-5
PMCID: PMC3265589  PMID: 21833572
Occipitocervical disorders; Occipitocervical reconstruction; Halo vest
3.  The Pathophysiology of Primary Hip Osteoarthritis may Originate from Bone Alterations 
Objectives:
The aim of this study was to investigate whether bone alterations detected by hip magnetic resonance imaging (MRI) were associated with subsequent primary hip OA.
Methods:
We enrolled 7 patients with hip joint pain from their first visit, at which hip joints were classified as grade 0 or I on the Kellgren-Lawrence grading scale. Plain radiographs and magnetic resonance imaging (MRI) were performed on all cases, and pain was assessed with the Denis pain scale. Average age, height, weight, body mass index, bone mineral density (L1-4), central edge angle, Sharp’s angle, and acetabular hip index were calculated.
Results:
Within two months of the onset of pain, 4 of the 7 cases showed broad bone signal changes, while 3 cases showed local signal changes in the proximal femur on hip MRI. Three to 6 months after the onset of pain, in all patients whose pain was much improved, plain radiographs showed progression to further-stage OA.
Conclusion:
Our findings suggest that bone abnormalities in the proximal femur might be involved in the pathogenesis of primary hip OA.
doi:10.2174/1874312920130930003
PMCID: PMC3866704  PMID: 24358070
Pathophysiology; bone; hip osteoarthritis; MRI; joint pain.
4.  Cervical Pedicle Screw Fixation Combined with Laminoplasty for Cervical Spondylotic Myelopathy with Instability 
Asian Spine Journal  2012;6(4):241-248.
Study Design
A retrospective study.
Purpose
To evaluate the surgical results of cervical pedicle screw (CPS) fixation combined with laminoplasty for treating cervical spondylotic myelopathy (CSM) with instability.
Overview of Literature
Cervical fixation and spinal cord decompression are required for CSM patients with instability. However, only a few studies have reported on CPS fixation combined with posterior decompression for unstable CSM patients.
Methods
Thirteen patients that underwent CPS fixation combined with laminoplasty for CSM with instability were evaluated in this study. We assessed the clinical and radiological results of the surgical procedures. The Japanese Orthopedic Association (JOA) scoring system was used to evaluate the clinical results. The percentages of sli p, difference in sli p angle between maximum flexion and maximum extension of unstable intervertebrae, and perforation rate of CPS were evaluated.
Results
The mean JOA scores before surgery, immediately after surgery, and at final follow-up were 9.1, 13.3, and 12.6, respectively. The mean percentages of sli p before surgery, immediately after surgery, and at final follow-up were 9.1%, 3.2%, and 3.5%, respectively; there were significant improvements immediately after surgery and at final follow-up. The difference in sli p angle between the maximum flexion and maximum extension of the unstable intervertebrae changed from 9.0° before surgery to 1.6° at the final follow-up. The perforation rate of CPS was 10.9%.
Conclusions
The results suggest that CPS fixation combined with laminoplasty is an effective surgical procedure for treating CSM with instability.
doi:10.4184/asj.2012.6.4.241
PMCID: PMC3530698  PMID: 23275807
Cervical spondylosis; Myelopathy; Instability; Cervical fixation
5.  A Case of Pyogenic Spondylodiscitis Caused by Campylobacter fetus for Which Early Diagnosis by Magnetic Resonance Imaging Was Difficult 
Asian Spine Journal  2012;6(4):274-278.
The purpose of this case report was to report a rare case of pyogenic spondylodiscitis caused by Campylobacter fetus. A 37-year-old male presented with fever and low back pain. By lumbar magnetic resonance imaging (MRI), no abnormal finding was observed at the first presentation. However, low back pain was aggravated, and fever did not improve. Thus, lumbar MRI was repeated on the 26 day after the onset of symptoms, showing abnormal signals at vertebrae and disc spaces, and pyogenic spondylitis was diagnosed. The possibility of pyogenic spondylodiscitis should be taken into account if a patient presents with low back pain and fever, and areas of low signal intensity on a T1-weighted MRI should be carefully examined. When initial MRI does not reveal abnormal findings, repeated MRI after one or two weeks or, more favorably, immediate gadolinium enhancement MRI, are important for patients who have persistent low back pain and fever.
doi:10.4184/asj.2012.6.4.274
PMCID: PMC3530702  PMID: 23275811
Resonance imaging; Campylobacter fetus
6.  Computer-assisted C1-C2 Transarticular Screw Fixation "Magerl Technique" for Atlantoaxial Instability 
Asian Spine Journal  2012;6(3):168-177.
Study Design
A retrospective study.
Purpose
To evaluate the surgical results of computer-assisted C1-C2 transarticular screw fixation for atlantoaxial instability and the usefulness of the navigation system.
Overview of Literature
We used a computed tomography (CT)-based computer navigation system in planning and screw insertion in Magerl's procedure, which provides the most rigid atlantoaxial fusion, to avoid risk of vertebral artery (VA) tear by avoiding high-riding VA during screw insertion.
Methods
Twenty patients who underwent atlantoaxial fusion under the CT-based navigation system were studied. The mean observation period was 33.5 months. The evaluated items included the existence of VA stenosis by preoperative magnetic resonance angiography, surgical time, blood loss volume, Japanese Orthopaedic Association (JOA) score and Ranawat's pain criteria before surgery and at final follow-up, postoperative screw position evaluated by CT, and bony fusion.
Results
The mean operation time was 205 minutes, with the mean blood loss volume of 242 ml. The mean JOA score was 11.6 points before surgery and 13.7 at final follow-up. Occipital and/or cervical pain presented before operation was remitted or resolved in all patients. Evaluation of screw insertion by CT revealed correct penetration to atlantoaxial joints, with a perforation rate of 2.6%. There was no complication, including VA tear, and all patients who were followed-up during one year or more after surgery achieved bony fusion. Some subjects who appeared inappropriate for surgery from CT images were assessed as eligible for surgery based on the evaluation results obtained using the navigation system.
Conclusions
It was demonstrated that the CT-based navigation system is an effective support device for Magerl's procedure.
doi:10.4184/asj.2012.6.3.168
PMCID: PMC3429607  PMID: 22977696
Atlantoaxial joint; Atlantoaxial instability; CT-based computer navigation system; C1-C2 transarticular screw fixation
7.  Perforation Rates of Cervical Pedicle Screw Insertion by Disease and Vertebral Level 
Background:
Different perforation rates for cervical pedicle screws by disease are expected in relation to bone quality and pedicle morphology; however, no report comparing pedicle screw perforation rate by disease had previously been published. This study investigated the perforation rates of pedicle screws inserted to cervical pedicle by disease and vertebral level using a CT-based navigation system.
Materials/Methods:
Fifty-three patients who underwent cervical pedicle screw insertion using CT based navigation system were studied. Diseases included rheumatoid arthritis (RA) (24 cases), destructive spondyloarthropathy (DSA) (10), cervical spondylotic myelopathy (CSM) (9), spine tumor (6), and cervical spondylotic myelopathy associated with athetoid cerebral palsy (CP) (4). Screw perforation rates for cervical pedicle screws were studied. Major perforation was defined as perforation 50% of screw diameter or more.
Results:
Major perforation rate by disease from C3 to C7 was as follows: spine tumor (0/24, 0%), RA (2/59, 3.4%), DSA (3/65, 4.6%), CP (2/20, 10.0%), and CSM (6/40, 15.0%). There were no clinically important complications such as vertebra arterial injury, spinal cord injury, or nerve root injury caused by any screw perforation. Major perforation rate by vertebral level was: C2(2/30, 6.7%), C3(4/49, 8.2%), C4(6/43, 14.0%), C5(1/32, 3.1%), C6(1/41, 2.4%), and C7(1/45, 2.2%), showing highest rate for C4, followed by C3.
Conclusions:
Cervical pedicle screw perforation rate by disease was higher in CSM compared to RA and DSA. The perforation rate by vertebral level was higher for C4 and C3, in this order.
doi:10.2174/1874325001004010142
PMCID: PMC2864428  PMID: 20448816
Cervical pedicle screw; image guidance; perforation rate.

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