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Year of Publication
1.  Symptomatic Solitary Osteochondroma of the Subaxial Cervical Spine in a 52-Year-Old Patient 
Asian Spine Journal  2014;8(1):84-88.
Osteochondromas are the most common benign tumors of the bone. They mostly arise from the appendicular skeleton and present clinically in the second or third decade of life. Ostechondromas arising from the subaxial cervical spine and presenting after the 5th decade of life are extremely rare. We report a 52-year-old male patient who presented with numbness and subjective weakness of left upper and lower limbs and neck pain, and had lobulated bony hard fixed swelling in the right lower cervical paraspinal region. Radiological images revealed a bony swelling arising from C4 and C5 lamina with a cartilaginous cap and intraspinal extension. Excision biopsy with stabilisation of the spine was performed. Histopathalogical examination of the specimen confirmed the diagnosis of osteochondroma. We conclude surgical excision of such rare tumors, including the cartilaginous cap as well as the intraspinal component can reliably produce a good clinical outcome.
doi:10.4184/asj.2014.8.1.84
PMCID: PMC3939376  PMID: 24596611
Osteochondroma; Cervical spine; Elderly
2.  The Association of Each Disability Based on the Three Sub-Categories of the Roland-Morris Disability Questionnaire during Hospitalization with Itself at 1 Year Postoperatively in Patients with Degenerative Lumbar Spinal Stenosis 
Asian Spine Journal  2014;8(1):1-7.
Study Design
A prospective study in a hospital.
Purpose
To investigate whether each disability based on the three sub-categories of the Roland-Morris disability questionnaire (RDQ) during hospitalization is associated with itself at 1 year postoperatively in patients with degenerative lumbar spinal stenosis (LSS).
Overview of Literature
Although the total score of the RDQ represents whole pain-related disabilities or health-related quality of life, it is a shortcoming that multi-dimensional changes in disabilities are difficult to understand when only using the RDQ.
Methods
Fifty-seven patients with LSS (men, 28; women, 29; 63.0±12.1 years) were included. Disabilities, pain intensity and depressive feelings were assessed at preoperation, discharge and 1 year postoperatively.
Results
The range of "mental and physical activities (MPA)," "functional movements on/around a bed (FM)" and "walking function (WF)" scores were 0 to 13 (median, 8), 0 to 6 (median, 6) and 0 to 4 (median, 3) at preoperation; 0 to 12 (median, 0), 0 to 6 (median, 0), and 0 to 4 (median, 0) at discharge; and 0 to 8 (median, 0), 0 to 5 (median, 0), and 0 to 4 (median, 0) at 1 year postoperatively, respectively. The following significant multiple regression equations were obtained: MPA at 1 year postoperatively=0.56 (MPA at discharge)-0.10 (depression at discharge)+0.90 (adjusted r2=0.41), FM at 1 year postoperatively=0.35 (MPA at discharge)-0.06 (depression at discharge)+0.40 (adjusted r2=0.45) and WF at 1 year postoperatively=0.59 (WF at discharge)-0.08 (depression at discharge)+0.63 (adjusted r2=0.29).
Conclusions
In our LSS population, each disability based on MPA and WF at discharge is associated with itself in the future. Therefore, disabilities excluding functional movements are longitudinally independent.
doi:10.4184/asj.2014.8.1.1
PMCID: PMC3939362  PMID: 24596598
Activities of daily living; Lumbar vertebrae; Spinal stenosis; Roland-Morris disability questionnaire
3.  Tuberculosis of Sacrum 
Asian Spine Journal  2014;8(1):112.
doi:10.4184/asj.2014.8.1.112
PMCID: PMC3939363  PMID: 24596614
4.  Outcome of Salvage Lumbar Fusion after Lumbar Arthroplasty 
Asian Spine Journal  2014;8(1):13-18.
Study Design
Retrospective review.
Purpose
This study aims to define the role of lumbar fusion for persistent back pains after the lumbar disc replacement.
Overview of Literature
Little is written about lumbar fusion after optimally placed lumbar arthroplasty in patients with persistent lower back pains.
Methods
Retrospective review of cases of lumbar artificial disc requiring subsequent fusion because of persistent back pains despite optimally placed artificial discs. Outcomes were evaluated using Oswestry Disability Index (ODI) and visual analogue scale (VAS). Clinical improvements indicated 25% improvement in ODI and VAS values.
Results
Five patients met the study criteria. The mean baseline ODI for the five patients was 52. The mean baseline VAS scores for back and leg pains were 76 and 26, respectively. All the five patients had optimally placed prosthesis. The indication for surgery was the constant low back pains found in all the patients. Revision surgery involved disc explantation and fusion in two of the patients and posterolateral fusion without removing the prosthesis in three. None of the patients achieved adequate pain control after the revision surgery despite the solid bony fusion documented by postoperative computed tomography. The mean ODI value after the fusion was 55. The mean values for back and leg pains VAS were 72 and 30, respectively.
Conclusions
Lack of good pain relief after successful lumbar artifical disc replacements may indicate different etiology for the back pains. The spine-treating surgeons should have a high threshold level to perform salvage fusion at that level.
doi:10.4184/asj.2014.8.1.13
PMCID: PMC3939364  PMID: 24596600
Lumbar vertebrae; Intervertebral disc degeneration; Total disc replacement; Spinal fusion
5.  Analysis of the Prevalence and Distribution of Cervical and Thoracic Compressive Lesions of the Spinal Cord in Lumbar Degenerative Disease 
Asian Spine Journal  2014;8(1):19-26.
Study Design
Retrospective study.
Purpose
The aim of the present study is to analyze the prevalence and distribution of cervical and thoracic compressive lesions of the spinal cord in lumbar degenerative disease, using whole-spine postmyelographic computed tomography.
Overview of Literature
Of the various complications resulting from spinal surgery, unexpected neurological deterioration is the most undesired. There are reports of missed compressive lesions of the spinal cord at the cervical or thoracic level in lumbar degenerative disease.
Methods
There were 145 consecutive patients with symptomatic lumbar degenerative disease evaluated. Before the lumbar surgery, image data were obtained. The following parameters at the cervical and thoracic levels were analyzed: compressive lesions from the anterior parts; compressive lesions from the anterior and posterior parts; ossification of the ligamentum flavum; ossification of the posterior longitudinal ligament; and spinal cord tumor.
Results
Compressive lesions from the anterior parts were observed in 34 cases (23.4%). Compressive lesions from the anterior and posterior parts were observed in 34 cases (23.4%). Lesions of ossification of the ligamentum flavum were observed in 45 cases (31.0%). Lesions of ossification of the posterior longitudinal ligament were observed in 15 cases (10.3%). Spinal cord tumor was not observed.
Conclusions
A survey of compressive lesions at the cervical or thoracic level in lumbar degenerative disease is important in preventing unexpected neurological deterioration after the lumbar surgery.
doi:10.4184/asj.2014.8.1.19
PMCID: PMC3939365  PMID: 24596601
Cervical spine; Thoracic spine; Neurological deterioration; Lumbar surgery
6.  Comparative Analysis of Vertebroplasty and Kyphoplasty for Osteoporotic Vertebral Compression Fractures 
Asian Spine Journal  2014;8(1):27-34.
Study Design
A retrospective study.
Purpose
The aim of this study is to compare the efficacy and outcome of vertebroplasty compared with unipedicular and bipedicular kyphoplasty for the treatment of osteoporotic vertebral compression fractures in terms of pain, functional capacity and height restoration rates.
Overview of Literature
The vertebroplasty procedure was first performed in 1984 for the treatment of a hemangioma at the C2 vertebra. Kyphoplasty was first performed in 1998 and includes vertebral height restoration in addition to using inflation balloons and high-viscosity cement. Both are efficacious, safe and long-lasting procedures. However, controversy still exists about pain relief, improvement in functional capacity, quality of life and height restoration the superiority of these procedures and assessment of appropriate and specific indications of one over the other remains undefined.
Methods
Between 2004 and 2011, 296 patients suffering from osteoporotic vertebral compression fracture underwent 433 vertebroplasty and kyphoplasty procedures. Visual analogue scale (VAS), the Oswestry Disability Index (ODI) and height restoration rates were used to evaluate the results.
Results
Mean height restoration rate was 24.16%±1.27% in the vertebroplasty group, 24.25%±1.28% in the unipedicular kyphoplasty group and 37.05%±1.21% in the bipedicular kyphoplasty group. VAS and ODI scores improved all of the groups.
Conclusions
Vertebroplasty and kyphoplasty are both effective in providing pain relief and improvement in functional capacity and quality of life after the procedure, but the bipedicular kyphoplasty procedure has a further advantage in terms of height restoration when compared to unipedicular kyphoplasty and vertebroplasty procedures.
doi:10.4184/asj.2014.8.1.27
PMCID: PMC3939366  PMID: 24596602
Vertebral column; Spine; Osteoporosis; Vertebral compression fractures; Kyphoplasty; Vertebroplasty
7.  Pedicle Screw Configuration for Thoracolumbar Burst Fracture Treatment: Short versus Long Posterior Fixation Constructs with and without Anterior Column Augmentation 
Asian Spine Journal  2014;8(1):35-43.
Study Design
An in-vitro study.
Purpose
The current study is aimed at investigating the differences in stability between short posterior fixation (SPF), hybrid posterior fixation (HPF), and long posterior fixation (LPF) with and without anterior column augmentation using calcium phosphate bone cement (CaP) for treating burst fractures (BFs).
Overview of Literature
The ideal treatment for thoracolumbar BF is controversial regarding the use of short or LPF constructs.
Methods
Seven human thoracolumbar spines (T9-L4) were tested on a six degree of freedom spine simulator in three physiologic planes, flexion-extension (FE), lateral bending (LB), and axial rotation (AR). Tested surgical constructs included the following: intact, injury (BF), SPF (T12-L2), HPF (T11-L2), LPF (T11-L3), SPF+CaP, HPF+CaP, LPF+CaP, and CaP alone (CaP). Range of motion (ROM) was recorded at T12-L2 in FE, LB, and AR.
Results
The reduction in mean ROM trended as follows: LPF>HPF>SPF. Only LPF constructs and HPF with anterior column augmentation significantly reduced mean ROM in FE and LB compared to the intact state. All instrumented constructs (SPF, HPF, and LPF) significantly reduced ROM in FE and LB compared to the injured condition. Furthermore, the instrumented constructs did not provide significant rotational stability. Injecting CaP provided minimal additional stability.
Conclusions
For the injury created, LPF and HPF provided better stability than SPF with and without anterior column augmentation. Therefore, highly unstable fractures may require extended, long or hybrid fusion constructs for optimum stability.
doi:10.4184/asj.2014.8.1.35
PMCID: PMC3939367  PMID: 24596603
Spine; Fracture fixations; Bone screws; Bone cements
8.  Comparison of the Oswestry Disability Index and Magnetic Resonance Imaging Findings in Lumbar Canal Stenosis: An Observational Study 
Asian Spine Journal  2014;8(1):44-50.
Study Design
Cross-sectional study.
Purpose
The aim of the study was to determine relationship between the degrees of radiologically demonstrated anatomical lumbar canal stenosis using magnetic resonance imaging (MRI) and its correlation with the patient's disability level, using the Oswestry Disability Index (ODI).
Overview of Literature
The relationship between the imaging studies and clinical symptoms has been uncertain in patients suffering from symptomatic lumbar canal stenosis. There is a limited number of studies which correlates the degree of stenosis with simple reproducible scoring methods.
Methods
Fifty patients were selected from 350 patients who fulfilled the inclusion criteria. The patients answered the national-language translated form of ODI. The ratio of disability was interpreted, and the patients were grouped accordingly. They were subjected to MRI; and the anteroposterior diameters of the lumbar intervertebral disc spaces and the thecal sac cross sectional area were measured. Comparison was performed between the subdivisions of the degree of lumbar canal stenosis, based on the following: anteroposterior diameter (three groups: normal, relative stenosis and absolute stenosis); subdivisions of the degree of central canal stenosis, based on the thecal sac cross-sectional area, measured on axial views (three groups: normal, moderately stenotic and severely stenotic); and the ODI outcome, which was also presented in 20 percentiles.
Results
No significant correlation was established between the radiologically depicted anatomical lumbar stenosis and the Oswestry Disability scores.
Conclusions
Magnetic resonance imaging alone should not be considered in isolation when assessing and treating patients diagnosed with lumbar canal stenosis.
doi:10.4184/asj.2014.8.1.44
PMCID: PMC3939368  PMID: 24596604
Lumbar vertebrae; Low back ache; Magnetic resonance imaging scan; Radiculopathy
9.  Lumbosacral Transition Vertebra: Prevalence and Its Significance 
Asian Spine Journal  2014;8(1):51-58.
Study Design
Retrospective analysis of radiological images.
Purpose
To determine the prevalence of lumbosacral transition vertebra (LSTV) and to study its significance with respect to clinically significant spinal symptoms, disc degeneration and herniation.
Overview of Literature
LSTV is the most common congenital anomaly of the lumbosacral spine. The prevalence has been debated to vary between 7% and 30%, and its relationship to back pain, disc degeneration and herniation has also not been established.
Methods
The study involved examining the radiological images of 3 groups of patients. Group A consisted of kidney urinary bladder (KUB) X-rays of patients attending urology outpatient clinic. Group B consisted of X-rays with or without magnetic resonance images (MRIs) of patients at-tending a spine outpatient clinic, and group C consisted of X-rays and MRI of patients who had undergone surgery for lumbar disc herniation. One thousand patients meeting the inclusion criteria were selected to be in each group. LSTV was classified by Castellvi's classification and disc degeneration was assessed by Pfirrmann's grading on MRI scans.
Results
The prevalence of LSTV among urology outpatients, spine outpatients and discectomy patients was 8.1%, 14%, and 16.9% respectively. LSTV patients showed a higher Pfirrmann's grade of degeneration of the last mobile disc. Results were found to be significant statistically.
Conclusions
The prevalence of LSTV in spinal outpatients and discectomy patients was significantly higher as compared to those attending the urology outpatient clinic. There was a definite causal relationship between the transitional vertebra and the degeneration of the disc immediately cephalad to it.
doi:10.4184/asj.2014.8.1.51
PMCID: PMC3939369  PMID: 24596605
Lumbosacral transitional vertebra; Castellvi's classification; Pfirrmann's grading; Spine outpatients; Urology outpatients; Discectomy patients
10.  Incidence of Vascular Complications Arising from Anterior Spinal Surgery in the Thoraco-Lumbar Spine 
Asian Spine Journal  2014;8(1):59-63.
Study Design
Modern biomaterials and instrumentation have popularised surgery of the thoraco-lumbar spine through an anterior route. The advantage of anterior surgery is that it allows for a direct decompression of the compromised spinal canal. However, the potential for devastating long-term sequelae as a result of complications is high.
Purpose
The aim of this study was to give a general overview and identify the incidence of vascular complications.
Overview of Literature
There is limited literature describing the overall incidence and complications of anterior spinal surgery.
Methods
A retrospective review of a prospective database of 1,262 consecutive patients with anterior surgery over a twelve-year period.
Results
In our study, 1.58% (n=20) of patients suffered complications. Injury to a major vessel was encountered in 14 (1.11%) cases, of which nine involved an injury to the common iliac vein. In six cases, the original procedure was abandoned due to a life-threatening vascular injury (n=3) and unfavourable anatomy (n=3).
Conclusions
The incidence of vascular and other complications in our study was relatively low. Nevertheless, the potential for devastating long-term sequelae as a result of complications remains high. A thorough knowledge and awareness of normal and abnormal anatomy should be gained before attempting such a procedure, and a vascular surgical assistance especially should be readily accessible. We believe use of access surgeons is mandatory in cases with difficult or aberrant anatomy.
doi:10.4184/asj.2014.8.1.59
PMCID: PMC3939370  PMID: 24596606
Anterior thoraco-lumbar approach; Complications; Vascular injury; Left iliac vein; External iliac vein
11.  Robotic-Assisted Device in Posterior Spinal Fusion for a High Risk Thoraculombar Fracture in Ankylosing Spondylitis 
Asian Spine Journal  2014;8(1):64-68.
Fractures in ankylosing spondylitis (AS) are often difficult to treat and surgical treatment may be fraught with complications. We describe the use of a robotic-assisted device in the surgical treatment of an unstable L1 fracture in an elderly patient with chronic lymphocytic leukemia and AS. The postoperative course was uneventful and the patient was discharged after 3 days. The use of a robotic-assisted device in spine surgery is particularly indicated in difficult high risk cases.
doi:10.4184/asj.2014.8.1.64
PMCID: PMC3939371  PMID: 24596607
Ankylosing spondylitis; Posterior spine fusion; Robotic assisted
12.  Ordinary Disc Herniation Changing into Posterior Epidural Migration of Lumbar Disc Fragments Confirmed by Magnetic Resonance Imaging: A Case Report of a Successful Endoscopic Treatment 
Asian Spine Journal  2014;8(1):69-73.
The posterior epidural migration of lumbar disc fragments is an extremely rare event with an unknown pathogenesis. To the best of our knowledge, there are no previously reported cases of a change of ordinary disc herniation into the posterior epidural migration of lumbar disc fragments as confirmed by magnetic resonance imaging (MRI). A 26-year-old male presented to our department complaining of left buttock and lateral leg pain. An ordinary herniation was shown in the first MRI. The patient's unilateral symptoms changed into bilateral symptoms while awaiting admission to the hospital. Posterior migrated lumbar disc fragments were shown in the second MRI taken at the time of admission. Microendoscopic surgery providing a detailed observation of the region was performed. Our case indicates that an ordinary lumbar disc herniation may lead to the posterior migration of lumbar disc fragments, and that microendoscopic surgery may provide a treatment.
doi:10.4184/asj.2014.8.1.69
PMCID: PMC3939372  PMID: 24596608
Lumbar; Hernia; Endoscopy
13.  Cervical Symmetric Dumbbell Ganglioneuromas Causing Severe Paresis 
Asian Spine Journal  2014;8(1):74-78.
We report an extremely rare case with bilateral and symmetric dumbbell ganglioneuromas of the cervical spine in an elderly patient. A 72-year-old man came by ambulance to our hospital due to progressive incomplete paraplegia. Magnetic resonance imaging demonstrated bilateral symmetric dumbbell tumors at the C1/2 level. We performed total resection of the intracanalar tumor, aiming at complete decompression of the spinal cord, and partial and subtotal resection of foraminal outside portions. Histopathological examination of the surgical specimen indicated the tumor cells to be spindle cells with the presence of ganglion cells and no cellular pleomorphism, suggesting a diagnosis of ganglioneuroma. Although the surgery was not curative, the postoperative course was uneventful and provided a satisfactory outcome. This is the fourth known case of cervical ganglioneuromas of the bilateral symmetric dumbbell type.
doi:10.4184/asj.2014.8.1.74
PMCID: PMC3939373  PMID: 24596609
Ganglioneuroma; Symmetric; Dumbbell tumor; Cervical spine
14.  Ewing's Sarcoma of the Sacroiliac Joint Presenting as Tubercular Sacroiliitis: A Diagnostic Dilemma 
Asian Spine Journal  2014;8(1):79-83.
We report a case of Ewing's sarcoma of the sacroiliac joint in a 21-year-old male mimicking tubercular sacroiliitis, a rare entity not reported in literature. He presented with pain in the lower back radiating to the right lower limb along with constitutional symptoms of 3 months duration. On examination, the right sacroiliac joint was tender. The laboratory investigations showed anaemia, leukocytosis and raised erythrocyte sedimentation rate. On X-ray, features of right sacroiliitis were seen. This was further investigated with magnetic resonance imaging (MRI), which showed features consistent with tubercular sacroiliitis. Patient was then started on antitubercular treatment, but the improvement was not consistent. So, a contrast MRI was done, which indicated features of primary sarcoma. It was then further confirmed by a computed tomography-guided biopsy, which showed features consistent with Ewing's sarcoma of the sacroiliac joint.
doi:10.4184/asj.2014.8.1.79
PMCID: PMC3939374  PMID: 24596610
Sacroiliac joint; Sacroiliitis; Ewing sarcoma; Magnetic resonance imaging
15.  Comparison of the Combined Anterior-Posterior Approach versus Posterior-Only Approach in Scoliosis Treatment 
Asian Spine Journal  2014;8(1):8-12.
Study Design
This is descriptive analytical study.
Purpose
The present study aims at comparing treatment results found between the two groups comprising of patients who underwent posterior spinal fusion using thoracic pedicle screws and the ones who underwent combined anterior-posterior method, respectively.
Overview of Literature
There was controversy about surgical techniques including anterior, posterior, or a combined anterior-posterior approaches are applied to treat non-congenital scoliosis with surgical indications.
Methods
Medical records of 50 patients suffering from thoracic non-congenital scoliosis with curves exceeding 70° were reviewed. In this study, 25 patients who underwent posterior spinal fusion using thoracic pedicle screws were compared with 25 patients who underwent combined anterior-posterior method.
Results
Patients treated through posterior-only and combined approaches were respectively hospitalized for 11.84±5.18 and 26.5±5.2 days (p=0.001). There was a significant difference between these two groups considering intensive care unit admission duration (p=0.001), correction in sagittal view of X-ray (p=0.01), and number of days the patients underwent traction (0.001). Finally, coronal view was corrected without any significant difference (p=0.2).
Conclusions
According to our findings, it is hypothesized that posterior-only method is associated with some significant advantages and is an advisable method in patients with severe scoliosis over than 70°.
doi:10.4184/asj.2014.8.1.8
PMCID: PMC3939375  PMID: 24596599
Scoliosis; Curved spine; Spinal deformity
16.  Ossification of the Ligamentum Flavum 
Asian Spine Journal  2014;8(1):89-96.
Ossification of the ligamentum flavum is a rare cause of thoracic myelopathy. It develops in East Asians more frequently than in people from other areas. The exact pathophysiology has not been elucidated yet; however, it largely depends on biomechanical alterations, especially changes in the tensile force. Because the spinal cord is compressed from the posterior side, the first and most common clinical manifestation is usually loss of functional gait and spastic paralysis, which develop as the spinal cord compression progresses. The choice of diagnostic imaging is T2 sagittal magnetic resonance imaging scanning. Whole spine scanning is mandatory to identify multiple areas of compression and any associated distal lumbar diseases. Fine computed tomography imaging is necessary to make a differential diagnosis and set up a precise surgical plan. Conservative treatment does not work in this disorder. Decompression surgery is the only option and prognosis after surgical treatment is better with this disorder than with other causes of thoracic myelopathy. The severity of preoperative symptoms and the time interval before surgical treatment are the most important prognostic factors.
doi:10.4184/asj.2014.8.1.89
PMCID: PMC3939377  PMID: 24596612
Ossification of ligamentum flavum; Treatment; Prognostic factors
17.  Tuberculosis of Spine: Current Views in Diagnosis and Management 
Asian Spine Journal  2014;8(1):97-111.
Tuberculosis is the chronic consumptive disease and currently the world's leading cause of death. Tuberculous spondylitis is a less common yet the most dangerous form of skeletal tuberculosis. The recent re-emergence of Mycobacterium tuberculosis (M. tuberculosis) hints at a possible resurgence of tuberculosis in the coming years. This article discusses the clinical manifestations, diagnosis and treatment of tuberculous spondylitis, and updates material that the author has previously published on the subject. Treatment should be individualized according to different indications which is essential to recovery. A treatment model is suggested on the basis of the author's vast personal experiences.
doi:10.4184/asj.2014.8.1.97
PMCID: PMC3939378  PMID: 24596613
Tuberculous spondylitis; Mycobacterium tuberculosis
18.  Investigation of Efficacy of Mitomycin-C, Sodium Hyaluronate and Human Amniotic Fluid in Preventing Epidural Fibrosis and Adhesion Using a Rat Laminectomy Model 
Asian Spine Journal  2013;7(4):253-259.
Study Design
A retrospective study.
Purpose
The aim of this study was to evalute the effects of mitomycin-C, sodium hyaluronate and human amniotic fluid on preventing spinal epidural fibrosis.
Overview of Literature
The role of scar tissue in pain formation is not exactly known, but it is reported that scar tissue causes adhesions between anatomic structures. Intensive fibrotic tissue compresses on anatomic structures and increases the sensitivity of the nerve root for recurrent herniation and lateral spinal stenosis via limiting movements of the root. Also, neuronal atrophy and axonal degeneration occur under scar tissue.
Methods
The study design included 4 groups of rats: group 1 was the control group, groups 2, 3, and 4 receieved antifibrotic agents, mitomycin-C (group 2), sodium hyaluronate (group 3), and human amniotic fluid (group 4). Midline incision for all animals were done on L5 for total laminectomy. Four weeks after the surgery, the rats were sacrificed and specimens were stained with hematoxylin-eosin and photos of the slides were taken for quantitive assesment of the scar tissue.
Results
There was no significant scar tissue in the experimental animals of groups 2, 3, and 4. It was found that there was no significant difference between drug groups, but there was a statistically significant difference between the drug groups and the control group.
Conclusions
This experimental study shows that implantation of mitomycin-C, sodium hyaluronate and human amniotic fluid reduces epidural fibrosis and adhesions after spinal laminectomy in rat models. Further studies in humans are needed to determine the complications of the agents researched.
doi:10.4184/asj.2013.7.4.253
PMCID: PMC3863649  PMID: 24353840
Lumbar spine; Lumbar disc herniation; Lumbar spinal stenosis; Lumbar pain; Epidural fibrosis
19.  Posterior Surgery Alone in the Treatment of Post-traumatic Kyphosis by Posterior Column Osteotomy, Spondylodesis, Instrumentation, and Vertebroplasty 
Asian Spine Journal  2013;7(4):260-266.
Study Design
Retrospective study.
Purpose
To determine if posterior surgery alone can satisfactorily treat post-traumatic kyphosis (PTK).
Overview of Literature
One of the worst complications of vertebral fractures is PTK. The type of surgery and approach to treat a symptomatic and refractory PTK is a challenging issue in spinal surgery, and yet, there is no specific treatment algorithm.
Methods
From August 2003 to September 2010, we collected 26 cases (male to female ratio, 2.25; mean age, 31.9±9.7 years and follow-up period of 42.4±8.1 months) with PTK treated by posterior column osteotomy, spondylodesis, instrumentation and cement vertebroplasty in one stage posterior surgery. PTK angle, Oswestry Disability Index (ODI), visual analogue scale (VAS), and subjective satisfaction from surgery were used to determine the results. We used a student t test for analyzing the data before and after surgery.
Results
In our patients, T11 and L1 had the highest incidence of vertebral fractures. The results indicated that in PTK, ODI, and VAS were significantly improved this surgery. Solid fusion occurred in 96.2% of patients with 3.2°±2.1° loss of correction. A total of 84.6% of patients have satisfaction level of excellent and good.
Conclusions
Posterior surgery alone with posterior column osteotomy, vertebroplasty, posterior spinal fusion and instrumentation can effectively treat symptomatic PTK.
doi:10.4184/asj.2013.7.4.260
PMCID: PMC3863650  PMID: 24353841
Spinal fusion; Osteotomy; Kyphosis, Post traumatic
20.  Magnification Error in Digital Radiographs of the Cervical Spine Against Magnetic Resonance Imaging Measurements 
Asian Spine Journal  2013;7(4):267-272.
Study Design
Prospective study.
Purpose
The main purpose of this study was to clarify the range of magnification errors on digital plain radiographs and to determine if there is a correlation between the body mass index (BMI) of a patient and the magnification error.
Overview of Literature
Most clinicians currently use digital plain radiography. This new method allows one to access images and measure lengths and angles more easily than with the past technologies. In addition, conventional plain radiography has magnification errors. Although few articles mention magnification errors in regards to digital radiographs, they are known to have the same errors.
Methods
We used plain digital radiography and magnetic resonance imaging (MRI) to acquire images of the cervical spine with the goal of evaluating magnification errors by measuring the anteroposterior vertebral body lengths of C2 and C5. The magnification error (ME) was then calculated: ME=(length on radiograph-length on MRI)/length on MRI ×100 (%). The correlation coefficient between the magnification error and BMI was obtained using Pearson's correlation analysis.
Results
Average magnification errors in C2 and C5 were approximately 18.5%±5.4% (range, 0%-30%) and 20.7%±6.3% (range, 1%-32%). There was no positive correlation between BMI and the magnification error.
Conclusions
There were magnification errors on the digital plain radiographs, and they were different in each case. Maximum magnification error differences were 30% (C2) and 31% (C5). Based on these finding, clinicians must pay attention to magnification errors when measuring lengths using digital plain radiography.
doi:10.4184/asj.2013.7.4.267
PMCID: PMC3863651  PMID: 24353842
Cervical spine; Magnification error; Digital radiography; Body mass index; Picture archiving and communication system
21.  Analysis of Risk Factors for Adjacent Segment Degeneration Occurring More than 5 Years after Fusion with Pedicle Screw Fixation for Degenerative Lumbar Spine 
Asian Spine Journal  2013;7(4):273-281.
Study Design
A retrospective study.
Purpose
We investigated the risk factors in adjacent segment degeneration (ASD) after more than 5 years of follow-up of lumbar spinal fusion.
Overview of Literature
There are many concerns regarding ASD followed by lumbar spinal fusion. However, there is a great deal of dispute about the risk factors.
Methods
A total of 55 patients who were followed up for more than 5 years after lumbar fusion were observed. Gender, age, residence, fusion method, number of fusion segments and radiological measurements were analyzed. In the radiological measurement, disc height, lumbar lordotic angle (LLA), fusion segment lordotic angle and fusion segment lordotic angle per level (FSLA per level) were estimated. In preoperative MRI, Pfirrmann's classification was used. The clinical result was evaluated by the criteria of Kim and Kim. Statistical univariate analysis was performed with the chi-square test by using SPSS ver. 12.0. Multivariate logistic regression analysis was conducted with SAS ver. 9.
Results
There were 21 patients with adjacent segment degeneration. Further, there was little relationship between ASD and gender, age, residence, fusion method, number of fusion segments, degree of preoperative adjacent disc degeneration in MRI, or preoperative and postoperative LLA. However, the frequency of ASD was significantly low in cases where FSLA per level was >15° (p=0.009). There was no significant relationship between ASD and the clinical result.
Conclusions
In patients followed up for more than 5 years after lumbar spinal fusion, the most important factor in the prevention of ASD was the restoration of FSLA per level to >15°.
doi:10.4184/asj.2013.7.4.273
PMCID: PMC3863652  PMID: 24353843
Lumbar; Adjacent segment degeneration; Fusion; Pedicle screw fixation
22.  Adolescent Idiopathic Scoliosis: A 71 Cases Study Ascertaining that Straightening Is Possible, and a New Etiological Hypothesis 
Asian Spine Journal  2013;7(4):282-288.
Study Design
Seventy-one children (23 boys and 48 girls, aged 6 to 18 year-old) with adolescent idiopathic scoliosis (AIS) between 11° and 62°, without braces, have been treated manually, only at the level of the neck.
Purpose
To ascertain that non-surgical straightening of AIS is possible (without brace).
Overview of Literature
So far no disease modifying treatment for AIS existed. Braces can only slow down worsening (and this can only be achieved if they are worn 23 hours a day). Surgery is not without important risks.
Methods
All patients have been treated exclusively with a manual therapy called Brachy-Myotherapy. This method treats spasmed (contractured) muscles by placing them in a shortening position according to a specific protocol.
Results
An average straightening of 8° of AIS was observed, with a maximum of 25°. 94% of cases improved, 67 out of 71. The worst prognosis was, the better results. The more advanced AIS was, the better the results.
Conclusions
A simple and reliable treatment of AIS is possible. AIS seems to be a compensation mechanism of the body, with the aim of keeping the ears, and thus the labyrinths, at a horizontal level for correct equilibrium. When lasting post-traumatic neck muscle contractures causing a permanent side-bending of the skull have been treated, this compensation mechanism becomes irrelevant and scoliosis tends to subside.
doi:10.4184/asj.2013.7.4.282
PMCID: PMC3863653  PMID: 24353844
Scoliosis treatment; Skeletal muscle hypertonicity; Contracture; Musculoskeletal disease; Spinal curvature
23.  Cervical Foraminal and Discal Height after Dynamic Rotational Plating in the Cervical Discectomy and Fusion 
Asian Spine Journal  2013;7(4):289-293.
Study Design
This is a retrospective study.
Purpose
To evaluate the effect of the dynamic rotational plate to the intervertebral foraminal and discal height after anterior cervical discectomy and fusion.
Overview of Literature
There is no report regarding the changes of foraminal and discal height following cervical dynamic rotational plating.
Methods
We reviewed the outcomes of 30 patients (36 levels), who were followed-up for an average of 15 months (range, 12-57 months) after undergoing fusions with anterior cervical dynamic rotational plating for cervical radiculopathy, from March 2005 to February 2009. The changes of foraminal and intervertebral discal height of the operated levels were observed on oblique and lateral radiographs obtained at the preoperative, postoperative and follow-up examinations.
Results
The foraminal and discal height increased sufficiently, immediately following the operation. However, follow-up results showed gradual decrease in the foraminal and discal height. After 6 months of the surgery, they showed little difference compared with the preoperative heights. However, clinically, patients showed improvements in radiating pain during the follow-up period.
Conclusions
Anterior cervical dynamic rotational plating was an effective treatment modality for cervical radiculopathy without the deterioration of the foraminal and intervertebral discal height.
doi:10.4184/asj.2013.7.4.289
PMCID: PMC3863654  PMID: 24353845
Cervical spine; Cervical radiculopathy; Dynamic rotational plate
24.  Causes of Late Revision Surgery after Bone Cement Augmentation in Osteoporotic Vertebral Compression Fractures 
Asian Spine Journal  2013;7(4):294-300.
Study Design
A retrospective study.
Purpose
To elucidate the causes of late revision following bone cement augmentation for osteoporotic vertebral compression fractures (OVCFs).
Overview of Literature
Percutaneous vertebroplasty (PVP) or kyphoplasty (KP) is thought to be effective for the treatment of OVCFs. Many complications related to PVP or KP have been reported. However, there is a paucity of reports regarding the causes of late revision surgery after failed PVP or KP.
Methods
Twenty six patients who developed unremitted back pain and/or progressive neurological deficit after a symptom-free period since treatment with PVP or KP were enrolled. All patients underwent cement removal and anterior reconstruction. Among the 26 patients, 22 patients underwent anterior interbody fusion combined with posterior instrumentation; 4 patients underwent anterior reconstruction only. The causes of revision surgery were assessed. Clinical results were assessed using a visual analogue scale (VAS) and Oswestry Disability Index (ODI). The complications were analyzed.
Results
The average time to revision surgery was 18.9±14.6 months (range, 3-78 months). The causes of late revision surgery included 6 late infections, 8 progressive kyphoses, 10 proximal fractures after instrumented lumbar fusions, and 2 late neurological involvement. During the mean follow-up period of 13.5±7.8 months, pre-revision mean VAS (8.5±0.9) and ODI (81.2±12.5) were improved to 4.2±1.4 and 54.8±17.6, respectively. Five patients (19%) had serious complications after revision surgery.
Conclusions
This study presents complications of PVP or KP in the treatment of OVCFs although PVP or KP can be an effective treatment strategy for OVCF when applied in highly selected patients.
doi:10.4184/asj.2013.7.4.294
PMCID: PMC3863655  PMID: 24353846
Osteoporosis; Spinal fractures; Vertebroplasty; Surgical revision
25.  A Nation-Wide, Outpatient-Based Survey on the Pain, Disability, and Satisfaction of Patients with Osteoporotic Vertebral Compression Fractures 
Asian Spine Journal  2013;7(4):301-307.
Study Design
A nation-wide, outpatient-based, cross-sectional survey with the use of questionnaires.
Purpose
To evaluate the pain, disability and satisfaction of patients with osteoporotic vertebral compression fractures (OVCFs).
Overview of Literature
There are no nation-wide data in Korea on the degree of pain, disability and satisfaction with treatment in patients with OVCFs.
Methods
We performed a cross-sectional survey of 573 patients with OVCFs. After excluding incomplete questionnaires (missing more than 30% of the variables), 430 patient-physician-matched data sets were collected for this survey.
Results
Patients with OVCFs were managed with conservative treatment in 63% and with a vertebroplasty in 37%. The means of the latest visual analogue scale (VAS, 5.2) and Oswestry Disability Index (ODI, 47.7) scores checked at the time of survey were significantly higher than those VAS and ODI scores prior to OVCFs (the prefracture VAS and ODI scores, 3.6 and 26.3, respectively; p<0.001 for both comparisons). However, the means of the latest VAS and ODI scores were insignificantly different between the conservative and vertebroplasty groups, irrespective of the duration from the fractures. Overall, 75% of patients were satisfied with their clinical outcomes. However, the percentages of patient's satisfaction were not significantly different between the conservative and vertebroplasty groups. Eighty-eight percent of patients felt some or marked deterioration of their general health condition following OVCFs.
Conclusions
These results indicate that although most patients with OVCFs were satisfied with their clinical outcomes, their subjective general health conditions, as well as their pain and disability, did not recover to the prefracture state.
doi:10.4184/asj.2013.7.4.301
PMCID: PMC3863656  PMID: 24353847
Osteoporotic vertebral compression fracture; Pain; Disability; Satisfaction

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