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1.  Therapeutic Advantages of Treatment of High-Dose Curcumin in the Ovariectomized Rat 
Objective
Although curcumin has a protective effect on bone remodeling, appropriate therapeutic concentrations of curcumin are not well known as therapeutic drugs for osteoporosis. The purpose of this study was to compare the bone sparing effect of treatment of low-dose and high-dose curcumin after ovariectomy in rats.
Methods
Forty female Sprague-Dawley rats underwent either a sham operation (the sham group) or bilateral ovariectomy (OVX). The ovariectomized animals were randomly distributed among three groups; untreated OVX group, low-dose (10 mg/kg) curcumin administered group, and high-dose (50 mg/kg) curcumin group. At 4 and 8 weeks after surgery, serum biochemical markers of bone turnover were analyzed. Bone histomorphometric parameters of the 4th lumbar vertebrae were determined by micro-computed tomography (CT). In addition, mechanical strength was determined by a three-point bending test.
Results
High-dose curcumin group showed significantly lower osteocalcin, alkaline phosphatase, and the telopeptide fragment of type I collagen C-terminus concentration at 4 and 8 weeks compared with the untreated OVX group as well as low-dose curcumin group. In the analyses of micro-CT scans of 4th lumbar vertebrae, the high-dose curcumin treated group showed a significant increase in bone mineral densities (p=0.028) and cortical bone mineral densities (p=0.036) compared with the low-dose curcumin treated group. Only high-dose curcumin treated group had a significant increase of mechanical strength compared with the untreated OVX group (p=0.015).
Conclusion
The present study results demonstrat that a high-dose curcumin has therapeutic advantages over a low-dose curcumin of an antiresorptive effect on bone remodeling and improving bone mechanical strength.
doi:10.3340/jkns.2013.54.6.461
PMCID: PMC3921272  PMID: 24527187
Curcumin; Micro-computed tomography; Osteoporosis; Ovariectomy; Rat
2.  Surgical Tips to Preserve the Facet Joint during Microdiscectomy 
Lumbar microdiscectomy (MD) is the gold standard for treatment of lumbar disc herniation. Generally, the surgeon attempts to protect the facet joint in hopes of avoiding postoperative pain/instability and secondary degenerative arthropathy. We believe that preserving the facet joint is especially important in young patients, owing to their life expectancy and activity. However, preserving the facet joint is not easy during lumbar MD. We propose several technical tips (superolateral extension of conventional laminotomy, oblique drilling for laminotomy, and additional foraminotomy) for facet joint preservation during lumbar MD.
doi:10.3340/jkns.2013.54.4.366
PMCID: PMC3841285  PMID: 24294466
Lumbar disc herniation; Microdiscectomy; Facet joint; Laminotomy; Foraminotomy
3.  Anterior Cervical Discectomy and Fusion Using a Stand-Alone Polyetheretherketone Cage Packed with Local Autobone : Assessment of Bone Fusion and Subsidence 
Objective
It remains debatable whether cervical spine fusion cages should be filled with any kind of bone or bone substitute. Cortical and subcortical bone from the anterior and posterior osteophytes of the segment could be used to fill the cage. The purposes of the present study are to evaluate the clinical outcomes and radiological outcomes including bone fusion and subsidence that occurred after anterior cervical discectomy and fusion using a stand-alone cage packed with local autobone graft.
Methods
Thirty-one patients who underwent anterior cervical fusion using a stand-alone polyetheretherketone (PEEK) cage packed with local autobone graft from July 2009 to december 2011 were enrolled in this study. Bone fusion was assessed by cervical plain radiographs and computed tomographic scan. Nonunion was evaluated according to the absence of bony bridge on computed tomographic scan. Subsidence was defined as a ≥2 mm decrease of the interbody height at the final follow-up compared to that measured at the immediate postoperative period.
Results
Subsidence was observed in 7 patients (22.6%). Of 7 patients with subsidence greater 2 mm, nonunion was developed in 3. Three patients with subsidence greater 2 mm were related with endplate damage during intraoperative endplate preparation. Solid bone fusion was achieved in 28 out of 31 patients (90.3%).
Conclusion
With proper patient selection and careful endplate preparation, anterior cervical discectomy and fusion (ACDF) using a stand-alone PEEK cage packed with local autobone graft could be a good alternative to the standard ACDF techniques with plating.
doi:10.3340/jkns.2013.54.3.189
PMCID: PMC3836924  PMID: 24278646
Cage; Cervical spine; Discectomy; Local bone
4.  Primary Eosinophilic Granuloma of Adult Cervical Spine Presenting as a Radiculomyelopathy 
We report a case of 29-year-old man diagnosed as a primary eosinophilic granuloma (EG) lesion of the seventh cervical vertebra. He had paresthesia on both arms, and grasping weakness for 10 days. Cervical magnetic resonance image (MRI) showed an enhancing mass with ventral epidural bulging and cord compression on the seventh cervical vertebra. Additionally, we performed spine series MRI, bone scan and positive emission tomography for confirmation of other bone lesions. These studies showed no other pathological lesions. He underwent anterior cervical corpectomy of the seventh cervical vertebra and plate fixation with iliac bone graft. After surgical management, neurological symptoms were much improved. Histopathologic evaluation confirmed the diagnosis of EG. There was no evidence of tumor recurrence at 12 months postoperative cervical MRI follow-up. We reported symptomatic primary EG of cervical spine successfully treated with surgical resection.
doi:10.3340/jkns.2013.54.1.54
PMCID: PMC3772289  PMID: 24044083
Eosinophilic granuloma; Adult cervical tumor; Surgical approach
5.  Valproic Acid Increases Expression of Neuronal Stem/Progenitor Cell in Spinal Cord Injury 
Objective
This study investigates the effect of valproic acid (VPA) on expression of neural stem/progenitor cells (NSPCs) in a rat spinal cord injury (SCI) model.
Methods
Adult male rats (n=24) were randomly and blindly allocated into three groups. Laminectomy at T9 was performed in all three groups. In group 1 (sham), only laminectomy was performed. In group 2 (SCI-VPA), the animals received a dose of 200 mg/kg of VPA. In group 3 (SCI-saline), animals received 1.0 mL of the saline vehicle solution. A modified aneurysm clip with a closing force of 30 grams was applied extradurally around the spinal cord at T9, and then rapidly released with cord compression persisting for 2 minutes. The rats were sacrificed and the spinal cord were collected one week after SCI. Immunohistochemistry (IHC) and western blotting sample were obtained from 5 mm rostral region to the lesion and prepared. We analyzed the nestin immunoreactivity from the white matter of ventral cord and the ependyma of central canal. Nestin and SOX2 were used for markers for NSPCs and analyzed by IHC and western blotting, respectively.
Results
Nestin and SOX2 were expressed significantly in the SCI groups but not in the sham group. Comparing SCI groups, nestin and SOX2 expression were much stronger in SCI-VPA group than in SCI-saline group.
Conclusion
Nestin and SOX2 as markers for NSPCs showed increased expression in SCI-VPA group in comparison with SCI-saline group. This result suggests VPA increases expression of spinal NSPCs in SCI.
doi:10.3340/jkns.2013.54.1.8
PMCID: PMC3772294  PMID: 24044073
Neural stem/progenitor cell; Spinal cord injury; Valproic acid; Nestin; SOX2
6.  Effect of Dietary Calcium on Spinal Bone Fusion in an Ovariectomized Rat Model 
Objective
To evaluate the effect of calcium supplementation on spinal bone fusion in ovariectomized (OVX) rats.
Methods
Sixteen female Sprague Dawley rats underwent bilateral ovariectomy at 12 weeks of age to induce osteoporosis and were randomly assigned to two groups : control group (n=8) and calcium-supplemented group (OVX-Ca, n=8). Autologous spinal bone fusion surgery was performed on both groups 8 weeks later. After fusion surgery, the OVX-Ca group was supplemented with calcium in drinking water for 8 weeks. Blood was obtained 4 and 8 weeks after fusion surgery. Eight weeks after fusion surgery, the rats were euthanized and the L4-5 spine removed. Bone fusion status and fusion volume were evaluated by manual palpation and three-dimensional computed tomography.
Results
The mean fusion volume in the L4-5 spine was significantly greater in the OVX-Ca group (71.80±8.06 mm3) than in controls (35.34±8.24 mm3) (p<0.01). The level of osteocalcin, a bone formation marker, was higher in OVX-Ca rats than in controls 4 weeks (610.08±10.41 vs. 551.61±12.34 ng/mL) and 8 weeks (552.05±19.67 vs. 502.98±22.76 ng/mL) after fusion surgery (p<0.05). The level of C-terminal telopeptide fragment of type I collagen, a bone resorption marker, was significantly lower in OVX-Ca rats than in controls 4 weeks (77.07±12.57 vs. 101.75±7.20 ng/mL) and 8 weeks (69.58±2.45 vs. 77.15±4.10 ng/mL) after fusion surgery (p<0.05). A mechanical strength test showed that the L4-5 vertebrae in the OVX-Ca group withstood a 50% higher maximal load compared with the controls (p<0.01).
Conclusion
Dietary calcium given to OVX rats after lumbar fusion surgery improved fusion volume and mechanical strength in an ovariectomized rat model.
doi:10.3340/jkns.2012.52.4.281
PMCID: PMC3488633  PMID: 23133713
Osteoporosis; Ovariectomized rat; Calcium; Spinal bone fusion
7.  Minimally Invasive Removal of an Intradural Cervical Tumor : Assessment of a Combined Split-Spinous Laminectomy and Quadrant Tube Retractor System Technique 
Conventional laminectomy is the most popular technique for the complete removal of intradural spinal tumors. In particular, the central portion intramedullary tumor and large intradural extramedullary tumor often require a total laminectomy for the midline myelotomy, sufficient decompression, and adequate visualization. However, this technique has the disadvantages of a wide incision, extensive periosteal muscle dissection, and bony structural injury. Recently, split-spinous laminectomy and tubular retractor systems were found to decrease postoperative muscle injuries, skin incision size and discomfort. The combined technique of split-spinous laminectomy, using a quadrant tube retractor system allows for an excellent exposure of the tumor with minimal trauma of the surrounding tissue. We propose that this technique offers possible advantages over the traditional open tumor removal of the intradural spinal cord tumors, which covers one or two cervical levels and requires a total laminectomy.
doi:10.3340/jkns.2012.52.4.427
PMCID: PMC3488659  PMID: 23133739
Cervical cord tumor; Split-spinous laminectomy; Quadrant tube retractor
8.  Bilateral Internal Superior Laryngeal Nerve Palsy of Traumatic Cervical Injury Patient Who Presented as Loss of Cough Reflex after Anterior Cervical Discectomy with Fusion 
Injury to the bilateral internal branch of superior laryngeal nerve (ibSLN) brings on an impairment of the laryngeal cough reflex that could potentially result in aspiration pneumonia and other respiratory illnesses. We describe a patient with traumatic cervical injury who underwent bilateral ibSLN palsy after anterior cervical discectomy with fusion (ACDF). An 75-year-old man visited with cervical spine fracture and he underwent ACDF through a right side approach. During the post-operative days, he complained of high pitched tone defect, and occasional coughing during meals. With a suspicion of SLN injury and for the work up for the cause of aspiration, we performed several studies. According to the study results, he was diagnosed as right SLN and left ibSLN palsy. We managed him for protecting from silent aspiration. Swallowing study was repeated and no evidence of aspiration was found. The patient was discharged with incomplete recovery of a high pitched tone and improved state of neurologic status. The SLN is an important structure; therefore, spine surgeons need to be concerned and be cautious about SLN injury during high cervical neck dissection, especially around the level of C3-C4 and a suspicious condition of a contralateral nerve injury.
doi:10.3340/jkns.2012.52.3.264
PMCID: PMC3483333  PMID: 23115675
Superior laryngeal nerve; Cervical discectomy; Cough reflex
9.  Histomorphometric Analysis of the Spine and Femur in Ovariectomized Rats Using Micro-Computed Tomographic Scan 
Objective
The purpose of this study was to evaluate the different patterns of bone loss between the lumbar spine and the femur after ovariectomy in rats.
Methods
Twenty-four female Sprague-Dawley rats underwent a sham operation (the sham group) or bilateral ovariectomy (the ovariectomized group). Four and eight weeks after operation, six rats from each of the two groups were euthanized. Serum biochemical markers of bone turnover including osteocalcin and alkaline phosphatase (ALP), which are sensitive biochemical markers of bone formation, and the telopeptide fragment of type I collagen C-terminus (CTX), which is a sensitive biochemical marker of bone resorption, were analyzed. Bone histomorphometric parameters of the 4th lumbar vertebrae and femur were determined by micro-computed tomography.
Results
Ovariectomized rats were found to have higher osteocalcin, ALP and CTX levels than sham controls. Additionally, 8 weeks after ovariectomy in the OVX group, serum levels of osteocalcin, ALP and CTX were significantly higher than those of 4 weeks after ovariectomy. Bone loss after ovariectomy was more extensive in the 4th lumbar spine compared to the femur. Bone loss in the 4th lumbar spine was mainly caused by trabecular thinning, but in the femur, it was mainly caused by trabecular elimination.
Conclusion
The present study demonstrates different patterns of bone loss between the 4th lumbar spine and the femur in ovariectomized rats. Therefore, when considering animal models of osteoporosis, it is important that bone sites should be taken into account.
doi:10.3340/jkns.2012.52.1.1
PMCID: PMC3440496  PMID: 22993670
Bone loss; Micro-CT; Osteoporosis; Ovariectomy; Rat
10.  The Change of Bone Metabolism in Ovariectomized Rats : Analyses of MicroCT Scan and Biochemical Markers of Bone Turnover 
Objective
The purpose of this study was to verify the appropriateness of ovariectomized rats as the osteoporosis animal model.
Methods
Twelve female Sprague-Dawley rats underwent a sham operation (the sham group) or bilateral ovariectomy [the ovariectomy (OVX) group]. Eight weeks after operations, serum biochemical markers of bone turnover were analyzed; osteocalcin and alkaline phosphatase, which are sensitive biochemical markers of bone formation, and C-terminal telopeptide fragment of type I collagen C-terminus (CTX), which is a sensitive biochemical marker of bone resorption. Bone histomorphometric parameters and microarchitectural properties of 4th lumbar vertebrae were determined by micro-computed tomographic (CT) scan.
Results
The OVX group showed on average 75.4% higher osteocalcin and 72.5% higher CTX levels than the sham group, indicating increased bone turnover. Micro-CT analysis showed significantly lower bone mineral density (BMD) (p=0.005) and cortical BMD (p=0.021) in the OVX group. Furthermore, the OVX group was found to have a significantly lower trabecular bone volume fraction (p=0.002).
Conclusion
Our results showed that bone turnover was significantly increased and bone mass was significantly decreased 8 weeks after ovariectomy in rats. Thus, we propose that the ovariectomized rat model be considered a reproducible and reliable model of osteoporosis.
doi:10.3340/jkns.2012.51.6.323
PMCID: PMC3424170  PMID: 22949959
Bone loss; Bone turnover; Osteoporosis; Ovariectomy; Rat
11.  Epidural Hematoma Related with Low-Dose Aspirin : Complete Recovery without Surgical Treatment 
Hemorrhagic complications associated with aspirin use occur primarily at skin or gastrointestinal sites but can occasionally occur in the central nervous system. In particular, spontaneous spinal epidural hemorrhage (SSEH) associated with aspirin is very rare. We report a case of low-dose (100 mg daily) aspirin-related SSEH that was successfully treated with medical management. Our case indicates that low-dose aspirin could induce SSEH and that conservative treatment with close observation and repeated imaging studies should be considered in cases with neurological improvement or mild deficits.
doi:10.3340/jkns.2012.51.5.308
PMCID: PMC3393869  PMID: 22792431
Aspirin; Spinal epidural hematoma; Medical management
12.  Predictable Factors for Dural Tears in Lumbar Burst Fractures with Vertical Laminar Fractures 
Objective
The purpose of the present study was to determine the incidence of dural tears and predictable factors suggesting dural tears in patients who had lumbar burst fractures with vertical laminar fractures.
Methods
A retrospective review was done on thirty-one patients who underwent operative treatment for lumbar burst fractures with vertical laminar fractures between January 2003 and December 2008. All patients were divided into two groups according to existence of dural tears, which were surgically confirmed; 21 patients with dural tears and 10 patients without dural tears. Clinical and radiographic findings were analyzed for their association with dural tears.
Results
Among a total of 31 patients, dural tears were detected in 21 (67%) patients. A preoperative neurological deficits and mean separation distances of the edges in laminar fractures were found to be the reliable factors of dural tears (p=0.001 and 0.002, respectively). Decreased ratio of the central canal diameter and interpedicular distance were also the reliable factors suggesting dural tears (p=0.006 and 0.015, respectively). However, dural tears showed no significant association with age, sex, level of injury, absence of a posterior fat pad signal, the angle of retropulsed segment, or site of laminar fracture.
Conclusion
Our study of lumbar burst fracture combined laminar fracture revealed that dural tears should be ruled out in cases of a preoperative neurological deficits, wide separation of the laminar fracture, severe canal encroachment, and wider interpedicular distance.
doi:10.3340/jkns.2011.50.1.11
PMCID: PMC3159874  PMID: 21892398
Burst fracture; Dural tear; Laminar fracture
13.  Is All Anterior Oblique Fracture Orientation Really a Contraindication to Anterior Screw Fixation of Type II and Rostral Shallow Type III Odontoid Fractures? 
Objective
It is debatable whether an anterior oblique fracture orientation is really a contraindication to anterior odontoid screw fixation. The purpose of this study was to investigate the feasibility of anterior odontoid screw fixation of type II and rostral shallow type III fracture with an anterior oblique fracture orientation.
Methods
The authors evaluated 16 patients with type II and rostral shallow type III odontoid fracture with an anterior oblique fracture orientation. Of these 16 patients, 8 (group 1) were treated by anterior odontoid screw fixation, and 8 (group 2) by a posterior C1-2 arthrodesis.
Results
Of the 8 patients in group 1, seven patients achieved solid bone fusion (87.5%), and one experienced screw back-out of the C-2 body two months after anterior screw fixation. All patients treated by posterior C1-C2 fusion in group 2 achieved successful bone fusion. Mean fracture displacements and fracture gaps were not significantly different in two groups. (p=0.075 and 0.782). However, mean fracture orientation angles were 15.3±3.2 degrees in group 1, and 28.6+8.1 degrees in group 2 (p=0.002), and mean fragment angulations were 3.2±2.1 degrees in group 1, and 14.8±6.7 degrees in group 2 (p=0.001).
Conclusion
Even when the fracture lines of type II and rostral shallow type III fractures are oriented in an anterior oblique direction, anterior odontoid screw fixation can be feasible in carefully selected patients with a relatively small fracture orientation angle and relatively small fragment angulation.
doi:10.3340/jkns.2011.49.6.345
PMCID: PMC3158477  PMID: 21887392
Fracture; Fracture orientation; Internal fixation; Odontoid process
14.  End-to-End Anastomosis of an Unanticipated Vertebral Artery Injury during C2 Pedicle Screwing 
Vertebral artery (VA) injury is a rare and serious complication of cervical spine surgery; this is due to difficulty in controlling hemorrhage, which can result in severe hypotension and cardiac arrest, and uncertain neurologic consequences. The authors report an extremely rare case of a 56-year-old woman who underwent direct surgical repair by end-to-end anatomosis of an unanticipated VA injury during C2 pedicle screwing. Postoperatively, the patient showed no neurological deterioration and computed tomography angiography of the VA demonstrated normal blood flow. Although direct occlusion of an injured VA by surgical ligation or endovascular embolization has been used for management of an unanticipated VA injury during surgery, these methods may be associated with significant morbidity and mortality. However, despite its technical demand, microvascular primary repair can restore normal blood flow and minimizes the risk of immediate or delayed ischemic complications. Here we report an iatrogenic VA injury during C2 pedicle screwing, which was successfully treated by end-to-end anastomosis.
doi:10.3340/jkns.2010.48.4.363
PMCID: PMC2982918  PMID: 21113367
Vertebral artery injury; End-to-end anastomosis; Atlantoaxial complex
15.  Abducens Nerve Palsy after Lumbar Spinal Fusion Surgery with Inadvertent Dural Tearing 
Abducens nerve palsy associated with spinal surgery is extremely rare. We report an extremely rare case of abducens nerve palsy after lumbar spinal fusion surgery with inadvertent dural tearing, which resolved spontaneously and completely. A 61-year-old previous healthy man presented with chronic lower back pain of 6 weeks duration and 2 weeks history of bilateral leg pain. He was diagnosed as having isthmic spondylolisthesis at L4-5 and L5-S1, and posterior lumbar interbody fusion was conducted on L4-5 and L5-S1. During the operation, inadvertent dural tearing occurred, which was repaired with a watertight dural closure. The patient recovered uneventfully from general anesthesia and his visual analogue pain scores decreased from 9 pre-op to 3 immediately after his operation. However, on day 2 he developed headache and nausea, which were severe when he was upright, but alleviated when supine. This led us to consider the possibility of cerebrospinal fluid leakage, and thus, he was restricted to bed. After an interval of bed rest, the severe headache disappeared, but four days after surgery he experienced diplopia during right gaze, which was caused by right-side palsy of the abducens nerve. Under conservative treatment, the diplopia gradually disappeared and was completely resolved at 5 weeks post-op.
doi:10.3340/jkns.2009.46.6.581
PMCID: PMC2803277  PMID: 20062577
Abducens nerve palsy; Dural tearing; Surgical complication; Lumbar fusion surgery
16.  The Management of Bilateral Interfacetal Dislocation with Anterior Fixation in Cervical Spine : Comparison with Combined Antero-Posterior Fixation 
Objective
Combined antero-posterior fixation has been a standard method for bilateral interfacetal dislocation in cervical spine. The purpose of this study is to evaluate the efficacy and complication of anterior cervical stabilization in treatment of bilateral interfacetal dislocation.
Methods
A total of 65 cases of traumatic bilateral interfacetal dislocation in cervical spine who were managed in our institution, from Mar. 1997 to Feb. 2006, were included in this study. Closed reduction was tried in all cases before operation. If closed reduction was accomplished successfully, only anterior cervical fixation was performed (Group I), and attempted to place screws bicortically as possible with unicortical screws. If failed, posterior open reduction with fixation was first tried, followed by anterior cervical fixation (Group II). All patients were evaluated for neurological outcome and radiological evidence of healing.
Results
The Group I included 47 patients and the Group II, 18 patients. The improvement of Frankel grade and increase of mean cervical lordosis angles were not statistically different between two groups. Screw-plate system used did not influence the outcome. On follow up, solid bone fusion was evident and there were no cases of instability in both groups.
Conclusion
Our study demonstrated that anterior cervical fixation on BID is safe and effective in comparison with combined antero-posterior cervical fixation.
doi:10.3340/jkns.2007.42.4.305
PMCID: PMC2588208  PMID: 19096561
Cervical spine; Dislocation; Antero-posterior; Fixation; Stabilization

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