The purpose of this study was to compare the results of three types of short segment screw fixation for thoracolumbar burst fracture accompanying osteopenia.
The records of 70 patients who underwent short segment screw fixation for a thoracolumbar burst fracture accompanying osteopenia (-2.5< mean T score by bone mineral densitometry <-1.0) from January 2005 to January 2008 were reviewed. Patients were divided into three groups based on whether or not bone fusion and bone cement augmentation procedure 1) Group I (n=26) : short segment fixation with posterolateral bone fusion; 2) Group II (n=23) : bone cement augmented short segment fixation with posterolateral bone fusion; 3) Group III (n=21) : bone cement augmented, short segment percutaneous screw fixation without bone fusion. Clinical outcomes were assessed using a visual analogue scale and modified MacNab's criteria. Radiological findings, including kyphotic angle and vertebral height, and procedure-related complications, such as screw loosening or pull-out, were analyzed.
No significant difference in radiographic or clinical outcomes was noted between patients managed using the three different techniques at last follow up. However, Group I showed more correction loss of kyphotic deformities and vertebral height loss at final follow-up, and Group I had higher screw loosening and implant failure rates than Group II or III.
Bone cement augmented procedure can be an efficient and safe surgical techniques in terms of achieving better outcomes with minimal complications for thoracolumbar burst fracture accompanying osteopenia.
Burst fracture; Osteopenia; Fusion
The purpose of this study was to determine the efficacy of bone cement-augmented short segment fixation using percutaneous screws for thoracolumbar burst fractures in a background of severe osteoporosis.
Sixteen patients with a single-level thoracolumbar burst fracture (T11-L2) accompanying severe osteoporosis treated from January 2008 to November 2009 were prospectively analyzed. Surgical procedures included postural reduction for 3 days and bone cement augmented percutaneous screw fixation at the fracture level and at adjacent levels without bone fusion. Due to the possibility of implant failure, patients underwent implant removal 12 months after screw fixation. Imaging and clinical findings, including involved vertebral levels, local kyphosis, canal encroachment, and complications were analyzed.
Prior to surgery, mean pain score (visual analogue scale) was 8.2 and this decreased to a mean of 2.2 at 12 months after screw fixation. None of the patients complained of pain worsening during the 6 months following implant removal. The percentage of canal compromise at the fractured level improved from a mean of 41.0% to 18.4% at 12 months after surgery. Mean kyphotic angle was improved significantly from 19.8° before surgery to 7.8 at 12 months after screw fixation. Canal compromise and kyphotic angle improvements were maintained at 6 months after implant removal. No significant neurological deterioration or complications occurred after screw removal in any patient.
Bone cement augmented short segment fixation using a percutaneous system can be an alternative to the traditional open technique for the management of selected thoracolumbar burst fractures accompanied by severe osteoporosis.
Burst fracture; Fusion; Percutaneous
Bacterial meningitis is rarely complicated by an intradural spinal abscess, and recurrent meningitis is an uncommon presentation of a spinal intramedullary abscess. Here, we report a 63-year-old patient with recurrent meningitis as the first manifestation of an underlying spinal intramedullary abscess. To the best of our knowledge, no previous report has been issued on recurrent meningitis accompanied by a spinal intramedullary abscess in an adult. In this article, the pathophysiological mechanism of this uncommon entity is discussed and the relevant literature reviewed.
Spinal; Intramedullary abscess; Meningitis
The purpose of this prospective study was to evaluate the efficacy and safety of screw fixation without bone fusion for unstable thoracolumbar and lumbar burst fracture.
Nine patients younger than 40 years underwent screw fixation without bone fusion, following postural reduction using a soft roll at the involved vertebra, in cases of burst fracture. Their motor power was intact in spite of severe canal compromise. The surgical procedure included postural reduction for 3 days and screw fixations at one level above, one level below and at the fractured level itself. The patients underwent removal of implants 12 months after the initial operation, due to possibility of implant failure. Imaging and clinical findings, including canal encroachment, vertebral height, clinical outcome, and complications were analyzed.
Prior to surgery, the mean pain score (visual analogue scale) was 8.2, which decreased to 2.2 at 12 months after screw fixation. None of the patients complained of worsening of pain during 6 months after implant removal. All patients were graded as having excellent or good outcomes at 6 months after implant removal. The proportion of canal compromise at the fractured level improved from 55% to 35% at 12 months after surgery. The mean preoperative vertebral height loss was 45.3%, which improved to 20.6% at 6 months after implant removal. There were no neurological deficits related to neural injury. The improved vertebral height and canal compromise were maintained at 6 months after implant removal.
Short segment pedicle screw fixation, including fractured level itself, without bone fusion following postural reduction can be an effective and safe operative technique in the management of selected young patients suffering from unstable burst fracture.
Screw fixation; Burst fracture; Bone fusion
Discal cyst is rare and causes indistinguishable symptoms from lumbar disc herniation. The clinical manifestations and pathological features of discal cyst have not yet been completely known. Discal cyst has been treated with surgery or with direct intervention such as computed tomography (CT) guided aspiration and steroid injection. The purpose of this study is to evaluate the safety and efficacy of the percutaneous endoscopic surgery for lumbar discal cyst over at least 6 months follow-up.
All 8 cases of discal cyst with radiculopathy were treated by percutaneous endoscopic surgery by transforaminal approach. The involved levels include L5-S1 in 1 patient, L3-4 in 2, and L4-5 in 5. The preoperative magnetic resonance imaging and 3-dimensional CT with discogram images in all cases showed a connection between the cyst and the involved intervertebral disc. Over a 6-months period, self-reported measures were assessed using an outcome questionaire that incorporated total back-related medical resource utilization and improvement of leg pain [visual analogue scale (VAS) and Macnab's criteria].
All 8 patients underwent endoscopic excision of the cyst with additional partial discectomy. Seven patients obtained immediate relief of symptoms after removal of the cyst by endoscopic approach. There were no recurrent lesions during follow-up period. The mean preoperative VAS for leg pain was 8.25±0.5. At the last examination followed longer than 6 month, the mean VAS for leg pain was 2.25±2.21. According to MacNab' criteria, 4 patients (50%) had excellent results, 3 patients (37.5%) had good results; thus, satisfactory results were achieved in 7 patients (87.5%). However, one case had unsatisfactory result with persistent leg pain and another paresthesia.
The radicular symptoms were remarkably improved in most patients immediately after percutaneous endoscopic cystectomy by transforaminal approach.
Lumbar discal cyst; Percutaneous endoscopic transforaminal cystectomy
Simultaneous intracranial and spinal subdural hematomas are extremely rare. In most cases, they are attributed to major or minor trauma and iatrogenic causes, such as those resulting from spinal puncture. To the best of the authors' knowledge, there has been only two reports of spontaneous concomitant intracranial and spinal subdural hematomas in a patient receiving anticoagulant therapy who had an absence of evident trauma history. We report on a case of spontaneous concomitant intracranial and spinal subdural hematomas that occurred in association with anticoagulant therapy and present a review of the relevant literature.
Cranial; Spinal; Subdural hematoma; Anticoagulant therapy
Ankylosing spondylitis (AS) is frequently associated with inflammatory lesions of the spine and continuous fatigue stress fractures; however, an association with an intraspinal synovial cyst has not been previously reported. A 55-year-old man with a five year history of AS who presented with back pain and a right radiculopathy was admitted to the hospital. Five years previously, he underwent a percutaneous vertebroplasty for an osteoporotic L1 compression fracture, and was diagnosed with AS at that time. Plain radiographs showed aggravated kyphosis and a stress fracture through the ossified posterior element, below the prior vertebroplasty. Magnetic resonance images revealed a right foraminal cystic lesion at the L2-L3 level with effacement of the nerve root. A 1.6 cm cystic lesion that appeared to arise from the L2-L3 facet joint without direct communication was excised from the L2-L3 foramen. Pathological examination confirmed synovial cyst. The patient's symptoms resolved immediately after surgery except for a mild dysesthesia of the right leg. We report herein a rare case of foraminal synovial cyst associated with AS accompanying posterior element fracture with a review of literature.
Synovial cyst; Ankylosing spondylitis
Both the paraspinal muscle sparing approach and percutaneous screw fixation are less traumatic procedures in comparison with the conventional midline approach. These techniques have been used with the goal of reducing muscle injury. The purpose of this study was to evaluate and to compare the safety and efficacy of the paraspinal muscle sparing technique and percutaneous screw fixation for the treatment of L5-S1 spondylolisthesis.
Twenty patients who had undergone posterior lumbar interbody fusion (PLIF) at the L5-S1 segment for spondylolisthesis were prospectively studied. They were divided into two groups by screw fixation technique (Group I : paraspinal muscle sparing approach and Group II: percutaneous screw fixation). Clinical outcomes were assessed by Low Back Outcome Score (LBOS) and Visual Analogue Scale (VAS) for back and leg pain at different times after surgery. In addition, modified MacNab's grading criteria were used to assess subjective patients' outcomes 6 months after surgery. Postoperative midline surgical scarring, intraoperative blood loss, mean operation time, and procedure-related complications were analyzed.
Excellent or good results were observed in all patients in both groups 6 months after surgery. Patients in both groups showed marked improvement in terms of LBOSs all over time intervals. Postoperative midline surgical scarring and intraoperative blood loss were lower in Group II compared to Group I although these differences were not statistically significant. Low back pain (LBP) and leg pain in both groups also showed significant improvement when compared to preoperative scores. However, at 7 days and 1 month after surgery, patients in Group II had significantly better LBP scores compared to Group I.
In terms of LBP during the early postoperative period, patients who underwent percutaneous screw fixation showed better results compared to ones who underwent screw fixation via the paraspinal muscle sparing approach. Our results indicate that the percutaneous screw fixation procedure is the preferable minimally invasive technique for reducing LBP associated with L5-S1 spondylolisthesis.
Spondylolisthesis; Paraspinal muscle sparing approach; Percutaneous screw fixation; Back pain
The low lumbar spine is deeply located in flexible segments, and has a physiologic lordosis. Therefore, burst fractures of the low lumbar spine are uncommon injuries. The treatment for such injuries may either be conservative or surgical management according to canal compromise and the neurological status. However, there are no general guidelines or consensus for the treatment of low lumbar burst fractures especially in neurologically intact cases with severe canal compromise. We report a patient with a burst fracture of the fourth lumbar vertebra, who was treated surgically but without fusion because of the neurologically intact status in spite of severe canal compromise of more than 85%. It was possible to preserve motion segments by removal of screws at one year later. We also discuss why bone fusion was not necessary with review of the relevant literature.
Burst fracture; Low lumbar spine; Fusion
Bone cement augmentation procedures such as percutaneous vertebroplasty and balloon kyphoplasty have been shown to be effective treatment for acute or subacute osteoporotic vertebral compression fractures. The purpose of this study was to determine the efficacy of bone cement augmentation procedures for long standing osteoporotic vertebral compression fracture with late vertebral collapse and persistent back pain.
Among 278 single level osteoporotic vertebral compression fractures that were treated by vertebral augmentation procedures at our institute, 18 consecutive patients were included in this study. Study inclusion was limited to initially, minimal compression fractures, but showing a poor prognosis due to late vertebral collapse, intravertebral vacuum clefts and continuous back pain despite conservative treatment for more than one year. The subjects included three men and 15 women. The mean age was 70.7 with a range from 64 to 85 years of age. After postural reduction for two days, bone cement augmentation procedures following intraoperative pressure reduction were performed. Imaging and clinical findings, including the level of the vertebra involved, vertebral height restoration, injected cement volume, local kyphosis, clinical outcome and complications were analyzed.
The mean follow-up period after bone cement augmentation procedures was 14.3 months (range 12-27 months). The mean injected cement volume was 4.1 mL (range 2.4-5.9 mL). The unipedicular approach was possible in 15 patients. The mean pain score (visual analogue scale) prior to surgery was 7.1, which decreased to 3.1 at 7 days after the procedure. The pain relief was maintained at the final follow up. The kyphotic angle improved significantly from 21.2 ± 4.9° before surgery to 10.4 ± 3.8° after surgery. The fraction of vertebral height increased from 30% to 60% after bone cement augmentation, and the restored vertebral height was maintained at the final follow up. There were no serious complications related to cement leakage.
In the management of even long-standing osteoporotic vertebral compression fracture for over one year, bone cement augmentation procedures following postural reduction were considered safe and effective treatment in cases of non-healing evidence.
Long standing; Compression fracture; Osteoporosis; Bone cement
Bilateral pedicle stress fracture is a rare entity and few cases have been reported in the literature. Furthermore, the majority of these reports concern previous spine surgery or stress-related activities. Here, the authors report ankylosing spondylitis as a new cause of bilateral pedicle stress fractures accompanying spondylolysis. The reported case adds to the literature on bilateral pedicle stress fracture and spondylolysis by documenting that ankylosing spondylitis is another cause of this condition.
Spine fracture; Spondylolysis; Ankylosing spondylitis
We report an extremely rare case of traumatic cervical spinal subdural hematoma not related to intracranial injury. There has been no report on traumatic cervical spinal subdrual hematoma not related to intracranial injury. A 27-year-old female patient was admitted to our emergency room due to severe neck pain and right arm motor weakness after car collision. On admission, she presented with complete monoplegia and hypoesthesia of right arm. Magnetic resonance imaging (MRI) revealed subdural hematoma compressing spinal cord. Lumbar cerebrospinal fluid (CSF) analysis revealed 210,000 red blood cells/mm3. She was managed conservatively by administrations of steroid pulse therapy and CSF drainage. Her muscle power of right arm improved to a Grade III 16 days after admission. Follow-up MRI taken 16th days after admission revealed almost complete resolution of the hematoma. Here, the authors report a traumatic cervical spinal SDH not associated with intracranial injury.
Spinal subdural hematoma; Cervical spine; Monoplegia
The purpose of this study was to evaluate the efficacy of a transforaminal suprapedicular approach, semi-rigid flexible curved probe, and 3-dimensional reconstruction computed tomography (3D-CT) with discogram in the endoscopic treatment of non-contained lumbar disc herniations.
The subjects were 153 patients with difficult, non-contained lumbar disc herniations undergoing endoscopic treatment. The types of herniation were as follows : extraforaminal, 17 patients; foraminal, 21 patients; high grade migration, 59 patients; and high canal compromise, 56 patients. To overcome the difficulties in endoscopic treatment, the anatomic structures were analyzed by 3D reconstruction CT and the high grade disc was extracted using a semi-rigid flexible curved probe and a transforaminal suprapedicular approach.
The mean follow-up was 18.3 months. The mean visual analogue scale (VAS) of the patients prior to surgery was 9.48, and the mean postoperative VAS was 1.63. According to Macnab's criteria, 145 patients had excellent and good results, and thus satisfactory results were obtained in 94.77% cases.
In a posterolateral endoscopic lumbar discectomy, the difficult, non-contained disc is considered to be the most important factor impeding the success of surgery. By applying a semi-rigid flexible curved probe and using a transforaminal suprapedicular approach, good surgical results can be obtained, even in high grade, non-contained disc herniations.
Intervertebral disc herniation; Percutaneous discectomy; Posterolateal approach
We present a case of an acute psoas muscle hematoma following percutaneous endoscopic lumbar discectomy. A 60-year-old female who presented with far lateral lumbar disc herniation underwent endoscopic discectomy on the right side at the L4-5 level. On the second postoperative day, the patient complained of severe right flank and leg pain and her blood pressure decreased. A computed tomography scan showed a large acute psoas muscle hematoma at right L4-5 level. The patient was transfused with packed red blood cells and placed at absolute bed rest. After observing the patient in intensive care, the severe flank and leg pain subsided, but the mild back pain persisted. Although percutaneous endoscopic lumbar discectomy is an effective minimally invasive surgical technique for the treatment of lumbar disc herniation, this case highlights the inherent risks of acute lumbar segmental vessel injury.
Percutaneous endoscopic lumbar discectomy; Psoas muscle hematoma; Lumbar segmental vessel injury
Although most of sacral perineural cysts are asymptomatic, some may produce symptoms. Specific radicular pain may be due to distortion, compression, or stretching of nerve root by a space occupying cyst. We report a rare case of S1 radiculopathy caused by sacral perineural cyst accompanying disc herniation. The patient underwent a microscopic discectomy at L5-S1 level. However, the patient's symptoms did not improved. The hypesthesia persisted, as did the right leg pain. Cyst-subarachnoid shunt was set to decompress nerve root and to equalize the cerebrospinal fluid pressure between the cephalad thecal sac and cyst. Immediately after surgery, the patient had no leg pain. After 6 months, the patient still remained free of leg pain.
Sacral perineural cyst; Disc herniation
Acute traumatic spondylolisthesis at L5-S1 level is a rare condition, almost exclusively the result of major trauma, frequently associated with transverse process fractures and severe neurologic deficits. Recently, open reduction and internal fixation with posterior stabilization has been the method of treatment most frequently reported. We report a rare case of traumatic L5-S1 pondylolisthesis with a unilateral facet locking with a review of literatures.
Traumatic spondylolisthesis; Unilateral facet interlocking
Although endoscopic procedures for lumbar disc diseases have improved greatly, the postoperative outcomes for high grade inferior migrated discs are not satisfactory. Because of anatomic limitations, a rigid endoscope cannot reach all lesions effectively. The purpose of this study was to determine the feasibility of endoscopic transforaminal suprapedicular approach to high grade inferior-migrated lumbar disc herniations.
Between May 2006 and March 2008, a suprapedicular approach was performed in 53 patients with high grade inferior-migrated lumbar disc herniations using a rigid endoscope and a semi-rigid flexible curved probe. One-to-four hours after surgery, the presence of remnant discs was checked with MRI. The outcomes were evaluated with the visual analogue scale (VAS) score and the Oswestry Disability Index (ODI) one week after surgery.
The L2-3 level was involved in 2 patients and the L3-4 level was involved in 14 patients, while the L4-5 level was involved in 39 patients. There were single piece-type in 34 cases and a multiple piece-type in 19 cases. Satisfactory results were obtained in all cases. The mean preoperative VAS for leg pain was 9.32±0.43 points (range, 7-10 points), whereas the mean ODI was 79.82±4.53 points (range, 68-92 points). At the last follow-up examination, the mean postoperative VAS for leg pain was 1.78±0.71 points and the mean postoperative ODI improved to 15.27±3.82 points.
A high grade inferior migrated lumbar disc is difficult to remove sufficiently by posterolateral endoscopic lumbar dscectomy using a rigid endoscope. However, a satisfactory result can be obtained by applying a transforaminal suprapedicular approach with a flexible semi-rigid curved probe.
Migrated disc herniation; Percutaneous endoscopic lumbar discectomy; Rigid endoscope; Flexible curved probe
The purpose of this study was to determine the efficacy of short segment fixation following postural reduction for the re-expansion and stabilization of unstable burst fractures in patients with osteoporosis.
Twenty patients underwent short segment fixation following postural reduction using a soft roll at the involved vertebra in cases of severely collapsed vertebrae of more than half their original height. All patients had unstable burst fracture with canal compromise, but their motor power was intact. The surgical procedure included postural reduction for 2 days and bone cement-augmented pedicle screw fixations at one level above, one level below and the fractured level itself. Imaging and clinical findings, including the level of the vertebra involved, vertebral height restoration, injected cement volume, local kyphosis, clinical outcome and complications were analyzed.
The mean follow-up period was 15 months. The mean pain score (visual analogue scale) prior to surgery was 8.1, which decreased to 2.8 at 7 days after surgery. The kyphotic angle improved significantly from 21.6±5.8° before surgery to 5.2±3.7° after surgery. The fraction of the height of the vertebra increased from 35% and 40% to 70% in the anterior and middle portion. There were no signs of hardware pull-out, cement leakage into the spinal canal or aggravation of kyphotic deformities.
In the management of unstable burst fracture in patients with severe osteoporosis, short segment pedicle screw fixation with bone cement augmentation following postural reduction can be used to reduce the total levels of pedicle screw fixation and to correct kyphotic deformities.
Unstable burst fracture; Osteoporosis; Short segment fixation
We report a rare case of delayed cement displacement after balloon kyphoplasty in patient with Kümmell's desease. A 78-year-old woman with Kümmell's desease at T12 level received percutaneous balloon kyphoplasty. Two months after surgery, the patient complained of progressive severe back pain. Computed tomographic scans revealed a breakdown of the anterior cortex and anterior displacement of bone cement. Although this complication is very rare, it is likely to occur in treatment of Kümmell's desease accompanying anterior cortical defect.
Kümmell's desease; Balloon kyphoplasty; Bone cement displacement
The purpose of this study was to evaluate the efficacy of spinal implant removal and to determine the possible mechanisms of pain relief.
Fourteen patients with an average of 42 years (from 22 to 67 years) were retrospectively evaluated. All patients had posterior spinal instrumentation and fusion, who later developed recurrent back pain or persistent back pain despite a solid fusion mass. Patients' clinical charts, operative notes, and preoperative x-rays were evaluated. Relief of pain was evaluated by the Visual Analog Scale (VAS) pain change after implant removal. Clinical outcome using VAS and modified MacNab's criteria was assessed on before implant removal, 1 month after implant removal and at the last clinical follow-up. Radiological analysis of sagittal alignment was also assessed.
Average follow-up period was 18 months (from 12 to 25 months). There were 4 patients who had persistent back pain at the surgical site and 10 patients who had recurrent back pain. The median time after the first fusion operation and the recurrence of pain was 6.5 months (from 3 to 13 months). All patients except one had palpation pain at operative site. The mean blood loss was less than 100ml and there were no major complications. The mean pain score before screw removal and at final follow up was 6.4 and 2.9, respectively (p<0.005). Thirteen of the 14 patients were graded as excellent and good according to modified MacNab's criteria. Overall 5.9 degrees of sagittal correction loss was observed at final follow up, but was not statistically significant.
For the patients with persistent or recurrent back pain after spinal instrumentation, removal of the spinal implant may be safe and an efficient procedure for carefully selected patients who have palpation pain and are unresponsive to conservative treatment.
Spinal implant removal; Back pain
Forestier's disease is a systemic rheumatological abnormality in which exuberant ossification occurs along ligaments throughout the body, but most notably the anterior longitudinal ligament of the spine. This disease is usually asymptomatic; however dysphagia, dyspnea, and peripheral nerve entrapment have all been documented in association with the disorder. We report a rare case of catastrophic neurologic damage caused by Forestier's disease accompanying ossification of the posterior longitudinal ligament.
Forestier's disease; Ossification of the posterior longitudinal ligament
Kyphoplasty performed in the middle thoracic spine presents technical challenges that differ from those in the lower thoracic or lumbar region due to small pedicle size and angular severity for thoracic kyphosis. The purpose of this study was to evaluate the efficacy of balloon kyphoplasty through extrapedicular approach for the treatment of intractable osteoporotic compression fractures in the middle thoracic spine.
The patients who were performed with one level balloon kyphoplasty through extrapedicular approach due to painful osteoporotic compression fractures at T5-T8 from June 2003 to July 2005 were retrospectively analyzed. Imaging and clinical features were analyzed including involved vertebrae level, vertebral height, injected cement volume, clinical outcome and complications.
Eighteen female patients (age ranged from 60 to 77 years old) were included in this study. The average amount of the implanted cement was 4.2±1.5 cc. The mean cobb angle and compression rate were improved from 12.1±6.5° to 8.5±7.2° and from 30% to 15%, respectively. The mean pain score (visual analogue scale) prior to kyphoplasty was 7.9 and it decreased to 3.0 after the procedure. Cement leakage to the adjacent disc (2 cases) and paravertebral soft tissues (1 case) were seen but there were no major complications such as pneumothorax, segmental artery injury, pulmonary embolism, or epidural leakage.
Balloon kyphoplasty through extrapedicular approach is considered as a safe and effective in treating the middle thoracic regions with low complication rate.
Balloon kyphoplasty; Extrapedicular approach; Middle thoracic region; Osteoporotic compression fracture