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1.  Predictive Factors for a Kyphosis Recurrence Following Short-Segment Pedicle Screw Fixation Including Fractured Vertebral Body in Unstable Thoracolumbar Burst Fractures 
The technique of short segment pedicle screw fixation (SSPSF) has been widely used for stabilization in thoracolumbar burst fractures (TLBFs), but some studies reported high rate of kyphosis recurrence or hardware failure. This study was to evaluate the results of SSPSF including fractured level and to find the risk factors concerned with the kyphosis recurrence in TLBFs.
This study included 42 patients, including 25 males and 17 females, who underwent SSPSF for stabilization of TLBFs between January 2003 and December 2010. For radiologic assessments, Cobb angle (CA), vertebral wedge angle (VWA), vertebral body compression ratio (VBCR), and difference between VWA and Cobb angle (DbVC) were measured. The relationships between kyphosis recurrence and radiologic parameters or demographic features were investigated. Frankel classification and low back outcome score (LBOS) were used for assessment of clinical outcomes.
The mean follow-up period was 38.6 months. CA, VWA, and VBCR were improved after SSPSF, and these parameters were well maintained at the final follow-up with minimal degree of correction loss. Kyphosis recurrence showed a significant increase in patients with Denis burst type A, load-sharing classification (LSC) score >6 or DbVC >6 (p<0.05). There were no patients who worsened to clinical outcome, and there was no significant correlation between kyphosis recurrence and clinical outcome in this series.
SSPSF including the fractured vertebra is an effective surgical method for restoration and maintenance of vertebral column stability in TLBFs. However, kyphosis recurrence was significantly associated with Denis burst type A fracture, LSC score >6, or DbVC >6.
PMCID: PMC4217060  PMID: 25368766
Kyphosis; Short-segment pedicel screw fixation; Thoracolumbar burst fractures; Instability
2.  Comparison of Clinical and Radiologic Results between Expandable Cages and Titanium Mesh Cages for Thoracolumbar Burst Fracture 
A thoracolumbar burst fracture is usually unstable and can cause neurological deficits and angular deformity. Patients with unstable thoracolumbar burst fracture usually need surgery for decompression of the spinal canal, correction of the angular deformity, and stabilization of the spinal column. We compared two struts, titanium mesh cages (TMCs) and expandable cages.
33 patients, who underwent anterior thoracolumbar reconstruction using either TMCs (n=16) or expandable cages (n=17) between June 2000 and September 2011 were included in this study. Clinical outcome was measured by visual analogue scale (VAS), American Spinal Injury Association (ASIA) scale and Low Back Outcome Score (LBOS) for functional neurological evaluation. The Cobb angle, body height of the fractured vertebra, the operation time and amount of intra-operative bleeding were measured in both groups.
In the expandable cage group, operation time and amount of intraoperative blood loss were lower than that in the TMC group. The mean VAS scores and LBOS in both groups were improved, but no significant difference. Cobb angle was corrected higher than that in expandable cage group from postoperative to the last follow-up. The change in Cobb angles between preoperative, postoperative, and the last follow-up did not show any significant difference. There was no difference in the subsidence of anterior body height between both groups.
There was no significant difference in the change in Cobb angles with an inter-group comparison, the expandable cage group showed better results in loss of kyphosis correction, operation time, and amount of intraoperative blood loss.
PMCID: PMC4024813  PMID: 24851149
Thoracolumbar; Lumbar; Fracture; Corpectomy; Cage; Kyphosis
3.  Evaluation of Probability of Survival Using Trauma and Injury Severity Score Method in Severe Neurotrauma Patients 
Despite several limitations, the Trauma Injury Severity Score (TRISS) is normally used to evaluate trauma systems. The aim of this study was to evaluate the preventable trauma death rate using the TRISS method in severe trauma patients with traumatic brain injury using our emergency department data.
The use of the TRISS formula has been suggested to consider definitively preventable death (DP); the deaths occurred with a probability of survival (Ps) higher than 0.50 and possible preventable death (PP); the deaths occurred with a Ps between 0.50 and 0.25. Deaths in patients with a calculated Ps of less than 0.25 is considered as no-preventable death (NP). A retrospective case review of deaths attributed to mechanical trauma occurring between January 1, 2011 and December 31, 2011 was conducted.
A total of 565 consecutive severe trauma patients with ISS>15 or Revised Trauma Score<7 were admitted in our institute. We excluded a total of 24 patients from our analysis : 22 patients younger than 15 years, and 2 patients with burned injury. Of these, 221 patients with head injury were analyzed in the final study. One hundred eighty-two patients were in DP, 13 in PP and 24 in NP. The calculated predicted mortality rates were 11.13%, 59.04%, and 90.09%. The actual mortality rates were 12.64%, 61.547%, and 91.67%, respectively.
Although it needs to make some improvements, the present study showed that TRISS performed well in predicting survival of traumatic brain injured patients. Also, TRISS is relatively exact and acceptable compared with actual data, as a simple and time-saving method.
PMCID: PMC3772286  PMID: 24044080
Traumatic brain injury; TRISS; Survival
4.  Two Cases of Primary Osteolytic Intraosseous Meningioma of the Skull Metastasizing to Whole Skull and the Spine 
We report here two cases of primary intraosseous meningioma with aggressive behavior. A 68-year-old man presented with a one year history of a soft, enlarging mass in the right parietal region. Magnetic resonance image (MRI) revealed a 6 cm sized, heterogeneously-enhancing, bony expansile mass in the right parietal bone, and computed tomograph (CT) showed a bony, destructive lesion. The tumor, including the surrounding normal bone, was totally resected. Dural invasion was not apparent. Diagnosis was atypical meningioma, which extensively metastasized within the skull one year later. A 74-year-old woman presented with a 5-month history of a soft mass on the left frontal area. MRI revealed a 4 cm sized, multilobulated, strongly-enhancing lesion on the left frontal bone, and CT showed a destructive lesion. The mass was adhered tightly to the scalp and dura mater. The lesion was totally removed. Biopsy showed a papillary meningioma. The patient refused adjuvant radiation therapy and later underwent two reoperations for recurred lesions, at 19 and at 45 months postoperative. The patient experienced back pain 5 years later, and MRI showed an osteolytic lesion on the 11th thoracic vertebra. After her operation, a metastatic papillary meningioma was diagnosed. These osteolytic intraosseous meningiomas had atypical/malignant pathologies, which metastasized to whole skull and the spine.
PMCID: PMC3358602  PMID: 22639712
Intraosseous; Meningioma; Metastasis; Osteolysis
5.  Activation of Matrix Metalloproteinases-9 after Photothrombotic Spinal Cord Injury Model in Rats 
Matrix metalloproteinases (MMPs), especially MMP-2 and MMP-9 have been known to play an important role in secondary inflammatory reaction after spinal cord injury (SCI). The aim of this study was to investigate the expression and activity of MMP-2 and MMP-9 and to determine their relationship with disruption of endothelial blood-barrier after photochemically induced SCI in rats.
Female Sprague-Dawley rats, weighing between 250 and 300 g (aged 8 weeks) received focal spinal cord ischemia by photothrombosis using Rose Bengal. Expressions and activities of MMP-2 and MMP-9 were assessed by Western blot and gelatin zymography at various times from 6 h to 7 days. Endothelial blood-barrier integrity was assessed indirectly using spinal cord water content.
Zymography and Western blot analysis demonstrated rapid up-regulation of MMP-9 protein levels in spinal cord after ischemic onset. Expressions and activities of MMP-9 showed a significant increased at 6 h after the photothrombotic ischemic event, and reached a maximum level at 24 h after the insult. By contrast, activated MMP-2 was not detected at any time point in either the experimental or the control groups. When compared with the control group, a significant increase in spinal cord water content was detected in rats at 24 h after photothrombotic SCI.
Early up-regulation of MMP-9 might be correlated with increased water content in the spinal cord at 24 h after SCI in rats. Results of this study suggest that MMP-9 is the key factor involved in disruption of the endothelial blood-barrier of the spinal cord and subsequent secondary damage after photothrombotic SCI in rats.
PMCID: PMC3243829  PMID: 22200008
Endothelial blood-barrier; Matrix metalloproteinases-9; Photothrombosis; Rat; Spinal cord injury
6.  Laminotomy with Continuous Irrigation in Patients with Pyogenic Spondylitis in Thoracic and Lumbar Spine 
Pyogenic spondylitis often results in acute neurological deterioration requiring adequate surgical intervention and appropriate antibiotic treatment. The purpose of this study was to conduct an analysis of the clinical effect of continuous irrigation via laminotomy in a series of patients with pyogenic spondylitis in thoracic and lumbar spine.
The authors conducted a retrospective investigation of 31 consecutive patients with pyogenic thoracic and lumbar spondylitis who underwent continuous irrigation through laminotomy from 2004 to 2008. The study included 22 men and 9 women, ranging in age from 38 to 78 years (mean 58.1 years). The average follow-up duration was 13.4 months (range, 8-34 months). We performed debridement and abscess removal after simple laminotomy, and then washed out epidural and disc space using a continuous irrigation system. Broad spectrum antibiotics were administered empirically and changed according to the subsequent culture result. Clinical outcomes were based on the low back outcome scale (LBOS), visual analogue scale (VAS) score, and Frankel grade at the last follow-up. Radiological assessment involved plain radiographs, including functional views.
Common predisposing factors included local injection for pain therapy, diabetes mellitus, chronic renal failure, and liver cirrhosis. Causative microorganisms were identified in 22 cases (70.9%) : Staphylococcus aureus and Streptococcus spp. were the main organisms. After surgery, LBOS, VAS score, and Frankel grade showed significant improvement in most patients. Spinal stability was maintained during the follow-up period, making secondary reconstructive surgery unnecessary for all patients, except one.
Simple laminotomy with continuous irrigation by insertion of a catheter into intervertebral disc space or epidural space was minimally invasive and effective in the treatment of pyogenic spondylitis. This procedure could be a beneficial treatment option in patients with thoracolumbar spondylitis combined with minimal or moderate destructive change of vertebrae.
PMCID: PMC3243837  PMID: 22200016
Irrigation; Laminotomy; Pyogenic; Spondylitis; Thoracolumbar
7.  Post-Traumatic Cerebral Infarction : Outcome after Decompressive Hemicraniectomy for the Treatment of Traumatic Brain Injury 
Posttraumatic cerebral infarction (PTCI), an infarction in well-defined arterial distributions after head trauma, is a known complication in patients with severe head trauma. The primary aims of this study were to evaluate the clinical and radiographic characteristics of PTCI, and to assess the effect on outcome of decompressive hemicraniectomy (DHC) in patients with PTCI.
We present a retrospective analysis of 20 patients with PTCI who were treated between January 2003 and August 2005. Twelve patients among them showed malignant PTCI, which is defined as PTCI including the territory of Middle Cerebral Artery (MCA). Medical records and radiologic imaging studies of patients were reviewed.
Infarction of posterior cerebral artery distribution was the most common site of PTCI. Fourteen patients underwent DHC an average of 16 hours after trauma. The overall mortality rate was 75%. Glasgow outcome scale (GOS) of survivors showed that one patient was remained in a persistent vegetative state, two patients were severely disabled and only two patients were moderately disabled at the time of discharge. Despite aggressive treatments, all patients with malignant PTCI had died. Malignant PTCI was the indicator of poor clinical outcome. Furthermore, Glasgow coma scale (GCS) at the admission was the most valuable prognostic factor. Significant correlation was observed between a GCS less than 5 on admission and high mortality (p<0.05).
In patients who developed non-malignant PTCI and GCS higher than 5 after head injury, early DHC and duroplasty should be considered, before occurrence of irreversible ischemic brain damage. High mortality rate was observed in patients with malignant PTCI or PTCI with a GCS of 3-5 at the admission. A large prospective randomized controlled study will be required to justify for aggressive treatments including DHC and medical treatment in these patients.
PMCID: PMC3243842  PMID: 22200021
Brain trauma; Cerebral infarction; Decompressive craniectomy
8.  Clinical Features and Treatments of Upper Lumbar Disc Herniations 
Disc herniations at the L1-L2 and L2-L3 levels are different from those at lower levels of the lumbar spine with regard to clinical characteristics and surgical outcome. Spinal canals are narrower than those of lower levels, which may compromise multiple spinal nerve roots or conus medullaris. The aim of this study was to evaluate the clinical features and surgical outcomes of upper lumbar disc herniations.
We retrospectively reviewed the clinical features of 41 patients who had undergone surgery for single disc herniations at the L1-L2 and L2-3 levels from 1998 to 2007. The affected levels were L1-L2 in 14 patients and L2-L3 in 27 patients. Presenting symptoms and signs, patient characteristics, radiologic findings, operative methods, and surgical outcomes were investigated.
The mean age of patients with upper lumbar disc was 55.5 years (ranged 31 to 78). The mean follow-up period was 16.6 months. Most patients complained of back and buttock pain (38 patients, 92%), and radiating pain in areas such as the anterior or anterolateral aspect of the thigh (32 patients, 78%). Weakness of lower extremities was observed in 16 patients (39%) and sensory disturbance was presented in 19 patients (46%). Only 6 patients (14%) had undergone previous lumbar disc surgery. Discectomy was performed using three methods : unilateral laminectomy in 27 cases, bilateral laminectomy in 3 cases, and the transdural approach in 11 cases, which were performed through total laminectomy in 10 cases and unilateral laminectomy in 1 case. With regard to surgical outcomes, preoperative symptoms improved significantly in 33 patients (80.5%), partially in 7 patients (17%), and were aggravated in 1 patient (2.5%).
Clinical features of disc herniations at the L1-L2 and L2-L3 levels were variable, and localized sensory change or pain was rarely demonstrated. In most cases, the discectomy was performed successfully by conventional posterior laminectomy. On the other hand, in large central broad based disc herniation, when the neural elements are severely compromised, the posterior transdural approach could be an alternative.
PMCID: PMC2941853  PMID: 20856659
Clinical feature; Disc herniation; Transdural; Upper lumbar
9.  Synovial Sarcoma of the Posterior Neck : A Case Report and Review of Literature 
We recently experienced a case of synovial sarcoma in the posterior neck, which involved adjacent bony structures. Synovial sarcoma is rare, malignant soft tissue tumor that occur predominantly in the lower extremities. Wide surgical excision with involved tissue is the treatment of first choice, because most synovial sarcomas reveal aggressive features. We removed the tumor with involved bony structures and patient was given postoperative radiation therapy. Despite these treatment options, the patient died 1 year after surgery. We report this case with a review of the literature.
PMCID: PMC2864827  PMID: 20461175
Synovial sarcoma; Posterior neck; Bony involvement
10.  Small Bowel Injury as a Complication of Lumbar Microdiscectomy : Case Report and Literature Review 
Small bowel injury resulting from unforeseen penetration of the anterior annulus fibrosus and longitudinal ligament is a rare complication of lumbar microdiscectomy. The patient complained of abdominal tenderness and distention immediately after microdiscectomy for L4-5 and L5-S1 disc herniation. Using abdominal computed tomography, we found several foci of air overlying the anterior aspect of the vertebral body at the L5-S1 level. Segmental resection of the small bowel including small tears and primary anastomosis of the jejunum were performed. Here, we present a case of intestinal perforation after lumbar microdiscectomy and discuss technical methods to prevent this complication with a review of literature.
PMCID: PMC2851092  PMID: 20379478
Bowel injury; Complication; Lumbosacral region; Microdiscectomy
11.  A Mouse Model of Photochemically Induced Spinal Cord Injury 
A mouse model of spinal cord injury (SCI) could further increase our basic understanding of the mechanisms involved in injury and repair of the nervous system. The purpose of this study was to investigate whether methods used to produce and evaluate photochemical graded ischemic SCI in rats, could be successfully adapted to mice, in a reliable and reproducible manner.
Thirty female imprinting control region mice (weighting 25-30 g, 8 weeks of age) were used in this study. Following intraperitoneal injection of Rose bengal, the translucent dorsal surface of the T8-T9 vertebral laminae of the mice were illuminated with a fiber optic bundle of a cold light source. The mice were divided into three groups; Group 1 (20 mg/kg Rose bengal, 5 minutes illumination), Group 2 (20 mg/kg Rose bengal, 10 minutes illumination), and Group 3 (40 mg/kg Rose bengal, 10 minutes illumination). The locomotor function, according to the Basso-Beattie-Bresnahan scale, was assessed at three days after the injury and then once per week for four weeks. The animals were sacrificed at 28 days after the injury, and the histopathology of the lesions was assessed.
The mice in group 1 had no hindlimb movement until seven days after the injury. Most mice had later recovery with movement in more than two joints at 28 days after injury. There was limited recovery of one joint, with only slight movement, for the mice in groups 2 and 3. The histopathology showed that the mice in group 1 had a cystic cavity involving the dorsal and partial involvement of the dorsolateral funiculi. A larger cavity, involving the dorsal, dorsolateral funiculi and the gray matter of the dorsal and ventral horns was found in group 2. In group 3, most of the spinal cord was destroyed and only a thin rim of tissue remained.
The results of this study show that the photochemical graded ischemic SCI model, described in rats, can be successfully adapted to mice, in a reliable and reproducible manner. The functional deficits are correlated an increase in the irradiation time and, therefore, to the severity of the injury. The photothrombotic model of SCI, in mice with 20 mg/kg Rose bengal for 5 minutes illumination, provides an effective model that could be used in future research. This photochemical model can be used for investigating secondary responses associated with traumatic SCI.
PMCID: PMC2796355  PMID: 20041059
Photochemical; Spinal cord Injury; Mouse
12.  Thoracic Myelopathy Caused by Ossification of the Ligamentum Flavum 
Ossification of the ligamentum flavum (OLF) is a rare cause of thoracic myelopathy. The aim of this study was to identify factors associated with the surgical outcome on the basis of preoperative clinical and radiological findings.
Data obtained in 26 patients whot underwent posterior decompression for thoracic myelopathy, caused by thoracic OLF, were analyzed retrospectively. Patient age, duration of symptoms, OLF type, preoperative and postoperative neurological status using the Japanese Orthopedic Association (JOA) scoring system, surgical outcome, and other factors were reviewed. We compared the various factors and postoperative prognosis. All patients had undergone decompressive laminectomy and excision of the OLF.
Using the JOA score, the functional improvement was excellent in 8 patients, good in 14, fair in 2, and unchanged in 2. A mean preoperative JOA score of 6.65 improved to 8.17 after an average of 27.3 months. According to our analysis, age, gender, duration of symptoms, the involved spinal level, coexisting spinal disorders, associated trauma, intramedullary signal change, and dural adhesions were not related to the surgical outcome. However, the preoperative JOA score and type of OLF were the most important predictors of the surgical outcome.
Early diagnosis and sufficient surgical decompression could improve the functional prognosis for thoracic OLF. The postoperative results were found to be significantly associated with the preoperative severity of myelopathy and type of OLF.
PMCID: PMC2764014  PMID: 19844616
Ossification of ligamentum flavum; Thoracic myelopathy; Surgical outcome
13.  Clinical Analysis of Risk Factors Related to Recurrent Chronic Subdural Hematoma 
Burr hole drainage has been widely used to treat chronic subdural hematoma (CSDH). However, the incidence of recurrent CSDH varies from 3.7 to 30% after surgery. The authors attempted to elucidate the risk factors associated with the recurrence of CSDH in one burr hole drainage technique.
A total of 255 consecutive cases who underwent one burr hole drainage for CSDH were included in this study. Twenty-four patients (9.4%) underwent a repeated operation because of the recurrence of CSDH. We analyzed retrospectively the demographic, clinical and radiologic factors associated with the recurrence of CSDH.
In this study, two risk factors were found to be independently associated with the recurrence of CSDH. The incidence of CSDH recurrence in the high- and mixed-density groups was significantly higher than those in the low- and iso-density groups (p<0.001). Bleeding tendency such as in leukemia, liver disease and chronic renal failure was also significantly associated with recurrence of CSDH (p=0.037).
These results suggest that high- and mixed- density shown on computed tomographic scan was closely relates with a high incidence of recurrence. Therefore, the operation could be delayed in those cases unless severe symptoms or signs are present. Reoperation using the previous burr hole site is a preferred modality to treat the recurrent CSDH.
PMCID: PMC2588154  PMID: 19096538
Chronic subdural hematoma (CSDH); Recurrence; Computed tomography

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