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1.  Prevalence and Correlates of Low Back Pain in Primary Care: What Are the Contributing Factors in a Rapidly Developing Country 
Asian Spine Journal  2014;8(3):227-236.
Study Design
Cross-sectional.
Purpose
The purpose of the study was to determine the prevalence of low back pain (LBP) in the primary care setting with emphasis on the socio-demographic contributing factors and impact of LBP on lifestyle habits.
Overview of Literature
LBP is one of the most common medical conditions seen in the Primary Health Care Clinic.
Methods
A representative sample of 2,600 patients were approached and 1,829 subjects agreed to participate in this study (70.0%). Data on socio-demographic characteristics, life style habits and type of treatment were collected through a questionnaire.
Results
The prevalence of LBP in the study sample was 56.5% (95% confidence interval, 54.2-58.8). LBP was more prevalent among women (53.9%) compared to men (46.1%). There was significant difference between male and female patients of LBP in terms of ethnicity (p<0.001), marital status (p=0.010), occupation (p<0.001), monthly household income (p=0.004), and cigarette/sheesha smokers (p<0.001). The percentages of different aspects of functional disabilities were statistically significantly higher among females compared to male patients with LBP. Almost a quarter of female patients with LBP (26%) and 18% male patients with LBP reported pain in the arms and legs (p=0.002). In addition, gastrointestinal complaints such as abdominal pain and food intolerance were significantly higher among female patients with LBP as compared to males (31% vs. 24.6%, p=0.018; and 25% vs. 18%, p=0.008, respectively). Complaints about headache and fainting were also significantly higher among female patients as compared to male LBP patients (43% vs. 36%, p=0.029; and 26% vs. 20%, p=0.016, respectively). The multivariate logistic regression revealed that being female, prolonged standing, prolonged sitting, heavy weight lifting, weakness in the legs, regular exercise, and cigarette/sheesh a smoking had a significant effect on the presence of LBP.
Conclusions
LBP is highly prevalent among both genders and in older age. Also, weakness in the legs, smoking, prolonged standing and sitting had a significant effect on LBP. Furthermore, the current study findings support the fact that LBP continues to be an important clinical, social and economic, burden and a public health problem affecting the population of the entire world.
doi:10.4184/asj.2014.8.3.227
PMCID: PMC4068841  PMID: 24967035
Epidemiology; Low back pain; Roland-Morris disability; Risk factors; Life-style habits; Primary health care
2.  Accuracy of Free Hand Pedicle Screw Installation in the Thoracic and Lumbar Spine by a Young Surgeon: An Analysis of the First Consecutive 306 Screws Using Computed Tomography 
Asian Spine Journal  2014;8(3):237-243.
Study Design
A retrospective cross-sectional study.
Purpose
The purpose of this study is to evaluate the accuracy and safety of free-hand pedicle screw insertion performed by a young surgeon.
Overview of Literature
Few articles exist regarding the safety of the free-hand technique without inspection by an experienced spine surgeon.
Methods
The index surgeon has performed spinal surgery for 2 years by himself. He performed fluoroscopy-assisted pedicle screw installation for his first year. Since then, he has used the free-hand technique. We retrospectively reviewed the records of all consecutive patients undergoing pedicle screw installation using the free-hand technique without fluoroscopy in the thoracic or lumbar spine by the index surgeon. Incidence and extent of cortical breach by misplaced pedicle screw was determined by a review of postoperative computed tomography (CT) images.
Results
A total of 36 patients received 306 free-hand placed pedicle screws in the thoracic or lumbar spine. A total of 12 screws (3.9%) were identified as breaching the pedicle in 9 patients. Upper thoracic spine was the most frequent location of screw breach (10.8%). Lateral breach (2.3%) was more frequent than any other direction. Screw breach on the right side (9 patients) was more common than that on the left side (3 patients) (p<0.01).
Conclusions
An analysis by CT scan shows that young spine surgeons who have trained under the supervision of an experienced surgeon can safely place free-hand pedicle screws with an acceptable breach rate through repetitive confirmatory steps.
doi:10.4184/asj.2014.8.3.237
PMCID: PMC4068842  PMID: 24967036
Pedicle screw; Thoracic; Lumbar: Free hand; Accuracy; Safety
3.  Comparison of Unilateral versus Bilateral Kyphoplasty in Multiple Myeloma Patients and the Importance of Preoperative Planning 
Asian Spine Journal  2014;8(3):244-252.
Study Design
Retrospective comparative study and technical note.
Purpose
To determine if there is a difference in clinical and radiographic parameters between unilateral and bilateral kyphoplasty in a uniform cancer population and to stress the importance of preoperative planning.
Overview of Literature
While unipedicular kyphoplasty is gaining popularity, a few comparative studies have reported on superior kyphotic reduction with the bipedicular approach.
Methods
We reviewed 69 myeloma patients with 105 operated levels (51 levels were done bilaterally vs. 54 unilaterally). Pain reduction, height restoration, cement volume and complications were recorded up to three months postoperatively. A technical note to identify the skin entry point on the basis of the magnetic resonance imaging and fluoroscopy (lateral view) is being described.
Results
Both procedures resulted in significant pain reduction (5.4-5.6/10 points, p=0.8). There was significant height restoration after the operation (p<0.001), while there was no sustained difference between the procedures (p=0.5) up to three months postoperatively. More cement was injected in the bilateral group (4.1 mL vs. 4.9 mL, p=0.002); no difference in cement extravasation in the spinal canal was observed (p=0.5).
Conclusions
There was no difference in the clinical or radiological outcomes between the unilateral and bilateral approaches. Therefore, unilateral kyphoplasty may be performed whenever it is technically feasible and this may be determined preoperatively.
doi:10.4184/asj.2014.8.3.244
PMCID: PMC4068843  PMID: 24967037
Compression fracture; Magnetic resonance imaging; Multiple myeloma; Kyphoplasty; Unilateral
4.  Percutaneous Drainage Combined with Hyperbaric Oxygen Therapy for Pyogenic Spondylitis with Iliopsoas Abscess 
Asian Spine Journal  2014;8(3):253-259.
Study Design
A retrospective study.
Purpose
The purpose of this study was to evaluate outcomes in patients with pyogenic spondylitis accompanied by iliopsoas abscess who were treated by percutaneous drainage combined with hyperbaric oxygen (HBO) therapy.
Overview of Literature
To the best of our knowledge, there have been no previous reports of the use of percutaneous drainage combined with HBO therapy for the treatment of this condition.
Methods
Twenty-three patients (13 men, 10 women; mean age, 69.0 years; range, 45-85 years) were treated with percutaneous drainage combined with HBO therapy in addition to commonly used conservative therapy. Mean follow-up duration was 27.7 months (range, 12-48 months). Clinical outcomes and imaging examinations were retrospectively investigated.
Results
Symptoms such as low back pain, radicular pain, and hip pain resolved in all patients immediately after treatment. Mean time from the start of treatment to the return of C-reactive protein levels to normal or baseline values recorded before the onset of spondylitis was 28.3 days (range, 8-56 days). In the final set of follow-up radiographic studies, all patients were free from progressive destructive changes. Follow-up magnetic resonance images or computed tomography with contrast enhancement confirmed the disappearance or near-total resolution of the iliopsoas abscess cavity with healing of the pyogenic spondylitis in all 23 patients. No recurrences were observed during follow-up.
Conclusions
The present study suggests that patients with pyogenic spondylitis accompanied by iliopsoas abscess can be cured without a prolonged period of therapy or recurrence using this treatment.
doi:10.4184/asj.2014.8.3.253
PMCID: PMC4068844  PMID: 24967038
Psoas abscess; Spondylitis; Hyperbaric oxgen therapy; Drainage
5.  Interspinous Ligament Lidocaine and Steroid Injections for the Management of Baastrup's Disease: A Case Series 
Asian Spine Journal  2014;8(3):260-266.
Study Design
Prospective study.
Purpose
To examine the long-term effects of interspinous ligament injections of local anesthetics and steroids for the treatment of Baastrup's diseases.
Overview of Literature
Baastrup's disease is associated with axial low back pains. Baastrup's disease has been more recently described as the "kissing spinous processes" disease. Several authors have reported methods for the diagnosis and treatment of the disease. However, there has been only one report of patients receiving interspinous ligament injections of agents for the treatment of Baastrup's disease.
Methods
Seventeen patients showed severe low back pains between spinous processes at L3-L4 or L4-L5. X-ray imaging, computed tomography, and magnetic resonance imaging revealed kissing spinous processes, consolidation of spinous process, or inflammation of an interspinous ligament. Pain reliefs after lidocaine and dexamethasone administration into interspinous ligament as therapy for low back pains were being examined and followed up.
Results
Low back pain scores significantly improved immediately after injection of the agents into interspinous ligaments. At final follow-up (1.4 year), low back pain scores significantly improved as compared with before the treatment.
Conclusions
Findings from the current study indicate that lidocaine and dexamethasone administration into interspinous ligament in patients diagnosed with Baastrup's disease is effective for managing the pain associated with this disease.
doi:10.4184/asj.2014.8.3.260
PMCID: PMC4068845  PMID: 24967039
Pain; Local anesthetic; Steroid
6.  Outcomes after Surgery for Spinal Metastasis of Colorectal Origin: Case Series 
Asian Spine Journal  2014;8(3):267-272.
Study Design
Retrospective study.
Purpose
The aim of this study was to evaluate the clinical management and outcomes of patients who underwent surgical intervention for metastatic colorectal adenocarcinoma of the spine.
Overview of Literature
Gastrointestinal (GI) cancer metastasis to the spine are relatively rare and represent later manifestations of the disease. Studies and reports on the outcomes of patients who undergo surgery for spinal metastasis of GI origin are scarce.
Methods
A retrospective chart review of all patients who underwent surgery for spinal metastasis of colorectal origin was performed. Four patients were identified. Patient characteristics, outcomes, and survival were analyzed.
Results
Two patients experienced improvement in pain or myelopathic symptoms. Although the mean survival was 15.3 months, this average included a patient still living at 57.1 months. The mean survival was just 1.3 months for the 3 patients who expired.
Conclusions
In certain cases, symptomatic improvement with prolonged survival is possible after surgery for metastatic spinal lesions of colorectal origin; however, survival is poor in the majority of cases.
doi:10.4184/asj.2014.8.3.267
PMCID: PMC4068846  PMID: 24967040
Cancer; Colorectal; Gastrointestinal; Metastasis; Spine; Surgery
7.  Cervical Pedicle Screw Fixation: Anatomic Feasibility of Pedicle Morphology and Radiologic Evaluation of the Anatomical Measurements 
Asian Spine Journal  2014;8(3):273-280.
Study Design
All parameters were measured manually and with a computed tomography (CT) scanner. For the manual measurements, a Vernier scale instrument was used.
Purpose
This study evaluates quantitatively pedicles of middle and lower cervical spine (C3 to C7) and to evaluate the possibilities of using these structures as anchors in posterior cervical fusion.
Overview of Literature
Pedicle screws may be an alternative fixation technique for posterior cervical instrumentation.
Methods
Twenty-two bony sets of adult cervical spines were studied (110 vertebrae, 220 pedicles) from C3 down to C7.
Results
CT measurement of cervical pedicles appeared to be accurate and valuable for preoperative planning of cervical pedicle screw instrumentation. The study showed a high correlation between the values obtained by manual and CT measurements of pedicle dimensions. The technical challenge of insertion is the obvious theoretical drawback of the use of cervical pedicle screws. Many technical factors are important to consider, namely, the point of screw entry, the pedicle dimensions, the screw direction according to the pedicle angle and orientation, the screw diameter and length, and the method of screw introduction.
Conclusions
Transpedicular screw fixation of the cervical spine appears to be promising. Anatomic limitations should be clear to the surgeon. Further clinical and biomechanical studies are needed to settle this technique.
doi:10.4184/asj.2014.8.3.273
PMCID: PMC4068847  PMID: 24967041
Spine; Morphology; Screw; Pedicle
8.  Lumbar Transpedicular Implant Failure: A Clinical and Surgical Challenge and Its Radiological Assessment 
Asian Spine Journal  2014;8(3):281-297.
Study Design
It is a multicenter, controlled case study review of a big scale of pedicle-screw procedures from January 2000 to June 2010. The outcomes were compared to those with no implant failure.
Purpose
The purpose of this study was to review retrospectively the outcome of 100 patients with implant failure in comparison to 100 control-patients, and to study the causes of failure and its prevention.
Overview of Literature
Transpedicular fixation is associated with risks of hardware failure, such as screw/rod breakage and/or loosening at the screw-rod interface and difficulties in the system assembly, which remain a significant clinical problem. Removal or revision of the spinal hardware is often required.
Methods
Two hundred patients (88 women, 112 men) were divided into 2 major groups, with 100 patients in group I (implant failure group G1) and 100 patients in group II (successful fusion, control group G2). We subdivided the study groups into two subgroups: subgroup a (single-level instrumented group) and subgroup b (multilevel instrumented group). The implant status was assessed based on intraoperative and follow-up radiographs.
Results
Implant failure in general was present in 36% in G1a, and in 64% in G1b, and types of implant failure included screw fracture (34%), rod fracture (24%), rod loosening (22%), screw loosening (16%), and failure of both rod and screw (4%). Most of the failures (90%) occurred within 6 months after surgery, with no reported cases 1 year postoperatively.
Conclusions
We tried to address the problem and study the causes of failure, and proposed solutions for its prevention.
doi:10.4184/asj.2014.8.3.281
PMCID: PMC4068848  PMID: 24967042
Lumbar, fixation; Screw, failure; Fusion; Fracture fixations, prosthesis; Loosening
9.  Outcome of Pedicle Screw Fixation and Monosegmental Fusion in Patients with Fresh Thoracolumbar Fractures 
Asian Spine Journal  2014;8(3):298-308.
Study Design
Prospective clinical study.
Purpose
The present prospective study aims to evaluate the clinical, radiological, and functional and quality of life outcomes in patients with fresh thoracolumbar fractures managed by posterior instrumentation of the spine, using pedicle screw fixation and monosegmental fusion.
Overview of Literature
The goals of treatment in thoracolumbar fractures are restoring vertebral column stability and obtaining spinal canal decompression, leading to early mobilization of the patient.
Methods
Sixty-six patients (46 males and 20 females) of thoracolumbar fractures with neurological deficit were stabilized with pedicle screw fixation and monosegmental fusion. Clinical, radiological and functional outcomes were evaluated.
Results
The mean preoperative values of Sagittal index, and compression percentage of the height of the fractured vertebra were 22.75° and 46.73, respectively, improved (statistically significant) to 12.39°, and 24.91, postoperatively. The loss of correction of these values at one year follow-up was not statistically significant. The mean preoperative canal compromise (%) improved from 65.22±17.61 to 10.06±5.31 at one year follow-up. There was a mean improvement in the grade of 1.03 in neurological status from the preoperative to final follow-up at one year. Average Denis work scale index was 4.1. Average Denis pain scale index was 2.5. Average WHOQOL-BREF showed reduced quality of life in these patients. Patients of early surgery group (operated within 7 days of injury) had a greater mean improvement of neurological grade, radiological and functional outcomes than those in the late surgery group, but it was not statistically significant.
Conclusions
Posterior surgical instrumentation using pedicle screws with posterolateral fusion is safe, reliable and effective method in the management of fresh thoracolumbar fractures. Fusion helps to decrease the postoperative correction loss of radiological parameters. There is no correlation between radiographic corrections achieved for deformities and functional outcome and quality of life post spinal cord injury.
doi:10.4184/asj.2014.8.3.298
PMCID: PMC4068849  PMID: 24967043
Thoracolumbar; Fractures; Pedicle screws; Neurological involvement; Functional outcome; Radiological outcome
10.  Paraspinal Transposition Flap for Reconstruction of Sacral Soft Tissue Defects: A Series of 53 Cases from a Single Institute 
Asian Spine Journal  2014;8(3):309-314.
Study Design
Case series.
Purpose
To describe paraspinal transposition flap for coverage of sacral soft tissue defects.
Overview of Literature
Soft tissue defects in the sacral region pose a major challenge to the reconstructive surgeon. Goals of sacral wound reconstruction are to provide a durable skin and soft tissue cover adequate for even large sacral defects; minimize recurrence; and minimize donor site morbidity. Various musculocutaneous and fasciocutanous flaps have been described in the literature.
Methods
The flap was applied in 53 patients with sacral soft tissue defects of diverse etiology. Defects ranged in size from small (6 cm×5 cm) to extensive (21 cm×10 cm). The median age of the patients was 58 years (range, 16-78 years).
Results
There was no flap necrosis. Primary closure of donor sites was possible in all the cases. The median follow up of the patients was 33 months (range, 4-84 months). The aesthetic outcomes were acceptable. There has been no recurrence of pressure sores.
Conclusions
The authors conclude that paraspinal transposition flap is suitable for reconstruction of large sacral soft tissue defects with minimum morbidity and excellent long term results.
doi:10.4184/asj.2014.8.3.309
PMCID: PMC4068850  PMID: 24967044
Transposition flap; Pressure ulcer; Sacral defect
11.  Non-Surgical Management of Cord Compression in Tuberculosis: A Series of Surprises 
Asian Spine Journal  2014;8(3):315-321.
Study Design
Prospective study.
Purpose
We present a series of 50 patients with tuberculous cord compression who were offered systematic non-surgical treatment, and thereby, the author proposes that clinico-radiological soft tissue cord compression is not an emergency indication for surgery.
Overview of Literature
Spinal cord compression whether clinical or radiological has usually been believed to be an indication for emergency surgery in spinal tuberculosis.
Methods
Fifty adults were prospectively studied at our clinic for spinal cord compression due to tuberculous spondylitis, between May 1993 and July 2002. The inclusion criteria were cases with clinical and/or radiological evidence of cord compression (documented soft tissue effacement of the cord with complete obliteration of the thecal sac at that level on magnetic resonance imaging scan). Exclusion criteria were lesions below the conus level, presence of bony compression, severe or progressive neurological deficit (
Results
At the time of presentation, 10 patients had a motor deficit, 18 had clinically detectable hyper-reflexia and 22 had normal neurology. Forty-seven of the 50 patients responded completely to non-operative treatment and healed with no residual neurological deficit. Three patients with progressive neurological deficit while on treatment were operated on with eventual excellent recovery.
Conclusions
Radiological evidence of cord compression and early neurological signs need not be an emergency surgical indication in the management of spinal tuberculosis.
doi:10.4184/asj.2014.8.3.315
PMCID: PMC4068851  PMID: 24967045
Non-surgical management; Spinal tuberculosis; Spinal cord compression
Asian Spine Journal  2014;8(3):322-330.
Study Design
A retrospective study.
Purpose
To clarify the differences among the three major surgeries for osteoporotic vertebral fractures based on the clinical and radiological results.
Overview of Literature
Minimally invasive surgery like balloon kyphoplasty has been used to treat osteoporotic vertebral fractures, but major surgery is necessary for severely impaired patients. However, there are controversies on the surgical procedures.
Methods
The clinical and radiographic results of patients who underwent major surgery for osteoporotic vertebral fracture were retrospectively compared, among anterior spinal fusion (group A, 9 patients), single-stage combined anterior-posterior procedure (group AP, 8 patients) and posterior closing wedge osteotomy (group P, 9 patients). Patients who underwent revision surgery were evaluated just before the revision surgery, and the other patients were evaluated at the final follow-up examination, which was defined as the end point of the evaluations for the comparison.
Results
The operation time was significantly longer in group AP than in the other two groups. The postoperative correction of kyphosis was significantly greater in group P than in group A. Although the differences were not significant, better outcomes were obtained in group P in: back pain relief at the end point; ambulatory ability at the end point; and average loss of correction.
Conclusions
The posterior closing wedge osteotomy demonstrated better surgical results than the anterior spinal fusion procedure and the single-stage combined anterior-posterior procedure.
doi:10.4184/asj.2014.8.3.322
PMCID: PMC4068852  PMID: 24967046
Osteoporosis; Vertebral body fracture; Posterior closing wedge osteotomy; Single-stage combined anterior-posterior procedure; Anterior spinal fusion
Asian Spine Journal  2014;8(3):331-338.
Study Design
Retrospective study.
Purpose
We compared the accuracy of O-arm-based navigation with computed tomography (CT)-based navigation in scoliotic surgery.
Overview of Literature
No previous reports comparing the results of O-arm-based navigation with conventional CT-based navigation in scoliotic surgery have been published.
Methods
A total of 222 pedicle screws were implanted in 29 patients using CT-based navigation (group C) and 416 screws were implanted in 32 patients using O-arm-based navigation (group O). Postoperative CT was performed to assess the screw accuracy, using the established Neo classification (grade 0: no perforation, grade 1: perforation <2 mm, grade 2: perforation ≥2 and <4, and grade 3: perforation ≥4 mm).
Results
In group C, 188 (84.7%) of the 222 pedicle screw placements were categorized as grade 0, 23 (10.4%) were grade 1, 11 (5.0%) were grade 2, and 0 were grade 3. In group O, 351 (84.4%) of the 416 pedicle screw placements were categorized as grade 0, 52 (12.5%) were grade 1, 13 (3.1%) were grade 2, and 0 were grade 3. Statistical analysis showed no significant difference in the prevalence of grade 2.3 perforations between groups C and O. The time to position one screw, including registration, was 10.9±3.2 minutes in group C, but was significantly decreased to 5.4±1.1 minutes in group O.
Conclusions
O-arm-based navigation facilitates pedicle screw insertion as accurately as conventional CT-based navigation. The use of O-arm-based navigation successfully reduced the time, demonstrating advantages in the safety and accuracy of pedicle screw placement for scoliotic surgery.
doi:10.4184/asj.2014.8.3.331
PMCID: PMC4068853  PMID: 24967047
Scoliosis; Computer-assisted surgery; Image-guided surgery; Spine
Asian Spine Journal  2014;8(3):339-345.
Study Design
A retrospective study.
Purpose
The aim of present study was to investigate imaging findings suggestive of cauda equina entrapment in thoracolumbar and lumbar burst fractures.
Overview of Literature
Burst fractures with cauda equina entrapment can cause neurologic deterioration during surgery. However, dural tears and cauda equina entrapment are very difficult to diagnose clinically or radiographically before surgery.
Methods
Twenty-three patients who underwent spinal surgery for thoracolumbar or lumbar burst fractures were enrolled in this study. In magnetic resonance imaging T2-weighted images of the transverse plane, we defined cauda equina notch sign (CENS) as a v-shaped image that entrapped cauda equina gathers between lamina fractures. We evaluated the fractured spine by using CENS and lamina fractures and the rate of available space for the spinal canal at the narrowest portion of the burst fracture level. We classified patients into entrapment group or non-entrapment group, based on whether cauda equina entrapment existed.
Results
Lamina fractures were detected in 18 (78.3%) and CENS were detected in 6 (26.1%) of 23 burst-fracture patients. Cauda equina entrapment existed in all the patients with CENS. In addition, the rate of available space for the spinal canal increased according to logistic regression. The size of the retropulsed fragment in the spinal canal was the most reliable of all the factors, suggesting cauda equina entrapment.
Conclusions
CENS was the most predictable sign of cauda equina entrapment associated with burst fractures.
doi:10.4184/asj.2014.8.3.339
PMCID: PMC4068854  PMID: 24967048
Burst fracture; Dural tear; Cauda equina entrapment; Lamina fracture; Magnetic resonance imaging
Asian Spine Journal  2014;8(3):346-352.
Study Design
A cross-sectional study.
Purpose
To explore the impact of chronic low back pain (CLBP) on individuals' quality of life; to understand current treatment practices and level of satisfaction with treatment in patients with CLBP.
Overview of Literature
Assessing subjective, patient-reported outcomes such as quality of life is essential to health care research.
Methods
Influences of the CLBP were analyzed via a questionnaire, which contained the character of CLBP, effect of pain management, Korean version Oswestry Disability Index (K-ODI) and Korean version of 12-item Short Form Health Survey (SF-12v2).
Results
Of 3,121 subjects who responded, 67.3% had moderate to severe pain; 43.5% presented prolonged CLBP of more than two years; and 32.4% had suffered from sleep disturbance due to pain. 22.8% of the patients were not satisfied with current pain management. The mean K-ODI score was 37.63; and it was positively correlated with the mean pain intensity (r=0.6, p<0.001). The SF-12v2 result was negatively correlated with mean pain intensity (PCS: r=-0.5, p<0.001; MCS: r=-0.4, p<0.001) and also negatively correlated with the K-ODI score (PCS: r=-0.75, p<0.001; MCS: r=-0.5, p<0.001). The conformity between patients and doctors in pain assessment was fair (κ=0.2463).
Conclusions
CLBP negatively affects quality of life. Of total 22.8% of the patients were not satisfied with current pain management. Such needs to be taken more seriously by doctors for improvement of satisfaction and quality of life in patients with CLBP.
doi:10.4184/asj.2014.8.3.346
PMCID: PMC4068855  PMID: 24967049
Chronic low back pain; Assessment; Quality of life
Asian Spine Journal  2014;8(2):113-118.
Study Design
Prospective in vivo toxicity study.
Purpose
To evaluate the conducted acute toxicity study of Escherichia coli (E. coli)-derived recombinant human bone morphogenetic protein-2 (rhBMP-2) with 6-weeks old Sprague-Dawley rats.
Overview of Literature
rhBMP-2 has well-known osteoinductivity and it is used as a bone graft substitute. E. coli-derived rhBMP-2 can be mass-produced with relatively low costs. E. coli-derived rhBMP-2 facilitates osteoblastic differentiation and bone formation in vitro and in vivo. However, studies regarding side effects or toxicity of E. coli-derived rhBMP-2 have not been published. Thus, we conducted the acute toxicity study of E. coli-derived rhBMP-2 on 6-weeks old Sprague-Dawley rats.
Methods
One mg of BMP-2 was diluted in 0.285 mL of glycine buffer to prepare high BMP-2 concentrations (3.5 mg/mL). Intermediate (0.9 mg/mL) or low (0.35 mg/mL) concentrations of BMP-2 solution was prepared by serial dilutions. The compound was administrated at a dose of 0, 0.7, 1.8, 7 mg/kg by single intravenous injection to five of male and female rats. After the injection, the gross general observations including changes of body weight and histopathological analysis was performed for 14 days.
Results
No animal was found dead during the experiment and the body weight changes were both statistically insignificant in the control and experimental groups. No abnormal sign was shown in general observations and autopsy examinations.
Conclusions
Thus, the lethal dose of E. coli-derived rhBMP-2 should be higher than 7 mg/kg with a single intravenous injection.
doi:10.4184/asj.2014.8.2.113
PMCID: PMC3996333  PMID: 24761191
Recombinant human-bone morphogenetic protein-2; Acute toxicity test; Mortality; Intravenous injection
Asian Spine Journal  2014;8(2):119-128.
Study Design
A prospective cohort.
Purpose
To report the short and long term outcomes of fluoroscopically guided lumbar transforaminal epidural steroid injection (TFESI) in degenerative lumbar spondylolisthesis (DLS) patients.
Overview of Literature
TFESI has been widely used for the treatment of lumbosacral radicular pains. However, to our knowledge, there has been no study which has evaluated the outcomes of TFESI in patients with DLS.
Methods
The DLS patients received fluoroscopically guided lumbar TFESI with 80 mg of methylprednisolone and 2 mL of 1% lidocaine hydrochloride. Patients were evaluated by an independent observer before the initial injection, at 2 weeks, at 6 weeks, at 3 months, and at 12 months after the injections. Visual analog scale (VAS), Roland 5-point pain scale, standing tolerance, walking tolerance, and patient satisfaction scale were evaluated for outcomes.
Results
Thirty three DLS patients treated with TFESI, who were completely followed up, were included in this study. The average number of injections per patient was 1.9 (range from 1 to 3 injections per patient). Significant improvements in VAS and Roland 5-point pain scale were observed over the follow up period from 2 weeks to 12 months. However, the standing and walking tolerance were not significantly improved after 2 weeks. At 2 weeks, the patient satisfaction scale was highest, although, these outcomes declined with time. The DLS patients with one level of spinal stenosis showed significantly better outcome than the DLS patients with two levels of spinal stenosis. Five patients (13%) underwent surgical treatment during the 3 to 12 months follow up.
Conclusions
TFESI provides short term improvements in VAS and Roland 5-point pain scale, standing tolerance, walking tolerance and patient satisfaction scale in DLS patients. In the long term, it improves VAS but limits the improvements in Roland 5-point pain scale, standing tolerance, walking tolerance and patient satisfaction scale.
doi:10.4184/asj.2014.8.2.119
PMCID: PMC3996334  PMID: 24761192
Degenerative lumbar; Spondylolisthesis; Epidural injection; Steroid; Outcome
Asian Spine Journal  2014;8(2):129-137.
Study Design
A case controlled study with prospective data collection.
Purpose
To evaluate the early influence and the final consequence of demineralized bone matrix (DBM) on auto-local bone as a graft enhancer in posterior lumbar interbody fusion (PLIF).
Overview of Literature
DBM is known as an osteoinductive material; however, it has not been clearly recognized to enhance auto-local bone with a small amount.
Methods
Patients who had a PLIF were allocated into two groups. Group I (70 cases) used auto-local bone chips and group II (44 cases) used DBM as an additive to auto-local bone, 1 mL per a segment. Group selection was alternated. Early assessment was performed by computed tomography at 6 months and final assessment was done by simple radiography after 24 months at least. The degree of bone formation was assessed by 4 grade scale.
Results
The subjects of both groups were homogenous and had similar Oswestry Disability Index at final assessment. The ratio of auto-local bone chips and DBM was 6:1. The degree of bone formation at 6 months after surgery was superior in group II. However, there was no significant difference between the two groups at the final assessment.
Conclusions
DBM was not recognized to enhance auto-local bone with small amount.
doi:10.4184/asj.2014.8.2.129
PMCID: PMC3996335  PMID: 24761193
Demineralized bone matrix; Graft enhancer; Posterior lumbar interbody fusion
Asian Spine Journal  2014;8(2):138-144.
Study Design
Retrospective study.
Purpose
The main purpose of this study was to investigate the union-rate of the spinous process after performing a spinous process osteotomy and whether union affects the clinical results after surgery.
Overview of Literature
In the present study, spinous process osteotomy was used to facilitate access to the spinal canal when performing a decompressive procedure for lumbar spinal stenosis. The aim of this study was to evaluate the union rate of the spinous process and its effect on the clinical results of the procedure.
Methods
All patients were included in the study that underwent a decompressive procedure through spinous process osteotomy be between January 1, 2007 and December 31, 2007. Operation protocols were reviewed. A computed tomography (CT) scan was performed to evaluate the union of the osteotomies of the spinous process. According to the CT-scans, patients were divided into three groups: "complete-union," "partial-union," and "non-union." Patients reported their clinical results through a self-administered questionnaire.
Results
The mean period of follow up was 21.6 months (range, 16-28 months). A total of 44% of the performed osteotomies were considered as united. Ten patients (18%) were classified as "complete-union," 30 patients (55%) as "partial-union," and 15 patients (27%) as "non-union." The "complete-union" group showed better clinical results and scored significantly better in the Oswestry Disability Index and EQ-5D. However, no statistical difference was found in the pain-scores. There were no differences between the "partial-union" group and the "no-union" group.
Conclusions
We found a radiologic union for 60 out of 135 (44%) spinous process osteotomies.
doi:10.4184/asj.2014.8.2.138
PMCID: PMC3996336  PMID: 24761194
Spinal stenosis; Osteotomy
Asian Spine Journal  2014;8(2):145-149.
Study Design
A retrospective study.
Purpose
To examine the effectiveness of using an electrodiagnostic technique as a new approach in the clinical diagnosis of extraforaminal stenosis at L5-S1.
Overview of Literature
We introduced a new effective approach to the diagnosis of extraforaminal stenosis at the lumbosacral junction using the existing electrophysiological evaluation technique.
Methods
A consecutive series of 124 patients with fifth lumbar radiculopathy were enrolled, comprising a group of 74 patients with spinal canal stenosis and a second group of 50 patients with extraforaminal stenosis at L5-S1. The technique involved inserting a pair of needle electrodes into the foraminal exit zone of the fifth lumbar spinal nerves, which were used to provide electrical stimulation. The compound muscle action potentials from each of the tibialis anterior muscles were recorded.
Results
The distal motor latency (DML) of the potentials ranged from 11.2 to 24.6 milliseconds in patients with extraforaminal stenosis. In contrast, the DML in patients with spinal canal stenosis ranged from 10.0 to 17.2 milliseconds. After comparing the DML of each of the 2 groups and at the same time comparing the differences in DML between the affected and unaffected side of each patient, we concluded there were statistically significant differences (p<0.01) between the 2 groups. Using receiver operating characteristic curve analysis, the cutoff values were calculated to be 15.2 milliseconds and 1.1 milliseconds, respectively.
Conclusions
This approach using a means of DML measurement enables us to identify and localize lesions, which offers an advantage in diagnosing extraforaminal stenosis at L5-S1.
doi:10.4184/asj.2014.8.2.145
PMCID: PMC3996337  PMID: 24761195
Diagnosis; Evoked potencials; Spinal stenosis; Diagnostic techniques and procedures; Far-out syndrome
Asian Spine Journal  2014;8(2):150-155.
Study Design
Descriptive, cases series study.
Purpose
To evaluate clinical findings and results of treatment of patients with spinal osteoid osteoma who underwent surgery.
Overview of Literature
Osteoid osteoma is a benign tumor with spinal involvement rate of about 10%. It is manifested during adolescence with symptoms such as painful scoliosis. To treat the problem, operation on the patients and excising the nidus are suggested.
Methods
This descriptive study was conducted on 11 patients with spinal osteoid osteoma at our orthopedic educational center. All patients were treated through open surgery and nidus curettage. All samples were pathologically confirmed. Imaging methods (spiral computed tomography-scan) was used in preoperative planning. Scoliosis and other clinical findings were studied.
Results
The study was conducted on 11 patients comprising 6 females (54.5%) and 5 males (45.5%) with the mean age of 14.6 years. Mean deviation of scoliosis resulting from spinal osteoid osteoma was 22.8 degrees. There was more scoliosis in the involvement of the lumbar vertebra. In comparison with adults, scoliosis was more severe in youths. There was one case of vertebra body involvement with manifestation of painful scoliosis. Due to lack of careful preoperative examination, the surgery was repeated for this case. No sign of recurrence was observed in patients who underwent open surgery and all scoliosis in the follow-up had improved.
Conclusions
Based on our findings, surgical excision of spinal ostoeid osteoma was successful and complete recovery was achieved in spinal deformity in the course of follow-up. Scoliosis is often seen during adolescence and lumbar involvement is more severe.
doi:10.4184/asj.2014.8.2.150
PMCID: PMC3996338  PMID: 24761196
Osteoid osteoma; Review; Spinal deformity; Scoliosis
Asian Spine Journal  2014;8(2):156-160.
Study Design
A retrospective study.
Purpose
To evaluate the efficacy and the safety of craniocervical and upper cervical stabilization by using C2 pars/pedicle screw fixations.
Overview of Literature
The management of craniocervical and upper cervical instability has progressed over the past two decades due to good achievements in the instrumentation and the increased awareness on spinal anatomy and biomechanics. However, there is insufficient studies or solid conclusions on this topic, thus, we tried to investigate and present our findings.
Methods
Twenty-two patients were operated upon and were followed up from March 2008 to October 2010. One patient had craniocervical instability (post-surgical), 15 patients had atlantoaxial instability of different etiologies (trauma, tumors, inflammatory and degenerative) and 6 patients had hangman fractures. Patients' ages ranged from 18 to 52 years old. with 5 female patients and 17 male patients.
Results
Radiological follow ups performed immediately post-operation showed good screw positioning and complete reductions in nearly all the cases. All patients were followed up for more than one year. Sound fusions were observed among all patients.
Conclusions
The use of pars/pedicle screws is a very effective, sound, safe and easy surgical modality for treating craniocervical, atlantoaxial and upper cervical instabilities. Increasing studies for the biomechanics of this important region and longer periods of follow-ups are necessary to document the usefulness of this modality when treating such patients.
doi:10.4184/asj.2014.8.2.156
PMCID: PMC3996339  PMID: 24761197
Craniocervical; Cervical spine; C2 pars screws; C2 pedicle
Asian Spine Journal  2014;8(2):161-169.
Study Design
Prospective cohort study.
Purpose
To assess whether additional implantation of Coflex following spinal decompression provided better clinical outcomes compared to decompression alone for symptomatic lumbar spinal stenosis (LSS) and to determine whether improvement in clinical outcomes correlated with changes in the radiological indices studied.
Overview of Literature
Literature on benefits of additional Coflex implantation compared to decompression alone for symptomatic LSS is limited.
Methods
Patients with symptomatic LSS who met the study criteria were offered spinal decompression with Coflex implantation. Those patients who accepted Coflex implantation were placed in the Coflex group (n=22); while those opting for decompression alone, were placed in the comparison group (n=24). Clinical outcomes were assessed preoperatively, six-months, one-year and two-years postoperatively, using the Oswestry disability index, 100 mm visual analogue scale (VAS)-back pain and VAS-leg pain, and short form-36 (SF-36). Radiological indices (disc height, foraminal height and sagittal angle) were assessed preoperatively, six months, one year, and two years postoperatively.
Results
Both groups showed statistically significant (p<0.001) improvement in all the clinical outcome indicators at all points in time as compared to the preoperative status. However, improvement in the Coflex group was significantly greater (p<0.001) than the comparison group. Changes in the radiological indices did not correlate significantly with the improvement in clinical outcome indicators.
Conclusions
Additional Coflex implantation after spinal decompression in symptomatic LSS offers better clinical outcomes than decompression alone in the short-term. Changes in radiological indices do not correlate with the improvements in clinical outcomes after surgery for symptomatic LSS.
doi:10.4184/asj.2014.8.2.161
PMCID: PMC3996340  PMID: 24761198
Spinal stenosis; Decompression; Interspinous process device; Coflex
Asian Spine Journal  2014;8(2):170-176.
Study Design
A retrospective study.
Purpose
To investigate clinical and radiological outcomes when using spinous process as a tricortical autograft for segmental spinal fusion in transforaminal lumbar interbody fusion (TLIF).
Overview of Literature
Interbody spinal fusion is one of the important procedures in spinal surgery. Many types of autografts are harvested at the expense of complications. Clinical and radiographic results of patients who underwent TLIF with intraoperative harvested spinous process autograft in Prasat Neurological Institue, Bangkok, Thailand, were assessed as new technical innovation.
Methods
Between October 2005 to July 2009, 30 cases of patients who underwent TLIF with spinous process tricortical autograft were included. Clinical evaluations were assessed by visual analog scales (VAS) and Prolo functional and economic scores at the preoperation and postoperation and at 2 years postoperation. Static and dynamic plain radiograph of lumbar spine were reviewed for achievement of fusion.
Results
Initial successful fusion time in lumbar interbody fusion with spinous process tricortical autograft was 4.72 months (range, 3.8-6.1 months) postoperation and 100% fusion rate was reported at 2 years. Our initial successful fusion time in lumbar interbody fusion was compared to the other types of grafts in previous literatures.
Conclusions
The use of intraoperative harvested spinous process tricortical autograft has overcome many disadvantages of harvesting autograft with better initial successful fusion time (4.72 months). VAS and Prolo scores showed some improvement in the outcomes between the preoperative and postoperative periods.
doi:10.4184/asj.2014.8.2.170
PMCID: PMC3996341  PMID: 24761199
Transpedicular screw fixation; Transforaminal lumbar interbody fusion; Spinous process autograft; Tricortical autograft
Asian Spine Journal  2014;8(2):177-182.
Study Design
Retrospective review of patients who had pyogenic discitis and were managed surgically.
Purpose
To analyze the bacteriology, pathology, management and outcome of pyogenic discitis of the lumbar region treated surgically.
Overview of Literature
Surgical management of pyogenic discitis is still an infrequently used modality of treatment.
Methods
A total of 42 patients comprised of 33 males and 9 females who had pyogenic discitis with a mean age of 51.61 years (range, 16-75 years) were included in this study. All the cases were confirmed as having pyogenic discitis by pus culture report and histopathological examination. The mean follow-up period was 41.9 months.
Results
Debridement and posterior lumbar interbody fusion with autologous iliac bone graft was done in all cases. Thirteen (30.95%) patients had other medical co-morbidities. Five cases had a previous operation of the spine, and three cases had a history of vertebral fracture. Three patients were operated for gynaecological problems, and four cases had a history of urological surgery. L4-5 level was the most frequent site of pyogenic discitis. The most common bacterium isolated was Staphylococcus aureus (S. aureus). Radiologically good fusion was seen in the majority of patients.
Conclusions
Pyogenic discitis should be suspected in people having pain and local tenderness in the spinal region with a rise in inflammatory parameters in blood. The most common bacterium was S. aureus, but there were still a greater number of patients infected with other types of bacteria. Therefore, antibiotics therapy should be started only after isolating the bacteria and making the culture sensitivity report.
doi:10.4184/asj.2014.8.2.177
PMCID: PMC3996342  PMID: 24761200
Pyogenic; Infection; Discitis; Antibiotics

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