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1.  The Influence of Fat Infiltration of Back Extensor Muscles on Osteoporotic Vertebral Fractures 
Asian Spine Journal  2013;7(4):308-313.
Study Design
Retrospective study.
Purpose
To investigate the influence of fat infiltration at low back extensor muscles on osteoporotic vertebral fracture.
Overview of Literature
In persons with stronger back muscles, the risk of osteoporotic vertebral fractures will likely be lower than in those persons with weaker back muscles. However, the degree of influence of fat infiltration of the back extensor muscle on osteoporotic vertebral fracture remains controversial.
Methods
Two hundred and thirty-seven patients who had undergone lumbar spine magnetic resonance imaging and bone mineral density (BMD) were enrolled in this study. The amount of low back extensor muscle was determined using the pseudocoloring technique on an axial view of the L3 level. The patients were divided into two groups: osteoporotic vertebral fracture group (group A) and non-fracture group (group B). The amount of low back extensor muscle is compared with BMD, degenerative change of disc, osteophyte grade of facet joint and promontory angle to reveal the association between these factors.
Results
A negative correlation is found between age and the amount of low back extensor muscle (p=0.001). The amount of low back extensor muscle in group A and group B was 60.3%±14.5% and 64.2%±9.3% respectively, thus showing a significantly smaller amount of low back extensor muscle in the osteoporotic vertebral fracture group (p=0.015).
Conclusions
Fat infiltration of low back extensor muscle was increased in osteoporotic vertebral fracture patients. Therefore, fat infiltration of low back extensor muscle in an elderly person may be a risk factor of osteoporotic vertebral fracture.
doi:10.4184/asj.2013.7.4.308
PMCID: PMC3863657  PMID: 24353848
Osteoporotic vertebral fracture; Fat infiltration; Back extensor muscle; Bone mineral density
2.  Feasibility of FRAX for Prediction of Osteoporotic Vertebral Fractures in Korea 
Asian Spine Journal  2012;6(1):22-28.
Study Design
Retrospective study.
Purpose
To assess the feasibility and limitations of fracture risk assessment tool (FRAX) for osteoporotic vertebral fractures in the Korean population.
Overview of Literature
The FRAX algorithm is country specific and uses clinical risk factor data to calculate an individual patient's 10-year probability of hip fracture and 10-year probability of major osteoporotic fracture. However, it has not been adequately investigated for Korean.
Methods
One hundred ninety four patients who had all risk factor data for the calculation of FRAX were divided into two groups depending on the existence of vertebral fractures: the fracture group was comprised of 88 patients and the non-facture group comprised of 105 patients. We analyzed prediction of the fracture by applying respectively the Korean, Japanese, USA and UK model, and compared their FRAX results by calculating lumbar bone mineral density (BMD) instead of femoral neck BMD.
Results
The prediction of vertebral fracture using FRAX was 10.9 ± 6.2% in the fracture group, 9.5 ± 5.5% of the non-fracture group in the Korean model (p = 0.108); 17.9 ± 10.2% in the fracture group, 14.6 ± 9.0% in the non-fracture group in the Japanese model (p = 0.017). Only the Japanese model exhibited significant difference in vertebral fracture risk. The prediction of vertebral fracture using lumbar BMD instead of femoral neck BMD was 19.5 ± 12.1% in the fracture group, 16.0 ± 10.3% in the non-fracture group in the Korean model (p = 0.029). All models had statistically significant differences for the prediction of osteoporotic vertebral fracture.
Conclusions
The 10-year probability of osteoporotic vertebral fracture had underestimation of the risk considering treatment eligibility based on the National Osteoporosis Foundation guidelines. BMD that accurately reflects the contribution of each result to fracture risk should be preferred for the prediction of fracture using FRAX, when lumbar spine and hip BMD measurements are both performed for clinical purposes in Korean.
doi:10.4184/asj.2012.6.1.22
PMCID: PMC3302911  PMID: 22439084
Osteoporosis; Vertebral fracture; Fracture risk; Fracture risk assessment tool
3.  Relationship between New Osteoporotic Vertebral Fracture and Instrumented Lumbar Arthrodesis 
Asian Spine Journal  2010;4(2):77-81.
Study Design
Retrospective study.
Purpose
To evaluate the relationship between a new osteoporotic vertebral fracture and instrumented lumbar arthrodesis.
Overview of Literature
In contrast to the growing recognition of the importance of adjacent segment disease after lumbar arthrodesis, relatively little attention has been paid to the relationship between osteoporotic vertebral fractures and instrumented lumbar arthrodesis.
Methods
Twenty five patients with a thoracolumbar vertebral fracture following instrumented arthrodesis for degenerative lumbar disorders (study group) were investigated. The influence of instrumented lumbar arthrodesis was examined by comparing the bone mineral density (BMD) of the femoral neck in the study group with that of 28 patients (control group) who had sustained a simple osteoporotic vertebral fracture. The fracture after instrumented arthrodesis was diagnosed at a mean 47 months (range, 7 to 100 months) after the surgery.
Results
There was a relatively better BMD in the study group, 0.67 ± 0.12 g/cm2 compared to the control group, 0.60 ± 0.13 g/cm2 (p = 0.013). The level of back pain improved from a mean of 7.5 ± 1.0 at the time of the fracture to a mean of 4.9 ± 2.0 at 1 year after the fracture (p = 0.001). However, 12 (48%) patients complained of severe back pain 1 year after the fracture. There was negative correlation between the BMD of the femoral neck and back pain at the last follow up (r = - 0.455, p = 0.022).
Conclusions
Osteoporotic vertebral fractures after instrumented arthrodesis contribute to the aggravation of back pain and the final outcome of degenerative lumbar disorders. Therefore, it is important to examine the possibility of new osteoporotic vertebral fractures for new-onset back pain after lumbar instrumented arthrodesis.
doi:10.4184/asj.2010.4.2.77
PMCID: PMC2996631  PMID: 21165309
Lumbar spine; Vertebral fracture; Osteoporosis; Instrumented arthrodesis
4.  The Effectiveness of Bone Mineral Density as Supplementary Tool for Evaluation of the Osteogenic Potential in Patients with Spinal Fusion 
Asian Spine Journal  2009;3(1):1-9.
Study Design
Retrospective study.
Purpose
This study was designed to determine the effectiveness of bone mineral density measurement as a supplementary tool for evaluation of osteogenic potential in patients with spinal fusion. To this end, we correlated bone mineral density (BMD) with osteogenic potential from cultured mesenchymal stem cells (MSCs).
Overview of Literature
Many studies have correlated osteogenic potential of in vitro cultured MSCs with aging or osteoporosis.
Methods
We studied twenty-five individuals with harvested bone marrow from the ilium during lumbar spinal surgery. The BMD of the femoral neck was measured using dual energy X-ray absorptiometry prior to bone marrow aspiration, and the osteoporotic group was classified as those with T-scores below-2.5. After MSCs were isolated from bone marrow, in vitro induction of osteogenesis was performed. We analyzed the patient's osteogenic potential from cultured MSCs such as mineral deposition stain, bone alkaline phosphatase (ALP) activity and osteoblast-specific gene expression in RT-PCR.
Results
On mineral staining, the osteoporotic group had a scanty matrix mineral deposition in contrast to the non-osteoporotic group. The expression of osteocalcin in the osteoporotic group was 1.5 to 3 times less than in the non-osteoporotic group. At the 3rd week after the induction of osteogenesis, the activity of ALP of cultured MSCs in the osteoporotic group was lower than in the control group (mean, 45±19 u/L, in osteoporotic group vs 136±7 u/L in non-osteoporotic), and there was a statistically significant and positive correlation between BMD & ALP (r=0.487, p=0.013).
Conclusions
There is a positive correlation between BMD and osteogenic potential derived from MSCs. The measurement of BMD can provide supplementary data for evaluating osteogenic potential clinically.
doi:10.4184/asj.2009.3.1.1
PMCID: PMC2852037  PMID: 20404939
Bone mineral density; Osteogenic potential; Mesenchymal stem cells
5.  Pathophysiology of Degenerative Disc Disease 
Asian Spine Journal  2009;3(1):39-44.
The intervertebral disc is characterized by a tension-resisting annulus fibrosus and a compression-resisting nucleus pulposus composed largely of proteoglycan. The most important function of the annulus and nucleus is to provide mechanical stability to the disc. Degenerative disc disease in the lumbar spine is a serious health problem. Although the three joint complex model of the degenerative process is widely accepted, the etiological basis of this degeneration is poorly understood. With the recent progress in molecular biology and modern biological techniques, there has been dramatic improvement in the understanding of aging and degenerative changes of the disc. Knowledge of the pathophysiology of the disc degeneration can help in the appropriate choice of treatment and to develop tissue engineering for biological restoration of degenerated discs.
doi:10.4184/asj.2009.3.1.39
PMCID: PMC2852042  PMID: 20404946
Lumbar spine; Degenerative disc; Pathophysiology
6.  Electron Microprobe Analysis and Tissue Reaction around Titanium Alloy Spinal Implants 
Asian Spine Journal  2007;1(1):1-7.
Study Design
A retrospective study of tissue surrounding titanium alloy spinal implants was performed using histological and electron microprobe analysis.
Purpose
To identify the metal debris generated by spinal implants, and then to evaluate the electron microprobe analysis results and the histological response of soft tissue surrounding the spinal implants.
Overview of Literature
Microscopic metal particles from the soft tissue surrounding joint arthroplasty have been shown to activate a macrophage response that leads to bone resorption and increased inflammation. The effect of unintended wear particles in spinal instrumentation remains a clinical concern.
Methods
Ten patients (average age, 51.3 years), 6 men and 4 women, who had undergone previous lumbar fusions using pedicle screw instrumentation and who were now undergoing revision surgery were included in the study. The tissues obtained from the adjacent area of these implants were analyzed by light microscopy, immunohistochemistry and scanning electron microscope. After the removing the spinal implants, the changes of back pain and the spinal fusion were assessed.
Results
There were metal particles in the soft tissue in 7 cases. Histological finding observed mild chronic inflammation surrounding the deposition of the metal particles and the anti Cotrel-Dubousset 68 positive macrophages were observed at tissue adjacent to the metal particles in 5 patients. Scanning electron microscopy of the specimens showed metallic debris within the tissue and mapping of the metallic particles revealed the distribution of titanium in the tissue in 5 cases. Nine patients had successful relief of back pain after removing the spinal implants. Improvement of the back pain may be an association macrophage response rather than the metal particle.
Conclusions
The presence of metallic particles generated from spinal implants may serve as the impetus for a late-onset inflammatory response and late operative site pain.
doi:10.4184/asj.2007.1.1.1
PMCID: PMC2857498  PMID: 20411145
Posterior pedicular instrumentations; Titanium alloy; Metallic debris; Tissue reaction

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