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2.  Osteoblastoma of C2 Corpus: 4 Years Follow-up 
Asian Spine Journal  2012;6(2):136-139.
Osteoblastomas are rare neoplasms of the spine. The majority of the spinal lesions arise from the posterior elements and involvement of the corpus is usually by extension through the pedicles. An extremely rare case of isolated C2 corpus osteoblastoma is presented herein. A 9-year-old boy who presented with neck pain and spasmodic torticollis was shown to have a lesion within the corpus of C2. He underwent surgery via an anterior cervical approach and the completely-resected mass was reported to be an osteoblastoma. The pain resolved immediately after surgery and he had radiologic assessments on a yearly basis. He was symptom-free 4 years post-operatively with benign radiologic findings. Although rare, an osteoblastoma should be considered in the differential diagnosis of neck pain and torticollis, especially in patients during the first two decades of life. The standard treatment for osteoblastomas is radical surgical excision because the recurrence rate is high following incomplete resection.
PMCID: PMC3372549  PMID: 22708018
Osteoblastoma; Osteoid osteoma; C2 corpus; Anterior cervical approach
3.  Focal Ligamentum Flavum Hypertrophy with Ochronotic Deposits: An Unusual Cause for Neurogenic Claudication in Alkaptonuria 
Asian Spine Journal  2012;6(2):148-151.
Neurogenic claudication resulting from focal hypertrophy of the ligamentum flavum in the lumbar spine due to ochronotic deposits has not been reported till date. The authors discuss one such case highlighting the pathogenesis, histological and radiological features. Salient features of management are also emphasized upon.
PMCID: PMC3372552  PMID: 22708021
Spinal stenosis; Ligamentum flavum; Alkaptonuria
4.  Motion Induced Artifact Mimicking Cervical Dens Fracture on the CT Scan: A Case Report 
Asian Spine Journal  2012;6(3):216-218.
The diagnostic performance of helical computed tomography (CT) is excellent. However, some artifacts have been reported, such as motion, beam hardening and scatter artifacts. We herein report a case of motion-induced artifact mimicking cervical dens fracture. A 60-year-old man was involved in a motorcycle accident that resulted in cervical spinal cord injury and quadri plegia. Reconstructed CT images of the cervical spine showed a dens fracture. We assessed axial CT in detail, and motion artifact was detected.
PMCID: PMC3429615  PMID: 22977704
Reconstruction; Motion artifact; Mimicking; Cervical fracture
5.  Spontaneous Reduction Finding: Magnetic Resonance Imaging Evaluation of Segmental Instability in Spondylolisthesis 
Asian Spine Journal  2012;6(4):221-226.
Study Design
Retrospective chart review.
To assess whether spontaneous reduction of spondylolisthesis, as seen on magnetic resonance imaging (MRI), is related to the degree of segmental instability and low back pain.
Overview of Literature
The flexion-extension radiographs obtained in the sagittal plane are frequently used when segmental instability of spondylolisthesis is evaluated.
We retrospectively reviewed 137 patients and measured the differences of the percentage of sagittal translation and sagittal angulation to determine the segmental instability between the flexion and extension radiographs, and the spontaneous reduction on MRI. We then compared the degrees of segmental instability and the degrees of spontaneous reduction. To assess the effect of low back pain on segmental motion in regards to the flexion-extension radiographs, we compared the preoperative visual analogue scales (VAS) score for low back pain between the more and the less spontaneous reduction groups.
The mean degree of spontaneous reduction was 5.2%. A statistically significant correlation was found between the sagittal translation on the flexion-extension radiographs and the degree of spontaneous reduction (r = 0.557, p < 0.001) and between the sagittal angulation on the flexion-extension radiographs and the degree of spontaneous reduction (r = 0.215, p = 0.012). The preoperative VAS scores for low back pain of the more spontaneous reduction group and the less spontaneous reduction group were 4.6 and 3.6 points, respectively, and this difference was statistically significant (p = 0.002).
Spontaneous reduction of spondylolisthesis on MRI was found to be closely related to segmental instability, and the degree of spontaneous reduction seen on MRI could be useful for the evaluation of segmental instability in patients with spondylolisthesis, especially with severe low back pain.
PMCID: PMC3530695  PMID: 23275804
Spondylolisthesis; Segmental instability; Spontaneous reduction; Magnetic resonance imaging
6.  The Efficacy and Persistence of Selective Nerve Root Block under Fluoroscopic Guidance for Cervical Radiculopathy 
Asian Spine Journal  2012;6(4):227-232.
Study Design
Retrospective study.
To investigate the outcomes of fluoroscopically guided selective nerve root block as a nonsurgical treatment for cervical radiculopathy.
Overview of Literature
Only a few studies have addressed the efficacy and persistence of cervical nerve root block.
This retrospective study was conducted on 28 consecutive patients with radicular pain due to cervical disc disease or cervical spondylosis. Myelopathy was excluded. Cervical nerve root blocks were administered every 2 weeks, up to 3 times. Outcomes were measured by comparing visual analogue scale (VAS) scores, patient satisfaction, and medication usage before the procedure and at 1 week and 3, 6, and 12 months after the procedure. In addition, complications associated with the procedure and need for other treatments were evaluated.
The average preoperative VAS score was 7.8 (range, 5 to 10), and this changed to 2.9 (range, 1 to 7) at 3 months and 4.6 (range, 2 to 7) at 12 months. Patient satisfaction was 71% at 3 months and 50% at 12 months. Five patients used medication at 3 months, whereas 13 used medication at 12 months. Average symptom free duration after the procedure was 7.8 months (range, 1 to 12 months). Two patients were treated surgically. Only two minor complications were noted; transient ptosis with Horner's syndrome and transient causalgia.
Although selective nerve root block for cervical radiculopathy is limited as a definitive treatment, it appears to be useful in terms of providing relief from radicular pain in about 50% of patients at 12 months.
PMCID: PMC3530696  PMID: 23275805
Cervical radiculopathy; Spinal nerve root; Nerve blocks
7.  Effect of the Number of Involved Spinal Cord Segments on Gait Function in Patients with Cervical Spondylotic Myelopathy 
Asian Spine Journal  2012;6(4):233-240.
Study Design
To determine the effect of severity of cervical spondylotic myelopathy (CSM) on gait parameters according to the number of involved spinal cord segments.
Overview of Literature
Although there are a large number of studies on CSM, almost all studies have focused on hand function and only a few studies have examined the gait function in patients with CSM.
Twenty-three patients with CSM underwent magnetic resonance imaging and gait analysis. The subjects were divided into 2 groups; group I consisted of 9 patients with a single-level stenotic lesion and group II comprised 14 patients with multi-level stenotic lesions. Gait parameters were compared between the 2 groups and the normal control group.
There was no significant difference in the Japanese Orthopaedic Association score between the 2 groups. Cadence, walking speed, stride length, and step length were decreased in group II compared to group I and normal control group. Peak ankle plantar flexion moments during the stance phase and peak knee flexion angle during the swing phase were decreased in group II. Peak ankle, knee, and hi p power generation during the stance phase were decreased in group II; in addition, the peak ankle power generation was decreased in group II than in the normal control group.
Patients with multi-level stenotic lesions had decreased gait ability compared to that in patients with a single-level stenotic lesion. The number of involved spinal cord segments can be one cause of gait deterioration in patients with CSM. Performing a gait analysis is useful for accurate evaluation of the patient.
PMCID: PMC3530697  PMID: 23275806
Cervical spondylotic myelopathy; Gait analysis; Multi-level
8.  Cervical Pedicle Screw Fixation Combined with Laminoplasty for Cervical Spondylotic Myelopathy with Instability 
Asian Spine Journal  2012;6(4):241-248.
Study Design
A retrospective study.
To evaluate the surgical results of cervical pedicle screw (CPS) fixation combined with laminoplasty for treating cervical spondylotic myelopathy (CSM) with instability.
Overview of Literature
Cervical fixation and spinal cord decompression are required for CSM patients with instability. However, only a few studies have reported on CPS fixation combined with posterior decompression for unstable CSM patients.
Thirteen patients that underwent CPS fixation combined with laminoplasty for CSM with instability were evaluated in this study. We assessed the clinical and radiological results of the surgical procedures. The Japanese Orthopedic Association (JOA) scoring system was used to evaluate the clinical results. The percentages of sli p, difference in sli p angle between maximum flexion and maximum extension of unstable intervertebrae, and perforation rate of CPS were evaluated.
The mean JOA scores before surgery, immediately after surgery, and at final follow-up were 9.1, 13.3, and 12.6, respectively. The mean percentages of sli p before surgery, immediately after surgery, and at final follow-up were 9.1%, 3.2%, and 3.5%, respectively; there were significant improvements immediately after surgery and at final follow-up. The difference in sli p angle between the maximum flexion and maximum extension of the unstable intervertebrae changed from 9.0° before surgery to 1.6° at the final follow-up. The perforation rate of CPS was 10.9%.
The results suggest that CPS fixation combined with laminoplasty is an effective surgical procedure for treating CSM with instability.
PMCID: PMC3530698  PMID: 23275807
Cervical spondylosis; Myelopathy; Instability; Cervical fixation
9.  Magnetic Resonance Imaging of the Lumbar Spine in Young Arabs with Low Back Pain 
Asian Spine Journal  2012;6(4):249-256.
Study Design
A prospective study.
To Investigate the prevalence of magnetic resonance imaging (MRI) changes of the lumbar spine in low back pain (LBP) and the associated risk factors in young Arab population.
Overview of Literature
Studies on the prevalence of MRI findings and their relationship with LBP have been conducted; these have occurred in adult populations in developed countries. The prevalence of MRI changes in the young Arab population with LBP is not known.
Two hundred and fourteen patients of Arab origin in the 16 to 29 year age group with LBP symptoms underwent MRI examinations. The prevalence of MRI changes in the lumbar spine and associated risk factors were determined and compared to age, race, and gender-matched controls.
A majority (64%) of the patients with LBP (138 out of 214) were found to have MRI evidence of degenerative disc disease (DD) compared to 10% (22 out of 214) in the control group. The majority (61%) of patients had multiple level disease, most commonly involving the lowest 2 disc levels. Reduced signal of the disc followed by disc bulge was the most common MRI features seen in the symptomatic subjects. Obesity correlated with MRI prevalence of abnormalities, while activity demonstrated a positive trend.
The MRI prevalence of DD among the young Arab patients with LBP is high when compared to other reports in literature. Obesity correlated with MRI prevalence of abnormalities while activity demonstrated a positive trend.
PMCID: PMC3530699  PMID: 23275808
Magnetic resonance imaging; Lumbar spine; Disc; Degeneration; Prevalence; Young; Arabs
10.  Complications of Posterior Vertebral Resection for Spinal Deformity 
Asian Spine Journal  2012;6(4):257-265.
Study Design
Retrospective study.
To evaluate the incidence and risk factors of complications following posterior vertebral resection (PVR) for spinal deformity.
A review of 233 patients treated with PVR at one institution over a nine-year period (1997 to 2005) was performed. The average age was 33.5 years. Complications were assessed in terms of surgical techniques (posterior vertebral column resection [PVCR] and decancellation osteotomy) and etiologies of deformity.
Local kyphosis was corrected from 51.4° to 2.7°, thoracic scoliosis 63.9° to 24.5° (62.6% correction), and thoracolumbar or lumbar scoliosis 50.1° to 17.1° (67.6%). The overall incidence of complications was 40.3%. There was no significant difference between PVCR and decancellation osteotomy in the incidence of complications. There were more complications in the older patients (>35 years) than the younger (p < 0.05). Hig her than 3,000 ml of blood loss and 200 minutes of operation time increased the incidence of complications, with significant difference (p < 0.05). More than 5 levels of fusion significantly increased the total number of complications and postoperative neurologic deficit (p < 0.05). Most of the postoperative paraplegia cases had preoperative neurologic deficit. Preoperative kyphosis, especially in tuberculous sequela, had hig her incidences of complications and postoperative neurologic deficit (p < 0.05). More than 40° of kyphosis correction had the tendency to increase complications and postoperative neurologic deficit without statistical significance (p > 0.05). There was 1 mortality case by heart failure. Revision surgery was performed in 15 patients for metal failure or progressing curve.
The overall incidence of complications of PVR was 40.3%. Older age, abundant blood loss, preoperative kyphosis, and long fusion were risk factors for complications.
PMCID: PMC3530700  PMID: 23275809
Posterior vertebral resection; Posterior vertebral column resection; Decancellation osteotomy; Postoperative complications
11.  Role of the O-arm and Computer-assisted Navigation of Safe Screw Fixation in Children with Traumatic Rotatory Atlantoaxial Subluxation 
Asian Spine Journal  2012;6(4):266-273.
Study Design
A retrospective analysis of 7 patients with traumatic rotatory atlanto-axial subluxation.
Overview of Literature
Cases of traumatic rotatory atlantoaxial subluxation in children are difficult to be stabilized. Surgical challenges include: narrow pedicles, medial vertebral arteries, vertebral artery anomalies, fractured pedicles or lateral masses, and fixed subluxation. The use of O-arm and computer-assisted navigation are still tested as aiding tools in such operative modalities.
Report of clinical series for evaluation of the safety of use of the O-arm and computed assisted-navigation in screw fixation in children with traumatic rotatory atlantoaxial subluxation.
In the present study, 7 cases of rotatory atlantoaxial traumatic subluxation were operated between December 2009 and March 2011. All patient-cases had undergone open reduction and instrumentation using atlas lateral mass and axis pedicle screws with intraoperative O-arm with computer-assisted navigation.
All hardware was safely placed in the planned trajectories in all the 7 cases. Intraoperative O-arm and computer assisted-navigation were useful in securing neural and vascular tissues safety with tough-bony purchases of the hardware from the first and only trial of application with sufficient reduction of the subluxation.
Successful surgery is possible with using the intraoperative O-arm and computer-assisted navigation in safe and proper placement of difficult atlas lateral mass and axis pedicle screws for rotatory atlantoaxial subluxation in children.
PMCID: PMC3530701  PMID: 23275810
Atlantoaxial joint fusion; Intraoperative computer-assisted 3D navigation; Computer-assisted three-dimensional imaging
12.  A Case of Pyogenic Spondylodiscitis Caused by Campylobacter fetus for Which Early Diagnosis by Magnetic Resonance Imaging Was Difficult 
Asian Spine Journal  2012;6(4):274-278.
The purpose of this case report was to report a rare case of pyogenic spondylodiscitis caused by Campylobacter fetus. A 37-year-old male presented with fever and low back pain. By lumbar magnetic resonance imaging (MRI), no abnormal finding was observed at the first presentation. However, low back pain was aggravated, and fever did not improve. Thus, lumbar MRI was repeated on the 26 day after the onset of symptoms, showing abnormal signals at vertebrae and disc spaces, and pyogenic spondylitis was diagnosed. The possibility of pyogenic spondylodiscitis should be taken into account if a patient presents with low back pain and fever, and areas of low signal intensity on a T1-weighted MRI should be carefully examined. When initial MRI does not reveal abnormal findings, repeated MRI after one or two weeks or, more favorably, immediate gadolinium enhancement MRI, are important for patients who have persistent low back pain and fever.
PMCID: PMC3530702  PMID: 23275811
Resonance imaging; Campylobacter fetus
13.  Chondrosarcoma of the Spinous Process: A Rare Presentation 
Asian Spine Journal  2012;6(4):279-283.
Chondrosarcomas are malignant cartilage forming tumours. They form the second most common primary malignant tumour involving the vertebral axis. We present a rare presentation of a secondary chondrosarcoma from the spinous process of lumbar vertebra and discussed its management. The main emphasis is on the rare presentation and the need for awareness and suspicion of the pathology.
PMCID: PMC3530703  PMID: 23275812
Chondrosarcoma; Spinous process; Diagnosis; Treatment
14.  Hypertrophic Posterior Arch of Atlas Causing Cervical Myelopathy 
Asian Spine Journal  2012;6(4):284-286.
Cervical stenosis, especially of the upper cervical spine, is quite rare which can be developmental or acquired. Clefts or aplasias of anterior and posterior arches of atlas, ossification of the transverse atlantal ligament, hypertrophy of the dens and os odontoideum are rare conditions causing cervical myelopathy reported either singly or in combination. Hypertrophy of the posterior arch of atlas in the absence of any ring hypoplasia as a cause of cervical myelopathy has not been reported earlier. The authors report a case of cervical myelopathy in a 26-year-old female due to hypertrophied posterior arch of atlas which was preoperatively diagnosed as a bony tumor. Being aware of such an entity may avoid diagnostic surprises and facilitate patient prognostication and management.
PMCID: PMC3530704  PMID: 23275813
Hypertrophy; Cervical atlas; Spinal cord disease; Cervical
15.  Cortical Blindness Following Spinal Surgery: Very Rare Cause of Perioperative Vision Loss 
Asian Spine Journal  2012;6(4):287-290.
A 38-year-old man was operated with posterior spinal decompression and pedicle screw instrumentation for his L2 fracture with incomplete neurological deficit. In the recovery, he complained of blindness in both eyes after twelve hours. Computed tomographic scan and magnetic resonance angiography revealed bilateral occipital lobe infarcts. He remained permanently blind even after three years follow-up. Though rare, perioperative vision loss is a potential complication following spine surgery in prone position. We report a rare occurrence of cortical blindness following lumbar spine surgery.
PMCID: PMC3530705  PMID: 23275814
Blindness; Prone; Surgery; Spinal injuries; Postoperative vision loss
16.  Entrapment of the Fifth Lumbar Spinal Nerve by Advanced Osteophytic Changes of the Lumbosacral Zygapophyseal Joint: A Case Report 
Asian Spine Journal  2012;6(4):291-293.
A 54-year-old female patient had a 6-year history of backache and left sciatica. Five years earlier, she had undergone surgery in another hospital for left L4-5 disc herniation. Computed tomography revealed the ossified wall that enclosed the left L5 nerve root. There were also osteophytic changes in the left L5-S zygapophyseal joint. These osteophytes developed rostrally, along the left L5 nerve root, throug h the intervertebral foramina. We performed decompression surgery for the left L5 nerve root, and surgery resulted in symptomatic relief. We experienced a rare clinical presentation of osteophytic formation, with a specific configuration in relation to the nerve root. Surgeons should be aware of entrapment of the lumbar spinal nerve by advanced osteophytic changes occurring in the zygapophyseal joint after lumbar surgery.
PMCID: PMC3530706  PMID: 23275815
Osteophyte; Entrapment; Nerve root; Zygapophyseal joint
17.  Spinal Tuberculosis: Diagnosis and Management 
Asian Spine Journal  2012;6(4):294-308.
The spinal column is involved in less than 1% of all cases of tuberculosis (TB). Spinal TB is a very dangerous type of skeletal TB as it can be associated with neurologic deficit due to compression of adjacent neural structures and significant spinal deformity. Therefore, early diagnosis and management of spinal TB has special importance in preventing these serious complications. In order to extract current trends in diagnosis and medical or surgical treatment of spinal TB we performed a narrative review with analysis of all the articles available for us which were published between 1990 and 2011. Althoug h the development of more accurate imaging modalities such as magnetic resonance imaging and advanced surgical techniques have made the early diagnosis and management of spinal TB much easier, these are still very challenging topics. In this review we aim to discuss the diagnosis and management of spinal TB based on studies with acceptable design, clearly explained results and justifiable conclusions.
PMCID: PMC3530707  PMID: 23275816
Spinal tuberculosis; Diagnosis; Therapeutics; Drug therapy
18.  Management of Persistent Cerebrospinal Fluid Leakage Following Thoraco-lumbar Surgery 
Asian Spine Journal  2012;6(3):157-162.
Study Design
This was a retrospective study of patients who had developed a dural tear after thoracic and lumbar spine surgery that was not recognized during the surgery, and was treated either by lumbar drainage or over-sewing of the wounds.
To revisit the treatment strategies in postoperative dural leaks and present our experience with over-sewing of the wound and lumbar drainage.
Overview of Literature
Unintended durotomy is a frequent complication of spinal surgery. Management of subsequent cerebrospinal fluid leakage remains controversial. There is no distinct treatment guideline according to the etiology in the current literature.
The records of 368 consecutive patients who underwent thoracic and/or lumbar spine surgery from 2006 throug h 2010 were retrospectively reviewed. Seven cerebrospinal fluid fistulas and five pseudomeningoceles were noted in 12 (3.2%) procedures. Cerebrospinal fluid diversion by lumbar drainage in five pseudomeningoceles and over-sewing of wounds in seven cerebrospinal fluid fistulas employed in 12 patients. Clinical grading was evaluated by Wang.
Of the 12 patients who had a dural tear, 5 were managed successfully with lumbar drainage, and 7 with oversewing of the wound. The clinical outcomes were excellent in 9 patients, good in 2, and poor in 1. Complications such as neurological deficits, or superficial or deep wound infections did not develop. A recurrence of the fistula or pseudomeningocele after the treatment was not seen in any of our patients.
Pseudomeningoceles respond well to lumbar drainage, whereas over-sewing of the wound is an alternative treatment option in cerebrospinal fluid fistulas without neurological compromise.
PMCID: PMC3429605  PMID: 22977694
Cerebrospinal; Drainage; Spinal; Primary repair; Wound Healing
19.  The Validation of Ultrasound-Guided Lumbar Facet Nerve Blocks as Confirmed by Fluoroscopy 
Asian Spine Journal  2012;6(3):163-167.
Study Design
This is a prospective study.
To develop a methodological approach for conducting ultrasound-guided lumbar facet nerve block by defining essential ultrasound-guided landmarks in order to assess the feasibility of this method.
Overview of Literature
The current role of ultrasound guidance for musculoskeletal intervention treatments has been reported upon in previous literature.
Ultrasound-guided facet nerve block was done in 95 segments for 50 patients with chronic back pain by facet arthropathy. After the surface landmarks of the spinous process and iliac crest line were confirmed, longitudinal facet views were obtained by a curved array transducer to identify the different spinal segments. The spinous process and facet joint with transverse process were delineated by transverse sonograms at each level and the target point for the block was defined as lying on the upper edge of the transverse process. The needle was inserted toward the target point. After a contrast injection, the placement of the needle and contrast was checked by fluoroscopy.
Eighty-seven segments (91.6%) could be guided successfully to the right facet nerve block by using ultrasound. After fluoroscopic control, 8 needles had to be corrected because of problems with other segments (3 cases) and lamina placements (5 cases). For the 42 patients who underwent successful block by ultrasound, however, the mean visual analogue score for back pain was improved from 6.2 ± 0.9 before the block to 4.0 ± 1.0 after the block (p = 0.001).
Ultrasound-guided longitudinal facet view and the surface landmarks of the spinous process and iliac crest line seems to be a promising guidance technique for the lumbar facet nerve block technique.
PMCID: PMC3429606  PMID: 22977695
Lumbosacral region; Nerve block; Ultrasonography
20.  Computer-assisted C1-C2 Transarticular Screw Fixation "Magerl Technique" for Atlantoaxial Instability 
Asian Spine Journal  2012;6(3):168-177.
Study Design
A retrospective study.
To evaluate the surgical results of computer-assisted C1-C2 transarticular screw fixation for atlantoaxial instability and the usefulness of the navigation system.
Overview of Literature
We used a computed tomography (CT)-based computer navigation system in planning and screw insertion in Magerl's procedure, which provides the most rigid atlantoaxial fusion, to avoid risk of vertebral artery (VA) tear by avoiding high-riding VA during screw insertion.
Twenty patients who underwent atlantoaxial fusion under the CT-based navigation system were studied. The mean observation period was 33.5 months. The evaluated items included the existence of VA stenosis by preoperative magnetic resonance angiography, surgical time, blood loss volume, Japanese Orthopaedic Association (JOA) score and Ranawat's pain criteria before surgery and at final follow-up, postoperative screw position evaluated by CT, and bony fusion.
The mean operation time was 205 minutes, with the mean blood loss volume of 242 ml. The mean JOA score was 11.6 points before surgery and 13.7 at final follow-up. Occipital and/or cervical pain presented before operation was remitted or resolved in all patients. Evaluation of screw insertion by CT revealed correct penetration to atlantoaxial joints, with a perforation rate of 2.6%. There was no complication, including VA tear, and all patients who were followed-up during one year or more after surgery achieved bony fusion. Some subjects who appeared inappropriate for surgery from CT images were assessed as eligible for surgery based on the evaluation results obtained using the navigation system.
It was demonstrated that the CT-based navigation system is an effective support device for Magerl's procedure.
PMCID: PMC3429607  PMID: 22977696
Atlantoaxial joint; Atlantoaxial instability; CT-based computer navigation system; C1-C2 transarticular screw fixation
21.  Effect of Psychological Status on Outcome of Posterior Lumbar Interbody Fusion Surgery 
Asian Spine Journal  2012;6(3):178-182.
Study Design
Prospective longitudinal study.
To determine if preoperative psychological status affects outcome in spinal surgery.
Overview of Literature
Low back pain is known to have a psychosomatic component. Increased bodily awareness (somatization) and depressive symptoms are two factors that may affect outcome. It is possible to measure these components using questionnaires.
Patients who underwent posterior interbody fusion (PLIF) surgery were assessed preoperatively and at follow-up using a self-administered questionnaire. The visual analogue scale (VAS) for back and leg pain severity and the Oswestry Disability Index (ODI) were used as outcome measures. The psychological status of patients was classified into one of four groups using the Distress and Risk Assessment Method (DRAM); normal, at-risk, depressed somatic and distressed depressive.
Preoperative DRAM scores showed 14 had no psychological disturbance (normal), 39 were at-risk, 11 distressed somatic, and 10 distressed depressive. There was no significant difference between the 4 groups in the mean preoperative ODI (analysis of variance, p = 0.426). There was a statistically and clinically significant improvement in the ODI after surgery for all but distressed somatic patients (9.8; range, -5.2 to 24.8; p = 0.177). VAS scores for all groups apart from the distressed somatic showed a statistically and clinically significant improvement. Our results show that preoperative psychological state affects outcome in PLIF surgery.
Patients who were classified as distressed somatic preoperatively had a less favorable outcome compared to other groups. This group of patients may benefit from formal psychological assessment before undergoing PLIF surgery.
PMCID: PMC3429608  PMID: 22977697
Spine; Low back pain; Outcomes research; Spinal fusion; Psychological tests
22.  Evaluation of Role of Anterior Debridement and Decompression of Spinal Cord and Instrumentation in Treatment of Tubercular Spondylitis 
Asian Spine Journal  2012;6(3):183-193.
Study Design
Prospective study with simple randomization.
To evaluate the results of anterior spinal instrumentation, debridement and decompression of cord and compare it with results of a similar procedure done without the use of anterior instrumentation.
Overview of Literature
Use of anterior spinal instrumentation in treatment of tubercular spondylitis is still an infrequently followed modality of treatment and data regarding its usefulness are still emerging.
Thirty-two patients of tubercular paraplegia with involvement of dorsal and dorso-lumbar vertebrae were operated with anterior spinal cord decompression, autofibular strut grafting with anterior instrumentation in 18 patients and no implant in 14 patients. Results were compared on the basis of improvement in Frankel grade, correction of local kyphosis, decrease in canal compromise and further progression of kyphosis.
The mean local kyphosis correction in the immediate postoperative period was 24.1° in the instrumented group and was 6.1° in the non instrumented group. The mean late loss of correction of local kyphosis at 3 years follow-up was 1.7° in the instrumented and 6.7° in the non instrumented group. The mean improvement in canal compression was 39.5% in the instrumented group and 34.8% in the non instrumented group.
In treatment of tubercular spondylitis by anterior debridement and decompression of the spinal cord and autofibular strut grafting, the use of instrumentation has no relation with the improvement in neurological status, however the correction of local kyphosis and prevention of further progression of local kyphosis was better with the use anterior spinal instrumentation.
PMCID: PMC3429609  PMID: 22977698
Tuberculosis; Instrumentation; Kyphosis; Paraplegia
23.  Percutaneous Pedicle Screw Fixation of a Hangman's Fracture Using Intraoperative, Full Rotation, Three-dimensional Image (O-arm)-based Navigation: A Technical Case Report 
Asian Spine Journal  2012;6(3):194-198.
Surgical treatment of a hangman's fractures is technically demanding, even when using the standard open procedure. In this case report, a type II hangman's fracture was treated by percutaneous posterior screw fixation, without a midline incision, using intraoperative, full rotation, three-dimensional (3D) image (O-arm)-based navigation. A 48-year-old woman was injured in a motor vehicle accident and diagnosed with a unilateral hangman's fracture associated with subluxation of the C2 vertebral body on C3. After attaching the reference arc of the 3D-imaging system to the headholder, the cervical spine was screened using an O-arm without anatomical registration. Drilling and screw fixation were performed using a guide tube while referring to the reconstructed 3D-anatomical views. The operation was successfully completed without technical difficulties or neurovascular complications. This percutaneous procedure requires less dissection of normal tissue, which may allow earlier recovery. However, further validation of this procedure for its effectiveness and safety is required.
PMCID: PMC3429610  PMID: 22977699
Pedicle screw; Percutaneous; Minimally invasive; Hangman's fracture; Three-dimensional image-based navigation
24.  Surgical Treatment of T1-2 Disc Herniation with T1 Radiculopathy: A Case Report with Review of the Literature 
Asian Spine Journal  2012;6(3):199-202.
The prevalence of intervertebral disc herniation (IDH) of the thoracic spine is rare compared to the cervical or lumbar spine. In particular, IDH of the upper thoracic spine is extremely rare. We report the case of T1-2 IDH and its treatment, with a literature review. A 37-year-old male patient visited our hospital due to radiating pain at the left upper extremity and weakness of grip power. In cervical spine magnetic resonance images, T1-2 disc space showed herniated disc material and compressed T1 root was identified. Laminoforaminotomy was performed with a posterior approach. The radiating pain and weakness of grip power improved immediately after the surgery. Of patients who show radiating pain or numbness at the medial aspect of forearm, or weakness of intrinsic muscle of hand, can be suspected to have T1 radiculopathy. A detailed physical examination and a radiologic evaluation including this area should be required for the T1 radiculopathy.
PMCID: PMC3429611  PMID: 22977700
Thoracic Vertebrae; Intervertebral Disc; Radiculopathy; Laminotomy
25.  Solitary Epidural Lipoma with Ipsilateral Facet Arthritis Causing Lumbar Radiculopathy 
Asian Spine Journal  2012;6(3):203-206.
A 55-year-old obese man (body mass index, 31.6 kg/m2) presented radiating pain and motor weakness in the left leg. Magnetic resonance imaging showed an epidural mass posterior to the L5 vertebral body, which was isosignal to subcutaneous fat and it asymmetrically compressed the left side of the cauda equina and the exiting left L5 nerve root on the axial T1 weighted images. Severe arthritis of the left facet joint and edema of the bone marrow regarding the left pedicle were also found. As far as we know, there have been no reports concerning a solitary epidural lipoma combined with ipsilateral facet arthorsis causing lumbar radiculopathy. Solitary epidural lipoma with ipsilateral facet arthritis causing lumbar radiculopathy was removed after the failure of conservative treatment. After decompression, the neurologic deficit was relieved. At a 2 year follow-up, motor weakness had completely recovered and the patient was satisfied with the result. We recommend that a solitary epidural lipoma causing neurologic deficit should be excised at the time of diagnosis.
PMCID: PMC3429612  PMID: 22977701
Solitary epidural lipoma; Posterior facet; Ipsilateral arthritis; Lumbar radiculopathy

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