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1.  Treatment Outcome of Cervical Tear Drop Fracture 
Asian Spine Journal  2009;3(2):73-79.
Study Design
This is a retrospective study.
We wanted to evaluate the clinical results of surgical and conservative treatment for cervical tear drop fracture.
Overview of Literature
The tear drop fracture of the lower cervical spine is generally associated with a high incidence of neurological deficits and surgery is needed to treat this injury. Tear drop fracture of C2 is usually a stable fracture that is amendable to conservative treatment.
We reviewed the outcomes of 25 patients. Cervical tear drop fracture was classified as the extension and flexion types according to the mechanism of injury. The neurologic symptoms were evaluated by the Frankel classification system, and the loss of lordosis and disc height, and the duration of bony union were analyzed.
Twenty one patients had the flexion type injury and 4 patients had the extension type injury. All the patients with the flexion type were treated by anterior decompression and plate stabilization. All the patients with the extension type were treated conservatively. Ten patients with the flexion type had neurologic deficits. The nerve root injuries recovered fully and the incomplete injuries had an average 1.5 grade recovery. Radiologically, the extension type fracture showed bony union at an average of 12.8 weeks. For the patients with the flexion type fracture, the loss of lordosis was 2.6° and the loss of disc height was 2.1 mm. The period of bony union in 20 cases was 13.0 weeks.
Anterior plate stabilization was an effective treatment for the flexion type tear drop fracture. Conservative treatment is thought to be one of the good clinical methods for treating the extension type tear drop fracture.
PMCID: PMC2852077  PMID: 20404951
Cervical spine; Tear drop fracture; Anterior plate stabilization
2.  Kyphotic Angle Progression of Thoracic and Thoracolumbar Tuberculous Spondylitis after Surgical Treatment: Comparison with Predicted Kyphosis Outcome after Conservative Treatment 
Asian Spine Journal  2009;3(2):80-88.
Study Design
Retrospective comparative study.
To compare the progression of the kyphotic angle (KA) in a surgically treated group with the predicted outcome of a conservatively treated group.
Overview of Literature
Late onset kyphosis is a complication of tuberculous spondylitis making its prevention a major goal of surgery.
Twenty six consecutive patients underwent an anterior reconstruction and posterior instrumented fusion in conjunction with antituberculous chemotherapy. The mean follow up was 56 months (range, 28 to 112 months). The patients were divided into subgroups based on the involved region of the thoracic and the thoracolumbar spine, initial KA, and the initial vertebral body loss (VBL(x)). The predicted KA (KAPd) was calculated using the formula, KAPd=5.5+30.5 VBL(x), to predict the final gibbus deformity. Kyphotic angle progression (ΔKA) based on the radiographic measurements after surgery (ΔKAR), and the predicted outcome of conservative treatment (ΔKAP) with chemotherapy were compared.
Among the subgroups of the regions involved and initial KA, the ΔKA was radiographically superior with a reduced amount of kyphogenesis in the surgery group than the predicted outcome of the conservatively treated patients (p<0.05). The radiographic ΔKA was similar (p>0.05) with VBL(x)≤0.5 in the VBL(x) subgroup.
These results showed that in the VBL(x) subgroup, an initial VBL(x)≤0.5 is an indication of conservative antituberculous chemotherapy without surgery.
PMCID: PMC2852082  PMID: 20404952
Tuberculous spondylitis; Kyphosis; Initial vertebral body loss
3.  Mechanical Properties of Blood-Mixed Polymethylmetacrylate in Percutaneous Vertebroplasty 
Asian Spine Journal  2009;3(2):45-52.
Study Design
Mechanical study of polymethylmetacrylate (PMMA) mixed with blood as a filler.
An attempt was made to modify the properties of PMMA to make it more suitable for percutaneous vertebroplasty (PVP).
Overview of Literature
The expected mechanical changes by adding a filler into PMMA included decreasing the Young's modulus, polymerization temperature and setting time. These changes in PMMA were considered to be more suitable and adaptable conditions in PVP for an osteoporotic vertebral compression fracture.
Porous PMMA were produced by mixing 2 ml (B2), 4 ml (B4) and 6 ml (B6) of blood as a filler with 20 g of regular PMMA. The mechanical properties were examined and compared with regular PMMA(R) in view of the Young's modulus, polymerization temperature, setting time and optimal passing-time within an injectable viscosity (20-50 N-needed) through a 2.8 mm-diameter cement-filler tube. The porosity was examined using microcomputed tomography.
The Young's modulus decreased from 919.5 MPa (R) to 701.0 MPa (B2), 693.5 Mpa (B4), and 545.6 MPa (B6). The polymerization temperature decreased from 74.2℃ (R) to 59.8℃ (B2), 54.2℃ (B4) and 47.5℃ (B6). The setting time decreased from 1,065 seconds (R) to 624 seconds (B2), 678 seconds (B4), and 606 seconds (B6), and the optimal passing-time decreased from 75.6 seconds (R) to 46.6 seconds (B2), 65.0 seconds (B4), and 79.0 seconds (B6). The porosity increased from 4.2% (R) to 27.6% (B2), 27.5% (B4) and 29.5% (B6). A homogenous microstructure with very fine pores was observed in all blood-mixed PMMAs.
Blood is an excellent filler for PMMA. Group B6 showed more suitable mechanical properties, including a lower elastic modulus due to the higher porosity, less heating and retarded optimal passing-time by the serum barrier, which reduced the level of friction between PMMA and a cement-filler tube.
PMCID: PMC2852075  PMID: 20404947
Filler; Bone cement; Vertebroplasty; Osteoporotic verterbral compression fracture
4.  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.
PMCID: PMC2852042  PMID: 20404946
Lumbar spine; Degenerative disc; Pathophysiology
5.  Correlation of Pelvic Parameters with Isthmic Spondylolisthesis 
Asian Spine Journal  2009;3(1):21-26.
Study Design
A retrospective radiological evaluation.
To verify that PI is related with progression of IS as well as development of IS and to assess the differences of pelvic parameters between the L4 & L5 IS, as well as between single & two level IS.
Overview of Literature
High pelvic incidence (PI) has been known to be related with development of IS. However, the previous studies were limited to just L5 spondylolisthesis or there was no differentiation between L4 & L5 spondylolisthesis
Sixty five IS patients and 30 persons as a control group participated the study. Among the 65 patients, 30 had L4 IS, 30 had L5 IS and 5 had bi-level IS. We used the whole spine lateral radiographs to measure the slip percentage, the pelvic tilt (PT) and the pelvic incidence (PI), and we compared them between the normal control group and the IS patients, as well as between single-level and bi-level spondylolisthesis, and we investigated the correlation between the degree of slip of spondylolisthesis and the pelvic parameters.
The averages of the PT, PI and lumbar lordosis (LL) in the control group and the IS group were 11.0° vs 21.4° (p<0.001), 49.1° vs 61.8° (p<0.001) and 48.5° vs 57.6° (p<0.001), respectively. On comparison between the L4 and L5 IS groups, there was no difference in all the pelvic parameters (p>0.05). On comparison between the single-level IS group and the bilevel IS group, there was a significant difference of the PT and PI (p<0.05), and the slip percentage had a correlation with only the PI among all the pelvic parameters (Spearman's r=0.293, p=0.023). There was a significant correlation of the degree of slip with the PI for the L5 single level IS, but not with the L4 single level IS (r=0.362, p=0.05).
The high pelvic incidence can be a factor of L4 & L5 spondylolysis and it may have an influence on the slip progression in patients with L5 isthmic spondylolisthesis, but not on the slip progression in patients with L4 IS. Yet other factors seem to have an influence on the slip progression in patients with L4 isthmic spondylolisthesis.
PMCID: PMC2852036  PMID: 20404942
Isthmic spondylolisthesis; Pelvic parameter; Sacral slope; Pelvic tilt; Pelvic incidence
6.  Reliability of MRI findings for Symptomatic Extraforaminal Disc Herniation in Lumbar Spine 
Asian Spine Journal  2009;3(1):16-20.
Study Design
A retrospective study
This study examined the reliability of the MRI findings in detecting symptomatic extraforaminal disc herniation in the lumbar spine.
Overview of Literature
There are no reports of the characteristics and reliable MRI findings of extraforaminal disc herniation.
Thirty age-and gender-matched asymptomatic volunteers and 30 patients with symptomatic extraforaminal disc herniation, who underwent surgery between March 2006 and Dec 2008, were enrolled in this study. All subjects underwent spinal MRI. The following parameters were evaluated: the presence or absence of focal eccentricity of the disc, change in the diameter of the nerve root, and displacement of the nerve root at the extraforaminal zones. Radiologic studies were reviewed blindly and independently by 3 spine surgeons.
The overall agreement in determining the presence or absence of a symptomatic extraforaminal disc herniation between the three reviewers was 89.4% (161/180). The consensus showed focal eccentricity of the disc in 33 cases (55%), a change in diameter in the nerve root in 31 cases (51.7%), and a displacement of the nerve root in 23 cases (38.3%). An assessment of the paired intraobserver and interobserver reliability revealed mean Kappa statistics of 0.833 and 0.667 for focal eccentricity of the disc, 0.656 and 0.556 for a change in the diameter of the nerve root, and 0.669 and 0.020 for a displacement of the nerve root, respectively.
There are three possible MRI findings that can be used to determine the presence or absence of symptomatic extraforaminal disc herniation. Among these MRI findings, focal eccentricity of the disc was found to be the most reliable.
PMCID: PMC2852038  PMID: 20404941
Extraforaminal; Disc herniation; Lumbar spine; Magnetic resonance imaging; Reliability
7.  Surgical Excision of the Lumbar Disc Herniation in Elementary School Age 
Asian Spine Journal  2009;3(1):10-15.
Study Design
A retrospective study.
To assess the radiological, clinical features and surgical outcomes of six patients of elementary school age with lumbar disc herniation (LDH).
Overview of Literature
LDH is common in people in their fourth and fifth decades. However, the condition is extremely rare in children of elementary school age. Moreover, the clinical symptoms and treatments are different from those of adults.
We reviewed a series of 6 patients under the age of 12 years, who underwent surgery for LDH at our institution between 1992-2002. Initially, all patients were treated conservatively. The indications for surgery were failure of conservative treatment for 3 months, intractable pain and/or progressive neurological impairment.
The surgical findings revealed a protruding disc in five cases and a ruptured disc in one. In addition, separation of the vertebral ring apophysis was observed in 3 cases. The symptoms had disappeared completely at the last follow-up. At the last follow-up, the Japanese Orthopaedic Association score was 10 points in 5 cases and 9 points in 1, and the Kirkaldy-Willis criteria was excellent in all patients. No intervertebral disc space narrowing was observed in any patient at last follow up. In addition, there were no degenerative changes in the vertebral endplate and facet joint.
Patients with symptoms that persist for more than 3 months or those with a progressive neurological deficit must be considered for surgical discectomy.
PMCID: PMC2852041  PMID: 20404940
Lumbar disc herniation; Elementary school age
8.  Treatment for Multiple Aspergillus Spondylitis Including a Hip Joint 
Asian Spine Journal  2009;3(2):106-112.
Multiple aspergillus spondylitis (AS) is a life threatening infection that occurs more commonly in immunocompromised patients, and is commonly treated with antifungal agents. However, there is relatively little information available on the treatment of multiple AS. The authors encountered a 46-year-old man suffering from low back and neck pain with radiculomyelopathy after a liver transplant. The patient had concomitant multiple AS in the cervico-thoraco-lumbar spine and right hip joint, as confirmed by radiologic imaging studies. The pathological examination of a biopsy specimen revealed fungal hyphae at the cervical and lumbar spine. Anterior decompression and interbody fusion were performed for the cervical and lumbar lesions, which showed instability and related neurological symptoms. Additional antifungal therapy was also performed. The patient was treated successfully with remission of his symptoms.
PMCID: PMC2852076  PMID: 20404956
Multiple spondylitis; Aspergillus; Immunocompromised
9.  The Quantitative Analysis of Back Muscle Degeneration after Posterior Lumbar Fusion: Comparison of Minimally Invasive and Conventional Open Surgery 
Asian Spine Journal  2009;3(2):89-95.
Study Design
Prospective controlled study.
The results of conventional open surgery was compared with those from minimally invasive transforaminal lumbar interbody fusion (MI-TLIF) for lumbar fusion to determine which approach resulted in less postoperative paraspinal muscle degeneration.
Overview of Literature
MI TLIF is new surgical technique that appears to minimize iatrogenic injury. However, there aren't any reports yet that have quantitatively analyzed and proved whether there's difference in back muscle injury and degeneration between the minimally invasive surgery and conventional open surgery in more than 1 year follow-up after surgery.
This study examined a consecutive series of 48 patients who underwent lumbar fusion in our hospital during the period, March 2006 to March 2008, with a 1-year follow-up evaluation using MRI. There were 17 cases of conventional open surgery and 31 cases of MI-TLIF (31 cases of single segment fusion and 17 cases of multi-segment fusion). The digital images of the paravertebral back muscles were analyzed and compared using the T2-weighted axial images. The point of interest was the paraspinal muscle of the intervertebral disc level from L1 to L5. Picture archiving and communication system viewing software was used for quantitative analysis of the change in fat infiltration percentage and the change in cross-sectional area of the paraspinal muscle, before and after surgery.
A comparison of the traditional posterior fusion method with MI-TLIF revealed single segment fusion to result in an average increase in fat infiltration in the paraspinal muscle of 4.30% and 1.37% and a decrease in cross-sectional area of 0.10 and 0.07 before and after surgery, respectively. Multi-segment fusion showed an average 7.90% and 2.79% increase in fat infiltration and a 0.16 and 0.10 decrease in cross-sectional area, respectively. Both single and multi segment fusion showed less change in the fat infiltration percentage and cross-sectional area, particularly in multi segment fusion. There was no significant difference between the two groups in terms of the radiologic results.
A comparison of conventional open surgery with MI-TLIF upon degeneration of the paraspinal muscle with a 1 year follow-up evaluation revealed that both single and multi segment fusion showed less change in fat infiltration percentage and cross-sectional area in the MI-TLIF but there was no significant difference between the two groups. This suggests that as time passes after surgery, there is no significant difference in the level of degeneration of the paraspinal muscle between surgical techniques.
PMCID: PMC2852079  PMID: 20404953
Paraspainal muscle; Fat degeneration; MRI; Posterior fusion
10.  Radiographic Progression of Degenerative Lumbar Scoliosis after Short Segment Decompression and Fusion 
Asian Spine Journal  2009;3(2):58-65.
Study Design
A retrospective study.
To assess the radiographic progression of degenerative lumbar scoliosis after short segment decompression and fusion without deformity correction.
Overview of Literature
The aims of surgery in degenerative lumbar scoliosis are the relief of low back and leg pain along with a correction of the deformity. Short segment decompression and fusion can be performed to decrease the level of low back and leg pain provided the patient is not indicated for a deformity correction due to medical problems. In such circumstance, the patients and surgeon should be concerned with whether the scoliotic angle increases postoperatively.
Forty-seven patients who had undergone short segment decompression and fusion were evaluated. The average follow-up period was more than 3 years. The preoperative scoliotic angle and number of fusion segments was 13.6±3.9° and 2.3±0.5, respectively. The preoperative, postoperative and last follow-up scoliotic angles were compared and the time of progression of scoliotic angle was determined.
The postoperative and last follow-up scoliotic angle was 10.4±2.3° and 12.1±3.6°, respectively. In eight patients, conversion to long segment fusion was required due to the rapid progression of the scoliotic angle that accelerated from 6 to 9 months after the primary surgery. The postoperative scoliosis aggravated rapidly when the preoperative scoliotic angle was larger and the fusion was extended to the apical vertebra.
The scoliotic angle after short segment decompression and fusion was not deteriorated seriously in degenerative lumbar scoliosis. A larger scoliotic angle and fusion to the apical vertebra are significant risk factors for the acceleration of degenerative lumbar scoliosis.
PMCID: PMC2852080  PMID: 20404949
Degenerative lumbar scoliosis; Short segment fusion; Radiographic progression
11.  The Clinical Effect of Gait Load Test in Two Level Lumbar Spinal Stenosis 
Asian Spine Journal  2009;3(2):96-100.
Study Design
This study is a prospective, clinical study assessing the efficacy of selective decompression of the level responsible in a two-level stenosis in accordance with the neurological findings defined by the gait load test with a treadmill.
To clarify the clinical features of multilevel lumbar spinal stenosis (LSS) regarding the neurological level responsible for the symptoms, neurogenic claudication, and outcomes of selective decompression.
Overview of Literature
Most spine surgeons have reported that multilevel compression of the cauda equina induces a more severe impairment of the nerve function than a single-level compression. However, the clinical effects of multilevel LSS on the cauda equine and nerve roots are unknown.
A total of 21 patients with lumbar spinal canal stenosis due to spondylosis and degenerative spondylolisthesis were selected. The level responsible for the symptoms in the two-level stenosis was determined from the neurological findings on the gait load test and functional diagnosis based on a selective nerve root block. All patients underwent a prospective, selective decompression at the level neurologically responsible only. The average follow-up period was 2.6 years (range, 1 to 6 years). The postsurgical outcome was defined using the Visual Analogue Scale (VAS) at the post-gait load test, 2 weeks after surgery, 3 months after surgery and at the last follow up.
Before surgery, the mean threshold distance and mean walking tolerance was 34.3 m and 113 m, respectively. All patients had neurogenic claudication and 19 of the patients had cauda equina syndrome, including hypesthesia in 11 cases, muscle weakness in 5 cases and radicular pain in 7 cases. Selective nerve blocks to determine the level responsible for the lumbosacral symptoms in 2 cases revealed a mean VAS score of 7.1, 2.61, 3.04, and 3.47 at the post-gait load test, 2 weeks after surgery, 3 months after surgery and at the last follow up, respectively. All subjects underwent surgery. After the operation, neurogenic claudication with or without cauda equna syndrome subsided in all patients.
The gait load test allows an objective and quantitative evaluation of the gait characteristics of patients with lumbar canal stenosis and is useful for determining the appropriate level for surgical treatment.
PMCID: PMC2852081  PMID: 20404954
Gait load test; Neurogenic claudication; Lumbar canal stenosis
12.  Multiple Levels of Lumbar Spondylolysis - A Case Report - 
Asian Spine Journal  2009;3(1):35-38.
We report here on an unusual case of multiple levels of asymmetric lumbar spondylolysis in a 19-year-old woman. The patient had severe low back pain of increasing intensity with lumbar instability, which was evident on the dynamic radiographs. MRI demonstrated the presence of abnormalities and the three dimensional CT scan revealed asymmetric complete spondylolysis at the left L2, L3 and L4 levels and the right L1, L2 and L3 levels. This case was treated surgically by posterior and posterolateral fusion at L2-3-4 with intersegmental fixation using pedicle screws and an auto iliac bone graft. The patient was relieved of her low back pain after the surgery.
PMCID: PMC2852035  PMID: 20404945
Lower back pain; Multiple spondylolysis; Fusion
13.  Successfull Management of a Life Threatening Cerebellar Haemorrhage Following Spine Surgery - A Case Report - 
Asian Spine Journal  2009;3(1):32-34.
Cerebellar haemorrhages are rare life-threatening complications following spine surgery that present challenges for their diagnostic and their therapeutic management. Their patho-physiology remains unclear.
We report a case of a life-threatening cerebellar haemorrhage secondary to an occult dural tear following a planned L5-S1 laminectomy. The patient was treated with emergent external ventriculostomy following by a posterior fossa decompressive craniectomy. Cerebellar haemorrhages have to be suspected systematically when unexpected neurological signs occur after spine surgery since their rapid management lead to favourable outcomes. The present imaging findings allow us proposing that cerebellar haemorrhages result primarily from superior cerebellar venous stretching and tearing, and that cerebellar infarction and swelling occur secondarily.
PMCID: PMC2852039  PMID: 20404944
Cerebellar haemorrhage; Dural tear; Spine surgery
14.  20-Year-Follow up of Treatment Using Spine Osteotomy and Halo-pelvic Traction for Tuberculous Kyphosis - A Case Report - 
Asian Spine Journal  2009;3(1):27-31.
A 23-year-old male whose medical history included tuberculous spondylitis presented with a kyphotic deformity and incomplete paraplegia of twenty days duration. Preoperative radiographs demonstrated a T12-L4 kyphotic Cobb's angle of 100° with a complete block showing on the lumbar myelogram at L4-5. The patient underwent anterior osteotomy and release. After the operation, a halo-pelvic apparatus was fit onto the patient, and distraction was begun. After distraction for 2 months, posterior osteotomy and release was performed for final correction, and distraction was maintained for another three weeks. Finally, the kyphotic deformity was corrected to a Cobb's angle of 62° from T12 to L4. Supplementary anterior fusion was done, and the apparatus was removed after consolidation of the fusion mass.
Even twenty years after correction of a tuberculous kyphosis, he had no neurological deterioration, and could work as a farmer using agricultural machines. Correction angle and sagittal balance were well maintained.
PMCID: PMC2852040  PMID: 20404943
Tuberculous kyphosis; Halo-pelvic traction; Spine osteotomy
15.  En Bloc Partial Laminectomy and Posterior Lumbar Interbody Fusion in Foraminal Spinal Stenosis 
Asian Spine Journal  2009;3(2):66-72.
Study Design
A retrospective study.
An en bloc partial laminectomy and posterior lumbar interbody fusion (PLIF) in spinal stenosis patients with severe foraminal narrowing has a shorter operation time, less neural manipulation and allows indirect decompression by restoring the interforaminal height compared to other procedures. This study investigated the efficacy of the procedure.
Overview of Literature
PLIF is one of the most popular surgery for degenerative spine such as foraminal spinal stenosis, instability spondylolisthesis and discogenic pain. Various techniques for PLIF have their own advantages and disadvantages. But in some severe cases, we need an efficient method of PLIF for decompression and fusion.
This study examined 61 patients, who had 85 levels treated with PLIF using an en bloc partial laminectomy and facetectomy, and could be followed up for more than 2 years. The mean age of the patients and mean follow up period was 66 years and 39 months, respectively. The clinical results were evaluated using the MacNab's criteria, Visual Analogue Scale (VAS) score, and Korea Version Oswestry Disability Index (KODI). The union of the intervertebral space was evaluated using Lenke's criteria. The intervertebral angle and height of the posterior intervertebral disc were also measured.
Excellent and good results were obtained in 54 cases (89%) according to MacNab's criteria. The VAS and KODI scores were 8.1 and 34.6, preoperatively, and 3.4, and 14.1, postoperatively. Bone union was A and B grades according to Lenke's criteria in 57 cases. The mean segmental angle and mean height of the posterior disc were respectively, 7.4° and 6.5 mm preoperatively, 9.1° and 10.6 mm postoperatively, and 8.0° and 9.7 mm in the last follow-up. There were 5 cases of postoperative infection, 4 cases of junctional problems and 1 case of screw malposition.
En bloc partial laminectomy and PLIF is an effective method for treating severe spinal stenosis with foraminal narrowing.
PMCID: PMC2852073  PMID: 20404950
Lumbar vertebra; Spinal stenosis; Laminectomy; Posterior lumbar interbody fusion
16.  Osteotomy of the Spine to Correct the Spinal Deformity 
Asian Spine Journal  2009;3(2):113-123.
There are a number of reports on Smith-Petersen osteotomy (SPO), pedicle subtraction osteotomy (PSO) and vertebral column resection (VCR). However, there are few systematic reviews of all three kinds of osteotomies. Literature review and author's experience of SPO, PSO and VCR osteotomy will be described. Various surgical techniques can be applied according to the disease entity and magnitude of the deformity. The most appropriate methods for deformity correction should be chosen and the potential complications should be considered. Before attempting an osteotomy of the spine for a spinal deformity, sufficient surgical experience and a thorough understanding of the anatomy of the spine and adjacent structures are needed. In addition, a well-organized team with the other departments is essential.
PMCID: PMC2852074  PMID: 20404957
Spinal osteotomy; Smith-Petersen osteotomy; Pedicle subtraction osteotomy; Vertebral column resection
17.  Is Complex Regional Pain Syndrome a Cause of Post-Operative Syndrome in the Lumbar Spine? - A Case Report - 
Asian Spine Journal  2009;3(2):101-105.
Complex regional pain syndrome (CRPS) along with post-operative syndrome in the lumbar spine shows confusing and duplicated symptoms, and this makes it difficult to make a clear differential diagnosis. Therefore, the patient with post-operative syndrome in the lumbar spine suffers losses of time and money, and the surgeon who diagnoses and treats post-operative syndrome in the lumbar spine also agonize from the patient's losses. It is necessary to provide these patients with a multidisciplinary approach to their disease and symptoms. We diagnosed herniation of an intervertebral disc of the lumbar spine (L4/5) and we performed discetomy twice in different hospitals. However, the symptoms did not improve, so we re-operated and performed discetomy along with monosegmental fixation using pedicular screws and interbody cages. There was improvement of pre-operation symptoms, but neurogenic symptoms occurred and then progressed after the surgery. Therefore, we report here on the case of CRPS that was diagnosed with the exclusion of the causes of post-operative syndrome in the lumbar spine, and the patient was finally effectively treated with spinal cord stimulation. Although differentiating post-operative syndrome in the lumbar spine from CRPS is difficult, we recommend suspecting CRPS as the cause of post-operative syndrome in the lumbar spine and taking CRPS as the main interest in order to diagnose and treat CRPS more effectively and accurately.
PMCID: PMC2852078  PMID: 20404955
Complex regional pain syndrome; Post-operative syndrome; Lumbar spine; Spinal cord stimulation
18.  Genetic Markers for Idiopathic Scoliosis in Arab Population: A Pilot Study 
Asian Spine Journal  2009;3(2):53-57.
Study Design
Cross-sectional screening.
This study was conducted to determine if there is any association of the three microsatellite markers on chromosome 19p 13.3 in unrelated Saudi Arabian girls who were suffering with adolescent idiopathic scoliosis (AIS) and their healthy siblings.
Overview of Literature
The genetic influence on the development of familial scoliosis has been previously described, but the genetic influence on AIS still remains unknown. Three microsatellite markers (D19S216, D19S894, and DS1034) of chromosome 19p 13.3 were reported to be significantly associated with familial scoliosis. This cross-sectional screening was carried out in AIS patients and their siblings.
For eleven Saudi Arabian girls who were treated for AIS and their 11 siblings, we performed a linkage analysis using parametric and nonparametric methods and using GENEHUNTER ver. 2.1. Multipoint linkage analysis was used to specify an autosomal dominant trait with a gene frequency of 0.01 at the genotypic and the allelic levels. One sided Fisher's exact tests were used in the analysis of the contingency tables for the D19S216, D19S894 and DS1034 markers.
The analysis between the patient group and the healthy siblings showed that at the genotypic level there was a significant association of the markers and scoliosis (D19S894 [p=0.036], D19S216 [p=0.004], and DS1034 [p=0.013]). Yet at the allelic level, there was no statistically significant association of the markers between the AIS patients and their siblings.
Our pilot study shows that there is a genetic influence between the AIS patients and the siblings. We believe large scale genetic screening is warranted for the patients with AIS to identify beyond any doubt the influence of these markers.
PMCID: PMC2852083  PMID: 20404948
Adolescent idiopathic scoliosis; Genetic markers; Chromosome 19p 13.3
19.  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.
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.
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.
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).
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.
PMCID: PMC2852037  PMID: 20404939
Bone mineral density; Osteogenic potential; Mesenchymal stem cells

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