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1.  The Effect of Radiofrequency Neurotomy on Chronic Low Back Pain 
Asian Spine Journal  2007;1(2):88-90.
Study Design
A prospective study.
Purpose
To determine the success rate and duration of relief of radiofrequency neurotomy for lumbar facet joint pain.
Overview of Literature
There is a lack of effective treatment for chronic low back pain. Radiofrequency denervation appears to be an emerging technology, with substantial variations in use.
Methods
Fifty-eight patients underwent radiofrequent neurotomy on the posterior primary ramus for chronic low back pain. All patients with low back pain of more than 3 months duration, with or without non-radicular radiation to the buttock and hip, were included in the study. From October 2005 to December 2006, eligible patients underwent a standardized diagnostic work-up, which included the use of a visual analog scale (VAS), physical examination, review of imaging studies, and diagnostic blockades. Pain relief was assessed on the third day, and at 3 months and 6 months post-treatment, using the visual analog scale.
Results
There were 44 women and 14 men included in the study. The mean age was 57.7 years (range, 20~80 years). Radiofrequency neurotomy denervated three segments and a bilateral lesion in all patients. The visual analogue scale (VAS) scores on the third day (mean VAS score: 1.48) and 3 months (mean VAS score: 1.79) after treatment decreased significantly when compared with the pre-treatment scores (mean VAS score: 6.56). However, the final values of the VAS scores after 6 months were slightly increased as compared to the VAS scores measured at the beginning of the study (mean VAS score: 2.91). No cases of infection, new motor deficits, or new sensory deficits were identified.
Conclusions
We suggest that radiofrequency neurotomy offers an effective palliative management of lumbar facet pain. However, there is limited evidence that radiofrequency neurotomy offers short-term relief for chronic low back pain. Further high-quality randomized controlled trials are needed with larger patient numbers and more data on the long-term effects, for which current evidence is inconclusive.
doi:10.4184/asj.2007.1.2.88
PMCID: PMC2857474  PMID: 20411130
Lumbar facet joint; Chronic low back pain; Radiofrequency neurotomy
2.  Anterior Debridement and Strut Graft with Pedicle Screw Fixation for Pyogenic Spondylitis 
Asian Spine Journal  2007;1(2):91-97.
Study Design
A retrospective study.
Purpose
We evaluated the results of the use of anterior debridement and interbody fusion followed by posterior spinal instrumentation.
Overview of Literature
An early diagnosis of pyogenic spondylitis is difficult to obtain. The disease can be treated with various surgical methods (such as anterior debridement and bone graft, anterior instrumentation, and posterior instrumentation).
Methods
This study included 20 patients who received anterior debridement and interbody fusion with strut bone graft followed by posterior spinal fusion for pyogenic spondylitis between 1996 and 2005. We analyzed the culture studies, the correction of the kyphotic angle, blood chemistry, the bony union period, and the amount of symptom relief.
Results
In terms of clinical symptoms relief, eight patients were grouped as "excellent", eleven patients as "good", and one patient as "fair". The vertebral body cultures were positive in 14 patients showing coagulase (-) streptococcus and S. aureus. The average times for normalization of the erythrocyte sedimentation rate and C-reactive protein level were 3.3 and 1.9 months, respectively. Four months was required for bony union. For complications, meralgia paresthetica was found in two cases.
Conclusions
Due to early ambulation and the correction of the kyphotic angle, anterior interbody fusion with strut bone graft and posterior instrumentation could be another favorable method for the treatment of pyogenic spondyulitis.
doi:10.4184/asj.2007.1.2.91
PMCID: PMC2857475  PMID: 20411131
Pyogenic spondylitis; Anterior interbody fusion; Posterior instrumentation
3.  Tuberculosis of the Lower Lumbar Spine with an Atypical Radiological Presentation - A Case Mimicking a Malignancy - 
Asian Spine Journal  2007;1(2):102-105.
A 65-year-old woman was treated for an atypical radiological presentation of spinal tuberculosis. Compared with previously reported cases, the following two different radiographic features were found. 1) Although there was multiple and skipped involvement of the vertebral body, the intervertebral disc was relatively preserved. 2) The presence of an epidural granuloma indicated an epidural extension of the lesion of the adjacent vertebral body. These findings strongly mimicked bone marrow infiltrative disease such as a malignancy. Tuberculosis was confirmed through an open biopsy and the patient was treated successfully with antitubercular chemotherapy. This case highlights the importance of being aware that spinal tuberculosis has many different radiographic features and can mimic a spinal malignancy.
doi:10.4184/asj.2007.1.2.102
PMCID: PMC2857476  PMID: 20411133
Atypical tuberculosis; Spondylitis; Malignancy
4.  Delayed Onset Neurological Deterioration due to a Spinal Epidural Hematoma after a Spine Fracture 
Asian Spine Journal  2007;1(2):98-101.
There are no reports of a 7-day delay in the onset of neurological deterioration because of a spinal epidural hematoma (SEH) after a spinal fracture. A hematoma was detected from the T12 to L2 area in a 36-year-old male patient with a T12 burst fracture. On the same day, the patient underwent in situ posterior pedicle instrumentation on T10-L3 with no additional laminectomy. On the seventh postoperative day, the patient suddenly developed weakness and sensory changes in both extremities, together with a sharp pain. A MRI showed that the hematoma had definitely increased in size. A partial laminectomy was performed 12 hours after the onset of symptoms. Two days after surgery, recovery of neurological function was noted. This case shows that spinal surgeons need to be aware of the possible occurrence of a delayed aggravated SEH and neurological deterioration after a spinal fracture.
doi:10.4184/asj.2007.1.2.98
PMCID: PMC2857477  PMID: 20411132
Spinal epidural hematoma; Spine fracture; Neurology
5.  Sagittal Plane Lumbar Responses after Anterior Selective Thoracic Fusion for Main Thoracic Adolescent Idiopathic Scoliosis 
Asian Spine Journal  2007;1(2):80-87.
Study Design
A retrospective radiographic study.
Purpose
To verify the correlation of sagittal and coronal plane changes after selective thoracic fusion in main thoracic (MT) adolescent idiopathic scoliosis (AIS).
Overview of Literature
Sagittal plane deformity is known to be essential in the evolution of scoliosis.
Methods
Twenty-eight MT AIS patients treated by anterior selective thoracic fusion were evaluated after minimal follow-up of two years. The unfused lumbar area was divided into proximal and distal parts by the lumbar apex in the coronal plane, and into proximal and distal lumbar lordosis by L2 in the sagittal plane. Surgical motion (the difference between preoperative and postoperative values) and follow-up motion (the difference between postoperative and the last follow-up values) were compared.
Results
Immediately after surgery, as thoracic kyphosis increased, lumbar lordosis decreased (r=0.734); proximal lumbar lordosis increased, and distal lumbar lordosis decreased. The proximal lumbar area was mobilized in the sagittal plane, and was straightened in the coronal plane. However, the distal lumbar area was stabilized in the sagittal plane, and showed resistant motion against MT translation in the coronal plane. The surgical motion was correlated to the follow-up motion, i. e., was regulated during follow-up, and the regulatory motion was more precise in the distal than proximal lumbar area in both sagittal and coronal planes.
Conclusions
Sagittal and coronal motions were co-related; optimal sagittal motions were necessary for optimal coronal motions after anterior selective thoracic fusion for MT AIS. Proximal and distal lumbar motions were different for different roles; the proximal lumbar area played a role as a bumper to absorb the MT translatory force, and the distal lumbar area played a role of resistance against MT translation.
doi:10.4184/asj.2007.1.2.80
PMCID: PMC2857478  PMID: 20411129
Sagittal plane; Selective thoracic fusion; Anterior spinal fusion; Adolescent idiopathic scoliosis
6.  Diagnosis and Treatment of Tuberclous Spondylitis and Pyogenic Spondylitis in Atypical Cases 
Asian Spine Journal  2007;1(2):75-79.
Study Design
A retrospective study.
Purpose
This is a study of the diagnosis and treatment of tuberculous spondylitis and pyogenic spondylitis in atypical cases.
Overview of Literature
There have been several reports about clinical, hematological, pathological and radiological findings to differentiate pyogenic & tuberculous spondylitis.
Methods
We screened 55 patients diagnosed with tuberculous spondylitis and pyogenic spondylitis from January 1999 to June 2003. There were seven cases where it was difficult to make an accurate diagnosis. We reviewed the clinical manifestation, laboratory tests, radiological findings and confirmed the diagnoses by the use of biopsies and/or clinical response to treatment.
Results
Four cases, which were initially diagnosed as pyogenic spondylitis, had a clinical presentation of fever (37.4~38.5℃) on the day of hospitalization. These cases later turned out to be tuberculous spondylitis, as confirmed by an open biopsy and pathologic study. Three cases initially diagnosed as pyogenic spondylitis were treated with broad-spectrum antibiotics. Symptoms were aggravated in these cases, but improved after the use of an anti-tubercular drug. Bony union was observed in all cases in an averageof 4 months (range, 3~6 months).
Conclusions
In infectious spondylitis, it is important to establish an accurate diagnosis. An accurate diagnosis can be made by laboratory findings and by estimation of the response to treatment during follow-up. If there is no response or aggravation of symptoms despite treatment based on an initial diagnosis, the etiologic organism must be re-evaluated. A biopsy and observation of clinical response are needed to confirm the diagnosis.
doi:10.4184/asj.2007.1.2.75
PMCID: PMC2857479  PMID: 20411128
Tuberclous spondylitis; Pyogenic spondylitis
7.  Expression Profile of Tumor Endothelial Marker 7 and a Putative Ligand in the Rat Spinal Cord and Dorsal Root Ganglion 
Asian Spine Journal  2007;1(2):65-74.
Study Design
To analyze the expression profile of tumor endothelial marker 7 (TEM7) in the spinal cord and dorsal root ganglion (DRG).
Purpose
To investigate the expression profile of TEM7 in the spinal cord and DRG of adult and developing rats.
Overview of Literature
Tumor endothelial marker 7 (TEM7) is a putative transmembrane protein that is highly expressed in the tumor endothelium and in cerebellar neurons.
Methods
In the present study, the expression profile of TEM7 in the spinal cord and DRG of the rat was investigated using in situ hybridization and immunohistochemical analysis. In addition, the secreted recombinant ectodomain of TEM7 was employed to label the expression of a putative ligand of TEM7 in the spinal cord and DRG.
Results
Specific TEM7 mRNA localization was observed in the motor neurons of the spinal cord and sensory neurons of the DRG. Glial cells and vascular endothelial cells did not show hybridization signals. Immunohistochemical analysis with a specific polyclonal antibody revealed a similar localization profile for TEM7 mRNA expression. In the spinal cord, weak labeling was observed in the gray matter. The TEM7 ectodomain localized the expression of a putative ligand of TEM7 in the neurilemmal structures and perineurium of the spinal nerve roots. In the DRG, ligand labeling was observed in the endoneurium and perineurium of the spinal nerves, and extracellular matrix around the sensory neurons. A developmental study has shown that TEM7 mRNA expression in the motor neurons of the spinal cord and DRG increased with age during postnatal development.
Conclusion
These findings indicate that TEM7 plays a role as a transmembrane receptor in neuronal populations of the spinal cord and DRG.
doi:10.4184/asj.2007.1.2.65
PMCID: PMC2857480  PMID: 20411127
Tumor endothelial marker; Spinal cord; Dorsal root ganglion; Ligand
8.  Pyogenic Spondylitis after Vertebroplasty - A Report of Two Cases - 
Asian Spine Journal  2007;1(2):106-109.
Vertebroplasty is now extensively used worldwide for thoracic and lumbar osteoporotic compression fractures. Although percutaneous vertebroplasty is considered a minimally invasive procedure, it may result in several complications. In this report, we present two patients where pyogenic spondylitis developed after vertebroplasty surgery was required. The serious nature of these infections, surgical management and complication avoidance are discussed.
doi:10.4184/asj.2007.1.2.106
PMCID: PMC2857481  PMID: 20411134
Vertebroplasty; Complications; Pyogenic spondylitis
9.  Incidence of Proximal Adjacent Failure in Adult Lumbar Deformity Correction Based on Proximal Fusion Level 
Asian Spine Journal  2007;1(1):19-26.
Study Design
Retrospective study.
Purpose
To review the results and proximal adjacent problems of long fusion (more than 4 levels) according to the level of proximal fusion (L2~T9) in adult lumbar deformity using pedicle screw fixation.
Overview of Literature
There are few written reports concerning proximal adjacent segmental failure according to the level of proximal fusion in adult lumbar deformity.
Methods
The radiographs and clinical records of thirty-five patients (30 females, 5 males) of adult lumbar deformity with more than 2-year follow-up after surgery were analyzed. The average age was 62 years (range, 38~75). All patients were divided into three groups according to the level of proximal fusion: Group 1 (n=14) fusion up to L1 or L2; Group 2 (n=14) fusion up to T11 or T12; and Group 3 (n=7) fusion up to T9 or T10.
Results
The preoperative coronal curve of 28±14° was corrected to 9±7° immediately after surgery and 11±7° at the final follow-up. The preoperative local kyphosis of 24±12° was corrected to -1±10° immediately after surgery and 1±11° at the final follow-up. The lumbar lordosis was 14±18° before surgery; 27±11° after surgery; and 16±12° at the final follow- up. The parameters of coronal and sagittal balance were improved in all patients after surgery, except one patient in group 2 who showed coronal imbalance due to over-correction. Sagittal imbalance at the most recent follow-up was detected in 10 patients with significant difference between the groups; 5 (36%) in Group 1, 5 (36%) in Group 2, and none in Group 3. Proximal adjacent segmental problems that are consisted with proximal disc degeneration with kyphosis, compression fractures above the fusion and screw failure proximal to the end of the fusion were observed in 15 patients with significant difference between the groups; 7 (50%) in Group 1, 7 (50%) in Group 2, and 1 (14%) in Group 3. There was 1 superficial infection and 2 transient neurologies.
Conclusions
Fusion up to throacolumbar junction (L2~T11) in surgical treatment of adult lumbar deformity had more proximal adjacent problems with poorer results. Fusion higher than T10 is recommended for adult lumbar deformity.
doi:10.4184/asj.2007.1.1.19
PMCID: PMC2857492  PMID: 20411148
Adult lumbar deformity; Proximal fusion level; Proximal adjacent problem; Adjacent segmental failure
10.  Prevalence and Morphologic Features of Ponticulus Posticus in Koreans: Analysis of 312 Radiographs and 225 Three-dimensional CT Scans 
Asian Spine Journal  2007;1(1):27-31.
Study Design
A retrospective review of three-dimensional CT scan images and radiographs.
Purpose
To investigate the prevalence and morphologic features of ponticulus posticus in Koreans.
Overview of Literature
There has been little reported on the prevalence or morphologic characteristics of ponticulus posticus in Asians, predisposing them to vertebral artery injury during screw placement in the lateral mass of the atlas.
Methods
The presence and types of ponticulus posticus were investigated on 225 consecutive cervical three-dimensional CT scans and 312 consecutive digital lateral cephalometric head radiographs.
Results
Various spectra of ponticulus posticus were found in 26% of the CT scans and 14% of the radiographs.
Conclusions
Ponticulus posticus is a relatively common anomaly in Koreans. Therefore, the presence of this anomaly should be carefully examined for on radiographs before lateral mass screw placement. If ponticulus posticus is suspected or confirmed on radiographs, three-dimensional CT scanning should be considered before placement of lateral mass screws into the posterior arch, especially given its wide variation of size and shape.
doi:10.4184/asj.2007.1.1.27
PMCID: PMC2857493  PMID: 20411149
Ponticulus posticus; Atlas; Lateral mass screw
11.  Surgical Correction of Fixed Kyphosis 
Asian Spine Journal  2007;1(1):12-18.
Study Design
A retrospective review was carried out on 23 patients with rigid fixed kyphosis who underwent surgical correction for their deformity.
Purpose
To report the results of surgical correction of fixed kyphosis according to the surgical approaches or methods.
Overview of Literature
Surgical correction of fixed kyphosis is more dangerous than the correction of any other spinal deformity because of the high incidence of paraplegia.
Methods
There were 12 cases of acute angular kyphosis (6 congenital, 6 healed tuberculosis) and 11 cases of round kyphosis (10 ankylosing spondylitis, 1 Scheuermann's kyphosis). Patients were excluded if their kyphosis was due to active tuberculosis, fractures, or degenerative lumbar changes. Operative procedures consisted of anterior, posterior and combined approaches with or without total vertebrectomy. Anterior procedure only was performed in 2 cases, while posterior procedure only was performed in 8 cases. Combined procedures were used in 13 cases, including 4 total vertebrectomies.
Results
The average kyphotic angle was 71.8° preoperatively, 31.0° postoperatively, and the average final angle was 39.2°. Thus, the correction rate was 57% and the correction loss rate was 12%. In acute angular kyphosis, correction rate of an anterior procedure only was 71%, correction rate of the combined procedures without total vertebrectomy was 49% and correction rate of the combined procedures with total vertebrectomy was 60%. In round kyphosis, correction rate of posterior procedure only was 65% and correction rate of combined procedures was 59%. The clinical results according to the Kirkaldy-Willis scale demonstrated 17 excellent outcomes, 5 good outcomes and one poor outcome.
Conclusions
Our data indicates that the combined approach and especially the total vertebrectomy showed the safety and the greatest correction rate if acute angular kyphosis was greater than 60 degrees.
doi:10.4184/asj.2007.1.1.12
PMCID: PMC2857494  PMID: 20411147
Surgical correction; Fixed kyphosis; Total vertebrectomy
12.  New Cervical Laminoplasty Polyethererketone Cage - Two Case Reports - 
Asian Spine Journal  2007;1(1):53-56.
Cervical laminoplasty is a widely used technique to enlarge the spinal canal for spinal cord decompression. The two common methods are an open door laminoplasty and a midline splitting laminoplasty. Several devices and materials have been used as a spacer for maintaining or stabilizing the lamina in the open or split position, however, some are difficult to implant. Moreover, they are not designed to restore the natural dynamics of the cervical spine, and can cause discomfort to the patient. There is a need to develop a device and material that will be effective in maintaining and stabilizing the position of the lamina after laminoplasty, being able to be implanted easily and safely to restore the natural dynamics of the cervical spine, as well as getting the bony union to the host bone. We report two cervical laminoplasty patients who were treated using a new laminoplasty polyetheretherketone cage.
doi:10.4184/asj.2007.1.1.53
PMCID: PMC2857495  PMID: 20411154
Cervical laminoplasty; Polyetheretherketone cage
13.  The Utility of Somatosensory Evoked Potential Monitoring During Cervical Spine Surgery: How Often Does It Prompt Intervention and Affect Outcome? 
Asian Spine Journal  2007;1(1):43-47.
Study Design
Retrospective review of the results of somatosensory evoked potentials (SSEP) performed in cervical spine surgery.
Purpose
To evaluate the utility of spinal cord monitoring during cervical spine surgery in a single surgeon's practice, based on how often it prompted an intraoperative intervention.
Overview of Literature
Intraoperative monitoring during cervical spine surgery is not a universally accepted standard of care. This is due in part to the paucity of literature regarding the impact of monitoring on patient management or outcome.
Methods
SSEP for tibial, median, and ulnar nerves were monitored in 809 consecutive cervical spine operations performed by a single surgeon. The average patient age was 52 years (range, 2 to 88 years), with 472 males and 339 females. Cases were screened for significant degradation or loss of SSEP data. Specific attention was paid to 1) what interventions were performed in response to the SSEP degradation with subsequent improvement, and 2) whether SSEP changes corresponded with postoperative neurological deficits.
Results
Seventeen of 809 patients (2.1%) had SSEP degradation that met warning criteria and therefore prompted intervention. Release of shoulder tape (8) or traction (4) most often resulted in SSEP improvement. Failure of SSEP data to return to within acceptable limits of baseline was associated with neurological deficit (p=0.04). Two patients awoke with new postoperative neurological deficits, which resolved in 6 hours and 2 months respectively. Patients with ossification of the posterior longitudinal ligament (OPLL) were at seven-fold greater risk of intraoperative SSEP degradation.
Conclusions
SSEP monitoring in this surgical population proved sensitive to perioperative factors which may increase the risk of postoperative neurologic deficit, and probably prevented neurological deficits in 15 of 809 patients (1.9%). Improvement in data following intervention appears to correlate well with unchanged neurologic status. Experience with intraoperative monitoring in this patient series has led to incorporation of these techniques as a standard of care in cervical spine surgeries performed by this surgeon.
doi:10.4184/asj.2007.1.1.43
PMCID: PMC2857496  PMID: 20411152
Somatosensory evoked potentials; Cervical spine surgery; Postoperative neurological deficits
14.  Serum Levels of TGF-β1, TIMP-1 and TIMP-2 in Patients with Lumbar Spinal Stenosis and Disc Herniation 
Asian Spine Journal  2007;1(1):8-11.
Study Design
The serum levels of transforming growth factor-beta 1 (TGF-β1), tissue inhibitor of matrix metalloproteinase-1 (TIMP-1) and TIMP-2 were measured by enzyme-linked immunosorbent assay.
Purpose
To compare the serum levels of TGF-β1, TIMP-1 and TIMP-2 between patients with lumbar spinal stenosis and disc herniation.
Overview of Literature
It has been reported that increased concentrations of TGF-β1, TIMP-1 and TIMP-2 in the ligamentum flavum might be a possible pathogenesis for ligamentum flavum hypertrophy in spinal stenosis. However, it is not determined whether this phenomenon in spinal stenosis is a local or systemic problem.
Methods
The concentrations of TGF-β1, TIMP-1 and TIMP-2 were quantitatively analyzed by ELISA in the ligamentum flavum and serum of patients with lumbar spinal stenosis (n=16) and disc herniation (n=16). The thickness of ligamentum flavum was measured on axial T1-weigted magnetic resonance image. The biochemical and radiological results were compared for the two conditions.
Results
The thickness of the ligamentum flavum was larger in patients with spinal stenosis compared with that with disc herniation (p=0.001). The mean concentrations of TGF-β1, TIMP-1, and TIMP-2 in the ligamentum flavum were significantly higher in patients with spinal stenosis than those with disc herniation (all, p < 0.05). However, the difference in serum levels of TGF-β1 (p=0.464), TIMP-1 (p=0.146) and TIMP-2 (p=0.794) was not significant between the lumbar spinal stenosis and disc herniation patients.
Conclusions
Despite increased levels of TGF-β1, TIMP-1, and TIMP-2 in the ligamentum flavum of spinal stenosis patients compared to disc herniation patients, the serum levels of TGF-β1, TIMP-1 and TIMP-2 were very similar in both groups. These results indicate that the role of TGF-β1, TIMP-1 and TIMP-2 on hypertrophy of the ligamentum flavum in spinal stenosis patients is a local phenomenon, not systemic.
doi:10.4184/asj.2007.1.1.8
PMCID: PMC2857497  PMID: 20411146
Spinal stenosis; Hypertrophy of ligamentum flavum; TGF-β1; TIMPs; Local phenomenon
15.  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
16.  Epidural Hematoma Presenting with Severe Neck Pain without Neurological Deficit - A Late Complication of Posterior Cervical Spine Surgery: Presentation of Three Unusual Cases 
Asian Spine Journal  2007;1(1):57-60.
Postoperative epidural hematoma (EDH) usually present with neurological deficit. Massive EDH presenting with only severe pain without neurological deficit are rare. Atypical presentations of postoperative EDHs may lead to delayed diagnosis and treatment. We present three such cases after posterior cervical spine surgery. Three patients presented with severe neck pain and spasms without motor deficits several days after posterior cervical decompressive procedures. Imaging studies identified compressive EDHs at the surgical site with severe compression of the spinal cord. All were treated with emergent decompression, with resulting improvement of symptoms and pain relief without further neurological sequelae. In conclusion, postoperative EDHs after posterior cervical spine surgery may result in minimal neurological deficit. Our report reminds surgeons to keep this possibility in mind when patients complain of unusually severe neck pain and spasms after posterior cervical spine surgery.
doi:10.4184/asj.2007.1.1.57
PMCID: PMC2857499  PMID: 20411155
Cervical spine; Epidural hematoma; Postoperative complication
17.  Delayed Post-traumatic Vertebral Collapse: MR Categorization and MR-Pathology Correlation 
Asian Spine Journal  2007;1(1):32-37.
Study Design
A retrospective study.
Purpose
To categorize the MR appearance of ischemic vertebral collapse and to correlate surgical and histologic findings.
Overview of Literature
X-ray and MRI findings of delayed posttraumatic vertebral collapse shows several patterns. Histopathologic signs of osteonecrosis were present only in minor portion of cases sampled for biopsy of delayed post-traumatic vertebral collapse in the literature.
Methods
Twenty-one patients (22 vertebral bodies), with surgically and histopathologically proven ischemic vertebral collapse were included. The patients were examined with a 1.5 T MR imager. Spin echo T1- and T2-weighted images were obtained in axial and sagittal planes. Two experienced musculoskeletal radiologists, who reached consensus, evaluated the MR images. Then, MR-pathology correlations were made.
Results
Four different MR patterns were identified. Fluid patterns, were seen in 14% (3/22) of the affected vertebral bodies, and were characterized by hypo-intense signals on T1-weighted images, and hyper-intense signals, similar to water, on T2-weighted images. Extensive bone necrosis was predominant. Compression pattern, the most common pattern, found in 41% (9/22 vertebral bodies), was characterized by a marked decrease of anterior column height. Bone necrosis, granulation tissue, marrow fibrosis, and reactive new bone formation were found in relatively equal proportion. Granulation pattern, seen in 27% (6/22 vertebral bodies), was characterized by hypo-intense signals on T1-weighted images, and intermediate signals on T2-weighted images. Extensive granulation tissue was predominant. Mixed patterns were present in 18% (4/22), of the vertebral bodies.
Conclusions
Awareness of histopathologic correlation of MR patterns in patients with delayed post-traumatic vertebral collapse may facilitate effective interpretation of clinical MR images of the spine.
doi:10.4184/asj.2007.1.1.32
PMCID: PMC2857500  PMID: 20411150
MR patterns; Delayed vertebral collapse; Pathology
18.  High-Intensity Zone on L-spine MRI: Clinical Relevance and Association with Trauma History 
Asian Spine Journal  2007;1(1):38-42.
Study Design
This is a retrospective study.
Purpose
We wanted to investigate the clinical relevance of the lumbar high intensity zone (HIZ) on magnetic resonance imaging (MRI) and the relationship of trauma history to internal disc disruption (IDD).
Overview of Literature
HIZs on lumbar spine (L-spine) MRI have been suggested as a reliable marker of IDD by some authors. The prevalence and type of spinal trauma in IDD have not yet been carefully analyzed.
Methods
L-spine MRIs of 737 patients with low back pain with or without associated leg pain were reviewed for the presence of HIZs. HIZs on T2-weighted MR images were determined according to the Aprill and Bogduk criteria. A review of medical records and a telephone interview were performed for further analyses of pain.
Results
HIZs were found in 117 patients and 153 discs among a total of 737 patients who met the inclusion criteria. Both a medical record review and a telephone interview were possible with 99 patients. Among these, 42 patients had had an episode of trauma. Seventeen of these had a relatively high-energy injury such as a traffic accident or a fall. Regarding back pain, 27 patients complained of typical discogenic back pain. Only 11 patients had both a trauma history and typical discogenic pain and 41 patients (42%) had neither a trauma history nor typical natural pain.
Conclusions
Given the low incidence of discogenic pain, a HIZ on an L-spine MRI appears less meaningful than often assumed as a specific marker of IDD. Trauma, such as a traffic accident, seems unlikely to be the main cause of IDD.
doi:10.4184/asj.2007.1.1.38
PMCID: PMC2857501  PMID: 20411151
High-intensity zone; Trauma history; Discogenic pain; Internal disc disruption
19.  Spinal Epidural Abscess with Pyogenic Arthritis of Facet Joint Treated with Antibiotic-Bone Cement Beads - A Case Report - 
Asian Spine Journal  2007;1(1):61-64.
Most epidural abscesses are a secondary lesion of pyogenic spondylodiscitis. An epidural abscess associated with pyogenic arthritis of the facet joint is quite rare. To the best of our knowledge, there is no report of the use of antibiotic-cement beads in the surgical treatment of an epidural abscess. This paper reports a 63-year-old male who sustained a 1-week history of radiating pain to both lower extremities combined with lower back pain. MRI revealed space-occupying lesions, which were located in both sides of the anterior epidural space of L4, and CT scans showed irregular widening and bony erosion of the facet joints of L4-5. A staphylococcal infection was identified after a posterior decompression and an open drainage. Antibiotic- bone cement beads were used as a local controller of the infection and as a spacer or an indicator for the second operation. An intravenous injection of anti-staphylococcal antibiotics resolved the back pain and radicular pain and normalized the laboratory findings. We point out not only the association of an epidural abscess with facet joint infection, but also the possible indication of antibiotic-bone cement beads in the treatment of epidural abscesses.
doi:10.4184/asj.2007.1.1.61
PMCID: PMC2857502  PMID: 20411156
Epidural abscess; Facet joint infection; Lumbar spine; Antibiotic-bone cement bead
20.  Cervical Myelopathy Secondary to Atlas Hypoplasia - Reports of 3 Adult Cases - 
Asian Spine Journal  2007;1(1):48-52.
There have been paucity of reports on atlas hypoplasia, and as a result this condition is not clearly defined, nor well understood. The authors reported three cases of atlas hypoplasia that were found in adults who presented with myelopathic symptoms. On radiographic examination, it was found that the anterior-posterior diameter of the atlas was remarkably narrower in all three cases in comparison with normal persons. The MRI in all three cases also revealed intramedullary high signal lesions at the levels where severe spinal cord compression was present. This led to our diagnosis of atlas hypoplasia causing myelopathy.
doi:10.4184/asj.2007.1.1.48
PMCID: PMC2857503  PMID: 20411153
Atlas hypoplasia; Cervical myelopathy; Cervical spinal stenosis

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