A Treatment Guideline for Neuropathic Pain

STUDY DESIGN: A review of literature including definition, diagnosis and treatment of neuropathic pain. OBJECTIVES: To review and discuss the treatment guideline for neuropathic pain. SUMMARY OF LITERATURE REVIEW: Neuropathic pains are characterized by partial or complete somatosensory change caused by various disorders affecting central and peripheral nervous system, and are especially problematic because of their severity, chronicity and resistance to simple analgesics. MATERIALS AND METHODS: Review of literature. RESULTS: Tricyclic antidepressants and the anticonvulsants gabapentin and pregablin were recommended as first-line treatments for neuropathic pain. Opioid analgesics and tramadol were recommended as second-line treatments that can be considered for first-line use in selected clinical circumstances. Other medications such as dual reuptake inhibitors of both serotonin and norepinephrine would be used in severe cases. More invasive interventions (e.g., spinal cord stimulation) may sometimes be helpful. CONCLUSIONS: Treatment must be individualized for each patient and aggressive, combinatory pharmacotherapy and multidisciplinary approach are recommended for the treatment of neuropathic pain.

Prevalence And Risk Factor of Degenerative Disease of Adjacent Segment after Anterior Cervical Arthrodesis

STUDY DESIGN: A retrospective radiologic and clinical analysis of 48 patients following anterior cervical fusion. OBJECTIVES: To examine the prevalence of symptomatic adjacent segment disease after anterior cervical fusion and determine the risk factors affecting its progression. SUMMARY OF LITERATURE REVIEW: Symptomatic adjacent segment disease appears to occur at a rate of 2% to 3% per year. MATERIALS AND METHODS: Forty-eight patients, who were followed up for more than 3 years after anterior cervical arthrodesis, were enrolled in this study. A modification of the Robinson criteria was used for the clinical evaluation and the radiographic grading of Hilibrand was used for the radiology evaluation. Kaplan-Meier survival analysis was used to examine the survival rate. Age, gender, number of fusion segments, preoperative ROM, angle of lordosis, spinal canal diameter and radiologic degeneration of adjacent segments were selected as potential risk factors. The subjects were divided into two groups according to their clinical symptoms. RESULTS: Symptomatic adjacent segment disease developed in 11 of the 48 patients(22.9%). The disease free survival rates were 88.7%, 82.4% and 58.7% at 5, 10 and 15 years, respectively. A study of the risk factors showed that preoperative degenerative changes and narrow spinal canal in the adjacent segments were significant. However, there were no significant associations with age, gender, number of fusion segments, preoperative ROM and angle of lordosis. CONCLUSION: The prevalence of symptomatic adjacent segment disease after anterior cervical fusion was considerable and higher when the patients had preoperative degenerative changes and a narrow spinal canal in the adjacent segments.

Change of Deformity due to Position and Anesthesia in Adolescent Idiopathic Scoliosis / 대한정형외과학회잡지

PURPOSE: To determine changes in the end vertebra and neutral vertebra as well as in the magnitudes of coronal and rotational deformities according to position and anesthesia in patients with adolescent idiopathic scoliosis. MATERIALS AND METHODS: Sixty-two structural curves in 31 patients were evaluated using standing, supine, side bending, post-anesthesia, and postoperative anteroposterior plain radiographs. Cobb angles and rotation angles by perdriolle torsionmeter were measured, and the end vertebra and neutral vertebra were identified in each radiograph. RESULTS: Coronal cobb angles decreased significantly with correction rates of 25.0%, 31.7%, 59.5%, and 74.0%, and rotational deformities decreased with correction ratesof 6.1%, 24.5%, 6.2%, and 25.7% by supine position, anesthesia, side bending and surgery, respectively.The end vertebrae changed in 18 patients (58.1%) in both supine and post-anesthesia radiographs, and the neutral vertebrae changed in 10 patients (32.3%) in supine radiographs and in 20 patients (64.5%) in post-anesthesia radiographs. CONCLUSION: Coronal deformities are significantly corrected by supine position and anesthesia. Anesthesia significantly corrects axial rotation, but more correction cannot be achieved by rod derotation. The end vertebra and neutral vertebra have a tendency to vary by position and anesthesia, which gives rise to confusion in the determination of fusion level.

Early-Onset Facioscapulohumeral Muscular Dystrophy: Significance of Pelvic Extensor in Sagittal Spinal Imbalance / 대한정형외과학회잡지

An 11-year-old girl with early-onset facioscapulohumeral muscular dystrophy (FSHD) presented with progressive gait disturbance and lumbar hyperlordosis. The motor power of her pelvic extensor muscles was grade 3. Pelvic tilt and hip flexion were markedly increased as determined by gait analysis. This FSHD case is an impressive example of a patient demonstrating the concept that weak pelvic extensor muscles cannot keep the spine upright and balanced. The most important factor in the development of hyperlordosis is the weakness of the pelvic extensor muscles, and the results of gait analysis exquisitely explain the pathophysiology. The patient stands with her spine hyperextended to maintain upright posture by a compensatory mechanism of relatively strong back extensor muscles. Corrective surgery for lumbar hyperlordosis was not considered as it could eliminate the compensatory lumbar hyperextension, thus making the spine of the patient stoop forward through the hip joint during walking, being caused by the weakness of her pelvic extensor muscles.

Herpes Zoster Confused with Radiculopathy / 대한정형외과학회잡지

PURPOSE: To describe the clinical features of herpes zoster that can be easily misdiagnosed as cervical or lumbar radiculopathy. MATERIALS AND METHODS: We retrospectively reviewed the medical records and diagnostic studies of 7 patients with herpes zoster-related arm or leg pain. RESULTS: Except one immunocompromised patient with suspected postherpetic neuralgia or sequelae of herpetic myelitis, the other 6 patients with herpes zoster complained of very severe initial pain of sudden onset. Three patients did not show skin lesions on initial examination, and 2 of 5 patients with an MRI of the cervical or lumbar spine had findings consistent with their arm or leg pain and may have been confused with radiculopathy. Conservative treatment, including antiviral agents, improved the symptoms of all patients except the immunocompromised one. Selective nerve root blocks of the corresponding dermatomes were performed in 5 patients and extremity pain decreased over 50% in 4 of them. CONCLUSION: Herpes zoster can be confused with radiculopathy in patients with arm or leg pain if the typical skin lesions have not been developed. Unnecessary treatments including surgery should be avoided by early, correct diagnosis through prudent history taking and physical examination.

Risk Factors for Adjacent Segment Disease After Lumbar Fusion / 대한척추외과학회지

STUDY DESIGN: Retrospective study of adjacent segment disease. OBJECTIVES: To describe the incidence and clinical features of adjacent segment disease (ASD) after lumbar fusion and to determine its risk factors. SUMMARY OF LITERATURE REVIEW: The reported incidence of adjacent segment problems is variable, and little has been discussed about surgically treated cases. Risk factors also have not been precisely identified, especially based on structural changes seen on magnetic resonance imaging (MRI). MATERIALS AND METHODS: We analyzed the records of 1,124 patients who underwent lumbar or lumbosacral instrumented fusions between August 1995 and March 2006 and had at least one year follow-up. Of these patients, 28 patients who needed secondary operations because of ASD were included in this study. The disease group was compared with an age-, sex-, fusion level-, and follow-up period-matched control group composed of the same number of patients, toward the purpose of analyzing six variables as risk factors. RESULTS: The incidence of ASD requiring surgical treatment was 2.48%. The mean patient age was 58.4 years, which showed no statistically significant difference from that of the population in which ASD did not develop (57.0 years, p=0.429). Only 1 distal ASD occurred among 21 floating fusions. Facet degeneration was a significant risk factor (p<0.01) on logistic regression analysis. CONCLUSION: Our study patients with ASD complained of severe symptoms with frequent neurological abnormalities. The incidence of distal ASD was much lower than that of proximal ASD. Pre-existing facet degeneration may confer a high risk of adjacent segment problems after lumbar fusion procedures.

A Novel Concept for the Best Coronal Alignment of Pedicle Screws in Multilevel Lumbar Posterior Instrumentation - A Technical Note / 대한척추외과학회지

Correct alignment of pedicle screws is imperative in multilevel instrumentation. However, there has been no report addressing the technical aspects of this subject. If the head diameter of a pedicle screw is D, the head height is H, and the convergence angle of the screw being inserted is alpha, then the distance between the extension line of the medial borders of the inserted screw heads and the insertion point of the adjacent screw (A) is described by the following formula: A = 1/2Dcos alpha- Hsin alpha If an L3 pedicle screw (D=13 mm, H=15 mm) is to be inserted with a convergence angle of 14 degrees after the insertion of L4 and L5 screws, its insertion point should be 3.6 mm medial to the extension line of the centers of the L4 and L5 screws and 2.7 mm lateral to the extension line of their medial borders for all screw heads, so it can be aligned in the coronal plane. In order to achieve the best alignment, a pedicle screw is inserted between the extended line of the centers and that of the medial borders of the inserted adjacent screw heads. For the routine range of convergence angles, it is essential to move the entry point medially toward the extended line connecting the medial borders of the inserted adjacent screw heads.

Scoliosis Correction with Thoracic Pedicle Screws: Posteroanterior C-arm Rotation Method / 대한정형외과학회잡지

Purpose: This study evaluated a practical, safe and accurate method of thoracic pedicle screw insertion for the surgical treatment of scoliosis using the posteroanterior C-arm fluoroscopy rotation method. Materials and Methods: A total of 611 thoracic pedicle screws were inserted in 45 patients using the posteroanterior (PA) C-arm rotation method. CT scans were taken postoperatively in the transverse and sagittal sections to evaluate the pedicle screw placement. Results: A mean preoperative curve of 57.7o was corrected to 17.1o (range, 3o-45o) in the coronal plane. The postoperative CT scans revealed that 10 screws (1.6%) had penetrated the medial cortex by a mean distance of 3.0 mm and 56 screws (9.2%) penetrated the lateral cortex by a mean distance of 3.5 mm. No screw penetrated the inferior or superior cortex in the sagittal plane. However, 21 screws (3.4%) penetrated the anterior cortex. No neurological or vascular complications were encountered, and none of the screws required replacement. Conclusion: Thoracic pedicle screw insertion in scoliosis patients using the posteroanterior C-arm rotation method is a practical, simple and safe technique that allows the en face visualization of both pedicles by rotating the C-arm to compensate for the rotational deformity.

A Comparative Experimental Study of Allograft andPorous Hydroxyapatite as Bone Substitutes / 대한정형외과학회잡지

PURPOSE: An experimental animal study was performed to compare the bone fusion capacity of an allograft and porous hydroxyapatite. MATERIALS AND METHODS: Three milliliters of allograft or porous hydroxyapatite particles were inserted between the 4th and 5th lumbar transverse processes of New Zealand white rabbits weighing 3-3.5 kg. The total number of rabbits was 30, which were divided randomly into 2 groups. The bone formation and fusion capacity were evaluated 12 weeks after surgery through the gross findings and manual palpation, as well as radiological, biomechanical, and histological studies. Six rabbits in the allograft group died during breeding but the autopsy finding did not show any evidence suggesting an infection or graft rejection. The allograft was harvested from the iliac crest of the rabbits of the same species aseptically and was preserved at ??80oC for at least 7 days before implantation. RESULTS: The fusion rates were 55.6% (5/9) and 66.7% (10/15) in the allograft and porous hydroxyapatite groups, respectively. The mean values of the tensile strengths were 140.7 N in the allograft group and 189.6 N in the porous hydroxyapatite group. Histological analysis of 2 specimens from each group revealed theporous hydroxyapatite group to show a slightly better osteoconduction capacity. CONCLUSION: The porous hydroxyapatite group showed better bony union capacity even though there was no significant difference between the 2 groups.

A Radiographic Analysis of Sagittal Spinal Alignment for the Standardization of Standing Lateral Position / 대한정형외과학회잡지

PURPOSE: To analyze the difference in sagittal balance based on different positions of both arms and to promote the proper lateral spine view which can reconstruct the most functional posture of sagittal balance. MATERIALS AND METHODS: We applied X-rays to thirty healthy male adults with no spinal diseases after application of marks on the skin surface at the location of the C7 and S1 vertebrae with the following five postures, standing lateral position with both arms neutral (posture A) with both shoulders flexed thirty degrees and ninety degrees (postures B and C) with both arms crossed (posture D) with both shoulders flexed ninety degrees and with both arms on a parallel bar (posture E). We analyzed the differences of the sagittal vertical axis, thoracic kyphotic angle, lumbar lordotic angle, and sacral inclination angle after the postural changes. RESULTS: The average sagittal vertical axis value from posture A to E was 1.47+/-2.06 cm, -0.58+/-2.96 cm, -2.11+/-2.67 cm, 0.16+/-2.38 cm, and -0.51+/-2.70 cm. We discovered that five postures were statistically different (one-way ANOVA, p<0.001) and that posture D was the closest to posture A (Duncan's multiple comparison test). However we did not observe any statistical differences among the thoracic kyphotic angle, the lumbar lordotic angle, and sacral inclination angle postures. CONCLUSION: We can reconstruct the functional sagittal alignment in the cross-arm position, which is the closest to the normal standing position.