Conservative Treatment of Compression and Stable Burst Fractures in the Thoracolumbar Junction: Early Ambulation Vs. Late Ambulation / 대한정형외과학회잡지

PURPOSE: To analyze the efficacy of early ambulation in a selected group of patients with compression and stable burst fractures in the thoracolumbar junction. MATERIALS AND METHODS: We reviewed retrospectively 65 cases of compression and stable burst fractures in the thoracolumbar junction. Group I was composed of 36 cases treated with bed-rest for 2 weeks or less followed by ambulation with bracing, Group II 29 cases treated with bed-rest for 4 weeks or more followed by ambulation with bracing. Radiologic results were compared for the two groups using lateral radiographs, and functional results were analyzed using Denis pain and work scores. RESULTS: Change in wedge angle at last follow up was 6.39+/-3.67degrees in group I and 5.28+/-2.72degrees in group II. Change in anterior body height was 14.46+/-8.25% in group I and 12.25+/-4.58% in group II (p>0.05). Satisfactory pain scores of less than or equal to P3 were noted in 11 cases (69%) of group I and in 12 cases (80%) of group II. Satisfactory work scores of less than or equal to W3 were noted in 12 cases (75%) of group I and in 12 cases (80%) of group II (p>0.05). CONCLUSION: Conservative management of compression and stable burst fractures in the thoracolumbar junction with 2 weeks or less of bed-rest followed by ambulation with bracing can predictably lead to satisfactory functional results.

Surgical Treatments of Intradural Extramedullary Tumor / 대한척추외과학회지

STUDY DESIGN: Retrospective study on 12 cases of intradural extramedullary tumor. OBJECTIES : To analyze the clinical symptoms and the outcome of the treatments in the 12 patients who had intradural extramedullary tumors. SUMMARY OF LITERATURE REVIEW : In order to provide a good prognosis and achieve a satisfactory clinical outcome for the treatment of intradural extramedullary tumors, early diagnosis and careful surgical resection is necessary. MATERIALS AND METHODS: Twelve cases of intradural extradmedullary tumors were treated surgically from September 1990 to July 2000. Of the 12 cases, 7 were male and 5 were femal. Average follow-up period was 37 months. Mean age of the cases was 48.3 years. The followings were analyzed; 1)histopathologic diagnoses, 2)locations of tumors, 3)clinical findings, 4)duration of symptoms, and 5)radiologic findings. In addition, both changes of symptoms as well as neurologic findings during the preoperative stage and the postoperative follow-up were evaluated according to the Frankel's and Kim 's criteria. RESULTS: Histiopathologic results were as follows; 6 cases (50%) confirmed as schwannoma, 3 cases (25%) as meningioma, 1 case as epidermoid cyst, 1 case as neurofibroma, and 1 case as arachnoid cyst. Locations of tumors were as follows; 6 cases (50%) located in the thoracic region, 4 cases (33%) located in the lumbar, 1 case located in the cervical region, and 1 case located in the sacrum. Clinical findings were as follows: 6 cases complained of back pain and radiating pain to leg, 6 cases noticed motor weaknesses and sensory changes of varying degrees. The average duration from initial symptoms to admission was 57 months (23-140 months). Laminectomy and complete resection of tumors were performed in all cases. Posterior spinal fusion with instrumentation was necessary only in one case. The preoperative Frankel's grades were as follows; 6 cases were in grade C, 4 cases in grade D, and 2 cases in grade E. At the final follow-up, all cases were graded as E . CONCLUSION: The Early diagnosis and careful surgical resection for intradural extramedullary tumors provide for a good prognosis as well as a positive clinical outcome. Intradural tumors should be included in the differential diagnosis of spine diseases and considered as a subdivision of orthopaedic spine surgery.

Intraoperative Spinal Nerve Root Injuries during Surgery for Degenerative Low Back Disease / 대한척추외과학회지

STUDY DESIGN: A retrospective study OBJECTIVE: To analyze incidence, causes and prognosis of the spinal nerve root injury during the degenerative low back surgery. SUMMARY OF LITERATURE REVIEW: There were very few studies about intraoperative spinal nerve root injuries during low back surgery. MATERIALS AND METHODS: Six hundred and twenty seven patients underwent degenerative low back surgery from Jan 1990 to Jan 2001 were included in this study. All patients were operated on by the first author and operation records made by the author himself were reviewed. Eight cases of intraoperative spinal nerve root injury were identified and causes and level of injuries, preoperative diagnosis, types of surgery and follow-up clinical results were analyzed. RESULTS: Eight cases of nerve root injury were developed during 5 posterior laminotomies for discectomy and 3 instrumentation and fusion. Spinal nerve root injuries were caused by Kerrison punch in 4 cases, pituitary forcep in 2, rongeur in 1, and not certain but probably by Kerrison punch in 1 case. The levels of injuries were 5th lumbar nerve root in 4 cases, and 1st sacral nerve root and 2nd lumbar nerve root in 1 case respectively. Two cases had sacral nerve rootlet injury with paramedian dural tear but the level of root injury was uncertain. Six of 8 patients had symptoms. There were sensory loss in 4 patients, pain in 2, and one patient had both sensory loss and loss of big toe extension power. Neurological symptoms were not improved throughout the follow-up period, but 2 patients who had pain were resolved their symptoms by 3 months. CONCLUSIONS: Incidental spinal nerve root injury occurred in 1.3 percentage of the patients who underwent low back surgery. Half of them had neurologic symptoms and they showed poor prognosis. However motor deficit was relatively uncommon and it might be related to the anatomical characteristics of spinal nerve root.

Analysis of Aortic Passage in the Thoracic Region by Magnetic Resonance Imaging / 대한척추외과학회지

STUDY DESIGN: The relationships between aorta and thoracic vertebrae were analyzed by using MR images. OBJECTIVES: The purpose of this study was to provide information upon the thoracic aortic passage to prevent vascular compli-cations during anterior and posterior instrumentations for various spinal disorders and traumas. SUMMARY OF BACKGROUND DATA: A number of morphometric investigations have been performed on the thoracic vertebrae, but the anatomical relationship between aorta and the thoracic vertebral body has not been analyzed. METHODS: The MR images of 32 patients with normal thoracic vertebral column were obtained. The angle between the transverse axis of the thoracic vertebral body and the thoracic aorta, the diameter of the thoracic aorta and the closest distance between the thoracic vertebral body and the thoracic aorta from T2 to T12 were measured on axial MR images. RESULTS: The smallest angle between the transverse axis of the thoracic vertebral body and the line connecting the centers of the vertebral body and aorta was 6.8 degrees/3.7 degrees(male/female) in the T5-6 region and highest angle observed was 56.3 degrees/55 degrees in the T12 region. The angle decreased between T2 and T5-6 and then increased after T6. The mean external diameter of the thoracic aorta was 32.8 mm, and the largest diameter of the thoracic aorta was 24.7/25.4 mm (M/F) in the T4-5 region. The aortic arch was first seen in the T2 region and it formed an arch in the T3-4 region. The shortest distance between the thoracic vertebral body and the thoracic aorta wall was 0.8/0.7 mm in the T12 region and the greatest distance between the vertebral body and the aorta was 11.84/6.75 mm in the T2-3 region. CONCLUSION: From T4 to T8, the aorta is located just left lateral to the vertebral body. In this area, the aorta is jeopardized by a screw penetrating the vertebral body during anterior instrumentation, if the screw protrudes beyond the pedicle during posterior instrumentation. The surgeon should be familiar with the anatomical relationship between aorta and the vertebral column when planning a surgical procedure or the use of instrumentation in this region.

Decision of Posterior Fixation Level by Load-Sharing Classification in Thoracolumbar and Lumbar Burst Fracture / 대한척추외과학회지

STUDY DESIGN: Retrospective study on 54 thoracolumbar and lumbar burst fractures treated with pedicle screw instrumentation. OBJECTIVES: To decide the optimal level of fusion in thoracolumbar and lumbar burst fractures treated with pedicle screw instru-mentation by load sharing concept. SUMMARY OF LITERATURE REVIEW: Short segment pedicle screw fixation is condemned with frequent failure in maintenance of reduction. The type of posterior fixation construct that is most desirable is less well defined. MATERIALS AND METHODS: Using the Load-Sharing classification, Group I consisted of 24 cases with fractures totaling 6 points or less underwent surgery which was subdivided into two subgroups(A : 1 level above and below including fractured vertebra, B : long segment fixation). Group II consisted of 30 cases with fractures totaling 7 points or more underwent surgery which was sub-divided into three subgroups(C : 1 level above and below including fractured vertebra, D : 2 levels above, 1 level below including fractured vertebra, E : 2 levels above and below the fractured vertebra). Change of segmental kyphosis, inter-screw angle, upper disc height, lower disc height and anterior body height were measured using post-operative and follow-up lateral radiographs. RESULTS: Comparing two subgroups in group I(A Vs. B), group A showed definitely more loss of upper disc height than group B but the others were not significantly different. Comparing three subgroups in group II(C, D, E), group C showed definitely more loss of reduction than two other groups but loss of anterior body height was not significantly different. There were no significant differences between group D and E. CONCLUSIONS: For fracture totaling 6 points or less, the long segment fixation(2 level above and 1 level below including fractured vertebra) is a successful method at thoracolumbar junction and short segment fixation to preserve motion segment at lumbar spine. For fracture totaling 7 points or more, short segment fixation is inappropriate and long segment pedicle screw fixation (2 level above and 1 level below including fractured vertebra) could effectively treat burst fractures of thoracolumbar and lumbar spine.

Pre-sacral Giant Schwannoma: Removal by a Combined Anterior and Posterior Approach: A Case Report / 대한척추외과학회지

STUDY DESIGN: This case report presents a rare case of pre-sacral giant schwannoma which originates from the S1 nerve root. OBJECTIVES: To discuss a surgical approach for removal of pre-sacral giant schwannoma and review the pertinent literatures. SUMMARY OF LITERATURE REVIEW: Pre-sacral tumors are unusual neoplasms that cause approximately one in 40,000 hospital admissions. Schwannoma represents only a small fraction of the many types of tumors that may be present in this region. Less than 1% of all spinal schwannomas occur in the sacrum. The treatment of this lesion is complete removal, which is curative. MATERIALS AND METHODS: A 46-year-old woman developed gradual back pain and radiating pain on her left lower extremity for about a year. There was no noted improvement with the use of conservative treatment. T1-weighted sagittal MRI reveals a large homogeneous low-signal intensity mass on left pre-sacral area and intrasacral extension of the tumor forming a dumbbell shaped mass. RESULTS: The tumor was completely removed by a combined anterior and posterior approach. The excised mass was cylindrical, measuring 8x4x3cm in size, which had originated from the S1 nerve root. It was histologically diagnosed as benign schwannoma. Satisfactory result was obtained after the complete removal of the mass. CONCLUSIONS: We report a case of the successful and complete removal of a pre-sacral giant schwannoma and the affected nerve root through a combined anterior and posterior approach.

Injury of Posterior Ligament Complex with Cervical Spine Fracture / 대한척추외과학회지

OBJECTIVE: To define the clinical and radiological characteristics of the patients with injury of the posterior ligament complex of the cervical spine using MR imaging. MATERIALS AND METHODS: Forty patients with acute cervical spine fracture who underwent surgery were examined with MR imaging and plain radiography. Twenty-five patients underwent posterior fusion. The MR findings were correlated with surgical findings, clinical findings, and plain radiographs. RESULTS: Posterior ligament complex injury was detected in 75% (n=30) of all patients. Of the 20 patients with distractive-flexion injury, 90%(n=18) had posterior ligament complex injury (p<0.05). Of the 15 patients with compressive-flexion injury, 73% (n=11) had ligament injury. Of the 4 patients with vertical compression injury, 1 patient (25%) showed ligament injury. One patient with distractive-extension injury did not show ligament injury. Of the 23 patients with complete spinal cord injury, 96% (n=22) showed ligament tear (p<0.05). Of the 17 patients without complete cord injury (15 incomplete injury, 2 no cord injury), 47% (n=8) had ligament injury. Surgical findings were well correlated with MR imaging in patients who underwent posterior surgery (p<0.05). CONCLUSIONS: Injury of the posterior ligament complex in patients with cervical spine fracture was most common in patients with distractive-flexion injury and was more frequent with complete cord injury. MR imaging could reliably reveal such injuries.