Withdrawn: Spinal Abnormalities Associated with Marfan Syndrome

This article was withdrawn by the authors' request.

Withdrawn: Spinal Abnormalities Associated with Marfan Syndrome

This article was withdrawn by the authors' request.

Lumbar Epidermoid Inclusion Cyst after Single Spinal Puncture: A case report / 대한척추외과학회지

Epidermoid tumors of the central nervous system are infrequent(2%) and can occur congenitally or iatrogenically. Since Choremis et. al. reported intradural-extramedullary epidermoid tumor after repeated lumbar puncture, several cases have been reported. We experienced a case of epidermoid inclusion cyst after single lumbar puncture in a 7-year-old boy and report the clinical and radiologic findings with relevant literatures.

Spinal Abnormalities Associated with Marfan Syndrome / 대한척추외과학회지

STUDY DESIGN: This is a retrospective review on the spinal abnormalities in Marfan syndrome. OBJECTIVES: To analyze clinical and radiological features of the spine in Marfan syndrome. SUMMARY OF LITERATURE: Scoliosis & kyphosis are common spinal abnormalities in Marfan syndrome. Other spinal abnormalities associated with Marfan syndrome are rarely reported in the literature. MATERIALS AND METHODS: The spinal abnormalities which can be associated with Marfan syndrome were analyzed in 32 patients who were diagnosed as Marfan syndrome. Coronal and sagittal curvatures on whole spine standing film were evaluated with Cobb's method. Uncommon spinal abnormalities which can be associated with this syndrome, such as spondylolisthesis and dural ectasia were also evaluated. RESULTS: Scoliosis was identified in 18 of 32 patients(56.3%). The mean scoliotic angle was 26 degrees and thoracic curve was most common. Thoracic kyphosis, lumbar lordosis and thoracolumbar kyphosis were measured as 27 degrees +/- 13 degrees ( 0 degrees ~ 53 degrees), -42 degrees +/- 13 degrees( -10 degrees ~ -70 degrees ) and 9 degrees +/- 12 degrees ( -5 degrees ~ 4 5 degrees) respectively. Spondylolisthesis was present in two cases(6.3%), one of which was 15% slip and the other was 50% slip. Two cases of dural ectasia were confirmed with MRI. CONCLUSION: Marfan syndrome showed high incidence of scoliosis(56.3%) and thoracolumbar kyphosis(50%). The frequency of spondylolisthesis was only slightly higher than that in the general population. The dural ectasia is a common but little known abnormality. Therefore it has a significant diagnostic value without clinical importance. In Marfan syndrome, we should keep these common and uncommon spinal abnormalities in mind.

Evaluation of Factors on Clinical Results Following Expansive Laminoplasty for Cervical Myelopathy / 대한정형외과학회잡지

PURPOSE: To evaluate the results of expansive laminoplasty and to investigate the validity of various factors as prognostic indicators. MATERIALS AND METHODS: We studied retrospectively 37 patients between August 1993 and August 1998. The severity of the pre- and postoperative myelopathy was determined with the Japanese Orthopaedic Association (JOA) score. The recovery ratio was calculated. We divided the patients into two groups with good and fair outcomes, and then assessed for prognostic factors such as preop JOA scores, ages, sex, trauma, duration, Pavlov ratios, compression ratios and signal change in cord on T2W MRI. RESULTS: In 19 patients the percentage recovery of JOA score was higher than 50%, while in 18 patients it was lower than 50%. There were no significant differences in regards to history of trauma, sex, and duration, there was a tendency of good results when there were no changes in the signal in cord on T2W MRI. There were significant differences in the preoperative JOA scores, Pavlov ratios and compression ratios. CONCLUSION: The preoperative JOA score, Pavlov ratio, compression ratio and high signal intensity on T2W MRI can be used to predict prognosis.

Effect of Low Back Motion on the Morphometric changes of the Spinal Canal / 대한정형외과학회잡지

PURPOSE: To define possible mechanism of posture-dependent symptom of spinal stenosis by measuring the effect of low back motion on the morphologic change of intervertebral disc and spinal canal. MATERIALS AND METHODS: Twenty healthy young volunteers underwent magnetic resonance imaging (1.5T MR scanner, GE) while supine with their lumbar spine in neutral, flexed, extended, and right and left rotational positions. The axial MR images at the middle of the intervertebral disc of L3-4 and L4-5 were analyzed to measure the difference of the size and shape of the disc and spinal canal in each posture. RESULTS: Extension decreased the sagittal diameters and the cross-sectional areas of the dural sac and spinal canal and increased the thickness of ligamentum flavum, whereas flexion had the opposite effects. The gap between convex posterior disc margin and anterior margin of facet joint of each side, represented as subarticular sagittal diameter, increased with flexion and decreased with extension or rotation. The directions of the rotation did not result any asymmetry of the subarticular sagittal diameter, but right rotation resulted thickening of right ligamentum flavum. The shape and dimensions of disc did not significantly change according to the positions of low back. CONCLUSIONS: With extension or rotation, the thickness of ligamentum flavum increased and posterior margin of the intervertebral disc was approximated to facet joint secondary to posterior movement of upper vertebral body without any change of shape and size of the disc. These phenomena result decrease of the size of spinal canal and dural sac in extension or rotation posture in young healthy people and may explain the posture-dependent symptom of spinal stenosis.

Iatrogenic Aspergillus Spondylitis after Posterior Instrumentation: A Case Report / 대한척추외과학회지

STUDY DESIGN: This case report presents a rare case of Aspergillus osteomyelitis of the vertebra in an immunocompetent host. OBJECTIVES: To discuss the iatrogenic Aspergillus spondylitis after posterior instrumentation in an immunocompetent patient and review the pertinent literatures. SUMMARY OF BACKGROUND DATA: Aspergillus spondylitis is very rare especially in immunocompetent host. Treatment requires early debridement and continuous medication with antifungal drugs. RESULT: This report discusses a case that occured in an immunocompetent 60 year-old woman who had posterolateral fusion with posterior instrumentation for T12 burst fracture. After a few months of operation, she complained chronic back pain and progressive neurologic compromise. The MR imaging showed an epidural mass compressing the spinal cord, so hardware removal and curettage was done at neurosurgical department. Her symptoms were not improved after hardware removal, so anterior decompression and fusion was done again. The biopsy of the epidural mass showed septated hyphae which is the characteristic of Aspergillosis. With aggressive surgical debridement and continuous treatment with amphotericin B, follow-up examination at postoperative 2 years showed neurologic improvement about 2 grades by Frankel classification.

Correlation between Clinical Features and MRI Findings in One Level Lumbar Spinal Stenosis / 대한정형외과학회잡지

PURPOSE: To evaluate the clinical features and assess the MRI measurements of the stenosis quantitatively in patients undergoing surgery for level one lumbar stenosis. The goal of this study was to correlate MRI measurements with clinical features and define whether the measurements have prognostic value. MATERIALS AND METHODS: From October 1994 to October 1996, 31 patients with level one lumbar spinal stenosis underwent posterior decompression and posterolateral fusion with instrumentation. Average age of the patients at the time of surgery was 56 years (range, 34-77 years). There were 11 men and 20 women. Most commonly involved level was L4-L5 (29 patients). All patients were evaluated before surgery and at defined intervals of 6 weeks, 3 months, 6 months, 1 year after surgery and at last follow up. The average follow up period was 29 months (range, 19-43 months). Clinical features of the patients were back pain, radiating pain, intermittent neurogenic claudication and gross pain score. MRI measurements of the patients were measured by anteroposterior diameter of spinal canal, canal area, foraminal area and depth of lateral recess. A statistical analysis was performed with the Chi-square test and Mann Whitney test. RESULTS: Patients with smaller spinal canal area (area 80 mm2) (P0.05). Other MRI measurements did not correlate with the preoperative and postoperative clinical features. CONCLUSIONS: In conclusion, spinal canal area measured on the MR image seems to have some prognostic value in patients undergoing surgery for level one lumbar stenosis.

Analysis of the Sagittal Alignment of Normal Spines / 대한정형외과학회잡지

PURPOSE: This study was undertaken to increase the knowledge of the intra- and extra-spinal alignments and to help recovery of sagittal alignment in operation by measuring the normal values of the spinal alignment in relation to hip axis as well as those of the thoracic, thoracolumbar junction, lumbar and lumbosacral junction of sagittal alignment and their correlation. MATERIALS AND METHODS: Whole spine standing lateral radiographs were taken in young 100 adults without spinal abnormalities clinically and radiographically. Intraspinal alignment was measured with angles of thoracic kyphosis, lumbar lordosis, maximum thoracic kyphosis, maximum lumbar lordosis, angle of the thoracolumbar junction, sacral inclination, segmental angles and disc angles respectively with special emphasis on lumbar lordosis. Extraspinal alignment was measured with sacropelvic angle, spinopelvic balance and spinal balance in relation to hip axis. Correlations among these parameters were analyzed. RESULTS: Lumbar lordosis and thoracic kyphosis were measured -49 degree(-22 - -79 degree) and 32 degree(6 degree-56 degree), respectively. Slight amount of kyphosis in thoracolumbar junctional area was considered normal. Lumbar lordosis had significant correlation with thoracic kyphosis and sacral inclination. However, there was no correlation between thoracic kyphosis and sacral inclination. Lowest two lumbar segments comprised 71% of total lordosis. Lumbar lordosis usually started at L1-2 and gradually increased at each level caudally to the sacrum. Sacropelvic angle, spinopevlic balance and spinal balance were measured -11 degree(-6 degree - 24 degree), -4 cm (-10 - 2 cm), and -2 cm (-7 - 4 cm) respectively with C7 positioned posterior to hip axis mostly. CONCLUSIONS: There was a wide range of normal sagittal alignment of the thoracic and lumbar spines, and normal values of these alignments were not easily defined. Therefore, normal patterns of sagittal curvature and sagittal balance should be more emphasized.

Analysis on the Risk Factors of Vertebral Body Collapse in Metastatic Spine Tumors using MRI / 대한정형외과학회잡지

PURPOSE: Recently, MRI has been routinely used in detection and treatment of metastatic spine tumors, but no previous study on prediction and prevention of vertebral body collapse was done using MRI. This study was done to analyze the risk factors of collapse and to define criteria of impending collapse using MRI. MATERIALS AND METHODS: Ninety-five vertebrae of 69 patients with metastatic lesions were evaluated using ratio of involved axial area, sagittal area, costovertebral joint, pedicle, facet joint and uncovertebral joint involvement as independent variables. We defined collapse when there was a fracture of the end plate and loss of vertebral body height over 10%, and degree of collapse was measured as ratio of the body height to the mean of the height of adjacent bodies. The ratio of the involved area was measured on T1-weighted images which showed the largest area of tumor involvement. RESULTS: There noted collapse of the bodies in 11 of 14 cervical vertebrae, 24 of 48 thoracic vertebrae and 15 of 33 lumbar vertebrae. Metastatic involvement on axial images was considered as a significant risk factor regardless of the vertebral level, while costovertebral joint destruction and axial involvement were significant risk factors in the thoracic spine. The criteria of impending collapse were: 51-60% axial involvement of the vertebral body in the cervical and lumbar spine; 61-70% axial involvement of the vertebral body with no destruction of other structures, 21-30% involvement of the vertebral body with destruction of one costovertebral joint or destruction of both costovertebral joints regardless of body involvement in thoracic spine. CONCLUSIONS: Using the above criteria with consideration of the patient s general condition and biologic behavior of the primary tumor, prophylactic stabilization can be performed to prevent ver-tebral body collapse which results in severe pain or paralysis.

The Influence of the Various Configurations of Lower Lumbar and Lumbosacral Spine on the Disc Degeneration: Multifactorial Analysis / 대한정형외과학회잡지

There are some controversies on the mechanism of the lumbar disc degeneration and disc prolapse. But,it is clear that many factors are related to the disc degeneration. Configurations of the lower lumbar and lumbosacral spine have long been proposed as one of the important factors of disc degeneration in these areas. To look for the configurational risk factors and the probability of disc degeneration by the combinations of these factors, we analyzed simple radiographs and MRI of 73 patients who complaints of low back pain and are between 20 years and 39 years of age. We performed chi-square test and multivariate logistic regression analysis: L4-5 disc degeneration and L5-Sl disc degeneration as dependent variables and lumbar lordosis, sacral inclination, height of intercrest line, transitional vertebra and facet joint asymmetry as independent variables. We could not find any of these variables significantly related to the L4-5 intervertebral disc degeneration. For L5-S1 disc degeneration, only the presence of transitional vertebra was signicantly related. When there is no transitional vertebra, the probability of disc degeneration is 9 times(8.889) as large as that of presence of transitional vertebra. The probability of L4-5 disc degeneration without the degeneration of L5-S1 is 3 times as large as that of degeneration of both of L4-5 and L5-S1 disc in case of the presence of transitional vertebra.

Intravertebral Vacuum Phenomenon / 대한정형외과학회잡지

There are several reports on the intervertebral vacuum phenomenon since Maldague s report in 1978. This disease is, however, considered as uncommon and miscellaneous entity. We performed retrospective review of 27 collapsed vertebral bodies of 21 osteoporotic patients to define the clinical, radiological and pathological characteristics of intravertebral vacuum phenomenon. Simple radiographs and MRIs were reviewed and the pathological findings from 6 specimens were matched with MRI. Intravertebral air shadows were shown in all cases either on A-P or lateral view, more definite on extension lateral views. Basically, it was considered as a burst fracture with loss of anterior and middle column height. The extent of collapse could be classified as complete or incomplete and the shape of spinal canal intrusion as bulging or local beak type. 12 cases of MRI findings were classified in to three types by T1, T2 and gadolinium enhancement patterns. The extent of spinal canal intrusion was less then 50% in all cases but neurolgic deficits were examined in 10 cases. Pathologically, necrotic trabeculae with fibrous granulation tissue was mixed with reactive new bone and callus formation in some area. This phenomenon is considered not so uncommon, which can be noticed easily in lateral flexion/extension view. Basically, this is a burst fracture with nonunion from ischemic necrosis and neurologic status should be carefully obserued.

The Effectiveness of Fibular Strut Grafting in Early Atraumatic Avascular necrosis of the Femoral Head / 대한정형외과학회잡지

Between 1982 and 1991, 33 cases(47 patients) with Ficat stage I and II avascular necrosis of the femoral head which had decompression with fibular strut grafting were followed up for average 62 months ranging from 36 to 136 months, The authors analyzed the results by Harris Hip Score(H.H.S) clinically and according to Ficat stage progression radiologically and evaluated the effectivencess of this procedure in the early stage of atraumatic avascular necrosis of the femoral head. The results were as follows. 29 hips were mon, 4 hips were women and 11 patients were bilateral. The ages ranged from 26 to 75 years and the mean age was 46.6 years. By the radiological classification of Japnese Investigation Committee, 23 hips(79%) of stage II showed diffuse involvement of the femoral heads(type 1-C, 2, 3-B). By Ficat stage, stage I were 4(12%) and stage II were 29(88%). At follow up, 2 hips were in stage I(6%), 15 hips were in stage II(46%), 11 hips were in stage III(33%) and 5 hips showed stage IV (15%). Two hips were converted to total hip arthroplasty due to failure. Preoperative Harris Hip Score was 84 points in average and at most recent follow up, the score was 89 points in average. The clinical surccess rate was 73% and radiological success rate was 52%, but 83% of the patients were satisfied with the procedure subjectively. There noted some disparity between the clinical and raiological results, but the effect of the decompression with fibular strut grafting will be known if more long term follow up is available.