Advantages of New Endoscopic Unilateral Laminectomy for Bilateral Decompression (ULBD) over Conventional Microscopic ULBD

Background@#Biportal endoscopic unilateral laminectomy for bilateral decompression (ULBD) is an emerging minimally invasive procedure for spinal stenosis. However, reports of the results associated with this surgical method are still lacking. @*Methods@#We conducted a retrospective study of 60 patients who underwent bilateral decompression for lumbar central canal stenosis. The patients were divided into 2 groups according to the surgical method (endoscopic ULBD vs. microscopic ULBD). We compared the outcomes between the 2 groups in terms of postoperative segmental spinal instability, dura expansion, operation time, estimated blood loss, serum creatine kinase (CK), serum C-reactive protein (CRP), visual analog scale (VAS) score, Oswestry Disability Index (ODI), modified MacNab score, and the incidence of complications. @*Results@#The mean VAS, ODI, and modified MacNab score improved significantly from the preoperative period to the last follow-up in both groups and were better in the endoscopic ULBD group until the first day after treatment. The degree of horizontal displacement was lower in the endoscopic ULBD group than in the microscopic ULBD group at postoperative 12 months. Dura expansion, operation time, and estimated blood loss did not differ significantly between the 2 groups. Serum CK and CRP on the first day after treatment were lower in the endoscopic ULBD group than in the microscopic ULBD group. @*Conclusions@#This study shows that both endoscopic ULBD and microscopic ULBD can provide favorable outcomes for lumbar central canal stenosis. However, compared to microscopic ULBD, endoscopic ULBD has advantages in terms of postoperative segmental spinal instability, pain control, and serum CK and CRP.

Characteristics of Blood Mixed Cement in Percutaneous Vertebroplasty / 대한정형외과학회잡지

PURPOSE: This study evaluated the efficacy of blood mixed cement for osteoporotic vertebral compression fractures in reducing the complications of percutaneous vertebroplasty using conventional cement. MATERIALS AND METHODS: This study was performed retrospectively in 80 patients, from January 2016 to January 2017. Porous cement was formed by mixing 2, 4, and 6 ml of blood with 20 g of cement used previously. A tube with a diameter and length of 2.8 mm and 215 mm, respectively, was used and the polymerization temperature, setting time, and optimal passing-time were measured and compared with those using only conventional cement. Radiologically, the results were evaluated and compared. RESULTS: The polymerization temperature was 70.3℃, 55.3℃, 52.7℃, and 45.5℃ in the conventional cement (R), 2 ml (B2), 4 ml (B4), and 6 ml (B6), respectively, and the corresponding setting time decreased from 960 seconds (R) to 558 seconds (B2), 533 seconds (B4), and 500 seconds (B6). The optimal passing-time was 45 seconds (B2), 60 seconds (B4), and 78 seconds (B6) at 73 seconds (R), respectively and as the amount of blood increased, it was similar to the cement passing-time. The radiological results showed that the height restoration rates and the vertebral subsidence rates similar among the groups. Two cases of adjacent vertebral compression fractures in the R group and one in the B2 and B4 groups were encountered, and the leakage rate of the cement was approximately two times higher than that in the conventional cement group. CONCLUSION: In conventional percutaneous vertebroplasty, the procedure of using autologous blood with cement decreased the polymerization temperature, reduced the setting time, and the incidence of cement leakage was low. These properties may contribute to more favorable mechanical properties that can reduce the complications compared to conventional cements alone.

Tophaceous Gout of the Lumbar Spine Mimicking Infectious Spondylodiscitis and Epidural Abscess / 대한척추외과학회지

STUDY DESIGN: Case report OBJECTIVES: We report a case of surgically proven tophaceous gout of the lumbar spine at the L5-S1 level in a 43-year-old man that mimicked infectious spondylodiscitis and epidural abscess on magnetic resonance (MR) images. SUMMARY OF LITERATURE REVIEW: Some patients have chronic back pain with an epidural mass. Among the many causes of epidural masses, tophaceous gout of the lumbar spine is very rare. MATERIALS AND METHODS: A 43-year-old man presented with fever and chronic back pain with radiating pain. In an MR image of L4-5, an abnormal subcutaneous mass was found in the posterior epidural space. The subcutaneous mass was isointense on T1-weighted images compared with the intervertebral disc, and focally and strongly hyperintense and heterogeneous on T2-weighted images. After the intravenous administration of gadolinium contrast, the mass was fairly homogenous, with a low signal intensity and without enhancement. With the diagnosis of infective spondylitis with epidural abscess, we performed a decompressive mass resection. RESULTS: The pathologic examination revealed multinuclear giant cells and amorphous crystalline fibrous tissue. The lesion was diagnosed as tophaceous gout. CONCLUSIONS: This case underscores the importance of considering tophaceous gout in the differential diagnosis of an epidural mass in a patient with chronic back pain.

Efficacy of Taurolidine Irrigation in Primary Total Knee Arthroplasty

PURPOSE: Taurolidine is an antimicrobial agent that was originally used in the local treatment of peritonitis. The aim of this study was to evaluate the efficacy of taurolidine irrigation in primary total knee arthroplasty (TKA). MATERIALS AND METHODS: All patients who underwent TKA at our institute from January 2015 to March 2017 were eligible. There were 300 patients in the taurolidine irrigation group and 300 patients in the control group. The patients in the taurolidine irrigation group were irrigated after implantation with a mix of 250 mL of taurolidine and 750 mL of normal saline. The patients in the control group were not irrigated after implantation. We compared postoperative C-reactive protein (CRP), erythrocyte sedimentation rate (ESR), and infection rate between groups. RESULTS: The taurolidine irrigation group had a significantly lower CRP (5.39 mg/dL vs. 7.55 mg/dL; p<0.001) and ESR (53.21 mm/hr vs. 58.74 mm/hr; p=0.003) on postoperative day 3 after TKA, as compared with the control group. However, there was no difference between the two groups on postoperative days 6, 13, and 20. Periprosthetic joint infection occurred in one patient in the taurolidine irrigation group. CONCLUSIONS: We believe that it is not necessary to use taurolidine for patients who undergo primary TKA.

Munchausen Syndrome in Orthopedics / 대한정형외과학회잡지

Munchausen syndrome is a rare factitious disorder in which a person repeatedly and deliberately acts as if he or she has a physical or mental illness when he or she is not really sick. These patients distort their medical history, undergoing dangerous diagnostic and therapeutic procedures, often resulting in misdiagnosis. Management of this syndrome requires collateral history taking, sound clinical approach, exclusion of organicity, and addressing psychological issues. We report a 54-year-old female, who underwent orthopedic surgery 13 times. She was always unsatisfied with her surgical outcomes, and underwent additional surgical treatment of the shoulder, elbow, wrist, and knee joint. She repeatedly complained of joint pain, which was much more exaggerated than expected from her examination results. Therefore, we considered artificial arthrosis for a differential diagnosis of unclear arthrosis, and paid special attention when she exhibited odd behaviors.

Tophaceous Gout of the Lumbar Spine Mimicking Infectious Spondylodiscitis and Epidural Abscess

OBJECTIVES@#We report a case of surgically proven tophaceous gout of the lumbar spine at the L5-S1 level in a 43-year-old man that mimicked infectious spondylodiscitis and epidural abscess on magnetic resonance (MR) images.SUMMARY OF LITERATURE REVIEW: Some patients have chronic back pain with an epidural mass. Among the many causes of epidural masses, tophaceous gout of the lumbar spine is very rare.@*MATERIALS AND METHODS@#A 43-year-old man presented with fever and chronic back pain with radiating pain. In an MR image of L4-5, an abnormal subcutaneous mass was found in the posterior epidural space. The subcutaneous mass was isointense on T1-weighted images compared with the intervertebral disc, and focally and strongly hyperintense and heterogeneous on T2-weighted images. After the intravenous administration of gadolinium contrast, the mass was fairly homogenous, with a low signal intensity and without enhancement. With the diagnosis of infective spondylitis with epidural abscess, we performed a decompressive mass resection.@*RESULTS@#The pathologic examination revealed multinuclear giant cells and amorphous crystalline fibrous tissue. The lesion was diagnosed as tophaceous gout.@*CONCLUSIONS@#This case underscores the importance of considering tophaceous gout in the differential diagnosis of an epidural mass in a patient with chronic back pain.

Epidermoid Cyst after Groin Flap Mimicking Malignancy

Epidermoid cyst is a benign tumor containing a layer composed by stratified squamous epithelium and filled with keratin. The epidermoid cyst after soft tissue damage such as bite, laceration could be caused by implantation of epidermal cells. There are reports of epidermoid cyst rarely occurred after surgical procedures such as bone graft or spine puncture. However, the report of epidermoid cyst associated with flap in the hand is very rare. We experienced such epidermoid cyst after the groin flap mimicking malignancy in the distal phalanx of the thumb. We found calcified mass with bony erosions in radiologic findings and heterotrophic signals and partial necrosis in magnetic resonance imaging that suggested malignancy. However, it was pathologically diagnosed as an epidermoid cyst. Therefore, we report the case and literature review.

Comparison of Ultrasonography and Magnetic Resonance Imaging in Measurement of Lumbar Muscles / 대한정형외과학회잡지

PURPOSE: The purpose of this study was to compare magnetic resonance imaging (MRI) and ultrasonography measurement of peri-lumbar muscle atrophy which is thought to be a cause of low back pain. MATERIALS AND METHODS: Eighty-two patients (44 males, 38 females) who visited Wonkang University Hospital from March, 2015 to August, 2015 complaining of lumbar back pain and underwent lumbar MRI were enrolled in this study. Cross section area (CSAMRI) and muscle thickness (MTMRI) of psoas major (PS) and lumbar extensor (LM) located on both sides of L4/5 and L3/4 was measured by MRI, and sono measurement of thickness of the same muscle (MTUS) at the same level of that MRI measurement were analyzed. RESULTS: In correlation analysis of PS CSAMRI and PS MTUS is the correlation coefficient of L4/5 was 0.136 (p=0.64), L3/4 right (Rt) was 0.070 (p=0.81), and L3/4 left (Lt) was 0.288 (p=0.32). PS CSAMRI at L4/5 Rt showed that correlation coefficient of PS MTUS showed a positive correlation to 0.559 (p=0.04). In analysis of the PS MTMRI and PS MTUS, the correlation coefficient of L4/5 Rt was measured by a 0.316 (p=0.27), L4/5 Lt was 0.022 (p=0.94), L3/4 Rt was 0.236 (p=0.41), and L3/4 Lt did not show a significant result with 0.287 (p=0.31). In the results of correlation analysis of the LM MTMRI and LM MTUS, the correlation coefficient of L4/5 Rt was 0.207 (p=0.49), L4/5 Lt was 0.051 (p=0.86), and L3/4 was Rt 0.048 (p=0.87), L3/4 Lt did not show a significant value with 0.154 (p=0.61). CONCLUSION: This study proved that muscle volume obtained from ultrasono is effective for evaluation of cross-sectional area of lumbar muscle.

Change in Neural Tube Size for a Lumbar Spinal Stenosis Patient on Axial Loading Magnetic Resonance Imaging / 대한정형외과학회잡지

PURPOSE: A conventional magnetic resonance imaging (MRI) was conducted in supine position, showing a slight different from that conducted in upright position. Therefore, we simulated the upright position by applying the axial load on a lumbar spinal stenosis patient and measured the change of neural tube size in axial load and standardized the data. MATERIALS AND METHODS: We compared the axial loading MRI obtained from spinal stenosis patients who visited Wonkwang University Hospital outpatient clinic between October 2010 and May 2011 showing radiologic and physical symptoms. RESULTS: Neural tube sizes by conventional MRI were as follows: 195.57 mm² and 203.20 mm² on average between the left and right sides in L3/4; 194.64 mm² and 211.43 mm² on average in L4/5; and 199.38 mm² and 203.04 mm² on average in L5/S1. Neural tube sizes by axial loading MRI were as follows: 166.43 mm² and 174.27 mm² on average between the left and right sides in L3/4; 154.81 mm² and 158.67 mm² on average in L4/5; and 148.48 mm² and 157.19 mm² on average in L5/S1. Changes of neural tube sizes in L3/4, L4/5, and L5/S1 had a significant correlation (p<0.05). CONCLUSION: The axial loading device was an excellent tool in simulating the upright position for spinal stenosis patients, and the change of neural tube sizes reproduced for the upright position was statistically significant. This is thought to be meaningful for clinical applicability.

Early Full Weight Bearing after an Autogenous Structural Bone Graft for Treating a Medial Tibial Bone Defect in Total Knee Arthroplasty: Minimum 5 Years Follow up Results

PURPOSE: We evaluated the results of early full weight bearing after an autogenous bone graft and metal screw fixation of severe varus deformity with a medial tibial bone defect in total knee arthroplasty. MATERIALS AND METHODS: From August 1996 to March 2004, 34 patients (43 cases) were selected for the analysis. The average age was 68 and the mean follow up period was 72 month. The clinical results were evaluated using the knee range of motion and the Hospital for Special Surgery (HSS) score. The radiological results were evaluated using the tibiofemoral angle, the presence of loosening, radiolucent lines and osteolysis and the component's location. RESULTS: The mean HSS score increased from 46 to 87 points on the final follow up. The mean range of motion was increased from 71degrees to 118degrees on the final follow up. The mean femorotibial angle showed varus deformity angulation (23.5degrees) at pre-operative surgery, 6.2degrees valgus deformity for the first 7 postoperative days and 6.1 valgus at the last follow up. CONCLUSION: These findings suggest that an autogenous structural bone graft and metal screw fixation has fine results and makes early ambulation possible for the patient who has severe varus deformity with a medial tibial bone defect.

Eythromelalgia Mimicking Lower Leg Pain of Spinal Origin : Case Report / 대한정형외과학회잡지

Erythromelalgia is a rare condition, of uncertain etiology, characterized by episodic erythema, intense burning pain and warmth of the hands and/or feet. We present here a case of erythromelalgia that was almost mistaken for lower leg pain of spinal origin. The diagnosis is based on a thorough history and physical exam during a painful episode along with diagnostic test to exclude other causes. A 69-year-old man developed recurrent attacks of redness, swelling and burning painful sensations of both feet. His symptom was aggravation of pain with warm water immersion. His symptom improved by antidepressant and steroid. To be learned an important general lesson is to pay attention to performing extensive diagnostic and therapeutic procedures. It should be appreciated that discontinuation of medication can also be used as a simple diagnostic test for clinical syndromes, such as erythermalgia.