Unusual Fatal Infections after Anterior Cervical Spine Surgeries

We report two cases of cervical spinal epidural abscess (SEA), which are related to anterior cervical surgeries. The first case reveals a late postoperative infection without any predisposing factor. The second case reveals combined complication of infection and instrument failure (artificial disc). Both two cases manifested ascending infections that are unusual courses of anterior cervical infections. The abscess extended upwards and, finally, caused life threatening bacterial meningitis. We suggest aggressive surgical interventions with anti-bacterial therapies in such cases.

Remote Cerebral and Cerebellar Hemorrhage after Massive Cerebrospinal Fluid Leakage

Dural tears can occur during spinal surgery and may lead to cerebrospinal fluid (CSF) leakage which is rarely involved in remote cerebellar hemorrhage. Only a few of cases of simultaneous cerebral and cerebellar hemorrhage have been reported in the English literature. We experienced a case of multiple remote cerebral and cerebellar hemorrhages in a 63-year-old man who exhibited no significant neurologic deficits after spinal surgery. Magnetic resonance imaging (MRI) performed 4 days after the surgery showed a large amount of CSF leakage in the lumbosacral space. The patient underwent the second surgery for primary repair of the dural defect, but complained of headache after dural repair surgery. Brain MRI taken 6 days after the dural repair surgery revealed multifocal remote intracerebral and cerebellar hemorrhages in the right temporal lobe and both cerebellar hemispheres. We recommend diagnostic imaging to secure early identification and treatment of this complication in order to prevent serious neurologic deficits.

Remote Cerebral and Cerebellar Hemorrhage after Massive Cerebrospinal Fluid Leakage

Dural tears can occur during spinal surgery and may lead to cerebrospinal fluid (CSF) leakage which is rarely involved in remote cerebellar hemorrhage. Only a few of cases of simultaneous cerebral and cerebellar hemorrhage have been reported in the English literature. We experienced a case of multiple remote cerebral and cerebellar hemorrhages in a 63-year-old man who exhibited no significant neurologic deficits after spinal surgery. Magnetic resonance imaging (MRI) performed 4 days after the surgery showed a large amount of CSF leakage in the lumbosacral space. The patient underwent the second surgery for primary repair of the dural defect, but complained of headache after dural repair surgery. Brain MRI taken 6 days after the dural repair surgery revealed multifocal remote intracerebral and cerebellar hemorrhages in the right temporal lobe and both cerebellar hemispheres. We recommend diagnostic imaging to secure early identification and treatment of this complication in order to prevent serious neurologic deficits.

The Correlation between Insertion Depth of Prodisc-C Artificial Disc and Postoperative Kyphotic Deformity: Clinical Importance of Insertion Depth of Artificial Disc

OBJECTIVE: This study was designed to investigate the correlation between insertion depth of artificial disc and postoperative kyphotic deformity after Prodisc-C total disc replacement surgery, and the range of artificial disc insertion depth which is effective in preventing postoperative whole cervical or segmental kyphotic deformity. METHODS: A retrospective radiological analysis was performed in 50 patients who had undergone single level total disc replacement surgery. Records were reviewed to obtain demographic data. Preoperative and postoperative radiographs were assessed to determine C2-7 Cobb's angle and segmental angle and to investigate postoperative kyphotic deformity. A formula was introduced to calculate insertion depth of Prodisc-C artificial disc. Statistical analysis was performed to search the correlation between insertion depth of Prodisc-C artificial disc and postoperative kyphotic deformity, and to estimate insertion depth of Prodisc-C artificial disc to prevent postoperative kyphotic deformity. RESULTS: In this study no significant statistical correlation was observed between insertion depth of Prodisc-C artificial disc and postoperative kyphotic deformity regarding C2-7 Cobb's angle. Statistical correlation between insertion depth of Prodisc-C artificial disc and postoperative kyphotic deformity was observed regarding segmental angle (p<0.05). It failed to estimate proper insertion depth of Prodisc-C artificial disc effective in preventing postoperative kyphotic deformity. CONCLUSION: Postoperative segmental kyphotic deformity is associated with insertion depth of Prodisc-C artificial disc. Anterior located artificial disc leads to lordotic segmental angle and posterior located artificial disc leads to kyphotic segmental angle postoperatively. But C2-7 Cobb's angle is not affected by artificial disc location after the surgery.

Increased Vascular Endothelial Growth Factor in the Ventricular Cerebrospinal Fluid as a Predictive Marker for Subsequent Ventriculoperitoneal Shunt Infection : A Comparison Study among Hydrocephalic Patients

OBJECTIVE: The aim of this study is to determine the association between the cerebrospinal fluid (CSF) biomarkers and inflammation, and the predictive value of these CSF biomarkers for subsequent shunt associated infection. METHODS: We obtained CSF samples from the patients with hydrocephalus during ventriculoperitoneal (VP) shunt operations. Twenty-two patients were enrolled for this study and divided into 3 groups: subarachnoid hemorrhage (SAH)-induced hydrocephalus, idiopathic normal pressure hydrocephalus (INPH) and hydrocephalus with a subsequent shunt infection. We analyzed the transforming growth factor-beta1, tumor necrosis factor-alpha, vascular endothelial growth factor (VEGF) and total tau in the CSF by performing enzyme-linked immunosorbent assay. The subsequent development of shunt infection was confirmed by the clinical presentations, the CSF parameters and CSF culture from the shunt devices. RESULTS: The mean VEGF concentration (+/-standard deviation) in the CSF of the SAH-induced hydrocephalus, INPH and shunt infection groups was 236+/-138, 237+/-80 and 627+/-391 pg/mL, respectively. There was a significant difference among the three groups (p=0.01). Between the SAH-induced hydrocephalus and infection groups and between the INPH and infection groups, there was a significant difference of the VEGF levels (p<0.01). However, the other marker levels did not differ among them. CONCLUSION: The present study showed that only the CSF VEGF levels are associated with the subsequent development of shunt infection. Our results suggest that increased CSF VEGF could provide a good condition for bacteria that are introduced at the time of surgery to grow in the brain, rather than reflecting a sequel of bacterial infection before VP shunt.

Traumatic Cervical Cord Transection without Facet Dislocations-A Proposal of Combined Hyperflexion-Hyperextension Mechanism: A Case Report

A patient is presented with a cervical spinal cord transection which occurred after a motor vehicle accident in which the air bag deployed and the seat belt was not in use. The patient had complete quadriplegia below the C5 level and his imaging study showed cervical cord transection at the level of the C5/6 disc space with C5, C6 vertebral bodies and laminar fractures. He underwent a C5 laminectomy and a C4-7 posterior fusion with lateral mass screw fixation. Previous reports have described central cord syndromes occurring in hyperextension injuries, but in adults, acute spinal cord transections have only developed after fracture-dislocations of the spine. A case involving a post-traumatic spinal cord transection without any evidence of radiologic facet dislocations is reported. Also, we propose a combined hyperflexion-hyperextension mechanism to explain this type of injury.

Clinical and Radiographic Analysis of Cervical Total Disc Replacement Versus Anterior Cervical fusion using Stand-alone Cage

OBJECTIVE: Total intervertebral disc replacement is designed to preserve motion and avoid limitations of fusion after removing local pathology. The authors report the results of a signle-center study to determine functional and radi- ologic outcomes associated with cervical total disc replacement versus those of cervical fusion. METHODS: We retrospectively reviewed the charts and radiographs of patients who underwent a total intervertebral disc replacement(TDR) or a single-level anterior cervical fusion(ACDF) between January 1, 2004, and September 31, 2007. Clinical symptom was assessed using the Visual Analog Scale(VAS) of the neck and of the arm pain. Range of motion was determined by radiologic assessment of flexion-extension radiographs. Data were collected before surgery and at 6 weeks, 3, 6, 12, and 24 months after surgery. RESULT: A total of 125 patients were identified with 63 having TDR(43 males and 20 females) and 62 having fusion(42 males and 20 females). The average age was 49.1 years(TDR) and 51.7 years(ACDF)(p=0.229). The mean neck pain VAS before surgery was 6.52(TDR) and 6.61(ACDF)(p=0.732). At 2-year follow-up, the average neck pain VAS for the TDR group was 1.59 and ACDF 1.85(p=0.168). The mean arm pain VAS before surgery was 6.37(TDR) and 6.60(ACDF)(p=0.335). At 2 years: 1.41(TDR) and 1.65(ACDF)(P = 0.148). More motion(an average of 9.00 degrees at 24 months) was retained after surgery in the TDR group than the fusion group at the treatment level. There was no significant diffe- rence in motion at adjacent levels. CONCLUSION: Total disc replacement maintained physiological segmental motion at the 2-year follow-up. The finding that there was no statistically significant difference between the groups in motion at adjacent levels must be verified on further studies.

Preliminary Clinical Experience of Anterior Cervical Interbody Fusion with the AMSLU(TM) Cage

OBJECTIVE: The authors investigate the effectiveness and the demerits of the AMSLU(TM) cervical cage used in cervical spinal fusion for correction of cervical degenerative disc disease. METHODS: A total of 19 patients with cervical degenerative disc disease underwent anterior microdiscectomy and the AMSLU(TM) cage fusion. We made a retrospective comparative analysis between cases using the AMSLU(TM) cage and the classical autogenous iliac crest graft(AICG) with plate fixation about operative time, blood loss and hospital stay. The patient's neurological and functional outcomes were assessed on the basis of the modified Odom's criteria. RESULTS: The use of the AMSLU(TM) cage was found to save operative time(mean, 153+/-52min: P=0.004) and blood loss(mean, 236+/-171cc: P=0.032) as compared with the use of AICG. There was no donor-site complications and all patients were tolerable to ambulation at 1 day postoperatively. The patient's clinical success rate was 89% on discharge and 84% at 6 months postoperatively. CONCLUSION: The use of the AMSLU(TM) cage provides several advantages: no donor-site complications, brief instrument procedures, short operative time, small amount of blood loss and satisfactory clinical success rate. But it also has many limitations: short follow up period, kyphotic change and subsidence. Further investigations and clinical applications are necessary to use AMSLU(TM) cage in cases of spondylolisthesis and traumatic cervical disease.

Prognostic Factors of Primary Intraventricular Hemorrhage

OBJECTIVE: Primary intraventricular hemorrhage(PIVH) is uncommon and accounts for only 3.1 % of all non-traumatic intracerebral hemorrhage. The aim of this study is to analyze clinical characteristics, image features, etiology and prognostic factors of outcome in patients with PIVH. METHODS: We identified 25 patients with PIVH during 9-year period between 1994 and 2002 at our institute. The clinical data, complimentary examination, outcome and computed tomographic blood amounts were reviewed. RESULTS: Major symptoms included sudden decreased level of consciousness, headache, nausea/vomiting and neck stiffness. Cerebral angiography was performed in 12 patients(48%) and revealed vascular malformation in 6 patients(24%). The positive result of angiography was more common in young patients and among vascular malformation the incidence of Moyamoya disease was relatively high(4 patients). Other causative factors were coagulation disorder, arterial hypertension, tumor bleeding. Outcome were death in 9 patients(36%): 7 patients(28%) died by direct consequence of bleeding and 2 patients died after other adverse events(sepsis, hepatic failure) but prognosis of survivor was good. Factors correlating with the outcome were the presence of coagulopathy, initial Glasgow Coma Scale(GCS), obstruction of 4th ventricle and ventricular blood amount including hemorrhagic dilatation of temporal horn of lateral ventricle, 3rd and 4th ventricle. CONCLUSION: The poor prognosis factors of PIVH are the presence of coagulopathy, low initial GCS, obstruction of 4th ventricle and large ventricular blood amount. Additionally patients whose initial clinical condition is not serious need an appropriate work up including cerebral angiography, because cause of bleeding is vascular malformation especially in young patients.

The Effects of Nimodipine on Irradiation-Induced Apoptosis in the Rat Spinal Cord

OBJECTIVE: Radiation therapy is an effective adjunctive therapy in the management of brain and spinal cord tumors. The damage to normal tissue, however, has been often the dose-limiting factor in radiation therapy. The purpose of this study is to see whether nimodipine, the one of calcium channel blockers, is effective for the prevention of irradiation-induced apoptosis in the rat spinal cord. METHODS: Sprague-Dawley rats were used: Control(n=12), Nimodipine-treated(0.5mg/kg, n=12). After nimodipine was administered intraperitoneally, the spinal cord of cervicothoracic junction was exposed to a single 10Gy dose of gamma rays using Ir-192. All spinal cords underwent histological examination at 4, 8, and 12 hours after irradiation, and apoptotic cells were detected by TUNEL assay and were determined by direct visual counting at magnification of x200. RESULTS: On the standard H-E stain, little evidence of histopathological change was noted within the 12 hours after irradiation. Both groups showed gradual increase of apoptotic cell counts with the lapse of time. But, in nimodipine-treated group, apoptotic cell counts were reduced significantly, compared to those of control group after irradiation, especially at 8 and 12 hours. CONCLUSION: The results suggest that nimodipine may have effects on the prevention of radiation-induced apoptosis in the spinal cord.

Evaluation of Cerebrospinal Fluid Vascular Endothelial Growth Factor for the Brain Tumor

OBJECTIVE: Vascular endothelial growth factor(VEGF), which is also known as vascular permeability factor, induces angiogenesis and may play a key role in tumor-related neovascularization and peritumoral edema. There are many pathological conditions associated with VEGF expression, such as brain tumor, infection and trauma. Malignant brain tumor is characterized by its prominent neovascularization and severe peritumoral edema and it is known to express high VEGF activity. The aim of this study is to investigate any differences in cerebrospinal fluid(CSF) VEGF level among gliomas, and between tumors and non-tumorous conditions. METHODS: Cerebrospinal fluid samples were collected from 28 patients whose diagnosis had been surgically proven and they were centrifuged and stored at -73 degrees C. The concentration of VEGF was analyzed using commercially available ELISA kit. RESULTS: Glioblastoma patients showed much higher level of CSF VEGF than those of other gliomas and non-tumorous conditions. And higher CSF VEGF level was found in invasive pituitary adenoma, recurrent oligoden-droglioma, central neurocytoma and diffuse axonal injury. CONCLUSION: Absolute CSF VEGF level can be useful biological marker for primary malignant glioma, especially glioblastoma, and serial check-ups may contribute to early diagnosis of malignant transformation of low grade astrocytoma.

The Effects of Steroid and Calcium Channel Blocker on Single High Dose Irradiation-induced Apoptosis in Rat Brain

OBJECTIVE: Radiation injury includes radiation necrosis and apoptosis. The purpose of this study is whether steroids and calcium channel blockers are effective for the prevention of single high dose irradiation-induced apoptosis in the rat brain. METHODS: Eighty Sprague-Dawley rats were divided into four experimental groups: Control(nontreated, n=20), Dexamethasone-treated(0.1mg/kg, n=20), Prednisolone-treated(2mg/kg, n=20), Nimodipine-treated (0.5mg/kg, n=20). After drug was administered, the right hemisphere of rat's brain was exposed to a single 10Gy dose of gamma rays using Ir-192. All brains underwent histological examination at 1 week, 2 weeks, 4 weeks, and 8 weeks after irradiation to evaluate cortical thickness and number of apoptotic cells. Apoptotic cells were detected by TUNEL assay. RESULTS: In nimodipine-treated group, apoptotic cell count was reduced significantly, compared to that of control(non treated) group at 4 and 8 weeks after irradiation(p<0.05). The decrease of cortical thickness was reduced significantly in nimodipine-treated group, compared to that of control group(p<0.05). There was no significant changes in the number of apoptotic cells and cortical thickness in prednisolone and dexamethasone-treated groups compared with those of control. CONCLUSION: These results suggest that nimodipine treatment may have effects on the prevention of radiation-induced apoptosis. If it could be established that calcium channel blockers inhibit radiation injury, they might be useful in radiation therapy. Further investigation of calcium channel blockers including dosage effectiveness, intracellular calcium ion concentration and effects on tumor tissue are necessary to clarify the usefulness of nimodipine.

Multiple Infarcts after Intra-arterial Carboplatin Therapy

We report a case of multiple cerebral infarcts, which developed after intra-arterial(IA) carboplatin therapy in a patient with glioblastoma who had received surgery with conventional and intraoperative radiation therapy (IORT). A 31-year-old male patient presented with one-month history of worsening headaches and visual dimness. Seven years previously, he had been subjected to a subtotal resection of anaplastic astrocytoma in the right occipital lobe, followed by external radiation therapy with a total dose of 5580cGy. Carboplatin was given at an initial dose of 300mg/m2. Before and after the infusion of carboplatin, solumedrol(500mg/day) was given for seven days, with the dosage being gradually reduced over the next five days. In addition, 20% mannitol(100ml) was infused over a 15-minute period before chemotherapy, and the fluid volume of electrolyte was adjusted to maintain an optimal urine output. The patient underwent five cycles of IA carboplatin therapy. Careful attention should be given during IA carboplatin chemotherapy to patients who are also being treated with IORT.

Fibrous Dysplasia Involving the Fronto-Orbital Bone: Surgical Experience

OBJECTIVE: To suggest early surgical treatment of fronto-orbital fibrous dysplasia, the authors present the surgical experiences of fronto-orbital fibrous dysplasia in 8 cases. METHODS: A total of 8 surgically treated patients with fronto-orbital fibrous dysplasia is included in this study. There were 4 males and 4 females with age range between 6 and 50(average 23.5 years). All presented with painless bulging mass in fronto-orbital region, and seven had varying degrees of proptosis with variable degrees of visual symptoms. Six cases were treated with radical resection and immediate orbital and cranial reconstruction using polymethylmethacrylate(PMMA) and miniplates. Two cases were treated with minimal resection and contouring using autogenous bone graft. RESULTS: No complications were seen except transient ptosis and wound infection in one case, respectively. There were no signs of recurrence during follow-up period(up to 4 years). Cosmetic results were acceptable in 7 seven patients but reoperation was required in remaining one patient 4 years after first operation. The patients who had visual symptoms showed improvement postoperatively. CONCLUSION: These results emphasize the importance of the early treatment with surgical approach in patients with fronto-orbital fibrous dysplasia who have visual sympotoms and cosmetinc problems. However, further study with larger population is warranted to validate early surgical correction in patients with varying degrees of symptomatologies.

Gray Ramus Communicans Nerve Block: A Useful Therapeutic Adjuvant for Painful Osteoporotic Vertebral Compression Fracture

OBJECTIVE: There are limited treatment options for patients with painful osteoporotic vertebral compression fracture(OVCF) in whom surgery is not strongly indicated or when pain persists even after vertebroplasty. Conservative treatments generally do not provide adequate or prolonged pain relief since the pain in these patients is thought to originate from within and surrounding vertebra. The purpose of this study is to verify the usefulness of percutaneous nerve block on gray ramus communicans in these patients. METHODS: We retrospectively analyzed 36 patients in whom nerve blocks on gray ramus communicans were performed for painful OVCF after failure of conservative therapy and/or after percutaneous vertebroplasty. Bilateral nerve blocks were done on the gray ramus tracts of the somatic nerve roots corresponding with OVCF under C-arm fluoroscopic guidance. Patient-reported pain scores and amount of analgesic medication were measured. RESULTS: All patients tolerated procedures well. Significant initial pain relief was noted in 34 (94.4%) patients and the pain relief was durable in 30(88.2%) of these 34 patients at last visit (at least 4 months after procedure). None of these patients required surgeries during the follow-up period. Decreased analgesic requirement was documented in 30(83.3%) of patients. There was no procedure related complication. CONCLUSION: Prompt and relatively prolonged improvement of pain without complication after this procedure in majority of patients with persistently painful OVCF supports its effectiveness and safety. Thus, it may be considered a useful adjuvant therapeutic option in these clinical settings.

Effects of Decompressive Craniectomy for the Management of Patients with Refractory Intracranial Hypertension

OBJECTIVE: The beneficial effect of decompressive craniectomy in the treatment of patients with uncontrolled intracranial hypertension is controversial. We conducted this study to evaluate the efficacy of decompressive craniectomy in patients with refractory intracranial hypertension. METHODS: We retrospectively investigated 38 patients who underwent decompressive craniectomy as the treatment of increased intracranial pressure in our hospital from October 1999 to March 2002. The causes of intracranial hypertension were traumatic brain injury(28 cases), cerebrovascular disease(8 cases), and tumor(2 cases). Age, Glasgow Coma Scale at admission, preop and postop, intracranial pressure and findings on Computed Tomography before and after decompressive craniectomy, and finally Glasgow Outcome Scale at 6 months after surgery were evaluated. RESULTS: Favorable outcome(good or moderate disability) was 39%(15 of 38 patients) and poor outcome(severe disability, vegetative state or death) was 61%(23 of 38 patients). Overall mortality rate was 47%(18 of 38 patients). After decompressive craniectomy, statistically significant decrease in intracranial pressure and improvement of midline shifting were observed. Two important prognostic factors in our study were neurological status before surgery and findings in follow-up brain CT after decompressive craniectomy. CONCLUSION: Decompressive craniectomy for the refractory intracranial hypertension is an effective strategy to decrease intracranial pressure. So it may contribute to improve the patient's outcome. But it is necessary to conduct the multi-institutional randomized prospective study to determine whether the decompressive craniectomy actually improves the patient's outcomes or not.

Prognostic Factors of Percutaneous Radiofrequency Neurotomy on the Posterior Primary Ramus

OBJECTIVE: We report our experience of percutaneous radiofrequency neurotomy(PRN) on the posterior primary ramus with at least two years follow up. METHODS: Two hundred and twenty-eight patients were underwent PRN on the posterior primary ramus for refractory low back pain during last three years. One hundred and twenty-eight patients were met all inclusion criteria indicating facetal originated pain(group II), and 100 patients were not(group I). Radiofrequency procedures were done in usual manner. Pain reliefs were estimated at 1 week, 1 month, 6 months and 2 years using visual analog scale. RESULTS: Positive responders were 56% at 1 week, 46% at 1 month, 18% at 6 months, and 13% at 2 years after PRN in group I, and 78.9% at 1 week, 75.4% at 1 month, 62.5% at 6 months, and 54.7% at 2 years in group II. Prominent local tenderness, percussion tenderness, pain on getting up, extension and transitional movement, radiating pain on buttock and/or posterior thigh, and good immediate response were found to be significantly related to outcome. And age, sex, symptom duration, bilateral symptoms, favorable imaging study results, previous lumbar surgery, and degrees of pain relief from diagnostic block were not. CONCLUSION: Percutaneous radiofrequency neurotomy on the posterior primary ramus has long-term beneficial effect, without any morbidity in our series. And the long-term good results will be anticipated after proper selection among patients with facet joints related low back pain.

Oblique Posterior Interbody Fusion with Bone Plugs by Unilateral Approach for Treatment of Lumbar Instability: Technical Note

A new technical method using bone plugs with oblique posterior interbody fusion(OPIF) was designed to increase the fusion rate. One hundred-seventy-five patients were operated for lumbar instability between November 1990 and December 2000. The L5/S1 segment was affected in 129 cases(74%) of the patients. Oblique posteior interbody fusion with bone plugs by unilateral approach was performed in all patients. Eight-nine percent of these patients showed good surgical results. This stable transplant interbody fusion has the several advantages. Foreign substance is not used and this method increases fusion rate and cost-effective. OPIF using bone plugs along with Oh's screw could provide sufficient stability for segmental instability of the lumbar spine including spondylolisthesis of the lumbar spine, with or without concurrent herniated intervertebral disc or spondylotic narrowing.

Prognostic Factors of Percutaneous Radiofrequency Neurotomy for Chronic Low Back Pain

BACKGROUNDS: Percutaneous radiofrequency neurotomy of posterior primary ramus has been in use as a treatment for persistent, mechanical low back pain for two decades. However, there has been limited studies regarding to prognostic factors related to outcome. We report our experience with at least 2-year follow up with special aftention on prognostic factors. METHODS: Of total 228 patients who underwent percutaneous radiofrequency neurotomy (PRN) of posterior primary ramus for refractory low back pain during last 3 years, 128 patients whose pain was considered to be originated from facets joints or their surrounding soft tissue and responded to temporary blocks were assigned to a group II. All patients had more than 6 months of pain. These patients were compared with 100 patients to whom PRN were provided for chronic nonspecific low back pain without all inclusion criteria (Group I). RF procedures were done under local anesthesia with C-arm intensifier guidance. Pain reliefs were estimated at 1week, 1month, 6months and 2 years using visual analog scale(VAS). For patients with more that 50% reduction of previous pain was regarded as positive responder. Various clinical variables such as age, sex, symptom duration, types of pain, bilaterality, and previous surgery were studied for prognostic factors. RESULTS: Positive responders were 56% at 1week, 46% at lmonth, 18% at 6months, and 13% at 2years after PRN in group I, and 78.9% at lweek, 75.4% at lmonth, 62.5% at 6months, and 54.7% at 2years in group II. Some variables were found to be significantly related to outcome including prominent local tenderness, percussion tenderness, combination of symptoms with pain on gefting up, extension, transitional movement, pain radiating to buttock and/or posterior thigh, and good immediate response. Age, sex, symptom duration, bilaterality, imaging study results, previous lumbar surgery, and degrees of pain relief from diagnostic block were not related to outcome. CONCLUSIONS: These results indicate that PRN of posterior primary ramus has a moderate overall long-term beneficial effect, with no morbidity in our series. But, the long-term good results will be anticipated only in properly selected patients with low back pain originating from facet joints and surrounding structures.

Pulmonary Embolism after Percutaneous Vertebroplasty with Polymethylmethacrylate: Case Report

We present a case with rare complication of percutaneous vertebroplasty with polymethylmethacrylate (PMMA). A pulmonary embolus was detected in a 79-year-old woman with osteoporotic compression fracture after percutaneous verteroplasty. Chest radiography, computed tomography, and ventilation perfusion lung scan con-firmed pulmonary infarction and the presence of PMMA in the pulmonary arteries. She was treated with anticoagulants and responded favorably. Although venous leakage of PMMA has shown to be not uncommon, only a few cases of symptomatic pulmonary embolism have been reported. Adequate preparation of PMMA, optimal injection technique, and confirmation with biplane fluoroscopy are mandatory to minimize this type of complication.