Comparative Analysis of Surgical Options in the Treatment of Lumbar Degenerative Kyphosis / 대한척추외과학회지

STUDY DESIGN: A retrospective study OBJECTIVES: To compare the radiological and clinical outcomes of three surgical methods SUMMARY OF LITERATURE REVIEW: There were many proposed surgical treatments for lumbar degenerative kyphosis but the best treatment is still controversial. MATERIALS AND METHODS: Thirty three patients (all female) had undergone surgery. The mean age at surgery was 61.2. The average follow-up period was 34.7 months. The patients were divided into three groups. Group A included 7 cases with a correction by a posterior osteotomy, Group B included 15 with a posterior correction without an osteotomy, and Group C included 11 with combined anterior-posterior surgery. The radiographic measurements of lumbar lordosis, upper lumbar lordosis, lower lumbar lordosis, and pelvic tilt were performed before surgery, after surgery, and at the final follow-up visit. The loss of correction, complication rates and the clinical results were also compared. RESULTS: Postoperative correction of the lumbar and lower lumbar lordosis were significantly higher in group A and C than group B. The correction of upper lumbar lordosis was significantly higher in group A than group C. On the final follow-up, there was no significant difference in the loss of correction and clinical results between the three groups. The number of cases with complications in groups A, B and C was 4 (57%), 2 (13.3%) and 2 (18.2%), respectively. Two patients in group A required additional surgery. CONCLUSIONS: Groups A and C were more effective than posterior-only correction. There was no significant difference in the clinical results between the three groups but complication rate was higher in Group A than the other groups. Combined anterior and posterior surgery can be a safe and effective method for correction.

Unilateral Undercutting Laminoplasty in the Treatment of Lumbar Spinal Stenosis: Comparison with Conventional Bilateral Partial Laminectomy / 대한척추외과학회지

STUDY DESIGN: A retrospective study OBJECTIVES: Contralateral undercutting laminoplasty via a unilateral laminotomy has been performed instead of bilateral partial laminectomy in lumbar spinal stenosis. This study compared the radiographic and clinical results of undercutting laminoplasty with bilateral partial laminectomy. SUMMARY OF LITERATURE REVIEW: Less invasive surgery has become attractive for minimizing soft tissue injury and reducing the recovery time. MATERIALS AND METHODS: Twenty five patients, who underwent decompressive surgery for lumbar spinal stenosis and were followed-up more than one year, were enrolled in this study. Unilateral undercutting laminoplasty and bilateral partial laminectomy was performed in 13 and 12 cases, respectively. The blood loss was compared and the presence of instability was observed. The increase in dural cross sectional area was measured in the preoperative and postoperative CT scans. In the clinical assessment, the Oswestry disability index (ODI) and visual analogue scale (VAS) to pain was used. RESULTS: The average blood loss per segment was 273 ml and 436 ml in the laminoplasty and laminectomy group. There was no case of instability after surgery but there was a significant difference in the increase in dural cross sectional area between the two groups: 109.7 mm2 and 78.6 mm2 in the laminoplasty and laminectomy group, respectively. The preoperative and final change in the ODI and VAS scores was similar between the two groups. CONCLUSIONS: Unilateral undercutting laminoplasty is a minimally invasive procedure with less blood loss than the conventional technique and is equally effective.

More Than 5 Year Follow-Up of Thoracolumbar Fractures Treated By Pedicle Screw Fixation / 대한척추외과학회지

STUDY DESIGN: This is a retrospective study. OBJECTIVES: We wanted to analyze the frequency of instrument breakage and the long term reduction loss for patients who received pedicle screw fixation for thoracolumbar fractures. SUMMARY OF THE LITERATURE REVIEW: A pedicle screw fixation system for thoracolumbar fractures has become popular since the late 1980s, but it is difficult to find articles mentioning its mid and long term results. MATERIALS AND METHODS: Twenty-seven patients those received pedicle screw fixation for thoracolumbar fractures and dislocations and who were followed up more than 5 years were included. The average follow-up period was 139.0 months. We compared the anterior column height, the kyphotic angle and the local kyphotic angle on serial radiographs, and we measured the changes of the intervertebral disc height and the changes of the angle between screws. We also investigated the breakage and loosening of instruments. RESULTS: The breakage of screws was observed in 11 cases (40.7%) and it had a statistical correlation with the loss of the lower intervertebral disc height and the loss of angles between the screws. During the follow-up, the kyphotic angle, the upper and lower disc height and the interscrew angle were decreased over time, whereas the anterior column height and wedge angle of the vertebra were maintained after the operation. There was no statistical correlation between the breakage of instruments and the degree of lower back pain. CONCLUSIONS: On the mid and long-term follow-up of the patients who were treated by pedicle screws for thoracolumbar fractures, the correction of the kyphotic angle was lost over time and breakage of screws may eventually occur. The loss of the kyphotic angle was mainly due to the continuous loss of the intervertebral disc height.

Safety and Efficacy of Pedicle Screws and Titanium Mesh Cage in the Treatments of Tuberculous Spondylitis of the Thoracolumbar Spine

STUDY DESIGN: This is a retrospective series. PURPOSE: We wanted to analyze the safety and effectiveness of using the newer generation metallic implants (pedicle screws and/or titanium mesh) for the treatment of tuberculous spondylitis. Overview of the Literature: There have been various efforts to prevent the development of a kyphotic deformity after the treatment of tuberculous spondylitis, including instrumentation of the spine. Pedicle screws and titanium mesh cages have become more and more popular for treating various spinal problems. METHODS: Twenty two patients who had tuberculous spondylitis were treated with anterior radical debridement and their anterior column of spine was supported with a tricortical iliac bone graft (12 patients) or by mesh (10 patients). Supplementary posterior pedicle screw instrumentation was performed in 17 of 22 patients. The combination of surgeries were anterior strut bone grafting and posterior pedicle screws in 12 patients, anterior titanium mesh and posterior pedicle screws in 5 patients and anterior mesh only without pedicle screws in 5 patients. The patients were followed up with assessing the laboratory inflammatory parameters, the serial plain radiographs and the neurological recovery. RESULTS: The erythrocyte sedimentation rate and C-reactive protein levels were eventually normalized and there was no case of persistent infection or failure to control infection in spite of a mettalic implant in situ. The overall correction of kyphotic deformity was initially 8.9 degrees, and the loss of correction was 6.2 degrees. In spite of some loss of correction, this technique effectively prevented clinically significant kyphotic deformity. The preoperative Frankel grades were B for 1 patient, C for 4, D for 4 and E for 13. At the final follow-up, 7 of 9 patients recovered completely to Frankel grade E and only two patients showed a Frankel grade of D. CONCLUSIONS: Stabilizing the spine with pedicle screws and/or titanium mesh in patients with tubercuous spondylitis effectively prevents the development of kyphotic deformity and this did not prevent controlling infection when this technique was combined with radical debridement and anti-tuberculous chemotherapy.

Congenital Absence of a Pedicle of L4 in the Spinal Stenosis: A Case Report / 대한척추외과학회지

Congenital absence of a lumbar pedicle is an uncommon anomaly, and most cases are asymptomatic and discovered incidentally. A 72-year-old man presented with lower back pain that radiated to his bilateral lower extremities. Physical examination revealed no neurological deficits. Plain radiographs of the lumbar spine revealed absence of the left L4 pedicle, along with hypertrophy and sclerosis of the contralateral pedicle. Magnetic resonance imaging showed stenosis of the L3-4 neural canal. Computed tomography revealed absence of the left L4 pedicle associated with hypertrophy and sclerosis of the right L4 pedicle and facet joint. The symptoms of the patient were resolved after posterior decompression without fusion. Here, we report one case of congenital absence of an L4 pedicle detected in a spinal stenosis patient who need to undergo a decompressive surgery for the spinal stenosis caused by contralateral facet hypertrophy.

More than 5 year-Follow-Up After Pedicle Screw Fixation and Fusion for Isthmic Spondylolisthesis / 대한척추외과학회지

STUDY DESIGN: A retrospective study. OBJECTIVES: The aim of this study was to analyze the long term follow-up results of the isthmic spondylolisthesis patients who had been treated with pedicle screw fixation and fusion, and were followed up for more than 5 years. An attempt was made to determine the differences between posterior lumbar interbod fusion(PLIF) and posterolateral fusion (PLF). SUMMARY OF LITERATURE REVIEW: The surgical treatment of isthmic spondylolisthesis has developed markedly after the introduction of spine fusion and pedicle screw fixation. However, the long-term prognosis after such treatments has not been investigated sufficiently. MATERIALS AND METHODS: Among 53 patients, 38(72%) patients were examined more than 5 years after surgery. The clinical results were evaluated according to Kim's criteria. Radiologically, the degree of slippage and disc height was measured. The changes in the adjacent segments were also observed. RESULTS: PLIF was performed in 26 patients and PLF was performed in 12 patients. In the PLIF group, the clinical results were 'excellent' in 15 patients, 'good' in 8, 'fair' in 2, and 'poor' in 1. In the PLF group, the results were 'excellent' in 8 patients, 'good' in 2, 'fair' in 1, and 'poor' in 1. According to the fusion method, a satisfactory outcome was obtained in 89% of patients in the PLIF group, and 83% in the PLF group, without any statistically significant differences. Radiological analysis was available in 28 (52.8%) patients. There were no statistically significant differences between the PLIF and PLF groups in terms of the reduction and maintenance of slippage and the disc height. CONCLUSIONS: The clinical result of isthmic spondylolisthesis patients who were treated with pedicle screws and fusion were satisfactory in 87% of patients. The clinical and radiological comparison of the fusion methods showed no significant differences between the PLIF and PLF groups.

Calcium Pyrophosphate Dihydrate Crystal Deposition Disease in the Cervical Ligamentum Flavum: A Case Report / 대한척추외과학회지

Calcium pyrophosphate dihydrate deposition disease (CPPD) is an inflammatory arthropathy that is defined by the deposition of CPPD crystals in articular and periarticular structures. The cervical ligamentum flavum is a rare location of CPPD deposition. A 65-year-old woman was admitted with complaints of neck pain and a tingling sensation and numbness below the xiphoid process for 2 months. Magnetic resonance (MR) imaging and computed tomography (CT) revealed compression of the spinal cord due to a nodular calcified mass in or attached to the ligamentum flavum at the C4-5, C5-6, or C6-7 level. The patient underwent a laminectomy at C4-5, C5-6, and C6-7, and resectioning of calcified extradural nodules that impinged on the cervical cord. The operation resulted in a resolution of neck pain and hypoesthesia, except in the feet. Histopathological examination of the excised specimen revealed rectangular CPPD crystals. Here, we report a case of compressive cervical spine due to CPPD deposition disease of the cervical spine and describe the literature relevant to CPPD deposition disease of the cervical spine.

Rosai-Dorfman Disease Occurred in Epidural Space of the Thoracic Spinal Canal / 대한척추외과학회지

Rosai-Dorfman disease is a rare, non-neoplastic lymphoproliferative disorder that is characterized by its specific histological features. However, it is uncommon for it to involve the thoracic spinal cord as a site of extranodal disease. A 36 year-old man developed progressive paraparesis 2 weeks prior to admission. On an MRI study, the spinal cord was compressed at the T4 and T5 levels posteriorly by an epidural mass. A decompressive laminectomy and removal of the mass were performed and Rosai-Dorfman disease was confirmed histologically. After the operation, additional high-dose radiotherapy was performed. The motor weakness and hypesthesia in the lower extremities resolved completely and there was no evidence of recurrence at the final follow-up examination.

Posterior Lumbar Interbody Fusion Using Titanium Cages and Morselized Local Bone Autograft / 대한척추외과학회지

STUDY DESIGN: A retrospective study to evaluate the results of posterior lumbar interbody fusion (PLIF) using titanium cages filled with morselized local bone. OBJECTIVE: To verify the clinical and radiological results of the PLIF procedure using rectangular titanium cages filled with morselized local bone. SUMMARY AND LITERATURE REVIEW: Stabilization of the spine can be achieved by interbody arthrodesis through the posterior approach. However many significant problems including bone graft collapse, resorption, nonunion, and iliac donor site morbidity caused by the classic PLIF procedure need to be solved. The use of local bone and a titanium cage might be a solution. MATERIALS AND METHOD: Fifty-nine patients(average age at surgery, 51.3 years), who underwent surgery for degenerated low back disease, were enrolled in this study. The average follow-up duration was 19.9 months. The radiological fusion status, intervertebral disc heights, visual analogue scales, clinical outcomes were evaluated. RESULTS: Forty-three (73%) patients were classified as complete-union, 16 (27%) patients as probable-union, and no patients were classified as non-union. The average intervertebral disc height increased by 3.7 mm at immediate postoperatively, and the average subsidence was 1.1 mm at the final follow-up. The average visual analogue scale decreased from 5.5 to 1.4 for back pain and from 6.6 to 0.8 for radicular pain. Nineteen (32%) and 28 (48%) patients were classified as excellent and good, respectively, according to clinical outcome assessment by Kim and Kim criteria. The complications encountered were a dural tear in 8 patients, partial root injury in 1, and upper adjacent segment instability during follow-up in 2. CONCLUSION: PLIF using titanium cages filled with morselized local bone has the advantages of maintaining an intervertebral disc height, immediate stability, and the avoidance of donor site morbidity. However, longer-term results are needed, because the follow-up period of this study was relatively short

Clinical Outcome after Surgical Treatment of the Central Disc Herniation / 대한척추외과학회지

STUDY DESIGN: This is a retrospective study OBJECTIVE: We wanted to to assess the clinical features of central disc herniation and the differences in the clinical outcome between discectomy and fusion. Summary of the literature REVIEW: Central disc herniation appears to have poorer results than does posterolateral herniation in the literature. In most reports, persistent back pain was often found after discectomy and it may be related to the anatomical characteristics of the posterior longitudinal ligament in the lower lumbar region. MATERIALS AND METHOD: Central disc herniation was defined as a herniated mass that occupied more than 50% of the spinal canal and the maximal deviation of the apex was within 2 mm from the midline. 27 patients were operated on with using these criteria and they were subdivided by the operation methods. Laminotomy and discectomy was done in 20 patients. Posterior lumbar interbody fusions were performed on the other 7 patients with significant back pain. We compared the neurological improvement and the clinical outcomes. RESULTS: Preoperative back pain was significantly more frequent in the PLIF group. The other clinical features were significantly improved in the both groups, but the differences were not statistically significant. Satisfactory clinical outcomes were obtained in 70 percent of the discectomy group and in 100 percent of the PLIF group, respectively, but this was not significantly different. CONCLUSION: The presence of significant back pain was considered as an indication for performing fusion in our series. The clinical outcome of central disc herniation after PLIF was slightly better than that of discectomy in spite of the preoperative back pain in the PLIF group, but the difference was not statistically significant.

A Minimum Follow-up Study of 10 years After Pedicle Screw Fixation and Fusion for Degenerative Lumbar Diseases / 대한척추외과학회지

STUDY DESIGN: A retrospective study was conducted. OBJECTIVES: To evaluate the long-term clinical results and radiological changes of lumbar spinal fusions with pedicle screw fixation for degenerative lumbar disease. SUMMARY OF LITERATURE REVIEW: Pedicle screw fixation of the lumbar spine is a widely used procedure, but there is little longterm follow-up information on the results of the technique. MATERIALS AND METHODS: Patients, who underwent surgery for degenerative lumbar diseases, from May 1988 through December 1994, were included. Those patients who received surgery for tumors, infections, traumas, and deformities were excluded, as were those who received long-level fusions . The clinical results were evaluated with Kim's criteria. Radiologically, changes in lumbar lordosis and disc height were measured, and calcification in the disc spaces was evaluated. RESULTS: One hundred-thirty-six patients matched the study criteria. Of these, 13 had died, and there were 123 available for the study. Clinical follow-up was completed in 58 patients. There were 36 women and 22 men. The average age at the time of surgery was 52.7 years. The average follow-up was 148 months. Forty-four patients had satisfactory results at the final follow-up. Repeat surgery was necessary in 7 patients: 6 of them on a single segment and 4 with a posterior lumbar interbody fusion. A final radiologic analysis was completed in 44 patients. Lumbar lordosis was reduced from 43 degrees to 33 degrees. The lordotic angle of the fusion segments was reduced from 22 degrees to 13 degrees. The relative heights of the discs were markedly reduced at L3-4 and L4-5, from 40% to 30% and from 37% to 27%, respectively. Calcification of the disc space was observed in 37 segments out of a total of 58 that were treated with posterolateral fusions. CONCLUSION: The clinically satisfactory result rate was similar to that of the 5-year follow-up reported in a previous study by the author. Repeat operations were necessary if disc herniation or stenosis developed in the adjacent vertebral segments. Patients who were treated with a single-level PLIF demonstrated a higher repeat operation rate. Lordotic angles and disc space heights were reduced significantly during the follow-up period. Many disc spaces (64%) involved in posterolateral fusions had calcific deposits, which meant that spontaneous disc space fusion would occur over time, even though the disc space was not fused at the time of surgery.

Gorham's Disease Misdiagnosed as a Simple Compression Fracture in the Thoracic Spine: A Case Report / 대한척추외과학회지

Gorham's disease is a rare condition of unknown etiology that is characterized by progressive osteolysis. A 48 year-old woman had a burst fracture at T10, which was treated by pedicle screw instrumentation at another hospital. She was transferred due to progressive paraparesis, which was not observed initially. An MRI demonstrated severe cord compression at the T10 level. Under the assumption that the patient had a highly vascular metastatic tumor, an anterior decompression with instrumentation was performed. However, neurologic symptoms and bone destruction worsened after six weeks postoperatively. A repeat decompression was performed through the posterior route and long-level pedicle screw instrumentation was applied. After the second operation, Gorham's disease was confirmed histologically. Care must be taken not to overlook a pathologic fracture caused by a spinal tumor as a simple fracture, especially an osteoporotic one.

Cauda Equina Syndrome After Percutaneous Endoscopic Discectomy At L5-S1: A case Report / 대한척추외과학회지

The Cauda Equina syndrome after spine surgery is a relatively uncommon condition, but it is a serious complication that needs emergency treatment. A 35-year-old woman was transferred to our hospital and she presented with decreased perianal sensation and rectal tone after percutaneous endoscopic discectomy. Magnetic resonance image showed that the dura sac was compressed by herniated disc material at L5-S1. After performing emergency open discectomy for the cauda eguina syndrome, the patient's neurologic symptoms were completely resolved at 12 months follow-up. There has been no previous report on Cauda Equina syndrome after percutaneous endoscopic discectomy, and so we report here on one case.

Anterior Decompression and Instrumentation in the Patients with Neurologically Compromised Vertebral Body Collapse After Osteoporotic Compression Fracture / 대한척추외과학회지

STUDY DESIGN: A retrospective study OBJECTIVES: To evaluate the clinical and radiological results of anterior decompression and instrumentation for delayed vertebral body collapse in neurologically compromised osteoporotic compression fractures. LITERATURE REVIEW SUMMARY: Indications for an operation in delayed vertebral body collapse, following osteoporotic compression fractures, are intractable pain, progressive kyphosis and neurological deficits. The options for an operation are anterior, posterior and combined anterior and posterior approaches. Posterior surgery may need some degree of destruction of intact posterior elements. Combined anterior and posterior surgery increases the morbidity and mortality due to increased operative time and blood loss. Therefore, a one stage anterior surgery is a reasonable choice. MATERIALS AND METHODS: Between June 1989 and May 2003, seven cases of delayed vertebral body collapse, with neurological deficit, were treated using anterior decompression and anterior Kaneda instrumentation. All the cases were female, with a mean age of 67, ranging from 57 to 77 years. The average follow up period was 3.4, ranging from 1 to 13 years. One patient had a history of steroid medication. The operation time, intraoperative blood loss and bone mineral density were retrospectively reviewed. The changes in the kyphotic angle, preoperatively, postoperatively and on the last follow-up plain lateral radiograph were measured. The clinical results were evaluated based on a modified Frankel grading and visual analogue scale RESULTS: The average kyphotic angles preoperatively, postoperatively and at the last follow up were 29 degrees(25~47 degrees), 14 degrees(6~20 degrees) and 19 degrees(10~27 degrees), respectively. In all cases, the preoperative neurological deficits were improved by more than one degree in the Frankel grading at the final follow up. The mean operation time, blood loss and mean bone mineral density were 3.2 hours, 1514ml and T: -3.51, respectively. The values from the visual analogue scale preoperatively and at the last follow up were 7.0 and 0.5, respectively. CONCLUSIONS: Anterior decompression and instrumentation provides effective neurological decompression and stabilization of the spine by supporting the deficient anterior column in delayed vertebral body collapse.

Anterior Decompression and Instrumentation in the Patients with Neurologically Compromised Vertebral Body Collapse After Osteoporotic Compression Fracture / 대한척추외과학회지

STUDY DESIGN: A retrospective study OBJECTIVES: To evaluate the clinical and radiological results of anterior decompression and instrumentation for delayed vertebral body collapse in neurologically compromised osteoporotic compression fractures. LITERATURE REVIEW SUMMARY: Indications for an operation in delayed vertebral body collapse, following osteoporotic compression fractures, are intractable pain, progressive kyphosis and neurological deficits. The options for an operation are anterior, posterior and combined anterior and posterior approaches. Posterior surgery may need some degree of destruction of intact posterior elements. Combined anterior and posterior surgery increases the morbidity and mortality due to increased operative time and blood loss. Therefore, a one stage anterior surgery is a reasonable choice. MATERIALS AND METHODS: Between June 1989 and May 2003, seven cases of delayed vertebral body collapse, with neurological deficit, were treated using anterior decompression and anterior Kaneda instrumentation. All the cases were female, with a mean age of 67, ranging from 57 to 77 years. The average follow up period was 3.4, ranging from 1 to 13 years. One patient had a history of steroid medication. The operation time, intraoperative blood loss and bone mineral density were retrospectively reviewed. The changes in the kyphotic angle, preoperatively, postoperatively and on the last follow-up plain lateral radiograph were measured. The clinical results were evaluated based on a modified Frankel grading and visual analogue scale RESULTS: The average kyphotic angles preoperatively, postoperatively and at the last follow up were 29 degrees(25~47 degrees), 14 degrees(6~20 degrees) and 19 degrees(10~27 degrees), respectively. In all cases, the preoperative neurological deficits were improved by more than one degree in the Frankel grading at the final follow up. The mean operation time, blood loss and mean bone mineral density were 3.2 hours, 1514ml and T: -3.51, respectively. The values from the visual analogue scale preoperatively and at the last follow up were 7.0 and 0.5, respectively. CONCLUSIONS: Anterior decompression and instrumentation provides effective neurological decompression and stabilization of the spine by supporting the deficient anterior column in delayed vertebral body collapse.

Safety and Efficacy of Metalic Implants in the Treatments of Tuberculous Spondylitis / 대한척추외과학회지

STUDY DESIGN: A retrospective study OBJECTIVE: To analyze the safety and effectiveness of treatments using metallic implants in the tuberculous spondylitis. SUMMARY OF LITERATURE REVIEW: Residual kyphosis and loss of correction remain the major problems following surgery for tuberculous spondylitis. Several authors have used metallic implants for the prevention of these complications. However, the safety of metallic implants use in tuberculous spine infections are still controversial. MATERIALS AND METHODS: Seventeen patients, who underwent surgery, and were stabilized by the use of a metallic implant for tuberculous spondylitis, and followed up for more than 1 year were included in this study. All patients were treated with combined anterior fusion (with or without mesh) and/or posterior pedicle screw instrumentation. The patients were followed up with serial plain radiographs, laboratory inflammatory parameters and neurological recovery. RESULTS: The overall correction of the kyphotic deformity was initially 8.5 degrees, and loss of correction occurred at 5.8 degrees. Although some loss of correction occurred, even after the use of a metallic implant, clinically significant kyphotic deformity was effectively prevented. There were no cases of persistent infection or failure to control infection when the metallic implantation was combined with an anterior radical debridement and chemotherapy. The erythrocyte sedimentation rate and C-reactive protein were eventually normalized in all patients. The preoperative neurological deficits were: incomplete paralysis in 9 cases and radiculopathy in 4. At the final follow-up, 11 cases had completely recovered, partial residual neurological deficits remaining in 2. CONCLUSIONS: The use of instrumentation with metallic implants, in tubercuous spondylitis of the spine, provided immediate stability, and did not prohibit the control of infection when combined with radical debridement and anti-tuberculous chemotherapy.

Pyogenic Arthritis and Paraspinal Abscess Following Facet Joint Steroid Injection: A Case Report / 대한척추외과학회지

STUDY DESIGN: A case report and literature review. OBJECTIVES: To discuss pyogenic infections of the facet joints and paraspinal intramuscular abscess that developed after a steroid injection into the facet joint of the lower back. MATERIAL AND METHODS: A 39-year-old man who received a steroid injection to the facet joint, 3 weeks prior to admission, experienced increasing lower back pain and a high fever. RESULTS: Plain radiographs of the lumbar spine showed osteolytic erosion of the articular process at the L3-4 facet joint. On a CT scan, the destructed facet joint was connected to a paraspinal intramuscular abscess. MR images also showed a paraspinal intramuscular abscess on multiplane views. In the operative field, the paraspinal abscess, which extended from 2nd to 5th lumbar vertebrae, was found on the right side, with the L3-4 facet destructed and directly connected to the abscess. Some chalky material, considered to be steroid crystals, was found at the L3-4 facet joint. Drainage, debridement and irrigation were performed. Staphylococcus aureus was isolated from the culture. After surgery, intravenous antibiotics were administered, and the patients' symptoms quickly resolved. CONCLUSIONS: A posterior facet joint injection has its own risks of developing a pyogenic infection of the facet joint. Pyogenic facet joint infections may progress to a paraspinal intramuscular abscess. Surgical drainage is mandatory in cases resistant to antibiotic treatment, with evidence of pus formation on imaging studies.

Incidental Dural Tear during Posterior Surgery of Degenerative Lumbar Disease / 대한척추외과학회지

STUDY DESIGN: A retrospective study. OBJECTIVE: To analyze the clinical features and prognosis of intraoperative incidental durotomy during posterior surgery for degenerative lumbar disease. In addition, we tried to evaluate clinical outcome and safety of skillful neglect of pin point dural tear. SUMMARY OF LITERATURE REVIEW : Incidental durotomy is one of the most common complications during the operation of degenerative lumbar disease. It may cause signs and symptoms of cerebrospinal fluid leakage and complications such as meningitis, wound infection, pseudomeningocele and fistula. From the literature review, primary repair is mandatory even in the case of pin point dural tear. MATERIALS AND METHODS: Seven hundred fifty-five patients with degenerative lumbar disease, who were operated posteriorly from Jan. 1990 to Feb. 2002, were reviewed retrospectively. Primary operations were 378 cases of laminectomy without instrumentation and 377 cases of decompression and instrumented fusion. Of these patients, 44 (6 percent) sustained an incidental dural tear. We analyzed the mechanisms of dural tear, intraoperative treatment, postoperative management and clinical outcome. RESULTS: Eight cases (2.1%) of dural tears occurred during discectomy, 36 (9.5%) during instrumentation and fusion, and 12 (20%) during revision surgery. Dural tears were treated intraoperatively by primary repair in 20 cases, by fascial graft in 2 and without repair (skillful neglect) in 22. There were no cases of persistent cerebrospinal fluid leakage or fistula formation, and the symptoms of cerebrospinal fluid leakage were transient. Of 36 patients followed for more than one year, 82% had good or excellent result. CONCLUSION: Incidental durotomy occurred in 5.8 percent of lower back surgery patients, and more frequently in revision surgery. Very small dural tears did not have significant influence on the clinical outcome, whether they were repaired or not. Skillful neglect of pin point dural tear may be a reasonable treatment option.

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.

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.