Causes and Clinical Manifestations of Cauda Equina Syndrome

STUDY DESIGN: A literature review. OBJECTIVES: To describe the causes and clinical characteristics of cauda equina syndrome. SUMMARY OF LITERATURE REVIEW: The cauda equina syndrome, complex symptoms and signs expressed as variable clinical manifestation, has rare incidence but needs attention since it can bring about serious complications and sequales if neglected. MATERIALS AND METHODS: The Author reviewed articles reporting the causes and clinical manifestation of cauda equina syndrome. RESULTS: There are marked inconsistencies in the current evidence base surrounding the definition due to various clinical presentation of cauda equina syndrome. CONCLUSION: As there is no symptom or sign which has an absolute diagnostic value in establishing the diagnosis of cauda equina syndrome, any patient in whom a clinical suspicion of cauda equina syndrome arises must undergo urgent magnetic resonance imaging for diagnosis.

Fusion Rates of Instrumented Lumbar Spinal Arthrodesis according to Surgical Approach: A Systematic Review of Randomized Trials

BACKGROUND: Lumbar spine fusion rates can vary according to the surgical technique. Although many studies on spinal fusion have been conducted and reported, the heterogeneity of the study designs and data handling make it difficult to identify which approach yields the highest fusion rate. This paper reviews studies that compared the lumbosacral fusion rates achieved with different surgical techniques. METHODS: Relevant randomized trials comparing the fusion rates of different surgical approaches for instrumented lumbosacral spinal fusion surgery were identified through highly sensitive and targeted keyword search strategies. A methodological quality assessment was performed according to the checklist suggested by the Cochrane Collaboration Back Review Group. Qualitative analysis was performed. RESULTS: A literature search identified six randomized controlled trials (RCTs) comparing the fusion rates of different surgical approaches. One trial compared anterior lumbar interbody fusion (ALIF) plus adjunctive posterior transpedicular instrumentation with circumferential fusion and posterolateral fusion (PLF) with posterior lumbar interbody fusion (PLIF). Three studies compared PLF with circumferential fusion. One study compared three fusion approaches: PLF, PLIF and circumferential fusion. CONCLUSIONS: One low quality RCT reported no difference in fusion rate between ALIF with posterior transpedicular instrumentation and circumferential fusion, and PLIF and circumferential fusion. There is moderate evidence suggesting no difference in fusion rate between PLF and PLIF. The evidence on the fusion rate of circumferential fusion compared to PLF from qualitative analysis was conflicting. However, no general conclusion could be made due to the scarcity of data, heterogeneity of the trials included, and some methodological defects of the six studies reviewed.

Study about Biodegradation of Hydroxyapatite and beta-tricalcium Phosphate Coating Layer

OBJECTIVE: Biodegradation of synthetic calcium phosphate depends on two mechanisms; dissolution in body fluid and a cellular reaction. The chemical dissolution process is well understood, but details of the cellular reaction are not yet fully understood. Thus, we investigated whether the resorption mechanisms of hydroxyapatite (HA) and beta-tricalcium phosphate (beta-TCP) coating layer were identical, and, if not, what differences were observed. METHODS: Titanium discs, 12 mm in diameter and 2 mm in thickness, were coated with HA (n = 40) or beta-TCP (n = 40) by a dip and spin method. In each group, specimens were divided into two subgroups; the Dissolution group (D) and the Osteoclast Culture group (C). Discs in the D group were immersed in the distilled water or cell culture medium for 5 days, whereas, in the C group, osteoclast-like cells, which were obtained from giant cell tumor of bone, were seeded onto specimens and cultured for 5 days. The degradation characteristics of the surface coating were observed by light microscopy and scanning electron microscopy. RESULTS: Extent of the cracks and denudations were much greater in the beta-TCP coating than the HA coating after dissolution. In the C groups, the mean area fraction of resorption lacunae in the HA-C group was 11.62%, which was significantly higher than the 0.73% noted in the beta-TCP-C group (P = 0.001). CONCLUSION: The resorption mechanism of HA and beta-TCP coating was different and the beta-TCP coating was degraded principally by dissolution and separation from the implant, but the HA coating was resorbed by osteoclastic activity.

Prevalence And Risk Factor of Degenerative Disease of Adjacent Segment after Anterior Cervical Arthrodesis

STUDY DESIGN: A retrospective radiologic and clinical analysis of 48 patients following anterior cervical fusion. OBJECTIVES: To examine the prevalence of symptomatic adjacent segment disease after anterior cervical fusion and determine the risk factors affecting its progression. SUMMARY OF LITERATURE REVIEW: Symptomatic adjacent segment disease appears to occur at a rate of 2% to 3% per year. MATERIALS AND METHODS: Forty-eight patients, who were followed up for more than 3 years after anterior cervical arthrodesis, were enrolled in this study. A modification of the Robinson criteria was used for the clinical evaluation and the radiographic grading of Hilibrand was used for the radiology evaluation. Kaplan-Meier survival analysis was used to examine the survival rate. Age, gender, number of fusion segments, preoperative ROM, angle of lordosis, spinal canal diameter and radiologic degeneration of adjacent segments were selected as potential risk factors. The subjects were divided into two groups according to their clinical symptoms. RESULTS: Symptomatic adjacent segment disease developed in 11 of the 48 patients(22.9%). The disease free survival rates were 88.7%, 82.4% and 58.7% at 5, 10 and 15 years, respectively. A study of the risk factors showed that preoperative degenerative changes and narrow spinal canal in the adjacent segments were significant. However, there were no significant associations with age, gender, number of fusion segments, preoperative ROM and angle of lordosis. CONCLUSION: The prevalence of symptomatic adjacent segment disease after anterior cervical fusion was considerable and higher when the patients had preoperative degenerative changes and a narrow spinal canal in the adjacent segments.

Change of Deformity due to Position and Anesthesia in Adolescent Idiopathic Scoliosis / 대한정형외과학회잡지

PURPOSE: To determine changes in the end vertebra and neutral vertebra as well as in the magnitudes of coronal and rotational deformities according to position and anesthesia in patients with adolescent idiopathic scoliosis. MATERIALS AND METHODS: Sixty-two structural curves in 31 patients were evaluated using standing, supine, side bending, post-anesthesia, and postoperative anteroposterior plain radiographs. Cobb angles and rotation angles by perdriolle torsionmeter were measured, and the end vertebra and neutral vertebra were identified in each radiograph. RESULTS: Coronal cobb angles decreased significantly with correction rates of 25.0%, 31.7%, 59.5%, and 74.0%, and rotational deformities decreased with correction ratesof 6.1%, 24.5%, 6.2%, and 25.7% by supine position, anesthesia, side bending and surgery, respectively.The end vertebrae changed in 18 patients (58.1%) in both supine and post-anesthesia radiographs, and the neutral vertebrae changed in 10 patients (32.3%) in supine radiographs and in 20 patients (64.5%) in post-anesthesia radiographs. CONCLUSION: Coronal deformities are significantly corrected by supine position and anesthesia. Anesthesia significantly corrects axial rotation, but more correction cannot be achieved by rod derotation. The end vertebra and neutral vertebra have a tendency to vary by position and anesthesia, which gives rise to confusion in the determination of fusion level.

Early-Onset Facioscapulohumeral Muscular Dystrophy: Significance of Pelvic Extensor in Sagittal Spinal Imbalance / 대한정형외과학회잡지

An 11-year-old girl with early-onset facioscapulohumeral muscular dystrophy (FSHD) presented with progressive gait disturbance and lumbar hyperlordosis. The motor power of her pelvic extensor muscles was grade 3. Pelvic tilt and hip flexion were markedly increased as determined by gait analysis. This FSHD case is an impressive example of a patient demonstrating the concept that weak pelvic extensor muscles cannot keep the spine upright and balanced. The most important factor in the development of hyperlordosis is the weakness of the pelvic extensor muscles, and the results of gait analysis exquisitely explain the pathophysiology. The patient stands with her spine hyperextended to maintain upright posture by a compensatory mechanism of relatively strong back extensor muscles. Corrective surgery for lumbar hyperlordosis was not considered as it could eliminate the compensatory lumbar hyperextension, thus making the spine of the patient stoop forward through the hip joint during walking, being caused by the weakness of her pelvic extensor muscles.

Herpes Zoster Confused with Radiculopathy / 대한정형외과학회잡지

PURPOSE: To describe the clinical features of herpes zoster that can be easily misdiagnosed as cervical or lumbar radiculopathy. MATERIALS AND METHODS: We retrospectively reviewed the medical records and diagnostic studies of 7 patients with herpes zoster-related arm or leg pain. RESULTS: Except one immunocompromised patient with suspected postherpetic neuralgia or sequelae of herpetic myelitis, the other 6 patients with herpes zoster complained of very severe initial pain of sudden onset. Three patients did not show skin lesions on initial examination, and 2 of 5 patients with an MRI of the cervical or lumbar spine had findings consistent with their arm or leg pain and may have been confused with radiculopathy. Conservative treatment, including antiviral agents, improved the symptoms of all patients except the immunocompromised one. Selective nerve root blocks of the corresponding dermatomes were performed in 5 patients and extremity pain decreased over 50% in 4 of them. CONCLUSION: Herpes zoster can be confused with radiculopathy in patients with arm or leg pain if the typical skin lesions have not been developed. Unnecessary treatments including surgery should be avoided by early, correct diagnosis through prudent history taking and physical examination.

The Comparison of the Results Between AO Internal Fixator (Long lever-arm) and Screw-Rod System (Short lever-arm) Through Posterior Approach in Unstable Thoracolumbar Fractures / 대한척추외과학회지

STUDY DESIGN: Prospective study. OBJECTIVES: To analyze the outcome of posterior reduction and fixation with the AO internal fixator and with the screw-rod system in unstable thoracolumbar fractures and to investigate differences in effectiveness between the two methods. SUMMARY OF LITERATURE REVIEW: In unstable thoracolumbar fractures, fixation with the AO internal fixator is an effective method for posterior reduction. However, the results of correction are quite variable. MATERIALS AND METHODS: We analyzed 51 patients with unstable thoracolumbar fractures who underwent correction through posterior approach between 1997 and 2003. We divided the patients into two groups: Patients in Group A (25 cases) were treated with the AO internal fixator, and patients in Group B (26 cases) were treated with the screw-rod system. We added transpedicular bone grafts for 17 patients in Group A. We evaluated correction of deformity (anterior and posterior height of vertebral body, sagittal index, disc height), loss of correction, spinal canal clearance, and neurological recovery. RESULTS: Comparing correction of deformity, we saw better results in Group A than in Group B in regards to sagittal index and anterior height of vertebral body. However, we saw a higher degree of correction loss in the anterior height of the vertebral body in Group A. We grafted autogenous bone into the fracture site by transpedicular approach for 17 patients in Group A. We saw less correction loss in the anterior vertebral body height and sagittal index. In regard to spinal canal clearance, we saw better results in Group A (18%) than in Group B (10%). As for neurological recovery, we could not find any statistically significant difference between the two groups. CONCLUSIONS: Through an operative procedure, we could achieve better results in restoration of anterior vertebral height and canal clearance with the AO internal fixator system. Further study is necessary to keep the reduced state of vertebral height.

Risk Factors for Adjacent Segment Disease After Lumbar Fusion / 대한척추외과학회지

STUDY DESIGN: Retrospective study of adjacent segment disease. OBJECTIVES: To describe the incidence and clinical features of adjacent segment disease (ASD) after lumbar fusion and to determine its risk factors. SUMMARY OF LITERATURE REVIEW: The reported incidence of adjacent segment problems is variable, and little has been discussed about surgically treated cases. Risk factors also have not been precisely identified, especially based on structural changes seen on magnetic resonance imaging (MRI). MATERIALS AND METHODS: We analyzed the records of 1,124 patients who underwent lumbar or lumbosacral instrumented fusions between August 1995 and March 2006 and had at least one year follow-up. Of these patients, 28 patients who needed secondary operations because of ASD were included in this study. The disease group was compared with an age-, sex-, fusion level-, and follow-up period-matched control group composed of the same number of patients, toward the purpose of analyzing six variables as risk factors. RESULTS: The incidence of ASD requiring surgical treatment was 2.48%. The mean patient age was 58.4 years, which showed no statistically significant difference from that of the population in which ASD did not develop (57.0 years, p=0.429). Only 1 distal ASD occurred among 21 floating fusions. Facet degeneration was a significant risk factor (p<0.01) on logistic regression analysis. CONCLUSION: Our study patients with ASD complained of severe symptoms with frequent neurological abnormalities. The incidence of distal ASD was much lower than that of proximal ASD. Pre-existing facet degeneration may confer a high risk of adjacent segment problems after lumbar fusion procedures.

A Novel Concept for the Best Coronal Alignment of Pedicle Screws in Multilevel Lumbar Posterior Instrumentation - A Technical Note / 대한척추외과학회지

Correct alignment of pedicle screws is imperative in multilevel instrumentation. However, there has been no report addressing the technical aspects of this subject. If the head diameter of a pedicle screw is D, the head height is H, and the convergence angle of the screw being inserted is alpha, then the distance between the extension line of the medial borders of the inserted screw heads and the insertion point of the adjacent screw (A) is described by the following formula: A = 1/2Dcos alpha- Hsin alpha If an L3 pedicle screw (D=13 mm, H=15 mm) is to be inserted with a convergence angle of 14 degrees after the insertion of L4 and L5 screws, its insertion point should be 3.6 mm medial to the extension line of the centers of the L4 and L5 screws and 2.7 mm lateral to the extension line of their medial borders for all screw heads, so it can be aligned in the coronal plane. In order to achieve the best alignment, a pedicle screw is inserted between the extended line of the centers and that of the medial borders of the inserted adjacent screw heads. For the routine range of convergence angles, it is essential to move the entry point medially toward the extended line connecting the medial borders of the inserted adjacent screw heads.

Scoliosis Correction with Thoracic Pedicle Screws: Posteroanterior C-arm Rotation Method / 대한정형외과학회잡지

Purpose: This study evaluated a practical, safe and accurate method of thoracic pedicle screw insertion for the surgical treatment of scoliosis using the posteroanterior C-arm fluoroscopy rotation method. Materials and Methods: A total of 611 thoracic pedicle screws were inserted in 45 patients using the posteroanterior (PA) C-arm rotation method. CT scans were taken postoperatively in the transverse and sagittal sections to evaluate the pedicle screw placement. Results: A mean preoperative curve of 57.7o was corrected to 17.1o (range, 3o-45o) in the coronal plane. The postoperative CT scans revealed that 10 screws (1.6%) had penetrated the medial cortex by a mean distance of 3.0 mm and 56 screws (9.2%) penetrated the lateral cortex by a mean distance of 3.5 mm. No screw penetrated the inferior or superior cortex in the sagittal plane. However, 21 screws (3.4%) penetrated the anterior cortex. No neurological or vascular complications were encountered, and none of the screws required replacement. Conclusion: Thoracic pedicle screw insertion in scoliosis patients using the posteroanterior C-arm rotation method is a practical, simple and safe technique that allows the en face visualization of both pedicles by rotating the C-arm to compensate for the rotational deformity.

The Association of the Activation-Inducible Tumor Necrosis Factor Receptor and Ligand with Lumbar Disc Herniation

PURPOSE: Herniated nucleus pulposus fragments are recognized by the immune system as a foreign-body, which results in an autoimmune reaction. Human activation-inducible tumor necrosis factor receptor (AITR) and its ligand, AITRL, are important costimulatory molecules in the pathogenesis of autoimmune diseases. Despite the importance of these costimulatory molecules in autoimmune disease, their role in the autoimmune reaction to herniated disc fragments has yet to be explored. The purpose of the present study is to investigate whether the overexpression of AITR and AITRL might be associated with lumbar disc herniation. MATERIALS AND METHODS: The study population consisted of 20 symptomatic lumbar disc herniation patients. Ten macroscopically normal control discs were obtained from patients with spinal fractures managed with anterior procedures that involved a discectomy. Peripheral blood samples from both the study patients and controls were collected. The expression levels of AITR and AITRL were investigated by flow cytometric analysis, confocal laser scanning microscopy, immunohistochemistry and by reverse transcriptase-polymerase chain reaction (RT-PCR). The soluble AITR and AITRL serum levels were measured by an enzyme-linked immunosorbent assay. RESULTS: Flow cytometric analysis revealed significantly higher levels of both AITR and AITRL in the lumbar disc herniation patients than in the controls. The AITRL expression levels were also increased in patients with lumbar disc herniation, shown by using confocal laser scanning microscopy, immunohisto-chemistry, and RT-PCR. Finally, soluble AITR and AITRL were elevated in the patients with lumbar disc herniations. CONCLUSION: The AITR and AITRL are increased in both the herniated disc tissue and the peripheral blood of patients with lumbar disc herniation.

Idiopathic Scoliosis in the Eleven Years Old: Prevalence Study / 대한정형외과학회잡지

PURPOSE: To evaluate the epidemiological findings of idiopathic scoliosis in eleven years olds. MATERIALS AND METHODS: A total of 18,521 adolescents who were eleven years old were screened for scoliosis. There were 10,204 boys and 8,317 girls. The adolescents who had an abnormal moire topography were assessed subsequently using standardized clinical and radiological examinations. The scoliotic curve was defined as a curve of 10 or more. RESULTS: The prevalence of scoliosis was 0.31 per cent (57 of 18,521 adolescents), and most of the curves (42; prevalence, 0.23 per cent) were small (10 to 19 degrees). The ratio of boys to girls was 1:4.7 overall. Thoracolumbar curves were the most common type of curve identified, followed by thoracic and lumbar curves. CONCLUSION: The prevalence of idiopathic scoliosis in eleven year olds was 0.31 per cent. The size and pattern of idiopathic scoliosis were similar with those in the adolescents twelve years and older reported in the literature.

Thoracic Pedicle Screw Insertion in Scoliosis Using Posteroanterior C-arm rotation Method / 대한척추외과학회지

STUDY DESIGN: A prospective study of the accuracy of thoracic pedicle screws inserted in scoliotic patients. OBJECTIVES: To evaluate and present a practical, safe and accurate method for thoracic pedicle screw insertion in the surgical treatment of scoliosis using the posteroanterior c-arm fluoroscopy rotating method. SUMMARY OF LITERATURE REVIEW: Previous studies have emphasized the clinical importance, yet difficulty, of accurate thoracic pedicle screw insertion in scoliotic patients. Three-dimensional alterations in the pedicle orientation of scoliotic patients makes the accurate insertion challenging. No reports exist on the accuracy and benefits of posteroanterior c-arm fluoroscopy, which is rotated to allow visualization from en face, in real patients. MATERIALS AND METHODS: A total of 350 thoracic pedicle screws were inserted in 29 patients, including 24 with idiopathic scoliosis, using the posteroanterior (PA) c-arm rotation method. The smallest patient weighed 14 kg, and the next smallest 17 kg. The average preoperative curve was 60.9 degrees(range, 45 degrees~101 degrees). CT scans were taken, postoperatively, in the transverse and sagittal sections to evaluate the pedicle screw placement. RESULTS: The mean preoperative curve of 60.9 degrees was corrected to 15.4 degrees(range, 3 degrees~45 degrees) in the coronal plane, a correction of 74.7%. A mean of 12.1 thoracic screws were inserted per patient. On analysis of the postoperative CT scans, 39(11.1%) of the 350 screws penetrated the medial or lateral pedicle cortices, 8(2.3%) into the medial cortex and 31(8.9%) into the lateral cortex, by mean distances of 3.3 and 3.6 mm, respectively. No screws penetrated the inferior or superior cortices in the sagittal plane, but 16(4.6%) penetrated the anterior cortex. No neurological or vascular complications were encountered, and none of the screws required subsequent replacement. CONCLUSIONS: Thoracic pedicle screw insertion in scoliotic patients, using a posteroanterior c-arm rotation method, allows the en face visualization of both pedicles by rotating the c-arm to compensate for rotational deformity, which makes it a practical, simple and safe method.

Prognostic Factors Affecting the Results of the Surgery for Cervical Spondylotic Myelopathy / 대한척추외과학회지

STUDY DESIGN: This retrospective study was designed to investigate and define the factors affecting the results of surgery for cervical spondylotic myelopathy. OBJECTIVE: This study was performed in an attempt to investigate and define the factors affecting the results of surgery for cervical spondylotic myelopathy. SUMMARY OF THE LITERATURE REVIEW: There have been few studies about the factors affecting the results of surgery for cervical myelopathy, including MEP (Motor evoked potential) studies and gait analysis, so we investigated the factors that affect the results of surgery for cervical myelopathy. MATERIALS AND METHODS: We retrospectively studied 59 cervical spondylotic myelopathy patients who underwent operation from Nov. 1994 to Oct. 2002. We analyzed 13 prognostic factors: age, disease duration, the pre-op JOA score, the pre-op. AP canal diameter, the Pavlov ratio, disease level, the AP and lateral cord diameter, the transverse area and the compression ratio at the level of the maximal cord compression on MRI, the cord signal changes on MRI, the MEP(Motor evoked potential) and the gait analysis. The mean follow up period was 29 months. The clinical results were evaluated according to the JOA score. Statistical analysis was performed using the Pearson correlation test, ANOVA and the Kruskal-Wallis test. RESULTS: The mean pre-op JOA score was 11.1 and the post-op. JOA score was improved to 14.7. The average recovery rate was 67%. The following factors were proved to an influence on the surgical outcomes: age and multiplicity of involvement, and the signal changes of the cord on MRI showed a negative correlation with the recovery rate. The pre-op JOA score, the mean sagittal diameter and the transverse area of the spinal cord at the level of maximum compression showed a positive correlation with the recovery rate. Spasticity on the gait analysis and central conduction block on MEP had an influence on the surgical outcomes. CONCLUSIONS: The prognostic factors affecting the results of surgery for cervical myelopathy are age, the pre-op JOA score, the disease level, the mean sagittal diameter and the transverse area of the spinal cord at the level of maximum compression, signal change of the cord on MRI, spasticity on the gait analysis and central conduction block on MEP.

Prognostic Factors Affecting the Results of the Surgery for Cervical Myelopathy / 대한정형외과학회잡지

PURPOSE: This study was performed to investigate and define the factors affecting the results of surgery for a cervical myelopathy. MATERIALS AND METHODS: Seventy-eight cervical myelopathy cases, who underwent surgery from Jan. 1991 to Sep. 2001, were retrospectively reviewed. The patients were composed of developmental stenosis in 9, spondylosis in 21, OPLL in 12, HIVD in 34 and trauma in 2 cases. The causes of the disease, age, onset, pre-op JOA score, pre-op and post-op spinal canal diameter, Pavlov ratio and cord diameter and signal changes of cord on MRI were examined. The mean follow-up period was two years. The clinical results were evaluated according to the JOA score. Statistical analysis was made using the Pearson correlation coefficient and the Kruskal-Wallis method. RESULTS: The mean pre-op and post-op JOA score were 11.2 and 14.8 respectively. The mean recovery rate was 68.0%. The preoperative JOA score showed a positive correlation with recovery rate, and age, sagittal diameter and transverse area of the cord on MRI correlated negatively with the recovery rate. The result was poorer the higher the level involved. Patients with signal changes in the cord on MRI had a poor outcome after surgery. CONCLUSION: The prognostic factors affecting the results of the surgery for cervical myelopathy were age, pre-op JOA score, disease level, and sagittal diameter, transverse area and the signal changes in the cord on MRI.

Expression of Heat Shock Protein 27 in Human Chondrocytes Confers Resistance to Apoptosis / 대한정형외과학회잡지

PURPOSE: This study was designed to examine whether human articular chondrocytes express heat shock protein 27 (hsp27) and to evaluate the relation between hsp27 and the apoptosis of chondrocytes. MATERIALS AND METHODS: Knee joint articular cartilage was obtained from femoral condyle in osteoarthritis patients who underwent joint replacement surgery. Chondrocytes were isolated, cultured and then exposed to heat shock (42degrees C) for 1 hour to induce the expression of hsp27. 20 mM of sodium nitroprusside (SNP) was then added for 12 hours to evaluate the ability of hsp27 to prevent SNPinduced chondrocyte apoptosis. The expression of hsp27 was verified by Western blot and the rate of apoptosis was determined by flow cytometric analysis. RESULTS: Heat shock resulted in the increased expression of hsp27 in chondrocytes. Heat-shocked groups had smaller numbers of apoptotic cells than control groups when both were exposed to apoptosis inducing stimuli. CONCLUSION: We conclude that hsp27 was expressed in human articular chondrocytes by heat shock and that the expression of hsp27 in chondrocytes increases their resistance to apoptosis. This result presents clues, which suggest that the induction of hsp27 could be a desirable future therapeutic strategy in human osteoarthritis

Clinical Features of Degenerative Scoliosis / 대한척추외과학회지

PURPOSE: To describe and analyze the clinical features of degenerative scoliosis so that we could guess the pathogenesis of the disease. MATERIALS AND METHODS: Forty-eight adults with degenerative scoliosis were reviewed. We evaluated the symptoms and physi-cal findings. Simple radiographs of the lumbar spine and MRI films were investigated. RESULTS: All patients had low-back pain, and eleven of them had severe low-back pain. Forty-six patients(96%) had lower extremity symptoms, and 80% of them had severe symptoms. The mean curve was 18 dgrees (range, 11o-44 dgrees). The mean lordosis was 2 7 dgrees (range, -16 dgrees -+ 45 dgrees). The frequency of significant degenerative change was highest in the low- lumbar region. Stenosis detected on MRI was present in the low-lumbar area in most cases and a limited number of cases revealed stenosis on the mid-lumbar area. The most frequent incidence of stenosis was at L4-5. SUMMARY AND CONCLUSION: The frequency of degenerative change was highest in the low-lumbar region and significant cases revealed degenerative change only in low-lumbar area. This may imply that degeneration and instability of low-lumbar area can cause secondary biomechanical compensation at above levels, resulting in scoliosis and degenerative change.

Posterior Fusion of Spondylolisthesis (Posterolateral Fusion and Posterior Lumbar Interbody Fusion) / 대한척추외과학회지

Spondylolithesis is defined as forward slipping of a vertebral body on distal vertebra, and this slipping causes a spectrum of symptoms from mild back pain to overt spinal stenosis. The various treatment modality for spondylolisthesis is introduced. In general, the slip of lesser than 50 per cent can be successfully treated with in situ fusion in children and early adolescent without neurologic deficit. Operative reduction of spondylolisthesis may be indicated in cauda equina syndrome, progressive slip surpassing 40 to 50 per cent, major deformity causing decompensation or distress, major pain or deficit plus two or more risk factor. Risk factors for in situ fusion include the following: slip angle greater than 25 degrees, trapezoidal L5, rounded sacral end plate, hyperlordosis exceeding 50 degrees L2-S1, L5 radiculopathy requiring decompression, female adolescents, excess lumbosacral mobility, sign of sacral root stretch. Stabilization after decompression of high grade isthmic spondylolisthesis is difficult due to insufficiency of fusion base, gap between the bases and incompetent anterior disc support. So posterior lumbar interbody fusion(PLIF) offered anterior support, reduction of the deformity and a broad fusion base may be applied. PLIF may be indicated in spinal stenosis with narrow euroforaminal space, isthmic spondylolisthesis with instability after removal of posterior structure of vertebra, grade 3,4 isthmic spondylolisthesis, failure of posterolateral fusion, symptomatic degenerative disc disease.

Operative Treatment of Degenerative Scoliosis / 대한척추외과학회지

STUDY DESIGN: The retrospective study was designed to propose treatment options of degenerative scoliosis OBJECTIVES: To propose various treatment options based on patients'clinical symptoms & radiologic findings and finally to get a standard treatment options. SUMMARY OF LITERATURE REVIEW: The studies about the treatment options of degenerative scoliosis were few, so we propose the treatment options of degenerative scoliosis. MATERIALS & METHODS: Between January, 1994 and August, 2000, 136 cases of degenerative scoliosis were diagnosed. Among these cases, 45 cases (33%) were performed operative treatment. There were 45 women and 4 men. The average patients age was 62.6 years (range 43~78years). The average follow up time was 23 months (range 12 mon~66 months). Scoliotic angle within curve was measured by Cobb's methods, and rotation of pedicles were measured by Nash and Moe methods. RESULTS: The overall satisfactory clinical results was noted in 37 (82%) of 45 patients. By Kirkardy-Willis questionnaire, 14 cases were excellent, 23 cases were good, 5 cases were fair, 3 cases were poor. Before surgery, average Cobb's angle measured 16 degree (range 7~44 degree), after surgery, this corrected to 9.2 degree (range 2~25 degree). But, degree of improvement in Cobb's angle and one of clinical symptom relief had no statistic correlations (p>0.05). CONCLUSION: 1) When neurologic symptoms were chief complaints, and scoliosis curvature was stable. only decompression surgery should be performed. 2) when mild back pain and neurologic symptoms were chief complaints, and rotatory subluxation at stenotic level, decompression & limited post. instrumentation & fusion. 3) when severe back pain and neurologic symptoms were chief complaints, and scoliosis curvature was unstable, decompression & long post. instrumentation & fusion. 4) When only technical pain-no neurologic symptoms-was a chief complaints, correction & fusion with instrumentation.