Radiologic Adjacent Segment Degeneration: Two Levels fusion (L3-4-5 and L4-5-S1) Using Percutaneous Pedicle Screw Fixation in Degenerative Lumbar Spinal Disease; A Preliminary Report

OBJECTIVE: The purpose of this study is to examine radiological adjacent segment degeneration (ASD) and clinical results after two levels percutaneous pedicle screw fixation. METHODS: From 2007 to 2009, 34 patients who underwent percutaneous pedicle screw fixation on L3-4-5 or L4-5-S1 for lumbar degenerative disorders were selected. According to the presence of radiological ASD, ASD group and non-ASD group were compared for clinical results and radiologic results such as total lordotic angle (TLA), segmental lordotic angle (SLA) via lumbar X-rays during follow up periods. Furthermore, we compared pre-operative degree of disc degeneration at adjacent segment between two groups via MRI. RESULTS: The mean follow-up period and mean age were 27.38+/-9.45 months and 59.21+/-12.73 years. ASD group were 7 patients, and non-ASD group were 27 patients. The mean age of the ASD group (67.40+/-4.81) was significantly older than that of the non-ASD group (57.46+/-13.18). Pre-operative disc degeneration of cranial adjacent segment in ASD group were 6 patients (25.9%), whereas that in non-ASD group were 4 patients (14.8%), showing that preoperative disc degeneration was significantly more severe in the ASD group. CONCLUSION: Percutaneous pedicle screw fixation is favorable technique to prevent ASD for two levels fusion, however, when the patient is old or the preoperative disc degeneration of the adjacent segment is severe, there is the risk of postoperative ASD, and thus special attention should be paid during the follow-up period.

Wedge Shape Cage in Posterior Lumbar Interbody Fusion: Focusing on Changes of Lordotic Curve

OBJECTIVE: Lumbar lordotic curve on L4 to S1 level is important in maintaining spinal sagittal alignment. Although there has been no definite report in lordotic value, loss of lumbar lordotic curve may lead to pathologic change especially in degenerative lumbar disease. This study examines the changes of lumbar lordotic curve after posterior lumbar interbody fusion with wedge shape cage. METHODS: We studied 45patients who had undergone posterior lumbar interbody fusion with wedge shape cage and screw fixation due to degenerative lumbar disease. Preoperative and postoperative lateral radiographs were taken and one independent observer measured the change of lordotic curve and height of intervertebral space where cages were placed. Segmental lordotic curve angle was measured by Cobb method. Height of intervertebral space was measured by averaging the sum of anterior, posterior, and midpoint interbody distance. Clinical outcome was assessed on Prolo scale at 1month of postoperative period. RESULTS: Nineteen paired wedge shape cages were placed on L4-5 level and 6 paired same cages were inserted on L5-S1 level. Among them, 18patients showed increased segmental lordotic curve angle. Mean increased segmental lordotic curve angle after placing the wedge shape cages was 1.96? Mean increased disc height was 3.21mm. No cases showed retropulsion of cage. The clinical success rate on Prolo's scale was 92.0%. CONCLUSION: Posterior lumbar interbody fusion with wedge shape cage provides increased lordotic curve, increased height of intervertebral space, and satisfactory clinical outcome in a short-term period.

The Changes of Sagittal Alignment after Anterior Interbody Fusion with Posterior Fixation in Spondylolisthesis of the Lumbar Spine / 대한척추외과학회지

STUDY DESIGN: A prospective radiological assessment was conducted. OBJECTIVES: To analyze the changes in the height of the intervertebral disc, the slippage, slip angle, lumbar lordotic angle and sacral inclination after anterior lumbar interbody fusion and posterior pedicle screw fixation in a lumbar spondylolisthesis. SUMMARY OF LITERATURE REVIEW: The anterior lumbar interbody fusion causes changes in the lumbar sagittal alignment. METHODS: The mini-open anterior lumbar interbody fusion and pedicle screw fixation was undertaken in 33 cases from April 1995 to November 2003. MRI was done before and 6 months after surgery. The measuring factors were the heights of the intervertebral disc, slippage, slip angle, lumbar lordotic angle and sacral inclination. The measuring factors were independently assessed three times by three different orthopedic surgeons. The postoperative changes in measuring the factors were analyzed by a paired t-test statistically. RESULTS: The height of the intervertebral disc was increased by a mean of 14.0%, slippage was reduced by a mean of 2.8%, the slip angle was reduced by a mean of 16.0%, the lumbar lordotic angle was increased by a mean of 15.6% and the scaral inclination was increased by a mean of 3.0%. There was significance in the increase in the disc height, the reduction of slippage and the slip angle, and the increase in lumbar lordotic angle, but there were no significance regarding the changes in sacral inclina-tion. CONCLUSIONS: The anterior lumbar interbody fusion and the pedicle screw fixation significantly improved the height of the intervertebral disc, slippage, slip angle, and lumbar lordotic angle, except sacral inclination.

Relation of Postoperative Deformity with Clinical Results in Degenerative Lumbar Scoliosis with Spinal Stenosis / 대한척추외과학회지

STUDY DESIGN: A retrospective study OBJECTIVES: This study was designed to compare the clinical results, with the correction of the lumbar lordotic and scoliotic angles, in degenerative lumbar scoliosis patients, with spinal stenosis, who underwent an operation. SUMMARY OF LITERATURE REVIEW: Few studies have compared the postoperative lordotic angle with the clinical results in degenerative lumbar scoliosis, with spinal stenosis. SUBJECTS AND METHODS: Out of 68 cases, where the patients underwent posterior decompression, pedicle screw fixation and fusion, due to the degenerative lumbar scoliosis with spinal stenosis, between February 1997 and February 2001, 59 cases, with the possible follow-ups for over 2 year, were studied and are herein reported. The decompression was carried out over a segment that showed the neurological symptom and occlusion of the spinal canal or the compression on the nerve root observed on CT or MRI scans. The pedicle screw fixation and fusion were carried out over the segment that received the decompression. The average age of the patients was 63.4, ranging from 51 to 76 years, and the average follow-up period was 38, ranging from 24 to 56 months. The measurements were performed in relation to the vertebral rotation, scoliotic and lumbar lordotic angles preoperatively, postoperatively and at the time of the final follow-ups, respectively. The clinical results were classified by the Kirkaldy-Willis questionnaire, and the statistical calculations performed through chi-squared and Pearson's correlation tests. RESULTS: The average lumbar scoliotic angles preoperatively, postoperatively and at the time of the final follow-ups were 15.7+/-4.9, 8.9+/-3.1 and 10.8+/-4.7 degrees, respectively. The average lumbar lordotic angles were 14.2+/-6.1, 20.1+/-7.3 and 19.4+/-7.2 degrees, respectively. The vertebral rotation degrees were 0.88, 0.62 and 0.64, respectively. The clinical results by the Kirkaldy- Willis questionnaire indicated over 73% satisfactory results, showing 9 excellent, 34 good, 13 fair and 3 poor cases. The lumbar lordotic angle was statistically correlated with the clinical results (p=0.04), while the scoliotic angle (p=0.41) and the vertebral rotation degree (p=0.29) were not. The scoliotic and lordotic angles had negative correlations, but these were not statistically significant (r=-0.09 and p>0.05). CONCLUSION: It is my belief that the correction of the lumbar lordotic angle, in patients having spinal stenosis, with degenerative lumbar scoliosis, is associated with an improvement in the clinical results.

The Patterns of Spinal Deformity in Duchenne Muscular Dystrophy

OBJECTIVE: To investigate the relationships between scoliosis and kyphotic or lordotic posture in Duchenne muscular dystrophy (DMD) patients, this study explored the factors influencing the development of spinal deformity. METHOD: Twenty five DMD patients with scoliosis were conducted to roentgenographic study to obtain Cobb's angle. In addition, rotation grade of the spine, as well as the degree of kyphotic and lordotic postures were obtained using the Moe pedicle method, kyphotic index and lumbo sacral angle respectively. The data were assessed for the correlations among spinal deformities as well as the evaluation of functional state. After comprehensive rehabilitation programs for six months including scoliosis correction exercise, breathing exercise and thoracolumbosacral spinal orthosis, the effects of spinal deformity and pulmonary function were analyzed. An age-matched control group of 15 male patients with scoliosis were analyzed and compared with the experimental group. RESULTS: In the experimental group, the scoliosis angles were negatively correlated with kyphotic index (r= 0.80, p<0.01). In the control group, no correlations of statistical significance were detected among different types of spinal deformity. In addition, the rotation grade was found to be positively correlated with the scoliosis angle in the experimental group (r=0.89, p<0.01). Furthermore, the larger the scoliosis angle, the patients functional state was found to be poorer (r=0.56, p<0.01). CONCLUSION: In DMD patients, a strong correlation was found between the scoliosis and kyphotic posture. For the prevention of kyphotic posture, further study on the relevant therapeutic approach would be needed.

Anterior Cervical Fusion with the PCB Instrumentation (Cervical Plate Cage System) in Degenerative Cervical Disease

OBJECTIVE: The anterior interbody fusion for cervical spine disorder may not provide adequate immediate stabilization, whereas anterior cervical spine plating has overcome this main disadvantage. Recently, several types of hardware were introduced and the complications related to these were also reported. In case of degenerative cervical spine disorders, the adequate intervertebral disc space height and lordotic curvature are the major factors for preventing recurrence of symptoms. So we used the PCB instrumentation(cervical plate cage system) for these purpose. MATERIAL AND METHOD: From April 1998 to October 1998, 16 patients with degenerative cervical spine disorders who had radiculopathy or myelopathy were underwent anterior cervical spine fusion with the PCB instrumentation(cervical plate cage system). Single level fusion was accomplished in 8 patients and two level fusion in 8. The mean follow-up period was 4 month. RESULT: All patients show some recovery at discharge. There were no hardware problems. The intervertebral disc space height and lordotic curvature were not changed during follow up. CONCLUSION: These finding suggest that PCB instrumentation can be considered to be one of the useful hardwares for anterior cervical spine fusion in degenerative cervical spine disorders.

Anterior Interbody Fusion in Unstable Fracture and Fracture / 대한정형외과학회잡지

Authors had reviewed the results of 20 anterior cervical fusions performed between 1975 and 1980 to determine which factors were important to a successful result. There had been 18 single level fusions and 2 fusions at two levels, the majority at C and C. The indications for fusion operation were: firstly in acutely traumatized patient was the spine representing radiologically the signs of segmental instability, secondly was the chronic segmental instability in old traumatized spine representing the nuchal rigidity and severe cervicobrachial pain which. was not ceased by conservative treatments. The index of successful fusion was complete relief of pain, loss of cervical rigidity and radiologlcal stability of fused segment indicated by no-movement in flexion-extension lateral radiograms, and the bony bridges between the fused segments. The postoperative stability of spine was assessed by measuring the changes of disc space and kyphotic angle. The result obtained were as follows: 1. Pre-and post-operative immobilization with cervical traction played an immportant role for successful results after fusion: 4–6 weeks of pre-operative traction in acutely injured spine provided the torn soft tissue structures with sufficient time needed for its healing, and 6 weeks of postoperative traction also provided the bone graft with sufficient time needed for its cooperation with graft bed. 2. ln all cases succeasful fusion was obtained. In a case a adjacent level was incorrectly fused, but it was fused soundly in time, while the unstable unfused segment was not fused spontaneously. 3. The fused segment or segments of spine stabilized clinically in 6-8 weeks after fusion operation which was proven by serial radiograms, and solid bony fusion was obtained radiologically averaging in 12 weeks after fusion operation. 4. The average increase of kyphosis after interbody fusion till solid fusion was negligible, averaging 3.0 degrees. 5. The solid fusion occurred in one to 2 weeks earlier in the spines with wedge and axial conpression fractures than the spines with flexion-rotation and shear types of fractures. 6. No further neurogical damage developed after successful fusion.