Lumbar Interbody Fusion and Osteobiologics for Lumbar Fusion

Lumbar interbody fusion (LIF) is an excellent treatment option for a number of lumbar diseases. LIF can be performed through posterior, transforaminal, anterior, and lateral or oblique approaches. Each technique has its own pearls and pitfalls. Through LIF, segmental stabilization, neural decompression, and deformity correction can be achieved. Minimally invasive surgery has recently gained popularity and each LIF procedure can be performed using minimally invasive techniques to reduce surgery-related complications and improve early postoperative recovery. Despite advances in surgical technology, surgery-related complications after LIF, such as pseudoarthrosis, have not yet been overcome. Although autogenous iliac crest bone graft is the gold standard for spinal fusion, other bone substitutes are available to enhance fusion rate and reduce complications associated with bone harvest. This article reviews the surgical procedures and characteristics of each LIF and the osteobiologics utilized in LIF based on the available evidence.

Predicting Working Memory Capacity in Older Subjects Using Quantitative Electroencephalography

OBJECTIVE: We utilized a spectral and network analysis technique with an integrated support vector classification algorithm for the automated detection of cognitive capacity using resting state electroencephalogram (EEG) signals. METHODS: An eyes-closed resting EEG was recorded in 158 older subjects, and spectral EEG parameters in seven frequency bands, as well as functional brain network parameters were, calculated. In the feature extraction stage, the statistical power of the spectral and network parameters was calculated for the low-, moderate-, and high-performance groups. Afterward, the highly-powered features were selected as input into a support vector machine classifier with two discrete outputs: low- or high-performance groups. The classifier was then trained using a training set and the performance of the classification process was evaluated using a test set. RESULTS: The performance of the Support Vector Machine was evaluated using a 5-fold cross-validation and area under the curve values of 70.15% and 74.06% were achieved for the letter numbering task and the spatial span task. CONCLUSION: In this study, reliable results for classification accuracy and specificity were achieved. These findings provide an example of a novel method for parameter analysis, feature extraction, training, and testing the cognitive function of elderly subjects based on a quantitative EEG signal.

Ulnar Nerve Injury Caused by the Incomplete Insertion of a Screw Head after Internal Fixation with Dual Locking Plates in AO/OTA Type C2 Distal Humerus Fractures

After dual plating with a locking compression plate for comminuted intraarticular fractures of the distal humerus, the incidence of ulnar nerve injury after surgery has been reported to be up to 38%. This can be reduced by an anterior transposition of the ulnar nerve but some surgeons believe that extensive handling of the nerve with transposition can increase the risk of an ulnar nerve dysfunction. This paper reports ulnar nerve injuries caused by the incomplete insertion of a screw head in dual plating without an anterior ulnar nerve transposition for AO/OTA type C2 distal humerus fractures. When an anatomical locking plate is applied to a distal humeral fracture, locking screws around the ulnar nerve should be inserted fully without protrusion of the screw because an incompletely inserted screw can cause irritation or injury to the ulnar nerve because the screw head in the locking system usually has a slightly sharp edge because screw head has threads. If the change in insertion angle and resulting protruded head of the screw are unavoidable for firm fixation of fracture, the anterior transposition of the ulnar nerve is recommended over a soft tissue shield.

Ulnar Nerve Injury Caused by the Incomplete Insertion of a Screw Head after Internal Fixation with Dual Locking Plates in AO/OTA Type C2 Distal Humerus Fractures

After dual plating with a locking compression plate for comminuted intraarticular fractures of the distal humerus, the incidence of ulnar nerve injury after surgery has been reported to be up to 38%. This can be reduced by an anterior transposition of the ulnar nerve but some surgeons believe that extensive handling of the nerve with transposition can increase the risk of an ulnar nerve dysfunction. This paper reports ulnar nerve injuries caused by the incomplete insertion of a screw head in dual plating without an anterior ulnar nerve transposition for AO/OTA type C2 distal humerus fractures. When an anatomical locking plate is applied to a distal humeral fracture, locking screws around the ulnar nerve should be inserted fully without protrusion of the screw because an incompletely inserted screw can cause irritation or injury to the ulnar nerve because the screw head in the locking system usually has a slightly sharp edge because screw head has threads. If the change in insertion angle and resulting protruded head of the screw are unavoidable for firm fixation of fracture, the anterior transposition of the ulnar nerve is recommended over a soft tissue shield.

Decompressive Sacral Foraminotomy for Nerve Root Injury during Conservative Treatment of Sacral Fracture: A Case Report

A 35-year-old woman visited the emergency department for a pedestrian traffic accident. Severe tenderness was noted at the posterior sacrum area, without open wound or initial neurologic deficit. Fracture of the left sacral ala extended to the S1 foramen, anterior acetabulum, and pubic ramus. Two weeks after the injury, she presented aggravating radiculopathy with the weakness of the left great toe plantar flexion. The S1 nerve root was compressed by the fracture fragments in the left S1 foramen. Decompressive S1 foraminotomy was performed. The postoperative follow-up computed tomography scan showed successful decompression of the encroachment, and the patient recovered well from the radiculopathy with motor weakness. She was able to resume her daily routine activity. We suggest that early decompressive sacral foraminotomy could be a useful additional procedure in selective sacral zone II fractures that are accompanied by radiculopathy with a motor deficit.

Decompressive Sacral Foraminotomy for Nerve Root Injury during Conservative Treatment of Sacral Fracture: A Case Report

A 35-year-old woman visited the emergency department for a pedestrian traffic accident. Severe tenderness was noted at the posterior sacrum area, without open wound or initial neurologic deficit. Fracture of the left sacral ala extended to the S1 foramen, anterior acetabulum, and pubic ramus. Two weeks after the injury, she presented aggravating radiculopathy with the weakness of the left great toe plantar flexion. The S1 nerve root was compressed by the fracture fragments in the left S1 foramen. Decompressive S1 foraminotomy was performed. The postoperative follow-up computed tomography scan showed successful decompression of the encroachment, and the patient recovered well from the radiculopathy with motor weakness. She was able to resume her daily routine activity. We suggest that early decompressive sacral foraminotomy could be a useful additional procedure in selective sacral zone II fractures that are accompanied by radiculopathy with a motor deficit.

Clinical and Radiographic Results of Artificial Disc Replacement Combined with Anterior Cervical Discectomy and Fusion Versus Two-Level Anterior Cervical Discectomy and Fusion in Two-Level Cervical Disc Disease

STUDY DESIGN: Retrospective case-control study. OBJECTIVES: To compare the clinical and radiographic outcomes of a hybrid construct (HC) of cervical artificial disc replacement (CADR) combined with anterior cervical discectomy and fusion (ACDF) (group I) with 2-level ACDF (group II) in patients with 2-level cervical disc disease. SUMMARY OF LITERATURE REVIEW: ACDF is reported to potentially promote degenerative changes in the adjacent segment. CADR has been expected to reduce the risk of adjacent segment degeneration. However, its clinical course has yet to be sufficiently clarified. MATERIALS AND METHODS: Twenty-six patients underwent 2-level cervical disc surgery. Single-level CADR combined with ACDF was performed in 14 patients. Twelve patients underwent 2-level ACDF. Clinical profiles were assessed using the neck disability index (NDI) and visual analogue scale scores of arm and neck pain. Dynamic lateral cervical radiographs were obtained preoperatively and at 1, 6, 12, and 18 months postoperatively. The range of motion (ROM) of the overall cervical spine (C2-7) and the adjacent segments was measured. RESULTS: Group I showed superior NDI 18 months postoperatively (p 0.05). CONCLUSIONS: The HC group showed comparable clinical and radiographic outcomes to those of the 2-level ACDF group. HC can be used selectively in the treatment of patients with 2-level cervical disc disease.

The Effect of Weightbearing after Distal Reverse Oblique Osteotomy for Bunionette Deformity / 대한족부족관절학회지

PURPOSE: To evaluate the radiological and clinical effects of early eightbearing after distal reverse oblique osteotomy of bunionette. MATERIALS AND METHODS: Between 2009 and 2015, 52 patients who underwent surgical treatment at our hospital for bunionette deformity with a minimum follow up of one year were included in the study. Postoperatively, foot cast was applied and full weightbearing was permitted in 28 patients. And short leg splint was applied with only partial weightbearing using crutches allowed in 24 patients. Clinical scores were evaluated. Radiologically, the 4th~5th intermetatarsal angle (IMA), and 5th metatarsophalangeal angle (MPA) were analyzed preoperatively and at the final follow up visit. RESULTS: The visual analogue scale and American Orthopaedic Foot and Ankle Society scores improved in the partial weightbearing group and full weightbearing group, but without significant differences. The average 4th~5th IMA and average 5th MPA correction also did not showed significant differences between the partial weightbearing group and full weightbearing group. Moreover, the full weightbearing group did not encourage non-union rate compared with the partial weightbearing group. CONCLUSION: Effective bone union may be achieved through early weightbearing, resulting in better clinical outcomes. It is considered that early weightbearing did not have any effect on the changes of IMA and bone union.

Pigmented Villonodular Synovitis of the Ankle and Subtalar Joint Treated by Surgical Excision and Ligament Reconstructions: A Case Report / 대한족부족관절학회지

Diffuse pigmented villonodular synovitis (PVNS) involving ankle joint needs complete mass excision and total synovectomy to reduce recurrence rate, while surrounding ligaments can be easily damaged. So the concurrent ligament reconstruction should be considered for post-excisional instability in subtalar joint as well as lateral ankle joint. We describe our experience in the management of a diffuse type PVNS, invades lateral talocrural joint extended to subtalar joint and introduce a new technique of all-in-one reconstruction for anterior talofibular,calcaneofibular and cervical ligament. Our new reconstruction technique applying modified Chrisman and Snook technique is useful in stabilization for deficiencies of the ligament complexafter PVNS excisionat lateral ankle and subtalar joint.

Parosteal Lipoma in the Metatarsus: A Case Report / 대한족부족관절학회지

We experienced a rare case of parosteal lipoma, which located on the periosteum of the foot 4th metatarsus. A 22-year-old woman visited the hospital with painful mass in her foot. Based on the assessment of plain radiographs, computed tomography scan, and magnetic resonance image, it was suspected as lipoma. Marginal excision was performed and parosteal lipoma was confirmed histologically. Any local recurrence and complications were not observed in 2 years after surgery.

Salvage Therapy from Traumatic Ischemic Finger Necrosis via Prostaglandin E1 Assisted Conservative Treatment: A Case Report

Prostaglandin E1 (PGE-1) is a potent vasodilator, which also inhibits platelet aggregation, affects the blood flow viscosity, and fibrinolysis. The compound also excerts anti-inflammatory effects by inhibiting the monocyte and neutrophil function. PGE-1 has been widely administered following microvascular flap surgery, along with perioperative antithrombotic agents such as low molecular weight heparin or aspirin, showing excellent results. We report a case showing successful salvage recovery from post-traumatic ischemic necrosis of the finger via PGE-1 assisted conservative treatment.

Loss of Lordosis and Clinical Outcomes after Anterior Cervical Fusion with Dynamic Rotational Plates

PURPOSE: The cervical dynamic rotational plating system may induce bone graft subsidence, so it may cause loss of cervical lordosis. However there were few studies for alignments of cervical spines influencing the clinical results after using dynamic rotational plates. The purpose is to evaluate the effect of graft subsidence on cervical alignments due to the dynamic rotational cervical plates and correlating it with the clinical outcomes of patients undergoing anterior cervical fusion. MATERIALS AND METHODS: Thirty-three patients with disease or fracture underwent anterior cervical decompression and fusion using a dynamic rotational plate. The presence and extent of implant complications, graft subsidence, loss of lordosis were identified and Visual Analog Scale score (VAS score), Japanese Orthopaedic Association score (JOA score), clinical outcomes based on Odom's criteria were recorded. RESULTS: Fusion was achieved without implant complications in all cases. The mean graft subsidence at 6 months after the surgery was 1.46 mm. The lordotic changes in local cervical angles were 5.85degrees which was obtained postoperatively. VAS score for radicular pain was improved by 5.19 and the JOA score was improved by 3. Clinical outcomes based on Odom's criteria showed sixteen excellent, ten good and two satisfactory results. There was no significant relationship between clinical outcomes and changes in the cervical angles. CONCLUSION: Dynamic rotational anterior cervical plating provides comparable clinical outcomes to that of the reports of former static cervical platings. The loss of lordosis is related to the amount of graft settling but it is not related to the clinical outcomes.

Delayed Infrarenal Aortic Pseudoaneurysm Treated by Endovascular Stent Graft in Pyogenic Spondylitis

A 61-year-old male patient with pyogenic spondylodiscitis and epidural and psoas abscesses underwent posterior decompression, debridement, and instrumented fusion, followed by anterior debridement and reconstruction. Sudden onset flank pain was diagnosed 7 weeks postoperatively and was determined to be a pseudoaneurysm located at the aorta inferior to the renal artery and superior to the aortic bifurcation area. An endovascular stent graft was applied to successfully treat the pseudoaneurysm. Postoperative recovery was uneventful and infection status was stabilized.

Preliminary Report of Three-Dimensional Reconstructive Intraoperative C-Arm in Percutaneous Vertebroplasty

OBJECTIVE: Percutaneous vertebroplasty (PVP) is usually carried out under three-dimensional (2D) fluoroscopic guidance. However, operative complications or bone cement distribution might be difficult to assess on the basis of only 2D radiographic projection images. We evaluated the feasibility of performing an intraoperative and postoperative examination in patients undergoing PVP by using three-dimensional (3D) reconstructive C-arm. METHODS: Standard PVP procedures were performed on 14 consecutive patients by using a Siremobil Iso-C3D and a multidetector computed tomography machine. Post-processing of acquired volumetric datasets included multiplanar reconstruction (MPR) and surface shaded display (SSD). We analyzed intraoperative and immediate postoperative evaluation of the needle trajectory and bone cement distribution. RESULTS: The male : female ratio was 2 : 12; mean age of patients, 70 (range, 77-54) years; and mean T score, -3.4. The mean operation time was 52.14 min, but the time required to perform and post-process the rotational acquisitions was 7.76 min. The detection of bone cement distribution and leakage after PVP by using MPR and SSD was possible in all patients. However, detection of the safe trajectory for needle insertion was not possible. CONCLUSION: 3D rotational image acquisition can enable intra- or post-procedural assessment of vertebroplasty procedures for the detection of bone cement distribution and leakage. However, it is difficult to assess the safe trajectory for needle insertion.

Periprosthetic Fracture after Proximal Humeral Intramedullary Nail, Treated by Functional Bracing: A Case Report

Periprosthetic fracture following a proximal humeral intramedullary (IM) nailing is rarely reported neither for its occurrence nor for its treatment. Proximal humeral IM nail (Acumed, LLC, Hillsboro, OR, USA) has been increasingly reported of its successful treatment outcomes, yet there is paucity of data describing its complications. Here we report a 26 year-old female patient, who sustained a proximal humerus fracture which was initially successfully treated by proximal humeral IM nail, and was complicated by a periprosthetic fracture distal to the nail tip at postoperative 4 months. Serial application of U-shaped coaptation splint, hanging cast, and functional bracing resulted in satisfactory clinical outcome. Periprosthetic fracture after proximal humerus IM nail can occur by a low energy injury, which need to reminded in treating young and sports-active patients.

The Trajectory of Iliac Screw in the Axial Plane in 200 Korean Patients

STUDY DESIGN: A retrospective radiographic analysis. PURPOSE: To estimate the accurate trajectory in the axial plane for iliac screw insertion in 200 Korean patients using radiographic images. OVERVIEW OF LITERATURE: Several complications have been encountered after fusion to the lumbosacral junction, including pseudarthrosis, S1 screw loosening, and sacral fractures. Iliac screw fixation is considered an efficient method for augmenting sacral screw fixation but there are few reports on the trajectory of iliac screw insertion. The trajectory in the sagittal plane can be visualized by intraoperative fluoroscopy. However, there is no method to check the accuracy of the trajectory in the axial plane during surgery. METHODS: Between January 2007 and February 2009, 200 patients (107 men and 93 women) who underwent L-spine computed tomography were enrolled in this study. The mean age of the patients was 55.6 +/- 18.3 years (range, 13 to 92 years). The spino-iliac angle (SIA) was measured on the axial image at the S1 level, which was defined as the angle between a vertical line through the center of the spinous process and an oblique line that passed through the center of the outer and inner cortices of the ilium. RESULTS: The group mean SIA was 30.1degrees +/- 7.8degrees; 30.1degrees +/- 7.7degrees for men and 29.9degrees +/- 81.1degrees for women. There was no significant difference according to gender or age (p > 0.05). CONCLUSIONS: The SIA for the axial trajectory of iliac screws is approximately 30degrees in Korean patients.

Kyphotic Angle Progression of Thoracic and Thoracolumbar Tuberculous Spondylitis after Surgical Treatment: Comparison with Predicted Kyphosis Outcome after Conservative Treatment

STUDY DESIGN: Retrospective comparative study. PURPOSE: To compare the progression of the kyphotic angle (KA) in a surgically treated group with the predicted outcome of a conservatively treated group. OVERVIEW OF LITERATURE: Late onset kyphosis is a complication of tuberculous spondylitis making its prevention a major goal of surgery. METHODS: Twenty six consecutive patients underwent an anterior reconstruction and posterior instrumented fusion in conjunction with antituberculous chemotherapy. The mean follow up was 56 months (range, 28 to 112 months). The patients were divided into subgroups based on the involved region of the thoracic and the thoracolumbar spine, initial KA, and the initial vertebral body loss (VBL(x)). The predicted KA (KA(Pd)) was calculated using the formula, KA(Pd)=5.5+30.5 VBL(x), to predict the final gibbus deformity. Kyphotic angle progression (DeltaKA) based on the radiographic measurements after surgery (DeltaKA(R)), and the predicted outcome of conservative treatment (DeltaKA(P)) with chemotherapy were compared. RESULTS: Among the subgroups of the regions involved and initial KA, the DeltaKA was radiographically superior with a reduced amount of kyphogenesis in the surgery group than the predicted outcome of the conservatively treated patients (p0.05) with VBL(x)< or =0.5 in the VBL(x) subgroup. CONCLUSIONS: These results showed that in the VBL(x) subgroup, an initial VBL(x)< or =0.5 is an indication of conservative antituberculous chemotherapy without surgery.

Nerve Ingrowth into Intervertebral Disc in Internal Disc Disruption / 대한척추외과학회지

STUDY DESIGN: The ingrowth of the nociceptive nerve ending into intervertebral disc was examined using immunohistochemistry and quantified using western blotting. OBJECTIVES: To determine if the nociceptive nerve innervates into the intervertebral discs of internal disc disruption (IDD). SUMMARY AND LITERATURE REVIEW: Nociceptive nerve ending and vessel ingrowth into intervertebral disc is associated with IDD and HNP. Substance P is a neurotransmitter that is found in the nociceptive nerve endings. Immunohistochemistry has confirmed the presence, and western blot has isolated the target. The localization of novel nociceptive innervation, and a quantitative comparison was made according to the original pathology is of interest. MATERIALS AND METHODS: 10 specimens of intervertebral disc were collected from IDD during total disc replacement surgery , and another 10 specimens of intervertebral disc from HNP were collected during discectomy. The control samples of intervertebral disc were obtained from 3 adolescent patients with idiopathic scoliosis, and 2 patients with a lumbar bursting fracture. Standard immunohistochemical techniques were used to test for the nociceptive neurotransmitter (substance P), which is a protein expressed during axonogenesis (growth-associated protein 43, GAP43), and a general nerve marker (protein gene produce 9.5, PGP9.5). The expression of substance P protein was quantified using western blot for its polyclonal antibody. RESULTS: In IDD (n=10), substance P was expressed in 6 cases of outer annulus fibrosus (AF), 5 cases of inner AF, and 3 cases of nucleus pulposus (NP). In HNP (n=10), substance P was expressed in 4 cases of outer AF, 3 cases of inner AF, and 2 cases of NP. In the control group, only 2 cases expressed substance P in outer AF. GAP43 was only positive in outer AF as follows: IDD 3 cases, HNP 1 case, and control 1 case. None of the specimens showed localized PGP 9.5. Substance P was localized significantly in larger quantities in IDD than in the control group (p=0.002). In HNP, the expression level was larger than the control and lower than the IDD group but this was not statistically significant (p=0.158, p=0.108). CONCLUSIONS: Innervation of nociceptive nerve endings was identified at the degenerative intervertebral disc of IDD, which may contribute to back pain.

The Effect of Posterior Lumbar Interbody Fusion After Posterolateral Fusion in Degenerative Spondylolisthesis / 대한정형외과학회잡지

PURPOSE: To determine the necessity of an additional posterior lumbar interbody fusion (PLIF) after a posterolateral fusion (PLF) for the treatment of degenerative spondylolisthesis (DS). MATERIALS AND METHODS: A retrospective study, after a minimum follow-up of 2 years was conducted on forty patients who underwent a single level decompression and instrumented fusion for DS with spinal stenosis at the L4-5 level. A PLF was performed in 21 patients, and a circumferential fusion (CF) with an additional PLIF in 19 patients. According to the fusion methods and preoperative segmental mobility, the patients were divided into four groups; s-PLF group (PLF in the stable group, n=13), s-PLIF group (CF in the stable group, n=11), u-PLF group (PLF in the unstable group, n=8), and u-PLIF group (CF in the unstable group, n=8). Clinical and radiographic comparisions between the PLF and PLIF groups were performed. RESULTS: The mean decrements of Oswestry Disability Index (Visual Analog Scale) scores were 29% (5.5), 29% (5.9), 22% (2.6) and 42% (5.9) respectively for the s-PLF, s-PLIF, u-PLF and u-PLIF groups, and a statistical difference was found only between the u-PLF and u-PLIF groups (ODI: p=0.032, VAS: p=0.004). Fusion rates were 92%, 100%, 88% and 100% respectively. The mean slip angle increments were serially 2.5 degrees, -3.1 degrees, -1.5 degrees and -0.3 degrees, and the mean percent slip decrements were 6.7%, 8.7%, 5.1% and 3.7%, and the mean disc height increments were -0.4 mm, 1.8 mm, 0.5 mm and 3.0 mm, and the mean lumbar lordosis increments were 8.6 degrees, 4.7 degrees, -1.9 degrees and 1.9 degrees and the mean sacral tilt increments were 3.8 degrees, 3.4 degrees, -1.3 degrees and 0.9 degrees. Statistical differences were found only between the s-PLF and s-PLIF groups in slip angle increments (p=0.029) and between the s-PLF and s-PLIF groups (p=0.043) and between the u-PLF and u-PLIF groups (p=0.042) in disc height increments. CONCLUSION: PLF alone provided successful clinical outcome in stable group, but CF provided better clinical outcomes in the unstable groups. This study suggests that preoperative segmental mobility may be a criterion to determine whether or not an additional PLIF is necessary in the treatment of lumbar DS.

Ectopic Ureter Associated with Ipsilateral Renal Dysgenesis / 대한비뇨기과학회지

An ectopic ureter inserts at a point other than the normal trigonal position of the bladder and its association with ectopic renal dysgenesis is extraordinarily rare. We report two cases of ectopic ureter associated with ipsilateral ectopic renal dysgenesis. One was a 44-year-old man whose right ureteral opening was identified at the right seminal vesicle and who was treated successfully by nephroureterectomy and ipsilateral seminal vesiculectomy. The kidney drained by the ectopic ureter was dysplastic. The other was a 32-year-old woman whose right ureter drained into the right anterior vaginal wall and who was also treated successfully by nephroureterectomy. On pathologic examination, there was no renal tissue in the postoperative specimen. From the marked dilatation of the right ureter, this condition was interpreted as an acquired form of renal agenesis, in which renal tissue developed but atrophied during development or during childhood because of an associated ureteral obstruction rather than true renal agenesis which is defined as the complete congenital absence of renal tissue.