Late Occlusion of the Femoral Artery Occurred after the Operation for a Femoral Shaft Fracture / 대한정형외과학회잡지

Once ischemic necrosis occurs in the tissue below an injury site after trauma, a vascular injury is suspected first. On the other hand, it is not common for a blood vessel to become obstructed after a delay of a few days after the initial trauma. The authors experienced a case where the blood flow was maintained at the time of a femoral fracture injury and immediately after surgery, but the femoral artery was occluded later. On the 5th day after surgery, ischemic necrosis of the lower limb was confirmed and treated. This case is reported with a review of the relevant literature.

Long-Term Clinical and Radiological Outcomes of Minimally Invasive Transforaminal Lumbar Interbody Fusion: 10-Year Follow-up Results

Background@#Many studies have reported that minimally invasive transforaminal lumbar interbody fusion (MI-TLIF) provides satisfactory treatment comparable to other fusion methods. However, in the case of MI-TLIF, there are concerns about the long-term outcome compared to conventional bilateral PLIF due to the small amount of disc removal and the lack of autogenous bone graft. Long-term follow-up studies are still lacking as most of the previous reports have follow-up periods of up to 5 years. @*Methods@#Thirty patients who underwent MI-TLIF were followed up for > 10 years (mean, 11.1 years). Interbody fusion rates were determined using a modified Bridwell grading system.Adjacent segment disease (ASD) was defined as radiological adjacent segment degeneration (R-ASDeg) as seen on plain X-rays; reoperated adjacent segment disease referred to the subsequent need for revision surgery. Clinical outcomes after surgery were assessed based on back and leg pain as well as the Oswestry disability index (ODI). @*Results@#The overall radiological fusion rate, at the 1-, 5-, and 10-year follow-up was 77.1%, 91.4%, and 94.3%, respectively. The incidence of R-ASDeg 1, 5, and 10 years after surgery was 6.7%, 16.7%, and 43.3% at the proximal adjacent segment and 4.8%, 14.3%, and 28.6% at the distal adjacent segment, respectively. R-ASDeg at either the proximal or distal segment was determined in 50.0% of the patients 10 years postoperatively. All clinical parameters improved significantly during follow-up, although the ODI and the visual analog scale (VAS) for leg pain at the 10-year follow-up were significantly worse in the R-ASDeg group than in the other patients (P = 0.009, P = 0.040). @*Conclusion@#MI-TLIF improved both clinical and radiological outcomes, and the improvements were maintained for up to 10 years after surgery. However, R-ASDeg developed in up to 50% of the patients within 10 years, and both leg pain on the VAS and the ODI were worse in patients with R-ASDeg.

Current Concepts of Degenerative Disc Disease -A Significance of Endplate- / 대한정형외과학회잡지

Degenerative disc disease has traditionally been thought of as low back pain caused by changes in the nucleus pulposus and annulus fibrous, in recent studies, however, changes in the upper and lower endplates cause degeneration of the disc, resulting in mechanical pressure, inflammatory reactions and low back pain. Recently, the bone marrow of the vertebral body-endplate-nucleus pulposus and annulus fibrous were considered as a single unit, and the relationship was explained. Once the endplate is damaged, it eventually aggravates the degeneration of the bone marrow, nucleus pulposus, and annulus fibrosus. In this process, the compression force of the annulus fibrosus increases, and an inflammatory reaction occurs due to inflammatory mediators. Hence, the sinuvertebral nerves and the basivertebral nerves are stimulated to cause back pain. If these changes become chronic, degenerative changes such as Modic changes occur in the bone marrow in the vertebrae. Finally, in the case of degenerative intervertebral disc disease, the bone marrow of the vertebral body-endplate-nucleus pulposus and annulus fibrous need to be considered as a single unit. Therefore, when treating patients with chronic low back pain, it is necessary to consider the changes in the nucleus pulposus and annulus fibrosus and a lesion of the endplate.

Minimally Invasive Lateral Lumbar Interbody Fusion: Indications, Outcomes and Complications / 대한정형외과학회잡지

The aim of this review was to evaluate minimally invasive lateral lumbar interbody fusion on the latest update. Lumbar interbody fusion was introduced recently. This study performed, a literature review of the indications, clinical outcomes, fusion rate, and complications regarding recently highlighted minimally invasive lateral lumbar interbody fusion. The indications of lateral lumbar interbody fusion are similar to the conventional anterior and posterior interbody fusion in degenerative lumbar diseases. In particular, lateral lumbar interbody fusion is an effective minimally invasive surgery in spinal stenosis, degenerative spondylolisthesis, degenerative adult deformity, degenerative disc disease and adjacent segment disease. In addition, the clinical outcomes and fusion rates of lateral lumbar interbody fusion are similar compared to conventional lumbar fusion. On the other hand, non-specific complications including hip flexor weakness, nerve injury, vascular injury, visceral injury, cage subsidence and pseudohernia have been reported. Lateral lumbar interbody fusion is a very useful minimally invasive surgery because it has advantages over conventional anterior and posterior interbody fusion without many of the disadvantages. Nevertheless, nonspecific complications during lateral lumbar interbody fusion procedure remain a challenge to be improved.

Comparison of the Results between Conservative and Operative Treatments for Pyogenic Spondylitis / 대한정형외과학회잡지

PURPOSE: With advancements in antibiotics, the ability to treat pyogenic spondylitis is increasing. This study aimed to compare and analyze the outcomes between conservative and operative treatments. MATERIALS AND METHODS: Sixty patients (28 males and 32 females) with pyogenic spondylitis, who were hospitalized and treated between February 2008 and June 2016, were enrolled. Patients were divided according to the following: type of treatment – conservative or operative treatment, method of surgery, radiographic parameters, location of the affected spine. Clinical parameters as durations of hospital stay, intravenous antibiotics use, normalization in laboratory findings, and residual symptoms were analyzed. For statistical evaluation, independent-sample t-test, Mann-Whitney U-test, Pearson's chi-square test, one-way ANOVA, and Spearman correlation analysis were performed retrospectively. RESULTS: There was no significant difference in the duration of hospital stay, intravenous antibiotics use, normalization in laboratory findings, and residual symptoms between the conservative and operative treatment groups. CONCLUSION: In treating pyogenic spondylitis, conservative treatment can be considered as the first choice, and operative treatment can be chosen in refractory cases.

Analysis of Factors Affecting Postoperative Loss of Reduction in Unstable Thoracolumbar Fractures

STUDY DESIGN: Retrospective analysis OBJECTIVES: Loss of fracture reduction after posterior surgery to treat unstable thoracolumbar fractures can cause several complications. We analyzed the factors influencing postoperative loss of reduction. SUMMARY OF LITERATURE REVIEW: Controversy exists about the factors causing postoperative loss of reduction in thoracolumbar fractures during the follow-up period. MATERIALS AND METHODS: We analyzed the records of 59 patients who underwent posterior surgery for thoracolumbar unstable fractures and had completed a minimum follow-up of 1 year. Postoperative loss of reduction was defined as 30% or more loss of vertebral body height or 15° or more progression of the kyphotic angle at the 1-year follow-up compared to immediately after surgery. The associations between the patients??gender, age, level of fracture, injury of the posterior column, initial loss of fractured vertebral body height, load-sharing score, Thoraco-Lumbar Injury Classification and Severity score, number of fixed segments, type of pedicle screws, degree of postoperative reduction, degree of postoperative corrected kyphotic angle, changes in the insertion angle of the most proximal and the most distal pedicle screws, decreases in the upper and lower disc height of the fractured vertebral body, and postoperative loss of reduction were analyzed. RESULTS: Thirteen patients (22.0%) had postoperative loss of reduction. Age at the time of the operation (p=0.034), initial loss of fractured vertebral body height (p=0.042), and changes in the insertion angles of the most distal pedicle screws (p=0.021) were significantly associated with postoperative loss of reduction. However, the other factors did not show a significant relationship. CONCLUSIONS: In patients who underwent posterior surgery for unstable thoracolumbar fractures, the frequency of loss of reduction was high in patients more than 45 years old at the time of the operation, with a 50% or more loss of the initial fractured vertebral body height, and with changes of 5° or more in the insertion angles of the most distal pedicle screws.

Minimally Invasive Lateral Lumbar Interbody Fusion: Surgical Technique and Review

STUDY DESIGN: Review of the current surgical technique and literature. OBJECTIVES: The aim of this study was to review the surgical technique and the current evidence on minimally invasive lateral lumbar interbody fusion (LLIF). SUMMARY OF LITERATURE REVIEW: Spinal fusion is a useful method in the treatment of various degenerative lumbar diseases. Recently, minimally invasive LLIF has been developed, enabling spine surgeons to perform anterior interbody fusion in a minimally invasive manner. MATERIALS AND METHODS: Review of the surgical technique and the literature. RESULTS: Minimally invasive LLIF may reduce the incidence of complications of anterior lumbar interbody fusion. LLIF may restore disc height more effectively than posterior lumbar interbody fusion and indirectly decompress the neural canal without nerve root or dural retraction or perineural scaring. The current indications for LLIF are almost equivalent to those of anterior and posterior lumbar interbody fusion. Recent studies have reported no differences in the fusion rate or clinical outcomes between LLIF and the conventional anterior or posterior interbody fusion techniques. However, LLIF has nonspecific complications, such as anterior thigh pain and hip flexor weakness. CONCLUSIONS: Minimally invasive LLIF is a promising surgical alternative to the conventional anterior or posterior fusion techniques. LLIF has the advantages of less intraoperative bleeding and soft tissue injury, and a faster return to work. However, postoperative nonspecific complications are problems that need to be addressed.

Comparative Analysis of Revision Surgery Groups between within 5 Years and More than 10 Years after Lumbar Spinal Fusion Due to Adjacent Segment Disease / 대한정형외과학회잡지

PURPOSE: The purpose of this study is to analyze the risk factors for early adjacent segment disease (EASD) in patients undergoing revision surgery within 5 years from the first operation as compared with those after more than 10 years. MATERIALS AND METHODS: A total of 755 patients with degenerative lumbar disease underwent lumbar spinal fusion of 3 or less segments between August, 1988 and May, 2009. Of these, 44 patients underwent revision surgery due to adjacent segment disease (ASD) until May, 2014. These patients presented with ASD, 19 and 13 of whom underwent revision surgery within 5 years and after more than 10 years of the first one, and were thus assigned to group A (n=19) and group B (n=13), respectively. Thirty-two of these patients were enrolled in this study and baseline and clinical characteristics, including sex, age, fusion method, preoperative diagnosis, the number of fused segments, fusion level, and radiological measurements were compared between the two groups. Radiological measurements included pre- and postoperative lumbar lordotic angle (LLA), pre- and postoperative fusion segment lordotic angle (FSLA), pre- and postoperative FSLA per level and the correction of LLA, FSLA, and FSLA per level. For statistical analysis, univariate analysis with the chi-square test was performed using SPSS 14.0. RESULTS: In group A, the number of patients undergoing posterior lumbar interbody fusion (PLIF) rather than posterolateral fusion, those with postoperative FSLA per level of <20° and the adjacent segment levels to L4-5 and L5-S1 was significantly larger compared with group B (p=0.018, 0.046, and 0.009, respectively. CONCLUSION: In conclusion, our results indicate that the degree of risk of EASD was relatively higher in association with PLIF, postoperative FSLA per level of <20° and the adjacent segment levels to L4-5 and L5-S1.

Analysis of Risk Factors for Adjacent Segment Degeneration Occurring More than 5 Years after Fusion with Pedicle Screw Fixation for Degenerative Lumbar Spine

STUDY DESIGN: A retrospective study. PURPOSE: We investigated the risk factors in adjacent segment degeneration (ASD) after more than 5 years of follow-up of lumbar spinal fusion. OVERVIEW OF LITERATURE: There are many concerns regarding ASD followed by lumbar spinal fusion. However, there is a great deal of dispute about the risk factors. METHODS: A total of 55 patients who were followed up for more than 5 years after lumbar fusion were observed. Gender, age, residence, fusion method, number of fusion segments and radiological measurements were analyzed. In the radiological measurement, disc height, lumbar lordotic angle (LLA), fusion segment lordotic angle and fusion segment lordotic angle per level (FSLA per level) were estimated. In preoperative MRI, Pfirrmann's classification was used. The clinical result was evaluated by the criteria of Kim and Kim. Statistical univariate analysis was performed with the chi-square test by using SPSS ver. 12.0. Multivariate logistic regression analysis was conducted with SAS ver. 9. RESULTS: There were 21 patients with adjacent segment degeneration. Further, there was little relationship between ASD and gender, age, residence, fusion method, number of fusion segments, degree of preoperative adjacent disc degeneration in MRI, or preoperative and postoperative LLA. However, the frequency of ASD was significantly low in cases where FSLA per level was >15degrees (p=0.009). There was no significant relationship between ASD and the clinical result. CONCLUSIONS: In patients followed up for more than 5 years after lumbar spinal fusion, the most important factor in the prevention of ASD was the restoration of FSLA per level to >15degrees.