Spinal Cord Regeneration in Rat using Neural Stem Cell Differentiated from Human Telencephalon / 대한정형외과학회잡지

PURPOSE: To evaluate the effect of neural stem cells differentiated from a human telencephalon on the neural regeneration in the severed spinal cord. MATERIALS AND METHODS: The 1st surgery involving the insertion of plastic membrane in the transected cord was performed to prevent spontaneous healing of adult female rats (n=20, 171-237 g) with a complete spinal cord transection. The media was inserted only after removing the previously inserted plastic membrane in the control group (n=6). In the experimental group (n=14), media and neural stem cell (1x) were transplanted after removing the membrane, and immunohistochemical staining was performed. The experimental group was perfused transcardially 5 weeks after the 2nd surgery, and the level of neural cell regeneration determined by immunohistochemical staining. In behavioral analysis, the Basso-Beatie-Bresnahan (BBB) scores of the control and experimental group were compared weekly from immediately after the injury until 5 weeks post-injury after the 2nd surgery. RESULTS: Immunohistochemical stain revealed no neural regeneration in the control group. On the other hand, the survival of transplanted human neural stem cells and remarkable neural regeneration (differentiate to neuron and astrocyte) were observed in the experimental group. In the BBB locomotor scale, the experimental group showed significant recovery in terms of control; and the score increased from postoperative 2 weeks to 3 weeks, and reached a plateau from 3 weeks to 5 weeks. CONCLUSION: The effect of neural stem cells differentiated from human telencephalon on cord regeneration does not produce functional recovery in the BBB locomotor scale, but there is slight recovery of the muscle function. The survival of transplanted human neural stem cells and the possibility of differentiation to neurons or astrocytes were observed.

Cemented Bipolar Hemiarthroplasty for the Femoal Neckor Intertrochanteric Fracture in Elderly Patients: Multicenter Study / 대한정형외과학회잡지

Purpose: This multicenter study was carried out to estimate the clinical and radiological results of cemented bipolar endoprosthesis replacement arthroplasty of a hip fracture in patients aged over 50 years in Jeju Island. Materials and Methods: Eighty-eight hips underwent bipolar endoprosthesis in 2002. Thirty-two patients died during the follow-up period and 7 patients refused a radiological evaluation or an interview. Two patients who underwent cementless bipolar endoprosthesis were excluded. Forty- nine hips (48 patients) completed the average 27 months follow-up. A neck fracture was involved in 40 hips (39 patient) and an intertrochanteric fracture was involved in 9 hips (9 patients). The average age was 77.7 years. The results were evaluated using clinical and radiological methods. Results: At the last follow-up, the average Harris hip score was 70.1 and 22 hips (45%), which indicated excellent and good results, respectively. Among the 42 patients with normal activity at the preoperative period, 28 patients were still active at the final follow-up. The number of medical illnesses and the severity of mental deterioration were also associated with the poor Harris hip scores. The pressurization cementing technique was found to be excellent at the radiological evaluation. One femoral stem appeared to have loosened and subsided but there was no revision surgery. Conclusion: The clinical result of the cemented bipolar endoprosthesis in multicenter study showed that the only 45% of patients showed results >good. The major factors influencing the results were the postoperative activity, the number of medical illnesses, and the severity of the mental changes.

Significance of Pelvic Incidence in the Development of Abnormal Sagittal Alignment / 대한정형외과학회잡지

PURPOSE: Under the assumption that the pelvic incidence influences the development of an abnormal curvature, this study examined the relationship between the pelvic incidence and the development of an abnormal curvature. MATERIALS AND METHODS: Twenty-two adults with a normal curvature and seventy-nine adults with an abnormal curvature were enrolled in this study. All subjects were older than fifty years of age at the time of the study. The patients were classified based on the alignment of the spine and the strategic vertebrae as follows: extension of the lordosis of the lumbar spine to the upper part of the thoracolumbar transitional portion (Group 1), kyphosis on the lower lumbar area but an extension of the lordosis from the upper lumbar area to the upper part of the thoracolumbar transitional portion (Group 2), extension of the kyphosis from the thoracic spine to the lower lumbar area (Group 3), the presence of lordosis on the lower lumbar portion but an extension of the kyphosis from the upper lumbar portion to the upper portion of the thoracolumbar area (Group 4). In each group, the interrelationship between the sagittal alignment, pelvic tilt, sacral slope and pelvic incidence were evaluated, and the changes in the numerical figures were compared and analyzed. RESULTS: In the normal group the average pelvic incidence was 52.5 degrees. The average pelvic incidence was higher in groups 1 and 2 (61.6 and 58.5 degrees, respectively) than in groups 3 and 4 (44.5 and 47.2 degrees, respectively) (p<0.001). The average sacral slope was 31.5 in the normal group, 34.5 in group 1, 25.1 in group 4, 20.1 in group 2, and 9.2 in group 3. In groups 1 and 2, group 2 showed a lower sacral slope compared with group 1 (p<0.001). In groups 3 and 4, group 4 had a larger sacral slope than group 3 (p<0.001). The average pelvic tilt was 21 in the normal group. Groups 2 and 3 showed a larger pelvic tilt (38.4 and 35.3, respectively) than that of groups 1 and 4 (27.1 and 22.1, respectively). CONCLUSION: In the elderly with an abnormal lordotic curve, the sagittal alignment of the spine is associated with the pelvic tilt, sacral slope and pelvic incidence, in a similar manner to that in normal adults with a normal lordotic curve. Therefore, measuring these figureswould help in making an estimate of the perspective changes in the sagittal alignment of spine.

Mortality and Activity after Hip Fracture: A Prospective Study / 대한정형외과학회잡지

PURPOSE: This prospective study conducted to estimate mortality and activity of hip fracture among persons over 50 years of age, in Jeju island, Korea during the year 2002. MATERIALS AND METHODS: One hundred forty-nine patients among 150 patients over 50 years of age who lived in Jeju island and sustained a femoral neck or intertrochanteric fracture during the year 2002 were followed-up for average 2 years. Standardized annual mortality ratio was calculated and comparison was made between hip fracture patients and general population in Jeju island. RESULTS: One hundred forty-nine patient were followed-up (35 in men, 114 in women). The mean age of patients was 77.4 years (range 50-98 years). Mortality at 2 years (range, 1.6-2.6 years) was 28.2% (42 patients), mortality at 1 year was 16.8% (25 patients) and mortality at 6 months was 12.1% (18 patients). Patients who were classified as poor (Halpin grade III and IV) increased in number from preoperative 11 patients to postoperative 37 patients. CONCLUSION: Considering 28.2% of high mortality and 25.2% of poor activity who can not do outside activity at average 2 year follow up, the hip fracture is life threatening risk factor of elderly. Prevention falling and hip fracture risk is needed.

Computed Tomographical Evaluation of C1-2 for Transarticular Posterior Screw Fixation / 대한정형외과학회잡지

PURPOSE: To avoid neurovascular injuries and to establish the ideal trajectory of screw insertion, a computed tomographical evaluation was conducted. MATERIALS AND METHODS: Twenty volunteers without cervical disease were employed for this study. Axial and oblique CT scans were selected for evaluation. Oblique CT scans were obtained in the direction of provisional screw insertion, starting from the junction of the lamina and the inferior articular facet of the axis and extending to the center of anterior tubercle of the atlas. In the axial and oblique reconstructed views, the screw length, the diameters of the medial and lateral cortexes of the isthmus, the vertical distance, and the angle of C1 were measured. RESULTS: The screw lengths averaged 37.6 mm (35.1-40.5 mm) in males and 37.2 mm (33.6-43.4 mm) in females. The diameters of the medial cortex of the isthmus were 4.3 mm (3.3-5.2 mm) in males and 4.0 mm (2.8-5.6 mm) in females. No measurement was statistically different between males and females. CONCLUSION: Due to individual variations of atlantoaxial anatomy, especially in terms of the size of cortical diameter of the isthmus, 3-D reconstruction CT is a useful tool for planning transarticular C1-2 screw insertion.

Comparison of Unilateral and Bilateral Approaches for Posterior Lumbar Interbody Fusion / 대한정형외과학회잡지

PURPOSE: A comparison of the unilateral and bilateral approaches for posterior lumbar interbody fusion was made by measuring the clinical and radiological results. MATERIALS AND METHODS: The clinical outcomes of 22 cases of the unilateral approaches and 26 cases of the bilateral approaches to the lumbar spine were analyzed using Kirkaldy-Willis method. The amount of intraoperative blood loss, surgery time, transfusions as well as postoperative drainage and transfusions were also investigated. The fusion rate, the changes in the height and angles of the disc in the fused segments and lumbar lordotic angles were analyzed radiologically. RESULTS: Radiologically, there were no significant differences between the two groups in terms of the fusion rate, the changes in the disc height and angles in the fused segments and lumbar lordotic angels. Good or excellent results were observed in 82.1% and 81% of the unilateral and bilateral approach group, respectively. A longer surgery time was needed and the amount of blood loss was larger in the two level bilateral approaches groups. CONCLUSION: In a comparison of the unilateral versus bilateral approaches, similar radiological and clinical outcomes were obtained, but significantly less blood loss and surgery time occurred using the unilateral approaches in the two-level fusions. Therefore, a unilateral approaches is particularly useful in multilevel fusions.

Bilateral Microscopic Laminotomy for Lumbar Spinal Stenosis / 대한척추외과학회지

STUDY DESIGN AND OBJECTIVES: In the treatment of lumbar spinal stenosis, a less invasive technique is preferred, for which good results have been observed. In this study, 34 patients who had undergone a bilateral microscopic laminotomy for lumbar spinal stenosis were retrospectively investigated. MATERIALS AND METHODS: Thirty-four patients with lumbar spinal stenosis who had undergone a bilateral microscopic laminotomy, between March 1997 and December 2000 were reviewed. The subjects comprised of 18 men and 16 women, with a median age of 46.1years. The average follow-up period was 32 months. Demographic data and the durations of back and radiating pains of these patients were analyzed. For the prognostic factors, the clinical outcomes were analyzed using the McNab's criteria, and the postoperative instability, ambulation time after surgery, hospital stay, operative time and complications reviewed. RESULTS: The analysis showed excellent, good, fair and poor results in 12, 12, 6 and 4 patients, respectively. The satisfaction rate with the surgery was over 70.6%. The average length of hospital stay, operative time and estimated intraoperative blood loss were 7.3 days, 109minutes and 160cc, respectively. A longer duration of lower back pain (p=0.0154) was associated with a poor result, whereas increasing age (p=0.1884), gender (p=1.0) and duration of radiating pain (P=0.4449) showed no statistical significance. CONCLUSION: A bilateral microscopic laminotomy can be used as a less invasive technique for lumbar spinal stenosis, with which satisfactory results are usually achieved. It may be especially beneficial in young patient with lower back pain of only a short duration. However, late postoperative instability should be carefully observed.

Results of Multilevel Lumbar Fusion for Degenerative Disorder of the Lumbar Spine / 대한척추외과학회지

PURPOSE: To investigate the causative factors of the complications and clinical results of 82 patients that underwent multilevel fusion due to degenerative lumbar disease. MATERIALS AND METHODS: This was a retrospective study, between October 1994 and July 2001, of 101 patients that had undergone spinal fusion at more than 3 levels, due to degenerative lumbar disease, and excluding 19 patients, which included 8 revisions, 1 postop infection and 10 lost to follow-up. The average age of the 82 patients was 61, ranging from 49 to 81 years. There were 22 men and 60 women, with an average follow up of 35, ranging from 12 to 79 months. Inclusion in the study required a minimum of 1 year of radiographic follow-up, where the lumbar lordotic angle, lateral sagittal angle of the fusion segments, problems associated with instrumentation (screw loosening, breakage and rod breakage), nonunion, fusion level, extension to sacrum, medical comorbidities and their influences on the clinical results were evaluated. Evaluation of the clinical results were quantified using Kirkaldy-Willis'criteria. T-test, Chi-square test and Pearson correlation tests were performed to evaluate the statistical significance, using SPSS version 10.0. RESULTS: 12, 35, 20 and 15 of the 82 patients declared their outcomes to be excellent, good, fair and poor, respectively. The clinical results were statistically associated with the difference between the postoperative and final sagittal angle in the fusion segments (p<0.05). The more fusion segments involved, the more problems associated with the instrumentation occurred. The number of fusion levels affected the clinical results. CONCLUSION: It seems to be difficult to reach satisfactory results in the case of multilevel spinal fusion, which was mostly associated with problems of instrumentation and nonunion, which showed poorer clinical results. Maintenance of the sagittal angle in the fusion segments was challenging when the number of fusion levels was increased.

Comparison of PLIF with Circumferential Fusion / 대한정형외과학회잡지

PURPOSE: To investigate the necessity of additional posterolateral fusion in posterior lumbar interbody fusion (PLIF) by comparing the clinical and radiological results of PLIF with circumferential fusion. MATERIALS AND METHODS: In 22 cases of circumferential fusion and 21 cases of PLIF, clinical outcomes were analyzed by Kirkaldy-Willis method. Intensity of pain, usage of analgesics and patient's satisfaction were also investigated. The fusion rates and changes of the heights and angles of discs in fused and adjacent segments were analyzed radiologically. RESULTS: No significant radiologic differences were found between two groups in terms of fusion rate, changes of disc height and angles in fused and adjacent segments. In each group, good or excellent results were obtained in 71% and 73%, respectively. A longer operation time was needed and the amount of blood loss was larger in the circumferential fusion groups. CONCLUSION: The addition of posterolateral fusion seems to have no more advantages than PLIF only.

Laparoscopy Assisted Miniopen Lateral Approach for Anterior Lumbar Interbody Fusion / 대한척추외과학회지

STUDY DESIGN: A new approach to anterior lumbar interbody fusion (ALIF). OBJECTIVE: To investigate the advantages, technical pitfalls and complications of the laparoscopy assisted miniopen lateral approach. SUMMARY OF LITERATURE REVIEW: Several kinds of miniopen approach or laparoscopy are now used for ALIF. MATERIALS AND METHODS: Thirty-five patients with various disease entities were included. Blood loss, operation time, incision size, postoperative time to mobilization, length of hospital stay, technical problems and complications were analyzed. RESULTS: Using this approach, T12 to L5 can be reached sub-diaphragmatically. Blood loss and operation time were 45.7 cc and 82.8 minutes for 1 level, 103.2 cc and 107.6 minutes for two levels, 272.5 cc and 150 minutes for three levels, and 520 cc and 190 minutes for four-level-fusion, respectively, The incision sizes were on average 4.1cm for 1 level, 6.2 cm for 2 levels, 8.2 cm for 3 levels and 10.1 cm for four-level-fusion. Complications were retroperitoneal hematoma in 2 cases, pneumonia in 1 case and transient lumbosacral plexus palsy in 3 cases. CONCLUSION: The laparoscopy assisted miniopen lateral approach is an advantageous approach with a very short learning curve. However, special attention is required if complications such as transient lumbosacral plexus palsy are to be avoided.

Survivor Ship Analysis of Lumbar Microdiscectomy / 대한정형외과학회잡지

PURPOSE: To analyze the post-operative clinical results of lumbar microdiscectomy with respect to time, and to evaluate the causes of fail-ure by survivor ship analysis. MATERIALS AND METHODS: The clinical results of 162 patients were evaluated using MacNab's criteria and the survival rate was analyzed by using Kaplan-Meier survivor ship analysis. Several factors suspected of influencing survival were evaluated. RESULTS: Survival was 93.7% at 12 months after the operation, and showed annual decrements to reach 84.7% at 60 months but did not change thereafter until the final follow up. There were total 18 failed cases and the failure rate after 5 years was 0%. Statistically significant factors influencing the survival rate were, the type and level of disc herniation. The causes of early failure, which occurred within 12 months of surgery, were usually due to residual or recurrent radiating pain, whereas the major cause of late failure, which occurred after 12 months, was usually residual back pain. CONCLUSION: The failure rate was relatively high during the early post-operative period, but this decreased with time. Since long-term survival was relatively high, lumbar microdiscectomy could be considered an effective and satisfactory surgical technique.

Significance of Chin-brow Vertical Angle in Correction of Kyphotic Deformity of Ankylosing Spondylitis Patients / 대한척추외과학회지

STUDY DESIGN: Retrospective study of 34 ankylosing spondylitis patients with kyphotic deformity who performed correction osteotomy. OBJECTIVES: To assess significance of chin-brow vertical angle for planning and evaluating correction of kyphotic deformity with ankylosis of cervical spine in ankylosing spondylitis patients. SUMMARY OF LITERATURE REVIEW: Accurate assessment and measurement of spinal kyphotic deformity is required when planning treatment and assessing its results. The most reliable measure of trunk deformity is the chin-brow vertical angle. MATERIALS AND METHODS: Thirty-four ankylosing spondylitis patients with cervical ankylosis who had underwent pedicle subtraction extension osteotomy for correction of kyphotic deformity were studied. The patients consisted of 32 male and 2 female patients. Mean age was 35.7 years. Most common apex of kyphosis was T12 in 11 cases. The levels of osteotomy were L1 in 3 case, L2 in 4 cases, L3 in 17 cases, and L4 in 10 cases. Radiographic assessment for sagittal balance was performed by measuring thoracic kyphosis, lumbar lordosis, and distance between the vertical line on anterosuperior point of T1 and that of S1. Chin brow-vertical angle was measured on the preoperative and postoperative clinical photo of the patients. Clinical outcomes were assessed by questionnaire measuring changes in physical function, indoor activity, outdoor activity, psychosocial activity, pain, and patient 's satisfaction with the surgery. RESULTS: Chin brow-vertical angle was 35.5 degrees preoperatively and 1.8 degrees postoperatively. Final follow-up radiograph showed an increase in lumbar lordosis from 5.5 to 43.2 degrees(an increase of 37.7 degrees) while thoracic kyphosis remain stable from 50.4 to 50.2 degrees. Sagittal imbalance significantly improved from 101.5 to12.7 mm. Decreased chin-brow vertical angle correlated negatively with correction angle while chin-brow vertical angle did not correlate with overall clinical outcome. However, the patients with chin brow vertical angle greater than 10 degrees or less than -10 degree had significantly low score concerning the item of horizontal gaze. CONCLUSIONS: The ankylosing spondylitis patient with cervical ankylosis, who had chin-brow vertical angle ranging from -10 to 10 degrees, had better horizontal gaze. Based on the results of this study, measurement of chin-brow vertical angle was recom-mended for planning correction of kyphosis and accurate evaluation of treatment outcome.

Eosinophilic Granuloma of the Adult Spine: Report of a Case / 대한척추외과학회지

Eosinophilic granuloma of bone well-documented in the literature. This lytic bone disease most commonly occurs in children, but a fraction of the cases does occurs in adult. When the disease occurs in adults, the bone most often affected include the skull, ribs, mandible, clavicle, pelvis, and long bone of the extremities. We report the case of a 31-year old woman with isolated eosinophilic granuloma of the thoracic spine. She had a 1-month history of progressive back pain that radiated to the right anterior chest. Authors performed resection of vertebral body lesion and soft tissue lesion and anterior fusion from T7 to T9. Immunochemical staining showed a positive S100 protein stain. EM demonstrated characteristic Birbeck granule. Postoperatively, the patient underwent a 5-day course of RT to the T6-T10 spine with 200cGY fractions (total dose 1000cGY). Postoperatively, the patient's back and chest pain had disappeared. There is no evidence of local recurrence or distant metastasis at 18 months follow-up. Though rare, eosinophilic granuloma of the adult spine could be considered in the differential diagnosis of osteolytic lesions.