Safety and Efficacy of Metalic Implants in the Treatments of Tuberculous Spondylitis / 대한척추외과학회지

STUDY DESIGN: A retrospective study OBJECTIVE: To analyze the safety and effectiveness of treatments using metallic implants in the tuberculous spondylitis. SUMMARY OF LITERATURE REVIEW: Residual kyphosis and loss of correction remain the major problems following surgery for tuberculous spondylitis. Several authors have used metallic implants for the prevention of these complications. However, the safety of metallic implants use in tuberculous spine infections are still controversial. MATERIALS AND METHODS: Seventeen patients, who underwent surgery, and were stabilized by the use of a metallic implant for tuberculous spondylitis, and followed up for more than 1 year were included in this study. All patients were treated with combined anterior fusion (with or without mesh) and/or posterior pedicle screw instrumentation. The patients were followed up with serial plain radiographs, laboratory inflammatory parameters and neurological recovery. RESULTS: The overall correction of the kyphotic deformity was initially 8.5 degrees, and loss of correction occurred at 5.8 degrees. Although some loss of correction occurred, even after the use of a metallic implant, clinically significant kyphotic deformity was effectively prevented. There were no cases of persistent infection or failure to control infection when the metallic implantation was combined with an anterior radical debridement and chemotherapy. The erythrocyte sedimentation rate and C-reactive protein were eventually normalized in all patients. The preoperative neurological deficits were: incomplete paralysis in 9 cases and radiculopathy in 4. At the final follow-up, 11 cases had completely recovered, partial residual neurological deficits remaining in 2. CONCLUSIONS: The use of instrumentation with metallic implants, in tubercuous spondylitis of the spine, provided immediate stability, and did not prohibit the control of infection when combined with radical debridement and anti-tuberculous chemotherapy.

Pyogenic Arthritis and Paraspinal Abscess Following Facet Joint Steroid Injection: A Case Report / 대한척추외과학회지

STUDY DESIGN: A case report and literature review. OBJECTIVES: To discuss pyogenic infections of the facet joints and paraspinal intramuscular abscess that developed after a steroid injection into the facet joint of the lower back. MATERIAL AND METHODS: A 39-year-old man who received a steroid injection to the facet joint, 3 weeks prior to admission, experienced increasing lower back pain and a high fever. RESULTS: Plain radiographs of the lumbar spine showed osteolytic erosion of the articular process at the L3-4 facet joint. On a CT scan, the destructed facet joint was connected to a paraspinal intramuscular abscess. MR images also showed a paraspinal intramuscular abscess on multiplane views. In the operative field, the paraspinal abscess, which extended from 2nd to 5th lumbar vertebrae, was found on the right side, with the L3-4 facet destructed and directly connected to the abscess. Some chalky material, considered to be steroid crystals, was found at the L3-4 facet joint. Drainage, debridement and irrigation were performed. Staphylococcus aureus was isolated from the culture. After surgery, intravenous antibiotics were administered, and the patients' symptoms quickly resolved. CONCLUSIONS: A posterior facet joint injection has its own risks of developing a pyogenic infection of the facet joint. Pyogenic facet joint infections may progress to a paraspinal intramuscular abscess. Surgical drainage is mandatory in cases resistant to antibiotic treatment, with evidence of pus formation on imaging studies.

Incidental Dural Tear during Posterior Surgery of Degenerative Lumbar Disease / 대한척추외과학회지

STUDY DESIGN: A retrospective study. OBJECTIVE: To analyze the clinical features and prognosis of intraoperative incidental durotomy during posterior surgery for degenerative lumbar disease. In addition, we tried to evaluate clinical outcome and safety of skillful neglect of pin point dural tear. SUMMARY OF LITERATURE REVIEW : Incidental durotomy is one of the most common complications during the operation of degenerative lumbar disease. It may cause signs and symptoms of cerebrospinal fluid leakage and complications such as meningitis, wound infection, pseudomeningocele and fistula. From the literature review, primary repair is mandatory even in the case of pin point dural tear. MATERIALS AND METHODS: Seven hundred fifty-five patients with degenerative lumbar disease, who were operated posteriorly from Jan. 1990 to Feb. 2002, were reviewed retrospectively. Primary operations were 378 cases of laminectomy without instrumentation and 377 cases of decompression and instrumented fusion. Of these patients, 44 (6 percent) sustained an incidental dural tear. We analyzed the mechanisms of dural tear, intraoperative treatment, postoperative management and clinical outcome. RESULTS: Eight cases (2.1%) of dural tears occurred during discectomy, 36 (9.5%) during instrumentation and fusion, and 12 (20%) during revision surgery. Dural tears were treated intraoperatively by primary repair in 20 cases, by fascial graft in 2 and without repair (skillful neglect) in 22. There were no cases of persistent cerebrospinal fluid leakage or fistula formation, and the symptoms of cerebrospinal fluid leakage were transient. Of 36 patients followed for more than one year, 82% had good or excellent result. CONCLUSION: Incidental durotomy occurred in 5.8 percent of lower back surgery patients, and more frequently in revision surgery. Very small dural tears did not have significant influence on the clinical outcome, whether they were repaired or not. Skillful neglect of pin point dural tear may be a reasonable treatment option.

Conservative Treatment of Compression and Stable Burst Fractures in the Thoracolumbar Junction: Early Ambulation Vs. Late Ambulation / 대한정형외과학회잡지

PURPOSE: To analyze the efficacy of early ambulation in a selected group of patients with compression and stable burst fractures in the thoracolumbar junction. MATERIALS AND METHODS: We reviewed retrospectively 65 cases of compression and stable burst fractures in the thoracolumbar junction. Group I was composed of 36 cases treated with bed-rest for 2 weeks or less followed by ambulation with bracing, Group II 29 cases treated with bed-rest for 4 weeks or more followed by ambulation with bracing. Radiologic results were compared for the two groups using lateral radiographs, and functional results were analyzed using Denis pain and work scores. RESULTS: Change in wedge angle at last follow up was 6.39+/-3.67degrees in group I and 5.28+/-2.72degrees in group II. Change in anterior body height was 14.46+/-8.25% in group I and 12.25+/-4.58% in group II (p>0.05). Satisfactory pain scores of less than or equal to P3 were noted in 11 cases (69%) of group I and in 12 cases (80%) of group II. Satisfactory work scores of less than or equal to W3 were noted in 12 cases (75%) of group I and in 12 cases (80%) of group II (p>0.05). CONCLUSION: Conservative management of compression and stable burst fractures in the thoracolumbar junction with 2 weeks or less of bed-rest followed by ambulation with bracing can predictably lead to satisfactory functional results.

Surgical Treatments of Intradural Extramedullary Tumor / 대한척추외과학회지

STUDY DESIGN: Retrospective study on 12 cases of intradural extramedullary tumor. OBJECTIES : To analyze the clinical symptoms and the outcome of the treatments in the 12 patients who had intradural extramedullary tumors. SUMMARY OF LITERATURE REVIEW : In order to provide a good prognosis and achieve a satisfactory clinical outcome for the treatment of intradural extramedullary tumors, early diagnosis and careful surgical resection is necessary. MATERIALS AND METHODS: Twelve cases of intradural extradmedullary tumors were treated surgically from September 1990 to July 2000. Of the 12 cases, 7 were male and 5 were femal. Average follow-up period was 37 months. Mean age of the cases was 48.3 years. The followings were analyzed; 1)histopathologic diagnoses, 2)locations of tumors, 3)clinical findings, 4)duration of symptoms, and 5)radiologic findings. In addition, both changes of symptoms as well as neurologic findings during the preoperative stage and the postoperative follow-up were evaluated according to the Frankel's and Kim 's criteria. RESULTS: Histiopathologic results were as follows; 6 cases (50%) confirmed as schwannoma, 3 cases (25%) as meningioma, 1 case as epidermoid cyst, 1 case as neurofibroma, and 1 case as arachnoid cyst. Locations of tumors were as follows; 6 cases (50%) located in the thoracic region, 4 cases (33%) located in the lumbar, 1 case located in the cervical region, and 1 case located in the sacrum. Clinical findings were as follows: 6 cases complained of back pain and radiating pain to leg, 6 cases noticed motor weaknesses and sensory changes of varying degrees. The average duration from initial symptoms to admission was 57 months (23-140 months). Laminectomy and complete resection of tumors were performed in all cases. Posterior spinal fusion with instrumentation was necessary only in one case. The preoperative Frankel's grades were as follows; 6 cases were in grade C, 4 cases in grade D, and 2 cases in grade E. At the final follow-up, all cases were graded as E . CONCLUSION: The Early diagnosis and careful surgical resection for intradural extramedullary tumors provide for a good prognosis as well as a positive clinical outcome. Intradural tumors should be included in the differential diagnosis of spine diseases and considered as a subdivision of orthopaedic spine surgery.

Intraoperative Spinal Nerve Root Injuries during Surgery for Degenerative Low Back Disease / 대한척추외과학회지

STUDY DESIGN: A retrospective study OBJECTIVE: To analyze incidence, causes and prognosis of the spinal nerve root injury during the degenerative low back surgery. SUMMARY OF LITERATURE REVIEW: There were very few studies about intraoperative spinal nerve root injuries during low back surgery. MATERIALS AND METHODS: Six hundred and twenty seven patients underwent degenerative low back surgery from Jan 1990 to Jan 2001 were included in this study. All patients were operated on by the first author and operation records made by the author himself were reviewed. Eight cases of intraoperative spinal nerve root injury were identified and causes and level of injuries, preoperative diagnosis, types of surgery and follow-up clinical results were analyzed. RESULTS: Eight cases of nerve root injury were developed during 5 posterior laminotomies for discectomy and 3 instrumentation and fusion. Spinal nerve root injuries were caused by Kerrison punch in 4 cases, pituitary forcep in 2, rongeur in 1, and not certain but probably by Kerrison punch in 1 case. The levels of injuries were 5th lumbar nerve root in 4 cases, and 1st sacral nerve root and 2nd lumbar nerve root in 1 case respectively. Two cases had sacral nerve rootlet injury with paramedian dural tear but the level of root injury was uncertain. Six of 8 patients had symptoms. There were sensory loss in 4 patients, pain in 2, and one patient had both sensory loss and loss of big toe extension power. Neurological symptoms were not improved throughout the follow-up period, but 2 patients who had pain were resolved their symptoms by 3 months. CONCLUSIONS: Incidental spinal nerve root injury occurred in 1.3 percentage of the patients who underwent low back surgery. Half of them had neurologic symptoms and they showed poor prognosis. However motor deficit was relatively uncommon and it might be related to the anatomical characteristics of spinal nerve root.

Lumbar HIVD Associated with Spondylolysis / 대한척추외과학회지

STUDY DESIGN: This is a retrospective study determining the surgical result of lumbar HIVD associated with spondylolysis. OBJECTIVES: To analyze the incidence of lumbar HIVD associated with spondylolysis and to compare the results of open discectomy for lumbar HIVD associated with spondylolysis to simple lumbar HIVD. SUMMARY OF LITERATURE REVIEW: Lumbar HIVD associated with spondylolysis need be treated by spinal fusion. MATERIALS AND METHODS: Nine patients(5 males and 4 females) who had lumbar HIVD with spondylolysis, no instability, fol-low-up period of 1yr were identified out of 273 patients with lumbar HIVD, treated by open discectomy from March 1989 to Feb. 1999. The type of HIVD and level of spondylolysis were evaluated, the clinical symptoms and signs including SLR, motor deficit, sensory deficit, change of DTR and severity of radiating pain were periodically followed up on the predesigned protocol. RESULTS: The incidence of lumbar HIVD associated with spondylolysis is 3.7%. The recovery of back pain was 2.1 to 2.1 by visu-al analogue scale, radiating pain was 7.6 to 0.8. The recovery rate of SLR was 100%, motor deficit; 100%, sensory deficit; 85%, change of DTR; 40%. The clinical evaluation was excellent(2), good(6), fair(1). CONCLUSIONS: According to the recovery rate of the clinical symptoms, the results of open discectomy for lumbar HIVD associ-ated with spondylolysis without spinal instability and simple HIVD was not different. Therefore, we conclude that lumbar HIVD associated with spondylolysis need not be treated by spinal fusion.

Intraspinal Gas with Lumberjack Injury: A Case Report / 대한척추외과학회지

STUDY DESIGN: A case report and review of the literature. OBJECTIVE: To discuss the intraspinal gas associated with lumberjack injury and review the literature. MATERIAL AND METHOD: A 60-year-old man developed chest pain & paraplegia by fall down from 4m height, having hypoes-thesia on T7-8 dermatome and complete motor-sensory loss below T9. RESULTS: Multiple rib fractures and hemopneumothorax were observed on chest radiograph and only mild offset was noted on plain spine lateral radiograph. CT scan reveals multiple air bubbles around epidural space at T7-8 and fracture of T7 pedicle. MRI shows rupture of both anterior and posterior longitudinal ligaments and extruded intervertebral disc of T7-8. Posterior decompression and stabilization with posterolateral fusion was performed on T5-9, but pain was persisted and paralysis was not improved after surgery. SUMMARY: The intraspinal gas of this case is supposed to be made by air migration from pleural cavity to intraspinal canal because of severe soft tissue injuries and fistula formation. Immediate and precise diagnosis with operative treatment was con-sidered to be important.

Chondroblastoma of the First Lumbar Vertebra: A Case Report / 대한척추외과학회지

STUDY DESIGN: A case report and review of the literature. OBJECTIVES: To discuss the chondroblastoma of the lumbar spine and review the literatures. MATERIALS AND METHODS: A 36-year-old woman had back pain and pain radiating to the left lateral abdomen. Straight leg rais-ing was not limited. Plain roentgenograms show a small round radiolucent area in left L1 vertebral pedicle and expansile sclerotic margin in L1 vertebral body. T1-weighted MR images show the lesion displaying low signal intensity, T2-weighted images show high signal intensity, Gadolinium enhanced images show a necrotic area with low signal intensity in the lesion. RESULTS: The mass of left L1 transverse process and pedicle was excised through posterior approach and pedicle screws were inserted T12 and L2 pedicle. L1 vertebral body was excised through anterior approach and a titanium mesh was inserted. It was a ovoid mass, measured 2.3 x 2 x 1.5 cmcm in size and histologically diagnosed as chondroblastoma consisting of chondroid matrix and chondroblast. Soft tissue nodule shows chicken-wire calcification. All the symptoms were relieved at 14 months follow-up and no evidence of recurrence on follow-up roentgenogram and bone scan. However, the patient had persistent lower back pain. CONCLUSIONS: A case of chondroblastoma in L1 vertebral body was successfully excised by combined anterior and posterior approach and stabilized with a titanium meh.

Radiologic Results of Posterior Lumbosacral Fixation according to Sacral Fixation Methods: Single Screw vs Double Screws / 대한척추외과학회지

STUDY DESIGN: This is a retrospective study comparing the radiologic results of sacral fixation using anteromedially directedsingle screw and triangulated double sacral screws. OBJECTIVES: To know whether the single screw fixation is enough for short level lumbosacral fusion. SUMMARY OF LITERATURE REVIEW: Method of sacral fixation is one of a hot issue in spinal instrumentation because of high complication rate. So, many kinds of sacral fixation methods were developed for long level spinal instrumentation. But, it is unclear whether we should use the special sacral fixation techniques instead of simple single screw fixation for the short level lumbosacral fusion. MATERIALS AND METHODS: Inclusion criteria of this study were fixation down to sacrum or sacralized L5, less than three segments fixation and minimum radiologic follow-up for one year. Of those patients treated with lumbosacral fixation using pedicle screw instrumentation from March 1989 to June 1998, forty-four patients met these criteria. They were divided into two groups according to the method of sacral fixation, Group I for single screw fixation and Group II for double screw fixation. Number of patients were 37 in Group I and 7 in Group II. The mean follow-up was 36.5 and 66.6 months, respectively. The radiologic results were evaluated by metal failure, change of lumbar lordosis, change of lumbosacral angle and change of L5-S1 disc space height. RESULTS: metal failure were identified in five patients(13.5%), all in sacral screws of Group I. There were 4 screw breakages and 1 screwrod dissociation. The change of lumbar lordosis was averaged 2.3 degrees(-17~38) in Group I and -4.0 degrees(-25~17) in Group II(p=0.194). The change of lumbosacral angle was averaged 2.3 degrees(-7~12) and 3.7 degrees(-1~12), respectively(p=0.596). The change of disc height was 5.6%(-13~33) and 8.8%(-5~16), respectively(p=0.381). CONCLUSIONS: Group I has much higher rate of instrumentation failure than Group II and all the instrumentation failures were occured at sacral screws. Other radiologic measurements were not statistically significant between the two groups. Stable fixation of the sacrum is necessary to prevent instrumentation failure at the sacrum even though the fusion is less than three levels.

Intradural Epidermoid Cyst: A Case Report / 대한척추외과학회지

STUDY DESIGN: A case report and review of the literature. OBJECTIVES: To discuss the iatrogenic intradural-extramedullary epidermoid cyst and review the literatures. SUMMARY OF LITERATURE REVIEW: Intradural epidermoid cyst has two types of lesions, congenital and iatrogenic. The former is fre-quently associated with bone or skin malformations(spina bifida. etc) and the latter resulting from lumbar puncture, due to direct implantation of epithelial cell by puncture needle. MATERIALS AND METHODS: A 13-year-old boy had pain radiating down to the right lower extremity and hypoesthesia on the anterolateral aspect of right thigh. Straight leg raising was markedly limited. T1 weighted image reveals round intradural mass on L3-4, which was not enhanced by gadolinium. He had the history of spinal tapping two and a half years ago for the work-up of headache. RESULTS: The mass was excised through posterior approach and midline durotomy. It was whitish ovoid mass, measuring 2x1.5x1.5cm in size and histologically diagnosed as epidermoid cyst consisting of keratinous material and cholesterol. All the symptoms were completely relieved at 16 months follow-up. CONCLUSIONS: A case of iatrogenic epidermoid cyst was successfully treated by excision. Epidermoid cyst must be ruled out if space occupying lesion exists in lumbar spine and patients complaining of lower back pain.

Early Problems of Open discectomy for Lumbar Intervertebral Disc Herniation / 대한척추외과학회지

STUDY DESIGN: This is a retrospective study analyzing early problems of open discectomy for lumbar intervertebral disc herniation. OBJECTIVES: To analyse the incidence of intraoperative and postoperative problems developed within six weeks and their relationship with reoperation and prognosis. MATERIALS AND METHODS: Hundred and ninty-four patients with intervertebral disc herniation, treated by open discectomy from April 1987 to December 1997, were assessed for intraoperative and postoperative problems. The problems were classified into three degrees : major, moderate and minor problem. when the problem was related to readmission, reoperation and prolonged admission for more than six weeks, it was classified as major problem. When the problem was related to prolongation of duration of admission for two to six weeks, it was classified as moderate problem. When the problem was not related to any prolongation of duration of admission, it was classified as minor one. RESULTS: Seven intraoperative and twenty-three postoperative problems were developed in twenty-seven patients. There were seven major problems : three recurrence of symptom and four suspicious deep infections. Nine moderate problems : six remained radiating pain, two serous discharge from operative wound and one urinary tract infection. and remained fourteen were minor problems : two recurrent symptom, two persistent pain, three serous discharge and seven intraoperative complications. CONCLUSIONS: The early major problems of open discectomy were recurrence of intervertebral disc herniation and deep infections. Problems with remainded radiating pain usually don't need reoperation and those symptoms were relieved with time goes. The prognosis was not influenced by minor problems.

Posterior Lumbar Interbody Fusion using Laminar Bone Block / 대한척추외과학회지

STUDY DESIGN: This is a retrospective study analyzing the results of posterior lumbar interbody fusion(PLIF) using laminar bone block and pedicle screw instrumentation. OBJECTIVES: To analyse the clinical and radiological results of PLIF using laminar bone block to evaluate whether this method is clinically valuable. MATERIALS AND METHODS: From March 1997 to February 1998, twenty three patients were treated by PLIF using bone block obtained from spinous process, facets and lamina. All of the patient were followed up over 12 months clinically. The mean age was 49 years and mean follow-up was 13.6 months. The clinical results were evaluated by Kim's criteria and adiological union, subsidence of disc space and change of lordotic curve were assessed by simple X-ray. RESULTS: The satisfactory clinical result rate was 82.6% and radiological union rate was 92.3%. The mean subsidence of disc space and change of lordotic curve were 2.0 mm and 2.2 degrees. There were four complications : two minimal dural tear, one pedicle screw breakage and one superficial infection. CONCLUSION: PLIF using laminar bone block showed acceptable radiological union rate and clinical results. It could be a good alternative to obtain bony union without taking bone graft from the posterior ilium in various spinal lesions.

Survivorship Analysis of Pedicle Screw Fixation / 대한척추외과학회지

STUDY DESIGN: This is a retrospective study analyzing survivorship of pedicle screw fixation in various spinal lesions. OBJECTIVES: To determine the survivorship of pedicle screw fixation and to assess the risk factors for the death of system. SUMMARY OF LITERATURE REVIEW: The previous reports of ten years survival rate of pedicle screw instruments was about eighty percent and the factors which influenced were bone quality, strength of instruments, design of instruments and compliance of patients. MATERIALS AND METHODS: Three hundred and thirty-eight patients(178 males and 160 females), treated by pedicle screw fixation from May 1988 to Dec. 1997, were analysed. Follow-up averaged 26.8months(3 to 116 months). The survival rates according to spinal lesions which caused spinal fixation, types of instruments, level of fusion and methods of fusion were predicted by life table method. The criteria of death were 1)breakage of screw or rod 2)gross bending of screw >5 degree 3)screw pullout and 4)dissociation of rod-screw coupling mechanism. RESULTS: Death of instrumentation was identified in twenty-six patients(7.7%). Of the 1,827 screws used, forty-three screws(2.4%) in twenty patients had broken(28) or bent(15). Thirty-nine Cotrel-Dubousset screws(3.5%) and four Diapason screws(1.6%) had involved. Four patients showed pullout of screws and two had dissociation of rod and screw. There was no rod broken. Life table calculations predicted the survivorship of instrumentation would be 88.7% at 10 years of follow-up. Single segment fixation showed higher survival rate than more than three segments fixation(93.3% vs 83.4%). Fracture had the lowest survival rate(78.3%). Screw failure was not influenced by the method of fusion. Suspected causes of death were collapse of disc space(12 patients), increased kyphosis(6), forceful reduction of fracture(3), infection(2), nonunion(2) and trauma(1). CONCLUSIONS: Ten year survival rate of pedicle screw fixaion was 88.7%. The survival rate was influenced by 1)number of fixed segments 2)cause of fixation .