Multiple Cervical Spinous Process Fractures in a Novice Golf Player

Avulsion of spinous process, also called Clay-shoveler's fracture, is most prevalent among those engaged in hard physical labor. To the best of the author's knowledge, only one case of multiple spinous process fractures of the upper thoracic spine in a novice golfer has been reported. A 45-year-old female presented with intractable posterior neck pain. The patient experienced a sharp, sudden pain on the neck while swinging a golf club, immediately after the club head struck the ground. Dynamic cervical radiographic findings were C6 and C7 spinous process fractures. Magnetic resonance imaging revealed C6 and C7 spinous process fractures without spinal cord pathology. The patient was treated with pain medications and cervical bracing. The patient's pain gradually improved. The injury mechanism was speculated to be similar to Clay-shoveler's fracture. Lower cervical spinous process fractures can be associated with a golf swing. If the patient complains of long lasting neck pain and has a history of golf activity, further study should be conducted to rule out lower cervical spinous fracture.

Spinal Intraosseous Schwannoma : A Case Report and Review

A case of spinal intraosseous schwannoma (SIS) in the lumbar vertebra is reported. Clinical and radiologic characteristics of 16 reported cases of SIS were reviewed. SIS can be a rare differential diagnosis for intraosseous tumors.

Minimum 2-Year Follow-Up Result of Degenerative Spinal Stenosis Treated with Interspinous U (Coflex(TM))

OBJECTIVE: Clinical and radiological results of posterior dynamic stabilization using interspinous U (ISU, Coflex(TM), Paradigm Spine Inc.(R), NY, USA) were analyzed in comparison with posterior lumbar interbody fusion (PLIF) in degenerative lumbar spinal stenosis (LSS). METHODS: A retrospective study was conducted for a consecutive series of 61 patients with degenerative LSS between May 2003 and December 2005. We included only the patients completed minimum 24 months follow up evaluation. Among them, 30 patients were treated with implantation of ISU after decompressive laminectomy (Group ISU) and 31 patients were treated with wide decompressive laminectomy and posterior lumbar interbody fusion (PLIF; Group PLIF). We evaluated visual analogue scale (VAS) and Oswestry Disability Index (ODI) for clinical outcomes (VAS, ODI), disc height ratio disc height (DH), disc height/vertebral body length x100), static vertebral slip (VS) and depth of maximal radiolucent gap between ISU and spinous process) in preoperative, immediate postoperative and last follow up. RESULTS: The mean age of group ISU (66.2 +/- 6.7 years) was 6.2 years older than the mean age of group PLIF (60.4 +/- 8.1 years; p = 0.003 ). In both groups, clinical measures improved significantly than preoperative values (p 18.6 +/- 5.9%), however decreased significantly in last follow up (13.8 +/- 6.6%, p = 0.027). Vertebral slip (VS) of spondylolisthesis in group ISU increased during postoperative follow-up (2.3 +/- 3.3 --> 8.7 +/- 6.2, p = 0.040). Meanwhile, the postoperatively improved DH and VS was maintained in group PLIF in last follow up. CONCLUSION: According to our result, implantation of ISU after decompressive laminectomy in degenerative LSS is less invasive and provides similar clinical outcome in comparison with the instrumented fusion. However, the device has only transient effect on the postoperative restoration of disc height and reduction of slip in spondylolisthesis. Therefore, in the biomechanical standpoint, it is hard to expect that use of Interspinous U in decompressive laminectomy for degenerative LSS had long term beneficial effect.

Enhancing Box Sign : Enhancement Pattern of Acute Osteoprotic Compression Fracture

OBJECTIVE: Although gadolinium enhancement of compression fractures is well known, the enhancement pattern of the acute stage of a fracture is not completely understood. Here, we investigated the enhancement pattern of acute vertebral compression fractures (VCFs). METHODS: We conducted a retrospective study of patients with acute osteoporotic VCFs admitted to hospital between January 2004 and December 2005. The demographic details, stage of the fracture, management data, and results were analyzed. There were nine men and 22 women, and the mean age was 71 years (range, 53-92 years). According to the onset of pain, patients were divided into the following four groups : Group I (less than 3 days), Group II (4-7 days), Group III (8-14 days), and Group IV (14-30 days). RESULTS: All patients had central low-signal intensity of the nonenhancing part of vertebral bodies on T1 images. Enhancing box sign (EBS) was seen 7 days of VCF development. After 7 days of onset (Groups III and IV), patch or Kummell's enhancements occurred. EBS has been statistically correlated with stage of compression fracture (Pearson's correlation = -0.774). However, EBS had no statistically significant correlation with prognosis in our study (Pearson's correlation = 0.059). CONCLUSION: EBS represents a characteristic sign 7 days of VCF development.

Unilateral Augmented Pedicle Screw Fixation for Foraminal Stenosis

OBJECTIVE: The purpose of this study is to evaluate the effectiveness of unilateral decompression and pedicle screw fixation for the unilateral symptomatic foraminal stenosis. METHODS: The study group comprises consecutive 16 patients who underwent unilateral decompression and bone cement augmented pedicle screw fixation from May 2003 to January 2006. The patients were evaluated by visual analog scale (VAS) for pain and the scoring system of the Japanese Orthopedic Association (JOA) for low back pain. The result of surgery was also evaluated with McNab's classification. Excellent or good outcome was considered as successful. The patients were followed at postoperative 1 month, 3 month, 6 month, and 1 year with standing AP and lateral films. RESULTS: The average VAS and JOA score of the 16 patients were 7.8 (range, 6-9) and 5.8 (range, 3 - 10) before surgery and 2.2 (range, 0 - 5) and 12.3 (range, 9 - 15) at the time of last follow up. Both VAS and JOA score improved significantly after the surgery (p < 0.05, t-test). All patients improved after the operation and no revision surgery was required. No metal failure or pseudoarthrosis was observed during the follow-up. The success rate was 87.5%. CONCLUSION: Our data suggest that unilateral decompression and pedicle screw fixation for the unilateral symptomatic foraminal stenosis is an effect method for obtaining satisfactory clinical outcome. Its possible advantage is shorter operation time and reduced surgical extent. We believe that the reduced stiffness of unilateral fixation was compensated by pedicle screw augmentation and interbody fusion.

Cervical Intervertebral Disc Arthroplasty: Update

Since 1966 the first metal ball shape implant was inserted into the cervical and lumbar areas by Dr. Fernstrom, numerous attempts and prostheses have been tried to maintain physiologic range of motion and prevent adjacent segment degeneration (ASD) after surgery. However fusion itself is not a single causative factor of ASD and other biologic factors including natural progression of degenerative process and mechanical factors also contribute in the development of ASD. Several well designed prospective randomized control studies for Bryan disc and Prodisc C have been recently documented preservation of spinal motion, superior or, at least, equivalent clinical outcome in comparing with anterior cervical arthrodesis, and less adverse postoperative events both in frequency and severity. Still remained or undetermined problems in cervical arthroplasty are heterotopic ossifications, segmental kyphosis of implanted levels, MR imaging compatibility, vertebral body fracture by keeled prostheses and long term wear properties. In spite of these unsolved problems and incompleteness of prosthetic design, cervical arthroplasty is now considered as one of standard methods in surgical management of one or two level cervical disc diseases and its indication may be broader in near future.

Granulocytic Sarcoma Presenting as Epidural Mass in Lumbosacral Spine: A Case Report

Granulocytic sarcoma, as known as chloroma, is a localized solid tumor consisting of immature myeloid cells. It is a infrequent extramedullary manifestation of acute or chronic leukemias and can often precede their bone marrow involvement. Spinal involvement of granulocytic sarcoma is very rare. A 17-year-old man presented with low back pain, gluteal pain and perianal numbness for 1 month. Lumbar spine magnetic resonance imaging (MRI) was taken under impression of herniated lumbar intervertebral disc and showed an epidural mass at the lumbosacral spinal canal. Leukocytosis, thrombocytopenia and anemia were found on blood cell count. Excisional biopsy of mass was done and the histopathologic examination confirmed the diagnosis of granulocytic sarcoma. Subsequent bone marrow biopsy revealed myelodysplastic syndrome. He had received anti-leukemic chemotherapy and the size of lumbosacral mass was markedly decreased. As a granulocytic sarcoma of spinal column is uncommon, high index of suspicion is inevitable to diagnose it. Therefore it must be included as a differential diagnosis of spinal epidural mass.

Therapeutic Effect of Epidural Steroid Injection in Patients Suspected of having an Internal Disc Disruption: A Prospective Case Study

PURPOSE: To assess the effect of the epidural steroid injection for patients suspected of having an internal disc disruption. MATERIALS AND METHODS: Thirteen patients at the pain intervention clinic that received a lumbar interlaminar epidural steroid injection and were suspected of having an internal disc disruption were prospectively enrolled in this study. The treatment outcome was assessed using a 5-point patient satisfaction scale (no pain, much improved, slightly improved, no effect, aggravated) two weeks after injection. A successful outcome required a patient satisfaction scale of "much improved" or "no pain". All patients received follow-up for two months. Two radiologists evaluated the presence of HIZ (high intensity zone), a dark disc by MR (n = 10) and a diffuse bulging disc by CT (n = 3). RESULTS: Nine (69%) of the 13 patients achieved a successful outcome two weeks after injection. These nine patients showed no recurrence during the two months months follow-up. Of the 22 abnormal discs demonstrated by MRI and CT, MRI showed a dark disc in six patients and HIZ in 13 patients. CT showed diffuse bulging in three discs. Nine of 10 patients showed at least one HIZ. CONCLUSION: An lumbar interlaminar epidural steroid injection might be an effective tool for managing patients suspected of having an internal disc disruption.

Transforaminal Epidural Steroid Injection for Lumbosacral Radiculopathy: Preganglionic versus Conventional Approach

OBJECTIVE: The present study was undertaken to evaluate the effectiveness of transforaminal epidural steroid injection (TFESI) with using a preganglionic approach for treating lumbar radiculopathy when the nerve root compression was located at the level of the supra-adjacent intervertebral disc. MATERIALS AND METHODS: The medical records of the patients who received conventional TFESI at our department from June 2003 to May 2004 were retrospectively reviewed. TFESI was performed in a total of 13 cases at the level of the exiting nerve root, in which the nerve root compression was at the level of the supra-adjacent intervertebral disc (the conventional TFESI group). Since June 2004, we have performed TFESI with using a preganglionic approach at the level of the supra-adjacent intervertebral disc (for example, at the neural foramen of L4-5 for the L5 nerve root) if the nerve root compression was at the level of the supra-adjacent intervertebral disc. Using the inclusion criteria described above, 20 of these patients were also consecutively enrolled in our study (the preganglionic TFESI group). The treatment outcome was assessed using a 5-point patient satisfaction scale and by using a VAS (visual assessment scale). A successful outcome required a patient satisfaction scale score of 3 (very good) or 4 (excellent), and a reduction on the VAS score of > 50% two weeks after performing TFESI. Logistic regression analysis was also performed. RESULTS: Of the 13 patients in the conventional TFESI group, nine showed satisfactory improvement two weeks after TFESI (69.2%). However, in the preganglionic TFESI group, 18 of the 20 patients (90%) showed satisfactory improvement. The difference between the two approaches in terms of TFESI effectiveness was of borderline significance (p = 0.056; odds ratio: 10.483). CONCLUSION: We conclude that preganglionic TFESI has the better therapeutic effect on radiculopathy caused by nerve root compression at the level of the supra-adjacent disc than does conventional TFESI, and the diffence between the two treatments had borderline statistical significance.

Value of Preoperative Cervical Discography

PURPOSE: The aim of this study was to describe the method and the value of cervical discography as correlated with the MR findings. MATERIALS AND METHODS: Twenty-one discs in 11 consecutive patients who underwent cervical discography were analyzed. MR and CT discography (CTD) were performed in all patients. Discography was performed after swallowing barium for visualizing the pharynx and the esophagus to prevent penetration. We also analyzed the preceding causes of the subjects' cervical pain. The results of the pain provocation test were classified into concordant pain, discordant pain and a negative test. MRI was analyzed according to the T2-signal intensity (SI) of the disc, disc height, annular bulging and disc herniation. The CTD was analyzed for degeneration or radial tear of the disc, epidural leakage of the contrast agent and pooling of the contrast agent at the periphery of the disc. The pain provocation tests were correlated with the MR and CTD findings. We used the chi-square test to analyze the results. RESULTS: Concordant pain was observed in 14 cases, discordant pain in 3 cases and there were negative tests in 4 cases. There were no complications related to the procedure. Four patients had undergone anterior cervical fusion and four patients had pain that developed after traffic injuries. The decreased T2-SI and annular bulging on MRI, disc degeneration and peripheral pooling of the contrast agent on CT were significantly correlated with pain provocation. CONCLUSION: When the diagnosis of disc disease is difficult with performing MRI, cervical discography with using swallowed barium solution to reduce the penetration of the esophagus or hypopharynx may play be helpful. The decreased T2-SI and annular bulging on MRI correlated significantly with a positive result on the pain provocation test.

A Survival Analysis of Surgically Treated Metastatic Spine Tumors

OBJECTIVE: The purpose of this study is to assess the survival and prognostic factors of surgically treated metastatic spine tumors. METHODS: A retrospective review of 68 patients who underwent the surgical treatment of metastatic spine tumors from 1988 to 2001 was conducted. The survival of each patient was confirmed on Feb 2002. The survival rates were calculated and several variables were examined for prognostic factors. RESULTS: Postoperative mean survival time was 21.1 months. Three month and 2 year cumulative survival was 70.3% and 21.4%, respectively. The patients who survived less than 3 months after operation were 23(33.8%). The significant prognostic factors were the category of primary tumors, postoperative ambulation, preoperative functional status, and the interval between initial diagnosis and spine metastasis. CONCLUSION: The postoperative survival was related with the biologic behavior of primary tumor and general physical condition. High mortality rate in postoperative three months suggests that more sophisticated selection criterion is needed.

Comparative Study of Laparoscopic L5-S1 Fusion versus Open Mini-Anterior Lumbar Interbody Fusion

OBJECTIVE: To investigate the effectiveness and safety of the laparoscopic L5-S1 fusion, its perioperative parameters and long-term outcome are compared with those of open anterior surgical approach. METHODS: Data of 54 consecutive patients who underwent anterior approach for L5-S1 fusion either by laparoscopic or open mini-anterior lumbar interbody fusion(ALIF) from 1997 to 1999 were analyzed. Among them, 47 cases were available with more than 2-years follow-up data. In all cases, carbon cage and autologous bone graft were used. RESULTS: Twenty five patients underwent a laparoscopic procedure and twenty two a open mini-ALIF. Three laparoscopic procedures were converted to open ones. For perioperative parameter, only the operative time was statistically different(p=0.001) while length of postoperative hospital stay and blood loss were not. The incidence of operative complication was three in laparoscopic group and two in open mini-ALIF group. After the follow-up of at least two years, the two groups showed no statistical difference in visual analog scale for pain, Oswestry disability index, and patient satisfaction index. The fusion rate was 91% in each group. CONCLUSION: The findings of this study suggest that laparoscopic ALIF has similar effectiveness and safety with open mini-ALIF. However, the advantage of laparoscopic approach as a minimally invasive surgery should be reconsidered because no objective additional benefit was found.

Anterior Lumbar Interbody Fusion for Focal Type of Degenerative Flat Back: Preliminary Report

OBJECTIVE: The purpose of this study is to determine the efficacy of anterior lumbar interbody fusion(ALIF) for the patients with focal type of degenerative flat back. METHODS: The authors reviewed clinical and radiologic data of 16 patients with focal type of degenerative flat back who underwent ALIF during the period between December 1999 and November 2000. The operation procedure was ALIF using titanium or carbon fiber cages of lordotic angle, which were filled with allograft or autograft mixed with allograft through minilaparotomy. RESULTS: The majority of the patients were female(15 female: 1 male) and the mean age was 60.1 years. Six patients were operated on one level, ten on two levels. The mean follow up period was 10.7 months. The mean operation time was 131minutes and the average estimated blood loss was 133ml. Transfusion was not needed in any case. The mean preoperative lumbar lordotic angle was 4.1 degree(-7.4-41.6) and improved to 17.5 degree(-4.5-41.9) postoperatively. Radiological fusion was achieved in 13 patients(81%). The Oswestry disability index score improved from 62.5% to 23.9% and the patient's subjective improvement rate was 80%. Complications were infection in one patient, incisional hernia in one, symptomatic pseudoarthrosis in one and transient sympathetic disturbance in left leg in three. CONCLUSION: In a subset of the patients with degenerative flat back who showed disc degeneration in one or two levels, ALIF using cages improved patient's symptoms effectively. It seems that ALIF through minilaparotomy can be one of the surgical options in the treatment of the focal type of degenerative flat back.

The Efficacy of Anterior Lumbar Interbody Fusion in Degenerative Disc Disease and Degenerative Spondylolisthesis: Comparative Review of 44 Single-Level Cases

OBJECTIVE: The authors conduct a retrospective study to evaluate the efficacy of anterior lumbar interbody fusion(ALIF) in treating degenerative disc disease(DDD) and degenerative spondylolisthesis(DS). METHODS: During 1998, eighty-six patients underwent mini-retroperitoneal ALIF with Brantigan carbon cages. Among them, 19 patients were lost during the follow-up period and 23 patients underwent multilevel fusion procedures. The authors evaluated 44 single-level cases(31 with DDD; 13 with DS) with Macnab's criteria for clinical outcomes and the Criteria of Brantigan and Steffee for fusion results. The extent of slippage of patient with DS was not greater than grade 1. The mean follow-up period was 24 months. RESULTS: The overall fusion rate was 88.6%(94% in DDD; 77% in DS). Based on the Macnab's criteria, excellent or good results were achieved in 38 of 44 patients(86.3%). Overall clinical outcome was significantly associated with preoperative diagnosis(p=0.03), radiologically demonstrated fusion(p=0.001), and subsidence of cages(p=0.03). In DDD sub-group, two cases of fusion failure and four of subsidence of cages belonged to excellent or good results. But, in DS sub-group, fusion failure or subsidence rate were significantly high and all three cases with poor result belonged to this sub-group. One of them underwent posterior operation. CONCLUSION: ALIF is considered as a good surgical method for a patient with discogenic back pain caused by degenerative disc disease. But in degenerative spondylolisthesis, considering the comparatively poor clinical and radiological result, it seems that ALIF alone does not provide sufficient strength to overcome the instability. Despite the advantage of minimal invasiveness, more careful application of ALIF is needed in the of degenerative spondylolisthesis.

Surgical Treatment of Spinal Cord Intramedullary Cavernous Angioma

Cavernous angiomas are commonly found within the intracranial cavity. However, these malformations are uncommon in the spinal column and rarely found within the spinal cord. There have been only a few isolated reports on surgical resection for spinal cord intramedullary cavernous malformations. However, cavernous angiomas are being increasingly well recognized throughout the central nervous system since introduction of magnetic resonance image(MRI). A series of six patients with spinal cord intramedullary cavernous angioma, which were treated by complete surgical excision, is described. Intramedullary cavernous angiomas cause sensorimotor symptoms, typically with progressive painful paraparesis. The cavernous angioma manifest as reticulated mixed signal areas on both T-1 and T-2 weighted images, surrounded by low signal intensity prominent in T-2 weighted images. Intramedullary cavernous angiomas are mostly located in dorsal aspect of spinal cord. In the five cases, a bluish area is visible on the spinal surface and myelotomy is performed at this level. Four cases improved but two cases worsened in Nurick classification. A worsened case had a ventrally located cavernous angioma. Sensory function were aggravated in four cases. It is concluded that intramedullary spinal cord cavernous angiomas are uncommon causes of progressive myelopathy that can be safely and effectively treated by surgical excision.

Surgical Treatment of Arteriovenous Malformations of the Spinal Cord

Spinal arteriovenous malformations(AVM's) may subject patients to the risk of paraplegia or quadriplegia. To determine the clinical features of patients with spinal AVM's, the authors reviewed the medical records of 26 such patients diagnosed and treated in our department, between 1986 and 1996. Among these, there were two cases of dural arteriovenous fistula(dural AVF), eight of perimedullary fistula, twelve of intramedullary AVM, and three of intramedullary cavernous angioma. In one case, the type of AVM was not identified. The most common presenting symptom was acute or slowly progressive myelopathy. The patients were treated with embolization, surgery, or both, and because of residual or recurrent disease, treatment was repeated in six cases, five of which were intramedullary AVM. All patients with dural AVF improved after treatment. Among patients with intradural AVM(perimeudllary AVF or intramedullary AVM), 25% were improved and 25% deteriorated : two of three patients with cavernous angiomas improved. Diagnostic and therapeutic considerations in the cases of AVM of the spinal cord are discussed. Since recurrence or residual arteriovenous shunting is a common problem in the treatment of this condition, follow-up observation of clinical and angiographic findings is mandatory.