Unintentional temporomandibular joint disc reduction after orthognathic surgery: A case report with long-term imaging follow-up

This report presents a rare case where a displaced temporomandibular joint (TMJ) disc was reduced to its normal position after orthognathic surgery, and long-term magnetic resonance imaging (MRI) follow-up visualized these postoperative changes. A 22-year-old male patient presented for facial asymmetry. He also complained of pain in the right TMJ area, and MRI showed disc displacements in both TMJs. After orthognathic surgery for facial asymmetry correction, the TMJ was re-evaluated. The symptom had resolved and the disc was positioned within the normal range during mouth opening. However, 6 and a half years after surgery, he complained of recurrent pain in the right joint, and MRI revealed medial disc displacement in the right TMJ. In conclusion, the influence of orthognathic surgery on the disc position might continue for a long time until the TMJ adapts to the new position. Careful and long-term follow-up is suggested to assess the TMJ complex.

Hemodynamic Consideration in Intraoperative Neurophysiological Monitoring in Neuromuscular Scoliosis Surgery

Objective@#To prove the hypothesis that the parameters of intraoperative neurophysiological monitoring (IONM) during will be more deteriorated in neuromuscular scoliosis (NMS) than in adolescent idiopathic scoliosis (AIS). @*Methods@#This retrospective study reviewed the data of 69 patients (NMS=32, AIS=37) who underwent scoliosis surgery under IONM. The amplitude of motor evoked potentials (MEPs), and the amplitude and the latency of somatosensory evoked potentials (SEPs) were examined. Demographic, preoperative, perioperative and postoperative data were analyzed to determine whether they affected the IONM parameters for each group. @*Results@#Of the items analyzed, the bleeding amount was the only significant risk factor for SEP latency deterioration in the NMS group only. The amplitude of SEP and MEP did not correlate with the hemodynamic parameters. The NMS/AIS ratios of the bleeding-related parameters were higher in the order of bleeding amount/weight (2.62, p<0.01), bleeding amount/body mass index (2.13, p<0.01), and bleeding amount (1.56, p<0.01). This study suggests that SEP latency is more vulnerable than SEP or MEP amplitude in ischemic conditions during scoliosis surgery. @*Conclusion@#In NMS patients, it should be considered that the bleeding amount can have a critical effect on intraoperative electrophysiological deterioration.

Transfer learning in a deep convolutional neural network for implant fixture classification:A pilot study

Purpose@#This study aimed to evaluate the performance of transfer learning in a deep convolutional neural network for classifying implant fixtures. @*Materials and Methods@#Periapical radiographs of implant fixtures obtained using the Superline (Dentium Co. Ltd., Seoul, Korea), TS III (Osstem Implant Co. Ltd., Seoul, Korea), and Bone Level Implant (Institut Straumann AG, Basel, Switzerland) systems were selected from patients who underwent dental implant treatment. All 355 implant fixtures comprised the total dataset and were annotated with the name of the system. The total dataset was split into a training dataset and a test dataset at a ratio of 8 to 2, respectively. YOLOv3 (You Only Look Once version 3, available at https://pjreddie.com/darknet/yolo/), a deep convolutional neural network that has been pretrained with a large image dataset of objects, was used to train the model to classify fixtures in periapical images, in a process called transfer learning. This network was trained with the training dataset for 100, 200, and 300 epochs. Using the test dataset, the performance of the network was evaluated in terms of sensitivity, specificity, and accuracy. @*Results@#When YOLOv3 was trained for 200 epochs, the sensitivity, specificity, accuracy, and confidence score were the highest for all systems, with overall results of 94.4%, 97.9%, 96.7%, and 0.75, respectively. The network showed the best performance in classifying Bone Level Implant fixtures, with 100.0% sensitivity, specificity, and accuracy. @*Conclusion@#Through transfer learning, high performance could be achieved with YOLOv3, even using a small amount of data.

Direct Internal Fixation for Unstable Atlas Fractures

Purpose@#To investigate the radiologic and clinical outcomes of direct internal fixation for unstable atlas fractures. @*Materials and Methods@#This retrospective study included 12 patients with unstable atlas fractures surgically treated using C1 lateral mass screws, rods, and transverse connector constructs. Nine lateral mass fractures with transverse atlantal ligament (TAL) avulsion injury and three 4-part fractures with TAL injury (two avulsion injuries, one TAL substance tear) were treated. Radiologic outcomes included the anterior atlantodental interval (AADI) in flexion and extension cervical spine lateral radiographs at 6 months and 1 year after treatment. CT was also performed to visualize bony healing of the atlas at 6 months and 1 year. Visual Analog Scale (VAS) scores for neck pain, Neck Disability Index (NDI) values, and cervical range of motion (flexion, extension, and rotation) were recorded at 6 months after surgery. @*Results@#The mean postoperative extension and flexion AADIs were 3.79±1.56 (mean±SD) and 3.13±1.01 mm, respectively. Then mean AADI was 3.42±1.34 and 3.33±1.24 mm at 6 months and 1 year after surgery, respectively. At 1 year after surgery, 11 patients showed bony healing of the atlas on CT images. Only one patient underwent revision surgery 8 months after primary surgery due to nonunion and instability findings. The mean VAS score for neck pain was 0.92±0.99, and the mean NDI value was 8.08±5.70. @*Conclusion@#C1 motion-preserving direct internal fixation technique results in good reduction and stabilization of unstable atlas fractures. This technique allows for the preservation of craniocervical and atlantoaxial motion.

Efficacy of corticosteroid ductal irrigation in acute salivary gland inflammation induced in a rat model

Purpose@#This study aimed to compare the therapeutic effects of corticosteroid irrigations and normal saline irrigations in the early inflammatory state of the salivary gland. @*Materials and Methods@#Adult male Wistar rats were divided into experimental (n=6) and control (n=3) groups. Inflammation was induced in the experimental subjects on both sides of the submandibular gland with ligation. After 14 days, both sides of the glands were de-ligated and retroductal irrigation using saline (n=3) and a corticosteroid (n=3) was performed on the left sides only. The controls (n=3) were used to normalize the gland state for the effects of diet and aging. Magnetic resonance imaging was performed to confirm inflammation and post-irrigation gland recovery by measuring relative signal intensity (SI). The glands were excised for histological examination. @*Results@#All experimental animals showed inflamed glands with increased SI and subsequent recovery of the gland with decreased SI to varying degrees. The SI of the controls showed no significant changes during the overall period. The mean SI change of the irrigated gland was higher than that of the non-irrigated side, without a significant difference. The corticosteroid-irrigated glands showed a greater change in SI than that of the saline-irrigated glands. Histology revealed that inflammation was not observed in most of the irrigated glands, while mild to moderate quantities inflammatory cells were found in non-irrigated glands. @*Conclusion@#Corticosteroid irrigation mitigated the early stages of salivary gland inflammation more effectively than normal saline.

Posterior Device Fixation Using Pedicle Screws in Patients with Degenerative Spine Disease:A Prospective, Single-Group, Therapeutic Pilot Study

Objectives@#To evaluate the effectiveness and safety of posterior interbody fusion with a new type of pedicle screws after posterior decompression for degenerative spinal disease.Summary of Literature Review: There are no reports of surgical treatment results using the new type of pedicle screw (LumFix™) analyzed herein. We report the results of posterior interbody fusion with this new type of pedicle screw. @*Materials and Methods@#Ten patients underwent surgical treatment for degenerative spinal disease and were followed up for at least 1 year. In all cases, fixation using pedicle screws and posterior interbody fusion were performed after posterior decompression. Visual analogue scale (VAS) and Oswestry Disability Index (ODI) scores were measured before surgery, at 3 months postoperatively, and at 12 months postoperatively. Bone union was investigated through simple radiographs and computed tomography (CT) at 12 months postoperatively. In addition, blood inflammation levels and basic vital signs were investigated preoperatively and at the last follow-up. @*Results@#In all cases, preoperative symptoms improved, and the back pain VAS improved from 7.30±1.49 preoperatively to 2.70±1.64 at 3 months postoperatively and 1.80±1.40 at the final follow-up. Leg pain was 7.40±1.17 preoperatively and 2.60±2.17 at 3 months postoperatively. At the last follow-up, it improved to 2.40±1.96 (p<0.001). The ODI improved from 28.80±4.89 preoperatively to 15.60±5.04 at 3 months postoperatively and 16.90±6.61 (p=0.002) at the final follow-up. Bone union was achieved in all cases. Inflammation levels and vital signs were within the normal range both preoperatively and at 12 months postoperatively. @*Conclusions@#The LumFix™ pedicle screws used in this study were fused in 100% of patients with degenerative spinal diseases. No complications were observed, and the VAS of back and leg pain and ODI of the lumbar spine significantly improved. There were no abnormal findings in blood tests or vital signs, demonstrating biocompatibility. Therefore, the type of new pedicle screw analyzed in this study can be used in fusion surgery for degenerative spinal diseases.

Prevalence of Gastrointestinal and Cardiovascular Risk in Patients with Degenerative Lumbar Spinal Disease

Background@#Limited information is available about the proportion of patients with degenerative lumbar spinal disease (DLSD) who have gastrointestinal (GI) and cardiovascular (CV) risk factors. Many DLSD patients are prescribed nonsteroidal anti-inflammatory drugs (NSAIDs) that are known to carry risks to the GI and CV systems by increasing GI bleeding and thromboembolic events.This study aimed to measure the prevalence of GI and CV risk in patients with DLSD and to ascertain whether the prescription of NSAIDs is in line with current guidelines. @*Methods@#This study included 153 patients with symptomatic DLSD who were planning to undergo lumbar spinal surgery. The GI profile was checked using the GI Standardized Calculator of Risk for Event system and CV risk was evaluated using the presence of metabolic syndrome. The conformity of the prescription of NSAIDs was investigated according to the recommendations in current guidelines. @*Results@#More than half of the patients (59.5%) had high or very high GI risk, and 66% of the patients were diagnosed with metabolic syndrome, which corresponds with CV risk. The rate of simultaneous GI and CV risk was 40.5% (n = 62 / 153; gastrointestinal Standardized Calculator of Risk for Event, > high and metabolic syndrome, yes). The actual prescription of NSAIDs was not in accordance with current guidelines. @*Conclusions@#Two out of 3 patients had GI or CV risk factors, and approximately 40% of patients had both. Detailed assessment of GI and CV risk in patients with DLSD by using effective evaluation tools is mandatory for optimal medical treatment.

Lumbar Spinal Stenosis: Pathophysiology and Treatment Principle: A Narrative Review

Patients with lumbar spinal stenosis may exhibit symptoms such as back pain, radiating pain, and neurogenic claudication. Although long-term outcome of treatments manifests similar results for both nonsurgical and surgical treatments, positive effects such as short-term improvement in symptoms and decreased fall risk may be expected with surgery. Surgical treatment is basically decompression, and a combination of treatments can be added depending on the degree of decompression and the accompanying instability. Recently, minimally invasive surgery has been found to result in excellent outcomes in the treatment of lumbar spinal stenosis. Therefore, better treatment effects can be anticipated with an approach aimed at understanding the overall pathophysiology and treatment methods of lumbar spinal stenosis.

Posterior Device Fixation Using Pedicle Screws in Patients with Degenerative Spine Disease:A Prospective, Single-Group, Therapeutic Pilot Study

Objectives@#To evaluate the effectiveness and safety of posterior interbody fusion with a new type of pedicle screws after posterior decompression for degenerative spinal disease.Summary of Literature Review: There are no reports of surgical treatment results using the new type of pedicle screw (LumFix™) analyzed herein. We report the results of posterior interbody fusion with this new type of pedicle screw. @*Materials and Methods@#Ten patients underwent surgical treatment for degenerative spinal disease and were followed up for at least 1 year. In all cases, fixation using pedicle screws and posterior interbody fusion were performed after posterior decompression. Visual analogue scale (VAS) and Oswestry Disability Index (ODI) scores were measured before surgery, at 3 months postoperatively, and at 12 months postoperatively. Bone union was investigated through simple radiographs and computed tomography (CT) at 12 months postoperatively. In addition, blood inflammation levels and basic vital signs were investigated preoperatively and at the last follow-up. @*Results@#In all cases, preoperative symptoms improved, and the back pain VAS improved from 7.30±1.49 preoperatively to 2.70±1.64 at 3 months postoperatively and 1.80±1.40 at the final follow-up. Leg pain was 7.40±1.17 preoperatively and 2.60±2.17 at 3 months postoperatively. At the last follow-up, it improved to 2.40±1.96 (p<0.001). The ODI improved from 28.80±4.89 preoperatively to 15.60±5.04 at 3 months postoperatively and 16.90±6.61 (p=0.002) at the final follow-up. Bone union was achieved in all cases. Inflammation levels and vital signs were within the normal range both preoperatively and at 12 months postoperatively. @*Conclusions@#The LumFix™ pedicle screws used in this study were fused in 100% of patients with degenerative spinal diseases. No complications were observed, and the VAS of back and leg pain and ODI of the lumbar spine significantly improved. There were no abnormal findings in blood tests or vital signs, demonstrating biocompatibility. Therefore, the type of new pedicle screw analyzed in this study can be used in fusion surgery for degenerative spinal diseases.

Assessment of Korea's Orthopedic Research Activities in the Top 15 Orthopedic Journals, 2008–2017

BACKGROUND: Bibliometrics is increasingly used to assess the quantity and quality of scientific research output in many research fields worldwide. This study aims to update Korea's worldwide research productivity in the field of orthopedics using bibliometric methods and to provide Korean surgeons and researchers with insights into such research. METHODS: Articles published in the top 15 orthopedic journals between 2008 and 2017 were retrieved using the Web of Science. The number of articles, citations and h-index (Hirsch index), funding sources, institutions, and journal patterns were analyzed. RESULTS: Of the total 39,494 articles, Korea's contribution accounted for 5.6% (2,161 articles), ranking fifth in the world in the number of publications. Korea ranked sixth (with 29,456) for total citations worldwide but ranked 17th (13.64) in terms of average citation per item and 14th (55) in terms of h-index. Korea showed the most prolific productivity in the field of sports medicine and arthroscopy. The institution that produced the highest number of publications was Seoul National University (n = 386, 17.9%). CONCLUSIONS: Orthopedic research in South Korea demonstrated high productivity in terms of the number of publications in high-quality journals between 2008 and 2017. However, total citations and average citations per article were still relatively low. Efforts should be made to increase citation rates for further improvement in research productivity in the field of orthopedics.

The Evidence for Nonoperative Treatment of Lumbar Spinal Diseases / 대한척추외과학회지

STUDY DESIGN: Review article.OBJECTIVES: To assess the evidence for nonoperative treatment of various degenerative spinal degenerative diseases.SUMMARY OF LITERATURE REVIEW: No study has yet evaluated the evidence for preoperative nonoperative treatment of lumbar spinal diseases.METHODS: The evidence regarding nonoperative treatment for each disease was reviewed through NASS guidelines, and the treatment effect compared to surgical treatment was reviewed through the SPORT series. The efficacy of nonoperative treatment according to disease severity and certain special conditions was investigated through corresponding individual articles.RESULTS: No kind of nonoperative treatment could change the fundamental progression of degenerative spinal disease. The natural course of lumbar disc herniation is favorable regardless of treatment. More than 70% of routine cases improve within 6 weeks. However, it does not take a full 6 weeks to decide whether to perform surgery or not. The evidence for transforaminal epidural steroid injections for short-term pain control is grade A. There is grade B evidence for nonoperative treatment with the goal of mid- to long-term pain control. However, we cannot say that those outcomes are better than the natural course of the disease itself. In cases of radicular weakness, the degree of weakness is correlated with the final outcomes, but it is not evident whether the duration of weakness is correlated with surgical outcomes. Early surgery is usually necessary due to intolerable pain, rather than stable motor weakness. The social cost of herniated discs arises from the loss of patients’ productivity, rather than from direct medical expenses. The natural course of spinal stenosis involves provoked pain and the need for palliative care. Unlike disc herniation, rapid deterioration and marked improvement do not occur. The symptoms of mild to moderate lumbar stenosis are unchanged in 70% of cases, improve in 15%, and worsen in 15%. No study has compared nonoperative treatment with the natural course of the disease. There is no evidence for nonoperative treatment of severe stenosis. Epidural spinal injections are effective for controlling short-term pain. Spontaneous recovery of radicular weakness does not occur, and urgent surgery is necessary in such cases. There is no evidence regarding the natural course and nonoperative treatment of degenerative spondylolisthesis. The working group consensus recommends that it should follow the pattern of nonoperative treatment of spinal stenosis when radicular stenosis symptoms are predominant. Overall, 40%–66% of cases of adult bilateral isthmic spondylolysis progress to symptomatic spondylolisthesis. No studies have investigated nonoperative treatment except physical exercise.CONCLUSIONS: Although short-term symptom amelioration can be achieved by nonoperative treatment, the fundamental progression of the disease is not affected. For conditions excluded from most studies, such as prior spine surgery, cauda equina syndrome, progressive neurological deficit, and uncontrollable severe pain associated with instability, deformity, or vertebral fractures, there were not enough studies to reach informed conclusions. Our review found no evidence regarding nonoperative treatment for such conditions. Furthermore, the treatment methods for each disease are not clearly distinguished from each other, and the techniques used for disc herniation have been applied to other diseases without any evidence.

The Evidence for Nonoperative Treatment of Lumbar Spinal Diseases

OBJECTIVES@#To assess the evidence for nonoperative treatment of various degenerative spinal degenerative diseases.SUMMARY OF LITERATURE REVIEW: No study has yet evaluated the evidence for preoperative nonoperative treatment of lumbar spinal diseases.@*METHODS@#The evidence regarding nonoperative treatment for each disease was reviewed through NASS guidelines, and the treatment effect compared to surgical treatment was reviewed through the SPORT series. The efficacy of nonoperative treatment according to disease severity and certain special conditions was investigated through corresponding individual articles.@*RESULTS@#No kind of nonoperative treatment could change the fundamental progression of degenerative spinal disease. The natural course of lumbar disc herniation is favorable regardless of treatment. More than 70% of routine cases improve within 6 weeks. However, it does not take a full 6 weeks to decide whether to perform surgery or not. The evidence for transforaminal epidural steroid injections for short-term pain control is grade A. There is grade B evidence for nonoperative treatment with the goal of mid- to long-term pain control. However, we cannot say that those outcomes are better than the natural course of the disease itself. In cases of radicular weakness, the degree of weakness is correlated with the final outcomes, but it is not evident whether the duration of weakness is correlated with surgical outcomes. Early surgery is usually necessary due to intolerable pain, rather than stable motor weakness. The social cost of herniated discs arises from the loss of patients’ productivity, rather than from direct medical expenses. The natural course of spinal stenosis involves provoked pain and the need for palliative care. Unlike disc herniation, rapid deterioration and marked improvement do not occur. The symptoms of mild to moderate lumbar stenosis are unchanged in 70% of cases, improve in 15%, and worsen in 15%. No study has compared nonoperative treatment with the natural course of the disease. There is no evidence for nonoperative treatment of severe stenosis. Epidural spinal injections are effective for controlling short-term pain. Spontaneous recovery of radicular weakness does not occur, and urgent surgery is necessary in such cases. There is no evidence regarding the natural course and nonoperative treatment of degenerative spondylolisthesis. The working group consensus recommends that it should follow the pattern of nonoperative treatment of spinal stenosis when radicular stenosis symptoms are predominant. Overall, 40%–66% of cases of adult bilateral isthmic spondylolysis progress to symptomatic spondylolisthesis. No studies have investigated nonoperative treatment except physical exercise.@*CONCLUSIONS@#Although short-term symptom amelioration can be achieved by nonoperative treatment, the fundamental progression of the disease is not affected. For conditions excluded from most studies, such as prior spine surgery, cauda equina syndrome, progressive neurological deficit, and uncontrollable severe pain associated with instability, deformity, or vertebral fractures, there were not enough studies to reach informed conclusions. Our review found no evidence regarding nonoperative treatment for such conditions. Furthermore, the treatment methods for each disease are not clearly distinguished from each other, and the techniques used for disc herniation have been applied to other diseases without any evidence.

Temporomandibular joint synovial chondromatosis accompanying temporal bone proliferation: A case report

Synovial chondromatosis is a rare metaplastic disease affecting the joints, including the temporomandibular joint (TMJ). Since its symptoms are similar to those of temporomandibular disorders, a careful differential diagnosis is essential. A 50-year-old male patient was referred with the chief complaint of pain and radiopaque masses around the left TMJ on panoramic radiography. Clinically, pre-auricular swelling and resting pain was found, without limitation of mouth opening. On cone-beam computed tomographic images, multiple calcified nodules adjacent to the TMJ and bone proliferation with sclerosis at the articular fossa and eminence were found. T2-weighted magnetic resonance images showed multiple signal-void nodules with high signal effusion in the superior joint space and thickened cortical bone at the articular fossa and eminence. The calcified nodules were removed by surgical excision, but the hypertrophic articular fossa and eminence remained. A histopathological examination confirmed the diagnosis. The patient was followed up few months later without recurrence.

Gelatinous Transformation of Bone Marrow Mimicking Malignant Marrow-Replacing Lesion on Magnetic Resonance Imaging in a Patient without Underlying Devastating Disease

Gelatinous transformation of bone marrow is characterized by hypoplasia of fat cells with focal loss of hematopoietic cells and deposition of extracellular gelatinous substances. It is known to be associated with devastating underlying diseases that starve bone marrow. Here, we present a case of a patient whose magnetic resonance (MR) imaging findings of vertebral column were interpreted as metastasis or hematologic malignancy, however, the final diagnosis revealed a gelatinous transformation of bone marrow. This is the first report of gelatinous transformation of bone marrow without evidence of underlying devastating disease.

Fistula Formation Between the Disc and Dura after Percutaneous Endoscopic Lumbar Discectomy: A Case Report / 대한척추외과학회지

STUDY DESIGN: Case report OBJECTIVES: To document fistula formation between the disc and dura by an unrecognized dural tear after percutaneous endoscopic lumbar discectomy (PELD). SUMMARY OF LITERATURE REVIEW: The risk of durotomy is relatively low with PELD, but cases of unrecognized durotomies have been reported. An effective diagnostic tool for such situations has not yet been identified. MATERIALS AND METHODS: A patient twice underwent transforaminal PELD under the diagnosis of a herniated lumbar disc at L4-5. She still complained of intractable pain and motor weakness around the left lower extremity at 6 months postoperatively. Magnetic resonance imaging showed no specific findings suggestive of violation of the nerve root. However, L5 and S1 nerve root injury was noted on electromyography. An exploratory operation was planned to characterize damage to the neural structures. RESULTS: In the exploration, a dural tear was found at the previous operative site, along with a fistula between the disc and dura was also found at the dural tear site. The durotomy site was located on the ventrolateral side of the dura and measured approximately 5 mm. The durotomy site was repaired with Nylon 5-0 and adhesive sealants. The patient's preoperative symptoms diminished considerably. CONCLUSIONS: Fistula formation between the disc and dura can be caused by an unrecognized dural tear after PELD. Discography is a reliable diagnostic tool for fistulas formed by an unrecognized durotomy.

Results of Magnetically Controlled Growing Rods for Early Onset Scoliosis / 대한정형외과학회잡지

PURPOSE: To evaluate the first results of surgical treatment using newly developed magnetically controlled growing rods (MCGR) for early onset scoliosis (EOS). MATERIALS AND METHODS: From January 2013 to January 2017, 5 patients, who underwent surgical treatment with MCGR for EOS and were followed for more than one year, were analyzed retrospectively. The demographic and radiology data, including age at surgery, diagnosis, number of lengthening, Cobb angle, T1–S1 length, T1–T12 length, and complications, were analyzed. RESULTS: The mean age of the patients was 6.0±2.7 years old. The subjects were 3 males and 2 females: 2 with neuromuscular scoliosis, 1 with syndromic scoliosis, 1 with idiopathic scoliosis, and 1 with congenital scoliosis. The mean number of lengthening was 9.8±2.9 times and the follow-up was 21.6±5.7 months. The Cobb angle improved from 82.0°±28.5° to 48.3°±28.8° at the last follow-up. The T1–S1 length increased from 283.1±72.7 mm to 342.6±86.3 mm at the last follow-up. The T1–T12 length increased from 163.1±50.5 mm to 202.3±65.5 mm at the last follow-up. One screw loosening complication was encountered and there were no neurological complications. CONCLUSION: The treatment using MCGR for EOS is effective and useful.

Fistula Formation Between the Disc and Dura after Percutaneous Endoscopic Lumbar Discectomy: A Case Report

OBJECTIVES@#To document fistula formation between the disc and dura by an unrecognized dural tear after percutaneous endoscopic lumbar discectomy (PELD).SUMMARY OF LITERATURE REVIEW: The risk of durotomy is relatively low with PELD, but cases of unrecognized durotomies have been reported. An effective diagnostic tool for such situations has not yet been identified.@*MATERIALS AND METHODS@#A patient twice underwent transforaminal PELD under the diagnosis of a herniated lumbar disc at L4-5. She still complained of intractable pain and motor weakness around the left lower extremity at 6 months postoperatively. Magnetic resonance imaging showed no specific findings suggestive of violation of the nerve root. However, L5 and S1 nerve root injury was noted on electromyography. An exploratory operation was planned to characterize damage to the neural structures.@*RESULTS@#In the exploration, a dural tear was found at the previous operative site, along with a fistula between the disc and dura was also found at the dural tear site. The durotomy site was located on the ventrolateral side of the dura and measured approximately 5 mm. The durotomy site was repaired with Nylon 5-0 and adhesive sealants. The patient's preoperative symptoms diminished considerably.@*CONCLUSIONS@#Fistula formation between the disc and dura can be caused by an unrecognized dural tear after PELD. Discography is a reliable diagnostic tool for fistulas formed by an unrecognized durotomy.

Effect of Sagittal Balance on Risk of Falling after Lateral Lumbar Interbody Fusion Surgery Combined with Posterior Surgery

PURPOSE: To demonstrate the impact of correcting sagittal balance (SB) on functional outcomes of surgical treatment for degenerative spinal disease and actual falls via utilization of new minimally invasive lumbar fusion techniques via a lateral approach. MATERIALS AND METHODS: From November 2011 to March 2015, we enrolled 56 patients who underwent minimally invasive lateral lumbar interbody fusion (LLIF) and matched 112 patients receiving decompression/postero-lateral fusion (PLF) surgery for lumbar spinal stenosis. According to SB status using C7-plumb line-distance (C7PL) and surgery type, patients were divided into three groups: SB PLF, sagittal imbalance (SI) PLF, and LLIF groups. We then compared their outcomes. RESULTS: The mean C7PL was 6.2±13.6 mm in the SB PLF group, 72.9±33.8 mm in the SI PLF group, and 74.8±38.2 mm in the LLIF group preoperatively. Postoperatively, C7PL in only the LLIF group improved significantly (p=0.000). Patients in the LLIF group showed greater improvement in fall-related functional test scores than the SI PLF group (p=0.007 for Alternate-Step test, p=0.032 for Sit-to-Stand test). The average number of postoperative falls was 0.4±0.7 in the SB PLF group, 1.1±1.4 in the SI PLF group, and 0.8±1.0 in the LLIF group (p=0.041). Oswestry Disability Index and the Euro-QoL 5 dimension visual analogue scale scores also showed greater improvements in the LLIF group than in the SI PLF group at postoperative 1 year (p=0.003, 0.016). CONCLUSION: Surgical correction of SI in patients with lumbar spinal stenosis using a combination of minimal invasive LLIF and posterior surgery achieved better surgical outcomes and a lower incidence of actual falls than PLF surgery.

Dual Growing Rod Treatment for Progressive Pediatric Spinal Deformity

STUDY DESIGN: Retrospective study. OBJECTIVES: To evaluate the outcomes of dual growing rod treatment over a follow-up period of at least 2 years in patients with progressive pediatric spinal deformity. SUMMARY OF LITERATURE REVIEW: The dual growing rod treatment is safe and effective in curve correction and maintenance in patients with progressive pediatric spinal deformity. MATERIALS AND METHODS: Between 2009 to 2017, 14 patients who underwent dual growing rod treatment were followed up for more than 2 years. We analyzed their demographic and radiologic data, including age at surgery, sex, diagnosis, instrumented levels, number of total operations, number of lengthening procedures, interval of lengthening, Cobb angle, thoracic kyphosis angle, lumbar lordosis angle, T1-S1 length, and complications. RESULTS: The mean age of the patients was 11.0±2.9 years old. There were 10 male and 4 female patients, including 8 cases of neuromuscular scoliosis, 3 cases of idiopathic scoliosis, 2 cases of spondyloepiphyseal dysplasia, and 1 case of congenital scoliosis. The mean follow-up period was 42.4±14.0 months. The total number of operations was 6.6±2.6. The average number of lengthening procedures was 4.3±2.3 at an interval of 6.9±2.1 months. The Cobb angle improved from 60.4°±27.9° to 33.5°±19.7° after the initial treatment and 29.1°±16.4° after the last follow-up or final fusion. The T1-S1 length increased from 328.2±57.5 mm to 388.0±64.9 mm after the initial treatment and 424.9±64.4 mm after the last follow-up or final spinal fusion. The average growth rate was 11.5 mm/year. Six patients experienced 11 complications, of which 4 were Implant-related, and 7 were Infections. CONCLUSIONS: The dual growing rod technique is an effective and relatively safe treatment in patients with progressive pediatric spinal deformity.

Efficacy and Safety of Different Aceclofenac Treatments for Chronic Lower Back Pain: Prospective, Randomized, Single Center, Open-Label Clinical Trials

PURPOSE: Nonsteroidal anti-inflammatory drugs are a mainstay for medical treatment of chronic lower back pain (CLBP). Increased dose intervals for medication have been associated with increased patient adherence to prescriptions. The purpose of this clinical trial was to compare the efficacy and safety of a once daily dose of aceclofenac controlled release (CR) and a twice daily dose of aceclofenac for CLBP management. MATERIALS AND METHODS: A prospective, randomized, single center, open-label clinical trial was performed to compare the efficacy and safety of aceclofenac CR (200 mg once daily) to aceclofenac dose (100 mg twice daily). Fifty patients in each group were enrolled for the study. The primary end point was Visual Analogue Scale (VAS) change at baseline to that at 2 weeks after medication and safety profiles. Also, change in quality of life measured by EuroQoL 5D (EQ-5D) and Oswestry Disability Index (ODI) functional score for the lumbar spine were also assessed. RESULTS: Within groups at pre- and post-treatment, there were significant VAS reductions for aceclofenac CR and aceclofenac (p=0.028). EQ-5D increased significantly in both groups (p=0.037). ODI scores decreased significantly in both groups (p=0.012). However, there were no significant differences between aceclofenac CR and aceclofenac at pre- and post-treatment. Patients with aceclofenac CR showed significant increases in heartburn and indigestion and adverse gastrointestinal effects, compared to aceclofenac. CONCLUSION: In patients with CLBP, aceclofenac CR and aceclofenac demonstrated significant symptomatic pain relief, improvement in quality of life and functional scores. Aceclofenac CR slightly increased gastrointestinal adverse effects, such as heartburn and indigestion.