Radiological Assessment of Morphological Changes of Lumbar Spine: From First to 9th Decade of Life.

STUDY DESIGN: Analysis of lumbar spine radiograms of 1,496 Jeju islanders of Korea. PURPOSE: To look into the age- and gender-matched incidences of morphological changes and their severities. OVERVIEW OF LITERATURE: There have been several prior research on the prevalence and severity of age-related diseases, both related and unrelated. Those offer some fundamental clinical data for clinicians. METHODS: Radiograms of 1,496 patients (555 males and 941 females) from the first to 9th decade were examined for this study. Sagittal and coronal alignment, disc space narrowing, spur formation including diffuse idiopathic spinal hyperostosis (DISH), spondylolisthesis, and ballooned discs associated with biconcave bodies due to osteoporosis were among the parameters of lumbar spine morphologies examined on high-quality radiographs by both human observers and computers. RESULTS: The alignment of the lumbar spine altered after birth and set at growth maturity, and then the curve was maintained till the end of the 5th decade afterward and the curve gradually hypolordotic. There were three types of coronal alignment abnormalities can be seen: idiopathic, osteopathic, and discogenic (degenerative lumbar scoliosis [DLS]). DLS developed after 6th decade. There was no scoliosis associated with spondylolysis or the post-laminofacetectomy period. Disc space narrowing and corporal spur formation were not seen till the end of 3rd decade comparatively speaking, the corporal spurs generated in the non-scoliotic spine were smaller than those in the scoliotic spine. DISH began to appear in the 5th-decade patients and its incidences increased gradually afterward. Porosis-related vertebral body collapse started to happen after 6th decade. There are three different types of spondylolisthesis: anterior, posterior, and lateral. The lateral slip occurred only in the scoliotic spine. All types were related to degenerative discs. CONCLUSIONS: It has been shown that the morphology of the lumbar spine changes throughout time.

Usefulness of Percutaneous Pedicle Screw Fixation for Treatment of Lower Lumbar Burst (A3-A4) Fractures: Comparative Study with Thoracolumbar Junction Fractures.

Background: Percutaneous pedicle screw fixation (PPSF) without fusion has been recently recommended in the treatment of thoracolumbar fracture to reduce the adverse effects associated with the conventional open approaches and to restore range of motion. However, those studies report on the thoracolumbar junction, and there is no report on lower lumbar fracture. Purpose: To assess effectiveness of PPSF without fusion for treating lower lumbar burst (A3 and A4) fractures. Methods: A retrospective analysis was made to evaluate consecutive 50 patients with AO type A3 and A4 thoracolumbar fracture underwent PPSF. Patients were divided into a thoracolumbar junction (TLJ) group (T11-L2) and lower lumbar (LL) group (L3-5). The following items were measured and compared between the two groups. Vertebral height and consolidation, retropulsed fragment, sagittal curve and fixation failure were assessed with certain interval regularly. Results: The average height at pre- and post-reduction were 56.2% (36.2-74.3), 95.3% (84.2-98.3) in TLJ group and 65.7% (45.7-86.2), 91% (73.1-100) in LL group. The average canal area occupancy rate at pre- and post-reduction were 46.1% (37.4%-67.5%), 38.1% (31.3%-40.8%) in TLJ group and 40.4% (15.0-65.7), 19.3% (9.4-26.6) in LL group. Consolidation was completed within 12 months after surgery in both groups. There was no significant difference between two groups in clinical and radiographic parameters except cobb angle loss. Conclusion: Patients with lower lumbar fracture can be effectively managed with PPSF without fusion. PPSF following the implant removal can restore the movement of the lower lumbar spine, which is essential for daily life.

Effect of Congenital C4-5 Synostosis on Adjacent Mobile Segments: Radiographic Assessment.

STUDY DESIGN: Prospective case series. PURPOSE: To assess the corporal morphology of the fused body and adjacent segment conditions. OVERVIEW OF LITERATURE: It is known that two fused vertebral bodies take the similar shape of the single body with inwaisting, with or without caudal flaring of the fused body, and that the fused body can cause the fusion disease at the adjacent segment that can be a risk factor for potential neurological compromise. METHODS: Radiograms of the 11 study subjects (six men and five women), aged 22-90 years who visited the outpatients' clinic for various neck complaints without trauma history were examined. C4-5 synostosis was an incidental finding in all the subjects. RESULTS: All the fused bodies were inwaisted and had anterior caudal breaking but no interior corporal flaring. Adjacent segment disease was not found in eight patients aged <40 years. Disk degeneration was found at C3-4 and C5-6 in three patients each and at C6-7 in two patients. Disk degeneration was limited to the adjacent segments. CONCLUSIONS: Degenerative disk changes are associated with the natural aging process, and the corporal morphology of the fused vertebral becomes inwaisted similar to that in the single vertebrae.

Pavlov's Ratio of the Cervical Spine in a Korean Population: A Comparative Study by Age in Patients with Minor Trauma without Neurologic Symptoms.

BACKGROUD: There are many studies on the vertebral body-to-canal ratio, the so-called Pavlov's ratio of the cervical spine. However, there are no studies on its relation with age to clarify each bony component's contribution to the spinal canal formation and its size. The aim of this study was to investigate differences and changes in the vertebral body-to-canal ratio according to age in an asymptomatic population. METHODS: This is a cross-sectional study of 280 asymptomatic individuals. A total of 140 men and 140 women representing each decade of life from the first to the seventh were included in this study. The anteroposterior length of the vertebral body and canal from C3 to C6 was measured on sagittal radiographs to calculate the vertebral body-to-canal ratio. RESULTS: The average Pavlov's ratio was significantly larger (p < 0.001) in the first decade of life. The average Pavlov's ratio of the individuals in the first decade of life was 1.09 between C3 and C6 (1.08 at C3, 1.07 at C4, 1.11 at C5, and 1.13 at C6; range, 0.78-1.51). There was no significant difference among the other decades of life. CONCLUSIONS: We assessed the Pavlov's ratio of the cervical spine in an asymptomatic population. It is our belief that the spinal canal size is the largest in the first decade of life, and the Pavlov's ratio becomes almost fixed throughout life after maturity.

Essential Basic Bacteriology in Managing Musculoarticuloskeletal Infection: Bacterial Anatomy, Their Behavior, Host Phagocytic Activity, Immune System, Nutrition, And Antibiotics.

Surgery-related infections have not been irradicated until now. To solve this problem, it is important to know the relationship between bacterial anatomy and bacterial behavior in the tug-of-war between host and pathogen. In this article, bacterial anatomy and functional behavior, host phagocytic activity, immune system, nutrition and antibiotics are reviewed to win the war against the tiny invaders and leave the host unharmed. My suggestion is that scientists should direct their studies not only to developing potent new antibiotics that will never give rise to drug-resistant mutants, but also to developing a very competitive immune system that can suppress or control infection without the aid of antibiotics.

Magnetic Resonance Imaging Observations of the Conus Medullaris in a Korean Population.

STUDY DESIGN: Retrospective study (level of evidence: level 3). PURPOSE: To study the anatomy of the conus medullaris in Koreans. OVERVIEW OF LITERATURE: The anatomical position of the conus medullaris is well-documented in anatomy textbooks; however, the shape of the conus in the canal rarely described. Furthermore, to our knowledge, no study in Korea has not yet assessed the shape of the conus as well as its position in the canal via cadavaric dissection and/or magnetic resonance imaging (MRI). METHODS: MRI findings of 189 Korean patients aged 2-94 years (93 men and 94 women) were assessed. No subjects from other ethnicities were included. The method proposed by Arai and colleagues was used to assess the termination point and shape of the conus in the canal. The position of the intervertebral disc trisection of the vertebral body closest to the tip of the conus was recorded at the canal level. RESULTS: The tip of the conus medullaris was positioned from the upper T12 body to the L2-L3 disc, mostly in L1 bodies (52.4%), followed by the L2 bodies (22.5%), the L1-L2 disc, and the L2-L3 disc (1.1%). The shape of the conus was classified as type A in 74 (39.6%), type B in 58 (31%), and type C in 55 patients (29.4%). The conus did not terminate at the L3 body in any patient. In the first decade ones (five children) conus positioned rather lowly from L1 bodies to L2-L3 disc, and no type A conus shape, and mostly type B (80%). CONCLUSIONS: The conus medullaris was positioned mostly in the lower one-third of L1 and it in the first decades terminated lowly. No type A in the first decade one, and type B was mostly frequently formed which was followed by type C.

Most Reliable Time in Predicting Residual Kyphosis and Stability: Pediatric Spinal Tuberculosis.

STUDY DESIGN: A case study. PURPOSE: To assess the chronological changes of the disease-related kyphosis after chemotherapy alone, secondly to clarify the role of growth cartilage in the healed lesion on kyphosis change, and to define the accurate prediction time in assessing residual kyphosis. OVERVIEW OF LITERATURE: None of the previous papers up to now dealt with the residual kyphosis, stability and remodeling processes of the affected segments. METHODS: One hundred and one spinal tuberculosis children with various stages of disease processes, age 2 to 15 years, were the subject materials, between 1971 to 2010. They were treated with two different chemotherapy formula: before 1975, 18 months of triple chemotherapy (isoniazid [INH], para-aminosalicylic acid, streptomycin); and since 1976, 12 months triple chemotherapy (INH, rifampicin, ethambutol, or pyrazinamide). The first assessment at post-chemotherapy one year and at the final discharge time from the follow-up (36 months at minimum and 20 years at maximum) were analyzed by utilizing the images effect of the remaining growth plate cartilage on chronological changes of kyphosis after initiation of chemotherapy. RESULTS: Complete disc destruction at the initial examination were observed in two (5.0%) out of 40 cervical spine, eight (26.7%) out of 30 dorsal spine, and six (19.4%) out of 31 lumbosacral spine. In all those cases residual kyphosis developed inevitably. In the remainders the discs were partially preserved or remained intact. Among 101 children kyphosis was maintained without change in 20 (19.8%), while kyphosis decreased in 14 children (13.7%), and increased in 67 children (66.3%) with non-recoverably damaged growth plate, respectively. CONCLUSIONS: It could tentatively be possible to predict the deformity progress or non-progress and spontaneous correction at the time of initial treatment, but it predictive accuracy was low. Therefore, assessment of the trend of kyphotic change is recommended at the end of chemotherapy. In children with progressive curve change, the deformity assessment should be continued till the maturity.

Spinopelvic Orientation on Radiographs in Various Body Postures: Upright Standing, Chair Sitting, Japanese Style Kneel Sitting, and Korean Style Cross-Legged Sitting.

BACKGROUND: Several previous studies reported on the impact of upright standing and chair sitting on the sagittal spinopelvic alignment. However, there are no studies on the impact of the two Asian (Korean and Japanese) style floor-sitting positions on the sagittal spinopelvic alignment. The purpose of this study was to evaluate the impact of four different body postures (standing, chair sitting, kneel sitting, and cross-legged sitting) on the sagittal spinopelvic alignment. METHODS: Sixteen selected healthy volunteers (10 males and six females) were subjects of this pilot study. In all subjects, radiographs were taken in comfortable standing and sitting positions. All spinal curvatures including lumbar lordotic angle (LLA), sacral slope (SS), pelvic tilt (PT), and pelvic incidence (PI) were measured on the radiographs. RESULTS: In standing position, the average LLA, SS, PT, and PI were 37.1°, 35.3°, 15.7°, and 51.0°, respectively. In chair sitting, the average LLA, SS, PT, and PI were 17.9°, 20.3°, 28.2°, and 49.5°, respectively. In kneel sitting (Japanese style), the average LLA, SS, PT, and PI were 31.8°, 38.3°, 14.2°, and 52.5°, respectively. In cross-legged sitting (Korean style), the average LLA, SS, PT, and PI were 9.8°, 13.4°, 38.3°, and 51.7°, respectively. LLA in standing (37.1°) and kneel sitting (31.8°) were very similar. Remarkable reduction in LLA was observed in Korean-style cross-legged sitting (9.8°), and LLA in chair sitting (17.9°) was about half of that in standing. SS was similar in standing (35.3°) and kneel sitting (38.3°), and it was reduced remarkably in cross-legged sitting (13.4°). PT was largest in cross-legged sitting (38.3°), and it was similar between standing (15.7°) and kneel sitting (14.2°). PIs were similar in all positions. CONCLUSIONS: The kneel sitting position did not show significant differences with the standing position when assessed using four parameters related to the sagittal spinopelvic alignment, whereas chair sitting and cross-legged sitting positions significantly altered the spinopelvic alignment compared to the standing position.

Traumatic Absence of the Shaft of the Radius in a Child: A 15-Year Follow-up after Reconstruction by a Modified Define's One Bone Forearm Procedure.

Traumatic absence of the entire radial shaft in children has not been reported though there are a few reports of adult cases. We report a 5-year-old boy with traumatic absence of the entire right radial shaft. The Define's reconstruction procedure was chosen to localize the surgery only to the distal forearm and avoid further additional damage to the forearm muscles. The child's forearm was successfully reconstructed by the authors' modified Define's procedure, which was followed until his maturity. Hand function was well maintained.

Prevalence of Diffuse Idiopathic Skeletal Hyperostosis Diagnosed by Whole Spine Computed Tomography: A Preliminary Study.

BACKGROUND: Diffuse idiopathic skeletal hyperostosis (DISH) is characterized by ossification of the enthesis. The diagnosis has been mainly based on the chest or whole spine lateral plain film. Recently, chest or thoracolumbar computed tomography (CT) has been reported to be more reliable for the diagnosis of DISH. The purposes of this study were to investigate the prevalence and location of DISH and evaluate the prevalence of comorbidities, such as ossification of the posterior longitudinal ligament (OPLL) and ossification of the ligamentum flavum (OLF), using whole spine CT. METHODS: Whole spine CT scans of patients over 16 years of age who were examined at Cheju Halla General Hospital between February 2011 and December 2016 were reviewed for this study. The diagnosis of DISH was made according to the modified Resnick criteria. The prevalence of DISH in each age decade and its location were evaluated. Also, the prevalence of OPLL and OLF in DISH patients was investigated. RESULTS: The overall incidence of DISH was 24.4% (40 of 164 cases). There was no case of DISH in patients in their 40s and younger. The percentile incidences of DISH in patients in their fifth, sixth, seventh, eighth, and ninth decades were 20.0% (4 of 20 cases), 32.3% (10 of 31 cases), 40.0% (10 of 25 cases), 34.5% (10 of 29 cases), and 27.3% (6 of 22 cases), respectively. A strong positive correlation between the age decade and the incidence of DISH was noted (r = 0.853, p = 0.007). DISH patients had higher incidences of OLF (22.5%) and OPLL (37.5%). The most common location of DISH was the middle thoracic spine (90.0%) followed by the lower thoracic spine (87.5%). There was one case of DISH involving only the cervical spine. CONCLUSIONS: The incidence of DISH diagnosed by CT was higher than we expected. Whole spine CT can be a valuable modality to evaluate the location of DISH in the cervical and lumbar spine and the comorbidity rates of OLF and OPLL.

Mycobacterium Tuberculosis in Spinal Tuberculosis.

Even in an era of remarkable medical advances, there is an issue of why tuberculosis remains in the list of disastrous diseases, afflicting humans and causing suffering. There has not been a plausible answer to this, and it has been suggested that clinicians and medical scientists could presently not win the war against the tubercle bacilli. With regards to this issue, based on the authors' own clinical and research experiences, in this review, the available literature was revisited in order to address the raised questions and to provide recent information on characteristics of tubercle bacilli and possible ways to more effectively treat tuberculosis.

Analysis of Sacrococcygeal Morphology in Koreans Using Computed Tomography.

BACKGROUND: The sacrococcygeal morphology of Arabs and Europeans has been studied using computed tomography (CT) or magnetic resonance imaging to determine the cause of coccydynia. Studies have suggested differences in sacrococcygeal morphology among ethnic groups. However, there are no data on the sacrococcygeal anatomy of Koreans. METHODS: We conducted a retrospective analysis of 606 pelvic CT scans that were taken at Cheju Halla General Hospital between 2008 and 2014. Fractures of the sacrum or coccyx were excluded. Differences in the sacrococcygeal morphology among age groups stratified by decade of life and between genders were analyzed using sagittal plane pelvic CT scans. The morphological parameters studied were the sacral and coccygeal curved indexes, sacrococcygeal angle, intercoccygeal angle, coccygeal type, coccygeal segmental number, and sacrococcygeal fusion. RESULTS: The average sacral and coccygeal curved indexes were 6.15 and 7.41, respectively. The average sacrococcygeal and intercoccygeal angles were 110° and 49°, respectively. Type II coccyx was most common, and the rate of sacrococcygeal fusion was 34%. There was a moderate positive correlation between age and the sacral curved index (r = 0.493, p = 0.000) and a weak negative correlation between age and the coccyx curved index (r = -0.257, p = 0.000). There was a weak negative correlation between age and the intercoccygeal angle (r = -0.187, p = 0.000). The average intercoccygeal angle in males and females was 53.9° and 44.7°, respectively. CONCLUSIONS: The sacrum tended to be more curved and the coccyx straighter with age. The coccyx was straighter in females than males. Knowledge of the sacrococcygeal anatomy of Koreans will promote better understanding of anatomical differences among ethnicities and future studies on coccydynia.

Age-Related Incidence of Cervical Spondylosis in Residents of Jeju Island.

STUDY DESIGN: Cervical spine radiograms of 460 Jeju islanders. PURPOSE: To investigate the age-matched incidences and severity of the cervical disc degeneration and associated pathologic findings. OVERVIEW OF LITERATURE: Several related studies on the incidences of disc and Luschka's and facet joint degeneration have provided some basic data for clinicians. METHODS: Cervical radiographs of 460 (220 males and 240 females) patients in their fourth to ninth decade were analyzed. Ninety patients in their third decade were excluded because of absence of spondylotic findings. RESULTS: Overall incidence of cervical spondylosis was 47.8% (220 of 460 patients). The percentile incidences of spondylosis in the fourth, fifth, sixth, seventh, eighth and ninth decade was 13.2% (10 of 76 patients), 34.6% (37 of 107 patients), 58.9% (66 of 112 patients), 58.8% (50 of 85 patients), 70.3% (45 of 64 patients) and 75.0% (12 of 16 patients), respectively. The percentile incidences of one, two, three, four and five level spondylosis among 220 spondylosis patients was 45.5% (n=100), 34.1% (n=75), 15.0% (n=33), 4.5% (n=10), and 0.9% (n=2). Severity of disc degeneration ranged from ± to ++++, and was ± in 6.0% (24 segments), + in 49.6% (198 segments), ++ in 35.3% (141 segments), +++ in 9.0% (36 segments) and ++++ in 0.25% (one segment). Spurs and anterior ligament ossicle formed at the spondylotic segments, mostly at C4~6. The rate of posterior corporal spurs formation was very low. Olisthesis and ossification of the posterior longitudinal ligament were rarely combined with spondylosis. Cervical lordotic curve decreased gradually according to the progress of severity of spondylosis. CONCLUSIONS: The incidence of cervical spondylosis and number of spondylotic segments increase, and degeneration gradually becomes more severe with age.

Radiological Assessment of the Effect of Congenital C3-4 Synostosis on Adjacent Segments.

STUDY DESIGN: Retrospective case series. PURPOSE: To assess the effect of non-kyphotic aligned congenital C3-4 synostosis on the adjacent segment in 10 patients. OVERVIEW OF LITERATURE: In the cervical spine, fusion disease at the adjacent motion segments may be a risk factor for potential neurological compromise and death. METHODS: Radiograms of 10 patients 13 to 69 years of age presenting with neck/shoulder discomfort or pain with or without trauma history were examined. C3-4 synostosis was found incidentally in all patients on routine examination radiographs of cervical spine. RESULTS: Adjacent segment disease (ASD) was not found in the three patients younger than 39 years of age. Five of the 10 (50%) patients, including a 67-year-old man, did not develop spondylosis in any of the cervical mobile segments. Spondylosis was observed only in the caudal 1-2 mobile segments in the remaining five patients. The youngest was a 40-year-old male who had spondylosis in the two caudal mobile segments (C4-5 and C5-6). Spondylosis was limited to the two close caudal mobile segments and was not in the cranial segments. Flaring of the lower part of synostotic vertebra associated with advanced narrowed degenerate disc was evident in five patients. CONCLUSIONS: Mobile segment spondylosis in the individuals with congenital monosegment C3-4 synostosis over age of 40 years may be a natural manifestation of aging and is not solely an adjacent segment disease directly and fully related with congenital C3-4 synostosis.

Radiographic Assessment of Effect of Congenital Monosegment Synostosis of Lower Cervical Spine between C2-C6 on Adjacent Mobile Segments.

STUDY DESIGN: A prospective radiographic study of cervical spine with congenital monosegment fusion. PURPOSE: To evaluate the effect of cervical synostosis on adjacent segments and the vertebral morphology. OVERVIEW OF LITERATURE: There are numerous clinical studies of adjacent segment disease (ASD) after monosegment surgical fusion. However, there was no report on ASD in the cervical spine with congenital monosegment synostosis. METHODS: Radiograms of 52 patients, aged 5 to 90 years, with congenital monosegment synostosis (CMS) between C2 and C6, who complained of neck/shoulder discomfort or pain were studied. 51 were normally aligned and one was kyphotically aligned. RESULTS: Spondylosis was not found in the patients below 35 years of age. Only 12 out of 24 patients with normally aligned C2-3 synostosis had spondylosis in 19 more caudal segments, and only one at C3-4. A patient with kyphotic C2-3 had spondylolysis at C3-4. In 8 patients with C3-4 synostosis, spondylosis was found in only 9 caudal segments (4 at C4-5, 4 at C5-6, and 1 at C6-7). The caudate C4-5 disc was the most liable to degenerate in comparison with other caudate segments. Caudal corporal flaring and inwaisting of the synostotic vertebra were the features that were the most evident. In 2 of 9 C4-5 and 7 out of 10 C5-6 synostosis patients, spondylosis was found at the two adjacent cephalad and caudate segments, respectively. Only corporal inwaisting without flaring was found. In all cases, spondylosis was confined to the adjacent segments. More advanced spondylosis was found in the immediate caudal segment than the cephalad one. CONCLUSIONS: It is concluded that spondylosis at the mobile segments in a synostotic spine is thought to be a fusion-related pathology rather than solely age-related disc degeneration. Those data suggested that CMS definitely precipitated the disc degeneration in the adjacent segments.

Surgery-related complications and sequelae in management of tuberculosis of spine.

STUDY DESIGN: Medical record-based survey. PURPOSE: To survey the overall incidence of the intra- and postoperative complications and sequelae, and to propose the preventive measures to reduce complications in the spinal tuberculosis surgery. OVERVIEW OF LITERATURE: There is no study focused on the surgery-related complications and sequelae, with some touching lightly on the clinical problems. METHODS: There were 901 patients in this study, including 92 paraplegics. One hundred eighty-six patients had no visible deformity, while those of 715 patients were visible. Six hundred fifty-nine patients had slight to moderate non-rigid kyphosis, and 56 had severe rigid kyphosis. Sixty-seven out of 92 paraplegics had slight to moderate non-rigid kyphosis, and 25 had severe kyphosis. There were 134 cervical and cervicodorsal lesions, 518 thoracic and thoracolumbar lesions, and 249 lumbar and lumbosacral lesions. Seven hundred sixty-four patients had primarily anterior surgeries, and 137 had posterior surgeries. Instrumentation surgery was combined in 174 patients. RESULTS: There were intra- and postoperative complications: direct large vessel and neurological injuries (cord, roots, nerves), late thrombophlebitis, various thoracic cavity problems, esophagus and ureter injuries, peritoneum perforation, ileus, wound infections, stabilization failure, increase of deformity and late adjacent joint and bone problems. Thrombophlebitis and sympatheticolysis symptoms and signs in the lower limbs were the most common complications related with anterior lumbar and lumbosacral surgeries. Kyphosis increased in 31.5% of the non-instrumented anterior surgery cases (42% in children and 21% in adults). CONCLUSIONS: The safe, effective and most familiar surgical procedure should be adopted to minimize complications and sequelae. Cosmetic spinal surgery should be withheld if functional improvement could not be expected.

Preoperative nutritional status of the surgical patients in Jeju.

BACKGROUND: To assess the preoperative nutritional status of patients with various disorders and to provide data for pre- and postoperative patient management plans, particularly in the elderly. There is no published information on age-matched and disease-matched preoperative nutritional/immunologic status for orthopedic patients, especially in the elderly, in Jeju. METHODS: In total, 331 patients with four categories of orthopedic conditions were assessed: 92 elective surgery patients, 59 arthroplasty patients, 145 patients with fractures, and 35 infection patients. Malnutrition was defined as body mass index (BMI) below 18 kg/m(2) of expected body weight (below 20% of normal), serum albumin/globulin ratio below 1.5 (normal range, 1.5 to 2.3), albumin level below 3.5 g/dL, total lymphocyte count below 1,500 cells/mm(3), and lymphocyte/monocyte ratio below 5 versus 1. RESULTS: In 92 elective surgery patients, the average BMI was 23 kg/m(2), hemoglobin was 15 g/dL, lymphocytes (2,486 cells)/monocytes (465 cells) ratio was 6.1, and the albumin (4.4 g/dL)/globulin (2.5 g/dL) ratio as a protein quotient was 1.7. Among the 59 hip and knee arthroplasty patients, the average BMI was 25 kg/m(2), hemoglobin was 12 g/dL, lymphocytes (2,038 cells)/monocytes (391 cells) ratio was 6.6, and albumin (4.1 g/dL)/globulin (2.4 g/dL) ratio was 1.6. No subject showed malnutrition. Among the 145 fracture patients, the average BMI was 23 kg/m(2). The hemoglobin level was 13 g/dL, monocytes (495 cells)/lymphocytes (1,905 cells) ratio was 1 versus 4.6, and albumin (4.1 d/gL)/globulin (2.5 d/gL) ratio was 1.6. However, both ratios decreased after 70 years of age. Among the 17 of 35 infection patients, albumin levels were below 3.5 g/dL, the average BMI was 22 kg/m(2), lymphocytes (1,532 cells)/monocytes (545 cells) ratio was 2.4 versus 1, and albumin (3.0 g/dL)/globulin (3.3 g/dL) ratio was 0.9, while in 18 patients albumin levels were over 3.5 g/dL, the average BMI was 22 kg/m(2), hemoglobin was 12 g/dL, lymphocytes (1,998 cells)/monocytes (583 cells) ratio was 3 versus 1, and albumin/globulin ratio was 1.4. Thus, in the infection group, approximately 50% of the patients showed poor nutrition and immunosuppression. CONCLUSIONS: It was found that nutritional and immune condition deteriorated gradually to some degree in elderly patients over 60 years of age.

Tuberculosis of the trochanteric bursa: a case report.

Tuberculous trochanteric bursitis is rare. We report on a 48-year-old man with a huge gravitational abscess in the thigh secondary to tuberculosis of the trochanteric bursa.

Tuberculosis of spine: current views in diagnosis and management.

Tuberculosis is the chronic consumptive disease and currently the world's leading cause of death. Tuberculous spondylitis is a less common yet the most dangerous form of skeletal tuberculosis. The recent re-emergence of Mycobacterium tuberculosis (M. tuberculosis) hints at a possible resurgence of tuberculosis in the coming years. This article discusses the clinical manifestations, diagnosis and treatment of tuberculous spondylitis, and updates material that the author has previously published on the subject. Treatment should be individualized according to different indications which is essential to recovery. A treatment model is suggested on the basis of the author's vast personal experiences.