Primary headaches in children and adolescents - experiences at a single headache center in Korea.

BACKGROUND: Headache is a common complaint in children and adolescents. Recently, an increased prevalence of headache in children and adolescents has been reported. METHODS: We retrospectively reviewed the medical records of children and adolescents attending the Headache Clinic of Daejeon St. Mary's Hospital during the period from January 2005 through December 2016. RESULTS: The study population consisted of 2466 children, aged between 3 and 18 years (mean age: 10.9). Our study showed an increase in the number of patients visiting the hospital with headaches during the past decade. Compared with 2005, the number of patients with headache increased three-fold in 2016. Interestingly, the proportion of boys, preschool children, and other primary headaches revealed a steady and statistically significant increase. CONCLUSION: Due to a steady increase in pediatric headaches, the earlier the problem is recognized and properly diagnosed and a treatment plan is established, the greater the likelihood of a better lifelong outcome. Studies are needed to estimate recent trend in prevalence and to identify the demographic and socioeconomic factors predicting the occurrence of headache.

Congenital anomaly of the atlas misdiagnosed as posterior arch fracture of the atlas and atlantoaxial subluxation.

Partial or complete absence of the posterior arch of the atlas is a well-documented anomaly but a relatively rare condition. This condition is usually asymptomatic so most are diagnosed incidentally. There have been a few documented cases of congenital defects of the posterior arch of the atlas combined with atlantoaxial subluxation. We report a very rare case of congenital anomaly of the atlas combined with atlantoaxial subluxation, that can be misdiagnosed as posterior arch fracture.

Minimally invasive transforaminal lumbar interbody fusion for spondylolisthesis and degenerative spondylosis: 5-year results.

BACKGROUND: Multiple studies have reported favorable short-term results after treatment of spondylolisthesis and other degenerative lumbar diseases with minimally invasive transforaminal lumbar interbody fusion. However, to our knowledge, results at a minimum of 5 years have not been reported. QUESTIONS/PURPOSES: We determined (1) changes to the Oswestry Disability Index, (2) frequency of radiographic fusion, (3) complications and reoperations, and (4) the learning curve associated with minimally invasive transforaminal lumbar interbody fusion at minimum 5-year followup. METHODS: We reviewed our first 124 patients who underwent minimally invasive transforaminal lumbar interbody fusion to treat low-grade spondylolisthesis and degenerative lumbar diseases and did not need a major deformity correction. This represented 63% (124 of 198) of the transforaminal lumbar interbody fusion procedures we performed for those indications during the study period (2003-2007). Eighty-three (67%) patients had complete 5-year followup. Plain radiographs and CT scans were evaluated by two reviewers. Trends of surgical time, blood loss, and hospital stay over time were examined by logarithmic curve fit-regression analysis to evaluate the learning curve. RESULTS: At 5 years, mean Oswestry Disability Index improved from 60 points preoperatively to 24 points and 79 of 83 patients (95%) had improvement of greater than 10 points. At 5 years, 67 of 83 (81%) achieved radiographic fusion, including 64 of 72 patients (89%) who had single-level surgery. Perioperative complications occurred in 11 of 124 patients (9%), and another surgical procedure was performed in eight of 124 patients (6.5%) involving the index level and seven of 124 patients (5.6%) at adjacent levels. There were slowly decreasing trends of surgical time and hospital stay only in single-level surgery and almost no change in intraoperative blood loss over time, suggesting a challenging learning curve. CONCLUSIONS: Oswestry Disability Index scores improved for patients with spondylolisthesis and degenerative lumbar diseases treated with minimally invasive transforaminal lumbar interbody fusion at minimum 5-year followup. We suggest this procedure is reasonable for properly selected patients with these indications; however, traditional approaches should still be performed for patients with high-grade spondylolisthesis, patients with a severely collapsed disc space and no motion seen on the dynamic radiographs, patients who need multilevel decompression and arthrodesis, and patients with kyphoscoliosis needing correction. LEVEL OF EVIDENCE: Level IV, therapeutic study. See the Instructions for Authors for a complete description of levels of evidence.

Surgical outcomes of minimally invasive transforaminal lumbar interbody fusion for the treatment of spondylolisthesis and degenerative segmental instability.

STUDY DESIGN: This is a retrospective case study. PURPOSE: This study was designed to analyze the surgical outcomes of patients who underwent minimally invasive transforaminal lumbar interbody fusion (TLIF) for the treatment of spondylolisthesis and degenerative segmental instability. OVERVIEW OF LITERATURE: If the surgical outcomes of a procedure are evaluated together with multiple indications, it is not clear how the procedure helped each subgroup of patients. For the reason that some indications achieve better outcomes than the others, we performed a subgroup analysis using validated outcome measures to demonstrate the optimal indications and the treatment results of TLIF. METHODS: We conducted subgroup analyses by comparing the prospectively collecting data from the consecutive patients who underwent single-level minimally invasive TLIF for the treatment of the following 3 subgroups of indications: 23 cases of low-grade spondylolytic spondylolisthesis, 24 cases of degenerative spondylolisthesis, and 19 cases of degenerative segmental instability. RESULTS: The average duration of follow up was 36.1 ± 9.9 months (range, 24 to 63 months). The preoperative pain and disability scores were significantly improved at final postoperative follow-up in all the subgroups (all measurements: p < 0.0001). The 3 subgroups exhibited an equivalent improvement of the pain and disability scores at the final follow-up. The rates of radiographic solid fusion and complications were also similar among the 3 groups. CONCLUSIONS: Our data suggests that minimally invasive TLIF optimally and equivalently alleviates all of the associated symptoms and disabilities from low-grade spondylolisthesis and degenerative segmental instability. Furthermore, these patients seem to have optimal surgical indications for minimally invasive TLIF, while maintaining favorable surgical outcomes.

Percutaneous placement of pedicle screws in overweight and obese patients.

BACKGROUND CONTEXT: In obese patients, placing pedicle screws percutaneously is a particular challenge. As the bulky and thick configuration of obese patients may produce fuzzier fluoroscopic view and longer passage of surgical instruments, the chances of misplacement might increase. PURPOSE: This study was designed to evaluate the effect of patient's body habitus on the incidence of percutaneous pedicle screw misplacements. STUDY DESIGN/SETTING: A retrospective study with prospectively collecting data. PATIENT SAMPLE: Three hundred seventy percutaneous pedicle screws for minimally invasive lumbar spinal fusion surgery were noted in 89 consecutive patients. OUTCOME MEASURES: The position and direction of screws to pedicle were evaluated using the findings in computed tomography (CT) scan with the following grading method: Grade A, completely in the range without pedicle cortex violation; Grade B, pedicle wall violation <2 mm; Grade C, pedicle wall violation 2 to 4 mm; and Grade D, pedicle wall violation >4 mm. The direction of violation was grouped as medial, lateral, cranial, and caudal. METHODS: Two independent observers retrospectively examined all of the postoperative CT images. All screws were assigned into one of the following three groups along with patient's body mass index (BMI): 157 screws (38 patients) in normal weight (BMI<25) group; 124 (29) in overweight (25≤BMI<30) group; and 89 (22) in obese (BMI≥30) group. A pedicle screw was considered misplaced if the grade was defined as B, C, and D. Multivariate logistic regression analyses were performed to evaluate the association between screw misplacements and BMI. RESULTS: Sixty-two screws (16.8%) were misplaced with the majority of Grade B (72.6%, 45/62) and lateral direction (72.6%, 45/62). Twenty-eight screws (22.6%, 28/124) were misplaced in overweight group, 12 (13.5%, 12/89) in obese group, and 22 (14.0%, 22/157) in normal weight group. Two symptomatic pedicle violations were noted with Grade D: a caudal violation was found in overweight group, which happened in the third case of surgeon's series; a medial misplacement, which was occurred in the 29th case, was noticed in obese group. There was no statistically significant association of pedicle violations along with patient's BMI (odds ratio [OR]=1.00, 95% confidence interval [CI]=0.94-1.07, p=.99). Moreover, no other factors, such as patient's age, gender, preoperative diagnosis, number of the fused segments, and year of the surgery, had a statistically significant relationship with pedicle violations. On the contrary, pedicle violations observed approximately five times more frequently at the level of L3 (47.1%, 8/17) and L4 (28.8%, 36/125) rather than L5 (10.1%, 16/158) and S1 (2.9%, 2/70) (OR=4.95, 95% CI=2.62-9.33, p<.0001). CONCLUSIONS: Although symptomatic pedicle violations were noted in the earlier period of surgeon's learning curve and in overweight and obese patients, no statistical evidence could be found between patient's body habitus and percutaneous pedicle screw misplacement. Our data also suggest that greater caution should be exercised to avoid pedicle violations especially at L3 and L4.

Cranial facet joint violations by percutaneously placed pedicle screws adjacent to a minimally invasive lumbar spinal fusion.

BACKGROUND CONTEXT: Protecting cranial facet joint is a modifiable risk factor that may decrease the incidence of adjacent segment disease after lumbar spinal fusion. Percutaneously instrumented screws may more frequently violate cranial facet joints because of the potential limitation of screw entry site selection. To our knowledge, however, there is no study that has evaluated the cranial facet joint violations adjacent to minimally invasive lumbar fusion related to percutaneously placed pedicle screws. PURPOSE: We investigated the incidence and relating factors of cranial facet joint violations by percutaneous pedicle screws. STUDY DESIGN/SETTING: A retrospective study of prospectively collecting data. PATIENT SAMPLE: The sample comprises 184 pedicle screws percutaneously placed at the cranial fusion segments in 92 patients who underwent minimally invasive lumbar spinal fusion. OUTCOME MEASURES: The facet joint violations adjacent to a cranial fusion segment were examined on the postoperative computed tomography (CT) scans. METHODS: Two independent observers retrospectively examined all the postoperative CT images. A facet joint was considered violated if any of the following situations were encountered: pedicle screw clearly within the facet joint; pedicle screw head clearly within the facet joint; and pedicle screw and/or screw head within 1 mm from or abutting the facet joint, without clear joint involvement. RESULTS: The incidence of the violations was 50% (46/92) of all patients and 31.5% (58/184) of all screws, which were significantly higher than the previously reported rates with the traditional open procedure (50% vs. 23.5% of all patients, p<.001; 31.5% vs. 15.2% of all screws, p<.001). The violations occurred approximately 3.3 times more frequently at the most cranial pedicle screws of L5 pedicle than at the other pedicles (70.8% vs. 42.6%, odds ratio [OR]=3.3, p=.021). Logistic regression analysis revealed a significant trend toward reducing the incidence of the violations as increasing the year of surgery (OR=0.7, p=.008). The incidence showed no significant relationships with patients' age, gender, body mass index, preoperative diagnosis, the number of fused segments, or the side of screw placement. CONCLUSIONS: Our data raise a concern about the higher incidence of cranial facet joint violations by percutaneously placed pedicle screws than that previously reported rates by traditionally instrumented screws. Furthermore, more care should be taken to avoid cranial facet joint violations when the surgeon is a novice to percutaneous pedicle screw placement and/or minimally invasive fusion surgery is considered at the L5-S1 segment.

The effect of a radiographic solid fusion on clinical outcomes after minimally invasive transforaminal lumbar interbody fusion.

BACKGROUND CONTEXT: The correlation between radiographic solid fusion and favorable clinical outcome has not been fully established. Many surgeons believe that patients who achieve a radiographic solid fusion will exhibit a more positive clinical outcome than those getting an unsuccessful fusion. To our knowledge, there is no study that has evaluated whether a solid fusion influences clinical outcome after minimally invasive lumbar fusion. PURPOSE: This study was designed to evaluate the effect of radiographic solid fusion on clinical outcome after minimally invasive transforaminal lumbar interbody fusion (TLIF). STUDY DESIGN: We conducted a retrospective study by comparing the prospectively collecting data. PATIENT SAMPLE: The sample comprises 66 patients who had achieved a solid fusion or nonunion at least 2 years after minimally invasive TLIF for the treatment of low-grade spondylolisthesis or degenerative segmental instability. OUTCOME MEASURES: The outcome measures were visual analog scale (VAS) for back pain and radiating leg pain, Oswestry Disability Index (ODI), functional scale (defined as a modified method of Whitecloud et al.), and radiographic fusion status. METHODS: Two independent spine surgeons reviewed the completed medical records and radiographic data of 66 patients who had undergone minimally invasive TLIF by one surgeon at an institution. Clinical outcome was evaluated using VAS, ODI, and functional scale. The radiographic fusion status was assessed using flexion-extension lateral radiographs and computed tomography scans. Comparison and correlation analyses were performed to examine the relationship between fusion status and clinical outcome. RESULTS: There were 51 (77%) patients in the solid fusion (control) group and 15 patients in the nonunion group. The improvement from baseline with regard to VAS scores for back and leg pain as well as ODI scores was significant in both groups (all, p<.0001), with patients in the control group reporting significantly better improvement of back pain scores than those in nonunion group (p=.04). Conversely, the improvement of VAS scores for leg pain and ODI scores was comparable between two groups. Forty-one patients (80%) in the control group and 13 (87%) in the nonunion group demonstrated an excellent or good result in the final functional scale as well. The presence of radiographic solid fusion positively, but not strongly, correlated with the improvement of VAS scores for back pain (r=0.255, p=.039). CONCLUSIONS: At least 2 years after minimally invasive TLIF, better reduction of back pain was noted in patients who achieved a radiographic solid fusion as opposed to those with nonunion. However, there was no clear evidence that radiographic solid fusion was associated with better clinical outcome scores or improvement in leg pain than nonunion.