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Study Design: We studied the changes of the adjacent-level after performing anterior cervical interbody fusion. Objectives: We retrospectively analyzed the radiologic changes such as the degenerative changes and osteophyte formation in the adjacent-level and the affecting factors that affect the changes of the adjacent level after anterior cervical interbody fusion. Summary of the Literature Review: We studied the patients who were more than sixty years old and who had more degeneration at the time of operation and who developed symptomatic new disease within the first four years after their procedure. When the interbody spacer was shortened by 10% to simulate subsidence, the plate lost nearly 70% of its load-sharing capabilities. Materials and Methods: All the patients were treated with a plate and an autoiliac bone graft. We reviewed the correlation between the changes in the adjacent level and the factors that included gender, age, the fused segments, the plate-to-disc distance, the preoperative degenerative changes in the adjacent level, subsidence of the graft bone, the height of the graft bone, fracture and dislocation, and loosening of the implant. Results: Radiologic changes in the adjacent-level were seen in 35 cases and these cases included 27 cases in the upper level and 17 cases in lower level. Adjacent level changes were seen in 27 of the 37 (73%) patient who were above 50 years old. Adjacent level changes were seen in 19 (90.5%) of the 21 cases that had preoperative cephalad level degeneration, and adjacent level changes were seen in 9 (81.8%) of the 11 cases that had preoperative caudal degeneration. Adjacent level degeneration developed or increased in the cases of subsidence of a graft over 2 mm. Conclusions: The patients who undergo anterior cervical interbody fusion need to be continuously followed up because radiologic changes can increase in the case with degenerative change in the adjacent segment and subsidence of the bone graft of more than 2 mm.

Study Design: This is a retrospective study. Objectives: We analyzed the radiological and clinical results to verify the efficacy of anterior interbody fusion with using cages gradually increases in the treatment of cervical radiculopathy. Summary of the Literature Review: Anterior cervical decompression and fusion is well accepted treatments for cervical radiculopathy. Performing anterior interbody fusion using cages has recently gradually increased to minimize the extent of surgery. While there are numerous reports on the primary stabilizing effects of the cervical cages, little is known about the subsidence behavior of such cages in vivo. Materials and Methods: We retrospectively analyzed 38 patients with cervical disc herniation who underwent anterior decompression and interbody fusion with autoiliac bone graft and plate fixation (Group I, 21 patients) or who underwent with standalone cage (Group II, 17 patients). We statistically analyzed the changes of the cervical lordosis, the segmental lordosis, the vertebral body height, the fusion rate on the plain x-ray and the clinical results with using a pain visual analogue scale. Results: All the cases were fused by 11.2±2.7 weeks after operation. The changes of the cervical lordosis and segmental lordosis show no statistically significant difference between the two groups (p=0.07, 0.66). The anterior and posterior vertebral heights of the fused segments of group II were more decreased than those of group I, but there was no statistically difference between the two groups (p=0.06, 0.30). The clinical results were not statistically difference between the two groups (p=0.64, 0.45). Conclusions: Implantation of autoiliac cancellous bone impacted stand-alone cages or on a tricortical iliac crest autograft after anterior decompression was safe and reliable options for the treatment of cervical disc herniation that causes single level radiculopathy. Both procedures produced equally satisfying clinical and radiological results, leading to a high fusion rate and they maintained the intervertebral height.

Study Design: This is a retrospective analysis Objectives: We wanted to analyze the risk factors related to deep infection and removing an implant after thoracic and lumbar spinal arthrodesis. Summary of literature reviews: The relationship between deep infection and implant removal is controversial. Materials and Methods: We retrospectively compared the infection group with the non-infection group for the rates of deep infection, the preoperative diagnosis, the number of fused segments, the operative methods, the graft materials, the operating time and the blood loss. Moreover, we classified the deep infection patients into two groups: those who underwent implant removal and those who did not, and we compared the microorganisms that were cultured out of the patients. We also compared the relationship of deep infection with the risk factors, the mean hospital stay and the mean number of operations. Results: There were 18 cases (2.46%) of deep infection. The factors that did not show a significant difference were the preoperative diagnosis, the graft material, the increased number of fused segments, age, gender and BMI. The factors that were significant were the operating time (p=0.001), the amount of blood loss (p<0.000), DM (p=0.021), and PLF (p=0.054). The incidence of implant removal was higher for the cases with deep infection caused by MRSA. We were able to see a significant difference of between the group that had undergone implant removal and the group that had not undergone implant removal. Conclusions: The incidence of deep infection after thoracic and lumbar spinal athrodesis increased as the operating time and blood loss increased, and it was also higher when either PLF or DM were present. Implant removal causes bad clinical results, so physicians should be very cautious when operating on a case of implant removal.

Study design: A randomized, controlled study Objectives: We wanted to investigate whether osteogenesis can be enhanced when a small amount of demineralized bone matrix (1 cc/segment) is mixed with local bone chips. Summary of the Literature Review: Demineralized bone matrix (DBM) has been used for spinal arthrodesis. However, there are only a few reports about its use as a composite graft with local bone chips for posterior lumbar interbody fusion Materials and Methods: Degenerative spine patients, who would normally be treated by decompression and posterior lumbar interbody fusion with using a pedicle screw system and one cage, were randomly, prospectively selected for whether they would be treated with using local bone chips mixed with 1cc of DBM (Group I: 15 patients and 19 segments) or local bone chips (Group II: 12 patients and 13 segments) for graft material. The sampling bias was investigated for gender, age, endocrine diseases, previous operation, habits (alcohol drinking, smoking), steroid medication, bone mineral density and the amount of local bone. The amount of bone formation was measured at 6 months after operation. On the sagittal and coronal reconstruction CT images, the bone formation outside of the cage was measured, and this was interpreted in a “blinded”fashion by 2 independent doctors who did not take part in the operations. Results: There was no sampling bias between the 2 groups except for age (Group I= 65.3±7.1, Group II=58.9±6.0, p=0.010). The ratio of local bone chips and DBM was 5.98:1 in Group I. There was moderate concurrence between the 2 interpreters (kappa coefficiency= 0.494, p<0.001 for the sagittal plain images and kappa co-efficiency=0.467, p<0.001 for the coronal plain images) and Group I showed significantly more bone formation (p=0.003). Conclusion: DBM that is mixed with local bone chips, even with small amount, enhanced bone formation in the posterior lumbar interbody fusion. This is regarded to act as a graft enhancer to increase the fusion rate, even when using local bone chips for graft material, for the cases that show unfavorable conditions for fusion or for the cases that are prone to loosening of hardware.

Study Design: This is a retrospective study Objectives: The coronal MR images were carefully evaluated to document the efficacy of diagnosing foraminal and extraforaminal disc herniations. Summary of the Literature Review: Extraforaminal disc herniations constitute 1~11.7% of all disc herniations. The diagnosis of it demands great caution because it must be distinguished from intraspinal canal disc herniation. Diagnosing extraforaminal disc herniations can be neglected with using ordinary diagnostic methods. Materials and Methods: A retrospective analysis was performed on 24 patients, (26 cases) that underwent lumbar spine MRI, with the T2 coronal images, for the evaluation of disc herniations from March 2006 to March 2007. Every MRI image of each patient who had foraminal or extraforaminal disc herniations was graded according to the Pfirrmann’s classification of diagnostic efficacy by two spinal surgery specialists and two radiology specialists. Results: There were 13 cases of foraminal disc herniation and 13 cases of extraforaminal disc herniation in all 26 cases that were diagnosed by MRI. The coronal and axial images were more effective than the sagittal images for the discrimination of a compressed root. Especially, for the extraforaminal disc herniation, all of the coronal images were graded as grade 3; on the other hand, all of the sagittal images were not helpful for the assessment and the axial images were graded as grade 2 for 38.5% of the and as grade 3 for 61.5%. So, the coronal images were most effective for making the diagnosis of extraforaminal disc herniation and this was statistically significant (p<0.05). Conclusion: For the accurate discrimination of the location and the grading of foraminal and extraforaminal disc herniation, MRI, and especially the coronal images, is an effective and useful method in addition to conducting a physical examination.

Study Design: This is a retrospective study. Objective: We wanted to analyze the treatment outcome and the risk factors for adjacent segment disease after lumbar fusion. Summary of Literature Review: Biomechanical alterations likely play a primary role in causing adjacent segment disease. Radiographically apparent, asymptomatic adjacent segment disease is common after lumbar fusion, but this does not correlate with the functional outcomes. Materials and Methods: We reviewed 544 patients who underwent lumbar fusion at a minimum of 5-year follow-up between March 1993 and August 2006. Risk factors analysis was performed for 48 of 544 patients with adjacent segment disease and who were needed a second operation, and the treatment outcomes were assessed for 46 patients with a minimum 1-year follow- up after the second operation. The average interval to the second operation was 4.5 years, and the average follow-up after the second operation was 34.5 months. The treatment outcome was assessed by using the modified Brodsky criteria and the reoperation rate was assessed in relation to several risk factors. Results: Excellent and good operative results were obtained in 29 cases (63%) and bony fusion was achieved in 41 cases (89%). Of the risk factors we examined, multi-level fusion, a high grade of initial radiographic degeneration, the loss of physiologic lumbar lordosis and the involvement of degenerative scoliosis were associated with a high reoperation rate, with statistical significance. Age, gender, the initial diagnosis, the upper placement of the proximal screws and the extent to the sacrum were not correlated with the reoperation rate. Conclusion: The treatment outcome was relatively satisfactory; however, the factors influencing the treatment outcome of the second operation still need to be considered. The fusion level, the initial radiographic degeneration, the preservation of lumbar lordosis and the involvement of degenerative scoliosis are considered to be risk factors for the failure of lumbar fusion.

Study Design: This is a retrospective study that focused on the perioperative complications when performing posterior arthrodesis for treating degenerative lumbar disorders in elderly patients. Objectives: We wanted to analyze the perioperative risk factors and the complications associated with posterior lumbar decompression and arthrodesis in patients who were sixty-five years of age or older. Summary of the Literature Review: Lumbar arthrodesis is commonly done in elderly patients to treat degenerative spine problems. These patients may be at an increased risk for complications because of their age and their associated medical conditions. Materials and Methods: We studied 111 patients who were over 65 years old and they were able to be followed up for more than 3 months after performing posterior arthrodesis during the recent 5 years. Sixty-one patients who had undergone posterolateral fusion (PLF) were classified as group A, and 50 patients who had undergone posterior lumbar interbody fusion (PLIF) using a PEEK cage were classified as group B. We analyzed their rates of complications and the causative factors, according to operative methods and age, and these complications occurred within 12 weeks after the operations. Results: Complications occurred for 43 patients of group A, and for 26 patients of group B. The differences in the rates of complications were statistically significant, and group A had a more complications than did group B. The relations between medical problems and the incidence of perioperative complications were statistically significant for both groups. Conclusions: Elderly patients with medical problems should be made aware that they are at an increased risk for surgical com plications, and attention should be paid to controlling the blood loss and limiting the operative time. The PLIF using a PEEK cage was identified as a procedure that could reduce the perioperative complications.

Posterior epidural migration of sequestered lumbar disc fragments is an uncommon event. We present here an especially uncommon case involving a patient with paraparesis that was due to posterior migration of a ruptured disc in the adjacent segment after spinal fusion. The patient had a herniated lumbar disc in a diseased spinal junction with sequestered fragments that were located posterior to the thecal sac.

A spontaneous spinal epidural hematoma (SSEH) of the thoracic spine is a rare space-occupying disease that accompanied with severe axial pain in the spine. Because there is the possibility of a significant neurological injury such as paraplegia, SSEH requires careful diagnosis and management. A SSEH is mainly caused by a coagulating disorder or anticoagulant medication, while certain cases have shown that this disease is related with spinal inflammatory conditions. A SSEH tends to occur in patients who have risk factors for hemorrhage. However, the incidence of SSEH is quite low, and there are few domestic reports of a SSEH in young adults who are without the risk factors for hemorrhage. We encountered a 25 years old young male without a prior significant medical history and he was suffering from severe back pain and paraplegia due to a SSEH at the thoracic spine. The early diagnosis was made via MRI. We report here on a favorable clinical outcome that was achieved with immediate operative treatment, and we include a review of the relevant literature.

Spinal perineural cyst rarely appears in the upper lumbar spinal region as compared it occurrence at other spinal region. These cysts seldom cause radiating pain and neurologic symptoms because the majority of these cysts involve the sacral portion of the spine. Spinal perineural cyst can be recognized incidentally on magnetic resonance imaging while differentiating other diseases that cause back pain. The differential diagnosis of symptoms is needed to rule out whether or not the intraspinal cystic mass is the actual cause of radiculopathy. We report here on a case of perineural cyst at a left neural foramen of L2-3 and the patient displayed neurologic manifestations. The patient had progressively aggravated low back pain and sciatica of two years duration. MRI well demonstrated neural compression of the left 2nd lumbar neural root. Relief of symptoms were achieved by performing posterior decompression (hemilaminectomy, fascectomy & decompression of the ligamentum flavum), excision of the cyst and posterolateral fusion of L2-3.

Study Design: This is a literature review Objectives: We wanted to provide updated information for spine clinicians on the pathophysiology, medical treatment and the timing of surgical treatment after acute spinal cord injury. Summary of the Literature Review: There are many studies concerned with understanding the mechanisms of injury and improving the neurologic function after acute spinal cord injury. However, methylprednisolone therapy has been used only recently for the treatment of this malady. Materials and Methods: We conducted a literature review, with a particular focus on the development of pathophysiology and the emerging pharmacologic treatment of acute spinal cord injury, and on the effectiveness of performing early decompression. Results: After primary mechanical impact, a complex cascade of secondary injury follows during acute spinal cord injury. Neuroprotection and axonal regeneration are the main strategies to treat spinal cord injury. Beyond methylprednisolone, a number of other pharmacological treatments have been studied for the acute treatment of spinal cord injury. Animal studies support early decompression of the injured cord. Although there is no standard regarding the timing of decompression, there are many advantages of performing early decompression in human. Conclusion: Although a number of pharmacological therapies seem to have neuroprotective potential, high-dose methyprednisolone therapy is the only clinically approved treatment for acute spinal cord injury. Urgent decompression for acute spinal cord injury remains a reasonable practice option.