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Study Design: An experimental animal study. Objectives: To create a more appropriate disc degeneration model which shows how Interleukin 1α may induce the activation of metalloproteinases within the nucleus pulposus. Summary of Literature Review: There are few disc degeneration models wherein there is activation of metalloproteinases within the nucleus pulposus without structural destruction of the intervertebral disc. Materials and Methods: Three consecutive intervertebral discs in New Zealand White Rabbits were exposed. Each disc was injected with 0.1ml of saline (Saline group), 0.1ml of 1μg/ml (IL-1 group), 0.1ml of 10μg/ml (IL-10 group) of IL-1α through a 30-gauge needle. The lumbar spine was harvested 12 weeks after operation. We then analyzed radiographic findings and histological changes. Results: There was no difference in the radiological disc height index among the three groups; 0.071 in saline group, 0.045 in IL-1 group and 0.058 in IL-10 group (p=0.194). The histological cellularity of the nucleus pulposus revealed a decrease in the number of cells (p=0.0001,1.42 in saline group vs. 3.00 in IL-10 group; p=0.001, 2.00 in IL-1 group and 3.00 in IL-10). The histological matrix of the nucleus pulposus was 1.42 in saline group and 2.42 in IL-10(p=0.007), which meant that there had been condensation of the extracellular nucleus pulposus matrix. Conclusions: The results of this study demonstrate that interleukin-1α may contribute to degradation of the nucleus pulposus. This is useful for future study into the effects of the cytokine inhibitor on matrix regeneration and cellularity in the nucleus pulposus in intervertebral disc disease.

Study Design: A retrospective study. Objectives: To evaluate the clinical and radiological outcomes of anterior cervical fusion within Harms cage versus an iliac bone block graft. Summary of Literature Review: There is no current consensus regarding the optimal material for anterior cervical fusion. Materials and Methods: This was a single-center study of 107 patients who either underwent anterior cervical fusion with an iliac bone block graft (n=56; group A) or a cancellous bone graft within the cervical Harms titanium cage (n=51; group B). Anterior plating occurred in all cases. Clinical outcomes and complications were evaluated using Visual Analogue Scale (VAS) scores and Odom’s Criteria. Radiological outcomes were evaluated by the height of vertebral bodies, sagittal lordosis, the rate of bony union, and the subsidence of cage. Results: The VAS of donor site pain was significantly higher in group A than in group B at the final follow-up. Sagittal lordosis was increased in both groups, but was significantly higher in group B than group A. The rate of bony union was 95% and 91% for both groups 6 months after surgery and reached 100% for both groups at the final follow-up. In terms of cage subsidence, the highest point of subsidence was at the inferior and posterior aspect of the cage and the average amount of subsidence was approximately 1.3 mm at final follow-up. Conclusions: Anterior cervical fusion using a cancellous bone graft within Harms titanium cage is a good method for anterior cervical fusion with iliac bone block.

Study Design: A retrospective study. Objectives: To evaluate the effectiveness of unilateral extrapedicular approach in the treatment of osteoporotic compression fracture,as compared to transbipedicular approach. Summary of Literature Review: There has been no comparative study assessing this topic. Materials and Methods: 115 patients presenting with percutaneous vertebroplasty between Mar. 2002 and Feb. 2009, were divided into three groups: Group A (43 vertebrae; 29 patients) who were treated with bipedicular approach, Group B (66 vertebrae; 47 patients)treated with early cases of unilateral extrapedicular approach, and Group C (43 vertebrae; 39 patients) treated with late cases of unilateral extrapedicular approach. We analyzed radiological test results including the volume of injected cement and the distribution of intravertebral body, cement leakage, height restoration and kyphosis correction. Statistical analysis was done using SPSS. Clinical results were analyzed using VAS scores. Results: The mean follow-up period varied from one year at minimum to seven years and six months at maximum. The mean volume of injected cement was 3.39cc/5.39cc/3.79cc for groups A, B and C respectively. Cement leakage was at 13.4/34.8/12.8% in each group. Cement leakage was higher in group B, but most leakage took place in early cases that we tried to inject more and more cement in early inexperienced period. Bilaterally well distributed cement in the vertebral body was at 85.7/76.9% in groups B and C respectively. VAS scores improved from 8.4/8.3/8.5 preoperatively to 2.0/2.0/1.6 postoperatively. Conclusions: Percutaneous vertebroplasty treated with unilateral extrapedicular approach can lessen perioperative operating

Study Design: This is a retrospective study. Objectives: We will discuss clinical outcomes of adult traumatic atlantoaxial rotatory subluxation (Fielding type I) and verify the correlation between the clinical outcomes and radiological reduction rate. Summary of Literature Review: Atlantoaxial rotatory subluxation which usually occur in children by non-traumatic sources or minor trauma has been discussed persistently. However, studies of atlantoaxial rotatory subluxation which occur in adults over 20 years old,especially by traumatic injury is rare. Materials and Methods: From October 2004 to April 2011, thirty patients diagnosed of traumatic atlantoaxial rotatory subluxation with 6 months follow-up period were enrolled in the study. After diagnosis, we started treating Halter traction with 5 lbs. We discontinued traction when the patient recovered over 90% of ROM and applied Philadelphia collar to the patient. We measured visual analogue scale (VAS) for cervical pain and ROM. We measured atlanto-dens interval (ADI) and lateral mass-dens interval (LDI) difference using threedimensional computed tomography (3D-CT) to validate radiological reduction rate. Results: At the end of follow-up, none of the patients complained over pain and all recovered to full ROM. ADI was in normal range during the whole treatment period. LDI difference gradually decreased during treatment period, however, only 8 cases (26.7%) came back to normal range. Conclusions: In traumatic atlantoaxial rotatory subluxation (Fielding type I), satisfactory clinical outcomes such as pain relief or ROM improvement using traction and the radiological reduction rate was also improved but it failed to achieve a complete reduction of LDI difference in radiography.

Study Design: Comparative study. Objectives: To compare the outcomes of unilateral TLIF, bilateral TLIF using Wiltse approach and bilateral TLIF using conventional midline approach. Summary of Literature Review: There are many studies about outcomes of Unilateral TLIF, but few have compared the 3 different fusion procedures. Materials and Methods: 60 patients were divided into 3 groups. Each group has enrolled 20 patients (Study group: unilateral TLIF,Control group 1: bilateral TLIF using Wiltse approach, Control group 2: bilateral TLIF using conventional midline approach). For clinical outcomes, we compared operative time, blood loss, time for ambulation and discharge, VAS for back pain and leg pain and ODI among three groups. For radiologic evaluation, disc height and segmental lordosis were examined. Results: The mean operative time was 147 minutes in study group(SG), 172 minutes in control group 1(CG1), 167 minutes in control group 2(CG2). The mean total blood loss was 466ml in SG, 569ml in CG1, 1140ml in CG2 respectively. VAS for back pain at the third postoperative day significantly decreased in SG and CG1 compared with CG2. There was no significant difference in ODI, disc height and segmental lordosis among the groups. Conclusion: Using Wiltse approach, there were several advantages in decreasing blood loss, immediate postoperative back pain,hospital stay and early ambulation. Clinical and radiological results of unilateral TLIF were comparable with bilateral TLIF.

Study Design: A retrospective study. Objectives: This study analyzed the clinical and radiographic results of the posterior lumbar interbody fusion performed on patients 50–65 and >7-years-of-age suffering from degenerative lumbar disease. Literature Review Summary: Several studies on posterior lumbar interbody fusion performed on patients aged about 65 years reported insignificant age-related differences in the spinal-fusion results. Materials and Methods: The records of 121 patients with degenerative lumbar disease treated with posterior lumbar interbody fusion between 2004 and 2010 were assessed. The patients’ clinical results, visual analogue scale (VAS) scores, Oswestry disability index (ODI)values, and complications before and after the surgery were compared. The radiographic results and changes in the fusion segmental angle before and after the surgery as well as in the height of the posterior intervertebral disc were also compared. Results: In group A, comprising 44 patients >70-years-of-age, follow-up duration and number of comorbidities were 73.3 years and 17.8months, respectively. In group B, comprising 77 patients 50–65-years-of-age, follow-up duration and number of comorbidities were 58.8years and 31.8 months, respectively. In both groups, the average VAS scores and ODI values decreased. The incidence rate of vertebrarelated postoperative complications was 13.6% in group A and 9.0% in group B. The incidence rate of general complications unrelated to the vertebra, was 18.1% in group A and 9.0% in group B. Conclusions: Posterior lumbar interbody fusion is considered effective even in patients over 70 years with a degenerative lumbar disease.

Study Design: A radiographic study of normal subjects. Objectives: To analyze sagittal spinal parameters according to the size of pelvic incidence (PI). Summary of Literature Review: There has been no previous study about the classification of spinopelvic parameters that has used a large cohort of asymptomatic older men with the same ethnic background as those in the current study. Materials and Methods: We examined 160 males aged over 50 without disease, trauma, or history of operation on spine or lower extremities. Sagittal standing radiographs of the whole spine on 36-inch film were taken. Group 1 (n=30) had a PI of less than 40°. Group 2 (n=71) had PI between 40° and 50°, and group 3 (n=59) had a PI greater than 50°. Thoracic kyphosis, thoracolumbar kyphosis, lumbar lordosis, the vertebral slope of T12, sacral slope, and pelvic incidence were measured. The distances from the plumb line of C7, T12, and the lumbar apex to the posterosuperior corner of the sacrum were also measured. Results: Subjects’ average age was 64.1(53~83).Lumbar lordosis, sacral slope and pelvic tilt were all significantly increased in group 3. Thoracic kyphosis and the vertebral slope of T12 were not different between groups. The distances from the plumb line of C7, T12, and the lumbar apex to the posterosuperior corner of the sacrum were significantly translated anteriorly in group 3. Conclusions: Group 3, who had the largest PI, demonstrated the largest lumbar lordosis and the most forward transition of trunk. However there were no differences in thoracic kyphosis and the vertebral slope of T12 among the three groups.

Study Design: A retrospective study. Objectives: To evaluate the three-plus year follow-up results of patients who underwent posterior lumbar interbody fusion with PEEK cage and pedicle screw fixation for lumbar degenerative disease. Summary of Literature Review: There are few previous reports addressing posterior lumbar interbody fusion using PEEK cage with mid-term follow up periods. Materials and Methods: 260 patients who underwent posterior lumbar interbody fusion with PEEK cage and pedicle screw fixation for lumbar degenerative disease were enrolled. We classified patients into three groups according to their fusion level: group A (n=151) had one-level fusion, and group B (n=91) had two-level fusion, and group C (n=18) had three-level fusion. Clinical outcomes were evaluated by pre- and post-operative Visual analogue scale (VAS) scores, the Oswestry Disability Index (ODI), and complication and reoperation rates. Radiologic outcomes were measured by the fusion rate, sagittal alignment, disc height and changes. Results: VAS (pre-operative to final follow-up) changed from 7.62±2.03 (5-10) to 3.19±1.94 (1-8) in group A, from 6.83±2.28(4-9)to 4.51±2.18(2-9) in group B and from 7.17±2.46 (5-10) to 4.63±1.97(1-9) in group C. Final follow-up ODI also decreased in group A (17.6±8.56%), group B (15.4±5.46%) and group C (24.7±7.46%). This corresponds to scores of 94.7% in group A, 92.3% in group B and 94.4% in group C. There were significant differences between preoperative, post-operative and final follow-up lumbar lordosis [p=0.042(group A), 0.036(group B), 0.045(group C)], segmental lordosis [p=0.036(group A), 0.039(group B), 0.047(group C)]. Reoperation was performed in patients 8 group A, 4 group B, and 1 group C, and there is no significant diffrence between groups. Adjacent segmental change was found in all reoperation patients, but showed no correlation with clinical results. Conclusions: Posterior lumbar interbody fusion with PEEK cage and pedicle screw fixation in lumbar degenerative disease showed excellent clinical results and fusion rates, regardless of patient fusion levels.

Study Design: A cross-section observational study. Objectives: To evaluate the current prescription patterns of non-steroidal anti-inflammatory drugs (NSAIDs) and gastrointestinal (GI) risk assessment in patients with lumbar spine disease. Summary of Literature Review: NSAIDs are commonly prescribed medications for lumbar spine disease patients. Since the rate of GI complication varies for each patient, identification of individual GI risks is a prerequisite to prevent such a complication. There are few reports about the GI risks in patients with lumbar spine disease who take NSAIDs. Materials and Methods: 2264 patients with lumbar degenerative spondylopathy who were taking NSAIDs were enrolled from May 2010 to September 2010. The Standardized Calculator of Risk for Event (SCORE) was used to measure patients’ GI risk factors. NSAID prescription patterns and GI protective agents were also investigated. Results: Being aged over 65 (1098 patients; 48.5%) and the presence of GI side-effects from NSAIDs (896 patients;,39.6%) were the most common risk factors. 31.9% and 5.8% percent of patients belonged to each of the high risk and the very high risk groups in GI risk factor analysis. The total prescription rate of gastroprotectants was 91.7% for all patients. However, the prescription rate of selective COX-2 inhibitors in the high risk group was low, and in 54.8% of patients who took COX-2 inhibitors there was GI discomfort. Conclusions: The prescription pattern of GI protective agents was not correlated with GI symptoms. Therefore, physicians should consider NSAID prescription based on the GI risk factors of individual patients.

Study Design: A review of literature including definition, diagnosis and treatment of neuropathic pain. Objectives: To review and discuss the treatment guideline for neuropathic pain. Summary of Literature Review: Neuropathic pains are characterized by partial or complete somatosensory change caused by various disorders affecting central and peripheral nervous system, and are especially problematic because of their severity, chronicity and resistance to simple analgesics. Materials and Methods: Review of literature. Results: Tricyclic antidepressants and the anticonvulsants gabapentin and pregablin were recommended as first-line treatments for neuropathic pain. Opioid analgesics and tramadol were recommended as second-line treatments that can be considered for first-line use in selected clinical circumstances. Other medications such as dual reuptake inhibitors of both serotonin and norepinephrine would be used in severe cases. More invasive interventions (e.g., spinal cord stimulation) may sometimes be helpful. Conclusions: Treatment must be individualized for each patient and aggressive, combinatory pharmacotherapy and multidisciplinary approach are recommended for the treatment of neuropathic pain.

Study Design: A case report. Objectives: This case report presents a child who was treated conservatively after having being diagnosed with cervical intervertebral disc calcification. Summary of Literature Review: Cervical intervertebral disc calcification is considered as a degenerative change of spine. It is common in adults and in most cases, no symptoms are observed. In children, by contrast, it is a rare condition and frequently accompanies symptoms such as severe neck pain and dysphagia. Materials and Methods: A 7-year-old male patient who suffered from neck pain and torticollis without trauma had been diagnosed with cervical intervertebral disc calcification and was treated conservatively. He was discharged after symptom relief, and has been followed up and observed in our outpatient department. Results: The improvements of symptom and radiographic findings were found in the month follow up. Conclusions: Cervical intervertebral disc calcification shows similar symptoms to laryngopharyngeal abscess, traumatic injury and infective spondylitis, but through careful physical examination and radiologic evaluation, differential diagnosis is possible. After diagnosis, conservative treatment alone is sufficient. Antibiotic usage and surgical treatment are avoidable.

Study Design: A case report. Objective: We wanted to present the clinical manifestation and imaging findings of a rare case of acute sciatic nerve palsy with a foot drop similar to lumbar disc herniation developed after sleeping for 8 hours in a sitting position in inebriated condition. Summary of Literature Review: Sciatic nerve palsy as a complication from being operated in a sitting position have been reported, but here have not been any reported cases of after-sleep sciatic nerve palsy. Study Subject and Methods: Sixty eight year old male admitted to hospital due to acute onset of right foot drop, subsequent walking difficulty, and numbness of the right calf and foot. Symptoms began after 8 hours of sleeping in a sitting position. Pelvic MRI exam revealed sciatic neuropathy, and also electrophysiological exam revealed sciatic nerve palsy. Results: The subject patient’s conditions started improving after 6 weeks and he was able to walk again on his own. Conclusion: Sciatic nerve injury by prolonged pressure around the buttocks or posterior thighs, albeit rare, can develop and may cause foot drop, parethesia and sciatica.

Study Design: A case report. Objectives: To report a case of thoracic spinal meningioma and lumbar spinal schwannoma found in one patient. Summary of Literature Review: patients with different types of spinal cord tumor, specifically meningioma and schwannoma, are rare in medical literature. Materials and Methods: A 66 year-old female presented with complaints of walking difficulty. She had masses on the thoracic and lumbar spine and underwent open excision and biopsy. Results: Three months after operation, the patient could walk independently and no recurrence was found at 1-year follow up. Conclusions: Thoracic spinal meningioma and lumbar spinal schwannoma occurring in one individual were treated successfully by operative management.

Study design: A case report. Objectives: To document that Gelfoam®(Pharmacia & Upjohn, Kalamazoo, MI) contributes to granuloma formation and spinal cord irritation by immune response. Summary of Literature Review: The Gelfoam® or microfibrillar collagen applied during various operation for hemostasis. Some complications of Gelfoam®, such as mechanical cord compression, postoperative swelling and mass effect in closed cavity have been reported. Materials and Methods: The patient was underwent posterior decompression and instrumented posterolateral fusion under the diagnosis of the ossification of ligamentum flavum at T10-11 and T11-12. In operation, Gelfoam® was used at epidural space. She complained of sensory deterioration and muscle weakness around lower extremities after 10days postoperatively. A second operation was performed. Results: Postoperatively, the patient immediately improved motor grade except spasticity. She is under observation. Conclusion: Gelfoam® at epidural space after posterior decompression can result hyperactive immune reaction and irritate spinal cord.