KJC Korea
Journal Central

Study Design: Retrospective study. Objectives: To evaluate the effectiveness of microdiscectomy under local anesthesia in comparison with general anesthesia. Summary of Literature Review: No comparative studies regarding the outcomes of microdiscectomy under local and general anesthesia could be found in the literature. Materials and Methods: Between May 2000 and June 2004, 88 patients who underwent microdiscectomy under local anesthesia (n=50,local anesthesia group) or under general anesthesia (n=38, general anesthesia group) were selected and included in this study with a follow up period more than 3 years. The operation time and duration of hospital stay were documented. The Visual Analogue Scale (VAS)and the Oswestry Disability Index (ODI) were used to evaluate the degree of symptom relief. The patient satisfaction was evaluated using the MacNab’s criteria and postoperative complications. Results: Between both groups there is no significant operation time difference. However, the average hospital stay duration in the general anesthesia group was 7.3 days, while it was 4.7 days in the local anesthesia group (P<0.05). The VAS and ODI scores were improved in both groups. Thirty-two cases (84.2%) of the general anesthesia group and 40 cases (80%) of the local anesthesia group showed satisfied results by the MacNab’s criteria with no statistically significant difference (P>0.05). Three patients in the general anesthesia group and 7 patients in the local anesthesia group needed a reoperation. Conclusions: A microdiscectomy under local anesthesia shows faster recovery period. But it shows also a relative high revision rate. In patients with old age and underlying disease, local anesthesia can be used for the microdiscectomy selectively and careful exploration of the herniated disc is required.

Study Design: Retrospective study. Objective: To compare patients who underwent spinal revision surgery of adjacent segment degeneration with above one and above two vertebral segment preceded by initial spinal fusion surgery. Summary of Literature Review: The adjacent segment disease(ASD) occurs more frequently at the more proximal segment of the spinal fusion. Also, the preexisting degenerative segments (with discs or facet joints) not included in the fusion procedure, fusion segmental sagittal angle, fixed appliances method, gender, and age, have been accepted as the causes. Materials and Methods: The patients were watched over a year after the spinal revision operation followed by initial spinal fusion of single or multiple segments; the subjects were limited to 41 patients. The average age, entity of diseases, average duration between the initial spinal fusion and the revision surgery, multiple clinical and radiographic parameters were evaluated and compared. Results: Using the UCLA grade of intervertebral disc degeneration, the average grade of 1 level upper segment was 2.2 in group A and 1.9in group B without statistical significance(p=0.426). However, the average grade of 2-level upper segment was 1.8 in group A and 2.4 in group B with significant difference(p=0.021). There was no statistical difference in other factors between the two groups. Conclusions: Patients with ASD of above two-vertebral segment after spinal fusion were more severe in disc degeneration than those with ASD of above one vertebral segment before initial spinal fusions.

Study Design: Retrospective study. Objectives: To identify the implementation of self-exercise therapy and analyze the effects of exercise therapy after lumbar discectomy Materials and Methods: Studied 47 patients who underwent partial lumbar discectomy and laminectomy from January, 2009 to December, 2009. They were instructed on 16 kinds of exercise therapy in total from postoperative 1day to postoperative 6weeks. Group A (n=25), whose frequency of outpatient clinic visit is above the average, and Group B (n=22), whose frequency of visit is relatively low;,below 5 times. We tested the visual analog scale (VAS scale) of back, Oswestry disability index and the strength of the two groups before surgery and at postoperative 3, 6, and 12 months. Results: The degree of pain was significantly different (26.6±9.4 and 53.5±18.6) between group A and group B at postoperative 6months. Function of daily life and strength test were significantly different (6.6±4.8 and 11.3±4.0 at group A, 3.6±0.9 and 3.0±1.1 at group B) between the two groups at postoperative 12 months. The characteristics of low compliance patients are low accessibility to the hospital and lack of knowledge on the importance of exercise according to the degree of pain. Conclusion: These results suggested that postoperative exercise program has significant effects on the pain, the function of daily life. It also increases flexibility and strengthens the muscle of patients with high compliance of outpatient clinic visit. The factors influencing the results are the age of patients, the willingness to exercise, and the environment in which each patient lives/resides.

Study Design: Restrospective study. Objectives: We tried to find out the effects of minimal invasive anterior lumbar interbody fusion (ALIF) combined with posterior lumbar interbody fusion for degenerative lumbar flat back disease. Summary of Literature Review: ALIF combined with PLIF is effective in correcting lumbar lordosis. However, the complication rate with conventional ALIF is higher on the lower level. Materials and Methods: 21 cases (9 men and 12 women, 46-83 years of age) of having undergone minimal invasive ALIF and PLIF due to degenerative flat back disease were reviewed. The follow-up period was an average of 23 months. We compared the prepostoperative pain, the functional outcome, the correction of sagittal imbalance and lordotic angle. Results: At final follow-up, 21 cases with the solid fusion experienced a great improvement in their lower back pain(VAS: 7.3 → 2.6)and leg pain (VAS: 7.0 → 2.7) and ODI(38.5 → 18.1). And we experienced correction in sagital imbalance. On levels with anterior fusion,lordotic angle is corrected 6.3 degrees while on levels with posterior fusion, lordotic angle is corrected 9.7 degrees. Plumb line is corrected by 5.2cm, and no complication was found in the follow-up period. Conclusions: Combined surgery with minimal invasive anterior lumbar interbody fusion and posterior fusion is an effective procedure on patients who need long level surgery for correction of lumbar deformity and decompression.

Study Design: Retrospective study. Objectives: As we analyze the incidence and the risk factor for proximal junctional problem after surgical treatment of lumbar degenerative sagittal imbalance, we want to contribute to reducing the junctional problem of surgical treatment of lumbar degenerative sagittal imbalance. Summary of Literature Review: Surgical treatment of degenerative spinal deformity has increased. Rigid fixation was a risk factor for degenerative change of adjacent segment and failure, and it remains a big challenge for the junctional problem of surgical treatment. However, research on the correlation with risk factors is rare. Materials and Methods: Forty four patients (mean age 66.5; range, 50-74) who had surgery due to lumbar degenerative sagittal imbalance were evaluated by the risk factor associated with junctional problems from January, 2005 to December, 2011. The risk factors were analyzed by surgical factor (proximal fusion level, using iliac screw, correction or undercorrection of lumbar lordosis compared with pelvic incidence) and patient factor (age, bone marrow density, body mass index). Results: Junctional problems occurred in 18 patients (41%) out of 44 patients. Among these problems, there were 10 cases of fractures, 8 cases of junctional kyphosis, and 4 cases of proximal screw pull out. . Among the risk factors, only the correction or undercorrection of lumbar lordosis compared with pelvic incidence in surgical factor was statistically significant. Other surgical factors and patient factors were not statistically significant. Conclusions: Junctional problems after a surgical treatment of lumbar degenerative sagittal imbalance were common. However, we could not know the exact risk factor of junctional problems except the degree of correction of lumbar lordosis compared with pelvic incidence, because most of the risk factors were not statistically significant. So, further evaluations of the risk factor of lumbar degenerative sagittal imbalance are required.

Study Design: A retrospective study. Objectives: To find out the characteristics and the risk factors of adjacent vertebral compression fracture after percutaneous vertebroplasty. Summary of Literature Review: Percutaneous vertebroplasty is regarded as more effective treatment than conservative care, but additional fracture could cause complications during follow up. Materials and Methods: We analyzed 43 patients who had only one vertebral compression fracture after one vertebroplasty. The number of patients who had additional compression fracture within one level from the operated vertebra were 23 cases (Group I); beyond two levels from the operated vertebra were 20 cases (Group II). We compared the onset period of additional compression fracture, the degree of osteoporosis, age, level, restoration of vertebral body height and kyphosis between the two groups. Results: The onset period of additional compression fracture was 18.7±28.1 months in Group I and 42.7±39.4 months in Group II,showing significant difference between the two groups. Group I had more cases of previous vertebroplasty on thoraco-lumbar vertebra than Group II. The restoration rate of vertebral body height of Group I was 42.3±40.9% and that of Group II was 22.8±21.6%, which shows significant difference between the two. Conclusion: Adjacent vertebral compression fracture after vertebroplasty can occur earlier than non adjacent one. We need to pay attention to the patients who had higher restoration rate of vertebral body height after vertebroplsty as they are more prone to having additional adjacent compression fracture.

Study Design: A retrospective study. Objectives: Using computed tomography, it is to measure pedicle size of lower cervical spine in Koreas to find ideal insertion point and angle in fixating pedicular screws. Summary of Literature Review: Although techniques in pedicular screw fixation and pedicle’s anatomical shape in foreign populations have been well documented and studied, no anatomical study on lower cervical pedicle in Korean population has been reported. Materials and Methods: A total of 180 patients with computed tomography taken at our institution were selected for the study. Width,total length, and length of pedicle, insertion point and angle, and safe insertion angles were measured on axial view. On sagittal view,height of pedicle, insertion point and angle, and safe insertion angles were determined. Results: Mean height of study subject was 164.2cm. Mean width of pedicle was 5.5mm, mean height 7.2mm, mean total length 31.2mm,and mean length 14.8mm. Mean insertion point from 3rd to 7th cervical spines was medially 3.3mm from lateral mass and downward 4.7mm from margin of upper facet. Mean insertion angles from 3rd to 7th cervical spines were 41.6° axially and 6.4° sagittally. Calculated safe insertion angles were 8° on medial and lateral sides and 14° on superior and inferior sides. Conclusions: Using computed tomography images, ideal insertion point and angle were measured for pedicular screw insertion, but,due to individual variation, preoperative measurement of insertion point and angle on computed tomography is necessary.

Study Design: A prospective study. Objectives: To evaluate the effectiveness of ultrasound guidance in caudal epidural block and sonographic feature of sacral hiatus. Summary of Literature Review: High success rate of ultrasound-guided regional nerve block has been reported and recently, ultrasound-guided nerve block in spinal field has been introduced. Materials and Methods: Ultrasound-guided caudal epidural block was performed in 48 patients with radiating pain to leg. Patient was placed in the prone position and sonographic image of sacral hiatus was obtained using linear probe. After measuring the intercornual distance, thickness of sacrococcygeal membrane and depth of sacral canal in transverse view, then the probe was rotated 90° to obtain the longitudinal view of the sacral hiatus. Under ultrasound guidance, a 21-gauge needle was inserted into the sacral hiatus in parallel with sacrum base. After contrast dye injection, needle placement was checked by the fluoroscopy and then medication was injected into the caudal epidural space. We investigated the change of radiating pain after caudal epidural block using visual analogue scale(VAS). Results: The intercornual distance was mean 16.4±2.3mm, thickness of sacrococcygeal membrane was mean 2.8±0.9mm and depth of sacral hiatus was mean 2.6±0.9mm. There was 97.9% success rate of the caudal epidural block under ultrasound guidance. The mean VAS for radiating pain was improved from 7.5±0.7 before the block to 2.8±1.5 after the block. Conclusions: Ultrasound-guided caudal epidural block seems to provide good anatomical landmark of sacral hiatus and an effective tool with high success.

Study Design: A case report. Objectives: In patients with fracture-dislocation of the lumbar spine with neurologic deficit and hemodynamic instability, minimally invasive surgery made/produced good clinical results. So the authors have reported the results with literature review Summary of Literature Review: In patients with unstable lumbar spine fracture-dislocation, early surgical treatment has been preferred due to its many advantages of anatomical reduction, nerve decompression, recovery of nerve function, and early rehabilitation, etc. But for patients with unstable lumbar spine fracture-dislocation and who are hemodynamically unstable, the surgical treatment is generally delayed, so there are many cases that cannot fulfill the expectation of neurologic recovery. Materials and Methods: In patients with unstable lumbar 2-3 spine fracture-dislocation and who are hemodynamically unstable, applying the concept of stage operation, postural reduction and minimal invasive percutaneous pedicle screw fixation were conducted as soon as possible. Then after recover of general condition, decompression and posterior fusion were conducted as a second stage operation. Results: After the first stage operation, motor grade was improved from 3 to 4 below the L3 spine level in postoperative physical examination. The second stage operation was conducted two weeks later and neurologic symptom was more improved after the second stage operation. Conclusions: In patients with lumbar spine fracture-dislocation having hemodynamic instability and neurologic deficit, early minimally invasive fixation for reducing complications of open reduction and internal fixation may contribute to improving general conditions and recovery of neurologic deficits.

Study Design: Case report. Objectives: To report a case of preventive intubation to coronary artery disease patient who underwent percutaneous coronary intervention following an anterior cervical spine surgery Summary of Literature Review: Postpharyngeal hematoma occurs more to a patient who underwent percutaneous coronary intervention for myocardial infarction following an anterior cervical spine surgery. And postoperative airway obstruction due to it is one of the most serious adverse events associated with anterior cervical spine surgery. Preventive intubation was tried and it was useful for treatment. Materials and Methods: A 61-year-old man suffered from neck pain and radiating pain on left upper extremity was performed an anterior cervical spine surgery. After operation, he complained acute myocardial infarction symptoms and Emergency percutaneous coronary intervention was performed. After that, postpharyngeal hematoma appeared and compressed the airway. Intubation was performed to prevent airway obstruction. Result: Airway obstruction was prevented through early intubation. Hematoma evacuation and insertion of Hemovac performed and the patient discharged without any complications such as neurologic or cardiac problems. Conclusion: Preventive intubation to coronary artery disease patient who underwent percutaneous coronary intervention following an anterior cervical spine surgery is useful for treatment of airway obstruction due to postpharyngeal hematoma.

Study Design: A case report. Objectives: To investigate the outcomes of recapping laminoplasty for the treatment of atraumatic spinal interdural hematoma. Summary of Literature Review: There are several causes for a spinal hematoma. The occurrence of spinal hematoma is rare; in particular, the ones arising atraumaticaly are considered extremely rare. Materials and Methods: We studied a 33 year old male patient without any known risk factor. Magnetic resonance image has revealed an intraspinal epidural cyst compressing on the spinal nerve. After performing recapping laminoplasty, followed by partial excision of dura mater and resection of hematoma, we were able to observe another layer of dura mater, confirming the location of hematoma within two epidural layers, i.e., an interdural hematoma. Results: Performing recapping laminoplasty is a more effective and less invasive procedure for removing cyst than conventionally used laminectomy. Patients were found to have synostosis after three months post-op, and they have exhibited neither lumbosacral pain nor lower limb motor weakness after six months follow-up. There were no recurrences or complications reported on our study. Conclusion: There are a few reported cases of atraumatic spinal interdural hematoma. Our study shows that performing pars osteotomy with recapping laminoplasty yield good clinical outcome for the treatment of atraumatic spinal interdural hematoma.

Study Design: Case report. Objectives: To report a case of a giant intramuscular lipoma after a blunt trauma. Summary of Literature Review: Lipomas are the most frequent benign tumor of the mesenchymal tissue. Although the etiopathogenesis is not complete understood yet, it is known that lipoma develope with a 1% rate after traumas in the related localizations. Traumata induce hematoma and initiates inflammatory reactions in fatty tissue and can trigger the development of lipoma. Materials and Methods: 2 years after a blunt trauma a 56years male patient developed a back mass. A massive lipoma was confirmed clinical and radiological. Results: A total excision was performed and the result was histopathologic confirmed. Conclusions: Patients who develop hematoma after a trauma need a close lipoma progress observation which decrease the invasive treatment of post-trauma hematoma.

Study Design: A literature review. Objectives: To describe the causes and clinical characteristics of cauda equina syndrome. Summary of Literature Review: The cauda equina syndrome, complex symptoms and signs expressed as variable clinical manifestation, has rare incidence but needs attention since it can bring about serious complications and sequales if neglected. Materials and Methods: The Author reviewed articles reporting the causes and clinical manifestation of cauda equina syndrome. Results: There are marked inconsistencies in the current evidence base surrounding the definition due to various clinical presentation of cauda equina syndrome. Conclusion: As there is no symptom or sign which has an absolute diagnostic value in establishing the diagnosis of cauda equina syndrome, any patient in whom a clinical suspicion of cauda equina syndrome arises must undergo urgent magnetic resonance imaging for diagnosis.

Study Design: Review of literature on anatomical and pathophysiological features of cauda equina. Objectives: To look into the anatomical and pathophysiological features of cauda equina and support their basic knowledge of treating cauda equina syndrome. Summary of Literature Review: Cauda equina has different anatomical and pathophysiological features to peripheral nerve. Materials and Methods: Review of literature. Results: When compressing to cauda equina, the pathophysiologic mechanism develop as follows; increasing the vascular permiablity of nerve root, intraneural edema, and subsequent blood and nutritional impairment. Nerve root injury develops through this pathophysiologic mechanism. Conclusions: Cauda equina has an extensive ateriovenous anastomosis and guaze-like pia mater, which supply blood and neutrition to it. These anatomical features prevent it from complete cauda equina syndrome when compressing to it under arterial blood pressure.