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Objective: To evaluate the accuracy in determining the degree of lumbar spinal stenosis in patients utilizing lumbar spine magnetic resonance imaging (MRI) with axial loading as compared to conventional lumbar spine MRI with clinical correlation. To assess the difference in the dural cross sectional area (DCSA) between lumbar spine MRI with axial loading and conventional lumbar spine MRI. Materials and Methods: Thirteen patients with clinically diagnosed lumbar spinal stenosis, which comprised of three males and ten females, aged 20 to 80 years, and that had the severity of their stenosis clinically and radiologically graded by history taking, physical examination, and by performing both conventional and axial loaded MRI were included in this study. Results: The present study found a statistically significant difference (p<0.05) after applying load at all lumbar levels. The L4-L5 level showed the greatest reduction at 12.8%, followed by L3-L4 and L2-L3, in which the DCSA was reduced by 11.2% and 9.0%, respectively. Comparing the clinical severity and degree of each lumbar spinotic level and the maximum severity per person, the results showed that the most accuracy was at the L3-L4 level followed by L5-S1 and L2-L3 levels. No accuracy between clinical severity and the degree of lumbar spinal stenosis at L1-L2 and L4-L5 levels were shown, suggesting that more than the DCSA change influence the clinical severity. To gain further insights, following up patients and a study with more patients are needed. The maximum severity by D CSA measurement, both pre- and post-loading, of individual patients compared with clinical severity showed concordance for three patients. No significant difference in accuracy was found between pre- and post-loading. Conclusion: Changes in the DCSA of lumbar spinal stenosis after loading MRI was statistically significant especially at the moderate and severe stenotic levels particularly at the L3-4 level and L5-S1 level. [ABSTRACT FROM AUTHOR]

Objective: To evaluate the results of DLF in MDLS performed by a single experienced spine surgeon for both radiographic and clinical outcomes. Materials and Methods: The database of single-institution was retrospectively reviewed. To identify MDLS patients who had undergone DLF (> 2 levels) between 2007 and 2017. Clinical presentation, radiographic measurements, perioperative complications, and postoperative results were analyzed. The Oswestry disability index (ODI) and EuroQol five dimensions' questionnaire (EQ-5D-5L) were used to evaluate the outcomes comparing the preoperative and the most recent postoperative results. Results: In total, 84 patients (23 males and 61 females) were enrolled, with an average age of 64.4±8.6 (46-81) years old. Among these, 39 patients had fusion to L5 and 45 patients had fusion to the sacrum. Mean operative time was 66.9+23.4 minutes per level (range: 22.2-140) and the average length of stay was 10.7+5.7 days (range: 5-39). The mean estimated blood loss was 290.6+168.5 ml (range: 21.4-666.7). Average follow-up was 50.0+29.8 months (range: 0.5-124). The average preoperative ODI score was 60.6+16.3 (28-97.8) and 24.2+17.3 (0-71.1) postoperatively, while the average preoperative and postoperative EQ-5D-5L scores were 0.161+0.268 and 0.818+0.225, respectively. Both these clinical scores (ODI and EQ-5D-5L) showed a statistically significant improvement (p < 0.001). Finally, 13% (11/84) of patients had further surgery. Conclusion: Decompressive laminectomy and long spinal fusion performed in patients with multi-level deteriorating lumbar spinal stenosis are safe and effective in terms of the patients' quality of life and disability improvement. [ABSTRACT FROM AUTHOR]

Introduction: Intrathecal transplantation is a minimally invasive method for the delivery of stem cells, however, whether the cells migrate from the lumbar to the injured cervical spinal cord has not been proved in humans. We describe an attempt to track bone marrow-derived mesenchymal stem cells in a patient with a chronic cervical spinal cord injury.Case Presentation: A 33-year-old Thai man who sustained an incomplete spinal cord injury from the atlanto-axial subluxation was enrolled into a pilot study aiming to track bone marrow-derived mesenchymal stem cells, labeled with superparamagnetic iron oxide nanoparticles, from intrathecal transplantation in chronic cervical spinal cord injury. He had been dependent on respiratory support since 2005. There had been no improvement in his neurological function for the past 54 months. Bone marrow-derived mesenchymal stem cells were retrieved from his iliac crest and repopulated to the target number. One half of the total cells were labeled with superparamagnetic iron oxide nanoparticles before transplantation to the intrathecal space between L4 and L5. Magnetic resonance imaging studies were performed immediately after the transplantation and at 48 hours, two weeks, one month and seven months after the transplantation. His magnetic resonance imaging scan performed immediately after the transplantation showed hyposignal intensity of paramagnetic substance tagged stem cells in the subarachnoid space at the lumbar spine area. This phenomenon was observed at the surface around his cervical spinal cord at 48 hours. A focal hyposignal intensity of tagged bone marrow-derived stem cells was detected at his cervical spinal cord with magnetic resonance imaging at 48 hours, which faded after two weeks, and then disappeared after one month. No clinical improvement of the neurological function had occurred at the end of this study. However, at 48 hours after the transplantation, he presented with a fever, headache, myalgia and worsening of his motor function (by one grade of all key muscles by the American Spinal Injury Association impairment scale), which lasted for 48 hours.Conclusion: Intrathecal injection of bone marrow-derived stem cells at the lumbar spine level could deliver the cells to the injured cervical spinal cord. Transient complications should be observed closely in the first 48 hours after transplantation. Further study should be carried out to evaluate the result of the treatment. [ABSTRACT FROM AUTHOR]

Background: Microdecompression (MD) is a minimally invasive spine surgery for lumbar spinal stenosis (LSS). However, there was no long-term outcome study of this procedure in Thailand., Objective: The aim of this study was to evaluate the safety, complications, and surgical outcomes in Thai patients who underwent MD for LSS., Material and Method: A single-institution database was reviewed for Thai patients with LSS who underwent MD during the 2005 to 2014 study period. We analyzed demographic data and clinical data, intraoperative and postoperative data, and immediate complications. Oswestry Low Back Disability Index (ODI) and EQ-5D-5L were used to measure outcomes., Results: Seventy patients were enrolled (43 female and 27 male), with an average age of 64.1+10.6 years. Mean operative time was 99.5+31.6 minutes per level. Average length of stay was 5.2+2.8 days. Estimated blood loss was 90.5+65.6 ml. The most common level was L4-5. The average follow-up was 47.5+33.8 months. All postoperative patient-reported outcome measures were statistically significantly improved compared to preoperative measures (p<0.05). Average preoperative and postoperative ODI score was 60.8+20.6 and 15.9+15.7, respectively. Average pre-operative and postoperative EQ-5D-5L scores were 35.2+23.4 and 92.2+10, respectively. Immediate complications were found in 7 patients, including 5 incidental dural tear, 1 epidural hematoma, and 1 superficial wound infection. Late complications were found in 5 patients, including 1 cerebrospinal fluid leakage and 4 additional fusion surgeries. Of note, 14 patients had grade I degenerative spondylolisthesis (DS) before surgery although none of these patients complained of significant back pain. However, 3 of 4 cases that underwent additional fusion had pre-operative DS., Conclusion: Microdecompression surgery was found to be effective for treating patients with degenerative spinal stenosis. This procedure should be cautiously used in patients with spondylolisthesis, even in the absence of significant back pain.

Background: Bone marrow (BM), which is a good source of stem cells and biological factors, has the potential to enhance bone fusion. Simple centrifugation technique is one of the procedures used to concentrate BM aspirate for increasing number of cells. However, there are limited clinical study for using BM concentrate augmentation in spinal fusion., Objective: This study was designed to examine the spinal fusion enhancement effects of bone marrow (BM) concentrate augmentation on poster lateral lumbar fusion (PLF) with autologous local bone graft in terms of both quality and quantity, as compared with a control procedure without BM concentrate augmentation., Material and Method: Twelve patients with L4-L5 spondylolisthesis scheduled for PLF after decompressive laminectomy and pedicle screw instrumentation were included in this study. This prospective randomized controlled trial was conducted at Siriraj Hospital during the 2009 to 2012 study period. Patients were randomly assigned to two groups. One group underwent PLF with local bone graft with BM concentrate augmentation (BM group) and the other group underwent PLF with local bone graft only (non-BM group). Clinical outcomes were evaluated by the Oswestry Disability Index (ODI) preoperatively and at 3 and 6 months after PLF. Bone fusion quality was evaluated by bony bridging on 3D-CT imaging. Fusion mass volumes were measured on quantitative 3D-CT scans at 1 week and 6 months, postoperatively., Results: Clinical outcome scores did not differ between groups. Six-month postoperative 3D-CT imaging showed complete PLF bridging in 58.3% and 100% of patients in the BM and non-BM groups, respectively. PLF mass volumes were decreased at 6 months by 51.1% in the BM group and by 48.5% in the non-BM group. One patient in the BM group had local inflammation at the BM aspiration site., Conclusion: Bone marrow concentrate augmentation in this small randomized controlled trial failed to demonstrate positive effects on autologous local bone graft in posterolateral lumbar fusion relative to both quality and quantity. The high percentage of incomplete bridging should also be noted and further investigated.

Background: Cervical spinal cord injuries (SCI) are a major public health problem. Respiratory complications are among the most important causes of morbidity and mortality in patients with cervical SCI, especially respiratory failure. Based on our evaluation of the existing English language literature, few previous studies appear to have reported on risk factors associated with the need for mechanical ventilation in isolated cervical SCI patients who had no concomitant injuries or diseases at the time ofadmission., Objective: The purpose of this study was to determine incidence and riskfactors relating to the needfor mechanical ventilation in isolated cervical spinal cord injury (SCI) patients who had no concomitant injuries., Material and Method: This retrospective study was conducted by reviewing and analyzing the patient data of 66 isolated cervical-SCI patients who were admitted in our hospital between January 1995 andDecember 2009. Patient medical records were reviewed for demographic data, neurological injuries, needfor mechanical ventilation, definitive treatment, complications, and outcomes. Univariate and multivariate analysis were used to identify predisposing risk factors relating to patient dependency on mechanical ventilation., Results: Of the 66patients, 30.3% (20/66) required mechanical ventilation and 22.7% (15/66) were identified as complete cord injury, ofwhich seven sustained injury above CS. Of the patients with complete SCI, 66.7% (10/15) were dependent on mechanical ventilation, as were 85% (6/7) with SCI above C5. All five of the patients with complete-SCI above C5 who received operative treatment were dependent upon mechanical ventilation, postoperatively. Only 19.6% (10/51) of the incomplete injury group required mechanical ventilation. Univariate analysis indicated the following factors as significantly increasing the risk ofventilator dependence: complete SCI (p = 0.001), SCI above C5 level (p = 0.011) and operative treatment (p = 0.008). Multivariate analysis identified the following factors as being predisposing risk factors relating to the need of mechanical ventilation: complete SCI (OR: 12.8; 95% CI 2.4-66.9; p = 0.003), SCI above C5 level (OR: 12.0; 95% CI 2.4-60.2; p = 0.002), and operative treatment (OR: 14.8; 95% CI2.1-106.9;p = 0.008)., Conclusion: Complete SCI, SCI above C5, and operative treatment were predisposing risk factors relating to the need for mechanical ventilation in isolated cervical SCI patients. The data and findings put forth in this study suggest that these factors may assist in predicting the needfor mechanical ventilation as a long-term treatment for isolated cervical SCI patients.

Background: Pulmonary embolism (PE) is a serious condition in orthopedic surgery. The incidence of PE, which is a sequelae of VTE in spinal surgery, is quite low. In the limited available published data, incidence rates of PE in spinal surgery are comparable to that of hip or knee arthroplasty surgery. The role of pharmacologic thomboprophylaxis remains controversial in spinal surgery., Objective: The present study was designed to evaluate the incidence of symptomatic pulmonary embolism in spinal surgery at a single tertiary care institute., Material and Method: A retrospective study of the medical records of patients that were diagnosed with symptomatic pulmonary embolism in spinal surgery from 2002-2012. The reviewed data were retrieved from the database of the Faculty of Medicine Siriraj Hospital, Mahidol University in Bangkok, Thailand., Results: Three cases of symptomatic pulmonary embolism were found from 9,184 spinal surgery cases. The incidence rate was 0.033%. There were two patients with lumbar spine surgery and one case with thoracolumnbar surgery. All three cases had different underlying conditions, operations, and clinical course. One case of fatal pulmonary embolism was found in our study., Conclusion: Although there is a very low incidence of symptomatic pulmonary embolism, this is a catastrophic condition for affected patients and their families. PE can occur in spinal surgery cases at all levels of severity and complexity, even with no apparent risk factors.

Background: Core decompression has been recommended in treatment of non-traumatic femoral head necrosis in early stage. Injection with patient's own bone marrow from the iliac crest might promote bone formation in the femoral head., Objective: To evaluate the result of patients treated by this technique., Material and Method: Retrospective review of a series cases by the medical records and radiographic pictures., Results: There were 34 procedures from 32 patients. Mean follow-up time was 24.6 months in stage 2 and 27.8 months in stage 3. Radiographic progression was observed in 76% and 69% of stage 2 and 3. Twenty one percent of stage 2 hips underwent other surgeries when 46% of stage 3 did at last follow-up. Pain relief was observed in all cases after the surgery., Conclusion: The proposed technique yielded only fair results. Probably due to most patients had steroid related pathology.

Objective: To evaluate the postoperative analgesic effect and postoperative nausea and vomiting (PONV) after using epidural low-dose morphine-soaked microfibrillar collagen sponge (MMCS), as compared with placebo., Material and Method: A prospective randomized double-blind placebo-controlled study was performed on patients under-going single-level posterior lumbar spinal decompression and instrumented fusion at the Department of Orthopedic Surgery, Siriraj Hospital, between August 2012 and December 2013. Patients were randomly allocated into two groups to receive either an epidural MMCS or an epidural normal saline-soaked microfibrillar collagen sponge (placebo). Intensity ofpain, PONV and total amount of morphine were recorded at 4, 24, 48, and 72 hours, postoperatively., Results: The analgesic effect was enhanced significantly in the epidural MMCS group, as the amount ofmorphine used was statistically less than in the placebo group at 4 and 24 hours (p < 0.05)., Conclusion: A single low-dose epidural MMCS is effectiveforpain control after posterior lumbar spinal surgery with a low incidence of PONV.

Calcium pyrophosphate dihydrate (CPPD) crystal deposition disease is one of the most common forms of crystal-associated arthropathy in the elderly. However, cervical spine is rarely affected, especially in upper cervical area. There have been previous reported cases of symptomatic retro-odontoid CPPD deposition disease in English literature but this case is the first reported in Thai patients. This is a case report of a 67-year-old man who presented with neck pain with progressive myelopathy. Neurologic examination demonstrated a cervical myelopathy with muscle weakness and sensory disturbance of both extremities. Imaging studies showed extradural retro-odontoid mass compressing the spinal cord. The patient underwent occiput to C3 fusion with plating, posterior arch of atlas resection, transoral odontoidectomy, and mass removal. Histological examination of the mass revealed fibrocartilage tissue and rhomboid shaped crystals that showed positive biferingent in polarized light microscopy consistent with CPPD crystals. After surgery, no complication was found, and his neurological function had improved.

Background: Herniated nucleus pulposus (HNP) is a common cause of low back pain. The conventional technique could injure to the surrounding structures. The tubular retractor system (METRx-X tube, Medtronic, Inc, Minneapolis, USA) is instrument to improve visualization and limited soft tissue damage for minimal invasive lumbar discetomy., Objective: To evaluate the surgical outcomes, complications, reoperation rates and patient satisfaction for using tubular retractor system in lumbar disectomy in long term follow-up at least 4 years., Material and Method: Forty-five patients who had been operated for lumbar microdisectomy with tubular retractor system between Jan 2004-Dec 2007. Demographic data, ODI, VAS scores of back pain and leg pain were collected at the date of admission, 1st week, 1st month, 3rd month and every 6 months until 48 months follow-up., Results: Forty-two patients (26 males with average age 30.4; range 20-45 years, 16 females with average age 32.6; range 23-54 years) were included in the present study by excluding 3 loss follow-up patients. The average operating time with tubular retractor system was 90.5 (range 60-250) minutes.Average blood loss was about 45 (range 30-100) milliliters. Length of stay in the present study was about 4.6 days (2-10 days). The average size of incision was about 2.4 (range 2.0-3.5) centimeters. The average follow-up time of all cases was 4 years 7 months (4-7 years). The VAS score of back pain was significantly improved at 1st month post-operation (p < or = 0.05). The VAS score of leg pain was significantly improved at 1st week post-operation (p < or = 0.05). The ODI score was significantly improved at 1st month post-operation (p < or = 0.05). The complication rate was about 9.5% (4 patients) and the recurrent disc that need to re-operation rate was about 4.9% (2 patients)., Conclusion: The tubular retractor system has the advantage over the conventional open technique. The result of operation with the tubular retractor was satisfied by the surgeons and the patients. However, This system is quite expensive and need technological equipment. Besides experience of the surgeons, using tubular retractor system also should be carefully considered for the most benefit to the patients, the surgeons and budgets of the institute.

Background: Vertebroplasty is one of the minimally invasive surgery that benefit in pain relief from the osteoporotic or malignancy related vertebral compression fractures. However, many literatures reported both asymptomatic and serious complications. The aim of the present study was to summarize, collect data and report the complication ofvertebroplastyfrom our experience at a single institute., Material and Method: Three hundred and twenty five vertebroplasty procedures from 236 patients performed in our institute were retrospectively reviewed. Data of diagnosis, age at the time of procedure were collected. All complications found were reviewed in detail., Results: Commonly performed procedures were at thoracolumbar junction (51.4%). Osteoporosis was the most common cause of fracture. The present study found 88 (27%) complications with 26 (8%) symptomatic patients. Most common complication was cement leakage, which intervertebral disc was the most common site (42.9). Spinal canal leakage was found in 14 cases (20%). Four out of 14 cases had neurological complications and need further managements. Two cases had neurologic complications from needle injury.Adjacent level collapse found in 13 patients (4%) and remote segment collapse occurred in 5 patients (1.5%). Three had progressive kyphosis required later surgical treatment. One asymptomatic cement pulmonary embolism was found in the present study., Conclusion: The complications of vertebroplasty were mostly asymptomatic, but serious complication such as neurologic injury could occur. Vertebroplasty could be considered a quite safe treatment for osteoporotic vertebral fracture. Meticulous technique should be executed during the procedure to avoid the leakage complication.

Background: Osteonecrosis of the femoral head is a deficiency of blood supply resulting in femoral head collapse and joint destruction. This usually found in young adults as the leading cause of hip arthroplasty. Core decompression has been reported to reduce the bone marrow pressure for treatment of stage I and II of disease. Later, addition of concentrated bone marrow injection was proposed and reported good result. The purpose of the present study was to report the result of core decompression and concentrated bone marrow injection., Material and Method: Twelve patients with osteonecrosis of femoral head underwent a core decompression and concentrated autologous bone marrow injection. Data of age, sex, underlying disease, risk of osteonecrosis were collected. Patients were followed at 3 months, 6 months, 1 year and then yearly. Radiographic data were recorded., Results: Thirteen hips in 12 patients underwent the procedure. Two cases were excluded due to loss of follow-up. Mean age was 36.2 (12-56). One hip were in stage I, five in stage II and five in stage III. Risk factor included steroid usage in 6 hips and alcohol consumption in 3 hips. Underlying diseases were SLE (5), dermatitis (1), post-traumatic (1). Average nucleated cell from marrow was 91.58 x 10(6)/ml (+/- 55.9). CD34 was 17.25 x 10(6)/ml cells and percentage of recovery of mononuclear cell was 70.4%. Mean follow-up time was 3.6 years (range 1-7 years). All cases had good pain relief initially. At the last followup 8 hips (72%) had progression and 2 underwent surgery. No infection occurred. No adverse effect detected., Conclusion: This report showed low success rate of core decompression with concentrated autologous bone marrow grafting. The effect of delayed progression is not clear. However, the procedure appeared to be safe without immediate complication.

Objective: Establish the predictive value of magnetic resonance imaging (MRI) for cervical spondylotic myelopathy as being a good operative outcome., Material and Method: A retrospective study of the 52 consecutive patients with cervical spondylotic myelopathy underwent both magnetic resonance imaging (MRI) cervical spines examination at Siriraj Hospital between January 2005 and June 2007. Surgery was divided into two groups: "Good" operative outcome (35 patients) and "No improvement group" (17 patients). Two neuroradiologists independently identified the MR images data that showed the maximum stenosis on sagittal and axial sections and recorded predictive MRL parameters: T2-weighted signal change of the spinal cord, cross-sectional area of the spinal cord, anteroposterior (AP) diameter of the spinal canal and the spinal cord and AP-compression ratio (AP diameter/transverse diameter of the spinal cord)., Results: There were no statistically significant differences between both groups in all parameters., Conclusion: The AP-diameter of the spinal canal and spinal cord, AP-compression ratio and signal change of the spinal cord are not useful in predicting prognosis outcome in patients with cervical spondylotic myelopathy. In addition, cross-sectional area of the spinal cord cannot confidentially be used as predictive factor in CSM patients due to many influent factors of surgical outcome. A further prospective study without patient selective bias may offer more definite results to confirm these findings.

Objectives: To produce a knee model for medical students and residents to practice knee aspiration and intra-articular injection., Material and Method: The model was made of plastic, rubber and silicone that included the lower third of the femur, the upper third of the tibia and the patella. They were fixed on 2 plastic boxes in the anatomical position and the boxes were connected together with 2 small hinge joints. A rubber bag was made in the pattern of synovial space of the knee. Quadriceps, anterior muscles of the leg and patellar tendon were also presented. The model was covered with silicon sheet, representing the skin. Water was used to fill up the synovial bag to simulate joint aspiration via supero-lateral approach with the knee in extension. The model was appraised by 30 medical students, 26 orthopedic residents and 10 orthopedic staff in terms of size, anatomy, physical examination, feeling during aspiration, need of the model in education and commercial use., Results: Most of the medical students, residents and staff (80-90%) were satisfied with the model and rated it as good to very good teaching media. However, the model should come out in different sizes and the synovial bag should be modified to improve the ballotment test. Mass production of the model should be done., Conclusion: The knee model is an acceptable teaching model for arthrocentesis simulation with affordable cost.

A review was carried out on 59 patients (10 males and 49 females) who had anterior interbody fusion performed with femoral ring allograft packed with autograft bone chips with a minimum follow up of 2 years. The average age at the time of surgery was 49.1 year old (26 to 75). The total number of levels grafted was 141. The diagnosis consisted of multiple degenerative disease in 6, degenerative change below the long segment of fusion for scoliosis in 9, osteoporosis with collapsed fracture in 3, pseudarthrosis after posterior laminectomy and fusion in 35, congenital scoliosis in 3, scoliosis in 2 and paralytic scoliosis due to multiple sclerosis in one. The distribution of levels fused was T12-L1 in 6, L1-2 in 12, L2-3 in 17, L3-4 in 22, L4-5 in 35 and L5-S1 in 39. The remaining 10 levels were in the lower thoracic areas (T7-T12). The operations were performed as anterior fusion alone in 13 patients, one-stage anterior and posterior fusion in 26 patients and two-stage surgery in 20 patients. Anterior instrumentation was used in all 141 levels. At average follow-up (33.7 months) there was no significant change in allograft angles (average = 1.6 degrees ). Fusion of the allograft was classified by Bridwell's grading system. At 24 months of the follow up, 97 % of the allografts were in grade I (fully incorporated) and 3% were in grade II (partially incorporated). Compared to 12 months follow-up only 76.2% of the grafts were in grade I, 28 % were in grade II and 0.8% were in grade III. Two patients had deep posterior infections which required further surgery (without resorption of the allograft anteriorly). One patient had a screw migration anteriorly which required removal. Three patients had persistence of radiolucent line at one of the vertebral end plates - graft interfaces but no subsidence of the graft or pain. In conclusion, the femoral ring allograft appeared to benefit the anterior interbody fusion in complex spinal surgery.