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We report a case of a 66-year-old woman with progressing myelopathy. Her history revealed instrumented fusion from T10 to S1 for degenerative lumbar kyphosis and spinal stenosis. The plain radiographs showed narrowing of the intervertebral disc space with a gas shadow and sclerotic end-plate changes at T9-T10. Magnetic resonance imaging revealed a posterolateral mass compressing the spinal cord at the T9-T10 level. The patient was treated with a discectomy through the posterior approach combined with posterior instrumentation. The patient's symptoms and myelopathy resolved completely after the discectomy and instrumented fusion. The thoracic disc herniation might have been caused by the increased motion and stress concentration at the adjacent segment.

Study Design: A retrospective radiographic study. Purpose: To verify the correlation of sagittal and coronal plane changes after selective thoracic fusion in main thoracic (MT) adolescent idiopathic scoliosis (AIS). Overview of Literature: Sagittal plane deformity is known to be essential in the evolution of scoliosis. Methods: Twenty-eight MT AIS patients treated by anterior selective thoracic fusion were evaluated after minimal follow- up of two years. The unfused lumbar area was divided into proximal and distal parts by the lumbar apex in the coronal plane, and into proximal and distal lumbar lordosis by L2 in the sagittal plane. Surgical motion (the difference between pre- operative and postoperative values) and follow-up motion (the difference between postoperative and the last follow-up val- ues) were compared. Results: Immediately after surgery, as thoracic kyphosis increased, lumbar lordosis decreased (r=0.734); proximal lumbar lordosis increased, and distal lumbar lordosis decreased. The proximal lumbar area was mobilized in the sagittal plane, and was straightened in the coronal plane. However, the distal lumbar area was stabilized in the sagittal plane, and showed resistant motion against MT translation in the coronal plane. The surgical motion was correlated to the follow-up motion, i. e., was regulated during follow-up, and the regulatory motion was more precise in the distal than proximal lumbar area in both sagittal and coronal planes. Conclusions: Sagittal and coronal motions were co-related; optimal sagittal motions were necessary for optimal coronal motions after anterior selective thoracic fusion for MT AIS. Proximal and distal lumbar motions were different for different roles; the proximal lumbar area played a role as a bumper to absorb the MT translatory force, and the distal lumbar area played a role of resistance against MT translation.

Abstract - Study D Design: Retrospective risk-factor analysis Objectives: This study investigated the clinical and radiological risk factors associated with the progression of osteoporotic spinal fractures (OSFs) after conservative treatment. Summary o of L Literature R Review: Nonunion and cleft signs on radiographs are strongly associated with complicated osteoporotic spinal fractures. Materials aand M Methods: From Jan. 2005 to Dec. 2007, 84 patients (15 males and 69 females; mean 72.6 yrs) were enrolled in this retrospective review. The progressive OSF, clinical and radiological factors were analyzed considering the progression of the kyphotic angle (PKA>20� ) and the presence of intravertebral cleft signs (IVC). Age, gender, body mass index, vertebral level involved, BMD score, MRI classification and initial kyphotic angle were adopted for the analysis. For statistical analysis, a chi- square test was performed to analyze the relationship between each factor and multiple logistic regression analysis was per- formed to analyze the multifactorial explanatory factor. Results: The presence of IVC was related to the thoracolumbar fracture, mid-portion MR classification and high body mass index. PKA>20�was related to the thoracolumbar fracture and mid-portion classification. For multifactorial analysis using these seven factors, two factors (the level of fracture and MR classification) were found to be associated with the presence of IVC with statistical significance. In the thoracolumbar fracture, the incidence of IVC was 5.2 times higher than the other levels. The incidence of IVC in endplate classification was 16% lower than in the mid-portion. Conclusion: BMI, the fracture level involved and MR classification were associated with the development of IVC and PKA>20� for a conservative treatment of OSF. Multiple logistic analysis revealed the level of the fracture and MR classification to be significant.

Study Design: In vitro motility assays were carried out using rat intervertebral discs (IVDs). Objectives: To demonstrate the motile properties of the cartilage endplate (CE) chondrocytes and the effect of notochordal cells on this property. Literature Review: Although previous in vivo studies have provided evidence for the migration of CE chondrocyte from hyaline CEs into the notochordal nucleus pulposus (NP), it is unclear if CE chondrocytes of the IVD actually have motile properties. In addition, the effect of notochordal cells on these properties has not been reported. Materials and Methods: Notochordal cells and CE chondrocytes were harvested from three-month-old male Wistar rats and cultured separately. The motility was assayed in quadruplicate using a 48-well microchemotaxis chamber and a gelatin-coated 8-μm polycarbonate membrane filter. The control medium (serum-free culture medium), notochordal cells (4×, 2×, 1× and 0.5×10) and concentrated conditioned medium (10-, 50-fold) where notochordal cells were cultured were loaded into the wells of the lower chamber, and CE chondrocytes were added to the wells of the upper chamber. At the end of the assays, the CE chondrocytes that migrated to the bottom side of the membrane filter were stained, counted, and compared. Results: Compared with the control medium, the notochordal cells (N = 4×, 2×, 1× and 0.5×10) and concentrated conditioned medium (10and 50-fold) significantly increased the chemotactic motility of the CE chondrocytes in a numberand concentration-dependent manner (p�0.05). Conclusion: The CE chondrocytes of the intervertebral disc are motile, and soluble factors produced by notochordal cells induce the chemotaxis of CE chondrocytes.

Study Design: The ingrowth of the nociceptive nerve ending into intervertebral disc was examined using immunohistochemistry and quantified using western blotting. Objectives: To determine if the nociceptive nerve innervates into the intervertebral discs of internal disc disruption (IDD). Summary and Literature Review: Nociceptive nerve ending and vessel ingrowth into intervertebral disc is associated with IDD and HNP. Substance P is a neurotransmitter that is found in the nociceptive nerve endings. Immunohistochemistry has confirmed the presence, and western blot has isolated the target. The localization of novel nociceptive innervation, and a quantitative comparison was made according to the original pathology is of interest. Materials and Methods: 10 specimens of intervertebral disc were collected from IDD during total disc replacement surgery , and another 10 specimens of intervertebral disc from HNP were collected during discectomy. The control samples of intervertebral disc were obtained from 3 adolescent patients with idiopathic scoliosis, and 2 patients with a lumbar bursting fracture. Standard immunohistochemical techniques were used to test for the nociceptive neurotransmitter (substance P), which is a protein expressed during axonogenesis (growth-associated protein 43, GAP43), and a general nerve marker (protein gene produce 9.5, PGP9.5). The expression of substance P protein was quantified using western blot for its polyclonal antibody. Results: In IDD (n=10), substance P was expressed in 6 cases of outer annulus fibrosus (AF), 5 cases of inner AF, and 3 cases of nucleus pulposus (NP). In HNP (n=10), substance P was expressed in 4 cases of outer AF, 3 cases of inner AF, and 2 cases of NP. In the control group, only 2 cases expressed substance P in outer AF. GAP43 was only positive in outer AF as follows: IDD 3 cases, HNP 1 case, and control 1 case. None of the specimens showed localized PGP 9.5. Substance P was localized significantly in larger quantities in IDD than in the control group (p=0.002). In HNP, the expression level was larger than the control and lower than the IDD group but this was not statistically significant (p=0.158, p=0.108). Conclusions: Innervation of nociceptive nerve endings was identified at the degenerative intervertebral disc of IDD, which may contribute to back pain.

Purpose: This study was performed to investigate the differences in the expression of matrix metalloproteinase-3 in degenerative scoliosis compared with other degenerative disc disease of the spine. Materials and Methods: The intervertebral disc materials were obtained during discectomies. Six, 13 and 12 cases of herniated nucleus pulposus, spinal stenosis and degenerative lumbar scoliosis, respectively, were included in the experimental group. The expression of MMP-3 was evaluated three times that of the means, in the immunohistochemical staining, western blotting using anti human MMP-3 antibody and RT-PCR with MMP-3 primer, respectively Results: On the immunohistochemical stains, extensive and strong staining was noted in the discs of degenerative lumbar scoliosis compared to those with spinal stenosis and HNP. In the western blotting, greater expression of MMP-3 was noted in the discs of degenerative lumbar scoliosis (mean optical density: 20.68) than in other degenerative disc diseases (SS: 6.24, HNP: 2.0). In the RT-PCR, a similar result was shown (DLS: 62.1, SS: 27.4 & HNP: 10.4). There were statistically significant differences between degenerative lumbar scoliosis and degenerative disc disease (p

비 신경성 기원인 암의 경막내 경로를 통한 수질외 전 이는 거의 보고된 바가 없다. Frey 등은 전신성 종양의 전이되는 범위를 알아내기는 매우 어려우며, MRI 등을 시행하기 전에 이러한 상태를 알기는 더욱 어렵다고 주 장하였다. Mosdal과 Bang은 암세포들은 혈행성 전파와 신경주변의 림프절을 통해 척수와 지주막하 공간에 도 달한다고 하였다. 뇌척수액을 경유한 암의 전이는 이미 보고 되었으며, 그 경우의 대부분은 선행된 뇌 전이와 암종괴의 직접적인침습이 있는경우였다. 이에 저자들은 선행된 뇌 전이 없이 전이된 추체의 인 접 경막의 개구부로 직접 파종된 직장선종이 경막내 경 로를 통해 원격 수질외 부위로 전이되었던 환자 1례에 대한 치험을문헌고찰과 함께보고 한다. 대한척추외과학회지 제 12 권 제 1 호 Journal of Korean Spine Surg. Vol. 12, No. 1, pp 83~86, 2 0 0 5

Study Design: A Retrospective study Objective: To evaluate the results after an anterior decompression and fusion, with anterior instrumentation, using a Z-plate in osteoporotic vertebral fractures. Summary of Literature review: Despite conservative treatment, continuous severe pain, progressive neurological impairments and deformity may need surgical treatment in osteoporotic vertebral fractures accompanied with neurological deficit. Materials and Methods: Fourteen patients that had undergone anterior decompression and an autogenous iliac bone graft, with anterior internal fixation, between 1997 and 2001, under the diagnosis of an osteoporotic vertebral fracture, were reviewed. The chief complaints, severity of pain measured, using the Denis pain scale, fracture patterns, fracture level, changes of kyphotic angle (revised with sagittal index) and complications were analyzed. Results: Symptoms subsided completely in 5 patients, one case showed no definite improvement and 8 showed improved symptoms. The fracture levels included: 1 and 2 cases at the 11th and 12th thoracic spine, and 8, 1 and 2 in the 1st, 2nd and 3rd lumbar spine, respectively. 10 patients showed wedge type fractures, three a compression type and one a biconcave type. The average kyphotic deformity decreased 49.0% (50.9% when revised with sagittal index) after surgery, but the average loss of correction angle was 28.8% (26.0% when revised with sagittal index), compared with the immediate postoperative correction angle. The complications included: screw loosening and adjacent vertebral fractures in 3 and 4 patients, respectively. Two patients had the combined problem of screw loosening and an adjacent vertebral fracture. Conclusion: In anterior decompression and fusion, with instrumentation, for osteoporotic vertebral fracture treatment, the complications were primarily related, directly or indirectly, to the underlying osteoporosis. Complete neurological recovery occurred 9 of the 11 patients, but residual pain was common.

Study Design : A retrospective study of functional outcome after surgical correction of neuromuscular scoliosis. Objectives : To assess functional outcomes and their significances after the surgical correction of neuromuscular scoliosis. Summary of Literature Review : The surgical correction of neuromuscular scoliosis has been used to stabilize the trunk for balanced sitting, to improve cardiopulmonary function, and the function of the upper extremities. Many authors have reported favorable surgical results, but few studies have been undertaken on functional assessment after surgery. Materials and Methods : Eighteen adult patients with neuromuscular scoliosis underwent surgical correction. Functional assessments were performed in terms of impairments, disabilities, and handicaps. The impairments included sitting ability, coronal Cobb’s angle, pain after surgery, and cosmesis after surgery. The disabilities included dressing, feeding, toilet/bathing, locomotion, and the use of both hands, and the handicaps included the effort and time to care for patients. Each parameter was checked preoperatively, 6 months after surgery, and at the last follow-up. Results : In terms of impairments, sitting ability, coronal Cobb’s angle, pain, and cosmesis were improved by surgery. In terms of disabilities, dressing, toilet/bathing, and locomotion were not improved after surgical correction. However, the feeding and use of both hands were significantly improved. And, in terms of handicaps, both the effort and the time required for care were reduced post-surgically. Conclusions : We conclude that impairments, handicaps, and the functions of the upper extremities were improved after surgical intervention to stabilize the trunk and spine in cases of neuromuscular scoliosis, but that overall disabilities were unaffected. This latter apparent shortcoming is attributed to the inability of surgery to treat previous systemic disease affecting physical disabilities of lower extremities. However, surgical correction of neuromuscular scoliosis was found to be clinically significant in terms of improving the functions of the trunk and of the upper extremities.

Purpose : To report upon surgical outcome in terms of adjacent segment changes after lumbosacral fusion and to analyze for risk factors indicating early surgical intervention for adjacent segment changes. Material and Methods : This was a retrospective study of twenty patients who underwent revision surgery for adjacent segment changes after lumbosacral fusion. Inclusion criteria were as follows: 1) minimum 24 months follow-up, 2) confirmed adjacent segment changes by CT-myelogram or MRI, 3) conservative treatment for at least 3months, 4) available preoperative Xray films and 5) posterolateral fusions at a prior fusion. Correlation analysis was performed for age, sex, the number of fused levels, grade of radiographic degeneration and instrumentation using the independent sample t-Test. Results : Age, sex, the number of fused levels, the use of instrumentation and the preservation of lumbar lordosis were not correlated with the interval to revision (IR). However, the grade of radiographic degeneration (plain film and CT) were highly correlated with IR (R= -0.699, -0.654). Degenerative scoliosis had a shorter IR, with statistical significance (P

Study Design : The motor impairment and sensory dysfunction were evaluated in twenty-eight rats after dropping of leukotriene B4 and thromboxane B2 on lumbar nerve roots. Objectives : To evaluate the effects of inflammatory products on lumbar nerve roots of the rats without mechanical compression. Materials and Methods : Twenty-eight Sprague-Dawley rats were evenly divided into four groups (7 rats in each group) according to the substances applied: In group I (sham operation), even dropping of normal saline on left 4, 5 th and 6 th lumbar nerve roots: In group II, leukotriene B4; In group III, thromboxane B2: In group IV, leukotriene B4 and thromboxane B2. All rats were tested at 1, 3, 5, 7, 10 and 14 postoperative day for motor impairment and sensory dysfunction to the heat. Results : Hypersensitivity to the heat started to appear at 1 postoperative day in group IV and at 3 day in groups II and III and was maximum at 5 day in group III and 7 day in groups II and IV compared with the control group. The histological study also showed moderate to marked necrosis of ganglion cells and infiltration of the inflammatory cells compared to the control group. Conclusion : These results suggest that leukotriene B4 and thromboxane B2 produce inflammatory reactions in or around the nerve roots and lead to thermal hyperalgesia in rats without mechanical copmpression, therefore these results may apply to human lumbar nerve roots.