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This study investigated the efficacy of a novel surgical method that relies on the transient fixation of L4 in Lenke Type 5C and 6C adolescent idiopathic scoliosis. Thirty-six transient surgically treated L4 fixation patients were retrospectively evaluated. The first surgery involved mechanical correction of scoliosis; the lowest instrumented vertebra (LIV) was L4. After an average of 1.3 years (range, 0.3–3.4), the second surgery to remove transient L4 pedicle screws was performed. Radiographic parameters and SRS-22 scores were measured. Cobb’s angle, coronal balance, LIV tilting angle, and LIV coronal disc angle clearly improved after the first surgery (p

In the world, epilepsy is a common neurological disorder, and around 50 million people have epilepsy. The risk of premature death in epileptic patients is up to 3 times higher than the general population. To improve epilepsy patients’ quality of life, the use of non-invasive brain rhythm, i.e., electroencephalogram (EEG) has an important role in detecting an epileptic seizure that is the hallmark of epilepsy. By measuring the complexity of the EEG signals from patients, various entropy methods are used for detecting a variety of types of epileptic seizures. Conventional entropy methods such as the Approximate Entropy (ApEn) and Sample Entropy (SampEn) are dependent on data length and predetermined parameters. Here, we present a multiscale extension of Distribution Entropy (DistEn) that addresses the disadvantages of conventional entropy measures, which is referred to as multiscale DistEn (MDE). The proposed MDE is composed of a moving averaging procedure and DistEn estimation to reflect the reliable complexities over multiple temporal scales for short length EEG signals. The validation of the performance of MDE using actual normal and epileptic EEG signals is carried out. The experimental results show that MDE yields an outstanding performance in distinguishing the ictal EEG recordings compared to other entropy measures for short EEG recordings.

Purpose To demonstrate the impact of correcting sagittal balance (SB) on functional outcomes of surgical treatment for degenerative spinal disease and actual falls via utilization of new minimally invasive lumbar fusion techniques via a lateral approach. Materials and methods From November 2011 to March 2015, we enrolled 56 patients who underwent minimally invasive lateral lumbar interbody fusion (LLIF) and matched 112 patients receiving decompression/postero-lateral fusion (PLF) surgery for lumbar spinal stenosis. According to SB status using C7-plumb line-distance (C7PL) and surgery type, patients were divided into three groups: SB PLF, sagittal imbalance (SI) PLF, and LLIF groups. We then compared their outcomes. Results The mean C7PL was 6.2±13.6 mm in the SB PLF group, 72.9±33.8 mm in the SI PLF group, and 74.8±38.2 mm in the LLIF group preoperatively. Postoperatively, C7PL in only the LLIF group improved significantly (p=0.000). Patients in the LLIF group showed greater improvement in fall-related functional test scores than the SI PLF group (p=0.007 for Alternate-Step test, p=0.032 for Sit-to-Stand test). The average number of postoperative falls was 0.4±0.7 in the SB PLF group, 1.1±1.4 in the SI PLF group, and 0.8±1.0 in the LLIF group (p=0.041). Oswestry Disability Index and the Euro-QoL 5 dimension visual analogue scale scores also showed greater improvements in the LLIF group than in the SI PLF group at postoperative 1 year (p=0.003, 0.016). Conclusion Surgical correction of SI in patients with lumbar spinal stenosis using a combination of minimal invasive LLIF and posterior surgery achieved better surgical outcomes and a lower incidence of actual falls than PLF surgery.

It has been reported that good spinal sagittal alignment reduces the risk of fall and positive sagittal balance is the radiographic parameter that is most highly correlated with adverse health outcomes. However, no reports have demonstrated a change in risk of falling in patients with lumbar spinal stenosis (LSS) according to sagittal balance status.From September 2013 to October 2014, 141 patients who underwent lumbar spine surgery, including decompression and fusion in-situ for LSS, were enrolled in this study. Based on sagittal balance status, patients were divided into sagittal balance (SB) and sagittal imbalance (SI) groups. Four functional mobility tests were used to evaluate the risk of falling, and a fall diary, Oswestry disability index (ODI), and the Euro-QoL 5D(EQ-5D) visual analogue scale (VAS) were utilized to assess clinical improvement.The mean patient age was 70.1 years in the SB group (N=46) and 70.9 years in the SI group (N=95) (not significant). The mean C7PL was 7.9mm in the SB group and 66.1mm in the SI group preoperatively (p0.05). Among the four functional tests, only postoperative SMT and STS improved significantly in the SB group (p0.05). Patients in the SI group showed significantly improved scores for all four functional tests during postoperative follow-up (p0.05), but their performance was still worse than patients in the SB group. Average number of falls per individual during the follow-up period was 1.1±2.5 in the SB group and 1.9±3.2 in the SI group (p0.05). There was a significant difference in the distribution of non-fallers and fallers (single and multiple fallers) between the two groups postoperatively(p0.05). ODI and the EQ-5D VAS showed greater improvement in the SB group than the SI group. Multiple regression analysis revealed that sagittal balance during follow-up significantly affected ODI, EQ-VAS, functional mobility tests. (p0.05).Therefore, when fusion surgery is planned in patients with LSS, careful consideration of sagittal balance status might be important to attain better surgical and functional outcomes and decrease the incidence of actual falls after surgical treatment.

Currently, there are limited ways to preserve or recover insulin secretory capacity in human pancreas. We evaluated the efficacy of cell therapy using insulin-secreting cells differentiated from human eyelid adipose tissue-derived stem cells (hEAs) into type 2 diabetes mice. After differentiating hEAs into insulin-secreting cells (hEA-ISCs) in vitro, cells were transplanted into a type 2 diabetes mouse model. Serum levels of glucose, insulin and c-peptide were measured, and changes of metabolism and inflammation were assessed in mice that received undifferentiated hEAs (UDC group), differentiated hEA-ISCs (DC group), or sham operation (sham group). Human gene expression and immunohistochemical analysis were done. DC group mice showed improved glucose level, and survival up to 60 days compared to those of UDC and sham group. Significantly increased levels of human insulin and c-peptide were detected in sera of DC mice. RT-PCR and immunohistochemical analysis showed human gene expression and the presence of human cells in kidneys of DC mice. When compared to sham mice, DC mice exhibited lower levels of IL-6, triglyceride and free fatty acids as the control mice. Transplantation of hEA-ISCs lowered blood glucose level in type 2 diabetes mice by increasing circulating insulin level, and ameliorating metabolic parameters including IL-6.

Background: Hematogeneous infectious spondylodiscitis usually occurs in older immunocompromised patients with other comorbidities. They are usually unable to undergo reconstructive anterior and posterior surgeries. Therefore, an alternative, less aggressive surgical method of transpedicular curettage and drainage was suggested. This study was designed to compare the surgical outcomes for the treatment of hematogeneous infectious spondylodiscitis between transpedicular curettage and drainage technique and conventional combined anterior and posterior surgery. Materials and Methods: Between January 2002 and July 2011, 26 patients underwent surgical treatment for hematogeneous infectious spondylodiscitis. The patients were classified into two groups depending on surgical modality: a transpedicular curettage and drainage (TCD) group and a combined anterior and posterior surgery (CAPS) group. Results: The TCD group consisted of 10 patients (mean age 68.0 years), and the CAPS group consisted of 16 patients (mean age 58.4 years).The mean postoperative followup periods were 36.9 (months) in the TCD group and 69.9 (months) in the CAPS group. The operation time was 180.6 ± 33.6 minutes in the TCD group and 332.7 ± 74.5 minutes in the CAPS group (P < 0.05). Postoperative independent ambulation began at postoperative 4.9 ± 2.4 days in the TCD group but at postoperative 15.1 ± 15.3 days in the CAPS group (P < 0.05). The postoperative hospital stays were 19.9 ± 7.8 days in the TCD group and 35.4 ± 33.3 days in the CAPS group (P < 0.05). The level of C-reactive proteins decreased significantly in both groups after surgery (P < 0.05). Conclusion: Transpedicular curettage and drainage technique proved to be a useful technique for treating hematogeneous infectious spondylodiscitis in patients who were in poor heath with multiple comorbidities unable to undergo the conventional combined anterior and posterior surgery in a single day in terms of earlier ambulation, shorter hospitalization and similar clinical success rate.

Dupuytren's disease is a fibroproliferative connective tissue disorder characterized by contracture of the palmer fascia of the hand. Relaxin (RLN) is a multifunctional factor which contributes to the remodeling of the pelvic ligament by inhibiting fibrosis and inflammatory activities. The aim of this study was to investigate the effect of the RLN gene on the inhibition of fibrosis in myofibroblastic cells. Myofibroblast cells with adenovirus LacZ (Ad-LacZ) as a marker gene or adenovirus relaxin (Ad-RLN) as therapeutic gene showed transgene expressions in beta-galactosidase assay and Western blot analysis. Myofibroblastic cells with Ad-RLN demonstrated a 22% and 48% reduction in collagen I and III mRNA expressions respectively, a 50% decrease in MMP-1, 70% decrease in MMP-2, 80% decrease in MMP-9, and a 15% reduction in MMP-13 protein expression compared with cultures with viral control and saline control. In addition, myofibroblastic cells with Ad-RLN showed a 40% decrease in TIMP 1 and a 15% increase in TIMP 3 protein expression at 48 h compared to cultures with viral control and saline control. Also, myofibroblastic cell with Ad-RLN demonstrated a 74% inhibition of fibronectin and a 52% decrease in total collagen synthesis at 48 h compared with cultures with viral control and saline control. In conclusion, the RLN gene render antifibrogenic effect on myofibroblastic cells from Dupuytren's nodule via direct inhibition of collagen synthesis not through collagenolytic pathway such as MMP-1, -13, TIMP 1, and 3. Therefore relaxin can be an alternative therapeutic strategy in initial stage of Dupuytren's disease by its antifibrogenic effect. © 2013 Orthopaedic Research Society. Published by Wiley Periodicals, Inc. J Orthop Res 32:515–523, 2014.

Background: Patients with lumbar spinal stenosis (LSS) are at a great risk of a fall and fracture, which vitamin D protects against. Vitamin D deficiency is expected to be highly prevalent in LSS patient, and pain is thought to have a profound effect on vitamin D status by limiting activity and sunlight exposure. Objective: To identify the prevalence of vitamin D deficiency (serum 25-hydroxyvitamin D [25-OHD] < 20ng/mL) and its relationship with pain. Study Design: Nonblinded, cross-sectional clinical study. Setting: University-based outpatient clinic of the Department of Orthopedic Surgery, Yonsei University College of Medicine, Korea. Methods: Consecutive patients who visited the orthopedic outpatient clinic for chronic low back pain and leg pain and were diagnosed as LSS between May 2012 and October 2012 were included. Pain was categorized into 4 groups based on location and severity: 1) mild to moderate back or leg pain; 2) severe back pain; 3) severe leg pain; and 4) severe back and leg pain. Covariates for vitamin D deficiency included age, sex, body mass index, level of education, medical history, season, region of residence, sunlight exposure score and functional disability. 25-OHD level was measured by radioimmunoassay, and bone metabolic status including bone mineral density and bone turnover markers was also measured. Multivariable logistic regression modeling was used to adjust all risk estimates for covariates. Results: The study had 350 patients enrolled. Mean serum 25-OHD level was 15.9 ± 7.1 ng/mL (range, 2.5 ~ 36.6). of the 350 patients, 260 patients out of 350 (74.3%) were vitamin D deficient. Univariate logistic regression analysis showed a significantly higher prevalence of vitamin D deficiency in the following patients: 1) medical comorbidity; 2) urban residence rather than rural; 3) lower score for sunlight exposure; and 4) severe leg pain, or severe back and leg pain rather than mild to moderate pain. Pain category was significantly associated with lower sunlight exposure; however, the association between pain category and vitamin D deficiency remained significant even after adjustment for the sunlight exposure. Furthermore, severe back pain, and severe back and leg pain were also associated with higher incidence of osteoporosis and higher level of bone resorption marker (serum CTx). Limitations: The limitation of our study is that due to its cross-sectional design, causal relationships between pain and vitamin D deficiency could not be established. Conclusion: Vitamin D deficiency was highly prevalent in LSS patients (74.3%), and severe pain was associated with higher prevalence of vitamin D deficiency and osteoporosis which could be potential risk factors or a fall and fracture. As evidenced by the present study, assessment of serum 25-OHD and bone mineral density are recommended in LSS patients with severe pain, and active treatment combining vitamin D, calcium, or bisphosphonate should be considered according to the status of the bone metabolism. Key words: Vitamin D, lumbar spinal stenosis, pain, bone mineral density

PURPOSE The incidence of adolescent idiopathic scoliosis (AIS) has rapidly increased, and with it, physician consultations and expenditures (about one and a half times) in the last 5 years. Recent etiological studies reveal that AIS is a complex genetic disorder that results from the interaction of multiple gene loci and the environment. For personalized treatment of AIS, a tool that can accurately measure the progression of Cobb's angle would be of great use. Gene analysis utilizing single nucleotide polymorphism (SNP) has been developed as a diagnostic tool for use in Caucasians but not Koreans. Therefore, we attempted to reveal AIS-related genes and their relevance in Koreans, exploring the potential use of gene analysis as a diagnostic tool for personalized treatment of AIS therein. MATERIALS AND METHODS A total of 68 Korean AIS and 35 age- and sex-matched, healthy adolescents were enrolled in this study and were examined for 10 candidate scoliosis gene SNPs. RESULTS This study revealed that the SNPs of rs2449539 in lysosomal-associated transmembrane protein 4 beta (LAPTM4B) and rs5742612 in upstream and insulin-like growth factor 1 (IGF1) were associated with both susceptibility to and curve severity in AIS. The results suggested that both LAPTM4B and IGF1 genes were important in AIS predisposition and progression. CONCLUSION Thus, on the basis of this study, if more SNPs or candidate genes are studied in a larger population in Korea, personalized treatment of Korean AIS patients might become a possibility.

To date, skillful medical management and advanced surgical techniques have provided increased quality of life with less postoperative morbidity in patients with spinal metastasis. We assessed the survival of patients with spinal metastasis according to two treatment modalities: surgery and conservative treatment. From 2005 to 2010, a total of 577 patients (200 surgery, 377 conservative treatment) who had spinal metastasis were enrolled. Prognostic factors and survival were assessed by Cox regression and Kaplan–Meier analyses in patients receiving either surgery or conservative treatment. The mean age was 59.7 (range 21–87) years in the surgery group and 59.9 (range 28–90) years in the conservative treatment group. The major primary cancers were of lung, liver, and colorectal origin in the surgery group and lung, liver, and breast in the conservative group. The mean ± SD Tokuhashi score in the surgery group was 8.12 ± 3.09 and in the conservative group was 8.0 ± 2.8 (not significant). The hazard ratio of the primary cancer group ranged from 1.870 to 3.217 compared to that of the most favorable primary cancer group in all patients. Survival was affected significantly by sex, adjuvant therapy, and postoperative survival in the surgery group and by clinical symptom, metastasis to major internal organ, and primary cancer origin in the conservative group. With this retrospective review of 577 cases of spinal metastasis, different prognostic factors depending on the treatment modality were discovered. Hence, consideration of these factors depending on the treatment modality could be helpful in treating patients with spinal metastasis.

Study design. A prospective case control study. Objectives: To investigate the risk of a fall using functional mobility tests in patients with lumbar spinal stenosis (LSS) via a comparison with patients with knee osteoarthritis (KOA). Summary of Background Data: LSS is a degenerative arthritic disease in the spine that results in decreasing function, impaired balance and gait deficit with increased levels of leg and back pain. This physical impairment might result in an increased risk of fall later in the disease process as shown in knee osteoarthritis. However, there has been no study regarding the association between the risk of a fall and LSS. Methods: The study was an age- and weight-matched case control study consisting of two groups, one group consisting of 40 patients with LSS who were scheduled to undergo spine surgery (LSS group), the other group consisting of 40 patients with advanced OA in both knees, scheduled to undergo TKA on both knees (KOA group). For both groups, four functional mobility tests such as a six meter walk test (SMT), sit-to-stand test (STS), alternative step test (AST), and timed up and go test (TUGT) were performed. Results: There was no difference in demographic data between both groups except for BMI. For the SMT and STS, the patients in the LSS spent significantly more time performing these tests than the patients in the KOA. For the AST, however, patients in the KOA group presented a statistically worse performance in functional mobility, compared to the LSS group. The mean TUGT time was not statistically different between the two groups. Conclusions: The current study highlights that patients with symptomatic LSS have a comparable risk of a fall to patients who had degenerative KOA based on the results of functional mobility tests (SMT, STS, AST, and TUGT). Language: en

PURPOSE The purpose of this study is to report the comparative results of thoracoscopic correction achieved via cantilever technique using a 4.5 mm thin rod and the poly-axial reduction screw technique using a 5.5 mm thick rod in Lenke type 1 adolescent idiopathic scoliosis (AIS). MATERIALS AND METHODS Radiographic data, Scoliosis Research Society (SRS) patient-based outcome questionnaires, and operative records were reviewed for forty-nine patients undergoing surgical treatment of scoliosis. The study group was divided into a 4.5 mm thin rod group (n = 24) and a 5.5 mm thick rod group (n = 25). The radiographic parameters that were analyzed included coronal curve correction, the most caudal instrumented vertebra tilt angle correction, coronal balance, and thoracic kyphosis. RESULTS The major curve was corrected from 49.8 degrees and 47.2 degrees pre-operatively to 24.5 degrees and 18.8 degrees at the final follow-up for the thin and thick rod groups, respectively (50.8% vs. 60.2% correction). There were no significant differences between the two groups in terms of kyphosis, coronal balance, or tilt angle at the time of the final follow-up. The mean number of levels fused was 6.2 in the thin rod group, compared with 5.9 levels in the thick rod group. There were no major intraoperative complications in either group. CONCLUSION Significant correction loss was observed in the thin rod system at the final follow-up though both groups had comparable correction immediately post-operative. Therefore, the thick rod with poly axial screw system helps to maintain post-operative correction.

Study design Prospective short-term longitudinal study. Objective To investigate changes in the bone turnover rate in patients with lumbar spinal stenosis (LSS) before and after decompression surgery. SUMMARY OF BACK GROUND DATA: Decompression surgery enables elderly patients with LSS to participate in daily activities and physical exercise by reducing or alleviating leg and back pain. However, there have been no studies to date regarding the effect of decompression surgery on bone metabolism in such patients. Methods Twenty-three patients with spinal stenosis who were scheduled to undergo decompression surgery were enrolled in our study. Ten patients were given oral bisphosphonates after the operation (B+ group), while the remaining 13 patients did not receive oral bisphosphonate (B- group). In both groups, walking distance without rest, the Oswestry Disability Index (ODI) scores, duration of symptoms, bone formation, and resorption markers, and bone mineral density were recorded before surgery. Three months after surgery, bone turnover markers, a single trial for walking distance without rest and ODI scores were measured for both groups. Results Three months after the operation, the bone resorption marker u-NTx was decreased significantly for both groups. Although there was a decrease in bALP, a bone formation maker, in both groups, the change in each group was not statistical significant. Distance in a single trial walk was increased and ODI scores were decreased significantly for both groups. Conclusion This study suggests that decompression surgery has a beneficial effect on bone metabolism in patients with LSS who have walking intolerance and limited physical activity.

Study design Retrospective study. Objectives To investigate the 10-year survival of a large number of elderly patients who underwent spine surgery for lumbar spinal stenosis, and to identify significant risk factors and compare them with age- and gender-matched controls from the general population. Summary of background data There have been many studies on treatment options and surgical outcomes for lumbar spinal stenosis. However, survival outcomes after lumbar spinal stenosis surgery have not previously been studied. Because these operations are usually performed for elderly patients, we consider patient survival or life expectancy to be a significant outcome measure. Methods Between January 1997 and June 2006, patients underwent spine surgery for lumbar spinal stenosis. The date of death was verified using records from the National Health Insurance Corporation. Cumulative 10-year survival was calculated using the Kaplan-Meier method, and the survival of patients who had undergone spine surgery was compared to that of age- and sex-matched members of the general population. A Cox multivariate regression analysis was used in order to compare the survival rates for different covariates. Results Using Kaplan-Meier curves, the overall 10-year survival was 87.8% in patients 60 to 70 years old at surgery, and 83.8% in patients 70 to 85 years old at surgery. The 10-year survival rate of female patients and patients who underwent fusion surgery were higher than those of male patients and patients with nonfusion surgery. Compared to the adjusted corresponding portion in general population, the standardized mortality ratios were 0.21, 0.53, and 0.45 in patients aged 50 to 59, 60 to 69, and 70 to 85, respectively. Conclusion Elderly patients who underwent spine surgery for spinal stenosis had reduced mortality compared to the corresponding portion of the general population. Therefore, surgery for spinal stenosis is a justifiable procedure even in elderly patients.

Study Design Retrospective study. Purpose First, to examine the association between bone mineral density (BMD) and the halo phenomenon, and second, to investigate risk factors predisposing to the halo phenomenon and its correlation with clinical outcomes. Overview of Literature The few in vivo studies regarding the relationship between pedicle screw stability and BMD have shown conflicting results. Methods Forty-four female patients who underwent spine fusion surgery due to spinal stenosis were included in this study. The halo phenomenon and fusion state were evaluated through plain radiographs performed immediately after surgery and through the final outpatient follow-up examination. BMD, osteoarthritis grade in the hip and knee joints, and surgical outcome were also evaluated. Results BMD was not related to the halo phenomenon, but age, absence of osteoarthritis in the knee, and non-union state were found to be significant risk factors for the halo phenomenon. However, the radiological halo phenomenon did not correlate with clinical outcome (visual analogue scale for back pain and leg pain). Conclusions The halo phenomenon is a simple phenomenon that can develop during follow-up after pedicle screw fixation. It does not influence clinical outcomes, and thus it is thought that hydroxyapatite coating screws, expandable screws, cement augmentation, and additional surgeries are not required, if their purpose is to prevent the halo phenomenon.

OBJECTIVE: Most patients with muscular dystrophy (MD) develop progressive scoliosis after losing ambulatory status, but some cases develop severe scoliosis at a skeletally immature age before losing ambulatory status. Only a few studies have been conducted in skeletally immature patients with severe scoliosis. The purpose of this study was to assess the functional and cosmetic outcome in skeletally immature patients with severe scoliosis. METHODS: Preoperative, immediate postoperative, and final follow-up radiographs were analyzed in 10 consecutive skeletally immature patients with respect to the Cobb angle degree and the pelvic obliquity angle correction, how long the correction was maintained, and the development of the crankshaft phenomenon. In the functional assessment, the ability to sit balanced, according to the Mulcahy method, and the ability to use hands, according to the Rhyu method, were evaluated. Furthermore, the degree of subjective satisfaction was evaluated in these patients. RESULTS: The average age of the patients was 10.4 years, and the average follow-up period was 33 months with minimum 2 years' follow-up. All 10 patients survived and were available at the follow-up. The mean Cobb and pelvic obliquity angles were 80 degrees and 17 degrees at the time of the surgery, 31 degrees and 3.7 degrees immediately after the surgery, and 35 degrees and 4.7 degrees at the time of the final follow-up, respectively. The initial mean Cobb angle correction averaged 61%, with 78% of pelvic obliquity corrected. These corrections were maintained over time in most cases. At the time of the surgery, the mean volume of blood loss was 1111 mL, with an average operation time of 411 minutes. There were no major complications. At the time of the last follow-up, no patient showed development of the crankshaft phenomenon. The average score for the ability to sit balanced improved from 4.4 to 6.6 according to the Mulcahy evaluation method. The scores for hand use were 2.2-2.7. However, the forced vital capacity of the lungs decreased from a preoperative 48% to 46.1%. CONCLUSIONS: These results indicate that even in very young MD patients with severe scoliosis, acceptable curve correction can be achieved and maintained with surgery. The improved pelvic obliquity and scoliosis angle stabilized the spine, freeing the upper extremities and allowing productive activities characteristic of childhood.

Background Incidental renal cysts are a very common finding in routine lumbar spine magnetic resonance imaging (MRI). However, there is no report of the renal cyst detection rate on routine lumbar spine MRI. Purpose To determine the renal cyst detection rate in routine lumbar spine MRI based on findings of abdominal computed tomography (CT), and to investigate if the largest renal cyst seen by abdominal CT could be also detected by routine lumbar spine MRI. Material and Methods A retrospective study was conducted of 70 patients who underwent both routine lumbar spine MRI and abdominal CT between December 2011 and January 2014. The detection rate of all renal cysts>5 mm as well as the largest renal cyst seen by abdominal CT were assessed in routine lumbar spine MRI. Results On routine lumbar spine MRI, the detection rate of renal cysts was 46.5% (73/157) for>5-mm renal cysts and 68.0% (34/50) for>10-mm renal cysts, correlating with abdominal CT. The detection rate of the largest renal cyst seen by abdominal CT was 60.0% (27/45). Non-detection of the largest renal cyst could be caused by upper positioning ( n = 7), lateral positioning ( n = 6), or relatively small cyst size ( n = 5). Conclusion Approximately half of renal cysts>5 mm and two-thirds of renal cysts>10 mm were detected on routine lumbar spine MRI. However, radiologists should be aware that kidney lesions may not be included in the scan coverage of routine lumbar spine MRI.

PURPOSE Teriparatide markedly increases bone formation and strength, while reducing the incidence of new-onset osteoporotic vertebral compression fractures (OVCFs). In some countries, expenses for teriparatide use are covered by medical insurance for up to 6 months; however, the national medical insurance of the authors' country does not cover these expenses. This retrospective cohort study compared the therapeutic effects of teriparatide on the initial onset of a new OVCF after treatment of osteoporosis and/or related OVCFs with regard to therapeutic durations of longer than 3 months (LT3M) or shorter than 3 months (ST3M). MATERIALS AND METHODS From May 2007 to February 2012, 404 patients who were prescribed and administered teriparatide and who could be followed-up for longer than 12 months were enrolled. They were divided into two groups depending on teriparatide duration: LT3M (n=132) and ST3M (n=272). RESULTS The group with the teriparatide duration of LT3M showed significantly less development of an initial OVCF within 1 year (p=0.004, chi-square). Duration of teriparatide use, body mass index, pre-teriparatide lowest spinal bone mineral density, and severity of osteoporosis significantly affected multiple regression analysis results (p

The functional level of children with progressive neuromuscular disease is a major factor that affects the quality of life (QOL) of parents. However, only a few publications have reported changes in the QOL of parents after correctional spinal surgery.The purpose was to compare changes in QOL for both patients and parents after spinal correctional surgery for better sitting balance and to analyze correlation among radiographic parameters, functional outcome, and QOL questionnaires. Finally, the QOL of patients and parents was compared with the population norm.This study is a retrospective analysis of prospectively gathered data.From 2008 to 2011, 58 patients who underwent correctional surgery for progressive neuromuscular scoliosis and their parents were enrolled.A Muscular Dystrophy Spine Questionnaire (MDSQ) and short-form questionnaire 36 (SF-36) were used.The gathered functional outcome and QOL data using MDSQ and SF-36 for both enrolled patients and parents were compared preoperatively, postoperatively at 3 months, and at 1-year follow-up.Mean age was 15.0±4.1 years. Forty male and 18 female patients were enrolled. Mean follow-up was 38.4±13.7 months. Cobb angle was 61.5°±23.5° preoperatively, 39.0°±20.1° immediately postoperative, and 40.0°±20.2° at the final follow-up. Cobb angle, pelvic obliquity, and lumbar lordosis were significantly improved after surgery (p.001). Among sitting-related questions, answers to questions 15 (sitting comfortably), 16 (change weight in wheelchair), 22 (sit all day), 24 (sit at table for meal), 26 (keep balance while sitting in wheelchair), and 27 (look good while sitting in wheelchair) were significantly improved after correctional surgery (p.001). Regarding the SF-36 scales for patients, bodily pain and social functioning significantly improved postoperatively (p.001).Muscular Dystrophy Spine Questionnaire results indicated that patients had significantly improved sitting balance-related outcomes, whereas the SF-36 indicated improvements only in bodily pain and social functioning scales. For parents, no SF-36 scales improved significantly postoperatively. Accordingly, improved sitting balance and QOL for neuromuscular scoliosis patients after surgery do not necessarily increase parent QOL.

STUDY DESIGN A retrospective clinical case series. OBJECTIVE To investigate knee osteoarthritis (KOA) and total knee replacement (TKR) status as prognostic factors for surgical outcomes in female patients with lumbar spinal stenosis (LSS). SUMMARY OF BACKGROUND DATA There have been many reports on numerous prognostic factors for surgical outcomes in patients with degenerative lumbar conditions; however, there has been no report on the surgical outcome in patients who underwent spinal surgery with coexisting KOA and TKR. METHODS This study included 141 female patients (mean age, 67.6 y) who underwent spinal surgery for LSS between January 2006 and December 2010. At 1 year postoperatively, surgical outcomes were measured using the Oswestry disability index (ODI). Various clinical factors including KOA and TKR were analyzed as prognostic factors for surgical outcomes. RESULTS Mean average scores at preoperative evaluation were 26.1±6.6 in the no KOA group, 23.6±7.9 in the KOA group, and 30.4±6.7 in the TKR group (P

This study aimed to investigate the association between intraocular pressure and metabolic syndrome according to menopause status in nonglaucomatous Korean women.We examined the relationship between intraocular pressure and metabolic syndrome in 4,524 nonglaucomatous Korean women (2,866 premenopausal women and 1,658 postmenopausal women) who participated in the 2008 Korean National Health and Nutrition Examination Survey. Multivariate linear regression analysis was used to assess the relationship between metabolic syndrome and intraocular pressure after adjusting for age, body mass index, smoking status, alcohol consumption, regular exercise, hypertension medication, and diabetes medication according to menopause status in women.The prevalence of metabolic syndrome was 5.4% for premenopausal women and 28.0% for postmenopausal women. The mean intraocular pressure gradually increased in accordance with the increasing number of components for metabolic syndrome in postmenopausal women (P = 0.002), but not in premenopausal women (P = 0.387). In multivariate regression analysis, intraocular pressure was significantly associated with metabolic syndrome in postmenopausal women (P = 0.015) after adjusting for confounding variables, but not in premenopausal women (P = 0.940).Intraocular pressure was associated with metabolic syndrome in postmenopausal women, but not in premenopausal women. These findings suggest that intraocular pressure changes may be linked to metabolic syndrome in postmenopausal women.

Study Design: In vitro experiment using degenerated human ligamentum flavum (LF) and various inflammatory cytokines. Objectives: To examine the effect of inflammatory cytokines on LF cells and to identify their roles in the pathogenesis of LF hypertrophy and ossification. Summary of Background Data: Spinal stenosis is caused, in part, by hypertrophy and ossification of the LF, which are induced by the degenerative processes (ie, increased collagen synthesis and chondroid metaplasia) of ligament fibroblasts. Degenerated intervertebral disk spontaneously produces inflammatory cytokines, which might affect the adjacent LF through local milieu of the spinal canal. Methods: The interlaminar portion of the LF was collected during surgical spinal procedures in 15 patients (age range, 49–78 y) with lumbar spinal stenosis. LF fibroblasts were isolated by enzymatic digestion of LF tissue. LF cell cultures were treated with various inflammatory cytokines: interleukin (IL)-1α, IL-6, tumor necrosis factor-α (TNF-α), prostaglandin E2 (PGE2), and nitric oxide (NO). Cytotoxicity was analyzed by MTT assays. DNA synthesis was measured with 3H-thymidine incorporation, and mRNA expression of types I, III, V, and XI collagen and osteocalcin were performed by reverse transcription-polymerase chain reaction. Histochemical stains such as Von Kossa were also performed to detect bone nodule formation. Results: There was no cytotoxicity in the LF cells treated with each cytokine. There were significant increases in DNA synthesis and upregulated mRNA expression of types I, V, XI collagen and osteocalcin in LF cultures treated with various cytokines. LF cultures treated with IL-6, TNF-α, PGE2, and NO showed positive Von Kossa staining, indicating bone nodule formation from LF cells. Conclusions: Inflammatory cytokines (IL-6, TNF-α, PGE2, and NO) seem to play a crucial role in hypertrophy and ossification of LF. Degenerated, herniated intervertebral disks, and facet arthrosis may influence LF through inflammatory cytokines and cause hypertrophy and ossification of LF.

STUDY DESIGN A prospective cohort study. OBJECTIVE To demonstrate the changes in vitamin D status after surgery in female patients with lumbar spinal stenosis (LSS), and its correlation with surgical outcomes. SUMMARY OF BACKGROUND DATA In patients with LSS, general health including walking ability and nutritional status can be markedly improved by decompressive surgery. It can be hypothesized that such improvement may have a positive effect on their vitamin D status. METHODS In total, 31 female patients who underwent decompression and instrumented posterolateral fusion for LSS were enrolled. Serum 25-hydroxyvitamin D (25-OHD) level was measured before the surgery and at 1 year postoperative visit. According to serum 25-OHD level, patients were classified into 3 groups: (1) deficient group, when 25-OHD level was less than 20 ng/mL (< 50 nmol/L); (2) insufficient group, when 25-OHD level was between 20 to 30 ng/mL (50 nmol/L ≤ 25-OHD < 75 nmol/L); (3) and normal group, when 25-OHD level was 30 ng/mL or more (≥ 75 nmol/L). The Oswestry Disability Index (ODI) score and health-related quality of life (EQ-5D) were compared according to the level of 25-OHD at 1 year postoperatively. RESULTS Preoperatively, there were 20 patients in the deficient group, 11 patients in the insufficient group and no patient in the normal group. There were no differences in age, body mass index, preoperative ODI scores, preoperative EQ-5D index scores, and EQ-5D visual analogue scale scores between the 2 groups. Mean preoperative 25-OHD level was 15.8 ng/mL (range, 5.2-29.4 ng/mL) and increased to 19.5 ng/mL (range, 6.3-47.7 ng/mL) 1 year after surgery (P = 0.075). Significant increase of 25-OHD was noted only in the deficient group (P = 0.017). Postoperatively, there were 18 patients in the deficient group, 8 patients in the insufficient group, and 5 patients in the normal group. In the postoperative deficient group, postoperative ODI scores and EQ-5D index scores showed significantly worse outcomes than those in the other groups. The changes in serum 25-OHD level were significantly correlated with the changes in ODI scores (r = -0.580; P = 0.001) and with the changes in EQ-5D index scores (r = 0.379; P = 0.035). In all the groups, postoperative ODI scores (r = -0.665; P < 0.001) and EQ-5D index scores (r = 0.601; P < 0.001) were significantly correlated with postoperative 25-OHD level. CONCLUSION Vitamin D deficiency was common in patients with LSS. However, vitamin D status was improved after decompressive surgery, and postoperative 25-OHD level was significantly correlated with surgical outcomes.

Background Infective spondylodiscitis usually occurs in patients of older age, immunocompromisation, co-morbidity, and individuals suffering from an overall poor general condition unable to undergo reconstructive anterior and posterior surgeries. Therefore, an alternative, less aggressive surgical method is needed for these select cases of infective spondylodiscitis. This retrospective clinical case series reports our novel surgical technique for the treatment of infective spondylodiscitis. Methods Between January 2005 and July 2011, among 48 patients who were diagnosed with pyogenic lumbar spondylodiscitis or tuberculosis lumbar spondylodiscitis, 10 patients (7 males and 3 females; 68 years and 48 to 78 years, respectively) underwent transpedicular curettage and drainage. The mean postoperative follow-up period was 29 months (range, 7 to 61 months). The pedicle screws were inserted to the adjacent healthy vertebrae in the usual manner. After insertion of pedicle screws, the drainage pedicle holes were made through pedicles of infected vertebra(e) in order to prevent possible seeding of infective emboli to the healthy vertebra, as the same instruments and utensils are used for both pedicle screws and the drainage holes. A minimum of 15,000 mL of sterilized normal saline was used for continuous irrigation through the pedicular pathways until the drained fluid looked clear. Results All patients' symptoms and inflammatory markers significantly improved clinically between postoperative 2 weeks and postoperative 3 months, and they were satisfied with their clinical results. Radiologically, all patients reached the spontaneous fusion between infected vertebrae and 3 patients had the screw pulled-out but they were clinically tolerable. Conclusions We suggest that our method of transpedicular curettage and drainage is a useful technique in regards to the treatment of infectious spondylodiscitic patients, who could not tolerate conventional combined anterior and posterior surgery due to multiple co-morbidities, multiple level infectious lesions and poor general condition.

Study design retrospective comparative study (Level III). Objective to compare the operative results of posterior fusion and a 2-stage anterior L5-S1 fusion followed by posterior fusion in neuromuscular scoliosis patients with significant pelvic obliquity (PO). Summary of background data PO in neuromuscular scoliosis is common and a challenging problem that affects proper sitting balance, necessarily addressing the deformity and proper maintenance of the correction. Methods a total of 54 patients with neuromuscular scoliosis and significant PO (>10°) were divided into 2 groups. Group 1 (n = 24) was operated on for posterior fusion and pelvic fixation. Group 2 (n = 30) included patients who were subjected to a first-stage procedure consisting of a lumbosacral junction release and fusion through a midline retroperitoneal approach and then a second-stage procedure of posterior fusion and pelvic fixation. Parameters measured included length of the follow-up, number of fusion levels, age at operation, forced vital capacity, operative time, estimated blood loss, and postoperative complications. Radiologic parameters measured before surgery, after surgery at the time of discharge, and at a final follow-up included Cobb angle, T1 translation, sitting pelvic obliquity (PO) in the frontal plane, C7 plumb line, thoracic kyphosis, lumbar lordosis, and sacral inclination angle in the sagittal plane. Results the correction of scoliosis was similar in both groups. The preoperative PO averaged 19.5° in Group I and 22.9° in Group II (P = 0.22), which corrected after surgery to 9.7° versus 7.4° (P = 0.23), respectively. Group II correction progressively improved significantly compared to Group I (7.0° vs. 11.6° at P = 0.046) at the latest follow-up. A 40.6% correction (mean correction = 7.9) in sitting PO in Group I compared to 70.7% correction (mean correction = 5.9°) in Group II was observed (P = 0.004). The average loss of correction of PO at the final follow-up was lesser in group II, but not statistically significant (P = 0.07). Conclusion anterior fusion of the lumbosacral junction followed by posterior fusion provides superior correction and maintenance of PO in patients with neuromuscular scoliosis.

STUDY DESIGN A cross-sectional study. OBJECTIVE To investigate bone mineral density (BMD) and the change of bone turnover rate in postmenopausal women with lumbar spinal stenosis (LSS). SUMMARY OF BACKGROUND DATA Symptomatic LSS prevents elderly patients from performing daily activities because of back pain and neurogenic claudication. Walking intolerance due to neurologic claudication might have a negative effect on bone metabolism and BMD. However, there has been no study on the relationship between LSS and bone metabolism, especially on bone turnover rate. METHODS Sixty-seven patients were in the LSS group. As a control group, 67 age- and weight-matched subjects were selected. In both groups, BMD, bone turnover markers, vitamin D, severity of knee osteoarthritis, and demographic data were obtained. In the LSS group, walking distance without rest was also recorded. BMD, bone turnover markers, vitamin D, and severity of knee osteoarthritis were compared between the two groups. In the LSS group, the correlation between walking intolerance and bone turnover markers was also analyzed. RESULTS In the LSS group, urinary N-terminal telopeptide of type I collagen (u-NTx) and alkaline phosphatase were significantly elevated when compared with those of the control group (P < 0.05). However, BMD was significantly low in the control group in all of the measured sites (P < 0.05). In the LSS group, neither bone markers nor BMD were correlated with the extent of walking difficulty. CONCLUSION Our study highlights the fact that limited physical activity results in high bone turnover rate in patients with LSS.

An incidental thyroid nodule is a very common finding in magnetic resonance imaging (MRI) with scan coverage of the neck area (1, 2) , and is also a very important finding because of the high possibility of malignancy (~12-28%) (3, 4). A recent study reported that an incidental thyroid nodule was detected by cervical spine MRI in approximately 5% of patients (5). In lumbar spine MRI, if the additional cervicothoracic sagittal T2-weighted image (C-T sag T2WI) is acquired as a routine scanning protocol, thyroid nodules also can be detected in those images. Although it has been reported This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/ by-nc/3.0/) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited. Received: November 18, 2015 Revised: December 24, 2015 Accepted: December 25, 2015

Anterior bulging of the abdomen and posterior protrusion of the buttocks are externally visible deformities reflecting lumbosacral hyperlordosis. Imbalance in pelvic femoral muscles may account for this posture. Despite the clinical significance of hyperlordosis, its surgical treatment has not been well-described. In the current preliminary study, the authors compare two techniques used at the authors' institution for lower limb lengthening, one of which affects the correction of lumbosacral hyperlordosis. Ten patients had bilateral lower extremity lengthening procedures. Seven patients had bilateral tibial lengthening and three patients had combined femoral and tibial lengthening. Ring external fixators were used. Correction of hyperlordosis was assessed by comparing four radiographs with measurements in the sagittal plane obtained preoperatively with those at the latest followup. In the femoral lengthening group, the average preoperative lumbar lordosis angle was 18 degrees, the lumbosacral joint angle was 12 degrees, the sacral inclination angle was 58.3 degrees, and the sacrohorizontal angle was 31 degrees. The mean changes at the latest followup were: lumbar lordosis angle (+1 degree), lumbosacral joint angle (+0.3 degrees), sacral inclination angle (-19 degrees), and sacrohorizontal angle (-15 degrees). In the tibia lengthening group, all parameters were relatively unaltered at the last followup compared with their preoperative levels. Tibial lengthening had no effect on lumbosacral hyperlordosis. However, femoral lengthening resulted in an improved apparent lumbosacral hyperlordosis, although the lumbar lordosis angle was not changed significantly. The change in sacrum tilting provides a likely explanation for the improvement in cosmetic hyperlordosis observed in patients who have had femoral lengthening.

Background: Falls are a major factor contributing to fragility fractures. Patients with lumbar spinal stenosis have an increased risk of falling. We are aware of no prior report demonstrating the effect of medical treatment and decompression surgery on the risk of patients with lumbar spinal stenosis falling. Methods: From June to November 2011, seventy-six patients were enrolled into the surgery group and fifty patients, into the nonoperative group. Four functional mobility tests, including the Alternate-Step test, Six-Meter Walk test, Sit-to-Stand test, and timed “Up & Go” test, were used to evaluate the risk of falling. The Oswestry Disability Index (ODI) and the EuroQoL-5D (EQ-5D) visual analog scale (VAS) were utilized to assess clinical improvement. Results: The mean age was 62.4 years in the surgery group and 64.6 years in the nonoperative group. The results of the Alternate-Step test significantly improved during the follow-up period in the surgery group (p = 0.001). However, the results of the Alternate-Step test significantly worsened during the follow-up period in the nonoperative group (p = 0.001). Comparison between the two groups showed more significant improvement in the surgery group, especially for the Six-Meter Walk test at one year postoperatively (p = 0.042) and for the timed “Up & Go” test at three months and one year (p = 0.046 and 0.000). However, the ODI and EQ-5D VAS scores improved in both groups. In a linear mixed model, age, surgery, and the presence of an osteoporotic compression fracture significantly affected the test results related to the risk of falling (p < 0.05). Conclusions: The surgery group showed a greater decrease in the risk of falling than those in the nonoperative group. Improved physical performance, including walking and balancing, after decompression lumbar spinal surgery reduces the future risk of falling. Level of Evidence: Therapeutic Level II. Retrospective analysis of prospectively collected data. See Instructions for Authors for a complete description of levels of evidence.

Study Design. A retrospective follow-up study. Objectives. To review and analyze the sexual function of patients who have sustained lumbar fractures with incomplete paraparesis. Summary of Background Data. As a result of advances in surgical techniques, most patients with lumbar fractures have significant recovery of neurologic status. Because motor functions are important to patients, most of the studies have concentrated their analyses on motor recovery. Many patients who have almost completely recovered motor function, however, may have sexual dysfunction, especially men. Methods. Forty-three patients with lumbar fractures that resulted in incomplete paraparesis were analyzed. American Spinal Injury Association motor index points were determined for each patient before and after surgery and used for comparison between American Spinal Injury Association motor index and international index of erectile function score. Eleven male patients who reported sexual dysfunction were evaluated by using Rigiscan. Results. During the follow-up period, 42 patients showed neurologic recovery. Average improvement of American Spinal Injury Association motor score was 13.1 and average international index of erectile function score was 45. Average improvement of American Spinal Injury Association motor score for patients who had not reported sexual dysfunction was 12.5, and average international index of erectile function score was 52. For 11 patients in the sexual dysfunction group, preoperative motor score was 28.0, and average improvement of score was 14.9. Nocturnal penile tumescence monitoring results were abnormal in four cases. Averaged international index of erectile function score was 15. There was a statistically significant difference between the sexually healthy and dysfunctional groups in international index of erectile function score (P < 0.05), whereas no difference was noted in American Spinal Injury Association motor score. Conclusions. Neurologic recovery after lumbar fractures was improved. Regardless of neurologic recovery, most patients reported some disability, usually caused by pain and occasionally sexual dysfunction. Impairment of sexual function was present in four patients (9.3%). Although these patients may preserve psychiatric erection potential, they usually experienced sexual problems.

Study design Prospective study of 34 patients with thoracolumbar spinal fractures. Objectives To assess the reliability of magnetic resonance imaging (MRI) for posterior ligament complex injury in thoracolumbar spinal fractures. Summary of background data Some researchers have studied posterior ligament complex injury in spinal fracture using MRI. However, most did not evaluate the findings of MRI compared with the operative findings. Methods Thirty-four patients with thoracolumbar spinal fracture were evaluated by palpation of the interspinous gap, plain radiography, and MRI before operation. In addition to conventional MRI sequences, a fat-suppressed T2-weighted sagittal sequence was performed. Surgery was performed by a posterior approach. During the operation, posterior ligament complex injury was carefully examined. Results A wide interspinous gap was palpated in 14 patients and was found in 21 patients on plain radiography. Magnetic resonance imaging raised suspicion of injury to the posterior ligament complex in 30 patients. According to interpretation of MRI, injury to the supraspinous ligament was suspected in 27 patients, the interspinous ligament in 30 patients, and the ligamentum flavum in 9 patients. There were 28 supraspinous ligament injuries, 29 interspinous ligament injuries, and 7 ligamentum flavum injuries in operative findings. There was a significant relation between MRI interpretation and operative findings. Conclusion A fat-suppressed T2-weighted sagittal sequence of MRI was a highly sensitive, specific, and accurate method of evaluating posterior ligament complex injury. Based on the results of this study, a fat-suppressed T2-weighted sagittal sequence of MRIs is recommended for the accurate evaluation of posterior ligament complex injury and would be helpful in the selection of treatment options.

imaging was used to identify at least one radiologically normal disc from the middle thoracic (T6-7 or T7-8) and lower thoracic (T9-10 or T10-11) regions in each volunteer for IDP measurement. Pressure measurements were taken with a needle-mounted thin film metal diaphragm pressure transducer (Gaeltec, Isle of Skye, Scotland). Local anesthetic was administered, and the needle was placed into the nucleus pulposa under fluoroscopic guidance. Nuclear pressure was measured while the subjects performed a sequence of maneuvers in the prone, sitting, and standing positions. In the prone, sitting upright, and standing upright positions, readings were taken with the needle oriented horizontally and vertically to assess the directional dependence of the sensor, while the rest of the positions were recorded with the needle orientated vertically. Global position and disc level comparisons were made using a two-way ANOVA, and pairwise comparisons were made using the Student-Newman-Keuls method. RESULTS: Intradiscal pressure measurements from one middle and one lower thoracic disc were taken in all but one of the participants; due to the inability to access a middle disc in one subject, two discs from the lower region were measured. Globally, different maneuvers had a statistically significant effect on IDP (p 0.0001). The highest pressures recorded were while the subject was sitting and holding 20 kg with arms flexed (mean SEM, 2.77 0.07 MPa), while the lowest pressures were observed while in the prone position (0.21 0.07). The thoracic level (middle or lower) from which the measurements were taken did not show an overall significant pressure difference (p 0.681). There was no significant difference between pressures takenwith needle oriented vertically versus horizontally (p 0.755). DISCUSSION: This study used a minimally invasive technique to measure IDP of the middle and lower thoracic discs in various body positions. Interestingly, there was not a significant difference in pressures recorded from the middle and lower levels of the thoracic spine despite apparently different mechanical environments. Comparison of pressures from the lumbar spine reportedbyNachemson in1970 to thoseof themiddle and lower thoracic spine show the magnitudes of the thoracic pressures to be similar to those reported in the lumbar spinebutwerenot consistentlyhigheror lower. CONCLUSIONS: The information presented here will aid in understanding intervertebral disc biomechanics, and its relationship to spine pathology and treatment. DISCLOSURES: No disclosures. CONFLICT OF INTEREST: No conflicts.

Purpose The objectives of this study are to describe the outcome of adolescent idiopathic scoliosis (AIS) patients treated with Video Assisted Thoracoscopic Surgery (VATS) plus supplementary minimal incision in the lumbar region for thoracic and lumbar deformity correction and fusion. Materials and Methods This is a case series of 13 patients treated with VATS plus lumbar mini-open surgery for AIS. A total of 13 patients requiring fusions of both the thoracic and lumbar regions were included in this study: 5 of these patients were classified as Lenke type 1A and 8 as Lenke type 5C. Fusion was performed using VATS up to T12 or L1 vertebral level. Lower levels were accessed via a small mini-incision in the lumbar area to gain access to the lumbar spine via the retroperitoneal space. All patients had a minimum follow-up of 1 year. Results The average number of fused vertebrae was 7.1 levels. A significant correction in the Cobb angle was obtained at the final follow-up (p = 0.001). The instrumented segmental angle in the sagittal plane was relatively well-maintained following surgery, albeit with a slight increase. Scoliosis Research Society-22 (SRS-22) scores were noted have significantly improved at the final follow-up (p < 0.05). Conclusion Indications for the use of VATS may be extended from patients with localized thoracic scoliosis to those with thoracolumbar scoliosis. By utilizing a supplementary minimal incision in the lumbar region, a satisfactory deformity correction may be accomplished with minimal post-operative scarring.

Study Design Retrospective comparative study. Purpose To study and compare the surgical outcomes of muscular dystrophy (MD) and spinal muscle atrophy (SMA). Overview of Literature There are few reports that have evaluated and compared the surgical outcomes of MD and SMA patients. Methods The patients (n = 35) were divided into two groups: a MD group with 24 patients and a SMA group with 11 patients. The average follow-up period was 21 months. All patients were operated for scoliosis correction using posterior instrumentation and fusion. In the immediate postoperative period, all efforts were made to reduce the pulmonary complications using non-invasive positive pressure ventilation and a coughing assist devices. The patients were evaluated by radiograph in terms of the Cobb's angle, pelvic obliquity, T1 translation, thoracic kyphosis and lumbar lordosis. The pulmonary function and self-image satisfaction were also assessed. Results There was a lower correction rate in the MD group (41.5%) than in the SMA group (48.3%), even though the curves were smaller in the MD group. The correction in the pelvic obliquity was significantly better in the SMA group (p = 0.03). The predicted vital capacity showed a 4% reduction in the MD group 1 year after surgery, while the SMA group showed a 10% reduction. The peak cough flow and end tidal PCO2 did not deteriorate and were well maintained. The average score for the improvement in self-image satisfaction postoperatively was 3.96 and 4.64 for the MD and SMA groups, respectively. The total complication rate was 45.7%; 14.3% of which were respiratory-related. Conclusions Surgical intervention for MD and SMA may be performed safely in patients with a very low forced vital capacity (< 30%) through aggressive preoperative and postoperative rehabilitation efforts.

Purpose: Surgical treatment in the case of thoracolumbar burst fractures is very controversial. Posterior instrumentation is most frequently used, however, but the number of levels to be instrumented still remains a matter of debate. Materials and Methods: A total of 94 patients who had a single burst fracture between T11 and L2 were selected and were managed using posterior instrumentation with anterior fusion when necessary. They were divided into three groups as follows; Group I (n = 28) included patients who were operated by intermediate segment fixation, Group II (n = 32) included patients operated by long segment fixation, and Group III (n = 34) included those operated by intermediate segment fixation with a pair of additional screws in the fractured vertebra. The mean follow-up period was twenty one months. The outcomes were analyzed in terms of kyphosis angle (KA), regional kyphosis angle (RA), sagittal index (SI), anterior height compression rate, Frankel classification, and Oswestry Disability Index questionnaire. Results: In Groups II and III, the correction values of KA, RA, and SI were much better than in Group I. At the final follow up, the correction values of KA (6.3 and 12.1, respectively) and SI (6.2 and 12.0, respectively) were in Groups II and III found to be better in the latter. Conclusion: The intermediate segment fixation with an additional pair of screws at the fracture level vertebra gives results that are comparable or even better than long segment fixation and gives an advantage of preserving an extra mobile segment.

Purpose: To evaluate the rate of new fractures of the spine after risedronate, alendronate or calcium carbonate in patients who had vertebroplasty or kyphoplasty due to compression fracture. Materials and Methods: We studied 292 patients with osteoporotic compression fractures who had received vertebroplasty or kyophoplasty between June 2003 and October 2007. Of these, 199 were evaluated for new fractures of the spine after treatment with risedronate, alendronate or calcium carbonate. Patients (n=199) were assigned to 1 of 4 groups: No treatment (n=71), risendronate (n=64), alendronate (n=42) or calcium carbonate group (n=22). Results: New fractures of the spine were morphogenically found in 19 patients (26.8%) in the no treatment group, in 11 (17.2%) in the risendronate group, in 8 (19.1%) in the alendronate group, in 5 (22.8%) in the calcium carbonate group. Symptomatically, they were found in 6 patients (8.5%) in the no treatment group, in 4 (6.3%) in the risendronate group, in 3 patients (7.1%) in the alendronate group, and in 2 patients (9.1%) in the calcium carbonate group. Conclusion: At one year follow up none of the differences between groups in new fracture rates of the spine were statistically significant.

National Health Insurance Corporation Ilsan HospitalStudy DDesign: Retrospective study.Purpose: To more accurately determine the incidence and clarify risk factors.Overview of Literature: Superior mesenteric artery syndrome is one of the possible complications following correctionaloperation for scoliosis. However, when preliminary symptoms are vague, the diagnosis of superior mesenteric artery syn-drome may be easily missed.Methods: We conducted a retrospective study using clinical data from 118 patients (43 men and 75 women) who underwentcorrectional operations for scoliosis between September 2001 and August 2007. The mean patient age was 15.9 years (range9�24 years). The risk factors under scrutiny were the patient body mass index (BMI), change in Cobb’s angle, and trunklength. Results: The incidence of subjects confirmed to have obstruction was 2.5%. However, the rate increased to 7.6% with theinclusion of the 6 subjects who only showed clinical symptoms of obstruction without confirmative study. The BMI for theasymptomatic and symptomatic groups were 18.4±3.4 and 14.6±3, respectively. The change in Cobb’s angle for the asymp-tomatic and symptomatic groups were 24.8±13.6�and 23.4±9.1�, respectively. The change in trunk length for the asymp-tomatic and symptomatic groups were 2.3±2.1 cm and 4.5±4.8 cm, respectively. Differences in Cobb’s angle and the changein trunk length between the two groups did not reach statistical significance, although there was a greater increase in trunklength for the symptomatic group than for the asymptomatic group. Conclusions: Our study shows that the incidence of superior mesenteric artery syndrome may be greater than the previouslyaccepted rate of 4.7%. Therefore, in the face of any early signs or symptoms of superior mesenteric artery syndrome, promptrecognition and treatment are necessary.Key WWords: Scoliosis, Superior mesenteric artery syndrome, Body mass index, Trunk length

Meningioma is one of the most common tumors of the spinal canal. Spinal meningiomas are usually found in the thoracic spine and intradural extramedullary space. Intraspinal clear cell meningiomas are a rare histological variant. Fewer than 20 intraspinal cases have been reported in the literature and only two cases have been reported in the Korean literature, but there is no report available in the Korean orthopedic literature. We report here on a case of an intraspinal clear cell meningioma that was found in the thoracic region and it was completely resected. The nonspecific MR imaging characteristics make the diagnosis of this tumor difficult. Histological examination must be used to differentiate clear cell meningiomas from other tumors. Clear cell meningioma represents an aggressive variant of meningiomas, and surgical reatment and adjuvant radiotherapy are though to be essential. Further more, long term follow-up observation will be needed for detecting recurrence of clear cell meningioma.

Radiographic sagittal plane analysis of VATS (video-assisted thoracoscopic surgery) anterior instrumentation for adolescent idiopathic scoliosis. This is retrospective study. To report, in details about effects of VATS anterior instrumentation on the sagittal plane. Evaluations of the surgical outcome of scoliosis have primarily studied in coronal plane correction, functional, and cosmetic aspects. Sagittal balance, as well as coronal balance, is important in functional spine. Recently, scoliosis surgery applying VATS has been increasingly performed. Its outcome has been reported several times; however, according to our search of the literature, the only one study partially mentioned. The study population was a total of 42 cases of idiopathic scoliosis patients (8 male, 34 female). Their mean age was 15.6 years (13 to 18 years). The 18 cases were Lenke IA type, 16 cases were Lenke IB type, and 8 cases were Lenke IC type. The preoperative Cobb's angle was 54.5 +/- 13.9 degrees. All patients were followed up for a minimum of 2 years and implanted, on average, at the 5.9 level (5 to 8 levels). The most proximal implant was the 4th thoracic spine, and the most distal implant was the 1st lumbar spine. Whole spine standing PA and lateral radiographs were taken before surgery, 2 months after surgery, and at the last follow up (range 24-48 months, mean 35 months). The C7 plumbline proximal junctional measurement (PJM), distal junctional measurement (DJM), thoracic kyphosis, and lumbar lordosis angles were measured and compared. In all cases, follow-ups were possible and survived till the last follow up. The Cobb's angle in coronal plane at the last follow up was 19.7 +/- 9.3 degrees and was corrected to 63.8% on average. The preoperative C7 sagittal plumbline before surgery was -13.9 +/- 29.1 mm, the final follow up was -9.9 +/- 23.8 mm, and the average positive displacement was 4 mm. Thoracic kyphosis was increased from preoperative 18.2 +/- 7.7 degrees to 22.4 +/- 7.2 degrees on average at the last follow up, and the increase was, on average, 4.2 degrees. The PJM angel was increased from 6.2+/- 4.3 degrees preoperative to 8.8 +/- 3.7 degrees at the last follow up, and the increment was, on the average, 2.6 degrees. The DJM angle before surgery was 6.8 +/- 5.1 degrees and 6.7 +/- 4 degrees at the last follow up, and did not change noticeably. Preoperative lumbar lordosis was 42 +/- 10.7 degrees and 43.5 +/- 11.1 degrees after surgery. Similarly, it did not change greatly. The scoliosis surgery applying VATS displaced the C7 sagittal plumb line by 4 mm to the anteriorly, increased thoracic kyphosis by 4.2 degrees, and increased PJM by 2.6 degrees. DJM and lumbar lordosis, before and after operation, were not significantly different. Although the surgical technique of VATS thoracic instrumentation is difficult to make the normal thoracic kyphosis, an acceptable sagittal balance can be obtained in Lenke type I adolescent idiopathic scoliosis using VATS.

There are no reports of a 7-day delay in the onset of neurological deterioration because of a spinal epidural hematoma (SEH) after a spinal fracture. A hematoma was detected from the T12 to L2 area in a 36-year-old male patient with a T12 burst fracture. On the same day, the patient underwent in situ posterior pedicle instrumentation on T10-L3 with no additional laminectomy. On the seventh postoperative day, the patient suddenly developed weakness and sensory changes in both extremities, together with a sharp pain. A MRI showed that the hematoma had definitely increased in size. A partial laminectomy was performed 12 hours after the onset of symptoms. Two days after surgery, recovery of neurological function was noted. This case shows that spinal surgeons need to be aware of the possible occurrence of a delayed aggravated SEH and neurological deterioration after a spinal fracture.

Study Design: A Cross-sectional study Objective: This study evaluated the degree of osteoporosis of adolescent idiopathic scoliosis (AIS) and neuromuscular scoliosis (NMS) and compared bone mineral density. Literature Review: In osteoporosis, bone mineral density was not as dense even in the outer layer, and the cortex was thinner than normal. A larger screw doss not enhance the screw stability and can break the thin cortex in osteoporotic vertebrae. Materials and Methods: This study reviewed the cases of consecutive patients with scoliosis, who underwent an osteoporosis examination before surgery between August 2004 and June 2006. The osteoporosis examination included DEXA in lumbar vertebrae and proximal femur. The mean osteoporotic degree of both femurs was recorded. The data was analyzed using the BMD(bone mineral density, g/cm) and Z value of the BMD according to age, gender, and ethnicity. Results: The mean degree of the coronal deformity was 48.4 in AIS and 62.9 in NMS. A comparison of both groups revealed a significantly lower BMD and Z value of Femur, and BMD of the vertebra in the NMS patients (p�0.05). A comparison between AIS and non-ambulant NMS showed that all parameters were significantly lower in the non-ambulant NMS (p� 0.05). Neither the BMD and Z value of the AIS nor the NMS were associated with the severity of the spinal deformity. Conclusion: A lower BMD was measured in patients with non ambulant NMS than AIS. The degree of the osteoporosis, particularly of the non ambulant NMS patients need to be considered before undergoing surgery.

To date, there have been no prospective, objective studies comparing the accuracy of the MRI, myelo-CT and myelography. The purpose of this study is to compare the diagnostic and predictive values of MRIs, myelo-CTs, and myelographies. Myelographies with dynamic motion views, myelo-CTs, MRIs and exercise treadmill tests were performed in 35 cases. The narrowest AP diameter of the dural sac was measured by myelography. At the pathologic level, dural cross-sectional area (D-CSA) was calculated in the MRI and Myelo-CT. The time to the first symptoms (TAF) and the total ambulation time (TAT) were measured during the exercise treadmill test and used as the standard in the comparison of correlation between radiographic parameters and walking capacity. The mean D-CSA by CT was 58.3 mm(2) and 47.6 mm(2) by MRI. All radiographic parameters such as AP diameters and D-CSA have no correlation to TAF or TAT (p > 0.05). Our data showed no statistically significant differences in the correlation of the patients' walking capacity to the severity of stenosis as assessed by myelography, myelo-CT and MRI.

Address reprint requests to Hak-Sun Kim, M.D. Department of Orthopaedic Surgery, Youngdong Severance Hospital, Yonsei University College of Medicine #146-92 Dogok-dong, Gangnam-gu, Seoul, Korea Tel: 82-2-3497-3411, Fax: 82-2-573-5393, E-mail:haksunkim@yumc.yonsei.ac.kr *This study was supported by a grant from the Brain Korea 21 project administered by Yonsei University Medical College, Stryker Korea, Gold Medical, infra Med Korea, and DePuy Korea. 흉곽 내시경을 사용한 척추 기형 수술시 학습 곡선