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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 preoperative and postoperative values) and follow-up motion (the difference between postoperative and the last follow-up values) 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.

Study Design: A prospective study., Purpose: To determine the success rate and duration of relief of radiofrequency neurotomy for lumbar facet joint pain., Overview of Literature: There is a lack of effective treatment for chronic low back pain. Radiofrequency denervation appears to be an emerging technology, with substantial variations in use., Methods: Fifty-eight patients underwent radiofrequent neurotomy on the posterior primary ramus for chronic low back pain. All patients with low back pain of more than 3 months duration, with or without non-radicular radiation to the buttock and hip, were included in the study. From October 2005 to December 2006, eligible patients underwent a standardized diagnostic work-up, which included the use of a visual analog scale (VAS), physical examination, review of imaging studies, and diagnostic blockades. Pain relief was assessed on the third day, and at 3 months and 6 months post-treatment, using the visual analog scale., Results: There were 44 women and 14 men included in the study. The mean age was 57.7 years (range, 20~80 years). Radiofrequency neurotomy denervated three segments and a bilateral lesion in all patients. The visual analogue scale (VAS) scores on the third day (mean VAS score: 1.48) and 3 months (mean VAS score: 1.79) after treatment decreased significantly when compared with the pre-treatment scores (mean VAS score: 6.56). However, the final values of the VAS scores after 6 months were slightly increased as compared to the VAS scores measured at the beginning of the study (mean VAS score: 2.91). No cases of infection, new motor deficits, or new sensory deficits were identified., Conclusions: We suggest that radiofrequency neurotomy offers an effective palliative management of lumbar facet pain. However, there is limited evidence that radiofrequency neurotomy offers short-term relief for chronic low back pain. Further high-quality randomized controlled trials are needed with larger patient numbers and more data on the long-term effects, for which current evidence is inconclusive.

Study Design: Western blotting and flow cytometric analyses were performed using rat notochordal cells., Objective: To demonstrate the apoptotic effect of oxidative stress and the antiapoptotic effects of caspase inhibitors on rat notochordal cells., Summary of Background Data: Although oxidative stress causes apoptosis in many cell types, its effect on the apoptosis of notochordal cell and antiapoptotic effects of caspase inhibitors on the oxidative stress-induced apoptosis are unknown., Methods: Cultured rat notochordal cells were exposed to oxidative stress [500 micromol/L of hydrogen peroxide (H2O2)]. To determine the oxidative stress-induced apoptotic pathways, activations of caspases (-3, -8, and -9) as well as cleavages of Bid and poly (ADP-ribose) polymerase (PARP) were evaluated with Western blotting 6 hours after oxidative stress. To elucidate the antiapoptotic effects of caspase inhibitors on the oxidative stress induced-apoptosis, apoptotic rates of notochordal cells with or without treatment of specific caspase inhibitors (z-IETD-fmk for caspase-8, z-LEHD-fmk for caspase-9, and z-DEVD-fmk for caspase-3) were quantified by flow cytometry., Results: Oxidative stress significantly increased apoptosis of rat notochordal cells (2.1% vs. 4.75%, P = 0.008) and led to activations of initiators of intrinsic (caspases-9) and extrinsic (caspase-8) pathways as well as their common executioner (caspase-3). It also caused cleavages of Bid and PARP. Flow cytometric analysis showed that inhibition of only one of the intrinsic and extrinsic pathways by caspase-9 inhibitor (4.75% vs. 3.56%, P = 0.31) and caspase-8 inhibitor (4.75% vs. 5.24%, P = 0.84) did not significantly suppress the oxidative stress-induced apoptosis. However, inhibition of both pathways by caspase-3 inhibitor significantly reduced the oxidative stress-induced apoptosis (4.75% vs. 2.64%, P = 0.008) to the control level (2.1% vs. 2.64%, P = 0.15)., Conclusion: Oxidative stress caused apoptosis of rat notochordal cells via both intrinsic and extrinsic (Type I and Type II) pathways. Because caspase inhibitors are being used in clinical trials, inhibition of both pathways using caspase inhibitors might be of future therapeutic importance in oxidative stress-induced apoptosis of notochordal cells. Our results suggest that inhibition of inappropriate or premature oxidative stress-induced apoptosis of notochordal cells may delay the starting point of disc degeneration.

Aspergillosis is a rare cause of spondylitis. Moreover, early diagnosis by MR imaging and adequate treatment can prevent the serious complications of fungal infection. To our knowledge, the MR findings of multilevel aspergillus spondylitis in the cervico-thoraco-lumbar spine have not been previously described. Here, we report the MR findings of aspergillus spondylitis involving the cervical, thoracic, and lumbar spine in a liver transplant recipient.

Background: Even though there are several physical tests available for superior labrum anterior posterior lesions, there have been very few reports on their accuracy, and none can be regarded as completely predictive for the presence of a superior labrum anterior posterior lesion in the shoulder joint., Hypothesis: This new clinical test is a useful and accurate technique for detecting superior labral tears in the shoulder joint., Study Design: Cohort study (diagnosis); Level of evidence, 2., Methods: This test was conducted independently by 2 physicians before any other diagnostic evaluation. In all cases, the glenohumeral joint was investigated first, and the appropriate treatments were performed on the lesion. A protocol was established to evaluate the sensitivity, specificity, and positive and negative predictive values of this new clinical test. The reproducibility of this test was evaluated with a kappa coefficient., Results: Sixty-one patients (61 shoulders) were examined with the passive compression test, and all underwent arthroscopic surgery. In 31 patients with a positive passive compression test result, 27 had a superior labrum anterior posterior lesion, and in 30 patients with a negative passive compression test result, 6 had a superior labrum anterior posterior lesion. The sensitivity of the test was 81.8%, and the specificity was 85.7%. The positive predictive value was 87.1%, and the negative predictive value was 80.0%. The kappa coefficient was 0.771 between the 2 independent examiners (P< .01)., Conclusion: The passive compression test is a useful and accurate technique for predicting superior labral tears of the shoulder joint.

Study Design: A retrospective clinical study., Objective: To assess the results of anterior strut grafting and the loss of the reduction in anterior interbody fusion and anterior interbody fusion combined with posterior instrumental fusion in pyogenic spondylodiscitis., Summary of Background Data: Resorption of the anterior graft is an ominous sign following most anterior surgery. Thus, additional posterior instrumentation has been used to prevent collapse of the anterior graft. However, its effect is controversial, and few studies have examined the fate of the anterior strut graft., Methods: Twenty-four consecutive patients underwent surgical treatment for pyogenic spondylodiscitis. The patients were divided into Group I (anterior interbody fusion) and Group II (anterior interbody fusion + posterior instrumented fusion). The sagittal angle, intervertebral height, and complications relating to the anterior graft were compared., Results: Solid bone fusion was achieved in 23 (95.8%) patients. The sagittal angle and the intervertebral height were similar in Groups I and II (P = 0.61, P = 0.89, respectively). In Groups I and II, the postoperative sagittal angle was maintained until 1 month after surgery (P > 0.05), but it decreased significantly by 3 months after surgery (P < 0.05). In Groups I and II, intervertebral height correction was maintained until 1 month after surgery (P > 0.05), but by 3 months after surgery, it had collapsed significantly (P < 0.05). Subsidence of the graft occurred through the damaged endplate. Group I included 1 case of graft dislodgement necessitating revision; there were no such cases in Group II. There were no recurrences of infection in either group., Conclusion: Reduction of intervertebral height and loss of sagittal profile occurred in both groups. Complications relating to the bone graft were more common in Group I than in Group II. Despite loss of correction, both groups had a high fusion rate without recurrence of infection. The reduction of intervertebral graft height appears to be the result of destruction of the endplate either due to surgical debridement or the infective process.

Study Design: A retrospective study examining the clinical features, management, and treatment outcome of patients with spinal tuberculosis (TB)., Objective: To determine the influence of disease severity and treatment modality on outcome of patients with spinal TB., Summary of Background Data: Although anti-TB chemotherapy is now the mainstay treatment for spinal TB, it may not be applicable to all situations, especially in patients with risk of deformity, instability, and progression of neurologic deficit., Methods: In this retrospective study (1994-2003), medical records and radiographic findings of patients with spinal TB were reviewed at 7 teaching hospitals in South Korea. The duration of triple chemotherapy with isoniazid, rifampin, and ethambutol, disease severity, operative procedures, and outcome were analyzed. The outcome was assessed as both favorable and unfavorable according to predefined criteria., Results: A total of 137 patients were diagnosed with spinal TB during the study period. Twenty-one patients were lost to follow-up and excluded from analysis. The mean age was 44.07 +/- 16.57 years. The most common vertebral area involved was the lumbar (44.8%). The mean number of vertebra involved was 2.25. The mean angle of kyphosis was 21.58 degrees. Forty-seven patients (35.1%) had severe symptoms. Radical surgery was carried out in 84 (62.2%) patients. Twenty patients were treated with short-term chemotherapy, while 96 under long-term. At the end of chemotherapy, 94 patients had achieved a favorable status and 22 an unfavorable one. Statistically, there was no significant difference between the 2 groups in terms of gender, chemotherapy duration, or the severity of spinal TB; however, age (P = 0.025; odds ratio = 0.963; 95% confidence interval 0.932-0.995) and radical surgery (P = 0.043; odds ratio = 3.047; 95% confidence interval 1.038-8.942) were significantly related to a favorable outcome by logistic analysis., Conclusions: Our results showed that a younger age and radical surgery in conjunction with anti-TB chemotherapy were significant favorable prognostic factors.

Study Design: Human intervertebral disc was obtained for the study of hypoxia inducible factor (HIF)-1alpha and apoptosis using immunohistochemical staining., Objective: To study the expression of HIF-1alpha and apoptosis in herniated lumbar discs., Summary of Background Data: The presence of HIF-1alpha in human chondrocytes and rat intervertebral discs has been proven; however, to our knowledge, its expression in human intervertebral disc cells has not been reported. Apoptosis of the human intervertebral disc appears as a degenerative change caused by the aging of the intervertebral disc. To our knowledge, there is no reported study showing the correlation between apoptosis and HIF-1alpha in the human intervertebral disc., Methods: There were 15 human intervertebral discs stained for HIF-1alpha immunohistochemically, and apoptosis was detected using the terminal deoxynucleotidyl transferase mediated-dUTP nick end labeling method. On average, the patients were 32.9 years old. The intervertebral discs were divided into noncontained (9 patients) and contained (6) groups. For the control group, 5 disc samples were used., Results: The expression of HIF-1alpha was visualized in every case, with an average of 62.2% +/- 9.5% in the noncontained group, 30.5% +/- 3.6% in the contained group, and 11.4% +/- 9.3% in the control group. Apoptosis occurred in 74.3% +/- 7.3% of the cells in the noncontained group, 42.8% +/- 5.5% of the cells in the contained group, and 28% +/- 8.4% of the cells in the control group. HIF-1alpha and apoptosis expressions were both observed more frequently in the noncontained disc herniation group (P < 0.001). The correlation analysis between the degree of HIF-1alpha expression and apoptosis was also statistically significant., Conclusions: HIF-1alpha and apoptosis physiologically occur in human beings. Their expression was the highest in the noncontained group. HIF-1alpha may play a crucial role for the survival of disc cells and resorption of the herniated disc in human intervertebral discs.

Study Design: Immunohistochemistry was performed in organ-cultured intact and cartilage endplate (CE)-fractured rat intervertebral discs (IVDs)., Objectives: To demonstrate biologic events associated with migration of chondrocytes from hyaline CE into nucleus pulposus (NP)., Summary of Background Data: It was recently revealed that the transition from a notochordal NP to a fibrocartilaginous NP in the rabbit IVD is accomplished exogenously by chondrocytes migrating from CEs into the NP. This observation has not been studied in other animal models, and the biologic events associated with chondrocyte migration have not been elucidated in the literature., Methods: IVDs including cranial and caudal CEs were obtained from 4-week, 6-month, 12-month, and 18-month old Wistar rats. To accelerate chondrocyte migration, CEs of IVDs were fractured and cultured for 48 hours. IVDs without CE-fracture were used as a control for each age group. Expressions of membrane-type I matrix metalloproteinase (MT1-MMP, as a marker for cell migration and extracellular matrix digestion) and Ki-67 protein (as a proliferation marker) and pericellular deposition of type II collagen (as a marker for fibrocartilaginous matrix) by the chondrocytes migrating from CE into NP were examined immunohistochemically., Results: In the control groups, chondrocyte migration limited only along the periphery of the notochordal NP and no chondrocytes were inside the NP proper. However, all the IVDs in the CE-fracture groups showed direct and more extensive migration of chondrocytes from CEs into the NP proper. The migrating chondrocytes in both control and CE-fracture groups expressed MT1-MMP and Ki-67 protein and deposited type II collagen in the NP., Conclusions: This report demonstrates the chondrocyte migration from CE into NP in the organ-cultured rat IVDs. This phenomenon is accelerated in the presence of CE fracture. The chondrocytes migrating from CEs into the NP expressed MT1-MMP and Ki-67 protein and deposited type II collagen. These biologic strategies probably enable chondrocytes of the hyaline CE to migrate into the ectopic NP region, replace notochordal cells, and change the notochordal tissue into fibrocartilage. These results suggest that similar biologic mechanisms may be involved in the natural transition from the notochordal NP to the fibrocartilaginous NP in other animal models, including human.

Study Design: Immunohistochemistry and in situ nick end-labeling (TUNEL) were performed in rat lumbar intervertebral discs., Objectives: To demonstrate the mechanism of notochordal cell death in the nucleus pulposus (NP)., Summary of Background Data: With age, notochordal cells gradually disappear in the NP. We hypothesized that this phenomenon might be related to Fas-mediated apoptosis., Materials and Methods: Expressions of Fas; Fas ligand (FasL); caspase 3, 8, 9, 10; Ki-67 protein; and TUNEL were examined in 4-week-, 6-month- and 12-month-old rat NPs. Apoptosis (TUNEL-positive) and proliferation potential (Ki-67-positive) indexes of notochordal cells were calculated and compared among age groups., Results: Notochordal cells constitutively expressed both Fas and FasL. Among their downstream initiator (caspase 8, 9, and 10) and executioner (caspase 3) caspases tested, caspase 9 and 3 were expressed. Proliferation potential of the notochordal cells was the highest at 4 weeks (1.96 +/- 1.3%) and decreased to a significantly lower level at 6 (0.81 +/- 0.68%) and 12 months (0.8 +/- 0.37%; P = 0.03 and 0.01, respectively). In contrast, apoptosis of the notochordal cells was the lowest at 4 weeks (3.52 +/- 1.07%) and increased to a significantly higher level at 6 (19.38 +/- 10.99%) and 12 months (21.51 +/- 16.99%; P < 0.001 in both comparisons)., Conclusions: Fas-mediated mitochondrial caspase 9 pathway is constitutively present in the rat notochordal cells. The constitutive expression of Fas, FasL and its downstream caspases, as well as the homogeneity ofnotochordal cell population suggests an autocrine or paracrine Fas-mediated counterattack to be a potential mechanism for apoptosis of rat notochordal cells. A regulated negative balance of notochordal cell proliferation against apoptosis is likely to involve the disappearance of notochordal cells in the rat NP. This information on the mechanism for apoptosis of notochordal cells could be important in the investigation of intervertebral disc development as well as aging and perhaps degeneration.

Objective: To correlate MR and CT discography findings with pain response at provocative discography in patients with discogenic back pain., Materials and Methods: Forty-seven patients aged 25-54 years who underwent MR imaging and subsequent CT discography (97 discs) were included in this study. MR images were retrospectively evaluated regarding disc degeneration, endplate abnormalities, facet joint osteoarthritis, and high intensity zone. During discography concordant pain was regarded as positive, whereas discordant pain and no pain were regarded as negative. MR and CT discographic findings were analyzed on the base of concordant pain using the Chi-square test., Results: : Concordant pain was significantly common in the following (P < 0.05): grade 4 or 5 disc degeneration [88% (30/34) in concordant pain versus 48% (30/63) in discordant pain and no pain], high intensity zone [56% (19/34) versus 30% (19/63)], combination of above two findings [53% (18/34) versus 25% (16/63)], fissured and ruptured disc at discogram [94% (32/34) versus 57% (36/63)], and contrast beyond inner annulus at CT discogram [97% (33/34) versus 57% (36/63)]., Conclusion: Typical MR findings with concordant pain at discography include grade 4 or 5 disc degeneration and presence of a high intensity zone. Typical CT discography findings with concordant pain were fissured/ruptured discs and contrast extending into/beyond the outer annulus on CT.

Study Design: Immunohistochemical study was done by harvesting articular cartilage of the facet joints during the decompressive surgery for spinal stenosis., Objectives: To observe the expression of estrogen receptor on the articular cartilage of the facet joints in degenerative spondylolisthesis (DS) SUMMARY OF BACKGROUND DATA: Few attempts have been made to evaluate the effect of sex-hormone, although DS is more common in females than in males., Methods: After harvesting the articular cartilage of the facet joints in 17 DS and in 15 spinal stenosis (SS) patients, the expression of estrogen receptor and the severity of facet arthritis were observed by H-E and immunohistochemical staining, respectively. Measurements of both staining were made by using a semiquantitative analysis., Results: The significantly increased expression of estrogen receptor correlated with the severity of facet arthritis (r = 0.78, P < 0.05). There was a significantly increased expression of estrogen receptor of the facet joint in DS compared with SS (P < 0.01). The histologic-histochemical grading of cartilage lesion in DS was 12.4 (SEM, 0.6), which was significantly higher than in SS (P < 0.05)., Conclusions: These findings suggest that the higher expression of estrogen receptor might aggravate degenerative change of the facet articular cartilage and might also be considered one of the causative factors for DS in postmenopausal women.

Study Design: Bacterial adherence and biofilm formation in implant-associated infection may vary depending on species of microorganisms and characteristics of implant surfaces., Objectives: We evaluated the differences in adherence and biofilm formation between Staphylococcus epidermidis and Mycobacterium tuberculosis on various spinal implant surfaces., Summary of Background Data: In implant-associated infections, bacteria in biofilm are resistant to antibiotics or host defense mechanism. The removal of implants is usually necessary to eradicate infection. On the contrary, in tuberculous infection, complete debridement and antituberculous chemotherapy without removal of implant have been regarded as a safe procedure., Methods: S. epidermidis and M. tuberculosis were cultured with 4 types of metal segments, smooth or rough-surfaced stainless steel, and titanium alloy, respectively. After isolation of colonized microorganisms and biofilm with trypsin treatment and culture on plate media, colony-forming units were counted. The features of adherence and biofilm formation were observed under scanning electron microscopy., Results: Biofilm-forming S. epidermidis showed heavy adhesion and multiplication on the surface of all 4 metal segments, 16.5 times more colony-forming units than nonbiofilm-forming ones. On scanning electron microscopy, there were many aggregated microcolonies with thick biofilm in biofilm-forming S. epidermidis but much less in nonbiofilm-forming S. epidermidis. M. tuberculosis were rarely adhered to metal surfaces and showed scanty biofilm formation., Conclusions: On the contrary to S. epidermidis, adherence and biofilm formation of M. tuberculosis on implant surface are less likely, and it can provide the basis of successful instrumentation in spine tuberculosis.

The recommended surgical options for postoperative wound infections after instrumented spine surgery include a wide debridement and irrigation with antibiotics. In most cases, implant removal is not recommended for a solid fusion. However, there are few reports on the treatment choices for persistent postoperative wound infections following a posterior lumbar interbody fusion (PLIF) using cages. This paper reviewed ten patients referred to our department, who underwent revision surgery for a postoperative, deep infection after a PLIF with cages. The surgery included an anterior radical debridement and interbody fusion with removal of all implants. The clinical and laboratory results, including a bacteriologic study for the causative organism and the radiological changes, were analyzed. All patients complained of persistent severe back pain after the primary surgery. MRSA was the main organism found in these patients (five cases). Complete bony fusion was obtained in nine patients (90%). In one patient, back pain and radiating pain prevented him from returning to his original work. Despite the anterior interbody fusion with an autogenous iliac bone graft, all cases had a complete collapse of the intervertebral disc space, without a dislodgement or collapse of the graft bone. The mean loss of the height and lordosis in the involved segment was 12.7 mm (range 4-46 mm) and 5.6 degrees (range 0-15 degrees ), respectively. Anterior radical debridement with the removal of all implants would be an effective way to manage patients with postoperative spondylitis after a PLIF using cages.

The purpose of this study was to demonstrate the course of a nerve root in the neural foramen and its relationship with foraminal entrapment or impingement in 19 adult patients with isthmic spondylolisthesis and radicular pain. Myelo-computed tomography and magnetic resonance imaging showed that the course of the nerve root was normal (ie, medial and then inferior, along the pedicle) in 10 patients and was deviated posteriorly in 9 patients. The patients with a normal nerve root course (N-NRC) had either a bony callus projecting medially into the spinal canal (n = 6) or a low mean percentile of vertebral slip (n = 4; 13.9 +/- 1.3). Those nine patients with a posteriorly deviated nerve root course (PD-NRC) had no medially projecting bony callus in the spinal canal but had a higher mean percentile of vertebral slip (n = 9; 31.5 +/- 10.1; P = 0.005). In the neural foramen, nerve roots of the N-NRC patients were entrapped craniocaudally between the pedicle and superior part of the intervertebral disc. In contrast, nerve roots of the PD-NRC patients were impinged ventrodorsally between the posterosuperior part of the intervertebral disc and either bony callus projecting inferiorly toward the neural foramen or fibrocartilaginous mass arising around the isthmic defect. The foraminal craniocaudal entrapment and ventrodorsal impingement highly agreed with the side of radicular pain (kappa= 0.73, P < 0.001). Our results demonstrate that the medially projecting bony callus and the percentile of vertebral slip affect the course of the nerve root in the neural foramen, which in turn determines the foraminal craniocaudal entrapment or ventrodorsal impingement. These two mechanisms, based on the course of the nerve root, correlate well with the side of radicular pain.

Objective: The purpose of this study was to determine the accuracy of MRI for discrimination between tuberculous spondylitis and pyogenic spondylitis., Materials and Methods: MR images of 52 patients who had MRI of the spine and confirmed spondylitis were retrospectively reviewed. After review of medical records, we compared MRI findings in 20 patients with tuberculous spondylitis and 20 patients with pyogenic spondylitis. Statistical analysis was performed with the chi-square test., Results: The reviewer identified tuberculous spondylitis with sensitivity, specificity, and accuracy of 100% (20/20), 80% (16/20), and 90% (36/40), and pyogenic spondylitis with sensitivity, specificity, and accuracy of 80% (16/20), 100% (20/20), and 90% (36/40), respectively. The patients with tuberculous spondylitis had a significantly higher incidence of MRI findings as follows (p < 0.05): a well-defined paraspinal abnormal signal (95% [19/20] in tuberculous vs 25% [5/20] in pyogenic), a thin and smooth abscess wall (95% [19/20] vs 15% [3/20]), combination of both findings (90% [18/20] vs 0% [0/20]), presence of paraspinal or intraosseous abscess (95% [19/20] vs 50% [10/20]), subligamentous spread to three or more vertebral levels (85% [17/20] vs 40% [8/20]), involvement of multiple vertebral bodies (60% [12/20] vs 25% [5/20]), thoracic spine involvement (40% [8/20] vs 10% [2/20]), and hyperintense signal on T2-weighted images (95% [19/20] vs 65% [13/20])., Conclusion: MRI was accurate for differentiation of tuberculous spondylitis from pyogenic spondylitis.

The purpose of this study was to determine whether MR findings can correlate disease activity as measured by laboratory markers in ankylosing spondylitis. MR images in 19 patients with ankylosing spondylitis were retrospectively analyzed for cartilage abnormality, periarticular erosion, synovial enhancement, and bone marrow edema. Each MR finding was correlated with laboratory inflammatory markers (erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP)) and the sum of ESR + CRP. Synovial enhancement showed a significant correlation with ESR (r=0.58; p<0.01) and increased activity at bone scan (r=0.74; p<0.005), whereas there was no significant correlation with CRP. A significant correlation was found between ESR + CRP and synovial enhancement (r=0.54; p<0.05). Synovial enhancement was more common when ESR + CRP was greater than 30 (p<0.05). In conclusion, synovial enhancement at MR imaging could correlate disease activity as measured by laboratory inflammatory markers in ankylosing spondylitis.

Study Design: A case report and review of the literature., Objectives: To present a case of chronic inflammatory epidural granuloma formed after acupuncture., Summary of the Background Data: A number of cases of complications resulting from acupuncture have been reported, including acute infection, hemorrhage, and direct injury to internal organs or neural tissues. However, to the best of our knowledge, there has been no report of epidural granuloma formed following acupuncture and mimicking clinical manifestations of lumbar stenosis., Methods: A 68-year-old woman suffered from low back pain and sciatica aggravated by acupuncture. We reviewed her medical record, imaging studies, microscopic findings of the mass, and related literature., Results: Microscopic examination revealed the mass as a chronic inflammatory granuloma. From her previous history and imaging study, the mass, which compressed the lumbar forth nerve and dural sac,was highly suspected to have been formed after acupuncture. Surgical decompression and excision of the epidural mass relieved her symptoms., Conclusion: Chronic inflammatory granuloma may be formed as a complication of acupuncture. Under such circumstances, surgical excision of the mass may be an effective way of relieving the symptoms.

Study Design: A case of bilateral pedicle stress fracture is reported, and the literature is reviewed., Objectives: To report the rare case of bilateral pedicle stress fracture after instrumented posterolateral fusion, and to investigate the contributing factors., Summary of Background Data: A 62-year-old man underwent revision spinal surgery for adjacent-segment degeneration. Decompression and instrumented posterolateral fusion from L1 to L3 were performed after removal of the previously inserted pedicular screws. In the patient's history, he had undergone L3-L5 instrumented posterolateral fusion for spinal stenosis 6 years previously. At 1 year after the revision surgery, he presented with severe progressive low back pain. Computer-assisted tomogram and bone scan demonstrated bilateral L4 pedicle stress fracture. To the best of the authors' knowledge, only two cases of pedicle stress fracture after lumbar posterolateral fusion have been reported., Methods: This study reviewed the reported patient's medical record, his imaging studies, and related literature. The possible factors contributing to bilateral pedicle stress fractures were investigated., Results: In the reported case, the features of radiographic studies confirmed bilateral pedicle stress fracture. The involved vertebra was L4. In all three cases reported so far, including the current case, the site of the pedicle stress fracture was at the junction of the pedicle and vertebral bodies., Conclusions: Bilateral pedicle stress fracture occurs as a complication of posterolateral lumbar fusion. Pedicle weakening by prior inserted screws and persistent anterior motion after posterolateral fusion are the contributing factors.

Study Design: A case report and review of the literature are presented., Objective: To describe an unusual simple bone cyst involving the pedicle of lumbar spine., Summary of Background Data: To the authors' knowledge, only nine cases of a simple bone cyst involving the spine have been reported. Most of these reports have described mild back or neck pain because the presenting symptoms or cysts were found incidentally. In the reported case, acute severe back pain with radiating pain developed. Therefore, the study focus was on the unusual location, the presenting symptoms, and its spinal involvement., Methods: A cystic lesion involving the left pedicle of the first lumber vertebra was identified in a 53-year-old woman with sudden-onset severe back pain with pain radiating to the left leg. Surgical resection was undertaken along with review of the patient's medical record, imaging studies, microscopic findings of the lesion, and the related literature., Results: Microscopic examination of the cystic lesion corresponded with the findings of a simple bone cyst. A thin fibrous membrane with reactive bone formation was identified without evidence of hemorrhage. A favorable result was achieved by surgical resection., Conclusions: This case study suggests that a simple bone cyst may be found in any portion of the spine, including the pedicle. Severe resting pain would be elicited by a pathologic fracture of the pedicle. Direct nerve compression by the fractured fragment and chemical irritation by cystic fluid would be compatible with the observed clinical manifestations.

A study was performed to determine which magnetic resonance (MR) imaging findings are useful in discrimination between metastatic compression fractures and acute osteoporotic compression fractures of the spine. The MR imaging findings in 27 patients with metastatic compression fractures and 55 patients with acute osteoporotic compression fractures were compared by using the chi(2) test. MR imaging findings suggestive of metastatic compression fractures were as follows: a convex posterior border of the vertebral body, abnormal signal intensity of the pedicle or posterior element, an epidural mass, an encasing epidural mass, a focal paraspinal mass, and other spinal metastases. MR imaging findings suggestive of acute osteoporotic compression fractures were as follows: a low-signal-intensity band on T1- and T2-weighted images, spared normal bone marrow signal intensity of the vertebral body, retropulsion of a posterior bone fragment, and multiple compression fractures. The signal intensity on fast spin-echo T2-weighted images obtained without fat suppression played little role in distinguishing between metastatic compression fractures and acute osteoporotic compression fractures., (Copyright RSNA, 2003.)