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No study has investigated preoperative anxiety about spinal surgery under general anesthesia. The purposes of this study were (1) to determine how many patients have preoperative anxiety about spinal surgery and general anesthesia, (2) to evaluate the level of anxiety, (3) to identify patient factors potentially associated with the level of anxiety, and (4) to describe the characteristics of the anxiety that patients experience during the perioperative period. This study was performed in 175 consecutive patients undergoing laminectomy for lumbar stenosis or discectomy for herniated nucleus pulposus under general anesthesia. Demographic data, information related to surgery, and characteristics of anxiety were obtained using a questionnaire. The level of anxiety was assessed using a visual analog scale of anxiety (VAS-anxiety). Patient factors potentially associated with the level of anxiety were investigated using multiple stepwise regression analysis. Of 157 patients finally included in this study, 137 (87 %) had preoperative anxiety (VAS-anxiety > 0). The mean VAS-anxiety score for spinal surgery was significantly higher than that for general anesthesia (4.6 ± 3.0 vs. 3.2 ± 2.7; P

To investigate volumetric changes in lumbar disc herniation (LDH) using three-dimensional measurements obtained by magnetic resonance imaging (MRI) and to identify possible factors affecting such changes. Between January 2004 and December 2011, 43 patients who underwent conservative treatment for LDH were enrolled. In all, 56 disc levels were investigated. MRI was performed on two or more occasions (minimally, at the initial visit and 6 months later). The volume of each herniated disc was determined. For each patient, disc migration, morphology, initial LDH size, and clinical outcome were evaluated. The mean volumes of herniated discs at the initial and follow-up visits were 1,304.57 ± 837.99 and 993.84 ± 610.04 mm3, respectively. The mean change in volume from the initial to the follow-up visit was 310.73 ± 743.60 mm3. Volumes decreased at 35 disc levels and increased at 21 levels. The disc containment, the extent of LDH, the initial size of the herniated disc, and the degree of intactness of the posterior longitudinal ligament were significantly correlated with disc resorption and an increase in disc volume (p = 0.01, p = 0.018, p = 0.001, and p

Patients in whom good intertransverse fusion had been achieved were selected for the volumetric study of the fusion mass using sequential computed tomography scans.To assess the natural volumetric change of intertransverse fusion mass and the effect of the disease entity and spinal instrumentation on the fusion mass volume.The magnitude of volumetric change of the graft bone after intertransverse fusion is still inconclusive.Fifteen adult patients who underwent decompression surgery with single-level lumbar and lumbosacral intertransverse fusion were selected for this study. Preoperative diagnoses were degenerative spondylolisthesis in nine patients and isthmic spondylolisthesis in six. Seven of the 15 patients received pedicle screw fixation. They were categorized into two major groups: 1) instrumented and noninstrumented groups and 2) isthmic and degenerative groups. To assess the volumetric change of the graft bone, sequential computed tomography scans were obtained 2 weeks after surgery and again 18 months after surgery.The overall initial mean graft volume was 6251 mm3, which decreased to 2842 mm3 by 18 months after surgery (P0.001). The overall mean volume loss between the two periods was 54.8% of the initial graft volume. Although there was no significant difference in the mean graft volume between the groups at either 2 weeks or 18 months after surgery (P0.05 in all comparisons), the mean graft volume in each group decreased significantly during the observation period (P0.01 in all comparisons). There was no significant difference in the mean volume loss or in the ratio of residual volume to the initial graft volume between the groups during the study period (P0.05 in all comparisons). The initial graft volume correlated positively with the graft volume at 18 months after surgery (r = 0.612, P0.01) and volume loss (r = 0.949, P0.01), but negatively with the residual volume ratio (r = -0.507, P0.01).These results showed that more than one half of the initial graft bone volume was being absorbed during the consolidation processes of the graft bone, and that the volume loss during the period was not significantly affected by the spinal instrumentation or by the disease entity. It was also found that the greater the amount of the initial graft bone, the larger the fusion mass at 18 months after surgery. The volume loss, however, increased proportionally to an increase in the initial graft bone volume. The efficiency (ratio of residual volume to the initial graft volume) of the intertransverse fusion also tended to decline as the initial graft volume increased.

Fractalkine (CX3CL1) and its receptor (CX3CR1) comprise a chemokine system involved in leukocyte recruitment and adhesion in chronic inflammatory disease, but its role in spinal diseases is unknown. The purpose of this study is to investigate the role of CX3CL1/CX3CR1 chemokine on hypertrophy of the ligamentum flavum (LF) in degenerative lumbar stenosis (DLS) compared with that of non-degenerative spinal condition (NDS) of the lumbar spine and correlation between expression of CX3CL1/CX3CR1 chemokine and thickness of LF. The mRNA concentrations of CX3CL1/CX3CR1 chemokine were analyzed in the surgically obtained LF specimens from DLS (n = 10) and NDS (n = 11) by real-time PCR. The localization of CX3CL1/CX3CR1 chemokine within the LF was determined using immunohistochemical study. Plasma levels of soluble FKN (sFKN) were measured by enzyme-linked immunosorbent assay, respectively. The thickness of the LF was measured with axial T1-weighted MRI. The cells that express CX3CL1/CX3CR1 chemokine ratio in the LF observed in DLS group were substantially higher than in NDS group. In ELISA, the plasma levels of sFKN was significantly increased in DLS compared with patients in the other groups (p = 0.006). There was greater CX3CL1/CX3CR1 expression in DLS as quantified by RT-PCR (p = 0.004, 0.010). Thickness of LF in patients was significantly correlated with serum CX3CL1 level (R(2) = 0.824, p = 0.003) and with mRNA expression of CX3CL1/CX3CR1 (R(2) = 0.671, p = 0.000) (R(2) = 0.514, p = 0.001). This study identified for the first time that increases in CX3CL1 and CX3CR1-expressing cells are significantly related to LF hypertrophy.

STUDY DESIGN Animal experimental study. OBJECTIVE To present experimental evidence for mesenchymal cell therapy for spinal cord injury (SCI). SUMMARY OF BACKGROUND DATA Prior to clinical application of stem cell therapy for SCI, many critical issues have to be addressed including efficiency, safety, method of transplantation, and differentiation of the transplanted cells. METHODS Chronic contusive SCI was induced in 36 Sprague-Dawley rats and randomly assigned to the intralesional (IL), intravenous (IV), or control groups. At 6 weeks post injury, allogenic mesenchymal stem cells (MSCs, 1 × 10 cells) were transplanted either intralesionally or intravenously for the intervention groups. Engraftment of the transplanted MSCs was evaluated with PKH 26 staining. Differentiation was evaluated using double stain with neuronal and glial cell markers. Brain-derived neurotrophic factor and nerve growth factor (NGF) were used for neurotrophic factor expression. Basso, Beattie, and Bresnahan locomotor rating scale was used for evaluation of functional recovery. RESULTS The estimated engraftment percentage of the transplanted cells in the IL group and IV group were 36.5%, and 15.5%, respectively. The engraftment of the transplanted MSCs was higher in the IL group than in the IV group. Most of the transplanted MSCs were colocalized with GFAP in both transplantation groups. Brain-derived neurotrophic factor and NGF expression (Western blot and real-time polymerase chain reaction) in the injured spinal cord was higher in both transplanted groups compared with those in the control group. At 6 weeks post transplantation, the mean Basso, Beattie, and Bresnahan locomotor scales in the IL, IV, and control groups were 5.63 ± 0.89, 5.63 ± 1.03, and 2.88 ± 0.44, respectively. The functional recovery seen in the rats that underwent transplantation was significantly better than that in the control group (P < 0.05). CONCLUSION Although the number of engrafted cells and expression of neurotrophic factors were lower in the IV group than those in the IL group, both IL and IV transplantation of MSC in the chronic SCI gave a significant clinical improvement. However, there were no differences in differentiation of the transplanted cells between the IL group and IV group. Astrocytic differentiation of the transplanted cells was predominant. LEVEL OF EVIDENCE N/A.

Sixty-seven patients were treated for Pott's paraplegia: 58 were adults and 9 were children. Sixty-four patients had active disease, and 3 had healed disease. All patients had triple chemotherapy with or without decompression surgery. Thirteen patients, including 9 children, were treated conservatively, whereas 54 patients who met the selection criteria for surgery were treated surgically. Fifty-two patients had anterior radical decompression surgery, and for 14 of them, anterior surgery was preceded by posterior instrumental stabilization surgery. Two patients with healed disease had posterior decompressive corpectomy. There was functional recovery in 60 (89.6%) patients, including 13 who had active disease that was treated conservatively. In 47 of the 54 surgically treated patients there was neurologic recovery, and 2 of these recovered incompletely with some residual spasticity. In the remaining 7 patients, there was no recovery. It took 2 to 6 months for recovery for the patients with conservative treatment, whereas it took

The authors undertook this study to investigate the validity of the rationale for posterior dynamic stabilization using the Device for Intervertebral Assisted Motion (DIAM) in the treatment of degenerative lumbar stenosis.A cohort of 31 patients who underwent single-level decompression and DIAM placement for degenerative lumbar stenosis were followed up for at least 2 years and data pertaining to their cases were analyzed prospectively. Of these patients, 7 had retrolisthesis. Preoperative and postoperative plain lumbar radiographs obtained in all patients and CT images obtained in 14 patients were analyzed. Posterior disc heights; range of motion (ROM) of proximal, distal, and implant segments; lordotic angles of implant segments; percentage of retrolisthesis; and cross-sectional area and heights of intervertebral foramina on CT sagittal images were analyzed. Clinical outcomes were evaluated using visual analog scale scores and Oswestry Disability Index scores.The mean values for posterior disc height before surgery, at 1 week after surgery, and at the final follow-up visits were 6.4 ± 2.0 mm, 9.7 ± 2.8 mm, and 6.8 ± 2.5 mm, respectively. The mean lordotic angles at the implant levels before surgery, at 1 week after surgery, and at the final follow-up visits were 7.1° ± 3.3°, 4.1° ± 2.7°, and 7.0° ± 3.7°, respectively. No statistically significant difference was found between the preoperative values and values from final follow-up visits for posterior disc height and lordotic angles at implant levels (p = 0.17 and p = 0.10, respectively). There was no statistically significant difference between the preoperative and final follow-up visit values for intervertebral foramen cross-sectional area and heights on CT images. The ROMs of proximal and distal segments also showed no significant decrease (p = 0.98 and p = 0.92, respectively). However, the ROMs of implant segments decreased significantly (p = 0.02). The average 31.4-month improvement for all clinical outcome measures was significant (p0.001).Based on radiological findings, the DIAM failed to show validity in terms of the rationale of indirect decompression, but it did restrict motion at the instrumented level without significant change in adjacent-segment ROM. The clinical condition of the patients, however, was improved, and improvement was maintained despite progressive loss of posterior disc height after surgery.

The device for intervertebral assisted motion (DIAM) is a dynamic implant that consists of a silicone bumper enveloped by a polyethylene terephthalate (PET) fiber sack. Silicone and PET were used because of their biological inertness, but repetitive motion of the spine can cause wear on the implant nonetheless. The purpose of this study is to report a case of foreign body reaction (FBR) against a DIAM. A 72-year-old female patient presented with lower back pain and both legs radiating pain. She had undergone DIAM implantation at L4–5 for spinal stenosis 5 years previously. The intervertebral disc space of L4–5, where the DIAM was inserted, had collapsed and degenerative scoliosis had developed due to left-side collapse. MRI showed L3–4 thecal sac compression and left L4–5 foraminal stenosis. The patient underwent removal of the DIAM and instrumented fusion from L3 to L5. During surgery, fluid and granulation tissue were evident around the DIAM. Histopathology showed scattered wear debris from the DIAM causing chronic inflammation due to the resulting FBR. A FBR due to wear debris of a DIAM can induce a hypersensitivity reaction and bone resorption around the implant, causing it to loosen.

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.

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.

To develop a clinically relevant anterior cervical approach (ACA) to the C2-3 level.Frequently encountered nerves [hypoglossal (HyN), internal (ISLN) and external superior laryngeal nerves (ESLN)] and vessels [lingual (LiA), superior laryngeal (SLA) and superior thyroid arteries (STA)] in the field of high ACA and the anatomic spatial markers [submandibular gland (SMG); sling for digastrics muscle (SDG); hyoid bone (HyB), and thyroid cartilage (ThC)] were evaluated using 18 fresh cadavers. The vertical distance of each structure at the carotid sheath and larynx and each disc for cervical level were measured from the suprasternal notch.The cervical levels of SDG, SMG and HyB were mostly C3 and that of ThC was C5. The vertical locations of HyN and LiA were not significantly different and the levels corresponded to C2. The levels for ISLN and ESLN were C3 at carotid and C4 and C5 at larynx sides, respectively. The vertical locations of ISLN and HyN were significantly different at carotid (p = 0.001) and larynx (p0.001) sides. The vertical locations and cervical levels of SLA and STA at carotid and larynx sides were not significantly different with those of ISLN and ESLN, respectively. The HyN traversed C2 with accompanying LiA. The ISLN passed C3 and C4 from carotid to larynx sides and accompanied SLA.The C2-3 level can be exposed through the space between the HyN and the ISLN by retracting the LiA superiorly, the SLA inferiorly, the HyB medially, and the carotid sheath laterally.

Metastatic spine disease (MSD) is a complex disease entity requiring multi-discipline and multi-modality approach to obtain the most reasonable clinical outcomes. As one of these trials, radiofrequency ablation (RFA) has been tried. Here, we describe four cases of metastatic spine lesions (2 hepatomas, 1 lung cancer, 1 breast cancer) that were treated with intraoperative RFA to control the lesion and to limit tumor contamination. During 3-month follow-up, most patients experienced effective pain relief and improvement of their functional status. However, their final results were diverse. There were no complications related to this procedure. In two cases, the treated lesions were re-evaluated radiologically using PET–CT and diffusion-weighted MRI. Up to the time of this report, the patients are well without progressive deterioration of the treated lesion. With review of the related literatures, we discuss the efficacy and safety of this therapeutic approach as one of options for the treatment of MSD with neurologic manifestations.

This research was performed to investigate the differences of the transplanted cells' survival and differentiation, and its efficacy according to the delivery routes following spinal cord injury. Allogenic mesenchymal stem cells (MSCs) were transplanted intravenously (IV group) or intralesionally (IL group) at post-injury 1 day in rats. Behavioral improvement, engraftment and differentiation of the transplanted cells and the expression of neurotrophic factors of the transplanted groups were analyzed and compared with those of the control group. At 6 weeks post-injury, the mean BBB motor scales in the control, IV and IL groups were 6.5 ± 1.8, 11.1 ± 2.1, and 8.5 ± 2.8, respectively. Regardless of the delivery route, the MSCs transplantation following spinal cord injuries presented better behavioral improvement. The differentiations of the engrafted cells were different according to the delivery routes. The engrafted cells predominantly differentiated into astrocytes in the IV group and on the other hand, engrafted cells of the IL group demonstrated relatively even neural and glial differentiation. The expressions of neuronal growth factor were significantly higher in the IL group (mean relative optical density, 2.4 ± 0.15) than those in the control (2.16 ± 0.04) or IV group (1.7 ± 0.23). Transplantation of MSCs in the early stage of spinal cord injury gives a significant clinical improvement. However, the fate of the transplanted MSCs and expression of neuronal growth factors are different along the transplantation route.

Sacral bone remodeling with abnormal dilatation of intervertebral foramina is usually associated with Tarlov's perineurial cysts but can also be caused by slow-growth lesions. In this case report, an atypical inflammatory sacral cyst with bone scalloping was found and some possible causes are suggested. A 77-year-old woman complained of severe back pain and claudication with anal tone weakness. A plain roentgenogram and CT showed spinal canal expansion and characteristic border scalloping of the sacrum. MRI showed septated cystic content with peripheral enhancement. Laminectomy was performed. The cyst contained yellowish viscous material that was easily removed. The neurological symptoms improved after surgery. The cystic wall was composed of dense fibrous tissue without epithelial cell lining; the cystic content was, on histology, inflammatory cells including neutrophils and lymphocytes. Patients who have sacral intraspinal cysts should be identified before doing the treatment such as acupuncture and epidural steroid injection to avoid infection to those cysts.

Study design Prospective cohort study. Objective To investigate the fate of posterior osteophytes after anterior cervical discectomy and fusion (ACDF) using computed tomography. Summary of background data As a method of ACDF, indirect decompression through interbody height distraction and spontaneous posterior osteophyte resorption has the advantage of reducing complications that can occur during direct decompression. However, the outcome of resorption, of the posterior osteophytes, has not been considered to be satisfactory. Methods Thirty-one patients underwent ACDF with plate fixation for cervical spondylotic radiculomyelopathy. The areas and lengths of the most prominent posterior osteophytes in each patient and the anteroposterior diameter of the intervertebral foramen were measured from computed tomographic images using commercial software. Results Among 31 patients, the posterior osteophytes decreased in 7 (23%), increased in 5 (16%), and were unchanged in 19 (61%). The mean change of area of prominent posterior osteophytes (ΔArea(5 years - 3 months)) was -0.42 ± 4.21 mm. There was no statistically significant change between Area(3 months) and Area(5 years) (P = 0.82). The mean change of length (ΔLength(5 years - 3 months)) was -0.02 ± 0.41 mm. There was no statistically significant difference between Length(3 months) and Length(5 years) (P = 0.84). The mean anteroposterior diameter of each intervertebral foramen of fused segments did not change significantly between 3 months and 5 years postoperatively on oblique foraminal images (C5 Rt. P = 0.31, Lt. P = 0.56; C6 Rt. P = 0.61, Lt. P = 0.49) and axial images (C5 Rt. P = 0.61, Lt. P = 0.49; C6 Rt. P = 0.71, Lt. P = 0.51). Conclusion Contrary to previous reports, there was no evidence of consistent posterior osteophyte resorption during 5 years of follow-up.

STUDY DESIGN Comparative genomic hybridization (CGH) microarrays. OBJECTIVE To identify genomic copy number variations (CNVs) in degenerative lumbar scoliosis (DLS) patients, and investigate the possibility of genetic predisposition in DLS. SUMMARY OF BACKGROUND DATA Genome scanning technology enables search for presence of CNVs. CGH microarray is a useful procedure in a genome-wide study. METHODS Among 45 consecutive patients who were diagnosed as DLS, 15 patients who manifested greatest Cobb's angle were selected for the array-CGH based CNV analysis. Control group was blood samples from 58 individuals without DLS. Oligonucleotide CGH microarray was utilized to analyze the CNV. Gene searches were performed for CNV DNA with significant gene-dosage difference. Validation qualitative PCR(qPCR) was performed at 3 genetic loci: at chromosome 2--TMEM163 gene, at chromosome 16--ANKRD 11 gene, and at chromosome 18--NFATC1 gene. RESULTS Genomic gains and losses were observed using the oligonucleotide CGH microarray. Identified CNVs were 446 ± 129 per individual. Gain- and loss-CNVs were identified as 196 ± 24 and 250 ± 110, respectively. The length of total CNV per individual was 30,946,730 ± 31,658,175 bp, and mean CNV-length was 61,017 ± 40,620 (median length 6411 ± 1994). Comparison with control group revealed 260 CNVs, which were significant (P < 10(-3)). Validation qPCR for gene-dosage comparison of DLS group DNA versus control group DNA in TMEM163 (P < 0.001); ANKRD 11 (P = 0.000); and NFATC1 (P = 0.000) gene showed significant difference. CONCLUSION Various whole-genome CNVs specific to DLS patients were observed. Validation qPCR confirmed significantly different gene-dosages for TMEM163, ANKRD 11, and NFATC1 genes. We consider that the expression of DLS is supported by various typical CNV-associated structural variants of the genome.

Study design Both sequestrated nucleus pulposus (SNP) and the remaining nucleus pulposus (RNP) were studied from the discs of the same patient to evaluate apoptosis using immunohistochemical staining. Objective To compare apoptosis of the SNP and the RNP in the disc of the same patient. Summary of background data Many studies have been conducted on the natural history and apoptosis of the herniated nucleus pulposus; however, apoptosis of the remaining nucleus cells, after removal of the sequestrated disc, in the same patient, has not been reported. Materials and methods Eight samples of SNP and RNP from the disc of the same patient were obtained. The TUNEL stain was performed to confirm the occurrence of apoptosis in disc cells. Immunohistochemistry staining and Western blot analysis were performed to determine the presence of proteins, including caspase-3,-8,-9, and Bid. Results TUNEL-positive chondrocytes were identified in all of the SNP and RNP samples; the apoptotic index was 5.8 ± 1.9% and 5.9 ± 1.2%, respectively (P = 0.60). Caspase-3,-8,-9, and Bid were expressed in the SNP and the RNP of the cytoplasm and the nucleus by the immunohistochemical staining. The expression of active caspase-3,-8,-9, and Bid in the RNP of the disc and the SNP was different in each patient. Conclusion The frequency of chondrocyte apoptosis in the SNP and the RNP was not different in the disc. The pathways involved in chondrocyte apoptosis of the SNP and the RNP differed among individuals and included intrinsic and/or extrinsic pathways.

Study design This study investigated the outcome of combined therapy with irradiation and methylprednisolone (MP) after a traumatic spinal cord injury (SCI). Objective To evaluate the neurologic outcomes as well as the antiapoptotic and anti-inflammatory effects on traumatic SCI in rats after combined therapy. Summary of background data Although irradiation carries the risk of secondary SCI, it has been effective for the regeneration of the axons of nerve cells by reducing gliosis. Thus, to minimize apoptosis and irradiation risks after SCI, this study investigated the effects of steroid injections before irradiation. Methods Thirty-two rats were used for the experimental procedure. After a traumatic SCI, they were divided into 4 groups of 8 rats each: (1) a control group that only had rats with a SCI (Group 1); (2) a group that received MP at 30 minutes, 6 hours and 24 hours, and then received irradiation 2 days after the SCI (Group 2); (3) a group that received MP at 30 minutes, and irradiation 2 days after the SCI (Group 3); and (4) a group that received irradiation 2 days after the traumatic SCI (Group 4). Results The degree of recovery using the inclined plane climbing test was greatest in Group 2, followed by Group 3, Group 4, and Group 1. The cavitation lesions, Terminal Deoxynucleotidyl Transferase dUTP Nick End Labeling -positive apoptosis, glial fibrillary acidic protein-positive astrocyte count, and CC-1-positive oligodendrocyte count significantly decreased in the irradiated groups (Groups 2, 3, 4) compared to the control group (Group 1). In particular, they decreased considerably more in the group that received MP 3 times (Group 2) compared to the group that received MP only once (Group 3). Conclusion These results suggest that the combined therapy was effective and might provide synergistic effects for neurologic recovery after a traumatic SCI.

STUDY DESIGN Prospective clinical study. OBJECTIVE To determine the effect of vertebroplasty on pulmonary function in patients with osteoporotic compression fractures of the thoracic spine. SUMMARY OF BACKGROUND DATA A percutaneous vertebroplasty is an excellent method for relieving pain and improving the quality of life in patients with osteoporotic compression fractures of the thoracic spine. However, the effect of vertebroplasty on pulmonary functions in such patients has not been reported. METHODS This study included 72 patients (85 vertebrae) who underwent percutaneous vertebroplasty for thoracic osteoporotic compression fractures (male/female, 10/62; mean age, 75.7±7.6 y). Pulmonary function tests (PFTs) were conducted preoperatively on the study patients, and 2 days, 1 month, and 3 months postoperatively. PFT parameters [% predicted forced expiratory volume in 1 s (% pred FEV1), % predicted forced vital capacity (% pred FVC), and FEV1/FVC ratio] were measured using a spirometer. A visual analogue scale (VAS) score, the thoracic kyphotic angles, and the local kyphotic angles were obtained before and after vertebroplasty to evaluate the clinical and radiologic outcomes. The correlations among variables (PFT parameters, age, gender, the number of vertebrae involved in the vertebroplasty, the change of thoracic kyphotic angles, the change of local kyphotic angles, and the VAS scores) were analyzed. RESULTS The preoperative and postoperative (2 d, 1 mo, and 3 mo) PFT parameters were as follows: % pred FVC, 58±23.8, 71.8±22.2, 75.4±21.4, and 76±22.1; % pred FEV1, 58.3±24.3, 66.1±23.7, 67.5±24.2, and 68±24.5; FEV1/FVC ratio (%), 101.2±17.8, 91.3±15.5, 88.8±15.2, and 88.6±14.2, respectively. The preoperative mean VAS score was 7.93±1.5 and significantly decreased to 3.15±1.59, 1.76±1.26, and 1.67±1.23 at 2 days, 1 month, and 3 months after the vertebroplasty, respectively. There were no significant differences in the thoracic and local kyphotic angles after the vertebroplasty compared with the preoperative values. The decrease in the VAS scores and age correlated with the PFT parameters; however, there were no significant correlations between the PFT parameters and other variables. CONCLUSIONS Vertebroplasty improved pulmonary function immediately after the procedure in patients with osteoporotic compression fractures of the thoracic spine, and this improvement correlated with pain relief.

To (1) clarify the role of various risk factors in the development of ASD, (2) compare instrumentation configuration with the development of ASD, (3) correlate the radiological incidence of ASD and its clinical outcome and (4) compare the clinical outcome between patients with radiological evidence of ASD and without ASD.This study prospectively examined 74 consecutive patients who underwent instrumented lumbar/lumbosacral fusion for degenerative disease with a minimum follow-up of 5 years. Among the patients, 68 were enrolled in the study. All of the patients had undergone preoperative radiological assessment and postoperative radiological assessment at regular intervals. The onset and progression of ASD changes were evaluated. The patients were divided in two groups: patients with radiographic evidence of ASD (group 1) and patients without ASD changes (group 2). Comprehensive analysis of various risk factors between group 1 and group 2 patients was performed. The Visual Analog Scale (VAS) was used to evaluate the clinical outcome and the functional outcome was evaluated using the Oswestry Disability Index (ODI) before and after surgery along with radiological assessment.Radiographic ASD occurred in 20.6% (14/68) of patients. Preoperative disc degeneration at an adjacent segment was a significant risk factor for ASD. Other risk factors such as the age of a patient at the time of surgery, gender, preoperative diagnosis, length of fusion, instrumentation configuration, sagittal alignment and lumbar or lumbosacral fusion were not significant risk factors for the development of ASD. There was no correlation between ASD and its clinical outcome as determined at the final follow-up session. In addition, clinical outcome of patients with ASD and without ASD were not comparable.Patients with preoperative disc degeneration at an adjacent segment were more at risk for the development of ASD. Other risk factors including instrumentation configuration were not significantly associated with ASD. There was no correlation between both the radiological development of ASD and its clinical outcome and the clinical outcome of patients with and without ASD.

Study design A case report and review of the literature. Objectives To report a rare case of a vertebral compression fracture in the middle of fused segments in the absence of a history of trauma, and to investigate the contributory factors. Summary of background data Few articles have been published on vertebral fractures among fused segments. However, several articles have addressed fractures at juxtafused segments after implant removal. To the best of the authors' knowledge, only one case of compression fracture within fused segments has been previously reported. Methods This study involved the case of a 62-year-old woman with vertebral compression fracture of L4 within a solid fused segment region after implant removal. An investigation was conducted to identify the factors that contributed to this compression fracture. Results Plain radiographs and bone scanning showed a compression fracture of L4 within a region of fused segments (L3-S1) after implant removal without the history of injury. BMD revealed osteopenia of -2.3 SD on the neck of the femur. The patient's symptoms were relieved by conservative treatment. The contributory factors may have been persistent anterior motion, osteopenia and/or osteoporosis, and a subcortical substance defect associated with screw tracks after implant removal. Conclusion Vertebral compression fractures in solid fused segments may occur as a complication of implant removal. Accordingly, if spinal implant removal is needed for revision surgery, surgeons should be aware of this significant complication.

Study Design Retrospective radiographic study. Purpose To evaluate the efficacy of the proximal lumbar curve flexibility compared with the traditional whole lumbar curve flexibility in patients with main thoracic adolescent idiopathic scoliosis (MT-AIS). Overview of Literature Traditionally the flexibility of the whole lumbar curve was measured, and the flexibility of the proximal lumbar curve was not analyzed in any study. Methods Twenty-eight MT-AIS patients treated by anterior selective thoracic fusion (STF) were evaluated after mean follow-up of 50.1 months (range, 25 to 116 months). The male : female ratio was in 5 : 23. The man age at surgery was 14 years and 8 months (range, 11.4 to 18.4 years). The lumbar curve was divided into the proximal and distal curves by the lumbar apex. Results The mean final correction rates (CR)/(flexibilities) of the MT, lumbar, proximal lumbar, and distal lumbar curves were 65.2%/(50.5%), 61.9%/(92.8%), 65.3%/(90.9%), and 36.4%/(134%), respectively. With the final lumbar CR, the lumbar flexibility (r = 0.267, p > 0.05) and the proximal lumbar flexibility (r = 0.327, p > 0.05) was similarly correlated. The mean lumbar CR was similar to the proximal lumbar CR (61.9% vs. 65.3%, p = 0.305). And the correlation between the flexibility and the CR was significant only in the proximal lumbar curve (r = 0.457, p < 0.05), but not in the lumbar curve (r = 0.267, p > 0.05) or the distal lumbar curve (r = 0.175, p > 0.05). Conclusions The proximal lumbar curve flexibility may be an alternative method of measuring the lumbar flexibility in MT-AIS patients treated by STF.

Study design Human ligamentum flavum (LF) was examined for the activity level of matrix metalloproteinase-3 (MMP-3) in degenerative spondylolithesis (DS) patients using immunohistochemistry, Western blot, reverse transcriptase-polymerase chain reaction (RT-PCR), and quantitative real-time PCR. Objective To investigate the hypothesis that the activity of MMP-3 is elevated in LF of DS patients, which might contribute to DS pathogenesis. Summary of background data MMP-3 is a proteinase produced by connective tissue cells and is responsible for the degradation and modification of extracellular matrix molecules. MMP-3 activity has been established in articular cartilage, synovial membrane, and intervertebral discs, but not in the LF. Methods The experimental group consisted of 18 patients with DS and the control group consisted of 18 patients with spinal stenosis (SS) without any instabilities. MMP-3 expression was measured with in situ using immunohistochemistry and both for mRNA and protein levels. Results The MMP-3 positive cell ratio in the LF observed in DS patients was substantially higher than in SS patients (P = 0.030). In Western blot, the average optical density (OD) of MMP-3 was higher in LF of DS than of SS (P = 0.028). There was greater MMP-3 expression in DS patients as quantified by RT-PCR (P = 0.004). Conclusion Our study shows that MMP-3 expression in the LF of DS patients was significantly higher than in SS patients. Increased MMP-3 expression may be associated with the degenerative changes of LF in DS patients comprising one of the mechanisms of pathogenesis in DS.

Study Design. Prospective cohort study. Objective. To determine: (1) patterns of bone graft volumetric changes, (2) whether different fusion methods, numbers of fusion segments, and range of fusion affect bone graft volumetric changes, and (3) whether these changes affect clinical and functional outcomes after surgery. Summary of Background Data. Bone graft volumetric change is likely to importantly determine successful fusion. However, despite the importance of graft volumetric changes, little information is available on bone graft volumetric changes after instrumented fusion. Methods. Thirty-one patients with lumbosacral disease who underwent decompression and instrumented spinal fusion using autologous iliac bone graft were included in this study. Patients were classified into 3 major categories, based on fusion methods, the number of fusion segments, and range of fusion, namely, (1) the posterolateral fusion and the posterior lumbar interbody fusion groups, (2) the one-segment fusion and 2-segment fusion groups, and (3) the floating fusion (fusion to L5) and fixed fusion (fusion to S1) groups. To evaluate bone graft volumetric changes, computed tomography scans were performed. Group graft volumes were compared, and Oswestry Disability Index and visual analogue scales scores were obtained to evaluate clinical and functional outcomes. Results. Initial graft volumes had decreased by 8% at 6 months and by 26.3% between 6 and 12 months after surgery (P =0.0025, P = 0.0001, respectively). Mean group bone graft volume losses at 5 years after surgery were not significantly different between the posterolateral fusion and posterior lumbar interbody fusion groups or the floating fusion and fixed fusion groups (P= 0.722, P = 0.076, respectively). However, mean bone graft volume loss was significant greater in the 2-segment fusion group than in the one-segment fusion group (P = 0.007). No statistical difference in visual analogue scales and Oswestry Disability Index score decreases were observed between the groups. Mean graft bone volume loss during 5 years increased with initial graft volume (r = 0.525, P = 0.003). However, ratios of volume loss over 5 years versus initial graft volume decreased with initial graft volume (r = -0.459, P = 0.011). Conclusion. One-third of initial bone grafts were found to be resorbed over 5 years and the majority of this resorption was found to occur between 6 months and 1 year after instrumented lumbar/lumbosacral fusion. Furthermore, bone graft volumetric changes were not affected by fusion methods or ranges of fusion, and did not affect clinical or functional outcomes. Although bone graft volume loss was found to increase with initial graft volume, larger bone grafts were found to result in a larger fusion mass.

The population of senescent disc cells has been shown to increase in degenerated or herniated discs. However, the mechanism and signaling pathway involved in the senescence of nucleus pulposus (NP) chondrocytes are unknown.To demonstrate the mechanisms involved in the senescence of NP chondrocytes.Senescence-related markers were assessed in the surgically obtained human NP specimens.NP specimens remaining in the central region of the intervertebral disc were obtained from 25 patients (mean: 49 years, range: 20-75 years) undergoing discectomy. Based on the preoperative magnetic resonance images, there were 3 patients with Grade II degeneration, 17 patients with Grade III degeneration, and 5 patients with Grade IV degeneration.We examined cell senescence markers (senescence-associated beta-galactosidase [SA-beta-gal], telomere length, telomerase activity, p53, p21, pRB, and p16) and the hydrogen peroxide (H(2)O(2)) content as a marker for an oxidative stress in the human NP specimens.SA-beta-gal expression, telomere length, telomerase activity, and H(2)O(2) content as well as their relationships with age and degeneration grades were analyzed. For the mechanism involved in the senescence of NP chondrocytes, expressions of p53, p21, pRB, and p16 in these cells were assessed with immunohistochemistry and Western blotting.The percentages of SA-beta-gal-positive NP chondrocytes increased with age (r=.82, p.001), whereas the telomere length and telomerase activity declined (r=-.41, p=.045; r=-.52, p=.008, respectively) However, there was no significant correlation between age and H(2)O(2) contents (p=.18). The NP specimens with Grade III or Grade IV degeneration showed significantly higher percentages of SA-beta-gal-positive NP chondrocytes than those with Grade II degeneration (p=.01 and p=.025, respectively). Immunohistochemistry showed that the senescent NP chondrocytes in all the specimens expressed p53, p21, and pRB, but a few NP chondrocytes in only two specimens expressed p16. Western blotting showed that the expressions of p53, p21, and pRB displayed a corresponding pattern, that is, a strong p53 expression led to strong p21 and pRB expressions and vice versa.Our in vivo study demonstrated that senescent NP chondrocytes increased or accumulated in the NP with increasing age and advancing disc degeneration. The NP chondrocytes in the aging discs exhibited characteristic senescent features such as an increased SA-beta-gal expression, shortened telomeres, and decreased telomerase activity. We further demonstrated that the telomere-based p53-p21-pRB pathway, rather than the stress-based p16-pRB pathway, plays a more important role in the senescence of NP chondrocytes in an in vivo condition. Our results suggest that prevention or reversal of the senescence of NP chondrocytes can be a novel therapeutic target for human disc degeneration.

Study Design A retrospective radiographic study. Purpose To evaluate the axial plane lumbar responses after anterior selective thoracic fusion (STF) in patients with main thoracic adolescent idiopathic scoliosis (MT-AIS). Overview of Literature Anterior scoliosis surgery induces more MT derotation through disc preparation than posterior surgery. Methods Twenty-eight MT-AIS patients treated with STF were evaluated after a minimum follow-up (FU) of 2 years. The MT and lumbar coronal angles, as well as the MT and lumbar rotational angles at the most rotated vertebrae were measured. Results At the last FU, the MT coronal correction and derotation rates were 65% and 41%, respectively. The lumbar coronal correction rate was 61% but there was minimal lumbar derotation (2%). Nine cases were decompensated (coronal balance >10 mm). After surgery, the compensated and decompensated groups showed similar MT coronal and axial correction rates. During the FU, the MT and lumbar apecies rotated in the same direction (r=0.443). In addition, significant MT derotation occurred in the decompensated group with increasing lumbar rotational correction loss. At the last FU, while the MT coronal correction was similar between the two groups, there was more MT derotation in the decompensated group. Furthermore, the MT rotational change was strongly associated with the coronal C7 plumb line position (r=0.728). Conclusions After anterior STF in patients with MT-AIS, the final MT derotation is strongly associated with the coronal C7 plumb line position. During the FU, the excessive MT derotation in the decompensated group was attributed to excessive lumbar rotational correction loss.

Only 6 cases of pyogenic spondylitis following vertebroplasty or kyphoplasty have been reported, and their causes remained unclear. The authors report on 4 cases of delayed pyogenic spondylitis (DPS) following vertebroplasty or ky-phoplasty for osteoporotic compression fractures and metastatic disease.Four patients presented with DPS after vertebroplasty or kyphoplasty and underwent surgical treatment. Clinical history, laboratory examination, and MR imaging confirmed the diagnosis of DPS. Anterior debridement, reconstruction, and posterior instrumented fusion were performed.The mean interval for the delayed occurrence of pyogenic spondylitis after surgery was 12.3 months. The infections were primarily bacterial in origin, but most patients also suffered diverse medical comorbidities. Despite successful treatment of the infections, comorbidity was and is a factor that compromises good results.Medical comorbidities associated with compromised immunity may increase susceptibility to DPS after vertebroplasty or kyphoplasty. In cases of incapacitating back pain after a pain-free period following either of these surgeries, evaluation of the erythrocyte sedimentation rate and C-reactive protein level and examination of contrast-enhanced MR imaging studies are essential to rule out delayed vertebral infection. Surgical treatment requires cement removal and anterior reconstruction with or without additional posterior instrumented fusion.

STUDY DESIGN An animal experimental study on hypothermia after spinal cord injury(SCI). OBJECTIVE.: To investigate the neuroprotective effect of moderate epidural hypothermia (MEH) on SCI in rats and evaluate the antiapoptotic and anti-inflammatory effect of hypothermia. SUMMARY OF BACKGROUND DATA Experimental systemic or local hypothermia has been tried for neuroprotection after ischemic or traumatic SCI. However, its clinical application is limited due to its technical difficulties. If hypothermia is to be considered in the future for treating SCI, then alternative approaches and further studies on the advantages and disadvantages of hypothermia will be mandatory. METHODS Author's designed MEH (30 degrees C for 48 hours) was tried as a neuroprotector after traumatic SCI. The functional recovery and histopathological changes were assessed. A spinal cord contusion (25 g-cm at T-9) was produced in all 16 rats, and these rats were randomly divided into 2 groups; (1) the control group (spinal cord contusion only), (2) the hypothermia group (spinal cord contusion followed by MEH). RESULTS MEH significantly reduced the apoptosis of neurons and glial cells when compared with the control group (P < 0.05). Furthermore, MEH significantly inhibited the activation of the microglia and it improved functional recovery after SCI (P < 0.05). CONCLUSION These results suggest that MEH may be a possible therapeutic candidate when combined with clinically proven surgical and medical methods for SCI.

The surgical approach that should be used for degenerative spondylolisthesis (DS) is a controversial issue. Decompression and posterolateral fusion (PLF) with or without lumbar interbody fusion is widely used. Many studies have compared the outcomes of these 2 approaches, but the appropriate indications for these approaches are still unclear. The authors retrospectively studied the effects of posterior lumbar interbody fusion (PLIF) after PLF for the treatment of DS.Forty patients who underwent single level decompression and posterior instrumentation for DS at L4-5 and were followed for at least 2 years were retrospectively studied. The patients were divided into 4 groups: the stable PLF group (S-PLF, n=13); the stable PLF with additional PLIF group (S-PLIF, n=11); the unstable PLF group (U-PLF, n=8); and the unstable PLF with additional PLIF group (U-PLIF, n=8). Clinical and radiographic comparisons were carried out between the S-PLF and S-PLIF groups, and between the U-PLF and U-PLIF groups.Clinical assessments, using the improvements of the Oswestry Disability Index (ODI) and the Visual Analog Scale (VAS), were statistically significantly different between the 2 unstable groups (DeltaU-PLFDeltaU-PLIF, P(ODI)=0.032, P(VAS)=0.004, respectively). On radiologic assessment, the slip angle increment was significantly different between the 2 stable groups (DeltaS-PLFDeltaS-PLIF, P=0.029), and the disc height increment was significantly different between the 2 stable groups (DeltaS-PLFDeltaS-PLIF, P=0.043) and between the 2 unstable groups (DeltaU-PLFDeltaU-PLIF, P=0.042).This study suggests that preoperative segmental instability may be a criterion determining whether an additional PLIF would be beneficial in the treatment of lumbar DS.

STUDY DESIGN A prospective cohort study. OBJECTIVE To determine the cause-effect relationship between fusion and sacroiliac joint (SIJ) degeneration after instrumented posterolateral lumbar or lumbosacral fusion. SUMMARY OF BACKGROUND DATA Adjacent segment degeneration following spinal fusion has attracted considerable attention. However, little attention has been paid to the SIJ, which is one of the adjacent joints. METHODS This study prospectively examined 37 patients, who underwent instrumented posterolateral lumbar/lumbosacral fusion from July 1997 to October 1998. Among them, 32 patients were included in this study and defined as the fusion group (male/female: 10/22, mean age: 64 years). The fusion group was divided into 2 subgroups according to the range of fusion. Group 1 had floating fusion (fusion to L5) and included 22 patients (male/female: 7/15, mean age: 65.6 years). Group 2 had fixed fusion (fusion to S1) and included 10 patients (male/female: 3/7, mean age: 60.5 years). Thirty-four age-matched normal individuals (male/female: 18/16, mean age: 64.5 years) were recruited as a control group. SIJ degeneration was assessed by confirming the absence of degeneration in the SIJ by computed tomography scans before surgery and 2 weeks after surgery. The SIJ was evaluated again by taking computed tomography scans at 1 year and 5 years after surgery. The incidence of SIJ degeneration was evaluated and compared (fusion group vs. control group; group 1 vs. group 2). The clinical outcomes were evaluated using the Visual Analog Scales (VAS) and Oswestry Disability Index (ODI) before surgery and at the final follow-up. RESULTS The incidence of SIJ degeneration in the fusion group was 75% (24/32), which was significantly higher than that of the control Group 38.2% (13/34) (P < 0.05). The incidence of SIJ degeneration (bilateral and unilateral) and bilateral SIJ degeneration was higher in group 2 than in group 1 (P = 0.028 and 0.04, respectively). The incidence of SIJ degeneration was not associated with the number of fusion segments. At the 5-year follow-up, the patients in groups 1 and 2 reported significant improvements in the VAS and ODI scores compared with the preoperative scores. However, there was no significant difference in the decrease in VAS and ODI scores between the 2 groups (P = 0.145 and 0.278, respectively). CONCLUSION Instrumented posterolateral lumbar/lumbosacral fusion can be a cause of SIJ degeneration. SIJ degeneration develops more often in patients undergoing lumbosacral fusion regardless of the number of fusion segments.

STUDY DESIGN: A case report of Trichosporon asahii spondylodiscitis. OBJECTIVE: To report the first case of T. asahii spondylodiscitis that developed in a healthy woman at the site of an open lumbar discectomy. SUMMARY OF BACKGROUND DATA: Trichosporon is a genus of basidiomycetous yeasts that is common in nature and a member of the normal flora of the mouth, skin, and nails. It causes deep infections and fungemia mainly in immunocompromised patients or patients with underlying hematologic malignancies. To our knowledge, there is no reported case of bone and joint infections caused by T. asahii. METHODS: A 42-year-old female gynecologist was transferred to our hospital with a chief complaint of severe lower back pain after an open L4-L5 discectomy. The infection indexes showed an elevated erythrocyte sedimentation rate and the C-reactive protein. Despite bed rest and antibiotic therapy, the lower back pain and tingling sensation on both lower extremities continued to worsen. The magnetic resonance imaging showed an abscess-like fluid collection compressing the thecal sac and showed a signal change in the bone marrow of the L4 and L5 vertebral bodies, suggesting spondylodiscitis. Laminectomy, curettage, and debridement of the infected discs were performed. Cultures of the abscess yielded yeasts that were sensitive to fluconazole. The yeast was identified as T. asahii. RESULTS: She received fluconazole therapy for 5 months, and returned to her work after the fourth postoperative month. She has remained in a satisfactory condition since. CONCLUSION: We present the first case of T. asahii spondylodiscitis, which developed unexpectedly in a healthy woman at the site of an open lumbar discectomy. We successfully treated the patient with surgical debridement and 5 months of fluconazole therapy.

The purpose of this study was to evaluate and compare the clinical results of arthroscopic capsulolabral reconstruction using arthroscopic transglenoid fixation and a suture anchor fixation for anterior dislocation of the shoulder.From December 1999 to September 2006, 46 patients who underwent arthroscopic capsulolabral reconstruction for their anterior dislocation of the shoulder were enrolled, and their surgical outcomes were retrospectively evaluated. In group A (26 patients), the procedure was performed with Caspari's transglenoid technique. In group B (20 patients), the capsulolabral reconstruction was done using the suture anchor method. The postoperative assessment including American Shoulder and Elbow Surgeons' (ASES) scores, recurrent instability, the level of return to previous sports activity, and satisfaction with the treatment were compared between the two groups. Statistical analysis was performed using Student's t-test, chi-squared analysis, and a Pearson correlation coefficient.There were significant differences in ASES scores (group A 76.8 vs. group B 85.5), satisfaction with the surgery (group A 6.5 vs. group B 8.2 - out of 10) and in the level of return to previous sports activity (group A 7.2 vs. group B 8.3 - out of 10) at last follow-up. Recurrent instability occurred in 7 patients in group A (26.9%) and in two cases in group B (10.0%).The arthroscopic capsulolabral reconstruction using a suture anchor was a more reliable treatment option (in regard to satisfaction, functional recovery, and recurrent instability) than the transglenoid fixation technique for anterior dislocation of the shoulder.

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.

Introduction There is no report on the effect of DVR on the shoulder balance using segmental pedicle screw instrumentation in the treatment of double thoracic adolescent idiopathic scoliosis (AIS) with minimum 5-year follow-up. This study is to evaluate the shoulder balance resulting from the correction of double thoracic AIS comparing rod derotation (RD) with direct vertebral rotation (DVR) and RD only following pedicle screw instrumentations. Materials and Methods Double thoracic AIS patients ( n = 57) were treated by fusing both thoracic curves with RD and DVR ( n = 35), or RD ( n = 22) methods and retrospectively studied with a minimum 5 years follow-up. Results In the RD with DVR group, the preoperative PT curve of 40.2 degrees improved to 17.9 degrees postoperatively and 19.9 degrees at last follow-up. In the RD group, the preoperative PT curve of 37.5 degrees improved to 22.4 degrees postoperatively and 23.2 degrees at last follow-up. In the RD with DVR group, the preoperative DT curve of 56.6 degrees improved to 16.1 degrees postoperatively and 16.7 degrees at last follow-up. In the RD group, the preoperative DT curve of 50.6 degrees improved to 17.8 degrees postoperatively and 18.2 degrees at last follow-up. In the RD with DVR group, the average preoperative SHD of 16.3 mm was improved to 7.2 mm postoperatively and was 7.0 mm at last follow-up. In the RD group, the average preoperative SHD of 15.1 mm was changed to 7.5 mm postoperatively and was 7.3 mm at last follow-up. Conclusion Shoulder balance was not significantly improved even with additional correction method of DVR using segmental pedicle screw instrumentation in double thoracic AIS. The PT curve was rigid and corrected less in both groups. Therefore, less correction of the DT curve effectively achieves better shoulder balance.

Introduction CX3CL1 and its receptor (CX3CR1) are part of a chemokine system involved in leukocyte recruitment and adhesion in chronic inflammatory disease. From previous study, the CX3CL1 and CX3CR1 activity has been investigated in ligamentum flavum, synovial membrane, and intervertebral discs, but not with the facet joint capsule-related issue. The purpose of this study is to investigate the following: (1) The role of fractalkine (CX3CL1)/CX3CR1 chemokine on facet joint capsular laxity in degenerative lumbar spondylolisthesis (DLS); (2) Correlation between expression of CX3CL1/CX3CR1 chemokine and degree of slippage by lumbar spondylolisthesis. Method The mRNA concentrations of CX3CL1/CX3CR1 chemokine were analyzed in the surgically obtained facet joint capsule specimens from grade 1 spondylolisthesis ( n = 12), grade 2 spondylolisthesis ( n = 12), and more than grade 3 spondylolisthesis ( n = 11) by real-time PCR. Grade 1 to 3 is being decided on degree of slippage which is, less than 5 mm, between 5 to 10 mm, and more than 10 mm. The localization of CX3CL1/CX3CR1 chemokine within the facet joint capsule was determined using immunohistochemical study. Plasma level of soluble fractalkine (sFKN) was measured by enzyme-linked immunosorbent assay (ELISA), respectively. Result The cells that shows higher CX3CL1/CX3CR1 chemokine expression ratio in the facet joint capsule are observed in tissues acquired from patients with higher degree of slippage by lumbar spondylolisthesis ( p = 0.000, 0.000). In ELISA, the plasma levels of sFKN was significantly higher in the group with more severe degree of slippage ( p = 0.002). There was greater CX3CL1/CX3CR1 expression in higher grade spondylolisthesis as quantified by RT–PCR ( p = 0.000, 0.003). Degree of slippage in patients with DLS were significantly correlated with serum CX3CL1 level ( R2 = 0.451, p = 0.000) and with mRNA expression of CX3CL1/CX3CR1 ( R2 = 0.360, p = 0.000) ( R2 = 0.205, p = 0.006). Conclusion This study identified for the first time that increases in CX3CL1 and CX3CR1 expressing cells are significantly related to facet joint capsular laxity, which may provide new conceptual and therapeutic approaches for treating spinal spondylolisthesis.

Efficacy and safety of bone cement augmentations for spinal pathologic fractures related to multiple myeloma, and usefulness of radionuclide studies for surgical decision were retrospectively evaluated. Forty eight vertebrae from 27 patients for bone cement augmentation procedures and 48 vertebrae from 29 patients for conservative treatment were enrolled. Clinical results using visual analogue scale (VAS) and Oswestry disability index (ODI), and radiologic results were assessed. For clinical decisions on treatment of spinal pathologic fracture, bone scan or single photon emission computed tomography was done for 20 patients who underwent surgery. Mean follow-up was 16.8 months. In terms of clinical results, immediate pain relief was superior in the operated group to that in the conservative group. ODI, maintenance of vertebral height and local kyphotic angle at the last follow-up were superior in the operated group in comparison to the conservative group. At one year follow-up, cumulative survival rate were 77.4% and 74.7% in the operated and conservative groups, respectively (log rank test> 0.05). Leakage of bone cement was noted at 10 treated vertebrae. Bone cement augmentations presented short-term pain relief for spinal pathologic fractures by myeloma with relative safety in highly selected patients, and radionuclide imaging studies were useful for the surgical decision on these procedures. Graphical Abstract

Metastatic lesions are the most common spinal column tumors, arising from cancerous lesions including the lung, prostate, breast, kidney, and gastrointestinal system.1,2,3) Despite its frequency, there is no consensus as to which therapeutic modality or aggregate of modalities, be it radiotherapy (RT) or surgery, is the ideal strategy to best address this complex disease process.4,5) Loblaw et al.,4) in their comprehensive systematic reviews, stated that patients with bony compression, specifically high-grade compression fractures of the vertebral body or bony collapse of the spinal column, and particularly those with mild to moderate paraparesis, who were treated with RT seemed less likely to recover ambulation compared with paretic patients without bony compression, i.e., soft tissue epidural disease. The evidence amassed precluded any conclusions but managed to produce clinical practice guidelines for treatment and highlighted the potential of surgery for malignant epidural spinal cord compression.4,5) In their randomized control trial, Patchell et al.6) concluded that direct decompressive surgery plus postoperative RT was more favorable than treatment with RT alone for patients with spinal cord compression caused by metastatic cancer. This was subsequently followed by similar prospective studies that, although cautioning against potential morbidity, supported this claim.7,8,9,10) Despite the abundance of evidence, many questions still remain about surgery for metastatic spine disease regarding which patients should be advised to undergo it, its appropriate timing, and the optimal surgical procedure.1) Surgery for decompression and stabilization of the affected spine has proven to be a vital strategy that significantly impacts the patient's neurologic function, pain relief, and quality of life.6,7,8,9,10) In conjunction with this, scoring systems have been developed and validated to serve as decision-making guides and to emulate a model of consistency in dealing with this complex disease process.11,12,13,14,15,16) Treatment strategies and combinations thereof have also been proposed and modified in light of advancements17,18,19) and are continually being improved as we learn more of the metastatic process and refine our technique in addressing it. However, despite the progression in our capability to handle these tumors, much can still be done in terms of reducing morbidity and increasing the effectiveness of surgical options. Therefore, by comparing results of different surgical strategies and analyzing factors affecting survival of metastatic lung and hepatocellular cancer, we hope to determine if surgery type and other factors such as preoperative performance status and predictive score systems significantly influence the outcomes of metastatic spine disease.

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.

The purpose of this study was to determine the accuracy of MRI for discrimination between tuberculous spondylitis and pyogenic spondylitis.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.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 (p0.05): 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]).MRI was accurate for differentiation of tuberculous spondylitis from pyogenic spondylitis.

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.

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.

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.