Real-time CT Fluoroscopy (CTF)-Guided Vertebroplasty in Osteoporotic Spine Fractures

The purpose of this study was to evaluate the clinical feasibility, benefits, and limitations of CT fluoroscopy (CTF)-guided percutaneous vertebroplasty (PVP). PVP under the guidance of CTF without additional guidance by conventional C-arm fluoroscopy was performed in a total of 29 vertebral bodies in 21 patients with vertebral compression fractures. While monitoring sectional CTF images, the needle was advanced from the skin to the target vertebra. Contrast media and polymethylmethacrylate (PMMA) were injected into the target vertebra with careful monitoring of their distribution. After the procedure, an evaluation was conducted to determine whether extraosseous leakage of PMMA occurred and whether sufficient filling of PMMA had been achieved. Needle placement into the target vertebra was easily achieved with both the transpedicular and posterolateral approaches. Injection of PMMA and venous leakage of contrast media were carefully monitored in all patients, and early detection of PMMA leaking was achieved in 5 patients. Extraosseous leakage that had not been detected during the procedure was not found upon postoperative evaluation. Pain scales were significantly decreased after the procedure, and no obvious complications occurred following the procedure. CTF-guided PVP without the combined use of C-arm fluoroscopy was feasible and showed definite benefits. We believe that, in spite of some limitations, CTF-guided PVP provides an alternative technique appropriate in certain situations

The Risk Factors Associated With Delirium After Lumbar Spine Surgery in Elderly Patients

Background: To prospectively explore the incidence and risk factors for postoperative delirium in elderly patients following lumbar spine surgery. Methods: This prospective study enrolled 148 consecutive patients over the age of 65 who were scheduled to undergo spine surgery. Patients were screened for delirium using the short Confusion Assessment Method (CAM) postoperatively. Patient demographics and relevant medical information were collected. Logistic regression analysis was used to identify the risk factors associated with postoperative delirium. Results: Eighty-three patients (56.1%) who underwent lumbar spine surgery (not coexisting with cervical or thoracic spine surgery) were enrolled in our study. Post-operative delirium was noted in 14.5% of patients over 65 years old. The presence of preoperative Parkinsonism was significantly higher in the delirium group (41.7% vs. 8.5%, P=0.002), as was a higher preoperative C-reactive protein (CRP) (7.0±15.2 vs. 1.3±2.3 mg/L, P=0.017) when compared with the non-delirium group. Of the risk factors, male sex [odds ratio (OR) =0.10, 95% confidence interval (CI): 0.01-0.66, P=0.017], Parkinsonism (OR =5.83, 95% CI: 1.03-32.89, P=0.046), and lower baseline MMSE score (OR =0.71, 95% CI: 0.52-0.97, P=0.032) were independently associated with postoperative delirium in elderly patients undergoing lumbar spine surgery. Conclusions: Post-operative delirium occurred in 14.5% of elderly patients who underwent lumbar spine surgery. Male sex, Parkinsonism, and lower baseline MMSE score were identified as independent risk factors for postoperative delirium in elderly patients following lumbar surgery.ope

Posterolateral Approach of Percutaneous Vertebroplasty in Thoracolumbar Fractures

Objective: Transpedicular percutaneous vertebroplasty has been widely used for the treatment of osteoporotic vertebral compression fractures. The authors introduce a novel method of approach by the posterolateral route for percutaneous vertebroplasty. Materials and Methods: A retrospective review was conducted on 30 consecutive patients with 42 vertebrae of acute osteoporotic thoracolumbar compression fractures treated from Mar. 2002 to May 2003 with percutaneous vertebroplasty using this approach. Pain response, volume of polymethylmethacrylate (PMMA), epidural leakage of PMMA, distribution of PMMA in vertebral body and complications were investigated. Results: Among 30 patients, 27 had marked to complete pain relief, 2 moderate pain relief and 1 no significant change during follow up period. A mean volume of PMMA injected by this unilateral approach was 5.8cc. Epidural leakage of PMMA was noted on 28 vertebrae(66.7%) on postoperative CT scan. All vertebrae except one injected by this method showed bilateral distribution of PMMA on postoperative CT scan. Minor complication (transient radicular pain) occured in 2(6.7%) patients. Conclusion: Unilateral posterolateral approach of percutaneous vertebroplasty was a safe and effective method for the treatment of acute osteoporotic thoracolumbar compression fractures.ope

Influence of Diabetes Mellitus on Patients With Lumbar Spinal Stenosis: A Nationwide Population-Based Study

Purpose: To evaluate the relationship between comorbidities, medical cost, and surgical outcome in patients with lumbar spinal stenosis (LSS) and diabetes mellitus (DM). Methods: Data on patients with LSS (n = 14,298) were collected from the Korean National Health Insurance Service database from 2005 to 2007. After 8 years of follow-up, a "DM group" (n = 3,478) and a "non-DM group" (n = 10,820) were compared according to outcome measures. Cox proportional hazard regressions were performed to examine the relationship between DM, hypertension (HTN), cardiovascular disease (CVD), chronic kidney disease (CKD), cerebrovascular disease (CbVD), and surgery for LSS. The admission rate and medical cost as well asthe overall survival rate for those who underwent lumbar surgery were also assessed among patients with DM and LSS. Results: Mortality was about 1.35 times higher in the DM group than in the non-DM group. Patients with DM and comorbidities including HTN (hazard ratio [HR], 1.40; 95% confidence interval [CI], 1.25-1.56; p<0.001), CVD (HR, 1.53; 95% CI, 1.36-1.73; p<0.001), CKD (HR, 3.18; 95% CI, 2.7-3.76; p<0.001), and CbVD (HR, 1.69; 95% CI, 1.49-1.91; p<0.001) showed an increased risk of mortality. The mean hospitalization time and average medical cost of patients with DM who underwent lumbar surgery were 60.8 days, and 7,127 USD, respectively. This was 31.3 days longer, and 6,207 USD higher, respectively, than those of patients with DM who underwent conservative treatment for LSS. Within the DM group, the survival rate of surgical management of LSS had a significant tendency for positive prognosis compared with those administered conservative treatment (p = 0.046). Conclusions: In patients with LSS, DM was associated both with poor prognosis (most significantly in those with CKD), and increased medical cost in those who underwent surgery. Nevertheless, surgical treatment for LSS in patients with DM was related to favorable prognosis compared with conservative treatment.ope

Hemorrhagic Complication after Spine Surgery

Objectives: Spinal epidural hematoma after spinal surgery is a dreadful complication that can cause major neurologic deficit. We have evaluated factors leading to increased risk for epidural hematoma and its outcome after decompression surgery. Materials and Methods: We retrospectively reviewed 3,720 cases of spine operation over period of 7 years (1998 April~2005 July) where 9 cases of postoperative spinal epidural hematoma were experienced. We evaluated patient factors including underlying medical disease and use of anticoagulation therapy, surgical strategies, and neurological outcome in these patients. Results: The incidence of spinal epidural hematoma after surgery was 0.24%. Their original diagnoses were tumor in 3 cases, cervical stenosis in 2 cases, lumbar stenosis in 3 cases and herniated lumbar disc in 1case. Factors increasing the risk of postoperative epidural hematoma were coagulopathy from medical illness, anticoagulation therapy and surgery of highly vascularized tumor. After decompression for epidural hematoma, clinical outcome varied. Complete recovery was achieved in 3 cases (33.3%), incomplete recovery in 5 cases (55.6%) and no change in 1 case (11.1%). The neurologic recovery after decompression was thought to be related to the preoperative minimal neurological deficit and short interval from diagnosis to decompression. Conclusion: Epidural hematoma following spinal surgery is a rare but devastating complication. Patients with coagulopathy and highly vascularized tumor were more vulnerable to spinal epidural hematoma. The neurologic recovery was related to the degree of preoperative neurological deficit and time interval to the decompression.ope

Surgical Treatment of Spinal Stenosis Secondary to Achondroplasia

OBJECTIVE: To report the clinical outcome of surgical treatment of spinal stenosis secondary to achondroplasia, the authors review the clinical and radiological presentation. METHODS: Five cases, two males and three females, of spinal stenosis secondary to achondroplasia were reviewed with medical records and radiologic study. The mean follow-up period was 26.8(range:10-72)months. RESULTS: In four patients, stenosis was more pronounced at lumbar area. The other patient revealed thoracolumbar and lumbar stenosis with kyphosis at thoracolumbar junction. All patients suffered from neurogenic intermittent claudication. Two patients presented with paraparesis and urinary dysfunction. On radiologic evaluation, all patients showed typical short pedicle, decreased interpedicular distance and severe stenosis. Only decompressive laminectomy was performed without fusion at lumbar area in four patients. One stage posterior interbody fusion and pedicle screw fixation was performed in one case which showed thoracolumbar stenosis and kyphosis. Radicular pain and neurogenic intermittent claudication improved after surgery. CONCLUSION: One stage posterior lumbar interbody fusion and pedicle screw fixation might be an effective method for the thoracolumbar kyphosis in patients of achondroplasia and for the cases of potential instability following decompression.ope

Histologically Confirmed Bone Formation in the Carbon Fiber Cage Implant

The authors report the first case of histologically confirmed bone formation in the carbon fiber cage implant which used in posterior lumbar interbody fusion. A case of degenerative lumbar disc desease was treated by posterior lumbar interbody fusion with carbon fiber cage implant and local bone from posterior decompression. One year after the operation the cage was migrated into the spinal canal and compressed dural sac and nerve root. The cage was removed and investigated by light microscope. The histologic examination revealed viable bony traveculae in the cage. This finding suggest autogenous bone in the cage has a biologic bone-growth function after interbody fusion.ope

Lactoferrin-Anchored Tannylated Mesoporous Silica Nanomaterials for Enhanced Osteo-Differentiation Ability

In the present study, we created lactoferrin-anchored mesoporous silica nanomaterials with absorbed tannic acid (LF/TA-MSNs) and evaluated the effect of these LF/TA-MSNs on the in vitro osteo-differentiation ability of adipose-derived stem cells (ADSCs) by testing alkaline phosphatase (ALP) level, calcium accumulation, and expression of osteo-differentiation-specific genes, including osteocalcin (OCN) and osteopontin (OPN). Both bare MSNs and LF/TA-MSNs exhibited round nano-particle structures. The LF/TA-MSNs demonstrated prolonged LF release for up to 28 days. Treatment of ADSCs with LF (50 μg)/TA-MSNs resulted in markedly higher ALP level and calcium accumulation compared to treatment with LF (10 μg)/TA-MSNs or bare MSNs. Furthermore, LF (50 μg)/TA-MSNs remarkably increased mRNA levels of osteo-differentiation-specific genes, including OCN and OPN, compared to MSNs or LF (10 μg)/TA-MSNs. Together, these data suggest that the ability of LF/TA-MSNs to enhance osteo-differentiation of ADSCs make them a possible nanovehicle for bone healing and bone regeneration in patients with bone defect or disease.ope

Differential Diagnosis of Low Back Pain in Woman

Various clinical conditions can cause low back pain, and in most cases it is of a degenerative origin. Degenerative disc disease is a common condition which affects young to middle-aged women. Changes in the mechanical properties of the disc lead to degenerative arthritis in the intervertebral joints, osteophytes, and narrowing the intervertebral foramen or the spinal canal. Degenerative cascade is the widely accepted pathophysiologic model describing the degenerative process as it affects the lumbar spine in 3 phases. There are two forms of low back pain secondary to degenerative disc disease: a) lumbalgia and b) lumbar radiculopathy. Limitation of movement, problems with balance, pain, loss of reflexes in the extremities, muscle weakness, loss of sensation or other signs of neurological damage can be found on physical examination. For accurate diagnosis, it is often necessary to combine clinical examination and sophisticated technology. To diagnose low back pain in women, the uterus and other pelvic organs must be examined. Dysmenorrhea (functional) is often the cause, but tubo-ovarian abscess, ovarian cysts, endometriosis, fibroids, retroversionor flexion of the uterus, and uterine carcinomas must be looked for. The bladder and urethra are infrequent causes of low back pain, but a urinalysis and culture may be necessary to rule out infections. Other diseases, gastric or peptic ulcer, aortic aortic aneurysm, herpes zoster should be rule out for accurate diagnosisope

Diagnostic Significance of Discography on Multiple Lumbar Disc Herniation

Objective：The introduction of MRI makes it easy to detect multiple lumbar disc herniation. However, MRI is not a physiologic test for detecting the symptomatic level. For the surgical plan, it is very important to determine the symtomatic level among the multiple lumbar disc herniation. In this regard, we studied diagnostic significance of discography on multiple lumbar disc herniation in determining the symptomatic level. Method and Material：We retrospectvely analyzed the discographic and clinical findings of 121 patients with multiple lumbar disc herniation for investigating the diagnostic availability of discography. All were surgically treated from January 1995 through May 1998. Result：Discography provocated the same pain as usual symptom in 99 out of 121 patients(81.8%). Compared with surgical findings, the diagnostic accuracy of the discography in multiple lumbar disc herniation was 75.6%, sensitivity was 64.6%, and specificity 87.2%. There was no correlation between the pain provocation of discography and the extent of annular degeneration on CT/discogram. The pain provocation showed good correlation with the extent of annular disruption on CT/discogram. The rate of same result(correlation rate) between the discography and D.I.T.I was 81.4% in multiple lumbar disc herniation patients with unilateral leg pain. Conclusion：These results indicate that in multiple lumbar disc herniation, the discography is considered useful diagnostic tool to determine the symptomatic level and to decide the surgical plan.ope