Innate-like Cytotoxic Function of Bystander-Activated CD8+ T Cells Is Associated with Liver Injury in Acute Hepatitis A.

Acute hepatitis A (AHA) involves severe CD8+ T cell-mediated liver injury. Here we showed during AHA, CD8+ T cells specific to unrelated viruses became activated. Hepatitis A virus (HAV)-infected cells produced IL-15 that induced T cell receptor (TCR)-independent activation of memory CD8+ T cells. TCR-independent activation of non-HAV-specific CD8+ T cells were detected in patients, as indicated by NKG2D upregulation, a marker of TCR-independent T cell activation by IL-15. CD8+ T cells derived from AHA patients exerted innate-like cytotoxicity triggered by activating receptors NKG2D and NKp30 without TCR engagement. We demonstrated that the severity of liver injury in AHA patients correlated with the activation of HAV-unrelated virus-specific CD8+ T cells and the innate-like cytolytic activity of CD8+ T cells, but not the activation of HAV-specific T cells. Thus, host injury in AHA is associated with innate-like cytotoxicity of bystander-activated CD8+ T cells, a result with implications for acute viral diseases.

Preemptive multimodal analgesia for postoperative pain management after lumbar fusion surgery: a randomized controlled trial.

PURPOSE: To assess the efficacy of a novel preemptive multimodal analgesic regimen for reducing postoperative pain and complications after primary lumbar fusion surgery. Preemptive multimodal analgesia is revealed to be an effective alternative to conventional morphine administration providing improved postoperative pain control with diminished side effects. However, an optimal regimen for spinal fusion surgery remains unknown. METHODS: After Institutional Review Board approval, 80 patients who underwent primary lumbar 4-5 fusion surgery were randomly assigned to receive either only intravenous morphine or a preemptive multimodal (celecoxib, pregabalin, extended-release oxycodone, and acetaminophen) analgesic regimen. Postoperative pain and functional levels were measured by the visual analog scale (VAS) and Oswestry Disability Index (ODI), respectively, and intraoperative blood loss, postoperative Hemovac drain output, and nonunion rates were evaluated for complications. RESULTS: No differences were observed in the patient demographics, intraoperative blood loss, postoperative Hemovac drain output, or nonunion rate between two groups. The VAS and ODI were lower at all postoperative time points, except the ODI on postoperative day 1 in patients randomized to receive the preemptive multimodal analgesic regimen. No major identifiable postoperative complications were observed in either treatment group. CONCLUSIONS: The preemptive multimodal analgesic combination in this study appears to be safe and effective after lumbar fusion surgery.

A study of sacral anthropometry to determine S1 screw placement for spinal lumbosacral fixation in the Korean population.

PURPOSE: 1. To investigate the incidence of closed-type PSIS in the Korean population. 2. To categorize the morphological features of Korean sacrum. 3. To measure the safe marginal length and angle for screw fixation considering the PSIS and course of the external iliac vein, using a Korean sacrum model. METHODS: We performed our study in 160 sacra including the pelvic ring obtained from 80 Korean cadavers. The bony measurements were obtained by performing 1-mm computed tomography cuts from the L5 lumbar vertebra to the pelvic ring and excluding other structures. We evaluated the incidence of anatomic variation of the PSIS and measured the safe marginal length and angle for screw fixation considering the PSIS and course of the external iliac vein, using a Korean sacrum model. RESULTS: Our study showed that the closed type of PSIS is more frequent in males than in females. The optimal angle for screw fixation is 16.91 ± 6.85 (°), while the left side S1 pedicle insertion angle is 16.00 ± 6.20 (°). The average Korean optimal screw length is 58.35 ± 14.90 (cm) for the right side and 55.89 ± 16.16 (cm) for the left side. CONCLUSION: With reference to these parameters, the optimal screw length and angle can be chosen and bicortical anteromedial screw fixation can be easily and safely performed.

Hypertrophy of the ligament flavum in degenerative lumbar stenosis associated with the increased expression of fractalkine (CX3CL1)/CX3CR1 chemokine.

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.

Pure hyperextension injury of the lower lumbar spine with an ureteral impingement.

INTRODUCTION: Pure hyperextension thoracolumbar spinal fractures are unusual and occur primarily in patients with ankylosing spondylitis and diffuse idiopathic skeletal hyperostosis due to the rigidity of the spine. MATERIAL AND METHODS: A 62-year-old female with osteoporosis presented with a significantly displaced fourth vertebral body fracture after being hit by a motorcycle. An imaging study showed widening of the vertebral height of L4 anteriorly with a horizontal fracture extending across the vertebral body. An in situ instrumented lumbar fusion from the second to fifth lumbar vertebrae was performed. Postoperatively, the patient complained of abdominal pain and difficulty in voiding. Computed tomography and intravenous pyelography showed that the right ureter was impinged between the fractured gaps of the vertebral body of L4. RESULTS: Solid bony union was obtained with surgical intervention. CONCLUSIONS: This case reports a rare distractive extension injury in the lower lumbar spine with ureteral impingement. One should be aware of possible complications such as ureteral impingement following a pure hyperextension injury in the lower lumbar spine.

Adjacent segment degeneration after instrumented posterolateral lumbar fusion: a prospective cohort study with a minimum five-year follow-up.

PURPOSE: 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. METHODS: 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. RESULTS: 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. CONCLUSIONS: 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.

Case report: Lower extremity sparganosis in a bursa.

BACKGROUND: Sparganosis is a rare parasitic infection caused by the plerocercoid tapeworm larva of the genus Spirometra. CASE DESCRIPTION: We report the case of a 67-year-old man with a mass over the anteromedial surface of the proximal extremity of the tibia. We surgically excised a bursa containing Spirometra larvae. LITERATURE REVIEW: Sparganosis is a rare parasitic infection. We found no cases of lower extremity sparganosis combined with bursitis reported in the literature. PURPOSES AND CLINICAL RELEVANCE: Sparganosis should be considered in the differential diagnosis of soft tissue tumors, especially among patients who frequently have consumed mountain water or raw snakes or frogs.

Spinal Surgery for Parkinson Disease With Camptocormia: Propensity Score-Matched Cohort Study With Degenerative Sagittal Imbalance (DSI).

STUDY DESIGN: A propensity score-matched cohort study. OBJECTIVE: The objective of this study was to compare the radiologic and clinical outcomes of camptocormia in Parkinson disease (PD) with degenerative sagittal imbalance (DSI) patients. SUMMARY OF BACKGROUND DATA: Camptocormia in PD and DSI could be characterized by a dynamic deformity. However, no study has directly evaluated the outcomes of patients with camptocormia and DSI. METHODS: Thirteen consecutive PD patients undergoing surgical correction for camptocormia were matched in a 1-to-2 format with 26 patients in the DSI group by propensity score-matching. Radiologic outcomes, including paravertebral muscle changes, and clinical outcomes were compared between the 2 groups. The rate of proximal junctional problems and reoperations were assessed. RESULTS: PD patients with camptocormia had significantly greater preoperative coronal and sagittal malalignments (29.9 vs. 16.9 mm, P=0.019; 142.8 vs. 64.4 mm, P=0.0001, respectively) and weakness of paravertebral muscles compared with the DSI patients. Regarding the clinical outcomes, reoperations were significantly higher in the camptocormia group, compared with the DSI group (53.8% vs. 7.7%, P=0.001). Moreover, proximal junctional failure was developed in 8 patients in the camptocormia group, while 1 patient in the DSI group (61.5% vs. 3.8%, P=0.0001). In subgroup analysis, independent risk factors for the proximal junctional failure were the total fusion levels (hazard ratio=0.26, P=0.018) and the degree of fatty changes of the paravertebral muscles (hazard ratio=1.15, P=0.048). CONCLUSIONS: PD patients undergoing spinal surgery for camptocormia had global malalignment and higher rates of complications compared with DSI patients. Patients should be appropriately counseled regarding the increased risk of operative complications and closely followed for incipient failure.

Sex-specific and Age-specific Analgesia for Early Postoperative Pain Management After Lumbar Decompressive Surgery: A Randomized Clinical Trial.

STUDY DESIGN: This was a randomized clinical trial. OBJECTIVE: To compare the efficacy and safety of nonsteroidal anti-inflammatory drug and opioid for acute pain management after lumbar decompressive surgery. SUMMARY OF BACKGROUND DATA: Multimodal analgesia is associated with synergistic effects while reducing opioid-related adverse effects. However, there is no consensus on the ideal multimodal analgesic regimen. We assumed that each agent in various multimodal regimens under different conditions may have different effects. MATERIALS AND METHODS: This prospective randomized clinical trial recruited adult patients who underwent single-level lumbar decompressive surgery. Patients were randomized to receive our postoperative analgesic regimen including either nonsteroidal anti-inflammatory drug (celecoxib) or opioid (extended-release oxycodone) from postoperative day 3 to 14. The Visual Analog Scale (VAS) and Oswestry Back Pain Disability Index (ODI) were used to evaluate effectiveness preoperatively and on postoperative days 2, 3, 7, and 14, and at 6 months. Drug-related adverse effects were also recorded. RESULTS: One hundred patients were enrolled and 93 patients (46 patients with celecoxib vs. 47 patients with oxycodone) were randomized. No differences were observed in patient demographics and preoperative VAS and ODI between the 2 groups. VAS and ODI were not different at all postoperative time points. However, subanalysis according to sex and age, revealed significant differences in efficacy: celecoxib was effective in female individuals and oxycodone was effective in male individuals on postoperative days 7 and 14; oxycodone was effective in patients aged above 65 years on postoperative days 7 and 14. Although nausea/vomiting and constipation were more common in the oxycodone group than in the celecoxib group, other adverse effects were not different. CONCLUSIONS: In patients who underwent single-level lumbar decompressive surgery, treatment with celecoxib and oxycodone for postoperative pain management showed no significant differences in efficacy. However, subanalysis showed that each drug was effective in different ages and sex groups. LEVEL OF EVIDENCE: Level II.

Clinical and Radiographic Features of Subtypes of Acute Proximal Junctional Failures Following Correction Surgery for Degenerative Sagittal Imbalance.

OBJECTIVE: To identify clinical and radiographic features of subtypes of acute proximal junctional failures (PJFs) following correction surgery for degenerative sagittal imbalance. METHODS: The study included 157 patients with mean age 68.0 ± 6.3 years who underwent correction surgery for degenerative sagittal imbalance. Acute PJFs were categorized into 4 subtypes: fracture at uppermost instrumented vertebra (UIV), fracture at vertebra just proximal to UIV (UIV+1), fixation failure at UIV, and junctional subluxation. Demographic, clinical, and radiographic data were analyzed retrospectively. RESULTS: There were 18 patients with acute PJFs. PJF group had significantly lower T-score (-3.3 ± 1.1 vs. -1.9 ± 1.5) on bone densitometry and lower body mass index (BMI) (23.0 ± 3.9 kg/m2 vs. 25.6 ± 3.7 kg/m2) than non-PJF group. Radiographic parameters exhibited no significant differences. UIV fracture, UIV+1 fracture, UIV fixation failure, and junctional subluxation were observed in 5, 6, 4, and 3 patients. Fixation failure developed the earliest (median 1.3 months), followed by UIV fracture (1.5 months). UIV fracture occurred earlier than UIV+1 fracture (36 months). Patients with UIV or UIV+1 fracture had significantly lower T-scores than others. Although BMI and T-score were significant risk factors for all PJFs (P = 0.043 and P = 0.021, respectively), different risk factors for each subtype of PJFs were identified on separate risk factor analysis. CONCLUSIONS: Patients with acute PJFs had lower T-score and BMI. Each subtype of PJFs had different clinical and radiographic features. Although BMI and T-score were associated with all PJFs, each subtype may have different risk factors. Identifying risk factors for each subtype of acute PJFs may help avoid it.

Minimally Invasive Lateral Lumbar Interbody Fusion for Clinical Adjacent Segment Pathology: A Comparative Study With Conventional Posterior Lumbar Interbody Fusion.

STUDY DESIGN: This was a retrospective comparative study. OBJECTIVE: The main objective of this article was to evaluate the clinical and radiologic efficacies of minimally invasive lateral lumbar interbody fusion (LLIF) for clinical adjacent segment pathology (ASP). SUMMARY OF BACKGROUND DATA: Minimally invasive techniques have been increasingly applied for spinal surgery. No report has compared LLIF with conventional posterior lumbar interbody fusion for clinical ASP. METHODS: Forty patients undergoing LLIF with posterior fusion (hybrid surgery) were compared with 40 patients undergoing conventional posterior lumbar interbody fusion (posterior surgery). The radiologic outcomes including indirect decompression in hybrid surgery group, and clinical outcomes such as the Oswestry Disability Index (ODI) and Visual Analog Scale (VAS) were assessed. Postoperative major complications and reoperations were also compared between the 2 groups. RESULTS: Correction of coronal Cobb's angle and segmental lordosis in the hybrid surgery were significantly greater postoperatively (2.8 vs. 0.9 degrees, P=0.012; 7.4 vs. 2.5 degrees, P=0.009) and at the last follow-up (2.4 vs. 0.5 degrees, P=0.026; 4.8 vs. 0.8 degrees, P=0.016) compared with posterior surgery. As regards indirect decompression of the LLIF, significant increases in thecal sac (83.4 vs. 113.8 mm) and foraminal height (17.8 vs. 20.9 mm) were noted on postoperative magnetic resonance imaging. Although postoperative back VAS (4.1 vs. 5.6, P=0.011) and ODI (48.9% vs. 59.6%, P=0.007) were significantly better in hybrid surgery, clinical outcomes at the last follow-up were similar. Moreover, intraoperative endplate fractures developed in 17.7% and lower leg symptoms occurred in 30.0% of patients undergoing hybrid surgery. CONCLUSIONS: Hybrid surgery for clinical ASP has advantages of segmental coronal and sagittal correction, and indirect decompression compared with conventional posterior surgery. However, LLIF-related complications such as endplate fracture and lower leg symptoms also developed. LLIF should be performed considering advantages and approach-related complications for the clinical ASP.

How to Avoid Distal Adding-on Phenomenon for Rigid Curves in Major Thoracolumbar and Lumbar Adolescent Idiopathic Scoliosis? Identifying the Incidence of Distal Adding-on by Selection of Lowest Instrumented Vertebra.

OBJECTIVE: We sought to compare the radiologic outcomes for different distal fusion levels in a rigid curve with major thoracolumbar and lumbar (TL/L) adolescent idiopathic scoliosis (AIS) using rod derotation (RD) with direct vertebral rotation (DVR) after pedicle screw instrumentation (PSI). METHODS: This study finally enrolled 28 patients who were diagnosed with AIS in rigid curve with major TL/L curves, treated by PSI with RD and DVR and with a minimum 2-year follow-up. Patients were divided into 2 groups, L3 and L4, on the basis of the distal fusion level at the lowest instrumented vertebra (LIV) of L3 or L4. RESULTS: There was no significant difference in TL/L curve, thoracic (minor), and compensatory (caudal) curves between the L3 and L4 groups either postoperatively (P = 0.162, 0.426, and 0.762, respectively) or at the last follow-up (P = 0.952, 0.620, and 0.562, respectively). The overall prevalence of unsatisfactory results was 42.9% (12/28 patients). The prevalence of unsatisfactory results was 61.1% (11/18) in the L3 group and 10% (1/10) in the L4 group, which was significantly different (P < 0.05). CONCLUSIONS: Unsatisfactory results occurred more often in the L3 group than in the L4 group, and unsatisfactory results had significant influence on progression of TL/L and distal compensatory curves. Such progression was closely correlated with deteriorating LIV disk angle in the L3 group. Therefore if the curve is rigid, LIV should be extended to L4 to avoid the adding-on phenomenon in the treatment of major TL/L AIS using RD with DVR after PSI.

Clinical Significance of Preoperative Embolization for Non-Hypervascular Metastatic Spine Tumors.

OBJECTIVE: The efficacy of preoperative embolization for hypervascular metastatic spine disease (MSD) such as renal cell and thyroid cancers has been reported. However, the debate on the efficacy of preoperative embolization for non-hypervascular MSD still remains unsettled. The purpose of this study is to determine whether preoperative embolization for non-hypervascular MSD decreases perioperative blood loss. METHODS: A total of 79 patients (36 cases of preoperative embolization and 43 cases of non-embolization) who underwent surgery for metastatic spine lesions were included. Representative hypervascular tumors such as renal cell and thyroid cancers were excluded. Intraoperative and perioperative estimated blood losses (EBL), total number of transfusion and calibrated EBL were recorded in the embolization and non-embolization groups. The differences in EBL were also compared along with the type of surgery. In addition, the incidence of Adamkiewicz artery and complications of embolization were assessed. RESULTS: The average age of 50 males and 29 females was 57.6±13.5 years. Lung (30), hepatocellular (14), gastrointestinal (nine) and others (26) were the primary cancers. The demographic data was not significantly different between the embolization and the non-embolization groups. There were no significant differences in intraoperative EBL, perioperative EBL, total transfusion and calibrated EBL between two groups. However, intraoperative EBL and total transfusion in patients with preoperative embolization were significantly lower than in non-embolization in the corpectomy group (1645.5 vs. 892.6 mL, p=0.017 for intraoperative EBL and 6.1 vs. 3.9, p=0.018 for number of transfusion). In addition, the presence of Adamkiewicz artery at the index level was noted in two patients. Disruption of this major feeder artery resulted in significant changes in intraoperative neuromonitoring. CONCLUSION: Preoperative embolization for non-hypervascular MSD did not reduce perioperative blood loss. However, the embolization significantly reduced intraoperative bleeding and total transfusion in corpectomy group. Moreover, the procedure provided insights into the anatomy of tumor and spinal cord vasculature.

Effect of Direct Vertebral Rotation in Single Thoracic Adolescent Idiopathic Scoliosis: Better 3-Dimensional Deformity Correction.

OBJECTIVE: To analyze the effects of direct vertebral rotation (DVR) on radiologic outcomes in the treatment of thoracic adolescent idiopathic scoliosis after selective thoracic fusion with pedicle screw instrumentation. METHODS: Adolescent idiopathic scoliosis patients with single thoracic curves (n = 110) treated by selective thoracic fusion with a minimum of 2 years of follow-up were retrospectively analyzed. The patients were separated into 2 groups: non-DVR (n = 63) and DVR (n = 47). RESULTS: There was a significant difference in fused segments between the non-DVR and DVR groups (P < 0.001). There was also a significant difference in main thoracic curve postoperatively (P = 0.001) and at the last follow-up (P = 0.006) between the non-DVR and DVR groups. However, there was no significant difference in proximal thoracic and lumbar curves postoperatively (proximal thoracic curve: P = 0.186; lumbar curve: P = 0.155) and at the last follow-up (proximal thoracic curve: P = 0.250; lumbar curve: P = 0.060) between the 2 groups. Significant improvements in the lowest instrumented vertebra tilt and disc angle were noted but then slight deteriorations in such were observed during the follow-up period in the non-DVR group. The prevalence of unsatisfactory results was 20.6% (13 of 63) in the non-DVR group and 19.1% (9 of 47) in the DVR group, with no significant difference (P = 0.522). CONCLUSIONS: For correcting single thoracic adolescent idiopathic scoliosis by selective thoracic fusion with pedicle screw instrumentation, the addition of DVR to the surgical procedure showed comparable radiologic outcomes compared with non-DVR procedures.

Mediating effect of emotional/behavioral problems and academic competence between parental abuse/neglect and school adjustment.

The current study examined the mediating effects of emotional/behavioral problems and academic competence between parental abuse/neglect and a child's school adjustment by investigating 2070 student surveys from the Korean Child Youth Panel Study (KCYPS). A path analysis yielded the following key findings. Firstly, childhood abuse and neglect showed a significant negative and direct effect on school adjustment. It is particularly important to note that the effect of neglect was bigger than that of abuse in this study. Secondly, emotional/behavioral problems were found to partially mediate between abuse/neglect and school adjustment. Thirdly, academic competence partially mediated the effect of neglect on school adjustment, while it did not mediate the effect of abuse on school adjustment. The indirect effect of parental neglect via emotional/behavioral problems and academic competence was stronger than that of parental abuse. The influence of parental abuse and neglect on children's school adjustments was discussed in terms of emotional/behavioral problems and academic competence considering unique Korean cultural context.

Predictive Factors for Postoperative Follow-up: Which Patients are Prone to Loss to Follow-up After Spinal Surgery?

STUDY DESIGN: Retrospective cohort study. OBJECTIVE: To find out the predictive factors for the failure to follow-up in patients who underwent spinal surgery. SUMMARY OF BACKGROUND DATA: Causes for loss to follow-up range from geographical accessibility to dissatisfaction with surgeons. There were few reports that investigated loss to follow-up after spinal surgery. METHODS: A total of 649 patients who underwent laminectomy and 193 patients who underwent L4-L5 fusion from August 2006 to August 2013 were enrolled in this retrospective study. In each surgical group, demographic data and comorbidities as assessed by the Charlson index were investigated and analyzed for correlation with follow-up. The between-group difference of failure to follow-up was also evaluated. RESULTS: The fusion group (n=193) was more likely to follow-up and the between-group difference was statistically significant (P=0.047). In the laminectomy group (n=649), 271 patients (41.8%) made regular hospital visits. Those who were male, had a spouse, or had fewer comorbidities were less prone to loss to follow-up (P<0.001). Other parameters including age, number of spinal segments operated on during surgery, distance from home to hospital, income, education level, and whether or not patients exercised were also significantly correlated with follow-up compliance (P>0.05). In contrast, 51.8% (n=100) of patients who underwent fusion had regular follow-ups. The fusion group showed a statistical difference in follow-up rate based only on sex (P=0.002). CONCLUSIONS: Our study shows that patients who underwent decompression alone were less likely to attend follow-up than were patients who underwent fusion surgery. Whereas the factors correlated with loss to follow-up after laminectomy alone were sex, marital status, and number of comorbidities, the only predictor after fusion was male sex. Sex was the only shared risk factor for loss to follow-up. LEVEL OF EVIDENCE: Level III.

Delayed Height Loss After Kyphoplasty in Osteoporotic Vertebral Fracture with Severe Collapse: Comparison with Vertebroplasty.

OBJECTIVE: To compare clinical and radiographic outcomes and complications after vertebroplasty (VP) and kyphoplasty (KP) for osteoporotic vertebral fractures with severe collapse. METHODS: Patients >65 years old with single osteoporotic vertebral fracture (T10-L2) with severe collapse (>40%) were prospectively enrolled and allocated to either KP or VP. Visual analog scale and Oswestry Disability Index were used for clinical assessment. Vertebral height loss (HL) and segmental kyphotic angle were measured radiographically at preoperative; postoperative; and 1-, 3-, 6-, and 12-month postoperative time points. Procedure-related and postoperative complications were recorded. RESULTS: Forty-six patients (27 with VP, 19 with KP) were enrolled. Visual analog scale and Oswestry Disability Index scores were similar at all time points in the 2 groups. Complication rates were also similar. HL and kyphotic angle were restored significantly in both groups. KP showed a better result in HL (KP group HL 20.5% ± 5.6% vs. VP group HL 29.8% ± 4.6%, P < 0.001). Progressive vertebral HL was observed, and patients with KP showed a greater collapse in height. At 1-year follow-up, there was no significant difference in vertebral height (KP group HL 29.8% ± 6.3% vs. VP group HL 33.0% ± 5.2%, P = 0.075). CONCLUSIONS: KP and VP showed similar improvements in pain and disability during treatment for osteoporotic vertebral fractures. Although vertebral height and segmental kyphotic angle were restored significantly in both groups, progressive vertebral HL was inevitable, especially after KP. This likely resulted from the difference of bone-cement interface as a consequence of balloon tamping in KP. Surgeons must consider the respective features of vertebral augmentations.

A Comparative Study of Decompressive Laminectomy and Posterior Lumbar Interbody Fusion in Grade I Degenerative Lumbar Spondylolisthesis.

BACKGROUND: For Grade I degenerative lumbar spondylolisthesis (DLS), both decompression alone and decompression with fusion are effective surgical treatments. Which of the two techniques is superior is still under debate. The purpose of this study was to compare clinical outcomes after decompression alone versus decompression with fusion for Grade I DLS. MATERIALS AND METHODS: 139 patients who underwent surgery for Grade I DLS at L4-L5 were prospectively enrolled. Decompression alone was used to treat 74 patients, and decompression with fusion was used to treat 65 patients. Six patients in the first group and four patients in the second group were lost during the 2-year followup. Demographic data were recorded. Operation time, perioperative blood loss, total blood transfusion volume, and length of hospital stay were compared between the two groups. Back pain and functional outcomes were evaluated using the visual analog scale (VAS) and the Oswestry Disability Index (ODI), respectively. RESULTS: Baseline demographic data were not different between the two groups. Operation time, blood loss, total blood transfusion volume, and length of hospital stay were all significantly greater in the fusion group than in the decompression group. This would be expected because fusion is the more invasive procedure. VAS scores were not different up until 6 months postoperatively. Twelve months after surgery, however, VAS scores were significantly lower in the fusion group. The same results were shown in terms of ODI. Although ODI decreased in both groups over time, the fusion group showed better functional outcomes than did the decompression group. CONCLUSIONS: Although both decompression alone and decompression with fusion improved functional outcomes for Grade I DLS, fusion surgery resulted in better results compared to decompression alone. Therefore, fusion should be considered as the treatment of choice for Grade I DLS.

Clinical and Radiologic Features of Osteoporotic Spine Fracture with Delayed Neurologic Compromises.

OBJECTIVES: Osteoporotic spine fractures (OSFs) with delayed neurologic compromises (NCs) have been increasingly reported. Although several studies have addressed that the pathologic mechanism of NC involves nonunion and segmental instability, the risk factors remain unclear. Therefore, the purpose of this study was to assess the radiologic and clinical features of OSFs with delayed NC. METHODS: Thirty patients with delayed NC (group 1) were matched in a 1-to-1 format with 30 patients without delayed NC (group 2) by age, bone mineral density, body mass index, and medical treatment for osteoporosis. Clinical and radiologic parameters were assessed to determine the risk factors related to delayed NC. Clinical outcomes were also compared between the 2 groups. RESULTS: Neurologic compromises were presented as myelopathy in 20 patients and radiculopathy in 10 patients. Initial kyphotic angle (KA) and height loss (HL) were significantly greater in group 1 (21.6 ± 12.9 degrees vs. 10.5 ± 8.6 degrees, P = 0.0001 for KA; 55.8% ± 15.2% vs. 19.9% ± 10.9%, P = 0.0001 for HL). Fracture instability with intravertebral cleft, posterior wall involvement, midportion type of magnetic resonance classification, thoracolumbar level, and aortic calcification were significantly correlated with delayed NC. In multivariate analysis, initial HL (hazard ratio = 1.24; P = 0.012) and midportion-type fracture (hazard ratio = 14.9: P = 0.03) were the independent risk factors related to delayed NC. In addition, clinical outcomes at the last follow-up were significantly better in group 2. CONCLUSIONS: Initial HL and midportion-type fracture were correlated with delayed NC following OSFs. Moreover, pre-existing stenotic lesions might be associated with delayed NC.

Delayed bilateral facet dislocation at L4-5: A case report.

RATIONALE: Traumatic bilateral facet dislocation in the lumbar (L) spine has rarely been reported. All reported cases were presented with acute facet dislocation. However, we present the first case of delayed bilateral facet dislocation at L4-5. PATIENT CONCERNS: A 34-year-old woman presented with back pain after a head-on collision. The patient was treated conservatively for 3 months with rigid orthosis and activity restriction. Even after this conservative treatment, she continued to suffer from persistent back pain that radiated down her left leg and a progressively kyphotic posture. DIAGNOSES: Initial imaging studies revealed a fracture of the left L5 superior articular process with a posterior ligament complex (PLC) injury. Subsequent radiographs showed the locked facet dislocation with kyphotic changes. INTERVENTIONS: The patient underwent surgical reduction and fusion, and the operative findings revealed the L4-5 bilateral facet dislocation and rupture of the PLC at the index level. OUTCOMES: After surgical reduction and fusion at L4-5 by posterior interbody fusion, we achieved a satisfactory clinical outcome. LESSONS: Injury of the PLC in the lower lumbar region deserves careful attention for the development of sequelae. The anatomic transition from lordosis to kyphosis, in the lumbosacral region may be related to this type of injury.