Comparison of Union Rates Between Autogenous Iliac Crest Bone Graft and Local Bone Graft as Fusion Materials in Lumbar Fusion Surgery: An Evaluation of Up to 3-Level Fusion.

OBJECTIVE: To compare the radiologic union rates between autogenous iliac crest bone graft (ICBG) and local bone graft in 1- to 3-level lumbar fusion. METHODS: We reviewed 178 consecutive patients who underwent 1- to 3-level lumbar fusion surgery because of lumbar spinal stenosis. Fusion status of the anterior or posterior column was evaluated by plain radiographs obtained at 24 months postoperatively. If at least either the anterior or posterior column was fused, that segment was regarded as having achieved fusion and was termed segment union. The definition of overall union was achieving union of all segments in a single patient. RESULTS: For each ICBG group and local bone graft group, fusion rate of the anterior and posterior column, and rate of the segments and overall union at postoperative 2 years were not different between the groups, regardless of surgery level. In the overall union rate according to the fusion level, the ICBG group showed constant overall fusion rate according to the fusion level (i.e., 96.9%, 96.9%, and 93.1% for 1-, 2-, and 3-level fusion), but tended to decrease with increasing level in the local bone graft group (100%, 95.8%, and 85.7% for 1-, 2-, and 3-level fusion, respectively) without statistically significant differences. CONCLUSIONS: The union rate of 3-level fusion was not inferior to those of 1- or 2-level fusion in both ICBG and local bone graft patients. Local bone graft could be regarded as an adequate option for not only 1- or 2-level lumbar fusion but also 3-level lumbar fusion surgery.

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.

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.

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.

Pure distraction injury of T1-2 with quad fever.

INTRODUCTION: We report a pure distraction injury of the upper thoracic spine and uncontrolled hyperthermia without an infectious cause. Quad fever appears in the first several weeks to months after a cervical or upper thoracic SCI and is characterized by an extreme elevation in body core temperature beyond 40 °C without an infectious cause. Discriminating between infectious and noninfectious causes is important, and a thorough clinical assessment is required. MATERIALS AND METHODS: A 52-year-old male visited the emergency room complaining of back pain with complete paralysis [American Spinal Injury Association (ASIA) A] of both lower extremities after a pedestrian-motor vehicle accident. He had trouble breathing due to a hemothorax and flail chest caused by fractures of the right second to eleventh and left fourth to seventh ribs. A computed tomography scan revealed severe distraction of the T1-2 intervertebral space. A magnetic resonance image showed signal changes in the spinal cord and a clean-cut margin between the T1-2 disc and T2 body. The neurological level of injury was C8 upon the initial neurological assessment. Emergency surgery was performed. C6-T3 posterior instrumentation and an autologous iliac bone graft were performed. RESULTS: After surgery, the core temperature increased gradually to above 38.0 °C on post-trauma day 4 and increased to 40.8 °C on post-trauma day 7. None of the repeated aerobic, anaerobic, or fungal cultures of the blood, tracheal aspirate, line tips, urine, or stool was positive until post-trauma day 21, when Candida tropicalis was identified in the urine culture. On post-trauma day 63, the blood pressure, pulse, and body temperature stabilized and the patient was transferred to the general ward. At post-trauma year 6, the injury state was still complete and the neurological level of injury was changed to C4. CONCLUSIONS: Based on the Grand Round case and relevant literature, we discuss the case of pure distraction injury of T1-2 with quad fever. Spinal surgeons should be knowledgeable regarding quad fever as well as the differential diagnoses and treatment strategies.

Foreign Body Reaction after Implantation of a Device for Intervertebral Assisted Motion.

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.

Bone cement augmentation procedures for spinal pathologic fractures by multiple myeloma.

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.

Does extracorporeal shock wave introduce alteration of microenvironment in cell therapy for chronic spinal cord injury?

STUDY DESIGN: Animal experimental study. OBJECTIVE: To present experimental evidence for cell therapy for spinal cord injury (SCI). SUMMARY OF BACKGROUND DATA: In chronic SCI, the efficacy of cell engraftment has been known to be low due to its distinct pathology. Alteration of microenvironment was tried using extracorporeal shock waves (ESW) for chronic SCI, and the efficacy of cell therapy was investigated. METHODS: A chronic contusive SCI model was made in 36 Sprague-Dawley rats. The rats were allocated into (1) control group (SCI only), (2) ESW control group (SCI + ESW), (3) IV group (SCI + intravenous transplantation of mesenchymal stem cells; MSCs), and (4) ESW + IV group (SCI + MSCs IV transplantation after ESW). ESW were applied at the energy determined by our preliminary trials. Engraftment of the cells and expressions of growth factors (brain-derived neurotrophic factor, neuronal growth factor) and cytokines (SDF-1, CXCR4, VEGF) at the epicenter were assessed. The Basso, Beattie, and Bresnahan locomotor scale was used for the clinical assessment. RESULTS: The mean numbers of engrafted cells were higher in the ESW+ IV than that in the IV with a statistical significance. The expression of SDF-1 was higher in the ESW groups than that in the control or IV group. CXCR4 was highly expressed in the transplanted groups. The expressions of growth factors in the treated group were higher in the treated group than those in the control group. However, various statistical significances were noted. The improvement of locomotor was higher in the transplanted groups than that in the control and ESW only group. CONCLUSION: At a given energy level, ESW presented more engraftment of the transplanted MSCs without any clinical deterioration in a chronic SCI. Based on this promising result and possible explanations, ESW may cause an alteration of the microenvironment for the cell therapy in chronic SCI. LEVEL OF EVIDENCE: N/A.

Spinal cord compression by B-cell lymphoma, unclassifiable, with features intermediate between diffuse large B-cell lymphoma and Burkitt lymphoma in a patient seropositive for human immunodeficiency virus: a case report.

INTRODUCTION: Although non-Hodgkin's lymphoma is one of the most common and frequently fatal of the acquired immune deficiency syndrome-defining illnesses, survival has improved significantly since the introduction of antiretroviral therapy. Patients with spinal cord compression resulting from non-Hodgkin's lymphoma present with clinically acute or rapidly progressive neurologic deficits. The purpose of this case report is to present a case of a patient seropositive for human immunodeficiency virus with spinal cord compression due to B-cell lymphoma, unclassifiable, with features intermediate between diffuse large B-cell lymphoma and Burkitt lymphoma. CASE PRESENTATION: A 40-year-old Asian man, who was seropositive for human immunodeficiency virus, presented with progressive neurological deficits. Magnetic resonance images of his thoracic spine showed an epidural mass from T2 to T4, resulting in severe cord compression. Emergent surgical decompression and biopsy were performed, followed by palliative radiation therapy. The pathologic findings showed that the specimen was compatible with B-cell lymphoma, unclassifiable, with features intermediate between diffuse large B-cell lymphoma and Burkitt lymphoma. Palliative radiation therapy was performed; however, leptomeningeal seeding and pulmonary embolism led to his death. CONCLUSIONS: When a patient infected with human immunodeficiency virus presents with a rapidly progressive spinal tumor accompanying paraplegia, non-Hodgkin's lymphoma should be considered, and surgical decompression should be weighed with respect to the patient's general condition and the subtype/prognosis of the lymphoma.

Distal femoral cortical proliferative irregularity with excavation in a 6-year-old girl.

The distal femur is a common site for benign or malignant bone tumors in children or adolescents. Distal femoral cortical irregularities at the posterior aspect of the distal femoral metaphysis must be differentiated from malignant bone tumors because they might be misinterpreted as malignant neoplasm. Plain radiographs of a 6-year-old girl complaining of left knee pain for 4 weeks showed cortical proliferation with excavation on her distal femoral metaphysis. Computed tomography, magnetic resonance imaging and bone scan helped to differentiate the cortical irregularity from malignant lesions. Therefore unnecessary invasive surgery was avoided in this patient.

Percutaneous vertebroplasty for cephalad vertebral fractures after instrumented lumbar fusion.

STUDY DESIGN: Retrospective cohort study. OBJECTIVE: To identify the effect of cement augmentation for cephalad vertebral fracture after instrumented lumbar fusion. SUMMARY OF BACKGROUND DATA: Osteoporosis may contribute to cephalad vertebral fractures by an altered biomechanics in the adjacent segments due to the loss of motion at the fused segments. However, few studies on the treatment for cephalad fractures using bone cement augmentation after instrumented lumbar fusion have been published. METHODS: Seventeen patients who had cephalad vertebral fractures after instrumented lumbar fusion underwent percutaneous vertebroplasty (PVP). All patients were divided into 2 groups according to the presence of intravertebral vacuum clefts (IVC) on plain radiographs and magnetic resonance imaging: group 1 consisted of 9 patients without an associated IVC and group 2 consisted of 8 patients with an IVC. The Oswestry Disability Index and the Visual Analogue Scale were recorded prospectively. The radiologic parameters of kyphotic deformity, vertebral height changes, and leakage of cement were studied. RESULTS: The Oswestry Disability Index and Visual Analogue Scale scores in group 1 decreased after PVP, but the mean score in group 2 was higher than in group 1 at the last follow-up. The mean kyphosis measured 15.7±7.4 degrees preoperatively and 15.6±7.1 degrees at the final follow-up in group 1, and 16.9±8.8 degrees preoperatively and 27.2±8.8 degrees at the final follow-up in group 2.The mean preoperative anterior and posterior vertebral height ratio measured 0.6±0.2 preoperatively and 0.6±0.2 at the final follow-up in group 1, and 0.6±0.2 preoperatively and 0.5±0.2 at the final follow-up in group 2.The mean preoperative middle and posterior vertebral height ratio measured 0.5±0.1 preoperatively and 0.6±0.1 at the final follow-up in group 1, and 0.5±0.1 preoperatively and 0.4±0.2 at the final follow-up in group 2. Four patients underwent revision surgery in group 2 and 1 in group 1. CONCLUSIONS: Although PVP treatment may be a useful method for cephalad vertebral fractures after instrumented lumbar fusion in elderly patients with persistent unremitting back pain, recollapse of the vertebral body can occur after a PVP for cephalad or adjacent vertebral fractures with an IVC.

Percutaneous posterior instrumentation followed by direct lateral interbody fusion for lumbar infectious spondylitis.

STUDY DESIGN: Retrospective study. OBJECTIVES: To investigate the clinical feasibility and outcomes from direct lateral interbody fusion (DLIF) using autogenous bone grafts and percutaneous posterior instrumentation (PPI) for infectious spondylitis. SUMMARY OF BACKGROUND DATA: As one of the minimally invasive techniques, PPI has been attempted for various degenerative lumbar spine disorders combined with anterior lumbar interbody fusion or transforaminal lumbar interbody fusion. PPI has been played more roles recently as an internal fixation method for infectious spondylitis. However, the clinical outcomes of DLIF using an autogenous bone graft combined with PPI for infectious spondylitis have been rarely reported. MATERIALS AND METHODS: Sixteen patients (mean age, 60.3 ± 18.8 y) who suffered from pyogenic spondylitis underwent single-stage DLIF using an autogenous iliac bone graft combined with PPI. Clinical and radiologic outcomes were evaluated by visual analog scale (VAS), Oswestry Disability Index (ODI), and eradication of primary disease. Radiologic outcomes were evaluated by changes of affected segmental lordosis and fusion status. RESULTS: Bony fusion and eradication of primary disease were obtained in all patient except 1 case during the follow-up (mean, 31.3 ± 13.1 mo; range 14-46 mo). Preoperative VAS (7 ± 1.2) and ODI (61.3 ± 5.4) scores improved significantly at the last follow-up (VAS, 3.4 ± 1.5; ODI, 32.3 ± 15.4). C-reactive protein normalized at postoperative 20.1 ± 0.7 days (range, 15-28 d). Although height and lordosis in the affected segment were restored by surgery, all patients showed loss of the restored lordosis and height at the final follow-up. Loss of the restored lordosis and height were related to subsidence of the grafted bone. CONCLUSIONS: Minimally invasive PPI followed by debridement and DLIF was a feasible surgical alternative in our consecutive 16 cases of pyogenic spondylitis. In most cases, however the subsidence of anteriorly grafted fusion was inevitable despite successful fusion and eradication of the primary lesion.

Posterior dynamic stabilization in the treatment of degenerative lumbar stenosis: validity of its rationale.

OBJECT: 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. METHODS: 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. RESULTS: 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 (p < 0.001). CONCLUSIONS: 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.

Thoracic myelopathy caused by ossification of the yellow ligament in patients with posterior instrumented lumbar fusion.

PURPOSE: The objective of this study was to investigate thoracic myelopathy caused by ossification of the yellow ligament (OYL) in patients with posterior instrumented lumbar fusion. METHODS: Seven patients, who had undergone posterior instrumented lumbar fusion, presented with thoracic myelopathy caused by OYL. No patient had a history of thoracic myelopathy at previous surgery. Instrumented fusions were performed from L1-5 in two patients, L2-5 in three patients and L1-S1 and L2-S1 in one patient each, respectively. MRI and CT scans were performed to confirm cord compression by OYL. Of the seven patients, six patients underwent decompressive laminectomy and OYL removal while one was treated conservatively. RESULTS: The average time to presentation after first surgery was 63.4 months. OYL was located at T9-10 in two patients, T11-12 in three patients, and T10-11 and T9-11 in one patient each, respectively. All patients had a myelopathic gait and the average Japanese Orthopaedic Association (JOA) score was 3.9, preoperatively. The average JOA score improved from 3.7 to 8 and the average recovery rate was 58.9 % in the six patients who underwent surgical intervention. However, the JOA score fell from 5 to 4 in the one patient who was treated conservatively. CONCLUSIONS: We report seven patients who suffered from thoracic myelopathy after instrumented lumbar fusion. Surgeons must be aware of the possibility of thoracic myelopathy caused by OYL at the thoracolumbar junction, especially in patients with a complaint of gait disturbance after long instrumented lumbar fusion.

Chronic suppurative inflammatory cyst in the sacrum.

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.

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.

Treatment for multiple Aspergillus spondylitis including a hip joint.

Multiple aspergillus spondylitis (AS) is a life threatening infection that occurs more commonly in immunocompromised patients, and is commonly treated with antifungal agents. However, there is relatively little information available on the treatment of multiple AS. The authors encountered a 46-year-old man suffering from low back and neck pain with radiculomyelopathy after a liver transplant. The patient had concomitant multiple AS in the cervico-thoraco-lumbar spine and right hip joint, as confirmed by radiologic imaging studies. The pathological examination of a biopsy specimen revealed fungal hyphae at the cervical and lumbar spine. Anterior decompression and interbody fusion were performed for the cervical and lumbar lesions, which showed instability and related neurological symptoms. Additional antifungal therapy was also performed. The patient was treated successfully with remission of his symptoms.