Non-operative Treatment of Osteoporotic Thoracolumbar Extension-distraction Fracture Using Teriparatide in Elderly Female Patient with Severe Osteoporosis under Inoperable Condition: A Case Report / 대한신경손상학회지

Vertebral extension-distraction fractures are a type of unstable fracture and require surgical stabilization with instrumentation. Unfortunately, in elderly patients with severe osteoporosis, poor bone quality can be related to postoperative pseudo-arthrosis and instability. Teriparatide is known as an effective anabolic agent for bone healing, union, and managing osteoporosis. In this report, we describe a rare case of extension-distraction thoracolumbar fractures in 86-year-old female patient with severe osteoporosis, which was treated conservatively. The patient was inoperable due to the presence of concomitant cardiopulmonary problems and the patients' old age. She had poor bone quality on bone mineral densitometry (−6.7, lumbar spine) but no neurologic deficits. As conservative treatment, bedrest and pain control were first performed for three weeks along with the use of teriparatide for 6-month and supplementation of calcium and vitamin D. Afterwards, sitting and standing with wearable orthoses were gradually implemented. After 1 year, the patient achieved bone fusion and was able to walk by herself, and there was radiological correction of the initial segmental lordotic curvature and disappearance of the intravertebral gap caused by the extension-distraction fracture.

Therapeutic Effect of Teriparatide for Osteoporotic Thoracolumbar Burst Fracture in Elderly Female Patients

Objective@#: Teriparatide is known as an effective anabolic agent not only for severe osteoporosis but also for bone healing and union. We explored the possibility of teriparatide as an alternative treatment option for osteoporotic thoracolumbar (TL) burst fracture. @*Methods@#: This retrospective study enrolled 35 female patients with mean age of 73.77±6.71 years (61–88) diagnosed as osteoporotic TL burst fracture with ≥4 of thoracolumbar injury classification and severity (TLICS) score and no neurological deficits. All patients were treated by teriparatide only (12 of group A), teriparatide plus vertebroplasty (12 of group B), or surgical fixation with fusion (11 of group C), and followed up for 12 months. Radiological outcomes were evaluated using radiological parameters including kyphotic angle (KA), segmental vertebral kyphotic angle (SVKA), compression ratio (CR), and vertebral body height (anterior [AH], middle [MH], posterior [PH]). Functional outcomes were evaluated using visual analog scale (VAS) and Macnab classification (MC). @*Results@#: There were no statistical significant differences in age, bone mineral density (-3.36±0.73), and TLICS score (4.34±0.48) among the three groups (p>0.05). Teriparatide was administered during 8.63±2.32 months in group A and B. In 12-month radiological outcomes, there were significant restoration in SVKA, CR, AH, and MH of group B and KA, SVKA, CR, AH, and MH of group C compared to group A with no radiological changes (p<0.05). All groups showed similar significant improvements in 12-month functional outcomes, although group B and C showed a better 1-month VAS, 1-month MC, 3-month MC compared to group A (p<0.05). @*Conclusion@#: Non-surgical treatment with teriparatide showed similar 12-month functional outcomes compared to surgical fixation with fusion. The additional vertebroplasty to teriparatide and surgical fixation with fusion were more helpful to improve short-term functional outcomes with structural restoration compared to teriparatide only.

Fracture-dislocation of L5 Combined with Multi-level Traumatic Spondylolisthesis of the Lower Lumbar Spine Treated via the Posterior-only Approach: A Case Report / 대한신경손상학회지

Fracture-dislocation of the lower lumbar spine, which is commonly caused by high-impact trauma and can lead to instability in the spine, is relatively rare. Surgical treatment is indicated to restore spinal balance, weight-bearing ability, and decompression of the neural elements. There are various available surgical options, including the posterior-only or anterior-only approaches, or a combination of them. However, there is still no definite classification and treatment strategy for fracture-dislocation of the lower lumbar spine. In this report, we describe a 65-year-old man presenting cauda equina syndrome caused by a fracture-dislocation of L5 combined with multi-level traumatic spondylolisthesis of the lower lumbar spine. The patient was treated via the posterior-only approach with neural decompression and anterior reconstruction with posterior instrumentation. We discuss the reasons why the posterior-only approach was decided upon and several meaningful points during the surgery in detail.

Application of Simultaneous 18F-FDG PET/MRI for Evaluating Residual Lesion in Pyogenic Spine Infection:a Case Report

Magnetic resonance imaging (MRI) is the preferred imaging method for evaluating treatment response in spine infection. However, there are still no definite correlation between followup MRI findings and clinical status. Recently, Fluorine-18 fluorodeoxyglucose positron emission tomography (18F-FDG PET) shows great potential as diagnostic and monitoring options. Simultaneous 18F-FDG PET/MRI makes us to expect a huge synergic effect on diagnosis and evaluation of treatment response with metabolic and anatomical advantages in spine infection. We introduce an application of 18F-FDG PET/MRI for evaluating residual lesion in the patient with pyogenic spine infection.

Application of Simultaneous 18F-FDG PET/MRI for Evaluating Residual Lesion in Pyogenic Spine Infection:a Case Report

Magnetic resonance imaging (MRI) is the preferred imaging method for evaluating treatment response in spine infection. However, there are still no definite correlation between followup MRI findings and clinical status. Recently, Fluorine-18 fluorodeoxyglucose positron emission tomography (18F-FDG PET) shows great potential as diagnostic and monitoring options. Simultaneous 18F-FDG PET/MRI makes us to expect a huge synergic effect on diagnosis and evaluation of treatment response with metabolic and anatomical advantages in spine infection. We introduce an application of 18F-FDG PET/MRI for evaluating residual lesion in the patient with pyogenic spine infection.

Analysis of Factors Contributing to Repeat Surgery in Multi-Segments Cervical Ossification of Posterior Longitudinal Ligament

OBJECTIVE: Cervical ossification of the posterior longitudinal ligament (OPLL) can be treated via anterior or posterior approach, or both. The optimal approach depends on the characteristics of OPLL and cervical curvature. Although most patients can be successfully treated by a single surgery with the proper approach, renewed or newly developed neurological deterioration often requires repeat surgery.METHODS: Twenty-seven patients with renewed or newly developed neurological deterioration requiring salvage surgery for multi-segment cervical OPLL were enrolled. Ten patients (group AP) underwent anterior approach, and 17 patients (group PA) underwent posterior approach at the initial surgery. Clinical and radiological data from initial and repeat surgeries were obtained and analyzed retrospectively.RESULTS: The intervals between the initial and repeat surgeries were 102.80±60.08 months (group AP) and 61.00±8.16 months (group PA) (p < 0.05). In group AP, the main OPLL lesions were removed during the initial surgery. There was a tendency that the site of main OPLL lesions causing renewed or newly developed neurological deterioration were different from that of the initial surgery (8/10, p < 0.05). Repeat surgery was performed for progressed OPLL lesions at another segment as the main pathology. In group PA, the main OPLL lesions at the initial surgery continued as the main pathology for repeat surgery. Progression of kyphosis in the cervical curvature (Cobb’s angle on C2–7 and segmental angle on the main OPLL lesion) was noted between the initial and repeat surgeries. Group PA showed more kyphotic cervical curvature compared to group AP at the time of repeat surgery (p < 0.05).CONCLUSION: The reasons for repeat surgery depend on the type of initial surgery. The main factors leading to repeat surgery are progression of remnant OPLL at a different segment in group AP and kyphotic change of the cervical curvature in group PA.

Investigation of Symptomatic Unstable Changes of Non-Fused Component in the Mixed-Type Cervical Ossification of Posterior Longitudinal Ligament Using Dynamic Magnetic Resonance Imaging: A Case Report / 대한신경손상학회지

A 43-year-old man was transferred to our hospital with recurring myelopathic symptoms after previous anterior and posterior surgical decompressions for mixed-type cervical ossification of the posterior longitudinal ligament (OPLL). Conventional magnetic resonance imaging (MRI) showed a preserved cervical curve and the achievement of successful decompression after the previous surgeries. The patient's symptoms were aggravated when he was in the extended neck posture. Dynamic MRI performed with the patient in an extended neck position revealed cord compression by OPLL from C3 to C4 with newly developed retrolisthesis of the C4–5 segment. We recommend the use of dynamic MRI to investigate motion-dependent cord compression caused by instability of the non-fused OPLL component.

Analysis of Factors Contributing to Repeat Surgery in Multi-Segments Cervical Ossification of Posterior Longitudinal Ligament

OBJECTIVE: Cervical ossification of the posterior longitudinal ligament (OPLL) can be treated via anterior or posterior approach, or both. The optimal approach depends on the characteristics of OPLL and cervical curvature. Although most patients can be successfully treated by a single surgery with the proper approach, renewed or newly developed neurological deterioration often requires repeat surgery. METHODS: Twenty-seven patients with renewed or newly developed neurological deterioration requiring salvage surgery for multi-segment cervical OPLL were enrolled. Ten patients (group AP) underwent anterior approach, and 17 patients (group PA) underwent posterior approach at the initial surgery. Clinical and radiological data from initial and repeat surgeries were obtained and analyzed retrospectively. RESULTS: The intervals between the initial and repeat surgeries were 102.80±60.08 months (group AP) and 61.00±8.16 months (group PA) (p < 0.05). In group AP, the main OPLL lesions were removed during the initial surgery. There was a tendency that the site of main OPLL lesions causing renewed or newly developed neurological deterioration were different from that of the initial surgery (8/10, p < 0.05). Repeat surgery was performed for progressed OPLL lesions at another segment as the main pathology. In group PA, the main OPLL lesions at the initial surgery continued as the main pathology for repeat surgery. Progression of kyphosis in the cervical curvature (Cobb’s angle on C2–7 and segmental angle on the main OPLL lesion) was noted between the initial and repeat surgeries. Group PA showed more kyphotic cervical curvature compared to group AP at the time of repeat surgery (p < 0.05). CONCLUSION: The reasons for repeat surgery depend on the type of initial surgery. The main factors leading to repeat surgery are progression of remnant OPLL at a different segment in group AP and kyphotic change of the cervical curvature in group PA.

Application of Lateral Approach for the Removal of Migrated Interbody Cage: Taphole and Fixing Technique

When a revision surgery related with removal of failed interbody cage is required, going through the previous passage can lead to a higher risk of neurological deficits or incidental dural injuries. Recently, the lateral approach has become a popular method instead of the conventional anterior or posterior approaches. The lateral approach is also useful method to remove failed interbody cage previously placed and re-do interbody fusion with lower risks compared to revision surgery via previous passage. However, there is still some difficulty in retrieving the interbody cage from the intervertebral space because of no spacious passage, subsidence, and uncontrolled movable cage. In this study, we introduce our experience that we removed failed interbody cage more easily with only the simple additional steps of making a taphole and fixing the cage using a thread-tipped stick.

Intradural Extramedullary Capillary Hemangioma In the Upper Thoracic Spine with Simultaneous Extensive Arachnoiditis

Capillary hemangiomas are common benign vascular tumors on skin and soft tissues, but developing as an intradural and extramedullary (IDEM) tumor in spine is extremely rare. In this report, we present IDEM tumor compressing thoracic cord in T2–3 level with extensive arachnoiditis below the tumor level in a 60-year-old man. The lesion was removed and histological diagnosis was capillary hemangioma. Prompt diagnosis and resection are important to avoid neurological deterioration from acute hemorrhagic condition. Simultaneous arachnoiditis may be originated from old subarachnoid hemorrhage associated tumor before diagnosis, and we suggest it as a helpful diagnostic feature to suspect vascular tumors such as capillary hemangioma.

Three-Years Outcome of Microdiscectomy via Paramedian Approach for Lumbar Foraminal or Extraforaminal Disc Herniations in Elderly Patients over 65 Years Old

OBJECTIVE: Lumbar foraminal or extraforaminal disc herniations (FEFDH) have unusual clinical features and higher incidence in elderly patients compared to usual intraspinal canal disc herniations. We evaluated the efficacy of microdiscectomy via paramedian approach for lumbar FEFDH in elderly patients over the age of 65. METHODS: Retrospective study was performed in 68 patients over the age of 65 (23 male and 45 female patients; 71.46±3.87 years) who underwent microdiscectomy via paramedian approach for unilateral lumbar FEFDH causing sciatica. The radiological factors including degree of slippage, presence of instability, disc height, and degree of disc degeneration; pain and functional status by the means of visual analogue scale score, Oswestry Disability Index score, and Macnab classification were analyzed preoperatively and during the postoperative follow-up period of 3 years to evaluate the efficacy of the surgical treatment. RESULTS: Pain and functional status improved according to short- and long-term follow-up evaluations after surgery. Radiological changes following surgery, which can be understood as structural deteriorations and deformations, did not represent patient condition. Nine patients underwent additional surgery due to sustained or recurring leg pain of aggravation of back pain, and fusion surgery was required for 3 patients. Degree of preoperative slippage was the only statistically significant factor related to additional surgery (p<0.05). CONCLUSION: Microdiscectomy via paramedian approach for FEFDH may be a good surgical alternative in elderly patients. Radiological changes after surgery did not show a concordance with patients' actual functional status. The excessive preoperative slippage tended to lead to unfavorable result after surgery and was associated with additional surgery.

Spontaneous Spinal Subdural Hematoma with Simultaneous Cranial Subarachnoid Hemorrhage

Spontaneous spinal subdural hematoma is reported at a rare level of incidence, and is frequently associated with underlying coagulopathy or those receiving anticoagulant or antiplatelet agents; some cases accompany concomitant intracranial hemorrhage. The spontaneous development of spinal subdural hemorrhage (SDH) is a neurological emergency; therefore, early diagnosis, the discontinuation of anticoagulant, and urgent surgical decompression are required to enable neurological recovery. In this report, we present a simultaneous spinal subdural hematoma and cranial subarachnoid hemorrhage, which mimicked an aneurysmal origin in a female patient who had been taking warfarin due to aortic valve replacement surgery.

Delayed or Missed Diagnosis of Cervical Instability after Traumatic Injury: Usefulness of Dynamic Flexion and Extension Radiographs

Prompt and accurate diagnosis of cervical spine injury is important to prevent the catastrophic results that can be caused by undetected lesions. Delayed or missed diagnosis of cervical spine injury occurs with an incidence of 5 to 20% according to previous studies. In this study, we report four cases of cervical instability without initial radiologic evidence. These cases demonstrate that dynamic flexion and extension radiographies can be a proper choice of modality to diagnose and exclude the possibility of cervical instability in a patient with a suspicious ligament injury on the static radiographies following acute cervical trauma.

Brown-Sequard Syndrome after an Accidental Stab Injury of Cervical Spine: A Case Report / 대한신경손상학회지

We report a case of Brown-Sequard syndrome (BSS) caused by an accidental stab injury of the cervical spine that shows clear magnetic resonance imaging (MRI) findings and clinical presentation. A 42-year-old woman was brought into the emergency department after a stab injury on the right side of the posterior neck from a knife that was lying in a fruit basket after slipping. The patient complained of hemiparesis of the right-side extremities, and ipsilateral hypoesthesia and contralateral sensory loss of pain and temperature were also found on neurological examination. MRI showed a signal change of the C6-7 cord level and the tract of the stab wound through the posterior neck. Irrigation and primary closure of the laceration was performed under the impression of BSS. The neurologic deficit was improved with rehabilitation therapy.

Delayed Traumatic Diaphragm Hernia after Thoracolumbar Fracture in a Patient with Ankylosing Spondylitis

Traumatic diaphragm hernia can occur in rare cases and generally accompanies thoracic or abdominal injuries. When suffering from ankylosing spondylitis, a small force can develop into vertebral fracture and an adjacent structural injury, and lead to diaphragm hernia without accompanying concomitant thoracoabdominal injury. A high level of suspicion may be a most reliable diagnostic tool in the detection of a diaphragm injury, and we need to keep in mind a possibility in a patient with ankylosing spondylitis and a thoracolumbar fracture, even in the case of minor trauma.

Retrolisthesis as a Compensatory Mechanism in Degenerative Lumbar Spine

OBJECTIVE: Posterior vertebral translation as a type of spondylolisthesis, retrolisthesis is observed commonly in patients with degenerative spinal problems. Nevertheless, there is insufficient literature on retrolisthesis compared to anterolisthesis. The purpose of this study is to clarify the clinical features of retrolisthesis, and its developmental mechanism associated with a compensatory role in sagittal imbalance of the lumbar spine. METHODS: From 2003 to 2012, 230 Korean patients who underwent spinal surgery in our department under the impression of degenerative lumbar spinal disease were enrolled. All participants were divided into four groups : 35 patients with retrolisthesis (group R), 32 patients with simultaneous retrolisthesis and anterolisthesis (group R+A), 76 patients with anterolisthesis (group A), and 87 patients with non-translation (group N). The clinical features and the sagittal parameters related to retrolisthesis were retrospectively analyzed based on the patients' medical records. RESULTS: There were different clinical features and developmental mechanisms between retrolisthesis and anterolisthesis. The location of retrolisthesis was affected by the presence of simultaneous anterolisthesis, even though it predominantly manifest in L3. The relative lower pelvic incidence, pelvic tilt, and lumbar lordosis compared to anterolisthesis were related to the generation of retrolisthesis, with the opposite observations of patients with anterolisthesis. CONCLUSION: Retrolisthesis acts as a compensatory mechanism for moving the gravity axis posteriorly for sagittal imbalance in the lumbar spine under low pelvic incidence and insufficient intra-spinal compensation.