The Sagittal Balance of Cervical Spine : Comprehensive Review of Recent Update

The cervical spine plays a critical role in supporting the skull, maintaining horizontal gaze, and facilitating walking. Its unique characteristics, including the widest range of motion among spinal segments, have led to extensive research on cervical sagittal alignment. Various parameters have been proposed to evaluate cervical alignment, with studies investigating their clinical significance, correlation with symptoms, and implications for surgical interventions. Recent findings suggest that cervical sagittal alignment not only impacts the cervical spine but also influences global spine-pelvic alignment through compensatory mechanisms. This comprehensive review examines classical and new parameters of cervical sagittal alignment and considers the dynamic and muscular factors associated with it.

Comparison of Midline Splitting versus Unilateral Open Door Laminoplasty and Its Impact on Patient Outcomes

Background@#Laminoplasty is a common and effective surgery for decompression of the spinal cord in multilevel cervical myelopathy. The midline splitting technique (MST) and the unilateral open door technique (UODT) are the two most commonly performed laminoplasty techniques with continuous debate on which is preferable. This study aimed to add light to the matter by comparing and exploring the possible causes of different outcomes. @*Methods@#A total of 101 patients who underwent laminoplasty for degenerative cervical myelopathy were included in this study.Radiographic measurements including C2–7 Cobb angle, C2–7 range of motion (ROM), Pavlov ratio of the most compressed level, and canal area with diameter were compared. Modified Japanese Orthopedic Association (mJOA) score and complications including C5 palsy, axial neck pain, hinge fractures, and spacer displacement were also compared. Statistical analysis was performed using independent samples t-test, chi-square test, Fisher’s exact test, and linear mixed model. @*Results@#C2–7 ROM, canal diameter, Pavlov ratio, and mJOA score did not demonstrate differences between the two techniques.The UODT group had greater postoperative canal expansion but had more loss of C2–7 lordosis than did the MST group. Of the complications, hinge fractures were more common in the UODT group, with more loss of C2–7 lordosis in patients with hinge fractures. On the other hand, spacer displacement occurred only in the MST group, with lesser canal expansion in patients with spacer displacement. @*Conclusions@#The two laminoplasty techniques both demonstrated effectiveness in treating patients with multilevel cervical myelopathy. However, care should be given to avoid hinge fractures and spacer displacement since both can possibly lead to unfavorable outcomes.

Diffusion Metrics as a Potential Prognostic Biomarker in Cervical Myelopathy

Diffusion tensor imaging (DTI) has a diagnostic value in cervical myelopathy. The usefulness of diffusion metrics as a potential prognostic biomarker was assessed in this review. Various diffusion metrics, such as fractional anisotropy, mean diffusivity, apparent diffusion coefficient, and radial diffusivity, were significant in correlation with functional recovery after surgery. Changes in diffusion metrics not only at the compression level, but also above and below the compression level were confirmed. However, it was difficult to confirm the results owing to the diversity of studies. Further efforts to make a consensus on spinal cord DTI are needed.

Responses to the Letter: Cervical Foraminal and Discal Height after Dynamic Rotational Plating in the Cervical Discectomy and Fusion

No abstract available.

The Role of the Pelvis in Sagittal Alignment of Lumbar Degenerative Disease Patients

STUDY DESIGN: Literature review. OBJECTIVES: To present updated information on the relationship of the pelvis and lumbar degenerative disease (LDD) patients and to emphasize the importance of the pelvis in sagittal alignment of LDD patients. SUMMARY OF LITERATURE REVIEW: Although the relationship of the pelvis and sagittal alignment of LDD patients is controversial, many authors have reported a significant impact of the pelvis on LDD sagittal alignment. MATERIALS AND METHODS: The authors identified references through a literature search on the pelvis and LDD and continuous monitoring of the literature during the past 30 years. RESULTS: The pelvis and lumbar levels were related to whole-body sagittal alignment. The pelvis is also closely related to sagittal alignment of LDD patients. Therefore, the entire area should be regarded as a lumbopelvic complex. CONCLUSIONS: We need to consider the concept of a lumbopelvic joint and lumbopelvic lordosis, not a lumbosacral joint and lumbar lordosis. We must also evaluate the lumbopelvic complex to assess whole-body sagittal alignment and dynamic balance.

A Suspected Case of Cutaneous Mycobacterium immunogenum Infection / 나학회지

M. immunogenum was identified as the etiologic agent of a variety of hospital-acquired infections, including an outbreak of keratitis, and as the potential cause of hypersensitivity pneumonitis in industrial metal-grinding machinists. This microorganism appears to differ from other members of the M. chelonae?abscessus group. Clinically significant isolates have been recovered from skin lesions, corneal ulcers, joint fluid, central venous catheter sites, and blood. There have been some cases of M. immunogenum skin infection reported. We report a suspected case of cutaneous Mycobacterium immunogenum infection in a 23-year-old male, migrant Workers from Sri Lanka, who presented with an erythematous plaque on his right ear. M. immunogenum was suspected by PCR-restriction fragment length polymorphism & sequencing of PCR product. The patient was treated with clarithromycin & ofloxacin. The lesion started to improve 4 weeks after initiation of the therapy. We have the patient in therapy for 3 months, and the lesion is slowing disappeared.

The Analysis of Causes of Anemia in Persons affected leprosy / 나학회지

The anemia still remains the most common hematologic disorder in the world despite improvements in general health and nutrition. Recently, the prevalence of anemia in the persons affected leprosy aged over 60 years was reported 22.4% in 60-69 years and 47.4% in 70 years or older in male and was reported 33.8% in 60-69 years and 46.0% in 70 years or older in female. This study was aimed at assessing the causes of anemia in the persons affected leprosy aged over 60 years. For evaluation of anemia, including prevalence, typing, and cause, hemoglobin, MCV(mean corpucular volume), RDW(red blood cell distribution width), ferritin, iron, TIBC, reticulocyte count, serum vitamin B12, serum folate and etc were checked. The proportion of the anemia classified by MCV was 6.6%(microcytic), 63.2%(normocytic), and 30.3%(macrocytic) and a half of the anemia was attributed to chronic diseases, 14.5% to anemia of iron deficiencies, 5.3% to anemia of nutrient(vitamin B12 & folate) deficiencies, 3.9% to anemia of hemolysis, and a quarter(27.6%) was "unexplained". We will consider about the evaluation of more detailed causes of anemia in persons affected leprosy, and management plan for anemia in them by the in-depth studies.

Loss of Lordosis and Clinical Outcomes after Anterior Cervical Fusion with Dynamic Rotational Plates

PURPOSE: The cervical dynamic rotational plating system may induce bone graft subsidence, so it may cause loss of cervical lordosis. However there were few studies for alignments of cervical spines influencing the clinical results after using dynamic rotational plates. The purpose is to evaluate the effect of graft subsidence on cervical alignments due to the dynamic rotational cervical plates and correlating it with the clinical outcomes of patients undergoing anterior cervical fusion. MATERIALS AND METHODS: Thirty-three patients with disease or fracture underwent anterior cervical decompression and fusion using a dynamic rotational plate. The presence and extent of implant complications, graft subsidence, loss of lordosis were identified and Visual Analog Scale score (VAS score), Japanese Orthopaedic Association score (JOA score), clinical outcomes based on Odom's criteria were recorded. RESULTS: Fusion was achieved without implant complications in all cases. The mean graft subsidence at 6 months after the surgery was 1.46 mm. The lordotic changes in local cervical angles were 5.85degrees which was obtained postoperatively. VAS score for radicular pain was improved by 5.19 and the JOA score was improved by 3. Clinical outcomes based on Odom's criteria showed sixteen excellent, ten good and two satisfactory results. There was no significant relationship between clinical outcomes and changes in the cervical angles. CONCLUSION: Dynamic rotational anterior cervical plating provides comparable clinical outcomes to that of the reports of former static cervical platings. The loss of lordosis is related to the amount of graft settling but it is not related to the clinical outcomes.

T1 Slope and Cervical Sagittal Alignment on Cervical CT Radiographs of Asymptomatic Persons

OBJECTIVE: We performed a retrospective analysis of medical records and radiographic images of patients who never underwent spinal treatment including diagnosis. The objective of this study is to explain the biomechanical and physiologic characteristics of cervical alignment related to thoracic inlet angle including T1 slope changes in each individual. METHODS: We reviewed the cervical CT radiographs of 80 patients who visited ENT outpatient clinic without any symptom, diagnosis and treatment of cervical spine from January 2011 to September 2012. All targeted people were randomized without any prejudice. We assessed the data-T1 slope, Cobb's angle C2-7, neck tilt, sagittal vertical axis (SVA) C2-7 and thoracic inlet angle by the CT radiographs. RESULTS: The relationships between each value were analyzed and we concluded that Cobb's angle C2-7 gets higher as the T1 slope gets higher, while the SVA C2-7 value decreases. CONCLUSION: We propose that the T1 slope is background information in deciding how much angle can be made in the cervical spinal angle of surgical lordotic curvature, especially severe cervical deformity.

Cervical Foraminal and Discal Height after Dynamic Rotational Plating in the Cervical Discectomy and Fusion

STUDY DESIGN: This is a retrospective study. PURPOSE: To evaluate the effect of the dynamic rotational plate to the intervertebral foraminal and discal height after anterior cervical discectomy and fusion. OVERVIEW OF LITERATURE: There is no report regarding the changes of foraminal and discal height following cervical dynamic rotational plating. METHODS: We reviewed the outcomes of 30 patients (36 levels), who were followed-up for an average of 15 months (range, 12-57 months) after undergoing fusions with anterior cervical dynamic rotational plating for cervical radiculopathy, from March 2005 to February 2009. The changes of foraminal and intervertebral discal height of the operated levels were observed on oblique and lateral radiographs obtained at the preoperative, postoperative and follow-up examinations. RESULTS: The foraminal and discal height increased sufficiently, immediately following the operation. However, follow-up results showed gradual decrease in the foraminal and discal height. After 6 months of the surgery, they showed little difference compared with the preoperative heights. However, clinically, patients showed improvements in radiating pain during the follow-up period. CONCLUSIONS: Anterior cervical dynamic rotational plating was an effective treatment modality for cervical radiculopathy without the deterioration of the foraminal and intervertebral discal height.

A Nation-Wide, Outpatient-Based Survey on the Pain, Disability, and Satisfaction of Patients with Osteoporotic Vertebral Compression Fractures

STUDY DESIGN: A nation-wide, outpatient-based, cross-sectional survey with the use of questionnaires. PURPOSE: To evaluate the pain, disability and satisfaction of patients with osteoporotic vertebral compression fractures (OVCFs). OVERVIEW OF LITERATURE: There are no nation-wide data in Korea on the degree of pain, disability and satisfaction with treatment in patients with OVCFs. METHODS: We performed a cross-sectional survey of 573 patients with OVCFs. After excluding incomplete questionnaires (missing more than 30% of the variables), 430 patient-physician-matched data sets were collected for this survey. RESULTS: Patients with OVCFs were managed with conservative treatment in 63% and with a vertebroplasty in 37%. The means of the latest visual analogue scale (VAS, 5.2) and Oswestry Disability Index (ODI, 47.7) scores checked at the time of survey were significantly higher than those VAS and ODI scores prior to OVCFs (the prefracture VAS and ODI scores, 3.6 and 26.3, respectively; p<0.001 for both comparisons). However, the means of the latest VAS and ODI scores were insignificantly different between the conservative and vertebroplasty groups, irrespective of the duration from the fractures. Overall, 75% of patients were satisfied with their clinical outcomes. However, the percentages of patient's satisfaction were not significantly different between the conservative and vertebroplasty groups. Eighty-eight percent of patients felt some or marked deterioration of their general health condition following OVCFs. CONCLUSIONS: These results indicate that although most patients with OVCFs were satisfied with their clinical outcomes, their subjective general health conditions, as well as their pain and disability, did not recover to the prefracture state.

The Solid Variant of the Aneurysmal Bone Cyst in the Lumbar Spine Mimicking a Malignant Bone Tumor / 대한정형외과학회잡지

The Solid variant of the aneurysmal bone cyst is clinically important, because its solid composition is comparable to that observed in osteosarcoma or osteoblastoma, presenting difficulty for the correct diagnosis. The fluid-fluid level, which is a common sign of the conventional aneurismal bone cyst, is not apparent in radiographs of the solid type. These cysts were localized, equally within the whole spine as compared to most conventional aneurysmal bone cysts in which are localized to the posterior neural arch of the cervical spine. In this particular patient case, a young male aged 11.5 years presented with lower back pain and radiating pain which was misdiagnosed as a malignant bone tumor. Surgical intervention was considered and the incisional biopsy and laminectomy were conducted due to the low possibility of malignancy. We present this case and literature reviews with radiological and pathological findings as an example of the differential diagnosis of malignant tumors.

Adequate Serial Monolayer Passage Number of Human Intervertebral Disc Cells for Cell Therapy: Growth and Phenotype of Cells

STUDY DESIGN: This is an in-vitro experimental study. OBJECTIVES: We wanted to analyze the changes in the growth and phenotype of human degenerative intervertebral disc cells depending on the frequency of subculture in an in vitro monolayer culture system. SUMMARY OF THE LITERATURE REVIEW: A subculture of disc cells is needed to obtain an adequate amount of disc cells for cell therapy, tissue engineering and analysis of the biological characteristics of degenerative disc cells. MATERIALS AND METHODS: The obtained intervertebral discs were divided into the nucleus pulposus (NP) and the annulus fibrosus (AF). The AF and NP cells were cultured in a monolayer manner, respectively. At each subculture time, we analyzed the morphological changes, the adhesion rate, the proliferation rate and the viability. The expressions of types I and II collagen and proteoglycan were analyzed at the mRNA gene level. RESULTS: Both the AF and NP cells gradually showed a fibroblast-like spindle shape while undergoing subculture. The adhesion rate was higher at the second and third times of subculture. The cell proliferation was the highest at the second subculture time. The viability was markedly lower prior to the subculture. On RT-PCR, the type II collagen expression was gradually decreased in the NP cells. In the AF cells, Type II collagen was not expressed from the second time of subculture. The expression of proteoglycan was gradually decreased in both. CONCLUSIONS: Following the 3rd subculture, the degenerative disc cells had completely changed their original growth and phenotypic characteristics. Therefore, we believe that it is not desirable for us to do passage cultures more than three times for cell therapy.

A Case of Dialysis-related Amyloidosis of the Hip and Cervical Spine: Imaging Findings

Dialysis-related amyloidosis is a complication of long-term hemodialysis and it is characterized by the accumulation of beta2-microglobulin in the osteoarticular structures. We describe here the imaging findings of a case of dialysis-related amyloidosis involving the hip and cervical spine in a 62-year-old woman who received long-term dialysis. We focus here on the CT and MR imaging findings of the cervical spine and we include a review of the relevant literatures.

A Prospective Comparison of Surgical Approach for Lateral Retroperitoneal L4-5 Fusion: Laparoscopic Versus Mini-ALIF / 대한척추외과학회지

STUDY DESIGN: We have analyzed the laparoscopic lateral retroperitoneal approach of the L4-5 interspace to the miniopen retroperitoneal approach for lateral lumbar interbody fusion. OBJECTIVES: To prospectively compare the laparoscopic lateral retroperitoneal approach of the L4-5 interspace to the miniopen retroperitoneal approach for lateral lumbar interbody fusion Summary of Background Data : The introduction of laparoscopic techniques in 1993 has stimulated a great deal of discussion regarding the risks and benefits of such minimally invasive approaches. In many centers the anterior endoscopic approach to L5-S1 has become routine. However exposure at L4-5 can be much more difficult. MATERIALS AND METHODS: From 1997 to 1999 thirty eight patients were entered into a prospective study. These patients were all undergoing anterior interbody fusion at the L4-5 level. The patients were divided into two groups for analysis. Group I patients underwent anterior interbody fusion utilizing threaded interbody devices placed via laparoscopic lateral retroperitoneal approach. Group II patients underwent anterior lumbar interbody fusion using threaded interbody devices placed via a miniopen retroperitoneal approach. RESULTS: In Group I, Operation time was 48 minutes longer than Group II (p=0.035) but there were no significant statistical differences in bleeding amount and hospitalization period. Parethesia and tingling sensation of thigh were developed in two cases of Group I patients, one case of Group II patients but they were gradually diminished. In Group I, only one cage was inserted in five cases of patients (28%) who had an inadequate exposure of L4-5 area. However, all of the patients in Group II (100%) had an adequate exposure of L4-5 area. CONCLUSION: The surgical results of laparoscopic technique was not superior to miniopen technique.

Localized Pigmented Villonodular Synovitis with Recurrent Subluxation of the Patella: A Case Report / 대한정형외과학회잡지

Pigmented villonodular synovitis is a slow, usually monoarticular, progressive proliferative disorder of uncertain etiology involving joint tissue, tendon sheath, and bursae. Pigmented villonodular synovitis has been divided in two forms-diffuse and localized. Localized pigmented villonodular synovitis of the knee joint can present with symptoms of pain, locking and instability. We report a case of a patient who presented with symptoms of recurrent subluxation of patella due to a localized pigmented villonodular synovitis occurring in the medial patellofemoral joint.

Anterior Interbody Fusion using a Horizontal Cylinder Cage in a Degenerative Lumbar Spine / 대한정형외과학회잡지

PURPOSE: To evaluate the surgical effect of anterior interbody fusion using a horizontal cylinder cage in a degenerative lumbar spine. MATERIALS AND METHODS: We evaluated 16 patients (at 20 levels) who received anterior interbody fusion using a horizontal cylinder cage in a degenerative lumbar spine or in secondary segmental lumbar instability following decompression at the same level from May 1997 to May 1998. Preoperative, postoperative, and follow-up radiographs were taken to compare the posterior disc height, neuroforaminal area, and the neuroforaminal volume. Fusion rates and clinical results were also reviewed. RESULTS: Posterior disc height (mm), neuroforaminal area (mm2) and neuroforaminal volume (mm3) were increased and maintained during the follow-up period. Radiological fusion was noted in 17 levels (85%) at a postoperative 1 year. Satisfactory clinical results were also obtained in 17 levels (85%). CONCLUSION: Anterior interbody fusion using a horizontal cylinder cage might be an effective method in the surgical treatment of degenerative lumbar spine or secondary segmental lumbar instability.

Long Term Follow-up of Osteoporotic Vertebral Fractures According to the Morphologic Analysis of Fracture Pattern / 대한척추외과학회지

STUDY DESIGN: We have analyzed vertebral fractures caused by osteoporosis to find the clinical correlations with fracture types, level of lesion sites, numbers of involved vertebrae, age of patients, and the degree of osteoporosis. OBJECTIVES: To analyze osteoporotic vertebral fractures clinically and it help us to increase our understandings of osteoporotic vertebral fractures and treat the patients more effectively. SUMMARY OF BACKGROUND DATA: There are increasing number of patients with osteoporotic vertebral fractures. However, there are few articles analyzing patients according to their correlating factors. MATERIALS AND METHODS: We evaluated sixty-three patients who were diagnosed and treated conservatively with osteoporotic compression fractures from January 1995 to June 1997. Plain radiographs and DEXA were taken to compare wedge compression ratio, biconcavity ratio, crush ratio according to fracture pattern, level of injury, number of injured vertebral body, and bone mineral density(BMD). All datas were statistically analyzed. RESULTS: There were no significant differences among fracture pattern, level of injury and BMD. However, BMD was more sig-nificantly decreased in patients who was fractured their back at thoracic spine. BMD was lowered at multiply(3 or more vertebral bodies)injured, continuously involved(2 level or more) vertebral bodies. CONCLUSION: We have concluded that careful observation and the efforts to differentiate osteoporotic compression fractures according to fracture pattern, injury level, BMD, and any objective clinical datas would be needed to manage these osteoporotic patients effectively.

Radiographic Comparison of Stable Burst Fractures with Compression Fractures in Thoracolumbar Spine / 대한척추외과학회지

STUDY DESIGN: A retrospective study was designed to evaluate the radiographic diagnostic method to detect any abnormal findings and differentiate stable burst fractures with compression fractures at thoracolumbar spine. OBJECTIVES: To evaluate diagnostic sensitivity of radiographic analysis and confirm the effectiveness of the radiographic diagnostic methods to differentiate stable burst fractures with pure compression fractures. SUMMARY OF BACKGROUND DATA: A data showed that the diagnostic sensitivity using radiographic analysis was 83%. The greater sensitivity was obtained at high posterior superior vertebral angle and PSVA/PIVA > 1.3. MATERIALS AND METHODS: Thirty-one patients with thoracolumbar spine fractures were evaluate to differentiate stable burst fractures with pure compression fractures. All patients were taken X-ray and CT. The PSVA(Posterior superior vertebral angle), PIVA(Posterior inferior vertebral angle), PSVA/PIVA were checked using lateral plain radiographs during follow-up period, and the final data was analysed using radiological & statistical methods. RESULTS: Middle column failure of stable burst fractures was greatly observed at high PSVA(especially >100degree) and high PSVA/PIVA ratio(> 1.3). CONCLUSION: The radiographic analysis using PSVA(Posterior superior vertebral angle), PIVA(Posterior inferior vertebral angle), PSVA/PIVA might be the one of useful methods to differentiate stable burst fractures with pure compression fractures at thoracolumbar spine during follow-up period.

The Results of the Surgical Treatment using Posterior Spinal instrumentation for Tuberculous Spondylitis / 대한척추외과학회지

STUDY DESIGN: Twenty-nine patients with spinal tuberculousis were evaluated according to the surgical treatment methods using posterior spinal instrumentation and conventional anterior excision and interbody fusion methods without posterior spinal instrumentation. OBJECTIVE: To confirm the effectiveness of the surgical treatment methods using posterior spinal instrumentation (combined with anterior radical excision and anterior interbody fusion ) in tuberculous spondylitis. SUMMARY OF BACKGROUND DATA: Relatively good results(maintaining corrected kyphotic angle , short fusion time, rapid rehabilitation etc.)were obtained in posterior spinal instrumetnation group, especially at thoracic and thoracolumbar spine, but no specific benefits of posterior instrumentation at low lumbar spine during follow-up period. METHODS: Twenty-nine patients with tuberculous spondylitis were divided into two groups depending on their use of posterior spinal instrument in surgical treatment methods ; one group consisted of 18 cases which were treated by anterior radical excision of involved body and anterior interbody fusion with posterior spinal instrumentation(Group I), and the other groups consisted of 11 cases which were treated by anterior radical excision of involved body and anterior interbody fusion(Group II). Change of corrected kyphotic angle according to the level of lesion, number of involved body and complications were measured using pre-, post-operative, and follow-up radiographs and chart review. RESULTS: Comparing the two groups, relatively short fusion time, less kyphotic angle loss, and low complication rates were obtained in posterior spinal instrumentation group(Group I) during the follow up period, especilally, at thoracic and thoracolumbar spine. However, there were no significant postoperative and follow-up results in both groups at low lumbar spine. CONCLUSIONS: Tuberculous spondylitis can be treated, and correction can be maintained with anterior radical excision of involved body and anterior interbody fusion with posterior spinal instrumentation during follow up period.