Comparison of Posterior Lumbar Interbody Fusion and Microendoscopic Muscle-preserving Interlaminar Decompression for Degenerative Lumbar Spondylolisthesis With >5-Year Follow-up.

STUDY DESIGN: Retrospective analysis of prospectively collected observational multicenter data. OBJECTIVE: To compare the clinical results and rates of revision surgery after posterior lumbar interbody fusion (PLIF) and microendoscopic muscle-preserving interlaminar decompression (ME-MILD) in patients with single-level, mild degenerative lumbar spondylolisthesis (DLS) and follow-up of at least 5 years. SUMMARY OF BACKGROUND DATA: Surgery for symptomatic DLS remains controversial. Evaluating long-term results may reveal problems such as adjacent segmental diseases of the PLIF and decreased quality of life because of slippage and restenosis of the ME-MILD. METHODS: We enrolled 116 patients who underwent PLIF (79 patients) or ME-MILD (37 patients). Operative times, blood losses, surgical complications, Short-Form 36 (SF-36), Japanese Orthopedic Association (JOA) score, the JOA Back Pain Questionnaire (JOABPEQ), visual analog scales (VAS), and Zurich Claudication Questionnaire (ZCQ) were evaluated. RESULTS: PLIF was observed to require significantly longer operative times and entailed greater operative blood losses than did ME-MILD (151.1 vs. 119.9 min; 202.2 vs. 6.4 mL, respectively). Surgery-related complications were identified in 3 cases in the PLIF group and 2 cases in the ME-MILD group. Seventy-eight patients (50 and 28 patients in the PLIF and ME-MILD groups, respectively) were successfully followed-up for >5 years. The follow-up rate was 67.2%. No significant differences between the groups were found in terms of preoperative and postoperative JOA scores, postoperative JOABPEQ, VAS, or ZCQ. Significant improvements in JOA scores were observed in both groups. Significant improvements in the SF-36 were observed in all subscales except in role physical, general health, vitality, and mental health in the ME-MILD group. Revision surgical procedures were performed in 2 patients in the ME-MILD group and 4 patients in the PLIF group. CONCLUSIONS: PLIF and ME-MILD resulted in equivalent improvements in SF-36 and JOA scores. There were no differences in revision surgery rates among patients with single-level, mild DLS. LEVEL OF EVIDENCE: Level III-a retrospective analysis.

Limaprost or Pregabalin: Preoperative and Postoperative Medication for Pain due to Lumbar Spinal Stenosis.

PURPOSE: We aimed to evaluate the incidence of (and risk factors for) postoperative pregabalin and/or limaprost to treat persistent numbness and/or pain of the lower extremities after lumbar spinal stenosis (LSS) surgery. METHODS: Medical records of 329 patients (168 men, 161 women; average age 70 years) were retrospectively reviewed for data on the duration of LSS diagnosis; LSS disease; preoperative medication (limaprost, pregabalin, or combined limaprost/pregabalin; duration); symptoms; preoperative/postoperative intermittent claudication (IC); operation type; and postoperative medication and period. RESULTS: Limaprost, pregabalin, and combined limaprost/pregabalin were prescribed preoperatively for 43%, 7%, and 5% of patients, respectively. At an average of 21 months postoperatively, limaprost, pregabalin, and combined therapy were prescribed in 11%, 8%, 4% of patients, respectively. Medication requirement was significantly lower postoperatively than preoperatively (P < 0.0001). Significant risk factors for required postoperative medication were required preoperative medication (odds ratio [OR] 3.088, 95% confidence interval [CI] 1.679 to 5.681]; postoperative period (OR 1.063, 95% CI 1.031 to 1.096); and postoperative IC (OR 3.868, 95% CI 1.481 to 10.103). A negative impact from postoperative medication was seen in patients who had undergone decompression surgery (OR 0.589, 95% CI 0.377 to 0.918). CONCLUSIONS: Overall, 23% of LSS patients required medication for pain and/or numbness at 21 months postoperatively. Significant factors portending required postoperative medication were preoperative medication, longer postoperative period, and postoperative IC. A negative influence from postoperative medication was seen in patients who had undergone decompression surgery without fusion.

Clinical diagnosis of upper lumbar disc herniation: Pain and/or numbness distribution are more useful for appropriate level diagnosis.

OBJECTIVE: The purpose of this study is to disclose the characteristic symptoms and signs in L2, L3 and L4 nerve root disturbance. MATERIALS AND METHODS: Fifty eight patients who underwent lateral herniotomy were analyzed. Breakdowns are 15 patients with L2/3 lateral disc herniation (group A), 20 patients with L3/4 lateral disc herniation (group B), and 23 patients with L4/5 lateral disc herniation (group C). The following items were examined: 1) localization of the subjective pain and numbness, 2) objective neurological findings, including deep tendon reflex, manual muscle strength (MMT), straight leg raising test (SLRT) and femoral nerve stretch test (FNST). RESULTS: In group A, subjective pain and/or numbness was present in the thigh aspect, proximal to the knee joint in all patients. In group B, 80% of the patients had subjective pain and/or numbness in the medial site of the knee joint. In group C, the subjective pain and/or numbness was localized in various aspects of the lower extremity. Weakness in the iliopsoas, the femoral quadriceps, and the anterior tibial muscle were observed in 60-95%, 27-70%, 0-43% of three groups, respectively. Depression or absence of the patella tendon reflex was present in 27-100% of three groups. SLRT and FNST were positive in 13-87% and 91-95% of three groups. CONCLUSION: Symptomatic levels of nerve root disturbance in the upper lumbar spine could not be accurately identified by objective neurological findings alone. Pain and/or numbness localized in the thigh area proximal to the knee joint is a specific sign of L2 nerve root disturbance. Either subjective pain or numbness in the medial knee joint aspect is another key sign which strongly suggests L3 nerve root disturbance.

Negative magnetic resonance imaging in femoral neck stress fracture with joint effusion: a case report.

Femoral neck stress fracture (FNSF) is well documented in the orthopedic literature and is generally associated with strenuous activities such as long-distance running and military training. The diagnostic yield of magnetic resonance imaging (MRI) for FNSF was reported to be 100 %, and early MRI is recommended when this fracture is suspected. We encountered a 16-year-old male long-distance runner with FNSF in whom the left femoral neck showed no signal changes on MRI although an effusion was detected in the left hip joint. One month later, roentgenograms revealed periosteal callus and oblique consolidation of the left femoral neck, confirming the diagnosis of compression FNSF. Because FNSF with a normal bone marrow signal on MRI is very rare, this patient is presented here.

Spine-shortening vertebral osteotomy for tethered cord syndrome: report of three cases.

STUDY DESIGN: Retrospective case series. OBJECTIVE: To review findings from 3 patients who underwent spine-shortening vertebral osteotomy for tethered cord syndrome with a minimum follow-up of 3 years. SUMMARY OF BACKGROUND DATA: Surgical detethering is the gold standard for symptomatic tethered cord syndrome. However, complications such as cerebrospinal fluid leakage and neurologic deterioration are common. Spine-shortening vertebral osteotomy, proposed by Kokubun, is an alternative surgical technique to reduce neural tension indirectly. However, case series of this novel procedure for tethered cord syndrome have not been reported in the English literature. METHODS: Three patients aged 13, 22, and 27 years presented with progressive pain and/or neurologic dysfunction. They underwent spine-shortening vertebral osteotomy of L1 with a pedicle screw and rod system. Their clinical and radiologic outcomes are reviewed. RESULTS: All patients got relief from their preoperative symptoms after surgery, and no complications occurred. Complete bone union was obtained in all patients without correction loss. CONCLUSION: Spine-shortening vertebral osteotomy can be a safe and alternative surgical technique for tethered cord syndrome.

PLIF with a titanium cage and excised facet joint bone for degenerative spondylolisthesis--in augmentation with a pedicle screw.

OBJECTIVES: To determine the validity of posterior lumbar interbody fusion (PLIF) using a titanium cage filled with excised facet joint bone and a pedicle screw for degenerative spondylolisthesis. METHODS: PLIF using a titanium cage filled with excised facet joint bone and a pedicle screw was performed in 28 consecutive patients (men 10, women 18). The mean age of the patients was 60 years (range, 52 to 75 y) at the time of surgery. The mean follow-up period was 2.3 years (range, 2.0 to 4.5 y). The operation was done at L3/4 in 5, L4/5 in 20, and L3/4/5 in 3 patients. The mean operative bleeding was 318+/-151 g (mean+/-standard deviation), and the mean operative time was 3.34+/-0.57 hours per fixed segment. Clinical outcome was assessed by Denis' Pain and Work scale. Radiologic assessment was done using Boxell's method. Fusion outcome was assessed using an established criteria. RESULTS: On Pain scale, 20 and 8 patients were rated P4 and P5 before surgery, and 11, 12, 2, 2, and 1 patients were rated P1, P2, P3, P4, and P5 at final follow-up, respectively. On Work scale (for only physical labors), 12 and 9 patients were rated W4 and W5, before surgery, and 12, 5, 1, and 3 patients were rated W1, W2, W3 and W5 at final follow-up, respectively. There was significant difference in clinical outcome (P<0.01, Wilcoxon singled-rank test) The mean %Slip and Slip Angle was 17.9+/-8.1% and 3.9+/-5.8 degrees before surgery. The mean % Slip and Slip Angle was 5.4+/-4.4% and -2.0+/-4.8 degrees at final follow-up. There was a significant difference between the values (P<0.01, paired t test). "Union" and "probable union" was determined in 29 (93.5%) and 2 (6.5%) of 31 operated segments at 2.3 years (range, 2.0 to 4.5 y), postoperatively. CONCLUSIONS: PLIF using a titanium cage filled with excised facet joint bone and a pedicle screw provided a satisfactory clinical outcome and an excellent union rate without harvesting and grafting the autologous iliac bone.