Kyphectomy and interbody fixation using lag screws in a child with myelomeningocele kyphosis: a technical case report.

A 5-year-old boy had a thoracolumbar-level MMC that had been repaired at the day after birth and kyphotic deformity got worse as he grew. He complained of discomfort about not being able to take a supine posture and decided to perform surgery for kyphosis. In our case, surgical correction is offered to stop the deformity progression, manage the associated pain, and finally to gain sitting and supine posture. We report the surgical procedure with 4 levels of en bloc kyphectomy and using the lag screws. Especially when lag screws are used, several complications including posterior instrumentation failure, hardware prominence and wound break down can be solved by removing the implants after bone fusion has been achieved.

Long-term recurrence rates after the removal of spinal meningiomas in relation to Simpson grades.

PURPOSE: Simpson grade II removal (coagulation of the dural attachment after gross total removal) of spinal meningioma is considered an acceptable alternative, but increased recurrence after more than 10 years has been reported. More attention must be paid to the long-term surgical outcomes after Simpson grade II removal. METHODS: A retrospective review was performed for 20 patients (M:F = 5:15; age, 59 ± 9 years) with Simpson grade II removal (mean follow-up period, 12.9 years; range 10.0-17.5). Magnetic resonance (MR) imaging was conducted in 17 patients at 88 ± 52 months (range 12-157). During the same period, Simpson grade I removal (removal of the dural origin) was performed in 21 patients (follow-up, 89 ± 87 months; range 9-316). Radiological recurrence was defined as a visible tumor on a follow-up MR image, and clinical tumor recurrence was defined as the recurrence of symptoms. RESULTS: At the final follow-up, neurological symptoms had improved in 16/20 patients and remained stable in 4/20. A recurrent tumor was detected in one patient due to increased back pain at 92 months postoperative, but the symptom was stable without surgery until the last follow-up (124 months). The radiological and clinical recurrence-free survival periods were 150 ± 7 months (95 % CI 136-163) and 204 ± 6 months (95 % CI 193-215), respectively. There was no recurrence after Simpson grade I removal, whereas neurological deterioration occurred in two patients after surgery. CONCLUSIONS: Simpson grade II removal may be an alternative option if the risk of complications with Simpson grade I removal is expected to be high.

Facet joint changes after application of lumbar nonfusion dynamic stabilization.

OBJECTIVE The long-term effects on adjacent-segment pathology after nonfusion dynamic stabilization is unclear, and, in particular, changes at the adjacent facet joints have not been reported in a clinical study. This study aims to compare changes in the adjacent facet joints after lumbar spinal surgery. METHODS Patients who underwent monosegmental surgery at L4-5 with nonfusion dynamic stabilization using the Dynesys system (Dynesys group) or transforaminal lumbar interbody fusion with pedicle screw fixation (fusion group) were retrospectively compared. Facet joint degeneration was evaluated at each segment using the CT grading system. RESULTS The Dynesys group included 15 patients, while the fusion group included 22 patients. The preoperative facet joint degeneration CT grades were not different between the 2 groups. Compared with the preoperative CT grades, 1 side of the facet joints at L3-4 and L4-5 had significantly more degeneration in the Dynesys group. In the fusion group, significant facet joint degeneration developed on both sides at L2-3, L3-4, and L5-S1. The subjective back and leg pain scores were not different between the 2 groups during follow-up, but functional outcome based on the Oswestry Disability Index improved less in the fusion group than in the Dynesys group. CONCLUSIONS Nonfusion dynamic stabilization using the Dynesys system had a greater preventative effect on facet joint degeneration in comparison with that obtained using fusion surgery. The Dynesys system, however, resulted in facet joint degeneration at the instrumented segments and above. An improved physiological nonfusion dynamic stabilization system for lumbar spinal surgery should be developed.

Dynamic stabilization using the Dynesys system versus posterior lumbar interbody fusion for the treatment of degenerative lumbar spinal disease: a clinical and radiological outcomes-based meta-analysis.

OBJECTIVE The Dynesys, a pedicle-based dynamic stabilization (PDS) system, was introduced to overcome the drawbacks of fusion procedures. Nevertheless, the theoretical advantages of PDS over fusion have not been clearly confirmed. The aim of this study was to compare clinical and radiological outcomes of patients who underwent PDS using the Dynesys system with those who underwent posterior lumbar interbody fusion (PLIF). METHODS The authors searched PubMed, Embase, Web of Science, and the Cochrane Database. Studies that reported outcomes of patients who underwent PDS or PLIF for the treatment of degenerative lumbar spinal disease were included. The primary efficacy end points were perioperative outcomes. The secondary efficacy end points were changes in the Oswestry Disability Index (ODI) and back and leg pain visual analog scale (VAS) scores and in range of motion (ROM) at the treated and adjacent segments. A meta-analysis was performed to calculate weighted mean differences (WMDs), 95% confidence intervals, Q statistics, and I(2) values. Forest plots were constructed for each analysis group. RESULTS Of the 274 retrieved articles, 7 (which involved 506 participants [Dynesys, 250; PLIF, 256]) met the inclusion criteria. The Dynesys group showed a competitive advantage in mean surgery duration (20.73 minutes, 95% CI 8.76-32.70 minutes), blood loss (81.87 ml, 95% CI 45.11-118.63 ml), and length of hospital stay (1.32 days, 95% CI 0.23-2.41 days). Both the Dynesys and PLIF groups experienced improved ODI and VAS scores after 2 years of follow-up. Regarding the ODI and VAS scores, no statistically significant difference was noted according to surgical procedure (ODI: WMD 0.12, 95% CI -3.48 to 3.72; back pain VAS score: WMD -0.15; 95% CI -0.56 to 0.26; leg pain VAS score: WMD -0.07; 95% CI -0.47 to 0.32). The mean ROM at the adjacent segment increased in both groups, and there was no substantial difference between them (WMD 1.13; 95% CI -0.33 to 2.59). Although the United States is the biggest market for Dynesys, no eligible study from the United States was found, and 4 of 8 enrolled studies were performed in China. The results must be interpreted with caution because of publication bias. During Dynesys implantation, surgeons have to decide the length of the spacer and cord pretension. These values are debatable and can vary according to the surgeon's experience and the patient's condition. Differences between the surgical procedures were not considered in this study. CONCLUSIONS Fusion still remains the method of choice for advanced degeneration and gross instability. However, spinal degenerative disease with or without Grade I spondylolisthesis, particularly in patients who require a quicker recovery, will likely constitute the main indication for PDS using the Dynesys system.

Which one is a valuable surrogate for predicting survival between Tomita and Tokuhashi scores in patients with spinal metastases? A meta-analysis for diagnostic test accuracy and individual participant data analysis.

This study is to estimate the diagnostic accuracy of Tokuhashi and Tomita scores that assures 6-month predicting survival regarded as a standard of surgical treatment. We searched PubMed, EMBASE, European PubMed central, and the Cochrane library for papers about the sensitivities and specificities of the Tokuhashi and/or Tomita scores to estimate predicting survival. Studies with cut-off values of ≥9 for Tokuhashi and ≤7 for Tomita scores based on prior studies were enrolled. Sensitivity, specificity, diagnostic odds ratio (DOR), area under the curve (AUC), and the best cut-off value were calculated via meta-analysis and individual participant data analysis. Finally, 22 studies were enrolled in the meta-analysis, and 1095 patients from 8 studies were included in the individual data analysis. In the meta-analysis, the pooled sensitivity/specificity/DOR for 6-month survival were 57.7 %/76.6 %/4.70 for the Tokuhashi score and 81.8 %/47.8 %/4.93 for Tomita score. The AUC of summary receiver operating characteristic plots was 0.748 for the Tokuhashi score and 0.714 for the Tomita score. Although Tokuhashi score was more accurate than Tomita score slightly, both showed low accuracy to predict 6 months residual survival. Moreover, the best cut-off values of Tokuhashi and Tomita scores were 8 and 6, not 9 and 7, for predicting 6-month survival, respectively. Estimation of 6-month predicting survival to decide surgery in patients with spinal metastasis is quite limited by using Tokuhashi and Tomita scores alone. Tokuhashi and Tomita scores could be incorporated as part of a multidisciplinary approach or perhaps interpreted in the context of a multidisciplinary approach.

Correlation between cervical lordosis and adjacent segment pathology after anterior cervical spinal surgery.

PURPOSE: To evaluate the incidence and risk factors for adjacent segment pathology (ASP) after anterior cervical spinal surgery. METHODS: Fourteen patients (12 male, mean age 47.1 years) who underwent single-level cervical disk arthroplasty (CDA group) and 28 case-matched patients (24 male, mean age 53.6 years) who underwent single-level anterior cervical discectomy and fusion (ACDF group) were included. Presence of radiologic ASP (RASP) was based on observed changes in anterior osteophytes, disks, and calcification of the anterior longitudinal ligament on lateral radiographs. RESULTS: The mean follow-up period was 43.4 months in the CDA group and 44.6 months in the ACDF group. At final follow-up, ASP was observed in 5 (35.7%) CDA patients and 16 (57.1%) ACDF patients (p = 0.272). The interval between surgery and ASP development was 33.8 months in the CDA group and 16.3 months in the ACDF group (p = 0.046). The ASP risk factor analysis indicated postoperative cervical angle at C3-7 being more lordotic in non-ASP patients in both groups. Restoration of lordosis occurred in the CDA group regardless of the presence of ASP, but heterotopic ossification development was associated with the presence of ASP in the CDA group. And the CDA group had significantly greater clinical improvements than those in the ACDF group when ASP was present. CONCLUSION: In both CDA and ACDF patients, RASP developed, but CDA was associated with a delay in ASP development. A good clinical outcome was expected in CDA group, even when ASP developed. Restoration of cervical lordosis was an important factor in anterior cervical spine surgery.

Subsidence as of 12 months after single-level anterior cervical inter-body fusion. Is it related to clinical outcomes?

BACKGROUND: Subsidence is a frequent phenomenon in the interbody fusion process in patients with anterior cervical discectomy and fusion (ACDF). There is little evidence of whether subsidence in the cervical spine has any impact on clinical outcomes. OBJECTIVES: The purpose of this study is to investigate the correlation of subsidence and clinical outcomes after ACDF and to consider reasons subsidence might not cause unfavorable clinical outcomes. METHODS: A total of 158 consecutive patients who underwent single-level ACDF were included. The patients were divided into a subsidence group (S-group) and a no subsidence group (N-group), with subsidence defined as a decrease by ≥3 mm in total intervertebral height (TIH). We analyzed outcomes resulting from subsidence, particularly focusing on clinical outcomes and subsequent global and segmental kyphosis using a repeated measure analysis of variance (RM-ANOVA). RESULTS: Subsidence occurred in 74 patients (46.8%) as of a 12-month follow-up. The S-group included 58.6% with a stand-alone cage for interbody fusion (p = 0.002). Clinical outcomes improved significantly over time (neck pain, RM-ANOVA: F(1.3, 205) = 125.1, p < 0.001; arm pain, RM-ANOVA: F(1.3, 203) = 290.8, p < 0.001). There was no significant difference in interaction with subsidence and clinical outcomes between the S- and N-group (neck pain, RM-ANOVA: F(2,153) = 1.04, p = 0.356, partial η(2) = 0.229; arm pain, RM-ANOVA: F(2,153) = 0.56, p = 0.571, partial η(2) = 0.142). Segmental angle increased in both groups over time and showed a statistically significant difference between the S- and N-groups (RM-ANOVA: F(3,143) = 6.148, p = 0.001, partial η(2) = 0.959). Although, global cervical angle decreased generally and displayed no statically significant difference between the S- and N-group (RM-ANOVA: F(3,119) = 2.361, p = 0.075, partial η(2) = 0.056). CONCLUSIONS: Radiographic subsidence after ACDF occurred in 46.8% patients as of 12 months after the single-level ACDF. The lack of correlation between bad clinical outcome and radiographic subsidence may be due to segmental kyphosis, preserved posterior height, and maintaining the global cervical angle.

Intramedullary schwannomas: long-term outcomes of ten operated cases.

Intramedullary schwannomas are very rare. Most studies on intramedullary schwannomas have been case reports with literature reviews. This study presented a surgical series of ten patients with histologically proven intramedullary schwannomas. From 1995 to 2010, ten patients (2.7 %) presented with intramedullary schwannomas out of 365 patients with spinal schwannomas. Their clinical and radiological findings and operative records were reviewed. There were 6 female and 4 male patients with a mean age of 45.5 years. The mean follow-up period was 75.7 months. Three tumors were located in the cervical spine and 7 were located in the thoracic spine. Intraoperatively, the tumor was connected with the dorsal rootlet in 4 cases and with the ventral rootlet in 1 case. Gross total resection (GTR) of the tumor with a well-demarcated dissection plane was achieved in 8 cases and subtotal resection (STR) was achieved in 2 cases. The current status of all the patients was improved compared to the preoperative presentation at last follow-up and the symptoms present before the surgery were improved in all the cases at last follow-up. The postoperative follow-up magnetic resonance imaging showed no recurrence in the 8 GTR cases during the follow-up period of 83.5 months on average. No interval change in residual tumors was observed in the 2 STR cases (45- and 55-month follow-up periods). Intramedullary schwannomas are amenable to surgery. It is possible to achieve GTR of intramedullary schwannomas that have a well-demarcated dissection plane. Additionally, a good clinical outcome after GTR can be expected.

Isolated abducens nerve palsy due to cerebrospinal fluid leakage following lumbar discectomy: a rare clinical entity.

BACKGROUND AND IMPORTANCE: Cerebrospinal fluid (CSF) leakage can cause abducens nerve palsy which is such a rare complication after spine surgery. CLINICAL PRESENTATION: A 48-year-old man was diagnosed with isolated abducens nerve palsy due to CSF leakage by inadvertent dural tearing after lumbar discectomy. We performed primary dural repair of CSF leakage and 1 week after, the diplopia and headache disappeared with complete resolution of CSF leakage. We will also review the clinical features and outcomes of three cases that have been reported in the literature. CONCLUSION: This rare complication of spinal surgery helped us to discuss appropriate therapeutic strategies for the early surgical management of cranial nerve palsy following CSF leakage.

Chiari I malformation associated with syringomyelia: can foramen magnum decompression lead to restore cervical alignment?

PURPOSE: There are few researches that demonstrate the relationship between the extent of syringomyelia and sagittal alignment of the cervical spine. The purpose of this study is to investigate the correlation between the change of syrinx size and cervical alignment. METHODS: From January 2001 to June 2008, we operated on 207 patients who had syringomyelia. The associated diseases were categorized by Chiari I malformation, tumor, trauma, spinal stenotic lesion, inflammatory disease and idiopathic causes. Thirty patients who had Chiari I malformation associated with syringomyelia and who underwent foramen magnum decompression (FMD), participated in this study. We excluded patients with scoliosis, cervical instrumentation, tumor, trauma, myelomeningocele, hydrocephalus, tethered cord and congenital vertebral anomalies. Lateral radiographs in neutral and magnetic resonance imaging were taken pre- and postoperatively. RESULTS: Mean follow-up was 6.5 ± 1.5 years (ranged from 4.0 to 9.5 years). The mean pre- and postoperative lordosis angles at C2-C7 were -5.9° ± 1.0° and -10.4° ± 1.0°, respectively (P = 0.001). There was significant correlation between the differences of syrinx width and the cervical lordotic angles before and after surgery (P = 0.016). After FMD, syringomyelia and cervical alignment improved in 28 (93.3%) and 25 (85.18%) of 30 patients, respectively. There was significant correlation between recovery rate by Japanese Orthopaedic Association scores and the difference of the cervical lordotic angles before and after surgery (P = 0.022). CONCLUSIONS: The present results demonstrate that the decrease of syrinx size by FMD may restore the cervical lordosis. We suggest that the postoperative cervical alignment might be a predictive factor for neurological outcome.

Comparative analysis of 3 different construct systems for single-level anterior cervical discectomy and fusion: stand-alone cage, iliac graft plus plate augmentation, and cage plus plating.

STUDY DESIGN: A retrospective cohort-nested longitudinal study. OBJECTIVE: To evaluate radiologic and clinically functional outcomes after single-level anterior cervical discectomy and fusion (ACDF) using 3 different fusion construct systems applying an accurate and reliable methodology. SUMMARY OF BACKGROUND DATA: ACDF is an established procedure that uses 3 different fusion construct systems: cage alone (CA), iliac tricortical bone block with plate (IP), and cage with plate construct (CP). The outcome of a previous study is quite different and did not correlate with experimental studies. METHODS: ACDF was performed on 158 patients (90 male and 68 female), who were followed up for >12 months. The patients were divided into the following 3 treatment groups: CA, IP, and CP. Factors related to outcome were also evaluated. Fusion rate, subsidence rate, and cervical angles were used to measure radiologic outcome. The Odom criteria and the visual analog scale were used to evaluate the clinical outcome. RESULTS: The fusion rate was higher for patients in the IP (87.1%) and CP (79.5%) groups than for those in the CA group (63.2%) after 12 months of follow-up (P=0.019). The subsidence rate was lower for patients in the IP (28.1%) and CP (38.5%) groups than for those in the CA group (58.6%) (P=0.010). Subsidence occurred for the anterior height regardless of constructs. Radiating arm pain showed greater relief in the CP group than in the CA group (P=0.015). It improved more in the CP group than in the IP group, but the differences were not statistically significant (P=0.388). Other clinical outcomes did not show significant differences. CONCLUSIONS: The trend of excellent radiologic outcome was observed for IP≥CP>CA. Plating may play a key role in the support of anterior height. As a result, plating prevents segmental kyphosis and subsidence and promotes bone fusion. Although the overall clinical outcomes were not different among the 3 groups, except for arm pain, more favorable trends regarding clinical outcome were observed for CP≥IP>CA.

What is a reasonable surgical procedure for spinal extradural arachnoid cysts: is cyst removal mandatory? Eight consecutive cases and a review of the literature.

BACKGROUND: Spinal epidural arachnoid cysts (EAC) are rare and may present with myelopathy, which can be completely curable with surgery. The majority of investigators believe that the repairment of dural defect is important to treat EAC. However, the necessity of excising EACs remains controversial. The purpose of this study was to find a reasonable surgical technique for treatment of EACs after considering the clinical outcome, recurrence, and complications. METHODS: The data from 44 operations in the literature and eight cases from our own experience were analyzed. This data included the surgical method, patient characteristics, level and size of the EAC, global assessment of the clinical outcomes, and the incidence of recurrence. RESULTS: The recurrence rate was 2.0 % and 66.7 % in the patients who underwent repair of the dural defect and in those failed to repair of the dural defect, respectively (p = 0.007). The recurrence rate was 8.3 % and 3.6 % in patients who underwent complete EAC excision totally, and those who underwent EAC fenestration only, respectively (p = 0.590). The clinical outcome in patients with repaired dural defects was significantly better than that in patients with unrepaired dural defects (2.61 vs.1.67) (p = 0.027). The clinical outcome score was 2.42 and 2.68 in patients who underwent complete EAC excision and those who underwent EAC fenestration only, respectively (p = 0.158). The mean EAC length was 5.04 vertebral body levels (range, 2-13). Six of the 51 patients (11.7 %) had multiple EACs. CONCLUSIONS: Total excision of EACs may have little benefit in terms of cyst recurrence and clinical outcome. The procedure for EAC resection carries a risk of complications such as kyphosis. If EAC resection is performed, we suggest that a tailored short-level laminotomy be used to allow for the repair of dural defects. Particularly in patients with small EAC, a partial hemilaminectomy with dural defect repair may be a possible method to reduce complications.

Temozolomide for malignant primary spinal cord glioma: an experience of six cases and a literature review.

Malignant primary spinal cord gliomas (PSCGs) are rare, and the optimal treatment for these lesions remains controversial. We report herein treatment outcomes of six malignant PSCGs managed with temozolomide (TMZ)-based multidisciplinary treatment. TMZ was administered concomitantly with fractionated radiotherapy for two newly diagnosed primary spinal cord glioblastoma multiforme (GBM), followed by adjuvant chemotherapy with TMZ. For one anaplastic astrocytoma (AA) and one anaplastic ependymoma (AEPN), TMZ was given as adjuvant therapy at first recurrence. One malignantly transformed ependymoma (EPN) and one malignantly transformed diffuse astrocytoma (DA) were treated with TMZ after radiotherapy at second recurrence. Two patients with newly diagnosed GBM died, 12 and 16 months, respectively, after being treated with TMZ, during and after radiation therapy. One patient with AA and one with malignantly transformed EPN showed good response to salvage therapy with TMZ and had stable disease 21 and 20 months, respectively, after TMZ treatment. One patient with recurrent AEPN and one with malignantly transformed DA died from uncontrolled progression of the lesions despite TMZ chemotherapy. Three patients developed grade 1 or 2 neutropenia, anemia, and infection. Nonhematologic toxicities occurred in all patients; however, they were below grade 3 in severity. TMZ treatment may have a positive effect on control of malignant PSCGs and survival for some patients. Specifically, treatment with TMZ during and after radiation therapy might provide survival benefit to patients with primary spinal cord GBM. A multicenter cooperative investigation for a large-scale study on malignant PSCGs may be required.

Clinical analysis of thoracic ossified ligamentum flavum without ventral compressive lesion.

The aim of this study was to analyze the clinical characteristics of thoracic ossified ligamentum flavum (OLF) and to elucidate prognostic factors as well as effective surgical treatment modality. The authors analyzed 106 thoracic OLF cases retrospectively from January 1999 to December 2008. The operative (n = 40) and the non-operative group (n = 66) were diagnosed by magnetic resonance imaging (MRI) and/or computed tomography (CT) imaging. We excluded cases exhibiting ventral compressive lesions causing subarachnoid space effacement in thoracic vertebrae as well as those with a coexisting cervical compressive myelopathy. Those in the operative group were treated with decompressive laminectomy as well as resection of OLF. The preoperative neurologic status and postoperative outcomes of patients, as indicated by their modified Japanese Orthopedic Association (mJOA) scores and recovery rate (RR), Modic changes, the axial (fused or non-fused) and sagittal (omega or beak) configurations of OLF, and the ratios of the cross-sectional area (CSA) and anteroposterior diameter (APD) of the most compressed level were studied. The most commonly affected segment was the T10-11 vertebral body level (n = 49, 27.1%) and the least affected segment was the T7-8 level (n = 1, 0.6%). The ratios of the CSA in non-fused and fused types were 77.3 and 59.3% (p < 0.001). When Modic changes were present with OLF, initial mJOA score was found to be significantly lower than those without Modic change (7.62 vs. 9.09, p = 0.033). Neurological status improved after decompressive laminectomy without fusion (preoperative vs. last mJOA; 7.1 ± 2.01 vs. 8.57 ± 1.91, p < 0.001). However, one patient exhibited transient deterioration of her neurological status after surgery. In the axial configuration, fused-type OLF revealed a significant risk for a decreased postoperative mJOA score (0-7, severe and moderate) (Odds ratio: 5.54, χ (2) = 4.41, p = 0.036, 95% CI: 1.014-30.256). The results indicated that the new categorization of axial-type of OLF is a helpful predictor of postoperative patient outcome and fused type was related with poor prognosis. In OLF cases free from ventral lesions compressing the spinal cord, decompressive laminectomy is enough for successful surgical outcome. Therefore, early surgical treatment will be considered in cases with fused-type OLF compressing spinal cord even though they do not have myelopathic symptoms.

A practical MRI grading system for lumbar foraminal stenosis.

OBJECTIVE: This study aimed to evaluate the reproducibility of a new grading system for lumbar foraminal stenosis. MATERIALS AND METHODS: Four grades were developed for lumbar foraminal stenosis on the basis of sagittal MRI. Grade 0 refers to the absence of foraminal stenosis; grade 1 refers to mild foraminal stenosis showing perineural fat obliteration in the two opposing directions, vertical or transverse; grade 2 refers to moderate foraminal stenosis showing perineural fat obliteration in the four directions without morphologic change, both vertical and transverse directions; and grade 3 refers to severe foraminal stenosis showing nerve root collapse or morphologic change. A total of 576 foramina in 96 patients were analyzed (from L3-L4 to L5-S1). Two experienced radiologists independently assessed the sagittal MR images. Interobserver agreement between the two radiologists and intraobserver agreement by one reader were analyzed using kappa statistics. RESULTS: According to reader 1, grade 1 foraminal stenosis was found in 33 foramina, grade 2 in six, and grade 3 in seven. According to reader 2, grade 1 foraminal stenosis was found in 32 foramina, grade 2 in six, and grade 3 in eight. Interobserver agreement in the grading of foraminal stenosis between the two readers was found to be nearly perfect (kappa value: right L3-L4, 1.0; left L3-L4, 0.905; right L4-L5, 0.929; left L4-L5, 0.942; right L5-S1, 0.919; and left L5-S1, 0.909). In intraobserver agreement by reader 1, grade 1 foraminal stenosis was found in 34 foramina, grade 2 in eight, and grade 3 in seven. Intraobserver agreement in the grading of foraminal stenosis was also found to be nearly perfect (kappa value: right L3-L4, 0.883; left L3-L4, 1.00; right L4-L5, 0.957; left L4-L5, 0.885; right L5-S1, 0.800; and left L5-S1, 0.905). CONCLUSION: The new grading system for foraminal stenosis of the lumbar spine showed nearly perfect interobserver and intraobserver agreement and would be helpful for clinical study and routine practice.

Pyogenic vertebral osteomyelitis: identification of microorganism and laboratory markers used to predict clinical outcome.

The aim of this study is to determine the predictive values of laboratory indicators of pyogenic vertebral osteomyelitis (PVO) and a potential cure if the microorganism cannot be identified. Forty-five consecutive patients with PVO were enrolled. Antibiotic therapy with or without surgery was performed according to microorganism. In the negative-culture (NC) group, cefazolin was administered in cases of hematogenous PVO, and vancomycin was administered in cases of postoperative or procedure-related PVO. The clinical, laboratory, and radiological findings were followed up with regard to an appropriate response to antimicrobial therapy. Nine patients were treated with antibiotics alone. We were able to identify the microorganism in 34 cases (75.6%). Ten cases in NC group were cured without recurrence, but one was not. Identification of the microorganisms did not have any significant influence on the treatment outcome, duration of antibiotic administration or normalization of laboratory profiles. For erythrocyte sedimentation rate (ESR) values over 55 mm/h and C-reactive protein (CRP) values of 2.75 mg/dL at fourth week after antibiotic administration by means of ROC curve analysis, we expect significantly high rates of treatment failure by Pearson chi(2) test (chi(2) = 4.344, Odds ratio = 5.15, p = 0.037, 95% CI 1.004-26.597). Even in patients with negative culture findings, it is expected that a good outcome will be achieved by the administration of cefazolin or vancomycin for about 6 weeks. It is concluded that antibiotics selected according to the etiological setting can be initiated without the need to start empirical antibiotics. In every instance at fourth week after the initiation of antibiotic therapy, the values of CRP and ESR can provide meaningful information regarding whether clinicians need to reevaluate the effectiveness of antibiotics by performing follow-up imaging studies and monitoring the patient's clinical manifestations.

Inflammatory myofibroblastic tumor in the intradural extramedullary space of the lumbar spine with spondylolisthesis: case report and review of the literature.

An inflammatory myofibroblastic tumor (IMT) is a rare disease entity reported to arise in various organs but still thought to be a neoplastic or reactive inflammatory condition controversially. The author reports an extremely rare case of intradural extramedullary IMT of lumbar spine which was presenting radiculopathy and neurogenic intermittent claudication due to concomitant spondylolisthesis.

Fluoroscopically guided caudal epidural steroid injection for management of degenerative lumbar spinal stenosis: short-term and long-term results.

OBJECTIVE: To evaluate the short-term and long-term effects of fluoroscopically guided caudal epidural steroid injection (ESI) for the management of degenerative lumbar spinal stenosis (DLSS) and to analyze outcome predictors. MATERIALS AND METHODS: All patients who underwent caudal ESI in 2006 for DLSS were included in the study. Response was based on chart documentation (aggravated, no change, slightly improved, much improved, no pain). In June 2009 telephone interviews were conducted, using formatted questions including the North American Spine Society (NASS) patient satisfaction scale. For short-term and long-term effects, age difference was evaluated by the Mann-Whitney U test, and gender, duration of symptoms, level of DLSS, spondylolisthesis, and previous operations were evaluated by Fisher's exact test. RESULTS: Two hundred and sixteen patients (male:female = 75:141; mean age 69.2 years; range 48 approximately 91 years) were included in the study. Improvements (slightly improved, much improved, no pain) were seen in 185 patients (85.6%) after an initial caudal ESI and in 189 patients (87.5%) after a series of caudal ESIs. Half of the patients (89/179, 49.8%) replied positively to the NASS patient satisfaction scale (1 or 2). There were no significant outcome predictors for either the short-term or the long-term responses. CONCLUSION: Fluoroscopically guided caudal ESI was effective for the management of DLSS (especially central canal stenosis) with excellent short-term and good long-term results, without significant outcome predictors.

Percutaneous vertebroplasty for intravertebral cleft: analysis of therapeutic effects and outcome predictors.

OBJECTIVE: To investigate the short-term therapeutic effect of percutaneous vertebroplasty (PVP) for intravertebral cleft (IVC) and to analyze possible outcome predictors. MATERIALS AND METHODS: After retrospective review of spot radiographs during PVP, 23 patients were included in this study. Age, sex, symptom duration, functional status, injected cement volume, and type of approach were evaluated using patients' medical and operative records. The following factors were analyzed on radiographs, MRI, dual bone densitometry, spot radiographs during PVP, and CT: anatomical location of the fracture, bone mineral density, morphology of the fracture, IVC morphology, presence of surrounding non-enhanced area and bone marrow edema, degeneration of adjacent discs, co-existing old compression fractures, patterns of cement opacification, pre-procedural kyphosis, and post-procedural kyphosis correction. Effectiveness was defined as a much-improved state or no pain after 1 week, 1 month, and 2 months. Statistical analyses were conducted to evaluate the relationship between those factors and therapeutic outcome using Fisher's exact test, Chi-squared test, and the Mann-Whitney U test. RESULTS: Percutaneous vertebroplasty of IVC was effective in 16 out of 23 (69.6%) patients after 1 week and 1 month and 15 out of 23 (65.2%) patients after 2 months. Post-procedural kyphosis correction >or=5 and poor functional status (full dependency) were more common in the ineffective group after 1 week and 2 months respectively (P = 0.047, P = 0.02). Kyphotic correction >or=5 was related to pre-procedural kyphosis >or=15 (P = 0.018). Functional status was related to subsequent fracture (P = 0.005). Other factors were not statistically significant (P > 0.05). CONCLUSIONS: Percutaneous vertebroplasty on osteoporotic vertebral compression fractures (VCF) with IVC was effective in only about 69.6% of patients after the first week and month and in 65.2% of patients after 2 months. Post-procedural kyphosis correction >or=5 was associated with poor outcomes after the first week. Two months after PVP, the functional status was more important because of the development of subsequent fractures.

Bicortical Screw Purchase at Upper Instrumented Vertebra (UIV) Can Cause UIV Fracture After Adult Spinal Deformity Surgery: A Finite Element Analysis Study.

OBJECTIVE: To examine the biomechanical stress distribution at the upper instrumented vertebra (UIV) according to unicortical- and bicortical purchase model by finite element analysis (FEA). METHODS: A T8 to Sacrum with implant finite element model was developed and validated. The pedicle screws were unicortically or bicortically inserted from T10 to L5, and each model was compared and the von Mises (VM) yield stress of T10 was calculated. According to the motion (flexion, extension, lateral bending, and axial rotation) of spine, boundary condition values were set as 15°, 15°, 10°, 4°. RESULTS: Although the 2 stress values did not show a significant difference between the unicortical- and bicortical purchase models in the flexion and extension, bicortical purchase model showed a larger stress distribution. However, the asymmetric behavior was significantly greater in the case of lateral bending (0.802 MPa vs. 0.489 MPa) and the rotation (5.545 MPa vs. 4.905 MPa). The greater stress was observed on the spinal body surface abutting the implanted screw. Although the maximum stress was observed around the implanted screw in the bicortical purchase model under axial loading, the VM stress of both models was not significantly different. CONCLUSION: Bicortical purchase model showed a larger stress distribution than the unicortical model, especially in the case of lateral bending and the rotation behavior. Our biomechanical simulation by FEA indicates that bicortical fixation at UIV can be a risk factor for early UIV compression fracture after adult spinal deformity surgery.