Is Routine Use of Drain Really Necessary for Posterior Lumbar Interbody Fusion Surgery? A Retrospective Case Series with a Historical Control Group

STUDY DESIGN

A retrospective case-control study.

OBJECTIVES

The usefulness of a drain in spinal surgery has always been controversial. The purposes of this study were to determine the incidence of hematoma-related complications after posterior lumbar interbody fusion (PLIF) without a drain and to evaluate its usefulness.

METHODS

We included 347 consecutive patients with degenerative lumbar disease who underwent single- or double-level PLIF. The participants were divided into 2 groups by the use of a drain or not; drain group and no-drain group.

RESULTS

In 165 cases of PLIF without drain, there was neither a newly developed neurological deficit due to hematoma nor reoperation for hematoma evacuation. In the no-drain group, there were 5 (3.0%) patients who suffered from surgical site infection (SSI), all superficial, and 17 (10.3%) patients who complained of postoperative transient recurred leg pain, all treated conservatively. Days from surgery to ambulation and length of hospital stay (LOS) of the no-drain group were faster than those of the drain group (P < 0.001). In a multiple regression analysis, a drain insertion was found to have a significant effect on the delayed ambulation and increased LOS. No significant differences existed between the 2 groups in additional surgery for hematoma evacuation, or SSI.

CONCLUSIONS

No hematoma-related neurological deficits or reoperations caused by epidural hematoma and SSI were observed in the no-drain group. The no-drain group did not show significantly more frequent postoperative complications than the drain use group, hence the routine insertion of a drain following PLIF should be reconsidered carefully.

Computed Tomography Evaluation of Percutaneous Pedicle Screws Inserted during Minimally Invasive Transforaminal Lumbar Interbody Fusion: Long-term Follow-up Results of Screw Violation

Background

To evaluate the accuracy of percutaneous pedicle screw (PPS) insertion in degenerative lumbar disease treated with minimally invasive transforaminal lumbar interbody fusion (MI-TLIF) and to analyze risk factors and long-term clinical outcomes of screw violation.

Methods

Sixty-two consecutive patients (262 screws) were included. Based on postoperative computed tomography (CT) axial images, a PPS that perforated out of the pedicle was classified into a violation group, while screws surrounded by pedicular cortical bone were classified into a correct group. A logistic regression model was used for risk factor analysis of violation. We also observed the long-term clinical outcomes using the Oswestry disability index and visual analog scale.

Results

Of the 262 screws, 14 (5.3%) were considered to be violated (10 medial violations and 4 lateral violations). All violations of S1 and L5 were in the medial direction. In contrast, entire violations of L4 were always lateral and of the 2 violations of L3, one was lateral and the other was medial. There were no cases of superior or inferior violation. The mean pedicle convergence angle (CA) was significantly higher in the violation group (mean ± standard deviation, 27.0° ± 6.2°) than in the correct group (21.7° ± 5.4°). There were no significant differences according to vertebral rotational angle, body mass index, bone mineral density, and surgical timing (learning curve) between the two groups. Logistic regression analyses demonstrated that a high CA was a significant risk factor for pedicle wall violation (p = 0.002). There were no significant differences in clinical or radiographic results between the two groups in 60 patients who were followed up for more than 1 year and in 40 patients who were followed up for more than 5 years. There were 2 patients who required reoperation to replace a screw due to leg pain.

Conclusions

With PPS insertion during MI-TLIF, the rate of pedicle violation was 5.3% (14/262). An understanding of the anatomical characteristics of each vertebra and the unique structures of the patient is essential to prevent pedicle violations. Even in the violation group, PPS fixation was found to be a safe and useful procedure with successful long-term radiographic and clinical outcomes.

Management of Osteoporotic Vertebral Fracture: Review Update 2022

A vertebral fracture is the most common type of osteoporotic fracture. Osteoporotic vertebral fractures (OVFs) cause a variety of morbidities and deaths. There are currently few "gold standard treatments" outlined for the management of OVFs in terms of quantity and quality. Conservative treatment is the primary treatment option for OVFs. The treatment of pain includes short-term bed rest, analgesic medication, anti-osteoporotic medications, exercise, and a brace. Numerous reports have been made on studies for vertebral augmentation (VA), including vertebroplasty and kyphoplasty. There is still debate and controversy about the effectiveness of VA in comparison with conservative treatment. Until more robust data are available, current evidence does not support the routine use of VA for OVF. Despite the fact that the majority of OVFs heal without surgery, 15%-35% of patients with an unstable fracture, persistent intractable back pain, or severely collapsed vertebra that causes a neurologic deficit, kyphosis, or chronic pseudarthrosis frequently require surgery. Because no single approach can guarantee the best surgical outcomes, customized surgical techniques are required. Surgeons must stay current on developments in the osteoporotic spine field and be open to new treatment options. Osteoporosis management and prevention are critical to lowering the risk of future OVFs. Clinical studies on bisphosphonate's effects on fracture healing are lacking. Teriparatide was intermittently administered, which dramatically improved spinal fusion and fracture healing while lowering mortality risk. According to the available literature, there are no standard management methods for OVFs. More multimodal approaches, including conservative and surgical treatment, VA, and medications that treat osteoporosis and promote fracture healing, are required to improve the quality of the majority of guidelines.

Clinical differences between delayed and acute onset postoperative spinal infection

Spine surgeons often encounter cases of delayed postoperative spinal infection (PSI). Delayed-onset PSI is a common clinical problem. However, since many studies have investigated acute PSIs, reports of delayed PSI are rare. The purpose of this study was to compare the clinical features, treatment course, and prognosis of delayed PSI with acute PSI.Ninety-six patients diagnosed with postoperative spinal infection were enrolled in this study. Patients were classified into 2 groups: acute onset (AO) within 90 days (n = 73) and delayed onset (DO) after 90 days (n = 23). The baseline data, clinical manifestations, specific treatments, and treatment outcomes were compared between the 2 groups.The history of diabetes mellitus (DM) and metallic instrumentation at index surgery were more DO than the AO group. The causative organisms did not differ between the 2 groups. Redness or heat sensation around the surgical wound was more frequent in the AO group (47.9%) than in the DO group (21.7%) (P = .02). The mean C-reactive protein levels during infection diagnosis was 8.9 mg/dL in the AO and 4.0 mg/dL in the DO group (P = .02). All patients in the DO group had deep-layer infection. In the DO group, revision surgery and additional instrumentation were required, and the duration of parenteral antibiotic use and total antibiotic use was significantly longer than that in the AO group. Screw loosening, disc space collapse, and instability were higher in the DO group (65.2%) than in the AO group (41.1%) (P = .04). However, the length of hospital stay did not differ between the groups.Delayed-onset PSI requires more extensive and longer treatment than acute-onset surgical site infection. Clinicians should try to detect the surgical site infection as early as possible.

Long-Term Clinical and Radiological Outcomes of Minimally Invasive Transforaminal Lumbar Interbody Fusion: 10-Year Follow-up Results

BACKGROUND

Many studies have reported that minimally invasive transforaminal lumbar interbody fusion (MI-TLIF) provides satisfactory treatment comparable to other fusion methods. However, in the case of MI-TLIF, there are concerns about the long-term outcome compared to conventional bilateral PLIF due to the small amount of disc removal and the lack of autogenous bone graft. Long-term follow-up studies are still lacking as most of the previous reports have follow-up periods of up to 5 years.

METHODS

Thirty patients who underwent MI-TLIF were followed up for > 10 years (mean, 11.1 years). Interbody fusion rates were determined using a modified Bridwell grading system. Adjacent segment disease (ASD) was defined as radiological adjacent segment degeneration (R-ASDeg) as seen on plain X-rays; reoperated adjacent segment disease referred to the subsequent need for revision surgery. Clinical outcomes after surgery were assessed based on back and leg pain as well as the Oswestry disability index (ODI).

RESULTS

The overall radiological fusion rate, at the 1-, 5-, and 10-year follow-up was 77.1%, 91.4%, and 94.3%, respectively. The incidence of R-ASDeg 1, 5, and 10 years after surgery was 6.7%, 16.7%, and 43.3% at the proximal adjacent segment and 4.8%, 14.3%, and 28.6% at the distal adjacent segment, respectively. R-ASDeg at either the proximal or distal segment was determined in 50.0% of the patients 10 years postoperatively. All clinical parameters improved significantly during follow-up, although the ODI and the visual analog scale (VAS) for leg pain at the 10-year follow-up were significantly worse in the R-ASDeg group than in the other patients (P = 0.009, P = 0.040).

CONCLUSION

MI-TLIF improved both clinical and radiological outcomes, and the improvements were maintained for up to 10 years after surgery. However, R-ASDeg developed in up to 50% of the patients within 10 years, and both leg pain on the VAS and the ODI were worse in patients with R-ASDeg.

Comparative Study of Radiological and Clinical Outcomes in Patients Undergoing Minimally Invasive Lateral Lumbar Interbody Fusion Using Demineralized Bone Matrix Alone or with Low-Dose Escherichia coli-Derived rhBMP-2

OBJECTIVE

To compare the results of interbody fusion in patients undergoing minimally invasive lateral lumbar interbody fusion (LLIF) using demineralized bone matrix (DBM) alone versus DBM+recombinant human bone morphogenetic protein-2 (rhBMP2).

METHODS

This retrospective case-controlled study was conducted in patients undergoing minimally invasive LLIF (n = 54) for lumbar interbody fusion; they were divided into 2 groups: DBM-only group and DMB+rhBMP2 group. The improvements of segmental and lumbar lordosis and restoration of disc height were measured, and the interbody fusion rates were determined using a modified Bridwell grading system. Clinical outcomes after surgery, such as visual analog scale scores of back pain and leg pain, and Oswestry disability index were compared.

RESULTS

There were no significant differences in disc height, lumbar and segmental lordosis, or interbody fusion rate between the 2 groups. However, the proportion of Bridwell grade 1 as complete interbody bridging was higher in the DBM+rhBMP2 group than in the DBM-only group at both 6 and 12 months (P < 0.001). Clinical parameters showed equally significant improvement during follow-up in both groups, with no significant differences between the groups.

CONCLUSION

In minimally invasive LLIF, adding Escherichia coli-derived rhBMP2 to DBM did not affect clinical outcomes or radiation parameters, but increased the speed of fusion and interbody bony bridging rate.

Comparison of Minimally Invasive Lateral Lumbar Interbody Fusion, Minimally Invasive Lateral Lumbar Interbody Fusion, and Open Posterior Lumbar Interbody Fusion in the Treatment of Single-Level Spondylolisthesis of L4-L5

OBJECTIVE

To compare the outcomes of minimally invasive lateral lumbar interbody fusion (LLIF) with minimally invasive transforaminal lumbar interbody fusion (TLIF) and conventional open posterior lumbar interbody fusion (PLIF) for treating single-level spondylolisthesis at L4-L5.

METHODS

The patients underwent minimally invasive LLIF (n = 18), minimally invasive TLIF (n = 17), and conventional open PLIF (n = 20) for spondylolisthesis at L4-L5. Reduction of slippage, improvement in segmental lordosis, and restoration of foraminal height were measured. Perioperative parameters such as blood loss and operation time and clinical outcomes such as visual analog scale score and Oswestry Disability Index were compared.

RESULTS

Compared with the open PLIF group, the minimally invasive LLIF group showed greater restoration of mean foraminal height, significantly smaller mean intraoperative estimated blood loss, and less mean hemoglobin reduction on the third day postoperatively. Compared with the minimally invasive TLIF group, the minimally invasive LLIF group showed greater restoration of mean segmental lordosis. The minimally invasive LLIF group showed a significantly shorter mean time to start walking after surgery compared with the conventional open PLIF and minimally invasive TLIF groups. However, compared with the minimally invasive TLIF group, the minimally invasive LLIF group showed a significantly longer mean operating time. Clinical outcomes were not statistically different among the 3 groups.

CONCLUSIONS

In the treatment of spondylolisthesis of L4-L5, minimally invasive LLIF provided an effective surgical alternative to minimally invasive TLIF or conventional open PLIF, with the advantages of less blood loss, the faster start of postoperative walking, and comparable improvement in radiologic parameters.

Analysis of factors influencing improvement of idiopathic flatfoot

Idiopathic flatfoot is common in infants and children, and patients with this condition are frequently referred to pediatric orthopedic clinics. Flatfoot is a physiologic process, and that the arch of the foot elevates spontaneously in most children during the first decade of life. To achieve a consensus as the rate of spontaneous improvement of flatfoot, the present study aimed to estimate the rate of spontaneous improvement of flatfoot and to analyze correlating factors.We reviewed the records of patients examined between May 2013 and May 2019 so as to identify those factors associated with idiopathic flatfoot below 12 years of age. We included patients with who had been followed for >6 months, and those for whom ≥2 (anteroposterior and lateral) weight-bearing bilateral radiographs of the foot had been obtained. The progression rates of the anteroposterior (AP) talo-first metatarsal angle, talonavicular coverage angle, lateral talo-first metatarsal angle, and calcaneal pitch angle were adjusted by multiple factors using a linear mixed model, with sex, body mass index, and Achilles tendon contracture as the fixed effects and age and each subject as the random effects.We found that 4 of the radiographic measurements improved as patients grew older. The AP talo-first metatarsal angle, talonavicular coverage angle, and the lateral talo-first metatarsal angle decreased, while the calcaneal pitch angle increased. The AP talo-first metatarsal angle (P < .001), talonavicular coverage angle (P < .001), and lateral talo-first metatarsal angle (P < .001) improved significantly; however, the calcaneal pitch angle (P = .367) did not show any significant difference. In general, the flatfeet showed an improving trend; after analyzing the factors, no sex difference was observed (P = .117), while body mass index (P < .001) and Achilles tendon contracture (P < .001) showed a negative correlation.The study demonstrated that children's flatfeet spontaneously improved at the age of 12 years. It would be more beneficial if the clinician shows the predicted appearance of the foot at the completion of growth by calculating the radiographic indices and identifying the correlating factors in addition to explaining that flatfoot may gradually improve. This will prevent unnecessary medical expenses and the psychological adverse effects to the children caused by unnecessary treatment.

Current Concepts in the Management of Osteoporotic Vertebral Fractures: A Narrative Review

Vertebral fractures are the most common type of osteoporotic fracture and can increase morbidity and mortality. To date, the guidelines for managing osteoporotic vertebral fractures (OVFs) are limited in quantity and quality, and there is no gold standard treatment for these fractures. Conservative treatment is considered the primary treatment option for OVFs and includes pain relief through shortterm bed rest, analgesics, antiosteoporotic drugs, exercise, and braces. Studies on vertebral augmentation (VA) including vertebroplasty and kyphoplasty have been widely reported, but there is still debate and controversy regarding the effectiveness of VA when compared with conservative treatment, and the routine use of VA for OVF is not supported by current evidence. Although most OVFs heal well, approximately 15%-35% of patients with unstable fractures, chronic intractable back pain, severely collapsed vertebra (leading to neurological deficits and kyphosis), or chronic pseudarthrosis frequently require surgery. Given that there is no single technique for optimizing surgical outcomes in OVFs, tailored surgical techniques are needed. Surgeons need to pay attention to advances in osteoporotic spinal surgery and should be open to novel thoughts and techniques. Prevention and management of osteoporosis is the key element in reducing the risk of subsequent OVFs. Bisphosphonates and teriparatide are mainstay drugs for improving fracture healing in OVF. The effects of bisphosphonates on fracture healing have not been clinically evaluated. The intermittent administration of teriparatide significantly enhanced spinal fusion and fracture healing and reduced mortality risk. Based on the current literature, there is still a lack of standard management strategies for OVF. There is a need for greater efforts through multimodal approaches including conservative treatment, surgery, osteoporosis treatment, and drugs that promote fracture healing to improve the quality of the guidelines.

Prevalence and Risk Factors for Positive Nasal Methicillin-Resistant Staphylococcus aureus Carriage Among Orthopedic Patients in Korea

Methicillin-resistant Staphylococcus aureus (MRSA) causes purulent skin and soft tissue infections as well as other life-threatening diseases. Recent guidelines recommend screening for MRSA at the time of admission. However, few studies have been conducted to determine the prevalence and risk factors for MRSA colonization. A prospective data collection and retrospective analysis was performed. MRSA screening tests were performed using nasal swabs in patients enrolled between January 2017 and July 2018. Demographic data, socio-economic data, medical comorbidities, and other risk factors for MRSA carriage were evaluated among 1577 patients enrolled in the study. The prevalence of MRSA nasal carriage was 7.2%. Univariate regression analysis showed that colonization with MRSA at the time of hospital admission was significantly related to patient age, body mass index, smoking, alcohol, trauma, recent antibiotic use, and route of hospital admission. Multiple logistic regression analysis for the risk factors for positive MRSA nasal carriage showed that being under- or overweight, trauma diagnosis, antibiotic use one month prior to admission, and admission through an emergency department were related to MRSA colonization. This study highlights the importance of a preoperative screening test for patients scheduled to undergo surgery involving implant insertion, particularly those at risk for MRSA.

Relationship between dementia and ankylosing spondylitis: A nationwide, population-based, retrospective longitudinal cohort study

Among a variety of comorbidities of ankylosing spondylitis (AS), the association between dementia and AS by using an extensive dataset from the Korean National Health Insurance System was evaluated in this study. We extracted 15,547 newly diagnosed AS subjects among the entire Korean population and excluded wash-out patients (n = 162) and patients that were inappropriate for cohort match (n = 1192). Finally, 14,193 subjects were chosen as the AS group, and through 1:5 age- and sex-stratified matching, 70,965 subjects were chosen as the control group. We evaluated patient demographics, household incomes, and comorbidities, including hypertension, diabetes, and dyslipidemia. The prevalence of overall dementia (1.37%) and Alzheimer’s dementia (AD) (0.99%) in the AS group was significantly higher than in the control group (0.87% and 0.63%), respectively. The adjusted hazard ratio of the AS group for overall dementia (1.758) and AD (1.782) showed statistical significance also. On the other hand, the prevalence of vascular dementia did not differ significantly between the two groups. Subgroup analyses revealed the following risk factors for dementia in the AS group: male gender, greater than 65 years in age, fair income (household income greater than 20% of the median), urban residency, no diabetes, and no hypertension. From the nationwide, population-based, retrospective, longitudinal cohort study, AS patients showed a significantly higher prevalence of overall dementia and Alzheimer’s dementia. Comprehensive patient assessment using our subgroup analysis could help to prevent dementia in patients suffering from AS.

Comparison of Cortical Ring Allograft and Plate Fixation with Autologous Iliac Bone Graft for Anterior Cervical Discectomy and Fusion

Study Design

A retrospective cohort study.

Purpose

To compare the clinical and radiological outcomes of patients who underwent anterior cervical discectomy and fusion (ACDF) supplemented with plate fixation using allograft with those who underwent ACDF using tricortical iliac autograft.

Overview of Literature

As plate fixation is becoming popular, it is reported that ACDF using allograft may have similar outcomes compared with ACDF using autograft.

Methods

Forty-one patients who underwent ACDF supplemented with plate fixation were included in this study. We evaluated 24 patients who used cortical ring allograft filled with demineralized bone matrix (DBM) (group A) and 17 patients who used tricortical iliac autograft (group B). In radiological evaluations, fusion rate, subsidence of grafted material, cervical lordosis, fused segmental lordosis, and radiological adjacent segment degeneration (ASD) were observed and analyzed with preoperative and postoperative plain radiographs. Clinical outcomes were evaluated using the Neck Disability Index score, Odom criteria, and Visual Analog Scale score of neck and upper extremity pain. Radiological union was determined by dynamic radiographs using cutoff values of 1 mm of interspinous motion as the indication of pseudarthrosis.

Results

There was no significant difference in the fusion rate, graft subsidence, cervical lordosis, fused segmental lordosis, and ASD incidence between the groups. Operative time was shorter in group A (136 min) than in group B (141 min), but it was not significant (p>0.05). Blood loss was greater in group B (325 mL) than in group A (210 mL, p=0.013). There was no difference in the clinical outcomes before and after surgery.

Conclusions

In ACDF with plate fixation, cortical ring allograft filled with DBM group showed similar radiological and clinical outcomes compared with those of the autograft group. If the metal plate is reinforced, using cortical ring allograft could be a viable alternative to autograft.

Pneumomediastinum and pneumopericardium as rare complications after retroperitoneal transpsoas lateral lumbar interbody fusion surgery: A case report

RATIONALE

Pneumomediastinum and pneumopericardium refer to conditions in which air exists within the mediastinum and pericardium, respectively. There is the communication between the mediastinum, pericardium, and retroperitoneum. We present the first report of rare complications (pneumomediastinum and pneumopericardium) after retroperitoneal transpsoas lateral lumbar interbody fusion (LLIF) surgery.

PATIENT CONCERNS

A 73-year-old female who underwent LLIF using the retroperitoneal approach complained of dysphagia but no other abnormal symptom after surgery.

DIAGNOSIS AND INTERVENTIONS

A plain chest radiograph (CXR) taken immediately the following surgery did not show any unusual findings but CXR took on postoperative day (POD) 1 indicated pneumopericardium and pneumomediastinum with abnormal air density along the pericardium and mediastinum with subdiaphragmatic air density. A chest computed tomography revealed bilateral pleural effusion and abnormal air density (pneumopericardium and pneumomediastinum) connected to a large amount of air around the aorta and retroperitoneal space (pneumoretroperitoneum).

OUTCOMES

The patient complained of no unusual symptom and the CXR on POD 6 indicated that no air density surrounding the mediastinum and pericardium was found.

LESSONS

Pneumomediastinum and pneumopericardium should be considered possible complications of LLIF using retroperitoneal transpsoas approach. Such a condition may progress to fatal conditions without early recognition and rapid management.

Retrospective analysis of culture-negative versus culture-positive postoperative spinal infections

Retrospective analysis.This study aimed to investigate the characteristics, clinical features, and outcomes of culture-negative (CN) and culture-positive (CP) postoperative spinal infections (PSIs).Causative organism cultures and the use of adequate antibiotics are essential for treating postoperative spinal wound infections. However, managing infected surgical sites with negative wound culture results is a common clinical problem. Although the outcomes of microbiologically confirmed PSIs have been well studied, the outcomes and clinical characteristics of CN PSIs have not been previously published.Between January 1995 and December 2014, 69 patients diagnosed with PSIs were enrolled. Enrolled patients were classified into 2 groups: CN (28 patients) and CP (41 patients). Baseline data, clinical manifestations, specific treatments, and treatment outcomes were compared with the groups.The overall rate of CN PSI was 40.6% (28/69). Baseline data and clinical manifestations were similar between the 2 groups. There were no significant differences in the duration of parenteral antibiotic use between the CN and CP groups. Revision surgery was required less often for the CN group (64.3%) than for the CP group (87.8%) (P = .020). Revision surgeries were repeated 0.82 times/case in the CN group and 1.34 times/case in the CP group (P = .014). Treatment outcomes, such as poor radiologic findings, need for additional anterior surgery, extension of fusion to adjacent segment surgery, and total length of hospital stay, were not different between groups.Revision surgery was performed less often for the CN group than for the CP group. From the perspective of revision surgery, CN PSIs have better prognosis than CP PSIs. However, clinical presentations and radiologic prognoses were not different between the two groups. We suggest that CN PSIs may be treated in the same way as CP PSIs.

Risk factor analysis for predicting vertebral body re-collapse after posterior instrumented fusion in thoracolumbar burst fracture

BACKGROUND CONTEXT

In the posterior instrumented fusion surgery for thoracolumbar (T-L) burst fracture, early postoperative re-collapse of well-reduced vertebral body fracture could induce critical complications such as correction loss, posttraumatic kyphosis, and metal failure, often leading to revision surgery. Furthermore, re-collapse is quite difficult to predict because of the variety of risk factors, and no widely accepted accurate prediction systems exist. Although load-sharing classification has been known to help to decide the need for additional anterior column support, this radiographic scoring system has several critical limitations.

PURPOSE

(1) To evaluate risk factors and predictors for postoperative re-collapse in T-L burst fractures. (2) Through the decision-making model, we aimed to predict re-collapse and prevent unnecessary additional anterior spinal surgery.

STUDY DESIGN

Retrospective comparative study.

PATIENT SAMPLE

Two-hundred and eight (104 men and 104 women) consecutive patients with T-L burst fracture who underwent posterior instrumented fusion were reviewed retrospectively. Burst fractures caused by high-energy trauma (fall from a height and motor vehicle accident) with a minimum 1-year follow-up were included. The average age at the time of surgery was 45.9 years (range, 15-79). With respect to the involved spinal level, 95 cases (45.6%) involved L1, 51 involved T12, 54 involved L2, and 8 involved T11. Mean fixation segments were 3.5 (range, 2-5). Pedicle screw instrumentation including fractured vertebra had been performed in 129 patients (62.3%).

OUTCOME MEASURES

Clinical data using self-report measures (visual analog scale score), radiographic measurements (plain radiograph, computed tomography, and magnetic resonance image), and functional measures using the Oswestry Disability Index were evaluated.

METHODS

Body height loss of fractured vertebra, body wedge angle, and Cobb angle were measured in serial plain radiographs. We assigned patients to the re-collapse group if their body height loss progressed greater than 20% at any follow-up time compared with immediate postoperative body height loss; we assigned the remaining patients to the well-maintained group. The chi-square test and t test of SPSS were used for comparison of differences between two groups and multiple logistic regression analysis for risk factor evaluation. Through the decision tree analysis of statistical package R, a decision-making model was composed, and a cutoff value of revealed risk factors and re-collapse rate of each subgroup were identified. The present study wassupported by the University College of Medicine Research Fund (university to which authors belong). There was no external funding source for this study. The authors have no conflict of interest to declare.

RESULTS

Re-collapse occurred in 31 of 208 patients (14.9%). In this group, age, the proportion of male gender, preoperative height loss, and preoperative wedge angle were significantly greater than the well-maintained group. Multivariable logistic regression analysis identified two independent risk factors: age (adjusted odds ratio 1.084, p=.002) and body height loss (adjusted odds ratio 1.065, p=.003). According to the decision-making tree, age (>43 years) was the most discriminating variable, andpreoperative body height loss (>54%) was the second. In this model, the re-collapse rate was zero in ages less than 43 years, and among those remaining, nearly 80% patients with greater than 54% of body height loss belonged to the re-collapse group.

CONCLUSIONS

The independent predictors of re-collapse after posterior instrumented fusion for T-L burst fracture were the age at operation (>43 years old) and preoperative body height loss (>54%). Careful assessment using our decision-making model could help to predict re-collapse and prevent unnecessary additional spinal surgery for anterior column support, especially in young patients.

Quality of Life in Patients with Osteoporotic Vertebral Compression Fractures

BACKGROUND

This study aimed to evaluate quality of life (QOL) using the EuroQOL-5 dimensions (EQ-5D) index and to examine factors affecting QOL in patients with an osteoporotic vertebral compression fracture (OVCF).

METHODS

This ambispective study used a questionnaire interview. Patients over 50 years old with an OVCF at least 6 months previously were enrolled. Individual results were used to calculate the EQ-5D index. Statistical analysis was performed, and factors related to QOL were examined.

RESULTS

Of 196 patients in the study, 84.2% were female, with an average age of 72.7 years. There were 66 (33.7%) patients with multilevel fractures. Conservative management was used in 75.0% of patients, and 56.1% received anti-osteoporosis treatment. The mean EQ-5D index was 0.737±0.221 and was significantly correlated with the Oswestry disability index score (correlation coefficient -0.807, P<0.001). The EQ-5D index was significantly correlated with age (Spearman's rho=-2.0, P=0.005), treatment method (P=0.005), and history of fracture (P=0.044) on univariate analysis and with conservative treatment (P<0.001) and osteoporotic treatment (P=0.017) on multivariate analysis.

CONCLUSIONS

OVCF markedly lowers QOL in several dimensions for up to 12 months, even in patients who have healed. Treatment of osteoporosis and conservative treatment methods affect QOL and should be considered in OVCF management.

Relationship between bone mineral density and alcohol intake: A nationwide health survey analysis of postmenopausal women

OBJECTIVES

Among a variety of relevant factors of osteoporosis, the association between alcohol intake and postmenopausal women's bone mineral density (BMD) by using data from the Korean National Health and Nutrition Examination Survey was evaluated in this study.

MATERIALS AND METHODS

Among a total of 31,596 subjects, males, premenopausal women, participants without BMD data were excluded. Finally, a total number of subjects in the study was 3,312. The frequency and amount of alcohol intake were determined by self-reported questionnaires, and BMD was measured by dual-energy x-ray absorptiometry.

RESULTS

Mean femoral BMD for light drinkers was statistically significantly greater than that for heavy drinkers and non-drinkers. We observed the characteristic trends for BMD by drinking frequency; the mean BMD gradually increased from non-drinkers to the participants who drank 2-3 times per week; these participants exhibited the highest BMD. Participants who drank alcohol greater than 4 times per week showed a lower BMD. In the risk factor analysis, the adjusted odds ratio for osteoporosis (at femoral neck) was 1.68 in non-drinkers and 1.70 in heavy drinkers compared with light drinkers.

CONCLUSIONS

Light alcohol intake (2-3 times per week and 1-2 or 5-6 glasses per occasion) in South Korean postmenopausal women was related to high femoral BMD. Non-drinkers and heavy drinkers had approximately a 1.7-times greater risk for osteoporosis than light drinkers.

Does the location of the arterial input function affect quantitative CTP in patients with vasospasm?

BACKGROUND AND PURPOSE

In recent years, there has been increasing use of CTP imaging in patients with aneurysmal SAH to evaluate for vasospasm. Given the critical role of the arterial input function for generation of accurate CTP data, several studies have evaluated the effect of varying the arterial input function location in patients with acute stroke. Our aim was to determine the effect on quantitative CTP data when the arterial input function location is distal to significant vasospasm in patients with aneurysmal SAH.

MATERIALS AND METHODS

A retrospective study was conducted of patients with aneurysmal SAH admitted from 2005 to 2011. Inclusion criteria were the presence of at least 1 anterior cerebral artery or MCA vessel with a radiologically significant vasospasm and at least 1 of these vessels without vasospasm. We postprocessed each CTP dataset 4 separate times by using standardized methods, only varying the selection of the arterial input function location in the anterior cerebral artery and MCA vessels. For each of the 4 separately processed examinations for each patient, quantitative data for CBF, CBV, and MTT were calculated by region-of-interest sampling of the vascular territories. Statistical analysis was performed by using a linear mixed-effects model.

RESULTS

One hundred twelve uniquely processed CTP levels were analyzed in 28 patients (mean age, 52 years; 24 women and 4 men) recruited from January 2005 to December 2011. The average Hunt and Hess scale score was 2.89 ± 0.79. The average time to CTP from initial presentation was 8.2 ± 5.1 days. For each vascular territory (right and left anterior cerebral artery, MCA, posterior cerebral artery), there were no significant differences in the quantitative CBF, CBV, and MTT generated by arterial input function locations distal to significant vasospasm compared with nonvasospasm vessels (P > .05).

CONCLUSIONS

Arterial input function placement distal to significant vasospasm does not affect the quantitative CTP data in the corresponding vascular territory or any other vascular territory in aneurysmal SAH.

Radiographic grading of facet degeneration, is it reliable? - a comparison of MR or CT grading with histologic grading in lumbar fusion candidates

BACKGROUND CONTEXT

The current interest in motion-sparing surgery highlights the need for a more accurate radiologic evaluation of the degree of facet degeneration. In the presence of severe facet degeneration, a surgeon cannot ensure a positive outcome, even after successful surgery. To the best of our knowledge, no prospective study has compared the accuracy of grading facet degeneration by computed tomography (CT) or magnetic resonance (MR) scans with that attained from a real histologic evaluation.

PURPOSE

The purpose of this study was to determine the accuracy and reliability of CT or MR assessments of lumbar facet degeneration by comparing it with the histologic grading of the resected facets during surgery.

STUDY DESIGN/SETTING

A prospective study of consecutive patients undergoing posterior lumbar fusion surgery.

METHODS

Forty-four excised facets from 18 patients who received lumbar fusion were evaluated using radiographic and histologic techniques. All patients prospectively underwent CT scanning, routine axial T2-weighted MR scanning, and axial MR using a double echo steady state (DESS) sequence for cartilage imaging. The facets were graded radiologically using four-point scales. The inferior articular processes including the cartilage and subchondral bone of the corresponding facets were resected during surgery and evaluated histologically using a four-point grading system.

RESULTS

Radiologic grading revealed a tendency for underestimating facet degeneration than histologic grading. The number of facets undergraded by radiologic evaluations was 24 (55%) facets by CT, 16 (36%) by routine MR, and 22 (49%) by DESS. The weighted kappa coefficients between the histologic and radiologic grading also showed a poor correlation (0.120 for CT, 0.128 for routine MR, and 0.280 for MR using DESS sequence, respectively). The false-negative rates for detecting histologic degeneration by radiologic studies were 41% to 54%. The receiver operating characteristic curve revealed MR using DESS to have a better performance.

CONCLUSIONS

The degree of facet degeneration can be underestimated by current radiologic modalities, and their ability to detect facet degeneration is quite limited. Surgeons should be aware of these limitations during a preoperative evaluation of patients considered for motion-sparing techniques in lumbar spinal surgery.

Intra-arterial chemotherapy for malignant gliomas: a critical analysis

Intra-arterial (IA) chemotherapy for malignant gliomas including glioblastoma multiforme was initiated decades ago, with many preclinical and clinical studies having been performed since then. Although novel endovascular devices and techniques such as microcatheter or balloon assistance have been introduced into clinical practice, the question remains whether IA therapy is safe and superior to other drug delivery modalities such as intravenous (IV) or oral treatment regimens. This review focuses on IA delivery and surveys the available literature to assess the advantages and disadvantages of IA chemotherapy for treatment of malignant gliomas. In addition, we introduce our hypothesis of using IA delivery to selectively target cancer stem cells residing in the perivascular stem cell niche.

Molecular cloning and targeting of a fibrillarin homolog from Arabidopsis

Fibrillarin is a nucleolar protein known to be involved in the processing of ribosomal RNA precursors. We isolated AtFbr1, a cDNA encoding a homolog of fibrillarin in Arabidopsis. The cDNA is 1.2 kb in size and encodes a polypeptide of 310 amino acid residues with a molecular mass of 33 kD. AtFbr1 is expressed at high levels in the flower and root tissue and at a slightly lower level in leaf tissue, whereas it was nearly undetectable in siliques. Expression of AtFbr1 was compared with that of the FLP (fibrillarin-like protein) gene identified by the Arabidopsis genome project. Abscisic acid treatment resulted in the down-regulation of the expression of both AtFbr1 and FLP genes in seedlings, although the degree of suppression was higher for FLP than for AtFbr1. In addition, the expression level of FLP decreased with the age of the seedlings, whereas AtFbr1 did not exhibit any detectable change. The subcellular localization of AtFbrl was studied with an in vivo targeting approach using a fusion protein, and was found to be correctly targeted to the nucleolus in protoplasts when expressed as a green fluorescent fusion protein (GFP). Deletion experiments showed that the N-terminal glycine- and arginine-rich region is necessary and sufficient to target AtFbr1 to the nucleolus.

Effects of endoscopic variceal ligation in lower esophageal motor function: a prospective study

OBJECTIVES

Endoscopic variceal ligation (EVL), a recently developed method for controlling active variceal bleeding and eradicating esophageal varices, has similar efficacy to endoscopic injection sclerotherapy (EIS) and is known to have a minimal risk of complications and fewer complications in the lower esophagus. However, since the site of EVL is chiefly done in the lower esophagus, we prospectively evaluated to investigate the effect of EVL on the lower esophageal motor function.

METHODS

We evaluated the severity of esophageal varix with the endoscopy and the lower esophageal manometry in 27 patients who had no history of interventional therapy, for varices before EVL, 3 weeks and 6 months after the last EVL session.

RESULTS

The EVL caused considerable diminution in the size of esophageal varix by a mean 8.2 (range 3-21) ligations in mean 1.7 (range 1-3) sessions. In most of the cases, the varices reappeared and enlarged when the procedure of EVL was stopped. There were two different types of changes (intermediate and late) in the lower esophageal motility. The intermediate post-EVL effects were the increase of peristaltic contraction amplitude and duration in the lower esophageal body after EVL. The late post-EVL effects were the prolongation of lower esophageal sphinctor (LES) relaxation duration and speedier peristaltic velocity in the lower esophageal body.

CONCLUSIONS

We conclude from these findings that the intermediate post-EVL effect may be transient and the increase of peristaltic wave was due to diminution of esophageal varix.