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Seung-Jae Hyun, Ki-Jeong Kim, and Tae-Ahn Jahng

OBJECTIVE

No reports have investigated how cervical reconstructive surgery affects global sagittal alignment (GSA), including the lower extremities, and health-related quality of life (HRQOL). The study was aimed at elucidating the effects of cervical reconstruction on GSA and HRQOL.

METHODS

Twenty-three patients who underwent reconstructive surgery for cervical kyphosis were divided into a head-balanced group (n = 13) and a trunk-balanced group (n = 10) according to the values of the C7 plumb line, T1 slope (T1S), and pelvic incidence minus lumbar lordosis (PI-LL). Head-balanced patients are those with a negative C7 sagittal vertical axis (SVA), a larger LL than PI, and a low T1S. Trunk-balanced patients are those with a positive SVAC7, a normal PI-LL, and a normal to high T1S. Various sagittal Cobb angles, SVA, and lower-extremity alignment parameters were measured before and after surgery using whole-body stereoradiography.

RESULTS

Cervical malalignment was corrected to achieve cervical sagittal balance and occiput-trunk (OT) concordance (center of gravity [COG]–C7 SVA < 30 mm). Significant changes in the upper cervical spine and thoracolumbar spine were observed in the head-balanced group, but no significant change in lumbopelvic alignment was observed in the trunk-balanced group. Lower-extremity alignment did not change substantially in either group. HRQOL scores improved significantly after surgery in both groups. SVACOG–C7 and SVAC2–7 were negatively and positively correlated with the 36-Item Short-Form Health Survey physical component score and Neck Disability Index, respectively. The visual analog scale for back pain, Oswestry Disability Index, and PI-LL mismatch improved significantly in the head-balanced group after cervical reconstruction surgery.

CONCLUSIONS

Patients with cervical kyphosis exhibited compensatory changes in the upper cervical spine and thoracolumbar spine, instead of in the lower extremities. These compensatory mechanisms resolved reciprocally in a different fashion in the head- and trunk-balanced groups. HRQOL scores improved significantly with GSA restoration and OT concordance following cervical reconstruction.

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Jong-myung Jung, Seung-Jae Hyun, Ki-Jeong Kim, and Tae-Ahn Jahng

OBJECTIVE

This study investigated the incidence and risk factors of rod fracture (RF) after multiple-rod constructs (MRCs) for adult spinal deformity (ASD) surgery.

METHODS

A single-center, single-surgeon consecutive series of adult patients who underwent posterior thoracolumbar fusion at 4 or more levels using MRCs after osteotomy with at least 1 year of follow-up were retrospectively reviewed. Patient characteristics, radiological parameters, operative data, and clinical outcomes (on the Scoliosis Research Society-22r questionnaire) were analyzed at baseline and follow-up.

RESULTS

Seventy-six patients were enrolled in this study. RF occurred in 9 patients (11.8%), with all cases involving partial rod breakage. Seven patients (9.2%) underwent revision surgery. There were no significant differences in baseline demographic characteristics, radiological parameters, and surgical factors between the RF and non-RF groups. Multivariable analysis revealed that interbody fusion at the L5–S1 and L4–S1 levels could significantly reduce the occurrence of RF after MRCs for ASD (adjusted odds ratios 0.070 and 0.035, respectively). The RF group had significantly worse function score (mean 2.9 ± 0.8 vs 3.5 ± 0.7) and pain score (mean 2.8 ± 1.0 vs 3.5 ± 0.8) compared with the non-RF group at last visit.

CONCLUSIONS

RF occurred in 11.8% of patients with MRCs after ASD surgery. Most RFs occurred at the lumbosacral junction or adjacent level (77%). Interbody fusion at the lumbosacral junction (L5–S1 or L4–S1 level) could significantly prevent the occurrence of RF after MRCs for ASD.

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Sang-Hyun Han, Seung-Jae Hyun, Tae-Ahn Jahng, and Ki-Jeong Kim

Spontaneous bilateral pedicle fractures of the lumbar spine are rare, and an optimal surgical treatment has not been suggested. The authors report the case of a 50-year-old woman who presented with low-back pain and right leg radiating pain of 1 year’s duration. Radiological studies revealed a spontaneous bilateral pedicle fracture of L-5. All efforts at conservative treatment failed, and the patient underwent surgery for osteosynthesis of the fractured pedicle using bilateral pedicle screws connected with a bent rod. Her low-back and right leg pain were relieved postoperatively. A CT scan performed 3 months postoperatively revealed the disappearance of the pedicle fracture gap and presence of newly formed bony trabeculation. In rare cases of spontaneous bilateral pedicle fracture of the lumbar spine, osteosynthesis of the fractured pedicle using bilateral pedicle screws and a bent rod is a motion-preserving technique that may be an effective option when conservative management has failed.

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Sanghyun Han, Seung-Jae Hyun, Ki-Jeong Kim, Tae-Ahn Jahng, and Hyun-Jib Kim

OBJECTIVE

Posterior column osteotomy (PCO) has been known to provide an angular change (AC) of approximately 10° in sagittal plane deformity. However, whether PCO can actually obtain an AC of ≥ 10° depending on the particular level in the lumbar spine and which factors can effect a gain of ≥ 10° AC after PCO remain to be elucidated. The aim of this study was to identify the factors that effect a gain of ≥ 10° AC through PCO by comparing radiographic measurements between an AC group and a control group before and after adult spinal deformity (ASD) surgery.

METHODS

Forty consecutive patients who underwent multilevel PCOs for ASD at a single institution between 2012 and 2016 were included in this study. PCO was performed in 142 disc space levels in the lumbar spine. The authors defined the disc space level that obtained ≥ 10° AC in the sagittal plane by PCO as the AC group and the remaining patients as controls. The modified Pfirrmann grade, surgical level, implementation of the transforaminal lumbar interbody fusion (TLIF), and radiographic measurements were compared between the groups.

RESULTS

There were 67 levels in the AC group and 75 in the control group. Multivariate analysis identified the surgical level at L4–5 (OR 3.802, 95% CI 1.127–12.827, p = 0.031), performing TLIF with PCO (OR 3.303, 95% CI 1.258–8.674, p = 0.015), and a preoperative kyphotic disc space angle (OR 1.397, 95% CI 1.231–1.585, p < 0.001) as the factors that significantly effected ≥ 10° AC in the sagittal plane after PCO.

CONCLUSIONS

In ASD surgery, PCO cannot always achieve ≥ 10° AC in the sagittal plane. The factors that effected ≥ 10° AC in PCO for ASD were surgical level at L4–5, performing TLIF with PCO, and the preoperative kyphotic disc space angle.

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Young-Seop Park, Seung-Jae Hyun, Ho Yong Choi, Ki-Jeong Kim, and Tae-Ahn Jahng

OBJECTIVE

The aim of this study was to investigate the risk of upper instrumented vertebra (UIV) fractures associated with UIV screw fixation (unicortical vs bicortical) and polymethylmethacrylate (PMMA) augmentation after adult spinal deformity surgery.

METHODS

A single-center, single-surgeon consecutive series of adult patients who underwent lumbar fusion for ≥ 4 levels (that is, the lower instrumented vertebra at the sacrum or pelvis and the UIV of the thoracolumbar spine [T9–L2]) were retrospectively reviewed. Age, sex, follow-up duration, sagittal UIV angle immediately postoperatively including several balance-related parameters (lumbar lordosis [LL], pelvic incidence, and sagittal vertical axis), bone mineral density, UIV screw fixation type, UIV PMMA augmentation, and UIV fracture were evaluated. Patients were divided into 3 groups: Group U, 15 patients with unicortical screw fixation at the UIV; Group P, 16 with bicortical screw fixation and PMMA augmentation at the UIV; and Group B, 21 with bicortical screw fixation without PMMA augmentation at the UIV.

RESULTS

The mean number of levels fused was 6.5 ± 2.5, 7.5 ± 2.5, and 6.5 ± 2.5; the median age was 50 ± 29, 72 ± 6, and 59 ± 24 years; and the mean follow-up was 31.5 ± 23.5, 13 ± 6, and 24 ± 17.5 months in Groups U, P, and B, respectively (p > 0.05). There were no significant differences in balance-related parameters (LL, sagittal vertical axis, pelvic incidence–LL, and so on) among the groups. UIV fracture rates in Groups U (0%), P (31.3%), and B (42.9%) increased in sequence by group (p = 0.006). UIV bicortical screw fixation increased the risk for UIV fracture (OR 5.39; p = 0.02).

CONCLUSIONS

Bicortical screw fixation at the UIV is a major risk factor for early UIV compression fracture, regardless of whether a thoracolumbosacral orthosis is used. To reduce the proximal junctional failure, unicortical screw fixation at the UIV is essential in adult spinal deformity correction surgery.

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Chang-Hyun Lee, Jaebong Lee, James D. Kang, Seung-Jae Hyun, Ki-Jeong Kim, Tae-Ahn Jahng, and Hyun-Jib Kim

OBJECT

Posterior cervical surgery, expansive laminoplasty (EL) or laminectomy followed by fusion (LF), is usually performed in patients with multilevel (≥ 3) cervical spondylotic myelopathy (CSM). However, the superiority of either of these techniques is still open to debate. The aim of this study was to compare clinical outcomes and postoperative kyphosis in patients undergoing EL versus LF by performing a meta-analysis.

METHODS

Included in the meta-analysis were all studies of EL versus LF in adults with multilevel CSM in MEDLINE (PubMed), EMBASE, and the Cochrane library. A random-effects model was applied to pool data using the mean difference (MD) for continuous outcomes, such as the Japanese Orthopaedic Association (JOA) grade, the cervical curvature index (CCI), and the visual analog scale (VAS) score for neck pain.

RESULTS

Seven studies comprising 302 and 290 patients treated with EL and LF, respectively, were included in the final analyses. Both treatment groups showed slight cervical lordosis and moderate neck pain in the baseline state. Both groups were similarly improved in JOA grade (MD 0.09, 95% CI −0.37 to 0.54, p = 0.07) and neck pain VAS score (MD −0.33, 95% CI −1.50 to 0.84, p = 0.58). Both groups evenly lost cervical lordosis. In the LF group lordosis seemed to be preserved in long-term follow-up studies, although the difference between the 2 treatment groups was not statistically significant.

CONCLUSIONS

Both EL and LF lead to clinical improvement and loss of lordosis evenly. There is no evidence to support EL over LF in the treatment of multilevel CSM. Any superiority between EL and LF remains in question, although the LF group shows favorable long-term results.

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Jae Hyo Park, Seung-Yeob Yang, You-Nam Chung, Jeong Eun Kim, Seung-Ki Kim, Dae Hee Han, and Byung-Kyu Cho

✓The authors describe a modified technique of encephaloduroarteriosynangiosis (EDAS) with bifrontal encephalogaleoperiosteal synangiosis (EGPS) and present the preliminary results of the procedure. Between January 2004 and June 2005 the authors performed modified EDAS with bifrontal EGPS in 17 patients with moyamoya disease. Surgical results were evaluated in terms of clinical outcomes, changes visible on neuroimages, extent of revascularization noted on angiograms, and hemodynamic changes demonstrated on single-photon emission computed tomography (SPECT) scans. The follow-up period ranged from 6 to 21 months (mean 11.5 months). The overall clinical outcomes were excellent or good in 15 patients (88.2%) and poor in two (11.8%). The overall morbidity rate was 5.9% (one of 17 patients). Based on changes in the anterior cerebral artery (ACA) and middle cerebral artery (MCA) territories after surgery, as shown on SPECT scans following administration of acetazolamide, 14 patients (82.4%) exhibited an improved vascular reserve capacity in both the ACA and MCA territories. It is the authors' opinion that wide covering of the cortex is necessary for sufficient revascularization. In the present study they demonstrate that modified EDAS with bifrontal EGPS is a safe and efficient surgical approach that covers not only the MCA territory but also the ACA territory.

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Jung-Hee Lee, Ki-Tack Kim, Kyung-Soo Suk, Sang-Hun Lee, Bi-O Jeong, Hyun-Seok Oh, Chul-Hee Lee, and Myung-Seo Kim

Intraspinal cystic lesions with different pathogeneses have been reported to cause neurological deficits; however, no one has focused on the intraspinal extradural cysts that develop after osteoporotic compression fracture. The reported case features a 66-year-old woman presenting with progressive neurological deficit, back pain, and no history of additional trauma after undergoing conservative treatment for an osteoporotic fracture of L-1. The authors present serial radiographs and MR images demonstrating an epidural cyst successfully treated via a single posterior approach. This appears to be the first such case reported in the literature.

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Won-Sang Cho, Ki-Jeong Kim, O-Ki Kwon, Chi Heon Kim, Jiha Kim, Moon Hee Han, and Chun Kee Chung

Object

Spinal vascular diseases, such as spinal dural arteriovenous fistulas (DAVFs), perimedullary arteriovenous fistulas (AVFs), and spinal arteriovenous malformations (AVMs), are very rare. The authors analyzed the features and treatment outcomes of these conditions.

Methods

Data from 64 patients were retrospectively reviewed. There were 33 spinal DAVFs (1 patient had 2 lesions), 20 perimedullary AVFs, and 12 spinal AVMs. Clinical features, radiological findings, treatment results, and clinical outcomes were evaluated according to the diseases, subtypes, and treatment modalities. The median duration of follow-up was 20, 42, and 56 months for spinal DAVFs, perimedullary AVFs, and spinal AVMs, respectively.

Results

Spinal DAVFs showed faster progression of symptoms (median 5, 12, and 36 months for spinal DAVFs, perimedullary AVFs, and spinal AVMs, respectively) and worse neurological status at diagnosis (poor neurological status in 56%, 65%, and 33%, respectively). On MRI, signal voids were demonstrated in all except 1 spinal DAVF. At the last follow-up, 94% of spinal DAVFs, 68% of perimedullary AVFs, and 50% of spinal AVMs were completely obliterated. Favorable clinical outcomes were achieved in 91%, 95%, and 58%, respectively. In detail, the majority (78%) of spinal DAVFs were embolized, resulting in complete obliteration in 92% and favorable clinical outcomes in 92%. Most Type IVa and IVb perimedullary AVFs were surgically treated (71% and 88%), with complete obliterations of 86% and 71%, and favorable clinical outcomes in 100% and 86%, respectively. All Type IVc lesions were embolized with a low cure rate of 40%; however, clinical outcomes were satisfactory. Spinal AVMs were generally embolized (67%), and only glomus-type lesions attained a satisfactory cure rate (80%) and clinical outcome (100%).

Conclusions

Embolization produced satisfactory outcomes in spinal DAVFs and glomus-type spinal AVMs. Surgery is advantageous in Type IVa and IVb perimedullary AVFs. Palliative embolization can be effective in Type IVc perimedullary AVFs and juvenile spinal AVMs.

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Jae Hyo Park, Park In Sung, Dae Hee Han, Seong Hyun Kim, Chang Wan Oh, Jeong-Eun Kim, Hyun Jib Kim, Moon Hee Han, and O-Ki Kwon

Object

Because of its thin wall, an aneurysm arising from the posterior wall of the internal carotid artery (ICA), the so-called blood blister–like aneurysm (BBA), is difficult to manage surgically and is often associated with high morbidity and mortality rates. The authors treated these aneurysms endovascularly. In this paper, they present angiographic and clinical results obtained in patients with ICA BBAs treated endovascularly.

Methods

In seven patients with ICA BBAs who presented with subarachnoid hemorrhage, a total number of 12 endovascular treatments were performed, including seven endosaccular coil embolizations (four conventional, two stent-assisted and one balloon-assisted procedure) in four patients and five endovascular ICA trapping procedures in five patients. Repeated endovascular treatments were undertaken in four patients. In two patients, the endovascular treatment was performed after failure of surgical treatment (one case of rebleeding after clip placement and one aneurysmal regrowth after wrapping). A balloon occlusion test (BOT) was performed in all patients prior to ICA trapping.

All four patients treated by endosaccular coil embolization showed aneurysmal regrowth. Neither stents nor balloons helpfully prevented aneurysmal regrowth. Of these four patients, two experienced rebleeding. These two patients remained vegetative at the last follow-up examination. After the BOT, ICA trapping was performed with coils and balloons without complication in five patients; excellent outcomes were achieved in all cases but one in which the patient had been in poor neurological condition due to rebleeding after surgical clip therapy.

Conclusions

All ICA BBAs that were treated by endosaccular coil embolization exhibited regrowth of the aneurysm. Some of the lesions rebled. The majority of patients who underwent ICA trapping experienced excellent outcomes. Based on the authors' experiences, they suggest that ICA trapping including the lesion segment should be considered as a first option for definitive treatment if a BOT reveals satisfactory results. Regarding trapping methods, endovascular treatment may be preferred because of its convenience and safety.