Choon-Keun Park

Comparison Study of the Instrumented Circumferential Fusion with Instrumented Anterior Lumbar Interbody Fusion as a Surgical Procedure for Adult Low-Grade Isthmic Spondylolisthesis

BACKGROUND Instrumented circumferential fusion has been used as a primary and salvage procedure in lumbar spine fusion, especially for adult low-grade isthmic spondylolisthesis. Recently, instrumented anterior lumbar interbody fusion (ALIF) has been shown to provide good clinical and radiologic results that are comparable with those attained with traditional lumbar fusion. However, there have been no reports available that compare instrumented circumferential fusion with instrumented ALIF. METHODS Between January 2003 and November 2004, a total of 43 consecutive patients underwent instrumented ALIF (group I) at one hospital of the authors. Between February 2003 and October 2006, a total of 32 consecutive patients underwent instrumented circumferential fusion (group II) at the other hospital of the authors. The authors retrospectively reviewed clinical and radiologic data from patients. The time spent on the operation, blood loss, blood transfusions, the length of hospital stay, complications, clinical results, and radiologic results, including disc height (DH), degree of listhesis, segmental lordosis (SL), and whole lumbar lordosis (WL), were analyzed and compared. Clinical outcomes were graded using visual analog scale (VAS) scores. Functional outcomes were measured using Oswestry Disability Index (ODI) scores and return-to-work status. RESULTS The mean follow-up period was 41.1 and 32.9 months in group I and group II, respectively. Radiologic evidence of fusion was noted in 42 of 43 patients in group I and in 32 of 32 patients in group II. In both groups, all of the radiologic data, including the DH, degree of listhesis, SL, and WL significantly changed from the preoperative to postoperative period except for WL in group II. In both groups, VAS scores for back and leg pain and ODI scores significantly changed from the preoperative to postoperative period. There was no significant difference for VAS scores for back ODI scores in the two treatment groups after surgery. The mean time until return to work was 3.7 months in group I and 3.6 months in group II (p < .05). The mean hospital stay for group I (7.4 days) was shorter than that for group II (15.2 days) (p < .05). The mean operation time in group I (190 minutes) was shorter than that in group II (260.8 minutes) (p < .05). The mean blood loss in group I (300 mL) was less than that in group II (379 mL) (p < .05). CONCLUSIONS According to the present clinical outcome, instrumented ALIF is at least as effective as instrumented circumferential fusion for the treatment of back pain in adult patients with low-grade isthmic spondylolisthesis. Moreover, in terms of operative data including the duration of operation and hospital stay, as well as blood loss, instrumented ALIF demonstrates better results.

A Strategy of Percutaneous Endoscopic Lumbar Discectomy for Migrated Disc Herniation

OBJECTIVE Percutaneous endoscopic lumbar discectomy (PELD) with remarkable advancements has led to successful results comparable with open discectomy; however, its application in herniated disc (HD) with migration is still challenging and technically demanding. The purpose of this study is to propose various strategies for PELD according to HD with migration. METHODS A retrospective review was performed on 434 consecutive patients who had undergone PELD. HD with migration was classified into 4 zones: low-grade up/down and high-grade up/down based on the extent and direction of migration. Clinical outcomes were assessed by visual analogue scale score for back and leg pain, Oswestry Disability Index, and modified Macnab criteria. Endoscopic approaches and techniques were analyzed depending on HD with migration. RESULTS A total of 149 patients underwent PELD for HD with migration. There were 93 low-grade down HD patients, 13 high-grade down, 11 low-grade up, and 32 high-grade up. High-grade up HDs were removed with the outside or outside-in techniques from L1-2 to L4-5. High-grade down HDs were removed via the outside technique with additional foraminoplasty. Low-grade up/down HDs with disc space continuity were removed with the inside-out technique. Meanwhile, at the L5-S1 level, interlaminar PELD was used to treat high-grade up/down HD with migration. The mean visual analogue scale score for back pain, leg pain, and Oswestry Disability Index were significantly improved after PELD. Favorable outcome was achieved in 90.6% of cases. CONCLUSIONS An appropriate strategy for PELD is important for successful removal of HD considering the extent of migration and direction.

Percutaneous endoscopic lumbar discectomy: minimally invasive technique for multiple episodes of lumbar disc herniation

BackgroundsAlthough open lumbar discectomy is a gold standard surgical technique for lumbar disc herniation (LDH), surgery-induced tissue injury may actually become a source of postsurgical pain. Percutaneous endoscopic lumbar discectomy (PELD) is introduced as a minimal invasive spinal technique for LDH. The PELD has gained popularity and shown successful results. The authors report the clinical usefulness of the PELD technique in two patients with the serial multilevel LDHs.Case presentationsA 32-year-old man suffered from radicular pain at the L5 dermatome due to the down migrated soft LDH at the L4–5 level. The PELD was performed to remove the ruptured fragments, yielding a complete decompression of the L5 nerve root. Four years later, he visited the clinic because of right leg radiating pain along the S1 dermatome. An MRI scan revealed the LDH at the L5-S1 level. The PELD with foraminoplasty was also performed successfully at the L5-S1 level. Two months after the second PELD, he visited the clinic again because of severe pain along the left L4 dermatome; consequently, the PELD was also performed at the L3–4 level without any complications. A 34-year-old man presented with radiating pain in the back and both legs at the L5 dermatome. The MR images show a disc extrusion at the L4–5. The patient underwent the PELD at the L4–5 via the left approach. After the PELD, the back and leg pain both improved. One year later, the patient suffered from severe pain in the back and the left anterior thigh. The MR images show a left paramedian LDH at the L2–3. After the PELD was performed at the L2–3, the pain was relieved. The final MR images show no signs of any aggravated degeneration of the intervertebral discs or the facet joints at all of the treated levels.ConclusionWhen multiple episodes of LDH occur in a patient’s life span, PELD could be considered as an alternative good technique to treat LDH in each step by preserving normal anatomic structures.

Usefulness of Percutaneous Endoscopic Lumbar Foraminoplasty for Lumbar Disc Herniation

OBJECTIVE Endoscopic foraminoplasty facilitates engagement of the working cannula via the intervertebral foramen, allowing cannula access near a herniated disc (HD) for successful application of percutaneous endoscopic lumbar discectomy (PELD). The purpose of this study was to evaluate the efficacy of foraminoplasty for HD and propose applicable situations for foraminoplasty in PELD. METHODS A retrospective review of consecutive patients who underwent PELD was performed. Patients were divided into a foraminoplasty group (FG) and nonforaminoplasty group (NFG). Group differences in disc location and radiologic parameters, such as disc height (DH), foraminal width, lamina angle, facet angle, superior articular process thickness, and iliac height, were evaluated. Clinical outcomes were assessed using a visual analog scale for back and leg pain. RESULTS There were 136 patients (36 FG and 100 NFG) were. The FG had a significantly smaller DH and higher prevalence of high-grade down migration, downward sequestration, and recurrent HD compared with the NFG. For HDs at the L5-S1 level, the FG had a significantly greater iliac crest height and smaller DH and foraminal width compared with the NFG. For central HDs, the FG had a wider lamina angle and smaller DH compared with the NFG. Improvements in back and leg pain were similar in the 2 groups. CONCLUSIONS Percutaneous endoscopic lumbar foraminoplasty may be effective for small DH, migration, sequestration, recurrent HD, HD in L5-S1 with a high iliac crest, and central HD with a wide lamina angle.

Minimally Invasive Oblique Lumbar Interbody Fusion with Spinal Endoscope Assistance: Technical Note

OBJECTIVE The purpose of this report is to describe the surgical methodology and effectiveness of minimally invasive oblique lumbar interbody fusion (OLIF) assisted by spinal endoscopy, which can treat disk herniation from the central to contralateral foramen. OLIF showed indirect decompression effects on reduction of spondylolisthesis and a foraminal widening effect on disk height restoration. METHODS In this study, the indirect decompression effect of OLIF was augmented by direct endoscopic decompression and spinal endoscopy for removal of herniated disk materials. RESULTS Twelve patients with confirmed degenerative lumbar stenosis, herniated lumbar disks, and degenerative spondylolisthesis were treated using OLIF with spinal endoscopic discectomy. Direct ventral decompression was achieved by removal of herniated disk materials. The symptoms of all patients improved postoperatively. CONCLUSIONS OLIF with spinal endoscopic discectomy can achieve neural decompression without additional posterior decompression and can be used as an alternative treatment in selected cases.

Effects of Percutaneous Sacroplasty on Pain and Mobility in Sacral Insufficiency Fracture.

Objective Sacral insufficiency fracture (SIF) contributes to severe low back pain. Prolonged immobilization resulting from SIF can cause significant complications in the elderly. Sacroplasty, a treatment similar to vertebroplasty, has recently been introduced for providing pain relief in SIF. The purpose of this study is to investigate the clinical short-term effects of percutaneous sacroplasty on pain and mobility in SIF. Methods This study is conducted prospectively with data collection. Sixteen patients (3 men and 13 women) with a mean age of 77.5 years (58 to 91) underwent sacroplasty. Patients reported visual analogue scale (VAS; 0–10) and Oswestry disability index (ODI; 0–100%) scores. VAS and ODI scores were collected preoperatively and again at one day, one month, and three months postoperatively. Questionnaires measuring six activities of daily living (ADLs) including ambulating, performing housework, dressing, bathing, transferring from chair, and transferring from bed were collected. Ability to perform ADLs were reported preoperatively and again at three months postoperatively. Results The mean preoperative VAS score (mean±SD) of 7.5±0.8 was significantly reduced to 4.1±1.6, 3.3±1.0, and 3.2±1.2 postoperatively at one day, one month, and three months, respectively (p<0.01). The mean ODI score (%) also significantly improved from 59±14 preoperatively to 15.5±8.2 postoperatively at one month and 14.8±8.8 at three months (p<0.01). All ADL scores significantly improved at three months postoperatively (p<0.01). Conclusion Percutaneous sacroplasty alleviates pain quickly and improves mobility and quality of life in patients treated for SIF.

Usefulness of Oblique Lumbar Magnetic Resonance Imaging for Nerve Root Anomalies and Extraforaminal Entrapment Lesions

Study Design A retrospective review of prospectively evaluated magnetic resonance (MR) images. Purpose Routine lumbar axial and sagittal MR images may not clearly demonstrate nerve root anomalies and entrapments in the extraforaminal region. Thus, lumbar extraforaminal lesions or nerve root anomalies may be underdiagnosed because of unfamiliar radiological anatomy. We aimed to investigate the clinical efficacy of our oblique magnetic resonance imaging (MRI) technique for diagnosing nerve root anomalies and entrapment lesions. Overview of Literature Evaluation of clinical usefulness of oblique lumbar MRI for nerve root anomalies and extraforaminal entrapment lesions. Methods In total, 162 patients (60 males and 102 females; mean age, 59.8±17.8 years) with suspected nerve root anomalies and entrapments in routine axial and sagittal MR images underwent unilateral or bilateral oblique lumbar T2-weighted MRI. The axial angle of the oblique image was parallel to the foramen. The oblique MRI findings of the symptomatic side were compared with those of the asymptomatic side in cases with unilateral pathologic lesions. Interobserver agreement was analyzed using kappa statistics. Results The following abnormal findings were obtained: nerve root entrapment due to foraminal stenosis in 82 cases; extraforaminal disk herniation in 29; conjoined nerve root in six; and foraminal bony cyst in one. Forty-three of the 46 patients experienced unilateral lateralizing symptoms, unilateral nerve root entrapment due to foraminal stenosis, herniated disk, and extraforaminal bony cyst compared with the asymptomatic contralateral side (p <0.05). Conclusions Our results suggest that oblique lumbar MRI is a simple and valuable modality for diagnosing anomalous lumbar nerve root lesions and entrapment.