Ho Shin

Endoscopic Discectomy for the Cauda Equina Syndrome During Third Trimester of Pregnancy

Low back pain is common during pregnancy. However, the prevalence of symtomatic lumbar disc herniation is rare, and cauda equina syndrome due to disc herniation during pregnancy is even rarer. We report a rare case of lumbar disc herniation causing cauda equina syndrome during third trimester of pregnancy which successfully treated by endoscopic discectomy. This case shows that endoscopic discectomy can be the treatment option for the lumbar disc herniation during pregnancy.

Primary Intradural Extraosseous Ewing's Sarcoma.

Ewings sarcoma usually arises from skeletal bone, but rarely may have an extraskeletal origin. However, Ewings sarcoma that originates around the spinal column, especially, the intradural extramedullary type is extremely rare. We report a rare case of primary intraspinal extraskeletal Ewings sarcoma.

Sacral perineural cyst accompanying disc herniation.

Although most of sacral perineural cysts are asymptomatic, some may produce symptoms. Specific radicular pain may be due to distortion, compression, or stretching of nerve root by a space occupying cyst. We report a rare case of S1 radiculopathy caused by sacral perineural cyst accompanying disc herniation. The patient underwent a microscopic discectomy at L5-S1 level. However, the patients symptoms did not improved. The hypesthesia persisted, as did the right leg pain. Cyst-subarachnoid shunt was set to decompress nerve root and to equalize the cerebrospinal fluid pressure between the cephalad thecal sac and cyst. Immediately after surgery, the patient had no leg pain. After 6 months, the patient still remained free of leg pain.

The Role of Bone Cement Augmentation in the Treatment of Chronic Symptomatic Osteoporotic Compression Fracture

OBJECTIVE Bone cement augmentation procedures such as percutaneous vertebroplasty and balloon kyphoplasty have been shown to be effective treatment for acute or subacute osteoporotic vertebral compression fractures. The purpose of this study was to determine the efficacy of bone cement augmentation procedures for long standing osteoporotic vertebral compression fracture with late vertebral collapse and persistent back pain. METHODS Among 278 single level osteoporotic vertebral compression fractures that were treated by vertebral augmentation procedures at our institute, 18 consecutive patients were included in this study. Study inclusion was limited to initially, minimal compression fractures, but showing a poor prognosis due to late vertebral collapse, intravertebral vacuum clefts and continuous back pain despite conservative treatment for more than one year. The subjects included three men and 15 women. The mean age was 70.7 with a range from 64 to 85 years of age. After postural reduction for two days, bone cement augmentation procedures following intraoperative pressure reduction were performed. Imaging and clinical findings, including the level of the vertebra involved, vertebral height restoration, injected cement volume, local kyphosis, clinical outcome and complications were analyzed. RESULTS The mean follow-up period after bone cement augmentation procedures was 14.3 months (range 12-27 months). The mean injected cement volume was 4.1 mL (range 2.4-5.9 mL). The unipedicular approach was possible in 15 patients. The mean pain score (visual analogue scale) prior to surgery was 7.1, which decreased to 3.1 at 7 days after the procedure. The pain relief was maintained at the final follow up. The kyphotic angle improved significantly from 21.2 ± 4.9° before surgery to 10.4 ± 3.8° after surgery. The fraction of vertebral height increased from 30% to 60% after bone cement augmentation, and the restored vertebral height was maintained at the final follow up. There were no serious complications related to cement leakage. CONCLUSION In the management of even long-standing osteoporotic vertebral compression fracture for over one year, bone cement augmentation procedures following postural reduction were considered safe and effective treatment in cases of non-healing evidence.

Minimally Invasive Multi-Level Posterior Lumbar Interbody Fusion Using a Percutaneously Inserted Spinal Fixation System : Technical Tips, Surgical Outcomes

OBJECTIVE There are technical limitations of multi-level posterior pedicle screw fixation performed by the percutaneous technique. The purpose of this study was to describe the surgical technique and outcome of minimally invasive multi-level posterior lumbar interbody fusion (PLIF) and to determine its efficacy. METHODS Forty-two patients who underwent mini-open PLIF using the percutaneous screw fixation system were studied. The mean age of the patients was 59.1 (range, 23 to 78 years). Two levels were involved in 32 cases and three levels in 10 cases. The clinical outcome was assessed using the visual analog scale (VAS) and Low Back Outcome Score (LBOS). Achievement of radiological fusion, intra-operative blood loss, the midline surgical scar and procedure related complications were also analyzed. RESULTS The mean follow-up period was 25.3 months. The mean LBOS prior to surgery was 34.5, which was improved to 49.1 at the final follow up. The mean pain score (VAS) prior to surgery was 7.5 and it was decreased to 2.9 at the last follow up. The mean estimated blood loss was 238 mL (140-350) for the two level procedures and 387 mL (278-458) for three levels. The midline surgical scar was 6.27 cm for two levels and 8.25 cm for three level procedures. Complications included two cases of asymptomatic medial penetration of the pedicle border. However, there were no signs of neurological deterioration or fusion failure. CONCLUSION Multi-level, minimally invasive PLIF can be performed effectively using the percutaneous transpedicular screw fixation system. It can be an alternative to the traditional open procedures.

Clinical efficacy of bone cement augmented screw fixation for the severe osteoporotic spine.

Objective Transpedicular instrumentation of the osteoporotic spine is a challenge for the spine surgeon due to the probability of screw loosening and the potential possibility of nonunion. The purpose of this study was to evaluate the clinical efficacy of bone cement augmented screw fixation in patients with severe osteoporosis. Methods Between February 2004 and August 2007, 250 patients with severe osteoporosis (T-score on BMD < -3.0) that had screw fixation were included in this study. The patients were divided into two groups (Group I: 157 patients that underwent bone cement augmented screw fixation that had a variety of spine spinal diseases including fractures, and Group II: 93 patients with severe osteoporosis that had screw fixation without bone cement augmentation). The imaging and clinical features were analyzed, including bone cement augmented levels, fusion rate and related complications. The visual analog scale (VAS), Oswestry disability questionnaire (ODI) and modified MacNabs criteria were used for the assessment of pain and functional capacity. Results In both groups, a significant improvement in the VAS and ODI was achieved. 146 out of 157 patients (93%) in Group I and 83 out of 93 patients (90%) in Group II were graded as an excellent or good result according to the modified MacNabs criteria. None of the patients experienced serious complications. However, there were two cases with neurological deterioration as a result of bone cement extravasation in Group I. For Group II, there were five cases of screw loosening that required re-operation for bone cement augmentation. Conclusion Whether bone cement augmentation was performed or not, it was possible to achieve satisfactory results in patients with severe osteoporosis. However, if used carefully, bone cement augmented transpedicular screwing can reduce screw loosening and pullout in patients with severe osteoporosis.

Combined anterior and posterior en bloc vertebrectomy for lumbar chordoma.

Chordoma is a rare bone tumor derived from remnants of the notochord. The majority of chordomas involve the sacrum or skull base. We report a rare case of a L4 vertebral body chordoma treated with anterior en bloc vertebrectomy and posterior stabilization. No tumor recurrence was observed at the 5 year follow-up examination.

Repeated migration of a fusion cage after posterior lumbar interbody fusion.

Although posterior lumbar interbody fusion (PLIF) is a widely accepted procedure, perioperative and postoperative complications are still encountered. In particular, cage migration can result in severe sequelae, and revision surgery is technically demanded. Here, we report a rare case of repeated migration of a fusion cage after PLIF. To the best of our knowledge, no report has been previously issued on repeated migration of a fusion cage after PLIF. The authors discuss the radiological and clinical findings of this unusual complication with a review of the literature.

Ligamentum Flavum Hematoma in the Adjacent Segment after a long Level Fusion.

Ligamentum flavum hematoma (LFH) is a very rare condition of dural compression; most are observed in the mobile cervical and lumbar spine regions. A 67-year-old man who had a long level interbody fusion at L3-S1 four years ago presented with symptoms suggestive of dural compression. Magnetic resonance imaging showed a posterior semicircular mass located at the adjacent L2-L3 level. After decompression of the spinal canal and removal of the mass lesion, pathological examination of the surgical specimen revealed a hematoma within the ligamentum. The patient fully recovered to normal status after surgery. Here, we report our experience with a LFH in the adjacent segment after a long level fusion procedure and discuss the possible associated mechanisms.

Isolated Spinal Neurocysticercosis : Unusual Ocular Presentation Mimicking Pseudotumor Cerebri

Spinal intradural cysticercosis is a rare manifestation of neurocysticercosis. We report a unique patient who showed visual symptoms and normal imaging of the brain caused by isolated spinal neurocysticercosis. A 59-year-old male patient was admitted to the emergency unit with a history of severe headache and progressive blurred vision. Brain computed tomographic scanning and magnetic resonance imaging showed normal cerebral anatomy without hydrocephalus. The fundoscopic evaluation by an ophthalmologist showed bilateral papilledema. Perimetry studies revealed visual field defects in both eyes. With the diagnosis of pseudotumor cerebri, a lumbar tap was attempted; however, we could not drain the cerebrospinal fluid in spite of appropriate attempts. Lumbar magnetic resonance imaging revealed multilevel intraspinal lesions that were confirmed histologically to be neurocysticercosis. An intraoperative lumbar puncture revealed an increased opening pressure and cytochemical analysis showed elevated cerebrospinal fluid protein level. The headache resolved immediately after surgery. However, the visual symptoms remained and recovered only marginally despite antihelminthic medications after six months of operation.