In-Soo Oh

Preemptive multimodal analgesia for postoperative pain management after lumbar fusion surgery: a randomized controlled trial

PurposeTo assess the efficacy of a novel preemptive multimodal analgesic regimen for reducing postoperative pain and complications after primary lumbar fusion surgery. Preemptive multimodal analgesia is revealed to be an effective alternative to conventional morphine administration providing improved postoperative pain control with diminished side effects. However, an optimal regimen for spinal fusion surgery remains unknown.MethodsAfter Institutional Review Board approval, 80 patients who underwent primary lumbar 4–5 fusion surgery were randomly assigned to receive either only intravenous morphine or a preemptive multimodal (celecoxib, pregabalin, extended-release oxycodone, and acetaminophen) analgesic regimen. Postoperative pain and functional levels were measured by the visual analog scale (VAS) and Oswestry Disability Index (ODI), respectively, and intraoperative blood loss, postoperative Hemovac drain output, and nonunion rates were evaluated for complications.ResultsNo differences were observed in the patient demographics, intraoperative blood loss, postoperative Hemovac drain output, or nonunion rate between two groups. The VAS and ODI were lower at all postoperative time points, except the ODI on postoperative day 1 in patients randomized to receive the preemptive multimodal analgesic regimen. No major identifiable postoperative complications were observed in either treatment group.ConclusionsThe preemptive multimodal analgesic combination in this study appears to be safe and effective after lumbar fusion surgery.

Risk factors for adjacent segment degeneration after surgical correction of degenerative lumbar scoliosis

Background: Degenerative lumbar scoliosis surgery can lead to development of adjacent segment degeneration (ASD) after lumbar or thoracolumbar fusion. Its incidence, risk factors, morbidity and correlation between radiological and clinical symptoms of ASD have no consensus. We evaluated the correlation between the occurrence of radiologic adjacent segment disease and certain imperative parameters. Materials and Methods: 98 patients who had undergone surgical correction and lumbar/thoracolumbar fusion with pedicle screw instrumentation for degenerative lumbar scoliosis with a minimum 5 year followup were included in the study. We evaluated the correlation between the occurrence of radiologic adjacent segment disease and imperative patient parameters like age at operation, sex, body mass index (BMI), medical comorbidities and bone mineral density (BMD). The radiological parameters taken into consideration were Cobbs angle, angle type, lumbar lordosis, pelvic incidence, intercristal line, preoperative existence of an ASD on plain radiograph and magnetic resonance imaging (MRI) and surgical parameters were number of the fusion level, decompression level, floating OP (interlumbar fusion excluding L5-S1 level) and posterolateral lumbar interbody fusion (PLIF). Clinical outcomes were assessed with the Visual Analogue Score (VAS) and Oswestry Disability Index (ODI). Results: ASD was present in 44 (44.9%) patients at an average period of 48.0 months (range 6-98 months). Factors related to occurrence of ASD were preoperative existence of disc degeneration (as revealed by MRI) and age at operation (P = 0.0001, 0.0364). There were no statistically significant differences between radiological adjacent segment degeneration and clinical results (VAS, P = 0.446; ODI, P = 0.531). Conclusions: Patients over the age of 65 years and with preoperative disc degeneration (as revealed by plain radiograph and MRI) were at a higher risk of developing ASD.

Revision Surgery after Vertebroplasty or Kyphoplasty

Background We wanted to investigate the leading cause of failed vertebroplasty or kyphoplasty. Methods Twelve patients (10 females and 2 males) who underwent revision surgery after vertebroplasty or kyphoplasty were included. In 4 cases, vertebroplasty was done for two or more levels. Six cases with kyphoplasty were included. Through the retrospective review of the radiographic studies and medical record, we analyzed the etiology of the revision surgery. Results Uncontrolled back pain was the main clinical presentation. In 4 cases, neurological symptoms were noted, including one case with conus medullaris syndrome. The average time to the revision surgery after vertebroplasty or kyphoplasty was 15 months. Infection (4 cases) and progressive kyphosis with collapse (8 cases) were the causes for the revision. A solid pattern of inserted bone cement and bone resorption around the cement were noted in the all cases with progressive collapse and kyphosis. Conclusions Infection, misdiagnosis and progressive kyphosis were causes of the revision surgery after vertebroplasty and kyphoplasty. A solid pattern of accumulation of bone cement and peri-cement bone resorption might be related with the progressive collapse.

The Clinical Effect of Gait Load Test in Two Level Lumbar Spinal Stenosis

Study Design This study is a prospective, clinical study assessing the efficacy of selective decompression of the level responsible in a two-level stenosis in accordance with the neurological findings defined by the gait load test with a treadmill. Purpose To clarify the clinical features of multilevel lumbar spinal stenosis (LSS) regarding the neurological level responsible for the symptoms, neurogenic claudication, and outcomes of selective decompression. Overview of Literature Most spine surgeons have reported that multilevel compression of the cauda equina induces a more severe impairment of the nerve function than a single-level compression. However, the clinical effects of multilevel LSS on the cauda equine and nerve roots are unknown. Methods A total of 21 patients with lumbar spinal canal stenosis due to spondylosis and degenerative spondylolisthesis were selected. The level responsible for the symptoms in the two-level stenosis was determined from the neurological findings on the gait load test and functional diagnosis based on a selective nerve root block. All patients underwent a prospective, selective decompression at the level neurologically responsible only. The average follow-up period was 2.6 years (range, 1 to 6 years). The postsurgical outcome was defined using the Visual Analogue Scale (VAS) at the post-gait load test, 2 weeks after surgery, 3 months after surgery and at the last follow up. Results Before surgery, the mean threshold distance and mean walking tolerance was 34.3 m and 113 m, respectively. All patients had neurogenic claudication and 19 of the patients had cauda equina syndrome, including hypesthesia in 11 cases, muscle weakness in 5 cases and radicular pain in 7 cases. Selective nerve blocks to determine the level responsible for the lumbosacral symptoms in 2 cases revealed a mean VAS score of 7.1, 2.61, 3.04, and 3.47 at the post-gait load test, 2 weeks after surgery, 3 months after surgery and at the last follow up, respectively. All subjects underwent surgery. After the operation, neurogenic claudication with or without cauda equna syndrome subsided in all patients. Conclusions The gait load test allows an objective and quantitative evaluation of the gait characteristics of patients with lumbar canal stenosis and is useful for determining the appropriate level for surgical treatment.

Apoptosis in the Sequestrated Nucleus Pulposus Compared to the Remaining Nucleus Pulposus in the Same Patient

Study Design. Both sequestrated nucleus pulposus (SNP) and the remaining nucleus pulposus (RNP) were studied from the discs of the same patient to evaluate apoptosis using immunohistochemical staining. Objective. To compare apoptosis of the SNP and the RNP in the disc of the same patient. Summary of Background Data. Many studies have been conducted on the natural history and apoptosis of the herniated nucleus pulposus; however, apoptosis of the remaining nucleus cells, after removal of the sequestrated disc, in the same patient, has not been reported. Materials and Methods. Eight samples of SNP and RNP from the disc of the same patient were obtained. The TUNEL stain was performed to confirm the occurrence of apoptosis in disc cells. Immunohistochemistry staining and Western blot analysis were performed to determine the presence of proteins, including caspase-3,-8,-9, and Bid. Results. TUNEL-positive chondrocytes were identified in all of the SNP and RNP samples; the apoptotic index was 5.8 ± 1.9% and 5.9 ± 1.2%, respectively (P = 0.60). Caspase-3,-8,-9, and Bid were expressed in the SNP and the RNP of the cytoplasm and the nucleus by the immunohistochemical staining. The expression of active caspase-3,-8,-9, and Bid in the RNP of the disc and the SNP was different in each patient. Conclusion. The frequency of chondrocyte apoptosis in the SNP and the RNP was not different in the disc. The pathways involved in chondrocyte apoptosis of the SNP and the RNP differed among individuals and included intrinsic and/or extrinsic pathways.

Matrix metalloproteinase-3 on ligamentum flavum in degenerative lumbar spondylolisthesis.

Study Design. Human ligamentum flavum (LF) was examined for the activity level of matrix metalloproteinase-3 (MMP-3) in degenerative spondylolithesis (DS) patients using immunohistochemistry, Western blot, reverse transcriptase-polymerase chain reaction (RT-PCR), and quantitative real-time PCR. Objective. To investigate the hypothesis that the activity of MMP-3 is elevated in LF of DS patients, which might contribute to DS pathogenesis. Summary of Background Data. MMP-3 is a proteinase produced by connective tissue cells and is responsible for the degradation and modification of extracellular matrix molecules. MMP-3 activity has been established in articular cartilage, synovial membrane, and intervertebral discs, but not in the LF. Methods. The experimental group consisted of 18 patients with DS and the control group consisted of 18 patients with spinal stenosis (SS) without any instabilities. MMP-3 expression was measured with in situ using immunohistochemistry and both for mRNA and protein levels. Results. The MMP-3 positive cell ratio in the LF observed in DS patients was substantially higher than in SS patients (P = 0.030). In Western blot, the average optical density (OD) of MMP-3 was higher in LF of DS than of SS (P = 0.028). There was greater MMP-3 expression in DS patients as quantified by RT-PCR (P = 0.004). Conclusion. Our study shows that MMP-3 expression in the LF of DS patients was significantly higher than in SS patients. Increased MMP-3 expression may be associated with the degenerative changes of LF in DS patients comprising one of the mechanisms of pathogenesis in DS.

The Effect of Irradiation and Methylprednisolone in Spinal Cord Injured Rats

Study Design. This study investigated the outcome of combined therapy with irradiation and methylprednisolone (MP) after a traumatic spinal cord injury (SCI). Objective. To evaluate the neurologic outcomes as well as the antiapoptotic and anti-inflammatory effects on traumatic SCI in rats after combined therapy. Summary of Background Data. Although irradiation carries the risk of secondary SCI, it has been effective for the regeneration of the axons of nerve cells by reducing gliosis. Thus, to minimize apoptosis and irradiation risks after SCI, this study investigated the effects of steroid injections before irradiation. Methods. Thirty-two rats were used for the experimental procedure. After a traumatic SCI, they were divided into 4 groups of 8 rats each: (1) a control group that only had rats with a SCI (Group 1); (2) a group that received MP at 30 minutes, 6 hours and 24 hours, and then received irradiation 2 days after the SCI (Group 2); (3) a group that received MP at 30 minutes, and irradiation 2 days after the SCI (Group 3); and (4) a group that received irradiation 2 days after the traumatic SCI (Group 4). Results. The degree of recovery using the inclined plane climbing test was greatest in Group 2, followed by Group 3, Group 4, and Group 1. The cavitation lesions, Terminal Deoxynucleotidyl Transferase dUTP Nick End Labeling -positive apoptosis, glial fibrillary acidic protein-positive astrocyte count, and CC-1-positive oligodendrocyte count significantly decreased in the irradiated groups (Groups 2, 3, 4) compared to the control group (Group 1). In particular, they decreased considerably more in the group that received MP 3 times (Group 2) compared to the group that received MP only once (Group 3). Conclusion. These results suggest that the combined therapy was effective and might provide synergistic effects for neurologic recovery after a traumatic SCI.

Pure hyperextension injury of the lower lumbar spine with an ureteral impingement

IntroductionPure hyperextension thoracolumbar spinal fractures are unusual and occur primarily in patients with ankylosing spondylitis and diffuse idiopathic skeletal hyperostosis due to the rigidity of the spine.Material and methodsA 62-year-old female with osteoporosis presented with a significantly displaced fourth vertebral body fracture after being hit by a motorcycle. An imaging study showed widening of the vertebral height of L4 anteriorly with a horizontal fracture extending across the vertebral body. An in situ instrumented lumbar fusion from the second to fifth lumbar vertebrae was performed. Postoperatively, the patient complained of abdominal pain and difficulty in voiding. Computed tomography and intravenous pyelography showed that the right ureter was impinged between the fractured gaps of the vertebral body of L4.ResultsSolid bony union was obtained with surgical intervention.ConclusionsThis case reports a rare distractive extension injury in the lower lumbar spine with ureteral impingement. One should be aware of possible complications such as ureteral impingement following a pure hyperextension injury in the lower lumbar spine.

Thoracic Disc Herniation of the Adjacent Segment With Acutely Progressing Myelopathy

We report a case of a 66-year-old woman with progressing myelopathy. Her history revealed instrumented fusion from T10 to S1 for degenerative lumbar kyphosis and spinal stenosis. The plain radiographs showed narrowing of the intervertebral disc space with a gas shadow and sclerotic end-plate changes at T9-T10. Magnetic resonance imaging revealed a posterolateral mass compressing the spinal cord at the T9-T10 level. The patient was treated with a discectomy through the posterior approach combined with posterior instrumentation. The patients symptoms and myelopathy resolved completely after the discectomy and instrumented fusion. The thoracic disc herniation might have been caused by the increased motion and stress concentration at the adjacent segment.

Case Report: Lower Extremity Sparganosis in a Bursa

BackgroundSparganosis is a rare parasitic infection caused by the plerocercoid tapeworm larva of the genus Spirometra.Case DescriptionWe report the case of a 67-year-old man with a mass over the anteromedial surface of the proximal extremity of the tibia. We surgically excised a bursa containing Spirometra larvae.Literature ReviewSparganosis is a rare parasitic infection. We found no cases of lower extremity sparganosis combined with bursitis reported in the literature.Purposes and Clinical RelevanceSparganosis should be considered in the differential diagnosis of soft tissue tumors, especially among patients who frequently have consumed mountain water or raw snakes or frogs.