Seung Myung Lee

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.

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.

Strategies for Noncontained Lumbar Disc Herniation by an Endoscopic Approach : Transforaminal Suprapedicular Approach, Semi-Rigid Flexible Curved Probe, and 3-Dimensional Reconstruction CT with Discogram

OBJECTIVE The purpose of this study was to evaluate the efficacy of a transforaminal suprapedicular approach, semi-rigid flexible curved probe, and 3-dimensional reconstruction computed tomography (3D-CT) with discogram in the endoscopic treatment of non-contained lumbar disc herniations. METHODS The subjects were 153 patients with difficult, non-contained lumbar disc herniations undergoing endoscopic treatment. The types of herniation were as follows : extraforaminal, 17 patients; foraminal, 21 patients; high grade migration, 59 patients; and high canal compromise, 56 patients. To overcome the difficulties in endoscopic treatment, the anatomic structures were analyzed by 3D reconstruction CT and the high grade disc was extracted using a semi-rigid flexible curved probe and a transforaminal suprapedicular approach. RESULTS The mean follow-up was 18.3 months. The mean visual analogue scale (VAS) of the patients prior to surgery was 9.48, and the mean postoperative VAS was 1.63. According to Macnabs criteria, 145 patients had excellent and good results, and thus satisfactory results were obtained in 94.77% cases. CONCLUSION In a posterolateral endoscopic lumbar discectomy, the difficult, non-contained disc is considered to be the most important factor impeding the success of surgery. By applying a semi-rigid flexible curved probe and using a transforaminal suprapedicular approach, good surgical results can be obtained, even in high grade, non-contained disc herniations.

Minimally invasive percutaneous endoscopic 2 levels adjacent lumbar discectomy through 1 portal skin incision: Preliminary study

Background: Acute lumbar disc herniation can occur in every lumbar intervertebral disc space and in multiple levels simultaneously. In the cases of 2 levels adjacent lumbar disc herniations of severe unilateral radiculopathic leg pain caused by compression of the nerve roots, respectively, multiple incision or long incision is generally needed for simultaneous removal of disc fragment in 2 levels. Objectives: We proposed the minimally invasive one portal skin incision endoscopic discectomy is effective and safe method to treat 2 levels adjacent lumbar disc herniation. Materials and Methods: We have experimented total 8 cases of 2 levels adjacent lumbar disc herniation having unilateral radiculopathic pain respectively. All cases are 2 levels adjacent lumbar disc herniation. We have tried a percutaneous endoscopic transforaminal approach through minimal one portal skin incision and remove the two herniated disc materials in the adjacent levels. Results: The L2-L3 level was involved in 2 patients, L3-L4 level in 6 patients, while the L4-L5 level was involved in 7 patients, L5-S1 level in 1 patient. The mean follow-up was 18.5 months. The mean visual analogue score (VAS) of the patients prior to surgery was 7.75, and the mean postoperative VAS was 2.375. According to Macnab′s criteria, 3 patients had excellent results, 4 patients had good results, 1 patient had fair results, and no patient had a poor result; satisfactory results were obtained in 87.5% of the cases. Conclusion: The percutaneous endoscopic transforaminal approach through 1 skin portal incision could be effective surgical method in unilateral adjacent 2 levels lumbar disc herniation.

Symptomatic Myelopathy Caused by Ossification of the Yellow Ligament

Objective This study was performed to describe the clinical presentation, surgical outcome in patients with symptomatic myelopathy caused by ossification of the yellow ligament (OYL). Methods The authors reviewed consequent 12 patients in whom posterior decompressive laminectomies were performed for OYL from 1999 to 2005. Diagnostic imagings including simple radiographs, computed tomography and magnetic resonance images were performed in each case. The patients were reviewed to evaluate the clinical presentation, surgical outcome and complications of the operation. Results In all patients, OYL was located in the lower thoracic region and all patients presented with numbness on both limbs and pain. Among them, 5 patients presented with gait disturbance due to paraparesis and two patients had sphincter dysfunction. Decompressive laminectomy through a posterior approach using microscope resulted in improvement of symptoms in all patients, but, recovery was incomplete in a half of the patients. The mean postoperative Japanese orthopaedics association (JOA) score was 7.9 when compared with 4.9 in preoperative assessment and the mean recovery rate was 65%. Dural tear was noticed in four patients, so dural repair was performed, but there were no neurological deficits related to neural injury. Conclusion OYL is an uncommon cause of myelopathy but it can lead to debilitating thoracic myelopathy. Careful decompressive laminectomy can achieve favorable results.

Radiological analysis of symptomatic complications after bilateral laminotomy for lumbar spinal stenosis.

Objective The purpose of this study was to describe the various symptomatic complications following decompressive bilateral laminotomy for treating lumbar spinal stenosis. Methods Out of 878 patients who underwent decompressive laminotomy from 2006 through 2008, 178 patients who were able to be followed for a minimum of 24 months were included in this study. The mean age at the time of surgery was 64.4 years (range, 38-79), and the average follow-up period was 32.7 months. The development of symptomatic complications was observed using simple radiographs and MR imaging during the follow-up period. Imaging and clinical complications were focused on postoperative spondylolisthesis, disc herniation, and facet cysts, and were analyzed according to developmenttime, the degree of symptom, and their course. Results Postoperative simple radiographs revealed that eight out of 178 patients (4.4%) had developed symptomatic spondylolisthesis and six required an interbody fusion procedure. Five patients with disc herniation (2.8%) at the level of the decompressive bilateral laminotomy site underwent another operation within 24 months after the first surgery. In two patients, disc herniations developed within 1 month after surgery. Three (1.7%) out of 178 patients showed facet cysts but all symptoms were relieved by conservative treatment. Spontaneous regression of the cysts was observed during the follow-up period. Conclusions Although decompressive bilateral laminotomy for spinal stenosis is believed to effective and reduces the need for fusion, various symptomatic complications were observed after this procedure. It is important to be aware of the possibility for these various complications to improve the surgical outcome.

Comparison of the Results of Balloon Kyphoplasty Performed at Different Times after Injury

OBJECTIVE Balloon kyphoplasty is a minimally invasive procedure that is mainly performed for refractory pain due to osteoporotic compression fractures. The purpose of this study was to evaluate the results of balloon kyphoplasty performed at different times after an injury. METHODS In this retrospective study, the records of 99 patients who underwent one level of balloon kyphoplasty between January 2005 and December 2007 were reviewed. The patients were divided into three groups : 21 patients treated within 3 weeks of an injury (the acute group), 49 treated within 3 weeks to 2 months of an injury (the subacute group), and 29 patients treated at more than 2 months after an injury (the chronic group). Clinical outcomes were assessed using a visual analogue scale (VAS). In addition, modified MacNabs grading criteria was used to assess the subjective patient outcome. The radiology findings, including vertebral height restoration and procedure related complications, were analyzed based on the different time intervals after the injury. RESULTS Patients in all three groups achieved marked pain relief in terms of the VAS within 7 days of the procedure. Good or excellent results were achieved by most patients in all three groups. However, the height restoration, the main advantage to performing a balloon kyphoplasty, was not achieved in the chronic group. Moreover, evidence of complications including cement leakage was observed significantly less frequently in the subacute group compared to the other two groups. CONCLUSION Although balloon kyphoplasty is an effective treatment for osteoporotic compression fractures, with regard to pain relief, the subacute stage appears to be optimal for treating patients with a balloon kyphoplasty in terms of achieving the best outcomes with minimal complications.

Complete Cord Injury after Minimal Trauma in a Patient with Forestier's Disease Accompanying Ossification of the Posterior Longitudinal Ligament

Forestiers disease is a systemic rheumatological abnormality in which exuberant ossification occurs along ligaments throughout the body, but most notably the anterior longitudinal ligament of the spine. This disease is usually asymptomatic; however dysphagia, dyspnea, and peripheral nerve entrapment have all been documented in association with the disorder. We report a rare case of catastrophic neurologic damage caused by Forestiers disease accompanying ossification of the posterior longitudinal ligament.

A New Sling Technique in Cervical Radiculopathy Caused by Vertebral Artery Loop Compression

BACKGROUND A 52-year-old woman had a 20-month history of progressive radiating pain in the left arm and numbness on C7 dermatome. CASE DESCRIPTION On physical examination, left head rotation aggravated the radiculopathic pain. For an anatomic diagnosis of the vertebral artery and nerve root, magnetic resonance angiography was performed (computed tomography angiography was not possible because of her dye allergy history). Magnetic resonance angiography showed a left vertebral artery loop entering at the C6-7 intervertebral foramen. Surgical microvascular decompression was performed by an anterior cervical approach and the loop of the artery was fixed using a sling technique. Postoperative computed tomography angiography showed that the left vertebral artery was retracted anteriorly and the C7 nerve root was decompressed in the intervertebral foramen at the left C6-7 level. CONCLUSIONS The patients radiculopathic symptoms were improved and especially the aggravated pain by left head rotation subsided dramatically.