Young-Sul Yoon

Recollapse of previous vertebral compression fracture after percutaneous vertebroplasty

SummaryThis study was undertaken to investigate the incidence rate, characteristics, and predisposing factors associated with recollapse of the same vertebrae after percutaneous vertebroplasty (PVP). Recollapse of the same vertebra after PVP is the one of the complications of the procedure, and the incidence rate in our study was 3.21%. The most important predisposing factor was pre-operative osteonecrosis. Recollapse was not related to trauma.IntroductionPVP using polymethylmethacrylate has become a popular treatment for osteoporotic vertebral compression fracture. Recollapse of the same vertebrae after PVP has rarely been reported. This study was undertaken to investigate the incidence, characteristics, and predisposing factors associated with recollapse of the same vertebrae after PVP.MethodsEleven patients (seven females and four males; mean age, 69.91u2009±u20095.49xa0years), out of a total of 343 patients, developed recollapse of the same vertebra after PVP. The 11 patients who developed recollapse comprised the “recollapse group”, while the remaining 332 patients comprised the “well-maintained group”.ResultsPre-operative magnetic resonance imaging revealed that the incidence of osteonecrosis was significantly higher in the recollapse group than the well-maintained group (pu2009<u20090.05). The degree of re-expansion of the compressed vertebral body after PVP was significantly higher in the recollapse group than in the well-maintained group (pu2009<u20090.05).ConclusionsThe most important predisposing factor for recollapse was pre-operative osteonecrosis. Recollapse was not related to trauma. Osteoporotic vertebral compression fracture with osteonecrosis or pseudoarthrosis has been regarded as a relative indication for PVP; however, the findings of this study suggest that this disease category may be a relative contraindication for PVP.

Prevalence of osteoporosis in patients requiring spine surgery: incidence and significance of osteoporosis in spine disease.

SummaryThe purpose of this study is to evaluate the incidence of osteoporosis in patients requiring spine surgery. Among patients older than 50xa0years, the rate of osteoporosis in males was 14.5% and the rate osteoporosis in females was 51.3%. We strongly recommend an evaluation and treatment for osteoporosis in the patients requiring spine surgery, especially in females over 50xa0years old.IntroductionBecause lifespan is increasing, there is an increase in the incidence of osteoporosis in elderly spine surgery patients. The osteoporosis may adversely influence the fusion rate and the surgical outcome. The purpose of this study is to evaluate the incidence of osteoporosis in patients requiring spine surgery.MethodsA total of 1,321 patients underwent spine surgeries at our institute from January 1, 2005 to December 31, 2005. Among them, there were 562 patients (42.5%) younger than 50xa0years old, and 759 patients (57.6%) older than 50xa0years old. Prior to operation, we evaluated the patients for osteoporosis on both the femur head and lumbar spine by measuring the bone mineral density (BMD) by the dual-energy X-ray absorptiometry (DXA). Based on the World Health Organization (WHO) criteria for osteoporosis, we chose the T-score to determine normal (>−1), osteopenia (−1≥, >−2.5), and osteoporosis (≤−2.5). Among the 562 patients younger than 50xa0years, DXA was performed in 22 (3.9%) patients and there were 13 (2.3%) cases of osteopenia and 2 (0.3%) cases of osteoporosis.ResultsAmong 759 patients older than 50xa0years, DXA was performed on 516 (68.0%) patients, 193 males and 323 females. Among the male patients, there were 89 (46.1%) patients with osteopenia and 28 (14.5%) with osteoporosis. Among the female patients, there were 134 (41.4%) with osteopenia and 166 (51.3%) with osteoporosis. The incidence of osteoporosis was higher in female patients and significantly increased with increasing age. Among 759 patients older than 50xa0years, 676 patients underwent a major spine operation with or without fusion. Among these patients, DXA was performed in 446 (66.0%) patients and there were 207 (46.4%) patients with osteopenia and 139 (31.1%) with osteoporosis.ConclusionsThe patients over 50xa0year-old who need spine operation have osteoporosis often. In conclusion, the number of spine operations in elderly patients is increasing and the incidence of osteoporosis in spine surgery patients is also increasing. We strongly recommend an evaluation for osteoporosis and post-operative treatment for osteoporosis in patients over 50xa0years old, especially for female patients.

Spinal surgery in patients with end-stage renal disease undergoing hemodialysis therapy.

Study Design. Case series retrospective review. Objective. To present the surgical treatment guideline for spinal diseases with end-stage renal disease (ESRD) patients undergoing hemodialysis. Summary of Background Data. Treatment for spinal diseases with ESRD patients in is a special clinical challenge because of complex medical and clinical problems. Methods. We retrospectively reviewed 12 patients who underwent spinal surgeries among patients with chronic renal failure at our hospital from May 2000 to September 2007. The medical records and radiologic findings for these patients were reviewed and concomitant medical diseases, laboratory findings, pre- and postoperative care, clinical outcomes, and complications were investigated. Results. One patient died of pneumonia and sepsis 2 months after fusion surgery. Other postoperative complications included postoperative delirium in 3 patients and terminal ileitis and delayed primary spondylodiscitis in 1 patient each. There were no postoperative wound infections associated with the spinal surgery. The preoperative mean visual analogue scale score was 7.9 ± 0.61, which improved to 2.2 ± 1.25 at the time of final follow-up for 11 patients. Among 5 patients who underwent fusion surgery, solid bone fusion was achieved in only 3 patients and included those who underwent posterior lumbar interbody fusion with pedicle screw fixation. In 2 patients who underwent posterior lumbar interbody fusion with cage alone, solid fusion was not achieved. In 1 of 2 patients who underwent anterior cervical fusion with plating, solid fusion was achieved. The overall fusion rate was 57.1% in patients with ESRD undergoing hemodialysis. Conclusion. Spinal surgeries in ESRD patients undergoing hemodialysis can be performed with acceptable outcomes; however, the complication rates and mortality rates are relatively high and the fusion rate is low. To obtain a better outcome, multiple factors such as comorbid medical diseases, laboratory abnormalities, and osteoporosis should be carefully considered.

MAGNETIC RESONANCE IMAGING FINDINGS OF SUBSEQUENT FRACTURES AFTER VERTEBROPLASTY

OBJECTIVEThe biomechanical effect of injected cement has been considered as the cause of adjacent vertebral fracture (AVF) after vertebroplasty, but the clinical evidence supporting this hypothesis is still insufficient. METHODSWe retrospectively reviewed 33 patients with subsequent fractures among 278 patients who underwent percutaneous vertebroplasty at our hospital from January 2002 to December 2005. The bone marrow edema pattern of subsequent fractures on magnetic resonance imaging was analyzed in 33 patients. In addition, the relationship between the location and distribution pattern of inserted cement and site of subsequent fractures was investigated. RESULTSAmong 33 subsequent fractures, we found 13 cranial AVFs, 7 caudal AVFs, and 13 remote fractures. The incidence rate of AVFs was 7.3% of 273 patients. Among 33 subsequent vertebral fractures, 13 were cranial AVFs (Group 1), 3 were superior, 7 were inferior, and 3 were overall (23.1%, 53.8%, and 23.1%, respectively). Of 7 caudal AVFs (Group 2), 7 were superior (100%). In 13 remote fractures (Group 3), 10 were superior, 1 was inferior, 2 were overall (76.9%, 7.7%, and 15.4%, respectively). In AVFs, bone marrow edema appeared mainly toward injected cement (P = 0.005). When injected cement made a solid mass rather than interdigitation, the occurrence rate of cranial AVFs was high (P = 0.004). CONCLUSIONBone marrow edema of AVFs appeared significantly toward the previous injected cement. This phenomenon supports the idea that the biomechanical effect of injected cement is one of the causative factors which affect the occurrence of AVF after percutaneous vertebroplasty. In particular, when injected cement forms a solid mass rather than interdigitation, the risk of cranial AVF may increase.

Kyphoplasty versus vertebroplasty: restoration of vertebral body height and correction of kyphotic deformity with special attention to the shape of the fractured vertebrae.

Study Design Retrospective comparative analysis. Objective We analyzed kyphosis correction, vertebral height restoration, and bone cement leakage in patients treated by vertebroplasty (VP) and kyphoplasty (KP) to compare the effectiveness of VP and KP for the treatment of osteoporotic vertebral compression fractures. Summary of Background Data Superior results have been reported for the use of KP for kyphotic deformity correction and collapsed vertebral height restoration. However, there are no previous comparative reports comparing the efficacy of KP versus VP according to the shapes of fractured vertebrae. Methods A total of 103 patients underwent either VP (n=58) or KP (n=45) for treatment of osteoporotic vertebral compression fracture between October 2006 and September 2009. We organized the patients into 6 groups according to treatment method and fracture type: VP (wedge‐shaped), VP (V‐shaped), VP (flat‐shaped), KP (wedge‐shaped), KP (V‐shaped), and KP (flat‐shaped). Comparisons were performed for kyphosis correction, vertebral height restoration, and cement leakage between VP and KP groups. Results KP was more effective than VP, especially for middle column height restoration and bone cement leakage prevention, for all fracture types (P value <0.05). In addition, KP was more effective in anterior height restoration and kyphosis correction in both flat and wedge‐shape fractures (P value <0.05). However, posterior column vertebral height was not restored in either the KP group or the VP group. The clinical outcomes did not differ between the 2 groups (P value >0.05). Conclusions KP has a significant advantage over VP in terms of kyphosis correction, vertebral height restoration, and cement leakage prevention. KP has an obvious advantage in terms of middle vertebral height restoration and cement leakage prevention, especially for V‐shape compression fractures.

Clinical approach and surgical strategy for spinal diseases in pregnant women: a report of ten cases

Study Design. Case series retrospective review. Objective. To present the treatment guideline for spinal diseases in pregnant women. Summary of Background Data. Treatment for spinal diseases in pregnant women is a special clinical challenge because of complex medical and surgical clinical problems. Methods. We retrospectively reviewed 10 patients who underwent surgery for spinal diseases, who were diagnosed during pregnancy at our hospital from February 1992 to October 2005. Six patients had herniated lumbar discs, 3 patients had spinal tumors, and 1 patient had spinal tuberculosis. Results. Five patients with HLDs underwent partial hemilaminectomy and discectomy during pregnancy and maintained the pregnancy. One patient underwent posterior lumbar interbody fusion and had a therapeutic abortion 6 days after lumbar surgery. In 1 patient with hemangioblastoma at the level of T8–T9 level, prepartum surgery was performed maintaining pregnancy in gestational age, 29 weeks. In another patient with hemangioblastoma at the T10 level, a preoperative cesarean section and tumor removal surgery were performed under the same anesthesia in gestational age 34 weeks. One patient had recurrent intramedullary ependymoma at the C3–T2 level. She had the preterm baby by vaginal delivery before spinal operation in gestational age 33 weeks and underwent tumor removal surgery. One patient with tuberculous spondylitis at the level of T3–T5 level, therapeutic abortion performed in gestational age, 16 weeks because of inevitable radiation exposure during fusion surgery. Conclusion. In most spinal diseases, including HLD and tumors, prepartum surgical treatment can be safely performed maintaining pregnancy. For patients with progressive neurologic deficit at 34 to 36 weeks gestation or later, spine surgery should be performed following the induction of delivery or a cesarean section, or at the same time.

Pre-operative embolisation of internal carotid artery branches and pial vessels in hypervascular brain tumours

SummaryBackground. Pre-operative embolisation is an effective method used to reduce intra-operative bleeding and operative difficulty in hypervascular brain tumour surgery. However, embolisation of the internal carotid artery (ICA) and pial tumour feeding branches has certain limitations.n Methods. From March 2000 to November 2006, 8 patients underwent superselective embolisation for hypervascular brain tumour. Seven tumours were extra-axial (6 meningiomas, 1 solitary fibrous tumour) and 1 was intra-axial (metastatic hepatocellular carcinoma).n Results. In all patients, feeding vessels from ICA branches or pial arteries were successfully embolised using superselective microcatheterisation. A provocative test was applied in 4 patients who had tumours adjacent to the motor cortex. Angiographic devascularisation was slight to extensive. Mean devascularisation on post-embolisation MRI ranged from 40 to 80% (mean 63.8%). One patient (12.5%) suffered an embolisation-related complication (loss of choroidal brush), but was not clinically worse because of the pre-existing blindness.n Conclusions. Superselective embolisation of ICA branches or pial vessels should be performed if several conditions are met, especially angiographic findings, pre-existing neurologic deficits, provocative test, and technical feasibility. If the ICA embolisation for hypervascular tumour is successfully achieved, the bleeding loss and operative risk can be reduced.

Surgical Treatments for Lumbar Disc Disease in Adolescent Patients; Chemonucleolysis / Microsurgical Discectomy / PLIF with Cages

The herniated lumbar disc (HLD) in adolescent patients is characterized by typical discogenic pain that originates from a soft herniated disc. It is frequently related to back trauma, and sometimes it is also combined with a degenerative process and a bony spur such as posterior Schmorls node. Chemonucleolysis is an excellent minimally invasive treatment having these criteria: leg pain rather than back pain, severe limitation on the straight leg raising test (SLRT), and soft disc protrusion on computed tomography (CT). Microsurgical discectomy is useful in the cases of extruded or sequestered HLD and lateral recess stenosis due to bony spur because the nerve root is not decompressed with chymopapain. Spinal fusion, like as PLIF, should be considered in the cases of severe disc degeneration, instability, and stenosis due to posterior central bony spur. In our study, 185 adolescent patients, whose follow-up period was more than 1 year (the range was 1 - 4 years), underwent spinal surgery due to HLD from March, 1998 to December, 2002 at our institute. Among these cases, we performed chemonucleolysis in 65 cases, microsurgical discectomy in 94 cases, and posterior lumbar interbody fusion (PLIF) with cages in 33 cases including 7 reoperation cases. The clinical success rate was 91% for chemonucleolysis, 95% for microsurgical disectomy, and 89% for PLIF with cages, and there were no nonunion cases for the PLIF patients with cages. In adolescent HLD, chemonucleolysis was the 1st choice of treatment because the soft adolescent HLD was effectively treated with chemonucleolysis, especially when the patient satisfied the chemonucleolysis indications.