• Journal of Korean Neurosurgical Society
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• v.41 no.3
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• pp.161-165
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• 2007

Objective : Percutaneous approach to the middle thoracic vertebra through the transpedicular route for the patients with osteoporotic vertebral compression fractures is difficult due to the small size of the pedicle and parasagittally oriented vertebra body anatomy. The percutaneous vertebral body access [PVBA] technique utilizing the posterolateral extrapedicular approach avoids the pedicle and provides direct access to the vertebral body. The objective of this study is to evaluate the efficacy of the vertebroplasty utilizing PVBA technique for osteoporotic vertebral compression fractures in the middle thoracic vertebrae. Methods : A retrospective review was done on 20 patients who underwent vertebroplasty utilizing PVBA technique performed for painful osteoporotic compression fracture in the middle thoracic vertebrae at 22 levels from May 2003 to June 2006. The average amount of the injected cement was 1.5-2.5ml. The postprocedural outcome was assessed using a visual analogue scale [VAS]. Results : The treated vertebrae were T5 [1 level], T6 [5 levels], 17 [7 levels], and T8 [9 levels]. The compression rate and kyphotic angle were improved after procedure from $18%{\pm}13.4$ to $16%{\pm}13.8$ [p > 0.05] and from $6.9^{\circ}{\pm}6.7$ to $6.6^{\circ}{\pm}6.2$ [p>005], respectively. Preprocedural VAS was $8.2{\pm}0.70$ and was decreased to $2.1{\pm}1.02$ [p < 0.01] after treatment. Postprocedural cement leakage was noted in 3 levels [13.7%]. There were no cases of leakage to epidural space or neural foramen, segmental artery injury, and pneumothorax. Conclusion : These results suggest that the complication rates are low and good results can be achieved with vertebroplasty utilizing PVBA technique for the osteoporotic vertebral compression fractures especially in the middle thoracic vertebrae.

• The Korean Journal of Pain
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• v.18 no.2
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• pp.142-145
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• 2005

Background: Vertebroplasty that is performed in the upper and middle thoracic spine presents technical challenges that are different from those in the lower thoracic or lumbar region due to the small pedicle size and angular severity for thoracic kyphosis. We report the results of percutaneous vertebroplasty and review its effectiveness in treating intractable osteoporotic compression fractures in the upper and middle thoracic spine. Methods: Patients who underwent vertebroplasty due to painful osteoporotic compression fractures at T3 T8 were retrospectively analyzed. The compression rate, volume of injected cement, clinical outcome (VAS score) and complications were analyzed. Results: Forty-three vertebral bodies from 41 patients (32 females and 9 males, age from 64 to 78 years old) underwent vertebroplasty. The mean compression rate improved from 35% to 17%. Bipedicular injections of bone cement were performed at 3 levels of 2 patients, and unipedicular injections were performed in 40 levels of 39 patients. The mean VAS score prior to surgery was 7.7, which improved to 2.4 within 48 hours after surgery, and the mean VAS score after 6 months was 1.5, which was significantly lower. All patients recovered uneventfully, and the neurological examination revealed no deficits. Cement leakage to the adjacent disc (9 levels) and paravertebral soft tissues (10 levels) developed. However, there were no significant complications related to the procedure such as a pneumothorax or pulmonary embolism. Conclusions: Transpedicular vertebroplasty is a safe and effective treatment for the upper and middle thoracic regions, and has a low complication rate.

• Journal of Korean Neurosurgical Society
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• v.29 no.5
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• pp.615-622
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• 2000

Objective : Percutaneous vertebroplasty is an effective and minimally invasive procedure consisting of the injection of a PMMA(polymethyl methacrylate) into the vertebral body compression fracture with osteoporosis. Matherials and Methods : Twenty-eight procedures were performed for vertebral body compression fractures with osteoporosis in 25 patients(22 women, 3 men). The mean age was 65.9 years old. The inclusion criteria for percutaneous vertebroplasty were 1) acute vertebral body compression fracture with osteoporosis, 2) expected high operative morbidity in old age, 3) no neurologic deficits, 4) no or minimal canal enchroachment, 5) patient refusal of invasive surgery. All patients underwent MR images before the procedure. Under local anesthesia, after the percutaneous needle puncture of the involved vertebra via a transpedicular approach and venography using the water soluble contrast material, PMMA injection was introduced into the fractured vertebral body. Results : The procedure was technically successful in all patients. All patients experienced excellent pain relief (complete pain relief ; 10, marked pain relief ; 14). One patient experienced marked pain relief, however, the patient died during the follow-up period due to stomach cancer. There were twelve paravertebral tissue leaks, twelve paravertebral venous plexus leaks, four epidural leaks and one intradiskal leak, but no clinically significant complications occurred in all patients. Conclusion : Percutaneous vertebraoplasty is a valuable procedure in the treatment of vertebral body compression fracture with osteoporosis, providing immediate pain relief and early mobilization. MRI is the most reliable diagnostic tool for identifying painful fractured vertebral body.

• Journal of Korean Neurosurgical Society
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• v.38 no.4
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• pp.265-268
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• 2005

Objective : With the increasing popularity of pedicle screw fixation devices for several indications, the safety and reliability of screw insertion in the small pedicle has become a major issue. Many studies have investigated the accuracy of screw placement after pedicle screw fixation using various method. The reported displacement rates have been very different. The purpose of the study is to investigate the proper placement of pedicle screw insertion in the lumbar spine on 26 consecutive patients. Methods : Between September and December 2003, 26 consecutive patients [16women and 10men] were analyzed after transpedicular screw fixation of the lumbar and lumbosacral spine. After pedicle screw fixation in this study, 2-mm slices of CT scan were performed in all patients to detect caudal and cranial deviation of screw and medial and lateral deviation. Pedcile screw placement related complication was evaluated clinically. Results : A total of 144 inserted pedicle were analyzed in 26patients, and 58pedicle screws [40.3%] were detected to be improper placement. There were 14level [9.0%] of caudal or cranial deviation and 44level [30.6%] of medial or lateral deviation to the pedicle. Extra-pedicle placement was found on 4levels [2.7%] with only lease of neurologic injury. Conclusion : Proper screw placement, though complication rate is low, is important not only for clinical symptom but also for biomechanics. Further study for screw placement related biomechanical changes is needed.

• Journal of Korean Neurosurgical Society
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• v.29 no.9
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• pp.1262-1266
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• 2000

Objective : Flat back syndrome constitutes a syndrome complex characterized by the loss of normal lumbar lordosis. Various techniques of correction for flat back syndrome have been reported. Posterior extension osteotomy has certain drawbacks. Forceful hyperextension of the spine may result in vascular complications such as rupture of the aorta or the inferior vena cava and stretching of superior mesenteric artery, and pseudoarthrosis. We describe a rationale and technique of transvertebral posterior extension osteotomy to avoid complications of posterior extension osteotomy and to achieve an correction of 30 degrees of flat back syndrome. Method : A 63-year-old woman with degenerative lumbar kyphosis presented with low back pain, thigh pain, knee pain and walking difficulty. Transpedicular fixation from L1 vertebra to S1 vertebra was accomplished for lumbar degenerative kyphosis. After 6 months, the patient presented with flat back syndrome. A second operation was performed with transvertebral posterior extension osteotomy. Result : With short segemental fusion, early bone fusion and correction of 30 degrees were achieved. Conclusion : Transvertebral posterior extension osteotomy provide an 30-60 degrees of correction of flat back syndrome. This technique is considered to be good method for the revision of lumbar degenerative kyphosis.

• Journal of Korean Neurosurgical Society
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• v.42 no.1
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• pp.6-10
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• 2007

Objective : The purpose of this study was to determine the effect of bone cement augmentation of pedicular screwing in severe osteoporotic spondylolisthetic patients. Methods : Twenty patients with spondylolisthesis (8 : spondylolytic spondylolisthesis 12 : degenerative spondylolisthesis) who had undergone pedicular screwing and interbody fusion for osteoporotic lumbar spine (T-score on bone mineral density<-3.0) from 2002 to 2005 were reviewed. Mean age was 62.3 years with 3 male and 17 female patients. Average follow-up period was 14 months. Average T-score on bone mineral density (BMD) was -3.62. After decompression of neural elements, about 6cc of polymethylmethacrylate (PMMA) was injected into the each vertebral body through transpedicular route. All patients underwent one level interbody fusion and pedicular screw fixation. Clinical outcome was assessed using Oswestry Disability Index (ODI) on the last clinical follow-up. In addition, a modified MacNab's grading criteria was used to objectively assess patient's outcome postoperatively. Radiographic analysis of sagittal contour was assessed preoperatively, immediately postoperatively, and at final follow-up including fusion rate. Results : Eighteen of 20 patients were graded as excellent or good according to the modified MacNab's criteria. An significant improvement of ODI was achieved in both groups. Mean sagittal angle at the preoperative state, postoperative state and at the last follow-up state was $11.0^{\circ},\;20.1^{\circ}$ and $18.3^{\circ}$, respectively, with mean sagittal angle correction gain $7.3^{\circ}$. Firm fusion was achieved in all patients. There were one compression fracture above the fused segment after 6 months follow-up and one case of seroma. But there were no postoperative complications related to bone cement leakage and pedicular screwings such as screw pullout or screw cut-up. Conclusion : Bone cement augmentation of pedicular screwing can be an effective procedure for osteoporotic lumbar spine in spondylolisthetic patients.

• Journal of Korean Neurosurgical Society
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• v.48 no.1
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• pp.37-45
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• 2010

Objective : Craniovertebral junction (CVJ) consists of the occipital bone that surrounds the foramen magnum, the atlas and the axis vertebrae. The mortality and morbidity is high for irreducible CVJ lesion with cervico-medullary compression. In a clinical retrospective study, the authors reviewed clinical and radiographic results of occipitocervical fusion using a various methods in 32 patients with CVJ instability. Methods : Thirty-two CVJ lesions (18 male and 14 female) were treated in our department for 12 years. Instability resulted from trauma (14 cases), rheumatoid arthritis (8 cases), assimilation of atlas (4 cases), tumor (2 cases), basilar invagination (2 cases) and miscellaneous (2 cases). Thirty-two patients were internally fixed with 7 anterior and posterior decompression with occipitocervical fusion, 15 posterior decompression and occipitocervical fusion with wire-rod, 5 C1-2 transarticular screw fixation, and 5 C1 lateral mass-C2 transpedicular screw. Outcome (mean follow-up period, 38 months) was based on clinical and radiographic review. The clinical outcome was assessed by Japanese Orthopedic Association (JOA) score. Results : Nine neurologically intact patients remained same after surgery. Among 23 patients with cervical myelopathy, clinical improvement was noted in 18 cases (78.3%). One patient died 2 months after the surgery because of pneumonia and sepsis. Fusion was achieved in 27 patients (93%) at last follow-up. No patient developed evidence of new, recurrent, or progressive instability. Conclusion : The authors conclude that early occipitocervical fusion to be recommended in case of reducible CVJ lesion and the appropriate decompression and occipitocervical fusion are recommended in case of irreducible craniovertebral junction lesion.

• Journal of Korean Neurosurgical Society
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• v.50 no.5
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• pp.441-445
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• 2011

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.

• Journal of Korean Neurosurgical Society
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• v.46 no.4
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• pp.317-321
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• 2009

Objective : In the thoracic spine, insertion of a pedicle screw is annoying due to small pedicle size and wide morphological variation between different levels of the spine and between individuals. The aim of our study was to analyze radiologic parameters of the pedicle morphometry from T1 to T8 using computed tomographic myelography (CTM) in Korean population. Methods : For evaluation of the thoracic pedicle morphometry, the authors prospectively analyzed a consecutive series of 26 patients with stable thoracic spines. With the consent of patients, thoracic CTM were performed, from T1 to T8. We calculated the transverse outer diameters and the transverse angles of the pedicle, distance from the cord to the inner cortical wall of the pedicle, and distance from the cord to the dura. Results : Transverse outer pedicle diameter was widest at T1 ($7.66{\pm}2.14\;mm$) and narrowest at T4 ($4.38{\pm}1.55\;mm$). Transverse pedicle angle was widest at T1 ($30.2{\pm}12.0^{\circ}$ and it became less than $9.0^{\circ}$ below T6 level. Theoretical safety zone of the medial perforation of the pedicle screw, namely, distance from the cord to inner cortical wall of the pedicle was more than 4.5 mm. Conclusion : Based on this study, we suggest that the current pedicle screw system is not always suitable for Korean patients. Computed tomography is required before performing a transpedicular screw fixation at the thoracic levels.

• Journal of Korean Neurosurgical Society
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• v.29 no.3
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• pp.365-371
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• 2000

Objectives : To describe a technique for percutaneous vertebroplasty of osteoporotic vertebral body compression fractures and to report preliminary results of its use. Methods : The technique was used over a 8-month period in 9 patients with 10 painful vertebral fractures. The technique involves percutaneous puncture of the involved vertebrae with a Jamshidi needle via a transpedicular approach followed by injection of polymethylmethacrylate(PMMA) into the vertebral body. Results : The procedure was technically successful in all patients, with an average injection amount of 5.9 cc per vertebral body. One patient complained of flank pain postoperatively in spite of improvement in back pain caused by the fractured vertebra. Remaining eight patients reported significant pain relief early after treatment. The patients were followed up for 3 to 15 months(average 7.2 months) and demonstrated no recurrence of pain or aggravation of deformity. Conclusion : Vertebroplasty appears to be a valuable tool in the treatment of painful osteoporotic vertebral fractures, providing acute pain relief and early mobilization in appropriate patients. However, it needs to have more extensive prospective clinical study to confirm its definitive role in the management of this condition.