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Recent developments in tissue clearing methods such as the passive clearing technique (PACT) have allowed three-dimensional analysis of biological structures in whole, intact tissues, thereby providing a greater understanding of spatial relationships and biological circuits. Nonetheless, the issues that remain in maintaining structural integrity and preventing tissue expansion/shrinkage with rapid clearing still inhibit the wide application of these techniques in hard bone tissues, such as femurs and tibias. Here, we present an optimized PACT-based bone-clearing method, Bone-mPACT+, that protects biological structures. Bone-mPACT+ and four different decalcifying procedures were tested for their ability to improve bone tissue clearing efficiency without sacrificing optical transparency; they rendered nearly all types of bone tissues transparent. Both mouse and rat bones were nearly transparent after the clearing process. We also present a further modification, the Bone-mPACT+ Advance protocol, which is specifically optimized for processing the largest and hardest rat bones for easy clearing and imaging using established tissue clearing methods.

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Spinal intradural arachnoid cysts (SACs) account for approximately 10% of total arachnoid cysts, and iatrogenic attribution is rare. A 50-year-old male presented with low back pain and severe radiating pain in his right leg along the S1 dermatome. He had an interspinous device (ISD) inserted 10 years earlier. Plain radiographs showed breakage and angular movement of the ISD at L4/5. Magnetic resonance imaging (MRI) of the lumbosacral spine disclosed multiple intradural cystic tumors in the entire lumbar region. He underwent removal of the ISD, laminectomy, and resection of the intradural cyst. The pathologic finding of the cystic tumor was compatible with arachnoid cyst. Antibodies to parasites, including cysticercosis, were negative in both the serum and cerebrospinal fluid (CSF). The ventral surface of the implant was clearly broken.

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OBJECTIVE: In this study, we investigate about relationship between postoperative global sagittal imbalance and occurrence of mechanical complications after adult spinal deformity (ASD) surgery. In global sagittal balance parameters, odontoid-hip axis (OD-HA) angle and T1 pelvic angle (TPA) were analyzed. METHODS: Between January 2009 and December 2016, 199 consecutive patients (26 males and 173 females) with ASD underwent corrective fusion of more than 4 levels and were followed up for more than 2 years. Immediate postoperative and postoperative 2 years whole spine x-rays were checked for evaluating immediate postoperative OD-HA, TPA, and other parameters. In clinical outcomes, back and leg pain visual analogue scale, Scoliosis Research Society-22 spinal deformity questionnaire (SRS-22), Oswestry Disability Index (ODI), 36- item Short Form Health Survey (SF-36) were evaluated. RESULTS: Based on the occurrence of mechanical complications, a comparative analysis was performed for each parameter. In univariable analysis, mechanical complications were significantly much more occurred in OD-HA abnormal group (odds ratio [OR], 3.296; p < 0.001; area under the curve [AUC] = 0.645). In multivariable analysis, the result was much more related (OR, 2.924; p = 0.001; AUC = 0.727). In contrast, there was no significant difference between normal and the occurrence of mechanical complications in TPA. In clinical outcomes (normal vs. abnormal), the differences of SRS-22 (0.88 ± 0.73 vs. 0.68 ± 0.64, p = 0.042), ODI (-24.72 ± 20.16 vs. -19.01 ± 19.95, p = 0.046), SF-36 physical composite score (19.33 ± 18.55 vs. 12.90 ± 16.73, p = 0.011) were significantly improved in OD-HA normal group. CONCLUSION: The goal of ASD surgery is to improve patient life quality through correction. In our study, TPA was associated with spinopelvic parameter and OD-HA angle was associated with health-related quality of life and complications. OD-HA angle is predictable factor for mechanical complications after ASD surgery.

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Recent developments in tissue clearing methods have significantly advanced the three-dimensional analysis of biological structures in whole, intact tissue, providing a greater understanding of spatial relationships and biological circuits. Nonetheless, studies have reported issues with maintaining structural integrity and preventing tissue disintegration, limiting the wide application of these techniques to fragile tissues such as developing embryos. Here, we present an optimized passive tissue clearing technique (PACT)-based embryo clearing method, initial embedding PACT (IMPACT)-Basic, that improves tissue rigidity without compromising optical transparency. We also present IMPACT-Advance, which is specifically optimized for thin slices of mouse embryos past E13.5. We demonstrate proof-of-concept by investigating the expression of two relatively understudied PR domain (PRDM) proteins, PRDM10 and PRDM13, in intact cleared mouse embryos at various stages of development. We observed strong PRDM10 and PRDM13 expression in the developing nervous system and skeletal cartilage, suggesting a functional role for these proteins in these tissues throughout embryogenesis.

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STUDY DESIGN: Retrospective study. OBJECTIVES: Unilateral biportal endoscopic surgery (UBES) is a popular surgical method used to treat degenerative spinal diseases because of its merits, such as reduced tissue damage and outstanding visual capacity. However, dural injury is the most common complication of UBES with an incidence rate of 1.9% to 5.8%. The purpose of this study was to analyze the pattern of dural injury during UBES and to report the clinical course. METHODS: We retrospectively reviewed the medical and radiographic records of surgically treated patients who underwent UBES at a single institute between January 2018 and December 2019. RESULTS: Fifty-three patients, representing 67 segments, underwent UBES. Seven dural injuries occurred, and the incidence rate was 13.2%. Among 16 far lateral approaches, 2 dural injuries of the exiting roots occurred and were treated with fibrin sealant reinforcement. Among 51 median approaches, dural injury occurred at the thecal sac (n = 3) and traversing root (n = 2). A dural injury of the shoulder of the traversing root was treated with a fibrin sealant; however, a defect in the thecal sac required a revision for reconstruction. The other 2 thecal sac injuries were directly repaired via microscopic surgery. CONCLUSIONS: Dural injury during UBES can occur because of the various anatomical features of the meningo-vertebral ligaments. Direct repair of the central dural defect should be considered under microscopic vision. A linear tear in the lateral dura or root can be controlled with a simple patchy reinforcement under endoscopic vision.

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BACKGROUND: Transdural disc herniation (TDH) is a rare event accounting for 0.3-1.5% of all disc herniation cases. Considering the risk of leakage of the cerebrospinal fluid from the dural defect after removal of TDH or incomplete removal, it is very important to recognize TDH before surgery. This study is a retrospective case analysis to analyze the imaging findings of seven cases and to construct a preoperative prediction model for TDH. METHODS: Retrospective radiographic examination was performed among patients operated for TDH in two institutions from 2008 to 2018. The radiographic images were analyzed according to the following eight signs: including absence of dural tent, complete block of spinal canal, hawk-beak sign, double-layered lesion, increased distance between the dura and cauda equina, rim enhancement, dural tent enhancement, and epidural gas. To clarify the predictive ability of these radiographic signs, consecutive 131 surgically confirmed epidural disc herniation (EDH) patients for the last 2 years were set as a control group for TDH. The sum of radiographic findings was compared between TDH and EDH patients to determine the cutoff value. RESULTS: There were 1 thoracic and 6 lumbar TDHs among 75 thoracic and 6674 lumbar disc herniation cases with an incidence of 1.33% and 0.09%, respectively. Dural tent (p = 0.000, odds ratio = 106.67), double-layered lesion (p = 0.000, odds ratio = 22.69), and distance between the dura and cauda equina (p = 0.007, odds ratio = 52.00) were statistically significantly different between TDH and EDH. According to the receiver operating characteristic curve, the cutoff value of 1.5 had 85.7% sensitivity and 90.8% specificity. CONCLUSION: Preoperative imaging can be useful for TDH diagnosis. It is safe to consider the possibility of TDH in patients with more than two findings in the preoperative images.

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STUDY DESIGN: Retrospective case analysis. OBJECTIVE: This study was conducted to investigate the course of ossification of the posterior longitudinal ligament (OPLL) progression after laminoplasty (LP) or laminectomy with posterior fixation (PF). SUMMARY OF BACKGROUND DATA: LP is now recognized as a standard technique for the treatment of cervical multisegment OPLL; however, PF is beneficial for patients with severe stenosis. In recent years, there has been increasing interest in mechanical stress in OPLL, which is assumed to significantly impact progression. METHODS: The progression of OPLL was assessed using midline sagittal computed tomography images of the cervical spine at various follow-up points. Radiographic parameters including the C2-C7 Cobb angle, C2-C7 range of motion (ROM), and adjacent cranial and caudal segmental ROMs were measured. Postoperative changes and differences between the LP and PF groups in the radiographic parameters were calculated to assess biomechanical stress. Logistic regression analysis was used to analyze the risk factors affecting the progression rate. RESULTS: The authors included 14 PF and 36 LP patients, with a mean follow-up period of 28.9±20.8 and 37.6±16.8 months, respectively (P=0.069). After surgical treatment, both groups showed loss of cervical lordosis (9.2±6.9 vs. 5.3±8.2 degrees, P=0.220) and C2-C7 ROM (14.6± 13.5 vs. 13.1±12.2 degrees, P=0.861). The decrease of ROM in the cranial adjacent segment was larger in the LP group than in the PF group (0.7±4.1 vs. 1.4±5.5 degrees, P=0.453). The ROM in the caudal adjacent segment decreased in the LP group but increased in the PF group (-1.4±6.2 vs. 2.6±5.1 degrees, P=0.041). The progression rate was 2.15±1.31 mm/mo in the PF group and 1.53±1.04 mm/mo in the LP group (P=0.041). PF showed an odds ratio of 12.917 for a higher progression rate (95% confidence interval, 1.397-119.443; P=0.024). CONCLUSION: The rate of progression of cervical OPLL was significantly higher after PF than after LP.Level III-a retrospective analysis.

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BACKGROUND: We compared the outcomes of endovascular embolization and surgery and investigated the factors affecting the clinical outcomes of spinal intradural dorsal arteriovenous fistulas (SIDAVFs). METHODS: The medical records of 26 patients who had undergone endovascular embolization or surgery for SIDAVFs from 2004 to 2014 were retrospectively reviewed. The recurrence rate and clinical outcomes for each treatment modality were compared. Multivariate analysis was used to identify significant factors influencing the clinical outcomes using the Aminoff and Logue (AL) score. RESULTS: Of the 26 patients, 14 (56%) had undergone endovascular embolization and 11 (44%) had undergone surgery as the initial treatment. Embolization was applied as the primary treatment for most patients. Surgery was chosen for patients with difficult superselection (n = 5), multiple feeders (n = 2), or easy surgical accessibility (n = 4). Of the 14 patients who had undergone embolization as initial treatment, 5 (36%) had developed a recurrence within an average of 29.6 months (range, 2-87). One patient with recurrent SIDAVF was treated with repeat embolization and four with surgery. None of patients in the surgical group developed recurrence. Embolization as the initial treatment resulted in significantly greater recurrence compared with surgery (odds ratio, 2.222; 95% confidence interval, 1.369-3.608; P = 0.046). Surgery resulted in better clinical outcomes than embolization (P = 0.021). The final AL score was also strongly affected by the preoperative AL score, micturition score, and recurrence (P = 0.000, P = 0.000, and P = 0.011, respectively). CONCLUSIONS: Our results have shown that surgery results in a low recurrence rate and superior clinical outcomes. A multidisciplinary and ordered decision is crucial for the treatment choice to ensure better outcomes, especially for patients with a definite neurologic deficit at diagnosis.

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OBJECTIVE: To describe our experience in treating esophageal and pharyngeal perforation after anterior cervical spine surgery. METHODS: Six patients with esophageal injury and one patient with pharyngeal injury after anterior cervical spinal surgery, managed at our department between 2000 and 2015, were analyzed retrospectively. RESULTS: During the study period, 7 patients (6 male and 1 female; mean age, 45 years) presented with esophageal perforation. The original anterior cervical spinal surgery was performed due to trauma in 2 patients and because of a degenerative cervical disorder in 5. Early esophageal perforation was diagnosed in 2 patients, and delayed esophageal injury due to chronic irritation with the cervical implants was noted in 5. Three of the five delayed perforation cases were related to cervical instrument displacement. Two patients showed no definite signs of infection, whereas 5 patients had various symptoms, including fever, neck pain, odynophagia, neck swelling, and upper extremity weakness. Two patients with a large defect underwent surgical repair and three with minimal perforation due to chronic irritation from the implants underwent instrument removal without direct repair of defect. Two asymptomatic patients received no intervention. Six patients with infection completely recovered from esophageal injury after treatment for a mean duration of 5.2 weeks (range, 4-8 weeks). One patient died because of postoperative pneumonia and sepsis after implant removal. CONCLUSIONS: Esophageal and pharyngeal injury after cervical spinal surgery may occur either directly due to spinal trauma and vigorous intraoperative retraction or due to chronic irritation with cervical implants. In cases of perforation associated with infection, various surgical modalities, including primary closure and reinforcement with a flap, could be considered depending on factors such as esophageal defect size, infection severity, and timing of recognition of injury.

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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.

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PURPOSE: The neurological outcome of cervical spondylotic myelopathy (CSM) may depend on multiple factors, including age, symptom duration, cord compression ratio, cervical curvature, canal stenosis, and factors related to magnetic resonance (MR) signal intensity (SI). Each factor may act independently or interactively with others. To clarify the factors in prognosis, we prospectively analyzed the outcomes of patients with myelopathy caused by soft disc herniation in correlation with magnetic resonance imaging (MRI) findings and other clinical parameters. MATERIALS AND METHODS: From June 2006 to July 2009, we performed surgical operations in 137 patients with CSM. Of these patients, 70 (51.1%), including 45 men and 25 women with ventral cord compression at one or two levels, underwent anterior cervical discectomy and fusion. The mean duration of follow-up was 32.7 months. We surveyed the cervical curvature index (CCI), canal stenosis (Torg-Pavlov ratio), cord compression ratio, the length of SI change on T2WI, and clinical outcome using the Japanese Orthopedic Association (JOA) score for cervical myelopathy. The MRI SI was evaluated by grade: grade 0, no change in signal intensity; grade 1, light signal change; and grade 2, bright signal change on the T2WI. Multifactorial effects were identified by regression analysis. RESULTS: The mean preoperative and postoperative JOA scores were 10.5 ± 2.9 and 14.9 ± 2.1, respectively (p < 0.05). The mean recovery rate based on the JOA score was 70.0 ± 20.1%. The respective preoperative JOA scores and recovery ratios(%) were 11.6 ± 2.3 and 81.5 ± 17.0% in 20 patients with SI grade 0; 10.8 ± 2.3 and 70.1 ± 17.3% in 25 patients with grade 1; and 9.2 ± 3.6 and 60.7 ± 20.9% in 25 patients with grade 2, respectively. Post-surgical neurological outcome showed no significant relationship to age, symptom duration, cervical alignment, stenosis, or cord compression. CONCLUSIONS: Among the variables tested, preoperative neurological status and intramedullary signal intensity were significantly related to neurological outcome. The better the preoperative neurological status was, the better the post-operative neurological outcome. The SI grade on the preoperative T2WI was negatively related to neurological outcome. Hence, the severity of SI change and preoperative neurological status emerged as significant prognostic factors in post-operative CSM.

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OBJECTIVE: Recurrent lumbar disc herniation has been reported to occur in 5% to 15% of surgically treated primary lumbar disc herniation cases. We investigated the molecular biologic characteristics of primary herniated discs and recurrent discs to see whether the recurrent discs has the similar biological features with primary herniated discs. METHODS: Primary herniated disc and recurrent disc cells were obtained by discectomy of lumbar disc patients and cells were isolated and then taken through monolayer cultures. We compared chondrogenic and osteogenic mRNA gene expression, and western blot between the two groups. RESULTS: The mRNA gene expression of recurrent disc cells were increased 1.47* times for aggrecan, 1.38 times for type I collagen, 2.04 times for type II collagen, 1.22 times for both Sox-9 and osteocalcin, and 1.31 times for alkaline phosphatase, respectively, compared with the primary herniated lumbar disc cells (*indicates p < 0.05). Western blot results for each aggrecan, type I collagen, type II collagen, Sox-9, osteocalcin, and alkaline phosphatase were similar between the primary herniated disc cells and recurrent disc cells. CONCLUSION: These results indicate that the recurrent disc cells have similar chondrogenic and osteogenic gene expression compared to primary herniated disc cells. Therefore, we assumed that the regeneration of remaining discs could fill the previous discectomy space and also it could be one of the factors for disc recurrence especially in the molecular biologic field.

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PURPOSE: We investigated whether primary malignancy entities and the extent of tumor resection have an effect on the survival rate and neurological improvement in patients with spinal metastases that extend beyond the vertebral compartment (Tomita's classification > or = type 4). MATERIALS AND METHODS: We retrospectively reviewed 87 patients with advanced spinal metastasis who underwent surgery. They were divided into groups 1 and 2 according to whether they responded to adjuvant therapy or not, respectively. They were subdivided according to the extent of tumor resection: group 1, gross total resection (G1GT); group 1, subtotal resection (G1ST); group 2, gross total resection (G2GT); and group 2, subtotal resection (G2ST). The origin of the tumor, survival rate, extent of resection, and neurological improvement were analyzed. RESULTS: Group 1 had a better survival rate than group 2. The G1GT subgroup showed a better prognosis than the G1ST subgroup. In group 2, the extent of tumor resection (G2GT vs. G2ST) did not affect survival rate. In all subgroups, neurological status improved one month after surgery, however, the G2ST subgroup had worsened at the last follow-up. There was no local recurrence at the last follow-up in the G1GT subgroup. Four out of 13 patients in the G2GT subgroup showed a local recurrence of spinal tumors and progressive worsening of neurological status. CONCLUSION: In patients with spinal metastases (Tomita's classification > or = type 4), individuals who underwent gross total resection of tumors that responded to adjuvant therapy showed a higher survival rate than those who underwent subtotal resection. For tumors not responding to adjuvant therapy, we suggest palliative surgical decompression.

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OBJECTIVE: Posterior lumbar interbody fusion (PLIF) is considered to have the best theoretical potential in promoting bony fusion of unstable vertebral segments by way of a load sharing effect of the anterior column. This study was undertaken to investigate the efficacy of PLIF with cages in chronic degenerative disc disease with Modic degeneration (changes of vertebral end plate). METHODS: A total of 597 patients underwent a PLIF with threaded fusion cages (TFC) from 1993 to 2000. Three-hundred-fifty-one patients, who could be followed for more than 3 years, were enrolled in this study. Patients were grouped into 4 categories according to Modic classification (no degeneration : 259, type 1 : 26, type 2 : 55, type 3 : 11). Clinical and radiographic data were evaluated retrospectively. RESULTS: The clinical success rate according to the Prolo's functional and economic outcome scale was 86% in patients without degeneration and 83% in patients with Modic degeneration. The clinical outcomes in each group were 88% in type 1, 84% in type 2, and 73% in type 3. The bony fusion rate was 97% in patients without degeneration and 83% in patients with Modic degeneration. The bony fusion rate in each group was 81% in type 1, 84% in type 2, and 55% in type 3. The clinical success and fusion rates were significantly lower in patients with type 3 degeneration. CONCLUSION: The PLIF with TFC has been found to be an effective procedure for lumbar spine fusion. But, the clinical outcome and bony fusion rates were significantly low in the patients with Modic type 3. The authors suggest that PLIF combined with pedicle screw fixation would be the better for them.

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Intradural lumbar disc herniation (ILDH) is rare. In this report, authors present 2 cases of ILDHs associated with severe adhesion between the dural sac and posterior longitudinal ligament. In a 40-year-old man, ILDH occurred in association with epidural adhesion due to ossification of the posterior longitudinal ligament (OPLL). In other 31-year-old man, ILDH occurred in presence of epidural adhesion due to previous spine surgery.

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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.

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OBJECTIVE: This study is a retrospective clinical study over more than 4 years of follow up to understand the mechanism of load sharing across the graft-bone interface in the static locking plate (SLP) fixation compared with non-locking plate (NLP). METHODS: Orion locking plates and Top non-locking plates were used for SLP fixation in 29 patients and NLP fixation in 24 patients, respectively. Successful interbody fusion was estimated by dynamic X-ray films. The checking parameters were as follows : screw angle (SA) between upper and lower screw, anterior and posterior height of fusion segment between upper and lower endplate (AH & PH), and upper and lower distance from vertebral endplate to the end of plate (UD & LD). Each follow-up value of AH and PH were compared to initial values. Contributions of upper and lower collapse to whole segment collapse were estimated. RESULTS: Successful intervertebral bone fusion rate was 100% in the SLP group and 92% in the NLP group. The follow-up mean value of SA in SLP group was not significantly changed compared with initial value, but follow-up mean value of SA in NLP group decreased more than those in SLP group (p=0.0067). Statistical analysis did not show a significant difference in the change in AH and PH between SLP and NLP groups (p>0.05). Follow-up AH of NLP group showed more collapse than PH of same group (p=0.04). The upper portion of the vertebral body collapsed more than the lower portion in the SLP fixation (p=0.00058). CONCLUSION: The fused segments with SLP had successful bone fusion without change in initial screw angle, which was not observed in NLP fixation. It suggests that there was enough load sharing across bone-graft interface in SLP fixation.

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OBJECTIVE: The 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. METHODS: We 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. RESULTS: Among 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). CONCLUSION: Bone 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.

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OBJECTIVE: The objective of this study was to evaluate the characteristics and surgical outcome of the conus medullaris tumors. METHODS: We retrospectively reviewed 26 patients who underwent surgery for conus medullaris tumor from August 1986 to July 2007. We analyzed clinical manifestation, preoperative MRI findings, extent of surgical resection, histopathologic type, adjuvant therapy, and outcomes. RESULTS: There were ependymoma (13), hemangioblastoma (3), lipoma (3), astrocytoma (3), primitive neuroectodermal tumor (PNET) (2), mature teratoma (1), and capillary hemangioma (1) on histopathologic type. Leg pain was the most common symptom and was seen in 80.8% of patients. Pain or sensory change in the saddle area was seen in 50% of patients and 2 patients had severe pain in the perineum and genitalia. Gross total or complete tumor resection was obtained in 80.8% of patients. On surgical outcome, modified JOA score worsened in 26.9% of patients, improved in 34.6%, and remained stable in 38.5%. The mean VAS score was improved from 5.4 to 1.8 among 21 patients who had lower back pain and leg pain. CONCLUSION: The surgical outcome of conus medullaris tumor mainly depends on preoperative neurological condition and pathological type. The surgical treatment of conus medullaris tumor needs understanding the anatomical and functional characteristics of conus meudllaris tumor for better outcome.

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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.

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