Asymmetric Facet Joint Osteoarthritis and its Relationships to Facet Orientation, Facet Tropism and Ligamentum Flavum Thickening

Brief review

이 논문은 작년 11월에 나온 논문인데, 얼마전에 포스팅한 논문에 나와있던 facet joint osteoarthritis-4 grade를 인용한 논문 입니다. 연구목적은 관절염에 의해 비대칭된 후관절과 후관절의 방향, 비대칭, 황색인대의 비대 와의 관련성을 밝히는 것 입니다.

후관절의 대칭정도에 따라 연구대상을 비대칭그룹과 대칭 그룹으로 나누었습니다.

대칭그룹은 후관절 양쪽의 osteoarthritis가 모두 grade1 or 2 거나 혹은 모두 grade3 or 4 이며, 비대칭그룹은 한쪽이 grade1 or 2이고, 나머지 한쪽이 grade3 or 4 인 환자가 포함되었습니다. 
후관절의 orientation, tropism 및 Ligamentum Flavum Thickness는 모두 CT image를 측정했습니다.

결론적으로, 비대칭 후관절의 관절염은 facet orietation, tropism과 연관성이 있지만 요추레벨과는 관련이 없었습니다. 그리고 후관절의 관절염과 Ligamentum Flavum의 thickness와는 밀접한 관련이 있었습니다.

아래 bibliography에 해당저널 링크 걸어두었으니 읽어보세요:)

*Title: Asymmetric Facet Joint Osteoarthritis and its Relationships to Facet Orientation, Facet Tropism and Ligamentum Flavum Thickening.

비대칭 후관절의 관절염과 후관절의 방향, 비대칭, 황색인대의 비대 와의 관련성

*Authors: Liu HX, Shen Y, Shang P, Ma YX, Cheng XJ, Xu HZ.

*Bibliography: J Spinal Disord Tech. 2013 Nov 8. [Epubahead of print]

STUDY DESIGN

The degrees of osteoarthritis of the left and right facet joints were evaluated by using CT among elderly patients with low back or leg pain.

OBJECTIVE

To reveal the phenomenon of asymmetry regarding facet joint osteoarthritis (FJOA) in old patients.

To establish its relationships to spinal level, facet orientation, facet tropism and ligamentum flavum (LF) thickening.

SUMMARY OF BACKGROUND DATA

There were few reports regarding left-right asymmetry among severity of FJOA and its relationships to spinal level, facet orientation, facet tropism and LF thickening remained unclear.

METHODS

▶Evaluating method: FJOA was evaluated using 4-grade scale (L3-4, L4-5, L5-S1)

▶All subjects were divided into two groups:

1) symmetric FJOA group: (FJOA I-II on both sides or FJOA III-IV on both sides)

2) asymmetric FJOA group: (FJOA I-II on one side and FJOA III-IV on the other side).

-facet joint osteoarthritis를 4개의 grade로 나눈 figure 참고(Kalichman et al)

-The relationships of FJOA to spinal level, facet orientation, facet tropism, and LF hypertrophy were evaluated.

RESULTS

▶Spinal level: -No association with asymmetric FJOA.

▶Facet orientation: significantly associated with facet orientation at the L4-5, L5-S1.

▶Facet tropism: significant prevalence in asymmetric FJOA > symmetric FJOA (L5-S1).

▶Ligamentum flavum: significantly thicker FJOA III-IV > FJOA I-II (in asymmetric FJOA group)

(no difference in thickness in symmetric FJOA group)

CONCLUSIONS

-Asymmetric FJOA is associated with facet orientation and tropism, but not with spinal level.

-There is a close relationship between severity of FJOA and LF thickness.

Clinical and Radiologic Outcomes of TLIF Applications With or Without Pedicle Screw: A Double Center Prospective Pilot Comparative Study

Brief review

*Title: Clinical and Radiologic Outcomes of TLIF Applications With or Without Pedicle Screw: A Double Center Prospective Pilot Comparative Study

척추경나사 사용 유무에 따른 추간공경유 요추 유합술의 임상적, 방사선학적 결과

: 두 기관의 예비 전향적 비교 연구

*Author: Kadir Kotil, Mustafa Ali Akc¸etin, Yildiray Savas

*Bibliography: J Spinal Disord Tech. 2013Oct;26(7):359-66.

STUDY DESIGN

Prospective cohort data by merging data from comparative studies.

OBJECTIVE

To compare clinical and radiologic outcomes of the transforaminal lumbar interbody fusion (TLIF) procedure with or without pedicle screw support in stable patients with a degenerative disease.

SUMMARY OF BACKGROUND DATA

-TLIF is routinely performed with the support of pedicle screws.

-Problem: TLIF procedure without pedicle screw support has not yet been reported.

METHODS

▶Period: 2006.02 ~ 2009.05

▶Subject: patients underwent decompression and fusion (using TLIF)

-Group A: TLIF with pedicle screw (n=30)

-Group B: TLIF without pedicle screw (n=30)

▶Mean follow-up period: 31mon

▶Mean age: 45.5 yrs

RESULTS

	group A	group B
Sex ratio (female: male)	19:11	18:12
Pseudoarthrosis (patients)	2	3
Mean operating time (min)	110	73
Mean blood loss (mL)	410	220
Cage loosening (patients)	0	1
sciatic pain	4	1

-VAS, ODI (after 1months):  A > B (P<0.005)

                 (after 3 months): Not significantly differ (P<0.89).

-Cost: A(3-fold higher) > B

CONCLUSIONS

-TLIF procedure without pedicle screw would be sufficient in the management of stable patients with lumbar degenerative disease after single-level decompression.

-And this technique is less costs and complications compared with pedicle screwing.

Assessment of Magnetic Resonance Imaging in the diagnosis of lumbar spine foraminal stenosis -A surgeon's perspective

Detailed review

*Title: Assessment of Magnetic Resonance Imaging in the diagnosis of lumbar spine foraminal stenosis -A surgeon's perspective

요추 추간공 협착증 진단에서의 MRI의 측정 -외과의의 관점

*Author: Naftaly Attias, MD, Anne Hayman, MD, John A. Hipp, PhDz Philip Noble, PhD,

and Stephen I. Esses, MD

*Bibliography: J Spinal Disord Tech 2006;19:249-256

Study Design: A 2-part cadaveric study

Introduction:

1. Lumbar spine foraminal stenosis (LSFS) incidence >> 8% ~ 11%

2. Limitations of MRI itself for the diagnosis of LSFS

3. Not well understood about the effect of the variability on assessing LSFS

   1) Various Techniques

   2) Various Observers

4. No control over the final quality, or quantity of images provided to the surgeons

5. Glenn's words for size of a lesion in spine

   >> 1) normal, 2) slight, 3) mild, 4)moderate, 5) sever

6. Wildermuth et al's semi-quantitative classification system for grading LSFS

   1) On the basis of 'Open' MRI findings

   2) Grade 0 >> foramina without pathology

   3) Grade 1 >> slight foraminal stenosis

   4) Grade 2 >> marked foraminal stenosis

   5) Grade 3 >> advanced stenosis

7. About this study

   1) 2-part study to investigate the use of MRI in diagnosing LSFS

     ① Take MRIs of 3 cadavers in 3 centers, 8 spine surgeons to assess

       >> Reliability of Wildermuth semiquantitative classification system

       >> Variability in MRI examinations carried out in different institutions

     ② Compare MRI measurements vs. cadaveric slices to assess

       >> Differences between measurements from MRI vs. cadaveric specimens

Methods:

1. Fresh, frozen human lumbar spines (3 cadavers)

2. Examined with 3 different clinical MRI systems

3. Graded foramina by 8 surgeons on the basis of Wildermuth semiquantitative way

4. MRI measurements

   1) Foraminal height

   2) Superior foraminal width

   3) Middle foraminal width

   4) Posterior disc height

5. Specimen measurements

   1) Foraminal height

   2) Superior foraminal width

   3) Middle foraminal width

Results, Part 1:

1. 9set MRI scan review/total 72 foramina per one observer

2. Grading

   0) Grade 0 >> 222 foramina (39%)

   1) Grade 1 >> 201 foramina (35%)

   2) Grade 2 >> 127 foramina (22%)

   3) Grade 3 >>  26 foramina (04%)

   4) P = 0.15, nearly significant on the basis of paired t-tests

3. Level of interobserver agreement

   0) k grade 0 >> 0.13

   1) k grade 1 >> -0.01

   2) k grade 2 >> 0.06

   3) k grade 3 >> 0.11

   4) combined >> 0.07

   5) Most observers underestimated LSFS grade as compared with grading specimens.

   6) Preferred Method to assess the foramen >> T1 sagittal sequence

Results, Part 2:

1. MRI measurements

   1) Foraminal height >> 14.78mm (SD 4.53)

   2) Superior foraminal width >> 7.73mm (SD 1.77)

   3) Middle foraminal width >> 3.79mm (SD 1.68)

   4) Posterior disc height >> 5.55mm (SD 1.63)

   5) Correlation between MRI measurements and Actual dimensions in specimens >> Poor

2. Specimen measurements

   1) Measured 24 foramina and Graded according to Wildermuth classification

     Grade 0 >> 8 (33%)

     Grade 1 >> 3 (12%)

     Grade 2 >> 10 (42%)

     Grade 3 >> 3 (12%)

   2) Measurments of foraminal size

     Foraminal height >> 16.12mm (SD -3.11)

     Proximal foraminal width >> 8.99mm (SD -2.43)

     Middle foraminal width >> 4.76mm (SD -2.80)

Conclusion:

The parameters associated with the grade of stenosis assigned to the foramen were as follows: 

(1) the observer doing the grading

(2) the place it was imaged

(3) the location of the foramen.

There was poor correlation between measurements of the foramina carried out on MRI and the specimens.

Perioperative complications in transforaminal lumbar interbody fusion versus anterior-posterior reconstruction for lumbar disc degeneration and instability.

Brief review 2

*Title: Perioperative complications in transforaminal lumbar interbody fusion versus anterior-posterior reconstruction for lumbar disc degeneration and instability.

*Authors: Alan T. Villavicencio, MD,  Sigita Burneikiene, MD,  Ketan R. Bulsara, MD,  Jeffrey J. Thramann, MD

*Bibliography: J Spinal Disord Tech. 2006Apr;19(2):92-7.

OBJECTIVES: 

To assess clinical parameters for TLIF and AP reconstructive surgery for lumbar fusion.

(clinical parameters: 1)surgical blood loss, 2)duration of the procedure, 3)length of 

hospitalization, 4)complications)

METHODS: retrospective analysis -chart review (2002.01~2004.03)

▶Subject number: Total 167 cases

-TLIF: 124 patients (73 minimally invasive + 51 open cases) & AP surgery: 43 patients

▶Indications: 

-painful degenerative disc disease

-facet arthropathy

-degenerative instability

-spinal stenosis

-degenerative spondylolisthesis.

RESULTS:

1)blood loss, 2)operative times, 3)hospitalization times are listed belows.

 >OR Time: OpeRation Time

   EBL: Estimated Blood Loss

   LOS: Length Of Stay

4)complication rate are as follows.

-Major Complications

-Minor Complications

CONCLUSIONS:

1)blood loss : AP lumbar interbody fusion (significantly increased) > TLIF 

2)operative times: AP lumbar interbody fusion (more longer) > TLIF

3)hospitalization times: AP lumbar interbody fusion (more longer) > TLIF

4)complication rate: AP lumbar interbody fusion (more than 2 times higher) > TLIF

Mini-Transforaminal Lumbar Interbody Fusion Versus Anterior Lumbar Interbody fusion Augmented by Percutaneous Pedicle Screw Fixation

3rd journal review

*Title: Mini-Transforaminal Lumbar Interbody Fusion Versus Anterior Lumbar Interbody fusion Augmented by Percutaneous Pedicle Screw Fixation.

*Author: Jin-Sung Kim, MD,  Byung-Uk Kang, MD,  Sang-Ho Lee, MD, PhD,  Byungjoo Jung, MD, PhD,  Young-Gun Choi, MD,  Sang Hyeop Jeon, MD  Ho Yeon Lee, MD, PhD 

*Bibliography: J Spinal Disord Tech. 2009 Apr;22(2):114-21.

Study Design: Retrospective clinical data analysis.

Objective: To compare clinical results with radiologic results of 2 fusion techniques for adult low-grade isthmic spondylolisthesis.

Summary of Background Data: There is clear evidence that comparing ALIF versus PLIF.

However, there are no recent studies that compare these 2 fusion techniques(ALIF and TLIF).

Methods: 
>Patient population
-patient characteristics (2004.03~2004.12)

-inclusion criteria

1) presence of single-level low-grade isthmic spondylolisthesis

2) chronic and persistent radiculopathy despite conservative treatment

3) progressive neurologic deficits

4) persistent and unremitting lower-back pain for more than 6months

5) loss of quality of life because of neurologic claudication

6) minimum follow-up period 2years

7) age range of 18 to 65 years

-exclusion criteria

1) previous spine surgery

2) concomitant scoliosis of more than 15 degrees

3) compression fracture or instability at the adjacent segment

4) underwent simultaneous decompression at adjacent segments

>Outcome assessment

-Radiologic outcome:

evaluated on anteroposterior, lateral, and flexion-extension radiographs.

 Radiologic data: 1)disc height 2) segmental lordosis 3) whole lumbar lordosis 4) degree of listhesis

<radiologic measurement method>

 Clinical outcome: 1) VAS(visual analog scale) 2) ODI(oswestry disability index)

>Surgical Techniques

-All ALIF procedures were performed using the mini-laparotomic retroperitoneal approach.

>Mini-TLIF with PPF

>Statistical Analysis

-An analysis of variance was conducted using the 2 proportions test, independent 2 sample t test, x^test, paired t test. (p<0.05)

Results

>Radiologic results

The postoperative radiologic data revealed below.

-DH and SL -->  significant difference
-degree of listhesis and WL--> Not  significant difference


>Clinical outcomes
-VAS score
ALIF- back: 7.7 --> 2.9
        leg:    7.5--> 2.7
TLIF- back: 7.0 --> 2.3
        leg:    6.3--> 2.2

-ODI score
ALIF: 51.4%--> 23.2%
TLIF: 52%   --> 14.4%


Conclusions
-The mini-ALIF group demonstrated key radiographic advantages compared with the mini-TLIF group for adult low-grade isthmic spondylolisthesis. 

-However, clinical and functional outcomes did not demonstrate significant differences between groups.