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Objective: The purpose of this study was to evaluate the safety and efficacy of cervical midline-splitting French-door laminoplasty with a polyether ether ketone (PEEK) plate. The authors retrospectively analyzed the results of patients with cervical laminoplasty miniplate (MAXPACER®) without bone grafts in multilevel cervical stenosis., Methods: Fifteen patients (13 males and 2 females, mean age 50.0 years (range 35-72)) with multilevel cervical stenosis (ossification of the posterior longitudinal ligament and cervical spondylotic myelopathy) underwent a combined surgery of midline-splitting French-door laminoplasty with or without mini plate. All 15 patients were followed for at least 12 months (mean follow-up 13.3 months) after surgery, and a retrospective review of the clinical, radiological and surgical data was conducted., Results: The radiographic results showed a significant increase over the postoperative period in anterior-posterior diameter (9.4±2.2 cm to 16.2±1.1 cm), open angles in cervical lamina (46.5±16.0° to 77.2±13.1°), and sectional volume of cervical central canal (100.5±0.7 cm(2) to 146.5±4.9 cm(2)) (p<0.001). The sagittal alignment of the cervical spine was well preserved (31.7±10.0° to 31.2±7.6°, p=0.877) during the follow-up period. The clinical results were successful, and there were no significant intraoperative complications except for screw displacement in two cases. The mini plate constructs did not fail during the 12 month follow-up period, and the decompression was maintained., Conclusion: Despite the small cohort and short follow-up duration, the present study demonstrated that combined cervical expansive laminoplasty using the mini plate is an effective treatment for multilevel cervical stenosis.

Objective: Epidural injection of hyaluronic acid may prevent adhesion formation after spine surgery, but the compounds used to stabilize hyaluronidase could interfere with its anti-adhesion effects. The present study was conducted as a clinical trial to evaluate the efficacy and safety of an experimental medical gel in preventing adhesion formation., Methods: This study was designed as a multicenter, randomized, double-blind, and comparative controlled clinical trial with an observation period of 6 weeks. Subjects were randomly assigned into two groups: group A with sodium hyaluronate + 1,4-butanediol diglycidyl ether (BDDE) and group B with sodium hyaluronate + sodium carboxymethylcellulose (CMC). Visual analogue scale (VAS) of back and leg pain and the Oswestry disability index (ODI) and scar score ratings were assessed after surgery., Results: Mean scar grade was 2.37±1.13 in group A and 2.75±0.97 in group B, a statistically significant difference (p=0.012). VAS of back and leg pain and ODI scores decreased significantly from baseline to 3 and 6 weeks postoperatively in both groups (p<0.001). However, VAS and ODI scores were not statistically different between groups A and B at baseline or at 3 and 6 weeks after operation (p>0.3). The number of adverse reactions related to the anti-adhesion gels was not statistically different (p=0.569), but subsequent analysis of nervous adverse reactions showed group B was superior with a statistically difference (p=0.027)., Conclusion: Sodium hyaluronate with BDDE demonstrated similar anti-adhesion properties to sodium hyaluronate with CMC. But, care should be used to nervous adverse reactions by using sodium hyaluronate with BDDE.

Vascular injury presented immediately after the penetration, but delayed onset of vascular symptom caused by an embolism or vessel dissection after cervical fusion or traumatic event is extremely rare. We present a case of a 56-year-old woman who underwent an operation for cervical fusion for type II Odontoid process fracture. She presented symptoms of seizure with hemiparesis in 6 days after the operation. Multifocal acute infarction due to an embolism from the left VA (V3 segment) dissection was observed without a definite screw breach the transverse foramen. We hereby reported the instructive case report of delayed onset of vertebral artery dissection after posterior cervical fusion with type II odontoid process fracture patient. When a cervical operation performed in the cervical trauma patient, even if no apparent VA injury occurs before and during the operation, the surgeon must take caution not to risk cerebral infarction because of the delayed VA dissection.

Objective: A general orientation along the cervical spine could be estimated by external landmarks, and it was useful, quick and less exposable to radiation, but, sometimes it gave reference confusion of target cervical level. The authors reviewed the corresponding between the neck external landmarks and cervical levels., Methods: Totally 1,031 cervical lateral radiographs of different patients were reviewed in single university hospital. Its compositions were 534 of males and 497 females; 86 of second decades (10-19 years-old), 169 of third decades, 159 of fourth decades, 209 of fifth decades, 275 of sixth decades, and 133 of more than seventh decades (>60 years-old). Reference external landmarks (mandible, hyoid bone, thyroid cartilage, and cricothyroid membrane) with compounding factors were reviewed., Results: The reference levels of cervical landmarks were C2.13 with mandible angle, C3.54 with hyoid bone, C5.12 with thyroid cartilage, and C6.01 with cricothyroid membrane. The reference levels of cervical landmarks were differently observed by sex, age, and somatometric measurement (height) accordingly mandible angle from C1 to C3, hyoid bone from disc level of C2 and C3 to C5, thyroid cartilage from disc level of C3 and C4 to C7, and cricothyroid membrane from C4 to disc level of C7 and T1., Conclusion: Surface landmarks only provide general reference points, but not correspond to exact levels of the cervical spine. Intraoperative fluoroscopy ensures a more precise placement to the targeted cervical level.

A patients with atlantoaixial instability and osodontoideum underwent atlantoaixial fusion (Harms and Melcher technique) with demineralized bone matrix. But, unfortunately, the both pedicle screws in C2 were fractured within 9 weeks follow-up periods after several suspected episode of neck hyper-flexion. Fractured screws were not contact to occipital bone in several imaging studies, but it could irritate the occipital bone when neck extension because the relatively close distance between the occipital bone and C1 posterior arch. The patient underwent revision operation with translaminar screw fixation with autologus iliac bone graft. Postsurgical course were uneventful except donor site pain, but the bony fusion was not satisfied after 4 months follow-up. The patient re-underwent revision operation in other hospital. Continuous complication after atlantoaixial fusion is rare, but the clinical course could be unlucky to patients. Postoperative immobilization could be important to prevent the unintended clinical course of patients.

Objective: To compare the slip reduction rate and clinical outcomes between unilateral conventional transforaminal lumbar interbody fusion (conventional TLIF) and unilateral minimal invasive TLIF (minimal TLIF) with pedicle screw fixation for treatment of one level low-grade symptomatic isthmic spondylolisthesis., Methods: Between February 2008 and April 2012, 25 patients with low-grade isthmic spondylolisthesis underwent conventional TLIF (12 patients) and minimal TLIF (13 patients) in single university hospital by a single surgeon. Lateral radiographs of lumbar spine were taken 12 months after surgery to analyze the degree of slip reduction and the clinical outcome. All measurements were performed by a single observer., Results: The demographic data between conventional TLIF and minimal TLIF were not different. Slip percentage was reduced from 15.00% to 8.33% in conventional TLIF, and from 14.15% to 9.62% in minimal TLIF. In both groups, slip percentage was significantly improved postoperatively (p=0.002), but no significant intergroup differences of slip percentage in preoperative and postoperative were found. The reduction rate also not different between conventional TLIF (45.41±28.80%) and minimal TLIF (32.91±32.12%, p=0.318)., Conclusion: Conventional TLIF and minimal TLIF with pedicle screw fixation showed good slip reduction in patients with one level low-grade symptomatic isthmic spondylolisthesis. The slip percentage and reduction rate were similar in the conventional TLIF and minimal TLIF.

There are few reports in the literature of complete obstruction of the vertebral artery (VA) due to an electric screw driver bit penetration through the neural foramen into the spinal canal with Brown-Séquard syndrome (BSS). A 25-year-old man was admitted to the emergency department with a penetrated neck injury by an electric screw driver bit after a struggle. The patient presented the clinical features of BSS. Computed tomography scan revealed that the electric screw driver bit penetrated through the right neural foramen at the level of C3-4, and it caused an injury to the right half of the spinal cord. Emergent angiography revealed VA dissection, which was managed by immediate coil embolization at both proximal and distal ends of the injury site. After occlusion of the VA, the electric screw driver bit was extracted under general anesthesia. Bleeding was minimal and controlled without difficulties. No postoperative complications, such as wound dehiscence, CSF leakage, or infection, were noted. Endovascular approaches for occlusion of vertebral artery lesions are safe and effective methods of treatment.