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Study design A retrospective observational and case control study. Purpose To identify appropriate treatment options according to the types of surgical site infections (SSI) in instrumented posterior lumbar interbody fusion (PLIF). Overview of literature There has been no agreement or consensus with regard to this matter. Methods Thirty-two consecutive SSIs were included and followed for more than one year. The elapsed time to diagnosis (ETD) according to the type of SSI was analyzed. The treatment options for each type and consequent clinical results were reviewed. The risk factors of removing the implants were analyzed. Results There were 6/32 (19%) superficial incisional, 6/32 (19%) deep incisional, and 20/32 (62%) organ/space infection cases (SII, DII, and O/SI, respectively) (p=0.002). ETD was 8.5±2.3 days in SII, 8.7±2.3 days in DII, and 164.5±131.1 days in O/SI (p=0.013). All cases of SII and DII retained implants and were treated by repeated irrigation and secondary closure. Among O/SIs, 10/20 were treated conservatively. Nine out of ten underwent posterior one stage simultaneous revision (POSSR) and in one case, the cage was removed anteriorly. Those who had ETDs longer than 3 months showed a significant risk of implant removal (p=0.008, odds ratio [OR]=40.3). The Oswestry disability index (ODI) improved from 47.3% to 33.8% in SII, from 55.0% to 32.3% in DII, and from 53.4% to 42.1% in O/SI (p=0.002). There was no difference among the three groups (p=0.106); however, there was a partial correlation between ETD and final ODI (r=0.382, p=0.034). Conclusions Latent O/SI was the most common type of SSI in PLIF. In cases of SII and DII, early aggressive wound management and secondary closure was effective and implant removal was not necessary. In some cases of O/SI, implant removal was unavoidable. However, implant removal could be averted by an earlier diagnosis. POSSR was feasible and safe. Functional outcomes were improved; however, disability increased as ETD increased.

Ossification of the ligamentum flavum is a rare cause of thoracic myelopathy. It develops in East Asians more frequently than in people from other areas. The exact pathophysiology has not been elucidated yet; however, it largely depends on biomechanical alterations, especially changes in the tensile force. Because the spinal cord is compressed from the posterior side, the first and most common clinical manifestation is usually loss of functional gait and spastic paralysis, which develop as the spinal cord compression progresses. The choice of diagnostic imaging is T2 sagittal magnetic resonance imaging scanning. Whole spine scanning is mandatory to identify multiple areas of compression and any associated distal lumbar diseases. Fine computed tomography imaging is necessary to make a differential diagnosis and set up a precise surgical plan. Conservative treatment does not work in this disorder. Decompression surgery is the only option and prognosis after surgical treatment is better with this disorder than with other causes of thoracic myelopathy. The severity of preoperative symptoms and the time interval before surgical treatment are the most important prognostic factors.

Background: Epidural hematoma is a rare but serious complication. According to previous studies, it is not prevented by suction drains. This study evaluated the following alternative hypothesis: the larger the diameter of a suction drain, the less the remaining epidural hematoma after spinal surgery. Methods: This was a randomized prospective study. Patients who underwent posterior lumbar decompression and instrumented fusion were divided into two groups: the large drain (LD, 2.8-mm-diameter tube) and small drain (SD, 1.6-mm-diameter tube) groups according to the diameter of the suction drains. All patients were consecutive and allocated alternately according to the date of operations. Suction drains were removed on day 3 and magnetic resonance imaging was performed on day 7 postoperatively. The size of remaining hematomas was measured by the degree of thecal sac compression in cross section using the following 4-point numeric scale: G1, less than one quarter; G2, between one quarter and half; G3, more than half; and G4, more than subtotal obstruction. Results: There were 39 patients with LDs and 38 with SDs. They did not differ significantly in terms of sex, number of fusion segments, revision or not, antiplatelet medication, intraoperative injection of tranexamic acid. However, patient age differed significantly between the two groups (LD, 63.3 years and < SD, 68.6 years; p = 0.007). The two groups did not differ significantly in terms of prothrombin time, activated partial thromboplastin time, platelet number, blood loss, or operation duration. However, platelet function analysis exhibited a significant difference (LD, 164.7 seconds and < SD, 222.3 seconds; p = 0.002). The two blinded readers showed high consistency (Kappa value = 0.740; p = 0.000). The results of reader 1 were as follows: LD and SD had 21 and 21 cases of G1, 9 and 11 cases of G2, 6 and 6 cases of G3, and 3 and 0 cases of G4, respectively. The results of reader 2 were as follows: LD and SD had 22 and 23 cases of G1, 7 and 9 cases of G2, 7 and 6 cases of G3, and 3 and 0 cases of G4, respectively. There was no difference between the two groups (reader 1, p = 0.636; reader 2, p = 0.466). Conclusions: The alternative hypothesis was rejected. Therefore, postoperative spinal epidural hematoma would not be prevented by LD.

Purpose To identify the modes of failure after total knee arthroplasty (TKA) in patients >55 years of age and to compare with those >55 years of age in patients who underwent revision TKA. Materials and Methods We retrospectively reviewed 256 revision TKAs among patients who underwent TKA for knee osteoarthritis between January 1992 and December 2012. The causes of TKA failure were analyzed and compared between the groups. Results Thirty-one revision TKAs were performed in patients ≤55 years of age at the time of primary TKA, whereas 225 cases were in those >55 years of age at primary TKA. In the ≤55 years of age group, the most common cause of TKA failure was polyethylene wear (45%) followed by infection (26%) and loosening (17%). The interval from primary TKA to revision was 8.6 years (range, 1 to 17 years). There were relatively lower infection rate and higher loosening rate in patients ≤55 years of age, but the difference was not statistically significant. Conclusions The main causes of failure after TKA in patients ≤55 years of age were polyethylene wear, infection and loosening, and there was no significant difference in the modes of failure after TKA between the two groups.

경추부 중재술은 전통적으로 방사선 투시하에서 시행되었다. 그러나 방사선 투시기로는 연부 조직, 특히 신경과 혈관 등의 주요 구조물들을 볼 수 없다 는 단점이 있는데 방사선 투시하 경추간공(transforaminal) 주사의 경우 조영제를 사용하여 혈관 내 주입을 피하고자 함에도 불구하고 신경근 동맥 (radicular artery)내 주사가 되어 척수 손상이라는 심각한 합병증을 발생시킨 증례들이 보고되는 등 방 사선 투시하 시술의 위험성이 부각되고 있다. 비 교적 안전하다고 생각되었던 컴퓨터단층촬영 유도 하 시술에서도 소뇌와 뇌간의 경색이 발생하는 등 그 안전성에 대한 근본적인 논란이 있는 것이 사실 이다. 이에 비해 초음파 유도하 경추부 중재술은 방사선 투시기로 볼 수 없는 신경과 혈관 등 주요 구 조물들을 실시간으로 보면서 시술할 수 있고 주사제 가 목표물 주위로 퍼져 나가는 정도와 양상을 동영 상으로 보면서 주사할 수 있다는 큰 장점을 가지고 있다. 따라서 주요 신경과 혈관 등의 구조물로 주사 되거나 그 조직을 손상시키지 않도록 하여 안전성을 높이고 주사제가 퍼지는 영역을 보면서 조절할 수 있기 때문에 안전성과 정확도를 높일 수 있는 우수 성을 가진 방법이다. 더구나 이러한 시술 과정을 시 술자나 환자가 방사선 피폭이 없이 시행할 수 있다 는 큰 장점도 가지고 있지만 아직 해상도가 떨어지 고 시술자의 숙련도에 의해 의존성이 많은 등의 단 Ultrasound-guided Intervention in Cervical Spine