Humans ; Ligamentum Flavum ; Lumbar Vertebrae ; Needles ; Spinal Stenosis/surgery* ; Thoracic Vertebrae/surgery*

STUDY DESIGN: Experimental study. PURPOSE: To determine whether epidural fat (EF) tissue contains mesenchymal stem cells (MSC). OVERVIEW OF LITERATURE: Spine surgeons are unaware of the contents of EF tissue and the reason for its presence between the ligamentum flavum and the dura mater; therefore, EF tissues are routinely eliminated during surgical procedures. However, EF removal causes certain postoperative problems, such as post-laminectomy syndrome. We hypothesized that the EF tissue may play a significant supportive role for the neural structures and other nearby conditions. METHODS: EF tissues were obtained from consenting patients (n=3) during posterior decompression surgery of the lumbar spine. The primary cells were isolated and cultured as per previously described methods with some modifications, and the cell morphology and cumulation were examined. Thereafter, reverse transcription–polymerase chain reaction (RT-PCR), a fluorescence-activated cell sorting (FACS) analysis, and differentiation potency for differentiation into osteoblasts, chondroblasts, and adipocytes were investigated to identify whether the cells derived from EF are MSC. RESULTS: The cells from the EF tissue had a fibroblast or neuron-like morphology that persisted until the senescence at p18. MSC-specific genes, such as OCT4, SOX2, KLF4, MYC, and GAPDH were expressed in the RT-PCR study, while MSC-specific surface markers such as CD105, CD90, and CD73 were exhibited in the FACS analysis. The differentiation properties of EF-MSC for differentiation into the three types of cells (osteoblast, chondroblast, and adipocyte) were also confirmed. CONCLUSIONS: Based on the cell culture, FACS analysis, RT-PCR analysis, and differentiation potent outcomes, all the features of the cells corresponded to MSC. This is the first study to identify EF-MSC derived from the EF tissue.
Adipocytes ; Aging ; Cell Culture Techniques ; Chondrocytes ; Decompression ; Dura Mater ; Fibroblasts ; Flow Cytometry ; Humans ; Ligamentum Flavum ; Mesenchymal Stromal Cells ; Osteoblasts ; Spine ; Surgeons

BACKGROUND: Diffuse idiopathic skeletal hyperostosis (DISH) is characterized by ossification of the enthesis. The diagnosis has been mainly based on the chest or whole spine lateral plain film. Recently, chest or thoracolumbar computed tomography (CT) has been reported to be more reliable for the diagnosis of DISH. The purposes of this study were to investigate the prevalence and location of DISH and evaluate the prevalence of comorbidities, such as ossification of the posterior longitudinal ligament (OPLL) and ossification of the ligamentum flavum (OLF), using whole spine CT. METHODS: Whole spine CT scans of patients over 16 years of age who were examined at Cheju Halla General Hospital between February 2011 and December 2016 were reviewed for this study. The diagnosis of DISH was made according to the modified Resnick criteria. The prevalence of DISH in each age decade and its location were evaluated. Also, the prevalence of OPLL and OLF in DISH patients was investigated. RESULTS: The overall incidence of DISH was 24.4% (40 of 164 cases). There was no case of DISH in patients in their 40s and younger. The percentile incidences of DISH in patients in their fifth, sixth, seventh, eighth, and ninth decades were 20.0% (4 of 20 cases), 32.3% (10 of 31 cases), 40.0% (10 of 25 cases), 34.5% (10 of 29 cases), and 27.3% (6 of 22 cases), respectively. A strong positive correlation between the age decade and the incidence of DISH was noted (r = 0.853, p = 0.007). DISH patients had higher incidences of OLF (22.5%) and OPLL (37.5%). The most common location of DISH was the middle thoracic spine (90.0%) followed by the lower thoracic spine (87.5%). There was one case of DISH involving only the cervical spine. CONCLUSIONS: The incidence of DISH diagnosed by CT was higher than we expected. Whole spine CT can be a valuable modality to evaluate the location of DISH in the cervical and lumbar spine and the comorbidity rates of OLF and OPLL.
Comorbidity ; Diagnosis ; Hospitals, General ; Humans ; Hyperostosis ; Hyperostosis, Diffuse Idiopathic Skeletal* ; Incidence ; Jeju-do ; Ligamentum Flavum ; Longitudinal Ligaments ; Prevalence* ; Spine* ; Thorax ; Tomography, X-Ray Computed

In patients with tumors and spinal cord lesions, inflammation and tissue infection can result in mass effect detection on imaging. As a result, surgical biopsy procedures are often performed on the lesions. We report a rare case in which the thickening ligamentum flavum (LF) appeared to be a tumor in the epidural space of the cervical spine based on imaging findings. A 52-year-old man visited our outpatient clinic with severe shoulder pain and radicular pain in his right arm that had developed gradually after a traffic accident two months earlier. Magnetic resonance imaging of the cervical spine revealed an extradural mass at the cervicothoracic junction level. Suspecting a tumor, spinal decompression surgery was performed and a biopsy of the mass was obtained. At the time of surgery, the LF was thick and compressed the spinal cord. After successful removal of the LF, the spinal cord appeared normal. Histopathological examination confirmed the mass as the LF. The patient was discharged without pain or weakness two weeks postoperatively. This case demonstrated that when the LF of the cervicothoracic junction is thickened, it may be misdiagnosed as a cervical spine tumor compressing the spinal cord.
Accidents, Traffic ; Ambulatory Care Facilities ; Arm ; Biopsy ; Cervical Vertebrae ; Decompression ; Epidural Space* ; Female ; Humans ; Inflammation ; Ligamentum Flavum* ; Magnetic Resonance Imaging ; Middle Aged ; Radiculopathy ; Shoulder Pain ; Spinal Cord ; Spinal Cord Compression ; Spine*

PURPOSE: To investigate the various imaging factors associated with aggravation of lumbar disc herniation (LDH) and develop a scoring system for prediction of LDH aggravation. MATERIALS AND METHODS: From 2015 to 2017, we retrospectively reviewed the magnetic resonance imaging (MRI) findings of 60 patients (30 patients with aggravated LDH and 30 patients without any altered LDH). Imaging factors for MRI evaluation included the level of LDH, disc degeneration, back muscle atrophy, facet joint degeneration, ligamentum flavum thickness and interspinous ligament degeneration. Flexion-extension difference was measured with simple radiography. The scoring system was analyzed using receiver operating characteristic (ROC) analysis. RESULTS: The aggravated group manifested a higher grade of disc degeneration, back muscle atrophy and facet degeneration than the control group. The ligamentum flavum thickness in the aggravated group was thicker than in the group with unaltered LDH. The summation score was defined as the sum of the grade of disc degeneration, back muscle atrophy and facet joint degeneration. The area under the ROC curve showing the threshold value of the summation score for prediction of aggravation of LDH was 0.832 and the threshold value corresponded to 6.5. CONCLUSION: Disc degeneration, facet degeneration, back muscle atrophy and ligamentum flavum thickness are important factors in predicting aggravation of LDH and may facilitate the determination of treatment strategy in patients with LDH. The summation score is available as supplemental data.
Atrophy ; Back Muscles ; Humans ; Intervertebral Disc Degeneration ; Ligaments ; Ligamentum Flavum ; Magnetic Resonance Imaging ; Radiography ; Retrospective Studies ; ROC Curve ; Zygapophyseal Joint

PURPOSE: To describe the technical skills and to estimate the clinical outcomes of port-hole decompression preserving the posterior ligaments during lumbar spinal stenosis surgery. MATERIALS AND METHODS: Between March 2014 and March 2016, a total of 101 patients who underwent port-hole decompression were retrospectively analyzed. The mean age was 71.3 years (58–84 years) and there were 46 males and 55 females. The mean follow-up period was 18 months. Degenerative spondylolisthesis was observed in 24.8% of patients (25/101). Port-hole decompression was performed by removing the central portion of the distal part of the upper lamina with a burr. Then, the contralateral side of ligamentum flavum and hypertrophied facet joints were removed. We estimated the lumbar lordotic angle using radiographs, and measured the depth from skin to upper lamina central area using magnetic resonance imaging axial images. We estimated the mean slip angle and mean degree of slip in preoperative and postoperative radiography in standing flexion and extension. We also measured the operational time, length of skin incision, and blood loss. The clinical results were estimated by a walking distance caused by neurologic intermittent claudication, visual analogue scale, and Oswestry disability index. RESULTS: Most patients were generally older, and the mean lordotic angle was 25.3°, which is considered to be lower when compared with younger people. The mean depth from skin to lamina was mean 5.4 cm. With respect to the radiological results, there were no significant differences between the preoperative and postoperative groups. The operation time, length of skin incision, and bleeding were not increased proportionally to the operation level. The walking distance caused by neurologic intermittent claudication, visual analogue scale, and Oswestry disability index of the post-operative group were all improved compared with the pre-operative group. CONCLUSION: The port-hole decompression, which decompresses the contralateral side while preserving the posterior ligaments and facet joints may be a useful technique for elderly patients with multiple level stenosis, minimizing spinal segmental instability.
Aged ; Constriction, Pathologic ; Decompression ; Female ; Follow-Up Studies ; Hemorrhage ; Humans ; Intermittent Claudication ; Ligaments ; Ligamentum Flavum ; Magnetic Resonance Imaging ; Male ; Radiography ; Retrospective Studies ; Skin ; Spinal Stenosis ; Spondylolisthesis ; Walking ; Zygapophyseal Joint

No abstract available.
Coloring Agents ; Diskectomy ; Elastic Tissue ; Humans ; Hypertrophy ; Intervertebral Disc ; Ligamentum Flavum ; Spinal Stenosis ; Hemosiderin ; Elastin

No abstract available.
Ligamentum Flavum

Foraminal decompression using a minimally invasive technique to preserve facet joint stability and function without fusion reportedly improves the radicular symptoms in approximately 80% of patients and is considered one of the good surgical treatment choices for lumbar foraminal or extraforaminal stenosis. However, proper decompression was not possible because of the inability to access the foramen at the L5–S1 level due to prominence of the iliac crest. To overcome this challenge, endoscopy-based minimally invasive spine surgery has recently gained attention. Here, we report the technical skills required in unilateral extraforaminal biportal endoscopic spinal surgery using a 30° arthroscope to enable foraminal decompression at the L5–S1 level. Two 0.8-cm portals were created 2 cm lateral from the lateral border of the pedicles at the L5–S1 level. After sufficient working space was made, half of the superior articular process (SAP) in the hypertrophied facet joint was removed using a high-speed burr and a 5-mm wide osteotome, whereas the remaining inside part of the SAP was removed using a Kerrison punch and pituitary punch. The foraminal ligamentum flavum should be removed to inspect the conditions of the L5 exiting root and disc. Removing of the extruded disc could decompress the L5 root. The extraforaminal approach using a 30° arthroscope is considered a minimally invasive alternative technique for decompressing foraminal stenosis at the L5–S1 level that preserves facet stability and provides symptomatic relief.
Arthroscopes* ; Constriction, Pathologic ; Decompression* ; Endoscopes ; Humans ; Ligamentum Flavum ; Lumbosacral Region ; Spinal Stenosis ; Spine ; Zygapophyseal Joint

BACKGROUND: Previous studies have shown that measuring the distance from the skin to the ligamentum flavum by ultrasound preceding cervical epidural block can be beneficial in excluding false loss of resistance. However, the measurement value using ultrasound may vary depending on the degree of operator experience. Therefore, we aimed to determine the depth from skin to cervical epidural space by using lateral cervical spine X-ray, which is a more intuitive method. METHODS: We enrolled 102 adult patients who were scheduled to undergo cervical epidural anesthesia for vascular bypass surgery of upper arm. After attaching a steel rod on the needle insertion site, lateral cervical spine X-ray was taken before the epidural procedure. We measured the distance from the steel rod to the midpoint of interlaminar space on the spinolaminar line. The X-ray depth was compared with needle depth. RESULTS: Of the 102 enrolled patients, 18 patients including 13 in whom we were unable to measure X-ray depth were excluded from the analysis. In total, 84 patients were included in the analysis. Concordance correlation coefficient between the X-ray-measured depth and needle depth was 0.925. Bland-Altman analysis indicated a mean difference of ± 1.96 SD with 0.06 ± 0.56 cm. CONCLUSIONS: Lateral cervical spine X-ray can be useful for prediction of the midline depth from skin to epidural space, particularly for operators who are not skilled at spine ultrasound or the use the C-arm fluoroscopy.
Adult ; Anesthesia ; Anesthesia, Epidural ; Arm ; Cervical Vertebrae ; Epidural Space* ; Female ; Fluoroscopy ; Humans ; Ligamentum Flavum ; Methods ; Neck ; Needles ; Skin* ; Spine* ; Steel ; Ultrasonography