Reconstruction surgery for pseudarthrosis after spinal fusion in patients with osteoporosis is difficult and complicated. Despite aggressive surgical intervention, significant proportion of patients develop failure. Therefore, there is suppressing need to find alternative methods. We treated 5 cases using transpedicular impaction allogenic bone graft to improve the fixation strength of pedicle screws and processed fibula to reinforce endplate for the prevention of subsidence. All cases achieved spinal fusion without loosening of pedicle screws and subsidence of intervertebral cages. This augmentation technique together with fibula plate offer a possibility of improving fusion rate not only for pseudarthrosis but also primary cases with reduced bone quality due to severe osteoporosis.

Introduction: Surgical treatment was indicated for patients with pyogenic spondylitis with failed conservative treatment or significant progressive spinal deformity with biomechanical instability. Traditionally, anterior decompression and debridement, followed by an anterior spinal fusion (ASF), is the surgical treatment for pyogenic spondylitis. Some studies have shown that patients may be good candidates for percutaneous pedicle screw (PPS) and rod fixation. Since 2014, posterior fusion using PPS has been performed in addition to ASF. Therefore, this study aimed to compare the postoperative results of only ASF (ASF alone group) with PPS in addition to ASF (PPS combination group) in our hospital.

Methods: We included 8 patients in the ASF alone group who underwent surgery in our hospital between 2003 and 2013 and 11 patients in the PPS combination group after 2014. The causative bacteria, Kulowski's classification, presence or absence of postoperative paralysis, number of postoperative days until C-reactive protein (CRP) -negative conversion, number of days until postoperative bed rest, and presence or absence of bone fusion were investigated.

Results: In the ASF alone group, 2 patients with MSSA, 2 with MRSA, 2 with CNS and 3 with culture negative were observed as the causative bacteria. In the PPS combination group, 3 patients with MSSA, 2 with CNS, 1 with Streptococcus pneumoniae, 1 with GBS, 1 with Edwardsiella tarda, and 3 with culture negative were observed. The culture-positive rates were 62.5% and 72.2% in the ASF alone and 72.2% PPS combination groups, respectively. According to Kulowski's classification, 3 patients were classified as subacute and 5 as chronic in the ASF alone group, and 4 as subacute and 7 as chronic in the PPS combination group (p = 0.703). No postoperative paralytic symptoms were observed. The mean day until CRP-negative conversion was 40.9 and 34.9 days in the ASF alone and 34.9 PPS combination groups, respectively (p = 0.316). The mean day until postoperative bed rest was 52.8 days and 3.7 days in the ASF alone and PPS combination groups, respectively (p = 0.006). Non-union occurred in 37.5% and 9.1% patients in the ASF alone and PPS combination groups, respectively (p = 0.177).

Conclusions: Minimally invasive percutaneous posterior instrumentation provided an alternative method for the treatment of pyogenic spondylitis, resulting in lesser bed rest time compared to the traditional only ASF approach. In our series, the percutaneous technique achieved satisfactory results in a long-term follow-up and showed no adverse effects on infection control.

Introduction: To investigate the treatment and natural course of extensive cerebrospinal fluid (CSF) after spine surgery.

Methods: Eight patients (two females and six males) who underwent spine surgery and exhibited extensive CSF after surgery between April 2010 and March 2020 at a single institution were retrospectively reviewed.

Results: Surgical sites were the cervical spine in five patients and the lumbar spine in three patients. In seven of eight patients, incidental durotomy occurred intraoperatively; incidental durotomy did not occur in one patient. Intraoperative dural repair with suture was not performed in three patients. Additional surgical wound exploration was performed in three patients with symptomatic neurological deterioration or deep infection. In the remaining five asymptomatic patients, CSF improved spontaneously.

Conclusion: Asymptomatic patients with extensive CSF may be able to be treated conservatively.

Introduction: We report four cases of sudden and rapid intraoperative shock, following posterior lumbar interbody fusion (PLIF).

Case Report: A 79-year-old woman underwent uneventful L3-4 PLIF for L3 spondylolisthesis. A suction tube was connected to the wound drainage bag to aspirate blood and clear the surgical field during fascial suture. The patient developed severe hypotension immediately after fascial closure; therefore, she was placed in the supine position and underwent successful cardiopulmonary resuscitation. The subcutaneous layer was sutured in the lateral decubitus position. The patient was monitored in the intensive care unit (ICU) overnight; her level of consciousness and vital signs remained normal. She was discharged on postoperative day 12, following a stable postoperative course. The 3 other patients described in this study also underwent one- or two-level PLIF. Intraoperative blood loss and operation time were within the normal ranges in these patients. No patient developed an obvious intraoperative dural tear, required prolonged ICU stay, or showed permanent motor function loss.

Conclusions: In our view, suction of the surgical field by suction tube led to a high negative pressure in the extradural space immediately after completion of fascial closure, which precipitated neurogenic shock in these patients.

Background: Pedicle fracture is a common complication of spinal fusion surgery but rarely requires early reoperation. We present three cases of pedicle fracture at the end of the instrumented vertebrae after spinal fusion surgery, requiring early reoperation.

Case 1: A 72-year old man underwent L2-L4 TLIF for treating lumbar spinal canal stenosis. On the seventh postoperative day, his lower extremity pain flared up, and computed tomography (CT) showed that the L2/3 cage was dislodged thus, he underwent reoperation. Intraoperatively, a fracture of the L2 pedicle was found, and the screw diameter was increased in size and the screw hole was filled with HA granules.

Case 2: A 79-year old man underwent T9-L5 decompression and fixation for pseudoarthrosis and spinal canal stenosis after a T12 fracture. CT showed a fracture of the L5 pedicle, and the patient underwent extension of the fixation to the iliac bone.

Case 3: A 72-year old woman underwent corrective fusion of L1-L5 for lumbar degenerative scoliosis. Suspecting foramen stenosis at L5/S, decompression of the foramen and extension of the fixation to the iliac bone were performed, but a fracture of the right L5 pedicle was found intraoperatively.

Conclusion: The new lower extremity pain after lumbar fusion surgery may be due to a pedicle fracture. Diagnosis of the fracture is difficult even with CT, and this possibility should be considered.

Introduction: Methotrexate-associated lymphoproliferative disorder (MTX-LPD) has been reported as a lymphoma developing in a patient with methotrexate administration. Here we report a rare case of MTX-LPD growing in the thoracic spine.

Case Report: The patient was a 37-year-old female who showed paraplegia while receiving MTX therapy for 10 years for rheumatoid arthritis (RA). The sensation distal to the bilateral inguinal regions was disappeared except around the anus, and no muscle contraction was observed in both lower extremities. Magnetic resonance imaging (MRI) demonstrated occupied lesion which progressed into the spinal canal at the level of Th11 vertebra. We emergently performed Th10-11 laminectomy and tumor resection because she showed progressive paraplegia. The pathological examination indicated malignant lymphoma, suggesting MTX-LPD. The remaining legion showed spontaneous remission 2 weeks after MTX withdrawal, however, it subsequently recurred in 4 weeks.

Conclusions: Because MTX-LPD can be developed in tissues other than lymph nodes, such as in bones and joints, we need to take MTX-LPD into a candidate when we diagnose spinal tumor in patients with MTX treatment.

Introduction: Pelvic ring fractures potentially cause several complications that include neuropathy, severe complication that affects a patient's quality of life. However, despite its seriousness, neurologic symptoms in the patient are often unnoticed due to crucial pathologies existing at the acute stage of the traumatic injury. Here we report on a case of a patient with a pelvic ring fracture associated with delayed S1 radiculopathy, which was successfully treated by a surgical nerve decompression four months after the injury.

Case Report: A 23-years-old woman was emergently seen after a crush injury by building materials during her work. A pelvic ring fracture was diagnosed, and surgical osteosynthesis was performed six days after the injury. On rehabilitation, weight-bearing on her bilateral legs was prohibited, and partial weight-bearing was started four weeks after the surgery. Immediately after the start of weight-bearing, she complained of pain and muscle weakness in her right leg. Right S1 nerve compression was suspected by CT and MRI examinations. We treated her conservatively, but her symptoms were persistent. We conducted surgical decompression on the right S1 nerve four months after the injury, and the patient showed resolution of pain and muscle weakness.

Conclusions: We experienced a case of delayed S1 radiculopathy developed after a pelvic ring fracture. Although the occurrence of neurologic disorder caused by a pelvic ring fracture is rare, clinicians should consider a potential risk of neurologic disorder at the chronic stage of pelvic ring fractures.