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Choll W Kim

Publications and source records attributed to Choll W Kim.

9 recordsLinked to original sources

A preclinical post laminectomy rat model mimics the human post laminectomy syndrome.

Chronic low back pain with sciatica complicating post laminectomy surgery is poorly understood. It is likely that some aspects of persistent pain of the syndrome results from spinal facilitation in which there is lowering of pain excitation levels. A small animal preclinical model is needed that mimics the clinical condition to permit detailed studies of the underlying altered neurochemistry of the sensory pathways. We propose herein a rat laminectomy model containing the elements required for study of the neurobiology of the condition. The model consists of a surgical laminectomy that includes L5 spinal nerve manipulation and disc injury, elements necessarily employed in human disc herniation surgery. At 8 weeks post laminectomy the proposed model demonstrates paraspinous muscle spasm, tail contracture, behavioral pain behavior, tactile allodynia, epidural and nerve root scarring, and nerve root adherence by scar to the underlying disc and adjacent pedicle. Two underlying pain facilitation states are invoked in the clinical condition: (1) an inflammatory state required to achieve wound healing; and (2) a nerve injury state resulting from nerve manipulation and subsequent epidural scarring, spinal nerve scarring, and spinal nerve tethering to the adjacent disc and pedicle. Both pain facilitation states are active in the model.

Analysis of Variance↗

Personal watercraft injuries: 62 patients admitted to the San Diego County trauma services.

OBJECTIVE: To determine the types and patterns of injuries seen in personal watercraft (PWC) accidents. DESIGN: A retrospective review of medical records and imaging studies. SETTING: Level 1 and 2 trauma centers in San Diego County, California. PATIENTS/PARTICIPANTS: Trauma patients treated for PWC-related injuries between 1984 and 1997. MAIN OUTCOME MEASUREMENTS: Evaluation of injury patterns via chart review and imaging studies. INTERVENTION: None. RESULTS: A total of 62 patients were identified. The average age was 23 years (range 2-59 years). There were 41 males and 21 females. A total of 35 injuries (56%) involved another PWC. Of patients, 24 had loss of consciousness, with 8 closed head injuries. There were 17 chest injuries, with 10 pneumothoraces, and 16 lower extremity fractures (9 femur, 3 hip, 3 tibia-fibula, and 1 patella). CONCLUSIONS: Injuries related to PWC have increased dramatically over the past several years, becoming one of the leading causes of recreational water-sport injuries. This study supports a high level of awareness for significant blunt trauma to the chest and lower extremities in patients involved in PWC accidents.

Adolescent↗

Metastatic disease of the spine: evaluation and treatment.

Treatment of patients with metastatic disease of the spine continues to be a challenging problem. Advances in imaging studies and surgical techniques have improved patient outcomes with operative intervention. However, the lack of a validated set of criteria to determine spinal instability makes patient selection for surgical intervention difficult. Multiple classification systems that assist surgeons in determining appropriate operative candidates have been proposed. We will review current information on the evaluation and treatment of metastatic disease of the spine and discuss classification systems that assist in determining appropriate operative candidates.

Algorithms↗

Safety of supplemental endplate screws in thoracic pedicle hook fixation.

OBJECT: The AO Universal Spine System thoracic pedicle hook design includes a fixation screw that passes obliquely through the inferior facet into the pedicle to engage in the posterior portion of the superior vertebral body endplate. This endplate screw provides additional purchase at the hook-bone interface. To determine the safety of this fixation system the authors reviewed the operative notes, radiographs, and outcomes of patients who underwent placement of endplate screws. METHODS: Thirty-six patients (16 male and 20 female patients) who required posterior thoracic instrumentation for spinal deformity (11 cases), neoplasm (15 cases), and traumatic injury (10 cases) were included in this study. One hundred sixty-four endplate screws were placed (mean 4.3/patient) to augment pedicle hooks for posterior thoracic instrumentation. The number of instrumented levels ranged from seven to 16. The positions of the screws in relation to the pedicle, neural foramen, spinal canal, and endplate were evaluated by assessing plain radiographs and computerized tomography scans (10 cases). Eighty-two screws (56%) were in ideal position. Lateral pedicle wall perforation occurred with 51 screws (35%). Three screws violated the medial wall and nine screws violated the superior or inferior walls of the pedicle. There were no clinical sequelae associated with any of the malpositioned screws. Adequate follow-up radiographic data were not available in five patients. The mean follow-up duration was 19.8 months (range 3-61 months). Two patients required revision surgery at 3 months and 18 months, respectively, because of hook/endplate screw displacement. There was also one case of an endplate screw fracture without hook displacement that was discovered during subsequent revision surgery. The remainder of the endplate screws and associated pedicles hooks maintained their original positions. There was no case of spinal cord, nerve root, pulmonary, or vascular injury. CONCLUSIONS: The placement of supplemental endplate screws in conjunction with thoracic pedicle hooks can be conducted safely.

Adolescent↗

Bowel and bladder function after major sacral resection.

Major sacral resection generally is reserved for patients with malignant lesions. Because of the uncommon nature of these diseases, little is known about outcomes of surgical treatment. The current authors describe the retrospective analysis of bowel and bladder function in patients having major sacral resection at their institution during a 10-year period. Fifty-three patients were identified. In patients who had unilateral sacrectomy, in whom the contralateral sacral nerves were preserved, normal bowel and bladder function was retained in 87% and 89%, respectively. In patients who had bilateral S2-S5 nerve roots sacrificed, all had abnormal bowel and bladder function. In patients who had bilateral S3-S5 resection, normal bowel and bladder function was retained in 40% and 25%, respectively. In patients who had bilateral S4-S5 resection, with preservation of the S3 nerves bilaterally, normal bowel and bladder function was retained in 100% and 69%, respectively. In patients who had asymmetric sacral resections, with preservation of at least one S3 nerve root, normal bowel and bladder function was retained in 67% and 60%, respectively. These results show that unilateral resection of sacral roots or preservation of at least one S3 root in bilateral resection preserves bowel and bladder function in the majority of patients.

Adolescent↗

Relationship between surgical margins and local recurrence in sarcomas of the spine.

The combination of improved resection, stabilization, and fusion techniques allows for more aggressive removal of malignant spinal tumors with acceptable mortality and morbidity. Thirty consecutive patients with primary sarcomas of the mobile spine, who were operated on at the authors' institution from January 1970 to December 2000, were included in the current study. Demographic information, tumor location, type of resection, resection margins, local recurrence, and overall survival data were retrieved and analyzed. Treatment consisted of en bloc resection in 12 patients (40%) and piecemeal resections in 18 patients (60%). The resection was classified as wide in seven patients (23.3%), marginal in three patients (10%), and intralesional in 20 patients (66.7%). Pathology reports showed tumor-free resection margins in 12 patients (40%). In the remaining 18 patients (60%), resection margins were positive and resulted in a fivefold increase in the risk of a local recurrence. Ninety-two percent of the patients with local recurrence died of sequelae associated with the local recurrence. Primary sarcomas of the mobile spine in certain cases, can be removed completely with tumor-free resection margins. En bloc resection with tumor-free margins provides substantial improvement in overall survival.

Adolescent↗

Treatment of post-traumatic ankle arthrosis with bipolar tibiotalar osteochondral shell allografts.

We report on tibiotalar osteochondral shell allografts for post-traumatic ankle arthropathy in seven patients. Average follow-up was 148 months (range, 85 to 198). Patients were evaluated by a questionnaire, SF-12 survey, ankle score, physical exam and radiographs. The ankle score increased from 25 preoperatively to 43 at latest follow-up (maximum score 100). SF-12 scores increased from 30 to 38 (Physical Component) and 46 to 53 (Mental Component). The failure rate was 42%. Four of seven patients reported good or excellent results. Five patients stated they would undergo a similar procedure again. Complications included graft fragmentation, poor graft fit, graft subluxation, and non-union. Follow-up radiographs demonstrated joint space narrowing, osteophytes, and sclerosis, even in cases with excellent clinical status. Fresh osteochondral shell allografting may provide a viable alternative for the treatment of post-traumatic ankle arthrosis in selected individuals.

Adult↗

Response of fractured osteoporotic bone to polymethylacrylate after vertebroplasty: case report.

BACKGROUND CONTEXT: Polymethylmethacrylate (PMMA) is the most commonly used bone cement for vertebroplasties to treat osteoporotic vertebral compression fractures (VCFs). Several studies have described the reaction of normal bone to PMMA, but it is still unclear how fractured osteoporotic bone responds to PMMA. PURPOSE: To describe the response of fractured osteoporotic bone to PMMA after vertebroplasty. STUDY DESIGN/SETTING: Case report. METHODS: A 69-year-old woman with a previous vertebroplasty at T8 to treat an osteoporotic VCF was admitted to the hospital after she developed lower extremity motor weakness, diffuse hypoesthesia and decreased rectal tone. Magnetic resonance imaging studies of the thoracic spine showed that she had severe spinal cord compression at the level of T8 and T9, as well as akyphotic deformity. A corpectomy of T8 and T9 was performed as part of a spinal cord decompression procedure. Tissue from vertebral body T8, intervertebral discs T7-T8 and T8-T9 and the PMMA implant were then submitted for histologic evaluation. RESULTS: Vertebral body T8 demonstrated viable bone trabeculae, osteoid. fibrosis, granulation tissue and multinucleated giant cells containing PMMA. Scattered necrotic bone fragments were identified throughout the vertebral body, most evident near the PMMA. PMMA leakage into the T7-T8 disc was identified without significant disc inflammation or necrosis. CONCLUSION: Fractured osteoporotic bone is capable of undergoing a reparative healing response after vertebroplasty using PMMA.

Aged↗

Topical high-molecular-weight hyaluronan and a roofing barrier sheet equally inhibit postlaminectomy fibrosis.

BACKGROUND CONTEXT: The relevance of epidural fibrosis to failed back surgical outcomes remains controversial. Previous studies on the correlation between epidural fibrosis and clinical outcome after laminectomy are inconclusive, and clinical approaches applied to reduce postlaminectomy spinal canal scarring have produced mixed outcomes. PURPOSE: Improved preclinical models are required to address the fundamental question of the relationship between postlaminectomy fibrosis and chronic pain. This study is directed at establishing small animal postlaminectomy models characterized by significantly reduced scar within the spinal canal postoperatively. Such preclinical models are offered as a platform for future studies to explore the potential relationship between postlaminectomy epidural fibrosis and persistent neuropathy with its potential for altered spinal mechanisms for pain processing, so-called spinal facilitation. Such experiments could be constructed in these models for comparison of pain behavior and its underlying neurochemistry both in the presence and absence of extensive postlaminectomy epidural scar. STUDY DESIGN/SETTING: A modified rat laminectomy model was employed to assess epidural fibrosis using a quantitative biochemical collagen assessment approach along with correlative histology. This group served as the control for comparison with groups in which antifibrotic measures were employed. We compared antifibrotic efficacy of a bioabsorbable roofing barrier sheet placed over the laminectomy defect with topical high-molecular-weight hyaluronan (HMW HA) gel, each applied postoperatively to prevent proliferative epidural scarring. Routine biomechanical tensile strength testing was employed to assess wound-healing strength. METHODS: A bilateral laminectomy (L5 and L6) with associated unilateral disc injury (L5-L6) was performed in 98 male Harlan Sprague-Dawley rats. The laminectomy models described incorporated a unilateral disc injury at L5-L6 because herniated disc material has been shown to contribute proinflammatory cytokines in the postoperative wound. Five groups were employed for the study: 1) normal controls without surgery; 2) a laminectomy-disc injury group without treatment; 3) a laminectomy-disc injury group treated with topical HMW HA gel; 4) a laminectomy-disc injury group treated with 0.2-mm thick bioabsorbable roofing barrier sheet in which a protected space was maintained between overlying paraspinous muscles and the dura and 5) a 0.02-mm thin barrier sheet treatment group in which the sheet was placed directly on the dura. The animals were sacrificed at 3- and 8-week postoperative intervals for analysis. The dissected specimens were studied biochemically for hydroxyproline content to estimate total collagen within the canal and on the dura between L4 and L7. Additional specimens were prepared histologically and stained with Masson-Goldner Trichrome stain to confirm presence of proliferative collagen and to describe the presence or absence of wound-healing scar adherence to the dura. The surgical incisions were studied biomechanically by uniaxial tensile testing to determine ultimate force, strain and prefailure stiffness. Statistics were performed using analysis of variance. RESULTS: Gross appearance and histology studies showed that the untreated laminectomy group demonstrated postoperative scar formation that is adherent between the wound and the dorsum of the dura mater in both 3- and 8-week groups. Proliferative scar was substantially increased grossly between the 3- and 8-week intervals. By gross observation there was adherence of the L5 spinal nerve to the underlying disc and adjacent pedicle on the disc injury side. Gross observation of treatment groups, in contrast, disclosed that both the 0.2-mm thick roofing barrier sheet and topical HMW HA gel each prevented scar attachment to the dural sleeve at both the 3- and 8-week postoperative intervals. Furthermore, both the HMW HA gel and 0.2-mm thick roofing barrier sheet treatment groups had significant reduction of total collagen content in the laminectomy specimens measured biochemically at the two time periods compared with the untreated controls. Histologically, the HMW HA gel and the 0.2-mm thick barrier sheet findings were consistent with the gross observations concerning lack of adherence between scar of the overlying wound and the dura. Notably, both the 0.2- and the 0.02-mm barrier sheets became enveloped by a fibrotic envelope consistent with a foreign body reaction. In the group in which the 0.02-mm thin sheet was placed within the canal on top of the dura, there was an increase of fibrosis around the sheet within the canal leading to a space-occupying mass within the canal. Although the 0.2-mm thick roofing barrier placed external to the canal became enveloped by scar, it appeared to attract proliferative scar away from the epidural space, leaving the dura relatively free of scarring or adherence to overlying tissues. The mechanical properties of the incisional wound increased significantly between 3 and 8 weeks. The ultimate strength, stress, strain and stiffness of the several groups were similar at each time point. CONCLUSION: These results provide two preclinical rat laminectomy models of potential usefulness for the future study of the relevance of epidural fibrosis to behaviorally defined pain states, and for the study of the potential of an altered neurochemical signature in postlaminectomy pain conditions. Such preclinical models have become standard in studies of pain behavior and its neurochemistry in preclinical sciatic nerve and spinal nerve injury models, and should be of utility in the studies of postlaminectomy fibrosis. There was progressive scar proliferation and maturation in the untreated postlaminectomy group in the postoperative interval between 3 and 8 weeks. HMW HA gel applied topically and a 0.2-mm thick bioabsorbable Macropore sheet used as a roofing barrier each significantly reduced postlaminectomy proliferative scar without affecting the integrity of incisional wound healing. However, if the 0.02-mm thin barrier sheet used in this study is placed within the canal in contact with the dura and adjacent to the pedicles, the process of reabsorption results in a fibrotic mass within the canal. The preferred barrier sheet placement for this model is clearly in a roofing position bridging over the open epidural space. It must be placed in a manner to block off the paraspinous muscle healing response and still leave a gap between the sheet and the dura.

Adjuvants, Immunologic↗