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I. World-Class Korean Spine Research1. Basic Information on the Spine2. History of Korean Neurosurgery3. History and Development of the Korean Spinal Neurosurgery Society

II. Introduction to Prominent Diseases1. Spinal tumor 2. Degenerative spinal disease

(cervical and lumbar herniated intervertebral disc [HIVD])3. Myelopathy 4. Deformity: Osteoporosis, adolescent idiopathic scoliosis (AIS),

adult (degenerative) deformity, and revision surgery

III. Medical Korea1. Why Korea 2. Cases of Overseas Patients

IV. Institutions that specialize in treating spinal diseases in Korea

Contents

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I. World-Class Korean Spine Research

I. World-Class Korean Spine Research

◦ Definition of the spineThe spine is made up of bones called vertebrae that form the vertebral column or the backbone.

◦ Composition and role of the spineThe spine, which supports the weight at the center of the body, consists of 33 vertebrae: 7 cervical vertebrae that support the neck, 12 thoracic vertebrae that hold the chest and back, and 5 lumbar vertebrae that support the waist), 5 sacral vertebrae in the hip region, and 4 coccygeal vertebrae. The spine has an S-shaped curve when viewed from the side, and such shape keeps the balance of the body and relieves shocks through elasticity similar to a spring, so maintaining the said shape is important to ensure a healthy spine. Moreover, the spine protects the spinal cord, which is part of the central nervous system. Therefore, it is a very important part of the body, which is why it is called the “girder of the body.”

◦ Change of spinal diseases in each eraSpinal diseases are common that 80% of the world’s population have experienced having them at least once in their lives. In the past, spinal diseases were regarded as for the elderly, but as modern people maintain unhealthy lifestyles, such as lack of exercise, obesity, prolonged sitting, etc., spinal diseases have become common regardless of sex or age.

In particular, young people often have spinal diseases, and the main causes are incorrect postures and change of lifestyles because of development and the increased use of information devices such as IT gadgets, smartphones, computers, tablet PCs, etc.

The World Health Organization (WHO) designated October 16 as “World Spine Day,” and it was celebrated for the first time in January 2000 to draw the attention on spinal diseases that are becoming chronic diseases of modern people.

2. History of Korean Neurosurgery

The spine surgeons of Korea are divided into surgeons from the Department of Neurosurgery (NS) and the Department of Orthopedic Surgery (OS). During World War II, doctors who were dispatched by the Copenhagen University Hospital of Denmark treated the spines of wounded soldiers and passed on their neurosurgical skills to Korean army physicians. That period was the beginning of the neurosurgery history of Korea.

[Figure 1] Structure of the spine

Cervical vertebrae

Thoracic vertebrae

Lumbar vertebrae

Sacrum and Coccyx

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When the war ended, army physicians left for the United States, Canada, Europe, etc., to undergo training. On March 11, 1961, 18 neurosurgeons established the Korean Neurosurgical Society (KNS), and in 1963, the first Korean Neurosurgical Board Examination was held, which produced 31 neurosurgeons. In 1973, the first microsurgery was performed, and by the 1980s, it was commercialized. However, at that time, spine surgeries were limited to those for disc diseases, spinal stenoses, etc.1)

As of 2015, there are 2,562 neurosurgeons, 432 residents, and 86 training hospitals. In addition, about 100 people have neurosurgeon’s licenses.

3. History and Development of the Korean Spinal Neurosurgery Society

(1) HistoryThe Korean Spinal Neurosurgery Society that was established in 1987 has grown to a very large research society with about 1,600 members through sacrifices and services of many elders like Hwan-young Jeong, Young-soo Kim, etc. for the last 30 years. Currently, the Korean Spinal Neurosurgery Society has six subsocieties and two branches so that the growth has continued in each area. Also, each one is competitive enough to hold at least two academic conferences every year, where world-class research is shared and treatments are performed so that doctors around the world would visit Korea to learn about the excellent spine treatments in the country.

[Picture 1] Overseas doctors during training

(2) Academic activityThe Korean Journal of Spine published by the Korean Spinal Neurosurgery Society is registered in PubMed Central (PMC)*.* PubMed Central (PMC) is an electronic library of the biomedical and life sciences journal literature of the U.S. National Library of Medicine (NLM) of the National Institutes of Health (NIH).

◦ Vol. 1 No. 1 published in 2004 (first issue: 2 reviews, 2 laboratory investigations, 14 clinical articles, 5 case reports, 160 pages)

◦ Vol. 13 No. 1 published in 2016 (5 clinical articles, 2 case reports, 1 technical note, 40 pages)

1. Spine tumor

By showing the overall status of Korean spinal tumor surgeries, the world-class level of Korean spinal tumor treatment is presented based on the objective data of the Health Insurance Review and Assessment Service of Korea. The Health Insurance Review and Assessment Service database can exist because of the National Health Insurance System that covers all medical institutions in Korea. The Health Insurance Review and Assessment Service data are based on ICD-10 codes, so an analysis was performed using additional conditions based on ICD-10. In addition, research articles that are published in international journals and written by Korean spine surgeons were used as references.

(1) Understanding spinal tumor A spinal tumor means any tumor that grows in the spine. It can be classified as a primary spinal tumor or a metastatic spinal tumor.

(2) Spinal tumor treatment and surgery① Primary spinal tumor

◦ Clinical symptoms A primary spinal tumor refers to a new tumor that has grown in the spine. Tumors can be classified as a spinal cord tumor, which occurs intrathecally, and a spinal column tumor, which occurs in the vertebrae. In many cases, abnormal sensation or paralysis of the arms and legs progress insidiously for a few months or years, which might be accompanied by pain.

◦ DiagnosisA simple X-ray can be used to diagnose a tumor, but most of the time a magnetic resonance imaging (MRI) scan is most important in the imaging.

II. Introduction to Prominent Diseases

1) Sung-nam Hwang, “History of Korean Neurosurgery,” World Neurosurgery 84, No. 2 (August 2015): 192–196.

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◦ TreatmentA primary spinal cord tumor, particularly a benign tumor, must be completely removed while maintaining neurologic functions. To do this, the tumor is safely removed using a nervous system monitor, and sometimes, the tumor is removed while the patient undergoes a temporary paralysis.

◦ Incidence rate of primary spinal tumorsThe number of patients with a newly diagnosed spinal tumor from 2009 to 2012 was 1,600. Among them, 373 (23.3%) patients had malignant primary spinal tumors, whereas 1,227 (76.7%) patients had benign or borderline tumors. A spinal cord tumor is the most common type of malignant tumors (C72.0, 51.5%) and benign or borderline tumors (D33.4, 66.2%). The total incidence rates for C72.0 and D33.4 were 0.99 and 3.24 per 100,000 people, respectively.

In terms of gender, the incidence rates of primary malignant spinal tumor per 100,000 people were 1.14 among males and 0.84 among females (P = 0.004). The incidence rates of new diseases related to benign or borderline primary spinal tumor per 100,000 people were 2.91 among males and 3.57 among females (P ≦0.001) [Table 4].

[Table 4] Primary and Metastatic Spinal Tumor Incidence Rate Based on the Selected Characteristics in Korea (2009–2012)

Source: The Health Insurance Review and Assessment Service

[Table 5] Primary and Metastatic Spinal Tumor Incidence Rate among Korean Males and Females (2009–2012)


② Metastasis spinal tumor

◦ SymptomsPain, which can be local or neuromuscular, is reported by 95% of the patients. Such pain is continuous, and staying in a supine position does not relieve it, which means that it occurs even when the patients are at rest or asleep. Removing a spine tumor might induce spine deformity or instability.

◦ DiagnosisA spinal tumor can be diagnosed using X-ray, computed tomography (CT), or MRI. If an abnormal finding is observed through a diagnosis, a biopsy is performed.

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◦ TreatmentA treatment must be performed using a multidisciplinary approach that combines chemotherapy, radiation therapy, and surgical treatment. If a gait disturbance occurs, the patient’s walking function can be recovered within three days of a placebo occurrence. In addition, 90% of the patients whose strength in their lower extremities is greater than Grade IV can recover their walking function as well.

◦ Metastatic spinal tumor incidence rateThe metastatic spinal tumor incidence rate was 35.13 per 100,000 people. As the survival rate of cancer patients has been gradually increasing, the significance of metastatic spinal tumor will increase gradually. Metastatic spinal tumor showed an increasing tendency as patients become older (P≦0.001, Table 2); in particular, the group that has the highest incidence rate was composed of patients in their 70s–90s.

In Korea, metastatic spinal tumors caused by lung cancer were the most common (28.1%), followed by those caused by liver cancer (12.9%), which is particularly common in Korea, breast cancer (10.2%), colon cancer (9.1%), stomach cancer (8.9%), prostate cancer (5.8%), rectal cancer (4.0%), pancreatic cancer (3.8%), and others [Table 6].

[Table 6] Status of Metastatic Spinal Tumors in Korea (2009–2012)


◦ Status of metastatic spinal tumors for each primary tumorKorean patients with metastatic spinal tumors can be classified based on their primary tumors caused by the following: lung cancer, liver cancer, breast cancer, colon cancer, stomach cancer, and prostate cancer. In terms of the primary tumors of metastatic spinal tumors, 7.36 persons had lung cancer, 3.32 persons had liver cancer, 2.59 persons had breast cancer, and 2.37 persons had colon cancer per 100,000 people [Table 7].

[Table 7] Metastatic Spinal Tumor Incidence Rate and Characteristics in Korea (2009–2011)


(3) Development process of the treatment and surgery for spinal tumorsKorea has cutting-edge radiation technology such as Novalis, Cyberknife, and proton therapy. Relevant societies (radiosurgery societies) are active, and the number of radiosurgeries has been increasing gradually, so the nonsurgical tumor treatment in the country is of world-class level.

[Table 8] Primary and Metastatic Spinal Tumor Incidence Rate (2009–2012)

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(4) Successful cases of spinal tumor surgeries[Figure 5] Total en bloc spondylectomy for the removal of a giant-cell tumor in the thoracic

spine

A. Tumor in the thoracic spine B. After the removal of a vertebra C. After the surgery

• Patient: A patient who reported pain in his/her thoracic spine• Diagnosis: A giant-cell tumor in the patient’s thoracic spine• Surgery: Total en bloc spondylectomy• Result: The patient was able to return to a normal life after full recovery.

[Figure 6] Total spondylectomy for the removal of a meningioma

Before/after surgery for a patient with meningioma

• Patient: A 61–year-old woman who reported abnormal sensations in both her arms (particularly her left arm)

• Diagnosis: Meningioma• Surgery: Total spondylectomy• Result: The abnormal sensation in both of her arms were eliminated after the surgery.

[Figure 7] Radiosurgery for the removal of a metastatic spinal tumor in the cervical spine

MRI of a patient who was cured through radiation therapy

• Patient: A 48–year-old woman who reported pain in her neck because of a spinal tumor• Diagnosis: A metastatic spinal tumor• Surgery: Radiosurgery• Result: The neck pain was eliminated, and it has not recurred in two years.

(5) Spinal tumor surgery recurrence rate, average length of stay, and average treatment cost

◦ Spinal tumor surgery recurrence rateThe success rate of a spinal tumor surgery can be based on the average recurrence rate. As there are many types of spinal tumors, comparing each one with those reported in other countries is nearly impossible, but a recent research article that studied meningioma can be used as a reference.

For 12 years, researchers in Japan followed up on patients who underwent surgery for their meningioma 12 years prior and found a recurrence rate of 32%. However, for Korean patients with meningioma, the recurrence rate was reported to be 14% according to hospital records (Kim et al. Eur Spine J [25: 4025–4032, 2016]).

◦ Average length of stay in a hospitalTable 9 shows the total number of days in one year when patients with spinal tumors used a hospital (outpatient + inpatient), and based on the data, the average is between 70.8 and 78.9 days.

[Table 9] Annual Hospital Stay (Days) of a New Patient with Spinal Tumor in South Korea (2009–2011)


◦ Average treatment costAs of 2011, the yearly treatment costs were USD 15,223 for primary spinal tumors, USD 6,502 for primary benign and borderline tumors, and USD 16,038 for metastatic spinal tumors. The cost represents the total medical expenses of a patient for one year. Of course, the costs were for Korean patients who are covered by medical insurance, but they are still data that can be used as references [Table 10].

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[Table 10] Annual Medical Expenses of a New Patient with a Spinal Tumor in Korea (2009–2011)


As there is no research article that shows the data of all people in other countries with spinal tumors, an accurate comparison cannot be conducted. Nevertheless, according to data from the United States in 2006, a research article stated that the admission cost alone in the country for the metastatic spinal tumor ranged from USD 17,143 to USD 36,295 for one year. Considering that the data was made about 10 years ago, it can be said that the medical cost in Korea is much lower than that in the United States.

The yearly medical cost for the treatment of a metastatic spinal tumor was between USD 12,734 (primary tumor site, prostate) and USD 15,556 (primary tumor site, lung). The admission cost alone ranged from USD 5,570 ± 6,150 to USD 2,117 ± 3,201 [Table 11].

[Table 11] Annual Medical Cost and Hospital Stay of Patients Newly Diagnosed with Metastatic Spinal Tumors Categorized by Primary Tumor Sites (Korea, 2009–2011)


(6) Korea’s international status in spinal tumor treatment and surgery

◦ Status of holding the Korean Spinal Tumor Research Society Academic ConferencesThe society with neurosurgeons who mainly specialize in spinal tumors has been holding academic conferences at least twice a year since 2010. In every conference, about 100 spine neurosurgeons gather, and some of the physicians from the Department of Radiation Oncology and the Department of Oncology participate as well. In particular, oncologists attend lectures every time so that a multidisciplinary treatment strategy can be established.

[Table 12] Status of Holding the Korean Spinal Tumor Research Society Academic Conferences

No. Date Location Topic

1 2010.02.06. Seoul National University Hospital Metastatic spine tumor

2 2010.08.21. Seoul National University Hospital Primary spine tumor

3 2011.02.19. Korea Institute of Radiological and Medical Cancer-related bone disease

4 2011.08.20. Seoul National University Hospital Spine radiosurgery

5 2012.02.11. Samsung Medical Center Stability in spine tumor surge ry

6 2012.08. Hanyang University Seoul Hospital Socioeconomic aspect of spinal metastasis treatmentSurgical treatment of neurogenic tumors

7 2013.02.16. Seoul National University Hospital Quality of life in spinal metastasis patientsSystemic treatment of spinal metastasis

8 2013.08.17. National Cancer Center Neurogenic tumor (Neurofibromatosis)

9 2014.02.15. Hanyang University Seoul Hospital Spinal tumor resection and reconstruction Cervical spine (NS), lumbosacral spine (OS)

10 2014.08.23. Inje University Paik HospitalOrgan specific metastatic tumor (Breast

cancer)Spine sarcoma

11 2015.02.14. Samsung Medical CenterOrgan specific metastatic tumor (Prostate

cancer)Solitary spinal metastasis

12 2015.08.22. Seoul National University Bundang Hospital Hemostasis in spine tumor surgery

13 2016.02.13. Chosun University Hospital Spine involvement of hematologic malignancyDidactic course lectures; metastatic spine tumors

2. Degenerative spinal disease (cervical and lumbar HIVD)

(1) Understanding degenerative spinal diseaseAs the aged population has greatly increased in the recent years, degenerative spinal diseases have become very common because of the lack of physical activities of modern people and lifestyles that can easily lead to obesity. In addition, surgeries and treatment costs for them are increasing as well. Degenerative spinal diseases are those in which degenerative changes progress in the spine because of the continuous use of spinal segments, and the most common of these diseases are spine instability including disc disease (herniation of the intervertebral disc; occurs in the neck, back, waist, etc.), spinal stenosis, and spondylolisthesis. The symptoms of most of these diseases can be eliminated through nonsurgical treatments, such as pharmacotherapy, injection, exercise, etc., but if severe pain persists and neurological damages progress because of nerve compression, surgical treatment is required. In fact, surgeries are required for less than 10% of the patients who report symptoms of degenerative spinal diseases.

(2) Treatment and surgery for degenerative spinal diseasesA conventional surgery for degenerative spinal diseases is performed by making an incision on the skin around the lesion, removing the muscles and tendons around it, pulling the nerve, and removing the disc that compresses the nerve or relieving the nerve. However, such conventional surgery has disadvantages such as a large incision area on the skin; damages on normal structures, such as the muscles and tendons; heavy bleeding; and

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a long recovery period for patients. As spine surgeries have developed, microscopic spine surgeries using a surgical microscope have helped minimize such problems, and recently, endoscopic spine surgeries using spine endoscopy have extremely minimized problems that occur during a surgery such as hematoma, inflammation, muscle damage, tendon injury, etc.

[Figure 8] Development of surgeries of degenerative spine diseases

Conventional discectomy with incision Conventional nerve

decompression with incision Conventional spinal fusion with incision

Conventional spine surgery

Microscopic discectomy Microscopic nerve decompression Microscopic spinal fusion

Endoscopic discectomy Endoscopic nerve decompression Minimally invasive

spinal fusion

Microscopic spine surgery

Minimally invasive spine surgery

(3) Development of treatment and surgery for degenerative spinal diseasesAs modern science and medicine have developed, there has been an increase in the demand to minimize the damages caused by surgery, and minimally invasive spine surgery has been developing as well. Minimally invasive spine surgery is a surgical method that operates on a lesion using a spine endoscopy, minimal retractor, percutaneous screws, etc., and compared with the preexisting surgical methods, it minimizes the damages on the nerves, muscles, and tendons, hastening the recovery and reversion to normalcy after surgery. Therefore, it is effective for patients who would want to return to their happy lives quickly in this era with an increased average life span.

◦ Areas of minimally invasive spine surgeryThe areas of minimally invasive spine surgery have recently expanded, and the following are the main areas for minimally invasive spine surgery.

- Spine fracture: ■ Vertebroplasty ■ A surgery for spine fracture using percutaneous pedicle screws [Figure 9]

- Disc diseases (cervical, thoracic, and lumbar regions) ■ Minimally invasive discectomy ■ Endoscopic cervical discectomy [Figure 10] ■ Endoscopic lumbar discectomy [Figure 11]

- Spinal stenosis ■ Minimally invasive spinal nerve decompression ■ Endoscopic spinal nerve decompression [Figure 12]

- Spine instability and spondylolisthesis ■ Minimally invasive spinal fusion and percutaneous pedicle screw fixation [Figure 13]

- Minimally invasive spinal pain treatment, etc.

◦ Development of minimally invasive spine surgeryKorea has been developing spine surgery since the 1980s, and with the introduction of minimally invasive spine surgery in the 2000s, such surgery in the country has greatly improved. Korean spine societies established the Korean Minimally Invasive Spine Surgery Society (KOMISS) for the development of spine surgery in 2002, and the KOMISS leads spine treatment through numerous research and academic activities.

[Table 13] History of the Korean Minimally Invasive Spine Surgery Society (KOMISS)

Year Date Academic Conference Location

2002 06. 01 1st KOMISS Annual Meeting Seoul St. Mary’s Hospital

2003 05. 30 2nd KOMISS Annual Meeting Seoul St. Mary’s Hospital

2004 05. 15 3th KOMISS Annual Meeting Seoul St. Mary’s Hospital





200905. 30 8th KOMISS Annual Meeting YONSEI University college of Medicine

11. 27 1st KOMISS Advanced Course YONSEI University college of Medicine

201005. 29 9th KOMISS Annual Meeting YONSEI University college of Medicine

11. 27 2nd KOMISS Advanced Course YONSEI University college of Medicine

201105.21 20th KOMISS Annual Meeting Seoul Asan Hospital

12.10 3rd KOMISS Advanced Course YONSEI University college of Medicine

201206.21 11th KOMISS Annual Meeting Seoul Asan Hospital

11.17 1st KOMISS International Symposium and Workshop Seoul St. Mary’s Hospital

201306.01 12th KOMISS Annual Meeting Seoul St. Mary’s Hospital

12.01 4th KOMISS Advanced Course Seoul St. Mary’s Hospital

201405.31 13th KOMISS Annual Meeting Seoul St. Mary’s Hospital

11.28 2nd KOMISS International Symposium and Workshop

Songdo Convesia / Seoul St. Mary’s Hospital

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(4) Successful cases of degenerative spinal disease surgeries[Figure 9] Surgery for a spine fracture using percutaneous pedicle screws

A. Before surgery B. Six months after surgery

• Patient: A 16-year-old male patient who came to the hospital for severe back pain and paralysis of his lower extremities after a fall

• Diagnosis: Burst fracture at L3

• Surgery: Spine correction and minimally invasive percutaneous transpedicular screw fixation

• Result: The patient made a full recovery and returned to his normal life.

[Figure 10] Percutaneous endoscopic spine surgery for a ruptured disc in the cervical region

A. MRI before the surgery B. CT scan after the surgery C. MRI after the surgery D. Skin incision

• Patient: A 37-year-old male patient with severe neck pain and radiating pain in the right upper limb

• Diagnosis: A herniated cervical disc at C6-C7• Surgery: Percutaneous endoscopic discectomy and foraminotomy• Result: The patient made a full recovery and returned to his normal life.

[Figure 11] Percutaneous endoscopic spine surgery: the lumbar region

A. Before the surgery B. CT scan after the surgery C. Surgery diagram / D. Skin incision

• Patient: A 75-year-old man with severe back pain, as well as radiating pain and muscle weakness in his lower extremities

• Diagnosis: Ruptured disc at L3-L4

• Surgery: Percutaneous endoscopic discectomy

• Result: The patient made a full recovery and returned to his normal life.

[Figure 12] Percutaneous endoscopic nerve decompression for lumbar spinal stenosis

C. Skin incision after the surgery

D. Walking patient a day after the surgery

A. MRI before the surgery / B. CT scan after the surgery

• Patient: A 90-year-old man with severe back pain, as well as radiating pain and muscle weakness in his lower extremities

• Diagnosis: Spinal stenosis at L2-L3-L4-L5• Surgery: Percutaneous endoscopic laminectory and nerve decompression• Result: The patient made a full recovery and returned to his normal life.

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(5) Success rate of surgeries for degenerative spinal diseases, reoperation rate within five years, and average length of hospital stayThe prognosis of a surgery is assessed using the Visual Analogue Scale (VAS), which is an international standard method for pain diagnosis; MacNab’s Criteria; etc. The following is based on MacNab’s Criteria, which can be easily understood.

① Success rate of surgery for degenerative spinal diseases

◦ Lumbar herniated intervertebral disc diseasePreoperative VAS scores decreased significantly from 7.29 ± 0.90 to 1.84 ± 0.98 (P ＜0.01). The MacNab outcomes were as follows: excellent in 47 (43.51%), good in 54 (50.00%), and fair in 7 (6.49%).→ Success rate of surgery: 94%

Source: Kim, H. S. et al. Analysis of Clinical Results of Three Different Routes of Percutaneous Endoscopic Transforaminal Lumbar Discectomy for Lumbar Herniated Disk. World Neurosurgery, 2017.

◦ Spinal stenosisThe MacNab outcome grade was between good and excellent in 96% of the patients.→ Success rate of surgery: 96%

Source: Kim, H. S. et al. Percutaneous Full Endoscopic Bilateral Lumbar Decompression of Spinal Stenosis through Uniportal-Contralateral Approach: Techniques and Preliminary Results. World Neurosurgery, 2017.

◦ Lumbar interbody fusionIn five years, the mean Oswestry Disability Index has improved from 60 points preoperatively to 24 points, and 79 out of 83 patients (95%) showed improvement by more than 10 points.→ Success rate of surgery: 95%

Source: Park, Y. et al. Minimally Invasive Transforaminal Lumbar Interbody Fusion for Spondylolisthesis and Degenerative Spondylosis: Five-Year Results. Clin Orthop Relat Res, 2014.

② Reoperation rate within five years

◦ Lumbar herniated intervertebral disc diseaseThe cumulative reoperation rate was 5.4% at 3 months, 7.4% at 1 year, 9% at 2 years, 10.5% at 3 years, 12.1% at 4 years, and 13.4% at 5 years.

Source: Kim, C. H. et al. Reoperation Rate after Surgery for Lumbar Herniated Intervertebral Disc Disease: A Nationwide Cohort Study. Spine, 2013.

◦ Spinal stenosisThe cumulative reoperation rate was 4.7% at 3 months, 7.2% at 1 year, 9.4% at 2 years, 11.2% at 3 years, 12.5% at 4 years, and 14.2% at 5 years. The calculated reoperation rate was expected to be 22.9% at 10 years.

Source: Kim, C. H. et al. Reoperation Rate after Surgery for Lumbar Spinal Stenosis without Spondylolisthesis: A Nationwide Cohort Study. Spine, 2013.

③ Average length of hospital stay

◦ Lumbar herniated intervertebral disc diseaseThe average length of hospital stay was 10.85 days, and the recorded cases of readmission within 30 days after the patients’ discharge was 1,063 (1.2%).

Source: Han, K. T. et al. Length of Stay and Readmission in Lumbar Intervertebral Disc Disorder in Patients by Hospital Characteristics and Volumes. Health Policy, 2016.

The mean hospital stay was 12 hr → Mean hospital stay: 1–10 days

Source: Choi, G. et al. Percutaneous Endoscopic Interlaminar Discectomy for Intracanalicular Disc Herniations at L5-S1 Using a Rigid Working Channel Endoscope. Neurosurgery, 2006.

[Figure 13] Minimally invasive spinal fusion and percutaneous transpedicular screw fixation for spondylolisthesis

C. Skin incision after the surgeryA. X-ray and MRI before the surgery / B. X-ray and MRI after the surgery

• Patient: A 43–year-old female with severe back pain, as well as radiating pain, neurogenic limping, and muscle weakness in her lower extremities

• Diagnosis: Isthmic spondylolisthesis at L5 (Grade 4) (arrow)• Surgery: Minimally invasive spinal fusion, spinal fusion, and percutaneous

transpedicular screw fixation• Result: The patient made a full recovery and returned to her normal life.

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Figure 15 shows the status of the abstract presentation in Global Spine, which was an international spine surgery academic conference held in 2017, where Korea is one of the top five countries. Korea leads the spine surgery and research areas that are concerned not only with minimally invasive spine surgery but also with high-level spine surgery, and through international academic activities, the results have been proven.

[Figure 15] Number of cases presented by each country at Global Spine in 2017

Source: http://gsc2017.org

Korean spine societies have continually provided lectures and presented research articles at international conferences based on the developed spine surgery in the country, and have held important academic conferences every year and trainings for overseas doctors. Through these, for the world’s spine surgeons, Korea has become their preferred country to visit to learn how to perform spine surgeries, one of the countries that hold the largest number of spine surgery–related international academic conferences, and one of the countries that provide the most number of spine surgery–related international lectures.

[Picture 2] 2014 KOMISS International Symposium and Workshop

[Picture 3] 2016 World Congress of Minimally Invasive Spine Surgery and Techniques (WCMISST)

(6) International status of Korea in terms of treatment and surgery for degenerative spinal diseasesKorea’s spine surgeries and procedures have been developed through continuous research and efforts for the last 50 years. In particular, in the area of microinvasive spine surgery, which is an advanced type of spine surgery and treatment, Korea is the leading country in terms of research [Figure 14].

[Figure 14] The 39 countries that contributed to the Minimally Invasive Spine Surgery (MISS) research

Total of 39 countries contributed to the MISS research.

Total of 2051 articles were identified USA(855/2051, 41.7%)Germany (245/2051, 11.9%)Korea(160/2051, 7.8%)China(147/2051, 7.2%)Japan(108/2051, 5.2%)

Total citationsUSA (12472)Germany (2825)Korea (1401)China (621)Japan (916)

Acerage citationsUSA (11.53)Germany (11.53)Japan (11.98)Korea (8.7)China (4.14)

Source: Fan, G. et al. Worldwide Research Productivity in the Field of Minimally Invasive Spine Surgery: A 20-Year Survey of Publication Activities. Spine, 2015.

In Korea, minimally invasive spine surgeries, including endoscopic spinal surgery, are commonly performed, and compared with the preexisting conventional surgeries, they give better results. Through these surgeries, Korea has become one of the countries that lead the spine surgery and minimally invasive spine surgery areas, doing the most number of research related to spine surgery and minimally invasive spine surgery, and among those whose results on spine surgery and minimally invasive spine surgery are the best [Table 14].

[Table 14] Spine Surgeries for Degenerative Spinal Diseases That Have Been Performed in Korea and Their Results

A Korean national health insurance database

1) 2003 and 18,590 patients were selected.2) Open discectomy was the most common procedure (68.9%) followed by endoscopic discectomy (16.1%),

laminectomy (7.9%), fusion (3.9%), and nucleolysis (3.2%).3) The reoperation rates were 18.6%, 14.7%, 13.8%, 12.4%, and 11.8% after laminectomy, nucleolysis, open

discectomy, endoscopic discectomy, and fusion, respectively.

The cumulative reoperation rate after 5 years was 13.4% and half of the reoperations occurred during the first postoperative year. With the exception of laminectomy, the reoperation rates of the other procedures were not different from that of open discectomy.

Source: Kim, C. H. et al. Reoperation Rate after Surgery for Lumbar Herniated Intervertebral Disc Disease: Nationwide Cohort Study. Spine, 2013.

http://gsc2017.org

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cord and the subarachnoid space. It shows not only the status of nearby soft tissues—such as the degeneration of the intervertebral disc, posterior protrusion, the thickening of the ligamenta flava, etc.—but also the direct cause of spinal cord compression and the status of the spinal cord itself. If the spinal cord compression is severe, high signal intensity can be seen in the T2-weighted image, and the cause might be a direct effect of spinal cord compression, spinal cord edema, gliosis, myelomalacia, intramedullary spinal cord hemorrhage, etc.

(d) Neuropsychological testElectromyography (EMG) is an essential test for diagnosing spondylotic myelopathy, which must be distinguished from diseases, such as amyotrophic lateral sclerosis or multiple sclerosis, which show very similar clinical symptoms.

◦ Treatment(a) Natural courseThe worsening of a disease in patients with minor symptoms is rare, so it has been agreed that a surgical treatment is only necessary for patients with myelopathy whose conditions deteriorate gradually. On the other hand, some scholars have reported the importance of a surgical treatment for patients with myelopathy as even a minor trauma can cause severe spine damage.

(b) Conservative managementPharmacotherapy (NSAID, narcotic analgesics, neuromodulator, etc.), injection through the vertebral foramen, wearing a cervical collar, equipping one’s car with an airbag for driving, being cautious when walking downhill or exercising, traction, etc., can be tried, but for patients who have the symptoms of myelopathy, such as gait disturbance, impaired delicate hand movement, etc., a surgical treatment is necessary.

(c) Surgical treatmentThe natural course of patients with cervical spondylotic myelopathy is often unpredictable that if a severe symptom occurs, a surgical treatment is usually necessary as it progresses without being healed naturally. In terms of surgical approaches, anterior and posterior approaches may be taken, and the cervical curvature is an important consideration when choosing which one to apply.

- Anterior approachIt is the most common surgical approach for spondylotic myelopathy and characterized for leaving a lesion with less than three segments or an anterior lesion. Moreover, with this approach, various surgeries, such as a simple discectomy and vertebral corpectomy, can be performed.

- Posterior approachThe posterior approach is applied if a lesion with three or more segments would be left on the skin, the main lesion had to be placed in the posterior part, a congenital spinal stenosis is found, or a difficulty in performing a surgery using the anterior approach is encountered. Typical surgeries using the posterior approach are laminectomy, and laminoplasty that are commonly done and safer surgical methods than surgeries that use the anterior approach. The disadvantages of the posterior approach are: spine instability accompanied with kyphosis deformation, difficulty of removing anterior lesion, and severe or residual pain in the cervical region after the surgery.

3. Myelopathy

(1) Understanding myelopathyDegenerative myelopathy is a spinal cord disease caused by changes in the spine, intervertebral disc, and spinal segments because of aging, and the prevalence rates are 95% for males older than 65 years and 75% for females older than 65 years. Moreover, the prevalence rate is particularly high in Asia. It is an important degenerative disease because 53.5% of the patients experience its symptoms, and 7.5% of them need treatment.

(2) Treatment and surgery of myelopathy① Cervical spondylotic myelopathy

In general, cervical spondylosis refers to the cervical joint rigidity normal degenerative change in the cervical spine as humans age. Such spondylosis sometimes causes severe cervical stenosis that leads to myelopathy, which is called spondylotic myelopathy. Cervical spondylosis shows the pathophysiology totally different from lumbar spondylosis. It causes not only a partial paralysis of the lower extremities or all extremities but also impairments in defecation and urination, as well as sexual dysfunction, because of the abnormal functioning of the autonomic nervous system.

◦ Clinical symptomsThe clinical symptoms of cervical spondylotic myelopathy vary depending on the location of the spinal cord compression and the number of compressed segments. Patients typically have gait disturbance and impaired hand movements. In particular, patients report impairment in delicate hand movements. Although gait disturbance occurs in the earlier stage, patients usually come to the hospital when they experience impaired hand movements. When patients walk, their sense of balance is abnormal, causing them to stagger. Furthermore, they report muscle weakness and difficulty in performing delicate hand movements such as writing, using chopsticks, buttoning, etc. In addition, they sometimes report abnormal sensation and numbness in their hands or pain in their upper extremities. Twenty percent of the patients exhibited bladder dysfunctions accompanied with low urine output, but instances of fecal and urinary incontinence are somewhat rare. Patients might also experience pain in their necks but not in their extremities. The symptoms usually progress slowly but can manifest acutely. For acute manifestation, most of the time, the patients have had repeated episodes of minor traumas such as falling in the past.

◦ Diagnosis(a) Simple radiographic imaging Through an X-ray, a disease can be seen in a simple form in the bone curves. In particular, spine angle problems, such as scoliosis, kyphosis, lordosis, etc., can be diagnosed through simple radiographic imaging.

(b) CT scanA CT scan shows the anatomic structure of the cross section of bones. Through this scan, calcified disc lesions and tendons are clearly distinguished from soft tissues or discs, which makes it useful for deciding on an appropriate surgical method. In addition, for a surgery that requires posterior fusion, it helps assess the size of the cervical spine, the size of the exterior mass, the bone quality, etc.

(c) MRIMRI is essential for the diagnosis of cervical spondylotic myelopathy, which is mostly caused by the mechanical compression of the spinal cord. It clearly shows the spinal

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◦ TreatmentPatients who have the symptoms of myelopathy such as gait disturbance, impaired delicate movement of hands, etc., undergo surgical treatment. A spinal cord that has been compressed for a long time may cause an irreversible change so that decompression surgery is necessary for patients who show severe symptoms of myelopathy. However, for patients who have no or little symptoms of cervical myelopathy, a surgery as a preventive measure is not recommended even if the spinal cord compression is caused by the ossification of the posterior longitudinal ligament. Whether an anterior or posterior approach should be applied can be determined using the same context as the cervical spondylotic myelopathy.

◦ PrognosisFor cases of long-term morbidity with symptoms, old age, severe symptoms before surgery, and myelopathy caused by trauma, the postoperation results are not good. After the surgery, the accompanied ossification of the posterior longitudinal ligament of the thoracic spine or ossification of the ligamenta flava, the recurrence of the ossification of the posterior longitudinal ligament of the cervical spine, or the accompanied degenerative disease in the lumbar spine can deteriorate the neurological symptoms in a delayed manner. Among these, for the case of the recurrence of the ossification of the posterior longitudinal ligament of the cervical spine, a multicenter study was done as a two-year follow-up study in Japan. The results showed that the recurrence rate was 56.5% when decompression using the posterior approach was done. In particular, for patients younger than 60 years old or with mixed type of ossification of the posterior longitudinal ligament, recurrence was more likely to happen and for the segmental type, the recurrence cases were rarer. The 10-year follow-up study showed that the ossification of the posterior longitudinal ligament recurred in 70%–73% of the patients when decompression using the posterior approach was done and 36%–64% when the anterior approach was used.

(3) Development process of myelopathy treatment and surgeryVarious methods have been tried because of the characteristics of the enlargement of the ossification in the posterior longitudinal ligament. Posterior decompression using laminectory, various types of anterior approaches (for patients Cloward, Smith, and Robinson, Hakuba, etc.), combination of posterior decompression and anterior approach, etc., have been tried, and selection and changing of surgical treatments have been done based on the broad clinical case reports per medical institution.

◦ PrognosisFor the anterior approach, 77%–92% of patients show symptom improvement, 14% maintain their status without neurological deteriorations, and 0%–15% may have deteriorated symptoms after surgery. The death rate related to the surgery is 0%–3%, and fatality rate is 13%–47.5%. For the laminectory, 50%–85% of patients show improvement, 13%–26% maintain their neurological status, and 8%–26% show deterioration. Both death rate and fatality rate are about 2%.

① Ossification of the posterior longitudinal ligament of the cervical spineIn 1977, Myeong-sang Moon et al. presented a case report on a patient with the ossification of the posterior longitudinal ligament for the first time in Korea, and in 1989, Young-soo Kim et al. performed a laminoplasty for the ossification of the posterior longitudinal ligament for the first time. Regarding the prevalence rates, differences were observed among ethnic groups. According to the study done on 1,058 patients by Ohtsuka et al. in Japan, the prevalence rate was 3.7%, and the incidence rate among adults in their 30s was about 2%–4%. The incidence rate in other East Asian countries was 0.8%–2.83%. On the other hand, in the USA and Germany, the incidence rate was low to be 0.09%–0.23%. However, most of the prevalence rate studies rely on the simple imaging of the cervical region; thus, their accuracy is low, and additional studies using CT scan, etc., would reveal a higher prevalence rate. According to a study by Se-il Son et al. in 2013 using CT scan, the prevalence rate in Korea was 4.6%, which was not lower than the prevalence rate in Japan.

◦ Clinical symptomsMany patients with the ossification of the posterior longitudinal ligament of the cervical spine initially have no symptoms at all or do not complain about minor neck pain or abnormal sensation in the hands. However, as the size of the ossification of the posterior longitudinal ligament gradually becomes larger, the spinal cord and nerve are compressed, inducing symptoms. The symptoms of the ossification of the posterior longitudinal ligament of the cervical spine usually indicate myelopathy caused by spinal cord compression rather than nerve root compression. In 80%–85% of patients, the symptoms progress slowly, but a minor trauma or hyperextension might cause a rapid deterioration or paralysis of all extremities. The most common symptoms of the ossification of the posterior longitudinal ligament are hands’ abnormal sensation, numbness, or clumsiness. The gait disturbance related to the symptoms of the lower extremities gradually begins to manifest.

◦ DiagnosisA simple radiographic imaging can diagnose the ossification of the posterior longitudinal ligament to some extent. However, CT scan can confirm the diagnosis.

[Figure 16] Morphological classification of the ossification of the posterior longitudinal ligament of the cervical spine

Continuous type

Segmental type

Mixed type

Local type

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[Figure 19] Complex vertebral corpectomy using the anterior approach, decompression through discectomy, anterior spinal fusion of the long segment, and fixation

A. CT and MRI images before the surgery B. CT and MRI images after the surgery

• Patient: A 73-year-old male who complained about pain in his left hand and weakness in his right-hand fingers that went on for a few years

• Diagnosis: Cervical spinal cord compression of the long segment because of the complex lesion of the ossification of the posterior longitudinal ligament

• Surgery: Complex vertebral corpectomy using the anterior approach, decompression through discectomy, anterior spinal fusion of the long segment, and fixation

• Result: There was an alleviation of the symptoms after the removal of the vertebrae, and the pain was eliminated. The paralysis of his fingers has not been observed for seven months.

[Figure 20] Decompression of the long segment through laminoplasty using the posterior approach


• Patient: A 69-year-old female who was experiencing an abnormal sensation and dis-comfort in both her hands for two years

• Diagnosis: Nerve compression and damage caused by the ossification of the posterior longitudinal ligament and cervical spondylosis

• Surgery: Decompression of the long segment through laminoplasty using the posterior approach

• Result: The abnormal sensation in both of the patients’ hands was confirmed to have been alleviated one year after the surgery, and the patient has lived a normal life.

(4) Successful cases of myelopathy surgery[Figure 17] Multisegmental discectomy using the anterior approach, decompression, and

fixation


• Patient: A 64-year-old male whose disease began one year prior to the diagnosis and complained about numbness in both hands that began about three months ago

• Diagnosis: Cervical spondylotic myelopathy caused by multisegmental cervical spinal stenosis

• Surgery: Multisegmental discectomy using the anterior approach, decompression, and fixation

• Results: Decompression in the cervical spinal cord was confirmed, followed by the confirmation of the alleviation of symptoms six months later, and the patient has been followed up as an outpatient.

[Figure 18] Vertebral corpectomy using the anterior approach, decompression, and anterior and posterior fixation

A.CT and MRI images before the surgery B. CT and MRI images after the surgery

• Patient: A 69–year-old female whose fingers in both hands were paralyzed after a minor head trauma

• Diagnosis: Cervical spinal cord compression and damage, along with the ossification of the posterior longitudinal ligament

• Surgery: Vertebral corpectomy of two segments, removal of the ossification of the posterior longitudinal ligament, decompression, anterior spinal fusion and fixation, and unilateral transpedicular screw fixation using the posterior approach

• Result: The symptoms remained right after the decompression, but an alleviation of the symptoms were observed three months later, and the patient was able to do daily life activities.

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(5) Success rate of surgeries for myelopathy, the average length of hospital stay, the average treatment cost

◦ Success rate for myelopathy surgeryThe U.S. Cervical Spine Research Society has recently reported that nonsurgical treatments do not produce good results. Likewise, most symptoms of myelopathy gradually progress with the alternation of deterioration and relief of symptoms, and symptoms are not expected to improve through conservative treatments. The recovery rate after surgeries based on each cause is shown in the following table.

[Table 15] Recovery Rate according to Cause

Cause Recovery rate

Developmental steonosis 64.11±25.34

Spondylosis 66.55±21.36

OPLL* 68.21±17.31

HIVD† 71.76±23.14

Trauma 46.02±12.05

(p=0.435) Kruskal-Wallis method.*, Ossification of Posterior Longitudinal Ligament; †, Herniated Interverebral Disc.

Based on the report, the mortality rate related to postsurgical complications is 0.3%–1%, and the morbidity rate is 7%–9%. The following table shows the statistics of the postsurgical mortality rate and morbidity rate for the last 10 years.

[Table 16] Postsurgical Mortality Rate and Morbidity Rate (2001–2010)

In foreign countries, the recovery rate does not have a significant difference compared with that of Korea.

◦ Average length of hospital stayThe patients’ average length of hospital stay for each type of surgery for the treatment of a spinal cord disease for 10 years is shown in the following table.

[Figure 21] Laminectomy using the posterior approach, spinal fusion of the long segment, and transpedicular screw fixation

A. CT and MRI images before the surgery B.CT and MRI images after the surgery

• Patient: A 69-year-old male who was experiencing gradual gait disturbance and an abnormal sensation

• Diagnosis: Nerve compression and damage caused by a severe complex ossification of the posterior longitudinal ligament

• Surgery: Laminectomy using the posterior approach, the spinal fusion of the long seg-ment, and transpedicular screw fixation

• Result: Symptom alleviation was confirmed one year after the surgery, and the gait disturbance and abnormal sensation were cured.

[Figure 22] Bilateral laminoplasty using the posterior approach, spinal fusion, and transpedicular screw fixation

A.CT and MRI images before the surgery B. CT and MRI images after the surgery

• Patient: A 79-year-old female who was experiencing gradual numbness in her upper extremities, hand weakness, and gait disturbance

• Diagnosis: Nerve compression and damage caused by a severe complex ossification of the posterior longitudinal ligament

• Surgery: Bilateral laminoplasty of the long segment using the posterior approach, spi-nal fusion of the long segment, and transpedicular screw fixation

• Result: Gait disturbance alleviation was confirmed after 15 months of follow-up check-ups. Numbness was alleviated as well, and the patient might be able to return to normal daily functions.

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4. Deformity: osteoporosis, AIS, adult (degenerative) deformity, revision surgery

(1) Understanding scoliosisScoliosis is a medical condition in which the spine bends to one side. It is defined as a three-dimensional deviation from the central axis of the spine. As the standard of diagnosis, it is defined to have more than 10° of curvature to the right or left in the coronal plane. The curvature of the spine is generally “S” or “C” shaped. Most of the time, the curvature of the spine is stable, but, for some people, the angle becomes larger as time passes. Minor scoliosis usually does not cause a problem, but for severe cases, it can interfere with breathing. Most of the time, the causes are not known (idiopathic), but it seems that genetic and environmental factors are complexly related. The risk factors include family medical history as well. It can occur secondarily after muscle convulsion, cerebral palsy, Marfan syndrome, and tumor such as neurofibroma. A diagnosis can be confirmed through X-ray. Scoliosis is classified into structural scoliosis in which the curvature is fixed and functional scoliosis in which the spine has a normal shape.

Scoliosis affects about 2%–3% of the population, and there are about 5–9 million cases. Among patients with scoliosis, 1.5%–3% of them have spine curvatures of less than 10°. Among children or adolescents, the age of disease onset is usually from 10 to 15 years, so it can occur at an early age and affect about 85% of the diagnosed patients. The reason seems that rapid growth and development happen in puberty, when a person is easily affected by genetic and environmental factors. Because growth is experienced by women before their musculoskeletal system matures, there are more cases of scoliosis among them than their male counterparts. Scoliosis is a common abnormality seen in healthy children. Idiopathic scoliosis (IS) does not occur after puberty in which the musculoskeletal system has reached to its maturity. However, because of spinal osteoporosis and muscle weakness, the curvature may progress in late adulthood.

(2) Surgery and treatment for scoliosis

◦ Symptoms of scoliosis- Constipation caused by compression of the

internal organs because of the curvature- Back pain, shoulder pain, neck pain, and hip pain- Radiating pain in the lower extremities

because of the compression of nerves that run along the lower extremities

- Movement limitations - Painful menstruation secondary to pelvic

tilt(menstrual pain)

◦ Signs of scoliosis- The muscles around the spine deviate to one side- In thoracic scoliosis, the ribs or the scapulae protrude because of the rotation of the thorax- Nonsymmetric hips or arm or leg length- Slow neurologic reactions- Heart or lung problems in severe cases

[Figure 23] Normal spine and spine with scoliosis

Normal spineScoliosis

[Table 17] Average Length of Hospital Stay for Each Surgery (2001–2010)

When both anterior and posterior fusions were done at the same time, the average length of stay was longer than that of any of other three surgeries.

◦ Average treatment costIn foreign countries, the average treatment cost for a cervical spine disease increased significantly within 10 years, that is, from 2001 to 2010.

[Table 18] Treatment Cost for Each Surgery (2001–2010)

(6) Korea’s international status in terms of spine treatment and surgeryKorea and other foreign countries do not treat the aforementioned diseases differently. There is also no difference in postsurgical recovery rate, mortality rate, morbidity rate, etc., and research on surgery and disease is ongoing. Nonetheless, there is a large difference in cost. In overseas countries, an anterior fusion costs more than KRW 40 million in average, but in Korea, the treatment cost is much lower. Therefore, Korea’s medical services that all people can use are cost effective for consumers.

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For such surgeries, one or two surgeons might be necessary. The surgery can be done in 1–2 steps, and takes about 4–8 hr in average.

(3) Development process of scoliosis treatment and surgery As the aging population increases, the number of patients with spinal diseases requiring surgeries also increases. According to the Health Insurance Review and Assessment Service, the number of patients who are admitted because of disc diseases in 2014 was 278,327, which increased by 73% compared to 2010 (161,337 patients). The number of spine surgeries also increased by 86% in 2012 compared to 2006, thereby showing the increase rate of 12% in yearly average. As the number of elderly people has recently increased, surgery techniques have been developed. Moreover, as the demand for a better quality of life grows, the demand for surgeries for such adult spinal deformity increases. According to the statistics in 2015, the number of outpatients who were treated for scoliosis was 110,400, and the number of outpatients with any spinal deformity was 356,646. The number of admitted patients with scoliosis was 2,174, and the number of admitted patients with any spinal deformity was 25,599. Furthermore, the number of fixation surgeries for spinal deformities was 868.

[Table 19] Number of Surgeries for Scoliosis per Year

Surgical devices for scoliosis have been continually evolving. Harrington devices improved the degree of curvature correction and enabled movement only with simple braces instead of large casts. Luque enabled segmental correction using a sublaminar wire. As Cotrel–Dubousset implants became available, such concepts have been expanded to include hook, hybrid, and most recently, an all-screw structure. In particular, for the last 10 years, research on sagittal balance during surgical correction of scoliosis has increased.

Transpedicular screws have become basic tools for surgery on scoliosis. Transpedicular screws achieve three-column fixation in the spine and show better biodynamical characteristics than other structures. Through these, surgeons can better correct the curvature in the three planes, as well as rotation. Before the introduction of the transpedicular screw fixation, to correct a severe case of scoliosis, both anterior and posterior fusions were necessary. For such a case, an open-chest operation was performed, which usually causes the complication of further deteriorating the lung function. However, transpedicular screw fixation provides an equal degree of curvature correction through posterior fusion only so that an open chest operation is not necessary. At present, transpedicular screw fixation is used for most surgeries for scoliosis. The improved biodynamical profile of transpedicular screws have brought about the improvement in the correction of curvatures. In addition, transpedicular screws greatly contributed to the low complication incidence rate. Using the recent three-dimensional

◦ Surgery and treatment for scoliosisFor those whose skeletons have fully grown, the deterioration of scoliosis is rare. Severe scoliosis may lead to a decline in lung capacity, abnormal pressure on the heart, or limited physical activities. According to recent research, idiopathic scoliosis that manifests late rarely causes other physical disabilities, except back pain or cosmetic problem, and the mortality rate is similar to that of the general population. The treatment is different depending on the degree of curvature, location, and cause. For a moderate curvature, a simple periodic observation is enough. As for treatments, braces can be worn, or a surgery can be done. If patients opt to wear braces, the braces must fit them well, and these must be worn every day until growth stops. The effects of chiropractic treatment, food supplements, and exercise for preventing deterioration are not sufficiently supported by evidence. However, exercise is still recommended because of its other advantages.

◦ Universal treatment for scoliosisThe principle of the universal treatment for scoliosis is complex and determined based on the degree of the curvature and skeleton maturity, which help predict the possibility of progress. The universal treatment method for children and adolescents is as follows.

Children and Adolescents Adults

- Observation- Wearing of braces- Surgery

- Analgesics- Wearing of braces- Surgery

* For adults, the purpose of a treatment is to relieve the pain

◦ Treatment for idiopathic scoliosisThe treatment method for idiopathic scoliosis becomes different depending on the degree of the curvature, possibility of spine growth, and the risk of curvature growth. Minor scoliosis (less than 30°) can be treated with simple monitoring and exercise. For growing children, moderate scoliosis (30°–45°) might need correction. For a severe curvature that progresses rapidly, treatment is done through a surgical installation of a spine fixation apparatus. Braces can prevent gradual curvature, but this claim is not sufficiently supported by evidence. For all cases, early interventions provide the best results. An increasing number of scientific research have focused on the effects of physical therapy.

Surgery is generally done by a spine surgeon when: 1) the possibility of progression is high (that is, curvature of larger than 45°–50°); 2) severe cosmetic problems exist; 3) patients with spine of dichotomy or cerebral palsy cannot sit down or live normal lives; or 4) the curvature affects physiologic functions such as breathing.

◦ Surgery for scoliosisThe surgery for scoliosis is done by a spine surgeon who specializes in spine surgeries. For various reasons, making the scoliotic spine completely straight is not possible, but most of the time, an important correction is made. The two main types of surgery are as follows.

- Anterior fusion: This surgical approach is done by making an incision on the side of chest wall.

- Posterior fusion: This surgical approach is done by making an incision on the back, and the curvature is corrected using a metallic implant.

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[Figure 26] Correction of a flat back syndrome

• Patient: A 69–year-old female

• Diagnosis: LBP and LBuP with weak-ness in both legs, G4

• Surgery: Correction using transpedic-ular screw fixation

• Result: Before the correction, walking was difficult because of the pain caused by the bending of the patient’s back, but after the surgery, the patient was able to walk without experi-encing back pain.

A. Before the surgery B. After the surgery

[Figure 27] Correction of camptocormia accompanied with Parkinson’s disease

• Patient: A 72–year-old female with a bent body

• Diagnosis: Camptocormia

• Surgery: Correction using trans-pedicular screw fixation

• Result: The patient could not even look straight ahead because of the anterior bending of her back whenever she walks, but after the surgery, she could look straight ahead while walking.


(5) Success rate of scoliosis surgery, readmission rate within five years, average length of hos-pital stay, and average treatment cost

◦ Success rate of scoliosis surgeryThrough the development of diagnostic methods, surgical devices, surgical methods, and postsurgical rehabilitations, the success rate of scoliosis surgeries has greatly improved. Based on the types of scoliosis, the success rates of surgeries are different, and for the representative idiopathic scoliosis, the success rate is about 80%–90%.

◦ Readmission rate within five yearsAccording to the statistical data, the readmission rate within five years is less than 3%, which is similar to that of general spine surgeries. However, this number is an average, and the readmission rate can be different depending on the severity or type. The most common reasons for readmission are fixation device fracture and degenerative changes in adjacent areas, as well as instances of postsurgical infections or pain have been reported

printing technology, a three-dimensional model is manufactured before surgery for surgical planning.

With the development of medical technologies, the safety and efficacy of spine surgeries have been improving. Safer anesthetics are being used, and as the monitoring equipment during anesthesia has become sophisticated, the risk of medical accident is lower than ever. For instance, during surgery, a Cell Saver, which infuses blood back to the blood vessels after filtering the blood being lost, decreases the amount of blood transfusion. Surgical beds that enable various surgical positions and equipment that maintain the temperature of patients at a certain temperature have decreased possible surgical complications. For surgeries for scoliosis in which the risk of neurologic damage exists, the development of neurologic monitoring equipment has decreased the occurrences of neurologic complications. After a scoliosis correction, if a problem in the neurologic monitoring is reported, a surgeon can undo the correction immediately and try a safe restoration. Moreover, through the development of minimally invasive surgical methods, the size of the injury has been considerably minimized, and the postsurgical pain has diminished as well. Therefore, patients recover faster, their admission periods are reduced, and they can save on medical costs.

[Figure 24] Transpedicular screws that have brought revolutionary development for scoliosis surgery and spine model that is printed by a three-dimensional printer

(4) Successful scoliosis surgery cases[Figure 25] Correction of idiopathic scoliosis

• Patient: An 18–year–old femalewho was experiencing chronic back pain and body imbalance

• Diagnosis: Idiopathic scoliosis• Surgery: Correction using trans-

pedicular screw fixation• Result: The chronic back pain has

disappeared, and the deviat-ed spine has been corrected. The patient was very satis-fied with the outcome.


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1. Why Korea

The Korean Spinal Neurosurgery Society, which was established in 1987, has grown to be a very large society in which about 1,600 members work actively, following the sacrifices and services of many predecessors, including honorary presidents Hwan-young Jeong and Young-soo Kim, for the last 30 years. At present, there are six research societies and two branches under the Korean Spinal Neurosurgery Society, and they are growing in each area and competitive enough to hold at least two international academic conferences. Moreover, as they perform world-class research and treatment, many doctors around the world visit them to learn about Korea’s excellent spine procedures. Thus, for spine surgeons, Korea has become one of the best countries for learning spine surgeries, one of the countries that hold the largest number of spine surgery–related international academic conferences, and one of the countries that provide the most number of spine surgery–related international lectures.

◦ Annual number of spine surgeries and research articlesFigure 1 shows a graph of the number of cases presented by Korean spine surgeons from 2004 to 2013. Including endoscopic spine surgeries, there were more than 140,000 cases yearly from 2009 to 2011 and more than 160,000 cases yearly in 2012 and 2013. Achieving these numbers means that the level of spine surgery practiced in Korea has already reached a world-class status.

[Figure 1] Surgical cases of Korean spine surgeons

Source: Research Articles Published by Korean Spine Surgeons: Scientific Progress and the Increase in Spine Surgery

Figure 2 shows a graph of spine-related research articles of Korean spine surgeons arranged by type. Original articles have the most number, followed by case reports. In addition, many world-class research articles and achievements are related to surgical skills or basic research.

III. Medical Korea◦ Average length of hospital stay

The patients’ average length of hospital stay for idiopathic scoliosis is about five days, which is not different from that of general spine surgeries. Through the development of surgical technologies and anesthetic technologies, postsurgical recovery has been improved. Although the surgical area is larger than that of general spine surgeries, the average length of stay is similar because of such medical technology development and effective pain medication.

◦ Average treatment costTreatment costs can differ depending on the surgical methods and devices to be used. The cost of surgery for idiopathic scoliosis is about KRW 10 million, including the hospital stay (when the national medical insurance of Korea is applied. The cost for foreign patients to whom the insurance is not applied is about KRW 30 million). However, it is only an average, and the cost can be lower if the surgical area is small and fewer instruments are used.

(6) Korea’s international status in terms of scoliosis treatment and surgeryThe surgery for scoliosis in Korea started in the 1960s, and the surgical method of thoracic scoliosis correction using transpedicular screws, which is globally recognized, was presented by Seok et al. in 1995. In Korea, scoliosis centers are operated in most tertiary medical institutions and hospitals that specialize in spine, where there are resident surgeons that specialize in the said disease. In scoliosis centers, not only surgical treatment but also rehabilitation and pharmacotherapy are provided so that a holistic treatment is possible. In Korea, active research and discussions are being conducted by the Korean Spinal Deformity Research Society, which is composed of neurosurgeons, and the Korean Paediatric Orthopaedic Society, composed of orthopedic surgeons.

Spine surgeries in Korea have been increasing for the last 10 years, and the number of research articles has increased as well. Various studies for all areas of spine diseases have been done, and in particular, research on spine deformity has been actively performed, which has resulted in the publication of more than 150 research articles since 2000. During 2000–2014, 1,982 surgery-related research articles were published by Korean spine surgeons. The number of research articles increased from 20 in 2000 to 293 in 2014. Most research articles (65.9%) were written by neurosurgeons who specialized in spine surgery.

At present, young spine surgeons lead active surgical treatments, and the results are outstanding as well. Scoliosis needs objective and scientifically proven diagnosis and treatment. Therefore, it is important to receive appropriate treatments from medical professionals who have abundant treatment experiences based on the severity of the disease rather than to follow a wrong information or treatment.

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[Figure 4] Analysis of the effect factors


◦ Korean research in international journals

[Figure 2] Number of research articles presented by Korean spine surgeons per year


Figure 3 is a graph that analyzes the research articles of Korean spine surgeons based on evidence level.

[Figure 3] Yearly publications based on evidence level by Oxford


Figure 4 is a graph that shows the impact factor of the research articles written by Korean spine surgeons. It shows that the research articles of Korean spine surgeons were submitted to world-class journals such as Spine, The Spine Journal, European Spine Journal, JNS Spine, etc.

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(2) Mr. A (M/70, UAE)He is a retired solider who is proud of his former profession. As he aged, walking became difficult for him because of back pain and neurogenic claudication, and in his country, he was diagnosed with degenerative lumbar scoliosis, as well as the spinal canal and foraminal stenosis that are accompanied with congenital spinal deformity. To receive better treatment, he came to Korea, where he underwent a surgery performed by the Department of Neurosurgery, Seoul National University Bundang Hospital. After the surgery, his symptoms improved, and he went back to his country greatly satisfied.

Mr. A suffers from degenerative spinal disease in his old age

Mr. A is a retired solider in his 70’s who is proud of his former profession. As he aged, walking became difficult for him because of back pain and neurogenic claudication, and in his country, he was diagnosed with degenerative lumbar scoliosis, as well as the spinal canal and foraminal stenosis that are accompanied with congenital spinal deformity.

Visiting Korea for a better treatment

Mr. A visited Korea to receive a better treatment after a thorough search, and came to the Department of Neurosurgery, Seoul National University. He underwent a successful surgery in Korea, and his symptoms improved. He was satisfied with the result and came back to his country.

2. Cases of Foreign Patients

(1) Ms. A (F/42, USA)She underwent surgery in the United States about 30 years ago because of adolescent idiopathic scoliosis, and her implant was removed later. However, she experienced back pains after she turned 30 years old, and while she was living in Korea, the pain in her lower back worsened, coupled with radiating pain and numbness in her lower extremities, so she received treatment for the pain for a few years. However, her symptoms did not improve. She was informed about the difficulty of the treatment because of the severe degenerative lesion in her lower extremities where a Harrington rod was used for her scoliosis surgery. She received a successful deformity correction and reconstructive surgery from the Department of Neurosurgery, Seoul National University Bundang Hospital, which improved her symptoms so that she is satisfied with the treatments.

A spine surgery received in U.S.A 30 years ago gives the worst pain

42-year-old Ms. A who underwent surgery in the United States when she was 12 years old because of scoliosis had another surgery later to remove the implant that was inserted during the surgery. However, she experienced back pains after she turned 30 years old, and the pain in her lower back worsened, coupled with radiating pain and numbness in her lower extremities, so she received treatment for the pain for a few years. However, her symptoms did not improve. Even she was informed about the difficulty of the treatment because of the severe degenerative lesion where the scoliosis surgery was performed previously. So, she was very concerned about it.

Treatment for Ms. A that was given up in U.S.A meets the Korean medicine

Ms. A was looking for a hospital in which the high-level spine surgery could be performed, and finally found Seoul National University Bundang Hospital. She received a successful deformity correction and reconstructive surgery from the Department of Neurosurgery. As a result, her painful symptoms improved and she is having a very satisfactory life because of the spine surgery she received in Korea.

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(6) Mr. E (M/38, Russia) Because of a car accident in January 2014, he had a burst fracture at L1, and his lower extremities were paralyzed. He received a vertebral corpectomy for the corresponding vertebra, cage reconstruction, and posterior pedicle screw fixation from one of the hospitals in Yakutsk, Russia. However, the motor function of his lower extremities hardly came back, so he was limited to lying down at home.

Three months later, in April 2014, he visited the Soon Cheon Hyang University Bucheon Hospital and underwent an examination. Through the examination, an infection in the surgery area, deviation of the inserted cage, etc., were confirmed. Therefore, the inserted cage was removed, the abscess was drained and washed, and antibiotics (vancomycin and piperacillin/tazobactam) were administered for about five weeks. During this period, the patient gradually recovered the muscle strength of his lower extremities, and cage reinforcement and reconstruction were performed on him. After the second surgery, he could walk with the help of a walker, and his symptoms improved when he was discharged. The patient was seen about one year after the surgery, and he could walk with a stick or without a brace. He was also able to drive to the hospital for a visit.

(7) Mr. L (M/56, Vietnam)As his pain in both legs was too severe for him to walk, he visited the hospital multiple times, but because of the high possibility of a neurologic damage, he was informed that it was unlikely for him to receive a surgery. However, through an acquaintance in Korea, he visited Suwon Nanoori Hospital on February 4, 2015. After an examination, he was diagnosed with a chronic ruptured disc with severe spinal stenosis, and he received microscopic lumbar decompression and disc removal from Dr. H. S. Kim on February 6. After the surgery, the pain was greatly lessened, and the paralysis in both legs disappeared slowly, enabling him to go back to his country one month later.

(3) Ms. M (F/16, Kazakhstan)Since 2012, the patient has been having intermittent back pain, and she was diagnosed with congenital hemivertebra at T9 by a Kazakhstani hospital, but the symptoms were not severe and were merely observed. In 2015, the pain gradually became more severe, and her spine progressively deviated to the right, prompting her to come to Korea through an international treatment team. On November 3, 2016, the removal of a hemivertebra at T9 and scoliosis corre ction was performed on her by the spine team (Professor Il-sup Kim and Professor Jae-taek Hong) of the Department of Neurosurgery, St. Vincent’s Hospital of the Catholic University of Korea. Her symptoms have improved, and she is doing well in her daily life.

(4) Ms. E (F/39, Mongolia)Because of a back pain that she had for a long time, she received treatments such as physical therapy, injection, etc., but effects only briefly lasted, and the pain became so severe that she could not even walk for 100 m. Nonsurgical treatments were not effective anymore, so she received anterior lumbar interbody fusion (ALIF) of which surgical burden is low, and her symptoms improved. ALIF is a fairly high-level surgical method that passes through areas that are close to main organs such as the aorta, the kidney, etc.

ALIF was performed by the director of Wiltse Memorial Hospital in Suwon, Dr. C. K. Park, who was invited by Gyeonggi-do and the Mongolian Department of Health. The Mongolian National Broadcaster (MNB) filmed the entire surgery processes, and its documentary was broadcasted in Mongolia, which was well received.

(5) Ms. R (F/56, Russia)She is a chief prosecutor in the far eastern region of Khabarovsk, and she received a surgery after suffering from a herniated disc. Through the recommendation of a local medical staff, she came to Korea to receive a minimally invasive surgery. In November 2016, she received a minimally invasive interbody fusion from the Department of Neurosurgery, Hanyang University Hospital. A day after the surgery, she could already walk by herself, so she was very satisfied with the result. When she was admitted, she had difficulty eating Korean food, but after bringing in a caregiver and a cook from Russia, she was fine.

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(8) Ms. H (F/57, Mongolia)She is a pediatrician from Mongolia, and received pedicle screw fixation and fusion in 2014 because of the herniated lumbar discs of three segments. However, after the surgery, the pain did not decrease and, instead, persisted for two years, so she was recommended to undergo a reoperation. In March 2016, through a specialized medical tourism agency, she requested an online consultation, and among many hospitals, she visited Gangnam Nanoori Hospital. At that time, because of radiating pain that ran from the waist, buttock or right extremity to the sole, she could not walk, or even stand still, and she could not last a day without taking an analgesic. On April 20, 2016, she received DLIF and PSF T12-L5 from Dr. J. H. Lim. Although she went through 13 hours of complex and difficult processes, her symptoms were significantly alleviated right after the surgery that she could walk one day later. One week after the surgery, all the discomforts that she used to feel disappeared that she could walk by herself without any help and had a great time with her family. Three months later, she was seen smiling in her country.

(9) Mr. G (M/80, USA)He had a cervical fracture while playing football in the 1950s and thought it was healed after undergoing conservative treatment. However, he exhibited the symptoms of degenerative diseases, such as neck pain, among others, in the late 1980s, so he underwent another conservative treatment in his country. Someone recommended that he undergo a surgery. Recently, for a month, his posterior neck pain, as well as the pain that he felt in his right upper extremity, has worsened such that an MRI was taken. He was diagnosed with cervical spinal stenosis. He received anterior cervical discectomy and fusion at Seoul University Hospital, and his symptoms, such as the pain in his neck and upper extremities, were alleviated.

(10) Mr. T (M/62, USA)He had a traumatic fracture of the lumbar spine in 1979, and since then, he experienced persistent lower back pain. Because of an intracranial tumor (vestibular schwannoma), he underwent tumor removal and ventriculoperitoneal (V-P) shunting on February 22, 2001, and March 30, 2001, respectively. After these treatments, he experienced residual weakness on the right side of his body. In 2014, his back pain became so severe that he received nerve blocks twice in his country to relieve it. However, his back pain and the pain in both his legs worsened gradually, which required him to receive posterior lumbar interbody fusion after being diagnosed with isthmic spondylolisthesis of L5 at the Severance Hospital. After the treatment, his symptoms were alleviated. He went back to his country a month later.

(11) Mr. A (M/64, UAE)He was diagnosed in his country with spinal stenosis because of the weakness in his left extremity and gait disturbance. He received anterior cervical discectomy and fusion at C3-C5, but even after the surgery, the pain in his right lower extremity and right waist worsened, so he took a thoracic MRI. The MRI scan revealed a spinal tumor at T4, prompting him to receive a T3-4 tumor removal at Seoul University Hospital. Afterward, the weakness that he felt in his left extremity and his gait disturbance improved.

(12) Mr. A (M/66, UAE)He has a medical history of hypertension, diabetes, myocardial infarction, etc., and began to experience gradual muscle weakness in his upper and lower extremities about two years ago. At the Al Qassimi Neuro Spinal Hospital and the Phyathai International Hospital in Thailand in January 2016, he was diagnosed with multiple cervical stenoses (C3-7) with myelopathy, and he was recommended to undergo surgery. Afterward, the muscle weakness in his upper and lower extremities gradually worsened, and he could not control his defecation and urination, which required him to receive C3-7 decompression and posterior fusion from Severance Hospital. After the treatment, his symptoms were alleviated, and he was discharged after rehabilitation.

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2. Neurosurgeons Who Specialize in the Spine in Korea

As of 2017, the number of neurosurgeons who specialize in the spine and who are affiliated with the Korean Spinal Neurosurgery Society is 1,503. This number only included life members, regular members, and specialists. Associate members are residents, and special members are medical professionals from other departments and nurses.

[Table 2] Medical Professionals Who Specialize in the Spine and Who Are Affiliated with the Korean Spinal Neurosurgery Society

Life Member Regular Member

Specialist Associate Member

Special Member

Honorary Member

Total Number of MembersOnline Off-line Online Off-line

41627

1060178 98 1 1780

390 26 862 198

3. Statistics of yearly spine surgery operations

[Table 3] Statistics of General Spine Surgeries (2010–2015)

Classification 2010 2011 2012 2013 2014 2015 Intensification Factor (Compared with 2010)

General spine surgeries 155,229 149,770 166,517 163,518 157,385 155,450 0.1

Source: 2016 statistics of the National Health Insurance Service

1. Hospitals That Specialize in Spine In Korea, there are 17 hospitals that specialize in spine designated by the Ministry of Health and Welfare and 127 hospitals nationwide, including university hospitals, that belong to the members of the Korean Spinal Neurosurgery Society who treat spine.

[Table 1] Hospitals That Specialize in the Spine Designated by the Ministry of Health and Welfare

Name of the Institution Website Region

1 Seoul Gimpo Airport Wooridul Hospital wooridul.com Seoul

2 Seoul Gangnam Wooridul Spine Hospital wooridul.com Seoul

3 Seoul Nanoori Hospital www.nanoori.co.kr Seoul

4 The Joeun Hospital http://joeun4u.com/newhome/ Seoul

5 Seoul Chuk Hospial http://seoul.chukhospital.com/seindex.html Seoul

6 Busan Wooridul Spine Hospital http://busan.wooridul.co.kr/ Busan

7 Wiltse Memorial Hospital www.allspine.com Gyeonggi-do

8 Incheon Hospital 21 www.hospital21.co.kr Incheon

9 Wiltse Memorial Hospital www.allspine.com Gyeonggi-do

10 Incheon Nanoori Hospital www.nanoori.co.kr Incheon

11 Daejeon Woori Hospital http://www.woorispine.com/ Daejeon

12 Cheonan Woori Hospital www.spinewoori.com/ Chungcheong-nam-do

13 Gwangju Saewoori Spine Hospital www.saewoori.com Gwangju

14 Bokwang Hospital http://www.bkhosp.co.kr/ Daegu

15 Bogang Hospital http://www.bogang.co.kr/ Daegu

16 Charmjoeun Hospital www.nicehospital.co.kr Daegu

17 Daegu Wooridul Spine Hospital www.wooridul.co.kr Daegu

IV. Institutions that specialize in treating spinal diseases in Korea

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