Negative Effect of Rapidly Resorbing Properties of Bioactive Glass-Ceramics as Bone Graft Substitute in a Rabbit Lumbar Fusion Model

BACKGROUND: Bioactive glass-ceramics have the ability to directly bind to bones and have been widely used as bone graft substitutes due to their high osteoconductivity and biocompatibility. CaO-SiO2-P2O5-B2O3 glass-ceramics are known to have good osteoconductivity and are used as bone graft extenders. METHODS: This study aimed to evaluate the effects of the resorbing properties of glass-ceramics in bone fusion after producing and analyzing three types of CaO-SiO2-P2O5-B2O3 glass-ceramics with high osteoconductivity that had enhanced resorption by having an increased B2O3 content. The three types of CaO-SiO2-P2O5-B2O3 glass-ceramics with B2O3 contents of 8.0, 9.0, and 9.5 weight % were designated and grouped as P20B80, P10B90, and P5B95, respectively. Glass-ceramic types were tested for fusion rates and bone formation by employing the lumbar 5-6 intertransverse process fusion model in 51 New Zealand male rabbits. Bioactivity was assessed by soaking in simulated body fluid (SBF). RESULTS: In vitro study results showed sufficient hydroxycarbonate apatite layer formation occurred for P20B80 in1 day, for P10B90 in 3 days, and for P5B95 in 5 days after soaking in SBF. For the rabbit lumbar spine posterolateral fusion model, the autograft group recorded a 100% fusion rate with levels significantly higher than those of P20B80 (29.4%), P10B90 (0%), and P5B95 (14.3%), with high resorbing properties. Resorbing property differences among the three glass-ceramic groups were not significant. Histological results showed new bone formation confirming osteoconductivity in all three types of glass-ceramics. Radiomorphometric results also confirmed the resorbing properties of the three glass-ceramic types. CONCLUSIONS: The high resorbing properties and osteoconductivity of porous glass-ceramics can be advantageous as no glass-ceramics remain in the body. However, their relatively fast rate of resorption in the body negatively affects their role as an osteoconductive scaffold as glass-ceramics are resorbed before bony fusion.

The Efficacy of Carotid Tubercle as an Anatomical Landmark for Identification of Cervical Spinal Level in the Anterior Cervical Surgery: Comparison with Preoperative C-arm Fluoroscopy

BACKGROUND: In cervical anterior approach, transverse skin incision is preferred due to cosmetic reasons. Precise skin incision is required to reach the surgery segment while minimizing soft tissue injury. Skin incision site is frequently identified using C-arm fluoroscopy or the carotid tubercle. Accordingly, this study was conducted to investigate the efficacy of skin incision using the carotid tubercle as a marker. METHODS: This study was retrospectively conducted on 114 patients who underwent anterior cervical surgery by the same surgeon from April 2004 to June 2012. The rate of the appropriate insertion of K-wire, which was inserted into the disc after anterior approach, into the surgery segment was compared between 62 patients where skin incision site was identified using C-arm fluoroscopy before skin incision and 52 patients where skin incision site was identified using carotid tubercle palpitation before surgery. RESULTS: The needle was shown to have been inserted into the planned site in 106 patients out of the total 114 patients. The appropriate insertion of the needle was shown in 59 patients of group I (95.2%) and in 47 patients of group II (90.4%). Although the success rate was higher in group I than group II, it was statistically insignificant. The success rate of one-segment surgery was shown to be 89.7% in group I and 82.6% in group II. Although the success rate was higher in group I than group II, it was statistically insignificant. The success rate of two-segment surgery was shown to be 100% in group I, and 96.4% in group II due to one case of the failure at C3-4 and C5-6. The success rate of three- and four-segment surgeries was shown to be 100% in both groups. CONCLUSIONS: The identification of skin incision site via carotid tubercle palpation was useful for surgeries involving two or more segments. Furthermore, it could be useful for one-segment surgery if surgical site is identified using vertebral body or soft tissues such as longus collis rather than insertion into the disc.

Normal Range of the Inflammation Related Laboratory Findings and Predictors of the Postoperative Infection in Spinal Posterior Fusion Surgery

BACKGROUND: Inflammation related hematological parameters vary greatly depending on patients. It is not well known how much increase of which parameter warrants suspicion of postoperative infection. This study proposes to identify the normal range and the predictive factors for postoperative infection by conducting a time series analysis of the hematological parameters of patients after the spinal posterior fusion. METHODS: A retrospective study was done with 608 patients who underwent spinal posterior fusion with pedicle screw fixation. Laboratory assessment including the leucocyte, neutrophil, C-reactive protein (CRP), and erythrocyte sedimentation rate (ESR) of patients for 2 weeks after operation. The patients were divided into the one-level fusion group (group I), the two-level fusion group (group II), the three or multi-level fusion or reoperation group (group III), and the postoperative infection group (group IV). Blood was drawn before breakfast prior to the operation, and then 2-3 days, 4-7 days, 8-11 days, and 12-14 days after the operation. The leucocyte count, neutrophil count, CRP, and ESR were measured. RESULTS: From 4-7 days after the operation, the CRP and neutrophil count of group IV were significantly higher than those of group I and II, and from 8-11 days after operation, the CRP and neutrophil counts were significantly higher than those of all groups. Twelve to fourteen days after the operation, the neutrophil count of group IV was significantly higher than that of group I and II, while the neutrophil count of group III was also higher than that of group I. The lower limit of the 95% confidence interval (CI) of the CRP and neutrophil count group IV was greater than the upper limit of the 95% CI of group I and II. The ESR of group IV was significantly higher than that of group I and III. CONCLUSIONS: If the postoperative CRP and neutrophil counts are high, or if the CRP begins to rise again 8 days after the operation, the likelihood of infection increases, but caution must be exercised in interpreting the results. If the hematological parameters are higher than the lower limit of the 95% CI of the postoperative infection group, infection must be strongly suspected.

Prevalence Rate of Osteoporosis in the Patients Who Underwent Posterior Instrumentation of Degenerative Lumbar Spine / 대한골다공증학회지

OBJECTIVES: To identify the prevalence rate of osteoporosis in the patients who underwent posterior instrumentation of degenerative lumbar spine and to identity the prescription rate of osteoporosis medication after operation, and to identify the importance of preoperative BMD. MATERIALS AND METHODS: This study was done with 354 patients who underwent posterior instrumentation of lumbar spine from January of 2006 to July of 2011. The patients were divided into 4 groups according to their pre-operative BMD, normal, osteopenia, osteoporosis (-2.5>T> or =-3.0) and severe osteoporosis (3.0>T). We evaluated the prevalence rate of osteopenia and osteoporosis and analyzed the prescription rate and treatment options of osteoporosis medication on the patients who underwent posterior instrumentation surgery within one year after surgery. RESULTS: BMD was performed on 85.5% of all patients. By group those with osteopenia were 85 patients, the osteoporosis group was 47 patients and the severe osteoporosis group included 30 patients. Among the osteopenia group, 7.0% were under osteoporosis treatment. Among the osteoporosis group, 74.5% were under osteoporosis treatment. Among the severe osteoporosis group, 83.3% were under osteoporosis treatment within 1 year, postoperatively. CONCLUSIONS: The prevalence rate of osteoporosis was 25.4% in the patients who underwent posterior instrumentation of degenerative lumbar spine. The correlation between the patient's preoperative bone mineral density and the stability of the instrumentation was significant. Therefore, determining the patient's BMD via preoperative DEXA is very important because it can decide the treatment methods for osteoporosis before the surgery and help advance the timing of the initiation of treatment.

A Case of Central Nervous System Toxicity Assoclated with Cyclosporine

Benign and malignant papillary neoplasms of the breast may be difficult to distinguish in both cytologic and histologic preparations. To define the cytologic features of benign and malignant papillary lesions, we retrospectively reviewed 18 cases of fine needle aspirates from histologically confirmed cases of papilloma or papillary carcinoma of the breast. This study included 3 intraductal papillary carcinomas, 3 invasive papillary carcinomas, and 12 intraductal papillomas. All cases were evaluated for presence or absence of papillary fragments, bloody background, apocrine metaplasia, macrophages, and degree of cellularity, atypia, and single isolated columnar epithelial cells. Papillary fragments were present in all cases. The background of the smear was bloody in all 6 carcinomas, but in only 7 out of 12 papillomas. Markedly increased cellularity was present in 4 carcinomas (67%) and 7 papillomas (58%). Single cells were present in 5 carcinomas (83%) and 8 papillomas (67%). The majority of papillomas and papillary carcinomas had mild to moderate atypia, and severe atypia was noted in one case of intraductal papillary carcinoma and one case of invasive papillary carcinoma. Apocrine metaplasia was absent in all cases of papillary carcinomas, but present in 8 papillomas (67%). Macrophages were noted in 4 carcinomas and were present in all cases of papillomas. The constellation of severe atypia, bloody background, absence of apocrine metaplasia and/or macrophages were features to favor carcinoma. Malignant lesions tended to show higher cellularity and more single isolated cells. The cytologic features mentioned above would be helpful to distinguish benign from malignant papillary lesions of the breast. However, because of overlapping of cytologic features, surgical excision should be warranted in all cases of papillary lesions of the breast to further characterize the tumor

Serum Eosinophil Cationic Protein Levels in Patients with Recurrent Croup

PURPOSE: Most patients suffer from croup only once in a life time. However, a small group of patients suffer from it several times. A type of croup from which they suffer more than 3 times is called recurrent croup. The cause of recurrent croup has not been clearly described, but in recent years the allergic reaction is considered as a cause of recurrent croup. ECP is one of the 4 major basic proteins of eosinophil, means eosinophil activation, and has been reported as a clinical indicator of bronchial asthma and other an allergic diseases. We measured serum ECP levels in recurrent croup patients in order to evaluate the roles of ECP as a diagnostic tools and eosinophil activation as part of the pathophysiology of recurrent croup. METHODS: 25 patients with 1st croup episode were enrolled in the study between April and August 1994. We phoned the 22 patients if they had ever caught any respiratory and allergic diseases including croup about 2 years since their discharge from the hospital. Three patients could not be connected. We divided these patients into two groups according to the recurrent rate of attack after discharge. The patients with more than three times of episode were diagnosed as recurrent croup patients, and others with one time of episode were diagnosed as single croup patients. The patients with two times episode were dropt out. Non-allergic 10 patients of the same age with acute viral enteritis were enrolled as a control group. Blood sampling was done at admission. Serum ECP levels were measured by ECP radioimmunosorbent assay kit (Phamarcia, Sweden). RESULTS: 1) Recurrent croup (n=9): The ECP level was 52.1+/-17.3 g/L. Single croup (n=12): The ECP level was 11.6+/-7.0 g/L. Control (n=10): The ECP level was 6.3+/-3.2 g/L. 2) There was no meaningful difference between the control and the single croup patients (p>0.05). 3) There was a meaningful difference between the control and the recurrent croup patients (p<0.05). 4) There was a meaningful difference between the single croup and the recurrent croup patients (p<0.05). 5) There was a linear correlation between eosinophil count and serum ECP levels (r=0.63, p<0.01). 6) For 2 years after discharge, pneumoniae was developed in 2 single croup patients. The recurrent rate of croup was 3-6 times in recurrent croup patients. Asthma was developed in 4 recurrent croup patients. And bronchiolitis was developed in 2 recurrent croup patients. CONCLUSIONS: The investigation of serum ECP levels enables us to distinguish recurrent croup patients from single croup patients. It suggests that eosinophil activation may play an important role in the pathophysiology of recurrent croup.

A Case of Common Bile Duct Stone Treatment with Endoscopic Sphincterotomy

The cholelithiasis and common bile duct(CBD) stone are rare problems among children. Endoscopic retrograde cholangiopancretogram(ERCP) and endoscopic sphincterotomy are rarely commomly utilized in the treatment of children, primarily because there are fewer indications. ERCP is an established procedure for visualization of the biliary tract. Endoscopic sphincterotomy with stone extraction has been accepted as the treatment of choice for CBD stone removal in adults. However, the role and value of these procedures in children are not as clear. We experienced a case of CBD stone in 3-year-old boy, who suffered reccurent jaundice and abdominal pain. The boy was administrated and was diagnosed with a mild abnormal gallbldder on ultrasound. Laboratory data showed obstructive jaundice, so, an ERCP was performed and identified that the child had a distal CBD stone. An Endoscopic sphincterotomy was then performed. After the sphincterotomy, the stone passed the Ampulla of Vater spontaneously without the use of a Dormia basket or Forgathy catheter.