Correction of Coronal Imbalance in Degenerative Lumbar Spine Disease Following Direct Lateral Interbody Fusion (DLIF)

OBJECTIVE: The authors have recently been using a surgical technique of minimally invasive direct lateral interbody fusion (DLIF) for correcting of coronal imbalance. The purpose of this study was to evaluate the surgical outcome and complication of DLIF. METHODS: We undertook retrospective analysis of a consecutive series of 8 DLIF procedures in Degenerative lumbar spine disease since May 2011. Four patients underwent DLIF only, and the others underwent combined DLIF and posterior fixation. Data on intra- and postoperative complications were collected. The pre- and postoperative X-rays were reviewed. We investigated coronal deformity, Cobb's angle, and apical vertebral translation (AVT). The mean follow-up period was months with a range of 2 to 8 months. RESULTS: A mean preoperative coronal Cobb's angle was 21.8degrees (range 11.5-32.4degrees). Following after DLIF, the mean Cobb's angle was decreased to 13.0degrees (range 2.9-21.5degrees). Following additional posterior screw fixation, mean Cobb's angle was further decreased to 7.4degrees (range 2.9-13.2degrees). A mean preoperative AVT was 2.0 cm(range 0.6-3.5 cm), and improved to 1.4 cm(range 0.3-2.4 cm) and 0.8 cm(range 0.2-1.8 cm) postoperatively (DLIF and, posterior fixation respectively). One patient (12.5%) showed cage migration during follow-up period. Two patients (25%) developed motor weakness, and 4 patients (50%) experienced postoperative thigh paresthesias or dysesthesias. During follow up period, motor weakness had resolved in 1 patient. Sensory symptoms were improved in all patients at the last follow-up. CONCLUSION: Degenerative lumbar disease can be effectively corrected by DLIF with acceptable complications.

Initial Clinical Outcomes of Minimally Invasive Lateral Lumbar Interbody Fusion in Degenerative Lumbar Disease: A Preliminary Report on the Experience of a Single Institution with 30 Cases

OBJECTIVE: The object of this study was to evaluate the clinical and radiological outcomes of minimally invasive lateral lumbar interbody fusion. METHODS: This study included 30 patients who underwent minimally invasive lateral lumbar interbody fusion at our hospital between May 2011 and February 2012 for the following diagnoses: degenerative disc disease, adjacent-segment degeneration, degenerative spondylolisthesis and lumbar degenerative scoliosis. Pain assessment was reported from 0 to 10 using a subjective visual analog scale (VAS) upon admission and at every follow-up day. Lumbar X-rays were obtained in the standing position upon admission and the 1st and 5th postoperative day, and at every follow-up day after the operation. The heights of the intervertebral disc space and neural foramen were measured using an electronic caliper with the PACS software. The surgical outcome was assessed as excellent, good, fair or poor using the Odom scale at the last follow-up. RESULTS: The mean VAS for low back pain were 4.93+/-1.47 on admission and 2.01+/-1.35 at last follow-up, respectively, and for leg pain, the scores were 4.87+/-2.16 on admission and 1.58+/-1.52 at last follow-up. The mean height of intervertebral disc space increased by 34% (7.93+/-2.33 preoperatively, and 11.09+/-4.33 immediately after surgery, p<0.01). The mean height of neural foramen also increased by 6.4% without any statistical significance (19.17+/-2.84 preoperatively, and 20.49+/-4.50 immediately after the surgery). Minimally invasive lateral lumbar interbody fusion was successful in 27 patients (90%) at last follow-up. Surgical complications were reported as transient postoperative thigh sensory changes (5 patients, 16.7%), transient psoas muscle weakness (3 patients, 10%), cage migration (2 patients, 6.7%), lumbar plexus injury (1 patient, 3.3%), and pain aggravation (1 patient, 3.3%). CONCLUSION: The minimally invasive lateral lumbar interbody fusion is a safe and effective procedure for treating degenerative lumbar disease with good outcomes and moderate complications. Further follow-up is necessary to establish its safety and efficacy.

Surgical Outcomes of Spine Disorders in Patients with Parkinson's Disease

PURPOSE: Patients with Parkinson's disease also commonly have movement disorders, osteoporosis, and other comorbidities. These patients are more likely to have complications after spinal surgery. The aim of the present study is to show the relation ship between complications of spinal surgery and Parkinson's disease. METHODS: A computerized search using diagnostic and procedural codes identified 13 patients with Parkinson's disease who underwent spinal surgery between January 1998 and December 2010. Their medical records and imaging studies were reviewed and recent updatesfor all patients were done by telephone interview. RESULTS: Retrospectively, 13 consecutive patients were reviewed. The mean age was 63.8 (range 44~87) years old and the mean durationof Parkinson's disease was 7.6 (range 1~22) years at the time of the index procedure. The mean T score of the lumbar spine on Dual-energy X-ray absorptiometry (DEXA) scan bone mineral density (BMD) was -2.5 (range -1.0~-5.1). These patients had nine lumbar lesions, two thoracic lesions, one cervical lesion, and one thoracolumbar lesion. Nine patients required no more surgical treatment for lesions which had been previously operated on (index level). However, four patients (30.8%) needed at least one more operation related to their index procedure; segmental degeneration on the adjacent levels in two, retropulsion of an intervertebral cage with screw loosening in one, and pedicle fracture in one. CONCLUSION: It has been reported that patients with Parkinson's disease have high complication rates in spinal surgery. Spine surgeons should be aware of the risk of complications and need to conduct careful follow-up after the surgery.

Prognostic Significance of Pre-operative FDG-PET in Colorectal Cancer Patients with Hepatic Metastasis / 핵의학분자영상

PURPOSE: The purpose of this study was to assess the prognostic value of preoperative FDG-PET in colorectal cancer (CRC) patients with hepatic metastasis (HM). MATERIALS AND METHODS: 24 CRC patients (M:F=14:10; age, 63+/-10 yrs) with HM who had undergone preoperative FDG PET were included. Cure-intent surgery was performed in all the patients and HMs were controlled using resection (n=13), radio-frequency ablation (RFA) (n=7), and resection plus RFA (n=4). Potential prognostic markers tested were maxSUV of primary tumor, maxSUV of HM, maxSUV ratio of HM over primary tumor (M/P ratio), histologic grade, CEA level, venous/lymphatic/nerve invasion, T stage, N stage, no. of HM, no. of lymph node metastasis, and treatment modality of HM. RESULTS: 14 CRC patients developed a recurrence with a median follow-up duration of 244 days, whereas 10 patients did not develop recurrence with a median follow-up duration of 504 days. M/P ratios but other potential prognostic markers were significantly higher in the recurrent patients (0.72+/-0.14) than recurrence-free patients (0.54+/-0.23) (p=0.038). M/P ratio only was found to predict recurrence by Cox multivariate analysis (hazard ratio 37.7, 95% confidence interval 2.01-706.1, p=0.016). The 11 patients with lower M/P ratio of or =0.61) (p=0.026). CONCLUSION: maxSUV ratio of HM over primary tumor (M/P ratio) may be useful for prognosis prediction of CRC patients with HM. Higher FDG uptake of HM than that of primary tumor may indicate a more advanced status in stage IV CRC.

A Study of Clinical Significance of Dizziness in Diagnostic Approach for Children with Chronic Headache / 대한소아신경학회지

PURPOSE: Headache is a common neurologic symptom in children but chronic headache in them must be diagnosed in different ways. The aim of this study is to determine the algorithm of diagnostic approach for children with chronic headache and know the clinical significance of dizziness in evaluating those children. METHODS: We recruited children with headache at Myongji Hospital from January 2004 to July 2006. The study was based on a retrospective review of their medical records and interviews with the children and their parents. We divided them into two groups : Group A headache with dizziness, Group B headache without dizziness. RESULTS: The medical records of 86 children and adolescents with headache were reviewed. Age for group A ranged from 10 to 15 years(73.7%) and gender ratio was 1:1.7. Age for group B ranged mostly under 7 years(56.3%) and gender ratio was 1:0.85. Headache in group A frequently occurred predominantly in the morning(37.3%). The duration of the attack was over 90 min(87.5%) in group A and over 90 min(50.0%) in group B. Associated symptoms were mainly nausea(34.2%), vomiting(18.4%), blurred vision(12.7%) in group A. Over 90% of them had headache 4 times a week and so did dizziness. The final diagnoses in cases of group A were migraine(31.6%), orthostatic hypotension(15.8%), postural orthostatic tachycardia syndrome(13.2%), and benign paroxysmal positional vertigo(10.5%). While in group B diagnoses included sinusitis(50.0%), migraine(31.3%), and complications of migraine(8.3%). CONCLUSION: This study revealed high percentage of headache concurred with dizziness in children. The association of headache with dizziness is complex and maybe coincidental. If chronic headache with dizziness in girls occurs mainly in the morning, it maybe related to vestibular disorder and orthostatic instability. In conclusion, dizziness and other associated symptoms or clinical features should carefully be assessed in the diagnosis of headache.

Therapeutic Strategies of Middle Cerebral Artery M1 Trunk Aneurysms / 대한뇌혈관외과학회지

OBJECTIVE: This study was designed to define the clinical characteristics and to establish the therapeutic strategies for treating aneurysms located at the M1 trunk of the middle cerebral artery (MCA). METHODS: During the past 30 years from September 1976 to December 2006, 47 (6.2% of the 755 treated MCA aneurysms) consecutive patients with M1 aneurysms were treated at our institute. We retrospectively reviewed the database and imaging studies of these 47 patients for analysis. Nine patients (19.1%) were male and 38 (80.9%) patients were female. The mean age was 51.7 years (range: 381 years). Thirty-three (70.2%) patients had ruptured lesions: 3 patients were Hunt and Hess Grade I, 16 patients were Grade II, 7 patients-were Grade III, 4 patients were Grade IV and 3 patients were Grade V. Intracerebral hemorrhage was identified in 9 patients on the initial computed tomograph images. Fourteen patients had unruptured lesions. The diameters of the aneurysms were 25 mm in 2 patients. The mean diameter of the aneurysms was 5.1mm (range: 2.029.0mm). Eleven patients (23.4%) had multiple aneurysms. The repair methods for the aneurysms were microsurgery in 42 (89.4%) patients (clipping: 36, wrapping: 6, aneurysm resection and suture: 1) and coiling in 5 patients. The mean posttreatment follow up period was 45.5 months. The clinical outcome was assessed using the Glasgow Outcome Scale. The therapeutic results of lesion repair, the long-term clinical outcome and the causes of an unfavorable outcome were also analyzed. RESULTS: The overall outcome was favorable in 39 (82.9%) patients (excellent: 32, good: 7) and unfavorable in 8 (17.1%) (fair: 6, poor: 1, dead: 1) patients. The major causes of an unfavorable outcome were the initial insults. Seven patients suffered from a delayed ischemic deficit, and 3 of them were left with a permanent deficit. Surgery-related complications occurred in 8 patients (cerebral infarction: 6, intracerebral hemorrhage: 2) and 3 were left with a permanent deficit. The angiographic results of coiling were complete packing in 3 (60%), a neck remnant in 1 (20%) and incomplete packing for 1 (20%). There was no coiling-related complication. CONCLUSION: In our series, M1 aneurysms had characteristics of a female predominance, the patients more often presented with intracerebral hemorrhage, and a high risk of postoperative ischemic complication. Due to the small size, wide neck and location at the branching site, M1 aneurysms can be treated with surgery rather than coiling, but surgeons should be careful for injury of the branching vessels like the lateral lenticulostriate artery and they must be prepared for various inevitable situations that occur during surgery.

A Case of Cerebral Sinus Expansion and Concurrent Diffuse Meningeal Enhancement in Postlumbar Puncture Headache / 대한소아신경학회지

Post-lumbar puncture headache (PLPH) is a common complication developed after lumbar puncture, and it usually begins within 48 hours. The pain is postural; the it is relieved by reclining and worsened by sitting. Moreover, there are some related symptoms such as nausea, vomiting, tinnitus and blurred vision. PLPH is rare in children and it is effectively treated by bed rest and conservative treatment. However, when the pain is too severe or continuous or different types of headache are seen after LP, it is worthwhile to conduct brain MRI for exact diagnosis and proper treatment. Therefore, we report a patient with PLPH in whom brain MRI showed diffuse meningeal enhancement and concurrent cerebral venous expansion, with a review of literatures.

Enhanced tyrosine hydroxylase expression in PC12 cells co-cultured with feline mesenchymal stem cells

Mesenchymal stem cells (MSCs) secrete a variety of neuroregulatory molecules, such as nerve growth factor, brain-derived neurotrophic factor, and glial cell-derived neurotrophic factor, which upregulate tyrosine hydroxylase (TH) gene expression in PC12 cells. Enhancing TH gene expression is a critical step for treatment of Parkinson's disease (PD). The objective of this study was to assess the effects of co-culturing PC12 cells with MSCs from feline bone marrow on TH protein expression. We divided the study into three groups: an MSC group, a PC12 cell group, and the combined MSC + PC12 cell group (the co-culture group). All cells were cultured in DMEM-HG medium supplemented with 10% fetal bovine serum for three days. Thereafter, the cells were examined using western blot analysis and immunocytochemistry. In western blots, the co-culture group demonstrated a stronger signal at 60 kDa than the PC12 cell group (p < 0.001). TH was not expressed in the MSC group, either in western blot or immunocytochemistry. Thus, the MSCs of feline bone marrow can up-regulate TH expression in PC12 cells. This implies a new role for MSCs in the neurodegenerative disease process.

Myocardial Function in Infant Kawasaki Disease with Tissue Doppler Imaging

PURPOSE: The purpose of this study is to assess myocardial function in infant Kawasaki disease, with strain and tissue Doppler imaging, in addition to conventional echocardiographic measures. METHODS: Strain and tissue Doppler imaging were performed in 20 patients with infant Kawasaki disease. Peak velocities of systolic and early, late diastolic pulsed tissue Doppler velocities, strain, and time to peak strain values were measured at ventricular septal annulus from apical view. The data set were obtained at both acute period and convalescent period. RESULTS: All patients represents coronary arteriopathy. Measures of Systolic peak velocity (S') of pulsed wave tissue Doppler value and strain decreased in convalescent phase, and time to peak strain was delayed (P<0.01). Meanwhile, the diastolic measures (E' and A') demonstrated no significant differences between acute and convalescent phases using tissue Doppler velocity data. CONCLUSION: In convalescent phase, myocardial systolic function may not be completely improved yet. After convalescent period, continuous myocardial assessment should be followed.

A Study on the Clinical Features and the Predictors of Febrile Seizure Plus / 대한소아신경학회지

PURPOSE: We intended to investigate the clinical features and the predictors of febrile seizure plus(FS+), not suspected of generalized epilepsy with febrile seizure plus (GEFS+). METHODS: We selected 24 patients, aged more than 6 years old, who were admitted to Myongji Hospital of Kwandong University from January, 2001 to March, 2005 due to febrile seizures. All of those had neither a family history of febrile seizures or epilepsy nor abnormalities in the EEG or MRI. We examined sex, age of seizure onset, type of seizure, duration of seizure, the time until seizure after fever and frequency of febrile seizure. We investigated also the statistical significances of these clinical features by comparing with patients of simple febrile seizure(FS) as a control group. RESULTS: The male to female of the FS+ group was 2:1, which had no statistical significance compared with the FS. The age of seizure onsets in the FS+(39.4+/-5.0 months) was significantly older than FS the group(24.1+/-2.1 months)(P<0.05). In the types of seizures, non-generalized tonic clonic seizures occurred significantly more often in the FS+ group(20.9%) than the FS(8.4%)(P<0.05). The frequency of febrile seizures also was high in the FS+ group(n=3.2+/-0.8) than the FS group(n=1.1+/-0.1)(P<0.05). The duration of seizures and the time until seizure after fever did not have statistical significance. CONCLUSION: We suggest that FS+ can be characterized by late onsets of initial seizures, more frequent non-generalized tonic clonic seizures and recurrent febrile seizures. Therefore, FS+ should be suspected for patients more than 4 years old with non-generalized tonic clonic seizures or recurrent febrile seizures of more than 4 times.

Clinical & Pathological Characteristics of Intraductal Papillary Mucinous Tumor of the Pancreas

PURPOSE: Intraductal papillary mucinous tumors of the pancreas (IPMT) are becoming increasingly recognized. Despite a better understanding of these conditions, IPMT still present difficulty relating to the predictive factors and the risk of relapse after surgery. The aim of this study was to investigate the clinical, and pathological characteristics of IPMT. METHODS: Between October 1998 and July 2002, 22 patients with IPMT underwent surgery. We retrospectively examined the clinicopathological features and surgical outcomes of these patients. RESULTS: The types of IPMT were as follows: dysplasia (1); adenoma (4); borderline malignancy (9); carcinoma in situ (3); and carcinoma, both non-invasive (3) and invasive (2). Lymph node metastasis was not found, but stromal invasion was found in the 2 cases of invasive carcinoma. The locations of the IPMT were as follows: head (6); uncinate process (11); body (4); and tail (1). There were 11 main duct types, 10 branched duct types and 1 combined. All patients underwent surgical resection, including 3 pancreaticoduodenectomies, 12 pylorus-preserving pancreaticoduodenectomies, 4 distal pancreatectomies with splenectomies, 2 near-total pancreatectomies with splenectomies, and 1 enucleation. There were no operative or hospital deaths. A recurrence of the IPMT following surgery occurred in 2 cases. Their pathological features were a carcinoma in situ and a borderline malignancy, but not the invasive type. However, one case of recurrence expired 7 month after surgery. A combination of other malignancies in these patients was found in 2 cases. CONCLUSION: IPMT has a favorable prognosis, when compared with pancreatic duct carcinoma. However, long-term follow-up after surgery is necessary, even for a curative resection due to a recurrence or a combination of other malignancies. Because combination of other malignancies exist infrequently, surgeons should be aware of the possibility of co-existing other malignancies.

Clinical Analysis of CA19-9 Positive Rate of Hepatobiliary Pancreas Disease

PURPOSE: CA19-9 is the most widely used pancreatic-tumor marker, and has become the standard against which other makers. However, the CA19-9 level is increased in conditions such as gallbladder cancer, cholangiocarcinoma, hepatocellular carcinoma, gallbladder polyp, acute cholangitis, and chronic pancreatitis. Therefore, this study aimed to determine the CA19-9 positive rate of the above diseases in Korea. METHODS: A positive result was considered if the upper limit of normal was 37~40 U/ml. The CA19-9 level was measured in 53 patients with pancreatic cancer, 72 with cholangiocarcinoma, 41 with common bile duct cancer, 27 with gallbladder cancer, 35 with hepatocellular cancer, 70 with acute pancreatitis, 93 with chronic pancreatitis, and 30 with a gallbladder polyp from September 1998 to December 2000 in the Severance hospital. RESULTS: When the cut-off value was >40 U/ml, a positive result was found in 79.2% (42/53) of pancreatic cancer patients, 58.3% (42/72) of cholangiocarcinoma patients, 37% (10/27) of gallbladder cancer patients, 31.7% (13/41) of common bile duct cancer patients, 19.7% (14/70) of acute pancreatitis patients, 14.2% (5/35) of hepatocellular cancer patients, 16% (5/93) of chronic pancreatitis patients, and the 3.3% (1/30) of patients with a gallbladder polyp. CONCLUSION: The highest positive rate was 79.2% in the pancreatic cancer patients. We confirmed that the Lewis phenotype distribution indieates that pancreatic cancer, cholangiocarcinoma, and chronic pancreatitis show high frequency in Le(a-b-) group when they were statistically compared with a healthy control group, but that acute pancreatitis showed a stastically higher frequency in the Le(a-b-) group than chronic pancreatitis.

Gallbladder Carcinoma Diagnosed after Laparoscopic Cholecystectomy / 한국간담췌외과학회지

BACKGROUND/AIMS: Laparoscopic cholecystectomy has become popular. Occasionally, unsuspected gallbladder carcinoma is diagnosed after the operation by pathologic examination, incidentally. And even when the gallbladder carcinoma is suspected preoperatively, it is determined whether or not the additional radical operation will proceed, according to the pathologic diagnosis after laparoscopic cholecystectomy. Multiple staging systems have been described, including the modified Nevin classification (Donohue et al 1990, Nevin et al 1976), the AJCC TNM staging system, and there are controversies in the surgical management of gallbladder carcinoma for each stage. The purpose of this study was to evaluate the role and the meaning of the laparoscopic cholecystectomy in the surgical management of the gallbladder carcinoma. METHODS: A retrospective analysis was made of 24 patients with gallbladder carcinoma that was confirmed by pathologic diagnosis after laparoscopic cholecystectomy in Severance Hospital between January 1993 and Feburary 2002. RESULTS: Gallbladder carcinoma was found in 1.1% of the 2141 cholecystectomy specimens. Gallbladder carcinoma was suspected preoperatively in 11 patients (45.8%). The location of the lesions was the serosal side in 16 patients (66.7%), the liver bed side in 1 patient, and undetermined in 7 patients. The histologic type was adenocarcinoma in all patient, and well differentiated in 16 patients (66.7%), moderate and poorly differentiated in 8 patients (33.3%). According to the AJCC TNM staging system, there were 13 stage I (54%), 5 stage II (20.8%), 2 stage III (8.3%), 4 stage IV (16.7%). The lymph node metastasis was observed in 4 patients (16.7%). In 18 patients (75%), only laparoscopic cholecystectomies were performed, and additional radical cholecystectomies were performed in 4 patients (16.7%). The patients with stage I and II tumor were alive without recurrence except 1 follow-up loss, and there was not any port site recurrence. CONCLUSION: Laparoscopic cholecystectomy is sufficient with stage I gallbladder carcinoma. It may be considered that the patient with stage II gallbladder carcinoma is closely followed without additional radical cholecystectomy after laparoscopic cholecystectomy, if properly selected. The use of vinyl bag for retrieval of specimen is recommended to avoid the port site recurrence. For advanced gallbladder carcinoma (stage III and IV), the additional radical cholecystectomy is recommended. When gallbladder cancer is suspected, an open operation should be performed with sufficient preoperative staging work-up.

Transcriptional Regulation of the Xbr-1a/Xvent-2 Gene by BMP-4 Signaling during Xenopus Embryonic Development / 대한해부학회지

BMP-4 signaling is mediated through Smad proteins which may translocate to the nucleus to activate transcription. Little is known about how BMP-4 signaling regulates the transcription of its target genes, e.g., Xvent genes. Therefore, we isolated the genomic clone of a BMP-4 responsive homeobox gene, Xbr-1a/Xvent-2. This clone contains a promoter and three exons for the entire coding region. Using the primer extension, we identified the transcription initiation site corresponding to position -64 bp upstream to the ATG codon of the Xvent-2 gene. The promoter was linked to the luciferase reporter gene, and promoter activity determined by luciferase assay. The temporal promoter activity peaked between embryonic stages 13~17, in agreement with its temporal mRNA expression in the whole embryo. Through the serial deletion mutation, the upstream -235 bp of the promoter retains the full transcriptional activity, and is regulated by BMP-4 signaling. The present results suggest that the BMP-4 responsive element is located on the upstream 235 bp of the promoter.