Correlation of Sagittal Imbalance and Recollapse after Percutaneous Vertebroplasty for Thoracolumbar Osteoporotic Vertebral Compression Fracture: A Multivariate Study of Risk Factors

Methods@#Ambulatory patients who underwent single-level PVP for thoracolumbar OVF with a follow-up of at least 24 months were retrospectively reviewed. The patients were divided into two groups depending on the presence of symptomatic recollapse at the cemented vertebra: (1) recollapsed (RC) group and (2) noncollapsed (NC) group. The patient characteristics and radiographic measurements associated with sagittal imbalance were analyzed at each follow-up visit. @*Results@#Overall, 134 patients (RC group, n=28; NC group, n=106) were enrolled. The mean fracture-free interval was 3.2 months (range, 1.2–25.1 months). The multivariate binary logistic regression analysis identified low bone mineral density (p =0.047), degree of dynamic mobility within the vertebra (p =0.025), and sagittal imbalance as significant risk factors for recollapse (p =0.013; odds ratio, 5.405). The progression of sagittal imbalance and thoracolumbar kyphosis (T10–L2) was more significant in the RC and sagittal imbalance groups than in the NC group (both p =0.000). @*Conclusions@#Sagittal imbalance, lower bone mineral density, and dynamic mobility within the vertebra are associated with the recollapse of cemented vertebrae following PVP. Sagittal imbalance, rather than local kyphosis or thoracolumbar kyphosis, is particularly significant in that it results in more progressive collapse and sagittal deformity and is accompanied by substantial back pain and neurological deficits. Therefore, a stricter and more active management, including anti-osteoporosis medication, is required for the treatment of OVF with sagittal imbalance of the spine.

Comparison of Clinical Outcomes and Complications of Primary and Revision Surgery Using a Combined Anterior and Posterior Approach in Patients with Adult Spinal Deformity and Sagittal Imbalance

Background@#The purpose of this study was to compare clinical outcomes and complications of primary and revision surgery in patients with adult spinal deformity (ASD) accompanied by sagittal imbalance. Revision surgery has been associated with poor clinical outcomes and increased risk of complications. Previous studies comparing primary versus revision surgery included data for a wide variety of diseases and ages, but few investigated patients with ASD with sagittal imbalance undergoing anterior and posterior combined surgery. @*Methods@#Retrospective cohort analysis of prospectively collected data. We identified 60 consecutive patients with ASD combined with sagittal imbalance who underwent primary or revision surgery; of these, 6 patients were excluded for lack of a minimal 2-year follow-up. Patients’ surgical and radiological data, clinical outcomes, and complications were reviewed. @*Results@#There were 30 patients in the primary group and 24 patients in the revision group. Patient characteristics, including the prevalence of sarcopenia, were similar between the two groups. Pedicle subtraction osteotomy was performed more frequently in the revision group although there was no statistically significant difference between groups. The primary group had more proximal junctional problems, whereas the revision group had more rod breakage (p < 0.05). There were significant improvements in clinical outcomes in both groups when the preoperative and 2-year postoperative values were compared. The Oswestry disability index and visual analog scale score were similar in both groups 2 years postoperatively. @*Conclusions@#Considering the greater pain and disability at the time of the revision procedure, revision patients benefited more from surgery at the 2-year follow-up than the primary surgery patients. Complication rates were similar between the groups except for proximal junctional problems and rod breakage. Therefore, revision surgery should not be avoided in the treatment of ASD patients with sagittal imbalance.

Comparison of Clinical Outcomes and Complications of Primary and Revision Surgery Using a Combined Anterior and Posterior Approach in Patients with Adult Spinal Deformity and Sagittal Imbalance

Background@#The purpose of this study was to compare clinical outcomes and complications of primary and revision surgery in patients with adult spinal deformity (ASD) accompanied by sagittal imbalance. Revision surgery has been associated with poor clinical outcomes and increased risk of complications. Previous studies comparing primary versus revision surgery included data for a wide variety of diseases and ages, but few investigated patients with ASD with sagittal imbalance undergoing anterior and posterior combined surgery. @*Methods@#Retrospective cohort analysis of prospectively collected data. We identified 60 consecutive patients with ASD combined with sagittal imbalance who underwent primary or revision surgery; of these, 6 patients were excluded for lack of a minimal 2-year follow-up. Patients’ surgical and radiological data, clinical outcomes, and complications were reviewed. @*Results@#There were 30 patients in the primary group and 24 patients in the revision group. Patient characteristics, including the prevalence of sarcopenia, were similar between the two groups. Pedicle subtraction osteotomy was performed more frequently in the revision group although there was no statistically significant difference between groups. The primary group had more proximal junctional problems, whereas the revision group had more rod breakage (p < 0.05). There were significant improvements in clinical outcomes in both groups when the preoperative and 2-year postoperative values were compared. The Oswestry disability index and visual analog scale score were similar in both groups 2 years postoperatively. @*Conclusions@#Considering the greater pain and disability at the time of the revision procedure, revision patients benefited more from surgery at the 2-year follow-up than the primary surgery patients. Complication rates were similar between the groups except for proximal junctional problems and rod breakage. Therefore, revision surgery should not be avoided in the treatment of ASD patients with sagittal imbalance.

Lumbopelvic Fixation with Iliac Screw in Spinopelvic Dissociation / 대한정형외과학회잡지

PURPOSE: Spinopelvic dissociation which occurs by high energy trauma with associated fractures is rare. Treatment is difficult and only a few studies on treatment of spinopelvic dissociation have been reported. Therefore we evaluated spinopelvic dissociation patients treated with iliac screw. MATERIALS AND METHODS: We analyzed patients who underwent surgery using an iliac screw from 2005 to 2010. Preoperative radiologic classification was performed using the level of the transverse fracture line of the sacrum, shape of the fracture, and Roy-Camille classification. Neurologic evaluation was performed using Gibbons classification. Eleven patients underwent surgery with a pedicle screw in 1 level (L5 to S1) and bilateral iliac screws were added. RESULTS: A total of 11 patients were included in this study. The level of the transverse fracture line of the sacrum was mainly at S2, and there were mostly type 3 or 4 in Roy-Camille classification. Bony union was checked in 11 patients without metal failure. Six of 7 patients were treated by posterior decompression. Among them, 5 patients recovered from neurological deficit and 1 patient still had a sensory disorder on both lower legs. CONCLUSION: The more displacement of fracture, the more neurologic deficit occurred. In addition, we think that aggressive surgical treatment for spinopelvic dissociation should be considered, because a good clinical result was achieved with 1 level (L5 to S1) fixation and bilateral iliac screw fixation.

A Case of Rosai-Dorfman Disease Affecting the Palpebral Conjunctiva

PURPOSE: To report a single case of Rosai-Dorfman disease of the palpebral conjunctiva with a review of the relevant literature. CASE SUMMARY: A 39-years-old woman presented with a palpebral conjunctival mass 3 weeks in duration on both eyes. The patient had a history of excisional biopsy of lymphadenitis and wanted to remove the mass for cosmetic reasons. An excisional biopsy was performed to obtain a diagnosis for proper management. The histopathologic examination of the lesion showed an intensive proliferation of monotonous and histiocytoid cells beneath the epidermis. Immunohistochemical staining for the S-100 protein was positive and anti-CD1A antibody was negative. Five months after mass excision, there was no evidence of recurrence.

Nonsurgical Treatment of Abnormal Eyelid Position Using Hyaluronic Acid Gel

PURPOSE: The present study investigated the outcomes of nonsurgical treatment of abnormal eyelid position using hyaluronic acid gel. METHODS: Abnormal eyelid position including 18 eyes with lid retraction, 10 eyes with lagophthalmos, and 18 eyes with ectropion were treated with hyaluronic acid gel. The mean age was 50 +/- 17.8 years and the mean observation period was 11 +/- 2.4 months. The photographs of patients were taken before injection, 1 month, 4 months, and at the last follow-up after injection. The marginal reflex distance 1 (MRD1) and marginal reflex distance 2 (MRD2) of patients were measured and analyzed by the Image J Program. The severity of ectropion was graded by a scoring system. RESULTS: Ten eyes with lagopthalmos improved 1.9 +/- 1.2 mm after injection. The 16 eyes with lid retraction improved 1.3 +/- 0.9 mm. Twenty-three eyes with ectropion improved and 17 eyes (81%) were completely corrected. The average frequency of injection was 1.1 and the average dose of injection was 0.4 +/- 0.12 cc. No significant complications were observed in any patient. CONCLUSIONS: Hyaluronic acid gel injections can be used safely and effectively as a nonsurgical treatment for patients with abnormal eyelid position without any significant complications.

Dissociated Vertical Deviation with Microtia showing Familial Tendency

PURPOSE: We report two brothers having dissociated vertical deviation with microtia and familial history of the condition. METHODS: The subjects of this report are a 7-year-old patient with bilateral dissociated vertical deviation, exotropia, bilateral inferior oblique muscle overaction, and microtia, and his brother, a 6-year-old with bilateral dissociated vertical deviation, right dissociated horizontal deviation and microtia. RESULTS: The first patient underwent asymmetric bilateral lateral rectus muscle recession and bilateral inferior oblique muscle myotomy, while the second patient had asymmetric bilateral lateral rectus muscle recession. In the first patient, the exotropia was corrected, but the bilateral dissociated vertical deviation and left dissociated horizontal deviation remained. The right dissociated horizontal deviation improved in the second patient. Their father, two aunts and paternal grandmother also had strabismus and microtia. CONCLUSIONS: Physicians must investigate familial history in examining the strabismus patient with microtia. Additionally, genetic investigation is in need in more subjects of this study.

Surgical Result of Endoscopic Dacryocystorhinostomy according to Opening Size of Nasal Mucosa

PURPOSE: This study investigated the surgical results and nasal findings of an endoscopic dacryocystorhinostomy according to differences in nasal mucosal and lacrimal bone opening size. METHODS: This investigation included 40 eyes of 35 patients who had undergone endoscopic dacryocystorhinostomy by nasolacrimal duct obstruction between February 2003 and December 2004. Comparisons of nasal mucosal opening with lacrimal bone opening were performed using of digital images recorded during the operations. Opening size was defined as the definite to average length of the long and short axes of each opening. Success rates were evaluated by postoperative subjective symptoms and syringing findings. Postoperative nasal cavity findings were obtained by endonasal evaluation. The results were verified by the Pearson chi-square test. RESULTS: The success rate was higher in the group with a nasal mucosal opening size at least twice as wide as their lacrimal bone opening size (84.62%) compared to the group with a nasal mucosal opening sizes less than twice as wide as their lacrimal bone opening size (78.57%), but the difference was not significant (p=0.78). Granulation tissues were observed at a significantly lower rate in the group with nasal mucosal opening sizes at least twice as wide as their lacrimal bone opening size. CONCLUSIONS: Large resection of nasal mucosa in endoscopic dacryocystorhinostomy can improve the result by decreasing the granulation formation.

Anatomical Study of Medial Orbit in Human Cadavers

PURPOSE: This study investigated the anatomy of the anterior ethmoidal foramen, posterior ethmoidal foramen, optic foramen, and nasolacrimal duct located in the medial orbit. METHODS: The subjects of this investigation were 20 eyes of 10 cadavers, three were male and seven were female. After exenteration, anatomic evaluation of medial orbit and nasolacrimal duct were performed. The results were verified by Mann-Whitney U test. RESULTS: The distance from the posterior lacrimal crest is 16.10+/-1.07 mm to the anterior ethmoidal foramen, 30.35+/-4.08 mm to the posterior ethmoidal foramen and 37.40+/-2.03 mm to the optic foramen. The distance is 13.95+/-1.16 mm between the anterior and posterior ethmoidal foramen, 6.45+/-1.86 mm between the posterior ethmoidal foramen and optic foramen. The distance from the anterior ethmoidal foramen to its vertical contact point from the anterior ethmoidal foramen to the base line between the posterior lacrimal crest and optic foramen is 14.68+/-2.56 mm, from This vertical contact point to the posterior lacrimal crest is 4.00+/-1.35 mm and the angle between line from the anterior ethmoidal foramen to the posterior lacrimal crest and the line from the optic foramen to the posterior lacrimal crest is 16.15+/-7.03. The distance from the posterior ethmoidal foramen to its vertical contact point from the posterior ethmoidal foramen to the base line between the posterior lacrimal crest and optic foramen is 30.88+/-2.27 mm, from this vertical contact point to the posterior lacrimal crest is 2.30+/-0.71 mm and the angle between the line from the posterior ethmoidal foramen to the posterior lacrimal crest and the line from the optic foramen to the posterior lacrimal crest is 4.43+/-1.47. The total length is 33.55+/-5.34mm, the angle are 44.98+/-6.61 degrees between the coronal plane and 36.60+/-2.19 degrees between the sagittal palne in nasolacrimal duct. CONCLUSIONS: Our study evaluate normal anatomy of the medial orbit, suggest surgical index in Korean.

A Case of Complete Ophthalmoplegia in Herpes Zoster Ophthalmicus

PURPOSE: To report a case with complete ophthalmoplegia after herpes zoster ophthalmicus. METHODS: A 70-year-old male patient visited a clinic because of vesicular eruptions over the left side of his face with severe pain. Drooping and severe swelling of the left eyelid were present, along with keratitis and uveitis. While the lid swelling and uveitis were improving, external ophthalmoplegia and exophthalmos were discovered. Intramuscular injections of dexamethasone 5 mg were given for 10 days, followed by oral administration of prednisolone at a dosage of 15 mg for two weeks and 10 mg for two weeks. RESULTS: The patient was fully recovered from the complete ophthalmoplegia and exophthalmos six months after the onset of the cutaneous lesion. CONCLUSIONS: Complete ophthalmoplegia is a rare ophthalmic complication of herpes zoster infection. Therefore, an evaluation of extraocular muscle and lid function should be performed during the examination of herpes zoster patients in order to screen for ophthalmoplegia.

Muscle Width and Distance from Limbus to Muscle Insertion Site in Strabismus Patient

PURPOSE: This study investigated the differences of muscle width and distance from limbus to muscle insertion site according to age and sex, and the correlation with ocular axial length and strabismus degree. METHODS: The study subjects were 100 eyes of 50 horizontal strabismus patients undergoing rectus muscles recession. Ocular axial lengths were measured at preoperation, while muscle width and distance from limbus to muscle insertion site were measured during operation. Preoperative and postoperative comparison items were retrospectively investigated with the medical records. Correlations of muscle width, distance from limbus to muscle insertion site and the comparison items were verified by ANOVA test. RESULTS: Muscle width was 10.05+/-0.86 mm in medial rectus muscle and 9.38+/-1.03 mm in lateral rectus muscle. Distance from limbus to muscle insertion site was 5.21+/-0.85 mm in medial rectus muscle and 6.37+/-1.01 mm in lateral rectus muscle. Muscle width and distance from limbus to muscle insertion site had no correlations with ocular axial length and strabismus degree, but ocular axial length was significantly longer in the older group compared to the younger group and in the male group compared to the female group. CONCLUSIONS: It is presumed that muscle width and distance from limbus to muscle insertion site have no relationship with age, sex and strabismus degree.

Fungus at Removed Silicone Tubes in Nasolacrimal Duct Obstruction Patients

PURPOSE: This study investigated the fungi of silicone tubes in the patients with nasolacrimal duct obstruction, and investigated the identification of fungi according to operation type, clinical features and detailed locations of silicone tubes. METHODS: The subjects of this study were 49 eyes of 40 patients operated on for nasolacrimal duct obstruction from July 2003 to April 2004. The removed silicone tubes were divided into the parts of conjunctiva, lacrimal drainage system and nasal cavity according to insertion state, after which fungus culture was performed using them. We classified patients into the silicone tube intubation group and the dacryocystorhinostomy group. Preoperative nasal problems, dacryolith on dacryocystorhinostomy, postoperative features of nasal cavity during the follow-up period and success of operation were retrospectively investigated with the medical records. Correlations of the results of fungus culture and clinical features were verified by Pearson Chi-Square test. RESULTS: Fungus culture rate was significantly higher in the dacryocystorhinostomy group (37.5%) than in the silicone tube intubation group (12.12%) (p-value<0.05). In total patients according to insertion site, fungus culture rate was significantly higher in the nasal cavity than in the lacrimal drainage system, and in the lacrimal drainage system than in the conjunctiva (p-value<0.05). The species of cultured fungi were in the following order: Candida, Trichosporon, Penicillium and Aspergillus. CONCLUSIONS: Fungal infection of the silicone tube in patients with nasolacrimal duct obstruction was found and fungi species were cultured. Further study is needed of fungi in the nasolacrimal duct before surgery for determining the fungal infection causing nasolacrimal duct obstruction.

Cytologic Study of Removed Silicone Tube in Nasolacrimal Duct Obstruction Patients with the Liquid-based Thin Layer Preparation Technique

PURPOSE: This study investigated the cytological findings of the nasolacrimal duct by using the removed silicone tube in patients of nasolacrimal duct obstruction according to the surgical technique. METHODS: Cytologic study was performed in 49 eyes of 41 patients who underwent silicone tube intubation or dacryocystorhinostomy from May 2002 to April 2003. By using Thin Prep(R) 2000 (CYTYC. USA), the cells around the removed silicone tube inserted in the operation were observed by light microscope. The patients were classified into the silicone tube intubation group and the dacryocystorhinostomy group. Differences of observed cytological results were analyzed by the Pearson Chi-Square test. RESULTS: From the cytological results by the type of operation, there was no statistical difference between the silicone tube intubation group and the dacryocystorhinostomy group, and the frequency of hyphae detection was higher in the dacryocystorhinostomy group than in the silicone tube intubation group (p<0.05). CONCLUSIONS: In the dacryocystorhinostomy patient group, the frequent detection of fungus suggests a possible relationship with the pathogenesis of nasolacrimal duct obstruction. Further studies on the prevention and treatment of fungal infection are needed.

A Case of Glomus Tumor of the Stomach: Role of Endoscopic Ultrasonography / 대한소화기내시경학회지

A glomus tumor of the stomach is a rare submucosal lesion that was first described by De Busscher in 1948. Submucosal tumors of the stomach are mostly leiomyoma, leiomyosarcoma, and malignant lymphoma. It is difficult to diagnose this kind of tumor preoperatively. We present a patient with a gastric glomus tumor which showed the characteristic endoscopic ultrasonographic (EUS) finding. Our case was also diagnosed by pathology after surgery. The major EUS findings in the present case are circumscribed low echoic mass in the forth submucosal layer and an internal heterogenous echo mixed with high echoic spots. The EUS seems to be useful in distinguishing between glomus tumor and other submucosal tumors.

A Case of Massive Hematochezia from a Meckel's Diverticulum without Ectopic Mucosa / 대한소화기내시경학회지

Meckel's diverticulum, which is a persistence of a remnant of the omphalomesenteric duct, is the most common developmental anomaly of the gastrointestinal tract, with an incidence of about 2% in the general population. Typically, Meckel's diverticulum is a true diverticulum because it arises from the antimesenteric border of the small bowel and all layers of the intestinal wall are present. Complications of Meckel's diverticulum include bleeding, perforation, diverticulitis, intestinal obstruction, stones, intussusception, hernia, and neoplasm. Bleeding in particular is a common complication and has always been caused by an ulceration of the ileal mucosa adjacent to the acid-producing ectopic gastric mucosa in a Meckel's diverticulum. A case was recently experienced involving massive hematochezia from Meckel's diverticulum without ectopic gastric mucosa in a 27 year-old woman, and in herein reported.

A Case of Hypereosinophilic Syndrome with Hepatic and Gastrointestinal Involvement / 대한간학회지

Hypereosinophilic syndrome is characterized by prolonged eosinophilia of blood and tissue without an identifiable underlying cause and multiorgan system dysfunction by eosinophil-related tissue damage to variable organs: liver, heart, lung, kidney, gastrointestinal tract, skin, nerve. Some case of hypereosinophilic syndrome with hepatic and gastrointestinal involvement have been reported, but not much. We are reporting a case of hypereosinophilic syndrome with hepatic and gastrointestinal involvement in 56-year-old man who presented general weakness and epigastric discomfort. In abdominal US, CT and MRI, intrahepatic multifocal ill-defined lesions were detected. The patient was treated with prednisolone for 16 weeks and recovered from eosinophilia and gastric involvement. A gastric biopsy was taken to confirm recovery. Also, the ill-defined lesions in US and CT disappeared after treatment.

A Case of Tracheal Hemangioma Manifested Massive Hemoptysis / 결핵

Hemangioma is benign tumor that represent an fail in development of the vascular system, network or retiform stage. As with hemangioma elsewhere, spontaneous regression may occur. Histologically capillary hemangioma has a diagnostic lobular arrangement of capillaries and almost all of them are located in nasal or oral mucous membranes. But, as we know, there is no report of hemangioma located in the trachea in Korea, so we report a case of tracheal hemangioma which was manifested massive hemoptysis.

A Case of Complete Remission in Ruptured Hepatocellular Carcinoma after One -time Transcatheter Arterial Chemoembolization / 대한간학회지

There are many kinds of treatments for hepatocellular carcinoma (HCC) such as surgical resection, liver transplantation, chemotherapy, interventional therapy [TACE, ethanol embolization, Immuno -chemoembolization, I131 -lipiodol embolization], thermal therapy, cryotherapy, and radiation therapy. Generally spontaneous remission is not common in HCC, however underlying mechanism of spontaneous remission is uncertain. We report a case of complete remission after one time TACE in ruptured HCC with review of literature about the effect of TACE and spontaneous remission. We conclude that arterial embolization is an effective alternative to surgery for hepatic hemostasis in patients with spontaneous rupture of hepatocellular carcinoma.

A Case of Liddle's Syndrome Associated with Muscle Weakness / 대한신장학회잡지

Liddle's syndrome was described in 1963 by Liddle, et al., as the disease featuring a hypertension and hypokalemia but with negligible secretion of aldosterone. This syndrome, which morphologically belongs to an abnormal intrinsic tubular disorder with normal renal function, is characterized by hypokalemia, metabolic alkalosis, and hypertension due to the abnormal increase in excretion of potassium in distal tubules or collecting duct and the increase in reabsorption of sodium in distal tubules. This syndrome, which is rare disease, is observed with the low level of plasma and urinary aldosterone and suppressed plasma renin level and is known as dominant mode of inheritance with a family background. The authors paid attention to a 79-year-old man who showed a high blood pressure of 210/130mmHg as well as musle weakness, especially lower extremities due to metabolic alkalosis featuring a hypokalemia level of 2.0mEq/L when he was admitted to our hospital, Because his serum potassium were not improved with the medication of intravenous potassium supply, and his blood pressure continued to be high without the improvement of muscle weakness, we prescribed 300mg of spironolactone for two weeks. His symptom, however, was not cured. Then, instead of spironolactone, we prescribed 150mg of triamterene and a low salt diet which finally improved his symptoms. Because there has been no reported case in the Korean medical literature, we report a case of successfully treated Liddle's syndrome due to triamterene administration.

Three Cases of Dermatofibrosarcoma Protuberans / 대한피부과학회지

Dermatofibrosarcoma protuberans (DFSP) is a rare, distinctive cutaneous tumor, which consists of spindle shaped ceils arranged in densely packed interlacing bundles with the storiform or cartwheel pattern. Histologically, it resembles deep growing dermatofibroma, nodular fasciitis, neurofibroma and neural sheath tumors. DFSP is one of t.he connective tissue tumors which is difficult. to diagnose histologically as well as clinically. Recently, the immunochemical staining with a monoclonal antibody to CD34 is reported to give assistance in the clear differential diagnosis of DFSP from other fibrous or neural tumors. Herein, three cases of DFSP were stained by immunohistochemical staining with S-100 protein, vimentin, factor VIII and anti-CD34 antibody in order to assess the use of anti-CD34 in the differential diagnosis of DFSP.