Lumbar Interbody Fusion and Osteobiologics for Lumbar Fusion

Lumbar interbody fusion (LIF) is an excellent treatment option for a number of lumbar diseases. LIF can be performed through posterior, transforaminal, anterior, and lateral or oblique approaches. Each technique has its own pearls and pitfalls. Through LIF, segmental stabilization, neural decompression, and deformity correction can be achieved. Minimally invasive surgery has recently gained popularity and each LIF procedure can be performed using minimally invasive techniques to reduce surgery-related complications and improve early postoperative recovery. Despite advances in surgical technology, surgery-related complications after LIF, such as pseudoarthrosis, have not yet been overcome. Although autogenous iliac crest bone graft is the gold standard for spinal fusion, other bone substitutes are available to enhance fusion rate and reduce complications associated with bone harvest. This article reviews the surgical procedures and characteristics of each LIF and the osteobiologics utilized in LIF based on the available evidence.

Unstable Pathologic Vertebral Fractures in Multiple Myeloma : Propensity Score Matched Cohort Study between Reconstructive Surgery with Adjuvant Radiotherapy and Radiotherapy Alone

Objective@#: Although radiotherapy (RT) is recommended for multiple myeloma (MM) involving spine, the treatment of choice between reconstructive surgery with RT and RT alone for pathologic vertebral fractures (PVFs) associated with structural instability or neurologic compromises remains controversial. The purpose of this study was to evaluate the clinical efficacies of reconstructive surgery with adjuvant RT for treatment of MM with PVFs by comparing with matched cohorts treated with RT alone. @*Methods@#: Twenty-eight patients underwent reconstructive surgery followed by RT between 2008 and 2015 in a single institution, for management of PVFs associated with structural instability of the spine and/or neurologic compromises (group I). Twentyeight patients were treated with RT alone (group II) after propensity score matching in a 1-to-1 format based on instability of the spine, as well as age and performance. Clinical outcomes including the overall survival rates, duration of independent ambulation, neurological status, and numeric rating scale (NRS) for back pain were compared. @*Results@#: Clinical and radiological features before treatment were similar in both groups. The median survival period was similar between the two groups. However, the mean duration of independent ambulation was significantly longer in group I (88.8 months; 95% confidence interval [CI], 66.0–111.5) than in group II (39.4 months; 95% CI, 25.2–53.6) (log rank test; p=0.022). Deterioration of Frankel grade (21.4% vs. 60.7%, p=0.024) and NRS for back pain (2.7±2.2 vs. 5.0±2.7, p=0.000) at the last follow-up were higher in the group II. Treatment-related complications were similar in both groups. @*Conclusion@#: In patients with unstable PVFs due to MM, reconstructive surgery may yield superior clinical outcomes compared with RT alone in maintaining independent ambulation and neurological status, as well as pain control despite similar median survival and complications.

Analysis of Fracture Patterns and Characteristics in Sacral Insufficiency Fracture: Do Sacral Fractures Occur in Patients Who Had Previous Lumbosacral Fusion Insufficiency Fractures or Stress Fractures?

Methods@#In total, 55 patients with SIFs were retrospectively investigated in this study. The study population was divided into lumbosacral fusion (n=20) and non-fusion (n=35) groups. Subsequently, the patients’ demographic characteristics, comorbidities, medication history, results of diagnostic imaging studies, and bone mineral density were assessed. The fracture patterns were classified either according to the five typical types (H-pattern bilateral vertical plus horizontal component, unilateral vertical only, bilateral vertical only, unilateral vertical plus horizontal component, and horizontal only fracture) or atypical types. @*Results@#In total, 44 of 55 patients (80%) suffered from more than one senile disease and received corresponding medications that caused secondary osteoporosis. A total of 12 patients had S1 lumbosacral fixation. Moreover, three of these 12 patients who developed a SIF immediately after a lumbosacral fracture had an unstable sacral U fracture. The remaining nine patients showed fracture patterns similar to the non-fusion patients. Single-photon emission computed tomography (SPECT)/computed tomography (CT) can identify fracture recurrence in previously healed fractures. In total, 24 patients (43.6%) had fractures of the pelvis, femur, and thoracolumbar spine. @*Conclusions@#SIF develops in elderly patients with multiple adult diseases that can induce secondary osteoporosis. Such fractures may occur in the patients with instrumented lumbosacral fusion. Importantly, some patients showed stress fractures after multilevel instrumented lumbosacral fusion, whereas others showed insufficiency fractures. The different fracture patterns correspond to different grades of SIF, and SPECT/CT can easily identify the fracture status.

Decompressive Laminectomy Alone for Degenerative Lumbar Scoliosis with Spinal Stenosis: Incidence of Post-Laminectomy Instability in the Elderly

Background@#Decompressive laminectomy alone for degenerative lumbar scoliosis (DLS) is not recommended because it can lead to further instability. However, it is uncertain whether instability at the decompressed segments is directly affected by laminectomy or the natural progression of DLS. The purpose of this study was to evaluate the surgical outcome of decompressive laminectomy alone for DLS with spinal stenosis and to determine whether the procedure leads to post-laminectomy instability (PLI). @*Methods@#We retrospectively reviewed 60 patients with DLS. They were divided into 2 groups according to PLI criteria: stable group and PLI group. The PLI group was subdivided into 2 groups based on the level of PLI: the first group that showed PLI at the index laminectomy level (PLI-I) and the second group that showed PLI at another level other than the laminectomy level (PLI-NI). Radiological evaluation was performed to determine factors associated with the progression of DLS. Pain and disability outcomes were assessed. @*Results@#There were 34 patients (56.7%) in the stable group and 26 patients (43.3%) in the PLI group. Twelve patients (20.0%) underwent revision surgery. Eleven patients (18.3%) showed PLI at the index segments (PLI-I group), and 15 patients (25%) showed PLI at the adjacent or cephalad segments, not related to the laminectomy site (PLI-NI group). Four patients underwent revision surgery in the stable group and 8 in the PLI group. Survivorship analyses revealed that the predicted survivorship of DLS was 90.0% at 12 months and 86.4% at 24 months after laminectomy. @*Conclusions@#The development of PLI was not always related to laminectomy at the index level. However, PLI developed more rapidly at the index level, compared to the natural progression of the scoliotic curve at the adjacent segments.

Incidence and Risk Factors of Gastrointestinal and Hepatobiliary Complications after Spinal Fusion Surgery: a Retrospective Cohort Study

Background@#Spinal surgery holds a higher chance of unpredicted postoperative medical complications among orthopedic surgeries. Several studies have analyzed the risk factors for diverse postoperative medical complications, but the majority investigated incidences of each complication qualitatively. Among gastrointestinal complications, reports regarding postoperative ileus were relatively frequent. However, risk factors or incidences of hepatobiliary complications have yet to be investigated. The purpose of this study was to examine the incidence of gastrointestinal complications after spinal surgery, quantitatively analyze the risk factors of frequent complications, and to determine cues requiring early approaches. @*Methods@#In total, 234 consecutive patients who underwent spinal fusion surgery performed by one senior doctor at our institute in one-year period were retrospectively enrolled for analyses. The primary outcomes were presence of paralytic ileus, elevated serum alanine transaminase (ALT) and aspartate transaminase (AST) levels, and elevated total bilirubin levels. Univariate logistic regression analyses of all variables were performed. In turn, significant results were reanalyzed by multivariate logistic regression. The variables used were adjusted with age and gender. @*Results@#Gastrointestinal complications were observed in 15.8% of patients. Upon the risk factors of postoperative ileus, duration of anesthesia (odds ratio [OR], 1.373; P = 0.015), number of fused segments (OR, 1.202; P = 0.047), and hepatobiliary diseases (OR, 2.976; P = 0.029) were significantly different. For elevated liver enzymes, men (OR, 2.717; P = 0.003), number of fused segments (OR, 1.234; P = 0.033), and underlying hepatobiliary (OR, 2.704; P = 0.031) and rheumatoid diseases (OR, 5.021; P = 0.012) had significantly different results. Lastly, risk factors for total bilirubin elevation were: duration of anesthesia (OR, 1.431; P = 0.008), number of fused segments (OR, 1.359; P = 0.001), underlying hepatobiliary diseases (OR, 3.426; P = 0.014), and thoracolumbar junction involving fusions (OR, 4.134; P = 0.002) compared to lumbar spine limited fusions. @*Conclusion@#Patients on postoperative care after spinal surgery should receive direct attention as soon as possible after manifesting abdominal symptoms. Laboratory and radiologic results must be carefully reviewed, and early consultation to gastroenterologists or general surgeons is recommended to avoid preventable complications.

Lumbar Interbody Fusion: Techniques, Pearls and Pitfalls

Lumbar interbody fusion (LIF) is an effective and popular surgical procedure for the management of various spinal pathologies, especially degenerative diseases. Currently, LIF can be performed with posterior, transforaminal, anterior, and lateral approaches by open surgery or minimally invasive surgery (MIS). Each technique has its own advantages and disadvantages. In general, posterior LIF is a well-established procedure with good fusion rates and low complication rates but is limited by the possibility of iatrogenic injury to the neural structures and paraspinal muscles. Transforaminal LIF is frequently performed using an MIS technique and has an advantage of reducing these iatrogenic injuries. Anterior LIF (ALIF) can restore the disk height and sagittal alignment but has inherent approach-related challenges such as visceral and vascular complications. Lateral LIF and oblique LIF are performed using an MIS technique and have shown postoperative outcomes similar to ALIF; however, these approaches carry a risk of injury to psoas, lumbar plexus, and vascular structures. Herein, we provide a detailed description of the surgical procedures of each LIF technique. We shall then consider the pearls and pitfalls, as well as propose surgical indications and contraindications based on the available evidence in the literatures.

Surgery for Spinal Deformities in Patients with Osteoporosis

Objectives@#This review aims to present relevant considerations for the surgical treatment of spinal deformities accompanied by osteoporosis, how surgeons are trying to overcome the challenges posed by osteoporosis in patients with spinal deformities, and directions of further development.Summary of literature Review: Various trials have been done to overcome the short- and long-term complications associated with osteoporosis in order to achieve successful clinical results in the surgical treatment of spinal deformities. @*Materials and Methods@#Review of the relevant articles. @*Results@#The surgical goal of treating spinal deformities is to reverse neurological compromise and to restore balanced spine alignment. To achieve these goals, several surgical considerations should be kept in mind. Osteoporosis is an important issue related to early and long-term complications following surgery. As ways of overcoming the challenges posed by osteoporosis, rigid fixation techniques, proper selection of the fusion level, perioperative medical treatment, and effective bone grafting materials are described herein; however, further development in these domains is also necessary. @*Conclusions@#Osteoporosis may be a major obstacle in spinal deformity surgery. Although several effective attempts have been made to overcome these limitations, further research and trials are needed to obtain better results.

Surgical Extent of Metastatic Spine Tumor Excision and Its Effects on Postoperative Ambulatory Function: Comparison of Extensive Wide versus Palliative Excision Surgery / 대한척추외과학회지

STUDY DESIGN: Retrospective study. OBJECTIVES: To compare surgical outcomes such as the ambulatory period and survival according to different surgical excision tactics for metastatic spine tumors (MSTs). SUMMARY OF LITERATURE REVIEW: Surgical outcomes, such as pain relief and survival, in patients with MSTs have been reported in several studies, but the effects of differences in surgical extent on the ambulatory period have rarely been reported. MATERIALS AND METHODS: Ninety-six patients with MSTs who underwent palliative (n=60) or extensive wide excision (n=36) were included. Palliative excision was defined as partial removal of the tumor as an intralesional piecemeal procedure for decompression. Extensive wide excision was defined as a surgical attempt to remove the whole tumor at the index level as completely as possible. The primary outcome was the ambulatory period following surgery. Other demographic and radiographic parameters were analyzed to identify the risk factors for loss of ambulatory ability and survival. Perioperative complications were also assessed. RESULTS: The mean postoperative ambulatory period was longer in the extensive wide excision group (average 14.8 months) than in the palliative excision group (average 11.7 months) (p=0.021). The survival rates were not significantly different between the two surgical excision groups (p=0.680). However, postoperative ambulatory status and major complications within 30 days postoperatively were significant prognostic factors for survival (p=0.003 and p=0.032, respectively). CONCLUSIONS: The extent of surgical excision affected the ambulatory period, and the complication rates were similar, regardless of surgical excision tactics. A proper surgical strategy to achieve postoperative ambulatory ability and to reduce perioperative complications would have a favorable effect on survival.

Clinical Significance of Preoperative Embolization for Non-Hypervascular Metastatic Spine Tumors

OBJECTIVE: The efficacy of preoperative embolization for hypervascular metastatic spine disease (MSD) such as renal cell and thyroid cancers has been reported. However, the debate on the efficacy of preoperative embolization for non-hypervascular MSD still remains unsettled. The purpose of this study is to determine whether preoperative embolization for non-hypervascular MSD decreases perioperative blood loss. METHODS: A total of 79 patients (36 cases of preoperative embolization and 43 cases of non-embolization) who underwent surgery for metastatic spine lesions were included. Representative hypervascular tumors such as renal cell and thyroid cancers were excluded. Intraoperative and perioperative estimated blood losses (EBL), total number of transfusion and calibrated EBL were recorded in the embolization and non-embolization groups. The differences in EBL were also compared along with the type of surgery. In addition, the incidence of Adamkiewicz artery and complications of embolization were assessed. RESULTS: The average age of 50 males and 29 females was 57.6±13.5 years. Lung (30), hepatocellular (14), gastrointestinal (nine) and others (26) were the primary cancers. The demographic data was not significantly different between the embolization and the non-embolization groups. There were no significant differences in intraoperative EBL, perioperative EBL, total transfusion and calibrated EBL between two groups. However, intraoperative EBL and total transfusion in patients with preoperative embolization were significantly lower than in non-embolization in the corpectomy group (1645.5 vs. 892.6 mL, p=0.017 for intraoperative EBL and 6.1 vs. 3.9, p=0.018 for number of transfusion). In addition, the presence of Adamkiewicz artery at the index level was noted in two patients. Disruption of this major feeder artery resulted in significant changes in intraoperative neuromonitoring. CONCLUSION: Preoperative embolization for non-hypervascular MSD did not reduce perioperative blood loss. However, the embolization significantly reduced intraoperative bleeding and total transfusion in corpectomy group. Moreover, the procedure provided insights into the anatomy of tumor and spinal cord vasculature.

Clinical Significance of Preoperative Embolization for Non-Hypervascular Metastatic Spine Tumors

OBJECTIVE: The efficacy of preoperative embolization for hypervascular metastatic spine disease (MSD) such as renal cell and thyroid cancers has been reported. However, the debate on the efficacy of preoperative embolization for non-hypervascular MSD still remains unsettled. The purpose of this study is to determine whether preoperative embolization for non-hypervascular MSD decreases perioperative blood loss.METHODS: A total of 79 patients (36 cases of preoperative embolization and 43 cases of non-embolization) who underwent surgery for metastatic spine lesions were included. Representative hypervascular tumors such as renal cell and thyroid cancers were excluded. Intraoperative and perioperative estimated blood losses (EBL), total number of transfusion and calibrated EBL were recorded in the embolization and non-embolization groups. The differences in EBL were also compared along with the type of surgery. In addition, the incidence of Adamkiewicz artery and complications of embolization were assessed.RESULTS: The average age of 50 males and 29 females was 57.6±13.5 years. Lung (30), hepatocellular (14), gastrointestinal (nine) and others (26) were the primary cancers. The demographic data was not significantly different between the embolization and the non-embolization groups. There were no significant differences in intraoperative EBL, perioperative EBL, total transfusion and calibrated EBL between two groups. However, intraoperative EBL and total transfusion in patients with preoperative embolization were significantly lower than in non-embolization in the corpectomy group (1645.5 vs. 892.6 mL, p=0.017 for intraoperative EBL and 6.1 vs. 3.9, p=0.018 for number of transfusion). In addition, the presence of Adamkiewicz artery at the index level was noted in two patients. Disruption of this major feeder artery resulted in significant changes in intraoperative neuromonitoring.CONCLUSION: Preoperative embolization for non-hypervascular MSD did not reduce perioperative blood loss. However, the embolization significantly reduced intraoperative bleeding and total transfusion in corpectomy group. Moreover, the procedure provided insights into the anatomy of tumor and spinal cord vasculature.

Surgical Extent of Metastatic Spine Tumor Excision and Its Effects on Postoperative Ambulatory Function: Comparison of Extensive Wide versus Palliative Excision Surgery

OBJECTIVES@#To compare surgical outcomes such as the ambulatory period and survival according to different surgical excision tactics for metastatic spine tumors (MSTs).SUMMARY OF LITERATURE REVIEW: Surgical outcomes, such as pain relief and survival, in patients with MSTs have been reported in several studies, but the effects of differences in surgical extent on the ambulatory period have rarely been reported.@*MATERIALS AND METHODS@#Ninety-six patients with MSTs who underwent palliative (n=60) or extensive wide excision (n=36) were included. Palliative excision was defined as partial removal of the tumor as an intralesional piecemeal procedure for decompression. Extensive wide excision was defined as a surgical attempt to remove the whole tumor at the index level as completely as possible. The primary outcome was the ambulatory period following surgery. Other demographic and radiographic parameters were analyzed to identify the risk factors for loss of ambulatory ability and survival. Perioperative complications were also assessed.@*RESULTS@#The mean postoperative ambulatory period was longer in the extensive wide excision group (average 14.8 months) than in the palliative excision group (average 11.7 months) (p=0.021). The survival rates were not significantly different between the two surgical excision groups (p=0.680). However, postoperative ambulatory status and major complications within 30 days postoperatively were significant prognostic factors for survival (p=0.003 and p=0.032, respectively).@*CONCLUSIONS@#The extent of surgical excision affected the ambulatory period, and the complication rates were similar, regardless of surgical excision tactics. A proper surgical strategy to achieve postoperative ambulatory ability and to reduce perioperative complications would have a favorable effect on survival.

Bone Mineral Density and Osteoporotic Vertebral Fractures in Traditional, Unassisted, Free-Diving Women (Haenyeos)

BACKGROUND: Water pressure and muscle contraction may influence bone mineral density (BMD) in a positive way. However, divers experience weightlessness, which has a negative effect on BMD. The present study investigated BMD difference in normal controls and woman free-divers with vertebral fracture and with no fracture. METHODS: Between January 2010 and December 2014, traditional woman divers (known as Haenyeo in Korean), and non-diving women were investigated. The study population was divided into osteoporotic vertebral fracture and non-fracture groups. The BMD of the lumbar spine and femoral neck was measured. The radiological parameters for global spinal sagittal balance were measured. RESULTS: Thirty free-diving women and thirty-three non-diving women were enrolled in this study. The mean age of the divers was 72.1 ± 4.7 years and that of the controls was 72.7 ± 4.0 years (P = 0.61). There was no statistical difference in BMD between the divers and controls. In divers, cervical lordosis and pelvic tilt were significantly increased in the fracture subgroup compared to the non-fracture subgroup (P = 0.028 and P = 0.008, respectively). Sagittal vertical axis was statistically significantly correlated with cervical lordosis (Spearman's rho R = 0.41, P = 0.03), and pelvic tilt (Spearman's rho R = 0.46, P = 0.01) in divers. CONCLUSION: BMD did not differ significantly between divers and controls during their postmenopausal period. When osteoporotic spinal fractures develop, compensation mechanisms, such as increased cervical lordosis and pelvic tilt, was more evident in traditional woman divers. This may be due to the superior back muscle strength and spinal mobility of this group of women.

Surfer's Myelopathy: A Case Report

STUDY DESIGN: A case report. OBJECTIVES: To report a rare cause of non-traumatic spinal cord injury (SCI) during surfing SUMMARY OF LITERATURE REVIEW: Surfer's myelopathy is a non-traumatic SCI associated with the hyperextension posture during paddling in surfing. Although the definite pathomechanism has not been identified, cord ischemia followed by arterial infarction may be related to this injury. MATERIALS AND METHODS: A young healthy male patient presented with a SCI that occurred during his first time surfing. Magnetic resonance imaging revealed a T2-hyperintense lesion in the spinal cord from D10 to the conus medullaris. RESULTS: The patient completely recovered without any neurologic deficits after steroid therapy and other forms of supportive management. CONCLUSIONS: Since surfing is becoming more common in Korea, awareness of surfer's myelopathy is important for early diagnosis and proper management.

Is Extracorporeal Shock Wave Therapy Effective in the Treatment of Myofascial Pain Syndrome?

BACKGROUND: Extracorporeal shock wave therapy (ESWT) is one of the treatment options used for patients with myofascial pain syndrome (MPS), although its effectiveness is controversial. The purpose of this study was to evaluate the effectiveness of ESWT in the treatment of MPS in terms of pain relief and functional improvements. METHODS: We assessed 93 patients with MPS who underwent ESWT from March 2009 to July 2014. After exclusion of 25 patients with shoulder diseases, 68 patients were enrolled in the study. The mean follow-up period was 7.5 months (± 4.2 weeks), and the average duration of symptoms was 5 months (range, 2-16 months). ESWT was applied to intramuscular taut bands and referred pain areas once a week for 3 weeks. Visual analog scale (VAS) pain scores and American Shoulder and Elbow Surgeons (ASES) scores were obtained at an initial assessment and at the 6-week, 3-month, and 6-month follow-up assessments. RESULTS: VAS pain scores and ASES scores improved significantly after 3 sessions of ESWT (p0.05). CONCLUSIONS: ESWT is an effective treatment option for patients with MPS.

Is Extracorporeal Shock Wave Therapy Effective in the Treatment of Myofascial Pain Syndrome?

BACKGROUND: Extracorporeal shock wave therapy (ESWT) is one of the treatment options used for patients with myofascial pain syndrome (MPS), although its effectiveness is controversial. The purpose of this study was to evaluate the effectiveness of ESWT in the treatment of MPS in terms of pain relief and functional improvements. METHODS: We assessed 93 patients with MPS who underwent ESWT from March 2009 to July 2014. After exclusion of 25 patients with shoulder diseases, 68 patients were enrolled in the study. The mean follow-up period was 7.5 months (± 4.2 weeks), and the average duration of symptoms was 5 months (range, 2-16 months). ESWT was applied to intramuscular taut bands and referred pain areas once a week for 3 weeks. Visual analog scale (VAS) pain scores and American Shoulder and Elbow Surgeons (ASES) scores were obtained at an initial assessment and at the 6-week, 3-month, and 6-month follow-up assessments. RESULTS: VAS pain scores and ASES scores improved significantly after 3 sessions of ESWT (p0.05). CONCLUSIONS: ESWT is an effective treatment option for patients with MPS.

Factors Affecting Survival in Patients Undergoing Palliative Spine Surgery for Metastatic Lung and Hepatocellular Cancer: Dose the Type of Surgery Influence the Surgical Results for Metastatic Spine Disease?

BACKGROUND: Surgical treatment for metastatic spine disease has been becoming more prominent with the help of technological advances and a few favorable reports on the surgery. In cases of this peculiar condition, it is necessary to establish the role of surgery and analyze the factors affecting survival. METHODS: From January 2011 to April 2015, 119 patients were surgically treated for metastatic spine lesions. To reduce the bias along the heterogeneous cancers, the primary cancer was confined to either the lung (n = 25) or the liver (n = 18). Forty-three patients (male, 32; female, 11; mean age, 57.5 years) who had undergone palliative surgery were enrolled in this study. Posterior decompression and fusion was performed in 30 patients (P group), and anteroposterior (AP) reconstruction was performed in 13 patients (AP group) for palliative surgery. Pre- and postoperative (3 months) pain (visual analogue scale, VAS), performance status (Karnofsky performance score), neurologic status (American Spinal Injury Association [ASIA] grade), and spinal instability neoplastic score (SINS) were compared. The survival period and related hazard factors were also assessed by Kaplan-Meier and Cox regression analysis. RESULTS: Most patients experienced improvements in pain and performance status (12.3% +/- 17.2%) at 3 months postoperatively. In terms of neurologic recovery, 9 patients (20.9%) graded ASIA D experienced neurological improvement to ASIA E while the remainder was status quo. In an analysis according to operation type, there was no significant difference in patient demographics. At 12 months postoperatively, cumulative survival rates were 31.5% and 38.7% for the P group and the AP group, respectively (p > 0.05). Survival was not affected by the pre- and postoperative pain scale, Tokuhashi score, neurologic status, SINS, or operation type. Preoperative Karnofsky performance score (hazard ratio, 0.93; 95% confidence interval [CI], 0.89 to 0.96) and improvement of performance status after surgery (hazard ratio, 0.95; 95% CI, 0.92 to 0.97) significantly affected survival after operation. CONCLUSIONS: There was no significant difference in surgical outcomes and survival rates between posterior and AP surgery for metastatic lesions resulting from lung and hepatocellular cancer. Preoperative Karnofsky score and improvement of performance status had a significant impact on the survival rate following surgical treatment for these metastatic spine lesions.

The Relationship between the Bronchopulmonary Dysplasia and Illness Severity (SNAP)

PURPOSE: The objective of this study was to evaluate differences of Scores for Neonatal Acute Physiology (SNAP) in between neonates with bronchopulmonay dysplasia (BPD) and control group, and to utilize SNAP as an early predictive tool for development of BPD. METHOD: A retrospective chart review was done for a total of 30 neonates who were admitted to Pochun CHA University neonatal intensive care unit between April, 1995 and May, 2001. A study group included 15 neonates with BPD and a control group included 15 neonates matched for gestational age and birth weight. SNAP and cumulative SNAP were obtained at 1st, 4th, 6th postnatal day for each group. A comparative analysis of cumulative SNAP scores of various parameters was done in two groups. RESULTS: SNAP of 10.86 and 6.86 were obtained at 4th postnatal day for BPD and control group, respectively (P<0.05). Cumulative SNAP for 1st, 4th, 6th postnatal day were 30.40 and 21.93 in BPD and control group (P=0.059). A comparison of cumulative SNAP of various parameters between two groups showed that respiratory rate and apnea to be significant parameters as well as for blood pressure and arterial oxygen tension in neonates with BPD. CONCLUSION: Score for Neonatal Acute Physiology could be utilized as a tool to predict the development of BPD although larger study is needed to simplify its scoring system to be used easily and better predict the development of BPD.

Two Cases of Sporadic Hemiplegic Migraine

Hemiplegic migraine is characterized by the occurrence of migraine attacks with unilateral weakness. The attack usually starts in childhood, adolescence, or early adulthood. The diagnosis may be delayed if there is no relevant family history. We experienced two cases of hemiplegic migraine of 8 and 14 years old girls whose neuroimaging studies including MRA showed no abnormal findings in the acute phases and the ictal EEG findings also revealed normal. The hemiplegic attacks associated with sensory disturbance were improved by calcium channel blocker(Flunarizine). Hemiplegic migraine should be considered in the differential diagnosis of a pediatric hemiparesis even if there is no familial migraine history.

Prenatal Diagnosis of Complete Atrioventricular Septal, Defect:Clinical Outcome of 35 Cases

PURPOSE: Prenatal diagnosis of congenital heart disease has been made by fetal echocardiography and its clinical impact on the outcome of complete atrioventricular septal defect(AVSD) cases has been analysed. METHODS: A retrospective study was performed for the fetal cases for complete AVSD diagnosed, confirmed postnatally or at second study and/or at autopsy and/or follow up at CHA hospital between January 1993 and December 2001. The outcome of complete AVSD has been analysed, and the associated anomalies & chromosomal defects has been described. RESULTS: There were 450 cases of significant CHD that had been diagnosed prenatally during the study period. Of whom 35 cases had complete AVSD, and 32 cases had complete AVSD associated with visceral heterotaxy. In the cases with complete AVSD who with chromosomal study, 53.8% had Down syndrome and an additional 7.7% had other chromosomal anomaly. Associated cardiac malformation was 34.2%. Extracardiac anomaly without chromosomal defect was founded in 5 cases(14%) included polydactyly, hydrocephalus, duodenal atresia, omphalocele, cleft lip and single umbilical artery. Among 35 fetal complete AVSD cases, 29 cases of complete AVSD has been terminated, 1 case died in utero, 1 case died at neonatal period and 4 cases were referred to cardiac center for planned delivery. The most common factors of termination were extracardiac and chromosomal anomaly. CONCLUSION: Among the significant CHD, incidence rate of complete AVSD was 7.8%. And the most of the complete AVSD has been terminated. 4 cases(11.4%) were referred to the cardiac center for planned delivery. The rate of termination was 82.9%. Fetal diagnosis of complete AVSD greatly increased the rate of termination.