24-Hour shifts and frequent night shifts of Korean emergency medicine residents

OBJECTIVE@#The newly implemented Training Rule Standard limits the amount of resident working hours to serve the interests of the patients and residents alike. On the other hand, the law does not sufficiently protect emergency medicine residents from a long shift length and frequent night shift. Excessive shift work can cause physical and neuropsychological problems for residents. Therefore, this study examined the 24-hour shifts and night shifts status of emergency medicine residents at the training hospitals.@*METHODS@#The 30 training hospitals were divided into three groups according to the number of residents (≤4, 5-8, and ≥ 9) and the associations between each group and the 24-hour shifts, night shifts, number of working days, working hours, and annual patients per resident were checked. The associations between the resident grades and 24-hour shifts, night shifts, number of working days and working hours were also examined.@*RESULTS@#Hospital groups with fewer residents had the highest number of patients per resident with the highest number of 24-hour shifts and the highest number of night shifts. The first year residents had the highest number of 24-hour shifts, the highest number of night shifts, and the highest number of working hours.@*CONCLUSION@#More 24-hour shifts and more night shifts occur at hospitals that lack work force. Therefore, there is a need for new standards for limiting the working hours and frequency of night shifts in emergency rooms, and there is a need for discussions on reinforcing the work force.

Comparison of Sagittal Spinopelvic Alignment between Lumbar Degenerative Spondylolisthesis and Degenerative Spinal Stenosis

OBJECTIVE: The purpose of this study was to evaluate the differences in sagittal spinopelvic alignment between lumbar degenerative spondylolisthesis (DSPL) and degenerative spinal stenosis (DSS). METHODS: Seventy patients with DSPL and 72 patients with DSS who were treated with lumbar interbody fusion surgery were included in this study. The following spinopelvic parameters were measured on whole spine lateral radiographs in a standing position : pelvic incidence (PI), pelvic tilt (PT), sacral slope (SS), lumbar lordosis angle (LL), L4-S1 segmental lumbar angle (SLL), thoracic kyphosis (TK), and sagittal vertical axis from the C7 plumb line (SVA). Two groups were subdivided by SVA value, respectively. Normal SVA subgroup and positive SVA subgroup were divided as SVA value ( or =50 mm). Spinopelvic parameters/PI ratios were assessed and compared between the groups. RESULTS: The PI of DSPL was significantly greater than that of DSS (p=0.000). The SVA of DSPL was significantly greater than that of DSS (p=0.001). In sub-group analysis between the positive (34.3%) and normal SVA (65.7%), there were significant differences in LL/PI and SLL/PI (p<0.05) in the DSPL group. In sub-group analysis between the positive (12.5%) and normal SVA (87.5%), there were significant differences in PT/PI, SS/PI, LL/PI and SLL/PI ratios (p<0.05) in the DSS group. CONCLUSION: Patients with lumbar degenerative spondylolisthesis have the propensity for sagittal imbalance and higher pelvic incidence compared with those with degenerative spinal stenosis. Sagittal imbalance in patients with DSPL is significantly correlated with the loss of lumbar lordosis, especially loss of segmental lumbar lordosis.

Difference of Sagittal Spinopelvic Alignments between Degenerative Spondylolisthesis and Isthmic Spondylolisthesis

OBJECTIVE: The purpose of this study was to analyze the differences of spinopelvic parameters between degenerative spondylolisthesis (DSPL) and isthmic spondylolisthesis (ISPL) patients. METHODS: Thirty-four patients with DSPL and 19 patients with ISPL were included in this study. Spinopelvic parameters were evaluated on whole spine X-rays in a standing position. The following spinopelvic parameters were measured : pelvic incidence (PI), sacral slope, pelvic tilt (PT), lumbar lordosis (LL), and sagittal vertical axis from C7 plumb line (SVA). The population of patients was compared with a control population of 30 normal and asymptomatic adults. RESULTS: There were statistically significant differences in LL (p=0.004) and SVA (p=0.005) between the DSPL and ISPL group. The LL of DSPL (42+/-13degrees) was significantly lower than that of the control group (48+/-11degrees; p=0.029), but that of ISPL (55+/-6degrees) was significantly greater than a control group (p=0.004). The SVA of DSPL (55+/-49 mm) was greater than that of a control group (<40 mm), but that of ISPL (21+/-22 mm) was within 40 mm as that of a control group. The PT of DSPL (24+/-7degrees) and ISPL (21+/-7degrees) was significantly greater than that of a control group (11+/-6degrees; p=0.000). CONCLUSION: Both symptomatic DSPL and ISPL patients had a greater PI than that of the asymptomatic control group. In conclusion, DSPL populations are likely to have global sagittal imbalance (high SVA) compared with ISPL populations because of the difference of lumbar lordosis between two groups.

Radiographic Results of Minimally Invasive (MIS) Lumbar Interbody Fusion (LIF) Compared with Conventional Lumbar Interbody Fusion

OBJECTIVE: To evaluate the radiographic results of minimally invasive (MIS) anterior lumbar interbody fusion (ALIF) and transforaminal lumbar interbody fusion (TLIF). METHODS: Twelve and nineteen patients who underwent MIS-ALIF, MIS-TLIF, respectively, from 2006 to 2008 were analyzed with a minimum 24-months' follow-up. Additionally, 18 patients treated with single level open TLIF surgery in 2007 were evaluated as a comparative group. X-rays and CT images were evaluated preoperatively, postoperatively, and at the final follow-up. Fusion and subsidence rates were determined, and radiographic parameters, including lumbar lordosis angle (LLA), fused segment angle (FSA), sacral slope angle (SSA), disc height (DH), and foraminal height (FH), were analyzed. These parameters were also compared between the open and MIS-TLIF groups. RESULTS: In the MIS interbody fusion group, statistically significant increases were observed in LLA, FSA, and DH and FH between preoperative and final values. The changes in LLA, FSA, and DH were significantly increased in the MIS-ALIF group compared with the MIS-TLIF group, but SSA and FH were not significantly different. No significant differences were seen between open and MIS-TLIF except for DH. The interbody subsidence and fusion rates of the MIS groups were 12.0+/-4% and 96%, respectively. CONCLUSION: Radiographic results of MIS interbody fusion surgery are as favorable as those with conventional surgery regarding fusion, restoration of disc height, foraminal height, and lumbar lordosis. MIS-ALIF is more effective than MIS-TLIF for intervertebral disc height restoration and lumbar lordosis.

Anterior Interbody Grafting and Instrumentation for Advanced Spondylodiscitis

OBJECTIVE: To evaluate the surgical outcomes of ventral interbody grafting and anterior or posterior spinal instrumentation for the treatment of advanced spondylodiscitis in patients who had failed medical management. METHODS: A total of 28 patients were evaluated for associated medical illness, detected pathogen, level of involved spine, and perioperative complications. Radiological evaluation including the rate of bony union, segmental Cobb angle, graft- and instrumentation-related complications, and clinical outcomes by mean Frankel scale and VAS score were performed. RESULTS: There are 14 pyogenic spondylodiscitis, 6 postoperative spondylodiscitis, and 8 tuberculous spondylodiscitis. There were 21 males and 7 females. Mean age was 51 years, with a range from 18 to 77. Mean follow-up period was 10.9 months. Associated medical illnesses were 6 diabetes, 3 pulmonary tuberculosis, and 4 chronic liver diseases. Staphylococcus was the most common pathogen isolated (25%), and Mycobacterium tuberculosis was found in 18% of the patients. Operative approaches, either anterior or posterior spinal instrumentation, were done simultaneously or delayed after anterior aggressive debridement, neural decompression, and structural interbody bone grafting. All patients with neurological deficits improved after operation, except only one who died from aggravation as military tuberculosis. Mean Frankel scale was changed from 3.78+/-0.78 preoperatively to 4.78+/-0.35 at final follow up and mean VAS score was improved from 7.43+/-0.54 to 2.07+/-1.12. Solid bone fusion was obtained in all patients except only one patient who died. There was no need for prolongation of duration of antibiotics and no evidence of secondary infection owing to spinal instrumentations. CONCLUSION: According to these results, debridement and anterior column reconstruction with ventral interbody grafting and instrumentation is effective and safe in patients who had failed medical management and neurological deficits in advanced spondylodiscitis.

Blindness Caused by Wrapping of the ICA Aneurysm

The incidence of blindness after aneurysm surgery is very rare. We experienced a case of unilateral blindness after internal carotid artery(ICA) aneurysm wrapping. A 43-year-old male immediately developed ipsilateral ocular pain and visual loss in his left eye after the treatment of a lateral ICA aneurysm by wrapping with muscle pieces. He had also multiple aneurysms, which were multilobulated anterior communicating artery (A-com), middle cerebral artery(MCA) and posterior communicating artery (P-com) aneurysms. Coilings were done for a part of A-com artery aneurysm and P-com artery aneurysm on admission. The remaining A-com artery aneurysm was clipped and ICA aneurysm was wrapped with temporal muscle piece. A retrobulbar optic neuropathy might have resulted from either direct injury or damage to small dural vessels of the posterior optic nerve. Actually, the optico-carotid space was tight and the optic nerve was compressed by swollen muscle piece. Despite releasing of compression of the optic nerve on second day, his visual loss was irreversible.