Full-Endoscopic versus Minimally Invasive Lumbar Interbody Fusion for Lumbar Degenerative Diseases : A Systematic Review and Meta-Analysis

Objective@#: Although full-endoscopic lumbar interbody fusion (Endo-LIF) has been tried as the latest alternative technique to minimally invasive transforaminal lumbar interobody fusion (MIS-TLIF) since mid-2010, the evidence is still lacking. We compared the clinical outcome and safety of Endo-LIF to MIS-TLIF for lumbar degenerative disease. @*Methods@#: We systematically searched electronic databases, including PubMed, EMBASE, and Cochrane Library to find literature comparing Endo-LIF to MIS-TLIF. The results retrieved were last updated on December 11, 2020. The perioperative outcome included the operation time, blood loss, complication, and hospital stay. The clinical outcomes included Visual analog scale (VAS) of low back pain and leg pain and Oswestry disability index (ODI), and the radiological outcome included pseudoarthosis rate with 12-month minimum follow-up. @*Results@#: Four retrospective observational studies and one prospective observational study comprising 423 patients (183 Endo-LIF and 241 MIS-TLIF) were included, and the pooled data analysis revealed low heterogeneity between studies in our review. Baseline characteristics including age and sex were not different between the two groups. Operation time was significantly longer in Endo- LIF (mean difference [MD], 23.220 minutes; 95% confidence interval [CI], 10.669–35.771; p=0.001). However, Endo-LIF resulted in less perioperative blood loss (MD, -144.710 mL; 95% CI, 247.941–41.478; p=0.023). Although VAS back pain at final (MD, -0.120; p=0.586), leg pain within 2 weeks (MD, 0.005; p=0.293), VAS leg pain at final (MD, 0.099; p=0.099), ODI at final (MD, 0.141; p=0.093) were not different, VAS back pain within 2 weeks was more favorable in the Endo-LIF (MD, -1.538; 95% CI, -2.044 to -1.032; p<0.001). On the other hand, no statistically significant group difference in complication rate (relative risk [RR], 0.709; p=0.774), hospital stay (MD, -2.399; p=0.151), and pseudoarthrosis rate (RR, 1.284; p=0.736) were found. @*Conclusion@#: Relative to MIS-TLIF, immediate outcomes were favorable in Endo-LIF in terms of blood loss and immediate VAS back pain, although complication rate, mid-term clinical outcomes, and fusion rate were not different. However, the challenges for Endo-LIF include longer operation time which means a difficult learning curve and limited surgical indication which means patient selection bias. Larger-scale, well-designed study with long-term follow-up and randomized controlled trials are needed to confirm and update the results of this systematic review.

Intraoperative Frozen Cytology of Central Nervous System Neoplasms: An Ancillary Tool for Frozen Diagnosis

BACKGROUND: Pathologic diagnosis of central nervous system (CNS) neoplasms is made by comparing light microscopic, immunohistochemical, and molecular cytogenetic findings with clinicoradiologic observations. Intraoperative frozen cytology smears can improve the diagnostic accuracy for CNS neoplasms. Here, we evaluate the diagnostic value of cytology in frozen diagnoses of CNS neoplasms. METHODS: Cases were selected from patients undergoing both frozen cytology and frozen sections. Diagnostic accuracy was evaluated. RESULTS: Four hundred and fifty-four cases were included in this retrospective single-center review study covering a span of 10 years. Five discrepant cases (1.1%) were found after excluding 53 deferred cases (31 cases of tentative diagnosis, 22 cases of inadequate frozen sampling). A total of 346 cases of complete concordance and 50 cases of partial concordance were classified as not discordant cases in the present study. Diagnostic accuracy of intraoperative frozen diagnosis was 87.2%, and the accuracy was 98.8% after excluding deferred cases. Discrepancies between frozen and permanent diagnoses (n = 5, 1.1%) were found in cases of nonrepresentative sampling (n = 2) and misinterpretation (n = 3). High concordance was observed more frequently in meningeal tumors (97/98, 99%), metastatic brain tumors (51/52, 98.1%), pituitary adenomas (86/89, 96.6%), schwannomas (45/47, 95.8%), high-grade astrocytic tumors (47/58, 81%), low grade astrocytic tumors (10/13, 76.9%), non-neoplastic lesions (23/36, 63.9%), in decreasing frequency. CONCLUSIONS: Using intraoperative cytology and frozen sections of CNS tumors is a highly accurate diagnostic ancillary method, providing subtyping of CNS neoplasms, especially in frequently encountered entities.

Eggerthella Lenta Bacteremia after Appendectomy in a Healthy Patient / 대한내과학회지

Eggerthella lenta (E. lenta) has been reported to cause bacteremia in patients with gastrointestinal tract disorders or malignancies and in immunocompromised patients. Cases of E. lenta have been increasing with the recent development of testing equipment. The mortality rate due to E. lenta bacteremia is high. The authors report a case of E. lenta bacteremia in an immunocompetent patient.

Eggerthella Lenta Bacteremia after Appendectomy in a Healthy Patient / 대한내과학회지

Eggerthella lenta (E. lenta) has been reported to cause bacteremia in patients with gastrointestinal tract disorders or malignancies and in immunocompromised patients. Cases of E. lenta have been increasing with the recent development of testing equipment. The mortality rate due to E. lenta bacteremia is high. The authors report a case of E. lenta bacteremia in an immunocompetent patient.

Predictive Values of Magnetic Resonance Imaging Features for Tracheostomy in Traumatic Cervical Spinal Cord Injury

OBJECTIVE: To evaluate the magnetic resonance (MR) imaging features that have a statistically significant association with the need for a tracheostomy in patients with cervical spinal cord injury (SCI) during the acute stage of injury. METHODS: This study retrospectively reviewed the clinical data of 130 patients with cervical SCI. We analyzed the factors believed to increase the risk of requiring a tracheostomy, including the severity of SCI, the level of injury as determined by radiological assessment, three quantitative MR imaging parameters, and eleven qualitative MR imaging parameters. RESULTS: Significant differences between the non-tracheostomy and tracheostomy groups were determined by the following five factors on multivariate analysis : complete SCI (p=0.007), the radiological level of C5 and above (p=0.038), maximum canal compromise (MCC) (p=0.010), lesion length (p=0.022), and osteophyte formation (p=0.015). For the MCC, the cut-off value was 46%, and the risk of requiring a tracheostomy was three times higher at an interval between 50–60% and ten times higher between 60–70%. For lesion length, the cut-off value was 20 mm, and the risk of requiring a tracheostomy was two times higher at an interval between 20–30 mm and fourteen times higher between 40–50 mm. CONCLUSION: The American Spinal Injury Association grade A, a radiological injury level of C5 and above, an MCC ≥50%, a lesion length ≥20 mm, and osteophyte formation at the level of injury were considered to be predictive values for requiring tracheostomy intervention in patients with cervical SCI.

Predictive Values of Magnetic Resonance Imaging Features for Tracheostomy in Traumatic Cervical Spinal Cord Injury

OBJECTIVE: To evaluate the magnetic resonance (MR) imaging features that have a statistically significant association with the need for a tracheostomy in patients with cervical spinal cord injury (SCI) during the acute stage of injury.METHODS: This study retrospectively reviewed the clinical data of 130 patients with cervical SCI. We analyzed the factors believed to increase the risk of requiring a tracheostomy, including the severity of SCI, the level of injury as determined by radiological assessment, three quantitative MR imaging parameters, and eleven qualitative MR imaging parameters.RESULTS: Significant differences between the non-tracheostomy and tracheostomy groups were determined by the following five factors on multivariate analysis : complete SCI (p=0.007), the radiological level of C5 and above (p=0.038), maximum canal compromise (MCC) (p=0.010), lesion length (p=0.022), and osteophyte formation (p=0.015). For the MCC, the cut-off value was 46%, and the risk of requiring a tracheostomy was three times higher at an interval between 50–60% and ten times higher between 60–70%. For lesion length, the cut-off value was 20 mm, and the risk of requiring a tracheostomy was two times higher at an interval between 20–30 mm and fourteen times higher between 40–50 mm.CONCLUSION: The American Spinal Injury Association grade A, a radiological injury level of C5 and above, an MCC ≥50%, a lesion length ≥20 mm, and osteophyte formation at the level of injury were considered to be predictive values for requiring tracheostomy intervention in patients with cervical SCI.

Correlation between MRI Grading System and Surgical Findings for Lumbar Foraminal Stenosis

OBJECTIVE: Magnetic resonance imaging (MRI) grading systems using sagittal images are useful for evaluation of lumbar foraminal stenosis. We evaluated whether such a grading system is useful as a diagnostic tool for surgery. METHODS: Between July 2014 and June 2015, 99 consecutive patients underwent unilateral lumbar foraminotomy for lumbar foraminal stenosis. Surgically confirmed foraminal stenosis and the contralateral, asymptomatic neuroforamen were assessed based on a 4-point MRI grading system. Two experienced researchers independently evaluated the MR sagittal images. Interobserver agreement and intraobserver agreement were analyzed using κ statistics. RESULTS: The mean age of patients (54 women, 45 men) was 62.5 years. A total of 101 levels (202 neuroforamens) were evaluated. MRI grades for operated neuroforamens were as follows: Grade 0 in 0.99%, Grade 1 in 5.28%, Grade 2 in 14.85%, and Grade 3 in 78.88%. Interobserver agreement was moderate for operated neuroforamens (κ=0.511) and good for asymptomatic neuroforamens (κ=0.696). Intraobserver agreement by reader 1 for operated neuroforamens was good (κ=0.776) and that for asymptomatic neuroforamens was very good (κ=0.831). In terms of lumbar level, interobserver agreement for L5–S1 (κ=0.313, fair) was relatively lower than the other level (κ=0.804, very good). CONCLUSION: MRI grading system for lumbar foraminal stenosis is thought to be useful as a diagnostic tool for surgery in the lumbar spine; however, it is less reliable for symptomatic L5–S1 foraminal stenosis than for other levels. Thus, various clinical factors as well as the MRI grading system are required for surgical decision-making.

Prevalence of Hepatitis B Virus and HIV Co-infection in Korea

Hepatitis B virus (HBV) and human immunodeficiency virus (HIV) have a common route like sexually transmitted infections (STIs), vertical transmission and blood transfusion, etc. Therefore, it was necessary to be an attempt to confirm the relationship of HBV and HIV in Korea. We investigated the prevalence of Hepatitis B surface antigen (HBsAg) and Hepatitis B core antibody (anti-HBc) in HIV positive groups (n=430) and HIV negative groups (n=434) from January 2014 to October 2015. When comparing the prevalence of anti-HBc between the two groups, HIV positive group (36.0%) showed a higher prevalence than HIV negative group (24.7%), the result was statistically significant (p < 0.05). However, there was a little difference on HBsAg and not significant. Therefore, by showing a clear difference in anti-HBc between the two groups of HIV in Korea, it was confirmed to be associated with co-infections between Hepatitis B and HIV.

Septicemia Caused by Neisseria meningitidis With Decreased Ciprofloxacin Susceptibility: The First Case Report in Korea

No abstract available.

Is Surgical Drain Useful for Lumbar Disc Surgery?

OBJECTIVE: Surgical drains are commonly used after the spine surgeries for minimizing hematoma formation, which can delay wound healing and may become a source of fibrosis, infection, and pain. The drain, however, may provide a direct route for infection if it is contaminated. Our objective was to survey the relationship between surgical drains and infection. METHODS: The 70 patients who had undergone single-level lumbar discectomy from April 2011 to March 2012 were retrospectively analyzed. Each patient's medical chart and magnetic resonance image were thoroughly reviewed after all the patients had been divided into the drainage and the nondrainage groups. The amounts and durations of the surgical drains in the drainage group were analyzed. Additionally, the levels of C-reactive protein, rates of infection, scores of preoperative and postoperative visual analog scale (VAS), and lengths of hospital stay after operation were compared between the 2 groups. RESULTS: In this study, 70 patients were retrospectively analyzed; out of which, 42 and 28 patients were included in the drainage and the nondrainage groups, respectively. Two of the postoperative infection cases in the nondrainage group required to undergo repeated operations. The frequency of the postoperative infection cases was higher in the nondrainage group than in the drainage group; however, there was no significant statistical difference between the 2 groups (p=0.157). CONCLUSION: Surgical drains did not elevate postoperative infection. Furthermore, drain tip cultures allowed us to detect postoperative infection at an early stage, and it led to faster initiation of antibiotics treatment.

The Actual Level of Symptomatic Soft Disc Herniation in Patients with Cervical Disc Herniation

OBJECTIVE: The aim of this study was to predict the relationship between the symptomatic disc herniation level and the osteophyte level or decreased disc height in patients with cervical disc herniation. METHODS: Between January 2011 and December 2012, 69 patients with an osteophyte of the cervical spine underwent surgery at a single center due to soft cervical disc herniation. Data including soft disc herniation level, osteophyte level in the posterior vertebral margin, Cobb's angle, and symptom duration were retrospectively assessed. The patients were divided into three groups according to the relationship between the degenerative change level and the level of reported symptoms. RESULTS: Among the 69 patients, 48 (69.6%) showed a match between osteophyte level and soft disc herniation level. Disc herniation occurred at the adjacent segment to degenerative osteophyte level in 12 patients (17.4%) and at both the adjacent and the osteophyte level in nine (13.0%). There was no significant difference in Cobb's angle or duration among the three groups. Osteophyte type was not significant. The mean disc height of the prominent degenerative change level group was lower than the adjacent segment level, but this was not significant. CONCLUSION: Soft cervical disc herniation usually occurs at the level an osteophyte forms. However, it may also occur at segments adjacent to that of the osteophyte level. Therefore, in patients with cervical disc herniation, although a prominent osteophyte alone may appear on plain radiography, we must suspect the presence of soft disc herniation at other levels.

Influence of Compression Ratio Differences between Magnetic Resonance Images and Simple Radiographs on Osteoporotic Vertebral Compression Fracture Prognosis after Vertebroplasty

OBJECTIVE: The extent of collapse progression after vertebroplasty in osteoporotic vertebral compression fractures (OVCF) has known to be various. In this study, we investigated that how much difference of compression ratio between standing simple radiograph and supine magnetic resonance imaging (MRI) affects the collapse progression after vertebroplasty. METHODS: This retrospective cohort study was carried out based on 27 patients with 31 OVCFs undergone vertebrplastyin the thoracolumbar junction (T12-L2), from January to December 2009. The OVCFs were divided to two groups, the smaller group A and larger group B, by mean compression ratio difference (8.1%) between standing simple radiograph and supine MRI. RESULTS: There were no significant differences in the baseline characteristics of the two groups except age. There were also no significant differences between the periodic compression ratio, back pain, Cobb's angle during follow-up period. However, Group B seemed to show improvements from the initial state to the point just after the operation, but eventually took a much worse course than group A. In the end, judging from the compression ratios of the two groups at the last follow up, group A showed less progression. CONCLUSION: Although the clinical outcome was not different significantly, a greater compression ratio difference in the initial study resulted in a greater collapse progression at last follow-up. Therefore, we suggest that it is important to check the initial standing simple radiograph, as well as supine MRI, for predicting collapse progression after vertebroplasty.

Early Vertebroplasty versus Delayed Vertebroplasty for Acute Osteoporotic Compression Fracture : Are the Results of the Two Surgical Strategies the Same?

OBJECTIVE: In Korea, early vertebroplasty (EVP) or delayed vertebroplasty (DVP, which is performed at least 2 weeks after diagnosis) were performed for the treatment of acute osteoporotic compression fracture (OCF) of the spine. The present study compared the outcomes of two surgical strategies for the treatment of single-level acute OCF in the thoracolumbar junction (T12-L2). METHODS: From 2004 to 2010, 23 patients were allocated to the EVP group (EVPG) and 27 patients to the DVP group (DVPG). Overall mean age was 68.3+/-7.9 and minimum follow-up period was 1.0 year. Retrospective study of clinical and radiological results was conducted. RESULTS: No significant differences in baseline characteristics were observed between the two groups. As expected, mean duration from onset to vertebroplasty and mean duration of hospital stay were significantly longer in the DVPG (17.1+/-2.1 and 17.5+/-4.2) than in the EVPG (3.8+/-3.3 and 10.8+/-5.1, p=0.001). Final clinical outcome including visual analogue scale (VAS), Oswestry Disability Index, and Odom's criteria did not differ between the two groups. However, immediate improvement of the VAS after vertebroplasty was greater in the EVPG (5.1+/-1.3) than in the DVPG (4.0+/-1.0, p=0.002). The proportion of cement leakage was lower in the EVPG (30.4%) than in the DVPG (59.3%, p=0.039). In addition, semiquantitative grade of cement interdigitation was significantly more favorable in the EVPG than in the DVPG (p=0.003). Final vertebral body collapse and segmental kyphosis did not differ significantly between the two groups. CONCLUSION: Our findings suggest that EVP achieves a better immediate surgical effect with more favorable cost-effectiveness.

A Comparison of the Clinical Outcomes of Decompression Alone and Fusion in Elderly Patients with Two-Level or More Lumbar Spinal Stenosis

OBJECTIVE: We compared the results of two surgical techniques by retrospective study of 60 elderly patients (65 years or older) who underwent either decompression alone or fusion for the treatment of two-level or more lumbar spinal stenosis. METHODS: During the period of 2003 and 2008, two-level or more decompression alone or fusion was performed for lumbar spinal stenosis by three surgeons at our institution. Patients were allocated to two groups by surgical modality, namely, to a decompression group (31 patients) or a fusion group (29 patients). Overall mean age was 71.1 years (range, 65-84) and mean follow-up was 5.5 years (range, 3-9). A retrospective review of clinical, radiological, and surgical data was conducted. RESULTS: No significant difference between the two groups was found with respect to age, follow-up period, surgical levels, or preoperative condition. At the last follow-up, correction of lumbar lordotic angle (determined radiologically) was better in the fusion group. However, clinical outcomes including visual analogue scale, Oswestry Disability Index, and the Odom's criteria were not significantly different in the two groups. On the other hand, surgical outcomes, such as, operation time, estimated blood loss, and surgical complications were significantly better in the decompression alone group. CONCLUSION: Our findings suggest that decompressive laminectomy alone achieves good outcomes in patients with two-level or more lumbar spinal stenosis, associated with an advanced age, poor general condition, or osteoporosis.

Acute Hydrocephalus Following Cervical Spinal Cord Injury

We present a case of acute hydrocephalus secondary to cervical spinal cord injury in a patient with diffuse ossification of the posterior longitudinal ligament (OPLL). A 75-year-old male patient visited the emergency department with tetraparesis and spinal shock. Imaging studies showed cervical spinal cord injury with hemorrhage and diffuse OPLL from C1 to C4. We performed decompressive laminectomy and occipitocervical fusion. Two days after surgery, his mental status had deteriorated to drowsiness with dilatation of the right pupil. Findings on brain computed tomography revealed acute hydrocephalus and subarachnoid hemorrhage in the cerebellomedullary cistern, therefore, extraventricular drainage was performed immediately. Acute hydrocephalus as a complication of cervical spine trauma is rare, however, it should be considered if the patient shows deterioration of neurologic symptoms.

A Case of Colon Cancer Associated with Streptococcus gallolyticus Subspecies pasteurianus Bacteremia / 대한내과학회지

Streptococcus Gallolyticus subspecies pasteurianus is a biotype II/2 of Streptococcus bovis. Although there is a clear correlation between Streptococcus bovis bacteremia and the risk of developing colon cancer, the relationship between Streptococcus gallolyticus subspecies pasteurianus bacteremia and colon cancer is not clear. We report a 53-year-old female who initially presented with fever and low back pain. Streptococcus gallolyticus subspecies pasteurianus was isolated in blood cultures, so we performed a colonoscopy and discovered colon cancer.

Surgical Outcomes and Complications after Occipito-Cervical Fusion Using the Screw-Rod System in Craniocervical Instability

OBJECTIVE: Although there is no consensus on the ideal treatment of the craniocervical instability, biomechanical stabilization and bone fusion can be induced through occipito-cervical fusion (OCF). The authors conducted this study to evaluate efficacy of OCF, as well as to explore methods in reducing complications. METHODS: A total of 16 cases with craniocervical instability underwent OCF since the year 2002. The mean age of the patients was 51.5 years with a mean follow-up period of 34.9 months. The subjects were compared using lateral X-ray taken before the operation, after the operation, and during last follow-up. The Nurick score was used to assess neurological function pre and postoperatively. RESULTS: All patients showed improvements in myelopathic symptoms after the operation. The mean preoperative Nurick score was 3.1. At the end of follow-up after surgery, the mean Nurick score was 2.0. After surgery, most patients' posterior occipito-cervical angle entered the normal range as the pre operation angle decresed from 121 to 114 degree. There were three cases with complications, such as, vertebral artery injury, occipital screw failure and wound infection. In two cases with cerebral palsy, occipital screw failures occurred. But, reoperation was performed in one case. CONCLUSION: OCF is an effective method in treating craniocervical instability. However, the complication rate can be quite high when performing OCF in patients with cerebral palsy, rheumatoid arthritis. Much precaution should be taken when performing this procedure on high risk patients.

Combined Open Door Laminoplasty with Unilateral Screw Fixation for Unstable Multi-Level Cervical Stenosis : A Preliminary Report

OBJECTIVE: The authors reviewed their experiences of combined surgery (open door laminoplasty with unilateral screw fixation) for unstable multi-level cervical stenosis, to clarify the situation regarding the surgical approach most appropriate for the treatment of diffuse unstable multi-level cervical stenosis. METHODS: From January 2011 to January 2012, combined surgery was performed for unstable multi-level cervical stenosis by one surgeon at our institution. The subjects of this study were 6 men of mean age 53.7 years (range, 48-71) with a mean follow-up of 9.3 (range, 3-14) months. All imaging studies showed severe multi-level cervical stenosis with spinal cord signal change, and instability or kyphotic deformity. A retrospective review of clinical, radiological, and surgical data was conducted. RESULTS: Average laminoplasty level was 4.8 and the average screw fixation level was 5.0. Japanese Orthopedic Association score improved from an average of 5.2 to 11.2 points. According to Nurick's grades and Odom's criteria, symptom improvement was statistically significant. On the other hand, Cobb's angle changes were not significant. Average operation time was 5.86 hours with an average blood loss of 460 mL. No significant surgical complication was encountered. CONCLUSION: Despite the small cohort and the short follow-up duration, the present study demonstrates that laminoplasty with unilateral screw fixation is a safe and effective treatment for unstable multi-level cervical stenosis.

Solitary Ruptured Aneurysm of the Spinal Artery of Adamkiewicz with Subarachnoid Hemorrhage

Spinal subarachnoid hemorrhage (SAH) due to solitary spinal aneurysm is extremely rare. A 45-year-old female patient visited the emergency department with severe headache and back pain. Imaging studies showed cerebral SAH in parietal lobe and spinal SAH in thoracolumbar level. Spinal angiography revealed a small pearl and string-like aneurysm of the Adamkiewicz artery at the T12 level. One month after onset, her back pain aggravated, and follow-up imaging study showed arachnoiditis. Two months after onset, her symptoms improved, and follow-up imaging study showed resolution of SAH. The present case of spinal SAH due to rupture of dissecting aneurysm of the Adamkiewicz artery underwent subsequent spontaneous resolution, indicating that the wait-and-see strategy may provide adequate treatment option.

Prophylactic Intrawound Application of Vancomycin Powder in Instrumented Spinal Fusion Surgery

OBJECTIVE: We evaluated the effect of intrawound application of vancomycin powder for infection prophylaxis in wounds caused by instrumented spinal surgery. METHODS: From July 2012 to December 2012, 74 instrumented spinal fusion procedures were performed by 1 neurosurgeon at a single institute. We divided the patients into 2 groups, depending on the use of local application of vancomycin powder: Group A (intrawound application of vancomycin powder with perioperative intravenous cefazolin) and Group B (perioperative intravenous cefazolin alone). A retrospective cohort comparative study was conducted between the 2 groups. The age, sex, comorbidities, smoking, surgical procedure, and surgical site infection (SSI) of consecutive patients were analyzed. RESULTS: Among the 74 patients, 34 patients were assigned to group A and 40 patients to group B. No wound infections were found in group A. However, in group B, 5 cases of SSI (12.5%) were found. A statistically significant reduction in SSI incidence was observed in group A (p<0.033). The 5 cases of SSI in group B consisted of 3 cases of deep wound infection and 2 cases of superficial wound infection. All SSIs were found in cases of posterior approach surgery and tended to be more frequent in older patients. CONCLUSION: Adjunctive intrawound local application of vancomycin powder is a simple uncomplicated procedure and can result in a significant reduction of SSI in instrumented spinal fusions. Furthermore, culture of the drainage tip is very important for confirmation of deep wound infection.