Risk Factors of Proximal Junctional Kyphosis after Multilevel Fusion Surgery: More Than 2 Years Follow-Up Data

OBJECTIVE: Proximal junctional kyphosis (PJK) is radiologic finding, and is defined as kyphosis of >10° at the proximal end of a construct. The aim of this study is to identify factors associated with PJK after segmental spinal instrumented fusion in adults with spinal deformity with a minimum follow-up of 2 years. METHODS: A total of 49 cases of adult spinal deformity treated by segmental spinal instrumented fusion at two university hospitals from 2004 to 2011 were enrolled in this study. All enrolled cases included at least 4 or more levels from L5 or the sacral level. The patients were divided into two groups based on the presence of PJK during follow-up, and these two groups were compared to identify factors related to PJK. RESULTS: PJK was observed in 16 of the 49 cases. Age, sex and mean follow-up duration were not statistically different between two groups. However, mean bone marrow density (BMD) and mean back muscle volume at the T10 to L2 level was significantly lower in the PJK group. Preoperatively, the distance between the C7 plumb line and uppermost instrumented vertebra (UIV) were no different in the two groups, but at final follow-up a significant intergroup difference was observed. Interestingly, spinal instrumentation factors, such as, receipt of a revision operation, the use of a cross-link, and screw fracture were no different in the two groups at final follow-up. CONCLUSION: Preoperative BMD, sagittal imbalance at UIV, and thoracolumbar muscle volume were found to be strongly associated with the presence of PJK.

Comparison of the Effects of Sufentanil and Fentanyl Intravenous Patient Controlled Analgesia after Lumbar Fusion

OBJECTIVE: Postoperative pain is one of the major complaints of patients after lumbar fusion surgery. The authors evaluated the effects of intravenous patient controlled analgesia (IV-PCA) using fentanyl or sufentanil on postoperative pain management and pain-related complications. METHODS: Forty-two patients that had undergone surgery with lumbar instrumentation and fusion at single or double levels constituted the study cohort. Patients were equally and randomly allocated to a sufentanil group (group S) or a fentanyl group (group F) for patient controlled analgesia (PCA). Group S received sufentanil at a dose of 4 μg/kg IV-PCA and group F received fentanyl 24 μg/kg IV-PCA. A numeric rating scale (NRS) of postoperative pain was applied before surgery, and immediately and at 1, 6, and 24 hours (hrs) after surgery. Oswestry disability index (ODI) scores were obtained before surgery and one month after surgery. Opioid-related side effects were also evaluated. RESULTS: No significant intergroup difference was observed in NRS or ODI scores at any of the above-mentioned time points. Side effects were more frequent in group F. More specifically, nausea, vomiting rates were significantly higher (p=0.04), but pruritus, hypotension, and headache rates were non-significantly different in the two groups. CONCLUSION: Sufentanil displayed no analgesic advantage over fentanyl postoperatively. However, sufentanil should be considerable for patients at high risk of GI issues, because it had lower postoperative nausea and vomiting rates than fentanyl.

The Factors That Affect Improvement of Neurogenic Bladder by Severe Lumbar Disc Herniation in Operation

OBJECTIVE: This study analyzed retrospectively the bladder function of patients after early surgery for cauda equina syndrome (CES) performed within 24 or 48 hours, or after 48 hours of the onset of autonomic symptoms. METHODS: We retrospectively reviewed the clinical data of 31 patients after decompression surgery for lumbar disc herniation (LDH) who had been diagnosed with CES between January 2001 and December 2014 at Inha University Hospital. The following factors were assessed to evaluate the influence of time to surgery: bladder function, rectal incontinence, sexual dysfunction, LDH level, and degree of spinal canal compression. RESULTS: After decompression, the outcome group was categorized into normal bladder function and abnormal bladder function. The patients operated on within 48 hours showed an improved postoperative outcome. Among 16 patients operated on within 48 hours, 13 (81%) recovered normal bladder function. In contrast, among 15 patients with decompression after 48 hours, 6 (40%) recovered normal bladder function. Among 21 patients with mild bladder dysfunction at admission, 16 (76%) recovered normal bladder function after decompression. CONCLUSION: Our study suggests that patients who have decompression surgery within 48 hours of the onset of bladder dysfunction, improve their chances of recovering bladder function than those who have a late operation (>48 hours). Also, patients with mild bladder dysfunction are more likely to recover bladder function after decompression, than patients with severe bladder dysfunction.

Clinical and Radiological Comparison of Semirigid (WavefleX) and Rigid System for the Lumbar Spine

OBJECTIVE: Spinal fusion operation is an effective treatment in the spinal pathology, but it could change the physiological distribution of load at the instrumented and adjacent segments. This retrospective study compared the radiological and clinical outcomes of patients undergoing lumbar fusion with semirigid rods versus rigid rods system. METHODS: Using transpedicular fixation and posterior lumbar interbody fusion at the level of L4/L5, 20 patients were treated with semirigid rods (WavefleX, SR group), and 20 patients with rigid rods (titanium, RR group). Clinical and radiological outcomes were evaluated, including visual analog score for lower back pain and leg pain, Prolo functional and economic scores, statues of implanted instruments, fusion rate, and complications during 24-month follow-up. RESULTS: Clinical scores were significantly improved until postoperative 24-month follow-up as compared with preoperative scores in both groups (p<0.05), with similar levels of improvement observed at the same time points postoperatively between the 2 groups. Prolo economic scores were significantly improved in SR group compared to RR until 12 months, but this improvement became similar after 18 months. The overall fusion rate was 94.1% until the 24-month follow-up for both groups. No significant complication was observed in both groups. CONCLUSION: The results of the present study indicate that semirigid rods system with posterior lumbar interbody fusion showed similar clinical and radiological result with rigid rods system until 2 years after instrumentation. The WavefleX rods system, as a semirigid rods with unique characteristics, may be an effective alternative treatment for patients in lumbar fusion.

Therapeutic Hypothermia in Traumatic Brain injury; Review of History, Pathophysiology and Current Studies / 대한구급학회지

The fact that therapeutic hypothermia (TH) has lowered intracranial pressure and protected brain in severe traumatic brain injury (TBI) is well known throughout past sources and experimental data. In this paper, the result of TH in TBI needs to be confirmed. The result of North American Brain Injury Study; Hypothermia (NAVIS-H) 1 and 2, Eurotherm3235, Japan trauma society study was reviewed throughout randomized controlled study which performed recently. The prognosis was not confirmed throughout TH in NAVIS-H1; however, there was statistical significance among the group of 45 years or less and below 35 degree in celcius which checked when he or she visited initially. Hence, NAVIS-H2 study was preceded. In patient who had surgically removed hematoma, the effects of TH were proved compared to diffuse brain damage in NAVIS-H2 study. This was found in the result of Japan neurotrauma data bank. Eurotherm study has been doing, which leads to collect many data later on. The TBI of TH makes them better prognosis in patients who had surgically removed hematoma and lowered initial body temperature. Later on, it is considered further study is necessary.

Isolated Painless Foot Drop due to Cerebral Infarction Mimicking Lumbar Radiculopathy: A Case Report

Although they usually originate from peripheral problems, foot drop is caused by lesions affecting the neural pathway related to dorsiflexor muscles, whether of central or peripheral origin. We present a patient with sudden isolated foot drop caused by a small infarct in the primary motor cortex mimicking a peripheral origin. This report indicates that patients presenting isolated foot drop should be managed carefully and the possibility of both central and peripheral causes should be considered. To our knowledge, this is the first report of sudden isolated foot drop caused by a cortical infarction mimicking lumbar radiculopathy.

Therapeutic Hypothermia in Traumatic Brain injury; Review of History, Pathophysiology and Current Studies / 대한중환자의학회지

The fact that therapeutic hypothermia (TH) has lowered intracranial pressure and protected brain in severe traumatic brain injury (TBI) is well known throughout past sources and experimental data. In this paper, the result of TH in TBI needs to be confirmed. The result of North American Brain Injury Study; Hypothermia (NAVIS-H) 1 and 2, Eurotherm3235, Japan trauma society study was reviewed throughout randomized controlled study which performed recently. The prognosis was not confirmed throughout TH in NAVIS-H1; however, there was statistical significance among the group of 45 years or less and below 35 degree in celcius which checked when he or she visited initially. Hence, NAVIS-H2 study was preceded. In patient who had surgically removed hematoma, the effects of TH were proved compared to diffuse brain damage in NAVIS-H2 study. This was found in the result of Japan neurotrauma data bank. Eurotherm study has been doing, which leads to collect many data later on. The TBI of TH makes them better prognosis in patients who had surgically removed hematoma and lowered initial body temperature. Later on, it is considered further study is necessary.

Remote Cerebellar Hemorrhage after Surgery for Degenerative Lumbar Spine Disease: A Case Report / 대한신경손상학회지

Spine surgery has been increased as the population ages, but the occurrence of unusual complication such as remote cerebellar hemorrhage (RCH) is not well understood. We recently experienced a case of RCH in a 60-year-old woman showed neurologic dysfunction after degenerative lumbar spine surgery. There was no definite dural tearing and cerebrospinal fluid (CSF) loss during operation. Brain magnetic resonance imaging showed cerebellar hemorrhage. The patient received conservative management and rehabilitation program. Most other reports have been suggested that RCH after spinal surgery might be related with excessive CSF drainage perioperatively. Minimizing of CSF loss during operation would be helpful to reduce the risk of RCH. If large volume of CSF has been lost accompanied by neurologic deterioration, brain imaging is necessary simultaneously.

Isokinetic Muscle Strength and Muscle Endurance by the Types and Size of Rotator Cuff Tear in Men

BACKGROUND: Our study was to determine the effect on shoulder isokinetic muscle strength and muscle endurance in isolated full-thickness supraspinatus tendon tear and combined other rotator cuff tear. METHODS: Total of 81 male patients (mean age 57.8 +/- 7.4 years) who were diagnosed as a full-thickness supraspinatus tendon tear were included. They were classified into isolated or combined tear. The isokinetic muscle strength and muscle endurance were measured using the Biodex multi-joint system PRO(R) (Biodex Medical Systems, Shirley, NY, USA) in following movements: shoulder abduction, adduction, flexion, extension, external rotation, and internal rotation. Then, the difference in muscle function according to the type of tears were assessed. Fifty-seven patients had isolated supraspinatus tendon (mean age 56.9 +/- 7.3 years). They were classified into either anteroposterior tear or modified mediolateral tear. The size were measured using T2-weighted magnetic resonance imaging scans in sagittal plane. RESULTS: Between subjects categorized into the type of tear, we found significant inter-categorical differences in isokinetic muscle strength during abduction, adduction, flexion, extension, and internal rotation, and in muscle endurance during flexion, extension, and internal rotation. Anteroposterior diameter tear, we did not show significant differences in either isokinetic muscle strength or muscle endurance during any movements. However, with modified mediolateral diameter, we found significant differences with isokinetic muscle strength during adduction, and in muscle endurance the external rotation and internal rotation. CONCLUSIONS: We found that a supraspinatus tendon tear associated with more numbers of rotator cuff tears has lower isokinetic muscle strength and muscle endurance than a tear found alone.

Isokinetic Muscle Strength and Muscle Endurance by the Types and Size of Rotator Cuff Tear in Men

BACKGROUND: Our study was to determine the effect on shoulder isokinetic muscle strength and muscle endurance in isolated full-thickness supraspinatus tendon tear and combined other rotator cuff tear. METHODS: Total of 81 male patients (mean age 57.8 +/- 7.4 years) who were diagnosed as a full-thickness supraspinatus tendon tear were included. They were classified into isolated or combined tear. The isokinetic muscle strength and muscle endurance were measured using the Biodex multi-joint system PRO(R) (Biodex Medical Systems, Shirley, NY, USA) in following movements: shoulder abduction, adduction, flexion, extension, external rotation, and internal rotation. Then, the difference in muscle function according to the type of tears were assessed. Fifty-seven patients had isolated supraspinatus tendon (mean age 56.9 +/- 7.3 years). They were classified into either anteroposterior tear or modified mediolateral tear. The size were measured using T2-weighted magnetic resonance imaging scans in sagittal plane. RESULTS: Between subjects categorized into the type of tear, we found significant inter-categorical differences in isokinetic muscle strength during abduction, adduction, flexion, extension, and internal rotation, and in muscle endurance during flexion, extension, and internal rotation. Anteroposterior diameter tear, we did not show significant differences in either isokinetic muscle strength or muscle endurance during any movements. However, with modified mediolateral diameter, we found significant differences with isokinetic muscle strength during adduction, and in muscle endurance the external rotation and internal rotation. CONCLUSIONS: We found that a supraspinatus tendon tear associated with more numbers of rotator cuff tears has lower isokinetic muscle strength and muscle endurance than a tear found alone.

The Result of Minimally Invasive Transforaminal Lumbar Interbody Fusion in Low Grade Spondylolisthesis - Minimum 2 Years Follow Up -

STUDY DESIGNS: A retrospective study. OBJECTIVES: To analyze the clinical and radiological outcomes of spontaneous reduction via minimally invasive transforaminal lumbar interbody fusion (Mini-TLIF) as the treatment for low-grade symptomatic spondylolisthesis. SUMMARY OF LITERATURE REVIEW: Although minimally invasive transforaminal lumbar interbody fusion is technically demanding, this procedure is an effective method for spontaneous reduction of low grade spondylolisthesis. MATERIALS AND METHODS: We analyzed consecutive series of 41 patients with low grade spondylolisthesis who underwent minimally invasive transforaminal lumbar interbody fusion, between April 2008 and July 2009. The minimum follow-up period was 2 years. Clinical evaluation was performed by an analysis of Visual Analogue Scale and Oswestry Disability Index. For the radiological evaluation, disc space height, slip percentage, and slip angle were analyzed. At the final follow-up, the fusion rate was analyzed according to the Bridwell's anterior fusion grade. RESULTS: For the evaluation of clinical outcomes, the Visual Analogue Scale for back pain decreased from 6.8+/-1.2 to 2.0+/-1.1, and that for radiating pain decreased from 7.9+/-1.3 to 1.7+/-1.1. Oswetry Disability Index decreased from 38.5+/-8.4 to 13.4+/-6.1. For the radiological evaluation, disc space height increased from 8.4+/-2.14mm to 11.8+/-1.54mm(P<0.05), slip percentage was reduced from 18.4+/-5.1% to 13.3+/-3.1%(P<0.05) and slip angle decreased from 10.6+/-4.5degrees to 6.2+/-3.4degrees (P<0.05). At the final follow-up, radiological union was obtained in 38 cases (92.7%). CONCLUSIONS: We conclude that minimally invasive transforaminal lumbar interbody fusion appears to be an effective method for spontaneous reduction of low grade spondylolisthesis if the surgeon becomes familiar with this method.

Prevalence and Insight of Scoliosis among Korean Male Adolescents by Chest Radiographs

OBJECTIVE: We applied chest radiographs to scoliosis screening for conscription. Prevalence, types of scoliosis, and insight of examinees with scoliosis were investigated. METHODS: In this study, chest radiographs of 2417 males, who had been given an examination for conscription at the Seoul Regional Military Manpower Administration from April 2009 to May 2009, were analyzed. The prevalence of scoliosis more than a 10 degrees Cobb angle was calculated. The insight of scoliosis was investigated in every examinee and thoracolumbar radiographs were checked in those examinees with more than a 20 degree Cobb angle. RESULTS: Among 1904 males, 477 (19.7%) exhibited scoliosis involving more than a 5 degrees Cobb angle were and 131 (5.4%) exhibitedmore than a 10 degree Cobb angle. In those 131 cases, 18 (13.7%) had a known history of problems with scoliosis. Among the group measuring less than a 10 degree Cobb angle, 1.7% of them misunderstood scoliosis. Insight of scoliosis increased according to the severity of spinal curvature; however, nearly half of the cases with a 20 degree or greater Cobb angle had no insight with respect to their scoliosis. CONCLUSION: In male adolescents, the prevalence of scoliosis with a greater than 10 degree Cobb angle was 5.4% and there was a low insight with respect to scoliosis.

Preliminary Efficacy of Combination Decompressive Surgery, Stabilization and Cyberknife Radiosurgery: A New Treatment Paradigm for Metastatic Spinal Tumors with Cord Invasion

OBJECTIVE: The goal of this retrospective study was to assess clinical and radiographic outcomes of posterior surgical decompression with stabilization followed by image-guided robot Cyberknife radiosurgery for encircling malignant tumors of the spine. METHODS: From August 2008 to December 2009, 14 consecutive patients with a malignant spinal metastatic lesion with cord compression were treated at the author's institute. Patients underwent on a decompressive surgery by the posterior approach, and latent unstable spines were stabilized with instrumentation. After recovery, radiosurgery was administered at doses ranging from 16 to 26 Gy (mean 20.1Gy) prescribed to the 75-85% isodose line that encompassed at least 95% of tumor volumes. Visual Analogue Scale, American spine injury association grades, and MRI with gadolinium enhancement were used to monitor pain, neurology, and radiological outcomes, respectively, after the radiosurgery. RESULTS: No acute radiation-induced toxicity or new neurological deficit occurred during the follow-up period (mean 4.5 months). Axial pain improved in 10 out of the 14 patients. No hardware failure was encountered. At 3-6 months after the Cyberknife radiosurgery, local control and effective therapeutic rates were both 80%(8/10) and no lesion enhancement on vertebral bodies or pedicles was visualized by MRI. CONCLUSION: Posterior decompression with stabilization followed by radiosurgery of residual tumor in the anterolateral region is useful in cases where an anterior approach or a circumferential approach is not an option due to medical condition. Longer term follow-up is required to evaluate survival and late toxicities.

Prevalence of Lumbar Disc Herniation in Adolescent Males in Seoul, Korea: Prevalence of Adolescent LDH in Seoul, Korea

OBJECTIVE: The authors surveyed the prevalence and the clinical character of lumbar disc herniation (LDH) in Korean male adolescents, and the usefulness of current conscription criteria. METHODS: The data of 39,673 nineteen-year-old males that underwent a conscription examination at the Seoul Regional Korean Military Manpower Administration (MMA) from October 2010 to May 2011 were investigated. For those diagnosed as having lumbar disc herniation, prevalences, subject characteristics, herniation severities, levels of herniation, and modified Korean Oswestry low back pain disability scores by MMA physical grade were evaluated. The analysis was performed using medical certificates, medical records, medical images, and electromyographic and radiologic findings. RESULTS: The prevalence of adolescent LDH was 0.60%(237 of the 39,673 study subjects), and the prevalence of serious adolescent LDH with thecal sac compression or significant discogenic spinal stenosis was 0.28%(110 of the 39,673 study subjects). Of the 237 adolescent LDH cases, 105 (44.3%) were of single level LDH and 132 (55.7%) were of multiple level LDH, and the L4-5 level was the most severely and frequently affected. Oswestry back pain disability scores increased with herniation severity (p<0.01), and were well correlated with MMA grade. CONCLUSIONS: In this large cohort of 19-year-old Korean males, the prevalence of adolescent LDH was 0.60% and the prevalence of serious adolescent LDH, which requires management, was relatively high at 0.28%. MMA physical grade was confirmed to be a useful measure of the disability caused by LDH.

Considerations for Cancellation Reception in an Emergency Department

PURPOSE: The cancellation of reception in emergency department (ED) in Korea is similar to leaving without being seen in another country. But there are differences. We studied the actual conditions and reasons for cancellation of reception in the ED in each of several hospitals. METHODS: Thirty-six emergency centers and one hundred sixty-seven emergency physicians participated in this survey. We obtained information through a questionnaire about total hospital bed counts, emergency center bed counts, number of emergency physicians, number of cancellations of reception for one day, and emergency physicians' opinions about cancellation of reception. Also, we prospectively investigated reasons for cancellation of reception for emergency physicians and patients. We recorded the reason for cancellation of reception at the time of cancellation and then interviewed the patient by telephone within 10 days after their leaving the ED. RESULTS: Nine regional emergency centers, three specialized emergency centers, twenty-two local emergency centers and two local emergency facilities were involved in this study. We surveyed patient cancellation of reception from August 1, 2008, to October 31, 2008 in our hospital. The results of our study were variable but the average of cancellation of reception was 10% of all ED patients. The most common reason for cancellation of reception was the emergency physician sending the patient to an outpatient clinic, typically because they thought the patient had mild symptoms. The most common reasons causing emergency physicians to think about cancellation of reception were mild symptoms and too long a delay time. There was a significant difference of opinion between emergency physician and patient regarding cancellation of reception (p<0.01). The emergency physicians considered the reasons to be patient factors, while the patients considered the reasons to be doctor-related factors. CONCLUSION: There are many adverse effects from cancellation of reception in an ED for both emergency physicians and patients. We should considered methods for developing a consensus on ways to improve the situation.

Evaluation of Limit of Detection and Range of Quantitation for RT-PCR, Real-Time RT-PCR and RT-PCR-ELISA Detection of Bovine Viral Diarrhoea Virus Contamination in Biologics Derived from Cell Cultures

Risk of viral contamination is one of major concerns common to all biologics derived from cultivated cells. Bovine viral diarrhoea virus (BVDV) has widely been known as a contaminant of cell culture-derived vaccines. The objective of the study was to assess the limit of detection and range of quantitation of the detection methods for BVDV using a reverse transcription-polymerase chain reaction (RT-PCR) assay, real-time RT-PCR assay, and RT-PCR-ELISA. One milliliter of cell culture supernatant containing 106.5+/-0.2 median tissue culture infectious dose (TCID50)/ml of BVDV NADL strain was subjected to RNA isolation. The isolated RNA was 10-fold serially diluted and each diluted sample (10-1 to 10-6) was subjected to RT-PCR on a GeneAmpR PCR System 9700 and/or LightCycler(TM). The amplified products were analyzedly (1) agarose gel electrophoresis for RT-PCR assay, (2) melting curve analysis for real-time RT-PCR assay (in this case a program is automatically linked to amplification step), and (3) ELISA using capture and detection probes for RT-PCR-ELISA. The limit of detection of the 3 assay methods was equally estimated to be 316 TCID50/ml of starting virus culture supernatant subjected to the assay. The quantitation range of real-time RT-PCR assay and RT-PCR-ELISA was estimated to be from 3.16x105 to 3.16x102 TCID50/ml of starting virus culture supernatant. The overall results suggested that the 3 assay methods for BVDV detection can be reliably applied to evaluate BVDV contamination in biologics derived from cell cultures.

Development of One-step Real-time Reverse Transcription-polymerase Chain Reaction in Combination with Automated RNA Extraction for Detection and Quantitation of Hepatitis A Virus

One-step real-time reverse transcription-polymerase chain reaction (RT-PCR) assay using the MagNA Pure LC and LightCycler(TM) system was developed and validated for the detection and quantitation of hepatitis A virus (HAV) RNA. The assay was evaluated using in-house synthetic HAV RNA standard. The real-time RT-PCR assay could quantitate a dynamic range of HAV RNA standard between 10(2) and 10(8) copies per reaction. The regression coefficient of the standard curve was an 0.99. The detection limit of the assay was 31.3 RNA copies per reaction. The coefficient variations (CVs) of the assay in combination with automated RNA extraction were less than 1.91% in both intra- and inter-assay. The real-time RT-PCR assay for quantitative detection of HAV would serve a useful method for improving the safety of biological products.

Study on Variation of Endemic Mumps Viruses in Korea

No Abstract Available.