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Osteoporosis and osteoporotic fractures cause socioeconomic concerns, and medical system and policies appear insufficient to prepare for these issues in Korea, where the older adult population is rapidly increasing. Many countries around the world are already responding to osteoporosis and osteoporotic fractures by adopting fracture liaison service (FLS), and such an attempt has only begun in Korea. In this article, we introduce the operation methods for institutions implementing FLS and characteristics of services, and activities of the FLS Committee for FLS implementation in the Korean Society for Bone and Mineral Research. In addition, we hope that the current position statement will contribute to the implementation of FLS in Korea and impel policy changes to enable a multidisciplinary and integrated FLS operated under the medical system.
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Background/Aims@#We evaluated the role of next-generation sequencing (NGS)-based disease monitoring for elderly patients diagnosed with acute myeloid leukemia (AML) who received decitabine therapy. @*Methods@#A total of 123 patients aged > 65 years with AML who received decitabine were eligible. We analyzed the dynamics of variant allele frequency (VAF) in 49 available follow-up samples after the fourth cycle of decitabine. The 58.6% VAF clearance (Δ, [VAF at diagnosis − VAF at follow-up] × 100 / VAF at diagnosis) was the optimal cut-off for predicting overall survival (OS). @*Results@#The overall response rate was 34.1% (eight patients with complete remission [CR], six of CR with incomplete hematologic recovery, 22 with partial responses, and six with morphologic leukemia-free status). Responders (n = 42) had significantly better OS compared with non-responders (n = 42) (median, 15.3 months vs. 6.5 months; p < 0.001). Of the 49 patients available for follow-up targeted NGS analysis, 44 had trackable gene mutations. The median OS of patients with ΔVAF ≥ 58.6% (n=24) was significantly better than that of patients with ΔVAF < 58.6% (n = 19) (20.5 months vs. 9.8 months, p = 0.010). Moreover, responders with ΔVAF ≥ 58.6% (n = 20) had a significantly longer median OS compared with responders with VAF < 58.6% (n = 11) (22.5 months vs. 9.8 months, p = 0.004). @*Conclusions@#This study suggested that combining ΔVAF ≥ 58.6%, a molecular response, with morphologic and hematologic responses can more accurately predict OS in elderly AML patients after decitabine therapy.
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Purpose@#To investigate whether the signal or morphological changes in the adjacent bone or soft tissue after intradiscal electrothermal therapy (IDET) occur due to postprocedural inflammation or infectious spondylodiscitis. @*Materials and Methods@#Ten patients (female:male = 5:5; age range, 18–71 years; mean age: 36.5 years) who underwent lumbar IDET between January 2018 and December 2020 and complained of fever or pain were included in this study. The presence and extent of bone marrow and paraspinal soft tissue signal changes were evaluated using the first follow-up magnetic resonance imaging (MRI) after IDET. Signal changes in the treated discs and the presence and extent of epidural enhancement were evaluated. Additionally, we investigated the presence and margins of subchondral erosions in the vertebral body. @*Results@#Two radiologists analyzed the imaging findings by consensus. Six patients were diagnosed with postprocedural inflammation and four with infectious spondylodiscitis, which was confirmed by specimen culture after surgery. All 10 patients showed signal changes in the bone marrow of the vertebral bodies adjacent to the treated disc. Signal changes in the paraspinal soft tissue were observed in only five patients: three with infectious spondylodiscitis and two with postprocedural inflammation. In six patients with postprocedural inflammation, subchondral erosions had well-defined margins with a sclerotic rim and in four patients with infectious spondylodiscitis, subchondral erosions had ill-defined margins. Epidural enhancement showed an extensive pattern in all cases of infectious spondylodiscitis and localized patterns in cases of postprocedural inflammation. @*Conclusion@#MRI or computed tomography findings of well-defined subchondral erosions with a sclerotic rim and more localized signal changes in the paraspinal soft tissue or epidural space might aid in the differentiation of infectious spondylodiscitis and postprocedural inflammation in patients who underwent IDET.
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Purpose@#We evaluated the characteristics of CCAAT/enhancer-binding protein α (CEBPA) mutations and the significance of a basic leucine zipper in-frame mutation (bZIPin-f) of CEBPA in patients with acute myeloid leukemia with a normal karyotype. @*Materials and Methods@#Based on updated knowledge of CEBPA mutations, we conducted next-generation sequencing analyses in a previously established real-world cohort. @*Results@#Among 78 of a total of 395 patients (19.7%), 50 had bZIPin-f CEBPA, and 28 had non-bZIPin-f CEBPA. In the multivariate analysis, patients with NPM1mut, those with bZIPin-f CEBPA, and those who underwent allogeneic hematopoietic cell transplantation (allo-HCT) had favorable overall survival (OS), but FLT3-ITDmut was a poor prognostic indicator. For relapse-free survival (RFS) and cumulative incidence of relapse, bZIPin-f CEBPA, and allo-HCT were associated with favorable outcomes; FLT3-ITDpos was associated with worse outcomes. In the CEBPA double-mutated group (CEBPAdm), bZIPin-f CEBPA was associated with superior outcomes in terms of OS (p=0.007) and RFS (p=0.007) compared with non-bZIPin-f CEBPA. Of 50 patients with bZIPin-f CEBPA, 36 patients had at least one mutation. When grouped by the presence of mutations in chromatic/DNA modifiers (C), cohesion complex (C), and splicing genes (S) (CCS mutations), CCS-mutated bZIPin-f CEBPA was associated with poor OS (p=0.044; hazard ratio [HR], 2.419) and a trend in inferior RFS (p=0.186; HR, 1.838). @*Conclusion@#Only bZIPin-f CEBPA was associated with favorable outcomes in patients with CEBPAdm. However, some mutations accompanying bZIPin-f CEBPA showed inferior OS; thus, further studies with larger numbers of patients are required for clear conclusions of the significance of bZIPin-f CEBPA.
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Purpose@#This study aimed to evaluate the association of redundant nerve roots of the cauda equina (RNRCEs) with the degree and duration of symptoms in patients with lumbar spinal canal stenosis. @*Materials and Methods@#Between January 2017 and December 2018, 224 patients demonstrating central canal stenosis on lumbar spine MRI were included. Various imaging findings associated with spinal canal stenosis were investigated, as were the presence, level, type, and length of RNRCEs, and the presence of nerve root swelling. Clinically, the degree of symptoms and symptom changes after treatment were investigated. Multinomial logistic regression was used for statistical analysis. @*Results@#RNRCEs were present in 142 patients (63.4%). Most RNRCEs were observed above the level of stenosis (47.3%). RNRCE was associated with the number of stenoses and symptom duration (p < 0.05). The presence, level, type, and length of RNRCE and nerve root swelling significantly affected the severity of symptoms (p < 0.05). The type of treatment influenced symptom changes (p < 0.05). @*Conclusion@#The recognition and assessment of RNRCEs on spinal MRI are clinically important because the presence, level, type, and length of a RNRCE may be associated with the degree of symptoms and help predict the clinical outcome according to treatment methods.
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Objective@#: To investigate the clinical efficacy and safety of the controlled distraction-compression technique using an expandable titanium cage (ETC) in posttraumatic kyphosis (PTK). @*Methods@#: We retrospectively studied and collected data on 20 patients with PTK. From January 2014 to December 2017, the controlled distraction-compression technique using ETC was consecutively performed in 20 patients with PTK of the thoracolumbar zone (range, 36–82 years). Among them, nine were males and 11 were females and the mean age was 61.5 years. The patients were followed regularly at 1, 3, 6, and 12 months, and the last follow-up was more than 2 years after surgery. @*Results@#: The mean follow-up period was 27.3±7.3 months (range, 14–48). The average operation time was 286.8±33.1 minutes (range, 225–365). The preoperative regional kyphotic angle (RKA) ranged from 35.6° to 70.6° with an average of 47.5°±8.1°. The immediate postoperative mean RKA was 5.9°±3.8° (86.2% correction rate, p=0.000), and at the last follow-up more than 2 years later, the mean RKA was 9.2°±4.9° (80.2% correction rate, p=0.000). The preoperative mean thoracolumbar kyphosis was 49.1°±9.2° and was corrected to an average of 8.8°±5.3° immediately after surgery (p=0.000). At the last follow-up, a correction of 11.9°±6.3° was obtained (p=0.000). The preoperative mean back visual analog scale (VAS) score was 7.9±0.8 and at the last follow-up, the VAS score was improved to a mean of 2.3±1.0 with a 70.9% correction rate (p=0.000). The preoperative mean Oswestry disability index (ODI) score was 32.3±6.9 (64.6%) and the last follow-up ODI score was improved to a mean of 6.85±2.9 (3.7%) with a 78.8% correction rate (p=0.000). The overall complication was 15%, with two of distal junctional fractures and one of proximal junctional kyphosis and screw loosening. However, there were no complications directly related to the operation. @*Conclusion@#: PVCR through the controlled distraction-compression technique using ETC showed safe and good results in terms of complications, and clinical and radiologic outcomes in PTK. However, to further evaluate the efficacy of this surgical procedure, more patients need long-term follow-up and there is a need to apply it to other diseases.
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Objective@#Gait impairment reduces a patient’s quality of life. Exoskeletons and wearable robotics enable patients with gait disturbance to stand up and walk. An exoskeleton was developed for use in patients with stroke and spinal cord injuries. This study aimed to evaluate the effectiveness of overground exoskeleton-assisted gait training (OEGT) in spine diseases with gait disturbance. @*Methods@#This was a single-group preliminary study. Five participants with gait disorders because of root dysfunction accompanying spinal stenosis were included in this study. All participants underwent surgical treatment and an exoskeleton training protocol scheduled for 2 or 3 days per week for 4 weeks. Each session was 60 minutes. Clinical tests were performed before (T1) and at the end of the training (T2). @*Results@#One patient dropped out of the study because of medical issues that were not associated with the exoskeleton. Exoskeleton-assisted rehabilitation was feasible for all participants. All participants showed positive changes in gait performance, balance, proximal muscle strength, psychological state, and satisfaction with the rehabilitation. However, there was no significant improvement in neurological deficits. @*Conclusion@#OEGT is a feasible rehabilitation method for patients with gait disorders caused by degenerative spinal disease.
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Purpose@#To systematically compare the performance of liver imaging reporting and data system treatment response (LR-TR) with the modified Response Evaluation Criteria in Solid Tumors (mRECIST) for diagnosing viable hepatocellular carcinoma (HCC) treated with locoregional therapy (LRT). @*Materials and Methods@#Original studies of intra-individual comparisons between the diagnostic performance of LR-TR and mRECIST using dynamic contrast-enhanced CT or MRI were searched in MEDLINE and EMBASE, up to August 25, 2021. The reference standard for tumor viability was surgical pathology. The meta-analytic pooled sensitivity and specificity of the viable category using each criterion were calculated using a bivariate random-effects model and compared using bivariate meta-regression. @*Results@#For five eligible studies (430 patients with 631 treated observations), the pooled per-lesion sensitivities and specificities were 58% (95% confidence interval [CI], 45%–70%) and 93% (95% CI, 88%–96%) for the LR-TR viable category and 56% (95% CI, 42%–69%) and 86% (95% CI, 72%–94%) for the mRECIST viable category, respectively. The LR-TR viable category provided significantly higher pooled specificity (p < 0.01) than the mRECIST but comparable pooled sensitivity (p = 0.53). @*Conclusion@#The LR-TR algorithm demonstrated better specificity than mRECIST, without a significant difference in sensitivity for the diagnosis of pathologically viable HCC after LRT.
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Objective@#We aimed to evaluate the usefulness of arterial subtraction images for predicting the viability of hepatocellular carcinoma (HCC) after locoregional therapy (LRT) using gadoxetic acid-enhanced MRI and the Liver Imaging Reporting and Data System treatment response (LR-TR) algorithm. @*Materials and Methods@#This study included 90 patients (mean age ± standard deviation, 57 ± 9 years) who underwent liver transplantation or resection after LRT and had 73 viable and 32 nonviable HCCs. All patients underwent gadoxetic acid-enhanced MRI before surgery. Two radiologists assessed the presence of LR-TR features, including arterial phase hyperenhancement (APHE) and LR-TR categories (viable, nonviable, or equivocal), using ordinary arterial-phase and arterial subtraction images. The reference standard for tumor viability was surgical pathology. The sensitivity of APHE for diagnosing viable HCC was compared between ordinary arterial-phase and arterial subtraction images. The sensitivity and specificity of the LR-TR algorithm for diagnosing viable HCC was compared between the use of ordinary arterial-phase and the use of arterial subtraction images.Subgroup analysis was performed on lesions treated with transarterial chemoembolization (TACE) only. @*Results@#The sensitivity of APHE for viable HCCs was higher for arterial subtraction images than ordinary arterial-phase images (71.2% vs. 47.9%; p 0.999). In a subgroup of 63 lesions treated with TACE only, the use of arterial subtraction images showed a significant increase in sensitivity (81.4% [35/43] vs. 67.4% [29/43]; p = 0.031) without significant decrease in specificity (85.0% [17/20] vs. 90.0% [18/20]; p > 0.999). @*Conclusion@#Use of arterial subtraction images compared with ordinary arterial-phase images improved the sensitivity while maintaining specificity for diagnosing viable HCC after LRT using gadoxetic acid-enhanced MRI and the LR-TR algorithm.
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Background@#Altered level of consciousness (ALC) is a challenging condition in the emergency department (ED). We evaluated the clinical characteristics, causes, and prognosis of adult patients presenting with ALC at an ED of a university hospital. @*Methods@#The medical records of patients with ALC who visited the ED of a university hospital from February 2019 to November 2020 were reviewed to compare before and after the outbreak of coronavirus disease-19 (COVID-19) in Daegu, South Korea. The cause of ALC, its classification, the patients’ destinations, and prognosis were carefully decided and compared. @*Results@#A total of 1,851 patients with ALC in ED consisted of 1,068 before COVID-19 (BC; to February 17th, 2020) and 783 after COVID-19 (AC; from February 18th, 2020) were investigated. The all-time leading cause of ALC in ED was systemic infection (29.2% in BC, 25.0% in AC), followed by metabolic cause (21.0%) in BC and stroke (18.4%) in AC. Extra-cerebral etiologies of ALC were 1,206 (65.1%). The overall mortality of ALC in ED was 12.3%, consisting of 11.0% in BC and 14.2% in AC. During the daytime (07:00 to 18:59), patients in overall 1,179 patients (63.7%) with ALC visited ED, consisted of 665 (62.3%) in BC and 514 (65.5%) in AC. @*Conclusions@#This study demonstrated the extra-cerebral etiologies as the major causes of ALC in the ED. And there have been shifts in the etiology of ALC in ED.
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Fractures in patients with osteoporosis are attributable to falls and reduced bone mass. Therefore, balance and muscle strength should be improved and bone mass should be increased to prevent fractures. This study aims to investigate a rehabilitation treatment for osteoporosis. Exercise is a potentially safe and effective way to increase bone density and prevent postmenopausal bone loss. Based on bone densitometry results, rehabilitation exercises can be applied variably. Fractures caused by osteoporotic fragility may be prevented with multidisciplinary intervention programs including education, environmental modifications, aids, and individually tailored exercise programs. In addition, strengthening the paraspinal muscles may not only maintain bone mineral density but also reduce the risk of vertebral fractures. Rehabilitation after vertebral fractures includes proprioceptive dynamic posture training that decreases kyphotic posturing through the recruitment of back extensors. This training reduces pain, improves mobility, and leads to a better quality of life. Hip fractures may be prevented by hip protectors and exercise programs that can improve the strength and mobility of patients with hip fractures. Considering the musculoskeletal condition, the spine should be protected using a spinal orthosis, taping, hip pad, and walking aid, if necessary. Efforts to activate programs such as fracture liaison services should also be considered.
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Purpose@#We evaluated the diagnostic performance of LI-RADS version 2018 using gadoxetic acid enhanced MRI for recurrent but untreated HCC in patients with prior history of HCC. @*Materials and Methods@#We enrolled 50 consecutive patients who 1) prior history of treatment of HCC, 2) underwent liver surgery for radiological/clinical diagnosis of new HCC between 2013 to 2018, 3) had gadoxetic acid enhanced MRI within one month before surgery, and 4) did not have more than five HCCs or infiltrative tumors only. Two radiologists reviewed MRI and determined the presence of LR3, LR4 and LR5 observations except previously treated tumors based on LI-RADS version 2018 in consensus. We sub-classified LR4 into LR4m (LR4 with major features only) and LR4u (LR4 upgraded from LR3 by ancillary features). LR4u were further sub-classified into LR4ua (with arterial phase hyperenhancement) and LR4un (without arterial phase hyperenhancement). @*Results@#PPV for LR5, LR4 and LR3 observations for recurrent HCC were 100%, 61.5% and 25.0%, respectively. 100% (3/3) of LR4m were HCC. However, PPV of LR4u was 56.5%. PPV of LR4ua and LR4un were 73.3% and 25.0%, respectively. Sensitivity of LR5 and LR5+LR4 observations as a diagnostic threshold were 32.1% and 89.3%, respectively. Sensitivity for LR5+LR4m+LR4ua observations for diagnosis of HCC were 83.7% and significantly superior to that of LR5 without significant deterioration of specificity (75.0%). @*Conclusion@#In patients with prior history of HCC, LR4 observations by major features or with APHE may be regarded as recurrent HCCs given high sensitivity and comparable specificity/PPV to LR5 observations.
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Background@#The best treatment for isolated greater tuberosity (GT) fractures is still controversial. Although previous studies have suggested surgical options, they are either unable to provide firm fixation or present with a variety of complications. @*Methods@#We retrospectively studied the records of patients with isolated GT fractures who underwent open reduction and internal fixation using a 3.5-mm locking hook plate between January 2016 and January 2018. The surgical indication was an at least 5-mm displacement of the GT as observed in either simple radiography or three-dimensional computed tomography. Clinical outcomes were assessed using the following five parameters shortly before implant removal and at the final follow-up: visual analog scale (VAS) pain score, American Shoulder and Elbow Surgeons (ASES) score, Shoulder Rating Scale of the University of California, Los Angeles (UCLA), Constant-Murley score, and range of motion. @*Results@#Twenty-one patients with a mean age of 64 years were included. Bone union was achieved within 12–20 weeks of the first surgery in all patients. Implant removal was performed between 13 and 22 weeks after surgery. At the final follow-up, the mean VAS pain score, forward flexion, abduction, external rotation, internal rotation, ASES score, UCLA score, and ConstantMurley score were significantly better when compared to outcomes shortly before implant removal (p < 0.001, p < 0.001, p < 0.001, p = 0.008, p = 0.003, p < 0.001, p < 0.001, and p < 0.001, respectively). @*Conclusions@#The 3.5-mm locking hook plate provided sufficient stability and led to satisfactory clinical and radiological outcomes for isolated GT fractures. However, the hook plate may irritate the rotator cuff, and postoperative stiffness may be inevitable.Therefore, second surgery for implant removal is necessary after bone union is achieved.
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Objective@#The incidence of hip fractures is increasing worldwide with the aging population, causing a challenge to healthcare systems due to the associated morbidities and high risk of mortality. After hip fractures in frail geriatric patients, existing comorbidities worsen and new complications are prone to occur. Comprehensive rehabilitation is essential for promoting physical function recovery and minimizing complications, which can be achieved through a multidisciplinary approach. Recommendations are required to assist healthcare providers in making decisions on rehabilitation post-surgery. Clinical practice guidelines regarding rehabilitation (physical and occupational therapies) and management of comorbidities/complications in the postoperative phase of hip fractures have not been developed. This guideline aimed to provide evidence-based recommendations for various treatment items required for proper recovery after hip fracture surgeries. Methods Reflecting the complex perspectives associated with rehabilitation post-hip surgeries, 15 key questions (KQs) reflecting the complex perspectives associated with post-hip surgery rehabilitation were categorized into four areas: multidisciplinary, rehabilitation, community-care, and comorbidities/complications. Relevant literature from four databases (PubMed, EMBASE, Cochrane Library, and KoreaMed) was searched for articles published up to February 2020. The evidence level and recommended grade were determined according to the grade of recommendation assessment, development, and evaluation method. Results A multidisciplinary approach, progressive resistance exercises, and balance training are strongly recommended. Early ambulation, weigh-bearing exercises, activities of daily living training, community-level rehabilitation, management of comorbidities/complication prevention, and nutritional support were also suggested. This multidisciplinary approach reduced the total healthcare cost. @*Conclusion@#This guideline presents comprehensive recommendations for the rehabilitation of adult patients after hip fracture surgery.
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Objective@#We aimed to evaluate the usefulness of arterial subtraction images for predicting the viability of hepatocellular carcinoma (HCC) after locoregional therapy (LRT) using gadoxetic acid-enhanced MRI and the Liver Imaging Reporting and Data System treatment response (LR-TR) algorithm. @*Materials and Methods@#This study included 90 patients (mean age ± standard deviation, 57 ± 9 years) who underwent liver transplantation or resection after LRT and had 73 viable and 32 nonviable HCCs. All patients underwent gadoxetic acid-enhanced MRI before surgery. Two radiologists assessed the presence of LR-TR features, including arterial phase hyperenhancement (APHE) and LR-TR categories (viable, nonviable, or equivocal), using ordinary arterial-phase and arterial subtraction images. The reference standard for tumor viability was surgical pathology. The sensitivity of APHE for diagnosing viable HCC was compared between ordinary arterial-phase and arterial subtraction images. The sensitivity and specificity of the LR-TR algorithm for diagnosing viable HCC was compared between the use of ordinary arterial-phase and the use of arterial subtraction images.Subgroup analysis was performed on lesions treated with transarterial chemoembolization (TACE) only. @*Results@#The sensitivity of APHE for viable HCCs was higher for arterial subtraction images than ordinary arterial-phase images (71.2% vs. 47.9%; p 0.999). In a subgroup of 63 lesions treated with TACE only, the use of arterial subtraction images showed a significant increase in sensitivity (81.4% [35/43] vs. 67.4% [29/43]; p = 0.031) without significant decrease in specificity (85.0% [17/20] vs. 90.0% [18/20]; p > 0.999). @*Conclusion@#Use of arterial subtraction images compared with ordinary arterial-phase images improved the sensitivity while maintaining specificity for diagnosing viable HCC after LRT using gadoxetic acid-enhanced MRI and the LR-TR algorithm.
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Background@#Altered level of consciousness (ALC) is a challenging condition in the emergency department (ED). We evaluated the clinical characteristics, causes, and prognosis of adult patients presenting with ALC at an ED of a university hospital. @*Methods@#The medical records of patients with ALC who visited the ED of a university hospital from February 2019 to November 2020 were reviewed to compare before and after the outbreak of coronavirus disease-19 (COVID-19) in Daegu, South Korea. The cause of ALC, its classification, the patients’ destinations, and prognosis were carefully decided and compared. @*Results@#A total of 1,851 patients with ALC in ED consisted of 1,068 before COVID-19 (BC; to February 17th, 2020) and 783 after COVID-19 (AC; from February 18th, 2020) were investigated. The all-time leading cause of ALC in ED was systemic infection (29.2% in BC, 25.0% in AC), followed by metabolic cause (21.0%) in BC and stroke (18.4%) in AC. Extra-cerebral etiologies of ALC were 1,206 (65.1%). The overall mortality of ALC in ED was 12.3%, consisting of 11.0% in BC and 14.2% in AC. During the daytime (07:00 to 18:59), patients in overall 1,179 patients (63.7%) with ALC visited ED, consisted of 665 (62.3%) in BC and 514 (65.5%) in AC. @*Conclusions@#This study demonstrated the extra-cerebral etiologies as the major causes of ALC in the ED. And there have been shifts in the etiology of ALC in ED.
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Fractures in patients with osteoporosis are attributable to falls and reduced bone mass. Therefore, balance and muscle strength should be improved and bone mass should be increased to prevent fractures. This study aims to investigate a rehabilitation treatment for osteoporosis. Exercise is a potentially safe and effective way to increase bone density and prevent postmenopausal bone loss. Based on bone densitometry results, rehabilitation exercises can be applied variably. Fractures caused by osteoporotic fragility may be prevented with multidisciplinary intervention programs including education, environmental modifications, aids, and individually tailored exercise programs. In addition, strengthening the paraspinal muscles may not only maintain bone mineral density but also reduce the risk of vertebral fractures. Rehabilitation after vertebral fractures includes proprioceptive dynamic posture training that decreases kyphotic posturing through the recruitment of back extensors. This training reduces pain, improves mobility, and leads to a better quality of life. Hip fractures may be prevented by hip protectors and exercise programs that can improve the strength and mobility of patients with hip fractures. Considering the musculoskeletal condition, the spine should be protected using a spinal orthosis, taping, hip pad, and walking aid, if necessary. Efforts to activate programs such as fracture liaison services should also be considered.
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Purpose@#We evaluated the diagnostic performance of LI-RADS version 2018 using gadoxetic acid enhanced MRI for recurrent but untreated HCC in patients with prior history of HCC. @*Materials and Methods@#We enrolled 50 consecutive patients who 1) prior history of treatment of HCC, 2) underwent liver surgery for radiological/clinical diagnosis of new HCC between 2013 to 2018, 3) had gadoxetic acid enhanced MRI within one month before surgery, and 4) did not have more than five HCCs or infiltrative tumors only. Two radiologists reviewed MRI and determined the presence of LR3, LR4 and LR5 observations except previously treated tumors based on LI-RADS version 2018 in consensus. We sub-classified LR4 into LR4m (LR4 with major features only) and LR4u (LR4 upgraded from LR3 by ancillary features). LR4u were further sub-classified into LR4ua (with arterial phase hyperenhancement) and LR4un (without arterial phase hyperenhancement). @*Results@#PPV for LR5, LR4 and LR3 observations for recurrent HCC were 100%, 61.5% and 25.0%, respectively. 100% (3/3) of LR4m were HCC. However, PPV of LR4u was 56.5%. PPV of LR4ua and LR4un were 73.3% and 25.0%, respectively. Sensitivity of LR5 and LR5+LR4 observations as a diagnostic threshold were 32.1% and 89.3%, respectively. Sensitivity for LR5+LR4m+LR4ua observations for diagnosis of HCC were 83.7% and significantly superior to that of LR5 without significant deterioration of specificity (75.0%). @*Conclusion@#In patients with prior history of HCC, LR4 observations by major features or with APHE may be regarded as recurrent HCCs given high sensitivity and comparable specificity/PPV to LR5 observations.
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Objective@#To determine whether changes in the transiting nerve rootlet or its surroundings, as seen on MRI performed after lumbar hemilaminectomy, are associated with persistent postoperative pain (PPP), commonly known as the failed back surgery syndrome. @*Materials and Methods@#Seventy-three patients (mean age, 61 years; 43 males and 30 females) who underwent single-level partial hemilaminectomy of the lumbar spine without postoperative complications or other level spinal abnormalities between January 2010 and December 2018 were enrolled. Two musculoskeletal radiologists evaluated transiting nerve rootlet abnormalities (thickening, signal alteration, distinction, and displacement), epidural fibrosis, and intrathecal arachnoiditis on MRI obtained one year after the operations. A spine surgeon blinded to the radiologic findings evaluated each patient for PPP. Univariable and multivariable analyses were used to evaluate the association between the MRI findings and PPP. @*Results@#The presence of transiting nerve rootlet thickening, signal alteration, and ill-distinction was significantly different between the patients with PPP and those without, for both readers (p ≤ 0.020). Conversely, the presence of transiting nerve rootlet displacement, epidural fibrosis, and intrathecal arachnoiditis was not significantly different between the two groups (p ≥ 0.128). Among the above radiologic findings, transiting nerve rootlet thickening and signal alteration were the most significant findings in the multivariable analyses (p ≤ 0.009). @*Conclusion@#On MRI, PPP was associated with transiting nerve rootlet abnormalities, including thickening, signal alterations, and ill-distinction, but was not associated with epidural fibrosis or intrathecal arachnoiditis. The most relevant findings were the nerve rootlet thickening and signal alteration.
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Objective@#: Intraoperative neurophysiological monitoring (IONM) has been widely used during spine surgery to reduce or prevent neurologic deficits, however, its application to the surgical management for cervical myelopathy remains controversial. This study aimed to assess the success rate of IONM in patients with cervical myelopathy and to investigate the factors associated with successful baseline monitoring and the effect of increasing the stimulation intensity by focusing on motor evoked potentials (MEPs). @*Methods@#: The data of 88 patients who underwent surgery for cervical myelopathy with IONM between January 2016 and June 2018 were retrospectively reviewed. The success rate of baseline MEP monitoring at the initial stimulation of 400 V was investigated. In unmonitorable cases, the stimulation intensity was increased to 999 V, and the success rate final MEP monitoring was reinvestigated. In addition, factors related to the success rate of baseline MEP monitoring were investigated using independent t-test, Wilcoxon rank-sum test, chi-squared test, and Fisher’s exact probability test for statistical analysis. The factors included age, sex, body mass index, diabetes mellitus, smoking history, symptom duration, Torg-Pavlov ratio, space available for the cord (SAC), cord compression ratio (CCR), intramedullary increased signal intensity (SI) on magnetic resonance imaging, SI length, SI ratio, the Medical Research Council (MRC) grade, the preoperative modified Nurick grade and Japanese Orthopedic Association (JOA) score. @*Results@#: The overall success rate for reliable MEP response was 52.3% after increasing the stimulation intensity. No complications were observed to be associated with increased intensity. The factors related to the success rate of final MEP monitoring were found to be SAC (p<0.001), CCR (p<0.001), MRC grade (p<0.001), preoperative modified Nurick grade (p<0.001), and JOA score (p<0.001). The cut-off score for successful MEP monitoring was 5.67 mm for SAC, 47.33% for the CCR, 3 points for MRC grade, 2 points for the modified Nurick grade, and 12 points for the JOA score. @*Conclusion@#: Increasing the stimulation intensity could significantly improve the success rate of baseline MEP monitoring for unmonitorable cases at the initial stimulation in cervical myelopathy. In particular, the SAC, CCR, MRC grade, preoperative Nurick grade and JOA score may be considered as the more important related factors associated with the success rate of MEP monitoring. Therefore, the degree of preoperative neurological functional deficits and the presence of spinal cord compression on imaging could be used as new detailed criteria for the application of IONM in patients with cervical myelopathy.