Lumbar Interbody Fusion and Osteobiologics for Lumbar Fusion

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

Osteoid Osteoma of the Sacrum: A Case Report

OBJECTIVES@#To report a case of osteoid osteoma arising in the sacrum in a 29-year-old male patient.SUMMARY OF LITERATURE REVIEW: Osteoid osteoma is a benign osteoblastic tumor that usually arises in the long bones. Osteoid osteoma involving the sacrum is extremely rare.@*MATERIALS AND METHODS@#A 29-year-old male patient presented with pain localized in his sacral area for 10 months. His pain was worse at night, relieved by non-steroidal anti-inflammatory drugs, and independent of physical activity. Bone scintigraphy showed increased uptake in the second sacral vertebra (S2). Computed tomography revealed a nidus located in the S2 spinous process. Magnetic resonance imaging showed bone and soft tissue edema around the nidus.@*RESULTS@#En bloc excision including the nidus revealed a diagnosis of osteoid osteoma and provided immediate relief of the patient's long-lasting sacral pain.@*CONCLUSIONS@#When a young patient presents with localized sacral pain that is worse at night, relieved by non-steroidal anti-inflammatory drugs, independent of physical activity, and lasts longer than expected, proper imaging studies should be performed to rule out osteoid osteoma. Although less invasive treatment modalities have been introduced, classical en bloc excision is currently the gold standard for managing osteoid osteoma.

Osteoid Osteoma of the Sacrum: A Case Report / 대한척추외과학회지

STUDY DESIGN: Case report.OBJECTIVES: To report a case of osteoid osteoma arising in the sacrum in a 29-year-old male patient.SUMMARY OF LITERATURE REVIEW: Osteoid osteoma is a benign osteoblastic tumor that usually arises in the long bones. Osteoid osteoma involving the sacrum is extremely rare.MATERIALS AND METHODS: A 29-year-old male patient presented with pain localized in his sacral area for 10 months. His pain was worse at night, relieved by non-steroidal anti-inflammatory drugs, and independent of physical activity. Bone scintigraphy showed increased uptake in the second sacral vertebra (S2). Computed tomography revealed a nidus located in the S2 spinous process. Magnetic resonance imaging showed bone and soft tissue edema around the nidus.RESULTS: En bloc excision including the nidus revealed a diagnosis of osteoid osteoma and provided immediate relief of the patient's long-lasting sacral pain.CONCLUSIONS: When a young patient presents with localized sacral pain that is worse at night, relieved by non-steroidal anti-inflammatory drugs, independent of physical activity, and lasts longer than expected, proper imaging studies should be performed to rule out osteoid osteoma. Although less invasive treatment modalities have been introduced, classical en bloc excision is currently the gold standard for managing osteoid osteoma.

Acute Lumbar Paraspinal Compartment Syndrome after Weightlifting: A Case Report

OBJECTIVES@#To report 2 cases of acute lumbar paraspinal compartment syndrome due to weightlifting.SUMMARY OF LITERATURE REVIEW: Acute lumbar paraspinal compartment syndrome is very rare, but it causes muscle necrosis and acute renal failure. Therefore, it should be treated immediately.@*MATERIALS AND METHODS@#A 31-year-old male patient and a 30-year-old male patient visited the emergency room due to severe back pain. The left paraspinal compartment pressure of the 31-year-old patient was measured as 35 mm Hg using the Whitesides technique. The paraspinal compartment pressure of the 30-year-old patient was measured as 22 mm Hg on the left side and 30 mm Hg on the right side. We diagnosed acute lumbar paraspinal compartment syndrome and performed a fasciotomy. This study received Institutional Review Board approval (ID: SC18ZESE0032).@*RESULTS@#Lab findings improved after fasciotomy. The operative wounds healed after fasciocutaneous flap placement.@*CONCLUSIONS@#Acute lumbar paraspinal compartment syndrome is very rare, but should be considered in patients with severe back pain.

Acute Lumbar Paraspinal Compartment Syndrome after Weightlifting: A Case Report / 대한척추외과학회지

STUDY DESIGN: Case report. OBJECTIVES: To report 2 cases of acute lumbar paraspinal compartment syndrome due to weightlifting. SUMMARY OF LITERATURE REVIEW: Acute lumbar paraspinal compartment syndrome is very rare, but it causes muscle necrosis and acute renal failure. Therefore, it should be treated immediately. MATERIALS AND METHODS: A 31-year-old male patient and a 30-year-old male patient visited the emergency room due to severe back pain. The left paraspinal compartment pressure of the 31-year-old patient was measured as 35 mm Hg using the Whitesides technique. The paraspinal compartment pressure of the 30-year-old patient was measured as 22 mm Hg on the left side and 30 mm Hg on the right side. We diagnosed acute lumbar paraspinal compartment syndrome and performed a fasciotomy. This study received Institutional Review Board approval (ID: SC18ZESE0032). RESULTS: Lab findings improved after fasciotomy. The operative wounds healed after fasciocutaneous flap placement. CONCLUSIONS: Acute lumbar paraspinal compartment syndrome is very rare, but should be considered in patients with severe back pain.

Screening for Depressive Disorder in Elderly Patients with Chronic Physical Diseases Using the Patient Health Questionnaire-9

OBJECTIVE: We aimed to identify depressive symptom profiles that indicated the presence of depressive disorder and present optimal cut-off sub-scores for depressive symptom profiles for detecting depressive disorder in elderly subjects with chronic physical diseases including diabetes, chronic obstructive pulmonary disease/asthma, and coronary artery disease, using the Patient Health Questionnaire-9 (PHQ-9). METHODS: Two hundred and thirty-one elderly patients with chronic physical diseases were recruited consecutively from a university-affiliated general hospital in South Korea. RESULTS: Greater severities of all 9 depressive symptoms in the PHQ-9 were presented in those with depressive disorder rather than those without depressive disorder. A binary logistic regression modeling presented that little interest [adjusted odds ratio (aOR)=4.648, p<0.001], reduced/increased sleep (aOR=3.269, p<0.001), psychomotor retardation/agitation (aOR=2.243, p=0.004), and concentration problem (aOR=16.116, p<0.001) were independently associated with increased likelihood of having depressive disorder. Receiver operating characteristics (ROC) curve analysis presented that the optimal cut-off value of score on the items for little interest, reduced/increased sleep, psychomotor retardation/agitation and concentration problem (PHQ-9) for detecting depressive disorder was 4 with 61.9% of sensitivity and 91.5% of specificity [area under curve (AUC)=0.937, p<0.001]. CONCLUSION: Our findings suggested that the diagnostic weighting of little interest, reduced/increased sleep, psychomotor retardation/agitation, and concentration problem is needed to detect depressive disorder among the elderly patients with chronic physical diseases.

Current Status and Corresponding Strategy of Transplant Tourism / 대한이식학회지

Transplant tourism (TT) has developed into a global concern for international organizations, transplant communities, researchers, and the press. Increasing the knowledge of organ trafficking and TT is essential to raise awareness and prepare responses that will prevent the occurrence of illicit organ transplantation through TT. This review article describes the current status and legal framework of international organ trafficking and TT. Collection and analysis of data concerning TT from national and international registries will provide the best estimates of global activities, which are necessary to develop an appropriate local and worldwide collaborative response to organ trafficking and TT. International collaboration and multifaceted strategies are needed to address the complex challenges of TT.

Preliminary Examination for Apoptosis and Cell Proliferation Related to Aging Process in the Anterior Cruciate Ligament Cells of the Human Degenerative Arthritic Knee Joint / 대한정형외과학회잡지

PURPOSE: We investigated the association between aging-induced apoptosis and cell proliferation in the anterior cruciate ligament (ACL) of aged patients. MATERIALS AND METHODS: Twenty patients with osteoarthritis who underwent total knee replacement arthroplasty were enrolled in the study. They were divided into three groups according to age: group A ( or =76 years). The ACL tissue was obtained intraoperatively and subjected to terminal deoxynucleotidyl transferase dUTP nick-end labeling staining and immunohistochemistry to quantify the apoptosis and cell proliferation indices. RESULTS: Apoptosis occurred in all groups, with the highest apoptosis index found in group C, followed by that in groups B and A. A statistically significant positive linear correlation was observed, with a 1-year increase in age resulting in an average increase of 1.49 in the apoptotic index. The lowest cell proliferation index was observed in group C, followed by that in group B and group A, with a 1-year increase in age resulting in an average decrease of 1.0 in the cell proliferation index, which was a statistically significant negative linear correlation. Consequently, a statistically significant negative correlation was confirmed between the apoptosis and cell proliferation indices, whereby an increase of 1.0 in the apoptosis index was concurrent with a decrease of 0.45 in the cell proliferation index. CONCLUSION: Apoptosis occurred in the ACL of human knee joint. With increasing age, apoptosis increased and cell proliferation decreased.

Comparisons of Depressive Symptoms of the Hamilton Depression Rating Scale between Elderly and Non-Elderly Outpatients with Major Depressive Disorder / 신경정신의학

OBJECTIVES: Previous studies have reported that symptoms of patients with major depressive disorder (MDD) are different according to age groups, and the Hamilton Depression Rating Scale (HDRS) is the most widely used measure to evaluate the symptoms of MDD. However, few previous studies have compared the symptoms of HDRS between the elderly and non-elderly groups. METHODS: The study population consisted of 574 subjects with MDD who were > or =18 years old, evaluated using the Mini International Neuropsychiatric Interview and 17 items of HDRS. Differences between two groups were analyzed using independent t-test. A multivariate logistic regression model was used to evaluate associations between age and 17 items from HDRS after controlling for gender, years of education, marital status, and employment status. RESULTS: Among 574 patients with MDD, there were 80 elderly patients (age> or =65) and 494 non-elderly patients (age between 18 and 64). Elderly patients had higher scores on item 5 (middle insomnia) (t=-2.271, p=0.024) and item 6 (late insomnia) (t=-2.280, p=0.023), whereas they had lower scores on item 1 (depressed mood) (t=2.860, p=0.004), item 3 (suicide) (t=2.258, p=0.024), and item 9 (agitation) (t=2.031, p=0.043), although no significant difference in the total HDRS scores was observed between elderly and non-elderly. Multivariate logistic regression showed significant association of elderly with hypochondriasis [adjusted odds ratio (AOR)=1.894, 95% confidence interval (CI) 1.01-3.56] and agitation (AOR=0.50, 95% CI 0.29-0.87). CONCLUSION: Elderly MDD patients showed more insomnia and hypochondriasis and less depressed mood, suicidal ideation, and agitation than non-elderly.

A comparison of dimensional standard of several nickel-titanium rotary files

OBJECTIVES: The aim of this study was to compare the dimensional standard of several nickel-titanium (Ni-Ti) rotary files and verify the size conformity. MATERIALS AND METHODS: ProFile (Dentsply Maillefer), RaCe (FKG Dentaire), and TF file (SybronEndo) #25 with a 0.04 and 0.06 taper were investigated, with 10 in each group for a total of 60 files. Digital images of Ni-Ti files were captured under light microscope (SZX16, Olympus) at 32x. Taper and diameter at D1 to D16 of each files were calculated digitally with AnalySIS TS Materials (OLYMPUS Soft Imaging Solutions). Differences in taper, the diameter of each level (D1 to D16) at 1 mm interval from (ANSI/ADA) specification No. 101 were statistically analyzed using one-way ANOVA and Scheffe's post-hoc test at 95% confidence level. RESULTS: TF was the only group not conform to the nominal taper in both tapers (p < 0.05). All groups except 0.06 taper ProFile showed significant difference from the nominal diameter (p < 0.05). CONCLUSIONS: Actual size of Ni-Ti file, especially TF, was different from the manufacturer's statements.

Psychosocial, Physical, and Autonomic Correlates of Depression in Korean Adults: Results from a County-Based Depression Screening Study

OBJECTIVE: We aimed to investigate the prevalence and psychosocial and neurophysiological correlates of depression in a large county-based cohort of Korean adults. METHODS: We recruited 2355 adults from a rural county-based health promotion program. The following psychometric scales were used: the Center for Epidemiologic Studies Depression scale (CES-D) was used to assess depression, the General Health Questionnaire (GHQ) was used to evaluate stress, and the Medical Outcome Study Social Support Survey (MOS-SSS) was used to determine perceived social support. Heart rate variability (HRV) was used to assess neurophysiological properties. The psychosocial and neurophysiological variables of adults with depression (CES-D score > or =25) and without depression (CES-D score <25) were statistically compared. A logistic regression model was constructed to identify factors independently associated with depression. RESULTS: We estimated that 17.7% of the subjects had depression, which was associated with old age, being female, being single, less religious affiliation, high education, low body mass index (BMI), low levels of aerobic exercise, low social support, and a low HRV triangular index. The explanatory factors of depression included high education, less religious affiliation, low levels of current aerobic exercise, low BMI, and low social support. CONCLUSION: Given the relatively high prevalence of overall depression, subsyndromal depression should also be regarded as an important issue in screening. The independent factors associated with depression suggest that practical psychosocial intervention, including brief psychotherapy, aerobic exercise, and other self-help methods should be considered. In addition, the HRV results suggest that further depression screening accompanied by neurophysiological features would require fine methodological modifications with proactive efforts to prevent depressive symptoms.

Neurobiology of Aggression

Aggression can be defined as 'behavior intended to harm another' which can be seen both from humans and animals. However, trying to understand aggression in a simplistic view may make it difficult to develop an integrated approach. So, we tried to explain aggression in a multidisciplinary approach, affected by various factors such as neuroanatomical structures, neurotransmitter, genes, and sex hormone. Parallel with animal models, human aggression can be understood with two phenomena, offensive aggression and defensive aggression. Neurobiological model of aggression give a chance to explain aggression with an imbalance between prefrontal regulatory influences and hyper-reactivity of the subcortical areas involved in affective evaluation, finally in an aspect of brain organization. Serotonin and GABA usually inhibit aggression and norepinephrine while glutamate and dopamine precipitate aggressive behavior. As there is no one gene which has been identified as a cause of aggression, functions between gene to gene interaction and gene to environment interaction are being magnified. Contributions of sex hormone to aggression, especially molecular biologic interaction of testosterone and regulation of estrogen receptor have been emphasized during the research on aggression. This multidisciplinary approach on aggression with types, neurochemical bases, and animal models can bring integrated interpretation on aggression.

Attunement Disorder : A Disorder of Brain Connectivity

OBJECTIVES: We reviewed cellular and synaptic dysconnectivity, disturbances in micro- and macro- circuitries, and neurodevelopmentally-derived disruptions of neural connectivity in the pathogenesis of schizophrenia. METHOD: We reviewed the selected articles about disturbances in neural circuits which had been proposed as a pathogenetic mechanism of schizophrenia. RESULTS: The literature review reveals that schizophrenia may be a disease related to disturbance in neurodevelopmental mechanism, shown as 'a misconnection syndrome of neural circuit or neural network'. In descriptive psychopathological view, definition of a disorder of brain connectivity has limitation to explain other aspects of schizophrenia including deterministic strictness in thought process. CONCLUSION: Schizophrenia is considered as a disorder of brain connectivity as well as a neurodevelopmental disorder related with genetic and environmental factors. We could make a suggestion that "JoHyeonByung (attunement disorder)" denotes the disturbances of psychic fine-tuning which correspond to the neural correlates of brain dysconnectivity metaphorically.

Discrimination between Benign and Malignant Pelvic Masses Using the Risk of Malignancy Index 1 / 대한폐경학회지

OBJECTIVES: To assess the ability of risk of malignancy index (RMI) 1 to discriminate between benign and malignant pelvic masses. METHODS: Between January 2007 and December 2010, 547 women with pelvic masses were evaluated. Their medical records are reviewed here retrospectively. The sensitivity, specificity and positive and negative predictive values of the cancer antigen (CA) 125 level, ultrasound findings and menopausal status in the prediction of malignant pelvic masses were calculated and compared individually or combined using the RMI 1. RESULTS: The receiver operating characteristic (ROC) curves of CA 125, the ultrasound score and the RMI 1 were all found to be relevant predictors of malignancy. ROC analysis of the RMI 1, CA 125 serum levels, ultrasound score and menopausal status showed areas under the curves of 0.795, 0.782, 0.784 and 0.594, respectively. The RMI 1 was found to be statistically significantly correlated with menopausal status (P = 0.001), while not statistically significantly correlated with CA 125 (P = 0.628) or the ultrasound score (P = 0.541). The RMI 1 at a cut-off of 150 - with a sensitivity of 77.9%, specificity of 81.1%, positive predictive value of 51.7% and negative predictive value of 93.4% - showed the highest performance in determining the malignant tendency of pelvic masses. CONCLUSION: Accepting a RMI 1 cut-off value of 150 results in statistically more significant diagnostic criteria than menopausal status for the discrimination of benign and malignant pelvic masses.

A Case of Q Fever that may Mimic Systemic Lupus Erythematosus

Q fever is a zoonosis caused by a Coxiella burnetii. Q fever is clinically variable, presenting as asymptomatic infection, pneumonia, hepatitis and endocarditis. Treatment of acute Q fever with doxycycline is usually successful. Autoantibodies, such as anti-mitochondrial antibodies, smooth muscle antibodies (SMA), anti-cardiolipin and lupus anticoagulant, often rise in acute Q fever infection. Some cases may occasionally meet the criteria for autoimmune disease like systemic lupus erythematosus. We report a first case of Q fever that may mimic systemic lupus erythematosus in Korea.

A Case of Q Fever that may Mimic Systemic Lupus Erythematosus

Q fever is a zoonosis caused by a Coxiella burnetii. Q fever is clinically variable, presenting as asymptomatic infection, pneumonia, hepatitis and endocarditis. Treatment of acute Q fever with doxycycline is usually successful. Autoantibodies, such as anti-mitochondrial antibodies, smooth muscle antibodies (SMA), anti-cardiolipin and lupus anticoagulant, often rise in acute Q fever infection. Some cases may occasionally meet the criteria for autoimmune disease like systemic lupus erythematosus. We report a first case of Q fever that may mimic systemic lupus erythematosus in Korea.

Causes of Late Revision Surgery after Bone Cement Augmentation in Osteoporotic Vertebral Compression Fractures

STUDY DESIGN: A retrospective study. PURPOSE: To elucidate the causes of late revision following bone cement augmentation for osteoporotic vertebral compression fractures (OVCFs). OVERVIEW OF LITERATURE: Percutaneous vertebroplasty (PVP) or kyphoplasty (KP) is thought to be effective for the treatment of OVCFs. Many complications related to PVP or KP have been reported. However, there is a paucity of reports regarding the causes of late revision surgery after failed PVP or KP. METHODS: Twenty six patients who developed unremitted back pain and/or progressive neurological deficit after a symptom-free period since treatment with PVP or KP were enrolled. All patients underwent cement removal and anterior reconstruction. Among the 26 patients, 22 patients underwent anterior interbody fusion combined with posterior instrumentation; 4 patients underwent anterior reconstruction only. The causes of revision surgery were assessed. Clinical results were assessed using a visual analogue scale (VAS) and Oswestry Disability Index (ODI). The complications were analyzed. RESULTS: The average time to revision surgery was 18.9+/-14.6 months (range, 3-78 months). The causes of late revision surgery included 6 late infections, 8 progressive kyphoses, 10 proximal fractures after instrumented lumbar fusions, and 2 late neurological involvement. During the mean follow-up period of 13.5+/-7.8 months, pre-revision mean VAS (8.5+/-0.9) and ODI (81.2+/-12.5) were improved to 4.2+/-1.4 and 54.8+/-17.6, respectively. Five patients (19%) had serious complications after revision surgery. CONCLUSIONS: This study presents complications of PVP or KP in the treatment of OVCFs although PVP or KP can be an effective treatment strategy for OVCF when applied in highly selected patients.

A Nation-Wide, Outpatient-Based Survey on the Pain, Disability, and Satisfaction of Patients with Osteoporotic Vertebral Compression Fractures

STUDY DESIGN: A nation-wide, outpatient-based, cross-sectional survey with the use of questionnaires. PURPOSE: To evaluate the pain, disability and satisfaction of patients with osteoporotic vertebral compression fractures (OVCFs). OVERVIEW OF LITERATURE: There are no nation-wide data in Korea on the degree of pain, disability and satisfaction with treatment in patients with OVCFs. METHODS: We performed a cross-sectional survey of 573 patients with OVCFs. After excluding incomplete questionnaires (missing more than 30% of the variables), 430 patient-physician-matched data sets were collected for this survey. RESULTS: Patients with OVCFs were managed with conservative treatment in 63% and with a vertebroplasty in 37%. The means of the latest visual analogue scale (VAS, 5.2) and Oswestry Disability Index (ODI, 47.7) scores checked at the time of survey were significantly higher than those VAS and ODI scores prior to OVCFs (the prefracture VAS and ODI scores, 3.6 and 26.3, respectively; p<0.001 for both comparisons). However, the means of the latest VAS and ODI scores were insignificantly different between the conservative and vertebroplasty groups, irrespective of the duration from the fractures. Overall, 75% of patients were satisfied with their clinical outcomes. However, the percentages of patient's satisfaction were not significantly different between the conservative and vertebroplasty groups. Eighty-eight percent of patients felt some or marked deterioration of their general health condition following OVCFs. CONCLUSIONS: These results indicate that although most patients with OVCFs were satisfied with their clinical outcomes, their subjective general health conditions, as well as their pain and disability, did not recover to the prefracture state.

Insulin Autoimmune Syndrome with Diabetic Ketoacidosis / 임상당뇨병

Insulin autoimmune syndrome is characterized by spontaneous hypoglycemia, elevated insulin level and a high level of insulin autoantibodies without previous insulin exposure. Among the clinical manifestations of insulin autoimmune syndrome, diabetic ketoacidosis is extremely rare. A 72-year-old diabetic woman was hospitalized with diabetic ketoacidosis. She suffered repeated fasting hypoglycemia after treatment of the diabetic ketoacidosis. Here we describe this case of insulin autoimmune syndrome manifested as diabetic ketoacidosis followed by recurrent hypoglycemia with a review of the relevant literature.

Papillary Thyroid Carcinoma Manifesting as an Autonomously Functioning Thyroid Nodule

Hyperfunctioning thyroid carcinoma is very rare. Hence, radionuclide imaging of thyroid hot nodules usually suggests a benign tumor, and less than 4% of cases have been reported as malignant. We would like to present a case of a hyperfunctioning papillary thyroid carcinoma that was initially treated with radioactive iodine. A 58-year-old woman was referred to our hospital for palpable thyroid nodule and a 5-kg weight loss within 6 months. Thyroid function test revealed thyrotoxicosis, and thyroid autoantibodies were absent. 99mTc thyroid scintigraphy showed a 2 x 2 cm-sized hyperactive hot nodule at the left lobe. Despite radioactive iodine treatment with a dose of 10 mCi 131I, thyroid function did not improve. Fine needle aspiration revealed papillary thyroid cancer. The patient underwent total thyroidectomy. Although clinical features and thyroid scans suggest a benign nodule, the possibility of malignancy should not be ruled out. Malignant thyroid hot nodules are rare; however, its possibility should be taken into account. Therefore, we suggest that ruling out malignancy by existing diagnostic guidelines can misdiagnose even a typical case with benign features. As thyroid nodule detection is getting sensitive and accurate, we present this case to discuss whether additional diagnostic approaches would be necessary for thyroid nodules.