Trends in Survival and Surgical Methods in Patients Surgically Treated for Metastatic Spinal Tumors: 25-Year Experience in a Single Institution

Background@#This study aimed to examine trends in postoperative survival and surgical methods over a 25-year period in patients surgically treated for metastatic spinal tumors. @*Methods@#We performed a retrospective study of patients who underwent surgical treatment for metastatic spinal tumors between 1996 and 2020. For trend analysis, the study cohort was divided into three groups according to the year of surgery: 1996– 2004, 2005–2012, and 2013–2020. A Kaplan-Meier survival analysis was performed to examine survival, and the log-rank test was used to compare the survival of the top six common cancers among the periods. The surgical methods were grouped and examined as follows: fixation only, palliative decompression and fixation, gross total removal and fixation, and total en bloc spondylectomy. @*Results@#This study included a total of 608 patients. There were 78 patients in 1996–2004, 236 in 2005–2012, and 294 in 2013– 2020. Regarding the overall survival trend, the group 2013–2020 had a significantly improved survival as compared to the other two groups (p < 0.001). According to specific cancer sites, significant survival improvement was observed in patients with lung, kidney, and breast cancers (p < 0.001, p < 0.001, and p = 0.022, respectively). There were no significant changes in the primary sites of the liver, colorectum, or prostate. Regarding surgical methods, the proportion of gross total tumor removal declined, whereas the proportion of palliative decompression and fixation and fixation only procedures increased. @*Conclusions@#During the past 25 years, significant survival improvement was observed in patients with lung, kidney, and breast cancers. There was no improvement in survival in patients with liver, colorectal, and prostate cancers. In terms of surgical techniques, palliative decompression and fixation only procedures increased, while gross total tumor removal declined

Proximal Junctional Failure after Corrective Surgery: Focusing on Elderly Patients with Severe Sagittal Imbalance

Background@#Previous reports with proximal junctional failure (PJF) included relatively young patients or deformity without sagittal imbalance. The present study focused on the two well-known risk factors for PJF, old age and severe sagittal imbalance. With these high-risk patients, the present study aimed to identify a strategy that could prevent PJF and to investigate whether the degree of correction would really affect the PJF occurrence. @*Methods@#Patients who were ≥ 60 years of age and underwent long fusion (≥ 4) to the sacrum for severe sagittal imbalance (defined as pelvic incidence minus lumbar lordosis [PI–LL] ≥ 30°) were included. PJF was defined as a vertebral fracture at the uppermost instrumented vertebra (UIV) or UIV+1, failure of UIV fixation, myelopathy, or any need for proximal extension of fusion. Presumed risk factors were compared between the patients with and without PJF. @*Results@#Total 146 patients (mean age, 68.4 years) with preoperative mean PI–LL of 46.8° were included. PJF developed in 39 patients (26.7%) at a mean of 18.1 months after surgery. Multivariate analysis showed that osteoporosis (odds ratio [OR], 2.812; p = 0.019) and UIV located below T10 (OR, 3.773; p = 0.010) were significant risk factors for developing PJF. However, the degree of correction did not affect PJF occurrence. @*Conclusions@#The present study indicates that osteoporosis should be well corrected preoperatively and extending the fusion above T10 should be considered for severe imbalance in old patients. However, the amount of correction was not associated with PJF development.

Radiographic Factors of Proximal Junctional Failure According to Age Groups in Adult Spinal Deformity

Background@#Patient age has been associated with the development of proximal junctional failure (PJF). The characteristics of adult spinal deformity (ASD) are considered different between younger and older age groups. We hypothesized that the radiographic risk factors of PJF would be different according to age groups. This study aimed to evaluate different radiographic risk factors of PJF between two age groups undergoing thoracolumbar fusion for ASD. @*Methods@#ASD patients aged ≥ 60 years who underwent thoracolumbar fusion from the low thoracic level (T9–T12) to the sacrum were included. The minimum follow-up duration was 2 years. PJF was defined as proximal junctional angle (PJA) ≥ 20°, fixation failure, fracture, myelopathy, or necessity of revision surgery. Using various radiographic risk factors including age-adjusted ideal pelvic incidence (PI)-lumbar lordosis (LL), univariate and multivariate analyses were performed separately in two age groups: < 70 years and ≥ 70 years. @*Results@#A total of 186 patients (90.3% women) with a mean age of 69 years were enrolled. The mean follow-up duration was 67.4 months. PJF developed in 97 patients (52.2%). There were fractures in 53 patients, PJA ≥ 20° in 26, fixation failure in 12, and myelopathy in 6. PJF developed more frequently in patients 70 years or older than in those younger than 70 years. In patients aged less than 70 years, preoperative LL, PI-LL, and a change in LL were significant risk factors in univariate analysis. Multivariate analysis showed only a change in LL was significant for PJF development (odds ratio [OR], 1.025; p = 0.021). On the other hand, in patients 70 years or older, postoperative LL, postoperative PI-LL, and overcorrection relative to the conventional PI-LL target (within ± 10°) and age-adjusted ideal PI-LL target were significant risk factors. On multivariate analysis, only overcorrection of PI-LL relative to the age-adjusted ideal target was a single significant risk factor of PJF (OR, 5.250; p = 0.024). @*Conclusions@#In patients younger than 70 years, a greater change in LL was associated with PJF development regardless of PIrelated values. However, in older patients, overcorrection of PI-LL relative to the age-adjusted PI-LL target was a significant risk factor of PJF.

Treatment of Kümmell’s disease following the occurrence of osteoporotic vertebral compression fracture

The incidence of osteoporotic vertebral compression fracture (OVCF) is increasing with the increase in the elderly population. Kümmell’s disease following OVCF occurrence is not a rare complication and is frequently associated with severe pain or neurologic deficit with progressive kyphotic deformity. Kümmell’s disease initially meant post-traumatic delayed vertebral collapse, but now it is also termed nonunion, osteonecrosis, or intravertebral vacuum cleft, all of which suggest the disruption of the healing process.Current Concepts: The major pathogenesis of Kümmell’s disease is a vascular compromise caused by mechanical stress or intravascular pathology. The key radiologic sign to diagnose Kümmell’s disease is the presence of intravertebral vacuum cleft, observed using simple X-ray, computed tomography, or magnetic resonance imaging. Magnetic resonance imaging is the most useful diagnostic tool showing gas or fluid signals. The risk factors for the progression of Kümmell’s disease after OVCF include middle-column injury, confined low signal intensity on T2-weighted image, posterior wall combined fracture, kyphotic angle >10°, and a height loss >15%. Its treatment can be broadly classified as conservative treatment, bone cement injection, and surgical treatment. The appropriate treatment method is selected based on the pain intensity, neurological symptoms, and the severity of the kyphotic deformity.Discussion and Conclusion: Kümmell’s disease usually develops along with osteoporosis. Therefore, the treatment should be focused on relief from symptoms associated with Kümmell’s disease and osteoporosis. It is recommended that an anabolic agent should be administered after the diagnosis of Kümmell’s disease, regardless of the treatment modality.

Association between absolute lymphocyte count and overall mortality in patients with surgically resected gastric cancer

Background/Aims@#Lymphocytes are an important component of the cell-mediated immune system. As lymphopenia is reportedly associated with poor prognoses in patients with various cancers, we investigated this notion in patients who underwent curative gastrectomy. @*Methods@#We retrospectively analyzed the association between absolute lymphocyte count (ALC) and prognosis in patients with stage I–III gastric cancer who underwent curative surgical resection. Ever lymphopenic patients were defined as those with ALCs < 1,000/μL at any time post-diagnosis except within 30 days post-surgery. Adjusted multivariable regression models were used to evaluate the associations between lymphopenia and overall mortality, gastric cancer-specific mortality, and disease-free survival. @*Results@#We investigated 1,222 patients diagnosed between January 2011 and December 2015. Fifty-six patients (4.6%) were lymphopenic at diagnosis and nearly one-quarter (24.8%) were ever lymphopenic with a mean minimum ALC of 640/μL. Older age (odds ratio [OR], 1.02) and higher stage (stage III vs. I; OR, 3.01) were positively associated with ever lymphopenia. On multivariable analysis, ever lymphopenia predicted higher overall mortality (hazard ratio [HR], 1.83; p = 0.008), higher gastric cancer-specific mortality (HR, 1.58; p = 0.048), and shorter disease-free survival (HR, 1.83; p = 0.006). The 5-year gastric cancer-specific mortality rates for ever- and never lymphopenic patients were 10.9% and 3.7%, respectively; their 5-year cumulative recurrence rates were 15.1% and 4.6%, respectively. @*Conclusions@#This study demonstrate that ever lymphopenia is independent prognostic factor for overall mortality and recurrence in patients with potentially curable gastric cancer; hence, ALCs may be a biomarker for predicting the prognoses of patients with stage I–III gastric cancer who had curative gastrectomy.

Maintenance chemotherapy after 6 cycles of platinum-doublet regimen in anthracycline-and taxane-pretreated metastatic breast cancer

Background/Aims@#Sequential monotherapy is recommended for anthracycline-and taxane-resistant metastatic breast cancer (MBC), but combination chemotherapy is considered in patients with visceral crisis. Cisplatin-doublet chemotherapy is a combination regimen for MBC, but prolonged treatment is challenging because of toxicity. We analyzed the role of single-agent maintenance chemotherapy after cisplatin-doublet chemotherapy for MBC. @*Methods@#From January 2011 to December 2017, 96 anthracycline- and taxane-resistant MBC patients were retrospectively reviewed, and 49 patients with a sustained clinical benefit during the initial 6 cycles of cisplatin-doublet chemotherapy were enrolled for study. Patients were treated with gemcitabine-cisplatin (gemcitabine, 1,250 mg/m2, intravenously [IV], days 1 to 8; cisplatin 60 mg/m2, IV, day 1) or capecitabine-cisplatin (capecitabine 2,500 mg/m2, orally, days 1 to 14; cisplatin 60 mg/m2, IV, day 1) during the induction period. After 6 cycles, 16 patients were switched to single-maintenance treatment (gemcitabine or capecitabine) and the doublet regimen was continued in 24 patients. Survival outcomes (progression-free survival [PFS] and overall survival [OS]) were analyzed. @*Results@#Among the 49 patients who showed a clinical benefit during cisplatin-doublet therapy, 24 were maintained on the doublet regimen, 16 were switched to single-maintenance treatment, and chemotherapy was suspended until disease progression in nine patients. The single-maintenance chemotherapy group showed superior survival than the chemotherapy holiday and doublet regimen groups (median PFS 15.43 months vs. 8.37 and 10.67 months, respectively, p = 0.008; median OS 43.67 months vs. 22.17 and 22.33 months, respectively, p = 0.014). @*Conclusions@#Patients showing a clinical benefit during 6 cisplatin-doublet chemotherapy cycles may have a sustained survival benefit from single-maintenance chemotherapy.

Association between absolute lymphocyte count and overall mortality in patients with surgically resected gastric cancer

Background/Aims@#Lymphocytes are an important component of the cell-mediated immune system. As lymphopenia is reportedly associated with poor prognoses in patients with various cancers, we investigated this notion in patients who underwent curative gastrectomy. @*Methods@#We retrospectively analyzed the association between absolute lymphocyte count (ALC) and prognosis in patients with stage I–III gastric cancer who underwent curative surgical resection. Ever lymphopenic patients were defined as those with ALCs < 1,000/μL at any time post-diagnosis except within 30 days post-surgery. Adjusted multivariable regression models were used to evaluate the associations between lymphopenia and overall mortality, gastric cancer-specific mortality, and disease-free survival. @*Results@#We investigated 1,222 patients diagnosed between January 2011 and December 2015. Fifty-six patients (4.6%) were lymphopenic at diagnosis and nearly one-quarter (24.8%) were ever lymphopenic with a mean minimum ALC of 640/μL. Older age (odds ratio [OR], 1.02) and higher stage (stage III vs. I; OR, 3.01) were positively associated with ever lymphopenia. On multivariable analysis, ever lymphopenia predicted higher overall mortality (hazard ratio [HR], 1.83; p = 0.008), higher gastric cancer-specific mortality (HR, 1.58; p = 0.048), and shorter disease-free survival (HR, 1.83; p = 0.006). The 5-year gastric cancer-specific mortality rates for ever- and never lymphopenic patients were 10.9% and 3.7%, respectively; their 5-year cumulative recurrence rates were 15.1% and 4.6%, respectively. @*Conclusions@#This study demonstrate that ever lymphopenia is independent prognostic factor for overall mortality and recurrence in patients with potentially curable gastric cancer; hence, ALCs may be a biomarker for predicting the prognoses of patients with stage I–III gastric cancer who had curative gastrectomy.

Anterolateral and Posterior versus Posterior-Only Approaches for the Correction of Degenerative Adult Spinal Deformity

Objectives@#This study was conducted to demonstrate the reliability of mini-open anterior lumbar interbody fusion (ALIF) combined with lateral lumbar interbody fusion (LLIF) followed by 2-stage posterior fixation in patients with adult spinal deformity (ASD).Summary of Literature Review: Although the correction of ASD using LLIF has become more widespread, the amount of sagittal plane correction has been reported to be suboptimal.Materials and Method: Thirty ASD patients who underwent ALIF with LLIF followed by 2-stage posterior fixation (AP group) were compared to 60 patients who underwent posterior-only surgery (PO group) and were matched according to age, sex, diagnosis, fusion level, pelvic incidence, and follow-up duration. Spinopelvic parameters, hospitalization data, clinical outcomes, and complications were compared between the 2 groups. @*Results@#Postoperative lumbar lordosis was greater in the AP group than in the PO group (p<0.001). The reduction in the sagittal vertical axis was also greater in the AP group than in the PO group (p=0.005). Postoperatively, 90.0% of the AP group had a pelvic incidence– lumbar lordosis value within 9°, whereas only 50.0% of the PO group met that criterion (p<0.001). The operation time of the AP group was longer than that of the PO group, while estimated blood loss and red cell transfusion were lower in the AP group. Postoperative medical complications and delayed surgical complications developed more frequently in the PO group. @*Conclusions@#Mini-open ALIF with LLIF followed by 2-stage posterior fixation can restore sagittal balance more appropriately, with a lower rate of complications, than posterior-only surgery for the correction of ASD.

Clinical Significance of Resection Type and Margin following Surgical Treatment for Primary Sarcoma of the Spine: A Multi-Center Retrospective Study

OBJECTIVES@#To analyze oncological outcomes according to the resection type and surgical margin following surgical treatment for primary spinal sarcoma.SUMMARY OF LITERATURE REVIEW: Previous studies using registry databases have shown that surgery and negative margins were associated with improved survival for primary spinal sarcoma. However, few studies have comprehensively analyzed the clinical significance of the resection type and surgical margin for the oncological outcomes of this rare malignancy.@*MATERIALS AND METHODS@#We retrospectively reviewed consecutive patients who underwent surgical resection for primary spinal sarcoma between 1997 and 2016 at two tertiary medical centers. Overall survival and the occurrence of local recurrence and distant metastasis were compared between the groups using Kaplan-Meier curve analysis and the log-rank test.@*RESULTS@#Thirty-three patients (21 males,12 females) with a mean age of 45.1 years and a median follow-up of 36 months were included. There were 13 (39.4%) chondrosarcomas, 12 (36.4%) osteosarcomas, and eight different histological diagnoses. The cohort was categorized into four groups: 1) total en bloc resection with a negative margin (n=12; 36.4%), 2) total en bloc resection with a positive margin: (n=5; 15.2%), 3) total piecemeal resection (n=12; 36.4%), and 4) subtotal resection (n=4; 12.1%). Total en bloc resection with a negative margin was associated with improved overall survival (p=0.030) and less distant metastasis (p=0.025) and local recurrence (p=0.004).@*CONCLUSIONS@#Achieving a negative margin through total en bloc resection, although technically demanding, improves oncological outcomes in primary spinal sarcoma.

Clinical Significance of Resection Type and Margin following Surgical Treatment for Primary Sarcoma of the Spine: A Multi-Center Retrospective Study / 대한척추외과학회지

STUDY DESIGN: A retrospective multi-center study.OBJECTIVES: To analyze oncological outcomes according to the resection type and surgical margin following surgical treatment for primary spinal sarcoma.SUMMARY OF LITERATURE REVIEW: Previous studies using registry databases have shown that surgery and negative margins were associated with improved survival for primary spinal sarcoma. However, few studies have comprehensively analyzed the clinical significance of the resection type and surgical margin for the oncological outcomes of this rare malignancy.MATERIALS AND METHODS: We retrospectively reviewed consecutive patients who underwent surgical resection for primary spinal sarcoma between 1997 and 2016 at two tertiary medical centers. Overall survival and the occurrence of local recurrence and distant metastasis were compared between the groups using Kaplan-Meier curve analysis and the log-rank test.RESULTS: Thirty-three patients (21 males,12 females) with a mean age of 45.1 years and a median follow-up of 36 months were included. There were 13 (39.4%) chondrosarcomas, 12 (36.4%) osteosarcomas, and eight different histological diagnoses. The cohort was categorized into four groups: 1) total en bloc resection with a negative margin (n=12; 36.4%), 2) total en bloc resection with a positive margin: (n=5; 15.2%), 3) total piecemeal resection (n=12; 36.4%), and 4) subtotal resection (n=4; 12.1%). Total en bloc resection with a negative margin was associated with improved overall survival (p=0.030) and less distant metastasis (p=0.025) and local recurrence (p=0.004).CONCLUSIONS: Achieving a negative margin through total en bloc resection, although technically demanding, improves oncological outcomes in primary spinal sarcoma.

Usefulness of neutrophil gelatinase-associated lipocalin(NGAL) to confirm subclinical acute kidney injury and renal prognosis in patients following surgery / 고신대학교의과대학학술지

OBJECTIVES: The neutrophil gelatinase-associated lipocalin (NGAL) level following non cardiac surgery is useful for predicting acute kidney damage. However, there is insufficient conclusive evidence as to whether NGAL can be used to predict subclinical AKI following non-cardiac surgery. METHODS: We measured serum NGAL and creatinine levels in 41 patients following non-cardiac surgery, and the increase of these variables was used to predict acute decreases in kidney function. RESULTS: The study included a total of 41 patients. The mean age was 64.65 ± 17.09 years. The serum creatinine concentration was increased 12 hours after surgery. The mean SD serum NGAL decreased after 4hours after surgery and continued to decrease after 12 hours after surgery. The incidence of subclinical AKI determined by the 4 hour serum NGAL level was 10(24.4%), and the incidence of serum creatinine elevation was 0(0.0%). The incidence of subclinical AKI determined by the 12 hour serum NGAL level was 4(9.8%), and the incidence of subclinical AKI determined by serum creatinine was 4(9.8%). The elevation of NGAL was more rapid than the serum creatinine 4 hours after surgery. CONCLUSIONS: We verified the usefulness of the serum NGAL level as a predictive factor for subclinical AKI after non-cardiac surgery.

Mini-Open Anterior Lumbar Interbody Fusion Combined with Lateral Lumbar Interbody Fusion in Corrective Surgery for Adult Spinal Deformity

STUDY DESIGN: Prospective observational study. PURPOSE: To introduce the techniques and present the surgical outcomes of mini-open anterior lumbar interbody fusion (ALIF) at the most caudal segments of the spine combined with lateral lumbar interbody fusion (LLIF) for the correction of adult spinal deformity OVERVIEW OF LITERATURE: Although LLIF is increasingly used to correct adult spinal deformity, the correction of sagittal plane deformity with LLIF alone is reportedly suboptimal. METHODS: Thirty-two consecutive patients with adult spinal deformity underwent LLIF combined with mini-open ALIF at the L5–S1 or L4–S1 levels followed by 2-stage posterior fixation. ALIF was performed for a mean 1.3 levels and LLIF for a mean 2.7 levels. Then, percutaneous fixation was performed in 11 patients (percutaneous group), open correction with facetectomy with or without laminectomy in 16 (open group), and additional pedicle subtraction osteotomy (PSO) in 5 (PSO group). Spinopelvic parameters were compared preoperatively and postoperatively. Hospitalization data and clinical outcomes were recorded. RESULTS: No major medical complications developed, and clinical outcomes improved postoperatively in all groups. The mean postoperative segmental lordosis was greater after ALIF (17.5°±5.5°) than after LLIF (8.1°±5.3°, p <0.001). Four patients (12.5%) had lumbar lordosis with a pelvic incidence of ±9° preoperatively, whereas this outcome was achieved postoperatively in 30 patients (93.8%). The total increase in lumbar lordosis was 14.7° in the percutaneous group, 35.3° in the open group, and 57.0° in the PSO group. The ranges of potential lumbar lordosis increase were estimated as 4°–25°, 23°–42°, and 45°–65°, respectively. CONCLUSIONS: Mini-open ALIF combined with LLIF followed by posterior fixation may be a feasible technique for achieving optimal sagittal balance and reducing the necessity of more extensive surgery.

Surgical Strategies for Successful Minimally Invasive Transforaminal Lumbar Interbody Fusion

STUDY DESIGN: Literature review. OBJECTIVES: The aim of this study was to demonstrate surgical strategies for successful minimally invasive transforaminal lumbar interbody fusion (TLIF). SUMMARY OF LITERATURE REVIEW: Although many studies have reported the benefits and disadvantages of minimally invasive TLIF, few have described surgical strategies to improve the success rate or to reduce complications. MATERIALS AND METHODS: We searched for studies reporting the clinical and radiological outcomes of minimally invasive TLIF, and analyzed the optimal indications, technical pitfalls, and tips for successful surgical outcomes. RESULTS: The ideal candidate for minimally invasive TLIF is a patient with single or 2-level low-grade adult degenerative or isthmic spondylolisthesis. Incomplete decompression, dura tearing, nerve root injury, and implant-related complications were found to be the most commonly reported adverse events, especially in the early periods of a surgeon's experience. Precise positioning for skin incision and tube insertion, complete neural decompression, proper interbody preparation for bone graft and cage insertion, and the correct placement of percutaneous pedicle screws are critical strategies for successful surgical outcomes. Fully understanding the surgical pitfalls and tips described in this review is also important to avoid potential complications. CONCLUSIONS: It is imperative not only to carry out a comprehensive preoperative evaluation and proper patient selection, but also to perform meticulous surgical procedures with thoughtful considerations of potential pitfalls, in order to improve the success rate and to reduce the complications of minimally invasive TLIF.

An Unusual Case of Proctitis and Rectal Abscess due to Irritants by Artemisia asiatica Smoke (Ssukjwahun) / 대한소화기학회지

Proctitis is an inflammatory change of rectal mucosa induced by various agents or stimulus. Among many etiologies, it may be caused by medical treatments such as radiation or antibiotics. Proctitis usually presents with rectal ulcer but abscess formation is uncommon. Therapy using Ssukjwahun exerts its effect by directly applying the smoke around genital area and anus with various medicinal brewed herbs, especially worm-wood. Secondary metabolite of this plant, monoterpene, is known to facilitate circulation, exert anti-inflammatory effect, and help control pain. Herein, we report an unusual case of infectious proctitis presenting with rectal ulcer and abscess formation after perianal application of warm steam made by Artemisia asiatica smoke for treatment of dysmenorrhea.

Minimally Invasive Option Using Percutaneous Pedicle Screw for Instability of Metastasis Involving Thoracolumbar and Lumbar Spine : A Case Series in a Single Center

OBJECTIVE: To report a minimally invasive treatment option using percutaneous pedicle screw fixation with adjuvant treatment for metastatic thoraco-lumbar and lumbar spinal tumors. METHODS: This is a retrospective study of charts of patients with spinal metastases. All were older than 18 years of age and were considered to have more than 3 months of life expectancy. The patients had single or two level lesions, and compression fracture or impending fracture. Exclusion criterion was metastasis showing severe epidural compression with definite neurological symptoms. Usually spinal segments from one level above to below pathology were stabilized. Visual analog scale (VAS) score for pain assessment and Frankel scale for neurological deficit were used, while pre- and post-operative performance status was evaluated using the Eastern Cooperative Oncology Group (ECOG). RESULTS: Twelve patients (nine men, three women; median age 54.29 years) underwent surgery. All patients presented with back pain with/without radicular pain. There were no early complications and perioperative mortalities. Following surgery, a significant difference between average pre- and post-operative VAS scores was found (p=0.003). Overall, 91.8% of patients (11/12) experienced improvement in their ECOG score post-operatively. The mean ambulation time was 196.9 days [95% confidence interval (CI), 86.2-307.6 days; median, 97 days]. During follow-up, nine patients died and the mean overall survival time in enrolled twelve patients was 249.9 days (95% CI, 145.3-354.4 days; median, 176 days). CONCLUSION: Minimally invasive treatment using percutaneous pedicle screw fixation with adjuvant treatment is a good alternative treatment option for potential instability of the thoraco-lumbar and lumbar spinal metastasis.

Surgical Management with Radiation Therapy for Metastatic Spinal Tumors Located on Cervicothoracic Junction : A Single Center Study

OBJECTIVE: The cervicothoracic junction (CTJ) is a biomechanically and anatomically complex region that has traditionally posed problems for surgical access. In this retrospective study, we describe our clinical experiences of the treatment of metastatic spinal tumors at the CTJ and the results. METHODS: From June 2006 to December 2011, 23 patients who underwent surgery for spinal tumors involving the CTJ were enrolled in our study. All of the patients were operated on through the posterior approach, and extent of resection was classified as radical, debulking, and simple neural decompression. Adjuvant radiation therapy (RT) was also considered. Visual analog scale score for pain assessment and Medical Research Council (MRC) grade for motor weakness were used, while pre- and post-operative performance status was evaluated using the Eastern Cooperative Oncology Group (ECOG). RESULTS: Almost all of the patients were operated using palliative surgical methods (91.3%, 21/23). Ten complications following surgery occurred and revision was performed in four patients. Of the 23 patients of this study, 22 showed significant pain relief according to their visual analogue scale scores. Concerning the aspect of neurological and functional recovery, mean MRC grade and ECOG score was significantly improved after surgery (p<0.05). In terms of survival, radiation therapy had a significant role. Median overall survival was 124 days after surgery, and the adjuvant-RT group (median 214 days) had longer survival times than prior-RT (63 days) group. CONCLUSION: Although surgical procedure in CTJ may be difficult, we expect good clinical results by adopting a palliative posterior surgical method with appropriate preoperative preparation and postoperative treatment.

A Case of Secondary Hypertension Associated with the Nutcracker Phenomenon

A 25-year-old Korean woman was referred for uncontrolled hypertension. Laboratory examination revealed increased plasma renin activity and microscopic hematuria. Computed tomography demonstrated compression of the left renal vein (LRV) between the aorta and superior mesenteric artery; however, both renal arteries were intact and there was no adrenal mass. Renal vein catheterization showed external compression with a pressure gradient of up to 8 mm Hg between the LRV and the inferior vena cava. Plasma renin activity in the LRV was almost five times higher than that in the right renal vein. In this patient, renin-dependent hypertension was caused by renal congestion due to LRV obstruction.

Mini-Open Approach for Direct Lateral Lumbar Interbody Fusion

STUDY DESIGN: Retrospective analysis. PURPOSES: To introduce the mini-open lateral approach for the anterior lumbar interbody fusion (ALIF), and to investigate the advantages, technical pitfalls and complications by providing basic knowledge on extreme lateral interbody fusion (XLIF) or direct lumbar interbody fusion (DLIF). OVERVIEW OF LITERATURE: Recently, minimally invasive lateral approach for the lumbar spine is revived and receiving popularity under the name of XLIF or DLIF by modification of mini-open method when using the sequential tubular dilator and special expandable retractor system. METHODS: Seventy-four patients who underwent surgery by the mini-open lateral approach from September 2000 to April 2008 with various disease entities were included. Blood losses, operation times, incision sizes, postoperative time to mobilization, length of hospital stays, technical problems and complications were all analyzed. RESULTS: The blood losses and operation times of patients who underwent simple ALIF were 61.2 mL and 86 minutes for one level, 107 mL and 106 minutes for two levels, 250 mL and 142.8 minutes for three levels, and 400 mL and 190 minutes for four levels of fusion. The incision sizes were on average 4.5 cm for one level, 6.3 cm for two levels, 8.5 cm for three levels and 10.0 cm for four levels of fusion. The complications were retroperitoneal hematoma (2 cases), pneumonia (1 case) and transient lumbosacral plexus palsy (3 cases). CONCLUSIONS: Trials of mini-open lateral approach would be helpful before the trial of XLIF or DLIF. However, special attention is required for complications such as transient lumbosacral plexus palsy.

Stromal-cell-derived Factor 1-alpha Promotes Tumor Progression in Colorectal Cancer

PURPOSE: Although stromal-cell-derived factor (SDF)-1alpha is suggested to be involved in tumorigenicity and tumor angiogenesis, the clinicopathological significance of its expression in colorectal cancers is not fully understood. We examined SDF-1alpha expression in colorectal cancers and investigated its relationship to clinicopathological features such as tumor staging, lymph-node metastasis, vascular invasion (VI), lymphatic invasion (LI) and neural invasion (NI). METHODS: Specimens of 83 primary colorectal cancers were examined immunohistochemically, and the relationships between clinicopathological features and SDF-1alpha expression were analyzed. To compare the expressions between the normal colon tissue and colorectal cancer tissues, we performed Western blot analyses. RESULTS: According to the Western blot analyses, SDF-1alpha was more highly expressed in colorectal carcinoma tissues than in normal colonic mucosa (20/21). According to the immunohistochemical stain, SDF-1alpha was associated with nodal status, distant metastasis, tumor staging, VI and LI. SDF-1alpha expression had a significant prognostic value for overall survival. Kaplan-Meier plots of survival in patients with high SDF-1alpha showed that high SDF-1alpha expression was associated with a shorter overall survival. However, no association was found between SDF-1alpha expression and other pathologic or clinical variables, including age, gender, degree of differentiation, and presence of perineural invasion. CONCLUSION: The expression of SDF-1alpha might be associated with tumor progression in colorectal cancer. Inhibition of SDF-1alpha could be a therapeutic option in colorectal cancer patients.

The Association of Lumbosacral Sagittal Alignments and the Patterns of Lumbar Disc Degeneration

STUDY DESIGN: Retrospective review and radiological analysis. OBJECTIVES: We investigated whether the lumbosacral sagittal curvature have any relation to the patterns of lumbar disc degeneration. SUMMARY OF THE LITERATURE REVIEW: Recently, there have been many studies on the correlations between the changes of lumbar disc degeneration and associated factors, such as age, gender, weight, occupation, cigarette smoking, and genetics; but, it is hard to find research into lumbosacral sagittal alignments. MATERIALS AND METHODS: This study enrolled 117 young adult patients limited by age (18-35 years), BMD (<30kg/m2), no smoking, occupation except heavy worker, no prior lumbar surgery and no combined spinal deformity. By measuring the pelvic incidence, sacral slope, lumbar tilt angle, lumbar lordosis and lumbar axis indicating the parameters of sagittal alignments, we investigated the correlation between the number and severity of lumbar disc degeneration and the number of herniated intervertebral discs. RESULTS: This study found a moderate correlation between pelvic incidence, sacral slope, lumbar lordosis, and the number of lumbardegenerative disc (r=-0.451, p<0.001; r=-0.433, p<0.001; r=-0.425, p<0.001). We calculated the most proper cut-off value of pelvic incidence associated with more than three segments of multiple lumbar disc degeneration, using a minimum p-value approach. CONCLUSIONS: As pelvic incidence, sacral slope, and lumbar lordosis indicating the parameters of lumbosacral sagittal alignments get smaller, the numbers of lumbar disc degenerations and herniated intervertebral discs increase. When pelvic incidence is below 45.6 degrees, it is more likely for degenerative changes of lumbar disc to affect more than three segments.