Prevention of Adjacent Segmental Disease after Fusion in Degenerative Spinal Disorder: Correlation between Segmental Lumbar Lordosis Ratio and Pelvic Incidence–Lumbar Lordosis Mismatch for a Minimum 5-Year Follow-up

STUDY DESIGN: Retrospective study. PURPOSE: Associations among risk factors related to adjacent segmental disease (ASD) remain unclear. We evaluated the risk factors and segmental lordosis ratio to prevent ASD developing after lumbar spinal fusion. OVERVIEW OF LITERATURE: Risk factors related to ASD development are age, sex, obesity, pre-existing degeneration, number of fusion segments, and decreased postoperative lumbar lordosis (LL). However, the associations among these factors are still unclear and should be clearly identified. METHODS: We retrospectively reviewed data on 274 patients who underwent lumbar spinal fusion of three segments or below for lumbar degenerative disease from January 2010 to December 2012, with over 5 years of follow-up. Patients with preoperative sagittal vertical axis (SVA) >5 cm were excluded due to sagittal imbalance. A total of 37 patients with ASD and 40 control patients (CTRL) were randomly selected in a similar distribution of matching variables: age, sex, and preoperative degenerative changes. Sex, age, number of fusion segments, radiologic measurements, L4–5–S1/L1–S1 LL ratio, and spinopelvic parameters (pelvic incidence [PI], pelvic tilt [PT], sacral slope [SS], and SVA) were analyzed. Logistic regression was used to analyze the correlation between PI–LL mismatch and L4–5–S1 segmental lordosis rate. RESULTS: No significant difference was found between ASDs and CTRL groups regarding age, sex, number of fusion segments, fusion method, and preoperative and postoperative spinopelvic parameters (PI, SS, PT, and LL). However, regarding the L4–5–S1/L1–S1 lordosis ratio, 50% (p=0.045), 60% (p=0.031), 70% (p=0.042), 80% (p=0.023), and 90% (p=0.023) were statistically significant; 10 group, and the difference was statistically significant (p=0.048). CONCLUSIONS: Patients with a postoperative L4–5–S1/L1–S1 lordosis ratio >50% had less occurrence of ASD. Correcting LL according to PI and physiologic segmental lordosis ratio is important in preventing ASD.

Radiologic Features and Surgical Outcome of Juxtafacet Cyst Associated with Degenerative Lumbar Disease / 대한정형외과학회잡지

PURPOSE: The purpose of this study was to evaluate the radiologic features of juxtafacet cyst and determine the correlation between these features and clinical outcome. MATERIALS AND METHODS: We analyzed a total of 23 patients. The degree of facet joint degeneration was classified using the Fujiwara method. The facet joint angles were measured with an magnetic resonance imaging to determine whether there was a difference between the cystic lesion that was occupied and the cystic lesion that was not occupied. Disc degeneration was measured by the Pfirrmann classification method. The clinical result was evaluated using the Oswestry disability index score and visual analogue scale. RESULTS: The L4–5 level of juxtafacet cyst was mostly affected, as found in previous studies. Facet joint arthritis was more severe within the side with the cystic lesion. Significant correlation was found between disc degeneration and juxtafacet joint cyst. All patients underwent wide decompression and fusion. Clinical result was excellent. No patients had signs of recurrence during the follow-up periods. CONCLUSION: Juxtafacet cyst has a significant correlation with facet joint degeneration. Therefore, aggressive surgical treatment—not just simple cyst excision—should be considered as the treatment option for juxtafacet cyst associated with degenerative lumbar disease.

Natural History of Lumbar Degenerative Kyphosis with Conservative Treatment

STUDY DESIGN: Retrospective study. OBJECTIVES: To evaluate the natural history of conservatively treated lumbar degenerative kyphosis (LDK). SUMMARY OF LITERATURE REVIEW: The correlations between the clinical and radiologic parameters of general adult spinal deformity (ASD) are widely known. However, in LDK, dynamic sagittal imbalance is present during ambulation, meaning that its pathogenesis and natural history are different and not widely recognized compared to those of other forms of ASD, resulting in many controversies regarding treatment. To elucidate the natural history of LDK, we analyzed the clinical and radiologic outcomes of patients, comparing their first and final follow-up visits, and evaluated correlations among clinical and radiologic parameters. MATERIALS AND METHODS: From June 2006 to January 2014, 31 patients diagnosed with LDK who underwent conservative treatment were studied. The mean age of the patients was 72.5 years, and the mean follow-up period was 59.2 months. Clinical and radiologic evaluations were conducted on the first and final follow-up visits. Clinical evaluations were done using a visual analog scale and the Oswestry disability index, and radiologic evaluations were performed using spinal and pelvic parameters over a follow-up period of at least 24 months. RESULTS: Patients who were diagnosed with LDK and underwent conservative treatment showed no significant differences in their clinical outcomes between the first and final follow-up. Some radiologic parameters significantly progressed. There were no significant differences between clinical and radiologic parameters at the initial and final follow-up visits. CONCLUSIONS: During the follow-up period of patients diagnosed with LDK, some radiologic parameters progressed. However, the progress of LDK and the clinical symptoms reported by the patients did not significantly change. Decisions regarding the treatment of LDK should not be made according to radiologic parameters showing the degree of deformity, but by carefully determining the patients' clinical symptoms and disability level.

Risk Factors and Postoperative Prognostic Factors of Spontaneous Spinal Epidural Hematoma

STUDY DESIGN: Retrospective study. OBJECTIVES: To explore the risk factors and the factors associated with the neurological improvement after operation in the spontaneous spinal epidural hematoma. SUMMARY OF LITERATURE REVIEW: The cause of the spontaneous spinal epidural hematoma is unknown. The objective risk and prognostic factors are still controversial. MATERIALS AND METHODS: From January 2006 to December 2014, a total of 12 patients with spontaneous epidural hematoma were evaluated. The risk and prognostic factors analyzed were sex, age, underlying diseases, medications, neurologic status, level and extent of hematoma, cord edema, and interval from onset to surgery. We analyzed the correlation between each factor and neurologic recovery. The neurologic status was analyzed using the American Spinal Injury Association impairment scale (AIS) at the first and the last neurologic examination. RESULTS: The average age of the patients was 68.6 years. Seven patients were treated with anticoagulation therapy, and two were advised to switch to a healthier diet. The initial neurologic status of the patients was AIS A in 2 cases, B in 5 cases, C in 4 cases, D in 1 case, and in two patients, cord edema was revealed on magnetic resonance imaging (MRI). The interval of time from onset to surgery was less than 24 hours in 6 cases, 24-48 hours in 4 cases, and more than 48 hours in 2 cases. CONCLUSIONS: The prognostic factors associated with spontaneous spinal epidural hematoma were found to be initial neurologic status, cord edema on MRI, and interval from onset to surgery. We found no correlation between anticoagulation therapy or healthy diet and spontaneous spinal epidural hematoma, but anticoagulation therapy cannot be excluded as a risk factor.

Clinical Results And Prognostic Factors for Thoracic Myelopathy Caused by Ossification of Yellow Ligament after Surgical Treatment

STUDY DESIGN: Retrospective study. OBJECTIVES: We analyzed the clinical results of thoracic myelopathy caused by ossification of yellow ligament (OYL) and to explore prognostic factors after surgical treatment. SUMMARY OF LITERATURE REVIEW: Thoracic myelopathy due to OYL is difficult to treat; surgery is considered as treatment of choice. However, studies of the clinical results and prognostic factors are few due to its rare presentation. MATERIALS AND METHODS: Twenty six patients who had surgery for thoracic myelopathy caused by OYL were evaluated from February 2002 to April 2012. We describe the analysis of the clinical results after surgery and prognostic factors. RESULTS: Modified Japanese orthopedic association (JOA) score was recorded in all patients by 5.7+/-1.3 points (range, 2-9 points) preoperatively, 7.8+/-1.7 points (range, 4-10 points) postoperatively, and 8.4+/-2.1 points (range, 5-11 points) at final follow-up. Hirabayashi recovery rate was recorded by 60.2+/-20.2% (range, 45.5-72.0%) postoperatively, 64.5+/-17.3% (range, 50.2-75.1%) at final follow-up. The Visual Analogue Scale (VAS) score was also improved by 7.6+/-1.8 points (range, 7-10 points) preoperatively, 4.5+/-1.3 points (range, 3-6 points) postoperatively, and 3.8+/-1.6 points (range, 2-5 points) at final follow-up. Both modified JOA score and VAS score improved significantly (p<0.05). In prognostic factor analysis, OYL type on CT axial image, duration of symptom, and preoperative severity of myelopathy was significant (p<0.05). CONCLUSION: We showed the effectiveness of surgery on patients who suffer from thoracic myelopathy caused by OYL and that OYL type identified by CT axial image, duration of symptom, and preoperative severity of myelopathy were significant prognostic factors.

Changes of Spinopelvic Parameter using Iliac Screw In Surgical Correction of Sagittal Imbalance Patients

STUDY DESIGN: A retrospective-based study. OBJECTIVES: To evaluate the usefulness of iliac screws in the surgical correction of sagittal imbalance by changes of spinopelvic parameters. SUMMARY OF LITERATURE REVIEW: Although reports exist regarding the fusion rates on lumbosacral fusion by iliac screws, no previous studies address the issue of changes of spinopelvic parameters on surgical correction of sagittal imbalance by iliac screws. MATERIALS AND METHODS: We analyzed a total of 23 patients who were operated on by pedicle subtraction osteotomy and posterior fusion on sagittal imbalance. Patients were divided into two groups: 1) non-iliac screw fixation and; 2) iliac screw fixation. The two groups were compared during the preoperative and postoperative stages, and the last follow-up spinopelvic parameters of two groups. RESULTS: Spinopelvic parameters, except for pelvic incidence, were corrected after surgery; some corrected values of spinopelvic parameters were lost during follow-up. There was a statistically significant difference in the last follow-up period between lumbar lordosis and pelvic tilt. Values of postoperative lumbar lordosis and pelvic tilt was similar to each other; however, during the follow-up period corrected values of spinopelvic parameters of non-iliac screw fixation group were more lost. There were no statistically significant changes in postoperative and last follow-up sacral slope and pelvic incidence. CONCLUSIONS: Sagittal imbalance could be corrected by pedicle subtraction osteotomy, and corrected values of lumbar lordosis and pelvic tilt of iliac screw fixation group could be maintained well compared to non-iliac screw fixation. Iliac screw fixation could be useful for maintenance of corrected values of spinopelvic parameters in surgical correction of sagittal imbalance.

Eleven Levels of Spinous Process Fractures in Thoracolumbar Spine

Cases of over 5-level spinous process fractures are extremely rare. Thoracolumbar region of spine is superimposed on ribs; and as such additional studies such as computerized tomography are needed to diagnose fractures in this region. We report a case of 11 contiguous level thoracolumbar spinous process fractures, which has been treated conservatively.

A Comparison of Overgrowth after Treatment for Pediatric Femoral Shaft Fractures: Flexible Intramedullary Nailing versus External Fixation / 대한정형외과학회잡지

PURPOSE: Overgrowth is a common complication after the treatment of pediatric femoral fractures. However, the effect of treatment methods on the overgrowth is controversial. We compared the amount of overgrowth between flexible intramedullary nailing and external fixation. MATERIALS AND METHODS: Twenty-six children with femoral diaphyseal fractures after a minimum 2 year follow-up were enrolled in this retrospective study. Thirteen patients were treated with flexible intramedullary nailing (FIN) group, and the other 13 patients were treated with external fixation (EF) group. The overgrowth of femur, clinical outcomes, and complications were evaluated. RESULTS: Union was obtained in all patients without major complications, except for overgrowth. Average overgrowth at the 2-year follow-up was 4 mm (-6-13 mm) in the FIN group, and 3 mm (-13-13 mm) in the EF group (p=0.532). Overgrowths of more than 10 mm were observed in four patients; three patients in the FIN group, and one in the EF group. CONCLUSION: FIN and EF showed similar amounts of overgrowth, after the treatment for pediatric femoral fractures.

Effect of Adenotonsillectomy on Inattention and Hyperactivity in Children with Sleep Disordered Breathing / 대한이비인후과학회지

BACKGROUND AND OBJECTIVES: Sleep disordered breathing (SDB) is a common problem in the otolaryngology clinic and adenotonsillar hypertrophy is thought to be one of the most common etiologic factors. SDB possibly exhibits problems of behavioral regulation, such as inattention, hyperactivity and impulsive behavior. The goal of this study was to assess the effect of adenotonsillectomy on inattention and hyperactivity in children. SUBJECTS AND METHOD: We selected 54 pediatric patients with sleep disordered breathing. Adenotonsillectomy was performed for all patients. Adenotonsillar hypertrophy and the degree of SDB were evaluated preoperatively. The degree of inattention and hyperactivity was evaluated by attention deficit hyperactivity disorder rating scale-IV (ADHD RS-IV) before and after surgery. RESULTS: ADHD RS-IV score showed significant improvement after the operation in most children with SDB. But the improvement of ADHD RS-IV was not associated with the degree of adenotonsillar hypertrophy. However, much improvement in postoperative ADHD RS-IV was observed with children having higher preoperative ADHD RS-IV and/or SDB scale. CONCLUSION: Adenotonsillectomy seems to improve inattention and hyperactivity in most children with SDB. Improvement is more apparent in children with severe sleep disturbance and severe attention deficit and hyperactivity.

A Case of Congenital Sensorineural Hearing Loss with Multinodular Goiter / 대한이비인후과학회지

Pendred syndrome is an autosomal recessive condition classically characterized by congenital deafness and goiter, and is the most common cause of hereditary deafness in Korea. It is caused by mutations in the PDS gene (SLC26A4) located in 7q31. The PDS gene encodes a chloride-iodide transport protein called pendrin, which plays a role in the reabsorption of endolymph and the maintenance of the endolymph homeostasis in the inner ear and in the uptake and organification of iodide in the thyroid gland. A mutation in PDS also causes non-syndromic recessive deafness (DFNB4) and therefore securing the diagnosis is important for genetic counseling purposes. The perchlorate discharge test and radiological conformation of the inner ear anomaly are useful diagnostic aids but have limited diagnostic value. However, because PDS mutations are widely distributed along the gene, it consumes too much time and money to perform molecular studies in clinics. We present a case of congenital sensorineural hearing loss with multinodular goiter, which shows definite findings of Pendred syndrome.

Efficacy of Benzodiazepines to Laryngopharyngeal Reflux: A Double-Blind, Randomized Controlled Study / 대한이비인후과학회지

BACKGROUND AND OBJECTIVES: Anti-anxiety drugs such as benzodiazepines are often given to globus patients in practice, based on the notion that globus is a kind of somatization disorder. However, many of globus are caused by laryngopharyngeal reflux (LPR) and the effects of anti-anxiety drugs to LPR are unknown. The study goal was to assess the efficacy of benzodiazepines to LPR. SUBJECTS AND METHOD: We selected 51 LPR patients, who were confirmed by 24-hour double-probe ambulatory pH monitoring. Patients were allocated into case and control groups at random and entered into a double-blind trial. Patients in the control group received proton pump inhibitors and prokinetics. Diazepam was added to patients in the case group. Assessments were made after 4 weeks of treatment using reflux symptom index (RSI) and reflux finding score (RFS). RESULTS: In both groups, RSI and RFS were improved significantly at the end of the study. However, there was no significant difference between the two groups. CONCLUSION: Diazepam seems to have little efficacy in the treatment of LPR.

Study on Correlations among Polysomnogram Indices for Obstructive Sleep Apnea-Hypopnea Patients / 대한이비인후과학회지

BACKGROUND AND OBJECTIVES: The polysomnography is essential for diagnosis of obstructive sleep apnea-hypopnea (OSAH) and provides important objective information. But, in fact, there are some difficulties for comprehensive interpretation of multiple indices from the polysomnogram. This study was designed to find out which polysomnogram indices were significant to respiratory distress indices (RDI) and apnea index (AI) on statistical correlation and which other indices should be considered together for proper management plan apart from RDI and AI (respiratory index). SUBJECTS AND METHOD: We evaluated 40 patients whose RDI were over 5 as the result of overnight polysomnography before any management from February 2003 to September 2003 at Eulji medical center. By multiple linear regression analysis, we studied the relationship of RDI and AI as dependent variables to ST, O2 desaturation events (O2DE), lowest O2 saturation (LoO2), slow wave sleep portion (S3&S4), arousal index (ArI), body-mass index (BMI) and age. We also studied the relationship of ST as an dependent variable to O2DE, LoO2, S3&S4, ArI, BMI, and age. RESULTS: 1) There were significant correlations between RDI and O2DE, ArI as was true between AI and O2DE, ArI (p<0.05). And there was no significant difference in the degree of the correlation between RDI and AI. 2) Other variables such as ST, LoO2, S3&S4, BMI and age were not significant. 3) ST had no significant correlation with respiratory index and any other variables (p<0.05). CONCLUSION: Because the respiratory index may not the entire physical status during sleep for OSAH patients, multiple indices (such as LoO2, BMI, ST, S3&S4, age) should be considered together apart from the respiratory index for proper management plan.

A Case of Adenomatoid Hamartoma Originated from Nasal Cavity / 대한이비인후과학회지

Hamartomas are non-neoplastic malformations or congenital errors of tissue development. They are characterized by an abnormal mixture of tissues indigenous to that area of the body, but with an excess of one or more of the tissue types. Adenomatoid hamartomas are pathologically unique-appearing sinonasal tract and nasopharyngeal lesions and defined as follows ; the glandular component of the hamartoma consisted of respiratory epithelium originating from the surface epithelium, and polypoid growth resulted from respiratory epithelial-lined adenomatoid proliferation. Hamartomas occur in all areas of the body, especially in the liver, spleen, kidney and lung, but very rarely in the nasal cavity, paranasal sinuses, or nasopharynx. The histopathological differential diagnosis of adenomatoid hamartoma of the sinonasal tract includes inverted papilloma and adenocarcinoma. Misinterpretation as a true neoplasm may result in unnecessary radical surgery. We present a case of adenomatoid hamartoma in the nasal cavity, which was treated with complete resection by endonasal endoscopic approach.

Age-related Changes of Doublecortin Positive Cells in the Olfactory Bulb of the Rat / 대한이비인후과학회지

BACKGROUND AND OBJECTIVES: It is well-established that neurogenesis continues to occur during life in the restricted brain areas, such as the glomerular and granule cell layers of the olfactory bulb. Doublecortin is a protein required for neuronal migration in the developing brian and olfactrory bulb, and is expressed in postmitotic migrating and differentiating neurons during embryonic and postnatal development periods. We investigated age-related changes of doublecortin positive cells in the olfactory bulb of aged rat compared with new born rat. MATERIALS AND METHOD: Four months old (control group, n=7) and 24 months old (aged group, n=7) male Fischer 344 rats were used in this study. Olfactory bulbs of the rats were cut into 40 micro m-thick coronal sections and immunostained. We counted the doublecortin positive cells and neurofibrils, and measured the optical density of doublecortin by layer. We compared the results between the aged group and the control group. RESULTS: In the olfactory bulbs of aged group, we observed less doublecortin positive cells, neurofibrils and lower optical density than the control group. Doublecortin is expressed during life in migratory neuroblasts of the olfactory bulb of the rats. This expression is reduced in the aged group and the reduced degree is variable according to the layer. CONCLUSION: Age-related changes of the olfactory bulb are associated with the reduction of postnatal neurogenesis, especially during the migration and differentiaion stages. This changes result in reduction of interneurons of the olfactory bulb, and may be responsible for the decreased olfactory function.