Spinal Surgery for Parkinson Disease With Camptocormia: Propensity Score-Matched Cohort Study With Degenerative Sagittal Imbalance (DSI).

STUDY DESIGN: A propensity score-matched cohort study. OBJECTIVE: The objective of this study was to compare the radiologic and clinical outcomes of camptocormia in Parkinson disease (PD) with degenerative sagittal imbalance (DSI) patients. SUMMARY OF BACKGROUND DATA: Camptocormia in PD and DSI could be characterized by a dynamic deformity. However, no study has directly evaluated the outcomes of patients with camptocormia and DSI. METHODS: Thirteen consecutive PD patients undergoing surgical correction for camptocormia were matched in a 1-to-2 format with 26 patients in the DSI group by propensity score-matching. Radiologic outcomes, including paravertebral muscle changes, and clinical outcomes were compared between the 2 groups. The rate of proximal junctional problems and reoperations were assessed. RESULTS: PD patients with camptocormia had significantly greater preoperative coronal and sagittal malalignments (29.9 vs. 16.9 mm, P=0.019; 142.8 vs. 64.4 mm, P=0.0001, respectively) and weakness of paravertebral muscles compared with the DSI patients. Regarding the clinical outcomes, reoperations were significantly higher in the camptocormia group, compared with the DSI group (53.8% vs. 7.7%, P=0.001). Moreover, proximal junctional failure was developed in 8 patients in the camptocormia group, while 1 patient in the DSI group (61.5% vs. 3.8%, P=0.0001). In subgroup analysis, independent risk factors for the proximal junctional failure were the total fusion levels (hazard ratio=0.26, P=0.018) and the degree of fatty changes of the paravertebral muscles (hazard ratio=1.15, P=0.048). CONCLUSIONS: PD patients undergoing spinal surgery for camptocormia had global malalignment and higher rates of complications compared with DSI patients. Patients should be appropriately counseled regarding the increased risk of operative complications and closely followed for incipient failure.

How to Avoid Distal Adding-on Phenomenon for Rigid Curves in Major Thoracolumbar and Lumbar Adolescent Idiopathic Scoliosis? Identifying the Incidence of Distal Adding-on by Selection of Lowest Instrumented Vertebra.

OBJECTIVE: We sought to compare the radiologic outcomes for different distal fusion levels in a rigid curve with major thoracolumbar and lumbar (TL/L) adolescent idiopathic scoliosis (AIS) using rod derotation (RD) with direct vertebral rotation (DVR) after pedicle screw instrumentation (PSI). METHODS: This study finally enrolled 28 patients who were diagnosed with AIS in rigid curve with major TL/L curves, treated by PSI with RD and DVR and with a minimum 2-year follow-up. Patients were divided into 2 groups, L3 and L4, on the basis of the distal fusion level at the lowest instrumented vertebra (LIV) of L3 or L4. RESULTS: There was no significant difference in TL/L curve, thoracic (minor), and compensatory (caudal) curves between the L3 and L4 groups either postoperatively (P = 0.162, 0.426, and 0.762, respectively) or at the last follow-up (P = 0.952, 0.620, and 0.562, respectively). The overall prevalence of unsatisfactory results was 42.9% (12/28 patients). The prevalence of unsatisfactory results was 61.1% (11/18) in the L3 group and 10% (1/10) in the L4 group, which was significantly different (P < 0.05). CONCLUSIONS: Unsatisfactory results occurred more often in the L3 group than in the L4 group, and unsatisfactory results had significant influence on progression of TL/L and distal compensatory curves. Such progression was closely correlated with deteriorating LIV disk angle in the L3 group. Therefore if the curve is rigid, LIV should be extended to L4 to avoid the adding-on phenomenon in the treatment of major TL/L AIS using RD with DVR after PSI.

Effect of Direct Vertebral Rotation in Single Thoracic Adolescent Idiopathic Scoliosis: Better 3-Dimensional Deformity Correction.

OBJECTIVE: To analyze the effects of direct vertebral rotation (DVR) on radiologic outcomes in the treatment of thoracic adolescent idiopathic scoliosis after selective thoracic fusion with pedicle screw instrumentation. METHODS: Adolescent idiopathic scoliosis patients with single thoracic curves (n = 110) treated by selective thoracic fusion with a minimum of 2 years of follow-up were retrospectively analyzed. The patients were separated into 2 groups: non-DVR (n = 63) and DVR (n = 47). RESULTS: There was a significant difference in fused segments between the non-DVR and DVR groups (P < 0.001). There was also a significant difference in main thoracic curve postoperatively (P = 0.001) and at the last follow-up (P = 0.006) between the non-DVR and DVR groups. However, there was no significant difference in proximal thoracic and lumbar curves postoperatively (proximal thoracic curve: P = 0.186; lumbar curve: P = 0.155) and at the last follow-up (proximal thoracic curve: P = 0.250; lumbar curve: P = 0.060) between the 2 groups. Significant improvements in the lowest instrumented vertebra tilt and disc angle were noted but then slight deteriorations in such were observed during the follow-up period in the non-DVR group. The prevalence of unsatisfactory results was 20.6% (13 of 63) in the non-DVR group and 19.1% (9 of 47) in the DVR group, with no significant difference (P = 0.522). CONCLUSIONS: For correcting single thoracic adolescent idiopathic scoliosis by selective thoracic fusion with pedicle screw instrumentation, the addition of DVR to the surgical procedure showed comparable radiologic outcomes compared with non-DVR procedures.

Benign Gastric Ulcer with Epstein-Barr Virus Infection Mimicking Malignant Gastric Ulcer.

Epstein-Barr virus (EBV) is the cause of infectious mononucleosis, which is characterized by fever, lymphadenopathy, and sore throat. On the other hand, gastrointestinal symptoms of EBV infection like dyspepsia, abdominal pain are non-specific and rarely encountered, which means it is difficult to diagnose gastric involvement of EBV infection without suspicion. The relation between gastric carcinoma and gastric lymphoma associated with EBV infection is well defined, but relations with other EBV-associated gastrointestinal diseases such as gastritis and peptic ulcer disease have rarely been reported. We report a case of benign gastric ulcer with EBV infection confirmed by endoscopic and histological findings.

Minimally Invasive Lateral Lumbar Interbody Fusion for Clinical Adjacent Segment Pathology: A Comparative Study With Conventional Posterior Lumbar Interbody Fusion.

STUDY DESIGN: This was a retrospective comparative study. OBJECTIVE: The main objective of this article was to evaluate the clinical and radiologic efficacies of minimally invasive lateral lumbar interbody fusion (LLIF) for clinical adjacent segment pathology (ASP). SUMMARY OF BACKGROUND DATA: Minimally invasive techniques have been increasingly applied for spinal surgery. No report has compared LLIF with conventional posterior lumbar interbody fusion for clinical ASP. METHODS: Forty patients undergoing LLIF with posterior fusion (hybrid surgery) were compared with 40 patients undergoing conventional posterior lumbar interbody fusion (posterior surgery). The radiologic outcomes including indirect decompression in hybrid surgery group, and clinical outcomes such as the Oswestry Disability Index (ODI) and Visual Analog Scale (VAS) were assessed. Postoperative major complications and reoperations were also compared between the 2 groups. RESULTS: Correction of coronal Cobb's angle and segmental lordosis in the hybrid surgery were significantly greater postoperatively (2.8 vs. 0.9 degrees, P=0.012; 7.4 vs. 2.5 degrees, P=0.009) and at the last follow-up (2.4 vs. 0.5 degrees, P=0.026; 4.8 vs. 0.8 degrees, P=0.016) compared with posterior surgery. As regards indirect decompression of the LLIF, significant increases in thecal sac (83.4 vs. 113.8 mm) and foraminal height (17.8 vs. 20.9 mm) were noted on postoperative magnetic resonance imaging. Although postoperative back VAS (4.1 vs. 5.6, P=0.011) and ODI (48.9% vs. 59.6%, P=0.007) were significantly better in hybrid surgery, clinical outcomes at the last follow-up were similar. Moreover, intraoperative endplate fractures developed in 17.7% and lower leg symptoms occurred in 30.0% of patients undergoing hybrid surgery. CONCLUSIONS: Hybrid surgery for clinical ASP has advantages of segmental coronal and sagittal correction, and indirect decompression compared with conventional posterior surgery. However, LLIF-related complications such as endplate fracture and lower leg symptoms also developed. LLIF should be performed considering advantages and approach-related complications for the clinical ASP.

Clinical and Radiographic Features of Subtypes of Acute Proximal Junctional Failures Following Correction Surgery for Degenerative Sagittal Imbalance.

OBJECTIVE: To identify clinical and radiographic features of subtypes of acute proximal junctional failures (PJFs) following correction surgery for degenerative sagittal imbalance. METHODS: The study included 157 patients with mean age 68.0 ± 6.3 years who underwent correction surgery for degenerative sagittal imbalance. Acute PJFs were categorized into 4 subtypes: fracture at uppermost instrumented vertebra (UIV), fracture at vertebra just proximal to UIV (UIV+1), fixation failure at UIV, and junctional subluxation. Demographic, clinical, and radiographic data were analyzed retrospectively. RESULTS: There were 18 patients with acute PJFs. PJF group had significantly lower T-score (-3.3 ± 1.1 vs. -1.9 ± 1.5) on bone densitometry and lower body mass index (BMI) (23.0 ± 3.9 kg/m2 vs. 25.6 ± 3.7 kg/m2) than non-PJF group. Radiographic parameters exhibited no significant differences. UIV fracture, UIV+1 fracture, UIV fixation failure, and junctional subluxation were observed in 5, 6, 4, and 3 patients. Fixation failure developed the earliest (median 1.3 months), followed by UIV fracture (1.5 months). UIV fracture occurred earlier than UIV+1 fracture (36 months). Patients with UIV or UIV+1 fracture had significantly lower T-scores than others. Although BMI and T-score were significant risk factors for all PJFs (P = 0.043 and P = 0.021, respectively), different risk factors for each subtype of PJFs were identified on separate risk factor analysis. CONCLUSIONS: Patients with acute PJFs had lower T-score and BMI. Each subtype of PJFs had different clinical and radiographic features. Although BMI and T-score were associated with all PJFs, each subtype may have different risk factors. Identifying risk factors for each subtype of acute PJFs may help avoid it.

Clinical Significance of Preoperative Embolization for Non-Hypervascular Metastatic Spine Tumors.

OBJECTIVE: The efficacy of preoperative embolization for hypervascular metastatic spine disease (MSD) such as renal cell and thyroid cancers has been reported. However, the debate on the efficacy of preoperative embolization for non-hypervascular MSD still remains unsettled. The purpose of this study is to determine whether preoperative embolization for non-hypervascular MSD decreases perioperative blood loss. METHODS: A total of 79 patients (36 cases of preoperative embolization and 43 cases of non-embolization) who underwent surgery for metastatic spine lesions were included. Representative hypervascular tumors such as renal cell and thyroid cancers were excluded. Intraoperative and perioperative estimated blood losses (EBL), total number of transfusion and calibrated EBL were recorded in the embolization and non-embolization groups. The differences in EBL were also compared along with the type of surgery. In addition, the incidence of Adamkiewicz artery and complications of embolization were assessed. RESULTS: The average age of 50 males and 29 females was 57.6±13.5 years. Lung (30), hepatocellular (14), gastrointestinal (nine) and others (26) were the primary cancers. The demographic data was not significantly different between the embolization and the non-embolization groups. There were no significant differences in intraoperative EBL, perioperative EBL, total transfusion and calibrated EBL between two groups. However, intraoperative EBL and total transfusion in patients with preoperative embolization were significantly lower than in non-embolization in the corpectomy group (1645.5 vs. 892.6 mL, p=0.017 for intraoperative EBL and 6.1 vs. 3.9, p=0.018 for number of transfusion). In addition, the presence of Adamkiewicz artery at the index level was noted in two patients. Disruption of this major feeder artery resulted in significant changes in intraoperative neuromonitoring. CONCLUSION: Preoperative embolization for non-hypervascular MSD did not reduce perioperative blood loss. However, the embolization significantly reduced intraoperative bleeding and total transfusion in corpectomy group. Moreover, the procedure provided insights into the anatomy of tumor and spinal cord vasculature.

Sex-specific and Age-specific Analgesia for Early Postoperative Pain Management After Lumbar Decompressive Surgery: A Randomized Clinical Trial.

STUDY DESIGN: This was a randomized clinical trial. OBJECTIVE: To compare the efficacy and safety of nonsteroidal anti-inflammatory drug and opioid for acute pain management after lumbar decompressive surgery. SUMMARY OF BACKGROUND DATA: Multimodal analgesia is associated with synergistic effects while reducing opioid-related adverse effects. However, there is no consensus on the ideal multimodal analgesic regimen. We assumed that each agent in various multimodal regimens under different conditions may have different effects. MATERIALS AND METHODS: This prospective randomized clinical trial recruited adult patients who underwent single-level lumbar decompressive surgery. Patients were randomized to receive our postoperative analgesic regimen including either nonsteroidal anti-inflammatory drug (celecoxib) or opioid (extended-release oxycodone) from postoperative day 3 to 14. The Visual Analog Scale (VAS) and Oswestry Back Pain Disability Index (ODI) were used to evaluate effectiveness preoperatively and on postoperative days 2, 3, 7, and 14, and at 6 months. Drug-related adverse effects were also recorded. RESULTS: One hundred patients were enrolled and 93 patients (46 patients with celecoxib vs. 47 patients with oxycodone) were randomized. No differences were observed in patient demographics and preoperative VAS and ODI between the 2 groups. VAS and ODI were not different at all postoperative time points. However, subanalysis according to sex and age, revealed significant differences in efficacy: celecoxib was effective in female individuals and oxycodone was effective in male individuals on postoperative days 7 and 14; oxycodone was effective in patients aged above 65 years on postoperative days 7 and 14. Although nausea/vomiting and constipation were more common in the oxycodone group than in the celecoxib group, other adverse effects were not different. CONCLUSIONS: In patients who underwent single-level lumbar decompressive surgery, treatment with celecoxib and oxycodone for postoperative pain management showed no significant differences in efficacy. However, subanalysis showed that each drug was effective in different ages and sex groups. LEVEL OF EVIDENCE: Level II.

Seroepidemiology of Hepatitis Viruses and Hepatitis B Genotypes of Female Marriage Immigrants in Korea.

PURPOSE: The Korean society has moved rapidly toward becoming a multicultural society. This study aimed to estimate the seroprevalence of hepatitis viruses and investigate hepatitis B virus (HBV) genotypic diversity in female marriage immigrants. MATERIALS AND METHODS: Screening program was conducted at support centers for multicultural families in 21 administrative districts in Korea between July 2011 and January 2017. A total of 963 female marriage immigrants were included in this study. Blood samples were tested for hepatitis viral markers and HBV genotype. RESULTS: Subjects' median age was 33 years (20-40 years), and they originated from nine countries including Vietnam (n=422, 43.8%), China (n=311, 32.3%), the Philippines (n=85, 8.8%), Cambodia (n=58, 6.0%), and Japan (n=39, 4.0%). About 30% (n=288) of subjects required hepatitis A vaccination. HBsAg positive rate was 5.4% (n=52). Positive HBsAg results were the highest in subjects from Southeast Asia (6.6%, n=38). Anti-HBs positive rate was 60.4% (n=582). About 34% (n=329) of subjects who were negative for anti-HBs and HBsAg required HBV vaccinations. Genotypes B and C were found in 54.6% (n=12) and 45.4% (n=10) of the 22 subjects with HBV, in whom genotypes were tested. Eight (0.8%) subjects were positive for anti-HCV. Positive anti-HCV results were the highest in subjects from Central Asia (7.9%, n=3). CONCLUSION: Testing for hepatitis viral marker (hepatitis A virus IgG and HBsAg/anti-HBs) is needed for female marriage immigrants. Especially, HBV genotype B is different from genotype C of Koreans. Therefore, interest and attention to vaccination programs for female marriage immigrants are necessary for both clinicians and public health institutes.

Clinical and Radiologic Features of Osteoporotic Spine Fracture with Delayed Neurologic Compromises.

OBJECTIVES: Osteoporotic spine fractures (OSFs) with delayed neurologic compromises (NCs) have been increasingly reported. Although several studies have addressed that the pathologic mechanism of NC involves nonunion and segmental instability, the risk factors remain unclear. Therefore, the purpose of this study was to assess the radiologic and clinical features of OSFs with delayed NC. METHODS: Thirty patients with delayed NC (group 1) were matched in a 1-to-1 format with 30 patients without delayed NC (group 2) by age, bone mineral density, body mass index, and medical treatment for osteoporosis. Clinical and radiologic parameters were assessed to determine the risk factors related to delayed NC. Clinical outcomes were also compared between the 2 groups. RESULTS: Neurologic compromises were presented as myelopathy in 20 patients and radiculopathy in 10 patients. Initial kyphotic angle (KA) and height loss (HL) were significantly greater in group 1 (21.6 ± 12.9 degrees vs. 10.5 ± 8.6 degrees, P = 0.0001 for KA; 55.8% ± 15.2% vs. 19.9% ± 10.9%, P = 0.0001 for HL). Fracture instability with intravertebral cleft, posterior wall involvement, midportion type of magnetic resonance classification, thoracolumbar level, and aortic calcification were significantly correlated with delayed NC. In multivariate analysis, initial HL (hazard ratio = 1.24; P = 0.012) and midportion-type fracture (hazard ratio = 14.9: P = 0.03) were the independent risk factors related to delayed NC. In addition, clinical outcomes at the last follow-up were significantly better in group 2. CONCLUSIONS: Initial HL and midportion-type fracture were correlated with delayed NC following OSFs. Moreover, pre-existing stenotic lesions might be associated with delayed NC.

Pharmacological target therapy of neuropathic pain and patient-reported outcomes in patients with chronic low back pain in Korea: Results from the NLBP Outcomes Research.

A number of studies have demonstrated an association of neuropathic pain and chronic low back pain (CLBP), but the outcome difference in each medical management is poorly understood. This study is aimed to investigate treatment patterns of neuropathic pain in CLBP patients and to explore patient-reported outcomes (PROs) including quality of life (QoL) and functional disability by treatment patterns.Data were extracted from the neuropathic low back pain (NLBP) outcomes research. It was a multicenter and cross-sectional study in which 1200 patients were enrolled at 27 general hospitals, from 2014 to 2015. Of total, 478 patients classified as neuropathic pain were used for this subgroup analysis. The patients were divided into 2 groups according to treatment patterns (with vs. without the targeted therapy [TT] of neuropathic pain). Demographic and clinical features were collected by chart reviews and PROs were measured by patient's survey. QoL was assessed by EuroQoL 5-dimension (EQ-5D) questionnaire. Functional disability was measured by the Quebec Back Pain Disability Scale (QBPDS). Multiple linear regression analyses were conducted to compare the PROs between TT group and non-targeted therapy (nTT) group.Among the NLBP patients (mean age 63years, female 62%), EQ-5D index, EuroQoL-Visual Analog Scale (EQ-VAS), and QBPDS Scores (mean ±â€Šstandard deviation) were 0.40 ±â€Š0.28, 54.98 ±â€Š19.98, and 46.03 ±â€Š21.24, respectively. Only 142 (29.7%) patients had pharmacological TT of neuropathic pain. Univariate analyses revealed no significant mean differences between TT group and nTT group in the EQ-5D index (0.41 ±â€Š0.27 and 0.39 ±â€Š0.28), EQ-VAS (56.43 ±â€Š18.17 and 54.37 ±â€Š20.69), and QBPDS (45.31 ±â€Š21.32 and 46.31 ±â€Š21.24). After adjustment with covariates, TT group had higher scores of EQ-5D index (ß = 0.07; P < 0.01) and EQ-VAS (ß = 4.59; P < 0.05) than the nTT group. The TT group's QBPDS score was lower than the nTT group, although its statistical significance still has not been reached (ß = -4.13; P = 0.07).We found that considerable proportion of the NLBP patients remains untreated or undertreated. Although TT group had significantly better QoL than nTT group, only 29.7% of NLBP patients had pharmacological TT. Therefore, clinicians should consider using TT for better QoL of neuropathic pain patients.

Delayed bilateral facet dislocation at L4-5: A case report.

RATIONALE: Traumatic bilateral facet dislocation in the lumbar (L) spine has rarely been reported. All reported cases were presented with acute facet dislocation. However, we present the first case of delayed bilateral facet dislocation at L4-5. PATIENT CONCERNS: A 34-year-old woman presented with back pain after a head-on collision. The patient was treated conservatively for 3 months with rigid orthosis and activity restriction. Even after this conservative treatment, she continued to suffer from persistent back pain that radiated down her left leg and a progressively kyphotic posture. DIAGNOSES: Initial imaging studies revealed a fracture of the left L5 superior articular process with a posterior ligament complex (PLC) injury. Subsequent radiographs showed the locked facet dislocation with kyphotic changes. INTERVENTIONS: The patient underwent surgical reduction and fusion, and the operative findings revealed the L4-5 bilateral facet dislocation and rupture of the PLC at the index level. OUTCOMES: After surgical reduction and fusion at L4-5 by posterior interbody fusion, we achieved a satisfactory clinical outcome. LESSONS: Injury of the PLC in the lower lumbar region deserves careful attention for the development of sequelae. The anatomic transition from lordosis to kyphosis, in the lumbosacral region may be related to this type of injury.

Delayed Height Loss After Kyphoplasty in Osteoporotic Vertebral Fracture with Severe Collapse: Comparison with Vertebroplasty.

OBJECTIVE: To compare clinical and radiographic outcomes and complications after vertebroplasty (VP) and kyphoplasty (KP) for osteoporotic vertebral fractures with severe collapse. METHODS: Patients >65 years old with single osteoporotic vertebral fracture (T10-L2) with severe collapse (>40%) were prospectively enrolled and allocated to either KP or VP. Visual analog scale and Oswestry Disability Index were used for clinical assessment. Vertebral height loss (HL) and segmental kyphotic angle were measured radiographically at preoperative; postoperative; and 1-, 3-, 6-, and 12-month postoperative time points. Procedure-related and postoperative complications were recorded. RESULTS: Forty-six patients (27 with VP, 19 with KP) were enrolled. Visual analog scale and Oswestry Disability Index scores were similar at all time points in the 2 groups. Complication rates were also similar. HL and kyphotic angle were restored significantly in both groups. KP showed a better result in HL (KP group HL 20.5% ± 5.6% vs. VP group HL 29.8% ± 4.6%, P < 0.001). Progressive vertebral HL was observed, and patients with KP showed a greater collapse in height. At 1-year follow-up, there was no significant difference in vertebral height (KP group HL 29.8% ± 6.3% vs. VP group HL 33.0% ± 5.2%, P = 0.075). CONCLUSIONS: KP and VP showed similar improvements in pain and disability during treatment for osteoporotic vertebral fractures. Although vertebral height and segmental kyphotic angle were restored significantly in both groups, progressive vertebral HL was inevitable, especially after KP. This likely resulted from the difference of bone-cement interface as a consequence of balloon tamping in KP. Surgeons must consider the respective features of vertebral augmentations.

A Comparative Study of Decompressive Laminectomy and Posterior Lumbar Interbody Fusion in Grade I Degenerative Lumbar Spondylolisthesis.

BACKGROUND: For Grade I degenerative lumbar spondylolisthesis (DLS), both decompression alone and decompression with fusion are effective surgical treatments. Which of the two techniques is superior is still under debate. The purpose of this study was to compare clinical outcomes after decompression alone versus decompression with fusion for Grade I DLS. MATERIALS AND METHODS: 139 patients who underwent surgery for Grade I DLS at L4-L5 were prospectively enrolled. Decompression alone was used to treat 74 patients, and decompression with fusion was used to treat 65 patients. Six patients in the first group and four patients in the second group were lost during the 2-year followup. Demographic data were recorded. Operation time, perioperative blood loss, total blood transfusion volume, and length of hospital stay were compared between the two groups. Back pain and functional outcomes were evaluated using the visual analog scale (VAS) and the Oswestry Disability Index (ODI), respectively. RESULTS: Baseline demographic data were not different between the two groups. Operation time, blood loss, total blood transfusion volume, and length of hospital stay were all significantly greater in the fusion group than in the decompression group. This would be expected because fusion is the more invasive procedure. VAS scores were not different up until 6 months postoperatively. Twelve months after surgery, however, VAS scores were significantly lower in the fusion group. The same results were shown in terms of ODI. Although ODI decreased in both groups over time, the fusion group showed better functional outcomes than did the decompression group. CONCLUSIONS: Although both decompression alone and decompression with fusion improved functional outcomes for Grade I DLS, fusion surgery resulted in better results compared to decompression alone. Therefore, fusion should be considered as the treatment of choice for Grade I DLS.

Predictive Factors for Postoperative Follow-up: Which Patients are Prone to Loss to Follow-up After Spinal Surgery?

STUDY DESIGN: Retrospective cohort study. OBJECTIVE: To find out the predictive factors for the failure to follow-up in patients who underwent spinal surgery. SUMMARY OF BACKGROUND DATA: Causes for loss to follow-up range from geographical accessibility to dissatisfaction with surgeons. There were few reports that investigated loss to follow-up after spinal surgery. METHODS: A total of 649 patients who underwent laminectomy and 193 patients who underwent L4-L5 fusion from August 2006 to August 2013 were enrolled in this retrospective study. In each surgical group, demographic data and comorbidities as assessed by the Charlson index were investigated and analyzed for correlation with follow-up. The between-group difference of failure to follow-up was also evaluated. RESULTS: The fusion group (n=193) was more likely to follow-up and the between-group difference was statistically significant (P=0.047). In the laminectomy group (n=649), 271 patients (41.8%) made regular hospital visits. Those who were male, had a spouse, or had fewer comorbidities were less prone to loss to follow-up (P<0.001). Other parameters including age, number of spinal segments operated on during surgery, distance from home to hospital, income, education level, and whether or not patients exercised were also significantly correlated with follow-up compliance (P>0.05). In contrast, 51.8% (n=100) of patients who underwent fusion had regular follow-ups. The fusion group showed a statistical difference in follow-up rate based only on sex (P=0.002). CONCLUSIONS: Our study shows that patients who underwent decompression alone were less likely to attend follow-up than were patients who underwent fusion surgery. Whereas the factors correlated with loss to follow-up after laminectomy alone were sex, marital status, and number of comorbidities, the only predictor after fusion was male sex. Sex was the only shared risk factor for loss to follow-up. LEVEL OF EVIDENCE: Level III.

Prevalence of Neuropathic Pain and Patient-Reported Outcomes in Korean Adults with Chronic Low Back Pain Resulting from Neuropathic Low Back Pain.

STUDY DESIGN: A noninterventional, multicenter, cross-sectional study. PURPOSE: We investigated the prevalence of neuropathic pain (NP) and patient-reported outcomes (PROs) of the quality of life (QoL) and functional disability in Korean adults with chronic low back pain (CLBP). OVERVIEW OF LITERATURE: Among patients with CLBP, 20%-55% had NP. METHODS: Patients older than 20 years with CLBP lasting for longer than three months, with a visual analog scale (VAS) pain score higher than four, and with pain medications being used for at least four weeks before enrollment were recruited from 27 general hospitals between December 2014 and May 2015. Medical chart reviews were performed to collect demographic/clinical features and diagnosis of NP (douleur neuropathique 4, DN4). The QoL (EuroQoL 5-dimension, EQ-5D; EQ-VAS) and functional disability (Quebec Back Pain Disability Scale, QBPDS) were determined through patient surveys. Multiple linear regression analyses were performed to compare PROs between the NP (DN4≥4) and non-NP (DN4<4) groups. RESULTS: A total of 1,200 patients (females: 65.7%; mean age: 63.4±13.0 years) were enrolled. The mean scores of EQ-5D, EQ-VAS, and QBPDS were 0.5±0.3, 55.7±19.4, and 40.4±21.1, respectively. Among all patients, 492 (41.0%; 95% confidence interval, 38.2%-43.8%) suffered from NP. The prevalence of NP was higher in male patients (46.8%; p<0.01), in patients who had pain based on radiological and neurological findings (59.0%; p<0.01), and in patients who had severe pain (49.0%; p<0.01). There were significant mean differences in EQ-5D (NP group vs. non-NP group: 0.4±0.3 vs. 0.5±0.3; p<0.01) and QBPDS (NP group vs. non-NP group: 45.8±21.2 vs. 36.3±20.2; p<0.01) scores. In the multiple linear regression, patients with NP showed lower EQ-5D (ß=-0.1; p<0.01) and higher QBPDS (ß=7.0; p<0.01) scores than those without NP. CONCLUSIONS: NP was highly prevalent in Korean patients with CLBP. Patients with CLBP having NP had a lower QoL and more severe dysfunction than those without NP. To enhance the QoL and functional status of patients with CLBP, this study highlights the importance of appropriately diagnosing and treating NP.

Liver Function Assessment Using Albumin-Bilirubin Grade for Patients with Very Early-Stage Hepatocellular Carcinoma Treated with Radiofrequency Ablation.

BACKGROUND/AIM: Assessment of liver function is essential for management of hepatocellular carcinoma (HCC). Recently, albumin-bilirubin (ALBI) grade has been reported as a useful tool for assessing hepatic reserve in patients with HCC. The objective of this study was to determine whether ALBI grade could be used to predict the overall survival of very early-stage HCC patients treated with radiofrequency ablation (RF ablation). METHODS: A cohort of 368 patients with very early-stage HCC treated with RF ablation was retrospectively analyzed. The overall survival and recurrence-free survival were calculated in groups classified by ALBI grade and Child-Pugh score. RESULTS: Overall survival of patients with ALBI grade 1 was better than that of patients with ALBI grade 2 (5-year survival rate 88.5 vs. 73.8%, P < 0.001). In multivariable-adjusted model, ALBI grade was found to be an independent factor associated with overall survival (hazard ratio 2.44; 95% confidence interval 1.43-4.15). ALBI grade was able to stratify patients with distinct overall survival among patients within the same Child-Pugh score (5-year survival rate for Child-Pugh score 5: 88.5 vs. 76.6%, P = 0.002; for Child-Pugh score 6: 88.9 vs. 70.1%, P = 0.064). In contrast, Child-Pugh score was unable to stratify patients with distinct overall survival within the same ALBI grade. CONCLUSIONS: Among patients with very early-stage HCC treated with RF ablation, ALBI grade was a good stratifying biomarker. ALBI grade was better tool for assessing liver function than Child-Pugh score for very early-stage HCC treated with RF ablation.

Clinical implication of serum uric acid level in pegylated interferon and ribavirin combination therapy for chronic hepatitis C infection.

BACKGROUND/AIMS: Combined treatment of pegylated interferon-α (PEG-IFN) and ribavirin (RBV) has long been accepted as the standard treatment for chronic hepatitis C virus (HCV) infection. Many predictive factors for treatment response have been identified. The aim of this study was to evaluate the efficacy and safety of combined PEG-IFN plus RBV and to examine the value of serum uric acid as a predictive factor in the treatment of chronic hepatitis C. METHODS: A total of 74 patients chronically infected with HCV were enrolled between December 2004 and June 2009. Patients received subcutaneous PEG-IFN (α-2a: 180 µg once a week) in combination with RBV (1,000 to 1,200 mg daily depending on body weight). We evaluated treatment responses represented by early virologic response (EVR), end-of-treatment response (ETR), sustained virologic response (SVR), and relapse, as well as diverse adverse events. Various viral and host features were also assessed to clarify factors associated with treatment response. RESULTS: During treatment, EVR was achieved in 26 patients (26/33, 78.8%) with HCV genotype 1. ETR and SVR were achieved in 59 (77.6%) and 56 patients (73.6%), respectively, across all genotypes. Genotype 2/3, lower HCV RNA, and lower uric acid were associated with higher SVR. CONCLUSIONS: The treatment response to combination therapy with PEG-IFN plus RBV was effective, especially in genotype 2/3. Uric acid might be useful as a predictive factor for response to therapy for chronic hepatitis.

Risk factors for adjacent segment degeneration after iliac screw fixation in lumbar degenerative kyphoscoliosis.

PURPOSE: To analyze pre- and postoperative spinopelvic parameters and sagittal profiles in lumbar degenerative kyphoscoliosis (LDK) patients who underwent surgery using iliac screw (IS) and the incidence and risk factor of radiological adjacent segment degeneration (ASD). METHODS: A total of 32 patients, who had undergone surgical correction and lumbar/thoracolumbar fusion with pedicle screws and IS instrumentation for LDK with a minimum 2-year follow-up, were included. Ten cases with ASD (group 1) and 22 cases without ASD (group 2) were compared to see pre- and postoperative change in sagittal view of spine and adjacent segment. Parameters of both groups were analyzed before and after surgery with each parameters being tested on correlativity. All deformity types of patients were classified using Scoliosis Research Society (SRS)-Schwab classification. Risk factors of ASD were evaluated using variables of SRS-Schwab classification. RESULTS: Group 1, rather than group 2, showed significant increment in pelvic incidence (PI). Curve types, classified using SRS-Schwab classification, were all corrected using IS; and after correction, coronal curve type was N curve and PI minus lumbar lordosis (LL) and pelvic tilt showed tendency to decrease. Cases with preoperative sagittal vertical axis (SVA) more than 10 cm and with postoperative PI minus LL more than 20° were at higher risk of developing ASD. CONCLUSION: For those with high PI, it might be a risk to cause ASD. Maintaining normal thoracic and lumbar angle, correction of SVA less than 4 cm, and PI minus LL below 20° are proper ways to avoid ASD after surgery.

Immunoproteasome induction is suppressed in hepatitis C virus-infected cells in a protein kinase R-dependent manner.

By changing the relative abundance of generated antigenic peptides through alterations in the proteolytic activity, interferon (IFN)-γ-induced immunoproteasomes influence the outcome of CD8+ cytotoxic T lymphocyte responses. In the present study, we investigated the effects of hepatitis C virus (HCV) infection on IFN-γ-induced immunoproteasome expression using a HCV infection cell culture system. We found that, although IFN-γ induced the transcriptional expression of mRNAs encoding the ß1i/LMP2, ß2i/MECL-1 and ß5i/LMP7 immunoproteasome subunits, the formation of immunoproteasomes was significantly suppressed in HCV-infected cells. This finding indicated that immunoproteasome induction was impaired at the translational or posttranslational level by HCV infection. Gene silencing studies showed that the suppression of immunoproteasome induction is essentially dependent on protein kinase R (PKR). Indeed, the generation of a strictly immunoproteasome-dependent cytotoxic T lymphocyte epitope was impaired in in vitro processing experiments using isolated 20S proteasomes from HCV-infected cells and was restored by the silencing of PKR expression. In conclusion, our data point to a novel mechanism of immune regulation by HCV that affects the antigen-processing machinery through the PKR-mediated suppression of immunoproteasome induction in infected cells.