The impact of instrumented lumbar fusion surgery on psychiatric problems in elderly patients with degenerative spinal stenosis: The observational study.

This is a prospective cohort study to investigate the effects of instrumented lumbar fusion surgery on psychiatric problems, including anxiety, insomnia, and depression, in patients with degenerative spinal stenosis, as well as on pain and the activities of daily living. Surgery was performed in the patients with Schizas grade C or D spinal stenosis with; if a patient's quality of life was impaired for at least 3 months or if patient had neurologic deficits. Finally, 69 patients were reviewed. Beck anxiety inventory, insomnia severity index, geriatric depression scale short form-Korean, visual analog scale for back pain, visual analog scale for leg pain, and Oswestry disability index was measured on the day surgery was decided on (T1), the day before surgery (T2), the day before discharge (T3), and 6 months after surgery (T4). The patients had mild degrees of anxiety, insomnia, and depression at T1, and Beck anxiety inventory, insomnia severity index, visual analog scale for back pain, visual analog scale for leg pain, and Oswestry disability index improved significantly by T4. In elderly patients with degenerative spinal stenosis, instrumented lumbar fusion surgery improves not only pain and activities of daily living, but also anxiety and insomnia. However, there was no improvement in depression over the 6-month follow-up period.

Effect of Congenital C4-5 Synostosis on Adjacent Mobile Segments: Radiographic Assessment.

STUDY DESIGN: Prospective case series. PURPOSE: To assess the corporal morphology of the fused body and adjacent segment conditions. OVERVIEW OF LITERATURE: It is known that two fused vertebral bodies take the similar shape of the single body with inwaisting, with or without caudal flaring of the fused body, and that the fused body can cause the fusion disease at the adjacent segment that can be a risk factor for potential neurological compromise. METHODS: Radiograms of the 11 study subjects (six men and five women), aged 22-90 years who visited the outpatients' clinic for various neck complaints without trauma history were examined. C4-5 synostosis was an incidental finding in all the subjects. RESULTS: All the fused bodies were inwaisted and had anterior caudal breaking but no interior corporal flaring. Adjacent segment disease was not found in eight patients aged <40 years. Disk degeneration was found at C3-4 and C5-6 in three patients each and at C6-7 in two patients. Disk degeneration was limited to the adjacent segments. CONCLUSIONS: Degenerative disk changes are associated with the natural aging process, and the corporal morphology of the fused vertebral becomes inwaisted similar to that in the single vertebrae.

Pavlov's Ratio of the Cervical Spine in a Korean Population: A Comparative Study by Age in Patients with Minor Trauma without Neurologic Symptoms.

BACKGROUD: There are many studies on the vertebral body-to-canal ratio, the so-called Pavlov's ratio of the cervical spine. However, there are no studies on its relation with age to clarify each bony component's contribution to the spinal canal formation and its size. The aim of this study was to investigate differences and changes in the vertebral body-to-canal ratio according to age in an asymptomatic population. METHODS: This is a cross-sectional study of 280 asymptomatic individuals. A total of 140 men and 140 women representing each decade of life from the first to the seventh were included in this study. The anteroposterior length of the vertebral body and canal from C3 to C6 was measured on sagittal radiographs to calculate the vertebral body-to-canal ratio. RESULTS: The average Pavlov's ratio was significantly larger (p < 0.001) in the first decade of life. The average Pavlov's ratio of the individuals in the first decade of life was 1.09 between C3 and C6 (1.08 at C3, 1.07 at C4, 1.11 at C5, and 1.13 at C6; range, 0.78-1.51). There was no significant difference among the other decades of life. CONCLUSIONS: We assessed the Pavlov's ratio of the cervical spine in an asymptomatic population. It is our belief that the spinal canal size is the largest in the first decade of life, and the Pavlov's ratio becomes almost fixed throughout life after maturity.

The Impact of Epinephrine in the Periarticular Injection Cocktail using Ropivacaine for Total Knee Arthroplasty: A Prospective, Randomized, Double-Blind Comparison Study.

BACKGROUND: Epinephrine is used in periarticular injection using ropivacaine to produce a synergistic effect when used with local anesthetic agents but the effect has not been proven yet. The purpose of this study is to evaluate how effective epinephrine is on postoperative clinical outcomes in primary total knee arthroplasty (TKA). METHODS: One hundred sixteen cases (89 patients) who underwent primary TKA were randomized into 2 groups depending on whether epinephrine was mixed. Immediately after the operation, patient-controlled analgesia using fentanyl was initiated. The Numerical Rating Scale, the cumulative dose of fentanyl, active range of motion of the knee joint, and wound complications were evaluated postoperatively. RESULTS: There were no significant differences in mean postoperative Numerical Rating Scale, cumulative dose of fentanyl, and active range of motion between the 2 groups. Neither skin necrosis nor wound dehiscence requiring operative management for skin care was required in either group. CONCLUSION: The use of epinephrine in periarticular injection using ropivacaine after TKA did not have any effect on postoperative acute pain control and opioid usage. THE LEVEL OF EVIDENCE: Therapeutic level I.

MRI comparison of injury mechanism and anatomical factors between sexes in non-contact anterior cruciate ligament injuries.

Non-contact anterior cruciate ligament (ACL) rupture is mostly caused by a pivot shift mechanism including valgus collapse and internal tibial rotation. In female athletes, the incidence of ACL rupture has been reported to be significantly higher than in their male counterparts. However, to date, there have been limited reports and controversy regarding sex differences underlying injury mechanisms of ACL and severity of injury. In this study, we hypothesized that 1) in patients with non-contact ACL rupture, the incidence and severity of pivot shift injury, which are determined by injury pattern on MRI, would be significantly higher in females, and 2) anatomical factors associated with pivot shift injury would be significantly associated with female sex. A total of 148 primary ACL ruptures (145 patients) caused by non-contact injury mechanisms were included in this study. Among them, 41 knees (41 patients) were female and 107 knees (104 patients) were male. The status of the osseous lesions, lateral and medial tibial slope, depth of the medial tibial plateau, collateral ligaments, and menisci were assessed by MRI and compared between sexes. The severity of osseous lesions at the lateral tibial plateau, lateral femoral condyle, medial tibial plateau, and medial femoral condyle were comparable between sexes. There were no significant differences between sexes in the location of tibial contusions (p = 0.21), femoral contusions (p = 0.23), or meniscus tears (p = 0.189). Lateral tibial slope was found to be significantly larger in females (8.95° vs. 6.82°; p<0.0001; odds ratio = 1.464), and medial tibial depth was significantly shallower in females (1.80mm vs. 2.41mm; p<0.0001; odds ratio = 0.145). In conclusion, females showed greater lateral tibial slope and shallower medial tibial depth compared to males, however it did not affect the sex differences in injury pattern.

Magnetic Resonance Imaging-Based Prevalence of Anterolateral Ligament Abnormalities and Associated Injuries in Knees with Acute Anterior Cruciate Ligament Injury.

The purpose of this study was to determine and compare the prevalence of anterolateral ligament abnormality and associated injuries among patients with complete and partial anterior cruciate ligament tears. In addition, the prevalence of associated injuries with anterolateral ligament abnormality was further analyzed. Of the 158 patients diagnosed with acute anterior cruciate ligament tear, 82 patients were diagnosed with acute complete anterior cruciate ligament confirmed by magnetic resonance imaging (MRI) and arthroscopic procedures (Group C), and 74 patients were diagnosed with acute partial anterior cruciate ligament tears confirmed by MRI (Group P). The status of the anterolateral ligament, collateral ligaments, menisci, and osseous lesions was assessed. There was a significantly higher prevalence of anterolateral ligament abnormalities in Group C than Group P (36.6 vs. 4.1%, p < 0.001). Medial collateral ligament, lateral collateral ligament, Segond fracture, osseous lesion at the fibular head, lateral tibial plateau, lateral femoral condyle, and medial tibial plateau were significantly associated with anterolateral ligament abnormality. Furthermore, severity of osseous lesion at the lateral tibial plateau, lateral femoral condyle, and medial tibial plateau was significantly associated (with linear correlation) with anterolateral ligament abnormality. The prevalence of anterolateral ligament abnormality was significantly higher in patients with complete anterior cruciate ligament tear (36.6%) than those with partial anterior cruciate ligament tear (4.1%), but with noticeable prevalence of anterolateral ligament abnormality in the partial anterior cruciate ligament tear group. Associated lesions significant to anterolateral ligament abnormality were tears in both collateral ligaments, lateral-sided osseous lesions, and osseous lesion of the medial tibial plateau.

Risk factors for newly developed osteoporotic vertebral compression fractures following treatment for osteoporotic vertebral compression fractures.

BACKGROUND CONTEXT: It has been reported that newly developed osteoporotic vertebral compression fractures (OVCFs) occur at a relatively high frequency after treatment. While there are many reports on possible risk factors, these have not yet been clearly established. PURPOSE: The purpose of this study was to investigate the risk factors for newly developed OVCFs after treatment by vertebroplasty (VP), kyphoplasty (KP), or conservative treatment. STUDY DESIGN/SETTING: A retrospective comparative study. PATIENT SAMPLE: One hundred thirty-two patients who had radiographic follow-up data for one year or longer among 356 patients who were diagnosed with OVCF and underwent VP, KP or conservative treatment between March 2007 and February 2016. OUTCOME MEASURES: All records were examined for age, sex, body mass index (BMI), rheumatoid arthritis and other medical comorbidities, osteoporosis medication, bone mineral density (BMD), history of vertebral and nonvertebral fractures, treatment methods used, level of fractures, and presence of multiple fracture sites. METHODS: Patients were divided into those who manifested new OVCF (Group A) and those who did not (Group B). For the risk factor analysis, student's t-tests and chi-square tests were used in univariate analysis. Multivariate logistic regression analysis was carried out on variables with a p<.1 in the univariate analysis. RESULTS: Newly developed OVCFs occurred in 46 of the 132 patients (34.8%). Newly developed OVCF increased significantly with factors such as average age (p=.047), low BMD T-score of the lumbar spine (p=.04) and of the femoral neck (p=.046), advanced age (>70 years) (p=.011), treatment by cement augmentation (p=.047) and low compliance with osteoporosis medication (p=.029). In multivariate regression analysis, BMD T-score of the lumbar spine (p=.009) and treatment by cement augmentation (p=.044) showed significant correlations with the occurrence of new OVCFs with a predictability of 71.4%. CONCLUSION: Osteoporotic vertebral compression fracture patients with low BMD T-score of the lumbar spine and those who have been treated by cement augmentation have an increased risk of new OVCFs after treatment and, therefore, require especially careful observation and attention.

Magnetic Resonance Imaging Observations of the Conus Medullaris in a Korean Population.

STUDY DESIGN: Retrospective study (level of evidence: level 3). PURPOSE: To study the anatomy of the conus medullaris in Koreans. OVERVIEW OF LITERATURE: The anatomical position of the conus medullaris is well-documented in anatomy textbooks; however, the shape of the conus in the canal rarely described. Furthermore, to our knowledge, no study in Korea has not yet assessed the shape of the conus as well as its position in the canal via cadavaric dissection and/or magnetic resonance imaging (MRI). METHODS: MRI findings of 189 Korean patients aged 2-94 years (93 men and 94 women) were assessed. No subjects from other ethnicities were included. The method proposed by Arai and colleagues was used to assess the termination point and shape of the conus in the canal. The position of the intervertebral disc trisection of the vertebral body closest to the tip of the conus was recorded at the canal level. RESULTS: The tip of the conus medullaris was positioned from the upper T12 body to the L2-L3 disc, mostly in L1 bodies (52.4%), followed by the L2 bodies (22.5%), the L1-L2 disc, and the L2-L3 disc (1.1%). The shape of the conus was classified as type A in 74 (39.6%), type B in 58 (31%), and type C in 55 patients (29.4%). The conus did not terminate at the L3 body in any patient. In the first decade ones (five children) conus positioned rather lowly from L1 bodies to L2-L3 disc, and no type A conus shape, and mostly type B (80%). CONCLUSIONS: The conus medullaris was positioned mostly in the lower one-third of L1 and it in the first decades terminated lowly. No type A in the first decade one, and type B was mostly frequently formed which was followed by type C.

Co-Amorphous Screening for the Solubility Enhancement of Poorly Water-Soluble Mirabegron and Investigation of Their Intermolecular Interactions and Dissolution Behaviors.

In the present study, the screening of Mirabegron (MBR) co-amorphous was performed to produce water-soluble and thermodynamically stable MBR co-amorphous with the purpose of overcoming the water solubility problem of MBR. MBR is Biopharmaceutics Classification System (BCS) class II drug used for the treatment of an overreactive bladder. The co-amorphous screening was carried out by means of the vacuum evaporation crystallization technique in methanol solvent using three water-soluble carboxylic acids, characterized by a pKa difference greater than 3 with MBR such as fumaric acid (FA), l-pyroglutamic acid (PG), and citric acid (CA). Powder X-ray diffraction (PXRD) results suggested that all solid materials produced at MBR-FA (1 equivalent (eq.)/1 equivalent (eq.)), MBR-PG (1 eq./1 eq.), and MBR-CA (1 eq./1 eq.) conditions were amorphous state solid materials. Furthermore, by means of solution-state nuclear magnetic resonance (NMR) (¹H, 13C, and 2D) and attenuated total reflection Fourier transform infrared (ATR-FTIR) spectroscopy, we could assess that MBR and carboxylic acid molecules were linked via ionic interactions to produce MBR co-amorphous. Besides, solid-state cross polarization (CP)/magic angle spinning (MAS) 13C-NMR analysis was conducted for additional assessment of MBR co-amorphous. Afterwards, dissolution tests of MBR co-amorphouses, MBR crystalline solid, and MBR amorphous were carried out for 12 h to evaluate and to compare their solubilities, dissolution rates, and phase transformation phenomenon. Here, the results suggested that MBR co-amorphouses displayed more than 57-fold higher aqueous solubility compared to MBR crystalline solid, and PXRD monitoring result suggested that MBR co-amorphouses were able to maintain their amorphous state for more than 12 h. The same results revealed that MBR amorphous exhibited increased solubility of approximatively 6.7-fold higher compared to MBR crystalline solid. However, the PXRD monitoring result suggested that MBR amorphous undergo rapid phase transformation to crystalline form in just 35 min and that within an hour all MBR amorphous are completely converted to crystalline solid. Accordingly, the increase in MBR co-amorphous' solubility was attributed to the presence of ionic interactions in MBR co-amorphous molecules. Moreover, from the differential scanning calorimetry (DSC) monitoring results, we predicted that the high glass transition temperature (Tg) of MBR co-amorphous compared to MBR amorphous was the main factor influencing the phase stability of MBR co-amorphous.

Outcome of 3.5-mm Anatomical Locking Plates for the Treatment of Proximal Tibia Fractures Involving the Meta-Diaphyseal Junction.

The clinical and radiological outcomes of proximal tibia fractures involving the meta-diaphyseal junction treated with unilateral 3.5-mm locking precontoured anatomical plates are reported. Thirty-nine patients (41 proximal tibia fractures) who had proximal tibia fractures with complete meta-diaphyseal dissociation were enrolled in the study. For all patients, immediate postoperative and final follow-up simple radiographs were evaluated to determine the quality of the reduction by assessing coronal and sagittal alignment. In cases of intra-articular involvement, articular reduction quality and condylar width were additionally assessed. Clinical outcomes were assessed by knee range of motion and Lysholm knee score at final follow-up. Immediate postoperative radiographs showed satisfactory results: medial proximal tibial angle within 87°±5° in 87.8% (36 of 41), posterior tibia slope within 9°±5° in 85.4% (35 of 41), less than 2-mm articular step or gap in 79.3% (23 of 29), and a condylar width difference within 5 mm compared with the femoral condyles in 93.1% (27 of 29). All reductions but 1 were found to have satisfactory maintenance of the initial reduction. At final follow-up, the mean knee range of motion and Lysholm knee score were 122.5° (range, 100°-135°) and 75.8 (range, 50-100), respectively. A single lateral 3.5-mm plate fixation for proximal tibia fractures involving the meta-diaphyseal junction offers mechanically stable fixation with satisfactory clinical and radiological outcomes. [Orthopedics. 2018; 41(6):e777-e782.].

Estrogen deficiency exacerbates Aß-induced memory impairment through enhancement of neuroinflammation, amyloidogenesis and NF-ĸB activation in ovariectomized mice.

Estrogen is well known to have a preventative effect in Alzheimer's disease (AD) pathology. Several studies have demonstrated that nuclear factor kappa-B (NF-ĸB) can contribute to the effects of estrogen on the development of AD. We investigated whether NF-ĸB affects amyloid-beta (Aß)-induced memory impairment in an estrogen-lacking condition. In the present study, nine-week-old Institute cancer research (ICR) mice were ovariectomized to block estrogen stimulation. Ten weeks after the ovariectomization, mice were administered with Aß (300 pmol) via intracerebroventricular (ICV) infusion for 2 weeks. Memory impairment, neuroinflammatory protein expression, and amyloidogenic pathways were then measured. Ovariectomized mice demonstrated severe memory impairment, Aß accumulation, neprilysin downregulation, and activation of NF-ĸB signaling compared to sham-control mice. In vitro experiments demonstrated that ß-estradiol (10 µM) inhibited Aß (1 µM)-induced neuroinflammation in microglial BV-2 cells and prevented Aß-induced cell death in primary cultured neuronal cells. As in in vivo experiments, NF-ĸB activation was significantly upregulated in in vitro experiments. Furthermore ß-estradiol treatment inhibited NF-ĸB activation in both of microglial BV-2 cells and cultured neuronal cells. These findings suggest that estrogen may protect against memory impairment through the regulation of Aß accumulation and neurogenic inflammation by inhibiting NF-κB activity.

Antarctic Krill Oil Diet Protects against Lipopolysaccharide-Induced Oxidative Stress, Neuroinflammation and Cognitive Impairment.

Oxidative stress and neuroinflammation are implicated in the development and pathogenesis of Alzheimer's disease (AD). Here, we investigated the anti-inflammatory and antioxidative effects of krill oil. Oil from Euphausia superba (Antarctic krill), an Antarctic marine species, is rich in eicosapentaenoic acid (EPA) and docosahexaenoic acid (DHA). We examined whether krill oil diet (80 mg/kg/day for one month) prevents amyloidogenesis and cognitive impairment induced by intraperitoneal lipopolysaccharide (LPS) (250 µg/kg, seven times daily) injections in AD mice model and found that krill oil treatment inhibited the LPS-induced memory loss. We also found that krill oil treatment inhibited the LPS-induced expression of inducible nitric oxide synthase (iNOS) and cyclooxygenase-2 (COX-2) and decreased reactive oxygen species (ROS) and malondialdehyde levels. Krill oil also suppresses IκB degradation as well as p50 and p65 translocation into the nuclei of LPS-injected mice brain cells. In association with the inhibitory effect on neuroinflammation and oxidative stress, krill oil suppressed amyloid beta (1-42) peptide generation by the down-regulating APP and BACE1 expression in vivo. We found that eicosapentaenoic acid (EPA) and docosahexaenoic acid (DHA) (50 and 100 µM) dose-dependently decreased LPS-induced nitric oxide and ROS generation, and COX-2 and iNOS expression as well as nuclear factor-κB activity in cultured microglial BV-2 cells. These results suggest that krill oil ameliorated impairment via anti-inflammatory, antioxidative, and anti-amyloidogenic mechanisms.

Outcomes of Revision Surgery Following Instrumented Posterolateral Fusion in Degenerative Lumbar Spinal Stenosis: A Comparative Analysis between Pseudarthrosis and Adjacent Segment Disease.

STUDY DESIGN: Retrospective study. PURPOSE: We examined the clinical and radiological outcomes of patients who received revision surgery for pseudarthrosis or adjacent segment disease (ASD) following decompression and instrumented posterolateral fusion (PLF). OVERVIEW OF LITERATURE: At present, information regarding the outcomes of revision surgery for complications such as pseudarthrosis and ASD following instrumented PLF is limited. METHODS: This study examined 60 patients who received PLF for degenerative lumbar spinal stenosis and subsequently developed pseudarthrosis or ASD leading to revision surgery. Subjects were divided into a group of 21 patients who received revision surgery for pseudarthrosis (Group P) and a group of 39 patients who received revision surgery for ASD (Group A). Clinical outcomes were evaluated using the visual analogue scales for back pain (VAS-BP) and leg pain (VAS-LP), the Korean Oswestry disability index (K-ODI), and each patient's subjective satisfaction. Radiological outcomes were evaluated from the extent of bone union, and complications in the two groups were compared. RESULTS: VAS-LP at final follow-up was not statistically different between the two groups (p =0.353), although VAS-BP and K-ODI at final follow-up were significantly worse in Group P than in Group A (all p <0.05), and only 52% of the patients in Group P felt that their overall well-being had improved following revision surgery. Fusion rates after the first revision surgery were 71% (15/21) in Group P and 95% (37/39) in Group A (p =0.018). The rate of reoperation was significantly higher in Group P (29%) than in Group A (5%) (p =0.021) due to complications. CONCLUSIONS: Clinical and radiological outcomes were worse in patients who had received revision surgery for pseudarthrosis than in those who had revision surgery for ASD. Elderly patients should be carefully advised of the risks and benefits before planning revision surgery for pseudarthrosis.

Molluscum contagiosum as a skin manifestation of immune reconstitution inflammatory syndrome in an AIDS patient who is receiving HAART.

Highly active antiretroviral therapy (HAART), which restores specific immune responses, may paradoxically cause an inflammatory reaction known as immune reconstitution inflammatory syndrome (IRIS). We report a patient with acquired immune deficiency syndrome, who presented Molluscum contagiosum as IRIS after HAART, the first case in Korea.