Risk factors for mechanical complications after fusion extension surgery for lumbar adjacent segment disease.

PURPOSE: Adjacent segment disease (ASD) is a common complication in fusion surgery. In the event of solid segmental fusion, previous implants can be removed or preserved during fusion extension for ASD. To compare the surgical outcomes of patients with and without implants and analyzes the risk factors for postoperative mechanical complications. METHODS: Patients who underwent fusion extension for lumbar ASD from 2011 to 2019 with a minimum 2 year follow-up were retrospectively reviewed. Spinopelvic parameters were measured preoperatively and postoperatively. Clinical outcomes and surgical complications were compared between groups with implants preserved and removed. Risk factors for mechanical complications, including clinical, surgical, and radiographic factors were analyzed. RESULTS: Sixty-nine patients (mean age, 69.9 ± 6.9 years) were included. The mean numbers of initial and extended fused segments were 2.8 ± 0.7 and 2.7 ± 0.7, respectively. Previous implants were removed in 43 patients (R group) and preserved in 26 patients (P group). Both groups showed an improvement in clinical outcomes without between-group differences. The operation time was significantly longer in R group (260 vs 207 min, p < 0.001). Mechanical complications occurred in 13 patients (12 in R group and 1 in P group) and reoperation was needed in 3 patients (R group). Implant removal, index fusion surgery including L5-S1, and postoperative sagittal malalignment were risk factors for mechanical complications. CONCLUSION: Implant removal was a risk factor for mechanical complications. Index fusion surgery including L5-S1 and postoperative sagittal malalignment were also risk factors for mechanical complications.

Autophagy in an extruded disc compared to the remaining disc after lumbar disc herniation in the same patient.

PURPOSE: The purpose of this study was to investigate autophagy in an extruded disc and to compare this activity with the activity in the remaining disc after lumbar disc herniation in the same patient. METHODS: In total, 12 patients (females 4, males 8) with the extruded type of lumbar disc herniation (LDH) were surgically treated. Their mean age was 54.3 ± 15.8 years (range: 29 ~ 78 years). The mean interval from the occurrence of symptoms to the operation was 9.8 ± 9.4 weeks (range: 2 ~ 24 weeks). The extruded discs were excised, and the remaining disc material removed, to prevent recurrence of herniation. Immediately after specimen collection, all tissues were stored at -70 °C prior to analysis. Autophagy was assessed immunohistochemically and via Western blotting for Atg5, Atg7, Atg12, Atg12L1, and Beclin-1. And the relationship between autophagy and apoptosis was investigated by correlation analysis of caspase-3 with autophagy proteins. RESULTS: The expression levels of autophagic markers were significantly increased in the extruded discs compared to the remaining discs within the same patients. The mean expression levels of Atg5, Atg7, Atg12, and Beclin-1 in extruded discs were statistically significantly higher than those in the remaining discs (P < 0.01, P < 0.001, P < 0.01, and P < 0.001 respectively). CONCLUSIONS: The autophagic pathway was more active in extruded disc material than in remaining disc material within the same patient. This may explain spontaneous resorption of the extruded disc after LDH.

Structural analysis of customized 3D printed plate for pelvic bone by comparison with conventional plate based on bending process.

Pelvic bone fracture is highly complex, and its anatomical reduction is difficult. Therefore, patient-specific customized plates have been developed using three-dimensional (3D) printing technology and are being increasingly used. In this study, the reduction status in five representative pelvic fracture models was compared between two groups: the 3D printing plate (3DP) group using a patient-specific 3D printed plate after virtual reduction and the conventional plate (CP) group using a conventional plate by manual bending. The 3DP and CP groups included 10 and 5 cases, respectively. The fractured models were reduced virtually and their non-locking metal plates were customized using 3D printing. The process of contouring the conventional plates to fit the contact surface of the bone with the bending tool was conducted by an experienced pelvic bone trauma surgeon. The reduction and fixation achieved using the two different plate groups was compared, and the significance of differences in the results was analyzed using paired t-tests, after verifying the normality of data distribution. The vertex distances between the surface of the bone and the contact surface of the plate were significantly lower in the 3DP group than in the CP group (0.407 ± 0.342 and 2.195 ± 1.643, respectively, P = 0.008). Length and angular variations, which are measurements of the reduction state, were also lower in the 3DP group than in the CP group (length variation: 3.211 ± 2.497 and 5.493 ± 3.609, respectively, P = 0.051; angular variation: 2.958 ± 1.977 and 4.352 ± 1.947, respectively, P = 0.037). The customized 3D printed plate in the virtual reduction model provided a highly accurate reduction of pelvic bone fractures, suggesting that the customized 3D printed plate may help ensure easy and accurate reduction.

Effects of bone cement augmentation for uppermost instrumented vertebra on adjacent disc segment degeneration in lumbar fusions.

OBJECTIVE: We investigated the long-term effects of bone cement-augmented instrumentation in multilevel lumbar fusions in a retrospective cohort study. The use of cement-augmented screws is one of the techniques used to reduce early mechanical failure in treating multilevel lumbar fusion, especially in the elderly. However, little information is available regarding the long-term effects. METHODS: A total of 51 patients who had undergone ≥3 levels of lumbar fusion were divided into two groups according to the use of bone cement-augmented screw fixation involving the upper instrumented vertebra: 22 patients in the cement-augmented group (group I) and 29 patients in the non-cement-augmented group (group II). Analysis of radiographic adjacent disc segment degeneration (ASD) revealed patients with lumbosacral fusion with a similar degree of osteoporosis. Radiologic ASD was defined as progression of >2 UCLA (University of California, Los Angeles) grades at 2 years postoperatively. Other sagittal parameters and the preoperative magnetic resonance imaging Pfirrmann grades at the adjacent levels, possibly related to ASD, were also analyzed. RESULTS: No significant differences were present in the preoperative demographic and radiographic parameters between the 2 groups. However, the postoperative kyphotic changes at 3 months were greater for the non-cement-augmented group. In terms of the long-term effects, the incidence of radiologic ASD (group I, n = 20 [95.2%]; vs group II, n = 15 [53.6%]) was significantly higher in the cement-augmented group. Logistic regression analysis of radiologic ASD, including other clinical and radiologic parameters, postoperative pelvic incidence-lumbar lordosis mismatch (odds ratio, 5.201; 95% confidence interval, 1.123-24.090; P = 0.035), and cement augmentation (odds ratio, 20.193; 95% confidence interval, 2.195-185.729; P = 0.008) showed a significant correlation with the development of radiologic ASD at 2 years postoperatively. CONCLUSIONS: Although bone cement-augmented screw implantation can prevent kyphotic deformation at the proximal junction of upper instrumented vertebra in the early postoperative stages of multilevel lumbar fusion, a careful selection of patients is required because of possibly accelerated degeneration of adjacent segments.

Neonatal outcome after preterm delivery in HELLP syndrome.

The present study compares neonatal outcome after preterm delivery of infants in pregnancies complicated by the HELLP syndrome or severe preeclampsia (PS). The maternal and neonatal charts of 71 out of a total of 409 pregnancies that were complicated by hypertensive disorders at Severance hospital between January 1995 and December 2004 were reviewed. Twenty-one pregnancies were complicated by HELLP syndrome and 50 pregnancies were complicated by PS. Fifty normotensive (NT) patients who delivered because of preterm labor comprised the control group. Results were analyzed by the chi-square test and ANOVA. Gestational age and maternal age at delivery were matched among the three groups. The neonatal outcomes of the HELLP syndrome group were compared with the PS and NT groups. There were significant differences between the HELLP syndrome group and the PS group in the incidence of intraventricular hemorrhage (IVH) (61.9% vs. 26%, p=0.006), sepsis (85.7% vs. 44%, p =0.003) and mechanical ventilation (MV) rate (81% vs. 54%, p=0.039). There were significant differences between the HELLP syndrome group and the NT group in the incidence of neonatal death (ND) (19.5% vs. 2.0%, p=0.034), respiratory distress syndrome (RDS) (38.1% vs. 8%, p=0.0045), IVH (61.9% vs. 4%, p < 0.0001), sepsis (85.7% vs. 14%, p < 0.0001), intensive care (IC) (85.7% vs. 24%, p < 0.0001) and MV rate (80.1% vs. 14%, p < 0.0001). There were also significant differences between the PS and NT groups in the incidence of ND (20% vs. 2%, p=0.0192), RDS (30% vs. 8%, p=0.0085), IVH (26% vs. 4%, p=0.0070), sepsis (44% vs. 14%, p=0.0015), IC (78% vs. 24%, p < 0.0001), MV rate (54% vs. 14%, p < 0.0001) and low 5-min APGAR score (50% vs. 16%, p=0.0005). This study shows increased morbidity in newborns of mothers complicated with HELLP syndrome and indicates that early, regular and high quality management of these patients is essential to improve both maternal and neonatal outcome.

Relationship between obesity and the risk of gynecologic laparoscopy in Korean women.

STUDY OBJECTIVE: To determine whether obesity increases risk of performing laparoscopic gynecologic surgery in Korean women. DESIGN: Retrospective analysis over 35 consecutive months (Canadian Task Force classification II-2). SETTING: University-affiliated hospital. PATIENTS: Two hundred seventy-seven women who underwent gynecologic laparoscopic surgery. INTERVENTION: Patients were analyzed by chart review. MEASUREMENTS AND MAIN RESULTS: Obesity was defined as body mass index (BMI) 25 kg/m(2) or greater. Patients were categorized on the basis of BMI [weight (kg)/height(2) (m(2))] as obese (BMI > or =25, 74 women) or nonobese (BMI < 25, 203). Each group was further divided into three subgroups according to operation difficulty. No significant differences in patient age, parity, menopausal status, medicosurgical illness, or history of intraabdominal surgery were apparent between groups, except for distribution of operation difficulty and adhesion grade; however, the adhesion grade was evenly distributed in each operation grade subgroup. In the two BMI groups, no significant differences were seen in surgical values (estimated blood loss, operating time, operative complications, postoperative complications, hospital stay, rate of conversion to laparotomy). CONCLUSION: Obesity had generally been thought to increase the risk of laparoscopic surgery. In our study in obese Korean women, however, it did not seem to increase the risk, and gynecologic laparoscopic surgery was performed safely.