The positive impact of smoking cessation on fracture risk in a nationwide cohort study.

Many studies sought to demonstrate the association between smoking and fracture risk. However, the correlation between smoking and fractures remains controversial. This study aimed to examine the impact of smoking and smoking cessation on the occurrence of fractures using prospective nationwide cohort data. We enrolled those who underwent a National Health Insurance Service (NHIS) health checkup in 2009-2010 who had a previous health checkup 4-year prior (2005-2006). The study population of 4,028,559 subjects was classified into three groups (non-smoker, smoking cessation, current smoker). The study population was also analyzed according to fracture type (all fractures, vertebral fracture, hip fracture). Lastly, the smoking cessation group and current smoker group were divided into four subgroups based on a lifetime smoking amount cut-off of 20 pack-years (PY). Multivariate-adjusted hazard ratios (HRs) of fracture were examined through a Cox proportional hazards model. After multivariable adjustment, non-smokers showed the lowest risk of fracture (HR = 0.818, CI 0.807-0.828, p < 0.0001) and smoking cessation significantly lowered the risk of fracture (HR 0.938, 95% CI 0.917-0.959, p < 0.0001) compared to current smokers. Regardless of 20PY, all smoking cessation subgroups showed significantly less risk of fractures than current smokers with ≥ 20PYs. Smoking increases the risk of fracture, and smoking cessation lowers the risk of fracture.

Weight changes after smoking cessation affect the risk of vertebral fractures: a nationwide population-based cohort study.

BACKGROUND CONTEXT: Smoking cessation reduces the risk of vertebral and hip fractures but usually increases body weight. Since underweight is known as a risk factor for vertebral fractures, smoking cessation is considered to have a protective effect on vertebral fractures. However, the actual effect of weight change after smoking cessation on the risk of vertebral fractures remains uncertain. PURPPOSE: This study aimed to assess the risk of vertebral fractures among individuals who reported smoking cessation with a specific focus on changes in body weight. STUDY DESIGN: Retrospective cohort study based on nationwide health insurance database. PATIENT SAMPLE: Participants were from nationwide biennial health checkups between 2007 and 2009 conducted by the Korean National Health Insurance Service. Participants were followed up from 2010 to 2018 to find incidence of newly developed vertebral fractures. OUTCOME MEASURES: The incidence rate was defined as the incidence rate (IR) per 1,000 person-years (PY). Cox proportional regression analysis was used to analyze the risk of vertebral fracture to determine the hazard ratio (HR) associated with the incidence of vertebral fractures based on smoking status and weight changes. METHODS: Based on their self-reported questionnaires, the participants were classified into three groups: current smokers, quitters, and nonsmokers. The quitter was defined as an individual who were smokers in 2007 and ceased smoking in 2009. Individuals with smoking cessation were categorized according to the weight change between baseline and 2 years prior: weight maintenance (-5∼5 % of weight change), weight loss (<-5 % of weight change), and weight gain (>5 % of weight change). We used Cox proportional hazards analysis to determine the hazard ratio (HR) associated with the incidence of vertebral fractures based on smoking status and temporal weight change over 2 years. RESULTS: This study evaluated 913,805 eligible participants, of whom 672,858 were classified as nonsmokers, 34,143 as quitters, and 206,804 as current smokers. Among quitters, 2,372 (6.9%) individuals had weight loss, and 7,816 (22.9%) had weight gain over 2 years. About 23,952 (70.2%) individuals maintained their weight over 2 years. The overall risk of vertebral fractures was significantly higher in quitters (adjusted HR [aHR]=1.110, 95% confidence interval [CI] 1.013-1-216) than in nonsmokers, but it was lower than in current smokers (aHR=1.197, 95%CI 1.143-1.253), regardless of weight change after smoking cessation. However, individuals who experienced weight loss after smoking cessation exhibited a notably higher risk of vertebral fractures than current smokers (aHR=1.321, 95%CI 1.004-1.461). In the female population, weight gain after smoking cessation was associated with a higher risk of vertebral fractures (aHR = 1.470, 95%CI 1.002-2.587) than in current female smokers. CONCLUSIONS: Maintaining weight after smoking cessation may mitigate the risk of vertebral fractures. Weight loss after smoking cessation adversely affects the protective effects of smoking cessation on vertebral fractures in the general population.

Incidence and Risk Factors for Wound Revision after Surgical Treatment of Spinal Metastasis: A National Population-Based Study in South Korea.

Wound complications are commonly seen after surgeries for metastatic spine tumors. While numerous studies have pinpointed various risk factors, there is ongoing debate. Therefore, this study aimed to verify various factors that are still under debate utilizing the comprehensive Korean National Health Insurance Service database. We identified and retrospectively reviewed a cohort of 3001 patients who underwent one of five surgical treatments (corpectomy, decompression and instrumentation, instrumentation only, decompression only, and vertebroplasty) for newly diagnosed spinal metastasis between 2009 and 2017. A Cox regression analysis was performed to determine the risk factors. A total of 197 cases (6.6%) of wound revision were found. Only the surgical method and Charlson comorbidity index were significantly different between the group that underwent wound revision and the group that did not. Regarding surgical methods, the adjusted hazard ratios for decompression only, corpectomy, instrumentation and decompression, and instrumentation only were 1.3, 2.2, 2.2, and 2.4, with these ratios being compared to the vertebroplasty group (p for trend = 0.02). In this regard, based on a sizable South Korean cohort, both surgical methods and medical comorbidity were found to be associated with the wound revision rate among spinal surgery patients for spinal metastasis.

Factors affecting successful immediate indirect decompression in oblique lateral interbody fusion in lumbar spinal stenosis patients.

Background: Oblique lumbar interbody fusion (OLIF) offers indirect decompression of stenotic lesions of the spinal canal and foramen through immediate disc height restoration. Only a few studies have reported the effect of cage position and associated intraoperatively modifiable factors for successful immediate indirect decompression following OLIF surgery. This study aimed to investigate the intraoperatively modifiable factors for successful radiological outcomes of OLIF. Methods: This study included 46 patients with 80 surgical levels who underwent OLIF without direct posterior decompression. Preoperative and postoperative radiological parameters were evaluated and intraoperatively modifiable radiologic parameters for successful immediate radiologic decompression on magnetic resonance image (MRI) were determined. Radiologic parameters were preoperative and postoperative radiological parameters including anterior disc height (ADH), posterior disc height (PDH) lumbar lordotic angle (LLA), segmental lordotic angle (SLA), foraminal height (FH), cage position, cross-sectional area (CSA) of the thecal sac, cross-sectional foraminal area (CSF), facet distance (FD). Results: All radiologic outcomes significantly improved. Comparing preoperative and postoperative values, mean CSA increased from 99.63±40.21 mm2 to 125.02±45.90 mm2 (p<.0001), and mean left CSF increased from 44.54±12.90 mm2 to 69.91±10.80 mm2 (p<.0001). FD also increased from 1.40±0.44 to 1.92±0.71 mm (p<.0001). FH increased from 16.31±3.3 to 18.84±3.47 mm (p<.0001). ADH and PDH also significantly increased (p<.0001). Immediate postoperative CSF and FH improvement rate (%) were significantly correlated with posterior disc height restoration rate (%) (p=.0443, and p=.0234, respectively). In addition, the patients with a cage positioned in the middle of the vertebral body experienced a greater FH improvement rate (%) compared to the patients with a cage positioned anteriorly. Finally, Visual analogue scale (VAS) for leg pain was improved immediately. Conclusions: OLIF provided satisfactory immediate indirect decompression in central and foraminal spinal stenosis. Moreover, intraoperative surgical technique for successful radiologic CSF and FH improvement included restoration of the PDH and placement of the cage in the middle.

The novel use and feasibility of hemostatic oxidized regenerated cellulose agent (SurgiGuard®): multicenter retrospective study.

Background: SurgiGuard® is an absorbent hemostatic agent based on oxidized regenerated cellulose. The efficacy, effects and safety of SurgiGuard® are equivalent to existing hemostatic agents in animal experiments. This study was designed to confirm that the use of SurgiGuard® alone is effective, safe and feasible compared to combination with other hemostatic methods. Methods: We retrospectively reviewed clinical data from 12 surgery departments in seven tertiary centers in South Korea nationwide. All surgeries were performed between January and December 2018. Results: A total of 807 patients were enrolled; 447 patients (55.4%) had comorbidities. The rate of major surgery (operative time ≥4 hours) was 44% (n=355 patients). Regarding the type of SurgiGuard® used in surgery, more than 70% of minor surgeries used non-woven types. In major surgery, more than five SurgiGuards® were used in 7.3% (26 patients), and the proportion of co-usage (with four other hemostatic products) was 19.7% (70 patients). The effectiveness score was higher when SurgiGuard® was used alone in both major (5.3±0.5 vs. 5.1±0.6, P=0.048) and minor surgery (5.4±0.6 vs. 5.2±0.4, P<0.001). Seven patients had immediate re-bleeding, and all of them used SurgiGuard® and other products together. Nine patients reported adverse effects, such as abscess, bleeding, or leg swelling, but we found no direct correlation with SurgiGuard®. Conclusions: SurgiGuard® exhibited greater effectiveness when used alone. No direct adverse effects associated with SurgiGuard® use were reported, and SurgiGuard® had stable feasibility. Prospective comparative studies are needed in the future.

Anterior Cervical Discectomy and Fusion Performed Using a CaO-SiO2-P2O5-B2O3 Bioactive Glass Ceramic or Polyetheretherketone Cage Filled with Hydroxyapatite/ß-Tricalcium Phosphate: A Prospective Randomized Controlled Trial.

A CaO-SiO2-P2O5-B2O3 bioactive glass-ceramic (BGS-7) spacer provides high mechanical stability, produces a chemical bond to the adjacent endplate, and facilitates fusion after spine surgery. This prospective, randomized, single-blind, non-inferiority trial aimed to evaluate the radiographic outcomes and clinical efficacy of anterior cervical discectomy and fusion (ACDF) using a BGS-7 spacer for treating cervical degenerative disorders. Thirty-six patients underwent ACDF using a BGS-7 spacer (Group N), and 40 patients underwent ACDF using polyetheretherketone (PEEK) cages filled with a mixture of hydroxyapatite (HA) and ß-tricalcium phosphate (ß-TCP) for the treatment of cervical degenerative disorders. The spinal fusion rate was assessed 12 months postoperatively using three-dimensional computed tomography (CT) and dynamic radiographs. Clinical outcomes included patient-reported outcome measures, visual analog scale scores for neck and arm pain, and scores from the neck disability index (NDI), European Quality of Life-5 Dimensions (EQ-5D), and 12-item Short Form Survey (SF-12v2). All participants were randomly assigned to undergo ACDF using either a BGS-7 spacer or PEEK cage filled with HA and ß-TCP. The primary outcome was the fusion rate on CT scan image at 12 months after ACDF surgery based on a per-protocol strategy. Clinical outcomes and adverse events were also assessed. The 12-month fusion rates for the BGS-7 and PEEK groups based on CT scans were 81.8% and 74.4%, respectively, while those based on dynamic radiographs were 78.1% and 73.7%, respectively, with no significant difference between the groups. There were no significant differences in the clinical outcomes between the two groups. Neck pain, arm pain, NDI, EQ-5D, and SF-12v2 scores significantly improved postoperatively, with no significant differences between the groups. No adverse events were observed in either group. In ACDF surgery, the BGS-7 spacer showed similar fusion rates and clinical outcomes as PEEK cages filled with HA and ß-TCP.

Anterolateral versus posterior minimally invasive lumbar interbody fusion surgery for spondylolisthesis: comparison of outcomes from a global, multicenter study at 12-months follow-up.

BACKGROUND CONTEXT: Several minimally invasive lumbar interbody fusion techniques may be used as a treatment for spondylolisthesis to alleviate back and leg pain, improve function and provide stability to the spine. Surgeons may choose an anterolateral or posterior approach for the surgery however, there remains a lack of real-world evidence from comparative, prospective studies on effectiveness and safety with relatively large, geographically diverse samples and involving multiple surgical approaches. PURPOSE: To test the hypothesis that anterolateral and posterior minimally invasive approaches are equally effective in treating patients with spondylolisthesis affecting one or two segments at 3-months follow-up and to report and compare patient reported outcomes and safety profiles between patients at 12-months post-surgery. DESIGN: Prospective, multicenter, international, observational cohort study. PATIENT SAMPLE: Patients with degenerative or isthmic spondylolisthesis who underwent 1- or 2-level minimally invasive lumbar interbody fusion. OUTCOME MEASURES: Patient reported outcomes assessing disability (ODI), back pain (VAS), leg pain (VAS) and quality of life (EuroQol 5D-3L) at 4-weeks, 3-months and 12-months follow-up; adverse events up to 12-months; and fusion status at 12-months post-surgery using X-ray and/or CT-scan. The primary study outcome is improvement in ODI score at 3-months. METHODS: Eligible patients from 26 sites across Europe, Latin America and Asia were consecutively enrolled. Surgeons with experience in minimally invasive lumbar interbody fusion procedures used, according to clinical judgement, either an anterolateral (ie, ALIF, DLIF, OLIF) or posterior (MIDLF, PLIF, TLIF) approach. Mean improvement in disability (ODI) was compared between groups using ANCOVA with baseline ODI score used as a covariate. Paired t-tests were used to examine change from baseline in PRO for both surgical approaches at each timepoint after surgery. A secondary ANCOVA using a propensity score as a covariate was used to test the robustness of conclusions drawn from the between group comparison. RESULTS: Participants receiving an anterolateral approach (n=114) compared to those receiving a posterior approach (n=112) were younger (56.9 vs 62.0 years, p <.001), more likely to be employed (49.1% vs 25.0%, p<.001), have isthmic spondylolisthesis (38.6% vs 16.1%, p<.001) and less likely to only have central or lateral recess stenosis (44.9% vs 68.4%, p=.004). There were no statistically significant differences between the groups for gender, BMI, tobacco use, duration of conservative care, grade of spondylolisthesis, or the presence of stenosis. At 3-months follow-up there was no difference in the amount of improvement in ODI between the anterolateral and posterior groups (23.2 ± 21.3 vs 25.8 ± 19.5, p=.521). There were no clinically meaningful differences between the groups on mean improvement for back- and leg-pain, disability, or quality of life until the 12-months follow-up. Fusion rates of those assessed (n=158; 70% of the sample), were equivalent between groups (anterolateral, 72/88 [81.8%] fused vs posterior, 61/70 [87.1%] fused; p=.390). CONCLUSIONS: Patients with degenerative lumbar disease and spondylolisthesis who underwent minimally invasive lumbar interbody fusion presented statistically significant and clinically meaningful improvements from baseline up to 12-months follow-up. There were no clinically relevant differences between patients operated on using an anterolateral or posterior approach.

Underweight as a risk factor for vertebral fractures in the South Korean population.

BACKGROUND CONTEXT: Being underweight is a known risk factor for osteoporosis and sarcopenia that is strongly associated with vertebral fractures, particularly in the elderly. Being underweight can accelerate bone loss, contribute to impaired coordination, and increase fall risk in the elderly and the general population. PURPOSE: This study aimed to identify the degree of underweight as a risk factor for vertebral fractures in the South Korean population. STUDY DESIGN: Retrospective cohort study based on national health insurance database. PATIENT SAMPLE: Participants were included from nationwide regular health check-ups conducted by the Korean National Health Insurance Service in 2009. Participants were followed up from 2010 to 2018 to identify the incidence of newly developed fractures. OUTCOME MEASURES: The incidence rate (IR) was defined as the incident per 1,000 person-years (PY). Vertebral fracture development risk was analyzed using Cox proportional regression analysis. Subgroup analysis was performed based on several factors, including age, sex, smoking status, alcohol consumption, physical activity, and household income. METHODS: Based on body mass index, the study population was categorized into normal weight (18.50-22.99 kg/m2), mild underweight (17.50-18.49 kg/m2), moderate underweight (16.50-17.49 kg/m2), and severe underweight (<16.50 kg/m2) groups. Cox proportional hazards analyses were performed to calculate the hazard ratios for vertebral fractures based on the degree of underweight with respect to normal weight to identify the associated risk. RESULTS: This study evaluated 962,533 eligible participants, of whom 907,484 were classified as normal weight, 36,283 as mild underweight, 13,071 as moderate underweight, and 5,695 as severe underweight. The adjusted hazard ratio of vertebral fractures increased as the degree of underweight increased. Severe underweight was associated with a higher likelihood of vertebral fracture. The adjusted hazard ratio was 1.11 (95% confidence interval [CI], 1.04-1.17) in the mild underweight group, 1.15 (1.06-1.25) in the moderate underweight group, and 1.26 (1.14-1.40) in the severe underweight group when compared with the normal weight group. CONCLUSIONS: Underweight is a risk factor for vertebral fractures in the general population. Furthermore, severe underweight was associated with a higher risk of vertebral fractures, even after adjustment for other factors. Clinicians could provide real-world evidence that being underweight carries the risk of vertebral fractures.

Cumulative Burden of Being Underweight Increases the Risk of Hip Fracture: A Nationwide Population-Based Cohort Study.

(1) Background: Being underweight is a known risk factor for hip fractures. However, it is unclear whether the cumulative underweight burden affects the incidence of hip fractures. Therefore, we explored the effect of the cumulative underweight burden on the development of hip fractures; (2) Methods: In a cohort of adults aged 40 years and older, 561,779 participants who were not underweight and had no hip fractures from 2007 to 2009 were identified. The risk of hip fracture from the time of the last examination to December 2018 according to the cumulative burden of being underweight (based on 0 to 3 examinations) was prospectively analyzed; (3) Results: During follow-up (mean 8.3 ± 0.8 years), the prevalence of newly diagnosed hip fractures was 0.2%, 0.4%, 0.5%, and 0.9% among those with 0, 1, 2, and 3 cumulative underweight, respectively. The adjusted hazard ratios (HRs) with 95% confidence intervals (CIs) of groups meeting the diagnostic criteria for underweight 1, 2, and 3 compared to 0 were 2.3 (1.6−3.3), 2.9 (1.8−4.5), and 4.5 (3.4−6.1), respectively (p for trend < 0.01); (4) Conclusions: The risk of hip fracture increased as the burden of underweight accumulated.

The Efficiency and Reliability of Minimally Invasive Anterior Corpectomy and Percutaneous Posterior Stabilization for the Treatment of Unstable Thoracolumbar Burst Fractures.

OBJECTIVE: The purpose of this study was to evaluate the radiological and clinical outcomes of minimally invasive anterior corpectomy and percutaneous posterior stabilization for treating unstable thoracolumbar burst fractures. METHODS: Patients with unstable thoracolumbar burst fractures who underwent minimally invasive anterior corpectomy and percutaneous posterior stabilization between 2012 and 2019 at a tertiary hospital were enrolled. Radiological outcomes such as endplate subsidence and fusion status were identified on preoperative and postoperative plain radiographs and computed tomography images. Preoperative and postoperative neurological statuses were evaluated using the American Spinal Injury Association impairment scale. Furthermore, operation-related parameters were analyzed. RESULTS: In total, 21 patients (mean follow-up period, 21.7 months) were included in this study. Of them, 17 (80.95%) patients exhibited complete fusion according to the Bridwell's criteria at the final follow-up, and only 1 patient exhibited nonunion at the surgical level. Endplate subsidence was observed in 6 (28.57%) patients; however, there were no definite symptoms that would have necessitated a revision surgery. Of 15 patients with preoperative neurological impairment, 7 exhibited neurological improvement during follow-up. None of the patients experienced postoperative neurological deterioration. Regarding operation-related parameters, the mean operative time and intraoperative blood loss were 266.19 ± 51.54 min and 520.71 ± 190.86 ml, respectively. The mean length of hospital stays and days to postoperative ambulation were 12.14 and 4.20 days, respectively. CONCLUSIONS: Minimally invasive anterolateral corpectomy with percutaneous pedicle screw fixation is a reliable surgical treatment option for unstable thoracolumbar burst fractures.

Incidence of hip fracture in underweight individuals: a nationwide population-based cohort study in Korea.

BACKGROUND: Hip fracture is a major public health problem worldwide and being underweight is a risk factor for fractures. Few studies have investigated the association between being underweight and hip fracture in the general population. The present study investigated the incidence of hip fracture in a large population cohort based on detailed information about the degree of underweight. METHODS: A nationwide retrospective cohort study of adults ≥40 years of age included 962,533 subjects who were not overweight or obese in 2009. The incidence and risk of hip fracture occurring between 2010 and 2018 was assessed based on the degree of underweight. Based on body mass index (BMI), the study population was categorized into normal (18.50-22.99 kg/m2 ), mild (17.00-18.49 kg/m2 ), moderate (16.00-16.99 kg/m2 ), and severe underweight (<16.00 kg/m2 ) groups. Cox proportional hazards analyses were performed to calculate the hazard ratio (HR) for the hip fracture based on the degree of underweight in reference to the normal weight. RESULTS: Compared with subjects who were normal weight, those who were classified as mild underweight (1.03/1000 person-years (PY) increase in incidence rate (IR); adjusted HR (aHR) 1.61; 95% confidence interval (CI) 1.48-1.76), moderate underweight (2.04/1000 PY increase in IR; aHR 1.85; 95% CI 1.65-2.08), or severe underweight (4.58/1000 PY increase in IR; aHR 2.33; 95% CI 2.03-2.66) were at significantly increased risk of hip fracture. CONCLUSIONS: The severity of underweight was significantly associated with risk of hip fracture. The subdivision of underweight helps to estimate fracture risk more accurately.

The Influence of Rheumatoid Arthritis on Higher Reoperation Rates over Time Following Lumbar Spinal Fusion-A Nationwide Cohort Study.

This study aimed to compare the rates of reoperation over time following first lumbar fusion in rheumatoid arthritis (RA) patients and non-RA patients. This study was conducted using Korean Health Insurance Review and Assessment (HIRA) data. We identified the RA group as 2239 patients who underwent their first lumbar fusion with RA and the control group as 11,195 patients without RA. This reflects a ratio of 1:5, and the participants were matched by sex, age, and index surgery date. The index dates were between 2012 and 2013. When comparing the rate of patients undergoing reoperation, the adjusted HR was 1.31 (95% CI: 1.10−1.6) in the RA group (p = 0.002). In terms of the three time intervals, the values in the time frames of <3 months and 3 months−1 year were not statistically significant. However, at 1 year post-surgery, there was a higher risk of reoperation in the RA group, as demonstrated by the Kaplan−Meier cumulative event analysis. This higher risk of reoperation continued to increase throughout 5 years of follow-up, after which it was stable until the last follow-up at 7 years. This population-based cohort study showed that the RA patients had a 1.31 times higher risk of reoperation following lumbar fusion than did the controls. This difference was more pronounced at 1 year post-surgery.

National pharmacological treatment trends for ankylosing spondylitis in South Korea: A national health insurance database study.

No studies of the current status of treatment options are available for ankylosing spondylitis (AS) patients in South Korea. This study assesses the current status of AS treatment trends using a nationwide database. This study was conducted using a Korean National Health Insurance System (KNHIS) dataset from 2006 to 2016. We randomly extracted 50% of the total number of patients registered as As patients in the KNHIS. The distribution of the number of patients according to age and gender was analyzed each year. The types and combination methods of drugs used during the study period were estimated yearly. Between 2006 and 2016, the number of AS patients increased linearly by an average of 9% annually, 6372 in 2006 to 15188 in 2016. The study found that the use of nonsteroidal anti-inflammatory drugs (NSAIDs) was the most commonly prescribed pharmacological treatment option, followed by disease-modifying anti-rheumatic drugs (DMARDs) and then biologics. Biologics such as tumor necrosis factor alpha (TNF-α) inhibitors increased from 10% to 35% consistently for 10 years. In terms of combination therapy, DMARDs + NSAIDs accounted for almost 90% of treatments in 2006, but decreased by 65% in 2016. The use of biologics and NSAIDs increased from 3% to 28%. Prescriptions for dual therapies and mono therapies largely dominated prescription habits, accounted for up to approximately 80% of treatments. Among 10- to 14-year-old patients, there was no triple therapy, dual and triple therapies decreased gradually for those 60 and older, and the ratio of conservative treatments has increased. This study shows how South Korea reflects changes in AS treatment trends, along with the emergence of TNF-α inhibitors that are effective in treating AS. Research on clinical outcomes for AS treatments will be needed on following these drug changes.

Comparison of Minimally Invasive Versus Open Transforaminal Interbody Lumbar Fusion.

STUDY DESIGN: Narrative review. OBJECTIVES: In this review, we address the question of whether the literature supports the notion that minimally invasive transforaminal interbody fusion (MIS-TLIF) improves outcome as compared with open TLIF (open-TLIF). Short and long-term outcomes, fusion rate, and cost-effectiveness were reviewed. METHODS: This is a narrative review using various databases. Open-TLIF and MIS-TLIF studies were included and posterior lumbar interbody fusion studies were excluded. A description of paramedian incision in surgical technique was essential to the definition of MIS-TLIF. The present review included 14 prospective observational studies and 6 randomized controlled trials. RESULTS: With short-term outcomes, some studies indicate a better outcome with MIS-TLIF regarding intraoperative bleeding, hospital stay, time to ambulation, postoperative narcotic use, and time to resume work. Both MIS-TLIF and open-TLIF surgeries improved Oswestry Disability Index, back pain, and leg pain. Some studies show that MIS-TLIF resulted in lower back pain than open-TLIF. Radiation exposure was higher with MIS-TLIF. In the longer term, clinical outcomes were improved in both MIS and open TLIF groups. Fusion rates were more than 90% in both MIS-TLIF and open-TLIF. Cost-effectiveness and length of surgery had mixed results. CONCLUSIONS: The potential benefits of MIS-TLIF might be present in the early recovery period after surgery. Long-term outcomes were similar with both MIS-TLIF and open-TLIF.

Transforaminal epidural steroid injections in cervical spinal disease with moderate to severe disability: Comparative study in patients with or without surgery.

Despite many clinical trials on cervical epidural steroid injections, the indications for and long-standing outcomes of this treatment remain controversial. We evaluated the outcomes and indications for transforaminal cervical epidural steroid injection (TCESI) in patients with moderate to severe disability.We prospectively gathered data from patients with 1 or 2-level cervical degenerative disease (herniated disc, foraminal stenosis) with moderate to severe disability (3.5 < initial visual analog scale < 6.5, 15 < Neck Disability Index < 35) and greater than 12 weeks of pain, despite conservative treatment. Patients with persistent disability and those who desired surgical intervention underwent decompression surgery. The clinical and demographic characteristics were compared between groups.Of the 309 patients who underwent TCESI, 221 (72%) did not receive surgical treatment during the 1-year follow-up period. The remaining 88 patients (28%) underwent surgery at a mean of 4.1 months after initial TCESI. Patients who underwent injection alone showed a significant decrease in disability and pain that persisted until the 1-year follow-up visit (P < .05). In patients who underwent surgery, the mean disability and pain scores after injection did not decrease for several months, although the scores significantly decreased up to 1 year after surgery (P < .05).The TCESI significantly decreased pain and disability in the moderate to severe disability group up to 1 year after injection. We recommend cervical TCESI as an initial treatment with moderate to severe disability patients.

Accelerated Osteogenic Differentiation of MC3T3-E1 Cells by Lactoferrin-Conjugated Nanodiamonds through Enhanced Anti-Oxidant and Anti-Inflammatory Effects.

The purpose of this study was to investigate the effects of lactoferrin (LF)-conjugated nanodiamonds (NDs) in vitro on both anti-oxidant and anti-inflammation activity as well as osteogenic promotion. The application of LF-NDs resulted in sustained release of LF for up to 7 days. In vitro anti-oxidant analyses performed using Dichlorofluorescin diacetate (DCF-DA) assay and cell proliferation studies showed that LF (50 µg)-NDs effectively scavenged the reactive oxygen species (ROS) in MC3T3-E1 cells (osteoblast-like cells) after H2O2 treatment and increased proliferation of cells after H2O2 treatment. Treatment of lipopolysaccharide (LPS)-induced MC3T3-E1 cells with LF-NDs suppressed levels of pro-inflammatory cytokines, including interleukin-1ß (IL-1ß) and tumor necrosis factor-α (TNF-α). In addition, LF-NDs were associated with outstanding enhancement of osteogenic activity of MC3T3-E1 cells due to increased alkaline phosphatase (ALP) and calcium deposition. Our findings suggest that LF-NDs are an important substrate for alleviating ROS effects and inflammation, as well as promoting osteogenic differentiation of cells.

Association of Exposure to Diagnostic Low-Dose Ionizing Radiation With Risk of Cancer Among Youths in South Korea.

Importance: Diagnostic low-dose ionizing radiation has great medical benefits; however, its increasing use has raised concerns about possible cancer risks. Objective: To examine the risk of cancer after diagnostic low-dose radiation exposure. Design, Setting, and Participants: This population-based cohort study included youths aged 0 to 19 years at baseline from South Korean National Health Insurance System claim records from January 1, 2006, to December 31, 2015. Exposure to diagnostic low-dose ionizing radiation was classified as any that occurred on or after the entry date, when the participant was aged 0 to 19 years, on or before the exit date, and at least 2 years before any cancer diagnosis. Cancer diagnoses were based on International Statistical Classification of Diseases and Related Health Problems, Tenth Revision codes. Data were analyzed from March 2018 to September 2018. Main Outcomes and Measures: The primary analysis assessed the incidence rate ratios (IRRs) for exposed vs nonexposed individuals using the number of person-years as an offset. Results: The cohort included a total of 12 068 821 individuals (6 339 782 [52.5%] boys). There were 2 309 841 individuals (19.1%) aged 0 to 4 years, 2 951 679 individuals (24.5%) aged 5 to 9 years, 3 489 709 individuals (28.9%) aged 10 to 14 years, and 3 317 593 individuals (27.5%) aged 15 to 19 years. Of these, 1 275 829 individuals (10.6%) were exposed to diagnostic low-dose ionizing radiation between 2006 and 2015, and 10 792 992 individuals (89.4%) were not exposed. By December 31, 2015, 21 912 cancers were recorded. Among individuals who had been exposed, 1444 individuals (0.1%) received a cancer diagnosis. The overall cancer incidence was greater among exposed individuals than among nonexposed individuals after adjusting for age and sex (IRR, 1.64 [95% CI, 1.56-1.73]; P < .001). Among individuals who had undergone computed tomography scans in particular, the overall cancer incidence was greater among exposed individuals than among nonexposed individuals after adjusting for age and sex (IRR, 1.54 [95% CI, 1.45-1.63]; P < .001). The incidence of cancer increased significantly for many types of lymphoid, hematopoietic, and solid cancers after exposure to diagnostic low-dose ionizing radiation. Among lymphoid and hematopoietic cancers, incidence of cancer increased the most for other myeloid leukemias (IRR, 2.14 [95% CI, 1.86-2.46]) and myelodysplasia (IRR, 2.48 [95% CI, 1.77-3.47]). Among solid cancers, incidence of cancer increased the most for breast (IRR, 2.32 [95% CI, 1.35-3.99]) and thyroid (IRR, 2.19 [95% CI, 1.97-2.20]) cancers. Conclusions and Relevance: This study found an association of increased incidence of cancer with exposure to diagnostic low-dose ionizing radiation in a large cohort. Given this risk, diagnostic low-dose ionizing radiation should be limited to situations in which there is a definite clinical indication.

Impact of ankylosing spondylitis on depression: a nationwide cohort study.

The aim of this study is to determine the relationship between AS and subsequent depression. This study was conducted using a nationwide dataset available in Korean National Health Insurance System (KNHIS). We identified 11,465 newly diagnosed AS patients and 57,325 patients without AS in the ratio of 1:5 matched by sex, age, and index date, between 2010 and 2014. We investigated any latent characteristics in the patients' demographic information and chronic comorbidities that could trigger a depression when diagnosed with AS. By comparing the cohort data, the hazard ratio of developing subsequent depression in AS patients was calculated and adjusted based on several risk factors. Despite the adjustment of demographic variables and chronic comorbidities, the risk of depression was 2.21 times higher in the AS cohort than in the control group. Multivariate analysis showed that AS patients with female gender, old age and low-income status showed higher risks of developing depression. Additionally, the presence of chronic comorbidities including diabetes mellitus, hypertension, hyperlipidemia, cancer, stroke, and chronic kidney disease increased the patients' risk of depression. The AS patients with stroke were reported to have the highest risk of depression. This population-based cohort study showed that AS significantly increased the subsequent risk of developing depression. Moreover, the development of a depression is influenced by certain demographic variables and different chronic comorbidities.

Analysis of dural sac thickness in the human cervical spine.

The thickness of the dura mater in the human cervical spine can vary between individuals and by vertebral level; these differences can result in various clinical outcomes. The purpose was to measure and analyze cervical dura mater thickness. Microscopic measurements were made of tissue from human cadavers. The subjects were nine human cadavers with no previous history of spinal deformity or surgery. Fourteen segments of both anterior and posterior dura mater from the C1 to C7 cervical vertebrae were obtained. Dura mater thickness was measured using an infrared laser-based confocal microscope. Statistical analyses were performed to examine the relationships of cervical dura mater thickness with vertebral level, age, and sex. The overall average cervical dura mater thickness was 379.3 × 10-3 mm. Statistically significant differences in thickness were found between the anterior and posterior segments (P < 0.0001). Moreover, the thickness at each vertebral level was significantly different from the thicknesses at the other levels (P < 0.05). The posterior dura mater thickness was highest at C1 and lowest at C5/6. Posterior dura mater thickness was significantly different at the axial, sub-axial, and lower cervical levels, whereas anterior dura mater thickness was relatively constant among levels. A significant correlation was found between thickness and age (P < 0.05); however, the average dura mater thickness was not significantly different between males and females. This study shows anatomical differences in cervical dura mater thickness with respect to vertebral level and age. These results provide anatomical information that will inform basic research and clinical approaches.

Neuropathic Pain after Spinal Surgery.

Neuropathic pain after spinal surgery, the so-called failed back surgery syndrome (FBSS), is a frequently observed troublesome disease entity. Although medications may be effective to some degree, many patients continue experiencing intolerable pain and functional disability. Only gabapentin has been proven effective in patients with FBSS. No relevant studies regarding manipulation or physiotherapy for FBSS have been published. Spinal cord stimulation (SCS) has been widely investigated as a treatment option for chronic neuropathic pain, including FBSS. SCS was generally accepted to improve chronic back and leg pain, physical function, and sleep quality. Although the cost effectiveness of SCS has been proved in many studies, its routine application is limited considering that it is invasive and is associated with safety issues. Percutaneous epidural adhesiolysis has also shown good clinical outcomes; however, its effects persisted for only a short period. Because none of the current methods provide absolute superiority in terms of clinical outcomes, a multidisciplinary approach is required to manage this complex disease. Further studies concerning the etiology, diagnosis, treatment, and cost effectiveness of FBSS are warranted to deepen our understanding of this condition.