Surgical Strategy for Dumbbell-Shaped Cervical Schwannoma at the Vicinity of the Vertebral Artery: The Utilization of Anatomic Layer.

BACKGROUND AND OBJECTIVES: In cases where dumbbell-shaped cervical schwannoma encases the vertebral artery (VA), there is a risk of VA injury during surgery. The objective of this study is to propose a strategy for preserving the VA during the surgical excision of tumors adjacent to the VA through the utilization of anatomic layers. METHODS: A retrospective analysis was conducted on 37 patients who underwent surgery for dumbbell-shaped cervical schwannoma with contacting VA from January 2004 to July 2023. The VA encasement group consisted of 12 patients, and the VA nonencasement group included 25 patients. RESULTS: The perineurium acted as a protective barrier from direct VA exposure or injury during surgery. However, in the VA encasement group, 1 patient was unable to preserve the perineurium while removing a tumor adjacent to the VA, resulting in VA injury. The patient had the intact dominant VA on the opposite side, and there were no new neurological deficits or infarctions after the surgery. Gross total resection was achieved in 25 patients (67.6%), while residual tumor was confirmed in 12 patients (32.4%). Four patients (33.3% of 12 patients) underwent reoperation because of the regrowth of the residual tumor within the neural foramen. In the case of the 8 patients (66.7% of 12 patients) whose residual tumor was located outside the neural foramen, no regrowth was observed, and there was no recurrence of the tumor within the remaining perineurium after total resection. CONCLUSION: In conclusion, when resecting a dumbbell-shaped cervical schwannoma contacting VA, subperineurium dissection prevents VA injury because the perineurium acts as a protective barrier.

Trends in degenerative lumbar spinal surgery during the early COVID-19 pandemic in Republic of Korea: A national study utilizing the national health insurance database.

During the first year of the COVID-19 pandemic, the Republic of Korea (ROK) experienced three epidemic waves in February, August, and November 2020. These waves, combined with the overarching pandemic, significantly influenced trends in spinal surgery. This study aimed to investigate the trends in degenerative lumbar spinal surgery in ROK during the early COVID-19 pandemic, especially in relation to specific epidemic waves. Using the National Health Information Database in ROK, we identified all patients who underwent surgery for degenerative lumbar spinal diseases between January 1, 2019 and December 31, 2020. A joinpoint regression was used to assess temporal trends in spinal surgeries over the first year of the COVID-19 pandemic. The number of surgeries decreased following the first and second epidemic waves (p<0.01 and p = 0.34, respectively), but these were offset by compensatory increases later on (p<0.01 and p = 0.05, respectively). However, the third epidemic wave did not lead to a decrease in surgical volume, and the total number of surgeries remained comparable to the period before the pandemic. When compared to the pre-COVID-19 period, average LOH was reduced by 1 day during the COVID-19 period (p<0.01), while mean hospital costs increased significantly from 3,511 to 4,061 USD (p<0.01). Additionally, the transfer rate and the 30-day readmission rate significantly decreased (both p<0.01), while the reoperation rate remained stable (p = 0.36). Despite the impact of epidemic waves on monthly surgery numbers, a subsequent compensatory increase was observed, indicating that surgical care has adapted to the challenges of the pandemic. This adaptability, along with the stable total number of operations, highlights the potential for healthcare systems to continue elective spine surgery during public health crises with strategic resource allocation and patient triage. Policies should ensure that surgeries for degenerative spinal diseases, particularly those not requiring urgent care but crucial for patient quality of life, are not unnecessarily halted.

Customized Hydrogel Films for MicroRNA Super-Resolution Imaging in Liquid Biopsies.

Tissue biopsy for early diagnosis and monitoring comes with several challenges, such as its invasiveness, and issues related to tissue heterogeneity in sampling. To address these issues, researchers have proposed a noninvasive approach called liquid biopsy, which uses blood samples to detect specific noncoding RNA (microRNA, miRNA). However, the current process of isolating and amplifying miRNA can be time-consuming and yield nonspecific results. In this study, a new super-resolution imaging tool is introduced that utilizes a thin, hydrogel-based liquid view (LV) film. This film can undergo a ninefold expansion and allows the analysis of cells obtained from liquid biopsy. The potential of the LV film is validated as a tool for early diagnosis and prognosis by testing biofluids derived from a variety of diseases. This method is confirmed to accurately analyze a greater number of miRNAs with higher sensitivity in a shorter time compared to other analytical methods. These findings suggest that the LV film provides high specificity, and multiplexing in detecting small amounts of miRNAs within cells, making it suitable for 3D implementation. It is proposed that liquid biopsy with LV films can be a solution to limitations related to the invasiveness, cost, and time-consuming nature of molecular analysis.

Traumatic spinal cord injury in South Korea for 13 years (2008-2020).

Traumatic spinal cord injury (TSCI) has significant physical, psychological, and socioeconomic impacts. However, the epidemiological characteristics and treatment patterns of TSCI in South Korea remain unclear. This study aimed to investigate TSCI incidence and treatment behaviors in South Korea from 2008 to 2020. We included data from 30,979 newly diagnosed TSCI patients obtained from the Health Insurance Review and Assessment Service (HIRA). Treatment trends, location of surgery, surgical method, comorbidities, factors affecting hospital stay, and risk factors affecting readmission were analyzed. Patients were divided into the surgery group [n = 7719; (25%)] and the non-surgery group [n = 23,260; (75%)]. Surgical cases involved cervical (64%), thoracic (17%), and lumbar/sacral (19%) lesions. Anterior fusion (38%), posterior fusion (54%), and corpectomy (8%) were the surgical methods. Surgical treatments increased annually. Factors influencing hospital stay included male sex, older age, and higher Charlson comorbidity index (CCI). Female sex and higher CCI scores were associated with readmission. In conclusion, a quarter of all TSCI patients underwent surgery, with an upward trend. Risk factors for longer hospital stays were thoracic spine injury, older age, higher CCI, and male sex. Risk factors for readmission included age range of 40-59 years, lumbar/sacral spine injuries, CCI score of 2, and female sex.

Navigation-Guided/Robot-Assisted Spinal Surgery: A Review Article.

The development of minimally invasive spinal surgery utilizing navigation and robotics has significantly improved the feasibility, accuracy, and efficiency of this surgery. In particular, these methods provide improved accuracy of pedicle screw placement, reduced radiation exposure, and shortened learning curves for surgeons. However, research on the clinical outcomes and cost-effectiveness of navigation and robot-assisted spinal surgery is still in its infancy. Therefore, there is limited available evidence and this makes it difficult to draw definitive conclusions regarding the long-term benefits of these technologies. In this review article, we provide a summary of the current navigation and robotic spinal surgery systems. We concluded that despite the progress that has been made in recent years, and the clear advantages these methods can provide in terms of clinical outcomes and shortened learning curves, cost-effectiveness remains an issue. Therefore, future studies are required to consider training costs, variable initial expenses, maintenance and service fees, and operating costs of these advanced platforms so that they are feasible for implementation in standard clinical practice.

Screening patients requiring secondary lumbar surgery for degenerative lumbar spine diseases: a nationwide sample cohort study.

This study aims to identify healthcare costs indicators predicting secondary surgery for degenerative lumbar spine disease (DLSD), which significantly impacts healthcare budgets. Analyzing data from the National Health Insurance Service-National Sample Cohort (NHIS-NSC) database of Republic of Korea (ROK), the study included 3881 patients who had surgery for lumbar disc herniation (LDH), lumbar spinal stenosis without spondylolisthesis (LSS without SPL), lumbar spinal stenosis with spondylolisthesis (LSS with SPL), and spondylolysis (SP) from 2006 to 2008. Patients were categorized into two groups: those undergoing secondary surgery (S-group) and those not (NS-group). Surgical and interim costs were compared, with S-group having higher secondary surgery costs ($1829.59 vs $1618.40 in NS-group, P = 0.002) and higher interim costs ($30.03; 1.86% of initial surgery costs vs $16.09; 0.99% of initial surgery costs in NS-group, P < 0.0001). The same trend was observed in LDH, LSS without SPL, and LSS with SPL (P < 0.0001). Monitoring interim costs trends post-initial surgery can effectively identify patients requiring secondary surgery.

Comparing zero-profile and conventional cage and plate in anterior cervical discectomy and fusion using finite-element modeling.

Conventional cage and plate (CCP) implants usually used in ACDF surgery, do have limitations such as the development of postoperative dysphagia, adjacent segment degeneration, and soft tissue injury. To reduce the risk of these complications, zero-profile stand-alone cage were developed. We used finite-element modeling to compare the total von Mises stress applied to the bone, disc, endplate, cage and screw when using CCP and ZPSC implants. A 3-dimensional FE (Finite element) analysis was performed to investigate the effects of the CCP implant and ZPSC on the C3 ~ T1 vertebrae. We confirmed that the maximum von Mises stress applied with ZPSC implants was more than 2 times greater in the endplate than that applied with CCP implants. The 3D analysis of the ZPSC model von Mises stress measurements of screw shows areas of higher stress in red. Although using ZPSC implants in ACDF reduces CCP implant-related sequalae such as dysphagia, we have shown that greater von Mises stress is applied to the endplate, and screw when using ZPSC implants. This may explain the higher subsidence rate associated with ZPSC implant use in ACDF. When selecting an implant in ACDF, surgeons should consider patient characteristics and the advantages and disadvantages of each implant type.

Nationwide sample data analysis of additional surgery rate after anterior or posterior cervical spinal surgery.

Surgical outcomes of degenerative cervical spinal disease are dependent on the selection of surgical techniques. Although a standardized decision cannot be made in an actual clinical setting, continued education is provided to standardize the medical practice among surgeons. Therefore, it is necessary to supervise and regularly update overall surgical outcomes. This study aimed to compare the rate of additional surgery between anterior and posterior surgeries for degenerative cervical spinal disease using the National Health Insurance Service-National Sample Cohort (NHIS-NSC) nationwide patient database. The NHIS-NSC is a population-based cohort with about a million participants. This retrospective cohort study included 741 adult patients (> 18 years) who underwent their first cervical spinal surgery for degenerative cervical spinal disease. The median follow-up period was 7.3 years. An event was defined as the registration of any type of cervical spinal surgery during the follow-up period. Event-free survival analysis was used for outcome analysis, and the following factors were used as covariates for adjustment: location of disease, sex, age, type of insurance, disability, type of hospital, Charles comorbidity Index, and osteoporosis. Anterior cervical surgery was selected for 75.0% of the patients, and posterior cervical surgery for the remaining 25.0%. Cervical radiculopathy due to foraminal stenosis, hard disc, or soft disc was the primary diagnosis in 78.0% of the patients, and central spinal stenosis was the primary diagnosis in 22.0% of them. Additional surgery was performed for 5.0% of the patients after anterior cervical surgery and 6.5% of the patients after posterior cervical surgery (adjusted subhazard ratio, 0.83; 95% confidence interval, 0.40-1.74). The rates of additional surgery were not different between anterior and posterior cervical surgeries. The results would be helpful in evaluating current practice as a whole and adjusting the health insurance policy.

Demyelinating polyneuropathy combined with brachial plexopathy after nivolumab therapy for hodgkin lymphoma: a case report.

BACKGROUND: Nivolumab is an immune checkpoint inhibitor that targets the programmed cell death-1 protein and is effective in treating advanced cancer. However, it is also associated with various immune-related neurological complications, including myasthenia gravis, Guillain-Barré syndrome, and demyelinating polyneuropathy. These complications can easily mimic other neurological diseases and have greatly varying therapeutic approaches depending on the underlying pathophysiology. CASE PRESENTATION: Here, we report a case of nivolumab-induced demyelinating peripheral polyneuropathy involving the brachial plexus in a patient with Hodgkin lymphoma. Approximately 7 months after nivolumab treatment, the patient experienced muscle weakness with a tightness and tingling sensation in the right forearm. Electrodiagnostic studies showed features of demyelinating peripheral neuropathy with right brachial plexopathy. Magnetic resonance imaging revealed thickening with a diffuse enhancement of both brachial plexuses. The patient was eventually diagnosed with nivolumab-induced demyelinating polyneuropathy involving the brachial plexus. Oral steroid therapy improved motor weakness and sensory abnormalities without aggravation. CONCLUSION: Our study indicates the possibility of nivolumab-induced neuropathies in cases involving muscle weakness with sensory abnormalities of the upper extremity following nivolumab administration in patients with advanced cancer. Comprehensive electrodiagnostic studies and magnetic resonance imaging are helpful in the differential diagnosis of other neurological diseases. Appropriate diagnostic and therapeutic approaches may prevent further neurological deterioration.

Cervical kinematic change after posterior full-endoscopic cervical foraminotomy for disc herniation or foraminal stenosis.

OBJECTIVE: Posterior full-endoscopic cervical foraminotomy (PECF) is one of minimally invasive surgical techniques for cervical radiculopathy. Because of minimal disruption of posterior cervical structures, such as facet joint, cervical kinematics was minimally changed. However, a larger resection of facet joint is required for cervical foraminal stenosis (FS) than disc herniation (DH). The objective was to compare the cervical kinematics between patients with FS and DH after PECF. METHODS: Consecutive 52 patients (DH, 34 vs. FS, 18) who underwent PECF for single-level radiculopathy were retrospectively reviewed. Clinical parameters (neck disability index, neck pain and arm pain), and segmental, cervical and global radiological parameters were compared at postoperative 3, 6, and 12 months, and yearly thereafter. A linear mixed-effect model was used to assess interactions between groups and time. Any occurrence of significant pain during follow-up was recorded during a mean follow-up period of 45.5 months (range 24-113 months). RESULTS: Clinical parameters improved after PECF, with no significant differences between groups. Recurrent pain occurred in 6 patients and surgery (PECF, anterior discectomy and fusion) was performed in 2 patients. Pain-free survival rate was 91% for DH and 83% for FS, with no significant difference between the groups (P = 0.29). Radiological changes were not different between groups (P > 0.05). Segmental neutral and extension curvature became more lordotic. Cervical curvature became more lordotic on neutral and extension X-rays, and the range of cervical motion increased. The mismatch between T1-slope and cervical curvature decreased. Disc height did not change, but the index level showed degeneration at postoperative 2 years. CONCLUSION: Clinical and radiological outcomes after PECF were not different between DH and FS patients and kinematics were significantly improved. These findings may be informative in a shared decision-making process.

Determining the Factors Predicting the Response to Anti-HER2 Therapy in HER2-Positive Breast Cancer Patients.

PURPOSE: We aimed to identify the differently expressed genes or related pathways associated with good responses to anti-HER2 therapy and to suggest a model for predicting drug response in neoadjuvant systemic therapy with trastuzumab in HER2-positive breast cancer patients. METHODS: This study was retrospectively analyzed from consecutively collected patient data. We recruited 64 women with breast cancer and categorized them into 3 groups: complete response (CR), partial response (PR), and drug resistance (DR). The final number of patients in the study was 20. RNA from 20 core needle biopsy paraffin-embedded tissues and 4 cultured cell lines (SKBR3 and BT474 breast cancer parent cells and cultured resistant cells) was extracted, reverse transcribed, and subjected to GeneChip array analysis. The obtained data were analyzed using Gene Ontology, Kyoto Gene and Genome Encyclopedia, Database for Annotation, Visualization and Integrated Discovery. RESULTS: In total, 6,656 genes differentially expressed between trastuzumab-susceptible and trastuzumab-resistant cell lines were identified. Among these, 3,224 were upregulated and 3,432 were downregulated. Expression changes in 34 genes in several pathways were found to be related to the response to trastuzumab-containing treatment in HER2-type breast cancer, interfering with adhesion to other cells or tissues (focal adhesion) and regulating extracellular matrix interactions and phagosome action. Thus, decreased tumor invasiveness and enhanced drug effects might be the mechanisms explaining the better drug response in the CR group. CONCLUSIONS: This multigene assay-based study provides insights into breast cancer signaling and possible predictions of therapeutic response to targeted therapies such as trastuzumab.

Fusion Assessment of Oblique Lumbar Interbody Fusion Using Demineralized Bone Matrix: A 2-Year Prospective Study.

OBJECTIVE: Although several studies have reported successful fusion rates after oblique lumbar interbody fusion (OLIF) using allografts or dimerized bone matrix (DBM) instead of autografts, whether OLIF can achieve satisfactory solid fusion without the use of autografts remains unclear. This study investigated the real fusion rates after OLIF using allografts and DBM, which were evaluated using both dynamic radiographs and computed tomography scans. METHODS: We enrolled 79 consecutive patients who underwent minimally invasive OLIF followed by percutaneous pedicle screw fixation. All patients were treated with OLIF between L2 and L5 and underwent radiographic and clinical follow-ups at 12, 18, and 24 months after surgery. Radiographic assessment of fusion was performed using the modified BrantigaSteffee-Fraser (mBSF) scale, which was categorized as follows: grades I (radiographic pseudoarthrosis), II (indeterminate fusion), and III (solid radiographic fusion). Other radiologic and clinical outcomes were evaluated using the following parameters: vertebral slippage distance, disc height, subsidence, Oswestry Disability Index (ODI), and visual analogue scale (VAS). RESULTS: Clinical outcomes demonstrated significant improvements in the VAS scores for back pain, leg pain, and ODI after surgery. Subsidence was present in 34 cases (35.4%) at 12 months postoperatively, which increased to 47.9% and reached 50.0% at 1.5 years and 2 years after surgery, respectively. The solid fusion rate after OLIF was 32.3% at 1 year, increased to 58.3% at 1.5 years, and reached 72.9% at 2 years. Radiographic pseudoarthrosis was 24.0% at 1 year, which decreased to 6.3% at 1.5 years and 3.1% at 2 years. CONCLUSION: OLIF is a safe and effective surgical procedure for the treatment of degenerative lumbar diseases. The mBSF scale, which simultaneously evaluates both dynamic angles and bone bridge formation, offers great reliability for the radiological assessment of fusion. Moreover, OLIF using allografts and DBM, which is performed on one or 2 levels at L2-5, can achieve satisfactory fusion rates within 2 years after surgery.

A cost-utility analysis between decompression only and fusion surgery for elderly patients with lumbar spinal stenosis and sagittal imbalance.

Lumbar spinal stenosis (LSS) and sagittal imbalance are relatively common in elderly patients. Although the goals of surgery include both functional and radiological improvements, the criteria of correction may be too strict for elderly patients. If the main symptom of patients is not forward-stooping but neurogenic claudication or pain, lumbar decompression without adding fusion procedure may be a surgical option. We performed cost-utility analysis between lumbar decompression and lumbar fusion surgery for those patients. Elderly patients (age > 60 years) who underwent 1-2 levels lumbar fusion surgery (F-group, n = 31) or decompression surgery (D-group, n = 40) for LSS with sagittal imbalance (C7 sagittal vertical axis, C7-SVA > 40 mm) with follow-up ≥ 2 years were included. Clinical outcomes (Euro-Quality of Life-5 Dimensions, EQ-5D; Oswestry Disability Index, ODI; numerical rating score of pain on the back and leg, NRS-B and NRS-L) and radiological parameters (C7-SVA; lumbar lordosis, LL; the difference between pelvic incidence and lumbar lordosis, PI-LL; pelvic tilt, PT) were assessed. The quality-adjusted life year (QALY) and incremental cost-effective ratio (ICER) were calculated from a utility score of EQ-5D. Postoperatively, both groups attained clinical and radiological improvement in all parameters, but NRS-L was more improved in the F-group (p = 0.048). ICER of F-group over D-group was 49,833 US dollars/QALY. Cost-effective lumbar decompression may be a recommendable surgical option for certain elderly patients, despite less improvement of leg pain than with fusion surgery.

Biomechanical Effect of Disc Height on the Components of the Lumbar Column at the Same Axial Load: A Finite-Element Study.

Intervertebral discs are fibrocartilage structures, which play a role in buffering the compression applied to the vertebral bodies evenly while permitting limited movements. According to several previous studies, degenerative changes in the intervertebral disc could be accelerated by factors, such as aging, the female sex, obesity, and smoking. As degenerative change progresses, the disc height could be reduced due to the dehydration of the nucleus pulposus. This study aimed to quantitatively analyze the pressure that each structure of the spine receives according to the change in the disc height and predict the physiological effect of disc height on the spine. We analyzed the biomechanical effect on spinal structures when the disc height was decreased using a finite-element method investigation of the lumbar spine. Using a 3D FE model, the degree and distribution of von-Mises stress according to the disc height change were measured by applying the load of four different motions to the lumbar spine. The height was changed by dividing the anterior and posterior parts of the disc, and analysis was performed in the following four motions: flexion, extension, lateral bending, and axial rotation. Except for a few circumstances, the stress applied to the structure generally increased as the disc height decreased. Such a phenomenon was more pronounced when the direction in which the force was concentrated coincided with the portion where the disc height decreased. This study demonstrated that the degree of stress applied to the spinal structure generally increases as the disc height decreases. The increase in stress was more prominent when the part where the disc height was decreased and the part where the moment was additionally applied coincided. Disc height reduction could accelerate degenerative changes in the spine. Therefore, eliminating the controllable risk factors that cause disc height reduction may be beneficial for spinal health.

Radiological evaluation of atlantoaxial fusion using C2 translaminar screws and C2 pedicle screws: Does the screw halo sign imply fusion failure?

The purpose of this study was to identify the criteria for atlantoaxial (AA) fusion by comparing follow-up lateral radiographs and computed tomography (CT) images. We retrospectively analyzed data from 161 consecutive patients undergoing AA fusion. Patients with a minimum of 1 year of CT follow-up after AA fusion surgery using C2 pedicle screws or translaminar screws (C2TLS) were included. Patients were followed up radiographically at 3, 6, and 12 months after surgery, and dynamic lateral radiographs were also evaluated. A total of 49 patients were analyzed, with a mean CT image follow-up of 41.6 ±â€…37.6 months. Thirty eight patients had C2 pedicle screw placement, and 11 patients underwent planned C2TLS. AA fusion with bridging bone mass formation was achieved in 45/49 (91.8%) patients. Screw halos were observed in 14/49 (28.6%) patients. Among them, final fusion failure occurred in 2 (14.3%) patients. The last follow-up CT showed no difference in the fusion failure rate according to the presence or absence of a screw halo (no halo, 5.7%; halo, 14.3%; P = .33). The differences in C1-2 segmental angles (SA) in flexion-extension dynamic lateral radiographs were 1.99 ±â€…1.62° in the fusion group and 4.37 ±â€…2.13° in the non-fusion group (P = .01). The likelihood of fusion failure increased when the SA gap was greater than 2.62° (P = .05). C2TLS placement had a significantly higher incidence of screw halos. However, the halo sign was not significantly related to final bone fusion. Bone fusion could be predicted when the SA gap of C1-2 was less than 2.62° on the dynamic radiograph.

Indirect Decompression Using Oblique Lumbar Interbody Fusion Revision Surgery Following Previous Posterior Decompression: Comparison of Clinical and Radiologic Outcomes Between Direct and Indirect Decompression Revision Surgery.

OBJECTIVE: This study compared the radiological and clinical outcomes with transforaminal lumbar interbody fusion (TLIF) to evaluate the effect of indirect decompression through oblique lumbar interbody fusion (OLIF) as revision surgery. METHODS: We enrolled patients who underwent single-level fusion with revision surgery at the same level as the previous decompression level. We retrospectively reviewed 25 patients who underwent OLIF from 2017 to 2018 and 25 who received TLIF from 2014 to 2018. Radiologic and clinical outcomes were evaluated by cross-sectional area (CSA) of the spinal canal, thickness and area of ligamentum flavum (LF), subsidence, disc height, fusion rate, Oswestry Disability Index (ODI), and visual analogue scale (VAS). RESULTS: Compared with OLIF, the thickness and area of the LF after surgery were significantly less in TLIF, and the resulting CSA extension was also significantly higher. However, both groups showed improvement in ODI and VAS after surgery, and there was no difference between the groups. Complications related to the posterior approach in TLIF were 4 cases, and in OLIF, there were 2 cases that underwent additional posterior decompression surgery and 6 cases of transient paresthesia. CONCLUSION: Since complications associated with the posterior approach can be avoided, OLIF is a safer and useful minimally invasive surgery. Therefore, appropriate indications are applied, OLIF is a good alternative to TLIF when revision surgery is considered.

Temporal Changes in Subcutaneous Fibrosis in Patients with Lower Extremity Lymphedema Following Surgery for Gynecologic Cancer: A Computed Tomography-Based Quantitative Analysis.

Lymphedema causes inflammation, which provokes fibrosis within the epifascial tissue. Temporal change in fibrosis according to severity of the lymphedema has not been widely investigated. We aimed to study the quantitative changes in epifascial fibrosis during lymphedema treatment using computed tomography (CT). Forty-five patients (mean age: 57.75 ± 11.12 years) who developed lymphedema following gynecologic surgery were included in this retrospective study. Two weeks of complete decongestive therapy and continued self-bandaging or compression garments were prescribed under regular follow-up monitoring. Lower-extremity epifascial fibrosis was quantitatively analyzed on the initial and follow-up CT scans. Circumference, skin fibrosis, subcutaneous tissue, and fibrosis ratio were calculated in the axial scan. Based on the change in lymphedema severity, we divided subjects into 'improved' and 'aggravated' groups. The affected lower extremities showed higher circumference, more skin fibrosis and subcutaneous tissue, and higher fibrosis ratio than the unaffected sides on initial CT scan. At follow-up, compared to the aggravated group, the improved group showed significant decreases in fibrosis of skin and subcutaneous tissue and fibrosis ratio. Subcutaneous fibrosis was reversible with volume resolution of lymphedema. Therapeutic approaches should be established on the basis of the reversible nature of fibrotic changes in patients with lower extremity lymphedema.

Psoas weakness following oblique lateral interbody fusion surgery: a prospective observational study with an isokinetic dynamometer.

BACKGROUND CONTEXT: Although the surgical corridor used for oblique lateral interbody fusion (OLIF) protects the intrapsoas nerves by causing minimal compression, transient weakness remains the most commonly reported postoperative complication. PURPOSE: Using a dynamometer to evaluate how the hip flexor strength changes following OLIF. STUDY DESIGN/SETTING: A prospective observational study. PATIENT SAMPLE: Forty-six patients who underwent single or multi-level OLIF for lumbar spondylolisthesis. OUTCOME MEASURES: Isokinetic dynamometer values (peak torque, total work, average power), visual analogue scale (VAS) scores for leg pain, hypoesthesia, subjective weakness of the left hip flexor muscle, Oswestry disability index, body mass index, bone mineral density, radiologic findings of the psoas muscle (cross-sectional area, Hounsfield unit (HU), fat portion grade), and psoas retraction time. METHODS: The isokinetic muscle strength of the hip flexor was measured five times (preoperatively and postoperatively at 2 days, 1 week, 1 month, and 3 months) for both legs. The peak torque was defined as the postoperative strength of the left hip flexor muscles, and was compared to the preoperative baseline value. The strength of the left and right hip flexor muscles were also compared at each time point. For logistic regression analysis, when the peak torque was below the median value, it was defined as lower peak torque. RESULTS: Up to 1 week after surgery, the strength of the left hip flexor muscle decreased significantly (paired difference in peak torque was 22.6%, p<.001). In the results of multivariate logistic regression analysis, diabetes (odds ratio [OR]=8.43, p=.020) and the HU of the psoas muscle (OR=0.916, p=.034) were associated with lower peak torque 1 week after surgery. From 1 month after surgery, postoperative weakness of the psoas muscle was not significant. In the questionnaire survey, subjective left hip flexion weakness was reported in 8.5% (4/47) of patients 1 week after surgery, and it remained in only 2.1% (1/47) of patients after 3 months of operation. The frequency of left anterior thigh pain and hypoesthesia decreased from 85.1% (40/47) at 1 week to 2.1% (1/47) at 3 months after surgery. The mean VAS score for left anterior thigh or groin pain decreased significantly at 1 month after surgery (PO2D: 4.04±1.84, PO1M: 1.67±1.10, p<.001). CONCLUSIONS: Dynamometer measurement showed that psoas strength declined significantly up to 1 week after OLIF surgery. Patients with diabetes or lower HU of the psoas muscle showed delayed recovery from postoperative weakness of the psoas muscle. However, the weakness was insignificant from 1 month after surgery. At 3 months after surgery, the other psoas-related problems (left anterior thigh pain and hypoesthesia) also disappeared.

Curcumin as a Promising Neuroprotective Agent for the Treatment of Spinal Cord Injury: A Review of the Literature.

Curcumin is a polyphenolic chemical derived from the rhizomes of Curcuma longa. It has been used throughout the Indian subcontinent for medicinal purposes, religious events, and regional cuisine. It has various pharmacological benefits owing to its anti-inflammatory and antioxidant properties. Its neuroprotective effects on the brain and peripheral nerves have been demonstrated in several in vivo neuronal tissue studies. Because of these functional properties of curcumin, it is considered to have great potential for use in the treatment of spinal cord injuries (SCIs). Numerous immunopathological and biochemical studies have reported that curcumin can help prevent and alleviate subsequent secondary injuries, such as inflammation, edema, free radical damage, fibrosis, and glial scarring, after a primary SCI. Furthermore, following SCI, curcumin administration resulted in better outcomes of neurological function recovery as per the Basso, Beattie, and Bresnahan locomotor rating scale. However, to date, its utility in treating SCIs has only been reported in laboratories. More studies on its clinical applications are needed in the future for ensuring its bioavailability across the blood-brain barrier and for verifying the safe dose for treating SCIs in humans.

Mechanical Failure After Total En Bloc Spondylectomy and Salvage Surgery.

OBJECTIVE: Total en bloc spondylectomy (TES) is a curative surgical method for spinal tumors. After resecting the 3 spinal columns, reconstruction is of paramount importance. We present cases of mechanical failure and suggest strategies for salvage surgery. METHODS: The medical records of 19 patients who underwent TES (9 for primary tumors and 10 for metastatic tumors) were retrospectively reviewed. Previously reported surgical techniques were used, and the surgical extent was 1 level in 16 patients and 2 levels in 3 patients. A titanium-based mesh-type interbody spacer filled with autologous and cadaveric bone was used for anterior support, and a pedicle screw/rod system was used for posterior support. Radiotherapy was performed in 11 patients (pre-TES, 5; post-TES, 6). They were followed up for 59 ± 38 months (range, 11-133 months). RESULTS: During follow-up, 8 of 9 primary tumor patients (89%) and 5 of 10 metastatic tumor patients (50%) survived (mean survival time, 124 ± 8 months vs. 51 ± 13 months; p = 0.11). Mechanical failure occurred in 3 patients (33%) with primary tumors and 2 patients (20%) with metastatic tumors (p = 0.63). The mechanical failure-free time was 94.4 ± 14 months (primary tumors, 95 ± 18 months; metastatic tumors, 68 ± 16 months; p = 0.90). Revision surgery was performed in 4 of 5 patients, and bilateral broken rods were replaced with dual cobalt-chromium alloy rods. Repeated rod fractures occurred in 1 of 4 patients 2 years later, and the third operation (with multiple cobalt-chromium alloy rods) was successful for over 6 years. CONCLUSION: Considering the difficulty of reoperation and patients' suffering, preemptive use of a multiple-rod system may be advisable.