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OBJECTIVE: The efficacy of preoperative embolization for hypervascular metastatic spine disease (MSD) such as renal cell and thyroid cancers has been reported. However, the debate on the efficacy of preoperative embolization for non-hypervascular MSD still remains unsettled. The purpose of this study is to determine whether preoperative embolization for non-hypervascular MSD decreases perioperative blood loss. METHODS: A total of 79 patients (36 cases of preoperative embolization and 43 cases of non-embolization) who underwent surgery for metastatic spine lesions were included. Representative hypervascular tumors such as renal cell and thyroid cancers were excluded. Intraoperative and perioperative estimated blood losses (EBL), total number of transfusion and calibrated EBL were recorded in the embolization and non-embolization groups. The differences in EBL were also compared along with the type of surgery. In addition, the incidence of Adamkiewicz artery and complications of embolization were assessed. RESULTS: The average age of 50 males and 29 females was 57.6±13.5 years. Lung (30), hepatocellular (14), gastrointestinal (nine) and others (26) were the primary cancers. The demographic data was not significantly different between the embolization and the non-embolization groups. There were no significant differences in intraoperative EBL, perioperative EBL, total transfusion and calibrated EBL between two groups. However, intraoperative EBL and total transfusion in patients with preoperative embolization were significantly lower than in non-embolization in the corpectomy group (1645.5 vs. 892.6 mL, p=0.017 for intraoperative EBL and 6.1 vs. 3.9, p=0.018 for number of transfusion). In addition, the presence of Adamkiewicz artery at the index level was noted in two patients. Disruption of this major feeder artery resulted in significant changes in intraoperative neuromonitoring. CONCLUSION: Preoperative embolization for non-hypervascular MSD did not reduce perioperative blood loss. However, the embolization significantly reduced intraoperative bleeding and total transfusion in corpectomy group. Moreover, the procedure provided insights into the anatomy of tumor and spinal cord vasculature.
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INTRODUCTION: Although the majority of fifth metacarpal neck fractures can be treated nonoperatively, surgery may be indicated when there is severe shortening or angulation of the metacarpal bone1. STEP 1 ANTEGRADE INTRAMEDULLARY PINNING OPERATING-ROOM SETUP AND MAKING THE INCISION: Proper positioning of the image intensifier and the treating surgeons is important. STEP 2 ANTEGRADE INTRAMEDULLARY PINNING BEND THE KIRSCHNER WIRES: Prepare and bend the Kirschner wires before insertion. STEP 3 ANTEGRADE INTRAMEDULLARY PINNING MAKE A HOLE IN THE FIFTH METACARPAL BASE: Create a hole for Kirschner wire insertion in the center of the fifth metacarpal base. STEP 4 ANTEGRADE INTRAMEDULLARY PINNING INSERT KIRSCHNER WIRES AND CLOSE THE WOUND: Insert the Kirschner wires through the hole of the fifth metacarpal base. STEP 5 ANTEGRADE INTRAMEDULLARY PINNING POSTOPERATIVE CARE: An additional skin incision is necessary to remove the Kirschner wires after bone union. STEP 1 PERCUTANEOUS RETROGRADE INTRAMEDULLARY PINNING OPERATING-ROOM SETUP: Proper positioning of the image intensifier and treating surgeon is important. STEP 2 PERCUTANEOUS RETROGRADE INTRAMEDULLARY PINNING FRACTURE REDUCTION: Reduce the fifth metacarpal neck fracture using the Jahss maneuver. STEP 3 PERCUTANEOUS RETROGRADE INTRAMEDULLARY PINNING INSERT KIRSCHNER WIRES: Fix the reduced metacarpal neck fracture using 2 Kirschner wires placed percutaneously in a retrograde direction, with the second wire inserted after the first wire passes the fracture site but before it passes the metacarpal base. STEP 4 PERCUTANEOUS RETROGRADE INTRAMEDULLARY PINNING KIRSCHNER WIRE MANAGEMENT: The proximal end of the Kirschner wire penetrating outside the dorsal skin of the wrist enables the surgeon to percutaneously retrieve the Kirschner wire after fracture union. STEP 5 PERCUTANEOUS RETROGRADE INTRAMEDULLARY PINNING POSTOPERATIVE CARE: The percutaneous Kirschner wire is retrieved. RESULTS: In a previous prospective randomized analysis of patients treated with antegrade intramedullary pinning and percutaneous retrograde intramedullary pinning for displaced fifth metacarpal neck fracture1, we found that the flexion arc of the MCP joint, visual analog pain scale score, grip strength, and DASH (Disabilities of the Arm, Shoulder and Hand) score4 were significantly better in the antegrade intramedullary pinning group at 3 months postoperatively.