Connecting the S2 alar-iliac screw head to the satellite rod for surgical correction of degenerative sagittal imbalance.

PURPOSE: The S2AI screw technique has several advantages over the conventional iliac screw fixation technique. However, connecting the S2AI screw head to the main rod is difficult due to its medial entry point. We introduce a new technique for connecting the S2AI screw head to a satellite rod and compare it with the conventional method of connecting the S2AI screw to the main rod. METHODS: Seventy-four patients who underwent S2AI fixation for degenerative sagittal imbalance and were followed up for ≥ 2 years were included. All the patients underwent long fusion from T9 or T10 to the pelvis. The S2AI screw head was connected to the satellite rod (SS group) in 43 patients and the main rod (SM group) in 31 patients. In the SS group, the satellite rod was placed medial to the main rod and connected by the S2AI screw and domino connectors. In the SM group, the main rod was connected directly to the S2AI screw head and supported by accessory rods. Radiographic and clinical outcomes were evaluated in both groups. RESULTS: There were no significant differences in postoperative complications, including proximal junctional failure, proximal junctional kyphosis, rod breakage, screw loosening, wound problems, and infection between the two groups. Furthermore, the correction power of sagittal deformity and clinical results in the SS group were comparable to those in the SM group. CONCLUSION: Connecting the S2AI screw to the satellite rod is a convenient method comparable to the conventional S2AI connection method in terms of radiological and clinical outcomes.

Can We Control Lateral Shoulder Balance Through Proximal Thoracic Curve Correction in Lenke Type 2 Adolescent Idiopathic Scoliosis?

BACKGROUND: Proximal thoracic curve (PTC) correction has been considered to prevent lateral shoulder imbalance in Lenke Type 2 adolescent idiopathic scoliosis (AIS) patients; however, postoperative shoulder imbalance (PSI) commonly occurs despite these strategies with PTC correction. We investigated the hypothesis that PTC correction would not directly affect PSI in the majority of Lenke type 2 AIS cases. Furthermore, we investigated the risk factors for lateral PSI after corrective surgery. METHODS: This study examined the records for AIS patients with Lenke type 2 who underwent corrective surgery and followed up for >2 years. Patients were categorized into PSI (-); radiologic shoulder height (RSH)<15 mm, and PSI (+); RSH≥15 mm. Repeated measures analysis of variance was performed at preoperatively, postoperatively, 1 month, and final follow-up. Postoperative lateral shoulder imbalance was predicted by the identification of univariate analysis and multivariate analysis. RESULTS: Among the 151 patients reviewed, 29 (19.2%) showed PSI at final follow-up. Lateral shoulder balance parameters showed different directionalities between PSI (-) and (+) groups at postoperatively, 1 month, and final follow-up ( P <0.01 each). Preoperative PTC, middle thoracic curve (MTC) curve and MTC correction showed strong correlations with the RSH ( P =0.01, 0.03, and 0.04, respectively). However, PTC correction did not show a significant correlation with the RSH. Moreover, only a smaller MTC curve and larger MTC correction rate were related to lateral PSI in multivariate analysis. CONCLUSIONS: In Lenke type 2 AIS curves, the MTC curve and its correction predominantly influence lateral shoulder imbalance after corrective surgery, irrespective of the PTC correction extent. Consequently, overemphasizing the correction of the PTC curve may not necessarily lead to an improved lateral shoulder balance. When MTC curve is smaller, surgeons should be more careful for MCT overcorrection leading to a lateral shoulder imbalance. LEVEL OF EVIDENCE: Level III.

Mid-term efficacy and safety of Escherichia coli-derived rhBMP-2/hydroxyapatite carrier in lumbar posterolateral fusion: a randomized, multicenter study.

PURPOSE: This study aimed to evaluate the mid-term efficacy and safety of Escherichia coli-derived bone morphogenetic protein-2 (E.BMP-2)/hydroxyapatite (HA) in lumbar posterolateral fusion (PLF). METHODS: This multicenter, evaluator-blinded, observational study utilized prospectively collected clinical data. We enrolled 74 patients who underwent lumbar PLF and had previously participated in the BA06-CP01 clinical study, which compared the short-term outcomes of E.BMP-2 with an auto-iliac bone graft (AIBG). Radiographs and CT scans were analyzed to evaluate fusion grade at 12, 24, and 36 months. Visual analog scale (VAS), Oswestry disability index (ODI), and Short Form-36 (SF-36) scores were measured preoperatively and at 36 months after surgery. All adverse events in this study were assessed for its relationship with E.BMP-2. RESULTS: The fusion grade of the E.BMP-2 group (4.91 ± 0.41) was superior to that of the AIBG group (4.25 ± 1.26) in CT scans at 36 months after surgery (p = 0.007). Non-union cases were 4.3% in the E.BMP-2 and 16.7% in the AIBG. Both groups showed improvement in pain VAS, ODI, and SF-36 scores when compared to the baseline values, and there were no statistically significant differences between the two groups. No treatment-related serious adverse reactions were observed in either group. No neoplasm-related adverse events occurred in the E.BMP-2 group. CONCLUSIONS: The fusion quality of E.BMP-2/HA was superior to that of AIBG. E.BMP-2/HA showed comparable mid-term outcomes to that of AIBG in terms of efficacy and safety in one-level lumbar PLF surgery.

Risk factors for postoperative complaints in patients following lumbar decompression and fusion: Analyses focusing on preoperative symptoms.

BACKGROUND: Several patients complained of residual symptoms following lumbar decompressive surgery for lumbar degenerative disease (LDD). However, few studies analyze this dissatisfaction by focusing on preoperative patients' symptoms. This study was conduct to determine the factors that could predict the patients' postoperative complaints by focusing on their preoperative symptoms. METHODS: Four hundred and seventeen consecutive patients who underwent lumbar decompression and fusion surgery for LDD were included. Postoperative complaint was defined by at least twice same complaint during the outpatient follow-up of 6,12, 18 and 24 months after surgery. A comparative analysis was performed between complaint group (group C, N = 168) and non-complaint group (group NC, N = 249). Demographic, operative, symptomatic, and clinical factors were compared between the groups by univariate and multivariate analyses. RESULTS: The main preoperative chief complaints were radiating pain (318/417, 76.2%). However, most common postoperative complaint was residual radiating pain (60/168, 35.7%) followed by tingling sensation (43/168, 25.6%). The presence of psychiatric disease (adjusted odds ratio [aOR], 4.666; P = 0.017), longer pain duration (aOR, 1.021; P < 0.001), pain to below the knee (aOR, 2.326; P = 0.001), preoperative tingling sensation (aOR, 2.631; P < 0.001), preoperative sensory and motor power decrease (aOR, 2.152 and 1.678; P = 0,047 and 0.011, respectively) were significantly correlated with postoperative patients' complaints in multivariate analysis. CONCLUSIONS: The postoperative patients' complaints could be predicted and explained in advance by checking the preoperative characteristics of patients' symptoms, including the duration and site carefully. This could be helpful to enhance the understanding of the surgical results preoperatively, which could control the anticipation of the patients.

BMP-2 Induced Signaling Pathways and Phenotypes: Comparisons Between Senescent and Non-senescent Bone Marrow Mesenchymal Stem Cells.

The use of BMP-2 in orthopedic surgery is limited by uncertainty surrounding its effects on the differentiation of mesenchymal stem cells (MSCs) and how this is affected by cellular aging. This study compared the effects of recombinant human BMP-2 (rhBMP-2) on osteogenic and adipogenic differentiation between senescent and non-senescent MSCs. Senescent and non-senescent MSCs were cultured in osteogenic and adipogenic differentiation medium containing various concentrations of rhBMP-2. The phenotypes of these cells were compared by performing a calcium assay, adipogenesis assay, staining, real-time PCR, western blotting, and microarray analysis. rhBMP-2 induced osteogenic differentiation to a lesser extent (P < 0.001 and P = 0.005 for alkaline phosphatase activity and Ca2+ release) in senescent MSCs regardless of dose-dependent increase in both cells. However, the induction of adipogenic differentiation by rhBMP-2 was comparable between them. There was no difference between these two groups of cells in the adipogenesis assay (P = 0.279) and their expression levels of PPARγ were similar. Several genes such as CHRDL1, NOG, SMAD1, SMAD7, and FST encoding transcription factors were proposed to underlie the different responses of senescent and non-senescent MSCs to rhBMP-2 in microarray analyses. Furthermore, inflammatory, adipogenic, or cell death-related signaling pathways such as NF-kB or p38-MAPK pathways were upregulated by BMP-2 in senescent MSCs, whereas bone forming signaling pathways involving BMP, SMAD, and TGF- ß were upregulated in non-senescent MSCs as expected. This phenomenon explains bone forming dominance by non-senescent MSCs and possible frequent complications such as seroma, osteolysis, or neuritis in senescent MSCs during BMP-2 use in orthopedic surgery.

The medial window technique as a salvage method to insert C2 pedicle screw in the case of a high-riding vertebral artery or narrow pedicle: a technical note and case series.

PURPOSE: To describe the safety and feasibility of C2 medial window screw (C2MWS) as an alternative salvage method for C2 pedicle screws in cases of high-riding vertebral artery (HRVA) or narrow pedicle. METHODS: The C2MWS technique involves screw insertion by intentionally breaching the medial cortex of the pedicle to avoid vertebral artery injury. Twelve patients who underwent C2 screw insertion via the C2MWS were retrospectively reviewed. C2MWS was indicated in cases of high-riding vertebral artery (HRVA) or narrow pedicle (pedicle width ≤ 4 mm). The width of the canal breach by screw, vertebral artery groove (VAG) breach, solid fusion, neck pain visual analogue scale (VAS) score, and Japanese Orthopedic Association (JOA) score were assessed as outcome measurements. RESULTS: C2MWS was indicated due to both HRVA and narrow pedicle for 11 screws, narrow pedicle for one screw, and HRVA for two screws. No screw VAG breach or vertebral artery injury was noted postoperatively. The mean width of canal breach was 2.9 ± 1.3 mm. There were no cases demonstrating neurologic deterioration, and 11 patients (91.7%) demonstrated solid fusion at 1-year follow-up. Furthermore, neck pain VAS and JOA scores significantly improved after the surgery. CONCLUSIONS: The C2MWS technique can provide 3-column fixation while reliably avoiding VA injury. C2MWS could be considered as a salvage alternative method when the insertion of C2 pedicle screw is complicated by HRVA or a narrow pedicle, while there is a need to provide firmer fixation strength than that provided by pars or translaminar screws.

Factors affecting the prognosis of recovery of motor power and ambulatory function after surgery for metastatic epidural spinal cord compression.

OBJECTIVE: Metastatic epidural spinal cord compression (MESCC) causes neurological deficits that may hinder ambulation. Understanding the prognostic factors associated with increased neurological recovery and regaining ambulatory functions is important for surgical planning in MESCC patients with neurological deficits. The present study was conducted to elucidate prognostic factors of neurological recovery in MESCC patients. METHODS: A total of 192 patients who had surgery for MESCC due to preoperative neurological deficits were reviewed. A motor recovery rate ≥ 50% and ambulatory function restoration were defined as the primary favorable endpoints. Factors associated with a motor recovery rate ≥ 50%, regaining ambulatory function, and patient survival were analyzed. RESULTS: About one-half (48.4%) of the patients had a motor recovery rate ≥ 50%, and 24.4% of patients who were not able to walk due to MESCC before the surgery were able to walk after the operation. The factors "involvement of the thoracic spine" (p = 0.015) and "delayed operation" (p = 0.041) were associated with poor neurological recovery. Low preoperative muscle function grade was associated with a low likelihood of regaining ambulatory functions (p = 0.002). Furthermore, performing the operation ≥ 72 hours after the onset of the neurological deficit significantly decreased the likelihood of regaining ambulatory functions (p = 0.020). Postoperative ambulatory function significantly improved patient survival (p = 0.048). CONCLUSIONS: Delayed operation and the involvement of the thoracic spine were poor prognostic factors for neurological recovery after MESCC surgery. Furthermore, a more severe preoperative neurological deficit was associated with a lesser likelihood of regaining ambulatory functions postoperatively. Earlier detection of motor weaknesses and expeditious surgical interventions are necessary, not only to improve patient functional status and quality of life but also to enhance survival.

Is the Combination of Convex Compression for the Proximal Thoracic Curve and Concave Distraction for the Main Thoracic Curve Using Separate-rod Derotation Effective for Correcting Shoulder Balance and Thoracic Kyphosis?

BACKGROUND: Posterior correction of the proximal thoracic curve in patients with adolescent idiopathic scoliosis has been recommended to achieve shoulder balance. However, finding a good surgical method is challenging because of the small pedicle diameters on the concave side of the proximal thoracic curve. If the shoulder height can be corrected using screws on the convex side, this would appear to be a more feasible approach. QUESTIONS/PURPOSES: In patients with adolescent idiopathic scoliosis, we asked: (1) Is convex compression with separate-rod derotation effective for correcting the proximal thoracic curve, shoulder balance, and thoracic kyphosis? (2) Which vertebrum is most appropriate to serve as the uppermost-instrumented vertebra? (3) Is correction of the proximal thoracic curve related to the postoperative shoulder balance? METHODS: Between 2015 and 2017, we treated 672 patients with scoliosis. Of those, we considered patients with elevated left shoulder, Lenke Type 2 or 4, or King Type V idiopathic scoliosis as potentially eligible. Based on that, 17% (111 of 672) were eligible; 5% (6 of 111) were excluded because of other previous operations and left-side main thoracic curve, 22% (24 of 111) were excluded because they did not undergo surgery for the proximal thoracic curve with only pedicle screws, 21% (23 of 111) were excluded because the proximal thoracic curve was not corrected by convex compression and separate rod derotation, and another 3% (3 of 111) were lost before the minimum study follow-up of 2 years, leaving 50% (55 of 111) for analysis. During the study period, we generally chose T2 as the uppermost level instrumented when the apex was above T4, or T3 when the apex was T5. Apart from the uppermost-instrumented level, the groups did not differ in measurable ways such as age, sex, Cobb angles of proximal and main thoracic curves, and T1 tilt. However, shoulder balance was better in the T3 group preoperatively. The median (range) age at the time of surgery was 15 years (12 to 19 years). The median follow-up duration was 26 months (24 to 52 months). Whole-spine standing posteroanterior and lateral views were used to evaluate the improvement of radiologic parameters at the most recent follow-up and to compare the radiologic parameters between the uppermost-instrumented T2 (37 patients) and T3 (18 patients) vertebra groups. Finally, we analyzed radiologic factors related to shoulder balance, defined as the difference between the horizontal lines passing both superolateral tips of the clavicles (right-shoulder-up was positive), at the most recent follow-up. RESULTS: Convex compression with separate-rod derotation effectively corrected the proximal thoracic curve (41° ± 11° versus 17° ± 10°, mean difference 25° [95% CI 22° to 27°]; p < 0.001), and the most recent shoulder balance changed to right-shoulder-down compared with preoperative right-shoulder-up (8 ± 11 mm versus -8 ± 10 mm, mean difference 16 mm [95% CI 12 to 19]; p < 0.001). Proximal thoracic kyphosis decreased (13° ± 7° versus 11° ± 6°, mean difference 2° [95% CI 0° to 3°]; p = 0.02), while mid-thoracic kyphosis increased (12° ± 8° versus 18° ± 6°, mean difference -7° [95% CI -9° to -4°]; p < 0.001). Preoperative radiographic parameters did not differ between the groups, except for shoulder balance, which tended to be more right-shoulder-up in the T2 group (11 ± 10 mm versus 1 ± 11 mm, mean difference 10 mm [95% CI 4 to 16]; p = 0.002). At the most recent follow-up, the correction proportion of the proximal thoracic curve was better in the T2 group than the T3 group (67% ± 10% versus 49% ± 22%, mean difference 19% [95% CI 8% to 30%]; p < 0.001). In the T2 group, T1 tilt (6° ± 4° versus 6° ± 4°, mean difference 1° [95% CI 0° to 2°]; p = 0.045) and shoulder balance (-14 ± 11 mm versus -7 ± 9 mm, mean difference -7 mm [95% CI -11 to -3]; p = 0.002) at the most recent follow-up improved compared with those at the first erect radiograph. The most recent shoulder balance was correlated with the correction proportion of the proximal thoracic curve (r = 0.29 [95% CI 0.02 to 0.34]; p = 0.03) and change in T1 tilt (r = 0.35 [95% CI 0.20 to 1.31]; p = 0.009). CONCLUSION: Using the combination of convex compression and concave distraction with separate-rod derotation is an effective method to correct proximal and main thoracic curves, with reliable achievement of postoperative thoracic kyphosis and shoulder balance. T2 was a more appropriate uppermost-instrumented vertebra than T3, providing better correction of the proximal thoracic curve and T1 tilt. Additionally, spontaneous improvement in T1 tilt and shoulder balance is expected with upper-instrumented T2 vertebrae. Preoperatively, surgeons should evaluate shoulder balance because right-shoulder-down can occur after surgery in patients with a proximal thoracic curve. LEVEL OF EVIDENCE: Level III, therapeutic study.

Clinical and radiological outcomes in patients who underwent posterior lumbar interbody fusion: comparisons between unilateral and bilateral cage insertion.

BACKGROUND: Although the original technique involves inserting two cages bilaterally, there could be situations that only allow for insertion of one cage unilaterally. However, only a few studies have compared the outcomes between unilateral and bilateral cage insertion. The purpose of this study was to compare the clinical and radiological outcomes in patients who underwent posterior lumbar interbody fusion (PLIF) between unilaterally and bilaterally inserted cages. METHODS: Among 206 eligible patients who underwent 1- or 2-level PLIF, 78 patients were 1:3 cohort-matched by age, sex, and operation level (group U, 19 patients with unilateral cages; and group B, 57 patients with bilateral cages). Fusion status was evaluated by computed tomography (CT) scans at postoperative 1 year. Clinical outcomes were measured by visual analog scale (VAS), Oswestry Disability Index (ODI), and EQ-5D. Radiological and clinical parameters were compared between the two groups. Risk factors for pseudarthrosis were also analyzed by multivariate analysis. RESULTS: The demographic data were not significantly different between the two groups. However, previous laminectomy, asymmetric disc collapse, and fusion at L5-S1 level were more frequently found in group U (P = 0.003, P = 0.014, and P = 0.014, respectively). Furthermore, pseudarthrosis was more frequently observed in group U (36.8%) than in group B (7.0%) (P = 0.004). Back pain VAS was higher in group U at postoperative 1 year (P = 0.033). Lower general activity function of EQ-5D was observed in group U at postoperative 1 year (P = 0.035). Older age (P = 0.028), unilateral cage (P = 0.007), and higher bone mineral density (P = 0.033) were positively correlated with pseudarthrosis. CONCLUSIONS: Unilaterally inserted cage might be a possible risk factor for pseudarthrosis when performing PLIF, which could be related with the difficult working conditions such as scars due to previous laminectomy or asymmetric disc collapse. Furthermore, suboptimal clinical outcomes are expected following PLIF with unilateral cage insertion at postoperative 1 year regardless of similar clinical outcomes at postoperative 2 year. Therefore, caution is advised when inserting cages unilaterally, especially under above-mentioned conditions in terms of its possible relationship with symptomatic pseudarthrosis.

The influence of spinopelvic morphologies on sagittal spinal alignment: an analysis of incidence angle of inflection points.

PURPOSE: To elucidate whether specific spinopelvic morphologies affect the subsequent spinal sagittal alignments and determine the alignment patterns. METHODS: Whole-spine standing radiographs of 244 patients were analyzed. Sagittal alignment parameters were compared according to the three types of pelvic version: anteverted pelvis (AP), neutral pelvis, and retroverted pelvis (RP), grouped per the amount of pelvic tilt (PT) and the ratio of sacral slope to pelvic incidence (PI). Incidence angles of inflection points (IAIPs) were defined as the angle between a line from the center of the femoral heads through the midpoint of the sacral superior endplate and a line perpendicular to each L1, T1 superior endplate, C2 inferior endplate, and the C1 ring, respectively. RESULTS: C1 incidence equaled to the geometrical sum from the pelvis to the C1 vertebra; it also equaled the sum of the C1 slope and PT (p < 0.001). Moving from the AP group to the RP group, there were progressive increases in PT, PI, and IAIPs and decreases in LL, and SS/PI (p < 0.001). Negative correlation was observed between the pelvic anteversion and the IAIPs, and a significant positive correlation was observed between the pelvic retroversion and the IAIPs. CONCLUSION: IAIPs are novel PI-relevant radiographic parameters reflecting the relationship between the pelvis and the spinal alignment. An anteverted pelvis requires more lumbar lordosis than pelvic incidence and aligns with low IAIPs, and a retroverted pelvis requires less lumbar lordosis than pelvic incidence and aligns with high IAIPs. These slides can be retrieved under Electronic Supplementary Material.

Effect of osteoporosis on the clinical and radiological outcomes following one-level posterior lumbar interbody fusion.

BACKGROUND: Cage subsidence or pedicle screw loosening following lumbar fusion surgery is frequently reported in osteoporotic patients. However, few studies have analyzed clinical as well as radiological outcomes after such surgeries as a function of bone mineral density. We aimed to evaluate the impact of osteoporosis on the clinical and radiological outcomes of patients who underwent one-level posterior lumbar interbody fusion (PLIF). METHODS: Fifty-five non-osteoporotic (T-score ≥ -1.0) and 31 osteoporotic (T-score ≤ -2.5) patients who underwent one-level PLIF were followed up for >2 years. Visual Analog Scale (VAS), Oswestry Disability Index (ODI), and EuroQol 5-Dimension (EQ-5D) parameters were assessed. Fusion success was identified with dynamic plain radiographs and computed tomography. Pedicle screw loosening and cage subsidence were evaluated. The clinical and radiological parameters were compared between osteoporotic and non-osteoporotic patients. Subgroup analysis was performed on cage subsidence or screw loosening. RESULTS: Although VAS score for back pain was higher in osteoporotic patients than in non-osteoporotic patients at 6 months postoperatively (3.3 vs. 2.2, P = 0.062), this difference disappeared at 1 year postoperatively (2.9 vs. 2.5, P = 0.606). However, no differences were noted between the groups in ODI and EQ-5D grades. Cage subsidence (65.4% vs. 17.6%, P < 0.001) and screw loosening rates (32.3% vs. 12.7%, P = 0.029) were significantly higher in osteoporotic patients than in non-osteoporotic patients, but fusion rate did not differ between the groups. Although clinical outcomes did not differ between those who had cage subsidence or screw loosening and those who did not, fusion rate was lower in those who showed screw loosening than those who did not (71.4% vs. 93.9%, P = 0.038). CONCLUSIONS: Higher cage subsidence and pedicle screw loosening rates in osteoporotic patients did not significantly affect the clinical outcomes, but screw loosening, which occurred more frequently in older patients, significantly reduced the fusion success rate. Thus, PLIF procedure may be a good surgical treatment option to achieve good clinical outcomes, even in osteoporotic patients despite higher rates of cage subsidence and pedicle screw loosening. However, surgeons should monitor screw loosening because of its significant association with non-union.

Analysis of muscular elasticity according to infrared and ultrasound therapy by sonoelastography.

[Purpose] The purpose of this study was to evaluate the effect of physical therapy on elasticity of muscles quantitatively by using sonoelastography equipment in infrared and ultrasound treatment commonly used in hospital physical therapy rooms. [Participants and Methods] We also investigated correlations among various variables such as height, weight, BMI (Body Mass Index), body fat mass, muscle mass, and basal metabolic rate. From July 30th 2017 to August 30th, 2017, muscular elasticity ratio was measured in 10 males in their 20s by comparing muscles of the upper and lower extremities before and after ultrasound and infrared therapy. [Results] Results showed that muscular elasticity was increased 1.55 ± 0.41 folds in forearm muscle region of the upper extremity in ultrasound therapy, which was significantly higher than the increase (1.23 ± 0.10 folds) in infrared therapy. Thus, ultrasound therapy and infrared therapy both would have good result in cardiac treatment for 1-cm away region. In ultrasound therapy and infrared therapy, elasticity increase rates in forearm region of the upper extremity were higher when body fat mass and BMI were increased. [Conclusion] Results of this study could be used as basic data for ultrasound and infrared therapy studies in the future.

Effect of Coronary Artery Calcification Score by Lifestyle and Correlation With Coronary Artery Stenosis by Multidetector Computed Tomography.

OBJECTIVE: This study examined the effect of coronary artery calcification score by lifestyle and correlation with coronary artery stenosis in persons who underwent coronary artery computed tomography (CT) angiography among health examinees for heart diseases in Korea. METHODS AND MATERIALS: The study included 506 subjects (256 men and 250 women) who underwent coronary artery CT angiography among health examines for heart diseases at the Incheon Branch of the Korea Association of Health Promotion between January 2, 2014, and December 31, 2014. The demographical variables of the subjects were determined by frequency analysis, and the difference by sex was compared and analyzed using χ independence test. Independent 2-sample t test was performed to determine any difference in main factors by coronary artery calcification. RESULTS: According to the results, 175 (34.6%) had calcification, men showed statistically higher scores than women, and calcification seemed higher in those who were older, taller, heavier, and thicker in waist. Regarding blood pressure, calcification was shown if contraction phase and relaxation blood pressure was higher, blood sugar before meal was higher, and neutral fat was higher. By lifestyle, calcification seemed to be higher in those with more alcohol drinking per week, long past smoking years, and higher smoking amount per day in the past and present. In addition, coronary artery stenosis rate showed statistical correlation with calcification from the left anterior descending artery, right coronary artery, left circumflex artery, and left main coronary artery in sequence. CONCLUSIONS: In conclusion, coronary artery calcification score CT is deemed to be a suitable method for the estimation of coronary artery stenosis with short examination time, low radiation exposure, and noninvasive method.

Preoperative embolization in patients with metastatic spinal cord compression: mandatory or optional?

BACKGROUND: The contribution of preoperative embolization in reducing intraoperative blood loss and its clinical importance are unclear. So, we aimed to compare the perioperative clinical outcomes based on whether preoperative embolization was performed and assess the role and safety of preoperative embolization in metastatic spinal cord compression (MSCC) patients. METHODS: We enrolled 52 patients (men, 37; women, 15) who underwent palliative decompression for MSCC. Demographic data, neurologic status, surgery-related data (operation time, estimated blood loss, and transfusion), complications, and survival time were recorded. Patients were categorized based on whether they received preoperative embolization: groups E (embolization) (n = 18) and NE (non-embolization) (n = 34) and the clinical parameters were compared. Subgroup analysis was performed specifically for cases of hypervascular tumors (23/52, 44%). RESULTS: The transfusion degree was greater in the NE group (4.6 pints) than in the E group (2.5 pints, P = 0.025); the other parameters did not differ between the groups. However, massive bleeding (>2000 mL) was more frequent in the NE group (10/34) than in the E group (0/18, P = 0.010). Subgroup analysis indicated that intraoperative blood loss was greater in the NE group (1988 mL) than in the E group (1095 mL, P = 0.042) in hypervascular tumor patients. Although massive bleeding was more frequent among hypervascular tumor patients, 3 patients with non-hypervascularized tumors also exhibited massive bleeding (P = 0.087). CONCLUSIONS: Intraoperative blood loss and perioperative transfusion can be reduced by preoperative embolization in MSCC patients. Neurologic recovery, operation time, and complications did not differ according to the application of embolization. As preoperative embolization is relatively safe and effective for controlling intraoperative bleeding without any neurologic deterioration, it is highly recommended for hypervascular tumors. Moreover, it may also be effective for non-hypervascular tumors as massive bleeding may be noted in some cases.

Dose-Decreasing Effect of the First Reversed Laser Beam Collimator for C-Arm Type Angiographic Equipment.

This is a study on the dose-decreasing effect of the first reversed laser beam collimator (RLBC) for C-arm type angiographic equipment. A laser beam was located at the center of each plane at an oblique angle to the angiographic equipment detector. A field of view, which could be seen with the naked eye, was made by focusing the laser beam in the direction of the X-ray source. The height of the table was fixed at 75 cm and the iron balls were located within 2 mm of the top, bottom, left, and right edges of the output image. The time needed for location fixing, fluoroscopy, and measurement of dose area product (DAP) were compared by having 30 radiologists perform location fixing by looking at the fluoroscopic image while performing location fixing (no radiation) and while the RLBC was turned on. In the next test, the time needed for location fixing, fluoroscopy, and DAP were compared when varying the location of the iron balls from 2 to 10 mm from the edges of the output image. The results showed that the time needed for location fixing, the time needed for fluoroscopy, and DAP decreased, both in the first test and the second test. This study confirmed that the use of a RLBC for C-arm type angiographic equipment decreases both the time needed to perform the procedure and the radiation dose received. It is expected that continuous advancement of RLBC technology will contribute greatly to decreasing the dose of radiation needed and improving convenience during angiography.

A retrospective study to reveal the effect of surgical correction of cervical kyphosis on thoraco-lumbo-pelvic sagittal alignment.

PURPOSE: Recent studies suggest that cervical lordosis is influenced by thoracic kyphosis and that T1 slope is a key factor determining cervical sagittal alignment. However, no previous study has investigated the influence of cervical kyphosis correction on the remaining spinopelvic balance. The purpose of this study is to assess the effect of surgical correction of cervical kyphosis on thoraco-lumbo-pelvic alignment. METHODS: Fifty-five patients who underwent ≥2 level cervical fusions for cervical radiculopathy or myelopathy were included. All patients had regional or global cervical kyphosis, which was surgically corrected into lordosis. Radiographic measurements were made using whole spine standing lateral radigraphs pre- and postoperatively to analyze various sagittal parameters. The visual analogue scale (VAS) for neck pain and the neck disability index (NDI) were calculated. The paired t test was used to compare pre- and post-operative radiographic measures and functional scores. Correlations between changes in cervical sagittal parameters and those of other sagittal parameters were analyzed by Pearson's correlation method. RESULTS: Preoperative kyphosis (11.4° ± 8.3°) was corrected into lordosis (-9.3° ± 8.1°). The average fusion levels were 3.3 ± 1.0. With increasing C2-C7 lordosis after surgery (from -3.4° ± 10.0° to -15° ± 7.9°), C0-C2 lordosis decreased significantly (from -34.6° ± 8.2° to -27.7° ± 8.0°) (P < 0.001). Thoracic kyphosis (from 24.8 ± 13.9° to 33.5 ± 11.9°) and T1 slope (from 12.8° ± 7.9° to 20.4° ± 5.2°) significantly increased after surgery (P < 0.001). However, other parameters did not significantly change (P > 0.05). Neck pain VAS and NDI scores (31.8 ± 16.2) significantly improved (P < 0.001). The degree of increasing C2-C7 lordosis by surgical correction was negatively correlated with changes in both thoracic kyphosis and T1 slope (P < 0.01). CONCLUSIONS: Surgical correction of cervical kyphosis affects T1 slope and thoracic kyphosis, but not lumbo-pelvic alignment. These results indicate that the compensatory mechanisms to minimize positive sagittal malalignment of the head may occur mainly in the thoracic, and not in the lumbosacral spine.

Is it enough to stop distal fusion at L3 in adolescent idiopathic scoliosis with major thoracolumbar/lumbar curves?

PURPOSE: The choice of distal fusion level in adolescent idiopathic scoliosis (AIS) patients with major thoracolumbar or lumbar (TL/L) curves (Lenke type 3C, 5C, or 6C) remains debatable. One of the most controversial issues involves stopping the distal fusion at L3, which might result in an increased risk of decompensation but save more mobile spinal segments. The purpose of this study was to evaluate and compare the clinical and radiological outcomes of corrective surgery for AIS with major TL/L curves according to the distal fusion level. METHODS: 229 AIS patients with Lenke type 3C, 5C, or 6C curves that underwent corrective surgery were included. Patients were grouped according to distal fusion level, either L3 (group A) or L4 (group B), and followed up for over 2 years. Group A was further divided into lower end vertebra (LEV) and last touching vertebra (LTV). The SRS-22 score was used to assess clinical outcomes. All radiological parameters were assessed pre- and postoperatively by standing anteroposterior whole-spine radiographs. Clinical and radiological parameters were compared between the groups. RESULTS: Postoperative decompensation was found in 4.6 % (9/197) of group A patients and 9.3 % (3/32) of group B patients. This difference was not statistically significant (P = 0.258). No difference was found in the clinical and radiological parameters between the two groups either pre- or postoperatively. Subgroup analysis showed that the scoliosis correction rate and postoperative apical vertebral translation were lower in cases with an LEV ≤ L4 or LTV = L5 when the fusion stopped at L3 distally. The adjacent disc wedge angle was aggravated postoperatively in these cases, although this did not reach statistical significance. CONCLUSIONS: There is no difference in the radiological and clinical outcomes in AIS according to the distal fusion level. Major TL/L curve correction in AIS may be sufficient distally at L3 in cases with an LEV ≥ L3 and LTV ≥ L4. However, stopping fusion at L3 requires caution in LEV ≤ L4 or LTV = L5 patients, as this correction rate might be suboptimal and causes a possible progression of the adjacent disc wedge angle.

Effects of High-Intensity-Focused Ultrasound Treatment on Benign Uterine Tumor.

In this study, the effects of high-intensity-focused ultrasound (HIFU) treatment on benign uterine tumor patients were examined. A total of 333 patients diagnosed with fibroids or adenomyosis using diagnostic sonography, treated with HIFU between February 4, 2010 and December 29, 2014 at a hospital in Korea, and followed up for three or six months were selected for this study. Their benign uterine tumor volume was measured, and the effects of HIFU treatment on the volume were analyzed according to age, disease, fertility, and treatment duration. The volume of benign tumors of the uterus changed by age in all age groups after conducting HIFU treatment for 3 and 6 months, respectively. The rate of decrease in individuals' in their twenties was the largest, at 64.9%. When the decreasing volume of benign tumors of the uterus was analyzed by type of disease, the treatment efficacy for adenomyosis was the best, with a decrease of 164.83 cm(3) after 6 months. Myoma had the fastest decreasing rate, at 68.5%. When evaluated on the basis of fertility, the volume of benign tumors of the uterus continued to decrease until 6 months after completing all procedures. The volume has continued to decrease for 6 months after all procedures. This study showed that HIFU treatments for uterine fibroid and adenomyosis is an effective non-invasive therapy via reducing the benign uterine tumor volume. Therefore, the HIFU method might replace other conventional treatment methods.

Comparison between the treatment area of electrode used for radiofrequency ablation of liver cancer focusing on 15G cooled-tip and CWT electrode.

OBJECTIVES: To analyze the comparison between the treatment area of 15Gage internally cooled electrodes and 17 Gage Cool Wet-tip(CWT) electrodes. They are manufactured to broaden treatment area of the tumor in the radiofrequency ablation of hepatocellular carcinoma(HCC). METHODS: The study was designed for 62 patients with a mean age of 61, ranging from 44 to 87 years. The sample comprised of patients who used 15 G internally cooled electrodes and 17 G CWT electrodes respectively. Computed tomography (CT) images obtained after the procedure were observed, however, for the ablation lesion, the volume was determined by measuring complete necrotic tissue that did not contrast enhancement in the image. RESULTS: The treatment area of the tumor after radiofrequency ablation was 17.26±6.02 in the CWT, which was bigger than 15G. The treatment area ratio of the treatment before or after was significant at 581.85±339.56 in the CWT. After radiofrequency ablation, the treatment area got bigger, as 15G electrodes went toward CWT electrodes. Treatment area per electrode was 1.34 times higher in CWT than in 15G while the treatment area ratio of the treatment before or after was 1.001 times higher in the CWT than 15G. CONCLUSIONS: Ablation is more common for the safety margin in stable tumor and CWT type electrodes that can make larger ablation to reduce the number of times ablation is required for residual tumor and it decreases recurrence, ablation time and reoperation. Therefore it is considered t useful to reduce patients' pain.

Correlations between metabolic syndrome, serologic factors, and gallstones.

[Purpose] This study investigated the serologic factors associated with metabolic syndrome and gallstones. [Subjects and Methods] The study evaluated subjects who visited a health promotion center in Seoul from March 2, 2013 to February 28, 2014, and had undergone abdominal ultrasonography. Height, weight, and blood pressure were measured. Blood sampling was performed for high-density lipoprotein cholesterol, triglyceride, fasting blood glucose, total bilirubin, direct bilirubin, indirect bilirubin, aspartate aminotransferase, alanine aminotransferase, alkaline phosphatase, uric acid, total cholesterol, low-density lipoprotein cholesterol, thyroid stimulating hormone, and red and white blood cell counts. We conducted logistic regression analysis to assess the risk factors associated with metabolic syndrome. [Results] The risk factors for metabolic syndrome in men, in order of decreasing weight, were red blood cell count, body mass index, maximum size of gallstones, white blood cell count, waist circumference, and uric acid level. The factors in women, in order of decreasing weight, were red blood cell count, presence/absence of gallstones, uric acid level, body mass index, fasting blood glucose, and waist circumference. [Conclusion] Most serum biochemical factors and gallstone occurrence could be used to indicate the presence or absence of metabolic syndrome, independent of gender.