Multi-System-Level Analysis with RNA-Seq on Pterygium Inflammation Discovers Association between Inflammatory Responses, Oxidative Stress, and Oxidative Phosphorylation.

A pterygium is a common conjunctival degeneration and inflammatory condition. It grows onto the corneal surface or limbus, causing blurred vision and cosmetic issues. Ultraviolet is a well-known risk factor for the development of a pterygium, although its pathogenesis remains unclear, with only limited understanding of its hereditary basis. In this study, we collected RNA-seq from both pterygial tissues and conjunctival tissues (as controls) from six patients (a total of twelve biological samples) and retrieved publicly available data, including eight pterygium samples and eight controls. We investigated the intrinsic gene regulatory mechanisms closely linked to the inflammatory reactions of pterygiums and compared Asian (Korea) and the European (Germany) pterygiums using multiple analysis approaches from different perspectives. The increased expression of antioxidant genes in response to oxidative stress and DNA damage implies an association between these factors and pterygium development. Also, our comparative analysis revealed both similarities and differences between Asian and European pterygiums. The decrease in gene expressions involved in the three primary inflammatory signaling pathways-JAK/STAT, MAPK, and NF-kappa B signaling-suggests a connection between pathway dysfunction and pterygium development. We also observed relatively higher activity of autophagy and antioxidants in the Asian group, while the European group exhibited more pronounced stress responses against oxidative stress. These differences could potentially be necessitated by energy-associated pathways, specifically oxidative phosphorylation.

Seven-year outcomes of combined treatment of anti-vascular endothelial growth factor with photodynamic therapy for polypoidal choroidal vasculopathy; according to polypoidal lesion regression.

PURPOSE: To evaluate the long-term prognosis of polypoidal choroidal vasculopathy (PCV) treated with anti-vascular endothelial growth factor (anti-VEGF) combined with verteporfin photodynamic therapy (PDT), according to polypoidal lesion regression. METHODS: This study retrospectively reviewed the data of 33 naïve eyes with PCV treated with anti-VEGF combined with verteporfin PDT and followed-up for at least 7 years. The collected data included demographic profile, best-corrected visual acuity (BCVA), central foveal thickness (CFT), PED volume, and presence of submacular hemorrhage. Regression of polypoidal lesion was determined using indocyanine green angiography and optical coherence tomography. All eyes were divided into regression or persistent groups, based on the polypoidal lesion regression one year after the initial combined treatment. RESULTS: BCVA improvement was maintained for 3 years in the regression (p = 0.001) and 1 year in the persistent (p = 0.006) groups, respectively. The mean BCVA of the regression group was better than that of the persistent group over 7 years, but the difference was significant only at 1 year (p = 0.037). The number of eyes which maintained BCVA less than or equal to 0.3 logMAR at 7 years was 11 eyes (64.7%) in regression group and 4 eyes (25.0%) in persistent group (p = 0.022). CONCLUSIONS: Regression of the polypoidal lesion at 1 year after the initial combination treatment was associated with favorable long-term visual prognosis, particularly in terms of maintaining good visual acuity.

Peripapillary microvasculature changes after vitrectomy in epiretinal membrane via swept-source OCT angiography.

PURPOSE: To evaluate the peripapillary microvasculature changes in patients with epiretinal membrane (ERM) following pars plana vitrectomy (PPV) with internal limiting membrane (ILM) peeling using swept-source optical coherence tomography angiography (SS-OCTA). METHOD: Medical records and multimodal imaging data of 33 eyes after PPV for ERM were retrospectively reviewed. Peripapillary SS-OCTA images of 6×6 mm2 were recorded at at pre- and post-operatively every 6 months for 1 year. A semi-automated method was used to analyzed SS-OCTA images, excluding the optic disc area, using the MATLAB software. The peripapillary vessel density (pVD) of superficial capillary plexus (SCP) and deep capillary plexus (DCP) was quantified in four quadrants (superior, inferior, nasal and temporal). RESULT: The mean pVD in SCP and DCP decreased at 6- and 12-months follow-up. In sectoral analysis, superior, inferior, and temporal quadrants pVD in SCP and DCP were significantly reduced at 1 year after vitrectomy (all p < 0.05). Meanwhile, inferior quadrants pVD in SCP and DCP showed the earliest significant reduction at 6-months (p = 0.022 and 0.048, respectively). A reduction of post-operative mean pVD in DCP was significantly greater in patients with diabetic retinopathy (p = 0.043). CONCLUSION: Peripapillary capillary density significantly decreased after surgical removal of ERM. Vitrectomy with ILM peeling can cause peripapillary microvascular damage starting in inferior sector.

Optical coherence tomography angiography biomarkers in a bi-monthly maintenance dosing aflibercept in patients with neovascular age-related macular degeneration.

PURPOSE: To evaluate the correlations between swept-source optical coherence tomography angiography (SS-OCTA) parameters and clinical outcomes in eyes with neovascular age-related macular degeneration (nAMD) administered a bimonthly intravitreal aflibercept regimen. METHODS: This prospective, single-arm, interventional study enrolled 33 patients with treatment-naïve nAMD. The eyes received three monthly aflibercept injections followed by five bi-monthly regimens (total 50 weeks). The structural parameters including central subfield thickness (CST) and 5 mm pigment epithelial detachment (PED) volume and microvascular parameters including macular neovascularization (MNV) area, vessel density (VD), and vessel length density (VLD) were recorded every before and 1 week after treatment. RESULTS: Patients who gained > 5 letters of best-corrected visual acuity (BCVA) from the baseline showed greater decreases in VD and VLD during the loading phase. Patients without recurrent or persistent fluid during the maintenance phase showed greater decreases in CST and 5 mm PED volume after the first injection. The decrease in mean VD during the loading phase was significantly correlated with the final BCVA (r = -0.820, p = 0.004). Moreover, the decrease in mean VLD during the loading phase was significantly correlated with the improvement in the final BCVA (r = -0.726, p = 0.017). CONCLUSIONS: The decrease in mean VD during the loading phase was significantly negatively correlated with the final BCVA at the last visit. The decrease in mean VLD during the loading phase, mean CST during the loading phase, and the improvement in final BCVA showed significant correlations. Therefore, early changes in OCTA microvascular and OCT structural parameters could help predict clinical outcomes in nAMD. TRIAL REGISTRATION: The trial was registered with the Clinical Research Information Service (CRIS), which joined the WHO International Clinical Trials Registry Platform (ICTRP) (Registration number: KCT0007375, Date of first trial registration: 10/06/2022).

Perifoveal Microvascular Changes following Internal Limiting Membrane Peeling Surgery for Epiretinal Membrane and Macular Hole.

INTRODUCTION: The aim of the study was to evaluate perifoveal microvasculature changes following pars plana vitrectomy with internal limiting membrane peeling for the epiretinal membrane (ERM) and macular hole (MH). METHODS: This retrospective study included 59 eyes from 59 patients. Subjects were divided into two groups: an ERM group (n = 43) and an MH group (n = 16) based on the initial diagnosis. Swept-source optical coherence tomography angiography (SS-OCTA) was performed in the macular area, pre- and postoperatively. Perifoveal microvascular changes were calculated using MATLAB from the 6 × 6 mm SS-OCTA images, excluding the foveal avascular zone. Pre- and postoperative perifoveal vessel densities (pfVDs) were separately analyzed in six sectors (superior, superotemporal, inferotemporal, inferior, inferonasal, and superonasal) in the superficial capillary plexus (SCP) and deep capillary plexus (DCP). The baseline characteristics and other clinical factors were compared between the ERM and MH groups. RESULTS: The postoperative best-corrected visual acuity significantly improved in both groups (p < 0.05). One year after surgery, the pfVD in the SCP of the ERM group significantly decreased in the inferotemporal sector (p = 0.049). The postoperative pfVD in the DCP of the MH group significantly decreased in temporal sectors (p < 0.05). The postoperative mean pfVD in the SCP in the MH group was significantly lower than that in the ERM group (p = 0.003). The presence of a dissociated optic nerve fiber layer (DONFL) was 75% in the MH group and 22% in the ERM group (p = 0.018). The correlation between the pfVD and DONFL was not statistically significant. CONCLUSION: Postoperative pfVD reduction in the temporal sector, a corresponding area in which DONFL is present after MH surgery, was significantly observed. After vitreoretinal surgery in MH patients, OCTA may serve as a useful tool for monitoring perifoveal microvascular changes, especially in temporal sectors.

Biportal endoscopic paraspinal decompressive foraminotomy for lumbar foraminal stenosis: clinical outcomes and factors influencing unsatisfactory outcomes.

BACKGROUND: Lumbar foraminal stenosis (LFS) is an important pathologic entity that causes lumbar radiculopathies. Unrecognized LFS may be associated with surgical failure, and LFS remains challenging to treat surgically. This retrospective cohort study aimed to evaluate the clinical outcomes and prognostic factors of decompressive foraminotomy performed using the biportal endoscopic paraspinal approach for LFS. METHODS: A total of 102 consecutive patients with single-level unilateral LFS who underwent biportal endoscopic paraspinal decompressive foraminotomy were included. We evaluated the Visual Analogue Scale (VAS) score and the Oswestry Disability Index (ODI) before and after surgery. Demographic, preoperative data, and radiologic parameters, including the coronal root angle (CRA), were investigated. The patients were divided into Group A (satisfaction group) and Group B (unsatisfaction group). Parameters were compared between these two groups to identify the factors influencing unsatisfactory outcomes. RESULTS: In Group A (78.8% of patients), VAS and ODI scores significantly improved after biportal endoscopic paraspinal decompressive foraminotomy (p < 0.001). However, Group B (21.2% of patients) showed higher incidences of stenosis at the lower lumbar level (p = 0.009), wide segmental lordosis (p = 0.021), and narrow ipsilateral CRA (p = 0.009). In the logistic regression analysis, lower lumbar level (OR = 13.82, 95% CI: 1.33-143.48, p = 0.028) and narrow ipsilateral CRA (OR = 0.92, 95% CI: 0.86-1.00, p = 0.047) were associated with unsatisfactory outcomes. CONCLUSIONS: Significant improvement in clinical outcomes was observed for a year after biportal endoscopic paraspinal decompressive foraminotomy. However, clinical outcomes were unsatisfactory in 21.2% of patients, and lower lumbar level and narrow ipsilateral CRA were independent risk factors for unsatisfactory outcomes.

Biportal endoscopic extraforaminal lumbar interbody fusion using a 3D-printed porous titanium cage with large footprints: technical note and preliminary results.

PURPOSE: The aim of this study was to introduce biportal endoscopic extraforaminal lumbar interbody fusion (BE-EFLIF), which involves insertion of a cage through a more lateral side as compared to the conventional corridor of transforaminal lumbar interbody fusion. We described the advantages and surgical steps of 3D-printed porous titanium cage with large footprints insertion through multi-portal approach, and preliminary results of this technique. METHODS: This retrospective study included 12 consecutive patients who underwent BE-EFLIF for symptomatic single-level lumbar degenerative disease. Clinical outcomes, including a visual analog scale (VAS) for back and leg pain and the Oswestry disability index (ODI), were collected at preoperative months 1 and 3, and 6 months postoperatively. In addition, perioperative data and radiographic parameters were analyzed. RESULTS: The mean patient age, follow-up period, operation time, and volume of surgical drainage were 68.3 ± 8.4 years, 7.6 ± 2.8 months, 188.3 ± 42.4 min, 92.5 ± 49.6 mL, respectively. There were no transfusion cases. All patients showed significant improvement in VAS and ODI postoperatively, and these were maintained for 6 months after surgery (P < 0.001). The anterior and posterior disc heights significantly increased after surgery (P < 0.001), and the cage was ideally positioned in all patients. There were no incidences of early cage subsidence or other complications. CONCLUSIONS: BE-EFLIF using a 3D-printed porous titanium cage with large footprints is a feasible option for minimally invasive lumbar interbody fusion. This technique is expected to reduce the risk of cage subsidence and improve the fusion rate.

Biportal endoscopic discectomy versus tubular microscopic discectomy for treating single-level lumbar disc herniation in obese patients: a multicenter, retrospective analysis.

PURPOSE: In microscopic lumbar discectomy in obese patients, a correlation is found between the operation time and increase in estimated blood loss according to the increase in body mass index; however, no studies have investigated the outcomes of biportal endoscopic lumbar discectomy in obese patients. Therefore, this study aimed to compare the clinical and radiographic outcomes of microscopic and endoscopic discectomy in obese patients with lumbar herniated discs. METHODS: In this multicenter, retrospective study, clinical and radiological data were compared and analyzed in 73 obese patients with a body mass index of > 30 kg/m2 who underwent microscopic or biportal endoscopic lumbar discectomy. Clinical data on the visual analog scale (VAS), Oswestry disability index (ODI), and EuroQol-5D (EQ-5D) scores were measured, and radiological data were obtained using magnetic resonance imaging (MRI). RESULTS: This study enrolled 43 patients who underwent microscopic discectomy and 30 who underwent biportal endoscopic discectomy. The VAS, ODI, and EQ-5D scores in both groups improved after surgery compared with those before surgery, although there was no difference between the two groups. Although there was a difference in the incidence of recurrent disc herniation confirmed by MRI after surgery, no difference was found in the number of patients requiring surgery between the two groups. CONCLUSION: In obese patients with lumbar disc herniation that was not improved with conservative treatment, no significant clinical or radiological differences in outcomes were noted between microscopic and biportal endoscopic surgery methods. In contrast, minor complications were less common in the biportal group.

Stercoral Ulcer Presenting in a Patient with Cauda Equina Syndrome Secondary to Postoperative Epidural Hematoma.

Chronic constipation can lead to fecal impaction in the large bowel, which can cause pressure necrosis followed by perforation, known as a stercoral ulcer. In extensive posterior thoracolumbar surgery, a long operation time, large blood loss, and perioperative narcotic use may aggravate constipation. Moreover, sacral root palsy due to cauda equina syndrome (CES) can lead to the deterioration of fecal impaction. This report describes the case of a 77-year-old woman with CES who presented with saddle anesthesia, neurogenic bladder, bowel incontinence, and paraplegia. Five days prior, she had undergone extended posterior lumbar interbody fusion from L1 to L5. Lumbar magnetic resonance imaging (MRI) showed an extended epidural hematoma. After urgent neural decompression, she gradually recovered from the saddle anesthesia, leg pain, and paraplegia over 3 weeks. Thereafter, the patient suddenly developed massive hematochezia and hemorrhagic shock. Urgent colonoscopy was performed, and a stercoral ulcer in the sigmoid colon was diagnosed. After 4 weeks of intensive care for hemorrhagic shock, pneumonia, and systemic sepsis, the patient was transferred to a general ward for intensive rehabilitation. One year after the operation, she was able to walk with assistance, and her urinary and bowel incontinence completely recovered. Chronic constipation, a common clinical problem, can sometimes cause relatively obscure but potentially life-threatening complications such as stercoral ulceration. Possible factors including advanced age, extensive spinal surgeries, prolonged operation time, significant blood loss, perioperative narcotic use, and the presence of spinal cord injury might contribute to the development of this condition. It highlights the importance of recognizing the potential development of stercoral ulcers in patients with CES and emphasizes the need for prompt diagnosis and management to avert catastrophic complications.

Mid-Thoracic Vertebral Compression Fracture after Mini-Trampoline Exercise: A Case Series of Seven Patients.

Background and Objectives: Home-based training exercise gained popularity during the coronavirus disease 2019 pandemic era. Mini-trampoline exercise (MTE) is a home-based exercise that utilizes rebound force generated from the trampoline net and the motion of the joints of the lower extremities. It is known to be beneficial for improving postural balance, stability, muscle strength and coordination, bone strength, and overall health. However, we encountered several patients with mid-thoracic vertebral compression fractures (VCFs) following regular MTE, which was never reported previously, despite having no history of definite trauma. This study aims to report mid-thoracic VCFs after regular MTE and arouse public attention regarding this spinal injury and the necessity of appropriate prior instructions about the correct posture. Patients and Methods: All consecutive patients diagnosed with acute VCFs following regular MTE were included. We collected data on patient demographics, history of MTE, characteristics of symptoms, and radiological findings such as the location of fractures and anterior vertebral body compression percentage. Results: Seven patients (one man and six women) and ten fractures (T5 = 1, T6 = 3, T7 = 2, and T8 = 4) were identified. Symptoms started 2.57 ± 1.13 weeks after the beginning of regular MTE. All patients reported that they were never properly instructed on the correct posture. They also stated that they were exercising with a hunchback posture and insufficient joint motion of the lower extremities while holding the safety bar with both hands, which resulted in increased peak vertical force along the gravity z-axis in the mid-thoracic area and consequent mid-thoracic VCFs. Conclusions: Mid-thoracic VCFs can occur following regular MTE even without high-energy trauma in case of improper posture during exercise. Therefore, public attention on mid-thoracic VCFs following MTE and the appropriate prior instructions are imperative.

Clinical and radiologic outcomes of biportal endoscopic lumbar discectomy in obese patients: a retrospective case-control study.

BACKGROUND: Obese patients have a higher risk of complications during spinal surgery than non-obese patients. To the best of our knowledge, no studies have examined the differences in clinical and radiological outcomes after biportal endoscopic lumbar discectomy (BELD) between obese and non-obese patients. The study evaluated the association between obesity and outcomes after BELD in patients with lumbar disc herniation. METHODS: This was a retrospective case-control study conducted from March 2017 to March 2021 at two hospitals with 360 patients who underwent BELD after showing no improvement with conservative treatment. Clinical and radiologic outcomes were retrospectively analyzed after BELD in the non-obese (body mass index [BMI] < 30 kg/m2) and obese (BMI ≥ 30 kg/m2) groups. Demographic data and surgery-related factors were compared between the two groups. Clinical outcomes were followed up for 12 months after surgery and analyzed for differences. RESULTS: A total of 211 patients were enrolled in this study, and through case-control matching, the data of 115 patients (29, obese group; 86, non-obese group) were analyzed. The two groups showed no significant differences in Oswestry Disability Index, European Quality of Life-5 Dimensions (EQ-5D), and visual analog scale scores measured immediately after BELD and 12 months after surgery. After surgery, back pain, radiating leg pain, and EQ-5D scores improved. However, there was no significant difference in improvement, residual herniated disc, hematoma, or recurrence between the groups. CONCLUSIONS: Obese patients who underwent BELD for lumbar disc herniation showed no significant difference in clinical and radiologic outcomes compared with non-obese patients.

Percutaneous transpedicular intracorporeal cage grafting for Kümmell disease.

BACKGROUND: Osteonecrosis with progressive collapse and segmental kyphosis can lead to intersegmental instability in some osteoporotic vertebral compression fractures (OVCFs). These conditions are known as Kümmell's disease and often require anterior column reconstruction in elderly patients. METHODS: We attempted anterior column reconstruction by percutaneous transpedicular intracorporeal cage grafting (PTICG) with short-segment pedicle screw fixation and described the steps, with discussions on the surgical indications and pros and cons. CONCLUSION: PTICG is expected to be an alternative to vertebral anterior column reconstruction, which can preserve the thoracolumbar posterior arch and paravertebral musculature.

How i do it: biportal endoscopic thoracic decompression for ossification of the ligamentum flavum.

BACKGROUND: Currently, decompressive laminectomy with or without concomitant fusion is a standard treatment for ossification of the ligamentum flavum (OLF). However, conventional thoracic decompressive laminectomy is not free of the inevitable destruction of the posterior ligamentous complex, and facet injury may lead to various sequelae. METHOD: We used the biportal endoscopic technique for posterior thoracic decompression (BE-PTD) and describe the steps with discussion regarding the indications, advantages, possible complications, and ways to overcome complications. CONCLUSION: BE-PTD can obtain endoscopic visualizations of all the boundaries of the OLF lesion and achieve direct neural decompression of thoracic OLF.

How I do it: biportal endoscopic paraspinal approach for recurrent lumbar disc herniation following percutaneous endoscopic lumbar discectomy.

BACKGROUND: Although percutaneous endoscopic lumbar discectomy (PELD) has been popularized as an alternative to microscopic lumbar discectomy, it has been reported to be associated with a re-herniation rate of 5-11%. Recurrent lumbar disc herniation (RLDH) might occur not only at the same level previously operated upon but also at the annular penetration site created during PELD procedures. METHOD: Biportal endoscopic paraspinal approach (BE-Para) was used for revisional foraminal lumbar discectomy. Procedures and some discussions regarding indications, advantages, potential complications, and ways to avoid complications were described. CONCLUSION: BE-Para may be an effective modality for RLDH after PELD.

Contralateral retrodiscal transforaminal approach for percutaneous epidural adhesiolysis: A technical description and retrospective comparative study.

OBJECTIVES: Retrodiscal transforaminal (RdTF) epidural steroid injection (ESI) is clinically comparable to conventional transforaminal ESI and can avoid catastrophic complications. However, it poses a risk of inadvertent intradiscal, intravascular, and intrathecal injections. Therefore, we aimed to evaluate the feasibility of percutaneous epidural adhesiolysis (PEA) using the contralateral (Contra)-RdTF approach. METHODS: The electronic medical records of 332 patients with unilateral lumbar radiculopathy due to foraminal disk pathology were reviewed. Patients were categorized into two groups: Group A (ESI using the RdTF approach) and Group B (PEA using the Contra-RdTF approach). Effective pain relief (EPR; ≥50% pain relief from baseline) in patients was evaluated using the visual analog scale (VAS) at 4 and 12 weeks after the procedure. The presence of unintended fluoroscopic findings and complications was recorded. RESULTS: A total of 119 patients were enrolled in the final analysis: 81 in Group A and 38 in Group B. Both groups showed lesser VAS scores after 4 and 12 weeks than at baseline (p < 0.05). However, the proportion of patients with EPR was significantly greater in Group B after 12 weeks (p = 0.015). No complications, including intrathecal injection, infectious discitis, and neurologic deterioration, were reported. However, inadvertent intradiscal and intravascular injections were reported to be significantly higher in Group A than in Group B (14.8% and 0%, respectively; p = 0.009). CONCLUSIONS: Although applications of this study are limited by its retrospective design, the results suggest that PEA using the Contra-RdTF approach is feasible because it can achieve EPR and avoid unintended fluoroscopic findings.

Evaluation of the efficacy and safety of conventional and biportal endoscopic decompressive laminectomy in patients with lumbar spinal stenosis (ENDO-B trial): a protocol for a prospective, randomized, assessor-blind, multicenter trial.

BACKGROUND: Recent studies on biportal endoscopic spine surgery in patients with lumbar spinal stenosis have reported good clinical results. However, these studies have been limited by the small sample sizes and use of a retrospective study design. Therefore, we aim to compare the efficacy and safety of biportal endoscopic decompressive laminectomy with those of conventional decompressive laminectomy in a multicenter, prospective, randomized controlled trial. METHODS: This study will include 120 patients (60 per group, aged 20-80 years) with 1- or 2-level lumbar spinal stenosis, who will be recruited from six hospitals. The study will be conducted from July 2021 to December 2024. The primary outcome (Oswestry Disability Index at 12 months after surgery) will be evaluated through a modified intention-to-treat method. The secondary outcomes will include the following: visual analog scale score for low back and lower extremity radiating pain, EuroQol 5-dimensions score, surgery satisfaction, walking time, postoperative return to daily life period, postoperative surgical scars, and some surgery-related variables. Radiographic outcomes will be analyzed using magnetic resonance imaging or computed tomography. All outcomes will be evaluated before the surgery and at 2 weeks, 3 months, 6 months, and 12 months postoperatively. This protocol adheres to the Standard Protocol Items: Recommendations for Interventional Trials (SPIRIT) guidelines for reporting of clinical trial protocols. DISCUSSION: It is hypothesized that the efficacy and safety of biportal endoscopic and conventional decompressive laminectomy will be comparable in patients with lumbar spinal stenosis. The results of this trial will provide a high level of evidence for the efficacy and safety of the biportal endoscopic technique in patients with lumbar spinal stenosis and facilitate the development of clinical practice guidelines. Furthermore, the results of this study may indicate the feasibility of the biportal endoscopic technique for other types of spinal surgery. TRIAL REGISTRATION: The ENDO-B trial is registered at Clinical Research Information Service (CRIS, cris.nih.go.kr ) (KCT0006057; April 52,021).

How I do it? Extraforaminal lumbar interbody fusion assisted with biportal endoscopic technique.

BACKGROUND: The biportal endoscope-assisted unilateral foraminal approach is an option for various foraminal pathologies. Lumbar interbody fusion is the standard treatment for foraminal stenosis because both direct and indirect neural decompressions can be obtained. METHOD: We used the biportal endoscopic technique for extraforaminal lumbar interbody fusion (BE-EFLIF) and have described the steps, with discussion regarding the indications, advantages, possible complications, and ways to overcome complications. CONCLUSION: BE-EFLIF achieves direct neural decompression of lateral spinal canal under endoscopic visualization. It achieves indirect neural decompression using a large footprint lordotic interbody cage, while preserving the lumbar posterior arch as much as possible.

Factors influencing long-term treatment response to botulinum toxin injection for spasmodic dysphonia.

OBJECTIVE: The purpose of this study was to evaluate the outcomes of long-term botulinum toxin type A (BoNTA) treatment for adductor spasmodic dysphonia (AdSD) and to determine the factors predictive of treatment response by investigating dose stability and average intervals. DESIGN: Retrospective cohort study. SETTING: Academic tertiary medical centre. EXPOSURES: A total of 470 patients with adductor spasmodic dysphonia, who received electromyography-guided BoNTA injections over 12 years, were retrospectively enrolled in this study. MAIN OUTCOMES AND MEASURES: The patients' demographic data, baseline voice dynamics and treatment profiles (dose, frequency and intervals) were evaluated. Factors correlating with the dose adjustment ratio (number of increasing dosing/total number of BoNTA toxin injections) and changes in intervals between injections were statistically analysed. RESULTS: A total of 122 patients, who received ≥ 4 injections and whose average treatment interval was < 240 days, were finally evaluated. Of them, 115 (94.3%) were female and seven (5.7%) were male, and the mean age at initial treatment was 34.89 ± 13.07 and 41.14 ± 12.71 years, respectively. On average, patients received 18.00 ± 13.33 injections (1.67 ± 0.60 U/injection) to alternating unilateral vocal folds. The treatment period was 65.07 ± 43.28 months and the mean interval between injections was 4.16 ± 1.28 months. The mean dose adjustment ratio among patients who received ≥ 4 injections was 0.15 ± 0.13, and dose changes occurred 4.36 times/patient. The patients' age and gender significantly affected the treatment response, where younger or female patients showed greater dosing variability and shorter intervals between injections. However, the baseline voice dynamics (voice handicap index, fundamental frequency, jitter, shimmer, noise-to-harmonic ratio, maximum phonation time and degree of voice breaks) did not predict the dose adjustment ratio or interval changes. In addition, patients with fluctuating doses showed lower age and higher VHI subscale scores, and patients with short-treatment interval (< 100 days) showed higher SDF0. CONCLUSIONS: Almost all patients received stable low doses of BoNTA over time, irrespective of the baseline results. Patients' age, gender and VHI scores were correlated with poor treatment responses, such as frequent dose changes and shorter intervals between injections.

Comparison of Surgical Outcomes of Robotic and Conventional Approaches in Patients with Pre- and Poststyloid Parapharyngeal Space Tumors.

BACKGROUND: Benefits and drawbacks of robotic surgical approaches for parapharyngeal space (PPS) tumors remain undetermined. The purpose of this study is to compare surgical outcomes of PPS tumor patients who underwent robotic surgery with those of patients who received conventional surgical treatment. PATIENTS AND METHODS: We retrospectively analyzed clinicopathologic data from 136 patients who underwent surgical removal of PPS tumors via conventional or robotic approaches. RESULTS: We identified PPS tumors in pre- and poststyloid regions in 87 (64%) and 49 (36%) patients, respectively. There were 48 (35.3%) pleomorphic adenomas, 36 (26.5%) schwannomas, and 24 (17.6%) paragangliomas. Conventional surgical techniques were performed in 83 patients, and robotic surgical approaches were administered to 53 patients. Transcervical-parotid and transcervical approaches were most commonly performed in conventional surgery, while transoral and retroauricular approaches were the preferred surgical methods in robotic surgery for pre- and poststyloid PPS tumors, respectively. Robotic surgery resulted in less estimated blood loss during poststyloid PPS tumor surgery. Postoperative cranial nerve complications were noted in 36 of 83 cases (43.4%) in the conventional surgery group and in 17 of 53 cases (32.1%) in the robotic surgery group. Intraoperative tumor spillage of pleomorphic adenoma showed no significant differences between the two groups (13.6% in conventional vs. 15.4% in robotic surgery). The mean follow-up time was 4.9 ± 3.4 years, and recurrences were observed in two patients during follow-up without a significant difference between the two groups (4.5% in conventional vs. 3.8% in robotic surgery). CONCLUSIONS: Robotic surgery in PPS tumors is feasible through transoral, retroauricular, or combined approaches and provides treatment outcomes comparable to those of conventional open surgery.

Does p16+ Predict a Favorable Prognosis for Oropharyngeal Cancer? Risk Factors for Treatment Failure for Patients Who Underwent Surgery-Based Therapy.

BACKGROUND: This study aimed to identify prognostic clinicopathologic factors that could predict treatment failure and to analyze clinical data from p16+ oropharyngeal squamous cell carcinoma (OPSCC) patients who underwent surgery. METHODS: Data from p16+ OPSCC patients who underwent surgery at Severance Hospital of Yonsei University were retrospectively reviewed. RESULTS: The average smoking history was 14.6 pack-years (range 0-94 pack-years). Of the 188 patients, 73 (38.8%) underwent transoral robotic surgery (TORS) for surgical treatment of their primary lesions, and the remaining 115 patients (61.2%) underwent conventional surgery. Extracapsular nodal spread was detected in 87 patients (46.3%). At histologic examination, 67 patients (35.6%) showed positive surgical margins, and 121 patients (64.4%) had negative surgical margins. Postoperative adjuvant treatment was performed for 167 patients (88.8%). During the follow-up period, there were 18 recurrences including 2 local recurrences, 10 regional recurrences, and 6 distant metastases. During the study period, 17 deaths occurred. The univariate analysis showed that the American Joint Committee on Cancer (AJCC) 8th-edition staging system, lymphovascular invasion, more than four metastatic lymph nodes, and a smoking history of more than 10 pack-years were significantly associated with treatment failure. In the multivariate analysis, only the AJCC 8th-edition staging system was significantly associated with the patient's survival. CONCLUSION: Surgical treatment methods including TORS for p16+ OPSCC patients showed excellent oncologic results, and many previously known clinicopathologic factors did not show a significant relationship with patient prognosis. Only the newly revised AJCC 8th-edition staging system showed a significant relationship with patient survival, and this should be considered in the setting of p16+ OPSCC treatment guidelines in the future.