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

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

Efficiency of minimal oblique resection of the uncinate process during an anterior cervical discectomy and fusion.

ABSTRACT: Hypertrophy of the uncinate process (UP) can cause radiculopathy. Minimal UP resection is considered to remove the lesion while minimizing the risk of complications. This study aimed to elucidate the surgical results of minimal oblique resection of the UP. This study is a retrospective review of about sixty segments in 34 patients who underwent anterior cervical discectomy and fusion (ACDF) with minimal oblique uncinectomy between 2016 and 2018. The cross-sectional area of the UP was measured pre- and postoperatively. The interspinous distance, segmental Cobb angle, subsidence, fusion rate, surgical time, estimated blood loss, and postoperative complications were evaluated. The mean resected areas of the UP were 17.4 ±â€Š8.7 mm2 (25.9%) on the right and 17.3 ±â€Š11.2 mm2 (26.2%) on the left. The difference in interspinous distance in flexion-extension was 7.1 ±â€Š3.2 and 1.6 ±â€Š0.6 mm pre- and postoperatively, respectively (P = .000). The fusion rate after ACDF was 91.7% when measured according to segment (55/60) and 91.2% when measured according to patients (31/34). The difference in the segmental Cobb angle in flexion-extension was 8.3 ±â€Š6.2° and 1.9 ±â€Š0.3° pre and postoperatively, respectively (P = .000). Subsidence occurred in 4 (11.8%) patients and 5 (8.3%) segments. The average surgical time per segment was 68.8 ±â€Š9.3 minute, and the estimated blood loss was 48.5 ±â€Š25.0 mL. Postoperative complications comprised 1 case each of neck swelling, wound infection, pneumonia, and gastrointestinal bleeding. Our findings therefore revealed that minimal oblique uncinectomy during an ACDF can maintain the stability of the uncovertebral joint while sufficiently decompressing the neural foramen.

Regional Anesthesia for Lumbar Spine Surgery: Can It Be a Standard in the Future?

This paper is an overview of various features of regional anesthesia (RA) and aims to introduce spine surgeons unfamiliar with RA. RA is commonly used for procedures that involve the lower extremities, perineum, pelvic girdle, or lower abdomen. However, general anesthesia (GA) is preferred and most commonly used for lumbar spine surgery. Spinal anesthesia (SA) and epidural anesthesia (EA) are the most commonly used RA methods, and a combined method of SA and EA (CSE). Compared to GA, RA offers numerous benefits including reduced intraoperative blood loss, arterial and venous thrombosis, pulmonary embolism, perioperative cardiac ischemic incidents, renal failure, hypoxic episodes in the postanesthetic care unit, postoperative morbidity and mortality, and decreased incidence of cognitive dysfunction. In spine surgery, RA is associated with lower pain scores, postoperative nausea and vomiting, positioning injuries, shorter anesthesia time, and higher patient satisfaction. Currently, RA is mostly used in short lumbar spine surgeries. However, recent findings illustrate the possibility of applying RA in spinal tumors and spinal fusion. Various researches reveal that SA is an effective alternative to GA with lower minor complications incidence. Comprehensive insight on RA will promote spine surgery under RA, thereby broadening the horizon of spine surgery under RA.

Free-Hand Cervical Pedicle Screw Placement by Using Para-articular Minilaminotomy: Its Feasibility and Novice Neurosurgeons' Experience.

STUDY DESIGN.: Retrospective study. OBJECTIVE.: Cervical pedicle screw (CPS) placement is technically demanding because of the great variation in pedicle size, dimension, and angulations between cervical levels and patients and the lack of anatomical landmarks. This retrospective study was conducted to analyze novice neurosurgeons' experience of CPS placement by using the technique with direct exposure of pedicle via para-articular minilaminotomy. METHODS.: We retrospectively reviewed 78 CPSs in 22 consecutive patients performed by 2 surgeons. All pedicle screws were inserted under the direct visualization of the pedicle by using para-articular minilaminotomy without any fluoroscopic guidance. We analyzed the direction and grade of pedicle perforation on the postoperative computed tomography scan. The degree of perforation was classified as grade 0 to 3. Grades 0 and 1 were classified as the correct position and the others, as the incorrect position. RESULTS.: In total, the correct position (grade 0 and 1) was found in 72 (92.3%) screws and the incorrect position (grade 2 and 3) in 6 (7.7%). Among the 16 pedicle perforations (grade 1, 2, and 3 perforations), the directions were lateral in 15 (93.8%) and superior in 1 (6.2%). There were no neurovascular complications related to CPS insertion. CONCLUSION.: Free-hand CPS placement by using para-articular minilaminotomy seems to be feasible and reproducible.

Tenosynovial giant cell tumor of the upper cervical spine arising from the posterior atlanto-occipital membrane: a case report.

A tenosynovial giant cell tumor is a benign proliferative disease, mostly arising from the synovial membrane of tendon sheaths, bursae, and joints. Axial skeleton involvement is very rare, but it is often found in the cervical spine. Spinal tenosynovial giant cell tumors often arise at the facet joints; a completely extra-articular spinal tenosynovial giant cell tumor is rare. We report an extremely rare case of tenosynovial giant cell tumor in the upper cervical spine that extended from the posterior atlanto-occipital membrane rather than the facet joint. Herein, the clinical and radiological findings will be reviewed to better our understanding of the characteristics of spinal tenosynovial giant cell tumors, and to help improve their diagnosis despite their non-typical locations of origin.

Low vitamin D levels in post-menopausal women are associated with complex regional pain syndrome type I in surgically treated distal radius fractures.

BACKGROUND: Complex regional pain syndrome type I (CRPS I) is a chronic devastating condition and a relatively common complication of distal radius fractures (DRF). The purpose of this study was to investigate the relationship of vitamin D levels in surgically treated post-menopausal women with CRPS I occurrence in DRF. METHODS: From February 2016 to March 2017, 158 surgically treated post-menopausal patients with DRF were enrolled. Exclusion criteria were (1) patients who had been taking vitamin D or osteoporosis medication at the time of injury; (2) patients with medical factors that may affect vitamin D levels; (3) patients who were reluctant to enroll in the study; and (4) patient with additional fractures, ligamentous injuries, or neuropathy. A total of 107 patients were available for final analysis. We compared the serum vitamin D levels in post-menopausal women with DRF with CRPS I (group 1) and without CRPS I (group 2). Bone mineral density (BMD) of the femur and spine, osteocalcin, alkaline phosphatase (ALP), body mass index (BMI) were also measured. RESULTS: The average age at the time of surgery was 66.5 years (range, 39-86 years). The mean follow-up period was 16.3 months after surgery. Among the 107 surgically treated DRF patients, 19 (18%) met the Budapest criteria for CRPS I during the follow-up period. The mean serum vitamin D level in group 1 (15.2 ng/ml) was significantly lower than that in group 2 (20.5 ng/ml, p = 0.027). The mean values of osteocalcin, ALP, BMI, and BMD were not significantly different between the groups. CONCLUSION: Lower vitamin D levels in post-menopausal women can increase CRPS I occurrence in distal radius fractures.

A Developmental Model for Predicting Sport Participation among Female Korean College Students.

Although participating in regular physical activity has many benefits, female Korean college students tend to have much lower participation rates than their male counterparts. An effective means of increasing physical activity among female college students is sport participation. The purpose of this study is to incorporate three types of psychological needs from self-determination theory as precursor background variables into the theory of planned behavior to predict sport participation among female Korean college students. Our dataset consisted of 494 female undergraduate students attending Kyung Hee University in South Korea. Using structural equation modeling, the direct and indirect effects of attitude, subjective norm, perceived behavioral control, and psychological needs satisfaction such as competency, relatedness, and autonomy were examined. Although attitude towards and perceived behavioral control over sport participation were significantly associated with intention in all three models, subjective norm was not significantly associated with intention in any model. Satisfaction of the psychological needs for competency, relatedness, and autonomy had positive indirect effects on sport participation. This study underscores the importance of addressing the satisfaction of these three basic psychological needs when designing future sport promotion interventions for female college students.

Robustaflavone induces G0/G1 cell cycle arrest and apoptosis in human umbilical vein endothelial cells and exhibits anti-angiogenic effects in vivo.

We investigated the anti-angiogenic and pro-apoptotic effects of robustaflavone (RF), a naturally occurring biflavonoid, on human umbilical vein endothelial cells (HUVECs). RF inhibited HUVEC proliferation and showed cytotoxicity that inhibited HUVEC viability. RF-induced apoptosis was characterized by flow cytometry and caspase 3 analysis. We found that RF increased the number of sub-G1 cells and terminal deoxynucleotidyl transferase dUTP nick end-labeled cells. Additionally, RF induced caspase 3 and poly (ADP-ribose) polymerase activation. Potential molecular targets were identified using a human apoptosis antibody array. RF upregulated Bax, Bad, cleaved caspase 3, p21, and phosphorylated p53 levels. RF induced mitochondrial membrane potential loss and the release of cytochrome c and apoptosis-inducing factor. Cell cycle arrest at G0/G1 phase and the downregulation of Cdk4, Cdk6, and cyclin D1 expression were induced by RF. In vivo anti-angiogenic effects were investigated using a tumor allograft animal model and a Matrigel plug assay. RF reduced the volumes and weights of CT-26 cell-derived tumors. The blood vessel density was significantly decreased in RF-treated tumors. RF also inhibited VEGF-A-stimulated blood vessel formation in vivo in Matrigel plugs. These results suggest that RF can potentially inhibit angiogenesis-dependent tumor growth and metastasis.

Safety and completeness of using indocyanine green videoangiography combined with digital subtraction angiography for aneurysm surgery in a hybrid operating theater.

This study aimed to evaluate the safety and completeness of using intraoperative indocyanine green videoangiography (ICGV) combined with intraoperative angiography (IOA) for aneurysm clipping in a hybrid operating room (hOR). All patients who underwent microsurgical clipping in the hOR were identified from prospectively maintained neurosurgical databases. Medical charts and operative videos with ICGV and IOA were reviewed to determine the adequacy of clipping, and clinical and angiographic outcomes were retrospectively analyzed. Fifty-four cerebral aneurysms (ruptured, 31; unruptured, 23) in 50 patients (mean age, 59.4 ± 10.9 y; M:F, 22:28) were evaluated with ICGV and IOA during clipping. Additional IOA led to a clip adjustment during surgery in 9/54 (16.7%) aneurysms for which ICGV had been initially performed. Post-clip perforator compromise occurred in two (3.7%) cases, with a patient with an unruptured aneurysm experiencing permanent injury (grade 3 hemiparesis) and patient with a ruptured aneurysm experiencing transient deficit. Post-clip parent vessel stenosis occurred in one (1.9%) case; however, an ischemic event did not occur because the flow patency was identified by IOA. No other patients with unruptured aneurysms developed new neurologic deficits at discharge. Favorable outcomes (Glasgow Outcome Score [GOS], 4 or 5) were observed in 26/31 patients with ruptured aneurysms. Five patients had unfavorable outcomes (GOS, 2 or 3) from the initial insult. Post-treatment angiography within 1 week showed complete occlusion in 52 (96.3%) aneurysms and minor remnants in two (3.7%) aneurysms. Using combined ICGV and IOA in a hOR may improve the safety and completeness of microsurgical aneurysm clipping.

3-O-Acetyloleanolic acid inhibits angiopoietin-1-induced angiogenesis and lymphangiogenesis via suppression of angiopoietin-1/Tie-2 signaling.

Tumor angiogenesis and lymphangiogenesis are important processes in tumor progression and metastasis. The inhibitory effects of 3-O-acetyloleanolic acid (3AOA), a pentacyclic triterpenoid compound isolated from Vigna sinensis K., on tumor-induced angiogenesis and lymphangiogenesis in vitro and in vivo were studied. Angiopoietin-1 is an important angiogenic and lymphangiogenic factor secreted from colon carcinoma CT-26 cells under hypoxia conditions. 3AOA inhibited proliferation, migration, and tube formation of angiopoietin-1-treated human umbilical vein endothelial cells (HUVEC) and human lymphatic microvascular endothelial cells (HLMEC). 3AOA reduced angiogenesis and lymphangiogenesis in angiopoietin-1-stimulated Matrigel plugs. Also, 3AOA inhibited tumor growth and tumor-induced angiogenesis and lymphangiogenesis in an angiopoietin-1-induced CT-26 allograft colon carcinoma animal model. 3AOA inhibited activation of the angiopoietin-1 receptor Tie-2 and activation of the downstream signaling factors FAK, AKT, and ERK1/2 that are involved in the angiopoietin-1/Tie-2-signaling pathway. Thus, 3AOA has an inhibitory effect on angiogenesis and lymphangiogenesis induced by angiopoietin-1 both in vitro and in vivo, and the inhibitory effect of 3AOA is probably due to suppression of angiopoietin-1/Tie-2 signaling in HUVEC and HLMEC.

Decolorization of Acid Green 25 by Surface Display of CotA laccase on Bacillus subtilis spores.

In this study, we expressed cotA laccase from Bacillus subtilis on the surface of B. subtilis spores for efficient decolorization of synthetic dyes. The cotE, cotG, and cotY genes were used as anchoring motifs for efficient spore surface display of cotA laccase. Moreover, a His6 tag was inserted at the C-terminal end of cotA for the immunological detection of the expressed fusion protein. Appropriate expression of the CotE-CotA (74 kDa), CotG-CotA (76 kDa), and CotY-CotA (73 kDa) fusion proteins was confirmed by western blot. We verified the surface expression of each fusion protein on B. subtilis spore by flow cytometry. The decoloration rates of Acid Green 25 (anthraquinone dye) for the recombinant DB104 (pSDJH-EA), DB104 (pSDJH-GA), DB104 (pSDJH-YA), and the control DB104 spores were 48.75%, 16.12%, 21.10%, and 9.96%, respectively. DB104 (pSDJH-EA) showed the highest decolorization of Acid Green 25 and was subsequently tested on other synthetic dyes with different structures. The decolorization rates of the DB104 (pSDJH-EA) spore for Acid Red 18 (azo dye) and indigo carmine (indigo dye) were 18.58% and 43.20%, respectively. The optimum temperature for the decolorization of Acid Green 25 by the DB104 (pSDJH-EA) spore was found to be 50°C. Upon treatment with known laccase inhibitors, including EDTA, SDS, and NaN3, the decolorization rate of Acid Green 25 by the DB104 (pSDJH-EA) spore decreased by 23%, 80%, and 36%, respectively.

Upper gastrointestinal bleeding caused by direct invasion of diffuse large B-cell lymphoma into the stomach in a patient with HIV infection: A case report.

RATIONALE: Diffuse large B-cell lymphoma (DLBCL) is the most frequent human immunodeficiency virus (HIV)-related Non-Hodgkin's Lymphoma of the stomach. Although gastrointestinal (GI) bleeding due to primary gastric lymphoma has been previously reported in the literature, there have been no reports of stomach wall involvement of intra-abdominal lymphoma presenting as GI bleeding. PATIENT CONCERNS: We present a rare case of direct invasion of DLBCL to the stomach wall that presented as upper GI bleeding in a patient with HIV. DIAGNOSIS: Upper endoscopy showed a large ulcerofungating mass in the lesser curvature of upper stomach body. The computed tomography scan showed an about 22 × 12 cm sized huge mass that invades into the stomach wall in the abdominal cavity. A diagnosis of DLBCL was established after histological examination. INTERVENTION: The patient was treated with 6 courses of rituximab plus cyclophosphamide, doxorubicin, vincristine, and prednisone (R-CHOP). OUTCOMES: The patient achieved a complete response with 6 courses of R-CHOP treatment. No recurrence was observed during the 4-month follow-up period. LESSONS: Because of the high incidence of lymphoma in patients with HIV, if such patients complain of dyspepsia, epigastric soreness, or melena, malignant tumors, such as lymphomas or stomach cancers, should be suspected. As in this patient, doctors should be aware that intra-abdominal lymphoma can invade into the stomach wall and cause bleeding.

Neuroprotective effects of myristargenol A against glutamate-induced apoptotic HT22 cell death.

Glutamate is an important neurotransmitter in the central nervous system; however, at high concentrations, it causes excitotoxicity and many neurological disorders. Excitotoxicity induces cell death by apoptosis. Thus, factors that can inhibit the apoptotic pathways are a target of drug development for the treatment and prevention of neurodegenerative diseases. Herein, the antioxidative and neuroprotective effects of myristargenol A were examined in glutamate-induced mouse hippocampal neuronal HT22 cells. When the HT22 cells were stressed with glutamate, cell viability decreased to 44.4 ± 5.6% when compared with the case of the control cells (100 ± 4.8%); however, when these cells were treated with myristargenol A (10 µM), the cell viability was increased by 113.6 ± 2.3%. The protective effect of myristargenol A against the apoptosis of glutamate-induced HT22 cells was also confirmed using FITC-annexin V/propidium iodide double staining. In addition, myristargenol A protected the mitochondrial membrane potential (ΔΨ m). Subsequently, the expression levels of proteins in the caspase pathway related with the induction of apoptosis were decreased. Moreover, the expression levels of mitochondrial-related proteins, such as Bcl-2 and Bax, were examined, and it was found that the expression ratio of Bax/Bcl-2 decreased. In addition, myristargenol A inhibited the activity of mitogen-activated protein kinases, including p38 and c-Jun N-terminal kinase, for an oxidative stress protection effect but increased the activity of the extracellular signal-regulated kinases 1 and 2 for cell proliferation. These results reveal that myristargenol A possesses a neuroprotective effect against the neuronal cell damage caused by glutamate.

Endovascular Coiling for a Wide-neck Bifurcated Aneurysm with Anterograde Horizontal Stenting via Microcatheter Looping: A Technical Case Report.

Technical advances with devices such as catheters, balloons, and stents have widened the indications for endovascular coiling for unfavorable aneurysms. The authors report two cases of coil embolization for a wide-neck bifurcated aneurysm with anterograde horizontal stenting via microcatheter looping. Two women, aged 56 and 38 years, respectively, had an undertall- and overwide-neck aneurysm with bifurcated branches at the basilar bifurcation and middle cerebral bifurcation, respectively. The delivery microcatheter was steamed so that it could be looped deliberately to the opposite vessel. The enterprise stent was first anchored to the vessel of the posterior cerebral artery on one side. The remaining portion was spanned into a looped microcatheter to the opposite branch while pushing the stent. The Neuroform Atlas stent was passed directly through the looped segment of the microcatheter at the M2 branch and spanned horizontally by unsheathing. Under horizontal stenting, complete coil embolization was achieved without immediate or delayed complications in both cases. This novel technique presents a viable option for stent-assisted coiling within an optimal anatomy.

Human colorectal cancer antigen GA733-2-Fc fused to endoplasmic reticulum retention motif KDEL enhances its immunotherapeutic effects.

OBJECTIVE: The aim of this is to compare the immunotherapeutic effects of human colorectal cancer antigen GA733-2 fused to the Fc fragment of antibody (GA733-2-Fc) and to Fc and endoplasmic reticulum (ER) retention motif KDEL (GA733-2-Fc-KDEL). MATERIALS AND METHODS: Recombinant GA733-2-Fc and GA733-2-Fc-KDEL were produced from infiltrated Nicotiana benthamiana leaves and purified by affinity chromatography. Glycan structures were determined by matrix-assisted laser desorption/ionization-time-of-flight mass spectrometry. The allergic and immunogenic responses of recombinant GA733-2-Fc and GA733-2-Fc-KDEL were estimated in an intraperitoneally immunized mouse. The tumor regression effect of recombinant GA733-2-Fc and GA733-2-Fc-KDEL was examined using a colorectal carcinoma CT-26 animal model. RESULTS: Recombinant GA733-2-Fc contained plant-specific glycan structures including ß(1,2)-xylose and α(1,3)-fucose whereas recombinant GA733-2-Fc-KDEL contained oligomannose type glycan structures. Mice immunized intraperitoneally with recombinant GA733-2-Fc and GA733-2-Fc-KDEL elicited strong GA733-2-Fc-specific immunoglobulin G (IgG) and IgA serum antibody responses. Recombinant GA733-2-Fc-KDEL reduced the production of GA733-2-Fc-specific IgE. Recombinant GA733-2-Fc-KDEL increased the production of interferon-γ. Intraperitoneal preimmunization with recombinant GA733-2-Fc and GA733-2-Fc-KDEL regressed tumor growth in a colorectal carcinoma CT-26 animal model. The tumor regression effect induced by recombinant GA733-2-Fc-KDEL was greater than that induced by recombinant GA733-2-Fc. The human and mouse colorectal carcinoma cell binding activities of recombinant GA733-2-Fc-KDEL-immunized sera were higher than those of recombinant GA733-2-Fc. CONCLUSIONS: Our results suggest that GA733-2-Fc conjugated to ER-retention motif KDEL is a more efficient antigen to prevent tumor growth induced by colorectal carcinoma and minimize an allergic response.

3-O-Acetyloleanolic acid inhibits VEGF-A-induced lymphangiogenesis and lymph node metastasis in an oral cancer sentinel lymph node animal model.

BACKGROUND: Sentinel lymph node metastasis is a common and early event in the metastatic process of head and neck squamous cell carcinoma (HNSCC) and is the most powerful prognostic factor for survival of HNSCC patients. 3-O-acetyloleanolic acid (3AOA), a pentacyclic triterpenoid compound isolated from seeds of Vigna sinensis K., has been reported to have potent anti-angiogenesis and anti-tumor activities. However, its effects on tumor-related lymphangiogenesis and lymph node metastasis are not yet understood. METHODS: The in vitro inhibitory effects of 3AOA on VEGF-A-induced lymphangiogenesis were investigated via in vitro experiments using mouse oral squamous cell carcinoma (SCCVII) cells and human lymphatic microvascular endothelial cells (HLMECs). The in vivo inhibitory effects of 3AOA on VEGF-A-induced lymphangiogenesis and sentinel lymph node metastasis were investigated in an oral cancer sentinel lymph node (OCSLN) animal model. RESULTS: 3AOA inhibited tumor-induced lymphangiogenesis and sentinel lymph node metastasis in an OCSLN animal model, and reduced expression of VEGF-A, a lymphangiogenic factor in hypoxia mimetic agent CoCl2-treated SCCVII cells. 3AOA inhibited proliferation, tube formation, and migration of VEGF-A-treated HLMECs. The lymphatic vessel formation that was stimulated in vivo in a by VEGF-A Matrigel plug was reduced by 3AOA. 3AOA suppressed phosphorylation of vascular endothelial growth factor (VEGFR) -1 and - 2 receptors that was stimulated by VEGF-A. In addition, 3AOA suppressed phosphorylation of the lymphangiogenesis-related downstream signaling factors PI3K, FAK, AKT, and ERK1/2. 3AOA inhibited tumor growth, tumor-induced lymphangiogenesis, and sentinel lymph node metastasis in a VEGF-A-induced OCSLN animal model that was established using VEGF-A overexpressing SCCVII cells. CONCLUSION: 3AOA inhibits VEGF-A-induced lymphangiogenesis and sentinel lymph node metastasis both in vitro and in vivo. The anti-lymphangiogenic effects of 3AOA are probably mediated via suppression of VEGF-A/VEGFR-1 and VEGFR-2 signaling in HLMECs, and can be a useful anti-tumor agent to restrict the metastatic spread of oral cancer.

Transcervical access via direct neck exposure for neurointerventional procedures in the hybrid angiosuite.

PURPOSE: A complicated course of the femoral route for neurointervention can prevent approaching the target. Thus, we determined whether transcervical access in the hybrid angiosuite is applicable and beneficial in real practice. METHODS: From January 2014 to March 2017, this approach was used in 17 of 453 (3.75%) cases: 11 cerebral aneurysms (4 ruptured, 7 unruptured), 4 acute occlusions of the large cerebral artery, 1 proximal internal carotid artery (ICA) stenosis, and 1 direct carotid cavernous fistula (CCF). RESULTS: All patients were elderly (mean age, 78.1 years). The main cause was severe tortuosity of the supra-aortic course or the supra-aortic and infra-aortic courses (eight and five cases, respectively), orifice disturbance (three cases), and femoral occlusion (one case). Through neck dissection, 6-8Fr guiding catheters were placed via subcutaneous tunneling to enhance device stability and support. All cerebral aneurysms were embolized (eight complete and three neck remnants) using the combination of several additional devices. Mechanical stent retrieval with an 8Fr balloon guiding catheter was successfully achieved in a few runs (mean, 2 times; range, 1-3) within the proper time window (mean skin to puncture, 17 ± 4 min; puncture to recanalization, 25 ± 4 min). Each stent was satisfactorily deployed in the proximal ICA and direct CCF without catheter kick-back. All puncture sites were closed through direct suturing without complications. CONCLUSIONS: In the hybrid angiosuite, transcervical access via direct neck exposure is feasible in terms of device profile and support when the femoral route has an unfavorable anatomy.

Kümmell's Disease Treated with Percutaneous Vertebroplasty: Minimum 1 Year Follow-Up.

OBJECTIVE: To evaluate the radiographic and clinical outcomes of percutaneous vertebroplasty (PVP) in patients with Kümmell's disease. METHODS: A retrospective review was conducted for 19 vertebrae in 18 patients, between January 2012 and June 2016. A visual analogue scale (VAS) score was used to determine each patient's subjective level of pain (0=no pain to 10=severe pain) preoperative, immediately postoperative and at the last follow-up (at least 12 months after PVP).Radiographic parameters such as regional and global kyphotic angle, lumbar lordosis (LL), thoracolumbar junction (TLJ) angle, vertebral height, cement leakage, refracture, and adjacent level fracture were evaluated by the clinician preoperative, immediate postoperative and at the last follow-up. RESULTS: The mean VAS score significantly decreased after PVP and the decrease was maintained through to the final follow-up (p<0.05). However, the regional and global kyphotic angle, LL, and TLJ angle were not improved. Cement leakage was observed in 5 cases (26.3%): however, there were no cases of cement leakage into the spinal canal. No neurological deterioration was observed, even among patients with cement leakage. Adjacent level fractures were detected in 3 cases (15.8%). CONCLUSION: PVP can be considered as an effective treatment option for pain relief and maintenance of sagittal balance in patients with Kümmell's disease.

Single Stage Posterior Approach for Total Resection of Presacral Giant Schwannoma: A Technical Case Report.

The neurogenic tumor of frequent occurrence in the presacral area is a schwannoma. Giant presacral schwannoma has a risk for anterior surgical approach because of its massive size and proximity to abundant vascularity of presacral region. We report a single stage posterior approach for total resection of a giant presacral schwannoma. A 40-year-old female patient experienced left buttock pain and tingling sensation at left S1 dermatome. Magnetic resonance imaging showed that the presacral huge mass at S1-3 level with osseous extension and structural remodeling in left sacral ala. The presacral mass was ranging in maximum diameter from 8.0 to 8.6 cm. S2 foramen laminectomy was performed to expose the mass. The tumor capsule and the root were carefully dissected away. The tumor was removed while preserving the capsule by dissecting the plane between the inner wall of the capsule and the tumor. The single stage posterior approach for presacral giant schwannoma is feasible, and it can be a good surgical alternative to prevent pelvic organ or vascular damage and anterior approach related dystocia and infertility.

Radiographic and Clinical Results of Freehand S2 Alar-Iliac Screw Placement for Spinopelvic Fixation: An Analysis of 45 Consecutive Screws.

STUDY DESIGN: This was a retrospective clinical case series. OBJECTIVE: The purpose of this study was to evaluate mid-term outcomes of S2 ala-iliac (S2AI) screw fixation in patients who underwent multilevel posterior spinal fusion surgery. SUMMARY OF BACKGROUND DATA: There have been few reports on radiographic and clinical outcomes in patients who underwent spinopelvic reconstruction surgery using S2AI screw installation. MATERIALS AND METHODS: Twenty-three patients were treated by a single spinal surgeon between September 2013 and June 2014 utilizing segmental instrumentation with pedicle and S2AI screw. Instrumentation including S2AI screw was performed by a freehand technique. Surgical, radiographic, clinical outcomes and complications were evaluated to determine surgical results of S2AI screw fixation. RESULTS: The mean follow-up period was 16.9 months (ranged, 13-22 mo). The average number of fusion levels was 7.9 vertebral bodies. There were no cases of neurological deficit and violation of acetabulum or sciatic notch. A peri-screw halo was found in 1 patient and cortical wall violation was observed in 4 patients. The number of lateral and medial breaches was 2 and 3, respectively. All of them were asymptomatic. One patient experienced sacroiliac joint pain after S2AI screw installation. There was no case of screw/rod fracture and revision surgery for S2AI screw. CONCLUSIONS: Radiographic and clinical outcomes of freehand S2AI screw fixation was acceptable. Sacroiliac joint irritation symptoms after S2AI screw fixation were rare. S2AI screw instrumentation can be a good alternative for spinopelvic fixation. LEVEL OF EVIDENCE: Level 4.