Perioperative adverse cardiac events and mortality after non-cardiac surgery: a multicenter study.

BACKGROUND: Perioperative adverse cardiac events (PACE), a composite of myocardial infarction, coronary revascularization, congestive heart failure, arrhythmic attack, acute pulmonary embolism, cardiac arrest, and stroke during 30-day postoperative period, is associated with long-term mortality, but with limited clinical evidence. We compared long-term mortality with PACE using data from nationwide multicenter electronic health records. METHODS: Data from 7 hospitals, converted to Observational Medical Outcomes Partnership Common Data Model, were used. We extracted records of 277,787 adult patients over 18 years old undergoing non-cardiac surgery for the first time at the hospital and had medical records for more than 180 days before surgery. We performed propensity score matching and then an aggregated meta­analysis. RESULTS: After 1:4 propensity score matching, 7,970 patients with PACE and 28,807 patients without PACE were matched. The meta­analysis showed that PACE was associated with higher one-year mortality risk (hazard ratio [HR]: 1.33, 95% CI [1.10, 1.60], P = 0.005) and higher three-year mortality (HR: 1.18, 95% CI [1.01, 1.38], P = 0.038). In subgroup analysis, the risk of one-year mortality by PACE became greater with higher-risk surgical procedures (HR: 1.20, 95% CI [1.04, 1.39], P = 0.020 for low-risk surgery; HR: 1.69, 95% CI [1.45, 1.96], P < 0.001 for intermediate-risk; and HR: 2.38, 95% CI [1.47, 3.86], P = 0.034 for high-risk). CONCLUSIONS: A nationwide multicenter study showed that PACE was significantly associated with increased one-year mortality. This association was stronger in high-risk surgery, older, male, and chronic kidney disease subgroups. Further studies to improve mortality associated with PACE are needed.

Momordica charantia (bitter melon) efficacy and safety on glucose metabolism in Korean prediabetes participants: a 12-week, randomized clinical study.

This study was performed to investigate the effects of bitter melon extract (BME) on glucose metabolism, insulin resistance, and various metabolic parameters of participants with prediabetes. A 12-week randomized placebo-controlled clinical study was conducted with prediabetic patients. A total of 76 participants were randomly assigned to initiate the study. In the final analysis, 33 and 32 subjects were included in the BME and placebo groups, respectively. Results showed that 75 g oral glucose tolerance test (OGTT) blood glucose level decreased in BME group after 12 weeks. The glucose level after 30 min of glucose ingestion decreased significantly. The glucagon level in the BME group after 12 weeks significantly decreased 120 min after 75 g OGTT. These results suggested that bitter melon exhibits glucose-lowering effects through suppression of glucagon levels in people with prediabetes.

Prospective Cohort Study with a 2-Year Follow-up of Clinical Results, Fusion Rate, and Muscle Bulk for Uniportal Full Endoscopic Posterolateral Transforaminal Lumbar Interbody Fusion.

STUDY DESIGN: Retrospective cohort study. PURPOSE: Postoperative evaluation of the cross-sectional area of paraspinal muscle and clinical findings in patients who had interlaminar route uniportal full endoscopic posterolateral transforaminal lumbar interbody fusion (EPTLIF) after 2 years. OVERVIEW OF LITERATURE: There are limited short-term follow-up studies on efficacy, safety, and physiological changes with a 2-year follow-up. There is no study on paraspinal muscle cross-sectional area change in patients who had undergone uniportal EPTLIF. METHODS: We evaluated patients who underwent EPTLIF with a minimum 24-month follow-up. Clinical parameters of the Visual Analog Scale (VAS) and Oswestry Disability Index (ODI) were measured at the preoperative, 1-week postoperative mark, postoperative 3-month mark, and final follow-up. Preoperative and 1-year postoperative magnetic resonance imaging measurement of preoperative and postoperative Kjaer grade, right and left psoas muscle mass area, and right and left paraspinal muscle mass area was performed. RESULTS: EPTLIF with a minimum 24-month follow-up of 35 levels was included. The complication rate was 6%, and the mean Bridwell's fusion grade was 1.37 (1-2). There was statistically significant improvement at 1 week, 3 months, and 2 years in VAS (4.11±1.23, 4.94±1.30, and 5.46±1.29) and in ODI (40.34±10.06, 46.69±9.14, and 49.63±8.68), respectively (p <0.05). Successful operation rate with excellent and good MacNab's criteria at 2 years was 97%. There was an increment of statistically significant bilateral psoas muscle cross-sectional area, right side (70.03±149.1 mm²) and left side (67.59±113.2 mm²) (p <0.05). CONCLUSIONS: Uniportal EPTLIF achieved good fusion and improved clinical outcomes with favorable paraspinal musculature bulk at the 2-year follow-up.

Remodeling of Epidural Fluid Hematoma after Uniportal Lumbar Endoscopic Unilateral Laminotomy with Bilateral Decompression: Comparative Clinical and Radiological Outcomes with a Minimum Follow-up of 2 Years.

STUDY DESIGN: Retrospective cohort study. PURPOSE: To evaluate the clinical and radiological effects of epidural fluid hematoma in the medium term after lumbar endoscopic decompression. OVERVIEW OF LITERATURE: There is limited literature comparing the effect of postoperative epidural fluid hematoma after uniportal endoscopic decompression. METHODS: Magnetic resonance imaging (MRI) and clinical evaluation were performed for patients with single-level uniportal endoscopic lumbar decompression with a minimum follow-up of 2 years. RESULTS: A total of 126 patients were recruited with a minimum follow-up of 26 months. The incidence of epidural fluid hematoma was 27%. Postoperative MRI revealed a significant improvement in the postoperative dura sac area at postoperative day 1 and at the upper endplate at 6 months in the hematoma cohort (39.69±15.72 and 26.89±16.58 mm2) as compared with the nonhematoma cohort (48.92±21.36 and 35.1±20.44 mm2), respectively (p <0.05); and at the lower endplate on postoperative 1 day in the hematoma cohort (51.18±24.69 mm2) compared to the nonhematoma cohort (63.91±27.92 mm2) (p <0.05). No significant difference was observed in the dura sac area at postoperative 1 year in both cohorts. The hematoma cohort had statistically significant higher postoperative 1-week Visual Analog Scale (VAS; 3.32±0.68) pain and Oswestry Disability Index (ODI; 32.65±5.56) scores than the nonhematoma cohort (2.99±0.50 and 30.02±4.84, respectively; p <0.05). No significant difference was found at the final follow-up VAS, ODI, and MRI dura sac area. CONCLUSIONS: Epidural fluid hematoma is a common early postoperative MRI finding in lumbar endoscopic unilateral laminotomy with bilateral decompression. Conservative management is the preferred treatment option for patients who do not have a neurological deficit. Symptoms last only a few days and are self-limiting. A common endpoint is a remodeled fluid hematoma and the subsequent expansion of the dura sac area.

Percutaneous Biportal Endoscopic Fenestration for Symptomatic Foraminal Tarlov Cyst.

Perineural (Tarlov) cysts are a common benign pathology in the lumbosacral area but are rarely symptomatic, even when compressing the spinal root. Despite the rarity of Tarlov cyst formation in the foramen of the spine, this type is more symptomatic than those in other sites due to the narrow space. We introduce a biportal endoscopic fenestration for symptomatic foraminal Tarlov cysts. We present the case of a 40-year-old woman experiencing radiating pain in her right lower leg for 4 years. On seeking treatment, her great toe and ankle plantar flexion power had decreased. Magnetic resonance imaging revealed a cystic mass located in the L5-S1 intervertebral foramen that compressed the lumbar nerve root. Partial laminotomy was performed using a percutaneous biportal endoscopic system with a far lateral approach. An oval cystic mass of 2.6×1.1 cm was identified on high-definition images. Partial bone and foraminal ligament removal and cystic membrane fenestration were performed for nerve decompression. After decompression, the patient's motor weakness and radiating pain improved. Due to high-definition images and the minimally invasive laminotomy procedures associated with percutaneous biportal endoscopic fenestration, a foraminal Tarlov cyst was fenestrated safely, and weakness arising from radiculopathy was resolved in the current case. [Orthopedics. 2023;46(2):e125-e128.].

Comparison of the Effect of Sugammadex and Pyridostigmine on Postoperative Catheter-Related Bladder Discomfort: A Retrospective Matched Cohort Analysis.

Background and Objectives: As the use of sugammadex for reversing neuromuscular blockade during general anesthesia increases, additional effects of sugammadex have been reported compared to cholinesterase inhibitors. Here, we compare the incidence of postoperative catheter-related bladder discomfort (CRBD) between sugammadex and pyridostigmine/glycopyrrolate treatments for reversing neuromuscular blockade. Materials and Methods: We retrospectively analyzed patients aged ≥ 18 years who underwent surgery under general anesthesia, received sugammadex or pyridostigmine with glycopyrrolate to reverse neuromuscular blockade, and had a urinary catheter in the post-anesthesia care unit between March 2019 and February 2021. After applying the exclusion criteria, 1179 patients were included in the final analysis. The incidence and severity of CRBD were collected from post-anesthesia recovery records. Results: The incidence was 13.7% in the sugammadex group (n = 211) and 24.7% in the pyridostigmine group (n = 968). Following propensity score matching, 211 patients each were included in the pyridostigmine and sugammadex matched group (absolute standardized difference (ASD), 0.01-0.05). Compared to the pyridostigmine group, the odds ratio for CRBD occurring in the sugammadex group was 0.568 (95% confidential interval, 0.316-1.021, p = 0.059). Conclusions: Sugammadex has a similar effect on the occurrence of postoperative CRBD compared with pyridostigmine.

Remodeling Pattern of Spinal Canal after Full Endoscopic Uniportal Lumbar Endoscopic Unilateral Laminotomy for Bilateral Decompression: One Year Repetitive MRI and Clinical Follow-Up Evaluation.

Objective: There is limited literature on repetitive postoperative MRI and clinical evaluation after Uniportal Lumbar Endoscopic Unilateral Laminotomy for Bilateral Decompression. Methods: Clinical visual analog scale, Oswestry Disability Index, McNab's criteria evaluation and MRI evaluation of the axial cut spinal canal area of the upper end plate, mid disc and lower end plate were performed for patients who underwent single-level Uniportal Lumbar Endoscopic Unilateral Laminotomy for Bilateral Decompression. From the evaluation of the axial cut MRI, four types of patterns of remodeling were identified: type A: continuous expanded spinal canal, type B: restenosis with delayed expansion, type C: progressive expansion and type D: restenosis. Result: A total of 126 patients with single-level Uniportal Lumbar Endoscopic Unilateral Laminotomy for Bilateral Decompression were recruited with a minimum follow-up of 26 months. Thirty-six type A, fifty type B, thirty type C and ten type D patterns of spinal canal remodeling were observed. All four types of patterns of remodeling had statistically significant improvement in VAS at final follow-up compared to the preoperative state with type A (5.59 ± 1.58), B (5.58 ± 1.71), C (5.58 ± 1.71) and D (5.27 ± 1.68), p < 0.05. ODI was significantly improved at final follow-up with type A (49.19 ± 10.51), B (50.00 ± 11.29), C (45.60 ± 10.58) and D (45.60 ± 10.58), p < 0.05. A significant MRI axial cut increment of the spinal canal area was found at the upper endplate at postoperative day one and one year with type A (39.16 ± 22.73; 28.00 ± 42.57) mm2, B (47.42 ± 18.77; 42.38 ± 19.29) mm2, C (51.45 ± 18.16; 49.49 ± 18.41) mm2 and D (49.10 ± 23.05; 38.18 ± 18.94) mm2, respectively, p < 0.05. Similar significant increment was found at the mid-disc at postoperative day one, 6 months and one year with type A (55.16 ± 27.51; 37.23 ± 25.88; 44.86 ± 25.73) mm2, B (72.83 ± 23.87; 49.79 ± 21.93; 62.94 ± 24.43) mm2, C (66.85 ± 34.48; 54.92 ± 30.70; 64.33 ± 31.82) mm2 and D (71.65 ± 16.87; 41.55 ± 12.92; 49.83 ± 13.31) mm2 and the lower endplate at postoperative day one and one year with type A (49.89 ± 34.50; 41.04 ± 28.56) mm2, B (63.63 ± 23.70; 54.72 ± 24.29) mm2, C (58.50 ± 24.27; 55.32 ± 22.49) mm2 and D (81.43 ± 16.81; 58.40 ± 18.05) mm2 at postoperative day one and one year, respectively, p < 0.05. Conclusions: After full endoscopic lumbar decompression, despite achieving sufficient decompression immediately postoperatively, varying severity of asymptomatic restenosis was found in postoperative six months MRI without clinical significance. Further remodeling with a varying degree of increment of the spinal canal area occurs at postoperative one year with overall good clinical outcomes.

Retrospective lumbosacral CT analysis and prospective observational study of the ipsilateral tunnel view technique for fluoroscopy-guided selective S1 transforaminal epidural injection.

BACKGROUND: The purpose of this study was to retrospectively observe the anatomic relationship between dorsal S1 foramen (DS1F) and ventral S1 foramen (VS1F) through computed tomography (CT) analysis and to prospectively determine the optimal angle of ipsilateral tunnel view technique for performing S1 transforaminal epidural steroid injection (S1-TFESI). METHODS: The axial lumbosacral CTs taken between in 208 consecutive patients and the following measurements were obtained on both sides: (1) the α-angle was defined as an angle between a sagittal line passing through the center of the sacrum and an imaginary line passing through the center of DS1F, (2) the largest diameter of DS1F and VS1F. The fluoroscopy was adjusted to show the largest L5/S1 intervertebral disc space, which was defined as the cephalad angle, and tilted to the ipsilateral oblique side until the entrance of DS1F had a well-defined, round shape, which defined as the ß-angle in 40 humans. RESULTS: CT measurements showed that the α-angle was 26.3 ± 3.3 degrees (15-38 degrees) and the diameter of DS1F was 7.1 ± 0.7 mm (4-10.9 mm), which was significantly smaller than the diameter of VS1F, 10.1 ± 1.0 mm (7.2-13.8 mm). The ß-angle was 24 ± 4.6 degrees, which was not much different from the α-angle and the cephalad angle was 23 ± 4.6 degrees. The success rate of S1-TFESI was 100% and there were no procedure-related complications. CONCLUSIONS: The entrance of DS1F is easily identified with an ipsilateral 25 degrees-tunnel view technique while performing S1-TFESI, and it is a clinically applicable approach.

Dural Tears in Percutaneous Biportal Endoscopic Spine Surgery: Anatomical Location and Management.

OBJECTIVE: To determine the rate and anatomical location of dural tears associated with spinal surgery using a percutaneous biportal endoscopic surgery (PBES) technique. We investigated the relationship between dural tears and the type of procedure and type of instrument used. METHODS: We retrospectively analyzed 643 PBES cases by reviewing the medical records, operative records, and operative videos. Incidental durotomy was identified in 29 cases. We analyzed the size and anatomical location of the dural tears, the surgical instrument that caused the tear, and the technique used to seal the tear. RESULTS: The dural tear incidence was 4.5% (29 of 643 cases). Tears in the exiting nerve area (2 cases; 6.9%) had mainly been caused by curettage, tears in the thecal sac area (18 cases; 62.1%) were associated with electric drill and forceps use; and tears in the traversing nerve area were associated with the use of a Kerrison punch (9 cases; 31%). Of the 29 cases of dural tear, 12 were treated with in-hospital monitoring and bed rest, 14 were treated with a fibrin sealant, 2 were treated with a nonpenetrating titanium clip, and 1 was converted to microscopic surgery. One case of postoperative meningocele after conservative treatment required endoscopic revision surgery to close the dural tear. CONCLUSIONS: Most cases of incidental dural tear during PBES were treated with an endoscopic procedure. The incidence of dural tear was no greater than that associated with microscopic surgery. Our management strategy for incidental dural tears during PBES has been shown to be safe and effective.

Pooled analysis of unsuccessful percutaneous biportal endoscopic surgery outcomes from a multi-institutional retrospective cohort of 797 cases.

BACKGROUND: Spinal percutaneous biportal endoscopic surgery (PBES) is a minimally invasive surgery; however, it is associated with several poor outcomes. This study aimed to analyze unsuccessful PBES outcomes and verify their relationships with patient satisfaction. METHODS: From May 2015 to June 2018, PBES was performed at several institutions. Unsuccessful outcomes (reoperation and prolonged hospital stay) due to various reasons (hematoma, lesion recurrence, incomplete decompression, dural tear, instability, ascites, and infection) were analyzed. To verify the relationships between surgical experience and unsuccessful outcomes, the first 50 cases and the later cases were compared. Logistic regression was used to assess the relationships between unsuccessful outcomes and patient dissatisfaction. RESULTS: Among 866 patients, 797 cases with 1-year follow-up and complete data were analyzed. In total, 82 patients with unsuccessful outcomes were identified (10.29%). The incidences of hematoma (p < 0.04), incomplete operation (p < 0.01), and dural tear (p < 0.01) were significantly higher in the first 50 cases than in the later cases. Analyses of the relationship between unsuccessful outcomes and patient dissatisfaction showed that incomplete decompression (odds ratio (OR) 4.06), postoperative instability (OR 3.64), hematoma (OR 3.25), ascite (OR 3.25), dural tear (OR 3.02), and local recurrence (OR 2.45, 95%) contributed significantly. CONCLUSIONS: Unsuccessful PBES outcomes were mostly associated with hematomas, incomplete decompression, and dural tears; instability, ascites, and infection contributed to a lesser extent. Incomplete decompression, instability, hematoma, ascite, dural tear, and local recurrence were significantly related to patient dissatisfaction. The potential for poor outcomes should be described to the patient and considered prior to surgery.

Endoscopy-Assisted Diagnosis and Revision of a Malpositioned Screw.

BACKGROUND: Pedicle screw insertion is a common procedure in spine surgery, and freehand, fluoroscopic, and robotic-assisted techniques all are used. These are indirect methods that use fluoroscopy, and direct visualization of canal involvement has not been possible. However, owing to the development of high-definition imaging modalities, delicate procedures that use endoscopy are possible. CASE DESCRIPTION: A 47-year-old man presented with severe radiating pain in his leg after undergoing L5-S1 level endoscopic transforaminal lumbar interbody fusion and percutaneous pedicular screw fixation. The patient then underwent an endoscopy-assisted technique for violated spinal canal and screw revision in which the misplaced screw was directly visualized using endoscopy and the trajectory of the misplaced screw was changed. With 30° endoscopy, we directly visualized the screw thread and root compression. Then with 0° endoscopy, we changed the screw trajectory inside the pedicle with an anatomic landmark. The patient's radiating pain was completely relieved after revision of the malpositioned screw. Postoperative imaging showed the revised screw trajectory inside the pedicle. CONCLUSIONS: Endoscopy-assisted pedicle screw insertion does not require an additional incision, and early recovery after the procedure is possible. Accurate diagnosis of canal pathology and treatment are possible with direct visualization using endoscopy.

A Novel Percutaneous Biportal Endoscopic Technique for Symptomatic Spinal Epidural Lipomatosis: Technical Note and Case Presentations.

OBJECTIVE: To describe a minimally invasive decompression technique for symptomatic spinal epidural lipomatosis using percutaneous biportal endoscopic surgery. METHODS: In this report, we describe the indirect decompressive effect that was gained by partial laminotomy and ligamentum flavectomy under biportal endoscopic view. Direct neural decompression was then performed by removal of proliferated fat. We described the technical process and compared pre- and postoperative radiating leg pain, life quality, and a radiologic grading system of neural compression. RESULTS: This technique was performed successfully in 3 patients with idiopathic spinal epidural lipomatosis. Radiating pain was reduced, and functional disability and radiologic compression were improved. Postoperative instability and surgical complications related to the procedure were not observed. CONCLUSIONS: Percutaneous spinal endoscopy is a minimally invasive muscle-preserving technique for spinal lipomatosis that achieves neural decompression directly by lipoma removal and indirectly by partial bone and ligament removal.

Simplified equation for determining proper depth of peripherally inserted central catheter in relation to anatomical landmarks.

BACKGROUND: The aim of this study was to develop a formula guiding the peripherally inserted central catheter (PICC) tip placement based on anatomical landmarks such as the upper arm, clavicle, and sternum as well as the patient's height, weight, and body mass index. METHODS: Fifty-five patients who were scheduled to have PICCs were included in the study. We measured four distances along the passage of the PICC, which were as follows; the tip of the third finger to the middle of the elbow crease (Distance A), the middle of the elbow crease to the acromion process (Distance B), the acromion process to the sternal head of the clavicle (Distance C), and the sternal head of the clavicle to the end of the xiphoid process (Distance D). The lengths from the elbow creases to their carina bifurcations as determined by fluoroscopy during PICC insertions were recorded and used as reference. RESULTS: The formula for determining PICC depth based on the four distances was determined by regression analysis. The optimal formula was determined to be 25.3 + 0.5 × (Distance C) + 0.6 × (Distance D) which yielded an R2 value of 0.3. CONCLUSIONS: The formula proposed for proper depth of the adult, 25.0 + 0.5 × (clavicle length) + 0.6 × (sternum length) for PICC insertion can be used to place the tip at the carina bifurcation level. The distance from elbow crease to catheter insertion point should be added to the length generated by this formula.

Clinical comparison of unilateral biportal endoscopic technique versus open microdiscectomy for single-level lumbar discectomy: a multicenter, retrospective analysis.

BACKGROUND: The unilateral biportal endoscopic (UBE) technique is a minimally invasive procedure for spinal surgery, while open microscopic discectomy is the most common surgical treatment for ruptured or herniated discs of the lumbar spine. A new endoscopic technique that uses a UBE approach has been applied to conventional arthroscopic systems for the treatment of spinal disease. In this study, we aimed to compare and evaluate the perioperative parameters and clinical outcomes, including recovery from surgery, pain and life quality modification, patient's satisfaction, and complications, between UBE and open lumbar microdiscectomy (OLM) for single-level discectomy procedures. METHODS: This study included 141 patients with degenerative disc disease requiring discectomy at a single level from L2-L3 to L5-S1. A total of 60 and 81 patients underwent UBE and OLM, respectively. Analysis was based on comparison of perioperative metrics, operation time (OT); estimated blood loss (EBL); length of hospital stay (HS); clinical outcomes, including assessment using the Visual Analogue Scale (VAS) and Oswestry Disability Index (ODI); patient satisfaction (the MacNab score); and the incidence of reoperation and complications. RESULTS: The study cohort was 56.7% women, and the mean patient age was 50.98 ± 18.23 years. The mean VAS (the back and leg), MacNab score, and ODI improved significantly from the preoperative period to the last follow-up (12.92 ± 3.92) in both groups (p < 0.001). One week after operation, the back VAS score in the UBE group showed significantly more improvement than that in the OLM group. However, the 1-week, 3-month, and 12-month VAS (the back and leg), ODI improvement, modified MacNab score, and OT were not significantly different between the two groups. In the UBE group, EBL (34.67 ± 16.92) was smaller and HS (2.77 ± 1.2) was shorter than that of the OLM group (140.05 ± 57.8, 6.37 ± 1.39). However, OT (70.15 ± 22.0) was longer in the UBE group than in the OLM group (60.38 ± 15.5), and the difference was statistically significant. Meanwhile, the differences in the rate of surgical conversion and complications between the two groups were not statistically significant. CONCLUSIONS: The UBE for single-level discectomy yielded similar clinical outcomes to OLM, including pain control, functional disability, and patient satisfaction, but incurred minimal EBL, HS, and postoperative back pain. TRIAL REGISTRATION: Not applicable.

Different Risk Factors of Proximal Junctional Kyphosis and Proximal Junctional Failure Following Long Instrumented Fusion to the Sacrum for Adult Spinal Deformity: Survivorship Analysis of 160 Patients.

Background: The failure modes, time to development, and clinical relevance are known to differ between proximal junctional kyphosis (PJK) and proximal junctional failure (PJF). However, there are no reports that study the risk factors of PJK and PJF separately. Objective: The aim of this study was to investigate the risk factors for PJK and PJF separately. Methods: A retrospective study of 160 consecutive patients who underwent a long instrumented fusion to the sacrum for adult spinal deformity with a minimum follow-up of 2 years was conducted. A separate survivorship analysis of PJK and PJF was performed using the Cox proportional hazards model for the 3 categorical parameters of surgical, radiographic, and patient factors. Results: PJK developed in 27 patients (16.9%) and PJF in 29 patients (18.1%). The median survival time was 17.0 months for PJK and 3.0 months for PJF. Multivariate analyses revealed that a high body mass index was an independent risk factor for PJK (hazard ratio [HR] = 1.179), whereas the significant risk factors for PJF were older age, the presence of osteoporosis, the uppermost instrumented vertebra level at T11-L1, and a greater preoperative sagittal vertical axis (HR = 1.082, 6.465, 5.236, and 1.017, respectively). A large correction of sagittal deformity was shown to be a risk factor for PJF on univariate analyses, but not on multivariate analyses. Conclusion: PJK developed at a median of 17 months and PJF at a median of 3 months. A high body mass index was an independent risk factor for PJK, whereas older age, osteoporosis, uppermost instrumented vertebra level at the thoracolumbar junction, and greater preoperative sagittal vertical axis were risk factors for PJF.

The Ideal Cage Position for Achieving Both Indirect Neural Decompression and Segmental Angle Restoration in Lateral Lumbar Interbody Fusion (LLIF).

STUDY DESIGN: A prospective radiographic analysis. OBJECTIVE: To assess the ideal cage position for lateral lumbar interbody fusion (LLIF) together. SUMMARY OF BACKGROUND DATA: Achieving both indirect decompression and restoration of the segmental angle (SA) appear to be contrary to one another because the anteriorly located cage might be advantageous for restoring the SA, and posteriorly located cage might be favorable for achieving the indirect decompression effect. Little has been known about the significance of cage position in LLIF. METHODS: Forty-one patients who underwent LLIF followed by percutaneous pedicle screw fixation for 94 levels were evaluated. Postoperative plain radiographs and magnetic resonance images were obtained 3 days after surgery. The cage position was determined by the anterior, middle, and posterior portions. The anterior and posterior disk heights, SA, cross-sectional area of the thecal sac (CSA), and the foraminal area (FA) were compared according to the cage position. RESULTS: The cage was placed in the anterior area for 31 levels and middle for 63 levels. The cage height was 13.0±1.3 degrees. The increases in anterior disk height and SA were significantly greater in the anterior group (9.1 mm, 6.1 degrees) than those of the middle group (6.7 mm, 2.4 degrees). Posterior disk height increased by a mean of 4.5 mm, but its change did not differ according to the cage position. CSA and FA increased by 36.5% and 69.6%, respectively. There were no significant differences in the CSA and FA increases with respect to the cage position. Regression analysis showed that the increase of SA was affected by cage position, but the increase ratios of CSA and FA were not affected. CONCLUSIONS: The cage position within the anterior 1/3 of disk space is better for achieving the restoration of the SA without compromising the indirect neural decompression, if the height of cage is large enough.

Resorption of Massive Lumbar Disc Herniation on MRI Treated with Epidural Steroid Injection: A Retrospective Study of 28 Cases.

BACKGROUND: Although herniated disc fragments may resolve spontaneously, the optimal treatment option for massive lumbar disc herniation (LDH) has not been determined. OBJECTIVE: To evaluate the extent of reduction in the size of massive LDH on magnetic resonance imaging (MRI) and the pain relief effect of transforaminal epidural steroid injection (TFESI) during the study period. STUDY DESIGN: Retrospective evaluation. SETTING: Hospital and ambulatory pain clinic, Korea. METHODS: After Institutional Review Board approval, we conducted a retrospective review of 28 patients who underwent at least 2 MRIs during the period from January 2012 to December 2014. The size of the herniated mass was determined from the ratio of the anterior-posterior diameter of the spinal canal (C-value) to the maximum anterior-posterior diameter of the herniated disc (H-value) on axial MRI (C-H ratio). We also analyzed visual analogue scale (VAS) scores at baseline (T0), 2 weeks after the first and second TFESI (T1, T2), and at the second follow-up MRI (T3). RESULTS: The mean C-value was 18.3 ± 2.9 mm. The mean H-value changed from 10.4 ± 1.9 mm to 4.5 ± 2.7 mm, and the mean C-H ratio changed from 58 ± 1.0% to 24 ± 1.4% (P < 0.001). Twenty-four of 28 patients demonstrated a reduction in the size of the herniation, and the mean reduction rate of the C-H ratio was 59%. In 4 patients, the LDH had not resolved on MRI, but the symptoms had diminished to such an extent that surgery was not required. The mean VAS score had significantly decreased at T1 and showed a continued decrease at the time of the last follow-up (P < 0.001). LIMITATIONS: This is a retrospective study and only offers data for patients who chose not to undergo surgery. In addition, the timing of repeat MRI was not standardized. CONCLUSION: The majority of cases of massive LDH demonstrated resolution at variable points between 3 and 21 months. TFESI could provide effective pain relief for patients with massive LDH in the interval without severe neurologic deterioration.IRB approval: Kangdong Sacred Heart Hospital: IRB Number # 14-1-10.

Standard versus over-tensioning in the transfer of extensor indicis proprius to extensor pollicis longus for chronic rupture of the thumb extensor.

PURPOSE: The purpose of this study was to evaluate the functional outcomes of the over-tensioning technique compared with those of the standard tensioning technique in the transfer of extensor indicis proprius (EIP) to extensor pollicis longus (EPL) for the chronic rupture of the thumb extensor. METHODS: Data were collected from patients who underwent tendon transfer using EIP between March 2003 and August 2011. 23 were treated with the standard tensioning technique and 25 patients (Group B) with the over-tensioning technique. While standard tension was maintained with the thumb in full extension and the wrist in 30° of flexion, over-tension was maintained with the thumb in full extension and the wrist in the neutral position. All patients were assessed for total range of motion, elevation and flexion deficit, the thumb grip and pinch strength, and the thumb and the index extension strength compared to the unaffected side, EIP-EPL evaluation as suggested by Lemmen et al. and Disabilities of the Arm, Shoulder, and Hand questionnaire (DASH). RESULTS: Group A: total range of motion 115°, elevation deficit 2.0 cm, combined flexion deficit 1.0 cm, thumb extension strength 75%, thumb grip strength 91%, and pinch strength 87%. Functional outcomes were 13 excellent, 6 good, 3 fair, and 1 poor. Median DASH score was 21.3 points. Group B: total range of motion 125°, elevation deficit 1.0 cm, combined flexion deficit 1.5 cm, thumb extension strength 85%, thumb grip strength 88%, and pinch strength 83%. Functional outcomes were 16 excellent, 7 good, 2 fair, and 0 poor. Median DASH score was 19.8 points. There are significant differences in the range of motion, elevation deficit, and extension strength of thumb between the two groups (p=.001, p=.001, and p=.028, respectively). CONCLUSION: While the functional outcomes of both groups were favorably acceptable in a majority of the patients, there were significant differences in aspects of range of motion, elevation deficit, and strength of the thumb between both groups. LEVEL OF EVIDENCE: Case-control study, Level III.