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Subacute thyroiditis (SAT) is a painful thyroiditis that often requires steroid therapy. Here, we report the first case of severe SAT in a patient who received the first dose of mRNA coronavirus disease 2019 (COVID-19) vaccination. A 34-year-old man without a viral prodrome felt a lump when swallowing 5 days after his first dose of mRNA-1273 (Moderna) vaccination. Ten days after vaccination, the patient visited the hospital and was advised to rest and take nonsteroidal anti-inflammatory drugs. He revisited the hospital 10 days later as symptoms aggravated with anterior neck pain, headache, fatigue, muscle weakness, and weight loss. Thyroid hormone levels and inflammatory markers were consistent with thyrotoxicosis. A thyroid ultrasound scan revealed typical SAT findings. His symptoms rapidly improved after receiving prednisone. A week later, the patient successfully completed his second dose of the vaccine. The thyroid function test results were nearly normal 1 month after the completion of the vaccination. We report this case to raise awareness of the occurrence of SAT after COVID-19 vaccination. As the risk of COVID-19 outweighs the minor risks of the vaccine, managing the side effects of the first vaccine dose is crucial to complete COVID-19 vaccination.

Background and aim The feasibility of endoscopic submucosal dissection (ESD) as a treatment option for dysplasia in ulcerative colitis (UC) has been reported, but the associated therapeutic decision-making and clinical outcomes have not been extensively investigated. Methods We retrospectively reviewed 25 UC patients who were referred for potential ESD of non-polypoid or sessile dysplasia. We analyzed the treatment decisions and the ESD and colectomy outcomes for this patient group. Results All lesions were located at the colitic segments. The median UC duration was 13.4 years. A colectomy was recommended for 10 patients because of ulceration with indistinct borders (one patient), non-ulceration with indistinct borders (two patients), and non-lifting signs (seven patients). The remaining 15 patients underwent ESD. The en bloc and R0 resection rates were 93.3% and 80%, respectively. The median hospitalization periods were 1 (range, 1-2) day after ESD and 7 (range, 5-30) days after colectomy. No procedure-related complications occurred after ESD, but early and late postoperative complications occurred in two (22.2%) and six (66.7%) of the colectomized patients, respectively. Fourteen ESD cases were followed endoscopically for a median period of 24.7 (range, 5.2-64.8) months. Local recurrence occurred in 2 (14.3%) patients, and metachronous recurrence was identified in two separate patients (14.3%). Conclusions Endoscopic submucosal dissection is a feasible endoscopic treatment option for UC-associated dysplasia showing noninvasive pit or vascular patterns, no surface ulceration, distinct borders, and appropriate lifting after submucosal injection. Meticulous endoscopic surveillance is essential to monitor for local or metachronous recurrence of dysplasia after ESD.

Benign prostatic hypertrophy (BPH) is an intractable chronic inflammatory disease. We studied the efficacy of two ellagitannins, namely camptothin B (1) and cornusiin A (2) that were isolated from Cornus alba (CA) for the treatment of BPH, which is a common health issue in older men. The ellagitannins (1 and 2) were evaluated on its inhibitory activities of the enzyme 5α-reductase and tumor necrosis factor (TNF)-α, its interleukin (IL)-1β, IL-6, and IL-8 production, and its anti-proliferation and apoptosis induction in prostate cells that show hypertrophy (RWPE-1 cell). In inhibition of 5α-reductase, the ellagitannins (1 and 2) showed potential effects, compared to the positive control, finasteride. In the case of IL-1β, IL-6, IL-8, and TNF-α, 1 and 2 showed good inhibitory effects as compared to the control group treated with LPS. The ellagitannins (1 and 2) were also shown to inhibit proliferation of, and induce apoptosis in, the RWPE-1 cell. These results suggest that the ellagitannins (1 and 2) may be good candidates for the treatment of BPH.

Among various patient risk factors affecting survival after high tibial osteotomy (HTO), the ideal age limit for HTO is unclear. This study was performed to evaluate the effect of age on survival rate and complications after HTO for medial unicompartmental osteoarthritis. Among of 61,145 HTO patients from Korean National Health Insurance database, 41,112 patients underwent the procedure before the age of 60 years (Group A), 13,895 patients between the age of 60 and 65 years (Group B), and 6138 patients after the age of 65 years (Group C). We compared the survival rate in person-years among the three groups from the date of primary surgery until subsequent total knee arthroplasty. Perioperative complications were also recorded. The adjusted hazard ratio (HR) were calculated using the multivariable Cox proportional hazard regression model, adjusting for the potential confounders: age, sex, type of medical insurance, region of residence, hospital type, comorbidities, and Charlson comorbidity index score. The total number of HTO increased 6.5-fold, especially in patients aged > 65 years (by 8.2-fold) from 2008 to 2018. The overall revision rate was 4.2% in Group A, 6.4% in Group B, and 7.3% in Group C. The 5- and 10-year revision rate was significantly lower in Group A (p

This was a retrospective cohort study.The objective of this study was to investigate whether machine learning (ML) can perform better than a conventional logistic regression in predicting postoperative C5 palsy of cervical ossification of the posterior longitudinal ligament (OPLL) patients.C5 palsy is one of the most common postoperative complications after surgical treatment of OPLL, with an incidence rate of 1.4%-18.4%. ML has recently been used to predict the outcomes of neurosurgery. To our knowledge there has not been a study to predict postoperative C5 palsy of cervical OPLL patient with ML.Four sampling methods were used for data balancing. Six ML algorithms and conventional logistic regression were used for model development. A total of 35 ML prediction model and 5 conventional logistic prediction models were generated. The performances of each model were compared with the area under the curve (AUC). Patients who underwent surgery for cervical OPLL at our institute from January 1998 to January 2012 were reviewed. Twenty-five variables of each patient were used to make a prediction model.In total, 901 patients were included [651 male and 250 female, median age: 55 (49-63), mean±SD: 55.9±9.802]. Twenty-six (2.8%) patients developed postoperative C5 palsy. Age (P=0.043), surgical method (P=0.0112), involvement of OPLL at C1-3 (P=0.0359), and postoperative shoulder pain (P≤0.001) were significantly associated with C5 palsy. Among all ML models, a model using an adaptive reinforcement learning algorithm and downsampling showed the largest AUC (0.88; 95% confidence interval: 0.79-0.96), better than that of logistic regression (0.69; 95% confidence interval: 0.43-0.94).The ML algorithm seems to be superior to logistic regression for predicting postoperative C5 palsy of OPLL patient after surgery with respect to AUC. Age, surgical method, and involvement of OPLL at C1-C3 were significantly associated with C5 palsy. This study demonstrates that shoulder pain immediately after surgery is closely associated with postoperative C5 palsy of OPLL patient.

Background Genetic analyses have identified many variants associated with the risk of inflammatory bowel disease (IBD) development. Among these variants, the ones located within the NOD2 gene have the highest odds ratio of all IBD genetic risk variants. Also, patients with Crohn’s disease (CD) have been shown to have an altered gut microbiome, which might be a reflection of inflammation itself or an effect of other parameters that contribute to the risk of the disease. Since NOD2 is an intracellular pattern recognition receptor that senses bacterial peptidoglycan in the cytosol and stimulates the host immune response (Al Nabhani et al., PLoS Pathog 13:e1006177, 2017), it is hypothesized that NOD2 variants represent perfect candidates for influencing host-microbiome interactions. We hypothesized that NOD2 risk variants affect the microbiome composition of healthy first degree relative (FDR) of CD patients and thus potentially contribute to an altered microbiome state before disease onset. Methods Based on this, we studied a large cohort of 1546 healthy FDR of CD patients and performed a focused analysis of the association of three major CD SNPs in the coding region of the NOD2 gene, which are known to confer a 15–40-fold increased risk of developing CD in homozygous or compound heterozygous individuals. Results Our results show that carriers of the C allele at rs2066845 was significantly associated with an increase in relative abundance in the fecal bacterial family Erysipelotrichaceae. Conclusions This result suggests that NOD2 polymorphisms contribute to fecal microbiome composition in asymptomatic individuals. Whether this modulation of the microbiome influences the future development of CD remains to be assessed.

Background Up to 60% of patients with ulcerative colitis (UC) ultimately fail anti-tumor necrosis factor (TNF) treatment. We aimed to investigate early predictive markers of clinical and endoscopic outcomes in patients with UC who were anti-TNF-naïve commencing anti-TNF treatment, with particular focus on changes in albumin and C-reactive protein levels in the first 2 weeks of treatment. Methods We retrospectively investigated 210 patients with UC who started infliximab or adalimumab between 2009 and 2016 (male, 62.4%; median age at diagnosis, 37.9 years [interquartile range, 25.5–48.9 years]; median follow-up duration, 3.3 years [1.9–5.0 years]). Logistic and Cox proportional-hazards regressions were performed to identify variables associated with primary nonresponse (PNR), endoscopic outcomes, time-to-colectomy, and anti-TNF failure. Results Forty-one patients (19.5%) experienced PNR; week 0/week 2 ratio serum albumin was associated with PNR (adjusted odds ratio [aOR], 1.8; 95% confidence interval [CI], 1.1–2.9, per interquartile range increase). Week 0/week 2 ratio albumin was also associated with endoscopic response (aOR, 0.28; 95% CI, 0.31–0.82) and endoscopic remission (aOR, 0.61; 95% CI, 0.39–0.96) at weeks 8 to 14, time-to-colectomy (adjusted hazard ratio, 2.12; 95% CI, 1.29–3.49) and time-to-anti-TNF failure (adjusted hazard ratio, 1.54; 95% CI, 1.22–1.96), regardless of age, disease severity, or in-patient status. Association with time-to-colectomy and anti-TNF failure was externally validated in an independent cohort of inpatients with UC starting infliximab. Conclusions Change in serum albumin within the first 2 weeks of anti-TNF treatment is predictive of PNR, endoscopic outcomes, time-to-colectomy, and anti-TNF failure in patients with UC. Timely access to this biomarker enables early identification of patients with UC at risk of anti-TNF failure and may guide early optimization of anti-TNF treatment to improve disease outcomes.

Background and Study Aims Lumbar spinal stenosis (LSS) is the most common spinal disease in older adults. Although surgical modalities are recommended in patients who are unresponsive to conservative treatment, the most appropriate minimally invasive surgical procedure for patients with LSS remains controversial. Moreover, few previous studies have focused on patient-centered outcomes with radiologic correlation. In the present study, we aimed to investigate radiologic efficacy and patient satisfaction following bilateral decompression via unilateral laminotomy. Materials and Methods We performed a retrospective analysis of radiologic efficacy and patient satisfaction in a series of surgical patients treated at our institution. We classified patients into two groups based on the primary pathology (i.e., central or lateral recess stenosis). Medical records were analyzed retrospectively for radiologic outcomes and clinical parameters including pain and changes in quality of life. Data related to outcomes were collected at 2 weeks, 3 months, and 12 months after surgery in the outpatient clinic. Results Among the 122 patients enrolled in this study, 51 had central spinal stenosis; 71 had lateral recess stenosis. Radiologically, we observed significant improvements in the anteroposterior diameter and cross-sectional area of the dural sac (central stenosis) and the lateral width of the central canal and depth of the lateral recess (lateral recess stenosis). Two weeks and 12 months after the surgical procedure, we observed significant improvements in the extent of symptoms, patient satisfaction, and quality of life (including physical function). Conclusion Our findings suggest that bilateral decompression via a unilateral approach shows improved radiologic outcomes, varying based on the type of stenosis. Furthermore, patient satisfaction significantly improved regardless of the type of disease.

Background & Aims Increased intestinal permeability has been associated with Crohn’s disease (CD), but it is not clear whether it is a cause or result of the disease. We performed a prospective study to determine whether increased intestinal permeability is associated with future development of CD. Methods We assessed the intestinal permeability, measured by the urinary fractional excretion of lactulose-to-mannitol ratio (LMR) at recruitment in 1420 asymptomatic first-degree relatives (6–35 years old) of patients with CD (collected from 2008 through 2015). Participants were then followed up for a diagnosis of CD from 2008 to 2017, with a median follow-up time of 7.8 years. We analyzed data from 50 participants who developed CD after a median of 2.7 years during the study period, along with 1370 individuals who remained asymptomatic until October 2017. We used the Cox proportional hazards model to evaluate time-related risk of CD based on the baseline LMR. Results An abnormal LMR (>0.03) was associated with a diagnosis of CD during the follow-up period (hazard ratio, 3.03; 95% CI, 1.64–5.63; P = 3.97 × 10–4). This association remained significant even when the test was performed more than 3 years before the diagnosis of CD (hazard ratio, 1.62; 95% CI, 1.051–2.50; P = .029). Conclusions Increased intestinal permeability is associated with later development of CD; these findings support a model in which altered intestinal barrier function contributes to pathogenesis. Abnormal gut barrier function might serve as a biomarker for risk of CD onset.

Objectives To retrospectively determine the diagnostic ability of MRI in differentiating between intradural extramedullary spinal schwannomas and meningiomas. Methods A total of 199 patients with spinal intradural extramedullary tumors who underwent preoperative contrast-enhanced MRI between January 2012 and December 2018 were included in this study. Two radiologists independently analyzed the presence of cystic change, dural tail sign, and neural foraminal extension. Clinical and MRI features between the two groups were compared by univariable and multivariable analyses using logistic regression. Interobserver agreements were calculated using kappa statistics. Results Patients with schwannoma showed significantly higher frequency of cystic change (96% vs 24%, P < 0.001), neural foraminal extension (29% vs 3%, P = 0.001), and lumbar location (41% vs 5%, P = 0.008). Patients with meningioma showed significantly higher frequency of dural tail sign (64% vs 1%, P < 0.001), thoracic location (75% vs 31%, P = 0.007), older age (59.7 years vs 47.6 years, P < 0.001), higher female predominance (83% vs 50%, P < 0.001), and smaller size (19.8 cm vs 28.8 cm, P < 0.001). Multivariable analysis showed that cystic change (P < 0.001; odds ratio [OR], 0.02), dural tail sign (P < 0.001; OR, 36.23), age (P = 0.032; OR, 1.06), and lumbar location (P = 0.006; OR, 0.02) were independent factors. Interobserver agreements were almost perfect for all analyses. Conclusions MRI features were useful in differentiating between intradural extramedullary schwannomas from meningiomas. The presence of cystic change and dural tail sign were independently significant discriminators.

This study aimed to evaluate the clinical characteristics and clinical course of Asian elderly-onset Crohn's disease (EOCD) patients in a large well-defined cohort of South Korean IBD patients.From the Asan inflammatory bowel disease registry, we identified 29 EOCD patients (diagnosed with CD in age of 60 years or over) out of 2989 CD patients (1.0%). After excluding two patients with unclear data, 27 EOCD were matched with 108 young-onset CD (YOCD) and 108 middle age-onset CD (MOCD) for the interval from symptom onset to diagnosis (±3 years) and follow-up duration (±3 years).Females were predominant in the EOCD group (59.3%) compared to MOCD (31.5%) and YOCD (29.6%) groups (p = .012). In EOCD group, terminal ileal location was the most common (63.0%) at diagnosis, whereas ileocolonic location in other groups (57.4% in MOCD and 78.7% in YOCD, respectively) (p .001). Patients with perianal fistula at CD diagnosis were less common (14.8% in EOCD vs. 28.7% in MOCD vs. 49.1% in YOCD, p .001). During follow-up, thiopurines were used less frequently in the EOCD group (48.1% in EOCD vs. 87.0% in MOCD vs. 89.8% in YOCD, p .001), but the risk for intestinal resection was comparable among three groups (p = .583).EOCD may have a better clinical course than MOCD and YOCD, as demonstrated by the similar risk for intestinal resection despite the less frequent use of thiopurines.

Large-scale studies regarding the long-term outcomes of adalimumab (ADA) treatment in Asian patients with Crohn’s disease (CD) are still scarce. We retrospectively analyzed the long-term outcomes of ADA treatment in Korean CD patients who commenced on scheduled ADA treatment at Asan Medical Center between November 2008 and July 2016. Clinical response was defined as maintaining ADA treatment without dose intensification (DI) and/or major abdominal surgery (MAS). Of the 254 patients who received at least two doses of ADA at 2-week intervals as induction therapy, 250 patients (98.4%) showed an initial favorable response by week 4. Among responders, 243 patients were followed up for longer than 4 weeks and were included for further analysis. The median duration of ADA maintenance therapy was 19.4 months. At the last follow-up, 45 patients (18.5%) required DI after a median of 16.8 months and 31 (12.8%) required MAS after a median of 8.9 months. Finally, 161 patients (66.3%) were still receiving ADA without DI and/or MAS. The cumulative probability of maintaining ADA without DI and/or MAS was 81.1% at 1 year, and 36.5% at 5 years. Secondary loss of response to previous infliximab (P = 0.001) and elevated baseline C-reactive protein at starting ADA treatment (P = 0.008) were identified as independent predictors of a poor response to ADA treatment using multivariate regression analysis. The long-term outcome of ADA treatment in a real-life cohort of Korean patients with CD appears to be comparable to that reported in previously published Western studies.

BACKGROUND Although surgery followed by radiation effectively treats metastatic epidural compression, the ideal surgical approach should enable fast recovery and rapid institution of radiation and systemic therapy directed at the primary tumor. OBJECTIVE To assess spinal laser interstitial thermotherapy (SLITT) as an alternative to surgery monitored in real time by thermal magnetic resonance (MR) images. METHODS Patients referred for spinal metastasis without motor deficits underwent MR-guided SLITT, followed by stereotactic radiosurgery. Clinical and radiological data were gathered prospectively, according to routine practice. RESULTS MR imaging-guided SLITT was performed on 19 patients with metastatic epidural compression. No procedures were discontinued because of technical difficulties, and no permanent neurological injuries occurred. The median follow-up duration was 28 weeks (range 10-64 weeks). Systemic therapy was not interrupted to perform the procedures. The mean preoperative visual analog scale scores of 4.72 (SD ± 0.67) decreased to 2.56 (SD ± 0.71, P = .043) at 1 month and remained improved from baseline at 3.25 (SD ± 0.75, P = .021) 3 months after the procedure. The preoperative mean EQ-5D index for quality of life was 0.67 (SD ± 0.07) and remained without significant change at 1 month 0.79 (SD ± 0.06, P = .317) and improved at 3 months 0.83 (SD ± 0.06, P = .04) after SLITT. Follow-up MR imaging after 2 months revealed significant decompression of the neural component in 16 patients. However, 3 patients showed progression at follow-up, 1 was treated with surgical decompression and stabilization and 2 were treated with repeated SLITT. CONCLUSION MR-guided SLITT can be both a feasible and safe alternative to separation surgery in carefully selected cases of spinal metastatic tumor epidural compression. ABBREVIATIONS cEBRT, conventional external beam radiation therapyESCC, epidural spinal cord compressionSLITT, spinal laser interstitial thermotherapySSRS, stereotactic spinal radiosurgeryVAS, visual analog scale.

Currently, radiologic predictors for the resectability of cervical dumbbell schwannomas remain unknown. To identify radiologic predictors for resectability, we retrospectively reviewed data from 72 patients.From January 1995 to June 2017, 72 patients who underwent surgical treatment for cervical dumbbell schwannomas were enrolled. We focused on the relationship between preoperative magnetic resonance imaging (MRI) features and the extent of tumor removal. The MRI features evaluated were tumor size, tumor level, Eden classification, degree of vertebral artery (VA) involvement, and signal intensity (SI) on T2-weighted images (WIs).Among the 72 patients, gross total resection (GTR) and subtotal resection (STR) were achieved in 37 (51.4%) and 35 (48.6%) patients, respectively. Mean maximal tumor size (P = 0.011), mean size of foraminal and extraforaminal portion (P = 0.017), tumor level (P0.001), VA involvement (P0.001), and SI on T2-WIs (P = 0.006) were significantly different between the GTR and STR groups. Univariate analyses demonstrated that maximal tumor size (odds ratio [OR]: 0.93, P = 0.012), high cervical level (OR: 11.37, P0.001), pushed VA (OR: 0.11, P = 0.002), encased VA (OR: 0.02, P0.001), and hyper-SI on T2-WIs (OR: 12.46, P = 0.020) were significant predictors for GTR. In the multivariate analysis, only high cervical level (OR: 5.48, P = 0.033) and encased VA (OR: 0.07, P = 0.014) were significant predictors for GTR.The resectability of cervical dumbbell schwannomas may be predicted by MRI features, including tumor size, tumor level, and degree of VA involvement.

Objective To evaluate the validity of intraoperative somatosensory-evoked potential (SSEP) and motor-evoked potential (MEP) monitoring according to 2 different warning criteria during 6 months from intramedullary spinal ependymoma surgery. Methods Twenty-six patients who underwent intramedullary spinal ependymoma surgery with intraoperative monitoring from January 2010 to June 2017 were retrospectively analyzed. We examined the sensitivity, specificity, positive predictable value, negative predictable value, and diagnostic odds ratio of SSEP and MEP monitoring for each extremity according to 2 warning criteria: 50% decline and all-or-none. The postoperative motor deficit was evaluated using the Medical Research Council scale. The postoperative neurologic deficit was followed up during 6 months. Results Eighty-six extremities were evaluated. The success rates of SSEP and MEP monitoring were 84.9% and 83.7%, respectively. Indeterminate cases were 1 in SSEP and 6 in MEP. All-or-none criterion in SSEP and MEP monitoring showed greater specificity, positive predictable value, and diagnostic odds ratio than 50% decline criterion during 6 months. The validity of SSEP was high in the upper extremity, whereas that of MEP was high in the lower extremity. During the follow-up, 37 of 38 extremities (97.4%) and 18 of 29 extremities (62.1%) showed improvement in sensory and motor deficit, respectively. Seven indeterminate cases also showed good clinical outcomes. Conclusions Many false-positive and false-negative results of SSEP and MEP monitoring occurred during the immediate postoperative period. All-or-none criterion was more beneficial for assessing postoperative neurologic status than 50% decline criterion. This trend was maintained until 6 months after surgery.

Background/Aims: The clinical outcomes of angiography and transcatheter arterial embolization (TAE) for acute gastrointestinal bleeding (GIB) have not been completely assessed, especially according to bleeding sites. This study aimed to assess the efficacy of angiography and safety of TAE in acute GIB. Methods: This was a retrospective study evaluating the records of 321 patients with acute GIB who underwent angiography with or without TAE. Targeted TAE was conducted in 134 patients, in whom angiography showed bleeding sources. Prophylactic TAE was performed in 29 patients when the bleeding source was not detected but a specific vessel was strongly suspected by other examinations. The rate of technical success, clinical success, and complications were analyzed. Results : The detection rate of bleeding source via angiography was 50.8% (163/321), which was not different according to the bleeding sites. The detection rate was higher if the probable bleeding source had already been found by another investigation (59.7% vs. 35.8%, p

Simpson grade II removal (coagulation of the dural attachment after gross total removal) of spinal meningioma is considered an acceptable alternative, but increased recurrence after more than 10 years has been reported. More attention must be paid to the long-term surgical outcomes after Simpson grade II removal. A retrospective review was performed for 20 patients (M:F = 5:15; age, 59 ± 9 years) with Simpson grade II removal (mean follow-up period, 12.9 years; range 10.0–17.5). Magnetic resonance (MR) imaging was conducted in 17 patients at 88 ± 52 months (range 12–157). During the same period, Simpson grade I removal (removal of the dural origin) was performed in 21 patients (follow-up, 89 ± 87 months; range 9–316). Radiological recurrence was defined as a visible tumor on a follow-up MR image, and clinical tumor recurrence was defined as the recurrence of symptoms. At the final follow-up, neurological symptoms had improved in 16/20 patients and remained stable in 4/20. A recurrent tumor was detected in one patient due to increased back pain at 92 months postoperative, but the symptom was stable without surgery until the last follow-up (124 months). The radiological and clinical recurrence-free survival periods were 150 ± 7 months (95 % CI 136–163) and 204 ± 6 months (95 % CI 193–215), respectively. There was no recurrence after Simpson grade I removal, whereas neurological deterioration occurred in two patients after surgery. Simpson grade II removal may be an alternative option if the risk of complications with Simpson grade I removal is expected to be high.

Background We aimed to evaluate the role of fecal calprotectin (FC) as a noninvasive marker for the disease activity of ulcerative colitis (UC) in a Korean cohort. Methods A total of 181 fecal samples were collected from 181 consecutive UC patients between April 2015 and September 2016. FC levels were measured using the Quantum Blue® Calprotectin rapid test. The laboratory test results, partial Mayo Score (pMS), and colonoscopic imaging findings at FC level measurement were retrospectively reviewed. The Mayo endoscopic subscore (MES) and UC endoscopic index of severity (UCEIS) were graded by 2 certified endoscopists after training with 50 other cases. Results The FC levels were significantly correlated with pMS (Spearman correlation coefficient r = 0.428, p

The fatty acid profile of the fecal metabolome and its association with colorectal cancer (CRC) has not been fully evaluated. We aimed to compare the fecal fatty acid profiles of CRC patients and healthy controls. We enrolled 26 newly diagnosed CRC patients and 28 healthy individuals between July 2014 and August 2014 from our institute. Long- and short-chain fatty acids were extracted from fecal samples and analyzed using gas chromatography–mass spectrometry. Regarding fecal long-chain fatty acids, the levels of total ω-6 polyunsaturated fatty acids and, particularly, of linoleic acid (C18:2ω-6) were significantly higher in male CRC patients than in healthy men (2.750 ± 2.583 vs. 1.254 ± 0.966 µg/mg feces, P = 0.040; 2.670 ± 2.507 vs. 1.226 ± 0.940 µg/mg feces, P = 0.034, respectively). In addition, the levels of total monounsaturated fatty acid and, particularly, of oleic acid (C18:1ω-9) were significantly higher in male CRC patients than in healthy men (1.802 ± 1.331 vs. 0.977 ± 0.625 µg/mg feces, P = 0.027; 1.749 ± 1.320 vs. 0.932 ± 0.626 µg/mg feces, P = 0.011, respectively). However, those differences were not shown in female gender. The level of fecal short-chain fatty acids was not different between CRC patients and healthy controls. There were changes in the profiles of fecal fatty acid metabolomes in CRC patients compared to healthy controls, implying that fecal fatty acids could be used as a novel screening tool for CRC.

AIM To investigate the temporal trends in the misdiagnosis rate between Crohn’s disease (CD) and intestinal tuberculosis (ITB) in South Korea. METHODS We retrospectively reviewed the medical records of patients managed for CD or ITB at Asan Medical Center, a tertiary referral hospital, Seoul, Korea between 1996 and 2014. The temporal trends in the misdiagnosis rates between the two diseases were analyzed. The demographic and clinical characteristics were compared between CD patients who were initially misdiagnosed as ITB (final CD group) and vice versa (final ITB group). Final diagnostic criteria for ITB and medication for CD before definite diagnosis of TB were also analyzed in final ITB group. RESULTS In total, 2760 patients were managed for CD and 772 patients for ITB between 1996 and 2014. As well, 494 of the 2760 CD patients (17.9%) were initially misdiagnosed as ITB and 83 of the 772 ITB patients (10.8%) as CD. The temporal trend in misdiagnosing CD as ITB showed a decrease (OR = 0.89, 95%CI: 0.87-0.91, P < 0.001), whereas the temporal trend in misdiagnosing ITB as CD showed an increase (OR = 1.06, 95%CI: 1.01-1.11, P = 0.013). Age at diagnosis, presenting symptoms, and proportion of patients with active/past perianal fistula and active/inactive pulmonary tuberculosis (TB) were significantly different between final CD group and final ITB group. Forty patients (48.2%) in final ITB group were diagnosed by favorable response to empirical anti-TB treatment. Seventeen patients (20.5%) in final ITB group had inappropriately received corticosteroids and/or thiopurines due to misdiagnosis as CD. However, there were no mortalities in both groups. CONCLUSION Cases of CD misdiagnosed as ITB have been decreasing, whereas cases of ITB misdiagnosed as CD have been increasing over the past two decades.

Although early treatment of Crohn's disease (CD) patients with anti-tumor necrosis factor (TNF) agents or immunomodulators (IMs) may improve long-term outcomes, especially those with poor prognostic factors, their effectiveness in Asians remains unclear. In this study, Korean patients with CD naive to both intestinal surgery and intestinal complications, and with at least two risk factors for progression (diagnosis at age

Background: Large-scale studies regarding the long-term efficacy of infliximab (IFX) treatment in non-Caucasian patients with ulcerative colitis (UC) are lacking. Study: We analyzed the long-term outcomes of IFX in 195 Korean UC patients who received scheduled IFX treatments at Asan Medical Center. IFX failure was defined as IFX discontinuation due to colectomy or non-response to IFX, and additionally UC-related hospitalization or a need for rescue corticosteroids during the course of IFX. Results: Between December 2006 and October 2016, a total of 3101 infusions of IFX were administered to 195 patients over a median period of 21 months. At the end of the follow-up, 86 patients (44.1%) were still receiving IFX without failure. IFX was stopped in 73 (37.4%) patients due to colectomy (23 patients, 11.8%), non-response to IFX (35 patients, 17.9%) or other reasons such as adverse events or patients’ preferences (15 patients, 7.7%). An additional 36 (18.5%) patients experienced IFX failure during follow-up due to a need for rescue corticosteroids (13 patients, 6.7%), UC-related hospitalization (8 patients, 4.1%), or both (15 patients, 7.7%). The survival free of IFX failure was 58.1% at 1 year, 50.7% at 3 years and 44.8% at 5 years. In a multivariate regression analysis, cytomegalovirus colitis within 3 months before IFX initiation was a predictor of IFX failure (hazard ratio 1.57; 95% confidence interval 1.04–2.37; p = .032). Conclusions: The long-term efficacy of IFX in a large, real-life cohort of Korean UC patients appears to be comparable to that in previously published Western studies.

Department of Neurosurgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul(S.-H.L., E.-S.K., W.E.); Department of Neurosurgery, Seoul National University College of Medicine, Seoul(C.K.C., C.H.K.); Department of Neurosurgery, Seoul National University Bundang Hospital, Seongnam, SouthKorea (S.H.Y., S.-J.H., K.-J.K., H.-J.K.)Background. We sought to determine the surgical treat-ment and functionaloutcome andidentify the predictorsof survival in a retrospective cohort of patients withspinal cord ependymoma using data collected from theKorea Spinal Oncology Research Group database.Methods. The data regarding 88 patients who had beensurgically treated for histologically confirmed spinalcord intramedullary and extramedullary ependymomafrom January 1989 to December 2009 were retrospec-tively reviewed.Results. Histopathological examination revealed myxo-papillary ependymoma in 24 patients, ependymoma in61 patients, and anaplastic ependymoma in 3 patients.Gross total removal was achieved in 72 patients, subto-tal removal in 15 patients, and partial removal in 1patient.Twenty patientsweretreatedwithpostoperativeradiation. Fifty-two patients had stable or improvedpostoperative neurological function, while 36 experi-enced neurological deterioration. A permanent decreasein McCormick classification grade was seen in 17 pa-tients. The progression-free survival rate was 87% forall patients at 5 years and 80% at 10 years. Duringfollow-up, local recurrence/progression was seen in13 patients. Diffuse meningeal spread developed in 2anaplastic ependymoma patients. Postoperative radio-therapy after incomplete resection did not significantlycorrelate with longer times to recurrence. Multivariateanalysis revealed histology and surgical extent of resec-tion as independent predictors of longer progression-free survival.Conclusions. Gross total removal alone is a good treat-ment strategy for spinal ependymomas. Early diagnosisand surgery, before severe paralysis, are important toobtain good functional outcomes. Subtotal resection withradiation therapy for intramedullary lesions appears tooffernoadvantagesovergrosstotalremoval.Keywords: myxopapillary ependymoma, radiation, spinalependymoma, survival.

For the past decade, a screw–rod construct has been used commonly to stabilize the atlantoaxial joint, but the insertion of the screw through the C1 lateral mass (LM) can cause several complications. We evaluated whether using a higher screw entry point for C1 lateral mass (LM) fixation than in the standard procedure could prevent screw-induced occipital neuralgia. We enrolled 12 consecutive patients who underwent bilateral C1 LM fixation, with the modified screw insertion point at the junction of the C1 posterior arch and the midpoint of the posterior inferior portion of the C1 LM. We measured postoperative clinical and radiological parameters and recorded intraoperative complications, postoperative neurological deficits and the occurrence of occipital neuralgia. Postoperative plain radiographs were used to check for malpositioning of the screw or failure of the construct. Four patients underwent atlantoaxial stabilization for a transverse ligament injury or a C1 or C2 fracture, six patients for os odontoideum, and two patients for C2 metastasis. No patient experienced vertebral artery injury or cerebrospinal fluid leak, and all had minimal blood loss. No patient suffered significant occipital neuralgia, although one patient developed mild, transient unilateral neuralgia. There was also no radiographic evidence of construct failure. Twenty screws were positioned correctly through the intended entry points, but three screws were placed inferiorly (that is, below the arch), and one screw was inserted too medially. When performing C1–C2 fixation using the standard (Harms) construct, surgeons should be aware of the possible development of occipital neuralgia. A higher entry point may prevent this complication; therefore, we recommend that the screw should be inserted into the arch of C1 if it can be accommodated.

We analyzed the outcome of posterior fossa decompression accompanied by widening of the cisterna magna, without disturbing the arachnoid, in patients with Chiari I malformation (CMI) associated with syringomyelia. Twenty-five adult patients with CMI and syringomyelia, who underwent surgery between October 2000 and December 2008, were enrolled in this study. All patients underwent foramen magnum decompression with C1 decompression, with or without C2 decompression. Three surgeons performed a dura opening with duraplasty in 20 patients, and another surgeon excised the outer layer of the dura without duraplasty in five patients. Clinical and radiological assessments were performed preoperatively and during the follow-up period. After surgery, 20 (80%) patients achieved a significant improvement in their clinical symptoms. However, four patients (16%) achieved only a stable state, and one patient's symptoms worsened. Radiological analysis showed that 17 patients (68%) had a favorable result; that is, a total collapse, or a marked reduction, of the syrinx. Seven patients (28%) were stable in terms of syrinx size. However, the syrinx enlarged in one patient who had undergone excision of the outer dura. Twenty-four patients achieved a widened cisterna magna with ascent of the cerebellar tonsils into the posterior fossa and acquisition of a more rounded shape. Postoperative complications included a transient headache and vomiting in three patients and transient motor weakness in one patient. Two patients developed a superficial wound infection. This study shows that arachnoid-preserving posterior fossa decompression is a safe and effective treatment for patients with CMI with associated syringomyelia.

Purpose To assess the clinical outcomes of cyclosporine treatment for noninfectious uveitis. Methods A retrospective review of medical records was completed for 182 noninfectious uveitis patients who were treated with cyclosporine between January 2001 and August 2010. Data was obtained relevant to demographic characteristics, anatomic classification, and laterality of uveitis, associated systemic disorder, dosage of cyclosporine and prednisolone, usage of other immunosuppressive drugs, visual acuity (VA), control of uveitic activity, and adverse effects during the cyclosporine use. Results Uveitic activity was controlled to a level of minimal inflammation in 89.0% and completely in 78.6% of patients by the median duration of 49 and 98 days, respectively. Prednisolone-sparing (dose ≤10 mg) control of inflammation equal to or less than the minimal activity was achieved in 75.3% of patients. VA was aggravated more than 0.2 logarithm of the minimum angle of resolution in 17.3% of eyes in spite of cyclosporine treatment for the mean follow-up of 698.4 days. Dose reduction and cessation of cyclosporine was required only in 3.3% and 9.3%, respectively, due to the intolerable toxicity, although 44.0% of patients experienced mild to moderate adverse effects. Conclusions Cyclosporine combined with corticosteroids or other immunosuppressive drugs as needed is an effective treatment for noninfectious uveitis, thus minimizing the adverse effects of corticosteroids and other toxic drugs. However, careful monitoring for the toxicity of cyclosporine is needed, because a small group of patients cannot tolerate its toxicity.

Raf-1 kinase inhibitor protein (RKIP) has emerged as a significant metastatic suppressor in a variety of human malignancies. We have recently demonstrated that reduced expression of RKIP is significantly associated with invasion and metastasis in periampullary carcinomas, including pancreatic carcinoma, gallbladder carcinoma, and extrahepatic bile duct carcinoma. In this study, we evaluated RKIP expression in ampulla of Vater (AoV) carcinoma and investigated its prognostic significance. Immunostaining for RKIP was performed for 80 and 21 cases with primary and nodal metastatic AoV carcinoma, respectively. RKIP expression was reduced in 32.5% (26/80) and 66.7% (14/21) of primary and nodal metastatic AoV carcinoma cases, respectively. This distribution of RKIP expression was statistically significant (P < 0.001). The reduction in RKIP expression was significantly associated with the presence of nodal (P = 0.008) and distant (P = 0.002) metastases, a higher TNM stage group (P = 0.010), lymphatic invasion (P < 0.001), vascular invasion (P < 0.001), and a shorter disease-free survival (DFS; P = 0.028) and distant metastasis-free survival (DMFS; P = 0.005). In addition, reduced RKIP expression was an independent prognostic predictor for worse DFS and DMFS (P = 0.032 and P = 0.036, respectively). Our data suggest that a reduction in RKIP expression contributes to invasion and metastasis in AoV carcinoma and is a significant prognostic marker in patients with AoV carcinoma.

Patients with spinal cord injury (SCI) are at particular risk for deep vein thrombosis (DVT) during their hospital course. In most researches on the prevention of thromboembolic events after SCI, the cause of SCI was usually limited to traumatic origin, and pharmaco-prophylaxis was usually started immediately after SCI irrespective of the presence of DVT. For this reason, it is difficult to determine the exact incidence of DVT after SCI from all possible causes in the absence of anticoagulation treatment. We sought to determine the incidence of DVT and the effect of mechanical treatments without chemical prophylaxis.From November 2009 to October 2010, 37 consecutive patients were admitted to our institute for SCI regardless of causes. Patient data including age, sex, types of injury in motor completeness, causes of SCI, and results of color Doppler ultrasonography (DUS) were collected. Routine mechanical prophylaxis for DVT was performed in all patients; pharmacologic prophylaxis was not used to avoid the potential consequences that may have confounded their benefits. All patients were routinely checked for DVT of lower limbs. Examinations were usually performed within 1 week of injury and repeated fortnightly until any medications for DVT were started in cases of a positive DUS result.In total, 16 of the 37 (43%) patients with acute SCI routinely given mechanical prophylaxis without anticoagulation were found to have DVT in the lower extremities by color DUS. Ten patients showed new thrombosis by DUS within 7 days after injury, three patients after 2 weeks to 3 weeks, and three patients at more than 1 month after injury. The majority of DVT occurred in the distal leg vein (81.2%, soleal vein). The incidence of DVT in patients with traumatic SCI was not different from that of patients with nontraumatic SCI in this study (p0.05). Age, sex, type of motor impairment, and cause of SCI were not found to be significantly related to the occurrence of DVT.The incidence of DVT in patients with SCI routinely given mechanical prophylaxis without anticoagulation was higher when compared with those reported in the setting of routine pharmaco-prophylaxis. Anticoagulation should not be excluded from initial DVT prophylaxis measures in the SCI patients unless there is any ongoing bleeding or severe coagulopathy. Further studies will be necessary to get a more precise data and to understand the clinical relevance of these results.

The aim of this study is to reveal the association between lumbar spondylolysis and several radiologic parameters, which had been suggested to be significant. The authors examine interfacet distance (IFD), facet joint orientation (FJO), and lumbar segmental lordosis (LSL) all together on the basis of lumbar computed tomography (CT) scan of 35 patients with L5 spondylolysis and 36 unaffected control groups. Thirty-five Korean military recruits, aged 19-23 (mean 20.9 years), were diagnosed as L5 spondylolysis by lumber CT scans. As a control group, 36 male Korean military recruits, aged 18-25 (mean 21.3 years), were reconfirmed as not affected by lumbar spondylolysis by CT scan when they visited our hospital complaining of back pain. This study compares IFD, FJO, and LSL for each lumbar segment between the spondylolytic and unaffected groups. We also propose the use of normal mean data of IFD, FJO, and LSL of lumbar vertebrae from 36 Korean young military recruits because each measurement has power as an absolute value, like data from an osteologic collection in other studies. Comparison of IFD between spondylolytic and unaffected individuals reveals significant differences at the L3, L4, and L5 level (P = 0.0384, P = 0.0219, and P < 0.0001, respectively). In the group of spondylolysis, the increase of IFD from L4 to S1 was less pronounced (P < 0.0001) and the LSL at L5-S1 was more lordotic (P = 0.0203). Interfacet distance and lumbar lordosis were significantly different between patients with L5 spondylolysis and individuals without pars defect on L5. In the spondylolysis group, and the increase of IFD from L4 to S1 was less pronounced and the LSL at L5-S1 was more lordotic.

Beclin-1 has emerged as an autophagy gene in a variety of human carcinomas. The aim of this study was to evaluate beclin-1 expression and to determine its prognostic significance in patients with pancreatic ductal adenocarcinoma (PDA). We performed immunohistochemical staining for beclin-1 in 63 cases of PDA. We investigated whether beclin-1 expression correlated with clinicopathologic characteristics and patient outcomes. Beclin-1 expression was absent in normal pancreatic islet cells, acinar cells, and ductal epithelial cells. In contrast, in PDA, beclin-1 showed positive immunoreactivity in 14 of 63 (22.2%) PDA cases, while the remaining 49 (77.8%) PDA cases exhibited negative beclin-1 expression. We found significant associations between increased beclin-1 expression and the absence of lymphatic invasion (P = 0.032) and low rate of distant metastasis (P = 0.001). Univariate analysis of survival showed that the median distant metastasis-free survival of beclin-1-negative PDA patients (10 months) was significantly shorter than that of beclin-1-positive PDA patients (21 months; P = 0.031). Our results suggest that increased beclin-1 expression plays a role in the inhibition of PDA progression.

Purpose To evaluate the reproducibility of retinal nerve fiber layer (RNFL) thickness measurements in normal and glaucoma patients using the spectral optical coherence tomography (OCT)/scanning laser ophthalmosope (SLO). Methods One experienced operator measured peripapillary RNFL thickness 3 times in succession in 98 normal participants and 79 glaucoma patients by using the test-retest function of the spectral OCT/SLO. The intraclass correlation coefficient (ICC), coefficient of variation, and test-retest variability (TRV) were analyzed for the mean RNFL thickness, and the RNFL thickness in each quadrant and at each clock-hour, in randomly selected eyes. The correlation coefficient was calculated between the TRV and the mean RNFL thickness, and between the TRV and the mean deviation of the Humphrey visual field. Results The ICC for mean RNFL thickness was 0.988 in the normal group and 0.993 in the glaucoma group. The ICC for RNFL thickness in all quadrants and clock-hours in both normal and glaucoma patients ranged from 0.951 to 0.992. The coefficient of variation was between 1.9% and 5.0% in the normal group and between 2.0% and 5.3% in the glaucoma group. The TRV was between 4.3 and 11.5 μm in the normal group and between 3.8 and 10.0 μm in the glaucoma group. The TRV showed no correlation with the mean RNFL thickness or the mean deviation (Pearson r>0.15, P>0.2). Conclusions Spectral OCT/SLO equipped with a test-retest function showed excellent reproducibility with regard to RNFL thickness measurements. The severity of glaucoma did not affect the reproducibility. These findings suggest that spectral OCT/SLO fulfills one of the basic premises for the diagnosis and progression analysis of glaucoma.

PURPOSE The purpose of this study was to report the incidence and the underlying ocular pathology of a macular hole (MH) that develops in vitrectomized eyes and to evaluate its prognosis. METHODS A retrospective chart review was performed in patients who underwent vitrectomy between March 2004 and June 2009. Cases that developed an MH in vitrectomized eyes were identified, and the data from all ophthalmology examinations were collected. Patients with recurrent MHs after the initial MH surgery were excluded. RESULTS We identified 10 cases of secondary MH during a period of 64 months (incidence, 8 of 3,279 [0.24%]). Two cases of secondary MHs were not included in the calculations because the initial vitrectomies were performed before March 2004. The initial vitrectomy was performed on four eyes with vitreous hemorrhage caused by proliferative diabetic retinopathy, three eyes with retinal detachment from high myopia, one eye with combined retinal detachment with uveitis, one eye with rhegmatogenous retinal detachment, and one eye with an epiretinal membrane. The macular pathology identified before MH formation included cystoid macular edema in two eyes, epiretinal membrane in four eyes, and no specific lesion in another four eyes. The secondary MHs were managed by additional vitrectomy, peeling of the internal limiting membrane, and intravitreal gas tamponade. Nine of 10 eyes achieved hole closure after the secondary surgery, and 8 eyes recovered their previous visual acuity; the other 2 eyes had visual loss within 2 Snellen chart lines, and none of the 9 patients had a recurrence during a mean follow-up of 20.7 months (range, 4-31 months). CONCLUSION The development of secondary MHs after vitrectomy is rare. Pathogenic mechanisms other than idiopathic MH may be involved in these cases. The anatomical and functional outcome of the secondary MHs that developed after vitrectomy was good, although the final visual acuity was dependent on the underlying ocular pathology.

There has been no report about hereditary and clinical features of retinitis pigmentosa (RP) in Koreans. To evaluate these, data were collected from 365 RP patients including age, gender, visual acuity (VA), spherical equivalent (SE) of refractive errors, funduscopic findings, color vision test, visual field score (VFS) obtained from Goldmann perimetry, and the inheritance patterns from pedigrees. Simplex RP was the most common inheritance pattern (61.9%); followed by autosomal recessive RP (17.3%), autosomal dominant RP (12.1%) and X-linked recessive RP (8.8%). Myopia was the most common refractive errors (77.5%) including 16.1% of high myopia. The most common cataract type was posterior subcapsular cataract (25.8%). Observed retinal findings included changes of retinal pigment epithelium (88.8%), bony spicule-like pigmentation (79.7%), attenuation of retinal vessel (76.2%), waxy disc pallor (12.6%), golden ring around optic disc (2.2%), epiretinal membrane (0.8%) and cystoid macular edema (0.5%). Corrected VA and refractive errors did not show any significant difference between the inheritance patterns. VFS was significantly worse in autosomal recessive RP than in autosomal dominant RP. Color vision defect was noted in 66.1% on Hardy-Rand-Rittlers color vision test. In conclusion, Korean RP patients have the indigenous hereditary and clinical features as well as the ordinary ones.

The aim of this study was to examine the long-term outcomes of treating irreducible craniovertebral junction bony compression via the transoral approach, with a minimum of 4 years of follow-up. Between 1996 and 2005, the transoral transpharyngeal approach was used for 10 patients who underwent anterior decompression and posterior fusion and two who underwent only anterior decompression. All patients were monitored intraoperatively using combined somatosensory/motor evoked potentials. All patients reported substantial or complete resolution of pain. Six out of the eight patients with preoperative myelopathy experienced an improvement of one Ranawat classification level. Solid fusion was achieved in all patients, and no patient had iatrogenic neurological deficits or cerebrospinal fluid leaks. Two patients experienced wound dehiscence requiring resuturing, one experienced velopalatine incompetence, and one experienced wound infection. There was no re-growth of the bony lesion during follow up. Transoral repair provided generally acceptable long-term results for irreducible craniovertebral junction bony compression. Intraoperative spinal cord monitoring may be useful for preventing neurological complications.

OBJECTIVE: This study investigated olfactory dysfunction after using a contralateral or ipsilateral pterional approach for anterior circulation aneurysms and related risk factors. METHODS: This study included 189 patients who experienced an aneurysmal subarachnoid hemorrhage and in whom a pterional approach was used, including a contralateral pterional approach (12 patients), a pterional approach for an anterior communicating artery (AComA) aneurysm (70 patients), and an ipsilateral pterional approach for aneurysms of the anterior circulation, excluding the AComA (107 patients). In addi-tion to questionnaires on olfactory function, Sniffin' Sticks tests were performed 12 to 38 months after the operation. RESULTS: The incidence of olfactory dysfunction was high: 58% (7 of 12) with a contralateral pterional approach, 14% (10 of 70) with a pterional approach for an AComA aneurysm, and 4% (4 of 107) with an ipsilateral pterional approach for aneurysms of the anterior circulation, except for the AComA. In addition, patients 55 years and older had a higher incidence of olfactory dysfunction. Among the 12 patients in whom the contralateral pterional approach was used, 5 (42%) were anosmic and 2 (17%) were hyposmic. The incidence of olfactory dysfunction was also significantly higher at ages 55 years and older. The size and location of the contralateral aneurysm, if small (

Study Design. A case report. Objective. The authors report a unique experience with a 40-year-old male beginning golfer who presented with multiple isolated spinous process fractures of the upper thoracic spine. Summary of Background Data. Stress fractures are caused by repetitive loading and overuse, and they account for 10% of all sports-related injuries. Fractures of isolated spinous processes of the cervical and thoracic vertebrae are referred to as Clay-Shoveler’s fractures, and there is little clinical information on these injuries. Methods. A 40-year-old man was admitted to our clinic with a 2-week history of posterior neck pain that radiated bilaterally into the shoulder area. Radiograph findings were normal. However, with a suspicion of fracture due to severe tenderness in the upper thoracic area, we performed three-dimensional cervicothoracic spine computed tomography and magnetic resonance imaging, which revealed multiple spinous process fractures at upper thoracic vertebrae. Results. Conservative treatment was administered, and immobilization was maintained for more than 4 weeks. He has been symptom-free for more than 6 months. Conclusion. Although stress fractures of the spinous process are very rare and can be overlooked in clinical settings, they should be considered in the differential diagnosis of severe dorsal neck pain in golfers, especially beginners.

The aim of this study was to compare the effectiveness of gamma knife radiosurgery (GKS) for the treatment of multiple brain metastases from lung cancer with that of whole brain radiation therapy (WBRT). Patients with multiple (2-20) brain metastases were divided into two groups for initial brain tumor management: a GKS group (14 patients) and a WBRT group (19 patients). The patients were stratified by gender, age, initial Karnofsky performance status score, control of the primary site, known extracranial metastases, number of brain metastases, diameter of the maximal lesion, chemotherapy, and recursive partitioning analysis (RPA) Class. The 6-month and 1-year overall survival rates were 64.3% and 47.7%, respectively, in the GKS group, and 42.1% and 10.5%, respectively, in the WBRT group. The median survival time was 32 weeks in the GKS group and 24 weeks in the WBRT group. The overall survival time in the GKS group was significantly longer than in the WBRT group (p = 0.04). The univariate analysis suggests that survival was increased in both patients with a controlled primary tumor site and in the GKS group (p = 0.03, 0.04). The use of GKS in patients with multiple brain metastases significantly improved patient survival compared to the employment of WBRT. When we assessed the subgroups, systemic disease control and GKS were significant variables by univariate analysis.

Objective: This study examined the clinical and radiologic results of cervical spine injuries associated with a unilateral lateral mass-facet fracture (ULMFF) in an attempt to clarify the fracture pattern and treatment strategies using single-level anterior fusion. Methods: From July 2003 to June 2006, adult patients, who had sustained ULMFFs of the middle cervical spine, were reviewed retrospectively. The fractures were classified into six subtypes using roentgenogram and computed tomography imaging with three-dimensional analysis. Initially, 15 patients without severe translation and kyphosis were treated with external immobilization and 24 patients were treated surgically with anterior fusion. The fusion state and spinal alignment were evaluated at the follow-up visits. Results: Thirty-nine patients had 27 lateral mass fractures and 14 facet joint fractures. The lateral mass fractures were divided into the following four subtypes: unilateral spondylolithesis in 16, separation fracture in 5, comminution type in 4, and split type in 2. Facet fractures with/without facet dislocation were observed in seven patients. Twelve patients who received conservative management required delayed fusion due to persistent pain and late instability. Overall, 36 patients, with the exception of three cases with a successful result by external immobilization, underwent surgery using single-level anterior fixation with anterior plating. A poor radiologic outcome was observed in eight patients after the procedure. Five cases showed incomplete reduction or a failure of the reduction. Three cases had adjacent instability and malalignment despite the early fusion observed due to short-segment fusion in the separation type. Conclusion: This retrospective review of ULMFF showed that nonsurgical treatment is usually unsuccessful, and early single-level anterior arthrodesis has a favorable outcome. However, exclusive two-level stabilization or pedicle screw fixation needs to be considered in the separation type.

Background Surgical exposure of the upper cervical spine is challenging, and optima approaches are subjects of debate. The high anterior cervical approach to the upper cervical spine is a favorable method that provides direct and wide exposure for fusion and anterior decompression of the upper cervical spine. The authors present their experiences with 15 patients in whom fusion and instrumentation on the upper cervical spine were performed via the prevascular extraoral retropharyngeal approach. Methods A series of 15 patients who were surgically treated using the high anterior cervical retropharyngeal approach was reviewed. These cases involved a C2 hangman's fracture with significant angulation and translation (11 patients), C2 EDH (1 patient), C2 chordoma (1 patient), C3-4 metastasis (1 patient), and C2-3-4 OPLL (1 patient). Results Twelve patients underwent C2-3 fusion followed by instrumentation. C2-5 fusion with instrumentation was performed in 2 patients. One patient experienced occipitocervical fusion after anterior removal of a C2 chordoma. A solid fusion was achieved in 13 patients. However, 1 patient needed additional posterior fusion because of fusion failure, and the other died due to ischemic heart disease. There was 1 patient who developed permanent dysphagia related to the hypoglossal nerve and 2 who had transient dysphagia. No complications occurred related to the marginal branch of the facial nerve or submandibular gland. Conclusions The high anterior cervical approach is a useful surgical technique for an upper cervical lesion without severe morbidity, which allows direct anterior access to C2 and C3 while allowing extension to the lower cervical spine.

Hearing loss in patients who have undergone shunt placement for a hydrocephalus is perhaps an underestimated complication rather than a rare event. There appears to be a correlation between the occurrence of hearing loss and patient characteristics consistent with excessive drainage of cerebrospinal fluid (CSF) and patent cochlear aqueduct (CA). We present the case of a 77-year-old man with unilateral dominant sensorineural hearing loss after a shunt placement for normal pressure hydrocephalus (NPH) combined with a patent cochlear aqueduct. Based on our experience and a review of the literature, we suggest an early restoration of the reduced CSF pressure using a programmable valve as a treatment strategy, which might prevent the persistent hearing loss.

Objective The Disease Activity Score based on 28 joints (DAS28) has been widely used in clinical practice and research studies of rheumatoid arthritis (RA). The objective of this study was to evaluate the discordance in the DAS28 based on the erythrocyte sedimentation rate (ESR) versus C-reactive protein (CRP) levels in Korean patients with RA. Methods From August to December 2011, 540 patients with RA who visited two rheumatology clinics affiliated with Hallym University (Korea) and had at least one DAS28 evaluation were examined. Results The mean age of the included patients was 53 years, and 82% were female. The mean duration of disease was 32.9 ± 41.2 months. The mean DAS28-ESR was higher than the DAS28-CRP (3.65 vs. 3.44; P

The aim of this study was to determine the predictability of vertebral compression fracture (VCF) development applying the spinal instability neoplastic score (SINS) prior to delivery of stereotactic spinal radiosurgery (SSRS) for spinal metastases. From two prospective cohorts of SSRS for spinal metastases, we selected patients with a low degree of cord compression or cauda equine from C3 to S1 and analyzed 79 patients enrolled according to binary SINS criteria. The primary endpoint was the development of a de novo VCF or progression of an existing fracture after SSRS. We identified 32 fractures (40.5%): 19 de novo and 13 progressive. The mean time to fracture after SSRT was 3.3 months (range, 0.4-34.1 months). In 41 patients with low SINS (0-6), 7 patients (17.1%) developed a fracture after SSRS. In 38 patients with high SINS (7-12), 25 (65.8%) developed a fracture. Among the 32 fractures, 15 were symptomatic. Patients with high SINS were more likely to experience symptomatic fractures (31.6%) than were patients with lower SINS (7.4%). On univariate and multivariate analysis, 24-month fracture-free rates were 78.7 and 33.7% in low and high SINS group, respectively and high SINS was found to be a significant risk factor for VCFs and symptomatic fractures (respectively, HR 5.6, p = 0.04; HR 5.3, p = 0.01). SINS is a useful tool for predicting the development of VCF after SSRS for spinal metastases. Prophylactic cement augmentation should not be considered for patients with lower SINS, since the risk of fracture is low.

OBJECT High-grade malignant spinal cord compression is commonly managed with a combination of surgery aimed at removing the epidural tumor, followed by spinal stereotactic radiosurgery (SSRS) aimed at local tumor control. The authors here introduce the use of spinal laser interstitial thermotherapy (SLITT) as an alternative to surgery prior to SSRS. METHODS Patients with a high degree of epidural malignant compression due to radioresistant tumors were selected for study. Visual analog scale (VAS) scores for pain and quality of life were obtained before and within 30 and 60 days after treatment. A laser probe was percutaneously placed in the epidural space. Real-time thermal MRI was used to monitor tissue damage in the region of interest. All patients received postoperative SSRS. The maximum thickness of the epidural tumor was measured, and the degree of epidural spinal cord compression (ESCC) was scored in pre- and postprocedure MRI. RESULTS In the 11 patients eligible for study, the mean VAS score for pain decreased from 6.18 in the preoperative period to 4.27 within 30 days and 2.8 within 60 days after the procedure. A similar VAS interrogating the percentage of quality of life demonstrated improvement from 60% preoperatively to 70% within both 30 and 60 days after treatment. Imaging follow-up 2 months after the procedure demonstrated a significant reduction in the mean thickness of the epidural tumor from 8.82 mm (95% CI 7.38–10.25) before treatment to 6.36 mm (95% CI 4.65–8.07) after SLITT and SSRS (p = 0.0001). The median preoperative ESCC Grade 2 was scored as 4, which was significantly higher than the score of 2 for Grade 1b (p = 0.04) on imaging follow-up 2 months after the procedure. CONCLUTIONS The authors present the first report on an innovative minimally invasive alternative to surgery in the management of spinal metastasis. In their early experience, SLITT has provided local control with low morbidity and improvement in both pain and the quality of life of patients.

Background Anterior screw fixation provides the best anatomical and functional results for odontoid process fracture (type II and “shallow” type III) with intact transverse ligament. The purpose of this study is to evaluate the clinical results of the 4.5-mm-diameter cannulated Herbert screw in the anterior odontoid fixation. Methods From May 2003 to November 2005, 20 consecutive cases of types II and III odontoid process fractures were treated with anterior screw fixation using a 4.5-mm Herbert screw. The Herbert screw has double threads, with different pitches on the distal and proximal ends. It has no head, so it can be inserted through articular cartilage and buried below bone surface. Results There were 16 male and 4 female patients whose ages ranged from 15 to 76 years (mean, 43.7 years). The fracture type was type II-A in 4 patients, II-N in 9 patients, II-P in 5 patients, and III in 2 patients. The range of follow-up was 3 to 36 months (mean, 18.6 months). There were an overall bone fusion rate in 17 cases (85%), fibrous union in 1 (5%), and nonunion in 2 (10%). Overall, complication unrelated to hardware occurred in the one (postoperative dysphagia) without complication-related hardware failure. Conclusions The Herbert screw is very useful in anterior fixation for types II and III odontoid process fractures. This series showed successful clinical results comparable with that of the 3.5-mm cannulated cancellous screw and distinct advantages over conventional screws in the aspect of biomechanical properties and less invasiveness.

Delayed post-hypoxic leucoencephalopathy is a demyelinating syndrome characterized by acute onset of neuropsychiatric symptoms including parkinsonism or akinetic mutism that occurs days to weeks after recovery from cerebral hypo-oxygenation. We encountered a patient who presented with an akinetic mute state late after cervical cord injury without a definite hypoxic event.

A 65-year-old male was admitted for progressive lower back pain. The preoperative revealed an osteolytic expansile mass with a sclerotic margin involving the right lamina and pedicle of L2. The histopathology revealed an ancient schwannoma. We report a rare case of an intraosseous ancient schwannoma involving lumbar vertebra along with its imaging findings and surgical aspects.

Background The objective of this study was to compare clinical and radiological outcomes of total hip arthroplasty (THA) between ankylosing spondylitis (AS) of the hip joint and avascular necrosis (AVN) of the femoral head. Methods Thirty patients (30 hips) underwent cementless THA for AS between 2003 and 2012. They were compared to 30 patients (30 hips) who underwent the same procedure for AVN of the femoral head. Each group was matched for age and gender, and both groups had similar preoperative demographic characteristics. All cases were followed for minimum 4 postoperative years. Clinical evaluation was based on operation time, intraoperative blood loss, quantity of postoperative drainage, Harris Hip Score (HHS), and range of motion (ROM). Radiological results were evaluated by acetabular cup anteversion and inclination, femoral stem orientation, pre- and postoperative leg length discrepancy, and postoperative complications. Results The operation time was significantly longer in the AS group (120.2 ± 26.2 min) than in the AVN group (79.5 ± 11.1 min). The volume of postoperative drainage was significantly greater in the AS group (764.5 ± 355.4 mL vs. 510.5 ± 195.6 mL). Preoperative HHS was lower in the AS group (55.6 ± 13.8 vs. 59.2 ± 2.8). Similarly, postoperative HHS was significantly lower in the AS group (92.8 ± 2.7 vs. 97.4 ± 2.6). The arc of ROM was improved from 146.5° ± 13.2° preoperatively to 254.7° ± 17.2° postoperatively in the AS group and from 182.6° ± 15.5° to 260.4° ± 13.7° in the AVN group. Implant position and postoperative leg length discrepancy were not different between the groups. However, three cases of heterotopic ossification was observed in the AS group, whereas only 1 case was found in the AVN group. One deep infection and one aseptic stem loosening were found in the AS group, whereas none was observed in the AVN group. Conclusions Cementless THA showed satisfactory clinical and radiological results in both groups, despite the longer operation time, larger blood loss volume, and lower HHS score of the AS group. Our findings suggest that cementless THA is an effective and reliable treatment for both AS and AVN.