Publications by authors named "Jin Hoon Park"

100 Publications

Optimal Ratio of Wnt3a Expression in Human Mesenchymal Stem Cells Promotes Axonal Regeneration in Spinal Cord Injured Rat Model.

J Korean Neurosurg Soc 2021 May 28. Epub 2021 May 28.

Department of Neurological Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea.

Objective: Through our previous clinical trials, the demonstrated therapeutic effects of MSC in chronic spinal cord injury (SCI) were found to be not sufficient. Therefore, the need to develop stem cell agent with enhanced efficacy is increased. We transplanted enhanced Wnt3asecreting human mesenchymal stem cells (hMSC) into injured spines at 6 weeks after SCI to improve axonal regeneration in a rat model of chronic SCI. We hypothesized that enhanced Wnt3a protein expression could augment neuro-regeneration after SCI.

Methods: Thirty-six Sprague-Dawley rats were injured using an Infinite Horizon (IH) impactor at the T9-10 vertebrae and separated into five groups : 1) phosphate-buffered saline injection (injury only group, n=7); 2) hMSC transplantation (MSC, n=7); 3) hMSC transfected with pLenti vector (without Wnt3a gene) transplantation (pLenti-MSC, n=7); 4) hMSC transfected with Wnt3a gene transplantation (Wnt3a-MSC, n=7); and 5) hMSC transfected with enhanced Wnt3a gene (1.7 fold Wnt3a mRNA expression) transplantation (1.7 Wnt3a-MSC, n=8). Six weeks after SCI, each 5×105 cells/15 µL at 2 points were injected using stereotactic and microsyringe pump. To evaluate functional recovery from SCI, rats underwent Basso-Beattie-Bresnahan (BBB) locomotor test on the first, second, and third days post-injury and then weekly for 14 weeks. Axonal regeneration was assessed using growth-associated protein 43 (GAP43), microtubule-associated protein 2 (MAP2), and neurofilament (NF) immunostaining.

Results: Fourteen weeks after injury (8 weeks after transplantation), BBB score of the 1.7 Wnt3a-MSC group (15.0±0.28) was significantly higher than that of the injury only (10.0±0.48), MSC (12.57±0.48), pLenti-MSC (12.42±0.48), and Wnt3a-MSC (13.71±0.61) groups (p<0.05). Immunostaining revealed increased expression of axonal regeneration markers GAP43, MAP2, and NF in the Wnt3a-MSC and 1.7 Wnt3a-MSC groups.

Conclusion: Our results showed that enhanced gene expression of Wnt3a in hMSC can potentiate axonal regeneration and improve functional recovery in a rat model of chronic SCI.
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http://dx.doi.org/10.3340/jkns.2021.0003DOI Listing
May 2021

Spinal Bony Involvement of IgG4-related Disease Treated by a Spondylectomy.

NMC Case Rep J 2021 Apr 2;8(1):27-31. Epub 2021 Apr 2.

Department of Neurosurgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea.

Immunoglobulin G4-related sclerosing disease (IgG4RD) is an emerging immune-mediated fibro-inflammatory disorder which can involve any organ. We describe the first IgG4-RD spondylitis treated with total en-bloc spondylectomy (TES). A 55-year-old man presented with back pain. Magnetic resonance imaging (MRI) of the thoracic spine revealed a pathologic compression fracture on T11 vertebral body and both pedicles suggestive of primary bone tumor or bone metastasis. We conducted TES of T11, because we could not exclude the possibility of primary bone tumor including giant cell tumor. Immunohistochemical examination of the pathology specimens from pleura around the pedicle demonstrated diffuse infiltration of IgG4-bearing plasma cells. Six weeks later from the surgery, a delayed serologic test was done and his serum IgG4 concentration was 45 mg/dL. The final diagnosis was probable IgG4RD on the basis of serological, imaging, histopathological findings. After 6 weeks of oral prednisolone treatment, patient's back pain improved dramatically. IgG4RD is very rare systemic disease and its paraspinal soft tissue like pleura involvement with vertebra body invasion was absent until now. Our experience indicated that surrounding soft tissue biopsy would be helpful when a percutaneous vertebra bone biopsy mismatched with the image studies, even though vertebra body was main pathological lesion considering the possibility of IgG4RD.
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http://dx.doi.org/10.2176/nmccrj.cr.2020-0067DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8116914PMC
April 2021

Risk Factors for High-Grade Meningioma in Brain and Spine: Systematic Review and Meta-analysis.

World Neurosurg 2021 May 8. Epub 2021 May 8.

Department of Neurological Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea. Electronic address:

Background: Histologic grade has important implications for the management in meningioma. It is important to understand the risk of high-grade meningioma (grades II and III). In this article, we systematically reviewed the histologic grade of meningioma depending on the location and sex and its relationship with recurrence.

Methods: The PubMed and Embase databases were systematically searched until February 4, 2020. We included studies that were not restricted to specific anatomic locations, histologic grade, or the sizes of the tumors. The proportion of high-grade meningiomas depending on the location and sex and the odds ratio (OR) of recurrence were pooled using a random-effects model.

Results: Outcome data were analyzed for 20,336 tumors from 34 studies. We found different proportions of high-grade meningiomas in the brain (12.8%) (95% confidence interval [CI], 10.5%-15.1%) versus the spine (2.4%) (95% CI, 1.0%-3.7%) (P < 0.01). Skull base meningiomas (8.7%) (95% CI, 5.8%-11.6%) had a lower proportion of high-grade meningiomas than non-skull base meningiomas (16.5%) (95% CI, 11.9%-21.1%) (P < 0.01). In addition, high-grade meningiomas were more likely to occur in male patients (18.0%) (95% CI, 10.1%-25.9%) than female patients (7.0%) (95% CI, 3.5%-10.6%) (P = 0.01). Higher rates of recurrence (OR = 13.83) were confirmed for high-grade meningiomas than grade I meningiomas (95% CI, 4.10-46.65) (P < 0.01).

Conclusions: This meta-analysis found that intracranial, nonskull base, and male sex are risk factors for high-grade meningioma, and high-grade meningioma had a much higher recurrence rate as compared with grade I meningioma.
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http://dx.doi.org/10.1016/j.wneu.2021.04.138DOI Listing
May 2021

Effect of CCL11 on In Vitro Myogenesis and Its Clinical Relevance for Sarcopenia in Older Adults.

Endocrinol Metab (Seoul) 2021 Apr 14;36(2):455-465. Epub 2021 Apr 14.

Division of Endocrinology and Metabolism, Department of Internal Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea.

Background: The C-C motif chemokine ligand 11 (CCL11) has been receiving attention as a potential pro-aging factor. Accordingly, it may be involved in muscle metabolism and sarcopenia, a key component of aging phenotypes. To clarify this potential, we investigated the effects of CCL11 on in vitro muscle biology and its clinical relevance for sarcopenia parameters in older adults.

Methods: Myogenesis was induced in mouse C2C12 myoblasts with 2% horse serum. Human blood samples were collected from 79 participants who underwent a functional assessment. Thereafter, CCL11 level was measured using a quantikine ELISA kit. Sarcopenia was defined using the Asian-specific guideline.

Results: Recombinant CCL11 treatment significantly stimulated myogenesis in a dose-dependent manner, and consistently increased the expression of myogenic differentiation markers. Among the C-C chemokine receptors (CCRs), CCR5, not CCR2 and CCR3, was predominantly expressed in muscle cells. Further, the CCR5 inhibitor blocked recombinant CCL11-stimulated myogenesis. In a clinical study, serum CCL11 level was not significantly different according to the status of sarcopenia, low muscle mass, weak muscle strength, and poor physical performance, and was not associated with skeletal muscle index, grip strength, short physical performance battery score, gait speed, and time to complete 5 chair stands, after adjusting for sex, age, and body mass index.

Conclusion: Contrary to expectations, CCL11 exerted beneficial effects on muscle metabolism at least in vitro system. However, its impact on human muscle health was not evident, suggesting that circulating CCL11 may not be a useful biomarker for sarcopenia risk assessment in older adults.
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http://dx.doi.org/10.3803/EnM.2020.942DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8090464PMC
April 2021

Serum GDF15 Level Is Independent of Sarcopenia in Older Asian Adults.

Gerontology 2021 Mar 9:1-7. Epub 2021 Mar 9.

Division of Endocrinology and Metabolism, Department of Internal Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea.

Background: Growth differentiation factor 15 (GDF15), induced by tissue inflammation and mitochondrial stress, has received significant attention as a biomarker of mitochondrial dysfunction and has been implicated in various age-related diseases. However, the association between circulating GDF15 and sarcopenia-associated outcomes in older adults remains to be established.

Aim: To validate previous experimental data and to investigate the possible role of GDF15 in aging and muscle physiology in humans, this study examined serum GDF15 levels in relation to sarcopenia-related parameters in a cohort of older Asian adults.

Methods: Muscle mass and muscle function-related parameters, such as grip strength, gait speed, chair stands, and short physical performance battery score were evaluated by experienced nurses in 125 geriatric participants with or without sarcopenia. Sarcopenia was diagnosed using the Asian-specific cutoff points. Serum GDF15 levels were measured using an enzyme immunoassay kit.

Results: Serum GDF15 levels were not significantly different according to sarcopenia status, muscle mass, muscle strength, and physical performance and were not associated with the skeletal muscle index, grip strength, gait speed, time to complete 5 chair stands, and short physical performance battery score, regardless of adjustments for sex, age, and BMI.

Conclusions: These findings indicate that the definite role of GDF15 on muscle metabolism observed in animal models might not be evident in humans and that elevated GDF15 levels might not predict the risk for sarcopenia, at least in older Asian adults.
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http://dx.doi.org/10.1159/000513600DOI Listing
March 2021

Compensatory postural responses to backward loss of balance in patients with cerebellar disease.

Gait Posture 2021 May 25;86:7-12. Epub 2021 Feb 25.

Department of Physical Education, Korea University, Seoul, 136-701, South Korea. Electronic address:

Background: Impaired control of balance and coordinated reactions are a primary deficit of cerebellar dysfunction. As compared to other neurological patients with balance impairments, there has been little research assessing the characteristics of compensatory responses associated with falls in patients with cerebellar disease (CD).

Research Question: The aim of this study was to examine the effects of cerebellar disease on compensatory balance control in response to postural perturbation. Do CD patients increase the number of steps when responding to instability because of inappropriate initial step reactions or poor control of trunk motion or both?

Methods: In this explorative study, 10 patients suffering from degenerative cerebellar ataxia and 10 age-matched healthy controls were examined. The balance recovery reactions were assessed using a lean-and-release postural perturbation method. Spatiotemporal characteristics of stepping movement and COM variables associated with torso motion were analyzed using 3D motion capture system.

Results: CD patients took multiple steps whereas matched controls generally took single steps to recover balance following perturbation. The characteristics of the initial step at the time of the fall revealed that foot reaction time, foot response time, and step distance of the initial step were similar between CD patients and matched controls. However, CD patients exhibited a shorter foot-to-COM distance, higher COM velocity, and less trunk flexion with which to attenuate their body momentum after the landing of the first step than did matched controls.

Significance: Although initial step responses were probably adequate, poor control of torso motion appears to be a particular problem that causes multiple-step reactions in CD patients. This observation would help to guide the development of tailored fall intervention strategies in CD patients aimed at promoting their recovery capacity in response to a pronounced balance challenge.
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http://dx.doi.org/10.1016/j.gaitpost.2021.02.027DOI Listing
May 2021

A New Indicator Predicting the Degree of Cord Shift After Posterior Decompression of Cervical Ossification of the Posterior Longitudinal Ligament Extended to the C2 Level and Its Clinical Usefulness.

Turk Neurosurg 2020 Oct 16. Epub 2020 Oct 16.

Inje University Ilsan Paik Hospital, Neuroscience & Radiosurgery Hybrid Research Center, College of Medicine, Department of Neurosurgery, 170, Juwharo, Ilsan Seogu, Goyang, Gyeonggi 10380, Republic of Korea.

Aim: We sought to evaluate the usefulness of the rostral line (R-line) as a new index for determining the degree of C2 lamina decompression in the context of ossification of the posterior longitudinal ligament (OPLL) extending to the C2 level.

Material And Methods: The R-line was devised based on the mechanism by which the cord is shifted backward following cervical posterior decompression. According to their R-line status, 36 patients with cervical OPLL extending to the C2 level were divided into two groups of R-line (+)and R-line (-) cases, where the R-line touched the upper half of the posterior C2 lamina in the R-line (+) group and the inferior half of the posterior C2 lamina in the R-line (-) group, respectively.

Results: Eighteen patients were classified as R-line (+) and 18 patients were classified as R-line (-). Total laminectomy of the C2 lamina was more common in the R-line (+) group, while dome-shape C2 laminectomy was more common in the R-line (-) group. All patients requiring reoperation were included in the R-line (+) group. Only the operation type showed a statistically significant difference according to the need for reoperation in the R-line (+) group; specifically, all patients who underwent reoperation in the R-line (+) group had dome-shape C2 laminectomy. It was determined that the risk factor for reoperation in the R-line (+) group was a history of dome-shape C2 laminectomy.

Conclusion: If the R-line touches the upper half of the posterior C2 lamina, total decompression of the C2 lamina should be performed.
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http://dx.doi.org/10.5137/1019-5149.JTN.31668-20.1DOI Listing
October 2020

Association between serum FGF21 level and sarcopenia in older adults.

Bone 2021 Apr 8;145:115877. Epub 2021 Feb 8.

Division of Endocrinology and Metabolism, Department of Internal Medicine, Asan Medical Center, University of Ulsan College of Medicine, 88, Olympic-ro 43-gil, Songpa-gu, Seoul, South Korea. Electronic address:

Background: With emerging basic research evidence suggesting that fibroblast growth factor (FGF) 21 is a catabolic molecule on muscle metabolism, we aimed to analyze the serum FGF21 level in relation to sarcopenia in older adults.

Methods: Blood samples were collected from 125 participants who underwent evaluation for muscle mass and function in an outpatient geriatric clinic of a teaching hospital. Sarcopenia and related components were determined using cutoff values for the Asian population. The serum FGF21 level was measured using enzyme linked immunosorbent assay.

Results: After controlling for age, sex, and body mass index (BMI), participants with sarcopenia, low muscle mass, and weak muscle strength had 2.3-, 2.0-, and 1.5-fold higher serum FGF21 levels than controls, respectively (p = .033 to <0.001). The serum FGF21 level was positively correlated with sarcopenia phenotype score and inversely correlated with skeletal muscle mass index and grip strength by both crude and multivariate analysis adjusting potential confounders (p = .017 to <0.001). Consistently, higher serum FGF21 level was significantly associated with increased odds for sarcopenia, low muscle mass, and low muscle strength after adjusting for age, sex, and BMI (odds ratio, 1.53-2.61; p = .048 to <0.001).

Conclusions: Higher circulating FGF21 was associated with the likelihood of sarcopenia, lower muscle mass, and worse grip strength in older adults, supporting a potential catabolic role of FGF21 on human muscle health.
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http://dx.doi.org/10.1016/j.bone.2021.115877DOI Listing
April 2021

C1-2 Pedicle Screw Fixation for Ponticulus Posticus and Duplication of Vertebral Artery: 2-Dimensional Operative Video.

Oper Neurosurg (Hagerstown) 2021 03;20(4):E298-E299

Department of Neurosurgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, South Korea.

We previously introduced C1 pedicle screw placement to treat C1-2 pathology in a patient with normal vertebral artery anatomy.1 However, we should prepare to meet various anatomic variations. Ponticulus posticus is a bony prominence arising from the posterior arch or the superior articulating process of the atlas that completely or partially encircles the vertebral artery.2 We herein report a 79-yr-old female who presented with myelopathy and was diagnosed with compressive myelopathy at the C1 level in magnetic resonance imaging. A computed tomography showed ponticulus posticus (complete type to the right side) with duplication of vertebral artery.  She underwent surgical treatment of C1-2 pedicle screw placement and reduction of C1 vertebra under a microscopic view. After C1 laminectomy, both-side vertebral arteries were dissected with a microscissor. The mobilization of upper divisions of vertebral artery was identified to secure the entry point and pedicle to insert a C1 pedicle screw. After complete protection of the upper and lower divisions of vertebral artery and identification of pedicle, a C1 pedicle screw was inserted by a freehand technique. We inserted autologous bone chips in the distracted C1-2 facet joint for facet joint fusion, and the C1 vertebra was pulled out by a rod reducer.  After surgery, the patient's symptoms disappeared, and no vertebral artery injury was identified in postoperative 3-dimensional computed tomography angiography.  Patient consent was obtained prior to performing the procedure.
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http://dx.doi.org/10.1093/ons/opaa397DOI Listing
March 2021

Cervical Alignment Following Posterior Cervical Fusion Surgery: Cervical Pedicle Screw Versus Lateral Mass Screw Fixation.

Spine (Phila Pa 1976) 2021 May;46(10):E576-E583

Department of Neurological Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea.

Study Design: Retrospective comparative study.

Objective: The aim of this study was to compare cervical sagittal alignment after posterior fusion surgery with lateral mass screw (LMS) and cervical pedicle screw (CPS) fixation.

Summary Of Background Data: LMS fixation in the subaxial cervical spine has become the preferred method of posterior cervical fusion. Although CPS has biomechanical benefits, it also has neurovascular risks. Few studies to date have compared sagittal alignment changes after posterior cervical fusion using CPS and LMS fixation.

Methods: From 2006 to 2017, 71 consecutive patients underwent posterior cervical fusion using CPS (n = 51) or LMS (n = 20) fixation. Patients who underwent fusion with both types of screws and those who planned to undergo additional anterior fusion surgery were excluded. The minimum follow-up period was 12 months. C2-C7 Cobb angle for cervical lordosis (CL), fusion segmental angle (SA), C2-C7 sagittal vertical axis (SVA), and T1 slope (T1S) were measured.

Results: Immediate postoperative SA and SVA differed significantly in patients who underwent CPS and LMS fixation. SA changes were more substantial after CPS fixation, with a significant difference maintained until final follow-up. Over time, CL, SVA, and T1S tended to return to their preoperative states regardless of screw type. Two patients who underwent LMS fixation, but none who underwent CPS fixation, required unplanned or additional anterior fusion surgery for revision.

Conclusion: The present study is the first radiologic comparison of LMS and CPS fixation after posterior-only fusion surgery. CPS resulted in more reliable and well-preserved SA correction, whereas CL and SVA did not differ between the two groups over time due to loss of correction.Level of Evidence: 4.
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http://dx.doi.org/10.1097/BRS.0000000000003845DOI Listing
May 2021

The association of circulating kynurenine, a tryptophan metabolite, with frailty in older adults.

Aging (Albany NY) 2020 11 13;12(21):22253-22265. Epub 2020 Nov 13.

Division of Endocrinology and Metabolism, Department of Internal Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, South Korea.

Despite the accumulating evidence from and animal experiments supporting the role of kynurenine (a tryptophan metabolite) in a number of degenerative age-related changes, the relationship between kynurenine and frailty in older adults is not well understood. We collected blood samples from 73 participants who underwent a comprehensive geriatric assessment, measuring kynurenine levels using liquid chromatography-tandem mass spectrometry. We assessed the phenotypic frailty and the deficit accumulation frailty index using widely validated approaches proposed by Fried et al. and Rockwood et al., respectively. After adjusting for sex, age, and body mass index, the frail participants presented 52.9% and 34.3% higher serum kynurenine levels than those with robustness and prefrailty, respectively ( = 0.005 and 0.014, respectively). Serum kynurenine levels were positively associated with the frailty index, time to complete 5 chair stands, and patient health questionnaire-2 score and inversely associated with grip strength and gait speed ( = 0.042 to <0.001). Furthermore, the odds ratio per increase in serum kynurenine level for phenotypic frailty was approximately 2.62 (95% confidence interval = 1.22-5.65, = 0.014). These data provide clinical evidence that circulating kynurenine might be a potential biomarker for assessing the risk of frailty in humans.
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http://dx.doi.org/10.18632/aging.104179DOI Listing
November 2020

Posterior Facetectomy with Fusion Using a Pedicle Screw for Parallel-shaped Cervical Foraminal Stenosis.

Korean J Neurotrauma 2020 Oct 31;16(2):216-225. Epub 2020 Aug 31.

Department of Neurological Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea.

Objective: To assess the efficacy and safety of posterior facetectomy with fusion using pedicle screw (PF using FPS) for severe cervical foraminal stenosis of parallel shape.

Methods: Patients (n=8) with 1- or 2-level parallel-shaped cervical foraminal stenosis who underwent posterior facetectomy with fusion using cervical pedicle screw between March 2012 and August 2016 were enrolled. Patients were followed up immediately postoperatively and at 1, 3, 6, and 12 months postoperatively. We assessed arm and neck pains and clinical outcomes using a numeric rating scale (NRS) and neck disability index (NDI). We determined cervical Cobb's and segmental angles by radiological evaluations. We identified screw breech as a neurovascular complication.

Results: Neck and arm pains were significantly reduced postoperatively (neck visual analog scale [VAS]: 4.9±3.7 [preoperative] to 0.4±1.1 [final follow-up]; arm VAS: 9.0±0.8 to 0.4±1.1). Cobb's angle for cervical sagittal alignment improved from 11.1±8.4 to 17.0±5.9. Segmental angle of index surgery was maintained (3.4±7.0-4.9±5.6). NDI was also remained from 36.1±26.3 to 13.8±8.4. There are no injuries to the vertebral arteries and neural tissues because of screw insertion.

Conclusion: PF using FPS is a practical treatment option for parallel-shaped cervical foraminal stenosis.
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http://dx.doi.org/10.13004/kjnt.2020.16.e26DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7607040PMC
October 2020

Freehand Placement of the C1 Pedicle Screw Using Direct Visualization of the Pedicle Anatomy and Serial Dilatation.

Korean J Neurotrauma 2020 Oct 21;16(2):207-215. Epub 2020 May 21.

Department of Neurological Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea.

Objective: We designed a method for inserting C1 pedicle screws using the direct visualization technique of the pedicle and serial dilatation technique to reduce complications and malposition of screw, and assessed the accuracy of this method.

Methods: Free-hand C1 pedicle screw insertion using the direct visualization technique of the pedicle and serial dilatation technique was performed on 5 consecutive patients with C1-2 instability at a single institute from March to December 2018. The method involved protecting the vertebral artery (VA) and C1 root using the Penfield No. 1, securing the entry point of the posterior arch screw and the pedicle was visible directly in Trendelenburg position. The hole at the entry point of the C1 posterior arch was serially dilated using a 2.5×3.0 mm drill bit, and the C1 pedicle screw was inserted with the free hand technique. We measured postoperative radiological parameters and recorded intraoperative complications, postoperative neurological deficits and the occurrence of occipital neuralgia. Postoperative computed tomography (CT) was performed to check screw malposition or construction failure.

Results: Of the 10 C1 pedicle screws on postoperative CT, 20% of screws (grade A) were in the ideal position while 80% of screws (grade B) occupied a safe position. Overall, 100% of screws were safe (grade A or B). There were no iatrogenic neurological deficits, VA injury.

Conclusion: Freehand placement of the C1 pedicle screw through the direct visualization technique of the pedicle and serial dilatation technique is safe and effective without intraoperative fluoroscopy guidance.
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http://dx.doi.org/10.13004/kjnt.2020.16.e15DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7607029PMC
October 2020

Lack of association between circulating apelin level and frailty-related functional parameters in older adults: a cross-sectional study.

BMC Geriatr 2020 10 21;20(1):420. Epub 2020 Oct 21.

Division of Endocrinology and Metabolism, Department of Internal Medicine, Asan Medical Center, University of Ulsan College of Medicine, 88 Olympic-ro 43-gil, Songpa-gu, Seoul, 05505, South Korea.

Background: Apelin, an active endogenous peptide, has been recently receiving great attention as a promising target for antiaging intervention, primarily based on results from genetically altered mice. To validate previous experimental data and investigate the possible role of apelin in humans, in this study, we examined serum apelin level in relation to frailty and its associated parameters in a cohort of ambulatory, community-dwelling older adults.

Methods: Blood samples were collected from 80 participants who underwent a comprehensive geriatric assessment, and apelin level was measured using an enzyme immunoassay kit. Phenotypic frailty and deficit-accumulation frailty index (FI) were assessed using widely validated approaches, proposed by Fried and Rockwood groups, respectively.

Results: After adjustment for sex, age, and body mass index, serum apelin level was found to be not significantly different according to phenotypic frailty status (P = 0.550) and not associated with FI, grip strength, gait speed, time to complete 5 chair stands, and muscle mass (P = 0.433 to 0.982). To determine whether the association between serum apelin level and frailty has a threshold effect, we divided the participants into quartiles according to serum apelin level. However, there were no differences in terms of frailty-related parameters and the risk for frailty among the quartile groups (P = 0.248 to 0.741).

Conclusions: The serum apelin level was not associated with both phenotypic frailty and functional parameters in older adults, despite its beneficial effects against age-related physiologic decline in animal models. Further large-scale longitudinal studies are necessary to understand the definite role of circulating apelin in frailty risk assessment.
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http://dx.doi.org/10.1186/s12877-020-01837-9DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7579806PMC
October 2020

Lower Serum n-3 Fatty Acid Level in Older Adults with Sarcopenia.

Nutrients 2020 Sep 27;12(10). Epub 2020 Sep 27.

Division of Endocrinology and Metabolism, Department of Internal Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul 05505, Korea.

The n-3 fatty acid (FA) has evoked considerable interest as a modifiable factor for maintenance of muscle health owing to its anti-inflammatory properties. To clarify this possibility, we investigated circulating n-3 FA level, a reliable biomarker of FA status in the body, in relation to sarcopenia in a cohort of Asian older adults. Blood samples were collected from 125 participants who underwent comprehensive assessment of muscle mass and function. Serum FA level was measured by gas chromatography/mass spectrometry. Sarcopenia was diagnosed using the cut-off points specified for the Asian population. After adjusting for sex, age, and body mass index, subjects with sarcopenia and those with low muscle strength had 36.5% and 32.4% lower serum n-3 levels ( = 0.040 and 0.030), respectively, than controls. The odds ratios per standard deviation increment in serum n-3 level for sarcopenia and low muscle strength were 0.29 and 0.40 ( = 0.015 and 0.028), respectively. A higher serum n-3 level was significantly associated with greater muscle strength ( = 0.038). These findings suggest a possible protective effect of n-3 FA on human muscle homeostasis. Further well-designed large-scale longitudinal studies are necessary to understand the definite role of circulating n-3 FA level in sarcopenia risk assessment.
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http://dx.doi.org/10.3390/nu12102959DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7600475PMC
September 2020

Comparison of Early Surgical Treatment With Conservative Treatment of Incomplete Cervical Spinal Cord Injury Without Major Fracture or Dislocation in Patients With Pre-existing Cervical Spinal Stenosis.

Clin Spine Surg 2021 Apr;34(3):E141-E146

Department of Neurosurgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea.

Study Design: This was a retrospective comparative study.

Objective: The objective of this study was to evaluate the clinical outcomes of early surgical treatment (<24 h) and conservative treatment of incomplete cervical spinal cord injury (CSCI) without major fracture or dislocation in patients with pre-existing cervical spinal canal stenosis (CSCS).

Summary Of Background Data: The relative benefits of surgery, especially early surgical treatment, and conservative treatment for CSCI without major fracture or dislocation in patients with pre-existing CSCS remain unclear. Animal models of CSCI have demonstrated that early surgical decompression immediately after the initial insult may prevent or reverse secondary injury. However, the clinical outcomes of early surgery for incomplete CSCI in patients with pre-existing CSCS are still unclear.

Materials And Methods: The medical records and radiographic data of 54 patients admitted to our facility between 2005 and 2015 with American Spinal Injury Association (ASIA) impairment scale grade B or C and pre-existing CSCS without major fracture or dislocation were retrospectively reviewed. Thirty-three patients (mean age, 57.4±14.0 y) underwent early surgical treatment within 24 hours after initial trauma (S group), and 21 patients (mean age, 56.9±13.6 y) underwent conservative treatment (C group) performed by 2 spinal surgeons in accordance with their policies. The primary outcome was the degree of improvement in ASIA grade after 2 years.

Results: During the 2-year follow-up period, higher percentages of patients in the S group than in the C group showed ≥1 grade (90.9% vs. 57.1%, P=0.0051) and 2 grade (30.3% vs. 9.5%) improvements in ASIA grade. Multivariate analysis showed that treatment type, specifically early surgical treatment, was the only factor significantly associated with ASIA grade improvement after 2 years (P=0.0044).

Conclusions: Early surgery yielded better neurological outcomes than conservative treatment in patients with incomplete CSCI without major fracture or dislocation and pre-existing CSCS.

Level Of Evidence: Level III.
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http://dx.doi.org/10.1097/BSD.0000000000001065DOI Listing
April 2021

The R-line: A New Imaging Index for Decision Making Regarding C2 Lamina Decompression in Cervical Ossification of the Posterior Longitudinal Ligament.

Korean J Neurotrauma 2020 Apr 13;16(1):60-66. Epub 2020 Apr 13.

Department of Neurosurgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea.

Objective: The optimal treatment modality for cervical ossification of the posterior longitudinal ligament (OPLL) including the C2 level remains controversial. Cervical laminoplasty is a widely accepted considering of advantages such as development of few postoperative complications, including kyphosis or neck pain. We encountered seven patients with postoperative disabilities resulting from incomplete decompression after undercutting of the C2 lamina. Based on this experience, we developed a new index to determine the degree of decompression in cervical OPLL-the rostral line (R-line).

Methods: Total of 79 consecutive patients who underwent posterior decompression of cervical OPLL were included in this study. Mean age at the time of operation, the C2-C7 cervical lordotic angle and OPLL thickness at the most stenotic level of the spinal canal, and preoperative/postoperative Japanese Orthopedic Association score was checked in these group. We compared the correspondence between the degree of C2 lamina decompression using the R-line and actual degree of decompression.

Results: In all patients, the R-line touched the upper half of the C2 lamina on preoperative magnetic resonance imaging (MRI). The C2-C3 local segment lordotic angle and maximal degree of spinal cord compression by OPLL were independently correlated to postoperative C2 cord shifting. This result indicates that the R-line is a valid indicator to determine the degree of C2 lamina decompression in OPLL extending to the C2 level.

Conclusion: The results showed that undercutting the C2 lamina can result in incomplete spinal cord decompression and poor clinical outcome if the R-line touches the upper half of the C2 lamina on preoperative MRI.
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http://dx.doi.org/10.13004/kjnt.2020.16.e7DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7192802PMC
April 2020

Subaxial Cervical Pedicle Screw in Traumatic Spinal Surgery.

Korean J Neurotrauma 2020 Apr 24;16(1):18-27. Epub 2020 Apr 24.

Department of Neurosurgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea.

In cases of unstable cervical traumatic lesions, the biomechanical superiority of the cervical pedicle screw (CPS) allows the lesion to be stabilized effectively. In this study, we review and summarize the indications, technical guidelines, and potential neurovascular complications and their prevention of the use of the CPS for trauma. For patients with fractured lamina or lateral mass, a CPS is reliable for stabilization. In addition, the CPS can penetrate through a linear cervical spinal pedicle fracture gap and could stabilize three-column injury. CPS reduce the range of surgical approach and preserve the motion segment using short-segment fixation. Fluoroscopy-guided CPS insertion is popular and cost-effective. Image-guided navigation systems improve accuracy. Three-dimensional template-guided CPS placement is simple to use. Most spine surgeons can perform laminoforaminotomy easily. Freehand technique that can be performed quickly without heavy equipment is suitable for emergency situation. Possible complications due to screw misplacement are vertebral artery injury owing to a laterally misplaced screw, dural sac or spinal cord injury from a medially misplaced screw, and nerve root injury caused by a superiorly or inferiorly misplaced screw. To prevent neurovascular complications, meticulous preoperative anatomical evaluation and following the five steps are most important.
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http://dx.doi.org/10.13004/kjnt.2020.16.e13DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7192805PMC
April 2020

Comparison of the Accuracy of C1 Pedicle Screw Fixation Using Fluoroscopy and Free-Hand Techniques in Patients With Posterior Arch Thickness of Less Than 4 mm.

Oper Neurosurg (Hagerstown) 2020 Sep;19(4):429-435

Department of Neurosurgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, South Korea.

Background: C1 pedicle screw insertion is not easy, and more fluoroscopy can be required for safe insertion. Fluoroscopy is time consuming and increases patient radiation exposure. There have been no studies comparing the accuracy of C1 pedicle screw insertion using the fluoroscopy and free-hand techniques.

Objective: To describe a free-hand C1 pedicle screw insertion method in patients with the posterior arch thickness of less than 4 mm in the thinnest part of the groove, and to compare the clinical and radiological outcomes of C1 pedicle screw insertion using fluoroscopy vs using the free-hand technique.

Methods: A total of 25 patients who had atlantoaxial instability with a C1 posterior arch <4 mm and were treated with C1 pedicle screw insertion were included. In 10 patients, fluoroscopy was used for C1 pedicle screw insertion, and 15 patients underwent the free-hand technique. We compared the radiologic and clinical outcomes between the 2 groups.

Results: In patients who underwent the free-hand technique, 96.5% of screws were rated as safe (grade A or B), and 80.0% of screws in the fluoroscopy group were rated as safe. Postoperative occipital neuralgia occurred in one patient in the fluoroscopy group and did not occur in the free-hand technique group. There was no significant difference in the improvement of Nurick grade between the 2 groups.

Conclusion: C1 pedicle screw insertion using the free-hand technique is feasible and safe in patients with a C1 posterior arch <4 mm.
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http://dx.doi.org/10.1093/ons/opaa067DOI Listing
September 2020

The Subaxial Cervical Pedicle Screw for Cervical Spine Diseases: The Review of Technical Developments and Complication Avoidance.

Neurol Med Chir (Tokyo) 2020 May 15;60(5):231-243. Epub 2020 Apr 15.

Department of Neurosurgery, Asan Medical Center, University of Ulsan College of Medicine.

This study aimed to review information on the subaxial cervical pedicle screw (CPS) including recent anatomical considerations, entry points, placement techniques, accuracy, learning curve, and complications. Relevant literatures were reviewed, and the authors' experiences were summarized. The CPS is used for reconstruction of unstable cervical spine and achieves superior biomechanical stability compared to other fixation techniques. Various insertion and guidance techniques are established, among which, lateral fluoroscopy-assisted placement is the most common and cost-effective technique. Generally, placement under imaging guidance is more accurate than other techniques, and a three-dimensional template allows optimal trajectory for each pedicle regardless of intraoperative changes in spinal alignment. The free-hand technique using a curved pedicle probe without a funnel-like hole increases screw stability and reduces operation time, radiation exposure, and soft tissue injury. Compared to conventional lateral fluoroscopy-assisted placement, free-hand CPS placement by trained surgeons achieves superior accuracy comparable to that of image-guided navigation; in general, 30 training cases are sufficient for learning a safe and accurate technique for CPS placement. The complications of subaxial CPS are classified into three categories: complications due to screw misplacement, complications without screw misplacement, and others. Inexperienced surgeons may benefit from advanced techniques; however, the accuracy of CPS ultimately depends on the surgeon's experience. Inexperienced surgeons should master the placement of the thoracolumbar pedicle screw in real practice and practice CPS insertion using cadavers. During the initial phase of the learning curve, careful preparation of surgery, reiterated identification, patterned safety steps, and supervision of the expert are necessary.
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http://dx.doi.org/10.2176/nmc.ra.2019-0189DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7246229PMC
May 2020

Atlantoaxial instability treated with free-hand C1-C2 fusion in a child with Morquio syndrome.

Childs Nerv Syst 2020 08 14;36(8):1785-1789. Epub 2020 Mar 14.

Department of Neurosurgery, Asan Medical Center, University of Ulsan College of Medicine, 88 Olympic-ro 43-gil, Songpa-gu, Seoul, 05505, South Korea.

Mucopolysaccharidosis type IVA, also known as Morquio syndrome, is an autosomal recessive lysosomal storage disease. Skeletal dysplasia with short stature, dysplastic-hypoplastic dens (os odontoideum), ligamentous hyperlaxity, and C1-C2 instability are characteristic features. Most patients with Morquio syndrome present with compressive myelopathy at a young age as a result of a combination of C1-C2 instability and extradural soft tissue thickening; treatment generally consists of anterior decompression with occipito-cervical fusion and external orthosis. In this report, we describe the successful treatment of a young child using posterior C1-C2 fusion alone with a free-hand technique. A 3-year-old boy presented at our hospital with a 5-month history of progressive quadriparesis. A whole-body skeletal survey showed skeletal dysplasia with hypoplasia, thoracolumbar kyphosis, and atlantoaxial subluxation. Preoperative cervical imaging showed compressive myelopathy at C1-C2 and atlantoaxial subluxation. C1-C2 fixation and decompression were performed successfully. After the operation, the patient had improved strength and was able to walk independently 8 months postoperatively. Establishment of stability via C1-C2 fusion is challenging in patients with genetic disorders characterized by skeletal dysplasia because of these young patients' small bone size and deficient bone quality. In this unique case, the treatment consisted solely of C1-C2 fusion with a free-hand technique. This case report presents a new approach in the treatment of atlantoaxial instability in Morquio syndrome.
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http://dx.doi.org/10.1007/s00381-020-04561-2DOI Listing
August 2020

Postoperative Non-Pathological Fever Following Posterior Cervical Fusion Surgery : Is Laminoplasty a Better Preventive Method than Laminectomy?

J Korean Neurosurg Soc 2020 Jul 5;63(4):487-494. Epub 2020 Mar 5.

Department of Neurological Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea.

Objective: To analyze the incidence and characteristics of delayed postoperative fever in posterior cervical fusion using cervical pedicle screws (CPS).

Methods: This study analyzed 119 patients who underwent posterior cervical fusion surgery using CPS. Delayed fever was defined as no fever for the first 3 postoperative days, followed by an ear temperature ≥38°C on postoperative day 4 and subsequent days. Patient age, sex, diagnosis, laminectomy, surgical level, revision status, body mass index, underlying medical disease, surgical duration, and transfusion status were retrospectively reviewed.

Results: Of 119 patients, seven were excluded due to surgical site infection, spondylitis, pneumonia, or surgical level that included the thoracic spine. Of the 112 included patients, 28 (25%) were febrile and 84 (75%) were afebrile. Multivariate logistic regression analysis showed that laminectomy was a statistically significant risk factor for postoperative non-pathological fever (odds ratio, 10.251; p=0.000). In contrast, trauma or tumor surgery and underlying medical disease were not significant risk factors for fever.

Conclusion: Patients who develop delayed fever 4 days after posterior cervical fusion surgery using CPS are more likely to have non-pathologic fever than surgical site infection. Laminectomy is a significant risk factor for non-pathologic fever.
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http://dx.doi.org/10.3340/jkns.2019.0191DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7365284PMC
July 2020

Accuracy Analysis of Iliac Screw Using Freehand Technique in Spinal Surgery : Relation between Screw Breach and Revision Surgery.

J Korean Neurosurg Soc 2020 Mar 15;63(2):210-217. Epub 2020 Jan 15.

Department of Neurological Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea.

Objective: To analyze the accuracy of iliac screws using freehand technique performed by the same surgeon. We also analyzed how the breach of iliac screws was related to the clinical symptoms resulting in revision surgery.

Methods: From January 2009 to November 2015, 100 patients (193 iliac screws) were analyzed using postoperative computed tomography scans. The breaches were classified based on the superior, inferior, lateral, and medial iliac wall violation by the screw. According to the length of screw extrusion, the classification grades were as follows : grade 1, screw extrusion <1 cm; grade II, 1 cm ≤ screw extrusion <2 cm; grade III, 2 cm ≤ screw extrusion <3 cm; and grade IV, 3 cm ≤ screw extrusion. We also reviewed the revision surgery associated with iliac screw misplacement.

Results: Of the 193 inserted screws, 169 were correctly located and 24 were misplaced screws. There were eight grade I, six grade II, six grade III, and four grade IV screw breaches, and 11, 8, 2, and 3 screws violated the medial, lateral, superior, and inferior walls, respectively. Four revision surgeries were performed for the grade III or IV iliac screw breaches in the lateral or inferior direction with respect to its related symptoms.

Conclusion: In iliac screw placement, 12.4% breaches developed. Although most breaches were not problematic, symptomatic violations (2.1%) could result in revision surgery. Notably, the surgeon should keep in mind that lateral or inferior wall breaches longer than 2 cm can be risky and should be avoided.
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http://dx.doi.org/10.3340/jkns.2019.0090DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7054120PMC
March 2020

A distal start point facilitates safer insertion of S2-alar-iliac screws fixation.

J Clin Neurosci 2020 Feb 8;72:102-107. Epub 2020 Jan 8.

Department of Neurological Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea. Electronic address:

This study aimed to show that a more distal insertion of S2-alar-iliac screws (S2AI) towards the S2 foramen facilitates a more natural trajectory and results in fewer breaches of the iliac wing due to the anteroposterior relationship of the sacrum and pelvis. Thirty-six consecutive patients who had received S2AI and postoperative computed tomography (CT) imaging were retrospectively reviewed. A freehand technique was used to insert all screws. Screws were stratified into two groups (Zone A and Zone B) based on the insertion point within the sacrum. Zone A was defined as screw insertion proximal to the second sacral foramen. Zone B was defined as screw insertion at or distal to the level of the second sacral foramen. CT imaging was reviewed to identify passage of the screw through either the fibrous or bony sacroiliac joint, and to check for instrumentation breach of the iliac wing. Sixty-two S2AI in 36 patients were identified. Twenty-six screws (42%) were inserted into Zone A and 36 (58%) into Zone B. There were 11 instrumentation breaches of the iliac wing in Zone A (42%) and 0 in Zone B (p < 0.0001). In Zone A, 24 screws (92%) passed through the upper, fibrous portion of the sacroiliac joint. In Zone B, no screws passed through this region (p < 0.0001). In conclusion, insertion of S2AI at or distal to the second sacral foramen facilitates improved screw placement due to the anteroposterior relationship of the sacrum and pelvis at this level.
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http://dx.doi.org/10.1016/j.jocn.2019.12.058DOI Listing
February 2020

Posterior Cervical Muscle-Preserving Interspinous Process Approach and Decompression: More Minimally Invasive and Modified Shiraishi's Selective Laminectomy.

World Neurosurg 2020 Jan 16;133:e412-e420. Epub 2019 Sep 16.

Department of Emergency Medicine, Gangneung Asan Hospital, University of Ulsan College of Medicine, Gangneung-si, Republic of Korea.

Objective: The cervical extensor musculature is important in cases of neck pain and loss of cervical lordosis after laminoplasty. Therefore, various surgical methods have been developed to preserve the muscle during laminoplasty. We have developed a posterior cervical muscle-preserving interspinous process (MIS) approach and decompression method. We have described the operation details and clinical outcomes of selected patients who have undergone this procedure.

Methods: The MIS approach and decompression method were performed in 20 consecutive patients who had only required central decompression for cervical stenosis. This procedure includes an approach to the interspinous space that is similar to Shiraishi's method but includes decompression without fracturing the spina bifida.

Results: The patients had no complications and did not require conversion to conventional laminoplasty. The mean operative time and mean blood loss was 53.0 minutes and 63.0 mL per level, respectively, and the mean hospital stay was 4.0 days. The mean preoperative and 3-month postoperative modified Japanese Orthopedic Association scores were 12.6 and 16.2, and the mean preoperative and 3-month postoperative neck disability index scores were 15.4 and 2.5, respectively. The postoperative neck visual analog scale score was 0.8. The mean preoperative and postoperative sagittal vertical axis was 1.6 and 1.8 cm, respectively. The mean loss of lordosis was 1.0°, and the mean cervical range of motion did not change from preoperatively to postoperatively.

Conclusions: The MIS approach and decompression method was less invasive than both conventional laminoplasty and Shiraishi's selective laminectomy. It is a safe and effective minimally invasive technique for central stenosis caused by cervical spondylotic myelopathy.
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http://dx.doi.org/10.1016/j.wneu.2019.09.041DOI Listing
January 2020

The Learning Curve of Subaxial Cervical Pedicle Screw Placement: How Can We Avoid Neurovascular Complications in the Initial Period?

Oper Neurosurg (Hagerstown) 2019 12;17(6):603-607

Department of Neurosurgery, Asan Medical Center, College of Medicine, University of Ulsan, Seoul, Republic of Korea.

Background: Despite the biomechanical benefits of subaxial cervical pedicle screw (CPS) placement, possible neurovascular complications, including vertebral artery and nerve root injury, are of great concern. We have demonstrated many times the safety and efficacy of CPS deployments, even when using freehand technology.

Objective: To analyze the learning curve of CPS placement to determine the number of cases necessary for assuring safe CPS placement and to identify a reasonable accuracy rate.

Methods: From March 2012 to August 2018, a single surgeon performed posterior cervical fusion surgery using CPS placement on 162 consecutive patients. We classified whole surgical periods, 6 years, into 4 periods. We analyzed the screw breach rate, lateral mass screw conversion (LMSC) rate, and reposition rate. We also compared the CPS placement accuracy in the initial 15, 20, and 30 patients with the other 147, 142, and 132 patients, respectively, to assess the number of procedures necessary to reach the learning curve plateau and to identify a reasonable accuracy rate.

Result: The total number of planned CPS placements was 979. Our learning curve showed that the breach rate plateaus at 3% to 4%. The necessary numbers for safe and accurate CPS placement during learning curve were 30 patients and 170 screws. None of the patients undergoing CPS developed a neurologic or vascular complication.

Conclusion: By following our 5 safety steps, the steady state for safety and accuracy can be reached without neurovascular complications even in the initial period of the learning curve.
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http://dx.doi.org/10.1093/ons/opz070DOI Listing
December 2019

Anterior Odontoid Screw Fixation for the Treatment of Type 2 Odontoid Fracture with a Kyphotic Angulation or an Anterior Down-slope: A Technical Note.

Neurol Med Chir (Tokyo) 2019 Aug 9;59(8):321-325. Epub 2019 May 9.

Department of Neurosurgery, Asan Medical Center, University of Ulsan College of Medicine.

Anterior odontoid screw fixation (AOSF) is difficult and challenging to perform in patients with type 2 odontoid fracture with a kyphotic angulation or an anterior down-slope. To demonstrate two surgical techniques to resolve kyphotic angulation or difficult fracture direction issues. Anterior odontoid screw fixation was performed in two patients with type 2 odontoid fracture with a kyphotic angulation or an anterior down-slope. This technique can avoid sternal blocking using a percutaneous vertebroplasty puncture needle, and can reduce the kyphotic angle using a Cobb elevator in patients with type 2 odontoid fractures with a kyphotic angulation or an anterior down-sloped fracture. In both the patients, AOSF was successfully performed and a successful clinical outcome was achieved. The screws were well-maintained with reduced fracture segment and well-preserved, corrected kyphotic angles were achieved, as observed on cervical X-ray 6 months postoperatively. Our technique is a safe and effective method for the treatment of type 2 odontoid fracture with a kyphotic angulation or an anterior down-slope.
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http://dx.doi.org/10.2176/nmc.tn.2018-0249DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6694020PMC
August 2019

Surgical Treatment of Lumbar Spinal Discal Cyst: Is It Enough to Remove the Cyst Only without Following Discectomy?

Neurol Med Chir (Tokyo) 2019 Jun 9;59(6):204-212. Epub 2019 May 9.

Department of Neurosurgery, Asan Medical Center, University of Ulsan College of Medicine.

Discal cysts are a rare cause of low back pain and radiculopathy with unknown pathophysiologic mechanism. Associated symptoms are difficult to distinguish from those caused by extruded discs and other spinal canal lesions. Most discal cysts are treated surgically, but it is unclear whether the corresponding intervertebral disc should be excised along with cyst. We conducted a retrospective clinical review of 27 patients who underwent discal cyst excision at our institution between 2000 and 2017. The mean follow-up period was 63.6 months. We recorded symptoms, radiographs, operative findings, postoperative complications, and short- and long-term outcomes. Structured outcome assessment was based on Numeric Rating Scale (NRS) for pain intensity, Oswestry disability index, and Macnab classification. All patients underwent partial hemilaminectomy and microscopic cyst resection without discectomy. All patients had preoperative back or leg pain. Other preoperative clinical features included motor weakness, neurogenic intermittent claudication, and cauda equina syndrome. After surgery, NRS scores of back and leg pain decreased. The other symptoms also improved. During long-term follow-up, patients reported no restrictions on daily life activities, and were satisfied with our intervention. There were no cases of cyst recurrence. We conducted a review of the literature on lumbar discal cysts published before January, 2018. Including our cases, 126 patients were described. We compared two surgical modalities-cystectomy with and without discectomy-to elucidate both effectiveness and long-term complications. We found that microsurgical cystectomy without corresponding discectomy is an effective surgical treatment for lumbar discal cysts, and is associated with a low recurrence rate.
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http://dx.doi.org/10.2176/nmc.oa.2018-0219DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6580042PMC
June 2019

Minimally Invasive Cervical Pedicle Screw Placement With a Freehand Technique Through the Posterolateral Approach Using a Tubular Retractor: A Technical Note.

Oper Neurosurg (Hagerstown) 2019 10;17(4):E166-E172

Department of Neurological Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea.

Background And Importance: Although many studies have demonstrated the biomechanical superiority of cervical pedicle screw (CPS) placement with sufficient safety and accuracy, it also has an inevitable major drawback in that an extensive posterior neck muscle dissection results in immediate postoperative neck pain. To avoid this disadvantage and highlight the several biomechanical advantages of CPS, we conducted the first minimally invasive surgery using both a tubular retractor through the posterolateral approach and a freehand placement technique.

Clinical Presentation: A 77-yr-old man presented with quadriparesis and neck pain. The diagnosis was infectious discitis with ventral epidural abscess extending from C6 to T1. The surgery was performed in 2 steps. First, CPSs were inserted bilaterally in C6 and C7 with a freehand technique through the tubular retractor, and posterolateral fusion was performed with cancellous iliac bone chips after 2 rod connections. Second, C6-7 discectomy with partial upper bony resection of the C7 body was performed through an anterior approach. Anterior interbody fusion was performed with only iliac bone block, without plate fixation. The patient could sit without serious neck pain immediately postoperatively, and ambulation was possible the next day after surgery. Postoperative magnetic resonance images showed complete bilateral preservation of the semispinalis cervicis muscles. Six months after operation, dynamic radiographs showed stability and the visual analogue scale score for neck pain was 1 point.

Conclusion: We report on an advantageous minimally invasive approach combined with the freehand technique for the preservation of the posterior ligamentous complex and muscles during CPS placement.
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http://dx.doi.org/10.1093/ons/opy375DOI Listing
October 2019

Cervical Spondyloptosis Successfully Treated with Only Posterior Short Segment Fusion Using Cervical Pedicle Screw Fixation.

Neurol Med Chir (Tokyo) 2019 Jan 15;59(1):33-38. Epub 2018 Dec 15.

Department of Neurological Surgery, Asan Medical Center, University of Ulsan College of Medicine.

This paper describes two patients with cervical spondyloptosis with severe spinal cord injury treated with cervical pedicle screw (CPS) through a single-stage operation, posterior approach. A 60-year-old male patient with quadriparesis due to trauma 1 day before visited the emergency room. Cervical spine computed tomography (CT) and magnetic resonance imaging showed complete dislocation of the C7 and T1 vertebrae with severe spinal cord compression, disc injury, and disc herniation at the C7-T1 level. Cervical pedicle screw with freehand technique was done on C6 and T1 vertebrae, and bilateral distraction for a reduction was performed with a screw distractor. After reduction of the C7 vertebra on the surgical field, CPS placement on C7 body was done. After surgery, follow-up X-rays showed near complete reduction. The patient completed a rehabilitation program, and his condition improved. From the third month postoperatively, the patient could ambulate without assistance and perform nearly normal daily activities. A postoperative CT scan 1 year later showed accurate screw position and complete fusion bridges on the C6-C7-T1 vertebrae. The other patient, a 39-year-old male, also showed C7-T1 spondyloptosis with quadriparesis (grade IV). C6-T1-T2 fusion surgery was performed only through a posterior approach. The patient showed nearly normal neurology and reduction. Considering early surgery time followed by open reduction and biomechanical superiority of CPS, single posterior approach and short segment fusion appear to be a great surgical method.
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http://dx.doi.org/10.2176/nmc.tn.2018-0213DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6349999PMC
January 2019