개의 추간판탈출증 수술 : 결과와 예측인자

정인성 전북대학교 일반대학원 2018 국내박사

Intervertebral disk herniation (IVDH) commonly caused neck pain, back pain and neurologic dysfunction in dogs. IVDH is a pathological condition in which abnormal herniation or bulging out of the central nucleus portion of an intervertebral disc through the damaged portion of the outer rings. Currently, surgical treatment of the IVDD includes several options including ventral slot decompression (VSD), VSD with fixation, the modified slanted slot, dorsal laminectomy, hemilaminectomy, mini-hemilaminectomy, dorsal laminectomy, corpectomy, and disk fenestration. Several studies have reported that surgeries alleviated pain intensity and corrected neurological deficits, and the overall success functional outcome was ranges in up to 70–90% of cases and rate of recurrence from 20–28% in dogs. These circumstances have indicated the need for a structured physiotherapy program designed to overcome this situation. In veterinary practice, the effect of physiotherapy rehabilitation has not been well documented for patients with disc disease. Moreover, there is a scarcity of well-defined, structured physiotherapy programs. The objectives of these retrospective studies were to investigate the benefits of well-structured rehabilitation physiotherapy after surgical management of cervical and thoracolumbar IVDH for over about 5-year period as well as to evaluate the preoperative clinical characteristics to predict prognostic value in dogs. Part 1 Effect of ventral slot decompression and rehabilitation therapy on clinical outcome in dogs with cervical intervertebral disc herniation The objective of this study was to evaluate the clinical outcome of ventral slot decompression and rehabilitation therapy in 34 dogs with cervical intervertebral disc herniation (CIVDH). Disk herniation diagnosed by computed tomography and MRI. The patient classify to five groups based on the pre-operative clinical grading system from the clinical history of hospital electronic medical chart. Grade I for neck pain without neurological disorder (n=9), II for ambulatory with neurological disorder (n=7), III for ambulatory with moderate neurological disorder (n=4), IV for no ambulatory, tetraparesis or tetraparalysis (n=14), and V for necrogenous hypoventilation or paresthesia (n=0). In addition, cervical IVDH was occurred at C3-4 (41.0%) and Shit Tzu (35.3%) has most frequency in this study. The surgical decompression performed using ventral slot procedure. After surgery, physiotherapeutic rehabilitation was performed by a combination of electrotherapy, infrared therapy, and mechanical message and at last underwater treadmill exercise (UTE) was regimented when the animal could stand up. Pre and post-operative changes such as time of standing, and walking were evaluated until one month. Overall, 27 out of 34 (79.4 %) dogs were considered to have successful neurologic outcome due to normal walking which better previous history without rehabilitation therapy. Interestingly, this recovery rate differed when searched by preoperative grading system. All dogs were recovered (100%) with grade 1 and 2, and in grade 3 and 4 were 75.0% and 57.1%, respectively. This study suggests that application of physiotherapeutic rehabilitation following ventral slot decompression surgery may increase recovery rate but recovery also depends on the preclinical pathological condition. Part 2 Surgical management, rehabilitation therapy and neurological outcome of thoracolumbar intervertebral disk herniated dogs. The objective was to report neurologic outcome and factors influencing outcome after surgical decompression of intervertebral disc disease (IVDD) in dogs with rehabilitation therapy in a consecutive clinical series of 161 dogs. The dogs were classified to four groups based on the pre-operative clinical grading system from the clinical history of hospital e-book. Grade 2 for ambulatory paraparesis (n=58); 3 for Non-ambulatory paraparesis (n=76) and 4 for paraplegia with or without deep-pain perception intact (n=27). The same surgeon performed surgical decompression. After surgery, physiotherapeutic rehabilitation was performed by a combination of electrotherapy, infrared therapy, and mechanical message and at last UTE was regimented when the animal could stand up. Post-operative changes such as time of standing, and walking, success rate were evaluated and compared with non-rehabilitated group. The post-operative standing time in the rehabilitated dogs in the grade 2, 3 and 4 groups were 4.60±0.52, 5.10±0.56 and 8.00±0.42 days which were better than in the non-rehabilitated groups and the walking time were 6.90±0.32, 7.01±0.61 and 13.00±1.02 days, respectively. Overall, 141 out of 161 (87.58%) dogs were considered to have successful neurologic outcome based on walking status. Interestingly, the success rate differed when considered by preoperative grading system. The success rate of grade 2, 3 and 4 were 98.28%, 94.74% and 44.44% respectively. This study suggests that application of physiotherapeutic rehabilitation following decompression surgery could be the possible factor for better clinical outcome. Part 3 Evaluation of preoperative clinical characteristics to predict prognostic value in dogs with intervertebral herniated disk disease: retrospective clinical study. The objective of this retrospective study was to evaluate the preoperative clinical characteristics to predict neurologic recovery in dogs with intervertebral herniated disk disease (IVDD). The clinical cases were selected when preoperative MRI, pre and postoperative CT scan were performed in IVDD dogs. The dogs were classified according to postoperative neurologic recovery from the clinical history of hospital e-book. Excellent when dogs (n=13) were neurologically normal or fully ambulatory with subclinical neurologic deficits had resolved by discharge; Good (n=8) when postoperative neurologic grade was improved from preoperative condition and had improved sufficiently to require no or minor therapy after discharge; Fair (n=4) is considered when postoperative neurologic status was unchanged from preoperative condition and Poor (n=5) is considered when major postoperative complication developed and as a consequence, neurologic grade had worsen at discharge than their preoperative score or other clinical disability not present at admission was developed, or the patient died. The evaluated preoperative clinical characteristics in all groups are breed, age, sex, duration of clinical sign appearance (DCSA), preoperative neurologic grading system (PNGS), compression rate in MRI and CT scan, housefield unit (HU), type of IVDD and surgical procedures, and compared with the excellent group. The DCSA were 73.54±15.00, 117.63±31.58, 171.25±99.56 and 175.00±94.83 (p < 0.05), respectively. The PNGS were 3±0, 3±0, 4±0 and 4±0 (p < 0.01), respectively. Higher DCSA had a worse prognosis. More than 175 hours means significant poor prognosis. Pre-operatively neurologic exam was lower, prognosis worsen significantly. When compared before and after CT compressed rate, it was decreased after surgery. Compressed rate of MRI has not specific relationship with prognosis after surgery.

Surgical outcome of chiari I malformation in children

이승준 서울대학교 대학원 2013 국내석사

Objectives: Despite progress in understanding the pathophysiology of Chiari I malformations, the optimal surgical treatment is still being debated. The aim of this study was to evaluate the efficacy of surgery including foramen magnum decompression in the treatment of pediatric Chiari I malformation, focusing on clinico-radiologic factors and technical aspects that might influence the outcome. Patients and Methods: The subjects of this study included 58 patients with Chiari I malformation who received surgery at Seoul National University Children’s Hospital between 1991 and 2010. The age of the patients at the time of the operation ranged from 1 month to 17 years (mean 7.7 years). Twenty-six patients were boys and 32 were girls. The patients were divided into 3 groups: group I (9 cases) with hydrocephalus, group II (11 cases) without syrinx, and group III (38 cases) with syrinx. Group I received the cerebrospinal fluid (CSF) diverting operation initially, and group II and III received foramen magnum decompression as the initial operation. Excluding a case which initially treated with a syringoperitoneal shunt, Group III was further subdivided into two groups according to the difference in intradural procedures adopted: group IIIa (10 cases) operated on with minimal arachnoid manipulation, and group IIIb (27 cases) with aggressive intradural manipulation and decompression. The clinical and radiological outcomes were compared between the groups. The postoperative follow-up period ranged from 4 to 173 months (mean 72.4 months). In addition, patients under age 3 years were analyzed for demographics, radiographic findings, clinical and radiological outcome separately. Results: In group I, symptoms related to hydrocephalus resolved or improved in all patients. Only one patient needed foramen magnum decompression after the shunt operation because of either remaining symptoms or aggravating syrinx. Symptoms resolved or improved in 10 (91%), and 26 cases (84%) in groups II and III, respectively. Postoperative magnetic resonance imaging (MRI) showed that the syrinx was resolved in 14 cases (39%), improved in 17 cases (47%), unchanged 1 case (3%) and aggravated in 4 cases (11%) in group III. There were 8 surgical morbidities which were mostly minor and treated well with conservative care. One patient required repeated foramen magnum decompression due to aggravation of symptoms and syrinx despite the initial surgery. Grossly, outcomes between group II and III were similar; however, symptoms related to syrinx, such as motor, and sensory disturbances, were less likely to improve. In addition, outcomes between group IIIa and IIIb showed no significant difference. Scoliosis poorly responded to foramen magnum decompression. Failure to achieve syrinx resolution despite of foramen magnum decompression led to scoliosis progression. Longer symptom duration and curve severity also seemed to lead to the progression, but showed no statistical significance. The diagnostic value of the cine MRI was not clearly proven in this study. Patients under age of 3 years appeared to have more complication related to CSF leakage, but grossly there were no differences in the clinical and radiological outcome between the patients under age of 3 and the older patients. Conclusion: In most pediatric Chiari patients with hydrocephalus, the shunting operation would suffice and only few patients required foramen magnum decompression. Over 80% of the patients showed clinical and radiological improvement after foramen magnum decompression, and this could be recommended as the treatment of choice in pediatric Chiai I malformation patients with or without syrinx. However, the role and effect of specific intradural procedures are still not clear, and more studies are required to standardize the operating procedures.

Analysis of the risk factors affecting the surgical site infection after cranioplasty following decompressive craniectomy

김진성 경상대학교 대학원 2016 국내석사

Object: The relevant factors for surgical site infections (SSIs) after cranioplasty following decompressive craniectomy remain unclear. The goal of this study was to analyze the factors associated with developing SSIs after cranioplasty and to suggest valuable predictors. Methods: A retrospective review was conducted of patients who underwent cranioplasty following decompressive craniectomy at our institution from January 2011 to December 2014, a total of 78 patients who underwent 78 cranioplasties. Univariate and multivariate logistic regression analyses were carried out to determine possible factors associated with the development of SSIs. We analyzed both patient-specific and surgery-specific factors. Results: The overall rate of SSIs was 9.0% (7/78). SSIs after cranioplasty were significantly related to being female, having the primary etiology of traumatic brain injury (TBI) and having had a bilateral cranioplasty in the univariate analysis. Multivariate logistic regression analysis showed that being female (OR5.98, p=0.000) and having had a bilateral cranioplasty (OR 4.00, p=0.001) showed significant association with the development of SSIs. Conclusions: Based on our data, cranioplasty following decompressive craniectomy is associated with a high incidence of surgical site infection. Being female, having a primary etiology of TBI and having had a bilateral cranioplasty may be associated with surgical site infections after cranioplasty.

A Cost-Utility Analysis of Two Lumbar Surgeries for Elderly Patients with Lumbar Spinal Stenosis and Sagittal Imbalance: Decompression versus Fusion

원영일 서울대학교 대학원 2022 국내석사

Lumbar spinal stenosis (LSS) and sagittal imbalance are common condition for elder patients. The goal of surgery would be both functional and radiological improvement. However, achieving both goals may not be necessary for all patients. Moreover, the criteria of correction maybe too strict for elder patients. In this regards, we analyzed cost-utility analysis between lumbar decompression surgery and lumbar fusion surgery for those patients. Elderly patients (age > 60 years old) who underwent 1 or 2 levels lumbar fusion surgery (F group, n = 31) or decompression surgery (D group, n = 40) for LSS with sagittal imbalance (C7 sagittal vertical axis, C7 SVA > 40 mm) with followed-up period ≥ 2 years were included. Surgical method was a posterior bilateral decompression or oblique lumbar interbody fusion. Clinical outcomes were assessed with Euro-Quality of Life-5 Dimensions (EQ-5D), Oswestry Disability Index (ODI), and numerical rating score of pain on back (NRS-B) and leg (NRS-L). Radiological parameters were assessed with C7 SVA, lumbar lordosis (LL), difference between pelvic incidence and lumbar lordosis (PI-LL), and pelvic tilt (PT). Utility score of EQ-5D was used to calculate quality-adjusted life year (QALY). The incremental cost-effective ratio (ICER) was used to compare cost-utility between decompression and fusion surgery. Postoperatively, both groups attained clinical improvement in all parameters, but NRS-L was more improved in F group than D group at 24 months (p = 0.048). Preoperative C7 SVAs were 78.74 mm in D group and 82.77 mm in F group (p = 0.736) and those were significantly improved to 39.67 mm and 39.54 mm at postoperative 2 years without difference between groups (p = 0.991). All other radiological parameters were improved without difference between groups (p > 0.05). The ICER of F group over D group was 41,176 US dollar/QALY. A cost-effective lumbar decompression surgery may be a recommendable surgical option for elder patients, albeit less improvement of leg pain than fusion surgery. 요추관 협착증과 시상면 불균형은 노인 환자에게 흔한 질환이다. 수술의 목표는 임상적 증상 호전과 영상학적으로 시상면 불균형을 개선시키는 것이다. 그러나 반드시 두 가지 목표를 모두 달성하는 것이 모든 환자에게 필요한 것은 아니다. 시상면 불균형의 기준을 노인 환자들에게 적용하기에는 기준이 너무 까다로울 수 있기 때문이다. 이러한 관점으로, 요추관 협착증과 시상면 불균형이 동반된 환자에서 후방 감압술과 유합술의 비용 효과 분석을 시행하였다. 요추관 협착증으로 1-2 분절의 후방 감압술 또는 유합술을 받은 60세 이상의 환자들 중 시상 수직축(SVA) 이 40 mm 이상이며, 2년 이상 추적 관찰된 환자들을 대상으로 하였다. 수술은 후방 감압술 혹은 사측방 경유 척추 유합술을 시행하였다. 임상지표로써 삶의 질지표(EQ-5D)와 Oswestry 장애지수(ODI), 허리 및 다리 통증평가척도 (NRS-B, NRS-L)를 측정하였다. 영상학적 지표로 SVA와 요추 전만각(LL), 골반 입사각과 요추 전만각 사이의 차(PI-LL), 골반 경사(PT)를 측정하였다. 질보정기대여명(QALY)은 EQ-5D 의 utility score 를 통해 계산하였다. 두 수술 방법의 점증적 비용효과비(ICER) 를 산출하여 비교 하였다. 후방 감압술 40명, 유합술 31명으로 총 71명의 환자를 수집하였다. 두 그룹 모두 모든 임상지표에서 개선을 보였으나, NRS-L은 유합군에서 더 좋았다. 수술전 SVA 는 감압술군에서 78.74 mm, 유합술군에서 82.77 mm 였으며 (p = 0.736), 수술 후 2년 시점에서 각각 39.67 mm, 39.54 mm 로 호전되었다. 두 그룹간에 차이는 없었다 (p = 0.991). 다른 영상학적 지표들 모두 수술 후에 호전되었으며, 두 그룹간에 차이는 없었다. 감압술 대비 유합술의 점증적 비용효과비(ICER)는 41,176 US dollar/QALY 로 산출 되었다. 시상면 불균형이 동반된 요추관 협착증 환자에서 후방 감압술은 비용-효과비가 우수한 치료 방법이다. 비록 하지 통증의 호전 정도는 유합술에 비해 덜하지만, 고령의 환자에서 충분히 고려해 볼만한 수술이다.

Kaolin으로 유도된 실험적 수두증을 가진 쥐에서 Dopamine(DA)과 Norepinephrine(NE)의 변화와 수술적 감압의 효과

양국희 인하대학교 2002 국내박사