Surgical Treatment of Degenerative Lumbar Spine Disease in Geriatric Patients Over 70 Years Old: A Review of Two Decades

OBJECTIVE: The aim of this study is to evaluate the transition of lumbar spinal treatments for geriatric patients over 70 years old over two decades. METHODS: We retrospectively assessed 730 patients who were 70 years and older and underwent lumbar surgery. We analyzed the number of diseases, operation methods and complications with 5-year intervals from 1987 to 2006. RESULT: The number of patients older than 70 years who underwent lumbar surgery increased according to our analysis of the period spanning from 1987 to 2006. Thirty-two (1%), 77 (1.7%), 232 (4.4%), and 389 (8.2%) patients over 70 years underwent lumbar spine surgeries. Among them, the 8, 29 and 45 patients had one level degenerative spondylolisthesis for the periods 1992-1996, 1997-2001 and 2002-2006. Twenty-four, 29 and 58 patients had lumbar stenosis during all these time periods. Over time, we performed a larger variety of operations as well as more aggressive operations. From January 2002 to December 2006, a total of 308 patients were over 70 years old and had lumbar spine surgeries performed on them. Among them, the ASA class I was 58 (19%), the ASA class II was 213 (69%) and the ASA class III was 37 (12%). During that period, PLIFs and PS fixations were performed on 69 patients. Among them, 8 patients were ASA III. Large numbers of lumbar arthorodesis have been performed in geriatric patients over the age of 70 years in our series. CONCLUSION: The surgical treatment of degenerative spine disease in the elderly patients was increased due to improved surgical technique and advances in medical treatment including anesthesia. The authors suggest that fusion surgery can be done safely in elderly patients even though they have high-grade ASA classificationope

저산소 특이적 유전자 발현 시스템을 이용한 신경줄기세포주의 개발

Dept. of Medicine/박사Nonviral ex vivo local gene therapy systems consisting of regulated gene expression vectors and cellular delivery platforms represent a novel strategy for tissue repair and regeneration. We introduced a hypoxia-regulated plasmid-based system into mouse neural stem cells (NSCs) as an efficient gene expression and delivery platform for rapid, robust and persistent hypoxic/ischemic-regulated gene expression in the spinal cord. A synthetic hypoxia-responsive erythropoietin (Epo) enhancer, the SV40 minimal promoter and the luciferase (Luc) reporter gene were incorporated in a DsRed-expressing double-promoter plasmid for cell lipofection and Zeocin-selection to establish a hypoxia-regulated stable NSC line (NSC-Epo-SV-Luc). A non-hypoxia-regulated stable NSC line (NSC-SV-Luc) was also established as a control. Under the transcriptional regulation of the Epo enhancer, in vitro luciferase expression in NSC-Epo-SV-Luc, but not in NSC-SV-Luc, was sensitively augmented according to the strength and duration of the hypoxic stimulus and was quickly down-regulated to a low basal level after reoxygenation of the hypoxic cells. Furthermore, deoxygenation of the reoxygenated cells clearly enhanced the luciferase activity again. After transplantation into a rat spinal cord injury (SCI) model, only NSC-Epo-SV-Luc showed ischemic injury-specific luciferase expression Notably, the engineered NSC lines maintained the neural differentiation potential and retained the hypoxia-regulated luciferase expression after differentiation. We propose that NSCs engineered with the Epo-SV-therapeutic gene will be valuable for developing a controllable stem cell-mediated nonviral gene therapy for SCI or other central nervous system diseases accompanied with chronic or episodic hypoxic/ischemic stresses.ope

Clinical usefulness of magnetic resonance angiography in patient with risk factors of cerebrovascular disease

의학과/석사[한글] 1. 연구목적 : 뇌졸중의 원인으로 간주되는 뇌혈관의 동맥경화와 뇌지주막하출혈의 주요 원인인 비파열성 뇌동맥류를 조기진단하는데 있어 자기공명뇌혈관조영술의 임상적 가치를 평가하고, 뇌혈관질환의 위험인자들이 자기공명뇌혈관조영술상에서의 병소와 어떤 관계가 있는지를 알고자 하였다.2. 대상 및 방법2001년 5월 1일부터 2004년 5월 1일까지 3년간 연세의료원 영동세브란스병원 신경외과 외래에서 뇌자기공명영상 및 자기공명뇌혈관조영술을 받은 212례의 환자를 대상으로 성별, 연령, 진단 전 증상 등과 뇌혈관질환의 위험인자들을 후향적으로 조사하여 뇌자기공명영상 및 자기공명뇌혈관조영술상에서 보여지는 병소와의 관계를 분석하였다. 본 연구에서 대상으로 한 병소는 비파열성 뇌동맥류와 뇌혈관의 협착이다. 뇌혈관질환의 위험인자로는 고혈압의 과거력, 허혈성 심장질환의 과거력, 당뇨의 과거력, 뇌혈관질환의 가족력, HbA1c, 총 콜레스테롤 수치, 공복시 triglyceride, HDL 콜레스테롤, LDL 콜레스테롤, 흡연, 헤마토크릿, 심전도상의 좌심실비대 등을 조사하였다.3. 결과자기공명뇌혈관조영술의 결과 뇌혈관의 협착은 49례(23.1%)의 환자에서 발견되었고 뇌자기공명촬영에서는 뇌경색이 발견된 42례 중 17례(40%)에서는 자기공명뇌혈관조영술상 정상 소견을 보였다. 뇌자기공명촬영 결과 정상소견을 보인 170례 중 24례에서 자기공명뇌혈관조영술상 혈관의 협착이 관찰되어, 자기공명촬영만으로는 알지 못했던 추가적인 정보를 얻었다. 자기공명뇌혈관조영술에서 혈관의 협착이나 폐색이 관찰된 49례 중 25례(51%)에서는 혈관이상이 관찰된 부위가 뇌자기공명촬영에서의 뇌경색부위와 일치되는 소견이 관찰되었다. 자기공명뇌혈관조영술의 결과 10례(4.7%)에서 비파열성 뇌동맥류가 발견되었고 뇌혈관조영술을 시행하여 그 중 9례(90%)에서 확진이 가능하였다.다중 로지스틱 회귀분석의 결과 자기공명뇌혈관조영술에서 뇌혈관의 협착이 발견된 환자군에서 정상군에 비해 고혈압의 유병률, HbA1c와 LDL 콜레스테롤이 유의하게 높았고, 비파열성 뇌동맥류의 위험인자로는 성별(여자)과 고혈압으로 나타났다.4. 결론뇌혈관질환의 위험인자를 가진 환자에서 초기에 뇌자기공명영상과 뇌자기공명혈관조영술을 동시에 시행하여 신속한 진단과 조기치료를 함으로써 사망률과 유병률을 낮출 수 있다. 여러 가지 제약으로 자기공명뇌혈관조영술이 고식적인 뇌혈관조영술을 전적으로 대체하기 어려우나 위험성이 있는 침습적인 검사나 시술에 대한 일차적인 예검법으로 유용할 것으로 사료된다. [영문]1. Objectives : The aim of this study is to evaluate the role of magnetic resonance angiography (MRA) in detecting cerebrovascular disease including unruptured aneurysm and atherosclerotic lesions of the intracranial arteries, and to examine the relationship between cerebrovascular lesions detected on MRA and vascular risk factors in stroke-free population.2. MethodWe retrospectively assessed 212 patients who visited the Department of Neurosurgery of Yongdong Severance Hospital, Yonsei University College of Medicine and underwent both brain magnetic resonance imaging (MRI) and three-dimensional, time-of-flight MRA of the head between May 2001 and May 2004. We evaluated stenotic or occlusive lesions and unruptured aneurysm of the intracranial arteries using MRA. Age, sex, history of hypertension, history of schemic heart disease, family history of cerebrovascular disease, HbA1c, total cholesterol, fasting triglyceride, high density lipoprotein, low density lipoprotein, hematocrit, smoking and left ventricular hypertrophy (LVH) on ECG were included in the analysis.3. Results49 patients (23.1%) had stenotic or occlusive lesions of the intracranial arteries. The distribution of stenotic or occlusive vascular lesions were correlated with the location of infarction in 25 of the 49 positive cases(51%). MRA provided additional information not obtained from the MRI in 24 cases. Unruptured aneurysms were found in 10 patients (4.7%) and conventional angiography confirmed the 9 aneurysms among them. Univariate analysis showed that age, hypertension, LDL hypercholesterolemia and HbA1c were significantly correlated with atherosclerotic lesions of the intracranial arteries. Multiple logistic regression analysis showed that significant and independent predictors for atherosclerotic lesions of the intracranial arteries were HbA1c, LDL hypercholesterolemia and hypertension, and those for unruptured aneurysm were female sex and hypertension.4. ConclusionThe present study suggested that atherosclerotic lesion of the intracranial arteries detected in MRA was related to LDL hypercholesterolemia, hypertension and HbA1c while unruptured aneurysm was associated with hypertension and female sex. MRA is clinically useful method for screening cerebrovascular disease in patients with risk factors and selecting high-yield patients for conventional angiography.ope