Barrier Techniques for Spinal Cord Protection from Thermal Injury in Polymethylmethacrylate Reconstruction of Vertebral Body : Experimental and Theoretical Analyses

박춘근,지철,황장회,권성오,성재훈,최승진,이상원,박성찬,조경석,박춘근,강준기,Park, Choon Keun,Ji, Chul,Hwang, Jang Hoe,Kwun, Sung Oh,Sung, Jae Hoon,Choi, Seung Jin,Lee, Sang Won,Park, Sung Chan,Cho, Kyeung Suok,Park, Chun Kun,Yuan, Ha The Korean Neurosurgical Society 2001 Journal of Korean neurosurgical society Vol.30 No.3

Polymethylmethacrylate(PMMA)는 척추 전적출술후에 척추를 재건하기 위해 사용되지만 액체 형태의 PMMA가 응고하면서 발생되는 열은 척수 신경의 열 손상 가능성을 가지고 있다. 이 연구의 목적은 이미 응고된 PMMA sheet가 척수 신경을 보호하는 방어 벽으로서의 열 차단 역할을 할 수 있는지 또한 열손상으로부터 신경을 보호하기 위해 필요한 방어벽의 최소한의 두께를 탐구하는 데 있다. 실험실에서 제 12번째 흉추체 전 적출후의 상태와 동일한 크기와 모양의 정육면체의 용기를 제작하였다. 60ml의 액체형 PMMA를 용기 안에 주입하여 응고하는 PMMA중심부와 세 가지 다른 두께의(제 1 군 : 0mm, 제 2 군 : 5mm, 제 3 군 : 8mm) 이미 응고된 PMMA sheet의 하부(척수의 전면을 의미)에서 온도를 측정하였다. 또한 이 결과에 대한 위의 세 가지 군에 대해 열역학적 분석도 시행하였다. 응고하는 PMMA 덩이의 중심부에서의 온도는 18회의 실험 동안 매우 일정하여($106.8{\pm}3.9^{\circ}C$)이 실험 모델의 재현성을 보여주고 있었다. 방어 벽이 없는 군(제 1 군)에서 척수 신경 전면의 최고 온도가 $60.3^{\circ}C$이었으나 5mm군 (제 2 군)과 8mm군(제 3 군)에서는 각각 $47.3^{\circ}C$와 $43.3^{\circ}C$로 이미 응고된 PMMA는 통계적으로 유의한(p<0.00005) 온도 차단 효과를 보였다. 최고 온도에 도달하기까지의 계산된 시간은 실제 실험치 보다 35%이내의 오차를 보였으나 최고 온도에 대한 열역학적인 계산치는 실제 실험에서 나타난 수치의 1%이내의 오차를 보였다. 이상의 열역학적인 자료를 토대로 볼 때, PMMA를 이용한 척추의 재건술에서 PMMA 방어벽은 척수의 열손상을 방지하는 효과가 있으며, 이 실험에서 가정한 척수의 열손상 역치인 $39^{\circ}C$이하로 척수 온도를 유지하기 위해 필요한 PMMA방어벽의 두께는 10mm정도로 계산되었다. PMMA 방어벽의 임상 적용에 대해서는 추가적인 임상 실험이 필요하다고 사료된다. Objective : Polymethylmethacrylate(PMMA) is often used to reconstruct the spine after total corpectomy, but the exothermic curing of liquid PMMA poses a risk of thermal injury to the spinal cord. The purposes of this study are to analyze the heat blocking effect of pre-polymerized PMMA sheet in the corpectomy model and to establish the minimal thickness of PMMA sheet to protect the spinal cord from the thermal injury during PMMA cementation of vertebral body. Materials & Methods : An experimental fixture was fabricated with dimensions similar to those of a T12 corpectomy defect. Sixty milliliters of liquid PMMA were poured into the fixture, and temperature recordings were obtained at the center of the curing PMMA mass and on the undersurface(representing the spinal cord surface) of a prepolymerized PMMA sheet of variable thickness(group 1 : 0mm, group 2 : 5mm, or group 3 : 8mm). Six replicates were tested for each barrier thickness group. Results : Consistent temperatures($106.8{\pm}3.9^{\circ}C$) at center of the curing PMMA mass in eighteen experiments confirmed the reproducibility of the experimental fixture. Peak temperatures on the spinal cord surface were $47.3^{\circ}C$ in group 2, and $43.3^{\circ}C$ in group 3, compared with $60.0^{\circ}C$ in group 1(p<0.00005). So pre-polymerized PMMA provided statistically significant protection from heat transfer. The difference of peak temperature between theoretical and experimental value was less than 1%, while the predicted time was within 35% of experimental values. The data from the theoretical model indicate that a 10mm barrier of PMMA should protect the spinal cord from temperatures greater than $39^{\circ}C$(the threshold for thermal injury in the spinal cord). Conclusion : These results suggest that pre-polymerized PMMA sheet of 10mm thickness may protect the spinal cord from the thermal injury during PMMA reconstruction of vertebral body.

폴리메틸메타크리레이트를 사용한 경피적 척추성형술의 골다공증 척추체 압박골절에 대한 치료효과 : 예비보고

박춘근,이관성,최영근,류경식,박춘근,조경석,강준기,Park, Chun Kun,Lee, Kwan Sung,Choi, Yung Gun,Ryu, Kyung Sig,Park, Choon Keun,Cho, Kyung Suck,Kang, Joon Ki 대한신경외과학회 2000 Journal of Korean neurosurgical society Vol.29 No.3

Objectives : To describe a technique for percutaneous vertebroplasty of osteoporotic vertebral body compression fractures and to report preliminary results of its use. Methods : The technique was used over a 8-month period in 9 patients with 10 painful vertebral fractures. The technique involves percutaneous puncture of the involved vertebrae with a Jamshidi needle via a transpedicular approach followed by injection of polymethylmethacrylate(PMMA) into the vertebral body. Results : The procedure was technically successful in all patients, with an average injection amount of 5.9 cc per vertebral body. One patient complained of flank pain postoperatively in spite of improvement in back pain caused by the fractured vertebra. Remaining eight patients reported significant pain relief early after treatment. The patients were followed up for 3 to 15 months(average 7.2 months) and demonstrated no recurrence of pain or aggravation of deformity. Conclusion : Vertebroplasty appears to be a valuable tool in the treatment of painful osteoporotic vertebral fractures, providing acute pain relief and early mobilization in appropriate patients. However, it needs to have more extensive prospective clinical study to confirm its definitive role in the management of this condition.

골다공성 척추체 골절에서 척추 후만변형 복원술의 치료효과

박춘근,김동현,류경식,손병철,Park, Chun-Kun,Kim, Dong-Hyun,Ryu, Kyung-Sik,Son, Byung-Chul 대한신경외과학회 2005 Journal of Korean neurosurgical society Vol.37 No.2

Objective: Percutaneous kyphoplasty using a balloon-catheter is an widely accepted method which achieves the restoration of vertebral height and the correction of kyphotic deformity with little complication in osteoporotic vertebral compression fractures. The authors assess the results of 59 patients who underwent kyphoplasty, and analyze the factors that could affect the prognosis. Methods: From December 2001 to May 2003, fifty-nine patients underwent kyphoplasty. The patients included 49 women and 10 men aged 52-85 years. Average t-score on bone marrow density was -3.58. About 7cc of polymethylmethacrylate(PMMA) was injected into the fractured vertebral body using $Kyphon^{(R)}$ under local anesthesia. The vertical height of all fractured vertebrae was measured both before and after surgery. Outcome data were obtained by comparing pre- and post-operative VAS score and by assessing postoperative satisfaction, drug dependency and activity. Various clinical factors were analyzed to assess the relationship with the outcome. Results: The VAS score improved significantly, and the mean percentage of restored vertebral height was 53%. The mean improvement in kyphosis was $3.6^{\circ}$. Eighty-nine percent of the patients gained excellent or good results. Any of the clinical factors including the interval between fracture and operation, the degree of height loss, the degree of the vertebral height restoration or the correction rate of kyphosis did not affect the clinical results. Conclusion: Kyphoplasty is associated with a statistically significant improvement in pain and function with little complication. The clinical results are not affected by any clinical parameters. Further follow-up study is needed to determine whether the restoration affects the long-term clinical results.

159명의 골다공증성 흉추 및 요추부 골다공증성 추체 압박골절 환자에 대한 경피적 척추성형술 후 치료결과

이제언,류경식,박춘근,최영근,박춘근,지철,조경석,강준기,Lee, Jae-Un,Ryu, Kyeong-Sik,Park, Chun-Kun,Choi, Yeong-Kun,Park, Chun-Kun,Ji, Chul,Cho, Kyung-Suk,Kang, Joon-Ki 대한신경외과학회 2001 Journal of Korean neurosurgical society Vol.30 No.2

Purpose : To assess therapeutic effects of percutaneous polymethylmethacrylate(PMMA) vertebroplasty on the pain caused by osteoporotic thoracic and lumbar vertebral body compression fractures in a large scale of a prospective clinical design, and to determine clinical factors influencing its therapeutic effects. Methods : A prospective clinical study was carried out in 349 vertebral levels of 159 patients between April 1998 and July 1999. The compression fractures were confirmed with bone scan and spine CT, and bone marrow density was measured. Visual analogue scale(VAS) score was used for pre- and post-operative assessments of the pain. All 159 patients were assessed immediately after surgery, and 140 patients of them were followed-up for about 6 months in average. Results : Partial and complete pain relief was sustained immediately after operation in 73%, through follow-up period in 88% of the patients. Pain relief was not proportional to the amount of PMMA or the rate of increase in the height of the compressed vertebral body. It appears that 3 to 6cc of PMMA was proper enough to sustain pain relief. Better clinical improvement was achieved in the patients treated within 6 months after occurrence of vertebral body fracture. The most frequent surgical complication was epidural leakage of PMMA, and the most serious complication was extravertebral leakage into the paravertebral muscles, which appeared to exert the worst influence on the outcome. However, surgery was not required in these patients. Conclusion : Therapeutic effects of PMMA percutaneous vertebroplasty on osteoporotic vertebral body compression fractures were confirmed in a relatively large scale of prospective clinical study. It appears that good outcome can be achieved in patients treated within 6 months after fracture, treated each level with 3 to 6cc of PMMA in amount. without serious complications.

만성 추간판인성 요통 환자에서 추간판내 열 치료법의 치료효과 ; 예비보고

류경식,박춘근,Ryu, Kyung Sik,Park, Chun Kun 대한신경외과학회 2001 Journal of Korean neurosurgical society Vol.30 No.6

Objective : The IDET(Intradiscal electrothermal therapy) appears as a new therapeutic modality for intractable discogenic back pain. We carried out a prospective study to analyze and evaluate the therapeutic effects of IDET. Methods & Results : During a six month period, we performed IDET in 39 patients with chronic low back pain using RITA Model 30 Electrosurgical device. The patients included 21 men and 18 women. The mean patient age was 50.2 years(range 21-73 years). All patients underwent preoperative plain radiography and MRI for excluding non-discogenic back pain. We conducted discography-CT to reveal painful discs in all patients. During the study, we measured intradiscal pressure subjectively. The area of annular tear, which identified with post-discography CT scan, was coagulated in $90^{\circ}C$ of temperature for 15 minutes. Of the 17 patients who were followed up more than three months after surgery, the 10 patients(58.8%) experienced clinical improvement. Three patients had high intradiscal pressure on discography, other three patients had loss of disc height more than 30% of normal on plain radiography, and one patient suffered from postoperative epidural abscess. All of these patients were included in the remaining no improvement group(41.2%). Conclusion : The IDET procedure could be an alternative modality for discogenic back pain. It appears that a patient who has low intradiscal pressure on discography and intact disc height on plain radiography is considered a good candidate for IDET.

골다공증성 척추 압박골절 환자의 경피적 척추성형술에서 Polymethylmethacrylate의 경막 외 유출

오윤규,류경식,박춘근,강준기,Oh, Yoon-Kyu,Ryu, Kyeong-Sik,Park, Chun-Kun,Kang, Joon-Ki 대한신경외과학회 2001 Journal of Korean neurosurgical society Vol.30 No.3

Objectives : The percutaneous vertebroplasty provides a good result in the treatment of osteoporotic vertebral compression fractures. But, the epidural leakage of polymethylmetacrylate(PMMA) after vertebroplasty may decrease the therapeutic effects because of the compression of thecal sac and/or nerve roots. The authors carried out a prospective study to evaluate the causative factors of epidural leakage of PMMA and to assess the influence on the outcome. Methods : This study involved 347 vertebral levels of compression fractures in 159 patients. Among these, the epidural leakages were identified in 92 vertebral levels(26.5%) in 64 patients(40.3%) on post-operative CT scan. Results : The incidence of epidural leakage of PMMA was significantly higher in the level above T7(p=0.001). The large amount of the injected PMMA and the use of an injector also increased the incidence(p=0.03 and p=0.045, respectively). The position of the needle tip in the vertebral body and the pattern of venous drainage did not influence. The immediate post-operative visual analogue scale(VAS) scores and facial scales(FS) were higher in the patients with epidural leakage(p=0.009). But there were no significant differences between the two groups after three months of operation(p=0.541). Conclusions : The incidence of epidural leakage of PMMA after percutaneous vertebroplasty appears to have relationship with the amount of PMMA and the levels injected. The epidural leakage of PMMA reduced the immediate therapeutic effects of vertebroplasty, but did not influence the late outcome. However, the epidural leakage should be avoided because of its potential neurological complications.

에크만 분출 모델을 이용한 캐버티 내의 비정상 유동특성에 관한 수치해석

서용권(Yong-Kweon Suh),박춘근(Chun-Kun Park),최윤환(Yoon-Hwan Choi),문종춘(Jong-Chun Moon) 한국해양공학회 1997 韓國海洋工學會誌 Vol.11 No.4

A two dimensional shallow-water flow around a cavity driven by a sinusoidally oscillating external flow was studied numerically with an Ekman pumping model. A container model of "T" shape was constructed in the numerical computation for comparison with the experimental observation. The material transport in the external region is in good agreement with the experimentally recorded particle trajectories. It turns out that two large coherent vortices situated in the exterior region of the cavity are responsible for clockwise and counterclockwise drift motions, in large scale, of particles. The Ekman pumping model suggested in this study was found to be satisfactory.

급성 중증 뇌종창 환자의 양측성 감압개두술 후 뇌압 및 뇌혈류 측정

유도성,김달수,허필우,조경석,박춘근,강준기,Yoo, Do-Sung,Kim, Dal-Soo,Huh, Pil-Woo,Cho, Kyoung-Suck,Park, Chun-Kun,Kang, Joon-Ki 대한신경외과학회 2001 Journal of Korean neurosurgical society Vol.30 No.3

Objectives : The management of massive brain swelling remains an unsolved problem in neurosurgical field. Despite newly developed medical and pharmacological therapy, the mortality and morbidity due to massive brain swelling remains high. According to many recent reports, surgical decompression with dura expansion is superior to medical management in patients with massive brain swelling. We performed surgical treatment on the first line of treatment, and followed medical management in case with refractory increased intracranial pressure(ICP). To show the quantitative effect of decompressive surgery on the intracranial pressure, we performed ventricular puncture and checked the ventricular ICP continuously during the decompressive surgery and postoperative period. Materials and Methods : Fifty-one patients with massive brain swelling, undergoing bilateral decompressive craniectomy with dura expansion, were studied in this study. In all patients, ventricular puncture was performed at Kocher's point on the opposite side of massive brain swelling. The ventricular pressure was monitored continuously, during the bilateral decompression procedures and postoperative period. Results : The initial ventricular ICP were varied from 13mmHg to 112mmHg. Immediately after the bilateral craniectomy, mean ventricular ICP decreased to $53.1{\pm}15.8%$ of the initial ICP(ranges from 5mmHg to 87mmHg). Dura opening decreased mean ICP by additional 36.7% and made the ventricular pressure $16.4{\pm}10.5%$ of the initial pressure (ranges from 0mmHg to 28mmHg). Postoperatively, ventricular pressure was lowered to $20.2{\pm}22.6%$(ranged from 0mmHg to 62.3mmHg) of the initial ICP. The ventricular ICP value during the first 24 hours after decompressive surgery was found to be an important prognostic factor. If ICP was over 35mmHg, the mortality was 100% instead of additional medical(barbiturate coma therapy and hypothermia) treatments. Conclusion : Bilateral decompression with dura expansion is considered an effective therapeutic modality in ICP control. To obtain favorable clinical outcome in patients with massive brain swelling, early decision making on surgical management and proper patient selection are mandatory.

척수 경막외 혈관지방종 - 증 례 보 고 -

김래오,조경석,유도성,허필우,박춘근,김달수,강준기,Kim, Rae-Oh,Cho, Kyoung-Suok,Yoo, Do-Sung,Huh, Pil-Woo,Park, Chun-Kun,Kim, Dal-Soo,Kang, Jun-Ki 대한신경외과학회 2000 Journal of Korean neurosurgical society Vol.29 No.4

Crowth of an angiolipoma of the central nervous system is rare. Only about 60 cases were searched in the literature. We report one case of spinal angiolipoma recently treated in our institution. A 67-year-old man was admitted because of burning sensation on the both lower extremities and paraparesis. He felt burning sensation on the both great toes and it progressively involved to thighs and inguinal area during the past 1 year which gradually worsened. MR image showed a spinal mass lesion at the level of T4 to T6. The lesion was isodense and hyperdense in periphery on T1-weighted image and hyperintense on T2-weighted image. The tumor was located on the posterior area of the spinal cord and markedly enhanced after intravenous Gd-DTPA. At the operation, a soft, dark-red mass was totally removed. On histological examination, the tumor was shown to be mainly composed of mature fatty cells and numerous blood vessels with enlarged lumens. Postoperative course was uneventful and the symptoms improved gradually.

Transforming Growth Factor β가 돼지 난자의 체외성숙에 미치는 영향

신명균 ( Myung Kyun Shin ),박춘근 ( Chun Keun Park ),조재원 ( Je Won Cho ),정희태 ( Hee Tae Cheung ),양부근 ( Boo Kun Yang ),김정익 ( Chung Ik Kim ) 한국가축위생학회 1999 韓國家畜衛生學會誌 Vol.21 No.3

돼지 수정란의 체외생산은 난자의 체외성숙과 체외수정에 관한 기술의 부족으로 아직까지 만족스럽지 못한 수준이다. 특히 돼지 수정란의 체외생산에는 복잡한 세포질의 성숙과정과 높은 다정자침입율 및 전핵형성의 억제등의 문제점이 있다. 본 연구에서는 돼지 난자의 체외성숙 체계를 개선하기 위하여 transforming growth factorβ(TGFβ)의 첨가가 난자 및 난구세포에 미치는 효과에 대하여 검토하였다. 체외성숙용 배지에 TGFβ를 1~10ng/ml의 농도로 첨가하여 미성숙 난자를 배양한 결과 성숙율이 높아졌다. TGFβ의 효과는 난구세포가 제거된 난자의 성숙에도 효과적이었다. TGFβ의 첨가시기에 따른 차이는 없었으나, 난구세포를 제거한 난자의 경우에는 성숙배양 전반기(59%) 또는 후반기(57%) 24시간 동안에만 TGFβ를 첨가하는 것이 48시간 동안 계속하여 첨가(27%)하는 경우 또는 비첨가(38%)에 비하여 유의적으로 높은 성숙율을 나타냈다(p<0.05). 이와 같은 결과는 난구세포가 돼지 난자의 체외성숙에 필수적이지만 TGFβ는 난구세포가 제거된 난자의 체외성숙에 어느정도 유익한 효과를 발휘하는 것으로 추측된다.