True Posterior Communicating Artery Aneurysms with High Risk of Rupture despite Very Small Diameter

Objective@#: This retrospective study investigated the clinical and angiographic characteristics of ruptured true posterior communicating artery (PCoA) aneurysms in comparison with junctional PCoA aneurysms presenting with a subarachnoid hemorrhage. @*Methods@#: The medical records and radiological data of 93 consecutive patients who underwent three-dimensional rotational angiography and surgical or endovascular treatment for a ruptured junctional or true PCoA aneurysm over an 8-year period were examined. @*Results@#: The maximum diameter of the ruptured true PCoA aneurysm (n=13, 14.0%) was significantly smaller than that of the ruptured junctional PCoA aneurysms (n=80, 4.45±1.44 vs. 7.68±3.36 mm, p=0.001). In particular, the incidence of very small aneurysms <4 mm was 46.2% (six of 13 patients) in the ruptured true PCoA aneurysm group, yet only 2.5% (two of 80 patients) in the ruptured junctional PCoA aneurysm group. Meanwhile, the diameter of the PCoA was significantly larger in the true PCoA aneurysm group than that in the junctional PCoA aneurysm group (1.90±0.57 vs. 1.15±0.49 mm, p<0.001). In addition, the ipsilateral PCoA/P1 ratio was significantly larger in the true PCoA aneurysm group than that in the group of a junctional PCoA aneurysm (mean PCoA/P1 ratio±standard deviation, 2.67±1.22 vs. 1.14±0.88; p<0.001). No between-group difference was identified for the modified Fisher grade, clinical grade at admission, and 3-month modified Rankin Scale score. @*Conclusion@#: A true PCoA aneurysm was found to be associated with a larger PCoA and ruptured at a smaller diameter than a junctional PCoA aneurysm. In particular, the incidence of a ruptured aneurysm with a very small diameter <4 mm was significantly higher among the patients with a true PCoA aneurysm.

Clinical and Radiological Findings of Discogenic Low Back Pain Confirmed by Automated Pressure-Controlled Discography

OBJECTIVE: Few studies on the clinical spectrum of automated pressure-controlled discography (APCD)-defined positive discs have been reported to date. Thus, the present study was undertaken to analyze clinical parameters critical for diagnosis of discogenic pain and to correlate imaging findings with intradiscal pressures and pain responses in patients with APCD-positive discs. METHODS: Twenty-three patients who showed APCD-positive discs were selected for analysis. CT discogram findings and the degrees of nuclear degeneration seen on MRI were analyzed in comparison to changes of intradiscal pressure that provoked pain responses; and clinical pain patterns and dynamic factors were evaluated in relation to pain provocation. RESULTS: Low back pain (LBP), usually centralized, with diffuse leg pain was the most frequently reported pattern of pain in these patients. Overall, LBP was most commonly induced by sitting posture, however, standing was highly correlated with L5/S1 disc lesions (p < 0.01). MRI abnormalities were statistically correlated with grading of CT discogram results (p < 0.05); with most pain response observed in CT discogram Grades 3 and 4. Pain-provoking pressure was not statistically correlated with MRI grading. However, it was higher in Grade 3 than Grade 4. CONCLUSION: APCD-positive discs were demonstrated in patients reporting centralized low back pain with diffuse leg pain, aggravated by sitting and standing. MRI was helpful to assess the degree of nuclear degeneration, yet it could not guarantee exact localization of the painful discs. APCD was considered to be more useful than conventional discography for diagnosis of discogenic pain.

Clinical Relevance of Pain Patterns in Osteoporotic Vertebral Compression Fractures

Few studies have been conducted to explain the pain patterns resulting from osteoporotic vertebral compression fractures (OVCF). We analyzed pain patterns to elucidate the pain mechanism and to provide initial guide for the management of OVCFs. Sixty-four patients underwent percutaneous vertebroplasty (N=55) or kyphoplasty (N=9). Three pain patterns were formulized to classify pains due to OVCFs: midline paravertebral (Type A), diffuse paravertebral (Type B), and remote lumbosacral pains (Type C). The degree of compression was measured using scale of deformity index, kyphosis rate, and kyphosis angle. Numerical rating scores were serially measured to determine the postoperative outcomes. As vertebral body height (VBH) decreased, paravertebral pain became more enlarged and extended anteriorly (p<0.05). Type A and B patterns significantly showed the reverse relationship with deformity index (p<0.05), yet Type C pattern was not affected by deformity index. Postoperative pain severity was significantly improved (p<0.05), and patients with a limited pain distribution showed a more favorable outcome (p<0.05). The improvement was closely related with the restoration of VBH, but not with kyphosis rate or angle. Thus, pain pattern study is useful not only as a guide in decision making for the management of patients with OVCF, but also in predicting the treatment outcome.

Lumbo-iliac Fixation Using Modified Galveston Technique in a Patient with Metastatic Sacral Tumor

Lumbo-sacral junction is a transition zone between the mobile lumbar spine and immobile pelvis. Lumbosacral junction has been considered to be the most troublesome portion of the spine to be fused because of the difference in anatomical and biomechanical factors between spine and pelvis. A metastatic sacral tumor in a 57-year-old man was resected, followed by unilateral lumbo-iliac fixation across lumbosacral junction using modified Galveston technique. Rigid fixation was successfully achieved. Detailed anatomy and surgical techniques are presented.

Causes and Diagnostic Strategies for Chronic Low Back Pain

Chronic low back pain (CLBP) has become more prominent with globally increasing life expectancy. Its cause is more attributable to degenerative changes than to traumatic lesions. Although the diagnosis of CLBP is recently on higher demand, lack of clinical features and non-informative imaging findings in patients with CLBP are challenging to clinicians to establish the diagnosis. Therefore, understanding of the new concept of pathogenesis, elimination of prejudice, and evidence-based diagnostic steps are required to resolve the question of pain source. Analysis of pain distribution patterns and careful history taking can be utilized as an initial guide to divide CLBP into somatic and radicular pain. Zygapophyseal joint pain and sacroiliac joint pain representing somatic pain can be further investigated using medial branch and sacroiliac joint blocks. However, comparative blocks are essential to decreased false positive rate. Infiltration of a small volume of local anesthetics can increase the specificity of the procedures. Discogenic pain stemming from internal disk derangement can be confirmed by pressure-controlled discography. Automated discography is recommended to provide the constant rate of dye injection with obviating the fluctuation of intradiscal pressure. Evidencebased concept and diagnostic procedures can provide more accurate and efficient methods to establish the diagnosis of CLBP.

Usefulness of Pain Distribution Pattern Assessment in Decision-Making for the Patients with Lumbar Zygapophyseal and Sacroiliac Joint Arthropathy

There are currently no initial guides for the diagnosis of somatic referred pain of lumbar zygapophyseal joint (LZJ) or sacroiliac joint (SIJ). We developed a classification system of LZJ and SIJ pain, the "pain distribution pattern template (PDPT)" depending on the pain distribution patterns from a pool of 200 patients whose spinal pain source was confirmed. We prospectively applied the PDPT to determine its contribution to clinical decision-making for 419 patients whose pain was presumed to arise from the LZJs (259 patients) or SIJs (160 patients). Forty-nine percent (128/259) of LZJ and 46% (74/160) of SIJ arthopathies diagnosed by PDPT were confirmed by nerve blocks. Diagnostic reliabilities were significantly higher in Type A and C patterns in LZJ and Type C in SIJ arthropathies, 64%, 80%, and 68.4%, respectively. For both LZJ and SIJ arthropathies, favorable outcome after radiofrequency (RF) neurotomies was similar to the rate of positive responses to diagnostic blocks in Type A to Type D, whereas the outcome was unpredictable in those with undetermined type (Type E). Considering the paucity of currently available diagnostic methods for LZJ and SIJ arthropathies, PDPT is useful in clinical decision- making as well as in predicting the treatment outcome.

Radiofrequency Neurotomy of Cervical Medial Branches for Chronic Cervicobrachialgia

Chronic neck and arm pain or cervicobrachialgia commonly occurs with the degeneration of cervical spine. Authors investigated the usefulness of radiofrequency (RF) neurotomies of cervical medial branches in patients with cervicobrachialgia and analyzed the factors which can influence the treatment outcome. Demographic data, types of pain distribution, responses of double controlled blocks, electrical stimulation parameters, numbers and levels of neurotomies, and surgical outcomes were evaluated after mean follow-up of 12 months. Pain distribution pattern was not significantly correlated with the results of diagnostic blocks. Average stimulation intensity was 0.45 V, ranging from 0.3 to 0.69, to elicit pain response in cervical medial branches. The most common involvement of nerve branches was C4 (89%), followed by C5 (82%), C6 (75%), and C7 (43%). Among total of 28 patients, nineteen (68%) reported successful outcome according to outcome criteria after 6 months of followup (p=0.001), and eight (42%) of 19 patients reported complete relief (100%) of pain. Four patients showed recurrence of pain between 6 and 12 months. It was therefore concluded that cervical medial branch neurotomy is considered useful therapeutic modality for the management of cervicobrachialgia in selected patients, particularly in degenerative zygapophyseal disorders.

Preliminary Study on Effectiveness of Dexamethasone-Soaked Gelatin Sponges for Reducing Pain after Lumbar Microdiscectomy: A Randomized Controlled Trial

OBJECTIVE: A prospective, randomized, controlled clinical study is performed to verify the effectiveness of epidural dexamethasone-soaked gelatin sponges to reduce postoperative pain following lumbar microdiscectomy. METHODS: Twenty-three patients (10 men and 13 women) undergoing lumbar microdiscectomy were included. Five pieces of gelatin sponge measuring 1 x 1 cm (Gelfoam; Pharmacia & Upjohn, Kalamazoo, MI, USA), soaked with either 5mg dexamethasone or an equal amount (2 mL) of saline, were left on the decompressed nerve root after unilateral hemilaminectomy, flavectomy and discectomy. RESULTS: Subjective visual analog scale(VAS) scores of leg pain in the dexamethasone group on the first, third and fifth postoperative days (2.5, 2.5, 1.7, respectively) were significantly lower than in the control group (5.0, 4.8, 3.6) ( P<0.05). No side effects related to the dexamethasone-soaked gelatin sponges were observed. CONCLUSION: The intraoperative application of dexamethasone-soaked gelatin sponges during lumbar microdiscectomy can provide effective postoperative analgesia without complications.

Familial Idiopathic Basal Ganglia Calcification

Familial idiopathic basal ganglia calcification(FIBGC) is an inheritable neurological condition characterized by calcium deposits in the basal ganglia and extra-basal ganglia areas. The condition manifests as parkinsonism and other variable neuropsychiatric symptoms. FIBGC is a rare condition, and its pathophysiology has not yet been fully elucidated. Here we report the results of a clinical study of two related patients diagnosed with FIBGC.

Diagnostic Relevance of Pressure-Controlled Discography

Discogenic pain is a leading cause of chronic low back pain. The authors investigated the efficacy of pressure-controlled discography to determine its role in clinical decision-making for the management of patients with discogenic pain. Pressure-controlled discography was performed in 21 patients (51 discs) with pain-provocation, followed by post-discography computerized tomography scans. Pain response was classified as positive response and negative response, and measured with visual analog scale scores. Discographic findings were graded by the modified Dallas discogram scale. Elastance, pain provocation on intradiscal pressure, pressure and volume of initial pain response, and pain response intensity were statistically analyzed. Elastance showed significant differences between Grade 0 and Grade 4 and 5. Decreased elastance with positive pain response group was a good indicator to imply that disc degeneration presumably is a pain generator. Results of pain response were well correlated with intradiscal pressure but not with the amount of injected volume. Among 31 discs of Grade 4 and 5, 74% showed negative pain response and 26% showed positive response. It was concluded that pressure-controlled discography was useful to diagnose discogenic pain and excellent guide in decision-making for spinal operations.

Selective Neurotomy of Sacral Lateral Branches for Pain of Sacroiliac Joint Dysfunction

OBJECTIVE: The sacroiliac joint complex is often related with functionally incapacitating pain in old aged people. The purpose of this study is to delineate the investigation strategies and to determine the long-term effect of radiofrequency (RF) neurotomies for pain arising from sacroiliac joint dysfunction(SIJD) METHODS: Sixteen patients were diagnosed as having chronic pain from SIJD by comparative controlled blocks on L5 dorsal rami, sacroiliac joints and deep interosseous ligaments. After confirming the positive response (more than 50% of pain relief), sensory stimulation was applied to detect the `pathological' branches. Subsequently, RF neurotomies were performed on the selected nerve branches. Surgical outcome was graded as successful, moderate improvement, and failure after a 6month follow-up period. RESULTS: Stimulation intensity was 0.45V to elicit pain response in the L5 dorsal rami and lateral sacral branches. The number of RF-lesioned nerve branches was 6per patient. The average number of lesions for each branch was 1.3. Most commonly selected branches were L5 dorsal ramus (88%) and S2-upper division (88%). Ten patients (63%) reported a successful outcome according to the outcome criteria after 6months of follow-up, and five patients (31%) reported complete relief (100%). Five patients (31%) showed moderate improvements. One patient reported failure. CONCLUSION: RF neurotomy of lateral sacral branches is an excellent treatment modality for the pain due to SIJD, provided that comparative controlled block shows a positive response.

Pilocytic Astrocytoma Occuring in a Patient Treated with Gamma Knife Surgery: Case Report

We report a case of pilocytic astrocytoma and atypical meningioma occurred within the field of gamma knife surgery for the management of preexisting meningioma. A 76-year old woman received gamma knife surgery for the management of meningioma in the right parietal convexity 9 years ago. Three weeks before admission, left hemiparesis and speech disturbance were developed and magnetic resonance image showed cystic mass with nodular enhancement in the right parietal area. Craniotomy and total removal of mass was performed and the histological diagnosis of atypical meningioma and pilocytic asrtocytoma were done.

Cerebral Salt Wasting Syndrome Associated with Pseudomonas Meningitis ccurred after Removal of Pituitary Adenoma: A Case Report

The authors report a case of cerebral salt wasting(CSW) syndrome followed by diabetes insipidus and meningitis after transsphenoidal approach for pituitary adenoma. Fluid and electrolyte imbalance occurs occasionally in neurosurgical patients due to DI or SIADH, however, CSW is different disease entity and the methods of treatment are different from those of DI or SIADH. A number of studies in recent years have shown that hyponatremia in many patients with intracranial disease might actually be caused by CSW in which a renal loss of sodium leads to hyponatremia and massive urinary water loss. CSW of this patient was resolved by fluid and salt replacement after 6 months.

Effect of Eveing Primrose on Plasma Cholesterol Levels and Immune Response to Sheep Erythrocytes

Evening primrose oil(EPO), which contains 72% cis-linoleic acid and 9% cisgamma linolenic acid, has been clinically used for treatment of number of diseases in human and animals. And it is also known to lower cholesterol(CHO) level of hypercholesterolaemic individuals. But the role of EPO as CHO-suppressant is controversial, and the relationship of EPO to CHO level in immune regulating activities is unclear at present. To evaluate the effect of evening primrose on the normal plasma CHO-levels, rabbits were fed with evening primrose seed(EPS) or injected with evening primrose seed-extract(EPE), and measured the plasma CHO-levels by duration of treatment. Both of EPS and EPE did not influence the plasma CHO-levels until 4 day treatment and thereafter the levels were significantly reduced. For the investigation of the EPE-effect on immune response to sheep erythrocytes(SRBC), mice were injected with EPE for 4 days before SRBC-sensitization or with CHO just before SRBC, Sensitization or with CHO in regulating effect of immune response was evaluated by the measuring the footpad swelling reaction and antibody response to SRBC. EPE itself did not influence Arthus reaction but it remarkable reduced delayed type hypersensitivity(DTH) and antibody production in comparison with control. CHO slightly increased Arthus reaction and DTH, but it somewhat decreased antibody responses. However, CHO significantly recovered the EPE-induced decrement of DTH and humoral immunity. There results led to that conclusion the evening primrose triggers the decrease of plasma CHO-levels and immune responses, and suggested that the mechanisms responsible for the nonspecific immune inhibitory effect of evening primrose might be partially due to the decrement of the CHO-levels.