Clinical Characteristics of Spinal Epidural Abscess Accompanied by Bacteremia

Objective@#: The treatment of choice for spinal epidural abscess (SEA) generally is urgent surgery in combination with intravenous antibiotic treatment. However, the optimal duration of antibiotic treatment has not been established to date, although 4–8 weeks is generally advised. Moreover, some researchers have reported that bacteremia is a risk factor for failure of antibiotic treatment in SEA. In this study, we investigated the clinical characteristics of SEA accompanied by bacteremia and also determined whether the conventional 4–8 weeks of antibiotic treatment is sufficient. @*Methods@#: We retrospectively reviewed the medical records and radiological data of 23 patients with bacterial SEA who underwent open surgery from March 2010 to April 2020. All patients had bacteremia preoperatively and underwent weeks of perioperative antibiotic treatments based on their identified organisms until all symptoms of infection disappeared. All patients underwent microbiological studies of peripheral blood, specimens from SEA and concomitant infections. The mean follow-up duration was 35.2 months, excluding three patients who died. @*Results@#: The male : female ratio was 15 : 8, and the mean age was 68.9 years. The SEA most commonly involved the lumbar spinal segment (73.9%), and the mean size was 2.9 vertebral body lengths. Mean time periods of 8.4 days and 16.6 days were required from admission to diagnosis and from admission to surgery, respectively. Concomitant infections more frequently resulted in delayed diagnosis (p=0.032), masking the symptoms of SEA. Methicillin-sensitive Staphylococcus aureus was the most commonly identified pathogen in both blood and surgical specimens. Seventeen patients (73.9%) showed no deficits at the final follow-up. The overall antibiotic treatment duration was a mean of 66.6 days, excluding three patients who died. This duration was longer than the conventionally advised 4–8 weeks (p=0.010), and psoas or paraspinal abscess required prolonged duration of antibiotic treatment (p=0.038). @*Conclusion@#: SEA accompanied by bacteremia required a longer duration (>8 weeks) of antibiotic treatment. In addition, the diagnosis was more frequently delayed in patients with concomitant infections. The duration of antibiotic treatment should be extended for SEA with bacteremia, and a high index of suspicion is mandatory for early diagnosis, especially in patients with concomitant infections.

Endoscopic Treatment of Intussusception due to Intestinal Tuberculosis

Traditionally, adult intussusception has required a bowel resection because of the malignancy risk. A patient with anorexia, weight loss, and abdominal pain visited our clinic. A physical exam and imaging study revealed no acute peritoneal signs. A colonoscopy for biopsy and bowel reduction was attempted. The tissue sample was consistent with intestinal tuberculosis. We report intestinal tuberculosis complicating intussusception which was treated without surgical intervention.

Posttraumatic Intracranial Tuberculous Subdural Empyema in a Patient with Skull Fracture

Intracranial tuberculous subdural empyema (ITSE) is extremely rare. To our knowledge, only four cases of microbiologically confirmed ITSE have been reported in the English literature to date. Most cases have arisen in patients with pulmonary tuberculosis regardless of trauma. A 46-year-old man presented to the emergency department after a fall. On arrival, he complained of pain in his head, face, chest and left arm. He was alert and oriented. An initial neurological examination was normal. Radiologic evaluation revealed multiple fractures of his skull, ribs, left scapula and radius. Though he had suffered extensive skull fractures of his cranium, maxilla, zygoma and orbital wall, the sustained cerebral contusion and hemorrhage were mild. Eighteen days later, he suddenly experienced a general tonic-clonic seizure. Radiologic evaluation revealed a subdural empyema in the left occipital area that was not present on admission. We performed a craniotomy, and the empyema was completely removed. Microbiological examination identified Mycobacterium tuberculosis (M. tuberculosis). After eighteen months of anti-tuberculous treatment, the empyema disappeared completely. This case demonstrates that tuberculosis can induce empyema in patients with skull fractures. Thus, we recommend that M. tuberculosis should be considered as the probable pathogen in cases with posttraumatic empyema.

Delayed Brain Infarction due to Bilateral Vertebral Artery Occlusion Which Occurred 5 Days after Cervical Trauma

Vertebral artery (VA) injuries usually accompany cervical trauma. Although these injuries are commonly asymptomatic, some result in vertebrobasilar infarction. The symptoms of VA occlusion have been reported to usually manifest within 24 hours after trauma. The symptoms of bilateral VA occlusions seem to be more severe and seem to occur with shorter latencies than those of unilateral occlusions. A 48-year-old man had a C3-4 fracture-dislocation with spinal cord compression that resulted from a traffic accident. After surgery, his initial quadriparesis gradually improved. However, he complained of sudden headache and dizziness on the 5th postoperative day. His motor weakness was abruptly aggravated. Radiologic evaluation revealed an infarction in the occipital lobe and cerebellum. Cerebral angiography revealed complete bilateral VA occlusion. We administered anticoagulation therapy. After 6 months, his weakness had only partially improved. This case demonstrates that delayed infarction due to bilateral VA occlusion can occur at latencies as long as 5 days. Thus, we recommend that patients with cervical traumas that may be accompanied by bilateral VA occlusion should be closely observed for longer than 5 days.

Pure Spinal Epidural Cavernous Hemangioma with Intralesional Hemorrhage: A Rare Cause of Thoracic Myelopathy

Although cavernous hemangiomas occur frequently in the intracranial structures, they are rare in the spine. Most of spinal hemangiomas are vertebral origin and "pure" epidural hemangiomas not originating from the vertebral bone are very rare. Our spinal hemangioma case is extremely rare because of its "pure" epidural involvement and intralesional hemorrhage. A 64-year-old man presented with progressive paraparesis from two months ago. His motor weakness was rated as grade 4/5 in bilateral lower extremities. He also complained of decreased sensation below the T4 sensory dermatome, which continuously progressed to the higher dermatome level. Magnetic resonance imaging demonstrated thoracic spinal tumor at T3-T4 level. The tumor was located epidural space compressing thoracic spinal cord ventrally. The tumor was not involved with the thoracic vertebral bone. We performed T3-5 laminectomy and removed the tumor completely. The tumor was not infiltrating into intradural space or vertebral bone. The histopathologic study confirmed the epidural tumor as cavernous hemangioma. Postoperatively, his weakness improved gradually. Four months later, his paraparesis recovered completely. Here, we present a case of pure spinal epidural cavernous hemangioma, which has intralesional hemorrhage. We believe cavernous hemangioma should be included in the differential diagnosis of the spinal epidural tumors.

Cognitive Function of Korean Neurosurgical Patients: Cross-sectional Study Using the Korean Version of the Mini-mental Status Examination

OBJECTIVE: As interest in life quality and expectancy increases, cognitive dysfunction is becoming an important topic. Although there are many foreign articles on this topic, they require cultural interpretation to be applicable to Koreans. The purpose of this study was to assess cognitive function in Korean neurosurgical patients. METHODS: We recruited 214 adult Korean patients with various cerebral pathologies and treatments from an outpatient clinic. The male-to-female ratio was 88:126, and their ages ranged from 28 to 81 years (mean: 57.9 years). The Korean version of the mini-mental status examination (K-MMSE) was adopted as an instrument for measuring cognitive function, and a score < or =23 was defined as cognitive dysfunction. K-MMSE scores were analyzed considering the patients' gender, age, time elapsed since treatments, pathology and treatment modality. A serial analysis was performed for 59 patients who completed the K-MMSE more than once. RESULTS: The mean K-MMSE score of 214 patients was 22.3, and 133 patients (62.1%) had a score < or =23. Cognitive dysfunction was common regardless of age, gender, pathology or treatment modality. Serial analysis revealed K-MMSE score improvement in 45 of 59 patients (76.3%). The mean time interval between two tests was 11.9 months, and the mean K-MMSE score improvement was 2.7, which was statistically significant (P = 0.000). However, many still had cognitive impairment. CONCLUSION: Most Korean neurosurgical patients showed cognitive dysfunction despite improvement after several months. Patients with trauma or ischemic disease were more vulnerable. More attention should be paid to neuropsychological complications such as cognitive dysfunction.

Thoracoscopic Approach to the Thoracic Spine / 한양의대학술지

Nowadays, the minimally invasive technique is the current trends in all medical fields. The spine is not the exception. By the development of modern optical devices and computer technology, thoracoscopy arose as new powerful tool in thoracic area. Many spinal disorders which were previously treated by transthoracic surgery are entering into the area of thoracoscopic surgery. The indication for thracoscopic surgery is getting wider and wider as technologies progress. So it seems to be difficult to define its indication strictly, as long as the patient can tolerate one-lung ventilation and endoscopy is accessible. In thoracic discectomy, thoracoscopy not only shortened operation time, hospital stay and chest tube insertion duration, but also lowered medical expense, postoperative pain and complication rate. But the patient selection is not yet established. Corpectomy can be performed in metastatic tumor removal or debridement of osteomyelitis by thoracoscopy. Thereafter, reconstruction or instrumentation is possible to prevent postoperative spinal deformity. In correction of spinal deformity, thoracoscopic surgery showed similar outcomes compared to thoracotomy in deformity correction, bone fusion, and functional outcome. There was also no statistical difference in complication rates between them. Pulmonary complications seen in thoracoscopic surgery such as atelectasis, pneumothorax and hemothorax were common. They seem to be related with the one-lung ventilation and the thoracoscopic approach itself, distinct from thoracotomy. But most complications were not life-threatening with some exceptions. Considering the development during the past two decades, the speed of development of thoracoscopic surgery will accelerate and the role of thoracoscopic surgery will become more important. In the development of thoracoscopy, the technical progression of optics and computer engineering will play important roles.

Expression and Evaluation of Chikungunya Virus E1 and E2 Envelope Proteins for Serodiagnosis of Chikungunya Virus Infection

PURPOSE: Chikungunya virus (CHIKV) causes endemic or epidemic outbreaks of CHIKV fever, which is a mosquitoe-transmitted viral disease in Africa, India, South-East Asia, and recently Southern Europe. Currently, serological diagnostic tests such as hemagglutination inhibition test (HI test), in-house IgM capture enzyme-linked immunosorbent assays (ELISA), and indirect immunofluorescence test were used for diagnosis of chikungunya fever, which are based on whole virus antigens. MATERIALS AND METHODS: CHIKV E1, and E2 envelope proteins for the CHIKV-specific serodiagnostic reagents for chikungunya fever were expressed in baculovirus expression system. The seroreactivity of recombinant CHIKV E1 and E2 envelope proteins were evaluated using sera panels of patients from Laboratoire Marcel Merieux by indirect IgM capture ELISA. RESULTS: The recombinant CHIKV E1 and E2 envelope protein showed sensitivity of 77.5% and 90%, respectively. The specificities of both CHIKV E1 and E2 envelope proteins were 100%. CONCLUSION: The recombinant CHIKV E1 and E2 envelope proteins could be a useful diagnostic reagent for CHIKV infection.

Identification and functional characterization of an alternative splice variant within the fourth exon of human nanog

Nanog, a homeodomain (HD) transcription factor, plays a critical role in the maintenance of embryonic stem (ES) cell self-renewal. Here, we report the identification of an alternatively-spliced variant of nanog. This variant lacked a stretch of amino acids (residues 168-183) located between the HD and tryptophan-repeat (WR) of the previously-reported full length sequence, suggesting that the deleted sequence functions as a linker and possibly affects the flexibility of the C-terminal transactivation domain relative to the DNA binding domain. Expression of mRNA encoding the splice variant, designated as nanog-delta 48, was much lower than that of the full length version in human ES cells. The ratio of nanog-delta 48 transcript to full length transcript increased, however, in multipotent adult progenitor cells. EMSA analysis revealed that both forms of Nanog were able to bind a nanog binding sequence with roughly the same affinity. A reporter plasmid assay also showed that both variants of nanog modestly repressed transactivation of gata-4, whose expression is proposed to be inhibited by nanog, with comparable potency. We conclude that, despite the difference in primary structure and expression pattern in various stem cells, the alternatively-spliced variant of Nanog has similar activity to that of the full length version.