Tactics and Pitfalls of MED(Micro Endoscopic Discectomy) System for Lumbar Disc: For Surgeons Who Wish to Attempt

No abstract available.

Acute Panspinal Epidural Abscess

Epidural abscess of the spine is an uncommon disorder. However, this condition can cause irriversible neurologic injury or death if it is not recognized and treated early. The constellation of presenting symptoms is frequently nondiagnostic and may be especially confusing in patients with chronic neck or back pain. The most important source of infection is, via hematogenous spread, the furuncle and abscess of the skin. The most frequent site of infection is thoracolumbar region(50%), and the most common cause of pathogen is Staphylococcus The pathogenesis o f the associated spinal cord dysfunction remains unresolved, but histopathological data from a previous study suggested that a mechanical mass effect rather than vascular thrombosis or vasculitis was responsible for the initial neurological deficit. MRI offered the advantage of noninvasive early recognition and anatomical localization, which made it the imaging modality of choice. Rim enhancement indicates abscess and diffuse enhancement indicates granulation tissue and fibrosis. Tuberculous epidural abscess usually spreads to ventral epidural space whereas pyogenic epidural abscess encircles entire epidural space. The treatment of choice of the spinal epidural abscess is early surgical decompression and drainage. Rapid diagnosis and treatment of this disease is essential for neurologic recovery and even for preservation of life. The author report a case of spinal epidu ral abscess, which involved continuously from the second cervical vertebra to the forth lumbar vertebra. The patients neurological conditions were improved following emergent decompression.

Reoperation for Postoperative Intracranial Hemorrhage in Patients with Traumatic Intracranial Hematoma

Twenty five consecutive patients requiring reoperation due to hemorrhage following surgery for intracranial hematoma removal were identified in a retrospective review of 211 cases of traumatic intracranial lesions treated at our hospital between January 1990 and December 1994. In cases involving head injury, reoperation is nowadays not uncommon. The incidence of cases requiring reoperation was 11.8%, while delayed or recurrent lesions were more common among older patients(mean age=44.39 years). Acute subdural hemorrhage was the most common initial lesion requiring reoperation: in intracerebral and acute subdural hemorrhage, the incidence of reoperation was relatively high(23.1% and 14.7%, respectively): acute epidural hemorrhage was next most common(8.8%). In 88.0% of cases, reoperation was performed within 24 hours. At the time of discharge, good recovery was reported in five cases(20.0%), moderate disability in ten(40.0%), severe disability in two(8.0%), vegetative state in two(8.0%) and death in six(24.0%). The outcome seems to be related to lesions requiring reoperation rather than initial lesions. Furthermore, closed observation and aggressive management can rapidly improve the outcome, even in patients requiring reoperation: it is, in addition, of the utmost importance that CT scans be used early and repeatedly, especially in patients who are at risk of delayed or recurrent lesions.

Recurrent Meningitis due to Growing Basal Skull Fracture of Orbital Roof: A Case Report

A 6-year old boy was admitted with high fever and redness of the right eyelids and the surrounding area. He had previously suffered cerebral contusion, basal skull fracture and pneumocephalus following a traffic accident which required six months' hospitalization. Since then, and prior to admission, he had twice suffered probable bacterial meningitis and had been treated at an outstanding hospital. At the time of this admission, the patient again developed high fever, with redness of the right eyelid and surrounding area. His symptomatology suggested bacterial meningitis and cerebrospinal fluid culture revealed Streptococcus pneumoniae sensitive to penicillin. In accordance with the clinical course of meningitis and accompanying sinusitis, the appropriate antibiotic and its duration of usage were determined. Recurrent episodes of bacterial meningitis in this child raised the possibility of anatomical defect as an a contributory factor. Computerized tomographic(CT) cisternography suggested leakage of cerebrospinal fluid and revealed herniated frontal brain tissue protruding through a gap in the right frontal skull base, three dimensional CT(3-D CT) confirmed this defect, which was 3X4cm in size. After recovery from meningitis, surery to prevent recurrent meningitis, was performed. To locate pathologic areas, the subfrontal approach,involving bicoronal skin incision and bifrontal bone flap was used. Multiple fracture lines and a large bony defect on the orbital roof were observed, together with a dural defect, through which cerebromalatic tissue was herniated as encephalocele. Using lyophilized dura, the dural defect was made watertight; the bony defect was packed with autologous fats and covered with titanium mesh. The patient improved after surgery. Recurrent meningitis with anatomical pathologic focus after head trauma requires surgical intervention.

Clinical Analysis of Subarachnoid Hemorrhage with Intraventricular Hemorrhage due to Aneurysmal Rupture

Eventhough the morbidity and mortality rate of subarachnoid hemorrhage(SAH) due to aneurysmal rupture has dramatically decreased, SAH associated with intraventricular hemorrhage(IVH) still shows a high mortality rate. Among total of 419 patients with SAH due to aneurysmal rupture, 43 cases were associated with IVH. Authors conducted a retrospective study on these cases based on age, sex, Hunt-Hess grade, location of aneurysm, presence of intracerebral hematoma(ICH), ventriculocranial ratio, method of treatment, and final outcome. Results were as follows; 1) In patients associated with IVH, initial mental status was poor. 2) Worse the initial mental status, worse the final outcome. 3) A higher mortality rate was associated with those patients with ICH. 4) Severe ventricular enlargement was associated with increased mortality rate. We believe that a better prognostic outcome would result if aggressive therapeutic methods such as ventriculostomy, basal cistern irrigation as well as lamina terminalis opening, are performed.

Clinical Evaluation of Salvage Surgery for Patients with Failed Anterior Cervical Surgery

Although anterior cervical fusion provides an excellent choice for variable cervical pathologic conditions. However the potential risk of complications involved with its use have been the reason for its being less then universally accepted. The authors experienced 10 cases(5.8%) of failed anterior cervical surgery among the total of 171 during the past 5 years. The patients in our series averaged 52.9 years of age(range 26-75), consisted of 9 men and 1 woman. The clinical presentations were nuchal pain(80%), radiculopathy(50%), myelopathy(10%) and dysphagia (10%). The causes of failed anterior cervical surgery included 6 hardware failures and 4 graft failures. Salvage procedures included 9 anterior approach and 1 posterior approach. The mean follow up period was 15 months. All patients had achieved solid bony fusion in addition to marked symtomatic improvements of 70%(in 7 cases). The results of our study indicates that in order to reduce the need for salvage operations, accurate diagnosis, skillful surgical techniques are necessary.

Early Surgery for Poor-Grade Aneurysmal Subarachnoid Hemorrhage

In order to determine the effect of early surgery on poor grade subarachnoid hemorrhage(SAH) patients. 88 such patients were evaluated between January, 1990 and January, 1996. Clinical grade on admission was Hunt-Hess grade IV(n=58) and V(n=30). The protocol involved the use of computed tomography(CT) scanning to diagnose SAH and to obtain evidence of the destruction of vital brain function, involving massive cerebral infarction with midline shift, dominant basal ganglia or brain stem hematoma. Patients were assigned to either the early surgery group(n=54: surgery performed within 3 days of the first hemorrhage) or the non-surgical group(n=33). In seventeen of 58 in Hunt-Hess grade IV patients, the outcome was good(GOS 4 and 5); 15 of these were in the early surgery group. In only one of 30 Hunt Hess grade V patients was there a good outcome, however. Among Hunt-Hess grade IV patients, mortality was 36.8% in the early surgery group and 60% in the non-surgical group; in the Hunt-Hess grade V group, the corresponding figures were 75% and 100%. In conclusion, it is recommended that to prevent rebleeding and other complications, Hunt-Hess grade IV patients, especially those that showing destruction of vital brain function, should undergo early surgery. With regard to early surgery, non-operation and the existence of evidence of destruction of vital brain function, grade V patients showed no difference in terms of their mortality and morbidity rate.

Overview of Surgical Result of Multiple Intracranial Aneurysmal Patients

From January 1990 to January 1996, we analyzed outcome according to the distribution of aneurysms, the type of surgical treatment, the timing of operation, and the patient's pre-operative status in a total of 54 cases of multiple intracranial aneurysms. The frequency of multiple intracranial aneurysms was 13.4% and the sex ratio was 1:2 with female being predominant. The frequency of aneurismal location was MCA(35.0%), P-comm. Artery(25.0%) and A-comm. Artery(15.0%) in that order. The number of ruptured aneurysms was in the order to MCA aneurysms. A-comm aneurysms, and P-comm aneurysms. The size of ruptured aneurysms was 6-10mm in 34 cases(64.2%). The unilateral distribution of aneurysms was 31 cases(57.4%) and the bilateral was 28 cases(42.6%). Depending on how many times the patient had the operation, these were 29(57.4%) cases of complete single operation, 17 cases(31.5%) of complete two-stage operation, and 8 cases(14.8%) of partial operation. Surgical outcome was good(GOS< or =4) in 42 cases(77.8%), and six patients(11.1%) expired. Based on the results of the above study we have concluded that initial Hunt-Hess grade has a close relationship with the outcome, but the operation type, the timing of operation, the number and distribution of aneurysms do not significantly effect the outcome.

Primary Rhabdomyosarcoma in Temporal Bone Invading Petrous Bone

The rhabdomyosarcoma(RMS), a leading malignant soft tissue tumor in the pediatric population, occurs most commonly in the craniocervical region. RMS has involved the temporal bone approximately 7% in the literature. Petrous bone invasion was very rare and the overall outcome was always fatal, in spite of the efficacy of multimodality therapy, until recent years. The authors report a case of primary RMS in the temporal bone invading petrous bone and the result of multimodality treatment.

Long Term Follow up Results of Threaded Fusion Cage(T.F.C.) in Surgical Treatment of Spondylolisthesis

The goal of operation in spondylolisthesis is improving radiculopathy and relieving lower back pain preventing further progression of the slip, through decompression of neural elements and fusion of spinal pseudoarthrosis, respectively. The author performed the posterior lumbar interbody fusion technique using a Threaded Fusion Cage(T.F.C.) for 41 patients as the surgical treatment for mild spondylolisthesis. All patients enrolled in the study were implanted with a T.F.C. at a single unstable level. We have investigated the outcome results for at least one year(mean 25.8 months). Of these patients 95% have shown solid fusions. Using the Prolo scale for economic and functional rating, the combined results of excellent, good score is 51%, but clinically symptomatic improvement is 66%. Therefore, posterior lumbar interbody fusion using T.F.C. was useful in treatment of mild degree spondylolisthesis.

Spontaneous Epidural Hematoma of the Lumbo-Sacral Region

Spontaneous epidural hematoma in the spinal canal is an uncommon entity and has usually caused progressive neurological deficits and surgical decompression should be required. A 27-year old patient suffered from acutely developed back pain, associated with a wrenching movement of the back. Several hours later, the symptoms were exaggerated with severely radiating pain to the posterior thigh and calf. The diagnosis was made on CT scan. The patient's clinical manifestations improved completely over a few days with surgical intervention. We reviewed the literatures and discussed the etiological factors of spinal epidural hematoma and the utility of CT scan in differentiating other cause of back pain.

Presacral Mass in Currarino Triad: Case Report

The Currarino triad is a unique complex of congenital caudal anormalies including anorectal malformation, sacral bony abnormality, and presacral mass. Histologically the presacral mass has been identified as a meningocele, teratoma, enteric duplication or a combination of this. A Case of female infant with this triad was presented and was successfully treated by surgery. The presacral mass was a lipomyelomeningocele. The clinical features, unique radiologic findings, and importance of a correct diagnosis of currarino triad were reviewed.

Clinical Analysis of Subdural Hygroma

The authors analysed 140 cases of subdural hygroma developed after head injury and various neurosurgical operations and was treated at Hanyang university hospital from 1983 to 1989. The results were analysed and summarized as follows. 1) The peak incidence was the age over 50 and under 10. 2) 104 cases(74.4%) were bilateral frontotemporoparietal lesions. 3) Causes were head injury(121 cases), operation for intracranial aneurysms(5 cases), ventriculoperitoneal shunt(5 cases), traumatic(2 cases), external ventricular drainage(1 case). 4) Change in mental status without focal sign of brain damage was presenting symptom. 5) Operation was underwent if 63 cases and the reaccumulation rate was high (26.8%) after trephination but outcome was favorable. 6) Mortality rate in traumatic subdural hygroma was low(5.8%) because brain CT could detect subdural hygroma easily in early stage.