Surgical Treatment of Esophago-Cutaneous Fistula Developing after Anterior Cervical Spine Surgery: Case Report

Esophageal perforation is a rare but serious complication of anterior cervical spine surgery. Various methods have been developed for it's repair, and due to its multifocal blood supply, considerable length in the neck, and proximity to many important cervical structures, a sternocleidomastoid muscle flap has, in particular, been successfully utilized. The authors report two cases of cervical esophago-cutaneous fistula treated with sternocleidomastoid muscle flap.

Surgical Treatment of Instability of Upper Cervical Spine Associated with Trauma

With the aim of determining the outcome of surgery, a review of patients undergoing trauma-associated atrantoaxial arthrodesis. Between 1993 and 1997, 16 patients underwent 19 proceedures, with a follow-up period of between six and 29 months. The most common reasons for surgery were odontoid fracture(n=12), os odontoideum(n=1) procedure, and neurofibrimatosis type I(n=1). Ten posterior wiring, four Halifax clamp application, one anterior screw fixation of dens, two transarticular screw fixations, and one staged operation(anterior odontoiddectomy and posterior occipitocervical fusion) were performed. All patients has been surgically managed for about three months with a Halo-vest or rigid cervical neck collar, during which time three complications associated with operative procedures arose : Halifax clamp dislodgement, malunion and subluxation kyposis. In 15 of 16 patients, fusion was successful. In caes involving complicated atlantoaxial dislocation, the authors recommend postoperative Halo-vest immobilization for sucessful fusion after posterior C1-C2 wiring or Halifax clamping

Emergent Aneurysm Surgery without Cerebral Angiography for the Comatose Patients with ICH or SDH

Neurologically based clinical grading scales offer excellent prognostic information for the patient suffering diffuse subarachnoid hemorrhaging. These grading scales are less applicable to patients with life-threatening intraparenchymal or subdural hematomas after aneurysmal rupture. During 2 and half years, 9 patients(ICH;5,SDH;1, ICH+SDH;3) in a comatose state with brain stem compression syndromes documented by computerized tomographic scans have undergone emergent operation without angiography in our neurosurgical department. Each patient was so critically ill that we believed it unwise to delay craniotomy for diagnostic angiography. The average delay from the detection to operation was 2 hours. The origin of the hematoma was identified as a berry aneurysm of the middle cereral artery bifurcation in seven patients and a posterior communicating artery aneurysm in two patients. One patient had a good recovery, two patients reovered with hemiparesis and mild cognitive dysfunction, two patients were vegetative and died due to pneumonia, and four patients died due to brain swelling within two weeks postoperatively. Emergent craniotomy with empiric exploration of appropriate subarachnoid cisterns after hematoma decompression may be life-saving management in some cases. The delay imposedfor diagnostic angiography may be avoided in attempts to save vital minutes of severe brain stem compression.

A Clinical Analysis of the Patients with Thoracolumbar Vertebral Junction Fracture

To clarify the prognostic factors influencing clinical outcome, the authors retrospectively analyzed 50 cases of thoracolumbar vertebral junction fracture treated at our hospital between September 1989 and October 1992. The age of the patients ranged from 23 to 75 years(median 49 years) and the male-to-female ratio was 33:17. Falling was the major mode of injury(m=27). The kyphotic angle between fractured vertebrae and the ratio of neural canal encroachment was measured in a simple X-ray and a computed tomography(CT) of the thoracic spine. An ANOVA test was performed to evaluate the predicting factors to determine the final outcome. The kyphotic angle and loss of height of vertebral body were not significantly correlated with the neurological status of the patients. However, the ratio of the compromised area of the neural canal was closely correlated with the neurological outcome(p value<0.05). The worst prognosis was found in patients with fracture-dislocation. In conclusion, it is suggested that early surgical intervention must be considered in the neurologically compromised patients whose CT demonstrates neural canal encroachment by bony fragments.

Emergent Aneurysm Surgery without Cerebral Angiography for the Comatose Patients with ICH or SDH

Neurologically based clinical grading scales offer excellent prognostic information for the patient suffering diffuse subarachnoid hemorrhaging. These grading scales are less applicable to patients with life-threatening intraparenchymal or subdural hematomas after aneurysmal rupture. During 2 and half years, 9 patients(ICH;5,SDH;1, ICH+SDH;3) in a comatose state with brain stem compression syndromes documented by computerized tomographic scans have undergone emergent operation without angiography in our neurosurgical department. Each patient was so critically ill that we believed it unwise to delay craniotomy for diagnostic angiography. The average delay from the detection to operation was 2 hours. The origin of the hematoma was identified as a berry aneurysm of the middle cereral artery bifurcation in seven patients and a posterior communicating artery aneurysm in two patients. One patient had a good recovery, two patients reovered with hemiparesis and mild cognitive dysfunction, two patients were vegetative and died due to pneumonia, and four patients died due to brain swelling within two weeks postoperatively. Emergent craniotomy with empiric exploration of appropriate subarachnoid cisterns after hematoma decompression may be life-saving management in some cases. The delay imposedfor diagnostic angiography may be avoided in attempts to save vital minutes of severe brain stem compression.

A Clinical Analysis of the Patients with Thoracolumbar Vertebral Junction Fracture

To clarify the prognostic factors influencing clinical outcome, the authors retrospectively analyzed 50 cases of thoracolumbar vertebral junction fracture treated at our hospital between September 1989 and October 1992. The age of the patients ranged from 23 to 75 years(median 49 years) and the male-to-female ratio was 33:17. Falling was the major mode of injury(m=27). The kyphotic angle between fractured vertebrae and the ratio of neural canal encroachment was measured in a simple X-ray and a computed tomography(CT) of the thoracic spine. An ANOVA test was performed to evaluate the predicting factors to determine the final outcome. The kyphotic angle and loss of height of vertebral body were not significantly correlated with the neurological status of the patients. However, the ratio of the compromised area of the neural canal was closely correlated with the neurological outcome(p value<0.05). The worst prognosis was found in patients with fracture-dislocation. In conclusion, it is suggested that early surgical intervention must be considered in the neurologically compromised patients whose CT demonstrates neural canal encroachment by bony fragments.

Loss of Heterozygosity of Chromosome 17p in Brain Tumors

With the methods of restriction fragment length polymorphisms(RFLPs) and southern blot analysis, gene deletion of chromosome 17p in 16 cases of brain tumors, was investigated. There were 4 cases of glioblastoma multiforme, 1 case of anaplastic astrocytoma, 4 cases of low grade astrocytoma, 3 cases of oligodendroglioma, and 4 cases of meningioma. Among restriction fragment length polymorphism(RFLP) DNA located in chromosome 17p, p144D 6 and p SNZ 22 were imployed as the probes. In eight of 16 cases(50%) constitutional heterozygosity was observe dfor p144 D6 probe on the short arm of chromosome 17, and in nine of 16 cases(56%) for PYNZ 22.1 probe. With both probes constitutional heterozygosity was observed in thirteen of 16 cases(81%). And the loss of constitutional heterozygosity was detected in two of 14 informative cases. Although, with the malignant gliomas, including 4 cases of glioblastoma multiforme and 1 case of anaplastic astrocytoma, two of 4 informative cases showed loss of constitutional heterozygosty, None of 9 informative cases showed loss of heterozygosity with the other brain tumors(low grade astrocytoma, oligodendroglioma, and meningioma).

Far Lateral Lumbar disc Herniation

Far lateral disc herniation(FLDH) with compression of the nerve root as it exits through the foramen has been a recognized entity for a number of years. Failure to diagonose and precisely localize these herniations can lead to unsuccessful surgical exploration or exploration of the innocent interspace. If these herniation are diagnosed, they often cannot be adequately exposed by the classic minline hemilaminectomy approach. A partial or complete unilateral facetectomy to expose these herniations can lead to vertebral instability or contribute to continued postoperative back pain. The authors present 5 patients who were diagnosed as having far lateral lumbar disc herniations from 1988 to 1990. Two of these were at L4-5 level, two at L5-S1 level and one at L3-4 level and all were over 60 years old. High resolution CT scan appeared to be the best study and the paramedian muscle splitting microsurgical approach, done in 3 cases, was found to be the most direct and favorable anatomical route to FLDH for vertebral stability and minimal postoperative back pain.

The Clinical Analysis of 22 Cases of Encephalocele

An encepholocele is defined as a herniation of cranial contents through a defect in the skull. Encephaloceles are classified accroding to their contents and location. Encephalocele is a useful general term to refer to common features of the various forms of anomaly, but considerable differences exist in the pathology, treatment and prognosis of encephaloceles at each anatomical location. Improved neuroimaging facilities, especially MRI, make it easy not only to detect the encephalocele including its contents and location, but also to get preoperative informations. We have reviewed a total of 22 patients with encephalocele whom we have experienced from 1986, July to 1990, June. Twelve were at occipital location, six at cranial vault, three at cranial base, one at frontoethmoidal location. The size of cranium bifidum and herniating sac of the cranial vault and occipital location is larger than that of frontobasal location. The incidence of associated hydrocephalus is in order of occipital, cranial vault, frontobasal form, and its prognosis is also better in frontobasal form than in occipital of cranial vault form.

MR Finding in Subarachnoid Hemorrhage

In an effort to determine the value of the magnetic resonance imaging(MRI) in patients with subarachnoid hemorrhage(SAH), we compared MR findings with CT findings in 34 patients of aneurysmal SAH who taken MRI either preoperatively or postoperatively. MRI was taken in 8 patients and postoperatively in 31 patients. Preoperative abnormal MR findings were cisternal space obliteration(in one case), subacute hematoma in cisternal space(in one case), and visualization of turbulent signal void of aneurysm(in 3 cases). In 31 patients, MRI was taken postoperatively without any problem in spite of their intracranial aneurysm clip(in 9 patients among them, MRI was taken in high(2.0T) magnetic field). And characteristic MR artifact, with sausage shaped central low signal and surrounding high signal in T2WI, appeared in postoperative MRI scans. Their dimension were about 2+4cm in T2WI axial and T2WI sagittal scans. Findings of infarction were detected in 3 cases in both MRI scans and CT scans which were taken within 3dyas interval, postoperatively 1 in total 9 cases. But findings of the hemorrhagic infarction(3 cases) and subacute hemorrhage(2 cases) were detected only in MRI scans.