Endoscopic Spinal Surgery for Herniated Lumbar Discs

OBJECTIVE: So called "minimally invasive procedures" have evolved from chemonucleolysis, automated percutaneous discectomy, arthroscopic microdiscectomy that are mainly working within the confines of intradiscal space to transforaminal endoscopic technique to remove herniated epidural disc materials directly. The purpose of this study is to assess the result of endoscopic spinal surgery and favorable indications in the thoracolumbar spine. METHODS: The records of 71 patients, 73 endoscopic procedures, were retrospectively analysed. Yeung Endoscopic Spine Surgery system with 7 mm working sleeve and 25degrees viewing angle was used. The mean follow up period was 6 months (range,3-9). RESULTS: Operated levels were from T12-L1 disc down to L5-L6 or S1 disc. Of 71 cases, 2 patients underwent transforaminal endoscopic surgery twice due to recurrence after initial operation. MacNab's criteria was used to assess the outcome. Favorable outcome, excellent or good, was seen in 78% (57 procedures) of the patients. Among 11 fair outcomes, only 1 procedure was followed by secondary open procedure, laminectomy with discectomy. Two of 5 poor outcomes were operated again by same procedure which resulted in fair outcomes. One patient with aggravated cauda equina syndrome remained poor and a lumbar fusion procedure was performed in other patient with poor outcome. There were 2 postoperative discitis that were treated with conservative care in one and anterior lumbar interbody fusion in the other. CONCLUSION: Evolving technology of mechanical, visual instrument enables minimal invasive procedure possible and effective. The transforaminal endoscopic spinal surgery can reach as high as T12-L1 disc level. The rate of favorable outcome is mid-range among reported endoscopic lumbar surgery series. Authors believe that the outcome will be better as cases accumulate and will be able to reach the rate of standard open microsurgery.

Approximate Entropy of the Short-term Variability of Fetal Heart Rate as an Efficient Measurement of Fetal Distress / 대한산부인과학회잡지

OBJECTIVE: The purpose of this study was to evaluate the usefulness of approximate entropy on fetal heart rate variability of electronic fetal monitoring taken during antepartum and intrapartum periods as a new diagnostic method of fetal distress. METHODS: Among 76 pregnant women who underwent computerized electronic fetal monitoring and cord blood gas analysis, we divided them into 3 groups, i.e.; 36 into normal fetus group, 26 into presumed distress group and 14 into acidemic distress group. We performed a frequency analysis on time series of heart rate variability in three groups. In order to perform non-linear analysis on the raw data of the fetal heart rate, after resampling and low pass filtering, we investigated approximate entropy. RESULTS: The results of the approximate entropy showed that the value in normal fetus group was significantly high than the value in distress group. But in the distress group, ApEn value was not difference between acidemic and non-acidemic subgroup. ApEn of HRV was confirmed in nonlinear parameter without low pass filtering and resampling. CONCLUSION: The results show that the fetal heart rate variability has nonlinear characteristics and could distinguish normal fetal heart rate pattern and distress pattern numerically and objectively. And these ApEn value are useful for prediction and diagnosis of fetal distress in ante and prenatal periods.

Spinal Extradural Arachnoid Cyst: Case Report

We report a case of thoracolumbar extradural arachnoid cyst in a 39-year-old male who presented with left lower thoracolumbar back pain, left buttock pain, hypesthesia in the left leg for three months. Magnetic resonance image revealed a cystic mass which lies posterior to the spinal cord from T12 to L2 vertebra level. The spinal cord was displaced anteriorly and flattened. We performed total laminectomy from lower half of T12 to upper half of L2 to remove cystic mass which was found to be an extradural lesion. There was a dural opening near the left L1 nerve root sleeve through which cerebrospinal fluid(CSF) was leaking and part of nerve roots were moving back and forth by CSF pulsation. A prompt improvement of the symptoms was noted after surgery. Possible mechanisms of spinal extradural arachnoid cyst and surgical intervention are discussed.

A case of acute disseminated encephalomyelitis with liver abscess / 대한내과학회지

Acute disseminated encephalomyelitis (ADEM) is an acute inflammatory demyelinating disease of central nervous system, and is related to allergic or immune-mediated reaction to systemic viral infection or vaccination, which is usually self limited monophasic illness. As the clinical manifestations or laboratory findings is nonspecific, it is diagnosed by brain magnetic resonance imaging (MRI) showing multiple foci of increased T2 signal within white matter. We report the clinical and radiologic imaging findings in a 36-year-old man in whom acute disseminated encephalomyelitis developed after serologically proven herpes infection combined with liver abscess. His clinical course, despite without corticosteroid or plasmapheresis because of liver abscess, was shown spontaneous remission.

The Clinical Analysis of Bleeding Pattern in Patients with Ruptured Middle Cerebral Artery Aneurysm

OBJECTIVES: The rupture of middle cerebral artery(MCA) aneurysm usually cause or is associated with higher incidence of intracerebral hemorrhages(ICH) than any other aneurysmal ruptures. Also, the outcome of patients who had ICH is known to be worse than patients who had subarachnoid hemorrhage(SAH) only. The authors report the bleeding pattern and outcome of ruptured MCA aneurysm patients. PATIENTS AND METHODS: A total 106 ruptured MCA aneurysm patients who were surgically treated were included and they were divided into 2 groups by the initial brain CT findings according to the presence or absence of ICH over 10cc in amount. The clinical data were analysed retrospectively. RESULTS: The overall mortality was 18.9%. Among 81 patients(76.4%) who had subarachnoid hemorrhage(SAH) only, 68 patients(84%) showed favorable outcome. Twenty five patients(23.6%) had ICH over 10cc in amount with or without SAH, and among them, 11 patients(44%) showed favorable outcome. The ICH was located in temporal lobe(15 patients, 60%), frontal lobe(3, 12%), sylvian fissure(6, 24%) and frontal-temporal lobe(1, 4%). Among 15 patients who had ICH in temporal lobe, only 4 patients(26.6%) showed favorable outcome and all 3 patients who had ICH in frontal lobe showed favorable outcome. CONCLUSION: ICH was presented in 23.6% of ruptured MCA aneurysm patients and the prognosis of patients with ICH was worse than patients with SAH only. The ICH was located mainly in the temporal lobe and sylvian fissure.

Risk of Seizures after Operative Treatment of Ruptured Cerebral Aneurysms

OBJECTIVE: Postoperative seizure is a well documented complication of aneurysm surgery. The purpose of the present study was to analyze risk factors for postoperative seizure. METHODS: Between January 1990 and December 1996, we performed craniotomy for ruptured cerebral aneurysms in 321 patients. Among them 206 patients who could be followed up for more than 1 year(range, 1 to 4.6 years) were enrolled to present study. All patients were treated with anticonvulsants for 3 to 18 months postoperatively. We analyze the incidence of postoperative seizure in different sex and age groups, and risk factors associated with postoperative seizures following aneurysm rupture. For statistical processing chi-square test and Fisher's exact test were used. RESULTS: In the follow-up period of 1 to 4.6 years(mean, 1.8 years) postoperative seizure appeared in 18 out of 206 patients(8.7%). Mean latency between the operation and the first seizure was 6 months(range, 3 weeks to 18 months). The age of the patients has significant influence on the risk of seizure, it occurred more often in younger patients(p =0.0014). Aneurysm location in the MCA was associated with a significantly a higher risk of seizure(p =0.042). Eight patients(19%) out of 42 patients who suffered delayed ischemic neurologic deficit(DID) developed seizure. Delayed ischemic neurologic deficit was associated with significantly a higher risk of seizure(p =0.019). Infarct and hypertension were associated with significantly a higher risk of seizure(p < 0.05). pre- or postoperative intracranial hematoma(intracerebral or epidural hematoma) was associated with significantly a higher risk of seizure(p < 0.0001). H-H grade, Fisher grade, Glasgow Outcome Scale of patients and timing of operation after subarachnoid hemorrhage had no significant relation with the risk of seizure. CONCLUSION: Factors associated with the development of postoperative seizure were middle cerebral artery aneurysm, delayed ischemic neurologic deficit, infarct on late postoperative CT scan, hypertension, pre or postoperative intracranial hematoma(intracerebral or epidural hematoma). Identification of the risk factors may be help to focus the antiepileptic drug threapy in cases prone to develop seizures. Prospective evaluation is indicated.

Outcome Analysis of the Patients with and without Anterior Plating in Multi-Level Degenerative Cervical Diseases

OBJECTIVES: The rates of pseudarthrosis for two- and three level fusion have been reported to be 17-63 and 50% without anterior cervical plating. The purpose of this study is to assess the effects of anterior cervical plating in the treatment of multilevel degenerative cervical disease such mostly the additional risks associated with hardware implants and its benefits, fusion rate and radiographic results, and clinical outcomes. METHODS: Forty-seven patients who underwent operations between 1993 and 1997 were retrospectively reviewed. The technique for operation was same for both groups(Smith Robinson with autologous iliac bone graft). Group I consisted of 35 consecutive patients treated with anterior cervical decompression and fusion with anterior cervical plate fixation. Group II consisted of 12 consecutive patients treated without plate fixation. We compared clinical outcomes by Prolo score, radiographic results in the rate of fusion, cervical lordosis by Gore angle, disc height by Farfan method, and surgical complications between two groups. RESULTS: The favorable clinical outcomes(excellent and good) by Prolo score were observed with the use of anterior cervical plate fixation(89% vs 75%). The successful fusion rate of multilevel cervical fusion was as seen with anterior cervical plate fixation(97% vs 75%). The overall graft complication rate in multilevel fusions was decreased, with anterior cervical plate fixation, and the hardware related complications were relatively minimal without serious consequences. CONCLUSION: Anterior cervical plate fixation in the treatment of multilevel cervical disorders is an effective stabilizing method which provides increased bony fusion rate, decreased graft complications, maintained cervical lordosis, early mobilization of the these patients without serious hardware related complications.

A case of colon carcinoma in crohn's disease / 대한내과학회지

Crohn's disease is one of the chronic inflammatory disorders of unknown cause involving the gastrointestinal tract. The inflammation may occur in the colon, either alone or with small intestine. Crohn's disease has been associated with increased risk for coloretal carcinoma in patients with long-standing colitis, strictures and fistulae. Recently, we experienced a case of Crohn's disease complicating carcinoma in a 85 year old male. Ten years ago, he compained severe abdominal pain and diarrhea. and was detected colon obstruction and enteric fistula. But, he spontaneously improved. Recently, the patient was admitted complaining abdominal pain. He complaind abdominal pain and indigestion chronically and aggravated recently. He was examined with colonofibroscopy, and computered tomography, and carcinoma was detected at the site of Crohn's disease.

Pyogenic Spondylitis with Diffuse Spinal Epidural Abscess: A Case Report

No abstract available.

Subarachnoid Space Reconstruction for Treatment of Posttraymatic Syringomyelia

No abstract available.

Clinical Analysis of the Pattern of Anterior-Posterior Circulation in Patients with Posterior Communicating Artery Aneurysm

OBJECTIVE: The purpose of study was to assess the status of posterior communicating artery in patient with aneurysms arising from the internal carotid-posterior communicating artery and the angiographic blood flow pattern of anterior-posterior circulation through the posterior communicating artery especially to the posterior cerebral artery. The clinical outcomes according to the pattern of posterior communicating artery and the blood flow to the posterior cerebral artery were analysed. PATIENTS AND METHODS: The data includes 41 cases of internal carotid-posterior communicating artery aneurysm among 248 cases of aneurysms which were operated from September 1993 to August 1998. The clinical informations were obtained by review of the records and radiologic films retrospectively. The statistical analysis were performed using Chi-square tests. RESULTS: The female was predominant and peak age was fifties. The operative result was in close relation with initial Hunt-Hess grades(p=0.039), Fisher grade(p=0.001) but showed no statistical differences with age(p=0.106). The flow pattern of posterior cerebral artery was mainly from both anterior and posterior circulation(28cases, 68%), and the size of posterior communicating artery was smaller than P1 segment of posterior cerebral artery in 28cases(68%) but each of them showed no statistical differences with outcome. CONCLUSIONS: Even though there were no statistical differences of outcome according to the size of posterior communicating artery and the pattern of blood flow to the posterior cerebral artery, it is mandatory to save the posterior communicating artery for the preservation of otherwise normal blood flow to the perforators and main branches of posterior circulation.

Effect of Decompressive Surgery on Neurological Outcome Following Incomplete Cord Injury of the Mid and Lower Cervical Spines

To determine the effects of decompressive surgery on neurological outcome following incomplete cord injury of the mid and lower cervical spines, 44 patients(decompression and stabilization group: stabilization or conservative treatment group=21:23) who underwent operations between 1993 and 1995 were retrospectively reviewed. We compared neurological outcome by Frankel's grade, Prolo economic and functional rating scale, and final ambulatory status between two groups. Also, we analysed MRI findings related to neurologic outcome in these cervical cord injured patients. With regard to upgrading scale by Frankel's grade, decompressive surgery group was more improved(98% vs 78%). With regard to Prolo's scale, decompressive surgery group were excellent in 24%, good in 52%, and fair in 24%. Stabilization only or conservative treatment group were as follows: excellent(22%), good(39%), fair(30%), and poor (9%). In the viewpoint of walking status, the result of decompressive surgery group was better(90% vs 74%). Initial MRI findings and neurological assesment correlated with neurological recovery. In conclusion, decompressive surgery may be more effective in patients with incomplete cord injury on mid or lower cervical spines when there are cord compressive lesions such as traumatic disc herniation, spondylotic spur, bony impingement in the spinal canal, and irreducible spinal malalignment unless major intramedullary hemorrhage is present.

Rapid Spontaneous Resolution of Acute Subdural Hematoma

Usually, large amount of acute subdural hematoma needs prompt surgical removal. We report a case of rapid spontaneous resolution in a day. A 78-old female was admitted in comatose state after falling off from a bus. Initial brain CT scan revealed large amount of acute subdural hematoma that was completely resolved on follow-up brain CT taken 26hours after craniocerebral trauma. The spontaneous resolution needs redistribution of hematoma and dilution by CSF. The low density space between inner skull table and hematoma may suggest the possibility of spontaneous resolution.

Chronic Spinal Epidural Hematoma after Herniated Lumbar Disc Surgery: A Case Report

We report a case of chronic spinal epidural hematoma in a 21-year old male who was operated on his back due to herniated lumbar disc at the right side of L5-S1 level. The postoperative MRI demonstrated isointense mass on T1W1 and hyperintense on T2W1 at the point where the initial herniated disc compressed the right S1 root. Revision was done and the mass was disclosed to be well-encapsulated chronic spinal epidural hematoma and here-by we report the case with review of literature.

Clinical Outcome of Surgical Treatment with Instrumentation and Fusion in the Management of the Thoracolumbar Injured Patients

The goals of operation for unstable thoracolumbar spine injuries are decompression of any neural canal compression, restoration of normal anatomic contour of the spine and stabilization. A retrospective analysis on 64 thoracolumbar injured patients treated with internal instrumentation and fusion was performed from January 1991 to December 1996. The purpose of this study was to review the clinical outcome and efficacy of surgical treatment using internal instrumentation, and compare neurological, radiological and functional outcomes between anterior and posterior approach groups. Of these, 42 patients were operated via on posterior approaches and the other 22 patients by anterior approaches. At final follow up evaluation with mean period of 14.5 months, 50 patients(78%) were walking and 47 patients(92%) except 4 patients(A-A, three and C-C one patient) had improved using Frankel's grade in patients with neurological deficits(51 patients). No patient deteriorated. Radiological and functional outcomes were satisfactory in the majority of patients. In a comparison of the clinical outcomes between anterior and posterior approaches, there was no statistically significant difference in neurological outcome(the mean value of up-grade: anterior 1.05+/-.7, posterior 0.95+/-.9, p=0.42), but in radiological outcomes, there were no significant differences between the two groups in amount of restoration of vertebral compression(mean recovery rate: anterior 61.5%, posterior 50.9%), kyphotic deformity(mean recovery rate: anterior 47.9%, posterior 70.0%)(p>0.05), but the only difference was in the restoration of canal narrowing, with the anterior group more improved(recovery rate: anterior 86.4%, posterior 74.3%) (p<0.05). In functional outcomes by Prolo's scale, the anterior group was better than the posterior group(mean economic and functional status: anterior E(4.4), F(4.3); posterior E(3.5),F(3.9)). We conclude that agressive decompression, instrumentation and bone fusion has shown better clinical outcomes of the unstable thoracolumbar injured patients and the choice of surgical approaches depends on the general condition, age, status of bone mineral density, specific injury mechanism, radiological findings, and grade of neural injury at the time of injury of these patients.

Scalp Defect, Injuries of Skull and Brain Parenchyme Caused by High Voltage Electrical Burn: A Case Report

The authors describe a case of accidental eletrical injury from high voltage direct current in a young worker, who was struck by the electric shock in the left occipito-parietal region. This case is interesting due to the development of left ooccipito-parietal parenchymal brain lesion with transient anomic aphasia and visual disturbances. We believe that is first report on parenchymal brain injury due to high voltage electrical burn confirmed pathologically in Korea. The patient had full thickness scalp defect, skull necrosis, and parenchymal brain injury. We performed one stage brain and dural biopsy with split rib graft cranioplasty after removal of devitalized skull and scalp flap surgery. The clinical presentation, radiological, pathological finding, and outcome are reviewed.

A Clinical Analysis of the Patients Who "Talk and Deteriorate" as a Result of Delayed Traumatic Intracerebral Hematomas

During a six-year period, 15 cases of "Talk and Deteriorate"patients who were suffering from delayed traumatic intracerebral hematoma(DTICH) were found retrospectively among 1055 patients with head injuries. All fifteen had suffered initial mild head injury(GCS score, 13-15), and apoplectic events or progressive neurological deficits(GCS<8) requiring surgical intervention developed within 72 hours. Subsequent CT scanning showed worsening of the original contusional lesion in ten cases, new hematoma in six, and new lesion(contusion, ischemia and/or edema) in five. cases. The most common location of DTICH was the frontal lobe(11 cases) and the most common cause of injury was a fall(10 cases). The condition of most of these patients could not be predicted, and there was no clear evidence of secondary insults such as hypoxia, hypotension, anemia, or hypercarbia, but hyperglycemia and coagulopathy were seen. Our results demonstrated that in spite of an initially high GCS score, patients who had been injured during a fall and on initial CT scan showed frontal lobe hemorrhagic contusion and/or swelling should be observed closely for at least three days after the injury. Among patients in the "Talk and Deteriorate"group whose condition was caused by DTICH, early diagnosis and aggressive treatment may be the most important life-saving management strategy.

Streotactic Evacuation and Urokinase Irrigation in the Management of Spontaneous Intracerebral Hemorrhage

The best treatment modality of spontaneous intracerebral hematoma is still controversial. But stereotactic surgery can minimize the brain damage and be performed under local anesthesia. Recently we experienced 46 cases of spontaneous intracerebral hematoma which were operated using ZD(Zamorano-Dujovny) stereotactic system and urokinase irrigation from November 1990 to April 1993. Before operation, computerized tomographic scanning was done to locate the hematoma, assess the amount, and to determine the stereotactic coordinates. The silastic tube was inserted after stereotactic evacuation of hematoma and urokinase irrigation was repeated every 6 to 8 hours until the hematoma was cleared up. The results were analysed and we concluded that we can substitute open craniectomy or conservative treatment for stereotactic evacuation of spontaneous intracerebral hematoma combined with urokinase irrigation in certain instances and can minimize the brain damage regardless the patient's general condition or past history.

A Clinical Analysis of Cranioplasty Using Methyl Methacrylate

Cranioplasty has long been performed by many physicians with different materials from the prehistoric era. Among the materials, methyl methacrylate has been known to be the superior to any other substitutes since 1940s in biologic, chemical and physical characteristics and its availability. So the authors review 72 patients who underwent cranioplasty with methyl methacrylate at out hospital from 1985 to 1989. The clinical analyses were as follow : 1) There was male predominance and epidural hematomas, compound, comminuted depressed fractures by traffic accidents or fall down injuries were the main causes of craniectomy. 2) The location of defects was mainly frontal and/or parietal area and average size of defects was 17cm2 in plain skull film measurements. 3) The cosmetic results were satisfactory. 4) Complication rate was 6% and there was no mortality.