Cement Augmented Anterior Reconstruction and Decompression without Posterior Instrumentation:A Less Invasive Surgical Option for Osteoporotic Thoracolumbar Fracture with Cord Compression / 대한신경손상학회지

Objective@#We investigated the clinical and radiological outcomes of a cement augmented anterior reconstruction and decompression without pedicle screw fixation in patients with osteoporotic thoracolumbar vertebral fracture with myelopathy. @*Methods@#There were 2 male and 6 female patients with thoracolumbar fracture and myelopathy included in the study. The mean follow-up period was more than 1 years.The anterolateral decompression and cement augmented anterior reconstruction with poly(methyl methacrylate) (PMMA) was performed. Demographic data, clinical outcomes, perioperative parameters and radiologic parameter were retrospectively evaluated. @*Results@#The symptoms due to myelopathy were improved in all patients. The preoperative median visual analog scale score for lower back and leg were 8.5 that improved 4.25 and 3 at last follow up. The preoperative function state showed a median Oswestry Disability Index score 61.5 that improved 33. After surgery, preoperative encroachment of the spinal canal (5.12 mm, 37%) was disappeared. The median height of fractured vertebral body significantly increased from 7.83 to 12.63 mm. At the last follow-up point, the median height was 9.91 mm. The median kyphotic deformity was improved from 22.12° to 14.31°. At the final followup, the improvement was preserved (median value: 15.03). The acute complication according to PMMA such as leakage and embolization was none, but adjacent compression fracture as late complication according to cement augmentation was. One patient developed surgical site infection. @*Conclusion@#On the basis of the preliminary results, we considered that anterolateral decompression and PMMA augmentation might be an optimal method for treating osteoporotic fracture with myelopathy in elderly patients or those with multiple medical comorbidities.

Morphometric Analysis of Distances between Sacral Hiatus and Conus Medullaris Using Magnetic Resonance Image in Korean Adult / 체질인류학회지

The purpose of this study was to provide basic biometric data on Korean adults through magnetic resonance imaging (MRI)-based measurements of the distances between the apex of sacral hiatus (SH) and the termination of dural sac (DS), and between SH and conus medullaris (CM) because they are critical to the performance of epidural neuroplasty. A total of 200 patients (88 males and 112 females) with back pain, who had no spine fracture, significant spinal deformity, and spondyloisthesis were selected for this study. The subjects were of mean age 54.3 (20~84) years and mean height 161.3 cm (135~187). T2-weighted MRI images were used for correlation analysis to evaluate the relationships between the distances, and variables such as sex and height. In all patients, the mean distance between SH and DS was 62.8±9.4 mm and the mean distance between SH and CM was 232.2±21.8 mm. The minimum distance and the maximum distance between SH and DS were 34.8 mm and 93.9 mm respectively, and the minimum distance and the maximum distance between SH and CM were 155.0 mm and 284.0 mm respectively. In female patients, both the distances between the SH and DS, and between SH and CM were shorter when compared to those of the male patients (p<0.05). Both the distances between SH and DS and between SH and CM showed a significant correlation with height (p<0.01). The results of this study will provide a useful biometric data on the distances between SH and DS and between SH and CM in Korean in ensuring clinical safety and in the development of more effective catheterization techniques for epidural neuroplasty in Korean.

Anterior Lumbar Interbody Fusion with Percutaneous Pedicle Screw Fixation for the Treatment of Postoperative Pyogenic Spondylodiscitis

Deep wound infection is a serious surgical complication. The majority of patients with pyogenic spondylodiscitis can be treated non-surgically with antibiotics and immobilization. However, although surgical management of pyogenic spondylodiscitis continues to evolve, no consensus has yet been reached regarding the best surgical approaches and techniques. Anterior lumbar interbody fusion (ALIF) followed by percutaneous pedicle screw fixation (PPF) is an effective surgical option for treating postoperative pyogenic spondylodiscitis (PPS). In this report, we describe a case of PPS in a 64-year-old man who underwent ALIF with PPF.

Postoperative Acute Spinal Subdural Hematoma: Report of Two Cases

We report two very rare cases of postoperative acute spinal subdural hematoma (ASSH) and review the literature. ASSH is usually related to trauma or a previous lumbar puncture, and a review of the literature revealed only a few cases of spinal subdural hematomas occurring secondary to an underlying hematological disorder or to an iatrogenic coagulopathy. However, there have been no reports about the occurrence of ASSH as a complication of uneventful spinal surgery. The authors present two cases of postoperative ASSHs after open lumbar microdiscectomy (OLM) and underline the pitfalls in their diagnosis and treatment modalities. Two patients were treated with surgery, which progressed without sequelae, and their preoperative symptoms were resolved. Postoperative ASSH is an extremely rare complication, but precautions for meticulous hemostasis and careful awareness for minimal manipulation of the dura during lumbar surgery should be considered in all patients, even those who do not require multilevel decompressions and/or who have a preoperative coagulopathy.

Herniated Lumbar Disc Combined with Spinal Intradural Extramedullary Cysticercosis

Spinal cysticercosis is a very uncommon manifestation of neurocysticercosis which is caused by the larvae of Taenia solium. However, it can develop as a primary infection through blood stream or direct larval migration. It can result in high recurrence and severe neurologic morbidity if not treated appropriately. We report the case of a 43-year-old woman who presented with severe lower back pain and left leg radiating pain in recent 2 weeks. Magnetic resonance image (MRI) of lumbar spine demonstrated extruded disc at the L5-S1 level combined with intradural extramedullary cystic lesion. We performed the open lumbar microdiscectomy (OLM) at L5-S1 on the left with total excision of cystic mass. After surgery, the patient showed an improvement of previous symptoms. Diagnosis was confirmed by histopathological examination as intradural extramedullary cysticercosis. We discuss clinical features, diagnostic screening, and treatment options of spinal cysticercosis.

Thoracic Spinal Epidural Cavernous Hemangioma: A Case Report and Review of the Literature

We report a very rare case of thoracic epidural cavernous hemangioma in a 69-year-old male. He complained of a three-year history of dull ache at the interscapular region and progressive numbness and weakness of the lower extremities. He had been suffering from gait disturbance and difficulty in urination and defecation for the previous three months. Preoperative magnetic resonance images showed characteristic features: a lobulated epidural mass, which was isointense to the spinal cord on T1-weighted images and hyperintense to the spinal cord on T2-weighted images, in the posterior spinal canal of the upper thoracic spine with contrast enhancement and extension through the intervertebral foramen. A right hemilaminectomy was performed at the T1, T2, T3 and T4 levels. After bilateral flavectomy, using a microsurgical technique, total excision of the mass was successfully achieved. The patient improved dramatically, both in motor strength and sensations, after the operation. Presumptive preoperative diagnosis of epidural cavernous hemangioma could render the surgical approach less invasive to avoid severe intraoperative bleeding.

The Role of Multi-detector CT Angiography in Surgical Planning for Congenital Cervicothoracic Kyphoscoliosis: A Case Report

Surgical correction of a cervicothoracic deformity is difficult with a potential risk of vascular injury. Comprehensive preoperative vascular evaluation is important for safe and successful surgery. The use of multi-detector computed tomography angiography (MDCTA) allows a combined display of vascular and osseous structures of the musculoskeletal system. However, no clinical reports have described the use of MDCTA for surgical planning of anterior cervicothoracic surgery in patients with vascular malformation. The case of a 7-year-old girl with congenital cervicothoracic kyphoscoliosis who underwent preoperative MDCTA evaluation and successful correction is presented in this report.

The Clinical Comparison between Open Surgery and Percutaneous Endoscopic Lumbar Discectomy in Extraforaminal Lumbar Disc Herniation

OBJECTIVE: The objective of this study is to evaluate and compare the clinical results between classical open surgery and percutaneous endoscopic lumbar discectomy(PELD) in cases of extraforaminal lumbar disc herniation. METHODS: We obtained the clinical data from 47 patients with extraforaminal lumbar disc herniations who underwent the open paramedian muscle-splitting approach or percutaneous endoscopic lumbar discectomy(PELD) between January 2001 and February 2004. This study consisted of patients with soft disc extraforaminal herniations. The patients were assessed with the visual analogue scale(VAS) and MacNab's criteria before surgery, just before discharge, and postoperative 1 year. RESULTS: There were 25 cases in the open surgery group and 22 cases in the PELD group. The average operating time was 78+/-36.71 min in the PELD group and 110+/-29.68 min in the open surgery group. The mean hospital stay was 2.73+/-2.62 days in the PELD group and 7.68+/-2.59 days in the open surgery group. VAS decreased from 8.34+/-0.66 to 1.29+/-2.27 in the PELD group and from 8.40+/-1.40 to 1.70+/-1.72 in the open surgery group at the one-year follow-up. The success rate of PELD was 86.4%, compared with 80.0% for open surgery. However, there were no statistically significant difference between two groups for success rate and VAS. CONCLUSION: Although the success rates were similar in both groups, PELD is less invasive, faster, and safe procedure than open surgery for extraforaminal disc herniation in selected patients.

Percutaneous Endoscopic Lumbar Discectomy for the Treatment of Far Lateral Lumbar Disc Herniation

OBJECTIVE: There are few reports on the clinical outcomes of the percutaneous endoscopic lumbar discectomy(PELD) with laser for the treatment of far lateral lumbar disc herniation. The objective of this study is to assess the safety and efficacy of the PELD with laser for the treatment of far lateral lumbar disc herniation. METHODS: The clinical records of 42 patients who had far lateral lumbar disc herniation and underwent PELD with laser between January 1996 and August 2002 were analyzed retrospectively. There were 24(57.1%) males and 18(42.9%) females, with a mean age of 53(range, 26-73) years. The surgical procedure was performed via a posterolateral approach after induction of a local anesthesis. The clinical outcomes were measured with MacNabO s criteria. The mean follow-up period was 38(range, 5-77) months. RESULTS: Clinical outcomes were revealed as follows: excellent in 28 patients(66.7%); good in 11(26.2%); fair in 2(4.7%); and poor in 1(2.4%). Therefore, the percentage of successful(excellent and good) outcomes was 92.9%. There was no statistically significant variation in the success rates according to age and operation level(p>0.05). Before the introduction of the high resolution endoscope, the success rate was 90.3% but after upgrading to the high resolution endoscope, the success rate was 100%, and there was a statistically significant variation in the success rate(p<0.05). In all cases, there was no complication or recurrence. CONCLUSION: As a minimally invasive surgery, PELD with laser is a safe and efficacious procedure for the treatment of far lateral disc herniation.

Surgical Removal of a Large Distal Posterior Inferior Cerebellar Artery Aneurysm: Case Report

The authors report a rare case of right distal posterior inferior cerebellar artery(PICA) aneurysm arising from just distal to its vermian brance. A 36-year-old female patient presented with a sudden onset of headache, nausea, dizziness and ataxia without any other neurologic deficit. On brain computerized tomographic(CT) scan and magnetic resonance imaging(MRI), a well-defined round mass was detected just behind the fourth ventricle. On transfemoral vertebral angiogram(TFVAG), it was confirmed as a saccular aneurysm arising from the vermian brance of the right PICA. The aneurysm was initially directly clipped through bilateral suboccipital approach. Postoperative follow up angiogram after two weeks revealed a more enlarged aneurysm and an incompletely clipped neck. After making sufficient exposure of the aneurysm, the neck was reclipped and the sac removed. Postoperative results were uneventful.

A Case of Histiocytosis-X

The authors have experienced a case of histiocytosis-X. A 7-year-old male patient had three tender masses, one on the right parietal region, another on the left parietal region, the other on the left occipital region and revealed exophthalmus on his left side. Plain skull films showed multiple punched out skull defects and on lumbar spine films, collapse of body of second lumbar vertebra was detected. Among the masses, the largest right parietal one was excised totally. The final diagnosis revealed histiocytosis-X on pathologic basis and he was given subsequent chemotheraphy.