Clinical Analysis of Surgical Treatment for 3,913 Patients with Lumbar Disc Herniation

Lately, surgical treatment for lumbar disc herniations has advanced markedly with new improvements of neurosurgical procedures using microscope and microinstruments. The following is the authors' report of the surgical outcomes of 3,913 consecutive patients with lumbar disc herniations treated during a 230year period. These patients received treatments of laminectomy, hemilaminectomy or partial laminectomy with or without discectomy. After 1987, we also performed microdiscectomies using microscopes and microinstruments. The ratio of male to female was 71% to 29% and the fourth and fifth decades were most common with respect to age distribution. The causes of herniated discs include lifting, traffic accidents, falls or slipping, and sports Almost all patients had complained of low back pain and leg pain(99%), and 81% had radicular pain or sensory abnormality in a dermatomal distribution. The diagnosis was made by lumbar myelogram, CT scan and/or MRI. Complications were developed in 6.2% of the surgical cases. Several conclusions can be drawn from the above indicated results of this series: 1) male patients predominate in the lumbar disc herniation which are most common the fourth and fifth decades; 2) the incomplete herniation of disc was common; 3) MRI had the highest specificity as a single diagnostic tool, while the combination of myelogram, CT scan and MRI seems to e the best diagnostic method; 4) almost all patients had low back pain and leg pain and 90% of the patients were positive in Laseque test; 5) microdiscectomy is the most recommended treatment for lumbar disc herniations ; 6) The complication rate was 6.2% and the failed back surgery syndrome was most common.

Aberrant Expression of p53, MCM2 Protein and Proliferative Activity in Glioma

In gliomas, the most frequently studied tumor suppressor gene is the p53 gene which has been found to be mutated in a considerable fraction of astrocytomas and glioblastomas. Mutations that alter the function of the p53 gene product are thought to play a critical role in glial tumorigenesis. The murine double minute 2(MDM2) gene has been shown to code for a cellular protein that forms a complex with the p53 tumor suppressor gene product and inhibits its function. The fact that MDM2 can negatively regulate p53 suggests MDM2 could function as an oncogene when overexpressed. We investigated the expression of p53, MDM2 and proliferative activity of the tumor cells in 71 cases of gliomas(17 cases of differentiated astrocytomas. 25 cases of anaplastic astrocytomas and 29 cases of glioblastomas). Their paraffin-embedded tissue sections were immunostained with monoclonal antibody(p53 and PCNA, proliferating cell nuclear antigen) and polyclonal antibody(MDM2) for detection of p53, MDM2 and PCNA respectively. The results were as follows: The p53 staining was positive in 28 cases(39.4%) and MDM2 staining in 5 cases(7.0%) of 71 gliomas. The p53 positive-staining was detected in 2 cases(11.8%) of 17 differentiated astrocytomas, 9 cases(36.0%) of 25 anaplastic astrocytomas and 17 cases(58.6%) of 29 glioblastomas. The p53 expression was associated with malignancy grade(p<0.005) and proliferative activity was strongly associated with malignancy grade(p=0.0001). The p53 expression was closely associated with proliferative activity : p53-positive tumors had significantly higher median PCNA-labeling index than p53-negative tumors(40.6+/-10.1% versus 19.6+/-15.0%)(p=0.0001). But, MDM2 expression was not associated with proliferative activity(p=0.4575). The proportion of p53 immunoreactivity had significant association with proliferaive activity: the more the proportion of p53 immunoreactivity increased, the higher PCNA-labeling index elevated(p=0.0001). None of the tumors with MDM2 expression showed immunoreactivity for p53. These results suggest that the mutation of p53 gene plays a critical role in malignant transformation in glioma and it could be the prognostic factor for histologically same grade gliomas and that a subset of human gliomas escapes from p53-regulated growth control by amplification and overexpression of MDM2. Therefore gene study targeting these genes may be useful for the management of human glioma as a diagnostic modality.

Analysis of the Results of the Treatment According to the Change of Neurological Status in Hypertensive Putaminal Hemorrhage

One hundred and twenty four patients with hypertensive putaminal hemorrhage were analyzed by time course. All patients were brought to the emergency room within 3 hours after the ictus. Seventy three patients were conservatively treated and 51 patients operatively. The neurologic condition of each patient was evaluated by means of the Glasgow coma scale(GCS) score every 1 hour. CT scan of the brain of these patients were taken within 6 hours after the ictus. Clinical severity of the putaminal hemorrhage was graded as rapid deterioration, slow deterioration, and non deterioration by the CT and neurological status. A precise time course analysis of putaminal hemorrhage were compared with the conservative group and surgical group in a 7 hospital day period. Outcome was assessed 6 months later based on the degree of functional recovery(DOFR). The overall mortality was 16.1% and surgical mortality was 13.7%. Surgical treatment for the rapidly deteriorating patients appears to be beneficial when compared with the slowly deteriorating patients. Outcome of the non deteriorating patients didn't show any differences in the quality of life regardless of treatment modality.

Epidermoid Tumor of the Bony Orbit: Case Report

Epidermoid cyst originating within the diploic space of the bony orbit is rare. The authors describe two cases of epidermoid cyst of the orbit. The clinical presentation was dependent on the location of the slowly expanding epidermoid cyst. Proptosis caused by intraorbital extension of the mass was the presenting sign in both case. The finding in orbit CT scan appeared to be specific for intradipolic epidermoid cyst. Their clinical presentations and surgical management were briefly discussed.

Three Cases of Thoracic Myelopathy due to Ligamentum Flavum Ossification

Ossification of ligamentum flavum is a very rare disease and one of the new disease entities in myelopathy. We report three cases of ossification of ligamentum flavum in thoracic spine causing thoracic myelopathy. Main symptoms of this disease are numbness of both legs and feet, gait disturbance and spastic motor weakness. Simple spine X-ray, metrizamide myelogram, CT and MRI are most useful diagnostic tools. Sufficient decompressive laminectomy and facetectomy are treatment of choice.

Duplication of the Middle Cerebral Artery: Case Report

'Duplication of the middle cerebral artery' is a rere vascular anomaly of the brain. The authors experienced a case of duplication of the middle cerebral artery in a patient with a posterior communicating artery aneurysm. It was demonstrated by angiography and confirmed at surgery. The neck of aneurysm was successfully clipped. Postoperative course was uneventful.

Clinical Analysis of Cerebellopontine Angle Tumors

Although the cerbellopontine area is a relatively small portion in the intracranial cavity, various kinds of tumors could be found in this area due to it's anatomical characteristics. There are several cranial nerves, brain stem, aquaduct of Sylvius, cerebellum and important vascultures in this area, so various neurological symptoms and signs could be occurred when the tumor developed in this region. A clinical analysis of 49 patients with cerebellopontine angle tumors during the last 5 years at the department of neurosurgery of C.U.M.C was done retrospectively. There were 19 men and 30 women with mean age of 43.8 years. The most frequent tumor was acoustic neuroma-37 of these patients(75.8%) and followed by meniningioma and ependymoma in frequency. The most frequent clinical symptom were headache and hearing disturbance. On the radiological evaluation, simple plain X-ray film showed normal in 43.3% and CT scan of the brain showed hydrocephalus and asymmetric cistern in 28 % and in 25% of patients respectively. Surgery was done by total extirpation in 19 cases and partial removal in 23 cases and the result were excellent or good in 29 cases.

Results of Simultaneous Early Repair and Ventriculoperitoneal Shunt in Infants with Myelomeningocele and Hydrocephalus

Simultaneous early repair of the myelomeningocele and ventriculoperitoneal shunt in patients with myelomenimgocele and hydrocephalus not only decreases further brain damage, but also eliminates dangers of wound break down, CSF leak, and secondary CSF infection. During the years 1975-1990, we have experienced 45 patients with neural tube dysraphism which consist of 32 lipomyelomenigocele, 8 myelomeningocele, 3 meningocele and 2 encephalocele. Among those, 7 patients underwent simultaneous repair of myelomeningocele and insertion of ventriculoperitoneal shunt. 2 Patients developed wound infection, but none of the patients developed myelomeningocele repair break down or shunt infection in the follow up period of 1 to 4 years. All patients underwent neuropsychological testing during their follow up period and 5 patients were found to have their normal growth and developments. 1 patient developed low intelligence and moderate degree gait disturbance and the other 1 patient developed voiding difficulty. The authors suggest that this technique may be safe and helpful in some infants born with a myelomeningocele and hydrocephalus overt at birth.

Two Cases of Cavernous Hemangioma of the Cauda Equina: Case Report

Two cases of cavernous hemangioma of the cauda equina are presented. Cavernous hemangioma of the cauda equina is rare vascular malformation. This is the fifth and sixth case of cavernous hemangioma of the cauda equina in the literature. These cases are female patients. MRI is more sensitive method than spinal myelography and CT in diagnosis of cavernous hemangioma of the cauda equina. Total removal was possible without immediate post-operative complication.

Comparative Analysis of Management of Intracerebral Hematoma

Retrospective analysis of 46 patients with intracerebral hematoma showed that the attack was most frequent in sixth decade and more prevalent in female. The most common cause of the attack was hypertension(80%) and the site of hemorrhage was putamen 32%, thalamic area 15%, subcortical area 7%, cerebellum 17%, ventricle 3%, and brain stem 4%. Mortality of total cases was 36% and there was no difference of mortality in both conservatively or operatively treated group(38% in conservative group, and 35% in operative group). The prognosis of the patient was unfavorable in the group of poor pretreatment Glasgow coma scale(GCS) and those of cases demonstrated more than 30cc of hematoma on computerized tomography(CT) of the brain. The improvement of GCS after management was better in operative group than in the conservative group.

Mangagement of Brain Metastasis from Lung Cancer

No abstract available.

Treatment of Spinal Epidural Metastasis

No abstract available.

Anterloateral Approach Combined with Modified Posterolateral Approach for a Lesion of the Thoracic or Upper Lumbar Region

During recent 3 years, 10 patients with epidural cord compression from a lesion in the anterior portion of the thoracic or upper lumbar area have been treated surgically by an anterolateral approach combined with modified posterolateral approach for decompression. Of 10 patient-two cases of OPLL(ossification of posterior longitudinal ligament) with herniated disc, two cases of metastatic tumor, one case of neurilemmoma, one case of pyogenic osteomyelitis of the vertebral body, two cases of herniated disc, one case of traumatic fracture-dislocation, and one case of congenital hemivertebra-5 patients with mild paraparesis improved postoperatively and returned to normal neurologically, 4 patients with moderate gait disturbance were ambulatory without any device, and one completely paraplegic patient was able to walk with device at 1 year after the operation. This approach could be used for removal of disc material, transverse process, lamina, or pedicle through one stage operation. This point is an advantage of this method compared to postero-lateral approach, lateral approach, or anterolateral approach. Anterior decompression by a modified anterolateral approach should be considered for management of spinal cord compressions such as tumor, infective lesion, traumatic lesion, or congenital malformation.

The Effects of Acupuncture in Chronic Pain

Pain is one of the most complex human experience and the commonest cause of stress and the most frequent symptom that makes people seek medical help. The mechanism of its production and perception are poor understood. Since the past, various procedures have been tried to control or relieve pain. It had been observed that acupuncture stimulation has been effective in the relief of painful conditions. However, up to the present there had been no definite proof that acupuncture treatment has cured any pathological condition. Work is at present proceeding to make this a practical possibility. Recently, in modern medical science, several experiments are in progress and in some cases, cure had been obtained but until these studies are completed and proved to be effective, it is impossible at the present stage to evaluate whether these occasional cures are statistically significant. So, we launched studies and observations at our pain clinic at St. Paul's Hospital employing the "Somatosensory evoked Potential",(SEP) responses for chronic pain patient to relieve pain with acupuncture. The median and sural nerve of patients with chronic pain were stimulated and recorded using the SEP. Recordings were made before and after the acupuncture therapy was initiated. We analyzed the recorded SEP responses to see if ther are any physiological effects of the acupuncture therapy in patients with chronic pain. Findings: The important changes of the SEP responses recorded during acupuncture therapy in patients with chronic pain were the suppression of the amplitude of the SEP waves and delayed latency of the responses, similar to those manifested by patients, who are under morphine therapy. Then, naloxone an antagonist to morphine was administered. The effects were the same, that is the SEP responses were reversed in both the patients under morphine therapy and those under acupuncture therapy. So, we postulated that, since the meridian system is closely connected to the posterior column of the spinal cord conducting system, which is concerned in the somatosensory conducting system, peripheral stimulation by acupuncture may bring about the so called "pain suppression of descending system", which is closely connected to the meridian system of acupuncture. Though it is quite early to draw positive and definite conclusions, the results are very encouraging. More cases and further observations are advocated.

Case Study of A Cauda Equina Meningioma: Case Report

Spinal meningiomas are most commonly found in the thoracic sections while it is extremely rare in the cervical, lumbar and sacral regions. In Elsberg's series, there were 10 cervical, 59 thoracic and 4 lumbar ; none below the 3rd lumbar segment. Recently, we encountered a case of cauda equina meningioma and was completely extirpated with no remnants of any neurological deficits.

Evaluation of Brain Function in Human Head Trauma with Multimodality Evoked Potentials

The multimodality evoked potentials(MEP)(somatosensory, auditory, and visual evoked potentials) is studied in patients with various head trauma. The use of evoked potentials for the evaluation of disorders of the nervous system has become a most valuable aid to the neurosurgeon and neurologist, often providing information of critical value without recourse to invasive technique. The multimodality evoked potentials is classified in three grades per modality as the degree of abnormality of the electrophysiological data. Data from 20 normal Korean subject are given for comparison with the abnormal data obtained from 96 patiemts with head trauma. The multimodality evoked potentials is a simple and useful method for clinical evaluation of abnormal function of the brain and prediciton of the patient's outcome in the head trauma patients.

A Case of Leukemic Lesion(Chloroma) in the Spinal Canal

We have experienced a rare case of leukemic lesion(chloroma) in the lower spinal canal which was confirmed by the surgery and histologic examination of the tumor. A farmer, aged 39, was admitted to the Department of Neurosurgery, St. Paul Hospital in December 1974 with chief complaints of low back pain with radiating pain in the right lower extremity and voiding difficulty for one month. On admission, neurologically, the patient exhibited weakness of the right anterior tibialis, extensor hallucis longus and peroneus longus and brevis muscles and sensory involvement of the right third, fourth and fifth sacral dermatomes. He was disclosed the positive signs of the Naffziger's and Lasegue's and severe tenderness on the spinous process of the fifth lumbar and first sacral vertebrae. Lumbar myelogram demonstrated a total block at lower level of the fifth lumbar vertebra and a filling defect of the right fifth lumbar root area. Through the laminectomy of fourth lumbar to first sacral lamina, an extradural greenish soft mass located at the ventral aspect of the right fifth lumbar to upper sacral roots, and the mass was removed. The biopsy specimen disclosed chloroma with leukemic infiltration of the meninges.