How Long Can We Live?

Potential maximum life span of humans is estimated around 115-120 years by Cutler. His estimate agrees with an earlier observation by Buffon who claimed that animals tended to live six times the period needed to complete their growth. As humans reach their skeletal maturity at approximately 20 years. Life span has not changed throughout recorded history. Life expectany, the actual average survival for certain given population has increased thanks to social, economic and medical advances. There are two basic levels of biological explanations on aging: macrobiological and microbiological. Macrobiological explanation includes homeostasis, immune system, endocrine, lifestyle, nutrition and environment. Microbiological explanation includes cellular clock theory, free radical theory and metabolic theory with nutrition and antioxidants. Recent advances of genetics opened new era on telomere and telemorase. Gene therapy is applied mainly at the laboratory or limited as local use under investigation. Although the results are encouraging at the laboratory, application for clinical purpose will need tremendous thorough trial and errors.

Transoral Anterior Decompression and Posterior Fusion of Irreducible Atlantoaxial Dislocation with Spinal Cord Injury: Case Report

We report a case of irreducible atlantaxial dislocation with spinal cord injury. The patient was a 36-year-old man who suffered from the sudden onset of shallow respiration and severe motor weakness after slip down. We have performed the one-stage operation, the transoral decompression, reduction and posterior interspinous wiring with bone fusion. Three weeks after surgery, the reduction state and posterior wiring procedure were failed, due to severe osteoporotic change. So, we have performed second operation, the transarticular facet screw fixation and occipito-cervical fixation with Steinmann pin, from which good postoperative stability and neurological improvements, were obtained.

Clinical Analysis of Basilar Skull Fracture (BSF)

188 consecutive cases with basilar skull fractures(BSF) out of 2676 head injury patients who were treated in Chung-Ang Gil Hospital from July 1993 to June 1995, were analyzed. These fractures are difficult to diagnose by ordinary X-ray examinations, routine head computed tomography(CT) and are frequently inferred by clinical signs. Therefore, it's diagnosis is somtimes delayed or missed in initial assessment of trauma patients. They are different from cranial vault fractures in several aspects other than difficulties in the diagnosis. It involves more commonly the cranial nerves(CN), makes cerebrospinal fluid(CSF) fistulae and leads to central nervous system(CNS) infections if the CSF fistulae are not detected or treated early and properly. The authors reviewed the clinical features, radiological findings, rate of delayed diagnosis, complications and outcomes. The most common feature of BSF was otorrhea(64.4%) and followed by rhinorrhea(39.4%), raccoon eye(32.4%) and hemotympanum(24.5%). In only 6.4% of cases, the fracture lines were detected by ordinary skull radiographs and diagnosed as BSF. In contrast, the high resolution skull base CT confirmed the fractures in 62.2%. Clinical diagnoses were made in 14.9%. Commonly combined craniofacial lesions were cranial vault fractures(51.1%), intracranial hemorrhages(46.3%), and facial bone fractures(34.0%). Most of CSF leakages(89.7%) were noted within 24 hours after injury and most of the leakages (87.7%) had ceased by conservative management within 2 weeks, but 5.1% that did not respond to conservative treatment and lumbar CSF drainage, needed invasive operative repair. The incidence of meningitis was 3.2% and the prophylactic antibiotics had no benificial effect on lowering the infection rate. Facial nerve was the most frequently involved cranial nerve followed by vestibulo-cocchlear, oculomotor, and olfactory nerve in decreasing order of frequency. The onset of facial palsy was immediate in 31.8% and the remainder were delayed more than 24 hours after head injury. Of 188 patients, 21 cases(11.2%) were delayed in the diagnosis of BSF.

Six Cases of Thoraco-lumbar Tuberculosis Treated by Anterior Decompression and Fusion with or withought Instrumentation

The anterior decompression and fusion have been the choice of surgical treatment for spinal tuberculosis since 1960. From April 1995 to April 1996, we operated on six patients of thoraco-lumbar tuberculosis. The procedure consisted of anterior decompression through corpectomy, stabilization with anterior instrument and bone graft with or without Titanium MESH. MRI provides a valuable information about the extent of the disease in multiple planes, thereby helping surgeons in planning of the operation. The thoracic spine was involed in four patients, the lumbar spine in two. On average, two vertebral bodies were involved. Anterior and middle column of spine were involved in all patients, but posterior column was intact in all patients. Disc space involvement was seen in all patients. Paraspinal abscess was observed in three patients. Epidural compression of the spinal cord or cauda equina was noted in all patients. Four patients showed neurological improvements and relief of pain. However, the recovery of two remaning paraplegic patients was not remarkable. There was no single case associated with persistence or recurrence of infection after instrumentation.

A Clinical Analysis of Degenerative Supondylolisthesis

The auther has studied 60 patients of degenerative spondylolisthesis diagnosed and operatively treated at Hanyang University Hospital from January 1987 to June 1992, and analized the outcome. The results were summarized as followings: 1) Male to female ratio was 1:4, showing female predominance. Average peak ages were 5th and 6th decades. 2) "Pedicle-Facet Angle" and the degree of slipping had directly proportional relationship(Y=0.58X+110). The wider the angle is, the more slipping develops. 3) The significant symptom and sign were neurogenic intermittent claudication and negative straight-leg-raising test. 4) The degenerative spondylolisthesis developed most frequently at L4-5 level(74%), L5-S1(15%), L3-4(8%), 57 cases(95%) fell into Grade by Meyerding classification. 5) Complete or incomplete block on myelogram was present in 59%, and pseudodisc and lumbar spinal stenosis were noticed on CT. 6) Laminectomy with P.L.I.F. were done in 50 cases(83%) and total laminectomy and medial facetectomy and foraminotomy were done in only 4 cases(7%). In the comparision on the slipping degree before & after operation, in 55 cases(92%), slipping degrees showed no great change less than 2mm, but the almost showed exellent & good results. So we considered decom pression & fusion without excessive reduction was sufficient. 7) Threaded fusion cage(T.F.C) had the several benefits that 1) stability was good, 2) osteosynthesis through threaded was possible and 3) postoperative ambulation was possible earlier. Therefore recently, P.L.I.F. using T.F.C in the treatment of degenerative spondylolisthesis were used in many cases and further evaluation for T.F.C. should be considered.

A Case of Lymphocytic Adenohypophysitis Presenting as a Pituitary Tumor

A case of lymphocytic adenohypophysitis presenting as a pituitary tumor is reported. This 30-year-old woman, gravida 1, sought medical attention during the eight month of pregnancy because of progressive headache and bluring of vision and scintillations across both visual field. After delivery, her symptoms were progressive. A large round shaped homogeneous enhancing sellar mass, as a pituitary tumor, was hoswn on brain CT and contrast enhanced MR imaged. Total removal of the tumor was done via subfrontal approach without further neurologic deficit. The tumor was diagnosed as lymphocytic adenohypophysitis with H & E staning postoperative hormonal therapy was performed.

Analysis of Radiological Findings in Ruptured Anterior Communicating Artery Aneurysms

In anterior communicating artery aneurysm that accounts for about 30% of intracranial aneurysms, it has been pointed out that the hemodynamic factor plays a very important role in all stages such as initiation, growth and rupture of aneurysm. Based upon the relationship between the findings of brain CT and those of cerebral angigram, the authors reviewed 96 cases of ruptured anterior communicating artery aneurysms that were operated on at the Department of Neurosurgery of Hanyang University Hospital from Jan. 1985 to June 1990, to suggest a point referred to which carotid artery should be selected first when direct carotid angiography is inevitable. The results were summarized as followings: 1) Of 96 cases, hemorrhagic evidence was observed in 92 case(95.8%) and among them, subarachnoid hemorrhage accompanying intracerebral hematoma(37 cases, 38.5%) was the most common type of hemorrhage. 2) Of 96 cases, left A1 was operated as afferent artery in 61 case(63.5%), right A1 in 23 cases(24.0%), and both A1, in 12 cases(12.5%). And the direction of aneurysm was to the right in 49 cases(51.0%), to the left in 12 cases(12.5%) and to the midline in 35 cases(36.5%). 3) Of 53 cases which had intracranial hematoma, 28 cases showed unilateral predominance. Among them the predominance of hematoma was opposite to the afferent artery in 82.1%(23/28) and was ipsilateral to the direction of aneurysm in 64.3%(18/28). 4) Of 91 cases which had subarachnoid hemorrhage, 29 cases showed unilateral predominance. Among them the predominance of hemorrhage was opposite to the afferent artery in 72.4%(21/29) and was ipsilateral to the direction of aneurysm in 58.6%(17/29). 5) Above findings suggest that in the cases with suspicious ruptured anterior communicating artery aneurysms on brain CT and direct carotid angiography is inevitable, contralateral carotid angiography should be undertaken at first when intracranial hematoma or subarachnoid hemorrhage shows unilateral predominance on brain CT, and left carotid antiography is preferable than the right one if there is no predominance of intracranial hematoma or subarachnoid hemorrhage on brain CT.

A Study on the Level of Physiologic CSF Reflux into Ventricles

Using Omnipaque CT cisternogram, author prospectively studied on the level of physiologic CSF reflux into ventricles in 42 cases, who had not history of brain pathology or abnormal findings in neurologic examination. Results were as follows: 1) Age of all cases ranged from 26 to 78 years and male to female ratio was 2.8:1. 2) Of 7 cases used control, 6 cases showed maximum reflux at 2 hours scan and remaining 1 showed at 5 hours. 3) CSF reflux to 4th ventricle were detected in all cases, but reflux to Aqueductus of sylvius, posterior 3rd ventricle, anterior 3rd ventricle, foramen Monro and lateral ventricle were in 17 out of all 42 cases(40.5%), 12/42(28.6%), 3/42(7.2%), 3/42(7.2%), 2/42(4.8%) respectively. 4) Cases with reflux to 4th ventricle could be considered as normal, but authors with reflux above 4th ventricle need follow-up scan after 3 to 6 hours to decide as normal.

Angiographic Analysis of Ruptured Anterior Communicating artery Aneurysms

The authors reviewed angiographic findings of 96 cases of ruptured anterior communicating artery aneurysms that were operated at the Department of Neurosurgery of Hanyang University Hospital from Jan. 1986 to June 1990. The results were summarized as follows ; 1) Asymmetricity of caliber of A1 was observed in 71.9%(69/96) and which was 3 times more frequent than that of reported incidence of control group(2~23%). 2) The incidence of predominance of left A1 was 54.2%(53/96) and that of right A1 was 17.7%(17/96). Among them, predominant A1 was operated as afferent artery of aneurysm in 94.2%(65/69). 3) Of 69 cases in which a unilateral A1 showed predominance, the direction of aneurysm was opposite to the side of predominant A1 in 66.7%(46/69) and ipsilateral to the predominant A1 in only 2.9%(2/69). 4) Above findings suggest that it is desirable to approach the anterior communicating artery aneurysm via the side of predominant A1 when the direction of aneurysm is uncertain on cerebral angiogram.

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.

A Clinical Study on the Intracranial Arteriovenous Malformation

A retrospective clinical study was performed in 41 patients with intracranial AVM during the period from January 1985 to December 1989. 12 patients managed conservatively and 29 patients surgically were followed for an average of 15 months. The results were as follows ; 1) The age range of presentation of intracranial AVM was 5 years to 48 years, with peak incidence from second to third decade. 2) The presenting symptoms and signs were intracranial hemorrhage(75.6%), seizure(12.5%), and headache(9.7%) in order of frequency. 3) In intracranial hemorrhage, intracerebral hematoma was the most frequent. 4) In small intracranial AVM, 84.2% was presented with hemorrhage, and large intracranial AVM, 37.5% with seizure. 5) There was a correlation between AVM grade of Spetzler & Martin and the incidence of postoperative neurological complication. 6) The clinical outcome for patients managed surgically was more favorable than that for patients managed conversatively.

Clinical Analysis of Posterior Fossa Medulloblastoma in Children

The author analyzed 15 children with medulloblastoma confirmed histopathologically at the Department of Neurosurgery of the Hanyang University Hospital from Jan. 1981 to Jan. 1989. The results were as followings : 1) The mean age of incidence was 9.3 years and male to female ratio was 2 : 1. 2) The most common symptoms were those of increased intracranial pressure noted in all cases(100.0%), cerebellar symptoms and signs in 7 cases(46.7%) and the brain stem symptoms and signs in 2 cases(13.3%). The symptom duration varied from 7 to 180 days with a mean of 60 days. 3) In the majority of patients(12 cases, 80.0%), tumor was located in the midline on the computed tomographic scanning of the brain and as less typical features of the medulloblastoma, calcification and cystic or necrotic zone within the tumor mass occurred in 5 cases(33.3%) and in 6 cases(40.0%) respectively, suggesting higher frequency than observed in other articles. 4) The tumors with calcification within tumor mass were larger in size and presented with longer symptom duration than those without calcification. And tumors with cystic or necrotic zone within tumor mass were larger in size and presented with shorter symptom duration than those without such lesions. 5) Among 8 cases managed with various degree of surgical resections and full doses of postoperative radiotherapy, spinal metastasis occurred in 1 case(12.5%) at 26 months after the operation. 6) In conclusion, aggressive therapeutic approach with combined modalities, utilizing radical resection of the tumor, scheduled postoperative radiotherapy and chemotherapy, seemed to exert beneficial influence on the outcome, with no evidence of disease in 4 out of 6 cases during the follow up period of 8 to 27 months.

Clinical Study on 22 Cases of Delayed Traumatic Intracerebral Hematoma

The authors studied 22 patients with delayed traumatic intracerebral hematoma (DTICH) who had been admitted to Hanyang University Hospital from March 1987 to February 1988. The results of the study were summerized as follows : 1) DTICH occurred most frequently on frontal and temporal lobe and closely associated with contusion of the brain at initial brain computed tomographic scan. 2) 20 cases of DTICH discovered within 10 days after trauma and remained 2 cases occurred at 20 day and 30 day, respectively. 3) The prognosis of DTICH was mostly affected by the neurological status at admission and good results of the surgery was obtained from the patients operated within 48 hours. 4) It was though that closed observation of the neurological status, repeated computed tomographic scanning and prevention of the systemic insults such as hypoxia and hemorrhagic shock would be improved the clinical outcome of the DTICH.

Clinical Evaluation of 68 Cases of Spinal Cord Tumors

The author analyzed 68 cases of the spinal cord tumors who had been operated at the Department of Neurosurgery of the Hanyang University Hospital from 1985 to 1989. The results were summerized as followings : 1) The spinal cord tumor was most common in the 5th decade of age(18 cases, 26.5%) and the ratio of male to female was 1.5 : 1, male predominant. The most common pathologic type was neurogenic tumor(29 cases, 42.6%). 2) The tumors were located most frequently in the thoracic area(35 cases, 51.5%) and in the intradural extramedullary space(30 cases, 44.1%). The most common initial presentation was pain and the paraparesis was most frequent symptom on admission. 3) The ratio of positive findings in plain radiologic study was 55.9% and all cases were shown the complete or partial blockings in myelography. 4) The computed tomographic scanning with water-soluble contrast media was useful in planning of operation to provide the exact relationship between the tumor, spinal cord and location of dura. 5) The total or gross total removal was possible in 60.3%(41 cases) and the result within postoperative one month was recovery or improvement in 73.5%(50 cases), the follow-up result was 83%(49 cases among 59 cases). 6) The most common postoperative complication was the spinal deformity in children(37.5%), and the osteoplastic laminotomy was required in prevention of this. 7) The incidence of metastatic tumor was 16.2%(11 cases), relatively high rate and the lung was most common primary focus. In plain X-ray examination, the bone destruction was most commonly found(54.5%) and the follow-up result was poor than the other tumors.

Clinical Evaluation of Lumbar Sympathectomy for the Treatment of Buerger's Disease

The lumbar sympathectomy was performed for the treatment of 25 patients with Buerger's disease. 80% of patients received lumbar sympathectomy achieved improvement of clinical symptoms and signs. The lumbar sympathectomy had good results in following cases: 1) Patients with resection of L1 sympathetic ganglion which was performed completely, anatomically and widely. 2) Patient received operation within the 6th months of initial occurrence of symptoms. 3) Patients which main symptoms were rest pain, coldness and numbness. In case of resection which was included of L1 sympathetic ganglion, postoperative skin temperature measured on medial aspect of tibia was higher than normal side about 1degrees C. The prognosis was poor in patients which ulceration and necrosis were previously existed. Stop smoking must be preceded for the treatment of Buerger's disease.

Evaluation of Posterior Lumbar Interbody Fusion

Lumbar interbody fusion provides the most logical solution to diseases of the lumbar spine instabilities, such as spondylolysis, spondylolisthesis and retrolisthesis. The 33 cases of lumbar interbody fusion done after Cloward method, Wiltberger method, method using bovine bone employing Cloward technique, and anterolateral approach were analyzed. Posterior interbody fusion after Wiltberger technique using dowel bone graft is a more simplified method, providing accurate approximation of graft and host bone and preventing extrusion of graft then Cloward technique. Immediate correction of extruded graft if any after postoperative CT checking is essential for successful fusion.

Clinical Evaluation of Cervical Ossification of the Posterior Longitudinal Ligament

The authors treated 32 patients with Ossification of the Posterior Longitudinal Ligament(OPLL). Seventeen of these patient had surgery during the past 1 year between 1987 and 1988. In this study we present a radiological and clinical analysis of these cases with a literature review. We also discuss a clinical system of grading, different types of radiological patterns, the indication of surgical treatment and the choice of operative methods. 1) The incidence of the cervical OPLL was about 5.4% in our annual study, which was based on the cervical CT and CTM. 2) The highest incidence was in patients 50-60 years of age and male: female ratio was about 3:1. 3) The highest incidence was in C5, C6 and C4 levels of cervical spine and two and three level involvement was prominent. 4) The pattern of OPLL was devided into a continuous type (21%), a multiple segmented type(48%), a mixed type(25%), a localized type(6%). 5) Absolute diameter did not always parallel the extent of spinal cord signs as did the percentage of spinal canal narrowing. 6) In cases of a clinical grading of more than III, surgery must be considered. In grade II, surgery is indicative if conservative management failed to improve the clinical symptoms. 7) For the evaluation of the cervical OPLL, the CT-Scan of CT metrizamide myelography was more useful method. 8) Cervical Corpectomy and fusion with or without bone cement were found to be advisable in Cases of cervical OPLL.

A Case of Congenital Lumbosacral Dermal Sinus Associated with Recurrent Meningitis(Case Report)

Recurrent episode of meningitis in infants and children frequently constitute a frustrating and distressing, both in determination of course and treatment. The authors are reporting a infected case of congenital dermal sinus with dermoid cyst in the subarachnoid space of cauda equina and conus medullaris which was cured after complete removal of cyst and sinus tract.

Two Cases of Tuberous Sclerosis Associated with Subependymal Giant Cell Astrocytoma

Neurosurgical intervention in the syndrome is discussed in the light of two recently treated cases, one of which was admitted due to acute hydrocephalic attack, the other was confirmed by the typical computed tomographic findings as well as the classic triad of adenoma sebaceum, mental retardation and epilepsy. There cases had no family historty and were probably the result of new mutations and variable penetrance. Transcallosal microsurgical excision of tumor was accomplished in both cases and subependymal giant cell astrocytoma was confirmed. The hydrocephalus resolved but subduroperitoneal shunt was required in one case.

Thoracic Arteriovenous Malformation: Case Report

The authors experience a case of juvenile type thoracic arteriovenous malformation. It is acute onset and represent spastic paraparesis, sensory Impairment and voiding difficult. Intradural spinal arteriovenous malformation is relatively rare lesion. The authors treated with total excision of A-V malformed vessel with good results.