Cervical Myelopathy Secondary to Atlanto-occipital Assimilation: The Usefulness of the Simple Decompressive Surgery

Atlanto-occipital assimilation is one of the most common osseous anomalies observed at the craniocervical junction. Most patients with atlas assimilation show no symptom, but some have neurological problems such as myelopathy that may require surgical treatment. Occipitocervical fusion may be required if atlato-occipital assimilation is accompanied by occipito-axial instability. However, in cases of symptomatic atlas assimilation with minor cord compression without instability, simple decompressive surgery may be the treatment modality. This report describes a case of successful treatment of a patient with myelopathy secondary to atlanto-occipital assimilation without instability, using posterior simple decompressive surgery.

Anterior and Posterior Stabilization by One Stage Posterolateral Approach in the Unstable Fracture of Thoracolumbar and Lumbar Spine

OBJECTIVE: The purpose of this study is to investigate the clinical results of anterior and posterior stabilization by one stage posterolateral approach for the unstable fracture of thoracolumbar and lumbar spine. METHODS: By posterolateral approach with curved skin incision, unilateral facet and pedicle were removed. Through this route, corpectomy was performed, and then this space was replaced with mesh cage filled up with autologous bone graft. Both side pedicle screw fixation was followed to upper and lower levels. RESULTS: Six of seven patients of this study showed neurological improvement. The other one patient showed no neurological change. One patient had postoperative infection, another patient had postoperative kyphosis. The other patient had epidural hematoma on operation site after surgery. And all patinets on this study made to have spinal stability except one patient happened postoperative kyphosis. CONCLUSION: In the unstable fracture of thoracolumbar and lumbar spine, one stage anterior and posterior stabilization and fusion by posterolateral approach seems to be an effective procedure, if we have more care and supplementation.

Anterior Cervical Interbody Fusion with the Carbon Composite Osta-Pek Frame Cage in Degenerative Cervical Diseases

OBJECTIVE: Different types of interbody fusion cages are available for use in the surgical treatment of degenerative cervical diseases. The purpose of this study is to assess the technical feasibility, clinical efficacy and radiological results of intervertebral fusion with a carbon composite Osta-Pek frame cage (Co-Ligne AG, Switzerland) following anterior cervical discectomy. METHODS: 41patients (25males and 16females) with minimum 6months follow-up were included in the study. Disc height, cervical lordotic angle, segmental angle, and fusion rate were assessed by lateral radiographs. In this retrospective analysis, clinical outcome was assessed as evaluated according to Odom's criteria. RESULTS: Fifty-four cages were implanted in 30 single-level, 9 two-level, and 2 three-level procedures. The mean disc height, cervical lordosis angle, segmental angle were 4.2+/-1.8mm, 23.5+/-7.2degrees, 2.3+/-3.3degrees pre-operatively and 5.3+/-2.1mm, 24.2+/-8.3degrees, 3.8+/-3.5degrees at 6months after the surgery. Six months after surgery, there was radiographic evidence of fusion in 92.7% (38/41) of the patients. According to Odom's criteria, 37 of 41 (90.2%) patients experienced good to excellent functional recovery. CONCLUSION: These clinical and radiological results suggest that the carbon composite Osta-Pek frame cages are safe and effective alternative to autologous bone graft after anterior cervical discectomy for treatment of degenerative cervical disease.

Endoscopic Surgery for Pituitary Tumor

OBJECTIVE: The purpose of this study is to assess the efficacy and advantages of an endoscopic endonasal approach for the treatment of pituitary tumors. METHODS: We retrospectively analyzed the records of 31 patients with pituitary tumors having endoscopic endonasal surgery between March 1999 and August 2003. RESULTS: Among 31 patients with pituitary adenomas, 25 (81%) patients exhibited gross total removal of tumor on postoperative MRI within 3 days after surgery. Among 6 patients removed subtotally, 2 had only radiosurgery, 3 have had periodic follow-up MRIs and one patient with large extended tumor (grade IV, Stage E) had secondary transcranial removal of tumor before radiosurgery. Postoperative complications included cerebrospinal fluid leak in 2 patients, sinusitis in 1 patient, and one patient died due to unexpected intracerebral hemorrhage on 5 days after surgery. Besides considerable experiences with this approach are needed because of narrow working channel to the sella turcica, the results of our study showed following advantages of this procedure: visualization of areas not seen with the operating microscope, elimination of oronasal complications, more functional and cosmetic outcome, and shortened operative time and hospital stay. CONCLUSION: The authors consider that endoscopic endonasal transsphenoidal approach provides good results with minimal invasion for patients with pituitary tumors.

Surgical Treatment for Posterior Fossa Epidural Hematomas

OBJECTIVE: The purpose of this study is to investigate the interactions between prognostic factors and functional outcome of patients surgically treated posterior fossa epidural hematomas. METHODS: Between 1992 and 2001, twenty patients were surgically treated for the posterior fossa epidural hematomas. The medical records and radiologic findings of the patients were reviewed retrospectively. Information on potential prognostic factors was collected, and then univariate analysis was performed to determine significant prognostic factors. RESULTS: Initial Glasgow Coma Scale scores of 12 patients were 13 or better. Occipital skull fractures were found in 16 cases(80%). The degree of 4th ventricle compression measured on computed tomography scan. Seven cases showed total obliteration, nine cases showed partial obliteration and four cases showed normal. Eighteen patients experienced good or moderate outcomes(Glasgow Outcome Scale scores of 4 or 5). Functional outcome showed a significant correlation with Glasgow Coma Scale score, degree of 4th ventricle compression(p<.05). CONCLUSION: If poor initial consciousness level and severe 4th ventricle compression are noted, early and aggressive treatment are required. Although clinical progression of posterior fossa epidural hematoma is silent and slow, the deterioration might be sudden and quick to become fatal if not promptly treated.

A Case of Tuberculous Spondylitis Combined with Schwannoma of Spinal Cord

The authors report a very rare case of tuberculous spondylitis combined with a schwannoma of spinal cord. A 39-year-old man was admitted because of paraparesis(G1/G2). MRI showed severe cord compression at two different levels. One was by the bulged soft tissue and subligamentous abscess extending from T7 to T9 and the other was by an intradural extramedullary cord tumor at the level of T1-2. At first operation, T8 corpectomy and T7-9 plate fixation with autogenous iliac bone graft were performed. After then, Paraparesis was improved(G2/G3) postoperatively. The second operation underwent two weeks later. The tumor was totally removed and shortly after second operation, paraparesis was markedly improved(G3/G4). Histological diagnosis were tuberculous spondylitis and schwannoma, respectively. The authors reviewed this case where good surgical outcome was obtained by two stage operation.

Treatment of Cerebral Arteriovenous Malformations by Preoperative Embolization and Microsurgery

No abstract available.

Clinical Analysis of Anterolateral Approach with Instrumentation for the Thoracolumbar Lesions

Forty one patients with unstable thoracolumbar lesions were treated using anterior internal fixation device. There were 39 cases with unstable thoracolumbar fracture, 1 case with post-traumatic kyphosis, and 1 case with aspergillosis spondylitis. The procedures consisted of anterior decompression through vertebrectomy and discectomy, interbody fusion using autogenous iliac bone or rib, realignment and stabilization with Kaneda device(7 cases), or Z-plate ATL device(34 cases). Most patients with incomplete neurologic deficit were improved one or two grades according to Frankel's classification. No patient showed neurological deterioration after surgery. We concluded that the anteroloteral approach with instrumentation in various unstable thoracolumbar lesions would provide satisfactory neurologic improvement as well as immediate firm stability with early ambulation and high fusion rate involving only a minimum number of motion segments.

Aspergillosis of Thoracolumbar Vertebra: A Case Report

As the use of the antibiotics, antitumor substances, steroid hormone and immunosuppressive agent have been increased remarkably, the incidence of the fungal infection has also been increased. Aspergillus is a fungus belonged to ascomycetes family and distributed world-widely. Aspergillus infection of the spine is very rare. Mode of vertebral Aspergillosis is direct extension of primary lesion of lung in children, on the other hand, hematogenous metastasis in adults. We report a adult woman who suffered from thoracolumbar pain without any neurological deficit for 6 months prior to admission. Imaging studies revealed irregular bony destruction on the adajacent end plates of T12 and L1 vertebras with kyphotic change. We underwent operation via anterolateral approach using Z-plate fixation. followed by amphotericin-B administration.

Two Cases of Early Rebleeding after Total Removal of Hematoma due to Metastatic Choriocarcinoma

Among metastatic brain tumors, choriocarcinoma has a highly malignant nature and because of the vascular invasion of trophoblastic cells,tends to hemorrhage. Surgery is recommended for patients with a single cerebral metastasis, or for those who fail to respond to chemotherapy. We encountered two unusual cases in which early rebleeding occurred after the total removal of a hematoma arising from metastatic choriocarcinoma, and confirmed by post-operative tissue biopsy.

Clinical Features and Outcomes of Surgically Treated Pediatric Head Injuries

As the incidence of victims of traumatic craniocerebral injury in children has increased in modern times, we retrospectively analyzed 103 cases of surgically treated craniocerebral injuries among patients under the age of 15 who were admitted from January 1991 to December 1994. We classified the materials, i.e. 1) cause and incidence of craniocerebral injury, 2) clinical symptoms, 3) diagnosis and operation, 4) outcome and complication, and 5) period of hospitalization. The results were as follows: 1) The male to female ratio was 1.9:1(male patients 68, female patients 35). 2) The incidence peaked at the age of 6 and was mostly distributed from the age of 6 to 10. 3) As for time distribution most of the accidents occurred between 3 and 6 in the afternoon. 4) The main cause of craniocerebral injuries was attributed to traffic accidents (54 cases, 52.4%) and the second most common cause was falls from heights(30 cases, 29.1%). 5) In 85 cases, the Glasgow coma scale 13-15 before operation was observed. 6) Depression fractures were found to be the most common lesion in our cases. 7) In 48 cases(46.6%) a craniotomy was the operative procedure performed and in 40 cases(38.8%) an elevation of the depressed bone was performed. 8) In 93 cases, the Glasgow outcome scale 4-5 after operation was observed. 9) The many sequelae of operation were neurological deficit, cognitive impairent, and post-traumtic seizure. 10) The average period of hospitalization was 18.7 days(s.d=18.1). The cause and incidence of surgically treated pediatric head injuries were similar to those of total pediatric head injuries. A high GCS score at admission predicts a good outcome and fewer sequelae. However, papillary abnormalities and a neurological deficit at admission were poor prognostic factors. This study confirms that pediatric head injuries treated surgically provide better results than in adults.

Clinical Analysis of Linear Skull Fractures

A retrospective analysis of 351 linear skull fractures, during the period of January 1, 1992 to December 31, 1993, reveals the following: 1) Motor-Vehicle-related accidents were responsible for most of the injuries(56%), in which pedestrians(47%) were the primary victims. 2) In 172 cases(49%), the Glasgow Coma Scale(GCS) ranged from 13 to 15. Patients wth parietal fractures usually rated on a lower scale than those with fractures on other sites. 3) Occipital fractures were most common(23%), which was followed by parietal(19%), temporal(15%), frontal(15%), and multiple fractures(8%). Occipital fractures were frequently due to a pedstrian T.A. or a fall from high elevation while temporal or parietal fractures were frequently due to bicycle and motorcycle accidents. 4) The incidence of associated intracranial lesions was 70%. Patients with occipital fractures had a lower percentage of associated intracranial lesions than those with parietal fractures. Coup injuries were found in 175 cases and contre coup injuries in 106 cases. In many cases, frontal, parietal and temporal fractures were found to be coup injuries whereas with occipital fractures, contre coup injuries. 5) Sixty-one percents of the patients were assessed in Glasgow Outcome Scale(GOS) grade I.

A Case of Epidermoid Cyst in Interhemispheric Fissure: Case Report

A Case of the epidermoid cyst with highly unusual location which is occurred in the interhemispheric fissure is reported. Intracranial epidermoid tumor develops predominantly in the cerebellopontine angle and parasellar regions. There has been no literally reported case the epidermoid developed in the interhemispheric fissure. The patient was 31-year-old man with the chief complaint of generalized seizure which was the first attack occurred one day before admission. The lesion with the size of about 3cm in diameter demonstrated by MRI was completely removed through posterior interhemispheric approach. The patient's postoperative recovery was unremarkable and without neurological deficit.

Clinical Analysis of Hypertensive Intracranial Hemorrhage

367 patients with hypertensive intracranial hemorrhage, admitted to Masan Koryo neurosurgical department from Jan. 1988 to Dec. 1991, have been clinically analyzed. The results were as follows: 1) The group consisted of 176 males and 191 females. The peak age of the patients was at their 6th decade. Seasonal distribution of the incidence was peaked at spring and autumn. 2) 51.0% of these hemorrhage was located in putamen, 19.9% in thalamus, 12.5% in subcortex, 8.7% in cerebellum and 7.9% in brain stem. Patients with brain stem hemorrhage showed relatively poor prognosis compared with subcortex or cerebellar hemorrhage. 3) The level of consciousness at admission has significant relation to prognosis especially in non-operative group. 4) 130 patients underwent surgical treatment. In delayed operation group which was performed after at least 3 days from attack, good prognosis was obtained. 5) In 146 patients(39.8%), IVH was accompanied, which lead to poor prognosis. Especially in patients with thalamic hemorrhage, the incidence of IVH reached to 71.2%. 6) Overall outcome of 367 patients was good in 40.9%, and poor in 25.9%. Total motality rate was 33.2%.

Clinical Analysis of Hypertensive Intracranial Hemorrhage

367 patients with hypertensive intracranial hemorrhage, admitted to Masan Koryo neurosurgical department from Jan. 1988 to Dec. 1991, have been clinically analyzed. The results were as follows: 1) The group consisted of 176 males and 191 females. The peak age of the patients was at their 6th decade. Seasonal distribution of the incidence was peaked at spring and autumn. 2) 51.0% of these hemorrhage was located in putamen, 19.9% in thalamus, 12.5% in subcortex, 8.7% in cerebellum and 7.9% in brain stem. Patients with brain stem hemorrhage showed relatively poor prognosis compared with subcortex or cerebellar hemorrhage. 3) The level of consciousness at admission has significant relation to prognosis especially in non-operative group. 4) 130 patients underwent surgical treatment. In delayed operation group which was performed after at least 3 days from attack, good prognosis was obtained. 5) In 146 patients(39.8%), IVH was accompanied, which lead to poor prognosis. Especially in patients with thalamic hemorrhage, the incidence of IVH reached to 71.2%. 6) Overall outcome of 367 patients was good in 40.9%, and poor in 25.9%. Total motality rate was 33.2%.

A Case of Extracerebral Cavernous Hemangioma in the Middle Cranial Fossa

A case of extracerebral cavernous hemangioma located within the middle cranial fossa and involving superior petrosal sinus is described in a 58-year-old woman presented with left ocular pain and severe headache. We treated her with operation under the preoperative impression of meningioma which was removed totally. Postoperative pathologic diagnosis was a cavernous hemangioma.

Clinical Analysis on 96 Cases of Traumatic Intracerebral Hematoma Treated with Operation

The authors had studied 96 cases of traumatic intracerebral hematoma surgically treated in the Department of Neurosurgery, Masan Koryo Hospital from January 1987 to December 1991. The results were as follows: 1) The patients' age ranged from 8 to 73 years and sex distribution was dominant in male. 2) The most common cause of traumatic intracerebral hematoma was fall. 3) The most common site of hematoma was frontal lobe, followed by temporal lobe. 4) The neurologic status on admission was closely related to prognosis. 5) DTICH(Delayed traumatic intracerebral hematoma) was found in 7 cases(28.1%) which had poor prognosis. 6) Total mortality rate was 28.1%.

An Analysis of Chronic Subdural Hematoma

The authors analyzed 125 cases with chronic subdural hematoma admitted to the Department of Neurosurgery, Masan Koryo General Hospital from March 1987 until February 1992. The results obtained were as follows. 1) The male to female ratio was 4.9:1 and the incidence was predominant in the patients whose ages were over 50. 2) Antecedent history of head trauma was found in 79 cases(63%). 3) In 70 cases(56%), the density of hematoma shown on CT scan was low. In patients of under 60 years of age, the shape of hematoma was planoconvex, crescent, biconvex in the order of frequency whereas in patients of over 60, the sequence changed to biconvex, crescent, planoconvex. 4) In our series, the patients younger than 60 were managed either with burr hole drainage(40 cases) or craniotomy(34 cases), while the patients older than 60 were treated with burr hole drainage(45 cases) and craniotomy(6 cases). 5) Total mortality rate was 2.4%(3 cases). We have found a significant association between the neurologic grade at admission and prognosis of a patient.

Trapezial Osteosynthetic Plate Fixation Technique for Anterior Interbody Fusion in Cervical Spin Injury

Cases of cervial spine injury are increasing recently dure to traffic and injustrial accidents. Currently surgical approach is preferred in stabilizing cervical spin injuries which enables early mobilization, easy nursing care and early rehabilitation. The authors have experienced 23 cases of fracture-dislocation of cervical spine since May, 1987. All patients were treated with anterior interbody fusion using trapezial osteosynthetic plate after subtotal or total corpectomy and autogenous iliac bone graft. In overall patients, at average follow-up 6 months, stability of cervical column were maintained and graft were fully incorporated. There were no operative complications except only one case of screw ioosening.

A Clinical Analysis of Surgically Treated 145 Cases of Intracranial Anterior Circulating Aneurysms

We had clinically reviewed 145 cases of surgically treated intracranial anterior circulating aneurysms admitted to the neurosurgical service at Masan Koryo General Hospital between March, 1986 and December, 1990. The results obtained were as follows : 1) Over 60% of the patients were in their 6th and 7th decade. 2) The male to female ratio was 1 : 1.07 but male was predominant below the age of 40. 3) The location of aneurysm was below ; anterior communicating artery(54 cases, 37.2%), internal carotid artery(37 cases, 25.5%), middle cerebral artery(31 cases, 21.4%). 4) On admission, 102 patients were in Grade I or II of neurological scale(Hung & Hess Classification). 5) 38 patients had arterial hypertension prior to SAH. 6) Clinical vasospasm was found in 41 cases(28.3%). 7) Aveerage interval between ictus and vasospasm was 4-10 days. 8) A poor outcome was correlated with arterial hypertension and vasospasm. 9) Post operative mortality was 10.3%(15 cases) and common cause of the deaths was cerebral vasospam.