An Atypical Choroid Plexus Papilloma Initially Manifestating as Radicular Symptoms

A 29-year-old woman had 1-month history of back pain radiating into lower extremities, motor weakness, and sensory abnormalities in both lower extremities. Contrast-enhanced spinal magnetic resonance imaging (MRI) revealed a homogeneously enhancing mass at the T12∼L1 and several intradural enhancing nodular lesions at L2∼S1. Tumor resection surgery was performed and following histological examination showed that the tumor satisfied the diagnostic criteria for atypical choroid plexus papilloma (CPP). To find primary tumor sites, contrast-enhanced brain MRI, whole spine MRI, and PET-CT were carried out and additional lesions were detected at the fourth ventricle, right cerebellum, and upper thoracic spinal cord. This is a very rare case of metastatic atypical CPP that involves brain, upper thoracic spinal cord, and cauda equina with initial manifestation of radicular symptoms without clinical signs of primary brain lesion.

An Atypical Choroid Plexus Papilloma Initially Manifestating as Radicular Symptoms

A 29-year-old woman had 1-month history of back pain radiating into lower extremities, motor weakness, and sensory abnormalities in both lower extremities. Contrast-enhanced spinal magnetic resonance imaging (MRI) revealed a homogeneously enhancing mass at the T12∼L1 and several intradural enhancing nodular lesions at L2∼S1. Tumor resection surgery was performed and following histological examination showed that the tumor satisfied the diagnostic criteria for atypical choroid plexus papilloma (CPP). To find primary tumor sites, contrast-enhanced brain MRI, whole spine MRI, and PET-CT were carried out and additional lesions were detected at the fourth ventricle, right cerebellum, and upper thoracic spinal cord. This is a very rare case of metastatic atypical CPP that involves brain, upper thoracic spinal cord, and cauda equina with initial manifestation of radicular symptoms without clinical signs of primary brain lesion.

Surgery versus Nerve Blocks for Lumbar Disc Herniation : Quantitative Analysis of Radiological Factors as a Predictor for Successful Outcomes

OBJECTIVE: To assess the clinical and radiological factors as predictors for successful outcomes in lumbar disc herniation (LDH) treatment. METHODS: Two groups of patients with single level LDH (L4–5) requiring treatment were retrospectively studied. The surgery group (SG) included 34 patients, and 30 patients who initially refused the surgery were included in the nerve blocks group (NG). A visual analogue scale (VAS) for leg and back pain and motor deficit were initially evaluated before procedures, and repeated at 1, 6, and 12 months. Radiological factors including the disc herniation length, disc herniation area, canal length-occupying ratio, and canal area-occupying ratio were measured and compared. Predicting factors of successful outcomes were determined with multivariate logistic regression analysis after the optimal cut off values were established with a receiver operating characteristic curve. RESULTS: There was no significant demographic difference between two groups. A multivariate logistic regression analysis with radiological and clinical (12 months follow-up) data revealed that the high disc herniation length with cutoff value 6.31 mm [odds ratio (OR) 2.35; confidence interval (CI) 1.21–3.98] was a predictor of successful outcomes of leg pain relief in the SG. The low disc herniation length with cutoff value 6.23 mm (OR 0.05; CI 0.003–0.89) and high baseline VAS leg (OR 12.63; CI 1.64–97.45) were identified as predictors of successful outcomes of leg pain relief in the NG. CONCLUSION: The patients with the disc herniation length larger than 6.31 mm showed successful outcomes with surgery whereas the patients with the disc herniation length less than 6.23 mm showed successful outcomes with nerve block. These results could be considered as a radiological criteria in choosing optimal treatment options for LDH.

Preliminary Experiences of the Combined Midline-Splitting French Door Laminoplasty with Polyether Ether Ketone (PEEK) Plate for Cervical Spondylosis and OPLL

OBJECTIVE: The purpose of this study was to evaluate the safety and efficacy of cervical midline-splitting French-door laminoplasty with a polyether ether ketone (PEEK) plate. The authors retrospectively analyzed the results of patients with cervical laminoplasty miniplate (MAXPACER(R)) without bone grafts in multilevel cervical stenosis. METHODS: Fifteen patients (13 males and 2 females, mean age 50.0 years (range 35-72)) with multilevel cervical stenosis (ossification of the posterior longitudinal ligament and cervical spondylotic myelopathy) underwent a combined surgery of midline-splitting French-door laminoplasty with or without mini plate. All 15 patients were followed for at least 12 months (mean follow-up 13.3 months) after surgery, and a retrospective review of the clinical, radiological and surgical data was conducted. RESULTS: The radiographic results showed a significant increase over the postoperative period in anterior-posterior diameter (9.4+/-2.2 cm to 16.2+/-1.1 cm), open angles in cervical lamina (46.5+/-16.0degrees to 77.2+/-13.1degrees), and sectional volume of cervical central canal (100.5+/-0.7 cm2 to 146.5+/-4.9 cm2) (p<0.001). The sagittal alignment of the cervical spine was well preserved (31.7+/-10.0degrees to 31.2+/-7.6degrees, p=0.877) during the follow-up period. The clinical results were successful, and there were no significant intraoperative complications except for screw displacement in two cases. The mini plate constructs did not fail during the 12 month follow-up period, and the decompression was maintained. CONCLUSION: Despite the small cohort and short follow-up duration, the present study demonstrated that combined cervical expansive laminoplasty using the mini plate is an effective treatment for multilevel cervical stenosis.

Cervical Stand-Alone Polyetheretherketone Cage versus Zero-Profile Anchored Spacer in Single-Level Anterior Cervical Discectomy and Fusion : Minimum 2-Year Assessment of Radiographic and Clinical Outcome

OBJECTIVE: We compared the clinical and radiographic outcomes of stand-alone polyetheretherketone (PEEK) cage and Zero-Profile anchored spacer (Zero-P) for single level anterior cervical discectomy and fusion (ACDF). METHODS: We retrospectively reviewed 121 patients who underwent single level ACDF within 2 years (Jan 2011-Jan 2013) in a single institute. Total 50 patients were included for the analysis who were evaluated more than 2-year follow-up. Twenty-nine patients were allocated to the cage group (m : f=19 : 10) and 21 for Zero-P group (m : f=12 : 9). Clinical (neck disability index, visual analogue scale arm and neck) and radiographic (Cobb angle-segmental and global cervical, disc height, vertebral height) assessments were followed at pre-operative, immediate post-operative, post-3, 6, 12, and 24 month periods. RESULTS: Demographic features and the clinical outcome showed no difference between two groups. The change between final follow-up (24 months) and immediate post-op of Cobb-segmental angle (p=0.027), disc height (p=0.002), vertebral body height (p=0.033) showed statistically better outcome for the Zero-P group than the cage group, respectively. CONCLUSION: The Zero-Profile anchored spacer has some advantage after cage for maintaining segmental lordosis and lowering subsidence rate after single level anterior cervical discectomy and fusion.

A Rare Case of Malignant Lymphoma Occurred at Spinal Epidural Space: A Case Report

The sacral spinal epidural space is an uncommon site for primary malignant lymphomas, presenting with symptoms associated with cauda equina compression. Especially, lumbo-sacral epidural lymphoma has been reported to be very rare. We present a rare case of 29-year-old male with sacral spinal epidural malignant lymphoma. The patient complained of tingling sensation in his buttocks that was radiating to his calf. The neurological examination was normal. Magnetic resonance imaging (MRI) with contrast showed a well-defined extradural mass lesion at the mid L5 to mid S2 level. The lesion was iso- to hypointense on T1 and T2 weighted images and showed homogenous enhancement and a focal enhancement in the L5 vertebral body on post-contrast images. The patient underwent a L5-S2 laminectomy and subtotal excision of the lesion. Intra-operatively, the lesion was extradural and not densely adherent to the dura; the lesion was friable, not firm, fleshy, brownish and hypervascular. The histologic diagnosis was grade 2 non-Hodgkin's follicular lymphoma. Even though the primary spinal epidural non-Hodgkin's lymphoma is a very rare disease, clinicians should take it into consideration in the differential diagnosis of patients with spinal epidural tumor.

Unusual Fatal Infections after Anterior Cervical Spine Surgeries

We report two cases of cervical spinal epidural abscess (SEA), which are related to anterior cervical surgeries. The first case reveals a late postoperative infection without any predisposing factor. The second case reveals combined complication of infection and instrument failure (artificial disc). Both two cases manifested ascending infections that are unusual courses of anterior cervical infections. The abscess extended upwards and, finally, caused life threatening bacterial meningitis. We suggest aggressive surgical interventions with anti-bacterial therapies in such cases.

Intracranial Dissemination from Spinal Cord Anaplastic Astrocytoma

We report a case of intracranial dissemination developing approximately 4 months after partial removal of a spinal cord anplastic astrocytoma in a 22-year-old male. He presented with paraplegia on initial admission at a local hospital. Spinal magnetic resonance (MR) images disclosed multiple intramedullary lesions at the T3-11. The tumor was partially removed. The final histologic diagnosis was anaplastic astrocytoma. Four months after the operation, he was admitted with the symptoms of headache and deterioration of consciousness. MR images showed enhanced lesions in the anterior horn of the left lateral ventricle, and septum pellucidum. He underwent computed tomography-guided stereotactic biopsy and histological appearance was consistent with anaplastic astrocytoma. The clinical course indicates that the tumor originated in the spinal cord and extended into the subarachnoid space, first the spinal canal and later intracranial.

Clinical Efficacy of Radiofrequency Cervical Zygapophyseal Neurotomy in Patients with Chronic Cervicogenic Headache

The purpose of the present study was to assess the clinical efficacy of radiofrequency (RF) cervical zygapophyseal joint neurotomy in patients with cervicogenic headache. A total of thirty consecutive patients suffering from chronic cervicogenic headaches for longer than 6 months and showing a pain relief by greater than 50% from diagnostic/prognostic blocks were included in the study. These patients were treated with RF neurotomy of the cervical zygapophyseal joints and were subsequently assessed at 1 week, 1 month, 6 months, and at 12 months following the treatment. The results of this study showed that RF neurotomy of the cervical zygapophyseal joints significantly reduced the headache severity in 22 patients (73.3%) at 12 months after the treatment. In conclusion, RF cervical zygapophyseal joint neurotomy has shown to provide substantial pain relief in patients with chronic cervicogenic headache when carefully selected.

Expression of Cytokines in Radiation Injured Brain at Acute Phase

OBJECTIVE: Radiation therapy is an important treatment for brain tumor. However, serious complications such as radiation necrosis can occur and it may be secondary to the expression of acute phase genes, like cytokines. In particular, inflammatory cytokines (IL-1beta, TNF-alpha) and other immunomodulatory cytokines (TNF-alpha, TGF-beta1) might be changed after irradiation (high single dose irradiation). Although it has been reported that IL-1 level is remarkably elevated within 8 week after the irradiation to the rat brain, the change of cytokines levels at acute phase (within 24 hours) has not been reported. In the present study, we examined TNF-alpha, TGF-beta1, and IL-1beta levels in acute phase to clarify the early effect of cytokines on the radiation-induced brain damage. METHODS: Fifty Sprague-Dawley rats were used and these were divided into irradiation group and control group. After a burr-hole trephination on the right parietal area using a drill, a single 10 Gy was irradiated at the trephined site. Their forebrains were extirpated at 30 min, 2 hr, 8 hr, 12 hr and 24 hr, respectively and examined for the expression of TNF-alpha, TGF-beta1 and IL-1beta. RESULTS: The expression of TNF-alpha and TGF-beta1 were decreased until 12 hr after irradiation but elevated thereafter. The expression of IL-1 was peak at 8 hr and then decreased until 12 hr but elevated after this time window. The present study indicated that expression of cytokines (TNF-alpha, TGF-beta1 and IL-1beta) were increased at 24 hr after the irradiation to the rat brain. IL-1beta level, on the other hand, reached peak at 8 hr after radiation injury. CONCLUSION: These findings indicate that IL-1, among various cytokines, may have a more important role in the inflammatory reaction by radiation injury at acute phase and provide some clues for better understanding of the pathogenesis of radiation injury.

Expression of Cytokines in Radiation Injured Brain at Acute Phase

OBJECTIVE: Radiation therapy is an important treatment for brain tumor. However, serious complications such as radiation necrosis can occur and it may be secondary to the expression of acute phase genes, like cytokines. In particular, inflammatory cytokines (IL-1beta, TNF-alpha) and other immunomodulatory cytokines (TNF-alpha, TGF-beta1) might be changed after irradiation (high single dose irradiation). Although it has been reported that IL-1 level is remarkably elevated within 8 week after the irradiation to the rat brain, the change of cytokines levels at acute phase (within 24 hours) has not been reported. In the present study, we examined TNF-alpha, TGF-beta1, and IL-1beta levels in acute phase to clarify the early effect of cytokines on the radiation-induced brain damage. METHODS: Fifty Sprague-Dawley rats were used and these were divided into irradiation group and control group. After a burr-hole trephination on the right parietal area using a drill, a single 10 Gy was irradiated at the trephined site. Their forebrains were extirpated at 30 min, 2 hr, 8 hr, 12 hr and 24 hr, respectively and examined for the expression of TNF-alpha, TGF-beta1 and IL-1beta. RESULTS: The expression of TNF-alpha and TGF-beta1 were decreased until 12 hr after irradiation but elevated thereafter. The expression of IL-1 was peak at 8 hr and then decreased until 12 hr but elevated after this time window. The present study indicated that expression of cytokines (TNF-alpha, TGF-beta1 and IL-1beta) were increased at 24 hr after the irradiation to the rat brain. IL-1beta level, on the other hand, reached peak at 8 hr after radiation injury. CONCLUSION: These findings indicate that IL-1, among various cytokines, may have a more important role in the inflammatory reaction by radiation injury at acute phase and provide some clues for better understanding of the pathogenesis of radiation injury.

Clinical Analysis of External Ventricular Drainage Related Ventriculitis

OBJECTIVE: The aim of this study is to analyze on the external ventricular drainage (EVD) related ventriculitis, especially on their risk factors, management, and prevention. METHODS: From January 2003 to December 2005, a total of 174 EVD catheters were placed in 112 patients at our institution. Of these patients, EVD-related ventriculitis were developed in 15 cases. Clinical variables such as age, sex, prior clinical diagnosis, placement of EVD insertion, duration of EVD, total numbers of EVD per person, and outcome were analyzed in theses cases to verify the risk factors, causative agents and outcomes. RESULTS: Fifteen cases of EVD related ventriculitis were noted presenting infection incidence of 13.39 % per patient and 8.62% per procedure. Of these, five patients died from sepsis, seven patients were recovered from infection but neurological complications remained and three patients were recovered without any complications. Microbes were obtained from cerebrospinal fluid only in six patients. Acinetobactoer baumanii was the most common pathogen in our study (4 cases). Among the various risk factors, only the prior clinical diagnosis showed the statistical significance. Patients who underwent decompressive craniectomy after severe brain trauma showed unfavorable outcome because of possible contaminative environment compared with other cases. CONCLUSION: EVD is considered as a safe procedure with good control of intracranial pressure if meticulous care is provided for EVD procedure and maintenance. With regards to risk factors and prevention, the higher incidence and unfavorable outcome was seen especially in patients with severe head trauma. Thus, special attention is required in these clinical settings.

Cranioplasty with the Porous Polyethylene Implant(Medpor) for Large Cranial Defect

OBJECTIVE: This paper describes our experience and implant technique for cranioplasty of a large cranial defects using a porous polyethylene implant(Medpor) and compares the results with polymethylmethacrylate(PMMA). METHODS: Sixteen cranioplasties were performed using Medpor(n=10) and PMMA(n=6) implants between June 2003 and January 2005. The criterion for patient enrollment was a defect larger than 10cm in diameter. This study compared the operation times and complications. RESULTS: The operation times ranged from 105 to 250minutes(Mean 180 degrees +/-44minutes) in Medpor and from 185 to 460minutes (mean 128minutes) in PMMA. The absolute operation times were shorter using the Medpor implant and the differences were statistically significant(P=0.030). Satisfactory cosmetic results were obtained in all cases using the Medpor implant and with no implant-related complications. Bone ingrowth to the medpor implant was presumed to be the result on an increase in Houndsfield units of the implant, particularly at the marginal areas in the serial follow-up brain computed tomography images. CONCLUSION: It is believed that the properties of a Medpor implant make this implant an good alternative to the existing methods of a cranial contour correction. However, a further follow-up study will be needed.

Ocular Complications after Injection of Intra-arterial Carboplatin in Gliomas

Carboplatin intra-arterial chemotherapy(IAC) has an advantage of increased uptake during the first passage of the drugs through tumor capillaries. Although not common, this type of therapy is known to cause neurological complications, myelosuppression, and ototoxicity. However, the incidence of ocular toxicity is reported to be rare. Eleven of our patients with glioma(Grade II Astrocytoma: 3, Grade III Astrocytoma: 1, Grade IV Astrocytoma: 5, Gliofibroma: 1, Oligodendroglioma: 1) underwent IAC regimen with carboplatin(300mg/m2) which were administrated after blood-brain barrier disruption. Of there, 3 patients had ocular complications after supra-ophthalmic IAC injection of carboplatin but fully recovered following steroid therapy. Although our results from IAC seem to be favorable for these patients, we suggest that its complications, such as ocular toxicity, need to be carefully considered prior to treatment.