Spontaneous Cervical Epidural Hematoma Causing Brown-Sequard Syndrome

Spontaneous cervical epidural hematoma (SCEH) is a rare clinical entity and has a varied etiology. Urgent surgical decompression should be done to prevent serious permanent neurologic deficits. We describe a 59-year-old female who presented with Brown-Sequard syndrome due to spontaneous cervical epidural hematoma. Initially, she was misdiagnosed as cerebrovascular accident. Cervical magnetic resonance imaging revealed epidural hematoma to the right of the spinal cord extending from C3 to C6. She later underwent surgical evacuation and had complete restoration of neurologic function. The outcome in SCEH is essentially determined by the time taken from onset of the symptom to operation. Therefore, early and precise diagnosis such as careful history taking and MRI evaluation is mandatory.

Intraoperative Vertebral Artery Angiography to Guide C1-2 Transarticular Screw Fixation in a Patient with Athetoid Cerebral Palsy

We present a case of an athetoid cerebral palsy with quadriparesis caused by kyphotic deformity of the cervical spine, severe spinal stenosis at the cervicomedullary junction, and atlantoaxial instability. The patient improved after the first surgery, which included a C1 total laminectomy and C-arm guided righ side unilateral C1-2 transarticular screw fixation. C1-2 fixation was not performed on the other side because of an aberrant and dominant vertebral artery (VA). Eight months after the first operation, the patient required revision surgery for persistent neck pain and screw malposition. We used intraoperative VA angiography with simultaneous fluoroscopy for precise image guidance during bilateral C1-2 transarticular screw fixation. Intraoperative VA angiography allowed the accurate insertion of screws, and can therefore be used to avoid VA injury during C1-2 transarticular screw fixation in comorbid patients with atlantoaxial deformities.

Endoscope-Assisted Microsurgical Removal of an Epidermoid Tumor within the Cavernous Sinus

Epidermoid tumor of the cavernous sinus is rare. The aim of this case report is to discuss the role of neuroendoscopes in the removal of such lesions. A 21-year-old man presented with 6-year history of progressive headache, diplopia, and visual disturbance. Work-up revealed an epidermoid tumor located in the right cavernous sinus. An extradural transcavernous approach was utilized via a traditional frontotemporal craniotomy with endoscopic assistance. The postoperative course was uneventful with immediate improvement of the patient's headache. Postoperative magnetic resonance imaging demonstrated complete removal of the tumor. There were no signs of recurrence during a 2-year follow-up period. The endoscope is a useful tool for removing epidermoid tumors from the cavernous sinus and enhances visualization of areas that would otherwise be difficult to visualize with microscopes alone. Endoscopes also help minimize the retraction of neurovascular structures.

Surgery for a Case of Three-Compartment Trigeminal Schwannoma : Technical Aspects

Complete removal of three-compartment trigeminal schwannomas is a challenge to neurosurgeons. To expand exposure of each compartment, the combination and modification of skull base approaches are necessary. The 61-year-old woman was admitted with chronic headache. Preoperative magnetic resonance imaging showed 47x50x40 mm-sized tumor originating primarily in the middle cranial fossa extended to the posterior and the infratemporal fossa. We performed operation in five stage; 1. Zygomatic osteotomy, 2. Inferior temporal fossa plate removal and foramen ovale opening, 3. Cavernous sinus opening, 4. Tailored anterior petrosectomy, 5. Meckel's cave opening. Combination of skull base surgery should be concerned according to the patient. In this study, extradural basal extension with zygomatic osteotomy, interdural posterior extension with tailored anterior petrosectomy, and intracavernous exploration are reasonable options for remodeling three-compartment lesion into a single compartment. Tailoring of bone resection and exploring through natural pathway between meningeal layers accomplish single-stage operation for complete removal of tumors.

Long-term Follow-up Results of Anterior Cervical Microforaminotomy

OBJECTIVE: We previously reported excellent early and midterm clinical results of anterior cervical microforaminotomy (ACMF) for patients with cervical radiculopathy caused by disc herniation or foraminal stenosis. ACMF is accepted as a minimally invasive functional spinal surgery, but its long-term outcomes are unknown. The purpose of this study is to evaluate the long-term clinical and radiographic results of ACMF. METHODS: We performed a questionnaire survey and retrospective analysis of 13 patients with cervical radiculopathy who underwent ACMF from 1998 to 2002. Clinical and radiographic data from these 13 patients (one-level operations in seven patients, and two-level operations in six patients) were analysed. We measured disc height, sagittal plane displacement and sagittal plane angulation to evaluate instability. RESULTS: Thirteen patients answered the questionnaires. Mean follow-up was 77.3 months (ranged from 498 to 110 months). The surgical outcome was excellent in three patients (23%) and good in nine patients (69%). One patient had only a fair outcome, but there were no cases of recurrence, reoperation or additional surgery. Twelve of 13 patients were satisfied with the results of their surgery. On the average, the loss of disc height was 0.84mm(16.6% of preoperative disc height), increase of displacement was 0.47mm and increase of sagittal plane angulation was 0.65degrees. All patients maintained stability during the follow-up period. Although the patient sample included in this study is a different sample from that surveyed in our previous study of mid-term results, the long-term radiographic outcomes showed that the parameters of instability tended to decrease in comparison to those midterm results. Three-dimensional computed tomography scans showed signs indicative of bone remodeling, including regrowth of the resected bone and gradual fusion around the uncovertebral joint (UVJ) where ACMF was performed. In spite of bone regeneration around the UVJ, the neural foramen appeared to be well maintained in all patients. CONCLUSION: In the long-term, ACMF is clinically effective method for the treatment of cervical radiculopathy, although disc height was decreased and sagittal angulation was increased. UVJ with mild hypermobility that was apparent at midterm appears to be restored during long-term follow-up. The efficacy of this procedure should be evaluated in additional studies involving large patient series.

Long Term Clinical and Radiographic Results of Lumbar Spinal Stenosis with Grade I Degenerative Spondylolisthesis after Microsurgical Bilateral Decompression via Unilateral Laminotomy

OBJECTIVE: The purpose of this study was to assess long-term clinical outcomes and radiographic changes in patients with lumbar spinal stenosis with grade I degenerative spondylolisthesis who underwent microsurgical bilateral decompression via unilateral laminotomy, as a minimally invasive surgery. Method: Medical records of twenty-five patients who underwent the surgery between 1999 and 2005 were retrospectively evaluated. Clinical outcomes were evaluated through interviews over telephone with standardized questionnaires. Preoperative and postoperative radiographs were taken from all patients in neutral and dynamic lateral views. The mean follow-up period after surgery was 38.5 months(range 9-57 months). RESULTS: Seventy-two percent of patients were either pain free(48%) or doing well with occasional acetaminophens(24 %), and satisfied with the treatment. The most improved preoperative symptom was neurogenic intermittent claudication, which was ameliorated in 94.7% of patients(excellent 84.2%, good 10.5%, fair 5.3%). Postoperative vertebral slippage was also measured and appeared to be slightly increased but this was not statistically significant. Postoperative dynamic angulation did not change significantly compared to the preoperative value. CONCLUSION: Microsurgical bilateral decompression via unilateral laminotomy achieved a satisfactory decompression and symptomatic relief without extensive destruction of the weight-bearing structures and functional mobile segments. This treatment can be an effective modality for patients with lumbar spinal stenosis associated with mild degenerative spondylolisthesis.