Anti-Hu Antibody-Mediated Myelopathy Associated with Gastric Adenocarcinoma

Anti-Hu antibody causes paraneoplastic syndrome of the nervous system. Most of the anti-Hu antibodies are found with small cell lung cancer, but can rarely be found with other cancers such as non-small cell lung cancer, prostate cancer, and breast cancer. We report a 57-year-old male patient with advanced gastric adenocarcinoma who had paresthesia and limb ataxia. Electrophysiologic study and imaging showed peripheral neuropathy accompanied with myelitis. Anti-Hu antibody was detected in the patient’s serum, leading to the diagnosis of paraneoplastic syndrome.

Recurrent Cerebral Infarction Associated with Uterine Adenomyosis

Uterine adenomyosis, which is known as a benign gynecological disease, can induce hypercoagulable state and be an uncommon cause of cerebral thromboembolism, as cerebral infarction is common in patients with malignant neoplasm. We report a woman with uterine adenomyosis who shows several episodes of cerebral infarction and discuss the stoke mechanism and treatment of this under-recognized etiology of stroke.

Radiologic Changes of Operated and Adjacent Segments after Anterior Cervical Microforaminotomy

OBJECTIVE: Anterior cervical microforaminotomy (ACMF) is a motion-preserving surgical procedure. The purpose of this study is to assess radiologic changes of operated and adjacent segments after ACMF. METHODS: We retrospectively reviewed 52 patients who underwent ACMF between 1998 and 2008. From X-ray film-based changes, disc height and sagittal range of motion (ROM) of operated and adjacent segments were compared at preoperative and last follow-up periods. Radiological degeneration of both segments was analyzed as well. RESULTS: The mean follow-up period was 48.2 months. There were 78 operated, 52 upper adjacent, and 38 lower adjacent segments. There were statistically significant differences in the ROM and disc height of operated segment between preoperative and last follow-up periods. However, there were no statistically significant differences in the ROM and disc height of adjacent segment between both periods. Radiological degenerative changes of operated segments were observed in 30%. That of adjacent segments was observed in 11 and 11% at upper and lower segments, respectively. CONCLUSION: After mean 4-year follow-up periods, there were degenerative changes of operated segments. However, ACMF preserved motion and prevented degenerative changes of adjacent segments.

The Comparative Analysis of Clinical Characteristics and Surgical Results between the Upper and Lower Lumbar Disc Herniations

OBJECTIVE: There are differences in the clinical characteristics and surgical results between upper (L1-2 and L2-3) and lower (L3-4, L4-5, and L5-S1) lumbar disc herniations. We conducted this study to compare the clinical features and surgical outcomes between the two types of lumbar disc herniations. METHODS: We retrospectively reviewed the clinical features of patients who underwent microdiscectomies from 2008 to 2012. We evaluated the clinical characteristics such as age, preoperative autonomic dysfunction, the presence or absence of previous lumbar surgery and fusion required during surgery. Visual Analogue Scale (VAS) scores about back pain and leg pain were evaluated preoperatively and at the final follow-up. RESULTS: Upper lumbar group (n=15) was significantly older than lower lumbar group (n=148). The incidence of autonomic dysfunction was significantly higher in upper lumbar group. The number of patients with a previous lumbar surgery was significantly greater in upper lumbar group. There was no statistical significance for fusion required during surgery between two groups. Both groups showed a significant decrease in the VAS scores of leg pain. VAS scores of back pain were significantly decreased in lower lumbar group. But this was not seen in upper lumbar group. Both groups showed significant improvement of Oswestry Disability Index score. CONCLUSION: Upper lumbar group had different clinical characteristics from those of lower lumbar group and these include older age, a higher incidence of autonomic dysfunctions and a higher incidence of patients with previous lumbar surgery. There were no significant differences in surgical outcomes, except for back pain, between two groups.

Fulminant Meningitis after Radiotherapy for Clival Chordoma

The best treatment for clival chordoma is obtained with total surgical excision, sometimes combined with adjuvant radiotherapy. A cerebrospinal fluid (CSF) fistula is a fatal complication that may occur following extended transsphenoidal surgery (TSS) and adjuvant radiotherapy. We report a case of fulminant meningitis without a CSF fistula in a 57-year-old woman who underwent TSS and multiple radiotherapies for a clival chordoma. She presented to our emergency room with copious epistaxis and odor inside her nasal cavity and had an unexpected fatal outcome. She was diagnosed with meningitis based on CSF culture and blood culture. While treating clival chordomas with adjuvant radiotherapy, clinicians should be aware of the possibility of fulminant meningitis.

The Comparisons of Surgical Outcomes and Clinical Characteristics between the Far Lateral Lumbar Disc Herniations and the Paramedian Lumbar Disc Herniations

OBJECTIVE: The purpose of this study is to analyze clinical characteristics and surgical outcomes of the far lateral and the paramedian disc herniations. METHODS: The 88 patients who underwent an operation for lumbar disc herniations were reviewed. Visual analogue scale of leg and back pain, occurrence of sensory dysesthesia and motor deficit before and after operations were used to compare the far lateral with the paramedian disc herniations. RESULTS: Statistically, the far lateral herniations had more severe radicular leg pain and showed more frequent occurrence of sensory dysesthesia than paramedian herniations before operation (p0.05). CONCLUSION: Preoperatively, the far lateral herniations had more severe radicular leg pain and frequent occurrence of sensory dysesthesia. Postoperatively, the sensory dysesthesia was less improved and back pain was more severe in the far lateral herniations.

Surgical Treatment of Lumbar Hyperextension Injury in Ankylosing Spondylitis

Ankylosing spondylitis (AS) is a chronic systemic and inflammatory rheumatic disease with a variable course of the axial skeleton. Spinal involvement may accompany ossification of the ligaments, intervertebral disc, end-plates and apophyseal structures, and seems to be "bamboo spine". Because of these natures of the spine in AS, a spinal fracture can be occurred with minor trauma or spontaneously. The fracture of the AS can cause neurological complications extremely high, so special attention to prevent neurological deterioration. Operative management of the injured spine with AS is difficult, and associated with a high complication rate. Extreme care must be taken for surgery to prevent secondary neurological deterioration.

Intracranial Dural Arteriovenous Fistulas: Clinical Characteristics and Management Based on Location and Hemodynamics

OBJECTIVE: A dural arteriovenous fistula (DAVF) generally refers to a vascular malformation of the wall of a major venous sinus. These lesions have diverse symptoms according to the location and venous drainage, and require multidisciplinary treatment. We report on our experience and analyze the treatment outcome of intracranial DAVFs for a nine-year period. METHODS: Between January 2000 and December 2008, 95 patients with intracranial DAVFs were enrolled in this study. A retrospective review of clinical records and imaging studies of all patients was conducted. Endovascular embolization, surgical interruption, gamma knife stereotactic radiosurgery (GKS), or combinations of these treatments were performed based on clinical symptoms, lesion location, and venous drainage pattern. RESULTS: Borden type I, II, and III were 34, 48, and 13 patients, respectively. Aggressive presentation was reported in 6% of Borden type I, 31% of Borden type II, and 77% of Borden type III DAVFs, respectively, and DAVFs involving transverse, sigmoid, and superior sagittal sinus. Overall, the rate of complete obliteration was 68%. The complete occlusion rates with a combination treatment of endovascular embolization and surgery, surgery alone, and endovascular embolization were 89%, 86%, and 80%, respectively. When GKS was used with embolization, the obliteration rate was 83%, although it was only 54% in GKS alone. Spontaneous obliteration of the DAVF occurred in three patients. There were a few complications, including hemiparesis (in microsurgery), intracranial hemorrhage (in endovascular embolization), and facial palsy (in GKS). CONCLUSION: The hemorrhagic risk of DAVFs is dependent on the location and hemodynamics of the lesions. Strategies for treatment of intracranial DAVFs should be decided according to the characteristic of the DAVFs, based on the location and drainage pattern. GKS can be used as an optional treatment for intracranial DAVFs.

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.

Effectiveness of Nicardipine for Blood Pressure Control in Patients with Subarachnoid Hemorrhage

OBJECTIVE: The purpose of the study is to determine the effectiveness and safety of nicardipine infusion for controlling blood pressure in patients with subarachnoid hemorrhage (SAH). METHODS: We prospectively evaluated 52 patients with SAH and treated with nicardipine infusion for blood pressure control in a 29 months period. The mean blood pressure of pre-injection, bolus injection and continuous injection period were compared. This study evaluated the effectiveness of nicardipine for each Fisher grade, for different dose of continuous nicardipine infusion, and for the subgroups of systolic blood pressure. RESULTS: The blood pressure measurement showed that the mean systolic blood pressure / diastolic blood pressure (SBP/DBP) in continuous injection period (120.9/63.0 mmHg) was significantly lower than pre-injection period (145.6/80.3 mmHg) and bolus injection period (134.2/71.3 mmHg), and these were statistically significant (p 0.05). Furthermore, controlling blood pressure was more effective when injecting higher dose of nicardipine in higher SBP group rather than injecting lower dose in lower SBP group, and it also was statistically significant (p < 0.05). During the infusion, hypotension and cardiogenic problems were transiently combined in five cases. However, patients recovered without any complications. CONCLUSION: Nicardipine is an effective and safe agent for controlling acutely elevated blood pressure after SAH. A more systemic study with larger patients population will provide significant results and will bring solid evidence on effectiveness of nicardipine in SAH.

An Early Comparative Analysis of the Use of Autograft Versus Allograft in Anterior Cervical Discectomy and Fusion

OBJECTIVE: The purpose of this study is to verify the usefulness of autograft versus allograft in the radiographic and clinical outcome in early period after the surgery. METHODS: We performed a retrospective review of 38 patients who had undergone one- or two-level anterior cervical discectomy and fusion (ACDF) with rigid anterior plate fixation from March 2006 to May 2009. Interbody graft materials were iliac autograft (n=17) or with allograft (n=21). Fusion rate and graft collapse rate were assessed by radiographic analysis and clinical outcome was based on Odom's criteria. RESULTS: In autograft group, 13 patients achieved successful bone fusion (65%), whereas 7 patients (31.8%) in allograft group. There was statistically significant between two groups (p0.05), but statistically significant in allograft group (p<0.05). Clinical outcome was excellent or good in 94.1% in autograft group, and 90.5% in allograft group. CONCLUSION: In study, anterior cervical interbody fusion with an allograft got a result of lower fusion rate and higher collapse rate compared with autograft in early period after surgery, and clinical outcome showed similar results in both groups.

Surgical Results and Risk Factors for Recurrence of Lumbar Disc Herniation

OBJECTIVE: Recurrent lumbar disc herniation has been defined as disc herniation at the same level, regardless of ipsilateral or contralateral herniation, with a pain-free interval greater than 6 months. The aim of this study is to analyze outcomes and identify the potential risk factors for recurrent lumbar disc herniation. METHODS: The authors retrospectively reviewed the cases of 178 patients who underwent open discectomy for single-level lumbar disc herniation. Visual analogue scales and modified Macnab criteria were used to compare the clinical outcomes between the recurrent group and the non-recurrent group. Sex, age, discectomy level, degree of disc degeneration, type of disc herniation, pain-free interval after first-operation, smoking status, and trauma were investigated as potential recurrence risk factors. RESULTS: Of the 178 patients for whom the authors were able to definitely assess symptomatic recurrence status, 18 patients (10.1%) underwent revision surgery for recurrent disc herniation. The most common level involved was L4-L5 (61%) and the mean period of time to recurrence was 18.7 months (6-61 months). There were 17 cases of ipsilateral herniation and 1 case of contralateral herniation. The types of herniation for which revision surgery was done were protrusion (3 cases), and transligamentous extrusion (14 cases). There were five excellent, eight good, and two fair results. CONCLUSION: Repeated discectomy for recurrent disc herniation produced unsatisfactory outcomes. Factors such as sex, type of disc herniation and traumatic events were found to be significant risk factors.

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.

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.

The Avoidance of Microsurgical Complications in the Extradural Anterior Clinoidectomy to Paraclinoid Aneurysms

OBJECTIVE: Paraclinoid segment internal carotid artery (ICA) aneurysms have historically been a technical challenge for neurovascular surgeons. The development of microsurgical approach, advances in surgical techniques, and endovascular procedures have improved the outcome for paraclinoid aneurysms. However, many authors have reported high complication rates from microsurgical treatments. Therefore, the present study reviews the microsurgical complications of the extradural anterior clinoidectomy for treating paraclinoid aneurysms and investigates the prevention and management of observed complications. METHODS: Between January 2004 and April 2008, 22 patients with 24 paraclinoid aneurysms underwent microsurgical direct clipping by a cerebrovascular team at a regional neurosurgical center. Microsurgery was performed via an ipsilateral pterional approach with extradural anterior clinoidectomy. We retrospectively reviewed patients' medical charts, office records, radiographic studies, and operative records. RESULTS: In our series, the clinical outcomes after an ipsilateral pterional approach with extradural anterior clinoidectomy for paraclinoid aneurysms were excellent or good (Glasgows Outcome Scale : GOS 5 or 4) in 87.5% of cases. The microsurgical complications related directly to the extradural anterior clinoidectomy included transient cranial nerve palsy (6), cerebrospinal fluid leak (1), worsened change in vision (1), unplanned ICA occlusion (1), and epidural hematoma (1). Only one of the complications resulted in permanent morbidity (4.2%), and none resulted in death. CONCLUSION: Although surgical complications are still reported to occur more frequently for the treatment of paraclinoid aneurysms, the permanent morbidity and mortality resulting from a extradural anterior clinoidectomy in our series were lower than previously reported. Precise anatomical knowledge combined with several microsurgical tactics can help to achieve good outcomes with minimal complications.

Meningioma in the Lateral Cerebellomedullary Cistern without Dural Attachment

A 59-year-old female presented with headache and dizziness for one year. Magnetic resonance imaging revealed a 52 x 28 mm, well-circumscribed, homogenously enhancing mass lesion without dural attachment located in the left lateral cerebellomedullary cistern. The tumor was excised, and a histological diagnosis was a mixed pattern meningioma of meningothelial and fibroblastic type. A meningioma in the posterior fossa without dural attachment is quite rare. We report a rare case of lateral cerebellomedullary cistern meningioma without dural attachment with literature review.

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.

Technical Strategies and Surgical Results of C1 Lateral Mass-C2 Pedicular Screw Fixation in Atlantoaxial Disorders

OBJECTIVE: There are various posterior fusion techniques in managing C1-2 instability. The aim of this study is to evaluate surgical techniques and clinical results including complications of the C1 lateral mass and C2 pedicle screw fixation (C1-2 LMPSF) in atlantoaxial disorders. METHODS: From February 1997 to July 2008, 24 patients were performed C1-2 LMPSF due to C1-2 instability. Pathway of vertebral artery was classified into three groups by 3D-angiogram. Diameter of C1 lateral mass and C2 isthmus on the plain X-ray and CT was measured before operation. Surgical method was divided into four groups according to fixation site (bilateral or unilateral) and bone graft (with or without graft). Stability of C1-2 fixation was postoperatively evaluated by flexion and extension cervical lateral films. We reviewed clinical data, imaging studies and old chart retrospectively as sources for analysis. RESULTS: Among 24 patients, os odontoideum was the most common cause (16 out of 24). Four patients had anomalous vertebral artery. Mean diameters of C1 lateral mass was 9.9(range 4.2~16.4) mm at right side, 10.3 (range 3.4~14.2) mm at left side. Mean diameter of C2 isthmus was 5.8 (range 1.0~10.1) mm at right side and 5.8(range 2.1~8.2) mm at left side. Two patients showed very narrow C2 isthmus. As a result, unilateral C1-2 LMPSF was performed on 6 patients (4 for anomalous vertebral arteries and 2 for narrow C2 isthmus). 12 of 18 patients were with C1-2 interlaminar bone graft and 6 patients without bone graft. All patients showed stable C1-2 fixation by flexion and extension cervical lateral X-ray films taken at least 6 months after surgery. Five out of 8 patients who had preoperative radiculopathy only showed improved symptoms. However, Seven out of 8 patients who had myelopathy showed little neurological improvement . CONCLUSION: For C1-2 LMPSF, preoperative 3D CT-angiogram study is mandatory to identify abnormal vertebral artery and narrow C2 isthmus. Bilateral C1-2 LMPSF without bone graft is enough to obtain stable C1-2 fixation. If there is an abnormal vertebral artery or narrow C2 isthmus, unilateral C1-2 LMPSF with bone graft and wiring is alternative successful method.

Surgical Treatment of Degenerative Lumbar Spine Disease in Geriatric Patients Over 70 Years Old: A Review of Two Decades

OBJECTIVE: The aim of this study is to evaluate the transition of lumbar spinal treatments for geriatric patients over 70 years old over two decades. METHODS: We retrospectively assessed 730 patients who were 70 years and older and underwent lumbar surgery. We analyzed the number of diseases, operation methods and complications with 5-year intervals from 1987 to 2006. RESULT: The number of patients older than 70 years who underwent lumbar surgery increased according to our analysis of the period spanning from 1987 to 2006. Thirty-two (1%), 77 (1.7%), 232 (4.4%), and 389 (8.2%) patients over 70 years underwent lumbar spine surgeries. Among them, the 8, 29 and 45 patients had one level degenerative spondylolisthesis for the periods 1992-1996, 1997-2001 and 2002-2006. Twenty-four, 29 and 58 patients had lumbar stenosis during all these time periods. Over time, we performed a larger variety of operations as well as more aggressive operations. From January 2002 to December 2006, a total of 308 patients were over 70 years old and had lumbar spine surgeries performed on them. Among them, the ASA class I was 58 (19%), the ASA class II was 213 (69%) and the ASA class III was 37 (12%). During that period, PLIFs and PS fixations were performed on 69 patients. Among them, 8 patients were ASA III. Large numbers of lumbar arthorodesis have been performed in geriatric patients over the age of 70 years in our series. CONCLUSION: The surgical treatment of degenerative spine disease in the elderly patients was increased due to improved surgical technique and advances in medical treatment including anesthesia. The authors suggest that fusion surgery can be done safely in elderly patients even though they have high-grade ASA classification.

Surgical Treatment of Klippel-Feil Syndrome with Cervical Spondylosis

We report a case of Klippel-Feil syndrome. The patient was a 37-year-old man who developed progressive motor weakness and on C4-5 and C6-7 segments combined with severe cervical stenosis, basilar impression and C1 assimilation. He showed progressive quadriparesis and respiratory difficulty. He had combined congenital anomaly of right side facial palsy of peripheral type and right side sensorineural hearing loss. In May 2002, we performed, via transoral approach, anterior fusion with Harm's mesh and hydroxyapatite from the clivus to the C3. But, one month after the operation, Harm's mesh with hydroxyapatite slipped anteriorly due to non-union. So, we removed the mesh and reoperated with fibular bone graft from the clivus to the C3. Simultaneously, posterior approach was performed with on-lay autologous rib bone graft and wiring from the occiput to the C2, 3, 4. One year after the operation, his motor weakness has been gradually improved and there is minimal difficulty in self-respiration.