The Analysis of Polymethylmethacrylate Leakage after Vertebroplasty for Vertebral Body Compression Fractures

OBJECTIVE: To assess causative factors that may induce the leakage of the PMMA after the vertebroplasty performed on osteoporotic compression fracture patients. METHODS: Percutaneous vertebroplasty was done on 80 vertebral compression fractures in 54 patients from June.2001 to Nov.2002. Leakage of PMMA was divided into paravertebral, venous, epidural, and intradiscal leakage. The relationship between leakage of PMMA and various factors were analyzed such as clinical features, bone mineral density, existence of bone sclerosis, interval from injury to operation, amount of PMMA, tip location, operation method, compression pattern, compression ratio etc. RESULTS: Leakage was found in 39 vertebral bodies out of a total of 80 operated vertebral bodies. A large amount of PMMA, which was injected into compressed vertebra, induced a high incidence of leakage(P=0.042). Preoperative high bone mineral density in Compressed Vertebra induced a high incidence of leakage(P=0.014). The existence of sclerosis caused a high incidence of leakage.(P=0.014). Other factors, which were examined, did not induce the leakage of PMMA. CONCLUSION: Percutaneous vertebroplasty must be done carefully after a detailed examination of factors that might cause leakage of PMMA.

MR Angiographic Findings in Ischemic Stroke Patients with Extracranial Carotid Artery Stenosis

OBJECTIVE: The purpose of study is to help the diagnosis and define the management of the ischemic stroke with carotid stenosis. We report a clinical analysis of the clinical and radiological characteristics of extracranial carotid artery stenosis in patients presenting with ischemic stroke using non-invasive technique, magnetic resonance(MR) angiography. METHODS: The authors reviewed 232 patients with ischemic stroke, excluding cardiac origin, carrying out MR image and MR angiography at department of neurology and neurosurgery from May 1998 to May 2001. Stroke in this study were classified as carotid and vertebro-basilar stroke. According to clinical and radiological finding, carotid stroke was divided into lacunar and non-lacunar stroke. The patients with extracranial carotid artery stenosis were classified according to the symptoms, location, and the degree of stenosis. The locations of intracranial lesion and associated intracranial stenosis were analyzed also. RESULTS: Of 232 stroke patients, 23(9.9%) had extracranial carotid artery stenosis. Symptomatic stenosis were 9 and 14 patients were non-symptomatic. The locations of stenosis were 10 in carotid bifurcation, 11 in proximal internal carotid artery, and 2 in common carotid artery. Severe intracranial stenosis were observed in 16 patients(69.6%) among 23 patients with extracranial carotid artery stenosis. CONCLUSION: Intracranial stenosis were frequently observed in ischemic stroke patients than extracranial lesions. And the combined extra- and intracranial atherosclerotic lesions were frequently seen in the patients with carotid artery stenosis. And these charactreristics should be considered in surgical management of ischemic stroke.

Risk Factors for Development of Chronic Hydrocephalus Following Aneurysmal Subarachnoidal Hemorrhage

OBJECTIVE: Chronic hydrocephalus is a well known sequelae of an aneurysmal subarachnoid hemorrhage (SAH). However, the risk factors of the chronic hydrocephalus after SAH are still not well known. The authors design the study to focus on the incidence of chronic hydrocephalus, causal relationship between the development of chronic hydrocephalus and SAH. METHODS: The analysis of 105 consecutive patients of aneurysmal SAH was done to determine the risk factors significantly related to the development of chronic hydrocephalus needing for shunting. The risk factors for the analysis were age, sex, location of the aneurysm, Hunt-Hess grade at admission, Fisher Grade at admission CT scan, the presence of the acute hydrocephalus. RESULTS: The incidence of chronic hydrocephalus needing for shunt was 13.3%. The high Hunt-Hess grade and intraventricular hemorrhage and acute hydrocephalus were related to need for shunting of chronic hydrocephalus. CONCLUSION: We conclud that the development of chronic hydrocephalus following SAH is multifactorial. The high Hunt-Hess grade, intraventricular hemorrhage and acute hydrocephalus are related to the development of hydrocephalus.

Epithelioid Hemangioendothelioma of the Spinal Cord

Hemangioendotheliomas are vascular neoplasms characterized by histologic appearance that are intermediate between hemangiomas and angiosarcomas first described by Weiss and Enzinger in 1982. They are classified into at least 3 subgroups, including epithelioid hemangioendothelioma, spindle cell hemangioendothelioma, and malignant endovascular angioendothelioma, and have been reported principally in soft tissues of the extremities, lung, liver, and bone. The cases involving the central nervous system reported are very rare. We report an intraspinal epithelioid hemangioendothelioma occurring in a 52-year-old man. To our knowledge, it is first case of spinal hemangioendothelioma in Korea.

Clinical Outcomes according to Radiological Classification of Brainstem Hemorrhages

No abstract available.

Combined Anomalies of Atlantal Hypoplasia, Assimilation and Basilar Invagination: A Case Report

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.

Comparison of Fusion Rate between Iliac Autograft versus Fibular Allograft in Instrumented Anterior Cervical Fusion

OBJECTIVE: The authors performed instrumented anterior cervical fusion with either iliac autograft or fibular allograft for various clinical entities. The purposes of the study are to compare the fusion rate and the time to fusion according to graft material, and to identify the factors affecting fusion. METHOD:57 patients underwent instrumented anterior cervical fusion during 3 years between Jan. 1995 and Dec. 1997, among them 31 patients with iliac autograft(autograft group), and 26 patients with freeze-dried fibular allograft (allograft group). The clinical entities were trauma(n=0), soft disc herniation(n=), spondylotic radiculopathy(n=1), spondylotic myelopathy(n=6), and ossified posterior longitudinal ligament(n=). The method of fusion was either interbody fusion confined to disc space or strut fusion after corpectomy. Outcomes were assessed for fusion status and time to fusion, and comparison between autograft group versus allograft group. RESULT: Between autograft and allograft group there were no differences in distribution of perioperative clinical variables such as patients' age and gender, clinical entity, method of fusion, and length of fusion as determined by the number of disc space fused. Mean follow-up period was 19 months(range 10-28 months) in autograft group and 16 months(range 8-22 months) in allograft group. The fusion rate was 90% in autograft group and 85% in allograft group(p=.691). The median time to fusion was 7 months in autograft group and 15 months in allograft group(p<0.001). The perioperative variables affecting fusion, defined as those being significantly associated with the time to fusion, were the graft material(p=.000) and the length of fusion(p=.007). The rate of graft-related complications including donor-site morbidity was 41% in autograft group and 8% in allograft group. CONCLUSION: It is concluded that the use of freeze-dried fibular allograft in instrumented anterior cervical fusion is, though the time to fusion is delayed more than two times, as an effective way as the use of iliac autograft to achieve fusion, and is a better way to ameliorate graft-related complications.

A Comparison of Clinical Outcomes between Decompressive Lumbar Laminectomy Alone and with Arthrodesis in Degenerative Lumbar Spinal Stenosis

To evaluate the relationship between surgical procedures and clinical outcomes in degenerative lumbar spinal stenosis, we retrospectively analyzed the results of the patients who had been performed decompressive lumbar spinal surgery. Eighty-five patients with degenerative lumbar spinal stenosis underwent decompressive lumbar spinal surgery between Jan. 1994 and Dec. 1996. The patients were randomly assigned to one of two groups; decompression alone(47 patients) and decompression with arthrodesis(38 patients). Among the patients with arthrodesis, the instruments were placed in 34 patients. The follow-up duration was 16-51 months(mean; 32.8 months). Functional outcome was excellent or good in 96% of the patients with decompression alone and in 97% of those with decompression with arthrodesis(p=0.667), and the overall patient's satisfaction was 87.5% and 89.5%, respectively. Although the various factors, which could be possible influent to the clinical outcome, were considered, there were no statistically significant differences in results between the two groups. The findings of this study demonstrate that the spinal fusion procedure has no benefit in clinical outcomes of the patients with degenerative lumbar spinal stenosis. Thus the fusion procedures with instrumentation should be used only in carefully selected patients because of its potential risks of serious complications, such as nerve root injury, massive bleeding, and infection.

Ventral and Dorsal Stabilization of the Thoracolumbar Spine by Crossed-screw Fixation

For surgical stabilization of thoracolumbar instability either posterior transpedicular fixation or anterior interbody fixation is commonly performed. On some occasions, however, combined ventral and dorsal stabilization is needed, in which case surgery is usually performed in separate stages. To achieve this goal in a single operation, the authors used the crossed-screw fixation technique, with the pedicle screw-rod system, in eight patients. Their thoracolumbar instabilities were caused by trauma(n=6), tumor(n=1), and congenital deformity(n=1). In all patients, signs of myelo- and/or radiculopathy were present, and as this required extensive ventral and dorsal decompression, combined ventral and dorsal stabilizations was considered necessary. Surgery involved the lateral extracavitary approach: for dorsal stabilization, the conventional transpedicular fixation method, with pedicle screws of 5.5-mm diameter, was used. For ventral stabilization, interbody struts were grafted, using rib autograft or in the case of tumor fibula allograft, supplemented with transverse fixation of the vertebral body with pedicle screws of 7.5-mm diameter. The two stabilization systems, ventral and dorsal, were interconnected with cross-linking plates. Follow-up 12 to 26 (average 18) months after surgery revealed no hardware failures, and all patients showed improvement in their neurological functions during this period. Due to congenital deformity, graft dislodgement occurred in one patient. On the basis of these results the authors believe that the crossed-screw fixation technique is a viable option for three-dimensional stabilization of the thoracolumbar spine.

Petrosal Approach to Petroclival Meningiomas: Experience with 3 Cases

The authors report three patients of large petroclival meningiomas which were operated by retrolabyrinthine(petrosal) approach. This technique maximizes temporal bone drilling and therefore provide exquisite exposure of the clival and petrous regions with minimal brain retraction. The superior petrosal sinus is sacrificed and the tentorium completely cut. The sigmoid sinus on the other hand can be preserved, depending on the venous drainage and the degree of exposure required.

Classification of Spatial Direction of Anterior Communicating Artery Aneurysm Based on the Neck Origin Site and the Fundus Projection

Most anterior communicating artery aneurysms arise in association with ipsilateral, dominant, proximal anterior cerebral artery(A1) segments and, as direct extensions of those vessels, are often somewhat directed toward the contralateral cerebral hemispheres. We classified the directions of the anterior communicating artery aneurysms based on three dimensional orientations of neck orifices and fundus projections which were then described schematically to demonstrate spatial orientations. We also analyzed 32 cases of anterior communicating artery aneurysm who had been operated on during recent 3.5 years according to this classification. Only the difference in the size of aneurysm in relation to the site of aneurysmal neck was statistically significant(p=0.0116), and there were no correlations between A1 hypoplasia and the site of aneurysmal neck, the projection of aneurysmal fundus and the size of aneurysm, and the intraoperative rupture and the projection of the aneurysmal fundus. Although meaningful clinical results could not be obtained, we believe this classification can be very helpful in planning traditional or endovascular surgeries for, and in understanding spatial directions of anterior communicating artery aneurysms.

Spontaneous Cystic Degeneration of Solid Suprasellar Germinoma

Intracranial germinomas are malignant neoplasms arising from remnants of primitive germ cells that have failed to migrate to the genital crest during embryonic life. They are usually solid tumors, but focal cysts may occasionally be found within them and are thought to represent proteinaceous fluid. Cystic degeneration of the whole tumor, however, that is caused by intratumoral hemorrhage, has not yet been reported. We present a case of cystic degeneration of solid suprasellar germinoma. During surgery, cyst content was shown to be liquefied hematoma, and bleeding of the tumor had occurred. The exact time of intratumoral hemorrhage in the presented case is unknown, but since there had been no episode of apoplexy, we believe that degeneration occurred chronically. The patient's postoperative course was uneventful. On the basis of our findings we suggest that in diagnosing suprasellar cystic tumors, the possibility of germinomas must be taken into consideration and that spontaneous cystic degeneration of suprasellar germinoma can occur as a result of tumor bleeding.

High Cervical Chordoma Removed via Median Labiomandibular Glossotomy Approach

The authors report two cases of high cervical spinal chordomas that were removed via the median labiomandibular glossotomy(MLG) approach. One patient was a 62-year-old female in whom an extradural chordoma was found at the level of C3 vertebra with huge prevertebral extension, and causing dyspnea and dysphagia; the other was a 47-year-old female, found to be suffering from a chordoma of C2 vertebral body, which was found incidentally. After removal of the tumors, ventral instrumented fusions were performed in both patients, who showed good recoveries with only minor complications. The MLG approach is radical, and rarely performed by neurosurgeons, but for treatment of an expanded high cervical lesion that needs ventral surgery and seems to be inaccessible via the conventional transoropharyngeal or anterolateral retropharyngeal route, it should be considered. The authors discuss the clinicopathological characteristics of spinal chordomas and general considerations of the MLG approach to high cervical lesions, and briefly describe the surgical techniques involved in this approach.

Magnetic Resonance Neurography with Short Tau Inversion Recovery Sequences for Cervical Radiculopathy

In magnetic resonance(MR) imagings with short tau inversion recovery(STIR) sequences fat signals are specifically suppressed. These imaging techniques, therefore, have been used to identify optic nerve lesions in the orbits, because there are a lot of fat tissues which may obscure the optic nerves in the orbit. The cervical spinal nerves or ventral primary rami of brachial plexus, during their courses in the necks between anterior and middle scalene muscles, are also surrounded by considerable amount of fat deposits. So we used these MR imaging techniques with already used posterior neck coil system, to image cervical spinal nerves directly, and to know whether there are certain signal changes in those nerves of the involved nerve roots, in 12 patients who were considered to have cervical radiculopathies by conventional diagnostic means. In MR neurography with STIR sequences(STIR MRN) of axial and coronal images, signals of the cervical spinal nerves of the involved roots were detected as fairly bright, and were discerned from signals of the spinal nerves of the uninvolved roots. We also measured contrast-to-noise ratio(CNR) of the spinal nerve signals of the involved and uninvolved roots in axial images. The average CNR value of the former was 4.48+/-0.889 and of the latter 1.40+/-0.274. Our fingings indicate that STIR MRNs can be helpful in limiting the lesions more accurately and in making surgical decisions for cervical radiculopathies caused by multileveled discs or spondylosis.

Probable Primary Leptomeningeal Melanoma: A Case Report

Primary leptomeningeal melanomas(PLMs) are rare aggressive central nervous system(CNS) tumors without systemic foci. It can be very difficult, however, to clearly distinguish PLMs from those that have metastasized. We report a case of malignant leptomenigeal melanoma occurring in the right temporal convexity of a 77-yearold woman. Almost all malignant CNS melanomas in the old are secondary to the cutaneous melanoma and can cause diverse neurological manifestations; certain clinical findings of the presented case-namely, the patient's age, vague neurologic findings and absence of cutaneous lesions -are therefore interesting. Thorough clinical checkups, including whole-body bone scan, whole spine MRI, abdominal ultrasound, and tumor marker studies to find extracranial lesions revealed no abnormalities. Based on these clinical findings, we suppose-though are not certain-that the tumor of the presented case is a PLM.

A Case Report of Intradural Ruptured Lumbar Disc

Intradural ruptured discs are very rare occurrences and the incidence is reported to be 0.13% among total herniated discs, 90% of intradural ruptured discs are known to occur in the lumbar area. The symtoms and signs of the intradural disc are much more severe than those of the usual extradural herniated disc. MR imagings of the intradural disc demonstrate several typical findings, but intradural tumors must be ruled out. The authors present a case of intradural ruptured lumbar disc L4-L5 level in a 46-year-old female. Characteristic MR and operative findings of this case are reported. Pathogenetic mechanisms and differential diagnoses with certain intradural tumors and the extradural ruptured disc with similar MR findings are discussed.

Malignant Intracranial Osteolytic Meningioma Appearing as an Extracranial Soft Tissue Mass: A Cases Report

Malignant intracranial meningioma is a rare pathologic entity. Although the topic is widely discussed, there is little agreement in the literatures as to the histological and radiological features that warrant the diagnosis of malignant meningioma. An osteolytic lesion of the skull may have been suggested in several cases. But in adults, the most commonly suspected lesion is metastatic lesion;while meningioma is rarely suspected. Meningiomas are occasionally associated even with extracranial masses. However, most of these masses are firm, and are caused by hyperostosis. Extracranial soft-tissue masses rarely arise in meningiomas, thus, the presence of both osteolytic skull lesion and soft-tissue mass is exceedingly rare in meningiomas. The authors report a case of osteolytic malignant meningioma located at the frontal fossa extending to the subgaleal space appearing as an extracranial soft-tissue mass in a 19-year-old female. The clinical, radiological, neurosurgical, and histopathological features of these lesions are discussed together with a review of the literatures.

Spontaneous Spinal Epidural Hemorrhage

Spontaneous spinal epidural hematoma are rare disease and the cause of bleeding in epidural hematoma remains unknown in most of the cause. The most frequently identified risk factor is coagulopathy or treatment with anticoagulants. Recently, authors experienced I case of spontaneous spinal epidural hematoma at thoracic location. Laboratory examination showed no evidence of coagulopathy and hepatic disease. The patient had good surgical outcome after emergent decompressive laminectomy.

Rercutaneous Radiofrequency Denervation in Lumbago

A technique radiogrequency localization and coagulation of articular nerves supplying the lumbar facets is described and reported from a series of 46 patients with clinical diagnosis of facet syndrome over a 4-year period. None of them had clinical or radiologic evidence of a lumbar disc hrniation, and all had exhausted conservative treatment. The literature reviewed for anatomical accuracies in denervation of the medial branch of posterior primary(dorsal) ramus. The technique of facet denervation is simple and safe and relief of pain was achieved in 78% of the patient, the morbidity remains quite low.