Percutaneous Disc Coagulation Therapy (PDCT) comparing with Automated Percutaneous Lumbar Discectomy (APLD) in Patients of Herniated Lumbar Disc Disease: Preliminary Report

OBJECTIVE: Percutaneous techniques are rapidly replacing traditional open surgery. This is a randomized controlled trial study of clinical outcomes of Percutaneous Plasma Disc Coagulation Therapy (PDCT) in patients with HLD(herniated lumbar disc) as a new percutaneous access in comparison with Automated Percutaneous Lumbar Discectomy (APLD) in its clinical application and usefulness as a reliable alternative method. METHODS: The authors analyzed 25 patients who underwent PDCT randomized 1:1 to 25 who underwent APLD between June, 2010 and October, 2011. All patients had herniated lumbar disc diseases. The clinical outcomes were evaluated using Visual Analog Scales (VAS) score and MacNab's criteria. RESULTS: The age of the patients who underwent PDCT ranged from 29 to 88 years with a mean age of 51.8 years. The age of the APLD undergone patients' population ranged from 30 to 66 with a mean age of 46.0 years. The average preoperative VAS score in PDCT was 7.60 and 1.94 at 7months post-operatively, and in APLD was 7.32, and 3.53 at 7 months post-operatively (p<0.001). In Macnab's criteria, 20 patients (80%) had achieved favorable improvement (excellent and good) in PDCT group. In Macnab's criteria, 16 patients (64%) had achieved favorable improvement in APLD group (p<0.001). CONCLUSION: PDCT can be considered a viable option as a new percutaneous access to herniated lumbar disc. PDCT showed to be more effective than APLD in this study, allowing stable decompression and safe minimally invasive operation to an area desired by the operator in lumbar disc herniation patients, although further long term clinical evaluations are still necessary.

Traumatic Entrapment of the Vertebrobasilar Junction Due to a Longitudinal Clival Fracture: A Case Report

Vertebrobasilar junction entrapment due to a clivus fracture is a rare clinical observation. The present case report describes a 54-yr-old man who sustained a major craniofacial injury. The patient displayed a stuporous mental state (Glasgow Coma Scale [GCS]=8) and left hemiparesis (Grade 3). The initial computed tomography (CT) scan revealed a right subdural hemorrhage in the frontotemporal region, with a midline shift and longitudinal clival fracture. A decompressive craniectomy with removal of the hematoma was performed. Two days after surgery, a follow-up CT scan showed cerebellar and brain stem infarction, and a CT angiogram revealed occlusion of the left vertebral artery and entrapment of vertebrobasilar junction by the clival fracture. A decompressive suboccipital craniectomy was performed and the patient gradually recovered. This appears to be a rare case of traumatic vertebrobasilar junction entrapment due to a longitudinal clival fracture, including a cerebellar infarction caused by a left vertebral artery occlusion. A literature review is provided.

CT Angiography in Acute Ischemic Stroke: Clinical Research / 대한뇌혈관외과학회지

OBJECTIVE: This study was designed to evaluate the feasibility and clinical implications of CT angiography (CTA) in patients with acute ischemic stroke. METHODS: From August 2004 to July 2005, 24 cases of acute ischemic stroke were prospectively included in this study. We checked location of ischemic parenchymal lesion, location of vascular occlusion, degree of collateral supply, and presence of other accompanying vascular lesions on CT and CTA, and assessed the usefulness of CTA by comparing the findings with those of diffusionweighted MR imaging and digital subtraction angiography. RESULTS: Average time required for performing CT and CTA and getting reconstructed images was 30 minutes. Location of the parenchymal lesions and the corresponding occluded or stenosed artery could be clarified in 16 cases (67%) and 20 cases (83%), respectively. There were 13 cases of severe stenosis and 7 cases of occlusion. In 7 cases of major arterial occlusion, degree of collateral circulation could be assessed as good in 5, and moderate in 2. Incidental unruptured intracranial aneurysms were identified in 5 cases. CONCLUSION: CTA could provide valuable information regarding locations of parenchymal lesion and vascular occlusion, degree of collateral supply, and presence of accompanying intracranial aneurysm in cases of acute ischemic stroke without significant time delay, thereby guiding therapeutic plan.

Changes of Muscle Related Enzymes after Posterior Approaches to the Lumbar Spine

OBJECTIVE: Creatine phosphokinase-MM(CPK-MM) and lactate dehydrogenase(LDH) are well known indices of muscular injury. To know the degree of muscular injury during spinal surgery, the author report serial measurement of serum CPK-MM and LDH4 level. METHODS: The authors investigated 23 patients who underwent lumbar spinal surgery without bone fusion or instrumentation. Peripheral venous blood samples were serially collected 1 day before surgery, operation day, postoperative 3rd, 7th, 14th and 28th day. Postoperative back pain was measured by visual analogue scale. We evaluated the relationship between number of operation level, serial changes of serum CPK-MM, LDH4, duration of surgery and postoperative back pain. RESULTS: CPK-MM activity was higher after surgery than before it and reached at maximal level on the postoperative 3rd day, and it was returned to normal level on the postoperative 7th day. The score of postoperative back pain scale was the highest on the postoperative 3rd day. CPK-MM activity was significantly correlated with operation level, duration of surgery, and postoperative back pain(P0.05). CONCLUSION: Postoperative muscle injury is inevitable in all patient who underwent spinal surgery, and these injuries are related extent of exposure and duration of surgery. To reduce muscle injury and postoperative back pain, less invasive and shorter surgery in time is recommend.

Acute Expansion of Hematoma in Hypertensive Intracerebral Hemorrhage / 대한뇌혈관학회지

Hypertensive intracerebral hemorrhage is one of the most common cause of death in Korea and usually considered as a monophasic event. But recently acute expansion of the hematoma within an hour to a day, has been reported as a cause of severe neurological deterioration and death. To know the incidence and risk factors of acute expansion of the hematoma in hypertensive intracerebral hemorrhage, the authors retrospectively analysed 96 hypertensive intracerebral hemorrhage patients who were admitted to Minjoong hospital from January 1997 to December 1998. Neurological examination with Glasgow Coma Scale and first computed tomography (CT) scan were performed as soon as possible after arrival. Then second CT scan was performed within an hour to a day before the operation. Blood sample was taken within an hour for routine laboratory examination including liver function and coagulation test. The amount and shape of hematoma on CT scans were carefully measured to know whether acute expansion was occurred or not. The patients who have acute expansion of the hematoma were 15 patients (15.6%). Expansion of the hematoma was not correlated with sex, age, site, shape, or amount of hematoma statistically. But thalamic hematoma in location, irregular shape of hematoma, or large amount of hematoma has a tendency of acute expansion. The time of onset to arrival, initial systolic pressure, liver dysfunction and history of heavy alcohol drinking were correlated with acute expansion statistically (p<0.05). The shorter the time of onset to arrival and the higher initial systolic pressure, the more the incidence of acute expansion of the hematoma significantly. Acute expansion of the hematoma was significantly increased with the severity of liver dysfunction and history of heavy alcohol drinking. The levels of glutamic oxaloacetic transaminase (GOT), alkaline phosphatase, gamma-glutamyl transpeptidase (gamma-GTP) and platelet (PLT) count were meaningful indices of hematoma expansion.

Relationship between Cerebral Arteriovenous Oxygen Difference and Development of Delayed Cerebral Infarction in Patients with Severe Head Injury

No abstract available.

The Selective T3 Sympathicotomy in Patients with Essential Palmar Hyperhidrosis

No abstract available.

An Intradural Extramedullary Hemangioblastoma of Distal Spinal Cord: A Case Report

No abstract available.

The Analysis of Surgical Results to the Lumbar Spinal Disorders of Aged Persons

No abstract available.

The Factors Affecting the Fovorable Outcomes in the Treatment of the Failed Back Surgery Syndrome

No abstract available.

A Surgical Treatment of Low-Grade Spondylolisthesis: A Comparative Study of in Situ Fusion and Fusion after Reduction

OBJECTIVE: This study retrospectively analysed the influence of reduction to postoperative symptoms in 57 patients with low-grade degenerative or ishmic spondylolisthesis managed with posterolateral fusion delete. PATIENTS AND METHODS: The clinical and radiological severity were assessed with Prolo's grade(economic and functional) and static and dynamic lateral radiographs(displacement and angulation). The postoperative questionnaire and the change of translation and angulation of static and dynamic lateral radiographs were used to judge the clinical and radiological success. All patients were treated with decompression and stabilization with instrumentation and autologous bone fusion, with or without reduction. The patients were followed clinically for a mean of 693.11 days (range, 6 to 18 months). RESULTS: There were 32 cases of spondylolytic spondylolisthesis, and the remaining 25 cases were degenerative spondylolisthesis. The average Prolo's economic grade delete of 20 patients delete managed without reduction was not statistically different from that delete of 37 patients managed with reduction(4.20 vs. 4.24, p>0.01). Also, the average Prolo's functional grade delete of 20 patients managed without reduction was not statistically different from delete of 37 patients managed with reduction(4.05 vs. 3.97, p>0.01). CONCLUSIONS: The authors conclude that in situ stabilization using autologous posterolateral arthrodesis combined with pedicular screw fixation resulted a good outcome. The additional procedure of reduction, performed with decompression and instrumented posterolateral fusion, for the treatment of the patients with low-grade degenerative and isthmic spondylolisthesis does not appear to provide additional benefits on functional outcome.

Clinical Analysis of 54 Cases with Spondylolisthesis

Most cases of spondylolisthesis are asymptomatic and successfully managed with conservative treatment. Operation was performed in 20% of symptomatic cases having severe back pain, neurological symptoms and/or progressive slipping. Although surgical treatments are divided into decompression and fusion, various methods were tried from simple Gill's resection to posterior and/or anterior fusion with instrumentation in case of severe slipping. The authors reviewed 54 cases of symptomatic spondylolisthesis, who were surgically treated, and had follow up evaluations our institution during past 6 years from March, 1990, to March, 1996. 1) The age distribution was from 19 to 64 years of age and the highest prevalent decade was at the 5th. 2) There were 14 male and 40 female patients with female preponderance about 3 to 1 ratio. 3) Thirty one cases were isthmic type and 23 cases were degenerative type. The ratio between isthmic type and degenerative type was about 2:1. 4) The displacement between L4 and L5 was 25 cases and the displacement between L5 and sacrum was 18 cases, and others were L3 and L4, L4 and sacrum, L5 and L6. 5) Overall results are excellent in 7 cases(13%), good 35 cases(65%), fair 10 cases(19%), and poor 2 cases(4%). 6) There were no changes in slipping in 23 cases(42.6%). Occurred in partial reduction were possible in 30 cases (55.5%), and further slipping developed was 1 case(1.9%).

Intradural Spinal Fibrolipomatous Hamartoma: A Case Report

Fibrolipomatous harmatomas are rare, benign, fibrolipomatous process of peripheral nerves. It usually manifests as a soft slowly growing mass consisting of proliferating fibrofatty tissue surrounding and infiltrating major nerves and their branches. The median nerve is affected in the great majority of cases. Intradural spinal cases are extremely rare. The authors present a very rare case of a fibrolipomatous harmatoma involving the intradural space of lumbar spine with review of pertinent literature.

Availability of discographic computed tomography in automated percutaneous lumbar discectomy

Automated percutaneous lumbar discectomy (APLD) has been developed since 1984 when Gary Onik first attempted it. This procedure has many advantages and has been used widely in the treatment of protruded disc diseases. The success rate of APLD by authors from March 1988 to February 1993 when the discographic computed tomography (CT) had not been performed was 74%. In evaluating lumbar disc diseases, we have used discographic CT. According to the patterns of dye distribution in the disc, two different types of protrusion can be distinguished: broad dye base protrusion and narrow dye base protrusion. From April 1993 to July 1994, 52 patients with protruded disc diseases were performed discographic CT. 23 Patients had narrow dye base protrusion and 29 patients had broad dye base protrusion. 29 patients with a broad dye base on discographic CT were treated with APLD and evaluated. The success rate in these patients was 93% by Macnab's criteria. Thus, we suggest that it is mandatory to apply discographic CT to increase the success rate of APLD in patients with protruded disc diseases.

Prognostic Factors of Automated Percutaneous Nucleotome in Lumbar Disc Herniation

Percutaneous automated lumbar discectomy as it is now practiced appears to be an extremely safe procedure. One hundred fourty eight patients with lumbar disc herniation were treated with automated percutaneous lumbar discectomy(A.P.L.D). The postoperative results in 118 patients were evaluated at more than 3 months after the operation. Total satisfactory result was 74% ; excellent 16%, good 58%, fair 22%, poor 4% by Macnab's criteria. For further satisfactory result, more meticulous criteria is needed. The results indicated that several prognostic factors were considered : 1) less than 30 years of age, 2) more than 4ml of aspirated disc volume, 3) L4-5 of disc level, 4) follow up X-ray change(59%), but no CT change and possible MRI change.

Postoperative Evaluation of Lumbar Disc Herniation Using Digital Infrared Thermographic Imaging

Digital infrared thermographic imaging system is noninvasive, easy to reading, objective and physiologic instrument by measuring and imaging infrared energy emitted from skin surface. The authors present the result of digital infrared thermographic images of 83 patients of operated lumbar disc herniation from October, 1990 to March, 1991. 46 patients have received discectomy and the other 37 patients have received chemonucleolysis. We have done digital infrared thermographic imaging preoperatively and postoperatively. In preoperative digital infrared thermographic imaging, diagnostic sensitivity is about 76%, In postoperative digital infrared thermographic imaging, clinical results were well correlated in discectomy group. But in chemonucleolysis group, clinical results were not correlated with digital infrared thermographic images.

Regional Cerebral Blood Flow and Brain Edema Responses to Continuous Versus Intermittent Brain Retraction

Retraction of any part of the brain may damage the cortex as well as the parenchyma, so it is advisable to retract the brain with the least force necessary and for the shortest time as possible. The purpose of this study was to examine in cats the damage caused by retraction of the brain by measuring the regional blood flow and brain edema, and to determine which of two methods, continuous or intermittent brain retraction, is less harmful to the brain. Twenty five adult cats weighting 2.5 to 4.0Kg, were used in this study. The twenty five cats were divided into three groups ; control (n=5), continuous retraction (n=10) and intermittent retraction groups (n=10) respectively. The brain retraction was produced by applying the lead weight with the stainless retractor on the right frontal lobe through a craniectomy at the right frontal bone. The weight (20g) was supported throught the pulley so that its long axis was perpendicular to the cortical surface. In the continuous retraction group, the brain was retracted for 180 min with a retraction force of 20g and in the intermittent retraction group, a 15 min period of retraction was applied, followed by a 5 min release, repeated nine times. The regional cerebral blood flow (rCBF) and brain specific gravity measurements were carried out in each animal before and immediately after brain retraction, at the 30th min, 60th min, 90th min, 120th min, 150th min and 180th min after retraction. The rCBF was measured by hydrogen clearance method and the brain edema was measured by gravimetric technique. The results were as follows : 1) After the brain retraction, there were rise in blood pressure and bradycardia in 60 min. 2) Normal control cerebral blood flow (rCBF, ml/100g/min) were 38.7+/-1.9 in right frontal, 38.7+/-1.7 in left frontal, 38.6+/-2.3 in right parietal and 38.2+/-2,3 in left parietal lobes. 3) A considerable reduction in rCBF at the retraction site, has been demonstrated with continuous brain retraction in 60 min after retraction. A reduction in rCBF to 30% of control (RF ; 28.2+/-2.1ml/100g/min) in 180 min after continuous retraction of the right frontal lobe, however, intermittent retraction resulted in a reduction of flow to 12% of control(RF ; 37.5+/-2.9ml/100g/min) at retraction site in 180 min after retraction. 4) The changes of brain specific gravity relatively began to notice at rCBF less than 23.0ml/100g/min. It might be inferred from these that intermittent retraction was less harmful to the brain, which indicate adequate arterial blood flow under the retractor was vital for the preservation and return of the neuronal function following brain retraction.

Effect of Focal Brain Retraction on the Regional Cerebral Blood Flow and the Electroencephalographic Activity in the Cat

The use of brain retractors, unavoidable method in operation of deep intracranial lesions, may lead to focal cerebral ischemia and thereby cause brain infarction. In such operation, the surgical microscope is commonly used to get good surgical field. However, as the time of operation becomes lengthened, it results in longer retraction of the brain and probable greater ischemic infarction. To estimate the risk of ischemic damage, the authors investigated the regional cerebral blood flow(rCBF) and the electroencephalographic(EEG) activity at different forces and durations of the brain retraction in the cat models simulating the frontal approach of the pituitary surgery. Twenty-six adult cats weighing from 2.4 to 4.5 kg were used in this study. The animals were divided into 3 groups : control(n=6), 20g-retraction(n=10), and 30g-retraction groups(n=10) respectively. The brain retraction was produced by applying the lead weight with the stainless steel retractor on the right frontal lobe through a craniectomy over the right frontal bone. The weight(20g or 30g) was supported with the pulley so that its long axis was perpendicular to the cortical surface, The measurements of rCBF activity were carried out in each animal before and immediately after brain retraction at 30 min, 60 min, 90 min, 120 min and 180 min after retraction. The results were as follows ; 1) After brain retraction, there were rise in intracranial pressure, bradycardia, elevation in blood pressure and alteration in respiration at 60 min after brain retraction. 2) Normal control flows(rCBF, ml/100g/min) were 39.7+/-6.1 in the right frontal, 37.8+/-2.6 in the left frontal, 37.5+/-3.6 in the right parietal and 38.8+/-4.1 in the left parietal lobes. 3) A considerable reduction in rCBF was demonstrated at 60 min after brain retraction. A reduction of rCBF to 40% of control flow(19.5+/-7.5ml/100g/min) was found at 60 min after retraction in the right frontal with the 20g-retractor. With the 30g-retractor, rCBF were reduced to 64% of control flow(13.3+/-6.8ml/100g/min) at 60 min and 90% of control flow(4.0+/-2.1 ml/100g/min) at 180 min after retraction in the right frontal lobe. 4) A close correlation was found between EEG activity and rCBF changes, suggesting a threshold relationship. The changes of EEG activity began to be noted at the rCBF value of less than 20.0 ml/100g/min. A 50% suppression of the EEG activity appeared at the rCBF value of 4.0+/-1.2 ml/100g/min. It is concluded that EEG activity is secondarily is secondarily suppressed by reduction in local blood flow which is caused by local compression. It is advisable to retract the brain with the least force necessary and for the shortest time possible. It is also suggested to resect the brain partially before retraction to avoid irreversible ischemic infarction of the brain in consequence of forceful, longtime retraction in exploration of deep intracranial lesions.

Ependymoblastoma Associated with Massive Intracerebral Hemorrhage

The patient is a 17 month old girl admitted to the Korea General Hospital with histories of irritability, walking disturbance and right sided weakness. On admission, she had seizure followed by coma. Skull x-ray showed widely separated all cranial sutures. A left carotid angiogram revealed a space occupying lesion in the left frontotemporoparietal region with shifting of the midline to the right. At operation, a darkish hemorrhagic tumor with relative clear demarcation was explored after evacuation of massive intracerebral hematoma. The tumor was extended to the midline. The main mass was removed with difficulty. Additional fragments of the necrotic tumor tissue infiltrated in the surrounding structures were also removed. It was not directly connected to or have invaded the ventricular wall. On microscopic examination, the tumor was largely made up of solid sheets and cords of round or ovoid cells with darkly stained nuclei. In areas, typical ependymal rosettes as well as pseudorosettes, gliomatous features and occasional formation of tubule are presented. We think the tumor represents those rare tumors called ependymoblastoma of Rubinstein.

Bitemporal Hemianopsia Caused by Head Injury

Visual field defects being associated with severe closed head injury is well known. The nature and frequency of these association have been reported in a few literatures. Some hypotheses have been advanced to explain the field defects, but no prospective pathological study of the visual pathways in a large number of cases with closed head injury has been made. These hypotheses as to why vision is impaired after head injury have not explained most cases, if not at all. Authors have experienced a case of traumatic, complete bitemporal hemianopsia associated with macular sparing on the right and macular splitting on the left eye in 29 year old man. The patient had a head injury with traffic accident, which caused fractures of the frontal bone and orbital roofs. The various pathogenic possibilities of the chiasmal damage and consequent visual field defects are discussed.