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.

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.

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 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.

An Immunohistochemical Study of ErbB4 Receptor in Alzheimer's Disease Hippocampus / 대한해부학회지

Neuregulin-1 (NRG1) signaling participates in numerous neurodevelopmental processes. Although ErbB4, a key NRG1 receptor, is expressed in multiple regions in the adult animal brain, little is known about its expression in aged human brain. We show that ErbB4 immunoreactivity was shown regional difference in the hippocampus of age-matched control and that the distribution of these molecules was altered in Alzheimer's disease (AD) brains. Immunohistochemical characterization of the distribution of ErbB4 receptor in the hippocampus relative to pathology staging were performed in age-matched control (Braak stage I/II, n=5), early AD (Braak stage III/IV, n=5) and advanced AD(Braak stage V/VI, n=10). The intensity of ErbB4 immunoreactivity was higher in neurons of the CA2 than that in CA1 or CA3 in the age-matched control. Particularly, in the early AD, ErbB4 immunoreactivity was significantly increased in the apoptotic cells of the CA2 field. In the advanced AD, ErbB4 immunostaining was more intense in the apoptotic cell of the CA2 field. In the dentate gyrus (DG), ErbB4-positive granular cell density was gradually increased in proportion to the progression of pathology of AD brains. We have also found that ErbB4 immunostaining was increased in the nucleus, suggesting that the presenilin-dependent cleavage of ErbB4 generates the soluble ErbB4 ICD (intracellular domain) that translocalized to the nucleus. Together, these results provide the immunohistochemical analysis of ErbB4 receptor in the human hippocampus staged by the progression of pathology of AD.

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.

Anterior Cervical Microforaminotomy / 한양의대학술지

Anterior cervical microforaminotomy is the one of surgical options for treating cervical spondylotic lesions manifested by radiculopathy or myelopathy. This minimally invasive surgical procedure is gaining popularity due to the recent trends of avoidance of spinal fusion resulting in loss of the physiologic spinal motion and developing a future adjacent segment syndrome. Although the spinal fusion still remains a gold standard procedure for degenerative cervical spinal diseases, the eager for maintaining the function of the motion segment is another issue for contemporary spinal surgeons. Anterior cervical microforaminotomy is a target-oriented operation that decompresses the nerve root or spinal cord without destruction of the spinal anatomical functional unit. Unlike to other procedures including total or partial resection of the intervertebral disc, this surgical procedure removes only a small part of the uncovertebral joint or vertebral body. Through this narrow corridor, adequate decompression of the nerve root or spinal cord can be achieved while preserving functional motion. Technical variations of the original anterior cervical microforaminotomy have been continuously developed to minimize the concerns for the postoperative disc height loss and instability. As of now, the anterior cervical microforaminotomy and its technical variations have been proved to be an excellent procedure for treating the cervical spondylotic radiculopathy from literatures review. But the long-term clinical results and the efficacy of the procedure for cervical myelopathy still remain to be seen.

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.

Determination of Aneurysmal Location with 3 Dimension-Computed Tomographic Angiography in the Microsurgery of Paraclinoid Aneurysms

OBJECTIVE: Determining the location of paraclinoid aneurysms for microsurgery is important for selecting treatment options, especially when deciding on the release of the dural ring in direct clipping. We examined the reliability of using the optic strut as an anatomical landmark for evaluating the location of paraclinoid aneurysms. METHODS: Cadaveric dissection was performed to establish the relationship of the optic strut to the dural ring. Results from these anatomic studies were compared with the three-demensional computed tomographic angiographic (3D-CTA) findings of nine patients with ten paraclinoid aneurysms between May 2004 and October 2005. These, 3D-CTA results were then compared with intraoperative findings. RESULTS: The inferior boundary of the optic strut accurately localized the point at the proximal dural ring in cadaveric study. The optic strut and its relationship to the aneurysms was well observed on the multiplanar reformats of 3D-CTA. During microsurgery, nine of ten aneurysms were verified to arise from distal to the upper surface of the optic strut. Two aneurysms that had arisen between the inferior and superior boundary of the optic strut were observed to lie within the carotid cave. One aneurysm which had arisen at the inferior boundary of the optic strut and directed inferiorly was observed to lie within the cavernous sinus just after the release of the proximal ring. CONCLUSION: The optic strut, as identified with multiplanar reformats of 3D-CTA, provided a reliable anatomic landmark for the proximal rings and an important information about the location of aneurysms around the anterior clinoid process (ACP). Therefore, 3D-CTA and the optic strut could become an invaluable tool and a landmark in the assessment of the location of paraclinoid aneurysms for microsurgery.

The Influence of Central Venous Pressure on Blood Loss during Spinal Fusion in Prone Position

OBJECTIVE: The central venous pressure(CVP) could affect the vertebral venous pressure, which in turn may influence blood loss during lumbar spinal surgery. The authors perform prospective clinical study to investigate the influence of the CVP on the amount of intra-operative blood loss and operating time. METHODS: Total 134 patients having various degenerative lumbar spinal pathology were treated by laminectomy and spinal fusion using posterior lumbar interbody fusion with cages and pedicle screws. The CVP was measured after prone positioning in all the patients. The correlation between the CVP and intra-operative blood loss and operating time were analyzed. RESULTS: The mean CVP after prone positioning was 10 cmH2O(5-18). The mean amount of intra-operative blood loss and operating time were 1884 cc and 213 minutes, respectively. The amount of blood loss and operating time significantly increased with the extent of spinal fusion. The CVP was significantly correlated with intra-operative blood loss and operating time(p<0.05). CONCLUSION: With increased CVP on prone position, there is a tendency of increasing amount of blood loss and operating time. The measurement of CVP is useful in determining the position providing a bloodless field during spinal fusion.

Surgical Removal of Coil and Clipping of Aneurysm after Failure of Intraaneurysmal Coil Embolization: Case Report

Despite modern advances in endovascular techniques, intraaneurysmal coil embolization may be associated with serious complications such as parent artery occlusion by thromboembolism and coil migration or incomplete treatment, which require surgery. We report 5 cases in which surgical interventions had been necessary following coil embolization with Guglielmi Detachable Coil, either due to incomplete aneurysm obliteration or acute complication of parent artery occlusion by coil migration and throm-boembolism. Surgical intervention include removal of the coils and clipping of the aneurysm. Immediate recanalization of the occluded artery by use of intra-arterial thrombolytics and surgery is very important. The role of neurosurgical management in the care of the patients suffering from unsuccessful endovascular therapy of aneurysm is demonstrated.