The Change of Rectus Muscle Length Caused by Traction with Muscle Hooks in Strabismus Surgery: The Second Report

PURPOSE: To investigate the influence of the change in medial rectus resection amount caused by traction with muscle hooks on surgical results in exotropia. METHODS: In this prospective study 38 exotropia patients underwent unilateral lateral rectus recession-medial rectus resection (R & R). After isolation of the medial rectus muscle, the length of the muscle was measured with a muscle hook, and the portion to be resected was marked using gentian violet stain with calipers. After the medial rectus was retracted with two muscle hooks in either direction, its length was measured again with the calipers. Group 1 includes the patients with the planned resection amount changed to a more 0.5-1.0 mm when the rectus muscle was retracted, while group 2 did not change with the second muscle hook. The surgical results were compared between the 2 groups at postoperative 6 months. RESULTS: Mean resection amount was changed from 5.07 +/- 0.76 mm to 5.36 +/- 0.73 mm after pulling the second muscle hook. Sixteen patients (42.1%) were included in group 1 and 22 patients (57.9%) in group 2. There was no significant statistical difference in mean preoperative and postoperative deviated angle between the two groups. Success rates defined as the ocular alignment within +/- 10 PD in the primary position at postoperative 6 months were 75.0% in group 1 and 86.3% in group 2, which is not stastistically different (p > 0.05). CONCLUSIONS: Medial rectus resection amounts can be changed with the muscle traction with two muscle hooks, which induced the planned amount of resection less than first measured resection amount. However, there was little influence on surgical outcomes from the change occurred to a maximum 1 mm in resection measurement due to traction with two muscle hooks.

Surgical Results after Unilateral Laminectomy for the Removal of Spinal Cord Tumors

OBJECTIVE: To reduce the risk of postoperative spinal instability or deformity, unilateral laminectomy (UL) has been recommended to remove spinal space-occupying lesions. The purpose of this study was to determine whether there were any advantages of UL for removal of spinal cord tumors. METHODS: From May 1995 to May 2010, 94 patients with spinal cord tumors, who underwent tumor removal via UL in our institute, were enrolled in this study. Intramedullary spinal cord tumors were excluded. Simple radiographs were obtained for accessing the restoration of the spinal column. Spinal magnetic resonance imaging (MRI) was also obtained during the follow-up period to evaluate tumor recurrence. RESULTS: There were 51 women and 43 men; their mean age was 47.8 years (range, 9-83 years). The mean follow-up period was 52.6 months (range, 24 month-16 years). The sites of the tumors were cervical in 21 cases, thoracic in 37, lumbar in 33, and sacral in 3. These cases included 85 intradural extramedullary (IDEM) and 9 extradural (ED) lesions. IDEM tumors consisted mainly of neurilemmomas (56.3%) and meningiomas (22.3%).Tumors were totally removed in 80 cases and subtotally removed in 14 cases. Postoperative neurological status was improved in 53 cases, unchanged in 31 cases, and worsened in 10 cases. During follow-up, MRI showed tumor recurrence in 4 patients. Histopathologically, three cases were meningiomas and one case was neurilemmoma. None of the patients showed spinal instability or kyphotic deformity at last follow-up. CONCLUSION: UL is an optimal approach for providing sufficient exposure of spinal cord tumors without development of postoperative spinal instability and regional sagittal imbalance in any location of spinal column. In cases of meningioma, careful long-term follow up is needed due to it's relatively high recurrence rate after removal via UL.

The Factors Affecting Surgical Results in Cervical Spondylotic Myelopathy / 대한척추외과학회지

STUDY DESIGN: This is a retrospective study on the factors affecting the surgical results for cervical spondylotic myelopathy. OBJECTIVES: We wanted to analyze the clinical and radiologic factors affecting the results of treatment for cervical spondylotic myelopathy patients who underwent anterior decompression with fusion or open door laminoplasty. SUMMARY OF THE LITERATURE REVIEW: Many authors have reported on the prognostic factors affecting the results of surgical treatment for cervical spondylotic myelopathy; some of the reported factors do affect the results, but there is a wide range of opinion about them. MATERIALS AND METHODS: We reviewed 38 patients who underwent anterior decompression with fusion or open door laminoplasty for cervical spondylotic myelopathy between March 1999 and Dec. 2003. We analyzed the factors, including age, the duration of symptoms, the symptomatic classification, the preoperative and postoperative JOA scores, the compression ratio of the spinal cord and the surgical method. RESULT: The mean JOA score increased from 10.3+/-3.4 preoperatively to 14.9+/-4.6 postoperatively with a recovery rate of 69.0% +/- 21.24%. The preoperative JOA score and the compression ratio of the spinal cord on MRI correlated positively with the recovery rate. The patients' age showed negative correlation with the recovery rate. There is no difference between the two surgical methods for the recovery rate. CONCLUSION: The preoperative JOA score, the patients' age and the spinal cord compression ratio on MRI are the prognostic factors affecting the surgical results, but there are no difference between the two surgical method.

Clinical Analysis of Strabismus between Siblings

To investigate the clinical similarity between the siblings, we retrospectively studied the medical records of 64 patients, 32 pairs. 31 pairs showed the similar entity of strabismus between siblings. There was exotropia in 22 pairs, esotropia in 5 pairs, bilateral superior obliqre palsy in 2 pairs, exotropia, esotropia and Duane`s retraction syndrome in 1 pair. One was exotropia and the other was exotropia and Duane`s retraction syndrome in one pair. One pair was bilateral supperior obliqre palsy and esotropia and the other was right gypertropia and exotropia. The difference in the amount of deviation was less than 10 prism diopter in 23 pairs. There was no association between the strabismic siblings in refractive anomaly, amblyopia, and anisometropea. The surgical results were similar in 7 pairs of siblings among 8 pairs who underwent corrective operations.

Clinical Analysis of Strabismus between Siblings

To investigate the clinical similarity between the siblings, we retrospectively studied the medical records of 64 patients, 32 pairs. 31 pairs showed the similar entity of strabismus between siblings. There was exotropia in 22 pairs, esotropia in 5 pairs, bilateral superior obliqre palsy in 2 pairs, exotropia, esotropia and Duane`s retraction syndrome in 1 pair. One was exotropia and the other was exotropia and Duane`s retraction syndrome in one pair. One pair was bilateral supperior obliqre palsy and esotropia and the other was right gypertropia and exotropia. The difference in the amount of deviation was less than 10 prism diopter in 23 pairs. There was no association between the strabismic siblings in refractive anomaly, amblyopia, and anisometropea. The surgical results were similar in 7 pairs of siblings among 8 pairs who underwent corrective operations.

Surgical Results of Posterior Arthrodesis in Traumatic Atlantoaxial Instability: Wire Fixation vs Screw Fixation

OBJECTIVE: Although posterior wiring techniques have been commonly used with good results in treating the traumatic atlantoaxial instabilities, screw fixation technique has been gaining popularity to secure atlantoaxial arthrodesis in recent years. The purpose of this study is to compare the surgical results of posterior arthrodesis for the traumatic atlantoaxial instability between these two methods. METHODS: Twenty patients underwent 21 procedures over a 6-year period with a mean follow-up of 23 months. The most common condition of traumatic atlantoaxial instability was dens fracture(15 patients) followed by transverse atlantal ligament injury(4 patients), and traumatic os odontoideum(2 patients). Thirteen posterior wiring and eight posterior screw fixations were performed. Among 13 wiring methods, nine Galli fusions, two occipito-cervical fusions, one Brooks fusion, and one C1-C3 fusion were done. RESULTS: No patient developed neurological worsening after surgery. Compared to wire method, all patients of screw group had significant pain reduction when the patients was younger than 50 years old(p=0.01). The postoperative changes in distances of space available for cord(SAC) was not statistically significant between wire and screw methods(p=0.7). The rate of complication(23% in wire vs 25% in screw) was comparable to two methods. Although two screw malposition(25%) among screw fixations were developed, all revealed solid fusion without additional surgeries. The rate of fusion(85% in wire vs 100% in screw) was excellent in screw group. Postoperative loss of reduction, including redisplacement and kyphosis, was present only in wire group(31%). Two(15%) of wire fusions had redisplacement; both of these patients were type 2 dens fracture. Three procedures(23%) of wire fusions resulted in kyphotic change which occurred when delayed surgeries were done between 40 days and 90 days(mean: 63 days) after trauma. CONCLUSION: Considering both reduction loss and fusion rate, wire method caused more spinal deformity than screw method(38% vs 0%). This study demonstrates that screw method is a better surgical option for management of traumatic atlantoaxial instability.

Surgical Result in Glaucoma Associated with Iridocorneal Endothelial Syndrome

Iridocorneal endothelial(ICE) syndrome is charaterized by unilateral glaucoma, abnormal corneal endothelium with proliferation, and iris stromal abnormalities. Uncontrolled glaucoma in ICE syndrome has been treated with filtering surgery, but the late failures occurred frequently. The medical records of nine patients with ICE syndrome that underwent glaucoma surgery were retrospectively reviewed. 6 eyes were progressive iris atrophy, and 3 eyes were Cogan-Reese syndrome. The success rates of primary trabeculectomy at 1 and 2 years were 57.1% and 33.3%, respectively. Ahmed glaucoma valve implant oeprations were performed on 6 eyes with failed previous filtering operation. 4 of 6 eyes resulted in controlled IOP until last follow up visit(mean ; 18.8 months). Overall, 1.9 times operations were needed to control IOP. Operations were performed only one time in 4 patients and two times in 3 patients to control IOP.

Surgical Approach to Large Anterior Basal Meningioma

Anterior basal meningiomas, which belong the olfactory groove and suprasellar meningioma account for 12 to 22% of all intracranial meningioma. Anterior cranial base meningioma are difficult to operate on because of their proximity to the important neurovascular structure. The authors report 25 cases of large meningiomas of the anterior. cranial base operated on during recent 5-year period. The tumor ranged from 3cm to 6.5cm in diameter. Fifteen tumors were located in the suprasellae(included tuberculum sellae, planum sphenoidale, diaphragma sellae,and anterior clinoid process), ten on olfactory groove. The mean age of 19 female and 6 male patient was 55years. The main clinical symptom were visual disturbance, anosmia, headache, and psychotic syndrome. Tumors were approached in 11 cases by pterional, in 9 cases by bifrontal, in 3 cases by transbasal, in 2 case by orbitozygomatic infratemporal and in 1 case by combined approach with tranabasal and orbitozygomatic infratemporal. Total tumor removal was performed in 80% of cases. Postoperative complication include accentuated psychotic syndrome in two cases, worsening of visual function in two, major vessel injury in one, infection in one, CSF rhinorrhea in one, and oculomotor palse in one. Postoperative death was in four(16%). Results at follow up of the 21 survivours were good in 17(68%), fair in 4(16%). Selection criteria for operative approach is discussed with review of pertinent literature.

Aneurysms of the Posterior Inferior Cerebellar Artery

Aneurysms of the posterior inferior cerebellar artery are uncommon, comprising between 0.5 and 0.7% of all intracranial aneurysms and are usually tightly confined to the medulla oblongata, the anterolateral base of the skull, and the lower cranial nerves. During the period from January 1983 to December 1997, about 1,600 aneurysms were operated on the department of neurosurgery, Pusan Paik hospital, Inje University. Of these, there were 8 cases of aneurysms in the posterior inferior cerebellar artery(PICA). The average age was 43.2 years, with a range from 11 months to 56 years, and male to female ratio was equal. Presenting signs and symptoms on admission were mental deterioration and/or headache after subarachnoid hemorrhage in 7 cases and suboccipital headache due to mass effect in 1 case. The locations of these aneurysms were in the anterior-medullary segment in 4 cases, in the lateral medullary segment in one case, and telovelotonsillar segment in 3 cases. Surgical methods were as followed; unilateral suboccipital craniectomy or craniotomy(right side in 3 cases and left side in 2 cases) in lateral or park bench position was performed in 5 cases and suboccipital craniectomy in prone position was in 3 cases. Direct neck clipping were done in 5 cases, proximal ligation in 1 case, coating and trapping in 1 case each. Surgical results were good in 5 cases, fair in 2 cases, dead in a case. Although clipping of the aneurysm neck was preferable in the aneurysm of PICA, trapping was useful when neck clipping was impossible in segments distal to the choroidal arch.

Terson's Syndrome in Aneurysmal Subarachnoid Hemorrhage

Terson's syndrome is the oculocerebral syndrome of retinal and vitreous hemorrhage associated with spontaneous subarachnoid hemorrhage(SAH) or all forms of intracranial bleeding. Recent observations indicate that the patients with spontaneous subarachnoid hemorrhage have an 18% to 20% concurrent incidence of retinal and vitreous hemorrhages and about 4% incidence of viterous hemorrhage alone. Therefore, clinical ophthalmologic findings may have a significant diagnostic and prognostic value for the clinician. Total of 627 consecutive patients with aneurysmal subarachnoid hemorrhage were retrospectively studied by means of indirect fundoscopy to address the question of occur and prognostic implications of vitreous hemorrhage after subarachnoid hemorrhage from January 1993 to December 1996. Among these, we experienced 21 patients with vitreous hemorrhage(Terson's syndrome). The patients with vitreous hemorrhage commonly occurred in anterior communicating and internal carotid artery aneurysm. Twelve patients had intraocular hemorrhage within 48 hours after SAH. There were bilateral involvement in 15 cases, and the 14 experienced complete recovery of vision following massive intravitreal hemorrhage. A favorable surgical outcome was obtained in 14 of 21 patients(66.7%) and a satisfactory result in vision was achieved in 15 cases among 17 survivors(88.2%). From these results, we emphasize the significance of ocular findings in patients with aneurysmal subarachnoid hemorrhage.

Surgical Experiences of 1,500 Cases of Intracranial Aneurysm

The principle role of treatment for ruptured aneurysm has been to obliterate the aneurysmal sac and secure the patient's life from the hazards of rebleeding and vasospasm. The present study was conducted to evaluate the overally surgical results in 1,500 patients with intracranial aneurysms operated in our institution from January 1980 to February 1997. Among these, 547 cases were anterior communicating artery aneurysms, 453 internal carotid artery aneurysms, 400 middle cerebral artery aneurysms, 43 anterior cerebral artery aneurysms and 57 cases of vertebro basilar artery aneurysms. Overall surgical result was favorable outcome in 84% and mortality in 8%. The rebleeding rate of early operation group was 7 percent, as compared to 23 percent in late operation group. In this retrospective study, the incidence of angiographic vasospasm was 34.2 percent and clinical vasospasm in 28.7 percent of good grade patients. Incidental aneurysms constistuted 5.6 percent of the this series, and multiple aneurysm 8.7 percent. The causes of the mortality and morbidity were initial insult of bleeding, rebleeding, vasospasm, surgical complications, and systemic medical problems. Regarding the surgical timing, it is difficult to decide whether early or late surgery would provide a better prognosis.

Surgical Result for Ruptured Anterior Circulation Aneurysms in Elderly Patients

In order to define the surgical result for ruptured anterior circulation aneurysms in the elderly, 59 patients(from June 1989 to May 1994) whose age was 66 years of age or older were analyzed. The factors which might influence the outcome were statistically compared between those aged 66 years or older(elderly patients group:59 patients:12.5%) and those aged 65 years or younger(younger patients group :413 patients;87.5%);the clinical grading, the location of aneurysms, the multiplicity, the presence of the angiographic vasospasm, the development of the symptomatic vasospasm, the presence of the hypertension. Fisher's grade IV(intracerebral hemorrhage or intraventricular hemorrhage), and the timing of surgery. Overall outcome between two groups was not different significantly, and many factors did not affect the outcome except the location. Surgical outcome in good grade patients(Hunt and Hess Grade I, II) was excellent regardless of age and timing of surgery. "Early surgery in the elderly?" The answer was Yes especially in good grade patients. We conclude that surgical outcome for ruptured anterior circulation aneurysms in the elderly does not seem to be directly affected by age, so elderly patients need not therefore be excluded from the benefits of surgery just because of their chronological age. It is principally the patient's condition during the acute stage that determine the surgical outcome.

Surgical treatment of atrial septal defect in adult patients / 영남의대학술지

The study consisted of all patients over 35yerars old undergoing surgical repair of atrial septal defect for the period from June 1985, to August 1992. The following results were observed. 1. ASD was closed with patch in 11 (73%) patients. 2. The relationship of pulmonary artery systolic pressure to Qp/Qs ratio was not significant. 3. Before operation 6 patients were in NYHA functional class II. 8 were in class III, After operation 8 patients were in class I, 6 were in class II. 4. Atrial fibrillation has persisted in 3 patients and returned regular rhythm in 1 patient after surgery. 5. There was no operative mortality and we had good surgical results regardless of patient's age.

A Clinical Analysis of 81 Cases of Arseriovenous Malformations

The authors present a consecutive series of 81 patients admitted to the Department of Neurosurgery of Korea University and Ewha Woman's University with an intracranial arteriovenous malformation(AVM). Of these, 56 received surgical treatment, and 23 were treated conservatively. We have reviewed the modes of clinical presentations, result of diagnostic evaluation, and surgical consideration. Partial of total removal of the AVM was performed in all but 7 of the patients treated surgically. Operative mortality in this surgical series was 9%, with significant morbidity in 20%.

Clinical Analysis of Surgical Timing for Ruptured Intracranial Aneurysm

To evaluate the risk of definitive intracranial microsurgical aneurysm obliteration as a function of the timing of the operative intervention, we retrospectively reviewed 167 consecutive patients in the department of Neurosurgery of Busan Paik's Hospital, Inje medical college, from January 1980 to December 1983. The patients who were operated upon within the first 3 days of their most recent subarachnoid hemorrhage formed the early group;the patients operated upon after the 3 days were considered to have undergone the late surgery. On the base of their clinical outcome the patients were allocated to one of five outcome categories(excellent, good, fair, poor, death) both at the time of their hospital discharge and at their most recent clinical revaluation. The 83% favorable outcome estimated from early operation and 72% from late operation. The mortality was estimated 5% from early operation and estimated 11% from late operation. The optimal timing of surgery for ruptured intracranial aneurysms is currently unknown, but early operation is an effective and reliable method to reduce the occurrence of rebleeding, vasospasm, ischemic complication and medical complication etc. Recently, there has been a resurgence of interest in early operation and increasing numbers of surgeons have been adopting this modality, but prompt, accuate diagnosis and early referral to specialized centers is the only way in which significant advances in reducing the overall morbidity and mortality for majority of patients can be achieved.