Three-Years Outcome of Microdiscectomy via Paramedian Approach for Lumbar Foraminal or Extraforaminal Disc Herniations in Elderly Patients over 65 Years Old

OBJECTIVE: Lumbar foraminal or extraforaminal disc herniations (FEFDH) have unusual clinical features and higher incidence in elderly patients compared to usual intraspinal canal disc herniations. We evaluated the efficacy of microdiscectomy via paramedian approach for lumbar FEFDH in elderly patients over the age of 65. METHODS: Retrospective study was performed in 68 patients over the age of 65 (23 male and 45 female patients; 71.46±3.87 years) who underwent microdiscectomy via paramedian approach for unilateral lumbar FEFDH causing sciatica. The radiological factors including degree of slippage, presence of instability, disc height, and degree of disc degeneration; pain and functional status by the means of visual analogue scale score, Oswestry Disability Index score, and Macnab classification were analyzed preoperatively and during the postoperative follow-up period of 3 years to evaluate the efficacy of the surgical treatment. RESULTS: Pain and functional status improved according to short- and long-term follow-up evaluations after surgery. Radiological changes following surgery, which can be understood as structural deteriorations and deformations, did not represent patient condition. Nine patients underwent additional surgery due to sustained or recurring leg pain of aggravation of back pain, and fusion surgery was required for 3 patients. Degree of preoperative slippage was the only statistically significant factor related to additional surgery (p<0.05). CONCLUSION: Microdiscectomy via paramedian approach for FEFDH may be a good surgical alternative in elderly patients. Radiological changes after surgery did not show a concordance with patients' actual functional status. The excessive preoperative slippage tended to lead to unfavorable result after surgery and was associated with additional surgery.

A Case of Cervical Far Lateral Disc Herniation-Case Report-

Compared to the lumbar region, it is very rare to encounter far lateral disc herniation in the cervical spine, and because of this, correct diagnosis before surgery is difficult: the condition can, however, be identified through the use of advanced MRI imaging techniques. In this case, far lateral disc herniation at C7-T1 was effectivery removed through posterior laminoforaminotomy, and soon after surgery, the patient's symptoms showed complete remission.

Combined Approach for Large CPA Tumor with Sacrifice of Sigmoid Sinus

With large CPA tumor(>3 mm), brain stem is usually displaced and distorted to contralateral side. It is important minimize retraction to protect brain stem and to lower morbidity. In our previous report, we reported the result and method of combined approach for large CPA tumor. In order to minimize brain stem retraction and to get good operating field, three of 7 cases of large CPA tumor with combined approach were operated with sacrifice of sigmoid sinus. The sigmoid sinus can be sacrificed if it can be angiographically verified that the sagittal sinus represents the major drainage to the contralateral sigmoid sinus. During operation, if pressure difference between before and after occlusion of sinus is less than 10 mmHg and any brain swelling does not develop after occlusion, the sigmoid sinus can be sacrificed.

Morphological Changes of Cerebrum in Rabbits Exposed to Microwaves

The author measured the severity of brain damage of 36 rabbits irradiated 2.45 GHz microwave for 10 minutes, 20 minutes and 30 minutes, respectively. Electromicroscopic and light microscopic findings of just after, 1 weeks, 2 weeks and 4 weeks after irradiated brain were compared in each time. Swelling and vacualization of nerve cell and mitochondria were noted. Also these changes tend to increased severity along amount of radiation, but revealed reversible changes with time. Myelinated and unmyelinated nerve fibers were examined as same manner. These nerve fibers also revealed swelling and vascuolization, these findings also tend to increase severity with irradiation power and more prominent at unmyelinated nerve fibers. Reversability of these findings after each time period were more prominent in myelinated nerve fibers than unmyelinated nerve fibers.

The Effects of Microwave Irradiated on Rabbits' EEG

Microwaves may induce effect and damage on nervous tissue, either by thermal or mon-thermal mechnisms. EEGs were checked in left frontal lobe before and after irradiation of microwave at frequency of 2.45 GHz in 18 Rabbits. In results, mean total power of EEG was slightly decreased after irradiation of microwave. And mean composition percentage of delta wave was decreased and mean composition percentages of theta, alpha and beta wave were increased after irradiation in observation for 7 days. That mean decrease of electrophysiologic activity and trend of fast wave in brain after irradiation of microwave.

Complete Removal of Giant Craniophanyngioma by Drainage Through the Ommaya Reservior

Craniopharyngioma is one of the most challenging, Frustrating, and humbling benign intracranial tumors of childhood. Its behavior is a clinical malignancy even though it is benign tumor in microscopically. There is no single treatment of craniopharyngioma and there must be a plan customized for eacg patient. This decision may, be made from diagnostic studies alone, but in most cases exploration of the tumor and the testing of its adherence to its surroundings will be the only thorough and fair way to determine whether it can be totally excised or not. So the choice of treatment is "individualize". We experienced one case of giant cystic craniopharyngioma and performed combined operaion whih were percutaneous intermittent drainage of cystic fluid through Ommaya reservoir and following microsurgical radial excision. There was no complication and marked intellectual and psychological improvement until todays for 20 months.

Subependymal Giant Cell Astrocytoma in the tuberous Sclerosis / 영남의대학술지

Tuberous sclerosis is reported rarely and is associated with systemic lesions including central nervous system, skin, heart, eye and kidney. Approximately 5-15% of individuals with tuberous sclerosis will develop brain neoplasia, almost invariably subependymal giant-cell astrocytoma (SGCA). We experienced a case of SGCA with tuberous sclerosis operated by the transcallosal approach and report with literature review.

Stereotactic Guided Craniotomy:Method for Localization and Removal of Small Intra-Axial Lesion

Combining the stereotactic precise localization with open craniotomy can decrease post-operative morbidity and is helpful for total removal of small intra-axial lesion. The authors had good results by the stereotactic guided craniotomy. The method and results of the technique are discussed in reference to 8 patients.

Clinicopathologic Analysis of Meningioma

The authors analyzed the clinical and pathological characteristics of 66 meningioma patients, operated and pathologically confirmed at the Department of Neurosurgery > Pathology, Yeungnam University Hospital from 1984 to 1992. The results are as follows: 1) Meningioma was the most common in the 6th decase(39.4%) and the overall ratio of male to female was 1:2.5. 2) The most common pathologic types were meningothelial type(30.3%) and transitional type(30.3%). 3) The predilection sites were convexity, parasagittal and falx in order of frequency. 4) The most common clinical features were IICP signs(57.6%). 5) The marginal contour of the tumor on brain CT wre more irregular, mushrooming and fringing pattern in the case of angioblastic and atypical type. The brain edema was more severe in the case of these types. However, these findings had no correlation with prognosis. 6) Thre were 9 atypical cases(13.6%). 7) The total removal was done in 53 cases(80.3%) and the postoperative mortality rate was 7.5%. 8) The recurrence rate was 9.0% and the mean duration of recurrence was 36.5 months. The recurrence depended on grade of the surgical removal rather than the pathological type.

Clinical Analysis of Failed Back Surgery Syndrome

One hundred thirty-five patients undergone microdiscectomy of lumbar disc disease were analysed with soft-ware program which designed for effective analysis for spinal in-patients since February, 1990. Owing to that program, all the patients could be easily analyzed and get a regular follow-up. The surgical result was evaluated by our own score rating system which consists of 4 items:1) Frequency of medication, 2) Degree of social activity, 3) Post-operative symptom compared to pre-operative state and 4) Patient's satisfaction with the operation. According to that system, 21 patients(15.6%) were estimated with failure following microdiscectomy. Among them 6 patients of psychosocial problem, 4 patients of technical errors and 2 patients of recurrence were an important causes of failure. For the purpose of effective surgery for lumbar disc surgery, a careful analysis of the cases of surgical failure should be attempted and also a regular follow-up can be importment factor for more accurate estimation of surgical result.

Combined Approach for Large CPA Tumor

With large CPA tumors, the goal of surgery is safe total removal of the tumors and preservation of nearby neural structures. Although the suboccipital approach can be made for large CPA tumors, combined approach is more preferable method for the wide exposure of the CPA including brain stem and the lower cranial nerves. We have recently experienced favorable results by combined approach. Total removal of large tumors were obtained by these approaches. The authors present surgical points of view and a brief review of literature.

Internal Fixation of the Unstable Cervical Spine Fracture and Subluxation

Recently various kinds of anterior or posterior cervical instruments have been used for stabilization of unstable cervical spinal injury. Every device has different characteristics, so none can cover all of the various types of unstable injuries. Forty six patients of unstable cervical spine fracture and subluxation underwent stabilizing operation using the anterior Caspar plate(6 cases) and the Roy-Camille posterior plate system(40 cases) during recent 3-years. Each approach employed depends on the site of compression and mechanism of injury. Six patients who had complete neurological injury expired after the surgery. The follow-up period for the 40 patients was from 5 to 32 months(average-17.5 months). During follow-up period, 16 out of 22 patients(72.7%) who had a neurological deficit showed minimal to moderate improvement and only 4 patients(10%) complained of significant arm or neck pain. The only complication of instrumentation was 5 cases of screw breakout, but 3 of them did not have any problem. Radiologically 37 patients(92.5%) had firm fixation after surgery.

The Correlations between the Hematoma Volume and the Changes of ICP, Blood Pressure & Prognosis in the Spontaneous Intraparenchymal Hemorrhage

The development of CT scan and stereotaxic surgery with urokinase irrigation made possible early diagnosis and improved survival in the patients of spontaneous intraparenchymal hemorrhage. We had clinically reviewed and analyzed 30 patients of stereotactically treated spontaneous intraparenchymal hemorrhage, according to the hematoma volume, ICP, wital signs, GCS and prognosis. The results were summarized as follows: 1) As the hematoma volume increasing, ICP was also increased(p<0.05). 2) The systolic arterial pressure was increased as the hematoma volume increasing(p<0.05). 3) Mean ADL was 55(26% and ADL level were decreased in cases of large hematoma(p<0.05). 4) As the hematoma volume increasing, the level of verbal GCS and total GCS was low(p<0.1). 5) No significant correlation was noted between the hematoma volume and complications(T test).

Follow-up Lumbar Spondylolisthesis after Pedicle Screw Fixation

Sixty five patients of lumbar spondylolisthesis were treated with pedicle screw fixation during last 3-years. Roy-Camille plate system has been used in 17 patients, steffee system in 41 and Puno/Winter/Byrd(PWB) system in 7. We analysed the changes of symptoms and radiological findings during follow-up observation(average 15 months). After surgery the average time for low back pain reduction was 7 months, Twenty patients(3%) complained a graft donor site pain initially, but almost except one were alleviated after 7.3 months later on an average. Radiologically the reducton degree of the displacement was from 24% on preoperative state to 12% on last follow-up and pseudoarthrosis rate was 8%. Surgical result was evaluated by our score rating system, according to that system 64.5% of the patients had satisfactory result.

Lumbar synovial cyst associated with retrolis thesis: a case report / 영남의대학술지

In advent of high-resolutional CT and MRI, it is not so difficult to detect the lumbar synovial cyst, however the unusual disease should be included in the differential diagnosis of cauda equine compression syndromes. The case of a 55-year-old man who had a low back pain and severe radiating pain on both legs showed a retrolisthesis at L3-4 and L4-5 and epidural enhancing mass just around L4-5 facet joint on MRI. Microscopically a lining of synovial tissue was demonstrated. After surgery of the total resection of synovial cyst and stabilization, the patient's presenting symptoms were improved.

Clinical Analysis of Cerebral Arteriovenous Malformation

Clinical and cerebral angiographic findings were reviews retrospectively in thirty-seven patients with intracranial artero-venous malformation(AVM). The results were as follow. Many opatients who were in reproductive age had visited due to seiure(27%) and its angiographic findings were mixed Type(80%). Bleeding was predominant in the patients who had small sized nidus than medium or large one, and deep draining vein than superficial one. Medium sized AVM was located mainly in the anatomically deep portion(71%) and drained to deep portion also(71%). Associated aneurysm was more prevalent in deep seated or large sized AVM. Low grade AVM according to Spetzler's grading system showed good results of treatment. Postoperative hemorrhage or sizure were frequently found in patients who had superfically located AVM.

Direct Surgical Approach of the Spontaneous Carotid Cavernous Fistula

We report a case of spontaneous carotid cavernous fistula(CCF) showing low flow shunt, which was successfully occluded in the fistular site of CCF by direct surgical approach via anteromedial, paramedial and Parkinson's triangle intradurally through pterional subte mporal petrosal route extradurally after intermitten temporary clipping of internal corotid artery(ICA) in petrosal portion and proximal to the ophthalmic artery without hypotension, hypothermia, extracorporial circulation, or cardiac arrest.

Correlation of changes of intracranial pressure and clinical manifestations in spontaneous intracerebral hemorrhage / 영남의대학술지

Recently, many authors have reported about the relationship of the volumes of hemorrhage in the brain parenchyma, hemorrhagic sites, optimal operation time, and the effects of mannitol and steroid on control of ICP to clinical manifestations. Many attempts to measure ICP in hydrocephalus, brain tumor, and head injury have been reported. But the measurements of intracranial pressure in spontaneous intracerebral hemorrhage are rare. Intracranial pressure was monitored prospectively in 30 patients who had stereotaxic surgery for spontaneous intracerebral hemorrhage. The results are as follows. 1. Intracranial pressure was increased in high PaCO₂. 2. There were no correlation in ICP, rebleeding and ADL ad discharge (P>0.05). 3. ICP was the most high level in 72 hours after operation. 4. There was 63.2% decrease in ICP after irrigation with 6000 IU urokinase in the site of hemorrhage. 5. There was no correlation between the numbers of natural drainage and ADL at discharge (P>0.05). 6. The higher the initial GCS, the higher the postoperative GCS.

Multiple Aneurysm-Which One Ruptured?

Brain Computerized Tomography(CT) and cerebral angiography were reviewed in thirty-six patients with multiple intracranial aneurysms(22.5%) among the 160 consecutive surgical cases of intracranial aneurysms. The prevalent sites of multiple aneurysms were the middle cerebral artery(37.0%), posterior communicating artery(22.2%), and internal carotid artery(14.8%) in sequence. However, the vertebrobasilar system(83.3%), anterior communicating artery(63.6%), and posterior communicating artery(50.0%) had higher probability of rupture than internal carotid artery(8.3%) or middle cerebral artery(33.3%). Based on CT and angiographic information, the site of rupture can be predicted with a high degree of reliability. These factors were the presence of localized hemorrhage on CT, focal vasospasm, size and irregularity of aneurysms, and relative hyperplasia of parent artery.

Clinical Analysis of Pediatric Neurosurgical Diseases

The authors analyzed pediatric(under 15-year of age) neurosurgical disease patients admitted to the Department of Neurosurgery, Yeungnam University Hospital during the 6-year period from May 1983 to April 1989. The results were as follows : 1) Among the total 5,007 neurosurgical admission cases during this period, pediatric cases were 573(11.4%). 2) The total pediatric cases consist of traumatic(80.1%), tumor(5.9%), congenital anomaly(3.1%), infection(3.1%), vascular anomaly(2.1%) and miscellaneous(5.6%) lesions. 3) The male to female ratio was 1.67 : 1 in trauma. 4) The most common age of trauma are 3 to 8 years. 5) The incidence of trauma was relatively common in spring and autumn. 6) The traffic accident is most common cause of pediatric trauma. 7) The contusion case with GCS 9 to 15 revealed good result. 8) 23.1% of 108 intracranial hematoma had no skull fracture. 9) Mortality in trauma was relatively low(1.8%) compared to adult.