Abducens Nerve Palsy after Lumbar Spinal Fusion Surgery with Inadvertent Dural Tearing

Abducens nerve palsy associated with spinal surgery is extremely rare. We report an extremely rare case of abducens nerve palsy after lumbar spinal fusion surgery with inadvertent dural tearing, which resolved spontaneously and completely. A 61-year-old previous healthy man presented with chronic lower back pain of 6 weeks duration and 2 weeks history of bilateral leg pain. He was diagnosed as having isthmic spondylolisthesis at L4-5 and L5-S1, and posterior lumbar interbody fusion was conducted on L4-5 and L5-S1. During the operation, inadvertent dural tearing occurred, which was repaired with a watertight dural closure. The patient recovered uneventfully from general anesthesia and his visual analogue pain scores decreased from 9 pre-op to 3 immediately after his operation. However, on day 2 he developed headache and nausea, which were severe when he was upright, but alleviated when supine. This led us to consider the possibility of cerebrospinal fluid leakage, and thus, he was restricted to bed. After an interval of bed rest, the severe headache disappeared, but four days after surgery he experienced diplopia during right gaze, which was caused by right-side palsy of the abducens nerve. Under conservative treatment, the diplopia gradually disappeared and was completely resolved at 5 weeks post-op.

Clinical and Radiological Outcomes with the Lumbar Total Disc Replacements

OBJECTIVE: To determine the clinical and radiographic results and incidence of complications in lumbar arthroplasty patients. METHODS: From January, 2003 to March, 2005, 46 patients were implanted with 30 cases of the Charite Artificial Disc and 16 cases of the Prodisc. There were 28 males and 18 females with a mean age 40.6 years(range, 21~70). Diagnoses included 19 patients with discogenic back pain, and 27 patients with FBSS. All patients were examined at a minimum 2-year follow-up(mean 3.5 years). Clinical outcomes were assessed by Oswestry Disability lndex(ODI), Visual Analogue Scale(VAS),and Macnab's Criteria. Dynamic lateral flexion and extension radiographs were used to radiologic assessment. RESULTS: The ODI was reduced from 67.6% to 8.9% at the latest follow up. The mean VAS baseline was 8.29 and 2.08 at the latest follow-up. Clinical outcome was excellent or good in 40 patients(mean 87, 93% FBSS, 78% Discogenic back pain). Mean flexion/ extesion range of motion at L4-5 was 9.1degrees Charite, 9.8degrees Prodisc and at L5-S1 it were 5.5degrees, 5degrees. A total of 7 complications(15%) were noted [subsidence (2), polyethylene core wire break down (1), vertebral body posterior inferior cortex breakage (1), anhydrosis (2), nerve root damage (1)]. CONCLUSIONS: This study demonstrates the safety and efficacy of the total disc replacements especially FBSS cases.

The Time Evolution of Cerebral Apoptosis in the Permanent Middle Cerebral Artery Occlusion Model in Rats

OBJECTIVE: The purpose of this study is to determine the time evolution and distribution of cerebral apoptosis using the middle cerebral artery occlusion model in rats. METHODS: A total of twenty four male rats - with 2, 3, 4, 6, 8, 12, 24 and 48 hours of middle cerebral artery occlusion respectively - were studied. The terminal deoxynucleotidyl transferase-mediated deoxyuridine triphosphate-biotin nick-end labeling(TUNEL) method was used for the observation of the apoptotic cells. The apoptotic ratio was calculated and the distribution of apoptosis was inspected in the pyriform cortex, basal ganglia and middle cerebral artery territory cortex. The rats were divided into three groups(Group I: 2~4 hours of occlusion, Group II: 6~12 hours of occlusion, Group III: 24~48 hours of occlusion). RESULTS: In this study, the proportion of apoptosis increased with the duration of middle cerebral artery occlusion and reached a maximum after about 12 hours of middle cerebral artery occlusion. The mean values of the apoptotic ratio were 30.7+/-11.3% in group I, 60.8+/-2.6% in group II and 48.7+/-0.7% in group III. The distribution of apoptosis differed in the pyriform cortex, basal ganglia and middle cerebral artery territory cortex according to the duration of time of the middle cerebral artery occlusion. CONCLUSION: In the middle cerebral artery occlusion model of the rats, apoptosis is found to increase according to the occlusion time, reaching a peak after 6 hours, and the distribution of apoptosis changed from the pyriform cortex to the basal ganglia and middle cerebral artery territory cortex.

Problems in Managements of Cerebral Arteriovenous Malformations

The authors report the problems of treatment in 37 consecutive cerebralarteriovenous malformations(AVM's) who underwent embolization, operation, combined treatment, or conservative care. The preoperative embolization is an integral part of the multidisciplinary treatment protocol for patients with cerebral AVM's. Life threatening intracerebral hematoma caused by bleeding from AVM's will be managed effectively with stereotactic Urokinase irrigation for urgently reducing the increased intracranial pressure and getting a time to change emergent to elective surgery. We also discussed the problems along the management of cerebral AMV's.

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.