Clinical Analysis of Results of Shunt Operation for Hydrocephalus Following Traumatic Brain Injury / 대한신경손상학회지

OBJECTIVE: Ventricular enlargement following head injury is a frequent finding but cases requiring shunt operation are rare. The incidence and developing factors of post-traumatic hydrocephalus (PTH) have been variously reported, but studies for factors influencing outcomes of shunt operation for PTH are rare. The incidence of PTH requiring shunt operation, causing injuries, and factors influencing outcome of shunt operation need to be identified. METHODS: In total, 1,142 patients suffering from traumatic brain injury (TBI) between January 2007 and December 2012 were admitted to our department. Of them, 23 patients underwent shunt operation for diagnosed PTH. In this clinical study, we reviewed retrospectively our TBI database and in the 23 patients, we evaluated outcomes with Glasgow Outcome Score just before the operation, at 14 days, 3 months, and 6 months according to initial Glasgow Coma Scale (GCS) score, interval time between shunt operation and trauma, and lumbar cerebrospinal fluid (CSF) pressure. RESULTS: The incidence of PTH treated with shunt operation was 2.01%. Subdural hematoma (SDH) was the most common preceding head injury. The outcomes of shunt operation were not related with lumbar CSF pressure or interval time from trauma, but initial GCS score correlated with the outcome. CONCLUSION: In present study, 2.01% of TBI patients underwent shunt operation. SDH was the most common preceding injury. Admission GCS score was related to the outcome of shunt operation. However, there were no correlation between the outcome of shunt operation and initial lumbar CSF pressure or interval time of shunt operation after the trauma.

Combined Atlantoaxial Rotatory Fixation and Unilateral Counter Occipitoatlantal Subluxation after Minor Trauma / 대한신경손상학회지

Rotatory fixation of the atlantoaxial joint is relatively rare in adults but somewhat more common in children. Most of them are reduced spontaneously or after traction. However, combined rotatory injury of atlantoaxial joint and unilateral occipitoatlantal subluxation is a rare disease, and it is often difficult to diagnose accurately. Because the craniovertebral junction is complex and patients with combined atlantoaxial rotatory fixation (AARF) and occipitoatlantal subluxation has a less rotated head than patients with pure AARF. And injury of the occipitoatlantal and atlantoaxial joint can often result upper cervical instability, so early diagnosis is very important. We present a case of the combined AARF and unilateral counter occipitoatlantal subluxation after minor trauma.

Factor Affecting Recurrence of Chronic Subdural Hematoma after Burr-Hole Drainage / 대한신경손상학회지

OBJECTIVE: A variety of factors are known to have an influence on the recurrence of chronic subdural hematoma (CSDH). In this study, the authors investigated the influential factors for recurrence of CSDH after burr hole drainage. METHODS: 45 patients with unilateral CSDH were treated with one-burr hole trephination and closed drainage in our hospital during last 6 years, whom the drainage catheter tip was randomly located and checked on postoperative computed tomography (CT). The clinical status of patients, thickness of hematoma, midline displacement of before and after surgery, amount of subdural air collection, drainage catheter tip location were estimated and the relationship of those factors with the recurrence was analyzed. RESULTS: Patients with located catheter tip in frontal had a better clinical and radiological result. And the recurrence of CSDH was lower who has lesser amount of subdural air collection in postoperative CT. CONCLUSION: The recurrence rate of unilateral CSDH is influenced by the location of drainage catheter tip and the amount of subdural air collection.

The Value of Selective Nerve Root Block to Predict Surgical Outcome for Spinal Surgery

OBJECTIVE: The aim of this study was to evaluate the prognostic value of the selective nerve root block prior to the surgery. METHODS: Between January 2007 and December 2009, 52 cases of selective nerve root block prior to the spine surgery were performed. Three cervical lesions and 49 lumbar spinal lesions were selected. All selected patients had multilevel spine lesions or poorly defined radiologic findings with significant symptoms of neural foramen stenosis. RESULTS: In total of the 52 patients, 41 had positive and 11 had negative results with the nerve root block. Out of the 41 patients with positive results, 40 patients had good surgical outcome. From the 11 patients with negative results, 6 patients had good surgical outcome. All surgeries were performed at the positive level at the selective nerve root block and the most suspected lesion. CONCLUSION: Selective nerve root block can be used to evaluate the location generating the most serious radiating pain. Results of selective nerve root block corresponded with the results of the surgical outcome in the most cases. We can predict the outcome of the surgery, especially in case of multilevel spine problems or poorly defined radiologic findings, by performing preoperative selective nerve root block.

Delayed Diagnosis of Tuberculous Spondylitis Masked by Concomitant Methicillin Resistant Staphylococcus Aureus Infection

We present a case of tuberculous spondylitis in which diagnosis was masked by a concomitant pyogenic infection. The patient had undergone percutaneous needle aspiration of an abscess in the cavity of the psoas muscle. Early results from the culture regimen showed isolation of methicillin-resistant Staphylococcus aureus. After eight weeks, mycobacterium tuberculosis was grown at regimen which was cultured at the same site. Initial isolation of pyogenic bacteria, considered to be highly virulent organisms, led to delayed diagnosis and treatment of the tuberculosis.

Clinical Outcome of Minimally Invasive Tubular Retractor Assisted Microscopic Discectomy in Far Lateral Lumbar Disc Herniation

OBJECTIVE: The purpose of this study is to analyze the clinical outcomes of the minimally invasive approach for the surgical treatment of far lateral lumbar disc herniation. METHODS: Between January 2007 and May 2009, 19 patients who underwent minimally invasive, tubular retractor-assisted microscopic discectomy were retrospectively reviewed. The patients included 11 men and eight women with a mean age of 58 years. The mean symptom duration before surgery was 6.5 months, and the mean follow up time was 20.5 months. Clinical outcomes were assessed according to neurologic status, bleeding volume, surgical time, length of hospital stay, visual analogue scale (VAS) and the modified MacNab's criteria. RESULTS: The most frequent lesion was at the L4-L5 level (53%), and the mean bleeding volume was 59.3ml. The mean surgical time and length of hospital stay were 91.1 minutes and 6.4 days, respectively. The mean VAS for radicular pain was improved from 8.37 +/- 1.11 before surgery to 1.37 +/- 1.33 (P<0.05) at discharge and 0.68 +/- 0.89 one year after surgery. The mean VAS for back pain was decreased from 4.6 3 +/- 0.99 before surgery to 2.00 +/- 1.23 (P<0.05) at discharge and 0.42 +/- 0.61 one year after surgery. The success rates were 100% according to the modified MacNab's criteria, and there were no postoperative complications or recurrences. CONCLUSIONS: The minimally invasive, tubular retractor-assisted microscopic discectomy method is a safe and effective procedure and may be an alternative for treating far lateral lumbar disc herniations.

Comparison between Minimally Invasive Transforaminal Lumbar Interbody Fusion and Posterior Lumbar Interbody Fusion in Lumbar Degenerative Disease Patients

OBJECTIVE: Minimally invasive transforaminal lumbar interbody fusion(mini-TLIF) is an increasingly popular method because of several advantages, including rapid patient recovery, less postoperative pain, and minimized iatrogenic injury of soft tissue and muscle. The purpose of this study is to evaluate the clinical and imaging outcomes after mini-TLIF procedures. Results are compared with open posterior lumbar interbody fusion(oPLIF, Group B) and mini-TLIF(Group A) approach. METHODS: Between March 2007 and May 2008, mini-TLIF and oPLIF were performed in 23 and 36 consecutive patients with single or multilevel lumbar degenerative disease. Clinical outcomes were assessed by postoperative visual analogue scale(VAS) score, operation time, volume of blood loss, number of days to ambulation and duration of hospital stay. To assess fusion rate, all patients underwent postoperative radiography. And postoperative access were compared with an institutional reference series of 36 oPLIF procedures. RESULTS: Fusion success outcomes were obtained in 23(100%) out of 23 patients with mini-TLIF procedure. Mean VAS scores decreased from 8.2 to 1.9 in group A and from 8.1 to 2.4 in group B. The operation time, volume of blood loss, number of days to ambulation and duration of hospital stay were reduced in group A compared with group B. There was no complication associated to mini-TLIF procedure. CONCLUSION: Mini-TLIF yielded good clinical and radiological outcomes with safe and low complication. Further long- term investigating study is required to assess the definitive advantage of mini-TLIF.

Clinical Analysis of Surgical and Endovascular Treatment of Unruptured Intracranial Aneurysm / 대한뇌혈관외과학회지

OBJECTIVE: The purpose of this study was to review factors used to determine whether a patient with an unruptured intracranial aneurysm is treated using surgical therapy or endovascular therapy. METHODS: We retrospectively reviewed the records of 68 patients with 74 unruptured intracranial aneurysms who underwent embolization with Guglielmi Detachable Coil (GDC) or surgical occlusion at our institution between April 1990 and December 2005. Surgical clipping was performed in 58 consecutive patients (16 men and 42 women) with 63 unruptured intracranial aneurysms, and endovascular coiling was performed in 10 consecutive patients (4 men and 6 women) with 11 unruptured intracranial aneurysms. There were no standard selection criteria, irrespective of whether the patient was treated with endovascular coil therapy or with neurosurgical clip occlusion. RESULTS: Out of 58 patients who underwent surgical treatment, 3 (5.2%) had fair outcome. Each of these 3 had risk factors for surgical intervention: calcification, wide neck, or thrombosed giant aneurysm. GDC embolization in 1 (10%) patient with an unruptured pericallosal artery aneurysm resulted in a fair outcome due to infarction. CONCLUSION: Management decisions in patients with unruptured intracranial aneurysms require accurate assessment of the risk factors (such as aneurysm size, location, presence of calcification and/or atheroma, and patient age).

Giant Arachnoid Granulation Misdiagnosed as Transverse Sinus Thrombosis

We experienced a case of giant arachnoid granulation misdiagnosed as dural sinus thrombosis. A 66-year-old woman presented with a one month history of progressive occipital headache. Computed tomography angiography and cerebral angiography showed a round filling defect at the transverse sinus which was speculated as a transverse sinus thrombosis. Anticoagulation therapy was performed to prevent worsening of thrombosis for 2 weeks and then a Gadolinium-enhanced magnetic resonance imaging scan was performed. The filling defect lesion at the transverse sinus revealed a non-enhancing granule with central linear enhancement, which was compatible with giant arachnoid granulation. We checked the intrasinus pressure difference across the lesion the through the dural sinus in order to exclude the lesion as the cause of headache. Normal venous pressure with no significant differential pressure across the lesion was noted. Headache was treated with medical therapy.

Intradural Bone Cement Leakage Following Percutaneous Vertebroplasty

Bone cement extravasation is a frequent occurrence after percutaneous vertebroplasty(PVP) using polymethylmetacrylate(PMMA) for the treatment of osteoporotic vertebral compression fracture. Fortunately, major neurological complication is rare in spite of potential occurrence. The authors reported a case of in a 67-year-old woman whom a intradural cement leakage provoked left leg weakness with hypesthesia and paresthesia below the area of the left L1 dermatome. Emergency laminectomy with removal of intradural bone cement for decompression was performed. After operation, her pain resolved, but left leg weakness was persistent. PVP using PMMA are now being used wide spreadly for osteoporotic vertebral compression fracture as minimally invasive and safe procedure, but the potential risks of major complication exist always. We experienced a rare case of intradural bone cement leakage after PVP using PMMA,

Ischemic Complication after Surgery for Posterior Communicating Artery Aneurysm

OBJECTIVE: The purpose of this study is to elucidate the causes of the ischemic complication after surgery for posterior communicating artery aneurysm and to represent the ways of preventing or minimizing this specific complication. METHODS: Between January 2000 and December 2001, fifty one patients were treated for the posterior communicating artery aneurysm. The medical records and neuroimaging studies of the patients were reviewed retrospectively. RESULTS: Among the series of 51 surgically treated patients, the authors experienced 6 cases of ischemic complication involving 3 thalamus, 2 posterior cerebral artery territory and 1 periventircular white matter. Four patients were treated by aneurysmal neck clipping and one patient with fusiform aneurysm and one patient with infundibulum at internal carotid-posterior communicating artery junction by parent artery trapping and parent artery occlusion, respectively. In 4 cases with aneurysmal clipping the authors could not confirm the patency of the parent artery or posterior communicating artery during operation by the obstacle such as internal carotid artery and/or aneurysmal dome. The neurological deficits developed postoperatively were improved or subside during hospital courses and all six patients showed good outcome(Glasgow Outcome Scale score V) at discharge. CONCLUSION: In most cases the posterior communicating artery itself can be separated from the neck of the aneurysm and thereby preserved to avoid a significant infarct in the thalamus and occipital lobe.

Epidural Meningioma of the Upper Thoracic Spine in a Child: Case Report

Meningioma is the second most common primary intraspinal tumor. Most spinal meningiomas are located in the intradural extramedullary space and extradural meningiomas are less common. It is quite rare for this tumor to be found in the spinal epidural space of a child. These tumors may be easily confused as a malignant neoplasm because a metastatic lesion commonly located in the epidural space. We report a case of spinal epidural meningioma in a 12-year-old girl. Magnetic resonance findings led to the preoperative diagnosis of a metastatic lesion. The patient underwent total resection of the mass lesion and laminoplasty. She showed an excellent neurological recovery.