Adult Patients with Congenital Muscular Torticollis Treated with Bipolar Release: Report of 31 Cases

OBJECTIVE: We assessed the surgical results of bipolar release in 31 adult patients with uncorrected congenital muscular torticollis (CMT) and more than 12 months of follow-up. METHODS: Thirty-one patients underwent a bipolar release of the sternocleidomastoid muscle (SCM) and were retrospectively analyzed. The mean follow-up period was 14.9 months (range, 12–30). The mean age at time of surgery was 30.3 years (range, 20–54). Patients were evaluated with a modified Lee’s scoring system, cervicomandibular angle (CMA) measurement, and a global satisfaction rating scale using patient self-reporting. RESULTS: The modified Lee’s scoring system indicated excellent results in 4 (12.9%) patients, good in 18 (58.1%), and fair in 9 (29.0%) at the last follow-up after surgery. The improvements in neck movement and head tilt were statistically significant (p<0.05). The preoperative mean CMA was 15.4° (range, 5.4–29.0), which was reduced to a mean of CMA of 6.3° (range, 0–25) after surgery (p<0.05). The global satisfaction rating scale was 93.7% (range, 90–100). A transient sensory deficit on the ipsilateral lower ear lobe was noted in three cases. No significant permanent complications occurred. CONCLUSION: Bipolar release of the SCM is a safe and reliable technique for the treatment of CMT in adults.

Pneumocephalus and Pneumorrhachis due to a Subarachnoid Pleural Fistula That Developed after Thoracic Spine Surgery

Development of a communication between the spinal subarachnoid space and the pleural space after thoracic spine surgery is uncommon. Subarachnoid pleural fistula (SAPF), a distressing condition, involves cerebrospinal fluid leakage. Here we report an unusual case of SAPF, occurring after thoracic spine surgery, that was further complicated by pneumocephalus and pneumorrhachis postthoracentesis, which was performed for unilateral pleural effusion.

A Groove Technique for Securing an Electrode Connector on the Cranial Bone: Case Analysis of Efficacy

OBJECTIVE: A groove technique for securing an electrode connector was described as an alternative surgical technique in deep brain stimulation (DBS) surgery to avoid electrode connector-related complications, such as skin erosion, infection, and migration. METHODS: We retrospectively reviewed 109 patients undergoing one of two techniques; the standard technique (52 patients using 104 electrodes) and the groove technique (57 patients using 109 electrodes) for securing the electrode connector in DBS surgery, regardless of patient disease. In the standard percutaneous tunneling technique, the connector was placed on the vertex of the cranial surface. The other technique, so called the groove technique, created a groove (about 4 cm long, 8 mm wide) in the cranial bone at the posterior parietal area. Wound erosion and migration related to the connectors were compared between the two techniques. RESULTS: The mean follow-up period was 73 months for the standard method and 46 months for the groove technique. Connector-related complications were observed in three patients with the groove technique and in seven patients with the standard technique. Wound erosion at the connector sites per electrode was one (0.9%) with the groove technique and six (5.8%) with the standard technique. This difference was statistically significant. The electrode connector was migrated in two patients with the groove technique and in one patient with the standard technique. CONCLUSIONS: The groove technique, which involves securing an electrode using a groove in the cranial bone at the posterior parietal area, offers an effective and safe method to avoid electrode connector-related complications during DBS surgery.

Hemangiopericytoma of the Posterior Fossa: A Case Report and Review of the Literature

Intracranial hemangiopericytoma is unusual, and those occurring in the posterior fossa is extremely rare; we report such a rare case of hemangiopericytoma of the posterior fossa. The radiologic findings and gross characteristics of hemangiopericytomas are sometimes quite similar to those of meningiomas. Although extremely rare, the operator should be aware of the existence of this disorder to dexterously manage the aggressive nature and high vascular tendency of hemangiopericytomas. The radiological features and histological findings in this case are discussed in this study.

Deep Brain Stimulation of the Globus Pallidus in a 7-Year-Old Girl with DYT1 Generalized Dystonia

The experience of pediatric deep brain stimulation (DBS) of the globus pallidus internus (GPi) in the treatment of early-onset DYT1 generalized dystonia is still limited. Here, we report the surgical experience of bilateral GPi-DBS under general anesthesia by using microelectrode recording in a 7-year-old girl with early-onset DYT1 generalized dystonia. Excellent improvement of her dystonia without neurological complications was achieved. This case report demonstrates that GPi-DBS is an effective and safe method for the treatment of medically refractory early-onset DYT1 generalized dystonia in children.

Outcome of Pallidal Deep Brain Stimulation in Meige Syndrome

OBJECTIVE: Meige syndrome is the combination of blepharospasm and oromandibular dystonia. We assessed the surgical results of bilateral globus pallidus internus (GPi) deep brain stimulation (DBS) in patients with medically refractory Meige syndrome. METHODS: Eleven patients were retrospectively analyzed with follow-ups of more than 12 months. The mean follow-up period was 23.1 +/- 6.4 months. The mean age at time of surgery was 58.0 +/- 7.8 years. The mean duration of symptoms was 8.7 +/- 7.6 years. DBS electrodes were placed under local anesthesia using microelectrode recording and stimulation. After 2.4 +/- 1.3 days of trial tests, the stimulation device was implanted under general anesthesia. Patients were evaluated using the Burke-Fahn-Marsden Dystonia Rating Scale (BFMDRS). RESULTS: BFMDRS total movement scores improved by 59.8%, 63.5%, 74.1%, 74.5%, and 85.5% during the immediate postoperative period of test stimulation, 3, 6, 12, and 24 months (n = 5) after surgery, respectively. The BFMDRS total movement scores were reduced gradually and the results reached statistical significance in the postoperative period (test period, p < 0.001; 3 months, p < 0.001; 6 months, p = 0.003; 12 months, p < 0.001; 24 months, p = 0.042). There was no statistical difference between 12 months and 24 months. BFM subscores improved by 63.3% for the eyes, 80.9% for the mouth, 68.4% for speech/swallowing, and 87.9% for the neck at 12 months after surgery. The adverse effects were insignificant. CONCLUSION: The bilateral GPi-DBS can be effective for the treatment of intractable Meige syndrome without significant side effects.

Deep Brain Stimulation of the Subthalamic Area for Dystonic Tremor

The stereotactic surgical target for dystonic tremor is the subject of ongoing debate. Targeting the subthalamic area using deep brain stimulation has been regaining interest as a therapy for various types of involuntary movements. We describe the efficacy of stimulation of the subthalamic area in a patient with intractable dystonic tremor. Excellent control without neurological complications was achieved. This case report demonstrates that the subthalamic area is a valuable target for the control of dystonic tremor.

Pallidal Deep Brain Stimulation in Primary Cervical Dystonia with Phasic Type : Clinical Outcome and Postoperative Course

OBJECTIVE: The purpose of this study was to analyze in detail the relationship between outcome and time course of effect in medically refractory primary cervical dystonia (CD) with phasic type that was treated by bilateral globus pallidus internus (Gpi) deep brain stimulation (DBS). METHODS: Six patients underwent bilateral implantation of DBS into the Gpi under the guide of microelectrode recording and were followed for 18.7 +/- 11.1 months. The mean duration of the CD was 5.8 +/- 3.4 years. The mean age at time of surgery was 54.2 +/- 10.2 years. Patients were evaluated with the Toronto Western Spasmodic Torticollis Rating Scale (TWSTRS) and relief scale using patient self-reporting. RESULTS: The TWSTRS total scores improved by 64.5%, 65.5%, 75.8%, and 76.0% at 3, 6, 12 months, and at the last available follow-up after surgery, respectively. Statistically significant improvements in the TWSTRS scores were observed 3 months after surgery (p = 0.028) with gradual improvement up to 12 months after surgery, thereafter, the improvement was sustained. However, there was no statistically significant difference between the scores at 3 and 12 months. Subjective improvement reported averaged 81.7 +/- 6.8% at last follow-up. Mild dysarthria, the most frequent adverse event, occurred in 3 patients. Conclusions: Our results show that the bilateral Gpi-DBS can offer a significant therapeutic effect from 3 months postoperatively in patients with primary CD with phasic type, without significant side effects.

Percutaneous Balloon Compression of Trigeminal Ganglion for the Treatment of Idiopathic Trigeminal Neuralgia : Experience in 50 Patients

OBJECTIVE: We assessed the surgical results of percutaneous balloon compression in 50 patients with idiopathic trigeminal neuralgia. METHODS: Fifty patients with follow-up period of more than 12 months were retrospectively analyzed. The mean follow-up period was 42 months (range, 12-82). The mean age was 65.8 years (range, 27-83). Seventeen patients (34%) had other previous surgical procedures. The balloon was inflated by injecting radio-contrast media under brief general anesthesia according to Mullan's technique. The mean inflating time was 88 seconds (range, 60-120). The whole procedure took about 20 minutes. RESULTS: We reported excellent and good results in 70% of the cases, poor in 6% as annoying dysesthesia, recurrence in 16%, and 8% failure due to technical deficiencies. Forty-six patients (92%) were initially relieved of their pain. There were permanent motor weakness of the masseter muscle in 4% of patients and transitory diplopia in 8%. Neither anesthesia dolorosa nor keratitis occurred. Almost all patients (92%) were discharged postoperatively within two days. CONCLUSION: These results indicate that balloon compression would be an effective method with acceptable morbidity, technically, it can be performed rapidly and simply in the treatment of idiopathic trigeminal neuralgia.

Lateral Third Infraclavicular Implantation of the Vagal Nerve Stimulation Generator Through Axillary Incision

OBJECTIVE: This report describes the clinical study of the surgical method of lateral third infraclavicular implantation of vagal nerve stimulation (VNS) generator through the axillary wrinkle incision. METHODS: In a retrospective study, the data for 20 patients with medically intractable epilepsy treated by this approach were examined. The mean age was 31.4 years (range : 14-50), and the mean follow-up period was 12.15 months (range : 4-21 months). The male to female ratio was 2.3 : 1. The subcutaneous pocket for the generator was located in the lateral third infraclavicular area through the axillary wrinkle. Our method was a modification of the standard VNS generator implantation in the mid-infraclavicular pocket through anterior axillary incision. RESULTS: There were the excellent or good cosmetic satisfaction in 95% of the cases and fair in 5%. The generator was located outside the lung field in 15%, periphery of the lung field in 45%, and crossed over the lung field in 40%. Discomfort from shoulder motion occurred transiently in 35% of cases. Other complications were minimal. CONCLUSION: These results demonstrate that the lateral third infraclavicular apporach will offers cosmetic benefits and reduction of obscuration of the lung field without serious complications. Thus, this technique provides an attractive alternative among the surgical techniques for the vagal nerve stimulation.

A Morphometric Analysis of the Foramen Ovale and the Zygomatic Points Determined by a Computed Tomography in Patients with Idiopathic Trigeminal Neuralgia

OBJECTIVE: The purpose of this study is to measure the dimensions of foramen ovale and to localize the zygomatic point using computed tomography(CT) in Korean adults with idiopathic trigeminal neuralgia. METHODS: Facial axial CT scans using the orbitomeatal plane were performed in 67patients (39males and 28females; mean age 58.8years) with idiopathic classic trigeminal neuralgia. We measured the size of the foramen ovale and localized the zygomatic point which was a skin marker over the ipsilateral zygoma that approximates the lateral projection of a straight line joining the centers of the two foramen ovale. RESULTS: The axial dimensions of the foramen ovale on the orbitomeatal plane were of average length: 8.18+/-0.82mm (range 6.9~11.5mm), width: 4.06+/-0.86mm (2.5~5.7mm). The average distance between the external acoustic meatus and the zygomatic point was 21.64+/-1.99mm (16.3~25.0mm) and the average distance of anterior margin of condylar process of mandible to zygomatic point was 4.29+/-1.19mm (1.0~7.0mm). CONCLUSION: The anatomical understandings including the size of the foramen ovale and localization of the zygomatic point could be helpful in determining a plan of percutaneous approaches to foramen ovale.

Percutaneous Balloon Compression of Trigeminal Gasserian Ganglion for Idiopathic Trigeminal Neuralgia

OBJECTIVE: The purpose of this study is to review the surgical results of 19 patients with idiopathic trigeminal neuralgia treated by percutaneous ballooning compression(PBC) of trigeminal gasserian ganglion under brief general anesthesia. METHODS: The mean patient age was 63.5 years(range, 27-78). The mean follow-up period was 24 months(range, 1-46). Three patients had already undergone radiofreqnency trigeminal rhizotomy and two patients had previously microvascular decompression. The balloon was inflated by injecting radio-contrast media 0.7-1cc in amount. The mean inflating time is 81 seconds(range, 60-90). RESULTS: During the procedure, brief intraoperative bradycardia and hypotension were noted in seven cases(36.7%). All patients had immediate relief of pain except 1 case. 18 cases(94.5%) of patients were satisfied or very satisfied with their pain relief. There were immediate, mild to moderate sensory complication of hypesthesia, dysesthesia or paraesthesia in all cases and the immediate motor complication-difficulty of mastication in 3 cases, transient 6th nerve palsy in 2 cases. The immediate motor and sensory complications disappeared or much improved after 3-4 months. CONCLUSION: It is the simple technique that can be performed effectively in a brief period of general anesthesia. This procedure might be one of attractive methods in the treatment of idiopathic trigeminal neuralgia.

Suboccipital Lateral Approach in the Supine Position for Stereotactic Aspiration of Cerebellar Hematoma

OBJECTIVE: We report a suboccipital lateral approach in order to propose more suitable stereotactic aspiration technique for cerebellar hematoma. METHODS: Using the Leksell's CT-stereotactic system, the patient was kept on a supine position under local anesthesia turning the head 30 to 40 degrees contralateral to the side of the lesion and bending the neck forward, so that the approach was made laterally toward the ipsilateral suboccipital area. Eight patients with cerebellar hematoma underwent this stereotactic technique. Six patients complicated with intraventricular hemorrhage or obstructive hydrocephalus underwent simultaneously external ventricular drainage(EVD) via Kocher's point without position change. The mean amount of hematoma was 23.7ml (14~58ml). RESULTS: All showed initially a partial removal of the hematoma about 6.1ml in mean volume through stereotactically placed catheters and the residual hematoma was drained out by urokinase irrigation for mean of 3.3 days. The mean operation time took 2 hours in cases combined with EVD and one hour and half in cases not. CONCLUSION: This surgical technique for the cerebellar hematoma can be easily done in a supine position under local anesthesia and surgical invasion is minimal. It also has benefits that EVD can be done without any position change.

Spinal Cord Stimulation for Intractable Postherpetic Neuralgia

Postherpetic neuralgia(PHN) is a neuropathic pain syndrome that is often intractable. A 75-year-old man suffered intractable pain due to herpes zoster between T4 and T6 dermatome. Allodynia, the severe superficial pain that he could not wear his clothes, was improved by ablative surgery such as dorsal root entry zone lesions and dorsal root ganglionectomy. However, deep cramping pain was sustained. Because of this excruciating pain, spinal cord stimulation(SCS) was decided. After the operation, the pain has been improved to tolerable state. As with our case, a constant deep cramping pain associated with other refractory painful condition of PHN, SCS could be considered as a useful option.

A Case of Bullous Scabies / 대한피부과학회지

Atypical manifestations of scabies have been reported, including impetigo, folliculitis, tinea, psoriasis, contact dermatitis, urticaria, dermatitis herpetiformis, bullous pemphigoid and Darier's disease. Although vesicles are commonly found in children, they are extremely uncommon in adults. We report a case of bullous scabies in 57-year-old male who developed a bullous pemphigoid-like eruption associated with scabies. Direct immunofluorescence test showed linear deposition of IgM and C3 at the dermoepidermal junction. Treatment with topical crotamiton was successful for up to 12 month of follow-up.

A Study of Nail-splinting Technique with Flexible Plastic Tube in Ingrown Nail / 대한피부과학회지

BACKGROUND: Ingrown nail is a common disorder that occurs most frequently in the great toe and gives affected patients a great discomfort. Many treatments hae been described, such as nail extraction, partial matrix phenolization and wedge excision. However, these treatments modality may lead to damage of the nail and nail fold or to frequent relapses. OBJECTIVE: We attempted to determine the effectiveness of nail-splinting technique with flexible plastic tube in ingrown nails. METHODS: Twenty-nine consecutive patients were treated and enrolled in this study. Without local anesthesia, the lateral edge of the nail plate including the spicule is splinted with a lengthwise -incised small flexible plastic tube, for example, plastic drainage portion of scalp vein set. The plastic tube retained for 2 weeks without any medication. RESULTS: Among the 29 patients, 24 patients were treated successfully without recurrence. After splinting, the patients experienced relief of pain immediately or 1~2 days later, therefore patients are able to lead ordinary lives more qvldrly. CONCLUSION: Nail-splinting technique with flexible plastic tube in ingrown nails is an effective treatment with relatively low recurrence rate. This method demands little skill and carried out in general practice. It gives an excellent cosmetic result with immediate pain relief, thus fulfilling the main requirements for the primary treatment of choice.

Malignant Meningioma with Intracranial and Extracranial Multiple Metastases : Usefulness of Fractionated Stereotactic Radiation and Conventional External Radiation Therapy: A Case Report

No abstract available.

Atlantoaxial Subluxation due to Psoriatic Arthritis: Case Report

Psoriatic arthritis is a rare inflammatory joint disease associated with radiographic evidence of periarticular bone erosion and sometimes frank joints destruction among psoriatic patients. There have been only a few reports of atlantoaxial subluxation in patients with psoriatic arthritis in the world. The authors report a case of psoriatic arthritis with atlantoaxial subluxation. This 27-year-old man with a three year history of psoriatic skin lesion presented with painful limitation of neck and multiple joint deformities of the hands and feet, etc. We performed combined interspinous and Gallie fusion for the atlantoaxial subluxation and obtained good results of immediate and long term postoperative stability with Philadelphia neck collar only after this procedure.

Trigeminal Neuralgia in a Patient with Osteopetrosis: A Case Report

Osteopetrosis is a rare disease by a generalized increase in skeletal density and by abnormalities of bone modeling secondary to defective osteoclastic function with impairment of bone resorption. The various cranial nerve palsies may occur secondary to bony encroachment on the cranial foramina. The authors report a case of osteopetrosis with trigeminal neuralgia. This 30-year-old woman presented with the recurring attacks of severe lancinating paroxysmal pain on her right face(mandibular division>maxillary division>ophthalmic division) for 10 years and anosmia, both blindness for 20 years. Her foramen ovale and optic canal narrowings were caused by osteopetrosis. The neuralgia was refractory to medical treatment. Percutaneous radio-frequency rhizotomy for trigeminal neuralgia was performed and pain relief have been obtained. She was satisfied with the procedure, even if with facial numbness. In the case of trigeminal neuralgia in young patient without abnormal mass lesion on brain radiologic imaging studies, it is important to investigate the bony abnormalities of skull base. The authors believe that radiofrequency rhizotomy is the first choice of treatment for trigeminal neuralgia caused by the bony abnormalities of skull base such as osteopetrosis.

Supratentorial Surgery Complicated by Cerebellar Hemorrhage: Report of Three Cases

Among the complications of intracranial surgery, postoperative hemorrhage remote from the operative site is rare, especially when it occurs in the cerebellum after surgery involving the supratentorial region. We report three cases of cerebellar hemorrhage after supratentorial surgery : 1) A 66-year-old man with subdural hygroma in both frontotemporal areas ; 2) A 56-year-old man with chronic subdural hematoma in the left frontotemporal area ; 3) A 39-year-old woman with aneurysms at the right middle cerebral artery bifurcation and basilar tip. The possible etiologies of cerebellar hemorrhage in the three cases presented here were reviewed. We speculate that when the patient is in the supine position with head rotated and extended, the displacement of the cerebellum causes stretching of the superior vermian veins and their tributaries, resulting in tearing of these vessels, and that a sudden decrease in intracranial pressure may accelerate this process. To prevent this complication, meticulous perioperative management of the patient is essential.