The Usability of Various Flaps for Hindfoot Reconstruction

PURPOSE: Anatomically, the foot is provided with insufficient blood supply and is relatively vulnerable to venous congestion compared to other parts of the body. Soft tissue defects are more difficult to manage and palliative treatments can cause hyperkeratosis or ulcer formation, which subsequently requires repeated surgeries. For weight bearing area such as the heel, not only is it important to provide wound coverage but also to restore the protective senses. In these cases, application of flaps for hind foot reconstruction is widely recognized as an effective treatment. In this study, we report the cases of soft tissue reconstruction for which various types of flaps were used to produce good results in both functional and cosmetic aspects. METHODS: Data from 37 cases of hind foot operation utilizing flaps performed between from June 2000 to June 2008 were analyzed. RESULTS: Burn related factors were the most common cause of defects, accounting for 19 cases. In addition, chronic ulceration was responsible for 8 cases and so forth. Types of flaps used for the operations, listed in descending order are radial forearm free flap(18), medial plantar island flap(6), rotation flap(5), sural island flap(3), anterolateral thigh free flap(2), lattisimus dorsi muscular flap(2), and contra lateral medial plantar free flap(1). 37 cases were successful, but 8 cases required skin graft due to partial necrosis in small areas. CONCLUSION: Hind foot reconstruction surgeries that utilize flaps are advantageous in protecting the internal structure, restoring functions, and achieving proper contour aesthetically. Generally, medial plantar skin is preferred because of the anatomical characteristics of the foot (e.g. fibrous septa, soft tissue for cushion). However alternative methods must be applied for defects larger than medial plantar skin and cases in which injuries exist in the flap donor/recipient site(scars in the vicinity of the wound, combined vascular injury). We used various types of flaps including radial forearm neurosensory free flap in order to reconstruct hind foot defects, and report good results in both functional and cosmetic aspects.

Surgical Treatment of Squamous cell Carcinomas Arising in Scalp Burn Wounds: Two Case Reports

Marjolin's ulcer is a rare and often-aggressive cutaneous malignancy that arises in previously traumatized or chronically inflamed skin, particularly after burns. We experienced two cases after burns. Case I involved a forty eight year-old man who had suffered from a flame burn at the parietal scalp area, where had been initially described three years earlier as a full-thickness wound including the pericranium. The man consulted us for a persistent ulcerative and infected wound on the burned lesion during the last 24 months, which turned out on the contrast-enhanced computed tomography (CT) and magnetic resonance imaging (MRI) to be the squamous cell carcinoma with involving the skull and the dura mater. Although the posterior auricular lymph node was enlarged on the ipsilateral side, recent positron emission tomography (PET) CT did not show any metastatic lesion. It was impossible for us to resect the intracranial involvement of the tumor radically, and the postoperative PET CT still showed a focal fluorodeoxyglucose (FDG) uptake around the wall of the superior sagittal sinus. We think that an aggressive combined approach is essential for treatment in early stages for a high success rate, before the intracranial structures are involved because there is no consensus on the treatment for advanced disease, and the results are generally poor. Case 1 also did not involve a radical resection because of the intracranial invasion to the wall of superior sagittal sinus and the possibility of damage to the major cortical veins. He received adjuvant radiotherapy and must be followed periodically. Case 2 involved an eighty six year-old women who suffered from a painful scalp ulcer lesion after flame burns three years earlier. Unlike case 1, neither tumor infiltration into the dura nor lymph node enlargement was observed on the contrast-enhanced computed tomography (CT), magnetic resonance imaging (MRI), or positron emission tomography (PET) CT. We did a radical resection of the tumor, including the involved bone, and a cranioplasty with bone cement.

Effect of Radiofrequency Dorsal Root Entry Zone Lesion for Neuropathic Intractable Pain

OBJECTIVE: The authors report a retrospective analysis of the clinical effect of dorsal root entry zone (DREZ) lesioning for neuropathic intractable pain. METHODS: Fourteen patients who underwent dorsal root entry zone lesioning for various types of pain between September 1995 and August 2001 were evaluated retrospectively. Eleven male and three female patients whose ages ranging from 35 to 70 were studied. According to causes of intractable pain, patients were divided into paraplegic pain(7 patients), peripheral nerve injury pain(3), cancer pain(3), phantom limb pain(1) and root avulsion pain(1). Other preoperative pain managements showed no benificial effects. The changes in painful symtoms were closely observed during follow up period. The mean follow period after operation was 32.4 months. RESULTS: Postoperatively, the decrease in level of pain was classified into four groups : excellent, good, fair, poor. Excellent represented no pain without medication : Good, pain tolerable with non-opiate medicine ; Fair, pain tolerable with opiate medicine ; Poor, pain sustained. After operation, three patients were in excellent group, eight in good, one in fair, and two in poor. Twelve patients were in medically tolerable pain group accounting for 85.7%. There were no serious operation releated side effects. CONCLUSION: DREZ lesioning, in our series, provided substantial pain relief and this may be considered an option in management of these types of intractable neuropathic pain.

Clinical Analysis of Recurrent Lumbar Disc Herniation

Recurrent lumbar disc herniation after standard lumbar discectomy was the mostcommon complication among the failed back surgery syndrome. Clinical manifestations and radiologic findings were analyzed in 56 paients who were proved to have recurrent lumbar disc herniation. Comparative analysis with Lumbar Disc Surgery Predictive Score(LDSPS) between 160 patients of failed back surgery syndrome and 56 patients of recurrent disc herniation was performed. LDSPS of the recurrent disc herniation was 81.3. The interval of the reoperation after onset of symptom was considered to be one ofthe major factors in the prognosis of the recurrent disc herniation. The patient must be educated how to prevent lumbar disc herniation. When recurrency was suspected one must diagnose precisely with the help of MRI andreoperate as soon as possible.

The Role of ELISA in Prediction of the Prognosis after Treatment of Neurocysticercosis

The diagnosis of neurocysticercosis is relatively easy with brain computed tomo-grarhy(CT) and/or magnetic resonance imaging(MRI) and ELISA test of serum and cerebrospinal fluid(CSF). The clinical manifestation of the disease are varied and correlated with the infection sites. The use of praziquantel and/or surgical excision are effective in treatment of the disease. The effect of treatment has been evaluated with imaging studies and changes of clinical manifestation. The authors reviewed 97 neurocysticercosis patients to evaluate the prognostic predictability of serum and CSF ELISA titers after treatment . We classified the patients into two groups. Rebound group was patients which showed higher ELISA titers after praziquantel medication than pretreatment. The responses to treatment were evaluated with the changes on brain CT or MRI. The Initial ELISA titers were lower in rebound group than those of nonrebound group, but three month after treatment, rebound group showed higher titers. The changes of ELISA titers in rebound group were greater in CSF than those in serum. The reduction of cyst on brain CT or MRI was more remarkable in rebound group than in nonrebound group and the prognosis of rebound group was better. Changes of ELISA titers was valuable in predicting the effect of treatment and prognosis.

Two Cases of Tuberous Sclerosis Associated with Subependymal Giant Cell Astrocytoma

Neurosurgical intervention in the syndrome is discussed in the light of two recently treated cases, one of which was admitted due to acute hydrocephalic attack, the other was confirmed by the typical computed tomographic findings as well as the classic triad of adenoma sebaceum, mental retardation and epilepsy. There cases had no family historty and were probably the result of new mutations and variable penetrance. Transcallosal microsurgical excision of tumor was accomplished in both cases and subependymal giant cell astrocytoma was confirmed. The hydrocephalus resolved but subduroperitoneal shunt was required in one case.

A Study of Functional Lumbar Myelography

Functional myelography, applying spinal movements(flexion-extension) in myelography, has been frequently used for accurate diagnosis of posture-related disorders such as herniated lumbar disc or spinal stenosis. Measurements were performed on functional myelographic findings of 62 patients, and in 24 cases surgically verified herniated lumber discs were present. The object of this study was to analyze changes in position and shape of the dural sac in spinal movements and confirm the clinical importance of functional myelography. The present study demonstrated that: 1) The anterior border of the dural sac was straight with flexion, but indented at the level of intervertebral space and this indentation was less prominent at L5-S1. 2) With extension, posterior indentation of the dural sac was more prominent at the level of the intervertebral space than the body, the A-P diameter of the dural sac was narrowed at all levels of the intervertebral spaces except L5-S1, and the dural sac moved anteriorly at the level of L5-S1 and all spinal bodies. 3) In surgically verified disc patients, anterior indentation of the dural sac was persistent in both flexion and extension views, and was more exaggerated with extension, but less prominent at L5-S1. In patient at L5-S1, anterior movement of the anterior dural border at the level of surgery was much decreased.

A Case of Intracerebral Tension Pneumocephalus

Tension pneumocephalus is rare while pneumocephalus is relatively common. The former has sudden or insidious deterioration in neurologic symptoms and signs comparing to self-limited pneumocephalus. This report is of a 19 years old male with tension pneumocephalus in the right frontal lobe two underwent right frontal osteoplastic craniotomy.

Spinal Interbody Fusion with Bovine Bone: A preliminary report

The authors experienced on the use of bovine bone in 3 cases of interbody fusion employing the Cloward technique. Two patients were cervical fracture-dislocation and one patient was a case of lumbar spondylolysis. With use of bovine bone, iliac osteotomy is unnecessary, and this procedure is no problem of donor site pain and infection which can be possible in interbody fusion with iliac bone and rib graft. With the use of bovine bone the additional advantages are. 1) The operative procedure is simplified. 2) The time required for the operation is diminished. 3) Patient meralgia is eliminated completely. 4) The surgeon can have uniformly sized bones of a proven hardness on hand. 5) The epidural bleeding is showed through lattice of bovine bone.

A Case of Sturge-Weber Syndrome

Sturge-Weber syndrome was rare. But reported from 1860. We present a typical case of Sturge-Weber syndrome in a child and discussed the symptoms, signs, and pathological finding of various examinations in neurosurgical field such as plain x-ray, 4-vessel angiography, CT scan, EEG, IQ test, exophthamometry, opthalmometry, and fundoscopy. We find marked abnormality and asymmetry in that examination.

Cervical Cordotomy via Anterior Approach without Bone Graft

Cervical cordotomy via anterior approach without bone graft which is a modified Cloward's method is an effective and simple means of relieving of intractable pain with minimal destruction of bone lower morbidity and mortality. This method consists of an anterior surgical approach to the ventral surface of the cervical cord through a simple discectomy. A transverse incision in the dura mater gives excellent exposure permitting incision of the spinothalamic tracts under direct vision. For bilateral pain both incision are made at the same level of the cord without causing impairment of motor function of the lower extremities or bowel and bladder. This procedure has also many advantages and disavantages as follows ; 1. Cervical cordotomy by the this procedure has a much lower morbidity and fewer complications than the conventional procedure by laminectomy. 2. A more complete section of the spinothalamic tract is possible under direct vision. 3. A differential section of the tract with sparing of sensation in non-painful areas is possible by this procedure. 4. An incidence of the cord trauma can be minimized because the incision is possible without distorsion and traction of the cord during the operation. 5. This procedure without bone graft is simpler than original Cloward's method. 6. An water-tight closure of the dura is difficult but successful results are obtained by using a gelfoam. 7. This procedure above the level of the C3-4 interspace is difficult but possible. 8. A relief of pain below the level of the T3 dermatome is available and there is no good operative candidate when the brachial plexus is involved.