Bone Flap Changes after Cranioplasty Using Frozen Autologous Bone Flaps: A Three-Dimensional Volumetric Reconstruction Study.

PURPOSE: Bone flap resorption (BFR) after cranioplasty with an autologous bone flap (ABF) is well known. However, the prevalences and degrees of BFR remain unclear. This study aimed to evaluate changes in ABFs following cranioplasty and to investigate factors related with BFR. MATERIALS AND METHODS: We retrospectively reviewed 97 patients who underwent cranioplasty with frozen ABF between January 2007 and December 2016. Brain CT images of these patients were reconstructed to form three-dimensional (3D) images, and 3D images of ABF were separated using medical image editing software. ABF volumes on images were measured using 3D image editing software and were compared between images in the immediate postoperative period and at postoperative 12 months. Risk factors related with BFR were also analyzed. RESULTS: The volumes of bone flaps calculated from CT images immediately after cranioplasty ranged from 55.3 cm³ to 175 cm³. Remnant bone flap volumes at postoperative 12 months ranged from 14.2% to 102.5% of the original volume. Seventy-five patients (77.3%) had a BFR rate exceeding 10% at 12 months after cranioplasty, and 26 patients (26.8%) presented severe BFR over 40%. Ten patients (10.3%) underwent repeated cranioplasty due to severe BFR. The use of a 5-mm burr for central tack-up sutures was significantly associated with BFR (p<0.001). CONCLUSION: Most ABFs after cranioplasty are absorbed. Thus, when using frozen ABF, patients should be adequately informed. To prevent BFR, making holes must be kept to a minimum during ABF grafting.

Risk Factors for Hinge Fracture Associated with Surgery Following Cervical Open-Door Laminoplasty.

OBJECTIVE: The purpose of this study was to analyze the risk factors for hinge fracture (HF) and non-union during cervical open-door laminoplasty (CODL). METHODS: We included 25 patients who underwent CODL with available serial computed tomography scans acquired at 2 days and 1 year postoperatively. Patients' medical records and radiographic data were reviewed. Risk factors related to the surgical procedures were evaluated including the lamina angle, spinous angle, difference in the lamina angle, outer cortex location (OCL), and inner cortex location. RESULTS: There were a total of 76 hinges. Of these, 44 laminae were classified as deformed hinges, and 32 were classified as fragmented hinges. Additionally, 66 laminae were healed completely, and 10 laminae were not healed by 12 months postoperatively. The OCL (odds ratio, 70.45; 95% confidence interval, 7.73-641.76) was identified as a predictor of HFs immediately following CODL. However, none of the factors we evaluated was related to hinge non-union. CONCLUSION: A medially located hinge gutter ( >1.9 mm from the pedicle on the outer cortex) seems to be an important risk factor for HFs following CODL. However, the hinge healing status was not related to the surgical technique.

Trauma Patterns of Drowning after Falling from Bridges over Han River.

OBJECTIVE: Recently, the number of patients who fell or jumped from bridges over Han River has rapidly increased. However, the injury patterns and outcomes of these patients have been poorly characterized. The aim of this study was to determine the injury characteristics of these patients. METHODS: We reviewed the medical records of all patients who were transferred to the Emergency Room due to jumping or falling from bridges over Han River between 2011 and 2015. RESULTS: A total of 203 patients were included. Among them, 14 (6.9%) patients were dead on arrival, 51 (25.1%) patients were expired in the hospital, and 138 (70%) patients were discharged alive, including a patient who had severe neurologic sequelae after resuscitation. Skeletal and internal organ injuries were identified based on radiologic images. The most injured organ was thorax (58.1%), followed by spine (23.1%), abdomen (11.1%), extremity (7.7%), and cranium (5.2%). Chest tubing for pneumothorax or hemothorax was performed in four (2.9%) patients. Surgical intervention was needed for four patients (2.9%). CONCLUSION: Trauma patterns were concentrating on the thorax and spine regions. Therefore, complete radiographic evaluation should be performed for these patients.

Proper Management of Posttraumatic Tension Pneumocephalus.

Pneumocephalus is commonly seen after craniofacial injury. The pathogenesis of pneumocephalus has been debated as to whether it was caused by ball valve effect or combined episodic increased pressure within the nasopharynx on coughing. Discontinuous exchange of air and cerebrospinal fluid due to "inverted bottle" effect is assumed to be the cause of it. Delayed tension pneumocephalus is not common, but it requires an active management in order to prevent serious complication. We represent a clinical case of a 57-year-old male patient who fell down from 3 m height, complicated by tension pneumocephalus on 5 months after trauma. We recommend a surgical intervention, but the patient did not want that so we observe the patient. The patient was underwent seizure and meningitis after 7 months after trauma, he came on emergency room on stupor mentality. Tension pneumocephalus may result in a neurologic disturbance due to continued air entrainment and it significantly the likelihood of intracranial infection caused by continued open channel. Tension pneumocephalus threat a life, so need a neurosurgical emergency surgical intervention.

Microsurgical Anatomy of the Oculomotor Nerve.

The oculomotor nerve supplies the extraocular muscles. It also supplies the ciliary and sphincter pupillae muscles through the ciliary ganglion. The nerve fibers leave the midbrain through the most medial part of the cerebral peduncle and enter the interpeduncular cistern. After the oculomotor nerve emerges from the interpeduncular fossa, it enters the cavernous sinus slightly lateral and anterior to the dorsum sellae. It enters the orbit through the superior orbital fissure, after exiting the cavernous sinus, to innervate the extraocular muscles. Therefore, knowledge of the detailed anatomy and pathway of the oculomotor nerve is critical for the management of lesions located in the middle cranial fossa and the clival, cavernous, and orbital regions. This review describes the microsurgical anatomy of the oculomotor nerve and presents pictures illustrating this nerve and its surrounding connective and neurovascular structures. Clin. Anat. 30:21-31, 2017. © 2016 Wiley Periodicals, Inc.

Microsurgical Foraminotomy via Wiltse Paraspinal Approach for Foraminal or Extraforaminal Stenosis at L5-S1 Level : Risk Factor Analysis for Poor Outcome.

OBJECTIVE: The purpose of this study was to present the outcome of the microsurgical foraminotomy via Wiltse paraspinal approach for foraminal or extraforaminal (FEF) stenosis at L5-S1 level. We investigated risk factors associated with poor outcome of microsurgical foraminotomy at L5-S1 level. METHODS: We analyzed 21 patients who underwent the microsurgical foraminotomy for FEF stenosis at L5-S1 level. To investigate risk factors associated with poor outcome, patients were classified into two groups (success and failure in foraminotomy). Clinical outcomes were assessed by the visual analogue scale (VAS) scores of back and leg pain and Oswestry disability index (ODI). Radiographic parameters including existence of spondylolisthesis, existence and degree of coronal wedging, disc height, foramen height, segmental lordotic angle (SLA) on neutral and dynamic view, segmental range of motion, and global lumbar lordotic angle were investigated. RESULTS: Postoperative VAS score and ODI improved after foraminotomy. However, there were 7 patients (33%) who had persistent or recurrent leg pain. SLA on neutral and extension radiographic films were significantly associated with the failure in foraminotomy (p<0.05). Receiver-operating characteristics curve analysis revealed the optimal cut-off values of SLA on neutral and extension radiographic films for predicting failure in foraminotomy were 17.3° and 24°s, respectively. CONCLUSION: Microsurgical foraminotomy for FEF stenosis at L5-S1 level can provide good clinical outcomes in selected patients. Poor outcomes were associated with large SLA on preoperative neutral (>17.3°) and extension radiographic films (>24°).

Postlaminectomy Bilateral Lumbar Intraspinal Synovial Cysts.

Lumbar intraspinal synovial cysts are included in the difference diagnosis of lumbar radiculopathy. Developing imaging modalities has result in increased reporting about these lesions. However, the case of bilateral new lumbar intraspinal synovial cysts after laminectomy has been rarely reported. We report of a rare case with bilateral lumbar intraspinal synovial cysts after laminectomy, requiring surgical excision.

Analysis of the risk factors for development of post-operative extradural hematoma after intracranial surgery.

OBJECTIVE: Post-operative extradural hematoma (EDH) is a relatively common complication in patients undergoing intracranial operations. The risk factors associated with the occurrence of EDH are not well described in the literature. The objective of this study was to identify the risk factors and the incidence of post-operative EDH adjacent and regional to the craniotomy or the craniectomy site. METHOD: This was a retrospective study of 24 (2.6% of total) patients who underwent extradural hematoma evacuation after primary intracranial supratentorial surgery between January 2005 and December 2011. During this period, 941 intracranial operations were performed. The control group (72 patients) was selected on the basis of having undergone the same pre-operative diagnosis and treatment within 2 months of the operations for the 24 hematoma patients. The Glasgow Coma Scale score and operation character (emergency or elective) of the hematoma and control group were individually matched to minimize pre-operative conditional bias. The ages of both groups were individually matched with similar ages within 10 years of each other to minimize age bias. RESULT: Univariate analysis showed that the significant pre-operative and intra-operative factors associated with post-operative EDH were an intra-operative blood loss of greater than 800 mL (p=0.007), maximal craniotomy length of greater than or equal to 100 mm (p=0.001), and craniotomy area of greater than or equal to 71.53 cm2 (p=0.018). In multivariate analysis, intra-operative blood loss exceeding 800 mL (median of total patients) placed a patient at significantly increased risk for post-operative EDH. CONCLUSION: The data did not examine established risk factors for post-operative hematoma, such as thrombocytopenia, anti-coagulant and anti-platelet therapy, and a history of heavy alcohol consumption and/or tobacco intake. Recognizing the limitations of the study, large intra-operative blood loss and wide craniotomy area are implicated with an increased risk of post-operative EDH after intracranial surgery.

Brain Metastases of Papillary Thyroid Carcinoma with Horner's Syndrome.

Papillary thyroid carcinoma (PTC) is the most common type of thyroid malignancy and has relatively favorable prognosis. Blood-borne metastases of PTC are very rare among the thyroid malignancies. Moreover a case of blood-borne central nervous system metastasized PTC with only unilateral Horner's syndrome, and without any abnormalities in laboratory or physical examinations has not been described before. A 53-year-old female patient had been managed in ophthalmologic clinic due to vague symptoms of right monocular blurred vision with eye dryness for 3 months, but showed no signs of improvement. So it was performed a magnetic resonance imaging and magnetic resonance angiography to evaluate the possibilities of cerebral lesion. And a left frontal mass was incidentally found, and the tumor turned out to be a PTC that had metastasized to brain, regional lymph node, cervical, thoracic spine, and lung. We describe a PTC with extraordinary initial symptoms that metastasized to an unusual site. We recommend that if a papillary thyroid tumor with unusual symptoms or at an advanced stage is found, further investigation should be performed for distant metastasis.

Hinge Fracture during Cervical Open-door Laminoplasty: Does it Affect Clinical and Radiographic Outcomes?

OBJECTIVE: The purpose of this study was to determine whether the status of the hinge gutter affected clinical and radiographic outcomes of cervical open door laminoplasty. METHODS: We retrospectively analyzed 43 patients who had undergone cervical open door laminoplasty. 23 CT scans were performed at 2 days post-operation. The number of CT scans at 3, 6, 12 and 24 months were 16, 12, 21 and 11, respectively. We collected perioperative and follow-up data, including clinical and radiographic results. RESULTS: There were 7 patients without a hinge fracture and 16 patients with one or more hinge fractures at 2 days postoperation. There were 90 hinges, and the rate of ideal greenstick deformation of the hinge was 63% on 2-day-postoperative CT scans. Postoperative VAS scores of neck pain (p=0.012) in patients without a hinge fracture were higher than in patients with hinge fractures. The hinge healing rates were 37% at 3 months, 57.4% at 6 months, 86.4% at 12 months, and 85.4% at 24 months. Among the patients, 14 patients had healed hinges, and 7 patients had one or more hinge(s) that was/were not healed at 12 months post-operation. However, in clinical and radiographic outcomes, there was no difference between these patients. CONCLUSION: Cervical open door laminoplasty was safe and provided stable reconstruction of laminar expansion. In radiographs, the difference between hinges that had healed and hinges that had not healed was statistically negligible. Hinge fractures might not influence the clinical and radiographic outcomes of cervical open door laminoplasty.

Factors associated with the success of trial spinal cord stimulation in patients with chronic pain from failed back surgery syndrome.

OBJECTIVE: Spinal cord stimulation (SCS) is an effective means of treatment of chronic neuropathic pain from failed back surgery syndrome (FBSS). Because the success of trial stimulation is an essential part of SCS, we investigated factors associated with success of trial stimulation. METHODS: Successful trial stimulation was possible in 26 of 44 patients (63.6%) who underwent insertion of electrodes for the treatment of chronic pain from FBSS. To investigate factors associated with successful trial stimulation, patients were classified into two groups (success and failure in trial). We investigated the following factors : age, sex, predominant pain areas (axial, limb, axial combined with limbs), number of operations, duration of preoperative pain, type of electrode (cylindrical/paddle), predominant type of pain (nociceptive, neuropathic, mixed), degree of sensory loss in painful areas, presence of motor weakness, and preoperative Visual Analogue Scale. RESULTS: There were no significant differences between the two groups in terms of age, degree of pain, number of operations, and duration of pain (p>0.05). Univariate analysis revealed that the type of electrode and presence of severe sensory deficits were significantly associated with the success of trial stimulation (p<0.05). However, the remaining variable, sex, type of pain, main location of pain, degree of pain duration, degree of sensory loss, and presence of motor weakness, were not associated with the trial success of SCS for FBSS. CONCLUSION: Trial stimulation with paddle leads was more successful. If severe sensory deficits occur in the painful dermatomes in FBSS, trial stimulation were less effective.

Giant anterior cervical osteophyte leading to Dysphagia.

Large anterior cervical osteophytes can occur in degeneration of the cervical spine or in diffuse idiopathic skeletal hyperostosis(DISH). Large osteophytes can produce otolaryngological symptoms such as dysphagia, dysphonia, and foreign body sensation. We describe a DISH patient with giant anterior cervical osteophyte causing chronic dysphagia and dysphonia. A 56-year-old man presented with increasing dysphagia, dysphonia, neck pain and neck stiffness. Physical examination of the neck showed a non-tender and hard mass on the left side at the level of C4-5. Radiography showed extensive ossification of anterior longitudinal ligament along the left anterolateral aspect of vertebral bodies from C2 to T1. The ossification was espe cially prominent at the level of C4-5 and linear breakage was noted at same level. Esophagogram revealed a filling defect along the pharynx and lateral displacement of the esophagus. Giant anterior cervical osteophyte was removed through the leftsided anterolateral cervical approach to the spine. Anterior cervical interbody fusion at C4-5 was followed by posterior cervical fixation using lateral mass screws from C3 to C6. After surgery, dysphagia and dysphonia improved immediately. One year later, cervical CT showed bone fusion at C4-5 bodies and no recurrence of osteophyte. DISH is a common cause of anterior cervical osteophyte leading to progressive dysphagia. Keeping this clinical entity in the differential diagnosis is important in patients with progressive neck stiffness, dysphagia or dysphonia. And surgical treatment of symptomatic anterior cervical osteophyte due to DISH should be considered with a solid fusion procedure preventing postoperative instability or osteophyte progress.

Prevalence and epidemiological features of moyamoya disease in Korea.

OBJECTIVE: The objectives of the present study were to investigate the annual detection rate of patients with Moyamoya disease (MMD) and to describe the prevalence and epidemiological features of the Moyamoya patients in Korea. MATERIALS AND METHODS: The authors analyzed the epidemiological data of Korean patients taken from the National Health Insurance Corporation in Korea among Moyamoya patients who were treated from 2004 until 2008. RESULTS: Based on 2004 data, 2,539 MMD patients were treated in Korea and the prevalence rate was 5.2 per 100,000 people. There were 2,987 in 2005, 3,429 in 2006, 4,051 in 2007, and 4,517 cases in 2008, and the prevalence rates per 100.000 people were 6.3, 7.0, 8.6, and 9.1, for those respective years. This represents an annual increase of 15% of new cases during this period. In 2008, 466 people were newly diagnosed with MMD, representing an incidence rate of 1 per 100,000 persons. The gender ratio was 1,547 men (34%) and 2,970 women (66%). Women had a higher incidence rate than men (1.94 times). There were two age peaks: teenagers and those in their forties. CONCLUSION: The present study shows that the number of Moyamoya patients in Korea is increasing. This increase could partly be explained by a recent increase in newly diagnosed cases, suggesting that a more careful consideration of the disease and better diagnostic techniques should be promoted among clinicians.

Axial neck pain after cervical laminoplasty.

OBJECTIVE: It has been demonstrated that cervical laminoplasty is an effective and safe method of treating multi-level cervical spondylotic myelopathy and ossification of the posterior longitudinal ligament. However, recent reports have suggested that axial neck pain is frequently encountered after cervical laminoplasty. The aim of the present study was to determine clinical significance of the C7 spinous process on axial neck pain after cervical laminoplasty. METHODS: A total of 31 consecutive patients that underwent cervical laminoplasty between March 2002 and December 2008 were reviewed. The authors evaluated and compared axial neck pain and lordotic angle in patients that underwent C7 spinous process preserving surgery (group 1, n = 16) and in patients in which the C7 spinous process was sacrificed (group 2, n = 15). RESULTS: Severe or moderate early axial pain occurred in 56.2% of patients in group 1 and in 86.6% in group 2. Severe or moderate late axial pain occurred in 12.5% in group 1 and in 73.3% in group 2. Eighty-Six percent of patients in group 2 and 43% in group 1 experienced aggravation of their axial neck pain during the early postoperative period. Aggravation of axial neck pain during early postoperative period was less common in group 1 but not statistically significant (p = 0.073). Sixty-six percent of patients in group 2 and 12% in group 1 had aggravated axial neck pain at late postoperative period and aggravation of late axial neck pain was significantly less common in group 1 (p = 0.002). CONCLUSION: The present study demonstrates that C7 spinous process preserving laminoplasty decreases the incidence of aggravated axial neck pain after cervical laminoplasty.

Bow Hunter's Stroke Caused by a Severe Facet Hypertrophy of C1-2.

Bow hunter's stroke is a rare symptomatic vertebrobasilar insufficiency in which vertebral artery (VA) is mechanically occluded during head rotation. Various pathologic conditions have been reported as causes of bow hunter's stroke. However, bow hunter's stroke caused by facet hypertrophy of C1-2 has not been reported. A 71-year-old woman presented with symptoms of vertebrobasilar insufficiency. Spine computed tomography showed massive facet hypertrophy on the left side of C1-2 level. A VA angiogram with her head rotated to the right revealed significant stenosis of left VA. C1-2 posterior fixation and fusion was performed to prevent serious neurologic deficit from vertebrobasilar stroke.

Traumatic atlantoaxial rotatory fixation with accompanying odontoid and c2 articular facet fracture.

Traumatic atlantoaxial rotatory fixation (AARF) with accompanying odontoid and C2 articular facet fracture is a very rare injury, and only one such case has been reported in the medical literature. We present here a case of a traumatic AARF associated with an odontoid and comminuted C2 articular facet fracture, and this was treated with skull traction and halo-vest immobilization for 3 months. After removal of the halo-vest immobilization, his neck pain was improved and his neck motion was preserved without any neurologic deficits although mild torticolis was still observed in closer inspection.

The clinical efficacy of repeat brain computed tomography in patients with traumatic intracranial haemorrhage within 24 hours after blunt head injury.

This study was performed to determine the usefulness of repeated brain computed tomography (CT) within 24 hours of blunt head trauma in patients with traumatic intracranial haemorrhages (ICH) and who were initially treated nonsurgically. Factors associated with the worsening of lesions on repeat CT were evaluated. Medical records of all blunt head trauma patients with traumatic ICH admitted to our hospital from January 2003 to December 2006 were retrospectively reviewed. Patients older than 16 years of age with an initial Glasgow Coma Scale (GCS) of 8 or greater were included. From the results of the repeat CT, patients were categorized as Group 1 (improved or unchanged condition) or Group 2 (worsened condition). A total of 168 patients (mean age of 44.8 +/- 19.2; mean admission GCS of 13.42 +/- 2.07; male to female ratio 2.1:1) were included. In 161 patients, repeat CT was obtained on a routine basis. In the remaining 7, it was prompted by a worsening neurological condition. The mean time from initial to repeat CT was 10.10 +/- 7.25 hours. Based on the results of the repeat CT, 108 patients were included in Group 1 and 60 in Group 2. The mean initial GCS was lower in patients from Group 2 versus those from Group 1 (11.9 +/- 2.6 compared with 14.3 +/- 0.96; p < 0.001). After repeat CT, 28 (47%) of the patients in Group 2 underwent neurosurgical interventions. Of the 28 surgically treated patients from Group 2, 6 (10%) exhibited neurological worsening and 22 (37%) appeared neurologically stable. According to our data, we suggest that routine repeat CT within 24 hours after blunt head trauma might minimize potential neurological deterioration in patients with either a GCS lower than 12 or with an epidural haematoma or multiple lesions as indicated on initial CT.

Spontaneous bilateral supratentorial subdural and retroclival extradural hematomas in association with cervical epidural venous engorgement.

We describe a case of 36-year-old man who presented with a subacute headache preceded by a 1-month history of posterior neck pain without trauma history. Head and neck magnetic resonance imaging (MRI) studies disclosed bilateral supratentorial subdural and retroclival extradural hematomas associated with marked cervical epidural venous engorgement. Cerebral and spinal angiography disclosed no abnormalities except dilated cervical epidural veins. We performed serial follow-up MRI studied to monitor his condition. Patient's symptoms improved gradually. Serial radiologic studies revealed gradual resolution of pathologic findings. A 3-month follow-up MRI study of the brain and cervical spine revealed complete resolution of the retroclival extradural hematoma, disappearance of the cervical epidural venous engorgement, and partial resolution of the bilateral supratentorial subdural hematoma. Complete resolution of the bilateral supratentorial subdural hematoma was confirmed on a 5-month follow-up brain MRI. The diagnosis and possible mechanisms of this rare association are discussed.

Stereotactic Radiosurgery with the CyberKnife for Pituitary Adenomas.

OBJECTIVE: In recent years, CyberKnife has emerged as an important treatment modality in the management of pituitary adenomas. Treatment results after performing CyberKnife and the complications of this procedure are reviewed. METHODS: Twenty-six patients with pituitary adenomas received stereotactic radiosurgery with the CyberKnife (CKRS). The follow-up periods ranged from 7 months to 47 months (mean+/-SD : 30+/-12.7 months). The patients consisted of 17 with non-functioning adenomas, 3 with prolactinomas and 6 with acromegaly. The change in the tumor volume, visual acuity, hormonal function, and complications by this therapy were analyzed in each case. RESULTS: The tumor control rate was 92.3%. Hormonal function was improved in all of the 9 (100%) functioning adenomas. Hormonal normalization was observed in 4 of the 9 (44%) patients with a mean duration of 16 months. In two patients (7.6%), visual acuity worsened due to cystic enlargement of the tumor after CKRS. No other complications were observed. CONCLUSION: CyberKnife is considered safe and effective in selected patients with pituitary adenomas. However, longer follow-up is required for a more complete assessment of late toxicity and treatment efficacy.