Quantitative Pfirrmann Disc Degeneration Grading System to Overcome the Limitation of Pfirrmann Disc Degeneration Grade

OBJECTIVE: Pfirrmann disc degeneration grade is one of morphologic disc degeneration grading system and it was reliable on routine T2-weighted magnetic resonance (MR) images. The purpose of this study was to evaluate the agreement of Pfirrmann disc degeneration grade, and check the alternative technique of disc degeneration grading system. METHODS: Fifteen volunteers (4 medical doctors related to spinal disease, 2 medical doctors not related to spinal disease, 6 nurses in spinal hospital, and 3 para-medicines) were included in this study. Three different digitalized MR images were provided all volunteers, and they checked Pfirrmann disc degeneration grade of each disc levels after careful listening to explanation. Indeed, all volunteers checked the signal intensity of disc degeneration at the points of nucleus pulposus (NP), disc membrane, ligaments, fat, and air to modify the quantitative Pfirrmann disc degeneration grade. RESULTS: Total 225 grade results of Pfirrmann disc degeneration grade and 405 signal intensity results of quantitative Pfirrmann disc degeneration grade were analyzed. Average interobserver agreement was "moderate (mean±standard deviation, 0.575±0.251)" from poor to excellent. Completely agreed levels of Pfirrmann disc degeneration grade were only 4 levels (26.67%), and the disagreement levels were observed in 11 levels; two different grades in 8 levels (53.33%) and three different grades in 3 levels (20%). Quantitative Pfirrmann disc degeneration showed relatively cluster distribution with the interobserver deviations of 0.41-1.56 at the ratio of NP and disc membrane, and it showed relatively good cluster and distribution indicating that the proposed grading system has good discrimination ability. CONCLUSION: Pfirrmann disc degeneration grade showed the limitation of different interobserver results, but this limitation could be overcome by using quantitative techniques of MR signal intensity. Further evaluation is needed to access its advantage and reliabilities.

Clinical and Radiological Comparison of Semirigid (WavefleX) and Rigid System for the Lumbar Spine

OBJECTIVE: Spinal fusion operation is an effective treatment in the spinal pathology, but it could change the physiological distribution of load at the instrumented and adjacent segments. This retrospective study compared the radiological and clinical outcomes of patients undergoing lumbar fusion with semirigid rods versus rigid rods system. METHODS: Using transpedicular fixation and posterior lumbar interbody fusion at the level of L4/L5, 20 patients were treated with semirigid rods (WavefleX, SR group), and 20 patients with rigid rods (titanium, RR group). Clinical and radiological outcomes were evaluated, including visual analog score for lower back pain and leg pain, Prolo functional and economic scores, statues of implanted instruments, fusion rate, and complications during 24-month follow-up. RESULTS: Clinical scores were significantly improved until postoperative 24-month follow-up as compared with preoperative scores in both groups (p<0.05), with similar levels of improvement observed at the same time points postoperatively between the 2 groups. Prolo economic scores were significantly improved in SR group compared to RR until 12 months, but this improvement became similar after 18 months. The overall fusion rate was 94.1% until the 24-month follow-up for both groups. No significant complication was observed in both groups. CONCLUSION: The results of the present study indicate that semirigid rods system with posterior lumbar interbody fusion showed similar clinical and radiological result with rigid rods system until 2 years after instrumentation. The WavefleX rods system, as a semirigid rods with unique characteristics, may be an effective alternative treatment for patients in lumbar fusion.

Usefulness of Simple Rod Rotation to Correct Curve of Adolescent Idiopathic Scoliosis

OBJECTIVE: To correct apical vertebral rotation for adolescent idiopathic scoliosis (AIS), direct vertebral derotation (DVD) or simple rod rotation (SRR) might be considered. The aim of the present study is to introduce the surgical experiences of AIS by a Korean neurosurgeon and to evaluate the effectiveness of SRR for apical vertebral rotation. METHODS: A total of 9 patients (1 male and 8 females) underwent scoliosis surgery by a neurosurgeon of our hospital. The Lenke classifications of the patients were 1 of 1B, 2 of 1C, 1 of 2A, 1 of 2C, 3 of 5C and 1 of 6C. Surgery was done by manner of simple rod rotation on the concave side and in situ coronal bending. Coronal Cobb's angles, vertebral rotation angles and SRS-22 were measured on a plain standing X-ray and CT before and after surgery. RESULTS: The mean follow up period was 25.7 months (range : 5-52). The mean number of screw positioning level was nine (6-12). The mean age was 16.4 years (range : 13-25) at surgery. The mean Risser grade was 3.7+/-0.9. The apical vertebral rotation measured from the CT scans was 25.8+/-8.5degrees vs. 9.3+/-6.7degrees (p<0.001) and the Coronal Cobb's angle was 53.7+/-10.4degrees vs. 15.4+/-6.5degrees (p<0.001) preoperatively and postoperative, respectively. The SRS-22 improved from 71.9 preoperatively to 90.3 postoperatively. There were no complications related with the operations. CONCLUSION: SRR with pedicle screw instrumentation could be corrected successfully by axial rotation without complications. SRR might serve as a good option to correct AIS deformed curves of AIS.

Thoracic Extrapedicular (Transverse Process) Screws Fixation : Technical Note

Authors performed extrapedicular screws fixation in thoracic spines. Because patient had very narrow thoracic pedicles, classical transpedicular screws fixation could not be accomplished. In case of narrow thoracic pedicles, extrapedicular screws fixation would be a good alternative technique. We describe here a method for thoracic extrapedicular screws fixation.

Clinical Analysis of Spontaneous Intracerebral Hemorrhage in Young People / 대한뇌혈관외과학회지

OBJECTIVE: Spontaneous intracerebral hemorrhage (sICH) is a leading cause of morbidity and mortality, especially in Asian countries. Nevertheless, few reports of sICH in young people have been published. This study investigates the clinical features of sICH in young people. METHODS: Between February 1999 and December 2007, we retrospectively reviewed the medical records of patients aged 45 years diagnosed with sICH at our institute. We analyzed the causes, locations, risk factors, and final outcomes of sICH in these patients. RESULTS: Twenty-one patients (14.5%) were younger than 25 years, while 27 patients (18.6%) were 25~34 years old. Ninety-seven patients (66.9%) were between the ages of 35~45. The most common cause of sICH was hypertension (57.9%). The most common location of sICH was in the lobar region (35.2%). Vascular anomaly was the main cause in both the <25 age group (76.2%) and the 25~34 age group (70.4%). The diagnostic rate of angiography was 75% for the under 25 age group and 80% in the 25~34 age group. CONCLUSIONS: Hypertension is the most common cause of sICH in people between 35 and 45, and vascular anomaly is the main cause in people under 35 years of age. Thus, angiography should be mandatory for people under 35 with sICH, and for people with lobar hemorrhage. For young people, early diagnosis of hypertension and strict blood pressure control is recommended.

(One Year Interval) Staged Surgery of Giant Lumbar Dumbbell Neurofibroma

Giant dumbbell neurofibroma is a rare tumor which belongs to large family that is the nerve sheath tumor composed of two main types of tumors that include neurofibroma and schwannoma. Neurofibroma arises from a mesenchymal origin closer to a fibroblast which differs from the schwannoma arising from the progenitor of the schwann cell. I report on one case of giant lumbar dumbbell neurofibroma that occured in the spinal and paraspinal retoperitoneal region which was removed by combined and one-year delayed surgery.

A Multi-center Clinical Study of Posterior Lumbar Interbody Fusion with the Expandable Stand-alone Cage (Tyche(R) Cage) for Degenerative Lumbar Spinal Disorders

OBJECTIVE: This multi-center clinical study was designed to determine the long-term results of patients who received a one-level posterior lumbar interbody fusion with expandable cage (Tyche(R) cage) for degenerative spinal diseases during the same period in each hospital. METHODS: Fifty-seven patients with low back pain who had a one-level posterior lumbar interbody fusion using a newly designed expandable cage were enrolled in this study at five centers from June 2003 to December 2004 and followed up for 24 months. Pain improvement was checked with a Visual Analogue Scale (VAS) and their disability was evaluated with the Oswestry Disability Index. Radiographs were obtained before and after surgery. At the final follow-up, dynamic stability, quality of bone fusion, interveretebral disc height, and lumbar lordosis were assessed. In some cases, a lumbar computed tomography scan was also obtained. RESULTS: The mean VAS score of back pain was improved from 6.44 points preoperatively to 0.44 at the final visit and the score of sciatica was reduced from 4.84 to 0.26. Also, the Oswestry Disability Index was improved from 32.62 points preoperatively to 18.25 at the final visit. The fusion rate was 92.5%. Intervertebral disc height, recorded as 9.94+/-2.69 mm before surgery was increased to 12.23+/-3.31 mm at postoperative 1 month and was stabilized at 11.43+/-2.23 mm on final visit. The segmental angle of lordosis was changed significantly from 3.54+/-3.70 degrees before surgery to 6.37+/-3.97 degrees by 24 months postoperative, and total lumbar lordosis was 20.37+/-11.30 degrees preoperatively and 24.71+/-11.70 degrees at 24 months postoperative. CONCLUSION: The re have been no special complications regarding the expandable cage during the follow-up period and the results of this study demonstrates a high fusion rate and clinical success.

Surgical Treatment of the Atlantoaxial Osteoarthritis

Atlantoaxial facet joint osteoarthritis is rare, often undiagnosed because it may be misdiagnosed as occipital neuralgia, or degenerative cervical spondylosis. Unilateral occipitocervical pain aggravated by head rotation is a specific symptom. Conservative treatment is usually effective. But when the patient complains of intractable neck pain localized to occipitocervical junction and unresponsive to medical therapy, surgical treatment should be considered. Though a few reports of surgically treated atlantoaxial osteoarthritis has been published, surgical outcome is favorable. A case of a surgically treated atlantoaxial osteoarthritis is presented with a review of the literatures.

Ruptured Intracranial Aneurysm in a 45-day-old Infant

The incidence of intracranial aneurysms in childhood is rare, especially in infancy. We report a case of a 45-day-old girl who presented with seizure due to a ruptured large saccular aneurysm of the middle cerebral artery(MCA) with subsequent subarachnoid, intracerebral and intraventricular hemorrhage. The baby has enjoyed an excellent clinical outcome after surgical management. The clinical features of the case and review of the literature are presented.

Radiological Considerations of Posterior Cervical Lateral Mass Fixation Using Plate and Screw

The aim of this study is to determine whether the posterior cervical fusion methods with the plate-screw system applied to the lateral mass of cervical spine are radiologically safe to patients. The lateral cervical X-rays and CT scans were done on 40 normal adults without cervical problem. Based on Roy-Camille and Magerl's method, the theological trajectory of screw was shown on films and the parameters were measured. The study based on Roy-Camille's method showed less than one percent chance of injury on the facet joint and the mean depth of the screw to be 10.5+/-1.4mm. On the other hand, Magerl's method showed the mean depth of screw to be 11.9+/-1.5mm which is slightly larger than that of Roy-Camille's method and no chance of facet injury occurred. A reduced lateral angle of screw (19.6+/-3.5 degrees) performed with the concept based on Magerl's method resulted a longer depth of screw (13.5+/-2.1mm). Both Roy-Camille and Magerl's methods seemed to be radiologically safe to normal persons. However, the authors recommend the reduced lateral angle (19.6+/-3.5 degrees) of screw based on the Magerl's method more than an original Magerl's methods.

Cervical Spinal Epidural Abscess due to Salmonella Group D

We report a case of cervical spinal epidural abcess due to Salmonella group D. A 58-year-old man complained of progressive neck pain and right arm weakness with fever. Clinical and radiographic findings including cervical magnetic resonance(MR) image showed paraspinal soft tissue inflammation of neck and abcesses in prevertebral and epidural space at C3-5 level. The patient underwent a C4 corpectomy and adjacent diskectomy and continous irrigation suction drainage. A MR image taken at second postoperative day revealed diffuse cord swelling from C2 to T1 suggesting edema and/or myelitis and then laminectomy from C3 to C6 was performed immediately to decompress the spinal cord. The patient recovered excellently and the abscess culture revealed Salmonella group D.

Vertebral Artery Obstruction due to Anterior and Vertical Subluxation of Atlanto-Axial and Atlanto-Occipital Joint in Ankylosing Spondylitis

OBJECTIVE: We report a case with a long-standing history of the ankylosing spondylitis(AS) who showed multiple cerebellar infarctions with bulbar symptom owing to vertebral artery obstruction, due to anterior and vertical subluxation of atlanto-axial and atlanto-occipital joint. CLINICAL PRESENTARION: An 51-year-old male patient with swallowing difficulty, tongue deviation to the left side and severe nuchal pain and rigidity is presented. INTERVENTION: After removal of posterior portion of foramen magnum, posterior portion of left transverse foramen of axis was decompressed. CONCLUSIONS: Spontaneous anterior atlanto-axial subluxation occurs in patients with AS about 2% of presents with or without signs of spinal cord compression. Vertical subluxation occurs in 3-8% of patient with rheumatoid arthritis but it is an exceedingly rare complication of AS. Close observation and follow-up are needed in patients with AS and if subluxation occurs, good prognosis is anticipated using an early operative treatment.

Concurrence of Traumatic Spinal Epidural and Subdural Hematoma without Spine Injury at Occipitocervical Junction: A Cases Report

Spinal epidural and subdural hematomas are uncommonly recognized conditions. These conditions can result in severe irreversible neurologic deficits, if left untreated. Like intracranial lesions, these hematomas can expand rapidly and cause sudden spinal cord and/or cauda equina compression. This case is very rare in which is a concurrence of cervical spinal epidural and subdural hematoma after motor vehicle accident without spine fracture. The pathophysiology of these entities are discussed and the radiologic diagnosis focused on MR findings are reviewed. The importance of prompt surgical treatment is emphasized to facilitate good postoperative outcome.

Surgical Experience of Basilar Invagination by Transoral Transpharyngeal Approach

Basilar invagination or basilar impression involves the upward displacement of the margins of the foramen magnum into the base of the skull. That this entity may be asymptomatic or associated with symptoms referable to encroachment into the posterior fossa or embarrassment of the posterior circulation is well known. Currently the authors have experienced a young male patient with basilar invagination presented with progressive myelopathy and lower cranial neuropathies due to odontoid invagination. It was thought that a posterior decompression would be hazardous;therefore, the inferior clivus, odontoid process, and anterior arch of the atlas were removed transoral-transpharyngeally and bone fusion was performed with iliac bone. Furthermore the operative result was good without any serious complication. The operation technique is detailed.

An Extended Frontal Approach to Midline Lesions of the Anterior Skull Base

Relatively huge lesions in the parasellar and midline anterior skull base region are difficult to approach for radical procedures. To minimize brain retraction and achieve excellent exposure for safe manipulation within these regions, the authors have performed an extended frontal approach, a fibrontal craniotomy and a bilateral orbitofrontal osteotomy in 11 patients, and an additional transfacial maxillotomy in 1 patient. An additional removal of the orbital rim offers excellent visualization and permits unhindered surgical manipulation including postoperative reconstruction at the anterior skull base. But disadvantages include prolonged operative time and frequent ilateral olfactory denervation. Six patients with benign tumors, two patients with malignant tumors, one patient with hematoma in the ehtmoid and sphenoid sinuses, and three patients with delayed traumatic CSF rhinorheas were operated on using this approaches, with good results. The operative technique and its results are detailed.