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author:("Bak, kong Hum")
1.  The Safety and Efficacy of Cadaveric Allografts and Titanium Cage as a Fusion Substitutes in Pyogenic Osteomyelitis 
Objective
The safety and efficacy of various fusion substitutes in pyogenic osteomyelitis has not been investigated. We evaluated and compared the cadaveric allograft and titanium cages used to reconstruct, maintain alignment and achieve fusion in the management of pyogenic spinal infection.
Methods
There were 33 patients with pyogenic osteomyelitis underwent fusion in this study. Fifteen of the 33 patients were operated on by fusion with allografts (cadaveric patella bones) and 18 of those were operated with titanium mesh cages filled with autologous cancellous iliac bone. After the affected disc and vertebral body resection with pus drainage, cadaveric allograft or titanium cages were inserted into the resected space. Posterior transpedicular screw fixation and rod compression in resected space, where cadaveric allograft or titanium cages were inserted, was performed to prevent the malposition in all patients except in 1 case. Recurrent infection was identified by serial erythrocyte sedimentation rate and cross reactive protein follow-up. Osseous union and recurred infection available at a minimum of 2 years following operation was identified. The amount of kyphosis correction and the subsidence were measured radiographically.
Results
Spinal fusion was achieved in 29 of 33 patients. In the cadaveric allograft group, 93.3% of patient (14 of 15) showed the osseous union while 83.3% of patient (15 of 18) in the titanium cage group showed union. Subsidence was noted in 12 of the patients. Twelve patients (36.3%) showed unsettling amounts of subsidence postoperatively whereas 46.6% of patients in the cadaveric allograft group and 37.7% of patients in the titanium cage group showed similar subsidence, respectively. There were statistical difference in the fusion rate (p=0.397) and subsidence rate (p=0.276) between the two groups. There was significant statistical difference in the postoperative improvement of segmental kyphosis between the two groups (p=0.022), that is the improvement in sagittal alignment was greater in the titanium cage group than in the cadaveric allograft group. There was no case of recurred infection.
Conclusion
The cadaveric allograft and titanium cages are effective and safe in restoring and maintaining sagittal plane alignment without increased incidence in infection recurrence in pyogenic osteomyelitis. The postoperative improvement of segmental kyphosis was better in the cage group.
doi:10.3340/jkns.2011.50.4.348
PMCID: PMC3243839  PMID: 22200018
Allograft; Fusion; Spinal infection; Titanium cage
2.  Targeting a Safe Entry Point for C2 Pedicle Screw Fixation in Patients with Atlantoaxial Instability 
Objective
This investigation was conducted to evaluate a new, safe entry point for the C2 pedicle screw, determined using the anatomical landmarks of the C2 lateral mass, the lamina, and the isthmus of the pars interarticularis.
Methods
Fifteen patients underwent bilateral C1 lateral mass-C2 pedicle screw fixation, combined with posterior wiring. The C2 pedicle screw was inserted at the entry point determined using the following method : 4 mm lateral to and 4 mm inferior to the transitional point (from the superior end line of the lamina to the isthmus of the pars interarticularis). After a small hole was made with a high-speed drill, the taper was inserted with a 30 degree convergence in the cephalad direction. Other surgical procedures were performed according to Harm's description. Preoperatively, careful evaluation was performed with a cervical X-ray for C1-C2 alignment, magnetic resonance imaging for spinal cord and ligamentous structures, and a contrast-enhanced 3-dimensional computed tomogram (3-D CT) for bony anatomy and the course of the vertebral artery. A 3-D CT was checked postoperatively to evaluate screw placement.
Results
Bone fusion was achieved in all 15 patients (100%) without screw violation into the spinal canal, vertebral artery injury, or hardware failure. Occipital neuralgia developed in one patient, but this subsided after a C2 ganglion block.
Conclusion
C2 transpedicular screw fixation can be easily and safely performed using the entry point of the present study. However, careful preoperative radiographic evaluation, regardless of methods, is mandatory.
doi:10.3340/jkns.2011.49.6.351
PMCID: PMC3158478  PMID: 21887393
Atlantoaxial instability; C2 pedicle screw; Entry point; Technique
3.  Primary Intramedullary Spinal Sarcoma : A Case Report and Review of the Current Literatures 
Primary central nervous system (CNS) sarcomas are exceedingly rare, and, to the best of our knowledge, there has not yet been a report of intramedullary sarcoma. Here, we report a primary intradural intramedullary sarcoma of the spinal cord in a four-year-old boy who presented with low back pain and a radiculopathy involving both lower extremities. The tumor showed significant enhancement on magnetic resonance (MR) images due to its extreme vascularity. Gross total tumor removal was performed with microelectrical pulse recording, and the patient also received adjuvant radiotherapy and chemotherapy. After the operation, the patient's sensory deficits were improved. Because CNS dissemination is common, entire neuraxis evaluation is essential, although there was no evidence of dissemination in this case. The prognosis of primary CNS sarcoma is poor due to infiltrative nature and early CNS dissemination is common, and the treatment of choice is radical surgical resection. Adjuvant therapy is also beneficial with radiotherapy and chemotherapy.
doi:10.3340/jkns.2010.48.5.448
PMCID: PMC3030088  PMID: 21286485
Central nervous system; Intramedullary; Primary; Sarcoma
4.  Rod Migration into the Posterior Fossa after Harms Operation : Case Report and Review of Literatures 
C1 lateral mass and C2 pedicle (C1LM-C2P) fixation is a relatively new technique for atlantoaxial stabilization. Complications from C1LM-C2P fixation have been rarely reported. The authors report unilateral rod migration into the posterior fossa as a rare complication after this posterior C1-C2 stabilization technique. A 23-year-old man suffered severe head trauma and cervical spine injury after vehicle accident. He was unconscious for 2 months and regained consciousness. He underwent C1LM-C2P fixation for stabilization of type II odontoid process fracture described by Harms. The patient recovered without a major complication. Twenty months after operation, brain computed tomogram performed at psychology department for disability evaluation showed rod migration into the right cerebellar hemisphere. The patient had mild occipital headache and dizziness only regarding the misplaced rod. He refused further operation for rod removal. To our knowledge, this complication is the first report regarding rod migration after Harms method. We should be kept in mind the possibility of rod migration, and C1LM-C2P fixation should be performed with meticulous technique and long-term follow-up.
doi:10.3340/jkns.2010.47.3.221
PMCID: PMC2851083  PMID: 20379477
Atlantoaxial fixation; Harms technique; Migration; Odontoid process fracture; Rod
5.  Posterior Interspinous Fusion Device for One-Level Fusion in Degenerative Lumbar Spine Disease : Comparison with Pedicle Screw Fixation - Preliminary Report of at Least One Year Follow Up 
Objective
Transpedicular screw fixation has some disadvantages such as postoperative back pain through wide muscle dissection, long operative time, and cephalad adjacent segmental degeneration (ASD). The purposes of this study are investigation and comparison of radiological and clinical results between interspinous fusion device (IFD) and pedicle screw.
Methods
From Jan. 2008 to Aug. 2009, 40 patients underwent spinal fusion with IFD combined with posterior lumbar interbody fusion (PLIF). In same study period, 36 patients underwent spinal fusion with pedicle screw fixation as control group. Dynamic lateral radiographs, visual analogue scale (VAS), and Korean version of the Oswestry disability index (K-ODI) scores were evaluated in both groups.
Results
The lumbar spine diseases in the IFD group were as followings; spinal stenosis in 26, degenerative spondylolisthesis in 12, and intervertebral disc herniation in 2. The mean follow up period was 14.24 months (range; 12 to 22 months) in the IFD group and 18.3 months (range; 12 to 28 months) in pedicle screw group. The mean VAS scores was preoperatively 7.16±2.1 and 8.03±2.3 in the IFD and pedicle screw groups, respectively, and improved postoperatively to 1.3±2.9 and 1.2±3.2 in 1-year follow ups (p<0.05). The K-ODI was decreased significantly in an equal amount in both groups one year postoperatively (p<0.05). The statistics revealed a higher incidence of ASD in pedicle screw group than the IFD group (p=0.029).
Conclusion
Posterior IFD has several advantages over the pedicle screw fixation in terms of skin incision, muscle dissection and short operative time and less intraoperative estimated blood loss. The IFD with PLIF may be a favorable technique to replace the pedicle screw fixation in selective case.
doi:10.3340/jkns.2012.52.4.359
PMCID: PMC3488645  PMID: 23133725
Degenerative; Fusion device; Interspinous; Lumbar disease; Posterior; Adjacent segmental degeneration
6.  Long-Term Follow-Up Radiologic and Clinical Evaluation of Cylindrical Cage for Anterior Interbody Fusion in Degenerative Cervical Disc Disease 
Objective
Various procedures have been introduced for anterior interbody fusion in degenerative cervical disc disease including plate systems with autologous iliac bone, carbon cages, and cylindrical cages. However, except for plate systems, the long-term results of other methods have not been established. In the present study, we evaluated radiologic findings for cylindrical cervical cages over long-term follow up periods.
Methods
During 4 year period, radiologic findings of 138 patients who underwent anterior cervical fusion with cylindrical cage were evaluated at 6, 12, 24, and 36 postoperative months using plain radiographs. We investigated subsidence, osteophyte formation (anterior and posterior margin), cage direction change, kyphotic angle, and bone fusion on each radiograph.
Results
Among the 138 patients, a minimum of 36 month follow-up was achieved in 99 patients (mean follow-up : 38.61 months) with 115 levels. Mean disc height was 7.32 mm for preoperative evaluations, 9.00 for immediate postoperative evaluations, and 4.87 more than 36 months after surgery. Osteophytes were observed in 107 levels (93%) of the anterior portion and 48 levels (41%) of the posterior margin. The mean kyphotic angle was 9.87° in 35 levels showing cage directional change. There were several significant findings : 1) related subsidence [T-score (p=0.039) and anterior osteophyte (p=0.009)], 2) accompanying posterior osteophyte and outcome (p=0.05).
Conclusion
Cage subsidence and osteophyte formation were radiologically observed in most cases. Low T-scores may have led to subsidence and kyphosis during bone fusion although severe neurologic aggravation was not found, and therefore cylindrical cages should be used in selected cases.
doi:10.3340/jkns.2012.52.2.107
PMCID: PMC3467367  PMID: 23091668
Cylindrical cage; Kyphosis; Osteophyte; Radiologic; Subsidence
7.  Perioperative Risk Factors Related to Lumbar Spine Fusion Surgery in Korean Geriatric Patients 
Objective
Life expectancy for humans has increased dramatically and with this there has been a considerable increase in the number of patients suffering from lumbar spine disease. Symptomatic lumbar spinal disease should be treated, even in the elderly, and surgical procedures such as fusion surgery are needed for moderate to severe lumbar spinal disease. However, various perioperative complications are associated with fusion surgery. The aim of this study was to examine perioperative complications and assess risk factors associated with lumbar spinal fusion, focusing on geriatric patients at least 70 years of age in the Republic of Korea.
Methods
We retrospectively investigated 489 patients with various lumbar spinal diseases who underwent lumbar spinal fusion surgery between 2003 and 2007 at our institution. Three fusion procedures and the number of fused segments were analyzed in this study. Chronic diseases were also evaluated. Risk factors for complications and their association with age were analyzed.
Results
In this study, 74 patients experienced complications (15%). The rate of perioperative complications was significantly higher in patients 70 years of age or older than in other age groups (univariate analysis, p=0.001; multivariate analysis, p=0.004). However, perioperative complications were not significantly associated with the other factors tested (sex, comorbidities, operation procedures, fusion segments involved).
Conclusion
Increasing age was an important risk factor for perioperative complications in patients undergoing lumbar spinal fusion surgery whereas other factors were not significant. We recommend good clinical judgment and careful selection of geriatric patients undergoing lumbar spinal fusion surgery.
doi:10.3340/jkns.2012.51.6.350
PMCID: PMC3424175  PMID: 22949964
Complication; Elderly patients; Lumbar spinal fusion
8.  Traumatic Brainstem Hemorrhage Presenting with Hemiparesis 
Traumatic brainstem hemorrhage after blunt head injury is an uncommon event. The most frequent site of hemorrhage is the midline rostral brainstem. The prognosis of these patients is poor because of its critical location. We experienced a case of traumatic brainstem hemorrhage. A 41-year-old male was presented with drowsy mentality and right hemiparesis after blunt head injury. Plain skull radiographs and brain computerized tomography scans revealed a depressed skull fracture, epidural hematoma, and hemorrhagic contusion in the right parieto-occipital region. But, these findings did not explain the right hemiparesis. T2-weighted magnetic resonance (MR) image of the cervical spine demonstrated a focal hyperintense lesion in the left pontomedullary junction. Brain diffusion-weighted and FLAIR MR images showed a focal hyperintensity in the ventral pontomedullary lesion and it was more prominent in the left side. His mentality and weakness were progressively improved with conservative treatment. We should keep in mind the possibility of brainstem hemorrhage if supratentorial lesions or spinal cord lesions that caused neurological deficits in the head injured patients are unexplainable.
doi:10.3340/jkns.2009.45.3.176
PMCID: PMC2666120  PMID: 19352480
Brain stem hemorrhage; Head trauma; Hemiparesis
9.  Occludin Expression in Brain Tumors and its Relevance to Peritumoral Edema and Survival 
Purpose
Peritumoral brain edema (PTBE) is a serious causative factor that contributes the morbidity or mortality of brain tumors. The development of PTBE is influenced by many factors, including such tight junction proteins as occludin. We evaluated the PTBE volume and survival time with respect to the occludin expression in various pathological types of brain tumors.
Materials and Methods
Fresh-frozen specimens from sixty patients who had brain tumors were obtained during surgery and the tumors were confirmed pathologically. The occludin expression was investigated by Western blot analysis. The PTBE volume was measured by using preoperative magnetic resonance (MR) imaging, and the survival time in each patient was estimated retrospectively.
Results
Occludin was detected in 41 (68.3%) of the cases with brain tumors and it was not expressed in the other 19 (31.7%) cases. Although the lowest expression was revealed in high-grade gliomas, its expression was variable according to the pathology of the brain tumors (p>0.05). The difference of PTBE volume between occludin-positive and negative brain tumors was statistically significant (2072.46±328.73 mm3 vs. 7452.42±1504.19 mm3, respectively, p=0.002). The mean survival time was longer in the occludin-positive tumor group than in the occludin-negative group (38.63±1.57 months vs. 26.16±3.83 months, respectively; p=0.016).
Conclusions
This study suggests that the occludin expression is highly correlated to the development of PTBE in brain tumors and it might be a prognostic indicator for patient survival.
doi:10.4143/crt.2006.38.3.139
PMCID: PMC2741679  PMID: 19771274
Occludin; Peritumoral brain edema; Brain neoplasms; Survival rate
10.  Prognostic Implication of Telomerase Activity in Patients with Brain Tumors 
Journal of Korean Medical Science  2006;21(1):126-130.
Telomerase adds telomeric repeats to the ends of telomeres to compensate for their progressive loss. A favorable prognosis is associated with low or no telomerase in some tumors. The authors investigated whether telomerase activity is associated with survival of patients with brain tumors. Sixty-two consecutive patients with brain tumors underwent surgery, and their surgical specimens were investigated. The patients were pathologically categorized as group I (aggressive group) and group II (non-aggressive group). Telomerase activity was examined by the telomeric repeat amplification protocol (TRAP) assay. The median time was calculated in association with overall survival and progression-free survival in each group. The significant difference was noted in telomerase activity between high-grade gliomas and low-grade gliomas (p=0.022). Telomerase activity was significantly associated with the median overall survival and progression-free survival in all tumors of the aggressive group. On the other hand, the median overall survival in the non-aggressive group was not dependent on telomerase activity, while the median progression-free survival was. Our data suggests that telomerase is an important prognostic indicator of survival in patients with brain tumors.
doi:10.3346/jkms.2006.21.1.126
PMCID: PMC2733960  PMID: 16479078
Brain Neoplasms; Glioma; Survival; Telomerase
11.  Influence of Lamina Terminalis Fenestration on the Occurrence of the Shunt-Dependent Hydrocephalus in Anterior Communicating Artery Aneurysmal Subarachnoid Hemorrhage 
Journal of Korean Medical Science  2006;21(1):113-118.
Recently, it was reported that fenestration of the lamina terminalis (LT) may reduce the incidence of shunt-dependent hydrocephalus in aneurysmal subarachnoid hemorrhage (SAH). The authors investigated the efficacy of the LT opening on the incidence of shunt-dependent hydrocephalus in the ruptured anterior communicating artery (ACoA) aneurysms. The data of 71-ruptured ACoA aneurysm patients who underwent aneurysmal clipping in acute stage were reviewed retrospectively. Group I (n=36) included the patients with microsurgical fenestration of LT during surgery, Group II (n=35) consisted of patients in whom fenestration of LT was not feasible. The rate of shunt-dependent hydrocephalus was compared between two groups by logistic regression to control for confounding factors. Ventriculo-peritoneal shunts were performed after aneurysmal obliteration in 18 patients (25.4%). The conversion rates from acute hydrocephalus on admission to chronic hydrocephalus in each group were 29.6% (Group I) and 58.8% (Group II), respectively. However, there was no significant correlation between the microsurgical fenestration and the rate of occurrence of shunt-dependent hydrocephalus (p>0.05). Surgeons should carefully decide the concomitant use of LT fenestration during surgery for the ruptured ACoA aneurysms because of the microsurgical fenestration of LT can play a negative role in reducing the incidence of chronic hydrocephalus.
doi:10.3346/jkms.2006.21.1.113
PMCID: PMC2733958  PMID: 16479076
Hydrocephalus; Chronic; Ventriculostomy; Hypothalamus; Lamina Terminalis; Intracranial Aneurysm; Anterior Communicating Artery; Circle of Willis; Subarachnoid Hemorrhage
12.  Metachronous germinoma after total removal of mature teratoma in the third ventricle: a case report. 
Journal of Korean Medical Science  2002;17(2):287-291.
A rare case of intraventricular germinoma in the third ventricle, which occurred 30 months after total removal of mature teratoma on the same location in a 29- yr-old man is presented. Recurrence is supposed to represent an acceleration of localized dysplastic processes of totipotent germ cells present in the midline neuraxis or a growth of unidentified microscopic residue of germinoma component in mature teratoma. Although the radiation therapy after total removal of mature teratoma is still controversial, careful follow-up is warranted for evaluating a possible recurrence of other germ cell tumors.
PMCID: PMC3054861  PMID: 11961322

Results 1-12 (12)