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1.  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
2.  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
3.  Unilateral Posterior Atlantoaxial Transarticular Screw Fixation in Patients with Atlantoaxial Instability : Comparison with Bilateral Method 
Objective
Bilateral C1-2 transarticular screw fixation (TAF) with interspinous wiring has been the best treatment for atlantoaxial instability (AAI). However, several factors may disturb satisfactory placement of bilateral screws. This study evaluates the usefulness of unilateral TAF when bilateral TAF is not available.
Methods
Between January 2003 and December 2007, TAF was performed in 54 patients with AAI. Preoperative studies including cervical x-ray, three dimensional computed tomogram, CT angiogram, and magnetic resonance image were checked. The atlanto-dental interval (ADI) was measured in preoperative period, immediate postoperatively, and postoperative 1, 3 and 6 months.
Results
Unilateral TAF was performed in 27 patients (50%). The causes of unilateral TAF were anomalous course of vertebral artery in 20 patients (74%), severe degenerative arthritis in 3 (11%), fracture of C1 in 2, hemangioblastoma in one, and screw malposition in one. The mean ADI in unilateral group was measured as 2.63 mm in immediate postoperatively, 2.61 mm in 1 month, 2.64 mm in 3 months and 2.61 mm in 6 months postoperatively. The mean ADI of bilateral group was also measured as following; 2.76 mm in immediate postoperative, 2.71 mm in 1 month, 2.73 mm in 3 months, 2.73 mm in 6 months postoperatively. Comparison of ADI measurement showed no significant difference in both groups, and moreover fusion rate was 100% in bilateral and 96.3% in unilateral group (p=0.317).
Conclusion
Even though bilateral TAF is best option for AAI in biomechanical perspectives, unilateral screw fixation also can be a useful alternative in otherwise dangerous or infeasible cases through bilateral screw placement.
doi:10.3340/jkns.2009.45.3.164
PMCID: PMC2666118  PMID: 19352478
Atlatoaxial instability (AAI); Atlantodental interval (ADI); Transarticular screw fixation (TAF); Unilateral; Vertebral artery
4.  Comparison of Incidence and Risk Factors for Shunt-dependent Hydrocephalus in Aneurysmal Subarachnoid Hemorrhage Patients 
Objective
The objective of this study was to compare the incidence of ventricular shunt placement for shunt-dependent hydrocephalus (SDHC) after clipping versus coiling of ruptured aneurysms.
Materials and Methods
A retrospective review was conducted in 215 patients with aneurysmal subarachnoid hemorrhage (SAH) who underwent surgical clipping or endovascular coiling during the period from May 2008 to December 2011. Relevant clinical and radiographic data were analyzed with regard to the incidence of hydrocephalus and ventriculo-peritoneal shunt (VPS). Patients treated with clipping were assigned to Group A, while those treated with coiling were assigned to Group B.
Results
Of 215 patients (157 clipping, 58 coiling), no significant difference in the incidence of final VPS was observed between treatment modalities (15.3% vs. 10.3%) (p = 0.35). Independent risk factors for VPS for treatment of chronic hydrocephalus were as follows: (1) older than 65 years, (2) poorer Hunt-Hess grade IV and V, (3) Fisher grade III and IV, and (4) particularly initial presence of an intraventricular hemorrhage.
Conclusion
In this study comparing two modalities for treatment of aneurysm, there was no difference in the incidence of chronic hydrocephalus requiring VPS. A significantly higher rate of shunt dependency was observed for age older than 65 years, poor initial neurological status, and thick SAH with presence of initial intraventricular hemorrhage. By understanding these factors related to development of SDHC and results, it is expected that management of aneurysmal SAH will result in a better prognosis.
doi:10.7461/jcen.2014.16.2.78
PMCID: PMC4102754  PMID: 25045646
Acute hydrocephalus; Chronic hydrocephalus; Subarachnoid hemorrhage; Lumbar drain
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.  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
7.  Impact of Early Enteral Nutrition on In-Hospital Mortality in Patients with Hypertensive Intracerebral Hemorrhage 
Objective
We conducted this study to evaluate the clinical impact of early enteral nutrition (EN) on in-hospital mortality and outcome in patients with critical hypertensive intracerebral hemorrhage (ICH).
Methods
We retrospectively analyzed 123 ICH patients with Glasgow Coma Scale (GCS) score of 3-12. We divided the subjects into two groups : early EN group (< 48 hours, n = 89) and delayed EN group (≥ 48 hours, n = 34). Body weight, total intake and output, serum albumin, C-reactive protein, infectious complications, morbidity at discharge and in-hospital mortality were compared with statistical analysis.
Results
The incidence of nosocomial pneumonia and length of intensive care unit stay were significantly lower in the early EN group than in the delayed EN group (p < 0.05). In-hospital mortality was less in the early EN group than in the delayed EN group (10.1% vs. 35.3%, respectively; p = 0.001). By multivariate analysis, early EN [odds ratio (OR) 0.229, 95% CI : 0.066-0.793], nosocomial pneumonia (OR = 5.381, 95% CI : 1.621-17.865) and initial GCS score (OR = 1.482 95% CI : 1.160-1.893) were independent predictors of in-hospital mortality in patients with critical hypertensive ICH.
Conclusion
These findings indicate that early EN is an important predictor of outcome in patients with critical hypertensive ICH.
doi:10.3340/jkns.2010.48.2.99
PMCID: PMC2941869  PMID: 20856655
Enteral nutrition; Intracerebral hemorrhage; Mortality
8.  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
9.  Incidence and Risk Factors of Infection Caused by Vancomycin-Resistant Enterococcus Colonization in Neurosurgical Intensive Care Unit Patients 
Objective
This study was aimed to identify the incidence and risk factors of vancomycin-resistant enterococcus (VRE) colonization in neurosurgical practice of field, with particular attention to intensive care unit (ICU).
Methods
This retrospective study was carried out on the Neurosurgical ICU (NICU), during the period from January. 2005 to December. 2007, in 414 consecutive patients who had been admitted to the NICU. Demographics and known risk factors were retrieved and assessed by statistical methods.
Results
A total of 52 patients had VRE colonization among 414 patients enrolled, with an overall prevalence rate of 6.1%. E. faecium was the most frequently isolated pathogen, and 92.3% of all VRE were isolated from urine specimen. Active infection was noticed only in 2 patients with bacteremia and meningitis. Relative antibiotic agents were third-generation cephalosporin in 40%, and vancomycin in 23%, and multiple antibiotic usages were also identified in 13% of all cases. Multivariate analyses showed Glasgow coma scale (GCS) score less than 8, placement of Foley catheter longer than 2 weeks, ICU stay over 2 weeks and presence of nearby VRE-positive patients had a significantly independent association with VRE infection.
Conclusion
When managing the high-risk patients being prone to be infected VRE in the NICU, extreme caution should be paid upon. Because prevention and outbreak control is of ultimate importance, clinicians should be alert the possibility of impending colonization and infection by all means available. The most crucial interventions are careful hand washing, strict glove handling, meticulous and active screening, and complete segregation.
doi:10.3340/jkns.2009.46.2.123
PMCID: PMC2744021  PMID: 19763214
Glasgow coma scale score; Intensive care unit; Neurosurgery; Segregation; Vancomycin-resistant enterococcus
10.  Seizures and Epilepsy following Aneurysmal Subarachnoid Hemorrhage : Incidence and Risk Factors 
Objective
Although prophylactic antiepileptic drug (AED) use in patients with aneurysmal subarachnoid hemorrhage (SAH) is a common practice, lack of uniform definitions and guidelines for seizures and AEDs rendered this prescription more habitual instead of evidence-based manner. We herein evaluated the incidence and predictive factors of seizure and complications about AED use.
Methods
From July 1999 to June 2007, data of a total of 547 patients with aneurysmal SAH who underwent operative treatments were reviewed. For these, the incidence and risk factors of seizures and epilepsy were assessed, in addition to complications of AEDs.
Results
Eighty-three patients (15.2%) had at least one seizure following SAH. Forty-three patients (7.9%) had onset seizures, 34 (6.2%) had perioperative seizures, and 17 (3.1%) had late epilepsy. Younger age (< 40 years), poor clinical grade, thick hemorrhage, acute hydrocephalus, and rebleeding were related to the occurrence of onset seizures. Cortical infarction and thick hemorrhage were independent risk factors for the occurrence of late epilepsy. Onset seizures were not predictive of late epilepsy. Moreover, adverse drug effects were identified in 128 patients (23.4%) with AEDs.
Conclusion
Perioperative seizures are not significant predictors for late epilepsy. Instead, initial amount of SAH and surgery-induced cortical damage should be seriously considered as risk factors for late epilepsy. Because AEDs can not prevent early postoperative seizures (< 1 week) and potentially cause unexpected side effects, long-term use should be readjusted in high-risk patients.
doi:10.3340/jkns.2009.46.2.93
PMCID: PMC2744032  PMID: 19763209
Aneurysm; Antiepileptic drug; Complication; Epilepsy; Risk factors; Seizure
11.  Acute Physiology and Chronic Health Evaluation II and Simplified Acute Physiology Score II in Predicting Hospital Mortality of Neurosurgical Intensive Care Unit Patients 
Journal of Korean Medical Science  2009;24(3):420-426.
We study the predictive power of Acute Physiology and Chronic Health Evaluation II (APACHE II) and Simplified Acute Physiology Score II (SAPS II) in neurosurgical intensive care unit (ICU) patients. Retrospective investigation was conducted on 672 consecutive ICU patients during the last 2 yr. Data were collected during the first 24 hours of admission and analyzed to calculate predicted mortality. Mortality predicted by two systems was compared and, multivariate analyses were then performed for subarachnoid hemorrhage (SAH) and traumatic brain injury (TBI) patients. Observed mortality was 24.8% whereas predicted mortalities were 37.7% and 38.4%, according to APACHE II and SAPS II. Calibration curve was close to the line of perfect prediction. SAPS II was not statistically significant according to a Lemeshow-Hosmer test, but slightly favored by area under the curve (AUC). In SAH patients, SAPS II was an independent predictor for mortality. In TBI patients, both systems had independent prognostic implications. Scoring systems are useful in predicting mortality and measuring performance in neurosurgical ICU setting. TBI patients are more affected by systemic insults than SAH patients, and this discrepancy of predicting mortality in each neurosurgical disease prompts us to develop a more specific scoring system targeted to cerebral dysfunction.
doi:10.3346/jkms.2009.24.3.420
PMCID: PMC2698186  PMID: 19543503
APACHE; Intensive Care Units; Mortality; Simplified Acute Physiologic Score; Subarachnoid Hemorrhage; Brain Injuries
12.  Spinal Subdural Hemorrhage as a Cause of Post-Traumatic Delirium 
A 64-year-old man with TBI was admitted to our institute. In following days, he showed unusual behavior of agitation, restlessness, emotional instability and inattention. Post-traumatic delirium was tentatively diagnosed, and donepezil was given for his cognitive dysfunction. Although there was partial relief of agitation, he sustained back pain despite medication. Lumbar magnetic resonance image revealed SDH along the whole lumbar spine, and surgical drainage was followed. Postoperatively, his agitation disappeared and further medication was discontinued. We report a unique case of post-traumatic delirium in a patient with concomitant TBI and spinal subdural hemorrhage (SDH) that resolved with operative drainage of spinal hemorrhage.
doi:10.3340/jkns.2008.43.5.242
PMCID: PMC2588221  PMID: 19096605
Back pain; Delirium; Subdural hematoma; Traumatic brain injury
13.  Incidence and Risk Factors of Acute Postoperative Delirium in Geriatric Neurosurgical Patients 
Objective
Postoperative delirium (POD) is characterized by an acute change in cognitive function and can result in longer hospital stays, higher morbidity rates, and more frequent discharges to long-term care facilities. In this study, we investigated the incidence and risk factors of POD in 224 patients older than 70 years of age, who had undergone a neurosurgical operation in the last two years.
Methods
Data related to preoperative factors (male gender, >70 years, previous dementia or delirium, alcohol abuse, serum levels of sodium, potassium and glucose, and co morbidities), perioperative factors (type of surgery and anesthesia, and duration of surgery) and postoperative data (length of stay in recovery room, severity of pain and use of opioid analgesics) were retrospectively collected and statistically analyzed.
Results
POD appeared in 48 patients (21.4%) by postoperative day 3. When we excluded 26 patients with previous dementia or delirium, 17 spontaneously recovered by postoperative day 14, while 5 patients recovered by postoperative 2 months with medication, among 22 patients with newly developed POD. The univariate risk factors for POD included previously dementic or delirious patients, abnormal preoperative serum glucose level, pre-existent diabetes, the use of local anesthesia for the operation, longer operation time (>3.2 hr) or recovery room stay (>90 min), and severe pain (VAS>6.8) requiring opioid treatment (p<0.05). Backward regression analysis revealed that previously dementic patients with diabetes, the operation being performed under local anesthesia, and severe postoperative pain treated with opioids were independent risk factors for POD.
Conclusion
Our study shows that control of blood glucose levels and management of pain during local anesthesia and in the immediate postoperative period can reduce unexpected POD and help preventing unexpected medicolegal problems and economic burdens.
doi:10.3340/jkns.2008.43.3.143
PMCID: PMC2588241  PMID: 19096622
Anesthesia; Diabetes; Geriatric; Pain; Postoperative delirium (POD)

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