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1.  The Efficacy and Perioperative Complications Associated with Lumbar Spinal Fusion Surgery, Focusing on Geriatric Patients in the Republic of Korea 
Objective
The purpose of this study was to examine the efficacy and perioperative complications associated with lumbar spinal fusion surgery, focusing on geriatric patients in the Republic of Korea.
Methods
We retrospectively investigated 485 patients with degenerative spinal diseases who had lumbar spinal fusion surgeries between March 2006 and December 2010 at our institution. Age, sex, comorbidity, American Society of Anesthesiologists (ASA) class, fusion segments, perioperative complications, and outcomes were analyzed in this study. Risk factors for complications and their association with age were analyzed.
Results
In this study, 81 patients presented complications (16.7%). The rate of perioperative complications was significantly higher in patients 70 years or older than in other age groups (univariate analysis, p=0.015; multivariate analysis, p=0.024). The perioperative complications were not significantly associated with the other factors tested (sex, comorbidity, ASA class, and fusion segments). Post-operative outcomes of lumbar spinal fusion surgeries for the patients were determined on the basis of MacNab's criteria (average follow up period : 19.7 months), and 412 patients (85.0%) were classified as having "excellent" or "good" results.
Conclusion
Increasing age was an important risk factor for perioperative complications in patients undergoing lumbar spinal fusion surgery, whereas other factors were not significant. However, patients' satisfaction or return to daily activities when compared with younger patients did not show much difference. We recommend good clinical judgment as well as careful selection of geriatric patients for lumbar spinal fusion surgery.
doi:10.3340/jkns.2013.54.4.323
PMCID: PMC3841275  PMID: 24294456
Complications; Elderly patients; Lumbar spinal fusion surgery
2.  Giant Cystic Cerebral Cavernous Malformation with Multiple Calcification - Case Report 
Cerebral cavernous malformation with giant cysts is rare and literature descriptions of its clinical features are few. In this case study, the authors describe the clinical symptoms, radiological findings, and pathological diagnosis of cerebral cavernous malformations with giant cysts, reviewing the relevant literature to clearly differentiate this from other disease entities. The authors present a case of a 19-year-old male with a giant cystic cavernous malformation, who was referred to the division of neurosurgery due to right sided motor weakness (grade II/II). Imaging revealed a large homogenous cystic mass, 7.2×4.6×6 cm in size, in the left fronto-parietal lobe and basal ganglia. The mass had an intra-cystic lesion, abutting the basal portion of the mass. The initial diagnosis considered this mass a glioma or infection. A left frontal craniotomy was performed, followed by a transcortical approach to resect the mass. Total removal was accomplished without post-operative complications. An open biopsy and a histopathological exam diagnosed the mass as a giant cystic cavernous malformation. Imaging appearances of giant cavernous malformations may vary. The clinical features, radiological features, and management of giant cavernous malformations are described based on pertinent literature review.
doi:10.7461/jcen.2013.15.3.255
PMCID: PMC3804668  PMID: 24167810
Cavernous malformation; Giant cyst
3.  Comparison of Posterior Fixation Alone and Supplementation with Posterolateral Fusion in Thoracolumbar Burst Fractures 
Objective
We compared the radiological and clinical outcomes between patients who underwent posterior fixation alone and supplemented with fusion following the onset of thoracolumbar burst fractures. In addition, we also evaluated the necessity of posterolateral fusion for patients treated with posterior pedicle screw fixation.
Methods
From January 2007 to December 2009, 46 consecutive patients with thoracolumbar burst fracture were included in this study. On the basis of posterolateral fusion, we divided our patients into the non-fusion group and the fusion group. The radiological assessment was performed according to the Cobb's method, and results were obtained at immediately, 3, 6, 12 months after surgery. The clinical outcomes were evaluated using the modified Mcnab criteria at the final follow-up.
Results
The demographic data and the mean follow-up period were similar between the two groups. Patients of both groups achieved satisfactory clinical outcomes. The mean loss of kyphosis correction showed that patients of both groups experienced loss of correction with no respect to whether they underwent the posterolateral fusion. There was no significant difference in the degree of loss of correction at any time points of the follow-up between the two groups. In addition, we also compared the effect of fixed levels (i.e., short versus long segment) on loss of correction between the two groups and there was no significant difference. There were no major complications postoperatively and during follow-up period.
Conclusion
We suggest that posterolateral fusion may be unnecessary for patients with thoracolumbar burst fractures who underwent posterior pedicle screw fixation.
doi:10.3340/jkns.2012.52.4.346
PMCID: PMC3488643  PMID: 23133723
Thoracolumbar burst fracture; Posterior pedicle screw fixation; Posterolateral fusion; Loss of kyphosis correction
4.  The Role of Hyperthyroidism as the Predisposing Factor for Superior Sagittal Sinus Thrombosis 
Superior sagittal sinus thrombosis (SSST) is an uncommon cause of stroke, whose symptoms and clinical course are highly variable. It is frequently associated with a variety of hypercoagulable states. Coagulation abnormalities are commonly seen in patients with hyperthyroidism. To the best of our knowledge, there are few reports on the association between hyperthyroidism and cerebral venous thrombosis. We report on a 31-year-old male patient with a six-year history of hyperthyroidism who developed seizure and mental deterioration. Findings on brain computed tomography (CT) showed multiple hemorrhages in the subcortical area of both middle frontal gyrus and cerebral digital subtraction angiography (DSA) showed irregular intra-luminal filling defects of the superior sagittal sinus. These findings were consistent with hemorrhagic transformation of SSST. Findings on clinical laboratory tests were consistent with hyperthyroidism. In addition, our patient also showed high activity of factors IX and XI. The patient received treatment with oral anticoagulant and prophylthiouracil. His symptoms showed complete improvement. A follow-up cerebral angiography four weeks after treatment showed a recanalization of the SSS. In conclusion, findings of our case indicate that hypercoagulability may contribute to development of SSST in a patient with hyperthyroidism.
doi:10.7461/jcen.2012.14.3.251
PMCID: PMC3491224  PMID: 23210057
Cerebral venous thrombosis; Superior sagittal sinus; Hyperthyroidism; Hypercoagulability
5.  Comparative Study of Posterior Lumbar Interbody Fusion via Unilateral and Bilateral Approaches in Patients with Unilateral Leg Symptoms 
Objective
We investigated the clinical and radiological advantages of unilateral laminectomy in posterior lumbar interbody fusion (PLIF) procedure comparing with bilateral laminectomy, under the same procedural condition including bilateral instrumentation and insertion of two cages, in patients with degenerative lumbar disease with unilateral leg symptoms.
Methods
We retrospectively reviewed 124 consecutive cases of PLIF via unilateral or bilateral approach between January 2006 and April 2010. In 80 cases (bilateral group), two cages were inserted via bilateral laminectomy, and in 44 cases (unilateral group), via unilateral laminectomy. The average follow-up duration was 29.5 months. The clinical outcomes were evaluated with the Visual Analogue Scale (VAS) and the Oswestry disability index (ODI). The fusion rates and disc space heights were determined by dynamic standing radiographs and/or computed tomography. Operative times, intra-operative and post-operative blood losses and hospitalization periods were also evaluated.
Results
In clinical evaluation, the VAS and ODI scores showed excellent outcomes in both groups. There were no significant differences in term of fusion rate, but the perioperative blood loss and the operative time of the unilateral group were lower than that of the bilateral group.
Conclusion
Unilateral laminectomy can minimize the operative time and perioperative blood loss in PLIF procedure. However, the different preoperative disc height between two groups is a limitation of this study. Despite this limitation, solid fusion and satisfactory symptomatic improvement could be achieved uniquely by our surgical method. This surgical method can be an alternative surgical technique in patients with unilateral leg pain.
doi:10.3340/jkns.2011.50.4.363
PMCID: PMC3243841  PMID: 22200020
Posterior lumbar interbody fusion; Iatrogenic root injury; Unilateral approach; Unilateral leg symptoms
6.  Comparison of Fusion with Cage Alone and Plate Instrumentation in Two-Level Cervical Degenerative Disease 
Objective
This study assessed the efficacy of anterior cervical discectomy and fusion (ACDF) with cage alone compared with ACDF with plate instrumentation for radiologic and clinical outcomes in two-level cervical degenerative disease.
Methods
Patients with cervical degenerative disc disease from September 2004 to December 2009 were assessed retrospectively. A total of 42 patients received all ACDF at two-level cervical lesion. Twenty-two patients who underwent ACDF with cage alone were compared with 20 patients who underwent ACDF with plate fixation in consideration of radiologic and clinical outcomes. Clinical outcomes were assessed using Robinson's criteria and posterior neck pain, arm pain described by a 10 point-visual analog scale. Fusion rate, subsidence, kyphotic angle, instrument failure and the degenerative changes in adjacent segments were examined during each follow-up examination.
Results
VAS was checked during each follow-up and Robinson's criteria were compared in both groups. Both groups showed no significant difference. Fusion rates were 90.9% (20/22) in ACDF with the cage alone group, 95% (19/20) in ACDF with the plate fixation group (p = 0.966). Subsidence rates of ACDF with cage alone were 31.81% (7/22) and ACDF with plate fixation were 30% (6/20) (p = 0.928). Local and regional kyphotic angle difference showed no significant difference. At the final follow-up, adjacent level disease developed in 4.54% (1/22) of ACDF with cage alone and 10% (2/20) of ACDF with plate fixation (p = 0.654).
Conclusion
In two-level ACDF, ACDF with cage alone would be comparable with ACDF with plate fixation with regard to clinical outcome and radiologic result with no significant difference. We suggest that the routine use of plate and screw in 2-level surgery may not be beneficial.
doi:10.3340/jkns.2010.48.4.342
PMCID: PMC2982913  PMID: 21113362
ACDF with cage alone; ACDF with plate fixation; Fusion rate; Subsidence; Adjacent level degeneration
7.  Time to Recover Consciousness in Patients with Diffuse Axonal Injury : Assessment with Reference to Magnetic Resonance Grading 
Objective
This study was conducted to investigate the correlation between the degrees of injury on brain magnetic resonance imaging (MRI) and the time interval to recovery of consciousness in patients with diffuse axonal injury.
Methods
From January 2004 to December 2008, 25 patients with diffuse axonal injury were treated at our hospital. We retrospectively investigated the patients' medical records and radiological findings. We divided the patients into three groups according to the grade of MRI finding : grade I, small scattered lesions on the white matter of the cerebral hemisphere; grade II, focal lesions on the corpus callosum; and grade III, additional focal lesions on the brain stem.
Result
Seven patients belonged to the grade I group; 10 to the grade II group; and 8 to the grade III group. The mean Glasgow Coma Scale (GCS) score of all patients at the time of admission was 7.28. Recovery of consciousness was observed in 23 of the 25 patients; the remaining two patients never regained consciousness. The time interval to recovery of consciousness (awake status) ranged from 1 day to 125 days (mean 22.1 days) : grade I group patients, within approximately 1 week (mean 3.7 days); grade II group patients, within approximately 2 weeks (mean 12.5 days); and grade III group patients, within approximately 2 months (mean 59.5 days).
Conclusion
Our study results suggest a correlation between the mean time interval to recovery of consciousness in patients with diffuse axonal injuries and the degrees of brain injuries seen on MRI. Patients with grade I and II diffuse axonal injuries recovered consciousness within 2 weeks, while patients with grade III injuries required approximately 2 months.
doi:10.3340/jkns.2009.46.3.205
PMCID: PMC2764017  PMID: 19844619
Brain stem; Consciousness; Diffuse axonal injury; MRI
8.  The Angiographic Feature and Clinical Implication of Accessory Middle Cerebral Artery 
Objective
Although there are several descriptions of this vessel, there is no detailed angiographic study of the accessory middle cerebral artery (AMCA) in Korea. We describe the angiographic characteristics of the cortical territory and origin of AMCA and discuss the clinical significance of this anomaly.
Methods
We searched for patients with AMCAs from a retrospective review of 1,250 conventional cerebral angiograms. We determined the origins, diameters and cortical territories of these AMCAs.
Results
Fifteen patients (15 of 1250 = 1.2%) had 16 AMCAs (one patient had bilateral AMCAs). AMCAs originated from the distal A1 in eleven cases, middle A1 in two, proximal A1 in two, and proximal A2 in one case. All AMCAs followed a course parallel to the main middle cerebral artery (MCA). All but three of these arteries were smaller than the main MCA. Thirteen of the smaller diameter AMCAs had cortical distribution to the orbito-frontal and prefrontal, and precentral areas. Three AMCAs had diameter as large as the main MCA. These three supplied the orbitofrontal, prefrontal, precentral, central and anterior-parietal arteries.
Conclusion
The AMCAs originated from A1 or A2. Most had smaller diameter than the main MCA. The AMCAs coursed along the horizontal portion of the MCA, but supplied the orbital surface, the anterior frontal lobe and sometimes wider cortical territory, including the precentral, central, anterior-parietal areas.
doi:10.3340/jkns.2009.45.5.289
PMCID: PMC2693788  PMID: 19516946
Accessory middle cerebral artery; Cortical territory; Clinical implication
9.  Spontaneous Spinal Epidural Hematoma 
Spontaneous spinal epidural hematoma (SSEH) is a relatively rare but significant spinal condition. Urgent surgical evacuation of a hematoma is generally indicated to prevent serious permanent neurological deficits. We encountered three cases of spontaneous spinal epidural hematomas associated with motor weakness that were treated successfully by surgical intervention.
doi:10.3340/jkns.2008.44.1.40
PMCID: PMC2588288  PMID: 19096655
Spinal epidural hematana; Laminectomy
10.  Extraordinarily Long-Term Posttraumatic Cerebrospinal Fluid Fistula 
Most posttraumatic cerebrospinal fluid (CSF) leakage is noticed by the patients with the first symptom, rhinorrhea. A 38-year-old woman presented with frequent clear continuous rhinorrhea and otorrhea for 5 years after basilar skull fracture. After this, meningitis was developed with subsequent CSF fistula. Her clinical symptom was improved by medical treatment. The dural defect and CSF leakage were not detected by computerized tomography (CT) cisternography. We report a rare case of persistent posttraumatic CSF fistula that continued for five years.
doi:10.3340/jkns.2007.42.5.403
PMCID: PMC2588196  PMID: 19096578
Traumatic CSF fistula; Meningitis; CT cisternography

Results 1-10 (10)