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1.  Proteomic Analysis of a Rat Cerebral Ischemic Injury Model after Human Cerebral Endothelial Cell Transplantation 
Objective
Cerebral endothelial cells have unique biological features and are fascinating candidate cells for stroke therapy.
Methods
In order to understand the molecular mechanisms of human cerebral endothelial cell (hCMEC/D3) transplantation in a rat stroke model, we performed proteomic analysis using 2-dimensional electrophoresis and matrix-assisted laser desorption/ionization time-of-flight mass spectrometry. Protein expression was confirmed by quantitative real-time PCR and Western blot.
Results
Several protein spots were identified by gel electrophoresis in the sham, cerebral ischemia (CI), and CI with hCMEC/D3 treatment cerebral ischemia with cell transplantation (CT) groups, and we identified 14 differentially expressed proteins in the CT group. Proteins involved in mitochondrial dysfunction (paraplegin matrix AAA peptidase subunit, SPG7), neuroinflammation (peroxiredoxin 6, PRDX6), and neuronal death (zinc finger protein 90, ZFP90) were markedly reduced in the CT group compared with the CI group. The expression of chloride intracellular channel 4 proteins involved in post-ischemic vasculogenesis was significantly decreased in the CI group but comparable to sham in the CT group.
Conclusion
These results contribute to our understanding of the early phase processes that follow cerebral endothelial cell treatment in CI. Moreover, some of the identified proteins may present promising new targets for stroke therapy.
doi:10.3340/jkns.2016.59.6.544
PMCID: PMC5106351  PMID: 27847565
Brain; Ischemia; Cell therapy; Proteomics; 2-dimensional electrophoresis
2.  Metallothinein 1E Enhances Glioma Invasion through Modulation Matrix Metalloproteinases-2 and 9 in U87MG Mouse Brain Tumor Model 
Malignant glioma cells invading surrounding normal brain are inoperable and resistant to radio- and chemotherapy, and eventually lead to tumor regrowth. Identification of genes related to motility is important for understanding the molecular biological behavior of invasive gliomas. According to our previous studies, Metallothionein 1E (MT1E) was identified to enhance migration of human malignant glioma cells. The purpose of this study was to confirm that MT1E could modulate glioma invasion in vivo. Firstly we established 2 cell lines; MTS23, overexpressed by MT1E complementary DNA construct and pV12 as control. The expression of matrix metalloproteinases (MMP)-2, -9 and a disintegrin and metalloproteinase 17 were increased in MTS23 compared with pV12. Furthermore it was confirmed that MT1E could modulate MMPs secretion and translocation of NFkB p50 and B-cell lymphoma-3 through small interfering ribonucleic acid knocked U87MG cells. Then MTS23 and pV12 were injected into intracranial region of 5 week old male nude mouse. After 4 weeks, for brain tissues of these two groups, histological analysis, and immunohistochemical stain of MMP-2, 9 and Nestin were performed. As results, the group injected with MTS23 showed irregular margin and tumor cells infiltrating the surrounding normal brain, while that of pV12 (control) had round and clear margin. And regrowth of tumor cells in MTS23 group was observed in another site apart from tumor cell inoculation. MT1E could enhance tumor proliferation and invasion of malignant glioma through regulation of activation and expression of MMPs.
doi:10.3340/jkns.2016.59.6.551
PMCID: PMC5106352  PMID: 27847566
Metallothionein 1E; Malignant glioma; Invasion; Brain tumor model; MMP-2; MMP-9
3.  Temperature Distributions of the Lumbar Intervertebral Disc during Laser Annuloplasty : A Cadaveric Study 
Objective
Low back pain, caused intervertebral disc degeneration has been treated by thermal annuloplasty procedure, which is a non-surgical treatement. The theoretical backgrounds of the annuloplasty are thermal destruct of nociceptor and denaturization of collagen fiber to induce contraction, to shrink annulus and thus enhancing stability. This study is about temperature and its distribution during thermal annuloplasty using 1414 nm Nd : YAG laser.
Methods
Thermal annuloplasty was performed on fresh human cadaveric lumbar spine with 20 intact intervertebral discs in a 37℃ circulating water bath using newly developed 1414 nm Nd : YAG laser. Five thermocouples were attached to different locations on the disc, and at the same time, temperature during annuloplasty was measured and analyzed.
Results
Thermal probe's temperature was higher in locations closer to laser fiber tip and on lateral locations, rather than the in depth locations. In accordance with the laser fiber tip and the depth, temperatures above 45.0℃ was measured in 3.0 mm depth which trigger nociceptive ablation in 16 levels (80%), in accordance with the laser fiber end tip and laterality, every measurement had above 45.0℃, and also was measured temperature over 60.0℃, which can trigger collagen denaturation at 16 levels (80%).
Conclusion
When thermal annuloplasty is needed in a selective lesion, annuloplasty using a 1414 nm Nd : YAG laser can be one of the treatment options.
doi:10.3340/jkns.2016.59.6.559
PMCID: PMC5106353  PMID: 27847567
Low back pain; Intervertebral disc degeneration; Temperature; Nd : YAG laser
4.  Intradural Procedural Time to Assess Technical Difficulty of Superciliary Keyhole and Pterional Approaches for Unruptured Middle Cerebral Artery Aneurysms 
Objective
This study used the intradural procedural time to assess the overall technical difficulty involved in surgically clipping an unruptured middle cerebral artery (MCA) aneurysm via a pterional or superciliary approach. The clinical and radiological variables affecting the intradural procedural time were investigated, and the intradural procedural time compared between a superciliary keyhole approach and a pterional approach.
Methods
During a 5.5-year period, patients with a single MCA aneurysm were enrolled in this retrospective study. The selection criteria for a superciliary keyhole approach included : 1) maximum diameter of the unruptured MCA aneurysm <15 mm, 2) neck diameter of the MCA aneurysm <10 mm, and 3) aneurysm location involving the sphenoidal or horizontal segment of MCA (M1) segment and MCA bifurcation, excluding aneurysms distal to the MCA genu. Meanwhile, the control comparison group included patients with the same selection criteria as for a superciliary approach, yet who preferred a pterional approach to avoid a postoperative facial wound or due to preoperative skin trouble in the supraorbital area. To determine the variables affecting the intradural procedural time, a multiple regression analysis was performed using such data as the patient age and gender, maximum aneurysm diameter, aneurysm neck diameter, and length of the pre-aneurysm M1 segment. In addition, the intradural procedural times were compared between the superciliary and pterional patient groups, along with the other variables.
Results
A total of 160 patients underwent a superciliary (n=124) or pterional (n=36) approach for an unruptured MCA aneurysm. In the multiple regression analysis, an increase in the diameter of the aneurysm neck (p<0.001) was identified as a statistically significant factor increasing the intradural procedural time. A Pearson correlation analysis also showed a positive correlation (r=0.340) between the neck diameter and the intradural procedural time. When comparing the superciliary and pterional groups, no statistically significant between-group difference was found in terms of the intradural procedural time reflecting the technical difficulty (mean±standard deviation : 29.8±13.0 min versus 27.7±9.6 min).
Conclusion
A superciliary keyhole approach can be a useful alternative to a pterional approach for an unruptured MCA aneurysm with a maximum diameter <15 mm and neck diameter <10 mm, representing no more of a technical challenge. For both surgical approaches, the technical difficulty increases along with the neck diameter of the MCA aneurysm.
doi:10.3340/jkns.2016.59.6.564
PMCID: PMC5106354  PMID: 27847568
Intracranial aneurysm; Middle cerebral artery; Pterional approach; Superciliary approach
5.  Retrospective Analysis of Cerebrospinal Fluid Profiles in 228 Patients with Leptomeningeal Carcinomatosis : Differences According to the Sampling Site, Symptoms, and Systemic Factors 
Objective
Elevated cell counts and protein levels in cerebrospinal fluid (CSF) result from disease activity in patients with leptomeningeal carcinomatosis (LMC). Previous studies evaluated the use of CSF profiles to monitor a treatment response or predict prognosis. CSF profiles vary, however, according to the sampling site and the patient's systemic condition. We compared lumbar and ventricular CSF profiles collected before intraventricular chemotherapy for LMC and evaluated the association of these profiles with patients' systemic factors and LMC disease activity.
Methods
CSF profiles were retrospectively collected from 228 patients who underwent Ommaya reservoir insertion for intraventricular chemotherapy after a diagnosis of LMC. Lumbar samples taken via lumbar puncture were used for the diagnosis, and ventricular samples were obtained later at the time of Ommaya reservoir insertion. LMC disease activity was defined as the presence of LMC-related symptoms such as increased intracranial pressure, hydrocephalus, cranial neuropathy, and cauda equina syndrome.
Results
Cell counts (median : 8 vs. 1 cells/mL) and protein levels (median : 68 vs. 17 mg/dL) significantly higher in lumbar CSF than in ventricular CSF (p<0.001). Among the evaluated systemic factors, concomitant brain metastasis and previous radiation were significantly correlated with higher protein levels in the lumbar CSF (p=0.01 and <0.001, respectively). Among the LMC disease activity, patients presenting with hydrocephalus or cauda equina syndrome showed higher lumbar CSF protein level compared with that in patients without those symptoms (p=0.049 and p<0.001, respectively). The lumbar CSF cell count was significantly lower in patients with cranial neuropathy (p=0.046). The ventricular CSF cell counts and protein levels showed no correlation with LMC symptoms. Carcinoembryonic antigen (CEA), which was measured from ventricular CSF after the diagnosis in 109 patients, showed a significant association with the presence of hydrocephalus (p=0.01).
Conclusion
The protein level in lumbar CSF indicated the localized disease activity of hydrocephalus and cauda equina syndrome. In the ventricular CSF, only the CEA level reflected the presence of hydrocephalus. We suggest using more specific biomarkers for the evaluation of ventricular CSF to monitor disease activity and treatment response.
doi:10.3340/jkns.2016.59.6.570
PMCID: PMC5106355  PMID: 27847569
Cerebrospinal fluid; Leptomeningeal carcinomatosis; Lumbar; Ventricular
6.  Parasellar Extension Grades and Surgical Extent in Endoscopic Endonasal Transsphenoidal Surgery for Pituitary Adenomas : A Single Surgeon's Consecutive Series with the Aspects of Reliability and Clinical Validity 
Objective
The inter-rater reliability of the modified Knosp's classification was measured before the analysis. The clinical validity of the parasellar extension grading system was evaluated by investigating the extents of resection and complication rates among the grades in the endoscopic endonasal transsphenoidal surgery (EETS) for pituitary adenomas.
Methods
From November 2008 to August 2015, of the 286 patients who underwent EETS by the senior author, 208 were pituitary adenoma cases (146 non-functioning pituitary adenomas, 10 adrenocorticotropic hormone-secreting adenomas, 31 growth hormone-secreting adenomas, 17 prolactin-secreting adenomas, and 4 thyroid-stimulating hormone-secreting adenomas; 23 microadenomas, 174 macroadenomas, and 11 giant adenomas). Two neurosurgeons and a neuroradiologist independently measured the degree of parasellar extension on the preoperative sellar MRI according to the modified Knosp's classification. Inter-rater reliability was statistically assessed by measuring the intraclass correlation coefficient. The extents of resection were evaluated by comparison of the pre- and post-operative MR images; the neurovascular complications were assessed by reviewing the patients' medical records. The extent of resection was measured in each parasellar extension grade; thereafter, their statistical differences were calculated.
Results
The intraclass correlation coefficient value of reliability across the three raters amounted to 0.862. The gross total removal (GTR) rates achieved in each grade were 70.0, 69.8, 62.9, 21.4, 37.5, and 4.3% in Grades 0, 1, 2, 3A, 3B, and 4, respectively. A significant difference in the extent of resection was observed only between Grades 2 and 3A. In addition, significantly higher complication rates were observed in the groups above Grade 3A.
Conclusion
Although the modified Knosp's classification system appears to be complex, its inter-rater reliability proves to be excellent. Regarding the clinical validity of the parasellar extension grading system, Grades 3A, 3B, and 4 have a negative predictive value for the GTR rate, with higher complication rates.
doi:10.3340/jkns.2016.59.6.577
PMCID: PMC5106356  PMID: 27847570
Cavernous sinus; Complications; Endoscopy; Pituitary neoplasms; Reliability; Transsphenoidal surgery
7.  Sclerosing Meningioma : Radiological and Clinical Characteristics of 21 Cases 
Objective
A rare subtype of meningioma, sclerosing meningioma is not included in the current World Health Organization classification of meningiomas and is classified into the category of other morphological variation subtypes. Sclerosing meningioma is often misdiagnosed to other non-benign meningioma or malignant neoplasm, so it is important to diagnose sclerosing type correctly. We analyzed the radiological and clinical characteristics of a series of sclerosing meningiomas.
Methods
Twenty-one patients who underwent surgery in one institute with a histopathologically proven sclerosing meningioma were included from 2006 to 2014. Eighteen tumors were diagnosed as a pure sclerosing-type meningioma, and 3 as mixed type. Magnetic resonance image was taken for all patients including contrast enhancement image. Computed tomography (CT) scan was taken for 16 patients. One neuroradiologist and 1 neurosurgeon reviewed all images retrospectively.
Results
In the all 16 patients with preoperative CT images, higher attenuation was observed in the meningioma than in the brain parenchyma, and calcification was observed in 11 (69%). In 15 of the 21 patients (71%), a distinctive very low signal intensity appeared as a dark color in T2-weighted images. Nine of these 15 tumors (60%) exhibited heterogeneous enhancement, and 6 (40%) exhibited homogeneous enhancement that was unlike the homogeneous enhancing pattern shown by conventional meningiomas. Ten patients had a clear tumor margin without peritumoral edema.
Conclusion
Although these peculiar radiological characteristics are not unique to sclerosing meningioma, we believe that they are distinctive features that may be helpful for distinguishing sclerosing meningioma from other subtypes.
doi:10.3340/jkns.2016.59.6.584
PMCID: PMC5106357  PMID: 27847571
Meningioma; Magnetic resonance imaging
8.  Risk Factors for the Development and Progression of Atlantoaxial Subluxation in Surgically Treated Rheumatoid Arthritis Patients, Considering the Time Interval between Rheumatoid Arthritis Diagnosis and Surgery 
Objective
Rheumatoid arthritis (RA) is a systemic disease that can affect the cervical spine, especially the atlantoaxial region. The present study evaluated the risk factors for atlantoaxial subluxation (AAS) development and progression in patients who have undergone surgical treatment.
Methods
We retrospectively analyzed the data of 62 patients with RA and surgically treated AAS between 2002 and 2015. Additionally, we identified 62 patients as controls using propensity score matching of sex and age among 12667 RA patients from a rheumatology registry between 2007 and 2015. We extracted patient data, including sex, age at diagnosis, age at surgery, disease duration, radiographic hand joint changes, and history of methotrexate use, and laboratory data, including presence of rheumatoid factor and the C-reactive protein (CRP) level.
Results
The mean patient age at diagnosis was 38.0 years. The mean time interval between RA diagnosis and AAS surgery was 13.6±7.0 years. The risk factors for surgically treated AAS development were the serum CRP level (p=0.005) and radiographic hand joint erosion (p=0.009). The risk factors for AAS progression were a short time interval between RA diagnosis and radiographic hand joint erosion (p<0.001) and young age at RA diagnosis (p=0.04).
Conclusion
The CRP level at RA diagnosis and a short time interval between RA diagnosis and radiographic hand joint erosion might be risk factors for surgically treated AAS development in RA patients. Additionally, a short time interval between RA diagnosis and radiographic hand joint erosion and young age at RA diagnosis might be risk factors for AAS progression.
doi:10.3340/jkns.2016.59.6.590
PMCID: PMC5106358  PMID: 27847572
Atlantoaxial subluxation; Rheumatoid arthritis; Posterior cervical fusion
9.  The Effect of Perioperative Radiation Therapy on Spinal Bone Fusion Following Spine Tumor Surgery 
Introduction
Perioperative irradiation is often combined with spine tumor surgery. Radiation is known to be detrimental to healing process of bone fusion. We tried to investigate bone fusion rate in spine tumor surgery cases with perioperative radiation therapy (RT) and to analyze significant factors affecting successful bone fusion.
Methods
Study cohort was 33 patients who underwent spinal tumor resection and bone graft surgery combined with perioperative RT. Their medical records and radiological data were analyzed retrospectively. The analyzed factors were surgical approach, location of bone graft (anterior vs. posterior), kind of graft (autologous graft vs. allograft), timing of RT (preoperative vs. postoperative), interval of RT from operation in cases of postoperative RT (within 1 month vs. after 1 month) radiation dose (above 38 Gy vs. below 38 Gy) and type of radiation therapy (conventional RT vs. stereotactic radiosurgery). The bone fusion was determined on computed tomography images.
Result
Bone fusion was identified in 19 cases (57%). The only significant factors to affect bony fusion was the kind of graft (75% in autograft vs. 41 in allograft, p=0.049). Other factors proved to be insignificant relating to postoperative bone fusion. Regarding time interval of RT and operation in cases of postoperative RT, the time interval was not significant (p=0.101).
Conclusion
Spinal fusion surgery which was combined with perioperative RT showed relatively low bone fusion rate (57%). For successful bone fusion, the selection of bone graft was the most important.
doi:10.3340/jkns.2016.59.6.597
PMCID: PMC5106359  PMID: 27847573
Spine tumor; Bone fusion; Bone graft; Radiation therapy
10.  A Comparison of Implants Used in Double Door Laminoplasty : Allogeneic Bone Spacer versus Hydroxyapatite Spacer 
Objective
The aim of this study was to compare the clinical and radiological outcomes associated with the use of hydroxyapatite (HA) spacer and allogeneic bone (AB) spacer in laminoplasty.
Methods
From January 2006 to July 2014, 79 patients with cervical spondylotic myelopathy or ossification of the posterior longitudinal ligament underwent cervical laminoplasty. The radiologic parameters were obtained from plain radiography and three-dimensional computed tomography. All images were taken before and after surgery. Cervical lordosis, spinal canal dimension, fusion between lamina and spacer, and resorption of spacer were checked. Clinical outcomes were assessed using visual analog scale and Japanese Orthopedic Association.
Results
Double-door laminoplasty was performed on 280 levels : 182 in the HA group and 98 in the AB group. The mean follow-up was 23.1 months (range : 4–69 months). Similar fusion rates were found in these groups (p=0.3). The resorption rate between lamina and spacer was lower in the HA group (p<0.001). During the immediate postoperative period, the canal dimension of both groups increased compared with the results in the preoperative period. However, the canal dimension of the AB group decreased over time compared with that of the HA group (p<0.001).
Conclusion
Double-door laminoplasty improved the clinical outcomes of both groups. However, the spinal canal dimension in the AB group showed a greater degree of reduction than in the HA group at the final postoperative follow-up. Therefore, we suggest that surgeons consider the use of larger-sized AB spacers in double-door laminoplasties.
doi:10.3340/jkns.2016.59.6.604
PMCID: PMC5106360  PMID: 27847574
Allograft; Hydroxyapatites; Cervical myelopathy; Ossification of posterior longitudinal ligament; Spinal fusion
11.  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°).
doi:10.3340/jkns.2016.59.6.610
PMCID: PMC5106361  PMID: 27847575
Lumbar vertebrae; Foraminal stenosis; Foraminotomy; L5 root; Lordosis
12.  Surgical Outcomes of Post-Fusion Lumbar Flatback Deformity with Sagittal Imbalance 
Objectives
To review surgical results of post-fusion lumbar flatback treated with pedicle subtraction osteotomy (PSO) or Smith-Petersen osteotomies (SPOs).
Methods
Twenty-eight patients underwent osteotomies. Radiological outcomes by sagittal vertical axis (SVA), and pelvic tilt (PT), T1 pelvic angle (T1PA), and pelvic incidence (PI)-lumbar lordosis (LL) at preoperative, postoperative 1 month, and final were evaluated. Oswestry Disability Index (ODI), visual analog scale (VAS) score of back pain/leg pain, and Scoliosis Research Society-22 score (SRS-22r) were analyzed and compared. Patients were divided into 2 groups (SVA ≤5 cm : normal, SVA >5 cm : positive) at final and compared outcomes.
Results
Nineteen patients (68%) had PSO and the other 9 patients had SPOs with anterior lumbar interbody fusions (ALIFs) (Mean age : 65 years, follow-up : 31 months). The PT, PI-LL, SVA, T1PA were significantly improved at 1 month and at final (p<0.01). VAS score, ODI, and SRS-22r were also significantly improved at the final (p<0.01). 23 patients were restored with normal SVA and the rest 5 patients demonstrated to positive SVA. SVA and T1PA at 1 month and SVA, PI-LL, and T1PA at final were significantly different (p<0.05) while the ODI, VAS, and SRS-22r did not differ significantly between the groups (p>0.05). Common reoperations were early 4 proximal junctional failures (14%) and late four rod fractures.
Conclusion
Our results demonstrate that PSO and SPOs with ALIFs at the lower lumbar are significantly improves sagittal balance. For maintenance of normal SVA, PI-LL might be made negative value and T1PA might be less than 11° even though positive SVA group was also significantly improved clinical outcomes.
doi:10.3340/jkns.2016.59.6.615
PMCID: PMC5106362  PMID: 27847576
Post-fusion flatback deformity; Pedicle subtraction osteotomy; Smith-Petersen osteotomy; Anterior lumbar interbody fusion
13.  Analysis of Risk Factor for the Development of Chronic Subdural Hematoma in Patients with Traumatic Subdural Hygroma 
Objective
Although a high incidence of chronic subdural hematoma (CSDH) following traumatic subdural hygroma (SDG) has been reported, no study has evaluated risk factors for the development of CSDH. Therefore, we analyzed the risk factors contributing to formation of CSDH in patients with traumatic SDG.
Methods
We retrospectively reviewed patients admitted to Hallym University Hospital with traumatic head injury from January 2004 through December 2013. A total of 45 patients with these injuries in which traumatic SDG developed during the follow-up period were analyzed. All patients were divided into two groups based on the development of CSDH, and the associations between the development of CSDH and independent variables were investigated.
Results
Thirty-one patients suffered from bilateral SDG, whereas 14 had unilateral SDG. Follow-up computed tomography scans revealed regression of SDG in 25 of 45 patients (55.6%), but the remaining 20 patients (44.4%) suffered from transition to CSDH. Eight patients developed bilateral CSDH, and 12 patients developed unilateral CSDH. Hemorrhage-free survival rates were significantly lower in the male and bilateral SDG group (log-rank test; p=0.043 and p=0.013, respectively). Binary logistic regression analysis revealed male (OR, 7.68; 95% CI 1.18–49.78; p=0.033) and bilateral SDG (OR, 8.04; 95% CI 1.41–45.7; p=0.019) were significant risk factors for development of CSDH.
Conclusion
The potential to evolve into CSDH should be considered in patients with traumatic SDG, particularly male patients with bilateral SDG.
doi:10.3340/jkns.2016.59.6.622
PMCID: PMC5106363  PMID: 27847577
Chronic subdural hematoma; Subdural hygroma
14.  Spontaneous Resolution of Chronic Subdural Hematoma : Close Observation as a Treatment Strategy 
Objective
Chronic subdural hematoma (cSDH) is common condition in neurosurgical field. It is difficult to select the treatment modality between the surgical method and the conservative method when patients have no or mild symptoms. The purpose of this study is to provide a suggestion that the patients could be cured with conservative treatment modality.
Methods
We enrolled 16 patients who had received conservative treatment for cSDH without special medications which could affect hematoma resolution such as mannitol, steroids, tranexamic acid and angiotensin converting enzyme inhibitors. The patients were classified according to the Markwalder's Grading Scale.
Results
Among these 16 patients, 13 (81.3%) patients showed spontaneously resolved cSDH and 3 (18.7%) patients received surgery due to symptom aggravation and growing hematoma. They were categorized into two groups based on whether they were cured with conservative treatment or not. The first group was the spontaneous resolution group. The second group was the progression-surgery group. The mean hematoma volume in the spontaneous resolution group was 43.1 mL. The mean degree of midline shift in the spontaneous resolution group was 5.3 mm. The mean hematoma volume in the progression-surgery group was 62.0 mL. The mean degree of midline shift in the second group was 6 mm.
Conclusion
We suggest that the treatment modality should be determined according to the patient's symptoms and clinical condition and close observation could be performed in patients who do not have any symptoms or in patients who have mild to moderate headache without neurological deterioration.
doi:10.3340/jkns.2016.59.6.628
PMCID: PMC5106364  PMID: 27847578
Close observation; Chronic subdural hematoma; Treatment
15.  A Clinical Analysis of Secondary Surgery in Trigeminal Neuralgia Patients Who Failed Prior Treatment 
Objective
Although many treatment modalities have been introduced for trigeminal neuralgia (TN), the long-term clinical results remain unsatisfactory. It has been particularly challenging to determine an appropriate treatment strategy for patients who have responded poorly to initial therapies. We analyzed the surgical outcomes in TN patients who failed prior treatments.
Methods
We performed a retrospective analysis of 37 patients with recurrent or persistent TN symptoms who underwent surgery at our hospital between January 2010 and December 2014. Patients with follow-up data of at least one year were included. The prior treatment modalities of the 37 patients included microvascular decompression (MVD), gamma knife radiosurgery (GKRS), and percutaneous procedures such as radiofrequency rhizotomy (RFR), balloon compression, and glycerol rhizotomy (GR). The mean follow-up period was 69.9 months (range : 16–173). The mean interval between the prior treatment and second surgery was 26 months (range : 7–123). We evaluated the surgical outcomes using the Barrow Neurological Institute (BNI) pain intensity scale.
Results
Among the 37 recurrent or persistent TN patients, 22 underwent MVD with partial sensory rhizotomy (PSR), 8 received MVD alone, and 7 had PSR alone. Monitoring of the surgical treatment outcomes via the BNI pain intensity scale revealed 8 (21.6%) patients with a score of I, 13 (35.1%) scoring II, 13 (35.1%) scoring III, and 3 (8.2%) scoring IV at the end of the follow-up period. Overall, 91.8% of patients had good surgical outcomes. With regard to postoperative complications, 1 patient had transient cerebrospinal fluid rhinorrhea (2.7%), another had a subdural hematoma (2.7%), and facial sensory changes were noted in 8 (21.1%) patients after surgery.
Conclusion
Surgical interventions, such as MVD and PSR, are safe and very effective treatment modalities in TN patients who failed initial or prior treatments. We presume that the combination of MVD with PSR enabled us to obtain good short- and long-term surgical outcomes. Therefore, aggressive surgical treatment should be considered in patients with recurrent TN despite failure of various treatment modalities.
doi:10.3340/jkns.2016.59.6.637
PMCID: PMC5106365  PMID: 27847579
Trigeminal neuralgia; Microvascular decompression; Rhizotomy
16.  The Mechanical Effect of Rod Contouring on Rod-Screw System Strength in Spine Fixation 
Objective
Rod-screw fixation systems are widely used for spinal instrumentation. Although many biomechanical studies on rod-screw systems have been carried out, but the effects of rod contouring on the construct strength is still not very well defined in the literature. This work examines the mechanical impact of straight, 20° kyphotic, and 20° lordotic rod contouring on rod-screw fixation systems, by forming a corpectomy model.
Methods
The corpectomy groups were prepared using ultra-high molecular weight polyethylene samples. Non-destructive loads were applied during flexion/extension and torsion testing. Spine-loading conditions were simulated by load subjections of 100 N with a velocity of 5 mm min-1, to ensure 8.4-Nm moment. For torsional loading, the corpectomy models were subjected to rotational displacement of 0.5° s-1 to an end point of 5.0°, in a torsion testing machine.
Results
Under both flexion and extension loading conditions the stiffness values for the lordotic rod-screw system were the highest. Under torsional loading conditions, the lordotic rod-screw system exhibited the highest torsional rigidity.
Conclusion
We concluded that the lordotic rod-screw system was the most rigid among the systems tested and the risk of rod and screw failure is much higher in the kyphotic rod-screw systems. Further biomechanical studies should be attempted to compare between different rod kyphotic angles to minimize the kyphotic rod failure rate and to offer a more stable and rigid rod-screw construct models for surgical application in the kyphotic vertebrae.
doi:10.3340/jkns.2016.59.5.425
PMCID: PMC5028600  PMID: 27651858
Biomechanics; Rod contouring; Rod failure
17.  Chronic Paraspinal Muscle Injury Model in Rat 
Objective
The objective of this study is to establish an animal model of chronic paraspinal muscle injury in rat.
Methods
Fifty four Sprague-Dawley male rats were divided into experimental group (n=30), sham (n=15), and normal group (n=9). Incision was done from T7 to L2 and paraspinal muscles were detached from spine and tied at each level. The paraspinal muscles were exposed and untied at 2 weeks after surgery. Sham operation was done by paraspinal muscles dissection at the same levels and wound closure was done without tying. Kyphotic index and thoracolumbar Cobb's angle were measured at preoperative, 2, 4, 8, and 12 weeks after the first surgery for all groups. The rats were sacrificed at 4, 8, and 12 weeks after the first surgery, and performed histological examinations.
Results
At 4 weeks after surgery, the kyphotic index decreased, but, Cobb's angle increased significantly in the experimental group (p<0.05), and then that were maintained until the end of the experiment. However, there were no significant differences of the kyphotic index and Cobb's angle between sham and normal groups. In histological examinations, necrosis and fibrosis were observed definitely and persisted until 12 weeks after surgery. There were also presences of regenerated muscle cells which nucleus is at the center of cytoplasm, centronucleated myofibers.
Conclusion
Our chronic injury model of paraspinal muscles in rats shows necrosis and fibrosis in the muscles for 12 weeks after surgery, which might be useful to study the pathophysiology of the degenerative thoracolumbar kyphosis or degeneration of paraspinal muscles.
doi:10.3340/jkns.2016.59.5.430
PMCID: PMC5028601  PMID: 27651859
Animal model; Paraspinal muscle; Chronic injury; Kyphosis; Degeneration
18.  Neural Growth Factor Stimulates Proliferation of Spinal Cord Derived-Neural Precursor/Stem Cells 
Objective
Recently, regenerative therapies have been used in clinical trials (heart, cartilage, skeletal). We don't make use of these treatments to spinal cord injury (SCI) patients yet, but regenerative therapies are rising interest in recent study about SCI. Neural precursor/stem cell (NPSC) proliferation is a significant event in functional recovery of the central nervous system (CNS). However, brain NPSCs and spinal cord NPSCs (SC-NPSCs) have many differences including gene expression and proliferation. The purpose of this study was to investigate the influence of neural growth factor (NGF) on the proliferation of SC-NPSCs.
Methods
NPSCs (2×104) were suspended in 100 µL of neurobasal medium containing NGF-7S (Sigma-Aldrich) and cultured in a 96-well plate for 12 days. NPSC proliferation was analyzed five times for either concentration of NGF (0.02 and 2 ng/mL). Sixteen rats after SCI were randomly allocated into two groups. In group 1 (SCI-vehicle group, n=8), animals received 1.0 mL of the saline vehicle solution. In group 2 (SCI-NGF group, n=8), the animals received single doses of NGF (Sigma-Aldrich). A dose of 0.02 ng/mL of NGF or normal saline as a vehicle control was intra-thecally injected daily at 24 hour intervals for 7 days. For Immunohistochemistry analysis, rats were sacrificed after one week and the spinal cords were obtained.
Results
The elevation of cell proliferation with 0.02 ng/mL NGF was significant (p<0.05) but was not significant for 2 ng/mL NGF. The optical density was increased in the NGF 0.02 ng/mL group compared to the control group and NGF 2 ng/mL groups. The density of nestin in the SCI-NGF group was significantly increased over the SCI-vehicle group (p<0.05). High power microscopy revealed that the density of nestin in the SCI-NGF group was significantly increased over the SCI-vehicle group.
Conclusion
SC-NPSC proliferation is an important pathway in the functional recovery of SCI. NGF enhances SC-NPSC proliferation in vitro and in vivo. NGF may be a useful option for treatment of SCI patients pending further studies to verify the clinical applicability.
doi:10.3340/jkns.2016.59.5.437
PMCID: PMC5028602  PMID: 27651860
Neural growth factor; Spinal cord neural precursor/stem cell; Spinal cord injury
19.  Predicting Factors of Chronic Subdural Hematoma Following Surgical Clipping in Unruptured and Ruptured Intracranial Aneurysm 
Objective
The aim of this study is to analyze the differences in the incidence, predicting factors, and clinical course of chronic subdural hematoma (CSDH) following surgical clipping between unruptured (UIA) and ruptured intracranial aneurysm (RIA).
Methods
We conducted a retrospective analysis of 752 patients (UIA : 368 and RIA : 384) who underwent surgical clipping during 8 years. The incidence and predicting factors of CSDH development in the UIA and RIA were compared according to medical records and radiological data.
Results
The incidence of postoperative CSDH was higher in the UIA (10.9%) than in the RIA (3.1%) (p=0.000). In multivariate analysis, a high Hounsfield (HF) unit (blood clots) for subdural fluid collection (SFC), persistence of SFC ≥5 mm and male sex in the UIA and A high HF unit for SFC and SFC ≥5 mm without progression to hydrocephalus in the RIA were identified as the independent predicting factors for CSDH development (p<0.05).
Conclusion
There were differences in the incidence and predicting factors for CSDH following surgical clipping between UIA and RIA. Blood clots in the subdural space and persistence of SFC ≥5 mm were predicting factors in both UIA and RIA. However, progression to hydrocephalus may have in part contributed to low CSDH development in the RIA. We suggest that cleaning of blood clots in the subdural space and efforts to minimize SFC ≥5 mm at the end of surgery is helpful to prevent CSDH following aneurysmal clipping.
doi:10.3340/jkns.2016.59.5.458
PMCID: PMC5028605  PMID: 27651863
Chronic subdural hematoma; Surgical clipping; Intracranial aneurysm
20.  Craniopharyngiomas : Radiological Differentiation of Two Types 
Objective
To determine imaging features that may separate adamantinomatous and papillary variants of craniopharyngiomas given that tumors with adamantinomatous signature features are associated with higher recurrence rates, morbidity, and mortality. We specifically reviewed calcification on CT, T1 bright signal intensity, and cystic change on T2 weighted images for differentiating these two types.
Methods
We retrospectively reviewed the MRI and CT studies in 38 consecutive patients with pathologically proven craniopharyngiomas between January 2004 and February 2014 for the presence of calcification on CT scans, bright signal intensity on T1 weighted images, and cystic change on T2 weighted images.
Results
Of the 38 craniopharyngiomas, 30 were adamantinomatous type and 8 were papillary type. On CT scans, calcification was present in 25 of 38 tumors. All calcified tumors were adamantinomatous type. Twenty four of 38 tumors had bright signal intensity on T1 weighted images. Of these 24 tumors, 22 (91.7%) were adamantinomatous and 2 were papillary type. Cystic change on T2 weighted images was noted in 37 of 38 tumors; only 1 tumor with papillary type did not show cystic change.
Conclusion
T1 bright signal intensity and calcification on CT scans uniformly favor the adamantinomatous type over papillary type of craniopharyngioma in children. However, these findings are more variable in adults where calcification and T1 bright signal intensity occur in 70.6% and 58.8% respectively of adult adamantinomatous types of craniopharyngiomas.
doi:10.3340/jkns.2016.59.5.466
PMCID: PMC5028606  PMID: 27651864
Craniopharyngioma; Tomography scanners, X-ray computed; Magnetic resonance imaging
21.  Surgery versus Nerve Blocks for Lumbar Disc Herniation : Quantitative Analysis of Radiological Factors as a Predictor for Successful Outcomes 
Objective
To assess the clinical and radiological factors as predictors for successful outcomes in lumbar disc herniation (LDH) treatment.
Methods
Two groups of patients with single level LDH (L4–5) requiring treatment were retrospectively studied. The surgery group (SG) included 34 patients, and 30 patients who initially refused the surgery were included in the nerve blocks group (NG). A visual analogue scale (VAS) for leg and back pain and motor deficit were initially evaluated before procedures, and repeated at 1, 6, and 12 months. Radiological factors including the disc herniation length, disc herniation area, canal length-occupying ratio, and canal area-occupying ratio were measured and compared. Predicting factors of successful outcomes were determined with multivariate logistic regression analysis after the optimal cut off values were established with a receiver operating characteristic curve.
Results
There was no significant demographic difference between two groups. A multivariate logistic regression analysis with radiological and clinical (12 months follow-up) data revealed that the high disc herniation length with cutoff value 6.31 mm [odds ratio (OR) 2.35; confidence interval (CI) 1.21–3.98] was a predictor of successful outcomes of leg pain relief in the SG. The low disc herniation length with cutoff value 6.23 mm (OR 0.05; CI 0.003–0.89) and high baseline VAS leg (OR 12.63; CI 1.64–97.45) were identified as predictors of successful outcomes of leg pain relief in the NG.
Conclusion
The patients with the disc herniation length larger than 6.31 mm showed successful outcomes with surgery whereas the patients with the disc herniation length less than 6.23 mm showed successful outcomes with nerve block. These results could be considered as a radiological criteria in choosing optimal treatment options for LDH.
doi:10.3340/jkns.2016.59.5.478
PMCID: PMC5028608  PMID: 27651866
Lumbar disc herniation; Surgery; Nerve block; Outcomes; Criteria
22.  Analysis of Mortality and Epidemiology in 2617 Cases of Traumatic Brain Injury : Korean Neuro-Trauma Data Bank System 2010–2014 
Objective
The aims of the Korean Neuro-Trauma Data Bank System (KNTDBS) are to evaluate and improve treatment outcomes for brain trauma, prevent trauma, and provide data for research. Our purpose was to examine the mortality rates following traumatic brain injury (TBI) in a retrospective study and to investigate the sociodemographic variables, characteristics, and causes of TBI-related death based on data from the KNTDBS.
Methods
From 2010 to 2014, we analyzed the data of 2617 patients registered in the KNTDBS. The demographic characteristics of patients with TBI were investigated. We divided patients into 2 groups, survivors and nonsurvivors, and compared variables between the groups to investigate variables that are related to death after TBI. We also analyzed variables related to the interval between TBI and death, mortality by region, and cause of death in the nonsurvivor group.
Results
The frequency of TBI in men was higher than that in women. With increasing age of the patients, the incidence of TBI also increased. Among 2617 patients, 688 patients (26.2%) underwent surgical treatment and 125 patients (4.7%) died. The age distributions of survivors vs. nonsurvivor groups and mortality rates according the severity of the brain injury, surgical treatment, and initial Glasgow Coma Scale (GCS) scores were statistically significantly different. Among 125 hospitalized nonsurvivors, 70 patients (56%) died within 7 days and direct brain damage was the most common cause of death (80.8%). The time interval from TBI to death differed depending on the diagnosis, surgical or nonsurgical treatment, severity of brain injury, initial GCS score, and cause of death, and this difference was statistically significant.
Conclusion
Using the KNTDBS, we identified epidemiology, mortality, and various factors related to nonsurvival. Building on our study, we should make a conscious effort to increase the survival duration and provide rapid and adequate treatment for TBI patients.
doi:10.3340/jkns.2016.59.5.485
PMCID: PMC5028609  PMID: 27651867
Korean Neuro-Trauma Data Bank System; Mortality; Traumatic brain injury
23.  Which One Is Better to Reduce the Infection Rate, Early or Late Cranioplasty? 
Objective
Decompressive craniectomy is an effective therapy to relieve high intracranial pressure after acute brain damage. However, the optimal timing for cranioplasty after decompression is still controversial. Many authors reported that early cranioplasty may contribute to improve the cerebral blood flow and brain metabolism. However, despite all the advantages, there always remains a concern that early cranioplasty may increase the chance of infection. The purpose of this retrospective study is to investigate whether the early cranioplasty increase the infection rate. We also evaluated the risk factors of infection following cranioplasty.
Methods
We retrospectively examined the results of 131 patients who underwent cranioplasty in our institution between January 2008 and June 2015. We divided them into early (≤90 days) and late (>90 days after craniectomy) groups. We examined the risk factors of infection after cranioplasty. We analyzed the infection rate between two groups.
Results
There were more male patients (62%) than female (38%). The mean age was 49 years. Infection occurred in 17 patients (13%) after cranioplasty. The infection rate of early cranioplasty was lower than that of late cranioplasty (7% vs. 20%; p=0.02). Early cranioplasty, non-metal allograft materials, re-operation before cranioplasty and younger age were the significant factors in the infection rate after cranioplasty (p<0.05). Especially allograft was a significant risk factor of infection (odds ratio, 12.4; 95% confidence interval, 3.24–47.33; p<0.01). Younger age was also a significant risk factor of infection after cranioplasty by multivariable analysis (odds ratio, 0.96; 95% confidence interval, 0.96–0.99; p=0.02).
Conclusion
Early cranioplasty did not increase the infection rate in this study. The use of non-metal allograft materials influenced a more important role in infection in cranioplasty. Actually, timing itself was not a significant risk factor in multivariate analysis. So the early cranioplasty may bring better outcomes in cognitive functions or wound without raising the infection rate.
doi:10.3340/jkns.2016.59.5.492
PMCID: PMC5028610  PMID: 27651868
Cranioplasty; Infection; Decompressive craniectomy; Hydroxyapatities
24.  Impact of Time Interval between Trauma Onset and Burr Hole Surgery on Recurrence of Late Subacute or Chronic Subdural Hematoma 
Objective
Although subdural hematoma (SDH) is commonly treatable by burr hole surgery in the late subacute or chronic stage, there is no clear consensus regarding appropriate management and exact predictive factors for postoperative recurrence also remain unclear. The aim of this study was to evaluate risk factors associated with recurrence of SDH that requires burr hole surgery in the late subacute or chronic stage. We also identified the appropriate timing of surgery for reducing the recurrence.
Methods
We retrospectively reviewed 274 patients with SDH in the late subacute or chronic stage treated with burr hole surgery in our hospital between January 2007 and December 2014. Excluding patients with acute intracranial complications or unknown time of trauma onset left 216 patients included in the study.
Results
Of 216 patients with SDH in the late subacute or chronic stage, recurrence was observed in 36 patients (16.7%). The timing of the operation in patients with late subacute stage (15–28 days) resulted in a significant decrease in recurrence (RR, 0.33; 95% CI, 0.17–0.65; p=0.001) compared to chronic stage (>28 days). Otherwise, no significant risk factors were associated with recurrences including comorbidities and surgical details.
Conclusion
The results indicated that time from trauma onset to burr hole surgery may be important for decreasing the risk of recurrence. Therefore, unless patients can be treated conservatively without surgery, prompt surgical management is recommended in patients diagnosed as having late subacute or chronic subdural hematoma treatable by burr hole surgery, even when neurological deficits are unclear.
doi:10.3340/jkns.2016.59.5.498
PMCID: PMC5028611  PMID: 27651869
Subdural hematoma; Recurrence; Time
25.  Bioglue-Coated Teflon Sling Technique in Microvascular Decompression for Hemifacial Spasm Involving the Vertebral Artery 
Objective
Microvascular decompression (MVD) for hemifacial spasm (HFS) involving the vertebral artery (VA) can be technically challenging. We investigated the therapeutic effects of a bioglue-coated Teflon sling technique on the VA during MVD in 42 cases.
Methods
A bioglue-coated Teflon sling was crafted by the surgeon and applied to patients in whom neurovascular compression was caused by the VA. The radiologic data, intra-operative findings with detailed introduction of the procedure, and the clinical outcomes of each patient were reviewed and analyzed.
Results
The 42 patients included in the analysis consisted of 22 females and 20 males, with an average follow-up duration of 76 months (range 24–132 months). Intraoperative investigation revealed that an artery other than the VA was responsible for the neurovascular compression in all cases : posterior inferior cerebellar artery (PICA) in 23 patients (54.7%) and anterior inferior cerebellar artery (AICA) in 11 patients (26.2%). All patients became symptom-free after MVD. Neither recurrence nor postoperative neurological deficit was noted during the 2-year follow-up, except in one patient who developed permanent deafness. Cerebrospinal fluid (CSF) leak occurred in three patients, and one required dural repair.
Conclusion
Transposition of the VA using a bioglue-coated Teflon sling is a safe and effective surgical technique for HFS involving the VA. A future prospective study to compare clinical outcomes between groups with and without use of this novel technique is required.
doi:10.3340/jkns.2016.59.5.505
PMCID: PMC5028612  PMID: 27651870
Hemifacial spasm; Vertebral artery; Microvascular decompression; Sling; Teflon; Bioglue

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