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1.  Intracranial Extension of Spinal Subarachnoid Hematoma Causing Severe Cerebral Vasospasm 
Spinal subarachnoid hemorrhages (SAH) can extend into the intracranial subarachnoid space, but, severe cerebral vasospasm is rare complication of the extension of intracranial SAH from a spinal subarachnoid hematoma. A 67-year-old woman started anticoagulant therapy for unstable angina. The next day, she developed severe back pain and paraplegia. MRI showed intradural and extramedullar low signal intensity at the T2-3, consistent with intradural hematoma. High signal intensity was also noted in the spinal cord from C5 to T4. We removed subarachnoid hematoma compressing the spinal cord. The following day, the patient complained of severe headache. Brain CT revealed SAH around both parietal lobes. Three days later, her consciousness decreased and left hemiplegia also developed. Brain MRI demonstrated multiple cerebral infarctions, mainly in the right posterior cerebral artery territory, left parietal lobe and right watershed area. Conventional cerebral angiography confirmed diffuse severe vasospasm of the cerebral arteries. After intensive care for a month, the patient was transferred to the rehabilitation department. After 6 months, neurologic deterioration improved partially. We speculate that surgeons should anticipate possible delayed neurological complications due to cerebral vasospasm if intracranial SAH is detected after spinal subarachnoid hematoma.
doi:10.3340/jkns.2014.56.6.527
PMCID: PMC4303733  PMID: 25628817
Spinal subarachnoid hematoma; Intracranial subarachnoid hemorrhage; Vasospasm; Cerebral infarction
2.  Modic Degenerative Marrow Changes in the Thoracic Spine : A Single Center Experience 
Objective
The purposes of this study were to evaluate the prevalence, types, and locations of Modic changes (MCs) in the thoracic spine in a large number of subjects, and to investigate the relation between the distributions of MCs and disc herniations (DHs) in the thoracic spine.
Methods
Two experienced musculoskeletal radiologists assessed the presence of MCs and DHs by consensus in the thoracic MRIs of 144 patients with non-specific back pain. Patient ages ranged from 22 to 88 years (mean=53.3±14.66 years), and 72 were female (50%). The prevalence, distribution, relation of MCs and DHs was recorded.
Results
MC was observed in 8 of the 144 patients (5.6%) and 10 of 1728 segments (0.58%). The most common MC was type II. Of the 8 patients exhibiting MC, 6 had type II (75.0%), and 2 had mixed MCs (type I/II or type II/III). MCs were distributed mainly at the mid-thoracic level (from T5/6 to T9/10). DH was detected in 18 patients (12.5%), 36 of 1728 segments (2.1%). Of the 10 segments exhibiting MC, 5 had DHs at the same level (50.0%). Accordingly, DH was strongly associated with MC (p=0.000).
Conclusion
A low prevalence of MC was observed in the thoracic spine, and type II MC predominated. The low prevalence of MC in the thoracic spine suggests that it was caused by a relative lack of mobility as compared with the cervical and lumbar spines. And DHs were found to be strongly associated with MCs even in the thoracic spine.
doi:10.3340/jkns.2013.54.1.34
PMCID: PMC3772284  PMID: 24044078
Prevalence; Modic change; Thoracic spine; Disc herniation
3.  Imaging Findings of Solitary Spinal Bony Lesions and the Differential Diagnosis of Benign and Malignant Lesions 
Objective
The purpose of this study was to present the MRI and CT findings of solitary spinal bone lesions (SSBLs) with the aims of aiding the differential diagnoses of malignant tumors and benign lesions, and proposing a diagnostic strategy for obscure SSBLs.
Methods
The authors retrospectively reviewed the imaging findings of 19 patients with an obscure SSBL on MRI at our hospital from January 1994 to April 2011. The 19 patients were divided to benign groups and malignant groups according to final diagnosis. MRI and CT findings were evaluated and the results of additional work-up studies were conducted to achieve a differential diagnosis.
Results
At final diagnoses, 10 (52.6%) of the 19 SSBLs were malignant tumors and 9 (47.4%) were benign lesions. The malignant tumors included 6 metastatic cancers, 3 multiple myelomas, and 1 chordoma, and the benign lesions included 4 osteomyelitis, 2 hemangiomas, 2 nonspecific chronic inflammations, and 1 giant cell tumor. No MRI characteristics examined was found to be significantly different in the benign and malignant groups. Reactive sclerotic change was observed by CT in 1 (10.0%) of the 10 malignant lesions and in 7 (77.8%) of the 9 benign lesions (p=0.005).
Conclusion
Approximately half of the obscure SSBLs were malignant tumors. CT and MRI findings in combination may aid the differential diagnosis of obscure SSBLs. In particular, sclerotic change on CT images was an important finding implying benign lesion. Finally, we suggest a possible diagnostic strategy for obscure SSBLs on MRI.
doi:10.3340/jkns.2012.52.2.126
PMCID: PMC3467370  PMID: 23091671
Solitary spinal bone lesion; Differential diagnosis; MRI; CT; benign lesion; Malignant lesion
4.  The Obturator Guiding Technique in Percutaneous Endoscopic Lumbar Discectomy 
In conventional percutaneous disc surgery, introducing instruments into disc space starts by inserting a guide needle into the triangular working zone. However, landing the guide needle tip on the annular window is a challenging step in endoscopic discectomy. Surgeons tend to repeat the needling procedure to reach an optimal position on the annular target. Obturator guiding technique is a modification of standard endoscopic lumbar discectomy, in which, obturator is used to access triangular working zone instead of a guide needle. Obturator guiding technique provides more vivid feedback and easy manipulation. This technique decreases the steps of inserting instruments and takes safer route from the peritoneum.
doi:10.3340/jkns.2012.51.3.182
PMCID: PMC3358610  PMID: 22639720
Diskectomy; Percutaneous; Intervertebral disc disease; Endoscope
5.  The Effect of Body Mass Index on Intra-Abdominal Pressure and Blood Loss in Lumbar Spine Surgery 
Objective
The purpose of this prospective study was to evaluate the effects of body mass index (BMI) on intra-abdominal pressure (IAP) and intraoperative blood loss (IBL) during lumbar spinal surgery.
Methods
Thirty patients scheduled for single level posterior lumbar interbody fusion were allocated equally to a normal group (Group 1, BMI;18.5-22.9 kg/m2), an overweight group (Group 2, BMI; 23-24.9 kg/m2), and an obese group (Group 3, BMI; 25.0-29.9 kg/m2) according to BMI. IAP was measured using a urinary bladder catheter; 1) supine after anesthesia induction, 2) prone at skin incision, 3) prone at the end of surgery. In addition, IBL was also measured in the three groups.
Results
IAP in the supine position was not significantly different in groups 1, 2, and 3 (2.7 mm Hg, 3.0 mm Hg, and 4.2 mm Hg, respectively) (p=0.258), and IAP in the prone position at incision increased to 7.8 mm Hg, 8.2 mm Hg, and 10.4 mm Hg, respectively, in the three groups, and these intergroup differences were significant, especially for Group 3 (p=0.000). IAP at the end of surgery was slightly lower (7.0 mm Hg, 7.7 mm Hg, and 9.2 mm Hg, respectively). IBLs were not significantly different between the three groups. However, IBLs were found to increase with IAP in the prone position (p=0.022) and BMI (p<0.05).
Conclusion
These results show that BMI affects IAP in the prone position more than in the supine position during lumbar spinal surgery. In addition, IBLs were found to increase with IAP in the prone position and with BMI. Thus, IBLs can be expected to be higher in morbidly obese patients due to an increased IAP.
doi:10.3340/jkns.2012.51.2.81
PMCID: PMC3322212  PMID: 22500198
Body mass index; Intra-abdominal pressure; Urinary bladder pressure; Intraoperative blood loss; Posterior lumbar interbody fusion
6.  Computer-Assisted Modified Mid-Sacrectomy for En Bloc Resection of Chordoma and Preservation of Bladder Function 
A 67-year-old woman presented for evaluation of severe coccygeal pain. The computed tomography scans and magnetic resonance imaging showed an asymmetric midline sacral tumor invading the right lower portion of S2. To preserve both S2 nerve roots and to obtain negative surgical margins, a modified mid-sacrectomy with an aid of a computed navigation system was performed. The sacral tumor was excised en bloc with negative tumor margins. Both S2 nerve roots were preserved and additional reconstruction was not necessary because of minimal resection of the sacroiliac joint. We report a case of a sacral chordoma which was excised en bloc with adequate surgical margins by a computer-assisted modified mid-sacrectomy. The computed navigation system may be a useful tool for tumor targeting and safe osteotomies in sacral tumor surgery via the posterior only approach.
doi:10.3340/jkns.2011.50.6.523
PMCID: PMC3272515  PMID: 22323941
Sacral chordoma; Sacrectomy; En bloc resection; Computed navigation system
7.  An Unusual Case of Cerebral Penetrating Injury by a Driven Bone Fragment Secondary to Blunt Head Trauma 
Temple trauma that appears initially localized to the skin might possess intracranial complications. Early diagnosis and management of such complications are important, to avoid neurologic sequelae. Non-penetrating head injuries with intracranial hemorrhage caused by a driven bone fragment are extremely rare. A 53-year-old male was referred to our hospital because of intracerebral hemorrhage. He was a mechanic and one day before admission to a local clinic, tip of metallic rod hit his right temple while cutting the rod. Initial brain computed tomography (CT) and magnetic resonance imaging demonstrated scanty subdural hematoma at right temporal lobe and left falx and intracerebral hematoma at both frontal lobes. Facial CT with 3-D reconstruction images showed a small bony defect at the right sphenoid bone's greater wing and a small bone fragment at the left frontal lobe, crossing the falx. We present the unusual case of a temple trauma patient in whom a sphenoid bone fragment migrated from its origin upward, to the contralateral frontal lobe, producing hematoma along its trajectory.
doi:10.3340/jkns.2011.50.6.532
PMCID: PMC3272517  PMID: 22323943
Head injury; Penetrating; Bone fragment
8.  Cervical Fibrous Dysplasia Presenting as a Pathologic Fracture in an Older Patient 
Vertebral involvement of fibrous dysplasia (FD) is rare, especially in the cervical spine. Moreover, cervical FD presenting as a pathologic fracture in older patients is extremely rare. We report a case of symptomatic cervical FD associated with pathologic fracture in a 63-year-old man. The patient presented with progressive weakness of the left arm and pain in the shoulder and arm. Radiologic studies revealed a collapsed and typical 'ground glass' radiolucency of C4. Multiple lytic lesions involved the odontoid process of C2 and the body, left pedicle, and posterior elements of C4. Combined anterior and posterior decompression and reconstruction were performed. Post-operatively, the histopathologic examination confirmed FD. On the post-operative follow-up examination, the neurologic deficits had completely resolved.
doi:10.3340/jkns.2011.50.2.139
PMCID: PMC3206278  PMID: 22053236
Fibrous dysplasia; Cervical spine; Elderly
9.  Primary Extramedullary Ependymoma of the Cervical Spine : Case Report and Review of the Literature 
Intradural extramedullary (IDEM) ependymomas occur very rarely and little has been reported about their clinical characteristics. The authors present a case of a 57-year-old woman with an IDEM ependymoma. She was referred for the evaluation of a 4-month history of increasing neck pain and muscular weakness of the left extremities. Magnetic resonance imaging (MRI) of the cervical spine demonstrated an IDEM tumor with spinal cord compression. At the time of surgery, an encapsulated IDEM tumor without a dural attachment or medullary infiltration was noted, but the tumor capsule adherent to the spinal cord and root was left in place to minimize the risk of neurological sequelae. Histologic examination revealed a benign classic ependymoma. The post-operative course was uneventful and radiotherapy was performed. The patient showed an excellent clinical recovery, with no recurrence after 5 years of follow-up.
doi:10.3340/jkns.2011.50.1.57
PMCID: PMC3159884  PMID: 21892408
Intradural extramedullary; Ependymoma; Cervical spine
10.  Inferiorly Migrated Disc Fragment at T1 Body Treated by T1 Transcorporeal Approach 
Upper thoracic vertebral bodies are difficult to access using standard anterior approaches. It may require sternotomy and claviculectomy, which carries significant possibility of morbidities. We report a case of inferiorly migrated cervicothoracic junction disc treated successfully by anterior upper-vertebral transcorporeal approach. This specific technique obviated the need of sternotomy, created favorable working space and saved the motion segment at cervicothoracic junction. This report is the first transcorporeal approach to a disc fragment at T1-2 space without fusion.
doi:10.3340/jkns.2011.49.1.61
PMCID: PMC3070898  PMID: 21494366
Intervertebral disc; Transcorporeal approach; Upper thoracic vertebral disc
11.  Lumbar Osteochondroma Arising from Spondylolytic L3 Lamina 
Osteochondromas are common, benign tumors in the long bones, but osteochondromas are rare in the vertebrae. Most vertebral osteochondromas arise from the cervical or upper thoracic spine. However, lumbar osteochondromas have rarely been reported. In this report, a rare case of a lumbar osteochondroma arising from the spondylolytic L3 lamina in a 57-year-old woman is presented. She also had a ruptured disc and lumbar canal stenosis at L4-5-S1. The osteochondroma was completely removed and a posterior lumbar interbody fusion and instrumentation were performed. Considering the rarity of osteochondromas in the lumbar vertebrae, especially the L3 vertebra, it is possible that the pre-existing lumbar spondylolysis or spondylolisthesis was one of the factors affecting the occurrence or progression of the osteochondroma.
doi:10.3340/jkns.2010.47.4.313
PMCID: PMC2864829  PMID: 20461177
Lumbar osteochondroma; Spondylolysis
12.  Load Sharing Mechanism Across Graft-Bone Interface in Static Cervical Locking Plate Fixation 
Objective
This study is a retrospective clinical study over more than 4 years of follow up to understand the mechanism of load sharing across the graft-bone interface in the static locking plate (SLP) fixation compared with non-locking plate (NLP).
Methods
Orion locking plates and Top non-locking plates were used for SLP fixation in 29 patients and NLP fixation in 24 patients, respectively. Successful interbody fusion was estimated by dynamic X-ray films. The checking parameters were as follows : screw angle (SA) between upper and lower screw, anterior and posterior height of fusion segment between upper and lower endplate (AH & PH), and upper and lower distance from vertebral endplate to the end of plate (UD & LD). Each follow-up value of AH and PH were compared to initial values. Contributions of upper and lower collapse to whole segment collapse were estimated.
Results
Successful intervertebral bone fusion rate was 100% in the SLP group and 92% in the NLP group. The follow-up mean value of SA in SLP group was not significantly changed compared with initial value, but follow-up mean value of SA in NLP group decreased more than those in SLP group (p=0.0067). Statistical analysis did not show a significant difference in the change in AH and PH between SLP and NLP groups (p>0.05). Follow-up AH of NLP group showed more collapse than PH of same group (p=0.04). The upper portion of the vertebral body collapsed more than the lower portion in the SLP fixation (p=0.00058).
Conclusion
The fused segments with SLP had successful bone fusion without change in initial screw angle, which was not observed in NLP fixation. It suggests that there was enough load sharing across bone-graft interface in SLP fixation.
doi:10.3340/jkns.2009.45.4.213
PMCID: PMC2682116  PMID: 19444346
Cervical vertebrae; Spinal fusion; Surgical Fixation Devices
13.  Short Segment Anterior Correction of Adolescent Idiopathic Scoliosis 
Objective
The purpose of this study was to introduce our surgical experiences of scoliosis and to evaluate the effectiveness of anterior correction and fusion in adolescent idiopathic scoliosis (AIS).
Methods
Between August 2004 and August 2007, four patients with AIS were treated with anterior segmental fusion and fixation at our hospital. Mean follow-up period was 9 (6-12) months. The average age was 14.0 (13-15) years. According to Lenke classification, three patients showed Lenke 1 curve and one patient with Lenke 5 curve. Single rod instrumentation was performed in one patient, dual rod instrumentation in one patient and combined rod instrumentation in two patients. Coronal Cobb measurements were performed on all curves in thoracic, thoracolumbar and, lumbar spine and the angle of hump was measured by a scoliometer pre- and postoperatively.
Results
The average operative time was 394 minutes (255-525) with an average intraoperative blood loss of 1,225 ml (1,000-1,700). The mean period of hospital stay was 19.3 days and there was no complication related to the surgery. The mean Cobb angle was reduced from 43.3° to 14.8° (65.8% correction) postoperatively and the rib hump corrected less than 5°. All patients and their parents were satisfied with the deformity correction.
Conclusion
Anterior spinal correction and fusion of AIS with Lenke 1 and 5 curve showed excellent deformity correction without any complications. In particular, we recommend anterior dual rod instrumentation because of mechanical stability, better control of kyphosis, and a higher fusion rate.
doi:10.3340/jkns.2008.44.1.52
PMCID: PMC2588289  PMID: 19096658
Adolescent idiopathic scoliosis; Anterior correction and fusion; Rod instrumentation

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