A 38-year-old man fell from a chair with a chopstick in his hand. The chopstick penetrated his left eye. He noticed pain, swelling, and numbness around his left eye. On physical examination, a linear wound was noted at the medial aspect of the left eyelid. Noncontrast computed tomography (CT) study showed a linear hypodense structure extending from the medial aspect of the left orbit to the occipital bone, suggesting a foreign body. This foreign body was hyperdense relative to normal parenchyma. From a CT scan with 3-dimensional reconstruction, the foreign body was found to be passing through the optic canal into the cranium. The clear plastic chopstick was withdrawn without difficulty. The patient was discharged home 3 weeks after his surgery. A treatment plan for a transorbital penetrating injury should be determined by a multidisciplinary team, with input from neurosurgeons and ophthalmologists.
Penetrating; Foreign body; Orbit; Craniocerebral trauma
Tumors of the central nervous system are common in the pediatric population and constitute the second most prevalent tumor type in children. Within this group, spinal cord tumors are relatively rare and account for 1 to 10% of all pediatric central nervous system tumors. We describe a very rare case of an intradural extramedullary spinal cord tumor with a subcutaneous mass and discuss its clinical presentation, pathogenesis, and treatment. A male infant was delivered normally, with uneventful development. At 16 days post-delivery, his family took him to a pediatrician because of a mass on his upper back. Magnetic resonance imaging of the thoracic spine revealed a well-demarcated soft-tissue mass with central cystic change or necrosis at the subcutaneous layer of the posterior back (T2-7 level). Another mass was found with a fat component at the spinal canal of the T1-3 level, which was intradural extramedullary space. After six weeks, the spinal cord tumor and subcutaneous mass were grossly total resected; pathologic findings indicated an atypical myxoid spindle cell neoplasm, possibly nerve sheath in type. The final diagnosis of the mass was an atypical myxoid spindle cell neoplasm. The postoperative course was uneventful, and the patient was discharged after nine days without any neurological deficit. We report a rare case of an intradural extramedullary spinal tumor with subcutaneous mass in a neonate. It is necessary to monitor the patient's status by examining consecutive radiologic images, and the symptoms and neurological changes should be observed strictly during long-term follow-up.
Intradural extramedullary spinal cord neoplasm; Neonate; Congenital
Traumatic brachial plexus injuries can be devastating, causing partial to total denervation of the muscles of the upper extremities. Surgical reconstruction can restore motor and/or sensory function following nerve injuries. Direct nerve-to-nerve transfers can provide a closer nerve source to the target muscle, thereby enhancing the quality and rate of recovery. Restoration of elbow flexion is the primary goal for patients with brachial plexus injuries. A 4-year-old right-hand-dominant male sustained a fracture of the left scapula in a car accident. He was treated conservatively. After the accident, he presented with motor weakness of the left upper extremity. Shoulder abduction was grade 3 and elbow flexor was grade 0. Hand function was intact. Nerve conduction studies and an electromyogram were performed, which revealed left lateral and posterior cord brachial plexopathy with axonotmesis. He was admitted to Rehabilitation Medicine and treated. However, marked neurological dysfunction in the left upper extremity was still observed. Six months after trauma, under general anesthesia with the patient in the supine position, the brachial plexus was explored through infraclavicular and supraclavicular incisions. Each terminal branch was confirmed by electrophysiology. Avulsion of the C5 roots and absence of usable stump proximally were confirmed intraoperatively. Under a microscope, neurotization from the musculocutaneous nerve to two medial pectoral nerves was performed with nylon 8-0. Physical treatment and electrostimulation started 2 weeks postoperatively. At a 3-month postoperative visit, evidence of reinnervation of the elbow flexors was observed. At his last follow-up, 2 years following trauma, the patient had recovered Medical Research Council (MRC) grade 4+ elbow flexors. We propose that neurotization from medial pectoral nerves to musculocutaneous nerve can be used successfully to restore elbow flexion in patients with brachial plexus injuries.
Brachial plexus; Neurotization; Pectoral nerve; Musculocutaneous nerve
Compression of the ulnar nerve in Guyon's canal can result from repeated blunt trauma, fracture of the hamate's hook, and arterial thrombosis or aneurysm. In addition, conditions such as ganglia, rheumatoid arthritis and ulnar artery disease can rapidly compress the ulnar nerve in Guyon's canal. A ganglion cyst can acutely protrude or grow, which also might compress the ulnar nerve. So, clinicians should consider a ganglion cyst in Guyon's canal as a possible underlying cause of ulnar nerve compression in patients with a sudden decrease in hand strength. We believe that early decompression with removal of the ganglion is very important to promote complete recovery.
Guyon's canal; Ganglion cyst; Compression
The purpose of this study was to investigate the effectiveness and outcome of selective musculocutaneous neurotomy (SMcN) for spastic elbow.
We retrospectively reviewed the medical records of 14 patients with spasticity of their elbows. The patients were selected using clinical and analytical scales, as well as nerve block tests, for assessment. Their mean age was 37.29 years (range, 19-63 years). SMcN was performed for these patients, and the mean follow-up period was 30.71 months (range, 19-54 months).
The modified Ashworth scale (MAS) scores recorded before and after the SMcN showed that the patients' mean preoperative MAS score of 3.28 ± 0.12 was improved to 1.71 ± 0.12, 1.78 ± 0.18, 1.92 ± 0.16 and 1.78 ± 0.18 at postoperative 3, 6, 12 months and last follow-up, respectively. On the basis of a visual analogue score ranging from 0-100, the patients' mean degree of satisfaction score was 65.00 ± 16.52 (range, 30-90).
We believe that SMcN can be a good and effective treatment modality with low morbidity in appropriately selected patients who have localized spastic elbow with good antagonist muscles and without joint contracture.
Elbow; Muscle spasticity; Musculocutaneous nerve; Neurotomy; Surgical procedure
A 52-year-old female patient presented with an 8-year history of progressively intense pain, cold sensitivity, and severe tenderness to palpation of the ulnar side of the tip of her right little finger. Subsequent diagnostic evaluation with ultrasonographic imaging revealed the presence of a glomus tumor in the tender area. Glomus tumors are benign, occurring in the vascular hamartomatous tubercles of the glomus body, which is a myoarterial apparatus typically found in the reticular dermis of the skin. Distal glomus tumors are relatively uncommon, and account for approximately 1% of all hand tumors. Most of them are located in the subungual area because of its high concentration of glomus bodies. We report a case of a glomus tumor with a typical triad of symptoms, yet with a rare location : on the pulp of the ulnar aspect of the distal phalanx of the right little finger.
Glomus tumor; Finger; Pain
Sacral nerve stimulation (SNS) is an effective treatment for bladder and bowel dysfunction, and also has a role in the treatment of chronic pelvic pain. We report two cases of intractable pain associated with cauda equina syndrome (CES) that were treated successfully by SNS. The first patient suffered from intractable pelvic pain with urinary incontinence and fecal incontinence after surgery for a herniated lumbar disc. The second patient underwent surgery for treatment of a burst fracture and developed intractable pelvic area pain, right leg pain, excessive urinary frequency, urinary incontinence, voiding difficulty and constipation one year after surgery. A SNS trial was performed on both patients. Both patients' pain was significantly improved and urinary symptoms were much relieved. Neuromodulation of the sacral nerves is an effective treatment for idiopathic urinary frequency, urgency, and urge incontinence. Sacral neuromodulation has also been used to control various forms of pelvic pain. Although the mechanism of action of neuromodulation remains unexplained, numerous clinical success reports suggest that it is a therapy with efficacy and durability. From the results of our research, we believe that SNS can be a safe and effective option for the treatment of intractable pelvic pain with incomplete CES.
Sacral Plexus; Neuromodulator; Pain; Cauda Equina
Selective neurotomy is generally a safe, effective, and long-lasting treatment for patients with spastic equinovarus foot deformity. We retrospectively analyzed the results of microsurgical selective tibial neurotomy (STN) for spastic feet in adults and children.
A neurosurgeon selected 32 patients with 45 spastic feet (adults : 13, children : 32) to undergo microsurgical STN between October 1998 and September 2007. A physician of rehabilitation assessed spasticity pre- and postoperatively, that was based on the Ashworth scale, ankle clonus, and the amplitude of ankle dorsiflexion. The mean postoperative follow-up period was 36.7 months in adults and 42.5 months in children.
Spastic components of the feet were corrected immediately after surgery in both the adult and child groups. The mean Ashworth's grade changed from 3.6 ± 0.40 to 1.6 ± 0.70 in adults and from 3.7 ± 0.69 to 1.4 ± 0.49 in children. Mean ankle clonus decreased markedly, from 1.6 ± 0.79 to 0.3 ± 0.42 in adults and from 1.7 ± 0.65 to 0.3 ± 0.56 in children. The mean amplitude of ankle dorsiflexion was improved, but eight (adults: 4, children: 4) contracted feet needed complementary orthopedic correction for acceptable results.
STN can be effective in the long-term for improving lower limb function and reduction of equinovarus deformity. Our results demonstrate that STN might be an effective procedure for treating localized harmful spastic feet in adults and children.
Foot; Spasticity; Surgical procedures; Children; Adults
A 54-year-old man experienced injury to the second finger of his left hand due to damage from a paintball gun shot 8 years prior, and the metacarpo-phalangeal joint was amputated. He gradually developed mechanical allodynia and burning pain, and there were trophic changes of the thenar muscle and he reported coldness on his left hand and forearm. A neuroma was found on the left second common digital nerve and was removed, but his symptoms continued despite various conservative treatments including a morphine infusion pump on his left arm. We therefore attempted median nerve stimulation to treat the chronic pain. The procedure was performed in two stages. The first procedure involved exposure of the median nerve on the mid-humerus level and placing of the electrode. The trial stimulation lasted for 7 days and the patient's symptoms improved. The second procedure involved implantation of a pulse generator on the left subclavian area. The mechanical allodynia and pain relief score, based on the visual analogue scale, decreased from 9 before surgery to 4 after surgery. The patient's activity improved markedly, but trophic changes and vasomotor symptom recovered only moderately. In conclusion, median nerve stimulation can improve chronic pain from complex regional pain syndrome type II.
Complex regional pain syndrome; Median nerve; Peripheral nerve stimulation
Cardiac dysfunction after aneurysmal subarachnoid hemorrhage (SAH) is associated with elevation of serum cardiac troponin I (cTnI) levels. Elevation of cTnI predicts cardiopulmonary and neurological complications, and poor outcome.
We retrospectively reviewed the medical and radiologic records of 114 (male : 30, female : 84) patients who developed aneurysmal SAH between January 2006 and June 2007 and had no history of previous cardiac problems. We evaluated their electrocardiography and cTnI level, which had been measured at admission. A cTnI level above 0.5 µg/L was defined as an indicator of cardiac injury following SAH. We examined various clinical factors for their association with cTnI elevation and analyzed data using chi-square test, t-test and logistic regression test with SPSS version 12.0. The results were considered significant at p < 0.05.
The following parameters shows a correlation with cTnI elevation : higher Hunt-Hess (H-H) grade (p = 0.000), poor Glasgow Outcome Scale (GOS) score (p = 0.000), profound pulmonary complication (p = 0.043), higher heart rate during initial three days following SAH (p = 0.029), ruptured aneurysm on communicating segment of internal carotid artery (p = 0.025), incidence of vasospasm (p = 0.421), and duration of hyperdynamic therapy for vasospasm (p = 0.292). A significant determinants for outcome were cTnI elevation (p = 0.046) and H-H grade (p = 0.000) in a multivariate study.
A cTnI is a good indicator for cardiopulmonary and neurologic complications and outcome following SAH. Consideration of variable clinical factors that related with cTnI elevation may be useful tactics for treatment of SAH and concomitant complications.
Subarachnoid hemorrhage; Cardiac troponin I; Complications; Vasospasm
While syringomyelia is not a rare spinal disorder, syringomyelia associated with a spinal arachnoid cyst is very unusual. Here, we report a 62-year-old man who suffered from gait disturbance and numbness of bilateral lower extremities. Spinal magnetic resonance imaging (MRI) showed the presence of a spinal arachnoid cyst between the 7th cervical and 3rd thoracic vertebral segment and syringomyelia extending between the 6th cervical and 1st thoracic vertebral segment. The cyst had compressed the spinal cord anteriorly. Syringomyelia usually results from lesions that partially obstruct cerebrospinal fluid flow. Therefore, we concluded that the spinal arachnoid cyst was causing the syringomyelia. After simple excision of the arachnoid cyst, the symptoms were relieved. A follow-up MRI demonstrated that the syringomyelia had significantly decreased in size after removal of the arachnoid cyst. This report presents an unusual case of gait disturbance caused by syringomyelia associated with a spinal arachnoid cyst.
Syringomyelia; Arachnoid cyst; Spinal cord neoplasm
Although the incidence of unilateral abducens nerve palsy has been reported to be as high as 1% to 2.7% of head trauma cases, bilateral abducens nerve palsy following trauma is extremely rare. In this report, we present the case of a patient who developed a bilateral abducens nerve palsy and hypoglossal nerve palsy 3 days after suffering head trauma. He had a Glasgow Coma Score (GCS) of 15 points. Computed tomography (CT) images demonstrated clivus epidural hematoma and subarachnoid hemorrhage on the basal cistern. Herein, we discuss the possible mechanisms of these nerve palsies and its management.
Abducens nerve palsy; Hypoglossal nerve palsy; Epidural hematoma; Clivus
Premorbid demographic backgrounds of injured individuals are likely to reflect more accurately the status of patients with traumatic brian injury (TBI) than clinical factors. However, the concrete study about the relationship between the demographic factors and neurocognitive function in TBI patients has not been reported. The object of this study was to evaluate the effect of premorbid demographic factors on the recovery of neurocognitive function following TBI.
From July 1998 to February 2007, 293 patients (male: 228, female: 65) with a history of head injury, who had recovered from the acute phase, were selected from our hospital to include in this study. We analyzed the effect of premorbid demographic factors including age, sex, educational level and occupation on the recovery of neurocognitive function in each TBI subgroup as defined by Glasgow Coma Scale (GCS) score. Intelligence and memory are components of neurocognitive function, and the Korean Wechsler Intelligence Scale (K-WAIS) and the Korean memory assessment scale (K-MAS) were used in this study. The results were considered significant at p<0.05.
The higher level of education was a good prognostic factor for intelligence regardless of GCS score and younger age group showed a better result for memory with an exception of severe TBI group. In the severe TBI group, the meaningful effect of demographic factors was not noted by the cause of influence of severe brain injury.
The demographic factors used in this study may be helpful for predicting the precise prognosis and developing an appropriate rehabilitation program for TBI patients.
Traumatic brain injury; Premorbid demographic factors; Prognosis
Bone cement leakage is a well-known potential complication of percutaneous vertebroplasty (PVP) in patients with osteoporotic compression fracture. Even though there has been a controversy in the efficacy of antecedent venography to prevent this complication, many authors have performed intraosseous venography before bone cement injection. The goal of this study was to classify the venous drainage patterns of spine before PVP, and compare their patterns at different vertebral levels.
The authors retrospectively reviewed 1,042 intraosseous venographic patterns in 321 patients with 574 osteoporotic compression fractures during six-year period in one institution. To classify venogram patterns, we selected simple lateral X-ray of spine taken immediately after injection of the contrast dye. We classified the venography patterns according to contrast leakage pattern and leakage direction as follows; trabecular (TR), trabecular anterior (TA), trabecular posterior (TP), trabecular anterior-posterior (TAP), trabecular lateral (TL), venous anterior(VA), venous posterior (VP), venous anterior-posterior (VAP), soft tissue (ST). Also, we compared venogram patterns according to different spinal levels.
In overall, the most common pattern was TP type accounting for 37.4% (390/1042) of all intraosseous venograms. This is followed by TAP in 21.5%, TR 17.4%, TA 11.6%, TL 5.8%, ST 4.1%, VA 1.2%, VP 0.6%, and VAP 0.4% in descending order of frequency. According to the spinal level, TR and TAP types were most common in thoracic spine (T6-T10), TP type was most common in thoraco-lumbar spine (T11-L2), and TP and TAP types were most common in lumbo-sacral spine (L3-S1). Contrast dye leakage to soft tissue such as psoas muscle or disc were detected in 43 (4.1%) venograms. Direct venous drainage without staining of vertebral body was found in 23 (2.2%) venograms. The 8.3% of thoracic venogram showed direct venous drainage. Thoracic level showed a more tendency of direct venous drainage than other spine levels (p<0.01).
The authors propose a new classification system of intraosseous venography during PVP. The trabecular-posterior (TP) type is most common through all spine, and venous-filling (V) type was most frequent in thoracic spine. Further study would be necessary to elucidate the efficacy of this classification system to prevent bone cement leakage during PVP.
Percutaneous vertebroplasty; Bone cement leakage; Venography pattern; Osteoporosis; Compression fracture
The purpose of the present study is to assess the long-term results of microsurgical dorsal root entry zonotomy (MDT) for the treatment of medically intractable upper-extremity spasticity.
The records of nine adult patients who underwent MDT by one operating neurosurgeon from March 1999 to June 2004 were retrospectively reviewed by another investigator who had no role in the management of these patients. In all patients, MDT was performed on all roots of the upper limb (from C5 to T1) for spasticity of the upper extremity. The degree of spasticity was measured by the Modified Ashworth Scale (grade 0-4). Severity of the pain level was determined using the Numeric Rating Scale (NRS, score 0-10). Also, patient satisfaction of the post-operative outcome was assessed.
Comparing the preoperative and postoperative spasticity using the Modified Ashworth Scale, we observed improvement in all patients, particularly in five of the nine patients (55.6%) who improved by three grades over an average of 66.4 months (range, 40-96). Regarding patient satisfaction, seven patients (77.8%) had affirmative results. None of the patients experienced severe, life-threatening, postoperative complications. We observed a decrease in the intensity of painful spasms to less than three scores as measured by NRS in all four patients with associated pain.
This study shows that MDT provides significant, long-term reduction of harmful spasticity and associated pain in the upper limbs.
Muscle spasticity; Upper extremity; Spinal cord; DREZ operation; Long-term effect
The surgical approach is typically similar to those used for other supraclinoid internal carotid artery (ICA) lesions. However, the surgical clipping of this aneurysm is complicated and as a result, can result in postoperative ischemic complications. We studied to clarify the clip-induced ischemic complication risk of AChA aneurysm and to get the benefits for helping decision making.
We retrospectively investigated 53 cases (4.0%) of AchA aneurysm treated surgically. We divided the AChA aneurysm to 3 subtype according to the origin of aneurysmal neck; A type originating from the AChA itself, J type from junction of AChA and ICA, and I type from the ICA itself. We evaluated brain CT about 1 week post-operative day to confirm the low density in AChA territory.
Ruptured aneurysm was 26 cases and unruptured aneurysm 27 cases. The aneurysmal subtype of A, J, and I was 13, 17, and 23 cases. Of the 53 cases who performed surgical neck clipping, twelve (22.6%) had postoperative AChA distribution infarcts. Increased infarct after neck clipping had statistic significance in non-I subtype (p=0.005).
It is easy to classify as "easy" surgery. But surgery for AChA aneurysms carries with it a significant risk of postoperative stroke. Don't always stick to clipping only, especially in non-I type of incidental small aneurysm, which has high risk of post-clip ischemic complications.
Anterior choroidal artery infarction; Clip; Intracranial aneurysm
The purpose of this study is to identify the factors affecting the failure of trials (<50% pain reduction in pain for trial period) to improve success rate of spinal cord stimulation (SCS) trial.
A retrospective review of the failed trials (44 patients, 36.1%) among the patients (n=122) who underwent SCS trial between January 1990 and December 1998 was conducted. We reviewed the causes of failed trial stimulation, age, sex, etiology of pain, type of electrode, and third party support.
Of the 44 patients, 65.9% showed unacceptable pain relief in spite of sufficient paresthesia on the pain area with trial stimulation. Four of six patients felt insufficient paresthesia with stimulation had the lesions of the spinal cord. Seventy five percent of the patients experienced unpleasant or painful sensation during stimulation had allodynia dominant pain. Third-party involvement, sex, age and electrode type had no influence on the outcome.
We conclude that SCS trial is less effective for patients with neuropathic pain of cord lesions, postherpetic neuropathy or post-amputation state. Further, patients with allodynia dominant pain can feel unpleasant or painful during trial stimulation.
Spinal cord stimulation; Cord lesion; Allodynia; Paresthesia; Chronic pain
We report a case of arachnoid cyst in which subdural hematoma and intracystic hemorrhage developed spontaneously. Usually, arachnoid cysts are asymptomatic, but can become symptomatic because of cyst enlargement or hemorrhage, often after mild head trauma. Although they are sometimes combined with subdural hematoma, intracystic hemorrhage has rarely been observed. Our patient had a simultaneous subdural hematoma and intracystic hemorrhage without evidence of head trauma.
Arachnoid cyst; Spontaneous intracystic hemorrhage; Subdural hematoma