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1.  Neuroprotective Effects of Sacral Epidural Neuromodulation Following Spinal Cord Injury : An Experimental Study in Rats 
Objective
The purpose of this study is to evaluate neuroprotective effect of sacral neuromodulation in rat spinal cord injury (SCI) model in the histological and functional aspects.
Methods
Twenty-one female Sprague Dawley rats were randomly divided into 3 groups : the normal control group (CTL, n=7), the SCI with sham stimulation group (SCI, n=7), and the SCI with electrical stimulation (SCI+ES, n=7). Spinal cord was injured by dropping an impactor from 25 mm height. Sacral nerve electrical stimulation was performed by the following protocol : pulse duration, 0.1 ms; frequency, 20 Hz; stimulation time, 30 minutes; and stimulation duration, 4 weeks. Both locomotor function and histological examination were evaluated as scheduled.
Results
The number of anterior horn cell was 12.3±5.7 cells/high power field (HPF) in the CTL group, 7.8±4.9 cells/HPF in the SCI group, and 6.9±5.5 cells/HPF in the SCI+ES group, respectively. Both the SCI and the SCI+ES groups showed severe loss of anterior horn cells and myelin fibers compared with the CTL group. Cavitation and demyelinization of the nerve fibers has no significant difference between the SCI group and the SCI+ES group. Cavitation of dorsal column was more evident in only two rats of SCI group than the SCI+ES group. The locomotor function of all rats improved over time but there was no significant difference at any point in time between the SCI and the SCI+ES group.
Conclusion
In a rat thoracic spinal cord contusion model, we observed that sacral neuromodulation did not prevent SCI-induced myelin loss and apoptosis.
doi:10.3340/jkns.2012.52.6.509
PMCID: PMC3550416  PMID: 23346320
Electrical stimulation; Spinal cord injury; Neuroprotection; Sacral nerve; Neuromodulation
2.  Medial Loop of V2 Segment of Vertebral Artery Causing Compression of Proximal Cervical Root 
Objective
It is rare that the medial loop in the V2 segment of the vertebral artery (VA) causes compression of the proximal cervical root of the spinal cord without leading to bony erosion and an enlarged foramen. We evaluated the clinical significance and incidence of the medial loop in the V2 segment of the VA.
Methods
We reviewed the records from 1000 consecutive patients who had undergone magnetic resonance imaging evaluation of the cervical spine between January 2005 and January 2008. The inclusion criteria were that over a third of the axial aspect of the VA located in the intervertebral foramen was inside the line between the most ventral points of the bilateral lateral mass, and that the ipsilateral proximal root deviated dorsally because of the medial loop of the VA. We excluded cases of bone erosion, a widened foramen at the medial loop of the VA, any bony abnormalities, tumors displacing VA, or vertebral fractures. The medical records were reviewed retrospectively to search for factors of clinical significance.
Results
In six patients (0.6%), the VA formed a medial loop that caused compression of the proximal cervical root. One of these patients had the cervical radiculopathy that developed after minor trauma but the others did not present with cervical radiculopathy related to the medial loop of the VA.
Conclusion
The medial loop of the VA might have a direct effect on cervical radiculopathy. Therefore, this feature should be of critical consideration in preoperative planning and during surgery.
doi:10.3340/jkns.2012.52.6.513
PMCID: PMC3550417  PMID: 23346321
Vertebral artery; Medial loop; Spine
3.  Long-Term Follow-Up Result of Hydroxyurea Chemotherapy for Recurrent Meningiomas 
Objective
Meningiomas represent 18-20% of all intracranial tumors and have a 20-50% 10-year recurrence rate, despite aggressive surgery and irradiation. Hydroxyurea, an inhibitor of ribonucleotide reductase, is known to inhibit meningioma cells by induction of apoptosis. We report the long-term follow-up result of hydroxyurea therapy in the patients with recurrent meningiomas.
Methods
Thirteen patients with recurrent WHO grade I or II meningioma were treated with hydroxyurea (1000 mg/m2/day orally divided twice per day) from June 1998 to February 2012. Nine female and 4 male, ranging in age from 32 to 83 years (median age 61.7 years), were included. Follow-up assessment included physical examination, computed tomography, and magnetic resonance imaging (MRI). Standard neuro-oncological response criteria (Macdonald criteria) were used to evaluate the follow-up MRI scans. The treatment was continued until there was objective disease progression or onset of unmanageable toxicity.
Results
Ten of the 13 patients (76.9%) showed stable disease after treatment, with time to progression ranging from 8 to 128 months (median 72.4 months; 6 patients still accruing time). However, there was no complete response or partial response in any patients. Three patients had progressive disease after 88, 89, 36 months, respectively. There was no severe (Grade III-IV) blood systemic disorders and no episodes of non-hematological side effects.
Conclusion
This study showed that hydroxyurea is a modestly active agent against recurrent meningiomas and can induce long-term stabilization of disease in some patients. We think that hydroxyurea treatment is well tolerated and convenient, and could be considered as an alternative treatment option in patients with recurrent meningiomas prior to reoperation or radiotherapy.
doi:10.3340/jkns.2012.52.6.517
PMCID: PMC3550418  PMID: 23346322
Meningioma; Chemotherapy; Hydroxyurea; Recurrence
4.  Clinical Outcomes of Spontaneous Spinal Epidural Hematoma : A Comparative Study between Conservative and Surgical Treatment 
Objective
The incidence of spontaneous spinal epidural hematoma (SSEH) is rare. Patients with SSEH, however, present disabling neurologic deficits. Clinical outcomes are variable among patients. To evaluate the adequate treatment method according to initial patients' neurological status and clinical outcome with comparison of variables affecting the clinical outcome.
Methods
We included 15 patients suffered from SSEH. Patients were divided into two groups by treatment method. Initial neurological status and clinical outcomes were assessed by the American Spinal Injury Association (ASIA) impairment scale. Also sagittal hematoma location and length of involved segment was analyzed with magnetic resonance images. Other factors such as age, sex, premorbid medication and duration of hospital stay were reviewed with medical records. Nonparametric statistical analysis and subgroup analysis were performed to overcome small sample size.
Results
Among fifteen patients, ten patients underwent decompressive surgery, and remaining five were treated with conservative therapy. Patients showed no different initial neurologic status between treatment groups. Initial neurologic status was strongly associated with neurological recovery (p=0.030). Factors that did not seem to affect clinical outcomes included : age, sex, length of the involved spinal segment, sagittal location of hematoma, premorbid medication of antiplatelets or anticoagulants, and treatment methods.
Conclusion
For the management of SSEH, early decompressive surgery is usually recommended. However, conservative management can also be feasible in selective patients who present neurologic status as ASIA scale E or in whom early recovery of function has initiated with ASIA scale C or D.
doi:10.3340/jkns.2012.52.6.523
PMCID: PMC3550419  PMID: 23346323
Spinal epidural hematoma; Surgery; Conservative management; Outcome
5.  Clinical Comparison of the Predictive Value of the Simple Skull X-Ray and 3 Dimensional Computed Tomography for Skull Fractures of Children 
Objective
In the pediatric population the skull has not yet undergone ossification and it is assumed that the diagnostic rate of skull fractures by simple X-rays are lower than that of adults. It has been recently proposed that the diagnostic rates of skull fractures by 3-dimensional computer tomography (3D-CT) are higher than simple X-rays. The authors therefore attempted to compare the diagnostic rates of pediatric skull fractures by simple X-rays and 3D-CTs with respect to the type of fracture.
Methods
One-hundred patients aged less than 12 years who visited the Emergency Center for cranial injury were subject to simple X-rays and 3D-CTs. The type and location of the fractures were compared and Kappa statistical analysis and the t-test were conducted.
Results
Among the 100 pediatric patients, 65 were male and 35 were female. The mean age was 50±45 months. 63 patients had simple skull fractures and 22 had complex fractures, and the types of fractures were linear fractures in 74, diastatic fractures 15, depressed fractures in 10, penetrating fracture in 1, and greenstick fractures in 3 patients. Statistical difference was observed for the predictive value of simple skull fractures' diagnostic rate depending on the method for diagnosis. A significant difference of the Kappa value was noted in the diagnosis of depressed skull fractures and diastatic skull fractures.
Conclusion
In the majority of pediatric skull fractures, 3D-CT showed superior diagnosis rates compared to simple skull X-rays and therefore 3D-CT is recommended whenever skull fractures are suspected. This is especially true for depressed skull fractures and diastatic skull fractures.
doi:10.3340/jkns.2012.52.6.528
PMCID: PMC3550420  PMID: 23346324
3-dimensional computer tomography; Diastatic skull fracture; Pediatric skull fracture; Simple skull radiography; Depressed skull fracture
6.  Radiosurgical Techniques and Clinical Outcomes of Gamma Knife Radiosurgery for Brainstem Arteriovenous Malformations 
Objective
Brainstem arteriovenous malformation (AVM) is rare and radiosurgical management is complicated by the sensitivity of the adjacent neurological structures. Complete obliteration of the nidus is not always possible. We describe over 20 years of radiosurgical procedures for brainstem AVMs, focusing on clinical outcomes and radiosurgical techniques.
Methods
Between 1992 and 2011, the authors performed gamma knife radiosurgery (GKRS) in 464 cerebral AVMs. Twenty-nine of the 464 patients (6.3%) reviewed had brainstem AVMs. This series included sixteen males and thirteen females with a mean age of 30.7 years (range : 5-71 years). The symptoms that led to diagnoses were as follows : an altered mentality (5 patients, 17.3%), motor weakness (10 patients, 34.5%), cranial nerve symptoms (3 patients, 10.3%), headache (6 patients, 20.7%), dizziness (3 patients, 10.3%), and seizures (2 patients, 6.9%). Two patients had undergone a previous nidus resection, and three patients had undergone a previous embolization. Twenty-four patients underwent only GKRS. With respect to the nidus type and blood flow, the ratio of compact type to diffuse type and high flow to low flow were 17 : 12 and 16 : 13, respectively. In this series, 24 patients (82.8%) had a prior hemorrhage. The mean target volume was 1.7 cm3 (range 0.1-11.3 cm3). The mean maximal and marginal radiation doses were 38.5 Gy (range 28.6-43.6 Gy) and 23.4 Gy (range 18-27 Gy), and the mean isodose profile was 61.3% (range 50-70%).
Results
Twenty-four patients had brainstem AVMs and were followed for more than 3 years. Obliteration of the AVMs was eventually documented in 17 patients (70.8%) over a mean follow-up period of 77.5 months (range 36-216 months). With respect to nidus type and blood flow, the obliteration rate of compact types (75%) was higher than that of diffuse types (66.7%), and the obliteration rate of low flow AVMs (76.9%) was higher than that of high flow AVMs (63.6%) (p<0.05). Two patients (6.9%) with three hemorrhagic events suffered a hemorrhage during the follow-up period. The annual bleeding rate of AVM after GKRS was 1.95% per year. No adverse radiation effects or delayed cystic formations were found.
Conclusion
GKRS has an important clinical role in treatment of brainstem AVMs, which carry excessive surgical risks. Angiographic features and radiosurgical techniques using a lower maximal dose with higher isodose profiles are important for lesion obliteration and the avoidance of complications.
doi:10.3340/jkns.2012.52.6.534
PMCID: PMC3550421  PMID: 23346325
Brainstem; Arteriovenous malformation; Gamma knife radiosurgery
7.  Customized Cranioplasty Implants Using Three-Dimensional Printers and Polymethyl-Methacrylate Casting 
Objective
The prefabrication of customized cranioplastic implants has been introduced to overcome the difficulties of intra-operative implant molding. The authors present a new technique, which consists of the prefabrication of implant molds using three-dimensional (3D) printers and polymethyl-methacrylate (PMMA) casting.
Methods
A total of 16 patients with large skull defects (>100 cm2) underwent cranioplasty between November 2009 and April 2011. For unilateral cranial defects, 3D images of the skull were obtained from preoperative axial 1-mm spiral computed tomography (CT) scans. The image of the implant was generated by a digital subtraction mirror-imaging process using the normal side of the cranium as a model. For bilateral cranial defects, precraniectomy routine spiral CT scan data were merged with postcraniectomy 3D CT images following a smoothing process. Prefabrication of the mold was performed by the 3D printer. Intraoperatively, the PMMA implant was created with the prefabricated mold, and fit into the cranial defect.
Results
The median operation time was 184.36±26.07 minutes. Postoperative CT scans showed excellent restoration of the symmetrical contours and curvature of the cranium in all cases. The median follow-up period was 23 months (range, 14-28 months). Postoperative infection was developed in one case (6.2%) who had an open wound defect previously.
Conclusion
Customized cranioplasty PMMA implants using 3D printer may be a useful technique for the reconstruction of various cranial defects.
doi:10.3340/jkns.2012.52.6.541
PMCID: PMC3550422  PMID: 23346326
Decompressive craniectomy; Reconstructive surgical procedure; Computer-aided design; Polymethyl-methacrylate
8.  Successful Treatment of Tracheoinnominate Artery Fistula Following Tracheostomy in a Patient with Cerebrovascular Disease 
Tracheoinnominate artery fistula is a critical complication of tracheostomy. The most important factors influencing patient outcome are prompt diagnosis, immediate control of bleeding with a patent airway, and emergency operation with or without interruption of the innominate artery. Here, we report a case of tracheoinnominate artery fistula in a 40-year-old woman with cerebrovascular accident who was successfully managed with an aorta-axillary artery bypass.
doi:10.3340/jkns.2012.52.6.547
PMCID: PMC3550423  PMID: 23346327
Complication; Tracheoinnominate artery fistula; Tracheostomy
9.  Superficial Temporal Artery-Middle Cerebral Artery Anastomosis for Internal Carotid Artery Occlusion by Subacute In-Stent Thrombosis after Carotid Artery Stenting 
Alternative to carotid endarterectomy, carotid artery stenting (CAS) can be performed for symptomatic severe stenosis of internal carotid artery, especially for high-risk patients. Among several complications after CAS, subacute in-stent thrombosis is rare but important, because patient's condition can deteriorate rapidly. Subacute in-stent thrombosis with carotid artery occlusion can be managed by superficial temporal artery-middle cerebral artery (STA-MCA) anastomosis. We report two cases of STA-MCA anastomosis for internal carotid artery occlusion by subacute in-stent thrombosis after CAS.
doi:10.3340/jkns.2012.52.6.551
PMCID: PMC3550424  PMID: 23346328
Carotid artery stenting (CAS); Subacute in-stent thrombosis; Superficial temporal artery-middle cerebral artery (STA-MCA) anastomosis
10.  Endoscope-Assisted Trans-Sphenoidal Approach for Treatment of Sternberg's Canal 
We report an uncommon case of a 45-year-old woman who presented with spontaneous rhinorrhea. A computed tomography (CT) scan of the head revealed an abnormally large sphenoid sinus associated with a parasellar bony defect (Sternberg's canal) through which magnetic resonance imaging could detect an encephalocele of the right temporal lobe. An endoscope-assisted trans-sphenoidal approach was performed and, with the aid of image guided surgery, reduction of the encephalocele was obtained and followed by surgical repair of the dural and bony defects. The postoperative course was uneventful and the cerebrospinal fluid fistula was closed as confirmed by the postoperative CT scan and by the absence of rhinorrhea. After three years of monitoring the patient remained asymptomatic.
doi:10.3340/jkns.2012.52.6.555
PMCID: PMC3550425  PMID: 23346329
Cerebrospinal fluid; Endoscope-assisted procedures; Sternberg's canal
11.  Experience with 5-Aminolevulinic Acid in Fluorescence-Guided Resection of a Deep Sylvian Meningioma 
The 5-aminolevulinic acid (5-ALA)-induced tumor fluorescence is a useful intraoperative marker for the diagnosis and the detection of various malignancies, but its use in meningioma is only reported infrequently. In meningioma, a complete resection of the tumor mass is crucial for the prevention of recurrence and postoperative morbidities. Deep sylvian meningioma is a rare type of meningioma where complete tumor removal is complicated by its deep anatomical location and close involvement with the middle cerebral artery. From our experience, 5-ALA-mediated fluorescence facilitated a safe excision whilst preserving critical neurovascular structures. To our best knowledge, this is first report from use of 5-ALA in a deep sylvian meningioma.
doi:10.3340/jkns.2012.52.6.558
PMCID: PMC3550426  PMID: 23346330
5-aminolevulinic acid; Resection; Deep sylvian meningioma; Meningioma without dural attachment
12.  Desmoplastic Fibroma of the Cranium in a Young Man 
Desmoplastic fibroma, which develops predominantly in long bones and the mandible, is a rare and benign but locally aggressive tumor. Desmoplastic fibroma of the cranium is extremely rare. We report a case of desmoplastic fibroma of the frontal bone in a young man. Because of its locally aggressive behavior, complete surgical excision with a safety margin is essential.
doi:10.3340/jkns.2012.52.6.561
PMCID: PMC3550427  PMID: 23346331
Desmoplastic fibroma; Frontal bone; Skull
13.  Solitary Lymphoblastic Lymphoma of the Thoracic Spine 
Non-Hodgkin's lymphoma rarely originates from bone, and even more infrequently from a vertebral body. Lymphoblastic lymphoma is a rare type of non-Hodgkin's lymphoma, and results from an abnormality in adaptive immune cells. A 27-year-old man presented with a two-month history of night sweats, weight loss, and severe back pain. Radiological studies demonstrated an osteolytic lesion compressing the subarachnoid space at the T11 level. Posterolateral fusion with decompression was performed and a pathologic examination confirmed lymphoblastic lymphoma of the B-cell precursor type. To our knowledge, this is the first report of solitary lymphoblastic lymphoma from B-cell precursors in of the thoracic spine. Herein, we discuss the presenting symptoms and the management of this rare case of lymphoblastic lymphoma.
doi:10.3340/jkns.2012.52.6.564
PMCID: PMC3550428  PMID: 23346332
Lymphoblastic lymphoma; Spine
14.  Hemorrhagic Lumbar Synovial Cyst 
Synovial cysts of the lumbar spine are an uncommon cause of back and radicular pain. These cysts most frequently present as back pain, followed by chronic progressive radiculopathy or gradual onset of symptoms secondary to spinal canal compromise. Although less common, they can also present with acute spinal cord or root compression symptoms. We report of a case in which hemorrhaging into a right L2-3 facet synovial cyst caused an acute onset of back pain and radiculopathy, requiring surgical excision.
doi:10.3340/jkns.2012.52.6.567
PMCID: PMC3550429  PMID: 23346333
Lumbar spine; Synovial cyst; Hemorrhage
15.  Multiple Cervical Spinous Process Fractures in a Novice Golf Player 
Avulsion of spinous process, also called Clay-shoveler's fracture, is most prevalent among those engaged in hard physical labor. To the best of the author's knowledge, only one case of multiple spinous process fractures of the upper thoracic spine in a novice golfer has been reported. A 45-year-old female presented with intractable posterior neck pain. The patient experienced a sharp, sudden pain on the neck while swinging a golf club, immediately after the club head struck the ground. Dynamic cervical radiographic findings were C6 and C7 spinous process fractures. Magnetic resonance imaging revealed C6 and C7 spinous process fractures without spinal cord pathology. The patient was treated with pain medications and cervical bracing. The patient's pain gradually improved. The injury mechanism was speculated to be similar to Clay-shoveler's fracture. Lower cervical spinous process fractures can be associated with a golf swing. If the patient complains of long lasting neck pain and has a history of golf activity, further study should be conducted to rule out lower cervical spinous fracture.
doi:10.3340/jkns.2012.52.6.570
PMCID: PMC3550430  PMID: 23346334
Golf injury; Cervical spinous process fracture; Trapezius muscle
16.  Effect of Bone Cement Volume and Stiffness on Occurrences of Adjacent Vertebral Fractures after Vertebroplasty 
Objective
The purpose of this study is to find the optimal stiffness and volume of bone cement and their biomechanical effects on the adjacent vertebrae to determine a better strategy for conducting vertebroplasty.
Methods
A three-dimensional finite-element model of a functional spinal unit was developed using computed tomography scans of a normal motion segment, comprising the T11, T12 and L1 vertebrae. Volumes of bone cement, with appropriate mechanical properties, were inserted into the trabecular core of the T12 vertebra. Parametric studies were done by varying the volume and stiffness of the bone cement.
Results
When the bone cement filling volume reached 30% of the volume of a vertebral body, the level of stiffness was restored to that of normal bone, and when higher bone cement exceeded 30% of the volume, the result was stiffness in excess of that of normal bone. When the bone cement volume was varied, local stress in the bony structures (cortical shell, trabecular bone and endplate) of each vertebra monotonically increased. Low-modulus bone cement has the effect of reducing strain in the augmented body, but only in cases of relatively high volumes of bone cement (>50%). Furthermore, varying the stiffness of bone cement has a negligible effect on the stress distribution of vertebral bodies.
Conclusion
The volume of cement was considered to be the most important determinant in endplate fracture. Changing the stiffness of bone cement has a negligible effect on the stress distribution of vertebral bodies.
doi:10.3340/jkns.2012.52.5.435
PMCID: PMC3539076  PMID: 23323162
Finite element analysis; Bone cements; Vertebroplasty
17.  Effect of Cisternal Drainage on the Shunt Dependency Following Aneurysmal Subarachnoid Hemorrhage 
Objective
Shunt-dependent chronic hydrocephalus (SDCH) is known to be a major complication associated with aneurysmal subarachnoid hemorrhage (aSAH). Old age is known to be one of numerous factors related to the development of SDCH. This study investigated whether postoperative cisternal drainage affects the incidence of SDCH and clinical outcome in elderly patients with aSAH.
Methods
Fifty-nine patients participated in this study. All patients underwent aneurysmal clipping with cisternal cerebrospinal fluid (CSF) drainage. Clinical variables relevant to the study included age, sex, location of ruptured aneurysm, CT finding and clinical state on admission, clinical outcome, and CSF drainage. We first divided patients into two groups according to age (<70 years of age and ≥70 years of age) and compared the two groups. Secondly, we analyzed variables to find factors associated with SDCH in both groups (<70 years of age and ≥70 years of age).
Results
Of 59 patients, SDCH was observed in 20 patients (33.9 %), who underwent shunt placement for treatment of hydrocephalus. Forty seven percent of cases of acute hydrocephalus developed SDCH. In the elderly group (≥70 years of age), the duration and amount of CSF drainage did not affect the development of chronic hydrocephalus.
Conclusion
In elderly patients, although the incidence of SDCH was significantly higher, clinical outcome was acceptable. The duration and the amount of cisternal drainage did not seem to be related to subsequent development of chronic hydrocephalus within elderly patients aged 70 or older.
doi:10.3340/jkns.2012.52.5.441
PMCID: PMC3539077  PMID: 23323163
Aneurysmal subarachnoid hemorrhage; Acute hydrocephalus; Shunt-dependent chronic hydrocephalus; Old age; Intraventricular hemorrhage
18.  Introducing a New Risk Factor for Lumbar Disc Herniation in Females : Vertical Angle of the Sacral Curvature 
Objective
To characterize the importance of the vertical angle of the sacral curvature (VASC) in lumbar disc herniations.
Methods
Morphological data derived from lumbar sagittal MRI imaging. The statistical significance of the findings are discussed. The angles of 60 female patients with lumbar disc herniations (LDH) were compared with the 34 female patients without LDH.
Results
128 of the 185 patients met our inclusion criteria. The vertical angle of sacral curvature is statistically significantly bigger in females with lumbar disc herniations when compared to subjects in control group, 28.32 and 25.4, respectively. (p=0.034<0.05). Same difference was not seen in males.
Conclusion
The vertical angle of sagittal sacral curvature may be another risk factor in females with lumbar disc herniations.
doi:10.3340/jkns.2012.52.5.447
PMCID: PMC3539078  PMID: 23323164
Risk factor; Lumbar disc herniation; Females; Vertical angle of the sacral curvature
19.  Hybrid Surgery of Multilevel Cervical Degenerative Disc Disease : Review of Literature and Clinical Results 
Objective
In the present study, we evaluated the effect, safety and radiological outcomes of cervical hybrid surgery (cervical disc prosthesis replacement at one level, and interbody fusion at the other level) on the multilevel cervical degenerative disc disease (DDD).
Methods
Fifty-one patients (mean age 46.7 years) with symptomatic multilevel cervical spondylosis were treated using hybrid surgery (HS). Clinical [neck disability index (NDI) and Visual Analogue Scale (VAS) score] and radiologic outcomes [range of motion (ROM) for cervical spine, adjacent segment and arthroplasty level] were evaluated at routine postoperative intervals of 1, 6, 12, 24 months. Review of other similar studies that examined the HS in multilevel cervical DDD was performed.
Results
Out of 51 patients, 41 patients received 2 level hybrid surgery and 10 patients received 3 level hybrid surgery. The NDI and VAS score were significantly decreased during the follow up periods (p<0.05). The cervical ROM was recovered at 6 and 12 month postoperatively and the mean ROM of inferior adjacent segment was significantly larger than that of superior adjacent segments after surgery. The ROM of the arthoplasty level was preserved well during the follow up periods. No surgical and device related complications were observed.
Conclusion
Hybrid surgery is a safe and effective alternative to fusion for the management of multilevel cervical spondylosis.
doi:10.3340/jkns.2012.52.5.452
PMCID: PMC3539079  PMID: 23323165
Multilevel cervical spondylosis; Anterior cervical discectomy and fusion; Total disc replacement; Hybrid
20.  Cervical Pedicle Screw Insertion Using the Technique with Direct Exposure of the Pedicle by Laminoforaminotomy 
Objective
To present the accuracy and safety of cervical pedicle screw insertion using the technique with direct exposure of the pedicle by laminoforaminotomy.
Methods
We retrospectively reviewed 12 consecutive patients. A total of 104 subaxial cervical pedicle screws in 12 patients had been inserted. We also assessed the clinical and radiological outcomes and analyzed the direction and grade of pedicle perforation (grade 0: no perforation, 1: <25%, 2: 20% to 50%, 3: >50% of screw diameter) on the postoperative vascular-enhanced computed tomography scans. Grade 2 and 3 were considered as incorrect position.
Results
The correct position was found in 95 screws (91.3%); grade 0-75 screws, grade 1-20 screws and the incorrect position in 9 screws (8.7%); grade 2-6 screws, grade 3-3 screws. There was no neurovascular complication related with cervical pedicle screw insertion.
Conclusion
This technique (technique with direct exposure of the pedicle by laminoforaminotomy) could be considered relatively safe and easy method to insert cervical pedicle screw.
doi:10.3340/jkns.2012.52.5.459
PMCID: PMC3539080  PMID: 23323166
Cervical pedicle screw; Laminoforaminotomy; Pedicle perforation
21.  Magnetoencephalography Interictal Spike Clustering in Relation with Surgical Outcome of Cortical Dysplasia 
Objective
The aim of this study was to devise an objective clustering method for magnetoencephalography (MEG) interictal spike sources, and to identify the prognostic value of the new clustering method in adult epilepsy patients with cortical dysplasia (CD).
Methods
We retrospectively analyzed 25 adult patients with histologically proven CD, who underwent MEG examination and surgical resection for intractable epilepsy. The mean postoperative follow-up period was 3.1 years. A hierarchical clustering method was adopted for MEG interictal spike source clustering. Clustered sources were then tested for their prognostic value toward surgical outcome.
Results
Postoperative seizure outcome was Engel class I in 6 (24%), class II in 3 (12%), class III in 12 (48%), and class IV in 4 (16%) patients. With respect to MEG spike clustering, 12 of 25 (48%) patients showed 1 cluster, 2 (8%) showed 2 or more clusters within the same lobe, 10 (40%) showed 2 or more clusters in a different lobe, and 1 (4%) patient had only scattered spikes with no clustering. Patients who showed focal clustering achieved better surgical outcome than distributed cases (p=0.017).
Conclusion
This is the first study that introduces an objective method to classify the distribution of MEG interictal spike sources. By using a hierarchical clustering method, we found that the presence of focal clustered spikes predicts a better postoperative outcome in epilepsy patients with CD.
doi:10.3340/jkns.2012.52.5.466
PMCID: PMC3539081  PMID: 23323167
Epilepsy; Cortical dysplasia; Magnetoencephalography; Hierarchical clustering; Surgical outcome
22.  The Diagnostic Assessment of Hand Elevation Test in Carpal Tunnel Syndrome 
Objective
The aim of this study is to establish the value of hand elevation test as a reproducible provocative test for the diagnosis of carpal tunnel syndrome (CTS).
Methods
We had a prospective study of 45 hands of 38 patients diagnosed with CTS between April 2005 and February 2009. The diagnosis of CTS was based on the American Academy of Neurology clinical diagnostic criteria. Experimental and control group patients underwent Tinel's test, Phalen's test, carpal compression test and hand elevation test as provocative tests for CTS.
Results
We used chi-square analysis to compare Tinel's test and Phalen's test, carpal compression test with hand elevation test. The sensitivity and specificity of the hand elevation test is 86.7% and 88.9% each. Tinel's test had 82.2% sensitivity and 88.9% specificity. Phalen's test had 84.4% sensitivity and 86.7% specificity. Carpal compression test had 84.4% sensitivity 82.2% specificity. Comparisons of sensitivity and specificity between hand elevation test and Tinel's test, Phalen's test, and carpal compression test had no statistically significant differences. To compare the diagnostic accuracies of four tests, the area under the non-parametric receiver operating character curve was applied.
Conclusion
The hand elevation test has higher sensitivity and specificity than Tinel's test, Phalen's test, and carpal compression test. Chi-square statistical analysis confirms the hand elevation test is not ineffective campared with Tinel's test, Phalen's test, and carpal compression test.
doi:10.3340/jkns.2012.52.5.472
PMCID: PMC3539082  PMID: 23323168
Carpal tunnel syndrome; Hand elevation test; Tinel's test; Phalen's test; Carpal compression test
23.  Hyperperfusion Syndrome after Carotid Stent-Supported Angioplasty in Patients with Autonomic Dysfunction 
Cerebral hyperperfusion syndrome (CHS) is a rare, serious complication of carotid revascularization either after carotid endarterectomy or carotid stent placement. Although extensive effort has been devoted to reducing the incidence of CHS, little is known about the prevention. Postprocedural hypertension is very rare due to autoregulation of carotid baroreceptors but may occur if presented with autonomic dysfunction. We present two cases of CHS after cerebral revascularization that presented autonomic dysfunction.
doi:10.3340/jkns.2012.52.5.476
PMCID: PMC3539083  PMID: 23323169
Cerebral hyperperfusion syndrome; Autonomic dysfunction; Carotid artery angioplasty
24.  Dural Arteriovenous Fistula Involving an Isolated Sinus Treated Using Transarterial Onyx Embolization 
The authors present a case of isolated dural arteriovenous fistula (DAVF) in the transverse sinus, which developed six years after microvascular decompression caused by hemifacial spasm via suboccipital craniectomy. The lesion was successfully treated by transarterial embolization using Onyx. We reviewed the related radiologic and therapeutic features of DAVF involving an isolated sinus and described the feasibility of the use of Onyx.
doi:10.3340/jkns.2012.52.5.480
PMCID: PMC3539084  PMID: 23323170
Dural arteriovenous fistula; Isolated sinus; Onyx; Embolization
25.  Glioblastoma Multiforme with Subcutaneous Metastases, Case Report and Literature Review 
Glioblastoma multiforme (GBM) is the most common primary brain tumor and the most malignant astrocytoma in adults, with rare extra-cranial metastases, especially for subcutaneous metastases. It could be easily misdiagnosed as primary subcutaneous tumor. In this report, we describe a patient with pontine GBM who developed a subcutaneous swelling at the ipsilateral posterior cervical region 8 months after operation, and the pathological and immunocytochemical examination carry the same characteristics as the primary intracranial GBM cells, which defined it as subcutaneous metastasis. GBM with subcutaneous metastasis is extremely rare, and knowledge of a prior intracranial GBM, pathological examinations and immunocytochemical tests with markers typically expressed by GBM are of vital importance for the diagnosis of GBM metastasis. Surgical resection of subcutaneous swelling, followed by chemotherapy and radiotherapy, could be the best strategy of treatment for the patients with GBM subcutaneous metastasis.
doi:10.3340/jkns.2012.52.5.484
PMCID: PMC3539085  PMID: 23323171
Glioblastoma multiforme; Glioblastoma metastasis; Subcutaneous metastasis; Extracranial metastasis

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