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1.  Cervical Radiculopathy due to Cervical Degenerative Diseases : Anatomy, Diagnosis and Treatment 
A cervical radiculopathy is the most common symptom of cervical degenerative disease and its natural course is generally favorable. With a precise diagnosis using appropriate tools, the majority of patients will respond well to conservative treatment. Cervical radiculopathy with persistent radicular pain after conservative treatment and progressive or profound motor weakness may require surgery. Options for surgical management are extensive. Each technique has strengths and weaknesses, so the choice will depend on the patient's clinical profile and the surgeon's judgment.
doi:10.3340/jkns.2010.48.6.473
PMCID: PMC3053539  PMID: 21430971
Cervical radiculopathy; Diagnosis; Surgery
2.  The Role of Lumbar Drainage to Prevent Shunt-Dependent Hydrocephalus after Coil Embolization for Aneurysmal Subarachnoid Hemorrhage in Good-Grade Patients 
Objective
To evaluate the role of lumbar drainage in the prevention of shunt-dependent hydrocephalus after treatment of ruptured intracranial aneurysms by coil embolization in good-grade patients.
Methods
One-hundred-thirty consecutive patients with aneurysmal subarachnoid hemorrhage in good-grade patients (Hunt & Hess grades I-III), who were treated by coil embolization between August 2004 and April 2010 were retrospectively evaluated. Poor-grade patients (Hunt & Hess grades IV and V), a history of head trauma preceding the development of headache, negative angiograms, primary subarachnoid hemorrhage (SAH), and loss to follow-up were excluded from the study. We assessed the effects on lumbar drainage on the risk of shunt-dependent hydrocephalus related to coil embolization in patients with ruptured intracranial aneurysms.
Results
One-hundred-twenty-six patients (96.9%) did not develop shunt-dependent hydrocephalus. The 2 patients (1.5%) who developed acute hydrocephalus treated with temporary external ventricular drainage did not require permanent shunt diversion. Overall, 4 patients (3.1%) required permanent shunt diversion; acute hydrocephalus developed in 2 patients (50%). There was no morbidity or mortality amongst the patients who underwent a permanent shunt procedure.
Conclusion
Coil embolization of ruptured intracranial aneurysms may be associated with a lower risk for developing shunt-dependent hydrocephalus, possibly by active management of lumbar drainage, which may reflect less damage for cisternal anatomy than surgical clipping. Coil embolization might have an effect the long-term outcome and decision-making for ruptured intracranial aneurysms.
doi:10.3340/jkns.2010.48.6.480
PMCID: PMC3053540  PMID: 21430972
Coil embolization; Hydrocephalus; Lumbar drainage; Shunt
3.  In-Stent Stenosis of Stent Assisted Endovascular Treatment on Intracranial Complex Aneurysms 
Objective
To introduce the frequency and segment analysis of in-stent stenosis for intracranial stent assisted endovascular treatment on complex aneurysms.
Methods
A retrospective study was performed in 158 patients who had intracranial complex aneurysms and were treated by endovascular stent application with or without coil embolization. Of these, 102 patients were evaluated with catheter based angiography after 6, 12, and 18 months. Aneurysm location, using stent, time to stenosis, stenosis rate and narrowing segment were analyzed.
Results
Among follow-up cerebral angiography done in 102 patients, 8 patients (7.8%) were shown an in-stent stenosis. Two patients have unruptured aneurysm and six patients have ruptured one. Number of Neuroform stents were 7 cases (7.5%) and Enterprise stent in 1 case (11.1%). Six patients demonstrated in-stent stenosis at 6 months after stent application and remaining two patients were shown at 12 months, 18 months, respectively.
Conclusion
In-stent stenosis can be confronted after intracranial stent deployment. In our study, no patient showed symptomatic stenosis and there were no patients who required to further treatment except continuing antiplatets medication. In-stent stenosis has been known to be very few when they are placed into the non-pathologic parent artery during the complex aneurysm treatment, but the authors found that it was apt to happen on follow up angiography. Although the related symptom was not seen in our cases, the luminal narrowing at the stented area may result the untoward hemodynamic event in the specific condition.
doi:10.3340/jkns.2010.48.6.485
PMCID: PMC3053541  PMID: 21430973
Intracranial complex aneurysm; In-stent stenosis
4.  The Role of Bone Cement Augmentation in the Treatment of Chronic Symptomatic Osteoporotic Compression Fracture 
Objective
Bone cement augmentation procedures such as percutaneous vertebroplasty and balloon kyphoplasty have been shown to be effective treatment for acute or subacute osteoporotic vertebral compression fractures. The purpose of this study was to determine the efficacy of bone cement augmentation procedures for long standing osteoporotic vertebral compression fracture with late vertebral collapse and persistent back pain.
Methods
Among 278 single level osteoporotic vertebral compression fractures that were treated by vertebral augmentation procedures at our institute, 18 consecutive patients were included in this study. Study inclusion was limited to initially, minimal compression fractures, but showing a poor prognosis due to late vertebral collapse, intravertebral vacuum clefts and continuous back pain despite conservative treatment for more than one year. The subjects included three men and 15 women. The mean age was 70.7 with a range from 64 to 85 years of age. After postural reduction for two days, bone cement augmentation procedures following intraoperative pressure reduction were performed. Imaging and clinical findings, including the level of the vertebra involved, vertebral height restoration, injected cement volume, local kyphosis, clinical outcome and complications were analyzed.
Results
The mean follow-up period after bone cement augmentation procedures was 14.3 months (range 12-27 months). The mean injected cement volume was 4.1 mL (range 2.4-5.9 mL). The unipedicular approach was possible in 15 patients. The mean pain score (visual analogue scale) prior to surgery was 7.1, which decreased to 3.1 at 7 days after the procedure. The pain relief was maintained at the final follow up. The kyphotic angle improved significantly from 21.2 ± 4.9° before surgery to 10.4 ± 3.8° after surgery. The fraction of vertebral height increased from 30% to 60% after bone cement augmentation, and the restored vertebral height was maintained at the final follow up. There were no serious complications related to cement leakage.
Conclusion
In the management of even long-standing osteoporotic vertebral compression fracture for over one year, bone cement augmentation procedures following postural reduction were considered safe and effective treatment in cases of non-healing evidence.
doi:10.3340/jkns.2010.48.6.490
PMCID: PMC3053542  PMID: 21430974
Long standing; Compression fracture; Osteoporosis; Bone cement
5.  Clinical and Radiological Outcomes of Unilateral Facetectomy and Interbody Fusion Using Expandable Cages for Lumbosacral Foraminal Stenosis 
Objective
Surgical treatment of lumbosacral foraminal stenosis requires an understanding of the anatomy of the lumbosacral area in individual patients. Unilateral facetectomy has been used to completely decompress entrapment of the L5 nerve root, followed in some patients by posterior lumbar interbody fusion (PLIF) with stand-alone cages.
Methods
We assessed 34 patients with lumbosacral foraminal stenosis who were treated with unilateral facetectomy and PLIF using stand-alone cages in our center from January 2004 to September 2007. All the patients underwent follow-up X-rays, including a dynamic view, at 3, 6, 12, 24 months, and computed tomography (CT) at 24 months postoperatively. Clinical outcomes were analyzed with the mean numeric rating scale (NRS), Oswestry Disability Index (ODI) and Odom's criteria. Radiological outcomes were assessed with change of disc height, defined as the average of anterior, middle, and posterior height in plain X-rays. In addition, lumbosacral fusion was also assessed with dynamic X-ray and CT.
Results
Mean NRS score, which was 9.29 prior to surgery, was 1.5 at 18 months after surgery. The decrease in NRS was statistically significant. Excellent and good groups with regard to Odom's criteria were 31 cases (91%) and three cases (9%) were fair. Pre-operative mean ODI of 28.4 decreased to 14.2 at post-operative 24 months. In 30 patients, a bone bridge on CT scan was identified. The change in disc height was 8.11 mm, 10.02 mm and 9.63 mm preoperatively, immediate postoperatively and at 24 months after surgery, respectively.
Conclusion
In the treatment of lumbosacral foraminal stenosis, unilateral facetectomy and interbody fusion using expandable stand-alone cages may be considered as one treatment option to maintain post-operative alignment and to obtain satisfactory clinical outcomes.
doi:10.3340/jkns.2010.48.6.496
PMCID: PMC3053543  PMID: 21430975
Expandable cage; Foraminal stenosis; Lumbosacral spine
6.  Comparative Study of Lumbar Magnetic Resonance Imaging and Myelography in Young Soldiers with Herniated Lumbar Disc 
Objective
This study was undertaken to compare the diagnostic performances of magnetic resonance imaging (MRI), MR myelography (MRM) and myelography in young soldiers with a herniated lumbar disc (HLD).
Methods
Sixty-five male soldiers with HLD comprised the study cohort. A visual analogue scale for low back pain (VAS-LBP), VAS for leg radiating pain (VAS-LP), and Oswestry disability index (ODI) were applied. Lumbar MR, MRM, and myelographic findings were checked and evaluated by four independent radiologists, respectively. Each radiologist was asked to score (1 to 5) the degree of disc protrusion and nerve root compression using modified grading systems devised by the North American Spine Society and Pfirrmann and the physical examination rules for conscription in the Republic of Korea. Correlated coefficients between clinical and radiological factors were calculated. Interpretational reproducibility between MRI and myelography by four bases were calculated and compared.
Results
Mean patient age was 20.5 ± 1.1. Mean VAS-LBP and VAS-LP were 6.7 ± 1.6 and 7.4 ± 1.7, respectively. Mean ODI was 48.0 ± 16.2%. Mean MRI, MRM, and myelography scores were 3.3 ± 0.9, 3.5 ± 1.0, and 3.9 ± 1.1, respectively. All scores of diagnostic performances were significantly correlated (p < 0.05). However, none of these scores reflected the severity of patients' symptoms. There was no statistical difference of interpretational reproducibility between MRI and myelography.
Conclusion
Although MRI and myelography are based on different principles, they produce similar interpretational reproducibility in young soldiers with a HLD. However, these modalities do not reflect the severity of symptoms.
doi:10.3340/jkns.2010.48.6.501
PMCID: PMC3053544  PMID: 21430976
Comparison study; Herniated Lumbar Disc; Interpretational reproducibility; Magnetic Resonance Imaging; MR Myelography; Myelography
7.  Development of a Cognitive Level Explanation Model in Brain Injury : Comparisons between Disability and Non-Disability Evaluation Groups 
Objective
We investigated whether Disability Evaluation (DE) situations influence patients' neuropsychological test performances and psychopathological characteristics and which variable play a role to establish an explanation model using statistical analysis.
Methods
Patients were 536 (56.6%) brain-injured persons who met inclusion and exclusion criteria, classified into the DE group (DE; n = 300, 56.0%) and the non-DE group (NDE; n = 236, 44.0%) according to the neuropsychological testing's purpose. Next, we classified DE subjects into DE cluster 1 (DEC1; 91, 17.0%), DE cluster 2 (DEC2; 125; 23.3%), and DE cluster 3 (DEC3; 84, 15.7%) via two-step cluster analysis, to specify DE characteristics. All patients completed the K-WAIS, K-MAS, K-BNT, SCL-90-R, and MMPI.
Results
In comparisons between DE and NDE, the DE group showed lower intelligence quotients and more severe psychopathologic symptoms, as evaluated by the SCL-90-R and MMPI, than the NDE group did. When comparing the intelligence among the DE groups and NDE group, DEC1 group performed worst on intelligence and memory and had most severe psychopathologic symptoms than the NDE group did. The DEC2 group showed modest performance increase over the DEC1 and DEC3, similar to the NDE group. Paradoxically, the DEC3 group performed better than the NDE group did on all variables.
Conclusion
The DE group showed minimal "faking bad" patterns. When we divided the DE group into three groups, the DEC1 group showed typical malingering patterns, the DEC2 group showed passive malingering patterns, and the DEC3 group suggested denial of symptoms and resistance to treatment.
doi:10.3340/jkns.2010.48.6.506
PMCID: PMC3053545  PMID: 21430977
Disability evaluation; Brain injury; Malingering
8.  Postoperative Course and Recurrence of Chronic Subdural Hematoma 
Objective
Chronic subdural hematoma (CSDH) is known to have a significant recurrence rate. There are different criteria defining the recurrence of CSDH. We evaluated the postoperative course of CSDH and tried to propose the reasonable criteria of recurrence.
Methods
We retrospectively examined the medical records and pre- and postoperative CT scans of 149 consecutive patients who underwent surgery from January 2005 to December 2009. Diagnosis was confirmed by CT scanning or MRI. The postoperative courses were either resolved or recurrent. The resolved CSDH was one of the three types; early resolution, delayed resolution, or late resolution. The recurrent CSDH was one of the four types; recurrence without resolution, early recurrence after resolution, late recurrence after resolution, or recurrent-and-resolved type.
Results
The CSDH was resolved within 30 days after surgery in 58 (39%) patients, between 1 to 3 months in 62 (42%), and after 3 months in 11 (7%) patients. The CSDH was recurred in 18 (12%) patients. Late resolution or recurrence was more common in the aged. The recurrent hematoma was seen on the same side in 11 patients, on the different side in 7 patients. Recurrence was significantly more common in the thick hematomas.
Conclusion
For a working criteria of the recurrence of CSDH, we propose the early recurrence as return of symptoms or reaccumulation of the hematoma after a surgery within 3 months regardless of the location, amount or repeated operations. The late recurrence can be defined as reappearance or enlargement of a liquefied hematoma within the cranial cavity surrounded by the membranes or persistent CSDH beyond 3 months after surgery.
doi:10.3340/jkns.2010.48.6.518
PMCID: PMC3053546  PMID: 21430978
Chronic subdural hematoma; Craniocerebral trauma; Diagnosis; Recurrence; Risk Factors
9.  Transient Global Aphasia with Hemiparesis Following Cerebral Angiography : Relationship to Blood Brain Barrier Disruption 
Temporary disruption of the blood-brain barrier (BBB) after cerebral angiography is presumably caused by nonionic radiographic contrast medium (CM). We hereby report a case of 58-year-old woman who developed decreased mentality, global aphasia and aggravated right hemiparesis after cerebral angiography. Brain CT examination demonstrated gyriform enhancement throughout the left cerebral cortex and thalamus. MR diffusion did not reveal acute infarction. MR angiography did not show any stenosis, spasm or occlusion at the major cerebral vessels. Follow-up CT scan after 1 day did not show any gyriform enhancement. Worsened neurologic signs and symptoms were improved completely after 7 days. In the present study, disruption of the BBB with contrast medium after angiography seems to be the causative factor of transient neurologic deterioration.
doi:10.3340/jkns.2010.48.6.524
PMCID: PMC3053547  PMID: 21430979
Blood brain barrier (BBB) disruption; Contrast medium; Transient global aphasia; Transient hemiparesis; Cerebral angiography
10.  Fusiform Aneurysm Presenting with Cervical Radiculopathy in Ehlers-Danlos Syndrome 
Ehlers-Danlos syndrome (EDS) type IV is characterized by its clinical manifestations, which are easy bruising, thin skin with visible veins, and rupture of arteries, uterus, or intestines. Arterial complications are the leading cause of death in vascular EDS because they are unpredictable and surgical repair is difficult due to tissue fragility. The authors report a case presented with cervical radiculopathy due to a segmental fusiform aneurysm of the cervical vertebral artery. Transfemoral cerebral angiography (TFCA) was done to verify the aneurysmal dilatation. However, during TFCA, bleeding at the puncture site was not controlled, skin and underlying muscle was disrupted and profound bleeding occurred during manual compression after femoral catheter removal. Accordingly, surgical repair of the injured femoral artery was performed. At this time it was possible to diagnose it as an EDS with fusiform aneurysm on cervical vertebral artery. Particularly, cervical fusiform aneurysm is rare condition, and therefore, connective tissue disorder must be considered in such cases. If connective tissue disorder is suspected, the authors suggest that a noninvasive imaging modality, such as, high quality computed tomography angiography, be used to evaluate the vascular lesion to avoid potential arterial complications.
doi:10.3340/jkns.2010.48.6.528
PMCID: PMC3053548  PMID: 21430980
Ehlers-Danlos syndrome; Cervical radiculopathy; Fusiform aneurysm; Vascular reconstruction
11.  Development of De Novo Cavernous Hemangioma after Radiosurgery for Cavernous Hemangioma 
We report a rare case of cavernous hemangioma (CH) which developed in adjacent location to a preexisting CH after gamma knife radiosurgery (GKRS). A 36-year-old woman underwent GKRS for a CH in the left lentiform nucleus. Three-and-half years after radiosurgery, MRI revealed a new CH in the left caudate nucleus. Surgical excision of the new lesion was performed. The pathological examination confirmed the diagnosis of CH. In radiosurgery for CH, it should be noted that a new CH may develop, which is likely to result from the interaction between radiation and predisposing factors of the patient.
doi:10.3340/jkns.2010.48.6.532
PMCID: PMC3053549  PMID: 21430981
Cavernous hemangioma; Cavernous angioma; Gamma knife; Radiosurgery; Radiation-induced tumor
12.  Noncommunicating Spinal Extradural Meningeal Cyst in Thoracolumbar Spine 
Spinal extradural meningeal cyst has been rarely reported, whose etiologies are assumed to be the communication of cerebrospinal fluid (CSF) between intradural subarchnoid space and cyst due to the congenital defect in dura mater. Although the CSF communication due to this defect can be found, in most case, few cases in which there is a lack of the communication have also been reported. We report a case of the huge extradural meningeal cyst occurring in the thoracolumbar spine (from T10 to L2) where there was a lack of the communication between the intradural subarachnoid space and cyst in a 46-year-old man who presented with symptoms that were indicative of progressive paraparesis and leg pain. The patient underwent laminectomy and cyst excision. On intraoperative findings, the dura was intact and there was a lack of the communication with intradural subarachnoid space. Immediately after the surgery, weakness and leg pain disappeared shortly.
doi:10.3340/jkns.2010.48.6.534
PMCID: PMC3053550  PMID: 21430982
Meningeal cyst; Noncommunicating; Cerebrospinal fluid; Thoracolumbar spine
13.  Lumbar Disc Herniation in Tae Kwon Do Athletic Child 
Lumbar disc herniation is extremely uncommon in children below 10 years of age. A 7-year-old boy is reported who presented with low back pain and left leg radiating pain. The pain started seven days prior to presentation and was attributed to performing the jumping kick without any previous warm-up. Magnetic resonance imaging revealed a posterolateral disc herniation at the L3-4 level and multiple degenerative changes. The patient received conservative treatment including limitation of sports activities, anti-inflammatory and muscle relaxant medications as well as physical therapy. After three months of the aggressive treatment the child was symptom free. We present here a lumbar disc herniation in one of the youngest patient.
doi:10.3340/jkns.2010.48.6.538
PMCID: PMC3053551  PMID: 21430983
Lumbar disc herniation; Child; Tae Kwon Do
14.  Cervicothoracic Spinal Epidural Hematoma after Anterior Cervical Spinal Surgery 
The purpose of this case report is to describe a rare case of a cervicothoracic spinal epidural hematoma (SEH) after anterior cervical spine surgery. A 60-year-old man complained of severe neck and arm pain 4 hours after anterior cervical discectomy and fusion at the C5-6 level. Magnetic resonance imaging revealed a postoperative SEH extending from C1 to T4. Direct hemostasis and drainage of loculated hematoma at the C5-6 level completely improved the patient's condition. When a patient complains of severe neck and/or arm pain after anterior cervical spinal surgery, though rare, the possibility of a postoperative SEH extending to non-decompressed, adjacent levels should be considered as with our case.
doi:10.3340/jkns.2010.48.6.541
PMCID: PMC3053552  PMID: 21430984
Cervical spine; Complication; Hematoma
15.  Neurologic Complication Following Spinal Epidural Anesthesia in a Patient with Spinal Intradural Extramedullary Tumor 
Paraplegia following spinal epidural anesthesia is extremely rare. Various lesions for neurologic complications have been documented in the literature. We report a 66-year-old female who developed paraplegia after left knee surgery for osteoarthritis under spinal epidural anesthesia. In the recovery room, paraplegia and numbness below T4 vertebra was checked. A magnetic resonance image (MRI) scan showed a spinal thoracic intradural extramedullary (IDEM) tumor. After extirpation of the tumor, the motor weakness improved to the grade of 3/5. If a neurologic deficit following spinal epidural anesthesia does not resolve, a MRI should be performed without delay to accurately diagnose the cause of the deficit and optimal treatment should be rendered for the causative lesion.
doi:10.3340/jkns.2010.48.6.544
PMCID: PMC3053553  PMID: 21430985
Spinal epidural anesthesia; Spinal intradural extramedullary tumor
16.  Herniated Lumbar Disc Combined with Spinal Intradural Extramedullary Cysticercosis 
Spinal cysticercosis is a very uncommon manifestation of neurocysticercosis which is caused by the larvae of Taenia solium. However, it can develop as a primary infection through blood stream or direct larval migration. It can result in high recurrence and severe neurologic morbidity if not treated appropriately. We report the case of a 43-year-old woman who presented with severe lower back pain and left leg radiating pain in recent 2 weeks. Magnetic resonance image (MRI) of lumbar spine demonstrated extruded disc at the L5-S1 level combined with intradural extramedullary cystic lesion. We performed the open lumbar microdiscectomy (OLM) at L5-S1 on the left with total excision of cystic mass. After surgery, the patient showed an improvement of previous symptoms. Diagnosis was confirmed by histopathological examination as intradural extramedullary cysticercosis. We discuss clinical features, diagnostic screening, and treatment options of spinal cysticercosis.
doi:10.3340/jkns.2010.48.6.547
PMCID: PMC3053554  PMID: 21430986
Cysticercosis; Neurocysticercosis; Spinal cysticercosis; Intradural cysticercosis; Taenia solium
17.  Fibrous Dysplasia with Aneurysmal Bone Cyst Presenting as Painful Solitary Skull lesion 
We report a rare case of fibrous dysplasia with the development of a secondary aneurysmal bone cyst presenting as solitary tumor of calvarium. Although fibrous dysplasia with aneurysmal bone cyst is rare, it should be taken into account in differential diagnosis of the osteolytic solitary skull lesion.
doi:10.3340/jkns.2010.48.6.551
PMCID: PMC3053555  PMID: 21430987
Aneurysmal bone cyst; Fibrous dysplasia; Skull
18.  In vivo Tracking of Transplanted Bone Marrow-Derived Mesenchymal Stem Cells in a Murine Model of Stroke by Bioluminescence Imaging 
Objective
This study was designed to validate the cell trafficking efficiency of the in vivo bioluminescence image (BLI) study in the setting of transplantation of the luciferase expressing bone marrow-derived mesenchymal stem cells (BMSC), which were delivered at each different time after transient middle cerebral artery occlusion (MCAO) in a mouse model.
Methods
Transplanting donor BMSC were prepared by primary cell culture from transgenic mouse expressing luciferase (LUC). Transient focal infarcts were induced in 4-6-week-old male nude mice. The experiment mice were divided into five groups by the time of MSC transplantation : 1) sham-operation group, 2) 2-h group, 3) 1-day group, 4) 3-day group, and 5) 1- week group. BLI for detection of spatial distribution of transplanted MSC was performed by detecting emitted photons. Migration of the transplanted cells to the infarcted area was confirmed by histological examinations. Differences between groups were evaluated by paired t-test.
Results
A focal spot of bioluminescence was observed at the injection site on the next day after transplantation by signal intensity of bioluminescence. After 4 weeks, the mean signal intensities of 2-h, 1-day, 3-day, and 1-week group were 2.6×107 ± 7.4×106, 6.1×106 ± 1.2×106, 1.7×106 ± 4.4×105, and 8.9×106 ± 9.5×105, respectively. The 2-h group showed significantly higher signal intensity (p < 0.01). The engrafted BMSC showed around the infarct border zones on immunohistochemical examination. The counts of LUC-positive cells revealed the highest number in the 2-h group, in agreement with the results of BLI experiments (p < 0.01).
Conclusion
In this study, the results suggested that the transplanted BMSC migrated to the infarct border zone in BLI study and the higher signal intensity of LUC-positive cells seen in 2 hrs after MSC transplantation in MCAO mouse model. In addition, noninvasive imaging in real time is an ideal method for tracking stem cell transplantation. This method can be widely applied to various research fields of cell transplantation therapy.
doi:10.3340/jkns.2010.48.5.391
PMCID: PMC3030077  PMID: 21286474
Stroke; Bone marrow-derived mesenchymal stem cells; Bioluminescence image
19.  Role of 'Spot Sign' on CT Angiography to Predict Hematoma Expansion in Spontaneous Intracerebral Hemorrhage 
Objective
Patients with spontaneous intracerebral hemorrhage (ICH) presenting within 24 hours of symptom onset are known to be increased risk of hematoma expansion which is closely correlated with morbidity and mortality. We investigated whether tiny enhancing foci ('Spot sign') on axial view of 3-dimensional computed tomography angiography (3D-CTA) source images can predict subsequent hematoma expansion in spontaneous ICH.
Methods
During a 2-year period (March 2007-March 2009), we prospectively evaluated 3D-CTA of 110 patients with spontaneous ICH. Based on source images of 3D-CTA, patients were classified according to presence or absence of 'Spot sign'; 'Spot sign' (+) group, 'Spot sign' (-) group. Radiological factors and clinical outcomes were compared between two groups.
Results
Hematoma expansion occurred in 16 patients (15%). Mean Glasgow Coma Scale (GCS) score of patients with hematoma expansion was significantly different compared to score of patients without hematoma expansion (5 vs. 9, p < 0.001). Nineteen patients (16%) of 110 ICH patients demonstrated 'spot sign' on 3D-CTA. Among the 'spot sign' (+) group, 53% of patients developed hematoma expansion. Conversely 7% of patients without 'spot sign' demonstrated the hematoma expansion (p < 0.001). Initial volume and location of hematoma were significantly not associated with hematoma expansion except shape of hematoma.
Conclusion
Our study showed that patients with hematoma expansion of spontaneous ICH had significant clinical deterioration. And the fact that 'spot sign' (+) group have higher risk of hematoma expansion suggests the presence of 'spot sign' on source images of 3D-CTA can give a clue to predict hematoma expansion in spontaneous ICH.
doi:10.3340/jkns.2010.48.5.399
PMCID: PMC3030078  PMID: 21286475
Intracerebral hemorrhage; Computed tomography angiography; Hematoma expansion; Prognosis
20.  Hypopharyngeal Wall Exposure within the Surgical Field : The Role of Axial Rotation of the Thyroid Cartilage during Anterior Cervical Surgery 
Objective
Esophageal/hypopharyngeal injury can be a disastrous complication of anterior cervical surgery. The amount of hypopharyngeal wall exposure within the surgical field has not been studied. The objective of this study is to evaluate the chance of hypopharyngeal wall exposure by measuring the amount of axial rotation of the thyroid cartilage (ARTC) and posterior projection of the hypopharynx (PPH).
Methods
The study was prospectively designed using intraoperative ultrasonography. We measured the amount of ARTC in 27 cases. The amount of posterior projection of the hypopharynx (PPH) also was measured on pre-operative CT and compared at three different levels; the superior border of the thyroid cartilage (SBTC), cricoarytenoid joint and tip of inferior horn of the thyroid cartilage (TIHTC). The presence of air density was also checked on the same levels.
Results
The angle of ARTC ranged from -6.9° to 29.7°, with no statistical difference between the upper and lower cervical group. The amount of PPH was increased caudally. Air densities were observed in 26 cases at the SBTC, but none at the TIHTC.
Conclusion
Within the confines of the thyroid cartilage, surgeons are required to pay more attention to the status of hypopharynx/esophagus near the inferior horn of the thyroid cartilage. The hypopharynx/esophagus at the TIHTC is more likely to be exposed than at the upper and middle part of the thyroid cartilage, which may increase the risk of injury by pressure. Surgeons should be aware of the fact that the visceral component at C6-T1 surgeries also rotates as much as when the thyroid cartilage is engaged with a retractor. The esophagus at lower cervical levels warrants more careful retraction because it is not protected by the thyroid cartilage.
doi:10.3340/jkns.2010.48.5.406
PMCID: PMC3030079  PMID: 21286476
Anterior cervical surgery; Thyroid cartilage; Hypopharynx; Esophageal injury
21.  Lumbar Interbody Fusion Outcomes in Degenerative Lumbar Disease : Comparison of Results between Patients Over and Under 65 Years of Age 
Objective
To evaluate the clinical and radiological outcomes of lumbar interbody fusion and its correlation with various factors (e.g., age, comorbidities, fusion level, bone quality) in patients over and under 65 years of age who underwent lumbar fusion surgery for degenerative lumbar disease.
Methods
One-hundred-thirty-three patients with lumbar degenerative disease underwent lumbar fusion surgery between June 2006 and June 2007 and were followed for more than one year. Forty-eight (36.1%) were older than 65 years of age (group A) and 85 (63.9%) were under 65 years of age (group B). Diagnosis, comorbidities, length of hospital stay, and perioperative complications were recorded. The analysis of clinical outcomes was based on the visual analogue scale (VAS). Radiological results were evaluated using plain radiographs. Clinical outcomes, radiological outcomes, length of hospital stay, and complication rates were analyzed in relation to lumbar fusion level, the number of comorbidities, bone mineral density (BMD), and age.
Results
The mean age of the patients was 61.2 years (range, 33-86 years) and the mean BMD was -2.2 (range, -4.8 to -2.8). The mean length of hospital stay was 15.0 days (range, 5-60 days) and the mean follow-up was 23.0 months (range, 18-30 months). Eighty-five (64.0%) patients had more than one preoperative comorbidities. Perioperative complications occurred in 27 of 133 patients (20.3%). The incidence of overall complication was 22.9% in group A, and 18.8% in group B but there was no statistical difference between the two groups. The mean VAS scores for the back and leg were significantly decreased in both groups (p < 0.05), and bony fusion was achieved in 125 of 133 patients (94.0%). There was no significant difference in bony union rates between groups A and B (91.7% in group A vs. 95.3% in group B, p = 0.398). In group A, perioperative complications were more common with the increase in fusion level (p = 0.027). Perioperative complications in both groups A (p = 0.035) and B (p = 0.044) increased with an increasing number of comorbidities.
Conclusion
Elderly patients with comorbidities are at a high risk for complications and adverse outcomes after lumbar spine surgery. In our study, clinical outcomes, fusion rates, and perioperative complication rates in older patients were comparable with those in younger populations. The number of comorbidities and the extent of fusion level were significant factors in predicting the occurrence of postoperative complications. However, proper perioperative general supportive care with a thorough fusion strategy during the operation could improve the overall postoperative outcomes in lumbar fusion surgery for elderly patients.
doi:10.3340/jkns.2010.48.5.412
PMCID: PMC3030080  PMID: 21286477
Elderly patients; Lumbar interbody fusion; Comorbidities; Complications
22.  Computed Tomography Fluoroscopy-Guided Selective Nerve Root Block for Acute Cervical Disc Herniation 
Objective
To analyze the clinical outcomes of computed tomography (CT) fluoroscopy-guided selective nerve root block (SNRB) for severe arm pain caused by acute cervical disc herniation.
Methods
The authors analyzed the data obtained from 25 consecutive patients who underwent CT fluoroscopy-guided SNRB for severe arm pain, i.e., a visual analogue scale (VAS) score of 8 points or more, caused by acute soft cervical disc herniation. Patients with chronic arm pain, motor weakness, and/or hard disc herniation were excluded.
Results
The series comprised 19 men and 6 women whose mean age was 48.1 years (range 35-72 years). The mean symptom duration was 17.5 days (range 4-56 days) and the treated level was at C5-6 in 13 patients, C6-7 in 9, and both C5-6 and C6-7 in 3. Twenty-three patients underwent SNRB in 1 session and 2 underwent the procedure in 2 sessions. No complications related to the procedures occurred. At a mean follow-up duration of 11.5 months (range 6-22 months), the mean VAS score and NDI significantly improved from 9 and 58.2 to 3.4 and 28.1, respectively. Eighteen out of 25 patients (72%) showed successful clinical results. Seven patients (28%) did not improve after the procedure, and 5 of these 7 underwent subsequent anterior cervical discectomy and fusion.
Conclusion
CT fluoroscopy-guided SNRB may play a role as a primary conservative treatment for severe arm pain caused by acute cervical disc herniation.
doi:10.3340/jkns.2010.48.5.419
PMCID: PMC3030081  PMID: 21286478
Cervical vertebrae; Intervertebral disc; Nerve block
23.  Neuroradiologic and Neurophysiologic Findings of Neuralgic Amyotrophy 
Objective
Neuralgic amyotrophy (NA) is a distinct clinical syndrome that is characterized by the acute onset of shoulder and arm pain, weakness, and sensory loss. The purpose of this study was to assess the clinical characteristics of NA and to determine appropriate diagnostic modalities.
Methods
We reviewed the medical and radiologic records of 10 patients diagnosed with NA retrospectively. Neurophysiologic studies were performed in all patients and magnetic resonance neurography was performed in the last three patients.
Results
A total of 10 patients were enrolled in our study. All patients had clinical findings compatible with NA. The most common clinical presentation was severe shoulder pain and weakness in seven patients (70%). Neurophysiologic study results were abnormal in all patients. Brachial plexus magnetic resonance neurography showed that the affected brachial plexus showed a thickened and hyper-intense trunk. All patients were managed conservatively with analgesics and physical therapy. The pain and paralysis of all patients improved clinically within 6 months of the initiation of treatment.
Conclusion
NA is a rare disease but the symptoms of NA can mimic those of other diseases. Neurophysiologic studies and magnetic resonance neurography are extremely useful tools for the diagnosis of NA.
doi:10.3340/jkns.2010.48.5.423
PMCID: PMC3030082  PMID: 21286479
Neuralgic amyotrophy; Brachial plexus; Diagnosis; Neurophysiology; Magnetic resonance imaging
24.  Remifentanil-Propofol Sedation as an Ambulatory Anesthesia for Carpal Tunnel Release 
Objective
This prospective study evaluated the use of continuous sedation using propofol and remifentanil when carpal tunnel release (CTR) was performed under local anesthesia.
Methods
We sedated 60 patients undergoing CTR using local anesthesia with remifentanil at loading and continuous doses of 0.5 µg kg-1 and 0.05 µg kg-1min-1, respectively, and propofol, using a target controlled infusion (TCI) pump set to a target of 2 µg mL-1 (group A), or with the same drug doses except that the continuous remifentanil dose was 0.07 µg kg-1min-1 (group B) or 0.1 µg kg-1min-1 (group C).
Results
In group B, the levels of pain when local anesthetics were administered (p = 0.001), intraoperative pain (p < 0.001) and anxiety (p = 0.001) were significantly lower than those of group A. Furthermore, the incidence of adverse events, including desaturation (p < 0.001) and vomiting (p = 0.043), was significantly lower in group B than in group C.
Conclusion
Continuous sedation using an appropriate dose of remifentanil and propofol can be used as safe, efficacious ambulatory anesthesia in cases of CTR under local anesthesia, performed using only 2 mL of local anesthetic, with a high degree of patient satisfaction.
doi:10.3340/jkns.2010.48.5.429
PMCID: PMC3030083  PMID: 21286480
Carpal tunnel syndrome; Propofol; Remifentanil
25.  Cerebral Aneurysm in the Long Fenestration at the Middle Portion of M1 Segment 
We report a unique case of bilateral mirror image M1 aneurysms, one of which was an unruptured aneurysm arising from the proximal end of right middle cerebral artery fenestration with long loop and the other ruptured aneurysm from the contralateral side. We clipped ruptured aneurysm first and unruptured one in three months after the first operation. The difficulties of identifying this unusual vascular anomaly and possible problems during the surgery of an aneurysm at the site of fenestration are discussed with a review of the literature.
doi:10.3340/jkns.2010.48.5.434
PMCID: PMC3030084  PMID: 21286481
Cerebral aneurysm; Fenestration; Middle cerebral artery

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