Transdural Nerve Rootlet Entrapment in the Intervertebral Disc Space through Minimal Dural Tear : Report of 4 Cases

Four patients underwent lumbar surgery. In all four patients, the dura was minimally torn during the operation. However, none exhibited signs of postoperative cerebrospinal fluid leakage. In each case, a few days after the operation, the patient suddenly experienced severe recurring pain in the leg. Repeat magnetic resonance imaging showed transdural nerve rootlets entrapped in the intervertebral disc space. On exploration, ventral dural tears and transdural nerve rootlet entrapment were confirmed. Midline durotomy, herniated rootlet repositioning, and ventral dural tear repair were performed, and patients' symptoms improved after rootlet repositioning. Even with minimal dural tearing, nerve rootlets may become entrapped, resulting in severe recurring symptoms. Therefore, the dural tear must be identified and repaired during the first operation.

Cutaneous Wound Myiasis in a Missing Old Woman / 대한피부과학회지

No abstract available.

Mycosis Fungoides with Coincidental Ureter Cancer / 대한피부과학회지

An 82-year-old woman presented with a 5-year history of erythematous to brown patches and plaques on both legs, arms and trunk. Histopathological findings of biopsy specimens were consistent with mycosis fungoides, and the tumor cells were positive for CD3 and negative for CD20 in immunohistochemical stain. Imaging studies proposed the suspicion of ureter cancer, and the result of cystoscopic biopsy showed papillary urothelial carcinoma. Mycosis fungoides is the most common type of cutaneous T-cell lymphoma, characterized by variable cutaneous manifestations, including patches, plaques, tumors, and erythroderma. There were several studies concerning the evaluation of the second malignancy risk after cutaneous T-cell lymphoma, however the relationship between mycosis fungoides and ureter cancer is not revealed. This patient is considered a case of mycosis fungoides with coincidental ureter cancer.

Changes in the Cross-Sectional Area of Multifidus and Psoas in Unilateral Sciatica Caused by Lumbar Disc Herniation

OBJECTIVE: To quantitatively evaluate the asymmetry of the multifidus and psoas muscles in unilateral sciatica caused by lumbar disc herniation using magnetic resonance imaging (MRI). METHODS: Seventy-six patients who underwent open microdiscectomy for unilateral L5 radiculopathy caused by disc herniation at the L4-5 level were enrolled, of which 39 patients (51.3%) had a symptom duration of 1 month or less (group A), and 37 (48.7%) had a symptom duration of 3 months or more (group B). The cross-sectional areas (CSAs) of the multifidus and psoas muscles were measured at the mid-portion of the L4-5 disc level on axial MRI, and compared between the diseased and normal sides in each group. RESULTS: The mean symptom duration was 0.6+/-0.4 months and 5.4+/-2.7 months for groups A and B, respectively (p<0.001). There were no differences in the demographics between the 2 groups. There was a significant difference in the CSA of the multifidus muscle between the diseased and normal sides (p<0.01) in group B. In contrast, no significant multifidus muscle asymmetry was found in group A. The CSA of the psoas muscle was not affected by disc herniation in either group. CONCLUSION: The CSA of the multifidus muscle was reduced by lumbar disc herniation when symptom duration was 3 months or more.

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.

Asymptomatic Cervical or Thoracic Lesions in Elderly Patients who Have Undergone Decompressive Lumbar Surgery for Stenosis

STUDY DESIGN: A retrospective study. PURPOSE: To evaluate the prevalence and risk factors of asymptomatic cervical or thoracic lesions in elderly patients who have undergone surgery for lumbar spinal stenosis. OVERVIEW OF LITERATURE: Concurrent multiple spinal lesions have been reported in many studies with a varied prevalence, and described the characteristics of the disease and its treatment options. However, the cervical or thoracic lesions without apparent symptoms in patients with symptomatic lumbar stenosis had not been evaluated. METHODS: A total of 101 elderly patients (aged 65 or more), who had undergone surgery for lumbar spinal stenosis from January 2005 to December 2005, were enrolled in this study. All patients underwent lumbar magnetic resonance imaging (MRI) along with T2-weighted cervical and thoracic sagittal MRI prior to surgery. The concurrent cervical or thoracic lesions were classified according to the disease entity, and the severity of the lesions was graded from grade 0 (no lesion) to grade 4 (any lesion compressing the cord with a signal change). The prevalence of concurrent cervical and thoracic lesions was then analyzed. In addition, the risk factors for the development of concurrent lesions were evaluated, and the risk factors affecting the severity of the concurrent lesion were analyzed individually. RESULTS: Seventy-seven (76.2%) and 30 (29.7%) patients had a concurrent cervical and thoracic lesion, respectively. Twenty-six patients (25.7%) had both a cervical and thoracic lesion. There was a positive correlation between the symptom duration of lumbar stenosis and the prevalence of both cervical (p = 0.044) and thoracic (p = 0.022) lesions. CONCLUSIONS: The incidence of asymptomatic cervical or thoracic lesions is apparently high in elderly patients who have undergone surgery for lumbar spinal stenosis, particularly in those with longer symptom duration. This highlights the need for a preoperative evaluation of the cervical and thoracic spine in these patients.

L2 Radicular Compression Caused by a Foraminal Extradural Gas Pseudocyst

Gas pseudocysts are a rare cause of lumbar radiculopathy and most symptomatic gas pseudocysts are found within the confines of the spinal canal. A gas pseudocyst in the foramen causing lumbar radiculopathy is very rare. We present a case of a 67-year-old woman suffering from severe pain in the right leg. Computed tomography and magnetic resonance imaging revealed a gas pseudocyst compressing the L2 root at the right L2-3 foramen. The patient underwent cyst excision using the lateral transmuscular approach and her leg pain was improved after the operation.

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.

Effect of Regional Nerve Block in Total Knee Arthroplasty / 대한정형외과학회잡지

PURPOSE: The goal of this study is to evaluate the efficacy of femoral, obturator, and sciatic nerve regional blocks with using ropivacaine during total knee arthroplasty. MATERIALS AND METHODS: As a prospective study, we performed total knee arthroplasty for 383 patients from Oct. 2004 to Feb. 2009. There was 139 cases of femoral and obturator nerve regional block, 123 cases of femoral, obturator, and sciatic nerve regional block, and 121 cases of lidocaine local anesthesia at the synovium and subcutaneous tissue during wound closure. All the femoral nerve block cases used a femoral catheter for an additional ropivacaine injection at 10 hours after surgery. The pain was examined using a visual analogue scale (VAS). The VAS scores were checked on the day of surgery and at post operative 24 hours, 48 hours and 6 days. The pain control effects among the 3 groups were compared with one-way ANOVA test and Scheffe`s multiple comparison test. RESULTS: The mean postoperative VAS score on the day of surgery and at post operative 24 hours, 48 hours and 6 days in the femoral and obturator nerve block group, were 6.3, 5.6, 5.3, and 4.7, respectively. For the cases of femoral, obturator and sciatic nerve block, the VAS scores were 3.9, 4.3, 3.5 and 1.9, respectively, and the VAS scores in the lidocaine local anesthetic group were 7.1, 6.1, 5.8 and 5.2, respectively. There was a statistical significance in all three groups (p<.0001), and the additional sciatic nerve block groups had significant effectiveness. CONCLUSION: Pain control with the ropivacaine regional nerve block is more effective than the lidocaine local anesthesia, and additional sciatic nerve block is a important factor for decreasing the postoperative pain after total knee arthroplasty.

Comparison of Percutaneous Endoscopic Lumbar Discectomy and Open Lumbar Microdiscectomy for Recurrent Disc Herniation

OBJECTIVE: The purpose of this study was to compare clinical and radiological outcomes of percutaneous endoscopic lumbar discectomy (PELD) and open lumbar microdiscectomy (OLM) for recurrent disc herniation. METHODS: Fifty-four patients, who underwent surgery, either PELD (25 patients) or repeated OLM (29 patients), due to recurrent disc herniation at L4-5 level, were divided into two groups according to the surgical methods. Excluded were patients with sequestrated disc, calcified disc, severe neurological deficit, or instability. Clinical outcomes were assessed using Visual Analogue Scale (VAS) score and Oswestry Disability Index (ODI). Radiological variables were assessed using plain radiography and/or magnetic resonance imaging. RESULTS: Mean operating time and hospital stay were significantly shorter in PELD group (45.8 minutes and 0.9 day, respectively) than OLM group (73.8 minutes and 3.8 days, respectively) (p < 0.001). Complications occurred in 4% in PELD group and 10.3% in OLM group in the perioperative period. At a mean follow-up duration of 34.2 months, the mean improvements of back pain, leg pain, and functional improvement were 4.0, 5.5, and 40.9% for PELD group and 2.3, 5.1, and 45.0% for OLM group, respectively. Second recurrence occurred in 4% after PELD and 10.3% after OLM. Disc height did not change after PELD, but significantly decreased after OLM (p = 0.0001). Neither sagittal rotation angle nor volume of multifidus muscle changed significantly in both groups. CONCLUSION: Both PELD and repeated OLM showed favorable outcomes for recurrent disc herniation, but PELD had advantages in terms of shorter operating time, hospital stay, and disc height preservation.

A Novel Autogenous Iliac Bone Graft Technique for Distal Humeral Bone Loss in Revisional Total Elbow Arthroplasty: A Technical Note / 대한정형외과학회잡지

As the incidence of total elbow arthroplasty has increased, revisions of the procedure also increase including reconstruction of bony defects caused by bone destruction. Reconstruction techniques depend on location and severity of the bony defect, and allografts are useful in cases of substantial bone loss. However, this procedure is technically difficult and has a high complication rate. Here, we describe a novel autogenous bone graft technique using tricortical iliac bone for reconstruction of a distal bone loss in a revisional total elbow arthroplasty, providing an additional method to restore bone stock.

Contralateral Reherniation after Open Lumbar Microdiscectomy : A Comparison with Ipsilateral Reherniation

OBJECTIVE: To evaluate the risk factors that may be responsible for the development of contralateral reherniations from ipsilateral ones after open lumbar microdiscectomy (OLM), and to compare surgical outcomes of revision OLM for contralateral reherniations with those for ipsilateral ones. METHODS: Seventeen patients who underwent revision OLM for contralateral reherniation were enrolled into Group I, and 35 patients who underwent revision OLM for ipsilateral reherniation were enrolled into Group II. Using medical charts and imaging study results, the differences in the clinical and radiological factors were evaluated between the two groups. Clinical outcomes of each group were compared between the two groups. RESULTS: Significant differences were found in the interval to reherniation from initial surgery (33 months for Group I and 18.6 months for Group II, p=0.009), as well as in the incidences of both protruded disc (35.3% for Group I and 8.6% for Group II, p=0.045) and mild disc degeneration (29.4% for Group I and 5.7% for Group II, p=0.031) at initial surgery. On binary multi-logistic regression analysis, significant differences were found in the interval to reherniation (p=0.027, Odds ratio=1.051) and incidence of mild disc degeneration (p=0.025, Odds ratio=12.03) between the two groups. There were no significant differences in the improvement of clinical outcomes after revision OLM between the two groups. CONCLUSION: The interval to reherniation from initial surgery and the grade of disc degeneration at initial surgery were key factors that distinguished the development of contralateral reherniations from ipsilateral ones. Surgical outcomes of revision OLM were similar in both groups.

Microdecompression for Extraforaminal L5-S1 Disc Herniation; The Significance of Concomitant Foraminal Disc Herniation for Postoperative Leg Pain

OBJECTIVE: To analyze the relationship of concomitant foraminal lumbar disc herniation (FLDH) with postoperative leg pain after microdecompression for extraforaminal lumbar disc herniation (EFLDH) at the L5-S1 level. METHODS: Sixty-five patients who underwent microdecompression for symptomatic EFLDH at the L5-S1 level were enrolled. According to the severity of accompanying FLDH, EFLDH was classified into four categories (Class I : no FLDH; Class II : mild to moderate FLDH confined within a lateral foraminal zone; Class III : severe FLDH extending to a medial foraminal zone; Class IV : Class III with intracanalicular disc herniation). The incidence of postoperative leg pain, dysesthesia, analgesic medication, epidural block, and requirement for revision surgery due to leg pain were evaluated and compared at three months after initial surgery. RESULTS: The incidences of postoperative leg pain and dysesthesia were 36.9% and 26.1%, respectively. Pain medication and epidural block was performed on 40% and 41.5%, respectively. Revision surgery was recommended in six patients (9.2%) due to persistent leg pain. The incidences of leg pain, dysesthesia, and requirement for epidural block were higher in Class III/IV, compared with Class I/II. The incidence of requirement for analgesic medication was significantly higher in Class III/IV, compared with Class I/II (p=0.02, odds ratio=9.82). All patients who required revision surgery due to persistent leg pain were included in Class III/IV. CONCLUSION: Concomitant FLDH seems related to postoperative residual leg pain after microdecompression for EFLDH at the L5-S1 level.

Unilateral Isthmus Resection for Elderly Foraminal Stenosis

We present an elderly patient with unilateral foraminal stenosis treated by isthmus resection. An 83-year-old female could not walk due to severe leg pain along right L5 sensory dermatome. Despite the laminotomy for spinal stenosis on the right side at the L4-5 level, her leg pain did not improve. Careful review of computed tomography scans and coronal source images of magnetic resonance myelography revealed foraminal stenosis on the right side at the L5 vertebra. Because of medical problem, she underwent isthmus resection on the right side at the L5 level instead of total facetectomy and fusion. After surgery, her leg pain was markedly improved. Isthmus resection showed successful result for this medically compromised elderly patient with unilateral foraminal stenosis.

A Morphometric Analysis of Neuroforamen in Grade I Isthmic Spondylolisthesis by Anterior Lumbar Interbody Fusion with Pedicle Screw Fixation

OBJECTIVES: The aim of this study was to evaluate the morphometric changes in neuroforamen in grade I isthmic spondylolisthesis by anterior lumbar interbody fusion (ALIF). METHODS: Fourteen patients with grade I isthmic spondylolisthesis who underwent single level ALIF with percutaneous pedicle screw fixation were enrolled. All patients underwent standing lateral radiography and magnetic resonance imaging (MRI) before surgery and at 1 week after surgery. For quantitative analysis, the foraminal height, foraminal width, epidural foraminal height, epidural foraminal width, and epidural foraminal area were evaluated at the mid-portion of 28 foramens using T2-weighted sagittal MRI. For qualitative analysis, degree of neural compression in mid-portion of 28 foramens was classified into 4 grades using T2-weighted sagittal MRI. Clinical outcomes were assessed using Visual Analogue Sale (VAS) scores for leg pain and Oswestry disability index before surgery and at 1 year after surgery. RESULTS: The affected levels were L4-5 in 10 cases and L5-S1 in 4. The mean foraminal height was increased (p<0.001), and the mean foraminal width was decreased (p=0.014) significantly after surgery. The mean epidural foraminal height (p<0.001), epidural foraminal width (p<0.001), and epidural foraminal area (p<0.001) showed a significant increase after surgery. The mean grade for neural compression was decreased significantly after surgery (p<0.001). VAS scores for leg pain (p=0.001) and Oswestry disability index (p=0.001) was decreased significantly at one year after surgery. CONCLUSION: Foraminal stenosis in grade I isthmic spondylolisthesis may effectively decompressed by ALIF with percutaneous pedicle screw fixation.

Transforaminal Lumbar Interbody Fusion Using Wedged Cages for Isthmic Spondylolisthesis: A Short-Term Radiological Analysis

OBJECTIVE: The ability to induce segmental lordosis has been reported to be marginal with transforaminal lumbar interbody fusion(TLIF). Therefore, we analyzed the short-term radiological outcomes of TLIF using 8 degrees wedged cages for isthmic sp-ondylolisthesis. METHODS: Twenty-seven patients with isthmic spondyloisthesis who underwent single level TLIF with pedicle screw fixation (PSF) using 8 degrees wedged cages were retrospectively evaluated. Changes in disc height, degree of anterolisthesis, segmental lumbar lordosis, whole lumbar lordosis and L1 axis S1 distance were evaluated using standing lateral radiographs before surgery, at 6 weeks follow-up and at the final follow-up. RESULTS: The mean age of the patients was 49.9 years (range, 38 to 64 years). The affected levels were L4-5 in 17 cases and L5-S1 in 10. There were 18 cases of Grade I isthmic spondylolisthesis and 9 cases of Grade II. At a mean follow-up duration of 9.9 months (range, 6 to 18 months), the disc height (p<0.001) was significantly increased, and the degree of anterolisthesis was significantly reduced (p<0.001). Regarding the sagittal balance, the segmental lumbar lordosis was significantly increased (p=0.01), but other parameters were not significantly changed after surgery. CONCLUSION: TLIF with PSF using 8 degrees wedged cages significantly increased the segmental lumbar lordosis.

Functional MRI Study for Phonological and Semantic Language Processing in Strongly Right-Handed Korean Twenty Year Olds / 대한간질학회지

OBJECTIVE: Using functional magnetic resonance imaging, cerebral language areas were determined during a series of language tasks in normal strong right-handed subjects. METHODS: Twelve normal right-handed volunteers were examined on a 1.5T MR unit. Language task paradigms included two phonological tasks involving meaningless letters and sentences, and four semantic tasks using different types of words. Each language task was examined using a separate scan consisted of three blocks separated by rest periods. BOLD (blood oxygenation level dependent) signals during language tasks were compared using 24 sec alternating rest periods during which subjects concentrated on a plus symbol. After preprocessing and statistically analyzing individual data, group analysis (p<0.001, k=50) was performed using SPM99 software. RESULTS: Meaningless letter reading was more efficient than sentence reading, in terms of delineating brain regions related to phonological processing, we found significant regions in the left inferior frontal gyrus (IFG), left thalamus, bilateral cingulate gyri, right anterior superior temporal gyrus (STG), right IFG, and left inferior parietal lobule (IPL). During semantic tasks, left IFG, left posterior middle temporal gyrus, left IPL, bilateral medial frontal gyrus, right posterior STG, right parahippocampal, and fusiform gyri were found to be activated. CONCLUSION: During the two phonological tasks, normal strongly right-handed people more actively used the left IFG, right anterior temporal lobe, and right IFG than during semantic processing, whereas during the four semantic tasks, these subjects more actively used the bilateral posterior temporal and right medial temporal lobes.

Anterior Lumbar Interbody Fusion with Pedicle Screw Fixation for Elderly Isthmic Spondylolisthesis

OBJECTIVE: The surgical outcome of anterior lumbar interbody fusion(ALIF) with pedicle screw fixation for elderly isthmic spondylolisthesis was analyzed. METHODS: Consecutive nineteen elderly patients (aged 65 years or more) with isthmic spondylolisthesis (Grade I or II) who underwent single level ALIF with pedicle screw fixation in 2002 were analyzed. Using clinical chart and mailed questionnaires, preoperative and postoperative Visual Analogue Scale(VAS) of back and leg pain and postoperative Macnab criteria were evaluated. RESULTS: The mean age at the time of operation was 68.4 years (range 65 to 78 years). Twelve patients underwent ALIF with percutaneous pedicle screw fixation. Seven patients underwent ALIF followed by posterior decompression and pedicle screw fixation. The postoperative complication rate was 10.5% (wound dehiscence in 1 patient and incisional hernia in 1 patient). There was no postoperative major morbidity or mortality. At a mean follow-up duration of 30.7 months (range 25 to 35 months), 93.3% (14/15) of the patients showed excellent or good outcomes in terms of Macnab criteria. The mean VAS scores of back pain and leg pain significantly decreased after surgery. CONCLUSION: ALIF with pedicle screw fixation yielded favorable results for elderly isthmic spondylolisthesis in selected cases.

Acute Spinal Epidural Hematoma Following Unilateral Laminectomy for Bilateral Decompression

We present a case of acute spinal epidural hematoma(EDH) following unilateral laminectomy for bilateral decompression(ULBD). A 45-year-old male presented with severe multi-level spinal stenosis underwent ULBD on the left side at the L2-3 and L3-4 level. Five hours after operation, paraparesis developed along with severe bilateral buttock pain. The CT scan showed an acute spinal EDH at the L2-3 level. The acute spinal EDH was successfully decompressed after emergency decompressive surgery with performing an additional laminectomy on the contralateral side at the L2-3 level. Although ULBD is an effective minimally invasive surgical technique for treating spinal stenosis, the possibility of acute spinal EDH should be kept in mind, as happened in our case.

Isthmic Spondylolisthesis Associated with Foraminal Disc Herniation Treated by Anterior Lumbar Interbody Fusion

A 45-year-old man presented with lower back pain and pain in the right leg of 3years duration. A plain radiographic examination revealed grade I isthmic spondylolisthesis, with instability at L4-5. Computed tomography and magnetic resonance imaging demonstrated bilateral foraminal stenosis, with soft foraminal disc herniation on the right side at the L4-5 level. He underwent anterior lumbar interbody fusion(ALIF) with percutaneous posterior fixation(PF) at the L4-5 level. Without removing the posterior bony structures, removal of foraminal disc herniation and reduction of spondylolisthesis were successfully performed using ALIF with percutaneous PF. When there is no hard disc herniation or lateral recess stenosis, ALIF with percutaneous PF can be one of the treatment options for isthmic spondylolisthesis, even in the presence of foraminal disc herniation, as in our case.