Tuberculosis of the Craniovertebral Junction with Basilar Impression: A Case Report

We report a rare case of tuberculosis as a cause of secondary basilar impression. A 35-year-old man was admitted to our hospital complaining of severe neck pain and motor weakness on both sides (upper and lower limbs). CT and MRI demonstrated C1/C2 subluxation, basilar impression, and an abscess occupying the prevertebral space. We performed a single-stage operation, comprising anterior removal of the abscess, posterior fixation, and fusion. The patient was discharged five weeks after surgery without any neurologic deficits or complications. Only few reports have been published worldwide describing cases of tuberculosis as a cause of secondary basilar impression. Tuberculosis of the craniovertebral (CV) junction should be considered, especially in young patients with mid- to long-term histories of neck pain without clear origins, to allow for early intervention.

Sacral Insufficiency Fracture with Osteoporotic Compression Fracture of the Thoracolumbar Spine : Incidence and High Risk Factors

OBJECTIVE: The sacral insufficiency fractures (SIFs) are not uncommon and usually occur in osteoporotic bone with minimal or unremembered trauma. Especially, if they are accompanied by osteoporotic compression fracture of the thoracolumbar spine, SIFs can be usually overlooked due to subtle clinical symptoms and signs coupled with radiographic findings. The review aims to be raising awareness of the incidence & risk factors of the SIFs. METHODS: We retrospectively reviewed the 252 patients who were admitted at our hospital due to osteoporotic compression fracture of the thoracolumbar spine with minimal or unremembered trauma for 5 years. We assessed the incidence of the SIF being accompanied by osteoporotic compression fracture of the thoracolumbar spine and the effects according to sex, age, probable risk factors (diabetes mellitus & arterial hypertension), the location of fracture and the severity of osteoporosis. RESULTS: 252 patients, including 36 men (14.3%) and 216 women (85.7%) were involved in this study and the osteoporotic compression fractures were located at thoracic (36 cases), thoracolumbar junction (180 cases), lumbar spine (36 cases). There are 18 cases (the incidence: 7.1%), including 2 men (5.5%) and 16 women (7.4%) in which the SIF was accompanied by osteoporotic compression fracture of the thoracolumbar spine. The effects according to sex, age, probable risk factors, the location of fracture and the severity of osteoporosis were not statistically different in both groups (group with SIF and group without SIF). CONCLUSION:The clinicians need to consider the possibility of SIF in patients of osteoporotic compression fracture of the thoracolumbar spine.

Pitfall of Intraoperative Microvascular Doppler Sonography for Confirming the Complete Occlusion of Aneurysm / 대한뇌혈관외과학회지

OBJECTIVE: It is mandatory to optimaze clip placement in situ for complete clipping of cerebral aneurysm. Intraoperative microvascular doppler sonography (MDS) provides a functional and non-invasive intraoperative examination of the aneurysm proper. The present study was performed to investigate the reliability of MDS for assessing the complete aneurysm closure. METHODS: Blood flow velocities in the aneurysm sac were determined by MDS with a 20-MHz probe before and after aneurysm clipping, to confirm the obliteration of aneurysm since 1997. Complete aneurysm obliteration was confirmed by absent flow patterns in the domes of all aneurysms after clipping. RESULTS: The 1 mm microprobe was able to insonate all vessels and their major branches. The immediate adjustment of aneurysm clip placement or another clipping was done because hemorrhage after puncturing of completely clipped aneurysms on MDS developed in five patients including 3 middle cerebral artery aneurysms, 1 posterior communicating artery aneurysm, and 1 anterior communicating artery aneurysm. CONCLUSIONS: MDS is safe and cost-efficient for evaluation of aneurysm obliteration. In many cases, it can preclude the need of postoperative angiogram. However, although an intra-aneurysmal flow velocity is absent on MDS, it is necessary to puncture or cut the aneurysm sac if that is not shrunken after clipping, especially in cases of a complex aneurysm with a broad irregular base and atherosclerotic or thrombotic sac.

Clipping of Upward Projection Anterior Communicating Artery Aneurysms Adhering Tightly to the A2 Segment / 대한뇌혈관외과학회지

OBJECTIVE: The ideal treatment of intracranial aneurysms is an occlusion of the neck with a clip, which preserves the parent vessels. Upward projecting anterior communicating artery(Acom) aneurysms appear to be directed both above and below the plane formed by the two A2 segments, which usually conceal the contralateral A2 takeoff. It is difficult to perform complete clipping when these lesions are tightly adherent to the A2 segment. Neurosurgeons need to focus on the safe treatment of these lesions. A variety of clipping techniques can be used depending on the aneurysm anatomy, size, and morphology. The authors recommend a safe method of clipping these lesions safely. METHODS: The authors operated on 109 patients with upward projecting Acom aneurysms over the last 16 years. Among them, 34 aneurysms were clipped using fenestrated clips through the side of the dominant A1 segment, which were closely adhered to the A2 segment. RESULT: In each case, the aneurysm and both A2 segments formed a straight line in the narrow surgical field and were not easily separated, and consequently it was difficult to handle the aneurysm behind the ipsilateral A2. After partial identification of the Acom complex, careful dissection of the posterior aspect of the ipsilateral A2 and the aneurysm dome was continued to allow mobilization of both A2 segments and the aneurysm. All aneurysms were secured successfully without any surgery related complications. CONCLUSION: The authors recommend that fenestrated clip incorporating the ipsilateral A2 segment after complete mobilization of both A2 segments and the aneurysm may be useful for definitive clipping of upward projecting Acom aneurysm which is densely adherent to the A2 segment.