Comparison between Minimally Invasive Transforaminal Lumbar Interbody Fusion and Posterior Lumbar Interbody Fusion in Lumbar Degenerative Disease Patients

OBJECTIVE: Minimally invasive transforaminal lumbar interbody fusion(mini-TLIF) is an increasingly popular method because of several advantages, including rapid patient recovery, less postoperative pain, and minimized iatrogenic injury of soft tissue and muscle. The purpose of this study is to evaluate the clinical and imaging outcomes after mini-TLIF procedures. Results are compared with open posterior lumbar interbody fusion(oPLIF, Group B) and mini-TLIF(Group A) approach. METHODS: Between March 2007 and May 2008, mini-TLIF and oPLIF were performed in 23 and 36 consecutive patients with single or multilevel lumbar degenerative disease. Clinical outcomes were assessed by postoperative visual analogue scale(VAS) score, operation time, volume of blood loss, number of days to ambulation and duration of hospital stay. To assess fusion rate, all patients underwent postoperative radiography. And postoperative access were compared with an institutional reference series of 36 oPLIF procedures. RESULTS: Fusion success outcomes were obtained in 23(100%) out of 23 patients with mini-TLIF procedure. Mean VAS scores decreased from 8.2 to 1.9 in group A and from 8.1 to 2.4 in group B. The operation time, volume of blood loss, number of days to ambulation and duration of hospital stay were reduced in group A compared with group B. There was no complication associated to mini-TLIF procedure. CONCLUSION: Mini-TLIF yielded good clinical and radiological outcomes with safe and low complication. Further long- term investigating study is required to assess the definitive advantage of mini-TLIF.

Craniospinal Metastasis from a Metastasizing Mixed Tumor of Salivary Gland : Unusual Presentation

Metastasizing mixed tumors (MMT) of salivary glands are inexplicably metastasize maintaining benign histology. There is no pathologic and flow cytometric analysis criteria to predict the metastasis. MMT is known to metastasize by local implantation, vascular and lymphatic embolization after multiple surgery to local recurrences of primary tumor. However, multiple metastasis including cranium and spine occurred even without surgery to the primary tumor in this case. No pathological evidence of malignancy could be found in both primary and metastatic tumor. MMT is considered as an low grade malignancy based on clinical behavior rather than histologic evidence, such as low mortality rate, long delay of metastasis after primary lesion. Cranial metastasis is also extremely rare and only two cases have been reported. We report this unusual case with a literature review.

A Morphometric Analysis of the Foramen Ovale and the Zygomatic Points Determined by a Computed Tomography in Patients with Idiopathic Trigeminal Neuralgia

OBJECTIVE: The purpose of this study is to measure the dimensions of foramen ovale and to localize the zygomatic point using computed tomography(CT) in Korean adults with idiopathic trigeminal neuralgia. METHODS: Facial axial CT scans using the orbitomeatal plane were performed in 67patients (39males and 28females; mean age 58.8years) with idiopathic classic trigeminal neuralgia. We measured the size of the foramen ovale and localized the zygomatic point which was a skin marker over the ipsilateral zygoma that approximates the lateral projection of a straight line joining the centers of the two foramen ovale. RESULTS: The axial dimensions of the foramen ovale on the orbitomeatal plane were of average length: 8.18+/-0.82mm (range 6.9~11.5mm), width: 4.06+/-0.86mm (2.5~5.7mm). The average distance between the external acoustic meatus and the zygomatic point was 21.64+/-1.99mm (16.3~25.0mm) and the average distance of anterior margin of condylar process of mandible to zygomatic point was 4.29+/-1.19mm (1.0~7.0mm). CONCLUSION: The anatomical understandings including the size of the foramen ovale and localization of the zygomatic point could be helpful in determining a plan of percutaneous approaches to foramen ovale.

Percutaneous Balloon Compression of Trigeminal Gasserian Ganglion for Idiopathic Trigeminal Neuralgia

OBJECTIVE: The purpose of this study is to review the surgical results of 19 patients with idiopathic trigeminal neuralgia treated by percutaneous ballooning compression(PBC) of trigeminal gasserian ganglion under brief general anesthesia. METHODS: The mean patient age was 63.5 years(range, 27-78). The mean follow-up period was 24 months(range, 1-46). Three patients had already undergone radiofreqnency trigeminal rhizotomy and two patients had previously microvascular decompression. The balloon was inflated by injecting radio-contrast media 0.7-1cc in amount. The mean inflating time is 81 seconds(range, 60-90). RESULTS: During the procedure, brief intraoperative bradycardia and hypotension were noted in seven cases(36.7%). All patients had immediate relief of pain except 1 case. 18 cases(94.5%) of patients were satisfied or very satisfied with their pain relief. There were immediate, mild to moderate sensory complication of hypesthesia, dysesthesia or paraesthesia in all cases and the immediate motor complication-difficulty of mastication in 3 cases, transient 6th nerve palsy in 2 cases. The immediate motor and sensory complications disappeared or much improved after 3-4 months. CONCLUSION: It is the simple technique that can be performed effectively in a brief period of general anesthesia. This procedure might be one of attractive methods in the treatment of idiopathic trigeminal neuralgia.

Suboccipital Lateral Approach in the Supine Position for Stereotactic Aspiration of Cerebellar Hematoma

OBJECTIVE: We report a suboccipital lateral approach in order to propose more suitable stereotactic aspiration technique for cerebellar hematoma. METHODS: Using the Leksell's CT-stereotactic system, the patient was kept on a supine position under local anesthesia turning the head 30 to 40 degrees contralateral to the side of the lesion and bending the neck forward, so that the approach was made laterally toward the ipsilateral suboccipital area. Eight patients with cerebellar hematoma underwent this stereotactic technique. Six patients complicated with intraventricular hemorrhage or obstructive hydrocephalus underwent simultaneously external ventricular drainage(EVD) via Kocher's point without position change. The mean amount of hematoma was 23.7ml (14~58ml). RESULTS: All showed initially a partial removal of the hematoma about 6.1ml in mean volume through stereotactically placed catheters and the residual hematoma was drained out by urokinase irrigation for mean of 3.3 days. The mean operation time took 2 hours in cases combined with EVD and one hour and half in cases not. CONCLUSION: This surgical technique for the cerebellar hematoma can be easily done in a supine position under local anesthesia and surgical invasion is minimal. It also has benefits that EVD can be done without any position change.

Spinal Cord Stimulation for Intractable Postherpetic Neuralgia

Postherpetic neuralgia(PHN) is a neuropathic pain syndrome that is often intractable. A 75-year-old man suffered intractable pain due to herpes zoster between T4 and T6 dermatome. Allodynia, the severe superficial pain that he could not wear his clothes, was improved by ablative surgery such as dorsal root entry zone lesions and dorsal root ganglionectomy. However, deep cramping pain was sustained. Because of this excruciating pain, spinal cord stimulation(SCS) was decided. After the operation, the pain has been improved to tolerable state. As with our case, a constant deep cramping pain associated with other refractory painful condition of PHN, SCS could be considered as a useful option.

Malignant Meningioma with Intracranial and Extracranial Multiple Metastases : Usefulness of Fractionated Stereotactic Radiation and Conventional External Radiation Therapy: A Case Report

No abstract available.

Trigeminal Neuralgia in a Patient with Osteopetrosis: A Case Report

Osteopetrosis is a rare disease by a generalized increase in skeletal density and by abnormalities of bone modeling secondary to defective osteoclastic function with impairment of bone resorption. The various cranial nerve palsies may occur secondary to bony encroachment on the cranial foramina. The authors report a case of osteopetrosis with trigeminal neuralgia. This 30-year-old woman presented with the recurring attacks of severe lancinating paroxysmal pain on her right face(mandibular division>maxillary division>ophthalmic division) for 10 years and anosmia, both blindness for 20 years. Her foramen ovale and optic canal narrowings were caused by osteopetrosis. The neuralgia was refractory to medical treatment. Percutaneous radio-frequency rhizotomy for trigeminal neuralgia was performed and pain relief have been obtained. She was satisfied with the procedure, even if with facial numbness. In the case of trigeminal neuralgia in young patient without abnormal mass lesion on brain radiologic imaging studies, it is important to investigate the bony abnormalities of skull base. The authors believe that radiofrequency rhizotomy is the first choice of treatment for trigeminal neuralgia caused by the bony abnormalities of skull base such as osteopetrosis.

Atlantoaxial Subluxation due to Psoriatic Arthritis: Case Report

Psoriatic arthritis is a rare inflammatory joint disease associated with radiographic evidence of periarticular bone erosion and sometimes frank joints destruction among psoriatic patients. There have been only a few reports of atlantoaxial subluxation in patients with psoriatic arthritis in the world. The authors report a case of psoriatic arthritis with atlantoaxial subluxation. This 27-year-old man with a three year history of psoriatic skin lesion presented with painful limitation of neck and multiple joint deformities of the hands and feet, etc. We performed combined interspinous and Gallie fusion for the atlantoaxial subluxation and obtained good results of immediate and long term postoperative stability with Philadelphia neck collar only after this procedure.

Sequential Multiple Epidural Hematomas Following Ventriculoperitoneal Shunt

For the treatment of a hydrocephalic patient, the ventriculoperitoneal shunt operation has been widely accepted, and although extra-axial hematomas are a well-known complication of ventricular shunting, epidural hematomas are uncommon in this setting. We report an unusual case of sequential multiple epidural hematomas in a 24-year-old man with hydrocephalus treated by ventriculoperitoneal shunt. For the evacuation of hematomas which had developed at different sites, the patient required three craniotomies. Possible etiologies have been examined, and the mechanism for the development of epidural hematoma after shunt operation is thought to be due to the rapid lowering of intracranial pressure and separation of the dura from the skull, causing oozing from small dural vessels ; to avoid this complication, the sudden perioperative lowering of intracranial pressure should be prevented. In addition, the literature is reviewed and discussed.

Supratentorial Surgery Complicated by Cerebellar Hemorrhage: Report of Three Cases

Among the complications of intracranial surgery, postoperative hemorrhage remote from the operative site is rare, especially when it occurs in the cerebellum after surgery involving the supratentorial region. We report three cases of cerebellar hemorrhage after supratentorial surgery : 1) A 66-year-old man with subdural hygroma in both frontotemporal areas ; 2) A 56-year-old man with chronic subdural hematoma in the left frontotemporal area ; 3) A 39-year-old woman with aneurysms at the right middle cerebral artery bifurcation and basilar tip. The possible etiologies of cerebellar hemorrhage in the three cases presented here were reviewed. We speculate that when the patient is in the supine position with head rotated and extended, the displacement of the cerebellum causes stretching of the superior vermian veins and their tributaries, resulting in tearing of these vessels, and that a sudden decrease in intracranial pressure may accelerate this process. To prevent this complication, meticulous perioperative management of the patient is essential.

Treatment of Parkinson's Disease by Streotactic Thalamotomy and Pallidotomy

The authors report the surgical results of thalamotomy and pallidotomy, performed at our hospital between 1983 and 1993 for the treatment of Parkinson's disease. The series included a retrospective analysis of 156 patients with this condition by stereotactic ventrolateral(VL) thalamotomy(126 patients, 138 thalamotomies) and posterolateral pallidotomy(30 patients, 30 pallidotomies). Each patient was followed up postoperatively, for one year. Among those who underwent the stereotactic VL thalamotomy, 136/138 procedures(99%) led to improvement of tremor, and 83/138(60%) resulted in reduced rigidity. Stereotactic posterolateral pallidotomy, led to improvement of bradykinesia after 27/30 procedures(90%), of rigidity after 22/30(73%) and of tremor after 13/30(43%). Drug-induced dyskinesia showed a 42% improvement in the thalamotomy series and a 93% improvement in the pallidotomy series; the difference between the two series was significant(p0.557). In addition, for groups with greater preoperative disability(Hoehn & Yahr staging, groups III and IV), improvement was more likely after pallidotomy than after thalamotomy. In the pallidotomy series, dysphasia was the only serious complication and this was seen after 20% of procedures. In the thalamotomy series, however, complications included hypotonia(24%), transient confusion(19%), transient dysphasia(11%), permanent dysarthria(7%), subjective numbness(4%) and epileptic seizure(3%). The authors believe that posterolateral pallidotomy is much more effective than VL thalamotomy for the control of Parkinsonian bradykinesia and rigidity, but that thalamotomy is still a useful surgical option for the control of Parkinsonian tremor.

Solitary Plasmachtoma of the Spine: Case Reports

Solitary plasmacytoma of bone, one form of plasma cell neoplasms, is relatively rare. We successfully treated two cases of solitary plasmacytoma of the spine. Both patients underwent surgery. In a 46-year-old female, the tumor of C7 vertebral body was removed completely and the patient received postoperative radiotherapy(5400 rad). After a follow-up period of 27 months, she had no local recurrence. In the other 42-yea-old male, the tumor of the T6 vertebral body was partially removed and the patient did not receive postoperative radiotherapy. After 20 months, the patient had local recurrence with serious neurological deficits(paraparesis). We removed the regrown tumor mass totally, and his symptoms and signs were improved clinically. Then he received radiotherapy(5000 rad). After the mean follow up period of 33 months, neither patient developed disseminated systemic myeloma. The outcome of solitary osseous plasmacytoma is relatively good with surgically excision followed by local irradiation. Close long term follow-up of solitary plasmacytoma of bone is needed to detect progression to multiple myeloma. We report two cases of solitary plasmacytome of bone with a brief review of the literature.

Clinical Analysis of Posterior Lymbar Apophyseal Ring Fractures in Young Adults

Lumbar apophyseal ring fracture occurs between the vertebral ring apophyses and the cartilaginous rim of the superior or inferior margins of the vertebral end plates. This fracture is an unusual disease that if typically seen in adolescents or young adults. We analyzed the clinical records and neuroradiologic imagings of 49 patients who were less than 29 years old diagnosed with posterior lumbar apophyseal ring fractures in regards to the age, trauma history, the type and distribution of the fracture, clinical presentation, and postoperative outcome. The posterior lumbar apophseal ring fractures were detected in 29(9.2%) out of 533 young adult patients with herniated lumbar discs. There was trauma history in 37(75.5%) out of the 49 patients. The main presenting symptoms in most of the patients were low back pain and radiating leg pain. In patients who presented with symptoms, thirty-five patients(75.5%) had a positive straight leg-raising test. According to classification by Takata, they were type I in 12 cas es(24.0%), type II in 9 cases(18.0%), and type III in 29 cases(58.0%). The type III with trauma history was more common than with non-trauma history(p<0.01). Twenty-one patients(42.0%) had bony fragments projecting into the spinal canal from the upper border of S1. Partial hemilaminectomy(18 patients) and total laminectomy(3 patients) were performed. We could easily remove the bony fragments in all of the surgical cases. Chemonucleolysis were done in three patients. The overall results were good. We conclude that knowledge of this entity and correct radiographic diagnosis will help to facilitate the operative planning.

Surgical Experience of Stereotactic Psychosurgery for Psychiatric Diseases

The authors report surgical experiences in patients with severe psychiatric illness refractory to all other conventional treatments. All 5 patients in this series were referred from their own psychiatrists. One patient with aggressive-conductive disorder, who was cared for in a closed ward, underwent bilateral amygdalotomy and bifrontal leucotomy. Four patients with obsessive-compulsive disorder were treated by limbic leucotomy, which is a combination of subcaudate tractotomy and anterior cingulotomy. Target points were selected according to the individual symptoms of each patients. Target construction was performed under ventriculogram or computerized tomographic guidance, using a Hitchcock stereotactic frame. All the procedures were performed under local anesthesia, except for the patient with aggressive-conductive disorder for whom the surgery had to be performed under general anesthesia because of the incooperative nature of the patient. The result of each surgery was good without serious complication. During the follow-up period, all the patients were freed from disturbing symptoms and successfully returned to their premorbid social life. Psychosurgery can be helpful in certain patients with severe, chronic, disabling, and treatment-refractory psychiatric illness.

Surgical Experience of Stereotactic Psychosurgery for Psychiatric Diseases

The authors report surgical experiences in patients with severe psychiatric illness refractory to all other conventional treatments. All 5 patients in this series were referred from their own psychiatrists. One patient with aggressive-conductive disorder, who was cared for in a closed ward, underwent bilateral amygdalotomy and bifrontal leucotomy. Four patients with obsessive-compulsive disorder were treated by limbic leucotomy, which is a combination of subcaudate tractotomy and anterior cingulotomy. Target points were selected according to the individual symptoms of each patients. Target construction was performed under ventriculogram or computerized tomographic guidance, using a Hitchcock stereotactic frame. All the procedures were performed under local anesthesia, except for the patient with aggressive-conductive disorder for whom the surgery had to be performed under general anesthesia because of the incooperative nature of the patient. The result of each surgery was good without serious complication. During the follow-up period, all the patients were freed from disturbing symptoms and successfully returned to their premorbid social life. Psychosurgery can be helpful in certain patients with severe, chronic, disabling, and treatment-refractory psychiatric illness.

Selective Neurotomy of the Tibial Nerve for the Treatment of the Spastic Foot: Case Report

When the spasticity becomes wevere and hamful, in spite of physical and medical therapy, surgery can give functional improvement. The authors report two cases of selective neurotomy of the tibial nerve for the treatment of the spastic foot which led to abnormal posture, articular limitation, pain, and disturbances impairing standing and walking. Prior to surgery, the effectiveness of neurotomy had been verified by means of infiltrating the nerves with local anesthetic agents. The surgery was performed under the intraoperative electrostimulation for identifying the branches of tibial nerve to the muscle sustaining spasticity. After microdissection of each tibial nerve brance at the lower part of the popliteal region, the selected branches were cut, preserving at least one fourth of the motor fibers. Significant functional gains were observed as a result of substantial reduction of the harmful spasticity, without suppressing the useful muscle tone and impairing the residual motor and sensory function. For patients with disabling spastic foot, refractory to routine physical, orthopaedic and medical treatment a simple neurosurgical procedure, the selective tibial neurotomy has enabled them to stand and walk comfortably, and has allowed them to reach a significantly improved quality of life.

A Study of Therapeutic Modalities of Pineal Region Tumors

The management of pineal region tumors remains controversial. Advocates of a conservative approach emphasize the excellent results of radiotherapy, particularly with germinoma, while a number of recent reports have demonstrated the safety of direct surgery. We analyzed 8 cases of pineal region tumors which had been treated at our institution over the past 7 years. Tissue diagnosis was obtained in 3 patients before irradiation and 5 patients underwent irradiation without histological diagnosis. Among 5 irradiated patients initially, four patients had been achieved complete remission by radiotherapy thus they were presumptively germinoma, but other one patient had no response, so she had been underwent surgery. Among 3 biopsy proven cases, 2 were teratoma and other one was embryonal carcinoma. Complete gross microsurgical excision of well encapsulated tumor was possible in two teratoma cases. MRI and other neuroradiological studies have ben found to be useful in indicating the biological nature and histological type of pineal tumor. So, consideration of MRI scans together with tumor markers and response to small dose irradiation will generally allow a specific diagnosis with a high degree of probability. In this way, germinomas may be selected for radiotherapy and the tumor less likely to response may be subject to primary surgery to obtain complete tumor extirpation or tissue diagnosis.

Successful Removal of Hemangioblastoma Originating in the Medulla Oblongata: Report of 1 Case

Solid hemangioblastomas of the medulla oblongata are benign vascular neoplasms located in a critical area. We experienced a case of solid hemangioblastoma originated in the medulla oblongata with the syrinx in the cervical spinal cord. Preoperative magnetic resonance imaging provided precise anatomical location and radiologic features of the tumor, which facilitated its total removal. Cardiovascular and pulmonary disorders often complicate this type of surgery, and postoperative dysphagia is a frequent sequelae.

Primary Spinal Epidural Ewing's Sarcoma: Report of 1 Case

Ewing's sarcoma, originating primarily in the spinal epidural space is exceptionally rare. There are only 6 case reports in English literature until 1986. We experienced a case of epidural Ewing's sarcoma originated in thoracic spinal canal at T6~T7 level with myelopathy. Initial neural decompression was very effective and complete recovery was achieved. But local recurrence occurred in relatively short follow up period(8 months). Subsequent radiotherapy showed us dramatic tumor regression and improvement of neurologic deficit. The problems that concerned in this tumor are its accurate diagnosis and appropriate therapeutic modality. We reviewed the literatures that deal with exceptional locations of Ewing's sarcoma and current therapeutic approaches with their outcomes.