Long-Term Outcomes after Multimodal Treatment for Clival Chordoma: Efficacy of the Endonasal Transclival Approach with Early Adjuvant Radiation Therapy.

This study investigates the long-term outcomes of clival chordoma patients treated with the endonasal transclival approach (ETCA) and early adjuvant radiation therapy. A retrospective review of 17 patients (2002-2013) showed a 10-year progression-free survival (PFS) rate of 67.4%, with the ETCA group showing fewer progressions and cranial neuropathies than those treated with combined approaches. The ETCA, a minimally invasive technique, provided a similar extent of resection compared to conventional skull-base approaches and enabled safe delivery of high-dose adjuvant radiotherapy. The findings suggest that ETCA is an effective treatment for centrally located clival chordomas.

Decongestants, proton pump inhibitors, and systemic antibiotics are associated with an increased occurrence of dysbiosis.

BACKGROUND: Dysbiosis (also called dysbacteriosis) is characterized by a disruption of the microbiome, resulting in an imbalance in the microbiota, changes in their functional composition and metabolic activities, and a shift in their local distribution. Dysbiosis is most commonly reported as a condition affecting the gastrointestinal tract, for example with bacterial or fungal overgrowth in the small intestine. Known causes of dysbiosis include antibiotic use, liver disease, and alcohol misuse. AIMS: To determine those variables associated with the diagnosis of dysbiosis using a national database containing data supplied by general practitioners in Germany. MATERIALS AND METHODS: Patient data for the period January 2005 to December 2018 were obtained from the Disease Analyzer database (IQVIA) based on data from 1,193 general practices in Germany. Inclusion criteria were all adult patients (≥ 18 years) with an initial diagnosis of dysbiosis documented anonymously. Data for variables such as drug treatment, other diseases etc. associated with the diagnosis were analyzed using multivariable logistic regression analyses. RESULTS: A total of 4,013 patients diagnosed with dysbiosis and a comparative control cohort of 4,013 patients without such a dysbiosis were included in the study. The mean age in both groups was ~ 50 years where 65.2% of subjects were women. Decongestants and other nasal preparations for topical use (OR: 1.45, 95% CI: 1.14 - 1.85), proton pump inhibitors (OR: 1.39; 95% CI: 1.21 - 1.61), and systemic antibiotics (OR: 1.28, 95% CI: 1.13 - 1.47) were significantly associated with an increased occurrence of dysbiosis, whereas non-steroidal antirheumatic drugs (OR: 0.78, 95% CI: 0.69 - 0.87), lipid-lowering drugs (OR: 0.76, 95% CI: 0.63 - 0.93), and ACE inhibitors (OR: 0.64, 95% CI: 0.53 - 0.77) were associated with a decreased occurrence of dysbiosis. CONCLUSION: The study provides evidence that treatment with decongestants and other nasal preparations is strongly associated with an increased occurrence of dysbiosis. Although the pathophysiology of dysbiosis is multifactorial and confounding factors cannot be ruled out, the close correlation seen may have clinical significance.

Tailored antiplatelet therapy in stent assisted coiling for unruptured aneurysms: a nationwide registry study.

BACKGROUND: Antiplatelet therapy, where regimens are tailored based on platelet function testing, has been introduced into neurointerventional surgery. This nationwide registry study evaluated the effect and safety of tailored antiplatelet therapy in stent assisted coiling for unruptured aneurysms compared with conventional therapy using a standard regimen. METHODS: This study enrolled 1686 patients in 44 participating centers who received stent assisted coiling for unruptured aneurysms between January 1, 2019 and December 31, 2019. The standard regimen (aspirin and clopidogrel) was used for all patients in the conventional group (924, 19 centers). The regimen was selected based on platelet function testing (standard regimen for clopidogrel responders; adding cilostazol or replacing clopidogrel with other thienopyridines (ticlopidine, prasugrel, or ticagrelor) for clopidogrel non-responders) in the tailored group (762, 25 centers). The primary outcome was thromboembolic events. Secondary outcomes were bleeding and poor outcomes (increase in modified Rankin Scale score). Outcomes within 30 days after coiling were compared using logistic regression analysis. RESULTS: The thromboembolic event rate was lower in the tailored group than in the conventional group (30/762 (3.9%) vs 63/924 (6.8%), adjusted OR 0.560, 95% CI 0.359 to 0.875, P=0.001). The bleeding event rate was not different between the study groups (62/762 (8.1%) vs 73/924 (7.9%), adjusted OR 0.790, 95% CI 0.469 to 1.331, P=0.376). Poor outcomes were less frequent in the tailored group (12/762 (1.6%) vs 34 (3.7%), adjusted OR 0.252, 95% CI 0.112 to 0.568, P=0.001). CONCLUSION: Tailored antiplatelet therapy in stent assisted coiling for unruptured aneurysms reduced thromboembolic events and poor outcomes without increasing bleeding.

Dysbiosis: A Potential Precursor to the Development of a Depressive Disorder.

Background: Although previous investigations have indicated that gastrointestinal pathologies facilitate the occurrence of mood disorders, there is a lack of studies based on data from clinical practice. The aim of this study was to investigate the incidence of depression in patients with dysbiosis. Methods: Adult patients (≥18 years) from 1193 general practices in Germany between January 2005 and December 2018 with an initial diagnosis of dysbiosis documented anonymously in the Disease Analyzer database (IQVIA) were analyzed. The incidence of depression diagnoses as a function of dysbiosis was calculated and multivariate regression models were applied. Results: This study included 552 patients with and 552 patients without dysbiosis. Within five years of the index date, 20.5% of patients with dysbiosis and 5.5% of individuals without dysbiosis had been diagnosed with depression (p < 0.001). Dysbiosis was found to be significantly associated with the incidence of depression (HR: 2.85 (95% CI: 2.00−4.04)). This association was slightly stronger in men (HR: 3.54) than in women (HR: 2.61) and was more pronounced in the age group >60 years (HR: 4.43). Conclusions: We identified dysbiosis as a risk factor for developing depression within 5 years after the index date. This risk seems to be higher in male than in female patients.

Korean Clinical Practice Guidelines for Aneurysmal Subarachnoid Hemorrhage.

Despite advancements in treating ruptured cerebral aneurysms, an aneurysmal subarachnoid hemorrhage (aSAH) is still a grave cerebrovascular disease associated with a high rate of morbidity and mortality. Based on the literature published to date, worldwide academic and governmental committees have developed clinical practice guidelines (CPGs) to propose standards for disease management in order to achieve the best treatment outcomes for aSAHs. In 2013, the Korean Society of Cerebrovascular Surgeons issued a Korean version of the CPGs for aSAHs. The group researched all articles and major foreign CPGs published in English until December 2015 using several search engines. Based on these articles, levels of evidence and grades of recommendations were determined by our society as well as by other related Quality Control Committees from neurointervention, neurology and rehabilitation medicine. The Korean version of the CPGs for aSAHs includes risk factors, diagnosis, initial management, medical and surgical management to prevent rebleeding, management of delayed cerebral ischemia and vasospasm, treatment of hydrocephalus, treatment of medical complications and early rehabilitation. The CPGs are not the absolute standard but are the present reference as the evidence is still incomplete, each environment of clinical practice is different, and there is a high probability of variation in the current recommendations. The CPGs will be useful in the fields of clinical practice and research.

Radiologic Changes of Operated and Adjacent Segments after Anterior Cervical Microforaminotomy.

OBJECTIVE: Anterior cervical microforaminotomy (ACMF) is a motion-preserving surgical procedure. The purpose of this study is to assess radiologic changes of operated and adjacent segments after ACMF. METHODS: We retrospectively reviewed 52 patients who underwent ACMF between 1998 and 2008. From X-ray film-based changes, disc height and sagittal range of motion (ROM) of operated and adjacent segments were compared at preoperative and last follow-up periods. Radiological degeneration of both segments was analyzed as well. RESULTS: The mean follow-up period was 48.2 months. There were 78 operated, 52 upper adjacent, and 38 lower adjacent segments. There were statistically significant differences in the ROM and disc height of operated segment between preoperative and last follow-up periods. However, there were no statistically significant differences in the ROM and disc height of adjacent segment between both periods. Radiological degenerative changes of operated segments were observed in 30%. That of adjacent segments was observed in 11 and 11% at upper and lower segments, respectively. CONCLUSION: After mean 4-year follow-up periods, there were degenerative changes of operated segments. However, ACMF preserved motion and prevented degenerative changes of adjacent segments.

Clinical Analysis Comparing Efficacy between a Distal Filter Protection Device and Proximal Balloon Occlusion Device during Carotid Artery Stenting.

OBJECTIVE: The main concern during transfemoral carotid artery stenting (CAS) is preventing cerebral embolus dislodgement. We compared clinical outcomes and intraprocedural embolization rates of CAS using a distal filter protection device or proximal balloon occlusion device. METHODS: From January 2011 to March 2015, a series of 58 patients with symptomatic or asymptomatic internal carotid artery stenosis ≥70% were treated with CAS with embolic protection device in single center. All patients underwent post-CAS diffusion-weighted magnetic resonance imaging (DW-MRI) to detect new ischemic lesions. We compared clinical outcomes and postprocedural embolization rates. RESULTS: CAS was performed in all 61 patients. Distal filter protection success rate was 96.6% (28/29), whose mean age was 70.9 years, and mean stenosis was 81%. Their preprocedural infarction rate was 39% (11/28). Subsequent DW-MRI revealed 96 new ischemic lesions in 71% (20/28) patients. In contrast, the proximal balloon occlusion device success rate was 93.8% (30/32), whose mean age was 68.8 years and mean stenosis was 86%. Preprocedure infarction rate was 47% (14/30). DW-MRI revealed 45 new ischemic lesions in 57% (17/30) patients. Compared with distal filter protection device, proximal balloon occlusion device resulted in fewer ischemic lesions per patient (p=0.028). In each group, type of stent during CAS had no significant effect on number of periprocedural embolisms. Only 2 neurologic events occurred in the successfully treated patients (one from each group). CONCLUSION: Transfemoral CAS with proximal balloon occlusion device achieves good results. Compared with distal filter protection, proximal balloon occlusion might be more effective in reducing cerebral embolism during CAS.

Hemorrhagic Recurrence in Diffuse Astrocytoma without Malignant Transformation.

Although uncommon, hemorrhage can be a complication of low grade glioma with an unfavorable prognosis such as transformation to higher grade glioma. To our knowledge, hemorrhagic recurrence of World Health Organization Grade II, diffuse astrocytoma without malignant transformation has not been reported. Thus, we report a case of diffuse astrocytoma with hemorrhagic recurrence without malignant transformation. The patient had undergone craniotomy and tumor removal 7 years previously. Annual follow-up MRIs had shown evidence of slow tumor recurrence. With the sudden onset of seizure, the patient was diagnosed as hemorrhagic recurrence and underwent second tumor removal highly suspecting malignant change into higher grade glioma. Histopathology confirmed diffuse astrocytoma without malignant changes. As the patient's postoperative condition was excellent, we plan to withhold chemotherapy and radiation therapy for use as a later treatment option.

Preliminary study of neurocognitive dysfunction in adult moyamoya disease and improvement after superficial temporal artery-middle cerebral artery bypass.

OBJECTIVE: Moyamoya disease (MMD) is a chronic cerebrovascular occlusive disease of unknown etiology. In addition, the neurocognitive impairment of adults with MMD is infrequently reported and, to date, has not been well described. We attempted to determine both the neurocognitive profile of adult moyamoya disease and whether a superficial temporal artery-middle cerebral artery (STA-MCA) anastomosis can improve the neurocognitive impairment in exhibiting hemodynamic disturbance without stroke. METHODS: From September 2010 through November 2012, 12 patients with angiographically diagnosed MMD underwent STA-MCA anastomosis for hemodynamic impairment. Patients with hypoperfusion and impaired cerebrovascular reserve (CVR) capacity but without evidence of ischemic stroke underwent a cognitive function test, the Seoul Neuropsychological Screening Battery (SNSB). Five patients agreed to undergo a follow-up SNSB test. Data from preoperative and postoperative neurocognitive function tests were compared and analyzed. RESULTS: Five of 12 patients were enrolled. The median age was 45 years (range, 24-55 years). A comparison of preoperative to postoperative status of SNSB, memory domain, especially delayed recall showed significant improvement. Although most of the domains showed improvement after surgery, the results were not statistically significant. CONCLUSION: In our preliminary study, large proportions of adult patients with MMD demonstrate disruption of cognitive function. This suggests the possibility of chronic hypoperfusion as a primary cause of the neurocognitive impairment. When preoperative and postoperative status of cognitive function was compared, memory domain showed remarkable improvement. Although further study is needed, neurocognitive impairment may be an indication for earlier intervention with reperfusion procedures that can improve cognitive function.

A case of endovascular treatment for followed by side to side bypass for vertebral artery dissecting aneurysms involved posterior inferior cerebellar artery.

Treatment of complex aneurysms usually entails not only direct clipping but also alternative treatment modality. We recently experienced a case of vertebral artery dissecting aneurysm and obtained good treatment outcomes. Our case suggests that the endovascular segmental occlusion with posterior inferior cerebellar artery (PICA) to PICA side anastomosis might be a good treatment option in patients with complex vertebral artery dissecting aneurysms. A 45-year-old woman has a left vertebral dissecting aneurysm with dizziness. Based on the aneurysmal morphology and the involvement of PICA, the patient underwent side to side anastomosis of the PICA. This was followed by the endovascular segmental coil occlusion. The aneurysmal sac was completely obliterated. At a 2-year follow-up, the patient achieved a good patency of both PICA. In conclusion our case suggests that the endovascular segmental occlusion of the parent artery followed by PICA to PICA bypass surgery through a midline suboccipital approach is a reasonable multimodal treatment option in patients with complex vertebral artery dissecting aneurysms.

The usefulness of the ivy sign on fluid-attenuated intensity recovery images in improved brain hemodynamic changes after superficial temporal artery-middle cerebral artery anastomosis in adult patients with moyamoya disease.

OBJECTIVE: MR perfusion and single photon emission computerized tomography (SPECT) are well known imaging studies to evaluate hemodynamic change between prior to and following superficial temporal artery (STA)-middle cerebral artery (MCA) anastomosis in moyamoya disease. But their side effects and invasiveness make discomfort to patients. We evaluated the ivy sign on MR fluid attenuated inversion recovery (FLAIR) images in adult patients with moyamoya disease and compared it with result of SPECT and MR perfusion images. METHODS: We enrolled twelve patients (thirteen cases) who were diagnosed with moyamoya disease and underwent STA-MCA anastomosis at our medical institution during a period ranging from September of 2010 to December of 2012. The presence of the ivy sign on MR FLAIR images was classified as Negative (0), Minimal (1), and Positive (2). Regions were classified into four territories: the anterior cerebral artery (ACA), the anterior MCA, the posterior MCA and the posterior cerebral artery. RESULTS: Ivy signs on preoperative and postoperative MR FLAIR were improved (8 and 4 in the ACA regions, 13 and 4 in the anterior MCA regions and 19 and 9 in the posterior MCA regions). Like this result, the cerebrovascular reserve (CVR) on SPECT was significantly increased in the sum of CVR in same regions after STA-MCA anastomosis. CONCLUSION: After STA-MCA anastomosis, ivy signs were decreased in the cerebral hemisphere. As compared with conventional diagnostic modalities such as SPECT and MR perfusion images, the ivy sign on MR FLAIR is considered as a useful indicator in detecting brain hemodynamic changes between preoperatively and postoperatively in adult moyamoya patients.

Two indices affecting the directions of the sylvian fissure dissection in middle cerebral artery bifurcation aneurysms.

OBJECTIVE: This study proposes more objective methods for deciding the appropriate direction of the sylvian fissure dissection during surgical clipping in middle cerebral artery (MCA) bifurcation aneurysms. METHODS: We reviewed data of 36 consecutive patients with MCA bifurcation aneurysms. We measured 2 indices preoperatively on 3-dimensional computed tomography angiography (3D-CTA). Analysis of the calculated data allowed us to select the appropriate direction of sylvian fissure dissection for ease of proximal control of M1. Statistically, Mann-Whitney test was used. RESULTS: We classified subjects into 2 groups based on the technical level of M1 exposure during surgical clipping. When it was difficult to expose M1, subjects were assigned to Group I, and Group II were subjects in whom M1 exposure was easy. The mean difference between the distances extending from the limbus sphenoidale (LS) line to the internal carotid artery bifurcation and extending from the LS line to the MCA bifurcation was 1.00 ± 0.42 mm in group I and 4.39 ± 2.14 mm in group II. The mean M1 angle was 9.36 ± 3.73° in the group I and 34.05 ± 16.71° in the group II (M1 slope gap p < 0.05, M1 angle p < 0.05). CONCLUSION: We have found an objective method for preoperatively verifying ease of exposure of M1 artery during surgical clipping. Therefore, we suggest use of the preoperative M1 slope gap and M1 angle as indicators in 3D-CTA selecting the direction of sylvian fissure dissection for easy proximal control of M1.

Fulminant meningitis after radiotherapy for clival chordoma.

The best treatment for clival chordoma is obtained with total surgical excision, sometimes combined with adjuvant radiotherapy. A cerebrospinal fluid (CSF) fistula is a fatal complication that may occur following extended transsphenoidal surgery (TSS) and adjuvant radiotherapy. We report a case of fulminant meningitis without a CSF fistula in a 57-year-old woman who underwent TSS and multiple radiotherapies for a clival chordoma. She presented to our emergency room with copious epistaxis and odor inside her nasal cavity and had an unexpected fatal outcome. She was diagnosed with meningitis based on CSF culture and blood culture. While treating clival chordomas with adjuvant radiotherapy, clinicians should be aware of the possibility of fulminant meningitis.

The Comparisons of Surgical Outcomes and Clinical Characteristics between the Far Lateral Lumbar Disc Herniations and the Paramedian Lumbar Disc Herniations.

OBJECTIVE: The purpose of this study is to analyze clinical characteristics and surgical outcomes of the far lateral and the paramedian disc herniations. METHODS: The 88 patients who underwent an operation for lumbar disc herniations were reviewed. Visual analogue scale of leg and back pain, occurrence of sensory dysesthesia and motor deficit before and after operations were used to compare the far lateral with the paramedian disc herniations. RESULTS: Statistically, the far lateral herniations had more severe radicular leg pain and showed more frequent occurrence of sensory dysesthesia than paramedian herniations before operation (p<0.05). In the far lateral herniation group, preoperatively, 15 patients (75%) had sensory dysesthesia and among them, 4 patients (27%) showed improvement. In the paramedian herniation group, preoperatively, 25 patients (37%) had sensory dysesthesia and among them, 21 patients (84%) showed improvement. The degree of improvement in sensory dysesthesia was statistically higher in paramedian herniation group (p<0.05). In the far lateral herniation group, preoperatively, 11 patients (55%) had motor deficit and among them, 10 patients (91%) showed improvement. In the paramedian herniations, preoperatively, 29 patients (43%) had motor deficit and among them, 25 patients (86%) showed improvement. The degree of improvement in motor deficit was not statistically significant between groups (p>0.05). CONCLUSION: Preoperatively, the far lateral herniations had more severe radicular leg pain and frequent occurrence of sensory dysesthesia. Postoperatively, the sensory dysesthesia was less improved and back pain was more severe in the far lateral herniations.

Surgical treatment of lumbar hyperextension injury in ankylosing spondylitis.

Ankylosing spondylitis (AS) is a chronic systemic and inflammatory rheumatic disease with a variable course of the axial skeleton. Spinal involvement may accompany ossification of the ligaments, intervertebral disc, end-plates and apophyseal structures, and seems to be "bamboo spine". Because of these natures of the spine in AS, a spinal fracture can be occurred with minor trauma or spontaneously. The fracture of the AS can cause neurological complications extremely high, so special attention to prevent neurological deterioration. Operative management of the injured spine with AS is difficult, and associated with a high complication rate. Extreme care must be taken for surgery to prevent secondary neurological deterioration.

Intracranial dural arteriovenous fistulas: clinical characteristics and management based on location and hemodynamics.

OBJECTIVE: A dural arteriovenous fistula (DAVF) generally refers to a vascular malformation of the wall of a major venous sinus. These lesions have diverse symptoms according to the location and venous drainage, and require multidisciplinary treatment. We report on our experience and analyze the treatment outcome of intracranial DAVFs for a nine-year period. METHODS: Between January 2000 and December 2008, 95 patients with intracranial DAVFs were enrolled in this study. A retrospective review of clinical records and imaging studies of all patients was conducted. Endovascular embolization, surgical interruption, gamma knife stereotactic radiosurgery (GKS), or combinations of these treatments were performed based on clinical symptoms, lesion location, and venous drainage pattern. RESULTS: Borden type I, II, and III were 34, 48, and 13 patients, respectively. Aggressive presentation was reported in 6% of Borden type I, 31% of Borden type II, and 77% of Borden type III DAVFs, respectively, and DAVFs involving transverse, sigmoid, and superior sagittal sinus. Overall, the rate of complete obliteration was 68%. The complete occlusion rates with a combination treatment of endovascular embolization and surgery, surgery alone, and endovascular embolization were 89%, 86%, and 80%, respectively. When GKS was used with embolization, the obliteration rate was 83%, although it was only 54% in GKS alone. Spontaneous obliteration of the DAVF occurred in three patients. There were a few complications, including hemiparesis (in microsurgery), intracranial hemorrhage (in endovascular embolization), and facial palsy (in GKS). CONCLUSION: The hemorrhagic risk of DAVFs is dependent on the location and hemodynamics of the lesions. Strategies for treatment of intracranial DAVFs should be decided according to the characteristic of the DAVFs, based on the location and drainage pattern. GKS can be used as an optional treatment for intracranial DAVFs.

Meningeal layers around anterior clinoid process as a delicate area in extradural anterior clinoidectomy : anatomical and clinical study.

OBJECTIVE: Removal of the anterior clinoid process (ACP) is an essential process in the surgery of giant or complex aneurysms located near the proximal internal carotid artery or the distal basilar artery. An extradural clinoidectomy must be performed within the limits of the meningeal layers surrounding the ACP to prevent morbid complications. To identify the safest method of extradural exposure of the ACP, anatomical studies were done on cadaver heads. METHODS: Anatomical dissections for extradural exposure of the ACP were performed on both sides of seven cadavers. Before dividing the frontotemporal dural fold (FTDF), we measured its length from the superomedial apex attached to the periorbita to the posterolateral apex which connects to the anterosuperior end of the cavernous sinus. RESULTS: The average length of the FTDF on cadaver dissections was 7 mm on the right side and 7.14 mm on the left side. Cranial nerves were usually exposed when cutting FTDF more than 7 mm of the FTDF. CONCLUSION: The most delicate area in an extradural anterior clinoidectomy is the junction of the FTDF and the anterior triangular apex of the cavernous sinus. The FTDF must be cut from the anterior side of the triangle at the periorbital side rather than from the dural side. The length of the FTDF incision must not exceed 7 mm to avoid cranial nerve injury.

Endoscope-assisted microsurgical removal of an epidermoid tumor within the cavernous sinus.

Epidermoid tumor of the cavernous sinus is rare. The aim of this case report is to discuss the role of neuroendoscopes in the removal of such lesions. A 21-year-old man presented with 6-year history of progressive headache, diplopia, and visual disturbance. Work-up revealed an epidermoid tumor located in the right cavernous sinus. An extradural transcavernous approach was utilized via a traditional frontotemporal craniotomy with endoscopic assistance. The postoperative course was uneventful with immediate improvement of the patient's headache. Postoperative magnetic resonance imaging demonstrated complete removal of the tumor. There were no signs of recurrence during a 2-year follow-up period. The endoscope is a useful tool for removing epidermoid tumors from the cavernous sinus and enhances visualization of areas that would otherwise be difficult to visualize with microscopes alone. Endoscopes also help minimize the retraction of neurovascular structures.

Surgical results and risk factors for recurrence of lumbar disc herniation.

OBJECTIVE: Recurrent lumbar disc herniation has been defined as disc herniation at the same level, regardless of ipsilateral or contralateral herniation, with a pain-free interval greater than 6 months. The aim of this study is to analyze outcomes and identify the potential risk factors for recurrent lumbar disc herniation. METHODS: The authors retrospectively reviewed the cases of 178 patients who underwent open discectomy for single-level lumbar disc herniation. Visual analogue scales and modified Macnab criteria were used to compare the clinical outcomes between the recurrent group and the non-recurrent group. Sex, age, discectomy level, degree of disc degeneration, type of disc herniation, pain-free interval after first-operation, smoking status, and trauma were investigated as potential recurrence risk factors. RESULTS: Of the 178 patients for whom the authors were able to definitely assess symptomatic recurrence status, 18 patients (10.1%) underwent revision surgery for recurrent disc herniation. The most common level involved was L4-L5 (61%) and the mean period of time to recurrence was 18.7 months (6-61 months). There were 17 cases of ipsilateral herniation and 1 case of contralateral herniation. The types of herniation for which revision surgery was done were protrusion (3 cases), and transligamentous extrusion (14 cases). There were five excellent, eight good, and two fair results. CONCLUSION: Repeated discectomy for recurrent disc herniation produced unsatisfactory outcomes. Factors such as sex, type of disc herniation and traumatic events were found to be significant risk factors.

Spontaneous cervical epidural hematoma causing brown-sequard syndrome.

Spontaneous cervical epidural hematoma (SCEH) is a rare clinical entity and has a varied etiology. Urgent surgical decompression should be done to prevent serious permanent neurologic deficits. We describe a 59-year-old female who presented with Brown-Sequard syndrome due to spontaneous cervical epidural hematoma. Initially, she was misdiagnosed as cerebrovascular accident. Cervical magnetic resonance imaging revealed epidural hematoma to the right of the spinal cord extending from C3 to C6. She later underwent surgical evacuation and had complete restoration of neurologic function. The outcome in SCEH is essentially determined by the time taken from onset of the symptom to operation. Therefore, early and precise diagnosis such as careful history taking and MRI evaluation is mandatory.