Biologic response of degenerative living human nucleus pulposus cells to treatment with cytokines.

PURPOSE: To investigate the molecular responses of various genes and proteins related to disc degeneration upon treatment with cytokines that affect disc-cell proliferation and phenotype in living human intervertebral discs (IVDs). Responsiveness to these cytokines according to the degree of disc degeneration was also evaluated. MATERIALS AND METHODS: The disc specimens were classified into two groups: group 1 (6 patients) showed mild degeneration of IVDs and group 2 (6 patients) exhibited severe degeneration of IVDs. Gene expression was analyzed after treatment with four cytokines: recombinant human bone morphogenic protein (rhBMP-2), transforming growth factor-ß (TGF-ß), interleukin-1ß (IL-1ß), and tumor necrosis factor-α (TNF-α). Molecular responses were assessed after exposure of cells from the IVD specimens to these cytokines via real-time polymerase chain reaction and immunofluorescence staining. RESULTS: mRNA gene expression was significantly greater for aggrecan, type I collagen, type II collagen, alkaline phosphatase, osteocalcin, and Sox9 in group 1 than mRNA gene expression in group 2, when the samples were not treated with cytokines. Analysis of mRNA levels for these molecules after morphogen treatment revealed significant increases in both groups, which were much higher in group 1 than in group 2. The average number of IVD cells that were immunofluorescence stained positive for alkaline phosphatase increased after treatment with rhBMP-2 and TGF-ß in group 1. CONCLUSION: The biologic responsiveness to treatment of rhBMP-2, TGF-ß, TNF-α, and IL-1ß in the degenerative living human IVD can be different according to the degree of degeneration of the IVD.

Clinical Outcomes of Posterior C2-C3 Fixation for Unstable Hangman's Fracture Compared with Posterior C1-C3 Fusion.

OBJECTIVE: To verify the clinical outcomes of posterior C2-C3 fixation for unstable Hangman's fracture compared with posterior C1-C3 fixation. METHODS: Twenty four patients for unstable Hangman's fracture were enrolled between July 2007 and June 2010 in this study. Thirteen patients underwent posterior C2-C3 fusion and 11 patients underwent posterior C1-C3 fusion. Clinical outcomes were evaluated using Neck Disability Index (NDI) scores and Visual Analogue Scale (VAS) scores during preoperative and postoperative follow up period. Plain radiographs were obtained on postoperative 1 day, 1 week, and then at 1, 2, 6, and 12 months. CT was done at postoperative 12 months in all patients for evaluation of bone fusion. The mean period of clinical follow-up was 15 months. RESULTS: The mean ages were 43.3 years in C2-C3 group and 50.0 years in C1-C3 group. Mean follow-up period was 17.2 months in C2-C3 group and 16.3 months in C1-C3 group. VAS scores and NDI scores in C2-C3 group were much less than those in C1-C3 group at each follow-up period. The differences of VAS score and NDI scores between C2-C3 and C1-C3 groups at each follow-up period were statistically significant (p<0.001) by paired T-test. Solid Bone fusion was confirmed in all cases at the final follow-up. CONCLUSION: C2-C3 group showed better clinical and biomechanical results than C1-C3 group in terms of axial pain and disability of neck.

Effect of vertebroplasty with bone filler device and comparison with balloon kyphoplasty.

PURPOSE: To evaluate the effect of vertebroplasty with a bone filler device compared with balloon kyphoplasty. METHODS: A total of 222 patients underwent operations from January 2008 to October 2012. One-level fractures numbered 169 (86.7%) cases and two-level fractures numbered 26 (13.3%). A total of 221 vertebral levels were analyzed consequently. Vertebral height, compression ratio, and segmental Cobb's angle were measured in preoperative and postoperative lateral X-rays. RESULTS: The compression ratio was the most influential parameter among three variables. Adjusted postoperative compression ratio was not significantly different between two operation groups. Bone cement leakage rates did not differ (p < 0.05). Bone cement distribution was spongy type in the majority of the vertebroplasty with bone filler device (94.5%), but only in 42.0% of the kyphoplasty. High bone densitometry readings and long period from diagnosis to operation were significant risk factors for bone cement leakage. CONCLUSIONS: Vertebroplasty with a bone filler device could achieve equivalent compression reduction and bone cement leakage rate, as well as greater sponge-type bone cement distribution, which were advantages over balloon kyphoplasty.

Primary spinal cord melanoma in thoracic spine with leptomeningeal dissemination and presenting hydrocephalus.

Primary spinal cord melanoma is a rare central nervous system malignant tumor. Usually it resembles an intradural extramedullary (IDEM) nerve sheath tumor or melanoma. We experienced a patient with upper thoracic primary IDEM spinal cord melanoma who was diagnosed to be with hydrocephalus and without intracranial lesions. Initial symptoms of the patient were related to the hydrocephalus and the primary spinal cord melanoma was diagnosed eight months later. At the first operation, complete resection was impossible and the patient refused additional radiotherapy or chemotherapy. At 22 months after surgery, the patient revisited our institution with recurrent both leg weakness. Leptomeningeal dissemination was present in the whole spinal cord and only partial resection of tumor was performed. The symptoms slightly improved after surgery. Primary spinal cord melanoma is extremely rare but complete resection and additional radiotherapy or chemotherapy can prolong the disease free interval. Hydrocephalus or signs of increased intracranial pressure may be the diagnostic clue of spinal cord malignancy and progression.

Radiologic changes of anterior cervical discectomy and fusion using allograft and plate augmentation: comparison of using fixed and variable type screw.

OBJECTIVE: To evaluate radiologic result of anterior cervical discectomy and fusion with allobone graft and plate augmentation, and the change of radiologic outcome between screw type and insertion angle. METHODS: Retrospective review of clinical and radiological data of 29 patients. Segmental angle, height and screw angles were measured and followed. The fusion rate was assessed by plain radiography and CT scans. We divided the patients into two groups according to screw type and angles. Group A: fixed screw, Group B: variable screw. Interscrew angle was measured between most upper and lower screws with Cobb's methods. RESULTS: Overall fusion rate was 86.2% on plain radiography. Fusion was also assessed by CT scan and Bridwell's grading system. There was no difference in fusion and subsidence rates between two groups. Subsidence was found in 5 patients (17.2%). Segmental lordotic angle was increased from preoperative status and maximized at the immediate postoperative period and then reduced at 1 year follow up. Segmental height showed similar increase and decrease values. CONCLUSION: ACDF with allograft and plate showed favorable fusion rates, and the screw type and angle did not affect results of surgery.

Posterior C2-C3 Fixation for Unstable Hangman's Fracture.

OBJECTIVE: This is a retrospective review of 13 unstable Hangman's fractures who underwent posterior C2-3 fixation to describe clinical outcomes with a literature review. METHODS: Thirteen patients for unstable Hangman's fracture were enrolled between July 2007 and June 2010 were included in this study. The medical records of all patients were reviewed. Concurrently, clinical outcomes were evaluated using Neck Disability Index (NDI) scores and Visual Analogue Scale (VAS) scores during preoperative and postoperative follow up period. Plain radiographs were obtained on postoperative 1day, 1week, and then at 1, 2, 6, and 12 months. CT was done at postoperative 12 months in all patients for evaluation of bone fusion. The mean period of clinical follow-up was 17 months. RESULTS: Mean age were 43 years old. Bone fusion was recognized in all cases at the final follow-up. The average preoperative VAS score for neck pain was 8.3±1.1, while the final follow-up VAS score was 2.07±0.8 (p<0.001). The average immediate postoperative NDI was 84% points and final NDI was 22% points (p<0.001). There were one case of infection and 1 case of screw loosening. CONCLUSION: In the treatment of the patients with unstable Hangman's fracture, posterior C2-C3 fusions is effective and curative treatments to achieve cervical spinal stability.

Brachial plexus tumors in a consecutive series of twenty one patients.

OBJECTIVE: This is a retrospective review of 22 surgically treated benign and malignant tumors of brachial plexus region to describe clinical presentation, the characteristics of brachial plexus tumor and clinical outcomes with a literature review. METHODS: Twenty-one patients with consecutive 22 surgeries for primary brachial plexus tumors were enrolled between February 2002 and November 2011 were included in this study. The medical records of all patients were reviewed. RESULTS: Eleven male and 10 female patients were enrolled. Mean age was 39 years. Three patients had brachial plexus tumor associated with neurofibromatosis (13.6%). Presenting signs and symptoms included parenthesis and numbness (54.5%), radiating pain (22.7%), direct tenderness and pain (27.2%), palpable mass (77.3%). Twelve patients presented preoperative sensory deficit (54.5%) and 9 patients presented preoperative motor deficit (40.9%). Twenty tumors (90.9%) were benign and 2 tumors (9.1%) were malignant. Benign tumors included 15 schwannomas (68.2%), 4 neurofibromas (18.2%) and 1 granular cell tumor (4.5%). There were 1 malignant peripheral nerve sheath tumor (MPNST) and 1 malignant granular cell tumor. Gross total resection was achieved in 16 patients (72.7%), including all schwannomas, 1 neurofibroma. Subtotal resection was performed in 6 tumors (27.3%), including 3 neurofibromatosis associated with brachial plexus neurofibromas, 1 MPNST and 2 granular cell tumor in one patient. CONCLUSION: Resection of tumor is the choice of tumor in the most of benign and malignant brachial plexus tumors. Postoperative outcomes are related to grade of resection at surgery and pathological features of tumor.

Clinical outcomes of percutaneous plasma disc coagulation therapy for lumbar herniated disc diseases.

OBJECTIVE: This is prospective study of clinical outcomes of percutaneous plasma disc coagulation Therapy (PDCT) in patients with herniated lumbar disc disease (HLD) to evaluate the safety and efficacy in its clinical application and usefulness as a reliable alternative to microscopic discectomy. METHODS: Forty-six patients were enrolled in this study from April 2006 to June 2010. All patients had one-level HLD. Disc degeneration was graded on routine T2-weighted magnetic resonance Image (MRI) using the Pfirrmann's grading system and all index levels were grade 3 and grade 4. Indications for surgery were radiculopathy caused by disc protrusion with soft consistency. MRI was done at one month after the procedure in all patients to check post-PDCT change. The clinical outcomes were evaluated using Visual Analog Scales (VAS) score and MacNab's criteria. RESULTS: This study was approved by the Institutional Review Board of our institution. The age of the study population ranged from 16 to 59 years with a mean age of 37.2 years. There were 29 males and 17 females in this study. The mean period of clinical follow-up was 21 months. The average preoperative VAS score for radiculopathy was 7.4±1.4, while the final follow-up VAS score was 1.4±0.7 (p<0.001). In MacNab's criteria, 41 patients (89.1%) had achieved favorable improvement (excellent and good) until later follow-up. There were one patient from infection and two patients who needed to convert to open discectomy. CONCLUSION: PDCT is a safe and efficient treatment modality in a selective patient with HLD.

Granular cell tumor of brachial plexus mimicking nerve sheath tumor: a case report.

Primary tumors of the brachial plexus region are rare and granular cell tumors arising from the brachial plexus region is an extremely rare disease. We present a case of granular cell tumor arising from of the brachial plexus which appeared to be a usual presentation of nerve sheath tumor before the pathological confirmation. We report a granular cell tumor of the brachial plexus with literature review. Total resection is important for good clinical outcome and prognosis in the treatment of granular cell tumor.

Two separate episodes of intramedullary spinal cord metastasis in a single patient with breast cancer.

Intramedullary spinal cord metastases are very rare. Patients with breast cancer as the primary source of intramedullary spinal cord metastases tend to do better than other types of cancer. We report the very unusual case of a woman with breast cancer who had two separate episodes of intramedullary spinal cord metastasis.

Clinical and radiological outcomes of anterior cervical interbody fusion using hydroxyapatite spacer.

OBJECTIVE: This is retrospective study of clinical and radiological outcomes of anterior cervical fusion using Bongros-HA (BioAlpha, Seongnam, Korea) which is a type of synthetic hydroxyapatite (HA) spacer to evaluate the efficacy in its clinical application and usefulness as a reliable alternative to autograft bone. METHODS: Twenty-nine patients were enrolled in this study and 40 segments were involved. All patients were performed anterior cervical interbody fusion using HA spacer and plating system. Indications for surgery were radiculopathy caused by soft-disc herniation or spondylosis in 18 patients, spondylotic myelopathy in 1 patient, and spinal trauma in 10 patients. Cervical spine radiographs were obtained on postoperative 1day, 1week, and then at 1, 2, 6, and 12 months in all patients to evaluate intervertebral disc height, and the degrees of lordosis. Cervical computed tomography was done at postoperative 12 month in all patients to confirm the fusion status. The mean period of clinical follow-up was 17 months. RESULTS: Complete interbody fusion was achieved in 100% of patients. Preoperative kyphotic deformities were corrected in all cases after surgery. Intervertebral disc height was well maintained during follow up period. There were no cases of graft extrusion, graft deterioration and graft fracture. CONCLUSION: HA spacer is very efficient in achieving cervical fusion, maintaining intervertebral disc height, and restoring lordosis. When combined with the placement of a cervical plate, immediate stability can be achieved and graft related complication can be prevented.

Chordomas involving multiple neuraxial bones.

We present a patient with multifocal symptomatic osseous chordomas having unusual growth patterns with review of the pertinent literature. The patient was 62-year-old male and had multiple osseous chordomas located in sacral, thoracic, and paraclival jugular foramen areas. There was no metastasis in other organs. All affected sites were osseous. The multicentric chordomas are extremely rare. This case could be considered as a chordoma involving multiple neuraxial bones. But, the possibility of multicentricity could also be thought. In such cases radical resection should be performed for each lesion at the initial diagnosis. If complete surgical resections are infeasible or impossible, preoperative or postoperative radiation therapy should be planned for the highest possibility of successful treatment.

Spontaneous spinal epidural hematoma in an infant : a case report and review of the literature.

Spontaneous spinal epidural hematoma (SSEH) is rare in children, especially in infants, in whom only 12 cases have been reported. Because of the nonspecificity of presenting symptoms in children, the diagnosis may be delayed. We report herein a case of SSEH in a 20-month-old girl who initially presented with neck pain, and developed lower extremity motor weakness and symptoms of neurogenic bladder 2 weeks prior to admission. The magnetic resonance imaging showed an epidural mass lesion extending from C7 to T4, and the spinal cord was severely compressed by the mass. After emergency decompressive surgery the neurologic function was improved immediately. Two months after surgery, the neurological status was normal with achievement of spontaneous voiding. We suggest that surgical intervention can provide excellent prognosis in case of SSEH in infants, even if surgery delayed.

Spinal cord injury without radiological abnormality in an infant with delayed presentation of symptoms after a minor injury.

STUDY DESIGN: We present a very rare case of an infant with delayed presentation of spinal cord injury without radiologic abnormality (SCIWORA) after a minor injury. OBJECTIVE: To emphasize the importance of spinal evaluation with MRI in selected cases, even after minor injuries, especially in infants. SUMMARY OF BACKGROUND DATA: SCIWORA arises mainly in infants and children during accidental trauma or after sport injury. However, it has been very rare for a 6-day-delayed infant SCIWORA after a minor injury. METHODS: An infant presented with transient nausea and vomiting after falling from a baby-rocking horse of less than 30-cm height. The patient demonstrated right hemiparesis 6 days later. Plain cervical radiographs and brain and cervical spine computed tomograms (CT) were normal, but the cervical magnetic resonance imaging (MRI) demonstrated a high signal in the T2-weighted image of the lower cervical cord, and a neck collar was applied. RESULTS: A follow-up cervical MRI 1 month later showed that the high signal of the lower cervical cord had disappeared. Another follow-up cervical MRI 12 months later also showed normal radiographic findings but there still remained mild weakness of the right lower extremities. CONCLUSION: The authors present a rare case of infant SCIWORA who developed delayed neurologic symptoms 6 days after a minor injury and suggest that spinal evaluation with MRI could be warranted in the selected case even after minor injuries, especially in infants.

Valve pressure upgrade may produce progressive deterioration of vision in children with slit ventricle syndrome.

Recently, valve upgrade and/or endoscopic third ventriculostomy, which have the merit of no additional shunting, were introduced for the treatment of slit ventricle syndrome, because lumboperitoneal shunting entails various complications including development of Chiari malformation, shunt malfunction, and infection. However, the safety of valve upgrading is not confirmed, especially in a child with slit ventricle syndrome developed as a result of pseudotumor cerebri. A 5-year-old boy with pseudotumor cerebri presented with headache, intermittent vomiting, and sudden deterioration of visual acuity. His cerebrospinal pressure during lumbar puncture was 69 cm H(2)O and his magnetic resonance imaging revealed only small ventricles. He underwent a ventriculoperitoneal shunt resulting in dramatic improvement. Four months later, he returned with recurrent spontaneous valve malfunction with recurrent severe headache and visual deterioration. After shunt revision with a programmable valve, his intermittent valve malfunction was improved by upgrading the valve opening pressure. However, his visual acuity became progressively aggravated. He underwent a lumboperitoneal shunt with low-pressure valve, which resulted in the disappearance of intermittent headaches and a deterioration of visual acuity. We suggest that valve pressure upgrade in children with slit ventricle syndrome after ventriculoperitoneal shunt for pseudotumor cerebri may produce acute deterioration of vision that had already been compromised, even within the normal intracranial pressure range and with improvement of associated symptoms.

Lateral ventricular diverticulum extending into supracerebellar cistern from unilateral obstruction of the foramen of monro in a neonate.

A ventricular diverticulum is usually found in patients with long-standing severe obstructive hydrocephalus that may extend into the supracerebellar cistern. The route involved in the supracerebellar extension of the ventricular diverticulum is believed to originate through the tela choroidea of the temporal choroid plexus or of the antral choroid plexus. The authors report a 4-week-old girl with hydrocephalus as a result of unilateral obstruction of the foramen of Monro, which dilated the right ventricle and displaced the midline to the left side, collapsing the contralateral lateral ventricle. The dilated lateral ventricular diverticulum herniated to the supracerebellar cistern in the posterior fossa that compressed the cerebellum inferiorly. She was treated successfully by a ventriculoperitoneal shunt, resulting in a marked reduction of the ventricle and diverticulum on the follow-up computed tomography and magnetic resonance imaging. We reviewed the literature for the supracerebellar extension route of ventricular diverticulum and suggest that the medial choroidal fissure in the antrum and the velum interpositum may be important anatomical structures for the extension of the lateral ventricular diverticulum into the supracerebellar cistern.

Infantile lumbosacral spinal subdural abscess with sacral dermal sinus tract.

STUDY DESIGN: Clinical case report of a spinal subdural abscess in an infant presenting with sacral dermal sinus tract (DST). OBJECTIVES: To suggest that sacral DST with caudal direction may require surgical resection as early as possible. SUMMARY OF BACKGROUND DATA: DST may induce the formation of a spinal abscess. However, it is sometimes difficult to decide on early surgical resection for DST, especially in cases that are located at a lower level than the lumbar spine and directed caudally that is not accompanied by cerebrospinal fluid leakage. METHODS: A 9-month-old girl was transferred due to intermittent fever and vomiting, with the midline sinus of the lower back at the second sacral spinal level. She showed mild tenderness of the lower back and slight weakness of both lower extremities with increased residual urine volume of the bladder. Magnetic resonance imaging (MRI) showed that the low-lying sacral DST traced into the subdural space with caudal orientation, and the presence of extensive subdural spinal abscess from the first lumbar spine to the fourth sacrum. RESULTS: Emergency resection of the sacral DST was performed after laminotomy from the first lumbar spine to the second sacrum, and the subdural spinal abscess was also surgically removed. After 8 weeks of intravenous antibiotic treatment, she showed no neurologic deficit and no evidence of residual abscess on MRI. CONCLUSION: We suggest that even low-lying sacral DST may require surgical resection as early as possible because it may result in indolent and extensive spinal abscesses.

Tethered spinal cord with double spinal lipomas.

Although lumbosacral lipoma is reported to occur in 4-8 of 100,000 patients, and 66% of lipomyelomeningoceles in young patients are accompanied by hypertrophic filum terminale, it is very rare to find two isolated spinal lipomas simultaneously. A 3 month-old baby girl was admitted to the hospital for a protruding, non-tender, soft, subcutaneous 2.5 cm mass of the lumbosacral area that had been present since birth. Simple radiography showed a spinal posterior arch defect from L3 to L5, and magnetic resonance imaging (MRI) demonstrated two isolated spinal lipomas, a transitional type from L3 to L5, and a terminal type below S1 without dural defect. The cornus medullaris was severely tethered descending to the S1, but there was no cerebellar or brain stem herniation on the MRI. We suggest that the presence of a combined spinal lipoma should be a point for careful differentiation in an infant with spinal lipoma.

Blood blister-like aneurysms at nonbranching sites of the internal carotid artery.

OBJECT: The clinical features of blood blister-like aneurysms (BBAs) that arise at nonbranching sites of the internal carotid artery (ICA) differ from those of saccular aneurysms. In this study, the authors attempt to describe optimal treatments for BBAs, which have yet to be clearly established. METHODS: Ten of 483 patients with aneurysmal subarachnoid hemorrhage who had been seen at the authors' institution between March 2001 and June 2005 had intraoperatively confirmed BBAs at nonbranching sites of the ICA. All ten patients were women between the ages of 37 and 64 years (mean age 49.3 years); five had a history of hypertension. The BBAs were localized to the right side of the ICA in seven cases. All patients were successfully treated; clipping was undertaken in six, clipping combined with wrapping in three, and trapping in one. These methods were used in conjunction with various other surgical techniques such as brain relaxation by draining cerebrospinal fluid, anterior clinoidectomy, exposing the cervical ICA, gentle subpial dissection (for aneurysms that adhered to the frontal lobe), complete trapping of the ICA before clipping, and protecting the brain. Clip slippage occurred at the end of dural closing in two cases; the aneurysm was completely obliterated using multiple clips combined with ICA stenosis in one of these cases and ICA trapping with good collateral flow in the other. An excellent clinical outcome was achieved in eight patients, whereas two patients were disabled from massive vasospasm. The authors retrospectively reviewed radiological and surgical data in all cases to determine which treatment methods produced a favorable outcome. CONCLUSIONS: Blood blister-like aneurysms located at nonbranching sites of the ICA are difficult to treat. Preoperative awareness and careful consideration of these lesions during surgery can prevent poor clinical outcomes.

A large arachnoid cyst of the lateral ventricle extending from the supracerebellar cistern--case report.

BACKGROUND: The pathogenetic mechanism of intraventricular arachnoid cyst development is still controversial, but is believed to originate from the vascular mesenchyme or as an extension of the arachnoid cyst in the subarachnoid space into the ventricle through the choroidal fissure. We report a case supporting the extension hypothesis and suggest differential points between an intraventricular arachnoid cyst that extended from the supracerebellar space and a lateral ventricular diverticulum that extended into the supracerebellar cistern. CASE DESCRIPTION: A 12-month-old girl presented with macrocephaly and developmental delay. Her magnetic resonance imaging showed an arachnoid cyst that had developed from the supracerebellar space in the posterior fossa, and which extended into the left lateral ventricle resulting in expansion of the left lateral ventricle and displacing the choroids plexus anteriorly and laterally and the midline to the right. We treated an intraventricular arachnoid cyst by endoscopic fenestration resulting in dramatic reduction of the intraventricular arachnoid cyst with large bilateral subdural fluid collection. We performed a subduroperitoneal shunt for subdural fluid collection and subsequent cystoperitoneal shunt for the remnant cyst. CONCLUSION: We suggest that this case supports the extension hypothesis from the subarachnoid space through the choroidal fissure into the lateral ventricle. We also suggest that one of the radiological differential points between an intraventricular arachnoid cyst and a ventricular diverticulum is displacement and compression of the choroid plexus of the lateral ventricle.