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Man Kyu Choi, Dae Jean Jo and Chang Kyu Park

OBJECTIVE

Late-onset neurological deficits are a rare complication of spinal tuberculosis that may be caused by proximal adjacent segment degeneration (ASD) above the kyphus. The objective of this study was to report several cases of neurological deficits due to proximal ASD in patients with post-tuberculous kyphotic deformity and discuss the characteristics of the authors’ corrective surgical technique.

METHODS

The inclusion criteria in this study were severe angular kyphosis due to a post-tuberculous kyphotic deformity and a late-onset neurological deficit. The cause of these deficits was related to a lesion in the proximal cephalad portion of the kyphotic deformity. Surgical intervention, including decompression and compromised restoration of the sagittal imbalance, was performed in all patients. Preoperative surgical planning with a radiological evaluation included CT, plain radiograph, and MRI studies. Clinical outcomes were evaluated using the American Spinal Injury Association Impairment Scale and the Oswestry Disability Index (ODI).

RESULTS

The main goal of our surgical technique was the correction of sagittal malalignment by positioning the patient’s head above the kyphotic deformity on the sagittal plane, excluding aggressive osteotomy. The neurological symptoms showed immediate improvements postoperatively, except in 1 patient. Compared to the preoperative value of 66.9, the mean ODI score improved to 42.6 at the final follow-up for all patients. Preoperatively, the mean values of the angles of deformity and the sagittal vertical axis were 99.7° and 157.7 mm, respectively, and decreased to 75.3° and 46.0 mm, respectively, at the final follow-up. No major complications were observed, and the patients’ self-satisfaction was high with respect to both cosmetic and functional outcomes.

CONCLUSIONS

Clinicians should be aware of the degeneration of the vertebrae above the kyphotic segment in patients with post-tuberculosis deformity. Successful neurological recovery and compromised sagittal balance could be obtained by using our “head on kyphus” surgical concept.

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Chang Kyu Park, Choon Keun Park, Dong Chan Lee and Dong Geun Lee

OBJECT

In elderly patients with severe osteoporosis, instrumented lumbar interbody fusion may result in fixation failure or nonunion because of decreased pedicle screw pullout strength or increased interbody graft subsidence risk. Thus, given its many advantages, percutaneous pedicle screw fixation with cement augmentation can be an effective method to use in elderly patients. The authors report on an easy, safe, and economical technique for bone cement augmentation using a bone biopsy needle inserted into the disc space in 2 osteoporotic patients who were treated with posterior interbody fusion and percutaneous pedicle screw fixation.

METHODS

Two elderly patients who complained of back pain and intermittent neurological claudication underwent posterior interbody fusion with percutaneous pedicle screw fixation. After routinely assembling rods on the screws, a bone biopsy needle was inserted into the disc space via the operative field; the needle was then placed around the tips of the screws using fluoroscopic radiography for guidance. Bone cement was injected through the bone biopsy needle, also under fluoroscopic radiography guidance.

RESULTS

Both patients’ symptoms improved after the operation, and there was no evidence of cage subsidence or screw loosening at the 4-month follow-up.

CONCLUSIONS

The indirect technique of bone cement augmentation via the disc space for percutaneous screw fixation could be an easy, safe, and economical method.

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Na Young Jung, Chang Kyu Park, Won Seok Chang, Hyun Ho Jung and Jin Woo Chang

OBJECTIVE

Although neurosurgical procedures are effective treatments for controlling involuntary tremor in patients with essential tremor (ET), they can cause cognitive decline, which can affect quality of life (QOL). The purpose of this study is to assess the changes in the neuropsychological profile and QOL of patients following MR-guided focused ultrasound (MRgFUS) thalamotomy for ET.

METHODS

The authors prospectively analyzed 20 patients with ET who underwent unilateral MRgFUS thalamotomy at their institute in the period from March 2012 to September 2014. Patients were regularly evaluated with the Clinical Rating Scale for Tremor (CRST), neuroimaging, and cognition and QOL measures. The Seoul Neuropsychological Screening Battery was used to assess cognitive function, and the Quality of Life in Essential Tremor Questionnaire (QUEST) was used to evaluate the postoperative change in QOL.

RESULTS

The total CRST score improved by 67.3% (from 44.75 ± 9.57 to 14.65 ± 9.19, p < 0.001) at 1 year following MRgFUS thalamotomy. Mean tremor scores improved by 68% in the hand contralateral to the thalamotomy, but there was no significant improvement in the ipsilateral hand. Although minimal cognitive decline was observed without statistical significance, memory function was much improved (p = 0.031). The total QUEST score also showed the same trend of improving (64.16 ± 17.75 vs 27.38 ± 13.96, p < 0.001).

CONCLUSIONS

The authors report that MRgFUS thalamotomy had beneficial effects in terms of not only tremor control but also safety for cognitive function and QOL. Acceptable postoperative changes in cognition and much-improved QOL positively support the clinical significance of MRgFUS thalamotomy as a new, favorable surgical treatment in patients with ET.

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Na Young Jung, Chang Kyu Park, Minsoo Kim, Phil Hyu Lee, Young Ho Sohn and Jin Woo Chang

OBJECTIVE

Recently, MR-guided focused ultrasound (MRgFUS) has emerged as an innovative treatment for numerous neurological disorders, including essential tremor, Parkinson’s disease (PD), and some psychiatric disorders. Thus, clinical applications with this modality have been tried using various targets. The purpose of this study was to determine the feasibility, initial effectiveness, and potential side effects of unilateral MRgFUS pallidotomy for the treatment of parkinsonian dyskinesia.

METHODS

A prospective, nonrandomized, single-arm clinical trial was conducted between December 2013 and May 2016 at a single tertiary medical center. Ten patients with medication-refractory, dyskinesia-dominant PD were enrolled. Participants underwent unilateral MRgFUS pallidotomy using the Exablate 4000 device (InSightec) after providing written informed consent. Patients were serially evaluated for motor improvement, neuropsychological effects, and adverse events according to the 1-year follow-up protocol. Primary measures included the changes in the Unified Parkinson’s Disease Rating Scale (UPDRS) and Unified Dyskinesia Rating Scale (UDysRS) scores from baseline to 1 week, 1 month, 3 months, 6 months, and 1 year. Secondary measures consisted of neuropsychological batteries and quality of life questionnaire (SF-36). Technical failure and safety issues were also carefully assessed by monitoring all events during the study period.

RESULTS

Unilateral MRgFUS pallidotomy was successfully performed in 8 of 10 patients (80%), and patients were followed up for more than 6 months. Clinical outcomes showed significant improvements of 32.2% in the “medication-off” UPDRS part III score (p = 0.018) and 52.7% in UDysRS (p = 0.017) at the 6-month follow-up, as well as 39.1% (p = 0.046) and 42.7% (p = 0.046) at the 1-year follow-up, respectively. These results were accompanied by improvement in quality of life. Among 8 cases, 1 patient suffered an unusual side effect of sonication; however, no patient experienced persistent aftereffects.

CONCLUSIONS

In the present study, which marks the first Phase I pilot study of unilateral MRgFUS pallidotomy for parkinsonian dyskinesia, the authors demonstrated the efficacy of pallidal lesioning using MRgFUS and certain limitations that are unavoidably associated with incomplete thermal lesioning due to technical issues. Further investigation and long-term follow-up are necessary to validate the use of MRgFUS in clinical practice.

Clinical trial registration no.: NCT02003248 (clinicaltrials.gov)

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Sung Ho Lee, Bong Jin Park, Hee Sup Shin, Chang Kyu Park, Bong Arm Rhee and Young Jin Lim

OBJECTIVE

Abnormal lateral spread response (LSR) is a typical finding in facial electromyography (EMG) in patients with hemifacial spasm (HFS). Although intraoperative monitoring of LSR has been widely used during microvascular decompression (MVD), the prognostic value of this monitoring is still debated. The purpose of this study was to determine whether such monitoring exhibits prognostic value for the alleviation of LSR after treatment of HFS.

METHODS

Between January 2009 and December 2013, a total of 582 patients underwent MVD for HFS with intraoperative EMG monitoring at Kyung Hee University Hospital. The patients were categorized into 1 of 2 groups according to the presence of LSR at the conclusion of surgery (Group A, LSR free; Group B, LSR persisting). Patients were assessed for the presence of HFS 1 day, 6 months, and 1 year after surgery. Various parameters, including age, sex, symptom duration, offending vertebral artery, and offending perforating artery, were evaluated for their influence on surgical and electrophysiological results.

RESULTS

Overall, HFS was alleviated in 455 (78.2%) patients 1 day after MVD, in 509 (87.5%) patients 6 months after MVD, and in 546 (93.8%) patients 1 year after MVD. Patients in Group B were significantly younger than those in Group A (p = 0.022). Patients with a symptom duration of less than 1 year were significantly more likely to be classified in Group A than were patients whose symptoms had persisted for longer than 10 years (p = 0.023); however, analysis of the entire range of symptom durations did not reveal a significant effect (p = 0.132). A comparison of Groups A and B according to follow-up period revealed that HFS recovery correlated with LSR alleviation over a shorter period, but the same was not true of longer periods; the proportions of spasm-free patients were 80.6% and 71.1% (p = 0.021), 89.4% and 81.9% (p = 0.022), and 93.5% and 94.6% (p = 0.699) 1 day, 6 months, and 1 year after surgery in Groups A and B, respectively.

CONCLUSIONS

Although intraoperative EMG monitoring during MVD was beneficial for identifying the offending vessel and suggesting the most appropriate surgical end point, loss of LSR did not always correlate with long-term HFS treatment outcome. Because the HFS cure rate improved over time, revision might be considered for persistent LSR when follow-up has been performed for more than 1 year and the spasm remains despite adequate decompression.