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Sun Ho Kim, Soo Chul Park and Kyu Chang Lee

✓ The authors have developed a double-barreled tack suture procedure for carotid endarterectomy with minimal modification of a conventional needle holder. With this method surgeons can make two stitches simultaneously by using two needles threaded with double-armed suture material, which are held tightly in a parallel fashion in the jaws of a modified needle holder.

This method is very effective in preventing the buckling of the intimal wall of the arterectomized distal internal carotid artery. Also, it reduces the tack suture time markedly compared with the conventional tack suture method.

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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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Chang Sub Lee, Ji Hoon Phi, Seung-Ki Kim, Byung-Kyu Cho and Kyu-Chang Wang

Object

Congenital dermal sinus (CDS) usually develops in the midline of the body as a single tract. To date, only a few patients with multiple CDS tracts and ostia have been reported. The authors analyzed the clinical features of patients with spinal CDS and multiple ostia and proposed a novel hypothesis for the pathogenesis of the atypical CDS.

Methods

Five patients with spinal CDS and multiple ostia were included. The clinical, radiological, and operative features of these patients were reviewed retrospectively.

Results

Three patients demonstrated bilateral paramedian ostia at the same or a very similar spinal level. One patient showed a paramedian and a midline ostium. One patient had 2 unilateral paramedian ostia at different spinal levels. The layers of the internal ending of CDS tracts were diverse. Complete removal of the tracts was possible in all patients. Two patients had dermoid tumors. All patients had an associated anomaly, such as a lumbosacral lipoma or the Currarino triad. The authors propose a “zipping error” hypothesis for the formation of dual ostia located at the spinal level of primary neurulation. An associated anomaly such as a lumbosacral lipoma may contribute to the formation of dual ostia.

Conclusions

Unilateral or bilateral dual ostia may be present in patients with CDS, especially when an associated anomaly is present. The atypical CDS may develop from aberrant neural tube closure.

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Jeong-Yub Kim, Jongsun Lee, Jae-Soo Koh, Myung-Jin Park and Ung-Kyu Chang

OBJECTIVE

Chordoma is a rare bone tumor of the axial skeleton believed to originate from the remnants of the embryonic notochord. The available tumor cells are characteristically physaliferous and express brachyury, a transcription factor critical for mesoderm specification. Although chordomas are histologically not malignant, treatments remain challenging because they are resistant to radiation therapy and because wide resection is impossible in most cases. Therefore, a better understanding of the biology of chordomas using established cell lines may lead to the advancement of effective treatment strategies. The authors undertook a study to obtain this insight.

METHODS

Chordoma cells were isolated from the tissue of a patient with dedifferentiated-type chordoma (DTC) that had recurred. Cells were cultured with DMEM/F12 containing 10% fetal bovine serum and antibiotics (penicillin and streptomycin). Cell proliferation rate was measured by MTS assay. Cell-cycle distribution and cell surface expression of proteins were analyzed by fluorescence-activated cell sorting (FACS) analysis. Expression of proteins was analyzed by Western blot and immunocytochemistry. Radiation resistance was measured by clonogenic survival assay. Tumor formation was examined by injection of chordoma cells at hindlimb of nude mice.

RESULTS

The putative (DTC) cells were polygonal and did not have the conventional physaliferous characteristic seen in the U-CH1 cell line. The DTC cells exhibited similar growth rate and cell-cycle distribution, but they exhibited higher clonogenic activity in soft agar than U-CH1 cells. The DTC cells expressed high levels of platelet-derived growth factor receptor–β and a low level of brachyury and cytokeratins; they showed higher expression of stemness-related and epithelial to mesenchymal transition–related proteins than the U-CH1 cells. Intriguingly, FACS analysis revealed that DTC cells exhibited marginal surface expression of CD24 and CD44 and high surface expression of CXCR4 in comparison to U-CH1 cells. In addition, blockade of CXCR4 with its antagonist AMD3100 effectively suppressed the growth of both cell lines. The DTC cells were more resistant to paclitaxel, cisplatin, etoposide, and ionizing radiation than the U-CH1 cells. Injection of DTC cells into the hindlimb region of nude mice resulted in the efficient formation of tumors, and the histology of xenograft tumors was very similar to that of the original patient tumor.

CONCLUSIONS

The use of the established DTC cells along with preestablished cell lines of chordoma may help bring about greater understanding of the mechanisms underlying the chordoma that will lead to therapeutic strategies targeting chordomas.

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Hyunho Choi, Ji Yeoun Lee, Ji Hoon Phi, Seung-Ki Kim, Byung-Kyu Cho and Kyu-Chang Wang

Object

Postoperative epidural hematoma (EDH), a blood collection between the inserted galeal flap and the overlying skull flap (epigaleal flap hematoma), is a frustrating complication of the surgical treatment of moyamoya disease (MMD) in pediatric patients. The symptoms of postoperative EDH are often similar to those of postoperative cerebral ischemia, and may cause confusion during clinical decision making. The authors designed this study to evaluate the incidence, clinical presentation, risk factors, and treatment outcomes of postoperative EDH in pediatric patients with MMD.

Methods

A retrospective review of 148 pediatric patients with 250 craniotomies who underwent indirect bypass revascularization surgery between January 2002 and December 2006 was performed. This group consisted of 60 male and 88 female patients, and the mean age at surgery was 7.5 years (range 1–18 years).

Results

Of the 250 craniotomies, postoperative EDH was detected in 32 cases. In 12 cases of EDH, surgical treatment was necessary (4.8% of 250 craniotomies). During the same period, 743 non-MMD craniotomy operations were performed. In 6 of these 743 operations, patients developed postoperative EDH that required surgical treatment, significantly less than the percentage of EDH requiring postoperative treatment in patients with MMD (0.8%, p < 0.001). The average interval between craniotomy surgery and the detection of EDH was 1.8 days (range 0–5 days) in patients with MMD and 0.5 days (range 0–2 days; p = 0.018) in the non-MMD craniotomy group.

Postoperative EDH was observed in significantly fewer cases (17 of 191) when a subcutaneous drain (SCD) was inserted over the bone flap than in cases in which an SCD was not inserted (14 of 55; p = 0.001). The mean international normalized ratio of prothrombin time in the immediate postoperative blood test was 1.27 ± 0.17 in the EDH group and 1.20 ± 0.11 in the non-EDH group (values are expressed as the mean ± SD; p = 0.008). Central galeal flap tenting suture and immediate postoperative platelet count were not related to the incidence of postoperative EDH following pediatric MMD surgery.

Conclusions

Postoperative EDH is more likely to be found following craniotomy in patients with MMD than in those without MMD, and may occur in a delayed fashion. Insertion of an SCD and immediate correction of an abnormal value for international normalized ratio of prothrombin time can decrease the incidence of postoperative EDH following surgery for pediatric MMD.

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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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Ji Hoon Phi, Kyu-Chang Wang, Byung-Kyu Cho, Myung Sook Lee, Jong-Hwa Lee, Kyung-Sang Yu, Bong-Jin Hahm and Seung-Ki Kim

Object

Although the reported surgical outcome is favorable, there is little information regarding the long-term quality of life in pediatric patients with moyamoya disease (MMD) when they grow to adulthood. The authors conducted a survey to provide details of social adaptation and satisfaction in adults who underwent revascularization surgery for MMD during childhood.

Methods

One hundred twenty-three patients with MMD who had undergone surgery during childhood and were older than 18 years of age were recruited for this study. The authors mailed self-administered questionnaires regarding each patient's education, employment, marriage, driver's license, physical condition, and satisfaction. Sixty-five patients (53%) responded.

Results

Compared with the general population, the patients showed a similar rate of attaining a higher education. Forty-nine (80%) of 61 patients who were not currently high school students had entered college or university. However, the presence of neurological deficits on preoperative examination was a negative predictor of entrance into a college or university, as well as employment. Some patients had difficulty in planning marriage because of physical handicaps, and the rate of acquiring a driver's license and actual driving were relatively low. Approximately 80% of the responders were satisfied with their treatment outcomes, but more than one-half reported subjectively assessed neurological problems.

Conclusions

In this study, pediatric patients with MMD showed favorable social adaptation in adulthood. The findings also indicated that early diagnosis and intervention before the establishment of neurological deficits are essential to children with MMD in becoming better socially adapted. Further, more thorough clinical examinations are required during follow-up in patients with MMD.

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Ung-Kyu Chang, Daniel H. Kim, Max C. Lee, Rafer Willenberg, Se-Hoon Kim and Jesse Lim

Object

Range of motion (ROM) changes were evaluated at the surgically treated and adjacent segments in cadaveric specimens treated with two different cervical artificial discs compared with those measured in intact spine and fusion models.

Methods

Eighteen cadaveric human cervical spines were tested in the intact state for the different modes of motion (extension, flexion, lateral bending, and axial rotation) up to 2 Nm. Three groups of specimens (fitted with either the ProDisc-C or Prestige II cervical artificial disc or submitted to anterior cervical discectomy and fusion [ACDF]) were tested after implantation at C6–7 level. The ROM values were measured at treated and adjacent segments, and these values were then compared with those measured in the intact spine.

Results

At the surgically treated segment, the ROM increased after arthroplasty compared with the intact spine in extension (54% in the ProDisc-C group, 47% in the Prestige group) and in flexion (27% in the ProDisc-C group, 10% in the Prestige group). In bending and rotation, the postarthroplasty ROMs were greater than those of the intact spine (10% in the ProDisc-C group and 55% in the Prestige group in bending, 17% in the ProDisc-C group and 50% in the Prestige group in rotation). At the adjacent levels the ROMs decreased in all specimens treated with either artificial disc in all modes of motion (< 10%) except for extension at the inferior the level (29% decrease for ProDisc-C implant, 12% decrease for Prestige disc). The ROM for all motion modes in the ACDF-treated spine decreased at the treated level (range 18–44%) but increased at the adjacent levels (range 3–20%).

Conclusions

Both ProDisc-C and Prestige artificial discs were associated with increased ROM at the surgically treated segment compared with the intact spine with or without significance for all modes of testing. In addition, adjacent-level ROM decreased in all modes of motion except extension in specimens fitted with both artificial discs.

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Ung-Kyu Chang, Daniel H. Kim, Max C. Lee, Rafer Willenberg, Se-Hoon Kim and Jesse Lim

Object

The authors of previous in vitro investigations have reported an increase in adjacent-level intradiscal pressures (IDPs) and facet joint stresses following cervical spine fusion. This study was performed to compare adjacent-level IDPs and facet force following arthroplasty with the fusion model.

Methods

Eighteen human cadaveric cervical spines were tested in the intact state for different modes of motion (extension, flexion, bending, and rotation) up to 2 Nm. The specimens were then divided into three groups: those involving the ProDisc-C cervical artificial disc, Prestige cervical artificial disc, and cervical fusion. They were load tested after application of instrumentation or surgery at the C6–7 level. During the test, IDPs and facet forces were measured at adjacent levels.

Results

In arthroplasty-treated specimens, the IDP showed little difference from that of the intact spine at both proximal and distal levels. In fusion-treated specimens, the IDP increased at the posterior anulus fibrosus on extension and at the anterior anulus fibrosus on flexion at the proximal level. At the distal level, the IDP change was not significant. The facet force changes were minimal in flexion, bending, and rotation modes in both arthroplasty- and fusion-treated spines. Significant changes were noted in the extension mode only. In extension, arthroplasty models exhibited significant increases of facet force at the treated level. In the fusion model the facet forces decreased at the treated segment and increased at the adjacent segment.

Conclusions

The two artificial discs of the semiconstrained systems maintain adjacent-level IDPs near the preoperative values in all modes of motion, but with respect to facet force pressure tended to increase after arthroplasty.

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Haeng Jin Lee, Ji Hoon Phi, Seung-Ki Kim, Kyu-Chang Wang and Seong-Joon Kim

OBJECTIVE

The aim of this study was to report the incidence of and the factors associated with papilledema in children with hydrocephalus.

METHODS

Patients younger than 15 years of age who had been diagnosed with hydrocephalus and treated by extra-ventricular drainage or ventriculoperitoneal shunt surgery between 2005 and 2015 were retrospectively reviewed. Factors including patient age and sex, etiology of hydrocephalus, duration of signs or symptoms, intracranial pressure (ICP), and presence of papilledema were evaluated.

RESULTS

Forty-six patients, whose mean age was 6.3 ± 4.7 years, were included in the study. The 19 patients without papilledema had a mean age of 2.7 ± 2.7 years, and the 27 patients with papilledema had a mean age of 8.8 ± 4.2 years (p < 0.001). The mean ICP was 19.9 ± 10.0 cm H2O among those without papilledema and 33.3 ± 9.1 cm H2O among those with papilledema (p < 0.001). The mean duration of signs or symptoms was 3.0 ± 4.6 months in the patients without papilledema and 3.4 ± 3.9 months in those with papilledema (p = 0.704). The patients with papilledema were older and presented with higher ICP than those without. The causes of hydrocephalus were tumor (59%), congenital anomaly (19%), hemorrhage (13%), and infection (9%).

CONCLUSIONS

Papilledema was more common in patients who were older, who had higher ICP, and whose hydrocephalus had been induced by brain tumor. However, since papilledema was absent in 41% of the children with hydrocephalus, papilledema's absence does not ensure the absence of hydrocephalus, especially in younger patients.