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Kyu Ho Lee, Jun Kim, and Jin Mo Chung

✓ A late component of the cortical evoked potential elicited by somatosensory afferent input was studied in cats anesthetized with α-chloralose. Cortical evoked potentials were recorded from the somatosensory-motor cortex during stimulation of the sural nerve with graded intensities. The stimulus intensity was adjusted to activate Aαβ fibers only, then both Aαβ and Aδ fibers, and both A and C fibers, as judged by afferent volleys monitored from the sural nerve proximal to the stimulating site. In addition to early components reported previously, a very late component was identified at a latency of 400 to 600 msec following stimulation of the sural nerve with intensities above threshold for Aδ fibers. A further increase in stimulation intensity to include activation of C fibers did not reveal any more components. This late component was depressed by a systemic intravenous injection of morphine (2 mg/kg), and intravenous naloxone (0.1 mg/kg) reversed the effect of morphine. The late component of the evoked potential could also be recorded from subcortical tissue after decortication of the sensorimotor cortex.

From these results, it appears that a very late component of the cortical evoked potential can be recorded from cats anesthetized with α-chloralose. The late component is evoked by activation of peripheral Aδ fibers. Furthermore, its morphine sensitivity suggests that this component may be elicited by nociceptive afferent fibers. If further investigations prove this, the late component, which is analogous to human long-latency potentials, could be used in an experimental model for pain research.

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Ho Jun Seol, Chun Kee Chung, and Hyun Jib Kim

Object. The anterior upper thoracic spine (T1–3) is difficult to access because most neurosurgeons are unfamiliar with the anatomy. This study was performed to evaluate the different surgical options by retrospectively analyzing data on operations performed for anterior upper thoracic compression at the authors' institution.

Methods. Eighteen patients underwent surgery between November 1993 and May 2001. There were eight men and 10 women; their mean age was 55 years (range 28–80 years). All patients presented with pain and/or neurological deficits. The causes of anterior compression were diverse, although metastatic spinal tumor was most common. The approach chosen was primarily dictated by the axial involvement of the lesion. Anterior approaches, mainly the transmanubrium approach, were performed in six and posterior approaches in 12. In all cases except one, in which only an iliac bone graft was placed, instrumentation was used. The mean follow-up period was 11.4 months (range 1–57 months). One postoperative death occurred. Postoperative follow-up imaging studies, especially plain radiography, demonstrated no instrumentation failure. Improvement was shown in eight patients, an aggravation of symptoms in one, and stable clinical status in eight.

Conclusions. Decompression may be achieved on the anterior side of the upper thoracic spine if the operative approach is scrupulously chosen; this choice involves consideration of the locations of the lesion, the nature of the primary disease, and the surgery-related risk.

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Kyungmi Kim, Ji-Yeon Bang, Seon-Ok Kim, Saegyeol Kim, Joung Uk Kim, and Jun-Gol Song

OBJECTIVE

Hypoalbuminemia is known to be independently associated with postoperative acute kidney injury (AKI). However, little is known about the association between the preoperative serum albumin level and postoperative AKI in patients undergoing brain tumor surgery. The authors investigated the incidence of AKI, impact of preoperative serum albumin level on postoperative AKI, and death in patients undergoing brain tumor surgery.

METHODS

The authors retrospectively reviewed the electronic medical records and laboratory results of 2363 patients who underwent brain tumor surgery between January 2008 and December 2014. Postoperative AKI was defined according to Kidney Disease: Improving Global Outcomes Definition and Staging (KDIGO). Multivariate logistic regression analysis was used to identify demographic, preoperative laboratory, and intraoperative factors associated with AKI development. Cox proportional hazards models were used to investigate the adjusted odds ratio and hazard ratio for the association between preoperative serum albumin level and outcome variables.

RESULTS

The incidence of AKI was 1.8% (n = 43) using KDIGO criteria. The incidence of AKI was higher in patients with a preoperative serum albumin level < 3.8 g/dl (3.5%) than in those with a preoperative serum albumin level ≥ 3.8 g/dl (1.2%, p < 0.001). The overall mortality was also higher in the former than in the latter group (5.0% vs 1.8%, p < 0.001). After inverse probability of treatment-weighting adjustment, a preoperative serum albumin level < 3.8 g/dl was also found to be associated with postoperative AKI (OR 1.981, 95% CI 1.022–3.841; p = 0.043) and death (HR 2.726, 95% CI 1.522–4.880; p = 0.001).

CONCLUSIONS

The authors’ results demonstrated that a preoperative serum albumin level of < 3.8 g/dl was independently associated with AKI and mortality in patients undergoing brain tumor surgery.

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Jun-Yeong Seo, Kee-Yong Ha, Tae-Hyok Hwang, Ki-Won Kim, and Young-Hoon Kim

Object

In this paper the authors' goal was to determine the factors associated with the progression of degenerative lumbar scoliosis (DLS).

Methods

Twenty-seven patients (3 men and 24 women; mean age 64.9 years) with more than 10° of lumbar scoliosis at baseline were monitored for a mean period of 10 years. The radiological evaluation included measurement of the scoliosis angle using the Cobb method, the direction of the scoliosis, the relationship between the intercrest line and the L-5 vertebra, lateral listhesis, segmental angle, distance from the center of the sacral line to the apical vertebra, degenerative listhesis anteriorly or posteriorly or both, and lordosis angle. In addition, the lateral osteophyte difference, disc index, and severity of osteoporosis were measured. The pain and disability outcomes were assessed using the visual analog scale and the Oswestry Disability Index (ODI) relative to severity of the angle of scoliosis.

Results

The mean initial and final scoliosis angles were 14° ± 5.4° and 25° ± 8.5°, respectively. The initial disc index at the L-3 vertebra (Spearman ρ = 0.7, p < 0.001), the sum of the segmental wedging angles above and below the L-3 vertebra (ρ = 0.6, p < 0.001), and the initial disc index at the apical vertebra (ρ = 0.6, p < 0.001) were correlated with the last follow-up angle of the scoliosis. By contrast, there was no statistically significant correlation between the initial segmental angles at L2–3 and L3–4 and the final follow-up scoliosis angle (ρ = 0.2, p = 0.67; and ρ = 0.1, p = 0.22; respectively). When the authors separated the patients into 3 groups according to the sum of the segmental angles above and below L-3 (< 5°, 5° to 10°, and > 10°), they found that 3 (42.9%) of 7, 8 (66.7%) of 12, and 6 (75.0%) of 8 patients in the 3 groups showed increases of greater than 10° in scoliosis angle. The mean distance from the center of the sacral line to the apical vertebra was 36.0 ± 9.7 mm, and the distance correlated with the measurement of the last follow-up angle of the scoliosis (ρ = 0.6, p < 0.001). The mean angle of the scoliosis was significantly greater when the intercrest line passed through the L-5 or L4–5 disc space than when the line passed through the L-4 vertebral body (31.4° ± 7.9° vs 21.8° ± 6.7°, p = 0.01). The ODI correlated with the measurement of the angle of the scoliosis (ρ = 0.6, p < 0.001). Age, sex, osteoporosis, the direction of the scoliosis, listhesis of coronal and sagittal planes, the lateral osteophyte difference, and the vertebral body index did not correlate with curve progression.

Conclusions

The findings of this study demonstrated that the progression of DLS was affected by the relationship between the intercrest line and the L-5 vertebra. When L-5 was deep seated, progression of DLS was found. Asymmetrical change in the disc space above and below the L-3 or apical vertebra may also be an important predictor of curve progression.

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Jang-Hyun Baek, Byung Moon Kim, Ji Hoe Heo, Dong Joon Kim, Hyo Suk Nam, Young Dae Kim, Hyun Seok Choi, Jun-Hwee Kim, and Jin Woo Kim

OBJECTIVE

Hyperattenuation on CT scanning performed immediately after endovascular treatment (EVT) is known to be associated with the final infarct. As flat-panel CT (FPCT) scanning is readily accessible within their angiography suite, the authors evaluated the ability of the extent of hyperattenuation on FPCT to predict clinical outcomes after EVT.

METHODS

Patients with successful recanalization (modified Thrombolysis in Cerebral Infarction grade 2b or 3) were reviewed retrospectively. The extent of hyperattenuation was assessed by the Alberta Stroke Program Early CT Score on FPCT (FPCT-ASPECTS). FPCT-ASPECTS findings were compared according to functional outcome and malignant infarction. The predictive power of the FPCT-ASPECTS with initial CT images before EVT (CT-ASPECTS) and follow-up diffusion-weighted images (MR-ASPECTS) was also compared.

RESULTS

A total of 235 patients were included. All patients were treated with mechanical thrombectomy, and 45.5% of the patients received intravenous tissue plasminogen activator. The mean (± SD) time from stroke onset to recanalization was 383 ± 290 minutes. The FPCT-ASPECTS was significantly different between patients with a favorable outcome and those without (mean 9.3 ± 0.9 vs 6.7 ± 2.6) and between patients with malignant infarction and those without (3.4 ± 2.9 vs 8.8 ± 1.4). The FPCT-ASPECTS was an independent factor for a favorable outcome (adjusted OR 3.28, 95% CI 2.12–5.01) and malignant infarction (adjusted OR 0.42, 95% CI 0.31–0.57). The area under the curve (AUC) of the FPCT-ASPECTS for a favorable outcome (0.862, cutoff ≥ 8) was significantly greater than that of the CT-ASPECTS (0.637) (p < 0.001) and comparable to that of the MR-ASPECTS (0.853) (p = 0.983). For malignant infarction, the FPCT-ASPECTS was also more predictive than the CT-ASPECTS (AUC 0.906 vs 0.552; p = 0.001) with a cutoff of ≤ 5.

CONCLUSIONS

The FPCT-ASPECTS was highly predictive of clinical outcomes in patients with successful recanalization. FPCT could be a practical method to immediately predict clinical outcomes and thereby aid in acute management after EVT.

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Daniel H. Kim, Yong-Jun Cho, Robert L. Tiel, and David G. Kline

Object. Outcomes of 1019 brachial plexus lesions in patients who underwent surgery at Louisiana State University Health Sciences Center during a 30-year period are reviewed in this paper to provide management guidelines.

Methods. Causes of brachial plexus lesions included 509 stretches/contusions (50%), 161 plexus tumors (16%), 160 thoracic outlet syndromes (TOSs, 16%), 118 gunshot wounds (12%), and 71 lacerations (7%). Many features of clinical presentation, including prior treatment, patient's neurological status, results of electrophysiological studies, intraoperative findings, and postoperative level of function, were studied. The minimum follow-up period was 18 months and the mean follow-up period was 42 months. Repairs were best for injuries located at the C-5, C-6, and C-7 levels, the upper and middle trunk, the lateral cord to the musculocutaneous nerve, and the median and posterior cords to the axillary and radial nerves. Conversely, results were poor for injuries at the C-8 and T-1 levels, and for lower trunk and medial cord lesions, with the exception of injuries of the medial cord to the median nerve. Outcomes were most favorable when patients were carefully evaluated and selected for surgery, although variables such as lesion type, location, and severity, as well as time since injury also affected outcome. This was true also of TOSs and tumors arising from the plexus, especially if they had not been surgically treated previously.

Conclusions. Surgical exploration and repair of brachial plexus lesions is technically feasible and favorable outcomes can be achieved if patients are thoroughly evaluated and appropriately selected.

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Jun Kim, Vishal J. Patel, Tarek Y. El Ahmadieh, DaiWai M. Olson, and Dale M. Swift

OBJECTIVE

Ventriculoperitoneal shunts (VPSs) for hydrocephalus in patients with achondroplasia are known to have a higher failure rate than in other hydrocephalus populations. However, the etiology of hydrocephalus in this group is considered “communicating,” and, therefore, potentially not amenable to endoscopic third ventriculostomy (ETV). ETV has, nonetheless, been reported to be successful in a small number of patients with achondroplasia. The authors aimed to investigate the long-term results of ETV in this population.

METHODS

Patients with achondroplasia who had undergone surgical treatment for hydrocephalus (ETV or VPS placement) were identified. In patients who had undergone ETV, medical records and neuroimages were reviewed to determine ventricular volumes and frontal and occipital horn ratios (FOHRs) pre- and postoperatively, as well as the incidence of surgical complications and reoperation. Patients who underwent VPS placement were included for historical comparison, and their medical records were reviewed for basic demographic information as well as the incidence of surgical complications and reoperation.

RESULTS

Of 114 pediatric patients with achondroplasia referred for neurosurgical consultation, 19 (17%) were treated for hydrocephalus; 10 patients underwent ETV only, 7 patients underwent VPS placement only, and 2 patients had a VPS placed followed by ETV. In patients treated with ETV, ventricular volume and FOHRs were normal, if measured at birth, and increased significantly until the time of the ETV. After ETV, all patients demonstrated significant and sustained decreases in ventricular measurements with surveillance up to 15 years. There was a statistically significant difference in rates of repeat CSF surgery between the ETV and VPS cohorts (0/12 vs 7/9, p < 0.001).

CONCLUSIONS

ETV was efficacious, safe, and durable in the treatment of hydrocephalus in patients with achondroplasia. Although many studies have indicated that hydrocephalus in these patients is “communicating,” a subset may develop an “obstructive” component that is progressive and responsive to ETV.

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Jin-Sung Park, Se-Jun Park, Chong-Suh Lee, Tae-hoon Yum, and Bo-Taek Kim

OBJECTIVE

Several radiological parameters related to the aging spine have been reported as progression factors of early degenerative lumbar scoliosis (DLS). However, it has not been determined which factors are the most important. In this study the authors aimed to determine the risk factors associated with curve progression in early DLS.

METHODS

Fifty-one patients with early DLS and Cobb angles of 5°–15° were investigated. In total, 7 men and 44 women (mean age 61.6 years) were observed for a mean period of 13.7 years. The subjects were divided into two groups according to Cobb angle progression (≥ 15° or < 15°) at the final follow-up, and radiological parameters were compared. The direction of scoliosis, apical vertebral level and rotational grade, lateral subluxation, disc space difference, osteophyte difference, upper and lower disc wedging angles, and relationship between the intercrest line and L5 vertebra were evaluated.

RESULTS

During the follow-up period, the mean curve progression increased from 8.8° ± 3.2° to 19.4° ± 8.9°. The Cobb angle had progressed by ≥ 15° in 17 patients (33.3%) at the final follow-up. In these patients the mean Cobb angle increased from 9.4° ± 3.4° to 28.8° ± 7.5°, and in the 34 remaining patients it increased from 8.5° ± 3.1° to 14.7° ± 4.8°. The baseline lateral subluxation, disc space difference, and upper and lower disc wedging angles significantly differed between the groups. In multivariate logistic regression analysis, only the upper and lower disc wedging angles were significantly correlated with curve progression (OR 1.55, p = 0.035, and OR 1.89, p = 0.004, respectively).

CONCLUSIONS

Asymmetrical degenerative change in the lower apical vertebral disc, which leads to upper and lower disc wedging angles, is the most substantial factor in predicting early DLS progression.

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Jun-Hyeok Song, Myung-Hyun Kim, and Kyu-Man Shin

✓ The authors report the case of a spinal epidermoid cyst that developed in a patient who had undergone surgery for lipomyelomeningocele repair 15 years earlier. The patient presented with symptoms of retethering. Magnetic resonance imaging revealed a cystic intraspinal mass that extended from L-2 to L-5. The mass proved to be an epidermoid cyst. Spinal epidermoid cysts can cause retethering after a repair of lipomyelomeningocele, and the risk of this development can be present for decades.

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Jin-Sung Park, Se-Jun Park, Chong-Suh Lee, Tae-hoon Yum, and Bo-Taek Kim

OBJECTIVE

Several radiological parameters related to the aging spine have been reported as progression factors of early degenerative lumbar scoliosis (DLS). However, it has not been determined which factors are the most important. In this study the authors aimed to determine the risk factors associated with curve progression in early DLS.

METHODS

Fifty-one patients with early DLS and Cobb angles of 5°–15° were investigated. In total, 7 men and 44 women (mean age 61.6 years) were observed for a mean period of 13.7 years. The subjects were divided into two groups according to Cobb angle progression (≥ 15° or < 15°) at the final follow-up, and radiological parameters were compared. The direction of scoliosis, apical vertebral level and rotational grade, lateral subluxation, disc space difference, osteophyte difference, upper and lower disc wedging angles, and relationship between the intercrest line and L5 vertebra were evaluated.

RESULTS

During the follow-up period, the mean curve progression increased from 8.8° ± 3.2° to 19.4° ± 8.9°. The Cobb angle had progressed by ≥ 15° in 17 patients (33.3%) at the final follow-up. In these patients the mean Cobb angle increased from 9.4° ± 3.4° to 28.8° ± 7.5°, and in the 34 remaining patients it increased from 8.5° ± 3.1° to 14.7° ± 4.8°. The baseline lateral subluxation, disc space difference, and upper and lower disc wedging angles significantly differed between the groups. In multivariate logistic regression analysis, only the upper and lower disc wedging angles were significantly correlated with curve progression (OR 1.55, p = 0.035, and OR 1.89, p = 0.004, respectively).

CONCLUSIONS

Asymmetrical degenerative change in the lower apical vertebral disc, which leads to upper and lower disc wedging angles, is the most substantial factor in predicting early DLS progression.