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Min A. Yoon, Eunhee Kim, Bae-Ju Kwon, Jeong Eun Kim, Hyun-Seung Kang, Jae Hyo Park, Chul-Ho Sohn, Ji-Hoon Kim and Dong Hoon Lee

Object

Reinforcement of aneurysms with additional wrapping is an alternative procedure if the aneurysm cannot be completely clipped. Wrapping with muslin (cotton gauze) rarely incites foreign body inflammatory reactions. In this study, the authors describe the clinical and radiological features of muslinomas or muslin-induced foreign body reactions that can develop after treatment of intracranial aneurysms.

Methods

Over a 3-year period, 5 patients with muslinomas underwent treatment at the authors' institution. All patients underwent aneursym clipping and wrapping, and were subsequently readmitted with acute or subacute neurological symptoms. Clinical and imaging features on diffusion weighted MR images and cerebral angiography images were retrospectively reviewed. The patients' clinical course and follow-up imaging studies were also evaluated.

Results

In all 5 cases, muslinomas were seen as rim-enhancing inflammatory masses around the clipped aneurysms with perilesional edema visible on MR images at the time of clinical deterioration. The MR images also demonstrated adhesive arachnoiditis with a sterile intracranial abscess in 3 patients, optic neuropathy in 2, parent artery narrowing in 2, and a resultant acute ischemic infarction in 1 patient. Follow-up imaging revealed resolution of both the perilesional edema and adhesive arachnoiditis but no significant changes in the muslinomas. All patients underwent conservative management and fully recovered, but during the follow-up period, 2 patients experienced clinical and radiological relapses.

Conclusions

When a patient with a history of wrapping of an aneurysm presents with acute neurological symptoms and an enhancing intracranial mass in the region of the surgical site on MR imaging, a muslin-induced foreign body inflammatory reaction should be considered in the differential diagnosis, and careful clinical and radiological follow-up is advised.

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Won-Sang Cho, Young Seob Chung, Jeong Eun Kim, Jin Pyeong Jeon, Young Je Son, Jae Seung Bang, Hyun-Seung Kang, Chul-Ho Sohn and Chang Wan Oh

OBJECT

Moyamoya disease (MMD) is a rare cerebrovascular disease and its natural history is still unclear. The authors aimed to investigate the natural course of hemodynamically stable cases of adult MMD, with the analysis of stroke risk factors.

METHODS

Two hundred forty-one patients were included in this retrospective study. One hundred sixty-six (68.9%) were female, and mean age (± SD) at first visit was 41.3 ± 12.0 years (range 18–69 years). Unilateral involvement was identified in 33 patients, and 19 patients (7.9%) had a family history of MMD. According to the clinical presentations, patients were classified into hemorrhagic (n = 62, 25.7%), ischemic (n = 144, 59.8%), and asymptomatic (n = 35, 14.5%) groups. The mean duration of follow-up was 82.5 ± 62.9 months (range 7.3–347.0 months).

RESULTS

The annual stroke risk was 4.5%, and the annual risks of rebleeding in the hemorrhagic group and recurrent ischemic events in the ischemic group were 4.3% and 3.0%, respectively. There was no significant difference in cumulative stroke risk between the 3 groups (p = 0.461). Risk factors included thyroid disease for overall strokes (HR 2.56, 95% CI 1.16–5.67), initial hemorrhagic presentation for hemorrhagic strokes (HR 2.53, 95% CI 1.24–5.17), and initial ischemic presentation for ischemic strokes (HR 2.69, 95% CI 1.15–6.27). Familial MMD was a common risk factor for all types of stroke. Among the 3 clinical groups, the hemorrhagic group showed the worst clinical status at discharge and at most recent follow-up. Twenty-three patients (9.5%) eventually underwent revascularization surgery.

CONCLUSIONS

There was no statistically significant difference in the incidence of stroke in the different clinical groups; clinical status, however, was most severe in patients with hemorrhagic presentation. In patients who experienced stroke during the follow-up period, the stroke type tended to correspond to their initial presentation. Close follow-up is needed in patients with thyroid disease and a family history of MMD.

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Chang-Hyun Lee, Jaebong Lee, James D. Kang, Seung-Jae Hyun, Ki-Jeong Kim, Tae-Ahn Jahng and Hyun-Jib Kim

OBJECT

Posterior cervical surgery, expansive laminoplasty (EL) or laminectomy followed by fusion (LF), is usually performed in patients with multilevel (≥ 3) cervical spondylotic myelopathy (CSM). However, the superiority of either of these techniques is still open to debate. The aim of this study was to compare clinical outcomes and postoperative kyphosis in patients undergoing EL versus LF by performing a meta-analysis.

METHODS

Included in the meta-analysis were all studies of EL versus LF in adults with multilevel CSM in MEDLINE (PubMed), EMBASE, and the Cochrane library. A random-effects model was applied to pool data using the mean difference (MD) for continuous outcomes, such as the Japanese Orthopaedic Association (JOA) grade, the cervical curvature index (CCI), and the visual analog scale (VAS) score for neck pain.

RESULTS

Seven studies comprising 302 and 290 patients treated with EL and LF, respectively, were included in the final analyses. Both treatment groups showed slight cervical lordosis and moderate neck pain in the baseline state. Both groups were similarly improved in JOA grade (MD 0.09, 95% CI −0.37 to 0.54, p = 0.07) and neck pain VAS score (MD −0.33, 95% CI −1.50 to 0.84, p = 0.58). Both groups evenly lost cervical lordosis. In the LF group lordosis seemed to be preserved in long-term follow-up studies, although the difference between the 2 treatment groups was not statistically significant.

CONCLUSIONS

Both EL and LF lead to clinical improvement and loss of lordosis evenly. There is no evidence to support EL over LF in the treatment of multilevel CSM. Any superiority between EL and LF remains in question, although the LF group shows favorable long-term results.

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Chang-Hyun Lee, Tae-Ahn Jahng, Seung-Jae Hyun, Chi Heon Kim, Sung-Bae Park, Ki-Jeong Kim, Chun Kee Chung, Hyun-Jib Kim and Soo-Eon Lee

OBJECTIVE

The Dynesys, a pedicle-based dynamic stabilization (PDS) system, was introduced to overcome the drawbacks of fusion procedures. Nevertheless, the theoretical advantages of PDS over fusion have not been clearly confirmed. The aim of this study was to compare clinical and radiological outcomes of patients who underwent PDS using the Dynesys system with those who underwent posterior lumbar interbody fusion (PLIF).

METHODS

The authors searched PubMed, Embase, Web of Science, and the Cochrane Database. Studies that reported outcomes of patients who underwent PDS or PLIF for the treatment of degenerative lumbar spinal disease were included. The primary efficacy end points were perioperative outcomes. The secondary efficacy end points were changes in the Oswestry Disability Index (ODI) and back and leg pain visual analog scale (VAS) scores and in range of motion (ROM) at the treated and adjacent segments. A meta-analysis was performed to calculate weighted mean differences (WMDs), 95% confidence intervals, Q statistics, and I2 values. Forest plots were constructed for each analysis group.

RESULTS

Of the 274 retrieved articles, 7 (which involved 506 participants [Dynesys, 250; PLIF, 256]) met the inclusion criteria. The Dynesys group showed a competitive advantage in mean surgery duration (20.73 minutes, 95% CI 8.76–32.70 minutes), blood loss (81.87 ml, 95% CI 45.11–118.63 ml), and length of hospital stay (1.32 days, 95% CI 0.23–2.41 days). Both the Dynesys and PLIF groups experienced improved ODI and VAS scores after 2 years of follow-up. Regarding the ODI and VAS scores, no statistically significant difference was noted according to surgical procedure (ODI: WMD 0.12, 95% CI −3.48 to 3.72; back pain VAS score: WMD −0.15; 95% CI −0.56 to 0.26; leg pain VAS score: WMD −0.07; 95% CI −0.47 to 0.32). The mean ROM at the adjacent segment increased in both groups, and there was no substantial difference between them (WMD 1.13; 95% CI −0.33 to 2.59). Although the United States is the biggest market for Dynesys, no eligible study from the United States was found, and 4 of 8 enrolled studies were performed in China. The results must be interpreted with caution because of publication bias. During Dynesys implantation, surgeons have to decide the length of the spacer and cord pretension. These values are debatable and can vary according to the surgeon's experience and the patient's condition. Differences between the surgical procedures were not considered in this study.

CONCLUSIONS

Fusion still remains the method of choice for advanced degeneration and gross instability. However, spinal degenerative disease with or without Grade I spondylolisthesis, particularly in patients who require a quicker recovery, will likely constitute the main indication for PDS using the Dynesys system.

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Sang-Hyun Han, Seung-Jae Hyun, Tae-Ahn Jahng and Ki-Jeong Kim

Spontaneous bilateral pedicle fractures of the lumbar spine are rare, and an optimal surgical treatment has not been suggested. The authors report the case of a 50-year-old woman who presented with low-back pain and right leg radiating pain of 1 year’s duration. Radiological studies revealed a spontaneous bilateral pedicle fracture of L-5. All efforts at conservative treatment failed, and the patient underwent surgery for osteosynthesis of the fractured pedicle using bilateral pedicle screws connected with a bent rod. Her low-back and right leg pain were relieved postoperatively. A CT scan performed 3 months postoperatively revealed the disappearance of the pedicle fracture gap and presence of newly formed bony trabeculation. In rare cases of spontaneous bilateral pedicle fracture of the lumbar spine, osteosynthesis of the fractured pedicle using bilateral pedicle screws and a bent rod is a motion-preserving technique that may be an effective option when conservative management has failed.

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Jin Pyeong Jeon, Jeong Eun Kim, Jun Hyong Ahn, Won-Sang Cho, Young Dae Cho, Young-Je Son, Jae Seung Bang, Hyun-Seung Kang, Chul-Ho Sohn, Hyun-Tai Chung, Chang Wan Oh and Dong Gyu Kim

OBJECT

Treatment strategies for venous-predominant arteriovenous malformation (vp-AVM) remain unclear due to the limited number of cases and a lack of long-term outcomes. The purpose of this study was to report the authors’ experience with treatment outcomes with a review of the pertinent literature in patients with vp-AVM.

METHODS

Medical and radiological data from 1998 to 2011 were retrospectively evaluated. The degree of the arteriovenous (AV) shunt was categorized into 2 groups, a high- and low-flow AV shunt based on the angiographic findings.

RESULTS

Sixteen patients with a mean age of 45.3 years (range 16–78 years) and a mean follow-up of 79.9 months (range 25–264 months) were examined. Symptomatic lesions were noted in 13 patients: intracranial hemorrhage (ICH) in 9, seizure in 1, and headache in 3. A high-flow shunt was observed on angiography in 13 patients. Among these 13 patients, 12 patients were symptomatic. Nine patients presenting with ICH underwent hematoma removal with additional Gamma Knife surgery (GKS; n = 4), GKS only (n = 2), or conservative treatment (n = 3). The 3 asymptomatic patients received conservative treatment, and 1 rebleeding episode was observed. Seven of 8 patients who underwent GKS as an initial or secondary treatment modality experienced a marked reduction in the AV shunt on follow-up angiography, but complete obliteration was not observed.

CONCLUSIONS

Poor lesion localization makes a vp-AVM challenging to treat. Symptomatic patients with a high-flow shunt are supposedly best treated with GKS, despite the fact that only 87.5% of the vp-AVMs treated this way showed a reduction in the malformation volume, and none were cured.

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Tackeun Kim, Chang Wan Oh, O-Ki Kwon, Gyojun Hwang, Jeong Eun Kim, Hyun-Seung Kang, Won-Sang Cho and Jae Seung Bang

OBJECT

Moyamoya disease (MMD) is a progressive disease that can cause recurrent stroke. The authors undertook this retrospective case-control study with a large sample size in an attempt to assess the efficacy of direct or combined revascularization surgery for ischemia in adults with MMD.

METHODS

The authors investigated cases involving patients with moyamoya disease presenting with ischemia who visited Seoul National University Bundang Hospital and Seoul National University Hospital between 2000 and 2014. Among 441 eligible patients, 301 underwent revascularization surgery and 140 were treated conservatively. Variables evaluated included age at diagnosis, sex, surgical record, Suzuki stage, and occurrence of stroke. Patients were stratified into 2 groups based on whether or not they had undergone revascularization surgery. Actuarial 1-, 5-, and 10-year stroke rates were calculated using the life table method. Risk factor analysis for 5-year stroke occurrence was conducted with multivariate regression.

RESULTS

Of the 441 patients, 301 had been surgically treated (revascularization group) and 140 had not (control group). The mean follow-up durations were 45 and 77 months, respectively. The actuarial 10-year cumulative incidence rate for any kind of stroke was significantly lower in the revascularization group (9.4%) than in the control group (19.6%) (p = 0.041); the relative risk reduction (RRR) was also superior (52.0%) in the revascularization group, and the number needed to treat was 10. The 10-year rate of ischemic stroke was greater (13.3%) in the control group than in the revascularization group (3.9%) (p = 0.019). The RRR for ischemic stroke in the revascularization group was 70.7%, and the number needed to treat was 11. However, the actuarial 1- and 5-year rates of ischemic stroke did not significantly differently between the groups. Overall, revascularization surgery was shown to be an independent protective factor, as revealed by multivariate analysis.

CONCLUSIONS

Direct or combined revascularization for patients with adult-onset moyamoya disease presenting with ischemia can prevent further stroke.

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Young-Seop Park, Seung-Jae Hyun, Ho Yong Choi, Ki-Jeong Kim and Tae-Ahn Jahng

OBJECTIVE

The aim of this study was to investigate the risk of upper instrumented vertebra (UIV) fractures associated with UIV screw fixation (unicortical vs bicortical) and polymethylmethacrylate (PMMA) augmentation after adult spinal deformity surgery.

METHODS

A single-center, single-surgeon consecutive series of adult patients who underwent lumbar fusion for ≥ 4 levels (that is, the lower instrumented vertebra at the sacrum or pelvis and the UIV of the thoracolumbar spine [T9–L2]) were retrospectively reviewed. Age, sex, follow-up duration, sagittal UIV angle immediately postoperatively including several balance-related parameters (lumbar lordosis [LL], pelvic incidence, and sagittal vertical axis), bone mineral density, UIV screw fixation type, UIV PMMA augmentation, and UIV fracture were evaluated. Patients were divided into 3 groups: Group U, 15 patients with unicortical screw fixation at the UIV; Group P, 16 with bicortical screw fixation and PMMA augmentation at the UIV; and Group B, 21 with bicortical screw fixation without PMMA augmentation at the UIV.

RESULTS

The mean number of levels fused was 6.5 ± 2.5, 7.5 ± 2.5, and 6.5 ± 2.5; the median age was 50 ± 29, 72 ± 6, and 59 ± 24 years; and the mean follow-up was 31.5 ± 23.5, 13 ± 6, and 24 ± 17.5 months in Groups U, P, and B, respectively (p > 0.05). There were no significant differences in balance-related parameters (LL, sagittal vertical axis, pelvic incidence–LL, and so on) among the groups. UIV fracture rates in Groups U (0%), P (31.3%), and B (42.9%) increased in sequence by group (p = 0.006). UIV bicortical screw fixation increased the risk for UIV fracture (OR 5.39; p = 0.02).

CONCLUSIONS

Bicortical screw fixation at the UIV is a major risk factor for early UIV compression fracture, regardless of whether a thoracolumbosacral orthosis is used. To reduce the proximal junctional failure, unicortical screw fixation at the UIV is essential in adult spinal deformity correction surgery.

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Chang-Hyun Lee, Chun Kee Chung, Jee-Soo Jang, Sung-Min Kim, Dong-Kyu Chin, Jung-Kil Lee, Seung Hwan Yoon, Jae Taek Hong, Yoon Ha, Chi Heon Kim and Seung-Jae Hyun

OBJECTIVE

As life expectancy continues to increase, primary degenerative sagittal imbalance (PDSI) is diagnosed in an increasing number of elderly people. Although corrective surgery for this sagittal deformity is becoming more popular, the effectiveness of the procedure remains unclear. The authors aimed to collate the available evidence on the effectiveness and complications of deformity-correction surgery in patients with PDSI.

METHODS

The authors carried out a meta-analysis of clinical studies regarding deformity correction in patients with PDSI. The studies were identified through searches of the PubMed, Embase, Web of Science, and Cochrane databases. Surgery outcomes were evaluated and overall treatment effectiveness was assessed in terms of the minimum clinically important difference (MCID) in Oswestry Disability Index (ODI) values and pain levels according to visual analog scale (VAS) scores and in terms of restoration of spinopelvic parameters to within a normal range. Data are expressed as mean differences with 95% CIs.

RESULTS

Ten studies comprising 327 patients were included. The VAS and ODI values improved after deformity-correction surgery. The smallest treatment effect exceeded the MCID for VAS values (4.15 [95% CI 3.48–4.82]) but not for ODI values (18.11 [95% CI 10.99–25.23]). At the final follow-up visit, the mean lumbar lordosis angle (−38.60° [95% CI −44.19° to −33.01°]), thoracic kyphosis angle (31.10° [95% CI 24.67°–37.53°]), C-7 sagittal vertical axis (65.00 mm [95% CI 35.27–94.72 mm]), and pelvic tilt angle (30.82° [95% CI 24.41°–37.23°]) remained outside their normal ranges. Meta-regression analyses revealed a significant effect of ODI change in relation to lumbar lordosis change (p = 0.004). After a mean of 2 years after deformity correction, the mean lumbar lordosis angle and C-7 sagittal vertical axis decreased by 5.82° and 38.91 mm, respectively, and the mean thoracic kyphosis angle increased by 4.7°. The incidences of proximal junctional kyphosis and pseudarthrosis were 23.7% and 12.8%, respectively.

CONCLUSIONS

Deformity correction substantially relieves back pain for about 2 years in adult patients with PDSI. Sufficient surgical restoration of lumbar lordosis can lead to substantial improvement in patient disability and reduced decompensation. Deformity correction represents a viable therapeutic option for patients with PDSI, but further technical advancements are necessary to achieve sufficient lumbar lordosis and reduce complication rates.