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Ho Jun Yi, Jae Hoon Sung, Dong Hoon Lee, Seung Ho Yang and Jae Taek Hong

OBJECTIVE

Volume perfusion CT (VPCT) with added CT angiography (CTA)–like reconstruction from VPCT source data (VPCTA) can reveal multiple intracranial parameters. The authors examined the usefulness of VPCTA in terms of reducing the in-hospital time delay for mechanical thrombectomy.

METHODS

A total of 180 patients who underwent mechanical thrombectomy at the authors’ institution between January 2014 and March 2017 were divided into 2 groups: a CTA-based thrombectomy decision group (group 1: CTA) and a VPCTA-based decision group (group 2: VPCTA). Multiple time interval categories (from symptom onset to groin puncture, from hospital arrival to groin puncture, procedure time, from symptom onset to reperfusion, and from hospital arrival to reperfusion) were reviewed. All patients underwent clinical assessment with the National Institutes of Health Stroke Scale score and the modified Rankin Scale, and radiological results were evaluated by the Thrombolysis in Cerebral Infarction score.

RESULTS

In all of the time interval categories except for procedure time, the VPCTA group showed a significantly shorter in-hospital time delay during the prethrombectomy period than did the CTA group. The 3-month modified Rankin Scale score was significantly lower in the VPCTA group (2.8) compared with the CTA group (3.5) (p = 0.003). However, there were no statistically significant differences between the 2 groups in the other clinical and radiological outcomes.

CONCLUSIONS

Compared with CTA, VPCTA significantly reduced the in-hospital time delay during the prethrombectomy period.

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Ho Jun Yi, Jae Hoon Sung, Dong Hoon Lee, Seung Ho Yang and Jae Taek Hong

OBJECTIVE

Volume perfusion CT (VPCT) with added CT angiography (CTA)–like reconstruction from VPCT source data (VPCTA) can reveal multiple intracranial parameters. The authors examined the usefulness of VPCTA in terms of reducing the in-hospital time delay for mechanical thrombectomy.

METHODS

A total of 180 patients who underwent mechanical thrombectomy at the authors’ institution between January 2014 and March 2017 were divided into 2 groups: a CTA-based thrombectomy decision group (group 1: CTA) and a VPCTA-based decision group (group 2: VPCTA). Multiple time interval categories (from symptom onset to groin puncture, from hospital arrival to groin puncture, procedure time, from symptom onset to reperfusion, and from hospital arrival to reperfusion) were reviewed. All patients underwent clinical assessment with the National Institutes of Health Stroke Scale score and the modified Rankin Scale, and radiological results were evaluated by the Thrombolysis in Cerebral Infarction score.

RESULTS

In all of the time interval categories except for procedure time, the VPCTA group showed a significantly shorter in-hospital time delay during the prethrombectomy period than did the CTA group. The 3-month modified Rankin Scale score was significantly lower in the VPCTA group (2.8) compared with the CTA group (3.5) (p = 0.003). However, there were no statistically significant differences between the 2 groups in the other clinical and radiological outcomes.

CONCLUSIONS

Compared with CTA, VPCTA significantly reduced the in-hospital time delay during the prethrombectomy period.

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Jin-Sung Kim, Kil-Yong Lee, Sang-Ho Lee and Ho-Yeon Lee

Object

The purpose of this study was to investigate and compare clinical and radiographic outcomes of 2 kinds of lumbar interbody fusion (LIF) for the treatment of adult low-grade isthmic spondylolisthesis at L4–5 and L5–S1 levels.

Methods

The medical records and radiographs of 86 patients who underwent anterior LIF (ALIF) (L4–5, 42 patients; L5–S1, 44 patients) and 42 patients who underwent transforaminal LIF (TLIF) (L4–5, 22 patients; L5–S1, 20 patients) between 2001 and 2004 were retrospectively reviewed. Clinical results were investigated using the visual analog scale (VAS) and Oswestry Disability Index (ODI) scores, and using radiographic measurements, including disc height (DH), degree of spondylolisthesis, segmental lordosis, whole lumbar lordosis (WL), sacral slope (SS), and pelvic tilt; the L-1 axis S-1 distance (LASD) and pelvic incidence were also obtained.

Results

In both groups, VAS and ODI scores had significantly improved at both treatment levels. Statistical analysis showed no significant difference in postoperative VAS scores between groups at the L4–5 level and in postoperative VAS/ODI scores at the L5–S1 level. However, ODI scores were better in the TLIF than in the ALIF group at the L4–5 level. In terms of radiological changes, there were no significant differences between the 2 groups at the L4–5 level; however, at the L5–S1 level, radiographic results indicated that ALIF was superior to TLIF in its capacity to restore DH, WL, SS, and LASD. The radiological evidence of fusion shows no intergroup difference and no interlevel difference.

Conclusions

Considering the clinical and radiological outcomes in both groups, the authors recommend that instrumented mini-TLIF is preferable at the L4–5 level, whereas instrumented mini-ALIF might be preferable at the L5–S1 level for the treatment of unstable isthmic spondylolisthesis.

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Sun-Ho Lee and Joo-Kyung Sung

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Chang Ju Hwang, Choon Sung Lee, Dong-Ho Lee and Jae Hwan Cho

OBJECTIVE

Progression of trunk imbalance is an important finding during follow-up of patients with adolescent idiopathic scoliosis (AIS). Nevertheless, no factors that predict progression of trunk imbalance have been identified. The purpose of this study was to identify parameters that predict progression of trunk imbalance in cases of AIS with a structural thoracolumbar/lumbar (TL/L) curve.

METHODS

This study included 105 patients with AIS and a structural TL/L curve who were followed up at an outpatient clinic. Patients with trunk imbalance (trunk shift ≥ 20 mm) at the initial visit were excluded. All patients were followed up for more than 2 years. Patients were divided into the following groups according to progression of trunk imbalance: 1) Group P, trunk shift ≥ 20 mm at the final visit and degree of progression ≥ 10 mm; and 2) Group NP, trunk shift < 20 mm at the final visit or degree of progression < 10 mm. Radiological parameters included Cobb angle, upper end vertebrae and lower end vertebrae (LEV), LEV tilt, disc wedge angle between LEV and LEV+1, trunk shift, apical vertebral translation, and apical vertebral rotation (AVR). Each parameter was compared between groups. Radiological parameters were assessed at every visit using whole-spine standing anteroposterior radiographs.

RESULTS

Among the 105 patients examined, 13 showed trunk imbalance with progression ≥ 10 mm at the final visit (Group P). Multivariate logistic regression analysis identified a lower Risser grade (p = 0.002) and a greater initial AVR (p = 0.020) as predictors of progressive trunk imbalance. A change in LEV tilt during follow-up was associated with trunk imbalance (p = 0.001).

CONCLUSIONS

Risser grade and AVR measured at the initial visit may predict progression of trunk imbalance. Surgeons should consider the risk of progressive trunk imbalance if patients show skeletal immaturity and a greater AVR at the initial visit.

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Jae-Sung Ahn, Ho-Jin Lee, Dae-Jung Choi, Ki-young Lee and Sung-jin Hwang

This study was performed to describe the extraforaminal approach of biportal endoscopic spinal surgery (BESS) as a new endoscopic technique for transforaminal decompression and discectomy and to demonstrate the clinical outcomes of this new procedure for the first time. Twenty-one patients (27 segments) who underwent the extraforaminal approach of BESS between March 2015 and April 2016 were enrolled according to the inclusion and exclusion criteria. The operative time (minutes/level) and complications after the procedure were recorded. The visual analog scale (VAS) score was checked to assess the degree of radicular leg pain preoperatively and at the time of the last follow-up. The modified Macnab criteria were used to examine the clinical outcomes at the time of the last follow-up. The mean duration of the follow-up period was 14.8 months (minimum duration 12 months). The mean operative time was 96.7 minutes for one level. The mean VAS score for radicular leg pain dropped from a preoperative score of 7.5 ± 0.9 to a final follow-up score of 2.5 ± 1.2 (p < 0.001). The final outcome according to the modified Macnab criteria was excellent in 5 patients (23.8%), good in 12 (57.2%), fair in 4 (19.0%), and poor in 0. Therefore, excellent or good results (a satisfied outcome) were obtained in 80.9% of the patients. Complications were limited to one dural tear (4.8%). The authors found that the extraforaminal approach of BESS was a feasible and advantageous endoscopic technique for the treatment of foraminal lesions, including stenosis and disc herniation. They suggest that this technique represents a useful, alternative, minimally invasive method that can be used to treat lumbar foraminal stenosis and disc herniation.

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Hyung-Lea Cho, Jin-Sung Kim, Sung Suk Paeng and Sang-Ho Lee

A butterfly vertebra is a rare congenital anomaly that is usually asymptomatic. The authors, however, describe a novel case involving a butterfly vertebra overlapping with disc herniation that presented as radiculopathy. A butterfly vertebra is characterized by a symmetrical fusion defect resulting in a sagittal cleft vertebra. Only a few cases of butterfly vertebrae have been reported as incidental findings. This spinal anomaly may be associated with other congenital conditions such as Pfeiffer, Crouzon, Jarcho-Levin, and Alagille syndromes. Moreover, there is no previous report of a case associated with symptomatic disc herniation from the sagittal cleft.

The authors excised the herniated disc fragment. They performed intraoperative discography after exposure of the corresponding intervertebral space via a conventional interlaminar approach. Histological examination of a tissue specimen showed scattered chondrocytes in the myxohyaline stroma, which indicated the nucleus pulposus.

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Jae Hwan Cho, Chang Ju Hwang, Young Hyun Choi, Dong-Ho Lee and Choon Sung Lee

OBJECTIVE

Cervical sagittal alignment (CSA) is related to function and quality of life, but it has not been frequently studied in patients with adolescent idiopathic scoliosis. This study aimed to reveal the change in CSA following corrective surgery, compare the cervical sagittal parameters according to curve types, and assess related factors for postoperative aggravation of CSA.

METHODS

The authors studied 318 consecutive patients with adolescent idiopathic scoliosis who underwent corrective surgery at a single center. Occiput–C2 and C2–7 lordosis, C2–7 sagittal vertical axis (SVA), T-1 slope, thoracic kyphosis, and lumbar sagittal profiles were measured preoperatively and postoperatively. Scoliosis Research Society Outcomes Questionnaire (SRS-22) scores were used as clinical outcomes. Each radiological parameter was compared preoperatively and postoperatively according to curve types (double major, single thoracic, and double thoracic curves). Patients were grouped based on preoperative CSA: the lordotic group (group L) and the kyphotic group (group K). Each radiological parameter was compared between the groups. Related factors for postoperative aggravation of CSA were assessed using multivariate logistic analysis.

RESULTS

Of the total number of patients studied, 67.0% (213 of 318) and 54.4% (173 of 318) showed cervical kyphotic alignment preoperatively and postoperatively, respectively. C2–7 lordosis increased (from −5.8° to −1.1°; p < 0.001) and C2–7 SVA decreased (from 24.2 to 20.0 mm; p < 0.001) postoperatively regardless of curve types. Although group K showed improvement in C2–7 lordosis (from −12.7° to −4.8°; p < 0.001), group L showed no difference (from 9.0° to 6.9°; p = 0.115) postoperatively. Clinical outcomes were not related to the degree of cervical kyphosis in this cohort. C2–7 lordosis (p < 0.001) and pelvic tilt (p = 0.019) were related to postoperative aggravation of CSA.

CONCLUSIONS

Regardless of the trend of improvement in CSA, many patients (54.4%) still showed cervical kyphotic alignment postoperatively. C2–7 lordosis and C2–7 SVA improved postoperatively in all curve types. However, postoperative changes in C2–7 lordosis showed different results based on preoperative CSA, which could be related to T-1 slope and thoracic kyphosis. However, clinical outcomes showed no difference based on CSA in this study cohort. Greater C2–7 lordosis and proximal thoracic curve preoperatively were risk factors for postoperative aggravation of CSA (p < 0.001 and p = 0.019, respectively).

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Dong-Ho Lee, Youn-Suk Joo, Chang Ju Hwang, Choon Sung Lee and Jae Hwan Cho

OBJECTIVE

Although posterior decompressive surgery is widely used to treat patients with cervical myelopathy and multilevel ossification of the posterior longitudinal ligament (OPLL), a poor outcome is anticipated if the sagittal alignment is kyphotic (or K-line negative). Accordingly, it is mandatory to perform anterior decompression and fusion in patients with cervical kyphosis. However, it can be difficult to perform anterior surgery because of the high risk of complications. This present report proposes a novel “greenstick fracture technique” to change the K-line from negative to positive in patients with cervical myelopathy, OPLL, and kyphotic deformity.

METHODS

Four patients with cervical myelopathy, continuous-type OPLL, and kyphotic sagittal alignment (who were K-line negative) were indicated for surgery. Posterior laminectomy and lateral mass screw insertions using a posterior approach were performed, followed by anterior surgery. Multilevel discectomy and thinning of the OPLL mass by bur drilling was performed, then an intentional greenstick fracture at each disc level was made to convert the cervical K-line from negative to positive. Finally, posterior instrumentation using a rod was carried out to maintain cervical lordosis.

RESULTS

MRI showed complete decompression of the cord by posterior migration in all cases, which had been caused by cervical lordosis. Restoration of neurological defects was confirmed at the 1-year follow-up assessment. No specific complications were identified that were associated with this technique.

CONCLUSIONS

A greenstick fracture technique may be effective and safe when applied to patients with cervical myelopathy, continuous-type OPLL, and kyphotic deformity (K-line negative). However, further studies with more cases will be required to reveal its generalizability and safety.

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Sung Mo Ryu, Sun-Ho Lee, Kyung Min Lee, Whan Eoh and Eun-Sang Kim

OBJECTIVE

The objective of this study was to elucidate the features and surgical outcomes of cervical schwannomas.

METHODS

The authors retrospectively reviewed the records of 90 patients who underwent surgically treated cervical schwannomas from January 1995 to December 2017, with an emphasis on MRI findings such as tumor location, tumor size, extent of tumor resection, and growth of a residual tumor.

RESULTS

This study included 51 men (56.7%) and 39 women (43.3%) with a mean age of 44.5 years (range 7–77 years). Dumbbell-shaped tumors comprised 62 (68.9%) of 90 cases and gross-total resection (GTR) was achieved in 59 (65.6%) of 90 cases. All nondumbbell tumors (n = 28) underwent GTR. Only 1 case of recurrence in the GTR group showed a gradual increase in size (by 8.9 mm) during the 150-month follow-up period. For the regrowth patients in the subtotal resection group, the mean percentage increase in tumor size was 47.5% ± 33.1% and the mean growth rate was 5.8 ± 4.6 mm/year during the 20.3-month follow-up period. However, the size of residual tumor spontaneously decreased by a mean of 8.3% ± 11.1% during the 48.4-month follow-up period in the nonregrowth group.

CONCLUSIONS

These findings suggested that frequent MRI follow-up examinations are required for residual schwannomas in the cervical spine for at least 2 years, and continuous MRI follow-ups are also required thereafter.