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Il-Nam Son, Young-Hoon Kim, and Kee-Yong Ha

OBJECT

This retrospective study was designed to evaluate the clinical outcomes and radiological findings after open lumbar discectomy (OLD) in patients who were followed up for 10 years or longer.

METHODS

The authors classified 79 patients who had a mean age (± SD) of 53.6 ± 13.6 years (range 30–78 years) into 4 groups according to the length of their follow-up. Patients in Group 1 were followed up for 10–14 years, in Group 2 for 15–19 years, in Group 3 for 20–24 years, and in Group 4 for more than 25 years. In all of these patients, the clinical outcomes were assessed by using patients' self-reported scores on visual analog scales (VASs) measuring back and leg pain and by using scores from the Oswestry Disability Index (ODI). In addition, 10 radiological parameters suggesting degenerative changes or instability at the operated segment were recorded at various time points and used to calculate a numeric radiological finding (NRF) score by rating a presence for each finding of spinal degeneration or instability as 1.

RESULTS

The authors observed that OLD decreased pain and disability scores in all groups. Numeric radiological findings were highest in Group 4, and a significant correlation was detected between NRFs and VAS scores of back pain (p = 0.039). In this cohort, the reoperation rate was 13.9% during a mean follow-up period of 15.3 years. Clinical outcomes tended to be most favorable in Group 1, representing patients who had OLD most recently, and they tended to deteriorate in the other 3 groups, indicating some worsening of outcomes over time. Degeneration of the spine at the operated level measured with radiographic methods tended to increase over time, but some stabilization was observed. Although spinal degeneration was stable, clinical outcomes deteriorated over time.

CONCLUSIONS

This cross-sectional assessment of a retrospective cohort indicates that outcomes after OLD deteriorate over time. Increased back pain indicated a worsening of clinical outcomes, and this worsening was correlated with radiological findings of degeneration at the operated segment.

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Hyung-Youl Park, Young-Hoon Kim, Sang-Il Kim, Sung-Bin Han, and Kee-Yong Ha

OBJECTIVE

Few studies have addressed that dynamic sagittal imbalance can develop distal to the spinal fusion and cause sagittal malalignment, unlike proximal junctional kyphosis (PJK) in the proximal portion. The purpose of this study was to investigate risk factors between the 2 different types of postoperative sagittal imbalance after long fusion to the sacrum for the treatment of degenerative sagittal imbalance (DSI).

METHODS

Eighty patients who had undergone surgical correction for DSI were included. Radiographic measurements included spinopelvic parameters on whole-spine plain radiographs and degeneration of paravertebral muscles on MRI. Univariate and multivariate analyses for clinical and radiological factors were conducted for respective risk factors. In subgroup analyses, the 2 different types of postoperative sagittal imbalance were directly compared.

RESULTS

Forty patients (50%) developed postoperative sagittal imbalance; of these patients, 22 (55.0%) developed static proximal kyphosis from PJK, and 18 patients (45.0%) developed dynamic sagittal imbalance without PJK. The independent risk factors in proximal kyphosis were greater postoperative pelvic tilt (HR 1.11) and less change in sacral slope (SS) (HR 1.09), whereas there were more fusion levels (HR 3.11), less change in SS (HR 1.28), and less change in thoracic kyphosis (HR 1.26) in dynamic sagittal imbalance. Directly compared with the proximal kyphosis group, dynamic sagittal imbalance was more commonly found in patients who had less correction of sagittal parameters as well as fatty atrophy of the paravertebral muscles. Clinical outcomes in the dynamic sagittal imbalance group were superior to those in the proximal kyphosis group.

CONCLUSIONS

Optimal correction of sagittal alignment should be considered in long instrumented fusion for DSI, because insufficient correction might cause one of 2 different types of postoperative sagittal imbalance at different sites of decompression. Dynamic sagittal imbalance compared with proximal kyphosis was significantly associated with less correction of sagittal alignment, in conjunction with more fusion levels and degeneration of the paravertebral muscles.

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Moo Seong Kim, Se Young Pyo, Young Gyun Jeong, Sun Il Lee, Yong Tae Jung, and Jae Hong Sim

Object. The purpose of this study was to assess the benefits of radiosurgery for cavernous hemangioma.

Methods. Sixty-five cavernous hemangiomas were treated with gamma knife surgery (GKS) between October 1994 and December 2002. Forty-two patients attended follow up. The mean patient age was 37.6 years (range 7–60 years). The lesions were located in the frontal lobe in 12 cases, deep in the parietal lobe in five, in the basal ganglia in five, in the temporal in three, in the cerebellum in three, in the pons/midbrain in six, and in multiple locations in eight cases. The presenting symptoms were seizure in 12, hemorrhage in 11, and other in 19. The maximum dose was 26.78 Gy, and the mean margin dose was 14.55 Gy.

The mean follow-up period after radiosurgery was 29.6 months (range 5–93 months). The tumor decreased in size in 29 cases, was unchanged in 12, and increased in size in one. In the seizure group, seizures were controlled without anticonvulsant medication in nine cases (81.8%) after 31.3 months (range 12–80 months). After 93 months, one patient developed a cyst, which was resected. Rebleeding occurred in one case (2.3%). On T2-weighted imaging changes were seen in 11 cases (26.2%), in three (7.1%) of which neurological deterioration was correlated with imaging changes. In other cases these deficits were temporary.

Conclusions. The authors found that GKS was an effective treatment modality for cavernous hemangiomas, especially for those located within the brainstem, basal ganglia, or deep portions of the brain. It can reduce seizure frequency significantly although this takes time. In the group receiving a marginal dose below 15 Gy the patients fared better than when the dose exceeded 15 Gy.

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Kee-Yong Ha, Jun-Yeong Seo, Soon-Eok Kwon, Il-Nam Son, Ki-Won Kim, and Young-Hoon Kim

Object

The authors undertook this study to investigate the validity of the rationale for posterior dynamic stabilization using the Device for Intervertebral Assisted Motion (DIAM) in the treatment of degenerative lumbar stenosis.

Methods

A cohort of 31 patients who underwent single-level decompression and DIAM placement for degenerative lumbar stenosis were followed up for at least 2 years and data pertaining to their cases were analyzed prospectively. Of these patients, 7 had retrolisthesis. Preoperative and postoperative plain lumbar radiographs obtained in all patients and CT images obtained in 14 patients were analyzed. Posterior disc heights; range of motion (ROM) of proximal, distal, and implant segments; lordotic angles of implant segments; percentage of retrolisthesis; and cross-sectional area and heights of intervertebral foramina on CT sagittal images were analyzed. Clinical outcomes were evaluated using visual analog scale scores and Oswestry Disability Index scores.

Results

The mean values for posterior disc height before surgery, at 1 week after surgery, and at the final follow-up visits were 6.4 ± 2.0 mm, 9.7 ± 2.8 mm, and 6.8 ± 2.5 mm, respectively. The mean lordotic angles at the implant levels before surgery, at 1 week after surgery, and at the final follow-up visits were 7.1° ± 3.3°, 4.1° ± 2.7°, and 7.0° ± 3.7°, respectively. No statistically significant difference was found between the preoperative values and values from final follow-up visits for posterior disc height and lordotic angles at implant levels (p = 0.17 and p = 0.10, respectively). There was no statistically significant difference between the preoperative and final follow-up visit values for intervertebral foramen cross-sectional area and heights on CT images. The ROMs of proximal and distal segments also showed no significant decrease (p = 0.98 and p = 0.92, respectively). However, the ROMs of implant segments decreased significantly (p = 0.02). The average 31.4-month improvement for all clinical outcome measures was significant (p < 0.001).

Conclusions

Based on radiological findings, the DIAM failed to show validity in terms of the rationale of indirect decompression, but it did restrict motion at the instrumented level without significant change in adjacent-segment ROM. The clinical condition of the patients, however, was improved, and improvement was maintained despite progressive loss of posterior disc height after surgery.

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Chang-Young Lee, Man-Bin Yim, Il-Man Kim, Eun-Ik Son, and Dong-Won Kim

✓ This report documents the treatment of a traumatic aneurysm of the supraclinoid internal carotid artery (ICA) that was associated with a carotid—cavernous fistula (CCF), which appeared following closed head trauma. This life-threatening lesion, which is very rare, required aggressive management achieved using intravascular stents and coils. A 19-year-old man presented with severe traumatic intracerebral and subarachnoid hematoma after he had suffered a severe closed head injury in a motor vehicle accident. Cerebral angiography performed 11 days after the injury demonstrated a traumatic aneurysm and severe narrowing of the right supraclinoid ICA, which was consistent with a dissection-induced stenosis associated with a direct CCF. Both lesions were successfully obliterated with preservation of the parent artery by using stents in conjunction with coils. Follow-up angiography obtained 7 months postoperatively revealed persistent obliteration of the aneurysm and CCF as well as patency of the parent artery. The patient remained asymptomatic during the clinical follow-up period of 14 months. Endovascular treatment involving the use of a stent combined with coils appears to be a feasible, minimally invasive option for treatment of this hard-to-treat lesion.

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Seung-Yeob Yang, Kyu-Chang Wang, Byung-Kyu Cho, Young-Yim Kim, Su-Young Lim, Sung-Hye Park, Il Han Kim, and Seung-Ki Kim

✓Radiation-induced glioblastoma multiforme (GBM) is a rare complication of radiotherapy. The authors report such a case occurring 10 years after treatment of cerebellar medulloblastoma. The patient was a 15-year-old boy who had undergone a gross-total removal of a medulloblastoma and received radiation therapy at the age of 5 years. He had experienced no tumor recurrences for 10 years until a new enhancing mass was found at the original site of the medulloblastoma. Following its resection the new lesion was found to be a GBM and there was no evidence of a medulloblastoma. The second tumor developed at the same site as the previous one after a sufficient latent period and fulfilled the criteria for a radiation-induced neoplasm. The original tumor cells expressed synaptophysin without p53 overexpression, a characteristic feature of medulloblastomas. In contrast, cells from the later tumor expressed glial fibrillary acidic protein and p53 but not synaptophysin. A sequence analysis of the p53 gene showed deletion at codon 233 and a C to G transition at codon 278 in the GBM but no mutation in the medulloblastoma. A GBM specimen revealed no amplification of the epidermal growth factor receptor compared with a normal control specimen. In conclusion, the clinical features of a radiation-induced GBM are similar to that of the primary GBM, whereas its genetic alterations render it a secondary GBM. These findings indicate that radiation-induced GBM should be considered a distinct clinical entity.

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Ho Jun Yi, Jung Eun Lee, Dong Hoon Lee, Young Il Kim, Chul Bum Cho, Il Sup Kim, Jae Hoon Sung, and Seung Ho Yang

OBJECTIVE

Perilesional edema is a predominant mechanism underlying secondary brain injury after traumatic brain injury (TBI). Perilesional edema is characterized by inflammation, production of proinflammatory cytokines, and migration of peripheral immune cells into the brain. The nucleotide-binding domain and leucine-rich repeat (NLR) family pyrin domain–containing 3 protein (NLRP3) is a key component of secondary injury. Pioglitazone regulates NLRP3 and other inflammatory cytokines. In the present study, the role of NLRP3 and the pharmacological effects of pioglitazone were investigated in animal TBI models.

METHODS

Brain contusion was induced in a weight drop model involving 3 groups of mice: C57 BL/6 (sham group), NLRP3 knockout (K/O group), and pioglitazone-treated mice (treatment group). The percentage of brain water content of the 3 groups of mice was compared over a period of time. Western blot, immunohistochemistry, and immunofluorescence analyses were conducted to investigate NLRP3-related inflammasomes and the effects of pioglitazone in the TBI models.

RESULTS

Brain edema was the highest on day 3 after TBI in the sham group. Brain edema in both the K/O and the treatment groups was lower than in the sham group. In Western blot, the expression of inflammasomes was higher after TBI in the sham group, but the expression of interleukin-1β, caspase-1, and NLRP3 was decreased significantly following treatment with pioglitazone. The expression of GFAP (glial fibrillary acidic protein) and Iba1 was decreased in both the K/O and treatment groups. In addition, confocal microscopy revealed a decrease in microglial cell and astrocyte activation following pioglitazone therapy.

CONCLUSIONS

The inflammasome NLRP3 plays a pivotal role in regulating cerebral edema and secondary inflammation. Interestingly, pioglitazone reduced cerebral edema and immune response after TBI by downregulating the effects of NLRP3. These results suggest that the clinical application of pioglitazone may be a neuroprotective strategy in TBI.

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Hoyeon Cho, Kyung Il Jo, Jua Yu, Je Young Yeon, Seung-Chyul Hong, and Jong Soo Kim

OBJECTIVE

Direct and indirect bypass surgeries are recognized as the most effective treatments for preventing further stroke in adults with moyamoya disease (MMD). However, the risk factors for postoperative infarction after bypass surgery for MMD are not well established. Therefore, the objective of this study was to investigate the risk factors for postoperative infarction. In particular, the authors sought to determine whether transcranial Doppler (TCD) ultrasonography measurements of mean flow velocity (MFV) in the middle cerebral artery (MCA) could predict postrevascularization infarction.

METHODS

The medical records of patients with MMD who underwent direct bypass surgery at the authors' institution between July 2012 and April 2015 were reviewed. The MFV in the MCA was measured with TCD ultrasonography and categorized as high (> 80 cm/sec), medium (40–80 cm/sec), and low (< 40 cm/sec). Postoperative MRI, including diffusion-weighted imaging, was performed for all patients within a week of their surgery. Angiographic findings were classified according to the Suzuki scale. Postrevascularization infarction was defined as any diffusion restriction on postoperative MRI scans. Postoperative neurological status was assessed through a clinical chart review, and the modified Rankin Scale was used to evaluate clinical outcomes.

RESULTS

Of 43 hemispheres in which bypass surgery for MMD was performed, 11 showed postrevascularization infarction. Ten of these hemispheres had low MFV and 1 had medium MFV in the ipsilateral MCA. In both univariate and multivariate analyses, a low MFV was associated with postrevascularization infarction (adjusted OR 109.2, 95% CI 1.9–6245.3). A low MFV was also statistically significantly associated with more advanced MMD stage (p = 0.02).

CONCLUSIONS

A low MFV in the ipsilateral MCA may predict postrevascularization infarction. Bypass surgery for MMD appears to be safe in early-stage MMD. Results of TCD ultrasonography provide clinical data on the hemodynamics in MMD patients before and after revascularization.

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Taek-Kyun Nam, Jung-Il Lee, Young-Jo Jung, Yong-Seok Im, Hee-Ye An, Do-Hyun Nam, Kwan Park, and Jong-Hyun Kim

Object. This study was performed to evaluate the role of gamma knife surgery (GKS) in patients with a large number (four or more) of metastatic brain lesions.

Methods. The authors retrospectively reviewed the outcome in 130 patients who underwent GKS for metastatic lesions. Eighty-four patients presented with one to three lesions (Group A) and 46 presented with four or more lesions (Group B). The overall median survival time after GKS was 35 weeks. The median survival time in Group A (48 weeks) was significantly longer (p = 0.005) than the survival time in Group B (26 weeks). The recursive partitioning analysis (RPA) class was the only significant prognostic factor identified in multivariate analysis. The median survival for patients in RPA Classes I, II, and III was 72, 48, and 19 weeks, respectively, in Group A and 36 and 13 weeks for Classes II and III in Group B. The number of lesions, tumor volume, whole brain radiotherapy, primary tumor site, age, and sex did not affect survival significantly.

Conclusions. It is suggested that GKS provides an increase in survival time even in patients with a large number (four or more) of metastatic lesions. Concerning the selection of patients for GKS, RPA class should be considered as the most important factor and multiplicity of the lesions alone should not be a reason for withholding GKS.

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Il-Man Kim, Man-Bin Yim, Chang-Young Lee, Eun-Ik Son, Dong-Won Kim, Sang-Pyo Kim, and Chul-Ho Sohn

✓ In planning surgical treatment for extraaxial cavernous hemangiomas, care should be taken to control severe tumor bleeding. The authors present a case of a large cavernous hemangioma of the cavernous sinus, which was completely removed with the aid of multiple intratumoral injections of fibrin glue. This novel method is very effective for preventing excessive blood loss during surgery for this type of lesion.