Dong Ho Kang

Spontaneous Rapid Reduction of a Large Acute Subdural Hematoma

The majority of acute post-traumatic subdural hematomas (ASDH) require urgent surgical evacuation. Spontaneous resolution of ASDH has been reported in some cases. We report here on a case of a patient with a large amount of ASDH that was rapidly reduced. A 61-yr-old man was found unconscious following a high speed motor vehicle accident. On initial examination, his Glasgow Coma Score scale was 4/15. His pupils were fully dilated and non-reactive to bright light. Brain computed tomography (CT) showed a massive right-sided ASDH. The decision was made to treat him conservatively because of his poor clinical condition. Another brain CT approximately 14 hr after the initial scan demonstrated a remarkable reduction of the previous ASDH and there was the new appearance of high density in the subdural space adjacent to the falx and the tentorium. Thirty days after his admission, brain CT revealed chronic SDH and the patient underwent surgery. The patient is currently able to obey simple commands. In conclusion, spontaneous rapid resolution/reduction of ASDH may occur in some patients. The mechanisms are most likely the result of dilution by cerebrospinal fluid and the redistribution of hematoma especially in patients with brain atrophy.

Discal Cyst of the Lumbar Spine

Discal cysts are rare lesions that can cause radiating leg pain. Because they are very rare, their natural history and the details of the therapeutic guidelines for the treatment of these cysts are still unknown. A 30-year-old male patient presented to our institute with radiating pain in his left leg and mild back pain. Magnetic resonance imaging (MRI) revealed an intraspinal extradural cystic mass with low signal intensity on T1-weighted images and high signal intensity on T2-weighted images at the L5-S1 level. The partial hemilaminectomy and cyst resection were performed. We report a patient with low back pain and radiating leg pain caused by a lumbar discal cyst and discuss the treatment of this cyst.

The Analysis of Patterns and Risk Factors of Newly Developed Vertebral Compression Fractures after Percutaneous Vertebroplasty

Objective The purpose of this study was to investigate the patterns and the risk factors of newly developed vertebral compression fractures (VCFs) after percutaneous vertebroplasty (PVP). Methods We performed a retrospective review of the 244 patients treated with PVP from September 2006 to February 2011. Among these patients, we selected 49 patients with newly developed VCFs following PVP as the new VCFs group, and the remaining 195 patients as the no VCFs group. The new VCFs group was further divided into 2 groups : an adjacent fractures group and a nonadjacent fractures group. The following data were collected from the groups : age, gender, body weight/height, body mass index (BMI), bone mineral density (BMD) score of the spine and femur, level of initial fracture, restoration rate of anterior/middle vertebral height, and intradiscal cement leakage, volume of polymethylmethacrylate (PMMA). Results Age, gender, mean body height/weight, mean BMI and volume of PMMA of each of the group are not statistically significantly associated with fractures. In comparison between the new VCFs group and the no VCFs group, lower BMD, intradiscal cement leakage and anterior vertebral height restoration were the significant predictive factors of the fracture. In addition, new VCFs occurrence at the adjacent spines was statistically significant, when the initial fracture levels were confined to the thoracolumbar junction, among the subgroups of new VCFs. Conclusion Lower spinal BMD, the greater anterior vertebral height restoration rate and intradiscal cement leakage were confirmed as risk factors for newly formed VCFs after PVP.

Superimposed propionibacterium acnes subdural empyema in a patient with chronic subdural hematoma.

The authors present a case of subdural empyema in a macrocephalic patient. A 23-year-old male was admitted due to headache and fever. One month ago, he had mild head injury by his coworkers. Physical examination showed a macrocephaly and laboratory findings suggested purulent meningitis. Neuroimaging studies revealed a huge size of epidural space-occupying lesion. Under the impression of epidural abscess, operation was performed. Eventually, the lesion was located at subdural space and was proven to be subdural empyema. Later, histological examination of the specimen obtained by surgery demonstrated finings consistent with the capsule of the chronic subdural hematoma. Two weeks after operation, Propionibacterium acnes was isolated. The intravenous antibiotics were used for total of eight weeks under monitoring of the serum level of the C-reactive protein. Follow-up brain computed tomography (CT) scan showed the presence of significant amount of remaining subdural lesion. However, he has complained of minimal discomfort. It is suggested that the subdural empyema occurred with preexisting chronic subdural hematoma after head injury about one month prior to admission and it took a long time to treat Propionibacterium acnes subdural empyema with systemic antibiotics, at least over eight weeks.

Oral Extrusion of Screw after Anterior Cervical Interbody Fusion

We present a case of delayed oral extrusion of a screw after anterior cervical interbody fusion in a 68-year-old man with osteoporosis. Fifteen months earlier, he had undergone C5 corpectomy and anterior cervical interbody fusion at C4-6 for multiple spinal stenoses. The patient was nearly asymptomatic, except for a foreign body sensation in his throat. We conclude that the use of a mesh graft or other instrument in elderly patients and those with osteoporosis or problematic bone quality should be considered carefully and that if surgery were to be performed, periodic postoperative follow-up evaluations are mandatory.

Inferolateral Entry Point for C2 Pedicle Screw Fixation in High Cervical Lesions

OBJECTIVE The purpose of this retrospective study was to evaluate the efficacy and safety of atlantoaxial stabilization using a new entry point for C2 pedicle screw fixation. METHODS Data were collected from 44 patients undergoing posterior C1 lateral mass screw and C2 screw fixation. The 20 cases were approached by the Harms entry point, 21 by the inferolateral point, and three by pars screw. The new inferolateral entry point of the C2 pedicle was located about 3-5 mm medial to the lateral border of the C2 lateral mass and 5-7 mm superior to the inferior border of the C2-3 facet joint. The screw was inserted at an angle 30° to 45° toward the midline in the transverse plane and 40° to 50° cephalad in the sagittal plane. Patients received followed-up with clinical examinations, radiographs and/or CT scans. RESULTS There were 28 males and 16 females. No neurological deterioration or vertebral artery injuries were observed. Five cases showed malpositioned screws (2.84%), with four of the screws showing cortical breaches of the transverse foramen. There were no clinical consequences for these five patients. One screw in the C1 lateral mass had a medial cortical breach. None of the screws were malpositioned in patients treated using the new entry point. There was a significant relationship between two group (p=0.036). CONCLUSION Posterior C1-2 screw fixation can be performed safely using the new inferolateral entry point for C2 pedicle screw fixation for the treatment of high cervical lesions.

Is Titanium Mesh Cage Safe in Surgical Management of Pyogenic Spondylitis

OBJECTIVE To report our experience with pyogenic spondylitis treated with anterior radical debridement and insertion of a titanium mesh cage and to demonstrate the effectiveness and safety of the use of a titanium mesh cage in the surgical management of pyogenic spondylitis. METHODS We retrospectively analyzed the clinical characteristics of 19 patients who underwent surgical treatment in our department between January 2004 and December 2008. The average follow-up period was 11.16 months (range, 6-64 months). We evaluated risk factors, cultured organisms, lab data, clinical outcomes, and radiographic results. Surgical techniques for patients with pyogenic spondylitis were anterior radical debridement and reconstruction with titanium mesh cage insertion and screw fixation. All patients received intravenous antibiotics for at least 6 weeks postoperatively, and some patients received oral antibiotics. RESULTS The infections resolved in all of the patients as noted by normalization of their erythrocyte sedimentation rates and C-reactive protein levels. The mean pain score on a Visual Analog Scale was 7.8 (range, 4-10) before surgery and 2.4 (range, 1-5) after surgery. The Frankel grade was improved by one grade in seven patients. After surgery, the average difference of the angle was improved about 6.96° in all patients. At the last follow-up, the mean loss of correction was 4.86°. CONCLUSION Anterior radical debridement followed by the placement of instrumentation with a titanium mesh cage may be a safe and effective treatment for selected patients with pyogenic spondylitis. This surgical therapy does not lead to recurrent pyogenic spondylitis.

The Safety and Decision Making of Instrumented Surgery in Infectious Spondylitis

Objective Infectious spondylitis is mostly managed by appropriate antibiotic treatment options, and some patients may require surgical interventions. However, surgical interventions that use spinal instrumentation to correct the mechanical instability may be associated with the risk of an increase in the recurrence rate. In this study, we investigated whether spinal instrumentation effects on recurrence of infectious spondylitis. Methods The study was conducted as a retrospective study by dividing the subjects into the noninstrumentation surgery and instrumentation surgery groups among a total of 95 patients who had received surgical interventions in infectious spondylitis from 2009 to 2014. The study investigated patient variables such as underlying illness, presumed source of infection, clinical data, laboratory and radiological data, and ultimate outcome, and compared them between the 2 groups. Results In the 95 patients, instrumentation was not used in 21 patients but it was used in 74 patients. When the disease involved ≥3 vertebral bodies, lumbosacral level and epidural part, noninstrumentation surgery was mainly conducted, but when the disease involved the thoracic level and psoas muscle part, instrumentation surgery was mainly conducted. However, there were no differences between the 2 groups in terms of the recurrence rate and the incidence of primary failure. Conclusion The use of instrumentation in treating infectious spondylitis was determined by the level of involvement and part of the infection, but the use of instrumentation did not cause any increases in the recurrence rate and the incidence of primary failure.

A case of broncho-paraspinal fistula induced by metallic devices: delayed complication of thoracic spinal surgery.

We present a case report of a 45-year-old woman with spontaneous pneumocephalus accompanied by pneumorrhachis of the thoracic spine, which is a very rare condition generally associated with trauma and thoracic or spinal surgery. The patient had undergone an operation about 10 years earlier to treat a giant cell tumor of the thoracic spine. During the operation, a metallic device was installed, which destroyed the bronchus and caused the formation of a broncho-paraspinal fistula. This is the suspected cause of her pneumocephalus and pneumorrhachis. To our knowledge, this is a very rare case of pneumocephalus accompanied by pneumorrhachis induced by metallic device, and when considering the length of time after surgery these complications presented are also exceptional.

Posterior Atlantoaxial Screw-Rod Fixation in a Case of Aberrant Vertebral Artery Course Combined with Bilateral High-Riding Vertebral Artery

We present a case of posterior atlantoaxial screw-rod fixation in a patient with an aberrant vertebral artery (VA) course combined with bilateral high-riding VA. An aberrant VA which courses below the posterior arch of the atlas (C1) that does not pass through the C1 transverse foramen and without an osseous anomaly is rare. However, it is important to consider an abnormal course of the VA both preoperatively and intraoperatively in order to avoid critical vascular injuries in procedures which require exposure or control of the VA, such as the far-lateral approach and spinal operations.