Gyu Yeul Ji

Intraoperative indocyanine green video-angiography: spinal dural arteriovenous fistula.

Study Design. Technical note. Objective. To describe the use of intraoperative indocyanine green (ICG) video-angiography for obliteration of a spinal dural arteriovenous fistula (DAVF) and to show a video clip. Summary of Background Data. ICG video-angiography is an emerging tool for delineating intraoperative vascular anatomy, and it has a significant potential in the treatment of vascular diseases in the spine. Methods. The authors presented a case of a 73-year-old man with progressive and debilitating bilateral lower extremity weakness. The patient was diagnosed with a spinal DAVF of 10th thoracic spine based on the results of conventional spinal angiography. Results. The patient underwent T9–10 laminotomy for microsurgical clip occlusion. Intraoperative ICG video-angiography was used before clip placement to identify the arterialized veins of the fistula and after clip placement to confirm obliteration of the fistulous connection and restoration of normal blood flow. Conclusion. Intraoperative ICG video-angiography serves an important role in the microsurgical treatment of DAVF. It is simple and provides real-time information about the precise location of spinal DAVF and result after obliteration of spinal DAVF.

Stand-alone Cervical Cages Versus Anterior Cervical Plates in 2-Level Cervical Anterior Interbody Fusion Patients: Analysis of Adjacent Segment Degeneration.

Study Design: A retrospective study. Objective: To analyze adjacent segment degeneration (ASD) in 2-level anterior cervical discectomy, comparing fusion with stand-alone cages [anterior cervical discectomy and fusion (ACDF)-CA] and fusion with cage and plate constructs (ACDF-CPC) with respect to clinical outcomes and radiologic changes. Summary of Background Data: ACDF using a stand-alone cage or a cage and plate construct is a popular procedure. However, there is lack of knowledge concerning ASD between the 2 procedures. Methods: A total of 42 consecutive patients who underwent 2-level ACDF-CA or ACDF-CPC for 2-level cervical disk disease and who completed 2 years of follow-up were included in this study. The patients were divided into 2 groups: ACDF-CA group (n=22) and ACDF-CPC group (n=20). The following parameters were assessed using radiographs: disk space narrowing, anterior osteophyte formation, calcification of the anterior longitudinal ligament, and fusion status. Clinical outcomes were assessed using the Robinson criteria. Results: No difference in clinical outcomes was observed between the 2 groups. Moreover, the ACDF-CPC group showed a similar fusion rate compared with the ACDF-CA group (100% vs. 95%, P=0.335). There was also no statistical significance in anterior osteophyte formation and calcification of the anterior longitudinal ligament. However, mean intervertebral disk height change of an adjacent segment was significantly lower in the ACDF-CA group than the ACDF-CPC group (upper level: 0.08±0.24 vs. 0.49±0.35; lower level: 0.06±0.41 vs. 0.49±0.28; P<0.01). Conclusions: The use of a cage with or without plate constructs in 2-level ACDF provides similar clinical results and fusion rates. Notwithstanding, ACDF-CPC showed a higher incidence of ASD than ACDF-CA over the 2-year follow-up.

Sacral Reconstruction with a 3D-Printed Implant after Hemisacrectomy in a Patient with Sacral Osteosarcoma: 1-Year Follow-Up Result

Pelvic reconstruction after sacral resection is challenging in terms of anatomical complexity, excessive loadbearing, and wide defects. Nevertheless, the technological development of 3D-printed implants enables us to overcome these difficulties. Here, we present a case of sacral osteosarcoma surgically treated with hemisacrectomy and sacral reconstruction using a 3D-printed implant. The implant was printed as a customized titanium prosthesis from a 3D real-sized reconstruction of a patients CT images. It consisted mostly of a porous mesh and incorporated a dense strut. After 3-months of neoadjuvant chemotherapy, the patient underwent hemisacretomy with preservation of contralateral sacral nerves. The implant was anatomically installed on the defect and fixed with a screw-rod system up to the level of L3. Postoperative pain was significantly low and the patient recovered sufficiently to walk as early as 2 weeks postoperatively. The patient showed left-side foot drop only, without loss of sphincter function. In 1-year follow-up CT, excellent bony fusion was noticed. To our knowledge, this is the first report of a case of hemisacral reconstruction using a custom-made 3D-printed implant. We believe that this technique can be applied to spinal reconstructions after a partial or complete spondylectomy in a wide variety of spinal diseases.

Three cases of hemiplegia after cervical paraspinal muscle needling

BACKGROUND CONTEXT Muscle needling therapy is common for chronic pain management, but the development of unusual complications such as hemiplegia is not well understood. PURPOSE We report on three cases with hemiplegia after cervical paraspinal muscle needling and propose possible explanations for these unusual complications. STUDY DESIGN Case report. METHODS The authors retrospectively reviewed the medical charts from a decade (2002-2013) at Korea University Hospital. The records were systematically searched, and the cases with hemiplegia (grade<3) after needing therapy were collected. No conflict of interest reported. No funding received. RESULTS A 54-year-old woman, a 38-year-old woman, and a 60-year-old man with hemiplegia by cervical subdural or epidural hematoma after cervical posterior paraspinal muscle needling without direct invasion (intramuscular stimulation, acupuncture, or intramuscular lidocaine) were observed. All patients were taken for emergent decompressive laminectomy, and their postoperative motor function improved substantially. CONCLUSION Spinal hematoma after muscle needling is unusual but was thought to result after a rupture of the epidural or subarachnoid veins by a sharp increase in blood pressure delivered in the intraabdominal or intrathoracic areas after needling therapy.

The Use of Magnetic Resonance Imaging in Predicting the Clinical Outcome of Spinal Arteriovenous Fistula

Purpose Magnetic resonance imaging (MRI) has been used to screen and follow-up spinal dural arteriovenous fistulae (SDAVF). The purpose of this study was to evaluate the association between MRI findings and neurologic function in SDAVF. This study also investigated clinical features and treatment results of SDAVF. Materials and Methods A total of 15 consecutive patients who underwent embolization or surgery for SDAVF were included. We treated seven (60%) patients with embolization and six (40%) with surgery. We analysed clinical features, MRI findings, treatment results, and neurologic function. Neurologic function was measured by the Aminoff-Logue disability scale (ALS). Results Patients with longer levels of intramedullary high signal intensity in preoperative T2-weighted images (T2WI) exhibited worse pre- and postoperative ALS scores (r=0.557, p=0.031; r=0.530, p=0.042, Pearson correlation). Preoperative ALS score was significantly correlated with postoperative ALS score (r=0.908, p=0.000, Pearson correlation). The number of levels showing intramedullary high signal intensity in T2WI decreased significantly postoperatively (5.2±3.1 vs. 1.0±1.4, p=0.001, Wilcoxon ranked test). Conclusion The number of involved levels of high signal intensity in preoperative T2WI is useful for predicting pre- and postoperative neurologic function in SDAVF.

Surface Landmarks do not Correspond to Exact Levels of the Cervical Spine: References According to the Sex, Age and Height.

Objective A general orientation along the cervical spine could be estimated by external landmarks, and it was useful, quick and less exposable to radiation, but, sometimes it gave reference confusion of target cervical level. The authors reviewed the corresponding between the neck external landmarks and cervical levels. Methods Totally 1,031 cervical lateral radiographs of different patients were reviewed in single university hospital. Its compositions were 534 of males and 497 females; 86 of second decades (10-19 years-old), 169 of third decades, 159 of fourth decades, 209 of fifth decades, 275 of sixth decades, and 133 of more than seventh decades (>60 years-old). Reference external landmarks (mandible, hyoid bone, thyroid cartilage, and cricothyroid membrane) with compounding factors were reviewed. Results The reference levels of cervical landmarks were C2.13 with mandible angle, C3.54 with hyoid bone, C5.12 with thyroid cartilage, and C6.01 with cricothyroid membrane. The reference levels of cervical landmarks were differently observed by sex, age, and somatometric measurement (height) accordingly mandible angle from C1 to C3, hyoid bone from disc level of C2 and C3 to C5, thyroid cartilage from disc level of C3 and C4 to C7, and cricothyroid membrane from C4 to disc level of C7 and T1. Conclusion Surface landmarks only provide general reference points, but not correspond to exact levels of the cervical spine. Intraoperative fluoroscopy ensures a more precise placement to the targeted cervical level.

Intradural cauda equina metastasis of renal cell carcinoma: a case report with literature review of 10 cases.

Study Design. Case report with literature review. Objective. To describe a rare case of intradural spinal metastasis from renal cell carcinoma (RCC) spread to the cauda equina, and to discuss the clinical features of metastatic RCC in the cauda equina from the data available in the literature. Summary of Background Data. Intradural spinal metastasis is rare, representing 6% of all spinal metastasis. Indeed, intradural metastasis from a RCC to the cauda equina is extremely rare with previously only 9 case reports. Methods. A 68-year-old male presented with a 2-month history of worsening lower back pain radiating to both legs. The patient had undergone nephrectomy for the treatment of the clear cell RCC 16 years before admission. Magnetic resonance imaging showed a well-defined intradural extramedullary mass in the cauda equina at T12 to L1. Results. The pathological examination displayed metastatic clear cell RCC. Additional imaging studies showed no metastatic in other locations. The patient was discharged without neurological deficit and pain after the operation, and maintained an optimal condition for 2 years. Conclusion. When a lesion of the cauda equina presents, intradural metastasis should be in the differential diagnosis in patients who had been previously treated for RCC although any other metastatic lesion was not observed. Level of Evidence: N/A

Slip Reduction Rate between Minimal Invasive and Conventional Unilateral Transforaminal Interbody Fusion in Patients with Low-Grade Isthmic Spondylolisthesis

Objective To compare the slip reduction rate and clinical outcomes between unilateral conventional transforaminal lumbar interbody fusion (conventional TLIF) and unilateral minimal invasive TLIF (minimal TLIF) with pedicle screw fixation for treatment of one level low-grade symptomatic isthmic spondylolisthesis. Methods Between February 2008 and April 2012, 25 patients with low-grade isthmic spondylolisthesis underwent conventional TLIF (12 patients) and minimal TLIF (13 patients) in single university hospital by a single surgeon. Lateral radiographs of lumbar spine were taken 12 months after surgery to analyze the degree of slip reduction and the clinical outcome. All measurements were performed by a single observer. Results The demographic data between conventional TLIF and minimal TLIF were not different. Slip percentage was reduced from 15.00% to 8.33% in conventional TLIF, and from 14.15% to 9.62% in minimal TLIF. In both groups, slip percentage was significantly improved postoperatively (p=0.002), but no significant intergroup differences of slip percentage in preoperative and postoperative were found. The reduction rate also not different between conventional TLIF (45.41±28.80%) and minimal TLIF (32.91±32.12%, p=0.318). Conclusion Conventional TLIF and minimal TLIF with pedicle screw fixation showed good slip reduction in patients with one level low-grade symptomatic isthmic spondylolisthesis. The slip percentage and reduction rate were similar in the conventional TLIF and minimal TLIF.

Spinal Subdural Hematoma Following Cranial Subdural Hematoma : A Case Report with a Literature Review

Coexistence of cranial and spinal subdural hematomas is rare and only a few cases have been reported in the literature. Herein, we report a case of cranial and spinal subdural hematomas after previous head trauma. As the pathogenesis of simultaneous intracranial and spinal subdural hematoma yet remains unclear, we developed an alternative theory to those proposed in the literature for their coexistence, the migration of blood through the subdural space.

Usefulness of 3-dimensional Measurement of Ossification of the Posterior Longitudinal Ligament (OPLL) in Patients With OPLL-induced Myelopathy

Study Design. Retrospective study. Objective. To evaluate the usefulness of 3-dimensional (3D) measurement of ossification of the posterior longitudinal ligament (OPLL), and identify the reliability of a novel 3D method of measurement. Summary of Background data. OPLL is not a 2-dimensional (2D) disease, but rather a 3D disease. Therefore, conventional measurement of parameters using radiography may not be suitable for evaluating OPLL. However, there is no study that investigated the correlation between 3D parameters of OPLL and clinical outcomes. Methods. 50 patients (40 males and 10 females; mean age 57.2 yr) with symptomatic OPLL were enrolled. Neurological and clinical outcome scales were measured using the Japanese Orthopedic Association (JOA) score, visual analogue scale, short-form health survey (SF-36) and neck disability index. A 3D model was reconstructed with digital imaging and communications in medicine files from axial computed tomographic images using software (MIMICS; Materialise, Leuven, Belgium) to obtain the following parameters: 3D volume of OPLL, 3D volume of the spinal canal (confined to the vertebral level involving OPLL), spinal canal diameter, thickness of OPLL, and length of OPLL. All patients were divided into 2 different groups, the mild myelopathy group (JOA score ≥18, n = 11) and the severe myelopathy group (JOA score ⩽17, n = 23). Results. The 3D OPLL volume did not correlate with clinical outcomes (r =−0.275, P = 0.116). 3D OPLL ratio and OPLL thickness had a significant negative relationship with JOA score (r =−0.502, P < 0.005 and r =−0.437, P < 0.05, respectively). In particular, 3D OPLL ratio was an independent risk factor for increased severity of myelopathy (B =−29.71, P < 0.05). The mild myelopathy group showed lower 3D OPLL ratio than the severe myelopathy group (0.092 vs. 0.148, P < 0.05). Conclusion. 3D method of measurement is superior to the conventional method in terms of evaluating the clinical state of symptomatic patients with OPLL. Higher 3D OPLL ratio has an adverse effect on the spinal cord. Level of Evidence: 3