Jun Hyong Ahn

T1 slope and degenerative cervical spondylolisthesis.

Study Design. Retrospective analysis. Objective. The main objectives of this study were to analyze and compare cervical sagittal parameters, including the T1 slope, in a population of 45 patients with degenerative cervical spondylolisthesis (DCS) and to compare these patients with a control group of asymptomatic population. Summary of Background Data. Sagittal balance in the cervical spine is as important as the pelvic incidence and is related to the concept of T1 slope. Compared with degenerative lumbar spondylolisthesis, there are few studies evaluating DCS, and characteristic changes of the cervical sagittal parameters (including T1 slope) in patients with DCS are not well studied. Methods. We identified 45 patients with DCS (5.8%) from a database of 767 patients, using cervical radiograph in a standing position. All had radiograph and computed tomographic scan at the same time. Cervical sagittal parameters were analyzed on computed tomographic scan in a standardized supine position. The following cervical sagittal parameters were measured: T1 slope, neck tilt, thoracic inlet angle, and cervical lordosis (C2–C7 angle). The DCS group was compared with a control group of 45 asymptomatic age- and sex-matched adults to the DCS group, who were studied in a recently published study. Results. Of our initial group of 767 patients, 45 with anterolisthesis (5.8%) were included for this study. The T1 slope was significantly greater for DCS (26.06° ± 7.3°) compared with the control group (22.32° ± 7.0°). No significant difference of the neck tilt, thoracic inlet angle, and C2–C7 angle was seen between the DSC group and the control group. Therefore, the T1 slope of the DSC group was significantly greater than that of the control group (P < 0.005). Conclusion. The DCS group was characterized by a greater T1 slope than the control group; therefore, we suggest that a high T1 slope may be a predisposing factor in developing DCS. Level of Evidence: 3

The Effect of Lumbar Spinal Muscle on Spinal Sagittal Alignment: Evaluating Muscle Quantity and Quality.

BACKGROUND The majority of earlier studies of the parameters of sagittal balance did not consider the influence of spinal muscles on spinal sagittal alignment. OBJECTIVE To analyze the relationship between the paraspinal muscle (quantity and quality) and sagittal alignment in elderly patients. METHODS We reviewed 50 full-spine lateral standing radiographs and lumbar magnetic resonance images of elderly patients at a single center. The radiographic parameters examined were thoracic kyphosis, lumbar lordosis (LL), sagittal vertical axis, pelvic tilt, sacral slope, and pelvic incidence (PI). The lumbar muscularity (LM; quantity) and fatty degeneration ratio (FD; quality) in the paraspinal muscle were measured at the L3 level on magnetic resonance images. The relationships between the parameters, LM, and FD were analyzed with the Pearson correlation coefficient and multiple linear regression. RESULTS Pearson analysis demonstrated that the FD had significant correlations with age (r = 0.393), thoracic kyphosis (r = -0.559), pelvic tilt (r = 0.430), sagittal vertical axis (r = 0.488), and PI - LL (r = 0.479, P < .05), and a close negative correlation was found between the FD and LL (r = -0.505, P < .01). The LM had significant correlations with the LL (r = 0.342) and PI - LL (r = -0.283, P < .05). Regression models that controlled for confounding factors such as body mass index confirmed the correlations between the above parameters and FD (P < .05). CONCLUSION The quality of the paraspinal muscle could be one of the various factors that influence sagittal balance. ABBREVIATIONS BMI, body mass indexCSA, cross-sectional areaFD, fatty degeneration ratioLL, lumbar lordosisLM, lumbar muscularityPI, pelvic incidencePT, pelvic tiltSC, subcutaneous fatSS, sacral slopeSVA, sagittal vertical axisTK, thoracic kyphosisVB, vertebral body.

Clinical Aspects of Cerebral Venous Thrombosis: Experiences in Two Institutions

Objective Cerebral venous thrombosis (CVT) is a rare condition for which few clinical reviews have been conducted in Korea. Our aim was to investigate, risk factors, clinical presentations/courses, and outcomes of 22 patients treated for CVT at two centers. Materials and Methods A retrospective analysis was conducted, selecting 22 patients diagnosed with and treated for CVT at two patient care centers over a 10-year period (January 1, 2004 to August 31, 2015). Patient data, pathogenetic concerns (laboratory findings), risk factors, locations, symptoms, treatments, and clinical outcomes were reviewed. Results Mean patient age at diagnosis was 54.41 ± 16.19. Patients most often presented with headache (40%), followed by seizure (27%) and altered mental status (18%). Focal motor deficits (5%), visual symptoms (5%), and dysarthria (5%) were less common. Important predisposing factors in CVT included prothrombotic conditions (35%), infections (14%), hyperthyroidism (18%), trauma (14%), and malignancy (4%). By location, 9 patients (40%) experienced thrombosis of superior sagittal sinus predominantly, with involvement of transverse sinus in 20 (90%), sigmoid sinus in 12 (40%), and the deep venous system in 5 (23%). Treatment generally consisted of anticoagulants (63%) or antiplatelet (23%) drugs, but surgical decompression was considered if warranted (14%). Medical therapy in CVT yields good functional outcomes. Conclusion Mean age of patients with CVT in our study exceeded that reported in Europe or in America and had difference in risk factors. Functional outcomes are good with use of antithrombotic medication, whether or not hemorrhagic infarction is evident.

The Effect of Different Pillow Heights on the Parameters of Cervicothoracic Spine Segments

Objective To investigate the effect of different pillow heights on the slope of the cervicothoracic spine segments. Methods A prospective analysis of data from 16 asymptomatic adults (aged 20 to 30 years) was carried out. Exclusion criteria were history of injury or accident to the cervicothoracic spine, cervicothoracic spine surgery, or treatment for neck symptoms. We used three different pillow heights: flat (0 cm), 10-cm, and 20-cm pillows. Cervical sagittal parameters, measured with radiography, included; C2-7 Cobbs angle, T1 slope (T1S), thoracic inlet angle (TIA), and neck tilt (NT). Statistical analyses were performed using Spearman correlation coefficients. Results As the height of the pillow increased, the T1S & C2-7 Cobbs angle increased while the NT values tended to decrease. The TIA values, however, remained constant. Additionally, there was a statistically significant sex difference in T1S with the 0-cm pillow (p=0.01), and in NT with the 20-cm pillow (p=0.01). Conclusion From the data obtained in this study, we recommend that the most suitable pillow height is 10 cm, considering the normal cervical lordosis.

Epidemiology and Risk Factors for Bicycle-Related Severe Head Injury: A Single Center Experience

Objective Head injury is the main cause of death and severe disability in bicycle-related injuries. The purpose of this study was to compare the demographic characteristics and injury mechanisms of bicycle-related head injuries according to the severity and outcome and determine the main risk factors and common types of accompanying injuries. Methods A total of 205 patients who were admitted to the neurosurgery department of our hospital for bicycle-related head injuries between 2007 and 2016 were analyzed. We categorized the patients into two groups according to severity and outcome of head injury, and then identified the differences in age, sex, and cause of injury between the two groups. Results Collisions with a motor vehicle increased the risk of severe head injury (p=0.011), resulted in poor outcomes (Glasgow Outcome Scale [GOS] ≤3; p=0.022), and caused more accompanying chest/abdominal (p<0.001) and pelvic/lower extremity injuries (p=0.001) than other mechanisms. Older age and high grade of head injury severity resulted in poor outcomes (p=0.028 and p<0.001, respectively), and caused more accompanying chest/abdominal injuries (p<0.032 and p<0.001, respectively) compared with younger age and low grade of head injury severity. Conclusion In bicycle-related head injuries, collision with motor vehicle is one of the most important risk factor for high grade of head injury severity and outcome. In addition, bicycle-related head injuries are often accompanied by injuries of other parts of the body.

Therapeutic Hypothermia for Increased Intracranial Pressure after Decompressive Craniectomy: A Single Center Experience

Objective Therapeutic hypothermia (TH) and decompressive craniectomy are neuroprotective interventions following severe brain swelling. The precise benefits, risks, and clinical outcomes in brain swelling after TH are still being investigated. We aimed to investigate the effects of TH in severe brain injury after decompressive craniectomy. Methods We reviewed the cases of 24 patients who underwent decompressive craniectomy with intracranial pressure (ICP) monitor insertion in one medical center between January 2012 and May 2016. All patients had an ICP greater than 15 mmHg and a Glasgow Coma Scale score of less than 7 at the time of intervention. TH was induced in half of the patients (n=12) directly after surgery; the remaining 12 patients remained normothermic. The ICP, vital signs, complications, and functional outcomes were reviewed and compared between the patient groups. Results The mean ICP in the TH group was significantly lower than in the normothermia group. Complications during the 3 days after surgery were not different between the groups, with the exception of hypokalemia in the TH group. Mortality in the intensive care unit (ICU) was higher in the normothermia group, but the functional outcomes 3 months after surgery were not different between the TH and normothermia groups. Conclusion TH after decompressive craniectomy was effective for lowering ICP in patients with severe brain swelling. TH also reduced mortality in the ICU, but it had no benefit in functional outcomes.

Analysis of Risk Factor for the Development of Chronic Subdural Hematoma in Patients with Traumatic Subdural Hygroma

Objective Although a high incidence of chronic subdural hematoma (CSDH) following traumatic subdural hygroma (SDG) has been reported, no study has evaluated risk factors for the development of CSDH. Therefore, we analyzed the risk factors contributing to formation of CSDH in patients with traumatic SDG. Methods We retrospectively reviewed patients admitted to Hallym University Hospital with traumatic head injury from January 2004 through December 2013. A total of 45 patients with these injuries in which traumatic SDG developed during the follow-up period were analyzed. All patients were divided into two groups based on the development of CSDH, and the associations between the development of CSDH and independent variables were investigated. Results Thirty-one patients suffered from bilateral SDG, whereas 14 had unilateral SDG. Follow-up computed tomography scans revealed regression of SDG in 25 of 45 patients (55.6%), but the remaining 20 patients (44.4%) suffered from transition to CSDH. Eight patients developed bilateral CSDH, and 12 patients developed unilateral CSDH. Hemorrhage-free survival rates were significantly lower in the male and bilateral SDG group (log-rank test; p=0.043 and p=0.013, respectively). Binary logistic regression analysis revealed male (OR, 7.68; 95% CI 1.18–49.78; p=0.033) and bilateral SDG (OR, 8.04; 95% CI 1.41–45.7; p=0.019) were significant risk factors for development of CSDH. Conclusion The potential to evolve into CSDH should be considered in patients with traumatic SDG, particularly male patients with bilateral SDG.

Thrombus remnant despite intra-arterial thrombolysis for thrombus formation during endovascular treatment of ruptured cerebral aneurysms: Does it harm?

Background The fate and safety of thrombus remnant despite intra-arterial thrombolysis for unexpected thrombus formation has rarely been reported. Methods From January 2010 to May 2015, 131 consecutive patients with ruptured intracranial aneurysms were treated by endovascular methods at our institution. Among the 21 patients (16%) treated by intra-arterial thrombolysis for the thrombus formation during the procedure, nine patients (nine aneurysms) suffered from thrombus remnant. We reviewed the clinical and radiologic outcomes of patients with thrombus remnant as well as intraoperative and postoperative management of thrombus formation. Results Thrombus formation occurred near the coiled aneurysm in eight patients, and distal embolic occlusion was observed in one patient. All nine patients were initially managed by intra-arterial thrombolysis with tirofiban. One patient with persistent distal embolic occlusion and two patients with distal migration of the thrombus after intra-arterial thrombolysis were additionally treated with stent retriever. One patient with occlusion of the parent artery near the coiled aneurysm despite intra-arterial thrombolysis was partially recanalized by permanent deployment of a stent retriever. Delayed cerebral angiography showed no increase in size of thrombus remnant in any patients. After the procedure, thrombus remnant was managed by intravenous tirofiban. Follow-up CT angiography on the first postoperative day showed patent arterial flow, and ischemic complication related with thromboembolism did not occur in any patients. One patient suffered from hemorrhagic complication. Conclusion If the patency of parent artery is maintained and the size of the thrombus remnant does not increase on delayed angiography after intra-arterial thrombolysis, postoperative thromboembolic events rarely occur.