Ki Hong Cho

Successful reduction for a pediatric chronic atlantoaxial rotatory fixation (Grisel syndrome) with long-term halter traction: case report.

Study Design. Clinical case report of atlantoaxial rotatory fixation (AARF) in a girl presenting with torticollis and neck pain. Objective. To report this rare case that was successfully treated with long-term traction and a brace. Summary of Background Data. AARF is a rare kind of subluxation that is a pathologic fixation of the atlas on the axis. It is most common in pediatric patients and is usually reduced easily with conservative treatments only in the acute stage. However, previously reported chronic AARFs have usually been treated with operative reductions. Although high success rates have been achieved with operative reduction in chronic cases of AARF, even successful operative reduction may result in significant neck motion limitation. Methods. A 9-year-old girl had torticollis of more than 3 months duration develop as a result of an upper respiratory infection. Dynamic computerized tomography showed consistent fixation of the atlantoaxial joint consistent with type 1 AARF according to the classification of Li and Pang. The patient was treated with halter traction of 5-lb weight for 6 weeks, and with a brace for 4 months and collar for 2 months. Results. We successfully treated this patient with chronic AARF only with cervical traction. She had full recovery of neck motion and normal atlantoaxial angle on follow-up computerized tomography after 6 months. Conclusion. From this case, we suggest that long-term traction could be another treatment method for chronic AARF, especially in children.

Penetrating Craniofacial Injuries in Children with Wooden and Metal Chopsticks

Penetrating craniofacial injuries with chopsticks in children are peculiar accidents in the Oriental culture. All 10 cases previously reported were caused by wooden chopsticks that required surgical operations. However, there are no reported injuries with metal chopsticks in the past literature which should have been as common as that of wooden chopstick injuries in Asia. We evaluated the difference of injury patterns and clinical observations between wooden and metal chopstick injuries. We reviewed 6 treated children with penetrating craniofacial injuries from chopsticks: one wooden and five metal chopsticks. One child who had penetration through the nasal cavity presented with temporary rhinorrhea, another with mild hemiparesis, and one child with temporary upward gaze limitation of the left eye. Radiological examination revealed 1 patient with epidural hemorrhage, 1 patient with minimal subdural hemorrhage, and 4 with intracerebral hemorrhage that were fortunately too small to receive surgery. We performed surgical procedure only for a child who had a wooden chopstick that had impacted into the temporal cortex. We followed up all 6 children for more than 1 year, and found that all had fully recovered to near-normal neurological status. We observed that penetrating craniofacial injuries with metal chopsticks rarely require surgical intervention and usually results in good outcome because the resultant wound is usually small without broken fragments compared to injuries with wooden chopsticks.

Early experiences of elective stenting for symptomatic stenosis of the M1 segment of the middle cerebral artery: reports of three cases and review of the literature

The role of stenting in the treatment of patients with middle cerebral artery stenosis is not defined because of the high risk and difficulty in tracking. However, recent improvements in the technology, in particular of small, flexible stents and of small, flexible stents with accumulative stenting experience in occlusive intracranial disease endovascular treatment of this disease is now possible. We treated three patients with a symptomatic stenosis of the M1 segment of the middle cerebral artery despite combination anticoagulation therapy. All patients were successfully treated with a balloon-expandable S660 coronary stent. No procedure-related complications occurred and all patients were discharged and remained neurologically stable during the follow-up period (2-12 months). We propose stenting as one of the treatment modalities in patients with symptomatic stenosis of the M1 segment of the middle cerebral artery in selected cases. However, further studies on this new procedure should be done to determine its effect on long-term stroke prevention and to compare its safety with other treatment options.

Infantile lumbosacral spinal subdural abscess with sacral dermal sinus tract.

Study Design. Clinical case report of a spinal subdural abscess in an infant presenting with sacral dermal sinus tract (DST). Objectives. To suggest that sacral DST with caudal direction may require surgical resection as early as possible. Summary of Background Data. DST may induce the formation of a spinal abscess. However, it is sometimes difficult to decide on early surgical resection for DST, especially in cases that are located at a lower level than the lumbar spine and directed caudally that is not accompanied by cerebrospinal fluid leakage. Methods. A 9-month-old girl was transferred due to intermittent fever and vomiting, with the midline sinus of the lower back at the second sacral spinal level. She showed mild tenderness of the lower back and slight weakness of both lower extremities with increased residual urine volume of the bladder. Magnetic resonance imaging (MRI) showed that the low-lying sacral DST traced into the subdural space with caudal orientation, and the presence of extensive subdural spinal abscess from the first lumbar spine to the fourth sacrum. Results. Emergency resection of the sacral DST was performed after laminotomy from the first lumbar spine to the second sacrum, and the subdural spinal abscess was also surgically removed. After 8 weeks of intravenous antibiotic treatment, she showed no neurologic deficit and no evidence of residual abscess on MRI. Conclusion. We suggest that even low-lying sacral DST may require surgical resection as early as possible because it may result in indolent and extensive spinal abscesses.

Spinal cord injury without radiological abnormality in an infant with delayed presentation of symptoms after a minor injury.

Study Design. We present a very rare case of an infant with delayed presentation of spinal cord injury without radiologic abnormality (SCIWORA) after a minor injury. Objective. To emphasize the importance of spinal evaluation with MRI in selected cases, even after minor injuries, especially in infants. Summary of Background Data. SCIWORA arises mainly in infants and children during accidental trauma or after sport injury. However, it has been very rare for a 6-day-delayed infant SCIWORA after a minor injury. Methods. An infant presented with transient nausea and vomiting after falling from a baby-rocking horse of less than 30-cm height. The patient demonstrated right hemiparesis 6 days later. Plain cervical radiographs and brain and cervical spine computed tomograms (CT) were normal, but the cervical magnetic resonance imaging (MRI) demonstrated a high signal in the T2-weighted image of the lower cervical cord, and a neck collar was applied. Results. A follow-up cervical MRI 1 month later showed that the high signal of the lower cervical cord had disappeared. Another follow-up cervical MRI 12 months later also showed normal radiographic findings but there still remained mild weakness of the right lower extremities. Conclusion. The authors present a rare case of infant SCIWORA who developed delayed neurologic symptoms 6 days after a minor injury and suggest that spinal evaluation with MRI could be warranted in the selected case even after minor injuries, especially in infants.

Brachial plexus tumors in a consecutive series of twenty one patients.

Objective This is a retrospective review of 22 surgically treated benign and malignant tumors of brachial plexus region to describe clinical presentation, the characteristics of brachial plexus tumor and clinical outcomes with a literature review. Methods Twenty-one patients with consecutive 22 surgeries for primary brachial plexus tumors were enrolled between February 2002 and November 2011 were included in this study. The medical records of all patients were reviewed. Results Eleven male and 10 female patients were enrolled. Mean age was 39 years. Three patients had brachial plexus tumor associated with neurofibromatosis (13.6%). Presenting signs and symptoms included parenthesis and numbness (54.5%), radiating pain (22.7%), direct tenderness and pain (27.2%), palpable mass (77.3%). Twelve patients presented preoperative sensory deficit (54.5%) and 9 patients presented preoperative motor deficit (40.9%). Twenty tumors (90.9%) were benign and 2 tumors (9.1%) were malignant. Benign tumors included 15 schwannomas (68.2%), 4 neurofibromas (18.2%) and 1 granular cell tumor (4.5%). There were 1 malignant peripheral nerve sheath tumor (MPNST) and 1 malignant granular cell tumor. Gross total resection was achieved in 16 patients (72.7%), including all schwannomas, 1 neurofibroma. Subtotal resection was performed in 6 tumors (27.3%), including 3 neurofibromatosis associated with brachial plexus neurofibromas, 1 MPNST and 2 granular cell tumor in one patient. Conclusion Resection of tumor is the choice of tumor in the most of benign and malignant brachial plexus tumors. Postoperative outcomes are related to grade of resection at surgery and pathological features of tumor.

Spontaneous Spinal Epidural Hematoma in an Infant : A Case Report and Review of the Literature

Spontaneous spinal epidural hematoma (SSEH) is rare in children, especially in infants, in whom only 12 cases have been reported. Because of the nonspecificity of presenting symptoms in children, the diagnosis may be delayed. We report herein a case of SSEH in a 20-month-old girl who initially presented with neck pain, and developed lower extremity motor weakness and symptoms of neurogenic bladder 2 weeks prior to admission. The magnetic resonance imaging showed an epidural mass lesion extending from C7 to T4, and the spinal cord was severely compressed by the mass. After emergency decompressive surgery the neurologic function was improved immediately. Two months after surgery, the neurological status was normal with achievement of spontaneous voiding. We suggest that surgical intervention can provide excellent prognosis in case of SSEH in infants, even if surgery delayed.

Teratoma in human tail lipoma.

We report a case of a rare congenital teratoma that developed in a lipoma attached to a remnant human tail. A male newborn baby presented with a large, 3-cm mass with an open margin, which pedunculated from a tail attached to the midline skin of the coccygeal area. Magnetic resonance images demonstrated multiple sacral spinal bifida without cord tethering, and also showed neural roots and a lipoma and teratoma with peripheral homogeneous high density and internal low density on T2- weighted images. Intraoperatively, we found and dissected two nerve roots from the filum terminale which extended into the mass. Pathologic examination of the mass revealed abnormal differentiation of respiratory epithelium and squamous cell metaplasia along the open margin of the mass, and mainly lipoma in the rest of the mass. We suggest that this case could support the hypothesis of transient teratomatous cells in the pathogenesis of the spina bifida with lumbosacral lipoma.

Two separate episodes of intramedullary spinal cord metastasis in a single patient with breast cancer.

Intramedullary spinal cord metastases are very rare. Patients with breast cancer as the primary source of intramedullary spinal cord metastases tend to do better than other types of cancer. We report the very unusual case of a woman with breast cancer who had two separate episodes of intramedullary spinal cord metastasis.

Desmoplastic fibroma of the skull in an infant.

Case reportA 1-year-old girl presented with a 10-month history of progressive protuberance of the left frontal skull. Magnetic resonance imaging and computed tomography demonstrated a large osteolytic interosseous mass extending to the frontal sinus and temporal base without any intracranial invasion. A fronto-temporo-parietal craniectomy of the outer skull table and excision of an interosseous tumor resulted in local dural exposure in the temporal area that was covered by cranioplasty. Pathological examination identified desmoplastic fibroma (DF) of the skull. The patient’s cranial asymmetry was improved without recurrence of the tumor up to the 12th month after excision.DiscussionIn the literature, 11 cases of DF of the skull have been reported, two of which have involved children (one an infant). We report the second known infantile case of DF of the skull.