Seoung Woo Park

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.

Suppression of inducible nitric oxide synthase by (-)-isoeleutherin from the bulbs of Eleutherine americana through the regulation of NF-κB activity.

Eleutherine americana Merr. et Heyne (Iridaceae) has been used as a folk medicine for the treatment of coronary disorders and wound-healing. In our previous phytochemical study, several pyranonaphthoquinoids, including (-)-isoeleutherin, were isolated from the bulbs of E. americana. Because inhibitors of inducible nitric oxide synthase (iNOS) might be useful as anti-inflammatory agents, we investigated the potential of pyranonaphthoquinoids to inhibit iNOS activity. We found that (-)-isoeleutherin inhibits lipopolysaccharide (LPS)-stimulated induction of nitric oxide (NO) in a dose-dependent manner (IC(50)=7.4 microM). Using western blots and reverse transcription-polymerase chain reaction, we showed that (-)-isoeleutherin suppresses the expression of iNOS protein and mRNA. In addition, (-)-isoeleutherin inhibited the expression of various cytokines such as interleukin-1beta and interferon-beta. Activation of the transcriptional activity of NF-kappaB by LPS was also inhibited by treatment with (-)-isoeleutherin, suggesting that (-)-isoeleutherin-mediated suppression of iNOS expression is associated with the regulation of transcription factor NF-kappaB. These findings suggest that (-)-isoeleutherin might be a novel anti-inflammatory agent, and that it may work by inhibiting NFkB activation in macrophages.

Biomechanical evaluation of an interspinous stabilizing device, Locker.

Study Design. A biomechanical study. Objective. To evaluate the biomechanical properties of a novel dynamic interspinous device named Locke Summary of Background Data. There has been no biomechanical study on this device. Methods. Five human cadaveric lumbar spine specimens (L2–S1) were tested in the following sequence: (1) intact state; (2) after removal of the interspinous ligaments of L3–L4; (3) after application of the Locker at the interspinous space; (4) after destabilization of the L3–L4 motion segments; and (5) after reapplication of the Locker to the destabilized segments. Range of motion (ROM) and intradiscal pressure were measured by a video-based motion capture system and needle transducers. Results. Applied to the intact spine, the Locker significantly reduced the ROM of the segment in extension and flexion without significant effect on lateral bending and/or axial rotation. When applied to the destabilized segment, it significantly reduced the ROM in all directions of movement except in axial rotation, where it failed to restore the ROM of the segment. The ROM of adjacent segments was not significantly affected by the application of the Locker. Pressures at the posterior anulus and central nucleus were decreased by application of the Locker. Conclusion. The Locker showed a significant stabilizing effect on the spinal motion segment both in the intact and destabilized spine without any significant effect on adjacent segments. It also decreased the pressures of the posterior anulus and central nucleus significantly. However, in the destabilized spine, it showed no stabilizing effect in axial rotation. This biomechanical property should be considered in clinical application.

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.

An endoscopically proven ventriculitis-type, cyst-like intraventricular primary lymphoma of the central nervous system

SummaryPrimary ventriculitis form of primary CNS lymphoma (PCNSL) is very rare and difficult to diagnose from radiological findings. A 55-year-woman presented with a cystic mass in the lateral ventricle without evidence of demonstrable malignant cells in the cerebrospinal fluid (CSF). The endoscopic biopsy showed a ventriculitis-like thin web on the surface of the ventricular wall around the foramen of Monro, resulting in obstruction. Pathological diagnosis was non-Hodgkin’s lymphoma, B cell type. This case suggests that PCNSL should be considered as a differential diagnosis for a cystic ventricular lesion even with no malignant cells in the CSF.

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.

Valve Pressure Upgrade May Produce Progressive Deterioration of Vision in Children with Slit Ventricle Syndrome

Recently, valve upgrade and/or endoscopic third ventriculostomy, which have the merit of no additional shunting, were introduced for the treatment of slit ventricle syndrome, because lumboperitoneal shunting entails various complications including development of Chiari malformation, shunt malfunction, and infection. However, the safety of valve upgrading is not confirmed, especially in a child with slit ventricle syndrome developed as a result of pseudotumor cerebri. A 5-year-old boy with pseudotumor cerebri presented with headache, intermittent vomiting, and sudden deterioration of visual acuity. His cerebrospinal pressure during lumbar puncture was 69 cm H2O and his magnetic resonance imaging revealed only small ventricles. He underwent a ventriculoperitoneal shunt resulting in dramatic improvement. Four months later, he returned with recurrent spontaneous valve malfunction with recurrent severe headache and visual deterioration. After shunt revision with a programmable valve, his intermittent valve malfunction was improved by upgrading the valve opening pressure. However, his visual acuity became progressively aggravated. He underwent a lumboperitoneal shunt with low-pressure valve, which resulted in the disappearance of intermittent headaches and a deterioration of visual acuity. We suggest that valve pressure upgrade in children with slit ventricle syndrome after ventriculoperitoneal shunt for pseudotumor cerebri may produce acute deterioration of vision that had already been compromised, even within the normal intracranial pressure range and with improvement of associated symptoms.

A Case of Sotos Syndrome with Subduroperitoneal Shunt

The authors present a case of Sotos syndrome with increasing severity of subdural hygroma from the age of 5 months, which was managed with a subduroperitoneal shunt at 10 months of age. The patient had been followed up until 30 months of age with continuing improvement of symptoms. The patient initially presented with dolichocephaly accompanied by macrocrania, early tooth development, repeated pneumonia infections and developmental retardation concerning crawling, sitting, walking and speaking at 5 months of age. Magnetic resonance imaging (MRI) demonstrated partial hypoplasia of the corpus callosum and bifrontal subdural hygroma. The patient underwent subduroperitoneal shunting at 10 months of age with partial improvement of symptoms. At 18 months of age, the patient showed increased irritability and sweating, and development of spinal kyphosis, which resulted from shunt malfunction as shown in the shuntogram. The appearance of cervical syringomyelia was also seen in the MRI. After shunt revision, the irritability, sweating and kyphosis improved along with disappearance of the syringomyelia. The authors describe a case of Sotos syndrome with subduroperitoneal shunt that showed syringomyelia which developed with shunt malfunction but disappeared after shunt revision. We emphasize the importance of active management such as subduroperitoneal shunting to drain the cerebrospinal fluid in the Sotos syndrome.

Single-Stage Operation for Giant Schwannoma at the Craniocervical Junction with Minimal Laminectomy: A Case Report and Literature Review

Here we report a single-stage operation we performed on a patient with a large schwannoma that extended from the lower clivus to the cervico-thoracic junction caudally. A number of authors have previously performed multilevel laminectomy to remove giant schwannomas that extend for considerable length. This technique has caused cervical instability such as kyphosis or gooseneck deformity on several occasions. We removed the tumor with a left lateral suboccipital craniectomy with laminectomy only at C1 and without any subsequent surgery-related neurologic deficits. However, this technique requires meticulous preoperative evaluation on existence of Cerebrospinal fluid (CSF) cleft between the tumor and spinal cord on magnetic resonance imaging, of tumor origin located at the upper cervical root, and of detachment of tumor from the origin site.

Surgical Treatment for Falcotentorial Meningiomas

Among intracranial meningiomas, falcotentorial meningiomas, occurring at the junction of the falx cerebri and tentorial dural folds, are extremely rare. Because of their deep location, they are surrounded by critical structures, and have been regarded as one of the most challenging lesions for surgical treatment. In this study, we describe our surgical strategy for falcotentorial meningiomas and provide a review of our experience.