Yeon-Seong Kim

Endovascular embolization of iatrogenic vertebral artery injury during anterior cervical spine surgery: report of two cases and review of the literature.

Study Design. Case description. Objectives. To report 2 cases of vertebral artery injury (VAI) during anterior cervical decompression surgery and review the pertinent medical literature. Summary of Background Data. The incidence of VAI during an anterior surgical approach to the cervical spine is rare but potentially lethal. The spine surgeon should be aware of the detailed surgical anatomy and be prepared to manage an inadvertent injury to the vertebral artery. Methods. In the first case presented, infection was the cause of VAI. During aggressive irrigation and pus drainage, massive bleeding was encountered. For the second case, the vertebral artery was injured during decompression of cervical spondylosis while drilling the neural foramen. Intraoperative direct packing with hemostatic agents provided effective control of hemorrhage. Results. Ten days after surgery, sudden neck swelling and mental deterioration occurred because of rebleeding from a pseudoaneurysm in the first case. In the second case, a pseudoaneurysm was detected by angiography, obtained 4 days after surgery. Both pseudoaneurysms were successfully occluded by an endovascular technique without any neurologic sequelae. Conclusions. In case of bleeding control by hemostatic packing, there remains a risk of delayed hemorrhage from pseudoaneurysm. Postoperative vertebral angiography is helpful to avoid life-threatening complications. Endovascular treatment can be a good alternative in the treatment of VAI.

Post-traumatic atlantoaxial rotatory fixation in an adult: a case report.

Study Design. A case report. Objective. To describe an interesting patient who underwent open reduction and C1–C2 transpedicular screw fixation with interspinous wiring due to high-riding vertebral artery. Summary of Background Data. Atlantoaxial rotatory fixation (AARF) is a rare complication found most frequently after trauma in children and young adults; the clinical diagnosis is difficult and often made late. Methods. We report a case of post-traumatic AARF associated with a facet fracture in an adult. Reduction proved difficult to obtain by skull traction and gentle manipulation. Therefore, after open reduction under general anesthesia, we performed C1–C2 transpedicular screw fixation with posterior wiring to avoid vertebral artery injury due to high-riding transverse foramen at the C2 vertebra. Results. The normal atlantoaxial relation was restored and the torticollis resolved. The patient remains neurologically intact and has radiographic documentation of fusion. Conclusion. Although technically demanding, C1–C2 transpedicular screw fixation combined with interspinous bone graft wiring after open reduction may be an alternative treatment option if conservative treatment fails to reduce AARF.

Osteochondroma of the Cervical Spine Extending Multiple Segments with Cord Compression

Involvement of the cervical spinal cord by a solitary osteochondroma is rare. We describe a case of cervical osteochondroma extending from C5 to C7 in a 16-year-old male. The tumor, arising from the inner aspect of the C6 spinous process, projected longitudinally into the spinal canal and compressed the spinal cord; this caused clinical symptoms associated with myelopathy and radiculopathy. Total excision of the tumor by C5–C7 hemilaminectomy resulted in a good functional recovery.

Aortic aneurysm complicated with pyogenic spondylitis following vertebroplasty.

Percutaneous vertebroplasty is a commonly used procedure for the treatment of painful vertebral fractures induced by osteoporosis or metastatic disease. It is generally considered to be safe and effective. However, infectious complications can be serious. We present a patient in whom pyogenic spondylitis developed 3 months after vertebroplasty. During the debridement, profuse bleeding was encountered from injury to the aorta and the patient was managed with primary closure. Two months after the initial surgery, an aortic aneurysm was detected. A wide resection of all infected tissue, including the bony lesion and aortic aneurysm was performed, and the descending thoracic aorta was replaced with a vascular graft. A titanium mesh cage filled with bone graft was employed for anterior reconstruction. Our patient illustrates that a life-threatening aortic aneurysm can indeed occur as an infectious complication of this minimally invasive procedure due to the proximity of the aorta to the thoracolumbar vertebra. The spine surgeon should be aware of the possibility of aortic wall erosion caused by long-standing spondylitis, and be prepared to manage an inadvertent injury to the aorta during surgical debridement.

Transdural approach for calcified central disc herniations of the upper lumbar spine. Technical note.

Disc herniations of the upper lumbar spine (L1-2 and L2-3) have a frequency of 1 to 2% of all disc herniations. During posterior discectomy after laminectomy, significant manipulation of the exiting nerve root is unavoidable because of the narrow lamina and the difficulty in mobilizing the nerve root. The authors adopted a transdural approach in patients with calcified central disc herniation at the L1-2 level to reduce the risk of nerve root injury. Four patients suffering from radiating pain together with back pain were treated using the transdural approach. Preoperative neuroimaging studies revealed severe central disc herniation with calcification at the L1-2 level. After laminectomy or laminotomy, the incised dura mater was tacked, and the cauda equina rootlets were gently retracted. An intentional durotomy was performed over its maximal bulging of the ventral dura. After meticulous dissection of dense adhesions between the disc herniation and the dural sac, adequate decompression with removal of calcified disc fragments and osteophytes was accomplished. Clinical symptoms improved in all patients. Postoperative permanent cerebrospinal fluid leakage and pseudomeningocele were not observed, and no patient had a progressive lumbar deformity at an average follow-up of 53 months. Transient mild motor weakness and sensory change were observed in two patients postoperatively; however, these symptoms resolved completely within 1 week. The posterior transdural approach offers an alternative in central calcified upper lumbar disc herniation when root retraction is dangerous.

Fragmentectomy versus Conventional Microdiscectomy in Single-Level Lumbar Disc Herniations : Comparison of Clinical Results and Recurrence Rates

Objective This retrospective study aimed to compare clinical outcomes in terms of pain relief and recurrence rate between fragmentectomies and conventional microdiscectomies in patients with lumbar disc herniation (LDH). Methods Between January 2008 and May 2011, a total of 175 patients met the inclusion criteria of this study. The visual analogue scale (VAS) scores of back and radicular pains were recorded before surgery, 2 and 6 weeks after surgery. Recurrence was defined when a patient had the same pattern of preoperative symptoms and was confirmed with magnetic resonance imaging. Results Seventy-four patients (42.3%) were suitable for fragmentectomy, and 101 patients underwent conventional microdiscectomy. There were no significant differences in VAS scores between the fragmentectomy and conventional microdiscectomy groups 2 and 6 weeks after surgery. During the follow-up period, 3 patients (4.05%) in the fragmentectomy group and 7 patients (6.93%) in the conventional microdiscectomy group relapsed. Conclusion If patients are selected according to well-defined criteria, fragmentectomy can be a good surgical option for LDH, in the physiological aspect of preserving healthy intervertebral disc materials.