Objective : Morphometric data for the lumbar posterior longitudinal ligament (PLL) was investigated to identify whether there is a difference in the morphometry of the PLL of the lumbar spine at each level with respect to the pattern of intervertebral disc displacement. Methods : In 14 formalin-fixed adult cadavers (12 males and 2 females), from L1 to L5, the authors measured the width and height of the PLL and compared them with other landmarks such as the disc and the pedicle. Results : Horizontally, at the upper margin of the disc, the central portion of the superficial PLL covered 17.8-36.9% of the disc width and the fan-like portion of the PLL covered 63.9-76.7% of the disc width. At the level of the median portion of the disc, the PLL covered 69.1-74.5% of the disc width. Vertically, at the level of the medial margin of the pedicle, the fan-like portion of the PLL covered 23.5-29.9% of the disc height. In general, a significant difference in length was not found in the right-left and male-female comparisons. y Conclusion : This study presents the morphometric data on the pattern of intervertebral disc displacement and helps to improve the knowledge of the surgical anatomy of the lumbar PLL.

OBJECTIVE:The pathophysiology of chronic subdural hematoma (CSH) is not yet clear. Trauma alone is not sufficient to result in CSH in young individuals, while a trivial injury can result in CSH in older adults. Although the causality and apportionment of trauma are important issues in CSH, especially in terms of insurance, it is too obscure to solve all struggles.METHODS:There are three key factors for producing CSH. First, CSH necessitates a potential subdural reservoir. Other important precipitating factors are trauma and coagulopathy. However, these factors are not sufficient to cause CSH development. The trauma apportionment score (TAS) can be used to compare the relative importance of these three factors. Here, we applied the TAS to 239 consecutive cases of CSH. We retrospectively obtained the patients' history and laboratory results from their medical records.RESULTS:The TAS ranged from -5 to 5. The most common score was 0. If we defined the cause of CSH as being combined when the TAS was 0, then the cause was combined in 30 cases (12.6%). If we extended the criteria for a combined cause from 0 to -1 to 1, the cause was combined in 107 cases (44.8%). Regardless of the criteria used, traumatic CSHs were more common than were spontaneous CSHs. Spontaneous CSHs were more common in older than in younger patients (p<0.01, Fisher's exact test).CONCLUSION:The TAS is a useful tool for differentiating the causality of CSH.

Background: To evaluate the trends in age of stroke and compare with recent national wide data in a rapidly developing urban area over the 19 years from 1997 to 2015. Methods:We recruited 12,370 patients who were diagnosed from 1997 to 2015 with first-ever or recurrent stroke in our hospital, which is located in the center of Chungnam.We assessed the trends in mean age of first-ever or recurrent stroke by sex.In addition, we compared the trends in stroke by age and sex between our patient populations.We calculated trends in mean age of first-ever or recurrent stroke by sex and stroke subtype using a regression model.Results: Of total 12.370 patients, IS (ischemic stroke) were 64% and HS (hemorrhagic stroke) were 36%.The ratio of SAH (subarachnoid hemorrhage) in young age (<45), middle age (45~64), and old age (>64) group were 38%, 22%, and 13%, respectively.The ratio of IS in young age, middle age, and old age group were 41%, 58%, and 72%, respectively.From 1997 to 2009, the mean age of stroke onset increased annually by 0.10 year for overall stroke and by 0.32 year for IS, while that of HS onset significantly decreased annually by 0.25.From 2010 to 2015, the mean age of stroke onset increased annually by 0.34 year for overall stroke, by 0.03 year for IS, and by 0.72 year for HS.Since 2009, the campaign of health check-up widened to young and middle age population and to obtain the focused care and control for risk factors of stroke.During 19 years, the proportions of the middle age people in Chungchungnam-do increased steadily among both sexes (men; 20% in 1996 to 30% in 2015, women; 22% in 1996 to 28% in 2015). Conclusion:The stroke age trends tend to increase in rapidly developing urban areas, while that of hemorrhagic stroke showed a decreasing tendency.However, the mean age of HS began reversing to older age since health policy established and the proportion of population was changed with hyper-aging society.The stroke age trends are affected by many factors, so prevention of stroke, such as campaign or health check-up service, should be focused on the young and middle age population to prevent these trends.

Objective: To evaluate the efficacy of balloon guiding catheter (BGC) during thronnbectonny in anterior circulation ischennic stroke.Methods : Sixty-two patients with acute anterior circulation ischemic stroke were treated with thrombectomy using a Solitaire stent from 2011 to 2016. Patients were divided into the BGC group (n=24, 39%) and the non-BGC group (n=38, 61%). The number of retrievals, procedure time, thrombolysis in cerebral infarction (TICI) grade, presence of distal emboli, and clinical outcomes at 3 months were evaluated.Results: Successful recanalization was more frequent in BGC than in non-BGC (83% vs. 66%, p=013). Distal emboli occurred less in BGC than in non-BGC (231% vs. 57.1%, p=0.02). Good clinical outcome was more frequent in BGC than in non-BGC (50% vs. 16%, p=0.03). The multivariate analysis showed that use of BGC was the only independent predictor of good clinical outcome (odds ratio, 519 95% confidence interval, 1.07-25.11). More patients in BGC were successfully recanalized in internal carotid artery (ICA) occlusion with small retrieval numbers (<3) than those in non-BGC (70% vs. 24%, p=0.005). In successfully recanalized ICA occlusion, distal emboli did not occur in BGC, whereas nine patients had distal emboli in non-BGC (0% vs. 75%, p=0.001) and good clinical outcome was superior in BGC than in non-BGC (55.6% vs. 8.3%, p=0.01).Conclusion : A BGC significantly reduces the number of retrievals and the occurrence of distal emboli, thereby resulting in better clinical outcomes in patients with anterior circulation ischemic stroke, particularly

Retro-rectal cystic hamartoma (tailgut cyst), is an uncommon congenital developmental lesion, generally located in the retro-rectal space. Its diagnosis and approach is challenging because the retropelvic space is not familiar. We report a 51-year-old woman who presented with paresthesia and pain in perianal area. The magnetic resonance image showed high signal intensity on the T1-weighted image and iso to high signal intensity on the T2-weighted image of the retropelvic space and CT showed sacral bony defect. We chose the posterior approach for removal of the tailgut cyst. Histopathology exam of the retropelvic cyst revealed a multiloculated cyst containing abundant mucoid material lined by both squamous and glandular mucinous epithelium. The patient has recovered nicely with no recurrence. Tailgut cyst needs complete surgical excision for good prognosis. So, a preoperative high-resolution image and co-operation between neurosurgen and general surgeon would help to make safe and feasible diagnosis and surgical access.

OBJECTIVE:Preinjection gelfoam embolization during percutaneous vertebroplasty (PVP) has been thought alternative technique to prevent the leakage of bone cement. The goal of this study was to evaluate whether the gelfoam techniques are useful to reduce bone cement leakage.METHODS:Total 100 PVPs of osteoporotic spine compression fractures were performed by 1 spine surgeon who experienced more than 500 PVP cases under prospective control study. Operation was done in T-L junction (T10-L2) fractures with bi-transpedicular approach. Preinjection gelfoam PVP was done in the 50 levels. As control group, PVP without gelfoam was done in the 50 levels. We did not perform preoperative venography. We inserted normal saline-mixed gelfoam to the anterior third of vertebral body via PVP needle, and then 3mL of polymethylmetacrylate (PMMA) was injected. We prospectively evaluated the incidence and leakage pattern of PMMA by postoperative computed tomography.RESULTS:Between gelfoam and control groups, there were 11 leaks (22%) versus 12 leaks (26%). The mean operation time was 7.00 minutes versus 6.30 minutes. In gelfoam group, there were 6 spinal canal leaks, 4 paravertebral venous leaks, and 1 soft tissue leaks. In control group, there were 4 spinal canal leaks, 8 paravertebral venous leaks, and 1 disc space leak. In spite of cement leakage, there was no symptomatic case in both groups. Statistically, gelfoam technique was not related to decrease the incidence of leakage (p=0.64).CONCLUSION:Our prospective study showed that it did not significantly decrease cement leakage when vertebroplasty is performed by experienced spine surgeon.

Fractures in ankylosing spondylitis (AS) are often difficult to identify and treat. If combined with osteoporosis, the spine becomes weaker and vulnerable to minor trauma. An 83-year-old woman with a history of chronic AS and severe osteoporosis developed paraparesis and voiding difficulty for 4 days prior. She had been placed in the lateral decubitus position in a bedridden state in a convalescent hospital due to the progressive paraparesis. The laboratory findings showed CO2 retention in the arterial blood gas analysis. After the patient was transferred to the computed tomography (CT) room, a CT was taken in the supine position. Approximately half an hour later, the resident in our neurosurgical department checked on her, and the neurological examination showed a complete paraplegic state. She was treated conservatively and finally expired 20 days later.

Objective : Decompressive craniectomy is an effective therapy to relieve high intracranial pressure after acute brain damage. However, the optimal timing for cranioplasty after decompression is still controversial. Many authors reported that early cranioplasty may contribute to improve the cerebral blood flow and brain metabolism. However, despite all the advantages, there always remains a concern that early cranioplasty may increase the chance of infection. The purpose of this retrospective study is to investigate whether the early cranioplasty increase the infection rate. We also evaluated the risk factors of infection following cranioplasty.Methods : We retrospectively examined the results of 131 patients who underwent cranioplasty in our institution between January 2008 and June 2015. We divided them into early (<= 90 days) and late (>90 days after craniectomy) groups. We examined the risk factors of infection after cranioplasty. We analyzed the infection rate between two groups.Results : There were more male patients (62%) than female (38%). The mean age was 49 years. Infection occurred in 17 patients (13%) after cranioplasty. The infection rate of early cranioplasty was lower than that of late cranioplasty (7% vs. 20%; p=0.02). Early cranioplasty, non-metal allograft materials, re-operation before cranioplasty and younger age were the significant factors in the infection rate after cranioplasty (p<0.05). Especially allograft was a significant risk factor of infection (odds ratio, 12.4; 95% confidence interval, 3.24-47.33; p<0.01). Younger age was also a significant risk factor of infection after cranioplasty by multivariable analysis (odds ratio, 0.96; 95% confidence interval, 0.96-0.99; p=0.02).Conclusion : Early cranioplasty did not increase the infection rate in this study. The use of non-metal allograft materials influenced a more important role in infection in cranioplasty. Actually, timing itself was not a significant risk factor in multivariate analysis. So the early cranioplasty may bring better outcomes in cognitive functions or wound without raising the infection rate.

Although many patients with infective endocarditis (IE) complain of joint, muscle, and back pain, infections at these sights are rare. The incidence of spinal abscess in cervical spine complicating endocarditis is very rare. Although the surgical management is the mainstay of treatment, conservative treatment can get success in selected patients. We report a patient with cervical epidural abscess due to Streptococcus viridans endocarditis. Both epidural abscess and IE were managed conservatively with intravenous antibiotics for 8 weeks, with recovery. It is important to remind spinal epidural abscess can occur in those patients with bacterial endocarditis.

Objective Normal pressure hydrocephalus (NPH) is a syndrome characterized by gait disturbance, memory impairment and urinary incontinence. The isotope cisternography (ICG) became less useful because of low accuracy and complications. We tried to evaluate the safety and value of the ICG. Methods We retrospectively collected data on ICG of 175 consecutive patients with a suspected hydrocephalus. We classified the ICG into four types by the ventricular reflux and circulation time. The ventricular size was measured by Evans index and the width of the third ventricle. Results There were three complications including one case of paraplegia. Type 4 was the most common type, observed in 53%. Type 3 (33%), type 2 (7%), and type 1 (7%) were observed less often. Type 4 was more common in patients with large ventricles. Types of the ICG were not related to the causes of hydrocephalus, gender, or age of the patients. Shunting was more frequently performed in type 4 (71%), compared to type 1 (17%), type 2 (33%), and type 3 (46%). Surgery was more common when the cause was vascular. After the shunt surgery, 33.0% were graded as the improved. Although there were some improvements even in the not-improved patients, they still needed many helps. The improvement was related to the preoperative state. Conclusion ICG may bring a serious complication, however the incidence is very low. Although the predictability of response rate on the shunting is doubtful, ICG is a cheap and useful tool to select surgical candidates in NPH.

OBJECTIVE:Posttraumatic cerebral infarction (CI) is a well-known complication of traumatic brain injury (TBI). However, the causation and apportionment of trauma in patients with CI after TBI is not easy. There is a scoring method, so-called trauma apportionment score (TAS) for CI, consisted with the age, the interval, and the severity of the TBI. We evaluated the reliability of this score.METHODS:We selected two typical cases of traumatic CI. We also selected consecutive 50 patients due to spontaneous CI. We calculated TAS in both patients with traumatic and spontaneous CI. To enhance the reliability, we revised TAS (rTAS) adding three more items, such as systemic illness, bad health habits, and doctor's opinion. We also calculated rTAS in the same patients.RESULTS:Even in 50 patients with spontaneous CI, the TAS was 4 in 44 patients, and 5 in 6 patients. TAS could not assess the apportionment of trauma efficiently. We recalculated the rTAS in the same patients. The rTAS was not more than 11 in more than 70% of the spontaneous CI. Compared to TAS, rTAS definitely enhanced the discriminating ability. However, there were still significant overlapping areas.CONCLUSION:TAS alone is insufficient to differentiate the cause or apportionment of trauma in some obscure cases of CI. Although the rTAS may enhance the reliability, it also should be used with cautions.

Objective We assessed the life-time prevalence (LTP) of chronic low back pain (LBP) in young Korean males. We also evaluated the relationship between lumbar spinal lesions and their health related quality-of-life (HRQOL). Methods A cross-sectional, self-reported survey was conducted in Korean males (aged 19-year-old) who underwent physical examinations for the conscript. We examined 3331 examinees in November 2014. We included 2411 subjects, who accepted to participate this study without any comorbidities. We interviewed using simple binary questions for their LBP experience and chronicity. HRQOL was assessed by Short-Form Health-Survey-36 (SF-36) in chronic LBP and healthy control groups. Radiological assessment was performed in chronic LBP group to determine whether there were any pathological causes of their symptoms. Results The LTP of chronic LBP was 13.4%. Most (71.7%) of them didn't have any lumbar spinal lesions (i.e., non-specific chronic LBP). The SF-36 subscale and summary scores were significantly lower in subjects with chronic LBP. Between specific and non-specific chronic LBP group, all physical and mental subscale scores were significantly lower in specific chronic LBP group, except mental health (MH) subscale score. In MH subscale and mental component summary score, statistical significant differences didn't appear between two groups (p=0.154, 0.126). Conclusion In Korean males 19 years of age, the LTP of chronic LBP was 13.4%, and more than two-thirds were non-specific chronic LBP. Chronic LBP had a significant impact on HRQOL. The presence of lumbar spinal pathoanatomical lesions affected mainly on the physical aspect of HRQOL. It influenced little on the mental health.

Objective : Age is a strong predictor of mortality in traumatic brain injuries. A surgical decision making is difficult especially for the elderly patients with severe head injuries. We studied so-called 'withholding a life-saving surgery' over a two year period at a university hospital.Methods : We collected data from 227 elderly patients. In 35 patients with Glasgow Coma Score 3-8, 28 patients had lesions that required operation. A life-saving surgery was withheld in 15 patients either by doctors and/or the families (Group A). Surgery was performed in 13 patients (Group B). We retrospectively examined the medical records and radiological findings of these 28 patients. We calculated the predicted probability of 6 month mortality (IPM) and 6 month unfavorable outcome (IPU) to compare the result of decision by the International Mission for Prognosis and Analysis of Clinical Trials in TBI (IMPACT) calculator.Results : Types of the mass lesion did not affect on the surgical decision making. None of the motor score 1 underwent surgery, while all patients with reactive pupils underwent surgery. Causes of injury or episodes of hypoxia/hypotension might have affected on the decision making, however, their role was not distinct. All patients in the group A died. In the group B, the outcome was unfavorable in 11 of 13 patients. Patients with high IPM or IPU were more common in group A than group B. Wrong decisions brought futile cares.Conclusion : Ethical training and developing decision-making skills are necessary including shared decision making.

Ligamentum flavum cysts have rarely been reported and known to be the uncommon cause of spinal compression and radiculopathy. A 63-year-old man presented right sciatica lasting for 1 month. Lumbar computerized tomography and magnetic resonance imaging demonstrated an extradural cystic mass adjacent to the L5-S1 facet joints. Partial hemilaminectomy and flavectomy at the L5-S1 space were performed, and then the cystic mass was excised. Histopathology confirmed a connective tissue cyst, which is consistent with the ligamentum flavum. Microscopic examination of the cyst wall revealed that it is closely packed collagen fibril. The symptom of patient was improved after surgery. Because of rarity of ligamentum flavum cysts and nonspecific clinical and radiologic findings, the preoperative diagnosis is not easy. The histologic features of ligamentum flavum cysts are distinct from other cystic lesion of lumbar spine. This study presents a case and literature review of ligamentum flavum cyst. We summarize the pathophysiology, occurrence, differential diagnosis of rare ligamentum flavum cyst, especially on lumbar spine.

Objective Density of the chronic subdural hematoma (cSDH) is variable. It often appears to be mixed density. Multiple densities of cSDH may result from multiple episodes of trauma. We investigated the frequency of mixed density and the causes of head injuries representing each density. Methods We could collect 242 cases of chronic SDH. The cSDHs were classified into four groups; hypodensity, homogeneous isodensity, layered type, and mixed type on the basis of CT scans. Results The density of cSDH was isodense in 115 patients, hypodense in 31 patients, mixed in 79 cases, and layered in 17 cases. The cSDH was on the left side in 115 patients, on the right side in 70 patients, and bilateral in 40 patients. The history of trauma was identifiable in 122 patients. The etiology could be identified in 67.7% of the hypodense hematomas, while it was obscure in 59.5% of the mixed hematomas. Conclusion Mixed density of cSDH results from multiple episodes of trauma, usually in the aged. It is hard to remember all the trivial traumas for the patients with the mixed density cSDHs. Although there were membranes within the mixed density hematomas, burr-holes were usually enough to drain the hematomas.

This paper discusses the behaviour characteristics of the shaping formation of Single-Chorded Space Truss (SCST) structures by means of cable-tensioning of bottom chords. The innovative technique is fast and economical and issued in many types of space structures. The small-scale test models presented herein consist of uniform pyramids with multi-directional ball type joints which are erected into their final shape by cable-tensioning. Since the joint behaviour is very significant in studying the shaping of SCST structures, basic tests for beam and pyramidal units were performed. The feasibility of the proposed cable-tensioning technique and the reliability of the established geometric model were confirmed by finite element analysis. The proposed cable-tensioning technique indicates that the behaviour characteristic of joints is very important in the shaping formation of SCST structures. More specifically in situations where heavy cranes are inaccessible, the cable-tensioning construction technique has proven to be an easy and reasonable method compared to conventional construction methods that typically include heavy cranes and scaffolding.

Carpal tunnel syndrome (CTS) is the most common entrapment neuropathy. In most cases of CTS, characteristic clinical findings alone may be sufficient for diagnosis. Although the electrodiagnostic tests (EDT) have been reported to be high sensitivity and specificity, other studies noted a substantial false-positive and false-negative rate of 1020%. Since 1992, Buchberger et al. has been the first to quantify changes in CTS using ultrasonography (USG), many studies demonstrated a consistent and significantly increased median nerve cross-sectional area (CSA) in patients with CTS. The most frequently used criterion for USG study is at the level of carpal tunnel inlet, where the median nerve is identified most easily. However, the normal range and pathologic threshold of median nerve CSA vary widely between laboratories. The pathologic thresholds are ranging from 9 to 14 mm. The object of our study is to establish the clinical efficacy of USG in patients with CTS through reestablish the normal range and pathologic threshold of median nerve CSA at the level of carpal tunnel inlet in prospectively recruited patients with and without CTS; and also to correlate ultrasonographic measurements with electrophysiological measurements of CTS severity.

The book, Ossification of the Posterior Longitudinal Ligament, has a significant meaning as the first English contribution of comprehensive coverage for OPLL ever published in Korea.

OBJECTIVE:The purpose of this study is to elucidate the anatomic relationships between the uncinate process and surrounding neurovascular structures to prevent possible complications in anterior cervical surgery.METHODS:Twenty-eight formalin-fixed cervical spines were removed from adult cadavers and were studied. The authors investigated the morphometric relationships between the uncinate process, vertebral artery and adjacent nerve roots.RESULTS:The height of the uncinate process was 5.6-7.5 mm and the width was 5.8-8.0 mm. The angle between the posterior tip of the uncinate process and vertebral artery was 32.2-42.4°. The distance from the upper tip of the uncinate process to the vertebral body immediately above was 2.1-3.3 mm, and this distance was narrowest at the fifth cervical vertebrae. The distance from the posterior tip of the uncinate process to the nerve root was 1.3-2.0 mm. The distance from the uncinate process to the vertebral artery was measured at three different points of the uncinate process : upper-posterior tip, lateral wall and the most antero-medial point of the uncinate process, and the distances were 3.6-6.1 mm, 1.7-2.8 mm, and 4.2-5.7 mm, respectively. The distance from the uncinate process tip to the vertebral artery and the angle between the uncinate process tip and vertebral artery were significantly different between the right and left side.CONCLUSION:These data provide guidelines for anterior cervical surgery, and will aid in reducing neurovascular injury during anterior cervical surgery, especially in anterior microforaminotomy.

Background: Serum S100 protein has been known to reflect the severity of brain damage. The purpose of this study was to compare the degree of brain damage based on the serum S100 protein level between aneurysm clipping and coiling groups and to evaluate the prognostic value of S100 protein in patients with subarachnoid hemorrhage (SAH). Methods: Serum S100 protein was measured by Elecsys S100 immunoassay at admission, and at 6 and 24 h, and days 3 and 5 postoperatively for 100 consecutive SAH patients (clipping group: 56, coiling group: 44) and for 74 healthy controls. Hunt-Hess grade (HHG), Fisher grade (FG), the presence of intraventricular (IVH) or intracerebral hemorrhage (ICH), and outcome at discharge were evaluated. The time course of serum S100 was compared between the groups. The prognostic value of S100 protein was evaluated by logistic regression analysis. Results: The median S100 level in SAH patients on admission was significantly higher than in healthy controls (0.081 vs. 0.05 µg/l, p < 0.0001) and it was also higher as HHG and FG increased (p < 0.0001). Logistic regression analysis revealed that only the S100 value at admission was an independent prognostic factor for poor outcomes after adjusting for age, sex, HHG, presence of IVH or ICH, and treatment modality (OR: 100.5, 95% CI: 1.65–6,053.61). The baseline S100 value of 0.168 predicted poor outcomes with a sensitivity of 75% and a specificity of 83%. The time course of the median S100 level peaked at 6 h and then decreased serially in both clipping and coiling groups. However, the degree of S100 elevation was marked in the clipping group, especially at 6 h postoperatively (0.177 vs. 0.116 µg/l, p = 0.022), suggesting more severe brain damage in the clipping group. In the coiling group, the S100 value was significantly higher in patients who showed high signal intensity lesions in diffusion-weighted images, suggesting ischemic brain damage. Furthermore, even in patients who were categorized as good clinical grade at admission and as good outcome at discharge, the median S100 values at 6 and 24 h postoperatively were significantly higher in the clipping group than in the coiling group (p < 0.05). Conclusion: The initial S100 protein value is an independent prognostic factor for poor outcomes in SAH patients. Based on the S100 protein level, aneurysm clipping seems to provoke more brain damage than aneurysm coiling. Endovascular coiling should be considered the first therapeutic option for aneurysmal SAH patients.