PURPOSE: To evaluate the clinical and radiological results of tibio-talo-calcaneal arthrodesis using ipsilateral distal fibula buttress which had advantages of extended operative field and release of contracted soft tissue. MATERIALS AND METHODS: We retrospectively reviewed 4 postraumatic compartment syndrome, 2 residual poliomyelitis, 1 posttraumatic osteoarthritis with subtalar joint infection and 1 posttarumatic sciatic nerve palsy patients who underwent a tibio-talo-calcaneal arthrodesis from April, 1996 to March, 2002. Each of the cases was notable for a severe rigid equinovarus, persistent pus drainage of calcaneal area and paralytic foot. The mean duration of follow up was 18 months (range, 13~42 months). The pain, function and alignment were evaluated by the modified ankle hindfoot scale of the American Orthopaedic Foot and Ankle Society (AOFAS) and patients satisfaction clinically. The radiological union were evaluated by plain AP and lateral radiographs. RESULTS: The AOFAS score improved from 58 points (range, 47~78) preoperatively to 82 (range, 60~89) postoperatively. Patents satisfaction checked at 12 months after operation had favorable results (excellent and good 80%). Union rate was 100% radiographically and the mean duration of union was 12.5 weeks (range 8~22 weeks). There was 2 cases of superficial pin tract infection and one protrusion of screw. CONCLUSION: Tibio-talo-calcaneal arthrodesis using ipsilateral distal fibula buttress was good modality of arthrodesis which provides wide operative field and release of contracted soft tissue in some cases of contracted foot.
Ankle ; Arthrodesis* ; Clubfoot ; Compartment Syndromes ; Drainage ; Fibula* ; Follow-Up Studies ; Foot ; Humans ; Osteoarthritis ; Poliomyelitis ; Retrospective Studies ; Sciatic Neuropathy ; Subtalar Joint ; Suppuration

OBJECTIVE: The three-dimensional computed tomographic angiography(3D-CTA) images are not commonly used than the conventional digital subtraction angiography(DSA) as a postoperative examination to identify a remnant neck or whether the parent and branching arteries and the cerebral aneurysm are clipped together. We suggest that the neurosurgeons themselves can reconstruct 3D images using 3D reconstruction program in their personal computers and evaluate the aneurysm neck clipping state more precisely than DSA. METHODS: Both 3D-CTA and DSA images were obtained postoperatively on 40 patients with 45 cerebral aneurysms. 38 aneurysms were clipped by single clip, 6 by double clips, and 1 by triple clips. We compared 3D-CTA images, which are made by easy and noninvasive method of the new software to ascertain postoperatively the perfection of aneurysm neck clipping performed with titanium clips, with DSA. RESULT: Out of the total 45 cerebral aneurysms clipped with titanium clips, 3D-CTA clearly showed the state of the clipped necks and the parent and branching arteries of 44 aneurysms in 39 cases. There were three cases in which the remnant necks were found in 3D-CTA, but two of them were not identified in DSA. There was one patient who had cerebral aneurysms requiring 3 clips, resulting in a poor view of the remnant necks since the clips covered the necks. CONCLUSION: In case using one or two titanium clips for the aneurysmal clipping, 3D-CTA may be a reliable alternative method to DSA in the postoperative evaluation to define the cerebral aneurysm neck and the surrounding vessels after clipping.
Aneurysm* ; Angiography, Digital Subtraction ; Arteries ; Humans ; Intracranial Aneurysm ; Microcomputers ; Neck ; Parents ; Titanium* ; Tomography, Spiral Computed*

We report a case of malignant peripheral nerve sheath tumor in the cauda equina, which was associated with neurofibromatosis type I. The tissue specimen acquired from the mass of cauda equina was transformed from benign to malignant form within 3 months. We report this case with review of the literatures.
Cauda Equina* ; Neurofibromatoses* ; Neurofibromatosis 1 ; Peripheral Nerves*

Intracranial aneurysms are the most common source of nontraumatic subarachnoid hemorrhage (SAH) in elderly patients. Despite the fact that more patients who present with SAH are middle-aged, the age-specific incidence for SAH increases with increasing age. The elderly patients with aneurysmal SAH have a trend toward poor outcome. Furthermore there are age-associated factors that increase perioperative and postoperative risks. In this paper, authors will review and discuss the reason why older patients have a poorer outcome and management for aneurysmal SAH in geriatric patients.
Aged ; Aneurysm* ; Humans ; Incidence ; Intracranial Aneurysm ; Subarachnoid Hemorrhage*

We present two cases of deep cerebral venous thrombosis(DCVT) with the totally occluded straight sinus. A 42-year-old female received with altered mentality . She has taken antihistamine for six years to treat the paranasal sinusitis. Another 34-year-old female who used the oral contraceptive for 11 months presented with acute behavior change . Both of these patients were diagnosed by computed tomography(CT), magnetic resonance(MR) imaging, and cerebral angiography. They were fully recovered with systemic urokinase thrombolysis followed by heparin therapy. We report that the intravenous thrombolysis was potentially effective management strategy in our cases of DCVT with the totally occluded straight sinus.
Adult ; Cerebral Angiography ; Female ; Heparin* ; Humans ; Sinusitis ; Urokinase-Type Plasminogen Activator* ; Venous Thrombosis*

The authors reviewed the recent trend of surgical treatment for pediatric as well as adult onset moyamoya disease(MMD). Combined direct and indirect arterial anastomosis or multiple indirect arterial bypasss has been increasing for pediatric MMD and direct arterial bypass is recommended for adult MMD, especially in patients with hemorrhagic MMD. Besides perioperative complications related to the management of MMD and 1999 annual report by the Research Committee on Spontaneous Occlusion of the Circle of Willis(Moyamoya Disease) of the Ministry of Health and Welfare, Japan will be summarizd.
Adult ; Humans ; Japan ; Moyamoya Disease*

INTRODUCTION: The purpose of this study was to analyze the safety, pullout strength and radiographic characteristics of unicortical and bicortical screws of cervical facet within cadaveric specimens and evaluate the influence of level of training on the positioning of these screws. METHODS: Twenty-one cadavers, mean 78.9 years of age, underwent bilateral placement of 3.5mm AO lateral mass screw from C3-C6(n=168) using a slight variation of the Magerl technique. Intraoperative imaging was not used. The right side(unicortical) utilized only 14mm screws(effective length of 11mm) while on the left side to determine the length of the screw after the ventral cortex had been drilled. Three spine surgeons(attending, fellow, chief resident) with varying levels of spine training performed the procedure on seven cadavers each. All spines were harvested and lateral radiographs were taken. Individual cervical vertebrae were carefully dissected and then axial radiographs were taken. The screws were evaluated clinically and radiographically for their safety. Screws were graded clinically for their safety with respect to the spinal cord, facet joint, nerve root and vertebral artery. The grades consisted of the following categories: "satisfactory", "at risk" and "direct injury". Each screw was also graded according to its zone placement. Screw position was quantified by measuring a sagittal angle from the lateral radiograph and an axial angle from the axial radiograph. Pull-out force was determined for all screws using a material testing machine. RESULTS: Dissection revealed that fifteen screws on the left side actually had only unicortical and not bicortical purchase as intended. The majority of screws(92.8%) were satisfactory in terms of safety. There were no injuries to the spinal cord. On the right side(unicortical), 98.9% of the screws were "satisfactory" and on the left side(bicortical) 68.1% were "satisfactory". There was a 5.8% incidence of direct arterial injury and a 17.4% incidence of direct nerve root injury with the bicortical screws. There were no "direct injuries" with the unicortical screws for the nerve root or vertebral artery. The unicortical screws had a 21.4% incidence of direct injury of the facet joint, while the bicortical screws had a 21.7% incidence. The majority of "direct injury" of bicortical screws were placed by the surgeon with the least experience. The performance of the resident surgeon was significantly different from the attending or fellow(p<0.05) in terms of safety of the nerve root and vertebral artery. The attending's performance was significantly better than the resident or fellow(p<0.05) in terms of safety of the facet joint. There was no relationship between the safety of a screw and its zone placement. The axial deviation angle measured 23.5+/-6.6 degrees and 19.8+/-7.9 degrees for the unicortical and bicortical screws, respectively. The resident surgeon had a significantly lower angle than the attending or fellow(p<0.05). The sagittal angle measured 66.3+/-7.0 degrees and 62.3+/-7.9 degrees for the unicortical and bicortical screws, respectively. The attending had a significantly lower sagittal angle than the fellow or resident(p<0.05). Thirty-three screws that entered the facet joint were tested for pull-out strength but excluded from the data because they were not lateral mass screws per-se and had deviated substantially from the intended final trajectory. The mean pull-out force for all screws was 542.9+/-296.6N. There was no statistically significant difference between the pull-out force for unicortical(519.9+/-286.9N) and bicortical(565.2+/-306N) screws. There was no significant difference in pull-out strengths with respect to zone placement. CONCLUSION: It is our belief that the risk associated with bicortical purchase mandates formal spine training if it is to be done safely and accurately. Unicortical screws are safer regardless of level of training. It is apparent that 14mm lateral mass screws placed in a supero-lateral trajectory in the adult cervical spine provide an equivalent strength with a much lower risk of injury than the longer bicortical screws placed in a similar orientation.
Adult ; Cadaver ; Cervical Vertebrae ; Female ; Humans ; Incidence ; Spinal Cord ; Spine* ; Vertebral Artery ; Zygapophyseal Joint

OBJECTIVES: Polymethylmethacrylate(PMMA) is often used to reconstruct the spine after total corpectomy, but the exothermic curing of liquid PMMA poses a risk of thermal injury to the spinal cord. The purposes of this study are to analyze the heat blocking effect of pre-polymerized PMMA sheet in the corpectomy model and to establish the minimal thickness of PMMA sheet to protect the spinal cord from the thermal injury during PMMA cementation of vertebral body. MATERIALS AND METHODS: An experimental fixture was fabricated with dimensions similar to those of a T12 corpectomy defect. Sixty milliliters of liquid PMMA were poured into the fixture, and temperature recordings were obtained at the center of the curing PMMA mass and on the undersurface(representing the spinal cord surface) of a pre-polymerized PMMA sheet of variable thickness(group 1:0mm, group 2:5mm, or group 3:8mm). Six replicates were tested for each barrier thickness group. RESULTS: Consistent temperatures(106.8+/-3.9degreesC) at center of the curing PMMA mass in eighteen experiments confirmed the reproducibility of the experimental fixture. Peak temperatures on the spinal cord surface were 47.3degreesC in group 2, and 43.3degreesC in group 3, compared with 60.0degreesC in group 1(p<0.00005). So pre-polymerized PMMA provided statistically significant protection from heat transfer. The difference of peak temperature between theoretical and experimental value was less than 1%, while the predicted time was within 35% of experimental values. The data from the theoretical model indicate that a 10mm barrier of PMMA should protect the spinal cord from temperatures greater than 39degreesC(the threshold for thermal injury in the spinal cord). CONCLUSION: These results suggest that pre-polymerized PMMA sheet of 10mm thickness may protect the spinal cord from the thermal injury during PMMA reconstruction of vertebral body.
Cementation ; Hot Temperature ; Models, Theoretical ; Polymethyl Methacrylate* ; Spinal Cord* ; Spine

OBJECTIVES: An in vitro biomechanical study of posterior lumbar interbody fusion(PLIF) with threaded cage using two different approaches was performed on eighteen functional spinal units of bovine lumbar spines. The purpose of this study was to compare the segmental stiffnesses among PLIF with one long posterolateral cage, PLIF with one long posterolateral cage and simultaneous facet joint fixation, and PLIF with two posterior cages. METHODS: Eighteen bovine lumbar functional spinal units were divided into three groups. All specimens were tested intact and with cage insertion. Group 1(n=12) had a long threaded cage(15x36mm) inserted posterolaterally and oriented counter anterolaterally on the left side by posterior approach with left unilateral facetectomy. Group 2(n=6) had two regular length cages(15x24mm) inserted posteriorly with bilateral facetectomy. Six specimens from group 1 were then retested after unilateral facet joint screw fixation in neutral(group 3). Likewise, the other six specimens from group 1 were retested after fixation with a facet joint screw in an extended position(group 4). Nondestructive tests were performed in pure compression, flexion, extension, lateral bending, and torsion. RESULTS: PLIF with a single cage, group 1, had a significantly higher stiffnesses than PLIF with two cages, group 2, in left and right torsion(p<0.05). Group 1 showed higher stiffness values than group 2 in pure compression, flexion, left and right bending but were not significantly different. Group 3 showed a significant increase in stiffness in comparison to group 1 for pure compression, extension, left bending and right torsion(p<0.05). For group 4, the stiffness significantly increased in comparison to group 1 for extension, flexion and right torsion(p<0.05). Although there was no significant difference between groups 3 and 4, group 4 had increased stiffness in extension, flexion, right bending and torsion. CONCLUSION: Posterior lumbar interbody fusion with a single long threaded cage inserted posterolaterally with unilateral facetectomy enables sufficient decompression while maintaining a majority of the posterior elements. In combination with a facet joint screw fixation, adequate postoperative stability can be achieved. We suggest that posterolateral insertion of a long threaded cage is biomechanically an ideal alternative to PLIF.
Decompression ; Spine ; Zygapophyseal Joint

A variety of procedures have developed for the surgical augmentation of collateral circulation to the brain in some cerebral or cerebellar lesions such as hemodynamic ischemic stroke, giant aneurysm of circle of willis or skull base tumor. Carotid endarterectomy and extracranial-intracranial arterial bypass (EIAB) are included in surgical revascularization (SR), and thrombolysis and transluminal percutaneous angioplasty and/or stenting (PTAS) are included in endovascular revascularization (ER). This article focuses the revascularization procedure related complications in patients treated with surgical or endovascular revascularization.
Aneurysm ; Angioplasty ; Brain ; Cerebral Revascularization* ; Circle of Willis ; Collateral Circulation ; Endarterectomy, Carotid ; Hemodynamics ; Humans ; Skull Base ; Stents ; Stroke