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The cervical spine plays a critical role in supporting the skull, maintaining horizontal gaze, and facilitating walking. Its unique characteristics, including the widest range of motion among spinal segments, have led to extensive research on cervical sagittal alignment. Various parameters have been proposed to evaluate cervical alignment, with studies investigating their clinical significance, correlation with symptoms, and implications for surgical interventions. Recent findings suggest that cervical sagittal alignment not only impacts the cervical spine but also influences global spine-pelvic alignment through compensatory mechanisms. This comprehensive review examines classical and new parameters of cervical sagittal alignment and considers the dynamic and muscular factors associated with it.

Objective: Patients with mild ischemic stroke experience various sequela and residual symptoms, such as anxious behavior and deficits in movement. Few approaches have been proved to be effective and safe therapeutic approaches for patients with mild ischemic stroke by acute stroke. Sildenafil (SIL), a phosphodiesterase-5 inhibitor (PDE5i), is a known remedy for neurodegenerative disorders and vascular dementia through its angiogenesis and neurogenesis effects. In this study, we investigated the efficacy of PDE5i in the emotional and behavioral abnormalities in rats with mild ischemic stroke., Methods: We divided the rats into four groups as follows (n=20, respectively) : group 1, naïve; group 2, middle cerebral artery occlusion (MCAo30); group 3, MCAo30+SIL-pre; and group 4, MCAo30+SIL-post. In the case of drug administration groups, single dose of PDE5i (sildenafil citrate, 20 mg/kg) was given at 30-minute before and after reperfusion of MCAo in rats. After surgery, we investigated and confirmed the therapeutic effect of sildenafil on histology, immunofluorescence, behavioral assays and neural oscillations., Results: Sildenafil alleviated a neuronal loss and reduced the infarction volume. And results of behavior task and immunofluorescence shown possibility that anti-inflammation process and improve motor deficits sildenafil treatment after mild ischemic stroke. Furthermore, sildenafil treatment attenuated the alteration of theta-frequency rhythm in the CA1 region of the hippocampus, a known neural oscillatory marker for anxiety disorder in rodents, induced by mild ischemic stroke., Conclusion: PDE5i as effective therapeutic agents for anxiety and movement disorders and provide robust preclinical evidence to support the development and use of PDE5i for the treatment of mild ischemic stroke residual disorders.

Objective: Through our previous clinical trials, the demonstrated therapeutic effects of MSC in chronic spinal cord injury (SCI) were found to be not sufficient. Therefore, the need to develop stem cell agent with enhanced efficacy is increased. We transplanted enhanced Wnt3asecreting human mesenchymal stem cells (hMSC) into injured spines at 6 weeks after SCI to improve axonal regeneration in a rat model of chronic SCI. We hypothesized that enhanced Wnt3a protein expression could augment neuro-regeneration after SCI., Methods: Thirty-six Sprague-Dawley rats were injured using an Infinite Horizon (IH) impactor at the T9-10 vertebrae and separated into five groups : 1) phosphate-buffered saline injection (injury only group, n=7); 2) hMSC transplantation (MSC, n=7); 3) hMSC transfected with pLenti vector (without Wnt3a gene) transplantation (pLenti-MSC, n=7); 4) hMSC transfected with Wnt3a gene transplantation (Wnt3a-MSC, n=7); and 5) hMSC transfected with enhanced Wnt3a gene (1.7 fold Wnt3a mRNA expression) transplantation (1.7 Wnt3a-MSC, n=8). Six weeks after SCI, each 5×105 cells/15 µL at 2 points were injected using stereotactic and microsyringe pump. To evaluate functional recovery from SCI, rats underwent Basso-Beattie-Bresnahan (BBB) locomotor test on the first, second, and third days post-injury and then weekly for 14 weeks. Axonal regeneration was assessed using growth-associated protein 43 (GAP43), microtubule-associated protein 2 (MAP2), and neurofilament (NF) immunostaining., Results: Fourteen weeks after injury (8 weeks after transplantation), BBB score of the 1.7 Wnt3a-MSC group (15.0±0.28) was significantly higher than that of the injury only (10.0±0.48), MSC (12.57±0.48), pLenti-MSC (12.42±0.48), and Wnt3a-MSC (13.71±0.61) groups (p<0.05). Immunostaining revealed increased expression of axonal regeneration markers GAP43, MAP2, and NF in the Wnt3a-MSC and 1.7 Wnt3a-MSC groups., Conclusion: Our results showed that enhanced gene expression of Wnt3a in hMSC can potentiate axonal regeneration and improve functional recovery in a rat model of chronic SCI.

Objective: The purpose of this study was to evaluate the efficacy of the anterior approach following intraoperative reduction under general anesthesia in patients with cervical facet fracture and dislocation., Methods: Twenty-three patients with single level cervical facet fracture and dislocation who were subjected to the anterior approach alone following immediate intraoperative reduction under general anesthesia from March 2013 to December 2017 were enrolled in this study. Neurological status, clinical outcome, and radiological studies were evaluated preoperatively, postoperatively, and during the follow-up period., Results: The cohort comprised 15 men and eight women with a mean age of 57 years (from 24 to 81). All patients were operated on within the first 8 hours following the injury. After gentle manual reduction or closed reduction with Gardner-Wells traction, under general anesthesia monitored by somatosensory-evoked potentials, all operations were successfully completed using the anterior approach alone except in two patients, who had a risk of over-distraction. In them, a satisfactory gentle manual reduction or closed reduction was not possible, and required open posterior reduction of the locked facets followed by anterior cervical discectomy and fusion. In one patient, screw retropulsion was observed in 1 month after surgery. There were no reduction-related complications or neurological aggravations after surgery. All patients showed evidence of stability at the instrumented level at the final follow-up (mean follow-up, 12 months)., Conclusion: Anterior approach following intraoperative reduction monitored by somatosensory-evoked potentials under general anesthesia for cervical dislocation and locked facets is a relatively safe and effective alternative when cervical alignment is achieved by intraoperative reduction.

Objective: The purpose of this study was to determine the feasibility of screw fixation in previously augmented vertebrae with bone cement. We also investigated the influence of cement distribution pattern on the surgical technique., Methods: Fourteen patients who required screw fixation at the level of the previous percutaneous vertebroplasty or balloon kyphoplasty were enrolled in this study. The indications for screw fixation in the previously augmented vertebrae with bone cement included delayed complications, such as cement dislodgement, cement leakage with neurologic deficits, and various degenerative spinal diseases, such as spondylolisthesis or foraminal stenosis. Clinical outcomes, including pain scale scores, cement distribution pattern, and procedure-related complications were assessed., Results: Three patients underwent posterior screw fixation in previously cemented vertebrae due to cement dislodgement or progressive kyphosis. Three patients required posterior screw fixation for cement leakage or displacement of fracture fragments with neurologic deficits. Eight patients underwent posterior screw fixation due to various degenerative spinal diseases. It was possible to insert screws in the previously augmented vertebrae regardless of the cement distribution pattern; however, screw insertion was more difficult and changed directions in the patients with cemented vertebrae exhibiting a solid pattern rather than a trabecular pattern. All patients showed significant improvements in pain compared with the preoperative levels, and no patient experienced neurologic deterioration as seen at the final follow-up., Conclusion: For patients with vertebrae previously augmented with bone cement, posterior screw fixation is not a contraindication, but is a feasible option.

Objective: This study aimed to unravel the putative mechanism underlying the neurologic deficits contralateral to the side with lumbar disc herniation (LDH) and to elucidate the treatment for this condition., Methods: From January 2009 to June 2015, 8 patients with LDH with predominantly contralateral neurologic deficits underwent surgical treatment on the side with LDH with or without decompressing the symptomatic side. A retrospective review of charts and radiological records of these 8 patients was performed. The putative mechanisms underlying the associated contralateral neurological deficits, magnetic resonance imaging (MRI), electromyography (EMG), and the adequate surgical approach are discussed here., Results: MRI revealed a similar laterally skewed paramedian disc herniation, with the apex deviated from the symptomatic side rather than directly compressing the nerve root; this condition may generate a contralateral traction force. EMG revealed radiculopathies in both sides of 6 patients and in the herniated side of 2 patients. Based on EMG findings and the existence of suspicious lateral recess stenosis of the symptomatic side, 6 patients underwent bilateral decompression of nerve roots and 2 were subjected to a microscopic discectomy to treat the asymptomatic disc herniation. No specific conditions such as venous congestion, nerve root anomaly or epidural lipomatosis were observed, which may be considered the putative pathomechanism causing the contralateral neurological deficits. The symptoms resolved significantly after surgery., Conclusion: The traction force generated on the contralateral side and lateral recess stenosis, rather than direct compression, may cause the contralateral neurologic deficits observed in LDH.

Objective: We evaluated the validity of bone cement-augmented percutaneous screw fixation for treating malignant spinal metastases., Methods: Between 2011 and 2015, 14 patients (eight men and six women) who underwent bone cement-augmented percutaneous screw fixation for malignant spinal metastases were enrolled in this study. Their life expectancy was considered to be more than one month and less than one year, based on the revised Tokuhashi scoring system. Clinical findings including the back pain scale score, functional outcome, procedure related complications, and survival were assessed preoperatively, postoperatively, and then six months after the procedure., Results: Twelve of the patients (86%) survived up to six months after the procedure. Three required mini-open decompressive laminectomy for severe epidural compression. Bone cement-augmented percutaneous screw fixation was performed one level above, one level below, and at the pathologic level itself. The mean operation time was 60 minutes (45-180) and blood loss was less than 100 mL. Prior to surgery, the mean pain score on the visual analogue scale was 8.8, while one month after the procedure, it had reduced to 3.0; this improvement was maintained until the six-month assessment in the surviving patients. All patients were able to sit within the first two days after surgery, and no patient experienced neurological deterioration at the one-month follow up after the surgery. No patient experienced screw loosening during the six months of follow-up. Asymptomatic cement leakage into the epidural space was observed in two patients, but no major complications were observed., Conclusion: For selected patients with malignant spinal metastases, bone cement-augmented percutaneous screw fixation can provide significant pain relief and improve quality of life.

Objective: The inter-rater reliability of the modified Knosp's classification was measured before the analysis. The clinical validity of the parasellar extension grading system was evaluated by investigating the extents of resection and complication rates among the grades in the endoscopic endonasal transsphenoidal surgery (EETS) for pituitary adenomas., Methods: From November 2008 to August 2015, of the 286 patients who underwent EETS by the senior author, 208 were pituitary adenoma cases (146 non-functioning pituitary adenomas, 10 adrenocorticotropic hormone-secreting adenomas, 31 growth hormone-secreting adenomas, 17 prolactin-secreting adenomas, and 4 thyroid-stimulating hormone-secreting adenomas; 23 microadenomas, 174 macroadenomas, and 11 giant adenomas). Two neurosurgeons and a neuroradiologist independently measured the degree of parasellar extension on the preoperative sellar MRI according to the modified Knosp's classification. Inter-rater reliability was statistically assessed by measuring the intraclass correlation coefficient. The extents of resection were evaluated by comparison of the pre- and post-operative MR images; the neurovascular complications were assessed by reviewing the patients' medical records. The extent of resection was measured in each parasellar extension grade; thereafter, their statistical differences were calculated., Results: The intraclass correlation coefficient value of reliability across the three raters amounted to 0.862. The gross total removal (GTR) rates achieved in each grade were 70.0, 69.8, 62.9, 21.4, 37.5, and 4.3% in Grades 0, 1, 2, 3A, 3B, and 4, respectively. A significant difference in the extent of resection was observed only between Grades 2 and 3A. In addition, significantly higher complication rates were observed in the groups above Grade 3A., Conclusion: Although the modified Knosp's classification system appears to be complex, its inter-rater reliability proves to be excellent. Regarding the clinical validity of the parasellar extension grading system, Grades 3A, 3B, and 4 have a negative predictive value for the GTR rate, with higher complication rates.

Juxtafacet cysts are implicated in neural compression. Thus far, it is known that surgical removal is the definitive treatment for symptomatic juxtafacet cyst because spontaneous regression is rare, and the failure rate of conservative treatment is high. We have reported a rare case of right-sided juxtafacet cyst development after the spontaneous resolution of contralateral left-sided facet cyst. The left-sided facet cyst resolved spontaneously without surgical treatment, but a juxtacyst developed on the contralateral facet on the right side, as illustrated on 4-year follow-up magnetic resonance images. To the best of our knowledge, this is the first report of newly developed contralateral juxtafacet cyst after spontaneous regression. Herein, we have discussed the natural history and the management of this rare case.

It is well known that spinal instability should be evaluated in the standing lateral position. Standing dynamic flexion and extension radiographs are usually used to assess spinal instability. Here, we report a patient who experienced distraction instability while in the supine position rather than the standard standing position. To our knowledge, this is the first report of lying-down instability undetected on standing dynamic flexion and extension radiographs. We discuss the pathophysiological mechanism of this uncommon but possible entity and provide a review of the literature.

A Schmorl's node is defined as a simple endplate intravertebral herniation resulting from trauma or idiopathic causes. Although Schmorl's nodes have been considered clinically insignificant, they might indicate an active symptomatic process or cause serious complications. In this study, we report an interesting case of complete separation of a vertebral body caused by an untreated Schmorl's node accompanying severe osteoporosis. To our knowledge, this is the first clinical report in the published literature to evaluate the complete separation of a vertebral body associated with a Schmorl's node.

Objective: The aim of this prospective study was to evaluate the efficacy of bone cement-augmented percutaneous short segment fixation for treating Kummell's disease accompanied by severe osteoporosis., Methods: From 2009 to 2013, ten patients with single-level Kummell's disease accompanied by severe osteoporosis were enrolled in this study. After postural reduction for 1-2 days, bone cement-augmented percutaneous short segment fixation was performed at one level above, one level below, and at the collapsed vertebra. Clinical results, radiological parameters, and related complications were assessed preoperatively and at 1 month and 12 months after surgery., Results: Prior to surgery, the mean pain score on the visual analogue scale was 8.5±1.5. One month after the procedure, this score improved to 2.2±2.0 and the improvement was maintained at 12 months after surgery. The mean preoperative vertebral height loss was 48.2±10.5%, and the surgical procedure reduced this loss to 22.5±12.4%. In spite of some recurrent height loss, significant improvement was achieved at 12 months after surgery compared to preoperative values. The kyphotic angle improved significantly from 22.4±4.9° before the procedure to 10.1±3.8° after surgery and the improved angle was maintained at 12 months after surgery despite a slight correction loss. No patient sustained adjacent fractures after bone cement-augmented percutaneous short segment fixation during the follow-up period. Asymptomatic cement leakage into the paravertebral area was observed in one patient, but no major complications were seen., Conclusion: Bone cement-augmented percutaneous short segment fixation can be an effective and safe procedure for Kummell's disease.

Objective: Complete sellar floor reconstruction is critical to avoid postoperative cerebrospinal fluid (CSF) leakage during transsphenoidal surgery. Recently, the pedicled nasoseptal flap has undergone many modifications and eventually proved to be valuable and efficient. However, using these nasoseptal flaps in all patients who undergo transsphenoidal surgery, including those who had none or only minor CSF leakage, appears to be overly invasive and time-consuming., Methods: Patients undergoing endoscopic endonasal transsphenoidal tumor surgery within a 5 year-period were reviewed. Since 2009, we classified the intraoperative CSF leakage into grades from 0 to 3. Sellar floor reconstruction was tailored to each leak grade. We did not use any tissue grafts such as abdominal fat and did not include any procedures of CSF diversions such as lumbar drainage., Results: Among 200 cases in 188 patients (147 pituitary adenoma and 41 other pathologies), intraoperative CSF leakage was observed in 27.4% of 197 cases : 14.7% Grade 1, 4.6% Grade 2a, 3.0% Grade 2b, and 5.1% Grade 3. Postoperative CSF leakage was observed in none of the cases. Septal bone buttress was used for Grade 1 to 3 leakages instead of any other foreign materials. Pedicled nasoseptal flap was used for Grades 2b and 3 leakages. Unused septal bones and nasoseptal flaps were repositioned., Conclusion: Modified classification of intraoperative CSF leaks and tailored repair technique in a multilayered fashion using an en-bloc harvested septal bone and vascularized nasoseptal flaps is an effective and reliable method for the prevention of postoperative CSF leaks.

Unilateral pedicle stress fracture accompanying spondylolytic spondylolisthesis is rare even in the elderly. Most are associated with major trauma, previous spine surgery, or stress-related activity. Here, the authors describe an unique case of unilateral pedicle fracture associated with spondylolytic spondylolisthesis at the L5 level, which was successfully treated by posterior lumbar interbody fusion with screw fixation at the L5-S1 level. As far as the authors' knowledge, no such case has been previously reported in the literature. The pathophysiological mechanism of this uncommon entity is discussed and a review of relevant literature is included.

Spontaneous spinal subdural hematoma is reported at a rare level of incidence, and is frequently associated with underlying coagulopathy or those receiving anticoagulant or antiplatelet agents; some cases accompany concomitant intracranial hemorrhage. The spontaneous development of spinal subdural hemorrhage (SDH) is a neurological emergency; therefore, early diagnosis, the discontinuation of anticoagulant, and urgent surgical decompression are required to enable neurological recovery. In this report, we present a simultaneous spinal subdural hematoma and cranial subarachnoid hemorrhage, which mimicked an aneurysmal origin in a female patient who had been taking warfarin due to aortic valve replacement surgery.

Objective: Posterior vertebral translation as a type of spondylolisthesis, retrolisthesis is observed commonly in patients with degenerative spinal problems. Nevertheless, there is insufficient literature on retrolisthesis compared to anterolisthesis. The purpose of this study is to clarify the clinical features of retrolisthesis, and its developmental mechanism associated with a compensatory role in sagittal imbalance of the lumbar spine., Methods: From 2003 to 2012, 230 Korean patients who underwent spinal surgery in our department under the impression of degenerative lumbar spinal disease were enrolled. All participants were divided into four groups : 35 patients with retrolisthesis (group R), 32 patients with simultaneous retrolisthesis and anterolisthesis (group R+A), 76 patients with anterolisthesis (group A), and 87 patients with non-translation (group N). The clinical features and the sagittal parameters related to retrolisthesis were retrospectively analyzed based on the patients' medical records., Results: There were different clinical features and developmental mechanisms between retrolisthesis and anterolisthesis. The location of retrolisthesis was affected by the presence of simultaneous anterolisthesis, even though it predominantly manifest in L3. The relative lower pelvic incidence, pelvic tilt, and lumbar lordosis compared to anterolisthesis were related to the generation of retrolisthesis, with the opposite observations of patients with anterolisthesis., Conclusion: Retrolisthesis acts as a compensatory mechanism for moving the gravity axis posteriorly for sagittal imbalance in the lumbar spine under low pelvic incidence and insufficient intra-spinal compensation.

Traumatic diaphragm hernia can occur in rare cases and generally accompanies thoracic or abdominal injuries. When suffering from ankylosing spondylitis, a small force can develop into vertebral fracture and an adjacent structural injury, and lead to diaphragm hernia without accompanying concomitant thoracoabdominal injury. A high level of suspicion may be a most reliable diagnostic tool in the detection of a diaphragm injury, and we need to keep in mind a possibility in a patient with ankylosing spondylitis and a thoracolumbar fracture, even in the case of minor trauma.

Objective: The purpose of this study was to analyze the relationship between fracture pattern and the development of acute radiculopathy after osteoporotic lumbar compression fracture., Methods: This study included 59 patients who underwent bone cement augmentation for osteoporotic compression fracture below the L2 level, which can lead to radiculopathic radiating pain. The patients were divided into two groups according to the presence of radiculopathy (group A : back pain only; group B : back pain with newly developed radiating pain). We categorized compression fractures into three types by the position of the fracture line. The incidence of newly developed radiculopathy was examined retrospectively for each compression fracture type., Results: The overall incidence of newly developed leg pain (group B) was 25%, and the frequency increased with descending spinal levels (L2 : 0%, L3 : 22%, L4 : 43%, and L5 : 63%). The back pain-only group (group A) had mostly superior-type fractures. On the other hand, the back pain with radiculopathy group (group B) had mostly inferior-type fractures. Most patients in group B showed significant relief of leg pain as well as back pain after bone cement augmentation., Conclusion: The incidence of a newly developed, radiating pain after osteoporotic compression fractures increased gradually from the L3 to L5 levels. Most of these fractures were of the inferior type, and the bone cement augmentation procedures seemed to be sufficient for relief of both back and radiating pain.

Objective: The purpose of this study was to investigate the prenatal hypoxic effect on the fetal brain development., Methods: We used the guinea pig chronic placental insufficiency model to investigate the effect of hypoxia on fetal brain development. We ligated unilateral uterine artery at 30-32 days of gestation (dg : with term defined as -67 dg). At 50 dg, 60 dg, fetuses were sacrificed and assigned to either the growth-restricted (GR) or control (no ligation) group. After fixation, dissection, and sectioning of cerebral tissue from these animals, immunohistochemistry was performed with NeuN antibody, which is a mature neuronal marker in the cerebral cortex., Results: The number of NeuN-immunoreactive (IR) cells in the cerebral cortex did not differ between the GR and control groups at 50 dg. However, the number of NeuN-IR cells was lesser in GR fetuses than in controls at 60 dg (p<0.05)., Conclusion: These findings show that chronic prenatal hypoxia affect the number of neuron in the cerebral cortex of guinea pig fetus at 60 dg. The approach used in this study is helpful for extending our understanding of neurogenesis in the cerebral cortex, and the findings may be useful for elucidating the brain injury caused by prenatal hypoxia.

Penetrating cerebral injuries caused by foreign bodies occur rarely due to the substantial mechanical protection offered by the skull. Throughout most of history, the brain, residing in a "closed box" of bone, has not been vulnerable to external aggression. Recently, we encountered a serious penetrating craniocerebral injury caused by a nail gun. Total excision of the offending nail via emergency craniotomy was performed, but the patient's neurologic status was not improved in spite of aggressive rehabilitative treatment. Here, we report on this troublesome case in light of a review of the relevant literature.

Synovial cysts are recognized as an uncommon cause of radicular and myelopathic symptoms. They are most frequently found in the lumbar region. The cervical spine or cervicothoracic junction is a rare location for a degenerative intraspinal synovial cyst as compared with the lumbar spine. At given cervical spinal levels, synovial cysts probably share clinical features with disc herniation and stenosis. However, the pathogenesis of synovial cysts remains still controversial. Here, we report a rare case of a synovial cyst in the lower cervical spine presented as Brown-Séquard syndrome and include a brief review of the literature. To the best of our knowledge, no previous report has been issued in the English literature on a synovial cyst presenting with Brown-Séquard syndrome. Neurologic function recovered completely after complete removal of the cyst and expansive laminoplasty.

Giant cell tumor (GCT) of the spine is a rare benign tumor, but can be aggressive and can exhibit a high local recurrence rate. Furthermore, GCT of the upper thoracic spine may pose diagnostic and management difficulties. Here, we report a rare case of GCT of the upper thoracic spine with soft tissue extension to the spinal canal. The patient was managed by decompressive laminectomy and posterolateral fusion followed by an injection of polymethylmethacrylate into the vertebral lesion. The patient recovered clinically and showed radiological improvement after surgical treatment without tumor recurrence at his last follow-up of postoperative 7 years. We present this unusual case of GCT and include a review of the literature.

Objective: The purpose of this study was to evaluate the efficacy of implant removal of percutaneous short segment fixation after vertebral fracture consolidation in terms of motion preservation., Methods: Between May 2007 and January 2011, 44 patients underwent percutaneous short segment screw fixation due to a thoracolumbar burst fracture. Sixteen of these patients, who underwent implant removal 12 months after screw fixation, were enrolled in this study. Motor power was intact in all patients, despite significant vertebral height loss and canal compromise. The patients were divided into two groups by degree of osteoporosis : Group A (n=8), the non-osteoporotic group, and Group B (n=8), the osteoporotic group. Imaging and clinical findings including vertebral height loss, kyphotic angle, range of motion (ROM), and complications were analyzed., Results: Significant pain relief was achieved in both groups at final follow-up versus preoperative values. In terms of vertebral height loss, both groups showed significant improvement at 12 months after screw fixation and restored vertebral height was maintained to final follow-up in spite of some correction loss. ROM (measured using Cobb's method) in flexion and extension in Group A was 10.5° (19.5/9.0°) at last follow-up, and in Group B was 10.2° (18.8/8.6°) at last follow-up. Both groups showed marked improvement in ROM as compared with the screw fixation state, which was considered motionless., Conclusion: Removal of percutaneous implants after vertebral fracture consolidation can be an effective treatment to preserve motion regardless of osteoporosis for thoracolumbar burst fractures.

Objective: The aim of this study is to assess outcomes during first one year for patients with severe motor weakness caused by lumbar disc herniation that underwent surgical or nonsurgical treatment., Methods: The 46 patients with motor weakness because of lumbar disc herniation who were treated at neurosurgical department and rehabilitation in our hospital from 2006 to 2010, retrospectively. Each group had 26 surgical treatments and 20 conservative treatments. We followed up 1, 3, 6 months and 12 month and monitored a Visual Analogue rating Scale (VAS) of back and leg pain, Oswestry Disability Index (ODI) and degree of motor weakness. We analyzed the differences between surgical and nonsurgical groups using Mann-Whitney U test and repeat measure ANOVA in each follow-up periods., Results: In the recovery of motor weakness, surgical treatment uncovered a rapid functional recovery in the early periods (p=0.003) and no difference between groups at the end of follow-up period was found (p>0.05). In VAS of back and leg, the interaction between time and group was not found (p>0.05) and there was no difference between groups (p>0.05). In ODI, the interaction between time and group was not found (p>0.05) and there was no difference between groups (p>0.05)., Conclusion: Surgical treatment for motor weakness caused by herniated intervertebral disc resulted in a rapid recovery in the short-term period, especially 1 month. We think early and proper surgical treatment in a case of motor weakness from disc herniation could be a good way for providing a chance for rapid alleviation.

Intracranial calcifications are relatively common computed tomographic findings in the field of neurosurgery, and cysticercosis, tuberculosis, HIV, and cryptococcus are acquired intracranial infections typically associated with calcifications. However, intracranial calcification caused by a bacterial brain abscess is rare. Here, we present a rare case of intracranial calcification caused by a bacterial brain abscess, from which staphylococcus hominis was isolated. To the best of our knowledge, no previous report has been published on intracranial calcification caused by bacterial brain abscess after decompressive craniectomy for traumatic brain injury. In this article, the pathophysiological mechanism of this uncommon entity is discussed and relevant literature reviewed.

Pneumorrhachis, which involves the entrapment of air or gas within the spinal canal, is a rare clinical entity, and the pathogenesis and etiologies of this uncommon entity are various and can present a diagnostic challenge. Usually, pneumorrhachis represents an asymptomatic epiphenomenon but it can produce symptoms associated with its underlying pathology. Here, we report a rare case of symptomatic epidural pneumorrhachis accompanying pneumothorax. Possible pathogenic mechanisms are discussed and a review of the literature is included.

Objective: To suggest a new useful diagnostic technique, principles of the selective excitation technique-magnetic resonance images (Proset-MRI), and to know the precise radiologic findings that can prove symptomatic foraminal and extraforaminal stenosis at L5-S1., Methods: Nineteen patients with symptomatic L5-S1 stenosis were checked by Proset-MRI. Four patients were performed decompressive surgery and 15 patients were performed selective nerve root block (SNRB) at L5. The pain scale of patients was checked by Visual Analogue Scale (VAS) scores at the pre- and post-treatment state., Results: Proset-MRI findings of patients with symptomatic stenosis are root swelling (RS) and indentation. The comparisons with VAS scores had a meaningful statistical result at each RS (p<0.01) and indentation (p<0.01). However, the findings of RS combined with indentation lacked statistical significance (p=0.0249). In addition, according to a comparison with the treatment modalities, reducing of VAS scores had statistical meaningful significance in decompressive surgery cases (p<0.01), and also in SNRB cases (p<0.01) after a 3-month follow-up period., Conclusion: The three dimensional Proset-MRI is very useful and sensitive technique to diagnose the symptomatic foraminal and extraforaminal stenosis at L5-S1.

Objective: After spinal cord injury (SCI), functional and structural reorganization occurs at multiple levels of brain including motor cortex. However, the underlying mechanism still remains unclear. The current study was performed to investigate the alterations in the expression of the main regulators of neuronal development, survival and death, in the brain following thoracic contusive SCI in a mouse model., Methods: Eight-week-old female imprinting control region mice (n=60; 30-35 g) were used in this study. We analyzed the expression levels of regulators such as brain-derived neurotrophic factor (BDNF), glial cell line-derived neurotrophic factor (GDNF), nerve growth factor (NGF) and histone deacetylase (HDAC) 1 in the brain following thoracic contusive SCI., Results: The expression of BDNF levels were elevated significantly compared with control group at 2 weeks after injury (p<0.05). The expression of NGF levels were elevated at 2, 4 weeks compared with control group, but these difference were not significant (p>0.05). The GDNF levels were elevated at 2 week compared with control group, but these differences were not significant (p>0.05). The difference of HDAC1 levels were not significant at 2, 4 and 8 weeks compared with control group (p>0.05)., Conclusion: These results demonstrate that the upregulation of BDNF may play on important role in brain reorganization after SCI.

Objective: We performed a retrospective analysis of medical records and radiographic images of patients who never underwent spinal treatment including diagnosis. The objective of this study is to explain the biomechanical and physiologic characteristics of cervical alignment related to thoracic inlet angle including T1 slope changes in each individual., Methods: We reviewed the cervical CT radiographs of 80 patients who visited ENT outpatient clinic without any symptom, diagnosis and treatment of cervical spine from January 2011 to September 2012. All targeted people were randomized without any prejudice. We assessed the data-T1 slope, Cobb's angle C2-7, neck tilt, sagittal vertical axis (SVA) C2-7 and thoracic inlet angle by the CT radiographs., Results: The relationships between each value were analyzed and we concluded that Cobb's angle C2-7 gets higher as the T1 slope gets higher, while the SVA C2-7 value decreases., Conclusion: We propose that the T1 slope is background information in deciding how much angle can be made in the cervical spinal angle of surgical lordotic curvature, especially severe cervical deformity.

Perforation of the hypopharynx, which can occur after anterior cervical approach, is a very rare type of complication. If diagnosed late, it can lead to very fatal course, such as mediastinitis and hematosepsis. Therefore, a precise and prompt diagnosis is crucial. When conservative treatment alone is not expected to heal the perforated site or is likely to lead to serious complications, surgical treatment becomes necessary. This report demonstrates that surgical intervention performed immediately after an early diagnosis can lead to the successful treatment of a large perforation in the hypopharynx on a 58-year-old male patient.

Rhabdomyolysis is a rare but potentially life-threatening disorder caused by the release of injured skeletal muscle components into the circulation. The authors report a case of severe head injury, in which a hyperosmolar state and continuous seizure complicated by severe rhabdomyolysis and acute renal failure evolved during the course of treatment resulted in a fatal outcome despite intensive supportive treatment. Our bitter experience suggests that rhabdomyolysis should be born in mind in patients with severe head injury who may develop hyperosmolar state and continuous seizure.

Pneumocephalus is a condition characterized by the presence of air in the cranium, and it is mainly caused by trauma or a neurosurgical procedure. In the absence of head trauma or a neurosurgical procedure, meningitis is an extremely rare cause of pneumocephalus. Here, the authors present a rare case of spontaneous pneumocephalus caused by pneumococcal meningitis, in which simple lateral radiography and computed tomography (CT) findings of the skull suggested the diagnosis. Cerebrospinal fluid analysis showed bacterial meningitis which later revealed streptococcus pneumonia. The patient was treated with antibiotics and responded remarkably well. Repeat CT performed after 2 weeks of treatment showed complete resolution of the intracranial gas. Here, the authors report an unusual case of a pneumocephalus caused by meningitis in the absence of head trauma or a neurosurgical procedure.

In most cases, subdural hematoma (SDH) is regarded as a complication of head injury and nontraumatic causes are rare. Moreover, spontaneous chronic SDH in child or adolescent is very unusual. Here, we present the case of a healthy 14-year-old girl who was diagnosed as a spontaneous chronic SDH. The patient presented with severe headache following blurring of vision two weeks ago without any history of trivial head injury. Computed tomography and magnetic resonance imaging depicted a chronic SDH. The cause of the hematoma was not established. After performing burr hole drainage of the hematoma, the patient made an uneventful recovery. We explore the potential risk factors and pathophysiology implicated in this condition. Possible pathogenic mechanisms of this unique case are discussed and a review of the pertinent literature is included.

Burr hole drainage has been widely used to treat chronic subdural hematomas (SDH), and most of them are easily treated by simple trephination and drainage. However, various complications, such as, hematoma recurrence, infection, seizure, cerebral edema, tension pneumocephalus and failure of the brain to expand due to cerebro-cranial disproportion may develop after chronic SDH drainage. Among them, intracerebral hemorrhage after evacuation of a recurrent chronic SDH is very rare. Here, we report a fatal case of delayed intracerebral hemorrhage caused by coagulopathy following evacuation of a chronic SDH. Possible pathogenic mechanisms of this unfavorable complication are discussed and a review of pertinent literature is included.

Chondrosarcoma is a very uncommon malignant primary bone tumor, especially, it occurs extremely rare in the spine. A 52-year-old man was admitted to the emergency room with sudden paraplegia. Twelve hours prior to a paraplegic event, he visited an outpatient clinic with discomfort and tenderness around the medial border of the right scapular, and his neurologic status was absolutely intact. Magnetic resonance imaging showed a lobulated soft tissue mass from T3 to T5, which extended to the epidural space. Computed tomography scans showed soft tissue mass on the spinal posterior arch and osteolytic change of the adjacent bony structures. Emergent surgery was performed and the lesion was removed. Dark reddish blood and gel-like material were encountered around the dura and posterior arch during the operation. Multiple pulmonary nodules were found on a chest CT scan and a biopsy of one of them had been proven to be a metastasis of chondrosarcoma. The histologic examination showed dedifferentiated chondrosarcoma. The patient's neurologic deficit was improved slowly from ASIA A to ASIA D. Chondrosarcoma in the spine is extremely rare, even more with acute hemorrhage and sudden expansion into the epidural space. We named it chondrosarcoma apoplexy. We should consider the possibility of a hemorrhagic event when the patient's neurologic deficit worsens suddenly with spinal bone tumor.

Objective: The purpose of this study was to compare the results of three types of short segment screw fixation for thoracolumbar burst fracture accompanying osteopenia., Methods: The records of 70 patients who underwent short segment screw fixation for a thoracolumbar burst fracture accompanying osteopenia (-2.5< mean T score by bone mineral densitometry <-1.0) from January 2005 to January 2008 were reviewed. Patients were divided into three groups based on whether or not bone fusion and bone cement augmentation procedure 1) Group I (n=26) : short segment fixation with posterolateral bone fusion; 2) Group II (n=23) : bone cement augmented short segment fixation with posterolateral bone fusion; 3) Group III (n=21) : bone cement augmented, short segment percutaneous screw fixation without bone fusion. Clinical outcomes were assessed using a visual analogue scale and modified MacNab's criteria. Radiological findings, including kyphotic angle and vertebral height, and procedure-related complications, such as screw loosening or pull-out, were analyzed., Results: No significant difference in radiographic or clinical outcomes was noted between patients managed using the three different techniques at last follow up. However, Group I showed more correction loss of kyphotic deformities and vertebral height loss at final follow-up, and Group I had higher screw loosening and implant failure rates than Group II or III., Conclusion: Bone cement augmented procedure can be an efficient and safe surgical techniques in terms of achieving better outcomes with minimal complications for thoracolumbar burst fracture accompanying osteopenia.

Objective: Meningiomas represent 18-20% of all intracranial tumors and have a 20-50% 10-year recurrence rate, despite aggressive surgery and irradiation. Hydroxyurea, an inhibitor of ribonucleotide reductase, is known to inhibit meningioma cells by induction of apoptosis. We report the long-term follow-up result of hydroxyurea therapy in the patients with recurrent meningiomas., Methods: Thirteen patients with recurrent WHO grade I or II meningioma were treated with hydroxyurea (1000 mg/m(2)/day orally divided twice per day) from June 1998 to February 2012. Nine female and 4 male, ranging in age from 32 to 83 years (median age 61.7 years), were included. Follow-up assessment included physical examination, computed tomography, and magnetic resonance imaging (MRI). Standard neuro-oncological response criteria (Macdonald criteria) were used to evaluate the follow-up MRI scans. The treatment was continued until there was objective disease progression or onset of unmanageable toxicity., Results: Ten of the 13 patients (76.9%) showed stable disease after treatment, with time to progression ranging from 8 to 128 months (median 72.4 months; 6 patients still accruing time). However, there was no complete response or partial response in any patients. Three patients had progressive disease after 88, 89, 36 months, respectively. There was no severe (Grade III-IV) blood systemic disorders and no episodes of non-hematological side effects., Conclusion: This study showed that hydroxyurea is a modestly active agent against recurrent meningiomas and can induce long-term stabilization of disease in some patients. We think that hydroxyurea treatment is well tolerated and convenient, and could be considered as an alternative treatment option in patients with recurrent meningiomas prior to reoperation or radiotherapy.

Non-Hodgkin's lymphoma rarely originates from bone, and even more infrequently from a vertebral body. Lymphoblastic lymphoma is a rare type of non-Hodgkin's lymphoma, and results from an abnormality in adaptive immune cells. A 27-year-old man presented with a two-month history of night sweats, weight loss, and severe back pain. Radiological studies demonstrated an osteolytic lesion compressing the subarachnoid space at the T11 level. Posterolateral fusion with decompression was performed and a pathologic examination confirmed lymphoblastic lymphoma of the B-cell precursor type. To our knowledge, this is the first report of solitary lymphoblastic lymphoma from B-cell precursors in of the thoracic spine. Herein, we discuss the presenting symptoms and the management of this rare case of lymphoblastic lymphoma.

Isolated tuberculosis of the coccyx is extremely rare. A 35-year-old man presented with a 3-month history of coccygeal and gluteal pain. Computed tomography and magnetic resonance imaging revealed osseous destruction and a large enhancing mass involving the coccyx with anterior and posterior extension. Pathologic examination of the surgical specimen revealed necrosis, chronic granulomatous inflammation, and multinucleated giant cells consistent with tuberculosis. This case highlights the importance of considering tuberculosis as a diagnosis even though unusual sites are involved.

Objective: The purpose of this study was to determine the efficacy of bone cement-augmented short segment fixation using percutaneous screws for thoracolumbar burst fractures in a background of severe osteoporosis., Methods: Sixteen patients with a single-level thoracolumbar burst fracture (T11-L2) accompanying severe osteoporosis treated from January 2008 to November 2009 were prospectively analyzed. Surgical procedures included postural reduction for 3 days and bone cement augmented percutaneous screw fixation at the fracture level and at adjacent levels without bone fusion. Due to the possibility of implant failure, patients underwent implant removal 12 months after screw fixation. Imaging and clinical findings, including involved vertebral levels, local kyphosis, canal encroachment, and complications were analyzed., Results: Prior to surgery, mean pain score (visual analogue scale) was 8.2 and this decreased to a mean of 2.2 at 12 months after screw fixation. None of the patients complained of pain worsening during the 6 months following implant removal. The percentage of canal compromise at the fractured level improved from a mean of 41.0% to 18.4% at 12 months after surgery. Mean kyphotic angle was improved significantly from 19.8° before surgery to 7.8 at 12 months after screw fixation. Canal compromise and kyphotic angle improvements were maintained at 6 months after implant removal. No significant neurological deterioration or complications occurred after screw removal in any patient., Conclusion: Bone cement augmented short segment fixation using a percutaneous system can be an alternative to the traditional open technique for the management of selected thoracolumbar burst fractures accompanied by severe osteoporosis.

Osseous bridging between lumbar transverse processes is an uncommon condition that may cause low back pain. In most cases, its etiology is alleged to be trauma to the back and only rarely has a congenital origin been indicated. Furthermore, most reported cases involved adults, the majority of whom were middle-aged. Here, the authors describe the case of the youngest girl reported to date with congenital transverse process bridging. As far as the authors' knowledge, there has been no report of congenital bridging of transverse processes in children or adolescents in Korea.

Objective: Alcoholic neuropathy is characterized by allodynia (a discomfort evoked by normally innocuous stimuli), hyperalgesia (an exaggerated pain in response to painful stimuli) and spontaneous burning pain. The aim of the present study is to investigate the effect of rolipram, a phosphodiesterase 4 inhibitor, against alcohol-induced neuropathy in rats., Methods: Allodynia was induced by administering 35% v/v ethanol (10 g/kg; oral gavage) to Spraue-Dawley rats for 8 weeks. Rolipram and saline (vehicle) were administered intraperitoneally. Mechanical allodynia was measured by using von Frey filaments. Somatosensory evoked potential (SEP) was proposed as complementary measure to assess the integrity of nerve pathway., Results: The ethanol-induced mechanical allodynia began to manifest from 3 week, and then peaked within 1 week. Beginning from 3 week, latency significantly started to increased in control group. In rolipram treated rats, the shorter latency was sustained until 8 weeks (p<0.05). The mechanical allodynia, which began to manifest on the 3 weeks, intraperitoneal injections of rolipram sustained statistical difference until 8 weeks, the final week of the study (p<0.05)., Conclusion: This study suggests that rolipram might alleviate mechanical allodynia induced by alcohol in rats, which clearly has clinical implication.

Bacterial meningitis is rarely complicated by an intradural spinal abscess, and recurrent meningitis is an uncommon presentation of a spinal intramedullary abscess. Here, we report a 63-year-old patient with recurrent meningitis as the first manifestation of an underlying spinal intramedullary abscess. To the best of our knowledge, no previous report has been issued on recurrent meningitis accompanied by a spinal intramedullary abscess in an adult. In this article, the pathophysiological mechanism of this uncommon entity is discussed and the relevant literature reviewed.

There has been no report of bilateral pedicle stress fractures involving two vertebrae. The authors describe a unique case of spondylolisthesis accompanying a bilateral pedicle stress fracture involving two vertebrae. De novo development of spondylolisthesis at the L5-S1 vertebrae accompanying a bilateral pedicle stress fracture at L4 and L5 was observed in a 70-year-old woman. The patient's medical history was unremarkable and she did not have any predisposing factors except severe osteoporosis. Interbody fusion with bone cement augmented screw fixation was performed. Surgical treatment resulted in good pain management and improved functional recovery.

Oblique basal skull fractures resulting from lateral crushing injuries involving both clivus and occipital condyle are rare due to their deep locations. Furthermore, these fractures may present clinically with multiple cranial nerve injuries because neural exit routes are restricted in this intricate region. The authors present an interesting case of basal skull fractures involving the clivus and occipital condyle and presenting with sixth and contralateral twelfth cranial nerve deficits. Clinico-anatomic correlations and the courses of cranial nerve deficits are reiterated. To the authors' knowledge, no other report has been previously issued on concomitant sixth and contralateral twelfth cranial nerve palsies following closed head injury.

Objective: Discal cyst is rare and causes indistinguishable symptoms from lumbar disc herniation. The clinical manifestations and pathological features of discal cyst have not yet been completely known. Discal cyst has been treated with surgery or with direct intervention such as computed tomography (CT) guided aspiration and steroid injection. The purpose of this study is to evaluate the safety and efficacy of the percutaneous endoscopic surgery for lumbar discal cyst over at least 6 months follow-up., Methods: All 8 cases of discal cyst with radiculopathy were treated by percutaneous endoscopic surgery by transforaminal approach. The involved levels include L5-S1 in 1 patient, L3-4 in 2, and L4-5 in 5. The preoperative magnetic resonance imaging and 3-dimensional CT with discogram images in all cases showed a connection between the cyst and the involved intervertebral disc. Over a 6-months period, self-reported measures were assessed using an outcome questionaire that incorporated total back-related medical resource utilization and improvement of leg pain [visual analogue scale (VAS) and Macnab's criteria]., Results: All 8 patients underwent endoscopic excision of the cyst with additional partial discectomy. Seven patients obtained immediate relief of symptoms after removal of the cyst by endoscopic approach. There were no recurrent lesions during follow-up period. The mean preoperative VAS for leg pain was 8.25±0.5. At the last examination followed longer than 6 month, the mean VAS for leg pain was 2.25±2.21. According to MacNab' criteria, 4 patients (50%) had excellent results, 3 patients (37.5%) had good results; thus, satisfactory results were achieved in 7 patients (87.5%). However, one case had unsatisfactory result with persistent leg pain and another paresthesia., Conclusion: The radicular symptoms were remarkably improved in most patients immediately after percutaneous endoscopic cystectomy by transforaminal approach.

Simultaneous intracranial and spinal subdural hematomas are extremely rare. In most cases, they are attributed to major or minor trauma and iatrogenic causes, such as those resulting from spinal puncture. To the best of the authors' knowledge, there has been only two reports of spontaneous concomitant intracranial and spinal subdural hematomas in a patient receiving anticoagulant therapy who had an absence of evident trauma history. We report on a case of spontaneous concomitant intracranial and spinal subdural hematomas that occurred in association with anticoagulant therapy and present a review of the relevant literature.

Objective: The purpose of this prospective study was to evaluate the efficacy and safety of screw fixation without bone fusion for unstable thoracolumbar and lumbar burst fracture., Methods: Nine patients younger than 40 years underwent screw fixation without bone fusion, following postural reduction using a soft roll at the involved vertebra, in cases of burst fracture. Their motor power was intact in spite of severe canal compromise. The surgical procedure included postural reduction for 3 days and screw fixations at one level above, one level below and at the fractured level itself. The patients underwent removal of implants 12 months after the initial operation, due to possibility of implant failure. Imaging and clinical findings, including canal encroachment, vertebral height, clinical outcome, and complications were analyzed., Results: Prior to surgery, the mean pain score (visual analogue scale) was 8.2, which decreased to 2.2 at 12 months after screw fixation. None of the patients complained of worsening of pain during 6 months after implant removal. All patients were graded as having excellent or good outcomes at 6 months after implant removal. The proportion of canal compromise at the fractured level improved from 55% to 35% at 12 months after surgery. The mean preoperative vertebral height loss was 45.3%, which improved to 20.6% at 6 months after implant removal. There were no neurological deficits related to neural injury. The improved vertebral height and canal compromise were maintained at 6 months after implant removal., Conclusion: Short segment pedicle screw fixation, including fractured level itself, without bone fusion following postural reduction can be an effective and safe operative technique in the management of selected young patients suffering from unstable burst fracture.

Penetrating injuries to the upper cervical spine resulting from gunshots are rare in South Korea due to restrictions of gun use. Moreover, gunshot wounds to the upper cervical spine without neurological deficits occur infrequently because of the anatomic location and surrounding essential structures. We present an uncommon case involving the surgical removal of a bullet located in the anterior arch of first cervical vertebra (C1) via a transoral approach without neurological complications or subsequent mechanical instability.

Although decompressive craniectomy is an effective treatment for various situations of increased intracranial pressure, it may be accompanied by several complications. Paradoxical herniation is known as a rare complication of lumbar puncture in patients with decompressive craniectomy. A 38-year-old man underwent decompressive craniectomy for severe brain swelling. He remained neurologically stable for five weeks, but then showed mental deterioration right after a lumbar puncture which was performed to rule out meningitis. A brain computed tomographic scan revealed a marked midline shift. The patient responded to the Trendelenburg position and intravenous fluids, and he achieved full neurologic recovery after successive cranioplasty. The authors discuss the possible mechanism of this rare case with a review of the literature.