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Surgical outcomes of degenerative cervical spinal disease are dependent on the selection of surgical techniques. Although a standardized decision cannot be made in an actual clinical setting, continued education is provided to standardize the medical practice among surgeons. Therefore, it is necessary to supervise and regularly update overall surgical outcomes. This study aimed to compare the rate of additional surgery between anterior and posterior surgeries for degenerative cervical spinal disease using the National Health Insurance Service-National Sample Cohort (NHIS-NSC) nationwide patient database. The NHIS-NSC is a population-based cohort with about a million participants. This retrospective cohort study included 741 adult patients (> 18 years) who underwent their first cervical spinal surgery for degenerative cervical spinal disease. The median follow-up period was 7.3 years. An event was defined as the registration of any type of cervical spinal surgery during the follow-up period. Event-free survival analysis was used for outcome analysis, and the following factors were used as covariates for adjustment: location of disease, sex, age, type of insurance, disability, type of hospital, Charles comorbidity Index, and osteoporosis. Anterior cervical surgery was selected for 75.0% of the patients, and posterior cervical surgery for the remaining 25.0%. Cervical radiculopathy due to foraminal stenosis, hard disc, or soft disc was the primary diagnosis in 78.0% of the patients, and central spinal stenosis was the primary diagnosis in 22.0% of them. Additional surgery was performed for 5.0% of the patients after anterior cervical surgery and 6.5% of the patients after posterior cervical surgery (adjusted subhazard ratio, 0.83; 95% confidence interval, 0.40–1.74). The rates of additional surgery were not different between anterior and posterior cervical surgeries. The results would be helpful in evaluating current practice as a whole and adjusting the health insurance policy.

Background The endotracheal cuff pressure depends on the airway pressure during positive-pressure ventilation. A high endotracheal cuff pressure may be related to intraoperative coughing, which can be detrimental during neurosurgery. We investigated the incidence of intraoperative coughing and its association with peak inspiratory pressure (PIP) during neurosurgery under general anesthesia without neuromuscular blockade. Methods This retrospective study divided 1656 neurosurgical patients who underwent total intravenous anesthesia without additional neuromuscular blockade after tracheal intubation into high (PIP > 21.6 cmH2O, n = 318) and low (PIP ≤ 21.6 cmH2O, n = 1338) PIP groups. After propensity score matching, 206 patients were selected in each group. Demographic, preoperative, surgical, and anesthetic data were collected retrospectively from electronic medical records and continuous ventilator, infusion pump, and bispectral index data from a data registry. Results Intraoperative coughing occurred in 30 (1.8%) patients, including 9 (0.5%) during the main surgical procedure. Intraoperative coughing was more frequent in the high PIP group than in the low PIP group before (14/318 [4.4%] vs. 16/1338 [1.2%], P Conclusion The incidence of intraoperative coughing was 1.8% in neurosurgical patients undergoing general anesthesia without neuromuscular blockade and might be associated with a high PIP.

Background The restoration of the functional ability of mesenchymal stem cells (MSCs) using epigenetic modification is very promising for patients with weak osteogenesis ability. This study focused on the acceleration of osteogenesis from MSCs using microRNA (miRNA)2861 and a cell-penetrating peptide (CPP), LK. Methods We performed MSCs penetration test of complex between the LK peptides and miRNA 2861. Three different experiments were performed to investigate the effects of miRNA 2861 on osteogenic differentiation in MSCs: 1) intensity of alizarin red staining, which reflects the status of mineralization by osteoblasts; 2) gene expression related to osteoblast differentiation; and 3) confirmation of corresponding protein translation for comparison with RNA expression levels. Results We found that cLK effectively delivered miRNA 2861 into the cytoplasm of human MSCs and accelerated osteogenic differentiation from MSCs, as well as mineralization. Conclusion The complex of miRNA 2861 with LK may have a positive effect on the osteogenic differentiation from MSCs and mineralization. Therapies using miRNAs combined with LK may be good candidates for the augmentation of osteogenesis in patients.

MRI is the primary diagnostic modality for spinal cord tumors. However, its validity has never been vigorously scrutinized in daily routine clinical practice, where MRI tissue diagnosis is usually not a single one but multiple ones with several differential diagnoses. Here, we aimed to assess the validity of MRI in terms of predicting the pathology and location of the tumor in routine clinical settings. We analyzed 820 patients with primary spinal cord tumors, who have a pathological diagnosis and location in the operation record which were confirmed. We modified traditional measures for validity based upon a set of diagnoses instead of a single diagnosis. Sensitivity and specificity and positive and negative predictabilities were evaluated for the tumor location and pathology. For tumor location, 456 were intradural extramedullary; 165 were intramedullary, and 156 were extradural. The overall sensitivity and specificity were over 90.0%. However, the sensitivity became lower when the tumor resided simultaneously in two spaces such as in the intradural-and-extradural or intramedullary-and-extramedullary space (54.6% and 30.0%, respectively). Most common pathology was schwannoma (n = 416), followed by meningioma (114) and ependymoma (87). Sensitivities were 93.3%, 90.4%, and 89.7%, respectively. Specificities were 70.8%, 82.9%, and 76.0%. In rare tumors such as neurofibromas, and diffuse midline gliomas, the sensitivity was much lower (less than 30%). For common locations and pathologies, the validity of MRI is generally acceptable. However, for rare locations and pathologies, MRI diagnosis still needs some improvement.

Background Reoperation is one of the key factors affecting postoperative clinical outcomes. The reoperation rates of cervical surgeries might be different from those of lumbar surgeries due to the anatomical and biomechanical differences. However, there has been no study to compare the reoperation rate between them. The purpose is to compare reoperation rates after fusion surgeries for degenerative spinal diseases depending on the anatomic region of cervical and lumbar spines. Method We used the Korean Health Insurance Review & Assessment Service national database. Subjects were included if they had any of the primary procedures of fusion combined with the procedure of decompression procedures under the diagnosis of degenerative diseases (n = 42,060). We assigned the patients into two groups based on anatomical regions: cervical and lumbar fusion group (n = 11,784 vs 30,276). The primary endpoint of reoperation was the repeat of any aforementioned fusion procedures. Age, gender, presence of diabetes, associated comorbidities, and hospital types were considered potential confounding factors. Results The reoperation rate was higher in the patients who underwent lumbar fusion surgery than in the patients who underwent cervical fusion surgery during the entire follow up period (p = 0.0275). A similar pattern was found during the late period (p = 0.0468). However, in the early period, there was no difference in reoperation rates between the two groups. Associated comorbidities and hospital type were noted to be risk factors for reoperation. Conclusions The incidence of reoperation was higher in the patients who underwent lumbar fusion surgery than those who underwent cervical fusion surgery for degenerative spinal diseases.

Radiotherapy has played an important role in the treatment of spinal metastases. One of the major complications of radiotherapy is vertebral compression fracture (VCF). Although the spinal instability neoplastic score (SINS) was developed for evaluating spinal instability in patients with spinal metastases, it is also commonly used to predict VCF after radiotherapy in patients with spinal metastases. However, its accuracy for predicting radiotherapy-induced VCF and precision remain controversial. The aim of this study was to clarify the diagnostic value of the SINS to predict radiotherapy-induced VCF and to make recommendations for improving its diagnostic power. We searched core databases and identified 246 studies. Fourteen studies were analyzed, including 7 studies (with 1269 segments) for accuracy and 7 studies (with 280 patients) for precision. For accuracy, the area under the summary receiver operating characteristic curve was 0.776. When a SINS cut-off value of 7 was used, as was done in the included studies, the pooled sensitivity was 0.790 and the pooled specificity was 0.546. For precision, the summary estimate of interobserver agreement was the highest dividing 2 categories based on a cut-off value of 7, and the value was 0.788. The body collapse showed moderate relationship and precision with the VCF. The lytic tumor of bone lesion showed high accuracy and fair reliability, while location had excellent reliability, but low accuracy. The SINS system can be used to predict the occurrence of VCF after radiotherapy in spinal metastases with moderate accuracy and substantial reliability. Increasing the cut-off value and revising the domains may improve the diagnostic performance to predict the VCF of the SINS.

Physicians often encounter surgical candidates with lumbar disc herniation (LDH) who request non-surgical management even though surgery is recommended. However, second opinions may differ among doctors. Therefore, a prospective comprehensive cohort study (CCS) was designed to assess outcomes of nonsurgical treatment for surgical candidates who were recommended to undergo surgery for LDH but requested a second opinion. The CCS includes both randomized and observational cohorts, comprising a nonsurgery cohort and surgery cohort, in a parallel fashion. Crossover between the nonsurgery and surgery cohorts was allowed at any time. The present study was an as-treated interim analysis of 128 cases (nonsurgery cohort, n = 71; surgery cohort, n = 57). Patient-reported outcomes included visual analogue scores for the back (VAS-B) and leg (VAS-L), the Oswestry Disability Index, the EuroQol 5-Dimension instrument, and the 36-Item Short-Form Health Survey (SF-36), which were evaluated at baseline and at 1, 3, 6, 12, and 24 months. At baseline, age and SF-36 physical function were significantly lower in the surgery cohort than in the nonsurgery cohort (p 0.01). Nonsurgical management may be a negotiable option even for surgical candidates in the shared decision-making process.

Although ependymomas occur in both the brain and the spine, the prognosis is quite varied by tumor location. Spinal ependymomas usually follow a relatively benign course with more favorable prognosis than that of the intracranial ependymomas. The aim of this study is to evaluate the genetic differences between spinal ependymomas and their intracranial counterparts using a meta-analysis. We searched PubMed, Embase, Web of Science, and the Cochrane library. Comparative or single arm genetic studies that enrolled patients with both intracranial and spinal ependymoma were included. The frequency of genetic aberration was calculated in each group. We calculated the odds ratio (OR) with 95 % confidence intervals (CIs) for direct comparative studies and the logit event rate (LER) and 95 % CI for single arm studies. Twenty-five studies comprising of 380 spinal ependymomas and 964 intracranial ependymomas were compared to determine the association of the genetic differences of ependymomas at different locations. There were 25 comparable genetic aberrations between spinal and intracranial ependymomas. Among the genes, the NF2 mutation was significantly associated with the spinal ependymomas rather than with the intracranial ependymomas (spinal tumor: LER −0.750, 95 % CI −1.233 to −0.266, intracranial tumor: LER −3.080, 95 % CI −3.983 to −2.177). Intracranial ependymomas were found to be significantly associated with EPB41L3 deletion (OR 0.34; 95 % CI 0.14–0.80) and HIC1 methylation (OR 0.12; 95 % CI 0.02–0.68). The genetic aberrations of spinal ependymomas are quite different from those of intracranial ependymomas. The difference in prognosis of ependymoma by location may be associated with genetic difference. A more detailed understanding of them may enable the development of targeted therapy and the estimation of prognosis.

Simpson grade II removal (coagulation of the dural attachment after gross total removal) of spinal meningioma is considered an acceptable alternative, but increased recurrence after more than 10 years has been reported. More attention must be paid to the long-term surgical outcomes after Simpson grade II removal. A retrospective review was performed for 20 patients (M:F = 5:15; age, 59 ± 9 years) with Simpson grade II removal (mean follow-up period, 12.9 years; range 10.0–17.5). Magnetic resonance (MR) imaging was conducted in 17 patients at 88 ± 52 months (range 12–157). During the same period, Simpson grade I removal (removal of the dural origin) was performed in 21 patients (follow-up, 89 ± 87 months; range 9–316). Radiological recurrence was defined as a visible tumor on a follow-up MR image, and clinical tumor recurrence was defined as the recurrence of symptoms. At the final follow-up, neurological symptoms had improved in 16/20 patients and remained stable in 4/20. A recurrent tumor was detected in one patient due to increased back pain at 92 months postoperative, but the symptom was stable without surgery until the last follow-up (124 months). The radiological and clinical recurrence-free survival periods were 150 ± 7 months (95 % CI 136–163) and 204 ± 6 months (95 % CI 193–215), respectively. There was no recurrence after Simpson grade I removal, whereas neurological deterioration occurred in two patients after surgery. Simpson grade II removal may be an alternative option if the risk of complications with Simpson grade I removal is expected to be high.

Congenital craniocervical segmentation anomaly associated with malalignment of the odontoid process causes progressive spinal cord compression with myelopathy. Recent literatures have reported that ventral decompression could be achieved with posterior craniocervical realignment through posterior instrumented reduction. The purpose of the present study is to show the efficacy of intraoperative electrophysiological monitoring during craniocervical realignment through screws and rod system for congenital craniocervical segmentation anomaly. Consecutive ten patients with a congenital craniocervical segmentation anomaly and myelopathy due to a malaligned odontoid process, who underwent posterior craniocervical realignment, were included. Klippel–Feil syndrome (KFS) was combined in four patients. Gait disturbance and motor weakness were the main presentation. Craniocervical realignment was achieved by intraoperative distraction through a rod and screw system. Intraoperative neuromonitoring was performed with transcranial motor-evoked potential (TcMEP) and somatosensory-evoked potential (SSEP). Significant change in TcMEP occurred in two patients with KFS during surgery, but the change was reversed with release of distraction. All patients were awakened without neurological deficit. Motor weakness and gait disturbance were normalized within 6 months in all patients. Postoperative computed tomography scan and/or magnetic resonance imaging showed that the reduction was complete in all patients. Craniocervical realignment through screws and rod system may be safe and efficacious surgical technique for the treatment of congenital craniocervical anomaly with the help of intraoperative neuromonitoring. However, distraction should be cautiously monitored, especially when Klippel–Feil syndrome is combined.

Seizure is the most common presentation in patients with cerebral cavernous malformations (CCMs). Although many articles have documented seizure outcomes after resection of CCM, few have conducted long-term follow-ups; thus, the fluctuating seizure outcomes have been neglected. The purpose of this study is to describe long-term postoperative seizure outcomes in patients with CCM and to compare seizure outcomes between patients with sporadic seizures and those with chronic seizures. Forty-six patients with CCM presenting with seizures underwent surgery. The male-to-female ratio was 1:1, and the average age at initial seizure onset was 27.6 years. The mean preoperative seizure duration was 42.7 months. Patients were divided into two groups: a chronic group (N = 20) and a sporadic group (N = 26) according to seizure frequency and duration. The mean postoperative follow-up duration was 96.3 months, and the postoperative seizure outcomes were checked annually based upon Engel’s classification. After the first year of follow-up, 80.8 % of the sporadic group and 75.0 % of the chronic group were evaluated as Engel class I. These rates increased to 100.0 % and 90.0 %, respectively, at the eighth year of follow-up. Overall, 29 (63.0 %) of the 46 patients experienced changes in seizure outcomes over the follow-up period. Despite their delayed improvements, the chronic group showed less favorable outcomes throughout follow-up (p = 0.025). Long-term follow-up is indispensable for accurately assessing postoperative seizure outcomes because these outcomes change continuously. We recommend earlier surgery to achieve seizure-free status in patients with CCM. However, even in the chronic group, surgery is recommended, considering the overall delayed improvement.

Traumatic cervical spinal cord injuries (SCIs) frequently develop dural tears and resultant cerebrospinal fluid (CSF) leaks. They are not usually identified with advanced imaging, and there are no reports on managing CSF leaks after cervical trauma. Hence, the authors evaluated the incidence of CSF leaks after cervical SCIs and described how to predict and manage CSF leaks. An observational retrospective study was done confirming intraoperative CSF leaks among 53 patients with anterior cervical surgery after cervical spine trauma between 2004 and 2011. Seven patients (13.2 %) had dural tears and resultant CSF leaks intraoperatively (M:F ratio of 6:1; mean age, 44.7 years). An initial poor American Spinal Injury Association (ASIA) scale was significantly associated with CSF leaks (p = 0.009). From magnetic resonance imaging (MRI), disruption of the ligamentum flavum was correlated with CSF leaks (p = 0.02). Intraoperative application of fibrin glue on the operated site, postoperative management through the early removal of the wound drain within the first 24 h and early rehabilitation were performed in patients with CSF leaks without perioperative insertion of a lumbar drain. During the follow-up period, none of the patients developed CSF-leak-related complications. The incidence of CSF leaks after traumatic cervical SCI is relatively higher than that of degenerative cervical spinal surgery. An initial poor neurological status and disruption of the ligamentum flavum on the MRI in patients were predictable factors of dural tears and CSF leaks.

Cervical spondylotic myelopathy (CSM) may be caused by static and dynamic spinal cord compression, particularly during neck extension. Dynamic compression may be better evaluated with dynamic magnetic resonance (MR) images. We performed a retrospective study to determine the clinical indication for dynamic MR imaging, and conducted a survey regarding image interpretation by clinicians.A total of 32 patients (M:F = 20:12, 60.1 ± 10.7 years) who had undergone neutral/extension cervical MR imaging were included. The study population consisted of 22 patients with signs of cervical myelopathy (M group) and 10 patients without signs of myelopathy (NM group). The number of compression levels (complete obliteration of the anterior and posterior subarachnoid space) was assessed at each level in mid-sagittal, T2-weighted, neutral and extension MR images. Reproduced images from 22 patients in the M group were randomly arranged, and four experienced spine surgeons at four different institutes interpreted them to reach a clinicians' agreement. The agreements were then assessed with inter-rater correlation coefficients (ICC).Analysis with extension MR images found an increased number of compression levels in 23/32 (72 %) of patients; 20/22 in the M group and 3/10 in the NM group (p 0.01, chi-squared test), as compared to findings of the neutral MR images. Clinical factors for increased compression levels in extension MR images were age (p 0.01, 63.3 ± 10.0 years vs. 51.9 ± 8.1) and signs of myelopathy (p 0.01, odds ratio, 23.33). Clinician agreement was improved with extension MR images; ICC was 0.67 with neutral and 0.81 with extension MR images.The evaluation of CSM may be improved with dynamic MR images. Dynamic MR scanning may be considered for elderly patients with signs of myelopathy, but an interpretation for asymptomatic spinal compression based exclusively on extension MR image should be made with caution.

There have been numerous studies on the outcomes of surgery for spinal cord cavernous angiomas. However, the natural history of conservatively treated disease is not well known. The aim of this retrospective study was to investigate the outcomes of conservatively managed patients with spinal cord cavernous angioma to determine the appropriate treatment strategies.Twenty-four patients who visited a single institution over an 11-year period and who were treated conservatively were enrolled in this study. Their medical records and radiological images were reviewed retrospectively. The neurologic status of the patients was assessed using the Japanese Orthopedic Association scoring system and the clinical presentation of the patients was classified into the following 4 categories: type A, asymptomatic; B, pain only; C, sensory deficits; and D, sensory and motor deficits. The results of types C and D patients were compared with the results of previously reported surgical series from our institution.The mean age of the enrolled patients was 52.0 years (21-73). The mean duration of the clinical follow-up was 60.5 months (11-119) and the follow-up using magnetic resonance imaging was 52.4 months (3-122). Cavernous angiomas presented in the cervical spinal cord in 12 patients, thoracic spinal cord in 10 patients and in multiple levels of the spinal cord in 2 patients. There were 5, 5, 7, and 7 patients, respectively, classified with types A, B, C, and D for clinical presentations. The rate of recurrent hemorrhage was 1.7 %/patient-year and all recurrent hemorrhages only developed in type C or D patients. In types C and D patients, improvement in the JOA score during the follow-up period was 0.77 ± 1.8 in the conservative group and 1.07 ± 1.8 in the surgical group (p = 0.500). However, improvement in the JOA sensory score after surgical treatment was statistically significant (P = 0.007).Conservative treatment may be a reasonable treatment strategy for patients with types A and B. If patients present with type C or D, surgical treatment is recommended considering the better improvements in sensory deficits and the high rate of recurrent hemorrhage in such patients.

The authors report three cases of cerebral germinoma that occurred in young adults with unusual presentation. All three patients presented with hemiparesis and were treated at Seoul National University. A histological diagnosis of germinoma was made by a stereotactic biopsy in all three cases. Magnetic resonance (MR) images showed that their tumors were located in the internal capsule and thalamus, and were associated with ipsilateral cerebral hemisphere and brain stem atrophy. The hemiparesis slowly progressed and this was accompanied by a haemorrhagic cyst in each patient. Clinical diagnosis was not easy because of the unusual clinical presentations and atypical MR imaging findings. It is suggested that cerebral germinoma should be included in the differental diagnosis of a haemorrhagic mass which is associated with cerebral atrophy in the thalamus, basal ganglia, or internal capsule, especially in adolescents or young adults.