Lumbar disc herniations at the L1-L2, L2-L3, and L3-L4 level are rare. The purpose of this study is to observe the variable clinical finding of upper lumbar disc herniations and to provide proper treatment modality.

Between 1998 Jan. and 1999 Dec., seventeen patients with upper lumbar disc herniations who were undergone surgery in our institute were retrospectively evaluated. Patients were evaluated based on following factors : age, sex, aggravating factor, symptoms and signs type of disc herniation, type of surgery, and outcome of post-surgery.

The incidence of lumbar disc herniation at the level of L1-2, L2-3 and L3-4 is 6.1% with declining frequency as the level ascends. The peak age incidence is 6th decade in both sex. Preoperative symptomes and signs are variabe. In sixteen cases, posterior approach was done. In these cases, twelve cases were performed microscopic partial hemilaminectomy, and four cases with spinal stenosis were performed total laminectomy and posterior screw fixation with bone fusion. In one case, lateral extracavitary approach was done. In results of operation, fourteen cases showed more than good grade(82%).

The age incidence of lumbar disc herniations at the level of L1-2, L2-3 and L3-4 older than lumbar disc herniations at the lower level of L4-5 and L5-S1. The signs and symptoms are variable. In our cases, most of the patients were performed posterior approach with microscopic partial hemilaminectomy except the patients combined spinal stenosis. One case was performed a lateral extracavitary approach because the risk of the cord and cauda equina injuries. The prognosis of upper lumbar disc herniations after treatment with only microscopic partial hemilaminectomy and diskectomy is comparable with the prognosis of lumbar disc herniations at the lower level.

The microdiskectomy was developed out of attempts to refine the classical lumbar laminectomy and diskectomy. The ligament-sparing microdiskectomy, a more refined technique, was developed by the author. For this study a series of patients, operated by the present author, were reviewed.

Consecutive patients admitted to Ewha Mokdong hospital between August 1997 and June 2000 who were to undergo virgin, unilateral single-level lumbar ligament-sparing microdiskectomy undergoing unilateral single-level microdiskectomies were included. The technique of the ligament-sparing diskectomy was described in detail.

A total of 83 patients were operated on(M : F/63 : 21), with an average age of 37.2 years. Successful outcome was achieved in 78 patients(93.9%). Surgical complications included one wound infection and one reoperation for residual disk herniation.

The author believe that this technique is safe, can provide acceptable clinical outcome, and has an additional advantage of preserving the epidural fat.

Despite of recent advances in pharmacological treatment and improvement surgical and anesthetic techniques, subarachnoid hemorrhage(SHA) from ruptured intracranial aneurysms with poor clinical grades still carries unacceptably high morbidity and mortality rates. Recently surgery for aneurysmal SAH with poor clinical grade has increased interest.

The authors experienced 57 patients with poor clinical grade (Hunt and Hess grade IV-V) after ancurysmal SAH. Among them 25 patients were treated with immediate CSF drainage via ventriculostomy, blood pressure control, early angiography(except 3 patients) and surgery within 12 hour of admission.

The outcomes of patients were categorized using a four-tiered scale :

1) independent and working

2) impaired but independent

3) severly impaired and dependent

4) dead

The average age was 48(13-75) and the male to female ratio was 7:18 in surgical group. The average time to admission and surgery was 12 hours or less among the 25 patients. Among them 9 cases were dead, 2 cases were severly impaired and dependent, 3 cases were impaired but dependent, and 11 cases were independent and working. In this patient all cases, exception one could be ligated with a clip.

The above results suggest that the acute aggressive surgery based on appropriate selection in poor aneurysmal SAH patients can reduce of the mortality.

The timing of aneurysm surgery has been a topic of major neurosurgical controversy.

Aneurysmal rebleeding is the most cataclysmic and disabling event following initial subarachnoid hemorrhage. Thus, early surgical obliteration of aneurysm eliminates the potential for rebleeding during the highest risk period.

The results of operation for the twenty-three patients who had admitted to neurosurgical departments, Mokdong hospital and undergone surgery within the 24-72 hours after initial rupture of these aneurysms from October, 1993 to August, 1996, were reviewed.

Twenty-three patients underwent craniotomy for clipping and intracranial clot evacuation, and postoperative hypertensive, hypervolemic, and hemodilution therapy. The outcome was excellent in 10(43%), good in 3(13%), poor in 5(22%) and death in 5(22%). The mean age was 57.7 and the ratio of male to female was 13:10. The outcome according to Hunt-Hess(H-H) grade was followings. H-H grade 1 was 2(%) and all excellent outcome, H-H grade 2 24(61%) and the outcome were excellent in 8(35%), good in 1(4%), poor in 2(9%), death in 3(13%), H-H grade 3 was 6(26%) and good in 2(9%), poor in 2(9%), death in 2(9%), and H-H grade 4 was 1(4%) and the outcome was poor in 1(4%). The outcome according to grading system of Fisher was followings. Grade 2 was 6(26%), and the outcome was excellent in 5(22%) and death in 1(4%). The grade 3 was 14(61%) and excellent in 5(22%), good in 2(9%), poor in 3(13%), and death in 1(4%). The grade 4 was 3(31%) and good in (4%) and poor in 2(9%). The variations in anterior communicating complex were followings. The both A₁ equal in 6(26%), left A₁ dominancy was 1(4%), right A₁ atresia was 13(57%) and left atresia was 3(13%).

The most favorable outcomes and lowest mortality rate were patients of H-H grade 1 group. The surgical results of alert patients with early surgery should even further improve as compared to delay surgery. However, patients who present in poor medical condition at the time of operation were still indicated delay surgery.

The approaches for skull base lesions should allow excellent visualization, minimized working distance and avoid brain retraction. We consider the supraorbital approachto be the approach of choice for orbital, anterior and middle cranial fossae lesions. Thetechnique of procedure is described and reviewed its advantages.

the authors reviewed the eleven cases which were operated bysupraorbital approach and one case which were operated by supraorbital bifrontal approach,from May 1992 to May 1996.

Eleven patients(four cases of tuberculum sellae meningiomas, one case of pituitarymacroadenoma, two case of suprasellar germinoma, one case of cavernous hemangioma in theorbit, two cases of huge size of craniopharyngiomas, one case of optie and oculomotor nervepalsy due to compound fiacture of orbit) were cured or improved with the supraorrbtal andsupraorbito-bifrontal approsch. But one case of suprasellar germinoma died.

The supraorbital approach is preferred in lesions of orbital, anterior and middlecranial fossae, because it minimize brain retraction, shorten the distance of the target of lesionsand provide multiple pathways for dissection of the lesions. Also this approach may combinewith other skull base approaches.

The purpose of this study is to evaluate the clinical informations(symptoms, pathophysiologic phenomena, other associated vascular malformation and outcome) in order to define the guide of the management.

The authors reviewed the 54cases which were diagnosed by the high-resolution MRI and supplemented by computed tomography, from 1991 to 1996. The patho-physiologic phenomena of the CMs were classified into three groups by the finding of MRI. Surgical outcome was analysed according to the type of lesions, clinical variables, and indication of surgical management.

The mean patient age was 33.2 years, and the locations of CMs are in the cere-brum in 38 cases, basal ganglia/thalamus in 5 cases, brain stem in 16 cases, orbit in 2 cases and the spinal cord in 1case. Symptomatic hemorrhage were 25 patients(46%), seizure reported 16 patients(30%) and focal neurologic deficit 7(13%). Incidental cases were founded in 6 patients(11%) and their main complaints were headache. In 71% of the patients, the lesions were solitary and multiple in 29%. The 7 patients had coexisting venous angiomas. The A group had 24 patients(44%), B group 16 patients(30%) and the C group 14 patients(26%). Twenty nine patients who were asymptomatic or incidentally discovered lesions(6 patients) were treated conservatively. Twenty five patients(15 hemorrhage, 8 patients of intractable seizure and 2 patients of progressive neurologic deficits) underwent surgery.

This study suggest that surgical extirpation of the lesions is an effective management in accessible lesions, overt hemorrhage, medical intractable epilepsy and pro-gressive worsening focal neurologic deficits.