Anterior microforaminotomy (AMF) is an alternative procedure to treat unilateral cervical pathology. Although the results have been reported favorable in the previous studies, postoperative degeneration may occur. We analyze long-term outcome to determine the critical size of AMF.

A retrospective study was performed. Clinical data with chart review, radiologic data with picture archiving and communication system (PACS) images were obtained. Long-term clinical outcomes were accessed by a questionnaire, including visual analogue scale (VAS) and neck disability index (NDI). Various clinical, radiological data were statistically analyzed.

Eight-two patients were enrolled in this study. Main pathology was spondylotic spur (53.7%), soft disc herniation (36%). Mean age was 49 years old. There was no surgery-related complication. Mean follow-up was 6.1 years. 90.3% showed favorable clinical outcome. Mean VAS score was decreased from 8.2 to 2.9, and NDI score was decreased from 24.5 to 6.7 (P<0.05). 88.7% showed decrease of disc height (DH), and mean change was 1 mm. DH change was correlated positively with the disc invasion and AMF diameter (P<0.05). Mean diameter of AMF was 5.2 mm. According to statistical analysis, the critical diameter of AMF was 4.7 mm, directly affecting DH decrease. Any radiological parameters did not affect the clinical outcome.

AMF was an effective procedure to treat unilateral cervical pathology. Critical DH decreases and/or disc invasion may be the trigger of sequential degeneration. To preserve DH, AMF diameter should be small and disc invasion should be avoided.

Surgical approaches to the pituitary adenoma have undergone numerous refinements. Surgery on the pituitary adenoma is increasingly being performed through an endoscopic approach. The aim of this study is to report the results of a consecutive series of patients undergoing pituitary surgery using a pure endoscopic endonasal approach(EEA) and to evaluate the efficacy and safety of this procedure.

We reviewed 24 consecutive patients with pituitary adenoma who underwent purely endoscopic transsphenoidal resection of their lesions. The patients' clinical outcomes, including remission rates, degrees of tumor removal, and complications were evaluated.

Between September 2000 and August 2009, 76 patients with pituitary adenoma were operated on at Ewha University Mokdong Hospital. Of these, 24 patients were operated on using EEA. There were 18 nonfunctioning, 4 growth hormone-secreting, and 2 prolactin-secreting adenomas. Gross total removal was achieved in 62.5% of the cases after surgery. Visual disturbance was seen in 18 patients, which was improved in all patients. The main cause of failure of total removal was invasion to cavernous sinus. The remission results for patients with nonfunctioning adenomas was 83.3% and for functioning adenomas were 83.3%(75% for GH hormone-secreting, 100% for prolactin hormone-secreting), with no recurrence at the time of the last follow-up. Post-operative complications were present in 4(16.7%) cases. Three cases showed immediate postoperative CSF leakage, one case showed transient diabetes insipidus. There was no death related to the procedure in this series.

The endoscopic endonasal approach for resection of pituitary adenomas, provides acceptable results representing a safe alternative procedure to the microscopic approach. This less invasive method, associated with a small number of complications, provides acceptable tumor removal rates and represents an important tool for the achievement of good results in the pituitary surgery.

Recently, motion preservation has come to the forefront of emerging technologies in spine surgery. This is the important background information of the emergence of cervical arthroplasty as an alternative to arthrodesis that offers the promise of restoring normal spinal movement and reduces a kinematic strain on adjacent segments. The study was designed to evaluate early surgical outcome and radiological effects of Bryan cervical disc prosthesis.

The authors retrospectively reviewed radiographic and clinical outcomes in 49 patients who received the Bryan Cervical Disc prosthesis, for whom follow-up data were available. Static and dynamic radiographs were measured by computer to determine the angles formed by the endplates of the natural disc preoperatively, those formed by the shells of the implanted prosthesis, the angle of the FSU, and the C2-7 Cobb angle. The range of motion(ROM) was also determined radiographically, whereas clinical outcomes were assessed using Odom's criteria.

A total of 66 Bryan disc were placed in 49 patients. A single-level procedure was performed in 35 patients, a two-level procedure in 14 patients, and a three-level procedure in 3. Radiographic and clinical assessments were made preoperatively. Mean follow-up duration was 29.2 months, ranging from 6 to 36 months. All of the patients were satisfied with the surgical results by Odom's criteria. The postoperative ROM of the implanted level was preserved without significant difference from preoperative ROM of the operated level. 90% of patients with a preoperative lordotic sagittal orientation of the FSU were able to maintain lordosis. The overall sagittal alignment of the cervical spine was preserved in 89.4% of cases at the final follow up. Interestingly, preoperatively kyphotic FSU resulted in lordotic FSU in 57.7% of patients during the late follow up, and preoperatively kyphotic overall cervical alignment resulted in lordosis in 62.5% of the patients postoperatively.

Arthroplasty using the Bryan disc seemed to be safe and provided encouraging clinical and radiologic outcome in our study. Although early and intermediate results are promising, this is also a relatively new approach, long-term follow up studies are required to prove its efficacy and its ability to prevent adjacent segment disease.

The piriformis syndrome appears to be more common because it is often underdiagnosed and undertreated. This syndrome is caused by compression or irritation of the sciatic nerve by the piriformis muscle as it passes through the sciatic notch. This entrapment neuropathy presents as pain, numbness, paresthesias, and associated weakness in the distribution of the sciatic nerve. In this article. we present the clinical symptoms, anatomy of the piriformis muscle, and the technique and result of the injection therapy with local anesthetics and steroid.

A 72-year-old woman presented with 7 days history of severe pain in the right buttock, hip, numbness of the right thigh. Previous management had included non-steroidal anti-inflammatory drug and physical therapy in local orthopedic clinic. Her past medical history was unremarkable. Her right side buttock was tender and discomfort was increased by right hip flexion, adduction and internal rotation with pain radiating to the anterior thigh. The her leg lenghts were equal, the strenght of right hip abductors and abduction was normal. Also low back range of motion and neurological examination were normal. Radiographs of the lumbosacral spine, pelvis and the hip joint were unremarkable. The she didn't respond to conservative treatment including physcal theraphy combined with the use antiimflammatory drugs, analgesics and muscle relaxants.

One week later she received an injection of 0.5% mepibacaine HCI 8cc and methyl-predanisolone(Depomedrol) 40mg into the medal right piriformis muscle. She reported that the 3 days after the injection, her right buttock pain had resolved and 7 days after the injection the pain resolved completely and she resumed normal activities and continued pain free.

We reviewed the literature on piriformis syndrome and its signs, symptoms and treat-ments. In an isolated piriforms syndrome, the major finding include buttock tenderness from the sacrum to the greater trochanter, piriformis tenderness on rectal or vaginal examination. The patient with piriformis syndrome usually does not have neurologic deficits Through complete history, physical and neurologic examinations, the other causes of low back pain and sciatica should be eliminated. Patients who do not respond to conservative therapy are candidates for local anesthetics and steroid injection. We injected methyl prednisolone 40mg and 0.5% mepibacaine HCl 8cc into the medial right piriformis muscle. 3 days after injection, her pains of right buttock and trochanter had resolved and 7 days after the injection, she resumed normal activites and consumed free. In order to improve the reliability of proper needle placement and allow for definite and treatment, EMG-assisted or MRI guidance may utilize.

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.

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.