• Archives of Reconstructive Microsurgery
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• v.18 no.1
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• pp.23-26
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• 2009

Purpose: Artificial dura maters are commonly used in cranioplasty, but sometimes they can result in serious postoperative infection. Once complications such as epidural abscess or chronic draining ulcer arise, they are very difficult to treat. In this case, reclosure of dura defect using artificial dura mater may give rise to recurrence of infection. We experienced a case of intractable epidural abscess caused by use of artificial dura. To avoid repeated infection, we decided to use autologous tissue for the coverage of dura and soft tissue defect. Therefore, autologous tensor fascia lata graft and anterolateral thigh free flap were harvested at the same donor site incision to cover composite defect on the scalp and dura mater. Methods: A 13 year old male patient, who underwent the decompression cranioplasty and duroplasty, suffered from the intractable infection lesion. Twice, the epidural abscess was removed, both times the infection recurred. And eventually dura mater was exposed through the infected open wound. Nine months after dura exposed, infected aritificial dura mater was removed and extensive debridement was performed. Through a surgical incision on donor thigh, first, tensor fascia lata graft was harvested in process of the anterolateral thigh flap elevation. After the fascia lata graft was fixed over the dural defect, the anterolateral thigh flap was used to fill the dead space as well as the scalp defect. Results: Postoperatively, no recurrent infection and cerebrospinal fluid leakage are observed for a year. After the surgery, on the first and second day, venous congestion of the flap was observed, this problem was solved by thrombectomy and vein reanastomosis. And partial necrosis of flap occurred, but completely healed as conservative treatment for two weeks. Conclusion: Using the autologous tensor fascia lata graft and anterolateral thigh flap, we could obtain satisfactory results as treatment for the intractable infection lesion after duroplasty. Autologous tensor fascia lata in conjunction with anterolateral thigh flap is useful method for covering composite defect of scalp and dura mater.

• The Korean Journal of Pain
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• v.5 no.1
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• pp.23-28
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• 1992

The use of epidural narcotics to treat cancer pain was first described by Behar et al in 1979. More recently, a variety of implantable INDSs have been described for long-term intraspinal narcotic administration. Especially, among these systems INDS typeIII which is designed by Poletti et al is relatively low cost and less risk of infection, therefore this system has been widely accepted but the clinical experience is insufficient yet. 1, Problems, 1) thorough education of patients and care-givers about this system the method of drug delivery and the situations could be happen in using this system. 2) high cost of continuous drug delivery system 3) legal problems about morphine carry-out in the case of bolus infusion by syringe 1. Complications; 1) by morphine; Significant respiratory depression was not found in all 21cases. other morphine-related complications were occurred occasionally but improved within a few days by appropriate treatment. 2) by system, Blockage or leakage of catheter was occurred in 2cases and wound infection was occurred in 2cases and so reimplantation was done.

• Journal of Korean Neurosurgical Society
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• v.47 no.2
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• pp.140-142
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• 2010

Acupuncture appears to be a clinically effective treatment for acute and chronic pain. A considerable amount of research has been conducted to evaluate the role that acupuncture plays in pain suppression; however, few studies have been conducted to evaluate the side effects of the acupuncture procedure. This case report describes a suspected postdural puncture headache following acupuncture for lower back pain. Considering the high opening pressure, cerebrospinal fluid leakage, and the patient's history of acupuncture in the lower back area, our diagnosis was iatrogenic postdural puncture headache. Full relief of the headache was achieved after administration of an epidural blood patch.

• Journal of Korean Neurosurgical Society
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• v.60 no.2
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• pp.189-194
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• 2017

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.

• The Korean Journal of Pain
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• v.1 no.1
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• pp.53-58
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• 1988

We have treated patients who have visited pain clinic and those admitted to the other departments of Pusan National University Hospital from Mar. 1987 to Feb. 1988 with complaints of severe cancer pain on both upper and lower abdomen and extremities by continuous administration of a very small amount of morphine in the lumbar subarachnoid(group I) and epidural(group II) space in 10 cases respectively. The results of analgesia obtained are as follows: 1. The average duration in onset of analgesia was 8 mins. in group I and 23 mins. in group II. 2. The average duration In maintaining analgesia was 12.4 hrs. in group I and 18.4 hrs. in group II. 3. The efficiency of analgesia in group I was excellent in 5, good in 4, and null in 1, and group II was excellent in 5, good in 2, and moderate in 3. 4. The degree of tolerance in group I was rather mild comparable ti that of pain score 4 till the 22nd. day of morphine administration. 5. The complications are: 2 of respiratory distress in group I, 2 of voiding difficulties in both group I and II, 1 of itching sensation in both group I and II, 1 of euphoria with hallucination In group I, and 1 of C.S.F leakage in group II. As results, it is thought that epidural administration is safer than subarachnoid administration in achieving analgesia with morphine among patients with malignant pain if the problem of tolerance is solved.

• Journal of Korean Neurosurgical Society
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• v.41 no.3
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• pp.161-165
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• 2007

Objective : Percutaneous approach to the middle thoracic vertebra through the transpedicular route for the patients with osteoporotic vertebral compression fractures is difficult due to the small size of the pedicle and parasagittally oriented vertebra body anatomy. The percutaneous vertebral body access [PVBA] technique utilizing the posterolateral extrapedicular approach avoids the pedicle and provides direct access to the vertebral body. The objective of this study is to evaluate the efficacy of the vertebroplasty utilizing PVBA technique for osteoporotic vertebral compression fractures in the middle thoracic vertebrae. Methods : A retrospective review was done on 20 patients who underwent vertebroplasty utilizing PVBA technique performed for painful osteoporotic compression fracture in the middle thoracic vertebrae at 22 levels from May 2003 to June 2006. The average amount of the injected cement was 1.5-2.5ml. The postprocedural outcome was assessed using a visual analogue scale [VAS]. Results : The treated vertebrae were T5 [1 level], T6 [5 levels], 17 [7 levels], and T8 [9 levels]. The compression rate and kyphotic angle were improved after procedure from $18%{\pm}13.4$ to $16%{\pm}13.8$ [p > 0.05] and from $6.9^{\circ}{\pm}6.7$ to $6.6^{\circ}{\pm}6.2$ [p>005], respectively. Preprocedural VAS was $8.2{\pm}0.70$ and was decreased to $2.1{\pm}1.02$ [p < 0.01] after treatment. Postprocedural cement leakage was noted in 3 levels [13.7%]. There were no cases of leakage to epidural space or neural foramen, segmental artery injury, and pneumothorax. Conclusion : These results suggest that the complication rates are low and good results can be achieved with vertebroplasty utilizing PVBA technique for the osteoporotic vertebral compression fractures especially in the middle thoracic vertebrae.

• Journal of Korean Neurosurgical Society
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• v.42 no.5
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• pp.363-366
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• 2007

Objective : Kyphoplasty performed in the middle thoracic spine presents technical challenges that differ from those in the lower thoracic or lumbar region due to small pedicle size and angular severity for thoracic kyphosis. The purpose of this study was to evaluate the efficacy of balloon kyphoplasty through extrapedicular approach for the treatment of intractable osteoporotic compression fractures in the middle thoracic spine. Methods : The patients who were performed with one level balloon kyphoplasty through extrapedicular approach due to painful osteoporotic compression fractures at T5-T8 from June 2003 to July 2005 were retrospectively analyzed. Imaging and clinical features were analyzed including involved vertebrae level, vertebral height, Injected cement volume, clinical outcome and complications. Results : Eighteen female patients (age ranged from 60 to 77 years old) were included in this study. The average amount of the implanted cement was $4.2{\pm}1.5\;cc$. The mean cobb angle and compression rate were improved from $12.1{\pm}6.5^{\circ}$ to $8.5{\pm}7.2^{\circ}$ and from 30% to 15%, respectively. The mean pain score (visual analogue scale) prior to kyphoplasty was 7.9 and it decreased to 3.0 after the procedure. Cement leakage to the adjacent disc (2 cases) and paravertebral soft tissues (1 case) were seen but there were no major complications such as pneumothorax, segmental arte 이 Injury, pulmonary embolism, or epidural leakage. Conclusion : Balloon kyphoplasty through extrapedicular approach is considered as a safe and effective in treating the middle thoracic regions with low complication rate.

• Journal of Korean Neurosurgical Society
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• v.29 no.2
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• pp.240-248
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• 2000

Objective : Spontaneous intracranial hypotension is a rarely reported syndrome of spontaneous postural headache associated with low CSF pressure and has rarely been demonstrated radiographically or surgically. But recently, it is being recognized with increasing frequency. The purpose of this study was to characterize clinical and imaging features, etiologic factors, and outcome in the spontaneous intracranial hypotension. Patients and Methods : We reviewed our experience with documented cases of spontaneous intracranial hypotension in 5 consecutive patients with orthostatic headaches from April 1998 to April 1999. Results : The mean age was 41 years(from 35 to 49 years). All patients had postural headaches, which were completely alleviated by recumbency position. Nausea, neck pain, horizontal diplopia, photophobia, and blurred vision were noted in some of the patients. Brain MRI showed diffuse pachymeningeal gadolinium enhancement, subdural collections of fluid, and descent of the brain. The opening pressure from lumbar puncture was $4cmH_2O$ or less in three of five patients whereas the opening pressure was within normal range in two patients. All patients underwent radioisotope cisternography and computerized tomographic myelography. On radioisotope cisternography, CSF leakage was suspected at the level of cervical area(1 patient), upper thoracic area(2 patients), mid-thoracic area(1 patient). Computed tomography myelography revealed extraarachnoid accumulation of contrast media(compatible finding with CSF leakage) at the level of cervical or thoracic area. In all patients, the symptoms resolved in response to supportive measures or epidural blood patch(1 patient). Conclusion : Spontaneous spinal CSF leakage is increasingly recognized as a cause of spinal postural headache. Most CSF leaks are located at the cervicothoracic junction or in the thoracic spine and can be demonstrated by variable diagnostic method. The condition is usually self-limiting and its prognosis is typically good.

• Journal of Korean Neurosurgical Society
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• v.37 no.4
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• pp.253-257
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• 2005

Objective: We analyze pain relief, deformity correction and complication rate after percutaneous kyphoplasty for osteoporotic vertebral compression fractures. Methods: The authors retrospectively reviewed medical records and radiological findings of 32 patients who underwent percutaneous kyphoplasty for osteoporotic vertebral compression fractures. Results: The patients had significant pain improvement with the procedure. The visual analogue scale score reduced from 8.6 to 3.4 significantly after the procedure. The midline vertebral body height significantly increased postoperatively, but mean kyphotic angle did not. There was no serious complication except one case of epidural cement leakage without neurological impairment. Conclusion: Balloon kyphoplasty safely can reduce severe back pain and returned geriatric patients to higher activity levels. The midline vertebral height is restored significantly. However kyphotic deformity correction is not significant as contrary to what we expected from the present study before it was carried out.

• Archives of Plastic Surgery
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• v.36 no.5
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• pp.670-673
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• 2009

Purpose: Epidural abscesses and subdural empyemas after craniotomy are uncommon, potentially lethal, complications of neurosurgery. Patients with these complications may be difficult to manage and dural reconstruction in these patients are challenging. Methods: A 28 - year - old female patient showed recurrent intracranial infection after craniotomy for evacuation of a arachnoid cyst and subdural hematoma. Despite prolonged systemic antibiotic administration and a debridement of the subdural space, infection persisted, as evidenced by persistent fever, an elevated WBC count, CSF leakage, low CSF glucose level, and purulent wound discharge. The authors removed the previously applied lyophilized dura and transferred free omental flap to reconstruct the dura, obliterate the cyst and cover the cerebral hemisphere in the craniotomy defect. Microvascular anastomosis was between gastroepiploic and superficial temporal vessels. Results: The postoperative course was uneventful and flap survival was excellent. The infection - resistant omental tissue allowed sufficient blood circulation and dead space control. The patient was discharged 1 month after surgery and wound discharge or recurrence was absent during 13 months of follow up periods. Conclusion: The use of vascularized free omentum proved useful in cases of intractable cranial wound infection and cerebrospinal fluid leakages.