Publications by authors named "Kyung Seok Park"

89 Publications

The novel prognostic value of postoperative follow-up lateral spread response after microvascular decompression for hemifacial spasm.

J Neurosurg 2021 Sep 3:1-5. Epub 2021 Sep 3.

Departments of1Neurosurgery.

Objective: The lateral spread response (LSR) is an aberrant electrophysiological response in which a stimulus on one branch of the facial nerve spills over to other branches of the nerve, which can be captured by electrodes near each branch. The authors performed this study to evaluate the prognostic value of the follow-up LSR with a sufficient time interval from intraoperative LSR (IO-LSR) after microvascular decompression (MVD) for hemifacial spasm (HFS), excluding the interference of various intraoperative situations.

Methods: A total of 247 patients treated with MVD for HFS between June 2011 and March 2019 were enrolled in this study. The IO-LSR was routinely evaluated in all patients. The LSR was checked again on postoperative day (POD) 2 after surgery (POD2-LSR). A total of 228 patients (92.3%) were considered cured at the last clinical follow-up.

Results: The IO-LSR disappeared in 189 patients (76.5%), and among them, 181 patients (95.8%) were cured 1 year after surgery. The POD2-LSR disappeared in 193 patients (78.1%), and 185 patients (95.9%) among them were cured. Among the 189 patients in which the IO-LSR disappeared, the POD2-LSR reappeared in 26 patients (13.8%). In contrast, the POD2-LSR disappeared in 30 (51.7%) of 58 patients for whom the IO-LSR continued at the end of surgery. When classified into groups according to the status of the IO-LSR and POD2-LSR, in the group of patients in whom both LSRs disappeared, the cure rate was 98.2%, which was significantly higher than that of the other 3 groups (p < 0.05, Cochran-Armitage trend test). The use of both LSRs was found to be significantly associated with better predictability (p < 0.05, McNemar's test).

Conclusions: Postoperative follow-up LSR examination may be beneficial in predicting clinical outcomes after MVD for HFS, especially when considered together with IO-LSR.
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http://dx.doi.org/10.3171/2021.3.JNS21137DOI Listing
September 2021

Actinomycosis of the nasal cavity.

Braz J Otorhinolaryngol 2021 May 25. Epub 2021 May 25.

Chonnam National University Medical School & Hwasun Hospital, Department of Otolaryngology-Head and Neck Surgery, Hwasun, South Korea.

Introduction: Actinomycosis of the nasal cavity is very rare.

Objective: The purpose of this study was to investigate the clinical features, treatment methods, and treatment results of actinomycosis of the nasal cavity in our hospital.

Methods: We retrospectively enrolled 11 patients with histopathologically identified actinomycosis of the nasal cavity from January 2010 to May 2020.

Results: This study included five males and six females. The most common symptom was purulent nasal discharge (36.4%). Nasal actinomycosis occurred in the maxillary sinus in 5 (45.5%) patients, the ethmoid sinus in two, the hard palate in two, the frontal sinus in one, and the nasal septum in one. After surgery, intravenous administration of antibiotics was performed on average for 7.4 days and oral antibiotics were prescribed for about 120.5 days. The clinical characteristics of the patients with nasal actinomycosis and the duration of antibiotic usage were not significantly different. Trauma was significantly associated with repeated nasal actinomycosis infections (p < 0.05).

Conclusion: Actinomycosis of the nasal cavity should be suspected when a patient with chronic sinusitis does not respond to medical therapy and has a history of dental treatment, local surgery or radiation therapy. Nasal can be sufficiently treated with antibiotics and endoscopic surgery.
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http://dx.doi.org/10.1016/j.bjorl.2021.05.003DOI Listing
May 2021

Efficacy of intraoperative bulbocavernosus reflex monitoring for the prediction of postoperative voiding function in adult patients with lumbosacral spinal tumor.

J Clin Monit Comput 2021 Mar 8. Epub 2021 Mar 8.

Department of Neurology, Seoul National University Bundang Hospital, Seoul National University College of Medicine, 82, Gumi-ro 173 Beon-gil, Bundang-Gu, Seongnam-Si, Geonggi-Do, Republic of Korea.

Lumbosacral spinal tumor surgery is associated with a relatively high risk of postoperative voiding dysfunction. This study aimed to investigate the correlation between intraoperative bulbocavernosus reflex (BCR) changes and postoperative voiding function in adult patients with lumbosacral spinal tumors. We retrospectively reviewed 63 patients who underwent intradural conus and cauda equina tumor surgeries with intraoperative BCR monitoring. We evaluated patients' voiding functions for 6 months postoperatively. BCR was maintained in 60 patients and disappeared in 3 patients at the end of the surgery. Among the patients in whom BCR was maintained, examinations conducted at discharge and at 1- and 6-month follow-ups revealed that 7 (11.7%), 4 (6.7%), and zero (0.0%) patients experienced voiding difficulty, respectively. However, all 3 (100%) patients without BCR experienced voiding difficulty at the three corresponding follow-ups. Data analysis indicated no significant difference in voiding between the maintained and disappeared BCR groups 6-months postoperatively. The sensitivity, specificity, positive predictive, and negative predictive values of intraoperative BCR monitoring for detecting new and worsening difficulty in voiding were all 100% 6 months postoperatively. Our results shows that intraoperative BCR monitoring is a reliable predictor of voiding function following surgery in adult patients undergoing lumbosacral spinal tumor surgery. Intraoperative BCR monitoring can be useful for assessing and monitoring the integrity of the voiding function during lumbosacral spinal tumor surgery.
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http://dx.doi.org/10.1007/s10877-021-00678-0DOI Listing
March 2021

Neurophysiological monitoring during anterior cervical discectomy and fusion for ossification of the posterior longitudinal ligament.

Clin Neurophysiol Pract 2021 3;6:56-62. Epub 2021 Feb 3.

Department of Neurology, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seoul, Republic of Korea.

Objective: This study aimed to investigate the value of intraoperative neurophysiological monitoring (IONM) in anterior cervical spine discectomy with fusion (ACDF) for ossification of the posterior longitudinal ligament (OPLL).

Methods: Patients who underwent multimodal IONM (transcranial electrical motor-evoked potentials [tcMEP], somatosensory-evoked potentials, and continuous electromyography) for ACDF from 2009 to 2019 were compared to historical controls from 2003 to 2009. The rates of postoperative neurological deficits, neurophysiological warnings, and their characteristics were analyzed.

Results: Among 196 patients, postoperative neurological deficit rates were 3.79% and 14.06% in the IONM and historical control (non-IONM) groups, respectively (p < 0.05). The use of IONM (OR: 0.139, p = 0.003) and presence of myelopathy (OR: 8.240, p = 0.013) were associated with postoperative neurological complications on multivariate regression. In total, 23 warnings were observed during IONM (17 tcMEP and/or electromyography; six electromyography). Sensitivity and specificity of IONM warnings for detecting neurological complications were 84.2% and 93.7%, respectively.

Conclusions: IONM, especially multimodal IONM, may be a useful tool to detect neurological damage in ACDF for high-risk conditions such as OPLL with pre-existing myelopathy.

Significance: The utility of IONM in ACDF for OPLL has not been evaluated due to its rarity. This study supports the use of IONM in cervical OPLL with myelopathy.
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http://dx.doi.org/10.1016/j.cnp.2021.01.001DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7905394PMC
February 2021

Predictive value of intraoperative blink reflex monitoring for surgical outcome during microvascular decompression for hemifacial spasm.

Clin Neurophysiol 2020 09 16;131(9):2268-2275. Epub 2020 Jul 16.

Department of Neurology, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seoul,Republic of Korea. Electronic address:

Objective: To investigate the prognostic and predictive value of intraoperative blink reflex (BR) monitoring during microvascular decompression (MVD) for hemifacial spasm (HFS).

Methods: We retrospectively reviewed 41 patients with HFS undergoing MVD with intraoperative BR and lateral spread response (LSR) monitoring. Facial spasm was evaluated for six months postoperatively.

Results: The BR resolved in 38 patients and persisted in three after MVD. For patients who exhibited BR resolution, 1-day, 1-month, and 6-month follow-ups revealed that 35 (92.1%), 35 (92.1%), and 38 (100%) patients had spasm resolution, respectively. However, of the three patients with persistent BR, one (33.3%), one (33.3%), and zero (0%) patients exhibited spasm resolution at the three corresponding follow-ups. We found a statistically significant difference in spasm resolution between the persistent and resolved BR groups at six months postoperatively. A comparison between intraoperative BR and LSR monitoring revealed that BR was a better predictor of clinical outcomes.

Conclusions: Intraoperative BR monitoring is a potentially useful tool to help facilitate an adequate decompression and is a reliable prognostic predictor of surgical outcome.

Significance: This study is the first to document the relationship between intraoperative BR monitoring and surgical outcome in patients with HFS.
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http://dx.doi.org/10.1016/j.clinph.2020.06.025DOI Listing
September 2020

Bone health in neuromyelitis optica: Bone mineral density and fractures.

Mult Scler Relat Disord 2020 Jul 28;42:102080. Epub 2020 Apr 28.

Department of Neurology, Seoul National University Bundang Hospital, Gyeonggi, Republic of Korea; Department of Neurology, Neuroscience Research Institute, Seoul National University College of Medicine, Seoul, Republic of Korea. Electronic address:

Background: The bone health in neuromyelitis optica spectrum disorder with aquaporin-4 immunoglobulin G antibodies (NMOSD-AQP4) have not been fully evaluated. To evaluate the prevalence of fractures and bone loss in patients with NMOSD-AQP4 compared to healthy controls and patients with multiple sclerosis (MS) and to identify the risk factors associated with fractures and low bone mineral density (BMD) in patients with NMOSD-AQP4.

Methods: Seventy-one patients with NMOSD-AQP4 were included. The two control groups consisted of 213 age-, sex-, menopause-, and body mass index (BMI)-matched healthy participants from the Korean National Health and Nutrition Examination Survey (healthy controls) and 41 patients with multiple sclerosis (disease controls). We collected demographic and clinical data related to bone health including BMD and FRAX score.

Results: Patients with NMOSD-AQP4 had a higher prevalence of fractures than the healthy control group (OR = 5.40, CI = 2.004-14.524, p = 0.001), with falling, but not steroid use, being associated with an increased risk of fractures after diagnosis with NMOSD-AQP4 (OR = 24.902, CI = 3.086-200.947, p = 0.003). They also had significantly lower BMD than controls (femur neck, p = 0.044; total hip, p < 0.001), which was more prominent in young participants. The BMD in the NMOSD-AQP4 group was associated with cumulative dose of oral steroids, age, sex, BMI, and partly with the prophylactic calcium supplements. Though the patients with NMOSD-AQP4 did not differ significantly from patients with MS in terms of fracture rate and BMD, they had higher risk of fractures as measured by the Fracture Risk Assessment Tool (for major osteoporotic fractures, (p = 0.001; for hip fractures, p = 0.018).

Conclusion: Patients with NMOSD-AQP4 had a significantly higher risk of fractures that could mostly be attributed to falling. Additionally, low BMD was observed in these patients; it was more prominent among young patients, associated with steroid use, and may partially prevented by the use of prophylactic calcium supplements.
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http://dx.doi.org/10.1016/j.msard.2020.102080DOI Listing
July 2020

Characteristics of forearm mixed nerve conduction study in carpal tunnel syndrome: Comparison with ultrasound assessments.

J Clin Neurosci 2020 Mar 7;73:155-158. Epub 2020 Jan 7.

Department of Neurology, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seoul, Republic of Korea. Electronic address:

This study aimed to characterize forearm mixed nerve conduction study (NCS) findings in carpal tunnel syndrome (CTS). Eighty-two patients with CTS and 48 healthy controls were enrolled. We directly compared the forearm mixed NCS and ultrasonography results from CTS patients with those from the controls. Correlation analyses were performed to identify the relationship between forearm mixed NCS parameters and ultrasound measurements in CTS. We observed reduced forearm mixed nerve amplitude and increased cross-sectional area (CSA) of the median nerve at the proximal carpal tunnel (CT) inlet in CTS. The forearm mixed nerve amplitude negatively correlated with the CSA at the proximal CT inlet. We found a negative correlation between Bland's neurophysiological grade and the forearm mixed nerve amplitude as well as a positive correlation between the CSA of the median nerve at the proximal CT inlet and Bland's neurophysiological grade. We confirmed that the reduced median mixed nerve amplitude is the distinguishing feature of forearm mixed NCS in CTS. Our findings suggest that the forearm mixed NCS is potentially useful in evaluating its severity.
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http://dx.doi.org/10.1016/j.jocn.2019.12.053DOI Listing
March 2020

Successful Treatment of Glycine-Receptor-Antibody-Mediated Progressive Encephalomyelitis with Rigidity and Myoclonus by Combining Steroids and Azathioprine.

J Clin Neurol 2019 Oct;15(4):581-582

Department of Neurology, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam, Korea.

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http://dx.doi.org/10.3988/jcn.2019.15.4.581DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6785484PMC
October 2019

The comparison of recovery patterns between ischemic spinal cord injury and traumatic spinal cord injury from acute to chronic phase.

J Spinal Cord Med 2021 03 16;44(2):288-298. Epub 2019 Sep 16.

Department of Rehabilitation Medicine, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam-si, Gyeonggi-do, South Korea.

To investigate the neurological and functional recovery patterns of ischemic spinal cord injury (ISCI) compared with traumatic spinal cord injury (TSCI) in the acute to chronic phase. Retrospective cohort study. Department of Neurology, Neurosurgery, Rehabilitation Medicine at a tertiary hospital. Fifty-four patients with ISCI and 86 patients with TSCI. Not applicable. MRI findings, American Spinal Injury Association Impairment Scale (AIS), modified Rankin Scale (mRS), Korean Spinal Cord Independence Measure (KSCIM), ambulatory status, and bladder status were reviewed. The functional outcomes were measured at admission, discharge, and >6 months after discharge. AIS classification did not significantly change after 6 months in both ISCI and TSCI groups. Between admission and discharge, the proportion of patients needing a wheelchair or assistive device to ambulate decreased more in the ISCI group compared with the TSCI group [odds ratio (OR) 0.40, P = 0.04]. In addition, the proportion of catheterized voiding in the ISCI group was significantly higher than in the TSCI group at all time points (OR 5.12, P < 0.001). Lastly, both groups showed that functional improvement was the greatest between admission and discharge. In addition, the proportion of catheterized voiding decreased (Diff = -0.12, P = 0.019) and mRS score decreased (Diff=-0.48, P < 0.001) significantly in the ISCI group at >6 months post discharge. The ISCI group showed better recovery of mobility during inpatient rehabilitation period and worse recovery of bladder function as demonstrated by higher number of patients requiring bladder catheterization at all time points when compared with the TSCI group.
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http://dx.doi.org/10.1080/10790268.2019.1658338DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7952050PMC
March 2021

Intraoperative neuromonitoring during microsurgical clipping for unruptured anterior choroidal artery aneurysm.

Clin Neurol Neurosurg 2019 Nov 27;186:105503. Epub 2019 Aug 27.

Department of Neurology, Seoul National University Bundang Hospital, Seongnam-si, Gyeonggi-do, South Korea. Electronic address:

Objective: To investigate the safety and unexpected finding of the intraoperative neuromonitoring (IONM) including somatosensory evoked potentials (SSEPs) and motor evoked potentials (MEPs) during microsurgical clipping of an unruptured anterior choroidal artery (AChA) aneurysm.

Patients And Methods: From January 2011 to March 2018, the neurophysiological, clinical, and radiological data of 115 patients who underwent microsurgical clipping for an unruptured AChA aneurysm under IONM were retrospectively analyzed. The incidence of ischemic complications after microsurgical clipping of unruptured AChA aneurysms as well as the false-negative rate, sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) of IONM during surgery were calculated.

Results: Ischemic complications after the microsurgical clipping of an AChA aneurysm under IONM occurred in 7 of 115 patients (6.08%). Among them, 3 were symptomatic (2.6%). The false-negative rate of IONM for ischemic complications was 6.08% (7 patients). High specificity; 100% (95% confidence interval [95% CI] = 0.972-1.000), PPVs; 100% (95% CI = 0.055-1.000), and NPVs; 93% (95% CI = 0.945-0.973) with low sensitivity; 11.1% (95% CI = 0.006-0.111) were calculated.

Conclusions: IONM including transcranial MEP during microsurgical clipping of unruptured AChA aneurysm might have limited usefulness. Therefore, other MEP monitoring using direct cortical stimulation or modified transcranial methodology should be considered to compensate for it.
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http://dx.doi.org/10.1016/j.clineuro.2019.105503DOI Listing
November 2019

Correction to: Is the new ASNM intraoperative neuromonitoring supervision "guideline" a trustworthy guideline? A commentary.

J Clin Monit Comput 2019 04;33(2):191-192

Division of Neuroanesthesia, College of Medicine, University of Florida, Gainesville, FL, USA.

The article Is the new ASNM intraoperative neuromonitoring supervision "guideline" a trustworthy guideline? A commentary, written by Stanley A. Skinner, Elif Ilgaz Aydinlar, Lawrence F. Borges, Bob S. Carter, Bradford L. Currier, Vedran Deletis, Charles Dong, John Paul Dormans, Gea Drost, Isabel Fernandez‑Conejero, E. Matthew Hoffman, Robert N. Holdefer, Paulo Andre Teixeira Kimaid, Antoun Koht, Karl F. Kothbauer, David B. MacDonald, John J. McAuliffe III, David E. Morledge, Susan H. Morris, Jonathan Norton, Klaus Novak, Kyung Seok Park, Joseph H. Perra, Julian Prell, David M. Rippe, Francesco Sala, Daniel M. Schwartz, Martín J. Segura, Kathleen Seidel, Christoph Seubert, Mirela V. Simon, Francisco Soto, Jeffrey A. Strommen, Andrea Szelenyi, Armando Tello, Sedat Ulkatan, Javier Urriza and Marshall Wilkinson, was originally published electronically on the publisher's internet portal (currently SpringerLink) on 05 January 2019 without open access. With the author(s)' decision to opt for Open Choice the copyright of the article changed on 30 January 2019 to © The Author(s) 2019 and the article is forthwith distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits use, duplication, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license and indicate if changes were made. The original article has been corrected.
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http://dx.doi.org/10.1007/s10877-019-00266-3DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6420422PMC
April 2019

Teaching Video NeuroImages: Horizontal gaze palsy with progressive scoliosis.

Neurology 2019 02;92(8):e886-e887

From the Departments of Ophthalmology (H.K.Y., J.-M.H.), Neurology (J.-Y.C., K.S.P.), and Radiology (J.H.K.), Seoul National University College of Medicine, Seoul National University Bundang Hospital, Seongnam, South Korea.

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http://dx.doi.org/10.1212/WNL.0000000000006962DOI Listing
February 2019

Evaluation and validation of sustained upgaze combined with the ice-pack test for ocular myasthenia gravis in Asians.

Neuromuscul Disord 2019 04 22;29(4):296-301. Epub 2018 Dec 22.

Department of Neurology, Seoul National University College of Medicine, Seoul National University Bundang Hospital, Seongnam, Gyeonggi-do, South Korea.

The accuracy of the ice-pack test for diagnosing myasthenia gravis (MG) has been reported to be excellent, however, the sensitivity is low in patients with mild ptosis which is common in Asians who have absent or low double eyelid folds. Herein, we performed the ice-pack test after sustained upgaze and tested its validity for diagnosing MG. The study included 30 newly diagnosed MG patients with ptosis (median age 47 years, range 2-87 years) and 30 controls with ptosis other than MG (median age 58 years, range 5-83 years). All MG patients initially presented with ptosis and/or diplopia; 26 patients had purely ocular MG while 4 patients progressed to generalized MG. All patients performed the new ice-pack test after sustained upgaze for 2 min. The ice-pack test was judged positive if there was an improvement of at least 2 mm of margin reflex distance compared to the level of ptosis before (conventional ice-pack test) or after (new ice-pack test) sustained upgaze. Subgroup analysis was performed according to the level of ptosis. The conventional test showed 43.3% sensitivity and 100% specificity for diagnosing MG, while the new ice-pack test achieved 73.3% sensitivity and 96.7% specificity, respectively. In patients with mild ptosis, the sensitivity and specificity for diagnosing MG were 27.8% and 100% by the conventional test, and 72.2% and 96.7% by the new ice-pack test, respectively. The new ice-pack test combined with sustained upgaze was more sensitive for diagnosing MG, particularly in patients with mild ptosis which is common in Asians.
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http://dx.doi.org/10.1016/j.nmd.2018.12.011DOI Listing
April 2019

Abnormalities of Otoacoustic Emissions in Myasthenia Gravis: Association With Serological and Electrophysiological Features.

Front Neurol 2018 20;9:1124. Epub 2018 Dec 20.

Department of Neurology, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seoul, South Korea.

To investigate whether otoacoustic emissions (OAEs) are impaired in patients with myasthenia gravis (MG) and whether such dysfunction is associated with serological and electrophysiological features of MG. We tested 15 patients with MG (30 ears) and 10 healthy age- and sex-matched subjects (20 ears) for transiently evoked OAE (TEOAE) and distortion product OAE (DPOAE). Compared with controls, MG patients revealed a significant reduction in the amplitude of TEOAEs ( < 0.05) and DPOAEs at higher frequencies between 2,026 and 4,053 Hz ( < 0.05). In the subgroup analysis, TEOAE and DPOAE amplitudes were significantly lower in the acetylcholine receptor (AChR) antibody-positive group ( < 0.05) as well as in the repetitive nerve stimulation (RNS)-positive ( < 0.05) group. In particular, the OAE alteration significantly correlated with anti-AChR antibody titers. No significant difference of the OAEs was found between thymomatous and non-thymomatous MG or between purely ocular and generalized MG. Our study confirms that OAEs reveal subclinical dysfunction of the cholinergic neurotransmission of cochlear outer hair cells and correlate well with electrophysiological and serological characteristics of MG patients. Our findings imply that the measurement of OAEs might increase the diagnostic accuracy and help to monitor the severity of MG.
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http://dx.doi.org/10.3389/fneur.2018.01124DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6306561PMC
December 2018

Failure to generate baseline muscle motor evoked potentials during spine surgery: Risk factors and association with the postoperative outcomes.

Clin Neurophysiol 2018 11 22;129(11):2276-2283. Epub 2018 Aug 22.

Department of Neurology, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seoul, Republic of Korea. Electronic address:

Objective: To identify factors associated with the failure to generate baseline muscle motor evoked potentials (mMEPs) during spinal surgery, and to determine the association between baseline mMEP generation and postoperative outcomes.

Methods: A total of 345 patients who underwent spine surgery with intraoperative mMEP monitoring were included, and we retrospectively reviewed their demographic/clinical parameters, and mMEP recording results according to lesion locations.

Results: Multivariable logistic regression analysis revealed that preoperative Medical Research Council grade of the weakest muscle <3 was significantly associated with failure of baseline mMEP generation in both cervical and thoracic lesions. In addition, high intramedullary T2 signal intensity on spine MRI for cervical lesions and male sex for thoracic lesions were also significantly associated with baseline mMEP generation failure. Moreover, the failure of baseline mMEP generation was a significantly associated factor for poor functional outcome in patients with thoracic lesions.

Conclusion: Sex, radiological abnormality, and preoperative functional status were associated with baseline mMEP generation failure during spine surgery with different patterns according to lesion location. Moreover, baseline mMEP generation failure in thoracic lesion could be associated with risk of postoperative deficits.

Significance: The risk of baseline mMEP recording failure could be evaluated based on preoperative clinical parameters.
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http://dx.doi.org/10.1016/j.clinph.2018.08.001DOI Listing
November 2018

Risk Factor Analysis of Change in Intraoperative Neurophysiologic Monitoring During Cervical Open Door Laminoplasty.

World Neurosurg 2018 Nov 23;119:e235-e243. Epub 2018 Jul 23.

Department of Neurology, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seoul, Korea.

Objective: The aim of this study is to determine the risk factors affecting intraoperative neurophysiologic monitoring (IONM) changes, when such changes take place, and clinical outcomes associated with IONM change during cervical open door laminoplasty (COL) for cervical compressive myelopathy.

Methods: Between 2010 and 2015, 79 patients who underwent COL with IONM recording were studied. Changes in motor evoked potentials or somatosensory evoked potentials over an alarm criterion were defined as IONM change. Patients with IONM change were assigned to the alarm group, and the others were classified as the control group. Baseline data and radiographic measurements were compared between the 2 groups. Radiologic parameters including maximal compression level (MCL), area and diameter of the spinal canal and ventral compressive lesion, stenosis grade, and occupying ratio of area (ORA) and length at the MCL were measured with magnetic resonance imaging.

Results: Thirteen patients were assigned to the alarm group and 66 patients were assigned to the control group. Multivariate analysis identified ORA at the MCL (odds ratio, 1.520; 95% confidence interval, 1.192-1.37; P = 0.001) as an independent risk factor for IONM change. Immediately after decompression, the IONM change occurred. One of 4 patients who did not fully recover from the IONM change had postoperative motor deficits.

Conclusions: IONM change during COL occurred immediately after decompression, and a risk factor of IONM change was ORA at the MCL. If the IONM change was not fully recovered, a new motor deficit occurred after COL.
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http://dx.doi.org/10.1016/j.wneu.2018.07.121DOI Listing
November 2018

Efficacy of Gaze Photographs in Diagnosing Ocular Myasthenia Gravis.

J Clin Neurol 2018 Jul 31;14(3):333-338. Epub 2018 May 31.

Department of Ophthalmology, Seoul National University College of Medicine, Seoul, Korea.

Background And Purpose: The various tests that are routinely used to diagnose generalized myasthenia gravis, such as the edrophonium test, serum anti-acetylcholine-receptor antibodies (AChR-Ab), and repetitive nerve stimulation (RNS) tests, have lower diagnostic sensitivity in ocular myasthenia gravis (OMG). Diagnosing OMG becomes even more difficult when the clinical symptoms are subtle. There is no gold-standard diagnostic test available for OMG patients, and so this study compared the diagnostic sensitivity of gaze photographs with conventional tests in OMG.

Methods: Records of gaze photographs were available for 25 of 31 consecutive patients diagnosed with OMG. Each patient underwent a neuro-ophthalmologic examination, serum AChR-Ab, RNS, edrophonium test, ice tests, and the acquisition of gaze photographs. The margin reflex distance 1 (MRD1) was measured on each of the gaze photographs, with MRD1 <2 mm or an interlid MRD1 difference of ≥2 mm on any of the gaze photographs defined as a positive sign of OMG. The diagnostic sensitivities of the tests were assessed.

Results: The mean age at onset was 38.5 years (range, 2-76 years), and 13 patients (52%) were men. The diagnostic sensitivities of the RNS test, AChR-Ab test, gaze photographs, and ice test were 56%, 64%, 80%, and 73%, respectively.

Conclusions: The diagnostic sensitivity was higher for gaze photographs than for the other tests applied to OMG patients.
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http://dx.doi.org/10.3988/jcn.2018.14.3.333DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6031998PMC
July 2018

Anti-NMDA-receptor optic neuritis in a patient with a history of encephalitis.

Can J Ophthalmol 2017 12 26;52(6):e216-e218. Epub 2017 Jun 26.

Department of Ophthalmology, Seoul National University College of Medicine, Seoul National University Bundang Hospital, Seongnam, Korea. Electronic address:

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http://dx.doi.org/10.1016/j.jcjo.2017.04.018DOI Listing
December 2017

Clevudine Induced Mitochondrial Myopathy.

J Korean Med Sci 2017 Nov;32(11):1857-1860

Department of Hepatology, Dongguk University Ilsan Hospital, Goyang, Korea.

Clevudine was approved as an antiviral agent for hepatitis B virus, which showed marked, rapid inhibition of virus replication without significant toxicity. However, several studies have reported myopathy associated with clevudine therapy. Also, we experienced seven patients who suffered from myopathy during clevudine therapy. To characterize clevudine-induced myopathy, we collected previously reported cases of clevudine myopathy and analyzed all the cases including our cases. We searched electronic databases that were published in English or Korean using PubMed and KoreaMed. Ninety-five cases with clevudine myopathy, including our seven cases, were selected and analyzed for the demographic data, clinical features, and pathologic findings. The 95 patients with clevudine-induced myopathy comprised 52 women and 43 men aged 48.9 years (27-76 years). The patients received clevudine therapy for about 14.2 months (5-24 months) before the development of symptoms. Weakness mainly involved proximal extremities, especially in the lower extremities, and bulbar and neck weakness were observed in some cases (13.7%). Creatine kinase was elevated in the majority of patients (97.9%). Myopathic patterns on electromyography were observed in most patients examined (98.1%). Muscle biopsy presented patterns compatible with mitochondrial myopathy in the majority (90.2%). The weakness usually improved within about 3 months after the discontinuation of clevudine. Though clevudine has been known to be safe in a 6-month clinical trial, longer clevudine therapy for about 14 months may cause reversible mitochondrial myopathy. Careful clinical attention should be paid to patients with long-term clevudine therapy.
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http://dx.doi.org/10.3346/jkms.2017.32.11.1857DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5639069PMC
November 2017

Corticobulbar motor evoked potentials from tongue muscles used as a control in cervical spinal surgery.

Clin Neurophysiol Pract 2017 7;2:124-129. Epub 2017 Jun 7.

Department of Neurology, Seoul National University Bundang Hospital, Seoul National University, College of Medicine, Seoul, South Korea.

Objective: Motor evoked potentials (MEPs) changes might be caused to the non-surgically induced factors during cervical spinal surgery. Therefore, control MEPs recorded cranially to the exit of the C5 root are highly recommendable in cervical spinal surgery. We studied whether corticobulbar MEPs (C-MEPs) from tongue muscle could be used as a control MEPs in cervical spinal surgery.

Methods: Twenty-five consecutive cervical spinal surgeries were analyzed. Stimulation of motor area for tongue was done by subcutaneous electrodes placed at C3/C4 (10-20 EEG System), and recording was done from both sides of tongue.

Results: C-MEPs were recorded successfully 24 out of the 25 (96%) tested patients. Forty-six out of fifty MEPs (92%) from tongue muscles were monitorable from the baseline. In two patients, we could obtain only unilateral C-MEPs. Mean MEPs latencies obtained from the left and right side of the tongue were 11.5 ± 1 ms and 11.5 ± 0.8 ms, respectively.

Conclusions: Monitoring C-MEPs from tongue muscles might be useful control in cervical spinal surgery. They were easily elicited and relatively free from phenomenon of peripheral stimulation of the hypoglossal nerves.

Significance: This is first study to identify the usefulness of C-MEPs as a control of cervical spinal surgery.
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http://dx.doi.org/10.1016/j.cnp.2017.05.003DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6123852PMC
June 2017

Multi-channel motor evoked potential monitoring during anterior cervical discectomy and fusion.

Clin Neurophysiol Pract 2017 9;2:48-53. Epub 2017 Jan 9.

Department of Neurology, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seoul, Republic of Korea.

Objectives: Anterior cervical discectomy and fusion (ACDF) surgery is the most common surgical procedure for the cervical spine with low complication rate. Despite the potential prognostic benefit, intraoperative neurophysiological monitoring (IONM), a method for detecting impending neurological compromise, is not routinely used in ACDF surgery. The present study aimed to identify the potential benefits of monitoring multi-channel motor evoked potentials (MEPs) during ACDF surgery.

Methods: We retrospectively reviewed 200 consecutive patients who received IONM with multi-channel MEPs and somatosensory evoked potentials (SSEPs). On average, 9.2 muscles per patient were evaluated under MEP monitoring.

Results: The rate of MEP change during surgery in the multi-level ACDF group was significantly higher than the single-level group. Two patients from the single-level ACDF group (1.7%) and four patients from the multi-level ACDF group (4.9%) experienced post-operative motor deficits. Multi-channel MEPs monitoring during single and multi-level ACDF surgery demonstrated higher sensitivity, specificity, positive predictive and negative predictive value than SSEP monitoring.

Conclusions: Multi-channel MEP monitoring might be beneficial for the detection of segmental injury as well as long tract injury during single- and multi-level ACDF surgery.

Significance: This is first large scale study to identify the usefulness of multi-channel MEPs in monitoring ACDF surgery.
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http://dx.doi.org/10.1016/j.cnp.2016.12.006DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6123893PMC
January 2017

25-Hydroxycholesterol is involved in the pathogenesis of amyotrophic lateral sclerosis.

Oncotarget 2017 Feb;8(7):11855-11867

Department of Neurology, Hanyang University, College of Medicine, Seoul, Korea.

This study aimed to evaluate the levels of three major hydroxycholesterols (24-, 25-, and 27-hydroxycholesterols) in the serum and cerebrospinal fluid (CSF) of patients with amyotrophic lateral sclerosis (ALS), as well as to show their role in the pathogenesis of ALS experimental models. The level of 25-hydroxycholesterol were higher in untreated ALS patients (n = 30) than in controls without ALS (n = 33) and ALS patients treated with riluzole (n = 9) both in their serum and CSF. The level of 25-hydroxycholesterol in the serum of ALS patients were significantly associated with their disease severity and rate of progression. In the motor neuron-like cell line (NSC34) with the human mutant G93A superoxide dismutase 1 gene (mSOD1-G93A), 25-hydroxycholesterol induced motor neuronal death/ apoptosis via glycogen synthase kinase-3β and liver X receptor pathways; riluzole treatment attenuated these effects. The expressions of enzymes that synthesize 25-hydroxycholesterol were significantly increased in the brains of early symptomatic mSOD1G93A mice. Our data, obtained from patients with ALS, a cellular model of ALS, and an animal model of ALS, suggests that 25-hydroxycholesterol could be actively involved in the pathogenesis of ALS, mostly in the early symptomatic disease stage, by mediating neuronal apoptosis.
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http://dx.doi.org/10.18632/oncotarget.14416DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5355309PMC
February 2017

Is thyrotoxic periodic paralysis a disease caused by muscle membrane dysfunction?

Muscle Nerve 2017 Oct 21;56(4):780-786. Epub 2017 Mar 21.

Department of Neurology, Seoul National University Bundang Hospital, Seoul National University College of Medicine, 166 Gumi-Ro, Bundang-Gu, Seongnam-Si, Geonggi-Do, Seoul, Republic of Korea.

Introduction: Thyrotoxic periodic paralysis (TPP) is characterized by recurrent episodes of reversible paralysis with hyperthyroidism. It is clinically similar to hypokalemic periodic paralysis (HOPP), which features significant ion-channel dysfunction and reduced muscle fiber conduction velocity (MFCV). However, the muscle membrane function in TPP is not known.

Methods: For 13 patients with TPP and 15 age-matched controls, clinical assessment and serial neurophysiological testing, including nerve conduction, prolonged exercise (PE) testing, and MFCV. were performed.

Results: MFCV values were elevated up to 1 year from the paralytic attack in TPP patients. In the group with a positive PE test, MFCV values were higher. There was no significant relationship between MFCV values and either hypokalemia or hyperthyroidism.

Conclusions: Although clinical manifestations in TPP are similar to those observed in HOPP, TPP appears to feature an alternate pathogenic mechanism. Specifically, MFCV values increased rather than decreased. Further studies are needed to support these findings. Muscle Nerve, 2016 Muscle Nerve 56: 780-786, 2017.
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http://dx.doi.org/10.1002/mus.25532DOI Listing
October 2017

Hydroxycholesterol Levels in the Serum and Cerebrospinal Fluid of Patients with Neuromyelitis Optica Revealed by LC-Ag+CIS/MS/MS and LC-ESI/MS/MS with Picolinic Derivatization: Increased Levels and Association with Disability during Acute Attack.

PLoS One 2016 12;11(12):e0167819. Epub 2016 Dec 12.

Doping Control Center, Korea Institute of Science and Technology, Seoul, Korea.

Neuromyelitis optica (NMO) is an inflammatory demyelinating disease of the central nervous system (CNS). Hydroxycholesterols (OHCs), metabolites of CNS cholesterol, are involved in diverse cellular responses to inflammation and demyelination, and may also be involved in the pathogenesis of NMO. We aimed to develop a sensitive and reliable method for the quantitative analysis of three major OHCs (24S-, 25-, and 27-OHCs), and to evaluate their concentration in the cerebrospinal fluid (CSF) and serum of patients with NMO. The levels of the three OHCs in the serum and CSF were measured using liquid chromatography-silver ion coordination ionspray tandem mass spectrometry and liquid chromatography-electrospray ionization tandem mass spectrometry with picolinyl ester derivatization, respectively. The linear range was 5-250 ng/mL for 24S- and 27-OHC, and 0.5-25 ng/mL for 25-OHC in serum, and was 0.1-5 ng/mL for 24S- and 27-OHC, and 0.03-1 ng/mL for 25-OHC in CSF. Precision and accuracy were 0.5%-14.7% and 92.5%-109.7%, respectively, in serum, and were 0.8%-7.7% and 94.5%-119.2%, respectively, in CSF. Extraction recovery was 82.7%-90.7% in serum and 68.4%-105.0% in CSF. When analyzed in 26 NMO patients and 23 control patients, the 25-OHC (0.54 ± 0.96 ng/mL vs. 0.09 ± 0.04 ng/mL, p = 0.032) and 27-OHC (2.68 ± 3.18 ng/mL vs. 0.68 ± 0.25 ng/mL, p = 0.005) were increased in the CSF from NMO patients. When we measured the OHCCSF index that controls the effects of blood-brain barrier disruption on the level of OHC in the CSF, the 27-OHCCSF index was associated with disability (0.723; 95% confidence interval (CI)- 0.181, 0.620; p = 0.002), while the 24-OHCCSF index (0.518; 95% CI- 1.070, 38.121; p = 0.040) and 25-OHCCSF index (0.677; 95% CI- 4.313, 18.532; p = 0.004) were associated with the number of white blood cells in the CSF of NMO patients. Our results imply that OHCs in the CNS could play a role in the pathogenesis of NMO.
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http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0167819PLOS
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5152860PMC
June 2017

The incidence of and risk factors for ischemic complications after microsurgical clipping of unruptured middle cerebral artery aneurysms and the efficacy of intraoperative monitoring of somatosensory evoked potentials: A retrospective study.

Clin Neurol Neurosurg 2016 Dec 14;151:128-135. Epub 2016 Oct 14.

Department of Neurology, Seoul National University Bundang Hospital, Seoul National University Bundang Hospital, 82 Gumi-Ro 173 Beon-Gil, Bundang-Gu, Seongnam-Si, Gyeonggi-Do 13620, Korea. Electronic address:

Objectives: Ischemic complications (ICs) account for 6.7% after microsurgical clipping of unruptured intracranial aneurysms. This study aimed to evaluate the efficacy of somatosensory evoked potential (SSEP) monitoring during microsurgical clipping of unruptured middle cerebral artery (MCA) aneurysms and evaluate the incidence of and risk factors for ischemic complications after clipping of unruptured MCA aneurysms.

Patients And Methods: Herein, 1208 patients with cerebral aneurysms and treated with microsurgical clipping between May 2003 and February 2015 were enrolled. Those with multiple aneurysms, history of head trauma, subarachnoid hemorrhage, bypass and/or endovascular treatment, and intraoperative rupture were excluded. Subsequently, 411 patients with single unruptured MCA aneurysms treated with simple microsurgical clipping were enrolled. Patients were divided into two groups based on the application of SSEP monitoring during surgery.

Results: The IC rate was 0.9% and 5.6% in the SSEP and non-SSEP groups, respectively. Univariate analysis revealed that age≥62.5years, aneurysm size≥4.15mm, temporary clipping, history of hyperlipidemia and stroke, and no-SSEP monitoring were risk factors for ICs. Multivariate logistic regression analysis showed that age≥62.5years (odds ratio [OR]=7.7; 95% confidence interval [95% CI]=1.5-37.7; P=0.011), previous stroke (OR=26.8, 95% CI=2.4-289.2, P=0.007), and inversely SSEP monitoring (OR=0.14, 95% CI 0.02-0.72, P=0.019) were independent risk factors for ICs.

Conclusion: Clinicians should consider the possibility of IC during microsurgical clipping of unruptured MCA aneurysms in patient≥62.5years and/or a history of stroke. Intraoperative SSEP monitoring is an effective and feasible tool for preventing IC.
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http://dx.doi.org/10.1016/j.clineuro.2016.10.008DOI Listing
December 2016

Gender effect on neuromyelitis optica spectrum disorder with aquaporin4-immunoglobulin G.

Mult Scler 2017 Jul 19;23(8):1104-1111. Epub 2016 Oct 19.

Department of Neurology, Seoul National University College of Medicine, Seoul, Korea/Department of Neurology, Seoul National University, Bundang Hospital, Seongnam, Korea.

Background: Neuromyelitis optica spectrum disorder with aquaporin4-immunoglobulin G (NMOSD-AQP4) is an inflammatory disease characterised by a high female predominance. However, the effect of gender in patients with NMOSD-AQP4 has not been fully evaluated.

Objective: The aim of this study was to determine the effect of gender in clinical manifestations and prognosis of patients with NMOSD-AQP4.

Methods: The demographics, clinical and radiological characteristics, pattern reversal visual evoked potential (VEP) test results, and prognosis of 102 patients (18 males) with NMOSD-AQP4 were assessed.

Results: Male patients had a higher age at onset (48.7 vs 41 years, p = 0.037) and less optic neuritis as the onset attack (17% vs 44%, p = 0.026), higher tendency to manifest as isolated myelitis over the follow-up period (67% vs 28%, p = 0.005), fewer optic neuritis attacks per year (0.08 vs 0.27, p < 0.001), and shorter relative P100 latency on VEP testing (97.1% vs 108.3%, p = 0.001). Moreover, male gender was significantly associated with the absence of optic neuritis attacks over the follow-up period independent of their age of onset.

Conclusion: In NMOSD-AQP4 patients, gender impacts on disease onset age and site of attack. This may be an important clue in identifying NMOSD-AQP4 patients with limited manifestations as well as in predicting their clinical courses.
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http://dx.doi.org/10.1177/1352458516674366DOI Listing
July 2017

Intraoperative Motor-Evoked Potential Disappearance versus Amplitude-Decrement Alarm Criteria During Cervical Spinal Surgery: A Long-Term Prognosis.

J Clin Neurol 2017 Jan 7;13(1):38-46. Epub 2016 Oct 7.

Department of Neurology, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Korea.

Background And Purpose: We studied the clinical significance of amplitude-reduction and disappearance alarm criteria for transcranial electric muscle motor-evoked potentials (MEPs) during cervical spinal surgery according to different lesion locations [intramedullary (IM) vs. nonintramedullary (NIM)] by evaluating the long-term postoperative motor status.

Methods: In total, 723 patients were retrospectively dichotomized into the IM and NIM groups. Each limb was analyzed respectively. One hundred and sixteen limbs from 30 patients with IM tumors and 2,761 limbs from 693 patients without IM tumors were enrolled. Postoperative motor deficits were assessed up to 6 months after surgery.

Results: At the end of surgery, 61 limbs (2.2%) in the NIM group and 14 limbs (12.1%) in the IM group showed MEP amplitudes that had decreased to below 50% of baseline, with 13 of the NIM limbs (21.3%) and 2 of the IM limbs (14.3%) showing MEP disappearance. Thirteen NIM limbs (0.5%) and 5 IM limbs (4.3%) showed postoperative motor deficits. The criterion for disappearance showed a lower sensitivity for the immediate motor deficit than did the criterion for amplitude decrement in both the IM and NIM groups. However, the disappearance criterion showed the same sensitivity as the 70%-decrement criterion in IM (100%) and NIM (83%) surgeries for the motor deficit at 6 months after surgery. Moreover, it has the highest specificity for the motor deficits among diverse alarm criteria, from 24 hours to 6 months after surgery, in both the IM and NIM groups.

Conclusions: The MEP disappearance alarm criterion had a high specificity in predicting the long-term prognosis after cervical spinal surgery. However, because it can have a low sensitivity in predicting an immediate postoperative deficit, combining different MEP alarm criteria according to the aim of specific instances of cervical spinal surgery is likely to be useful in practical intraoperative monitoring.
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http://dx.doi.org/10.3988/jcn.2017.13.1.38DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5242147PMC
January 2017
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