Surgical Neurology最新文献

Background

Bicycle-related head injury is an important public health issue. A paucity of statistical data on bicycle accidents exists in Taiwan. The purpose of this study was to report the characteristics of bicycle-related head injuries among school-aged children in Taipei, Taiwan.

Methods

Between 2001 and 2002, basic patient information of those with bicycle-related head injuries was collected from the Trauma Data Registry in 5 hospitals of the Taipei area. Telephone interviews were conducted to collect specific information surrounding bicycle accidents.

Results

Of 324 patients with bicycle-related head injuries, 90 (27.8%) had severe head injuries. Boys compared with girls had a higher proportion of severe head injuries (34.1% vs 23.4%; P = .048). Children aged 5 to 9 years had a higher proportion of severe head injuries compared with ages 10 to 14 years (65.2% vs 6.4%; P = .043). Bicycles without reflectors had a higher proportion of severe head injuries compared to bicycles with reflectors (69.0% vs 5.7%; P = .004). Bicyclists carrying goods (such as backpacks or weighted toward the road) and speeding were associated with severe head injury (P < .05). Collisions with vehicles of a larger size resulted in a higher rate of severe head injury compared with collisions with pedestrians (76.9% vs 3.6%; P = .043).

Conclusions

For children whose main mode of transport is bicycles, the enforcement of helmet legislation, educational programs in bicycling safety and equipment, and improving the infrastructure for bicycling in urban areas are needed in Taiwan to reduce potentially debilitating or life-threatening injuries.

Background

Arterial dissection involving cervicocranial arteries usually results in ischemia or SAH. This study correlated the clinical manifestations, image characteristics, and outcome of arterial dissection and compared the differences between arterial dissection of anterior and posterior circulation at our institute.

Methods

Clinical symptoms and neuroradiologic findings were retrospectively analyzed in 73 patients (6-75 years old) who had a spontaneous arterial dissection of cervicocranial vessels verified by angiography or MRI. Twenty-four cases of ACAD and 49 cases of PCAD were included in this study.

Results

The leading presentation of arterial dissection of ACAD group was ischemic stroke (79.2%), and that of posterior circulation was SAH (44.9%), followed by ischemic stroke (42.8%). In the ACAD group, the extracranial ICA was more commonly involved (62.5%), with long segmental narrowing the most common angiographic finding. In the PCAD group, the intracranial VA was more commonly involved (81.6%), with alternating narrowing and dilatation the leading angiographic picture.

All the cases presenting with ischemic stroke or headache were conservatively treated with anticoagulants or antiplatelets, except for one treated with intra-arterial thrombolysis for thromboembolism in basilar artery at an early stage. One of them died of progressed brainstem infarct in spite of anticoagulation therapy. All the others reached improved or stable clinical condition. Eighteen cases were treated by surgical or endovascular intervention. None of them had rebleeding. Of the 5 patients with SAH due to dissecting lumens without treatment, 2 died of rebleeding.

Conclusions

Ischemia is the predominant presentation of ACAD; and PCAD has similar occurrence of SAH and ischemia. Intracranial arterial dissection is not uncommon; and it should be kept in the list of differential diagnosis of young stroke. Aggressive treatment of arterial dissection presenting with SAH should be considered; otherwise, rebleeding may occur.

Background

Stereotactic radiosurgery has proven a safe and effective treatment of cranial nerve sheath tumors. A similar approach should be successful for histologically identical spinal nerve sheath tumors.

Methods

The preliminary results of linear accelerator–based spinal radiosurgery were retrospectively reviewed for a group of 25 nerve sheath tumors. Tumor location was cervical 11, lumbar 10, and thoracic 4. Thirteen tumors caused sensory disturbance, 12 pain, and 9 weakness. Tumor size varied from 0.9 to 4.1 cm (median, 2.1 cm). Radiosurgery was performed with a 60-MV linear accelerator equipped with a micro-multileaf collimator. Median peripheral dose and prescription isodose were 12 Gy and 90%, respectively. Image guidance involved optical tracking of infrared reflectors, fusion of amorphous silicon radiographs with dynamically reconstructed digital radiographs, and automatic patient positioning. Follow-up varied from 12 to 58 months (median, 18).

Results

There have been no local failures. Tumor size remained stable in 18 cases, and 7 (28%) demonstrated more than 2 mm reduction in tumor size. Of 34 neurologic symptoms, 4 improved. There has been no clinical or imaging evidence for spinal cord injury. One patient had transient increase in pain and one transient increase in numbness.

Conclusions

Results of this limited experience indicate linear accelerator–based spinal radiosurgery is feasible for treatment of benign nerve sheath tumors. Further follow-up is necessary, but our results imply spinal radiosurgery may represent a therapeutic alternative to surgery for nerve sheath tumors. Symptom resolution may require a prescribed dose of more than 12 Gy.

Background

The complex management of dural lacerations occurring after the resection of multilevel ossification of the posterior longitudinal ligament (OPLL) requires further clarification.

Methods

Both preoperative MR and CT studies documented multilevel ventral cord compression attributed to OPLL with kyphosis in 82 patients requiring multilevel anterior corpectomy/fusion (ACF) (average, 2.6 levels) followed by posterior fusion (PF) (average, 6.6 levels) under the same anesthetic. The 5 patients who developed intraoperative dural lacerations/penetration demonstrated the single-layer sign (2 patients: large central mass) or the double-layer sign (3 patients: hyperdense/hypodense/hyperdense layers) on preoperative 2-dimensional CT studies. All 5 patients were managed with complex dural repair (sheep pericardial grafts, fibrin sealant, microfibrillar collagen) and had shunts placed (wound-peritoneal and lumboperitoneal).

Results

After complex dural repair/shunting, all 5 intraoperative dural lacerations (DLs) resolved. The application of low-pressure wound-peritoneal shunts was unique to this study (Uni-Shunts, Codman, Johnson and Johnson, Dorchester, Mass). The proximal end is placed lateral/parallel to the fibula strut graft/plate complex, whereas the distal catheter is tunneled into the peritoneum in the right upper quadrant (always prepared and draped in anticipation of the need for a shunt).

Conclusions

Of 82 patients undergoing multilevel anterior corpectomy for OPLL/kyphosis, 5 developed intraoperative DLs successfully managed with a complex dural repair, wound-peritoneal, and lumboperitoneal shunting procedures.

Background

Because both SCS and HBO therapy have shown some promise in treating patients with states of reduced consciousness, we evaluated the combination of therapies in a prospective trial in comatose patients.

Methods

Twelve patients who had received median nerve stimulation for 3 months without improvement in consciousness received cSCS for 1 year combined with simultaneous HBO therapy for the first 3 months. Another group enrolled 12 patients who received median nerve stimulation only were served as control.

Results

Six patients emerged from coma at 1 year (after conclusion of treatment). Glasgow Coma Scale score, SPECT imaging, and PVS scores (state and reaction subscores) of the 12 patients were all significantly increased at 1 year compared with enrollment (P < .05). Neither respirator nor tracheostomy was needed to assist respiration in any patient. Only 1 of 12 patients still needed nasogastric tube feeding at 1 year. By contrast, control patients (without cSCS and HBO therapy) showed no apparent improvement.

Conclusion

Increase of GCS score, cerebral blood perfusion, and PVS scores were observed in comatose patients treated with combined cSCS and HBO therapy.

Background

Spinal osteomyelitis and epidural abscess are uncommon but have a potentially disastrous outcome, although the surgical techniques and antimicrobial therapy have advanced.

Case Description

We present a case of cervical osteomyelitis and epidural abscess resulting from pharyngeal squamous cell carcinoma ablation, which were treated with a pectoralis major muscle flap successfully.

Conclusion

Muscle flap insertion to the cervical contaminated wound enables radical removal of the contaminated tissue, and the muscle flaps for dead-space obliteration and neovasculation were obligatory for successful management of the infected complex wound. Furthermore, the inserted pectoralis major muscle flap can divide vertebrae and epidural canal from these origins of infection. We believe that this technique is simple, can be performed in a one-stage management, has minimal associated morbidity, and thus, is advocated as a desirable treatment option in the treatment of cervical osteomyelitis and epidural abscess.