Posterior Median Approach Research Articles

Thoracic Intraspinal Ganglioneuroma with Cough as Its Main Symptom:Report of One Case

The ganglioneuroma is a benign tumor originating from sympathetic ganglion cells.It often locates in the posterior mediastinum,retroperitoneum,and adrenal medulla.The intraspinal ganglioneuromas is relatively rare in clinical practice,which mainly locates in the cervical and thoracolumbar segments.A patient with main symptom of cough was examined by magnetic resonance imaging before operation in our center.Intraspinal ganglioneuromas was confirmed in the left intervertebral cavity area.Total resection of the tumor via the posterior median approach was performed.HE staining showed the mature ganglion cells were scattered.The patient was followed up for three months and no tumor recurrence occured.

Early effectiveness of minimally invasive open reduction and internal fixation versus arthroscopic double-tunnel suture fixation for tibial avulsion fracture of posterior cruciate ligament

To compare the early effectiveness of minimally invasive open reduction and internal fixation via posterior median approach versus arthroscopic double-tunnel suture fixation in treatment of tibial avulsion fracture of the posterior cruciate ligament (PCL). A clinical data of 31 patients with the tibial avulsion fracture of the PCL and met the criteria between January 2015 and January 2019 was retrospectively analyzed. Nineteen patients (group A) were treated with open reduction and internal fixation with cannulated screw via posterior median approach. The other 12 patients (group B) were treated with arthroscopic double-tunnel suture fixation technique. There was no significant difference between the two groups ( P>0.05) in the gender, age, side of effected limb, the injury cause, the time from injury to operation, the combined meniscus injury, Meyers & McKeever classification and preoperative Lysholm score, Tegner score, International Knee Documentation Committee (IKDC) score, and the difference of tibial posterior displacement between bilateral knees. The operation time, postoperative complications, fracture healing, and the difference of tibial posterior displacement between bilateral knees, Lysholm score, Tegner score, and IKDC score were recorded. Group B spent significantly longer operation time than group A ( t=7.347, P=0.000). No postoperative complication occurred in group B, and 1 patient in group A had a screw breakage. All patients were followed up 6-36 months (mean, 22 months). X-ray films showed that all fractures healed at 3 months after operation. At last follow-up, there was no significant difference in the patients with normal knee range of motion between the two groups ( P=0.510). At last follow-up, the difference of tibial posterior displacement between bilateral knees, Lysholm score, Tegner score, and IKDC score in the two groups were superior to those before operation ( P<0.05); while there was no significant difference between the two groups ( P>0.05). For the tibial avulsion fracture of PCL, the minimally invasive open reduction and internal fixation and arthroscopic double-tunnel suture fixation can obtain similar early effectiveness. However, arthroscopic surgery has the advantages of being able to simultaneously deal with intra-articular combined injuries, avoiding internal fixator complications, and eliminating the need for secondary operation.

Efficiency of using polyacrylic acid silver salt in decompression and stabilization surgery on the lumbar spine involving 1 to 3 segments

Objective. To determine possible effect of the preparation of an incomplete polyacrylic acid silver salt on the volume of intraoperative and postoperative blood loss in open posterior surgery on the spine involving up to three segments.Material and Methods. Study design: randomized prospective multicenter cohort analysis. Level of evidence – IIb. The study was based on 90 patients aged 27 to 65 years who underwent decompression and stabilization surgical interventions on the lumbar spine through posterior median approach using transpedicular fixation system with fixation of up to three vertebrae. A comparison of perioperative blood loss volume in patients with local application of polyacrylic acid silver salt and without it was performed.Results. The volume of inraoperative blood loss (the sample was described using the mean value and standard deviation M ± σ) in the study group was 258.1 ± 164.5 ml (min 90; max 890), in the control group – 405.5 ± 157.9 ml (min 190; max 950). The postoperative blood loss through drainage (M ± σ) was 81.500 ± 77.046 ml (min 20; max 400) in the study group, 151.560 ± 74.745 (min 20; max 600) in the control group. Comparison of both intraoperative and postoperative blood loss according to the Mann-Whitney U-test confirms the high statistical significance of differences (p &lt; 0.01), which suggests the effectiveness of the preparation.Conclusion. The use of incomplete polyacrylic acid silver salt in decompression and stabilization interventions on the lumbar spine involving 1 to 3 segments can effectively reduce the volume of blood loss both during surgery and in the postoperative period.

Scoliosis induced by costotransversectomy in minipigs model.

Aim To validate surgical costotransversectomy as a technique for creating a scoliosis model in minipigs and to assess whether differences in approach (posterior medial approach, posterior paramedial approach and anterior approach by video-assisted thoracoscopy) lead to differences in the production of spinal deformity. Creation of disease models in experimental animals, specifically in minipigs, is controversial, as no appropriate technique has been reported. Methods Surgical costotransversectomy was performed in 11 minipigs using 3 different approaches: posterior medial approach (4 animals, group I), posterior paramedial approach (3 animals, group II) and anterior approach by videothoracoscopy (4 animals, group III). A conventional x-ray study was performed in the immediate postoperative period. Follow-up lasted for 4 months. Specimens were humanely killed according to current protocols, and a second x-ray study was performed. A deformation was measured using the Cobb angle and direct observation of the rotational component. Results Data from group I revealed a scoliosis deformation of 27º-41º (mean 34.5º) with a macroscopic rotational component. No deformity (<10º) or rotational component was observed in groups II and III. Only a posterior medial costotransversectomy produced a significant deformity in minipigs and established a valid model for studying scoliosis in these animals. Conclusion Only a posterior medial costotransversectomy produces a significant deformity in minipigs and establish a valid model for studying scoliosis in these animals. A tensegrity model would elucidate such results and harmonize disparate conclusions. Further investigation is needed to demonstrate the reliability of tensegrity principles for spinal biomechanics.

Effect of different approaches to thoracolumbar interfascial plane block on analgesic efficacy after lumbar spinal fusion

Objective To evaluate the effect of different approaches to thoracolumbar interfascial plane (TLIP) block on the analgesic efficacy after lumbar spinal fusion. Methods Seventy-five patients of both sexes, of American Society of Anesthesiologists physical status Ⅰ or Ⅱ, aged 40-70 yr, with body mass index ≤40 kg/m2, undergoing posterior median approach to lumbar spinal fusion, were divided into 3 groups (n=25 each) using a random number table method: patient-controlled intravenous analgesia (PCIA) group (group P), medial approach to TLIP combined with PCIA group (group MP) and lateral approach to TLIP combined with PCIA group (group LP). TLIP block was performed by advancing the block needle in a lateral to medial direction and injecting 0.5% ropivacaine 20 ml locally between the bilateral multifidus and longissimus muscles in group MP.TLIP block was performed by advancing the block needle in a medial to lateral direction and injecting 0.5% ropivacaine 20 ml locally between the bilateral longissimus and iliocostalis muscles in group LP.The identification rate and distinction score between multifidus and iliocostalis muscles obtained from ultrasonic images were recorded before block in MP and LP groups.All the patients received PCIA until 48 h after surgery.PCIA solution contained sufentanil 100 μg and tropisetron 10 mg diluted to 100 ml with 0.9% normal saline.The PCA pump was set up with a 2 ml bolus dose, a 15-min lockout interval and background infusion at a rate of 1 ml/h.When visual analogue scale score at rest >4 after surgery, parecoxib 40 mg was intravenously injected for rescue analgesia.The development of adverse reactions such as nausea and vomiting was recorded within 48 h after surgery. Results The identification rate and distinction score of the iliocostalis was significantly higher than that of the multifidus (P 0.05). There was no significant difference in the parameters mentioned above between group MP and group LP(P>0.05). Conclusion Ultrasound-guided medial and lateral approaches to TLIP block is helpful in achieving low-dose opioid anesthesia mode and more helpful in enhancing the efficacy of PCIA when used for lumbar spinal fusion. Key words: Nerve block; Fascia; Analgesia, patient-controlled

Long-term follow-up results of 550 cases of spastic torticollis treated with modified Foerster-Dandy operation

Objective To investigate the long-term efficacy and complications of modified Foerster-Dandy operation in the treatment of spasmodic torticollis (ST). Methods A total of 550 cases of ST admitted to Neurosurgery Department of China-Japan Friendship Hospital from April 2005 to April 2013 were retrospectively enrolled into this study. All patients were treated with modified Foerster-Dandy operation, in which occipitocervical posterior median approach was used without opening of occipital squama and foramen magnum. Limited laminectomy, endoscope-assisted bilateral subdural accessory nerve and C1 spinal nerve root cutting and selective partial cutting of anterior and posterior roots of C2-4 spinal nerve were conducted. The international Tsui scale was used to evaluate the efficacy post operation. We also analyzed the complications occurring following the operations. Results All patients were followed up for 60-156 months, with an average of 117.0±5.5 months. The median improvement rate of spasticity at 6 months, 12 months and the latest follow-up was 73.6% (54.7%, 86.4%), 70.2% (48.8%, 85.1%) and 73.2% (51.1%, 88.5%), respectively. The Tsui score before operation was 17.2 (13.6, 20.6). However, at 6 months, 12 months and the latest follow-up, the Tsui scores were 4.6 (2.2, 7.3), 4.9 (2.6, 8.1) and 4.3 (2.0, 7.5), respectively, which were significantly lower than those prior to operation (all P<0.05). However, 30 (5.5%) cases had neck rotation weakness, 34 (6.2%) reported shoulder shrug weakness, 32 (5.8%) had limited arms abduction, 45 (8.2%) developed long-term neck back pain and numbness, 11 (2.0%) reported neck circumference narrowing, and 62 (11.3%) suffered from dysphagia. Among them, no obvious improvement was achieved in 5 cases with neck rotation weakness and 9 cases with dysphagia. All the other complications were relieved to various degrees during the follow-up period after rehabilitation training. During the follow-up, spasm recurrence to various degrees was reported in 25 (4.5%) cases. Conclusion Modified Foerster-Dandy operation is a safe and effective surgical therapy for patients with ST. Key words: Spasmodic torticollis; Neurosurgical procedures; Treatment outcome; Postoperative complications; Foerster-Dandy operation

Fixation of bony avulsions of the posterior cruciate ligament by asuture-bridge™ technique

Anatomical reduction of bony avulsions of the posterior cruciate ligament (PCL) by asuture-bridge™ (Arthrex, Naples, FL, USA) technique to restore posterior knee stability. Acute bony tibial avulsions of the PCL and multifragmentary fractures. Chronic condition of avulsion fractures or posterior instability, advanced knee osteoarthritis, high-grade soft tissue injury, infection. Prone position, minimally invasive posterior medial approach, exposure and reduction of the bony fragment, positioning of the proximal suture-anchor (interfragment), suturing the PCL and knotting to achieve repositioning of the anterior part of the fragment, tighten both ends of the tape by two suture anchors distally to the PCL insertion to fix the posterior part of the fragment. Knee extension brace with posterior tibial support for 6weeks, 20 kg partial weight-bearing and restricted flexion up to 90° for 6weeks, physiotherapy in prone position from the first postoperative day. Full weight bearing after x‑ray and clinical control after 6weeks. Since 2016, 6cases of abony avulsion of the PCL treated with this technique (mean age 38years; range 17-60years). Postoperative x‑ray at 6weeks showed no fragment dislocation and complete bone healing. Irritation due to the anchor material was not observed up to 6months postoperatively. No wound healing problems, infections, thrombosis or arthrofibrosis observed. No revisions. According to a recent review comparing the open with an arthroscopic fracturetreatment the arthroscopic treatment may lead to a slightly higher subjective and objective outcome. Interestingly, the rate of arthrofibrosis was slightly elevated in the arthroscopic group. Seven of 18included studies describe a suture fixation in case of a comminuted fracture. Especially in these cases asuture-bridge ™ fixation seems to be reasonable.

Tanycytic ependymoma of filum terminale: Clinical characteristics and surgical outcomes.

Tanycytic ependymoma (TE), a rare subtype of ependymoma, was classified as grade II ependymoma by the World Health Organization in 2000 and 2007. Preoperative diagnosis of TE is challenging due to its similarities to schwannoma and astrocytoma; therefore, differentiation is required. The present study investigated the clinical, imaging and pathological characteristics of TE in the filum terminale. A retrospective analysis was conducted on the clinical, imaging, pathological and immunohistochemical characteristics of 8 patients with TE in the filum terminale and the relevant literature was reviewed. Of the 8 patients 7 were female and 1 was male, with an age range of 24–62 years old. The primary clinical symptom observed was lumbago, accompanied by lower limb pain and numbness. Magnetic resonance imaging predominantly identified isointensity on thoracic (T) 1-weighted images and iso- or hyperintense signal intensity on T2-weighted images, with homogeneous or inhomogeneous enhancement. All patients underwent resection of the tumor through a posterior median approach, and total resection was acighieved in 7 patients. During postoperative follow-up, all patients experienced improvement compared with their preoperative status, and were without tumor recurrence. The present study comprised the largest group of cases with TE in the filum terminale reported so far, to the best of our knowledge, which could foster a better understanding of this disease. Complete surgical resection of the tumor has the greatest effectiveness of any treatment for TE in the filum terminale. Postoperative histological examination, immunohistochemistry and electron microscopy for tumor specimens may assist in its diagnosis and differential diagnosis.

Treatment of posterior longitudinal ligament ossification of thoracic spine with posterior transforaminal spinal decompression

Objective To explore the safety, efficacy and outcomes of posterior transforaminal spinal cord reduction in the treatment of severe thoracic ossification of the posterior longitudinal ligament. Methods Since May 2010 to May 2016, 21 patients with thoracic spinal stenosis with ossification of the posterior longitudinal ligament and embedding rate of more than 50% underwent posterior circular decompression, 12 males and 9 females; age 42-71 years old, with an average of 63.3±1.6 years old. There were severe spinal cord compression symptoms before surgery. The operation was from the posterior median approach. First, the pedicle screw tract was preset in the upper and lower segments where decompression was required, and then the posterior wall of the spinal canal was removed by the uncovering method to complete the posterior decompression. Through the superior and inferior articular joints, the joints were removed, the intercostal nerves were pushed outward, the extracorporeal intervertebral space and intervertebral disc tissue were revealed, and the vertebral cancellous bone of the lower vertebral body was removed. Separate the adhesion of the dura mater, use the special tool to cut the upper and lower edges of the posterior longitudinal ligament, collapse, remove the posterior longitudinal ligament ossification block, and complete the decompression of the front of the spinal cord through one or both sides. Finally, the pedicle screw fixation and the intervertebral bone graft were completed. Postoperative follow-up (mean 38.5 months) CT and MRI scans were performed to observe the patency of the spinal canal and the state of the internal fixation. The Frankel graded evaluation function was restored, the JOA score was used to evaluate the neurological function, the Otani evaluation system was used to evaluate the surgical outcome, the clinical excellent rate was calculated, and the treatment effect was evaluated. Results Nineteen cases recovered after operation, and 1 case showed a transient decrease in unilateral lower extremity motor function on the second day after surgery. It returned to normal after dehydration and neurotrophic support treatment, and 1 case had bilateral lower limbs on the day after surgery. Muscle strength was transiently lost, feeling recovered after 6 hours, and exercise resumed after 48 hours. The operation time was 180-300 min, with an average of 240±23 min. The intraoperative blood loss was 168±12 ml. Postoperative spinal cord function recovered significantly. At the last follow-up, Frankel graded F in 8 cases and grade E in 13 cases. Preoperative average JOA score was 3.5, and the JOA score of the follow-up was increased from 3.5±0.98 points to 9.0±0.9 points. The improvement rate of JOA score was excellent in 14 cases, good in 5 cases, and fair in 2 cases. According to Otani system there was excellent in 14 cases, good in 6 cases, and fair in 1 case. The excellent and good rate was 95.24%. Cerebrospinal fluid leakage occurred in 3 cases and healed after symptomatic treatment. No chest occurred during the follow-up period. The vertebral instability, internal fixation loose, broken. Conclusion Posterior transforaminal spinal decompression of posterior longitudinal ligament ossification of thoracic spine can be finished using self-developed special surgical tools, which is safe, effective and can achieve full decompression of spinal cord. Key words: Thoracic vertebrae; Spinal stenosis; Ossification of posterior longitudinal ligament; Decompression, surgical; Spinal fusion

Tibial plateau posterior column fractures treated via the posteromedial approach dissecting the gastrocnemius medial head

Objective To discuss the treatment of tibial plateau posterior column fractures via the posteromedial approach which dissects the medial head of the gastrocnemius muscle. Methods From July 2013 to September 2016, 7 patients were treated at Department of Orthopaedics and Trauma, The First Affiliated Hospital to Dalian Medical University by surgery via the posteromedial approach dissecting the medial head of the gastrocnemius muscle for tibial plateau posterior column fractures. They were 6 men and one woman, aged from 38 to 61 years (49.3 years on average). According to AO/OTA classification, 4 cases belonged to type 41-B3.3, one to type 41-B3.1, one to type 41-C3.3 and one to type 41-C3.1. According to the three-column classification, 3 cases were categorized into three-column fracture, 2 cases into fracture of both medial and posterior columns, and 2 cases into simple posterior column fracture. Of the posterior column fractures, 5 had the medial posterior column split and the lateral column collapsed, and 2 had the medial posterior column split. According to Schatzker classification, 5 cases were categorized into type Ⅳ, one into type Ⅴ and one into type Ⅵ. Fracture reduction was assessed according to the Rasmussen criteria postoperation. The knee function was assessed at final follow-ups using The Hospital for Special Surgery (HSS) scoring system. The postoperative complications were documented. Results Insertion rupture of the posterior cruciate ligament was found in one case, lateral meniscus injury in 2 cases, and tibial external dislocation combined with bone fragment incarceration into the lateral femoral condyle in one case. All the lesions were repaired. All the incisions were healed at the first stage. No major neurovascular injuries were found. The 7 patients were followed up for 8 to 12 months (mean, 11.4 months). Bony union was achieved in all after 12 to 16 weeks (mean, 14.3 weeks). The postoperative Rasmussen reduction scores averaged 17.7 points. The average tibial plateau tilt angle was 9.5° postoperatively and 10.8° at final follow-ups; the average tibial plateau varus angle was 86.7° postoperatively and 87.3° at final follow-ups. The HSS knee scores at final follow-ups averaged 91.4 points. No significant reduction loss, implants loosening, infection or malunion was observed at final follow-ups. Conclusion The posterior medial approach which dissects the medial head of the gastrocnemius muscle is a safe and practical one for treatment of tibial plateau posterior column fractures, because it can well expose the posterior column of the entire tibial plateau so that is beneficial to the anatomical reduction of the fracture and placement of implants, leading to fine short-term curative effect. Key words: Tibial; Fractures, bone; Fracture fixation, internal; Posteromedial approach; Medial head of the gastrocnemius muscle

Fractures of femoral medial condyle treated with contralateral less invasive stabilization system through a medial-posterior approach

Objective To investigate the therapeutic efficacy of contralateral less invasive stabilization system (LISS) through a medial-posterior approach for fractures of femoral medial condyle. Methods From December 2010 to December 2014, 14 patients with fracture of femoral medial condyle were treated surgically at our department. They were 10 males and 4 females, aged from 33 to 64 years (average, 44.6 years). By AO classification, 10 cases were type 33-B2 and 4 cases type 33-B3. Causes of injury included traffic accident in 7 cases, falling in 6 and heavy object crush in one. Internals from injury to operation ranged from 3 to 10 days (average, 5.4 days). All the patients were treated by open reduction and internal fixation with contralateral LISS plate or T plate through a knee medial posterior approach. Results The 14 patients were followed up for 12 to 24 months (average, 18 months). All fractures got bony healing after 3 to 5 months (average, 3.5 months). No collapse of joint surface, joint stiffness, joint infection, malunion or nonunion occurred. According to the Schatzker-Lambert criteria for functional recovery of the distal femoral fractures, the function of the affected knee was assessed at the last follow-up as excellent in 9 cases, good in 3, fair in one and poor in one. Conclusion Open reduction and internal fixation with contralateral LISS plate through a medial-posterior approach is effective for fractures of femoral medial condyle due to its strong buttress, rigid fixation, advantage for early functional exercise, and satisfactory therapeutic outcome. Key words: Femoral fractures; Fracture fixation, internal; Bone plates; Posterior median approach

Quality of Life After Craniovertebral Junction Meningioma Resection: Shaping the Real Neurologic and Functional Expectancies About These Surgeries in a Contemporary Large Multicenter Experience.

Craniovertebral junction (CVJ) meningiomas are one of the most surgically complex conditions in neuro-oncologic surgery. The aim of this work is to correlate our data with clinical outcome to outline factors leading to a worse functional prognosis. We analyzed sex, age, clinical presentation, topography, surgical approach, Simpson grade resection, postoperative lower cranial nerve deficits, consistency, histology, site of origin, presence of a capsule, and radiologic and clinical follow-up at 1, 6, and 12 months of 61 patients affected by CVJ meningiomas, operated on in our institution from 1992 to2014. 78.7% of patients were women (mean age, 52.85 years); the onset symptom was pain in 65.5% of cases. The mean preoperative Nurick grade of the sample was 3.78; the most frequent histologic type was endotheliomatous (42.8%). We treated 22 patients with a posterior median approach (5 with lateral and 17 with posterolateral axial topography); in 39 cases (30 anterolateral and 9 anterior) we performed a posterolateral approach. Gross total removal was achieved in 85.2% of cases. We recorded a final follow-up step overall neurologic improvement in the cohort (average preoperative Nurick grade, 3.81, and at 12 months, 2.13). Twenty-nine patients presented with lower cranial nerve deficit (permanent or transient) and no statistically significant association was found between surgical approach and temporary or permanent postoperative complications. We selected, in our experience, some predictors of worse outcome: preoperative sphincter impairment, absence of a capsule, cranial site of origin, a poor preoperative functional status, and firm consistency of the tumor.

Curative effect analysis of 15 cases of cervical intra-and extra-spinal tumors by microsurgical resection

Objective: To explore the curative effect of microsurgical treatment of cervical intra- and extra-spinal tumors. Methods: The clinical data of 15 patients with cervical intra-and extra-spinal tumors in Department of Neurosurgery, the First Affiliated Hospital of Bengbu Medical College from January 2013 to February 2017 were retrospectively analyzed. According to Shaw's tumor stage: 6 cases in stage Ⅰ, 5 cases in stage Ⅱ, 3 cases in stage Ⅲ, and 1 case in stage Ⅳ. About the surgical methods: 9 cases were treated via posterior median semi-laminectomy approach, of which were internal fixation in 2 cases, and via posterior median approach spinous process and vertebral plate complex orthotopic replantation to spinal canal plasty in 3 cases, other 3 cases were operated via anterior cervical approach, including internal fixation in 1 case. After the surgery, vertebral canal MRI was adopted to evaluate the tumor, and CT three-dimensional reconstruction or X-ray of the spine was used for assessing the stability of spinal column, and Frankel grading standard was employed to evaluate the recovery of spinal cord function. Results: The tumors were totally resected in the first stage with the help of a microscope. Histological types of the tumors included schwannoma in 14 cases, gangliocytoma in 1 case. There was no leakage of cerebrospinal fluid and infection of incisional wound after operations. After the surgery, Frankel grading standard was adopted to assess the recovery of the spinal cord function, and the results showed grade D in 4 patients and grade E in 11 patients. All patients were followed-up for 1 to 24 months with an average of 13 months without tumor recurrence and spinal instability. Conclusion: Appropriate surgical approach should be selected to treat the cervical intra- and extra-spinal tumors, totally resection of the tumor could be achieved under the microscope, and the corresponding vertebral reconstruction and spinal fixation should be used to maintain spinal stability if necessary.

Clinical effects of microsurgery in spinal cord anaplastic astrocytoma

Objective: To investigate the surgical outcomes and prognosis of spinal cord anaplastic astrocytoma (AA). Methods: A total of 27 consecutive patients diagnosed as spinal cord AA between January 2008 and May 2015 in Department of Neurosurgery of Beijing Tiantan Hospital were retrospectively reviewed. There were 18 males and 9 females, the mean age was (30.7±13.0) years (ranging from 5 to 52 years). The lesions were located at cervical level in 8 patients, at thoracic level in 9 patients, at cervicothoracic level in 3 patients, and at thoracolumbar level in 7 patients, the average number of vertebral was 3.3±1.3.The median time from onset of symptom to surgery was 4 months, ranging from 3 days to 48 months. The clinical presentations were weakness (23 cases), paresthesia (22 cases), pain (20 cases), sphincter disorder (15 cases) and paralysis (7 cases). The preoperative modified McCormick scale was as follows: grade Ⅱ for 6 cases, grade Ⅲ for 7 cases, grade Ⅳ for 7 cases, grade Ⅴ for 7 cases. The tumors were surgically removed via posterior median approach with the monitoring of the somatosensory-evoked potentials to minimize the neurological injury. All of the patients were recommonded to receive adjuvant chemotherapy and radiotherapy postoperatively after pothological verified and followed up by clinic interview or telephone postoperatively. Log-rank test was used to calculate the survival rate. Results: Gross total resection and subtotal resection were achieved in 18 patients and partial resection in 9. Twenty patients received adjuvant chemotherapy and (or) radiotherapy, 7 patients did not received chemoradiation postoperatively. Nineteen patients died and 8 were alive at the last follow-up. The median survival time was 23 months with 1 and 2-year survival rates of 85.2% and 50.0%.There was no statistical significance between subtotal resection group and partial resection group(χ(2)=0.089, P=0.880), the survival rates of patients in chemotherapy group and radiotherapy group were increased significantly(χ(2)=6.687, P=0.001; χ(2)=14.887, P=0.002). Conclusions: Spinal cord AA is a rare spinal high-grade astrocytoma with aggressive nature, the prognosis remains poor even after comprehensive treatments. Microsurgery followed by adjuvant chemoradiation is recommended for the treatment.

Posterior medial approach inverted L-shaped incision combined with reconstruction plate for posterior condylar fracture of tibial plateau

To study the clinical therapeutic effects of posterior medial approach inverted L-shaped incision combined with reconstruction plate fixation in treating posterior tibial plateau condylar fracture. From February 2011 to February 2015, 19 patients that were clearly diagnosed with combined posterior tibial plateau condylar fracture were treated with internal fixation of reconstruction plate through the posterior medial approach L-shaped incision under direct vision, involved 14 males and 5 females with an average age of 45.5 years ranging from 28 to 71 years. The intervals between injury and operation ranged from 6 to 15 days with a mean of 9.2 days. According to Schatzker Classification, there were 6 cases in type II, 2 in type IV, 7 in type V, 4 in type VI In accordance with the three-column theory proposed by Luo Congfeng, 2 cases were medial column combined with posterior column fracture, 6 were lateral column combined with posterior column fracture, and 11 were three-column fracture. The major clinical symptoms before treatment were swelling and deformity of the knee, as well as limitation of motion. X-ray and CT examination were completed. The American Hospital for Special Surgery score(HSS) was used to evaluate clinical effect. One case developed skin infection in the posteromedial incision postoperatively, but other complications, such as neurovascular injury, deep venous thrombosis of lower limb, cracking and failure of internal fixation, and fracture re-displacement were not seen. The patients were followed up for an average of 12.5 months (10 to 24 months). The fracture healing time ranged from 5 to 11 months with a mean of 8.2 months. According to HSS, the total score was 82.1±7.3, 9 patients got an excellent result, 7 good, 2 poor and 1 bad. Regular postoperative re-check X-ray indicated that all fracture showed stage I healing. The difference was not significant on varus angle, post-dip angle and femorotibial angle between 3 days and 1 year after operaiton. Treating the posterior tibial plateau condylar fracture through the posterior medial approach L-shaped incision of the knee rendered sufficient exposure, little injury, as well as convenient and effective installation of internal fixation. Reconstruction plate possessed the advantages of good plasticity, strong supportability, small implant volume, together with low cost;and the structural and functional recovery of the knee could achieve satisfying clinical therapeutic effects as combined with appropriate postoperative rehabilitation training.

Efficacy analysis of microsurgery for brain stem solid hemangioblastomas

Objective To investigate the efficacy of microsurgery of brain stem solid hemangioblastomas under the techniques of nerve electrophysiological monitoring and temporary occlusion of feeding artery. Methods The treatment effect of microsurgery in 56 patients with brain stem solid hemangioblastoma treated at the Department of Neurosurgery, West China Hospital, Sichuan University from January 2005 to December 2014 were analyzed retrospectively. Of the 56 patients, 46 were treated via posterior median suboccipital approach, and 10 were treated with microsurgical treatment via extended far-lateral approach. All patients performed temporary occlusion of suspected blood supply artery for assisted tumor resection under the brainstem somatosensory evoked potential and motor evoked potential monitoring. Results In 56 patients, the postoperative magnetic resonance examination confirmed that the tumors of 54 patients were resected totally, and 2 were resected neartotally. Two patients who were not resected totally stopped their operation because of electrophysiological monitoring showed significant changes, and accompanied by a significant decrease in heart rate during the introperative separation of tumors. The 56 patients were followed up for a mean of 25 months. During the follow-up period, preoperative neurological dysfunction of 45 patients was improved significantly, 9 patients did not have any improvement compared with before procedure, and 2 developed new neurological deficits. Two patients had tumor recurrence during the follow-up period. One of them the tumor was resected neartotally. The gene detection of the latter was identified as Lindau VonHippel (VHL) disease. Conclusion Nerve electrophysiological monitoring and temporary occlusion of blood supply artery may reduce the risk of microsurgical resection of brainstem solid hemangioblastoma, improve the total tumor resection rate, and significantly improve the prognosis of patients. Key words: Central nervous system neoplasms; Brain stem; Hemangioblastoma; Microsugery

Intramedullary ependymoma: Microsurgical resection technique

Spinal ependymomas are predominantly slow-growing lesions constituting approximately 30–88% of primary spinal intramedullary tumors. They usually present as circumscribed lesions, with regular margins and a clear surgical plane. Gross-total resection is often feasible and potentially curative but neurosurgeons should keep in mind that the ultimate goal of surgery is the preservation of spinal cord function. We present the surgical technique to safely resect an intramedullary ependymoma using a posterior median sulcus approach. A brief description of current management of this pathology is also presented.

Craniovertebral Junction Meningiomas: Analysis of Clinical and Radiological Results

Introduction Craniovertebral junction (CVJ) meningiomas are lesions of complex surgical management for the delicate anatomical structures involved and for their tendency to encase/dislocate vital structures such as the vertebrobasilar system and the lower cranial nerves. Matherials and Methods: We analized sex, age, clinical presentation, topography, surgical approach, Simpson Grade Resection, Lower Cranial Nerves postoperative deficit and radiological, histology and clinical follow up at 1, 12 and 24 months of 61 patients affected by CVJ meningiomas, operated on in the Neurosurgical Divisions of the University of Rome “Sapienza” from 1997 to 2013. Results 78.7% of patients were women (mean age 52.85 years); the onset symptom was pain in 65.5% of cases. The mean preoperative Nurick grade of the sample was 3,78; The most frequent histological type was endotheliomatous (42.8%). Twenty-two patients (5 with lateral and 17 posterolateral axial topography) were treated with posterior median approach; in 39 cases (30 anterolateral and 9 anterior) we performed a posterolateral approach. A Gross Total Removal was achieved in 85.2% of cases. We reported an average neurological improvement in this series (average preoperative Nurick 3.81 and at 12 months 2.13). In 29 patients there was a transient deficit of IX, X and XI cranial nerves. No statistically significant association between surgical approach and temporary or permanent postoperative complications has been found. Conclusions In conclusion posterior and posterolateral with/without condilectomy and transposition of VA approaches represents the gold standard for the surgical removal of these tumors and are safe and effective in terms of postoperative morbidity.

AB193. Rectourethral fistula

ObjectiveTo investigate the treatment of rectourethral fistula.MethodsEleven cases of male patients with rectourethral fistula were treated in our department from 2011 to 2015. Age 16–66 years old. Causes: three cases of patients with congenital closed anus, four cases of traumatic pelvic fracture with urethral distraction and rectum injury, four cases after radical prostatectomy. The size of the fistula was 0.5–1.5 cm. In addition to the leakage of urine in the large fistula, urine mixed with stool samples. Three patients with congenital closed anal postoperative patients with posterior or anterior median sagittal approach for resection of the fistula, hierarchical closed urethral and rectal wall defect, at least three layer (between the urethral and rectal suture layer), indwelling catheter for 3–4 weeks, no cystostomy. Sigmoid colostomy underwent prior to the surgery. Of which six cases were repaired by perineal approach, one case by abdominal perineal approach, one case by abdominal repair. According to size of fistula and the surrounding scar decide whether or not to adopt tissue interposition, this group of five cases with gracilis muscle flap, one case with bulbocavernosus muscle flap interposed between the rectum and urethra; one case repaired by sigmoid colon pull-through procedure. Post-operation indwelling catheterization for 3–4 weeks with cystostomy.ResultsA total of 10 patients were successful, and no leakage of urine was found after removal of the catheter. One patient improved, occasionally a small amount of drops of urine voiding from anus. Reoperation was successful after 6 months. Recovered enteric continuity 3–6 months post-operation.ConclusionsThe median sagittal approach provide good exposure for the repair of congenital rectourethral fistula; perineal approach is a good choice for patients caused by trauma or surgery; complete resection of scar around the fistula, tension-free anastomosis, tissue interposition and sigmoid colostomy provide necessary guarantee for successful operation.

Surgical treatment of congenital anterior sacral meningomyelocele

Objective To investigate the clinical characteristics and surgical treatment method of congenital anterior sacral meningomyelocele in order to reduce surgical complications and improve prognosis by selecting the appropriate surgical approaches and surgical methods. Methods The clinical data of 4 patients with congenital anterior sacral meningomyelocele treated at the Department of Neurosurgery, Chinese PLA General Hospital from February 2014 to April 2015 were analyzed retrospectively. The clinical manifestations included abdominal pain, numbness of limbs, constipation, urinary urgency, urinary frequency, and other symptoms. The follow-up time ranged from 2 to 12 months (mean 6.5 months). Results The postoperative symptoms of the 4 patients had different degrees of improvement compare with the before procedure. The MRI reexamination revealed that the anterior sacral meningocele disappeared. No postoperative cerebrospinal fluid leakage, peritoneal effusion, wound infection, and other complications were found. Conclusions The clinical manifestation of congenital anterior sacral meningocele is mainly pelvic organ compression symptom. Microsurgical operation via posterior median approach can achieve good effect. Properly treating fistula and protecting sacral nerve during the operation may avoid the occurrence of postoperative cerebrospinal fluid leakage after procedure. Key words: Neural tube defects; Meningomyelocele; Microsurgery