Postoperative Follow-up Assessment Research Articles

Endoscopic Trans Planum Trans Inter Cavernous Sinus (ETPTICS) approach to pituitary microadenoma: Introduction of a novel technique to enhance endocrinological outcome

Background and Objective: Endoscopic transnasal approach to pituitary adenoma surgery has been recently introduced as an efficient alternative for traditional transcranial and conventional microscopic transnasal approaches. Recent studies have shown the advantages of this technique such as better cosmetic outcomes, low complication rate, lower duration of the surgery, higher patient satisfaction, and better tumor resection, compared to microscopic technique especially in large tumors with extensions into adjacent structures and tissues. Surgery for secreting microadenoma has been always a big surgical challenge in term of achieving full treatment especially in Cushing’s syndrome. Methods: A total of 12 cases secretory microadenoma was performed during 2011. Transplanum trans-intercavernous sinus approaches were used for better searching of the gland for microadenoma and checking the dural side adjacent for microadenoma since they were very useful in multi microadenoma and bilateral cases detections. In this approach, conventional techniques step by step were followed until the sellar floor was perforated. At this step, more resection of sellar bone was performed both anteriorly and posteriorly toward planum sphenoidale to expose intercavernous sinuses. Then, following careful bipolar cautery of the intercavernous sinuses, they were incised along with dura of the sellar floor. This approach makes an excellent view of the sella and pituitary adenoma as well as the pituitary gland itself and its stalk. Results: A total of 330 cases of pituitary adenoma underwent the endoscopic transsphenoidal (ETSS) surgery during 2005-2012. Of them, there were 27 cases of microadenoma, 15 of which underwent the surgery through classic ETSS and the rest (12 patients) were operated using ETPTICS. In the first group (conventional ETSS), 11 patients (73%) were completely recovered and only 2 cases showed recurrence after one year (both were Cushing’s syndrome). In the second group (ETPTICS), postoperative follow-up (5 months) assessments showed that all of 12 patients showed remission criteria with no recurrence. There was no postoperative cerebrospinal fluid (CSF) leak or any complication in both groups. There were 2 cases of transient diabetes insipidus (DI, unrelated to diabetes mellitus) in the ETSS group, while the other group showed 4 cases. However no permanent DI was observed in both groups. Discussion: Findings of the present study showed that application of ETPTICS approach can increase the endocrinological remission rate that was a formidable task in cases with multiple microadenoma or Cushing’s syndrome with normal MRI and microadenoma touching the cavernous sinus or invading the dura. Hypothetically, the chance of CSF leak might be higher in this novel technique that was efficiently controlled using meticulous repair. Furthermore, meticulous care by pituitary stalk blood supply should be implemented to avoid anterior pituitary insufficiency and permanent DI. Tin tituitary insufficiency and permanent DI are to be avoided.

Value of Bone Scan Imaging in Determining Painful Vertebrae of Osteoporotic Vertebral Compression Fractures Patients With Contraindications to MRI

To assess the value of bone scan imaging in determining painful vertebrae of osteoporotic vertebral compression fractures (OVCFs) patients with contraindications to MRI. Twenty-three OVCFs patients with contraindications to MRI, diagnosed and treated in our hospital between December 2007 and November 2010, were enrolled in this retrospective study. There were 18 females and five males, aged from 57 to 87 years, with a mean age of 69.5 years. All patients underwent X-ray, CT scans examinations and bone scan to determine painful vertebrae. After the painful vertebra was defined, percutaneous kyphoplasty (PKP) was performed. Efficacy of PKP was assessed with visual analog (VAS) pain scale and the Oswestry Disability Index (ODI) preoperatively, postoperatively and during final follow-up assessments. The painful vertebrae shown on radiological films did not accord with those found based on bone scan imaging, with a high rate of incongruent findings (27.3%, 9/33). Radiological films showed 33 vertebrae with fractures, but only 26 vertebrae (22 patients) were selected as painful vertebrae for PKP based on bone scan imaging. There were statistically significant differences in mean VAS and ODI between the preoperative and the postoperative assessments; no significant differences were observed between postoperative and final follow-up assessments. For the OVCFs patients with contraindications to MRI, bone scan imaging could be used to determine painful vertebrae, which is an effective method.

Arthroscopic anterior cruciate ligament reconstruction with remnant preservation: a prospective comparison study

To evaluate the clinical significance of arthroscopic anterior cruciate ligament (ACL) reconstruction using the remnant-preserved technique. From August 2008 to September 2009, 70 cases with the remnant of injured ACL were included in the trials, which were randomized into the remnant preservation (RP) group and the control group, 35 cases in each group. All patients in the two groups underwent arthroscopic ACL reconstruction surgeries, with ACL-remnant preserving technique in RP group and ACL-remnant resection in control group, respectively. The injured ACL was reconstructed with allograft in all cases. Postoperative follow-up assessment included the International Knee Documentation Committee (IKDC) grading and Lysholm score, Lachman test, pivot shift test and KT-1000 measurement, proprioception measurements and the arthroscopic second look evaluation. Sixty-one (61/70, 87%) cases were available for an average of 13.1 months follow-up assessment postoperatively. There were no significant differences between the RP and control group in functional outcome as evaluated with Lysholm score (96.4 vs. 94.9, P = 0.71) and IKDC grading (cases with A and B gradings: 30 vs. 29, P = 0.586). Regarding objective stability, there were no differences between the 2 group in mean side-to-side difference of KT-1000 (1.69 mm vs. 1.65 mm, P = 0.83), Lachman test (negative cases: 29 vs. 28, P = 1.00) and pivot shift test (negative cases: 31 vs. 27, P = 0.225). There was also no difference between the groups in proprioception evaluation measured with angle repetitive test (4.56° vs. 4.28°, P = 0.522). During second look arthroscopic examination, the grafts synovial coverage rates were found to be 85% in the RP group and 84.2% in the control group, without significant difference (P > 0.05). Arthroscopic ACL reconstruction with the remnant preserving technique using tendon allograft do not improve the postoperative knee-joint function scores, stability, proprioception and synovial coverage of grafts.

Post-traumatic osteoporotic vertebral osteonecrosis treated using balloon kyphoplasty

Nineteen patients with post-traumatic osteoporotic vertebral osteonecrosis were treated using percutaneous balloon kyphoplasty. The anterior and middle vertebral heights, as well as the kyphotic angle, were measured using a standing lateral radiograph before surgery, 2 days after surgery and at the final follow-up. At the same time points, a visual analog scale and the Oswestry Disability Index were used to evaluate pain status and functional activity, respectively. The mean follow-up was 24.7 months (range: 7–36 months). Statistically significant improvements were observed between the preoperative and postoperative assessments for each evaluated measure ( p < 0.05). There were no statistically significant differences between the postoperative and final follow-up assessments ( p > 0.05). Asymptomatic cement leakage into the intervertebral disc occurred in three patients. This study suggests that balloon kyphoplasty is a safe and effective procedure for treating this disease entity.

Chimney Modification Technique for Ureterointestinal Anastomosis after Radical Cystectomy: Preliminary Evaluation of Short-Term Outcome and Impact on Quality of Life

Objectives: To evaluate the short-term outcome of chimney modification technique of the Hautmann ileal neobladder for ureterointestinal anastomosis after radical cystectomy in cases of invasive bladder cancer. Patients and Methods: The study included 25 male patients with a mean age of 61.2 ± 6.6 years assigned for radical cystectomy. A neobladder reservoir was fashioned using an ileal loop in a W-shape with both ends not detubularized and used as chimneys of 3–5 cm for the afferent limb on each side for implantation of the 2 cm spatulated ureter into each side using the technique of end-to-end anastomosis. Patients were observed for early postoperative complications and ascending cystography was performed before catheter removal for assessment of reflux and pouch integrity. Postoperative follow-up assessment included evaluation of continence satisfaction, renal function was judged by estimation of serum creatinine and intravenous urography for evaluation of development of ureteric stricture. Quality of life (QoL) was assessed using the Quality of Life Questionnaire (QLQ-C30). Results: All patients passed a smooth intra-operative course with a mean operative time of 308 ± 53.2 minutes and mean intra-operative blood loss of 580 ± 175 ml. No mortality was reported, however, 3 patients had postoperative wound infection, another 3 patients had prolonged ileus for >48 hours and one patient developed neobladder leakage that was managed by prolonged uretheral catheterization for 5 weeks. Fourteen patients reported good continence for both day and night, 9 patients had good to satisfactory continence, while two patients had unsatisfactory continence. Postoperative serum creatinine levels were non-significantly higher compared to preoperative measurements. Urographic studies demonstrated no reflux or stricture in either of the implanted ureters, or hydronephrosis after 12-month followup. Throughout the first 6 months of follow-up, all patients showed progressive increase of total QoL score with a significant difference compared to that recorded at the first month post-operation and the mean 12-month collective score was improved by a mean score of 14.4 ± 5.4 than that of the first month post-operation. Conclusion: Chimney modification of the Hautmann neo-bladder after radical cystectomy is simple, safe and free of ureteric stricture or reflux. Also, the applied technique improved patient’s postoperative QoL.

Osteoporotic vertebral compression fractures with an intravertebral cleft treated by percutaneous balloon kyphoplasty

We investigated the safety and efficacy of treating osteoporotic vertebral compression fractures with an intravertebral cleft by balloon kyphoplasty. Our study included 27 patients who were treated in this way. The mean follow-up was 38.2 months (24 to 54). The anterior and middle heights of the vertebral body and the kyphotic angle were measured on standing lateral radiographs before surgery, one day after surgery, and at final follow-up. Leakage of cement was determined by CT scans. A visual analogue scale and the Oswestry disability index were chosen to evaluate pain and functional activity. Statistically significant improvements were found between the pre- and post-operative assessments (p < 0.05) but not between the post-operative and final follow-up assessments (p > 0.05). Asymptomatic leakage of cement into the paravertebral vein occurred in one patient, as did leakage into the intervertebral disc in another patient. We suggest that balloon kyphoplasty is a safe and effective minimally invasive procedure for the treatment of osteoporotic vertebral compression fractures with an intravertebral cleft.

Per-oral dual scope NOTES cholecystectomy in porcine model (with video)

Several working groups have already demonstrated the feasibility of transgastric surgery procedures using flexible endoscopes. However, technical limitations in natural orifice translumenal endoscopic surgery (NOTES) (e.g., exposure, retraction, insufflations, and triangulation) currently still require the use of at least one external instrument. Therefore, "pure NOTES" transgastric cholecystectomy has not yet been described. The authors successfully performed "pure NOTES" transgastric cholecystectomy using a transoral dual-scope technique (similar to the approach the authors previously reported for gastric closure) that allows completion of the procedure by pure NOTES without an external instrument. With the subject under general anesthesia, a double-channel gastroscope (Storz®, Tuttlingen, Germany) passed by mouth entered the peritoneum through the distal anterior gastric wall. The most ideal site for a second gastric exit was then selected for another single-channel scope. With the gallbladder retracted by the assistant operating the double-channel scope, retrograde cholecystectomy was performed by the primary surgeon using the single-channel scope. Four animals were killed immediately to study the quality of the operative dissection, whereas the other four pigs were kept alive. The gastrotomy was closed using a 27- to 30-mm cardiac septal occluder (Occlutech®, GmbH, Jena, Germany) according to a previously described method. The postoperative follow-up assessment of these animals included laparoscopy and necropsy 2 weeks later. All the cholecystectomies were immediately successful without any intraoperative complication. Scope withdrawal caused no injuries to the esophagus or pharynx. Although no overt postoperative complication was evident, two surviving pigs had signs of minor peritoneal infection. This study investigated "pure NOTES" transgastric cholecystectomy using tentative experimentation to overcome the "retraction" and "triangulation" issues and to realize a "pure NOTES" operation. The use of two endoscopes with selected differentiation of their gastric placements compensated for the lack of triangulation and retraction.

Balloon Kyphoplasty in the Treatment of Osteoporotic Vertebral Compression Fracture Nonunion

Patients with nonunion of osteoporotic vertebral compression fractures that are refractory to conservative treatments have persistent back pain, progressive vertebral body collapse and kyphosis, and mobility of the fracture. Although many previous reports have reported vertebral compression fractures treated by balloon kyphoplasty, few data is available on using this method to treat nonunion of vertebral compression fractures. This study evaluated the therapeutic potential of balloon kyphoplasty in the treatment of nonunion of osteoporotic vertebral compression fractures. Twenty-one patients with nonunion of osteoporotic vertebral compression fractures were treated with balloon kyphoplasty. The criteria for diagnosis of nonunion osteoporotic vertebral compression fractures included the following: (1) history of pain for at least 6 months at the fracture site; (2) low T1- and high T2-signal on magnetic resonance images; (3) widening of fracture line on routine radiographs; and (4) movement of the endplate and changes of anterior vertebral heights on hyperextension radiographs. All patients were followed for 9 to 33 months postoperatively (mean 25 months). Statistically significant improvements in the mean postoperative anterior and middle vertebral body heights were observed compared with preoperative values. There was also statistically significant improvement in the mean values for Cobb's angle, pain (visual analog scale), and the Oswestry Disability Index at the postoperative assessment compared with the preoperative assessment. No statistically significant differences were noted between the postoperative and final follow-up assessment in any of the evaluated efficacy measures. The study suggests that balloon kyphoplasty is an effective technique to treat nonunion of osteoporotic vertebral compression fractures.

Computerized acoustic voice analysis and subjective scaled evaluation of the voice can avoid the need for laryngoscopy after thyroid surgery

Because of frequent postoperative alterations in voice, many surgeons include laryngoscopy as a routine examination before/after thyroid surgery. The aim of this work was to determine whether more comfortable and easier subjective or objective postoperative voice assessments could complement or replace laryngoscopy. Sixty-four consecutive patients scheduled to undergo thyroid surgery underwent preoperative objective computerized acoustic voice analysis (CAVA), subjective scaled evaluation of the voice (SSEV) with the GIRBAS scale, and fiberoptic laryngoscopy. All patients had 7- and 30-day postoperative follow-up assessments using the same tests. CAVA measurements of jitter and noise-to-harmonic ratio showed the most frequent variations (36% and 31%, respectively) between the first and second tests. The mean preoperative SSEV GIRBAS value was 1.3 (range, 0-7) and had deteriorated in 36% of patients at 30 days postoperatively. All patients had a normal preoperative laryngoscopy. At 7 days postoperatively, 5 (8%) patients suffered unilateral vocal cord palsy which recovered in 2 (5%) patients after 1 month. GIRBAS values showed differences between patients with and without a vocal cord palsy both 7 and 30 days postoperatively (P < .05). The vocal parameters jitter and shimmer showed differences (P < .02 each) between patients with or without vocal cord palsy. When there was a change in >or=3 vocal parameters, vocal cord palsy was confirmed by laryngoscopy. After thyroid surgery, vocal cord palsy may be suspected when there is an alteration in GIRBAS scale or in several parameters of the CAVA. Laryngoscopy may only be necessary when the CAVA and SSEV are abnormal.

Using MRI to Determine Painful Vertebrae to be Treated by Kyphoplasty in Multiple-Level Vertebral Compression Fractures: A Prospective Study

A prospective study in 35 osteoporotic patients with 120 multiple-level vertebral compression fractures (VCFs) assessed the use of magnetic resonance imaging (MRI) to determine painful vertebrae for treatment with kyphoplasty (KP). A total of 51 vertebrae were identified as painful and selected for KP based on changes in MRI signal intensity between T1-weighted, T2-weighted and short tau inversion recovery MRI. Efficacy was assessed by the mean change in anterior/middle vertebral body height, Cobb's angle, a visual analogue pain scale and the Oswestry Disability Index at pre-operative, post-operative and final follow-up assessments. Significant improvements in all efficacy measures were observed at the postoperative versus pre-operative assessments; no significant differences were observed between post-operative and final follow-up assessments. It is concluded that painful vertebrae can be determined by MRI signal intensity changes and their selection for KP can improve outcomes in patients with multiple-level VCFs.

Spinal cord schistosomiasis japonica: a report of 4 cases

Background Neuroschistosomiasis is a severe presentation of schistosomal infection. Currently however, spinal cord schistosomiasis japonica is clinically rare, and very few cases are reported. Methods The purpose of this study is to retrospectively analyze the diagnosis and treatment of 4 patients who presented with a lower cord syndrome of acute progression characterized by motor, sensory, and autonomic dysfunctions. The patients were examined by MRI, and the biochemical and immunologic changes of blood and CSF of the patients were also analyzed before surgery. Treatments including surgical resection and antischistosomal drugs followed by a histologic examination were used to confirm the diagnosis. Results Spinal cord schistosomiasis japonica is a very rare disease. Magnetic resonance imaging can obtain precise position fixing, although it is hard to make preoperative qualitative determination. Postoperative follow-up assessment indicated that the symptoms of 4 patients had improved without further treatment. Conclusions The main clinical manifestations of spinal cord schistosomiasis japonica have some common features, and MRI is useful and important in diagnosing the disease. The most effective treatment for the disease that shows radiological evidence of spinal cord or conus compression and inefficacious expectant treatment by other methods is to excise it totally and apply antischistosomal drugs.

Objective and Subjective Scar Aesthetics in Minimal Access vs Conventional Access Parathyroidectomy and Thyroidectomy Surgical Procedures

To determine if performing parathyroidectomy surgery through minimal access (MA) incisions has any notable aesthetic or quality-of-life impact on patients compared with conventional access (CON) techniques. Paired cohort with (1) a prospective MA incision and scar cohort and (2) a sex- and age-matched (within 3 years) retrospective CON incision and scar cohort. Tertiary care center. Fifteen patients enrolled in prospective study protocol over a 2-year period; 11 patients met inclusion criteria. A sex- and age-matched retrospective cohort of patients was selected from a patient population undergoing surgical treatment of thyroid neoplastic diseases using a CON approach. Inclusion criteria were use of MA incision for parathyroidectomy and return for long-term follow-up scar assessment. Minimal access parathyroidectomy surgery vs CON thyroidectomy surgical procedures, postoperative follow-up assessment of scar aesthetics by patient and naive viewers, and digital photography and analysis of the surgical incision site. All patients were followed for at least 8 months after surgery. The Patient and Observer Scar Assessment Scale (POSAS), Vancouver Scar Scale, and photographic scar analysis by naive viewers. There was no significant difference in scar assessment scale scores between the MA and CON cohorts and no clinically significant difference in overall patient satisfaction with scars between cohorts (POSAS: Patient Scar Assessment Scale, P = .14, and Observer Scar Assessment Scale, P = .79; Vancouver Scar Scale, P = .76). There was increased visibility of scars in the CON cohort to naive viewers. Although they were more readily visible to naive viewers, CON (larger) cervical scars created in parathyroidectomy or thyroidectomy surgery do not translate into decreased patient satisfaction with their scar result. This may indicate a limited quality-of-life benefit in using MA approaches in transcervical surgical procedures.

A Simplified Use of Septal Extension Graft to Control Nasal Tip Location

For defining the shape and projection of the nasal tip, the bilateral and symmetric batten-type septal extension grafts proposed by Byrd and colleagues have drawbacks. The main problems are stiffness of the nasal tip and thickening of the septum in the nasal valve area. Since 1998, unilateral single-batten grafts, and more frequently, bilateral asymmetric batten grafts as compared with Byrd's bilateral symmetric application, have been used for 72 patients in our facility. At the 6-month postoperative follow-up assessment, tip projection was found to be satisfactory in 61 patients. Less than desired projection occurred in three cases and overprojection in two cases. Nasal lobule deviation was evident in one patient. The loss of the columellar break point was evident in five cases. Unilateral or asymmetric bilateral batten grafts facilitate adjustment of the nasal tip intraoperatively. This technique results in a more pliable nasal tip in the horizontal plane. Construction of a three-layered cartilage in the nasal valve area is not needed, and the nasal airway is preserved. With this modification, a reliable and predictable nasal tip location is obtained with a minimum of graft usage.

Intraspinal lymphangioma: 2 case reports and literature review

Background Lymphangioma of the soft tissue is not uncommon. However, as far as the authors know, intraspinal lymphangioma is clinically rare and very few cases have been reported previously. Methods Two patients who had backache and acratia of the lower limbs and difficulty in relieving themselves were examined by plain radiography and magnetic resonance imaging before surgery. Treatment consisted of the usual technique of surgical resection of the tumor microscopically. Histological examination of the resected material confirmed the diagnosis. Postoperative follow-up assessment was performed by magnetic resonance imaging. Results Intraspinal lymphangioma is very rare clinically and its cause remains controversial. Magnetic resonance imaging can obtain precise position fixing, but it is hard to make preoperative qualitative determination. The most effective treatment of intraspinal lymphangioma is to excise it totally. Conclusions The clinical appearance of intraspinal lymphangioma has no character. Magnetic resonance imaging is important in diagnosing it. The most effective treatment of intraspinal lymphangioma is to excise it totally. Further observation is recommended because of the possibility of local recurrence.

Natural history of voiding function after radical retropubic prostatectomy

Objectives To report results from a 2-year longitudinal survey of lower urinary tract function and quality of life (QOL) in men after radical retropubic prostatectomy (RP) for localized prostate cancer. Methods Between November 2001 and September 2003, self-report assessments were provided to 225 patients who underwent RP alone. The University of California Los Angeles Prostate Cancer Index (UCLA PCI), the International Prostate Symptom Score (IPSS), and the IPSS QOL score were administered before and 3, 6, 12, 18, and 24 months after RP. Results The overall mean total IPSS and IPSS QOL score progressively improved with time. The mean scores of several components improved significantly postoperatively. No significant difference was observed in nocturia between the baseline assessment and any of the postoperative follow-up assessments. The IPSS of the younger patients continued to recover significantly more rapidly than that of the older patients after RP. According to the UCLA PCI scores, urinary function substantially declined just after RP and continued to recover but scored lower than the baseline. The mean total IPSS and IPSS QOL scores observed in men with a UCLA PCI urinary function score of 80 or more were significantly better than in men with scores less than 80 at 24 months postoperatively. Conclusions Radical retropubic prostatectomy has a significant beneficial effect on lower urinary tract symptoms. The rate of improvement was lowest for nocturia among the seven symptoms of IPSS. Urinary continence after RP and age can affect the recovery of voiding function.

Impact of Large-Volume Liposuction on Serum Lipids in Orientals: A Pilot Study

Recent advances in liposuction techniques now make it possible to remove considerable amounts of subcutaneous adipose tissue. However, the metabolic consequences of this procedure are not well documented. The aim of this study was to identify the effects from the surgical removal of subcutaneous fat on the body weights and serum lipids of patients who have undergone large-volume liposuction. In this study, eleven consecutive patients with a minimum aspirate volume of 5,000 ml were evaluated, and their serum lipids were measured at a postoperative 2-month follow-up assessment. Tumescent fluid was infiltrated using the superwet technique. The liposuction device used was a Liposlim power-assisted liposuction system. The amount of solution infiltrated and the volume of aspirate were measured. Pre- and postoperative serum lipids, body weights, and body mass indices were compared. Statistical analysis was performed on lipid profile changes and aspirate volumes using Spearman's correlations. The average volumes of infiltrate and aspirate were 7,241 and 6,790 ml, respectively. Mean body weight decreased from 64.5 +/- 18.8 to 59.9 s +/- 17.8 kg (p < 0.01). The change in body weight per 1 l of aspirate volume was 0.67 +/- 0.10 kg/l. The mean body mass index dropped from 23.8 +/- 4.4 to 22.0 +/- 4.2 kg/m(2) (p < 0.01), and the mean total serum cholesterol levels from 168.2 +/- 23.6 to 162.9 +/- 26.5 mg/dl, an average of 3.2%. The mean low-density lipoprotein (LDL) decreased from 94.3 +/- 20.5 to 89.5 +/- 19.0 mg/dl, a 5.1% drop, and the mean high-density lipoprotein (HDL) decreased from 55.8 +/- 9.5 to 53.7 +/- 10.7 mg/dl, a 3,8% drop. The mean HDL/LDL proportion increased from 62.6 +/- 20.9% to 63.5 +/- 22.4%, averaging 1.4%. However, no significant correlation was found between the aspirated volume of fat and lipid profile change. In conclusion, over a 2-month period, large-volume liposuction reduced weight and total cholesterol level and increased the HDL/LDL ratio. The authors hope to discover whether the therapeutic impact of liposuction is long-lasting, and to determine whether it reduces the morbidity and mortality associated with obesity.

Magnetic Resonance Imaging-guided Stereotactic Limbic Leukotomy for Treatment of Intractable Psychiatric Disease

To assess the efficacy and complication rates of magnetic resonance imaging-guided stereotactic limbic leukotomy for the treatment of intractable major depressive disorder (MDD) and obsessive-compulsive disorder (OCD). We conducted preoperative evaluations and postoperative follow-up assessments of efficacy and complications for 21 patients who underwent limbic leukotomy. Efficacy was based on physician- and patient-rated global assessments of functioning, as well as evaluations using disease-specific rating scales commonly used in studies of MDD and OCD. The mean time from limbic leukotomy to follow-up assessment was 26 months. On the basis of standard outcome measures, 36 to 50% of patients were considered to be treatment responders. Although permanent surgical morbidity was rare, there were reports of postoperative sequelae, including apathy, urinary incontinence, and memory complaints, which occurred in a substantial minority of cases. For this cohort of 21 patients with chronic severe MDD or OCD, who had experienced failure with an exhaustive array of previous treatments, limbic leukotomy was associated with substantial benefit for 36 to 50%. This rate is comparable to those of previous studies of limbic system surgery and indicates that limbic leukotomy is a feasible treatment option for severe, treatment-refractory MDD or OCD. Adverse consequences associated with the procedure included affective, cognitive, and visceromotor sequelae, which were generally transient.

Late results of thoracolumbar fractures after posterior instrumentation and transpedicular bone grafting.

A retrospective clinical study was performed. To study clinical and radiologic late results after posterior stabilization of thoracolumbar fractures with internal fixator and interbody fusion via transpedicular bone grafting. The posterior approach, using an internal fixator, is a standard procedure for stabilizing the injured thoracolumbar spine. Transpedicular bone grafting was invented by Daniaux in 1986 for achieving an interbody fusion. Pedicle screw fixation with additional transpedicular fusion has remained controversial because of inconsistent reports and a lack of late results. Between January 1989 and July 1992, 76 patients with thoracolumbar fractures were operatively treated, and after a mean of more than 3 years, 56 of 62 patients (90%) still alive who had their implants removed were examined. According to the Magerl classification, 33 patients sustained Type A, 13 Type B, and 10 Type C fractures. Three patients with incomplete paraplegia returned to normal. In one case of complete paraplegia, no change occurred. The mean operative time was 3 hours. In this study, two complications (3.6%) were observed: one iatrogenic vertebral arch fracture without consequences and one deep infection. Compared with the preoperative status, follow-up examinations demonstrated permanent physical and social sequelae: The percentage of individuals able to do physical labor was reduced by half (22 to 11 patients), whereas the share of unemployed or retired patients doubled (4 to 8 patients). At the time of follow-up examination, only 21 of 42 patients continued in sports. The assessment of reported problems and functional outcome with the Hannover spine score reflected a significant difference between the status before injury (96.6/100 points) and at the time of follow-up evaluation (71. 4/100 points) (P < 0.001).The radiographic assessment in the lateral plane (Cobb technique) demonstrated a significant (P < 0.001) mean restoration from an initial angle of -15.6 degrees (kyphosis) to +0. 4 degrees (lordosis). Serial postoperative radiographic follow-up assessment showed progressive loss of correction. At follow-up examination, a mean difference from the postoperative angle of 10.1 degrees was found (P < 0.001). Compared with the preoperative deformity, a mean improvement of 6.1 degrees (average, -9.7 degrees ) at follow-up examination was noted. The addition of transpedicular cancellous bone grafting did not decrease the loss of correction. Computed tomography scans after implant removal were performed in nine cases: Only three of nine patients showed evidence of intervertebral fusion. No correlation could be found between the Magerl classification and radiographic outcome. However, the preoperative wedge angle of the vertebral body correlated significantly with the postoperative loss of reduction. Because of the disappointing results from this study, the authors cannot recommend the additional transpedicular cancellous bone grafting as an interbody fusion technique after posterior stabilization in cases of complete or incomplete burst injury to the vertebral body.

Intraoperative B-Mode Ultrasonography Is a Useful Adjunct to Peripheral Arterial Reconstruction

We used an ultrasound imaging system with a 10 MHz probe during 118 vascular procedures. These procedures included 56 cerebrovascular, 38 infrainguinal, 16 renal, 4 mesenteric, and 4 aortic reconstructions. In 29 procedures, intraoperative ultrasonography was used to supplement or replace preoperative arteriography to better define the extent of disease for the optimal placement of an anastomosis or to determine the need for an additional reconstructive procedure. In 106 cases, ultrasonography was used for postreconstruction assessment. Of the 21 (20%) defects found, 11 (10%) were deemed important enough to warrant correction. Defects were significantly more common following endarterectomy procedures (p < 0.01). All 11 of the major defects were successfully repaired, and neither the corrected defects nor the 10 uncorrected minor defects were associated with postoperative complications. Patients (with and without defects) underwent routine early postoperative follow-up assessment of the technical adequacy of their reconstruction using color duplex imaging; no residual defects were discovered. Two (2%) postoperative occlusions (one femorofemoral and one aortorenal bypass) occurred without a technical defect noted on reexploration. This clinical experience demonstrates that B-mode ultrasonography can supplement or replace preoperative arteriography in selected cases and is a valuable technique for identifying defects intraoperatively so that they can be immediately corrected.