Temporary Neurological Deterioration Research Articles

Anterior shift of the ventral dura mater: A novel concept of the posterior surgery for ossification of the posterior longitudinal ligament in thoracic spine.

Thoracic myelopathy caused by ossification of the posterior longitudinal ligament (OPLL) remains one of the most difficult disorders to treat. The Ohtsuka procedure, extirpation, or anterior floating of the OPLL through a posterior approach, has shown great surgical outcomes after several modifications. However, these procedures are technically demanding and pose a significant risk of neurological deterioration. We have developed a novel modified Ohtsuka procedure in which removal or minimization of the OPLL mass is unnecessary; instead, the ventral dura mater is shifted anteriorly with the posterior part of the vertebral bodies and targeted OPLL. First, pedicle screws were inserted at more than three spinal levels above and below the spinal level where pediculectomies were performed. After laminectomies and total pediculectomies, partial osteotomy of the posterior vertebra adjacent to the targeted OPLL was performed by using a curved air drill. Then, the PLL is completely resected at the cranial and caudal sites of the OPLL using special rongeurs or a threadwire saw with a diameter of 0.36 mm. The nerve roots were not resected during surgery. Eighteen patients (follow-up ≥1 year) treated with our modified Ohtsuka procedure were assessed clinically, including the Japanese Orthopaedic Association (JOA) score for thoracic myelopathy and radiographically. The average follow-up period was 3.2 years (range, 1.3-6.1 years). The preoperative JOA score was 2.7 ± 1.7, which improved to 8.2 ± 1.8 at 1 year postoperatively; therefore, the recovery rate was 65.8 ± 19.8%. The CT scan at 1year after surgery revealed the anterior shift of the OPLL averaged 3.1 ± 1.7 mm and the ossification-kyphosis angle of the anterior decompression site decreased at an average of 7.2 ± 6.8 degrees. Three patients demonstrated temporary neurological deterioration, all of whom completely recovered within 4 weeks postoperatively. The concept of our modified Ohtsuka procedure is 1) not OPLL extirpation or minimization but only the creation of space between the OPLL and spinal cord by an anterior shift of the ventral dura mater, which is achieved by complete resection of the PLL at the cranial and caudal sites of the OPLL; and 2) no nerve roots are sacrificed to prevent ischemic spinal cord injury. This procedure is not technically demanding and safe and provides secure decompression for thoracic OPLL. The anterior shift of the OPLL was smaller than expected, but it resulted in a relatively good surgical outcome with a recovery rate ≥65%. Our modified Ohtsuka procedure is quite secure and is not technically demanding, with a recovery rate of 65.8%.

Delayed temporary neurological deterioration after surgical treatment of gliomas in eloquent location under awake conditions

Delayed temporary neurological deterioration after surgical treatment of gliomas in eloquent location under awake conditions

P 13. The added benefit of intraoperative neuromonitoring for resection of motor eloquent brain lesions: A comparative study

Objective. Resection remains the most important form of treatment for patients with intracranial malignancies. The advantages of surgical resection must be balanced with the risk of surgery. Intraoperative neuromonitoring (IOM) is utilized to improve safety and enlarge the resection extent. However, comparative data on the use if IOM is scarce. Methods. Retrospective analysis of patients following resection of motor eloquent lesions between June 2018 and June 2020 was performed. A comparative analysis of the extend of resection; neurological squeal were compared between resections with or without IOM. Results. 66 patients (31 female, 35 male, age median, SD 62+/− 11,2) were identified. IOM was performed in 34 (51%) cases. 46% were female with a median age of 62 (range 31–82). There were no differences in baseline patient“s characteristics between both groups. 14% and 3% had a temporary neurological deterioration in the IOM and non-IOM group ( P = 0,198), respectively. 3% and 15% had a permanent neurological in the IOM and non-IOM group, respectively ( P = 0.100). 65% and 35% of resections were total and subtotal in both the IOM and non-IOM group ( P = 0.027), respectively. Conclusion. IOM is associated with lower rates of new postoperative neurological deterioration with the same rate resection quality following resection of motor eloquent lesions.

Posterolateral Debridement and Anterior Reconstruction by Limited Spinal Shortening in Thoracic Spine Infections

Background: Spinal infection is a very dangerous type of skeletal infection as it may be complicated with spin neurological deficit or spinal deformity, so early diagnosis and treatment is very important. Purpose: The aim of the current work was to evaluate the result of posterolateral debridement and anterior reconstruction by limited spinal shortening in thoracic spine infections. Patients and Methods: This retrospective clinical study included a total of 10 patients, 5 men and 5 women with thoracic spinal infection, attending at Sohag University Hospital. This study was conducted between 2003 and 2009. All patients were operated in the prone position through a single posterior midline exposure. Posterior stabilization by transpedicular screw fixation was performed. Medial 3 centimeters of 1 or 2 ribs were excised unilaterally. Anterior circumspinal dissection enables debridement of the lesion and evacuation of any abscess. Then, reconstruction of the anterior column was performed by limited spinal shortening followed by posterior fusion. Results: Causative organisms were TB in 8 patients, Staph aureus in 1 patient and bacteriologic testing of intraoperative samples did not find germs in 1 patient. Mean follow up was 90.3 months (range; 67- 150 months). No active infection occurred tell the end of follow up. Seven patients got neurological improvement. Two complications were encountered: kyphosis progression and temporary neurological deterioration. Conclusion: In cases of thoracic spinal infections, single posterolateral exposure is sufficient to debride the infected material, decompress the neural elements, and reconstruct the spine. Limited spinal shortening allows anterior reconstruction without the need for bone grafting.

Surgical outcome and prognostic factors in spinal cord ependymoma: a single-center, long-term follow-up study.

Objective:Spinal cord ependymomas account for 3–6% of all central nervous system tumors and around 60% of all intramedullary tumors. The aim of this study was to analyze the neurological outcome after surgery and to determine prognostic factors for functional outcome.Patients and Methods:Patients treated surgically due to a spinal cord ependymoma between 1990 and 2018 were retrospectively included. Demographics, neurological symptoms, radiological parameters, histopathology, and neurological outcome (using McCormick Score [MCS]) were analyzed. Possible prognostic factors for neurological outcome were evaluated.Results:In total, 148 patients were included (76 males, 51.4%). The mean age was 46.7 ± 15.3 years. The median follow-up period was 6.8 ± 5.4 years. The prevalence was mostly in the lumbar spine (45.9%), followed by the thoracic spine (28.4%) and cervical spine (25.7%). Gross-total resection was achieved in 129 patients (87.2%). The recurrence rate was 8.1% and depended on the extent of tumor resection (p = 0.001). Postoperative temporary neurological deterioration was observed in 63.2% of patients with ependymomas of the cervical spine, 50.0% of patients with ependymomas of the thoracic spine, and 7.4% of patients with ependymomas of the lumbosacral region. MCS 1–2 was detected in nearly two-thirds of patients with cervical and thoracic spinal cord ependymoma 36 months after surgery. Neurological recovery was superior in thoracic spine ependymomas compared with cervical spine ependymomas. Poor preoperative functional condition (MCS >2), cervical and thoracic spine location, and tumor extension >2 vertebrae were independent predictors of poor neurological outcome.Conclusion:Neurological deterioration was seen in the majority of cervical and thoracic spine ependymomas. Postoperative improvement was less in thoracic cervical spine ependymomas compared with thoracic spine ependymomas. Poor preoperative status and especially tumor extension >2 vertebrae are predictors of poor neurological outcome (MCS >2).

Abstract TP129: Intraoperative Prediction of Cerebral Hyperperfusion Syndrome After STA-MCA Bypass Surgery by a Newly Developed Hyperspectral Imaging System

Background: Superficial temporal artery (STA)-middle cerebral artery (MCA) bypass is the important treatment of moyamoya disease and other cerebral ischemic situations. However, cerebral hyperperfusion syndrome (HPS) may occur after vascular reconstructive surgery including STA-MCA bypass. 123 I-IMP-SPECT is useful to diagnose HPS after surgery, but there is no intraoperative device to predict HPS. Using intraoperative hyperspectral imaging data captured by hyperspectral camera (HSC), we can get the oxygen saturation value (SO2) of brain surface during surgery. We may predict HPS by analyzing intraoperative cerebral cortex SO2. Objective: To investigate whether the data from HSC during surgery is useful for prediction of postoperative HPS. Methods: 10 consecutive patients performed STA-MCA bypass were collected hyperspectral images of cerebral cortex by HSC before and after bypass. We got the SO2 data and analyzed the rate of change and correlation with HPS. Results: 3 patients presented temporary neurological deterioration several days after surgery and 123 I-IMP SPECT revealed focal intense increase in CBF at the sites of anastomosis. In these HPS patients, the rate of change of SO2 of cerebral cortex before and after bypass significantly increased in comparison with the patients didn’t present HPS (1.524 vs 1.089, P=0.0017). The receiver operating characteristic curve reveals if the rate of change of SO2 is more than 1.17, postoperative HPS is likely to occur (sensitivity=83%, AUC=0.81). Conclusions: Using the HSC, we may predict the occurrence of HPS after STA-MCA bypass. HSC can be the useful device in postoperative treatment for prevention of HPS.

Minimum five-year follow-up of posterior-only pedicle screw constructs for thoracic and thoracolumbar kyphosis.

Retrospective cohort study. To review/report 5-year follow-up data on patients diagnosed with thoracic and thoracolumbar kyphosis (TK/TLK) treated with posterior-only spinal fusion. TK/TLK was initially treated with combined anterior/posterior spinal fusion, evolving into widespread treatment with posterior-only spinal fusion. Forty-three patients who underwent a posterior-only spinal fusion for a primary diagnosis of TK/TLK from 1999 to 2009 with > 5-year follow-up were identified. Preoperative/postoperative/final follow-up measurements were recorded from full-length standing radiographs. Prospectively collected outcome scores were reviewed for the same time points, and charts were examined for complications. Patient age averaged 33years (range 13-77), and follow-up averaged 5.6years (range 5-12.2). Diagnoses included Scheuermann's disease (N = 15, 35%), idiopathic (N = 10, 23%), pseudarthrosis (N = 6, 14%), iatrogenic (N = 4, 9%), degenerative (N = 3, 7%), post-traumatic (N = 3, 7%), and congenital kyphosis (N = 2, 5%). Average correction of 44.3° (46%; 92.8° preoperatively vs 48.5° postoperatively) was achieved through posterior-only surgery. Loss of correction averaged only 1° in the instrumented segments at final follow-up. Eleven patients had a complication; proximal junctional kyphosis was the most common (N = 3, 7%). One patient lost intraoperative monitoring and one had temporary neurological deterioration postoperatively, but there was no permanent deficit. No pseudarthroses occurred. ODI scores improved 17.2 points on average (p = 0.01). SRS scores improved in all domains (average 0.79, p < 0.001). Pedicle screw constructs permit effective posterior-only correction of TK/TLK that is maintained at the 5-year follow-up time point. Patients report improvement, via outcome questionnaires, at the same follow-up time points. These slides can be retrieved under Electronic Supplementary Material.

THECALOSCOPY: A NOVEL METHOD IN SPINE SURGERY

ABSTRACT Objetive: Thecaloscopy is a less invasive method of exploration of the spinal subarachnoid space, using an ultra-thin, flexible endoscope and endoscopic fenestration of scars and adhesions. Thecalopscopy was used in Russian neurosurgery for the first time. Methods: Since 2009, we have operated on 32 patients with the following diagnoses: 17 - spinal adhesive arachnoiditis (8 - local forms, 9 - diffuse forms), 12 - spinal arachnoid cysts (7 - post-traumatic cysts, 5 - idiopathic cysts), and 3 - extramedullary tumors (thecaloscopic videoassistance and biopsy). In all cases, we performed exploration of subarachnoid space and pathologic lesion with endoscopic perforation of the cyst or dissection of adhesions using special instrumentation. The mean follow-up time in our group was 11.4 months. Results: Neurological improvement (mean 1.4 by the modified Frankel scale, 1.8 by the Ashworth spasticity scale) was seen in 87% of patients operated for spinal arachnopathies. Temporary neurological deterioration (mild disturbances of deep sensitivity) was seen in 9% of patients and managed successfully with conservative treatment. One patient (3.1%) was operated three times due to relapse of adhesions. There were no serious intraoperative complications (e.g. severe bleeding or dura perforation). Postoperative complications included one CSF leakage and one case of postoperative neuralgic pain. The mean hospitalization time was 7.6 days. Conclusion: According to our data, we conclude that thecaloscopy is efficient and safe method, and should be widely used for spinal arachnopathies, adhesive arachnoiditis and arachnoid cysts. Taking into account that adhesive spinal arachnoiditis is a systemic process, and that spinal arachnoid cysts may also be extended, thecaloscopy may be regarded as the most radical and less-invasive form of surgical treatment that currently exists in neurosurgery.

Surgical Treatment of Congenital Scoliosis Associated With Tethered Cord by Thoracic Spine-shortening Osteotomy Without Cord Detethering.

Retrospective case series. To investigate the safety and efficacy of spine-shortening osteotomy for congenital scoliosis with tethered cord. Conventional surgery for congenital scoliosis associated with tethered cord risks the complications of detethering. Spine-shortening osteotomy holds the potential to correct scoliosis and decrease spinal cord tension simultaneously without an extra detethering procedure, but no data on this issue is available. 21 patients (14 females and 7 males, average age 15.4 yr) underwent spine-shortening osteotomy without detethering. All of the patients had tethered cord. Patients with main curve more than 90° underwent vertebral column resection (VCR), whereas the others had pedicle subtraction osteotomy (PSO) performed. The average postoperative follow-up period was 45.2 months. The mean operation time was 544.5 min with average blood loss of 2769.1 ml. The deformity correction was 61.3% in the coronal plane and 43.9° in the sagittal plane. 10 patients had neurological deficits preoperatively. At the final follow-up, the deficits in 8 (80%) patients were significantly improved, whereas 2 (20%) remained unchanged. At final follow-up, 71.4% (5/7) patients reported improvement in motor function, 100% (3/3) had improved pain scores, and 75% (3/4) reported better sensory function after the spine-shortening osteotomy. Urinary dysfunction and bowel incontinence present preoperatively in 3 patients all recovered by final follow-up. 5 (23.8%) patients incurred complications including temporary neurological deterioration in 1 patient, urinary tract infection in 2 patients, cerebrospinal fluid leakage in 1 patient, and blood loss more than 5000 ml in 1 patient. Spine-shortening osteotomy is a safe and effective procedure for congenital scoliosis associated with tethered cord. Spine-shortening osteotomy at the thoracic apical vertebrae level not only corrects the spine deformity but also simultaneously releases the tension of the tethered cord, resulting in improved neurologic function.

Gradual spinal cord decompression through migration of floated plaques after anterior decompression via a posterolateral approach for OPLL in the thoracic spine.

Several surgical procedures have been developed to treat thoracic OPLL (ossification of the posterior longitudinal ligament). However, favorable surgical results are not always achieved, and consistent protocols and procedures for surgical treatment of OPLL in this region have not been established. Beak-type OPLL in the thoracic spine is known to be the most complicated form of OPLL to treat surgically. In this study, the authors examine the clinical outcomes after anterior decompression via a posterolateral approach for beak-type OPLL in the thoracic spine and address the gradual spinal cord decompression caused by migration of the floated plaques after surgery. Between 2011 and 2013, a total of 12 patients with thoracic myelopathy due to OPLL were surgically treated at the authors' institute. The study group for this paper comprises 6 of those 12 patients. These 6 patients, who had beak-type OPLL, underwent with anterior decompression and instrumented fusion via the authors' posterolateral approach-based surgical technique. The other 6 patients, who exhibited other types of OPLL, underwent posterior decompression and instrumented fusion. In the study group (the 6 patients with beak-type OPLL), half of the patients (the 3 patients who were treated first) were treated with removal of the ossified ligament. These patients are referred to as the removal group. The other 3 patients were treated by means of "floating" the OPLL plaques and are referred to as the floating group. Clinical and radiographic outcomes were evaluated in these 6 cases. The recovery rates were 52.4% in the removal group and 60.0% in the floating group. Two patients in the removal group had operative complications, including a dural tear and temporary neurological deterioration. No operative complications were encountered in the floating group. In all 3 cases in the floating group, floating of the ossified ligament was completely achieved, and the floated plaque gradually migrated into the ventral bone resection areas. The mean migration distances of the floated plaque were 2.4 mm, 4.3 mm, 4.7 mm, and 4.8 mm at 1, 3, 6, and 12 months after surgery. Treatment of beak-type OPLL in the thoracic spine via the posterolateral approach-based floating plaque technique was safe and effective in this small case series. Gradual migration of the floated plaques provided additional spinal cord decompression during the postoperative course.

Posterolateral Debridement and Anterior Reconstruction by Limited Spinal Shortening in Thoracic and Lumbosacral Spinal Infections

Introduction Anterior debridement and fusion using bone graft or cage is an accepted way of treatment of spinal infections. This can be achieved either through anterior or posterior or two-stage (anterior then posterior) surgery. In last few years, several research works reported good results with use of single posterior surgical approach for treatment of spinal infections. Spinal column shortening may be used in spinal fractures, deformities, and tumors. Since 2004, posterolateral exposure for debridement of thoracic and lumbosacral spinal infections and limited spinal shortening for anterior spinal reconstruction have been used. Patients and Methods A total of 32 patients with spinal infections (10 patients with infection of the thoracic spine and 22 patients with infections of the lumbar spine) were treated by this technique. Patients included 20 males and 12 females with a mean age of 56.3 (range, 20–72) years. Overall, 10 patients had neurological compromise (two Frankel grade A, three Frankel grade B, three Frankel grade C, and two Frankel grade D). Patients are operated under general anesthesia in the prone position through a single posterior exposure. Posterior stabilization by transpedicular screw fixation is performed. A rod is inserted in one side (usually the right side) while the rod in the other side is not inserted to give space sufficient for laminectomy and debridement. For full exposure of the anterior aspect of the vertebral bodies in the thoracic spine, excision of the medial 5 cm of one or two ribs may be performed. In the lumbar spine, dissection around the vertebral body is not needed as retraction of the cauda equine usually gives good space sufficient for curettage of the disc and debridement of the infected tissues and the technique is posterior lumbar interbody fusion (PLIF). Infected material is curetted and the second rod is inserted. Reconstruction of the anterior column is achieved by limited spinal shortening while carefully observing the dura for kinking. Then, posterior fusion is performed using local bone graft obtained from the laminae and ribs. Results Patients were followed up for a mean of 33 (range, 6–80) months. Causative organisms were TB in 20 patients, Staph aureus in 4 patients, salmonella typhi, 1 patient, brucella in 1 patient, and bacteriologic testing of intraoperative samples did not find germs in 6 patients. Operative time ranged between 100 and 190 (mean 135) minutes. Successful fusion was achieved in all patients 3 to 6 months postoperatively. Neurological recovery to Frankel grade E was obtained in all but four patients (three Frankel grade D and one Frankel grade B). Five complications were encountered; malpositioned pedicle screw, deep venous thrombosis (DVT), delayed wound healing, kyphosis progression, and temporary neurological deterioration. No active infection occurred till the end of follow-up. Conclusion Posterolateral debridement and anterior reconstruction by limited spinal shortening is an alternative method for surgical treatment of spinal infections. Advantages of this technique include a wide cancellous surface for bone healing, good stability, avoid the morbidity of bone graft harvesting, short operative time, and less morbidity.

Sylvian fissure arteriovenous malformations: long-term prognosis and risk factors

Sylvian fissure arteriovenous malformations (AVMs) are among the most challenging AVMs to manage surgically. The estimates of their risk factors and prediction of their long-term prognosis are crucial for clinical decision-making. The authors conducted a retrospective review to patients with sylvian AVMs treated microsurgically to evaluate the risk factors associated with long-term prognosis. Forty-one patients with sylvian fissure AVMs treated microsurgically between June 2009 and December 2011 were retrospectively reviewed with a mean follow-up time of 23 months (range 6-35 months). Chi-square test was utilized to compare proportions and rank-sum test to compare ordinal materials. Odds ratios (ORs) were used to assess risk factors associated with postoperative short-term outcome and long-term adverse outcome (mRS scores 3-6). One patient died in 1 month after surgery. Eighteen (43.9%) patients had postoperative transient neurological deterioration. Good outcomes (mRS scores 0-2) were observed in 29 (72.5%) patients in the follow-up. From the multiple logistic regression, a history of AVM bleeding and deep venous drainage increase the risk of postoperative transient neurological deterioration, with OR = 8.211 and OR = 4.869, respectively. A history of AVM bleeding was a risk factor for long-term adverse outcome, with OR = 7. Despite different Sugita classification subtypes, sylvian fissure AVMs' long-term results with microsurgical resection are better than expected; a history of AVM bleeding is a risk factor for postoperative temporary neurological deterioration and for long-term adverse outcome, while the AVM deep venous drainage is a risk factor only for temporary neurological deterioration.

Diastematomyelia

Retrospective case series study. This article describes our experience of the management of diastematomyelia. Diastematomyelia is a rare entity, which presents distinct clinical characteristics and requires different managements compared with other more common occult spinal dysraphism. A total of 156 patients with diastematomyelia were reviewed. All the patients underwent neurological and radiological examinations. Surgical excision of the lesion was performed for most patients and intradural exploration of the lumbar region was done to release tethering of conus in some patients. One patient died and autopsy was performed. Follow-up was carried out for all the patients, including surgical and nonsurgical approaches. There were 123 cases of type I diastematomyelia and 33 cases of type II diastematomyelia. The lumbar and thoracolumbar region was the most common site for diastematomyelia, and most spinal cords were split among 6 segments. The postoperative course was complicated by cerebrospinal fluid leakage in 2 patients, temporary neurological deterioration in 4 patients, and epidural hematoma in 1 patient. All cases did not have aggravation of symptoms during the follow-up of 2 to 20 years (mean of 4.5 yr). For the 123 patients with type I diastematomyelia, clinical symptoms were improved in 96 after surgical intervention and no worsening or occurrence of new clinical signs were observed during the follow-up. Those who did not receive surgery showed stabilization of neurological manifestation. Of the 33 type II cases, 9 surgical patients remained neurologically stable during the postoperative years without significant improvement in function, and 24 nonsurgical patients neither improved nor worsened in their neural deficit. Surgical treatment is the necessary management for type I diastematomyelia causing progressive neurological deterioration or with tethered filum, whereas conservative treatment is recommended to asymptomatic type I diastematomyelia and all type II diastematomyelia. 5.

Thecaloscopy – newest less invasive method of diagnosis and surgical treatment in spine surgery

Thecaloscopy is less invasive exploration of spinal subarachnoid space with ultra-thin flexible endoscope and endoscopic fenestratio of scars and adhesions. Thecaloscopy was used in Russian neurosurgery at the first time. Since 2009 we operated 32 patients with following diagnosis: 17 – spinal adhesive arachnoiditis (8 – local forms, 9 – diffuse forms), 12 –spinal arachnoid cysts (7 – posstraumatic cysts, 5 – idiopathic cysts), 3 – extramedullary tumors (thecaloscopic videoassistance and biopsy). In all cases we realized exploration of subarachnoid space and pathologic lesion with endoscopic perforation of cyst or dissection of adhesions using special instrumentation. Mean follow-up in our group was 11.4 months. Neurological improvement (mean 1.4 by modified Frankel scale, 1.8 by Ashworth spasticity scale) was seen in 87% of patients operated for spinal arachnopathies. Temporary neurological deterioration (mild disturbances of deep sensitivity) was seen in 9% of patients and managed successfully with conservative treatment. 1 patient (3.1%) was operated 3 times because of relapse of adhesions. There were no serious intraoperative complications (e.g., serious bleeding, dura perforation etc). Postoperative complications included 1 CSF leakage and 1 postoperative neuralgic pain. Mean term of hospitalization was 7.6 days. According to our data, we suppose that thecaloscopy is efficient and safe method, and should be widely used for spinal arachnopaties, adhesive arachnoiditis and arachnoid cysts. Taking into account that adhesive spinal arachnoiditis is systemic process and spinal arachnoid cysts can be extended as well, thecaloscopy may be regarded as the most radical and less-invasive way of surgical treatment existing currently in neurosurgery

Possible factors influencing postoperative temporary neurologic deterioration following standard superficial temporal artery-middle cerebral artery (STA-MCA) bypass surgery: diameter of STA and MCA (M4)

Objectives: Transient postoperative hyperperfusion may be the cause of the temporary neurologic deterioration (TND) frequently observed following superficial temporal artery-middle cerebral artery (STA-MCA) bypass surgery. The purpose of this study is to investigate the possible factors influencing postoperative temporary neurologic deterioration. Methods: The STA-MCA bypass surgery was performed in 13 patients with moyamoya disease and 9 patients with cerebrovascular occlusive disease. The diameter of the STA and MCA for anastomosis was measured and analyzed. Computed tomographic perfusion (CTP) was performed prior to the operation and on the third post-operative day to assess improvements in regional cerebral perfusion. Results: After surgery, five patients (22.7 %) with improvement of perfusion suffered TND such as dysphasia, motor deficit and sensory disturbance after surgery and 11 (50 %) patients with improvement of perfusion did not show temporary neurologic deterioration after surgery. There were six patients (27.3 %) without improvement of perfusion after surgery. The D-STA was 1.48 ± 0.92 mm in patients with TND, which was larger than the D-STA of 1.10 ± 0.14 mm in patients with improvement of perfusion and 1.08 ± 0.26 mm in patients without improvement of perfusion (P < 0.05); The D-MCA after surgery was also wider in patients with TND (D-MCA: 1.20 ± 0.19 mm) compared to both patients with hyperperfusion (D-MCA: 0.93 ± 0.15 mm, p = 0.028) and patients without hyperperfusion (D-MCA: 0.98 ± 0.12 mm, p = 0.012). The TOT was 34.40 ± 7.70 minutes in patients with TND, 32.83 ± 3.43 minutes in patients with improvement in perfusion and 33.45 ± 4.48 minutes in patients without improvement of perfusion; there was no significant difference between the three groups (P >0.05). Conclusions: The D-STA and D-MCA may influence the development of TND after STA-MCA bypass, but the TOT of the recipient arteries was not related to temporary neurologic deterioration.

Treatment of Acute Tuberculous Spondylitis by the Spinal Shortening Osteotomy: A Technical Notes and Case Illustrations

Dear Sir, I read with great interest the paper published in your journal entitled Treatment of acute tuberculous spondylitis by the spinal shortening osteotomy: technical notes and case illustrations. by Chanplakorn et al. [1]. In this paper the authors reported: However, to the best of our knowledge, there is no report on spinal shortening ostotomy as a surgical treatment for the active disease stage of tuberculous spondylitis without a severe rigid angular kyphotic deformity [1]. I am sending you this letter in order to clarify that the first research work reporting single stage posterior debridement of active spinal infections with anterior reconstruction performed by limited spinal shortening was completed by me in 2006 [2]. Within the paper I published my first experience with posterior single stage debridement and fusion for thoracic and lumbar spine infections in 12 patients. In 5 out of 12 patients, anterior reconstruction was performed utilizing limited spinal shortening (2 in the thoracic spine and 3 in the lumbar spine). In my study, Fig. 1 demonstrated a case of tuberculous (TB) spondylitis of the thoracic spine (Th8-9) similar to the cases presented by Chanplakorn et al. and the anterior defect was reconstructed through limited spinal shortening [2]. In SICOT 2011 XXV Triennial World Congress, held during September-6-9, 2011 in Prague, Czech Republic, I reported my experience in 10 patients of infections of the thoracic spine treated by the same technique with anterior reconstruction done in all cases by spinal shortening (abstract number 29530). The age of the patients ranged between 35 and 71 years with a mean age of 56.5 years. Causative organisms were TB in 8 patients, Staph aureus in 1 patient and bacteriologic testing of intraoperative samples did not find germs in 1 patient. The mean follow-up was 30.7 months (range, 5 to 80 months). Seven patients demonstrated neurological improvement. Two complications were encountered; kyphosis progression and temporary neurological deterioration [3].

Possible factors influencing postoperative temporary neurologic deterioration following standard superficial temporal artery-middle cerebral artery (STA-MCA) bypass surgery: diameter of STA and MCA (M4)

Possible factors influencing postoperative temporary neurologic deterioration following standard superficial temporal artery-middle cerebral artery (STA-MCA) bypass surgery: diameter of STA and MCA (M4)

Lessons Learned From Moyamoya Disease: Outcome of Direct/Indirect Revascularization Surgery for 150 Affected Hemispheres

Moyamoya disease is a chronic, occlusive cerebrovascular disease with unknown etiology characterized by bilateral steno-occlusive changes at the terminal portion of the internal carotid artery and an abnormal vascular network at the base of the brain. Recent advances in molecular biology and genetic research have provided better understanding of the pathophysiology of moyamoya disease, but surgical revascularization still remains the preferred treatment for this entity. The present study investigated the clinical course of 106 consecutive patients with moyamoya disease who underwent superficial temporal artery-middle cerebral artery anastomosis with indirect pial synangiosis in 150 hemispheres. The outcomes of surgery on the operated hemisphere were favorable, with no cerebrovascular event during the outpatient follow-up period (mean 58.4 months) in 89.3% (134/150). Two patients suffered hemorrhagic events on the operated hemisphere during the follow-up period (2/150, 1.33%), one of whom suffered deteriorated neurological status after hemorrhage. Despite the favorable long-term outcome, the incidence of temporary neurological deterioration due to cerebral hyperperfusion was 18.0% (27/150), but no patients suffered permanent neurological deterioration directly caused by hyperperfusion. In conclusion, direct/indirect revascularization surgery is a safe and effective treatment for moyamoya disease, although the issue of bleeding/re-bleeding remains to be solved. Postoperative cerebral hyperperfusion and peri-operative infarction are potential complications of this procedure, so we recommend intensive postoperative care and cerebral blood flow measurement in the acute stage, because the management of hyperperfusion is contradictory to that of ischemia.

Surgical treatment for lipomyelomeningocele in children

Lipomyelomeningocele (LMM) is a common and severe closed neural tube defect in children. Because of the complex anatomy of LMM and the difficulty in assessing the value of surgery, the management of patients with LMM is controversial. This study was undertaken to evaluate effective techniques and procedures in surgical treatment of LMM and to assess the value of early neurosurgical intervention. Twenty-five children with LMM aged from 2 months to 6 years underwent surgery between January 2004 and December 2006. Magnetic resonance imaging (MRI) of the spine and electromyography (EMG) of the lower limbs was conducted in all patients preoperatively. Urodynamic studies were appropriate even in asymptomatic patients. Hoffman's functional grading was used to assess the pre and postoperative status of the patients. The operation was composed of subtotal excision of lipoma, suturing of the spinal pia mater, and section of the filum terminale. Suturing of the spinal pia mater was performed in a wide process of reconstruction of meningeal layers including the dura. Follow-up lasted 1-4 years (mean 2.1 years), in which all children underwent neurological examination, EMG and MRI. After surgery a temporary neurological deterioration was found in two patients including slight weakness of a leg in one patient and urinary retention in the other, but it recovered completely a few days later. No postoperative complications were encountered. During the follow-up, 20 asymptomatic patients remained symptom-free. Symptoms disappeared totally in 2 of the 5 patients with neurological deficits, improved in one patient and stabilized in the remaining 2. MRI showed no tethered cord in all patients who underwent surgical procedures. Early operation for LMM patients, even asymptomatic ones, should be performed to prevent the development of neurological deficits. Subtotal excision of lipoma, suturing of the spinal pia mater, and section of the filum terminale are recommended in the surgical treatment of LMM. The longitudinal cut of the filum terminale, a technique we have established in our surgical practice, is a simple and practical way to identify the filum terminale by visual inspection. And suturing the spinal pia mater is of extreme importance in preventing postoperative tethering.

Transient Neurologic Deterioration after Total Removal of Parasagittal Meningioma Including Completely Occluding Superior Sagittal Sinus

In surgical planning of the parasagittal meningioma, invasion and occlusion of the superior sagittal sinus are important factors. When tumor is located within anterior 1/3, or when angiographic finding shows total occlusion of superior sagittal sinus, it is regarded that the ligation of superior sagittal sinus is safe. We report a case of parasagittal meningioma in 59-year-old male patient with complete occlusion of superior sagittal sinus which was confirmed by preoperative angiography, who developed temporary neurologic deterioration after superior sagittal sinus ligation and resection.