Circumferential decompression via the posterior approach for the surgical treatment of multilevel thoracic ossification of the posterior longitudinal ligaments: a single institution comparative study

Background The treatment strategies for multilevel thoracic ossification of the posterior longitudinal ligaments (T-OPLL) were rarely reported. The aim of this study was to investigate the clinical outcomes and complications of circumferential decompression for multilevel T-OPLL and compare two different methods in the management of the OPLL (resection or floating).

Methods Data of sequentially treated patients who received surgical treatment for thoracic spinal stenosis caused by multilevel T-OPLL from January 2005 to February 2012 were retrospectively reviewed. Based on the surgical approaches applied, the patients were divided into two groups. Group A consisted the patients who received posterior decompression and group B consisted the patients who received circumferential decompression via the posterior approach. Group B was further divided into two subgroups: subgroup 1 (the resection group) where the OPLL was completely resected and subgroup 2 (the floating group) where the OPLL was floated.

Results A total of 49 patients were included in the study. Fourteen patients with single posterior decompression were included in group A and 35 patients who received circumferential decompression were included in group B. In group B, 29 patients had complete resection of the ossified posterior longitudinal ligaments, while the other six underwent a flotation procedure. The follow-up data were available in 39 patients. Mean JOA scores improved from 5.4 ± 1.8 to 7.5 ± 2.8 in group A and from 3.7 ± 1.8 to 7.9 ± 2.4 in group B. The main complications included cerebrospinal fluid (CSF) leakage and postoperative neurologic deterioration (ND). Twenty-three of the 25 cases with postoperative CSF leakage achieved a complete recovery at the last follow-up and 12 of the 15 cases with ND achieved some neurological improvement at the last follow-up.

Conclusions Circumferential decompression via the posterior approach is an effective surgical method for thoracic spinal stenosis caused by multilevel OPLL of the thoracic spine. Patients who receive complete resection of the ossified posterior longitudinal ligaments may have better recovery rate than the “floating” group.

     

Clinic characteristics and surgical strategy of ossification of the posterior longitudinal ligament of thoracic spine

Objective To study the ossification of the posterior longitudinal ligament （OPLL） of thoracic spine which treated surgically, analysis the clinic characteristics and surgical strategy. Methods Fifty-five patients who had been treated surgically for thoracic OPLL were reviewed. There were 19 males and 36 females. The mean age was 51.9 years （ range, 35 - 73 years）. All cases were with neurological deficits. The treatment procedures consisted of anterior decompression with instrumentation （15 patients）, posterior removal of posterior wall of thoracic spinal canal （34 patients）,     

Computer-assisted minimally invasive spine surgery for resection of ossification of the ligamentum flavum in the thoracic spine

Background Ossification of the ligamentum flavum （OLF） has been widely recognized as one of the main causes of thoracic spinal canal stenosis and thoracic myelopathy.Decompression is the only effective strategy for treating thoracic myelopathy caused by OLF.The purpose of this study was to describe the clinical outcomes of computer-assisted minimally invasive spine surgery （CAMISS） for posterior decompression in patients with thoracic myelopathy caused by OLF.Methods In all cases,the surgical procedure was performed with the assistance of an intraoperative three-dimensional navigation system.Decompression of the spinal cord was performed with a high-speed drill; the supraspinal ligaments and spinous process were partially preserved.The outcomes were evaluated by a modified Japanese Orthopedic Association （JOA） scoring system and recovery rates.Results The mean duration of follow-up for the 14 cases was 3.9 years.All patients experienced neurological recovery,the mean JOA score improving from 6.1 points preoperatively to 8.6 points at final follow-up and the mean rate of recovery being 52.7% （excellent in two cases,good in eight,fair in three,and unchanged in one）.Conclusion CAMISS is a safe and effective procedure for resection of the OLF in the thoracic spine.     

SELECTION OF SURGICAL APPROACH TO TREAT TRAUMATIC INSTABILITY OF SUBAXIAL CERVICAL SPINE

Objective To evaluate the clinical outcomes of surgical therapy in treating traumatic instability of subaxial cervical spine through either anterior or posterior approach. Methods According to the A llen-Fergurson＇s classification, we retrospectively studied 42 cases of traumatic instability of subaxial cervical spine through either anterior or posterior surgical reconstruction. Patients requiring approach for either reduction or decompression were not included. Results The average follow-up interval was 3 years and 2 months. The anterior and posterior reconstructions were 24 and 18 cases, respectively. Before operation, the average scores of JOA and VAS were： 12.1 and 6. 9 for anterior group, and 12.3 and 7. 2 for posterior group. At the final assement, the scores of JOA and VAS improved to 16. 0 and 2.2 for anterior group, and 15. 7 and 2.6 for posterior group. The average ASIA motor scores of anterior and posterior group improved to 68. 2 and 65. 5 at the final follow-up from 58.4 and 59. 7 before operation, respectively. The ASIA grade （A-E） was converted to a numeric score. The average scores before operation in the anterior and posterior group were 3.3 and 3.4, and increased to 3.8 and 3. 7 at the final follow-up. After operation, there were different extent improvements of average radiological parameter, such as Cobb angle, vertebral body translation and disc height ratio. The average operation time and blood losing were 122 min and 125 mL for anterior group, and 153 min and 287 mL for posterior group. Fusion was achieved in all patients and 4 and 2 complications occurred at the anterior or posterior group. Conclusion The results showed that there were no obvious difference in parameters, such as neurological assements, functional grades, fusion rate, operation time and blood losing, between anterior and posterior group, except the virtues of anterior group in reconstruction and maintaining physiologic cervical lordosis and intervertrbal disc height occurred.     

Clinical results of surgery for thoracic myelopathy caused by upper thoracic OLF： Operative technique of posterior decompression with instrumented correction and fusion

Objective To investigate the ideal surgical treatment for ossification of upper thoracic ligamentum flavum and analyze its efiopathogenisis, segments distribution, operation effect and the correlation factors. Methods Retrospectivly studied 27 ossification of upper thoracic ligamentum flavum cases who had been operated from Jan, 2000 to Jun, 2005. There were 11 cases complicating OPLL in the same level. All the cases underwent posterior decompression by removing the OLF and posterior wall of the spinal canal with the technique of ＂isolating-thinning- separating-removing＂;     

Posterior Selective Thoracic Fusion in Adolescent Idiopathic Scoliosis Patients： a Comparison of All Pedicle Screws versus Hybrid Instrumentation

Objective To analyze the influence of segmental pedicle screws versus hybrid instrumentation on the correction results in adolescent idiopathic scoliosis patients undergoing posterior selective thoracic fusion. Methods By reviewing the medical records and roentgenograms of adolescent idiopathic scoliosis patients who underwent selective thoracic fusion from February 2000 to January 2007 in our hospital, the patients were divided into 2 groups according to different instrumentation fashions： Group A was hook-screw-rod （hybrid） internal fixation type, Group B was screw-rod （all pedicle screws） internal fixation type, and the screws were used in every segment on the concave side of the thoracic curve. The parameters of the scoliosis were measured and the correction results were analyzed. Results Totally, 48 patients （7 males, 41 females） were included, with an average age of 14.4 years old and a mean follow-up time of 12.3 months. Thirty and 18 patients were assigned to group A and group B, respectively. The mean preoperative coronal Cobb angles of the thoracic curve were 48.8° and 47.4°, respectively. After surgery, they were corrected to 13.7° and 6.8°, respectively. At final follow-up, they were 17.0° and 9.5°, with an average correction rate of 64.6% and 79.0%, respectively, and the correction rate of group B was significantly higher than that of group A （P=0.003）. The mean preoperative coronal Cobb angles of the lumbar curve were 32.6° and 35.2°, respectively. After surgery, they were corrected to 8.6° and 8.3°, respectively. At final follow-up, they were 10.3° and 11.1°, with an average correction rate of 66.8% and 69.9%, respectively, and the correction rate of group B was significantly higher than that of group A （P=0.003）. The correction loss of the thoracic curve and lumbar curve in the 2 groups were 3.1° and 1.8°, 2.4° and 2.4°, respectively. No significant difference was noted （both P〉0.05）. The decompensation rate at final follow-up in these 2 groups were 4% （1/25） and 7.1% （1/14） respectively, with no significant difference （P〉0.05）.     

Circumspinal decompression through a single posterior incision to treat thoracolumbar disc herniation

Background  Various surgical approaches have been successfully used in the treatment of thoracolumbar disc herniation (TLDH). Although the anterior transthoracic approach has a reputation for better visualization than the posterolateral and lateral approaches, it involves the manipulation of the thoracic and pulmonary structures. Thus, this approach is technically demanding and prone to compromising the respiratory system. An ideal approach would involve adequate visualization and be accomplished through the posterior midline approach that is familiar to spine surgeons. The objective of this retrospective preliminary clinical study was to introduce a new surgical procedure, circumspinal decompression through a single posterior incision, for the treatment of TLDH (T10/11–L1/2) and to evaluate the surgical outcome of this procedure by comparing it to the conventional anterior transthoracic approach.

Methods  In this study, 15 patients (10 males, 5 females; mean age 51 years) with symptomatic TLDH underwent the circumspinal decompression through a single posterior incision procedure between January 2008 and December 2009. Altogether, 17 herniated discs were excised, with 2 discs at T10/11, 4 discs at T11/12, 5 discs at T12/L1 and 6 discs at L1/2. Of these patients, 13 were followed up with a mean follow-up period of 23.5 months. Clinical outcomes, including operative time, blood loss, perioperative complications, postoperative time of hospitalization, neurologic status improvement, back pain and correction of local kyphosis, were investigated by comparing these data with the results from patients who underwent the anterior transthoracic approach for TLDH during the same period. The patients’ neurologic status was evaluated by a modified Japanese Orthopedic Association (JOA) scoring system of 11 points. Neurologic status improvement after the surgery was assessed by calculating the recovery rate, which was equal to the (postoperative JOA score–preoperative JOA score)/(11–preoperative JOA score)×100%. The rates of patients who improved at the final follow-up were also assessed.

Results  The mean operative time was 183 minutes, the mean blood loss was 1067 ml, and the mean postoperative hospitalization time was 8.4 days. Three patients suffered perioperative complications, but none of these complications involved the respiratory system. Local kyphotic angles at the fusion levels were reduced. Of the 13 patients that were followed up, 12 improved at the final follow-up, with a mean recovery rate of 52.8%. Patients who underwent the circumspinal decompression procedure showed a higher percentage of improvement at the final follow-up, a higher degree of local kyphosis correction and a lower percentage of complications (especially respiratory complications) compared to patients who underwent the anterior transthoracic decompression procedure.

Conclusions  The circumspinal decompression through a single posterior incision procedure is an effective and safe technique that is comparable to anterior tranthoracic approach for the surgical treatment of TLDH patients. It could be an attractive choice in certain circumstances.

     

Treatment of herniated lumbar disc by percutaneous laser disc decompression combined with synchronous suction technique through syringe

Objective： To compare the outcomes of percutaneous laser disc decompression （PLDD） and PLDD with synchronous suction through syringe in the patients with herniated lumbar disc（HLD）. Methods： Forty-two patients with HLD on MRI and those who did not respond to conservative treatment for 6 weeks were randomly divided into group A and group B. In group A, the patients were treated with PLDD and those in group B with PLDD and synchronous suction through syringe. GaAIAS diode laser at 810 nm was used for the ablation in both groups. The treatment effect was evaluated by modified MacNab＇s criteria on the 7^th, 30^th and 90^th day. Results： Evaluated by modified MacNab＇s criteria, the percentages of the excellent and good cases in total patients treated for group B and A were 80.95% and 57.14% on the 7^th follow-up day, 85.71% and 66.67% on the 30^th follow-up day, and 95.24% and 71.43% on the 90^th follow-up day, respectively. Conclusion： Synchronous suction technique through syringe during PLDD improves the overall outcome in the treatment of herniated lumbar disc.     

Intraoperative ultrasonography in “cave-in” 360° circumferential decompression for thoracic spinal stenosis

Background  The surgical outcomes of decompression for thoracic spinal stenosis (TSS) are unfavorable. The purpose of this study was to determine the efficacy of intraoperative ultrasonography during “cave-in” 360° circumferential decompression surgery in patients with TSS.

Methods  Thirteen patients with TSS underwent “cave-in” 360° circumferential decompression surgery between May 2010 and November 2010. Intraoperative ultrasonography was used after removal of the posterior wall of thoracic spinal canal to assess the morphologic restoration of the spinal cord and the anterior surface of the spinal canal. In seven patients, ultrasonography was used again after circumferential decompression to compare the cross-sectional area of the spinal cord before and after circumferential decompression.

Results  The average period of follow-up was (12±2) months (range 9–15 months). The Japanese Orthopedic Association score was significantly higher at the final follow-up (8.5±2.1, range 3–10) than preoperatively (5.2±1.1, range 3–7; P <0.01). The cross-sectional area of the spinal cord was (30.8±6.6) mm² before and (53.6±19.1) mm² after circumferential decompression (P <0.01). For five patients with TSS caused by thoracic disc herniation, the levels of circumferential decompression performed corresponded to those expected preoperatively. In contrast, for eight patients with TSS caused by ossification of the posterior longitudinal ligament, on average 1.6±0.9 fewer levels of circumferential decompression were performed than expected preoperatively.

Conclusions  “Cave-in” 360° circumferential decompression is an effective therapeutic option for TSS. Intraoperative ultrasonographic evaluation may reduce the levels of circumferential decompression and ensure sufficient decompression, and increase the efficacy of this surgical technique.

     

Surgical strategies for petroclival meningioma in 57 patients

Background Resection of petroclival meningioma （PCM） is difficult for neurosurgeons and usually brings poor performance status. In this study, we evaluated the possible risk factors for unfavorable clinical outcomes of surgical treatment of PCM, and tried to explore the optimal surgical strategies for better postoperative quality of life.Methods We recruited 57 patients （14 male, 43 female, mean age, 50.5 years） who underwent surgical resection of PCM in Huashan Hospital during 2002-2006. The primary outcomes including postoperative neurological deficits,modified Rankin scale （mRS） score and recurrence rate were evaluated, and all potential risk factors were assessed by the X2 test. Odds ratio and 95% confidence interval were calculated by univariate Logistic regression. The mean follow-up time was 34 months.Results Gross total resection was achieved in 58% of patients. One patient died during the perioperative period because of intracranial hemorrhage. Sixty-seven percent of patients experienced new postoperative neurological deficits and 26% had a higher mRS score at follow-up assessment. Postoperative complications were observed in 24 patients.Within the follow-up period, radiographic recurrence occurred in 12.3% of patients at a mean follow-up of 42 months.Postoperative radiosurgery was administered to 19 patients who had residual tumors or recurrence and no furtherprogression was found. Tumor adhesion, hypervascularity and engulfment of neurovascular structures were three risk factors for increased mRS score （P=0.0002; P=0.0051; P=0.0009）. Tumor adherence to adjacent structures clearly affected the extent of resection （P=0.0029）. The risk of postoperative cranial nerve deficits increased with tumor engulfment of neurovascular structures （P=0.0004）.Conclusions Intraoperatively defined tumor characteristics played a critical role in identifying postoperative functional status. An individual treatment strategy after careful preoperative evaluation could help improve quality of life.     

Neural endoscopic assisted micro-invasive management of Chiari I malformation

Background In order to make posterior fossa decompression for the management of Chiari I malformation simple and less invasive while using direct visualization, a novel solely endoscopic procedure has been employed for the decompression of Chiari malformation type I. The objective of this study was to present neural endoscopic posterior fossa decompression and atlas laminectomy for Chiari type I patients. Methods Twenty-one patients with Chiari type I underwent neural endoscopic posterior fossa decompression and atlas laminectomy. We described the procedure for neural endoscopic posterior fossa decompression and atlas laminectomy. All patients in this series demonstrated cerebellar tonsil herniation below the foramen magnum in addition to syringomyelia. All patients in the reviewed study underwent preoperative MRI as well as 3-month postoperative MRI. Additional follow-up MRI varied but was usually repeated 12 months to 18 months after surgery. Postoperative MRI studies were retrospectively reviewed and compared with preoperative studies. Results All patients showed clinical improvements, and none had any complications. Patients with syringomyelia had symptoms entirely disappear. Eleven patients （52.4%） experienced radiographic improvement in syringomyelia （decreased size or resolution） during the follow-up period. Nine patients （42.8%） demonstrated decreased syrinx size and four （19%） demonstrated resolved syrinx. Of the 15 patients with symptomatic syringomyelia, 11 （73.3%） experienced symptomatic improvement. The median time to symptom improvement was four months after surgery. Post surgical MRI examinations indicated complete and sufficient decompression of foramen magnum region. Conclusions Endoscope atlanto-occipital decompression surgery is an innovative, safe and effective surgical procedure. It has similar results compared to traditional surgery, however with the added advantages of being minimal invasive, having fewer complications, decreased influence on stability of occipital bony structure, and a faster recovery as well as reduced hospital stay and expenses.     

Classification and management of the tandem ossification of the posterior longitudinal ligament and flaval ligament

Objective To provide appropriate guidelines for treatment of tandem ossification of the posterior longitudinal ligament （OPLL） and flaval ligament （OFL）. Data sources Published articles about OPLL and OFL were selected using Medline and Embase electronic databases. Study selection An English literature search from January 1980 to December 2006 was conducted. Because many reported cases were incorporated in OFL studies, the key words for search were OFL or OFL and OPLL. The first step revealed 93 studies of which 13 reports of tandem OPLL and OFL （tandem ossification） were selected. Results All studies were case series or case report and advocated that the primary therapy for tandem ossification should be operative. The clinical outcomes of surgery were evaluated in most reports, predominantly using the JOA scores. Gender is the only factor which has prognostic value. A higher proportion of women was found in the failure group A two- stage classification of tandem ossification was developed to relate diagnosis to outcome. Conclusions All patients with suspected ossification of the spinal ligaments should undergo routine MRI screening of the whole spine. The correlation of the classification with surgical treatments needs further studies to validate its usefulness. Chin Med J 2009; 122（2）：219-224     

Clinical study of simultaneous lung volume reduction surgery during resection of pulmonary or esophageal neoplasms

Background If the emphysema lesions are not symmetrical, unilateral lung volume reduction surgery （LVRS） can be carried out on the more severe side. The aim of this research was to evaluate the feasibility and effects of LVRS performed simultaneously with resection of pulmonary and esophageal neoplasms. Methods Forty-five patients with pulmonary neoplasm and 37 patients with esophageal neoplasm were randomly assigned to group A or group B. In group A, LVRS was performed simultaneously on the same side as thoracotomy. In group B, only tumor resection was performed. The nonfunctional lung area was determined by preoperative chest computed tomography and lung ventilation/perfusion scan. The lung volume removed was about 20% to 30% of the lobes on one side. Preoperative and postoperative indexes including pulmonary function testing variables, arterial blood gas analysis variables, dyspnea scale, 6-minute walk distance, etc., were compared between the groups. Results There were no surgical deaths in this study. The postoperative forced vital capacity in 1 second, PaO2, PaCO2, dyspnea scale, and 6-minute walk distance were improved significantly in group A, whereas these indexes did not change or decreased slightly in group B. Conclusions For tumor patients who have associated emphysema, simultaneous LVRS not only increases the chance of receiving surgical therapy, but also improves the postoperative quality of life of the patient. LVRS has expanded the surgical indication for tumor patients.     

Microsurgical resection of craniopharyngioma of the third ventricle via an improved transventricular approach

Background Craniopharyngioma of the third ventricle is difficult to treat and its therapeutic regimens and operative approaches have been controversial. This study was undertaken to probe indications for microsurgical resection of craniopharyngioma of the third ventricle via an improved transventricular approach, its surgical procedures and therapeutic effects, and prevention of postoperative complications. Methods Fifty-one patients with craniopharyngioma of the third ventricle were treated from January 2000 to October 2004 by an improved transventricular approach for removing the tumor viathe interventricular foramen, the intermedius of the septum pellucidum or choroid fissure. Symptoms and signs of the patients, and results of imaging, operation, and follow-up were analyzed. Results Of the 51 patients who had received the improved transventricular resection, 4 underwent a combined approach with an entrance of the pterion. Forty patients (78.43%) underwent total resection and others subtotal resection, without an operative death. Epileptic seizures were found in 3 patients (5.88%) and subdural effusion in the operative field in 4 (7.84%). All patients showed good general conditions after operation, and follow-up for an average of 27.52 months showed relapse of the tumour in 8 patients (15.69%). Conclusions Microsurgical resection of craniopharyngioma of the third ventricle by an improved transventricular approach has advantages of operative safety and efficacy, lower mortality and disability, and less complications.     

Adjacent segment disease after anterior cervical decompression and fusion: analysis of risk factors on X-ray and magnetic resonance imaging

Background Adjacent segment disease （ASD） is common after cervical fusion.The aim of this study was to evaluate the risk factors for ASD on X-ray and magnetic resonance imaging （MRI）.Methods Patients included in this study had received revision surgeries after developing symptomatic ASD following anterior decompression and fusion.A control group that had not developed ASD was matched 1：1 by follow-up time and fusion segments.Plate-to-disc distances （PDDs）,developmental cervical canal stenosis on X-ray,cervical disc degeneration grading,and cervical disc bulge impingements on preoperative MRI were measured and compared between the ASD group and the control group.Results Thirty-four patients with complete radiographic data were included in the ASD group.The causative segments of ASD included nine cases of C3-4,18 cases of C4-5,three cases of C5-6,and four cases of C6-7.The ASD occurred at the upper adjacent segments in 26 patients and at the lower adjacent segments in eight patients.PDD distributions were similar between the ASD group and the control group.Developmental cervical canal stenosis was a risk factor for ASD,with an odd ratio value of 2.88.Preoperative cervical disc degenerations on MRI were similar between the ASD group and the control group.In the upper-level ASD group,the disc bulge impingement was （19.7±9.7）％,which was significantly higher than that of the control group of （11.8±4.8）％.Conclusions ASD was more likely to develop above the index level of fusion.Developmental cervical canal stenosis and greater disc bulge impingement may be risk factors for the development of ASD.     

Postoperative recovery from posterior communicating aneurysm complicated by oculomotor palsy

Background Oculomotor palsy is a common complication in patients with posterior communicating aneurysm. This study was conducted to investigate the postoperative recovery of patients with posterior communicating aneurysm complicated with oculomotor palsy and to analyze the factors influencing length of recovery.
Methods From 2000 to 2006, 148 patients with posterior communicating aneurysm were treated at our hospital, with 74 of them having concurrent unilateral oculomotor palsy. All of the patients underwent craniotomy after the diagnosis by means of whole-brain digital subtraction angiography （DSA）. The patients were divided into two groups for observation of postoperative recovery during the follow-up period. Patients in group A were treated with simple pedicle clipping of the aneurysm while patients in group B were treated with pedicle clipping of the aneurysm and decompression of the oculomotor nerve.
Results Of the 40 patients in group A, 20 underwent surgery within 14 days and completely recovered from oculomotor palsy in 10-40 days. Fourteen patients underwent surgery within 14-30 days, of whom 12 completely recovered within 30-90 days and 2 cases recovered incompletely. The remaining six patients underwent surgery after more than 30 days; of these, four patients recovered completely and two recovered incompletely. Of the 34 cases in group B, 15 underwent surgery within 14 days and completely recovered from oculomotor palsy in 10-40 days. Sixteen patients underwent surgery in 14-30 days, of whom 14 completely recovered in 30-90 days and 2 recovered incompletely. The remaining three patients underwent surgery after more than 30 days, of whom two patients recovered completely and one recovered incompletely.
Conclusions Early diagnosis and surgical treatment of patients with unilateral oculomotor palsy induced by posterior communicating aneurysm are important to full postoperative recovery of the oculomotor nerve. No correlation was found, however, between decompression of the oculomotor nerve, such a     

Single-stage Posterior Spondylectomy, Circumferential Decompression and Reconstruction Using Mesh Cage for Spinal Tumors

Objective To explore the feasibility and clinical results of circumferential decompression and threecolumn reconstruction through single-stage posterior transpedicular approach for spinal tumor treatment. Methods Totally, 24 patients with spinal tumor underwent tumor resection and spinal reconstruction through single-stage posterior transpedicular approach. Preoperatively, according to the Frankel classification, 12 patients were grade E, 9 grade D, and 3 grade C. Anterior column was reconstructed with non-expandable titanium cages. Posterior segmental instrumentation was used to maintain the stability of spine in all cases. Anterior and posterolateral fusion was performed with autograft and allogenic bone. The following data were followed up in these patients： deformity angle, local recurrence, neurological function, and spinal bony fusion. Results The average operating time and blood loss was 5.6 hours and 3 400 ml respectively. No intraoperative and postoperative complications were observed in this group. Postoperatively, 21 patients were Frankel grade E, 2 grade D, and 1 grade C. Four patients reported significant functional restoration and twenty patients reported complete resolution of pain. At follow-up （range, 6-42 months）, implant failure or recurrent neurological symptoms was not found. Conclusions The tumor resection and spinal reconstruction through single-stage posterior transpedicular approach is a safe and effective technique for the treatment of spinal tumor. It can fully decompress the neurological structures, correct the kyphosis, and achieve early weight-bearing. This technique can improve life quality for the patients with spinal tumor.     

Surgical management of large and giant intracavernous and paraclinoid aneurysms

Background Due to their location, large and giant intracavernous and paraclinoid aneurysms remain a challenge for vascular neurosurgeons, We identified characteristics, surgical indications and treatment strategies of large and giant intracavernous and paraclinoid aneurysms in 36 patients.
Methods The pterional approach was routinely used. The cervical internal carotid artery was exposed for proximal control of parent vessel and retrograde suction decompression. Paraclinoid aneurysms were directly clipped, intracavernous pseudoaneurysm was repaired and the intracavernous aneurysms were trapped with extracranial-intracranial bypass of saphenous vein graft. Intraoperative electroencephalogram （EEG） and somatosensory evoked potential （SSEP） monitoring were used to detect cerebral ischemia during the temporary occlusion of parent arteries. Microvascular Doppler ultrasonography was used to assess blood flow of the parent and branch vessels. Endoscopy was helpful particularly in dealing with internal carotid artery posterior wall aneurysms. Postoperative digital subtraction angiography （DSA） was performed in 33 of the 36 patients.
Results Thirty-two paraclinoid aneurysms were directly clipped, 1 intracavernous pseudoaneurysm was repaired and the other 3 intracavernous aneurysms were trapped with revascularization. Except for two patients who died in the early postoperative stage, 34 patients＇ follow-up was 6-65 months （mean 10 months） and a Glasgow Outcome Scale score of 4 to 5 at discharge. At the 6-month follow-up examination, Rankin Outcome Scale scores were 0 to 2 in 32 patients. EEG and SSEP monitoring changed in six patients. Twelve clips were readjusted when insufficient blood flow in parent and branch vessels was detected. Three posterior wall aneurysms were clipped.
Conclusions Intracavernous aneurysms not amenable to endovascular treatment should be treated surgically and surgical treatment is the first option for paraclinoid aneurysms. The temporary parent vessel occlusion, retrograde su     

Prognostic analysis of patients with gastrointestinal stromal tumors: a single unit experience with surgical treatment of primary disease

Background Gastrointestinal stromal tumor （GIST）, the most common type of mesenchymal tumors of the gastrointestinal tract, is a recently recognized tumor. The biological behavior of GIST is highly variable. Surgical resection remains the major treatment for GIST. In this study we retrospectively analyzed our surgical experience with 181 GIST patients to determine the effects of the treatment and the pathological features and prognosis factors of these GIST patients. Methods The clinicopathological features and follow-up data of the 181 patients with GIST who had received surgical resection between January 1999 and December 2007 at Ren Ji Hospital were retrospectively reviewed. Immunohistochemical stains including CDl17 （KIT）, CD34, and other markers were used. Tumor size, mitotic index and other pathological parameters were recorded. According to the consensus of NIH risk-group stratification system based on maximum tumor size and mitotic index （per 50 high power field）, tumors were classified into very-low-risk group （15 tumors, 8.3%）, low-risk group （48, 26.5%）, intermediate-risk group （52, 28.7%） and high-risk group （66, 36.5%）. Prognostic factors were analyzed by Cox analysis including age, sex, tumor size, tumor site, mitotic index, NIH categories and surgical procedures. Results One hundred and seven （59.1%） of the 181 tumors were located in the stomach, 51 （28.2%） in the small intestine, 9 （5.0%） in the colon and rectum, and 14 （7.7%） in other sites including the omentum and mesentery. The median age of the patients was 58 （range, 24-84） years, and 102 patients （56.4%） were male. Tumor size ranged from 0.5 to 30 cm, while the mean size was 7.02 cm. Metastasis was found in 7 patients. One hundred and seventy-six （97.2%） of the 181 patients underwent radical resection, and among them 26 patients received extensive resection with the adjacent organ adherent to the tumors. The positive rate for the KIT protein （CDl17） in immunostaining was 94.5% （171/181）, while that for CD34 was 86.2% （156/181）. The 1-, 3-,and 5-year survival rates of the 181 patients were estimated to be 95.2%, 87.9% and 78.5%, respectively. There was a significant difference in age, tumor size, tumor site, mitotic index, NIH categories, and presence or absence of multivisceral resection （P 〈0.05）. But there was no significant difference in sex between the groups. Cox hazard proportional model revealed that advanced clinical stage and large tumor size contributed to worse prognosis. The patients who were treated with imatinib because of recurrence and metastasis or high recurrence risk showed stable disease. Conclusions Surgical resection is the gold standard of treatment for primary GIST. NIH categorization is simple and effective to evaluate GIST behavior and prognosis. Targeted therapy such as imatinib, a KIT tyrosine kinase inhibitor, may play an important rote in the treatment of GIST.     

Flaps for the repair of bladder exstrophy.

From April 1986 to March 1992, flaps were used in the surgical treatment of 17 patients with congenital bladder exstrophy. Eleven of these patients had had surgery in other hospitals but all failed. Using the flap method for the repair all of them had procured a functional bladder except one who could not have a complete control of urination. The longest follow-up period was 3 years, and the renal and bladder functions were completely normal. The immediate result in 14 patients was good in the control of urination right after the removal of the catheter. The follow-up results were good in 16 cases. The flaps used included 8 types of skin flaps, fasciae and vascular pedicles. Provided with the central vascular supply, the new series of procedures were suitable for the treatment of a variety of exstrophy deformities.