Selective Musculocutaneous Neurotomy for Spastic Elbow

Objective

The purpose of this study was to investigate the effectiveness and outcome of selective musculocutaneous neurotomy (SMcN) for spastic elbow.

Methods

We retrospectively reviewed the medical records of 14 patients with spasticity of their elbows. The patients were selected using clinical and analytical scales, as well as nerve block tests, for assessment. Their mean age was 37.29 years (range, 19-63 years). SMcN was performed for these patients, and the mean follow-up period was 30.71 months (range, 19-54 months).

Results

The modified Ashworth scale (MAS) scores recorded before and after the SMcN showed that the patients'' mean preoperative MAS score of 3.28 ± 0.12 was improved to 1.71 ± 0.12, 1.78 ± 0.18, 1.92 ± 0.16 and 1.78 ± 0.18 at postoperative 3, 6, 12 months and last follow-up, respectively. On the basis of a visual analogue score ranging from 0-100, the patients'' mean degree of satisfaction score was 65.00 ± 16.52 (range, 30-90).

Conclusion

We believe that SMcN can be a good and effective treatment modality with low morbidity in appropriately selected patients who have localized spastic elbow with good antagonist muscles and without joint contracture.     

选择性正中神经分支部分切断术治疗脑瘫性腕、指痉挛

目的探讨选择性正中神经分支部分切断术治疗脑瘫患儿腕、指部痉挛状态的治疗效果：方法回顾分析2000年3月至2004年3月显微手术治疗的57例脑瘫患儿77侧腕、指部痉挛状态病例。全部病例采用选择性正中神经分支部分切断术治疗。结果全部病人平均随访25个月。100％病人术后立即感腕、指部痉挛状态缓解，随访期间缓解率为88．31％（68／77）。术后6周内运动功能改善率为90．91％（70／77），随访期间为74．03％（57／77）。生活质量提高率在随访期间为89．47％（51／57）。术后发生上肢感觉障碍37侧，肌无力26侧，随访期间均见好转？随访期间痉挛状态复发10侧（12．99％）。结论选择性正中神经分支部分切断术治疗脑瘫患儿腕、指部痉挛状态是安全有效的。     

胫神经部分切断治疗脑瘫性踝痉挛

目的 探讨胫神经部分切断治疗脑瘫患儿踝痉挛的效果。方法 回顾分析近1年37例病儿53只足踝痉挛采用胫神经部分切断术的疗效。结果 全部病人术后有不同程度踝痉挛缓解,平均随访8.6个月,缓解率为94.34％(50/53)。术后发生小腿、足部感觉障碍2例,随访期间均见好转。结论 胫神经部分切断术是治疗脑瘫患儿踝痉挛安全有效的显微外科手术方法。     

Long Term Results of Microsurgical Dorsal Root Entry Zonotomy for Upper Extremity Spasticity

Objective

The purpose of the present study is to assess the long-term results of microsurgical dorsal root entry zonotomy (MDT) for the treatment of medically intractable upper-extremity spasticity.

Methods

The records of nine adult patients who underwent MDT by one operating neurosurgeon from March 1999 to June 2004 were retrospectively reviewed by another investigator who had no role in the management of these patients. In all patients, MDT was performed on all roots of the upper limb (from C5 to T1) for spasticity of the upper extremity. The degree of spasticity was measured by the Modified Ashworth Scale (grade 0-4). Severity of the pain level was determined using the Numeric Rating Scale (NRS, score 0-10). Also, patient satisfaction of the post-operative outcome was assessed.

Results

Comparing the preoperative and postoperative spasticity using the Modified Ashworth Scale, we observed improvement in all patients, particularly in five of the nine patients (55.6%) who improved by three grades over an average of 66.4 months (range, 40-96). Regarding patient satisfaction, seven patients (77.8%) had affirmative results. None of the patients experienced severe, life-threatening, postoperative complications. We observed a decrease in the intensity of painful spasms to less than three scores as measured by NRS in all four patients with associated pain.

Conclusion

This study shows that MDT provides significant, long-term reduction of harmful spasticity and associated pain in the upper limbs.     

选择性坐骨神经分支部分切断术治疗膝关节屈曲痉挛

目的 探讨选择性坐骨神经分支部分切断术治疗膝关节屈曲痉挛的效果。方法 回顾分析2000年2月至2001年11月手术治疗的33例共计44侧膝屈曲痉挛状态的病人资料，所有病人均采用选择性坐骨神经分支部分切断术治疗。结果 全部病人平均随访11．6个月。所有病人术后立即感膝部痉挛状态缓解，随访期间缓解率为91％(30／33)。术后2周内步态功能均有改善，随访期间改善为87．88％(29／33)。生活质量在随访期间所有病人均有提高。术后发生小腿感觉障碍5例，随访期间3例完全恢复，2例部分恢复。无1例发生严重肌无力。结论 选择性坐骨神经分支部分切断术是治疗膝关节屈曲痉挛安全有效的方法。     

Stimulus Point Distribution in Deep or Superficial Peroneal Nerve for Treatment of Ankle Spasticity

Objectives: To develop effective electrical stimulation treatment to reduce spasticity, we examined the optimal stimulus point of the common peroneal nerve. Materials and Methods: The locations of selective stimulus points for the deep peroneal nerve or superficial peroneal nerve fiber were examined in 25 healthy subjects in both legs (50 legs) using the ratio of the tibialis anterior (TA) to the peroneus longus (PL) M‐wave amplitude (TA/PL ratio). In addition, we measured reciprocal Ia inhibition in ten healthy subjects. The amount of inhibition was determined from short‐latency suppression of the soleus (Sol) H‐reflex by conditioning stimuli to the deep or superficial peroneal nerve. The paired t‐test was used for statistical analysis. Results: The mean TA/PL ratio during deep peroneal nerve stimulation was significantly different from superficial peroneal nerve stimulation (p < 0.001). The mean stimulus point for the deep peroneal nerve was located 7 ± 5 mm distal and 3 ± 6 mm anterior from the distal edges of the head of fibula and was markedly different from the stimulus point for the superficial peroneal nerve (20 ± 7 mm distal and 12 ± 8 mm posterior). During deep peroneal nerve stimulation, the mean conditioned H‐reflex was depressed to 83.8 ± 10.7% of the unconditioned value of the H‐reflex. In contrast, during superficial peroneal nerve stimulation, the mean conditioned H‐reflex increased to 105.3 ± 5.2%. These values were significantly different (p < 0.001). Conclusions: In the present study, we revealed a stimulus area of the deep peroneal nerve. Also, we observed the inhibitory effects of stimulation upon the deep peroneal nerve at individual stimulus point. Our results appear to indicate that localized stimulation of the deep peroneal nerve is more useful for the reduction of ankle spasticity.     

选择性闭孔神经切断术治疗脑瘫性大腿内收肌群痉挛

目的 探讨选择性闭孔神经分支部分切断术治疗脑瘫患者大腿内收肌群痉挛状态的效果。方法 回顾分析2005年1月至2006年7月采用选择性闭孔神经分支部分切断术治疗的38例脑瘫性大腿内收肌群痉挛状态患者的临床资料。结果 全部病人平均随访7个月。100％的病人术后立即感大腿内收肌群痉挛状态缓解，随访期间缓解率为100％，运动功能改善率为78．9％（30／38）．生活质量提高率92．1％（35／38）。术后无下肢感觉障碍发生；出现大腿内收肌无力49侧，随访期间均见好转。痉挛状态无复发。结论 选择性闭孔神经分支部分切断术是治疗脑瘫性大腿内收肌群痉挛状态安全有效的显微外科手术方法。     

手法整复对桡骨远端骨折伴神经损伤的疗效

目的探究手术联合手法整复对老年桡骨远端骨折伴正中神经损伤患者功能恢复及预后的影响,为临床选择治疗方案提供参考依据。方法选择2016-10—2019-01在义马煤业集团股份有限责任公司总医院治疗的老年桡骨远端骨折伴正中神经损伤患者68例为研究对象。按照随机数表法,将68例患者随机分为对照组和研究组,每组34例。对照组仅使用手法整复进行治疗,研究组使用手术联合手法整复进行治疗。3个月后,比较2组患者的腕关节功能恢复情况以及预后情况。结果3个月后,研究组屈伸活动、旋前、旋后、桡偏、尺偏、握力等功能恢复程度分别为(87.43±5.56)°、(82.74±5.76)°、(80.58±4.14)°、(18.09±4.48)°、(25.76±4.29)°、(86.05±5.47)%,显著优于对照组的(78.75±5.28)°、(71.98±5.24)°、(68.89±4.46)°、(12.50±4.59)°、(21.48±4.02)°、(77.85±5.25)%,差异有统计学意义(P<0.05);研究组腕关节功能Gartland-Werley评分优良率(85.29%)显著高于对照组(73.53%),差异有统计学意义(P<0.05);研究组疼痛、两点辨别觉、大鱼际肌力、生活自理能力等疗效评分分别为(5.64±1.27)分、(9.03±0.75)分、(9.61±0.12)分、(62.67±5.56)分,显著高于对照组(3.05±0.81、7.45±0.42、8.02±0.32、58.59±5.79)分,差异有统计学意义(P<0.05);研究组预后不良率(14.71%)明显低于对照组(32.35%),比较差异有统计学意义(P<0.05)。结论应用手术联合手法整复治疗老年桡骨远端骨折伴正中神经损伤,患者腕关节功能恢复效果明显,预后效果良好,值得推广。     

Safety and Efficacy of Intrathecal Baclofen Infusion by Implantable Pump for the Treatment of Severe Spinal Spasticity: A Spanish Multicenter Study

Objective. To assess long‐term efficacy, safety and functional benefit of intrathecal baclofen for severe spinal spasticity. Materials and Methods. This prospective multicenter study was performed in two stages: the first one consisted of an intrathecal bolus injection of baclofen, and the second of a continuous intrathecal baclofen infusion by means of an implantable pump. The sample consisted of 72 adult patients with severe spinal spasticity. Sixty‐four were implanted and followed for 36 months. Muscular tone, spasms, and functional scales were evaluated before and periodically after administration of the drug, with a follow‐up period of 36 months. Results. A very significant decrease in tone and spasms was observed in all cases (p < 0.001). Tolerance appeared during the first 12 months, increasing doses from a mean initial dose of 83.2 μg (range 25–200 μg) to a mean final dose of 270 μg (range 25–800 μg). Later on, efficacy remained stable, except in cases of mechanical problems of the infusion system.     

Growing Organized Hematomas Following Gamma Knife Radiosurgery for Cerebral Arteriovenous Malformation : Five Cases of Surgical Excision

Organized hematoma is a rare complication that can develop following gamma knife radiosurgery (GKS) for cerebral arteriovenous malformation (AVM). Here, we describe 5 patients with growing organized hematomas that developed from completely obliterated AVMs several years after GKS. The patients were 15, 16, 30, 36, and 38 years old at the time of GKS, respectively, and 3 patients were female. Four AVMs were located in the lobe of the brain, and the remaining AVM were in the thalamus. Between 2-12 years after GKS, patients developed progressive symptoms such intractable headache or hemiparesis and enhancing mass lesions were identified. Follow-up visits revealed the slow expansion of the hematomas and surrounding edema. Steroids were ineffective, and thus surgery was performed. Histology revealed organized hematomas with a capsule, but there was no evidence of residual AVMs or vascular malformation. After surgery, the neurological symptoms of all patients improved and the surrounding edema resolved. However, the hematoma continued to expand and intraventricular hemorrhage developed in 1 patient whose hematoma was only partially removed. GKS for cerebral AVM can be complicated by growing, organized hematomas that develop after complete obliteration. Growing hematomas should be surgically evacuated if they are symptomatic. Radical resection of the hematoma capsule is also strongly recommended.     

Making a Case for Programmable Pumps Over Fixed Rate Pumps for the Management of Fluctuations in Chronic Pain and Spasticity: A Literature Review

This paper reviews data supporting the existence of individual, predictable, and unpredictable fluctuations in the severity of chronic pain and spasticity. It also evaluates what is known on the use of implantable programmable drug delivery systems for the management of predictable fluctuations in pain and spasticity. In addition to fixed rate infusion pumps, programmable drug delivery systems have been developed over the past 20 years for the management of predictable pain or spasticity fluctuations. The published literature on experimental and clinical studies of those topics is reviewed and evaluated. Programmable drug delivery systems can tailor dosing to a patient's individual pattern of symptoms, providing more medication during peak intensity of symptoms and less medication when symptoms are reduced. Fluctuations in either pain or spasticity are difficult to predict precisely, and therefore even programmable pumps cannot administer the appropriate amount of medication at any particular time. Ideally, the patient should be able to treat unpredictable fluctuations in symptoms, and a combination of patient controlled analgesia (PCA) with programmable drug delivery systems is currently in development. The future management of unpredictable fluctuations in the intensity of chronic pain and spasticity was subjected to critical evaluation. There seems to be a general agreement on the clinical importance of these phenomena, but stronger evidence is needed for a widespread change in the current management of most chronic pain patients.     

The Comparative Analysis of Clinical Characteristics and Surgical Results between the Upper and Lower Lumbar Disc Herniations

Objective

There are differences in the clinical characteristics and surgical results between upper (L1-2 and L2-3) and lower (L3-4, L4-5, and L5-S1) lumbar disc herniations. We conducted this study to compare the clinical features and surgical outcomes between the two types of lumbar disc herniations.

Methods

We retrospectively reviewed the clinical features of patients who underwent microdiscectomies from 2008 to 2012. We evaluated the clinical characteristics such as age, preoperative autonomic dysfunction, the presence or absence of previous lumbar surgery and fusion required during surgery. Visual Analogue Scale (VAS) scores about back pain and leg pain were evaluated preoperatively and at the final follow-up.

Results

Upper lumbar group (n=15) was significantly older than lower lumbar group (n=148). The incidence of autonomic dysfunction was significantly higher in upper lumbar group. The number of patients with a previous lumbar surgery was significantly greater in upper lumbar group. There was no statistical significance for fusion required during surgery between two groups. Both groups showed a significant decrease in the VAS scores of leg pain. VAS scores of back pain were significantly decreased in lower lumbar group. But this was not seen in upper lumbar group. Both groups showed significant improvement of Oswestry Disability Index score.

Conclusion

Upper lumbar group had different clinical characteristics from those of lower lumbar group and these include older age, a higher incidence of autonomic dysfunctions and a higher incidence of patients with previous lumbar surgery. There were no significant differences in surgical outcomes, except for back pain, between two groups.     

Seizures with Onset in the Sensorimotor Face Area: Clinical Patterns and Results of Surgical Treatment in 20 Patients

Summary: It is not generally appreciated that intractable seizures involving the face area are amenable to surgical treatment. Twenty patients with onset of sensorimotor seizures in the face area of the pre- and postcentral gyri have been studied and surgically treated since 1948. Seizures started in the face, tongue, or throat, followed by diverse patterns depending on spread of seizure activity. Two patients had epilepsia partialis continua; 6 had either tonic or atonic drop attacks. All patients had pre- and postcentral face area resections, 12 in the dominant hemisphere. In addition, 3 had more extensive postcentral removal, 7 had temporal lobe, and 4 had small separate or contiguous frontal or parietal resection. Because the seizures were not sufficiently reduced by the first operation, 6 required reoperation; 4 of these patients had residual epileptiform activity on electrocorticogram (ECoG) after the first resection. Three patients had new neurologic signs that did not return to the preoperative level, but in 2 of them the deficit related mainly to higher resection in the central area. All but 2 of these 20 patients had at least moderate seizure reduction. Corticectomy can be performed for treatment of seizures arising in the lower central area and usually does not lead to significant permanent neurologic deficit.     

Selective rhizotomies for spinal root pain and neuralgia of the inguinal region

Summary Our recent experience stimulated a review of selective rhizotomies for the alleviation of localized pain. Three patients with postoperative neuralgia in the inguinal region and two with neoplastic root compression were treated. Results were good and long-lasting in two cases, moderate in two and poor in one case. The relief appeared to be better, the more clearly the pain was localized. In lesions distal to the spinal root it is necessary to undertake selective paravertebral root blocks with local anaesthetics. Experimental data are discussed that help in an understanding of pain recurrence after rhizotomy.     

Extratemporal Cortical Resections and Lesionectomies for Partial Epilepsy: Complications of Surgical Treatment

Summary: Fifty patients with medically refractory extratemporal seizures underwent epilepsy surgery at our institution between 1988 and 1992. Twenty-nine patients (group 1) had an extratemporal (mainly frontal lobe) corticectomy, and 21 patients (group 11) had an epileptogenic lesion extirpated without resection of the epileptic brain tissue. Comprehensive neurologic evaluation was performed preoperatively, soon after operation, and ∼3 months postoperatively to assess operative outcome. Magnetic resonance imaging (MRI) in group I patients usually showed no abnormality or a large destructive lesion. Neuroimaging showed a foreign tissue lesion in most group II patients. Thirteen of the 29 patients who underwent corticectomy had at least one adverse event (AE) potentially related to operation at the time of initial assessment. Four of the 13 patients required a surgical procedure to treat the operative complication, but only 1 of the 13 patients had a persistent neurologic deficit at follow-up examination. Three of the 21 patients who received lesionectomy had acute and persistent neurologic morbidity. Patients undergoing cortical resection remained intubated longer postoperatively (p < 0·005), and required longer hospitalization after operation (p < 0·001) and in the intensive care unit (p < 0·001) as compared with the lesionectomy group. Results of this study may prove useful in counseling patients regarding neurologic outcome after extratemporal surgery.     

Comparative Cost Analysis for Surgical and Endovascular Treatment of Unruptured Intracranial Aneurysms in South Korea

Objective

A cost comparison of the surgical clipping and endovascular coiling of unruptured intracranial aneurysms (UIAs), and the identification of the principal cost determinants of these treatments.

Methods

This study conducted a retrospective review of data from a series of patients who underwent surgical clipping or endovascular coiling of UIAs between January 2011 and May 2014. The medical records, radiological data, and hospital cost data were all examined.

Results

When comparing the total hospital costs for surgical clipping of a single UIA (n=188) and endovascular coiling of a single UIA (n=188), surgical treatment [mean±standard deviation (SD) : ₩8,280,000±1,490,000] resulted in significantly lower total hospital costs than endovascular treatment (mean±SD : ₩11,700,000±3,050,000, p<0.001). In a multi regression analysis, the factors significantly associated with the total hospital costs for endovascular treatment were the aneurysm diameter (p<0.001) and patient age (p=0.014). For the endovascular group, a Pearson correlation analysis revealed a strong positive correlation (r=0.77) between the aneurysm diameter and the total hospital costs, while a simple linear regression provided the equation, y (₩)=6,658,630+855,250x (mm), where y represents the total hospital costs and x is the aneurysm diameter.

Conclusion

In South Korea, the total hospital costs for the surgical clipping of UIAs were found to be lower than those for endovascular coiling when the surgical results were favorable without significant complications. Plus, a strong positive correlation was noted between an increase in the aneurysm diameter and a dramatic increase in the costs of endovascular coiling.     

面肌痉挛微血管减压手术技巧及并发症分析(附34例报告)

目的探讨微血管减压术治疗面肌痉挛的手术策略及术后并发症。方法采用微血管减压术治疗原发性面肌痉挛患者34例。术前所有患者均行MRI或MRA检查,排除继发性因素并确定责任血管与面神经关系;分析术中经过及术后并发症。结果术后症状立即消失26例(76.5%,26/34),8例好转;术后并发症:9例耳鸣或听力下降,2例脑脊液耳漏,1例脑脊液鼻漏,1例颅内感染,2例面瘫。未见无效病例。随访6个月～3年,31例治愈,1例术后约1年复发;3例听力下降。结论微血管减压术治疗面肌痉挛效果确切,有针对性的手术策略和细致的手术操作能显著减少并发症的产生。