Corpus callosotomy in the treatment of secondary generalizing intractable epilepsy

Summary Over the past 5 years 9 patients underwent partial or complete corpus callosotomy for treatment of medically intractable epileptic seizures. A beneficial effect of the procedure was observed in 8 patients. Criteria for performance of the procedure included CT evidence of unilateral cerebral damage and non-localized epileptic foci in that hemisphere with secondary spread to the uninvolved side. The best results were obtained in atonic seizures. Long-term side effects were minor. The procedure is recommended in those patients with medically uncontrolled atonic or secondary generalized motor seizures in whom the corpus callosum is thought to mediate the spread of epileptic activity from a damaged cerebral hemisphere. Side effects are minimized by staging of the callosal section. If a partial callosotomy was beneficial, complete section can then be avoided.     

A stereotactic device for experimental Gamma Knife radiosurgery in rats

Summary A rat stereotactic device was designed for use in Gamma Knife radiosurgery. Experimental radiosurgical lesions were made in superficial and deep cerebral structures to verify the accuracy of the coordinate system, which is based on a standard rat stereotactic atlas. Calculated dosages were shown to be accurate utilizing thermoluminescence dosimetry. Two additional features of the device permit the surgical positioning and placement of electrodes, and postmortem slicing of the brain according to the same coordinate system. This new apparatus allows precise and repeatable gamma irradiation of the rat brain without the need for expensive and time-consuming imaging techniques. Studies of this type will provide a rapid means for examining the effects of radiosurgery on the central nervous system.     

Intensity-modulated stereotactic radiotherapy of paraspinal tumors: a preliminary report

OBJECTIVE: Radioresistant paraspinal tumors may benefit from conformal treatment techniques such as intensity-modulated radiotherapy (IMRT). Local tumor control and long-term palliation for both primary and metastatic tumors may be achieved with IMRT while reducing the risk of spinal cord toxicity associated with conventional radiotherapy techniques. In this article, we report our initial clinical experience in treating 16 paraspinal tumors with IMRT in which the planning target volume was 2 mm or greater from the spinal cord. METHODS: IMRT was administered by using a linear accelerator mounted with a multileaf collimator. Two immobilization body frames developed at Memorial Sloan-Kettering Cancer Center were used for patients with and without spinal implants. During a 30-month period, 16 patients underwent IMRT for metastatic and primary tumors. Eleven patients were treated for symptomatic recurrences after undergoing surgery and prior external beam radiotherapy, and one patient was treated after undergoing radiotherapy for a metastatic pancreatic gastrinoma with overlapping ports to the spine. Four patients with primary tumors were treated after primary resection that resulted in positive histological margins. Twelve patients were symptomatic with pain, functional radiculopathy, or both. Tumoral doses were determined on the basis of the relative radiosensitivity of tumors. Patients with metastatic tumors were administered a median tumoral dose of 20 Gy in four to five fractions and a spinal cord maximum dose of 6.0 Gy in addition to the full tolerance dose administered in previous radiation treatments. The primary tumors were delivered a median dose of 70 Gy in 33 to 37 fractions and a spinal cord maximum dose of 16 Gy. The median tumoral volume was 7.8 cm(3). RESULTS: Of the 15 patients who underwent radiographic follow-up, 13 demonstrated either no interval growth or a reduction in tumor size in a median follow-up period of 12 months (range, 2-23 mo). Two patients, one with a thoracic chondrosarcoma and one with a chordoma, showed tumor progression 1 year after undergoing IMRT. Pain symptoms improved in 11 of 11 patients, and 4 of 4 patients had significant improvement in their functionally significant radiculopathy and/or plexopathy. Pain relief was durable in all patients except the two with tumor progression. No patient showed signs or symptoms of radiation-induced myelopathy, radiculopathy, or plexopathy, including 12 patients with a median follow-up of 18 months. CONCLUSION: IMRT was effective for treating pain and improving functional radiculopathy in patients with metastatic and primary tumors. Although long-term tumor control is not established in this study, high-dose tumoral irradiation can be performed without causing radiation myelopathy in more than 1 year of follow-up.     

Image-directed functional neurosurgery with the Cosman-Roberts-Wells stereotactic instrument

Summary An isocentered system for functional stereotactic procedures with the Cosman-Roberts-Wells frame and a CT localizer that allows extrapolation of target data directly from the CT slice is presented. Based on anatomical landmarks and on the scaled corresponding transverse plates of the Schaltenbrand and Wahren atlas, we delineate the thalamic and cerebellar nuclei. Twenty three image-directed functional procedures were performed in one year on 18 patients (7 with Parkinson's disease, 4 with dystonia, 3 persons with essential tremor, 2 patients with choreo-athetosis and 2 with de-afferentiation pain). The 23 procedures included 19 thalamotomies, two dentatotomies and two stereotactic implantations of deep seated brain electrodes. Successful targeting was verified by intra-operative electrical stimulation and postoperative CT scan. Complete reduction of symptoms was observed in 4 persons with Parkinson's disease and in 2 patients with essential tremor with significant improvement observed in the rest of the patients with the exception of the individual with choreo-athetosis. There were no operation-related complications. The reported technique is safer and less distressing for patients than previous radiological procedures and it makes image-directed stereotactic functional neurosurgery available to many units with the CRW frame.     

Callosotomy for the management of intractable non-focal epilepsy: A preliminary personal assessment

Summary After reviewing the data of the literature, the authors report their personal series composed of twelve cases. In evaluating the results of surgical treatment only the first ten patients are taken into account. As previously stressed in the literature, callosotomy (total in two cases and anterior in the remainder) has proved effective in abolishing or significantly reducing atonic seizures. Tonico-clonic seizures have also benefitted in some cases, while in complex partial and partial seizures the effects of callosotomy have been so far unpredictable, albeit in some patients all kinds of seizures have been abolished or definitely reduced. The most impressive EEG and neuropsychological features after callosotomy are briefly summarized. Anterior callosotomy seems to be a relatively safe procedure, its results appear to be, on the whole, gratifying even though in patients with severe mental retardation and Lennox-Gastaut syndromes remain controversial.     

Target point calculation in the computerized tomography. Comparison of different stereotactic methods

The adaptation of computerized tomography for stereotactic operations requires the transformation of the coordinates of the target point from the CT image space into the stereotactic frame space. Two basic solutions for this transformation are realized in the most of the contemporary stereotactical systems. The indirect geometric method adjusts the frame coordinate system mechanically and identifies its origin in the CT image. There are 6 degrees of freedom: 3 of rotation and 3 of translation which have to be taken into consideration. The second method is a based on direct algebraic coordinate transformation and is independent of the explicite knowledge of the relationship between the image and the frame space. A localization frame serves to determine a transformation matrix which, applied to any point in the image, transforms the coordinates directly into the frame coordinate system. Only the algebraic method is independent of the position of the patient in the gantry. All other methods require high mechanical precision of the alignament and stability for the CT table.     

Circular external fixation in knee arthrodesis following septic trauma sequelae: preliminary report

Deep infection is one of the most devastating complications after knee fractures. It may be related to the initial fracture status or, more commonly, the surgical intervention. From 1991 to 2003, 12 patients underwent knee fusion to treat resistant infection after complex knee fractures or arthrodesis fractures using the Ilizarov method and frame. There were 9 men and 3 women (mean age, 39.7 years). Two-thirds of the patients had long-standing infection and 5 patients had undergone earlier attempts at knee arthrodesis. Correction of concurrent malalignment was achieved in 2 patients. Bone transport using the same arthrodesis frame was necessary in 2 patients to overcome large bony defects. Solid fusion was achieved in all patients by the end of treatment. The average duration of external fixation was 22 weeks (range: 11-44 weeks). No patients required secondary bone grafting to achieve union. Complications occurred in 6 (50%) patients. The most common problem seen was pin tract infection, but only 2 patients required surgical intervention for its treatment. The study emphasizes the clinical success of the Ilizarov method in knee arthrodesis after infected fractures.     

Evipal anesthesia: A preliminary report

Evipal affords an easy, rapid and safe method of inducing deep, general anesthesia for a brief period. It is adapted for minor operations upon any part of the body and is not followed by prolonged sleep, nausea or vomiting. As a preliminary to a general inhalation anesthesia, it has a field as yet not fully established.The safety of any anesthetic must be the measure by which its usefulness is judged. Our experience is too meager to allow us to advance any decisive statements. The report of the Anesthetic Committee, Medical Research Council, London, England, is most reassuring. This committee found 25,000 cases of evipal anesthesia reported with but one death attributed to the anesthetic itself.     

ISHKS joint registry: A preliminary report

Background:

Total knee arthroplasty (TKA) and total hip arthroplasty (THA) are the most widely practiced surgical options for arthritis all over the world and its application is rising in India. Indian Society of Hip and Knee Surgeons (ISHKS) has established a joints registry and has been collecting data for last 6 years.

Materials & Methods:

All members of ISHKS are encouraged to actively participate in the registry. A simple two page knee and hip form can be downloaded from the website www.ishks.com. The information collected includes patient demographics, indication for surgery, implant details and in case of revision arthroplasty: the details of implants removed and the cause of failure of primary arthroplasty. These forms are mailed to the central registry office and the data is fed in computerized registry. Data collection started in October 2006.

Results:

Joint registry is a very important initiative of ISHKS and till date, have data of 34,478 TKAs and 3604 THAs, contributed by 42 surgeons across India. Some important observations have emerged. Data of 34,478 TKAs was assessed: These included 8612 males (25%) and 25,866 females (75%). Average age was 64.4 years (Osteoarthritis range: 45 to 88 years; Rheumatoid arthritis range: 22 to 74 years). Average body mass index was 29.1 (Range: 18.1 to 42.9). The indication for TKA was osteoarthritis in 33,444 (97%) and rheumatoid arthritis in 759 (2.2%). Total of 3604 THA procedures were recorded. These included 2162 (60%) male patients and 1442 (40%) female patients. Average age was 52 years (Range 17 to 85 years) and average BMI was 25.8 (Range: 17.3 to 38.5). The indications for THA was AVN in 49%.

Conclusion:

The registry will become more meaningful in years to come. Active participation of all arthroplasty surgeons across India is vital for the success of the joints registry.     

Dynamic compression nail: A preliminary report

Background

Interlocking nailing, which has become the method of choice for treating fractures of the femoral and tibial shafts, still lacks ability to provide the important contact-compression at the fracture. An intramedullary compression nail is described, which provides axial compression at the fracture site with tightening of the specially designed distal interlocking screw. This uses the same principle as dynamic compression plating.

Methods

The study included 11 femoral and tibial nailings performed for various clinical applications such as acute fractures, non-unions and malunions.

Results

All the fractures attained radiological union, with good skeletal continuity across the fracture, within an average time of 13 weeks in fresh fractures and 18 weeks in non-unions.

Conclusions

Active compression through intramedullary compression nailing has great utility for treating non-unions where it provides greater degree of impaction of its irregular ends. This may prove greatly advantageous to the fracture union through increased stability and the osteogenic potential, particularly when utilized in combination with the small diameter unreamed nails.     

A preliminary report: cementless trapeziometacarpal arthroplasty

A cementless ball and socket trapeziometacarpal arthroplasty was used for the treatment of Eaton and Littler stage II and III trapeziometacarpal osteoarthritis. Forty-two joints were placed in 36 patients between 1986 and 1992. Five joints in 4 patients required revision. Thirty-four joints in 30 patients were evaluated with a mean follow-up period of 47 months (range, 15-86 months). Of the 33 monitored patients (39 joints), 79% reported good to excellent pain relief and excellent functional improvement and 12% reported poor to fair pain relief and functional improvement. Five joints required revision surgery and constituted 13% of the original arthroplasties. Thirty-three functional tests were graded before and after surgery and improvement was noted in all categories. Dramatic improvement was noted in the typical complaints for trapeziometacarpal joint disease, which are encountered in the activities of daily living. Radiolucent lines were present in 13 of 25 implants (52%), which were radiographically monitored. Radiographic loosening was present in 32%; 12 were around the trapezial component and 1 was around the metacarpal component. Radiographic loosening did not correlate with less satisfactory clinical results. Cementless trapeziometacarpal arthroplasty provides an operative alternative to arthrodesis in properly selected patients with trapeziometacarpal joint osteoarthritis. This joint is not intended to replace excisional or ligament reconstruction tendon interposition arthroplasty in lower demand patients or in those with pantrapezial arthritis. It also is not recommended in patients with rheumatoid arthritis or poor bone stock. It offers the advantages of maintaining excellent motion and stability. The cementless arthroplasty failures can be effectively salvaged by converting them to ligament reconstruction tendon interposition arthroplasty.     

Hang gliding injuries: A preliminary report

Six cases of injury associated with hang gliding are reported. The history and technique of the sport are briefly described. Fractures of the spine and limbs are the commonest injuries encountered in this highrisk activity and many of them could be avoided or reduced in severity by simple safety precautions.     

环状RNA与骨科相关疾病研究进展

环状RNA是最近发现的一类非编码RNA,缺少5'帽子和3'多聚A尾,以反向剪接的方式形成一个共价闭合的环形结构。最初认为circRNA是由基因转录过程中的错误引起的,然而,经过进一步调查,科学家们认为circRNAs具有重要的生物学意义。circRNAs具有稳定性、保守性和组织特异性。它们还可以作为miRNA海绵起作用,调节基因表达,并与蛋白质相互作用以影响细胞行为,参与多种骨科疾病(包括骨性关节炎、骨肉瘤等)的发生和发展,有望成为诊断生物标志物和治疗靶标。笔者简要回顾了circRNA的特征、生物起源、分类和功能,特别关注circRNA在多种骨科疾病中的作用。     

Syringoperitoneal shunt for syringomyelia: A preliminary report

Syringoperitoneal shunting has been used in the treatment of 4 patients with idiopathic syringomyelia. The procedures have been performed without morbidity or mortality. Postoperative observation, ranging from 7 to 23 months, has not revealed progression of symptoms or failure of the shunt. The pathophysiological theories of syringomyelia are discussed, and various surgical procedures for syringomyelia are reviewed and their results compared to the effectiveness of the syringoperitoneal shunt.     

Naltrexone in organic bulimia: A preliminary report

Multiple lines of experimental evidence point to the involvement of endogenous opiates in appetite regulation. Post brain injury patients often exhibit driven eating behaviour. Since this problem fails to respond to behaviour modification, appetite suppressants, lithium, or any other usual approach, the use of the oral narcotic antagonist, Naltrexone, was given to three such patients. Naltrexone binds multiple opiate receptor sites in the hypothalamus, including the kappa receptors which have been implicated in appetite regulation, the use of this narcotic antagonist in hypothalamic hyperphagia appears to be a rational approach to this intractable problem.

In this open trial, lasting from 4 1/2 to 9 months, the minimal effective dose appeared to be in the range of 100 mg per day. No side-effects (for example elevations in liver enzymes) were noted.

All of the patients had an improved sense of well-being and their behaviours were less difficult to manage when on the Naltrexone.

The significance of this preliminary trial is that narcotic antagonists may have a role in the treatment of brain-injured patients with bulimia. Also, Naltrexone may be useful in treating other maladaptive behavioural consequences of head trauma such as stealing, manipulation, demandingness, and depression. Likewise, the effects on the deranged endocrine system, such as the hypogonadism, are significant and deserve further exploration.