The ankylosed spine is prone to fracture even as a result of minor trauma due to its changed biomechanical properties. Fractures in ankylosing spondylitis (AS) patients are highly unstable and surgical intervention for fixation is warranted. Implant failure rates are high and combined anterior and posterior fixation is required to enhance the fixation outcome. For fusion, anterior interbody fusion or posterior bone graft fusion is often adopted. Here, we introduce a new method which combines vertebroplasty with anterior and posterior approaches to improve pain control, facilitate the long-term fixation outcome and mechanics, and decrease perioperative risks with prompt stabilization, especially in patients with spine curve deformity. Here, we present two AS cases with cervical spine fracture treated with this new method.
Introduction: The monitoring of intracranial pressure (ICP) in traumatic brain injury (TBI) is important for postoperative care. In our clinical practice, we have found that neurological deterioration because of contralateral epidural hematoma (EDH) occurs despite normal ICP in patients who have undergone decompressive craniectomy (DC). This study was performed to elucidate the dilemmas associated with ICP monitoring after DC and the possible complementary role of intraoperative and immediate postoperative imaging studies. Methods: Patients who had received DC due to TBI during a 7-year period were retrospectively identified from our database and evaluated. Logistic regression analyses were used to evaluate the associations between patients. Results: Twenty patients had contralateral skull fractures. Five patients (5 of 10, 50%) who developed EDH on the ipsilateral side of the skull fracture underwent operations for EDH evacuation due to the deterioration of their clinical condition. The ICP was significantly lower (P = 0.016) in these patients compared with patients who did not undergo secondary surgery due to EDH. Conclusions: ICP monitoring alone cannot absolutely ensure early detection of contralateral space-occupying lesion after DC due to improvement in cerebral compliance. Imaging studies using brain computed tomography is beneficial for early detection of delayed EDH after DC in a high-risk skull fracture with contralateral acute subdural hematoma patients.
*Department of Otolaryngology, Far Eastern Memorial Hospital, Taipei; †Department of Neurosurgery, Far Eastern Memorial Hospital, Taipei, Taiwan Address for correspondence and reprint requests Po-Wen Cheng, M.D., Department of Otolaryngology, Far Eastern Memorial Hospital, 21, Section 2, Nan-Ya South Road, Pan Chiao, Taipei, Taiwan; E-mail: [email protected]
We recently found that rubrospinal (RS) neurons, which typify central neurons projecting within the central nervous system (CNS), exhibited different neuronal and glial reactions to axotomy at proximal as opposed to distal sites. To determine whether distance also determines the reaction to axonal injury of central neurons projecting to the periphery, we studied the temporal expression of four free-radical-related enzymes as well as the severity of cell loss, perineuronal astrocytic and microglial reactions, and degeneration of the proximal central axons of facial motoneurons after axotomies performed at various sites on the brainstem surface and in the stylomastoid foramen, respectively. Distal lesions resulted in upregulation of these neurons' expression of nitric oxide synthase (NOS) and persistent downregulation of their expression of the NOS-activating enzyme calcineurin. It also led to transient upregulation of their expression of manganese-dependent superoxide dismutase (Mn-SOD), and resulted in a mild neuronal loss. Proximal axotomy led to an upregulation of NOS but a transient downregulation in the expression of calcineurin and Mn-SOD at 4 weeks after injury. This was accompanied by severe cell loss and swelling of mitochondria at 2-4 weeks postinjury. However, neither proximal nor distal axonal lesioning led to nuclear fragmentation or TUNEL staining of neurons. Proximal as opposed to distal axotomy produced an earlier transformation of glial morphology, including the hypertrophy of astrocytic processes and metamorphosis of ramified microglia to amoeboid cells. We unexpectedly found that unlike RS neurons, whose central axons degenerated slowly and in an anterograde manner only after the severe cell loss induced by proximal axotomy, the central axons of facial motoneurons degenerated rapidly and in a retrograde manner independently of the severity of loss of these neurons after axotomy. However, degeneration began sooner after proximal than after distal axotomy. Since the central axons of both rubrospinal neurons and facial motoneurons lie within the CNS, the differences in whether and how they degenerated after axotomy suggests that central neurons that project within and outside the CNS are inherently different. The significance of these and also the free radical environment regulation differences between these two types of neurons following close and distant axotomies remains to be explored.
Abstract Acidic fibroblast growth factor (aFGF) is a potent neurotrophic factor that may uphold neuronal survival in the injured spinal cord. It has been reported to promote functional recovery in open-label clinical studies. The first randomized, double-blind, placebo-controlled study was conducted to verify aFGF’s efficacy and safety in SCI patients. Patients with AIS Grade A or B SCI were randomized into two arms and given either aFGF or placebo every 4 weeks for total 3 doses. All patients were evaluated for medical, neurological, and functional changes at baseline, then every 4 weeks after the first dose of aFGF/placebo until 48 weeks. The first dose was administered directly to the injured site at the surgery within 6 weeks after SCI, and the 2nd and 3rd doses were given through lumbar puncture. Due to the impact of COVID-19 pandemic the study ended prematurely; nevertheless, explorative analyses revealed encouraging signals of the beneficial effect of aFGF albeit with a limited sample size. This is the first clinical report showing that aFGF may reduce myelomalacia and accelerate motor recovery in complete SCI patients with a significantly higher chance to achieve a 10-point improvement (Odds ratio = 6.06). Further studies to validate aFGF’s clinical efficacy are warranted.
An uncommon case of spinal gouty tophus was diagnosed in a 74-year-old man who presented in the emergency department with sudden onset of acute paraplegia. The patient underwent laminectomy and nodule removal for neurodecompression. After surgery, the patient demonstrated good functional recovery and returned to baseline performance status. Intraspinal tophi are rare. Image study may show irrelevant findings. In patients with gout, the differential diagnosis should include tophi. In the present case, imaging did not reveal much inflammatory change, but severe symptoms were observed, and a definite preoperative diagnosis was difficult. In cases with neurological compromise, timely neurosurgical decompression leads to good outcomes, as in the present case.
Summary Background To compare the efficacy of esomeprazole and famotidine against stress ulcers and the association of these prophylactic agents with ventilator‐associated pneumonia in patients admitted to neurosurgical intensive care unit (ICU). Patients and Methods Sixty patients were randomly allocated into two groups (the esomeprazole and famotidine groups; n = 30 each) to receive prophylaxis medication for 7 days within 24 hours of admission in a neurosurgical ICU. Patients in the esomeprazole group received esomeprazole (40 mg) dissolved in water once a day through a nasogastric tube, whereas patients in the famotidine group received an intravenous infusion of famotidine (20 mg) every 12 hours. We then compared the occurrence of overt upper gastrointestinal bleeding and ventilator‐associated pneumonia between these two groups. Results One patient in the famotidine group had overt upper gastrointestinal bleeding (3.3%), whereas the bleeding was not observed in patients in the esomeprazole group. Ventilator‐associated pneumonia occurred in one patient (3.3%) from each group. One patient died within 30 days (3.3%) in the esomeprazole group and three patients (10%) died in the famotidine group. There was no difference in the occurrence of overt upper gastrointestinal bleeding ( p = 1.000), ventilator‐associated pneumonia ( p = 1.000), and 30‐day mortality ( p = 0.612) between these two groups. Conclusion In this small‐scale study, the effect of administration of esomeprazole through a nasogastric tube on stress ulcer was similar to that of intravenous famotidine infusion in neurosurgical ICU patients. In addition, the association between prevalence of ventilator‐associated pneumonia and administration of esomeprazole was also similar to that observed with famotidine infusion.
To determine the clinical value of radionuclide shuntography in the evaluation of adult hydrocephalic patients with suspected ventriculoperitoneal (V-P) shunt malfunction. All adult patients who underwent Tc-99m diethylenetriamine pentaacetic acid shuntographic scans at Far Eastern Memorial Hospital between August 2005 and December 2015 were included. Shuntographic results were visually evaluated in a simple qualitative manner: prompt flow that reached the peritoneum on 30-minute early images and diffuse peritoneal tracer distribution on 2-hour delayed images were interpreted as nonobstructive shunt flow. Partial dysfunction was diagnosed as scintigraphic findings between no obstruction and complete obstruction (where complete malfunction indicated no peritoneal distribution on delayed images). The results were correlated with the clinical outcomes and surgical results within 30 days. Diagnostic sensitivity (Se), specificity (Sp), positive predictive value (PPV), negative predictive value (NPV), and overall accuracy were also calculated. A total of 93 scans in 69 patients with suspected V-P shunt malfunction were analyzed. Sixty-two scans were interpreted as abnormal, including complete (n = 26, 41.9) distal obstruction, partial (n = 35, 56.5) distal dysfunction, and miscellaneous (n = 1, 1.6, cerebrospinal fluid leak). The Se and Sp were 83.0% and 55.0%, respectively, and PPV, NPV, and accuracy were all 71.0%. Twenty-five patients (28 scans) underwent surgical revision, and the results were highly concordant with the imaging findings (Se, 92.0%; Sp, 100.0%; PPV, 100.0%; NPV, 60.0%; and accuracy, 92.9%). Radionuclide shuntography provides useful information in adult patients with V-P shunt malfunction and could be used to guide further surgical intervention.
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