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Jyi-Feng Chen, Chieh-Tsai Wu and Shih-Tseng Lee

✓ Percutaneous vertebroplasty is a useful procedure for patients with vertebral osteoporotic compression fractures; however, there has been no mention in the literature of the use of percutaneous vertebroplasty for the treatment of traumatic spinal fractures. The authors report the case of a 33-year-old man who harbored L-1, L-2, and L-5 burst fractures sustained in a work-related accident. The patient was successfully treated by percutaneous vertebroplasty with polymethylmethacrylate. The authors propose this procedure as a useful intervention in selected patients with lumbar burst fractures. The complications associated with major surgical procedures are absent.

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Jyi-Feng Chen, Chieh-Tsai Wu, Sai-Cheung Lee and Shih-Tseng Lee

✓ The authors describe a modified posterior atlantoaxial fixation technique for the treatment of reducible atlantoaxial instability, which can be performed simply and easily, and can decrease the risk of vessel and/or neural damage.

During an 18-month period, this technique was undertaken in 11 patients with atlantoaxial instability. There was no procedure-related morbidity. The follow-up period ranged from 8 to 18 months (mean 13.2 months). Fusion was documented in all 11 patients, and there was no progression of spinal deformity.

This technique can be considered an effective alternative in the treatment of atlantoaxial subluxation.

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Jyi-Feng Chen, Chieh-Tsai Wu, Sai-Cheung Lee and Shih-Tseng Lee

Object. Polymethylmethacrylate (PMMA) bone cement has been used as a spacer in the treatment of patients with cervical disc disease with good long-term outcomes, but solid bone fusion has not been demonstrated in all cases. To achieve cervical interbody fusion, the authors designed a modified PMMA cervical cage that they filled with spongy bone for the treatment of single-level cervical disc herniation.

Methods. Sixty-three patients underwent anterior cervical microdiscectomy and implantation of a PMMA cervical cage filled with autograft cancellous bone and were followed for a minimum of 2 years. The fusion rates were 90.5 and 100% at the 6- and 12-month follow-up examinations, respectively. The mean intervertebral disc height gain was 3.4 ± 1.9 mm when preoperative and 24-month postoperative values were compared. Neck pain, measured using the Huskissan visual analog scale (0 mm, no pain; 100 mm, worst possible pain), decreased from 71 ± 13 mm at preoperative baseline to 28 ± 17 at 6, 23 ± 19 at 12, and 31 ± 19 mm at 24 months. Based on the same scale, radicular pain decreased from 83 ± 15 mm at preoperative baseline to 24 ± 11 at 6, 27 ± 13 at 12, and 22 ± 11 mm at 24 months. The self-rated clinical outcome was excellent in 45 (71.4%) and good in 18 (28.6%) of the 63 patients.

Conclusions. The autograft cancellous bone—filled PMMA cage is safe and effective for cervical interbody fusion in the treatment of single-level cervical disc herniation and monoradiculopathy.

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Pin-Yuan Chen, Chieh-Tsai Wu, Tai-Ngar Lui and Shih-Ming Jung

✓Endodermal cysts of the central nervous system are unusual lesions. Most reported cysts develop in the spinal canal, whereas others, which occur intracranially, are usually located in the posterior fossa. Although endodermal cysts are considered congenital, a prenatal diagnosis has not been reported. In this report the authors present an extremely rare case of a large intracranial endodermal cyst detected prenatally and treated successfully after birth.

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Jyi-Feng Chen, Chieh-Tsai Wu, Sai-Cheung Lee and Shih-Tseng Lee

Object

This prospective study was conducted to assess the safety of using a cylindrical polymethylmethacrylate (PMMA) strut for fusion and reconstruction of the cervical spine after single-level cervical corpectomy. The authors describe the clinical results obtained in patients after surgery.

Methods

Fifty-four patients underwent single-level cervical corpectomy, fusion, and spinal reconstruction that involved the placement of hollow cylindrical PMMA struts. In each patient, the spine was reinforced with anterior cervical plates. The PMMA struts were filled with autologous bone obtained from the resected vertebral body. Follow-up radiographic evaluation involved plain lateral dynamic radiographs and computed tomography (CT) scans. Neurological status was assessed pre- and postoperatively using the Nurick Scale. A total of 46 patients (85.1%) attended follow-up visits for a minimum of 2 years. Spinal stability was documented in all patients on 12-month plain dynamic lateral radiographs; in 37 patients (80.4%), complete osseous fusion was demonstrated on the 12-month CT reconstructions. In the remaining nine patients, complete fusion had been achieved by 24 months. The overall mean preoperative Nurick grade was 2.94 ± 0.97, and this improved significantly to 1.71 ± 0.77 (p < 0.05) by 24 months. There were no complications related to the hollow cylindrical PMMA strut.

Conclusions

The findings of this preliminary study indicate that hollow cylindrical PMMA struts can be safely used in cervical fusion after single-level corpectomy and that the clinical results are satisfactory. The hollow cylindrical PMMA strut is a good substitute for spinal reconstruction and fusion when combined with plate fixation in patients who have undergone anterior cervical single-level corpectomy.

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Zhuo-Hao Liu, Nan-Yu Chen, Po-Hsun Tu, Shih-Tseng Lee and Chieh-Tsai Wu

Object

The management of subdural empyema (SDE) has been debated in the literature for decades. Craniotomy and bur hole drainage have been shown to achieve a favorable outcome. However, there is a lack of comparative data for these modes of management of SDE subsequent to meningitis in infants.

Methods

The authors conducted a retrospective review of 33 infants identified with SDE due to meningitis at the Department of Neurosurgery, Chang Gung Memorial Hospital between 2000 and 2006. Preoperative clinical presentation, duration of symptoms, radiological investigations, CSF data, and postoperative outcome were analyzed and compared between these 2 surgical groups.

Results

At diagnosis, there were no differences between the groups in age, weight, degree of consciousness, CSF analysis, or duration of fever. The outcome data showed no difference in the number of days until afebrile, number of days of postsurgical antibiotic treatment, neurological outcome, recurrence rate, or complication rate. There was only 1 death in the series.

Conclusions

Subdural empyema due to meningitis in infants is unique with respect to the pathophysiology, presentation, and treatment of SDE. Early detection and removal of SDE provide a favorable outcome in both surgical intervention groups. Bur hole drainage is less invasive, and it is possible to expect a clinical outcome as good as with craniotomy in postmeningitic SDE.

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Po-Chuan Hsieh, Yi-Ming Wu, Alvin Yi-Chou Wang, Ching-Chang Chen, Chien-Hung Chang, Shy-Chyi Chin, Tai-Wei Erich Wu, Chieh-Tsai Wu and Shih-Tseng Lee

OBJECTIVE

Diverse treatment results are observed in patients with poor-grade aneurysmal subarachnoid hemorrhage (aSAH). Significant initial perfusion compromise is thought to predict a worse treatment outcome, but this has scant support in the literature. In this cohort study, the authors correlate the treatment outcomes with a novel poor-outcome imaging predictor representing impaired cerebral perfusion on initial CT angiography (CTA).

METHODS

The authors reviewed the treatment results of 148 patients with poor-grade aSAH treated at a single tertiary referral center between 2007 and 2016. Patients with the “venous delay” phenomenon on initial CTA were identified. The outcome assessments used the modified Rankin Scale (mRS) at the 3rd month after aSAH. Factors that may have had an impact on outcome were retrospectively analyzed.

RESULTS

Compared with previously identified outcome predictors, the venous delay phenomenon on initial CTA was found to have the strongest correlation with posttreatment outcomes on both univariable (p < 0.0001) and multivariable analysis (OR 4.480, 95% CI 1.565–12.826; p = 0.0052). Older age and a higher Hunt and Hess grade at presentation were other factors that were associated with poor outcome, defined as an mRS score of 3 to 6.

CONCLUSIONS

The venous delay phenomenon on initial CTA can serve as an imaging predictor for worse functional outcome and may aid in decision making when treating patients with poor-grade aSAH.

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Ching-Chang Chen, Peng-Wei Hsu, Shih-Tseng Lee, Chen-Nen Chang, Kuo-Chen Wei, Chieh-Tsai Wu, Yung-Hsin Hsu, Tzu-Kang Lin, Sai-Cheung Lee and Yin-Cheng Huang

Object

Liver cirrhosis was identified as an independent predictor of poor outcomes in patients suffering trauma and in those undergoing major surgeries. The aim of this study was to report the authors' experiences treating patients with cirrhosis who undergo brain surgeries.

Methods

Between 2004 and 2009, 121 consecutive patients with cirrhosis underwent 144 brain procedures. Patients were categorized as Child-Turcotte-Pugh (referred to as “Child”) Class A, B, or C. The patient profiles, including the severity of cirrhosis, reason for surgery, complications, and prognosis factors, were analyzed.

Results

In this retrospective study, the overall surgical complication rate for patients with cirrhosis was 52.1% and the mortality rate was 24.3%. For patients with acute traumatic brain injury (TBI), the complication, rebleeding, and mortality rates reached 84.4%, 68.8%, and 37.5%, respectively. Surgery for TBI was a significant risk factor for postoperative complications (p = 0.0002) and postoperative hemorrhage (p < 0.0001). Otherwise, according to the Child classification, the complication rate increased in a stepwise fashion from 38.7% to 60% to 84.2%, the rebleeding rate from 29.3% to 48.0% to 63.2%, and the mortality rate from 5.3% to 38% to 63.2% for Child A, B, and C, respectively. The Child classification was associated with higher risk of complications—Child B vs A OR 2.84 (95% CI 1.28–6.29), Child C vs A OR 5.39 (95% CI 1.32–22.02). It was also associated with risk of death—Child C vs A OR 30.43 (95% CI 7.71–120.02), Child B vs A OR 10.88 (95% CI 3.42–34.63).

Conclusions

Liver cirrhosis is a poor comorbidity factor for brain surgery. The authors' results suggest that the Child classification used independently is a poor prognostic factor; in addition, grave outcomes were observed in patients with TBI.

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Mun-Chun Yeap, Ching-Chang Chen, Zhuo-Hao Liu, Po-Chuan Hsieh, Cheng-Chi Lee, Yu-Tse Liu, Alvin Yi-Chou Wang, Yin-Cheng Huang, Kuo-Chen Wei, Chieh-Tsai Wu and Po-Hsun Tu

OBJECTIVE

Cranioplasty is a relatively simple and less invasive intervention, but it is associated with a high incidence of postoperative seizures. The incidence of, and the risk factors for, such seizures and the effect of prophylactic antiepileptic drugs (AEDs) have not been well studied. The authors’ aim was to evaluate the risk factors that predispose patients to postcranioplasty seizures and to examine the role of seizure prophylaxis in cranioplasty.

METHODS

The records of patients who had undergone cranioplasty at the authors’ medical center between 2009 and 2014 with at last 2 years of follow-up were retrospectively reviewed. Demographic and clinical characteristics, the occurrence of postoperative seizures, and postoperative complications were analyzed.

RESULTS

Among the 583 patients eligible for inclusion in the study, 247 had preexisting seizures or used AEDs before the cranioplasty and 336 had no seizures prior to cranioplasty. Of these 336 patients, 89 (26.5%) had new-onset seizures following cranioplasty. Prophylactic AEDs were administered to 56 patients for 1 week after cranioplasty. No early seizures occurred in these patients, and this finding was statistically significant (p = 0.012). Liver cirrhosis, intraoperative blood loss, and shunt-dependent hydrocephalus were risk factors for postcranioplasty seizures in the multivariable analysis.

CONCLUSIONS

Cranioplasty is associated with a high incidence of postoperative seizures. The prophylactic use of AEDs can reduce the occurrence of early seizures.