Ali A. Baaj and Ziya L. Gokaslan
Wen-Dong Xu, Yu-Dong Gu, Jing-Bo Liu, Cong Yu, Cheng-Gang Zhang and Jian-Guang Xu
The status of pulmonary function following phrenic nerve transfer surgery is still largely unknown because of the high degree of variability in the accessory phrenic nerve that may be involved. In the present study, pulmonary functions were assessed in patients before and after full-length phrenic nerve transfer surgery, in whom the phrenic nerve was severed at a location just before its entry into the diaphragm.
Fifteen patients (average age 27.4 years) with complete brachial plexus palsy underwent full-length phrenic nerve transfer. The phrenic nerve was harvested from the thoracic cavity by means of video-assisted thoracic surgery and then transferred to the musculocutaneous nerve. Postoperative pulmonary functions were retrospectively analyzed. Patients underwent follow-up evaluation for 42 to 48 months; four patients were eventually lost to follow up.
Although no patient experienced pulmonary problems following the surgery, all sustained varying degrees of diaphragmatic paralysis and elevation (for 1–1.5 intercostal spaces) on the surgically treated side as seen on chest x-ray films. Pulmonary functional parameters, including vital capacity, vital capacity in percentage of predicted values, residual volume, total lung capacity, forced vital capacity, and forced expiratory volume in 1 second, recovered to preoperative levels by 1 year postsurgery. In contrast, the postoperative maximal inspiratory pressure value was significantly decreased compared with the predicted values (average decrease ∼20%) in all of the patients, even at 4 years after the surgery.
In young patients with healthy lung function, unilateral phrenic nerve transection surgery can cause unilateral diaphragmatic paralysis and reduce the inspiration muscle force; however, most pulmonary function parameters gradually recover to preoperative levels within 1 year.
Taolin Fang, Jian Dong, Xiaogang Zhou, Robert A. McGuire Jr. and Xilei Li
The object of this study was to compare the mini-open anterior corpectomy procedure with posterior total en bloc spondylectomy (TES) in treating patients with solitary metastases of the thoracolumbar spine.
From 2004 to 2010, 41 patients with solitary metastases of the thoracolumbar spine were treated in our hospital using either a mini-open anterior corpectomy or posterior TES. Intraoperative and diagnostic data, including perioperative complications, were collected using retrospective chart review. The surgical outcomes were assessed according to survival status, neurological function, local recurrence, and pain before and after surgery.
Seventeen patients underwent posterior TES and 24 underwent mini-open anterior corpectomy. Mean blood loss (TES, 1721 ± 293 ml; mini-open corpectomy, 1058 ± 263 ml; p < 0.05), and mean operative time (TES, 403 ± 55 minutes; mini-open corpectomy, 175 ± 38 minutes; p < 0.05) were recorded and calculated. Neurological improvement by at least 1 American Spinal Injury Association Impairment Scale grade was noted in 35 (97.2%) of the 36 cases with preoperative deficits. After the operation, 68.4% of nonambulatory patients became ambulatory again, including 84.6% after mini-open corpectomy and 33.3% after posterior TES (p > 0.05). The visual analog scale scores of the patients were significantly reduced after both procedures, with no difference between the procedures (p > 0.05). The local tumor recurrence rate of the TES group was significantly lower than that of the mini-open corpectomy group (p < 0.05), while the postoperative survival rates within 2 years after surgery were similar. The complication rate in the mini-open corpectomy group (29.2%) was higher than that in the TES group (11.8%), but this difference was not statistically significant (p = 0.185). There was no hardware failure and no loss of the sagittal Cobb angle in either group. Slight subsidence (< 3 mm) of the mesh cage was observed with a successful fusion in 3 (17.6%) of 17 patients in the TES group. No subsidence of polymethylmethacrylate block/autograft was recorded in the mini-open group.
Mini-open anterior corpectomy can be accomplished with less blood loss, fewer fixation instrumentations, and shorter surgical time than that required for TES, but patients who undergo a mini-open corpectomy might have a greater tendency to experience local recurrence. A mini-open anterior corpectomy has a relatively mild learning curve and involves fewer technical difficulties. With smaller incisions, mini-open anterior corpectomy is an option in treating solitary metastases of the thoracolumbar spine.
Fubing Liu, Zhenzhou Feng, Tianze Liu, Qinming Fei, Chun Jiang, Yuanchao Li, Xiaoxing Jiang and Jian Dong
This study sought to make a biomechanical comparison of 3 different posterior fixation techniques for 2-level lumbar spinal disorders.
Eight fresh-frozen human cadaver lumbar spines (4 from L-1 to L-5, 4 from L-1 to S-1) were tested by applying pure moments of ± 8 Nm. Each specimen was first tested intact, and then the left facetectomies of L3–4 and L4–5 were performed to establish an unstable condition without removal of discs. Three instrumentation systems were then tested randomly: unilateral pedicle screw (UPS), UPS with contralateral translaminar facet screw (UPSFS), and bilateral pedicle screw (BPS). The range of motion (ROM) and the neutral zone (NZ) of L3–5 were measured.
All fixation types could reduce the ROM of L3–5 significantly in flexion, extension, and lateral bending, compared with the intact state. In axial torsion, only BPS reduced the ROM significantly, compared with the intact state. The UPSFS technique provided intermediate stability, which was superior to the UPS in flexion-extension and lateral bending, and inferior to the BPS in lateral bending. Compared with the intact state, the NZs decreased significantly for UPS, UPSFS, and BPS in flexion-extension, while not significantly in lateral bending and axial torsion.
In this study, among the 3 fixation techniques, BPS offered the highest stability, UPSFS provided intermediate stability, and UPS was the least stable for 2-level lumbar spinal disorders. UPSFS appeared to be able to offer a less invasive choice than BPS in well-selected patients with 2-level lumbar spinal disorders.
Le-Bao Yu, Xin-Jian Yang, Qian Zhang, Shao-Sen Zhang, Yan Zhang, Rong Wang and Dong Zhang
Recurrent aneurysms after coil embolization remain a challenging issue. The goal of the present study was to report the authors’ experience with recurrent aneurysms after coil embolization and to discuss the radiographic classification scheme and recommended management strategy.
Aneurysm treatments from a single institution over a 6-year period were retrospectively reviewed. Ninety-seven aneurysms that recurred after initial coiling were managed during the study period. Recurrent aneurysms were classified into the following 5 types based on their angiographic characteristics: I, pure recanalization inside the aneurysm sac; II, pure coil compaction without aneurysm growth; III, new aneurysm neck formed without coil compaction; IV, new aneurysm neck formed with coil compaction; and V, newly formed aneurysm neck and sac.
Aneurysm recurrences resulted in rehemorrhages in 6 cases (6.2%) of type III–V aneurysms, but in none of type I–II aneurysms. There was a significantly higher proportion of ophthalmic artery aneurysms and complex internal carotid artery aneurysms presenting as types I and II than presented as the other 3 types (63.3% vs 16.4%, p < 0.001). In contrast, for posterior communicating artery aneurysms and anterior communicating artery aneurysms, a higher proportion of type III–V aneurysms was observed than for the other 2 types, but without a significant difference in the multivariate model (56.7% vs 23.3%). In addition, giant (> 25 mm) aneurysms were more common among type I and II lesions than among type III and IV aneurysms (36.7% vs 9.0%, p = 0.001), which exhibited a higher proportion of small (< 10 mm) lesions (65.7% vs 13.3%, p < 0.001). A single reembolization procedure was sufficient to occlude 80.0% of type I recurrences and 83.3% of type II recurrences from coil compaction but only 65.6% of type III–V recurrences from aneurysm regrowth.
Aneurysm size and location represent the determining factors of the angiographic recurrence types. Type I and II recurrences were safely treated by reembolization, whereas type III–V recurrences may be best managed surgically when technically feasible.
Chen Wang, Chien-Min Chen, Fang Shen, Xiao-Dong Fang, Guang-Yu Ying, Yu-Cheng Ren, Dan-Feng Yu, Liang-Liang Zhu, Yong-Jian Zhu and Jian-Min Zhang
Spinal dural arteriovenous fistulas (SDAVFs) are the most common type of spinal arteriovenous malformations, and microsurgical ligation is the treatment modality most frequently used for these lesions. Developments in endoscopic techniques have made endoscopy an even less invasive alternative to routine microsurgical approaches in spine surgery, but endoscopic management of SDAVF or other intradural spinal lesions has not been reported to date.
The authors describe the use of a microscope-assisted endoscopic interlaminar approach for the ligation of the proximal draining vein of an L-1 SDAVF in a 58-year-old man. A complete cure was confirmed by postoperative angiography. The postoperative course was uneventful, and short-term follow-up showed improvements in the patient's neurological function. The authors conclude that the endoscopic interlaminar approach with microscope assistance is a safe, minimally invasive, innovative technique for the surgical management of SDAVFs in selected patients.
Xu-Yun Hua, Bin Liu, Yan-Qun Qiu, Wei-Jun Tang, Wen-Dong Xu, Han-Qiu Liu, Jian-Guang Xu and Yu-Dong Gu
Contralateral C-7 nerve transfer was developed for the treatment of patients with brachial plexus avulsion injury (BPAI). In the surgical procedure the affected recipient nerve is connected to the ipsilateral motor cortex, and the dramatic peripheral alteration may trigger extensive cortical reorganization. However, little is known about the long-term results after such specific nerve transfers. The purpose of this study was to investigate the long-term cortical adaptive plasticity after BPAI and contralateral C-7 nerve transfer.
In this study, 9 healthy male volunteers and 5 male patients who suffered from right-sided BPAI and had undergone contralateral C-7-transfer more than 5 years earlier were included. Functional MRI studies were used for the investigation of long-term cerebral plasticity.
The neuroimaging results suggested that the ongoing cortical remodeling process after contralateral C-7 nerve transfer could last for a long period; at least for 5 years. The motor control of the reinnervated limb may finally transfer from the ipsilateral to the contralateral hemisphere exclusively, instead of the bilateral neural network activation.
The authors believe that the cortical remodeling may last for a long period after peripheral rearrangement and that the successful cortical transfer is the foundation of the independent motor recovery.
Wen-Dong Xu, Jiu-Zhou Lu, Yan-Qun Qiu, Su Jiang, Lei Xu, Jian-Guang Xu and Yu-Dong Gu
The functional recovery of hand prehension after complete brachial plexus avulsion injury (BPAI) remains an unsolved problem. The authors conducted a prospective study to elucidate a new method of resolving this injury.
Three patients with BPAI underwent a new procedure during which the full-length phrenic nerve was transferred to the medial root of the median nerve via endoscopic thoracic surgery support. All 3 patients were followed up for a postoperative period of > 3 years.
The power of the palmaris longus, flexor pollicis longus, and the flexor digitorum muscles of all 4 fingers reached Grade 3–4/5, and no symptoms of respiratory insufficiency occurred.
Neurotization of the phrenic nerve to the medial root of the median nerve via endoscopic thoracic surgery is a feasible means of early hand prehension recovery after complete BPAI.
Chuan-Tao Zuo, Xu-Yun Hua, Yi-Hui Guan, Wen-Dong Xu, Jian-Guang Xu and Yu-Dong Gu
Peripheral nerve injury in a limb usually causes intrahemispheric functional reorganization of the contralateral motor cortex. Recently, evidence has been emerging for significant interhemispheric cortical plasticity in humans, mostly from studies of direct cortical damage. However, in this study, a long-range interhemispheric plasticity was demonstrated in adults with brachial plexus avulsion injury (BPAI) who had received a contralateral cervical nerve transfer, and this plasticity reversed the BPAI-induced intrahemispheric cortical reorganization.
In this study, 8 adult male patients with BPAI were studied using PET scanning.
The results indicated that the right somatomotor cortices, which may contribute to the control of the injured limb before brachial plexus deafferentation, still played an important role when patients with BPAI tried to move their affected limbs, despite the fact that the contralateral C-7 nerve transfer had been performed and the peripheral output had changed dramatically. Such findings are consistent with the results of the authors' previous animal study.
The brain may try to restore the control of an injured limb to its original cortex area, and a complicated change of peripheral pathway also can induce long-range interhemispheric cortical reorganization in human motor cortex.