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Tao-Chen Lee, Kang Lu, Lin-Cheng Yang, Hsuan-Ying Huang and Cheng-Loong Liang

Object. Because modern imaging techniques now allow for early diagnosis of spinal tuberculosis, more conservative management options are possible. The authors evaluated the effectiveness of transpedicular instrumentation for treatment of thoracolumbar and lumbar spinal tuberculosis in patients with mild bone destruction and the main symptom of “instability catch” (a sudden painful “snap” that occurs when one extends from a forward bent to an upright position).

Methods. Eighteen patients (nine men and nine women, age range 49–71 years) with spinal tuberculosis were treated with transpedicular instrumentation that was supplemented with posterolateral fusion and chemotherapy. All patients were wheelchair dependent or bed-ridden due to severe instability catch, with a mean symptom duration of 2.5 months (range 1–6 months). Two contiguous vertebrae were involved in 17 patients, and a single vertebrae was involved in one. In five patients mild neurological deficits (Frankel Grade D) were present. During surgery, the screws were implanted into the two nonaffected pedicles nearest the lesion to stabilize the involved segments. No attempt at radical debridement or neural decompression was undertaken. The follow-up period ranged from 21 to 40 months. Postoperatively the instability catch was relieved within 10 days (excellent outcome) and within 1 month (good outcome) in seven and eight patients, respectively, and within 3 months (fair outcome) in two; in the remaining patient, the symptom did not resolve (poor outcome). A short duration of symptoms (generally < 3 months) and bone destruction of less than 50% in the involved vertebral bodies were observed in patients who made a good or excellent outcome. During the follow-up period, good maintenance of spinal alignment, stabilization of the involved segment, and resolution of the inflammatory process were shown; however, there was no strong evidence that fusion had occurred at the bony defect. Patients in whom a fair outcome was achieved experienced a longer duration of symptoms, and in each, one vertebral body with greater than 50% bone destruction was demonstrated. However, good maintenance of spinal alignment was also shown during the follow-up period. The patient whose outcome was poor had the longest history (6 months) of symptoms and the most extensive involvement of the spine (> 50% destruction of two adjacent lumbar vertebral bodies). Postoperatively, implant failure occurred and the patient developed a wound infection.

Conclusions. Transpedicular instrumentation provides rapid relief of instability catch and prevents late angular deformity in patients with thoracolumbar and lumbar spinal tuberculosis in whom limited (< 50%) bone destruction of the involved vertebral bodies has been shown and whose main symptom is instability catch.

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Bo Lin, Xuguang Lu, Xinli Zhai and Zhigang Cai

Object

The objective of this study was to develop an electrophysiological method for intraoperative localization of the trigeminal nerve branches during radiofrequency thermocoagulation (RFTC).

Methods

Twenty-three patients who were scheduled to undergo RFTC were included. The trigeminal nerve root was stimulated through the foramen ovale using the radiofrequency cannula. Antidromic responses were recorded from the target division through supraorbital, infraorbital, and mental foramina electrodes, and an additional electrode at the masseter muscle. Sensory and motor action responses, as well as verbal and masseter contraction responses, were recorded and correlated.

Results

The antidromic responses were easily recorded in the target division in all 23 patients, and they were invariably correlated with the patient's verbal responses. The potentials were recorded successively from V1 to V3. The amplitude in each division before and after RFTC showed little difference in response to electrical stimulation with the same current. The motor trigeminal nerve action potentials were recorded in 10 patients; 7 of these patients had postoperative masseter muscle weakness, while the remaining 3 had normal masseter muscle function. Potentials with low amplitudes were usually obtained from neighboring divisions, but no unexpected denervation of any branches was observed. All the patients experienced immediate pain relief after the procedure.

Conclusions

This technique is sensitive and easy to apply. The sensory and motor potentials matched the verbal responses and the complications. Although it cannot completely substitute for the patient's verbal response, this approach is helpful in uncooperative patients, and it predicts and reduces the incidence of masseter muscle weakness. The use of these complementary techniques could increase the chances of treatment success.

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Chueng-He Lu, Zhi-Fu Wu, Bo-Feng Lin, Meei-Shyuan Lee, Chin Lin, Yuan-Shiou Huang and Yi-Hsuan Huang

OBJECT

Anesthesia techniques can contribute to the reduction of anesthesia-controlled time and may therefore improve operating room efficiency. However, little is known about the difference in anesthesia-controlled time between propofol-based total intravenous anesthesia (TIVA) and desflurane (DES) anesthesia techniques for prolonged lumbar spine surgery under general anesthesia.

METHODS

A retrospective analysis was conducted using hospital databases to compare the anesthesia-controlled time of lengthy (surgical time > 180 minutes) lumbar spine surgery in patients receiving either TIVA via target-controlled infusion (TCI) with propofol/fentanyl or DES/fentanyl-based anesthesia, between January 2009 and December 2011. A variety of time intervals (surgical time, anesthesia time, extubation time, time in the operating room, postanesthesia care unit [PACU] length of stay, and total surgical suite time) comprising perioperative hemodynamic variables were compared between the 2 anesthesia techniques.

RESULTS

Data from 581 patients were included in the analysis; 307 patients received TIVA and 274 received DES anesthesia. The extubation time was faster (12.4 ± 5.3 vs 7.0 ± 4.5 minutes, p < 0.001), and the time in operating room and total surgical suite time was shorter in the TIVA group than in the DES group (326.5 ± 57.2 vs 338.4 ± 69.4 minutes, p = 0.025; and 402.6 ± 60.2 vs 414.4 ± 71.7 minutes, p = 0.033, respectively). However, there was no statistically significant difference in PACU length of stay between the groups. Heart rate and mean arterial blood pressure were more stable during extubation in the TIVA group than in the DES group.

CONCLUSIONS

Utilization of TIVA reduced the mean time to extubation and total surgical suite time by 5.4 minutes and 11.8 minutes, respectively, and produced more stable hemodynamics during extubation compared with the use of DES anesthesia in lengthy lumbar spine surgery.

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Cheng-shyuan Rau, Jui-wei Lin, Cheng-loong Liang, Tao-chen Lee, Han-jung Chen and Kang Lu

✓ An osteolytic meningioma in a 36-year-old woman was accompanied by elevated serum levels of human chorionic gonadotropin—β subunit (β-HCG), which returned to normal after removal of the tumor. Light microscopy examination demonstrated a transitional meningioma. Immunohistochemical analysis revealed that the tumor cells had a positive reaction for β-HCG. This case illustrates the possibility that meningioma may be associated with clinically detectable secretion of β-HCG. To the authors' knowledge, this is the first case in which meningioma has been shown to secrete β-HCG. The authors believe that meningioma should be considered in the differential diagnosis of choriocarcinoma, embryonal cell tumor, germinoma, and metastatic ovarian tumor associated with elevated levels of β-HCG.

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Bo Hou, Lu Gao, Lin Shi, Yishan Luo, Xiaopeng Guo, Geoffrey S. Young, Lei Qin, Huijuan Zhu, Lin Lu, Zihao Wang, Ming Feng, Xinjie Bao, Renzhi Wang, Bing Xing and Feng Feng

OBJECTIVE

Cushing’s disease (CD) involves brain impairments caused by excessive cortisol. Whether these impairments are reversible in remitted CD after surgery has long been controversial due to a lack of high-quality longitudinal studies. In this study the authors aimed to assess the reversibility of whole-brain changes in remitted CD after transsphenoidal surgery (TSS), and its correlations with clinical and hormonal parameters, in the largest longitudinal study cohort to date for CD patient brain analysis.

METHODS

Fifty patients with pathologically diagnosed CD and 36 matched healthy controls (HCs) were enrolled in a tertiary comprehensive hospital and national pituitary disease registry center in China. 3-T MRI studies were analyzed using an artificial intelligence–assisted web-based autosegmentation tool to quantify 3D brain volumes. Clinical parameters as well as levels of serum cortisol, adrenocorticotrophic hormone (ACTH), and 24-hour urinary free cortisol were collected for the correlation analysis. All CD patients underwent TSS and 46 patients achieved remission. All clinical, hormonal, and MRI parameters were reevaluated at the 3-month follow-up after surgery.

RESULTS

Widespread brain volume loss was observed in active CD patients compared with HCs, including total gray matter (p = 0.003, with false discovery rate [FDR] correction) and the frontal, parietal, occipital, and temporal lobes; insula; cingulate lobe; and enlargement of lateral and third ventricles (p < 0.05, corrected with FDR). All affected brain regions improved significantly after TSS (p < 0.05, corrected with FDR). In patients with remitted CD, total gray matter and most brain regions (except the frontal and temporal lobes) showed full recovery of volume, with volumes that did not differ from those of HCs (p > 0.05, corrected with FDR). ACTH and serum cortisol changes were negatively correlated with brain volume changes during recovery (p < 0.05).

CONCLUSIONS

This study demonstrates the rapid reversal of total gray matter loss in remitted CD. The combination of full recovery areas and partial recovery areas after TSS is consistent with the incomplete recovery of memory and cognitive function observed in CD patients in clinical practice. Correlation analyses suggest that ACTH and serum cortisol levels are reliable serum biomarkers of brain recovery for clinical use after surgery.

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Hung-Chen Wang, Tzu-Ming Yang, Wei-Che Lin, Yu-Jun Lin, Nai-Wen Tsai, Chia-Wei Liou, Aij-Lie Kwan and Cheng-Hsien Lu

Object

Increased plasma nuclear and mitochondrial DNA levels have been reported in critically ill patients, and extracellular DNA may originate from damaged tissues having undergone necrosis. This study tested the hypothesis that nuclear and mitochondrial DNA levels in CSF and plasma are substantially increased in patients with acute spontaneous aneurysmal subarachnoid hemorrhage (SAH) and decrease thereafter, such that nuclear and mitochondrial DNA levels may be predictive of treatment outcomes.

Methods

Serial nuclear and mitochondrial DNA levels in CSF and plasma from 21 adult patients with spontaneous aneurysmal SAH and 39 healthy volunteers who received myelography examinations during the study period were evaluated.

Results

Data showed that circulating plasma nuclear DNA concentrations and both nuclear and mitochondrial DNA levels in CSF significantly increased in patients with aneurysmal SAH on admission compared with the volunteers. In patients with poor outcome, the CSF nuclear and mitochondrial DNA levels were significantly higher on Days 1 and 4, and plasma nuclear DNA levels were significantly higher from Day 8 to Day 14. Higher CSF nuclear (> 85.1 ng/ml) and mitochondrial DNA levels (> 31.4 ng/ml) on presentation were associated with worse outcome in patients with aneurysmal SAH.

Conclusions

Higher CSF DNA levels on presentation, rather than plasma DNA levels, are associated with worse outcomes in patients with acute spontaneous aneurysmal SAH. More prospective multicenter investigations are needed to confirm the predictive value of CSF and plasma DNA levels on outcome.

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Tzu-Ming Yang, Wei-Che Lin, Wen-Neng Chang, Jih-Tsun Ho, Hung-Chen Wang, Nai-Wen Tsai, Yi-Ting Shih and Cheng-Hsien Lu

Object

Seizures are an important neurological complication of spontaneous intracerebral hemorrhage (ICH). A better understanding of the risk factors of seizures following ICH is needed to predict which patients will require treatment.

Methods

Two hundred and forty-three adult patients were enrolled in this 1-year retrospective study. Multiple logistic regression was used to evaluate the relationship between baseline clinical factors and the presence or absence of seizure during the study period.

Results

Seizures occurred in 20 patients with ICH, including acute symptomatic seizures in 9 and unprovoked seizures in 11. None progressed to status epilepticus during hospitalization. After a minimum 3-year follow-up period, the mean Glasgow Outcome Scale score was 3.8 ± 1.1 for patients who had had seizures and 3.5 ± 1.3 for those who had not. The multiple logistic regression model demonstrated that the mean ICH volume was independently associated with seizures, and any increase of 1 mm3 in ICH volume increased the seizure rate by 2.7%.

Conclusions

Higher mean ICH volumes at presentation were predictive of seizure, and the presence of late seizures was predictive of developing epilepsy. Most seizures occurred within 2 years of spontaneous ICH over a minimum of 3 years of follow-up.

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Suzhen Lin, Yiwen Wu, Hongxia Li, Chencheng Zhang, Tao Wang, Yixin Pan, Lu He, Ruinan Shen, Zhengdao Deng, Bomin Sun, Jianqing Ding and Dianyou Li

OBJECTIVE

Surgical procedures involving deep brain stimulation (DBS) of the globus pallidus internus (GPi) or subthalamic nucleus (STN) are well-established treatments for isolated dystonia. However, selection of the best stimulation target remains a matter of debate. The authors’ objective was to compare the effectiveness of DBS of the GPi and the STN in patients with isolated dystonia.

METHODS

In this matched retrospective cohort study, the authors searched an institutional database for data on all patients with isolated dystonia who had undergone bilateral implantation of DBS electrodes in either the GPi or STN in the period from January 30, 2014, to June 30, 2017. Standardized assessments of dystonia and health-related quality of life using the Burke-Fahn-Marsden Dystonia Rating Scale (BFMDRS) and SF-36 were conducted before and at 1, 6, and 12 months after surgery. No patients were lost to the 6-month follow-up; 5 patients were lost to the 12-month follow-up.

RESULTS

Both GPi (14 patients) and STN (16 patients) stimulation produced significant improvement in dystonia and quality of life in all 30 patients found in the database search. At the 1-month follow-up, however, the percentage improvement in the BFMDRS total movement score was significantly (p = 0.01) larger after STN DBS (64%) than after GPi DBS (48%). At the 12-month follow-up, the percentage improvement in the axis subscore was significantly (p = 0.03) larger after GPi DBS (93%) than after STN DBS (83%). Also, the total amount of electrical energy delivered was significantly (p = 0.008) lower with STN DBS than with GPi DBS (124 ± 52 vs 192 ± 65 μJ, respectively).

CONCLUSIONS

The GPi and STN are both effective targets in alleviating dystonia and improving quality of life. However, GPi stimulation may be better for patients with axial symptoms. Moreover, STN stimulation may produce a larger clinical response within 1 month after surgery and may have a potential economic advantage in terms of lower battery consumption.

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Cheng-Chia Lee, Sanford P. C. Hsu, Chung-Jung Lin, Hsiu-Mei Wu, Yu-Wei Chen, Yung-Hung Luo, Chi-Lu Chiang, Yong-Sin Hu, Wen-Yuh Chung, Cheng-Ying Shiau, Wan-Yuo Guo, David Hung-Chi Pan and Huai-Che Yang

OBJECTIVE

The presence of epidermal growth factor receptor (EGFR) mutations in non–small cell lung cancer (NSCLC) has been associated with elevated radiosensitivity in vitro. However, results from clinical studies on radiosensitivity in cases of NSCLC with EGFR mutations are inconclusive. This paper presents a retrospective analysis of patients with NSCLC who underwent regular follow-up imaging after radiotherapy for brain metastases (BMs). The authors also investigated the influence of EGFR mutations on the efficacy of Gamma Knife radiosurgery (GKRS).

METHODS

This study included 264 patients (1069 BMs) who underwent GKRS treatment and for whom EGFR mutation status, demographics, performance status, and tumor characteristics were available. Radiological images were obtained at 3 months after GKRS and at 3-month intervals thereafter. Kaplan-Meier plots and Cox regression analysis were used to correlate EGFR mutation status and other clinical features with tumor control and overall survival.

RESULTS

The tumor control rates and overall 12-month survival rates were 87.8% and 65.5%, respectively. Tumor control rates in the EGFR mutant group versus the EGFR wild-type group were 90.5% versus 79.4% at 12 months and 75.0% versus 24.5% at 24 months. During the 2-year follow-up period after SRS, the intracranial response rate in the EGFR mutant group was approximately 3-fold higher than that in the wild-type group (p < 0.001). Cox regression multivariate analysis identified EGFR mutation status, extracranial metastasis, primary tumor control, and prescribed margin dose as predictors of tumor control (p = 0.004, p < 0.001, p = 0.004, and p = 0.026, respectively). Treatment with a combination of GKRS and tyrosine kinase inhibitors (TKIs) was the most important predictor of overall survival (p < 0.001).

CONCLUSIONS

The current study demonstrated that, among patients with NSCLC-BMs, EGFR mutations were independent prognostic factors of tumor control. It was also determined that a combination of GKRS and TKI had the most pronounced effect on prolonging survival after SRS. In select patient groups, treatment with SRS in conjunction with EGFR-TKIs provided effective tumor control for NSCLC-BMs.

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Oral Presentations

2010 AANS Annual Meeting Philadelphia, Pennsylvania May 1–5, 2010