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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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Kang Lu, Cheng-Loong Liang, Tao-Chen Lee, Han-Jung Chen, Thung-Ming Su and Po-Chou Liliang

Object. Transthoracic endoscopic T-2 sympathectomy is currently the treatment of choice for palmar hyperhidrosis (PH). Intraoperative monitoring of palmar skin temperature (PST) is often used to assess the adequacy of sympathetic ablation. The aim of this study was to investigate the time course of PST changes during the operation and to determine factors involved in the sympathetic modulation of the palmar skin blood flow.

Methods. Eighty-one patients with PH underwent bilateral transthoracic endoscopic sympathectomy of T-2 in which continuous intraoperative PST monitoring was used. Palmar skin temperature data, recorded every 30 seconds throughout the operation, were plotted against time, and a graph of two PST curves was obtained in each case. A multiphasic curve pattern of great similarity was observed in nearly 70% of cases. Specific PST readings at different operative stages were collected and averaged for all cases. The trend of PST changes in response to different procedures during the operation was analyzed.

It was found that unilateral procedures caused simultaneous bilateral PST alterations. In almost all cases, bilateral PST was dramatically lowered when unilateral skin incision and intercostal muscle dissection were performed. The temperature remained low until the T-2 sympathectomy was finished on one side. In addition, unilateral T-2 sympathectomy induced synchronous elevation of bilateral PST. However, the ipsilateral response was significantly stronger than that on the contralateral side.

Conclusions. Although intraoperative monitoring of PST is a reliable guide for surgeons performing endoscopic transthoracic sympathectomy, it is important to realize that PST fluctuates at different stages during the operation and that surgical procedures themselves can significantly influence PST readings. The PST data recorded at specific time points, therefore, can be misleading in terms of accuracy and the completeness of ablation of the target sympathetic ganglia, especially when the sympathetic trunk or ganglia are anatomically aberrant.

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Xiao-lu Yin, Jesse C. Pang, Yan-hui Liu, Edith Y. Chong, Yue Cheng, Wai-sang Poon and Ho-keung Ng

Object. The loss of genetic material from specific chromosome loci is a common feature in the oncogenesis of tumors and is often indicative of the presence of important tumor suppressor genes at these loci. Recent molecular genetic analyses have demonstrated frequent loss of chromosomes 10q, 11, and 16 in medulloblastomas. The aim of this study was to localize the targeted deletion regions on the three aforementioned chromosomes in medulloblastomas.

Methods. Loss of heterozygosity (LOH) was examined on chromosomes 10q, 11, and 16 in a series of 22 primary and two recurrent medulloblastomas by using polymerase chain reaction—based microsatellite analysis. The DNA extracted from the tumors and corresponding normal blood samples were amplified independently in the presence of radioactively labeled microsatellite primers, resolved by denaturing gel electrophoresis and processed for autoradiography. The DNA obtained from control blood samples that displayed allelic heterozygosity at a given microsatellite locus were considered informative. Loss of heterozygosity was inferred when the allelic signal intensity of the tumor sample was reduced by at least 40%, relative to that of the constitutional control. The LOH analysis demonstrated that deletions of chromosomes 10q, 11p, and 16q are recurrent genetic events in the development of medulloblastomas. Three subchromosomal regions of loss have been identified and are localized to the deleted in malignant brain tumors 1 [DMBT1] gene site on chromosomes 10q25, 11p13–11p15.1, and 16q24.1–24.3.

Conclusions. These results indicate that DMBT1 is closely associated with the oncogenesis of medulloblastomas and highlight regions of loss on chromosomes 11p and 16q for further fine mapping and cloning of candidate tumor suppressor genes that are important for the genesis of medulloblastoma.

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Han-Jung Chen, Cheng-Loong Liang and Kang Lu

Object. Transthoracic endoscopic T2–3 sympathectomy is currently the treatment of choice for palmar hyperhidrosis. Compensatory sweating of the face, trunk, thigh, and sole of the foot was found in more than 50% of patients who underwent this procedure. The authors conducted this study to investigate the associated intraoperative changes in plantar skin temperature and postoperative plantar sweating.

Methods. One hundred patients with palmar hyperhidrosis underwent bilateral transthoracic endoscopic T2–3 sympathectomy. There were 60 female and 40 male patients who ranged in age from 13 to 40 years (mean age 21.6 years). Characteristics studied included changes in palmar and plantar skin temperature measured intraoperatively, as well as pre- and postoperative changes in plantar sweating and sympathetic skin responses (SSRs).

In 59 patients (59%) elevation of plantar temperature was demonstrated at the end of the surgical procedure. In this group, plantar sweating was found to be exacerbated in three patients (5%); plantar sweating was improved in 52 patients (88.1%); and no change was demonstrated in four patients (6.8%). In the other group of patients in whom no temperature change occurred, increased plantar sweating was demonstrated in three patients (7.3%); plantar sweating was improved in 20 patients (48.8%); and no change was shown in 18 patients (43.9%). The difference between temperature and sweating change was significant (p = 0.001).

Compared with the presympathectomy rate, the rate of absent SSR also significantly increased after sympathectomy: from 20 to 76% after electrical stimulation and 36 to 64% after deep inspiration stimulation, respectively (p < 0.05).

Conclusions. In contrast to compensatory sweating in other parts of the body after T2–3 sympathetomy, improvement in plantar sweating was shown in 72% and worsened symptoms in 6% of patients. The intraoperative plantar skin temperature change and perioperative SSR demonstrated a correlation between these changes.

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Cheng-Loong Liang, Chun-Chung Lui, Kang Lu, Tao-Chen Lee and Han-Jung Chen

✓ The authors describe a patient with ossiculum terminale. Thin-section three-dimensional computerized tomography reconstructions, magnetic resonance images, and radiographs of the cervical spine were obtained to evaluate the atlantoaxial stability and structures of the ossiculum terminale. Bone had formed between the ossicles and the body of the odontoid process, and good atlantoaxial stability was clearly demonstrated.

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Cheng-Shyuan Rau, Cheng-Loong Liang, Chun-Chung Lui, Tao-Chen Lee and Kang Lu

✓ Quadriplegia is a well-known complication of posterior fossa surgery performed while the patient is in the sitting position but is rarely associated with the prone position. A case of an 18-year-old man with a cerebellar medulloblastoma is described. There was no evidence of previous cervical disease. The patient suffered quadriplegia after undergoing surgery in the prone position. Postoperative magnetic resonance imaging demonstrated a long hyperintense C2—T1 lesion on T2-weighted sequences. The authors speculate that, during the prolonged period in which the neck was in hyperflexion, overstretching of the cervical spinal cord and compromise of its blood supply might have caused this devastating complication.

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Kang Lu, Cheng-Loong Liang, Chung-Lung Cho, Han-Jung Chen, Huan-Chen Hsu, Shuenn-Jiun Yiin, Chi-Liang Chern, Yun-Ching Chen and Tao-Chen Lee

Object. The need for wide dissection and forceful retraction of paraspinal muscles often required for posterolateral lumbar fusion and fixation may severely jeopardize the muscles, structurally and functionally. The underlying pathophysiology of muscle damage may involve both mechanical and ischemic mechanisms. On the other hand, the surgery-related stress may trigger certain protective responses within the insulted paraspinal muscles. This study was conducted to assess the relationship between the oxidative stress and the stress response mediated by heat shock protein 70 (HSP70) induction within paraspinal muscles being retracted.

Methods. Multifidus muscle specimens were surgically obtained before, during, and after retraction in patients with lumbar spondylolisthesis undergoing posterolateral lumbar fusion, pedicle fixation, and laminectomy. Muscle samples were analyzed to determine HSP70 and malondialdehyde (MDA) levels. Both HSP70 expression and MDA production within multifidus muscle cells were increased significantly by retraction. Expression of HSP70 then decreased after a peak at 1.5 hours of retraction, whereas MDA levels remained elevated even after release of retractors for reperfusion of the muscles. Analysis of histopathological and immunohistochemical evidence indicated that the decline of HSP70 synthesis within muscle cells after prolonged retraction was the result of severe muscle damage.

Conclusions. Results of this study highlight the deleterious effect of intraoperative retraction on human paraspinal muscles at the cellular and molecular levels. The authors also found that intraoperative maneuvers aimed at reducing the oxidative stress within the paraspinal muscles may help to attenuate surgery-related paraspinal muscle damage.

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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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Kang Lu, Cheng-Loong Liang, Han-Jung Chen, Shang-Der Chen, Huan-Chen Hsu, Yun-Ching Chen, Fu-Fei Hsu and Chung-Lung Cho

Object. Paraspinal muscle injury is a common but neglected complication of posterior spinal surgery. Evidence suggests that surgical retraction places mechanical and oxidative stress on the paraspinal muscles and that inflammation is a major postoperative pathological finding in the muscles. The roles of cyclooxygenase (COX)—2 and nuclear factor (NF)—κB in the inflammatory processes after retraction remains to be clarified.

Methods. In the control group, paraspinal muscles were dissected from the spine via a posterior incision and then laterally retracted. Paraspinal muscle specimens were harvested before as well as at designated time points during and after persistent retraction. The time course of NF-κB activation was determined by gel shift assay. Expression of COX-2 was examined using Western blot analysis and immunohistochemistry. The severity of inflammation was evaluated based on histopathology and myeloperoxidase (MPO) activity. The NF-κB activation was inhibited by the administration of pyrrolidine dithiolcarbamate (PDTC) in the PDTC-treated group. Retraction induced early activation of NF-κB in paraspinal muscle cells. The expression of COX-2 could not be detected until 1 day postoperativley, reaching a peak at 3 days. The time course of COX-2 expression correlated with that of inflammatory responses and MPO activity. Pretreatment with PDTC inhibited intraoperative NF-κB activation and greatly downregulated postoperative COX-2 expression and inflammation in the muscles. Postinflammation fibrosis was also abolished by PDTC administration.

Conclusions. Both NF-κB-regulated COX-2 expression and inflammation play an important role in the pathogenesis of surgery-associated paraspinal muscle injury. The therapeutic strategy of NF-κB inhibition may be applicable to the prevention of such injury.

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Cheng-Loong Liang, Meng-Wei Ho, Kang Lu, Yu-Duan Tsai, Po-Chou Liliang, Kuo-Wei Wang and Han-Jung Chen

Object

The authors conducted a study to assess the eye lens dosimetry in trigeminal neuralgia (TN) treatment when using the Leksell Gamma Knife model C.

Methods

Phantom studies were used to measure the maximal dose reaching the eye lens with and without eye shielding. Six consecutive patients with TN were evaluated for Gamma Knife surgery (GKS). The maximum prescribed dose of 80 Gy was delivered with a single shot using the 4-mm collimator helmet. High-sensitivity thermoluminescence dosimeter chips (TLDCs) were used to measure the dosimetry.

In vitro, the Leksell GammaPlan (LGP) system predicted the mean maximal doses of 1.08 ± 0.08 and 0.15 ± 0.01 Gy (mean ± standard deviation) to the lens ipsilateral to the treated trigeminal nerve without and with eye shielding, respectively. The TLDCs-measured dosimetry indicated the mean maximal doses of 1.12 ± 0.09 and 0.17 ± 0.01 Gy without and with eye shielding, respectively. The maximal doses to the lens contralateral to the nerve were similar.

In vivo, the LGP predicted the mean maximal doses to the lens ipsilateral to the treated nerve as 1.1 ± 0.07 and 0.16 ± 0.02 Gy, respectively, without and with eye shielding. The dosimetry measured by TLDCs indicated the mean maximal dose to the lens ipsilateral to the treated nerve as 0.17 ± 0.02 Gy with eye shielding. The mean maximal doses to the lens contralateral to the nerve were similar. Using the 110 and 125˚ gamma angles, the LGP predicted the mean maximal doses of 0.32 ± 0.04 and 0.12 ± 0.04 Gy to the lens without and with eye shielding, respectively.

Conclusions

Patients with TN undergoing GKS without eye shielding may develop cataracts due to the high radiation dose to the eye lenses. The authors suggest the routine use of bilateral eye shielding for the patients.