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Yao Li, Bang-ping Qian, Yong Qiu, Shi-zhou Zhao, Xiao-lin Zhong, and Bin Wang

OBJECTIVE

The objective of this study was to investigate the impact of the lumbar sagittal profile on pelvic orientation and pelvic motion during postural changes in patients with ankylosing spondylitis (AS) and thoracolumbar kyphosis and to evaluate the potential risk of prosthetic dislocation after total hip arthroplasty (THA) following pedicle subtraction osteotomy (PSO).

METHODS

Seventy-two patients with AS-related thoracolumbar kyphosis following spinal osteotomy were retrospectively reviewed, and 21 healthy volunteers were recruited as a control group. Pre- and postoperative 2D full-body images in standing and sitting positions were obtained to evaluate the anterior pelvic plane angle (APPA), lumbar lordosis (LL), sacral slope (SS), pelvic tilt (PT), proximal femur angle (PFA), and femoroacetabular flexion during postural changes. Patients with AS were categorized in either a lordotic or kyphotic group based on the lumbar sagittal profile.

RESULTS

Significant increases in the SS and decreases in the APPA, PT, and LL were observed postoperatively in both the standing and sitting positions (p < 0.001 for all). Significantly higher APPA, PT, LL, and ΔPT, and lower SS, ΔSS, and ΔSS+ΔPFA were observed in the kyphotic group (p < 0.05). After undergoing PSO, ΔPT and ΔSS significantly decreased while femoroacetabular flexion significantly increased in both AS groups (p < 0.05), and no significant difference was present between the two groups (p > 0.05). Bath Ankylosing Spondylitis Radiology Hip Index scores in the kyphotic group were significantly worse than those in the lordotic group pre- and postoperatively (p < 0.05). No significant difference in parameters concerning pelvic motion (ΔAPPA, ΔPT, and ΔSS) was found when PSO was performed in the thoracolumbar or lumbar spine.

CONCLUSIONS

Lumbar sagittal profiles greatly affect pelvic orientation and pelvic motion in AS. When THA is performed before PSO, AS patients with lumbar kyphosis are at higher risk of anterior prosthetic dislocation, while those with lordotic lumbar sagittal profiles are at higher risk of posterior dislocation. PSO should be performed prior to THA. After PSO, further decreased pelvic motion indicated a potential risk of posterior prosthetic dislocation after sequential THA, whereas theoretically patients with preoperative lumbar kyphosis are at higher risk of THA dislocation. The site where PSO was performed (thoracolumbar or lumbar spine) does not influence the risk of THA dislocation.

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Baotian Zhao, Chao Zhang, Xiu Wang, Yao Wang, Jiajie Mo, Zhong Zheng, Lin Ai, Kai Zhang, Jianguo Zhang, Xiao-qiu Shao, and Wenhan Hu

OBJECTIVE

The aim of this study was to characterize the clinical and electrophysiological findings of epilepsy originating from the orbitofrontal cortex (OFC) as well as its surgical outcomes.

METHODS

The authors retrospectively reviewed 27 consecutive cases of patients with drug-resistant orbitofrontal epilepsy (OFE) who underwent tailored resective surgery after a detailed presurgical workup. Demographic features, seizure semiology, imaging characteristics, resection site, pathological results, and surgical outcomes were analyzed. Patients were categorized according to semiology. The underlying neural network was further explored through quantitative FDG-PET and ictal stereo-electroencephalography (SEEG) analysis at the group level. FDG-PET studies between the semiology group and the control group were compared using a voxel-based independent t-test. Ictal SEEG was quantified by calculating the energy ratio (ER) of high- and low-frequency bands. An ER comparison between the anterior cingulate cortex (ACC) and the amygdala was performed to differentiate seizure spreading patterns in groups with different semiology.

RESULTS

Scalp electroencephalography (EEG) and MRI were inconclusive to a large extent. Patients were categorized into the following 3 semiology groups: the frontal group (n = 14), which included patients with hyperactive automatisms with agitated movements; the temporal group (n = 11), which included patients with oroalimentary or manual automatisms; and the other group (n = 2), which included patients with none of the abovementioned or indistinguishable manifestations. Patients in the frontal and temporal groups (n = 23) or in the frontal group only (n = 14) demonstrated significant hypometabolism mainly across the ipsilateral OFC, ACC, and anterior insula (AI), while patients in the temporal group (n = 9) had hypometabolism only in the OFC and AI. The ER results (n = 15) suggested distinct propagation pathways that allowed us to differentiate between the frontal and temporal groups. Pathologies included focal cortical dysplasia, dysembryoplastic neuroepithelial tumor, cavernous malformation, glial scar, and nonspecific findings. At a minimum follow-up of 12 months, 19 patients (70.4%) were seizure free, and Engel class II, III, and IV outcomes were observed in 4 patients (14.8%), 3 patients (11.1%), and 1 patient (3.7%), respectively.

CONCLUSIONS

The diagnosis of OFE requires careful presurgical evaluation. Based on their electrophysiological and metabolic evidence, the authors propose that varied semiological patterns could be explained by the extent of involvement of a network that includes at least the OFC, ACC, AI, and temporal lobe. Tailored resections for OFE may lead to a good overall outcome.

Free access

Baotian Zhao, Chao Zhang, Xiu Wang, Yao Wang, Jiajie Mo, Zhong Zheng, Lin Ai, Kai Zhang, Jianguo Zhang, Xiao-qiu Shao, and Wenhan Hu

OBJECTIVE

The aim of this study was to characterize the clinical and electrophysiological findings of epilepsy originating from the orbitofrontal cortex (OFC) as well as its surgical outcomes.

METHODS

The authors retrospectively reviewed 27 consecutive cases of patients with drug-resistant orbitofrontal epilepsy (OFE) who underwent tailored resective surgery after a detailed presurgical workup. Demographic features, seizure semiology, imaging characteristics, resection site, pathological results, and surgical outcomes were analyzed. Patients were categorized according to semiology. The underlying neural network was further explored through quantitative FDG-PET and ictal stereo-electroencephalography (SEEG) analysis at the group level. FDG-PET studies between the semiology group and the control group were compared using a voxel-based independent t-test. Ictal SEEG was quantified by calculating the energy ratio (ER) of high- and low-frequency bands. An ER comparison between the anterior cingulate cortex (ACC) and the amygdala was performed to differentiate seizure spreading patterns in groups with different semiology.

RESULTS

Scalp electroencephalography (EEG) and MRI were inconclusive to a large extent. Patients were categorized into the following 3 semiology groups: the frontal group (n = 14), which included patients with hyperactive automatisms with agitated movements; the temporal group (n = 11), which included patients with oroalimentary or manual automatisms; and the other group (n = 2), which included patients with none of the abovementioned or indistinguishable manifestations. Patients in the frontal and temporal groups (n = 23) or in the frontal group only (n = 14) demonstrated significant hypometabolism mainly across the ipsilateral OFC, ACC, and anterior insula (AI), while patients in the temporal group (n = 9) had hypometabolism only in the OFC and AI. The ER results (n = 15) suggested distinct propagation pathways that allowed us to differentiate between the frontal and temporal groups. Pathologies included focal cortical dysplasia, dysembryoplastic neuroepithelial tumor, cavernous malformation, glial scar, and nonspecific findings. At a minimum follow-up of 12 months, 19 patients (70.4%) were seizure free, and Engel class II, III, and IV outcomes were observed in 4 patients (14.8%), 3 patients (11.1%), and 1 patient (3.7%), respectively.

CONCLUSIONS

The diagnosis of OFE requires careful presurgical evaluation. Based on their electrophysiological and metabolic evidence, the authors propose that varied semiological patterns could be explained by the extent of involvement of a network that includes at least the OFC, ACC, AI, and temporal lobe. Tailored resections for OFE may lead to a good overall outcome.

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Xiao-hui Ren, Chun Chu, Chun Zeng, Yong-ji Tian, Zhen-yu Ma, Kai Tang, Lan-bing Yu, Xiang-li Cui, Zhong-cheng Wang, and Song Lin

Object

Intracranial epidermoid cysts are rare, potentially curable, benign lesions that are sometimes associated with severe postoperative complications, including hemorrhage. Delayed hemorrhage, defined as one that occurred after an initial unremarkable postoperative CT scan, contributed to most cases of postoperative hemorrhage in patients with epidermoid cyst. In this study, the authors focus on delayed hemorrhage as one of the severe postoperative complications in epidermoid cyst, report its incidence and its clinical features, and analyze related clinical parameters.

Methods

There were 428 cases of intracranial epidermoid cysts that were surgically treated between 2002 and 2008 in Beijing Tiantan Hospital, and these were retrospectively reviewed. Among them, the cases with delayed postoperative hemorrhage were chosen for analysis. Clinical parameters were recorded, including the patient's age and sex, the chief surgeon's experience in neurosurgery, the year in which the operation was performed, tumor size, adhesion to neurovascular structures, and degree of resection. These parameters were compared in patients with and without delayed postoperative hemorrhage to identify risk factors associated with this entity.

Results

The incidences of postoperative hemorrhage and delayed postoperative hemorrhage in patients with epidermoid cyst were 5.61% (24 of 428) and 4.91% (21 of 428), respectively, both of which were significantly higher than that of postoperative hemorrhage in all concurrently treated intracranial tumors, which was 0.91% (122 of 13,479). The onset of delayed postoperative hemorrhage ranged from the 5th to 23rd day after the operation; the median time of onset was the 8th day. The onset manifestation included signs of intracranial hypertension and/or meningeal irritation (71.4%), brain herniation (14.3%), seizures (9.5%), and syncope (4.8%). Neuroimages revealed hematoma in 11 cases and subarachnoid hemorrhage in 10 cases. The rehemorrhage rate was 38.1% (8 of 21). The mortality rate for delayed postoperative hemorrhage was 28.6% (6 of 21). None of the clinical parameters was correlated with delayed postoperative hemorrhage (p > 0.05), despite a relatively lower p value for adhesion to neurovascular structures (p = 0.096).

Conclusions

Delayed postoperative hemorrhage contributed to most of the postoperative hemorrhages in patients with intracranial epidermoid cysts and was a unique postoperative complication with unfavorable outcomes. Adhesion to neurovascular structures was possibly related to delayed postoperative hemorrhage (p = 0.096).