Postoperative analgesia of intraoperative nefopam in patients undergoing anterior cervical spine surgery: A prospective randomized controlled trial.

BACKGROUND: Nefopam is a non-opioid, non-nonsteroidal anti-imflammatory drug, analgesic drug that inhibits the reuptake of serotonin, norepinephrine, and dopamine. It is widely used as an adjuvant for pain. This study investigated whether the intraoperative, intravenous infusion of nefopam (20 mg) reduces postoperative morphine consumption, pain scores, and alleviates neuropathic pain in patients undergoing cervical spine surgery. METHODS: A prospective, paralleled design, randomized study was conducted on 50 patients (aged 18-75 years) in a university-based hospital. The patients were assigned to an intervention or a control group (25 patients in each). The intervention group received a 1-hour infusion of nefopam (20 mg) before the end of surgery. The control group received normal saline (NSS). The outcome measures were morphine consumption during the first 24 postoperative hours, numerical rating scale (NRS) pain scores, and scores for the Thai version of the Neuropathic Pain Symptom Inventory (NPSI-T) in patients with neuropathic pain and adverse drug reactions. The NPSI-T scores were assessed on the preoperative day, postoperative day 1, 3, 15, and 30. The outcome assessors were blinded to group allocation. RESULTS: Fifty patients were analyzed. During the first 24 postoperative hours, morphine consumption was 8 mg (nefopam) and 12 mg (NSS; P = .130). The intervention and control groups demonstrated no significant differences in the median NRS scores or total NPSI-T scores or adverse drug reactions. CONCLUSIONS: A single, intraoperative infusion of 20 mg of nefopam did not significantly reduce postoperative (24 hours) morphine consumption in patients undergoing anterior cervical spine surgery.

Dorsal Longitudinal T-Myelotomy (Bischof II Technique): A Useful, Antiquated Procedure for the Treatment of Intractable Spastic Paraplegia.

OBJECTIVE: Dorsal longitudinal T-myelotomy is a long-established operation to treat severe spastic paraplegia. The present study aimed to report this surgical technique and investigate the efficacy of T-myelotomy for spasticity relief. METHODS: All cases undergoing T-myelotomy for treatment of intractable spastic paraplegia during 2009-2017 were included. The severity of spasticity was evaluated with the Modified Ashworth Scale, Penn Spasm Frequency Scale, Adductor Tone Rating Scale, degree of passive range of motion, and occurrence of abdominal muscle spasms. Other clinical assessments included deep tendon reflex assessed by the National Institute of Neurological Disorders and Stroke scale, Babinski sign, healing of decubitus ulcers, and ambulatory status. RESULTS: Fourteen patients with a mean age of 39.3 ± 13.4 years were included. The 7 patients with abdominal muscle spasms before surgery had no spasms after surgery. The Babinski sign was absent in all cases after surgery. Unhealed pressure ulcers in all 9 cases were healed after surgery. All 4 patients with a preoperative bed-bound condition were able to ambulate with a wheelchair. A statistically significant improvement in mean Modified Ashworth Scale score, degree of passive range of motion, and National Institute of Neurological Disorders and Stroke scale score was found in the subgroup and overall analyses. There was also a statistically significant improvement in the Penn Spasm Frequency Scale and Adductor Tone Rating Scale scores. CONCLUSIONS: Dorsal longitudinal T-myelotomy remains an effective option for the treatment of intractable spastic paraplegia. It is suitable for, and may be an alternative to, intrathecal baclofen therapy for patients with complete spinal cord lesion or patients without hope of regaining motor function.

Comparison of efficacy between dorsal root entry zone lesioning and selective dorsal rhizotomy for spasticity of cerebral origin.

BACKGROUND: Severe spasticity adversely affects patient functional status and caregiving. No previous study has compared efficacy between dorsal root entry zone lesioning (DREZL) and selective dorsal rhizotomy (SDR) for reduction of spasticity. This study aimed to investigate the efficacy of DREZL and SDR for attenuating spasticity, and to compare efficacy between these two methods. METHODS: All patients who underwent DREZL, SDR, or both for treatment of intractable spasticity caused by cerebral pathology at Siriraj Hospital during 2009 to 2016 were recruited. Severity of spasticity was assessed using Modified Ashworth Scale (MAS) and Adductor Tone Rating Scale (ATRS). Ambulatory status was also evaluated. RESULTS: Fifteen patients (13 males) with a mean age of 30.3 ± 17.5 years were included. Eight, six, and one patient underwent DREZL, SDR, and combined cervical DREZL and lumbosacral SDR, respectively. Eight of ten patients with preoperative bed-bound status had postoperative improvement in ambulatory status. Spasticity was significantly reduced in the DREZL group (p < 0.001), the SDR group (p < 0.001), and in overall analysis (p < 0.001). SDR was effective in both pediatric and adult spasticity patients. A significantly greater reduction in spasticity as assessed by MAS score (p < 0.001) and ATRS score (p = 0.015) was found in the DREZL group. Transient lower limb weakness was found in a patient who underwent SDR. CONCLUSIONS: DREZL is more effective for reducing spasticity, but is more destructive than SDR. DREZL should be preferred for bed-ridden patients, and SDR for ambulatory patients. Both operations are helpful for improving ambulatory status. Gait improvement was observed only in patients who underwent SDR. Adult patients with spasticity of cerebral origin benefit from SDR.

The therapeutic effects of ablative neurosurgical procedures on the spinal cord for intractable spinal spasticity.

STUDY DESIGN: This research is a retrospective study. OBJECTIVE: To study the therapeutic effects of operative procedures, including dorsal longitudinal myelotomy (DLM) and dorsal root entry zone lesion (DREZL) on spasticity and associated aspects. SETTING: Tertiary university hospital in Bangkok, Thailand. METHODS: Eighteen patients with refractory spasticity of spinal origin who underwent the operations were recruited. Clinical parameters for evaluating severity of spasticity and ambulatory status were compared between before and after surgery, and between surgeries. RESULTS: A statistically significant reduction of spasticity as measured by the Modified Ashworth Scale (MAS), Adductor Tone Rating Scale (ATRS) and Penn Spasm Frequency Scale (PSFS) was found after surgeries and in the overall analysis (p < 0.05). Chronic pressure ulcers disappeared postoperatively in 11 cases. All of 7 bed-ridden subjects experienced improvement in their ambulatory status postoperatively. DLM was found to be more effective than DREZL in reduction of spasticity. CONCLUSION: Ablative neurosurgery on the spinal cord is still valuable in situations when intrathecal baclofen is unavailable. These operations are potentially effective in the treatment of intractable spasticity of spinal origin.

Predictors of meningioma consistency: A study in 243 consecutive cases.

BACKGROUND: Meningioma is a common neoplasm primarily arising in the central nervous system. Its consistency is considered to be one of the critical prognostic factors for determining surgical resectability. The present study endeavored to investigate predictive factors associated with the tumor consistency. METHODS: Two hundred and forty-three consecutive participants who underwent resective surgery of meningioma were examined. The authors designed an objective grading system for meningioma consistency and utilized it for assessing consistency among all cases. We focused on the relationship between preoperative tumor characteristics on neuroimaging studies and the consistency. RESULTS: The tumor attributes on T2-weighted image (T2WI) and fluid attenuated inversion recovery (FLAIR) image were significantly correlated with the tumor consistency (p = 0.004 and 0.045, respectively). The hypointense tumors on both MRI sequences tended to be hard, whereas the tumors showing hypersignal intensity were associated with soft consistency. There was no correlation between the consistency and age, gender, duration of neurologic symptoms, tumor location, size, calcification, cystic portion, en plague appearance, tumor-brain contact interface expressed by cerebrospinal fluid (CSF) cleft, perilesional vasogenic edema, bony status, features on T1-weighted image (T1WI) and pattern of contrast enhancement. In multiple logistic regression analysis, the tumor characteristics on T2WI and FLAIR image were independent factors significantly correlated with the tumor consistency (p = 0.005 and 0.041, respectively). The tumor consistency was also correlated with operative radicalness as evaluated by the Simpson criteria. CONCLUSIONS: Signal intensity on T2WI and FLAIR image can be used for insinuating meningioma consistency. Presurgical prediction of the consistency is highly valuable in operative planning, particularly in arduous cases.

Posterior C1-C2 fusion using C1 lateral mass and C2 pars screw with rod fixation: techniques and outcomes.

OBJECTIVE: The atlantoaxial instability often requires posterior fixation surgery. Multiple techniques have been described for C1-C2 fixation. Transarticular atlantoaxial screw has been demonstrated to be effective for C1-C2 stabilization. However, up to 20% of patients are not candidates for the procedure. New technique concerning the placement of individual screws in CI lateral mass and C2 pars screw with additional rods for their connection was described, either as a salvage method for unsuccessful C1-C2 stabilization or as an effective alternative technique. The authors presented their experience using C1 lateral mass and C2 pars screws with rod fixation for C1-C2 stabilization. MATERIAL AND METHOD: Between May 2007 and October 2008, 10 patients (7 male, 3 female) whose age ranged from 15 to 59 years-old underwent posterior fixation using C1 lateral mass and C2 pars screw with rod fixation. Six patients had atlantoaxial subluxation due to os odontoideum, two patients had chronic C1-C2 subluxation, and two patients had acute CI-C2 subluxation from a motor vehicle accident. All screws were placed under lateral fluoroscopic guidance. RESULTS: C1 lateral mass and C2 pars screw with rod fixation were used to achieve C1-C2 stabilization in all patients. All screws were positioned correctly in both C1 and C2. There were no permanent complications. In all cases, rigid fixation was confirmed on postoperative radiographs and maintained on follow-up radiographs. CONCLUSION: The lateral mass and C2 pars screw with rod fixation is an effective method of stabilizing the atlantoaxial complex. This procedure provides rigid fixation with relative safety.

Accuracy of various subthalamic nucleus targeting methods and an appropriated formula for Thai patients.

OBJECTIVE: Deep brain stimulation (DBS) of the subthalamic nucleus (STN) has recently been the standard surgical treatment for Parkinson's disease. Besides appropriate selection of patients, precise STN targeting is the most crucial factor for good surgical outcomes. However, there is no single targeting method universally accepted as the most accurate technique. Thus, the authors studied the accuracy of various STN targeting methods and proposed a formula for Thai patients. MATERIAL AND METHOD: Sixteen patients with Parkinson's disease who fulfilled the intraoperative criteria of good STN targeting and had significant clinical improvements, without any stimulation-induced adverse effects, were included in the present study. Positions of the STN were determined by four targeting methods, direct targeting by axial T2W MRI, direct targeting by coronal T2W MRI, indirect targeting by anterior commissure-posterior commissure based formula and indirect targeting by adjustable digital Schaltenbrand-Wahren (SW) atlas, were compared with the final lead positions. The final lead positions by the four targeting methods were averaged to get an appropriate AC-PC based formula for Thai patients. RESULTS: The most accurate STN targeting method was axial T2W MRL followed by coronal T2W MRI, AC-PC based formula and the SW atlas, respectively. The averaged final lead positions obtained from the four methods was X = 11.5 +/- 1.0, Y = -3.3 +/- 1.0 and Z = -4.8 +/- 0.42 mm. CONCLUSION: The direct targeting by axial T2W MRI yielded the highest accuracy and the appropriate STN formula for Thai patients appeared to be X = +/- 11.5, Y = -3.5 (-3.3) and Z = -5.0 (-4.8) mm.

Regeneration into protected and chronically denervated peripheral nerve stumps.

OBJECTIVE: Delayed repair of peripheral nerve injuries often results in poor motor functional recovery. This may be a result of the deterioration or loss of endoneurial pathways in the distal nerve stump before motor axons can regenerate into the stump. METHODS: Using the rat femoral nerve, we protected distal endoneurial pathways of the saphenous nerve with either cross-suture of the quadriceps motor nerve (Group A) or resuture of the saphenous nerve (Group B) to compare later motor regeneration into the "protected" saphenous nerve pathway to chronic denervation and "unprotected" saphenous nerve (Group C). A total of 60 rats, 20 per group, were operated on. After this protection (or lack thereof) for 8 weeks, the motor branch of the femoral nerve was cut and sutured to the distal saphenous nerve to allow motor regeneration into protected and unprotected saphenous nerve stumps. The quantitative assessment of axonal regeneration was performed after 6 weeks by use of nerve sampling for axon counts and retrogradely labeled motor neuron counts. RESULTS: Significantly more myelinated axons innervated the motor (A) than the sensory (B) and no-protection (C) groups. There were significantly more retrogradely labeled femoral motor neurons in Group A than in the unprotected group (C). CONCLUSION: We conclude that even 2 months of denervation of the distal nerve pathway is deleterious to regeneration and that protection of the pathway improves subsequent reinnervation and regeneration. Moreover, if the desired regeneration is motor, protection of the distal nerve pathway by a motor nerve conditions is better than a sensory nerve.