[Clinical analysis of the adolescent patients with multi-segments intramedullary spinal cord tumors].

OBJECTIVE: To prospectively analyze the clinical features and characteristics of multi-segments intramedullary spinal cord tumors in adolescent patients. METHODS: In our study, 25 consecutive adolescent patients with multi-segments intramedullary spinal cord tumors were recruited, who underwent microsurgery for the tumor using a posterior approach and were hospitalized in Peking University Third Hospital within a period of 8 years. The tumor was exposed through dorsal myelotomy. Preoperative and postoperative neurological functions were scored using the improved Japanese orthopaedic association score system (IJOA) grading system. The functional outcome was defined as postoperative IJOA score minus preoperative IJOA score. All the patients were followed-up until Oct. 30, 2011. RESULTS: There were 15 male and 10 female adolescent patients younger than 25 years. Their mean age was (15.3±6.83) years. The most common initial symptom was sensory disturbance (including pain and/or numbness, 52%, 13/25), followed by motor disturbance (including limbs weakness and gait deterioration, 24%, 6/25), pain and motor disturbance (12%, 3/25), as well as fever, limbs deformities, and sphincter dysfunction, respectively. The preoperative IJOA scores of the patients were (14.4±3.38). The postoperative IJOA scores of the patients were (15.5±3.31). The most commonly involved location was the cervicothoracic segments (36%, 9/25), followed by the conus terminalis (24%, 6/25), the cervical region(16%, 4/25), the thoracic region (16%, 4/25), and the lumbus region (8%, 2/25). The average involved segments were (4.4±1.38). The most frequent tumors were neurodevelopmental tumors (including lipoma, epidermoid cyst and teratoma) (32%, 8/25), followed by astrocytomas (28%, 7/25), ependymomas (20%, 5/25), hemangioblastomas (12%, 3/25), and glioblastomas and schwannomas, respectively. CONCLUSION: In adolescent patients with multi-segments intramedullary spinal cord tumors, the most commonly involved locations are the cervicothoracic segments and the conus terminalis, while the most frequent tumors are neurodevelopmental tumors and astrocytomas. Good prognosis in adolescent patients is observed in a long-term follow-up.

Comparative analysis on the diagnosis and treatments of multisegment intramedullary spinal cord tumors between the different age groups.

Multisegment intramedullary spinal cord tumors (MSICT) are a special type of spinal cord tumor. Up to now, no comparative clinical study of MSICT has been performed according to different age groups. Seventy-seven patients underwent microsurgery for MSICT. As grouped with two different methods, the parametric and nonparametric data of MSICT and patients were comparatively analyzed using statistically correlative methods. Forty-eight patients were males and 29 were females, ranging in age from 4 to 64 years (mean, 32.9 years). Among the six groups, being divided with intervals of 10 years, the whole difference in the initial symptoms of patients (Z = 17.4, P = 0.004) and in the histological classification of tumors (Z = 12.5, P = 0.03) was statistically significant, respectively. Neurodevelopmental tumor and benign glioma predominated in adolescents and decreased in frequency into adulthood where ependymoma became more predominant. In the 25 years old grouping method, there were 27 adolescent and 50 adult patients. The difference in initial symptoms of patients (Z = -2.08, P = 0.04) was statistically significant between the two groups. Pain with motor weakness and gait deterioration predominated in adolescents and decreased in frequency into adulthood where sensory disturbances became more predominant.

[Comparative analysis between multi-segments intramedullary spinal cord congenital tumors and benign ependymomas].

OBJECTIVE: To comparatively analyze the different and common points between multi-segments intramedullary spinal cord congenital tumors and benign ependymomas, such as the patient's age, gender, nervous functions and tumor location, longitudinal extension, and removed extent. METHODS: Data were studied from 12 patients with multi-segments intramedullary spinal cord congenital tumors and 19 patients with multi-segments intramedullary spinal cord benign ependymomas who underwent microsurgery for the tumor using a posterior approach. The tumor was exposed through dorsal myelotomy. Preoperative and postoperative nervous functions were scored using the Improved JOA (improved Japanese orthopaedic association, IJOA) score system. Independent sample t-test was performed for ages, preoperative IJOA scores, postoperative IJOA scores and IJOA difference values of the patients, and longitudinal extension of tumors in the two groups with congenital tumors and benign ependymomas. Two independent sample Mann-Whitney tests was performed for the patient's gender, stool and urine functions, limbs weakness, and tumor removed extent in the two groups. All patients were followed-up until June 30, 2009. RESULTS: The average age of patients in congenital tumors group was 23.5+/-14.3, and in benign ependymomas group was 37.8+/-12.9, the age difference between the two groups was statistically significant (t=-2.89, P=0.007). The difference for location (Z=-3.59, P=0.001) and removed extent (Z=-2.89, P=0.004) of tumors between the two groups was statistically significant. Those located at the conus accounted for almost 83.3% (10/12) multi-segments intramedullary spinal cord congenital tumors. Because of the stiff adhesion with adjacent neural structures or penetrative growth in surrounding spinal marrow, some congenital tumors could not totally removed by force. The main purpose of surgery for these tumors was not total removal but decompression on the adjacent neural structures. Total or nearly total resection was achieved in 66.7% (8/12) patients diagnosed with congenital tumors. 78.9 (15/19) percent of multi-segments intramedullary spinal cord benign ependymomas were located at the cervical and cervicothoracic segments. Total or nearly total resection was achieved in 94.7% (18/19) patients with benign ependymomas. CONCLUSION: It is known from the clinical files that most multi-segments intramedullary spinal cord congenital tumors are found in young patients and most benign ependymomas in the middle-aged. Most congenital tumors are located at the conus, and they are difficult to totally remove. Most benign ependymomas are located at the cervical and cervicothoracic segments, and they are easy to totally remove.

Discectomy versus discectomy with fusion versus discectomy with fusion and instrumentation: a prospective randomized study.

OBJECTIVE: The need for interbody fusion after anterior cervical discectomy for radiculopathy remains controversial. The purpose of this study was to assess clinical and radiographic outcomes in patients with cervical radiculopathy after discectomy without fusion (ACD), discectomy with intervertebral fusion (ACDF), and discectomy with intervertebral fusion and instrumentation (ACDFI). METHODS: Forty-two consecutive patients with cervical radiculopathy who failed medical management were randomized to one of three treatment groups: ACD, ACDF, or ACDFI. Indices including symptoms, work status, Short Form-36, McGill pain scores, and anteroposterior/lateral flexion/extension x-rays were obtained preoperatively and during the follow-up period. RESULTS: There were no inter-group differences observed during the 2-year follow-up period with respect to neck pain, interscapular pain, or arm pain (P > 0.05). Short Form-36 scores demonstrated a dramatic postoperative improvement followed by further gradual improvement in both physical and mental components as well as other subscale scores in all groups during the follow-up period (P < 0.05). Fusion occurred in 67% of the ACD patients compared with 93% of the ACDF patients and 100% of the ACDFI patients (P < 0.05). Segmental kyphosis was noted in 75% of the ACD patients postoperatively compared with 17% preoperatively. There was no change in sagittal balance in the ACDF or ACDFI groups (P > 0.05). CONCLUSION: Patient selection and surgical decompression remain the key to achieving desirable clinical outcomes after cervical discectomy for radiculopathy. Within a 2-year follow-up period, the technique of reconstruction plays no role in clinical results. However, ACD alone results in segmental kyphosis compared with ACDF and ACDFI.

Cerebrospinal fluid dynamics in Chiari malformation associated with syringomyelia.

BACKGROUND: About 50% - 70% of patients with Chiari malformation I (CMI) presented with syringomyelia (SM), which is supposed to be related to abnormal cerebrospinal fluid (CSF) flow around the foramen magnum. The aim of this study was to investigate the cerebrospinal fluid dynamics at levels of the aqueduct and upper cervical spine in patients with CMI associated with SM, and to discuss the possible mechanism of formation of SM. METHODS: From January to April 2004, we examined 10 adult patients with symptomatic CMI associated with SM and 10 healthy volunteers by phase-contrast MRI. CSF flow patterns were evaluated at seven regions of interest (ROI): the aqueduct and ventral and dorsal subarachnoid spaces of the spine at levels of the cerebellar tonsil, C2 - 3, and C5 - 6. The CSF flow waveforms were analyzed by measuring CSF circulation time, durations and maximum velocities of cranial- and caudal-directed flows, and the ratio between the two maximum velocities. Data were analyzed by t test using SPSS 11.5. RESULTS: We found no definite communication between the fourth ventricle and syringomyelia by MRI in the 10 patients. In both the groups, we observed cranial-directed flow of CSF in the early cardiac systolic phase, which changed the direction from cranial to caudal from the middle systolic phase to the early diastolic phase, and then turned back in cranial direction in the late diastolic phase. The CSF flow disappeared at the dorsal ROI at the level of C2 - 3 in 3 patients and 1 volunteer, and at the level of C5 - 6 in 6 patients and 3 volunteers. The durations of CSF circulation at all the ROIs were significantly shorter in the patients than those in the healthy volunteers (P = 0.014 at the midbrain aqueduct, P = 0.019 at the inferior margin of the cerebellar tonsil, P = 0.014 at the level of C2 - 3, and P = 0.022 at the level of C5 - 6). No significant difference existed between the two groups in the initial point and duration of the caudal-directed CSF flow during a cardiac cycle at all the ROIs. The maximum velocities of both cranial- and caudal-directed CSF flows were significantly higher in the patients than those in the volunteers at the aqueduct (P = 0.018 and P = 0.007) and ventral ROI at the inferior margin of the cerebellar tonsil (P < 0.001 and P = 0.002), as so did the maximum velocities of the caudal-directed flow in the ventral and dorsal ROIs at the level of C2 - 3 (P = 0.004; P = 0.007). CONCLUSIONS: The direction of CSF flow changes in accordance with cardiac cycle. The syringomyelia in patients with CMI may be due to the decreased circulation time and abnormal dynamics of the CSF in the upper cervical segment. The decompression of the foramen magnum with dural plasty is an alternative for patients with CMI associated with SM.

[Changes in cerebral oxygen metabolism and significance in patients with severe head injury].

OBJECTIVE: To investigate the changes in cerebral oxygen metabolism following head injury and their relationship with intracranial pressure (ICP), cerebral perfusion pressure (CPP), and Glasgow coma scale (GCS). METHODS: Forty-five patients after surgery for serious head injury were studied and divided into different groups according to ICP, CPP and GCS, 10 patients without head injury were enrolled as controls. GCS, ICP, CPP, blood gas analysis, jugular bulb for gas analysis, jugular bulb blood oxygen saturation (SjvO(2)), cerebral arterial venous oxygen content difference (AVDO(2)) were accessed and scored, and cerebral extraction of oxygen (CEO(2)) were calculated in all the patients. The relationships of these parameters with ICP, CPP and GCS score were analysed. RESULTS: On the 1 st postinjury day SjvO(2) decreased whereas CEO(2) and AVDO(2) increased in all patients, with significant differences compared with the controls (all P<0.05). During the 2nd-4th postoperative days, SjvO(2) gradually increased with CEO(2) and AVDO(2) decreased in patients with mild or moderate head injury of increased in ICP or lowered in CPP group, the changes in the above parameters were slower, with significant difference compared with patients with increase in ICP, and mild or moderate lowering of CPP (all P<0.05). There were significant differences in SjvO(2), CEO(2), and AVDO(2) between the group of GCS<5 and GCS>6-8 during the 2nd-5th days (all P<0.05). ICP was negatively correlated with SjvO(2) (r=-0.8652, P<0.01) and positively correlated with CEO(2) (r=0.4172, P<0.05) and AVDO(2) (r=0.4771, P<0.05). CPP was positively correlated with SjvO(2) (r=0.8830, P<0.01) and negatively correlated with CEO(2) (r=-0.6724, P<0.05) and AVDO(2) (r=-0.8350, P<0.01). GCS score was positively correlated with SjvO(2) (r=0.8230, P<0.01) and CEO(2) (r=0.8010, P<0.001), but there was no correlation between GCS score and AVDO(2) (r=2.6310, P=0.677). CONCLUSION: In patients with serious head injury, if the increase in ICP is mild or moderate, there are cerebral hypoxia and ischemia during the first 24 hours after injury. During the 2 nd-4 th postinjury days, the brain becomes hyperemic and hyperoxygenated. Marked increase in ICP results in persistent cerebral hypoxia and ischemia. ICP, CPP and GCS score are main factors affecting cerebral oxygen metabolism.

Microsurgery on foramen magnum meningioma with suboccipital.

OBJECTIVE: To analyze which factors influence the operative outcome, and compare advantages and disadvantages of relative surgical approaches. METHODS: Eleven cases with the foramen magnum meningioma were operated by using posterior approach with lateral extension. RESULTS: Complete removal of the tumor was performed in 7 patients (7/11, 64%), subtotal resection in 2 cases (2/11, 18%) and partial resection in 2 cases (2/11, 18%). There were no operative death and significant complication. CONCLUSION: The posterior approach with lateral enlargement is sufficient to expose and remove foramen magnum tumors without expensive bone resection.