[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.

[Changes of swallowing function and their significance in Chiari I malformation patients with dysphagia after decompression surgery].

OBJECTIVE: To survey changes of swallowing function and their significance in Chiari I malformation patients with dysphagia after Atlanto-occipital Decompression with Duraplasty by comparing water swallowing test results and other clinical features before and after surgery. METHODS: From January 2007 to July 2010, 126 Chiari I malformation patients were treated in Neurosurgery Department of Peking University Third Hospital. Clinical data were prospectively analyzed. There were 34 cases (26.9%, 34/126) with varying severity of dysphagia. All of those patients underwent Atlanto-occipital Decompression with Duraplasty. Water swallowing tests were performed 1 day before operation and after 7-10 days to assess dysphagia severity. The improvements of other major symptoms and signs after surgery were also compared. RESULTS: Postoperative dysphagia was improved in 23 cases (67.6%, 23/34), and drinking water test score of preoperation was (2.74±1.11). The score was significantly reduced to (1.71±0.91) after the operation (P<0.05). Other major symptoms and signs were analyzed by Fisher's exact test which showed that only neck and shoulder pain (P=0.01) improved significantly, compared with preoperation. CONCLUSION: Indeed part of the Chiari I malformation patients suffer from varying severity of dysphagia. The detailed clinical history collection and physical examination may improve the initial detection rate of dysphagia. Water swallow test is useful to quantify the degree of dysphagia. Atlanto-occipital Decompression with Duraplasty can improve treatment of Chiari I malformation patients with dysphagia. Improvement in treating dysphagia shortly after operation may be an effective index to evaluate the effect of surgery.

[Surgery strategy about C1-2 dumbbell tumor].

OBJECTIVE: To study the operation of C1-2 dumbbell-shaped tumor, and its effect on the cervical spine stability. METHODS: Different surgical tumor resection was selected according to the tumor size and the invasion scope. Hemilaminectomy was the first choice for the resection of the tumor at intr-extraspinal canal in the conventional prone position. After the tumor was fully revealed, the epidural tumor was removed first with enough space to be vacated, then the subdural section was removed. If the tumor in the spinal canal was more than half of the spinal canal, to prevent spinal cord injury, the part of the C1-2 spinous process base should be removed to facilitate the exposure. Dural defect should be repaired and the muscle sutured to achieve anatomic reduction in order to facilitate the stability of the cervical spine. Lateral approach should be combined to resect the tumor if its total removal was impossible as the tumor had invaded the spinal canal outside over 4 cm or completely surrounded the vertebral artery. RESULTS: C1-2 dumbbell-type tumors were treated in 16 cases, of which 12 were of schwannoma, 3 of meningioma and 1 of ganglion cell tumor. Total resection was in 14 cases, and subtotal resection in 2. After operation, the symptoms of pain in the neck and upper limb muscle weakness were relieved. All the patients were followed up. The follow-up period was 3-48 months. No cervical spine instability or tumor recurrence was found. CONCLUSION: C1-2 dumbbell-shaped tumors could be well resected by poster-median hemilamiectomy approach or joint lateral approach , and the stability of cervical spine could be better maintained at the same time.

[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.

[A case of peripheral T cell lymphomas-unspecified in vertebra canal].

Peripheral T cell lymphomas-unspecified (PTCL-U) is an uncommon malignant tumor, accounting for 5%-7% of non-Hodgkin's lymphoma. Clinical feature of a case of PTCL-U was investigated and the optimal treatment protocol was proposed. The clinical presentation of this case was progressing limbs weakness with sudden paralysis. Multiple superficial lymph nodes swelling and decreased sensation in all modalities below T10 level were found in physical examination. Bilateral leg paralysis (Grade 0/5) with high muscle tension, overactive knee reflex, bilateral Babinski sign (+) were present. Magnetic resonance imaging(MRI) showed the mass, which was around spinal cord located in T6-T8 vertebra canal, with intense enhancement after the administration of gadolinium diethylenetriamine penta-acetic acid. Abnormal signal in multiple centrum and accessories could also be found in MRI scan. Initial diagnosis was lymphoma, multiple systems involved. Laminectomy and epidural tumor resection were performed immediately. The dural sac was narrowed obviously by surrounding tumor. The result of pathological examination was PTCL-U. After operation, the level of pain sensation was descent, and touch sensation recovered. The patient received chemotherapy and his muscle strength was partly recovered in 4 months. Early diagnosis of peripheral T cell lymphomas-unspecified was difficult and easily misdiagnosed with poor prognosis. A review of literature showed central nervous system lesions occurred in advanced stage. However, the report of representation of intraspinal mass as initial symptom like the case was rare. For acute paraplegia, laminectomy and tumor resection should be performed as soon as possible. Regular radiotherapy and chemotherapy should be considered after operation. However, the value of local chemotherapy need to be further investigated.

[Inhibiting cerebral glioma growth with continuous low-dose chemotherapy and cyclooxygenase-2 inhibitor in nude mice].

OBJECTIVE: To observe the changes in glioma growth characteristic and apoptosis of tumor cells after single handed continuous low-dose chemotherapy, cyclooxygenase-2 inhibitor treatment alone and the combination of the two treatments. METHODS: The U251MG cells in exponential phase of growth were made into 10(7)/mL cell suspension in free-serum 1640 and stored in 37 degrees C incubator. The survival rate of cells was above 95%. The U251MG cells were implanted into the right parietooccipital lobe of the 4-week old nude mouse with a 5 micro liter micro amount sample injector. The number of injected U251MG cells was 5 x 10(4) for a mouse. Twenty days after the model making, the nude mice were treated with elemene and indometacin respectively and the combination of them, twice a week. The mice were divided into four groups. Group I was treated with indometacin alone, group II elemene alone, group III low-dose elemene plus indometacin, Group IV was used as controls, including tumor control and blank control. The animals were killed on the 40th and 50th day after implantation by breaking cervical vertebra. The fixed brain was made into 3 microm slices by paraffin section. The slices were carried out with HE staining and immunohistochemical staining of glial fibrillary acidic protein(GFAP), cell proliferation-associated antigen(Ki-67), cyclooxygenase-2(COX-2), CD34, programmed cell death 5(PDCD5) and terminal deoxynucleotidyl transferase mediated dUTP-biotin nick end labeling(TUNEL). RESULTS: The proliferation of glioma cells was predominant in the tumor control mouse brain. Several immature blood vessels were observed in the tumor implanted for 40 days. The white matter was infiltrated by bulk glioma cells along with capillary vessel clusters in the mouse brain implanted for 50 days. In groups with combination treatment of the two drugs, 40 days after the implantation, several apoptosis cells and glioma cells were observed in tumor where the positive signal for GFAP was showed; and 50 days after the implantation, lots of apoptosis cells were observed in tumor cell implantation area where the negative signal for GFAP and positive signal for PDCD5 was showed. The volume of tumor was (29.8+/-39.1) mm(3) 40 days after the implantation, and (78.4+/-125.9) mm(3) 50 days after the implantation. There was no statistically significant difference in tumor volume among groups(P=0.11). CONCLUSION: The combination of two treatments could merely prolong the survival time of the nude mouse model, without the effect of eliminating the tumor completely.

[Duraplasty with Neuropatch versus autologous fascia lata for Chiari I malformation with syringomyelia: a comparative study].

OBJECTIVE: To evaluate the outcome and postoperative reaction of dural substitute (Neuropatch) applying in the treatment of Chiari I malformation(CMI) associated with syringomyelia(SM). METHODS: Forty patients of CMI associated with SM were operated in our department from Jul. 2002 to Jul. 2004. All patients underwent posterior cranial fossa decompression and duraplasty. They were divided into two groups, 20 patients being repaired with Neuropatch (Neuropatch group), and the others with autologous fascia lata (fascia group). There were 6 males and 14 females in Neuropatch group and 10 males and 10 females in fascia group. The operations were performed under general anesthesia via suboccipital approach and the extent of posterior cranial fossa decompression ranged from 20 cm(2) (5 cmx4 cm) to 35 cm(2) (5 cmx7 cm). The removal of posterior arch of atlas depended on the extent of tonsillar herniation, and the dura was opened in Y shape. The Neuropatch was cut into triangular shape, and the same sized autologous fascia lata was used in fascia group. The patches were sutured tightly to the dura matter in each group. The incision was closed layer by layer and drainage was used, if necessary. Antibiotics and hormone were routinely used. The duration of operation, postoperative fever were evaluated, the outcome of the operation was evaluated by Tator scale, and the data were analyzed with statistic software SPSS 10.0. RESULTS: There were12 patients (60%) who suffered from postoperative fever in the Neuropatch group, and 9 patients (45%) in the fascia group(chi(2)=0.902,P=0.342). Seventeen patients in each group were improved postoperatively. The duration of operation, postoperative fever and antibiotics used were compared between the two groups. No significant difference was found, but the duration of postoperative fever and the time of hormone used were different. There were no postoperative infections that occurred after the follow up for 1 to 2 years, except for one patient in fascia group who developed infective granuloma and recovered later by treatment. CONCLUSION: Neuropatch is a useful dural substitute for the repair of dural defects in the treatment of CMI associated with syringomyelia.

Duraplasty with Neuropatch versus autologous fascia lata for Chiari I malformation with syringomyelia: A comparative study / 北京大学学报(医学版)

Objective: To evaluate the outcome and postoperative reaction of dural substitute (Neuropatch) applying in the treatment of Chiari I malformation(CMI) associated with syringomyelia(SM). Methods:Forty patients of CMI associated with SM were operated in our department from Jul. 2002 to Jul. 2004. All patients underwent posterior cranial fossa decompression and duraplasty. They were divided into two groups, 20 patients being repaired with Neuropatch (Neuropatch group), and the others with autologous fascia lata (fascia group). There were 6 males and 14 females in Neuropatch group and 10 males and 10 females in fascia group. The operations were performed under general anesthesia via suboccipital approach and the extent of posterior cranial fossa decompression ranged from 20 cm2 (5 cm×4 cm) to 35 cm2 (5 cm×7 cm). The removal of posterior arch of atlas depended on the extent of tonsillar herniation, and the dura was opened in Y shape. The Neuropatch was cut into triangular shape, and the same sized autologous fascia lata was used in fascia group. The patches were sutured tightly to the dura matter in each group. The incision was closed layer by layer and drainage was used, if necessary. Antibiotics and hormone were routinely used. The duration of operation, postoperative fever were evaluated, the outcome of the operation was evaluated by Tator scale, and the data were analyzed with statistic software SPSS 10.0. Results: There were12 patients (60%) who suffered from postoperative fever in the Neuropatch group, and 9 patients (45%) in the fascia group(χ2=0.902,P=0.342). Seventeen patients in each group were improved postoperatively. The duration of operation, postoperative fever and antibiotics used were compared between the two groups. No significant difference was found, but the duration of postoperative fever and the time of hormone used were different. There were no postoperative infections that occurred after the follow up for 1 to 2 years, except for one patient in fascia group who developed infective granuloma and recovered later by treatment. Conclusion: Neuropatch is a useful dural substitute for the repair of dural defects in the treatment of CMI associated with syringomyelia.

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.