Conjoined lumbosacral nerve root: a case report.

BACKGROUND: In patients with conjoined nerve roots, hemilaminectomy with sufficient exposure of the intervertebral foramen or lateral recess is required to prevent destabilization and ensure correct mobility of the lumbosacral spine. To the best of our knowledge, no case reports have detailed the long-term course of conjoined nerve roots after surgery. CASE PRESENTATION: We report the case of a 51-year-old Japanese man with a conjoined nerve root. The main symptoms were acute low back pain, radiating pain, and right leg muscle weakness. Partial laminectomy was performed with adequate exposure to the conjoined nerve root. The symptoms completely resolved immediately after surgery. However, the same symptoms recurred 7 years postoperatively. The nerve root was compressed because of foraminal stenosis resulting from L5-S disc degeneration. L5-S transforaminal lumbar interbody fusion was performed on the contralateral side because of an immobile conjoined nerve root. At 44 months after the second surgery, the patient had no low back pain or radiating pain, and the muscle weakness in the right leg had improved. CONCLUSIONS: This is the first report of the long-term course of conjoined nerve root after partial laminectomy. When foraminal stenosis occurs after partial laminectomy, transforaminal lumbar interbody fusion from the contralateral side may be required because of an immobile conjoined nerve root.

Decompression for lumbar spinal stenosis at the intrathecal catheter insertion site during intrathecal baclofen therapy: a case report.

BACKGROUND: Intrathecal baclofen therapy can substantially improve symptoms in most patients with severe spasticity due to traumatic spinal cord injury, multiple sclerosis, or cerebral paresis. To the best of our knowledge, decompression surgeries at the intrathecal catheter insertion site in patients with a preexisting intrathecal pump for drug delivery have not been reported. CASE PRESENTATION: We report the case of a 61-year-old Japanese man with lumbar spinal stenosis who underwent intrathecal baclofen therapy. We performed decompression for lumbar spinal stenosis at the intrathecal catheter insertion site during intrathecal baclofen therapy. The yellow ligament was removed by partial resection of the lamina under a microscope to avoid damage to the intrathecal catheter. The dura mater was distended. No obvious cerebrospinal fluid leakage was observed. Postoperatively, lumbar spinal stenosis symptoms improved, and spasticity remained well controlled with intrathecal baclofen therapy. CONCLUSIONS: This is the first reported case of lumbar spinal stenosis decompression at an intrathecal catheter insertion site during intrathecal baclofen therapy. Preoperative preparation is necessary, as the intrathecal catheter may be replaced during surgery. We performed surgery without removing or replacing the intrathecal catheter, taking care not to damage the spinal cord by migrating the intrathecal catheter.

The prevalence of locomotive syndrome and its associated factors in patients with Type 2 diabetes mellitus.

OBJECTIVES: We investigated the prevalence of locomotive syndrome (LS) and related musculoskeletal diseases [osteoarthritis (OA), lumbar spondylosis, and spinal alignment] in Type 2 diabetes mellitus (DM) patients. METHODS: Clinical data were collected from 101 patients (55 males; 46 females) admitted to our hospital for diabetes education from October 2018 to April 2021. Patients underwent full-spine and whole-legs standing radiography and physical measurements (10-m walking and grip strength tests and three LS risk tests). RESULTS: The estimated prevalence of LS was 86.1% (Stage 1: 44.5%, Stage 2: 41.6%), lumbar spondylosis was 11.9%, and hip, knee, and ankle OA were 16.9%, 51.5%, and 12.9%, respectively. Multiple logistic regression analysis identified grip strength [odds ratio (OR) = 0.89, confidence interval (CI) = 0.83-0.94], diabetic retinopathy (OR = 5.85, CI = 1.64-20.78), knee OA (OR = 3.34, CI = 1.11-10.02), and a sagittal vertical axis >40 mm (OR = 3.42, CI = 1.13-10.39) as significantly associated risk factors for worsening LS in Type 2 DM patients. CONCLUSIONS: This study clarified the epidemiological indicators of LS and associated factors in DM patients. Exercise therapy and DM management are effective strategies to reduce the occurrence and progression of LS.

Evaluation of factors related to morphological masseter muscle changes after preoperative orthodontic treatment in female patients with skeletal class III dentofacial deformities.

BACKGROUND: The purpose of the current study was to investigate factors related to morphological changes in the masseter muscle after preoperative orthodontic treatment in patients with skeletal class III dentofacial deformities for analysis of muscle changes and malocclusions. METHODS: Twenty female patients with dentofacial deformities were included in the study. Computed tomography was performed before and after preoperative orthodontic treatment, and the lengths, widths, and cross-sectional areas of the masseter muscles were measured. Changes in these parameters were evaluated, and factors related to changes in masseter muscle area after preoperative orthodontic treatment were analyzed. RESULTS: The lengths, widths, and areas of masseter muscles were significantly smaller after preoperative orthodontic treatment. Smaller masseter muscle area was significantly associated with changes in overbite and pretreatment values of SNA angle. CONCLUSIONS: Atrophy of the masseter muscle during preoperative orthodontic treatment was greater in patients with increased open bite due to improved dental compensation in patients with skeletal class III dentofacial deformities with maxillary retraction.

Bilateral simultaneous asymmetric hip fracture without major trauma in an elderly patient: a case report.

BACKGROUND: Simultaneous bilateral hip fractures without major trauma in the elderly are rare and usually symmetrical. To the best of our knowledge, only two cases of bilateral simultaneous asymmetric hip fracture in the elderly without major trauma have been reported. CASE PRESENTATION: We present the case of a 90-year-old Japanese man with simultaneous bilateral asymmetric hip fractures with trochanteric fracture on the right side and greater trochanteric fracture on the left side. He complained of dyspnea at midnight and was referred to our emergency department. He was admitted to the internal medicine department for bacterial pneumonia treatment. On the 8th day of hospitalization, he was referred to our orthopedic surgery department for hip pain and was found to have fractures of both hips. Computed tomography findings showed that the left femoral neck fracture was an old fracture, while the left greater trochanteric fracture and the right trochanteric fracture were fresh fractures. He was surgically treated through open reduction and internal fixation with an intramedullary nail on the right and hemiarthroplasty on the left in supine position, performed during the same surgical sessions on the 12th day of hospitalization. CONCLUSIONS: We report a new form of simultaneous bilateral asymmetric hip fracture in the elderly. The fracture types of the case were femoral trochanteric fracture and greater trochanteric fracture of the femur, which were different from the fracture types in the previously reported two cases. Clinicians should be aware of the possibility of simultaneous bilateral hip fractures, especially in the elderly.

Anterior cruciate ligament reconstruction with ultrasound-guided femoral nerve block does not adversely affect knee extensor strength beyond that seen with intravenous patient-controlled analgesia at 3 and 6 months postoperatively.

BACKGROUND: This study aimed to investigate the effect of anterior cruciate ligament (ACL) reconstruction with an ultrasound-guided femoral nerve block (FNB) on knee extensor strength weakness 3 and 6 months, and graft rupture in the 1 year following ACL reconstruction. METHODS: One hundred and seven patients who underwent ACL reconstruction were included in this retrospective study. The patients were divided into two groups stratified by the method of postoperative pain management. The FNB group included 66 patients, and there were 41 patients in the intravenous patient-controlled analgesia (iv-PCA) group. The isokinetic peak torque of knee flexor and extensor was measured preoperative, 3 and 6 months after ACL reconstruction. Muscle strength measurements were performed using the BIODEX dynamometer at a velocity of 60°/s and 180°/s. Peak torque of knee extensor and flexor strength, estimated pre-injury capacity (EPIC), body weight ratio (BW), and graft rupture incidence were compared between the two groups. RESULTS: There were no statistically significant differences in the knee extensor and flexor strength for all items at 3 and 6 months after ACL reconstruction. There was also not a statistically significant difference in the graft rupture incidence between the two groups: FNB group was two patients, 3.0% vs. iv-PCA group was one patient, 2.4% (p = 0.86). CONCLUSION: ACL reconstruction with ultrasound-guided FNB does not affect knee extensor strength at 6 months, nor graft rupture at 1 year postoperatively.

The prevalence and impact of sarcopenia in females undergoing total hip arthroplasty: A prospective study.

OBJECTIVES: Although both sarcopenia and hip disease decrease physical function, few studies have investigated the association. We investigated the prevalence of sarcopenia in patients awaiting total hip arthroplasty for osteoarthritis and examined the impact of sarcopenia on pre- and postoperative outcomes. METHODS: This prospective study included 96 females. Participants were classified using two criteria. Cases defined as having sarcopenia by the Asian Working Group for Sarcopenia (AWGS) criteria were categorized as the AWGS-sarcopenia (A-S) group, and others were categorized as the AWGS-non-sarcopenia (A-NS) group. Those classified by hand grip strength (HGS) constituted the lower-HGS (L-H) and normal-HGS (N-H) groups. Patient demographics, physical function, and Japanese Orthopaedic Association (JOA) score were compared between each group. RESULTS: The prevalence of the AWGS sarcopenia was 33.3%. In the pre- and postoperative analyses, the L-H group had significantly poorer physical function and JOA score than the N-H group. Postoperatively, the A-S group only demonstrated poorer HGS. CONCLUSION: Preoperative physical function and JOA score was significantly poorer in the L-H group; physical function was significantly poorer even postoperatively. A HGS test is useful for detecting a decline in the pre- and postoperative physical function in females with hip osteoarthritis.

The effect of gracilis tendon harvesting in addition to semitendinosus tendon harvesting on knee extensor and flexor strength after anterior cruciate ligament reconstruction.

INTRODUCTION: Anterior cruciate ligament (ACL) reconstruction using hamstring tendons may involve harvesting of the gracilis tendon in addition to the semitendinosus tendon (ST) depending on the size of the ST graft. However, the effect of gracilis harvesting in addition to ST harvesting on muscle strength, such as the hamstring-to-quadriceps (HQ) ratio, remains unclear. Hence, this study aimed to investigate the effect of gracilis harvesting on subsequent knee muscle strength. MATERIALS AND METHODS: Eighty-two patients who underwent ACL reconstruction were included in this retrospective study. They were divided into the following two groups depending on the tendon graft used for ACL reconstruction: the ST group (41 patients) and the semitendinosus tendon/gracilis tendon (STG) group (41 patients). The isokinetic peak torque of the knee extensor and flexor was measured using a BIODEX dynamometer at a velocity of 60°/s and 180°/s, respectively, 3 and 6 months after ACL reconstruction. The groups were compared in terms of the limb symmetry index (LSI) and HQ ratio. RESULTS: The significant difference in the knee flexor of the LSI at 6 months after ACL reconstruction was as follows: ST group, 120.3 ± 28.3 vs STG group, 105.6 ± 19.0 (p < 0.01) at 60°/s and ST group, 122.9 ± 35.2 vs STG group, 106.2 ± 24.6 (p = 0.02) at 180°/s. There were significant differences in the HQ ratio at 180°/s as follows: ST group, 0.67 ± 0.15 vs STG group, 0.60 ± 0.13 (p < 0.01) at 3 months and ST group, 0.67 ± 0.13 vs STG group, and 0.59 ± 0.12 (p < 0.01) at 6 months after ACL reconstruction. CONCLUSIONS: Gracilis tendon harvesting may contribute to a decrease in knee flexor strength and HQ ratio with fast contraction. Thus, the need for gracilis tendon harvesting in ACL reconstruction should be carefully considered. LEVEL OF EVIDENCE: III.

Prevalence of low skeletal muscle quantity and quality and their associated factors in patients before allogeneic hematopoietic stem cell transplantation.

Both quality and quantity of skeletal muscle are considered important for prognostic factors and clinical outcomes in solid cancers. However, few studies have examined both quality and quantity of skeletal muscle in patients with hematological malignancies. The aim of the present study was to clarify the prevalence of low skeletal muscle quantity and quality and their associated factors in patients before allogeneic hematopoietic stem cell transplantation (allo-HSCT). Pretransplant plain CT imaging at the third lumber vertebra level was used to measure the psoas muscle mass index (PMI) and the intramuscular adipose tissue content (IMAC) in 113 adult patients (age 47.1 ± 14.6 years) before HSCT. We analyzed the factors associated with PMI and IMAC, respectively. Although 62.8% of all patients had low skeletal muscle mass, only 8% had poor skeletal muscle quality. Multivariable logistic analysis showed that older age [odds ratio (OR) = 2.45, confidence interval (CI) = 1.04-5.76, P = 0.04], male (OR = 4.35, CI = 0.05-0.97, P = 0.04), and low BMI (OR = 0.83, CI = 0.71-0.97, P = 0.02) were independent risk factors for low PMI before HSCT. Only age (≤ 50 years) was significantly associated with muscle quality (modified OR = 0.07, CI = 0.00-0.43, P < 0.01) in univariate analysis. Most patients already showed low skeletal muscle mass before allo-HSCT although skeletal muscle quality was relatively preserved. These results may be indicative of pre-cachexia and may be useful for its long-term management in allo-HSCT patients.

Intrathecal baclofen therapy for severe spasticity in an adult with tethered cord syndrome: a case report.

BACKGROUND: Patients with tethered cord syndrome often suffer severe spasticity. To the best of our knowledge, intrathecal baclofen (ITB) therapy in a patient with tethered cord syndrome has not been reported previously. We describe a case in which ITB therapy was useful for treating severe spasticity in an adult with tethered cord syndrome. CASE PRESENTATION: We present the case of a 50-year-old Japanese woman with tethered cord syndrome and related conditions suffering from severe spasticity and pain in the lower limbs. She was born with a lumbosacral myelomeningocele, which was closed in the neonatal period. For 4-5 years before this presentation, spasticity in the lower limbs had been exacerbated without any obvious cause. She received rehabilitation and pharmacotherapy from a local doctor, but symptoms were unimproved, and her previous doctor referred her to this department. A test with 50 µg of intrathecally delivered baclofen showed total relief of spasticity and pain, so a pump was implanted for continuous baclofen delivery. During 24 months of follow-up, spasticity has remained under excellent control with baclofen at 38.5-41.0 µg/day. CONCLUSIONS: ITB therapy proved extremely effective in this adult with severe spasticity from tethered code syndrome.

The efficacy of total hip arthroplasty on locomotive syndrome and its related physical function in patients with hip osteoarthritis.

BACKGROUND: Locomotive syndrome (LS) is a predictive factor of future motor dysfunction. Our aim was to evaluate the change in the total LS grade and, its the association with the Japanese Orthopaedic Association (JOA) hip score after total hip arthroplasty (THA) among patients with hip osteoarthritis. METHODS: This was a prospective case-control study of 72 patients who underwent primary THA. The functional outcomes were measured before, and at 6 and 12 months after THA. LS was evaluated using the following tests: stand-up test, 2-step test, and 25-question Geriatric Locomotive Function Scale (GLFS-25). In addition, factors affecting the improvement of LS grade were examined. RESULTS: Prior to THA, 7% and 93% of patients were classified as LS grades 1 and 2. At 6 months after THA, an improvement in the total LS grade was observed in 57% of patients, with this percentage further increasing to 65% at 1 year. Only the preoperative GLFS-25 was correlated with the preoperative JOA hip scores. The postoperative GLFS-25 and the two-step test were correlated with the postoperative JOA hip scores. The preoperative functional reach test (FRT) was significantly correlated with the total LS grade improvement. CONCLUSIONS: THA can improve the total LS grade in 65% of patients at 1 year postoperatively. Improvement was largely achieved in the first 6 months after THA, with a change from LS grade 2 to grade 1. FRT could be used an indicator of the total LS grade improvement.

Glioma surgery under awake condition can lead to good independence and functional outcome excluding deep sensation and visuospatial cognition.

BACKGROUND: Awake surgery for the eloquent cortex is a common strategy for glioma surgery. Although a recent emphasis has been placed on awake surgery both for dominant and nondominant cerebral hemispheres to preserve neurological/neuropsychological functions, those functional outcomes are not well investigated because few studies have focused on the longitudinal recovery process. This study explored the outcome of neurological/neuropsychological functions following awake surgery until the chronic phase. METHODS: A total of 87 patients with glioma who underwent awake surgery were included, and of these 66 patients matched our inclusion criteria. Each patient was assessed for neurological/neuropsychological functions before surgery, as well as acute and chronic phase. Additionally, scores for the KPS were collected. RESULTS: Almost all functions recovered within 3 months postoperatively, even when transient deficits were observed in the acute phase; however, deep sensory perception deficits and visuospatial cognitive disorders persisted into the chronic phase (15.4% of patients with parietal lesions, 14.3% of patients with right cerebral hemispheric lesion, respectively). KPS score ≥90 was achieved in 86.0% of patients with lower-grade glioma, whereas only 52.2% of glioblastoma patients scored ≥90. Primary causes of declined KPS were disorder of visuospatial cognition, sensorimotor function including deep sensation, aphasia, and emotional function. CONCLUSIONS: Awake surgery leads to good functional outcome at the chronic phase of neurological/neuropsychological functions, except for deep sensory and visuospatial cognition. Because sensation and visuospatial cognitive disorder have major impacts on patients' independence level, further importance should be placed on preserving these functions during surgery.

Awake surgery for glioblastoma can preserve independence level, but is dependent on age and the preoperative condition.

PURPOSE: Lately, awake surgery has been frequently adapted for glioblastoma (GBM). However, even with awake surgery, the expected long-term independence levels may not be achieved. We studied the characteristics of independence levels in GBM patients, and investigated the usefulness and parameter thresholds of awake surgery from the standpoint of functional outcomes. METHODS: Totally, 60 GBM patients (awake group, n = 30; general anesthesia group, n = 30) who underwent tumor resection surgery were included. We collected preoperative and 1- and 3-month postoperative Karnofsky Performance Status (KPS) scores, and analyzed causes of low KPS scores from the aspect of function, brain region, and clinical factors. Then, we focused on the operative method, and investigated the usefulness of awake surgery. Finally, we explored the parameter standards of awake surgery in GBM considering independence levels. RESULTS: Postoperative KPS were significantly lower than preoperative scores. Responsible lesions for low KPS scores were deep part of the left superior temporal gyrus and the right posterior temporal gyri that may be causes of aphasia and neuropsychological dysfunctions, respectively. Additionally, operative methods influenced on low independence level; long-term KPS scores in the awake group were significantly higher than those in the general anesthesia group, but they depended on age and preoperative KPS scores. Receiver operating characteristic curve analysis showed preoperative KPS = 90 and age = 62 years as the cutoff values for preservation of long-term KPS scores in awake group. CONCLUSION: Awake surgery for GBM is useful for preserving long-term independence levels, but outcomes differ depending on age and preoperative KPS scores.

Simple semi-permanent blockade against rigid varus foot in a case with spasticity: possible practical benefits in ambulatory adults.

A 55-year-old ambulatory woman with hemiplegia and varus foot deformity had several problems in her daily life, including load pain and stance instability in the affected foot, easy fatigue of the non-paralysed leg, low back pain, neck stiffness and rapid shoe-rubber wear on the deformed side. We began repeated focal blockades using botulinum toxin to the tibialis posterior muscle to control varus spasticity. Distant influences presenting in the whole body were relieved soon after the first blockade, and shoe wear also stopped. Although, neither the deformed appearance nor foot contact pattern on walking changed in the initial period after beginning the blockade, the foot contact pattern revealed gradual improvement over several years. Generally, surgical correction is indicated for the treatment of deformed feet. The present case suggests that, in case of varus-deformed foot with some spastic elements, trial of focal blockade for varus spasticity may be worthwhile.

Recovery time from supplementary motor area syndrome: relationship to postoperative day 7 paralysis and damage of the cingulum.

OBJECTIVE: Supplementary motor area (SMA) syndrome is defined as temporary paralysis after the resection of brain tumor localized in the SMA. Although in most cases paralysis induced by SMA resection resolves within a short period, the time until complete recovery varies and has not been precisely analyzed to date. In this study, the authors investigated factors for predicting the time required for recovery from paralysis after SMA resection. METHODS: Data from 20 cases were analyzed. All 20 patients (mean age 54.9 ± 12.6 years) had undergone resection of frontal lobe glioma involving the SMA. The severity of postoperative paralysis was recorded until complete recovery using the Brunnstrom recovery stage index. To investigate factors associated with recovery time, the authors performed multivariate analysis with the following potentially explanatory variables: age, severity of paralysis after the surgery, resected volume of the SMA, and probability of disconnection of fibers running through or near the SMA. Moreover, voxel-based lesion symptom analysis was performed to clarify the resected regions related to prolonged recovery. RESULTS: In most cases of severe to moderate paralysis, there was substantial improvement within the 1st postoperative week, but 2-9 weeks were required for complete recovery. Significantly delayed recovery from paralysis was associated with resection of the cingulate cortex and its deep regions. The factors found to influence recovery time from paralysis were stage of paralysis at postoperative day 7 and disconnection probability of the cingulum (adjusted R2 = 0.63, p < 0.0001). CONCLUSIONS: Recovery time from paralysis due to SMA syndrome can be predicted by the severity of paralysis at postoperative day 7 and degree of damage to the cingulum.

Factors Associated With Discharge Destination in Advanced Cancer Patients With Bone Metastasis in a Japanese Hospital.

OBJECTIVE: To analyze patient characteristics of cancer rehabilitation and outcomes at our hospital. METHODS: This retrospective study analyzed 580 patients, who underwent cancer rehabilitation at our hospital and rehabilitation outcome after therapy were investigated. The relationship between the initial Barthel index and discharge outcomes was investigated, with a special focus on cancer patients with bone metastasis. The Barthel index and performance status (Eastern Cooperative Oncology Group) before and after rehabilitation were analyzed, and threshold value of home discharge was calculated from a receiver operating characteristic curve (ROC). General criteria for home discharge from our hospital included independence in performing basic activities of daily living such as bathing, feeding, and toileting or availability of home support from a family member/caregiver. RESULTS: The outcomes after rehabilitation among all the patients were as follows: discharge home 59%, death 13%, and others 27%. Statistical differences were observed between the initial and final values of the Barthel index in patients with bone metastasis, who could be discharged home (p=0.012). ROC analysis of the initial Barthel index for predicting home discharge revealed a threshold value of 60, sensitivity of 0.76, and specificity of 0.72. CONCLUSION: The patients with bone metastasis had a lower rate of home discharge and a higher rate of mortality than all the study patients who underwent cancer rehabilitation at our hospital. It is proposed that at the time of initiation of rehabilitation for patients with bone metastasis, an initial Barthel index lower than 60 might predict a worse outcome than home discharge.

Cardiac output response to exercise in patients before allogenic hematopoietic stem cell transplantation.

INTRODUCTION: High-dose chemotherapy for remission induction can induce cardiac toxicity prior to hematopoietic stem cell transplantation (HSCT). However, the details of cardiac function in patients undergoing HSCT are unclear, particularly during exercise. The aim of present study was to evaluate cardiac output responses to exercise in patients after high-dose chemotherapy before HSCT compared with in age-matched healthy controls. METHODS: Twenty-nine patients before HSCT (age 44.6 ± 15.2 years) and 13 controls (45.8 ± 16.0 years) performed the 6-min walk test (6MWT). Cardiac output (CO), stroke volume (SV), heart rate (HR), and cardiac index (CI) were continuously measured during the 6MWT using the noninvasive thoracic impedance method. RESULTS: No significant difference was observed in the six-minute walk distance (6MD) between the two groups. SV, CO, and CI both at rest and the end of the 6MWT in the patients were significantly lower, compared with the controls, but there was no significant difference in HR. In all subjects, the 6MD was positively correlated with SV, CO, CI, and HR after the 6MWT. CONCLUSION: These findings suggest that cardiac output response to exercise indicates exercise intolerance, which may not be detected by 6MD in patients before HSCT.

Neural Networks Mediating High-Level Mentalizing in Patients With Right Cerebral Hemispheric Gliomas.

Mentalizing is the ability to understand others' mental state through external cues. It consists of two networks, namely low-level and high-level metalizing. Although it is an essential function in our daily social life, surgical resection of right cerebral hemisphere disturbs mentalizing processing with high possibility. In the past, little was known about the white matter related to high-level mentalizing, and the conservation of high-level mentalizing during surgery has not been a focus of attention. Therefore, the main purpose of this study was to examine the neural networks underlying high-level mentalizing and then, secondarily, investigate the usefulness of awake surgery in preserving the mentalizing network. A total of 20 patients with glioma localized in the right hemisphere who underwent awake surgery participated in this study. All patients were assigned to two groups: with or without intraoperative assessment of high-level mentalizing. Their high-level mentalizing abilities were assessed before surgery and 1 week and 3 months after surgery. At 3 months after surgery, only patients who received the intraoperative high-level mentalizing test showed the same score as normal healthy volunteers. The tract-based lesion symptom analysis was performed to confirm the severity of damage of associated fibers and high-level mentalizing accuracy. This analysis revealed the superior longitudinal fascicles (SLF) III and fronto-striatal tract (FST) to be associated with high-level mentalizing processing. Moreover, the voxel-based lesion symptom analysis demonstrated that resection of orbito-frontal cortex (OFC) causes persistent mentalizing dysfunction. Our study indicates that damage of the OFC and structural connectivity of the SLF and FST causes the disorder of mentalizing after surgery, and assessing high-level mentalizing during surgery may be useful to preserve these pathways.

Damage of the right dorsal superior longitudinal fascicle by awake surgery for glioma causes persistent visuospatial dysfunction.

Patients with glioma frequently present with neuropsychological deficits preoperatively and/or postoperatively, and these deficits may remain after the chronic phase. However, little is known about postoperative recovery course of right hemispheric function. We therefore studied the characteristics and causes of persistent cognitive dysfunction in right cerebral hemispheric glioma. Eighteen patients who underwent awake surgery participated in this study. All patients who received preoperative neuropsychological examinations were assigned to two groups according to their test results: preoperative deficit and normal. They were reassessed 1 week and 3 months after surgery. The rates of remaining deficits in the deficit group at chronic phase were higher than those of the normal group for all functions. Despite preoperative normal function, the remaining rate for visuospatial cognitive deficits was the highest among all functions. The voxel-based lesion-symptom mapping analysis for visuospatial cognition revealed that a part of the medial superior and middle frontal gyri were resected with high probability in patients with low visuospatial cognitive accuracy. Our study indicates that in patients with preoperative neuropsychological deficits, these deficits tend to remain until the chronic phase. Visuospatial dysfunction frequently persists until the chronic phase, which might reflect damage to the superior longitudinal fasciclus I and II.

Intraoperative Motor Symptoms during Brain Tumor Resection in the Supplementary Motor Area (SMA) without Positive Mapping during Awake Surgery.

Awake surgery could be a useful modality for lesions locating in close proximity to the eloquent areas including primary motor cortex and pyramidal tract. In case with supplementary motor area (SMA) lesion, we often encounter with intraoperative motor symptoms during awake surgery even in area without positive mapping. Although the usual recovery of the SMA syndrome has been well documented, rare cases with permanent deficits could be encountered in the clinical setting. It has been difficult to evaluate during surgery whether the intraoperative motor symptoms lead to postoperative permanent deficits. The purpose of this study was to demonstrate the intraoperative motor symptoms could be reversible, further to provide useful information for making decision to continue surgical procedure of tumor resection. Eight consecutive patients (from July 2012 to June 2014, six men and two women, aged 33-63 years) with neoplastic lesions around the SMA underwent an awake surgery. Using a retrospective analysis of intraoperative video records, intraoperative motor symptoms during tumor resection were investigated. In continuous functional monitoring during resection of SMA tumor under awake conditions, the following motor symptoms were observed during resection of the region without positive mapping: delayed motor weakness, delay of movement initiation, slowness of movement, difficulty in dual task response, and coordination disturbance. In seven patients hemiparesis observed immediately after surgery recovered to preoperative level within 6 weeks. During awake surgery for SMA tumors, the above-mentioned motor symptoms could occur in area without positive mapping and might be predictors for reversible SMA syndrome.