Volume 90  ·   Issue 13  ·  2010

In the 21st century, neurosurgery has entered the era of minimally invasive neurosurgery. Looking back at the past 10 years, minimally invasive neurosurgery has been established in China, and it has stepped into the international advanced ranks ~ ([1-2]). In 2009, the 14th World neurosurgery Union Congress (WFNS) and the 8th National neurosurgery Annual Conference (Nanchang, Jiangxi Province), Chinese scholars' reports fully demonstrated this achievement. 　　

Microsurgery began in the early 1960s. The application of microscopic technology has greatly improved the curative effect of neurosurgery, and the surgical injury is greatly reduced compared with the traditional open-eyed surgery in the past. After the superiority of microsurgery has been gradually recognized by people, microsurgery has been widely used and has become a standard surgical procedure in neurosurgery. In the past 50 years, the accumulation of microsurgery experience, the improvement of microscopic technology and the improvement of microscopic instruments make it possible and necessary to further minimally invasive microsurgery ~ ([1-2]), thus the emergence of keyhole neurosurgery, which can also be called "microbone hole approach" surgery. Keyhole neurosurgery is the product of the combination of modern microsurgery technology and modern minimally invasive surgery concept ~ ([3]), which makes microsurgery move towards a new era of minimally invasive neurosurgery. 　　

Objective Cutaneous vertebral medullary angiomatosis, also known as Cobb's syndrome, is a part of spinal arteriovenous metameric syndromes (SAMs) , is derived from the vascular malformation triad of skin, bone,and spinal cord involvement It is poorly managed with current treatment modalities. We reviewed the treatment of Cobb's syndrome series and summarized the experiences. Methods A total of 61 cases of Cobb's syndrome with spinal cord dysfunction were treated at our department from February 2003 to December 2007. The treatment followed the same strategy: First step - investigating the pathogenic mechanisms by symptom onset, MRI, angiography and the response to initial treatment Second step - treating the problematic parts of the lesions with embolization alone, surgery alone or combination of both. Forty-eight cases were embolized, 3 cases treated with surgery and 10 cases treated with a combination of both. Nidus involving pathogenic mechanism for spinal cord were eliminated, completely and nearly disappeared in 36 cases and partially in 23 cases. All patients were followed up regularly. Results Among these 61 cases, the pathogenic mechanisms were identified as hemorrhage, mass effect, ischemia and venous hypertensive myelopathy. Two or more mechanisms could coexist in the same patient More than 1-year's spinal cord function follow-up showed; excellent in 9 cases, good in 26, fair in 23 and worse in 3. Conclusion Not all lesions of Cobb's syndrome can be or should be cured anatomically. Pathogenic mechanism should be analyzed carefully and the treatment should focus on the special cord-affecting targets. Long-term improvement or stabilization may be achieved.

Objective To summarize the clinical experiences of treating intracranial aneurysms associated with Moyamoya disease by endovascular approach. Methods A total of 13 patients were admitted into our hospital because of subarachnoid hemorrhage. Cerebral angiography revealed the evidence of Moyamoya disease and intracranial aneurysms. Endovascular embolization was performed for these aneurysms with coils, balloon-assisted coils placement and stent plus coils. Results All operations were successful Total occlusion was achieved in 11 patients and over 90% in 2. The patients recovered well with a patency of parent arteries. Conclusion Endovascular therapy is a valid and suitable approach for the treatment of intracranial aneurysms associated with Moyamoya disease.

Objective To investigate the advantages, disadvantages and indications of hemilaminectomy for microsurgical resection of intraspinal tumors. Methods We retrospectively reviewed and analyzed the clinical data of 542 cases of intraspinal tumors microsurgically resected by hemilaminectomy during the period from January 2005 to December 2008. Results The tumors were totally removed in 501 cases (92% ). The average postoperative stay was 5.2 days. Postoperative follow-ups ranged from 6 months to 3 years (mean 9 months). The clinical symptoms of 495 cases (91% ) improved. No tumor recurrence was reported in the totally removed cases. The stability of vertebral column was excellent and there was no spinal deformity in these patients. Conclusion With many advantages of minimal trauma, milder postoperative reaction, shorter length of recovery and better spinal stabilization, hemilaminectomy can be used for microsurgical resection of all lateralized epidural, subdural-extramedullary and some benign intramedullary tumors.

Objective To evaluate the surgical effects of such adjuvant techniques as type B ultrasound, neuronavigation and intraoperative indocyanine green vedioangiography (ICGA) on intracranial arteriovenous malformation ( AVM) surgery. Methods From January to October 2009, 43 AVM patients treated at our center were retrospectively studied, including 26 males and 17 females with an age range of 8 to S3 years old (mean; 26. 51). Type B ultrasound, neuronavigation or ICCA were employed during surgical procedures in all cases. Intraoperative findings were compared with those of postoperative digital subtraction angiography ( DSA) or computed tomography angiography (CTA) . And the clinical outcomes were evaluated. Results As confirmed by postoperative DSA or CTA, the lesions of all 43 patients were totally removed. Only 3 patients (7.0%) suffered from new neurological deficits, including homonymous hemianopia in 2 patients and diplopia in 1. And the Karnofsky performance scale was higher than 80 for each patient. Conclusion The feeding arteries and draining veins can be differentiated by intraoperative type B ultrasound, neuronavigation and ICGA. All three adjuvant techniques can define the lesion boundary. However, each of them has its own benefits and drawbacks. It indicates that the combination of two or more techniques may help to improve the quality and outcome of surgical procedures.

Objective To observe the effect of optimizing anesthetic injecting sequence during induction on fentanyl-induced coughing. Methods One hundred and twenty ASA Ⅰ or Ⅱ elective patients undergoing general anesthesia were randomly allocated to optimized group or control group: the optimized group induced with midazolam 0.06 mg/kg, followed by fentanyl 1 mg/kg at 1 min later, vecuronium 0. 1 mg/kg at 1 min55s, propofol 1.5-2 mg/kg at 2 min, a second dose of 3 mg/kg fentanyl at 2 min 20 s, intubated at time 5 min; the control group was induced with the same medication but all the fentanyl (4 mg/kg) was injected at time 1 min. Coughing after fentanyl injection was observed and hemodynamic parameters were recorded. Results Hemodynamic changes were identical between the two groups indicated similar intubation response suppression. The incidence of fentanyl-induced coughing was significantly lower in the optimized group ( 4/60) than in the control group ( 23/60) ( P < 0. 01). Conclusion Optimizing anesthetic injecting sequence during induction by separate fentanyl into two boluses significantly reduce fentanyl-induced coughing without affecting intubation response suppression.

Objective To explore the relationship between the changes of surface electromyography(sEMC) signal of thigh muscles and balance function in stroke patients during maximum isometric voluntary contraction (MIVC) of knee extension and flexion so as to provide rationales for rehabilitation. Methods Twenty-one stroke patients and 18 age-and sex-matched normal controls were recruited for this study. The surface electromyographic signals of of vastus medialis(VM) , rectus femoris (RF), vastus lateralis(RL) and biceps feomris(BF) were recorded during MIVC of knee extension and flexion. Root mean square (RMS) and co-contraction ratio (CR) of both groups were compared and analyzed. The balance function was assessed by Berg balance scale (BBS). Results There were significant differences in RMS of VM, RF, VL and BF of ipsilateral ［(136±63) μV, (107±24) ΜV, (154±19) ΜV, (91 ±63) μV］, thigh during knee extension and flexion (P<0. 05). There were significant differences in CR on ipsilateral thigh muscles than the unaffected (43% ± 13% vs 37% ±20%) and controls (43% ± 13% vs 32% ± 10%) during knee flexion(P < 0. 05). The RMS of RF and BF on ipsilateral thigh was significantly positively correlated with the score of BBS (rRF=0. 53, P = 0.01 vs rBF = 0. 51, P=0.02); The CR of knee extension and flexion on ipsilateral thigh had a significantly negative correlation(CRE = - 0.59, P = 0.005 vs. CRF = - 0.41, P = 0. 046). Conclusion The strength of bilateral thigh muscles decreases in stroke patients. The spasticity of "thigh extensor still exists. Besides reducing the spasticity of hemiplegic limb extensor, rehabilitation should also focus upon bilateral thigh muscles, particularly ipsilateral RF and BF strength training to improve the knee joint stability and improve the balance function.

Objective To investigate the relationship between polymorphisms in paraoxonasel (PON1) gene Glnl92Arg( Q192R) and arterial ischemic stroke in young adults.Methods The Q192R genotype was analyzed by polymerase chain reaction in 131 young adults with ischemic stroke and 135 age-and gender-matched controls. The plasma lipids were also determined in patients and controls respectively. Furthermore, carotid artery intuna-media thickness ( IMT) in patients were measured by carotid ultrasonography. Results The distributions of Q192R genotype frequency were significantly different between patients with ischemic stroke and control individuals. And the patients had more RR genotypes than control individuals (P <0.05). Odds ratio (OR) for stroke were 1. 743 (95% confidence interval [ CI] , 1.032-2. 943) in subjects with RR genotype. We also studied the relationship between the polymorphisms and the lipid concentration in patients and control individuals. However, no significant association was detected between Q/R192 genotype and any of lipid measurements. Further, the prevalence of cigarette smoking, hypertension and diabetes showed no significant difference between RR and non-RR genotypes in patients. Body mass index ( BMI) in two groups did not differ significantly. But IMT of patients with RR genotype obviously increased in comparison to those without RR genotype ( P < 0. 05 ). Conclusion The PON1 gene Q192R polymorphism may be associated with the susceptibility of ischemic stroke in young adults. RR genotype is a genetic risk for young adults with ischemic stroke through an increased carotid artery intima-media thickness and an accelerated atherosclerotic process.

Objective To investigate the association of eNOS 894G→T, -786T→C gene polymorphisms with disease severity and outcome in septic patients. Methods A total of 117 patients with severe sepsis were randomly selected from ICUs at 9 academic hospitals in Beijing during April 2007 to May 2009. PCR-RFLP and PCR-SSCP were used to analyze the alleles and genotypes in eNOS 894G→T and - 786T→C gene polymorphisms. Recorded clinical data included demographics, pathogens, APACHE Ⅱ score within 24 hours and SOFA score within 7 days after ICU admission, percentage of shock patients, days to shock onset (from infection to shock onset ), duration of shock and the mortality at Days 7 and 28. Results In comparison with genotype GT carriers, the patients with genotype GT in eNOS 894G→T polymorphism had a incremental trend in frequency of shock (87% vs 68. 1 % , P = 0. 071) and a significantly shortened days to shock onset [1. 0(0.1-6. 5)vs 2. 0 (0.10-27.0) days, median (range), P<0.05]. Those patients had been shown to have a significantly high APACHE Ⅱ score (23. 61 ± 7. 00 vs 19. 50 ± 6.99, P<0.05), SOFA score(9. 43 ±3.42 vs 5. 26 ±2. 94 , P <0.001)and mortality at Day 7 (34.8% vs 0% , P <0. 001) and Day 28 (78. 3% vs 23. 4% , P <0.001). Multivariate analyses revealed that age in years, SOFA score and genotype GT in eNOS 894G→T polymorphism were independent high-risk factors for the outcome in septic patients. However, eNOS -786T→C gene polymorphism was not associated with disease severity and outcome in septic patients. Conclusion Carriage of genotype GT in eNOS 894G→T polymorphism is associated with the occurrence of shock and impaired organ function.

Objective To analyze the effect of Argon-Helium ciyosurgery (AHCS) combined with transcatheter renal arterial embolization (TRAE) on the differentiation of regulatory CD4~+ CD25~+ T cell (Treg) and its implication in patients with renal carcinoma. Methods 77 patients were called in the study, and were devided into two groups: TRAE group (n = 45, receiving TRAE only) and TRAE + cryoablation group (n = 32, receiving cryoablation 2-3 weeks after TRAE) . The percentage of Treg cells and T lymphocyte subsets (CD3~+T, CD4~+ T, CD8~+ T, and CD4~+ T/CD8~+ T) in the peripheral blood was measured by flow cytometry before and 3 months after therapy. Meanwhile, the extent of tumor necrosis was mesured by MRI or CT 1 month after therapy. Results The percentages of Treg cells of patients in TRAE + cryoablation group were decreased from 6. 6% ±1.2% to 3. 9% ±1.2% ,(t =42. 768,P <0.01) , and the percentages of CD3~+ T, CD4~+ T, CD8~+ T, NK and CD4~+T/CD8~+T were significantly increased (P < 0.01). However, among the patients in TRAE group, the percentages of Treg ,CD3~+ T, CD4~+ T, CD8~+ T, NK and CD4~+ T/CD8~+ T were increased ( P > 0. 05 ) . The tumor necrosis rates of TRAE + cryoablation groups were 57. 5% , significantly higher than those of TRAE group, which shows 31.6% (t = 6. 784, P < 0.01). The median survival duration of the TRAE + cryoablation group was 20 months, significantly longer than that of the TRAE group (χ~2 =7. 368 ,P <0.01 ). The decreasing extent of Treg cells is correlated with tumor necrosis rates(r =0. 90 P <0. 01) and life time( r = 0. 67 P < 0. 01). Conclusion The therapy of TRAE combined with cryoablation contributed to reduce the percentage of Treg cells and improve the immune situation of patients with renal cell carcinoma, consequently increase tumor necrosis rate and prolongs the patients' survival duration.

Objective To determine the choice of palliative procedures, timing and techniques of second-stage operations. Methods Between April 2004 to July 2008, 50 consecutive patients with pulmonary atresia with ventricular septal defect ( PA/VSD) underwent two-stage operation. Palliative procedures included modified Blaloclc-Taussig shunt (n - 5 ) , central shunt ( n = 2 ) , pericardia] patch enlargement (n = 10), pericardia! tube (n =4) and Gore-Tex conduit (n =29). The interval period was 7-49 months (20. 0 ± 10. 0 months) . In the second stage, a surgical shunt was interrupted in 7 cases. Ventricular septal defect was closed in all patients, but fenestrated ventricular septal defect patch was used in 6 cases. Right ventricular outlet tract ( RVOT) was widened with pericardial patch in 42 cases and conduit exchange in 8 cases. Aortopulmonary collateral arteries ( MAPCASs) unifocalization ( n = 1) , ligation or transcatheter occlusion with embolization coils ( n = 4 ) and maintaining open or untreated (n = 4 ). Results Death occurred in 2 and the mortality rate was 4% . Postoperative complications included residual shunt (n = 3 ) , residual obstruction ( n = 3 ) , complete AV block ( n = 1) , athetosis (n = 1 ) and acute renal failure (n = 3). Neither death nor complication was reported during a follow-up period of 3 months to 4 years. Conclusion A palliative procedure should be individualized to the patient's morphology of central pulmonary artery and clinical status of a patient. Right ventricular outlet tract reconstruction, pulmonary arterioplasty, fenestration of VSD patch in baby with suprasystemic right ventricular pressure and appropriate interventions with MAPCASs are key to decrease the mortality and morbidity of staged operations for PA/ VSD.

Objective To investigate the situation of perioperative blood transfusion in Grade M-A hospitals in Zhejiang province, in order to provide statistics for improving appropriateness of blood transfusion. Method The questionnaire was conducted in 9 Grade M-A hospitals in Zhejiang province according to "The Technical Criterion of Clinical Blood Transfusion". The data including total quantity , whole blood and component blood transfusion in 2007 were analyzed. Results Among 19 102 cases, the percentage of component blood transfusion was 99. 3% ,but 44. 1% transfusion is conducted just according to doctors'experience without any medical indication .including 603 patients not reexamining the level of Hct or Hb in 72 h after operation. For the patients with complete transfusion record, the irrational rate of whole blood, RBCand platelet transfusion were 39. 2% , 39. 2% , 43. 7% , the mainly reason was the relax demand on the transfusion indication. Conclusions Although Grade Ⅲ-A hospitals in Zhejiang did fairly well in perioperative blood component transfusion, there are still some seriously unreasonable phenomenons . Every medical organization should pay more attention to improve the quality of clinical blood transfusion.

Objective To introduce a new C, screw insertion technique to avoid injury to C_(1-2) venous sinus in posterior atiantoaxial fixation. Methods 48 cases (96 sides of C_1 screws) undergoing posterior atiantoaxial fixation were retrospectively analyzed, including 28 cases of C_1 or C_2 fresh fracture and 20 cases of congenital malformation or old fracture &dislocation, among which 12 cases (24 sides) were operated by Coel lateral mass screws, 14 cases (28 sides) by TAN Mingsheng C_1 transpedicular screws and 44 sides of C, screws in 22 cases were inserted via notch on underside of C, posterior arch combined with bone wax column protecting C_(1-2) venous sinus. Results Bleeding was encountered in five sides of C_1 screws among 26 cases (52 sides) whose venous sinuses were not protected by bone wax column, involving 3 cases of Coel lateral screw implant fixation. There was statistical difference in the incidence rate of bleeding between Coel technique and ours ( P < 0.05) while there was no statistical difference between C_1 transpedicular technique and ours (P>0. 05) or between Goel sides of Goel lateral mass screws (12. 5% ) and 2 sides of C_1 transpedicular screws (7. 1% ). It occurred in none of 22 cases (44 sides) with our presented technique. There was a significant difference between Goel lateral screw implant fixation and C_1 transpedicular technique (P > 0. 05 ). All the screws were implanted successfully. All cases were followed up and there was not any sign of implant failure. Conclusions Our presented C_1 screw insertion technique can provide a better bony landmark and vascular protection, stronger bony holding power and more extensive applicability to reduce injury to C_(1-2) venous sinus and increase the surgical safety.

Objective To observe the early clinic outcome of treating thoracolumbar mono-segmental fracture with posterior fixation in combination with intermediate screws. Methods From July 2006 to August 2008, 35 of 62 patients with thoracolumbar mono-segmental fracture were treated with in Croup A and the remaining 27 with intermediate screw in combination with short segmental fixation in Croup B. Results The relative height of fractured vertebrae and reduction rate showed significant differences [(84.2±2.8 )vs (98.6 ± 1.9) ,P <0.05] between two groups while the change of segmental kyphotic angle showed no difference [ (8. 5 ± 1. 0) vs(8. 1 ± 1.3) ,P >0.05]. Conclusion Intermediate screw in combination with short segmental fixation has a better immediate efficiency in treating thoracolumbar mono-segmental fracture since it reduces the height of fractured vertebrae.

Objective To discuss the value of ~(11)C-PIB PET and ~(18)F-FDG micro PET imaging in Alzheimer's disease(AD)rat model. Methods The AD rat model was established by injection of Aβ1-40 into rat's hippocampus. Learning and memory function were estimated by the Morris water maze. Amyloid deposit and neuron loss were observed by Congo red staining and HE staining respectively. ~(11)C-PIB PET and ~(18)F-FDG micro PET scan were performed. Meanwhile the findings of PET imaging were compared with the results of behavior test and histology. Results The uptake of ~(18)F-FDG in hippocampus of AD rat model group was lower than that of control group(P <0.01). The Morris water maze showed that the escape latent period of rat model group was longer than that of control group (P < 0.01).Neuron loss was found in rat model brain. Thus the result of micro-PET imaging was matched with those of the Morris water maze and HE staining. ~(11)C-PIB was specifically bound to 8-amyloid in rat model brain, the uptake of ~(11)C-PIB in AD rat model was higher than that of control ( P < 0.05 ). AB deposit was observed in Congo red staining so that the result of ~(11)C-PIB Micrp-PET imaging was matched with that of B-amyloid deposition. Conclusion ~(11)C-PIB Micrp-PET imaging shows the plaque deposition while ~(18)F-FDG -PET imaging reflects the change of glucose metabolism in hippocampus in AD rat model. And PET scan can be used to verify the successful establishment of AD model rat model.

A 44-year-old female was admitted to the Department of Rheumatology and Immunology of Peking Union Medical College Hospital on December 20, 2007 due to earache, hearing loss for 16 months, nasal congestion and epistaxis for 12 months, increased serum creatinine for 15 days and blood in stool for 4 days. The patient developed left ear distension and pain and hearing loss since August 2006. After catching a cold in October of the same year, she developed cough and runny nose, accompanied by fatigue, intermittent low fever, and left knee joint pain. In November of the same year, soybean-sized blood blisters appeared in the pretibia of the right lower limb and gradually increased, accompanied by pain and exudation. In December of the same year, she developed nasal congestion, intermittent epistaxis, and red eyes. The chest CT of the local hospital showed "lung shadow" (the patient's oral account), considering "tuberculosis". After 9 months of antituberculosis administration of isoniazid, rifampicin and pyrazinamide, her body temperature was normal, but she still had nasal congestion and intermittent epistaxis. 　　

Rapid eye movement (REM) sleep behavior disorder (RBD) is a paroxysmal disease characterized by the disappearance of muscle tone during REM sleep and the complicated movements associated with unpleasant dreams. RBD is closely related to various neurodegenerative diseases and may be the prodromal manifestation of α-synucleinopathy. In-depth research on RBD is beneficial to further clarify the accurate relationship between RBD and α-synucleinopathy, find the biological markers that can identify the RBD population with high risk factors for α-synucleinopathy, identify the high risk population of α-synucleinopathy early, and provide neuroprotective treatment for them to help delay the progression of the disease. 　　

<The Tort Liability Law of the People's Republic of China was promulgated on December 26, 2009. The 11 articles of Chapter 7 of the Law on "Liability for Medical Damage" regulate a number of rights and interests between doctors and patients, not only pay attention to the hot legal issues related to doctors and patients, but also fill some legal "blind spots". The law will come into force on July 1, 2010. 　　

Patient 1, male, 15 years old, suffered from episodic headache accompanied by vertigo for 5 years. The episodic headache occurred 2-3 times a month, which could be induced by bright light irradiation, fatigue and nervousness. The headache was preceded by visual aura, followed by alternating moderate to severe skipping or distension pain on both temporal sides, accompanied by photophobia, phonophobia, nausea, difficulty in thinking, difficulty in speaking and aggravation after movement, lasting for several minutes to several hours. Four years ago, he was diagnosed with epilepsy in a local hospital. He was treated with carbamazepine, an antiepileptic drug, but his headache was not relieved significantly. After about one month of medication, he spontaneously stopped taking ibuprofen tablets for every headache attack. There were no obvious positive signs on physical examination. The self-rating depression scale ~ ([1]) tested as moderate depression. The EEG showed focal slow wave and increased brain power. The cranial magnetic resonance (MRI) examination was normal. The cerebrospinal fluid pressure of lumbar puncture was 223 mm H2O (1 mm H2O =0.0098 kPa), which was normal in routine and biochemistry. The preliminary diagnosis was basal migraine. The treatment process was as follows: preventive treatment: sodium valproate-valproic acid 250 mg, twice/d. Acute treatment: oral rizatriptan 5 mg, ibuprofen 1 tablet, domperidone 10 mg tablets. On the 7th and 10th day after consultation, the headache attacked twice without coma. The headache gradually relieved about 40 min after taking rizatriptan 5 mg. After six months of follow-up, no headache occurred again. 　　

A 71-year-old female was admitted to the hospital with repeated fever accompanied by chest tightness and shortness of breath after activity for 3 months. The fever was more severe in the afternoon and night, mainly low or moderate fever, with a maximum of 39℃, and the body temperature dropped to normal the next morning. She had a history of hypertension for 20 years. Physical examination showed that the body temperature was 36.4℃, the blood pressure was 152/68 mm Hg (1 mm Hg =0.133kPa), there was no jugular vein filling and distension, fine wet rales could be heard in both lower lungs, no bulge in the precordial area, the heart rhythm was uniform, the heart boundary was slightly enlarged to the lower left, no pathological murmur in the auscultation area of each valve, no pericardial friction, the abdomen was flat and soft, the liver and spleen were not enlarged, no moving turbidity, and no swelling in both lower limbs. Routine blood examination showed that white blood cells were 6.4×10~9/L, the percentage of neutrophils was 56.4%, red blood cells were 3.15×10~ (12) /L, hemoglobin was 110g/L, and the erythrocyte sedimentation rate was 1.66 mg/dl

A 27-year-old female was admitted to hospital on March 2, 2009 due to intermittent abdominal pain with joint pain for more than 4 months, aggravated with epileptic seizure for more than 1 month. The patient developed severe abdominal pain, located around the umbilical cord, paroxysmal colic, with abdominal distension and constipation, several hours after being shocked more than 4 months ago. The abdominal pain was relieved according to the symptomatic treatment of "acute gastroenteritis", but the abdominal pain was repeated after that, with an average of one attack per month, mostly on the day of menstruation or 2~3 days before menstruation, and the duration of each attack was gradually prolonged.