Volume 91  ·   Issue 25  ·  2011

The progress of modern science and technology has strongly promoted the rapid development of neurosurgery. After nearly 60 years of founding, starting and developing, neurosurgery in China has gone to the world. Every step forward is due to several generations of medical scientists who have continuously applied the high technology of the times to clinical practice, developed new technologies and created new achievements.

Objective To investigate the methods and efficacy of neuroendoscopic operation in the treatment of tethered spinal cord syndrome (TSCS) . Methods A total of 21 cases were recruited. There were 13 males and 8 females with an average age of 12.5 years old. TSCS was diagnosed by magnetic resonance imaging (MRI). They were operated under neuroendoscope. Results No complication was found during a follow-up period of 0.5-3 years. The symptoms improved in 18 cases. Neither obvious improvement nor aggravation was found in 3 cases. The total effective rate was 85.71%. Conclusion Neuroendoscopic treatment of TSCS is both safe and effective.

Objective To evaluate the method, strategy and efficacy of treating different types of quadrigeminal cistern arachnoid cysts (QCAC) with neuroendoscope. Methods A retrospective analysis was conducted for 12 QCAC patients with obstructive hydrocephalus. They were classified into 3 types and underwent neuroendoscopic operation at our hospital between November 2005 and November 2009. Their surgical approaches, complications and efficacy were analyzed. The mean age of first diagnosis was 3.7 years old. There were 7 type Ⅱ cases and 5 type Ⅲ cases with a varying level of symptoms. The follow-up period was 6-24 months. Cine-MRI (magnetic resonance imaging) examination was performed both pre- operatively and post-operatively. Results Among them, 12 patients recovered well without any occurrence of hemorrhage, paralysis, lower cranial nerve injury, cerebrospinal fluid leakage, infection or death.Subdural effusion occurred in 3 cases, but disappeared within 6 months. Severn feverish cases recovered after a symptomatic treatment The shapes of cysts and ventricles almost returned to a normal level in 8cases. Three cases of arachnoid cyst had a slight change. Conclusion In accordance with the QCAC patient types, different neuroendoscopic approaches can fully reconstruct the cerebrospinal fluid circulation.And the use of frameless navigation makes it more precise and safe.

Objective To explore the methods and techniques of repairing cerebrospinal fluid (CSF) rhinorrhea and reconstructing the defects of skull base under endoscopy. Methods The clinical data of 26 patients undergoing endoscopic repair of CSF rhinorrhea were analyzed retrospectively. There were 19males and 7 females with an average age of 31. 5 years old. Rhinorrhea was classified into 4 types: ethmoidalsinus type (n=6), sphenoid sinus type (n=14) and mixed type (n=6) and frontal sinus type (n=0).Results The causes of rhinorrhea were as follows: traumatic leakage (n=17) , post-operative breakage of saddle area (n=6) , damage after endonasal surgery (n=2) rhinorrhea after γ-knife for pituitary (n=1).All cases were successfully repaired via an endoscopic endonasal approach. Among them, 22 patients were repaired only once while 4 patients with recurrent CSF rhinorrhea were repaired again. The follow-up period was from 6 months to 4 years. And satisfactory outcomes were achieved in all. Conclusion Accurate localization of CSF leakage, reliable reconstruction of skull base, secure fixation of adhesive materials and continuous lumbar CSF drainage are keys surgical techniques. Endoscopic repair of front skull base and saddle bottom of CSF rhinorrhea is a reliable, effective and mini-invasive surgical approach worth further popularization.

Objective To further explore the application, approach, indication and prognosis of neuroendoscope treatment for skull base chordoma. Methods A total of 101 patients of skull base chordoma were admitted at our hospital from May 2000 to April 2010. There were 59 males and 42 females. Their major clinical manifestations included headache, cranial nerve damage and dyspnea. They were classified according to the patterns of tumor growth: Type Ⅰ (n=13) : tumor location at a single component of skull base, i. e. clivus or sphenoid sinus with intact cranial dura: Type Ⅱ (n=56): tumor involving more than two components of skull e. g clivus, sphenoid and nasal/oral cavity, etc. But there was no intracranial invasion; Type Ⅲ (n=32) : tumor extending widely and intradurally forming compression of brain stems and multiple cranial nerves. Based on the types of chordoma, different endoscopic approaches were employed, viz. transnasal, transoral, trans-subtemporal fossa and plus microsurgical craniotomy for staging in some complex cases. Results Among all patients, total resection was achieved (n=19), subtotal (n=58) and partial (n=24). In partial resection cases, 16 cases were considered to be subtotal due to a second-stage operation. Most cases had conspicuous clinical improvements. Self-care recovery within one week post-operation accounted for 58.4% , two weeks 30.7% , one month 6.9% and more than one month 1.9%. Postoperative complications occurred in 13 cases (12.8%) and included CSF leakage (n=4) ,cranial nerve palsy (n=5) , hemorrhagic nasal wounds (n=3) and delayed intracranial hemorrhage (n=1). All of these were cured or improved after an appropriate treatment. A follow-up of 6-60 months was conducted in 56 cases. Conclusion Early detection and early treatment are crucial for achieving a better outcome in chordoma. Neuroendoscopic treatment plays an important role in managing those complicated cases. Precise endoscopic techniques plus different surgical approaches and staging procedures are required to improve the post-operative quality of life for patients.

Objective To explore the application of neuroendoscopic treatment for intracranial lesions. Methods The clinic data of 372 patients with intracranial lesions, who underwent neuroendoscopic treatment at our department from May 1998 to May 2010, were reviewed retrospectively. Representative endoscopic treatments included endoscopic third ventriculostomy (ETV) (n=198), ETV & endoscopic biopsy (n=69) , neuroendoscopic ostomy for septum pellucidum fenestration (n=55) (for septum pellucidum cysts, n=37) and endoscopic cystoventriculostomy for ventricular cysts (n=50). Their surgical indications and clinical outcomes were summarized for analysis. Results ETV was performed successfully in 369 cases. Among them, 2 failed cases underwent other operations and endoscopic biopsy failed in 1case. Within a short post-operative period, the symptoms were resolved in 347 cases (93.3%) , showed no improvement in 23 cases (6.2%) and 2 died (0.5%). At Month 6 post-operation, a failure of ETV was detected in 22 cases (9.5%), a failure of neuroendoscopic ostomy for septum pellucidum cysts in 23(69.7%) and for ventricular cysts in 12 cases (26.7%). Conclusion ETV is effective in the treatment of obstructive hydrocephlus, but its indication should be strictly controlled for children. Effective rate of neuroendoscopic treatment for intracranial septum pellucidum cysts remains unsatisfactory so that its operative indication should be strictly controlled.

Objective To evaluate the diagnostic value of 64-slice spiral computed tomographic angiography (CTA) in vertebral artery stenosis through a meta-analysis of the relevant data. Methods A database search of Cochrane Library, PubMed, EBSCO, CBM-disc and CNKI was performed to identify the relevant English and Chinese language articles with such keywords as 64-slice computer tomography,angiography and vertebral artery stenosis. Quality evaluation, heterogeneity test and sensitivity and specificity to the qualified original data were conducted. Summary receiver operating characteristic (SROC)curve, the area under curve (AUC) and diagnostic odds ratio (DROC) were also calculated. Results A total of 4 studies were eligible for meta-analysis. Among them, 1 was graded as A and 3 were graded as B.No heterogeneity was found based upon a fixed effect model. For vertebral artery stenosis ≥50% , the pooled weighted sensitivity, specificity, DROC and SROC AUC was 0.98 (0.94-1.00) , 0.93 (0.89-0.96) ,526.33 and 0.9899 respectively; while for vertebral artery stenosis ≥50% , the parameters were 0.98(0.91-1.00), 0.97 (0.94-0.99), 838.40 and 0.9932 respectively. Conclusions 64-slice spiral CTA has such a high level of accuracy, sensitivity and specificity in the non-invasive diagnosis of vertebral artery stenosis.

Objective To review the type and number of pathogens and their antibiotic sensitivity in patients with late infected total joint replacement so as to offer guidance for the choice of antibiotics.Methods A retrospective analysis was conducted for 62 patients whose suspected specimens were obtained intra-operatively during a total hip arthroplasty since January 2002 to August 2010 at our department. Their demographic data, bacterial species and antibiotic sensitivity profiles were recorded. Results Among 62cases, the cultures were tested positive in 48 cases; the most common bacteria was Gram-positive bacteria(74%). And coagulase-negative staphylococci and Staphylococcus aureus accounted for 62.9% of all bacterial cultures. And the ratio of methicillin-resistant Staphylococcus was 41.18% . Conclusion The late infection of total hip arthroplasty is mainly caused by Gram-positive bacteria. Antibiotic treatment for late periprosthetic infection should be guided by the findings of drug susceptibility. Vancomycin may be used as a primary agent for the treatment of infected hip arthropalaty.

Objective To investigate the etiology, related factors and endoscopic characteristics of acute gastrointestinal hemorrhage. Methods The data including age, gender, medical and medication history, and endoscopic characteristics of patients receiving emergency treatment for acute gastrointestinal hemorrhage between February 2006 and February 2010 were collected to analyze the etiological profiles of this disorder. Results (1) A total of 1415 patients with a 2: 1 male-to-female ratio visited our hospital for acute gastrointestinal hemorrhage in the past 4 years. There was a higher mean age of disease onset in men than in women [(51±20) years old vs (61±17) years old, P=0.000]. The numbers of patients were 399, 361, 242 and 413 for 4 respective quarters in order of sequence. (2) And 1030 patients received endoscopy. Among them, there were 897 (87.1%) with upper gastrointestinal hemorrhage and 133(12.9%) with lower gastrointestinal hemorrhage. Significant differences existed in the mean age of two groups [(51±20) years old vs (57±18) years old, P=0.000]. The male-to-female ratio was 656:241and 65: 68 for these 2 groups respectively (P=0.000). The percentage of patient with a history of NSAID (non-steroidal anti-inflammatory drug) treatment was 22.1% (n=198) and 12.0% (n=16) for these 2groups respectively (P＜0.01). (3) The most common causative diseases of upper gastrointestinal hemorrhage were peptic ulcer (n=546, 60.8%) , esophageal & gastric varices hemorrhage (n=130,14.5%) and gastric cancer (n=40, 4.6%). When the patients were divided into 5 groups of ＜12h, 12-24 h, 24-48 h, 48-72 h and ≥72 h per time window of gastroscopy, their percentages with endoscopically active hemorrhage were 24.1% (20/83), 14.9% (24/161), 9.6% (16/166) , 7.5% (8/106) and 7.6% (29/381) for these groups respectively with statistically significant differences. When peptic ulcer was examined by the Forrest classification, the ratio of grade Ⅰa-Ⅱ c decreased gradually while the ratio of grade Ⅲ increased gradually among 5 groups (x2=80.414, P=0.040). (4) The most common causative diseases of lower gastrointestinal hemorrhage were ischemic colitis (n=44, 33.1%), small intestinal hemorrhage (n=26, 19.5%) and colonic polyps (n=18, 13.5%). (5) When the patients were divided into ＞65 years old group (n=277) and ≥ 65 years old group (n=620) , the ratio of gastric ulcer and cancer in upper gastrointestinal hemorrhage was higher in the former than in the latter [23.5% (n=65) vs 8.9% (n=55)&9.7% (n=27)vs 2.1% (n=13), P＜0.01)]. While the ratio of duodenal ulcer was lower in the former than in the latter [22.4% (n=62) vs 49.7% (n=308) , P＜0.01]. The ratio of small intestinal hemorrhage in lower gastrointestinal hemorrhage was higher in the former than in the latter (all P＜0.01). Conclusion At the lowest in the third quarter, the incidence rate of acute gastrointestinal hemorrhage is higher in males than that in females at a lower age of onset. More common than lower gastrointestinal hemorrhage, upper gastrointestinal hemorrhage has a lower mean age of onset Peptic ulcer is the most common disorder in upper gastrointestinal hemorrhage. Ischemic colitis is the most common disorder in lower gastrointestinal hemorrhage. The rate of gastric ulcer and gastric cancer in the old age group is higher than that in the young group. Emergency gastroscopy is recommended.

Objective To investigate the association of plasma homocysteine and OSA (obstructive sleep apnea) syndrome in ischemic stroke (IS) . Methods A total of 92 male IS patients were classified by apnea hypopnea index (AHI) into 2 groups: non-OSA group (AHI＜5/h) and OSA group (AHI≥5). All patients were tested for plasma homocysteine when polysomnography was finished at (14±2) d after the onset of IS. Results The mean level of homocysteine was significantly higher in the OSA group than that in the non-OSA group (17±5 vs 11±3μmol/L, P＜0.01). Pearson correlation analysis revealed a positive correlation between the homocysteine level and the severity of AHI (r=0.482, P＜0.01). Further multiple linear regression analysis showed that AHI and folate were independent predictors of homocysteine level (R2=0.553, P＜0.01, β for AHI=0.671, β for folate=-0.256). Conclusion The severity of OSA is significantly associated with an elevated level of homocysteine in IS patients. And this association is independent of other causative factors of an elevated level of homocysteine.

Objective To evaluate the incidence and risk factors of ROP (retinopathy of prematurity) through a prospective multicenter study. Methods Eleven children's or maternal & child hospitals participated in a collective network. All infants of birth weight＜2000 g, born in or transferred to one of the participating centers from January 1st 2005 to February 28th 2006 were recruited. Timely ophthalmologic examinations were performed. The relevant data at baseline and endpoints were collected at each unit. Results A total of 882 preterm infants fulfilled the screening criteria and 752 finished a follow-up. And 123 infants (16.4%) had some degree of ROP. Infants with ROP had a lower gestational age,birth weight and a longer duration of oxygen versus those without ROP[(30.82±0.20) weeks vs (32.56±0.09) weeks, (1430±25) g vs (1636±10) g, (11.6±1.4) d vs (4.4±0.3)d]. Through a univariate analysis, birth weight, gestational age, asphyxia, oxygen duration＞5 days, apnea, surfactant usage,pneumonia, anemia, blood transfusion, acidosis and neonatal respiratory distress syndrome (NRDS) were associated with ROP (P＜0.05) . Logistic regression analysis showed that birth weight (OR=0.998) ,apnea (OR=1.653) and blood transfusion (OR=1.763) were independent risk factors for ROP.Conclusion Asphyxia, oxygen duration＞5 days, surfactant usage, anemia, acidosis and NRDS, lower birth weight, apnea and blood transfusion may improve the risks of ROP.

Objective To identify the dural activities of neuroprotection and penetrating blood-brain barrier (BBB) for TAT-BDNF (transactivating-brain-derived neurotrophic factor) fusion protein to explore an alternative treatment for the injury of central nerve system (CNS). Methods With molecular cloning techniques, a recombinant vector termed pTAT-BDNF was constructed to encode both TAT protein transduction domain and human BDNF. Purified TAT-BDNF fusion protein was generated from Escherichia coli BL21 (DE3). The injury model was established with in vitro cultured cortical neurons of neonatal rats.To observe the neuroprotective effects of TAT-BDNF fusion protein on glutamate-mediated excitotoxic insults,the contents of lactate dehydrogenase (LDH) were measured by spectrophotometry. Immunofluorescence and Hoechst33342 analyses were used to observe the morphological changes. Immunocytochemical and Nissl stain analysis of TAT-BDNF content in CNS tissue were performed after an intravenous injection of TAT-BDNF fusion protein in normal or spinal cord injured rats. Results During the study of glutamate-induced excitotoxic insults, as compared with the control group, TAT-BDNF could decrease the apoptotic ratio,reduce the leakage of LDH and enhance the survival of neurons (P＜0.05) . As demonstrated by immunohistochemistry, TAT-BDNF fusion protein was efficiently delivered into rat brain and spinal cord tissues at 4 h post-injection. At Day 7 post-injury, Nissl stain show that the number and morphology of neurons in the TAT-BDNF group were better than those in the control group. Conclusion The synthetic neotype TAT-BDNF possess the dual biological effects of neuroprotection and penetrating BBB.

Objective To investigate the human tenocyte cytoskeleton under different in vitro stretching conditions and analyze the relations between the changes of tenocytic cytoskeleton and different stretching loads. Methods Human tenocytes, cultivated for 5 -7 passages, were stretched under 4% , 8%and 12% cyclic mechanical stretching with a duration of 2, 4, 8, 12, 24 hours and a frequency of 0.5 and 1.0 Hz. Laser scanning confocal microscope was used to examine the changes of F-actin and nucleus after immunofluorescent staining at different cyclic mechanical stretching loads on human tenocyte. The uni-cell average fluorescence intensity was measured with an image analysis system by the photos of human tenocyte cytoskeleton and analyzed by the single factor analysis of variance. Results After cyclic stretching under 4% stretching with a duration of 2 hours at 0.5 Hz, the microfilament of human tenocyte had an irregular and dim alignment. F-actin was thicker and ruptured under 4% stretching with a duration of 4 hours. Under 8% stretching with a duration of 4 hours at 0.5 Hz, all actin microfilaments ruptured, but part of membrane microfilament remained intact There was a rising trend of actin filament fracturing under 12% stretching with a duration of 2, 4, 8, 12, 24 hours at 1.0 Hz. And all actin filaments fractured at 24 hours. In the control group, the fluorescent intensity of F-actin was at the highest and the filament remained intact. Under the same stretching frequency, the fluorescent intensity of F-actin had a declining trend and significant differences existed under different stretching loads with different durations (P＜0.05) . The fluorescent intensity of F-actin increased in all experimental groups, but it was lower than that of the control group with a duration of 8 hours. The expression of F-actin decreased with a longer duration and reached its lowest at 24hours. The most obvious phenomenon of nuclear condensation and apoptotic body formation was observed under 4% stretching with a duration of 4 hours at 0.5 Hz. Conclusion Different cyclic mechanical stretching may cause the in vitro breakage and depolymerization of human tenocytic F-actin. Such an effect correlates with stretching force and its duration.

Objective To investigate the effects of lymphatic drainage and ω-3 polyunsaturated fatty acid (ω-3PUFA) on high mobility group box 1 (HMGB1) , inflammatory cytokines and endotoxin in rats with intestinal ischemia-reperfusion (Ⅰ/R) injury. Methods A total of 72 SD rats were randomly divided into drainage-alone group, Ⅰ/R group, ischemia-reperfusion plus drainage (Ⅰ/R+D) group (n=8 each)and 3 groups with 16 rats undergoing gastrostomy in each group: normal diet (N) group, enteral nutrition (EN) group and enteral nutrition & ω-3PUFA (PUFA) group. And they were further divided into 2 subgroups (n=8). The rats in Ⅰ/R and Ⅰ/R+D groups were subjected to a 60-min ischemia follow by 120-min reperfusion injury of superior mesenteric artery. When the rats suffered Ⅰ/R injury, intestinal lymph was drained for 180 min in the Ⅰ/R+D group. The rats in the drainage-alone group received 180-min lymph drainage without Ⅰ/R injury. After 5 days with different nutrition regimes, the models were established similarly. The rats in the Ⅰ/R+D sub-groups were treated with intestinal lymph drainage for 180 min. The serum and lymph samples were collected post-operatively. Endotoxin was detected by a Limulus kit. The inflammatory cytokines and high mobility group box 1 (HMGB1) were analyzed by enzyme-linked immunosorbent assay (ELISA).Results Endotoxin, inflammatory cytokines and lymphatic HMGB1 of lymphatic in the Ⅰ/R+D group were higher than those in the drainage-alone group [all P＜0.05 , IL-6 :(30±8) pg/ml vs (20±6) pg/ml, endotoxin: (0.029±0.011) U/ml vs (0.008+0.005) U/ml].The serum levels of endotoxin and inflammatory cytokines in the Ⅰ/R+ D group were lower than those in the Ⅰ/R group (P＜0.05).The lymphatic levels of TNF-a (tumor necrosis factor-alpha) and HMGB1 in the N and EN groups were higher than those in the PUFA group[TNF-α: (46±17)pg/ml, (54±16)pg/ml vs(28±9) pg/ml, HMGB1: (4.8±1.6) ng/ml, (5.3±1.8) ng/ml, (3.0±1.0) ng/ml, all P＜0.05) ].The serum levels of endotoxin, inflammatory cytokines and HMGB1 in the PUFA(l/R) group were lower than those in the N(Ⅰ/R) group (F＜0.05).The levels of TNF-a and HMGB1 were lower in the PUFA (Ⅰ/R+D) group than those in the N(Ⅰ/R+ D) group (both P＜0.05).Conclusion Lymphatic drainage may reduce the levels of endotoxin, inflammatory cytokines and HMGB1 so as to alleviate the intestinal Ⅰ/R injury. The intervention of ω-3PUFA has some protective effect through relieving inflammation.

Objective To evaluate the effect of proliferation and apoptosis of parathyroid cell in rabbits with primary hyperparathyroidism (PHPT) . Methods A total of 80 adult Chinese rabbits were randomly divided into two groups (n=40 each) . The control group was fed with a normal diet (Ca: P,1:0.7) while the experimental group a high phosphate diet (Ga: P, 1: 7) for3-,4- ,5-, or 6-month intervals to establish the animal model of PHPT. The parathyroid was totally removed for pathological examination after all rabbits were sacrificed. The thyroparathyroid complex was removed en bloc, fixed in neutral formalin and prepared for histological examination. The number of parathyroid cell in PHPT was calculated. Proliferation was determined by immunohistochemistry of proliferation cell nuclear antigen (PCNA) while apoptosis assessed by in situ dUTP biotin nick-end labeling (TUNEL). Results The number of parathyroid cell was 1.61 times in PHPT than that in the normal control (673±151, 418 ±25, t=-12.112, P＜0.01).Apoptotic index (AI) increased significantly more in PHPT than that in normal control (200.2‰±125.6‰, 11.0‰±3.0‰, t=-10.193, P＜0.01). The rate of PCNA positive-cell increased significantly more in PHPT than that in control (50.5%＞±11.6‰, 26.7‰±2.8‰,t=-13.120, P＜0.05).So did Bcl-2 (460‰±190‰, 67‰±4‰, t=-14.120,P＜0.05). There was a positive correlation between AI and PCNA (r=0.861, P＜0.05). It was the same as between AI and Bcl-2 (r=0.871, P＜0.05). The value of bone mineral density decreased significantly more in PHPT than that in normal control (152±34,189±12, t=9.236, P＜0.05). Conclusion PHPT may be mainly induced by an excessive proliferation of parathyroid cells and an acceleration of apoptotic process.

A 46-year-old male was admitted to the hospital on August 28, 2009 due to repeated cough for half a year and chest tightness and syncope for 1 d 3 years after pacemaker implantation. The patient went to the local hospital due to sudden syncope 3 years before the hospital. The electrocardiogram showed sinus bradycardia, and the slowest heart rate was 30~40 beats/min. According to the doctor's recommendation, the patient underwent pacemaker implantation in the local hospital. The postoperative heart rate was 60 beats/min, mainly autonomic heart rhythm.

Functional magnetic resonance (FMRI) is an effective method to study the work of human brain. The hemodynamic changes of cerebral blood oxygen level are induced by local stimulation, thus indirectly reflecting the neural activity. Most of the FMRI studies are by comparing the changes of blood oxygenation level-dependent (BOLD) signal intensity between the stimulation group and the control group (or baseline). Therefore, the careful design of the control group can make the changes of neural activity signal of special stimulation more meaningful.

A 71-year-old female, right-handed, was admitted to hospital on August 10, 2010 due to "confused speech with left limb weakness for 13d". When the patient went to the bathroom after getting up in the morning 13 d before the hospital, she suddenly developed left limb weakness, unstable left upper limb holding objects, and laborious left lower limb walking. She needed help from others when walking, her eyes were straight, and her speech was confused. She claimed that her left hand was grandson's hand, not her own hand. Her left hand was controlled by others, and she would fight when holding two hands together. There was involuntary groping movement in her left hand.

A 29-year-old male was admitted to Peking Union Medical College Hospital on April 21, 2010 due to rash for 10 years, aggravated for 2 years, fever, abdominal pain and weight loss for half a year.Ten years ago, the patient developed sporadic painful nodules in the distal part of the lower 1/3 of both calves without inducement, with repeated ulcers, ulcers and discharge, which healed in 1 to 2 months, leaving scars and pigmentation, which occurred 1 to 2 times a year. In the past 2 years, the symptoms have aggravated, occurring 3 to 4 times a year.