Intrawound Vancomycin Powder Application for Preventing Surgical Site Infection Following Cranioplasty

Objective@#: Surgical site infection is the most detrimental complication following cranioplasty. In other surgical fields, intrawound vancomycin powder application has been introduced to prevent surgical site infection and is widely used based on results in multiple studies. This study evaluated the effect of intrawound vancomycin powder in cranioplasty compared with the conventional method without topical antibiotics. @*Methods@#: This retrospective study included 580 patients with skull defects who underwent cranioplasty between August 1, 1998 and December 31, 2021. The conventional method was used in 475 (81.9%; conventional group) and vancomycin powder (1 g) was applied on the dura mater and bone flap in 105 patients (18.1%; vancomycin powder group). Surgical site infection was defined as infection of the incision, organ, or space that occurred after cranioplasty. Surgical site infection within 1-year surveillance period was compared between the conventional and vancomycin powder groups with logistic regression analysis. Penalized likelihood estimation method was used in logistic regression to deal with zero events. All local and systemic adverse events associated with topical vancomycin application were also evaluated. @*Results@#: Surgical site infection occurred in 31 patients (5.3%) and all were observed in the conventional group. The median time between cranioplasty and detection of surgical site infection was 13 days (range, 4–333). Staphylococci were the most common organisms and identified in 25 (80.6%) of 31 cases with surgical site infections. The surgical site infection rate in the vancomycin powder group (0/105, 0.0%) was significantly lower than that in the conventional group (31/475, 6.5%; crude odds ratio [OR], 0.067; 95% confidence interval [CI], 0.006–0.762; adjusted OR, 0.068; 95% CI, 0.006–0.731; p=0.026). No adverse events associated with intrawound vancomycin powder were observed during the follow-up. @*Conclusion@#: Intrawound vancomycin powder effectively prevented surgical site infections following cranioplasty without local or systemic adverse events. Our results suggest that intrawound vancomycin powder is an effective and safe strategy for patients undergoing cranioplasty.

Factors Affecting Postoperative Complications and Outcomes of Cervical Spondylotic Myelopathy with Cerebral Palsy : A Retrospective Analysis

Objective@#: Cervical surgery in patients with cervical spondylotic myelopathy (CSM) and cerebral palsy (CP) is challenging owing to the complexities of the deformity. We assessed factors affecting postoperative complications and outcomes after CSM surgery in patients with CP. @*Methods@#: Thirty-five consecutive patients with CP and CSM who underwent cervical operations between January 2006 and January 2014 were matched to 35 non-cerebral palsy (NCP) control patients. Postoperative complications and radiologic outcomes were compared between the groups. In the CP group, the Japanese Orthopaedic Association score; Oswestry neck disability index; modified Barthel index; and values for the grip and pinch, Box and Block, and Jebsen-Taylor hand function tests were obtained preand postoperatively and compared between those with and without postoperative complications. @*Results@#: Sixteen patients (16/35%) in the CP group and seven (7/35%) in the NCP group (p=0.021) had postoperative complications. Adjacent segment degeneration (p=0.021), postoperative motor weakness (p=0.037), and revisions (p=0.003) were significantly more frequent in the CP group than in the NCP group; however, instrument-related complications were not significantly higher in the CP group (7/35 vs. 5/35, p=0.280). The number of preoperative fixed cervical deformities were significantly higher in CP with postoperative complications (5/16 vs. 1/19, p=0.037). In the CP group, clinical outcomes were almost similar between those with and without postoperative complications. @*Conclusion@#: The occurrence of complications during the follow-up period was high in patients with CP. However, postoperative complications did not significantly affect clinical outcomes.

Factors Affecting Postoperative Complications and Outcomes of Cervical Spondylotic Myelopathy with Cerebral Palsy : A Retrospective Analysis

Objective@#: Cervical surgery in patients with cervical spondylotic myelopathy (CSM) and cerebral palsy (CP) is challenging owing to the complexities of the deformity. We assessed factors affecting postoperative complications and outcomes after CSM surgery in patients with CP. @*Methods@#: Thirty-five consecutive patients with CP and CSM who underwent cervical operations between January 2006 and January 2014 were matched to 35 non-cerebral palsy (NCP) control patients. Postoperative complications and radiologic outcomes were compared between the groups. In the CP group, the Japanese Orthopaedic Association score; Oswestry neck disability index; modified Barthel index; and values for the grip and pinch, Box and Block, and Jebsen-Taylor hand function tests were obtained preand postoperatively and compared between those with and without postoperative complications. @*Results@#: Sixteen patients (16/35%) in the CP group and seven (7/35%) in the NCP group (p=0.021) had postoperative complications. Adjacent segment degeneration (p=0.021), postoperative motor weakness (p=0.037), and revisions (p=0.003) were significantly more frequent in the CP group than in the NCP group; however, instrument-related complications were not significantly higher in the CP group (7/35 vs. 5/35, p=0.280). The number of preoperative fixed cervical deformities were significantly higher in CP with postoperative complications (5/16 vs. 1/19, p=0.037). In the CP group, clinical outcomes were almost similar between those with and without postoperative complications. @*Conclusion@#: The occurrence of complications during the follow-up period was high in patients with CP. However, postoperative complications did not significantly affect clinical outcomes.

The Effect of Different Pillow Heights on the Parameters of Cervicothoracic Spine Segments

OBJECTIVE: To investigate the effect of different pillow heights on the slope of the cervicothoracic spine segments. METHODS: A prospective analysis of data from 16 asymptomatic adults (aged 20 to 30 years) was carried out. Exclusion criteria were history of injury or accident to the cervicothoracic spine, cervicothoracic spine surgery, or treatment for neck symptoms. We used three different pillow heights: flat (0 cm), 10-cm, and 20-cm pillows. Cervical sagittal parameters, measured with radiography, included; C2-7 Cobb's angle, T1 slope (T1S), thoracic inlet angle (TIA), and neck tilt (NT). Statistical analyses were performed using Spearman correlation coefficients. RESULTS: As the height of the pillow increased, the T1S & C2-7 Cobb's angle increased while the NT values tended to decrease. The TIA values, however, remained constant. Additionally, there was a statistically significant sex difference in T1S with the 0-cm pillow (p=0.01), and in NT with the 20-cm pillow (p=0.01). CONCLUSION: From the data obtained in this study, we recommend that the most suitable pillow height is 10 cm, considering the normal cervical lordosis.

Ruptured Total Intrameatal Anterior Inferior Cerebellar Artery Aneurysm

Among the distal anterior inferior cerebellar artery (AICA) aneurysms, a unique aneurysm at the meatal loop inside the internal auditory meatus is extremely rare. The authors report a case of surgically treated total intrameatal AICA aneurysm. A 62-year-old female patient presenting with sudden bursting headache and neck pain was transferred to our department. Computed tomography and digital subtraction angiography showed subarachnoid hemorrhage at the basal, prepontine cistern and an aneurysm of the distal anterior inferior cerebellar artery inside the internal auditory meatus. Surgery was performed by retrosigmoid craniotomy with unroofing of the internal auditory meatus. The aneurysm was identified between the seventh and eighth cranial nerve in the meatus and was removed from the canal and clipped with a small straight Sugita clip. After operation the patient experienced transient facial paresis and tinnitus but improved during follow up.

The Effect of the Pedicle-Facet Angle on Degenerative Cervical Spondylolisthesis

OBJECTIVE: To measure the orientation of the facet joints of cervical spine (C-spine) segments in the sagittal plane, known as the pedicle-facet (P-F) angle, and to use these measurements to evaluate the relationship between the P-F angle and the amount of vertebral anterolisthesis in patients with degenerative cervical spondylolisthesis (DCS). METHODS: A retrospective case-control study was performed including 30 age- and sex-matched patients with DCS and 30 control participants. Anterior-posterior and lateral view radiographs of the C-spine were obtained in a standing position. The P-F angle at all cervical levels and the amount of anterolisthesis at C4-5 were measured from lateral view plain radiographs. RESULTS: The P-F angles at C4-5 were 141.14+/-7.14degrees for the DCS group and 130.53+/-13.50degrees (p=0.012) for the control group, and at C5-6 were 137.46+/-8.53degrees for the DCS group and 128.53+/-16.01degrees for the control group (p=0.001). The mean P-F angle at C4-5 did not correlate with the amount of anterolisthesis (p=0.483). The amount of anterior slippage did correlate with age (p<0.001). CONCLUSION: The P-F angle was intrinsically higher at C4-5, compared to C5-6, in both the DCS and control groups, which might explain the increased likelihood for anterolisthesis of C4. Higher P-F angles in the DCS group may be a predisposing factor to slippage. The P-F angle may interact with age to increase incidence of anterolisthesis with increasing age.

The Novel Approach of Multiple Colon Cancer Liver Metastases Treatment

Multiple bilobar liver metastases (MBLM) are the main cause of low resectability in the colon cancer liver metastases. The authors experienced one case of initially non-resectable colon cancer liver metastases. He was curatively and safely treated with a two-stage hepatectomy using the new method of future remnant liver volume growing. A 54-year-old man was referred to our department with the sigmoid colon cancer combined with MBLM, which were checked in two small metastatic lesions in the left lobe and five large sized lesions in the right lobe in the computed tomogram (CT). At first, a laparoscopy-assisted anterior resection was performed. We performed the 1st stage hepatectomy 3 weeks after the colon resection. Intra-operative Ultrasonogram (US) found 9 small superficial metastatic lesions in the left lobe. All that lesions were completely removed by non-anatomical wedge resection. An occlusion balloon catheter was placed in the right portal vein through a small branch of the inferior mesenteric vein at that time. The future remnant liver volume was sufficiently increased 3 weeks after the 1st hepatectomy. A right hepatectomy was safely performed 22 days after the 1st hepatectomy. The patient had received a regional chemotherapy (interleukin2 based immuno-chemotherapy through hepatic artery) for 6 months, then has been receiving a systemic chemotherapy (biweekly Oxaliplatin, leucovorin, plus 5-fluorouracil) without any recurrence evidence.

Hepatocellular Carcinoma with Biliary Tumor Thrombi

Hepatocellular carcinoma (HCC) with obstructive jaundice that is caused by bile duct tumor thrombi (BDT) is a rare finding and the appropriate treatment has not yet been detrmined. Some authors have reported that hepatic resection and the removal of the BDT without extrahepatic bile duct resection were sufficient procedures. On the other hand, other authors have reported that it was reasonable to resect the extrahepatic bile duct with the primary lesion. The 55-year-old man was admitted with obstructive jaundice and he was without any other symptoms. Preoperative ERCP (Endoscopic retrograde cholangiopancreatography) and CT (Computed tomography) showed the BDT extending from the main mass in the left lobe to the common hepatic duct. An ENBD (endoscopic naso-biliary drainage catheter) was placed to decrease the serum total bilirubin concentration (17.5 mg/dl on admission). The serum total bilirubin concentration was 4.7 mg/dl one day before the operation. The ICG-R15 was 36% one week before the operation. The serum AFP (alpha-fetoprotein) concentration was 4872 ng/ml. The serum ALP (alkaline phosphatase) and GGT (gamma-glutamyl transferase) concentrations were elevated. The serum albumin concentration and prothrombin time were normal. Left lobectomy, extrahepatic bile duct resection and Roux-en-Y hepaticojejunostomy were performed with stenting each bile duct orifice. Histologically, the BDT had partially invaded the confluence of the bile duct. At present, the patient is doing well without any recurrence of tumor. Many reports have insisted the BDT rarely invades the confluence portion of bile duct. Therefore BDT extraction without extrahepatic bile duct resection is a sufficient procedure for HCC with the BDT. However, this strategy was inadequate for our case.

Electroencephalographic and Clinical Aspects in Subjects with Paretic Form of Cerebral Palsy

There have been few articles describing incidences of epileptiform discharges in EEG and epilepsy in subjects with cerebral palsy(CP) and probably no references about lateralizing significance of EEG and brain imaging findings in asymmetrically quadriparetic patients. We reviewed clinical, EEG and brain imaging findings of one hundred and fifty patients with paretic cerebral palsy to assess incidences of epileptiform discharges(Eds), background abnormalities and epilepsy as well as lateralizing significance of those findings in 52 patients who were asymmetrically quadriparetic. The results were as follows. 1) Incidence of Ebs on serial EEG and epilepsy excluding febrile convulsion were 28.0 %(42/150) and 30.0 %(4S/1SO), respectively. 2) Among 42 patients with Eds, 19(45.2 %) did not have any history of epileptic seizure. 3) In 52 patients who were asymmetrically quadriparetic, unilateral background abnormality or focal BDs were observed in 21 and unilateral brain imaging abnormalities in 13 subjects. There was a positive correlation between side of unilateral EEG abnormalities and the more severely affected side of the body in 17/52 (32.3%), while there was a positive correlation between side of brain imaging abnormalities and the more severely affected side of the body in 12/52 (23.1%). Also, there was a positive correlation between unilateral EEG abnormalities and brain imaging laterality in 8 subjects. In conclusion, if any lateralized abnormalities, EEG as well as brain imaging are thought to be useful in determining the side of maximal brain damage in asymmetrically quadriparetic CP.