Functional MRI study of language organization in left-handed and right-handed trilingual subjects.

Functional MRI (fMRI) is gaining importance in the preoperative assessment of language. Selecting the appropriate language to test by fMRI in trilingual patients is intricate. Our objective is to compare fMRI maps for all three languages in left- and right-handed trilingual subjects. 15 right- and 15 left-handed trilingual volunteers were included in the study. We performed fMRI for each volunteer with a visual responsive naming paradigm that was repeated three times, once in each language. The activated areas and the laterality indices were calculated and correlation with the age of acquisition and proficiency of each language was determined. Strong statistical correlation was found between the Laterality Index (LI) of the three languages, in both the right and left-handed groups. Discordant lateralization of language was only observed in four left-handed subjects who demonstrated bilateral and left-lateralization. In right-handed subjects, the activation maps for the first and the second acquired language were similar. The largest activation was seen with the last acquired language. Irrespective of language proficiency and age of acquisition, the language lateralization might change for left-handed subjects. In right-handed subjects, there is no change and the last acquired language results in the largest activation. fMRI performed for a single language can accurately determine language lateralization in right-handed subjects, whereas in left-handed subjects, it is mandatory to test all languages.

Bupivacaine Field Block With Clonidine for Postoperative Pain Control in Posterior Spine Approaches: A Randomized Double-Blind Trial.

BACKGROUND: The synergistic effect of clonidine with bupivacaine, well established in peripheral nerve blocks, remains controversial in local field block for postoperative analgesia. OBJECTIVE: To investigate the potential analgesic benefit of adding clonidine to bupivacaine during preincisional field block in posterior approaches for spine surgeries. METHODS: Two hundred twenty-five patients were enrolled in this study and underwent lumbar spinal fusion (n = 80), lumbar laminectomy (n = 25), lumbar microdiscectomy (n = 94), or cervical laminectomy (n = 26). In each surgical subgroup, patients were randomly assigned in a double-blinded fashion to receive either 20 mL of 0.25% bupivacaine alone (control group, n = 109) or with 150 µg clonidine (clonidine group, n = 116) in the form of a preincisional field block. Outcome parameters included area under the curve of pain from postoperative day D0 to D8 and rescue morphine consumption from D0 to D3. RESULTS: The area under the curve was reduced in the clonidine group, particularly in the microdiscectomy subgroup, and without reaching statistical significance in the cervical laminectomy subgroup. Total rescue morphine consumption was reduced in the clonidine group, particularly at D1-D2, a benefit that was exclusive to the lumbar stenosis and lumbar fusion subgroups. Field block with clonidine, surgical subgroup, and the presence of preoperative spinal pain were factors independently influencing postoperative wound pain in multivariate analysis. CONCLUSION: The addition of clonidine to local preincisional field block with bupivacaine resulted in better and prolonged postoperative analgesia in posterior lumbar spine surgeries, an effect that was more pronounced in patients with no preoperative spinal pain.

Customized Polymethylmethacrylate Cranioplasty Implants Using 3-Dimensional Printed Polylactic Acid Molds: Technical Note with 2 Illustrative Cases.

OBJECTIVES: Prefabricated customized cranioplasty implants are anatomically more accurate than manually shaped acrylic implants but remain costly. The authors describe a new cost-effective technique of producing customized polymethylmethacrylate (PMMA) cranioplasty implants with the use of prefabricated 3-dimensional (3D) printed molds. METHODS: The first patient had a left frontal cranial defect after a craniotomy for a glial tumor. A 3D image of his skull was obtained from axial 0.6-mm computed tomography (CT) scan images. The image of the implant was generated by a digital subtraction mirror-imaging process using the normal side of his cranium as a model. The second patient had a bifrontal defect after the resection of an infected customized polyetheretherketone implant. A 3D image of the infected implant was directly obtained from an axial 0.6-mm CT scan before discarding it. The images were then used to produce for each patient a mold of the external surface of the cranium using a low-cost polylactic acid 3D printer. Intraoperatively, each mold was put in a sterile bag and then used to cast a customized PMMA implant subsequently trimmed before fixation. RESULTS: Both patients had excellent cosmetic results and underwent postoperative CT scans that showed excellent restoration of the symmetrical contours of the cranium. No neurologic or infectious complications occurred over a 6-month follow-up for either patient. CONCLUSIONS: Making customized PMMA cranioplasty implants via 3D printed polylactic acid molds is a cost-effective technique for delayed reconstruction of various cranial defects.