Prospective comparison of the therapeutic effect of teriparatide with that of combined vertebroplasty with antiresorptive agents for the treatment of new-onset adjacent vertebral compression fracture after percutaneous vertebroplasty.

UNLABELLED: Most post-vertebroplasty new-onset adjacent vertebral compression fractures (VCFs) occur within 2-3 months, and antiresorptive agents do not significantly reduce the risk of their occurrence. In opposite mechanism, teriparatide directly stimulates bone formation and improves bone strength and quality faster. The therapeutic effect of teriparatide is better than that of vertebroplasty combined with an antiresorptive treatment and is a potentially useful therapy for new-onset adjacent VCFs after vertebroplasty. INTRODUCTION: Following vertebroplasty, patients are at increased risk of new-onset adjacent-level VCFs. The therapeutic effect of antiresorptive agents is too slow, and they are associated with the risk of new VCFs. Teriparatide markedly increases bone formation and strength and reduces the incidence of new-onset VCFs. This prospective cohort study compared the therapeutic effects of teriparatide with those of combined vertebroplasty and an anti-resorber for treating new-onset adjacent VCFs after vertebroplasty. METHODS: Fifty patients with adjacent VCFs were randomly assigned to two groups: teriparatide only (group A) and additional vertebroplasty combined with an antiresorptive agent (group B). Relevant clinical data of the two groups were prospectively compared. RESULTS: The 22 patients in group A were at higher risk of new VCFs than those in group B (22 patients); they were older and had more pre-existing fractures (p < 0.05). Patients treated with teriparatide had a significantly lower incidence of new-onset VCFs (odds ratio = 0.21; 95% confidence interval, 0.02-2.10). Teriparatide-mediated VCF reduction was 78.57%, which was markedly better than that of group B. The teriparatide group had a significant decrease in the visual analog scale and an increase in the Japanese Orthopedic Association low back pain score after 6 months of treatment (p < 0.05). The increase in lumbar spine BMD was marked in the teriparatide group (21.70% vs. 6.87%) after an 18-month treatment. CONCLUSIONS: Treatment of post-vertebroplasty adjacent VCFs with teriparatide (no new vertebroplasty) was more effective than that of repeated vertebroplasties combined with an anti-resorber.

Atlantoaxial rotatory subluxation in skeletally immature patients.

Treatments of atlanto-axial rotatory subluxation in children are generally conservative. Previous reports have proposed that surgical treatment be reserved for fixed rotatory subluxation of more than 3 months duration, irreducible deformity or cases of recurrence. Six skeletally immature patients with Fielding type III atlanto-axial rotatory subluxation were treated conservatively with or without subsequent atlanto-axial arthrodesis. The follow-up period for all the cases exceeded 18 months. Results and outcomes were analysed with an emphasis on the delay until diagnosis, causes of delays in diagnosis and factors influencing the necessity of surgical intervention. Neither mortality nor major morbidity was noted in any cases in this study. In our experience, type III fixed rotatory subluxation of 6 weeks duration will potentially recur. We recommend early surgery for type III fixed rotatory subluxation of more than than 3 months' duration, with atlanto-axial arthrodesis being a safe and effective procedure in children.

F wave monitoring during surgery for adult tethered cord syndrome--a case report.

We would like to report our first attempt in intraoperative study of F wave response electromyography (EMG) to monitor the spinal motor function during a spinal surgery for excision of a giant lumbosacral lipoma.

Motor control assessment for rhizotomy in cerebral palsy.

OBJECTIVE: To apply motor control assessment for selection of appropriate spastic cerebral palsy children to receive selective posterior rhizotomy (SPR). DESIGN: Forty children with spastic cerebral palsy (3-16 yr) were divided into three groups: "independent ambulator," "dependent ambulator," and "nonambulator." Another 18 healthy children were selected as the control group. Both motor control (tested by using polyelectromyography (PEMG)) and clinical ambulatory capability were assessed within 1 mo before SPR and 12 mo after. PEMG patterns were classified into seven patterns according to electromyographic activities during hip/knee flexion and extension. Gait patterns, which were analyzed by computer DynoGraphy, were classified into four patterns for children with ambulatory capability. RESULTS: PEMG and gait patterns were correlated with ambulatory ability. PEMG patterns 2-3 could predict independent ambulatory ability, whereas patterns 6-7 will interfere with ambulatory ability. PEMG patterns showed significant improvement after SPR in the ambulatory groups (P < 0.05), whereas they did not improve in the nonambulator group. Children with cerebral palsy with co-contraction of proximal/distal muscles had better results after SPR, whereas those with diffuse co-contraction or reduced electromyography activities had poor results. CONCLUSIONS: PEMG patterns may allow the physician to select the appropriate children with spastic cerebral palsy to receive SPR with good results.

Coexistence of oto-palato-digital syndrome type II and Arnold-Chiari I malformation in an infant.

A Taiwanese infant with clinically apparent oto-palato-digital syndrome type II had Arnold-Chiari I malformation. Arnold-Chiari I malformation has not been reported previously to occur in association with oto-palato-digital type II syndrome. The pathogenesis of both conditions has remain unclear although the Arnold-Cliari I malformation is most likely due to a developmental abnormality of improperly times or incomplete closure of the neural tube. We propose the physician who care for children with OPD type II must be aware of one more condition.

Dermoid cyst with dermal sinus tract complicated with spinal subdural abscess.

Spinal subdural abscess caused by spread of infection with the dermal sinus tract is rare in children. This article reports on a 1-year-old male with prolonged fever, progressive paraplegia, and bowel and bladder dysfunction resulting from a spinal subdural abscess secondary to an infected spinal dermoid cyst with a dermal sinus tract. This is the youngest patient to be reported having this condition. Surgical intervention was performed to find a tumor that had capsule and keratinlike contents. Culture of the abscess was positive for Escherichia coli and Bacteroides vulgatus. He received 6 weeks of parenteral antibiotic treatment. This patient illustrates the importance of urgent radiologic examination, immediate surgical resection, and appropriate antibiotic therapy for spinal subdural abscess.

Efficacy of surgical treatment in traumatic central cord syndrome.

BACKGROUND: Controversy surrounds the treatment of traumatic central cord syndrome (TCCS), as there are strong advocates for nonsurgical treatment for most patients. However, conservative treatment has been shown to yield a longer period of discomfort from pain and weakness in certain cases. METHODS: In a retrospective review of 114 patients presenting with acute or chronic TCCS from 1988-94, four different age groups were separately observed under different treatments. Motor and sensory recovery were assessed. RESULTS: Better results were achieved in younger patients, with or without radiographic abnormalities, and in patients with clinically correlated encroaching cord lesions who received early surgical decompression. CONCLUSIONS: Surgical intervention for TCCS must be addressed with careful clinical and radiographic survey. Removal of offending lesions in the subacute period results in significant motor and sensory improvement in short-term and long-term follow-up.

Intracerebral osteoma: case report.

A 28-year-old woman presented with 6 months of intractable left frontal headache that was proved to be due to an intracranial lesion. After successful surgical removal, it was found to be an intracerebral osteoma without a dural attachment. The literature of intracerebral osteoma is reviewed.

Retrodental fibrocartilaginous mass. Report of a case.

STUDY DESIGN: This is a report of a 63-year-old woman with a retrodental fibrocartilaginous mass and myelopathy. OBJECTIVE: To describe the pathophysiology of the retrodental fibrocartilaginous mass formation and its association with the C2-C3 disc. SUMMARY OF BACKGROUND DATA: High cervical disc protrusion is an uncommon condition and presents even more rarely as a craniovertebral junction mass with spinal cord compression. Uncertainty remains regarding the etiology of its formation in the retrodental region. METHODS: The patient underwent surgical intervention with transoral decompression and posterior C1-C2 skeletal fusion with bony graft. RESULTS: On the basis of dynamic plain radiographs, magnetic resonance imaging, and surgical pathology, the origin of the mass may have been the C2-C3 disc. CONCLUSIONS: We hypothesized that the mechanism underlying the posterior odontoid fibrocartilaginous mass with spinal cord involvement most likely originate upward migration of the C2-C3 annulus fragment to the atlantoaxial joint as a result of aging. Secondary fibrocartilaginous metaplasia plays a major role in creating such disc-like material. To prevent unrecoverable myelopathy, early detection and anterior decompression with posterior C1-C2 skeletal fixation and bony fusion are the best treatment methods.

Spinal cord herniation after stabbing injury.

A 19-year-old man presented with delayed paraplegia on the second day after a stab injury of the spine. Magnetic resonance imaging showed herniation of the spinal cord through the dural defect. After emergency surgery, his paraplegia recovered leaving a Brown-Sequard syndrome immediate after injury. Spinal cord herniation should be considered as one of the possible factors in patients developing neurological deterioration after a stab injury of the spine. The possible pathogenesis of symptomatic non-spontaneous spinal cord herniation is discussed.

Early seizures after severe closed head injury.

BACKGROUND: We studied the incidence and clinical significance of early post-traumatic seizures after severe closed head injury. METHODS: This prospective study is based on clinical observation of 3340 adult patients with severe closed head injuries, each of them having a Glasgow Coma Scale (GCS) 3 to 8 after trauma. Anticonvulsant agents were not given to these patients unless there was evidence of seizure. RESULTS: One hundred and twenty-one patients (3.6%) experienced seizures within 1 week after head injury; 42 of these (1.26% of the series) had seizures within 24 hours after trauma. The incidence of intracerebral parenchymal damage was found to be higher among those patients who developed seizures in the first week (66.1%) than in those who did not (62.7%). However this result did not reach statistical significance. The patients with early seizures had a lower mortality rate (p < 0.01). In patients who survived from the initial injury, the occurrence of early post-traumatic seizures did not appear to influence the neurological recovery at 6 months after injury. CONCLUSION: Presence of intracerebral parenchymal damage on CT scan after severe closed head injury does not increase the risk of early post-traumatic seizures. With proper treatment, patients presenting with early seizures may have a lower mortality rate. However, the occurrence of early seizures does not influence the neurological recovery in patients who survive the initial severe closed head injury.

Combined use of stereotactic aspiration and intracerebral streptokinase infusion in the surgical treatment of hypertensive intracerebral hemorrhage.

Stereotactic aspiration is well known for its simplicity and safety in the surgical treatment of hypertensive intracerebral hemorrhage. Postoperative fibrinolytic infusion with urokinase or recombinant tissue plasminogen activator and drainage of liquified hematoma are often used to improve the removal of hematoma. We evaluated the safety and effectiveness of streptokinase in this treatment modality in patients with hypertensive intracerebral hemorrhage or cerebellar hemorrhage. Twelve patients with hypertensive intracerebral hemorrhage underwent stereotactic aspiration using streptokinase as a fibrinolytic agent. There were six cases of putaminal hemorrhage, three of thalamic hemorrhage, and three of cerebellar hemorrhage. All but one patient had a large hematoma and presented with intracranial hypertension. Stereotactic aspiration was undertaken to remove the hematoma. Postoperatively, streptokinase was infused into the residual hematoma every 6 to 12 hours via a catheter implanted during the operation. Liquified hematoma was aspirated by syringe manually just before each infusion of streptokinase. The average duration of the entire treatment was 6 days (range 1-7). The residual hematoma at the end of treatment was less than 10 mL in all patients. Intracranial hypertension also subsided significantly in all patients. Only one patient had aspiration-induced bleeding during the operation. We conclude that stereotactic aspiration of hypertensive intracerebral hemorrhage is relatively safe and simple. Streptokinase can be infused intracerebrally to drain residual hematoma without severe side-effects.

Coexistence of schizencephaly and intracranial arteriovenous malformation in an infant.

A 9-month-old infant had unilateral closed-lip schizencephaly in the right parietal lobe, which coexisted with an arteriovenous malformation in the nearby temporal area. Cranial MR showed a right parietal cleft lined with gray matter between the right lateral ventricle and the subarachnoid space, and cluster hypointensities throughout the right temporal lobe. Cerebral angiography revealed a right temporal arteriovenous malformation with feeding arteries arising from the right middle and posterior cerebral arteries and draining into the right sigmoid sinus via the engorged vein of Labbé.

Cystic meningioma in children: a case report.

The case of a child with a cystic meningioma is reported, along with a review of 25 cases from the literature. Cystic change is more common in infants in the first year of life. Eleven of the 26 cystic tumors were in infants. More than half of the cystic meningiomas in adults are meningotheliomatous, while that is the least common subtype in children. Complete removal of the cyst wall is necessary in the intratumoral type to prevent recurrence.

Tuberculoma en plaque: CT.

A 35-year-old woman presented with a 6-month history of intermittent headaches, vomiting and dizziness. CT showed a plaque-like mass with tiny calcifications along the surface of the left frontal lobe. The mass exhibited heterogeneous enhancement with a few low-density foci. Underlying sulcal obliteration and enhancement and white matter oedema were also noted. Histopathological examination of excised material was consistent with tuberculoma. Recognition of this unusual presentation of intracranial tuberculoma may facilitate appropriate diagnosis and management.

Mesencephalic cavernous hemangioma.

A 49-year-old female had experienced headaches and nausea for 2 months. Neurologic examinations showed mild blurring of the optic disc and limitation of ocular movement. Magnetic resonance imaging (MRI) studies disclosed a mass in the central and right paramedian mesencephalon with rostral extension to the third ventricle and the right side of the thalamus. This tumor had a peripheral low signal ring and a heterogeneous central signal on T1 weighted images. The findings were thought to be consistent with a cavernous hemangioma. The clear anatomic boundary of the lesion was defined by MRI enabling removal of the mesencephalic cavernoma. The patient headache remained well with no neurologic symptoms in the 3 years following the operation.

C1-C2 fracture-dislocations in children and adolescents.

OBJECTIVE: C1-C2 is the predominant level of cervical spine injuries in children and adolescents. Either a fracture of the dens or atlantoaxial dislocation (AAD) without fracture of the dens can occur. We present a number of cases to compare their clinical presentations and discuss the preferred method of treatment. MATERIAL AND METHODS: There were 12 cases of type II odontoid fracture and 10 cases of AAD without fracture over a 13-year period. There was a male predominance and traffic collisions were the major cause of injury. Two thirds of the dens fractures were in children over 13 years of age and seven out of ten dislocations without fracture were under 13 years of age. Eight patients with fractured dens suffered from spinal cord injuries but six of those with dislocations were neurologically intact. Two patients of fractured dens and one with AAD presented with chronic myelopathies because of undetected injuries. RESULTS: Three patients expired because of irreversible respiratory failure. Most of the fractured dens achieved bony union after 3 months of halo-vest immobilization but those patients with AAD without fracture usually needed a fusion procedure. Transoral decompression was performed in two cases of dens fracture malunion. All of the survivors of the dens fracture returned to normal or independent daily living. Six of the AAD patients returned to normal, one had a mild neural deficit, and one had persistent spastic quadriparesis. CONCLUSIONS: There is a higher incidence of atlantoaxial dislocation without fracture in children under 13 years of age and a higher incidence of dens fractures in those over 13 years of age. Those with fractures of the dens are more likely to present with evidence of neural injury while those with AAD are more likely to be neurologically intact; however, a correct diagnosis and proper management are mandatory to prevent chronic myelopathy. Halo-vest immobilization is sufficient for most fractures of the dens in children, with AAD usually requiring a fusion.

Fluctuating hemiparesis caused by a quadrigeminal arachnoid cyst: case report.

A 42-year-old woman presented with intermittent hemiparesis mimicking a reversible ischemic neurologic deficit. Magnetic resonance imaging (MRI) demonstrated a compression of the left side of the midbrain by a quadrigeminal arachnoid cyst without hydrocephalus. After the cystic wall was widely excised under operating microscope, the patient made a good recovery and remained well at a follow-up of 18 months. The absence of hydrocephalus in a symptomatic patient with a quadrigeminal cyst was exceptional, which might result from the early diagnosis with MRI. The use of microsurgical technique made it possible to excise the cystic wall widely and omit a shunting procedure.

Fractured odontoid: the management of delayed neurological symptoms.

Undiagnosed and untreated odontoid fractures are relatively common in developing countries where treatment for minor injuries is not considered. As a result, patients frequently present with neurological deterioration secondary to delayed odontoid dislocation. Fifty-one consecutive patients with this problem were entered into a management protocol and reviewed for this report. After diagnosis, reducibility was analyzed by extension films, and all patients who could not be reduced were initially managed in cranial long traction. Thirty-seven were reduced spontaneously or by traction alone, and 12 required transoral decompression. All underwent posterior C1-C2 fusion. Postoperatively, all were treated in external orthoses. The neurological recovery was excellent in 34 patients. Seven patients could function but had some disability, three patients had disabling spasticity, and three remained bedridden. Four deaths occurred as a result of respirator-dependent patients being taken home for social and financial reasons. As a result of this case-controlled study, we recommend that the treatment protocol first analyze reducibility by extension x-rays and then try traction for as long as 14 days to attempt reduction in patients who did not reduce in extension. Failure of reduction is indication for transoral decompression, and all patients require C1-C2 fusion. The neurological recovery is related to initial impairement but can be satisfactory in > 75% of patients.

Postoperative ambulation of patients with intraspinal neurilemomas and meningiomas.

Factors affecting the postoperative ambulatory state of patients with intraspinal neurilemomas and meningiomas were evaluated in 92 patients who underwent surgery at the Chang Gung Memoriam Hospital. The patients' records were reviewed retrospectively and leg power grading was noted (Medical Research Council of Great Britain grading system, zero to five). Of the 89 patients with a preoperative leg power of 1 or better, 87 could walk with or without aids shortly after surgery. The remaining three patients, with a preoperative leg power of zero, were all wheelchair-bound postoperatively. The presence of sensory deficits and sphincter incontinence did not correlates with a poor postoperative ambulatory state, provided the preoperative leg power was above zero. The average period between the onset of the earliest symptoms and the establishment of the diagnosis was 68 weeks for patients with intraspinal neurilemomas and 71 weeks for those with meningiomas. Surgical for patients with neurilemomas were as good as those with meningiomas. Patients with multiple spinal neurilemomas did not fare any worse after surgery.