Staged surgery for irregular giant pituitary adenomas: A report of two cases.

The resection of giant pituitary adenomas is one of the most challenging brain surgeries, especially when the giant pituitary adenomas have an irregular shape or irregular growth position. The purpose of the present study is to propose staged surgery for irregular giant pituitary adenomas through a retrospective analysis of two cases. The cases of two patients with irregular giant pituitary adenomas who underwent staged surgery are retrospectively analyzed. In one case, a 51-year-old male was hospitalized after 2 months of memory loss. Brain MRI showed that the pituitary adenoma was paginated and located in the sellar and right suprasellar regions, with a size of ~6.15×6.11×5.69 cm. In the second case, a 60-year-old male had a history of intermittent vertigo for 10 years and paroxysmal amaurosis for 1 year. Brain MRI showed that the pituitary adenoma grew laterally and eccentrically, and was located in the sellar region, with a size of ~4.35×3.96×3.07 cm. Both patients underwent staged surgery; more specifically, the tumors were totally removed through two-stage surgery. In the first-stage operation, most of the tumor was removed by the microscopic transcranial approach, while in the second-stage operation, the residual tumor was removed by the endoscopic transsphenoidal approach. Both patients recovered well without obvious postoperative complications after staged surgery. There was no recurrence during the follow-up. Staged surgery is characterized by only treating tumors in the visual field and achieving a total tumor resection, which has the advantages of a high tumor resection rate, high safety and fewer postoperative complications. Staged surgery is especially suitable for irregular giant pituitary adenomas with an irregular shape or irregular growth position.

Surgical treatment of severe scoliosis and kyphoscoliosis by stages.

BACKGROUND: Although previous reports had reported the use of temporary internal distraction as an aid to correct severe scoliosis, two-stage surgery strategy (less invasive internal distraction followed by posterior correction and instrumentation) has never been reported in the treatment of patients with severe spinal deformity. This study aimed to report the results of the surgical treatment of severe scoliosis and kyphoscoliosis by two-stage and analyse the safety and efficacy of this surgical strategy in the treatment of severe spinal deformities. METHODS: A total of 15 patients with severe scoliosis, kyphoscoliosis or kyphosis who underwent two-stage surgeries (less invasive internal distraction followed by posterior correction and instrumentation) were studied based on hospital records. Pretreatment radiographs and radiographs taken after first surgery (internal distraction by two small incisions), before second surgery (posterior correction, instrumentation and fusion), one week after second surgery and final follow-up were measured. Subjects were analyzed by age, gender, major coronal curve magnitude, flexibility of major curve, major sagittal curve magnitude before first surgery, after first surgery, before second surgery, after second surgery and at final follow-up. Complications related to two-stage surgeries were noted in each case. RESULTS: The average major curve magnitude was 129.4° (range, 95° to 175°), reduced 58.9° or 45.4% after first stage surgery and reduced 30.6° or 24.6% after second stage surgery. The loss of correction during the interval between two surgeries was 7.1%. The total major coronal curve correction was 81.4° or 62.9%. At the final follow up, the average loss of correction of major coronal curve was 3.9° and the final average correction rate was 59.7%. The average major sagittal curve magnitude was 80.3° (range, 30° to 170°), and the total major sagittal curve correction was 48.2°. Loss of correction averaged 4.0° for major sagittal curve and the final correction averaged 42.2°. Clinical complications were noted in the peri-operative and long-term periods. CONCLUSIONS: Two-stage surgery was a safe and effective surgical strategy in this difficult population. Using two-small-incision technique, the first stage surgery was less invasive. No permanent neurologic deficit was noted in this series.

[Balloon inflating and cement filling for treatment of avascular necrosis of the femoral head: a three-dimensional infinite-element study].

OBJECTIVE: To evaluate the biomechanical changes of balloon inflating and cement filling in avascular necrosis of the femoral head using finite-element analysis. METHODS: The procedure of percutaneous balloon inflating and cement filling was simulated in fresh specimen of human femoral head. CT scan and three-dimensional reconstruction were used to establish the three-dimensional model of the femoral head. The physiological load was analyzed using three-dimensional finite element model to simulate the load and calculate stress on the hip during walking. Finite element analysis was performed on the avascular necrosis model and balloon inflating and bone cement filling model to measure the Von-Mises force at the top, neck and weight-bearing area of the femoral head. Another 8 fresh specimens of femoral head necrosis of human were obtained to stimulate balloon inflating and bone cement filling procedures, and the displacement of the femoral head under different loads was recorded before and after the procedures. RESULTS: After bone cement filling in the necrosis area, the load reduced significantly in the weight-bearing area of the femoral head, and the load distribution became more uniform at the femoral neck and the top of the head. The anti-deformation ability of the necrosis femoral head increased after bone cement filling. The infinite-element analysis and specimen biomedical test showed similar results. CONCLUSION: Percutaneous balloon inflating and bone cement filling in the necrosis area can change the biomechanics mechanism of the femoral head and neck, improve the supporting capacity under load, and prevent the progression of head collapse.

[Clinical application of posterior paramedian approach in low back surgeries].

OBJECTIVE: To prospectively evaluate the clinical effects of posterior paramedian approach in nerve root decompression and reducing muscle damage in low back surgeries. METHODS: Study group included 30 cases treated from January 2007 to May 2008, DDD 8 cases, spondylolisthesis 6 cases, LDH 11 cases, Low back surgery failure re-operation 5 cases. Based on the comprehensive understanding of modern spine anatomy, we abandoned laminectomy in our procedure, applied a mid-waist skin incision, dissect to the paraspinal muscles where you could easily reach the facets by separating between the multifidus and longissimus, enlarge the canal by performing resection along ligamentum flavum and the inner broader of the articular process, remove enough tissue till you could expose the traversing root and the disc space, this method could achieve a limited but precise and effective decompression with not taking out all of the articular process. Once the anatomy mark of the pedicle is located (usually would be at the central area of the incision), pedicle screws placement would be precise and easy without struggling with muscle traction. The following procedures would be Spondylolisthesis reduction, discectomy and interbody fusion. RESULTS: Post-op patients of study group all showed significant improvement of pain symptoms, VAS reduced from 7.14 + or - 1.8, pre-op to 1.39 + or - 0.72 post-op, narrowed disc space regained height, spondylolisthesis reached anatomic reduction, no complications such as pedicle screw misplacement and nerve root damage were found, the lumbar spine regained it's physiological lordosis structure. Significant difference is discovered (P < 0.001) in statistic study concerning the rate of intractable low back pain between pre-op and post-op. CONCLUSIONS: Applying low back surgery through posterior para-median approach could directly reach the inferior/superior facets and the "soft" structures of the spinal canal, expose the exact decompression region and anatomy mark of the pedicle in the central surgical field without strong retraction on the para-spinal muscles. This approach has the advantage of lowering the surgical difficulty of implantation, reducing the risk of nerve damage and is also a minimum invasive procedure. In many cases, laminectomy is unnecessary, leaving the lamina intact could preserve the physiological anatomy of the spine.

Balloon kyphoplasty: an experience of 38 patients with painful osteoporotic vertebral compressive fractures.

OBJECTIVE: To evaluate the efficacy and safety of percutaneous balloon kyphoplasty as a new therapy for patients with painful osteoporotic vertebral compressive fractures of the lumbar and thoracic spine. METHODS: A retrospective analysis was conducted in 38 consecutive patients (28 females, 10 males), whose ages ranged from 56 to 82 years (mean age 72 years). The symptom- and sign-positive spinal segment was identified by MRI. The time between onset of symptoms and surgical intervention ranged from 2 days to 1 year. 62 segments (36 thoracic, 26 lumbar) were treated in this cohort. The pain score estimated by Visual Analog Scale and activity degree were assessed immediately after operation and at 1-, 6-, and 12-month postoperative follow-up. Preoperative and postoperative anterior, midline vertebral heights in fractured vertebrae were measured on lateral radiographs to evaluate the effect of the procedure. RESULTS: The method achieved a swift pain relief associated with an evidently increased weight-bearing ability. The pain score was reduced from 8.2 to 2.4 points. The anterior and midline vertebral heights in 62 fractured vertebral bodies increased up to 82.76%+/-26.84%, 88.82%+/-21.75% and the wedge decreased from 15 to 8 degrees. This effect persisted at least over a period of two years. The procedure did not induce narrowing of the spinal canal and no severe complications occurred. CONCLUSIONS: Balloon kyphoplasty can result in immediate clinical improvement of mobility and pain relief, increase vertebral body height, and quickly return patient's activity. The short-term results are approved excellent, and the long-term results need further judgment.

[Kyphoplasty for treatment of non-osteoporotic thoracolumbar compressive fractures: analysis of 17 cases].

OBJECTIVE: To evaluate the efficacy and safety of kyphoplasty for treatment of non-osteoporotic compressive fractures of thoracolumbar vertebrae. METHODS: Seven patients of non-osteoporotic thoracolumbar compressive fractures confirmed by plain X-ray examination and CT scanning, 14 males and 3 females, aged 35.2, all suffering from one level fracture, at T9 in 1 case, T11 in 2 cases, T12 in 7 cases, L1 in 5 cases, L2 in 1 case, and L3 in 1 case were. treated with percutaneous kyphoplasty. Under local anesthesia Kypho-X vertebra expander was inserted into the vertebral body and polymethylmethacrylate (PMMA) bone cement was filled. Then the patients were followed up for 6 months (6-24 months) by using the visual analog scale, Oswestry disability index (ODI), and the vertebra height and kyphosis were analyzed. RESULTS: All patients underwent the procedure safely. Except for two cases with complication of para-vertebra cement leakage no other complication occurred. The average surgery time was 55 min. All patients became able to get up of bed 2 days and discharged 7 days postoperatively and continued to be protected by hard prosthesis for two weeks more. The average score of VAS was 8.7 before the operation, and then gradually decreased, to 3.2 and 2.7 1 and 4 weeks postoperatively, and became 2.1 at the last follow-up (all P < 0.05). The average ODI score was 72.3 before the operation, and then gradually decreased to 48.6 and 28.9 1 week and 4 weeks postoperatively, and became 22.4 at the last follow-up (all P < 0.05). The average height of the vertebra was 14.3 mm preoperatively, and increased to 24.7 mm 1 week postoperative and 22.4 mm at the last follow up (both P < 0.05). The kyphosis of the fractured vertebra was 31.1 degrees preoperatively and decreased to 9.6 degrees 1 week postoperatively and 10.9 degrees at the last follow up (both P < 0.05). All patients returned to their previous work and life within 2 months postoperatively. CONCLUSION: Percutaneous kyphoplasty is effective and safe in the treatment of non-osteoporotic thoracolumbar compressive fractures with the advantages of minimum invasiveness, fast pain relief and recovery, as well as restoration of vertebra height and correction of kyphosis.

[Characteristic of medical support and health care for Shenzhou-5 and Shenzhou-6 astronauts at main landing site].

OBJECTIVE: To investigate the characteristics of medical support and health care for the Shenzhou-5 and Shenzhou-6 astronauts at the main landing site, with special emphasis on the technical requirements for two astronauts during flight, in order to provide reference data for medical support in the battle field and disasters. METHODS: The data associated with accidental injuries of astronauts during the space flight collected from foreign nations and domestically were reviewed retrospectively. Based on the experience in medical support for Shenzhou-5 and Shenzhou-6 astronauts and the special environments of field operations, a scheme for first-aid and emergent treatment were drafted for a system of organization, prophylactic measurements, equipment and their effective implementation pending the test in the real situation. RESULTS: Two sets of high-quality intensive care unit (ICU) equipment were set up in helicopters, and an ambulance was equipped with the instruments and facilities that could be used in the first-aid and surgical operation in case accident and injuries should happen. The three sets of highly mobile ICU mentioned above could cover a vast area of both grassland and desert at the landing site to ensure that the astronauts could be rescued should accident occur, reaction to emergency would be most rapid and technique and equipment would be best. This scheme of first-aid for emergency which might occur in astronauts would seem to be a scientific, reasonable and practical system and would also meet the need in battle field. CONCLUSION: The first-aid scheme for astronauts at the main landing site, and its equipment, first aid strategies as well as it execution might provide an advanced system for medical aid and emergency treatment in the battlefield, disasters, and other special occasions.

[Establishment of a mobile intensive care unit].

OBJECTIVE: To discuss the experience of establishment of a mobile intensive care unit (ICU) for emergency treatment following astronaut flight, disaster, and regional war. METHODS: The data from both foreign and our countries as well as our own clinical experience of first-aid were reviewed, and a mobile ICU was established, including the equipment, supply of drugs, training, and organization. RESULTS: The mobile ICU was set up at the site of landing of the first Chinese astronaut, and proved to be efficient. The new model could be expected to be prompt in first-aid for casualties in disasters and warfare. CONCLUSION: The first-aid on spot of casualties might reduce the rates of invalidity and mortality during disasters and regional war.

[Selection of surgical procedure for the treatment of idiopathic scoliosis].

OBJECTIVES: To discuss and evaluate the selection of surgical procedure for the treatment of idiopathic scoliosis according to the location and degree of the deformity. METHODS: 175 patients with idiopathic scoliosis underwent surgical treatment with correction and fusion. The patients were divided into four groups according to the location and degree of the deformity and four different procedures were used for each group. For each group, the blood loss, surgery time, correction rate, loss of correction at final follow up and complications were compared and analyzed. RESULTS: All patients underwent surgery safely and no neurological complication occurred. The correction rate was 81% for Group I, 86% for Group II, 68% for Group III and 72% for Group IV. All patients were followed up at least 2 years and the average time was 38 months (24 approximately 52). CONCLUSION: Proper selection of surgical procedure according to the location and degree of the scoliotic deformity, satisfactory results can be achieved in the treatment of idiopathic scoliosis.

[Measure on medical care and rescue for the first Chinese astronaut during manned space flight].

OBJECTIVE: To discuss the experience of medical care and rescue for the first Chinese astronaut during manned space flight. METHODS: Review the experiences of foreign nations in respect to accidental injuries of astronaut during manned space flight, the possible reasons were analyzed, and accordingly a reasonable and effective prophylactic measures and health care were formulated. RESULTS: An effective mobile intensive care unit (ICU) was established on desert or prairie where the capsule would land, so as to ensure the safety of the first Chinese astronaut, and to provide intensive care as well as successful emergency treatment in case of accidental injuries. CONCLUSION: Reasonable and effective prophylactic measures and health care appear to be an important aspect of the successful manned space flight.