Rare vermian pilocytic astrocytoma with recurrent spontaneous hemorrhage in the elderly: A case report and review of literature

Background

Pilocytic astrocytoma (PA) is a benign glial tumor predominately seen in pediatrics and early adolescence with associated overall good outcomes. Very few cases of elderly PA have been reported in the literature, and they are known to display unique anatomic, histologic, and genetic peculiarities distinct from pediatric disease. We report a rare case of vermian PA in an octogenarian with recurrent spontaneous intratumoral hemorrhage as a presenting symptom. Furthermore, a review of the literature on the peculiarities of PA in the elderly will be discussed.

Case Description

An 81-year-old woman presented with features suggestive of repeated posterior fossa hemorrhages characterized by headaches, diplopia, and alteration in sensorium occurring about 5 months apart. Brain neuroimaging showed a cerebellar vermian tumor with features suggestive of repeated intratumoral bleeding. She had an initial ventriculoperitoneal shunting for acute hydrocephalus and subsequently had a suboccipital craniotomy and subtotal tumor excision due to morbid adherence to the brainstem. The histologic diagnosis was PA with Ki-67 <1% and negative for isocitrate dehydrogenase-1. There was a slow but progressive clinical improvement, and she has remained symptom-free for 4 years on follow-up.

Conclusion

PA in the elderly is a rare disease with distinct histologic and genetic peculiarities. This case review showed one of the oldest cases of cerebellar vermian PA presenting with recurrent spontaneous intratumoral hemorrhage, an extremely rare occurrence in benign glioma. Although complete surgical excision is recommended, partial resection is advocated for morbidly adherent tumors. Overall prognosis is worse in elderly PA.

Contrast-enhanced CT rim sign may predict vestibular schwannoma adhesion and postoperative complications

AIM

To investigate the clinical and radiological features to predict adhesion between vestibular schwannoma (VS) and brain tissue which is a critical risk factor for postoperative infarction and residual tumour.

MATERIAL AND METHODS

One hundred and seven consecutive VS surgeries were analysed. After excluding cases without contrast-enhanced (CE) computed tomography (CT), Koos grades 1 and 2, and cases with incomplete clinical data, 44 patients were finally included in the study. Enhancement of the tumour capsule on the brainstem side on CE-CT was defined as the CE-CT rim sign, which was analysed along with clinical characteristics, including tumour adhesion and postoperative complications.

RESULTS

Eight patients exhibited CE-CT rim signs; 17 had tumour adhesions. Four patients had postoperative infarction at the ipsilateral middle cerebellar peduncle; 18 exhibited postoperative infarction and/or residual tumour at the middle cerebellar peduncle. The CE-CT rim sign significantly correlated with tumour adhesion, postoperative infarction, and postoperative infarction and/or residual tumour in the cerebellar peduncle. Univariate regression analysis revealed that the CE-CT rim sign significantly correlated with tumour adhesion (odds ratio [OR] 6.81, 95% confidence interval [CI] 1.18-39.25, p=0.032) and postoperative infarction and/or residual tumour at the cerebellar peduncle (OR 6.00, 95% CI 1.04-34.31, p=0.044).

CONCLUSION

The CE-CT rim sign was identified in 18.2% of patients with VS and significantly correlated with tumour adhesion and postoperative complications, such as postoperative infarction and residual tumour. This study highlights the importance of the preoperative CE-CT rim sign in VS, which is predictive of tumour adhesion and postoperative complications.

Feasibility and limitations of head MRI in patients with cochlear implants

OBJECTIVE

Cochlear implants (CIs) were noncompatible with magnetic resonance imaging (MRI) initially; however, recently, implants have become available that are compatible with MRI without the need for magnet removal or bandage fixation. The images produced by MRI scans are sometimes deteriorated by artifacts and are not clinically useful. In this study, we discussed the size differences of such artifacts with respect to the imaging modality and sequences with their clinical validity.

METHODS

We performed a head MRI, using a head bandage and without magnet removal in five patients who underwent cochlear implantation at our department and analyzed the MRI findings.

RESULTS

Without magnet removal, diffusion-weighted images and T2 star-weighted images had larger artifacts and less useful images. T1-weighted images, T2-weighted images (T2WIs), T2-weighted fluid-attenuated inversion recovery (T2-FLAIR) images, and heavy T2WIs could evaluate the unimplanted side and middle of the head but had limited applicability on the CI side.

CONCLUSION

The characteristic features of MRI scan images vary with the method used as well as with the sequence, suggesting that the choice of MRI is largely determined on the basis of clinical feasibility and the requirement. Accordingly, we need to judge well in advance of imaging whether the images would be clinically relevant.

Characteristics of an advanced epilepsy treatment gap in a region in Japan

To investigate the quality of epilepsy care in a region in Japan that lacked specialised care, we retrospectively evaluated patients who visited our newly established epilepsy division between April 2018 and March 2021, and had been treated with anti-seizure medications (ASMs) for at least 1 year prior. Of the 231 patients included, 169 had ongoing seizure episodes at first visit (seizure-persist group) and 62 had no seizure episodes for more than a year (seizure-free group). Eighty-three patients in the seizure-persist group had not received specialised epilepsy care, 15 had been treated with unnecessary medications, and seven had experienced side effects from ASMs. Twelve patients in the seizure-free group had been treated with unnecessary ASMs, 10 had been treated with ASMs with teratogenic potential and four had experienced ASM side effects. These patients could be classified as having an advanced epilepsy treatment gap (ETG) because they had not previously received necessary specialised care. The progressive decline in the number of patients with advanced ETG suggests that our new epilepsy division has addressed this issue. This study highlights that a significant number of patients with advanced ETGs exist in Japan and that proper countermeasures are required to address this gap.

Postoperative hematoma can be a risk factor in delayed facial palsy after vestibular schwannoma resection via a retrosigmoid approach: a retrospective single-center cohort study

PURPOSE

Delayed facial palsy (DFP) is a rare postoperative complication after vestibular schwannoma (VS) surgery. The exact mechanism of DFP remains uncertain and the risk factors for DFP are still controversial. The authors aimed to investigate the characteristics, risk factors, and etiology of DFP after VS resection retrospectively.

METHODS

Ninety-one consecutive surgeries with VS were analyzed. Patients with neurofibromatosis 2 in eight surgeries and postoperative facial palsy House-Brackmann (HB) grade more than 3 in two surgeries were excluded. Eighty-one surgeries were included in this research. Facial nerve function was evaluated using the HB grade. Delayed facial palsy was defined as deterioration in the facial function of at least 1 HB grade more than 1 day after undergoing VS resection. The characteristics of patients with VS and risk factors for DFP were analyzed.

RESULTS

All surgeries were performed via a retrosigmoid approach. DFP was observed in nine patients. There were no statistically significant differences between the DFP group and non-DFP group in terms of the following characteristics: sex, age, side, size, Koos grading system, postoperative facial palsy, or extent of resection. Postoperative hematoma in the cerebellopontine angle (CPA) cistern was significantly higher in the DFP group than in the non-DFP group (p = 0.0023), and was significantly associated with DFP after VS surgery (odds ratio 18.40, p < 0.001). DFP improved in seven patients, but two patients did not improve.

CONCLUSION

DFP occurred in 11.1% of patients after VS surgery. This study revealed that postoperative hematoma in the CPA cistern was significantly associated with DFP after VS surgery.

The Importance of Intratumoral Venous Drainage Preservation in Two-Stage Surgery of Large Hypervascular Choroid Plexus Papilloma: A Case Report

Two-stage surgery may be necessary when total tumor removal cannot be accomplished in the first surgery; however, the extent and condition in which the remaining tumor should be before the next surgery have not yet been established. There is a risk of postoperative hemorrhage in the residual tumor, especially in hypervascular tumors. We report a case of hypervascular choroid plexus papilloma (CPP) in a 22-year-old male patient where the preservation of intratumoral venous drainage was considered important to avoid hemorrhagic complications during a two-stage surgery. In the first surgery, it was difficult to control the bleeding from the debulked tumor, and the surgery was terminated due to severe blood loss. Large draining veins running in the tumor were preserved as it was suspected that these were important drainage routes of the bloodstream of the tumor. The preserved draining red veins changed to normal venous color in the second surgery performed after one week. The residual tumor was not vascularized during the second surgery and underwent gross total resection with less blood loss. The patient was discharged without sequelae. There was no recurrence of the tumor and no neurological deficit during the three-year follow-up. To prevent postoperative hemorrhage associated with a residual tumor, it may be important to preserve venous drainage of the tumor in hypervascular tumor resection.

Unexpected recovery from complete deafness to normal hearing post surgical excision of a cerebellopontine angle meningioma: A case report

Background

Cerebellopontine angle (CPA) meningioma presents a significant management challenge due to its intricate relationship with the brainstem neurovascular bundles. The emphasis in the past has been on facial nerve preservation, but the current management standard is hearing preservation in patients with serviceable hearing; however, hearing restoration after complete loss is rare. We report an elderly man who had restoration of hearing in the right ear after complete loss following tumor resection through the retrosigmoid route.

Case Description

A 73-year-old male patient presented with progressive hearing impairment in the right ear, culminating in hearing loss for about 2 months (the American Academy of Otolaryngology-Head and Neck Surgery [AAO-HNS] class D). He also had mild cerebellar symptoms, but other cranial nerves and long tracts were normal. Brain magnetic resonance imaging confirmed a right CPA meningioma, and he had tumor resection through the retrosigmoid route using meticulous microsurgical technique with vestibulocochlear nerve preservation, facial nerve monitoring, and intraoperative video angiography. He had restoration of hearing on follow-up (the American Academy of Otolaryngology-Head and Neck Surgery class A). Histology confirmed World Health Organization central nervous system grade 1 meningioma.

Conclusion

This case illustrates that hearing restoration is possible after complete loss in patients with CPA meningioma. We advocate hearing preservation surgery even in patients with non-serviceable hearing, as the chance of hearing recovery is possible.

Postoperative Intratumoral or Peritumoral Hematomas After Vestibular Schwannoma Resection

BACKGROUND

Surgical removal of a vestibular schwannoma is a complex and challenging procedure, which may be complicated by development of postoperative hematomas, particularly after incomplete resection of the tumor.

OBJECTIVE

To investigate the occurrence of postoperative intra- or peritumoral hematomas after surgery for a vestibular schwannoma.

METHODS

This retrospective study evaluated 49 patients (age range 17-78 years) with a vestibular schwannoma, who were treated surgically via the lateral suboccipital approach between 2011 and 2016. The tumors ranged in size from 0 mm (in a case of an intracanalicular lesion) to 56 mm. In 30 cases (61%), total or near-total resection was accomplished, and in 19 cases (39%), subtotal or partial resection was done. On the basis of their bleeding tendency during tumor removal, the patients were divided into a "less-bleeding" (38 cases; 78%) and a "more-bleeding" (11 cases; 22%) subgroups.

RESULTS

A maximal vestibular schwannoma diameter >30 mm, patient age >60 years, and more bleeding during tumor removal were significantly associated with incomplete (subtotal or partial) resection. In six cases (12%), serial computed tomography after surgery demonstrated a postoperative hematoma, which was caused by insufficient irrigation of the surgical field (in two cases) or resulted from peritumoral hemorrhage (in two cases), intratumoral hemorrhage (in one case), or both intra- and peritumoral hemorrhage (in one case). The latter patient required urgent reoperation. In all cases, postoperative hematomas occurred after incomplete (subtotal or partial) resection of a vestibular schwannoma, and their development was significantly associated with more bleeding during tumor removal.

CONCLUSION

For avoidance of postoperative hematomas, careful hemostasis is required after completion of vestibular schwannoma removal, especially in cases with incomplete resection and an excessive bleeding tendency of the tumor tissue.

[Brain Abscess]

Brain abscesses can be caused by bacteria, mycobacteria, fungi, or parasites. The incidence of brain abscess varies from 0.4 to 0.9 cases per 100,000 population. The rate of infection increases in immunosuppressed patients. Approximately 25% of brain abscesses occur in children. Outcomes for patients with brain abscesses have improved over the past 50 years. Despite the advantages in diagnostics and treatment leading to improved outcomes in patients with brain abscess, the overall outcome and quality of life issues in patients with brain abscess remain a challenge in neurosurgery. In this article, the etiology, pathogenesis, diagnostic imaging, and treatment of brain abscesses are discussed.

The Occurrence and Relationship of Postoperative Seizure and de novo Epilepsy after Craniotomy Surgery: A Retrospective Single-Center Cohort Study

Objective

Postoperative seizures and epilepsy are common complications of craniotomy. In this study, we aimed to investigate the characteristics of seizures and epilepsy after craniotomy.

Methods

A total of 293 consecutive craniotomy surgeries were analyzed. Infratentorial surgeries, epilepsy surgeries, surgeries using the same approach conducted for the same patients, and the cases with incomplete clinical data were excluded. A total of 211 surgeries were included in this study. We evaluated the following clinical characteristics in all patients: sex, age, preoperative epilepsy, use of preoperative antiseizure medication (ASM), indication for operation, early postoperative seizure (EPS), delayed postoperative seizure (DPS), and postoperative de novo epilepsy. The day of onset of EPSs was defined as within 7 days post-surgery, and the day of onset of DPSs was defined as later than 7 days and less than 60 days post-surgery.

Results

Twenty-eight patients were previously diagnosed with epilepsy. Nine patients had EPSs (4.3%), and 10 patients had DPSs (4.7%). Seven cases of EPSs and six cases of DPSs were observed in 183 patients without previous epilepsy (3.8% and 3.3%, respectively). Three of the seven patients with EPSs (42.9%) and all six patients with DPSs (100%) developed de novo epilepsy. Postoperative de novo epilepsy was observed in 9 (4.9%) of the 183 patients without epilepsy. EPSs and DPSs were significant risk factors for epilepsy (p &lt; 0.01). The odds ratios of EPSs and DPSs for the development of epilepsy were 12.71 (95% confidence interval [CI]: 3.94–112.80; p &lt; 0.01) and 22.88 (95% CI: 5.38–55.72; p &lt; 0.01), respectively. ASM was administered prophylactically to 51 patients. The prophylactic use of ASMs did not prevent EPSs or postoperative de novo epilepsy.

Conclusion

EPSs and DPSs occurred in 4.3% and 4.7% of the patients, respectively, after craniotomy. Postoperative de novo epilepsy occurred in 4.9% of patients. This study revealed that EPSs and DPSs were risk factors for de novo epilepsy. Previous epilepsy was not a significant risk factor for EPSs. The prophylactic use of ASMs did not prevent EPSs or de novo epilepsy.

Supratentorial Intraparenchymal Neurenteric Cyst Treated by Neuroendoscopic Fenestration: A Case Report and Review of Literature

Neurenteric cysts (NCs) are rare benign congenital neoplasms in the central nervous system that originate from endodermal elements. NCs are more commonly located in the spine than in the brain. Although almost all intracranial NCs are found in the posterior fossa, some have reported supratentorial NCs. The complete excision of the cyst wall is suggested as a curative treatment; however, endoscopic treatment is less discussed. We present a supratentorial intraparenchymal NC in the frontal lobe treated by neuroendoscopic fenestration and review the literature regarding supratentorial NCs. A 43-year-old woman presenting with right hemiparesis and gait disturbance who was found to have a huge cystic lesion with calcification in her left frontal lobe underwent endoscopic fenestration to the ipsilateral lateral ventricle and biopsy. The histopathological diagnosis was consistent with NC. Postoperatively, her right hemiparesis and gait disturbance disappeared. Postoperative MRI showed shrinkage of the cyst. She was discharged without neurological deficits and no recurrence was seen 1 year after surgery. To the best of our knowledge, there have been no reports of a supratentorial intraparenchymal NC treated by neuroendoscopic fenestration. Minimally invasive treatments, such as neuroendoscopic cyst fenestration, can be considered depending on the location of the cyst.

The Efficacy of Intraoperative Passive Language Mapping for Glioma Surgery: A Case Report

Background: Recently, electrocorticographic (ECoG) studies have emphasized the importance of gamma band-based functional mapping in the presurgical localization of the eloquent cortex. Passive functional mapping using ECoG signals provides a reliable method for identifying receptive language areas without many of the risks and limitations associated with electrical cortical stimulation. We report a surgical case of left temporal malignant glioma with intraoperative passive language mapping. Case Description: A 78-year-old woman was diagnosed with left temporal glioma with inspection of her language difficulty. MRI showed a left temporal tumor measuring 74.6 × 50.0 × 51.5 mm in size. Real-time CortiQ-based mapping using high-gamma activity by word-listening and story-listening tasks was performed. Significant listening task-evoked high gamma activities were detected in 5 channels in the superior temporal gyrus and one channel in the middle temporal gyrus. The tumor was grossly removed except for the region corresponding to listening task-evoked high gamma activities. Postoperatively, the patient's symptoms of language comprehension difficulty improved, and no new neurological deficits were observed. Conclusion: Intraoperative passive language mapping was successfully performed, and the patient's language function was well-preserved. Intraoperative passive language mapping, which is applicable in a short time and under general anesthesia, can be an important tool for detecting language areas.

Necessity for craniospinal irradiation of germinoma with positive cytology without spinal lesion on MR imaging-A controversy

Background

Cerebrospinal fluid (CSF) cytology and spinal MR imaging are routinely performed for staging before treatment of intracranial germinoma. However, the interpretation of the results of CSF cytology poses 2 unresolved clinical questions: (1) Does positive CSF cytology correlate with the presence of spinal lesion before treatment? and (2) Is craniospinal irradiation (CSI) necessary for patients with positive CSF cytology in the absence of spinal lesion?

Methods

Multicenter retrospective analyses were performed based on a questionnaire on clinical features, spinal MR imaging finding, results of CSF cytology, treatments, and outcomes which was sent to 86 neurosurgical and 35 pediatrics departments in Japan. Pretreatment frequencies of spinal lesion on MR imaging were compared between the patients with positive and negative cytology. Progression-free survival (PFS) rates were compared between patients with positive CSF cytology without spinal lesion on MR imaging treated with CSI and with whole brain or whole ventricular irradiation (non-CSI).

Results

A total of 92 germinoma patients from 45 institutes were evaluated by both CSF cytology and spinal MR images, but 26 patients were excluded because of tumor markers, the timing of CSF sampling or incomplete estimation of spinal lesion. Of the remaining 66 germinoma patients, spinal lesions were equally identified in patients with negative CSF cytology and positive cytology (4.9% and 8.0%, respectively). Eleven patients treated with non-CSI had excellent PFS comparable to 11 patients treated with CSI.

Conclusion

CSI is unnecessary for germinoma patients with positive CSF cytology without spinal lesions on MR imaging.

Microscopic Navigation-Guided Fence Post Technique for Maximal Tumor Resection During Glioma Surgery

BACKGROUND

The fence post technique, which involves insertion of catheters as fence posts around a tumor, has been widely used to demarcate the tumor border for maximal resection of intraparenchymal tumors, such as gliomas. However, a standard procedure for fence post insertion has not been established, and there are some limitations. To overcome this problem, a simple microscopic navigation-guided fence post technique was developed. The feasibility and efficacy of this novel technique during glioma surgery were assessed.

METHODS

The microscopic navigation-guided fence post technique was used in 46 glioma surgeries performed in 42 patients. Intraoperatively, the preplanned trajectory was overlaid on the microscopic surgical field, and the microscope angle was changed until the entry and target points of the trajectory overlapped. A fence post catheter was inserted as planned under microscopic view, and the tumor was resected with fence post guidance. Preoperative tumor characteristics and surgical outcomes were evaluated.

RESULTS

Mean age of patients was 50 years (range, 16-78 years), and 19 (45%) of 42 patients were women. Maximal safe resection was successfully achieved in 45 surgeries (97.8%), which was planned preoperatively with identification of the tumor border with fence posts without adverse effects of brain shift. No surgical complications attributable to fence post insertion occurred.

CONCLUSIONS

Clinical experience indicated that the microscopic navigation-guided fence post technique, in which fence posts can be placed without requiring the surgeon to take their eyes off the microscope, is safe and useful in glioma surgery.

So-called bifocal tumors with diabetes insipidus and negative tumor markers: are they all germinoma?

BACKGROUND

The Delphi consensus statements on the management of germ cell tumors (GCTs) failed to reach agreements on the statement that the cases with (i) pineal and neurohypophyseal bifocal lesion, (ii) with diabetes insipidus, and (iii) with negative tumor markers can be diagnosed as germinoma without histological verification. To answer this, multicenter retrospective analysis was performed.

METHODS

A questionnaire on clinical findings, histological diagnosis, and details of surgical procedures was sent to 86 neurosurgical and 35 pediatrics departments in Japan.

RESULTS

Fifty-one institutes reported 132 cases that fulfilled the 3 criteria. Tissue sampling was performed in 91 cases from pineal (n = 44), neurohypophyseal (n = 32), both (n = 6), and distant (n = 9) lesions. Histological diagnosis was established in 89 cases: pure germinoma or germinoma with syncytiotrophoblastic giant cells in 82 (92.1%) cases, germinoma and mature teratoma in 2 cases, and granulomatous inflammation in 2 cases. Histological diagnosis was not established in 2 cases. Although no tumors other than GCTs were identified, 3 (3.4%) patients had non-germinomatous GCTs (NGGCTs). None of the patients developed permanent complications after endoscopic or stereotactic biopsy. Thirty-nine patients underwent simultaneous procedure for acute hydrocephalus without permanent complications, and hydrocephalus was controlled in 94.9% of them.

CONCLUSION

All patients who fulfilled the 3 criteria had GCTs or granulomatous inflammation, but not other types of tumors. However, no fewer than 3.4% of the patients had NGGCTs. Considering the safety and the effects of simultaneous procedures for acute hydrocephalus, biopsy was recommended in such patients.

Aggressive growing of the infantile cavernous hemangioma of the calvaria: a case report and review of literature

INTRODUCTION

Primary intraosseous cavernous hemangiomas of the skull are very rare in the pediatric age group and usually slow-growing tumors.

CASE REPORT

We present a case of 5-month-old girl with a left occipital cavernous hemangioma that is rapidly growing. The subcutaneous occipital tiny mass was first noted at birth, and the lesion became rapidly enlarged in size and became soft for 3 months. The left occipital subcutaneous lesion was 4.0 × 4.0 × 2.0 cm (AP × LR × HT) in size. There was no history of trauma or bone tumor in her family. She underwent resection of the lesion, and a pathologic diagnosis of calvarial cavernous hemangioma was made. No recurrence was seen 1 year after surgery.

CONCLUSION

The rapid growth of the infant cavernous hemangioma might be related to not only bleeding and/or congestion of the lesion but the immature thin skull of the infant.

Intraoperative Lumbar Muscle Motor Evoked Potential Monitoring With Transcortical Stimulation

BACKGROUND

Stimulating electrodes for lower extremity motor-evoked potential (LE-MEP) monitoring with transcortical stimulation are usually placed on the medial side of motor cortex convexity, which is not lower extremity but lumbar motor area. Lumbar MEP may be elicited with lower stimulation intensity than LE-MEP through this location, and it is useful to monitor lower extremity motor function intraoperatively.

METHODS

Intraoperative lumbar and LE-MEP monitoring with transcortical stimulation during surgery of 12 patients with lesions involving the motor cortex from January 2012 to February 2019 at Shinshu University Hospital were reviewed retrospectively. Stimulations were delivered by a train of 5 pulses of anodal constant current stimulation. Stimulating electrode position was determined by motor cortex mapping. Recording needle electrodes were placed on bilateral lumbar muscles and contralateral leg muscles. The threshold-level stimulation method was used for MEP monitoring. The thresholds, monitoring result, and postoperative motor function of lumbar and lower extremities were compared.

RESULTS

The mean baseline thresholds were 19.9 ± 8.9 mA for lumbar MEP and 26.5 ± 11.5 mA for LE-MEP (P = 0.02). Patterns of intraoperative monitoring changes were the same between lumbar and LE-MEP monitoring.

CONCLUSIONS

Lumbar MEP was stimulated with lower stimulation intensity than the LE-MEP with the same intraoperative pattern of waveform changes in 12 patients. Lumbar MEP monitoring may be useful for preserving the corticospinal tract of lower extremities intraoperatively.

Primary myxoid temporal bone tumor: A rare neurosurgical manifestation of Carney complex?

Background:

Carney complex (CNC) is a rare autosomal dominant syndrome, manifesting mainly with cardiac, cutaneous, and mucosal myxomas. Osteochondromyxoma is known as an extremely rare bone lesion of CNC which usually appears early in life; however, there were no reports of primary bone myxoma of the skull in the patients with CNC. We present the first case of primary myxoid skull tumor in the patient with CNC.

Case Description:

We report the left temporal bone tumor with significant intracranial mass effect in a 58-year- old woman already diagnosed with CNC. Complete resection of the tumor with skull bone reconstruction was carried out. Pathological diagnosis was labeled the lesion as an atypical myxoid spindle cell neoplasm. The features were different from atrial myxoma and osteochondromyxoma which has been described in CNC. There have been no signs of recurrence in 9 years follow-up.

Conclusion:

To the best of our knowledge, there have been no reports of the primary myxoid tumors in the skull in the patients with CNC. This paper highlighted a possible important association between CNC and primary intracranial myxoid tumors.

Determination of Total Dietary Fiber (CODEX Definition) by Enzymatic-Gravimetric Method and Liquid Chromatography: Collaborative Study

A method for the determination of total dietary fiber (TDF), as defined by the CODEX Alimentarius, was validated in foods. Based upon the principles of AOAC Official MethodsSM 985.29, 991.43, 2001.03, and 2002.02, the method quantitates high- and low-molecular-weight dietary fiber (HMWDF and LMWDF, respectively). In 2007, McCleary described a method of extended enzymatic digestion at 37C to simulate human intestinal digestion followed by gravimetric isolation and quantitation of HMWDF and the use of LC to quantitate low-molecular-weight soluble dietary fiber (LMWSDF). The method thus quantitates the complete range of dietary fiber components from resistant starch (by utilizing the digestion conditions of AOAC Method 2002.02) to digestion resistant oligosaccharides (by incorporating the deionization and LC procedures of AOAC Method 2001.03). The method was evaluated through an AOAC collaborative study. Eighteen laboratories participated with 16 laboratories returning valid assay data for 16 test portions (eight blind duplicates) consisting of samples with a range of traditional dietary fiber, resistant starch, and nondigestible oligosaccharides. The dietary fiber content of the eight test pairs ranged from 11.57 to 47.83. Digestion of samples under the conditions of AOAC Method 2002.02 followed by the isolation and gravimetric procedures of AOAC Methods 985.29 and 991.43 results in quantitation of HMWDF. The filtrate from the quantitation of HMWDF is concentrated, deionized, concentrated again, and analyzed by LC to determine the LMWSDF, i.e., all nondigestible oligosaccharides of degree of polymerization 3. TDF is calculated as the sum of HMWDF and LMWSDF. Repeatability standard deviations (sr) ranged from 0.41 to 1.43, and reproducibility standard deviations (sR) ranged from 1.18 to 5.44. These results are comparable to other official dietary fiber methods, and the method is recommended for adoption as Official First Action.

Sagittal band reconstruction in the index finger using a modified Elson technique

PURPOSE

The Elson technique is a rigid reconstruction method for a hypoplastic or absent sagittal band in the treatment of chronic extensor digitorum communis (EDC) tendon dislocation. We performed a modified procedure based on the Elson technique for reconstruction of the radial sagittal band in case involving the index finger. We investigated the postoperative outcomes of chronic EDC dislocation after treatment with the original and modified Elson technique.

METHODS

We examined five fingers of five patients (2 males and 3 females) with a mean age of 41 years. The chronic EDC tendon dislocation was due to an old trauma, or a spontaneous or congenital condition involving the index in two, middle in two, and ring finger in one patient. Sagittal band reconstruction was performed using the modified Elson technique for the index finger and the original technique for the other fingers. The mean duration of postoperative follow-up was 58 months. Clinical findings such as pain and discomfort at metacarpophalangeal flexion associated with the tendon dislocation, range of motion (ROM), and disabilities of the arm, shoulder and hand were evaluated. We also examined postoperative recurrence and subjective patient evaluation.

RESULTS

All cases achieved pain-free stability of the EDC tendon with no recurrence, and full ROM was maintained at the latest examination after surgery. The postoperative subjective evaluation by the patients was "very satisfied" in four fingers and "neutral" in one finger.

CONCLUSION

We demonstrated our modified Elson technique for the treatment of chronic extensor tendon dislocation of the index finger.

Threshold variation of transcranial motor evoked potential with threshold criterion in frontotemporal craniotomy

•

Motor threshold can be variable during surgery in TES-MEP.

•

The motor threshold in TES-MEP was influenced by intraoperative environmental changes.

•

The threshold change was greater on the affected side than on the unaffected side.

Objective

Motor threshold usually varies in the intraoperative motor evoked potential (MEP) by transcranial evoked stimulation (TES). This study investigated the degree of change in the motor threshold before and after surgery in TES-MEP monitoring with threshold criterion. This study aimed to evaluate the threshold change and discuss the factors influencing the motor threshold.

Methods

We retrospectively analyzed TES-MEP monitoring during supratentorial surgery with frontotemporal craniotomy in 72 patients without pre- and postoperative motor weakness. We analyzed the percentage changes between the affected and the unaffected sides, correlating the changes on the two sides.

Results

The percentage change on the affected and the unaffected side was 4.4 ± 15.1% and 0.4 ± 6.5%, respectively. The percentage change on the affected side was significantly larger than that on the unaffected side. A significantly positive correlation between the percentage change on the affected and the unaffected sides was detected.

Conclusion

The threshold for the TES-MEP varied significantly more than that on the unaffected side.

Significance

It is important to understand the characteristics of threshold variation for the evaluation of TES-MEP.

Simultaneous non-union of scaphoid and capitate: a case report

A 44-year-old painter separately developed simultaneous nonunions at the middle of the capitate and distal third of the scaphoid, for which we performed a cancellous bone graft from the iliac crest and a pedicled 1,2-intercompartmental supraretinacular artery graft, respectively. Union of both bones was ultimately achieved.

Comparison of Intraoperative Motor Evoked Potentials Monitoring with Direct Cranial Stimulation by Peg-Screw and Transcranial Stimulation by Corkscrew for Supratentorial Surgery

OBJECTIVE

Corkscrew (CS) electrodes are usually used for transcranial electrical stimulation (TES) in the intraoperative monitoring of motor evoked potentials (MEP). Direct cranial stimulation with peg-screw (PS) electrodes can elicit MEP. The present study investigated the difference in the initial threshold between PS and CS electrodes for intraoperative MEP monitoring.

METHODS

We retrospectively analyzed TES-MEP monitoring for supratentorial surgery in 72 patients. Of these 72 patients, 44 were monitored with PS and CS electrodes (PS/CS group) and 28 were monitored with CS and CS electrodes (CS/CS group). TES was used to deliver electrical stimulation by a train of 4-pulse anodal constant current stimulation. The initial threshold in each electrode was checked and analyzed.

RESULTS

In the PS/CS group, the initial threshold with the PS electrode was 38.3 ± 15.1 mA (mean ± standard deviation) on the affected side, and the initial threshold with the CS electrode was 51.4 ± 13.9 mA on the unaffected side. The initial threshold with the PS electrode was significantly lower than that with the CS electrode (P = 0.0001). In the CS/CS group, the initial threshold was 56.2 ± 16.5 mA on the affected side and 62.1 ± 18.6 mA on the unaffected side, with no statistically significant difference (P = 0.23).

CONCLUSION

The initial threshold to elicit MEP was significantly lower with the PS electrode than with the CS electrode. A PS electrode can be used as a feasible stimulation electrode for TES-MEP.

Intraoperative facial motor evoked potential monitoring for pontine cavernous malformation resection

OBJECTIVE

The aim of this study was to predict postoperative facial nerve function during pontine cavernous malformation surgery by monitoring facial motor evoked potentials (FMEPs).

METHODS

From 2008 to 2017, 10 patients with pontine cavernous malformations underwent total resection via the trans-fourth ventricle floor approach with FMEP monitoring. House-Brackmann grades and Karnofsky Performance Scale (KPS) scores were obtained pre- and postoperatively. The surgeries were performed using one of 2 safe entry zones into the brainstem: the suprafacial triangle and infrafacial triangle approaches. Six patients underwent the suprafacial triangle approach, and 4 patients underwent the infrafacial triangle approach. A cranial peg screw electrode was used to deliver electrical stimulation for FMEP by a train of 4 or 5 pulse anodal constant current stimulation. FMEP was recorded from needle electrodes on the ipsilateral facial muscles and monitored throughout surgery by using a threshold-level stimulation method.

RESULTS

FMEPs were recorded and analyzed in 8 patients; they were not recorded in 2 patients who had severe preoperative facial palsy and underwent an infrafacial triangle approach. Warning signs appeared in all patients who underwent the suprafacial triangle approach. However, after temporarily stopping the procedures, FMEP findings during surgery showed recovery of the thresholds. FMEPs in patients who underwent the infrafacial triangle approach were stable during the surgery. House-Brackmann grades were unchanged postoperatively in all patients. Postoperative KPS scores improved in 3 patients, decreased in 1, and remained the same in 6 patients.

CONCLUSIONS

FMEPs can be used to monitor facial nerve function during surgery for pontine cavernous malformations, especially when the suprafacial triangle approach is performed.

Unilateral isolated hypoglossal nerve palsy due to pathologically adherent PICA fusiform aneurysm - A case report

Background:

Isolated hypoglossal nerve palsy due to mechanical compression by a vascular lesion is rare.

Case Description:

We report the case of a 72-year-old man who presented with a 4-year history of swallowing disturbance and subsequently progressively worsening left-sided tongue atrophy. He was referred to our department by a neurologist due a magnetic resonance imaging detected left vertebral artery compression of the medulla. Neurological examination was unremarkable except for left hypoglossal nerve dysfunction, which presented as left-sided atrophy and impaired movement of the tongue. Three-dimensional computed tomography angiography showed proximal left posterior inferior cerebellar artery (PICA) origin fusiform aneurysm. Microvascular decompression was done through a left transcondylar fossa approach. Intraoperative findings were thickened arachnoid around the lower cranial nerves, fusiform aneurysm of the left PICA at its origin from the left vertebral artery which was severely adherent to and compressing the left hypoglossal nerve rootlets.

Conclusion:

The PICA has a very close relationship to the hypoglossal nerve, and its fusiform dilatation could cause isolated hypoglossal nerve dysfunction. Pathological adhesions between hypoglossal rootlets and the PICA aneurysm wall could be a possible contributor in the development and progression of hypoglossal nerve palsy.

A Rare Case of Pediatric Lumbar Spinal Ependymoma Mimicking Meningitis

Spontaneous acute subarachnoid hemorrhage (SAH) from lumbar ependymoma in children is rare. We report a case of a 14-year-old boy who developed sudden radicular low back pain while playing baseball. He was initially managed conservatively in a local hospital for suspected lumbar disc herniation, but he later developed meningeal symptoms and fever before being referred to our hospital. He underwent a diagnostic lumbar puncture in the emergency department; his cerebrospinal fluid suggested an SAH. Physical examination showed meningeal signs and cauda equina features. Cerebrospinal fluid analysis was negative for bacterial meningitis. Lumbar magnetic resonance imaging revealed a mass characterized as a hemorrhagic lesion. The patient had an emergent evacuation of the mass through the posterior approach. Postoperatively, his symptoms resolved completely. The histologic diagnosis was, surprisingly, an ependymoma (World Health Organization grade II). This case is particularly interesting because of its rarity in children, and its pattern of presentation. Although bacterial or viral meningitis is the most frequent cause of meningeal features in children, SAH from a hemorrhagic spinal tumor should be considered. Ultimately, a high index of suspicion is needed for prompt diagnosis.

Intraneural Nodular Fasciitis in a Child: A Case Report and Review of the Literature

We present the case of an 11-year-old boy with intraneural nodular fasciitis of the median nerve at the distal part of the carpal tunnel. Complete excision of the involved median nerve and cable grafting using 4 fascicular segments of the sural nerve was performed for persistent pain and numbness after initial resection of the tumor in piecemeal fashion. Pain and numbness were completely resolved and there was no evidence of recurrence 24 months after the final surgery.

Long-term results after a free vascularized adipofascial graft for congenital proximal radioulnar synostosis with an average follow-up of 10 years: a series of four cases

BACKGROUND

The aim of this study was to observe the long-term and chronologic changes in clinical and radiologic findings after a free vascularized adipofascial graft interposition with radial osteotomy for congenital proximal radioulnar synostosis (PRUS).

METHODS

Six forearms in 4 patients with congenital PRUS who underwent a free vascularized adipofascial graft interposition combined with radial osteotomy were followed up for an average of 10 years (8-12 years) postoperatively. Extension and flexion angles of the elbow and pronation and supination angles of the forearm as well as radiographs were evaluated preoperatively and throughout the postoperative follow-up period.

RESULTS

The average extension/flexion angles of the elbow and the average pronation/supination angles of the forearm were 3°/130° and 14°/- before surgery, -4°/135° and 39°/23° at 1 year after surgery, 6°/138° and 44°/30° at 3 years after surgery, and -2°/139° and 35°/7° at the time of the final follow-up, respectively. Final radiographs showed hypertrophy of the radial head in 4 patients, dislocation of the radial head in 2 patients, and deformity of the radial head in 1 patient.

CONCLUSIONS

Extension and flexion angles of the elbow in patients with congenital PRUS were constant and the average range of pronation was relatively well maintained throughout the postoperative period, but the average range of supination decreased by 16° from 1 year postoperatively to the time of the final follow-up.

TRPV1, ASICs and P2X2/3 expressed in bone cells simultaneously regulate bone metabolic markers in ovariectomized mice

OBJECTIVES

Nociceptors are expressed at peripheral terminals of neurons. Recent studies have shown that TRPV1, a nociceptor, is expressed in bone tissue and regulates bone metabolism. We have demonstrated that a TRPV1 antagonist improved pain-like behavior in ovariectomized (OVX) mice. The aim of this study was to determine whether nociceptors, including TRPV1, acid-sensing ion channel (ASIC) and P2X2/3 are expressed in bone cells, and to examine the effects of nociceptor antagonists on bone metabolism.

METHODS

The expression of nociceptors in femoral bone tissue and cultured bone marrow cells in OVX and sham-operated mice were examined. The effects of nociceptor antagonists on the up-regulated expression of bone metabolic markers, Runx2, Osterix, osteocalcin and RANKL, were also examined.

RESULTS

TRPV1, ASIC 2 and 3, and P2X2 and 3, were expressed in bone tissue and bone marrow cells, and the expression levels of ASIC1 and 2, and P2X2 were significantly increased in OVX mice in comparison with those in sham mice. Treatment with nociceptor antagonists significantly inhibited the expression of bone metabolic markers in OVX mice.

CONCLUSION

An array of nociceptors, TRPV1, ASICs and P2X2/3, could simultaneously regulate not only increases in skeletal pain but also bone turnover in OVX mice.

Metachondromatosis without Enchondromas: A Case Report and Review of the Literature

CASE

A nine-year-old boy had multiple osteochondromas in the hands, feet, and tibiae, many of which pointed toward the adjacent joint. Although several were treated surgically, others resolved spontaneously. A heterozygous mutation in the PTPN11 gene was identified by genetic analysis of peripheral blood, so the patient was diagnosed with metachondromatosis despite the absence of enchondromatous lesions.

CONCLUSION

To the best of our knowledge, this is the first reported case of a patient with metachondromatosis without any enchondromatous lesions.

Dural Arteriovenous Fistula Could Be Due to Hemodynamic Disturbance in Dural Physiological Shunts? Histopathological Study and a Case Report

BACKGROUND

Histopathologic studies of dural arteriovenous fistulas (dAVFs) are important for clarifying the pathogenesis. We present a case of Cognard type IV dAVF with detailed histopathologic studies in correlation with radiologic and intraoperative findings.

CASE DESCRIPTION

An otherwise asymptomatic 53-year-old man presented with chronic headache. Neurologic examination revealed no abnormalities. Neuroimaging and cerebral catheter angiographic studies disclosed a left frontoparietal dAVF close to the middle third of the superior sagittal sinus, fed by the left superficial temporal and bilateral middle meningeal arteries and draining into ectatic cortical and dural veins. No evidence of superior sagittal sinus thrombosis or occlusion was seen. Intraoperatively, the parietal branch of the left superficial temporal artery penetrated the skull vault to feed the fistula; arterialized cortical and draining dural veins were also noted. Complete obliteration of the dAVF with removal of the affected dura mater was achieved safely. Histopathologic studies in serial sections documented a shunt point between the dural artery and the dural vein within the dura mater and a draining point between the dural and cortical veins.

CONCLUSIONS

On the basis of clinical, angiographic, intraoperative, and histologic findings in our case, we strongly excluded acquired etiologies.

Effect of simultaneous stretching of the wrist and finger extensors for lateral epicondylitis: a gross anatomical study of the tendinous origins of the extensor carpi radialis brevis and extensor digitorum communis

BACKGROUND

Pulling the wrist into flexion with the elbow in extension and forearm in pronation has been used as the stretching technique of wrist extensors for lateral epicondylitis. Simultaneous stretching of the fingers in addition to the wrist flexion has also been applied. However, the mechanism of this simultaneous stretching has not been clarified. This study is designed to clarify the mechanism underlying this simultaneous stretching technique based on the anatomical features of the origins of the extensor carpi radialis brevis (ECRB) and extensor digitorum communis (EDC).

METHODS

Thirty-nine arms from formalin-embalmed Japanese human specimens were dissected. The features of the origins of the ECRB and EDC were macroscopically observed, and the locations of each origin on the lateral epicondyle were measured.

RESULTS

The ECRB had a long and wide, purely tendinous origin which originated from the anterior slope of the lateral epicondyle. The tendinous origin of the index finger of the EDC (EDC-IF) arose from the posterior aspect of the ECRB tendinous origin, with a coexisting muscular portion observed at the level of the proximal forearm. The middle finger of the EDC (EDC-MF) had a short tendinous origin with an associated muscular portion and originated proximo-laterally to the origin of the ECRB on the lateral epicondyle. In addition, the muscular origin of the EDC-MF arose on the superficial and posterior aspect of the ECRB tendinous origin. In contrast, the ring and little fingers of the EDC originated from the tendinous septum of the extensor digiti minimi and extensor carpi ulnaris, and had no connection with the ECRB tendinous origin.

CONCLUSIONS

On the basis of our anatomical findings, simultaneous stretching of the wrist extensors by wrist, index and middle fingers flexion could provide stretching force to both the tendinous origins of the ECRB and EDC through the EDC-IF and EDC-MF.

Attrition Rupture of the Flexor Pollicis Longus Tendon after Arthrodesis of the Trapeziometacarpal Joint: A Case Report

We report a case of flexor pollicis longus tendon rupture after arthrodesis of the trapeziometacarpal joint with headless screws using the criss-cross technique. Although flexor pollicis longus tendon rupture is a conceivable complication after the trapeziometacarpal joint arthrodesis, very few cases have rarely been reported in the literature. We should remind that screws inserted into the trapezium could lead to a rupture of the flexor pollicis longus tendon.

"Dynamic" Rotational Canal Stenosis Caused by Osteoma of the Atlas: A Case Report and Review of Literature

The upper cervical canal stenosis is relatively rare compared to other cervical regions. We report a rare case of upper cervical canal stenosis caused by osteoma of C1 lamina related to dynamic factor of cervical rotation. A 43-year-old woman had a 2-year history of numbness and pain in the right hand. Because of aggravation of the numbness and loss of the fine movement and strength in the right hand, she visited our outpatient clinic. Computed tomographic (CT) scan revealed an ovoid bony lesion at the right side of the C1 lamina. And magnetic resonance (MR) imagings of the cervical spine showed intramedullary high intensity signals in T₂-weighted imaging at a site slightly distant from the bony lesion. Rotational dynamic myelo-CT scan was performed because aggravation of the radiating pain was observed with neck rotation to the right. Dynamic CT scan of the craniocervical junction with neck rotation to the right revealed that the bony lesion was moved to the dorsal side and posteriorly compressed the spinal cord. The symptoms were relieved following surgical removal of this bony lesion. The histopathological examination was compatible for osteoma. The dynamic rotational factor for cervical canal stenosis should be taken in consideration, especially in dealing with upper cervical lesions.

A Traumatic Partial Through-the-Elbow Amputation with Disarticulation of the Humerus: A Case Report and Review of the Literature

CASE

A fifty-two-year-old fisherman sustained a severely mangled open elbow dislocation; the distal part of the humerus was protruding from the wound. Although all of the soft tissue attached to the distal part of the humerus was stripped off the bone, no neurovascular structures were damaged. A hinged external fixator was applied and a lateral collateral ligament repair was performed. At the final follow-up, the range of elbow motion was -10° in extension and 125° in flexion, with no instability.

CONCLUSION

Despite the near amputation of the limb, a good functional outcome was achieved because the neurovascular structures remained intact.

Local increase in IgE and class switch recombination to IgE in nasal polyps in chronic rhinosinusitis

BACKGROUND

Chronic rhinosinusitis with nasal polyps is generally characterized by local Th2 inflammation and is categorized into two subtypes in Japan: eosinophilic chronic rhinosinusitis (similar to chronic rhinosinusitis with nasal polyps in western countries) and non-eosinophilic chronic rhinosinusitis (characterized by Th1-dominant inflammation).

OBJECTIVE

To investigate local IgE production and class switch recombination to IgE in these two subtypes of chronic rhinosinusitis with nasal polyps.

METHODS

The identity of IgE-positive cells was determined using double-immunofluorescent staining for IgE and cell-type-specific molecular markers. To investigate the local class switch recombination to IgE and IgE synthesis in the mucosa, we performed real-time polymerase chain reaction to examine the mRNA expression of Th2 cytokines and class-switch-related molecules, including IL-4, IL-5, IL-13, ε germline gene transcripts, IgE mature transcript, IgG mature transcript, RAG1, RAG2 and activation-induced cytidine deaminase in eosinophilic polyps, non-eosinophilic polyps and controls.

RESULTS

The concentrations of total IgE and number of IgE-positive cells were significantly higher in the eosinophilic polyps compared with control and non-eosinophilic polyps. IgE-positive cells were predominantly mast cells in eosinophilic polyps and significantly correlated with the number of FcεR1-positive cells in the subepithelial layer. IL-5 and IL-13 mRNA and ε germline gene transcripts expression levels were significantly higher in eosinophilic polyps compared with control and non-eosinophilic polyps. In contrast, the number of plasma cells and the expression of IgG mature transcripts were increased in non-eosinophilic polyps compared with eosinophilic polyps. RAG2 mRNA was significantly increased in both eosinophilic and non-eosinophilic polyps compared with control mucosa.

CONCLUSION AND CLINICAL RELEVANCE

The current study suggests local class switching to IgE, production of IgE and IgE localization to the surface of mast cells in eosinophilic chronic rhinosinusitis in the Japanese population. The difference in the IgE-related profiles between eosinophilic chronic rhinosinusitis and non-eosinophilic chronic rhinosinusitis suggests heterogeneity in the pathogenesis of chronic rhinosinusitis with nasal polyps.

Tumour necrosis factor inhibitor-associated sinusitis

AIM

To describe the features of chronic sinusitis associated with the use of tumour necrosis factor (TNF) inhibitors.

METHODOLOGY

A retrospective review of the medical records between 2003 and 2011 revealed that five patients had developed chronic sinusitis after the start of TNF inhibitor administration and required rhinological evaluation and treatment.

RESULTS

The incidence of refractory sinusitis associated with TNF inhibitors was approximately 2%. Of the five patients identified, four patients were medicated with etanercept and one with infliximab. The maxillary sinus was most commonly involved and cultures of the sinus discharge revealed Pseudomonas aeruginosa in three cases. Two patients showed improvement of sinusitis with antibiotic medication, despite the continuous use of TNF inhibitor, while in two other patients, sinusitis was resistant to antibiotic medication. Another patient who had developed recurrence of sinusitis after complete remission of previous chronic sinusitis by endoscopic sinus surgery showed remission only after cessation of TNF inhibitor.

CONCLUSION

Chronic sinusitis associated with TNF inhibitors is considered to be a new disease entity, and it will become more common due to the increasing use of TNF inhibitors.

Total dorsal capsulectomy for the treatment of mucous cysts

PURPOSE

To describe the technique of total dorsal capsulectomy alone for mucous cysts of the distal interphalangeal (DIP) joint and evaluate its outcomes and complications.

METHODS

Nineteen patients (18 women and 1 man) with 19 mucous cysts were treated by a total dorsal capsulectomy without cyst excision or osteophyte removal. The average age at surgery was 63 years. The thumb was involved in 4 patients, index finger in 1, middle finger in 7, ring finger in 4, and little finger in 3. Twelve patients had nail deformities associated with the mucous cyst. The average period of postoperative follow-up was 26 months. The dorsal half of the DIP joint capsule was resected with a punch and curette. The cyst and osteophytes were left intact.

RESULTS

The average preoperative range of motion for the DIP joint was from 10° of extension to 45° of flexion. Radiographs showed osteophytes at the DIP joint in all affected digits. After surgery, all cysts disappeared at an average of 3 weeks. There was no recurrence at the time of final follow-up. All nail deformities had resolved at an average of 5 months after surgery. The average motion for the DIP joint at the time of final follow-up was from 8° of extension to 56° of flexion. There were no acquired nail deformities or other complications.

CONCLUSIONS

A total dorsal capsulectomy alone was a simple treatment for mucous cysts and did not lead to any recurrence.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic IV.

Innervated thenar pedicle flap with the palmar cutaneous branch of the median nerve for treating a thumb pulp defect: a case report

A 51-year-old male plumber with a thumb pulp defect was treated with a reversed innervated thenar pedicle flap. The flap was based on the radial digital artery originating from the princeps pollicis artery with the palmar cutaneous branch of the median nerve. The flap survived and achieved good innervation with a moving 2-point discrimination of 6 mm at 12 months after surgery. This flap is indicated for patients who hesitate to have tissue taken from the foot. We believe that this flap is a feasible option for reconstructing thumb pulp defects.

Reconstruction of chronic thumb metacarpophalangeal joint radial collateral ligament injuries with a half-slip of the abductor pollicis brevis tendon

PURPOSE

To evaluate a reconstructive method for chronic radial collateral ligament (RCL) injuries of the thumb metacarpophalangeal (MCP) joint using a combination of RCL advancement and the transfer of a half-slip of the abductor pollicis brevis tendon.

METHODS

Eight patients (4 male and 4 female; mean age, 25 y) with chronic RCL injury of the thumb MCP joint were enrolled. All patients were referred to our institution because of continuing pain and instability on the radial side of the MCP joint when grasping or pinching objects. The mechanism of the injury was adduction stress to the thumb during sporting activities in 5 patients, a heavy object falling on the thumb in 1, and a fall in 2. The mean duration from RCL injury to surgery was 20 weeks. The average postoperative follow-up was 51 months. We evaluated postoperative outcomes including pain, range of motion of the thumb MCP joint, grip strength, key pinch strength, Disabilities of the Arm, Shoulder, and Hand score, and ability to return to preinjury work or sporting activities.

RESULTS

No patients demonstrated continuing symptoms, and the MCP joint was stable after surgery. Postoperative grip and pinch strength (37 and 6.3 kg, respectively) were increased compared with preoperative values (34 and 3.9 kg, respectively). All patients returned fully to their preinjury work or sporting activities within 6 months after surgery. Although postoperative flexion was decreased by an average of 6°, no patients noted functional deficiency.

CONCLUSIONS

We recommend the reconstructive method of RCL advancement and transfer of a half-slip of the abductor pollicis brevis tendon to alleviate pain and improve grip and pinch strength in chronic RCL injuries of the thumb MCP joint.

The Thompson procedure for chronic mallet finger deformity

PURPOSE

To evaluate the outcomes of the Thompson procedure for chronic mallet finger deformity and review the utility of this procedure.

METHODS

Seven cases of chronic mallet finger with a swan neck deformity were treated by the Thompson procedure. Ranges of motion for the distal interphalangeal (DIP) and proximal interphalangeal (PIP) joints were measured, and complications were investigated at the final examination. Patients were evaluated using the criteria reported by Abouna and Brown.

RESULTS

Four patients were men, and 3 were women. The average age at the time of surgery was 44 years (range, 25 to 71 y). The middle finger was affected in 4 cases, and the index, ring, and small finger were involved in 1 case each. The average extensor lag on the DIP joint was 42° (range, 35° to 50°). All cases were treated with the Thompson procedure. The swan neck deformity was corrected in all cases. The average motion at the final examination was -4° (range, -30° to 0°) in extension and 91° (range, 85° to 110°) in flexion for the PIP joint and -5° (range, -10° to 0 °) in extension and 63° (range, 45° to 85°) in flexion for the DIP joint. A buttonhole deformity and a dimple at the proximal tied end of the graft were seen in 1 case. Assessment by the criteria of Abouna and Brown revealed that 6 of 7 patients were categorized as cured and one as improved. No patient was categorized as unchanged.

CONCLUSIONS

The procedure provides a predictable method for correcting loss of DIP joint extension with or without PIP joint hyperextension. We believe that the Thompson procedure is an effective technique for the salvage, following failed treatment, of a closed mallet injury with an associated swan neck deformity.

Arthrography in thumb polydactyly with bifurcation at the interphalangeal or metacarpophalangeal joints provides practical information at surgery

We carried out arthrography in 19 thumbs of 18 patients in whom duplication was observed at the interphalangeal (Wassel type II) or metacarpophalangeal (Wassel type IV) joints on radiographs. The average age at surgery was 12.3 months and average duration of post-surgical follow-up was 21.3 months. Based on the arthrographic findings, the types of cartilaginous connections were subdivided into five groups. In group 1, there was a cartilaginous connection at the base of duplicated phalanges. In group 2, there was a cartilaginous connection of the radial digit between the distal and proximal phalanges, or between the proximal phalanx and metacarpal. In group 3, the phalanges separated at a common joint without any cartilaginous connection. In group 4, the radial digit demonstrated fibrous attachment to the capsule without any joint formation. In group 5, each joint was completely separated without any cartilaginous connection. These arthrographic findings could not be detected on radiographs. Different surgical procedures were carried out according to the form of cartilaginous connection.

Union rates and prognostic variables of osteoporotic vertebral fractures treated with a rigid external support

Object

External supports serve as a traditional treatment option for osteoporotic vertebral fractures (OVFs). However, the role of external supports in the treatment of OVF remains inconclusive. The purpose of this study was to determine the role of a rigid external support in the healing of OVFs by prospectively evaluating union (fracture settling) rates and prognostic variables for patients suffering from an incident OVF.

Methods

Fifty-five patients with acute back pain were enrolled in this study after being diagnosed with an OVF based on MRI findings. Patients were treated using a plastic thoracolumbosacral orthosis (TLSO) and underwent follow-up at 2, 3, and 6 months. Vertebrae were referred to as “settled” when there was no dynamic mobility on sitting lateral and supine lateral radiographs. At the time of the 3- and 6-month follow-up visits, the patients were divided into 2 groups, the “settled group” and the “unsettled group.” Patients in these groups were compared with regard to clinical and radiographic features.

Results

Of the 55 patients enrolled, 53 patients were followed up for 6 months. There were 14 men and 39 women with an average age of 75.3 years. Fracture settling of the affected vertebra was defined in 54.7% of the patients at 2 months, in 79.2% at 3 months, and in 88.7% at 6 months. All 5 components of the Japanese Orthopaedic Association Back Pain Evaluation Questionnaire improved significantly both at 3 months and 6 months. Patients in the unsettled group exhibited a statistically greater likelihood of having fractures at the thoracolumbar junction, Type A3 fractures, and fractures with a diffuse low-intensity area on T2-weighted MRI studies at 3 months. In contrast, at 6 months, the only statistically significant difference between the groups was patient age.

Conclusions

The biomechanical disadvantages of OVFs (location, type, and size) adversely influencing the fracture healing were overcome by the treatment using a TLSO within 6 months. The authors' findings show that a TLSO plays a biomechanical role in the healing of OVFs.

Detection of genes regulated by Lmx1b during limb dorsalization

Lmx1b is a homeodomain transcription factor that regulates dorsal identity during limb development. Lmx1b knockout (KO) mice develop distal ventral-ventral limbs. Although induction of Lmx1b is linked to Wnt7a expression in the dorsal limb ectoderm, the downstream targets of Lmx1b that accomplish limb dorsalization are unknown. To identify genes targeted by Lmx1b, we compared gene arrays from Lmx1b KO and wild type mouse limbs during limb dorsalization, i.e., 11.5, 12.5, and 13.5 days post coitum. We identified 54 target genes that were differentially expressed in all three stages. Several skeletal targets, including Emx2, Matrilin1 and Matrilin4, demonstrated a loss of scapular expression in the Lmx1b KO mice, supporting a role for Lmx1b in scapula development. Furthermore, the relative abundance of extracellular matrix-related soft tissue targets regulated by Lmx1b, such as collagens and proteoglycans, suggests a mechanism that includes changes in the extracellular matrix composition to accomplish limb dorsalization. Our study provides the most comprehensive characterization of genes regulated by Lmx1b during limb development to-date and provides targets for further investigation.