Bunpot Sitthinamsuwan

Predictors of meningioma consistency: A study in 243 consecutive cases.

BackgroundMeningioma is a common neoplasm primarily arising in the central nervous system. Its consistency is considered to be one of the critical prognostic factors for determining surgical resectability. The present study endeavored to investigate predictive factors associated with the tumor consistency.MethodsTwo hundred and forty-three consecutive participants who underwent resective surgery of meningioma were examined. The authors designed an objective grading system for meningioma consistency and utilized it for assessing consistency among all cases. We focused on the relationship between preoperative tumor characteristics on neuroimaging studies and the consistency.ResultsThe tumor attributes on T2-weighted image (T2WI) and fluid attenuated inversion recovery (FLAIR) image were significantly correlated with the tumor consistency (p = 0.004 and 0.045, respectively). The hypointense tumors on both MRI sequences tended to be hard, whereas the tumors showing hypersignal intensity were associated with soft consistency. There was no correlation between the consistency and age, gender, duration of neurologic symptoms, tumor location, size, calcification, cystic portion, en plague appearance, tumor-brain contact interface expressed by cerebrospinal fluid (CSF) cleft, perilesional vasogenic edema, bony status, features on T1-weighted image (T1WI) and pattern of contrast enhancement. In multiple logistic regression analysis, the tumor characteristics on T2WI and FLAIR image were independent factors significantly correlated with the tumor consistency (p = 0.005 and 0.041, respectively). The tumor consistency was also correlated with operative radicalness as evaluated by the Simpson criteria.ConclusionsSignal intensity on T2WI and FLAIR image can be used for insinuating meningioma consistency. Presurgical prediction of the consistency is highly valuable in operative planning, particularly in arduous cases.

Combined Ablative Neurosurgical Procedures in a Patient with Mixed Spastic and Dystonic Cerebral Palsy

Background: Harmful generalized spasticity is an obstacle in rehabilitation and caregiving. Neurosurgical intervention is a therapeutic option for patients with severe spasticity who do not respond to nonoperative management. Currently, intrathecal baclofen therapy (ITB) is a good alternative treatment for such patients. However, the ITB device is costly and the intrathecal drug is not available in Thailand. Case Description: We report a combined use of ablative neurosurgical procedures in a patient with severe generalized spasticity and disabling cervical dystonia (CD). The assembled operations including selective peripheral denervation for CD, microsurgical dorsal root entry zone lesion for upper limb spasticity, and selective dorsal rhizotomy for lower limb spasticity were conducted in a single session. Furthermore, recurrent spasticity of the upper extremities was subsequently treated by selective peripheral neurotomy. Results: The spasticity and CD totally disappeared after all operations. The patient became able to sit and perform head turning. Additionally, we also found an improvement in swallowing and the voluntary movement of the lower limbs.

Improvement of Sitting Ability and Ambulation Status after Selective Peripheral Neurotomy of the Sciatic Hamstring Nerve together with Obturator Branches for Severe Spasticity of the Lower Extremities

Background: The authors used selective peripheral neurotomy (SPN) on the sciatic and obturator nerves to restore the sitting posture and ambulation in bedridden patients suffering from severe proximal lower limb spasticity. Objective: To study the surgical outcome of sciatic and obturator neurotomies. Methods: All patients with refractory hamstring spasticity who encountered SPN on the hamstring nerve were recruited. Obturator neurotomy was undertaken in some individuals. The clinical assessment included Modified Ashworth Scale (MAS), passive range of motion (PROM), sitting competency and ambulatory condition. These parameters were compared between before and after the surgery by using the Wilcoxon signed-rank test. Results: Among the sciatic neurotomy group (n = 15), the mean pre- and postoperative MAS and PROM were 3.3 and 0.8 (p < 0.01) and 78.3 and 121.7° (p < 0.01), respectively. Those measurements of the obturator nerve surgery group (n = 11) were 3.7 and 1.1 (p < 0.01) as well as 21.0 and 45.0° (p < 0.01), respectively. Seven and 8 of a total of 9 patients had statistically significant improvement in sitting ability (p = 0.016) and ambulation status (p < 0.01), respectively. Conclusion: Bedridden patients who suffer from severe proximal lower limb spasticity have an optimum to return to sitting and ambulate with a wheelchair after SPN of the sciatic and obturator nerves.

The therapeutic effects of ablative neurosurgical procedures on the spinal cord for intractable spinal spasticity

Study design:This research is a retrospective study.Objective:To study the therapeutic effects of operative procedures, including dorsal longitudinal myelotomy (DLM) and dorsal root entry zone lesion (DREZL) on spasticity and associated aspects.Setting:Tertiary university hospital in Bangkok, Thailand.Methods:Eighteen patients with refractory spasticity of spinal origin who underwent the operations were recruited. Clinical parameters for evaluating severity of spasticity and ambulatory status were compared between before and after surgery, and between surgeries.Results:A statistically significant reduction of spasticity as measured by the Modified Ashworth Scale (MAS), Adductor Tone Rating Scale (ATRS) and Penn Spasm Frequency Scale (PSFS) was found after surgeries and in the overall analysis (p < 0.05). Chronic pressure ulcers disappeared postoperatively in 11 cases. All of 7 bed-ridden subjects experienced improvement in their ambulatory status postoperatively. DLM was found to be more effective than DREZL in reduction of spasticity.Conclusion:Ablative neurosurgery on the spinal cord is still valuable in situations when intrathecal baclofen is unavailable. These operations are potentially effective in the treatment of intractable spasticity of spinal origin.

Surgical Outcomes of Microsurgical Selective Peripheral Neurotomy for Intractable Limb Spasticity

Background: The authors frequently employed selective peripheral neurotomy (SPN) as the primary treatment of severe intractable focal and multifocal spastic hypertonia. We occasionally operated SPN in diffuse spastic disorders. Objective: To study surgical outcome of SPN in terms of severity of spasticity and functional condition. Methods: Patients harboring refractory harmful spasticity of various origins were enrolled into the present study. They were clinically evaluated by using the Modified Ashworth Scale (MAS), passive range of motion (PROM) and functional status. These variables were compared between pre- and postsurgery by using the paired t test and the Wilcoxon signed-rank matched-pairs test. Results: One hundred and forty-one SPNs were accomplished in 33 patients. Overall mean pre- and postoperative MAS and PROM were 3.0 and 0.7 (p < 0.001) and 78.3 and 102.3° (p < 0.001), respectively. Analysis of individual SPN subgroups also demonstrated statistically significant improvement of both parameters. Furthermore, we found significant gait improvement among 10 ambulatory subjects. Nine bed-bound cases attained significant enhancement of sitting competency and ambulatory condition. Conclusion: SPN is an efficacious neurosurgical intervention in the treatment of spasticity. It is apparently beneficial in the reduction of spasticity, amelioration of functional status, facilitation of patient care and prevention of long-term musculoskeletal sequelae.

Utilization of intraoperative electromyography for selecting targeted fascicles and determining the degree of fascicular resection in selective tibial neurotomy for ankle spasticity

BackgroundSelective tibial neurotomy (STN) is an effective neurosurgical intervention for treating ankle spasticity. The authors use intraoperative electromyography (EMG) for selecting targeted fascicles and determining the degree of fascicular resection in STN. This study reports surgical techniques and outcomes of the operation.MethodsParticipants who underwent STN with utilization of intraoperative EMG were recruited. Modified Ashworth Scale (MAS), passive range of motion (PROM) of the ankle in plantar flexion and dorsiflexion, Massachusetts General Hospital Functional Ambulatory Classification (MGHFAC) and ability to attain full plantigrade stance were assessed pre- and postoperatively.ResultsTwenty-one STNs were performed in 15 patients. The mean pre- and postoperative MAS and PROM were 2.8 and 0.4 (p < 0.001), 39.5o and 66.0o (p < 0.001), respectively. The mean level of MGHFAC was improved from 3.3 preoperatively to 4.9 postoperatively (p < 0.01). Six non-ambulators had significant amelioration in MGHFAC level. Postoperatively, 19 of 21 lower limbs achieved full plantigrade, and 6 patients could perform selective voluntary motor control of the ankle.ConclusionSTN is an effective procedure for spastic ankle in well-selected cases. Intraoperative EMG helps in selection of targeted fascicles, increases objectivity in neurotomy and prevents excessive denervation.

Dystonia and Peripheral Nerve Surgery in the Cervical Area

Cervical dystonia is the most common form of focal dystonia (Dashtipour et al., 2007). It is characterized by involuntary movement of the neck resulting in abnormal neck posture (Brin & Benabou, 1999; Dent, 2002). Cervicalgia and headache sometimes occur in patients suffering from the disease (Albanese, 2005; Brashear, 2004, Schim, 2006). A critical long-term sequelae of this kind of movement disorder is premature cervical spinal degenerative disease (Chawda et al., 2000) which possibly progresses to cervical spondylotic myelopathy (Hagenah et al., 2001; Jameson et al., 2010; Konrad et al., 2004; Krauss et al., 2002; Spitz et al., 2006; Tonomura et al., 2007; Waterston et al., 1989).

Two patients with rare causes of Weber's syndrome.

We report two patients with rare causes of Webers syndrome and review the relevant literature. The first patient presented with Webers syndrome caused by a partially thrombosed giant aneurysm of the posterior cerebral artery. The second patient was an immunocompetent patient who presented with progressive hemiparesis and subsequently developed Webers syndrome. Primary central nervous system lymphoma (PCNSL) was eventually diagnosed. To our knowledge, the association between Webers syndrome and PCNSL is rare.

Microvascular Decompression for Treatment of Trigeminal Neuralgia: Factors That Predict Complete Pain Relief and Study of Efficacy and Safety in Older Patients

OBJECTIVE Microvascular decompression (MVD) is an effective method for directly treating the etiology of trigeminal neuralgia (TGN). This study aims to investigate the factors that predict complete pain relief after MVD for treatment of TGN, and to study efficacy and safety in older patients. METHODS This study was conducted in patients with TGN that were treated by MVD at Siriraj Hospital between 2004 and 2015. Cases with secondary TGN were excluded. Data was gathered from medical records, preoperative magnetic resonance imaging, intraoperative findings, and by telephone in patients lost to follow-up. RESULTS Of 110 included patients, 68 and 42 patients were younger and older than 60 years, respectively. Median age was 53.6 years old. Typical type of TGN, paroxysmal pain, large offending vessel on preoperative magnetic resonance imaging, and multiple locations of trigeminal nerve compression were associated with early postoperative pain-free status. No variables were associated with long-term outcome. Multivariate analysis using binary logistic regression revealed typical type of TGN to be the only factor associated with early postoperative pain-free status. No significant difference was observed between the <60 and ≥60 age groups for surgical outcome and rate of complications. CONCLUSIONS Presence of typical type TGN was the only factor found to independently predict a pain-free outcome in the early postoperative period. No factors were associated long-term pain-free outcome. MVD is an effective and safe operative procedure, and it should be regarded as a safe and viable alternative for treating intractable TGN in older patients.

Seizures with tonic posturing: Semiologic difference between supplementary sensorimotor area (SSMA) origin and extra-SSMA origin.

In seizures with tonic posturing, differentiation of seizures originating in SSMA from seizures originating in cortices other than SSMA and spreading to SSMA has not been previously attempted. Twenty‐two patients were studied with intractable focal epilepsy with tonic limb posturing as the most prominent semiology, who underwent resective surgery and obtained favorable postoperative seizure outcomes. These 22 patients were divided into an SSMA group (N = 12) and an extra‐SSMA group (N = 10), according to the location of resection. Resection area in the extra‐SSMA group was located in the dorsolateral frontal or prefrontal area in four patients, the frontal operculum (insula) in two, the parietal cortex in three, and the temporoparietal cortex in one patient. Video‐recorded seizures were carefully reviewed. Tonic posturing characteristics and the presence or absence of accompanying symptoms were compared between groups. Incidence of preservation of consciousness was significantly higher in the SSMA group (p < 0.001). Patients in the SSMA group demonstrated a propensity for having unilateral or bilateral asymmetrical tonic limb posturing. In contrast, patients in the extra‐SSMA group had a statistically significantly higher incidence of bilateral symmetrical tonic limb posturing (p < 0.05). These findings may be helpful in identifying seizure origin.