目的 评估单侧锁孔微创椎板间入路腰骶段选择性脊神经后根切断术(SPR)对下肢痉挛型偏瘫患者的疗效及安全性.方法 回顾性分析清华大学玉泉医院神经外科2019年7月—2021年7月收治的23例痉挛型偏瘫患者的临床资料,根据随机化分组结果分别行单侧锁孔微创椎板间入路和经典Peacock腰骶段SPR治疗,术后12个月时进行随访,对患者一般资料、手术前后MAS评分和GMFCS评分等进行分析.结果 本组23例患者均可良好暴露脊神经根并进行选择性切断,术后MAS评分及GMFCS评分均较术前明显改善.结论 单侧锁孔微创椎板间入路SPR可对神经根进行良好的显露,手术效果与经典Peacock术式相同,且对脊柱结构破坏小,利于术后脊柱稳定性的维持,且不增加手术风险,可明显改善痉挛型偏瘫患者的患侧肌张力和运动功能.

Objective:To evaluate the efficacy and safety of selective posterior rhizotomy (SPR) through interlaminar approach in the treatment of spastic paralysis of lower limbs.Methods:The clinical data of 20 patients with spastic paralysis of the lower extremities treated by SPR through interlaminar approach, admitted to Neurosurgery Department of Yuquan Hospital of Tsinghua University from July 2019 to April 2020, were retrospectively analyzed. The patients were followed up for 1 year. The general data, modified Ashworth score (MAS) and gross motor function classification system score (GMFCS) before and after surgery were analyzed.Results:All the 20 patients completed the operation of interlaminar approach. The scores of MAS and GMFCS were significantly improved after operation.Conclusion:Interlaminar approach has no damage to the bony structure, less impact on the stability of the spine, and does not increase the risk of operation, so it is a more reasonable operation to expose the nerve root.

Objective To investigate the candidate selection,surgical methods,efficacy and complications of selective peripheral neurotomy (SPN) for the treatment of limb spasticity in cerebral palsy.Methods A total of 119 patients with spastic cerebral palsy admitted to Department of Neurosurgery,Yuquan Hospital,Tsinghua University from January 2016 to June 2017 were enrolled into study.All those patients underwent SPN,which involved 40 upper limbs and 156 lower limbs with 360 nerves operated on.The changes of muscle tension following operation were evaluated by modified Ashworth scale and surface electromyography (sEMG).The changes of upper and lower limb motor function were evaluated by action research arm test (ARAT) and gross motor function measure (GMFM) scales.Results The immediate postoperative successful rate with limb spasticity relief was 95.6％ (344/360).Moreover,the patients with Ashworth scales of 0,1,2,3 accounted for 60.0％ (216/360),25.6％ (92/360),8.9％ (32/360),1.1％ (4/360) respectively.Inefficient treatment accounted for 4.4％ (16/3630).The rate of sensory disturbance immediately post operation in the innervated region was 10.3％ (37/360) and the rate of postoperative muscle strength decline over at least 1 grade was 1.9％ (7/360).Sensory disturbance was all relieved within 3 months.All those patients were followed up for 6-24 (17.2 ±4.9) months.The improvement rate of limb motor function during follow-up was 67.3％ (132/196),of which the upper limb improvement rate was 47.5％ (19/40) and the lower limb improvement rate was 72.4％ (113/156).Recurrence with varying degrees was reported in 32 (8.9％) cases,of which 13 (3.6％) returned to preoperative levels.Conclusions The SPN has a significant alleviating effect on the limb spasticity of cerebral palsy.Proper surgical indications and operative methods are keys to improvement of treatment efficacy and reduction of clinical complications.

Objective To analyze surface electromyography activities of spastic cerebral palsy,to explore the role of surface electromyography (sEMG) in evaluation effectiveness of peripheral nerve surgery.Methods Peripheral nerve surgery was carried out in 218 cases,including 171 selective peripheral neurotomy (SPN) and 47 selective posterior rhizotomy (SPR).The sEMG of patients was recorded before and after operations while passive and voluntary movements were performed during recording.The root mean square (RMS) were calculated by time domain analysis.Analysis of Variance was applied to compare RMS before and after operations.Modified Asworth Scale was emplvyed to estimated the patients' muscle tension.And Manual Muscle Testing was applied to assessed patients' muscle strength.Investigate the correlation among MAS,MMT and RMS.Results Two hundred and three cases were followed up for 22 to 30 months (mean 25.6 months).15 cases were lost.Among them,the cases were followed up with 350 sides of adductor,197 sides of quadriceps and 374 sides of triceps.In passive movements,the RMS of adductors,quadriceps and triceps post-surgery were significantly decreased comparing to values of pre-surgery (all P ＜0.05).And those values follow-up were significantly decreased than pre-surgery (all P ＜ 0.05).In voluntary movements,the RMS of quadriceps post-surgery were significantly decreased than pre-surgery (all P ＜ 0.05).However,no significant differences were observed in adductors and triceps between post-surgery and pre-surgery(all P ＞0.05).And there were no significant differences of adductors,quadriceps and triceps observed in follow-up and post-surgery (all P ＞0.05).A higher remission rate (91％) of adductor spasm was observed in 318 postoperative cases of 350 cases,and 98％ (343/350) was observed during follow-up.The quadriceps spasm relief rate was 82％ (161/197) postoperative and 95％ (187/197) during follow-up.Besides the relief rate of triceps spasm was 93％ (348/374) postoperative and 99％ (370/374) during the follow-up.The muscle strength of adductor was reduced by 9％ (31/350) postoperative,while it was increased by 23％ (80/350) during follow-up.Moreover,there was a 21％ (41/197) reduced rate of muscle strength of quadriceps,however,it was increased by 19％ (37/197)during follow-up.The muscle strength of triceps was reduced by 18％ (67/374) postoperative,but it was increased by 29％ (108/374) follow-up.There are significant correlations between MAS,MMT and RMS(both P ＜ 0.05).Conclusions sEMG can objectively evaluate the clinical effectiveness of spastic cerebral palsy as a non-invasive method.Muscle tension is obviously reduced after peripheral nerve surgery carried on spastic cerebral palsy,meanwhile the muscle strength is not significantly decreased.

[Objective]To explore the surgical strategies and clinical efficacy for equines of spastic cerebral palsy in children.[Method]Total 1 321 spastic cerebral palsy children with equines underwent different surgical approaches.The clinical spastic index(CSI),range of motion(ROM) of the ankle and activities of daily living rating scale(ADL) were applied to assess the clinical outcome of the children before and after surgery.Analysis of variance was explored.[Result]Total 1 310 children with 2 608 limbs were followed up.It showed that the SCI of the children postoperative and follow-up were significantly decreased comparing with values of preoperative(both P < 0.05).And the ankle joint ROM of the children postoperative and follow-up were significantly increased than values of preoperative(both P < 0.05).The ADL revealed that the mean improvement rate was 76% after surgery,and 93% during follow-up.Among them all,the recurrence rate of surgical approach A was 16%,that of D was 19%,and that of surgical approach B、C、E(orD) was 5%.0.4% of the children appeared muscle strength decline short-term after surgery.0.2% of the children showed reversible sensory disability.[Conclusion]The selective tibial neurotomy or selective posterior rhizotomy combined with tendon lengthening or surgical approach is effect to the treatment of spastic cerebral palsy with equines.The treatment for spastic equines is more appropriate to choose individualized surgery.The different types of equines are applied for surgical approaches.

目的 探讨Dellon三联周围神经减压术(腓总神经、腓深神经及胫后神经减压术)治疗糖尿病周围神经病(DPN)下肢病变的手术疗效.方法 分析2006年7月～2011年11月采用Dellon三联周围神经减压手术治疗的40例(DPN)患者的资料,观察他们的临床特点、手术方法、手术效果和随访结果.结果 临床表现以渐进性小腿和足底、足背部麻木起病者35例,以渐进性疼痛起病者5例.术后下肢麻木症状缓解率90％,术后下肢疼痛症状缓解率92％.术后平均随访12个月临床症状缓解的所有患者病情稳定,1例患者术后1个月出现足底部分区域疼痛缓解后再次出现疼痛,其余病人症状无复发或加重.结论 Dellon三联周围神经减压术对于(DPN)缓解疼痛、恢复感觉有较好疗效,是一种安全、有效、微创治疗新技术和新方法.

The present study analyzed the anatomical association between intracranial subarachnoid space and the cervical lymphatic system. X-ray contrast medium and Microfil(®) (Microfil compounds fill and opacify microvascular and other spaces of non-surviving animals and post-mortem tissue under physiological injection pressure) were injected into the cisterna magna of the rabbit, and perineural routes of cerebrospinal fluid outflow into the lymphatic system were visualized. Under a surgical operating microscope, Microfil was found within the subarachnoid space and along the olfactory nerves. At the nasal mucosa, a lymphatic network was identified near the olfactory nerves, which crossed the nasopharyngeal region and finally emptied into the superficial and deep cervical lymph nodes. Under a light microscope, Microfil was visible around the olfactory nerves and within lymphatic vessels. These results suggested that cerebrospinal fluid drained from the subarachnoid space along the olfactory nerves to nasal lymphatic vessels, which in turn, emptied into the cervical lymph nodes. This anatomical route, therefore, allowed connection between the central nervous system and the lymphatic system.

This study aimed to explore the role of surface electromyography (sEMG) on the changes of myoelectric activities of quadriceps femoris and the assessment of its clinical effect before and after selective femoral neurotomy on spastic cerebral palsy with stiff knee. Selective femoral neurotomy was carried out in 15 patients on 26 sides. The electromyography of quadriceps femoris was recorded before and after the operation. Passive and voluntary movements were performed during recording. The root mean square (RMS) and integrated electromyography (iEMG) was calculated by time domain analysis. Meanwhile, the range of the patients' knee joint motion (ROM) was measured by a joint goniometer. The RMS and iEMG of the quadriceps femoris during passive movement was significantly decreased post-operation when compared to those pre-operation (both P<0.05, n=26). Meanwhile, the RMS and iEMG of the quadriceps femoris during voluntary movement post-operation was significantly reduced than those pre-operation (both P<0.05, n=26). Additionally, total excursion on the sagittal plane and the peak knee flexion in the swing phase were significantly raised post-operation than those pre-operation (both P<0.05, n=26). The spasms in the quadriceps femoris in spastic cerebral palsy patients with stiff knee was clearly improved, and the ROM of the knee was significantly enhanced after the selective femoral neurotomy. Importantly, surface EMG can objectively evaluate the clinical therapeutic effect of spastic cerebral palsy stiff knee as a noninvasive detection method.

Objective To explore the methods and effectiveness of neurosurgical management of hereditary spastic paraplegia.Methods Selective peripheral neurotomy(SPN) was carried out in 17 patients,including 12 SPN and 15 SPN+orthomorphia.Modified Asworth scale was employed to estimated the patients' muscle tone.And the Fugl-Meyer scores was applied to assessed the motor function of lower limbs.Results All patients were followed up from 8 to 15 months(means 12 months).The postoperative spasticity relief rate is 98.5% and the follow-up is 92.7%.The improvement of patients' motor function in lower limbs is 80.5% after the operation and 90.8% by follow-up.Temporary sensory disturbance in lower limbs occurred in 2 cases postoperatively and disappeared by follow-up.Muscle weakness with severe spasm occurred in one case.The spasm recured in 2 cases by follow up.Conclusion With strictly control indications,the neurosurgery can effectively relief spasm,improve motor function and delay the development in lower limbs of hereditary spastic paraplegia patients.

OBJECTIVE:To investigate the effects of topical fluorescein on the preoperative diagnosis of rhinorrhea of cerebrospinal fluid (CSF) and intraoperative localization of CSF fistula.METHODS:Cotton pads soaked with 5% fluorescein were placed in the middle turbinate meatus, roof of ethmoid plate, and sphenoethmoidalis recesses via endoscopic endonasal technique of 15 patients with CSF rhinorrhea, 5 caused by accidental trauma and 10 spontaneous. Change of the color of fluorescein from yellow to green fluorescence denoted the presence of CSF, and thus the site of the leak could be traced. The accuracy rates of diagnosis and leak site identification by this technique were compared with those by glucose analysis, intraoperative findings, and follow-up.RESULTS:The preoperative diagnosis rate of CSF rhinorrhea and the CSF fistula site localization rate by fluorescein-soaked cotton pad were both 100%. No recurrence was found during the follow-up for 2 - 24 months. No complication had been reported.CONCLUSIONS:Application of topical fluorescein is an easy, sensitive, safe, and highly accurate tool in the intraoperative localization of the site and extent of CSF fistulas and should be considered a viable noninvasive alternative to intrathecal fluorescein technique.

Background: The CSF rhinorrhea is a kind of common clinical disease. The preoperative diagnosis and intraoperative localization of CSF fistulas are critical to treatment of CSF rhinorrhea. At present, intrathecal fluorescein regarding endoscopic transnasal cerebrospinal leakage repair is a common method for localization of the fistula; however, it has some disadvantages because it needs a specific endoscope, and the trauma from lumbar Puncture as well as the potential complications of intrathecal fluorescein, as a result, widely limited its clinical use. Topical intranasal fluorescein can avoid the above-mentioned shortcoming. The aim of this work was to describe the use of topical fluorescein in the intraoperative localization of CSF fistulas and to screen its use in preoperative diagnosis of CSF rhinorrhea.Methods: Fifteen patients with CSF rhinorrhea were treated with an endoscopic endonasal technique. Topical intranasal 5% fluorescein for preoperative diagnosis and intraoperative localization of the site of the leak was placed in middle turbinate meatus, the roof of the ethmoid plate, and sphenoethmoidal recesses. A change in the color of the fluorescein from brown to green fluorescence denoted the presence of CSF, and the site of the leak could be traced. The accuracy rate of diagnosis and leak site identification was made by comparison with glucose analysis, intraoperative findings, and follow-up.Results: The cause of the leak was accidental trauma in 5 patients and spontaneous in 10 patients. The preoperative use of fluorescein-soaked cotton was 100% accurate in diagnosing CSF rhinorrhea. The intraoperative use of topical intranasal fluorescein was also 100% accurate in locating the site of the CSF fistula when compared with the surgical findings. It had achieved 100% success rate in sealing the CSF fistulas in our 15 patients with no recurrence detected during the follow-up period (mean, 2-24 months). No complications have been reported.Conclusion: In the presence of a clinically diagnosed CSF leakage and location of the leakage fistula, topical fluorescein is a very easy, sensitive, safe, and highly accurate tool in the intraoperative localization of the site and extent of CSF fistulas. It should be considered as a viable noninvasive alternative to intrathecal fluorescein. Crown Copyright (C) 2009 Published by Elsevier Inc. All rights reserved.

Objective To reveal morphological route between subarachnoid space and cervical lymphatic vessels by a new method. Methods MicrofilTM was injected into the cisterna magna of the rabbit and rat that were sacrificed just a moment ago,and its distributions in the olfactory bulbs,olfactory tracts and nasal mucosa were observed by operating microscopy 2 hours later after injection. Results Under the operating microscope,MicrofilTM was found in the subarachnoid space and along the olfactory nerves in rabbit and rat. At the nasal mucosa,a lymphatic network was stained in yellow was identified near the olfactory nerves,which crossed the nasopharyngeal region and finally emptied into the superficial and deep cervical lymph nodes. Between rabbit and rat,there is no difference in the distribution of MicrofilTM. Conclusion Subarachnoid injection of MicrofilTM is a new,quick and convenient method for showing morphological route between subarachnoid space and cervical lymphatic vessels.

Objective To demonstrate the morphology of drainage of the cerebrospinal fluid through the olfactory nerves into the cervical lymphatics. Methods Microfil was injected into the cisterna magna of the rabbit, cervical lymphatics, the olfactory bulbs, olfactory tracts and the nasal mucosa were observed by macroscopic anatomy and light microscopy. Results Under the operative microscope, Microfil was found within the subarachnoid space and along the olfactory nerves. At the nasal mucosa, a lymphatic network stained in yellow was identified near the olfactory nerves, which cross nasopharyngeal region and finally emptied into the superficial and deep cervical lymph nodes. Light microscopically, Microfil was distributed around the olfactory nerves and within the lymphatic vessels. At the nasal mucosa, the lymphatics were frequently located close to the nerves. Conclusion These results indicate that the cerebrospinal fluid drains from the subarachnoid space along the olfactory nerves to the nasal Lymphatics, which in turn, empties into the cervical lymph nodes. This anatomical communication, thus, allows the central nervous system to connect with the lymphatic system. The presence of this route may play an important role in immune disease of the central nervous system and regulation of the cerebrospinal fluid circulation.

Objective To demonstrate the connection between the subarachnoid space(SAS) and cervical lymphatic vessels in rabbit.Methods X-ray contrast examination was performed for cerebrospinal fluid(CSF) lymphatic drainage and the cervical lymphatic vessels in 10 New Zealand rabbit.Results X-ray contrast examination of CSF lymphatic drainage displayed the contrast medium reached the cribriform plate 7 min and distal the optic nerve 20 min after the contrast medium injection,and leaked into the nasal cavities 30 min later and the cervical lymphatic vessels were visualized at the same time.Cervical lymphangiography revealed contrast medium flowed slowly around foramen magnum at early stage after the injection,finally reached the chiasma via the optic nerve,and subsequently,the superficial lymphatic vessels in the nasal septum,ethmoid plate region,internal acoustic meatus,periphery of the superior sagittal sinus,and neck were visualized.Conclusion The intracranial subarachnoid space communicates with cervical lymphatic vessels.Under certain pressure,cervical lymph can retrogradely emptied into the cranial subarachnoid space.The pathophysiological significance of this phenomenon should be further researched.

Objective To summarize the surgical experience and intraoperative intrathecal fluorescein in repair of cerebrospinal fluid (CSF) rhinorrhea treated by endoscopic transnasal approaches.Methods Between Sep 2003 and May 2007,25 of 35 patients with CSF rhinorrhea were treated. Endoscopic endonasal approaches and surgical techniques in the repair of CSF leaks are reviewed in the series of 25 patients included 5 patients with traumatic CSF leaks,6 patients with spontaneous CSF leaks,and 14 patients with other reasons. 8 patients performed endoscopic endonasal surgery and received intrathecal fluorescein during operation. Results Follow-up 6 months to 3 yearn postoperative,achievement ratio at first attempt was 92%. 1 patient needed a second surgical repair and one patient a third surgical repair. The fistula of CSF leak can be detected in all of the 8 patients by intrathecal fluorescein examination. The complication included meningitis and obstruction hydrocephalus in two patients. Conclusions The endoscopic endonasal approaches is capital choice for repair of CSF leak for its minimal invasive injure and high achievement ratio. Leakage site identification, site preparation, accurate graft placement and postoperative management are critical to achieve an optimal prognosis. Injection of intrathecal fluorescein can improve identifying of leakage site.

Objective To explore the methods and effectiveness of neurosurgical management of spastic cerebral palsy. Method Among 351 patients of spastic cerebral palsy(aged from 2 to 14 years, 4.8 in average), the treatment includes 26 cervicothoracic selective posterior rhizotomy (SPR), 109 lumbosacral SPR; 216 selective peripheral neurotomy (SPN) include 92 single neural trunk neurotomies and 124 multiple neural trunk neurotomies. Results Following-up period was from 6 to 31 months (means 17.8 months). The spasm was improved by 82.7% and 91.4% in cervicothoracic SPR and lumbosacral SPR. The movement was improved by 83.7% and 72.5% in upper and lower limbs respectively. In peripheral neurotomy, the spasm was improved by 67.4% and 92.7% in upper and lower limbs. The movement was improved by 54.9% in upper limbs and 84.3% in lower limbs. Conclusions Neurosurgical management is an effective and safe method for treatment of spastic cerebral palsy, offers a chance for effectual rehabilitation. The preoperational evaluation, the suitable operation decision and the understanding of microsurgical techniques are the key to gain good effects and prevent complication.

Objective To study the effects of carotid sympathectomy on symptom or intercurrent damage of refractory cerebral palsy.Methods 204 cases with cerebral palsy of mixed type and with intercurrent damage were treated with bilateral carotid sympathectomy.Results 187 cases(91.7%) were followed up successfully,which showed 74.4% of torsion or tension spasm,42% of athetosis,63.6% of cognition language disturbance,81.6% of sialorrhoea,27.6% of strabismus and 88% of deglutition handicap improved.The scores of activity of daily living improved 43.8%.The total incidents effective rate was 82.7%.Conclusion Carotid sympathectomy is an effective and safe microsurgery method for the symptom or intercurrent damage of the refractory cerebral palsy.