To investigate the surgical procedure and clinical effectiveness of microsurgical reinforced radiculoplasty for postoperative recurrent sacral Tarlov cysts (TCs). A retrospective analysis was performed on 12 cases of postoperative recurrent symptomatic sacral Tarlov cysts (TCs) between 2019 and 2023, and the clinical features and causes of recurrence were summarized. Microsurgical reinforced radiculoplasty was performed on all patients, and the prognosis was summarized and analyzed. In addition, the experience of reinforced radiculoplasty was introduced. Microsurgical reinforced radiculoplasty was performed on 12 patients (6 females) with recurrent postoperative symptomatic sacral TCs. The ages of the patients ranged from 21 to 75 years. The mean follow-up period was over 1 year. Symptoms included severe pain in the lumbosacral and perineal regions, numbness, urinary dysfunction, and sexual dysfunction. There were 5 cases of solitary sacral cysts and 7 cases of multiple sacral cysts, with multiple cysts being more prevalent. After the second surgery, MRI imaging indicated that the postoperative recurrent sacral TCs had disappeared in all patients, and no adverse events such as new-onset neurological deficits, limb sensory/motor disorders, perineal sensory disorders, bowel/bladder dysfunction, sexual dysfunction, cerebrospinal fluid leakage, or wound infection occurred after the operation. Postoperative JOA scores were evaluated after the second surgery. There was a statistically significant difference between the preoperative and postoperative JOA scores (16.2 ± 1.1 versus 19.8 ± 0.9, p = 0.002). Microsurgical reinforced radiculoplasty demonstrates preliminary clinical efficacy in the treatment of postoperative recurrent sacral TCs and is both safe and effective.

OBJECTIVE:To precise classify sacral meningeal cysts, effective guide minimally invasive neurosurgery and postoperative personalized rehabilitation by multiple dimensions radiographic reconstruction MRI. METHODS:From March to December 2021, based on the original 3D-fast imaging employing steadystate acquisition (FIESTA) scanning sequence, 92 patients with sacral meningeal cysts were pre-operatively evaluated by multiple dimensional reconstruction MRI. The shape of nerve root and the leakage of cyst were reconstructed according to the direction of nerve root or leakage track showed on original MRI scans. Sacral canal cysts were accurately classified as including nerve root and without nerve root, so as to accurately design the incision of skin and formulate corresponding open range of the posterior wall of the sacral canal. Under the microscope intraoperation, the shape of the nerve roots inside cysts or leakage track of the cysts without nerve roots were verified and explored. After the reinforcement and shaping operation, several reexaminations of multiple dimensional reconstruction MRI were performed to understand the deformation of the nerve root and hydrops in the operation cavity, so as to formulate a persona-lized rehabilitation plan for the patients. RESULTS:Among the 92 patients with sacral mengingeal cyst, 58 (63.0%) cysts with nerve root cyst, 29 (31.5%) cysts without nerve root cyst, and 5 (5.4%) cysts with mixed sacral canal cyst. In 58 patients with nerve root cysts, the accuracy of preoperative clinical classification on MRI image reached 96.6% (56/58) through confirmation by operating microscope. Only 2 cases of large single cyst with nerve root on the head of cyst were mistaken for without nerve root type. In 29 patients with sacral cyst without nerve root, the accuracy of preoperative image reached 100% through confirmation by operating microscope. The accuracy of judging the internal nerve root and leakage of 12 cases with recurrent sacral cyst was also 100%. Two cases of delayed postoperative hydrops were found one month after operation. After rehabilitation treatment by moxibustion and bathing, the hydrops disappeared 4-6 months after operation. CONCLUSION:Multiple dimensional reconstruction MRI can precisely make clinical classification of sacral meningeal cysts before operation, guide minimally invasive neurosurgery effectively, and improve the rehabilitation effect.

OBJECTIVE:To explore the application and key points of microchannel approaches in resection of cervical intraspinal tumors.METHODS:A retrospective analysis was performed on 51 cases of cervical spinal canal tumors from February 2017 to March 2020. Among them, 5 cases were located epidural space, 6 cases were located epidural and subdural space, and 40 cases were located under the subdural extramedullary space(6 cases were located on the ventral side of the spinal cord). The maximum diameter ranged from 0.5 to 3.0 cm. The clinical manifestations included neck, shoulder or upper limb pain 43 cases, sensory disturbance (numbness) in 22 cases, and limb weakness in 8 cases. The microchannel keyhole technique was used to expose the tumor, and the tumor was resected microscopically.RESULTS:In this study, 35 patients underwent hemilaminectomy, 12 patients underwent interlaminar fenestration, 2 patients underwent medial 1/4 facetectomy on the basis of hemilaminectomy or interlaminar fenestration. Two tumors were resected through anatomy space (no bone was resected). The degree of tumor resection included total resection in 50 cases and subtotal resection in 1 case. The type of the tumor included 36 schwannomas, 12 meningiomas, 2 enterogenic cysts and 1 dermoid cyst. There was no infection and cerebrospinal fluid leakage postoperatively. Limb numbness occurred in 7 patients. The average follow-up time was 15 months (3 to 36 months). No deformity such as cervical instability or kyphosis was found. The tumor had no recurrence.CONCLUSION:The cervical spinal canal is relatively wide, cervical tumors with no more than three segments can be fully exposed by means of microchannel technology. Besides intramedullary or malignant tumors, they can be microsurgically removed. Preservation of the skeletal muscle structure of cervical spine is beneficial to recover the anatomy and function of cervical spine. The electrophysiological monitoring helps to avoid spinal cord or nerve root injury.

Background and purpose The classic Shamblin system fails to provide valuable guidance in many Shamblin's III carotid body tumors (III-CBTs) due to the variable forms of carotid arteries and the complex anatomic relationships in parapharyngeal space. We proposed a modified classification to separately divide III-CBTs into different subgroups on the basis of arterial relevant features and anatomical relevant features.Materials and methods From 2020 to 2023, a total of 129 III-CBTs at a single institution were retrospectively analyzed. All cases were independently classified as arterial-relevant and anatomical-relevant subgroups. The pre-, peri- and postoperative data were summarized and compared accordingly.Results Among the 129 cases, 69 cases were identified as "Classical type", 23 cases as "Medial type", 27 cases as "Lateral type" and 10 cases as "Enveloped type" according to arterial morphologies. Besides, 76 cases were identified as "Common type", 15 cases as "Pharynx- invasion type", 18 cases as "Skull base-invasion type" and 20 cases as "Mixed type" according to anatomical relationships. "Enveloped type" of tumors in arterial-relevant classification and "Mixed type" of tumors in anatomical-relevant classification are the most challenging cases for surgeons with the lowest resection rate, highest incidence of carotid arteries injury and postoperative stroke.Conclusion The modified classifications provide comprehensive understanding of different III-CBTs which are applicable for individualized treatment in clinical practice.

The aetiology of scoliosis remains unclear. Some studies have focused on the theory of possible muscular imbalance. The role of the spinal cord, which directly innervates the paraspinal muscles, in muscular imbalance has not yet been studied. Spinal astrocytomas often grow on one side of the spinal cord, destroying it asymmetrically. Asymmetrical damage to the spinal cord can lead to asymmetrical changes in paraspinal muscles. The present study investigated the effect of muscular imbalance on scoliosis by observing scoliosis caused by spinal astrocytomas. Patients diagnosed with spinal astrocytomas in a single centre were analysed, and the type and side of the symptoms, sagittal tumour position, scoliosis, end vertebrae and apical vertebrae of scoliosis were recorded. The tumour side was assumed from symptom type and side, and the cross-sectional area of the paraspinal muscles on both sides of the end vertebra was outlined and compared. The incidence of astrocytoma-induced scoliosis was significantly higher in patients with unilateral symptoms. The inferred tumour side was highly consistent with the convex side of scoliosis. The distal vertebral segments of scoliosis were consistent with the spinal cord segments involved in the astrocytomas. The apical vertebrae were more caudal in astrocytoma-induced scoliosis. The cross-sectional area of the multifidus muscle on the convex side of apical-level scoliosis was significantly smaller than that on the concave side. However, no significant differences were observed in the erector spinae muscles. Overall, spinal astrocytomas can cause asymmetric destruction of the corresponding spinal cord segment, resulting in asymmetric atrophy and weakness of the multifidus muscle innervated by the spinal cord segment, thereby causing scoliosis that is convex to the weaker side. This mechanism involves asymmetric lower neuron paralysis of the multifidus muscle. This is a type of scoliosis with several differences from idiopathic scoliosis.

Objective:Spinal meningeal cysts (SMCs) are currently classified into three types: extradural cysts without nerve root fibers (Type I), extradural cysts with nerve root fibers (Type II), and intradural cysts (Type III). However, the sacral terminal filar cyst is a distinct subtype with the filum terminale rather than nerve roots within the cyst. This study aimed to investigate the clinicoradiological characteristics and surgical outcomes of sacral terminal filar cysts.Methods:A total of 32 patients with sacral terminal filar cysts were enrolled. Clinical and radiological profiles were collected. All patients were surgically treated, and preoperative and follow-up neurological functions were evaluated.Results:Chronic lumbosacral pain and sphincter dysfunctions were the most common symptoms. On MRI, the filum terminale could be identified within the cyst in all cases, and low-lying conus medullaris was found in 23 (71.9%) cases. The filum terminale was dissociated and cut off in all cases, and the cyst wall was completely resected in 23 (71.9%) cases. After a median follow-up period of 26.5 ± 15.5 months, the pain and sphincter dysfunctions were significantly improved (both P < 0.0001). The cyst recurrence was noted in only 1 (3.1%) case.Conclusions:Sacral terminal filar cysts are rare, representing a distinct variant of SMCs. Typical MRI features, including filum terminale within the cyst and low-lying conus medullaris, may suggest the diagnosis. Although the optimal surgical strategy remains unclear, we recommend a combination of resection of the cyst wall and dissociation of the filum terminale. The clinical outcomes can be favorable.

Introduction Sacral laminoplasty with titanium mesh and titanium screws can reduce symptomatic sacral extradural spinal meningeal cysts (SESMCs) recurrence and operation complications. However, due to a defect or thinning of the sacrum, the screws cannot be securely anchored and there are also problems with permanent metal implantation for titanium mesh and screws. We propose that sacral laminoplasty with absorbable clamps can provide rigid fixation even for a thinned or defected sacrum without leaving permanent metal implants. Methods In the direct microsurgical treatment of symptomatic SESMCs, we performed one-stage sacral laminoplasty with autologous sacral lamina reimplantation fixed by absorbable fixation clamps. Retrospectively, we analyzed intraoperative handling, planarity of the sacral lamina, and stability of the fixation based on clinical and radiological data. Results Between November 2021 to October 2022, we performed sacral laminoplasty with the absorbable craniofix system in 28 consecutive patients with SESMCs. The size of the sacral lamina flaps ranged from 756 to 1,052 mm 2 (average 906.21 ± 84.04 mm 2 ). We applied a minimum of two (in four cases) and up to four (in four cases) Craniofix clamps in the operation, with three (in 20 cases) being the most common (82.14%, 20/28) and convenient to handle. Excellent sacral canal reconstruction could be confirmed intraoperatively by the surgeons and postoperatively by CT scans. No intraoperative complications occurred. Conclusions One-stage sacral laminoplasty with absorbable fixation clamps is technically feasible, and applying 3 of these can achieve a stable fixation effect and are easy to operate. Restoring the normal structure of the sacral canal could reduce complications and improve surgical efficacy.

BACKGROUND: Sacral cysts are classically divided into Tarlov cysts and meningeal diverticula. However, the pathogenesis of sacral cysts remains unclear. This study aimed to clarify a novel type of sacral extradural spinal meningeal cyst with a specific arachnoidal structure. METHODS: Nine patients with prophylactic diverticula were included in the study. All patients underwent MRI preoperative reconstruction and traditional neck transfixation. RESULTS: All patients presented with more than one symptom. The major symptom was lower extremity pain, followed by lower extremity numbness (77.8%, 7/9), lower extremity weakness (55.6%, 5/9), bowel/bladder and sexual dysfunction (55.6%, 5/9), and tenesmus (22.2%, 2/9). After long-term follow-up, the outcome was classified as improved in 9 patients (100%). CONCLUSIONS: The clinical findings of this study illustrate a special subtype and may help explain the mechanism of sacral cyst formation.

Objective:To explore the feasibility and effect of microchannel keyhole technique in minimally invasive resection of symptomatic sacral cysts.Methods:The clinical data of 45 patients with symptomatic solitary sacral cyst who were admitted to the Department of Neurosurgery, Peking University Third Hospital from February 2017 to December 2019 were retrospectively analyzed. All 45 patients underwent individualized laminectomy of posterior wall of sacral canal and then microsurgical resection of cyst through microchannel (width ≤1.5 cm). The patients′ pain conditions were evaluated based on the visual analogue scale (VAS) and their neurological functions were assessed using the Japanese Orthopedics Association (JOA) scale. The recurrence of cyst was evaluated by imaging follow-up.Results:The operation duration was 97.0±12.6 min (75-120 min). The length of hospital stay post operation was 6±1 days and ranged from 5 to 9 days. Of 45 patients, total resection of sacral cysts was achieved in 41 cases and subtotal resection with distal cyst wall remaining in 4 cases. Pathological results showed that all of sacral cysts were simple cysts. Except for 4 patients with numbness in the sacrococcygeal region after operation, the remaining 41 patients did not experience aggravation of neurological dysfunction. Forty-five patients were followed up for 3 to 36 months after surgery (median: 15 months). All 4 patients with sacrococcygeal numbness returned to normal, and no cyst recurrence was seen. The last follow-up VAS was 0 to 3 points (median: 0 points), and compared with 1 to 10 points before surgery (median: 3 points), the difference was statistically significant ( Z=-5.866, P<0.001). The JOA score at the last follow-up (28.7±1.1 points; range: 22-29 points) increased compared with that prior to operation (21.6±3.9 points; range: 14-28 points) and the difference was statistically significant ( t=-13.726, P<0.001). Conclusion:The application of microchannel keyhole approach in the minimally invasive treatment of symptomatic sacral cysts can effectively relieve the clinical symptoms with few complications and low recurrence rate.

Background and purpose The contents and subtypes of sacral cysts are sophisticated in many cases. We applied multiple dimensional magnetic resonance imaging (MRI) reconstruction to preoperatively clarify the specific subtype of sacral meningeal cysts. Materials and methods We preoperatively used multimodal neural reconstruction MRI sequences to evaluate 76 patients with sacral cysts. The linear nerve roots were precisely traced based on sagittal or coronal images processed at various angles and levels which was conducive to the design of the operation strategy. Results Cysts with nerve passage were detected in 47 cases (62%, 47/76), whereas cysts without nerve roots were detected in 24 cases (32%, 24/76). Five patients had mixed cysts with or without nerve roots. Intraoperative exploration results proved the high accuracy of image reconstruction; only one cyst without a nerve root was misdiagnosed prior to surgery. Conclusion MRI reconstruction based on the three-dimensional fast imaging employing steady-state acquisition T2 sequence precisely tracked the nerve roots of sacral cysts and guided the optimal strategy during surgery.

目的 探讨“四分区法”及个体化入路在显微手术治疗颈椎椎旁神经源性肿瘤中的应用价值. 方法 回顾性分析我科2013年1月～ 2018年12月显微手术治疗颈椎椎旁神经源性肿瘤42例资料.根据“四分区法”,肿瘤位于Ⅰ区6例,Ⅱ区5例,Ⅲ区5例,Ⅳ区7例,Ⅰ和Ⅱ区6例,Ⅰ、Ⅱ和Ⅲ区2例,Ⅱ和Ⅲ区3例,Ⅲ和Ⅳ区6例,Ⅱ、Ⅲ和Ⅳ区1例,Ⅰ、Ⅱ、Ⅲ和Ⅳ区1例.根据肿瘤主体所在节段及区域选择手术入路,采用后方旁正中入路12例,后侧方人路2例,颌下入路2例,胸锁乳突肌前人路9例,胸锁乳突肌后入路7例,锁骨上入路6例,经口腔入路1例,胸锁乳突肌前后联合入路2例,胸锁乳突肌后联合后方旁正中入路1例.术中行神经电生理监测. 结果 42例肿瘤均完全切除,病理诊断神经鞘瘤32例,神经纤维瘤10例.术后3例声音嘶哑,1周恢复,1例上肢肌力下降,3个月恢复,无其他并发症.术后随访12 ～84个月,中位数48.5月,无肿瘤复发. 结论 术前对颈椎椎旁肿瘤进行分区,根据分区个体化选择入路行显微手术安全有效.

目的 探讨微通道辅助经椎旁肌间隙入路(Wiltse入路)显微手术切除胸腰椎椎旁肿瘤的效果.方法 回顾性分析2017年2月 ～2020年3月12例胸腰椎椎旁肿瘤的临床资料,包括腰椎椎旁肿瘤8例,胸椎椎旁肿瘤4例.肿瘤长径1.5～3.5 cm,平均2.3 cm.临床症状包括相应神经支配区疼痛10例,感觉障碍(麻木)6例,下肢肢体无力1例.采用微通道辅助下椎旁肌间隙入路,显微手术切除肿瘤.结果 12例肿瘤均获全切除.手术时间60～100 min,平均78.5 min;术后住院时间4～7 d,平均5.3 d.术后病理均为神经鞘瘤.术后无感染,无死亡.均无明显腰背部疼痛.1例节段性感觉减退,6个月恢复正常;其余患者无神经功能障碍加重.术后随访3～36个月,中位数19.5月,未见脊柱畸形,未见肿瘤复发或残留.结论 微通道辅助经椎旁肌间隙入路显微手术切除胸腰椎椎旁肿瘤有利于避免多裂肌附着点和小关节的破坏,保护多裂肌及其供应血管和支配神经,有利于保持胸腰椎稳定性,避免术后慢性腰痛的发生.

目的 探讨微通道锁孔入路切除胸椎管肿瘤的可行性.方法 回顾性分析2017年2月～2020年3月49例胸椎管肿瘤资料,男29例,女20例.均为2个节段以内的胸椎管髓外肿瘤,包括硬膜外肿瘤6例,硬膜内外肿瘤3例,髓外硬膜下肿瘤40例(其中脊髓腹侧肿瘤7例).长径0.5～2.7 cm,平均1.3 cm.术中仅剥离肿瘤侧椎旁肌肉,导入微通道,切开肿瘤侧半椎板,肌肉剥离和椎板切开范围根据肿瘤大小个体化确定,必要时可潜行切除棘突根部或(和)切除小关节内侧1/4,显微手术切除肿瘤.结果 微通道下半椎板入路9例,半椎板入路+棘突根部潜行切除29例,半椎板入路+棘突根部潜行切除+小关节内侧1/4切除11例.肿瘤均获全切除.手术时间80～135 min,平均96.4 min;术后3～8 d出院,平均5.5 d.术后病理为神经鞘瘤27例,脊膜瘤16例,肠源性囊肿3例,单纯囊肿1例,皮样囊肿/表皮样囊肿2例.术后3例节段性感觉减退,2例下肢肌力减退.术后随访3～36个月,平均15.4月.5例症状加重者均恢复正常,无脊柱畸形,无肿瘤复发或残留.脊髓功能均为McCormickⅠ级.结论 2个节段以内的胸椎管髓外肿瘤(包括部分脊髓腹侧肿瘤)可通过个体化微通道技术全切,有利于保持胸椎稳定性.

Objective:To evaluate the efficacy of synchronous carotid endarterectomy (CEA) combined with coronary artery bypass grafting (CABG) for patients with concomitant severe carotid and coronary stenosis.Methods:The clinical data of 30 patients who underwent CEA + CABG surgeries from September 2014 to September 2019 at Department of Neurosurgery and Department of Cardiac Surgery, Peking University Third Hospital were prospectively analyzed. We documented the perioperative complications and followed up the therapeutic effects in those cases.Results:Among 30 cases, brain stem infarction occurred perioperatively in 1 patient (3.3%), hoarseness occurred in 1 patient (3.3%) due to the stretching of laryngeal recurrent nerve, and MRI revealed new infarction lesions in 3 patients (10.0%), which were all asymptomatic and completely disappeared after 1-3 months. Twenty-one patients underwent head and neck angiography at 1-3 months post surgery, and no carotid restenosis or coronary artery bridge restenosis was reported. The median follow-up time of 30 patients was 44.7 (6.0-67.2) months. Respiratory failure due to lung infection occurred in 1 patient (3.3%) who died of multiple organ failure after 6 months. Among the remaining 29 survivors, 26 had been followed up for 1 year after surgery, and 25 underwent imaging follow-up showing no restenosis. Twenty-two patients had been followed up for 2 years. One patient was diagnosed as severe in-stent stenosis before synchronous operations, for whom the stent and carotid plaque were removed during CEA. At 18 months post operation, asymptomatic restenosis was reported in that patient who underwent carotid artery stenting (CAS) again, and no obvious stenosis was found at 2-year follow-up. One patient had been followed up for 5 years. No new cardio-cerebral vascular accidents occurred at the end of follow-up. Some patients showed improvement of cardiac function. By the end of the latest follow-up, the patient’s heart function was graded as class Ⅰ in 9 cases, class Ⅱ in 19 cases, and could not be evaluated because of respiratory failure and brain stem infarction in 2 cases.Conclusion:Synchronous CEA and CABG surgeries are safe and effective for patients with concomitant severe carotid and coronary stenosis.

Purpose To summarise our experience treating patients with spinal angiolipomas (SAs) and to evaluate factors relating to its prognosis. Methods We retrospectively reviewed the records of patients diagnosed with SAs who received surgical treatment from January 2001 to February 2013. Results Twenty-one patients were described. We divide SAs into two types: “intraspinal” and “dumbbell-shaped”. The former were further subclassified as “with lipomatosis” and “without lipomatosis”. Overweight people are more likely to get the “with lipomatosis” type which needs different surgical strategy and/or a diet therapy to get better outcomes. Conclusion Diagnosis of SAs should be made with reference to clinical, radiological, and pathological findings. Application of different methods is needed to treat SAs.

BACKGROUND:Recapping laminoplasty has become the frequently-used approach to the spinal canal when bone decompression of the vertebral canal is not the goal. However, what changes will occur after surgery, and whether recapping laminoplasty can actually reduce the risk of delayed deformities remains unknown.METHODOLOGY:We designed an animal experiment using a caprine model, and partitioned the animals into in vitro and in vivo surgical groups. We performed recapping laminoplasty on one group and laminectomy on another group. These animals were sacrificed six months after operating, cervical spines removed, biomechanically tested, and these data were compared to determine whether the recapping laminoplasty technique leads to subsequent differences in range of motion. Image data were also obtained before the surgery and when the animals were killed. Besides, we investigated the initial differences in kinetics between recapping laminoplasty and laminectomy. We did this by comparing data obtained from biomechanical testing of in vitro-performed recapping laminoplasty and laminectomy. Finally, we investigated the effect that longitudinal distance has on cervical mechanics. This was determined by performing a two-level recapping laminoplasty, and then extending the laminoplasty to the next level and repeating the mechanical testing at each step.PRINCIPAL FINDINGS:There were three mainly morphological changes at the six months after laminoplasty: volume reduction and bone nonunion of the recapping laminae, irregular fibrosis formation around the facet joints and re-implanted lamina-ligamentous complex. In the biomechanical test, comparing with laminectomy, recapping laminoplasty didn't show significant differences in the immediate postoperative comparison, while recapping laminoplasty demonstrated significantly decreased motion in flexion/extension six months later. Inclusion of additional levels in the laminotomy procedure didn't lead to changes in immediate biomechanics.CONCLUSIONS:Recapping laminoplasty can't fully restore the posterior structure, but still reduced the risk of delayed cervical instability in a caprine model.