[Multilevel segmental interbody fusion versus vertebral body replacement: comparison of two operative methods]. / Mehrsegmentale interkorporelle Fusion vs. Wirbelkörperersatz: Vergleich zweier operativer Methoden.

BACKGROUND: The surgical techniques of interbody fusion and vertebral body replacement represent two concurrent options for multilevel anterior decompression and arthrodesis of the cervical spine. PATIENTS AND METHODS: In a retrospective study the data from 61 patients who received either interbody fusion (n = 38) as anterior cervical discectomy and fusion (ACDF) or vertebral body replacement (n = 23) (as anterior cervical corpectomy and fusion (ACCF) because of degenerative disc disease of the cervical spine were collected. RESULTS: The clinical outcome was better at all time points in the patient group with ACDF than in those with ACCF but with no statistically significant differences. The operated segments showed a more rapid fusion progress after ACDF during the time course in comparison to ACCF; however, there was no relationship between the grade of fusion and the clinical result. CONCLUSION: In direct comparison multisegmental interbody fusion showed better results with respect to the clinical outcome and bony fusion with a lower rate of complications than vertebral body replacement. However, the differences did not reach statistical significance.

First manifestation of lambda positive plasmacytoma in the orbital apex with acute unilateral loss of vision.

INTRODUCTION: An intracranial plasmacytoma is a rare form, which can involve the calvarium, dura or the cranial base. Only few case reports describe the manifestation of plasmacytoma of the skull base with affection of visual acuity. CASE REPORT: We describe the case of a 43-year-old woman, presenting with an acute unilateral loss of vision. The presumption diagnosis was retrobulbar neuritis as first manifestation of multiple sclerosis. MR imaging disclosed a tumour in the left orbital region and a meningioma was suspected. After complete resection with decompression of the optic nerve, the neuropathological examination revealed a lambda positive plasmacytoma. Additional work-up disclosed an involvement of multiple vertebral bodies. Due to the diagnosis of multiple myeloma, oncological therapy had been initiated. CONCLUSION: Skull base plasmacytoma is a rare disease. Solitary lesions causing neurological deficits should be treated aggressively including surgery for histological diagnosis and decompression of neural structures. Prognosis and further therapy depends on the systemic stage of disease, which has to be defined by diagnostic work-up.

T-cell lymphoma mimicking schwannoma of a cervical nerve root.

T-cell lymphoblastic lymphoma is a rare form of non-Hodgkin lymphoma, which shows preponderance for young men. Most common symptoms are painless swelling of lymph nodes, accompanied by B symptoms and large mediastinal masses. Most often, an involvement of the nervous system is due to paraneoplastic symptoms or side effects of treatment. In a literature research, we could not find a case with affection of a cervical nerve root as the first symptom for T-cell lymphoblastic lymphoma. A 39-year-old man presented with right-sided C8 radiculopathy, including pareses and paresthesia. Since the magnetic resonance image disclosed a right-sided mass lesion in the region of the neuroforamen C8, compressing the corresponding nerve root, a schwannoma was suspected. The tumor was removed using a dorsal approach. Neuropathological examination revealed the diagnosis of T-cell lymphoblastic lymphoma. The patient underwent diagnostic staging and received further treatment. He experienced a very grim course and succumbed to his disease 12 months after surgery. T-cell lymphoblastic lymphoma is a rare disease, and tropism of lymphoma cells to neural structures is seldom encountered. However, the presence of radiculopathy, together with signs, referring to B symptoms, should prompt the physician to consider this coincidence in the differential diagnosis of schwannoma.

Chiari malformation type I with concomitant persistent trigeminal artery -- report of an unusual case and a review of the current literature.

BACKGROUND: Chiari malformation type I is a stenosis of the subarachnoid space at the level of the foramen magnum due to a small posterior fossa and herniation of the cerebellar tonsils. We present here the unusual case of a Chiari malformation in conjunction with a persistent trigeminal artery and hypoplasia of the basilar artery, also known as a Saltzman anomaly. CASE REPORT: A 34-year-old female physician presented with recurrent headaches, bilateral weakness of deltoid muscles and numbness of the fingertips 3 to 5. A cranial MRI revealed a descent of the cerebellar tonsils to the level of C2 and a supracerebellar cyst. During surgery, a decompressive suboccipital craniectomy was performed. The supracerebellar cyst was fenestrated and the cerebellar tonsils were resected bilaterally. Two days after surgery the patient developed cranial nerve dysfunction and a right-sided hemiparesis. Cerebral angiography revealed a Saltzman type 1 anomaly with persistent primitive trigeminal artery and hypoplasia of the basilar artery. DISCUSSION: This is the first report in the literature about the coincidence of both unusual anomalies. The latest literature of both rare anatomy and the unusual clinical course will be discussed.

Endothelin-1 in plasma, cisternal CSF and microdialysate following aneurysmal SAH.

OBJECTIVE: Endothelin-1 (ET-1) is postulated to play an important role in the development of cerebral vasospasm (CVS) following SAH. This study was conducted to investigate the time course of ET-release in three different sources: CSF, plasma and microdialysate. METHODS: In a prospective study ET-1-concentrations were measured in plasma, cisternal CSF and microdialysate in 20 patients with aneurysmal SAH for at least 8 days after hemorrhage. RESULTS: ET-1 concentration in microdialysate was almost four times higher compared to CSF and plasma. (p<0.001) Only in CSF ET-1-release showed a significant increase over time with highest values on day 5 post ictus (p = 0.03). This was parallel to the increase of transcranial Doppler velocities. ET-1 in plasma and microdialysate did not change over time. CONCLUSION: ET-1 may have a different biological function in different biological tissues. Only ET-1 in CSF seemed to be associated with CVS.

[HAC-titanium as an implant for interbody fusion in spinal canal stenosis of the cervical spine. Six-year clinical trial]. / HAK-Titan als Interponat zur interkorporellen Fusion bei knöchern bedingter Spinalkanalstenose der HWS Ergebnisse nach 6-jährigem klinischen Einsatz.

A total of 102 patients were operated on in 134 levels because of an isolated spondylotic cervical stenosis in 6 years. A titanium implant coated with hydroxyapatite ceramic (HAC) was inserted. The average age of the patients was 53 years. The final clinical and radiological follow-up was performed after 15 months. The functional outcome was classified as good to excellent (Odoms's score) in 83.8% of the patients. Implant-related complications requiring revision surgery included two dislocated dowels and one vertebral collapse in a bisegmental operation. After 6 weeks beginning of bony growth around the implant was seen in 38% of all inserted titanium cages on roentgenograms. A complete solid bony incorporation was shown in 91.2% of the fused segments after 6 months and in 96% after 12 months or at follow-up, respectively. These results illustrate the efficacy of the easy to handle HAC titanium implant, demonstrating that this technique achieves good clinical outcome with the same complication rate as comparable techniques.

Real-time integration of ultrasound into neuronavigation: technical accuracy using a light-emitting-diode-based navigation system.

BACKGROUND: In brain surgery, intraoperative brain deformation is the major source of postimaging inaccuracy of neuronavigation. For intraoperative imaging of brain deformation, we developed a platform for the integration of ultrasound imaging into a navigation system. METHOD: A commercially available ultrasound system was linked to a light-emitting-diode- (LED) based neuronavigation system via rigid fixation of a position localiser to the ultrasound probe and ultrasound image transfer into the navigation system via a S-VHS port. Since the position of the ultrasound image co-ordinate system is not readily defined within the navigation reference co-ordinate system (REF CS), a transformation which links both co-ordinate systems has to be defined by a calibration procedure. Calibration of the ultrasound probe within the REF CS was performed via a cross-wire phantom. The phantom target was defined within the navigation co-ordinate system (by pointer under microscopic control) and imaged by ultrasound. Ultrasound presets were optimised (digital beam focusing, gain intensity) to attain a small echoic target for manual target definition. The transformation was derived from 150 ultrasound measures and iteration. Accuracy was calculated as mean linear error (LE; in X(REF), Y(REF), or Z(REF) direction), overall mean LE (linear errors of all axes X(REF) to Z(REF)) and Euclidean error (EE; vectorial distance from the physical target). FINDINGS: Optimised ultrasound presets (8 MHz frequency, digital beam focusing, 20% gain intensity) enabled a low interobserver error (mean: 0.5 mm, SD: 0.28) for target definition within the 2-D ultrasound image. Mean accuracy of pointer-based physical target definition in the REF CS was 0.7 mm (RMSE; SD: 0.23 mm). For navigated ultrasound, the overall mean LE was 0.43 mm (SD: 1.36 mm; 95%CL: 3.13 mm) with a mean EE of 2.26 mm (SD: 0.97 mm; 95%CL: 4.21 mm). INTERPRETATION: Using a single target cross-wire phantom, a highly accurate integration of ultrasound imaging into neuronavigation was achieved. The phantom accuracy of integration lies within the range of application accuracy of navigation systems and warrants clinical studies.

Treatment of pain from osteoporotic vertebral collapse by percutaneous PMMA vertebroplasty.

BACKGROUND: Vertebral compression fractures are common complications in advanced osteoporosis. In general, this disease of the elderly patient is characterized by severe local back pain. Pathophysiologically, bony instability triggers local pain during body movement. Serious pain immobilizes the patients and forces them to bed rest. As a result, complications like thrombosis or pneumonia occur. Invasive treatment with surgical instrumentation for vertebral stabilization is not indicated in elderly patients especially with additional diseases. The purpose of this study was to test the hypothesis that percutaneous polymethylmethacrylate (PMMA) vertebroplasty significantly reduces pain due to vertebral collapse in osteoporotic patients and improves quality of life. METHODS: A total of 38 patients with osteoporotic vertebral compression fractures of the thoracic and lumbar spine were treated by PMMA vertebroplasty. After admission, before discharge from the hospital, six weeks, half a year and one year later patients answered the Oswestry Low Back Pain Disability (OLBPD) Questionnaire for assessment of treatment related change in disability. In all patients percutaneous vertebroplasty was performed under local anesthesia. FINDINGS: A total of 92% of patients reported a significant pain reduction immediately after treatment. Also one year after vertebroplasty pain remained significantly reduced. Vertebroplasty was highly beneficial for patients with pain related to local instability of the spine. Extravasation of PMMA beyond the vertebral margins was observed in 26% of the cases. No treatment related clinical or neurological complications were noticed. INTERPRETATION: PMMA vertebroplasty is a useful and safe method of pain relief which rapidly regains quality of life for patients with osteoporotic vertebral compression.

[Operative stabilization of traumatic instabilities of the lower cervical spine. Experience with an angle instable anterior plate-screw system in 95 patients]. / Operative Stabilisierung traumatischer Instabilitäten der unteren Halswirbelsäule. Erfahrungen mit einem nicht winkelstabilen ventralen Platten-Schrauben-System bei 95 Patienten.

Traumatic instabilities of the cervical spine between C2 and T1 can successfully be treated by anterior spondylodesis with a plate and a tricortical iliac bone graft in most cases. Various plate-screw systems are available.Ninety-five patients with traumatic instability of the lower cervical spine were operated on using the Codman anterior cervical plate system (ACPS). The mean age was 42.1 years, and the mean follow-up was 14.9 months.Twenty-three patients with initial neurological deficits demonstrated an improvement of their symptoms at follow-up. No pseudarthrosis was detected among the 86 patients who were reexamined. Implant-related complications included one pulling out of a plate and one asymptomatic screw loosening. The Codman anterior cervical plate system (ACPS) is easy to use, safe, and a reliable method to stabilize instable injuries of the cervical spine by an anterior approach. The risk of dural or neurological injury is avoided. Implant-related complications are rare.

[Polymethylmethacrylate-vertebroplasty. A new and effective method of pain treatment in vertebral compression]. / Polymethylmethacrylat-Vertebroplastie - Eine neue und effektive Schmerztherapie bei Wirbelkompressionen -

BACKGROUND AND OBJECTIVE: Percutaneous polymethylmethacrylate (PMMA) vertebroplasty is increasingly used in the treatment of back pain related to compression of the vertebral bodies. After the procedure immediate mobilization of the patient is possible. The purpose of the study was to examine the change in quality of life of patients with vertebral collapse achieved by vertebroplasty during a six-month period. PATIENTS AND METHODS: 28 patients with osteolytic metastases (mean age 59,7 +/- 7,8 years, 2,1:1male/female ratio) and 38 patients with osteoporotic vertebral collapse (mean age 73 +/- 6 years, 1:3,5male/female ratio ) of the thoracal and lumbar spine were treated with PMMA vertebroplasty and analysed prospectively. After admission, before, six weeks and 6 months after discharge from the hospital patients answered the Oswestry Low Back Pain Disability (OLBPD) questionnaire for assessment of treatment-related changes in disability. RESULTS: Immediately and 6 months after treatment 83 % of tumor patients and 92 % of ostoporotic patients had significant pain reduction. Extravasation of PMMA beyond the vertebral margins were observed in 26 % of the patients. No treatment-related clinical or neurological complications were observed. CONCLUSION: PMMA vertebroplasty is an efficacious and safe method of pain relief for patients with osteolytic metastases or osteoporotic compression with good long-term results.

Nitric oxide metabolites in cisternal CSF correlate with cerebral vasospasm in patients with a subarachnoid haemorrhage.

BACKGROUND: The pathogenesis of cerebral vasospasm is likely to be multifactorial. Exposure of the adventitia of large cerebral arteries to blood breakdown products initiates a cascade of changes in both morphology and vasomotor regulation of the exposed vessels. The role of nitric oxide (NO) in development of cerebral vasospasm process is controversial. Basal cerebral vascular tone requires the continuous release of NO, nevertheless NO is involved in free radical mediated injury of endothelial cell membrane. Concentrations of nitrate/nitrite (stabile endproducts of NO metabolism) were studied in cisternal cerebrospinal fluid (cCSF) in patients suffering from aneurysmal subarachnoid haemorrhage (SAH). METHOD: 21 patients suffering from aneurysmal SAH were investigated. Treatment included aneurysm clipping, cisternal drainage of CSF and intravenous nimodipine in all patients as well as tripple H therapy when indicated. TCDS was performed on a daily basis. A mean flow velocity of more than 150 cm/sec and the development a delayed neurological deficit was defined as vasospasm. CSF samples were collected on the day of surgery and for the 7 days following. NO-M (nitrite and nitrate) were measured using a commercially available test kit. FINDINGS: 5 of 21 patients developed clinically symptomatic vasospasm. There was a significant difference in NO levels between the groups. Patients with cerebral vasospasm showed significantly higher levels of NO-M in CSF than patients with a uncomplicated follow-up between day 2 and 8. INTERPRETATION: Our preliminary results indicate that SAH leads to an increase in NO-M in CSF. This increase of NO-M significantly correlates with the flow velocities in TCDS measurement suggesting that NO plays an important role in the pathogenesis of cerebral vasospasm.

[Cervical myelopathy induced by calcium pyrophosphate tophus in primary chondrocalcinosis]. / Zervikale Myelopathie durch Kalzium-Pyrophosphat-Tophus bei primärer Chondrokalzinose.

A 78 year old female patient with cervical myelopathy induced by a calcium pyrophosphate dihydrate tophus around the dens axis with clinical signs of a cervical tumor is presented. After operation of the tumor, the diagnosis of a generalized CPPD disease was established retrospectively, where by patient had complained of joint pain already for many years. This known complication of a primary chondrocalcinosis should be a reason for a careful investigation of the cervical spine in CPPD disease, because neurological disturbances might increase the joint destruction in the manner of "Charcot joints".

[Influence of postoperative radiation therapy of cerebral metastases on survival time and disease related to living condition]. / Einfluss der postoperativen Nachbestrahlung zerebraler Metastasen auf Uberlebenszeit und krankheitsbedingte Lebensbedingungen der Patienten.

Cerebral metastases are frequently observed in patients with systemic carcinoma as indication for new progress of the disease. Neurological deficits or seizures indicating cerebral metastases reduce the disease-related living conditions of the patients. Improving quality of life and survival time is the overriding goal of an early treatment after the diagnosis of cerebral metastases. Contemporary treatment include surgical removal of the cerebral metastases followed by whole brain irradiation and in some cases additional systemic chemotherapy for the primary tumor. This study was conducted to test the hypothesis that whole brain radiation following surgical removal improves the quality of life and the survival time in patients with cerebral metastasis. From January 1, 1994 to December 31, 2000, a total of 139 patients (mean age 59 +/- 2.3 years, m : f = 84 : 55) with cerebral metastases were investigated. Disease-related living conditions were assessed by Karnofsky score, the median time of follow-up was 11 months. For the analysis, patients were divided into groups with and without radiation therapy. Additionally, groups of patients with singular and two brain metastases were defined. In patients with singular brain metastases neither the survival time nor disease-related living conditions during the remaining life time was increased by postoperative whole brain irradiation. Almost all patients died due to the progression of the primary tumor. Patients with more than one metastases seemed to have a slight but not significant benefit from irradiation therapy after surgical removal of all metastases. In conclusion, these results indicate that an uncritical irradiation therapy of neurocranium after surgical removal of cerebral metastases is not beneficial in terms of survival time or disease-related living conditions.

[Delayed appearance of posttraumatic cerebrospinal fluid fistulas as a cause of recurrent meningitis]. / Verzögertes Auftreten posttraumatischer Liquorfisteln als Ursache rezidivierender Meningitiden.

Immediate post-traumatic fistulas with rhinorrhea are well known after head injury with frontobasal trauma. Less attention is paid to the possibility of delayed onset of rhinorrhea after severe head injury. Unrecognised frontobasal injury may cause recurrent meningitis due to communication of CSF with the outside world. In the last 5 years, seven patients who developed rhinorrhea 2-25 years after trauma were treated in our department. All patients had been through at least two episodes of meningitis. Intermittent rhinorrhea was reported by four. In all cases, coronal bone window CT scan disclosed a bony defect of the anterior skull base, and in three cases an encephalocele was revealed on MRI. Treatment consisted of reconstruction of the anterior skull base with a pedicled galeal-pericranial flap via bifrontal craniotomy. Delayed traumatic CSF fistulas are not rare but must be considered in the differential diagnosis of recurrent meningitis.

CLL cells in a brain metastasis of bronchial adenocarcinoma in a patient with three different neoplasms - case report.

OBJECTIVE: We report the case of a patient with three different malignancies who had a brain metastasis of bronchial adenocarcinoma with infiltrates of CLL lymphocytes and who had been operated for prostate cancer years before. - PATIENT AND RESULTS: A 72-year-old man was admitted to our department after a Jacksonian seizure. The MRI showed a left temporal mass lesion. The patient was suffering from chronic lymphocytic leukemia (CLL) for ten years, he had had surgery for prostate cancer eight years ago and the diagnosis of bronchial carcinoma was made during preoperative routine diagnostics. After neurosurgical intervention the histologic examination of the cerebral mass lesion disclosed metastasis of a PSA-negative adenocarcinoma with perivasal infiltrates of lymphocytic leukemic cells. - DISCUSSION: There are few reports about patients with three primary malignancies. CLL may play a role in enabling tumor cells to escape the immune response and could facilitate development of the prostate cancer and of a bronchial adenocarcinoma as secondary cancers in this patient. The combined occurrence of adenocarcinoma cells and CLL lymphocytes in the brain metastasis can be explained by impairment of the blood-brain-barrier in the carcinoma metastasis enabling extravasation of circulating leukemic cells.

[Pain of the trigeminal nerve as the first symptom of a metastasis from an oesohaguscarcinoma in Meckel's cave - case report]. / Trigeminusneuralgie als Erstsymptom einer Oesophaguskarzinom-Metastase im Cavum Meckeli - Fallbericht.

Pain in all three divisions of the trigeminal nerve is in over 65% of all cases the first symptom of a tumour in Meckel's cave. Tumors in this location make up only 0,5% of all intracranial tumours. The most common are trigeminal schwannomas and meningeomas. A metastases as a cause of trigeminal pain is a rare description in the literature so far. We describe a patient with trigeminal pain and a tumour in Meckels's cave shown in the MRI, who were operated in our department. The histological examination of the tumour resulted in the diagnosis of metastatic carcinoma of an until then unknown oesophaguscarcinoma. - Although metastatic tumours are rare, we could show with our case, that they have to be included in differential dignostic considerations.

[Delayed traumatic CSF-fistulas: a retrospective analysis]. / Verzögernd auftretende Liquorfisteln - eine retrospektive Analyse.

Immediate posttraumatic CSF-fistulas are a well known entity after severe head injury. Delayed onset of rhinorrhea is considered to be rare. In the last 5 years 7 patients were treated in our department, who developed rhinorrhea 2-25 years after trauma. All patients went through episodes of meningitis. In 4 cases intermittent rhinorrhea was reported. In all cases a bony defect of the anterior skull base was detected by coronal bone window CT-scan. In three of them an encephalocele was revealed by MR-scanning. Treatment consisted in reconstruction of anterior skull base with a pedicled galeal-pericranial flap via a bifrontal craniotomy and went out without any complications. Delayed rhinorrhea after severe head injury is not a rare curiosity. In cases of bony defects after head injury reconstruction of anterior skull base is recommended to prevent episodes of recurrent meningitis.

[Patients' assessment of the importance of measures relevant for treatment in lumbar disc herniations and their satisfaction--a prospective study]. / Wichtigkeit therapierelevanter Massnahmen und Zufriedenheit von Patienten mit lumbalen Bandscheibenvorfällen - eine prospektive Studie.

In modern health system hospital is integral part of patients treatment. The hospital competes with an ubiquitous medical supply of adjacent institutions and general doctors. As a part of the medical supply chain a hospital may not exist as an "island" itself. Necessity in health politics and economics leads to image and advertisement strategies for a long term survival of hospitals. An analysis of medical output in patients treatment will build the basis for future development and strategies. By a questionnaire 170 patients suffering from a lumbar disc herniation were asked before starting medical treatment about their expectations and at the end of hospitalisation about their contentment with their stay in hospital. The very high expectations in medical treatment and nursing were fulfilled by the clinical staff. Here all patients were much more content they expected priorly. But the patients valued a distinct deficit in contentment in the co-treatment by other clinical faculties of the hospital. The reason of these results were explained by big distances inside the hospital and long time waiting between medical examinations. Our results show that intensive care by physicians and nurses increase contentment of patients. An additional improvement of patients judgement about hospital services will be possible by introduction of a routine co-treatment of other medical faculties.