RESUMO
A total of 58 patients consecutively underwent surgical treatment for lumbar intervertebral foraminal stenosis. We performed a microsurgical combined transarticular lateral and medial procedure with partial facetectomy in all patients to decompress the affected nerve root. All patients underwent assessment of depressive symptoms by means of the Zung Self Depression Scale (SDS). Subjective pain was self-evaluated by the Visual Analogue Scale (VAS). Both the tools were administered preoperatively, at 3 and 12 months' follow-up 0. The difference between the three SDS scores was significant (Friedman ANOVA, χ(2) = 53.171, p < 0.00001). The Wilcoxon rank test showed significant difference between preoperative SDS scores as compared with three months follow-up (Z = -6.393, p < 0.0001) and the last, in turn, as compared with twelve months follow- up (Z = -3.720, p = 0.0002). The comparison between preoperative and 12 months' follow-up also reached significance (Z = -3.285, p = 0.001). About VAS, the difference between the three VAS scores was significant (Friedman ANOVA, χ(2) = 69.932, p < 0.00001). The Wilcoxon rank test showed significant difference between preoperative VAS scores as compared with 3 months' follow-up (Z = -6.567, p < 0.0001) and the last, in turn, as compared with 12 months' follow-up (Z = -3.153, p < 0.002). The comparison between preoperative and 12 months' follow-up was also significance (Z = -5.520, p < 0.0001). Our results would alert clinicians to accurately consider the real need to treat and to include a careful psychiatric and psychological evaluation of these patients in the diagnosis and follow-up 0.
Assuntos
Depressão/cirurgia , Estenose Espinal/complicações , Estenose Espinal/cirurgia , Resultado do Tratamento , Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , Análise de Variância , Descompressão Cirúrgica , Depressão/etiologia , Feminino , Seguimentos , Humanos , Vértebras Lombares , Masculino , Pessoa de Meia-Idade , Medição da Dor , Escalas de Graduação Psiquiátrica , Estudos Retrospectivos , Estenose Espinal/diagnóstico , Adulto JovemRESUMO
OBJECTIVE: Intrathecal baclofen therapy (ITB) is a well-known treatment for spasticity. Despite this fact, several topics have to be still discussed: new indications and screening tools, appropriate surgical timing and complicance avoidance. METHODS: A total of 112 consecutive patients all with a severe, progressive and refractory to medical therapy spasticity from different causes were treated using ITB, after a bolus test. Every patient was assessed by means of Modified Ashworth Scale (MAS), Penn spasm frequency scale (SFS) and Visual Analog Scale for pain. Since available, a Gait analysis was also performed. RESULTS: There were 63 males (56%) and 49 females (44%). Seventy-four (66%) had a quadriparesis, 34 (30.4%) had a paraparesis and 4 (3.6%) were hemiplegic. Among these patients 77 (68.7%) were non ambulatory, while 35 (31.3%) were ambulatory. These patients suffered from spasticity due to many different diseases. Mean follow-up was 55 months. The mean Modified Ashworth score decreased from 4.5±0.5 preoperatively to 1.2±0.4 on chronic intrathecal baclofen. Daily baclofen dose varied between 23 and 500 mcg. Drug-induced complications and catheter related problems occurred, respectively in 7 (6.3%) and 10 patients (8.9%). CONCLUSIONS: Although ITB is a well known and good treatment option in the management of severe spasticity, because of the different goals and subgroups of patients treated, a variety of techniques are needed to evaluate the benefits of this therapy. New indications, effects of ITB on central nervous system and cognitive functions needs yet to be fully clarified.
Assuntos
Baclofeno/administração & dosagem , Baclofeno/uso terapêutico , Relaxantes Musculares Centrais/administração & dosagem , Relaxantes Musculares Centrais/uso terapêutico , Espasticidade Muscular/tratamento farmacológico , Adolescente , Adulto , Baclofeno/efeitos adversos , Criança , Transtornos da Consciência/induzido quimicamente , Pessoas com Deficiência , Relação Dose-Resposta a Droga , Quimioterapia Combinada , Feminino , Seguimentos , Transtornos Neurológicos da Marcha/diagnóstico , Transtornos Neurológicos da Marcha/etiologia , Humanos , Bombas de Infusão Implantáveis/efeitos adversos , Injeções Espinhais , Masculino , Pessoa de Meia-Idade , Relaxantes Musculares Centrais/efeitos adversos , Rigidez Muscular/fisiopatologia , Espasticidade Muscular/etiologia , Medição da Dor , Úlcera Cutânea/etiologia , Punção Espinal , Adulto JovemRESUMO
The case is described of a 50-year-old man, treated for 10 years in an outpatient psychiatric clinic for an obsessive compulsive disorder, who presented with acute loss of consciousness after forceful nose blowing. A CT scan revealed an intraparenchymal air collection with tension signs in the left frontal lobe and a bone defect in the roof of the ethmoid sinus. After emergency left frontal craniotomy and dura opening, the gaseous collection was evacuated by a ventricular catheter inserted into the brain and the bone defect was repaired with pericranium flap and muscle. The postoperative course was uneventful with neurocognitive improvement and regained motility. Spontaneous tension pneumocephalus is a rare life-threatening condition which is often caused by a bone defect near the tegmen tympani. This case illustrates both an unusual cause and a unique surgical treatment for spontaneous tension intraparenchymal pneumocephalus. It can be a dangerous entity with potential for early mortality and long-term morbidity if not promptly decompressed. The pathogenesis, diagnosis and surgical strategies for spontaneous tension pneumocephalus are briefly discussed.
Assuntos
Seio Etmoidal/lesões , Transtorno Obsessivo-Compulsivo/complicações , Pneumocefalia/psicologia , Fraturas Cranianas/psicologia , Inconsciência/psicologia , Doença Aguda , Humanos , Masculino , Pessoa de Meia-Idade , Nariz , Pneumocefalia/diagnóstico por imagem , Tomografia Computadorizada por Raios XRESUMO
A total of 73 patients underwent microdiscectomy for lumbar disc herniation between September 2001 and May 2002 at the Department of Neurosurgery of the Second University of Naples. Preoperatively and 3 and 6 months after surgery, patients were assessed on the Zung Self-rating Depression Scale (SDS) and on a visual analogue scale (VAS) for the subjective perception of pain. At 3 and 12 months, we found that patients with lower SDS scores (n=41) had a better outcome regarding pain than patients with relevant depressive symptoms (n=32). In agreement with the literature, our results confirm the negative role of depression in outcome after lumbar disc surgery. We emphasize the consideration of psychological factors in the management of lumbar disc herniation.
Assuntos
Depressão/diagnóstico , Depressão/psicologia , Discotomia/psicologia , Dor Pós-Operatória/diagnóstico , Dor Pós-Operatória/psicologia , Adolescente , Adulto , Idoso , Análise de Variância , Discotomia/efeitos adversos , Feminino , Seguimentos , Humanos , Vértebras Lombares/patologia , Vértebras Lombares/cirurgia , Masculino , Pessoa de Meia-Idade , Medição da Dor/psicologia , Medição da Dor/estatística & dados numéricos , Prognóstico , Análise de RegressãoRESUMO
BACKGROUND: We report our surgical experience in the treatment of fifteen consecutive patients with benign craniovertebral junction tumors, observed from 1993 to 2000 at our department. METHOD: We treated 7 meningiomas, 3 epidermoids, 3 C1 neurinomas and 2 neurinomas of the lower cranial nerves. Clinical results were evaluated by Karnofsky Performance Scale and all patients underwent preoperative neuroradiological evaluation with CT, MRI and MRA; angiography was not routinely performed and was considered for each individual case. FINDINGS: 11 partial transcondilar and 4 retrocondilar approaches were performed. Total removal was achieved in 11 cases (73,3%) and subtotal removal in 4 patients (26,7%). None of the patients required occipitocervical fusion. Patients were followed for an average period of 24+/-31 months. Clinical and radiological follow-up showed no recurrence in cases with total removal. In all patients a statistically significant postoperative increase of KPS scores was recorded. The treatment of epidermoid tumors presented particular issues: debulking the lesion, we obtained a surgical window, avoiding a large removal of bone. In Nakasu grade 1 or 2 meningiomas, we carried out total removal by piecemeal resection and without complete condylectomy and bone fixation. INTERPRETATION: The choice of these approaches and the extent of bone resection should be defined according to the tumor's location and size. Moreover we emphasize that preoperative neuroradiological evaluations on presumptive tumor type could be helpful to the surgeon in order to tailor the technique to different lesions, providing the required exposure, without unnecessary surgical steps.
Assuntos
Vértebras Cervicais/diagnóstico por imagem , Vértebras Cervicais/cirurgia , Neoplasias dos Nervos Cranianos/diagnóstico por imagem , Neoplasias dos Nervos Cranianos/cirurgia , Cisto Epidérmico/diagnóstico por imagem , Cisto Epidérmico/cirurgia , Neoplasias Meníngeas/diagnóstico por imagem , Neoplasias Meníngeas/cirurgia , Meningioma/diagnóstico por imagem , Meningioma/cirurgia , Neurilemoma/diagnóstico por imagem , Neurilemoma/cirurgia , Neoplasias Cranianas/diagnóstico por imagem , Neoplasias Cranianas/cirurgia , Neoplasias da Coluna Vertebral/diagnóstico por imagem , Neoplasias da Coluna Vertebral/cirurgia , Adolescente , Adulto , Idoso , Vértebras Cervicais/patologia , Neoplasias dos Nervos Cranianos/patologia , Cisto Epidérmico/patologia , Feminino , Humanos , Imageamento por Ressonância Magnética , Masculino , Neoplasias Meníngeas/patologia , Meningioma/patologia , Pessoa de Meia-Idade , Neurilemoma/patologia , Avaliação de Resultados em Cuidados de Saúde , Cuidados Pré-Operatórios , Estudos Retrospectivos , Neoplasias Cranianas/patologia , Neoplasias da Coluna Vertebral/patologia , Tomografia Computadorizada por Raios XRESUMO
Dural ectasia denotes circumferential expansion or dilatation of the dural sac, and has been frequently reported in association with type 1 neurofibromatosis (NF1). The pathogenesis has not been defined, but its correlation with NF1 infers a congenital malformative hypothesis. The neural elements in the dilated sleeve typically are not enlarged or abnormal, nevertheless the enlarged area contain an increased amount of cerebrospinal fluid. The dura in the area of ectasia is extremely thin and fragile, and erodes the surrounding bony structures destabilising the spine and permitting spectacular spinal deformities. We present two cases with lumbosacral dural ectasia, enlargement of the intervertebral foramina and posterior scalloping of vertebral bodies. Neurological examination showed sciatic nerve irritation. As the etiology of this malformation remains uncertain and dysplastic changes of the spine may be intrinsic or secondary controversies remain about optimum treatment. We conclude that patients affected by NF-1 require an accurate neuroradiological study of the whole spine in order to detect possible dural and spinal anomalies. Surgical treatment is indicated only in patients with progressive neurological deterioration. The thin dural sac predisposes to a high morbidity if surgery is undertaken.
Assuntos
Dura-Máter/fisiopatologia , Neurofibromatose 1/fisiopatologia , Adulto , Dilatação Patológica , Dura-Máter/patologia , Humanos , Região Lombossacral , Imageamento por Ressonância Magnética , Masculino , Neurofibromatose 1/diagnóstico , Tomografia , Tomografia Computadorizada por Raios XRESUMO
Endoscopic third ventriculostomy has become a routine intervention for the treatment of non-communicating hydrocephalus. This technique is largely considered safe and a very low incidence of complications is reported. However, hemorrhage in the course of neuroendoscopy is still a problem difficult to manage. The authors present a case in which endoscopic third ventriculostomy and tumor biopsy were performed in a young patient with a huge tumor growing in the posterior part of the third ventricle. The surgical approach to realize the stoma was difficult because the tumor size reduced the third ventricle diameter. Surgical manipulation produced a traumatic subependymal hematoma. This hematoma drained spontaneously after few minutes into the ventricle and the blood was washed away. The postoperative neurological course was uneventful and the ventriculostomy showed to work well by reducing the size of the lateral ventricles and the intracranial pressure in three days. This complication during endoscopic third ventriculostomy has never been reported before. We emphasize the difficulty of endoscopic procedures in patients with huge tumors in the third ventricle. Where reduction in size of the third ventricle and of the foramen of Monro ist present we suggest a careful approach to the third ventricle.
Assuntos
Hemorragia Cerebral/etiologia , Neoplasias do Ventrículo Cerebral/cirurgia , Endoscopia/efeitos adversos , Glioma Subependimal/cirurgia , Hematoma/etiologia , Terceiro Ventrículo/cirurgia , Ventriculostomia/efeitos adversos , Adolescente , Humanos , MasculinoRESUMO
BACKGROUND: Spontaneous resolution of chronic subdural hematoma has rarely been reported in the literature, and its mechanism has not been fully investigated. Response to surgery has been very satisfactory; in fact, this is generally considered the treatment of choice. METHODS: From a series of 24 cases of chronic subdural hematomas, we observed five patients between 1996 to 1998. These patients showed headache and decrease of cognitive level, 4-5 weeks after minor head injury. Neurologic evaluation revealed only worsening of mental function according to Mini Mental State Examination (MMSE). Computed tomography (CT) scans showed brain atrophy and chronic subdural hematoma without increased intracranial pressure. These patients were treated by clinical observation and serial cerebral CT scans. RESULTS: After 7 to 10 days, all patients showed improvement of clinical signs. After 30 to 45 days, radiological disappearance or marked reduction in size of the hematoma and complete clinical recovery were obtained. No neurological deficits and no recurrences have been observed during follow-up (3 months to 2 years). CONCLUSIONS: We believe that age greater than 70 years, decreased cognitive level (MMSE = 21), brain atrophy, and absence of increase of intracranial pressure are clinical and radiological signs that allow one to choose conservative treatment.
Assuntos
Hematoma Subdural/diagnóstico por imagem , Idoso , Doença Crônica , Feminino , Hematoma Subdural/etiologia , Humanos , Masculino , Remissão Espontânea , Tomografia Computadorizada por Raios XAssuntos
Encefalopatias/complicações , Doenças das Artérias Carótidas/complicações , Cisto Epidérmico/complicações , Aneurisma Intracraniano/complicações , Lobo Temporal , Adulto , Encefalopatias/cirurgia , Doenças das Artérias Carótidas/cirurgia , Cisto Epidérmico/cirurgia , Feminino , Humanos , Aneurisma Intracraniano/cirurgiaRESUMO
The authors present an anesthesiologic technique, consisting of the use of propofol + fentanyl + O2. The main advantages, described in 82 neurosurgically treated patients, are the following: moderate decrease both of ICP and MAP, absence of frequency, modifications rapid recovery both of consciousness and of motility, which allows a preliminary valuation of neurological status.
Assuntos
Anestesia Intravenosa , Encéfalo/cirurgia , Adulto , Idoso , Feminino , Humanos , Masculino , Pessoa de Meia-IdadeRESUMO
The authors report their experience on the use of urapidil in 31 patients, submitted to neurosurgical procedures. Urapidil, administered both in the inductive (0.7-1 mg/kg) and in preoperative phases (0.6-0.8 mg/kg/h), produced a MAP decrease of about 25% without significant variations in cardiac frequency or of other monitored parameters.
Assuntos
Encéfalo/cirurgia , Hipotensão , Piperazinas , Adulto , Idoso , Feminino , Humanos , Hipotensão/prevenção & controle , Masculino , Pessoa de Meia-IdadeRESUMO
The authors analyze the results they obtained by percutaneous radiofrequency technique for trigeminal neuralgia. The clinical material consists of 605 cases observed from 1977 to 1986 at their Institute. There was a female preponderance (62%) and an average age of 65 years. Idiopathic, atypical and symptomatic trigeminal neuralgia has been diagnosed respectively in 568, 21 and 16 cases. From 1977 to 1980 the working temperature was above 65 C, thereafter a lower temperature has been employed to coagulate the Gasserian ganglion. The rate of pain relief was 97% for idiopathic trigeminal neuralgia, 75% for symptomatic and 21% for atypical. The loss of facial sensation accounts for 80% of side effects of this procedure in their series. The recurrence of pain was observed in 16% of cases with a follow-up ranging from 2 to 10 years. It is noteworthy that there is a correlation between the coagulation temperature and the rate of recurrence, the higher the former, the lower the latter. The authors compare their results (rate of pain relief, morbidity, mortality, rate of recurrence) with those of major reports in the literature concerning either percutaneous or other surgical procedures (mircosurgical decompression of the trigeminal nerve, glycerol injection into the trigeminal cistern and percutaneous microcompression).
Assuntos
Eletrocoagulação , Neuralgia do Trigêmeo/cirurgia , Adulto , Idoso , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Medição da Dor , Complicações Pós-Operatórias/fisiopatologia , Complicações Pós-Operatórias/cirurgia , Recidiva , Reoperação , Nervo Trigêmeo/fisiopatologia , Neuralgia do Trigêmeo/fisiopatologiaRESUMO
A series of 78 intracranial meningiomas (68 suprasellar, 10 intraventricular) were operated on in our Institute after the advent of the operating microscope. In our review, we discuss the microsurgical technical problems related to the preservation of vascular and brain structures in the removal of intraventricular and parasellar meningiomas. Basic diagnostic criteria to plan correctly the surgical approach will be emphasized. Mortality and morbidity in parasellar meningiomas is, in our opinion, related to the experience of the surgeon in using the operating microscope rather then in using the laser and CUSA. We will also discuss the utility of preoperative embolization of the lesion as well as the indications for intraoperative EC/IC bypass. Finally, morbidity and mortality related to different approaches for intraventricular meningiomas will be discussed.
Assuntos
Neoplasias do Ventrículo Cerebral/cirurgia , Neoplasias Meníngeas/cirurgia , Meningioma/cirurgia , Microcirurgia , Adulto , Idoso , Neoplasias do Ventrículo Cerebral/diagnóstico , Feminino , Humanos , Imageamento por Ressonância Magnética , Masculino , Neoplasias Meníngeas/diagnóstico , Meningioma/diagnóstico , Pessoa de Meia-Idade , Exame Neurológico , Complicações Pós-Operatórias/diagnóstico , Complicações Pós-Operatórias/mortalidade , Sela Túrcica/patologia , Sela Túrcica/cirurgia , Tomografia Computadorizada por Raios XRESUMO
Two cases of patients harbouring simultaneously multiple brain tumors of different histological nature are here reported. Clinical presentation, site of growth and neuroradiological findings are illustrated and discussed in light of the data previously reported by the literature.
Assuntos
Astrocitoma/patologia , Neoplasias Encefálicas/patologia , Neoplasias Meníngeas/patologia , Meningioma/patologia , Neoplasias Primárias Múltiplas/patologia , Adulto , Astrocitoma/diagnóstico por imagem , Astrocitoma/cirurgia , Neoplasias Encefálicas/diagnóstico por imagem , Neoplasias Encefálicas/cirurgia , Angiografia Cerebral , Feminino , Humanos , Neoplasias Meníngeas/diagnóstico por imagem , Neoplasias Meníngeas/cirurgia , Meningioma/diagnóstico por imagem , Meningioma/cirurgia , Pessoa de Meia-Idade , Neoplasias Primárias Múltiplas/diagnóstico por imagem , Neoplasias Primárias Múltiplas/cirurgia , Tomografia Computadorizada por Raios XRESUMO
A 42-year-old patient with a bilateral extracranial internal carotid occlusion which was associated with a midline intracerebral tumour of the genu of the corpus callosum, is reported. This rare association is discussed in the light of the pathogenetic theories referred to in the literature in similar cases. It is felt that, such cases, although rarely encountered, should stimulate the adoption of more accurate neuroradiological investigations, in patients harbouring brain tumours, in order carefully to plan the anaesthetic and surgical procedures.
Assuntos
Neoplasias Encefálicas/complicações , Doenças das Artérias Carótidas/etiologia , Adulto , Artéria Carótida Interna/diagnóstico por imagem , Angiografia Cerebral , Constrição Patológica/etiologia , Corpo Caloso/diagnóstico por imagem , Humanos , Ataque Isquêmico Transitório/etiologia , Masculino , Tomografia Computadorizada por Raios XRESUMO
The authors report three cases of primary nontumoral aqueductal stenosis associated with von Recklinghausen's disease in children. Moreover, 16 similar cases collected from the literature are presented. The clinical features are evaluated in light of data from the literature. Among all 19 cases, the median age was 19 years (range 6-46 years), and nine patients were under the age of 13 years. Our own patients underwent ventriculoatrial shunt procedures, followed by clinical recovery (follow-up 2-5 years). In one patient, computed tomography scanning performed 20 months after the operation showed a chronic calcified subdural hematoma in the right frontoparietal area. In conclusion, it is felt that, among all the pathological events usually described in patients affected by neurofibromatosis, primary aqueductal stenosis seems to be part of the natural history of this neurological syndrome.
Assuntos
Aqueduto do Mesencéfalo/patologia , Neurofibromatose 1/patologia , Aqueduto do Mesencéfalo/diagnóstico por imagem , Aqueduto do Mesencéfalo/cirurgia , Derivações do Líquido Cefalorraquidiano , Criança , Pré-Escolar , Constrição Patológica , Feminino , Humanos , Masculino , Neurofibromatose 1/diagnóstico por imagem , Neurofibromatose 1/cirurgia , Transtornos da Pigmentação/complicações , Transtornos da Pigmentação/patologia , Tomografia Computadorizada por Raios XRESUMO
The Authors report three cases of non tumoral aqueductal stenosis associated with von Recklinghausen disease in children. Moreover, 16 similar cases collected from the literature are illustrated. The clinical features are evaluated in light of literature's data. Among all 19 cases, the median age was 19 years (range 6-46 years) and 9 patients were under the age of 13 years. In this latter group, the most represented clinical symptoms were headache and gait disturbances. As regards the neuroradiological procedures, CT scan represented the best tool in the evaluation of the ventricular size. Our own three cases underwent to ventriculo-atrial shunt procedures, followed by clinical recovery (follow-up: 3 months-5 years). In conclusion it is felt that, among all the pathological events usually described in patients affected by neurofibromatosis, aqueductal stenosis seems to belong to the natural history of this disease.