Diagnostic value of different electrophysiologic tests in cervical disk prolapse.

We evaluated 24 patients with radiologically verified cervical disk prolapse. EMG abnormalities appeared in 67% of cases studied; dermatomal somatosensory evoked potentials revealed 85% abnormal findings on the affected side, but also revealed abnormalities in adjacent segments. In 38%, F responses were abnormal. We found electrodiagnostic abnormalities at levels without a disk prolapse, probably due to degenerative spondylopathic changes and beginning consecutive vascular compromise.

Ocular manifestations of sphenoid mucoceles: clinical features and neurosurgical management of three cases and review of the literature.

BACKGROUND: Sphenoid mucoceles (SMCs) are unusual lesions, with about 130 cases reported in the literature. Although benign, they may involve the orbit and cause acute restrictive ophthalmoplegia, proptosis, and reduced visual acuity. METHODS AND RESULTS: We present three cases (1 male, 2 females, aged 35, 36, and 46 years) of orbital involvement with acute decreased visual acuity by SMC. The lesions were promptly excised via a transnasal approach to decompress the optic nerve. After the decompression, the patients recovered completely. CONCLUSION: We believe that immediate surgical drainage of the SMC and prolonged antibiotic therapy are necessary and resulted in recovery of visual acuity. Prompt microsurgical transsphenoidal decompression is simple, effective, safe, and is necessary for avoiding persistent visual loss. Antibiotic therapy alone usually results in a poor outcome. We discuss the etiology, clinical manifestations, and management of this rare condition in the light of 130 other cases in the literature.

Malignant prolactinoma: case report and review of the literature.

BACKGROUND: Malignant prolactinomas are rare events. To date, only 14 patients with metastases in- or outside the central nervous system have been reported. CASE DESCRIPTION: We present a patient who developed a metastasis to the cauda equina, which is the first case documented with MRI. A giant prolactinoma in this 51-year-old man was partially removed by a transcranial approach. After radiotherapy and treatment with bromocriptine, the patient had a remission for 3 years. Thereafter, a sacral intraspinal tumor was diagnosed. Because of increasing prolactin levels not responding to bromocriptine and a radiologically suspected intrasellar tumor, we operated transsphenoidally first and found only fibrous tissue. We performed a sacral laminectomy and almost totally removed an intradural tumor. Histopathology and immunohistochemistry confirmed the diagnosis of a prolactinoma metastasis. The patient received radiotherapy and bromocriptine and has no evidence of recurrent tumor or metastases after a follow-up of 38 months, thus being the second reported patient with long-term remission of the disease. DISCUSSION: We review the literature on this topic and try to establish common features of the course of this rare malignant disease and the efficacy of therapy in the cases reported hitherto.

[Somatosensory evoked potential in general anesthesia]. / Das somatosensorisch evozierte Potential unter Bedingungen der Allgemeinanästhesie.

Somatosensory evoked potentials (SSEP) were investigated under general anaesthesia in 12 patients with no history of previous cerebral disease. With the commonly-used stimulation of the median nerve on the wrist, conduction from the homolateral Erb's point, and contralateral conduction from the mastoid and sensory cortical area, SSEP were registered during the first 100 msec. after the stimulation. Latency period, shape and amplitude of the spinal and subcortical components and early cortical potentials (N 20, P 28) show no change, whereas the consecutive negative and positive cortical SSEP show a definite change in shape and latency period. No change was registered in somatosensory impulse conduction and early cortical response under general anaesthesia and these can, therefore, be used during neurosurgery as a parameter for the control of cortical and subcortical functioning.

[Peroperative evoked potentials in neurosurgery]. / Les potentiels évoqués per-opératoires en neuro-chirurgie.

The application of somatosensory evoked potentials in different fields of neurosurgical procedures are presented. SSEP are used for the intra-operative control in aneurysm surgery, during a.v. malformation surgery specially in the posterior fossa and in the operative treatment of large acoustic neurinomas. Finally the authors describe their technic of anterior spinal cord stimulation in transthoracic approach in spinal cord traumatic lesions. In this patients proven intra-operative neuronal continuity allows good prognosis of functional recovery.

[Temporary bypass in carotid surgery; peroperative study of various metabolic parameters and the EEG]. / Le by-pass temporaire en chirurgie carotidienne; étude per-opératoire de quelques paramètres métaboliques et de l'EEG.

Out of a whole of patients of nearly 1000 reconstructive operations of the extracranial carotid artery, which were carried out by a systematic application of the intraluminal shunt, 32 selected patients with extracranial stenosis of the internal carotid artery were examined intraoperatively as to the following parameters of the internal carotid artery and the internal jugular vein: pH, pCO2, pO2, B.E. and the lactate were determined as well. Statistic analysis shows a significant increase of the arteriovenous difference of the lactate from the first to the second and from the first to the third sample.

[Intraoperative somatosensory evoked potentials (SSEP) in surgery of cerebral aneurysms: topographical information]. / Intraoperative somatosensorisch evozierte Potentiale (SSEP) in der Chirurgie cerebraler Aneurysmen: topische Aussagen.

Out of 114 patients who were operated because of cerebral aneurysms, 16 patients were monitored by means of Somatosensory Evoked Potential (SSEP) during the operation. In 9 of these, successful monitoring was possible during the whole duration of the surgical procedure. In the remaining seven, monitoring was impossible over a long period so that these patients were excluded from the present study. Monitoring of the cerebral functions by means of SSEP provides help in aneurysm surgery as follows: Objective evaluation of the function of the somatosensory system. The induced arterial hypotension--usually done in our department--implies danger for the brain, particularly, if rupture of the aneurysm occurs at the same time. In this case, Somatosensory Evoked Potentials provide the possibility to detect lesions of somatosensory neurons at different levels. This makes prognostic conclusions possible. Pathological changes of some SSEP components during temporary occlusion of arteries of the Circle of Willis indicate developing lesions of brain structures. Intraoperative SSEP data were correlated with the postoperative course in all 9 patients. Prognostic conclusions derived from these data are discussed.

[Changes in somatosensory evoked potentials in response to the combined use of extra- and intracerebral pressure: an experimental study]. / Veränderungen somatosensorisch evozierter Potentiale bei kombinierter Anwendung von extra- und intrazerebralem Druck: eine experimentelle Studie.

The impact of the combined application of extra- and intracerebral pressure on somatosensory evoked potentials (SEP) was investigated on 24 rats. The pressure upon the somatosensory cortex was applied via a 5 x 5 mm glass stamp which included a ceramic-diaphragmal electrode for recording the SEP, EEG and DC-potentials. The intracerebral pressure was evoked by a Fogarty-balloon catheter. The balloon catheter was inserted into the ipsilateral sensorimotor white matter. Slow increase of the balloon volume without additional epicortical pressure caused SEP changes at about 0.08 ml balloon volume. The application of 50 g pressure onto the cortex prior to balloon inflation led to SEP changes at 0.02 ml balloon volume, which showed a steep increase with further expanding balloon volume. In view of possible brain lesions due to brain retraction in intracerebral mass removal procedures the effects of intermittently and continuously applied epicortical pressure in addition to a given intracerebral mass (0.05 ml) were studied. In intermittent as well as in continuous pressure application the effects of both small (P = 25 g) and severe (P = 100 g) pressure were compared with. Even small pressure lasting for 60 minutes continuously caused SEP changes, which recovered only incompletely. In cases of intermittent application of small pressure the SEP pattern recovered completely. Severe epicortical pressure was followed by SEP changes, which did not recover neither in intermittent nor in continuous application. Irreversible disturbance of the microcirculation was assumed to be the reason.(ABSTRACT TRUNCATED AT 250 WORDS)

Changes of somatosensory evoked potentials with increase of intracranial pressure in the rat's brain.

Somatosensory evoked potentials (SEPs) to various combinations of two independent brain compression modalities (localized epidural pressure and intracerebral pressure evoked by an inserted balloon) were investigated in 24 rats. The SEP pattern in response to gradually expanding volume without additional epidural pressure remained unchanged for a certain period. SEP changes occurred only shortly prior to death. On the other hand, remarkable SEP changes were observed in a gradually expanding intracerebral mass, when combined with epidural pressure application at about 50% of the lethal volume. SEP changes in response to intermittent and continuous epidural pressure, in addition to a small intracerebral mass, were investigated too. Intermittent application of minor epidural pressure led to specific P1 changes, which recovered after each pressure step. The same pressure, administered continuously, evoked SEP changes with only partial recovery in some instances. Severe epidural pressure, administered intermittently, gave rise to severe SEP changes with only partial recovery after each step. The same epidural pressure delivered continuously led to SEP changes with very small recovery. SEPs have proved to be a reliable method for signalling brain dysfunction corresponding to various modalities and degrees of intracranial pressure.

[Acupuncture and other forms of treatment for patients with chronic back pain]. / Akupuntur und andere Therapieformen beim Patienten mit chronischen Wirbelsäulenschmerzen.

As in all pain sites, one has to distinguish between acute and chronic pain in spinal pain syndromes. The treatment of chronic spinal pain is dominated by non-operative procedures. There are three main procedures in this field of treatment: the manual medicine, the therapeutic application of local anesthetics and acupuncture. By manual techniques the pain-producing spinal structures can be recognized and these techniques offer at the same time sufficient treatment options to the patients. Therefore, manual therapeutic strategies are applied at first in a treatment session followed by the therapeutical application of local anesthetics. With this treatment the pain-producing spinal sites are directly influenced with the aim of blocking the nociceptors. Acupuncture is the last step of the treatment cascade in out patients in any case, because acupuncture does not only serve as treatment option for pain relief, but also and even more so has an harmonizing effect upon physical and psychological disturbances. It is absolutely necessary for the patient to lie down for 25 to 30 minutes to reach these goals. More invasive methods are offered to patients unsuccessfully treated by the described methods. These are: X-ray conducted periradicular infiltration, epidural blockades with local anesthetics and steroids, hiatus sacralis blockade, percutaneous radiofrequency denervation of the facet joint and percutaneous lumbar radiofrequency sympathicotomy. The indications for these treatment modalities are discussed as well as technical details regarding the performance. Disc herniation with radicular symptoms, spinal canal stenosis, cervical stenotic myelopathy and degenerative spinal instability may represent indications for surgical intervention. The symptomatology of these diseases is described. The indications for the individual cases and circumstances are discussed. Lastly, the various operative techniques are also described shortly.

[Differential diagnosis and surgical indications in lumbar intervertebral disk recurrence]. / Differentialdiagnose und Operationsindikation beim lumbalen Bandscheibenrezidiv.

This retrospective study concerns 48 patients who underwent reoperation some time after lumbar disc surgery because of persistent or recurring leg pain. During the same period (January 1980 to October 1982) 821 primary lumbar discectomies were done. Surgical findings at reoperation of 48 patients: 30 patients (3%) had a recurrent disc herniation at the previous site, 9 patients (1%) had disc herniations at a new site only, and 9 patients (1%) had only considerable epidural scar formation. The preoperative differentiation between symptoms related to recurrent disc herniation and those related to epidural scar formation is difficult, because in this situation myelography can not be relied upon. In our series of 48 patients, myelography showed in 27% of the cases false positive or false negative results. The clinical signs and symptoms are therefore of paramount importance.

Somatosensory evoked potentials (SSEPs) in various groups of cerebro-vascular ischaemic disease.

Fifty-eight patients suffering from cerebrovascular ischaemic diseases were examined by means of somatosensory evoked potentials (SSEPs). The early components during the first 50 msec were evaluated (N13, P15, N20, P28, CCT = N13-N20). The patients were divided into 4 groups according to the affected vascular region and the reversibility of the symptoms. Reversible ischaemic attacks in the vertebro-basilar artery region: 16 patients. Reversible ischaemic attacks in the internal carotid artery region: 14 patients. Non-reversible ischaemic deficits in the internal carotid artery region: 16 patients. Diffuse vascular encephalopathy: 12 patients. The two groups suffering from reversible ischaemic attacks did not show any significant SSEP differences, either when the right and left sides were compared, or when the groups were compared to a control group. Patients with non-reversible ischaemic deficits of the carotid artery system showed a significant difference of the N20-P28 amplitude compared to controls; it was increased on the non-affected side. The latencies of N20 and CCT showed a significant increase on the affected side; P15 components revealed significant delays on both sides. In patients with diffuse vascular encephalopathy significant delays of N13 and P15 were found on both sides, whereas the CCT was unaffected on both sides. The results are discussed in view of the topologic aspects and reversibility of symptoms.

[Why still use myelography in neurosurgery?]. / Warum immer noch Myelographie in der Neurochirurgie?

Recently CT scan and NMR imaging have become diagnostic routine methods for spine lesions, while myelography is no longer the method of choice in most cases. From the experience of our clinic, however, there remain some neurosurgical indications, which will be the contents of this publication. We would like to give a review of the present literature. Still remaining indications are: 1. Traumatic nerve root lesions 2. Anomalies of lumbosacral nerve roots 3. Cervical disc herniation: anterior disc excision vs. posterior operation. 4. Stenosis of the spinal canal in more than 2 levels 5. Neurological deficit after trauma of the spine 6. Functional Myelography 7. Spinal arteriovenous malformations 3 Patients are presented in the crucial phase of diagnostic evaluation. Based on their outcome, the indications of myelography are discussed.

[Partial vertical nucleotomy as a modification of tractotomy of the trigeminal nerve]. / Partielle vertikale Nukleotomie als Modifikation der Traktotomie des Nervus trigeminus.

The authors report on partial vertical nucleotomy, a modification of tractotomy of the quintothalamic tract. In 1979 eight patients underwent this procedure. Three of them showed a recurrence of pain from genuine trigeminal neuralgia. Three patients had symptomatic trigeminal neuralgia, one patient atypical neuralgia of the face without organic cause, whereas in one case the neuralgia occurred subsequent to a herpes zoster. At the time of examination all patients were free from pain.

Carpal tunnel syndrome: neurographical parameters in different stages of median nerve compression.

In a series of 47 cases and 55 hands operated upon for carpal tunnel syndrome, the pre-operative electrodiagnostic findings have been compared retrospectively with the morphological findings within the carpal tunnel during operation. As a main result there was no significant correlation between the degree of electrophysiological changes and the degree of median nerve compression. Only the lack of any motor or sensory response seems to indicate a more severe median nerve compression. In about 20% of cases with operatively proven marked median nerve compression, both distal motor latency and motor nerve conduction velocity were well within normal limits and would not have led to the diagnosis of a carpal tunnel syndrome in these cases. The diagnosis, therefore, cannot be made on the basis of electrodiagnostic pathological values only of distal motor latency and motor nerve conduction velocity, but has to take into account as well the sensory nerve conduction velocity as well as the clinical picture and neurological findings.

Posterior cervical foraminotomy. A follow-up study of 67 surgically treated patients with compressive radiculopathy.

A retrospective study was conducted on 67 patients undergoing posterior cervical foraminotomy (PCF) for unilateral intraforaminal soft and hard disc disease. Neurologic impairment, employment, and severity of associated signs were assessed preoperatively and at a 3.1-year average follow-up (range, 1.5-7 years). Diminution or complete disappearance of radicular symptoms was observed in 62 cases (93%), 3 months to 3 years after surgery. Minimal neurologic deficits persisted in 5 cases (7%). Neck pain improved in 62 cases, remained unchanged in three, and progressed in two cases with severe preoperative deficits. Fifty-three patients (79%) returned to their previous occupation; only seven (10%) retired prematurely on the basis of disc disease alone. Based on Prolo's functional economic outcome rating scale, 60 patients (90%) showed excellent economic outcome. Posterior cervical foraminotomy is an efficient means of decompressing lateral spinal roots compromised by soft disk herniations or osteophytic spurs, without the risk of an anterior approach with or without fusion. Careful patient selection and microsurgical technique are essential in obtaining consistent, excellent results. Additionally, the recent trend toward minimally invasive techniques and key-hole operations in neurosurgery and other specialisations favours the posterior approach.

Free sequestered disc herniation at the S2 level misdiagnosed as neuroma.

The case of a 38 year-old-man with a mass at the S2 level similar to a benign nerve root tumor (neuroma) is reported. The CT scan examination revealed the mass close underneath but not in connection with a disc herniation at the L5/S1 level. During operation the mass was not encountered as tumor but as free sequestered disc herniation, which was confirmed by histological examination. The reasons for considering the mass a tumor are discussed.

Gliomatosis cerebri: intra vitam stereotactic determination in two cases and review of the literature.

Gliomatosis cerebri (GC) is an infiltrative neoplastic process that is diffusely distributed through neural structures, whose anatomical configuration remains intact. Most of the cases with GC reported in the literature were diagnosed at autopsy (101/110, 92%). We report two cases of GC in a 42-year-old woman and a 65-year-old man. The diagnosis was confirmed neuropathologically after MRI-guided stereoetactic biopsy. External radiation therapy was performed and led to a complete recovery of all clinical signs. Follow-up examinations 17 and 21 months after diagnosis showed permanent reversal of all clinical and radiological signs. MRI should be used as a primary imaging study in the evaluation of GC and for the determination of the target points for stereotactic biopsy. We discuss the aetiology, clinical manifestation, difficulties of intra vitam diagnosis, and management of this rare condition in the light of other 110 (101 postmortem and nine intra vitam) reported cases of GC in the literature.

[Glioblastoma multiforme developing after a gunshot injury of the brain (author's transl)]. / Glioblastoma multiforme nach Kopfschuss.

We report the case of a 28-year-old male who suffered a frontal penetrating gunshot injury with subsequent bifrontal brain abscess and subdural empyema, and five years later developed a large bifrontal tumour at the precise site of the meningo-cerebral scar and posttraumatic defect. Histological examination showed a glioblastoma multiforme adjacent to the dural scar and, in addition, old suture material was found within the glioma tissue. In spite of combined radiation and polychemotherapy the patient died eleven months after partial tumour resection. The temporal and local association of missile injury with subsequent recurred abscess and scar formation and the malignant glioma is highly suggestive of a causal relationship between trauma and the development of a brain tumour.

Development of supratentorial astrocytomas.

Six cases of supratentorial astrocytomas are presented in this study in order to demonstrate the typical development of this kind of tumors. All patients were controlled regularly by CT scan. Five of them were operated two times, one patient three times. The tumor growth was quite similar in all cases. Time interval between the first intervention and tumor recurrence was larger than between second intervention and tumor recurrence. In all cases the tumors tended to "explosive" growth after the second operation. There are discussed pros and cons of an early reintervention after tumor recurrence.