Vertebral Endplate Cavities (VEC) with titanium cages in posterior lumbar interbody fusion (PLIF).

BACKGROUND: Vertebral endplate cavities (VEC) have been reported with the use of Ti cages. Only few articles have recently demonstrated unfavorable radiographic changes in the form of cysts or cavities which may predispose to nonunion. METHODS: The aim was to assess the prevalence of VEC in posterior lumbar interbody fusion (PLIF) using Titanium (Ti) cages, and to estimate their impact on fusion. The term "cavity" was used to describe the endplate changes. CT analysis of the VEC and fusion status following PLIFs with Ti cages was conducted by two observers. VEC were assessed according to the size, multiplicity, location, and presence of sclerosis. RESULTS: 42 consecutive patients with surgeries conducted on 52 levels were enrolled. There were 20 males and 22 females. The mean age was 43.6 ±10.89 years. The mean follow-up was 20.85±8.49 months. Definite union was seen in 48 levels (92.3%) by observer 1 and in 40 levels (76.9%) by observer 2. The strength of agreement was moderate. The presence of VEC was observed in 9 levels (17.3%) by observer 1 and in 12 levels (23.1%) by observer 2. The strength of agreement was moderate. The majority of VEC in the endplates were <5mm. The strength of agreement was high. The strength of agreement for location and multiplicity were moderate. The VEC was significantly correlated with the fusion status. CONCLUSIONS: Our study confirmed that VEC were observed following Ti cage placement after PLIF procedures. They tend to be small and might be associated with non-union. Furthermore, it reflected the limited inter-rater reliability of the assessment of both the fusion status and VEC morphology after Ti PLIF cage placement.

Pros and Cons of Early and Very Early Surgery for Traumatic Central Cord Syndrome with Spinal Stenosis: Literature Review and Case Report.

BACKGROUND: The case of a 69-year-old patient with an acute traumatic central cord syndrome (ATCCS) with preexisting spinal stenosis raised a discussion over the question of conservative versus surgical treatment in the acute setting. We provide a literature overview on the management (conservative vs. surgical treatment) of ATCCS with preexisting spinal stenosis. METHODS: We reviewed the literature concerning essential concepts for the management of ATCCS with spinal stenosis and cervical spinal cord injury. The data retrieved from these studies were applied to the potential management of an illustrative case report. RESULTS: Not rarely has ATCCS an unpredictable neurologic course because of its dynamic character with secondary injury mechanisms within the cervical spinal cord in the early phase, the possibility of functional deterioration, and the appearance of a neuropathic pain syndrome during late follow-up. The result of the literature review favors early surgical treatment in ATCCS patients with preexisting cervical stenosis. CONCLUSION: Reluctance toward aggressive and timely surgical treatment of ATCCS should at least be questioned in patients with preexisting spinal stenosis.

Factors which predict adverse events following surgery in adults with cervical spinal deformity.

AIMS: The aim of this study was to identify the risk factors for adverse events following the surgical correction of cervical spinal deformities in adults. METHODS: We identified adult patients who underwent corrective cervical spinal surgery between 1 January 2007 and 31 December 2015 from the MarketScan database. The baseline comorbidities and characteristics of the operation were recorded. Adverse events were defined as the development of a complication, an unanticipated deleterious postoperative event, or further surgery. Patients aged < 18 years and those with a previous history of tumour or trauma were excluded from the study. RESULTS: A total of 13,549 adults in the database underwent primary corrective surgery for a cervical spinal deformity during the study period. A total of 3,785 (27.9%) had a complication within 90 days of the procedure, and 3,893 (28.7%) required further surgery within two years. In multivariate analysis, male sex (odds ratio (OR) 0.90 (95% confidence interval (CI) 0.8 to 0.9); p = 0.019) and a posterior approach (compared with a combined surgical approach, OR 0.66 (95% CI 0.5 to 0.8); p < 0.001) significantly decreased the risk of complications. Osteoporosis (OR 1.41 (95% CI 1.3 to 1.6); p < 0.001), dyspnoea (OR 1.48 (95% CI 1.3 to 1.6); p < 0.001), cerebrovascular accident (OR 1.81 (95% CI 1.6 to 2.0); p < 0.001), a posterior approach (compared with an anterior approach, OR 1.23 (95% CI 1.1 to 1.4); p < 0.001), and the use of bone morphogenic protein (BMP) (OR 1.22 (95% CI 1.1 to 1.4); p = 0.003) significantly increased the risks of 90-day complications. In multivariate regression analysis, preoperative dyspnoea (OR 1.50 (95% CI 1.3 to 1.7); p < 0.001), a posterior approach (compared with an anterior approach, OR 2.80 (95% CI 2.4 to 3.2; p < 0.001), and postoperative dysphagia (OR 2.50 (95% CI 1.8 to 3.4); p < 0.001) were associated with a significantly increased risk of further surgery two years postoperatively. A posterior approach (compared with a combined approach, OR 0.32 (95% CI 0.3 to 0.4); p < 0.001), the use of BMP (OR 0.48 (95% CI 0.4 to 0.5); p < 0.001) were associated with a significantly decreased risk of further surgery at this time. CONCLUSION: The surgical approach and intraoperative use of BMP strongly influence the risk of further surgery, whereas the comorbidity burden and the characteristics of the operation influence the rates of early complications in adult patients undergoing corrective cervical spinal surgery. These data may aid surgeons in patient selection and surgical planning. Cite this article: Bone Joint J 2021;103-B(4):734-738.

Influence of the Intensive Care Unit Environment on the Reliability of the Montreal Cognitive Assessment.

Background: Neuropsychological screening becomes increasingly important for the evaluation of subarachnoid hemorrhage (SAH) and stroke patients. It is often performed during the surveillance period on the intensive (ICU), while it remains unknown, whether the distraction in this environment influences the results. We aimed to study the reliability of the Montreal Cognitive Assessment (MoCA) in the ICU environment. Methods: Consecutive stable patients with recent brain injury (tumor, trauma, stroke, etc.) were evaluated twice within 36 h using official parallel versions of the MoCA (ΔMoCA). The sequence of assessment was randomized into (a) busy ICU first or (b) quiet office first with subsequent crossover. For repeated MoCA, we determined sequence, period, location effects, and the intraclass correlation coefficient (ICC). Results: N = 50 patients were studied [n = 30 (60%) male], with a mean age of 57 years. The assessment's sequence ["ICU first" mean ΔMoCA -1.14 (SD 2.34) vs. "Office first" -0.73 (SD 1.52)] did not influence the MoCA (p = 0.47). On the 2nd period, participants scored 0.96 points worse (SD 2.01; p = 0.001), indicating no MoCA learning effect but a possible difference in parallel versions. There was no location effect (p = 0.31) with ΔMoCA between locations (Office minus ICU) of -0.32 (SD 2.21). The ICC for repeated MoCA was 0.87 (95% CI 0.79-0.92). Conclusions: The reliability of the MoCA was excellent, independent from the testing environment being ICU or office. This finding is helpful for patient care and studies investigating the effect of a therapeutic intervention on the neuropsychological outcome after SAH, stroke or traumatic brain injury.

Smoking status and perioperative adverse events in patients undergoing cranial tumor surgery.

INTRODUCTION: Smoking is agreed to be a major health risk factor, but it is debated whether it has an influence on perioperative adverse events (AEs) in elective cranial tumor surgery. METHODS: We analyzed the 2013-2016 data from our prospective institutional patient registry. Consecutive patients undergoing elective microsurgical tumor surgery of a glioma or a meningioma were included. Patients were categorized as active smokers, former smokers, and non-smokers. AE were graded by the therapy-oriented Clavien-Dindo scale. Possible predictors of postoperative AE were identified with the help of a binomial logistic regression model. RESULTS: We identified 798 patients, out of which 480 were non-smokers, 193 active smokers, and 125 former smokers. The rate of AEs for active smokers (30%, 95% CI [23-37%]) was indistinguishable from the AE rate of non-smokers (32%, 95% CI [28-37%]). No difference between smoking status was found looking at all AE individually, the odds ratio of suffering from local AE and systemic AE respectively were the same between all smoking groups. The modified Rankin scale at hospital admission was a strong and significant predictor of postoperative AE (P = 0.013). CONCLUSIONS: Active smoking was not associated with an increased risk for postoperative AE, neither looking at the total number of AE nor looking at individual AE. Smoking status should therefore not be a major factor in preoperative decision making. Although not based on data of this study, doctors should always encourage patients to stop smoking due to its well-known detrimental health effect.

Posterior open reduction and internal fixation of C1 fractures: the C-clamp technique.

BACKGROUND: The treatment of isolated atlas (C1) fractures is still controversial. The surgical management usually involves an arthrodesis of the atlanto-axial (C1-C2) joint with or without occipital fixation. We reviewed the senior author's series of posterior only open reduction and internal fixation (ORIF) of isolated C1 fractures. METHODS: Retrospective analysis of consecutive patients with isolated C1 fractures, treated in one institution by posterior only ORIF between 2005 and 2017. All fractures of C1 with concomitant C2 or occipital condyle fractures were excluded. The C1 arch was reduced with C1 lateral mass screws, connected with a transverse rod in a C-clamp fashion. We analyzed neck pain on the visual analog scale (VAS) and imaging signs of instability on follow-up. RESULTS: We identified eight patients, six males, and two females with a mean age of 37.9 years (range 20-71 years). All were neurologically intact before surgery, none had a documented transverse ligament disruption, and the mean gap between the fractured pieces was 5.3 mm. Five patients were treated < 72 h of injury, two patients had failed halo vest for 8-10 weeks, and one patient was operated after 6 months because of painful pseudarthrosis despite wearing a hard collar. One patient developed a transient neurological deficit due to vertebral artery dissection that had resolved completely at time of follow-up. The mean follow-up after surgery was 12.6 months (range 1-49 months) and mean preoperative neck pain (VAS 5.1) was significantly decreased (VAS 0.8; p < 0.001). On follow-up radiological evaluation, no instability was noted in any patient. CONCLUSIONS: Posterior ORIF of C1 fractures may be an option for patients who fail or do not wish to pursue conservative management. The particular advantage of this technique over C1-C2 arthrodesis is the preserved range of rotational motion. Mono-axial screws seem to provide better reduction capacity.

Routinely Performed Serial Follow-Up Imaging in Asymptomatic Patients With Multiple Cerebral Cavernous Malformations Has No Influence on Surgical Decision Making.

Background: The best strategy to perform follow-up of patients with multiple cerebral cavernous malformations (mCCM) is unclear due to the unpredictable clinical course. Still, serial radiological follow-up is often performed. The objective of this work was to critically question whether active follow-up by serial imaging is justified and has an impact on clinical decision making. Methods: We included all consecutive patients with mCCM treated and followed at our Department between 2006 and 2016. Patient data were collected and analyzed retrospectively. Results: From a total number of 406 patients with CCM, n = 73 [18.0%; mean age at first diagnosis 45.2 years (±2.4 SE); n = 42 male (57.5 %)] were found to harbor multiple lesions (≤5 CCM in 58.9%; 6-25 in 21.9%; ≥ 25 in 19.2%). All of them were followed for a mean of 6.8 years (±0.85 SE). Conservative treatment was suggested in 43 patients over the complete follow-up period. Thirty patients underwent surgical extirpation of at least one CCM lesion. Forty-three surgical procedures were performed in total. During 500.5 follow-up years in total, routinely performed follow-up MRI in asymptomatic patients lead to an indication for surgery in only two occasions and even those two were questionable surgical indications. Conclusion: Routinely performed follow-up MRI in asymptomatic patients with mCCM is highly questionable as there is no evidence for therapeutic relevance.

The value of short-term pain relief in predicting the long-term outcome of 'indirect' cervical epidural steroid injections.

BACKGROUND: The predictive value of short-term arm pain relief after 'indirect' cervical epidural steroid injection (ESI) for the 1-month treatment response has been previously demonstrated. It remained to be answered whether the long-term response could be estimated by the early post-interventional pain course as well. METHODS: Prospective observational study, following a cohort of n = 45 patients for a period of 24 months after 'indirect' ESI for radiculopathy secondary to a single-level cervical disk herniation (CDH). Arm and neck pain on the visual analog scale (VAS), health-related quality of life with the Short Form-12 (SF-12), and functional outcome with the Neck Pain and Disability (NPAD) Scale were assessed. Any additional invasive treatment after a single injection (second injection or surgery) defined treatment outcome as 'non-response'. RESULTS: At 24 months, n = 30 (66.7%) patients were responders and n = 15 (33.3%) were non-responders. Non-responders exited the follow-up at 1 month (n = 10), at 3 months (n = 4), and at 6 months (n = 1). No patients were injected again or operated on between the 6- and 24-month follow-up. Patients with favorable treatment response at 24 months had significantly lower VAS arm pain (p < 0.05) than non-responders at days 6, 8-11, and at the 3-month follow-up. The previously defined cut-off of > 50% short term pain reduction was not a reliable predictor of the 24-month responder status. SF-12 and NPAD scores were better among treatment responders in the long term. CONCLUSIONS: Patients who require a second injection or surgery after 'indirect' cervical ESI for a symptomatic CDH do so within the first 6 months. Short-term pain relief cannot reliably predict the long-term outcome.

Decision-making and neurosurgeons' agreement in the management of aneurysmal subarachnoid haemorrhage based on computed tomography angiography.

BACKGROUND: To determine the neurosurgeon's agreement in aneurysmal subarachnoid haemorrhage (aSAH) management with special emphasis on the rater's level of experience. A secondary aim was to analyse potential aneurysm variables associated with the therapeutic recommendation. METHOD: Basic clinical information and admission computed tomography angiography (CTA) images of 30 consecutive aSAH patients were provided. Twelve neurosurgeons independently evaluated aneurysm characteristics and gave recommendations regarding the emergency management and aneurysm occlusion therapy. Inter-rater variability and predictors of treatment recommendation were evaluated. RESULTS: There was an overall moderate agreement in treatment decision [κ = 0.43; 95% confidence interval ((CI), 0.387-0.474] with moderate agreement for surgical (κ = 0.43; 95% CI, 0.386-0.479) and endovascular treatment recommendation (κ = 0.45; 95% CI, 0.398-0.49). Agreement on detailed treatment recommendations including clip, coil, bypass, stent, flow diverter and ventriculostomy was low to moderate. Inter-rater agreement did not significantly differ between residents and consultants. Middle cerebral artery (MCA) aneurysm location was a positive predictor of surgical treatment [odds ratio (OR), 49.57; 95% CI, 10.416-235.865; p < 0.001], while patients aged >65 years (OR, 0.12; 95% CI, 0.03-0.0434; p = 0.001), fusiform aneurysm type (OR, 0.18; 95% CI, 0.044-0.747; p = 0.018) and intracerebral haematoma (ICA) aneurysm location (OR, 0.24; 95% CI, 0.088-0.643; p = 0.005) were associated with a recommendation for endovascular treatment. CONCLUSIONS: Agreement on aSAH management varies considerably across neurosurgeons, while therapeutic decision-making is challenging on an individual patient level. However, patients aged >65 years, fusiform aneurysm shape and ICA location were associated with endovascular treatment recommendation, while MCA aneurysm location remains a surgical domain in the opinion of neurosurgeons without formal endovascular training.

The Value of Short-Term Pain Relief in Predicting the Long-Term Outcome of Lumbar Transforaminal Epidural Steroid Injections.

BACKGROUND: A previous report demonstrated predictive power of short-term leg pain relief after lumbar transforaminal epidural steroid injections for 1-month treatment response. The question whether the long-term response could be similarly predicted remained unanswered. METHODS: A prospective cohort of 57 patients who underwent a transforaminal epidural steroid injection for sciatica secondary to a lumbar disc herniation was followed for 24 months. Leg and back pain on the visual analog scale, health-related quality of life using the 12-Item Short Form Survey, and functional outcome using the Oswestry Disability Index were assessed. Responders were defined as not receiving any additional invasive treatment after a single injection. Patients who underwent a second injection or surgery were defined as treatment failures (nonresponders). RESULTS: At 24 months, 31 (54.4%) patients were responders, and 26 (45.6%) were nonresponders. Nonresponders left follow-up at 1 month (n = 9), 3 months (n = 9), 6 months (n = 6) and 12 months (n = 2). No patients were injected again or operated on between the 12- and 24-month follow-up. Responders at 24 months had significantly lower visual analog scale leg pain (P < 0.05) than nonresponders starting from the second week after TFESI and better 12-Item Short Form Survey scores and less disability on the Oswestry Disability Index. CONCLUSIONS: Most patients with a symptomatic lumbar disc herniation who opt for a second injection or surgery do so within the first 6 months. Reliable prediction of the long-term treatment response based on short-term pain relief is not possible.

Endoscope-Assisted Extreme-Lateral Interbody Fusion: Preliminary Experience and Technical Note.

BACKGROUND: The extreme lateral lumbar interbody fusion (XLIF) technique is safe and effective; however, the deep and tight surgical corridor makes visual identification of important landmark structures, as well as sufficient endplate and contralateral preparation, challenging. In the present study, we analyzed the safety and feasibility of endoscope-assisted (EA) XLIF procedures. METHODS: This was a retrospective single-center study on consecutive patients undergoing XLIF procedures between February 2014 and July 2016. EA-XLIF and conventional XLIF (c-XLIF) procedures were compared in terms of the duration of surgery, estimated blood loss (EBL), perioperative and postoperative complications, and postoperative outcomes. RESULTS: A total of 41 patients (mean age, 66.7 years ± 10.0 years; 22 males [53.7%]) underwent a XLIF procedure, including 6 (14.6%) who underwent EA-XLIF. EA-XLIF did not increase the duration of surgery or EBL. No perioperative or postoperative complications were observed in any of the EA-XLIF procedures. Clinical and radiologic outcomes at 6 weeks postsurgery and at the last follow-up (mean, 8.0 ± 5.8 months postsurgery) were similar for patients in the EA-XLIF and c-XLIF groups. The EA-XLIF technique was considered particularly helpful for checking the lumbar plexus anatomy on the psoas surface, identifying the relationship between the peritoneum and the psoas muscle, positioning the shim into the disc space, removing the disk, and checking the quality of contralateral release and endplate preparation. CONCLUSIONS: The EA-XLIF technique is safe and may be considered as an adjunct procedure, offering improved visualization to guide the surgeon in key steps of the XLIF procedure.

Residents' Learning Curve of Lumbar Transforaminal Epidural Steroid Injections.

Background and Study Aims There is a paucity of literature on beginners' training and on its connection with patient safety for transforaminal epidural steroid injections (TFESIs). This study retrospectively assessed the learning curves and associated complications of neurosurgery residents never previously exposed to TFESI and compared them with experienced board-certified faculty neurosurgeons (BCFNs). Material and Methods Procedure time in minutes, dose-area product (DAP) in cGy*cm2, periprocedural observations, and complications in 354 TFESIs for radicular pain secondary to lumbar disk herniation or lumbar spinal stenosis were extracted from operative notes and the electronic infiltration logbook in the per-injection format. Learning curves for 238 residents and 116 BCFN TFESIs in terms of procedure time and DAP were estimated using monotone regression. Results Residents' TFESI procedure time and DAP reached BCFN level (4.7 minutes and 140.2 Gy*cm2) after 67 and 68 cases, respectively. Residents' TFESIs were unsuccessful in 1.7%, mostly for severe obesity and hypertrophied facet joints, but no severe complications were noted. Obesity, however, did not result in increased procedure times or radiation exposure in general. Residents were faster and required less fluoroscopy in TFESI of the upper lumbar nerve roots than for L5 or S1 in particular. Conclusion The residents' learning curve for TFESIs in terms of procedure time and radiation exposure can be overcome safely after < 70 TFESIs. An outcome analysis correlating to the interventionalist's training level would be worth investigating in future studies.

Computed tomography angiography spot sign predicts intraprocedural aneurysm rupture in subarachnoid hemorrhage.

INTRODUCTION: To analyze whether the computed tomography angiography (CTA) spot sign predicts the intraprocedural rupture rate and outcome in patients with aneurysmal subarachnoid hemorrhage (aSAH). METHODS: From a prospective nationwide multicenter registry database, 1023 patients with aneurysmal subarachnoid hemorrhage (aSAH) were analyzed retrospectively. Descriptive statistics and logistic regression analysis were used to compare spot sign-positive and -negative patients with aneurysmal intracerebral hemorrhage (aICH) for baseline characteristics, aneurysmal and ICH imaging characteristics, treatment and admission status as well as outcome at discharge and 1-year follow-up (1YFU) using the modified Rankin Scale (mRS). RESULTS: A total of 218 out of 1023 aSAH patients (21%) presented with aICH including 23/218 (11%) patients with spot sign. Baseline characteristics were comparable between spot sign-positive and -negative patients. There was a higher clip-to-coil ratio in patients with than without aICH (both spot sign positive and negative). Median aICH volume was significantly higher in the spot sign-positive group (50 ml, 13-223 ml) than in the spot sign-negative group (18 ml, 1-416; p < 0.0001). Patients with a spot sign-positive aICH thus were three times as likely as those with spot sign-negative aICH to show an intraoperative aneurysm rupture [odds ratio (OR) 3.04, 95% confidence interval (CI) 1.04-8.92, p = 0.046]. Spot sign-positive aICH patients showed a significantly worse mRS at discharge (p = 0.039) than patients with spot sign-negative aICH (median mRS 5 vs. 4). Logistic regression analysis showed that the spot sign was an aICH volume-dependent predictor for outcome. Both spot sign-positive and -negative aICH patients showed comparable rates of hospital death, death at 1YFU and mRS at 1YFU. CONCLUSION: In this multicenter data analysis, patients with spot sign-positive aICH showed higher aICH volumes and a higher rate of intraprocedural aneurysm rupture, but comparable long-term outcome to spot sign-negative aICH patients.

Ten-Day Response to CT-Guided Spinal Infiltration Therapy in More Than a Thousand Patients.

BACKGROUND AND STUDY AIMS: Infiltration therapy (IT) for degenerative spine disease is considered a valuable nonsurgical treatment option in the absence of severe neurologic deficits. The aim of this study was to evaluate the 10-day response to computed tomography (CT)-guided IT and to identify parameters that are positively or negatively associated with short-term outcome. PATIENTS AND METHODS: We conducted a prospective study on 1327 consecutive patients that received CT-guided IT for various spinal disorders between February 2007 and June 2013. Different steroids (betamethasone, dexamethasone, triamcinolone) with or without bupivacaine were applied using different approaches (direct and indirect for cervical nerve roots; transforaminal and interlaminar as well as combined approaches for lumbar nerve roots; facet joint and sacroiliac joint infiltration). The primary end point was the patients' response 10 days after IT, which was graded as better, the same, or worse. The chi-square test was used for subgroup comparisons. RESULTS: A total of 1002 patients provided 10-day follow-up. Clinically meaningful pain relief was achieved in 65 of 107 patients treated for cervical disk herniation (60.8%), 27 of 60 for cervical foraminal stenosis (45%), 295 of 412 for lumbar disk herniation (71.6%), 134 of 199 for lumbar spinal stenosis (LSS) (67.3%), 35 of 61 for cervical facet joint pain (57.4%), 87 of 128 for lumbar facet joint pain (68%), and 25 of 35 for sacroiliac joint syndrome (SIJS) (71.4%). There was no difference with regard to the infiltration technique, types, and doses of steroids administered or the add-on of local anesthetics. An age-dependent difference was shown for elderly patients with LSS and SIJS. Repeated infiltrations were equally effective in alleviating pain compared with the first infiltration. CONCLUSIONS: CT-guided IT for various spinal disorders has an overall positive response rate of 66.7% after 10 days. Outcome was not unduly influenced by technical variations in technique, types, and doses of steroids administered and probably relates better to the correct indication than to technical aspects.

Little-known Swiss contributions to the description, diagnosis, and surgery of lumbar disc disease before the Mixter and Barr era.

The understanding of lumbar spine pathologies made substantial progress at the turn of the twentieth century. The authors review the original publication of Otto Veraguth in 1929 reporting on the successful resection of a herniated lumbar disc, published exclusively in the German language. His early report is put into the historical context, and its impact on the understanding of pathologies of the intervertebral disc (IVD) is estimated. The Swiss surgeon and Nobel Prize laureate Emil Theodor Kocher was among the first physicians to describe the traumatic rupture of the IVD in 1896. As early as 1909 Oppenheim and Krause published 2 case reports on surgery for a herniated lumbar disc. Goldthwait was the first physician to delineate the etiopathogenes is between annulus rupture, symptoms of sciatica, and neurological signs in his publication of 1911. Further publications by Middleton and Teacher in 1911 and Schmorl in 1929 added to the understanding of lumbar spinal pathologies. In 1929, the Swiss neurologist Veraguth (surgery performed by Hans Brun) and the American neurosurgeon Walter Edward Dandy both published their early experiences with the surgical therapy of a herniated lumbar disc. Veraguth's contribution, however, has not been appreciated internationally to date. The causal relationship between lumbar disc pathology and sciatica remained uncertain for some years to come. The causal relationship was not confirmed until Mixter and Barr's landmark paper in 1934 describing the association of sciatica and lumbar disc herniation, after which the surgical treatment became increasingly popular. Veraguth was among the first physicians to report on the clinical course of a patient with successful resection of a herniated lumbar disc. His observations should be acknowledged in view of the limited experience and literature on this ailment at that time.

Von Bergmann, Kocher, and Krönlein--a triumvirate of pioneers with a common neurosurgical concept.

BACKGROUND: The rise of a neurosurgical subspecialisation in general surgery was strongly influenced by some key surgeons. In the German-speaking regions of Europe, Ernst von Bergmann, Emil Theodor Kocher and Rudolf Ulrich Krönlein have to be especially highlighted. METHODS: This article describes their contributions to the neurosurgical field and their personal interactions. For this, the numerous publications on cranial neurosurgery of von Bergmann were reviewed. They are presented in chronological order. Kocher's and Krönlein's contributions to early neurosurgery have been valued recently by the authors and are briefly summarized. RESULTS: All three developed early interest in the neurosurgical field and conducted clinical and experimental research at the turn of the twentieth century. It becomes evident that von Bergmann, Kocher and Krönlein provided a basis for a transnational neurosurgical school. CONCLUSION: This triumvirate developed a common neurosurgical concept that was grounded in the physiological experiments and scientific evidence.

Resection of an intramedullary high cervical metastasis from a malignant mixed Muellerian tumour.

We present a 66-year-old female patient with a high cervical intramedullary metastasis from a malignant mixed Muellerian tumour (MMMT; carcinosarcoma) with concomitant syringomyelia. She was admitted to our clinic with symptoms of cervical myelopathy. MRI revealed an intramedullary tumour of 2.6cm×1.2cm at the cervical vertebral body C2. We performed a laminectomy on C2 followed by a dorsal median myelotomy from C1 to C3 to resect the tumour. The surgical intervention removed the tumour completely and resolved the syringomyelia. During the 36months of follow-up, the patient presented in a stable condition with no evidence of tumour recurrence. To our knowledge, this is the first report of an intramedullary metastasis of a MMMT.

Emil Theodor Kocher--valve surgery for epilepsy.

Emil Theodor Kocher (1841-1917) was a pioneering and versatile Swiss surgeon who played a decisive role in the surgical evolution on the threshold to the 20th century. Apart from conducting intense research and fostering the development of the surgical treatment of thyroid gland diseases (honored with a Nobel Prize in 1909), he remained a generalist and was active in orthopedic, genitourinary, and neurologic surgery. Even today, many surgical techniques and instruments are still named after him, thus providing evidence of his great impact. His neurosurgical ambitions included, in particular, cerebral and spinal trauma, the pathophysiology of elevated intracranial pressure, as well as etiological considerations and the operative treatment of epilepsy. This article aims to shed light on Kocher's work on epilepsy, published exclusively in German, and illustrates the development of his idea on valve surgery for recurrent general convulsions.

Intramedullary spinal cord metastasis and multiple brain metastases from urothelial carcinoma.

Intramedullary spinal cord metastases (ISCM) are rare spinal cord neoplasms associated with severe neurological deterioration and poor life expectancy. However, their incidence is expected to increase as a result of advances in diagnostic techniques and longer survival of patients with cancer due to improvements in cancer therapy. Reports on ISCM from primary urothelial carcinoma are virtually non existent. We report a 74-year-old male patient with a significant history of a high-grade urothelial carcinoma who presented with progressive back pain and concomitant weakness, grade 3-4/5 proximally and 0-1/5 distally, and distal hyperesthesia and hyperalgesia, particularly of the left lower limb. MRI revealed a contrast-enhancing intramedullary lesion at Th11/Th12. Laminectomies of Th11/Th12 and lesion resection were performed. Postoperative histopathological examinations confirmed the metastatic nature of the lesion. Subsequently the patient developed multiple brain metastases. Radiation therapy was refused by the patient. We conclude that ISCM are devastating complications of systemic cancer. Early and thorough diagnosis, as well as carefully considered and prompt therapy, is important for minimizing the patient's functional deficit, thus improving quality of life.